Health literacy and PFDI-20 and PFIQ-7 completion in urogynecology patients.

INTRODUCTION AND HYPOTHESIS: Our objectives were to describe the health literacy (HL) of urogynecology patients, characterize women with and without adequate HL, and compare errors made on the PFDI-20 and PFIQ-7. METHODS: English-speaking women presenting to an academic urogynecology clinic in June-July 2018 were invited to complete questionnaires including the Newest Vital Sign™ (NVS), the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20), and the Pelvic Floor Impact Questionnaire-Short Form 7 (PFIQ-7). An NVS score > 4 indicated adequate HL. Descriptive analyses compared women with and without adequate HL and the rates and types of errors made on the PFDI-20 and PFIQ-7. RESULTS: The mean age of participants (N = 115) was 65 + 15 years; 87% were white/Caucasian; 62% were college-educated. NVS scores indicated likely adequate HL in 61%. Participants at risk for limited HL (39%) were older, less educated, more likely to live alone, and more likely to require assistance to manage their healthcare (all p < 0.05). Those requesting help to complete the questionnaires (29%) had lower HL. Errors occurred more often on the PFDI-20 (44%) than PFIQ-7 (5%) regardless of HL status. Those who received help were less likely to make errors on the PFDI-20 (p < 0.05). CONCLUSIONS: Overall 39% of patients were at risk for limited HL. Older age, living alone, less education, and requiring assistance to manage healthcare increased risk of limited HL. Errors were more common on the PFDI-20 than PFIQ-7 regardless of HL status and occurred even when participants received help completing the questionnaires, though less frequently.

Prevalence and Predictors of Urinary Incontinence at 1 Year Postpartum.

OBJECTIVES: Postpartum urinary incontinence estimates range from 13% to 47%. Clinical factors associated with incontinence 1 year after first delivery are varied. We assessed the prevalence of and factors associated with urinary incontinence in primiparous women at 12 months postpartum. METHODS: Ancillary analysis of 99 nulliparous women from a prospective cohort study that assessed participants during the first and third trimesters and 12 months postpartum. Our primary outcome was urinary incontinence 12 months postpartum. Women were asked "How often do you experience urine leakage?" and considered to have urinary incontinence if a response other than "never" was reported. We collected vaginal swabs for assessment of matrix metalloproteinase-9 activity, a measure of tissue remodeling. Bivariable and logistic regression analyses were used to compare women with and without postpartum urinary incontinence. RESULTS: Of 99 primiparous women, 55% (n = 54) reported urinary incontinence at 12 months postpartum. Logistic regression demonstrated that urinary incontinence during pregnancy (odds ratio, 34.3; 95% confidence interval, 7.9-149.2) and a decrease in matrix metalloproteinase 9 activity between the first and third trimesters (odds ratio, 19.34; 95% confidence interval, 3.47-107.84) were associated with postpartum urinary incontinence. The sensitivity and specificity of urinary incontinence during pregnancy for predicting postpartum urinary incontinence were 87% and 67%, respectively. The positive and negative predictive values were 76% and 81%, respectively. CONCLUSIONS: Urinary incontinence affected 55% of primiparous women at 12 months postpartum. Urinary incontinence during pregnancy was strongly associated with postpartum incontinence. Importantly, vaginal tissue protease activity during pregnancy represents a possible mechanism for and biomarker of postpartum urinary incontinence.

Assessing Readability: Are Urogynecologic Patient Education Materials at an Appropriate Reading Level?

