Prevalence and co-occurrence of pelvic floor disorders in community-dwelling women

Treatment of Stress Urinary Incontinence: Does Race Matter?

IMPORTANCE

The importance of this study was to examine treatment patterns and surgical complications for stress urinary incontinence (SUI).

OBJECTIVES

The aim of this study was to describe the treatment of SUI and associated complications in a racially and ethnically diverse population.

STUDY DESIGN

This was a retrospective cohort study of patients with a new diagnosis of SUI. We identified patients who received treatment with a pessary, pelvic floor physical therapy, or surgery. Surgical complications were abstracted. Logistic regression was used to examine the association between race/ethnicity and treatment, as well as surgical complications.

RESULTS

A total of 67,187 patients with a new diagnosis of SUI were included. The population was predominately Hispanic (47.5%) followed by White, Asian, Black, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native. Comparing no treatment to any treatment, all racial/ethnic groups, except American Indian/Alaska Native, had decreased odds of receiving treatment compared with White women. Hispanic and Native Hawaiian/Pacific Islander women had increased odds of referral for pelvic floor physical therapy compared with White women. All racial/ethnic groups, except for American Indian/Alaska Native women, had decreased odds of receiving a sling procedure compared with White women. When these racial/ethnic minority groups did receive treatment, it was more likely to be conservative treatment compared with White women. There were no significant differences in individual surgical complications.

CONCLUSIONS

Racial minority women were 20-50% less likely to undergo a sling procedure, commonly posited as the gold standard surgical treatment. Racial minority women were 40-100% more likely to receive conservative management and 20-50% less likely to receive any treatment compared with White women.

Bony birth canal and pelvic organ prolapse: a quantitative assessment for dimensions of pelvic midplanes based on MRI

PURPOSE

Dimensions of the bony birth canal are hypothesized to be associated with pelvic organ prolapse (POP). However, the pelvic midplane, which represents the narrowest obstetrical plane, has not been thoroughly investigated. This study aims to compare the bony dimensions at the level of the pelvic midplane in childbearing women with and without POP and to evaluate their association with POP.

METHODS

Data from 131 patients with POP were prospectively collected between 2021 and 2023. A total of 85 cases were matched with 85 controls who had comparable demographic characteristics. A case-control study was conducted to compare bony dimensions at the pelvic midplane level between women with and without POP using 3D MRI models. Additionally, analysis of covariance was performed to examine the relationship between these dimensions and the maximum prolapse.

RESULTS

The comparison of dimensions (in centimeters) between 85 cases and 85 controls revealed the following significant differences: anterior-posterior diameter (11.3 ± 0.7 vs. 10.7 ± 0.7, p < 0.001); pubic symphysis to ischial spine-left (9.4 ± 0.4 vs. 9.1 ± 0.4, p < 0.001),-right (9.5 ± 0.4 vs. 9.1 ± 0.4, p < 0.001); Ischial spine to sacrococcygeal junction-left (6.7 ± 0.5 vs. 6.5 ± 0.5, p = 0.002),-right (6.7 ± 0.5 vs. 6.5 ± 0.5, p = 0.002); interspinous diameter (11.1 ± 0.7 vs. 10.8 ± 0.7, p = 0.004); and the area of the pelvic midplane (63.0 ± 0.6 vs. 58.5 ± 0.6 cm2, p < 0.001). A larger pelvic midplane was significantly associated with an increased risk of prolapse, with an odds ratio of 2.534 (95% CI 1.647-3.901, p < 0.001) for every 5 cm2 increase. Classification based on the presence or absence of prolapse showed that receiver operating characteristic analysis yielded an area under curve of 70.3% (p < 0.001). Furthermore, among POP patients, those with a larger pelvic midplane area exhibited more severe prolapse (trend p = 0.017).

CONCLUSION

Women with POP have significantly larger bony dimensions at the level of the pelvic midplane compared to women without POP. Additionally, advanced prolapse is associated with larger mid-pelvic dimensions.

Fertility and Pregnancy Outcomes in Primary Hyperparathyroidism: Observations From a Large Insured Population

CONTEXT

Primary hyperparathyroidism (PHPT) has initially been implicated in adverse maternal and neonatal outcomes, while subsequent population studies have failed to show an association.

OBJECTIVE

This work aimed to compare maternal, pregnancy, and neonatal outcomes in patients with and without PHPT.

METHODS

A retrospective matched-cohort study (2005-2020) was conducted at an integrated health-care delivery system in Southern California. Women aged 18 to 44 years were included. Patients with a biochemical diagnosis of PHPT were matched 1:3 with eucalcemic controls (non-PHPT). Main outcome measures included achievement of pregnancy, pregnancy outcomes (including rates of abortion, maternal complications), and neonatal outcomes (including hypocalcemia, need for intensive care).

RESULTS

The cohort comprised 386 women with PHPT and 1158 age-matched controls. Pregnancy rates between PHPT and control groups were similar (10.6% vs 12.8%). The adjusted rate ratio of pregnancy was 0.89 (95% CI, 0.64-1.24) (PHPT vs non-PHPT). Twenty-nine pregnancies occurred in women with coexisting PHPT and 191 pregnancies occurred in controls, resulting in 23 (79.3%) and 168 (88.0%) live births, respectively (P = .023). Neonatal outcomes were similar. Live birth rates were similar (86.4%, 80%, 79.2%) for those undergoing parathyroidectomy prior (n = 22), during (n = 5), or after pregnancy/never (n = 24). Among patients who underwent parathyroidectomy during pregnancy, no spontaneous abortions occurred in women entering pregnancy with peak calcium less than 11.5 mg/dL (2.9 mmol/L).

CONCLUSION

We observed no difference in pregnancy rates between women with or without PHPT. Performing parathyroidectomy before pregnancy or during the second trimester appears to be a safe and successful strategy, and adherence to this strategy may be most critical for patients with higher calcium levels (≥11.5 mg/dL [2.9 mmol/L]).

Comparison of clinical effects between sacrospinous ligament fixation and extraperitoneal high uterosacral ligament suspension for patients: A retrospective cohort clinical trials

AIM

The aim of the study is to compare the effect of extraperitoneal high uterosacral ligament suspension (EHUS) and sacrospinous ligament fixation on lower urinary tract symptoms (LUTS) and anatomical reduction in patients with pelvic organ prolapse (POP).

METHODS

This retrospective cohort study concluded 91 patients with POP who underwent EHUS or sacrospinous ligament fixation (SSLF) for apical repair. The primary outcome was the effect of the two operations on anatomical reduction. The main secondary outcomes included improvement of questionnaire scores, satisfaction, and subjective prolapse rate. Categorical variables, Student's t test, and the Mann-Whitney U test were used for analysis.

RESULTS

All patients' scores of POP-Q were significantly improved after surgery. The scores of urinary frequency and urgency in the SSLF group improved significantly from 6 months after surgery, with statistical significance (p < 0.05), while the scores of nocturia and urgency in the EHUS group improved from 1 month after surgery (p < 0.05). The scores of questionnaires in both groups were significantly lower than those before surgery, while the EHUS group showed more significant improvement (p < 0.05).

CONCLUSION

EHUS is easy to operate, has a short operative time, fewer perioperative and postoperative complications, and the apical can be suspended well if the prolapse is not severe. It also has a certain degree of relief for LUTS, which is a new type of operation that is worthy of clinical promotion.

Effect of Vaginal Prolapse Repair and Midurethral Sling on Urgency Incontinence Symptoms

IMPORTANCE

Limited evidence exists on the effect of combined native tissue vaginal prolapse repair with midurethral sling on urgency urinary incontinence (UUI) symptoms.

OBJECTIVES

This study aimed to evaluate the effect of combined native tissue vaginal prolapse repair with midurethral sling on UUI symptoms at 12 months postoperatively and identify risk factors for persistent UUI.

