Alexis A. Dieter

Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050

OBJECTIVE We sought to estimate the number of women who will undergo inpatient and outpatient surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP) in the United States from 2010 through 2050. STUDY DESIGN Using the 2007 Nationwide Inpatient Sample and the 2006 National Survey of Ambulatory Surgery, we calculated the rates for inpatient and outpatient SUI and POP surgery. We applied the surgery rates to the US Census Bureau population projections from 2010 through 2050. RESULTS The total number of women who will undergo SUI surgery will increase 47.2% from 210,700 in 2010 to 310,050 in 2050. Similarly, the total number of women who will have surgery for prolapse will increase from 166,000 in 2010 to 245,970 in 2050. CONCLUSION If the surgery rates for pelvic floor disorders remain unchanged, the number of surgeries for urinary incontinence and POP will increase substantially over the next 40 years.

Epidemiological trends and future care needs for pelvic floor disorders.

Purpose of review We sought to provide a review of the recent literature regarding the prevalence and epidemiological trends in pelvic floor disorders (PFDs) including pelvic organ prolapse (POP), urinary incontinence and fecal incontinence. We also examined the current trends in surgical treatment for these disorders and discuss future care needs. Recent findings Approximately, one quarter of all women suffer from at least one or more PFDs. Urinary incontinence represents the most common PFD with an estimated prevalence of 15–17%, whereas fecal incontinence affects, approximately, 9% of adult women. POP is more difficult to assess with prevalence estimates ranging from 3 to 8%. Surgery for PFDs is common as 20% of women undergo stress urinary incontinence or POP surgery over their lifetime. As the aging population grows, the number of women with PFDs will increase substantially and the demand for care for these disorders will continue to grow through the year 2050. Summary PFDs are a significant public health issue and they negatively impact the lives of millions of adult women. The projected increase in the number of women affected by PFDs over the next 40 years will create increased demand for providers properly trained in Female Pelvic Medicine and Reconstructive Surgery.

Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial.

OBJECTIVE: To evaluate whether nitrofurantoin prophylaxis prevents postoperative urinary tract infection (UTI) in patients receiving transurethral catheterization after pelvic reconstructive surgery. METHODS: In a randomized, double-blind, placebo-controlled trial, participants undergoing pelvic reconstructive surgery were randomized to 100 mg nitrofurantoin or placebo once daily during catheterization if they were: 1) discharged with a transurethral Foley or performing intermittent self-catheterization; or 2) hospitalized overnight with a transurethral Foley. Our primary outcome was treatment for clinically suspected or culture-proven UTI within 3 weeks of surgery. Statistical analysis was performed by &khgr;2 and logistic regression. Assuming 80% power at a P value of .05, 156 participants were needed to demonstrate a two-thirds reduction in UTI. RESULTS: Of 159 participants, 81 (51%) received nitrofurantoin and 78 (49%) received placebo. There were no significant differences in baseline demographics, intraoperative characteristics, duration and type of catheterization, or postoperative hospitalization, except a lower rate of hysterectomy in the nitrofurantoin group. Nitrofurantoin prophylaxis did not reduce the risk of UTI treatment within 3 weeks of surgery (22% UTI with nitrofurantoin compared with 13% UTI with placebo, relative risk 1.73, 95% confidence interval 0.85–3.52, P=.12). Urinary tract infection treatment was higher in premenopausal women, lower in diabetics, and increased with longer duration of catheterization. In logistic regression adjusting for menopause, diabetes, preoperative postvoid residual volume, creatinine clearance, hysterectomy, and duration of catheterization, there was still no difference in UTI with nitrofurantoin as compared with placebo. CONCLUSION: Prophylaxis with daily nitrofurantoin during catheterization does not reduce the risk of postoperative UTI in patients receiving short-term transurethral catheterization after pelvic reconstructive surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01450800. LEVEL OF EVIDENCE: I

Evaluation and management of overactive bladder: strategies for optimizing care

Overactive bladder (OAB) is a common condition affecting millions of men and women worldwide. It is an embarrassing condition with far-reaching consequences. Although many treatment options exist, no single treatment has been proven to be most effective. Often a combination of therapy is required to successfully manage OAB symptoms. In this review, we provide an overview of OAB, including risk factors for development of OAB; keys to diagnosis; therapeutic options including conservative and medical management, as well as treatments for refractory OAB; when to consider referral to a specialist; and resources for clinicians and patients. The aim of this review is to inform clinicians regarding OAB management in order to improve patient counseling and care.

