Andrea K. Crane

Effect of anticholinergic use for the treatment of overactive bladder on cognitive function in postmenopausal women.

BACKGROUND Overactive bladder (OAB) is a common condition affecting the elderly. The mainstay of treatment for OAB is medical therapy with anticholinergics. However, adverse events have been reported with this class of drugs, including cognitive changes. OBJECTIVE The objective of this study was to investigate the effect of an anticholinergic medication, trospium chloride, on cognitive function in postmenopausal women being treated for OAB. METHODS This was a prospective cohort study conducted at a urogynaecology clinic at one academic medical centre from January to December 2010, with 12-week follow-up after medication initiation. Women aged 55 years or older seeking treatment for OAB and opting for anticholinergic therapy were recruited. Baseline cognitive function was assessed via the Hopkins Verbal Learning Test-Revised Form (HVLT-R) [and its five subscales], the Orientation, Memory & Concentration (OMC) short form, and the Mini-Cog evaluation. After initiation of trospium chloride extended release, cognitive function was reassessed at Day 1, Week 1, Week 4 and Week 12. Bladder function was assessed via three condition-specific quality-of-life questionnaires. Secondary outcomes included change in bladder symptoms, correlation between cognitive and bladder symptoms, and overall medication compliance. The main outcome measure was change in HVLT-R score at Week 4 after medication initiation, compared with baseline (pre-medication) score. RESULTS Of 50 women enrolled, 35 completed the assessment. The average age was 70.4 years and 77.1% had previously taken anticholinergic medication for OAB. At enrollment 65.7% had severe overactive bladder and 71.4% had severe urge incontinence. Cognitive function showed an initial decline on Day 1 in HVLT-R total score (p = 0.037), HVLT-R Delayed Recognition subscale (p = 0.011) and HVLT-R Recognition Bias subscale (p = 0.01). At Week 1 the HVLT-R Learning subscale declined from baseline (p = 0.029). All HVLT-R scores normalized by Week 4. OMC remained stable throughout. The Mini-Cog nadired at a 90.9% pass rate at Week 4. OAB symptoms did not improve until Week 4, based on questionnaire scores (p < 0.05). CONCLUSION Cognitive function exhibited early changes after initiation of trospium chloride but normalized within 4 weeks. Cognitive changes occurred weeks prior to OAB symptom improvement. Surveillance for cognitive changes with anticholinergic use should be part of OAB management.

Outlet constipation 1 year after robotic sacrocolpopexy with and without concomitant posterior repair.

Objectives The aim of this study was to estimate the rate of outlet constipation at 1 year after robotic sacrocolpopexy (RSCP) with and without a concomitant distal posterior repair (PR). We sought, first, to determine the rate of persistent outlet constipation and second, to determine de novo outlet constipation. Methods This was a cohort study of women who underwent RSCP alone versus RSCP + PR, at each surgeon’s discretion, between November 2007 and February 2011 at an academic center. Specific questions in the Pelvic Floor Distress Inventory Short Form correlating to outlet constipation and its colorectal-anal subscale scores were compared between and within groups. Rates of posterior compartment reoperation were assessed. Results Of the 77 women who underwent RSCP, 21 (27%) had a concomitant distal PR. Overall, there was significant improvement in pelvic floor function and quality of life at 1 year after surgery (P = 0.01). Preoperatively, outlet constipation was present in 63.4% of those who underwent RSCP only and in 53.3% of those with concomitant PR. Postoperatively at 1 year, 56% of preoperative outlet constipation resolved and 44% persisted (P = 0.001), with no differences between groups (RSCP vs RSCP + PR). The rate of postoperative de novo outlet constipation was 13.6%. At 1 year after RSCP, 18.2% of patients had symptomatic posterior prolapse, with no difference between both groups (P = 0.746). Overall, 11.7% underwent a subsequent PR, none of whom underwent PR with the initial RSCP (P = 0.104). Conclusions At 1 year after RSCP, there was a high rate of persistent outlet constipation and a moderate rate of de novo outlet constipation. Concomitant PR did not significantly affect these bowel symptoms.