STUDY DESIGN

This secondary analysis utilized data from a randomized trial comparing retropubic versus single-incision slings in women undergoing treatment of stress incontinence and vaginal prolapse with native tissue vaginal repair and midurethral sling. Responses to Question 16 of the Pelvic Floor Distress Inventory-20 were grouped into no and mild UUI (0, 1) versus moderate and severe UUI (2, 3, 4), and associations between UUI symptoms and patient and surgical characteristics were explored.

RESULTS

At baseline, 196/254 (77%) reported at least moderate UUI bother, whereas 58 (23%) had no bother. At 12 months postoperatively, persistent, resolved and de novo UUI were 41%, 59%, and 11%, respectively. At baseline, higher body mass index (odds ratio [OR], 1.08 95% CI, 1.02-1.14; P = 0.005) and symptomatic SUI (OR, 4.76; 95% CI, 2.53-9.01; P < 0.001) were associated with UUI. At 12 months, age (OR, 1.18, 95% CI, 1.04-1.35; P = 0.012) and Charlson Comorbidity Index (OR, 1.21; 95% CI, 1.00-1.45; P = 0.049) were associated with UUI. Colpocleisis was the only significant protective factor for the presence of UUI at 12 months (OR, 0.35; 95% CI, 0.13-0.97; P = 0.043).

CONCLUSION

At 12 months postoperatively, almost 60% saw resolution of baseline UUI symptoms, especially those undergoing colpocleisis.

Family history and acquired risk factors for pelvic organ prolapse: a case-control study in Japan

This case-control study aimed to investigate the association between family history of pelvic organ prolapse (POP) and its development, combined with known clinical risk factors, in Japanese women. Participants included patients aged ≥ 40 years with and without POP. Self-reported questionnaires assessed delivery methods, disease history, and family history until third-degree relatives. Overall, 305 patients with POP and 338 healthy controls were included. After age-matching, a good balance was achieved between the groups (n = 129 each), with a mean age of 67.7 ± 8.3 years in the POP group and 67.4 ± 8.3 years in the control group. Multivariable logistic regression analysis revealed that the POP group had a significantly higher odds ratio for family history of POP (3.06 [1.09-8.56]; p = 0.03), body mass index (BMI) (1.12 [1.03-1.22]; p = 0.01), and parity (1.51 [1.20-1.89]; p = 0.001). An area under the curve of 0.693 was achieved with a family history of POP, BMI ≥ 23.1 kg/m2, and parity ≥ 3 for differentiation between the POP and control groups. This suggests that family history of POP combined with BMI and parity may be useful predictors for POP development in Japanese women.

Prevalence and impact of pelvic floor dysfunctions on quality of life in women 5-10 years after their first vaginal or caesarian delivery

Background

Pelvic floor dysfunction (PFD) in women is a health problem with repercussions on quality of life. The literature agrees that PFD prevention strategies begin with identifying women who are most at risk of developing PFD in the future. However, recent evidence addressing its multifactorial origin is scant.

Objective

Our aim was to investigate late prevalence, risk factors, and the impact on quality of life of PFD in women after their first vaginal or caesarian birth.

Methods

We conducted an ambispective cohort observational study. Participants were primiparous women who had given birth to only one child by vaginal delivery or cesarean section between 2012 and 2016. Exposure and response variables, assessed using the International Consultation on Incontinence Questionnaire and the Pelvic Floor Distress Inventory, were collected during a phone interview 5-10 years after childbirth. Pearson's Chi-square, Student's t-test and odds ratio (OR) with their respective 95 % confidence intervals (CI) were calculated.

Findings

A total of 456 women were included in the study. Overall, 50 % of the women had 1 or more PFD within 10 years of giving birth, while 43.9 % of women presented urinary incontinence, 5.5 % presented pelvic organ prolapse, and 15.6 % of women reported some type of anal incontinence. A third of the women perceived the symptoms as a dysfunction and a half of them reported mild or moderate symptoms.

Conclusion

PFD in women is a prevalent and underdiagnosed problem. Our study advocates for early detection of PFD risk factors and emphasizes the need for increased visibility, awareness, and proactive health measures related to PFD.

Adverse Effects of Intravesical OnabotulinumtoxinA Injection in Patients with Idiopathic Overactive Bladder or Neurogenic Detrusor Overactivity: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Despite the efficacy of onabotulinumtoxinA, its safety profile remains a concern. This meta-analysis reviewed the major adverse events (AEs) associated with intravesical onabotulinumtoxinA treatment in patients with neurogenic detrusor overactivity (NDO) and idiopathic overactive bladder (iOAB). Randomized controlled trials (RCTs) conducted between January 2000 and December 2022 were searched for adult patients administered different onabotulinumtoxinA dosages or onabotulinumtoxinA vs. placebo. Quality assessment was performed using the Cochrane Collaboration tool, and statistical analysis was performed using Review Manager version 5.3. A total of 26 RCTs were included in the analysis, including 8 on NDO and 18 on iOAB. OnabotulinumtoxinA vs. placebo significantly increased the urinary tract infection (UTI) incidence in patients with NDO (relative risk, or RR, 1.54) and iOAB (RR, 2.53). No difference in the RR with different onabotulinumtoxinA dosages was noted. Urinary retention was frequent with onabotulinumtoxinA use in the NDO (RR, 6.56) and iOAB (RR, 7.32) groups. Similar observations were made regarding the risks of de novo clean intermittent catheterization (CIC). The risk of voiding difficulty increased with onabotulinumtoxinA use in patients with iOAB. Systemic AEs of onabotulinumtoxinA, including muscle weakness (RR, 2.79) and nausea (RR, 3.15), were noted in patients with NDO; most systemic AEs had a low incidence and were sporadic.

Global Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Fecal incontinence (FI) can considerably impair quality of life. Through a systematic review and meta-analysis, we sought to determine the global prevalence and geographic distribution of FI and to characterize its relationship with sex and age.

METHODS

We searched PubMed, Web of Science, and Cochrane Library databases to identify population-based surveys of the prevalence of FI.

RESULTS

Of the 5175 articles identified, the final analysis included 80 studies; the median response rate was 66% (interquartile range [IQR], 54%-74%). Among 548,316 individuals, the pooled global prevalence of FI was 8.0% (95% confidence interval [CI], 6.8%-9.2%); by Rome criteria, it was 5.4% (95% CI, 3.1%-7.7%). FI prevalence was greater for persons aged 60 years and older (9.3%; 95% CI, 6.6%-12.0%) compared with younger persons (4.9%; 95% CI, 2.9%-6.9%) (odds ratio [OR], 1.75; 95% CI, 1.39-2.20), and it was more prevalent among women (9.1%; 95% CI, 7.6%-10.6%) than men (7.4%; 95% CI, 6.0%-8.8%]) (OR, 1.17; 95% CI, 1.06-1.28). The prevalence was highest in Australia and Oceania, followed by North America, Asia, and Europe, but prevalence could not be estimated in Africa and the Middle East. The risk of bias was low, moderate, and high for 19 (24%), 46 (57%), and 15 (19%) studies, respectively. Exclusion of studies with high risk of bias did not affect the prevalence of FI or heterogeneity. In the meta-regression, the high study heterogeneity (I2 = 99.61%) was partly explained by age.

CONCLUSIONS

Approximately 1 in 12 adults worldwide have FI. The prevalence is greater among women and older people.

Prevalence of colorectal symptoms and anal incontinence in patients with pelvic organ prolapse attended at an outpatient urogynecology service

Objective

To analyze data of patients with symptomatic pelvic organ prolapse evaluated with PFDI20 and its subscales to report the prevalence of lower gastrointestinal symptoms and anal incontinence in the population of a public hospital and analyze its impact on quality of life.

