Anna C. Kirby

An update on the current and future demand for care of pelvic floor disorders in the United States

OBJECTIVE In 2001, we predicted a 45% increase in the demand for care of women with pelvic floor disorders (PFDs) between 2000 and 2030. However, in 2010, we observed that in our clinic demand for care had increased substantially more than expected. Using updated data, we sought to provide more accurate projections of future demand for care of pelvic floor disorders in the United States. STUDY DESIGN Demographic data on all new female patients between 30 and 89 years of age seen for pelvic floor disorders in our Urogynecology Clinic between 2009 and 2011 were analyzed. These data were combined with United States Census Bureau projections for 2010 and 2030 stratified by 10-year age blocks. RESULTS In 2010, our clinic saw a 116% increase in new patients per year compared with 2000. There was an 85% increase in new patient visits per 1000 women per year compared with 2000. We estimate that 1,218,371 new patient visits took place in the United States in 2010 and predict 1,644,804 visits will occur in 2030. CONCLUSION If the United States population increases 24% by 2030 as projected by the United States Census Bureau, we predict the demand for care for pelvic floor disorders will increase by 35% between 2010 and 2030. This new, more accurate projection for 2030 is based on improved baseline data from 2010 and is 72% higher than we predicted in 2000. Accurately quantifying this growing demand for care of pelvic floor disorders is important for public health planning and physician training.

Systematic Review and Meta-analysis of Candidate Gene Association Studies of Lower Urinary Tract Symptoms in Men

Context Although family studies have shown that male lower urinary tract symptoms (LUTS) are highly heritable, no systematic review exists of genetic polymorphisms tested for association with LUTS. Objective To systematically review and meta-analyze studies assessing candidate polymorphisms/genes tested for an association with LUTS, and to assess the strength, consistency, and potential for bias among pooled associations. Evidence acquisition A systematic search of the PubMed and HuGE databases as well as abstracts of major urologic meetings was performed through to January 2013. Case-control studies reporting genetic associations in men with LUTS were included. Reviewers independently and in duplicate screened titles, abstracts, and full texts to determine eligibility, abstracted data, and assessed the credibility of pooled associations according to the interim Venice criteria. Authors were contacted for clarifications if needed. Meta-analyses were performed for variants assessed in more than two studies. Evidence synthesis We identified 74 eligible studies containing data on 70 different genes. A total of 35 meta-analyses were performed with statistical significance in five (ACE, ELAC2, GSTM1, TERT, and VDR). The heterogeneity was high in three of these meta-analyses. The rs731236 variant of the vitamin D receptor had a protective effect for LUTS (odds ratio: 0.64; 95% confidence interval, 0.49–0.83) with moderate heterogeneity (I2 = 27.2%). No evidence for publication bias was identified. Limitations include wide-ranging phenotype definitions for LUTS and limited power in most meta-analyses to detect smaller effect sizes. Conclusions Few putative genetic risk variants have been reliably replicated across populations. We found consistent evidence of a reduced risk of LUTS associated with the common rs731236 variant of the vitamin D receptor gene in our meta-analyses. Patient summary Combining the results from all previous studies of genetic variants that may cause urinary symptoms in men, we found significant variants in five genes. Only one, a variant of the vitamin D receptor, was consistently protective across different populations.

Preoperative voiding detrusor pressures do not predict stress incontinence surgery outcomes

Introduction and hypothesisThe aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery.MethodsOpening detrusor pressure, detrusor pressure at maximum flow (pdet Qmax), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests.ResultsThere were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes.ConclusionsWe found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.

Indications, contraindications, and complications of mesh in the surgical treatment of urinary incontinence.

The most commonly performed surgeries for stress urinary incontinence are full-length mesh midurethral slings. This chapter will review the indications, contraindications, and complications related to the use of these mesh midurethral slings. Unlike transvaginal mesh for prolapse, complications related to mesh midurethral slings are low and less than the complication rates with previous traditional continence surgeries. Given their safety profile and efficacy, full-length mesh midurethral slings have been rapidly adopted and remain the current standard of care for stress urinary incontinence surgical treatment.

Perineal surface electromyography does not typically demonstrate expected relaxation during normal voiding

To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms.

Measurement of dynamic urethral pressures with a high-resolution manometry system in continent and incontinent women.

Objectives Female stress urinary incontinence is caused by urethral dysfunction during dynamic conditions, but current technology has limitations in measuring urethral pressures under these conditions. An 8-French high-resolution manometry (HRM) catheter currently in clinical use in gastroenterology may accurately measure urethral pressures under dynamic conditions because it has a 25-millisecond response rate and circumferential pressure sensors along the length of the catheter (ManoScan ESO; Given Imaging, Yoqneam, Israel). We evaluated the concordance, repeatability, and tolerability of this catheter. Methods We measured resting, cough, and strain maximum urethral closure pressures (MUCPs) using HRM and measured resting MUCPs with water-perfusion side-hole catheter urethral pressure profilometry (UPP) in 37 continent and 28 stress-incontinent subjects. Maneuvers were repeated after moving the HRM catheter along the urethral length to evaluate whether results depend on catheter positioning. Visual analog pain scores evaluated the comfort of HRM compared to UPP. Results The correlation coefficient for resting MUCPs measured by HRM versus UPP was high (r = 0.79, P < 0.001). Repeatability after catheter repositioning was high for rest, cough, and strain with HRM: r = 0.92, 0.89, and 0.89. Mean MUCPs (rest, cough, and strain) were higher in continent than in incontinent subjects (all P < 0.001) and decreased more in incontinent subjects than in continent subjects during cough and strain maneuvers compared to rest. Conclusions This preliminary study shows that HRM is concordant with standard technology, repeatable, and well tolerated in the urethra. Incontinent women have more impairment of their urethral closure pressures during cough and strain than continent women.

Midurethral slings: which should I choose and what is the evidence for use?

Purpose of review Midurethral slings are currently the most commonly performed surgeries for stress urinary incontinence (SUI). This review examines the pros and cons of the main types of midurethral slings that are available for the surgical treatment of SUI – full-length retropubic, full-length transobturator, and single-incision slings – to assist patients and physicians in choosing between them. Recent findings Comparative studies have shown that full-length retropubic and transobturator midurethral slings have similar efficacy but differ in their risk profiles; retropubic slings have higher rates of bladder perforation whereas transobturator slings have more groin pain and dyspareunia. When a certain type of single-incision sling is excluded from systematic reviews, single-incision slings appear comparable to standard midurethral slings. Summary Both full-length midurethral slings – retropubic and transobturator – are reasonable for the surgical treatment of SUI. The decision to choose one or the other should be individualized based on patient preference after counseling about the risks of each. More recent data suggest that the currently available single-incision slings may be comparable.

Evaluation and management of vaginoplasty complications

Purpose of review Indications for vaginoplasty include congenital conditions such as adrenal hyperplasia, cloacal malformations, and Müllerian agenesis, acquired conditions including stenosis from radiation or surgical resection for malignancy, and gender affirmation. All vaginoplasty techniques carry significant risk of both immediate and long-term complications. Recent findings The purpose of this study is to provide a review of the evaluation and management of the neovagina, addressing management of human papilloma virus infections and complications including stenosis, fistula, prolapse, and neovaginal colitis. Summary Gynecologists who care for patients who have had a vaginoplasty need to understand the importance of long-term follow up and care, including evaluation and management of complications.

Characterization of colorectal symptoms in women with vesicovaginal fistulas

To characterize colorectal symptoms in women with a history of an obstetric vesicovaginal fistula (VVF).