Readability of patient information pamphlets in urogynecology.

OBJECTIVE: The purpose of this study was to determine the reading level of frequently used patient information pamphlets and documents in the field of urogynecology. METHODS: Urogynecology pamphlets were identified from a variety of sources. Readability was determined using 4 different accepted formulas: the Flesch-Kincaid Grade Level, the simple measure of gobbledygook Index, the Coleman-Liau Index, and the Gunning Fog index. The scores were calculated using an online calculator (http://www.readability-score.com). Descriptive statistics were used for analysis. The average of the 4 scores was calculated for each pamphlet. Subsequently, Z-scores were used to standardize the averages between the reading scales. RESULTS: Of the 40 documents reviewed, only a single pamphlet met the National Institutes of Health-recommended reading level. This document was developed by the American Urological Association and was specifically designated as a "Low-Literacy Brochure." The remainder of the patient education pamphlets, from both industry-sponsored and academic-sponsored sources, consistently rated above the recommended reading level for maximum comprehension. CONCLUSIONS: The majority of patient education pamphlets, from both industry-sponsored and academic-sponsored sources, are above the reading level recommended by the National Institutes of Health for maximum patient comprehension. Future work should be done to improve the educational resources available to patients by simplifying the verbiage in these documents.

Trends in sacral colpopexy for the management of apical prolapse.

OBJECTIVE: To evaluate trends in surgical approach for sacral colpopexy since the advent of robotic technology for gynecologic procedures. STUDY DESIGN: Women who underwent surgery for uterovaginal prolapse, cystocele, and/orvaginalvault prolapse were included in this study. The number of patients undergoing a vaginal approach for prolapse was compared to the number of patients receiving sacral colpopexy. Descriptive statistics comprised means and standard deviations, while categorical data were reported as frequencies. Inferential statistics comprised Student's t-test for assessing two-group differences between means ofcontinuous, normally distributed data and chi-squared tests for comparisons of equality of distribution between categorical variables. RESULTS: Patients undergoing sacral colpopexy were younger than their vaginal surgery counterparts (P< 0.001). When stage ofprolapsewas dichotomized, among those with stage 1-2 prolapse, a greater percentage of patients received colpopexy in favor of vaginal surgery in 2010 than in 2007 (P=0.001). CONCLUSION: There is an increasing trend towards robotic-assisted sacralcolpopexyforthe management of apical prolapse.

The impact of pessary use on bowel symptoms: one-year outcomes.

OBJECTIVES: The literature states that patients with pelvic organ prolapse have a higher prevalence of bothersome bowel symptoms and that surgical correction of prolapse may improve bowel function. There is limited knowledge regarding the impact of pessary use on bowel function in patients with prolapse. The aim of this study was to evaluate if there is a change in bowel symptoms in patients with prolapse treated with a vaginal pessary. METHODS: Women who presented for pessary insertion completed the validated questionnaires on the bowel symptom severity and on the effect of bowel symptoms on the quality of life at baseline and again at 12 months of continuous pessary use. Inferential statistics comprised Student t test for evaluating differences in continuous Gaussian data between groups and paired t tests were used to evaluate differences among subjects between the baseline and 12 months of use. RESULTS: One hundred four women participated in the original study, and 43 had complete data for analysis. Women who completed 12 months of pessary use reported significant improvements in both bowel-related symptoms and bowel-related quality of life (95% confidence interval of the difference 1.6-11.4 and 2.0-14.0, respectively). Patients who completed the 12-month follow-up were significantly older and more likely to have stage 3 or 4 prolapse than noncompleters, but there were no differences in body mass index, race, history of prior prolapse surgery, or menopause status. CONCLUSIONS: In women with prolapse, the use of a pessary is associated with a decrease in complaints related to bowel symptoms.

Does the impact of urinary incontinence on quality of life differ based on age?