Treatment for urinary tract infection after midurethral sling: a retrospective study comparing patients who receive short-term postoperative catheterization and patients who pass a void trial on the day of surgery.

Introduction This is a retrospective cohort study comparing the risk of treatment for postoperative urinary tract infection (UTI) in patients who receive short-term postoperative catheterization versus those who pass a void trial on the day of surgery after midurethral sling with or without concomitant pelvic surgery. Materials and Methods We compared two cohorts to determine our primary outcome: treatment for UTI, culture proven or empiric, within three weeks after surgery. Results 138 patients, were included in the study of which 80 (58%) received postoperative catheterization. The baseline characteristics of the catheterized and noncatheterized groups were similar except that the catheterized group had a lower mean body mass index (28 ± 5 vs 30 ± 5 kg/m2; P = 0.01), were more likely to have undergone concomitant pelvic surgery (51% vs 20%; P < 0.01), had higher estimated blood loss (92 ± 87 vs 47 ± 49 mL; P < 0.01), and had longer operative times (108 ± 75 vs 62 ± 47 min; P < 0.01). Overall, 19.6% of the patients received treatment for UTI. Patients in the catheterized group were more likely to receive treatment for UTI (24/80 [30%] catheterized vs 3/58 [5%] noncatheterized; P < 0.01). This significant difference in treatment for UTI persisted when examining patients who underwent midurethral sling only without concomitant pelvic surgery (6/29 [20.7%] catheterized vs 1/38 [2.6%] noncatheterized; P = 0.04). In a logistic regression model adjusting for age, body mass index, concomitant surgery, and postoperative catheterization, only postoperative catheterization remained significantly associated with treatment for UTI (OR, 6.6; 95% confidence interval, 1.8–24.5; P < 0.01). Conclusions Treatment for postoperative UTI is significantly higher in patients who receive short-term postoperative catheterization after midurethral sling with or without concomitant pelvic surgery.

How Does Site of Pelvic Organ Prolapse Repair Affect Overactive Bladder Symptoms

Objectives To assess how site of pelvic organ prolapse repair affects overactive bladder (OAB) symptoms, we compared change in OAB symptoms in women undergoing isolated anterior/apical (AA) repair versus isolated posterior (P) repair. Methods This is a retrospective cohort study of women with bothersome OAB undergoing either AA or P prolapse repair. The subjects completed the Pelvic Floor Distress Inventory short form and the Overactive Bladder Questionnaire (OAB-q) validated questionnaires preoperatively and 6 weeks postoperatively. Our primary outcome was OAB-q symptom severity (SS) change score (preoperative minus postoperative score) compared between the 2 groups. Results Of 175 subjects, 133 (76%) underwent AA repair and 42 (24%) underwent P repair. Baseline OAB-q SS scores and baseline characteristics were similar except that the AA group had more severe baseline prolapse (median pelvic organ prolapse quantification stage 3 for AA [interquartile range, 2–3] vs stage 2 for P [interquartile range, 1–3]; P<0.01] and a higher rate of concomitant midurethral sling (57% in AA vs 31% in P; P<0.01). Overall OAB symptoms significantly improved within 6 weeks of surgery (P<0.01). The mean±SD OAB-q SS change score was higher in the AA repair group (26±24 in AA vs 13 ± 28 in P; P=0.01), indicating greater improvement in OAB symptom severity after AA repair. In linear regression adjusting for age, body mass index, diabetes, stress urinary incontinence, pelvic organ prolapse quantification stage, anticholinergic use, and midurethral sling, this difference did not remain significant. Conclusions Patients have significant improvement in OAB symptoms after POP repair. In adjusted analyses, there was no difference in improvement in OAB-q SS scores in the patients who had AA versus P repair.

The effects of bilateral bipolar sacral neurostimulation on urinary bladder activity during filling before and after irritation in a rat model

To design an optimal rat model for studying sacral neurostimulation (SNS), and examine the effect of SNS on myogenic non‐voiding contractions (NVC) during filling before and after intraluminal irritation.

Perioperative anticholinergic medications and risk of catheterization after urogynecologic surgery.

