Nadine C. Kassis

Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse

OBJECTIVE The purpose of this study was to describe patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse symptoms and to describe predictors of preference for uterine preservation. STUDY DESIGN This multicenter, cross-sectional study evaluated patient preferences for uterine preservation vs hysterectomy in women with prolapse symptoms who were being examined for initial urogynecologic evaluation. Before meeting the physician, the women completed a questionnaire that asked them to indicate their prolapse treatment preference (uterine preservation vs hysterectomy) for scenarios in which the efficacy of treatment varied. Patient characteristics that were associated with preferences were determined, and predictors for uterine preservation preference were identified with multivariable logistic regression. RESULTS Two hundred thirteen women participated. Assuming outcomes were equal between hysterectomy and uterine preservation, 36% of the women preferred uterine preservation; 20% of the women preferred hysterectomy, and 44% of the women had no strong preference. If uterine preservation was superior, 46% of the women preferred uterine preservation, and 11% of the women preferred hysterectomy. If hysterectomy was superior, 21% of the women still preferred uterine preservation, despite inferior efficacy. On multivariable logistic regression, women in the South had decreased odds of preferring uterine preservation compared with women in the Northeast (odds ratio [OR], 0.17; 95% CI, 0.05-0.66). Women with at least some college education (OR, 2.87; 95% CI, 1.08-7.62) and those who believed that the uterus is important for their sense of self (OR, 28.2; 95% CI, 5.00-158.7) had increased odds for preferring uterine preservation. CONCLUSION A higher proportion of women with prolapse symptoms who were examined for urogynecologic evaluation preferred uterine preservation, compared with hysterectomy. Geographic region, education level, and belief that the uterus is important for a sense of self were predictors of preference for uterine preservation.

Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms.

OBJECTIVE The objective of the study was to describe the basic knowledge about prolapse and attitudes regarding the uterus in women seeking care for prolapse symptoms. STUDY DESIGN This was a cross-sectional study of English-speaking women presenting with prolapse symptoms. Patients completed a self-administered questionnaire that included 5 prolapse-related knowledge items and 6 benefit-of-uterus attitude items; higher scores indicated greater knowledge or more positive perception of the uterus. The data were analyzed using descriptive statistics and multiple linear regression. RESULTS A total of 213 women were included. The overall mean knowledge score was 2.2 ± 1.1 (range, 0-5); 44% of the items were answered correctly. Participants correctly responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises (34.3%) were prolapse treatment options. Prior evaluation by a female pelvic medicine and reconstructive surgery specialist (beta = 0.57, P = .001) and higher education (beta = 0.3, P = .07) was associated with a higher mean knowledge score. For attitude items, the overall mean score was 15.1 (4.7; range, 6-30). A total of 47.4% disagreed with the statement that the uterus is important for sex. The majority disagreed with the statement that the uterus is important for a sense of self (60.1%); that hysterectomy would make me feel less feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%). Previous consultation with a female pelvic medicine and reconstructive surgery specialist was associated with a higher mean benefit of uterus score (beta = 1.82, P = .01). CONCLUSION Prolapse-related knowledge is low in women seeking care for prolapse symptoms. The majority do not believe the uterus is important for body image or sexuality and do not believe that hysterectomy will negatively affect their sex lives.

The Association Between Stage II or Greater Posterior Prolapse and Bothersome Obstructive Bowel Symptoms.

Objective: The primary objective of this study was to estimate the association between stage II or greater posterior prolapse and individual obstructive bowel symptoms. Methods: We conducted a cross-sectional study of all women presenting for initial visit at a tertiary center for pelvic floor disorders. Exposure was defined as stage II or greater posterior vaginal prolapse as measured by pelvic organ prolapse quantification measurements. Outcomes included the separate bothersome obstructive bowel symptoms of splinting, straining, or incomplete bowel emptying. Results: Our study included 721 women. Univariate analysis did not show an association between stage II or greater posterior prolapse and the bothersome symptoms of straining or incomplete emptying. Stage II or greater posterior prolapse was associated with bothersome splinting (adjusted OR, 1.63; 95% CI, 1.06–2.53). Conclusions: Stage II or greater posterior prolapse was associated with the bothersome symptom of splinting, but not bothersome straining or the sensation of incomplete evacuation.

