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Harvie HS, Richter HE, Sung VW, Chermansky CJ, Menefee SA, Rahn DD, Amundsen CL, Arya LA, Huitema C, Mazloomdoost D, Thomas S. Trial Design for Mixed Urinary Incontinence: Midurethral Sling Versus Botulinum Toxin A. Urogynecology (Phila) 2024; 30:478-488. [PMID: 38212101 PMCID: PMC11058039 DOI: 10.1097/spv.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
IMPORTANCE Mixed urinary incontinence (MUI) is common and can be challenging to manage. OBJECTIVES We present the protocol design and rationale of a trial comparing the efficacy of 2 procedures for the treatment of women with MUI refractory to oral treatment. The Midurethral sling versus Botulinum toxin A ( MUSA) trial compares the efficacy of intradetrusor injection of 100 U of onabotulinimtoxinA (an office-based procedure directed at the urgency component) versus midurethral sling (MUS) placement (a surgical procedure directed at the stress component). STUDY DESIGN The MUSA is a multicenter, randomized trial of women with MUI electing to undergo procedural treatment for MUI at 7 clinical centers in the NICHD Pelvic Floor Disorders Network. Participants are randomized to either onabotulinumtoxinA 100 U or MUS. OnabotulinimtoxinA recipients may receive an additional injection between 3 and 6 months. Participants may receive additional treatment (including crossover to the alternative study intervention) between 6 and 12 months. The primary outcome is change from baseline in Urogenital Distress Inventory (UDI) at 6 months. Secondary outcomes include change in UDI at 3 and 12 months, irritative and stress subscores of the UDI, urinary incontinence episodes, predictors of poor treatment response, quality of life and global impression outcomes, adverse events, use of additional treatments, and cost effectiveness. RESULTS Recruitment and randomization of 150 participants is complete and participants are currently in the follow-up phase. CONCLUSIONS This trial will provide information to guide care for women with MUI refractory to oral treatment who seek surgical treatment with either onabotulinumtoxinA or MUS.
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Affiliation(s)
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University/Women and Infants Hospital, Providence, RI
| | | | - Shawn A Menefee
- Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, CA
| | - David D Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern, TX
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham
| | - Lily A Arya
- From the Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania
| | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Andy UU, Iriondo-Perez J, Carper B, Richter HE, Dyer KY, Florian-Rodriguez M, Napoe GS, Myers D, O'Shea M, Mazloomdoost D, Gantz MG. Dietary Intake and Symptom Severity in Women with Fecal Incontinence. Int Urogynecol J 2024:10.1007/s00192-024-05776-6. [PMID: 38656362 DOI: 10.1007/s00192-024-05776-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/04/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The goal of this study was to determine whether dietary fat/fiber intake was associated with fecal incontinence (FI) severity. METHODS Planned supplemental analysis of a randomized clinical trial evaluating the impact of 12-week treatment with percutaneous tibial nerve stimulation versus sham in reducing FI severity in women. All subjects completed a food screener questionnaire at baseline. FI severity was measured using the seven-item validated St. Mark's (Vaizey) FI severity scale. Participants also completed a 7-day bowel diary capturing the number of FI-free days, FI events, and bowel movements per week. Spearman's correlations were calculated between dietary, St. Mark's score, and bowel diary measures. RESULTS One hundred and eighty-six women were included in this analysis. Mean calories from fats were 32% (interquartile range [IQR] 30-35%). Mean dietary fiber intake was 13.9 ± 4.3 g. The percentage of calories from fats was at the higher end of recommended values, whereas fiber intake was lower than recommended for adult women (recommended values: calories from fat 20-35% and 22-28 g of fiber/day). There was no correlation between St. Mark's score and fat intake (r = 0.11, p = 0.14) or dietary fiber intake (r = -0.01, p = 0.90). There was a weak negative correlation between the number of FI-free days and total fat intake (r = -0.20, p = 0.008). Other correlations between dietary fat/fiber intake and bowel diary measures were negligible or nonsignificant. CONCLUSION Overall, in women with moderate to severe FI, there was no association between FI severity and dietary fat/fiber intake. Weak associations between FI frequency and fat intake may suggest a role for dietary assessment in the evaluation of women with FI.
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Affiliation(s)
- Uduak U Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3737 Market Street, 12Th Floor, Philadelphia, PA, 19104, USA.
| | - Jeniffer Iriondo-Perez
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, Durham, NC, USA
| | - Benjamin Carper
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, Durham, NC, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keisha Y Dyer
- Department of Obstetrics and Gynecology Kaiser Permanente, San Diego, CA, USA
| | - Maria Florian-Rodriguez
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G Sarah Napoe
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Deborah Myers
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Michele O'Shea
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Marie G Gantz
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, Durham, NC, USA
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Weinstein MM, Dunivan GC, Guaderrama NM, Richter HE. A Motion-based Device Urinary Incontinence Treatment: A Longitudinal Analysis at 18 and 24 Months. Int Urogynecol J 2024; 35:803-810. [PMID: 38252280 PMCID: PMC11052829 DOI: 10.1007/s00192-023-05721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024]
Abstract
INTRODUCTION AND HYPOTHESIS There are sparse data regarding the long-term efficacy of pelvic floor muscle training (PFMT) for the treatment of urinary incontinence (UI). The objective of this study was to evaluate the impact of an 8-week PFMT program guided by a motion-based intravaginal device versus a standard home program over 24 months. METHODS Between October 2020 and March 2021, a total of 363 women with stress or stress-predominant mixed UI were randomized and completed an 8-week PFMT program using a motion-based intravaginal device (intervention group) or a home program following written/video instructions (control group). Participants were not asked to continue training after the 8-week program. At 18 and 24 months' follow-up, the Urogenital Distress Inventory, short-form (UDI-6) and Patient Global Impression of Improvement (PGI-I) were collected. In the original trial, a total of 139 participants in each arm were needed to detect a 0.3 effect size (alpha = 0.05, power 0.8, one-tailed t test) in the difference in UDI-6 scores. RESULTS A total of 231 participants returned 24-month data. Mean age at 24 months was 51.7 ± 14.5 years, and mean BMI was 31.8 ± 7.4 kg/m2. Mean change in UDI-6 scores from baseline to 24 months was greater in the intervention group than the control group (-21.1 ± 24.5 vs -14.8 ± 19.4, p = 0.04). Reported improvement using PGI-I was greater in the intervention group than in the control group at 24 months (35% vs 22%, p = 0.03, OR 1.95(95% CI 1.08, 3.57). CONCLUSIONS Pelvic floor muscle training guided by a motion-based prescription intravaginal device yielded durable and significantly greater UI symptom improvement than a standard home program, even in the absence of continued therapy.
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Affiliation(s)
- Milena M Weinstein
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Female Pelvic Medicine and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Gena C Dunivan
- University of Alabama at Birmingham, Birmingham, AL, USA
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Asiimwe R, Knott B, Greene ME, Wright E, Bell M, Epstein D, Yates SD, Cheung MD, Gonzalez MV, Fry S, Boydston E, Clevenger S, Locke JE, George JF, Burney R, Arora N, Duncan VE, Richter HE, Gunn D, Freud AG, Little SC, Porrett PM. Inhibition of NFAT promotes loss of tissue resident uterine natural killer cells and attendant pregnancy complications in humans. bioRxiv 2024:2024.03.07.583906. [PMID: 38559147 PMCID: PMC10979847 DOI: 10.1101/2024.03.07.583906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Uterine natural killer cells (uNKs) are a tissue resident lymphocyte population that are critical for pregnancy success. Although mouse models have demonstrated that NK deficiency results in abnormal placentation and poor pregnancy outcomes, the generalizability of this knowledge to humans remains unclear. Here we identify uterus transplant (UTx) recipients as a human population with reduced endometrial NK cells and altered pregnancy phenotypes. We further show that the NK reduction in UTx is due to impaired transcriptional programming of NK tissue residency due to blockade of the transcription factor nuclear factor of activated T cells (NFAT). NFAT-dependent genes played a role in multiple molecular circuits governing tissue residency in uNKs, including early residency programs involving AP-1 transcription factors as well as TGFβ-mediated upregulation of surface integrins. Collectively, our data identify a previously undescribed role for NFAT in uterine NK tissue residency and provide novel mechanistic insights into the biologic basis of pregnancy complications due to alteration of tissue resident NK subsets in humans. One Sentence Summary Role of NFAT in uterine NK cell tissue residency.
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Chapman HL, Dholakia JJ, Marcrom S, Liang M, Richter HE. Treatment of Cervical Cancer Complicated by Advanced Pelvic Organ Prolapse: A Case Report. Urogynecology (Phila) 2024; 30:309-313. [PMID: 38484247 DOI: 10.1097/spv.0000000000001474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
ABSTRACT Concurrent cervical cancer with advanced pelvic organ prolapse is rare: there are no well-established treatment recommendations. It is hypothesized that chronic irritation, as with long-standing pelvic organ prolapse, may lead to dysplasia and human papillomavirus-independent carcinoma, which represents only 5% of cervical cancers. Two patients with complete uterine procidentia were referred to gynecologic oncology with cervical squamous cell carcinoma; both were clinically staged as International Federation of Gynaecology and Obstetrics IB3. Treatment planning was complicated by procidentia in both cases. Standard definitive treatment of locally advanced cervical cancer is radiation therapy and concurrent chemotherapy; however, the mobility and externalization of the target lesion raised concerns regarding anatomic reproducibility during radiation treatment. After multidisciplinary team discussion (gynecologic oncology, urogynecology, radiation oncology), surgical resection and co-management with gynecologic oncology and urogynecology were successfully performed for definitive management for both patients. Although rare, this case study demonstrates the importance of multidisciplinary coordination in these complex clinical scenarios.
