Qualitative Analysis of Knowledge, Attitudes, and Beliefs About Pessary Use Among Spanish-Speaking Women on the US-Mexico Border.

OBJECTIVES: To explore the knowledge, attitudes, and beliefs related to pessary use in Spanish-speaking women along the US-Mexico border. METHODS: Spanish-speaking women with symptoms of vaginal bulge were recruited from the urogynecology/gynecology clinics at Texas Tech University Health Sciences Center El Paso to participate in moderated focus groups. Discussion topics included knowledge of prolapse/pessaries, pros/cons of pessaries, alternatives, and prolapse surgery. Audio-recorded group discussions were transcribed verbatim, and qualitative analysis completed by independent review using grounded theory methodology. Common themes were identified and then aggregated to form consensus concepts, agreed upon by the reviewers. RESULTS: Twenty-nine Spanish-speaking women participated in 6 focus group discussions. Approximately half of women reported little or no prior knowledge about pessaries. Three main themes were identified from analysis: knowledge/perceptions, misinformation/misconceptions, and surgery-related concerns. Concepts identified from common themes included limited knowledge of pessaries, confusing "pessary" with "mesh," willingness to try pessaries in order to avoid surgery, desire to try pessary if it was recommended by physician, limited efficacy or complications of surgery, and mesh-related concerns. Interestingly, some women reported that pessaries appear to be a treatment more often offered in the United States rather than in Mexico. CONCLUSIONS: Most participants showed a willingness to try a pessary for symptoms of pelvic organ prolapse in an effort to avoid surgery, despite expressing limited knowledge about this treatment. Physician recommendations and risks of pessary use influence their likelihood of trying a pessary. These concepts serve as focus points for effective pessary counseling to help improve education and informed decision making in this patient population.

Decision Aid Video for Treatment Selection in Latinas With Symptomatic Pelvic Organ Prolapse: A Randomized Pilot Study.

OBJECTIVES: To assess impact of a decision aid video in Latina patients with symptomatic pelvic organ prolapse (POP) on knowledge, satisfaction and decisional conflict related to initial treatment selection. METHODS: Pilot study with randomized prospective design. Thirty Latina women with symptomatic POP were randomized to a decision aid intervention plus standard care (N = 15) or standard care alone (N = 15) group. Decision aid intervention consisted of a 10-minute video presented at time of initial evaluation for POP. Outcome measures included the Prolapse and Incontinence Knowledge Quiz ("Knowledge"), the Satisfaction with Decision ("Satisfaction") and Decisional Conflict (DCS) scales, and were assessed at 4 different timepoints: after initial visit, and at 1, 3 and 6 months after. Data was analyzed using repeated-measures ANOVA and pairwise between-group comparisons. RESULTS: Demographic and baseline data were similar between groups. There was a significant interaction between groups and time on the Knowledge scores (P = 0.03). Knowledge scores were higher at the initial visit in the intervention group (10.6 ± 0.8 vs 9.53 ± 1.4, P = 0.014). Satisfaction scores were lower in the intervention group on longitudinal analysis, indicating higher satisfaction (P = 0.02). There was no difference on overall Decisional Conflict scores between groups. The intervention group had lower scores on the "effective decision" DCS subscale at 3 and 6 months and "informed" DCS subscale at 3 months. CONCLUSIONS: A decision aid video intervention in Latina women with POP used at the time of initial evaluation may help the patient make a more informed treatment decision by increasing condition-related knowledge and lead to greater long-term satisfaction.

Spanish Language Pelvic Floor Disorders Patient Information Handouts: How Readable Are They?

