Validation of Spanish versions of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ): a multicenter validation randomized study.

INTRODUCTION AND HYPOTHESIS: The purpose of this study is to validate Spanish versions of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). METHODS: Spanish versions were developed using back translation and validation was performed by randomizing bilingual women to complete the Spanish or English versions of the questionnaires first. Weighted kappa statistics assessed agreement for individual questions; interclass correlation coefficients (ICC) compared primary and subscale scores. Cronbach's alpha assessed internal consistency of Spanish versions. To detect a 2.7 point difference in scores with 80% power and alpha of 0.05, 44 bilingual subjects were required. RESULTS: Individual questions showed good to excellent agreement (kappa > 0.6) for all but eight questions on the PFIQ. ICCs of primary and subscale scores for both questionnaires showed excellent agreement. (All ICC > 0.79). All Cronbach's alpha values were excellent (>0.84) for the primary scales of both questionnaires. CONCLUSIONS: Valid and reliable Spanish versions of the PFIQ and PFDI have been developed.

Lack of psychological resilience: an important correlate for urinary incontinence.

Our study evaluated medical conditions, level of physical functioning, and psychological health as correlates of urinary continence (UI) for four different age groups of women. Survey questions from the 1996 MIDUS survey were used in three domains of health: medical conditions, physical functioning, and psychological health. Mean questionnaire scores or prevalence percentages for individual and total medical conditions, physical functioning, and psychological health were computed. Two-sample independent t tests or chi-square tests were used to compare women with UI to those without. Prevalence of UI was as follows: 25-39 years: 13.3%, 40-49 years: 24.0%, 50-59 years: 32.7%, and 60-74 years: 32.8%. Lower psychological resilience scores were significantly associated with UI in all age groups. Significant correlates (p<0.02) for women 25-39 years were hysterectomy, weak core muscles, and lack of psychological resilience. In older women, more chronic conditions and parity were significantly (p<0.01) associated with UI. Although each age group had specific medical associations with UI, lack of resilience and poor core muscle strength are particularly correlated with UI in young women.

Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation.

The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.

Sacral neuromodulation for intractable urge incontinence: are there factors associated with cure?

OBJECTIVES: To determine the variables that affect the cure rate in patients with urge incontinence treated with sacral neuromodulation. METHODS: This prospective analysis of patients with refractory urinary urge incontinence who underwent placement of a neuromodulator lead and generator was undertaken between October 2000 and December 2003. Quantitative assessment of the severity of their urinary leakage was assessed by preoperative and postoperative 3-day bladder diaries documenting leakage episodes, number of pads used per day, and a 24-hour pad weight assessment. Cure was defined as no daily leakage episodes after permanent implantation. Subjective outcome was assessed using the Incontinence Impact Questionnaire. Two-sample independent t tests, two-way chi-square tests, and tests of two proportions were performed when appropriate, with P < 0.05 considered significant. RESULTS: The mean postimplantation follow-up was 29 months, and the average age was 60 years (range 29 to 83). The cure rate was associated with age, with individuals younger than 55 years having a statistically significant greater cure rate (65% versus 37% for older individuals; P < 0.05). Having three or more chronic conditions was associated with a lower cure rate in both younger and older individuals. Patients with a neurologic condition also had a lower cure rate, but no specific neurologic condition was associated. CONCLUSIONS: Age older than 55 years and more than three chronic conditions were independent factors associated with a lower cure rate in patients implanted with a sacral neuromodulator for refractory urge incontinence. A neurologic condition may be associated with a decrease in the cure rate.

Vascular anatomy of the presacral space: a fresh tissue cadaver dissection.

