Truth or Myth: Intra-abdominal Pressure Increases in the Lithotomy Position.

STUDY OBJECTIVE: To determine if there were differences in intra-abdominal pressure (IAP) in the supine, low lithotomy, and high lithotomy positions. DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Twenty-nine women undergoing surgery for prolapse or stress incontinence. INTERVENTIONS: Relevant medical history, including the pelvic organ prolapse quantification stage, body mass index, and airway grade (Mallampati score), was abstracted from patients' medical charts. IAP was measured in centimeters of water (cmH2O) on the day of their surgery before induction of general or intravenous anesthesia using a T-doc air charged urodynamic catheter (Laborie Aquarius; Ontario, Canada) placed in a patient's vagina (for patients with incontinence) or rectum (for patients with prolapse). MEASUREMENTS AND MAIN RESULTS: IAP was measured in 3 positions: supine (legs at 0°), low lithotomy (legs in Yellowfin stirrups at 45°; Allen Medical, Acton, MA), and high lithotomy (legs at 90°). The means ± SDs IAP for the groups were as follows: in the supine position, 18.6 cmH2O ± 7.6; low lithotomy, 17.7 cmH2O ± 6.6; and high lithotomy, 17.1 cmH2O ± 6.3. In the same women, there was a significant decrease in IAP from the supine to high lithotomy positions, with a mean difference of 1.4 cmH2O ± 3.7, p = .05. Similarly, there was a significant, though smaller, decrease in mean IAP when moving from the supine to low lithotomy positions in these same women (mean decrease of 0.9 cmH2O ± 1.5, p = .004). Neither change is clinically significant based on previous research that suggests 5 cmH2O is a clinically significant change. CONCLUSION: Placing patients' legs in a low or high lithotomy position does not result in a clinically significant increase in IAP. Therefore, surgeons and anesthesiologists can consider positioning patients' lower extremities in stirrups while patients are awake to minimize discomfort and possibly reduce the risk of nerve injuries.

Restricted Convalescence Following Urogynecologic Procedures: 1-Year Outcomes From a Randomized Controlled Study.

OBJECTIVE: To assess the relationship between postoperative activity recommendations and satisfaction and anatomic and functional outcomes 1 year after surgery for symptomatic prolapse. METHODS: This is a planned secondary analysis reporting 1-year functional and anatomic outcomes of a multicenter, randomized, double-masked clinical trial "ReCOUP." In the original trial, women undergoing surgery for prolapse were randomized to liberal (no limitations on physical activity) or restricted (heavy lifting and high-impact activity prohibited) postoperative activity recommendations for 3 months after surgery. At 1 year, our primary outcome was satisfaction, assessed using a 5-point Likert scale answer to the question, "How satisfied are you with the result of your prolapse surgery?" Anatomic surgical failure was met if women had prolapse beyond the hymen, apical descent greater than one third the vaginal length, OR retreatment for prolapse. RESULTS: Of the 95 women (n = 45 liberal, n = 50 restricted) who were randomized and completed primary 3-month outcomes, 83 (87%) completed a functional assessment, and 77 (81%) completed both functional and anatomic assessment at 1 year. Satisfaction with surgery remained high (91.5%) with no differences between groups (86.8% vs 95.6% P = 0.155) as did anatomic and functional outcomes. There were 7.8% women who met criteria for anatomic surgical failure with no difference between the restricted (7.0%) and liberal group (8.8%). Three women (2 in the restricted group, 1 in the liberal group) with recurrent prolapse and underwent surgery. CONCLUSIONS: There were no significant differences in anatomic and functional outcomes at 12 months after surgery in women who resume postoperative activity liberally and those who restrict postoperative activity.

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy. METHODS: In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum. RESULTS: Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index. CONCLUSION: At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.