OBJECTIVE: This study aimed to determine the readability of commonly available patient information materials for pelvic floor disorders written in Spanish and compare their readability based on type of content and source. METHODS: Spanish patient information handouts, including pamphlets from the National Institutes of Health, International Urogynecology Association, American Congress of Obstetricians and Gynecologists, online printable handouts, and industry-sponsored brochures were assessed for readability. Online materials for patients were obtained from Google searches using key words (pelvic floor disorders, urogynecology, patient information handouts, Spanish). Reading difficulty was assessed using INFLESZ v1.0, (Barrio-Cantalejo IM, Spain) a free software developed to calculate the readability of Spanish written texts. Three index scales were used: Flesch-Szigriszt Index, Word correlation Index, and the Fernandez-Huerta Index. RESULTS: Forty patient information handouts were analyzed. All pamphlets analyzed had readability scores within the "average" to "very difficult" reading difficulty levels as per the index scales used. None of the analyzed pamphlets met the sixth grade reading level criteria suggested by the National Institutes of Health and American Medical Association, including government-developed materials. There were no differences in readability scores between type of leaflet content or source. CONCLUSIONS: Current available free, industry-, organization-, and government-provided reading materials in Spanish do not serve the Spanish-speaking only or low English-speaking literacy population. Future work should aim to simplify the language in such documents to the suggested sixth grade reading level.

Barriers to seeking care for urinary incontinence in Mexican American women.

INTRODUCTION AND HYPOTHESIS: The majority of epidemiologic studies of urinary incontinence (UI) have been conducted in non-Hispanic populations. We conducted a case-control study to identify factors associated with delayed care-seeking behavior in adult Mexican American women with UI. METHODS: Cases were women with UI who sought care >2 years after the onset of symptoms (delayed care group). Controls were women with UI who sought care ≤2 years after the onset of symptoms. Participants were women who self-identified as Mexican American, Hispanic, Chicana or Latina, and were 18 years of age or older. RESULTS: A total of 209 records (107 cases and 102 controls) were available for analysis. Of the women in the delayed care and control groups, 32% and 23%, respectively, were ≥66 years of age (P = 0.12). Women in the delayed care group were less likely than those in the control group to report that the following item was a barrier (adjusted OR = 0.54, P = 0.06): "The wait is too long to the appointment". Women in the delayed care group were twice as likely as those in the control group (adjusted OR = 2.17, P = 0.03) to agree that lack of interest on the part of the health-care practitioner and staff was a barrier. In addition to standardized responses, open-ended responses were solicited and the most frequent barrier was lack of knowledge. CONCLUSIONS: Among Mexican American women with UI, those who delayed seeking care for their UI were more likely than those who sought care promptly to cite lack of interest on the part of a health-care provider as a barrier to seeking care in a timely fashion.

Knowledge, Perceptions, and Attitudes Toward Pelvic Organ Prolapse and Urinary Incontinence in Spanish-Speaking Latinas.

OBJECTIVES: The aim of the study was to explore individual views and perceptions of Spanish-speaking Latinas living on the US/Mexico border toward pelvic organ prolapse (POP) and urinary incontinence (UI), including awareness of conditions, implications of diagnoses, knowledge, and attitudes toward available treatment options. METHODS: Spanish-speaking Latina women were recruited from clinics at Texas Tech University Health Sciences Center El Paso. Focus group discussions were conducted, addressing topics including female pelvic anatomy, perceived etiology and course of POP and UI, and attitudes toward treatment options. Discussions were transcribed and qualitative analysis performed to identify common themes and concepts. RESULTS: Twenty-four women participated in 5 focus groups as follows: 2 groups of women diagnosed with POP/UI, 2 groups of women with POP/UI symptoms, and 1 group of asymptomatic women. Mean age of participants was 52 years. Participants had a good basic understanding of pelvic organs and function. The following 3 common themes were derived from our analysis: culture, barriers, and misconceptions. Concepts identified from common themes included views of POP/UI as "abnormal" conditions; perceptions that providers may downplay or ignore symptoms of POP/UI; fear of doctor; views of cancer as a common POP complication; embarrassment; views of "massage" therapy as an effective treatment for POP; and willingness to consider all available treatment options for POP and UI, including pessary. CONCLUSIONS: Findings suggest need for patient reassurance about the prevalence and benign course of POP and UI upon initial assessment, with continued reinforcement of basic concepts after diagnosis, and need for increased awareness and information resources for healthcare providers and Spanish-speaking Latina women regarding these common pelvic floor disorders.

Risk factors for ureteral occlusion during transvaginal uterosacral ligament suspension.

