Dee E. Fenner

Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse.

BACKGROUND: To compare levator ani defects and pelvic floor function among women with prolapse and controls. METHODS: Levator ani structure and function were measured in a case–control study with group matching for age, race, and hysterectomy status among 151 women with prolapse (cases) and 135 controls with normal support (controls) determined by pelvic organ prolapse quantification examination. Magnetic resonance imaging was used to determine whether there were “major” (more than half missing), “minor” (less than half of the muscle missing), or no defects in the levator ani muscles. Vaginal closure force at rest and during maximal pelvic muscle contraction was measured with an instrumented vaginal speculum. RESULTS: Cases were more likely to have major levator ani defects than controls (55% compared with 16%), with an adjusted odds ratio of 7.3 (95% confidence interval 3.9–13.6, P<.001) but equally likely to have minor defects (16% compared with 22%). Of women who reported delivery by forceps, 53% had major defects compared with 28% for the nonforceps women, adjusted odds ratio 3.4 (95% confidence interval 1.95–5.78). Women with prolapse generated less vaginal closure force during pelvic muscle contraction than controls (2.0 Newtons compared with 3.2 Newtons P<.001), whereas those with defects generated less force than women without defects (2.0 Newtons compared with 3.1 Newtons, P<.001). The genital hiatus was 50% longer in cases than controls (4.7±1.4 cm compared with 3.1±1.0 cm, P<.001). CONCLUSION: Women with prolapse more often have defects in the levator ani and generate less vaginal closure force during a maximal contraction than controls. LEVEL OF EVIDENCE: II

Predictors of physician career satisfaction, work-life balance, and burnout

OBJECTIVE: To explore factors associated with physician career satisfaction, work–life balance, and burnout focusing on differences across age, gender, and specialty. METHODS: A cross-sectional, mailed, self-administered survey was sent to a national sample of 2,000 randomly-selected physicians, stratified by specialty, age, and gender (response rate 48%). Main outcome measures included career satisfaction, burnout, and work–life balance. Scales ranged from 1 to 100. RESULTS: Both women and men report being highly satisfied with their careers (79% compared with 76%, P<.01), having moderate levels of satisfaction with work–life balance (48% compared with 49%, P=.24), and having moderate levels of emotional resilience (51% compared with 53%, P=.09). Measures of burnout strongly predicted career satisfaction (standardized β 0.36–0.60, P<.001). The strongest predictor of work–life balance and burnout was having some control over schedule and hours worked (standardized β 0.28, P<.001, and 0.20–0.32, P<.001, respectively). Physician gender, age, and specialty were not strong independent predictors of career satisfaction, work–life balance, or burnout. CONCLUSION: This national physician survey suggests that physicians can struggle with work–life balance yet remain highly satisfied with their career. Burnout is an important predictor of career satisfaction, and control over schedule and work hours are the most important predictors of work–life balance and burnout. LEVEL OF EVIDENCE: II

Stress Urinary Incontinence: Relative Importance of Urethral Support and Urethral Closure Pressure

PURPOSE Treatment strategies for stress incontinence are based on the concept that urethral mobility is the predominant causal factor with sphincter function a secondary contributor. To our knowledge the relative importance of these 2 factors has not been assessed in properly controlled studies. MATERIALS AND METHODS The Research on Stress Incontinence Etiology project is a case-control study that compared 103 women with stress incontinence and 108 asymptomatic controls in groups matched for age, race, parity and hysterectomy. Urethral closure pressure, urethral and pelvic organ support, levator ani muscle function and intravesical pressure were measured and analyzed using logistic regression and multivariable modeling. RESULTS Mean +/- SD maximal urethral closure pressure was 42% lower in cases (40.8 +/- 17.1 vs 70.2 +/- 22.4 cm H(2)O, d = 1.47). Lesser effect sizes were seen for support parameters, including resting urethral axis and urethrovaginal support (d = 0.41 and 0.50, respectively). Other pelvic floor parameters, including genital hiatus size and urethral axis during muscle contraction (d = 0.60 and 0.58, respectively), differed but levator strength and levator defect status did not. Maximum cough pressure, which is an assessment of stress on the continence mechanism, was also different (d = 0.43). After adjusting for body mass index the maximal urethral closure pressure alone correctly classified 50% of cases. Adding the best predictors for urethrovaginal support and cough strength to the model added 11% of predictive ability. CONCLUSIONS The finding that maximal urethral closure pressure and not urethral support is the factor most strongly associated with stress incontinence implies that improving urethral function may have therapeutic promise.

Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction.

Pelvic organ prolapse is a common and growing condition for which women seek help and frequently undergo surgical management. Prolapse of the posterior vaginal wall, alone or in combination with other compartment defects, can be a challenge for the pelvic surgeon. A clear understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship or lack of relationship between anatomy and function is required. Vaginal support defects occur with and without symptoms, and many of the symptoms attributed to pelvic organ prolapse can result from other causes. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been correlated with rectoceles. Whether the prolapse is the cause of these symptoms or is a result of straining and stretching of support tissues in women with defecation disorders is still unknown. We will present the current literature on these relationships and what evaluations are useful when caring for a woman with a rectocele and defecation disorders. Either pessaries or surgery can be used for treating rectoceles. Several surgical techniques have been described, including transvaginal, transanal, abdominal, and the use of graft materials to treat both anatomical defects and functional symptoms. The success, rationale, and complications of each approach, including anatomic cure, impact on defecation, and sexual function, are presented.

Complications requiring reoperation following vaginal mesh kit procedures for prolapse.