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Affiliation(s)
| | | | - Samuel Marcrom
- Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Maggie Liang
- From the Departments of ∗Obstetrics and Gynecology
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McKenzie CM, Woolfolk CL, Rieger MM, White AB, Tuuli MR, Srinivas SK, Caughey AB, Tita A, Gregory WT, Richter HE, Cahill AG. Impact of the Duration of the Second Stage of Labor on Postpartum Pelvic Floor Symptoms. Urogynecology (Phila) 2024; 30:381-387. [PMID: 38484257 PMCID: PMC10947063 DOI: 10.1097/spv.0000000000001477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
IMPORTANCE The associated effect of duration of the second stage of labor (SSL) on pelvic floor symptoms development is not well studied. OBJECTIVE This study aimed to examine the association between duration of SSL and pelvic floor symptoms at 6 months postpartum among primiparous women. STUDY DESIGN A planned secondary analysis of a multicenter randomized trial evaluating the impact of immediate versus delayed pushing on vaginal delivery rates, maternal morbidity, and neonatal outcomes was conducted between 2014 and 2018. For pelvic floor arm participants, demographic, pelvic examination, and validated questionnaire data were collected postpartum. Primary outcome was change in Pelvic Floor Distress Inventory 20 (PFDI-20) score from immediate to 6 months postpartum. Secondary outcomes included changes in the Pelvic Floor Impact Questionnaire, Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire scores, and Pelvic Organ Prolapse Quantification measurements at 6 months postpartum. Participants were analyzed by SSL duration ≤60 minutes or >60 minutes. RESULTS Of the 2,414 trial participants, 767 (32%) completed pelvic floor assessments at 6 months. Pelvic Floor Distress Inventory 20 scores significantly improved at 6 months in the ≤60 minutes SSL group compared with >60 minutes SSL (-14.3 ± 48.0 and -3.2 ± 45.3, respectively; P = 0.04). Changes from immediate postpartum in total and subscale scores for other questionnaires at 6 months did not differ between groups. Prolapse stage did not differ between groups. Perineal body was significantly shorter in the >60 minutes SSL group (3.7 ± 0.7, 3.5 ± 0.8; P = 0.03). CONCLUSIONS Women with SSL >60 minutes experience less improvement in PFDI-20 scores at 6 months. Greater tissue and innervation trauma in those with SSL >60 minutes may explain persistently less improvement in PFDI-20 scores.
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Affiliation(s)
- Collin M. McKenzie
- Department of Women’s Health, Dell School of Medicine, University of Texas at Austin
| | - Candice L. Woolfolk
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis
| | - Mary M. Rieger
- Department of Women’s Health, Dell School of Medicine, University of Texas at Austin
| | - Amanda B. White
- Department of Women’s Health, Dell School of Medicine, University of Texas at Austin
| | - Methodius R. Tuuli
- Department of Obstetrics and Gynecology, The Warren Alpert School of Medicine of Brown University
- Women and Infants Hospital of Rhode Island
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Department of Obstetrics and Gynecology
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University
| | - Alan Tita
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology
- Center for Women’s Reproductive Health
| | - W. Thomas Gregory
- Department of Obstetrics and Gynecology, Oregon Health & Science University
| | - Holly E. Richter
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology
- Center for Women’s Reproductive Health
| | - Alison G. Cahill
- Department of Women’s Health, Dell School of Medicine, University of Texas at Austin
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Chapman HL, Edwards JT, Hadikusumo Harsono AA, Baecher K, Zhai G, Meyer I, Richter HE. Characteristics Associated With Recurrent Urinary Tract Infections: A Case-Control Study. Urogynecology (Phila) 2024; 30:239-244. [PMID: 38484237 DOI: 10.1097/spv.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
IMPORTANCE Recurrent urinary tract infections (rUTIs) affect 2-10% of adult women and are associated with a significant effect on quality of life, daily activities, and mental health. OBJECTIVE The aim of this study was to identify clinical characteristics associated with rUTIs among women seeking care for pelvic floor disorders at an academic tertiary urogynecology clinic. STUDY DESIGN A retrospective case-control study of women presenting to an academic tertiary urogynecology clinic was conducted. Cases were women with rUTIs, defined as ≥2 UTIs in 6 months or ≥3 within 1 year. Controls were women with no culture documented UTIs. Cases were matched 2:1 to controls by age and body mass index. Demographic and clinical characteristics were compared between cases and controls, and bivariate characteristics with P values ≤0.2 were assessed for an independent association with rUTIs by multivariable logistic regression. RESULTS A total of 285 cases with rUTIs were identified, and 150 matched controls had a mean (SD) age of 72 (11.8) years and a body mass index of 29.6 (6.7; calculated as weight in kilograms divided by height in meters squared). Multivariable analysis revealed that prolapse beyond the introitus (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.13-0.60), parity (OR, 1.33; 95% CI, 1.08-1.64), Charlson Comorbidity Index (OR, 1.66; 95% CI, 1.37-2.03), and postvoid residual volume ≥100 mL (OR, 4.05; 95% CI, 2.01, 8.18) were associated with rUTIs. CONCLUSIONS In this ambulatory urogynecologic population, prolapse through the introitus was negatively associated with rUTIs, whereas parity, increased medical comorbidities, and elevated postvoid residual volume were positively associated with rUTI. Future research should seek an increased understanding of these factors associated with rUTI to implement effective preventive strategies.
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Affiliation(s)
- Hannah L Chapman
- From the Department of Obstetrics and Gynecology; University of Alabama at Birmingham, Birmingham, AL
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Rahn DD, Richter HE, Sung VW, Hynan LS, Pruszynski JE. Characteristics Associated With Surgical Failure After Native Tissue Apical Prolapse Repair. Obstet Gynecol 2024; 143:312-319. [PMID: 38061041 PMCID: PMC10841579 DOI: 10.1097/aog.0000000000005478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/26/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair. METHODS This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosacral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with P <.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model. RESULTS One hundred eighty-six participants underwent surgery; 183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.86-0.98, P =.016). CONCLUSION Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT02431897.
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Affiliation(s)
- David D. Rahn
- University of Texas Southwestern Medical Center, Dept. of Obstetrics and Gynecology
| | - Holly E. Richter
- University of Alabama at Birmingham, Dept. of Obstetrics and Gynecology
| | - Vivian W. Sung
- Women & Infants Hospital of Rhode Island, Dept. of Obstetrics and Gynecology
| | - Linda S. Hynan
- University of Texas Southwestern Medical Center, Peter O’Donnell Jr. School of Public Health & Dept. of Psychiatry
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Powell TC, Meyer I, Redden DT, Maier J, Nguyen C, Richter HE. Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience. Urogynecology (Phila) 2023; 29:946-952. [PMID: 37195629 DOI: 10.1097/spv.0000000000001365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
IMPORTANCE Understanding patients' perceptions of symptoms and outcomes of urogynecologic surgery is essential for providing high-quality care. OBJECTIVE The aim of the study was to assess association of pain catastrophizing with pelvic floor symptom distress and impact, postoperative pain, and voiding trial in patients undergoing urogynecologic surgery. STUDY DESIGN Individuals whose self-identified gender was female and were undergoing surgery March 2020-December 2021 were included. Participants completed the Pain Catastrophizing Scale (range 0-52), Pelvic Floor Distress Inventory, and Pelvic Floor Impact Questionnaire preoperatively. Pain catastrophizing was score ≥30 and describes the tendency to magnify the overall threat of pain. Voiding trial failure was inability to void ≥2/3 of instilled volume (≤300 mL). The association between pain catastrophizing and symptom distress and impact was assessed with linear regression. A P < 0.05 is significant. RESULTS Three hundred twenty patients were included (mean age, 60 years, 87% White). Forty-six of 320 participants (14%) had a pain catastrophizing score ≥30. The pain catastrophizing group had higher body mass index (33 ± 12 vs 29 ± 5), more benzodiazepine use (26% vs 12%), greater symptom distress (154 ± 58 vs 108 ± 60), and greater urogenital (59 ± 29 vs 47 ± 28), colorectal (42 ± 24 vs 26 ± 23), and prolapse (54 ± 24 vs 36 ± 24) subscale scores, all P ≤ 0.02. The pain catastrophizing group had greater impact (153 ± 72 vs 72 ± 64, P < 0.01) and urogenital (60 ± 29 vs 34 ± 28), colorectal (36 ± 33 vs 16 ± 26), and prolapse (57 ± 32 vs 22 ± 27) subscale scores, P < 0.01. Associations remained controlling for confounders ( P < 0.01). The pain catastrophizing group had higher 10-point pain scores (8 vs 6, P < 0.01) and was more likely to report pain at 2 weeks (59% vs 20%, P < 0.01) and 3 months (25% vs 6%, P = 0.01). Voiding trial failure did not differ (26% vs 28%, P = 0.98). CONCLUSIONS Pain catastrophizing is associated with greater pelvic floor symptom distress and impact and postoperative pain but not voiding trial failure.