Methods

Cross-sectional study of patients with symptomatic POP. Patients were evaluated with demographic data, POP-Q, pelvic floor ultrasonography, urological parameters, and pelvic floor symptoms (PFDI-20), and quality of life (P-QoL) surveys. Patients were classified as CRADI-8 "positive" for colorectal symptoms, with responses "moderate" in at least 3 and/or "severe" in at least 2 of the items in the CRADI-8 questionnaires.

Results

One hundred thirteen patients were included. 42.5% (48) were considered positive for colorectal symptoms on CRADI-8. 53.4% presented anal incontinence. No significant differences were found in sociodemographic variables, POP-Q stage, ultrasound parameters, or urological parameters. Positive patients had a significantly worse result in PFDI-20, POPDI (48 vs 28; p<0.001), UDI6 (51 vs 24; p<0.001), and in the areas of social limitation (44.4 vs 22.2; p = 0.045), sleep- energy (61.5 vs 44.4; p = 0.08), and severity (56.8 vs 43.7, p=0.015) according to P-QoL.

Conclusion

Moderate or severe colorectal symptoms are seen in 40% of patients with symptomatic POP in our unit. Full evaluation of pelvic floor dysfunction symptoms should be performed routinely in urogynecology units.(FONIS SA12I2I53 - NCT02113969).

Pelvic organ prolapse: a cross-sectional study during mass campaign in two hospitals in the city of Kananga in the Democratic Republic of Congo

Introduction

pelvic organ prolapse is a dynamic pathology that can worsen or regress especially postpartum and is the basis of several disorders that bother the patient and alter her quality of life. This study aims to determine the epidemiological, clinical, and therapeutic profile of pelvic organ prolapse in the town of Kananga.

Methods

this is a cross-sectional study of cases of pelvic organ prolapse recorded during the mass campaign organized in the Bon-Berger Hospital of Tshikaji and Saint Georges Hospital of Katoka in the town of Kananga, from January 1 to July 31, 2023. Non-probability convenience sampling was used to select cases.

Results

we recorded 138 cases of prolapse out of 572 patients. The prevalence of pelvic organ prolapse is 24.12% with an average monthly incidence of 19.71 (SD: 4.23) cases per month. The prevalence of recurrence of pelvic organ prolapse is 8.69%. The average age of patients is 54.86 (SD: 11.36) years with an average parity of 7.62 (SD: 1.8) deliveries. Its preoperative symptomatology consists of the intravaginal mass associated with digestive and urinary disorders in 97.00% (n=130), stage III hysterocele predominates in 68.70% (n=92), surgical treatment is the most practiced in 91.79% (n=123) and hysterectomy associated with the treatment of cystocele and rectocele by vaginal surgical access is the most practiced in 80.60% (n=108).

Conclusion

pelvic organ prolapse is a real public health problem in the city of Kananga, its symptoms are classic and its treatment is surgical via the vaginal route.

Prevalence and risk factors of pelvic organ prolapse among women in Sidama region, Ethiopia: A community-based survey

BACKGROUND

Pelvic organ prolapse is a descent of the vaginal compartments and the surrounding organ due to loss of support of the vaginal tissue. It has a significant psychological, physical, and social impact that affects women's quality of life. However, its true prevalence is unknown due to the variability in the methods used to diagnose the disorder.

OBJECTIVES

This study aimed to determine the prevalence of pelvic organ prolapse and its associated risk factors among women in Sidama region, Ethiopia.

STUDY DESIGN

A community-based cross-sectional survey was conducted in the Dale-Wonsho Health and Demographic Surveillance Site, Sidama region, from March to October 2023.

METHODS

A multi-stage stratified cluster sampling was used to select a sample of 816 women. Anatomical prolapse was diagnosed based on the standardized pelvic organ prolapse quantification method, and symptomatic prolapse was assessed by patient-reported symptoms. A complex survey-based modified Poisson regression was used to assess the risk factors associated with prolapse.

RESULTS

A total of 815 participated in the interview, and 779 (95.6%) underwent pelvic examination to assess for prolapse status. Anatomical prolapse (Stages II-IV) was observed in 241 (30.9%; 95% confidence interval = 24-38.7) of the participants. The prevalence of symptomatic pelvic organ prolapse was 78.5% (95% confidence interval = 69.1-85.7) among women with anatomical prolapse (189/241). This prevalence falls to 24.27% (95% confidence interval = 19.98-29.16) for the total sample population. Higher frequency of childbirth, prolonged heavy lifting activities, and prolonged labor increased the likelihood of developing anatomical prolapse. Childbirth at an early age and prolonged heavy lifting activities were significantly associated with symptomatic prolapse.

CONCLUSION

Anatomical prolapse and symptomatic prolapse are high in the study area. Parity, prolonged heavy lifting, prolonged labor, and early age childbirth were associated with pelvic organ prolapse. Community-based education and interventions that focus on the modification of risk factors are needed.

Diagnostic Value of Dynamic Magnetic Resonance Imaging (dMRI) of the Pelvic Floor in Genital Prolapses

Pelvic organ prolapse is a chronic disease resulting from a weakening of the musculoskeletal apparatus of the pelvic organs. For the diagnosis of this pathology, it is insufficient to conduct only a clinical examination. An effective diagnostic tool is the method of dynamic magnetic resonance imaging (MRI) of the pelvic floor, which allows a comprehensive assessment of the anatomical and functional characteristics of the walls of the pelvis and pelvic organs. The aim of the study was to analyze the literature data on the possibilities and limitations of using dynamic MRI in pelvic organ prolapse. The widespread use of the dynamic MRI method is due to the high quality of the resulting image, good reproducibility, and the maximum ability to display the characteristics of the pelvic floor. Dynamic MRI of the small pelvis allows a comprehensive assessment of the anatomical and functional features of the pelvis, excluding the effect of ionizing radiation on the body. The method is characterized by good visualization with high resolution and excellent soft tissue contrast. The method allows for assessing the state of the evacuation function of visualized structures in dynamics. Simultaneous imaging of all three parts of the pelvic floor using dynamic MRI makes it possible to assess multicompartment disorders. The anatomical characteristics of the state of the pelvic organs in the norm and in the event of prolapse are considered. The technique for performing the method and the procedure for analyzing the resulting images are described. The possibilities of diagnosing a multicomponent lesion are considered, while it is noted that dynamic MRI of the pelvic organs provides visualization and functional analysis of all three parts of the pelvis and often allows the choice and correction of tactics for the surgical treatment of pelvic organ prolapse. It is noted that dynamic MRI is characterized by a high resolution of the obtained images, and the advantage of the method is the ability to detect functional changes accompanying the pathology of the pelvic floor.

Evaluating the risk factors for the development of benign disorders of defaecation: a surgical perspective

PURPOSE

There remains uncertainty as to which risk factors are important for the development of defaecatory problems as a result of heterogeneity of published evidence. Understanding the impact of risk factors may be important in selecting targets for disease prevention or reversal. The aim of this study was to identify and evaluate risk factors for faecal incontinence and chronic constipation.

METHODS

Risk factors for chronic constipation and faecal incontinence were long-listed from scientific literature, then anonymously evaluated (by 50 predominantly colorectal surgical experts from the UK Pelvic Floor Society) using a Delphi technique. Each risk factor was rated as independent, a co-factor, or not a risk factor. Independent risk factors were rated between 1 (not important) and 10 (critically important) with mean (± standard deviation) calculated.

RESULTS

Thirty-eight risk factors for chronic constipation were evaluated. Eighteen were classed as independent and 16 as co-factors. Opioid analgesia (7.87 ± 2.05), eating disorders (7.80 ± 1.72), and history of abuse (7.70 ± 1.89) were scored as most important independent risk factors. Female sex (6.60 ± 2.02) was considered an independent risk factor but increasing age was rated a co-factor. Thirty-three risk factors for faecal incontinence were evaluated. Twenty were classed as independent and eight as co-factors. Third- or fourth-degree tear (8.88 ± 1.57), instrumental delivery (8.47 ± 1.58), and grand multiparity (8.00 ± 1.63) were rated most important. Increasing age (7.41 ± 2.14) and female sex (7.58 ± 2.05) were both considered independent risk factors.

