Gena C. Dunivan

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop.

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization.

OBJECTIVE We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI. STUDY DESIGN Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data. RESULTS FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients. CONCLUSION Increased screening of FI is needed.

Robotic vs abdominal sacrocolpopexy: 44-month pelvic floor outcomes.

OBJECTIVE To evaluate longer-term clinical outcomes after robotic vs abdominal sacrocolpopexy for the treatment of advanced pelvic organ prolapse (POP). MATERIAL AND METHODS This was a retrospective cohort assessment of women undergoing either robotic or abdominal sacrocolpopexy between March 2006 and October 2007. Pelvic floor support was measured using Pelvic Organ Prolapse Quantification (POP-Q) examination, and pelvic floor function was assessed via validated questionnaires, including the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). RESULTS The analysis included 51 subjects: 23 robotic and 28 abdominal. Mean time since surgery was 44.2 ± 6.4 months. Postoperative POP-Q improved similarly from baseline in both the robotic and abdominal groups: C (-8 vs -7), Aa (-2.5 vs -2.25), Ap (-2 vs -2) (all P >.05 based on route of surgery). Pelvic floor function also improved similarly in both groups: PFDI-20 (61.0 vs 54.7), PFIQ-7 (19.1 vs 15.7), with high sexual function PISQ-12 (35.1 vs 33.1) (all P >.05 based on route of surgery). Two mesh exposures occurred in each group for a rate of 8% and 7%, respectively. CONCLUSION Robotic sacrocolpopexy demonstrates similar long-term outcomes compared with abdominal sacrocolpopexy. The robotic approach offers an effective treatment alternative to abdominal sacrocolpopexy for the lasting treatment of advanced POP.

Pelvic Floor Function Before and After Robotic Sacrocolpopexy: One-Year Outcomes

STUDY OBJECTIVE Estimate pelvic floor function and support 1 year after robotic sacrocolpopexy. DESIGN Prospective cohort analysis of women undergoing robotic sacrocolpopexy for correction of advanced pelvic organ prolapse (Canadian Task Force Classification III). Primary outcome was pelvic floor function. Secondary outcomes included anatomic support and long-term surgical failures and complications. SETTING One university hospital in the southeastern United States. PATIENTS Primarily postmenopausal women (mean age 60) with advanced pelvic organ prolapse. INTERVENTIONS All subjects underwent robotic sacrocolpopexy during the study period. Subjects then underwent 1-year postoperative assessment of pelvic floor function via validated condition-specific quality of life questionnaires and assessment of pelvic floor support, long-term surgical failures, and complications via physical examination. MEASUREMENTS AND MAIN RESULTS From November 2007 to April 2009, there were 28 subjects, 25 of whom (89.3%) were evaluated. Mean time since surgery was 14.8 months. Pelvic floor function remained significantly improved over preoperative baseline: PFDI-20 (117 vs 38, p <.001), PFIQ-7 (60 vs 10, p = .001), with stable high sexual function: PISQ-12 (34 vs. 36, p = .17), and improved pelvic support on POP-Q: Ba (+3 vs -2, p = .001), Bp (+0.5 vs -1, p = .092), C (+2.25 vs -8, p = .001). Anatomic cure for vault prolapse was 100% at 1 year. There were two mesh exposures and two subsequent prolapse surgeries. CONCLUSION Robotic sacrocolpopexy demonstrates durable improvement in pelvic floor function and support, with high sexual function and reasonable failure and complication rates 1 year after surgery.

Severe separation of the pubic symphysis and prompt orthopedic surgical intervention

BACKGROUND: The incidence of pubic symphysis separation during delivery is 1 in 300 to 1 in 30,000 pregnancies, and it can cause a variety of problems such as pain, bladder dysfunction, and difficulty ambulating. There is no consensus on how to treat pregnancy-related pubic symphyseal separation. CASE: A patient, gravida 1 para 1, who underwent vacuum-assisted vaginal delivery was found to have a severe vaginal sidewall laceration and a 6.2-cm symphyseal disruption. The patient was treated with external fixation of an open book pelvis and physical therapy. She was discharged to home on postpartum day 4, voiding spontaneously and ambulatory with a walker. CONCLUSION: Aggressive treatment of severe pubic symphysis separation with external fixation resulted in early ability to ambulate, void, and care for self and baby.

The association between fecal incontinence and sexual activity and function in women attending a tertiary referral center

Introduction and hypothesisTo determine whether fecal incontinence (FI) is associated with sexual activity and to compare sexual function in women with and without FI.MethodsWe conducted a retrospective chart review of all new patients seen in an academic urogynecology clinic. Women who reported fecal incontinence, as defined by loss of fecal material on the Wexner scale, were compared with those without fecal incontinence. We compared sexual activity and Pelvic Organ Prolapse Incontinence Sexual Questionnaire-12 (PISQ-12) scores between groups.ResultsIn our population of women with pelvic floor disorder, 588 women reported FI compared with 527 who did not. On multivariate analysis, FI was not associated with sexual activity status, but was associated with worsened PISQ-12 scores (p < 0.001). PISQ-12 item analysis found that women with FI reported more dyspareunia, fear, and avoidance of sexual activity with greater partner problems (all p <0.05) than women without FI.ConclusionsWomen with FI were as likely to engage in sexual relations as women without FI; however, sexually active women with FI had poorer sexual function than those without FI.

Diagnostic accuracy of retrograde and spontaneous voiding trials for postoperative voiding dysfunction: a randomized controlled trial.