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to evaluate if the impact of urinary incontinence (UI) on quality of life (QOL) differs between women based on age. METHODS: A retrospective review of patients presenting for the management of UI was performed. Patients with UI and their corresponding degree of bother were identified by their responses to validated questionnaires. Distributions of comorbidities and types of UI were presented as frequencies and compared between age cohorts with a chi-square test. Mean scale scores were assessed for normality and a one-way analysis of variance with a post hoc Scheffé's test was used to compare the scores. RESULTS: Of 765 patients meeting inclusion criteria, 22.4 % were <45, 28.9 % were 45-55, and 48.8 % were >55 years of age. Women older than 55 were significantly more likely to have urge UI and mixed UI than their counterparts (p < 0.001). Women <45 and 45-55 were more negatively impacted in their ability to perform physical activities compared to women >55 (p = 0.004), whereas women >55 were significantly less likely to feel frustrated by their incontinence than women <45 (p = 0.022). However, there was no significant difference in overall impact of incontinence among groups (p = 0.585). CONCLUSIONS: UI equally impacts the functional and psychological QOL in women regardless of age. UI in women <55 results in a greater negative impact on level of physical activity, whereas women <45 are significantly more frustrated.

Changes in bowel symptoms 1 year after rectocele repair.

OBJECTIVE: We sought to evaluate changes in bowel symptoms after rectocele repair and identify risk factors for persistent symptoms. STUDY DESIGN: We conducted ancillary analysis of a randomized surgical trial for rectocele repair. Subjects underwent examinations and completed questionnaires for bowel symptoms at baseline and 12 months postoperatively. Outcomes included resolution, persistence, or de novo bowel symptoms. We used multiple logistic regression to identify risk factors for bowel symptom persistence. RESULTS: A total of 160 women enrolled: 139 had baseline bowel symptoms and 85% had 12-month data. The prevalence of bowel symptoms decreased after rectocele repair (56% vs 23% splinting, 74% vs 37% straining, 85% vs 19% incomplete evacuation, 66% vs 14% obstructive defecation; P < .001 for all). On multiple logistic regression, a longer history of splinting was a risk factor for persistent postoperative splinting (adjusted odds ratio, 2.25; 95% confidence interval, 1.02-4.93). CONCLUSION: Bowel symptoms may improve after rectocele repair, but almost half of women will have persistent symptoms.

Correlation of POP-Q posterior compartment measures with defecatory dysfunction.

INTRODUCTION AND HYPOTHESIS: The relationships of Pelvic Organ Prolapse Quantification (POP-Q) items pb and Bp with defecatory dysfunction were evaluated with the hypothesis that increased values for both items would correlate with symptoms of stool trapping. METHODS: Pelvic Floor Distress Inventory (PFDI-20) results and POP-Q exams from 1,663 urogynecology patients were compiled in a database. Rectocele was defined as POP-Q point Bp > -0.5 and perineocele as pb >3. PFDI-20 questions were used to compare defecatory symptoms and bother in women with and without rectocele and perineocele. RESULTS: While perineocele was not associated with symptoms or bother, women with isolated rectoceles had higher rates of splinting (p < 0.001) and incomplete evacuation (p = 0.001) and higher bother scores (p < 0.001) than those with neither rectocele nor perineocele. CONCLUSIONS: The POP-Q Bp point, but not the pb measurement, correlates with symptoms of defecatory dysfunction.

Porcine subintestinal submucosal graft augmentation for rectocele repair: a randomized controlled trial.