Estimating the early impact of the FDA safety communication on the use of surgical mesh.

Objectives To estimate the early impact of the July 2011 Food and Drug Administration Safety Communication on the practice patterns of gynecologic surgeons using surgical mesh to manage pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Methods A cross-sectional study was performed by administering a mesh usage questionnaire to physician attendees at the opening session of the American Association of Gynecologic Laparoscopists Global Congress of Minimally Invasive Gynecology in November 2011. Results Of the 827 physicians attending the opening session of the conference, 281 (34%) completed the questionnaire, 202 (72%) of whom reported performing surgery for POP and/or SUI. The respondents were attending physicians (83.4%) with at least 10 years of experience (65.7%), 136 (71.1%) identifying themselves as General Gynecology, 29 (17.3%) as Urogynecology, 13 (7.1%) as Minimally Invasive Gynecologic Surgery, and 3 (1.8%) as Urology. When compared with generalists, specialists were more likely to use mesh for abdominal (86% vs 56.3%, P < 0.001) and vaginal (65.9% vs 37.2%, P = 0.001) POP repair. Specialists reported using mesh for the anterior compartment (50% vs 28.3%, P = 0.01) and the posterior compartment (36.4% vs 12.5%, P = 0.001), and total vaginal mesh kits (13.6% vs 1.7%, P = 0.005). Respondents reported an increase in mesh use for primary abdominal POP repair (82 vs 92, P = 0.013) and a decrease in mesh use for recurrent vaginal POP repair (99 vs 75, P < 0.001), with more surgeons opting against mesh for recurrent POP (49 vs 74, P < 0.001). For patient counseling, 53.7% reported changing their methods. Conclusions In a self-selected sample of pelvic surgeons, we noted that the 2011 FDA Safety Communication had an impact, with changes in mesh usage and counseling patterns.

Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest

Objectives This study aimed to compare the prevalence and severity of pelvic floor symptoms and sexual function at 1 year postpartum in women who underwent either operative vaginal delivery (OVD) or cesarean delivery (CD) for second-stage arrest. Methods In this cohort study, women with second-stage arrest in their first pregnancy who delivered between January 2009 and May 2011 at 2 different institutions were identified by an obstetric database using International Classification of Diseases, Ninth Revision, codes. Validated questionnaires evaluating pelvic floor symptoms and sexual function were administered. Subjects were dichotomized into those who underwent an OVD or a CD. Additional analyses by intent-to-treat and stratification of vacuum versus forceps operative deliveries were performed. Results Of the 109 women who completed the 1-year postpartum symptom questionnaires, 53 (48.6%) had a successful OVD, 20 (18.3%) failed OVD and underwent CD, and 36 (33%) underwent CD only. There were no differences between those who had a successful OVD and those who underwent a CD in either pelvic floor function or sexual function, but bulge symptoms were more common in the OVD group (7.5% vs 0, P = 0.05). When analyzed by intent-to-treat (planned OVD vs planned CD), pelvic floor symptoms remained similar between groups. However, those in the planned CD group reported higher orgasm and overall sexual satisfaction scores. Conclusions In this sample of primiparous women with second-stage arrest, mode of delivery did not significantly impact pelvic floor function 1 year after delivery, except for bulge symptoms in the OVD group and sexual satisfaction in the planned CD group.

Short-term mesh exposure after robotic sacrocolpopexy with and without concomitant hysterectomy.

