Nicole M. Book

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.

Postoperative voiding dysfunction following posterior colporrhaphy.

Objective The primary objective of this study was to evaluate the rate of postoperative urinary retention in patients undergoing posterior colporrhaphy. This is compared with the rate of postoperative urinary retention in patients undergoing suburethral sling placement. Methods A retrospective analysis of women treated surgically for either a symptomatic posterior compartment defect or stress urinary incontinence was performed. The preoperative, operative, and postoperative records of women who underwent a sole procedure of a posterior colporrhaphy or tension-free suburethral sling by 2 fellowship-trained urogynecologists were reviewed and compared. Results Significantly more posterior colporrhaphy patients failed their voiding trial (32.4% ± 12%) than suburethral sling patients (15% ± 17%; P = 0.030). After replacement of a Foley catheter, the total length of catheterization was longer in the posterior colporrhaphy group (3.2 ± 0.9 days) than that in the suburethral sling group (1.8 ± 0.4 days; P = 0.007). No patients in either group demonstrated long-term voiding dysfunction, and no patients required further surgical management to reverse their transient voiding dysfunction. Conclusions In this study, the rate of postoperative transient urinary retention following posterior colporrhaphy is 32.4%, which is significantly higher than the rate observed following suburethral sling placement. Although the reason for this higher rate is unclear, it may be related to postoperative pain. Although it is standard practice to assess voiding function after suburethral sling placement, the findings of our study suggest that physicians should also consider assessing postoperative voiding function following posterior colporrhaphy.

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.

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.

Sexual Dysfunction in Perimenopause A Review

Sexual dysfunction is a common problem for women and often impairs their quality of life. Many women are reluctant to discuss these issues with their physicians. The perimenopause presents unique changes in sexual function. At this time, women and their partners undergo numerous physiologic, psychologic, and social/cultural changes. Women should be encouraged to engage their physicians in discussions to help them maintain a satisfying sexual life during this time of change. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to describe the types of female sexual disorders, summarize a plan of treatment for the different female sexual disorders, and outline special conditions during the perimenopause which might affect sexual function.

The association between post-void leakage and coital incontinence and intrinsic sphincter deficiency among women with urinary incontinence.

Objective: To identify whether an association exists between post-void urinary leakage and/or coital incontinence and the diagnosis of intrinsic sphincter deficiency (ISD) among women with urinary incontinence. Methods: Ninety women presenting to a tertiary urogynecology office with complaints of urinary incontinence were included in this retrospective chart review. All patients underwent a complete history and physical examination, including direct questioning about the symptoms of post-void leakage and coital incontinence. Multichannel urodynamic testing was evaluated for each patient and ISD was defined by a Valsalva leak point pressure of less than or equal to 60 cm H2O and/or a maximal urethral closure pressure of less than or equal to 20 cm H2O. The prevalence of ISD among those patients with post-void leakage and/or coital incontinence was evaluated. Results: The prevalence of ISD among the study population was 64%. Intrinsic sphincter deficiency was diagnosed in 45/62 patients with post-void leakage and in 13/28 patients without post-void leakage (72.6% and 46.4%, respectively, P = 0.0311). Intrinsic sphincter deficiency was present in 21/24 patients with coital incontinence and 37/66 patients without coital incontinence (87.5% and 56.1%, respectively, P = 0.0061). Patients with both symptoms were diagnosed with ISD 90% of the time, while only 41.7% of patients with neither symptom had ISD (P = 0.0014, sensitivity = 64.5%). Patients with either symptom were diagnosed with ISD 72.7% of the time, compared to 41.7% of patients with neither symptom (P = 0.0117, sensitivity = 82.8%). The positive predictive value for coital incontinence alone and ISD was 87.5%, and for both symptoms was 90%. Conclusions: The symptoms of post-void leakage and coital incontinence are associated with ISD. The strong positive predictive value of both symptoms with ISD should encourage physicians to include direct questioning about these symptoms during the history taking and treatment planning for women with urinary incontinence.