OBJECTIVE: To estimate the effect of porcine subintestinal submucosal graft augmentation on improving anatomic and subjective rectocele repair outcomes compared with native tissue repair. METHODS: We conducted a randomized controlled trial at two sites, including women with at least stage 2 symptomatic rectocele. Anatomic and subjective outcomes (vaginal bulge and defecatory) were collected 12 months postoperatively, including blinded Pelvic Organ Prolapse Quantification (POP-Q) examinations. Anatomic failure was defined as points Ap or Bp -1 or greater on POP-Q. Subjective failure was defined as no improvement or worsening of symptoms. We estimated number needed to treat and adjusted odds ratios (ORs). Assuming graft use is associated with 93% anatomic success, 63 women per group would be needed to detect a 20% difference at α=.05 and ß=.20. RESULTS: One hundred sixty women were randomized; 137 had 12-month anatomic data (67 graft; 70 control). There was no difference in anatomic failure (12% compared with 9%, P=.5), vaginal bulge symptom failure (3% compared with 7%, P=.4, number needed to treat=26) or defecatory symptom failure (44% compared with 45%, P=.9, number needed to treat=91) for graft compared with control, respectively. Both groups reported improvement in vaginal bulge and defecatory symptoms (P<.05 for all). On multiple logistic regression, graft use was not associated with a decreased odds of anatomic failure (adjusted OR 1.36, 95% confidence interval [CI] 0.44-4.25), vaginal bulge symptoms (adjusted OR 0.46, 95% CI 0.08-2.68), or defecatory symptoms (adjusted OR 0.98, 95% CI 0.48-2.03). CONCLUSION: Although rectocele repair by either approach is associated with improved symptoms, subintestinal submucosal graft augmentation was not superior to native tissue for anatomic or subjective outcomes at 12 months. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00321867.

Constipation symptoms before and after vaginal and abdominal pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: This article aims to evaluate how constipation symptoms change after pelvic reconstructive surgery using the Patient Assessment of Constipation Symptom Questionnaire (PAC-SYM). Our primary hypothesis was that constipation would improve after surgery. METHODS: Ninety-four subjects completed the PAC-SYM before and 7 weeks after pelvic reconstructive surgery from 2007 through 2009 inclusive. PAC-SYM scores were compared for the cohort before and 7 weeks post-surgery and based on route of surgery: vaginal or abdominal. RESULTS: Baseline PAC-SYM scores between those undergoing abdominal or vaginal reconstructive surgery were not significantly different (0.76 versus 0.83, respectively; p = 0.586). Subjects in the vaginal surgery group had a significant reduction in PAC-SYM scores, 0.83 to 0.62 (p = 0.049). After abdominal surgery, subjects had an increase in abdominal subscale scores, 0.69 to 1.03 (p = 0.012). CONCLUSIONS: Women undergoing vaginal prolapse surgery may have a short-term improvement in constipation symptoms, while those undergoing abdominal surgery have worsening of abdominal constipation symptoms.

Complex sacral abscess 8 years after abdominal sacral colpopexy.

BACKGROUND: Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period. CASE: A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh. CONCLUSION: Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

Characteristics of nulliparous women who would consider cesarean delivery on maternal request.

INTRODUCTION/HYPOTHESIS: To identify factors that influence nulliparous women to choose cesarean delivery on maternal request (CDMR). METHODS: Nulliparous women at > or = 34 weeks completed a 76-item survey about concerns during labor, delivery and postpartum. RESULTS: Mean age of the 294 respondents was 28.4 years (+/- 6.13 years SD) and mean gestational age was 35.4 weeks (+/- 2.8 weeks). Sixteen patients (5.4%) would request CDMR if offered. Women who would request CDMR were more likely to plan breastfeeding (OR 5.1, P=0.02), have a mother who delivered by C-section (OR 5.1, P= 0.01), and be concerned about the number of family members present (OR 1.75, P=0.002). Pelvic muscle damage, urinary incontinence, fecal incontinence, or need for prolapse surgery were notcited by any patient as her top concern. CONCLUSIONS: Few women in our sample desire CDMR. Concern for pelvic-floor problems was low.

Pessary use and impact on quality of life and body image.

OBJECTIVES: : The objective of the study was to determine if vaginal pessaries improve symptoms of prolapse and body image in women with pelvic organ prolapse. Our hypothesis was that pessary use would improve prolapse-related symptoms and body image up to 1 year. METHODS: : Women presenting for pessary insertion completed questionnaires regarding pelvic floor-related symptoms and body image with successful pessary insertion and after 6 to 12 months of continued pessary use. Scores were compared with a paired t test. RESULTS: : Forty-three subjects had complete data for analysis. Scores on both prolapse-related and body image questionnaires showed improvements at 6 months (P < 0.001) and 12 months (P < 0.010). Younger women and those with prior prolapse surgery were less likely to continue to use a pessary past 3 to 6 months. Stage of prolapse, body mass index, and scores on symptom questionnaires did not correlate with likelihood of continued pessary use versus surgery. CONCLUSIONS: : The use of a pessary for more than 12 months improves symptoms of prolapse and self perception of body image.

