Overactive bladder phenotypes: development and preliminary data.

INTRODUCTION: The purpose of this study is to develop overactive bladder (OAB) phenotypes that can be used to develop diagnostic and treatment pathways and offer clues to the underlying etiologies of patients with OAB. MATERIALS AND METHODS: This is a retrospective, multicenter study of patients with lower urinary tract symptoms (LUTS). Evaluation included a 24-hour bladder diary (24HBD), the lower urinary tract symptoms score (LUTSS) questionnaire, uroflowmetry (Q), and post-void residual urine (PVR) measurement. Patients completed the 24HBD and LUTSS on a smartphone application or paper. Those with an OAB symptom sub-score (OABSS) ≥ 8 were included. An expert panel developed a phenotype classification system based on variables considered to be important for treatment. RESULTS: The following variables were selected for inclusion in the phenotype modeling: 24-hour voided volume (24HV), maximum voided volume (MVV), Qmax and PVR. Subjects were divided into three phenotypes based on the 24HV: polyuria (24HV > 2.5 L), normal (24 HV 1-2.5 L), and oliguria (24HV < 1 L). Each phenotype was subdivided based on MVV, Qmax & PVR, resulting in 18 sub-types. Five hundred thirty-three patients, 348 men and 185 women, completed the LUTSS and 24HBD. OAB was present in 399 (75%) - 261 men and 138 women. The prevalence of the primary phenotypes was polyuria (25%), normal (63%), and oliguria (11%). CONCLUSIONS: Classification of OAB variants into phenotypes based on 24HV, MVV, Qmax, and PVR provides the substrate for further research into the diagnosis, etiology, treatment outcomes and development of granular diagnostic and treatment algorithms.

Urinary symptoms after bladder flap at the time of primary cesarean delivery: a randomized controlled trial (RTC).

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate urinary symptoms in the postpartum period after omission of the bladder flap at the time of primary cesarean delivery. METHODS: This was a single-blind parallel-group randomized comparison (bladder flap, no bladder flap) in women scheduled for a primary cesarean delivery at 37 weeks gestation or later. The primary outcome was urinary symptom scores at 6-8 weeks postpartum. Secondary outcomes included comparisons of preoperative and postoperative pelvic floor symptom scores and the proportions of symptom bother responses between the study groups. RESULTS: A total 43 women were available for analysis. Randomization was as follows: omission of the bladder flap (n = 22) and bladder flap (n = 21). Demographic characteristics and baseline pelvic floor symptom scores were similar between the groups. The primary outcome, urinary symptom scores at 6-8 weeks postpartum, did not differ significantly between the groups, but urinary symptom bother was significantly higher in women who received a bladder flap. Pelvic floor symptom scores improved significantly following delivery. CONCLUSIONS: Urinary symptom scores as measured by the UDI-6 did not differ between women randomized to bladder flap or omission of the bladder flap, but the proportion of women with urinary symptom bother was significantly higher among those who received a bladder flap.

Anatomic relation between single-incision slings and the obturator vessels.

The risk of arterial vascular injury within the retropubic space is a potentially life-threatening complication associated with mid-urethral sling placement for the treatment of female stress urinary incontinence. To determine the relationship between the major blood vessels and a single incision sling, these slings were placed in 12 fresh female cadavers. Following the insertion of each sling, the retropubic space was dissected and sling placement was observed relative to the obturator neurovascular bundle bilaterally. The distance between the most distal aspect of each sling arm, or the point of anchoring, was measured from the most medial aspect of the obturator vessels bilaterally. The mean distance between each sling arm and the medial portion of the obturator vessels was an average of 3.4 cm (range 2.0-6.0 cm) in 24 observations. Placement of the single incision sling may have a lower risk of injuring major vessels within the retropubic space compared to full-length mid-urethral slings.

Prevalence and Predictors of Intimate Partner Violence in a Military Urogynecology Clinic.