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Affiliation(s)
- T Clark Powell
- From the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology
| | - Isuzu Meyer
- From the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology
| | | | - Julia Maier
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Christine Nguyen
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Holly E Richter
- From the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology
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Meyer I, Blanchard CT, Szychowski JM, Richter HE. Five-year surgical outcomes of transvaginal apical approaches in women with advanced pelvic organ prolapse. Int Urogynecol J 2023; 34:2171-2181. [PMID: 37039859 DOI: 10.1007/s00192-023-05501-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/30/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION AND HYPOTHESIS In women with advanced prolapse, differences in vaginal apex anchoring sites may impact surgical outcomes over time. The primary aim was to compare 5-year surgical outcomes of uterosacral ligament suspension (ULS) versus sacrospinous ligament fixation (SSLF) in women with advanced (stage III-IV) prolapse. METHODS A secondary analysis was conducted in a subset of women with advanced prolapse from a multicenter randomized trial comparing ULS versus SSLF and its extended follow-up, using publicly accessible de-identified datasets. The primary outcome was time to failure, defined as any one of (1) apical descent > 1/3 into the vaginal canal or anterior/posterior compartment beyond the hymen, (2) bothersome vaginal bulge symptoms, or (3) re-treatment. Secondary outcomes include symptom severity measured by the Pelvic Organ Prolapse Distress Inventory (POPDI) and adverse events. RESULTS Of 285 women, 90/147 (61.2%) in ULS and 88/138 (63.8%) in SSLF had advanced prolapse. Baseline characteristics did not differ between groups except for median-vaginal deliveries (3.0 [2.0, 5.0] versus 3.0 [2.0, 4.0], p < 0.01). The median time to failure was 1.7 years ULS versus 2.0 years SSLF (p = 0.42). Surgical failure increased over time in both groups with no intergroup difference; by year 5, the estimated failure rate was 67.7% ULS versus 71.5% SSLF (adjusted difference -3.8; 95%CI [-21.9, 14.2]). No differences were noted in individual failure components (p > 0.05). POPDI scores improved over 5 years without intergroup difference (ULS -68.0 ± 61.1 versus SSLF -69.9 ± 60.3, adjusted difference -0.1 [-20.0, 19.9]). No difference in adverse events were observed (p > 0.05). CONCLUSION In women with advanced prolapse, surgical failure, symptom severity, and adverse events did not differ between ULS and SSLF over 5 years.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 35249, USA.
| | - Christina T Blanchard
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff M Szychowski
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 35249, USA
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Rahn DD, Richter HE, Sung VW, Hynan LS, Pruszynski JE. Effects of preoperative intravaginal estrogen on pelvic floor disorder symptoms in postmenopausal women with pelvic organ prolapse. Am J Obstet Gynecol 2023; 229:309.e1-309.e10. [PMID: 37244454 PMCID: PMC10683373 DOI: 10.1016/j.ajog.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/08/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Menopause and the decline in systemic estrogen are associated with the development of pelvic floor disorders, such as prolapse, urinary incontinence, overactive bladder, and vulvovaginal atrophy symptoms. Past evidence suggests that postmenopausal women with symptomatic prolapse gain benefit from the preoperative application of intravaginal estrogen, but it is unknown whether they would experience improvement in other pelvic floor symptoms when treated with intravaginal estrogen. OBJECTIVE This study aimed to determine the effects of intravaginal estrogen (compared with placebo) on stress and urgency urinary incontinence, urinary frequency, sexual function and dyspareunia, and vaginal atrophy symptoms and signs in postmenopausal women with symptomatic prolapse. STUDY DESIGN This was a planned ancillary analysis of a randomized, double-blind trial, "Investigation to Minimize Prolapse Recurrence Of the Vagina using Estrogen," which included participants with ≥stage 2 apical and/or anterior prolapse scheduled for transvaginal native tissue apical repair at 3 US sites. The intervention was 1 g conjugated estrogen intravaginal cream (0.625 mg/g) or identical placebo (1:1), inserted nightly for 2 weeks and then twice weekly for ≥5 weeks total before surgery and continued twice weekly for 1 year postoperatively. For this analysis, question responses were compared from participants' baseline and preoperative visits: lower urinary tract symptoms (Urogenital Distress Inventory-6 Questionnaire); sexual health questions, including dyspareunia (Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised); and atrophy-related symptoms (dryness, soreness, dyspareunia, discharge, and itching; each scored 1-4, 4 being quite a bit bothersome). Masked examiners assessed vaginal color, dryness, and petechiae (each scored 1-3, total range 3-9, with 9 being the most estrogenized appearing). Data were analyzed by intent to treat and "per protocol" (ie, those adherent with ≥50% of expected intravaginal cream use, per objective tube before and after weights). RESULTS Of 199 participants randomized (mean age of 65 years) and contributing baseline data, 191 had preoperative data. The characteristics were similar between groups. Total Urogenital Distress Inventory-6 Questionnaire scores showed minimal change during this median time of 7 weeks between baseline and preoperative visits, but for those with at least moderately bothersome baseline stress urinary incontinence (32 in the estrogen group and 21 in the placebo group), 16 (50%) in the estrogen group and 9 (43%) in the placebo group showed improvement (P=.78). In addition, 43% of participants in the estrogen group and 31% of participants in the placebo group showed improvement in urgency urinary incontinence (P=.41), and 41% of participants in the estrogen group and 26% of participants in the placebo group showed improvement in urinary frequency (P=.18). There was minimal change in the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised scores among sexually active women; dyspareunia rates did not differ between intravaginal estrogen and placebo at the preoperative assessment: 42% and 48%, respectively (P=.49). The maximum score for most bothersome atrophy symptom (among those with baseline symptoms and adherent to study cream) improved slightly more with intravaginal estrogen (adjusted mean difference, -0.33 points; 95% confidence interval, -0.98 to 0.31), but this was not statistically significant (P=.19). However, on examination, among adherent participants, objective signs of atrophy were more improved with intravaginal estrogen treatment (+1.54 vs +0.69; mean difference, 0.85; 95% confidence interval, 0.05-1.65; P=.01). CONCLUSION Despite objective changes in the vaginal epithelium consistent with increased estrogenization among drug-adherent participants, the results were inconclusive regarding whether 7 weeks of preoperative intravaginal estrogen cream in postmenopausal women with symptomatic pelvic organ prolapse was associated with improved urinary function, sexual function, dyspareunia symptoms, and other symptoms commonly attributed to atrophy. Additional study is needed.
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Affiliation(s)
- David D Rahn
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallax, TX.
| | - Holly E Richter
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Providence, RI
| | - Linda S Hynan
- Department of Psychiatry, Peter O'Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Jessica E Pruszynski
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallax, TX
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Rahn DD, Richter HE, Sung VW, Pruszynski JE, Hynan LS. Perioperative Vaginal Estrogen as Adjunct to Native Tissue Vaginal Apical Prolapse Repair: A Randomized Clinical Trial. JAMA 2023; 330:615-625. [PMID: 37581673 PMCID: PMC10427941 DOI: 10.1001/jama.2023.12317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/16/2023] [Indexed: 08/16/2023]
Abstract
Importance Surgical repairs of apical/uterovaginal prolapse are commonly performed using native tissue pelvic ligaments as the point of attachment for the vaginal cuff after a hysterectomy. Clinicians may recommend vaginal estrogen in an effort to reduce prolapse recurrence, but the effects of intravaginal estrogen on surgical prolapse management are uncertain. Objective To compare the efficacy of perioperative vaginal estrogen vs placebo cream on prolapse recurrence following native tissue surgical prolapse repair. Design, Setting, and Participants This randomized superiority clinical trial was conducted at 3 tertiary US clinical sites (Texas, Alabama, Rhode Island). Postmenopausal women (N = 206) with bothersome anterior and apical vaginal prolapse interested in surgical repair were enrolled in urogynecology clinics between December 2016 and February 2020. Interventions The intervention was 1 g of conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally nightly for 2 weeks and then twice weekly to complete at least 5 weeks of application preoperatively; this continued twice weekly for 12 months postoperatively. Participants underwent a vaginal hysterectomy (if uterus present) and standardized apical fixation (either uterosacral or sacrospinous ligament fixation). Main Outcomes and Measures The primary outcome was time to failure of prolapse repair by 12 months after surgery defined by at least 1 of the following 3 outcomes: anatomical/objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, subjective vaginal bulge symptoms, or repeated prolapse treatment. Secondary outcomes included measures of urinary and sexual function, symptoms and signs of urogenital atrophy, and adverse events. Results Of 206 postmenopausal women, 199 were randomized and 186 underwent surgery. The mean (SD) age of participants was 65 (6.7) years. The primary outcome was not significantly different for women receiving vaginal estrogen vs placebo through 12 months: 12-month failure incidence of 19% (n = 20) for vaginal estrogen vs 9% (n = 10) for placebo (adjusted hazard ratio, 1.97 [95% CI, 0.92-4.22]), with the anatomic recurrence component being most common, rather than vaginal bulge symptoms or prolapse repeated treatment. Masked surgeon assessment of vaginal tissue quality and estrogenization was significantly better in the vaginal estrogen group at the time of the operation. In the subset of participants with at least moderately bothersome vaginal atrophy symptoms at baseline (n = 109), the vaginal atrophy score for most bothersome symptom was significantly better at 12 months with vaginal estrogen. Conclusions and Relevance Adjunctive perioperative vaginal estrogen application did not improve surgical success rates after native tissue transvaginal prolapse repair. Trial Registration ClinicalTrials.gov Identifier: NCT02431897.
