Reanalysis of a randomized trial of 3 techniques of anterior colporrhaphy using clinically relevant definitions of success.

OBJECTIVE: The purpose of this study was to reanalyze the results of a previously published trial that compared 3 methods of anterior colporrhaphy according to the clinically relevant definitions of success. STUDY DESIGN: A secondary analysis of a trial of 114 subjects who underwent surgery for anterior pelvic organ prolapse who were assigned randomly to standard anterior colporrhaphy, ultralateral colporrhaphy, or anterior colporrhaphy plus polyglactin 910 mesh from 1996-1999. For the current analysis, success was defined as (1) no prolapse beyond the hymen, (2) the absence of prolapse symptoms (visual analog scale ≤ 2), and (3) the absence of retreatment. RESULTS: Eighty-eight percent of the women met our definition of success at 1 year. One subject (1%) underwent surgery for recurrence 29 months after surgery. No differences among the 3 groups were noted for any outcomes. CONCLUSION: Reanalysis of a trial of 3 methods of anterior colporrhaphy revealed considerably better success with the use of clinically relevant outcome criteria compared with strict anatomic criteria.

Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence.

BACKGROUND: We designed this trial to assess whether the addition of standardized Burch colposuspension to abdominal sacrocolpopexy for the treatment of pelvic-organ prolapse decreases postoperative stress urinary incontinence in women without preoperative symptoms of stress incontinence. METHODS: Women who did not report symptoms of stress incontinence and who chose to undergo sacrocolpopexy to treat prolapse were randomly assigned to concomitant Burch colposuspension or to no Burch colposuspension (control) and were evaluated in a blinded fashion three months after the surgery. The primary outcomes included measures of stress incontinence (symptoms, stress testing, or treatment) and measures of urge symptoms. Enrollment was stopped after the first interim analysis because of a significantly lower frequency of stress incontinence in the group that underwent the Burch colposuspension. RESULTS: Of 322 women who underwent randomization, 157 were assigned to Burch colposuspension and 165 to the control group. Three months after surgery, 33.6 percent of the women in the Burch group and 57.4 percent of the controls met one or more of the criteria for stress incontinence (P<0.001) [Corrected]. There was no significant difference between the Burch group and the control group in the frequency of urge incontinence (32.7 percent vs. 38.4 percent, P=0.48). After surgery, women in the control group were more likely to report bothersome symptoms of stress incontinence than those in the Burch group who had stress incontinence (24.5 percent vs. 6.1 percent, P<0.001). CONCLUSIONS: In women without stress incontinence who are undergoing abdominal sacrocolpopexy for prolapse, Burch colposuspension significantly reduced postoperative symptoms of stress incontinence without increasing other lower urinary tract symptoms.

Reproducibility of dynamic MR imaging pelvic measurements: a multi-institutional study.

PURPOSE: To assess the reproducibility of bone and soft-tissue pelvimetry measurements obtained from dynamic magnetic resonance (MR) imaging studies in primiparous women across multiple centers. MATERIALS AND METHODS: All subjects prospectively gave consent for participation in this institutional review board-approved, HIPAA-compliant study. At six clinical sites, standardized dynamic pelvic 1.5-T multiplanar T2-weighted MR imaging was performed in three groups of primiparous women at 6-12 months after birth: Group 1, vaginal delivery with anal sphincter tear (n = 93); group 2, vaginal delivery without anal sphincter tear (n = 79); and group 3, cesarean delivery without labor (n = 26). After standardized central training, blinded readers at separate clinical sites and a blinded expert central reader measured nine bone and 10 soft-tissue pelvimetry parameters. Subsequently, three readers underwent additional standardized training, and reread 20 MR imaging studies. Measurement variability was assessed by using intraclass correlation for agreement between the clinical site and central readers. Acceptable agreement was defined as an intraclass correlation coefficient (ICC) of at least 0.7. RESULTS: There was acceptable agreement (ICC range, 0.71-0.93) for eight of 19 MR imaging parameters at initial readings of 198 subjects. The remaining parameters had an ICC range of 0.13-0.66. Additional training reduced measurement variability: Twelve of 19 parameters had acceptable agreement (ICC range, 0.70-0.92). Correlations were greater for bone (ICC, >or=0.70 in five [initial readings] and eight of nine [rereadings] variables) than for soft-tissue measurements (ICC, >or=0.70 in three [initial readings] of 10 and four [rereadings] of 10 readings, respectively). CONCLUSION: Despite standardized central training, there is high variability of pelvic MR imaging measurements among readers, particularly for soft-tissue structures. Although slightly improved with additional training, measurement variability adversely affects the utility of many MR imaging measurements for multicenter pelvic floor disorder research.

