Postoperative Prescribing Practices Following Gynecologic Surgery.

BACKGROUND: Opioids prescribed for postoperative pain have exceeded patient need in the United States, playing a significant role in the opioid epidemic. In the preintervention phase of this project (September 2018 - March 2019), a chart review and patient survey revealed that patients were prescribed double the number of opioids they consumed following gynecologic surgery. OBJECTIVE: To ascertain whether an educational intervention recommending opiate prescriptions based on postoperative opioid use decreases gynecologic surgeons' opiate prescriptions. METHODS: An educational intervention implemented in January 2021 communicated the discrepancy between patient need and medications prescribed and made prescribing recommendations for common gynecologic procedures. A postintervention (February 2021 - April 2021) retrospective chart review ascertained postoperative opioid prescribing practices. Residents were surveyed about their prescribing practices in June 2021. Descriptive statistics compared each phase. RESULTS: For laparoscopic hysterectomy, the median morphine milligram equivalent (MME) was 150 (IQR 112.5-166.9) for preintervention and 150 (IQR 112.5-150) postintervention. For vaginal hysterectomy, median MME declined from 150 (IQR 112.5-225) to 112.5 (IQR 112.5-150). For laparoscopic surgery without hysterectomy, the median MME was 75 for both preintervention (IQR 75-120) and postintervention (IQR 60-80). For vaginal surgery without hysterectomy median MME went from 75 (IQR 75-142.5) to 54 (IQR 22.5-112.5). Median MME for hysteroscopy and dilation and curettage was 0 for both phases. When surveyed, residents reported prescribing lower amounts than actual prescribing practices. CONCLUSIONS: Despite education informing gynecologic surgeons that their opioid prescribing exceeded patient need, prescribing practices did not change. The difference between actual and resident-reported prescribing practices warrants further investigation.

Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry.

OBJECTIVE: The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research. STUDY DESIGN: This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy). RESULTS: A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036). CONCLUSION: Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Men and women experience different barriers to care seeking for fecal incontinence.

BACKGROUND: Despite effective treatments for fecal incontinence (FI), FI remains underdiagnosed and undertreated. This study sought to characterize and compare rates of, delays in, experiences with, and barriers to care seeking for FI among men and women. METHODS: This study was a secondary analysis of electronic survey data collected from adults with FI. The survey included the use of a validated instrument to assess FI severity and questions that now comprise a validated instrument for assessing barriers to care seeking for FI in women. Descriptive analyses characterized differences between men and women. χ2 testing for categorical variables and t-testing for normally distributed continuous variables compared statistical differences. RESULTS: The sample (N = 548) was predominately female (84%), non-Hispanic White (90%), and insured (96%), with a mean Vaizey score (13.4 ± 5.3) consistent with moderate or severe FI. Care seeking rates (p = 0.81) and symptom duration before care seeking (p = 0.23) did not differ between women and men, but women were more likely than men to be told that effective treatments exist; most male and female respondents who sought care were offered treatment. Very few respondents had been asked about FI by a healthcare provider. Whereas normative thinking, limited life impact, and believing that a healthcare provider could not help were more common barriers to care seeking among men, avoidance, fear, and discouragement were more common in women. CONCLUSIONS: Men and women with FI seek care at similar rates and after experiencing symptoms for a similar duration of time. Very few patients with FI have been screened for it by a healthcare provider. Barriers to FI care seeking are different for women and men, and men are less likely than women to be informed about effective treatments by a healthcare provider.

Fecal Incontinence and the Risk of Urinary Tract Infection in Patients Presenting for Urogynecological Consultation.