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Affiliation(s)
- David D. Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Holly E. Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Vivian W. Sung
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Providence
| | - Jessica E. Pruszynski
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Linda S. Hynan
- Department of Psychiatry, Peter O’Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas
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Robison K, Wohlrab K, Howe CJ, Richter HE, Sung V, Bevis KS, Luis C, McCourt C, Lowder J, Occhino J, Glaser G, Lokich E, Dunivan G, Brown A, Tunitsky-Bitton E, Wethington S, Chen CCG, Rahn D, Carlson M, Cram R, Raker C, Clark MA. Endometrial Cancer Surgery With or Without Concomitant Stress Urinary Incontinence Surgery. Obstet Gynecol 2023; 141:642-652. [PMID: 36897162 DOI: 10.1097/aog.0000000000005059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/13/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To compare quality of life (QOL) among patients with endometrial intraepithelial neoplasia or early-stage endometrial cancer and stress urinary incontinence (SUI) who chose to have concomitant surgery with cancer surgery alone. METHODS A multicenter, prospective cohort study was conducted across eight U.S. sites. Potentially eligible patients were screened for SUI symptoms. Those who screened positive were offered referral to urogynecology and incontinence treatment, including concomitant surgery. Participants were categorized into two groups: 1) concomitant cancer and SUI surgery or 2) cancer surgery alone. The primary outcome was cancer-related QOL as measured by the FACT-En (Functional Assessment of Cancer Therapy-Endometrial) (range 0-100; higher score indicates better QOL). The FACT-En and questionnaires assessing urinary symptom-specific severity and effects were assessed before surgery and 6 weeks, 6 months, and 12 months after surgery. Adjusted median regression accounting for clustering was used to examine the relationship between SUI treatment group and FACT-En scores. RESULTS Of 1,322 (53.1%) patients, 702 screened positive for SUI with 532 analyzed; 110 (21%) chose concomitant cancer and SUI surgery, and 422 (79%) chose cancer surgery alone. FACT-En scores increased for both the concomitant SUI surgery and cancer surgery-only groups from the preoperative to the postoperative period. After adjustment for timepoint and preoperative covariates, the median change in FACT-En score (postoperative-preoperative) was 1.2 points higher (95% CI -1.3 to 3.6) for the concomitant SUI surgery group compared with the cancer surgery-only group across the postoperative period. Median time until surgery (22 days vs 16 days; P <.001), estimated blood loss (150 mL vs 72.5 mL; P <.001), and operative time (185.5 minutes vs 152 minutes; P <.001) were all greater for the concomitant cancer and SUI surgery group compared with the cancer-only group, respectively. CONCLUSION Concomitant surgery did not result in improved QOL compared with cancer surgery alone for endometrial intraepithelial neoplasia and patients with early-stage endometrial cancer with SUI. However, FACT-En scores were improved in both groups.
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Affiliation(s)
- Katina Robison
- Women & Infants Hospital and Brown University, Providence, Rhode Island; the University of Alabama at Birmingham, Birmingham, Alabama; Washington University of St. Louis Hospital, St. Louis, Missouri; Mayo Clinic, Rochester, Minnesota; the University of New Mexico Hospital, Albuquerque, New Mexico; Hartford Hospital, Hartford, Connecticut; Johns Hopkins Hospital, Baltimore, Maryland; and the University of Texas Southwestern Medical Center, Dallas, Texas
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Tuuli MG, Gregory WT, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita ATN, Macones GA, Cahill AG, Richter HE. Effect of Second-Stage Pushing Timing on Postpartum Pelvic Floor Morbidity: A Randomized Controlled Trial. Obstet Gynecol 2023; 141:245-252. [PMID: 36603202 DOI: 10.1097/aog.0000000000005031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/07/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess whether immediate or delayed pushing in the second-stage results in higher risk of pelvic floor morbidity. METHODS This study was a planned secondary aim of a multicenter randomized clinical trial that included nulliparous patients at 37 weeks of gestation or greater in labor with neuraxial analgesia. Participants were randomized in the second stage to initiate pushing immediately or wait 60 minutes before pushing. Participants had pelvic floor assessments at 1-5 days postpartum, 6 weeks postpartum, and 6 months postpartum. Rates of perineal lacerations, pelvic organ prolapse quantification (POP-Q) measures, and scores on validated symptom-specific distress and quality-of-life questionnaires (PFDI-20 [Pelvic Floor Distress Inventory], PFIQ [Pelvic Floor Impact Questionnaire], FISI [Fecal Incontinence Severity Index], and MMHQ [Modified Manchester Health Questionnaire]) were compared. It was estimated that 630 participants would provide more than 80% power to detect a 40% difference in second-degree or greater perineal lacerations and approximately 80% power to detect a 40% difference in stage 2 or greater pelvic organ prolapse (POP). RESULTS Among 2,414 participants in the primary trial conducted between May 19, 2014, and December 16, 2017, 941 (39%) had pelvic floor assessments: 452 immediate pushing and 489 delayed pushing. The mean age was 24.8 years, and 93.4% had vaginal delivery. There were no significant differences in perineal lacerations at delivery and POP at 6 weeks and 6 months postpartum. Changes from baseline in total and subscale scores for the PFDI-20, the PFIQ, and the MMHQ were not significantly different at 6 weeks postpartum and 6 months postpartum. The change in FISI score was higher in the immediate pushing group at 6 months (2.9±5.7 vs 2.0±4.5, difference 0.9, P =.01), but less than the minimum important difference of 4. CONCLUSION Among nulliparous patients in the second stage with neuraxial analgesia, immediate pushing, compared with delayed pushing, did not increase perineal lacerations, POP-Q measures, or patient-reported pelvic floor symptoms at 6 weeks and 6 months postpartum. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT02137200.
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Affiliation(s)
- Methodius G Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, and Women & Infants Hospital of Rhode Island, Providence, Rhode Island; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; the Department of Obstetrics and Gynecology and the Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; the Department of Obstetrics and Gynecology and the Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, Texas
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Richter HE, Sridhar A, Nager CW, Komesu YM, Harvie HS, Zyczynski HM, Rardin C, Visco A, Mazloomdoost D, Thomas S. Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol 2023; 228:63.e1-63.e16. [PMID: 35931131 PMCID: PMC9790026 DOI: 10.1016/j.ajog.2022.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/19/2022] [Accepted: 07/26/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery in the Vaginal hysterectomy with Native Tissue Vault Suspension vs Sacrospinous Hysteropexy with Graft Suspension (Study for Uterine Prolapse Procedures Randomized Trial) trial, sacrospinous hysteropexy with graft (hysteropexy) resulted in a lower composite surgical failure rate than vaginal hysterectomy with uterosacral suspension over 5 years. OBJECTIVE This study aimed to identify factors associated with the rate of surgical failure over 5 years among women undergoing sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral suspension for uterovaginal prolapse. STUDY DESIGN This planned secondary analysis of a comparative effectiveness trial of 2 transvaginal apical suspensions (NCT01802281) defined surgical failure as either retreatment of prolapse, recurrence of prolapse beyond the hymen, or bothersome prolapse symptoms. Baseline clinical and sociodemographic factors for eligible participants receiving the randomized surgery (N=173) were compared across categories of failure (≤1 year, >1 year, and no failure) with rank-based tests. Factors with adequate prevalence and clinical relevance were assessed for minimally adjusted bivariate associations using piecewise exponential survival models adjusting for randomized apical repair and clinical site. The multivariable model included factors with bivariate P<.2, additional clinically important variables, apical repair, and clinical site. Backward selection determined final retained risk factors (P<.1) with statistical significance evaluated by Bonferroni correction (P<.005). Final factors were assessed for interaction with type of apical repair at P<.1. Association is presented by adjusted hazard ratios and further illustrated by categorization of risk factors. RESULTS In the final multivariable model, body mass index (increase of 5 kg/m2: adjusted hazard ratio, 1.7; 95% confidence interval, 1.3-2.2; P<.001) and duration of prolapse symptoms (increase of 1 year: adjusted hazard ratio, 1.1; 95% confidence interval, 1.0-1.1; P<.005) were associated with composite surgical failure, where rates of failure were 2.9 and 1.8 times higher in women with obesity and women who are overweight than women who have normal weight and women who are underweight (95% confidence intervals, 1.5-5.8 and 0.9-3.5) and 3.0 times higher in women experiencing >5 years prolapse symptoms than women experiencing ≤5 years prolapse symptoms (95% confidence interval, 1.8-5.0). Sacrospinous hysteropexy with graft had a lower rate of failure than hysterectomy with uterosacral suspension (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-1.0; P=.05). The interaction between symptom duration and apical repair (P=.07) indicated that failure was less likely after hysteropexy than hysterectomy for those with ≤5 years symptom duration (adjusted hazard ratio, 0.5; 95% confidence interval, 0.2-0.9), but not for those with >5 years symptom duration (adjusted hazard ratio, 1.0; 95% confidence interval 0.5-2.1). CONCLUSION Obesity and duration of prolapse symptoms have been determined as risk factors associated with surgical failure over 5 years from transvaginal prolapse repair, regardless of approach. Providers and patients should consider these modifiable risk factors when discussing treatment plans for bothersome prolapse.
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Affiliation(s)
- Holly E Richter
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.
| | | | | | | | | | - Halina M Zyczynski
- University of Pittsburgh, Magee-Women's Research Institute, Pittsburgh, PA
| | | | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Saucedo AM, Richter HE, Gregory WT, Woolfolk C, Tuuli MG, Lowder JL, Caughey AB, Srinivas SK, Tita ATN, Macones GA, Cahill AG. Intrapartum risk factors associated with pelvic organ prolapse at 6 months postpartum. Am J Obstet Gynecol MFM 2022; 4:100692. [PMID: 35853583 DOI: 10.1016/j.ajogmf.2022.100692] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pregnancy and childbirth are known risk factors associated with the development of pelvic organ prolapse; specific intrapartum risk factors are not well characterized. OBJECTIVE This study aimed to determine intrapartum factors associated with increased risk of pelvic organ prolapse identified after delivery. STUDY DESIGN A planned secondary analysis of a multicenter randomized clinical trial of delayed vs immediate pushing among nulliparous women at ≥37 weeks of gestation in labor with neuraxial analgesia was conducted at 6 academic and community hospitals in the United States. Intrapartum characteristics were identified, and Pelvic Organ Prolapse Quantification assessments at 6 weeks and 6 months after delivery were performed. The primary outcome was pelvic organ prolapse, defined as stage 2 or greater prolapse using the Pelvic Organ Prolapse Quantification assessment at 6 months. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, macrosomia, and maternal age. RESULTS Among the 941 women participating in the pelvic floor follow-up, 793 women had Pelvic Organ Prolapse Quantification assessments at 6 weeks with 91 of 793 women (11.5%) demonstrating stage 2 or greater prolapse. Of the 728 women followed up at 6 months, stage 2 or greater prolapse was identified in 58 of 728 women (8.0%). Prostaglandin use for induction of labor was associated with an increased risk at 6 months (adjusted odds ratio, 2.15; 95% confidence interval, 1.18-3.91; P<.01). The length and type (spontaneous vs induced) of the first stage of labor were not significantly associated with stage 2 or greater prolapse. Moreover, increased length of the second stage of labor and duration of pushing were not associated with stage 2 or greater prolapse. After adjusting for confounding factors, cesarean delivery was protective of pelvic organ prolapse at 6 months (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.90). CONCLUSION The management of the first and second stages of labor, including time length, was not associated with stage 2 or greater prolapse at 6 months. The findings that prostaglandin exposure was associated with increased risk likely were not directly affecting the risk of prolapse but may be surrogates for other labor features that deserve exploration. Cesarean delivery was associated with protection from stage 2 or greater pelvic organ prolapse at 6 months, consistent with previous literature.