BACKGROUND: Intimate partner violence (IPV) is common, with prevalence in women of 15 to 71% over the lifespan, 4 to 54% currently. Violence is associated with poor health, and may be more common in military populations. A history of abuse is also common in patients with pain, urinary/bowel symptoms, and dyspareunia. Our purpose was to determine the prevalence and predictors of abuse in a military urogynecology clinic. METHODS: Patients presenting to a military urogynecology clinic were screened for IPV with the 4-item Hurt-Insult-Threaten-Scream (HITS) screen. Patients' abuse history, reason for visit, and risk factors for IPV were assessed. χ2 and Fisher's exact tests were used for categorical variables. FINDINGS: Out of 142 surveys, only 4 (2.8%) indicated a positive HITS screen (score of 10 or greater on a scale of 4-20), and 39 (27.5%) responded positively to at least one item. These individuals were significantly more likely to have a history of physical abuse or abuse in their families, with at least one positive response in 45.4% of patients with a history of family abuse compared to 20.8% of patients without this history (p = 0.007). The lifetime prevalence of physical abuse by an intimate partner was reported by 10 women (7%). A total of 29 women (20%) reported a history of forced sex and 33 (23%) reported a history of abuse in their family. Participants with a family history of abuse were more likely to have a positive HITS score, relative risk (RR) 2.19 (95% confidence interval [CI] 1.29-3.71), p = 0.004, as were those with history of physical abuse RR 2.44 (95% CI 1.35-4.39), p = 0.003 and a history of forced sexual contact, RR 1.73 (95% CI 1.00-3.00), p = 0.049. Race, education, marital status, and employment showed no association with a positive HITS response. DISCUSSION/IMPACT/RECOMMENDATIONS: The self-reported rate of IPV in a sample of women presenting to a urogynecology clinic in a military setting was 2.8%, below the rate reported in the civilian literature of 4 to 54%. We found that lifetime prevalence of IPV (7%) was also lower than the civilian rate of 15 to 71%. Routine screening for IPV is recommended by the American College of Obstetricians and Gynecologists, U.S. Preventative Services Task Force, and the Joint Commission. Even though IPV rates in the military are below civilian rates, IPV affects 3 to 7% of our population and remains a significant and preventable problem affecting women. CONCLUSIONS: IPV in military urogynecology patients was lower than the civilian setting; however, women with a history of abuse may be at increased risk of experiencing current IPV, and continued screening is important.

Minimally invasive management of retropubic bleeding and hematoma evacuation after a TVT Secur or mini-sling procedure.

BACKGROUND: Retropubic hematomas may complicate up to 4.1% of tension-free vaginal tape (TVT) procedures in the surgical treatment of stress urinary incontinence. Symptomatic or expanding hematomas often require intervention, usually accomplished through an abdominal incision. CASE: A 43-year-old woman underwent transvaginal management of venous bleeding and evacuation of a 1500-mL retropubic hematoma after a TVT Secur or "mini-sling" procedure. CONCLUSIONS: Significant bleeding can complicate even the least invasive surgical approach to treat stress urinary incontinence. Transvaginal evacuation of a symptomatic retropubic hematoma with instillation of a hemostatic agent may be a safe alternative to laparotomy in a hemodynamically stable patient.

The impact of pregnancy on the individual and military organization: a postpartum active duty survey.

Using a postpartum survey, comparing singles to married, we sought to expand existing information on pregnancy occurring among active duty service women. The study instrument was a 59-question survey distributed in the initial 24 hours postpartum and collected prior to discharge. The majority affirmed that pregnancy had not changed career plans. Singles did not consider their commands supportive during pregnancy, (p=.04). Eighty-two percent of pregnancies among singles were unplanned, (p=.006). The majority of single pregnancies occurred while assigned to operational units, (p=.004); and during their first enlistment, (p<.001). Three-quarters of all singles required Women Infants and Children (WIC) financial support, (p<.001); and fewer fathers were, or planned to be involved, (p<.001). Unplanned pregnancy, contraceptive failure, and pregnancy complications highlight areas of organizational and individual concern warranting further study among active duty.

Factors affecting caesarean operative time and the effect of operative time on pregnancy outcomes.