The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: The objective of the study was to compare time to first bowel movement (BM) after surgery in subjects randomized to placebo or senna with docusate. STUDY DESIGN: Ninety-six subjects completed a baseline 7-day bowel diary before and after surgery. After pelvic reconstructive surgery, the subjects were randomized to either placebo (n=45) or senna (8.6 mg) with docusate (50 mg) (n=48). Time to first BM and postoperative use of magnesium citrate were compared. RESULTS: There was a significant difference in the time to first BM in those receiving senna with docusate vs placebo (3.00+/-1.50 vs 4.05+/-1.50 days; P<.002). More subjects in the placebo group needed to use magnesium citrate to initiate a bowel movement (43.6% vs 7.0%; P<.001). CONCLUSION: The use of senna with docusate decreases time to first BM in those undergoing pelvic reconstructive surgery compared with placebo. Subjects using senna with docusate are also significantly less likely to use magnesium citrate.

Impact of pessary use on prolapse symptoms, quality of life, and body image.

OBJECTIVE: We sought to evaluate whether use of a vaginal pessary would change body image, bother symptoms, and quality of life in women with pelvic organ prolapse. STUDY DESIGN: Women presenting for pessary insertion completed the short forms of Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire, and Body Image Scale. After successful pessary insertion and use for at least 3 months, subjects completed the surveys again. Scores were compared with a paired t test. RESULTS: A total of 75 subjects were enrolled and follow-up responses were available for 54 subjects for analysis. Body Image Scale scores showed a significant decrease (6.1-3.4; P<.001), indicating an improvement in these women's perception of themselves, as did Pelvic Floor Distress Inventory-20 scores (81.34-45.83; P<.001) and Pelvic Floor Impact Questionnaire scores (50.32-17.98; P=.003). CONCLUSION: The use of a pessary for 3 months reduces bother symptoms and improves both quality of life and perception of body image in women.

Factors associated with PISQ-12 completion in an academic urogynecology population.

INTRODUCTION AND HYPOTHESIS: Some new urogynecology patients who are given the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) complete it despite stating that they are not sexually active. This study compared sexually active (SA) and non-sexually active (NSA) women who complete the PISQ-12, hypothesizing that these groups differ substantially. METHODS: New patients during the study period were given the PISQ-12 and two other validated questionnaires. Medical and demographic data were collected and analyzed for univariate differences between SA and NSA PISQ-12 completers. Logistical regression identified factors predicting PISQ-12 completion. RESULTS: Of the 655 new patients during the study period, 399 completed the PISQ-12. Of these, 16.8% were NSA. These women were older, less likely married, and had higher BMI than their SA counterpart. Being sexually active, younger, and married are predictors of PISQ-12 completion. CONCLUSIONS: Some NSA women complete the PISQ-12. Instructions should specify that only SA women complete this questionnaire.

Is there a relationship between glomerular filtration rate and detrusor overactivity in women?

AIMS: The relationship of detrusor overactivity (DO) to neuromuscular causes is well established, but a connection to kidney function has not yet been studied. We sought to evaluate whether patients with DO have differences in estimated glomerular filtration rate (eGFR). METHODS: After Institutional Review Board approval, we collected data from all patients who underwent urodynamic testing in our office from September 1, 2006 to February 28, 2007 and calculated eGFR using the equation derived from the Modification of Diet in Renal Disease (MDRD) study. RESULTS: Data were collected on 359 patients, who had a mean eGFR for all patients of 82.99 ml/min/1.73 m(2) (+/-22.2). The patients were divided into groups by the presence or absence of DO on filling cystometry. There was no significant difference in eGFR between the patients with and without DO (80.9 ml/min/1.73 m(2) vs. 84.4, P = 0.290). CONCLUSIONS: Kidney function does not differ between patients with or without DO.