OBJECTIVE: To assess variability in the vascular structures of the presacral space and to estimate the risk of injury because of blind suture placement during sacral colpopexy. STUDY DESIGN: Ten fresh frozen female cadavers were evaluated. Three 0-polyester sutures were placed blindly through the peritoneum and around the midline of the anterior longitudinal ligament. The presacral space was dissected and the sutures examined for injury to vessels. The midline of the anterior longitudinal ligament was marked from the promontory to its inferior edge, and measurements were taken to the leading edge of vessels proximal to the presacral space. On a template, all vessels larger than 2 mm were drawn to scale and overlaid on the template. RESULTS: Unequivocal vascular injury was found in 5 cadavers because of blind sutures. Four injuries occurred to the middle sacral artery and 1 to the left common iliac vein. There was significant variability in location of vessels, particularly on the left side of the ligament. CONCLUSIONS: The vascular pattern of the presacral space is variable, and major vessels may deviate significantly from their expected positions. Surgeons should carefully expose this space prior to placing sutures during sacral colpopexy.

Nocturnal polyuria in women with overactive bladder symptoms and nocturia.

OBJECTIVE: This study was undertaken to determine the prevalence of nocturnal polyuria in women complaining of nocturia and overactive bladder (OAB) symptoms and to identify clinical and health characteristics associated with nocturnal polyuria. STUDY DESIGN: Women presenting to a urogynecology clinic with complaints of nocturia and OAB symptoms were asked to participate. They completed a health characteristic summary, 3-day voiding diary, Nordic sleep questionnaire, urinary distress inventory (UDI), and a nocturia distress visual log (NDVL). The 24-hour urine production, nighttime urine volume, and maximum bladder capacity were calculated from the bladder diary. Nocturnal polyuria was defined as production of greater than 33% of the 24-hour urine volume during an 8-hour sleep period. A histogram was performed to analyze at what age the prevalence of nocturnal polyuria increased. Women were then divided by presence or absence of nocturnal polyuria and compared by the health and clinical characteristics. RESULTS: Fifty-five women met the qualifications and participated in the study. Average age of the cohort was 65.8 +/- 13.5 years. The risk of nocturnal polyuria increased with age 65 years or older (prevalence for age 65-74 = 0.86 [0.62-1.00]) and with white race. On the basis of the mean population values for UDI, NDVL, sleepiness scores, and insomnia scores, all women were bothered by their nocturia. Median number of nighttime voids, 24-hour urine production, maximum bladder capacity, nocturnal index, UDI, NDVL, sleepiness scores, and insomnia scores did not differ, based on presence or absence of nocturnal polyuria. CONCLUSION: Among women complaining of nocturia and overactive bladder symptoms, age 65 years or older and white race appear to be risk factors for nocturnal polyuria.

Transvaginal endoscopic removal of eroded mesh after abdominal sacral colpopexy.

BACKGROUND: Abdominal sacral colpopexy with permanent mesh has become the preferred abdominal technique for correcting posthysterectomy vaginal vault prolapse. Although rare, mesh erosion after sacral colpopexy is often challenging to manage. We report on 3 cases of mesh erosion after abdominal sacral colpopexy managed by transvaginal endoscopic removal of the mesh. CASES: The cases involve patients who underwent an abdominal sacral colpopexy and had vaginal mesh erosions within 3 years of their surgeries. Conservative and traditional transvaginal techniques failed, and the patients continued to complain of vaginal discharge. All patients underwent transvaginal endoscopic removal of the mesh and are cured of their chronic discharges. CONCLUSION: Transvaginal endoscopic removal is an effective, minimally invasive option for removal of eroded mesh after abdominal sacral colpopexy.

Validation of a Spanish version of the Pelvic Organ Prolapse Incontinence Sexual Questionnaire.

