Patient-Focused Websites Related to Postpartum Pelvic Floor Health: A DISCERN Quality Analysis.

OBJECTIVE: The aim of the study was to evaluate the quality of patient-focused websites addressing postpartum pelvic floor health. METHODS: The Google search engine was used to perform a search of the following 3 terms: (1) "postpartum pelvic floor (PPF)," (2) "postpartum leaking urine (PLU)," and (3) "postpartum leaking stool (PLS)." The top 20 results from each search term were evaluated using the DISCERN quality appraisal tool and Journal of the American Medical Association (JAMA) benchmark criteria by 2 independent researchers. Websites were also categorized by type. Cohen κ was performed to determine interrater reliability between reviewers. The Kruskal-Wallis test was used to evaluate the differences in DISCERN and JAMA criteria scores. RESULTS: The weighted mean κ between the investigators for each search term was κ = 0.47 (range = 0.163 [PPF] to 0.759 [PLU]), suggesting moderate agreement between reviewers. There was a significant difference in mean DISCERN scores between the terms, with "postpartum leaking urine" yielding the highest mean score. When comparing DISCERN scores by category, society- and government-sponsored websites (mean = 55 ± 13) scored significantly higher than other categories. Using JAMA criteria, mean scores ranged between 1.83 and 2.83/4, but there were no significant differences between websites. CONCLUSIONS: The overall quality of health information available on the internet regarding postpartum pelvic health is low. Higher-quality search results are found within society- and government-sponsored websites as well as under the search term "postpartum leaking urine." It is important for health care providers to guide their patients to websites with reliable information about postpartum pelvic floor recovery.

Anterior Bilateral Sacrospinous Ligament Fixation: A Safe Route for Apical Repair.

OBJECTIVES: Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. METHODS: This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. RESULTS: In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. CONCLUSIONS: Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

Pelvic Floor Disorders.

Pelvic floor disorders commonly affect women and may cause distress and difficulty with daily functions and self-image. Urinary incontinence may present as stress incontinence, urgency incontinence, or in some combination (mixed incontinence). Symptomatic pelvic organ prolapse (POP) occurs when the patient is bothered by the sensation of a herniation of the pelvic organs through the vagina. Although POP is often distressing and embarrassing, it is not considered life-threatening unless the patient cannot urinate or defecate. There are numerous ways to treat these conditions, including conservative (including observation), medical, and surgical management.

Interventions to decrease pain and anxiety in patients undergoing urodynamic testing: A randomized controlled trial.

AIMS: To determine if music (at 60 beats/min) or watching a pre-procedure educational video decreases pain and anxiety in women undergoing multichannel urodynamic testing compared to usual care. METHODS: Women undergoing multichannel urodynamic testing at a tertiary care center were randomized to one of three groups: usual care (UC), music (M), in which music was played throughout the urodynamic test, or video (V), in which subjects watched an informational video on the procedure prior to undergoing the test. Visual analog scales (VAS) were used to measure patient's pain and anxiety before and after the test. Demographic information was obtained and five-item Likert questionnaires were given to assess information seeking behavior, preparedness, embarrassment, and privacy. RESULTS: 98 subjects were included in this analysis. In the overall group, mean perceived pain on the pre-test VAS was significantly higher than the post-test VAS with pre-test mean (SD) 47(±30) and post-test mean (SD) 26(±23), P = 0.0001. Overall the anxiety pre-test VAS was significantly greater than post-test VAS with pre-test mean (SD) 46.9(±29) and post-test mean 17.9(±18), P = 0.0001. There were no differences in pain and anxiety scores between the two intervention groups and usual care. Patients who were randomized to usual care or the video arm felt more prepared for the test compared to patients who were randomized to the music arm, with (mean ± SD): usual care (42 ± 8), video (43 ± 9), music (37 ± 11), P = 0.002. CONCLUSIONS: Music and an educational video do not decrease pain or anxiety in subjects undergoing multichannel urodynamics compared to usual care. Neurourol. Urodynam. 35:975-979, 2016. © 2015 Wiley Periodicals, Inc.

