Pamela J. Levin

Trends in the surgical management of stress urinary incontinence.

OBJECTIVES: To estimate the rates of stress urinary incontinence (SUI) surgery from 2000 to 2009 by type of procedure, year, age, and region of the country. METHODS: We used data between 2000 and 2009 from a database containing health care claims data from employer-based plans in the United States. We analyzed data for all women age 18–64 years, identifying all SUI procedures in this population. Rates per 100,000 person-years and 95% confidence intervals (CI) were calculated each year by procedure type, age, and region. RESULTS: The study population included 32.9 million women age 18–64 years observed for 74,007,937 person-years between 2000 and 2009. During that time, there were 182,110 SUI procedures for a rate of 246.1 per 100,000 person-years (95% CI 239.7–252.6). The most common SUI surgery was sling (198.3 per 100,000 person-years, 95% CI 192.8–203.9) followed by Burch (25.9 per 100,000 person-years, 95% CI 24.8–27.2). There was a dramatic increase in slings, with a corresponding decrease in Burch procedures from 2000 to 2009. Other SUI surgeries had lower rates. Although this trend was evident across all regions, the Northeast had the lowest rate of SUI surgery, whereas rates in the West, Midwest, and South were 1.44-times, 1.76-times, and 2.09-times higher, respectively. CONCLUSION: In a dramatic shift over the past decade, slings have become the dominant procedure for SUI among women age 18–64 years. Although this trend was seen across the United States, considerable variability exists in the SUI surgery rates by region. LEVEL OF EVIDENCE: III

Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial.

OBJECTIVE: To evaluate whether nitrofurantoin prophylaxis prevents postoperative urinary tract infection (UTI) in patients receiving transurethral catheterization after pelvic reconstructive surgery. METHODS: In a randomized, double-blind, placebo-controlled trial, participants undergoing pelvic reconstructive surgery were randomized to 100 mg nitrofurantoin or placebo once daily during catheterization if they were: 1) discharged with a transurethral Foley or performing intermittent self-catheterization; or 2) hospitalized overnight with a transurethral Foley. Our primary outcome was treatment for clinically suspected or culture-proven UTI within 3 weeks of surgery. Statistical analysis was performed by &khgr;2 and logistic regression. Assuming 80% power at a P value of .05, 156 participants were needed to demonstrate a two-thirds reduction in UTI. RESULTS: Of 159 participants, 81 (51%) received nitrofurantoin and 78 (49%) received placebo. There were no significant differences in baseline demographics, intraoperative characteristics, duration and type of catheterization, or postoperative hospitalization, except a lower rate of hysterectomy in the nitrofurantoin group. Nitrofurantoin prophylaxis did not reduce the risk of UTI treatment within 3 weeks of surgery (22% UTI with nitrofurantoin compared with 13% UTI with placebo, relative risk 1.73, 95% confidence interval 0.85–3.52, P=.12). Urinary tract infection treatment was higher in premenopausal women, lower in diabetics, and increased with longer duration of catheterization. In logistic regression adjusting for menopause, diabetes, preoperative postvoid residual volume, creatinine clearance, hysterectomy, and duration of catheterization, there was still no difference in UTI with nitrofurantoin as compared with placebo. CONCLUSION: Prophylaxis with daily nitrofurantoin during catheterization does not reduce the risk of postoperative UTI in patients receiving short-term transurethral catheterization after pelvic reconstructive surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01450800. LEVEL OF EVIDENCE: I

Perceptions about female urinary incontinence: a systematic review

Introduction and hypothesisPerceptions about urinary incontinence (UI) may have a differential impact on treatment-seeking behaviors. Thus, we aimed to systematically review perceptions regarding UI in women of different racial and ethnic populations.MethodsMEDLINE, EMBASE, Scirus, Google Scholar, Open J-Gate, AgeLine, and Global Health (CABI) were searched from January 1980 to August 2011. We included qualitative studies that described knowledge, perception, or personal views about UI in women. Studies were excluded if they did not specify race/ethnicity of subjects, if they reported on non-UI urinary symptoms, or if they were performed exclusively in men. Three independent reviewers screened all studies. The relevance, appropriateness, transparency, and soundness (RATS) scale for qualitative research was used to assess study quality. Because of the qualitative data, meta-analyses were not performed.ResultsOf 3,676 citations, 23 studies met the inclusion criteria. Based on the RATS scale, these were categorized into 11 high-, 2 moderate-, and 10 low-quality studies. Dominant themes fell into two categories, UI management and UI experience, and were similar across racial/ethnic groups. Across multiple studies, women reiterated a preference for discussing UI with other women, even if this was not a physician. Non-white women expressed self-blame and perceived UI as a negative outcome from childbirth or prior sexual experiences. Latina women maintained more secrecy around this issue, even amongst family members.ConclusionsWomen across different racial and ethnic groups share similar UI management strategies and UI experiences. However, perceptions about UI may differ in certain populations. These findings could be useful when considering future educational strategies regarding UI in women.

