Begüm Özel

The impact of pelvic organ prolapse on sexual function in women with urinary incontinence

The aim of the study is to evaluate the impact of pelvic organ prolapse (POP) on sexual function in women with urinary incontinence (UI). In this retrospective, case-cohort study, we reviewed the medical records of all women evaluated for UI between March and November 2003. All patients completed the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. Women with stage two or greater POP, as determined by the pelvic organ prolapse quantification (POPQ) system, were compared to women with stage 0 or 1 POP. Sixty-nine women with POP and 47 women without POP were included. Patient demographics did not differ between the two groups. Women with POP were significantly more likely to report absence of libido (53% versus 30%, P=0.02), lack of sexual excitement during intercourse (46% versus 27%, P=0.05), and that they rarely experienced orgasm during intercourse (49% versus 30%, P=0.05). In conclusion, women with POP in addition to UI are more likely to report decreased libido, decreased sexual excitement, and difficulty achieving orgasm during intercourse when compared to women with UI alone.

Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder

Objective:The aim of this study was to compare the efficacy of the ultralow-dose estradiol vaginal ring with that of oral oxybutynin in the treatment of overactive bladder in postmenopausal women. Methods:Postmenopausal women with an overactive bladder were recruited from the general gynecology clinic. Participants were randomized to receive either the ultralow-dose estradiol vaginal ring or oral oxybutynin for 12 weeks. The primary outcome was a decrease in the number of voids in 24 hours. The secondary outcomes were quality-of-life questionnaires, vaginal pH levels, and vaginal maturation index. Results:Fifty-nine women were enrolled. Thirty-one were randomized to receive oxybutynin, whereas 28 received the estradiol vaginal ring. Women who received oxybutynin had a mean decrease of 3.0 voids per day, and women who received the vaginal ring had a mean decrease of 4.5 voids per day, with no significant difference between the groups. There was a significant improvement in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores in both groups, with no significant difference in improvement between the two groups. Conclusions:Ultralow-dose estradiol-releasing vaginal ring and oral oxybutynin seem to be similarly effective in decreasing the number of daily voids in postmenopausal women with overactive bladder.

The effect of transdermal and vaginal estrogen therapy on markers of postmenopausal estrogen status.

Objective: To compare serum 17&bgr;-estradiol (E2), estrone (E1), estrone sulfate, follicle-stimulating hormone, luteinizing hormone, sex hormone-binding globulin, vaginal pH, and the vaginal maturation indices in women using a low-dose transdermal patch releasing 14 &mgr;g of E2 per day and a vaginal ring releasing 7.5 &mgr;g of E2 per day. Design: Twenty-four postmenopausal women were randomly assigned to either the patch (n = 12) or the ring (n = 12) for a 12-week study period. Serum E2, E1, estrone sulfate, follicle-stimulating hormone, luteinizing hormone, and sex hormone-binding globulin were measured by immunoassay at baseline and 6 and 12 weeks. Vaginal pH was determined at baseline and 6 and 12 weeks. Vaginal cytologic examinations for vaginal maturation index were done at baseline and 12 weeks. Results: Twenty women completed the study. The patch significantly increased serum E1 and E2 levels at 6 and 12 weeks (P < 0.01); there was no significant increase in serum E1 and E2 levels with the ring. Both the patch and the ring significantly reduced vaginal pH at 6 (P < 0.001) and 12 (P < 0.001) weeks and significantly reduced the percentage of vaginal parabasal cells at 12 weeks with no significant difference between the two groups. Both preparations increased the proportion of superficial cells; the increase was significant only with the patch (P = 0.04). Conclusions: A transdermal E2 skin patch releasing 14 &mgr;g of E2 per day had an effect on vaginal pH and vaginal maturation indices similar to that of a vaginal E2 ring releasing 7.5 &mgr;g of E2 per day. Therefore, this patch is likely to relieve symptoms of vulvovaginal atrophy.

