Sara B. Cichowski

The association between fecal incontinence and sexual activity and function in women attending a tertiary referral center

Introduction and hypothesisTo determine whether fecal incontinence (FI) is associated with sexual activity and to compare sexual function in women with and without FI.MethodsWe conducted a retrospective chart review of all new patients seen in an academic urogynecology clinic. Women who reported fecal incontinence, as defined by loss of fecal material on the Wexner scale, were compared with those without fecal incontinence. We compared sexual activity and Pelvic Organ Prolapse Incontinence Sexual Questionnaire-12 (PISQ-12) scores between groups.ResultsIn our population of women with pelvic floor disorder, 588 women reported FI compared with 527 who did not. On multivariate analysis, FI was not associated with sexual activity status, but was associated with worsened PISQ-12 scores (p < 0.001). PISQ-12 item analysis found that women with FI reported more dyspareunia, fear, and avoidance of sexual activity with greater partner problems (all p <0.05) than women without FI.ConclusionsWomen with FI were as likely to engage in sexual relations as women without FI; however, sexually active women with FI had poorer sexual function than those without FI.

Elder American Indian women's knowledge of pelvic floor disorders and barriers to seeking care.

Objectives The objectives of this study are to evaluate urinary incontinence and pelvic organ prolapse knowledge among elder southwestern American Indian women and to assess barriers to care for pelvic floor disorders through community-engaged research. Methods Our group was invited to provide an educational talk on urinary incontinence and pelvic organ prolapse at an annual meeting of American Indian elders. Female attendees aged 55 years or older anonymously completed demographic information and 2 validated questionnaires, the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and Barriers to Incontinence Care Seeking Questionnaire (BICS-Q). Questionnaire results were compared with historical controls from the original PIKQ and BICS-Q validation study. Results One hundred forty-four women completed the questionnaires. The mean age was 77.7 ± 9.1 years. The mean (SD) for PIKQ of urinary incontinence score was 6.6 (3.0) (similar to historic gynecology controls 6.8 [3.3], P = 0.49), and the mean (SD) for PIKQ on pelvic organ prolapse score was 5.4 (2.9) (better than historic gynecology controls 3.6 [3.2], P < 0.01). Barriers to care seeking reported by the elder women were highest on the BICS-Q subscales of “cost” and “inconvenience.” Conclusions Urinary incontinence knowledge is similar to historic gynecology controls, and pelvic organ prolapse knowledge is higher than historic gynecology controls among elder southwestern American Indian women. American Indian elder women report high levels of barriers to care. The greatest barriers to care seeking for this population were related to cost and inconvenience, reflecting the importance of assessing socioeconomic status when investigating barriers to care. Addressing these barriers may enhance care-seeking southwestern American Indian women.

Ethnicity and variations of pelvic organ prolapse bother

Introduction and hypothesisTo determine if prolapse symptom severity and bother varies among non-Hispanic white, Hispanic, and Native American women with equivalent prolapse stages on physical examination.MethodsThis was a retrospective chart review of new patients seen in an academic urogynecology clinic from January 2007 to September 2011. Data were extracted from a standardized intake form, including patients’ self-identified ethnicity. All patients underwent a Pelvic Organ Prolapse Quantification (POPQ) examination and completed the Pelvic Floor Distress Inventory-20 (PFDI-20) with its Pelvic Organ Prolapse Distress Inventory (POPDI) subscale.ResultsFive hundred and eighty-eight new patients were identified with pelvic organ prolapse. Groups did not differ by age, prior prolapse, and/or incontinence surgery, or sexual activity. Based on POPDI scores, Hispanic and Native American women reported more bother compared with non-Hispanic white women with stage 2 prolapse (p < 0.01). Level of bother between Hispanic and Native American women with stage 2 prolapse (p = 0.56) was not different. In subjects with ≥ stage 3 prolapse, POPDI scores did not differ by ethnicity (p = 0.24). In multivariate stepwise regression analysis controlling for significant factors, Hispanic and Native American ethnicity contributed to higher POPDI scores, as did depression.ConclusionsAmong women with stage 2 prolapse, both Hispanic and Native American women had a higher level of bother, as measured by the POPDI, compared with non-Hispanic white women. The level of symptom bother was not different between ethnicities in women with stage 3 prolapse or greater. Disease severity may overshadow ethnic differences at more advanced stages of prolapse.

