Kimberly Kenton

Prevalence of Symptomatic Pelvic Floor Disorders in US Women

CONTEXT Pelvic floor disorders (urinary incontinence, fecal incontinence, and pelvic organ prolapse) affect many women. No national prevalence estimates derived from the same population-based sample exists for multiple pelvic floor disorders in women in the United States. OBJECTIVE To provide national prevalence estimates of symptomatic pelvic floor disorders in US women. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of 1961 nonpregnant women (>or=20 years) who participated in the 2005-2006 National Health and Nutrition Examination Survey, a nationally representative survey of the US noninstitutionalized population. Women were interviewed in their homes and then underwent standardized physical examinations in a mobile examination center. Urinary incontinence (score of >or=3 on a validated incontinence severity index, constituting moderate to severe leakage), fecal incontinence (at least monthly leakage of solid, liquid, or mucous stool), and pelvic organ prolapse (seeing/feeling a bulge in or outside the vagina) symptoms were assessed. MAIN OUTCOME MEASURES Weighted prevalence estimates of urinary incontinence, fecal incontinence, and pelvic organ prolapse symptoms. RESULTS The weighted prevalence of at least 1 pelvic floor disorder was 23.7% (95% confidence interval [CI], 21.2%-26.2%), with 15.7% of women (95% CI, 13.2%-18.2%) experiencing urinary incontinence, 9.0% of women (95% CI, 7.3%-10.7%) experiencing fecal incontinence, and 2.9% of women (95% CI, 2.1%-3.7%) experiencing pelvic organ prolapse. The proportion of women reporting at least 1 disorder increased incrementally with age, ranging from 9.7% (95% CI, 7.8%-11.7%) in women between ages 20 and 39 years to 49.7% (95% CI, 40.3%-59.1%) in those aged 80 years or older (P < .001), and parity (12.8% [95% CI, 9.0%-16.6%], 18.4% [95% CI, 12.9%-23.9%], 24.6% [95% CI, 19.5%-29.8%], and 32.4% [95% CI, 27.8%-37.1%] for 0, 1, 2, and 3 or more deliveries, respectively; P < .001). Overweight and obese women were more likely to report at least 1 pelvic floor disorder than normal weight women (26.3% [95% CI, 21.7%-30.9%], 30.4% [95% CI, 25.8%-35.0%], and 15.1% [95% CI, 11.6%-18.7%], respectively; P < .001). We detected no differences in prevalence by racial/ethnic group. CONCLUSION Pelvic floor disorders affect a substantial proportion of women and increase with age.

Retropubic versus Transobturator Midurethral Slings for Stress Incontinence

BACKGROUND Midurethral slings are increasingly used for the treatment of stress incontinence, but there are limited data comparing types of slings and associated complications. METHODS We performed a multicenter, randomized equivalence trial comparing outcomes with retropubic and transobturator midurethral slings in women with stress incontinence. The primary outcome was treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). The predetermined equivalence margin was +/-12 percentage points. RESULTS A total of 597 women were randomly assigned to a study group; 565 (94.6%) completed the 12-month assessment. The rates of objectively assessed treatment success were 80.8% in the retropubic-sling group and 77.7% in the transobturator-sling group (3.0 percentage-point difference; 95% confidence interval [CI], -3.6 to 9.6). The rates of subjectively assessed success were 62.2% and 55.8%, respectively (6.4 percentage-point difference; 95% CI, -1.6 to 14.3). The rates of voiding dysfunction requiring surgery were 2.7% in those who received retropubic slings and 0% in those who received transobturator slings (P=0.004), and the respective rates of neurologic symptoms were 4.0% and 9.4% (P=0.01). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life. CONCLUSIONS The 12-month rates of objectively assessed success of treatment for stress incontinence with the retropubic and transobturator approaches met the prespecified criteria for equivalence; the rates of subjectively assessed success were similar between groups but did not meet the criteria for equivalence. Differences in the complications associated with the two procedures should be discussed with patients who are considering surgical treatment for incontinence. (ClinicalTrials.gov number, NCT00325039.)