OBJECTIVE: The National Institutes of Health recommends readability of patient material not exceed sixth-grade level. Our aim was to determine readability of American Urogynecologic Society (AUGS) and International Urogynecological Association (IUGA) patient education documents. METHODS: Available English- and Spanish-language IUGA patient information leaflets and AUGS patient fact sheets were scored for grade reading level. Readability assessment was performed using Flesch-Kincaid, Simple Measure of Gobbledygook, and Fry graph formulas for English documents. For Spanish documents, Fernandez-Huerta and SOL readability formulas were utilized. Each document was assessed by a health literacy expert using standards of plain language best practices. RESULTS: We assessed 86 documents: 18 AUGS, 34 IUGA, and 34 IUGA Spanish documents. Readability combined scores for English AUGS documents ranged from 8th to 12th grade level equivalents, whereas English IUGA documents ranged from 7th to 13th. Combined average readability score for AUGS sheets was 9.9 ± 1.2 grade level equivalents versus 10.5 ± 1.3 for IUGA leaflets. The AUGS documents had lower grade level equivalents on all 3 readability scales. Spanish-language IUGA leaflets had an average readability score of 5.9 ± 0.6 grade level equivalents, with a range of fifth to seventh. Health literacy expert analysis found only 1 document met all the criteria for plain language best practice. CONCLUSIONS: All assessed AUGS and IUGA patient information English documents had readability scores above National Institutes of Health-recommended reading level. Spanish IUGA documents were written at a lower reading level than their English counterparts. To best meet patient education needs, future materials development should emphasize readability and utilization of plain language best practices.

Considering Low Health Literacy: How Do the Pelvic Floor Distress Inventory-Short Form 20 and Pelvic Floor Impact Questionnaire-Short Form 7 Measure Up?

OBJECTIVE: The objective of this study was to evaluate the readability and understandability of 2 commonly used pelvic floor disorder questionnaires, Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and Pelvic Floor Impact Questionnaire-Short Form 7 (PFIQ-7), in a low health literacy patient population. METHODS: Flesh-Kincaid, SMOG, Fry, and FORCAST readability assessment tools were used to assign US grade levels to each questionnaire (PFDI-20, PFIQ-7). Two health literacy experts used PEMAT and ELF-Q tools to determine understandability, organization, content, and quality of each form. A focus group of women with low health literacy used Stop Light Coding and a facilitator-prompted discussion to further evaluate understandability and critique the forms. RESULTS: The PFIQ-7 required higher reading ability compared with PFDI-20 (ninth to 11th vs sixth to eighth mean grade level equivalents). Expert and focus group reviews identified concerns regarding purpose, formatting, and word choice in both forms. Focus group participants recommended assistance with questionnaire completion from clinical staff and gave mean overall ratings of 5.4 (0-10/worst to best) for PFDI-20 and 8.0 for PFIQ-7. CONCLUSIONS: Knowledge of potential barriers to understanding and completion may improve utilization of and accuracy of patient responses to PFDI-20 and PFIQ-7 in women with low health literacy.

Imaging of Pelvic Floor Reconstruction.

Stress urinary incontinence and pelvic organ prolapse are 2 common pelvic floor disorders that are important causes of pelvic pain and disability. Mesh and sling placement are some of the surgical treatment options available for treatment of these conditions. In addition to clinical assessment, imaging plays an important role in managing postoperative patients with complications such as recurrent organ prolapse and chronic pain. Role of high-resolution pelvic magnetic resonance imaging with additional advanced imaging techniques, such as magnetic resonance neurography that are invaluable in managing such patients, are discussed in this article.

Feasibility of prophylactic salpingectomy during vaginal hysterectomy.

BACKGROUND: The American Congress of Obstetricians and Gynecologists recommends that "the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy," resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy. OBJECTIVE: The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms. STUDY DESIGN: This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow-up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and χ2 test when appropriate. Questionnaire scores were compared using paired t tests. RESULTS: Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5-5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5-22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001). CONCLUSION: Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible.

Genital hiatus size is associated with and predictive of apical vaginal support loss.

BACKGROUND: Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1) Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely. OBJECTIVE: The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support. STUDY DESIGN: This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz et al. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated. RESULTS: Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was +2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models). CONCLUSIONS: Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery.

Management of recurrent stress urinary incontinence after burch and sling procedures.