OBJECTIVE: To compare the diagnostic accuracy of two voiding trial methods to predict postoperative voiding dysfunction. METHODS: Women undergoing operations for urinary incontinence, prolapse, or both urinary incontinence and prolapse from November 2009 and March 2010 were randomized into one of two groups: retrograde or spontaneous. All patients underwent both techniques of voiding trials with randomization determining order. RESULTS: Fifty women were randomized to 25 per group. Failure rates were 62% for retrograde and 84% for spontaneous. Women who failed both had 12.6±14.4 days of retention compared with 2.5±2.1 days for those who failed only one method (P=.004). The retrograde method had 94.4% sensitivity and 58.1% specificity to detect postoperative voiding dysfunction lasting at least 7 days compared with the spontaneous method with 100% sensitivity and 25.8% specificity. Positive and negative predictive values for the retrograde method were 56.7% and 94.7%, respectively, compared with the spontaneous method with 43.9% and 100%. Retrograde was preferred by patients (51.1% compared with 44.4%) regardless of randomization. CONCLUSION: The retrograde method is more accurate in evaluating postoperative voiding dysfunction, although both tests had a low positive predictive value. A longer period of retention was seen with failure of both methods. Retrograde was preferred by patients and provides an efficient alternative to the spontaneous method of voiding trial. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01091844. LEVEL OF EVIDENCE: I

Elder American Indian women's knowledge of pelvic floor disorders and barriers to seeking care.

Objectives The objectives of this study are to evaluate urinary incontinence and pelvic organ prolapse knowledge among elder southwestern American Indian women and to assess barriers to care for pelvic floor disorders through community-engaged research. Methods Our group was invited to provide an educational talk on urinary incontinence and pelvic organ prolapse at an annual meeting of American Indian elders. Female attendees aged 55 years or older anonymously completed demographic information and 2 validated questionnaires, the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and Barriers to Incontinence Care Seeking Questionnaire (BICS-Q). Questionnaire results were compared with historical controls from the original PIKQ and BICS-Q validation study. Results One hundred forty-four women completed the questionnaires. The mean age was 77.7 ± 9.1 years. The mean (SD) for PIKQ of urinary incontinence score was 6.6 (3.0) (similar to historic gynecology controls 6.8 [3.3], P = 0.49), and the mean (SD) for PIKQ on pelvic organ prolapse score was 5.4 (2.9) (better than historic gynecology controls 3.6 [3.2], P < 0.01). Barriers to care seeking reported by the elder women were highest on the BICS-Q subscales of “cost” and “inconvenience.” Conclusions Urinary incontinence knowledge is similar to historic gynecology controls, and pelvic organ prolapse knowledge is higher than historic gynecology controls among elder southwestern American Indian women. American Indian elder women report high levels of barriers to care. The greatest barriers to care seeking for this population were related to cost and inconvenience, reflecting the importance of assessing socioeconomic status when investigating barriers to care. Addressing these barriers may enhance care-seeking southwestern American Indian women.

Ethnicity and variations of pelvic organ prolapse bother

Introduction and hypothesisTo determine if prolapse symptom severity and bother varies among non-Hispanic white, Hispanic, and Native American women with equivalent prolapse stages on physical examination.MethodsThis was a retrospective chart review of new patients seen in an academic urogynecology clinic from January 2007 to September 2011. Data were extracted from a standardized intake form, including patients’ self-identified ethnicity. All patients underwent a Pelvic Organ Prolapse Quantification (POPQ) examination and completed the Pelvic Floor Distress Inventory-20 (PFDI-20) with its Pelvic Organ Prolapse Distress Inventory (POPDI) subscale.ResultsFive hundred and eighty-eight new patients were identified with pelvic organ prolapse. Groups did not differ by age, prior prolapse, and/or incontinence surgery, or sexual activity. Based on POPDI scores, Hispanic and Native American women reported more bother compared with non-Hispanic white women with stage 2 prolapse (p < 0.01). Level of bother between Hispanic and Native American women with stage 2 prolapse (p = 0.56) was not different. In subjects with ≥ stage 3 prolapse, POPDI scores did not differ by ethnicity (p = 0.24). In multivariate stepwise regression analysis controlling for significant factors, Hispanic and Native American ethnicity contributed to higher POPDI scores, as did depression.ConclusionsAmong women with stage 2 prolapse, both Hispanic and Native American women had a higher level of bother, as measured by the POPDI, compared with non-Hispanic white women. The level of symptom bother was not different between ethnicities in women with stage 3 prolapse or greater. Disease severity may overshadow ethnic differences at more advanced stages of prolapse.

Readability of common health-related quality-of-life instruments in female pelvic medicine.

Objectives The average American adult reads below the eighth-grade level. To determine whether self-reported health-related quality-of-life questionnaires used for pelvic floor disorders are appropriate for American women, we measured reading levels of questionnaires for urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI). Methods An online literature search identified questionnaires addressing UI, POP, and FI. Readability was assessed using Flesch-Kincaid reading level and ease formulas. Flesch-Kincaid grade level indicates the average grade one is expected to completely and lucidly comprehend the written text. Flesch-Kincaid reading ease score, from 0 to 100, indicates how easy the written text can be read. Results Questionnaires were categorized by UI, POP, FI, and combined pelvic floor symptoms. The median Flesch-Kincaid reading level was 7.2, 10.1, 7.6, and 9.7, for UI, POP, FI, and combined pelvic floor symptoms, respectively. Reading levels varied greatly between questionnaires, with only 54% of questionnaires written below the eighth-grade level. Conclusions We identified significant variation in reading levels among the questionnaires and found the 2 most commonly used questionnaires per survey in 2008 at Society of Urodynamics and Female Pelvic Medicine and Urogenital Reconstruction were above the recommended eighth-grade reading level. As specialty societies focus on standardizing questionnaires for research, reading levels should be considered so they are generalizable to larger populations of women with pelvic floor disorders.