Posterior tibial nerve stimulation for the treatment of fecal incontinence: A systematic evidence review

Importance and Objectives Posterior tibial nerve stimulation (PTNS) is a potential emerging therapy for fecal incontinence (FI). The aim of this study was to systematically review the literature regarding the efficacy of PTNS as a treatment of FI. Evidence Acquisition We searched MEDLINE/PubMed, EMBASE, and Cochrane databases from inception through November 2013. We included English-language full-text articles reporting outcomes for FI with either percutaneous PTNS or transcutaneous techniques (transcutaneous electrical nerve stimulation). We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to assess study quality. Results Our search yielded 1154 citations; 129 abstracts and 17 articles were included for full-text review. There were 13 case series and 4 randomized controlled trials. Fifteen studies were of low quality, none were of fair quality, and 2 studies were of good quality based on the Grades of Recommendation, Assessment, Development, and Evaluation system. In total, 745 subjects were studied, and of those, 90% were women and 10% were men. Studies involved percutaneous PTNS in 57% (428/745) of the subjects, transcutaneous electrical nerve stimulation in 30% (223/745), and sham technique in 13% (94/745). Therapy frequency, maintenance therapy, and follow-up time varied across studies. Eleven studies assessed FI episodes and bowel movement deferment time; all but 1 showed statistical improvement after therapy. Ten of the 11 studies that used the Cleveland Clinic Florida Fecal Incontinence score reported statistically significantly improved scores after treatment. Conclusions and Relevance Multiple low-quality studies show improvement in FI after PTNS. High-quality studies with comparison groups and clinically meaningful outcome measures would further establish the utility of PTNS for FI. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner will be better able to discuss the scope and impact of FI among women in the United States and initial treatment options; evaluate the available literature investigating bowel symptom responses after PTNS therapy for the treatment of FI; evaluate and explain the available literature investigating quality-of-life parameters after PTNS therapy for the treatment of FI; and analyze the available literature investigating adverse events with PTNS therapy for the treatment of FI.

Psychosocial factors related to the use of interStim® for the treatment of refractory overactive bladder

Objectives Sacral neuromodulation is a well-established treatment of refractory overactive bladder (OAB). Although literature exists on the psychosocial impact of other implanted medical devices, data do not exist for InterStim® therapy. We aim to evaluate the relationship between optimism and treatment satisfaction in women undergoing InterStim for refractory OAB and change in OAB symptoms. Methods Adult women undergoing InterStim therapy for refractory OAB completed a series of validated questionnaires before test stimulation assessing optimism, urinary symptom severity, depression, and body image. Questionnaires included the Life Orientation Test-Revised, OAB Questionnaire-Short Form, Major Depression Inventory, and a body image scale. Three months postoperatively, participants repeated the questionnaires to assess urinary symptoms, depression, and body image and completed the OAB Satisfaction with Treatment Questionnaire (OAB-SAT-q). Correlations assessed the relationship between the Life Orientation Test-Revised score and OAB-SAT-q subscale scores, and the OAB questionnaire subscale change scores. Subjects also completed the nonvalidated questions aimed at patients concerns regarding the implanted devices preoperatively and postoperatively. Results Twenty-eight women were included. Level of optimism was weakly correlated with subject satisfaction across all OAB-SAT-q subscales (r value of −0.11, −0.21, −0.42, and −0.20 for satisfaction, endorsement, adverse effects, and convenience, respectively). Optimism had a weak correlation with change in OAB symptoms in symptom severity and health-related quality of life subscales. Comparison of preoperative and postoperative questionnaires demonstrated statistically significant improvements in depression, body image, symptom severity, and health-related quality of life. Patients concerns regarding implanted devices changed only marginally. Conclusions The level of optimism did not correlate with satisfaction with InterStim treatment, change in OAB symptoms, or OAB-related quality of life. Health-related quality of life, OAB symptoms, depression, and body image improved after InterStim treatment.