Improvements in Physical Activity and Functioning After Undergoing Midurethral Sling Procedure for Urinary Incontinence

OBJECTIVE: The primary objective was to estimate the effect of the midurethral sling on improving leisure physical activity levels and physical functioning in women with stress urinary incontinence (SUI). Our secondary objective was to identify possible risk factors for postoperative insufficient physical activity. METHODS: We conducted a prospective, observational study of women undergoing outpatient midurethral sling for SUI. Women completed validated questionnaires for incontinence, leisure physical activity, and physical functioning at baseline and 6 months postoperatively. The primary outcome was leisure physical activity level. We used multiple logistic and linear regression to estimate the effect of improvements in urinary symptoms and life effect on physical activity levels and physical functioning scores. RESULTS: Ninety women underwent surgery and 85 returned for follow-up. At baseline, 38% had sedentary, 18% had moderate, and 44% had sufficient leisure physical activity levels. Postoperatively, this modestly improved to 26% sedentary, 20% moderate, and 54% sufficient levels. The median leisure physical activity energy expenditure increased from 396 to 693 metabolic equivalent-minutes per week (P=.04). Physical functioning scores also significantly improved (mean score 44 compared with 55 points, P<.001). On multiple logistic regression, improvements in incontinence life effect were associated with increased odds of leisure physical activity improvement (adjusted odds ratio 1.66; 95% confidence interval 1.08–2.54). On multiple linear regression, improvements in both urinary incontinence severity and effect were associated with improvements in physical functioning scores (P<.01 for both). Factors associated with insufficient postoperative physical activity included low baseline physical activity levels and smaller improvements in urinary effect scores. CONCLUSION: Midurethral sling and subsequent improvements in urinary incontinence are associated with improved leisure physical activity levels and physical functioning. LEVEL OF EVIDENCE: II

Effect of intrinsic sphincter deficiency on midurethral sling outcomes in women with mixed urinary incontinence.

Objective The objective of this study was to estimate the effect of intrinsic sphincter deficiency (ISD) on frequency and urge incontinence after midurethral sling (MUS) in women with mixed urinary incontinence (MUI). Methods We performed a retrospective study of 137 women with MUI who underwent MUS placement. We defined MUI as an affirmative response to the urge incontinence item (no. 16) on the Pelvic Floor Distress Inventory in a cohort of women with urodynamic stress incontinence. Intrinsic sphincter deficiency was defined as preoperative positive leak point pressure of less than 60 cm H2O and/or urethral closure pressure less than 20 cm H2O. Outcomes included resolution of frequency and urge incontinence as well as resolution of stress incontinence. Multivariable logistic regression was performed to estimate the association between ISD and urinary outcomes. Results One hundred thirty-seven women met our study inclusion criteria. Fifteen (11%) had preoperative ISD, and 122 (89%) did not. At 6 to 12 months after MUS placement, 67% of women with ISD-MUI versus 39% with non–ISD-MUI had complete resolution of both urinary frequency and urge incontinence (P = 0.04). The 2 groups did not differ postoperatively in regard to complete resolution of stress incontinence symptoms (85% vs 90%, P = 0.63). On regression analysis, women with ISD-MUI had increased odds of complete resolution of frequency and urge incontinence compared with women with non–ISD-MUI (adjusted odds ratio, 5.38 [95% confidence interval, 1.50–19.3]). Conclusions In women with MUI, preoperative ISD is associated with increased odds of urinary frequency and urge incontinence resolution after MUS.

Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence.

Objective We aimed to assess documentation completeness of the operative record for mesh implanted at the time of midurethral sling surgery and to identify modifiable predictors of documentation completeness. Methods A retrospective cross-sectional study of women with stress incontinence who underwent midurethral sling placement between January 2009 and December 2011 was conducted. Data from the dictated operative note and nursing operative record were extracted to determine if the specific mesh implanted during surgery was documented. The primary outcome was the rate of documentation of mesh implanted in the physician’s dictated operative note and in the nursing record. Logistic regression was used to determine if any characteristics were associated with the rate of documentation while accounting for correlation of patients from the same dictating surgeon. Results There were 816 surgeries involving the implantation of a midurethral sling during the study period. All surgeries were performed at 6 Indiana University hospitals. Fifty-two surgeons of varying specialties and levels of training dictated the operative notes. A urogynecologist dictated 71% of the operative notes. The rate of documentation completeness for mesh implanted in the physician’s note was 10%. The rate of documentation completeness for mesh implanted in the nursing operative record was 92%. Documentation of mesh implanted in the physician’s note was not significantly associated with the level of training, specialty, or year of surgery. Conclusions Documentation completeness for specific mesh implant in the physician’s note is low, independent of specialty and level of training. Nursing documentation practices are more rigorous. Postmarket surveillance, currently mandated by the Food and Drug Administration, may not be feasible if only the physician’s note is available or if nursing practices are inconsistent. Development of documentation guidelines for physicians would improve the feasibility of surveillance.