Evidence of Uncultivated Bacteria in the Adult Female Bladder

ABSTRACT Clinical urine specimens are usually considered to be sterile when they do not yield uropathogens using standard clinical cultivation procedures. Our aim was to test if the adult female bladder might contain bacteria that are not identified by these routine procedures. An additional aim was to identify and recommend the appropriate urine collection method for the study of bacterial communities in the female bladder. Consenting participants who were free of known urinary tract infection provided urine samples by voided, transurethral, and/or suprapubic collection methods. The presence of bacteria in these samples was assessed by bacterial culture, light microscopy, and 16S rRNA gene sequencing. Bacteria that are not or cannot be routinely cultivated (hereinafter called uncultivated bacteria) were common in voided urine, urine collected by transurethral catheter (TUC), and urine collected by suprapubic aspirate (SPA), regardless of whether the subjects had urinary symptoms. Voided urine samples contained mixtures of urinary and genital tract bacteria. Communities identified in parallel urine samples collected by TUC and SPA were similar. Uncultivated bacteria are clearly present in the bladders of some women. It remains unclear if these bacteria are viable and/or if their presence is relevant to idiopathic urinary tract conditions.

Graft use in transvaginal pelvic organ prolapse repair: A systematic review

OBJECTIVE: To estimate the anatomic and symptomatic efficacy of graft use in transvaginal prolapse repair and to estimate the rates and describe the spectrum of adverse events associated with graft use. DATA SOURCES: Eligible studies, published between 1950 and November 27, 2007, were retrieved through Medline and bibliography searches. METHODS OF STUDY SELECTION: To assess anatomic and symptomatic efficacy of graft use, we used transvaginal prolapse repair studies that compared graft use with either native tissue repair or repair with a different graft. To estimate rates of adverse events from graft use, all comparative studies and case series with at least 30 participants were included. For spectrum of adverse events, all study designs were included. TABULATION, INTEGRATION AND RESULTS: Eligible studies were extracted onto standardized forms by one reviewer and confirmed by a second reviewer. Comparative studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic-absorbable, synthetic nonabsorbable) and outcome (anatomic, symptomatic). We found 16 comparative studies, including six randomized trials, 37 noncomparative studies with at least 30 women, 11 case series with fewer than 30 women, and 10 case reports of adverse events. One randomized trial and one prospective comparative study evaluating synthetic, nonabsorbable graft use in the anterior compartment reported favorable anatomic and symptomatic outcomes with graft use. Data regarding graft use for posterior and apical compartments or for biologic or synthetic absorbable graft use in the anterior compartment were insufficient to determine efficacy. Rates and spectrum of adverse events associated with graft use included bleeding (0–3%), visceral injury (1–4%), urinary infection (0–19%), graft erosion (0–30%), and fistula (1%). There were insufficient data regarding dyspareunia, sexual, voiding, or defecatory dysfunction. CONCLUSION: Overall, the existing evidence is limited to guide decisions regarding whether to use graft materials in transvaginal prolapse surgery. Adequately powered randomized trials evaluating anatomic and symptomatic efficacy as well as adverse events are needed.

Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice.

Millions of women are afflicted with stress urinary incontinence (SUI) and pelvic organ prolapse (POP) around the globe, and the literature is abundant with different types of surgery to correct these problems. Only recently have outcome measures been applied to research in these areas. There are great variations in types of surgery performed, secondary to many factors such as surgeon’s training and socioeconomic factors. As the population of aging women increases worldwide, it is inevitable that these women’s disorders will become more prevalent. This will pose a major challenge to the health care systems.