OBJECTIVE: To develop a validated Spanish version of the Pelvic Organ Prolapse Incontinence Sexual Questionnaire (PISQ). METHODS: The PISQ is a previously described validated and reliable questionnaire. We used a back-translation method to develop a Spanish-language version. Twenty-six bilingual patients with pelvic organ prolapse and/or urinary incontinence were randomized to complete either the original English version or the final Spanish version of the PISQ first, followed by the other questionnaire. Scores of the two versions were compared. Paired t test for total PISQ and its three domain scores and Wilcoxon signed rank test for each item assessed the bias between the two equivalent versions. Agreement between the two versions was assessed by weighted kappa statistics, with 95% confidence intervals for each item. P values of .05 or less were considered significant, and kappa values of .75 or greater were considered to indicate good agreement. RESULTS: English and Spanish versions demonstrated no differences for each of the factors and total scores (P = .15, .83, .28, and .56, respectively). Wilcoxon signed rank test demonstrated that one item was answered differently in the English and Spanish versions. Good agreement between Spanish and English versions in 30 of the 31 items was demonstrated by weighted kappa statistics. Overall, 72% of women scored both versions of the questionnaire equivalently. CONCLUSIONS: We have developed a validated and reliable Spanish questionnaire to evaluate sexual functioning in Spanish-speaking patients with pelvic organ prolapse and/or urinary incontinence.

Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation.

OBJECTIVE: The purpose of this study was to compare intraoperative and postoperative complications of abdominal hysterectomy for the enlarged, myomatous uterus with vaginal hysterectomy with morcellation. STUDY DESIGN: Medical records of 139 patients who underwent vaginal hysterectomy with morcellation and 244 patients who underwent total abdominal hysterectomy for an enlarged, myomatous uterus between August 1990 and July 2001 were reviewed. Uterine weights of >982 g were excluded because this was the largest uterus removed vaginally, which left 208 evaluable cases of total abdominal hysterectomy. The perioperative and postoperative course of the two groups was compared. The Student t test was used for continuous variables, and the Fisher exact test was used for binary or categoric data. RESULTS: There were no significant differences between the two groups in surgical or anesthetic risk factors (P>.05). Operative time was similar between the groups (P>.05). Length of hospital stay was increased significantly with total abdominal hysterectomy (mean, 3.9 days vs 2.6 days; P<.001). Perioperative complications were increased with the abdominal route (10% vs 25%, P<.001). CONCLUSION: In this large series, uterine morcellation at the time of vaginal hysterectomy is safe and facilitates the removal of moderately enlarged and well-supported uteri and is associated with decreased hospital stay and perioperative morbidity rate compared with the abdominal route.

Is there a difference in survival for IA1 and IA2 adenocarcinoma of the uterine cervix?

OBJECTIVE: The goal of this study was to determine if International Federation of Obstetrics and Gynecology (FIGO) subdivision into IA1 versus IA2 is predictive of survival differences for early invasive adenocarcinoma. METHODS: The Surveillance, Epidemiology, and End-Results (SEER) Public-Use Database was used to identify all cases of IA1 and IA2 adenocarcinoma diagnosed between 1983 and 1997. A systematic literature search (MEDLINE 1966-2000) was used to identify all previously published cases. Stage, depth of invasion, node status, therapy, and survival were analyzed using Fisher's exact and log-rank tests. RESULTS: In SEER, 560 cases were identified: 200 IA1, 286 IA2, and 74 localized. Simple hysterectomy was performed in 272 (48.6%) and radical hysterectomy in 210 (37.5%). Positive lymph nodes were found in 3 of 197 (1.5%) who underwent lymphadenectomy, 2 of whom died. The censored survival by stage (mean follow-up 51.6 months) was not significantly different (P = 0.77) for IA1 versus IA2 (98.5% vs 98.6%). Combining these data with all other published series of early cervical adenocarcinoma, 1170 cases were identified, including 585 IA1, 358 IA2, and 227 "others," with less defined early disease. Of 531 (45.4%) who underwent lymphadenectomy, 15 (1.28%) had one or more positive nodes; of these, 11 (73.3%) recurred or died. For IA1 versus IA2 disease, there were no significant differences in the frequency of positive lymph nodes, recurrence, or death. However, "others," those with less well-defined lesions, or larger than IA2, were at increased risk. CONCLUSION: Early invasive adenocarcinoma (IA1 and IA2) has an excellent prognosis and conservative surgery may be appropriate. Since current FIGO staging definitions do not distinguish high- from low-risk disease, individualization of therapy based on pathology review, risk assessment, and patient preference is recommended.