Refractory idiopathic urge urinary incontinence and botulinum A injection.

PURPOSE: We compared 200 U intradetrusor botulinum toxin A vs placebo in women with refractory idiopathic urge incontinence. MATERIALS AND METHODS: This institutional review board approved, multicenter registered trial randomized women with refractory urge incontinence, detrusor overactivity incontinence and 6 or greater urge incontinence episodes in 3 days to botulinum toxin A or placebo at a 2:1 ratio. Refractory was defined as inadequate symptom control after 2 or more attempts at pharmacotherapy and 1 or more other first line therapies for detrusor overactivity incontinence. The primary outcome measure was time to failure, as evidenced by a Patient Global Impression of Improvement score of 4 or greater at least 2 months after injection, or changes in treatment (initiation or increase) at any time after injection. Safety data, including increased post-void residual volume, defined as more than 200 ml irrespective of symptoms, was obtained at specified time points. RESULTS: Approximately 60% of the women who received botulinum toxin A had a clinical response based on the Patient Global Impression of Improvement. The median duration of their responses was 373 days, significantly longer than the 62 days or less for placebo (p <0.0001). In the botulinum toxin A group increased post-void residual urine (12 of 28 women or 43%) and urinary tract infection in those with increased post-void residual urine (9 of 12 or 75%) exceeded expected ranges. Further injections were stopped after 43 patients were randomized, including 28 to botulinum toxin A and 15 to placebo. CONCLUSIONS: Local injection of 200 U botulinum toxin A was an effective and durable treatment for refractory overactive bladder. However, a transient post-void residual urine increase was experienced in 43% of patients. Botulinum toxin A for idiopathic overactive bladder is still under investigation.

The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse.

OBJECTIVE: To describe how simulated apical support affects the appearance of prolapse in the anterior and posterior vagina using a modification of the Pelvic Organ Prolapse Quantification (POP-Q) examination. METHODS: Women with prolapse stage II or greater were examined using the POP-Q. To simulate apical support, the posterior blade of a standard Graves speculum was positioned over the posterior vagina to support the vaginal apex while remeasuring points Aa and Ba and over the anterior vagina to support the apex while remeasuring points Ap and Bp. Change in anterior and posterior POP-Q points and prolapse stage with apical support were calculated. RESULTS: One hundred ninety-seven women were enrolled with mean age of 62+/-14 years, median parity of 2 (range 0-8), and mean body mass index of 28+/-5 kg/m(2). By standard POP-Q, 36% had stage II prolapse, 54% had stage III, and 10% had stage IV prolapse. With simulated apical support, point Ba changed to stage 0 or I in 55% of cases and point Bp changed to stage 0 or I in 30% (P<.001 for each point). Mean change for point Ba with apical support was 3.5+/-2.6 cm and point Bp was 1.9+/-2.9 cm (P<.001). CONCLUSION: When the POP-Q examination is performed with simulated apical support, the critical role of level I vaginal support on the position of the anterior and posterior vagina, particularly the anterior vagina, becomes apparent. LEVEL OF EVIDENCE: II.

Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence.