INTRODUCTION AND HYPOTHESIS: To determine any risk factors associated with ureteral occlusion during transvaginal uterosacral ligament suspension (USLS). METHODS: A retrospective query to identify patients that underwent transvaginal USLS at a teaching hospital from 2008 to 2013 was performed. Patients in which ureteral occlusion was identified by cystoscopy were identified (cases), and compared with those without occlusion (controls). Medical records were reviewed for data abstraction. Variables compared between cases and controls included demographics, medical history/examination, concomitant procedures, number of suspension sutures placed, estimated blood loss and length of hospital stay. Univariate analyses were performed to identify potential risk factors for ureteral occlusion, followed by multivariate regression analysis to estimate odds ratios for identified predictors. RESULTS: A total of 144 USLS procedures were performed. Thirteen cases of ureteral occlusion were identified (9%). Baseline prolapse stage, body mass index, parity, previous hysterectomy or pelvic surgery of the groups were similar (all P > 0.05). Univariate analysis identified age (P = 0.04), concomitant anterior colporrhaphy (P = 0.01), and use of a suture-capturing device for suture placement (P = 0.04) as significant factors. On multivariate logistic regression analysis, concomitant anterior colporrhaphy increased ureteral occlusion risk (OR 10.5, 95%CI 2.37-74.99, P = 0.001), while use of a suture-capturing device decreased it (OR 0.1, 95%CI 0-0.41, P = 0.01). The mean number of suspension sutures placed per side was similar in the two groups (2.6 [range 2-4] for cases and 2.4 [range 1-4] for controls, P = 0.15). CONCLUSIONS: During transvaginal USLS, performance of a concomitant anterior colporrhaphy increased the risk of ureteral occlusion, while the use of a suture-capturing device for suspension suture placement was associated with decreased risk.

The expectations of patients who undergo surgery for stress incontinence.

OBJECTIVE: The purpose of this study was to assess patient expectations of surgical outcome after preoperative counseling of surgical procedures in a randomized trial of 655 women in a comparison of the rectus fascial sling and Burch colposuspension. STUDY DESIGN: Women who selected surgery for treating stress incontinence and who consented to this randomized, surgical trial completed a preoperative questionnaire to assess expectations for the postsurgical effects of surgery on urinary incontinence-related symptoms, limitations, and emotions. Associations of expectations with a range of preoperative urinary incontinence measures were explored. RESULTS: The most frequent preoperative symptoms were urine leakage (98%), embarrassment (88%), frequency (74%), physical activity (72%), and urgency (70%). Sexual and social limitations were less frequent (< or = 44%). Treatment expectations were higher for women who reported more symptom bother. As expected, most women (98%) had an expectation that urine leakage would be completely or almost completely eliminated. However, most women (92%) who reported urgency or frequency (83%) expected significant improvement of these symptoms after surgery. CONCLUSION: Patients who undergo stress incontinence surgery have high expectations regarding the outcome of incontinence surgery, which include the resolution of urgency and frequency.

Pelvic-floor strength in women with incontinence as assessed by the brink scale.

BACKGROUND AND PURPOSE: The purpose of this study was to describe how clinical pelvic-floor muscle (PFM) strength (force-generating capacity) is related to patient characteristics, lower urinary tract symptoms, and fecal incontinence symptoms. SUBJECTS: Data were obtained from 643 women who were participating in a randomized surgical trial for treatment of stress urinary incontinence. METHODS: Patient demographic variables, baseline urinary and fecal incontinence symptom questionnaires, urodynamic data and urinary diary data, pad test results, and standardized assessment of pelvic organ support were compared with PFM strength as described by the Brink scoring system. Bivariate analysis of factors associated with the Brink scale score was done using analysis of variance and linear regression. Multivariate analysis included patient variables that were significant on bivariate analysis. RESULTS: The mean Brink scale score was 9 (SD=2) and did not vary widely in this large, but highly select, patient sample. We found a weak, but statistically strong, relationship between age and Brink score. Brink scores were not related to diary and pad test measures of incontinence severity. DISCUSSION AND CONCLUSION: Overall, PFM strength was good in this sample of women with stress incontinence. Scores tended to be similar, and it is possible that the Brink scale does not reflect real clinical differences in PFM strength.

