Joy A. Greer

Pelvic floor muscle training for urgency urinary incontinence in women: a systematic review

The objective of this study is to evaluate the effectiveness of existing physiotherapy modalities for the treatment of urge urinary incontinence (UUI). A systematic review was performed for primary studies of physiotherapy techniques for UUI published in English between 1996 and August 2010 in major electronic databases. Only randomized clinical trials that reported outcomes separately for women with UUI were included. Outcomes assessed were reduction in UUI, urinary frequency, and nocturia. Data from 13 full-text trials including the modalities of pelvic floor muscles exercises with or without biofeedback, vaginal electrical stimulation, magnetic stimulation, and vaginal cones were analyzed. The methodologic quality of these trials was fair. Significant improvement in UUI was reported for all physiotherapy techniques except vaginal cone therapy. There are insufficient data to determine if pelvic physiotherapy improves urinary frequency or nocturia. Evidence suggests that physiotherapy techniques may be beneficial for the treatment of UUI.

Functional status and postoperative morbidity in older women with prolapse.

PURPOSE We determined the relationship of preoperative functional status to postoperative morbidity after pelvic organ prolapse surgery in women older than 60 years. MATERIALS AND METHODS We performed a retrospective cohort study of 223 women older than 60 years who underwent surgery for stage II or greater pelvic organ prolapse. Our exposure was preoperative functional status, defined as American Society of Anesthesiologists (ASA) physical status class. We compared postoperative outcomes (length of stay in a medical facility, and number and severity of postoperative complications) in women with low functional status (ASA class III) to those in women with high functional status (ASA classes I and II). We determined the association of preoperative functional status with postoperative outcomes on multivariate analysis. RESULTS Women in ASA class III were significantly likely to be older (mean ± SD age 72.7 ± 7.3 vs 68.3 ± 6.5 years) and of nonwhite ethnicity (36.1% vs 20.1%), have a higher body mass index (mean 29.5 ± 5.6 vs 26.1 ± 3.8 kg/m(2)) and worse functional comorbidity score (median 3 vs 2), and have undergone obliterative surgery (33.3% vs 9.1%) than women in ASA classes I and II (each p <0.05). Low preoperative functional status was independently associated with increased length of stay in a medical facility (2.13 days, 95% CI 0.57, 3.70, p <0.01) and postoperative complications (OR 2.17, 95% CI 1.03, 4.56), after adjusting for age, body mass index, nonwhite ethnicity, number of comorbidities, surgeon and type of surgery. CONCLUSIONS As defined by ASA class, preoperative functional status is significantly associated with postoperative length of stay and complications. Preoperative functional status is useful for predicting postoperative outcomes in older women who undergo pelvic organ prolapse surgery.

Development and Validation of Simulation Training for Vaginal Hysterectomy

STUDY OBJECTIVE To develop and validate an educational intervention based on vaginal hysterectomy (VH) simulation. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING Surgical skills simulation center. PATIENTS Thirty residents in Obstetrics and Gynecology (11 PGY-2, 11 PGY-3, and 8 PGY-4). INTERVENTION VH educational intervention that included a lecture, a video, and surgical skill simulation using a new inexpensive model. MEASUREMENTS AND MAIN RESULTS The primary outcome was written test scores before and after the educational intervention, and the secondary outcome was self-rated confidence in performing VH. Baseline written scores were similar for all 3 training levels; however, baseline confidence scores were higher for PGY-3 and PGY-4 residents than for PGY-2 residents (p < .01). After the workshop, written test scores improved significantly for all trainees (median [range] improvement, 4 [3.5-5.0] points; p < .01). Mean (SD) improvement in confidence scores for PGY-4, PGY-3, and PGY-2 residents was 0 (0.5), 0.5 (0.8), and 1 (1.3), respectively, with improvement in confidence scores reaching significance only for PGY-2 residents (p < .02). All trainees expressed high satisfaction with the workshop. CONCLUSION An educational intervention based on VH simulation is feasible and improves knowledge and confidence in junior residents with limited exposure to VH.

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.

Short-Term Postoperative Functional Outcomes in Older Women Undergoing Prolapse Surgery

