Sylvia M. Botros

Site-Specific Rectocele Repair Compared With Standard Posterior Colporrhaphy

OBJECTIVE: To compare the anatomic and functional outcomes of site-specific rectocele repair and standard posterior colporrhaphy. METHODS: We reviewed charts of all patients who underwent repair of advanced posterior vaginal prolapse in our institution between July 1998 and June 2002 with at least 1 year of follow-up. RESULTS: This study comprised 124 consecutive patients following site-specific rectocele repair and 183 consecutive patients following standard posterior colporrhaphy without levator ani plication. Baseline characteristics, including age, body mass index, parity, previous pelvic surgeries, and preoperative prolapse were not significantly different between the 2 study groups. Recurrence of rectocele beyond the midvaginal plane (33% versus 14%, P = .001) and beyond the hymenal ring (11% versus 4%, P = .02), recurrence of a symptomatic bulge (11% versus 4%, P = .02), and postoperative Bp point (–2.2 versus –2.7 cm, P = .001) were significantly higher after the site-specific rectocele repair. Rates of postoperative dyspareunia (16% versus 17%), constipation (37% versus 34%), and fecal incontinence (19% versus 18%) were not significantly different between the 2 study groups. CONCLUSION: Site-specific rectocele repair is associated with higher anatomic recurrence rates and similar rates of dyspareunia and bowel symptoms than standard posterior colporrhaphy. LEVEL OF EVIDENCE: II-3

Histologic characterization of vaginal vs. abdominal surgical wound healing in a rabbit model

We aimed to compare the histologic characteristics of vaginal vs. abdominal surgical wound healing in the rabbit. Bilateral 6 mm full‐thickness circular segments were excised from the vagina and abdominal skin in 34 New Zealand white female rabbits. Animals were euthanized on the day of and 4, 7, 10, 14, 21, 28, and 35 days after wounding, and their wounds were evaluated using a modified scoring system. The inter‐ and intraobserver agreements of the scoring system were good (weighted κ 0.63 and 0.71, respectively). A transient fibrinous crust was evident in 75% of the abdominal and in none of the vaginal wound specimens on days 4–7 after wounding (p=0.01). Acute inflammation peaked at day 4 in both the vaginal and abdominal wounds, while chronic inflammation peaked at days 4–7 and 14–21 in the abdomen and vagina, respectively. Both neovascularization and the amount of granulation tissue peaked at days 4 and 7 in the vagina and abdomen, respectively. Maturation of granulation tissue and collagen deposition increased persistently in both tissues until postwounding day 35. Reepithelialization increased after wounding, and was completed by day 14 in both tissues. The surgical wound‐healing process in both the vagina and abdomen includes transient acute and chronic inflammation, fibroblast proliferation, and neovascularization, as well as progressive maturation of granulation tissue, reepithelialization, and collagen deposition. A transient fibrinous crust forms in the abdomen but not in the vagina 4–7 days after wounding. The modified histologic scoring system described here was found to be reliable and reproducible.

Effect of parity on sexual function : An identical twin study

OBJECTIVE: To assess the impact of childbirth on female sexual function by using an identical twin study design. METHODS: A survey including the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was administered to 542 twin sisters, and PISQ-12 scores of 29 twin pairs discordant for parity were compared. Multiple linear regression models were used to evaluate impact on total PISQ-12 scores in 276 identical, sexually active twins. Three models were used 1) to evaluate the effect of parity and general risk factors, 2) to examine the impact of birth mode, and 3) to examine the role of episiotomy and operative delivery. RESULTS: Mean PISQ-12 scores were significantly higher for discordant nulliparous twins than for parous twins (102.5 versus 93.5, P < .001). The mean (standard deviation) PISQ-12 score was 99.3 (11.7). Age of 50 years or older (difference in mean scores –5.4, P = .019), stress urinary incontinence (−3.3, P = .02), urge urinary incontinence (−5.9, P < .001), parity (−6.5, P < .001), and fecal incontinence (−5.7, P = .048) were associated with decreased mean PISQ scores in the univariable analysis. Parity (−4.9, P < .001) and urge urinary incontinence (−4.3, P = .009) were the only factors remaining independently predictive of diminished sexual function in the multivariable analysis. Mode of delivery did not significantly affect mean PISQ scores (P = .763). Among women who had vaginal deliveries only, neither episiotomy nor operative delivery was associated with change in PISQ scores (P = .553). CONCLUSION: Nulliparous women reported superior sexual satisfaction scores compared with parous women, regardless of age and mode of delivery. Childbirth appears to have a lasting impact on sexual function, due to psychological more than physical factors, well beyond the postpartum period. LEVEL OF EVIDENCE: II-2

Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study.

OBJECTIVE: To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance. METHODS: A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately. RESULTS: Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21–6.0; flatal: OR 1.90, 95% CI 1.11–3.24), menopause (fecal: OR 2.10, 95% CI 1.15–3.8; flatal: OR 2.11, 95% CI 1.43–3.13), increasing parity (parity ≥ 2; fecal: OR 3.09, 95% CI 1.25–7.65; flatal: OR 2.72, 95% CI 1.65–4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12–3.98; flatal: OR 1.72, 95% CI 1.14–2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries. CONCLUSION: Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence. LEVEL OF EVIDENCE: II-2

Predictors of persistent detrusor overactivity after transvaginal sling procedures

OBJECTIVE Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence STUDY DESIGN Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models. RESULTS Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001). CONCLUSION When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.

Arcus-anchored acellular dermal graft compared to anterior colporrhaphy for stage II cystoceles and beyond

Introduction and hypothesisThe aim of this study is to compare acellular dermal matrix to standard colporrhaphy for cystocele repair.MethodsOne hundred two patients with greater than or equal to stage II anterior prolapse (Aa or Ba 0) who underwent anterior colporrhaphy with acellular dermal implant attached to the arcus between October 2003 and February 2007 were compared to 89 controls who received standard anterior colporrhaphy. Objective recurrence was defined as greater than or equal to stage II (Aa or Ba −1).ResultsThe dermal graft and colporrhaphy groups were comparable in age, parity, body mass index, and concomitant surgeries except hysteropexy and hysterectomy. Regression was performed for possible confounders. Postoperatively, 14 (19%) recurrences were identified in the dermal graft group vs. 26 (43%) in the colporrhaphy group (p = 0.004). Two patients underwent reoperations for cystocele recurrence in the study group vs. four in the control group. Time to normal voiding, subjective stress urinary incontinence, estimated blood loss, and length of hospital stay did not differ between groups.ConclusionDermal acellular matrix provides benefit over standard colporrhaphy.

The effect of preemptive pudendal nerve blockade on pain after transvaginal pelvic reconstructive surgery.

OBJECTIVE: To assess the effect of preemptive pudendal nerve blockade on pain and consumption of narcotic analgesia following transvaginal pelvic reconstructive surgery. METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients undergoing transvaginal pelvic reconstructive surgery under general anesthesia were randomized to receive pudendal block with either bupivacaine 0.25% or placebo (normal saline 0.9%) immediately before surgery. All patients received postoperative intravenous hydromorphone patient-controlled analgesia. Patients were asked to report on their pain intensity 1, 3, 5, 7, 18, and 24 hours postoperatively, using a validated visual analog pain scale from 0–10. Main outcome measures included postoperative pain intensity and hydromorphone consumption. RESULTS: One hundred ten patients enrolled in the study, of whom 106 underwent randomization, and 102 received pudendal nerve blockade, 51 with bupivacaine and 51 with saline. Demographic and baseline clinical characteristics were not significantly different between the 2 patients groups. There were no significant differences in postoperative pain intensity (median scores: 1 hour, 4.0 versus 5.0; 3 hours, 3.0 versus 4.0; 7 hours, 2.0 versus 3.0; 18 hours, 3.0 versus 4.0), the consumption of hydromorphone (0–3 hours, 1.84 mg versus 1.77 mg; 4–7 hours, 1.19 mg versus 1.20 mg; 8–18 hours, 2.89 mg versus 2.35 mg), or mean hospital stay (39.6 versus 37.3 hours) between the bupivacaine and saline groups. CONCLUSION: Preemptive pudendal nerve blockade does not affect postoperative pain intensity or the consumption of narcotic analgesia after transvaginal pelvic reconstructive surgery. LEVEL OF EVIDENCE: I