Removing a misplaced retropubic midurethral sling from the urethra and bladder neck using ear, nose, and throat instruments.

BACKGROUND: The retropubic tension-free vaginal tape (TVT) procedure is a common procedure with complications attributed to voiding dysfunction, bladder perforation, and bleeding. We present a case of successful removal of a retropubic midurethral sling from the urethra using a head lamp and a combination of ear, nose, and throat instruments. CASE: A 63-year-old woman presented to our clinic with the symptom of gross hematuria after having undergone a TVT procedure. On office cystoscopy, the sling was noted to be placed within the urethral mucosa. Removal of the mesh was performed using a nasal speculum, left and right ethmoid scissors, left and right Blakesley graspers, and a head lamp to dissect the mesh directly out of the urethra. CONCLUSION: The utilization of ear, nose, and throat tools allowed us to resect the intraurethral mesh without necessitating incision of the urethral sphincter.

Histopathology of excised midurethral sling mesh.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the histological characteristics of pathological specimens of excised midurethral sling mesh and surrounding vaginal tissue in patients who presented preoperatively with pain and/or exposure of mesh to patients who underwent mesh excision for voiding dysfunction without pain and/or erosion. METHODS: This is a retrospective case-control study of women who underwent excision of midurethral sling mesh between 2008 and 2013. Three groups were identified: (1) voiding dysfunction without pain or exposure (control group), (2) pain and/or mesh exposure, and (3) voiding dysfunction with pain and/or mesh exposure. All original pathological specimens were rereviewed by one pathologist blinded to indication for excision and the previous pathology report. Degree of inflammation and fibrosis were recorded based on a 4-point scale along with the presence of giant cell reaction. RESULTS: A total of 130 subjects met inclusion criteria: 60 (46.2 %) with voiding dysfunction only, 21 (16.2 %) with pain/erosion, and 49 (37.7 %) with both pain/exposure and voiding dysfunction. The voiding dysfunction only group was found to have significantly higher levels of inflammation, median grade 2 (1-3), compared to the other two groups with a p value of 0.007. There were no statistical differences in fibrosis and giant cell reaction between the three groups. CONCLUSIONS: Midurethral sling mesh excised for voiding dysfunction demonstrates elevated levels of inflammation compared to mesh that is excised for pain and/or exposure. The vaginal tissue fibrosis and giant cell reaction are similar in patients who undergo mesh excision for voiding dysfunction and pain, and/or mesh exposure.

The Quality of Health Information Available on the Internet for Patients With Pelvic Organ Prolapse.

OBJECTIVE: This study aimed to assess the quality of Web sites that provide information on pelvic organ prolapse using validated quality measurement tools. METHODS: The Google search engine was used to perform a search of the following 4 terms: "pelvic organ prolapse," "dropped bladder," "cystocele," and "vaginal mesh." The DISCERN appraisal tool and JAMA benchmark criteria were used to determine the quality of health information of each Web site. Cohen κ was performed to determine interrater reliability between reviewers. Kruskal-Wallis and Wilcoxon rank sum tests were used to compare DISCERN scores and JAMA criteria among search terms. RESULTS: Interrater reliability between the two reviewers using DISCERN was κ = 0.71 [95% confidence interval (CI), 0.68-0.74] and using JAMA criteria was κ = 0.98 (95% CI, 0.74-1.0). On the basis of the DISCERN appraisal tool, the search term "vaginal mesh" had significantly lower Web site quality than "pelvic organ prolapse" and "cystocele," respectively [mean difference of DISCERN score, -14.65 (95% CI, -25.50 to 8.50, P < 0.0001) and -12.55 (95% CI, -24.00 to 7.00, P = 0.0007)]. "Dropped bladder" had significantly lower Web site quality compared to "pelvic organ prolapse" and "cystocele," respectively (mean difference of DISCERN score, -9.55 (95% CI, -20.00 to 3.00, P = 0.0098) and -7.80 (95% CI, -18.00 to 1.00, P = 0.0348). Using JAMA criteria, there were no statistically significant differences between Web sites. CONCLUSIONS: Web sites queried under search terms "vaginal mesh" and "dropped bladder" are lower in quality compared with the Web sites found using the search terms "pelvic organ prolapse" and "cystocele."