CONCLUSIONS

Several risk factors for chronic constipation and faecal incontinence were selected by Delphi approach. These factors will feed forward into Bayesian models of disease prediction that combine data and expert knowledge.

Co-occurrence of fecal incontinence with constipation or irritable bowel syndrome indicates the need for personalized treatment

BACKGROUND

This study aimed to compare the prevalence and symptoms of fecal incontinence (FI) in relation to irritable bowel syndrome (IBS-associated FI), constipation (constipation-associated FI), and isolation (isolated FI).

METHODS

Data were analyzed from 3145 respondents without organic comorbidities known to influence defecation function from the general Chinese population who filled in the online Groningen Defecation and Fecal Continence questionnaire. FI, IBS, and constipation were evaluated with the Rome IV criteria.

KEY RESULTS

The prevalence of FI was 10.5% (n = 329) in the non-comorbidity group. After multivariable logistic regression analysis, IBS (odds ratio [OR]: 12.55, 95% confidence interval [CI]: 9.06-17.36) and constipation (OR: 4.38, 95% CI: 3.27-5.85) were the most significant factors contributing to FI. Based on this finding, 106/329 (32.2%) had IBS-associated FI, 119/329 (36.2%) had constipation-associated FI, and 104/329 (31.6%) had isolated FI. Among the 329 FI respondents, there was a high prevalence of IBS and constipation-related symptoms, including abdominal pain (81.5%) and abdominal bloating (77.8%) for IBS and straining during defecation (75.4%), incomplete defecation (72.3%), defecation blockage (63.2%), anal pain during defecation (59.3%), and hard stools (24%) for constipation. The patients with IBS-associated FI asked for specialists' help less frequently than those with isolated FI. Interestingly, among the patients with constipation-associated FI, 56.3% used anti-diarrhea medicine.

CONCLUSIONS AND INFERENCES

The prevalence of IBS-associated FI, constipation-associated FI, and isolated FI is comparably high. It is important to diagnose and target the cause of FI to provide personalized and cause-targeting care instead of treating only the FI symptoms.

There is an obstetrical dilemma: Misconceptions about the evolution of human childbirth and pelvic form

Compared to other primates, modern humans face high rates of maternal and neonatal morbidity and mortality during childbirth. Since the early 20th century, this "difficulty" of human parturition has prompted numerous evolutionary explanations, typically assuming antagonistic selective forces acting on maternal and fetal traits, which has been termed the "obstetrical dilemma." Recently, there has been a growing tendency among some anthropologists to question the difficulty of human childbirth and its evolutionary origin in an antagonistic selective regime. Partly, this stems from the motivation to combat increasing pathologization and overmedicalization of childbirth in industrialized countries. Some authors have argued that there is no obstetrical dilemma at all, and that the difficulty of childbirth mainly results from modern lifestyles and inappropriate and patriarchal obstetric practices. The failure of some studies to identify biomechanical and metabolic constraints on pelvic dimensions is sometimes interpreted as empirical support for discarding an obstetrical dilemma. Here we explain why these points are important but do not invalidate evolutionary explanations of human childbirth. We present robust empirical evidence and solid evolutionary theory supporting an obstetrical dilemma, yet one that is much more complex than originally conceived in the 20th century. We argue that evolutionary research does not hinder appropriate midwifery and obstetric care, nor does it promote negative views of female bodies. Understanding the evolutionary entanglement of biological and sociocultural factors underlying human childbirth can help us to understand individual variation in the risk factors of obstructed labor, and thus can contribute to more individualized maternal care.

The RISE FOR HEALTH study: Methods for in-person musculoskeletal assessment

OBJECTIVES

To describe the methods for the in-person musculoskeletal (MSK) assessment of the RISE FOR HEALTH (RISE) study, a population-based multicenter prospective cohort study designed to identify factors associated with bladder health (BH) conducted by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS).

METHODS

A subset of RISE participants who express interest in the in-person assessment are screened to ensure eligibility (planned n = 525). Eligible consenting participants are asked to complete a standardized MSK assessment to evaluate core stability (four component core stability test, lumbar spine pain (seated slump test), pelvic girdle pain, (sacroiliac joint, anterior superior iliac spine, pubic symphysis tenderness, and pelvic girdle pain provocation test), hip pain (flexion, abduction, internal rotation and flexion, adduction and external rotation) and pelvic girdle function (active straight leg raise). Participants are also asked to complete the Short Physical Performance Battery to measure balance, gait speed, lower extremity strength, and functional capacity.

RESULTS

Detailed online and in-person MSK training sessions led by physical therapy were used to certify research staff at each clinical center before the start of RISE in-person assessments. All evaluators exceeded the pre-specified pass rates.

CONCLUSIONS

The RISE in-person MSK assessment will provide further insight into the role of general body MSK health and dysfunction and the spectrum of BH.

Current status of stem cell treatments and innovative approaches for stress urinary incontinence

Stem cells are capable of self-renewal, differentiation, and the promotion of the release of chemokines and progenitor cells essential for tissue regeneration. Stem cells have the potential to develop into specialized cells if given the right conditions, to self-renew and maintain themselves, to generate a large number of new differentiated cells if injured, and to either generate new tissues or repair existing ones. In the last decade, it has become clear that treating lower urinary tract dysfunction with the patient's own adult stem cells is an effective, root-cause method. Regenerative medicine is predicated on the idea that a damaged rhabdosphincter can be repaired, leading to enhanced blood flow and improved function of the sphincter's exterior (striated) and internal (smooth) muscles. Stem cell therapy has the potential to cure stress urinary incontinence according to preclinical models. In contrast, stem cell treatment has not been licensed for routine clinical usage. This article reviews the current state of stem cell for stres urinary incontinence research and recommends future avenues to facilitate practical uses of this potential therapy modality.

Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN)

BACKGROUND

The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms.

OBJECTIVE

This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement.

STUDY DESIGN

Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not).

RESULTS

A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4).

CONCLUSION

Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.

Pelvic organ prolapse and anal incontinence in women: screening with a validated epidemiology survey

PURPOSE

The primary objective of this study was to determine the prevalence of pelvic organ prolapse (POP) and anal incontinence (AI) in a Minnesota population using the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ). The secondary objective of this study was to determine the association of POP and AI with parity, age, smoking status, body mass index (BMI), and co-morbidities.

METHODS

Women ≥ 18 years old attending the 2018 Minnesota State Fair were asked to fill out a web-based version of the EPIQ. Multivariable logistic regression models were used to investigate the association of POP and AI with the variables of interest.

RESULTS

A total of 1426 women were included in the analysis. There was a 4.9% prevalence of POP and 14.9% prevalence of AI. POP was significantly associated with parity and higher BMI (p < 0.01 and p = 0.02, respectively). In this cohort, POP was not associated with older age, smoking, or presence of co-morbid conditions. Anal incontinence was associated with older age (p < 0.01), smoking status (p = 0.01), and presence of co-morbid conditions (p = 0.01) but was not associated with parity or higher BMI.

CONCLUSION

POP and AI were associated with some, but not all, of the variables tested, which differs from prior studies. In addition, the prevalence of POP and AI were different than rates reported in similar studies. This may suggest regional differences in prevalence of POP and AI.

Novel insight into the correlation between hernia orifice of cystocele and lower urinary tract function: a pilot study

BACKGROUND

It has been hypothesized that women with significant pelvic organ prolapse (POP), particularly of the anterior vaginal wall, may have voiding dysfunction (VD). Although the VD mechanism due to cystocele is not fully understood, different vaginal compartments have rarely been closely examined. This study attempted to further elucidate the correlation between POP and VD through a new subgroup classification using cystoscopy.