Objectives The primary objective of this study was to compare the short-term rate of mesh exposure after a robotic sacrocolpopexy (RSCP) compared with those after RSCP with a concomitant hysterectomy. Secondary objectives included a comparison of mesh exposure from total hysterectomies (TH) versus supracervical hysterectomies (SCH) and determination of risk factors for mesh exposure. Methods This was a retrospective cohort study of women who underwent RSCP between January 2009 and December 2011 at one academic center. The primary outcome was mesh exposure at 6 weeks postoperation. Subjects were divided into two groups: those with concomitant hysterectomy and those with RSCP alone. The hysterectomy group was subdivided into TH versus SCH. Mesh exposures and mesh revision procedures were identified using International Classification of Diseases-9 and CPT codes, respectively, and confirmed by chart review. Results There were 230 eligible women who underwent RSCP during the study period and were followed up at a 6-week postoperative visit; 118 (51.7%) had RSCP only and 112 (48.7%) had a concomitant hysterectomy. Of those who underwent hysterectomy, 79 patients (70.5%) had TH and 33 (29.5%) had SCH. There were nine (3.9%) mesh exposures attributed to RSCP. The difference between the RSCP + hysterectomy group and the RSCP-only group was 2.7% versus 5.1% (P = 0.50). The 2.7% of mesh exposures in the hysterectomy group were associated with TH and none with SCH, but this difference was not significant (P = 0.55). Conclusions Although mesh exposure with RSCP is low, serious morbidity can be associated with mesh use and appropriate preoperative counseling is critical.

Obstetric sphincter injury interacts with diarrhea and urgency to increase the risk of fecal incontinence in women with irritable bowel syndrome.

Objectives This study aimed to confirm that fecal urgency and diarrhea are independent risk factors for fecal incontinence (FI), to identify obstetrical risk factors associated with FI in women with irritable bowel syndrome, and to determine whether obstetric anal sphincter injuries interact with diarrhea or urgency to explain the occurrence of FI. Methods The study is a supplement to a diary study of bowel symptoms in 164 female patients with irritable bowel syndrome. Subjects completed daily bowel symptom diaries for 90 consecutive days and rated each bowel movement for stool consistency and presence of urgency, pain, and FI. All female participants from the parent study were invited to complete a telephone-administered 33-item bowel symptom and obstetric history questionnaire, which included the fecal incontinence severity index. Results Of the 164 women in the parent study, 115 (70.1%) completed the interview. Seventy-four (45.1%) reported FI on their diary including 34 (29.6%) who reported at least 1 episode per month, 112 (97.4%) reported episodes of urgency, and 106 (92.2%) reported episodes of diarrhea. The mean fecal incontinence severity index score was 13.9 (9.7). On multivariable analysis, FI was significantly associated with parity (P = 0.007), operative abdominal delivery (P = 0.049), obstetrical sphincter lacerations (P = 0.007), fecal urgency (P = 0.005), diarrhea (P = 0.008), and hysterectomy (P = 0.004), but was not associated with episiotomy, pelvic organ prolapse, or urinary incontinence. The synergistic interactions of obstetric anal sphincter laceration with urgency (P = 0.002) and diarrhea (P = 0.004) were significant risk factors for FI. Conclusions Fecal urgency and diarrhea are independent risk factors for FI, and they interact with obstetric anal sphincter laceration to amplify the risk of FI.

Diagnostic accuracy of visual urethral mobility exam versus Q-Tip test: a randomized crossover trial

OBJECTIVE The objective of the study was to compare the diagnostic accuracy of a visual urethral mobility examination (VUME) with a Q-Tip test in the assessment of urethral hypermobility. STUDY DESIGN Subjects were randomized to a VUME or Q-Tip test first, followed by the alternate assessment. Outcomes included hypermobile, not hypermobile, or indeterminate. Hypermobility was defined as 30° or greater from the horizontal. Pain perception and test preference were assessed. RESULTS For the 54 subjects, 61.1% demonstrated hypermobility on VUME vs 72.2% on the Q-Tip test (P = .39). Assessment of hypermobility was correlated between the 2 tools (ρ = 0.47, P = .001). Positive and negative predictive value, sensitivity, and specificity for VUME were 88%, 56%, 78%, and 71%, respectively, with a Q-Tip test as the reference standard. Mean pain score on visual analog scale was 0.72 for VUME and 3.15 for Q-tip test (P < .001). VUME was preferred by 83% of subjects. CONCLUSION VUME is a diagnostic alternative to the Q-Tip test for the assessment of urethral hypermobility and is preferred by subjects.

Surgical privileging in gynecology: a Fellows' Pelvic Research Network study.