Patient Ethnicity Affects Triage Assessments and Patient Prioritization in U.S. Department of Veterans Affairs Emergency Departments.

AbstractEthnic minority patients receive lower priority triage assignments in Veterans Affairs (VA) emergency departments (EDs) compared to White patients, but it is currently unknown whether this disparity arises from generalized biases across the triage assessment process or from differences in how objective and/or subjective institution-level or person-level information is incorporated into the triage assessment process, thus contributing to disparate treatment.The VA database of electronic medical records of patients who presented to the VA ED from 2008 to 2012 was used to measure patient ethnicity, self-reported pain intensity (PI) levels, heart rate (HR), respiratory rate (RR), and nurse-provided triage assignment, the Emergency Severity Index (ESI) score. Multilevel, random effects linear modeling was used to control for demographic and clinical characteristics of patients as well as age, gender, and experience of triage nurses.A total of 359,642 patient/provider encounters between 129,991 VA patients and 774 nurses were included in the study. Patients were 61% non-Hispanic White [NHW], 28% African-American, 7% Hispanic, 2% Asian-American, <1% American Indian/Alaska Native, and 1% mixed ethnicity. After controlling for demographic characteristics of nurses and patients, African-American, Hispanic, and mixed-ethnicity patients reported higher average PI scores but lower HRs and RRs than NHW patients. NHW patients received higher priority ESI ratings with lower PI when compared against African-American patients. NHW patients with low to moderate HRs also received higher priority ESI scoring than African-American, Hispanic, Asian-American, and Mixed-ethnicity patients; however, when HR was high NHWs received lower priority ESI ratings than each of the minority groups (except for African-Americans).This study provides evidence for systemic differences in how patients’ vital signs are applied for determining ESI scores for different ethnic groups. Additional prospective research will be needed to determine how this specific person-level mechanism affects healthcare quality and outcomes.

Misconceptions and miscommunication among Spanish-speaking and English-speaking women with pelvic organ prolapse

Introduction and hypothesisLimited data exist on women’s experience with pelvic organ prolapse (POP) symptoms. We aimed to describe factors that prevent disease understanding among Spanish-speaking and English-speaking women.MethodsWomen with POP were recruited from female urology and urogynecology clinics in Los Angeles, California, and Albuquerque, New Mexico. Eight focus groups were conducted, four in Spanish and four in English. Topics addressed patients’ emotional responses when noticing their prolapse, how they sought support, what verbal and written information was given, and their overall feelings of the process. Additionally, patients were asked about their experience with their treating physician. All interview transcripts were analyzed using grounded theory qualitative methods.ResultsQualitative analysis yielded two preliminary themes. First, women had misconceptions about what POP is as well as its causes and treatments. Second, there was a great deal of miscommunication between patient and physician which led to decreased understanding about the diagnosis and treatment options. This included the fact that women were often overwhelmed with information which they did not understand. The concept emerged that there is a strong need for better methods to achieve disease and treatment understanding for women with POP.ConclusionsOur findings emphasize that women with POP have considerable misconceptions about their disease. In addition, there is miscommunication during the patient–physician interaction that leads to further confusion among Spanish-speaking and English-speaking women. Spending more time explaining the diagnosis of POP, rather than focusing solely on treatment options, may reduce miscommunication and increase patient understanding.

Sexual Abuse History and Pelvic Floor Disorders in Women

Objectives Sexual abuse rates in the general female population range between 15% and 25%, and sexual abuse is known to have a long-term impact on a woman’s health. The aim of this study was to report the prevalence of sexual abuse history in women presenting to clinicians for pelvic floor disorders (PFD) and to determine whether a history of sexual abuse is associated with a specific type of PFD. Methods We conducted a retrospective chart review of new urogynecology patients seen at the University of New Mexico Hospital. All women underwent a standardized history and physical examination and completed symptom severity and quality-of-life measures. Univariate and multivariable analyses were conducted to determine which PFDs were associated with a history of sexual abuse among women with and without a history of sexual abuse. Results A total of 1899 new urogynecology patients with complete information were identified from January 2007 and October 2011; 1260 (66%) were asked about a history of sexual abuse. The prevalence of sexual abuse was 213/1260 (17%). In the multivariable analysis, only chronic pelvic pain remained significantly associated with a history of sexual abuse. Conclusions A history of sexual abuse is common among women with PFDs, and these women were more likely to have chronic pelvic pain.

Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions.

Objective The aim of this study was to compare perioperative complications by route of hysterectomy before and after the introduction of robotic surgery. Methods This is an ancillary analysis of a multicenter, retrospective cohort study with historical controls through the Fellows’ Pelvic Research Network. Hysterectomies performed for benign conditions were collected prior to introduction of the robot (prerobot) and the year after introduction of the robot (postrobot) at each institution. To obtain a representative annual case distribution for each institution, a maximum of 20 cases per month were selected using stratified random sampling. Patient demographics and intraoperative and postoperative complication data were collected. Results One thousand four hundred forty cases were included in this study, 732 in the prerobot and 708 in the postrobot period. Intraoperative complications in the prerobot group were highest in the abdominal group (7.4%) followed by vaginal (3.9%) and laparoscopic (3.7%) groups. Postoperative complications were higher in the vaginal (8.3%) and abdominal (7.4%) groups compared with laparoscopic (1.8%) groups (P = 0.03), because of a higher proportion of infections. In the postrobot period, intraoperative complications were lower in the vaginal (2.8%), robotic (3%), and laparoscopic (4.6%) groups compared with abdominal (10.8%) (P = 0.04). Postoperative complications were lowest in the vaginal (5.1%), laparoscopic (3.6%), and robotic (3%) approaches compared with the abdominal (13.9%) approach (P = 0.003). Conclusions Vaginal hysterectomy has comparable rates of perioperative complications when compared with robotic and laparoscopic approaches and should be considered as a primary surgical approach in the growing armamentarium of minimally invasive approaches for hysterectomy for benign conditions.

Can you find the source of her pain

BACKGROUND: The features of abdominal pain in this gravid patient mimicked more common diagnoses like preterm labor, chorioamnionitis, and appendicitis. CASE: A 40-year-old multipara presented at 30 weeks and 6 days with abdominal pain. The cause was not discovered until the time of cesarean delivery several days after admission. CONCLUSION: This common gynecologic problem can precipitate severe problems in a pregnant woman and should be considered part of the diagnosis in pregnant patients presenting with pain.

Improving biofeedback for the treatment of fecal incontinence in women: Implementation of a standardized multi-site manometric biofeedback protocol

Standardized training and clinical protocols using biofeedback for the treatment of fecal incontinence (FI) are important for clinical care. Our primary aims were to develop, implement, and evaluate adherence to a standardized protocol for manometric biofeedback to treat FI.

Standard compared with mnemonic counseling for fecal incontinence: a randomized controlled trial.

OBJECTIVE: To estimate whether women who underwent mnemonic counseling had better recall of fecal incontinence therapies at 2 months and if mnemonic counseling resulted in greater satisfaction with physician counseling and improvement in quality of life when compared with a group who underwent standard counseling. METHODS: Counseling-naive women with fecal incontinence were recruited from an academic urogynecology clinic. Women underwent physical examinations, completed the Quality of the Physician–Patient Interaction, recorded fecal incontinence treatment options they recalled, and completed the Fecal Incontinence Severity Index and Manchester Health Questionnaire immediately after counseling and again at 2 months. RESULTS: Ninety women consented to participate, were randomized, and completed baseline questionnaires. At baseline, women did not differ in age, ethnicity, education, Fecal Incontinence Severity Index, or Manchester Health Questionnaire scores. After counseling, the mnemonic group reported higher satisfaction on Quality of the Physician–Patient Interaction (66.4±6.5 compared with 62.2±10.7, P=.03). Ninety percent (81/90) of women followed up at 2 months. Our primary endpoint, 2-month recall of fecal incontinence treatments, was not different between groups (2.3±1.6 mnemonic counseling compared with 1.8±1.0 standard counseling; P=.08). Secondary endpoints for the mnemonic group reported greater improvement on total Manchester Health Questionnaire (P=.02), emotional (P=.03), sleep (0.045), role limitations (P<.01), and physical limitations (P=.04) when compared with the standard group. CONCLUSION: Fecal incontinence counseling with a mnemonic aid did not improve recall at 2 months but improved patient satisfaction and quality of life at 2 months. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT01778660. LEVEL OF EVIDENCE: I