OBJECTIVES: To report anatomic and functional outcomes 2 years after sacrocolpopexy in stress-continent women with or without prophylactic Burch colposuspension. METHODS: In the Colpopexy and Urinary Reduction Efforts (CARE) trial, stress-continent women undergoing sacrocolpopexy were randomized to receive or not receive a Burch colposuspension. Outcomes included urinary symptoms, other pelvic symptoms, and pelvic support. Standardized pelvic organ prolapse quantification examinations and validated outcome measures including the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire were completed before surgery and at several postoperative intervals, including at 2 years. RESULTS: This analysis is based on 322 randomized participants; certain analyses were done with a subset based on data availability. Most were Caucasian (94%), with a mean age of 62±10 years (mean±standard deviation). Two years after surgery, 41.8% and 57.9% of women in the Burch and control groups, respectively, met the stress incontinence endpoint (presence of symptoms or positive cough stress test or interval treatment for stress incontinence, P=.020). The apex was well supported (point C within 2 cm of total vaginal length) in 95% of women, and this was not affected by concomitant Burch (P=.18). There was a trend toward fewer urgency symptoms in the Burch group (32.0% versus 44.5% no Burch, P=.085). Twenty participants experienced mesh or suture erosions. CONCLUSION: The early advantage of prophylactic Burch colposuspension for stress incontinence that was seen at 3 months remains at 2 years. Apical anatomic success rates are high and not affected by concomitant Burch. CLINICAL TRIAL REGISTRATION: (www.clinicaltrials.gov), ClinicalTrials.gov, NCT00065845. LEVEL OF EVIDENCE: I.

Obesity and outcomes after sacrocolpopexy.

OBJECTIVE: The purpose of this study was to compare outcomes after sacrocolpopexy (SC) between obese and healthy-weight women. STUDY DESIGN: Baseline and postoperative data were analyzed from the Colpopexy And Urinary Reduction Efforts (CARE) randomized trial of SC with or without Burch colposuspension in stress continent women with stages II-IV prolapse. Outcomes and complications were compared between obese and healthy-weight women. RESULTS: CARE participants included 74 obese (body mass index >/=30 kg/m(2)), 122 overweight (25-29.9 kg/m(2)), and 125 healthy-weight (18.5-24.9 kg/m(2)) women, and 1 underweight (< 18.5 kg/m(2)) woman. Compared to healthy-weight women, obese women were younger (59.0 +/- 9.9 vs 62.1 +/- 10.3 yrs; P = .04), more likely to have stage II prolapse (25.7% vs 11.2%; P = .01), and had longer operative times (189 +/- 52 vs 169 +/- 58 min; P = .02). Two years after surgery, stress incontinence, prolapse, symptom resolution, and satisfaction did not differ between the obese and healthy-weight groups. CONCLUSION: Most outcomes and complication rates after SC are similar in obese and healthy-weight women.

The correlation of voiding variables between non-instrumented uroflowmetery and pressure-flow studies in women with pelvic organ prolapse.

AIMS: To (1) correlate peak and maximum flow rates from non-instrumented flow (NIF) and pressure-flow studies (PFS) in women with pelvic organ prolapse (POP); (2) measure the impact of voided volume and degree of prolapse on correlations. METHODS: We compared four groups of women with stages II-IV POP. Groups 1 and 2 were symptomatically stress continent women participating in the colpopexy and urinary reduction efforts (CARE) trial; during prolapse reduction before sacrocolpopexy, Group 1 (n = 67) did not have and Group 2 (n = 84) had urodynamic stress incontinence (USI). Group 3 (n = 74) and Group 4 participants (n = 73), recruited specifically for this study, had stress urinary incontinence (SUI) symptoms. Group 3 planned sacrocolpopexy. Group 4 planned a different treatment option. Participants completed standardized uroflowmetry and pressure voiding studies. RESULTS: Subjects' median age was 61 years; median parity 3% and 80% had stage III or IV POP. Based on the Blaivas-Groutz nomogram, 49% of all women were obstructed. NIF and PFS peak and average flow rates had low correlations with one another (0.31, P < 0.001 and 0.35, P < 0.001, respectively). When NIF and PFS voided volumes were within 25% of each other, the peak and average flow rate correlations improved (0.52, P < 0.001 and 0.57, P < 0.001, respectively). As vaginal prolapse increased, correlations between NIF and PFS peak and average flow rates decreased. CONCLUSION: Peak and average flow rates are highly dependent on voided volume in women with prolapse. As the prolapse stage increases, correlations between NIF and PFS variables decrease.