METHODS

This study reviewed clinical records of 49 women who underwent cystocele repair. All patients were scheduled for laparoscopic sacrocolpopexy, preoperatively underwent uroflowmetry and postvoid residual urine volume (PVR) measurement, and completed pelvic floor function questionnaires. Bladder examination by cystoscopy was additionally performed using the lithotomy position with the Valsalva maneuver.

RESULTS

Subjects were divided into four groups according to hernia orifice presence determined by cystoscopy, which included the trigone type, posterior wall type, trigone and urethra type, and trigone and posterior wall type. The posterior wall type had statistically higher PVR values versus the trigone and posterior wall type (P = 0.013). The posterior wall type had statistically lower values for average urine flow rate versus the urethra and trigone type (P = 0.020). There were no significant differences noted in the pelvic floor function questionnaires among the four groups.

CONCLUSIONS

A new bladder defect classification based upon hernia orifice location was associated with lower urinary tract function. Posterior wall hernia presence caused significant voiding function deterioration. This new subgroup classification, which can more clearly identify and indicate bladder function, is also comparable among patients.

A Randomized Trial of Social Media Versus Search Engine Advertising to Increase Awareness of Treatments for Female Stress Urinary Incontinence

IMPORTANCE

Outreach based on user characteristics through social media advertising is significantly more effective than outreach based on user interests with search engine advertising for female stress urinary incontinence.

OBJECTIVE

The aim of the study was to compare the effectiveness of 2 online outreach platforms to engage women at risk of stress urinary incontinence with a high-quality patient education website.

STUDY DESIGN

A geographic randomized trial was performed comparing online advertising on Facebook, a social media site, versus Google Ads, a search engine, to direct viewers to VoicesForPFD.org. Advertisements were developed using health communication theory and pretested before the randomized trial. Counties in the Pacific Northwest were grouped into approximately equal populations, called "supercounties," and randomized to advertisement platforms. Educational website views resulting from each campaign, called sessions, were measured using Google Analytics; the primary outcome was the number of sessions per supercounty. County characteristics were obtained from national survey data. Effectiveness of the advertising platforms was compared between randomization arms using Welch's unequal variances t test, and crude and adjusted linear regression models.

RESULTS

Mean user sessions were significantly higher in areas randomized to Facebook advertising (470 sessions) compared with areas randomized to Google Ads advertising [44 sessions; mean, 426 session difference (95% confidence interval, 199-653 sessions); P = 0.001]. After accounting for adult female population and rurality, randomization to Facebook instead of Google Ads still resulted in 409 additional sessions (95% confidence interval, 317-501 sessions; P < 0.001).

CONCLUSIONS

Social media was 10 times more effective (470 versus 44 mean sessions per supercounty) than search engine outreach advertising and should be prioritized in outreach efforts. Future work is needed on engagement and behavior change with online outreach.

Pelvic floor dysfunction symptoms and knowledge level in obese women

This study compared the pelvic floor dysfunction (PFD) symptoms and knowledge levels in obese and non-obese women. The study included 40 obese and 41 non-obese women. The presence of PFD and the severity of its symptoms were questioned with the Pelvic Floor Distress Inventory-20 (PFDI-20) (its sub-scales: Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6), Colorectal-Anal Distress Inventory-8 (CRADI-8), Urinary Distress Inventory-6 (UDI-6)). Participants' PFD knowledge levels were evaluated with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and the Anal Incontinence Knowledge Questionnaire (AIKQ). The rates of urinary incontinence (UI) and pelvic organ prolapse (POP) symptoms were higher in the obese group compared to the control group (p = .001). The POPDI-6, CRADI-8, UDI-6, and PFDI-20 scores were higher in the obese group compared to the control group (p < .001). Moreover, the knowledge level related to treatment methods for PFD was lower in the obese women compared to the non-obese women (p < .05). PFD symptom incidence and severity were higher and knowledge levels related to PFD were lower in the obese women compared to the non-obese women. Informative teaching programs on this issue would be beneficial as part of preventive health services.

"Things Are Happening That I Don't Understand": A Narrative Exploration of the Chaos of Living with Pelvic Floor Disorders

Pelvic floor disorders (PFDs), including fecal and urinary incontinence as well as pelvic organ prolapse, are common medical issues faced by one-third of all women across the lifespan. Despite this prevalence, many women are unaware of them, have highly stigmatized perceptions of them, and thus do not actively seek support or treatment for them. Given that PFDs can drastically impact quality of life to the point of social isolation and depression, this study examines chaos and desire as both lived and storied constructs that ultimately influence whether and how women with PFDs assert control over their social and corporeal disruption. Guided by narrative sensibilities and informed by semi-structured interviews with 22 women living with varying PFDs, our analysis highlights how chaos serves as a catalyst for continued chaos (i.e. barriers to seeking medical care), mitigation (i.e. resignation and/or public bodily containment), and/or change (i.e. motivations to seek medical care). These findings offer both theoretical and practical implications for helping individuals grappling with the dis-ease of PFDs (i.e. patients, providers, and practitioners) to envision and act otherwise.

Sociodemographic Disparities and Parity in Relation to Urinary Incontinence: A Nationwide Primary Healthcare Cohort Study (1997–2018)

Objectives: Urinary incontinence (UI) is a very common condition in the primary healthcare settings. Few studies have investigated whether sociodemographic factors are related to UI. This nationwide study aimed to investigate whether there is a relationship between sociodemographic factors and UI in women. Methods: A nationwide open cohort study included 2,044,065 women aged 15–50 years. Several national population-based (Sweden) databases including nationwide primary healthcare data were used. The outcome was the time to the first event of any UI diagnosis during the study period (1997–2018). Cox regression models were used to test for associations between individual sociodemographic factors and UI. Results: The study identified 44,250 UI events. These corresponded to 2.16% of the study population and an incidence rate (IR) per 1000 person-years of 1.85 (95% CI 1.84–1.87). In the fully adjusted model, a high age, low education level, and being born outside of Sweden were independently associated with a higher UI risk, while rural living was associated with a lower risk. The income level did not seem to have a large impact. Most notably, women born in the Middle East/North Africa and Latin America/Caribbean had a substantially higher risk of UI with HRs of 2.41 (95% CI 2.33–2.49) and 2.30 (95% CI 2.17–2.43), respectively. Parity was strongly and independently associated with UI. Conclusion: This study presents novel risk factors associated with UI. The findings provide new knowledge concerning the burden of this disease among women, which could be used to provide more equal healthcare for these patients in the future. Previous research allied with these findings suggests using a comprehensive approach targeting health disparities.

Approaching Combined Rectal and Vaginal Prolapse

Combined rectal prolapse and pelvic organ prolapse surgery provides significant quality-of-life benefits with improvements in bothersome symptoms of pain, bulge, constipation, urinary retention, as well as bowel and bladder incontinence. Robotic surgery is the ideal tool for a combined surgical repair. It allows enhanced suturing in the deep pelvis, three-dimensional (3D) visualization of the presacral space and easy mobilization of the rectum and dissection of the vagina. Combined procedures can be offered to patients with the advantages of a single operation and concurrent recovery period without increasing complications. In this article, we highlight our approach to combined prolapse repair.

International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs

INTRODUCTION AND HYPOTHESIS

This narrative review describes the existing epidemiologic literature and identifies gaps regarding pelvic organ prolapse (POP) prevalence, incidence, natural history, and current and future service needs.

MATERIALS AND METHODS

A PubMed search identified relevant citations published in 2000 or later. Pre-specified criteria were used to screen titles, abstracts, and manuscripts, including reference sections. Study findings were summarized to define what is known, identify gaps in current knowledge, and suggest priority areas for future research.

RESULTS

The reported prevalence of POP varies widely (1-65%) based on whether its presence is ascertained by symptoms (1-31%), pelvic examination (10-50%), or both (20-65%). Most existing population-based surveys do not include physical examination data. White women from higher income countries are overrepresented in the existing literature. Incidence and natural history data are limited and consist mainly of cohorts that follow women after pregnancy or menopause. Given global increases in aging populations in well-resourced countries, the need for POP treatment is anticipated to increase in the coming decades. In lower and middle income countries (LMICs) where demographic trends are different, there is a dearth of information about anticipated POP service needs.