Does obesity impact the success of an InterStim test phase for the treatment of refractory urge urinary incontinence in female patients

Objectives Some providers believe obesity may be a relative contraindication for InterStim; however, the relationship between obesity and treatment outcome has not been evaluated. Our objectives were to compare the test phase (stage 1) success and complications of obese versus nonobese women undergoing a 2-stage InterStim procedure for refractory urge urinary incontinence (UUI). Methods We conducted a retrospective cohort study of obese and nonobese women who underwent stage 1 InterStim for refractory UUI. We compared the stage 1 success, defined as undergoing stage 2 generator implantation after demonstrating improvement of 50% or greater during test phase and intraoperative and postoperative complications within 1 year between obese and nonobese cohorts. Results Of 149 subjects, 80 (53.7%) were obese (body mass index, 37.3 ± 5.87 kg/mg2), and 69 (46.3%) were nonobese (body mass index, 25.6 ± 2.82 kg/m2). The overall stage 1 success was 81%. No statistically significant difference existed in stage 1 success between obese and nonobese cohorts (83% vs 78%, P = 0.52). In a logistic regression model controlling for obesity, age, preoperative incontinence episodes per 24 hours, psychiatric diagnoses, arthritis, and diabetes mellitus, age per decade was the only variable significantly associated with stage 1 InterStim success (odds ratio, 0.61; 95% confidence interval, 0.39–0.96). Complications were also similar between cohorts (obese 20% vs nonobese 13%, P = 0.26). Conclusions In women undergoing staged InterStim therapy, stage 1 success and complications were similar between obese versus nonobese women. These data suggest that obesity should not be considered a limiting factor when determining whether a patient is a candidate for InterStim therapy for treatment of refractory UUI.

Characterizing the phenotype of advanced pelvic organ prolapse

Objective Genetic studies require a clearly defined phenotype to reach valid conclusions. Our aim was to characterize the phenotype of advanced prolapse by comparing women with stage III to IV prolapse with controls without prolapse. Methods Based on the pelvic organ prolapse quantification examination, women with stage 0 to stage I prolapse (controls) and those with stage III to stage IV prolapse (cases) were prospectively recruited as part of a genetic epidemiologic study. Data regarding sociodemographics; medical, obstetric, and surgical history; family history; and body mass index were obtained by a questionnaire administered by a trained coordinator and abstracted from electronic medical records. Results There were 275 case patients with advanced prolapse and 206 controls with stage 0 to stage I prolapse. Based on our recruitment strategy, the women were younger than the controls (64.7±10.1 vs 68.6±10.4 years; P<0.001); cases were also more likely to have had one or more vaginal deliveries (96.0% vs 82.0%; P<0.001). There were no differences in race, body mass index, and constipation. Regarding family history, cases were more likely to report that either their mother and/or sister(s) had prolapse (44.8% vs 16.9%, P<0.001). In a logistic regression model, vaginal parity (odds ratio, 4.05; 95% confidence interval, 1.67–9.85) and family history of prolapse (odds ratio, 3.74; 95% confidence interval, 2.16–6.46) remained significantly associated with advanced prolapse. Conclusions Vaginal parity and a family history of prolapse are more common in women with advanced prolapse compared to those without prolapse. These characteristics are important in phenotyping advanced prolapse, suggesting that these data should be collected in future genetic epidemiologic studies.

Sexual Activity and Vaginal Topography in Women with Symptomatic Pelvic Floor Disorders

INTRODUCTION Pelvic floor disorders affect vaginal anatomy and may affect sexual function. AIMS The aims of this study were to explore the relationship between vaginal anatomy and sexual activity in women with symptomatic pelvic floor disorders and to assess whether vaginal measurements (topography) correlate with sexual function. METHODS This is a retrospective cohort study comparing sexually active and nonsexually active women planning urogynecologic surgery. Our primary outcome was the difference in vaginal topography based on Pelvic Organ Prolapse Quantification (POP-Q) exam between cohorts. Correlations between POP-Q measurements and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores were assessed in sexually active women. MAIN OUTCOME MEASURE The POP-Q is a quantitative and standardized examination for prolapse. The PISQ-12 is a condition-specific sexual function questionnaire validated in sexually active women with pelvic floor disorders. RESULTS Of 535 women, 208 (39%) were sexually active and 327 (61%) were not. Median genital hiatus (GH) and perineal body (PB) measurements and a PB:GH ratio were not significantly different between the two cohorts. Total vaginal length (TVL) was longer in sexually active women (median 9 vs. 8 cm, P<0.001). In a linear regression analysis controlling for potential confounders, sexually active women still had a longer TVL by 0.4 cm (95% confidence interval 0.07, 0.6 cm) compared with those who were not sexually active. Of the 327 nonsexually active women, 28% indicated they avoided sexual activity because of pelvic floor symptoms. There was poor correlation between TVL, GH, PB, and PB : GH ratio with PISQ-12 scores (r=0.10, -0.05, -0.09, -0.03, respectively). CONCLUSIONS In women with pelvic floor disorders, sexual activity is associated with a longer vaginal length. One-quarter of women indicated they avoided sexual activity because of pelvic floor symptoms. Vaginal topography does not correlate with sexual function based on PISQ-12 scores.