AIMS: To examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow-up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures. METHODS: We performed a secondary analysis of the SISTER and ToMUS trials of participants who underwent primary stress urinary incontinence (SUI) treatment (without prior SUI surgery or concomitant procedures). Using Kaplan-Meier analysis, retreatment-free survival rates by initial surgical procedure were compared. Mean MESA (Medical Epidemiologic and Social Aspects of Aging) stress index was also compared between those retreated for rSUI compared to those not retreated. RESULTS: Half of the women in the SISTEr trial met inclusion criteria for this analysis (329/655, 174 Burch and 155 fascial sling), as did 444/597 (74%) of subjects in ToMUS (221 transobturator midurethral sling (TMUS), and 223 retropubic midurethral sling (RMUS). Types of surgical retreatment included autologous fascial sling (19), synthetic sling (1), and bulking agent (18). Five-year retreatment free survival rates (and standard errors) were 87% (3%), 96% (2%), 97% (1%), and 99% (0.7%) for Burch, autologous fascial sling, TMUS, and RMUS groups respectively (P < 0.0001). For all index surgery groups, the mean MESA stress index at last visit prior to retreatment for those retreated (n = 23) was significantly higher than mean MESA stress index at last visit for those not retreated (n = 645) (P < 0.0001). CONCLUSION: In these cohorts, 6% of women after standard anti-incontinence procedures were retreated within 5 years, mostly with injection therapy or autologous fascial sling. Not all women with rSUI chose surgical retreatment.

The Emotional Burden of Pelvic Organ Prolapse in Women Seeking Treatment: A Qualitative Study.

OBJECTIVE: We aimed to qualitatively describe the emotional burden experienced by women seeking treatment for prolapse. We hypothesized that the condition of prolapse would have an impact on women's emotional well-being. METHODS: Women with stage II or greater symptomatic prolapse participated in focus groups or individual phone interviews. A trained facilitator conducted semi-structured focus groups and interviews. These were audio-taped and transcribed. Two authors coded transcripts and identified themes using an "editing" approach. The codebook was amended until no new major themes emerged from the data. RESULTS: Forty-four women participated (25 in focus groups and 19 in phone interviews). Mean (SD) age of women was 60 (10) years and mean (SD) prolapse leading edge was 3 (2) cm. Analysis revealed the following 3 main themes: (1) emotions associated with the condition of prolapse (minimal emotions, annoyance, irritation, frustration, anger, sadness, anxiety, depression), (2) communicating emotions related to prolapse (to friends, family, healthcare providers), and (3) emotions relating to treatment (both positive and negative effects). CONCLUSIONS: Prolapse significantly impacts women's emotional health and subjective well-being. An improved understanding of women's emotional experiences of prolapse may help providers better meet patients' needs.

Maternal adaptations in preparation for parturition predict uncomplicated spontaneous delivery outcome.

OBJECTIVE: The objective of the study was to define maternal tissue adaptations in pregnancy associated with uncomplicated spontaneous vaginal delivery using anatomical and biological outcomes. STUDY DESIGN: Nulliparous gravidas were prospectively enrolled in the first trimester at 2 institutions. Demographic and delivery data were chart abstracted. Vaginal elastase activity (units per milligram of protein) and Pelvic Organ Prolapse Quantification measurements of pelvic organ support were obtained in the first and third trimesters. A subset underwent 3-dimensional ultrasound measures of levator hiatus. Uncomplicated spontaneous vaginal delivery (VD) was defined as no cesarean, forceps, vacuum, shoulder dystocia, third- or fourth-degree perineal laceration, or prolonged second stage labor. RESULTS: We enrolled 173 women in their first trimester, 50 of whom had ultrasounds. Mean age was 25.5 ± 5.5 years with a body mass index of 28.0 ± 7.3 kg/m(2). Sixty-seven percent were white/Caucasian, 27% black/African American, and 6% Hispanic/Latina. Mean delivery gestational age was 38.5 ± 2.9 weeks, with 23% delivering by cesarean and 59% achieving uncomplicated spontaneous VD. Vaginal support changed significantly over trimesters with posterior vaginal and hiatal relaxation, vaginal lengthening, and increased levator hiatus area during strain. Women achieving uncomplicated spontaneous VD demonstrated significantly greater relaxation on third-trimester Pelvic Organ Prolapse Quantification for anterior, apical, and hiatal measures than those without uncomplicated spontaneous VD. Higher first-trimester vaginal elastase activity was strongly associated with uncomplicated spontaneous VD (geometric mean activity 0.289 ± 0.830 U/mg vs -0.029 ± 0.585 U/mg, P = .009). Higher first-trimester elastase, younger age, lower first-trimester body mass index, and more third-trimester vaginal support laxity in points C and GH were predictive of VD success. CONCLUSION: Significant maternal adaptations occur in the vagina during pregnancy, presumably in preparation for vaginal delivery. Greater adaptation, including vaginal descent and higher first-trimester elastase activity, is associated with an increased likelihood of uncomplicated spontaneous VD.