CONCLUSION

Future POP incidence, prevalence, and natural history studies should include non-white women from LMICs and should combine pelvic examination data with validated patient-reported outcome measures when feasible. Anticipated future service needs differ globally, with a greater demand for POP treatment services in well-resourced settings where aging populations are prevalent.

Prevalence of pelvic floor dysfunction in women in Riyadh, Kingdom of Saudi Arabia: A cross-sectional study

Objective:

Pelvic floor dysfunction has a high prevalence among women worldwide. However, in the Kingdom of Saudi Arabia, it is underreported. Thus, we aimed to estimate the prevalence and risk factors of pelvic floor dysfunction in women in the Kingdom of Saudi Arabia.

Methods:

We conducted a cross-sectional study on literate non-pregnant women aged ⩾18 years who agreed to participate in our survey. We used the validated and translated Australian pelvic floor questionnaire and conducted a multivariate logistic regression analysis to assess the risk factors of pelvic floor dysfunction.

Results:

A total of 824 participants completed the questionnaire. While 60.2% of the participants had pelvic floor dysfunction, 67.7% reported signs of bowel dysfunction. Urinary dysfunction, prolapse, and sexual dysfunction were present in 44.1%, 67.7%, and 55.4% of the participants, respectively. Age, high body mass index, chronic medical illness, heavy weight lifting, and multiparity were found as the risk factors of bladder function problems. Meanwhile, chronic medical illness, heavy weight lifting, and multiparity were found as the risk factors of bowel dysfunction and prolapse. Age group and marital status were the independent factors associated with sexual dysfunction.

Conclusion:

We noted a high rate of pelvic floor dysfunction in the Kingdom of Saudi Arabia, which calls for the need to provide holistic approaches for the prevention and management of pelvic floor dysfunction among women.

The evolution of pelvic canal shape and rotational birth in humans

BACKGROUND

The human foetus typically needs to rotate when passing through the tight birth canal because of the complex shape of the pelvis. In most women, the upper part, or inlet, of the birth canal has a round or mediolaterally oval shape, which is considered ideal for parturition, but it is unknown why the lower part of the birth canal has a pronounced anteroposteriorly oval shape.

RESULTS

Here, we show that the shape of the lower birth canal affects the ability of the pelvic floor to resist the pressure exerted by the abdominal organs and the foetus. Based on a series of finite element analyses, we found that the highest deformation, stress, and strain occur in pelvic floors with a circular or mediolaterally oval shape, whereas an anteroposterior elongation increases pelvic floor stability.

CONCLUSIONS

This suggests that the anteroposterior oval outlet shape is an evolutionary adaptation for pelvic floor support. For the pelvic inlet, by contrast, it has long been assumed that the mediolateral dimension is constrained by the efficiency of upright locomotion. But we argue that the mediolateral elongation has evolved because of the limits on the anteroposterior diameter imposed by upright posture. We show that an anteroposteriorly deeper inlet would require greater pelvic tilt and lumbar lordosis, which compromises spine health and the stability of upright posture. These different requirements of the pelvic inlet and outlet likely have led to the complex shape of the pelvic canal and to the evolution of rotational birth characteristic of humans.

The obstetrical dilemma hypothesis: there's life in the old dog yet

The term 'obstetrical dilemma' was coined by Washburn in 1960 to describe the trade-off between selection for a larger birth canal, permitting successful passage of a big-brained human neonate, and the smaller pelvic dimensions required for bipedal locomotion. His suggested solution to these antagonistic pressures was to give birth prematurely, explaining the unusual degree of neurological and physical immaturity, or secondary altriciality, observed in human infants. This proposed trade-off has traditionally been offered as the predominant evolutionary explanation for why human childbirth is so challenging, and inherently risky, compared to that of other primates. This perceived difficulty is likely due to the tight fit of fetal to maternal pelvic dimensions along with the convoluted shape of the birth canal and a comparatively low degree of ligamentous flexibility. Although the ideas combined under the obstetrical dilemma hypothesis originated almost a century ago, they have received renewed attention and empirical scrutiny in the last decade, with some researchers advocating complete rejection of the hypothesis and its assumptions. However, the hypothesis is complex because it presently captures several, mutually non-exclusive ideas: (i) there is an evolutionary trade-off resulting from opposing selection pressures on the pelvis; (ii) selection favouring a narrow pelvis specifically derives from bipedalism; (iii) human neonates are secondarily altricial because they are born relatively immature to ensure that they fit through the maternal bony pelvis; (iv) as a corollary to the asymmetric selection pressure for a spacious birth canal in females, humans evolved pronounced sexual dimorphism of pelvic shape. Recently, the hypothesis has been challenged on both empirical and theoretical grounds. Here, we appraise the original ideas captured under the 'obstetrical dilemma' and their subsequent evolution. We also evaluate complementary and alternative explanations for a tight fetopelvic fit and obstructed labour, including ecological factors related to nutrition and thermoregulation, constraints imposed by the stability of the pelvic floor or by maternal and fetal metabolism, the energetics of bipedalism, and variability in pelvic shape. This reveals that human childbirth is affected by a complex combination of evolutionary, ecological, and biocultural factors, which variably constrain maternal pelvic form and fetal growth. Our review demonstrates that it is unwarranted to reject the obstetrical dilemma hypothesis entirely because several of its fundamental assumptions have not been successfully discounted despite claims to the contrary. As such, the obstetrical dilemma remains a tenable hypothesis that can be used productively to guide evolutionary research.

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.

A Preference-Sensitive Online Instrument to Support Shared Decision Making for Patients With Pelvic Organ Prolapse: A Pilot Multicenter Randomized Controlled Trial

A preference-sensitive instrument for women with pelvic organ prolapse was developed to increase shared decision-making. This study aimed to assess the feasibility of a randomized controlled trial to measure the effectiveness of the instrument. A pilot randomized controlled trial was conducted at three Danish gynecological clinics to assess feasibility through recruitment rates, per-protocol use and women's perception of (1) support for decision-making, (2) shared decision-making (Shared Decision-Making Questionnaire), and (3) satisfaction with their decisions. In addition, a focus group interview with participating gynecologists (five gynecologists) was conducted. We invited 226 women and recruited 46 (20%). The most common reason (45%) for nonparticipation was overlooking the invitation in their online public mailbox. Shared Decision-Making Questionnaire showed high data completeness (96%) but indicated a ceiling effect. Women felt the developed instrument supported their decision-making and more so if it was used interactively during consultations. Despite finding the instrument generally useful, gynecologists tended to apply the instrument inconsistently and not per protocol (41%), and some used it as a template for all consultations. This pilot study indicates that recruitment methods, for a future randomized controlled trial, for example, nurse-led preconsultations, need reconsideration due to low recruitment rates and inefficient per-protocol use. In a future randomized controlled trial, cluster randomization should avoid the carryover effect bias.

Basic Evaluation of Urinary Incontinence

Urinary incontinence is a significant, quality of life health condition affecting millions of women. Incontinence is increasingly common as the population ages, and women present with varying degrees of bother. With basic in-office evaluation, most subtypes of urinary incontinence can be defined, evaluated, and treated. Basic in-office evaluation involves a detailed history with a review of current medical problems and medications, a physical examination, and selective in-office testing.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition)

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

Urinary Incontinence and Pelvic Organ Prolapse

The multifactorial pathophysiology of pelvic floor disorder accounts for the coexistence of several pelvic floor disorders in many women. Up to 54% of women with pelvic organ prolapse (POP) report concurrent stress urinary incontinence (SUI). While POP is a risk factor for coexistent SUI, apical and anterior prolapse can also conceal SUI symptoms that are unmasked by POP repair, resulting in de novo SUI postoperatively. It is important for pelvic reconstructive surgeons to consider the relationship between POP and urinary incontinence in presurgical planning and to discuss with patients the risks and advantages of concurrent versus staged anti-incontinence procedures.