OBJECTIVE The objective of the study was to the characterize the symptoms and management of vaginal mesh-related complications requiring operative intervention. STUDY DESIGN This was a case series of patients undergoing excision of vaginal graft material. Only women who had vaginal mesh placement for the correction of pelvic organ prolapse (POP) were included. We describe the symptoms, complications, and management of women treated surgically for vaginal mesh-related complications. RESULTS Thirteen referred women underwent surgery for vaginal mesh-related complications. All meshes were Apogee and/or Perigee. Ten had symptomatic mesh exposures, 1 had an exposure with pelvic abscess, and 2 had pain syndromes without mesh exposure. Patients also had rectovaginal fistula, vesicovaginal fistula, recurrent POP, and persistent discharge. Five women had prior surgery for this problem. All patients underwent transvaginal mesh excision and other indicated procedures at our institution, and 6 women required a second surgery at our institution, with a median of 2 surgeries per patient. CONCLUSION Vaginal mesh placement for POP can be associated with pain, exposure, and fistula formation, requiring multiple operative interventions.

Development of a bench station objective structured assessment of technical skills.

OBJECTIVE We have previously shown that objective structured assessment of technical skills performed in an animal model was an innovative, reliable, and valid method of assessing surgical skills. Our goal was to develop a less costly bench station objective structured assessment of technical skills and to evaluate the feasibility, reliability, and validity of this exam. METHODS A seven‐station examination was administered to 24 residents. The tests included laparoscopic procedures (salpingostomy, intracorporeal knot tying, closure of port sites) and open abdominal procedures (subcuticular closure, bladder neck suspension, repair of enterotomy, abdominal wall closure). All tasks were performed using life‐like surgical models. Residents were timed and assessed at each station using three methods of scoring: a task‐specific checklist, a global rating scale, and a pass/fail grade. RESULTS Assessment of construct validity, the ability of the test to discriminate among residency levels, found significant differences on the checklist, global rating scale, time for procedures, and pass/fail grade by level of training. Reliability indices calculated with Cronbachs ∞ were 0.77 for the checklists and 0.94 for the global rating scale. Overall interrater reliability indices were 0.91 for the global rating scale and 0.92 for the checklists. Total cost for replaceable parts and facilities was

The use of graft materials in vaginal pelvic floor surgery

1900. CONCLUSION The less costly and more portable bench station objective structured assessment of technical skills can reliably and validly assess the surgical skills of gynecology residents. This type of examination can be a useful tool to identify residents who need additional surgical instruction, provide remediation, and may become a mechanism to certify surgical skill competence.

Establishing the Prevalence of Incontinence Study: Racial Differences in Women's Patterns of Urinary Incontinence

To review recent literature on graft materials used in vaginal pelvic floor surgery.

Effects of aging on lower urinary tract and pelvic floor function in nulliparous women.

PURPOSE We examine racial differences in urinary incontinence prevalence, frequency, quantity, type, and risk factors in a population based sample of community dwelling black and white women. MATERIALS AND METHODS Women 35 to 64 years old were sampled from telephone records from 3 southeast Michigan counties. Women self-identifying as black or white race completed a telephone interview that assessed demographics, health history, lifestyle factors and urinary incontinence experience. Statistical analysis included descriptive statistics, factor analysis and multivariable logistic regression to determine adjusted odds of urinary incontinence. Estimates were weighted to reflect probability and nonresponse characteristics of the sample, and to increase generalizability of the findings. RESULTS Interviews were completed by 1,922 black and 892 white women (response rate = 69%). The overall prevalence of urinary incontinence was 26.5%. By race, urinary incontinence prevalence was 14.6% for black women and 33.1% for white women (p <0.001). Among incontinent women there was no difference by race in the frequency of urinary incontinence. However, black women reported more urine loss per episode (p <0.05). A larger proportion of white women with incontinence (39.2%) reported symptoms of pure stress incontinence compared to black women (25.0%), whereas a larger proportion of black women (23.8%) reported symptoms of pure urge incontinence compared to white women (11.0%). Risk factors for urinary incontinence were generally similar for white and black women. CONCLUSIONS In this population based study we observed racial differences in prevalence, quantity and type of urinary incontinence. Frequency of and risk factors for urinary incontinence were generally similar for white and black women.

Economic Cost of Fecal Incontinence

OBJECTIVE: To evaluate the effects of aging, independent of parity, on pelvic organ and urethral support, urethral function, and levator function in a sample of nulliparous women. METHODS: A cohort of 82 nulliparous women, aged 21–70 years, were recruited from the community through advertisements. Subjects underwent pelvic examination using pelvic organ prolapse quantification, urethral angles by cotton-tipped swab, and multichannel urodynamics and uroflow. Vaginal closure force was quantified using an instrumented vaginal speculum. Subjects were grouped into five age categories and analyses performed using t tests, Fisher exact tests, Kruskal-Wallace, and Pearson correlation coefficients. Multiple linear regression modeling was performed to adjust for factors that might confound the results of our primary outcomes. RESULTS: Increasing age was associated with decreasing maximal urethral closure pressure (r=–0.758, P<.001) with a 15-cm-H2O decrease in pressure per decade. Pelvic organ support as measured by pelvic organ prolapse quantification did not differ by age group. Levator function as measured by resting vaginal closure force and augmentation of vaginal closure force also did not change with increasing age. CONCLUSION: In a sample of nulliparous women between 21 and 70 years of age maximal urethral closure pressure in the senescent urethra was 40% of that in the young urethra; increasing age did not affect clinical measures of pelvic organ support, urethral support, and levator function. LEVEL OF EVIDENCE: III