Randomized controlled trial of the effect of environment on patient embarrassment and anxiety with urodynamics.

INTRODUCTION AND HYPOTHESIS: In previous survey studies, women undergoing urodynamic testing (UDT) have reported bother and embarrassment and have provided suggestions for improving the experience. The suggestions include audio distraction and increased privacy, neither of which have been prospectively examined. We report a prospective randomized controlled trial to evaluate the hypothesis that an improved ambience can decrease UDT-related embarrassment and anxiety. METHODS: A total of 60 participants were recruited to achieve an 80% power to detect a conservative 20-point difference with a significance level of 0.05. Eligible participants were randomized to one of two conditions: dim lighting with light instrumental music (modified group, 30 patients), or no music and standard lighting (standard group, 30 patients). The aim of the dim lighting and music was to provide an increased sense of privacy and audio distraction based on participant feedback in previous studies. RESULTS: The study was complete with 60 participants. Patients in both groups reported less embarrassment after UDT. However, patients in the modified group showed a greater decrease in embarrassment scores (9.72 mm) than patients in the standard group (1.3 mm; p = 0.33). Although the study was under-powered, the difference found approached clinical significance. CONCLUSIONS: Simply dimming the lights and providing music during UDT resulted in a decrease in embarrassment scores of almost ten points. This low-cost and simple measure improved patient experience.

Review of the diagnosis, management and treatment of fecal incontinence.

Fecal incontinence is a common problem affecting women but is underreported because of patients' reluctance to discuss their symptoms and an inconsistent use of screening tools by physicians. Obstetric injury from vaginal delivery is the principal cause of fecal incontinence among young women. Prevalence rates are highest in the elderly, especially those with declining cognitive function. There are multiple diagnostic tests including anal manometry, endosonography, defecography, and pudendal nerve latency testing to assist physicians in the workup of patients and aid in the selection of appropriate treatment options. After patient identification and workup, most patients can be offered conservative measures including dietary measures and biofeedback. Surgery is indicated for specific abnormalities such as rectal prolapse, fistula, and recent obstetrical sphincter injury repair. Management of refractory cases may include sacral nerve stimulation and percutaneous tibial nerve stimulation. Fecal diversion or an artificial bowel sphincter may be considered when all else has failed. Primary care physicians, gynecologists, and specialists in female pelvic medicine should screen women for fecal incontinence. Initial conservative therapy may be directed by the primary health provider, and those resistant to this approach should be referred to specialist care.

Modified approach to vaginal hysterectomy without initial colpotomy.

PURPOSE OF REVIEW: To evaluate the surgical technique and outcomes of women undergoing the modified approach to vaginal hysterectomy at Harbor-University of California, Los Angeles Medical Center from 2000 to 2011. A retrospective chart review was performed of all vaginal hysterectomy cases performed using the modified technique. RECENT FINDINGS: There is much evidence in favor of the safety of vaginal hysterectomy over other modes of hysterectomy, such as the lower overall incidence of vaginal cuff dehiscence, shorter hospital stays and faster recovery from surgery. The traditional method of performing vaginal hysterectomy involves early anterior or posterior colpotomy. At times, this may be difficult secondary to a flush cervix, distorted anatomy, and adhesions from prior surgeries or infection. At our teaching institution, however, we have adopted a different technique, initially developed by Dr. Reza Mohajer who is one of our faculty members and co-author of this article, that facilitates ligation of uterine vessels without initial attempt at colpotomy. This enables Ob/Gyn residents to safely and successfully perform vaginal hysterectomies despite large uterine size, nulliparity, flush cervix and previous pelvic surgery. SUMMARY: Modified approach to difficult vaginal hysterectomy facilitates performance of vaginal hysterectomy without need for initial anterior or posterior colpotomy.

Urogenital fistula.

This review summarizes the available evidence in the literature on the etiology, diagnosis, management, and prevention of vesicovaginal, urethrovaginal, ureterovaginal, vesicocervical, and vesicouterine fistulae. Urogenital fistula is divided by origin: obstetric fistula occurring predominantly in developing countries and iatrogenic fistula, the most common cause in developed countries.

A pilot study of women's knowledge of pregnancy health risks: implications for contraception.

BACKGROUND: This study was performed to assess women's knowledge of the health risks of pregnancy and how their assessment of pregnancy risks compared to their estimates of the risks of oral contraceptives. STUDY DESIGN: A survey, which asked both open-ended and specific questions about the health benefits and risks of pregnancy, was administered verbally on a one-on-one basis to nonpregnant, English-speaking, reproductive-age women. RESULTS: Of the 248 women who provided information for analysis, over one quarter of women could not correctly name any health risk associated with pregnancy. When shown a list of potential health risks, only 13.3% correctly identified all the health problems that increased in pregnancy. Only 49% knew that risks of venous thromboembolism (VTE), diabetes and hypertension increase in pregnancy; 30.6% did not know that VTE risk increases. Over 75% of respondents rated birth control pills as more hazardous to a woman's health than pregnancy. The greater the women's education, the more likely she was to believe that oral contraceptives are riskier than pregnancy. CONCLUSION: This pilot project clearly demonstrates a need to assess women's understanding of the health hazards of pregnancy on a national level. Underestimation of pregnancy risks can lead to contraceptive method discontinuation, can decrease motivation to seek preconceptional care and can lead to greater medicolegal liability for providers of obstetrical care.

Uterosacral ligament vaginal vault suspension using delayed absorbable monofilament suture.

INTRODUCTION AND HYPOTHESIS: We investigated the incidence of suture complications and recurrent prolapse following uterosacral ligament suspension (USLS) using delayed absorbable polyglyconate monofilament suture (Maxon). METHODS: We reviewed the medical records of subjects who underwent vaginal USLS using polyglyconate suture. Primary outcomes were suture complications and anatomic failures defined as recurrent apical prolapse stage 1 or greater. Secondary outcomes were subjective failures and reoperation rate for apical prolapse. RESULTS: Fifty-seven out of 68 subjects who underwent USLS with polyglyconate suture over the study period were included in analysis. At median follow-up of 12 months, 3.5% had suture complications. The anatomic and symptomatic failure rate was 7%. One subject underwent repeat surgery for prolapse. CONCLUSIONS: Suture complications are uncommon using polyglyconate suture for USLS, and failure rates are low. This is in comparison to a 44.6% suture erosion rate with permanent suture reported by our institution using the same surgical technique.