Maternal lower urinary tract injury at the time of Cesarean delivery.

INTRODUCTION AND HYPOTHESIS: To determine the incidence of lower urinary tract (LUT) injury at the time of Cesarean delivery (CD) and to identify factors associated with LUT injury. METHODS: Cases of LUT injury at delivery between 2001 and 2012, were identified by ICD-9 code. Chart review was utilized for verification and descriptive data collection. LUT injury incidence rates were calculated using annual delivery totals and trends over time were calculated using simple linear regression. LUT injury was classified as full-thickness bladder injury (including ureteral injury) or partial-thickness bladder injury based on degree of injury and post-operative intervention. Each case was year-matched to generate two CD controls. Logistic regression analysis was performed using maternal, delivery, and health system characteristics to identify factors associated with full or partial injury. Appropriate statistical analyses were performed with significance at p < 0.05. RESULTS: Overall delivery and CD rates increased during the study time period, but despite the increase in CD rates, annual rates of LUT injury did not vary significantly (p = 0.658). Of the 72 LUT injuries reported, 39 (54 %) were full-thickness bladder, 2 (3 %) ureteral, and 31 (43 %) were partial-thickness bladder injuries. Full injury, controlling for repeat CD, was associated with increasing maternal age, transfusion, and active second stage of labor. Partial injury, was associated with increasing maternal age and delivery in the first half of the academic year. CONCLUSIONS: Despite an increasing volume of CDs, LUT injury remained relatively uncommon (0.3 % of all CDs). Full and partial bladder injuries have unique risk profiles.

Most older women recover baseline functional status following pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: To evaluate postoperative functional status changes in older women undergoing pelvic organ prolapse (POP) surgery and determine predictors for nonrecovery of baseline status. METHODS: We enrolled women ≥ 65 years in whom POP surgery was planned and measured functional status using the Katz Activities of Daily Living (ADL) and Lawton Instrumental Activities of Daily Living (IADL) scales at baseline, 1 week, 2 weeks, and 3 months postoperatively. We used logistic regression modeling to identify predictors of postoperative nonrecovery of functional status (score < baseline) and calculated score change over time. RESULTS: Sixty-six women were enrolled and 3-month data were complete for 53. Subjects had a mean age of 72 ± 5 years, were all Caucasian, and had predominantly undergone vaginal surgery (70 %). At baseline 31% were ADL-dependent and 12% were IADL-dependent. Both ADL and IADL scores changed significantly over time (p <0.001). At 3 months postoperatively, 19% of women failed to return to baseline ADLs and 25% failed to return to baseline IADLs. At all time points ADL dependence was almost entirely attributable to lack of continence, while IADL dependence was commonly due to the inability to independently perform activities outside the home. Age, number of comorbidities, depression, and baseline functional status were not significant predictors of IADL nonrecovery. In a model controlling for baseline IADL status, age, and BMI, higher baseline Colorectal-Anal Distress Inventory (CRADI) score significantly predicted IADL nonrecovery (AOR 1.13, 95% CI 1.00,1.27, p = 0.04). CONCLUSIONS: Most older women with baseline functional status independence undergoing POP surgery can expect to regain independence by 3 months postoperatively.