AIM: To determine the factors that influence caesarean operative time and operative time effects on pregnancy outcomes. METHODS: Prospective observational study of women undergoing a caesarean delivery (CD). Multiple antepartum, intrapartum and neonatal outcomes were assessed for their influence on the time of the CD and the time effect of CD on pregnancy outcomes. RESULTS: There were 386 (23%) caesarean deliveries performed < or = 30 min, 1070 (65%) between 31 and 60 min, and 200 deliveries > or = 60 min. Women younger than 18 years (P= 0.004) and who had caesarean for fetal labor intolerance were associated with shorter operation time (P < 0.001). Factors associated with an increased operation time were age > 35 years (P = 0.049), body mass index (BMI) > or = 30 (P < 0.001), pre-existing hypertension (P = 0.001), prior low segment transverse scar (P < 0.001), uterus incision other than transverse (P < 0.001), first-year resident as primary surgeon (P < 0.001) and accompanying sterilisation procedure (P < 0.001). Operation time was significantly related to blood loss (P < 0.001), likelihood of umbilical artery cord gas pH < 7.1 (P < 0.001) and Apgar scores at five minutes < 7 (P= 0.009). CONCLUSIONS: Operative time is shortened by age < 18 and delivery for fetal labor intolerance, lengthened by age > 35, BMI > 30, prior caesarean, uterine incision, operating surgeon inexperience and accompanying sterilisation. Increased operative time was linked with an increased blood loss, low five-minute Apgar scores and umbilical arterial pH < 7.1.

Anorectal symptoms in pregnancy and the postpartum period.

OBJECTIVE: To determine the frequency of anorectal complaints in nulliparous, pregnant women before and after delivery. STUDY DESIGN: This was a prospective, observational study. Nulliparous, pregnant women attending an active-duty prenatal clinic completed a 6-item anorectal symptom questionnaire that assessed anal continence and defecatory symptoms. RESULTS: Seventy-five active-duty, nulliparous women completed 158 questionnaires. Anorectal symptoms were reported both antepartum (AP) and postpartum (PP): straining to defecate (AP: 28-59%; PP: 30%), hard or lumpy stools (AP: 48-59%; PP: 66%), incomplete emptying (AP: 38-53%; PP: 38%), uncontrolled loss of gas or stool from the rectum (AP: 18-29%; PP: 15%), unpreventable soilage of underwear (AP: 15-33%; PP: 13%) and splinting (AP: 3-9%; PP: 9%). Constipation symptoms were reported most frequently in the first trimester (p = 0.031) and anal incontinence most often in the third trimester but loss of gas or stool "often" more in the postpartum period (p = 0.027). Anal incontinence was more frequent in women who delivered by forceps (p = 0.007). CONCLUSION: Anorectal symptoms are common both during pregnancy and in the postpartum period. Anal incontinence is reported more frequently in women who delivered by forceps.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study.

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

Depression screening in the pregnant soldier wellness program.

OBJECTIVES: The purpose of this study was to determine the prevalence of depression among active-duty low-risk pregnant women using the Edinburgh Postnatal Depression Scale. Rates for depression have been reported to be as high as 13% during pregnancy and 12 to 22% postpartum, with postpartum suicidal ideation at nearly 7%. METHODS: From April 2002 through March 2003, 82 women receiving prenatal care at Madigan Army Medical Center completed screening questionnaires during pregnancy and/or postpartum visits. RESULTS: A total of 97 questionnaires were administered (71 antepartum and 26 postpartum). During pregnancy, 24% of individuals screened scored positive. During the postpartum, 19% scored positive. A total of 15 women were screened twice during the study period. One woman was screened twice during pregnancy and the remaining 14 were screened once antepartum and once postpartum. Suicidal ideation was present in 11% of those screened during pregnancy and in 15% postpartum. CONCLUSIONS: Active-duty women appear to have a higher rate of depression and suicidal ideation compared with rates in nonmilitary populations; perhaps such screening should become a standard practice.

Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population.