Twenty-Four–Hour Voiding Diaries Versus 3-Day Voiding Diaries: A Clinical Comparison

Objective This study aimed to determine if 24-hour versus 3-day voiding diary affects medical decision making for women with urinary incontinence. Methods A retrospective chart review was conducted of patients presenting to the OhioHealth Urogynecology Physician group for urinary incontinence from 2009 to 2011. Practice protocol includes patient completion of a 3-day voiding diary before their appointment. Diagnostic and treatment plans were extracted based on the initial patient encounter and 3-day voiding diary. A chart review was then completed with the first 24 hours of the same diaries, principal history, and physical examination data compiled into a separate chart. These charts were then reevaluated by the same physician who initially provided care to the patient but were blinded to their previous orders, impressions, and plans. New plans were then created based on the 24-hour diaries and compared with the original plans. Results One hundred eighty-six charts were reviewed. There was good agreement between 24-hour and 3-day diaries in recommendations for first-line behavioral modifications (&Kgr; > 0.6) and moderate agreement between diaries in initiation of medical therapy or trial of incontinence pessary (&Kgr; > 0.4). However, 24-hour diaries resulted in a statistically significant increase in invasive diagnostic tests (P < 0.019) and other treatment recommendations when compared with 3-day diaries. Conclusions Use of 24-hour diaries may result in increased testing when compared with 3-day diaries. It may be prudent to postpone invasive testing in those patients who initially are noncompliant with a longer diary until a more complete history can be obtained.

48: Long-term anatomic and symptomatic outcomes for women who have undergone abdominal sacrohysteropexy

S602 American Journal of Obstetrics & Gynecology Supplement to MARCH 2 48 Long-term anatomic and symptomatic outcomes for women who have undergone abdominal sacrohysteropexy K. Roberts, N. Book, J. Novi OB/GYN, Riverside Methodist Hospital, Columbus, OH OBJECTIVES: To describe the anatomic and symptomatic outcomes of women treated with abdominal sacrohysteropexy (ASH). MATERIALS AND METHODS: We performed a retrospective chart review with prospective physical examination and quality of life measures for women who have undergone ASH. The ASH was performed at a single institution by a board certified Urogynecologist. All patients had a piece of hand tailored Gynemesh affixed to the posterior vaginal wall and sacral promontory. Women who had completed childbearing had a second piece of Gynemesh affixed to the anterior vaginal wall, passed through a window created in the broad ligament, and affixed to the sacral promontory. For women who were uncertain or desired future childbearing, the anterior dissection was not performed. Postoperative pelvic examinations were performed by a Urogynecology fellow independently of the surgeon who performed the surgical procedures, including supine POP-Q and standing examinations. Quality of life was assessed with the Incontinence Impact Questionnaire-7 (IIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20). RESULTS: Sixteen patients underwent ASH between 2006 and 2012 and met inclusion criteria. Thirteen women (81.3%) were available for follow-up. At baseline, all patients had a presenting complaint of pelvic organ prolapse, 6 reported stress urinary incontinence, and 2 reported mixed urinary incontinence. At initial presentation, mean (standard deviation [SD]) BMI was 26.6 (5.7). The number of patients in prolapse stages were: apical stage 0-I: 1, apical II-III: 12; anterior 0-I: 2, anterior II-III: 11; posterior 0I: 2, posterior II-III: 11. Mean (SD) operating time was 141 (36) minutes, average (SD) estimated blood loss was 114 (48) milliliters. Mean follow-up time was 40.9 (17.7) months. Postoperatively, mean (SD) BMI was 28.1 (5.9). The number of patients in prolapse stages were: apical stage 0-I: 13, apical II-III: 0; anterior 0-I: 10, anterior II-III: 2; posterior 0-I: 13, posterior II-III: 0. All stages were statistically significantly improved from preoperative staging. Postoperatively, 2 patients had a stage II cystocele, but both were asymptomatic. One patient had anterior wall mesh erosion, which was treated successfully with estrogen cream. Three patients had attempted pregnancy. At the time of follow-up, one patient had carried to term, and delivered via uncomplicated cesarean section. Another was 12 weeks pregnant. The last was attempting to get pregnant, although HSG demonstrated lack of dye spillage from a fallopian tube. Average (SD) PISQ-12, PFDI-20, and IIQ-7 scores were 37.6 (4.7), 38.6 (43.9), and 1.1 (2.5), respectively. CONCLUSION: Our study presents optimistic anatomic and symptomatic results from ASH. At an average of 40.9 months postoperatively, none of the thirteen patients had required further evaluation for prolapse or incontinence. Two of three patients who desired childbearing were able to achieve pregnancy, and one delivered via uncomplicated cesarean section. All quality of life post-operative scores indicated a high quality of life.