Behavioral Therapy to Enable Women with Urge Incontinence to Discontinue Drug Treatment: A Randomized Trial

BACKGROUND Women with urge urinary incontinence are commonly treated with antimuscarinic medications, but many discontinue therapy. OBJECTIVE To determine whether combining antimuscarinic drug therapy with supervised behavioral training, compared with drug therapy alone, improves the ability of women with urge incontinence to achieve clinically important reductions in incontinence episodes and to sustain these improvements after discontinuing drug therapy. DESIGN 2-stage, multicenter, randomized clinical trial conducted from July 2004 to January 2006. SETTING 9 university-affiliated outpatient clinics. PATIENTS 307 women with urge-predominant incontinence. INTERVENTION 10 weeks of open-label, extended-release tolterodine alone (n = 153) or combined with behavioral training (n = 154), followed by discontinuation of therapy and follow-up at 8 months. MEASUREMENTS The primary outcome, measured at 8 months, was no receipt of drugs or other therapy for urge incontinence and a 70% or greater reduction in frequency of incontinence episodes. Secondary outcomes were reduction in incontinence, self-reported satisfaction and improvement, and scores on validated questionnaires measuring symptom distress and bother and health-related quality of life. Study staff who performed outcome evaluations, but not participants and interventionists, were blinded to group assignment. RESULTS 237 participants completed the trial. According to life-table estimates, the rate of successful discontinuation of therapy at 8 months was the same in the combination therapy and drug therapy alone groups (41% in both groups; difference, 0 percentage points [95% CI, -12 to 12 percentage points]). A higher proportion of participants who received combination therapy than drug therapy alone achieved a 70% or greater reduction in incontinence at 10 weeks (69% vs. 58%; difference, 11 percentage points [CI, -0.3 to 22.1 percentage points]). Combination therapy yielded better outcomes over time on the Urogenital Distress Inventory and the Overactive Bladder Questionnaire (both P <0.001) at both time points for patient satisfaction and perceived improvement but not health-related quality of life. Adverse events were uncommon (12 events in 6 participants [3 in each group]). LIMITATIONS Behavioral therapy components (daily bladder diary and recommendations for fluid management) in the group receiving drug therapy alone may have attenuated between-group differences. Assigned treatment was completed by 68% of participants, whereas 8-month outcome status was assessed on 77%. CONCLUSION The addition of behavioral training to drug therapy may reduce incontinence frequency during active treatment but does not improve the ability to discontinue drug therapy and maintain improvement in urinary incontinence. Combination therapy has a beneficial effect on patient satisfaction, perceived improvement, and reduction of other bladder symptoms.

Sexual Function is Related to Body Image Perception in Women with Pelvic Organ Prolapse

INTRODUCTION A previous study demonstrated that women seeking treatment for advanced pelvic organ prolapsed (POP) reported decreased self-perceived body image and decreased quality of life. AIMS To determine the relationship between: (i) sexual function and POP, (ii) self-perceived body image and POP; and (iii) sexual function and self-perceived body image in women with prolapse. METHODS After IRB approval, consecutive women with POP stage II or greater presenting for urogynecologic care at one of eight academic medical centers in the United States were invited to participate. In addition to routine urogynecologic history and physical examination, including pelvic organ prolapse quantification (POPQ), consenting participants completed three validated questionnaires: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to assess sexual function; Modified Body Image Perception Scale (MBIS) to assess self-perceived body image; Prolapse subscale of Pelvic Floor Distress Inventory (POPDI-6) to assess condition specific bother from POP. Pearsons correlations were used to investigate the relationship between independent variables. MAIN OUTCOME MEASURES Sexual function and modified body image score and its correlation with symptoms of POP. RESULTS Three hundred eighty-four participants with a mean age of 62 +/- 12 years were enrolled. Median POPQ stage was 3 (range 2-4). 62% (N = 241) were sexually active and 77% (N = 304) were post-menopausal. Mean PISQ-12, MBIS, and POPDI scores were (33 +/- 7, 6 +/- 5, 39 +/- 23, respectively). PISQ-12 scores were not related to stage or compartment (anterior, apical, or posterior) of POP (P > 0.5). Worse sexual function (lower PSIQ-12 scores) correlated with lower body image perception (higher MBIS scores) (rho = -0.39, P < 0001) and more bothersome POP (higher POPDI scores) (rho = -0.34, P < 0001). CONCLUSIONS Sexual function is related to a womans self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a womans perception of her body image than to actual topographical changes from POP.