Decreased rate of obstetrical anal sphincter laceration is associated with change in obstetric practice

A study was conducted to describe the rate of obstetrical anal sphincter laceration in a large cohort of women and to identify the characteristics associated with this complication. Data from all vaginal deliveries occurring between January 1996 and December 2004 at one institution were used to compare women with and without anal sphincter lacerations. Among 16,667 vaginal deliveries, 1,703 (10.2%) anal sphincter lacerations occurred. Regression models suggested that episiotomy (OR 1.36; 95% CI 1.16, 1.58), vacuum delivery (OR 3.19; 95% CI 2.69, 3.79), and forceps delivery (OR 2.79; 95% CI 1.94, 4.02) were each associated with the increased risk of anal sphincter laceration. Year of delivery was associated with a decreased risk of anal sphincter laceration (OR 0.94; 95% CI 0.92, 0.96) with the rate of laceration decreasing from 11.2% to 7.9% during the study period. Episiotomy and operative vaginal delivery are significant, modifiable risk factors. Changes in obstetric practice may have contributed to the dramatic reduction in anal sphincter laceration during the study period.

Prevalence and risk factors for pelvic floor symptoms in women in rural El Salvador

Our aim was to assess the frequency of pelvic floor symptoms among women in rural El Salvador. After written informed consent was obtained, we administered the short form of the urodynamic distress inventory (UDI-6) plus four other pelvic floor questions to 236 women aged 30 to 75 in rural El Salvador attending a general medicine or gynecology clinic. Average (SD) age, parity, and body mass index were 48.0 (8.4) years, 5.9 (3.4), and 26.9 (4.9) kg/m2, respectively. Ten (4.2%) women had a prior hysterectomy, 16 (6.8%) women were smokers, and 108 (45.8%) women were postmenopausal. Seventy-one percent of women reported urinary incontinence (UI); 49.3 and 61.1% of women reported urge UI and stress UI, respectively. Forty-one percent of women reported fecal incontinence (FI) of solid or liquid stool. Women with UI were significantly more likely to have had a hysterectomy compared to women without UI. Women with FI had significantly fewer years of education when compared to women without FI. In conclusion, pelvic floor symptoms are highly prevalent among women in rural El Salvador.

Colorectal and anal symptoms in women with urinary incontinence and pelvic organ prolapse

Introduction and hypothesisOur aim was to determine the prevalence of colorectal and anal (CRA) symptoms in women with urinary incontinence and pelvic organ prolapse (UI/POP) in a predominantly Latina population.MethodsWe reviewed charts of women seen in the urogynecology clinic for UI/POP for those who completed the colorectal anal distress inventory-8 (CRADI-8) on their first visit. A detailed history was taken independent of the questionnaire.ResultsTwo hundred sixty-five women completed the questionnaire; 94% were Latina; 89% completed the questionnaire in Spanish. Of the women, 88% indicated at least one CRA symptom: 60% reported needing to strain hard to have a bowel movement; 59% reported sensation of incomplete bowel emptying; 21% indicated incontinence of solid or liquid stool, and an additional 30% of women reported flatal incontinence only, for a total anal incontinence rate of 58%.ConclusionCRA symptoms are highly prevalent among women with UI/POP who completed the CRADI-8 in a predominantly Latina patient population.

Comparison of 2 simulation models for teaching obstetric anal sphincter repair.

Objective The purpose of this study was to compare the utility of 2 surgical models for obstetric anal sphincter repair for improving resident knowledge, confidence level, and repair technique. Study Design Third- and fourth-year obstetrics and gynecology residents at LAC + USC Medical Center performed simulated anal sphincter repair on both sponge and beef tongue surgical models. Resident knowledge, confidence, technical skill, and preference were assessed after each model was performed. Results Both models significantly improved resident confidence (sponge, P = 0.017; tongue, P = 0.016) and knowledge (60% correct before intervention vs. 92% correct after intervention, P < 0.001). There was no difference detected between the 2 models. All participants preferred the tongue model to the sponge model. When performing both models, performing the tongue model after the sponge model resulted in a further increase in confidence (P = 0.008) Conclusions Both models are excellent tools to aid in resident teaching of obstetric anal sphincter repair and significantly increase residents’ knowledge and confidence.

