Multidisciplinary approach to evaluation of rectovaginal fistulas.

Thorough evaluation of a rectovaginal fistula is essential to optimize surgical repair. The underlying cause should be addressed and treated, which can affect the timing and the approach to repair. It is imperative to be well prepared because the highest chance of successful closure occurs during the initial repair attempt. Our objective was to demonstrate how multidisciplinary colorectal surgery and urogynecology teams use specific methods during the examination under anesthesia to evaluate a complex rectovaginal fistula and to optimize the surgical approach to repair. Anesthesia may be provided with monitored anesthesia care and a posterior perineal block. This pain control allows for a wide range of techniques to evaluate the fistula using anoscopy, fistula probe, hydrogen peroxide, and sigmoidoscopy. In addition, the teams show how curettage and subsequent seton placement can encourage closure by secondary intention and decrease the risk of abscess formation, respectively.

U.S.-Based Obstetrician/Gynecologists' Experiences with Delivering Care to Women with Female Genital Cutting.

Background: There has been an increase of women living in the United States who have experienced female genital cutting (FGC). However, limited research exists evaluating the experiences of obstetrician/gynecologists delivering care to this patient population. This study aimed to assess the overall experiences, including barriers and facilitators, of U.S.-based obstetrician/gynecologists (OBGYNs) with delivering care to patients with female genital cutting at a single academic health center in the United States. Materials and Methods: This is a qualitative study of OBGYNs at a large, U.S., urban, academic health center. OBGYNs participated in a one-on-one semistructured interview. Thematic analysis using a grounded theory approach was conducted to identify predominating themes regarding the overall experiences, barriers, and facilitators to delivering care to patients with FGC. Results: Analysis of 15 study interviews revealed 4 main themes impacting the ability of OBGYNs to deliver care to patients with FGC: (1) limited educational training on FGC, (2) challenges with identifying that a patient had FGC and with using the World Health Organization classification system, (3) questions regarding "normative" anatomy and reinfibulation after vaginal procedures, and (4) navigating affective responses of patient and self when FGC is encountered. Conclusion: The above findings have practical implications, showing that the limited educational experience and lack of a clear policy on how to manage the care of women with FGC lead to variation and even limitations in how care is delivered to these women. We encourage OBGYN professional societies to consider creating education and policy to aid clinicians in caring for patients with FGC.

Is Nocturia Associated With Detrusor Underactivity?

OBJECTIVES: Detrusor underactivity (DU) is diagnosed using urodynamic testing. We hypothesized that nocturia is associated with detrusor underactivity. METHODS: We performed a retrospective chart review of all women who underwent urodynamic testing at our institution between 2016 and 2018. Uroflowmetry and pressure-flow study parameters were compared between women with nocturia (≥2 voids/night) and without nocturia (0-1 void/night). Detrusor underactivity was diagnosed using 3 different criteria: (1) bladder voiding efficiency (BVE) of <90%, (2) bladder contractility index of <100, and (3) a composite of three urodynamic measures (Gammie criteria). RESULTS: Of 358 women, 172 (48%) were in the nocturia group and 186 (52%) were in the no nocturia group. On uroflowmetry, median postvoid residual volume was similar (20 mL) in both groups. Median maximum flow rate (15 vs 17 mL/s, P < 0.05) and average flow rate (6 mL/s vs 7 mL/s, P < 0.05) were significantly lower in the nocturia group compared with the no nocturia group. During pressure-flow study, a significantly greater proportion of women with nocturia were unable to void around the catheter (30% vs 27%, P < 0.01). The overall rate of DU varied with the criteria used: BVE (54%), bladder contractility index (41%), and Gammie criteria (7%). The rate of DU using the BVE criteria was significantly higher in the nocturia group (63% vs 48%, P < 0.01), but no significant differences were noted using the other criteria. CONCLUSIONS: Nocturia is associated with reduced voiding efficiency in women. The diagnosis of DU using urodynamics is challenging.

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.

Evidence of Public Health Nursing Effectiveness: A Realist Review.