Body image in the Pelvic Organ Prolapse Questionnaire: development and validation.

OBJECTIVE: The purpose of this study was to develop and validate a prolapse-specific body image questionnaire. STUDY DESIGN: Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability. RESULTS: Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbach's α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high. CONCLUSION: We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.

Inpatient procedures in elderly women: an analysis over time.

OBJECTIVES: To describe inpatient surgical and diagnostic/therapeutic procedures in women ≥65 years old and assess procedure trends over time. STUDY DESIGN: Procedure data for all women ≥65 years was collected using the National Hospital Discharge Survey, a federal dataset drawn from a representative sampling of U.S. inpatient hospitals which includes patient and hospital demographics and ICD-9-CM diagnosis and procedure codes for admissions from 1979 to 2006. MAIN OUTCOME MEASURES: Age-adjusted rates (AAR) per 1000 women were created using 1990 U.S. Census data to compare trends over time. RESULTS: Over 96 million procedures were performed in women age≥65 years from 1979 to 2006. Women age≥65 years constituted 17% of women with ≥1 inpatient procedure in 1979, rising to 32% in 2006. The most common surgical procedures were lower extremity joint replacement, open reduction internal fixation, and cholecystectomy. The most common concurrent diagnosis was femoral neck fracture. Women with femoral neck fracture were more likely to undergo open reduction internal fixation compared to joint replacement. AARs for ORIF fell from 4.3 to 3.2 (p=.02) from 1979 to 2006, while AARs for joint replacement increased from 0.2 to 3.4 (p≤.001, 1979-1988; p=.14, 1990-2006). CONCLUSIONS: The rate of women age≥65 years undergoing inpatient procedures has increased dramatically in the last 30 years. Hip fracture was the most common diagnosis for elderly women, highlighting the impact of osteoporosis and falls and the importance of prevention strategies and optimization of peri-operative care in this population. Further comparative study of hip fracture treatment strategies in this population is needed.

Effect of a preoperative self-catheterization video on anxiety: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to determine if a clean intermittent self-catheterization (CISC) instructional video could improve anxiety in women undergoing prolapse and/or incontinence surgery. METHODS: A total of 199 women were randomized to preoperative CISC video or routine counseling prior to prolapse/incontinence surgery. Patient anxiety, satisfaction, and concerns about CISC were evaluated using the State-Trait Anxiety Inventory-State (STAI-S) and study-specific visual analog scale (VAS) questions at four perioperative time points. RESULTS: STAI-S and VAS anxiety measures were similar at baseline between groups; no significant differences were seen by group at any time point. STAI-S scores varied considerably over time, with highest scores at voiding trial failure and lowest scores at postoperative visit. Women in the video group had improved STAI-S scores and reported less worry and more comfort with CISC immediately following video viewing. Women with anxiety/depression had higher STAI-S scores at voiding trial failure and discharge and reported less anxiety reduction following video viewing compared to non-anxious/non-depressed peers. CONCLUSIONS: Women undergoing prolapse/incontinence surgery have significant perioperative anxiety, which is exacerbated by voiding trial failure. Preoperative CISC video viewing decreases anxiety scores immediately following viewing, but this effect is not sustained at voiding trial failure. Women with baseline anxiety/depression exhibit less anxiety score improvement after video viewing and have overall higher anxiety scores perioperatively.

Midurethral sling for treatment of occult stress urinary incontinence at the time of colpocleisis: a decision analysis.

OBJECTIVE: The objective of this study was to estimate optimal timing for treatment of occult stress urinary incontinence in women undergoing colpocleisis using decision analysis methodology. METHODS: A decision tree was constructed comparing concomitant versus staged midurethral slings (MUSs). Simple roll-back methodology was used to determine average 1-year utilities of the compared approaches. RESULTS: One-year overall utility favored the staged approach to treating occult incontinence (0.945 vs 0.908) at time of colpocleisis. However, this difference was less than the accepted minimally important difference for utilities. Multiple 1-way sensitivity analyses of all utilities and probabilities identified few thresholds, confirming model robustness. In our model, only 22.5% of women in the staged group ultimately underwent MUS. CONCLUSIONS: Staged and concomitant MUSs have similar overall utilities. Both strategies are clinically reasonable, and surgical decision making should be tailored to individual patient needs and preferences. In our model, a staged approach greatly reduces the number of MUS performed.