Urge incontinence: estimating environmental and obstetrical risk factors using an identical twin study

Introduction and hypothesisThe objective of this study was to determine risk factors for urge urinary incontinence (UUI).MethodsA multi-item survey was administered to a community sample of identical twin sisters from 2002–2008. Generalized estimating equations accounting for co-twin correlation were used to perform three different regression models on the outcome: UUI (yes vs. no).ResultsMean age, median parity, and BMI were 41.4 ± 16.4 (18–85), 1.0, and 26.0 ± 6.5 (13.5–55.8), respectively. Thirty-five percent of women were post-menopausal, and 27.5% had UUI. Urge urinary incontinence was reported in 40.1% of parous versus 14.1% among nulliparous women (p < .0001). The rate of UUI was 40.6% after vaginal delivery, 36.7% after cesarean delivery, and 14.1% in nulliparous women (p < .0001). Obesity, age >40, and chronic constipation were also identified as risk factors for urge urinary incontinence.ConclusionRisk factors for UUI include parity, age, obesity, and chronic constipation. There was a 2.5-fold increased risk of UUI after one or more births, regardless of type of delivery.

Impact of hysterectomy on stress urinary incontinence: an identical twin study

OBJECTIVE This study uses the unique properties of twin research design to evaluate whether hysterectomy impacts stress urinary incontinence (SUI). STUDY DESIGN As part of the Evanston Twins Sister Study, we performed bivariate and multivariate analyses on 83 identical twin pairs discordant for hysterectomy. RESULTS In bivariate analysis, SUI was less common in women who had prior hysterectomy (P =0.028). Multivariate analysis suggested that SUI was significantly less common after hysterectomy (odds ratio [OR], 0.55, confidence interval [CI], 0.30 to 1.00). Exclusion of twin pairs with a history of pelvic floor defect surgery eliminated the statistical relationship between hysterectomy and SUI (OR, 0.79, CI, 0.4 to 1.40). CONCLUSION Hysterectomy, when analyzed with all cases, was associated with reduced SUI. When concurrent pelvic floor defect surgeries were excluded from the analysis, we found no relationship between hysterectomy and the risk of SUI afterward.

Nongenetic Factors Associated With Stress Urinary Incontinence

OBJECTIVE: To explore the role of hereditary and environmental factors on the development of stress urinary incontinence in a large cohort of identical and nonidentical twins. METHODS: This is a large, population-based, classic twin study of twin sisters recruited to complete a health survey at the worlds largest annual twins festival during 2003–2008. Concordance rates were calculated and structural equation models were used to estimate the contribution of genetic effects compared with environmental factors toward the development of stress urinary incontinence. RESULTS: Eight hundred eighty-two twin sister pairs (n=1,764), including 765 identical and 117 nonidentical twin sister pairs, completed the questionnaires. Sequential structural equation modeling revealed that common environmental factors contributed 77.6% (95% confidence interval [CI], 41.4–83.8; P<.001) of the variance and unique environmental factors contributed 20.9% (95% CI, 15.8–26.7; P<.001) of the variance. The effect of genetics was not statistically significant at 1.49% (95% CI, 0.0–38.8; P=.46). CONCLUSION: Female stress urinary incontinence is more a consequence of environmental risk factors than heredity. This epidemiologic insight should be considered in preventive health efforts. LEVEL OF EVIDENCE: II