OBJECTIVES: The purpose of this realist review was to examine PHN interventions and their outcomes during the period preceding the Affordable Care Act (1990-2010), to determine what types of interventions demonstrated effectiveness, and whether these were related to target population or setting. DESIGN AND SAMPLE: The review focused on PHN interventions with data support documented over 20 years. A search of the published literature using CINHAL, PubMed, and ancestry methods resulted in 64 articles meeting the search criteria. The researchers reviewed each article for the relevant variables; achieved consensus for each variable; and summarized results using descriptive statistics. RESULTS: Documented PHN interventions targeted vulnerable populations. Interventions included health education, behavior change, and screening. There was evidence of effectiveness of PHN interventions in a number of studies; however, the study limitations and variety of intervention types make overall conclusions about PHN effectiveness challenging. CONCLUSIONS: Despite the long history of PHN working in communities to promote and maintain the health of vulnerable populations, practice outcomes have not been well documented. Further work is needed to: strengthen the methods for documenting effectiveness of PHN practice; focus on promising PHN interventions via multisite studies; and translate evidence-based PHN interventions to practice settings.

Vaginoplasty with an Autologous Buccal Mucosa Fenestrated Graft in Two Patients with Vaginal Agenesis: A Multidisciplinary Approach and Literature Review.

Here we describe the procedure and outcomes of a multidisciplinary approach to vaginoplasty using autologous buccal mucosa fenestrated grafts in 2 patients with vaginal agenesis. This procedure resulted in anatomic success, with a functional neovagina with good vaginal length and caliber and satisfactory sexual function capacity and well-healed buccal mucosa. There were no complications, and the patients were satisfied with the surgical results. We conclude that the use of a single fenestrated graft of autologous buccal mucosa is a simple, effective procedure for the treatment of vaginal agenesis that results in an optimally functioning neovagina with respect to vaginal length, caliber, and sexual capacity.

Initial Results of an Evidence-Based Safe Patient Handling and Mobility Program to Decrease Hospital Worker Injuries.

The rate for musculoskeletal injuries among health care workers is one of the highest for all industrial sectors in the United States; these injuries often occur during manual handling (i.e., lifting, moving, transferring, and repositioning) of patients. The following article describes the process used to complete a comprehensive assessment, as well as the planning, implementation, and initial evaluation of a quality improvement program to reduce work-related musculoskeletal disorders (WMSD) among health care workers employed by a rural Midwest hospital. Key elements for WMSD injury reduction were identified and compared across literature sources, national standards, and current state and federal legislative requirements for hospitals. The program used a multi-factor design that included evidence-based interventions (i.e., those supported by emerging evidence) to create a comprehensive Safe Patient Handling and Mobility (SPHM) program intended to address the unique needs of the organization. Initial program results are reviewed as well as significant considerations and challenges for SPHM programs.

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.

The Journey to Meet Emerging Community Benefit Requirements in a Rural Hospital: A Case Study

The Affordable Care Act requires nonprofit hospitals to collaborate with public health agencies and community stakeholders to identify and address community health needs. As a rural organization, Wabash County (Indiana) Hospital pursued new approaches to achieve these revised requirements of the community benefit mandate. Using a case study approach, the authors provide a historical review of governmental relationships with nonprofit community hospitals, offer a case study application for implementing legislative mandates and community benefit requirements, share the insights they garnered on their journey to meet the mandates, and conclude that drawing upon the existing resources in the community and using current community assets in novel ways can help conserve time, and also financial, material, and human resources in meeting legislative mandates.

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.

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.

Enhancing quantity and quality of clinical experiences in a baccalaureate nursing program.

Nursing programs encounter barriers to clinical education, which may include limited clinical capacity for nursing students. Congestion of clinical placements compounded by multiple external influences prompted a need to develop an alternative approach for meeting program standards pertaining to clinical education. A curriculum improvement project was implemented within a school of nursing with the primary goal of expanding clinical learning opportunities while maintaining program quality. The unique aspect of this project was a comprehensive evaluative design, including qualitative responses from students, faculty, and clinical site stakeholders, as well as standardized student test scores. Augmenting the tools and processes for evaluation of clinical learning required collaboration from the faculty. Project outcomes include expanded clinical capacity, increased variety of clinical learning experiences, and improved quality of the clinical experiences. Collaborative partnerships yielded valuable lessons, which have implications for other nursing programs challenged with clinical placements.

