A randomized trial comparing perioperative pelvic FLOor physical therapy to current standard of care in transgender Women undergoing vaginoplasty for gendER affirmation: the FLOWER Trial.

INTRODUCTION AND HYPOTHESIS: There are sparse data on the use of postoperative pelvic floor physical therapy (PFPT) in patients undergoing vaginoplasty. The primary objective of this study was to compare the impact of PFPT on the ease of vaginal dilation after vaginoplasty in transgender women. We hypothesized that patients undergoing PFPT would report better ease of vaginal dilation following surgery. METHODS: This was a randomized trial of transgender women undergoing vaginoplasty. Patients were randomized to either no PFPT or PFPT 3 and 6 weeks following surgery. Subjects completed the Pelvic Floor Disorders Inventory and the Pelvic Floor Impact Questionnaire at baseline and at 12 weeks. At 12 weeks, subjects underwent vaginal length measurement and completed the Patient Global Impression of Improvement and a visual analogue scale (0-10) for ease of vaginal dilation and pain with dilation. A total of 17 subjects in each arm were needed to detect a significant difference in ease of dilation between the two groups. RESULTS: Forty-one subjects were enrolled and 12-week data were available for 37 subjects (20 PFPT, 17 no PFPT). Mean age and BMI were 31 ± 13 years and 24.9 (± 4.0) kg/m2. Subjects were on hormone therapy for a median of 39 (20-240) months and 5 (13.5%) patients had undergone previous orchiectomy. At 12 weeks, the median vaginal length was 12.5 (10-16) cm, reported mean ease of dilation was 7.3 (± 1.6), and pain with dilation was 2.4 (± 1.7). There were no differences in these outcomes or in pelvic floor symptoms between the groups. CONCLUSIONS: In this study, routine postoperative PFPT did not improve outcomes in patients undergoing vaginoplasty.

Postoperative adverse events following gender-affirming vaginoplasty: an American College of Surgeons National Surgical Quality Improvement Program study.

BACKGROUND: As a part of gender-affirming care, many transgender women undergo vaginoplasty surgery, which is increasingly being performed in the United States. There are considerable knowledge gaps about adverse events associated with vaginoplasty as most published articles report single-center results. OBJECTIVE: This study aimed to describe severe and overall 30-day adverse events after gender-affirming vaginoplasty using a large multicenter database. STUDY DESIGN: This was a retrospective cohort study of transgender women who underwent vaginoplasty between 2011 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were initially identified by diagnosis codes for gender identity disorders and procedure codes for male-to-female vaginoplasty. Adverse events at 30 days were identified, including unplanned reoperation or readmission, blood transfusion, wound dehiscence, surgical site infections, thromboembolic disease, sepsis, cerebrovascular or cardiac events, and urinary tract infection. Surgical procedures were further stratified by Clavien-Dindo grade, a standardized classification system for registering surgical complications. A score of 0 is given if there is no adverse event, whereas scores of 1 and 2 refer to deviations from the normal postoperative course, which may include additional pharmacologic treatment, bedside-managed wound complications, and blood transfusions. Clavien-Dindo grades of 3 to 4 include surgical interventions or life-threatening complications requiring intensive care unit management. A Clavien-Dindo grade of 5 is given for any complication resulting in death. RESULTS: A total of 488 cases were eligible for inclusion in this study. The mean age of the cohort was 37.5 years, and race distribution was as follows: 71.1% White, 15.2% Black, 5.5% Asian or Pacific Islander, and 8.2% other. Of the cohort, 18.6% were Hispanic. Surgeries were performed by plastic surgeons (87.9%), urologists (8.6%), gynecologists (1.8%), and other specialists (1.6%). Concurrent nongenital surgery was performed in 17% of cases. The median operative time for all cases was 271 minutes (interquartile range, 214-344). There was no reported death in the 30-day period (Clavien-Dindo grade 5), and 27 cases (5.5%) had a Clavien-Dindo grade of 3 to 4. On multivariate analysis, body mass index and higher American Society of Anesthesiologists class were associated with higher odds of having a Clavien-Dindo grade of 3 to 4 (adjusted odds ratios, 2.9 [95% confidence interval, 1.32-4.21; P=.01] and 1.23 [95% confidence interval, 0.56-2.57; P=.05], respectively). Wound dehiscence, superficial surgical site infection, or deep surgical site infection occurred in 46 cases (9.0%). The readmission rate was 4.3% (n=21). Several preoperative factors had higher odds of readmission: body mass index (adjusted odds ratio, 9.81; 95% confidence interval, 1.77-22.13; P=.005), higher American Society of Anesthesiologists class (adjusted odds ratio, 3.23; 95% confidence interval, 1.23-9.03; P=.003), diabetes mellitus (adjusted odds ratio, 5.39; 95% confidence interval, 1.42-20.45; P=.006), and hypertension (adjusted odds ratio, 3.63; 95% confidence interval, 1.26-10.47; P=.01). The reoperation rate was 4.7% (n=23), with no significant patient factor associated with this complication. Of the reoperations, 68.2% of cases were due to wound problems, vaginal bleeding, or hematoma. CONCLUSION: In transgender women undergoing vaginoplasty for gender affirmation, severe postoperative complications were rare, occurring in 1 of 20 patients. Most patients experienced minor complications or no complication after surgery.