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Gregory WT, Cahill AG, Woolfolk C, Lowder JL, Caughey AB, Srinivas SK, Tita AT, Tuuli MG, Richter HE. Impact of pushing timing on occult injury of levator ani: secondary analysis of a randomized trial. Am J Obstet Gynecol 2022; 226:718.e1-718.e10. [PMID: 35202591 PMCID: PMC9064971 DOI: 10.1016/j.ajog.2022.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Evidence of detachment of the levator ani muscle system is seen more frequently in patients with pelvic floor disorders. It has been suggested that passive descent of the fetus before pushing could be used to decrease operative vaginal delivery and levator ani muscle injury. OBJECTIVE This planned analysis aimed to determine whether immediate or delayed pushing was associated with an increased proportion of injury to the levator ani muscle system after the first delivery among nulliparous women. STUDY DESIGN The Optimizing Management of the Second Stage study was a multicenter randomized trial. Nulliparous women with term pregnancies and neuraxial analgesia were randomly assigned at complete cervical dilation to either immediate pushing or delayed pushing for 1 hour. A subset of participants consented to longitudinal objective pelvic floor assessments: (1) during postpartum stay (initial), (2) at 6 weeks (postpartum 1), and (3) at 6 months (postpartum 2) with transperineal 3-dimensional ultrasound. Following the completion of all visits by all subjects, saved 3-dimensional ultrasound volumes were assessed in a masked fashion. The outcome was "occult" levator ani muscle injury on the right or left, defined as a widening of the attachment of the levator ani to its origin utilizing the levator-urethra gap measurement. Measurements and proportions were compared between the 2 groups by study visit using the χ2 test or Fisher exact test for categorical variables and the t test or Mann-Whitney U test for continuous variables as appropriate. RESULTS Here, 941 of 2414 randomized subjects (39.0%) participated in the pelvic floor assessments: 452 in the immediate pushing group and 489 in the delayed pushing group. We obtained sonograms on 67%, 83%, and 77% of the pelvic floor assessment participants at the initial, postpartum 1, and postpartum-2 visits, respectively. Demographic and labor characteristics were comparable between the 2 groups; 94% of participants were non-Hispanic, and 50% of participants were Black. Levator ani muscle injury was noted in 77 participants (13.6%) at the initial visit, 99 (13.1%) at PP1, and 72 (10.6%) at PP2. There was no difference in injury between women in the immediate pushing group and women in the delayed pushing group. These findings did not change when the threshold (sensitivity) of levator ani muscle injury was adjusted to a less conservative measure. CONCLUSION Among nulliparous women at term with neuraxial analgesia, the rates of occult levator ani muscle injury were not different between women undergoing immediate pushing and women undergoing delayed pushing in the second stage of labor. Further research efforts are needed to understand the development and potential prevention of subsequent pelvic floor disorders.
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Zyczynski HM, Richter HE, Sung VW, Lukacz ES, Arya LA, Rahn DD, Visco AG, Mazloomdoost D, Carper B, Gantz MG. Percutaneous Tibial Nerve Stimulation vs Sham Stimulation for Fecal Incontinence in Women: NeurOmodulaTion for Accidental Bowel Leakage Randomized Clinical Trial. Am J Gastroenterol 2022; 117:654-667. [PMID: 35354778 PMCID: PMC8988447 DOI: 10.14309/ajg.0000000000001605] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To determine whether percutaneous tibial nerve stimulation (PTNS) is superior to sham stimulation for the treatment of fecal incontinence (FI) in women refractory to first-line treatments. METHODS Women aged 18 years or older with ≥3 months of moderate-to-severe FI that persisted after a 4-week run-in phase were randomized 2:1 (PTNS:sham stimulation) to 12 weekly 30-minute sessions in this multicenter, single-masked, controlled superiority trial. The primary outcome was change from baseline FI severity measured by St. Mark score after 12 weeks of treatment (range 0-24; minimal important difference, 3-5 points). The secondary outcomes included electronic bowel diary events and quality of life. The groups were compared using an adjusted general linear mixed model. RESULTS Of 199 women who entered the run-in period, 166 (of 170 eligible) were randomized, (111 in PTNS group and 55 in sham group); the mean (SD) age was 63.6 (11.6) years; baseline St. Mark score was 17.4 (2.7); and recording was 6.6 (5.5) FI episodes per week. There was no difference in improvement from baseline in St. Mark scores in the PTNS group when compared with the sham group (-5.3 vs -3.9 points, adjusted difference [95% confidence interval] -1.3 [-2.8 to 0.2]). The groups did not differ in reduction in weekly FI episodes (-2.1 vs -1.9 episodes, adjusted difference [95% confidence interval] -0.26 [-1.85 to 1.33]). Condition-specific quality of life measures did not indicate a benefit of PTNS over sham stimulation. Serious adverse events occurred in 4% of each group. DISCUSSION Although symptom reduction after 12 weeks of PTNS met a threshold of clinical importance, it did not differ from sham stimulation. These data do not support the use of PTNS as conducted for the treatment of FI in women.
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Affiliation(s)
- Halina M. Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh/ Magee-Womens Research Institute, Pittsburgh, PA
| | - Holly E. Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Vivian W. Sung
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women’s & Infants Hospital, Providence, RI
| | - Emily S. Lukacz
- Department of Obstetrics, Gynecology & Reproductive Sciences, UC San Diego Health, San Diego, CA
| | - Lily A. Arya
- Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, PA
| | - David D. Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anthony G. Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Benjamin Carper
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
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Gregory T, Cahill AG, Woolfolk C, Arya LA, Lowder JL, Caughey AB, Srinivas SK, Tita AT, Tuuli MG, Richter HE. Impact of Pushing Timing on Occult Injury of Levator Ani: a Multicenter Randomized Controlled Trial. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gregory T, Cahill AG, Woolfolk C, Arya LA, Lowder JL, Caughey AB, Srinivas SK, Tita AT, Tuuli MG, Richter HE. Association of lower degree perineal lacerations at delivery and occult injury of levator ani muscles. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Saucedo AM, Tuuli MG, Gregory T, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita AT, Macones GA, Richter HE, Cahill AG. Intrapartum Risk Factors for Pelvic Organ Prolapse Postpartum. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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22
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Weinstein MM, Pulliam SJ, Keyser L, Richter HE. Use of a motion-based digital therapeutic in women with fecal incontinence: A pilot study. Neurourol Urodyn 2021; 41:475-481. [PMID: 34897780 PMCID: PMC9300000 DOI: 10.1002/nau.24854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/23/2021] [Accepted: 11/08/2021] [Indexed: 11/06/2022]
Abstract
AIMS There is limited data addressing the value of vaginal biofeedback (VBF) on fecal incontinence (FI) symptoms. The objective of this pilot study was to evaluate whether use of a motion-based VBF device and app was effective for at-home treatment of women with FI. We hypothesized that VBF would result in improvement in FI symptoms. METHODS A single-arm 10-week prospective pilot trial in women with FI was conducted using the VBF device. The primary outcome was change in St. Mark's score from baseline to week 10. Secondary outcomes included change in 2-week bowel diary and FI quality of life (FIQoL). Statistical analysis included paired t test and Wilcoxon's signed-rank test. RESULTS Of 29 enrolled women, 27 had data available for analysis. Mean (±SD) age was 60.9 (±14.4). 63% (17) subjects were White, 33% (9) were Black. Mean St. Mark's score was 14.6 (±4.4) at baseline and 11.6 (±5.1) at 10-weeks (p = 0.005). Changes in the total FIQol, and three of four subsets of the FIQoL scores were also significantly improved (p < 0.001). Bowel diary showed decrease in FI episodes, baseline 8.4 (±8.73) to 10 weeks 4.8 (±3.79), (p = 0.052). CONCLUSIONS In this pilot study, there was significant improvement in FI symptom-specific severity and quality of life using a vaginal, motion-based device for biofeedback. A larger study is needed to better understand the value of this device, which may be useful for women who prefer a vaginal device, which can be utilized at home compared with standard anal biofeedback for treatment of FI in the clinical setting.
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Affiliation(s)
- Milena M Weinstein
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Female Pelvic Medicine and Reconstructive Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Samantha J Pulliam
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Tufts University School of Medicine, Renovia Inc., Boston, Massachusetts, USA
| | - Laura Keyser
- Renovia Inc., Boston, MA, USA.,Department of Physical Therapy, Andrews University, Berrien Spring, Michigan, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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23
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Bowen ST, Moalli PA, Abramowitch SD, Lockhart ME, Weidner AC, Ferrando CA, Nager CW, Richter HE, Rardin CR, Komesu YM, Harvie HS, Mazloomdoost D, Sridhar A, Gantz MG. Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria. Am J Obstet Gynecol 2021; 225:506.e1-506.e28. [PMID: 34087229 PMCID: PMC8578187 DOI: 10.1016/j.ajog.2021.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/13/2021] [Accepted: 05/26/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies. OBJECTIVE This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse. STUDY DESIGN This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging-based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests. RESULTS Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, -12 mm; 95% confidence interval, -19 to -6) and perineal body (difference, -7 mm; 95% confidence interval, -11 to -4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8-16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7-15). CONCLUSION The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.