The multicenter urogynecology study on education: Associations between educational outcomes and clerkship center characteristics

Objective: The objective of the study was to examine the effect of center characteristics on educational experiences and female pelvic medicine knowledge changes in third-year students at 6 medical schools. Methods: In this secondary analysis of data acquired during a prospective, multicenter study conducted from May 2008 through June 2009, preclerkship and postclerkship third-year medical students scored their knowledge of 12 female pelvic medicine topics and 4 office procedures (knowledge scores [KSs]). Postclerkship, students also reported the number and type of learning experiences they had encountered. Participating investigators provided data on length of clerkship, number of residents, number of fellowship-trained urogynecologists, presence of a fellowship program, clerkship grading system type, presence of a urogynecology clerkship rotation, and presence of a urogynecology lecture. Analyses used Wilcoxon tests/Spearman correlation, with an &agr; = 0.05. Results: Paired preclerkship and postclerkship survey data were available for 323 students. Increased numbers of learning experiences were positively associated with number of clerkship weeks (rs = 0.22, P < 0.001), presence of a urogynecology rotation (P = 0.03), and urogynecology lecture (P < 0.001). Knowledge scores were positively associated with the number of fellowship-trained urogynecology faculty (rs = 0.17, P = 0.002) and grading system (letter grades > pass/fail) (P < 0.001). Knowledge scores were negatively associated with increasing numbers of residents (rs = −0.29, P < 0.001) and presence of a urogynecology fellowship program (P < 0.001). The center characteristics of fellowship program and number of residents were highly correlated (rs = 0.74, P < 0.001); thus, multivariate modeling was not performed. Conclusions: The presence of fellowship-trained faculty, urogynecology rotation, longer duration of clerkship, and urogynecology lecture were positively correlated with higher subjective KSs. The inverse association of KS with increased resident number and presence of fellowship was an unexpected finding.

Vaginal Angiomyofibroblastoma: A Case Report and Review of Diagnostic Imaging

Background Angiomyofibroblastoma (AMFB) is a benign mesenchymal tumor most commonly found in the female genital tract of premenopausal women. Although rare, AMFB is an important consideration in the differential diagnosis of vulvar and vaginal masses, as it must be distinguished from aggressive angiomyxoma (AA), a locally recurrent, invasive, and damaging tumor with similar clinical and pathologic findings. Case We describe a patient with a 4 cm vaginal AMFB and the relevant preoperative radiographic imaging findings. Conclusion Preoperative diagnosis of AMFB remains difficult. Common findings on magnetic resonance imaging and transvaginal sonography are described. We conclude that both transvaginal ultrasound and MRI are potentially useful imaging modalities in the preoperative assessment of vulvar and vaginal AMFB, with more data needed to determine superiority of one modality over the other.

Outcomes of Treatment for Endometrial Hyperplasia in Women Younger Than Age 35 Years

INTRODUCTION: The objective of this study was to describe treatment outcomes in young women with endometrial hyperplasia. METHODS: A retrospective cohort study of women younger than 35 years with a biopsy diagnosis of endometrial hyperplasia was performed. Demographics, treatment, and histopathology were compared. The institutional review board at the University of Southern California approved this protocol. RESULTS: Two hundred twenty-three patients were identified: 70 atypical and 153 nonatypical endometrial hyperplasia. Mean age was 29.9±4.1 years, and mean body mass index was 40.1±10.5 kg/m2. There was no difference between groups in age, body mass index, gravidity, or parity. Women with atypical endometrial hyperplasia were more likely to have diabetes (25.7% compared with 13.7%, P=.037) and to have a thicker endometrium on ultrasound examination (15.2 mm compared with 12.1 mm, P=.03). Forty-six (20.6%) women had one biopsy and were lost to follow-up. For women managed nonsurgically, the median number of biopsies was four (range one to 22) and the mean follow-up was 24.1±23.3 months. The most common treatment was systemic progestin therapy (75.6%). Among women treated for nonatypical endometrial hyperplasia, the most recent biopsy was benign in 64 of 102 (62.7%), nonatypical in 24.5%, atypical in 11.8%, and cancer in 1.0%. Among women treated for atypical endometrial hyperplasia, the most recent biopsy was benign in 30 of 56 (53.6%), nonatypical in 19.6%, atypical in 17.9%, and cancer in 8.9%. CONCLUSIONS: After 2 years of treatment, nonatypical endometrial hyperplasia rarely progresses to cancer, but 11.8% progress to atypical endometrial hyperplasia. Atypical endometrial hyperplasia progresses to cancer in 8.9% of patients despite treatment. A high lost-to-follow-up rate highlights the need for aggressive counseling and outreach in this high-risk population.