Laparoscopic repair of recurrent lateral enterocele and rectocele.

It is difficult to determine what types of procedures should be attempted in patients who have recurrent prolapse. We present a case of recurrent lateral enterocele and rectocele after the patient had undergone multiple surgeries for pelvic organ prolapse (POP), including a vaginal hysterectomy, bladder-neck suspension, anterior colporrhaphy, site-specific rectocele repair, apical mesh implant, iliococcygeus vault suspension, and transobturator suburethral sling procedure. With recurrence, the patient underwent robot-assisted laparoscopic sacral colpopexy, tension-free vaginal tape transobturator sling insertion, rectocele repair, and perineorrhaphy with cystoscopy. She then presented with defecatory outlet obstruction and constipation and subsequently was treated with a stapled transanal rectal resection. The patient returned with continued defecatory dysfunction and a recurrent lateral enterocele and rectocele. The recurrence was treated laparoscopically using a lightweight polypropylene mesh. The postoperative period was uneventful. Two years later, the patient reported decreased defecatory symptoms and no further symptomatic prolapse.

Residency training in pediatric and adolescent gynecology across obstetrics and gynecology residency programs: a cross-sectional study.

STUDY OBJECTIVE: To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. DESIGN: Prospective, anonymous, cross-sectional study. PARTICIPANTS: United States program directors of Obstetrics and Gynecology residency programs, N = 242; respondents 104 (43%). RESULTS: 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n = 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n = 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P = .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P = .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P = .03). CONCLUSIONS: Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training.

Common postoperative pulmonary complications after hysterectomy for benign indications.

OBJECTIVE: The purpose of this study was to estimate the incidence of postoperative pulmonary complications after hysterectomy for benign indications. STUDY DESIGN: This was a retrospective cohort study of all women who underwent hysterectomy for benign indications at the Cleveland Clinic from Jan. 1, 2001, to Dec. 31, 2009. Exclusion criteria incorporated patients who underwent hysterectomy for premalignant or malignant conditions. Pulmonary complications were defined as postoperative pneumonia, respiratory failure, atelectasis, and pneumothorax based on International classification of diseases, ninth revision, codes. RESULTS: In the 9-year study period, 3226 women underwent hysterectomy for benign indications (abdominal, 38.4%; vaginal, 39.3%; laparoscopic, 22.3%). Ten of the 3226 women (0.3%; 95% confidence interval, 0.17-0.57%) who underwent hysterectomy were identified with postoperative pulmonary complications. Among the different types of hysterectomy, the incidence of pulmonary complications was not different (total abdominal hysterectomy, 0.9%; vaginal hysterectomy, 0.12%; laparoscopic hysterectomy, 0.9%; P = .8). CONCLUSION: The incidence of postoperative pulmonary complications after hysterectomy for benign indications is low.

Risk of deep venous thrombosis and pulmonary embolism in urogynecologic surgical patients.

OBJECTIVE: We sought to determine the incidence of symptomatic deep venous thrombosis and pulmonary embolism, collectively referred to as venous thromboembolic events (VTE), in patients undergoing urogynecologic surgery to guide development of a VTE prophylaxis policy for this patient population. STUDY DESIGN: We conducted a retrospective analysis of VTE incidence among women undergoing urogynecologic surgery over a 3-year period. All patients wore sequential compression devices intraoperatively through hospital discharge. RESULTS: Forty of 1104 patients (3.6%) undergoing urogynecologic surgery were evaluated with chest computed tomography, lower extremity ultrasound, or both for suspicion of VTE postoperatively. The overall rate of venous thromboembolism in this population was 0.3% (95% confidence interval, 0.1-0.8). CONCLUSION: Most women undergoing incontinence and reconstructive pelvic surgery are at a low risk for VTE. Sequential compression devices appear to provide adequate VTE prophylaxis in this patient population.