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Affiliation(s)
- Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Research Institute, Pittsburgh, PA.
| | | | - Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Charles W Nager
- Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego Health, San Diego, CA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Charles R Rardin
- Division of Urogyneology, Alpert Medical School of Brown University, Providence, RI
| | - Yuko M Komesu
- University of New Mexico, University of New Mexico, Albuquerque, NM
| | - Heidi S Harvie
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
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24
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Abstract
Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA.
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
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25
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Erekson E, Menefee S, Whitworth RE, Amundsen CL, Arya LA, Komesu YM, Ferrando CA, Zyczynski HM, Sung VW, Rahn DD, Tan-Kim J, Mazloomdoost D, Gantz MG, Richter HE. The Design of a Prospective Trial to Evaluate the Role of Preoperative Frailty Assessment in Older Women Undergoing Surgery for the Treatment of Pelvic Organ Prolapse: The FASt Supplemental Trial. Female Pelvic Med Reconstr Surg 2021; 27:e106-e111. [PMID: 32217922 PMCID: PMC7381379 DOI: 10.1097/spv.0000000000000833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We present the rationale for and the design of a prospective trial to evaluate the role of preoperative frailty and mobility assessments in older women undergoing surgery for the treatment of pelvic organ prolapse (POP) as a planned prospective supplemental trial to the ASPIRe (Apical Suspension Repair for Vault Prolapse In a Three-Arm Randomized Trial Design) trial. The Frailty ASPIRe Study (FASt) examines the impact of preoperative frailty and mobility on surgical outcomes in older women (≥65 years) participating in the ASPIRe trial. The primary objective of FASt is to determine the impact of preoperative age, multimorbidity, frailty, and decreased mobility on postoperative outcomes in older women (≥65 years old) undergoing surgery for POP. METHODS The selection of the preoperative assessments, primary outcome measures, and participant inclusion is described. Frailty and mobility measurements will be collected at the preoperative visit and include the 6 Robinson frailty measurements and the Timed Up and Go mobility test. The main outcome measure in the FASt supplemental study will be moderate to severe postoperative adverse events according to the Clavien-Dindo Severity Classification. CONCLUSIONS This trial will assess impact of preoperative age, multimorbidity, frailty, and decreased mobility on postoperative outcomes in older women (≥65 years old) undergoing surgical procedures for the correction of apical POP. Information from this trial may help both primary care providers and surgeons better advise/inform women on their individual risks of surgical complications and provide more comprehensive postoperative care to women at highest risk of complications.
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Affiliation(s)
- Elisabeth Erekson
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Shawn Menefee
- University of California, San Diego, and Kaiser Permanente, San Diego, CA
| | | | | | - Lily A Arya
- University of Pennsylvania, Philadelphia, PA
| | - Yuko M Komesu
- University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Cecile A Ferrando
- Department of Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Halina M Zyczynski
- The Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA
| | - Vivian W Sung
- Alpert Medical School of Brown University, Providence, RI
| | - David D Rahn
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Jasmine Tan-Kim
- University of California, San Diego, and Kaiser Permanente, San Diego, CA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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26
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Sanses TVD, Pearson S, Davis D, Chen CCG, Bentzen S, Guralnik J, Richter HE, Ryan AS. Physical performance measures in older women with urinary incontinence: pelvic floor disorder or geriatric syndrome? Int Urogynecol J 2020; 32:305-315. [PMID: 33201269 PMCID: PMC7856110 DOI: 10.1007/s00192-020-04603-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/04/2020] [Indexed: 12/02/2022]
Abstract
Objective: To evaluate physical performance measures of mobility and functional impairments and assess their association with urinary incontinence (UI) severity and impact on quality of life among older women with UI. Methods: In a cross-sectional pilot study, 20 women aged ≥ 70 years with UI completed UI questionnaires (Global Impression of Severity, Incontinence Impact Questionnaire (IIQ-7)) and functional status evaluation. Functional status evaluation included the Modified Physical Performance Test (MPPT; range 0–36), Short Physical Performance Battery (SPPB; range 0–12), and other physical performance measures (e.g., Timed Up and Go [TUG]). MPPT and SPPB scores <32 and <10, respectively, indicated impaired mobility and function. Descriptive statistics and spearman correlation coefficients evaluated study variables and associations between UI and physical performance measures. Results: Women were 76.6±4.7 years old with mean body mass index 33.5±9.0 kg/m2. Mixed UI was the most prevalent (n=17; 85%), and 14 (70%) participants rated their UI as moderate or severe. Low MPPT (<32) and SPPB (<10) scores were present in 65% (n=13) and 35% (n=7) of participants, respectively. Lower MPPT score (r=−0.46; P=0.04) and worse TUG performance (r=0.50; P=0.03) were associated with greater UI impact on quality of life based on IIQ-7. SPPB did not correlate (P>0.05) with UI measures. Conclusions: Mobility and functional impairments are common among older women with UI. Associations between MPPT score, TUG performance with UI impact on quality of life suggest these physical performance measures could be markers of mobility and functional impairments in future research on UI in older women. Further research in utility of physical performance measures as markers of mobility and functional impairments in older women with urinary incontinence is warranted.
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Affiliation(s)
- Tatiana V D Sanses
- Department of Obstetrics and Gynecology, Howard University College of Medicine, Washington, DC, USA. .,Howard University Hospital, OBGYN 3C-16, 2041 Georgia Ave. NW, Washington, DC, 20060, USA.
| | - Sharee Pearson
- Department of Obstetrics and Gynecology, Howard University College of Medicine, Washington, DC, USA
| | - Derik Davis
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chi Chiung Grace Chen
- Department of Gynecology and Obstetrics, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Soren Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jack Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Alice S Ryan
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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27
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Hoke TP, Meyer I, Blanchard CT, Szychowski JM, Richter HE. Characterization of symptom severity and impact on four fecal incontinence phenotypes in women presenting for evaluation. Neurourol Urodyn 2020; 40:237-244. [PMID: 33080084 DOI: 10.1002/nau.24541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/29/2020] [Accepted: 10/05/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Tanya P Hoke
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christina T Blanchard
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeff M Szychowski
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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28
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Zyczynski HM, Richter HE, Sung VW, Arya LA, Lukacz ES, Visco AG, Rahn DD, Carper B, Mazloomdoost D, Gantz MG. Performance, acceptability, and validation of a phone application bowel diary. Neurourol Urodyn 2020; 39:2480-2489. [PMID: 32960998 DOI: 10.1002/nau.24520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/07/2020] [Indexed: 12/11/2022]
Abstract
AIMS To assess performance, acceptability, external validity, and reliability of a phone application electronic bowel diary (PFDN Bowel eDiary). METHODS Women reporting refractory accidental bowel leakage (ABL) were enrolled in a randomized, crossover trial evaluating paper versus eDiary documentation of bowel movements (BM) and fecal incontinence episodes (FIE). Events were characterized by the presence or absence of urgency and Bristol stool scale consistency. The eDiary entries were date/time stamped and prompted by twice-daily phone notifications. Women were randomized to complete up to three consecutive 14-day diaries in two sequences. Diary events were compared between formats using the Pearson correlation. System usability scale (SUS) assessed eDiary usability. The eDiary test-retest reliability was assessed with intraclass correlations (ICCs). RESULTS Paired diary data were available from 60/69 (87%) women 63.8 ± 9.8 years old with mean 13.2 BM per week and 6.5 FIE per week (nearly half with urgency). Among those providing diaries, adherence did not differ by paper or eDiary (93.3% vs. 95.0%). Notifications prompted 29.6% of eDiary entries, improving adherence from 70% to 95%. Paper and eDiaries were moderate to-strongly correlated for BMs per week (r = .61), urgency BMs per week (r = .76), FIE per week (r = .66), urgency FIE per week (r = .72). Test-retest reliability was good (ICC = .81 BMs per week, .79 urgency BMs per week, .74 FIE per week, and .62 urgency FIE per week). The mean SUS score was high, 82.3 ± 17.5 (range, 0-100) with 91.4% rating it easy to use, and 75.9% preferring the eDiary over paper. CONCLUSION The PFDN Bowel eDiary correlated well with paper diary was considered easy to use, preferred to paper diaries, had high rates of confirmed real-time diary completion that obviated staff data entry.