Biomechanical trade-offs in the pelvic floor constrain the evolution of the human birth canal

Compared with most other primates, humans are characterized by a tight fit between the maternal birth canal and the fetal head, leading to a relatively high risk of neonatal and maternal mortality and morbidities. Obstetric selection is thought to favor a spacious birth canal, whereas the source for opposing selection is frequently assumed to relate to bipedal locomotion. Another, yet underinvestigated, hypothesis is that a more expansive birth canal suspends the soft tissue of the pelvic floor across a larger area, which is disadvantageous for continence and support of the weight of the inner organs and fetus. To test this "pelvic floor hypothesis," we generated a finite element model of the human female pelvic floor and varied its radial size and thickness while keeping all else constant. This allowed us to study the effect of pelvic geometry on pelvic floor deflection (i.e., the amount of bending from the original position) and tissue stresses and stretches. Deflection grew disproportionately fast with increasing radial size, and stresses and stretches also increased. By contrast, an increase in thickness increased pelvic floor stiffness (i.e., the resistance to deformation), which reduced deflection but was unable to fully compensate for the effect of increasing radial size. Moreover, larger thicknesses increase the intra-abdominal pressure necessary for childbirth. Our results support the pelvic floor hypothesis and evince functional trade-offs affecting not only the size of the birth canal but also the thickness and stiffness of the pelvic floor.

Urinary incontinence in women: state of the art and medical treatment

INTRODUCTION

Urinary incontinence, the involuntary loss of urine, is a common condition that affects approximately 50% of adult women. This condition increases with age, affecting 10% to 20% of all women and up to 77% of elderly women residing in nursing homes.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/MEDLINE database up to July 20, 2020. Focus was only for English language publications of original studies on urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Patients need an overview of their health condition through a detailed anamnestic collection and physical examination to identify the type of incontinence and offer the best treatment.

Clinical Consensus Statement: Association of Anticholinergic Medication Use and Cognition in Women With Overactive Bladder

ABSTRACT

Overactive bladder affects a significant portion of the overall population and has substantial impact on daily activities and quality of life. First-line treatment of overactive bladder includes behavioral therapies, which may be combined with pharmacologic management as indicated. Anticholinergic medications and β-3 agonists are often used as initial pharmacologic therapy, but caution should be taken in prescribing anticholinergic medications in frail or cognitively impaired patients. Recently, additional concerns have emerged regarding prolonged use of anticholinergic medications and the associated risk of cognitive impairment, dementia, and Alzheimer disease in the general population. Given the available evidence, which has shown significant associations between anticholinergic medication use and increased risk of cognitive impairment and dementia, providers should counsel on the associated risks, prescribe the lowest effective dose, and consider alternative medications in patients at risk.

Fibroids and Urinary Symptoms Study (FUSS)

OBJECTIVE

The aims of the study were to characterize pelvic floor and urinary symptoms in women seeking treatment for uterine fibroids and to explore the association between uterine/fibroid size and pelvic floor symptoms.

METHODS

Women seeking treatment for uterine fibroids at a single academic center were enrolled in this cross-sectional study. All participants underwent pelvic imaging and completed the Symptom Severity Subscale of the Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL) and the Pelvic Floor Distress Inventory (PFDI-20).

RESULTS

One hundred ninety-five women with a mean age of 41 ± 6 years and body mass index of 29 ± 7 kg/m2 were included. In this cohort, 58% identified as Black and 38% had at least 1 vaginal delivery. Women attributed pelvic pain (68%), dyspareunia (37%), and urinary incontinence (31%) to their fibroids. The mean ± SD UFS-QOL score was 48.7 ± 25.4, and 63% of participants reported being at least "somewhat bothered" by tightness/pressure in pelvic area, 60% by frequent daytime urination, and 47% by nocturia. The mean PFDI-20 score was 45.5 ± 31.9. Women reported being at least "somewhat bothered" by heaviness/dullness in the pelvis (60%), frequent urination (56%), pelvic pain or discomfort (48%), and sensation of incomplete bladder emptying (43%). The PFDI-20 and UFS-QOL scores were not correlated with uterine volume (r = 0.12, P = 0.12, and r = 0.06, P = 0.44) or fibroid size (r = 0.09, P = 0.26, and r = 0.01, P = 0.92).

CONCLUSIONS

Women presenting for evaluation and treatment of fibroids report high rates of pelvic floor symptoms, particularly urinary frequency and pelvic pressure. However, uterine size and fibroid size are not associated with pelvic floor symptom bother.

Correlation of severity of pelvic organ prolapse with lower urinary tract symptoms

OBJECTIVE

Relationships between pelvic organ prolapse (POP) staging and lower urinary tract symptoms (LUTS) are controversial. In this study, we evaluated correlations of POP staging with LUTS in different compartments.

MATERIALS AND METHODS

From January 2016 to December 2017, 250 consecutive patients with urogynecologic complaints who were referred to our urodynamic unit were recruited into this study. Different stages of different compartments (anterior, central and posterior) of POPs according to IUGA and ICS terminology were re-grouped into four categories as stage 0, 1, 2, and 3 (including stage 4 because of a limited number of patients in stage 4). Pearson correlation coefficient and general linear regression were used for correlations of POP staging in different compartments and LUTS (stress urinary incontinence, overactive bladder and voiding symptoms) as well as their associated factors.

RESULTS

Only OAB had a moderate correlation with different compartments of POP (anterior vaginal wall: -0.3116; cervix: -0.2954 and posterior vaginal wall: -0.3779; all p < 0.05). Stage 1 AVWP significantly increased (39.6%) the occurrence of OAB compared to no prolapse. Posterior compartment (stage 1-3) prolapse reduced the occurrence of OAB.

CONCLUSION

Only stage 1 AVWP is associated with an increase in OAB, and posterior compartment prolapse may reduce the occurrence of OAB.

Frequency and Sociodemographic Characteristics of Urinary Incontinence in Patients Over 65 Years of Age in Rural of Turkey

Aim: The aim of this study was to determine the prevalence of urinary incontinence in patients over 65 years of age and to investigate its relationship with sociodemographic characteristics. Methods: This study is a cross-sectional descriptive study performed using a face to face survey and conducted between the dates of May 1st, 2019 and August 1st, 2019 in patients aged 65 and above and who applied to Gemerek State Hospital Family Medicine Outpatient Clinics. Following a literature search, the questionnaire developed by the investigators was applied. Results: The prevalence of UI was 28.5%. Among those, 43.8% alone had not presented to any physician with this complaint. Among the patients with UI who refrained to tell this complaint to their physicians, 76% considered this condition as a natural consequence of ageing, 17.4% were shy to get examined and 6.6% told that they had no discomfort to have a UI. Among the patients, 72.9% (n=269) were never asked by a physician or a nurse whether they had experienced UI. Conclusions: The symptoms of urinary incontinence are generally considered as a reflection of ageing or patients are shy to express this complaint. In addition, the rate of questioning about urinary incontinence by the physicians or nurses seems to be very low. Keywords: geriatrics, urinary incontinence, aging

Concomitant Sacral Neuromodulation and Gynecologic Surgery: A Single-Institution Experience

AIMS

Sacral Neuromodulation (SNM) is a safe and minimally invasive treatment for urinary and fecal pelvic floor disorders (PFDs). With a high prevalence of women reporting multiple PFDs, knowledge regarding concomitant surgery may inform optimal patient care. Our literature search did not identify any published data on this topic, thus we sought to report our experience with concomitant SNM and gynecologic surgery. Our primary objective was to identify the rate of adverse events among cases. Secondarily, we reviewed the anesthetics used to identify potential associations when performing combined surgery.