IMPORTANCE: Urinary tract infection (UTI) is common in urogynecology patients. Patients with fecal incontinence (FI) often attribute their UTIs to FI, but this association has not been evaluated. OBJECTIVES: The objectives of this study were to compare the prevalence of UTI in urogynecology patients with and without FI and to characterize factors associated with UTI and recurrent UTI. STUDY DESIGN: This retrospective cohort study included all new adult patients who presented to an academic female pelvic medicine and reconstructive surgery practice with FI from January 2014 through December 2017. Patients were age-matched to new adult patients with stage <2 pelvic organ prolapse without FI. All urine culture results from 1 year before and 1 year after the first visit were identified. Logistic regression identified factors associated with UTI. RESULTS: Among 399 patients, 106 (27%) had a culture-confirmed UTI in the year before or after their first urogynecology visit; the prevalence of UTI was 23% (45/198) in patients with FI and 30% (61/201) in those without FI (P = 0.09). The rate of recurrent UTI was 11.5% overall and did not differ among those with and without FI. In multivariate models, variables that were statistically significantly associated with UTI included age, diabetes mellitus, anterior vaginal wall prolapse, and sexual activity. Fecal incontinence was not associated with any or recurrent UTI. CONCLUSIONS: The prevalence of UTI and recurrent UTI was similar in urogynecology patients with and without FI. Variables that were associated with UTI risk included older age, sexual activity, diabetes mellitus, and anterior vaginal wall prolapse.

Etiology and factors associated with urogenital fistula among women who have undergone cesarean section: a cross-sectional study.

BACKGROUND: The prevalence and impact of fistulas are more common in developing countries with limited access to emergency obstetric care. As a result, women in these settings often experience adverse psychosocial factors. The purpose of this study was to describe the characteristics of Congolese women who developed urogenital fistula following Cesarean sections (CS) to determine the characteristics associated with two etiologies: (1) prolonged obstructed labor; and (2) a complication of CS following obstructed labor. METHODS: We performed a cross-sectional study on abstracted data from all patients with urogenital fistula following CS who received care during a surgical campaign in a remote area of the Democratic Republic of the Congo (DRC). Descriptive analyses characterized patients with fistula related to obstructed labor versus CS. Univariate and multivariate logistic regression models identified factors associated with obstetric fistula after cesarean delivery following obstructed labor. Variables were included in the logistic regression models based upon biological plausibility. RESULTS: Among 125 patients, urogenital fistula etiology was attributed to obstructed labor in 77 (62%) and complications following CS in 48 (38%). Women with a fistula, attributed to obstructed labor, developed the fistula at a younger age (p = .04) and had a lower parity (p = .02). Attempted delivery before arriving at the hospital was associated with an increased risk of obstetric fistula after cesarean delivery following obstructed labor (p < .01). CONCLUSION: CS are commonly performed on women who arrive at the hospital following prolonged obstructed labor and fetal demise, and account for almost 40% of urogenital fistula. Obstetric providers should assess maternal status upon arrival to prevent unnecessary CS and identify women at risk of developing a fistula.

Validation of the Surgical Preparedness Assessment in women with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: We sought to further develop and validate the Surgical Preparedness Assessment (SPA) scale to evaluate patient preparedness for urogynecological surgery. METHODS: This was a planned ancillary analysis of a randomized controlled trial (RCT) evaluating the impact of a preoperative telehealth call on patient preparedness for urogynecological surgery. Patients completed the Preoperative Preparedness Questionnaire (PPQ), the modified Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ), the Pelvic Floor Distress Inventory (PFDI-20), the Satisfaction Decision Scale (SDS), and the Decision Regret Scale (DRS). Content validity was established through expert opinion and patient cognitive interviews. Factor analysis identified item grouping into domains. Cronbach's alpha reported internal consistency. Known group validity was assessed by comparing intervention arms. External validity was evaluated by comparing intervention arms and correlations with SDS and DRS. RESULTS: Eleven items and 3 domains met the criteria (information needs, satisfaction and pain, and catheterization). Cronbach's alpha values were acceptable for domains and ranged from 0.74 to 0.93. SPA scores did not correlate with other patient-reported outcomes. Mean SPA scores were lower among women who received a telehealth call vs those who did not (1.30 ± 0.31 vs 1.51 ± 0.44; p = 0.002). CONCLUSIONS: The content-valid SPA demonstrates high internal consistency and known group validity.

Screening and Treating Urinary Incontinence in Primary Care: A Missed Opportunity.