Is postoperative bowel function related to posterior compartment prolapse repair

Objectives This study aimed to assess how posterior repair (PR) affects change in bowel function in women undergoing anterior/apical surgery for prolapse. Methods We performed a retrospective cohort study of women undergoing prolapse surgery. Our 2 cohorts were women who underwent anterior/apical prolapse surgery either with or without a PR. All women completed the short form of the Colorectal-Anal Distress Inventory (CRADI-8) preoperatively and 6 weeks postoperatively. We compared change in CRADI-8 scores between those who received PR versus those who did not. Results Among 238 women who underwent anterior/apical prolapse surgery, 61 (26%) underwent PR, whereas 177 (74%) did not undergo PR. There were no significant differences in mean CRADI-8 scores at baseline or postoperatively, and scores improved significantly in both groups [baseline scores 23.2 (20.2) for PR vs 18.2 (19.3) for no PR, P = 0.12; postoperative scores 5.0 (10.5) for PR vs 8.4 (15.4) for no PR, P = 0.08]. For our primary outcome, we identified a significantly larger margin of symptom improvement in those who underwent PR compared to those who did not [mean CRADI-8 change scores 18.2 (20.1) for PR vs 9.9 (18.6) for no PR, P < 0.01]. In a linear regression model assessing postoperative CRADI-8 scores, women who underwent PR scored 4.9 points lower on the postoperative CRADI-8, suggesting more improvement in bowel-related symptoms, compared to those who did not undergo PR (95% confidence interval, 1.0, 8.8, P = 0.02). Conclusions Women undergoing surgery for anterior/apical prolapse demonstrated significant improvements in bowel symptoms after surgery. Those receiving concomitant PR had a significantly greater margin of improvement.

Relationship Between Pelvic Organ Prolapse and Non–human Papillomavirus Pap Smear Abnormalities

Objective The aim of this study was to determine the association between pelvic organ prolapse (POP) and non–human papillomavirus (HPV) Papanicolaou (Pap) smear abnormalities. Methods This was a retrospective cohort study of women aged 40 to 70 years who presented for consultation at our institution between 2010 and 2015 and had results of a Pap smear and HPV test available within 5 years of their visit. We extracted demographic information, medical and social history, Pap smear, and HPV results from the electronic medical record. Associations between the presence of POP and non-HPV Pap smear abnormalities were estimated using univariable and multivariable analyses. Results We reviewed 1590 charts and excluded 980 women, leaving 610 women in the study: 183 with POP and 427 without POP. Women with POP were significantly older (58.2 ± 7.2 vs 55.6 ± 6.6, P < 0.01) and more likely to have a remote (>10 year) history of abnormal Pap smear (24.0% vs 14.8%, P < 0.01). The rate of non–HPV-associated abnormal Pap smears was higher in the POP group than in the non-POP group (12/183 [6.6%] vs 12/427 [2.8%], P = 0.029). In the POP group, the rate of non-HPV Pap smear abnormality was significantly associated with increasing prolapse stage (stage 1: 0/16 [0%], stage 2: 5/77 [6.5%], stage 3: 3/73 [4.1%], stage 4: 4/17 [23.5%]; P = 0.02). After controlling for age and remote history of abnormal Pap smear, the odds ratio for non-HPV Pap smear abnormalities in the POP group remained significant (2.49; 95% confidence interval, 1.08–5.79). Conclusions Human papillomavirus–negative Pap smear abnormalities may be related to POP. Our findings have important implications for surgeons seeking to leave the cervix in situ in women with POP.