OBJECTIVE: The purpose of this study was to evaluate the association of constipation symptoms and anal incontinence with vaginal wall and pelvic organ descent in a general gynecologic population. STUDY DESIGN: In this multicenter, cross-sectional study, 1004 women attending routine gynecologic healthcare underwent pelvic organ prolapse quantification (POPQ) measurements, and were surveyed regarding anal incontinence, digitation, < 2 bowel movements (BMs)/week, and > 25% frequency of: straining, hard/lumpy stools, and incomplete emptying. Constipation scores reflected the sum of positive responses. Associations between POPQ measurements (Ba, C, Bp, gh+pb), constipation scores, and anal incontinence were evaluated using multivariable regression. RESULTS: Of 119 women with Bp > or = -1.00, 47% reported no constipation symptoms. Hard/lumpy stools (26%), incomplete emptying (24%), and straining (24%) were more prevalent; fewer women reported < 2 BMs/week (15%) or digitation (7%). Constipation scores were weakly correlated with Bp, gh+pb (both r < .1, P < .02). Women reporting > or = 2 symptoms had greater gh+pb measurements than women reporting 0 or 1 symptom (P = .03). Women with anal incontinence had greater gh+pb and gh values than women without anal incontinence (P < .01). POPQ measurements were regressed separately onto (1) total constipation scores, (2) dichotomized scores, and (3) individual symptoms, with BMI, age, number of vaginal deliveries (NVD), weight of largest vaginal delivery (WLVD), race, hysterectomy, study site, and income included as covariates. Total constipation scores and dichotomized scores were nonsignificant in all models. With regard to individual symptoms, straining at stool was significant in the models for Ba and gh+pb, with greater Ba and gh+pb measurements among strainers relative to nonstrainers. CONCLUSION: Most associations between bowel symptoms and vaginal or pelvic organ descent were weak. After controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent.

Decreased anal sphincter lacerations associated with restrictive episiotomy use.

OBJECTIVE: To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy. STUDY DESIGN: This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables. RESULTS: The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7). CONCLUSION: With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.

Pelvic organ support in pregnancy and postpartum.

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

An active duty woman with anal incontinence after vaginal delivery: an elusive diagnosis.

Anal sphincter injury as a result of birth trauma is the leading cause of fecal incontinence in women presenting to surgical clinics. A 36-year-old active duty woman was referred to the Urogynecology Clinic at Madigan Army Medical Center for evaluation of a deficient perineal body. She reluctantly reported a 12-year history of anal incontinence since the birth of her first child, predating her entry into the naval service. Examination revealed defects of the perineum and anal sphincter resembling a cloacal deformity. Uncomplicated overlapping anal sphincteroplasty and perineorrhaphy were performed, restoring perineal anatomy and continence. Anal incontinence and other anatomic defects attributable to lacerations sustained at childbirth may go undetected during routine screening examinations. Interview and examination techniques should be emphasized in primary care settings.

Informed consent and birth: protecting the pelvic floor and ourselves.

The controversy over elective cesarean versus vaginal birth with regard to pelvic floor trauma has left many caregivers and patients confused. With the growing evidence to support the development of fecal incontinence as a result of childbirth, we believe that it is imperative to reevaluate modern obstetric practices both for the patient's benefit and for our medical-legal protection. Our attention and energy need to be focused on good informed consent regarding these risks along with improved postpartum surveillance for injury.

Pelvic organ support in nulliparous pregnant and nonpregnant women: a case control study.

OBJECTIVE: Our purpose was to compare pelvic organ support in nulliparous pregnant and nonpregnant women at a single institution. STUDY DESIGN: This was a case-control study. Pregnant patients and nonpregnant control subjects were matched according to age and race. Subjects underwent pelvic organ support evaluation by use of the pelvic organ prolapse quantification (POPQ) examination as part of routine prenatal or gynecologic care. The Pearson chi(2) statistic was used for statistical analysis, with a P value of 5% set for significance. RESULTS: A total of 21 pregnant and 21 nonpregnant nulliparous women between the ages of 18 and 29 years were included. All patients in the nonpregnant group had a POPQ stage of 0 or 1, whereas 47.6% of the pregnant subjects had POPQ stage 2 (P <.001). Individual components of the POPQ examination were compared. Significant differences were noted for points Aa and Ba, Ap and Bp, and PB and TVL. CONCLUSIONS: In nulliparous women, pregnancy is associated with increased POPQ stage compared with nonpregnant control subjects.