Objectives This study aimed to describe the criteria used by US hospitals to grant surgical privileges for select gynecologic procedures and to compare the privileging processes between university-based and community-based hospitals. Methods We conducted a cross-sectional study from January 2011 to December 2012 that included institutions represented by Fellows’ Pelvic Research Network members. A 5-page, anonymous survey was distributed to hospitals to determine the hospital criteria used for initial surgical privileges and for renewal of privileges for 13 gynecologic procedures. Information on training requirements, minimum number of supervised cases, and annual case number needed for maintenance was obtained. Criteria for privileging were described and compared between university-based and community-based hospitals. Results Of the 25 institutions that completed the surveys, 56% were university-based and 44% were community-based. Community hospitals differed significantly from university institutions with a larger portion of community hospitals requiring preceptorship for laparoscopic hysterectomy (70% vs 15%, P = 0.027), robotic hysterectomy (90% vs 25%, P = 0.012), robotic sacrocolpopexy (90% vs 20%, P = 0.009), and sacral neuromodulation (67% vs 0%, P = 0.004). Conclusions Considerable variability exists in the criteria used by US hospitals for surgical privileging in gynecology. When compared to university centers, a higher proportion of community hospitals required preceptorship for minimally invasive hysterectomy, robotic sacrocolpopexy, and sacral neuromodulation.

Implementation of a standardized digital rectal exam to improve the accuracy of rectocele diagnosis

Introduction and hypothesisThe standardized evaluation of posterior compartment prolapse using the Pelvic Organ Prolapse Quantification (POP-Q) system is limited. The primary objective of this study is to develop and validate the interexaminer reliability of a new system for assessing the posterior vaginal wall for the presence of a rectocele.MethodsThis was a cross-sectional study of women presenting to an academic urogynecology clinic. Subjects underwent a routine pelvic examination that included a standard POP-Q followed by two Standardized Digital Rectal Exams (SDRE) by two different providers, each blinded to the other’s results. The SDRE measures the distance from the leading edge of a posterior bulge to the hymen with a finger in the distal rectum - first visually and then an actual measured distance using a marked cotton swab (Q-tip measurement). Correlations between examiners for the SDRE and the POP-Q were analyzed using Pearsons correlation coefficient (ρ).ResultsEight attending and fellow urogynecologists examined 50 subjects. Mean age was 57.3 years, mean BMI 30.9 kg/m2, with an overall median POP-Q stage 2 (range 0–3), and median posterior POP-Q stage 1 (range 0–3). Overall, 54 % of women had a noteworthy rectocele by typical digital rectal exam. Interexaminer correlations with SDRE for both the visual assessment (ρ = 0.697, p < 0.0001) and the Q-tip measurement (ρ = 0.767, p = p < 0.001) were strong. The intraexaminer visual assessment and the Q-tip measurement were highly correlated (ρ = 0.934, p = <0.001).ConclusionThis standardized rectal examination provides a consistent method for the reporting of distal rectoceles that can lend additional information to the POP-Q exam.

Overlapping sphincteroplasty and posterior repair

Introduction and hypothesisKnowledge of how to anatomically reconstruct extensive posterior-compartment defects is variable among gynecologists. The objective of this video is to demonstrate an effective technique of overlapping sphincteroplasty and posterior repair.MethodsIn this video, a scripted storyboard was constructed that outlines the key surgical steps of a comprehensive posterior compartment repair: (1) surgical incision that permits access to posterior compartment and perineal body, (2) dissection of the rectovaginal space up to the level of the cervix, (3) plication of the rectovaginal muscularis, (4) repair of internal and external anal sphincters, and (5) reconstruction of the perineal body. Using a combination of graphic illustrations and live video footage, tips on repair are highlighted.ResultsThe goals at the end of repair are to: (1) have improved vaginal caliber, (2) increase rectal tone along the entire posterior vaginal wall, (3) have the posterior vaginal wall at a perpendicular plane to the perineal body, (4) reform the hymenal ring, and (5) not have an overly elongated perineal body.ConclusionThis video provides a step-by-step guide on how to perform an overlapping sphincteroplasty and posterior repair.