Body image perceptions in women with pelvic organ prolapse: a qualitative study.

OBJECTIVE: To describe perceptions of prolapse-specific body image in women with symptomatic prolapse. STUDY DESIGN: Women with symptomatic pelvic organ prolapse quantification stage ≥ II prolapse participated in semistructured focus groups or self-report questionnaire. Transcripts were independently reviewed and body image themes were identified and confirmed by consensus. RESULTS: Twenty-five women participated in focus groups and 27 in online questionnaires. Transcript analysis revealed 3 central themes and 25 body-image related subthemes. Women living with prolapse were more likely to feel self-conscious, isolated, "different," less feminine, and less attractive. Women often changed sexual intimacy practices because of embarrassment or discomfort, and many avoided intimacy all together. Prolapse greatly affected women's personal and professional activities causing some women to adjust routines or stop activities. Women reported loss of interest in activities, distraction while performing daily/work-related tasks, and embarrassment when asking for help with activities. CONCLUSION: Themes identified in this qualitative study demonstrate the profound effect of prolapse on a woman's body image.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures.

OBJECTIVES: To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a woman's lifespan. METHODS: Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed. RESULTS: More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a woman's lifetime. CONCLUSION: Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women. LEVEL OF EVIDENCE: III.

Trends in inpatient prolapse procedures in the United States, 1979-2006.

OBJECTIVE: We sought to describe national trends for inpatient procedures for pelvic organ prolapse from 1979-2006. STUDY DESIGN: The National Hospital Discharge Survey was analyzed for patient and hospital demographics, as were International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedures codes from 1979-2006. Age-adjusted rates (AARs) per 1000 women were calculated using the 1990 US Census data. RESULTS: There was a significantly decreasing trend in the AARs for inpatient prolapse procedures, from 2.93-1.52 per 1000 women from 1979-2006. AARs for hysterectomy decreased from 8.39-4.55 per 1000 women from 1979-2006. Over the study period, AARs remained at about the 1979 level among the women>or=52 years old (2.73-2.86; P=.075). In women<52 years old, AARs declined to less than one-third of the 1979 rate (3.03-0.84; P<.001). CONCLUSION: AARs for inpatient procedures for prolapse in the United States remained stable for women aged>or=52 years from 1979-2006; rates declined by two-thirds for women aged<52 years.

Prophylactic bilateral oophorectomy or removal of remaining ovary at the time of hysterectomy in the United States, 1979-2004.

OBJECTIVE: The purpose of this study was to describe national rates and trends of prophylactic bilateral oophorectomy or remaining oophorectomy (BO/RO) at hysterectomy in women without specific gynecologic disease. STUDY DESIGN: Data from the National Hospital Discharge Survey were analyzed for 1979-2004. Hysterectomies were divided into 2 groups: (1) hysterectomy with BO/RO and (2) hysterectomy alone (> or =1 ovary remaining). Age-adjusted rates (AARs) were calculated with 2000 US census data. RESULTS: Approximately 3,686,000 hysterectomies with BO/RO were performed from 1979-2004. AARs of hysterectomy with BO/RO decreased during this period; the AARs in women > or =50 years old increased. The number of hysterectomies alone was 5,461,100, and AARs of hysterectomy alone decreased significantly from 2.9 per 1000 women in from 1979-1981 to 1.1 per 1000 women in 2001 (P < .001). The proportion of women who underwent hysterectomy with BO/RO increased from 29% in 1979 to 45% in 2004. CONCLUSION: Although AARs of prophylactic BO/RO decreased from 1979-2004, the actual proportion of BO/RO at hysterectomy increased.