More than 60% of adult women in the United States have urinary incontinence (UI), with the prevalence increasing to over 80% in women over age 65. Despite its high prevalence, most patients do not seek care and few clinicians screen for UI. The Medicare Health Outcomes Survey queries patients about satisfaction with their provider's discussion and management of UI, but formal recommendations about screening, diagnosis, and treatment are lacking. This review presents a practical algorithm for primary care providers to incorporate management of UI into routine preventive care for women, and outlines UI prevalence, risk factors, screening, and non-surgical treatment options.

Outcomes of Pessary Use at 1 Year in Women Treated for Pelvic Organ Prolapse in a Large Multicenter Registry: Developed by the Pelvic Floor Disorders Registry.

IMPORTANCE: There is a lack of high-quality long-term follow-up regarding pessary treatment. Most studies are case series or retrospective with a small sample size and short-term follow-up. OBJECTIVES: This study aimed to evaluate differences in women who continue versus discontinue pessary use and the effectiveness, quality of life, and safety associated with pessary management at 1 year. STUDY DESIGN: This study analyzed a multicenter national registry following women for 3 years with vaginal prolapse treated with a pessary or surgery. The primary outcome of this analysis was to compare the difference in characteristics among those who continue versus discontinue pessary use at 12 months. RESULTS: Among 1,153 participants enrolled, 376 (32.6%) opted for a pessary, and 296 (78.7%) were successfully fitted. Data were available for 240 participants (81%). At 1 year, 62% (n = 148) were still using pessaries, and 38% (n = 92) had stopped with 25% opting for surgery. Most commonly reported de novo adverse effects were urinary leakage (16%), feeling or seeing a bulge (12%), and vaginal discharge (11%). There was no difference in baseline characteristics among women who continued versus discontinued pessary use. At 12 months, subjective symptoms were similar between groups, with similar change in symptoms from baseline on most validated instruments. Those who continued to use a pessary reported worse urinary symptoms due to de novo urinary leakage ( P = 0.01). CONCLUSIONS: At 1 year, most women successfully fitted with a pessary continued pessary use. Although there was a significant improvement in condition-specific quality of life and low rates of complications, approximately 40% of women discontinued pessary use by 12 months. We were unable to identify any baseline characteristics associated with pessary discontinuation.

International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs.

INTRODUCTION AND HYPOTHESIS: This narrative review describes the existing epidemiologic literature and identifies gaps regarding pelvic organ prolapse (POP) prevalence, incidence, natural history, and current and future service needs. MATERIALS AND METHODS: A PubMed search identified relevant citations published in 2000 or later. Pre-specified criteria were used to screen titles, abstracts, and manuscripts, including reference sections. Study findings were summarized to define what is known, identify gaps in current knowledge, and suggest priority areas for future research. RESULTS: The reported prevalence of POP varies widely (1-65%) based on whether its presence is ascertained by symptoms (1-31%), pelvic examination (10-50%), or both (20-65%). Most existing population-based surveys do not include physical examination data. White women from higher income countries are overrepresented in the existing literature. Incidence and natural history data are limited and consist mainly of cohorts that follow women after pregnancy or menopause. Given global increases in aging populations in well-resourced countries, the need for POP treatment is anticipated to increase in the coming decades. In lower and middle income countries (LMICs) where demographic trends are different, there is a dearth of information about anticipated POP service needs. CONCLUSION: Future POP incidence, prevalence, and natural history studies should include non-white women from LMICs and should combine pelvic examination data with validated patient-reported outcome measures when feasible. Anticipated future service needs differ globally, with a greater demand for POP treatment services in well-resourced settings where aging populations are prevalent.

Updated Prevalence of Urinary Incontinence in Women: 2015-2018 National Population-Based Survey Data.