Patterns of telephone calls triaged by registered nurses in a urogynecology practice.

The volume and time required to manage a nurse telephone triage line in an urogynecology practice can be a concern for staffing, time management, and office patient flow. Therefore, telephone triage logs were retrospectively reviewed for a 12-month period to investigate whether call volume differed on days of the five-day office work week. Results showed Monday to be the busiest telephone triage day, with an average of 32.26 calls per day, and Friday as the second busiest day, with 28.52 calls per day. Based on this review, staffing patterns may need to be adjusted to accommodate the higher call volumes on Mondays and Fridays.

Can community-dwelling women reliably identify infected urine?

The purpose of this study was to evaluate whether community-dwelling women can reliably identify infected urine samples. A convenience sample of 25 women judged six urine samples. Of these, two were normal, two contained culture-proven infections, and two were intentionally abnormal because of ingestion of asparagus or vitamins. The women decided if each sample was infected based on its color, clarity, and odor. For the two normal samples, 56 and 96% women correctly identified them. Of the two samples positive for infection, women were correct 80 and 100% of the time. Of the two samples designed to be abnormal, women were correct in 92 and 64% of their evaluations. Using the 150 total evaluations of urine samples, the sensitivity was 90%, and the specificity was 77%. Based on this small sample, community-dwelling women can detect infected samples of urine. However, women should still be screened for factors that might have distorted normal urine.

Occurrence of postoperative hematomas after prolapse repair using a mesh augmentation system.

BACKGROUND: Mesh-augmented repair kits are increasingly being used for anterior compartment defect repair and can be associated with complications. CASES: Two cases are presented of postoperative pelvic hematomas confirmed on computerized tomography scan after anterior repair with a mesh-augmented anterior vaginal prolapse repair system. Both resolved without requiring drainage, although one patient did require a blood transfusion, and the other required intravenous antibiotics to treat an infected hematoma. CONCLUSION: Significant complications may arise from this new technology. Further studies are needed to determine whether the benefits of this technology outweigh its risk of use.

Resident education and training in urogynecology and pelvic reconstructive surgery: a survey.

The aim of the study is to assess satisfaction with urogynecology education among obstetrics and gynecology residents. An Internet-based survey was designed to obtain a cross-sectional sample of third- and fourth-year residents. Didactic and surgical training as well as perceived surgical competency were assessed. Responses were received from 205 residents for this convenience sample. Nearly half (46%) of the respondents were unsatisfied with urogynecology resident education. There was no significant difference between respondents from academic programs and community programs with regard to overall satisfaction, the opportunity to work with the presence of a fellowship-trained urogynecologist or having a dedicated urogynecology rotation. Respondents were more satisfied with their education if they did a urogynecology rotation or worked with a fellowship-trained urogynecologist. Female pelvic medicine and reconstructive surgery fellows were involved in the education of 23.9% of the respondents. Most respondents indicated comfort performing cystoscopy, anterior and posterior repairs, and McCall's culdoplasty following graduation. Overall, respondents indicated that residency training in urogynecology is less and later than desired, although they did feel competent at some urogynecologic surgeries.

Anterior vaginal wall prolapse and voiding dysfunction in urogynecology patients.

We investigated whether women with and without anterior vaginal wall prolapse have voiding differences. Women (n=109) who presented to a urogynecology practice were categorized into two groups based on anterior vaginal wall prolapse: stages 0 and 1 and stages 2, 3, and 4. Women with prolapse were older than the women without prolapse but the groups were otherwise similar demographically. There was a higher rate of activity-related urine loss and use of wetness protection amongst women without prolapse. There was no significant difference for urgency symptoms or urge incontinence. Urodynamic testing found no significant differences for maximal flow rate or maximal urethral closing pressures. Postvoid residual volume and detrusor overactivity were not different but approached significance. Anterior vaginal wall prolapse of stage 2 or greater was not associated with urge incontinence or voiding function in this population. Women without prolapse were more likely to report stress incontinence.