The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse.

OBJECTIVES: To compare perioperative morbidity and 1-year outcomes of older and younger women undergoing surgery for pelvic organ prolapse (POP). DESIGN: Prospective ancillary analysis. SETTING: Academic medical centers in National Institutes of Health, National Institute of Child Health and Human Development Colpopexy and Urinary Reduction Study. PARTICIPANTS: Women with POP and no symptoms of stress incontinence. INTERVENTION: Abdominal sacrocolpopexy with randomization to receive Burch colposuspension for treatment of possible occult incontinence or not. MEASUREMENTS: Perioperative complications and Pelvic Organ Prolapse Quantification and quality-of-life (QOL) questionnaires (Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and Medical Outcomes Study Short-Form Health Survey (SF-36) preoperatively, immediately postoperatively, and 6 weeks and 3 and 12 months postoperatively). RESULTS: Three hundred twenty-two women aged 31 to 82 (21% aged > or =70), 93% white. Older women had higher baseline comorbidity (P<.001) and more severe POP (P=.003). Controlling for prolapse stage and whether Burch was performed, there were no age differences in complication rates. Older women had longer hospital stays (3.1+/-1.0 vs 2.7+/-1.5 days, P=.02) and higher prevalence of incontinence at 6 weeks (54.7% vs 37.2%, P=.005). At 3 and 12 months, there were no differences in self-reported incontinence, stress testing for incontinence, or prolapse stage. Improvements from baseline were significant on all QOL measures but with no age differences. CONCLUSION: Outcomes of prolapse surgery were comparable between older and younger women except that older women had slightly longer hospital stays.

Risk factors for anal sphincter tear during vaginal delivery.

OBJECTIVE: To identify risk factors associated with anal sphincter tear during vaginal delivery and to identify opportunities for preventing this cause of fecal incontinence in young women. METHODS: We used baseline data from two groups of women who participated in the Childbirth and Pelvic Symptoms (CAPS) study: those women who delivered vaginally, either those with or those without a recognized anal sphincter tear. Univariable analyses of demographic and obstetric information identified factors associated with anal sphincter tear. We calculated odds ratios (ORs) for these factors alone and in combination, adjusted for maternal age, race, and gestational age. RESULTS: We included data from 797 primaparous women: 407 with a recognized anal sphincter tear and 390 without. Based on univariable analysis, a woman with a sphincter tear was more likely to be older, to be white, to have longer gestation or prolonged second stage of labor, to have a larger infant (birth weight/head circumference), or an infant who was in occiput posterior position, or to have an episiotomy or operative delivery. Logistic regression found forceps delivery (OR 13.6, 95% confidence interval [CI] 7.9-23.2) and episiotomy (OR 5.3, 95% CI 3.8-7.6) were strongly associated with a sphincter tear. The combination of forceps and episiotomy was markedly associated with sphincter tear (OR 25.3, 95% CI 10.2-62.6). The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4). CONCLUSION: Our results highlight the existence of modifiable obstetric interventions that increase the risk of anal sphincter tear during vaginal delivery. Our results may be used by clinicians and women to help inform their decisions regarding obstetric interventions. LEVEL OF EVIDENCE: II.

Anal sphincter laceration at vaginal delivery: is this event coded accurately?

OBJECTIVE: To determine the error rate for discharge coding of anal sphincter laceration at vaginal delivery in a cohort of primiparous women. METHODS: As part of the Childbirth and Pelvic Symptoms study performed by the National Institutes of Health Pelvic Floor Disorders Network, we assessed the relationship between perineal lacerations and corresponding discharge codes in three groups of primiparous women: 393 women with anal sphincter laceration after vaginal delivery, 383 without anal sphincter laceration after vaginal delivery, and 107 after cesarean delivery before labor. Discharge codes for perineal lacerations were compared with data abstracted directly from the medical record shortly after delivery. Patterns of coding and coding error rates were described. RESULTS: The coding error rate varied by delivery group. Of 393 women with clinically recognized and repaired anal sphincter lacerations by medical record documentation, 92 (23.4%) were coded incorrectly (four as first- or second-degree perineal laceration and 88 with no code for perineal diagnosis or procedure). One (0.3%) of the 383 women who delivered vaginally without clinically reported anal sphincter laceration was coded with a sphincter tear. No women in the cesarean delivery group had a perineal laceration diagnostic code. Coding errors were not related to the number of deliveries at each clinical site. CONCLUSION: Discharge coding errors are common after delivery-associated anal sphincter laceration, with omitted codes representing the largest source of errors. Before diagnostic coding can be used as a quality measure of obstetric care, the clinical events of interest must be appropriately defined and accurately coded.

Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery.

OBJECTIVE: This study was performed to assess the effect of pregnancy, route of delivery, and parity on the risk of primary and subsequent anal sphincter laceration in women at first vaginal delivery (1st VD), vaginal birth after cesarean delivery (VBAC), or second vaginal delivery (2nd VD). METHODS: This retrospective cohort study used data from a perinatal database that included all deliveries at Magee-Womens Hospital from 1995 to 2002. Anal sphincter laceration was the primary outcome, defined as third- and fourth-degree perineal lacerations. The adjusted odds ratio (OR) for primary and subsequent anal sphincter laceration at delivery by risk group was estimated using logistic regression models and reported with 95% confidence intervals (CIs). RESULTS: We assessed 20,674 live, singleton, term deliveries at Magee-Womens Hospital from 1995 to 2002, including 13,183 with 1st VD, 6068 with 2nd VD, and 1423 with VBAC. Anal sphincter laceration occurred in 16% of women with 1st VD, 18% with VBAC, and 3% with 2nd VD. Multivariable logistic regression modeling for primary anal sphincter laceration showed that 1st VD had OR of 5.1 and 95% CI 4.4, 5.9, and VBAC had OR of 5.1, 95% CI 4.2, 6.2 when compared with the reference group with 2nd VD. Shown in order for 1st VD, VBAC, and 2nd VD, the following factors, adjusted for the other listed factors, were significantly related to anal sphincter laceration except as noted: forceps, ORs of 3.0, 2.6, 5.5; midline episiotomy, ORs of 2.7, 2.9, 2.9; infant birth weight 3500 g or more, ORs of 1.9, 1.9, 1.1, not significantly different from OR of 1.0; vacuum delivery, ORs of 1.7, 1.8, 1.5, not significantly different from OR of 1.0, and 2nd stage of labor 2 hours or longer, ORs of 1.8, 0.9, 0.9, last 2 not significantly different from OR of 1.0. Of women who had anal sphincter laceration in their first vaginal delivery, 7.2% (76 of 1054 women who had 2 pregnancies) had recurrent laceration in their second vaginal delivery, compared with 2.3% (123 of 5147) of women who had a primary anal sphincter laceration in their second vaginal delivery. Multivariable logistic regression modeling for recurrent anal sphincter laceration yielded the following significant factors: episiotomy, OR 8.5, 95% CI 4.1, 17.7; vertex malpresentation (primarily occiput posterior), OR 4.3, 95% CI 1.4, 12.6; shoulder dystocia, OR 2.7, 95% CI 1.2, 5.8; and infant birth weight 3500 g or greater, OR 1.7, 95% CI 1.1, 2.7. CONCLUSION: At this institution, women undergoing VBAC are at similarly high risk of anal sphincter laceration, compared with nulliparous women. Women with prior anal sphincter laceration are at 3 times increased risk for subsequent sphincter laceration, compared with women with prior vaginal delivery without sphincter laceration. Pregnancy by itself does not appear to be an important factor in decreasing the risk of anal sphincter laceration in subsequent deliveries.

Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse.