OBJECTIVES: This study aimed to update estimates of urinary incontinence (UI) prevalence and associated risk factors for adult women in the United States, using the National Health and Nutrition Examination Survey (NHANES). METHODS: We used descriptive analysis of 2015-2018 NHANES weighted data for women to estimate prevalence and characterize UI types and severity. Logistic regression modeling determined adjusted associations with UI. RESULTS: Complete data were available for 5,006 women. In weighted analyses, 61.8% had UI, corresponding to 78,297,094 adult U.S. women, with 32.4% of all women reporting symptoms at least monthly. Of those with UI, 37.5% had stress urinary incontinence, 22.0% had urgency urinary incontinence, 31.3% had mixed symptoms, and 9.2% had unspecified incontinence. The prevalence of moderate or more severe UI by Sandvik Severity Index was 22.1%, corresponding to 28,454,778 adult U.S. women. In multivariate models, increasing age, body mass index ≥25, prior vaginal birth, anxiety, depression, functional dependence, and non-Hispanic White ethnicity and race were associated with any and moderate UI. Urinary incontinence was not associated with diabetes, education level, prior hysterectomy, smoking status, physical activity level, or current pregnancy status. CONCLUSIONS: More than 60% of community-dwelling adult women in the United States experience any UI and an increase from prior estimates (38%-49%) using NHANES data from 1999 to 2004; more than 20% experience moderate or more severe UI. Increases in UI prevalence may be related to population aging and increasing obesity prevalence. Age greater than 70 years, body mass index >40, and vaginal birth had the strongest association with UI in multivariate modeling.

Can We Trust the Math? Correlation of Objective Postvoid Residual With Calculated Subtraction Postvoid Residual.

OBJECTIVE: The aim of the study was to determine the accuracy of postvoid residual (PVR) by subtraction as compared with objective measurement by bladder scan or catheterization. METHODS: This is a secondary analysis of postoperative patients who underwent avoiding trial by retrograde bladder instillation. Fill volume, spontaneous voided volume, and PVR were objectively measured; PVR was also calculated. Pearson correlation compared PVR by subtraction versus objective measurement. We then defined postoperative urinary retention (POUR) at 3 different PVR values (100 mL, 150 mL, and 200 mL) to compare the sensitivity, specificity, and positive and negative predictive values of subtraction for detecting urinary retention at these 3 thresholds. RESULTS: Data were available for 155 patients after urogynecologic surgery. Median PVR by objective measurement was 46 mL (interquartile range = 11-146 mL). Median calculated PVR by subtraction was 10 mL (interquartile range = 0-100 mL). Objective measure and subtraction PVR values were strongly correlated (Pearson coefficient = 0.78, P < 0.001). Using a threshold of 200 mL to define POUR resulted in the highest negative predictive value and the lowest absolute number of both false negatives and false positives. Even using this threshold, 11 (48%) of 23 women with POUR by measurement were misclassified as not having POUR when ascertained by subtraction. CONCLUSIONS: Although subtraction PVR correlates well with objective PVR measurement, almost half of women with a PVR volume of greater than 200 mL by objective measurement are miscategorized as voiding normally by subtraction PVR. Based on these findings, reliance on objective PVR measurement in postoperative patients is preferable to subtraction PVR.

A telehealth intervention to increase patient preparedness for surgery: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Methods to increase surgical preparedness in urogynecology are lacking. Our objective was to evaluate the impact of a preoperative provider-initiated telehealth call on surgical preparedness. METHODS: This was a multicenter randomized controlled trial. Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence were randomized to either a telehealth call 3 (± 2) days before surgery plus usual preoperative counseling versus usual preoperative counseling alone. Our primary outcome was surgical preparedness, as measured by the Preoperative Prepardeness Questionnaire. The Modified Surgical Pain Scale, Pelvic Floor Distress Inventory-20, Patient Global Impressions of Improvement, Patient Global Impressions of Severity, Satisfaction with Decision Scale, Decision Regret Scale, and Clavien-Dindo scores were obtained at 4-8 weeks postoperatively and comparisons were made between groups. RESULTS: Mean telehealth call time was 11.1 ± 4.11 min. Women who received a preoperative telehealth call (n = 63) were significantly more prepared for surgery than those who received usual preoperative counseling alone (n = 69); 82.5 vs 59.4%, p < 0.01). A preoperative telehealth call was associated with greater understanding of surgical alternatives (77.8 vs 59.4%, p = 0.03), complications (69.8 vs 47.8%, p = 0.01), hospital-based catheter care (54 vs 34.8%, p = 0.04) and patient perception that nurses and doctors had spent enough time preparing them for their upcoming surgery (84.1 vs 60.9%, p < 0.01). At 4-8 weeks, no differences in postoperative and patient reported outcomes were observed between groups (all p > 0.05). CONCLUSIONS: A short preoperative telehealth call improves patient preparedness for urogynecological surgery.