Concurrent Retropubic Midurethral Sling and OnabotulinumtoxinA for Mixed Urinary Incontinence: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether retropubic midurethral sling combined with onabotulinumtoxinA is more effective than sling alone in improving mixed urinary incontinence symptoms. METHODS: We conducted a prospective, double-blind, randomized, controlled trial of women with mixed urinary incontinence, planning to undergo midurethral sling. Women were randomly assigned to receive 100 unites of intradetrusor onabotulinumtoxinA or placebo during surgery. Participants completed the PGI-S (Patient Global Impression of Severity), the UDI-6 (Urinary Distress Inventory, Short Form), and the PFIQ-7 (Pelvic Floor Impact Questionnaire-Short Form 7) before and 3 months after surgery, and the primary outcome, PGI-I (Patient Global Impression of Improvement), 3 months postoperatively. Primary outcome was PGI-I score at 3 months for overall incontinence. We considered women "improved" with answers of "very much better" or "much better" on the PGI-I. Assuming a PGI-I response of "improved" in 66% of placebo and 93% of onabotulinumtoxinA participants, 68 women were needed to show a significant difference with 80% power at 0.05 significance level. RESULTS: From March 2016 to November 2019, 78 women completed a 3-month follow-up (onabotulinumtoxinA: 41; placebo: 37). Mean age was 51 years (±10). On the PGI-I, the number who "improved" did not differ between groups at 3 months (83% vs 84%, P=1.0). The onabotulinumtoxinA group had less severe urgency symptoms as indicated by median urgency PGI-S scores (1 [interquartile range 1-2] vs 2 [interquartile range 1-3], P=.033) and greater improvement in urgency symptoms based on median urgency PGI-I score (1 [interquartile range 1-3] vs 2 [interquartile range 2-4], P=.028). At 3 months, median UDI-6, PFIQ-7, and PGI-S scores improved significantly from baseline in both groups. Similarly, UDI-6 and PFIQ-7 scores did not differ between groups. More women in the onabotulinumtoxinA arm initiated intermittent self-catheterization, (3% placebo; 12% onabotulinumtoxinA, P=.20) and experienced urinary tract infections (5% placebo; 22% onabotulinumtoxinA, P=.051), but these did not differ statistically. CONCLUSION: Concurrent intradetrusor onabotulinumtoxinA injection did not improve overall incontinence symptoms at 3 months compared with placebo among women with mixed urinary incontinence undergoing midurethral sling placement. Women with mixed urinary incontinence undergoing sling report significant improvement in overall incontinence symptoms, regardless of the addition of onabotulinumtoxinA injections, but those receiving concurrent onabotulinumtoxinA injections reported less urgency severity and greater improvement in urgency symptoms at 3 months. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02678377.

Early Secondary Repair of Obstetric Anal Sphincter Injury Breakdown: Contemporary Surgical Techniques and Experiences From a Peripartum Subspecialty Clinic.

OBJECTIVE: To describe surgical technique and outcomes of early secondary repair of obstetric anal sphincter injury (OASIS) breakdown. METHODS: This was a case series of all women presenting to a subspecialty peripartum clinic within 2 months of an OASIS, who ultimately underwent secondary surgical repair between September 2013 and January 2018. Cases were identified using the following CPT codes: 57308 (transperineal fistula repair), 56910 (repair of the perineum), and 46750 (repair of anal sphincter). Four board-certified urogynecologists performed all surgical procedures using the same technique: demographics, delivery data, and preoperative and postoperative data were collected. RESULTS: Eighteen women were identified. The majority (16 [88.9%] of 18) were primiparous; 9 (50%) women underwent spontaneous vaginal delivery and 9 (50%) women underwent forceps-assisted vaginal delivery. Over 70% (13 [72.2%] of 18) suffered a 3rd-degree tear, whereas 5 (27.8%) of 18 had a 4th-degree laceration. The median time after delivery to specialty clinic presentation was 10 days (interquartile range, 5.3-52.5 days). All women were diagnosed with wound breakdown at their initial visit. Seven (38.9%) also had a concomitant rectovaginal fistula.Median time from diagnosis of wound breakdown to secondary operative revision was 19.5 days (interquartile range, 12-26.8 days). Seventeen (94.4%) of the 18 women underwent overlapping external anal sphincteroplasty with perineorrhaphy; of these, 7 (41.2%) also underwent concurrent repair of their rectovaginal fistula. One woman underwent perineorrhaphy alone. At 3 months postoperatively, no women had a wound breakdown or recurrent fistula. CONCLUSIONS: In women with OASIS breakdown, early secondary repair is both feasible and successful with meticulous surgical technique.

Bare Versus Hair: Do Pubic Hair Grooming Preferences Dictate the Urogenital Microbiome?

OBJECTIVE: The aim of the study was to determine whether the genitourinary microbiome differs between and within women with and without pubic hair. METHODS: Premenopausal women who self-identified into 2 groups were recruited: in the "hair" group, women did not remove any pubic hair, and in the "bare" group, all pubic hair was removed routinely. Participants submitted a vaginal swab, a voided urine sample, and a catheterized urine sample, and then "crossed over." The "hair" group removed all hair for 1 month, and the "bare" group grew hair for 2 months. After crossover, participants again submitted a vaginal swab, a voided urine sample, and a catheterized urine sample. Ten participants acted as controls. DNA was extracted, and the V4 region of 16S rRNA gene was amplified and sequenced using the MiSeq platform. Paired-end sequences were imported into QIIME2-2018.6. Alpha diversity (the number and proportion of species in an individual sample) and beta diversity (differences in microbial composition between samples) were evaluated. RESULTS: Forty-two participants were analyzed: 16 "bare to hair" crossovers, 16 "hair-to-bare" crossovers, and 10 controls. The microbiome varied by sample type: vaginal swabs had the lowest alpha diversity and catheterized urine had the highest (P < 0.001). At baseline, there were no differences in the alpha or beta diversity of urine or vaginal microbiomes between groups. Vaginal beta diversity at visit 2 was greater within crossovers than controls (P = 0.004), suggesting that altering hair status alters the microbiome composition. Urinary beta diversity was not different at visit 2 (P = 0.40). CONCLUSIONS: Pubic hair status does not determine one's baseline genitourinary microbiome, but women who change their hair status may alter their vaginal microbiome.