Antimicrobial activity of synthesized graphene oxide-selenium nanocomposites: A mechanistic insight.

Nanoparticles have recently gained interest as an anti-bacterial agent due to their large surface area/volume ratio and potential to compromise the integrity of bacterial cell membranes. Due to its versatility and anti-bacterial activity, graphene-based materials have drawn significant interest in biomedical applications. One of the greatest threats to life in the modern technological era is the pervasiveness of infectious diseases since bacteria cells are constantly updating themselves to resist antibiotics. In this presented study, GO-Se nanocomposite has been synthesized using polymer solution via a simple dispersion method. The structural and physicochemical properties of nanocomposite were investigated in detail. Staphylococcus aureus, Proteus vulgaris, and Bacillus subtilis bacterial strains were employed to study the anti-bacterial activity of GO-Se nanocomposite. The results show that the synthesized nanocomposites have good efficacy as an anti-bacterial agent. UV-vis spectroscopy, FTIR spectroscopy, HRTEM, XPS, and Raman spectroscopy were used to analyze the as-prepared GO and GO-Se nanocomposite.

Health inequities within the field of urogynecology.

PURPOSE OF REVIEW: To summarize some of the most recent evidence on disparities in the prevalence, treatment and outcomes of pelvic floor disorders (PFDs), and to address potential interventions to dismantle these inequities. RECENT FINDINGS: There is a paucity of data on the prevalence and treatment of PFDs in racial minority women. The existing studies are limited and poor quality. These studies suggest that racial and ethnic minorities may be at a higher risk of PFDs, however the epidemiologic data regarding prevalence varies by disorder and at times are conflicting. Nevertheless, the data on treatment and complications is clear. Racial and ethnic minorities are less likely to receive gold-standard treatment and are more likely to experience treatment related complications. SUMMARY: We discuss the lack of racially inclusive research that perpetuates ongoing health inequities.

Pharmacologic therapeutic options for sexual dysfunction.

PURPOSE OF REVIEW: Sexual problems are reported by up to 45% of individuals assigned female at birth. Although sexual function is a complex biopsychosocial construct, there are a number of pharmacologic treatment options aimed at addressing the changing vaginal hormonal milieu in postmenopausal individuals and moderating the excitatory and inhibitory aspects of the central nervous system in those with hypoactive sexual desire disorder. RECENT FINDINGS: The last decade has seen an increase in the number and type of pharmacologic treatment options for dysfunction primarily associated with menopause and hypoactive sexual desire disorder. Recent publications and systematic reviews have strengthened the safety data of existing FDA-approved medications as well as off-label therapies. SUMMARY: Pharmacologic treatment with local estrogen and testosterone replacement in postmenopausal individuals and with centrally-acting therapies such as flibanserin, bremelanotide, and testosterone in premenopausal individuals assigned female at birth are safe and can be used to improve sexual desire and sexual satisfaction.

Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse.

BACKGROUND: There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery. OBJECTIVE: This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity. STUDY DESIGN: This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity. RESULTS: A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02). CONCLUSION: There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.

Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Our primary objectives were to compare < 30-day postoperative complications and RP recurrence rates after RP-only surgery and combined surgery. Our secondary objectives were to determine preoperative predictors of < 30-day complications and RP recurrence. METHODS: A prospective IRB-approved cohort study was performed at a single tertiary care center from 2017 to 2020. Female patients with symptomatic RP underwent either RP-only surgery or combined surgery based on the discretion of the colorectal and FPMRS surgeons. Primary outcome measures were < 30-day complications separated into Clavien-Dindo (CD) classes and rectal prolapse on physical examination. RESULTS: Seventy women had RP-only surgery and 45 had combined surgery with a mean follow-up time of 208 days. Sixty-eight percent underwent abdominal RP repair, and 32% underwent perineal RP repair. Twenty percent had one or more complications, 14% in the RP-only group and 29% in the combined surgery group (p = 0.06). On multivariate analysis, combined surgery patients had a 30% increased risk of complications compared to RP-only surgery patients (RR = 1.3). Most of these complications were minor (14/17, 82.4%) and categorized as CD I or II, including urinary retention and UTI. Twelve percent of this cohort had RP recurrence, 11% in the RP-only group and 13% in the combined surgery group (p = 0.76). Preoperative risk factors for RP recurrence included a primary complaint of rectal bleeding (RR 5.5) and reporting stools consistent with Bristol Stool Scale of 1 (RR 2.1). CONCLUSION: Patients undergoing combined RP + POP surgery had a higher risk of complications and equivalent RP recurrence rates compared to patients undergoing RP-only surgery.

Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review.

BACKGROUND: Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise. OBJECTIVE: Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to "Terminologia Anatomica," the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding. STUDY DESIGN: From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review. RESULTS: Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. "Terminologia Anatomica" has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication. CONCLUSION: This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

A Collaborative Approach to Multicompartment Pelvic Organ Prolapse.

Multicompartment pelvic organ prolapse is common yet frequently underreported and unrecognized. Although not life-threatening, the impact on quality of life and daily functioning can be significant. Multidisciplinary evaluation and treatment with specialists in colorectal and female pelvic medicine and reconstructive surgery (FPMRS) help to identify patients who will benefit from surgical treatment of vaginal and rectal prolapse. Both abdominal and perineal combined procedures can be offered to patients with a single operation and concurrent recovery period without increasing complications.

A Millimeter-scale Single Charged Particle Dosimeter for Cancer Radiotherapy.

This paper presents a millimeter-scale CMOS 64×64 single charged particle radiation detector system for external beam cancer radiotherapy. A 1×1 µm2 diode measures energy deposition by a single charged particle in the depletion region, and the array design provides a large detection area of 512×512 µm2. Instead of sensing the voltage drop caused by radiation, the proposed system measures the pulse width, i.e., the time it takes for the voltage to return to its baseline. This obviates the need for using power-hungry and large analog-to-digital converters. A prototype ASIC is fabricated in TSMC 65 nm LP CMOS process and consumes the average static power of 0.535 mW under 1.2 V analog and digital power supply. The functionality of the whole system is successfully verified in a clinical 67.5 MeV proton beam setting. To our' knowledge, this is the first work to demonstrate single charged particle detection for implantable in-vivo dosimetry.

What to do after a mid-urethral sling fails.

PURPOSE OF REVIEW: After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated. RECENT FINDINGS: Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling. SUMMARY: MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

Oral isotretinoin and topical retinoid use in a series of young patients with ocular melanoma.

