Heidi W. Brown

Accidental bowel leakage in the mature women’s health study: prevalence and predictors

Background:  The 2007 National Institutes of Health incontinence consensus panel emphasised the need for classification and identification of persons at risk for faecal incontinence (FI).

Quality of life impact in women with accidental bowel leakage

Background:  Accidental bowel leakage (ABL) is associated with negative impact on quality of life (QoL) and many women do not seek care.

Factors associated with care seeking among women with accidental bowel leakage.

Objective The aim of this study was to characterize factors associated with care seeking among women with accidental bowel leakage (ABL). Methods A secondary analysis of 938 women with ABL identified in a community-based Internet survey of 5817 US women 45 years or older was performed. Demographics, medical history, incontinence severity, quality of life, coping, and care seeking were assessed using questions derived from validated questionnaires. Accidental bowel leakage was defined as at least 1 episode of stool leakage in the past year in the absence of acute diarrheal illness. Women with ABL were asked, “Have you ever talked to a physician about accidental leakage of stool and/or gas?” and were designated “care seekers” if they responded affirmatively. Factors associated with care seeking on univariate analysis with P < 0.1 were included in a multivariate model. Results The response rate overall was 85% (5817/6873) with 1096 women (19%) reporting ABL. Care-seeking data were available for 938 (86%). Of these, 85% were white, 6% were black/African American, 5% were of Hispanic/Latina/Spanish origin, and 4% other; median age was 55 to 59 years (range, 45 to 49, >75 years), and 87% were insured. Only 29% (268/938) of those with ABL sought care. Multivariate analysis demonstrated that care seekers were more likely to have a primary care physician (PCP), to have heard of ABL, and to have suffered longer with more severe leakage. Conclusions More than two thirds of women with ABL do not seek care. Because those with a PCP and those who have heard of the condition are more likely to seek care, educating the public about ABL and encouraging establishment of care and communication with a PCP may decrease silent suffering.

Lower reproductive tract fistula repairs in inpatient US women, 1979-2006.

Introduction and hypothesisThe objective of the study was to characterize trends in lower reproductive tract fistula (LRTF) repair in inpatient US women from 1979 to 2006.MethodsRetrospective data was obtained from the National Hospital Discharge Survey regarding LRTF diagnoses, demographics, comorbidities, and fistula repair procedures, using ICD-9-CM diagnostic and procedure codes. Age-adjusted rates (AARs) were calculated using 1990 census data. Trends in LRTF surgical repair were evaluated using regression analysis.ResultsBetween 1979 and 2006, the AAR of LRTF repair declined from 7.8 to 4.8 per 100,000 women (b = −2.97, p < 0.001). The most common surgical fistula repairs were rectovaginal, vesicovaginal, and colovaginal. The AARs of colovaginal and vesicovaginal fistula repair remained stable, while the AAR of rectovaginal fistula repair declined.ConclusionsThe AAR of inpatient LRTF repair declined between 1979 and 2006, perhaps reflecting a concurrent decrease in obstetric trauma, in the context of decreasing episiotomy and operative vaginal delivery and increasing cesarean section rates.

Risk factors for mesh extrusion after prolapse surgery: a case-control study.

Objectives To identify risk factors for mesh extrusion in women undergoing pelvic organ prolapse repair by abdominal sacral colpopexy (ASC) or vaginal mesh procedure (VMP). Methods A multicenter case-control study of patients who underwent ASC or VMP from 2006 to 2009 identified using diagnosis and procedure coding. Cases were defined as women who underwent eligible index procedure with synthetic mesh and had mesh visible through the vaginal epithelium at postoperative evaluation; controls were matched in an approximate 1:3 ratio by date and type of procedure. Two conditional logistic regression models were constructed to assess variables associated with mesh extrusion among women who underwent ASC and among women who underwent VMP. Results Eighty-four cases were identified (43 cases after ASC and 41 cases after VMP), and 252 patients were matched as controls (147 patients who underwent ASC and 105 patients who underwent VMP). Concomitant hysterectomy was positively associated with mesh extrusion) among women who underwent ASC (adjusted odds ratio, 3.18; 95% confidence interval, 1.27–7.93; P = 0.01) and VMP (adjusted odds ratio, 3.72, 95% confidence interval, 1.20–11.54; P = 0.02). Age, race, type of vaginal incision, menopausal status, medical comorbidities, and smoking were not significantly associated with extrusion in either group. Conclusions Concomitant hysterectomy is a risk factor for mesh extrusion after ASC and VMPs. This information may be helpful during informed preoperative counseling and planning.

Management of vesicovaginal fistulae: a multicenter analysis from the Fellows' Pelvic Research Network.

Objectives Vesicovaginal fistulae (VVF) are the most commonly acquired fistulae of the urinary tract, but we lack a standardized algorithm for their management. The purpose of this multicenter study was to describe practice patterns and treatment outcomes of VVF in the United States. Methods This institutional review board–approved multicenter review included 12 academic centers. Cases were identified using International Classification of Diseases codes for VVF from July 2006 through June 2011. Data collected included demographics, VVF type (simple or complex), location and size, management, and postoperative outcomes. &khgr;2, Fisher exact, and Student t tests, and odds ratios were used to compare VVF management strategies and treatment outcomes. Results Two hundred twenty-six subjects were included. The mean age was 50 (14) years; mean body mass index was 29 (8) kg/m2. Most were postmenopausal (53.0%), nonsmokers (59.5%), and white (71.4%). Benign gynecologic surgery was the cause for most VVF (76.2%). Most of VVF identified were simple (77.0%). Sixty (26.5%) VVF were initially managed conservatively with catheter drainage, of which 11.7% (7/60) resolved. Of the 166 VVF initially managed surgically, 77.5% resolved. In all, 219 subjects underwent surgical treatment and 83.1% of these were cured. Conclusions Most of VVF in this series was managed initially with surgery, with a 77.5% success rate. Of those treated conservatively, only 11.7% resolved. Surgery should be considered as the preferred approach to treat primary VVF.

