Kimberly A. Gerten

Prolapse and Incontinence Surgery in Older Women

PURPOSE Pelvic floor disorders including urinary incontinence, pelvic organ prolapse and fecal incontinence are common problems encountered by the older woman. With the increasing population of older American women urologists and gynecologists can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are amenable to medical and surgical therapies. MATERIALS AND METHODS Contemporary articles (2003 to the present) that included older women undergoing urogynecological surgery were included in this review. Current data on morbidity, mortality and/or surgical outcomes are presented with evidence based preoperative, intraoperative and postoperative surgical management strategies. RESULTS Older women undergoing pelvic floor surgery can expect operative risks as well as subjective and objective anatomical and quality-of-life outcomes similar to those of younger women. CONCLUSIONS The decision for surgical intervention for the treatment of pelvic floor disorders should not be based on chronological age alone. Before selecting a specific surgical procedure, all existing pelvic floor defects should be evaluated. Further research is required to understand the impact that surgery for pelvic floor disorders has on anatomical, physiological and functional outcomes in older women.

Pelvic floor surgery in the older woman.

Pelvic floor disorders including urinary incontinence, pelvic organ prolapse, and fecal incontinence are common problems encountered by the older woman. With the increasing population of older Americans, healthcare providers can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are amenable to both medical and surgical therapies. The older woman who undergoes surgery can expect similar risks and outcomes to that of younger women. Further research is required to more fully understand the functional, anatomic, and physiologic outcomes after treatment for pelvic floor disorders in the older woman.

Combined Tolterodine and Vaginal Estradiol Cream for Overactive Bladder Symptoms After Randomized Single-Therapy Treatment.

Objectives The aims of this study were to compare 12-week outcomes of single-therapy tolterodine (Detrol LA) extended release to intravaginal estrogen (Estrace) for overactive bladder (OAB) symptoms and characterize 24- and 52-week outcomes in women undergoing combined therapy. Methods A single-site randomized, open-label trial in women with urinary frequency, urgency, nocturia, and/or urgency urinary incontinence symptoms was performed. Fifty-eight participants were randomized to oral tolterodine extended release daily or intravaginal estradiol cream nightly for 6 weeks then twice per week. The primary outcome was change in Overactive Bladder Questionnaire (OAB-q) symptom bother score at 12 weeks. Secondary outcomes included the Health-Related Quality of Life Questionnaire (HRQL) of the OAB-q and a 3-day bladder diary. At 12 weeks, subjects were offered addition of the alternative therapy with follow-up at 24 and 52 weeks. Results There was no difference in symptom bother score improvement between the tolterodine and intravaginal estradiol groups baseline to 12 weeks (20.6 ± 21.7, −15.8 ± 23.3, respectively, P = 0.45). There was a significant within-group decrease in symptom bother score from baseline to 12 weeks (tolterodine, P < 0.0001, and intravaginal estradiol, P = 0.002). Secondary outcome improvement within groups was noted in the HRQL total, urinary incontinence episodes, and median voiding frequency (all P ⩽ 0.03) in the tolterodine group and in the HRQL total score (P = 0.03) in the intravaginal estradiol group, with no differences between groups. Combined therapy outcomes at 24 and 52 weeks compared with single therapy at 12 weeks revealed significant improvement in symptom bother score in the intravaginal estradiol + tolterodine group at 24 and 52 weeks (20.0 ± 23.9, P = 0.008; −16.7 ± 23.3, P = 0.02, respectively). Conclusions Significant within-group improvement in OAB-q symptom bother was noted in both the intravaginal estradiol and tolterodine groups for OAB symptoms, with no difference between groups. Greater improvement from 12-week single therapy to 24 and 52 weeks of combined therapy was noted in the group originally assigned to intravaginal estradiol. The role of combined medical therapy for OAB symptoms needs further investigation.

Factors Influencing Post-Operative Short-Term Outcomes of Vesicovaginal Fistula Repairs in a Community Hospital in Liberia.

Objectives: To assess factors influencing short-term outcomes of vesicovaginal fistula (VVF) repairs in community-dwelling women of Liberia, Africa. Methods: Forty patients who underwent VVF repairs were analyzed. Primary outcome was continence status at 14 days post repair. Factors influencing continence status were characterized. Results: The mean duration of leakage was 9.6 ±8.3 years, (3 months–28 years). Thirteen (33%) had previous repairs, and 6 (15%) had multiple fistula sites. Twenty-eight (70%) were continent at catheter removal. First time repairs had a higher continence rate compared to women with previous repairs, 78% and 54% respectively (p = 0.15). Seven (47%) juxtaurethral repairs were considered failures, while only one (9%) juxtacervical fistula remained incontinent (p =0.069). Controlling for duration of leakage, women with previous repairs were significantly less likely to be continent (p = 0.04; adjusted OR = 0.07; 95% CI: 0.005, 0.83). Conclusions: Patients with previous VVF repairs and juxtaurethral fistulae experience lower success rates; surgery remains an effective treatment for many VVF patients.

Obliterative Vaginal Surgery for Pelvic Organ Prolapse

Obliterative vaginal surgery is an appropriate management option for pelvic organ prolapse in women who do not desire future vaginal intercourse. When colpoclesis is not technically feasible, constricting repairs can be performed. Obliterative surgery in older women has the advantages of fewer complications and less surgical time than reconstructive procedures, especially in those with medical comorbidities. Age-related changes in physiology should be kept in mind along with the risk of postoperative delirium. Candidates should be counseled regarding high success and satisfaction rates.

Characterization of pelvic floor symptoms in community-dwelling women of northeastern Liberia.

Objective To characterize prevalence and quality of life (QoL) impact of urinary incontinence (UI), fecal incontinence (FI), and pelvic organ prolapse (POP) symptoms in women of Liberia.

Pharmacologic management of the older woman undergoing surgery

Surgical intervention for both emergency and elective surgeries will Increase as women live longer and maintain active lifestyles. Older women with operable conditions tolerate elective gynecologic and other nonvascular surgery with acceptable morbidity and mortality. However, increased medical comorbidities, with their associated increase in polypharmacy and perioperative risks as women age, make it important to a priori optimize perioperative medical conditions and medication management. Other considerations include assessing functional and cognitive status, since these may be impaired acutely with increased prevalence of drug use during surgical hospitalization. With aging and postmenopausal status, changes associated with aging appear to play a greater role than gender in pharmacologic responses. Surgical outcomes should be optimized to maintain and even improve womens quality of life.

A modified Mainz II pouch technique for management of refractory vesicovaginal fistulas: Patient focused outcomes

To follow‐up the quality of life outcomes in 2 women who underwent a modified Mainz II pouch procedure for refractory vesicovaginal fistulas.

Benign Gynecologic Disorders in the Older Woman

Nonmalignant genital tract conditions and pelvic floor disorders including pelvic organ prolapse and incontinence are common gynecologic problems encountered by the older woman. With the rapidly increasing population of active older American women, physicians can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are typically amenable to both medical and surgical therapies making individualization of treatment approaches important. An anatomically directed survey of nonneoplastic conditions of the lower and upper genital tract conditions is presented along with a discussion of pelvic floor support disorders common in the older woman. Evidenced-based evaluation and treatment suggestions are provided.