PURPOSE: To describe the first series of six young uveal melanoma (UM) patients with oral isotretinoin and/or topical retinoid therapy prior to diagnosis. OBSERVATIONS: The case series is based on clinical observations at our UM quaternary referral center. Six UM patient cases are reported, ages 16-44 years old. All had been using either oral (isotretinoin) and/or topical (tretinoin or tazarotene) retinoid treatment (3 months-~10 years) prior to or at the time of diagnosis (3 of 6 cases). All patients had ocular complaints on presentation, and the onset of certain symptoms corresponded with the course of retinoids. Other potential risk factors or relevant history included Caucasian background, cone-rod dystrophy and active smoker status (Case 2), family history of UM and pregnancy at time of diagnosis (Case 3), past smoking and possible secondary Chernobyl exposure as a baby (Case 5). All patients were treated with proton beam radiotherapy and currently have no sign of recurrent or metastatic disease. CONCLUSIONS AND IMPORTANCE: Retinoid therapy has been linked to various benign and/or reversible effects on the anterior and posterior eye, though pathophysiology remains not well understood. Uveal melanoma (UM) is a rare cancer diagnosis in young adults. We report here the first case series of young UM patients with a history of retinoid use and ocular complaints. No causal link is claimed and further systematic epidemiologic and biologic study of retinoid therapy and ocular impact may provide additional relevant data, particularly in young ocular melanoma patients.

Surgical approach, complications, and reoperation rates of combined rectal and pelvic organ prolapse surgery.

OBJECTIVES: Our primary objective was to determine rectal prolapse (RP) and pelvic organ prolapse (POP) reoperation rates and postoperative < 30-day complications after combined RP and POP surgery at a single institution. METHODS: This was an IRB-approved retrospective cohort study of all female patients who received combined RP and POP surgery at a single tertiary care center from 2008 to 2019. Recurrence was defined as the need for subsequent repeat RP or POP surgery at any point after the index surgery. Surgical complications were separated into Clavien-Dindo classes. RESULTS: Sixty-three patients were identified, and 18.3% (12/63) had < 30-day complications (55% Clavien-Dindo grade 1; 27% Clavien-Dindo grade 2; 18% Clavien-Dindo grade 4). Of patients undergoing combined abdominal RP and POP repair, no postoperative < 30-day complications were noted in the MIS group compared to 37.5% of those patients in the laparotomy group (p < 0.01). Overall, in those patients who underwent combined RP and POP surgery, the need for subsequent RP surgery for recurrent RP was 14% and the need for subsequent POP surgery for recurrent POP was 4.8% (p = 0.25). CONCLUSION: In this cohort of women undergoing combined RP and POP surgery, a higher proportion required subsequent RP surgery compared to those requiring subsequent POP surgery, although this was not statistically significant. Almost one-fifth of patients undergoing combined RP and POP surgery experienced a < 30-day surgical complication, regardless of whether the approach was perineal or abdominal. For those patients undergoing abdominal repair, < 30-day complications were more likely in those patients who had a laparotomy compared to those who had a minimally invasive surgery.

Practice Considerations for Proton Beam Radiation Therapy of Uveal Melanoma During the Coronavirus Disease Pandemic: Particle Therapy Co-Operative Group Ocular Experience.

Uveal melanoma (UM) is a rare but life-threatening cancer of the eye. In light of the coronavirus disease (COVID-19) pandemic, hospitals and proton eye therapy facilities must analyze several factors to ensure appropriate treatment protocols for patients and provider teams. Practice considerations to limit COVID-19 transmission in the proton ocular treatment setting for UM are necessary. The Particle Therapy Co-Operative Group is the largest international community of particle/proton therapy providers. Participating experts have current or former affiliation with the member institutions of the Particle Therapy Co-Operative Group Ocular subcommittee with long-standing high-volume proton ocular programs. The practices reviewed in this document must be taken in conjunction with local hospital procedures, multidisciplinary recommendations, and regional/national guidelines, as each community may have its unique needs, supplies, and protocols. Importantly, as the pandemic evolves, so will the strategies and recommendations. Given the unique circumstances for UM patients, along with indications of potential ophthalmologic transmission as a result of health care providers working in close proximity to patients and intrinsic infectious risk from eyelashes, tears, and hair, practice strategies may be adapted to reduce the risk of viral transmission. Certainly, providers and health care systems will continue to examine and provide as safe and effective care as possible for patients in the current environment.