Objective This study aimed to examine how anticholinergic medication exposure affects the risk of failed postoperative void trial (VT) in women undergoing urogynecologic surgery. Methods We conducted a retrospective cohort study of women undergoing outpatient prolapse or incontinence surgery. We evaluated perioperative anticholinergic exposure via the validated anticholinergic risk scale (ARS). Total ARS score was calculated by summing the individual ARS for each medication used during the following periods: at home before surgery, in preoperative holding, intraoperatively, and in postoperative recovery. The “low anticholinergic exposure” cohort (total ARS, ⩽7) was compared to the “high anticholinergic exposure” cohort (total ARS, ≥8) to assess our primary outcome: failed postoperative VT on day of surgery. Results Of 125 women in the study, 98 (78%) had low anticholinergic exposure and 27 (22%) had high anticholinergic exposure. Overall, 28 (22%) patients failed the postoperative VT. Women in the high anticholinergic group had a significantly higher risk of a failed VT (41% vs 17%, P = 0.01 for high vs low anticholinergic groups, respectively). In logistic regression analysis, adjusting for age, body mass index, diabetes, midurethral sling and anterior repair, high anticholinergic exposure (AOR, 4.15; 95% confidence interval, 1.49–11.57), and anterior repair (AOR, 3.15; 95% CI, 1.15–8.61) remained significantly associated with failed postoperative VT. Conclusions Higher exposure to perioperative anticholinergic medications increases the risk of a failed postoperative VT after outpatient urogynecologic surgery.

Cumulative Incidence of a Subsequent Surgery After Stress Urinary Incontinence and Pelvic Organ Prolapse Procedure.

OBJECTIVE To assess the 5-year risk and timing of repeat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures. METHODS We conducted a retrospective cohort study using a nationwide database, the 2007-2014 MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases (Truven Health Analytics), which contain deidentified health care claims data from approximately 150 employer-based insurance plans across the United States. We included women aged 18-84 years and used Current Procedural Terminology codes to identify surgeries for SUI and POP. We identified index procedures for SUI or POP after at least 3 years of continuous enrollment without a prior procedure. We defined three groups of women based on the index procedure: 1) SUI surgery only; 2) POP surgery only; and 3) Both SUI+POP surgery. We assessed the occurrence of a subsequent SUI or POP procedure over time for women younger than 65 years and 65 years or older with a median follow-up time of 2 years (interquartile range 1-4). RESULTS We identified a total of 138,003 index procedures: SUI only n=48,196, POP only n=49,120, and both SUI+POP n=40,687. The overall cumulative incidence of a subsequent SUI or POP surgery within 5 years after any index procedure was 7.8% (95% confidence interval [CI] 7.6-8.1) for women younger than 65 years and 9.9% (95% CI 9.4-10.4) for women 65 years or older. The cumulative incidence was lower if the initial surgery was SUI only and higher if an initial POP procedure was performed, whether POP only or SUI+POP. CONCLUSIONS The 5-year risk of undergoing a repeat SUI or POP surgery was less than 10% with higher risks for women 65 years or older and for those who underwent an initial POP surgery.

Sexual Activity and Vaginal Topography in Women with Symptomatic Pelvic Floor Disorders

INTRODUCTION Pelvic floor disorders affect vaginal anatomy and may affect sexual function. AIMS The aims of this study were to explore the relationship between vaginal anatomy and sexual activity in women with symptomatic pelvic floor disorders and to assess whether vaginal measurements (topography) correlate with sexual function. METHODS This is a retrospective cohort study comparing sexually active and nonsexually active women planning urogynecologic surgery. Our primary outcome was the difference in vaginal topography based on Pelvic Organ Prolapse Quantification (POP-Q) exam between cohorts. Correlations between POP-Q measurements and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores were assessed in sexually active women. MAIN OUTCOME MEASURE The POP-Q is a quantitative and standardized examination for prolapse. The PISQ-12 is a condition-specific sexual function questionnaire validated in sexually active women with pelvic floor disorders. RESULTS Of 535 women, 208 (39%) were sexually active and 327 (61%) were not. Median genital hiatus (GH) and perineal body (PB) measurements and a PB:GH ratio were not significantly different between the two cohorts. Total vaginal length (TVL) was longer in sexually active women (median 9 vs. 8 cm, P<0.001). In a linear regression analysis controlling for potential confounders, sexually active women still had a longer TVL by 0.4 cm (95% confidence interval 0.07, 0.6 cm) compared with those who were not sexually active. Of the 327 nonsexually active women, 28% indicated they avoided sexual activity because of pelvic floor symptoms. There was poor correlation between TVL, GH, PB, and PB : GH ratio with PISQ-12 scores (r=0.10, -0.05, -0.09, -0.03, respectively). CONCLUSIONS In women with pelvic floor disorders, sexual activity is associated with a longer vaginal length. One-quarter of women indicated they avoided sexual activity because of pelvic floor symptoms. Vaginal topography does not correlate with sexual function based on PISQ-12 scores.