MATERIALS AND METHODS

This was retrospective case series of women undergoing SNM at a single academic center from 2012 to 2018. Cases were identified using current procedural terminology codes for SNM and common gynecologic procedures. These electronic medical records were reviewed to identify cases that occurred concomitantly in addition to obtaining demographics, adverse events, type of anesthesia, and overnight hospital stay. Descriptive data analysis was performed with Excel.

RESULTS

Of 200 identified cases of SNM, 15 (7.5%) were concomitantly performed with another procedure. Most concomitant surgeries occurred with insertion of implantable pulse generator. Three minor adverse events occurred: two urinary tract infections and one occurrence of urinary retention. Eight (53%) cases were performed under general anesthesia while seven (46%) received monitored sedation.

CONCLUSIONS

No serious adverse events or anesthesia-related complications were identified in this series. While general anesthesia was used more often, it was in accordance with our standard practice for the gynecologic procedures. This study supports the safety of concomitant gynecologic and SNM surgery.

Sphincter muscle activity before and after delivery: Does it depend on the type of birth?

AIM

There are ongoing discussions whether cesarean section is the safest mode of childbirth to prevent pelvic floor disorders. Pelvic floor electromyography (EMG) allows the analysis of external anal sphincter (EAS) function during voluntary contractions. The primary objective of this study was the evaluation of EMG amplitude of external anal sphincter in women who had vaginal delivery, compared to women who had cesarean section. The secondary objective was to evaluate the anal incontinence score changes before and after delivery between the groups, and to look for any relationship between the clinical and EMG findings.

METHODS

Multichannel surface EMG was detected during maximal contractions in three sessions: (i) during pregnancy, (ii) 6 weeks after delivery and (iii) 1 year after delivery. Women were divided into two groups: cesarean section and vaginal delivery.

RESULTS

External anal sphincter EMG amplitude decreases 6 weeks after vaginal deliveries from 10.1 to 8.6 μV with effect size of 0.4, but returns to baseline after 1 year. No differences were observed between groups in all other variables.

CONCLUSION

No differences were observed after 1 year in EMG activity between the two groups; however, a slight decrease of sphincter muscle amplitude was noted 6 weeks after vaginal delivery. The delivery mode does not have effect on the EAS amplitude 1 year after delivery. Incontinence score slightly increased in both groups after delivery, with no significant differences between the two groups. No association was observed between the increase of incontinence score and the decrease of EMG signal amplitude.

Sexual Activity and Dyspareunia 1 Year After Surgical Repair of Pelvic Organ Prolapse

OBJECTIVE

To describe sexual activity and risks for dyspareunia after pelvic organ prolapse surgery.

METHODS

This was a secondary analysis of data from four randomized trials conducted between 2002 and 2018. Standard assessments and validated measures of sexual function were assessed at baseline and at 12 months postoperatively. Anterior apical surgeries were grouped by approach: transvaginal native tissue repairs, transvaginal mesh or graft-augmented repairs, and abdominal sacrocolpopexy. Additional surgeries, which included posterior repair, hysterectomy, and slings, were analyzed. Bivariate analyses and logistic regression models identified risk factors for postoperative dyspareunia.

RESULTS

Of the 1,337 women enrolled in the trials, 932 had sufficient outcome data to determine dyspareunia status. Of these before surgery, 445 (47.8%) were sexually active without dyspareunia, 89 (9.6%) were sexually active with dyspareunia, 93 (10.0%) were not sexually active owing to fear of dyspareunia, and 305 (32.7%) were not sexually active for other reasons. At 12 months, dyspareunia or fear of dyspareunia was present in 63 of 627 (10.0%); occurred de novo in 17 of 445 (3.8%) and resolved in 136 of 182 (74.7%). Multivariable regression demonstrated baseline dyspareunia as the only factor associated with postoperative dyspareunia (adjusted odds ratio 7.8, 95% CI 4.2-14.4). No other factors, including surgical approach, were significantly associated with postoperative dyspareunia. Too few had de novo dyspareunia to perform modeling.

CONCLUSION

Dyspareunia is common in one in five women before undergoing prolapse surgery. Surgical repair resolves dyspareunia in three out of four women with low rates of de novo dyspareunia at less than 4%. Preoperative dyspareunia appears to be the only predictor of postoperative dyspareunia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00065845, NCT00460434, NCT00597935, and NCT01802281.

The Role of Obstetric Factors, miRNA-30d and miRNA-181a in Postpartum Women with Pelvic Organ Prolapse

Background

The diagnosis of postpartum pelvic organ prolapse (POP) relies on symptoms combined with pelvic organ prolapse-quantification (POP-Q) and lacks serological indicators. The objective of this study was to assess serum elastin, type I collagen, miRNA-30d, and miRNA-181a in the early postpartum period to identify hematologic predictors of POP.

Material and Methods

The study included 1013 42- to 60-day-postpartum women who had delivered at Quanzhou Women's and Children's Hospital from October 1, 2016, to October 31, 2017. This study was performed in accordance with the Declaration of Helsinki. The pregnancy and childbirth characteristics and pelvic floor function were evaluated. Forty cases with and without POP were matched, and serum elastin and type I collagen were determined by enzyme-linked immunosorbent assay (ELISA). Reverse-transcription polymerase chain reaction (RT-PCR) was used to detect miRNA-30d and miRNA-181a in 15 pairs.

Results

Of the 1013 women recruited, 699 (69.00%) were diagnosed with POP. The mean age was 29.00 years old, and the mean body mass index (BMI) was 22.6 kg/m². In the univariate analysis, age ≥35 years (OR, 1.449; 95% CI, 0.965, 2.298), postpartum BMI ≥ 24 (OR, 4.402; 95% CI, 2.657, 6.148), neonatal weight ≥4 kg (OR, 4.832; 95% CI, 1.373, 17.290) and vaginal delivery (OR, 2.751; 95% CI, 1.855, 4.081) were risk factors for postpartum POP. There were no significant differences in the concentrations of serum elastin and type I collagen between the groups (P=0.52; P=0.26). There were significant differences in the concentrations of miRNA-30d and miRNA-181a between the groups (P=0.004; P=0.003).

Conclusion

miRNA-30d and miRNA-181a tended to be increased in women with POP and could be potential clinical predictors.

Characterization of symptom severity and impact on four fecal incontinence phenotypes in women presenting for evaluation

AIM

To characterize symptom-specific distress and impact on quality of life (QOL) among women with urge, passive, and combined urge/passive fecal incontinence (FI) phenotypes. A secondary aim was to characterize FI symptom-specific distress and impact on women with a novel fourth phenotype, stress FI.

METHODS

Women with at least monthly FI from 2003 to 2017 were included. Participants completed the Modified Manchester Health Questionnaire (MMHQ) including MHQ and Fecal Incontinence Severity Index (FISI). Anorectal manometry (ARM) and endoanal ultrasound (EAUS) testing was performed. Total MHQ and FISI scores were compared across FI subtypes controlling for pertinent baseline covariates.

RESULTS

The cohort included 404 subjects, 220 meeting criteria for urge FI, 67 passive FI, and 117 combined urge/passive FI. On MHQ, women with combined urge/passive FI were most impacted (p < 0.01). FISI scores were significantly different from combined urge/passive FI having the greatest impact (38.1 ± 12.5) and urge FI (31.1 ± 11.3), p < 0.01 having the least. No differences were observed in ARM measurements or anal sphincter defects among the three groups (all p > 0.05). Twenty-nine subjects were identified with stress FI. There were no differences in overall MHQ or FISI scores or anal sphincter evaluation among the urge, passive, and stress FI groups (all p > 0.05).

CONCLUSION

Women with combined urge/passive FI have higher symptom distress and impact on QOL than urge or passive FI alone. Further research is needed to determine the significance of stress FI as a subtype and response to treatment.