Phase I/II randomized study of proton beam with anti-VEGF for exudative age-related macular degeneration: long-term results.

BACKGROUND/OBJECTIVE: To determine if treatment of exudative age-related macular degeneration (eAMD) using proton beam therapy (PBT) combined with intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy is safe and effective long term. SUBJECT/METHODS: Thirty eyes with newly diagnosed eAMD were enrolled in a phase I/II prospective, sham-controlled double-masked university study. Eyes were randomized 1:1:1-24 GyE, 16 GyE or sham radiation, and treated with three initial monthly intravitreal ranibizumab or bevacizumab. Subsequent anti-VEGF reinjection was based on monthly optical coherence tomography and examination for 2 years and standard of care thereafter. RESULTS: A total of 23 eyes completed 2-year study follow-up, of which 16 maintained monthly follow-up. Mean best-correct visual acuity (BCVA) at 2 years was similar among treatment groups (p > 0.05). The 24 GyE group required fewer anti-VEGF injections when compared with the sham group at 2 years (4.67 ± 1.9 vs 9.67 ± 3.5; p = 0.017). Extended follow-up (mean 4 years) available in 22 eyes showed persistent reduced need for anti-VEGF therapy among eyes treated with 24 GyE compared with sham radiation (2.0 ± 1.6 vs 4.84 ± 2.4 per year, p = 0.008). New and increasing geographic atrophy (GA), noted in some eyes in all treatment groups, resulted in decreased mean BCVA from baseline for the 24 GyE group on extended follow-up (p = 0.009). Possible mild radiation retinopathy noted in 15% of eyes was not visually significant. CONCLUSIONS: Initial treatment combining PBT (24 GyE) with intravitreal anti-VEGF therapy appears to decrease the need for anti-VEGF reinjection in eyes with newly diagnosed eAMD. Radiation retinopathy risk was low and does not appear visually significant. Long-term vision was limited by GA development especially in the 24 GyE group.

Delay in Seeking Care for Pelvic Floor Disorders Among Caregivers.

OBJECTIVE: In 2015, 44 million adults were informal, unpaid caregivers to an adult or child. Caregiving (CG) is associated with poor self-care, higher depression rates, and decreased quality of life. Our primary objective was to determine if CG is associated with a delay in seeking care for pelvic floor disorders (PFDs). METHODS: We performed a cross-sectional survey of new urogynecology patients from September 2015 to January 2016. Subjects completed the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, Patient Reported Outcomes Measurement Information System-Depression surveys, and a survey of care-seeking practices. Caregiving was defined as considering one's self a primary caregiver and assisting with 2 or more activities and instrumental activities of daily living. Multiple logistic regression identified variables associated with delayed care-seeking for 1 or more year. RESULTS: Two hundred fifty-six patients completed the survey, 82 caregivers (32%) and 174 noncaregivers (NCGs). Sixty-seven percent of caregivers cared for a child and 33% for an adult. There was no difference between caregivers and NCGs in PFD symptom duration, Pelvic Floor Distress Inventory, or Patient Reported Outcomes Measurement Information System depression scores. Caregiving had higher mean Pelvic Floor Impact Questionnaire scores (69.6 vs 51.0, P = 0.02). There was no difference in proportion of patients who delayed care for 1 year or more (42% vs 54%, P = 0.08). A higher proportion of caregivers for an adult waited for 1 year or more (75% vs 42% NCG, P = 0.001). On multiple logistic regression, CG for adults only was associated with delaying care for 1 year or more (adjusted odds ratio, 3.73; confidence interval, 1.33-10.44; P = 0.01). CONCLUSIONS: One third of patients presenting to a urogynecology practice are caregivers. Caregiving for an adult was associated with a delay in seeking care for PFDs.

Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women.

PURPOSE OF REVIEW: To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders. RECENT FINDINGS: Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery. SUMMARY: PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.