Practice patterns regarding management of rectovaginal fistulae: A multicenter review from the fellows' pelvic research network

Objectives Rectovaginal fistulae (RVFs) are often debilitating and there are no established treatment algorithms. We sought to describe current diagnosis and management strategies for RVFs across the United States. Methods This institutional review board–approved multicenter retrospective study included 12 sites. Cases were identified using International Classification of Diseases, Ninth Revision codes during a 5-year period. Demographics, management, and outcomes of RVF treatment were collected. Results Three hundred forty-two charts were identified; 176 (52%) met criteria for inclusion. The mean (SD) age was 45 (17) years. Medical history included hypertension (21%), cancer (17%), Crohn disease (11%), and diabetes (7%). Rectovaginal fistulae were often associated with obstetric trauma (42%), infection/inflammation (24%), and cancer (11%). Overall, most RVFs were primary (94%), small (0.5–1.5 cm; 49%), transsphincteric (31%), and diagnosed via vaginal and rectal (60%) examination. Eighteen percent (32/176) were initially managed conservatively for a median duration of 56 days (interquartile range, 29–168) and 66% (21/32) of these resolved. Almost half (45%) of RVFs treated expectantly were tiny (<0.5 cm). Eighty-two percent (144/176) of subjects were initially managed surgically and 81% (117/144) resolved. Procedures included simple fistulectomy with or without Martius graft (59%), transsphincteric repair (23%), transverse transperineal repair (10%), and open techniques (8%), and 87% of these procedures were performed by urogynecologists. Conclusions In this large retrospective review, most primary RVFs were treated surgically, with a success rate of more than 80%. Two thirds of RVFs managed conservatively resolved spontaneously, and most of these were tiny (<0.5 cm). These success rates can be used in counseling to help our patients make informed decisions about their treatment options.

Urinary incontinence in women

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Feasibility of prophylactic salpingectomy during vaginal hysterectomy

BACKGROUND: The American Congress of Obstetricians and Gynecologists recommends that “the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy,” resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy. OBJECTIVE: The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms. STUDY DESIGN: This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow‐up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and χ2 test when appropriate. Questionnaire scores were compared using paired t tests. RESULTS: Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5–5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5–22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001). CONCLUSION: Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible.

Patient reported outcome measures after incontinence and prolapse surgery: are the pictures painted by the ICIQ and PGI-I accurate?

Following surgery to treat stress urinary incontinence (SUI) or pelvic organ prolapse (POP), it is important to assess both objective and subjective outcomes. While not life-threatening, SUI and POP have potential for a significant adverse impact on quality of life, and thus the patient perspective has become increasingly important when evaluating treatment outcomes. Patient reported outcome measures (PROMs) are frequently used for subjective evaluation of the benefits of a treatment or intervention by gauging patients views on any change in their symptoms, function and health-related quality of life. In this issue, Larsen et al. report on the assessment of postoperative outcomes of SUI and POP surgery using PROMs [1]. It is commonly accepted in urogynaecological research and practice that different PROMs will measure different things. Although newly developed outcome measures are typically validated against a combination of existing objective and subjective measures, time and again, studies find limited correlations between different measures of disease severity or treatment improvement [2]. As a consequence, the available PROMs are often seen as complementary to one other. It is frequently recommended that clinicians should employ a range of PROMs, and it is usual for studies to employ a multitude of PROMs to fully capture different aspects of the patient experience of pelvic floor dysfunction [3, 4]. Larsen and colleagues compare the results of two different widely used PROMs. The International Consultation on Incontinence Questionnaire (ICIQ) system, developed from the earlier Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire, measures the severity and bother of individual symptoms. In the format used in this study the ICIQ also provides separate global measures of interference in everyday life for urinary incontinence and POP. The Patient Global Impression of Improvement (PGI-I) is a seven-point scale that provides a single global measure of condition improvement. It was initially developed during the licensing trials of duloxetine for the treatment of SUI, but has subsequently been revalidated as a measure for improvement following treatment for POP and urgency incontinence. Larsen et al.’s study has some remarkable features, most notably its sample size, with the underlying database including more than 90 % of all surgeries performed for SUI and POP in Denmark during 2013, likely representing the largest ever reported surgical cohort study in urogynaecology. They find that overall results for both SUI and POP surgeries are excellent, with very substantial mean improvements on both the ICIQ and the PGI-I at the 3-month post-operative followup. The response rate of 60 % also suggests some potential for bias, but regardless, these are largely reassuring data. Interestingly, the age trends in this study lead in the opposite directions for SUI and POP surgery, with younger women reporting better results for SUI surgery and worse results for POP surgery. To make comparisons between the ICIQ and the PGI-I measures, individual scores for each were converted to the same scale. This procedure is likely fraught with difficulties, as the numerical values assigned to each category in the underlying items is somewhat arbitrary, and it is certainly * Rufus Cartwright r.cartwright@imperial.ac.uk