Female urinary incontinence: what the epidemiologic data tell us.

The prevalence of urinary incontinence (UI) in women has been the subject of many epidemiologic studies. Since 1968 the field has accumulated sufficient data that we now know how stress UI and urge UI appear in populations categorized by race, age, parity, body mass index and other demographic factors. The first comprehensive study in the U.S., the MESA study, was done in 1983. For community-dwelling women 60 years or older, it came up with the now familiar figure of 38% in this age-group. Very similar figures have been found in other national populations, but there are great differences in sub-populations and also by type--stress, urge, or mixed UI. However, with all differences in prevalence acknowledged, no type of UI is unusual in a population of older women. This article delineates, with detailed discussion of individual studies, prevalence by type, age, race, obstetric and gynecologic-surgery history, and anatomic dysfunction, plus consideration of the effects of obesity and menopause on UI. The conclusion is that a problem so widespread is a candidate for prevention, and that the few trials in this direction should be augmented.

Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery.

UNLABELLED: HEADLINE: This is a longitudinal study of a cohort of primigravidae recruited between 1985 and 1987 and followed up 7 and 15 years later. Pelvic floor neurophysiology was performed and questionnaires were administered to determine the natural history of stress incontinence and to establish whether pelvic floor denervation after the first delivery is associated with symptoms of stress urinary incontinence in the future. OBJECTIVES: To study the natural history of stress urinary incontinence arising during the first pregnancy, to determine whether postnatal pelvic floor denervation progresses with time and whether it predisposes to stress urinary incontinence in the future. DESIGN: Prospective longitudinal cohort study. SETTING: Tertiary referral urogynaecology unit. SAMPLE: Cohort of 96 primigravidae studied prospectively between 1985 and 1987 and followed up 7 years (n = 76) and 15 years (n = 55) later. METHODS: Urinary incontinence symptoms were recorded and pelvic floor neurophysiology was performed antenatally and postnatally between 1985 and 1987. Repeat neurophysiological tests and questionnaires were completed by those relocated 7 and 15 years later. MAIN OUTCOME MEASURE: Symptoms of stress urinary incontinence. SECONDARY OUTCOMES: Symptoms of urge urinary incontinence and anal incontinence; motor unit potential duration and pudendal nerve terminal latency; vaginal squeeze pressure measured by perineometry. RESULTS: Prevalence of stress incontinence was highest during pregnancy and had increased seven years after the first postnatal period (P = 0.0129). Two-thirds of women with antenatal stress incontinence had stress incontinence 15 years later. One-third of women with stress incontinence at any time appear to undergo resolution of symptoms. Motor unit potential duration increased at seven years (P = 0.036). Vaginal squeeze pressure improved during the same period (P = 0.0007). CONCLUSIONS: When stress urinary incontinence arises during the first pregnancy, the risk of stress incontinence occurring 15 years later is doubled. Although pelvic floor reinnervation progressed after the postnatal period, the absence of an adequate marker for pelvic floor denervation makes it of uncertain clinical significance.

The unspeakable illness: the work-up of female urinary incontinence.

The work-up for female urinary incontinence--i.e., diagnosis and, perhaps, initial therapy-is a rational, multi-step procedure, complicated by the reticence of patients concerning their problem (except when the chief complaint is interference with sexual relations). The chief causes of incontinence are (genuine) stress incontinence and overactive bladder (OABR, although there is a continuum between them. Diagnosis begins with a review of symptoms and thorough history-taking, followed by testing: a urination diary and in-office neurologic and gynecologic tests, preceded by a thorough physical examination including all relevant gynecologic and neurologic aspects, the latter centered around S2-4--the so-called Q-tip test. If tests are inconclusive, or if medical history is suggestive, the patient is referred to a urodynamic laboratory for multi-channel urodynamic testing and other tests requiring sophisticated urodynamic equipment. Treatment plans include pharmacologic therapy of OAB and surgery, but are often less drastic.