OBJECTIVE: The aims of this secondary analysis of the "Colpopexy And Urinary Reduction Efforts" (CARE) study were to estimate the incidence of postoperative gastrointestinal complications and identify risk factors. STUDY DESIGN: We prospectively identified gastrointestinal complications and serious adverse events (SAE) for 12 months after sacrocolpopexy. Two surgeons independently reviewed reports of ileus or small bowel obstruction (SBO). RESULTS: Eighteen percent of 322 women (average age 61.3 years) reported "nausea, emesis, bloating, or ileus" during hospitalization and 9.8% at 6 weeks. Nineteen women (5.9%; CI 3.8%, 9.1%) had a possible ileus or SBO that generated SAE reports: 4 (1.2%, CI 0.5%,3.2%) were reoperated for SBO, 11 (3.4%, CI 1.9%,6.1%) were readmitted for medical management, and 4 had a prolonged initial hospitalization. Older age (P < .001) was a risk factor for ileus or SBO. CONCLUSION: One in 20 women experiences significant gastrointestinal morbidity after sacrocolpopexy. This information will aid preoperative counseling.

Sexual function before and after sacrocolpopexy for pelvic organ prolapse.

OBJECTIVE: The objective of the study was to describe sexual function before and after sacrocolpopexy. STUDY DESIGN: In the Colpopexy and Urinary Reduction Efforts trial, sexual function was assessed in 224 women with sexual partners before and 1 year after surgery using validated questionnaires. RESULTS: After surgery, significantly fewer women reported sexual interference from "pelvic or vaginal symptoms" (32.5% 1 year after surgery vs 7.8% prior to surgery); fear of incontinence (10.7% vs 3.3%); vaginal bulging (47.3% vs 4.6%); or pain (39.9% vs 21.6%). The proportion of women with infrequent sexual desire (32%) did not change. More women were sexually active 1 year after surgery (171, 76.3%) than before surgery (148, 66.1%). The 11 women (7.4%) who became sexually inactive were more likely than sexually active women to report infrequent sexual desire (70.0% vs 22.1%, P < .001). The addition of Burch colposuspension did not have an impact on postoperative sexual function. CONCLUSION: After sacrocolpopexy, most women reported improvements in pelvic floor symptoms that previously interfered with sexual function. The addition of Burch colposuspension did not adversely influence sexual function.

The impact of fecal and urinary incontinence on quality of life 6 months after childbirth.

OBJECTIVE: The objective of the study was to investigate the impact of postpartum fecal incontinence (FI) and urinary incontinence (UI) on quality of life (QOL). STUDY DESIGN: Seven hundred fifty-nine primiparous women in the Childbirth and Pelvic Symptoms study were interviewed 6 months postpartum. FI and UI were assessed with validated questionnaires. We measured QOL with SF-12 summary scores, health utility index score (a measure of self-rated overall health), and the modified Manchester Health Questionnaire. RESULTS: Women with FI had worse self-rated health utility index scores (85.1 +/- 9.8 vs 88.0 +/- 11.6, P = .02) and Medical Outcomes Study Short Form Health Survey (SF-12) mental summary scores (46.8 +/- 9.2 vs 51.1 +/- 8.7, P < .0001) than women without FI or flatal incontinence. Women with UI had worse SF-12 mental summary scores (48.3 +/- 9.8 vs 51.6 +/- 7.8, P < .01) and self-rated health utility index scores (84.1 +/- 12.5 vs 88.7 +/- 10.1, P < .01) than women without UI. Women with both FI and UI had the lowest SF-12 mental summary scores (44.5 +/- 9.0). CONCLUSION: Six months after delivery, women experiencing FI or UI reported negative effects on health-related QOL. FI and UI together have a greater impact than either condition alone.

Bowel symptoms in women 1 year after sacrocolpopexy.

OBJECTIVE: The objective of the study was to evaluate changes in bowel symptoms after sacrocolpopexy. STUDY DESIGN: This was a prospectively planned, ancillary analysis of the Colpopexy and Urinary Reduction Efforts study, a randomized trial of sacrocolpopexy with or without Burch colposuspension in stress continent women with stages II-IV prolapse. In addition to sacrocolpopexy (+/- Burch), subjects underwent posterior vaginal or perineal procedures (PR) at each surgeon's discretion. The preoperative and 1 year postoperative Colorectal-anal Distress Inventory (CRADI) scores were compared within and between groups using Wilcoxon signed-rank and rank-sum tests, respectively. RESULTS: The sacrocolpopexy + PR group (n = 87) had more baseline obstructive colorectal symptoms (higher CRADI and CRADI-obstructive scores: P = .04 and < .01, respectively) than the sacrocolpopexy alone group (n = 211). CRADI total, obstructive, and pain/irritation scores significantly improved in both groups (all P < .01). Most bothersome symptoms resolved after surgery in both groups. CONCLUSION: Most bowel symptoms improve in women with moderate to severe pelvic organ prolapse after sacrocolpopexy.

Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms.

OBJECTIVE: The objective of the study was to examine changes in bladder symptoms 1 year after abdominal sacrocolpopexy (ASC) with vs without Burch colposuspension. STUDY DESIGN: Women without stress urinary incontinence (SUI) symptoms undergoing ASC were randomized to receive or not receive Burch. One year later, irritative, obstructive, and SUI symptoms were assessed in 305 women using Urogenital Distress Inventory subscales. A composite "stress endpoint" combined SUI symptoms, positive stress test, and retreatment. RESULTS: In all women, the mean irritative score decreased from 19.6 +/- 16.3 (mean +/- SD) to 9.1 +/- 10.6; for obstructive symptoms, from 34.8 +/- 21.0 to 6.3 +/- 10.4 (both P < .001). Preoperative bothersome irritative symptoms resolved in 74.6% (126 of 169) and obstructive symptoms in 85.1% (212 of 249), independent of Burch. Fewer women with Burch had urge incontinence (14.5% vs 26.8%, P = .048) and fulfilled the stress endpoint (25.0% vs 40.1%, P = .012). CONCLUSION: ASC reduced bothersome irritative and obstructive symptoms. Prophylactic Burch reduced stress and urge incontinence.

Risk factors for sonographic internal anal sphincter gaps 6-12 months after delivery complicated by anal sphincter tear.

OBJECTIVE: The objective of the study was to identify risk factors for internal anal sphincter (IAS) gaps on postpartum endoanal ultrasound in women with obstetric anal sphincter tear. STUDY DESIGN: This prospective study included 106 women from the Childbirth and Pelvic Symptoms Imaging Supplementary Study who had third- or fourth-degree perineal laceration at delivery and endoanal ultrasound 6-12 months postpartum. Data were analyzed using Fisher's exact and t tests and logistic regression. RESULTS: Mean (+/- SD) age was 27.7 (+/- 6.2) years. Seventy-nine women (76%) were white and 22 (21%) black. Thirty-seven (35%) had sonographic IAS gaps. Risk factors for gaps included fourth- vs third-degree perineal laceration (odds ratio [OR] 15.4, 95% confidence interval [CI] 4.8, 50) and episiotomy (OR 3.3, 95% CI 1.2, 9.1). Black race (OR 0.23, 95% CI 0.05, 0.96) was protective. CONCLUSION: In women with obstetric anal sphincter repairs, fourth-degree tears and episiotomy are associated with more frequent sonographic IAS gaps.

Pelvic-floor muscle function in women with pelvic organ prolapse.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether pelvic organ prolapse severity, pelvic symptoms, quality of life, and sexual function differ based on pelvic-floor muscle function in women planning to have prolapse surgery. SUBJECTS AND METHODS: Three hundred seventeen women without urinary stress incontinence who were enrolled in a multicenter surgical trial were examined to determine pelvic-floor muscle function (by Brink scale score). The subjects were 61.6+/-10.2 (X+/-SD) years of age. Thirteen percent of the subjects had stage II (to the hymen) pelvic organ prolapse, 68% had stage III (beyond the hymen) prolapse, and 19% had stage IV (complete vaginal eversion) prolapse. Subjects with lowest (3-6) and highest (10-12) Brink scale scores were compared on prolapse severity, pelvic symptoms and bother, quality of life, and sexual function. RESULTS: Subjects with the highest Brink scores (n=75) had less advanced prolapse, smaller genital hiatus measurements, and less urinary symptom burden compared with those with the lowest Brink scores (n=56). The results indicated that pelvic-floor muscle function was not associated with condition-specific quality of life or sexual function. DISCUSSION AND CONCLUSION: Although modestly clinically significant, better pelvic-floor muscle function was associated with less severe prolapse and urinary symptoms.