Does concomitant anterior/apical repair during midurethral sling improve the overactive bladder component of mixed incontinence?

INTRODUCTION AND HYPOTHESIS: Midurethral sling (MUS) can improve overactive bladder (OAB) symptoms. It is unclear if anterior/apical prolapse (AA) repair provides additional benefit. We hypothesized that women with mixed urinary incontinence (MUI) experience greater improvement in the OAB component of their symptoms after concomitant MUS and AA repair compared with MUS alone. METHODS: This is a retrospective cohort study of women with bothersome MUI (defined by objective stress test and validated questionnaire) undergoing MUS alone ("MUS-only") or concomitant MUS and AA repair ("MUS + AA"). Our primary outcome was the Overactive Bladder Questionnaire Symptom Severity (OAB-q SS) change score 6 weeks after surgery. RESULTS: Of 151 women, 67 (44 %) underwent MUS-only and 84 (56 %) underwent MUS + AA. The MUS-only cohort was younger and had less severe baseline prolapse (p < 0.05 for both). Postoperative complications (predominantly UTI) occurred in 35 (23 %) patients and were similar between cohorts. For all subjects mean OAB-q SS scores significantly improved postoperatively (p < 0.05). Our primary outcome, OAB-q SS change score, showed no significant differences between cohorts (30 ± 26 MUS-only vs 25 ± 25 MUS + AA, p = 0.20), indicating similar improvements in OAB symptoms. Multivariate linear regression analysis revealed no difference in OAB-q SS change score between cohorts; however, OAB-q SS change scores were lower for women with a postoperative complication (ß = -19, 95 % CI -31 to -6; p < 0.01). CONCLUSIONS: In women with bothersome MUI, concomitant AA repair does not result in additional improvement in OAB symptoms over MUS alone. Patients with postoperative complications exhibit less improvement in OAB symptoms.

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.

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 χ2 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 HYPOTHESIS: Perceptions 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. METHODS: MEDLINE, 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. RESULTS: Of 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. CONCLUSIONS: Women 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.

Mindfulness interventions to reduce stress among nursing personnel: an occupational health perspective.

Workplace stress within health care settings is rampant and predicted to increase in coming years. The profound effects of workplace stress on the health and safety of nursing personnel and the financial impact on organizations are well documented. Although organizational modification can reduce some sources of stress, several unique stress-producing factors inherent in the work of nursing personnel are immutable to such approaches. Mindfulness training, an evidence-based approach to increase situational awareness and positive responses to stressful situations, is an inexpensive strategy to reduce stress and improve the quality of nurses' work lives. Several approaches to training, such as mindfulness-based stress reduction, can be tailored to health care settings. Considerations for occupational health nurses in incorporating mindfulness training as an aspect of a comprehensive work site health promotion program for nursing and other hospital personnel are discussed.

Embracing a competency-based specialty curriculum for community-based nursing roles.

The Quad Council competencies for public health nursing (PHN) provide guidance in developing curricula at both the generalist and specialist level. However, these competencies are based on nursing roles in traditional public health agencies and community/public health is defined more broadly than official agency practice. The question arises as to whether community-based specialties require largely the same knowledge and skill set as PHN. The purpose of the competency cross-mapping project reported here was to (a) assess the intersection of the Quad Council competencies with four community-based specialties and (b) ensure the appropriateness of a Quad Council-based curriculum to prepare graduates across these four specialties (home health, occupational health, environmental health, and school nursing). This article details the multistep cross-mapping process, including validation with practice leaders. Results indicate strong alignment of community-based specialty competencies with Quad Council competencies. Community-based specialty-specific content that did not align well is identified, along with examples of didactic and clinical strategies to address gaps. This work indicates that a Quad Council-based curriculum is appropriate to prepare graduates in community-based specialties when attention to the specialty-specific competencies in the clinical setting is included. This work guides the development of a doctorate of nursing practice curriculum in PHN, encompassing the four additional community-based specialties.