OBJECTIVE: To evaluate whether preoperative markers of functional status predict postoperative functional outcomes in older women undergoing surgery for pelvic organ prolapse (POP). METHODS: Prospective cohort study of women aged 60 years or older who underwent surgery for prolapse. Preoperative functional status was measured using number of functional limitations (such as difficulty walking or climbing), American Society of Anesthesiologists class, anemia, and history of recent weight loss. Our primary outcome was the number of postoperative functional limitations and secondary outcomes were failure to return to baseline functional status and length of stay after surgery. We determined the association of preoperative functional status markers with postoperative outcomes using univariable and multivariable regression. RESULTS: In 127 women, presence of a preoperative functional limitation was a significant predictor of a 0.55 (95% confidence interval [CI] 0.36–0.74) increase in the number of postoperative functional limitations after controlling for age, number of preoperative functional limitations, comorbidities, depression, surgeon, type of procedure, and complications (P<.001). History of recent weight loss and anemia increased risk for failure to return to baseline functional status after controlling for surgeon, type of surgery, and complications (relative risk 2.44, 95% CI 1.26–4.71 and relative risk 2.72, 95% CI 1.29–5.75), respectively). Preoperative markers associated with longer length of stay after surgery were American Society of Anesthesiologists class III (0.83 days, 95% CI 0.20–1.46) and history of weight loss (0.84 days, 95% CI 0.13–1.54). CONCLUSION: Preoperative markers of functional status are useful in predicting short-term postoperative functional outcomes in older women undergoing surgery for POP. LEVEL OF EVIDENCE: II

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 and disability in community-dwelling women: a cross-sectional study.

Disability, an individuals reduced capacity to perform physical tasks encountered in daily routine, is associated with urinary incontinence in the elderly. Our objective was to determine if urinary incontinence is associated with disability in community‐dwelling women 40 years and older.

Urinary Incontinence: Diagnosis and Treatment in the Elderly

Urinary incontinence is a prevalent condition among the elderly. History and physical exam are helpful in delineating the specific type or types of urinary incontinence present. When beginning treatment, clinicians should consider functional status, comorbidity, and goals of therapy. Therapeutic options include behavioral therapy, physical therapy, pharmacologic management, neuromodulation, mechanical devices, and surgery. The treatment options with the most data in the elderly are behavioral therapy and antimuscarinic medications, both showing effectiveness. Limited data are available for the other modalities, but generally show that they are effective in older patients. In this update, data from many recent meta-analyses and systematic reviews are synthesized to help guide treatment decisions for elderly patients suffering from urinary incontinence.

Return to military weight standards after pregnancy in active duty working women: comparison of marine corps vs. navy.

Objective: To compare the likelihood of being within weight standards before and after pregnancy between United States Marine Corps (USMC) and Navy (USN) active duty women (ADW). Methods: ADW with singleton gestations who delivered at a USMC base were followed for 6 months to determine likelihood of returning to military weight standards. Odds ratio (OR), adjusted odds ratio (AOR) and 95% confidence intervals were calculated; p < 0.05 was considered significant. Results: Similar proportions of USN and USMC ADW were within body weight standards one year prior to pregnancy (79%, 97%) and at first prenatal visit (69%, 96%), respectively. However, USMC ADW were significantly more likely to be within body weight standards at 3 months (AOR 4.30,1.28–14.43) and 6 months after delivery (AOR 9.94, 1.53–64.52) than USN ADW. Weight gained during pregnancy did not differ significantly for the two groups (40.4 lbs vs 44.2 lbs, p = 0.163). The likelihood of spontaneous vaginal delivery was significantly higher (OR 2.52, 1.20–5.27) and the mean birth weight was significantly lower (p = 0.0036) among USMC ADW as compared to USN ADW. Conclusions: Being within weight standards differs significantly for USMC and USN ADW after pregnancy.

Military Surgeon Volume and Stress Incontinence Surgery Complications: A Retrospective Cohort Study

STUDY OBJECTIVE To compare 12-month postoperative complication rates in women who underwent sling procedures by high-volume versus low-volume surgeons at US military treatment facilities (MTFs). DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING US MTFs. PATIENTS Female military beneficiaries enrolled in TRICARE. INTERVENTIONS Sling surgery for stress urinary incontinence between January 1, 2011 and December 31, 2012. MEASUREMENTS AND MAIN RESULTS The primary exposure was surgeon volume (high vs low). Surgeon volume was categorized as high or low based on the number of slings performed in the previous 2 years at US MTFs (January 1, 2009 to December 31, 2010). The primary outcome was a composite variable indicating at least 1 postoperative complication within 12 months. We used International Classification of Diseases, 9th revision and Current Procedural Terminology codes to identify postoperative complications that occurred in the 12 months after the index sling procedure. During the study period 348 gynecologic and urologic surgeons performed 1632 slings. The average patient age was 47.2 years. Based on our data distribution we classified surgeons as high volume (>12 slings/2 years) or low volume (<4 slings/2 years). High-volume surgeons operated on patients who were older, more likely to have comorbidities, and more likely to receive concomitant prolapse surgery. Using a cluster analysis the overall likelihood of at least 1 postoperative complication in 12 months for high-volume versus low-volume surgeons was 48.4% versus 42.2% (adjusted odds ratio, 1.24; 95% confidence interval, .99-1.54; p = .06). There were no differences between high- and low-volume surgeons in the rate of almost all other postoperative complications. CONCLUSION No significant differences in 12-month complication rates after sling surgery, stratified by surgeon volume, were seen in a setting of overall low-volume military surgeons.