Prevalence of urinary incontinence in pregnant and postpartum women in the Democratic Republic of Congo.

INTRODUCTION AND HYPOTHESIS: The objective was to describe the prevalence of urinary incontinence in pregnant and postpartum women in the Democratic Republic of Congo and to identify factors associated with urinary incontinence (UI) in these populations. METHODS: We interviewed eligible women who sought prenatal or postnatal reproductive health clinic consultations over a 2-year period. Interviews collected information about demographics, obstetric history, and urinary incontinence symptoms, as well as the impact on the quality of life, via a validated questionnaire. Descriptive analyses compared women with and without urinary incontinence and compared characteristics of UI, stratified by pregnancy status. Logistic regression identified factors associated with UI among the entire sample, pregnant women, and postpartum women. RESULTS: Overall, 268 out of 880 women had UI (30.5%); the prevalence was 33.4% (168 out of 503) among pregnant women and 26.5% (100 out of 377) among postpartum women, p = 0.03. Women who were pregnant were significantly more likely to experience stress incontinence (p = 0.01) and less likely to report moderate or large amounts of leakage (p = 0.002). A history of macrosomia and being currently pregnant were associated with UI in the entire sample (p < 0.05). Among pregnant women, the risk of UI decreased with increasing gestational age and increased with a history of macrosomia (p ≤ 0.01). Among postpartum women, a history of macrosomia and prior episiotomy were associated with UI (p < 0.05). CONCLUSIONS: Urinary incontinence is prevalent in pregnant and postpartum women in the Democratic Republic of Congo and is associated with a history of macrosomia. Efforts should focus on screening, evaluation, and treatment.

Generic Health-Related Quality of Life in Patients Seeking Care for Pelvic Organ Prolapse.

OBJECTIVE: Using the American Urogynecologic Society multicenter Pelvic Floor Disorder Registry for Research, we (1) compared generic quality of life (QOL) in women planning pelvic organ prolapse (POP) treatment (surgery vs pessary), (2) correlated generic and condition-specific QOL scores, and (3) identified associations between generic QOL and other factors. METHODS: This cross-sectional analysis assessed generic physical and mental QOL using the Patient-Reported Outcomes Measurement Information System Global Health Scale at baseline. Global Physical and Mental T-scores center on a representative US population sample (mean [SD], 50 [10]; higher scores, better health). Condition-specific QOL was assessed with Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and POP/Urinary Incontinence Sexual Function Questionnaire. Linear regression models identified associations between clinical factors and Global Physical/Mental scores. RESULTS: Five hundred sixty-eight women (419 surgery, 149 pessary) were included. Surgery patients were younger, heavier, and more often sexually active (all P's ≤ 0.01). Global Physical scores were lower in the surgery versus pessary group, but not likely clinically meaningful (mean [SD], 48.8 [8.1] vs 50.4 [8.5]; P = 0.035); Global Mental scores were similar (51.4 [8.4] vs 51.9 [9.5], P = 0.56). Global Health scores correlated with Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and POP/Urinary Incontinence Sexual Function Questionnaire scores (all P's < 0.0001). In multivariable models, menopause was associated with better physical QOL, and constipation, coronary artery disease, pelvic pain, and increased body mass index with worse physical QOL. Age was associated with better mental QOL, and constipation, fecal incontinence, pelvic pain, and coronary artery disease with worse mental QOL. CONCLUSIONS: Women choosing POP surgery versus pessary had similar physical and mental generic QOL.

Rethinking Bias to Achieve Maternal Health Equity: Changing Organizations, Not Just Individuals.

In this article, we address the limitations of existing implicit bias interventions as a strategy for achieving maternal health equity. We then focus on how institutionally sanctioned racial stereotyping harms Black maternal health and marginalizes a key group in the fight for health equity-Black physicians. Finally, we provide strategies to address racial bias in perinatal health care and structural barriers impeding Black physicians' success.

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.

Management of Fecal Incontinence.

Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.