Changes in Sexual Function after Treatment for Prolapse Are Related to the Improvement in Body Image Perception

INTRODUCTION In a previous study, sexual function was related to a womans self-perceived body image and degree of bother from pelvic organ prolapse (POP). AIMS To evaluate sexual function, prolapse symptoms, and self-perceived body image 6 months following treatment for POP and to explore differences in body image perception and sexual function following conservative and surgical treatment for POP. METHODS After institutional review board approval, consecutive women with > or = stage II POP were invited to participate. In addition to routine urogynecologic history and physical examination, including Pelvic Organ Prolapse Quantification (POP-Q), the participants completed three validated questionnaires before, and 6 months after, treatment for POP: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Modified Body Image Perception Scale and Prolapse subscale of Pelvic Floor Distress Inventory to assess condition specific bother from POP. Main Outcome Measures. Changes in sexual function and body image perception following treatment for POP. RESULTS A total of 235 women with a mean age of 62 +/- 12 years returned for a 6-month follow-up. The majority of our participants had surgical repair for POP (88%). At 6-month follow-up visits, the patients reported significant improvement in sexual function from baseline (33 +/- 0.6 vs. 43 +/- 0.8, respectively P < 0.0001). Improvement in sexual function, as measured by PISQ-12, was not significant among sexually active patients treated with a pessary compared with those treated surgically (-2.5 +/- 5.5 vs. 11.5 +/- 1, respectively P < 0.0001). A multivariate linear regression model demonstrated that body mass index and changes in body image perception were the only independent factors associated with changes in PISQ score following POP treatment (beta = -0.5, P < 0.01 and beta = -0.4, P < 0.03, respectively). CONCLUSIONS Resolution of POP symptoms after treatment improves womens self-perceived body image and sexual function. Not surprisingly, pessary is less effective in improving sexual function compared with surgical repair of POP.

The global burden of female pelvic floor disorders.

Half of women in the USA develop UI in their lifetime. In a recent, large population-based survey of USA women aged 30–90 years, the prevalence of UI was 45% and increased significantly with age [10]. A third of women aged > 80 years reported severe UI [10]. The prevalence of UI in the UK is similarly high, at 69% [14], while UI rates in Norway (25%) are significantly lower than in the USA and UK [15]. Ethnic differences in UI are still not well understood and might be secondary to genetic and/or cultural differences in risk factors or definitions of UI. In addition, many studies do not specify UI by subtype (stress or urge) which might contribute to variations in incidence and prevalence rates. In the USA study, half of women reported symptoms of mixed UI, a third reported pure stress UI, and only 13% reported pure urge UI [10], while in previous USA and Norwegian studies stress UI was more common than mixed or urge UI [15,16]. A French study reported mixed UI rates of 49% [17]. Twenty-two million people in six European countries (France, Germany, Italy, Spain, Sweden and UK) reported overactive bladder (OAB) symptoms, with 36% reporting urge UI [18]. The USA National Overactive Bladder Evaluation study indicated that 17% of women had OAB symptoms [19]. A review of the European literature showed the following stress UI rates: 17–28% in France; 5–17% in Italy; 29% in Spain; 25% in the UK [20]. Prevalence rates of UI subtypes might vary by respondents’ age and ethnicity, as well as how the question is asked and how UI is defined. Efforts to standardize definitions and create validated questionnaires are ongoing.

Patient-selected goals: the fourth dimension in assessment of pelvic floor disorders

The purpose of the study was to assess the relationship between self-expressed urogynecologic goals, symptoms, and treatment choice. Charts of women presenting for urogynecology consultation were reviewed. Demographics, diagnoses and responses to the pelvic floor distress inventory and medical, social, and epidemiologic aspects of aging questionnaires were recorded. Patients listed urogynecology goals before consultation. We categorized goals into five categories and then compared these categories by symptom type, severity, and treatment. Three hundred five women reported 635 goals (median 2, range 1–6). The number of goals listed per patient did not differ by age, race, comorbidities, or clinical diagnosis (p > 0.05). The most frequent goal category was symptoms (67%), followed by information seeking (12%), lifestyle (11%), emotional (4%), and “other” (6%). Women selecting non-surgical treatment were more likely to list information seeking as primary goal than those who chose surgery (p = 0.009). One third of participants expressed a primary non-symptom goal and were more likely to seek non-surgical therapy.