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Affiliation(s)
- Halina M Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh/Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women's and Infants Hospital, Providence, Rhode Island, USA
| | - Lily A Arya
- Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, UC San Diego Health Care System, San Diego, California, USA
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - David D Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, Texas, USA
| | - Benjamin Carper
- Biostatistics and Epidemiology Division, RTI International, Durham, NC, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Durham, NC, USA
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29
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Moalli PA, Bowen ST, Abramowitch SD, Lockhart ME, Ham M, Hahn M, Weidner AC, Richter HE, Rardin CR, Komesu YM, Harvie HS, Ridgeway BM, Mazloomdoost D, Shaffer A, Gantz MG. Methods for the defining mechanisms of anterior vaginal wall descent (DEMAND) study. Int Urogynecol J 2020; 32:809-818. [PMID: 32870340 PMCID: PMC7917148 DOI: 10.1007/s00192-020-04511-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The protocol and analysis methods for the Defining Mechanisms of Anterior Vaginal Wall Descent (DEMAND) study are presented. DEMAND was designed to identify mechanisms and contributors of prolapse recurrence after two transvaginal apical suspension procedures for uterovaginal prolapse. METHODS DEMAND is a supplementary cohort study of a clinical trial in which women with uterovaginal prolapse randomized to (1) vaginal hysterectomy with uterosacral ligament suspension or (2) vaginal mesh hysteropexy underwent pelvic magnetic resonance imaging (MRI) at 30-42 months post-surgery. Standardized protocols have been developed to systematize MRI examinations across multiple sites and to improve reliability of MRI measurements. Anatomical failure, based on MRI, is defined as prolapse beyond the hymen. Anatomic measures from co-registered rest, maximal strain, and post-strain rest (recovery) sequences are obtained from the "true mid-sagittal" plane defined by a 3D pelvic coordinate system. The primary outcome is the mechanism of failure (apical descent versus anterior vaginal wall elongation). Secondary outcomes include displacement of the vaginal apex and perineal body and elongation of the anterior wall, posterior wall, perimeter, and introitus of the vagina between (1) rest and strain and (2) rest and recovery. RESULTS Recruitment and MRI trials of 94 participants were completed by May 2018. CONCLUSIONS Methods papers which detail studies designed to evaluate anatomic outcomes of prolapse surgeries are few. We describe a systematic, standardized approach to define and quantitatively assess mechanisms of anatomic failure following prolapse repair. This study will provide a better understanding of how apical prolapse repairs fail anatomically.
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Affiliation(s)
- Pamela A Moalli
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee Women's Research Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Division of Urogynecology and Reconstructive Pelvic Surgery, Magee Women's Research Institute, Magee Women's Hospital of the University of Pittsburgh, 204 Craft Avenue, A320, Pittsburgh, PA, 15213, USA.
| | - Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Ham
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, Durham, NC, USA
| | - Michael Hahn
- Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego Health, San Diego, CA, USA
| | | | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Heidi S Harvie
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Beri M Ridgeway
- Division of Urogynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Amanda Shaffer
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, Durham, NC, USA
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, Durham, NC, USA
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30
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Kissane LM, Martin KD, Meyer I, Richter HE. Effect of darifenacin on fecal incontinence in women with double incontinence. Int Urogynecol J 2020; 32:2357-2363. [PMID: 32542466 DOI: 10.1007/s00192-020-04369-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/26/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To evaluate change in fecal incontinence symptom severity after 8 weeks of darifenacin therapy in patients with double incontinence-urgency urinary incontinence (UUI) and fecal incontinence. Important secondary outcomes included fecal incontinence symptom distress and impact on quality of life, fecal incontinence episodes, global impression of improvement and overactive bladder symptom distress and impact. METHODS Prospective open-label cohort study of women presenting primarily with UUI, diagnosed with double incontinence and electing antimuscarinic therapy for UUI. Women ≥ 18 years with moderate or greater bothersome UUI and fecal incontinence of liquid/solid stool with St. Marks (Vaizey) score ≥ 12 were included. Subjects were treated with darifenacin 15 mg daily for 8 weeks. The primary outcome was change in fecal incontinence symptom severity using the St. Marks (Vaizey) score after 8 weeks. Sample size was based on the minimally important difference of the St. Marks, -5, and standard deviation, ± 8.5; 30 subjects provided 80% power and type I error of 0.05, including a 15% attrition rate. RESULTS Thirty-two women were consented with mean baseline St. Marks (Vaizey) score of 18.0 ± 3.0. Mean age was 66.5 ± 10.3 years. Twenty-eight subjects (29/32, 87.5%) completed assessments. St. Marks (Vaizey) score significantly improved from 18.0 to 11.0 [mean difference - 7.0, 95% confidence interval (CI): -8.7, -5.3], and 19 subjects (19/32,67.9%) met the minimally important difference. Statistically significant improvements were also noted in fecal incontinence frequency, quality of life, and overactive bladder symptom bother and quality of life (all p < 0.01). CONCLUSIONS Darifenacin can be considered a highly effective early intervention in women suffering from double incontinence. CLINICAL TRIAL REGISTRATION Bladder Antimuscarinic Medication and Accidental Bowel Leakage (BAMA), https://clinicaltrials.gov/ct2/show/NCT03543566 , NCT03543566.
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Affiliation(s)
- Lindsay M Kissane
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, 1700 6th Ave S.WIC Rm 10382, Birmingham, AL, 35233, USA.
| | - Kimberly D Martin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, 1700 6th Ave S.WIC Rm 10382, Birmingham, AL, 35233, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, 1700 6th Ave S.WIC Rm 10382, Birmingham, AL, 35233, USA
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Meyer I, Whitworth RE, Lukacz ES, Smith AL, Sung VW, Visco AG, Ackenbom MF, Wai CY, Mazloomdoost D, Gantz MG, Richter HE. Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence. Int Urogynecol J 2020; 31:2155-2164. [PMID: 32146521 DOI: 10.1007/s00192-020-04271-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/18/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence. METHODS This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse. RESULTS Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II. CONCLUSIONS Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35249, USA.
| | - Ryan E Whitworth
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, University of California-San Diego Health Systems, San Diego, CA, USA
| | - Ariana L Smith
- Department of Surgery, Division of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Vivian W Sung
- Division of Urogynecology and Reconstructive Pelvic Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Anthony G Visco
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Mary F Ackenbom
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifford Y Wai
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Marie G Gantz
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35249, USA
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Abstract
Importance As surgical techniques evolve in the treatment of pelvic organ prolapse and patient preferences are better understood, more studies are investigating uterine-sparing procedures for efficacy, safety, and potentially improved quality of life. Much of the literature reflects the use of mesh material in uterine-sparing procedures, and there is a paucity of data regarding the safety and efficacy of native tissue uterine-sparing procedures for the treatment of pelvic organ prolapse. Objective To summarize existing evidence regarding objective and subjective outcomes of uterine-preserving procedures including the Manchester procedure (MP) as well as native tissue uterovaginal hysteropexy with repairs, namely, uterosacral hysteropexy (USH) and sacrospinous hysteropexy (SSH), compared with outcomes of total vaginal hysterectomy (TVH) with repairs for the management of uterovaginal prolapse. Evidence Acquisition A review of the literature included MEDLINE, Cochrane, and clinicaltrials.gov databases. Results Few level 1 data exist comparing outcomes of native tissue hysteropexy to vaginal hysterectomy for management of uterovaginal prolapse. In general, outcomes of the MP for the management of uterovaginal prolapse revealed that compared with TVH it is associated with shorter operative times, lower estimated blood loss and risk of blood transfusion with no difference in hospital stay, and similar quality of life and sexual function outcomes. Retrospective data suggest no difference with respect to recurrent prolapse of any compartment between USH and TVH with repairs. Level 1 data reveal that SSH has been shown to have similar 1-year outcomes and safety compared with TVH with native tissue suspension. Women with stage 4 prolapse who undergo an SSH may be at higher risk of recurrence and may benefit from an alternative method of apical prolapse repair. Conclusions and Relevance More level 1 data are needed in order to robustly understand long-term differences in outcomes between native tissue uterine-conserving versus vaginal hysterectomy surgical approaches in women with uterovaginal prolapse.
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Affiliation(s)
- Tanya P Hoke
- Clinical Instructor/Fellow, Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Jasmine Tan-Kim
- Voluntary Assistant Clinical Professor, Department of Reproductive Medicine, University of California, San Diego, La Jolla; Attending Physician, Division of Female Pelvic Medicine and Reconstructive Surgery Kaiser Permanente, San Diego, San Diego, CA
| | - Holly E Richter
- Professor and Research Director, Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
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Meyer I, Morgan SL, Markland AD, Szychowski JM, Richter HE. Pelvic floor disorder symptoms and bone strength in postmenopausal women. Int Urogynecol J 2020; 31:1777-1784. [PMID: 32114661 DOI: 10.1007/s00192-020-04254-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/04/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The current study is aimed at characterizing the association between pelvic floor disorder symptoms and bone strength reflecting a potential connective tissue pathophysiology in postmenopausal women. METHODS A cross-sectional study was conducted in postmenopausal women undergoing osteoporosis evaluation from 2007 to 2010. Urinary incontinence (UI) was defined as urinary leakage ≥2-3 times/week. UI types were defined using the 3 Incontinence Questionnaire. Fecal incontinence was defined as stool leakage ≥1/month, and pelvic organ prolapse as a positive response to "Do you have a bulge or something falling out that you can see or feel in your vaginal area?" Bone quality and quantity were assessed using the trabecular bone score (TBS) and bone mineral density respectively: bone strength was defined by combined quality/quantity index, low strength being equivalent to moderate to severe fracture risk; low quality as TBS ≤ 1.31; low quantity by T-score <-1 or on osteoporosis medication. RESULTS Of 681 subjects, 262 had low bone strength whereas 419 were normal using the combined quality/quantity bone assessment. Characteristics were similar except for age (low bone strength: 69.0 ± 8.2 vs normal: 65.0 ± 7.1, p < 0.01) and smoking (8.8% vs 3.3%, p < 0.01). Low bone strength was associated with any UI (adjusted odds ratio [aOR]: 1.48, 1.05-2.10), stress (aOR: 1.53, 1.06-2.21), and mixed (aOR :1.45, 1.02-2.05). Women with low bone quality had increased odds of UI (any, urgency, mixed), whereas none of the pelvic floor disorder symptoms was associated with low bone quantity. CONCLUSIONS Low bone strength defined by a combined quantity/quality index, as well as low bone quality alone, were associated with increased risk of UI.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL, 35233, USA.
| | - Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, UAB Osteoporosis Prevention and Treatment Clinic, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alayne D Markland
- Birmingham/Atlanta Geriatrics, Research, Education, and Clinical Center (GRECC) at the Birmingham VA Medical Center, Departments of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff M Szychowski
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL, 35233, USA
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Komesu YM, Dinwiddie DL, Richter HE, Lukacz ES, Sung VW, Siddiqui NY, Zyczynski HM, Ridgeway B, Rogers RG, Arya LA, Mazloomdoost D, Levy J, Carper B, Gantz MG. Defining the relationship between vaginal and urinary microbiomes. Am J Obstet Gynecol 2020; 222:154.e1-154.e10. [PMID: 31421123 DOI: 10.1016/j.ajog.2019.08.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/24/2019] [Accepted: 08/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although the vaginal and urinary microbiomes have been increasingly well-characterized in health and disease, few have described the relationship between these neighboring environments. Elucidating this relationship has implications for understanding how manipulation of the vaginal microbiome may affect the urinary microbiome and treatment of common urinary conditions. OBJECTIVE To describe the relationship between urinary and vaginal microbiomes using 16S rRNA gene sequencing. We hypothesized that the composition of the urinary and vaginal microbiomes would be significantly associated, with similarities in predominant taxa. STUDY DESIGN This multicenter study collected vaginal swabs and catheterized urine samples from 186 women with mixed urinary incontinence enrolled in a parent study and 84 similarly aged controls. Investigators decided a priori that if vaginal and/or urinary microbiomes differed between continent and incontinent women, the groups would be analyzed separately; if similar, samples from continent and incontinent women would be pooled and analyzed together. A central laboratory sequenced variable regions 1-3 (v1-3) and characterized bacteria to the genus level. Operational taxonomic unit abundance was described for paired vaginal and urine samples. Pearson's correlation characterized the relationship between individual operational taxonomic units of paired samples. Canonical correlation analysis evaluated the association between clinical variables (including mixed urinary incontinence and control status) and vaginal and urinary operational taxonomic units, using the Canonical correlation analysis function in the Vegan package (R version 3.5). Linear discriminant analysis effect size was used to find taxa that discriminated between vaginal and urinary samples. RESULTS Urinary and vaginal samples were collected from 212 women (mean age 53±11 years) and results from 197 paired samples were available for analysis. As operational taxonomic units in mixed urinary incontinence and control samples were related in canonical correlation analysis and since taxa did not discriminate between mixed urinary incontinence or controls in either vagina or urine, mixed urinary incontinence and control samples were pooled for further analysis. Canonical correlation analysis of vaginal and urinary samples indicated that that 60 of the 100 most abundant operational taxonomic units in the samples largely overlapped. Lactobacillus was the most abundant genus in both urine and vagina (contributing on average 53% to an individual's urine sample and 64% to an individual's vaginal sample) (Pearson correlation r=0.53). Although less abundant than Lactobacillus, other bacteria with high Pearson correlation coefficients also commonly found in vagina and urine included: Gardnerella (r=0.70), Prevotella (r=0.64), and Ureaplasma (r=0.50). Linear discriminant analysis effect size analysis identified Tepidimonas and Flavobacterium as bacteria that distinguished the urinary environment for both mixed urinary incontinence and controls as these bacteria were absent in the vagina (Tepidimonas effect size 2.38, P<.001, Flavobacterium effect size 2.15, P<.001). Although Lactobacillus was the most abundant bacteria in both urine and vagina, it was more abundant in the vagina (linear discriminant analysis effect size effect size 2.72, P<.001). CONCLUSION Significant associations between vaginal and urinary microbiomes were demonstrated, with Lactobacillus being predominant in both urine and vagina. Abundance of other bacteria also correlated highly between the vagina and urine. This inter-relatedness has implications for studying manipulation of the urogenital microbiome in treating conditions such as urgency urinary incontinence and urinary tract infections.
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Tuuli MG, Gregory T, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita AT, Cahill AG, Richter HE. 7: Impact of second stage pushing timing on maternal pelvic floor morbidity: Multicenter randomized controlled trial. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bliss DZ, Gurvich OV, Patel S, Meyer I, Richter HE. Self-management of accidental bowel leakage and interest in a supportive m-Health app among women. Int Urogynecol J 2019; 31:1133-1140. [PMID: 31875257 DOI: 10.1007/s00192-019-04192-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/18/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Self-management with clinician guidance is a cornerstone of successful conservative treatment for accidental bowel leakage (ABL). There are currently few resources to assist patients with that essential self-management. The purpose of this study was to describe self-management of ABL and explore interest in a mobile health application (m-Health app) for supporting ABL self-management among community-living women. METHODS Using an observational/descriptive design, women (18+ years) previously seen in a urogynecology clinic for ABL were mailed a survey containing eight multiple-choice questions and an open-ended prompt for comments. RESULTS Survey responses were received from 161 women (18% response rate). The highest percentage of participants was aged 61-70 years (39%). Nearly half of the participants (47%) "did not know anything" about ABL self-management before visiting a clinician. Only 4% "knew a lot." Of those who have been trying to self-manage their ABL (n = 132), 37% reported that it was not effective, and only 5% thought their self-management was "very effective." Half (50%) of the participants had "a lot of" interest in an m-Health app to support managing ABL, and 30% had "some" interest. The vast majority (89%) thought that it was "very important" to have ongoing guidance and support for self-managing ABL. CONCLUSIONS Before visiting a clinician, most women with ABL lacked knowledge about ABL self-management, and their self-management was not very effective. Women thought having guidance to self-manage ABL was important. There would be good interest among women in an m-Health app supporting self-management of ABL if one were created.
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Affiliation(s)
- Donna Z Bliss
- University of Minnesota School of Nursing, 5-140 Weaver Densford Hall, 308 Harvard Street, Minneapolis, MN, 55455, USA.
| | - Olga V Gurvich
- University of Minnesota School of Nursing, 5-140 Weaver Densford Hall, 308 Harvard Street, Minneapolis, MN, 55455, USA
| | - Sunita Patel
- Department Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Isuzu Meyer
- Department Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Holly E Richter
- Department Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Hoke TP, Berger AA, Pan CC, Jackson LA, Winkelman WD, High R, Volpe KA, Lin CP, Richter HE. Assessing patients' preferences for gender, age, and experience of their urogynecologic provider. Int Urogynecol J 2019; 31:1203-1208. [PMID: 31828405 DOI: 10.1007/s00192-019-04189-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Understanding patient preferences regarding provider characteristics is an under-explored area in urogynecology. This study aims to describe patient preferences for urogynecologic care, including provider gender, age, experience, and presence of medical trainees. METHODS This was a multicenter, cross-sectional, survey-based study assessing patient preferences with a voluntary, self-administered, anonymous questionnaire prior to their first urogynecology consult. A 5-point Likert scale addressing provider gender, age, experience, and presence of trainees was used. Descriptive statistics summarized patient characteristics and provider preferences. Chi-squared (or Fisher's exact) test was used to test for associations. RESULTS Six hundred fifteen women participated from eight sites including all geographic regions across the US; 70.8% identified as white with mean age of 58.5 ± 14.2 years. Urinary incontinence was the most commonly reported symptom (45.9%); 51.4% saw a female provider. The majority of patients saw a provider 45-60 years old (42.8%) with > 15 years' experience (60.9%). Sixty-five percent of patients preferred a female provider; 10% preferred a male provider. Sixteen percent preferred a provider < 45 years old, 36% preferred 45-60 years old, and 11% of patients preferred a provider > 60 years old. Most patients preferred a provider with 5-15 or > 15 years' experience (49% and 46%, respectively). Eleven percent preferred the presence of trainees while 24% preferred trainee absence. CONCLUSION Patient preferences regarding urogynecologic providers included female gender and provider age 45-60 years old with > 5 years' experience. Further study is needed to identify qualitative components associated with these preferences.
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Affiliation(s)
- Tanya P Hoke
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic, Reconstructive Surgery, University of Alabama at Birmingham, WIC Suite 10382, 619 19th Street South, 176F, Birmingham, AL, 35249-7333, USA.
| | - Alexander A Berger
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser San Diego, San Diego, CA, USA.,Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California-San Diego, San Diego, CA, USA
| | - Christine C Pan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lindsey A Jackson
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William D Winkelman
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rachel High
- Texas A & M Health Science Center, Temple, TX, USA.,Baylor Scott & White Health, Temple, TX, USA
| | - Katherine A Volpe
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Chee Paul Lin
- Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic, Reconstructive Surgery, University of Alabama at Birmingham, WIC Suite 10382, 619 19th Street South, 176F, Birmingham, AL, 35249-7333, USA
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Nager CW, Visco AG, Richter HE, Rardin CR, Rogers RG, Harvie HS, Zyczynski HM, Paraiso MFR, Mazloomdoost D, Grey S, Sridhar A, Wallace D. Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial. JAMA 2019; 322:1054-1065. [PMID: 31529008 PMCID: PMC6749543 DOI: 10.1001/jama.2019.12812] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Transvaginal mesh hysteropexy is an alternative option. OBJECTIVE To compare the efficacy and adverse events of vaginal hysterectomy with suture apical suspension and transvaginal mesh hysteropexy. DESIGN, SETTING, PARTICIPANTS At 9 clinical sites in the US Pelvic Floor Disorders Network, 183 postmenopausal women with symptomatic uterovaginal prolapse were enrolled in a randomized superiority clinical trial between April 2013 and February 2015. The study was designed for primary analysis when the last randomized participant reached 3 years of follow-up in February 2018. INTERVENTIONS Ninety-three women were randomized to undergo vaginal mesh hysteropexy and 90 were randomized to undergo vaginal hysterectomy with uterosacral ligament suspension. MAIN OUTCOMES AND MEASURES The primary treatment failure composite outcome (re-treatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival models. Secondary outcomes included operative outcomes and adverse events, and were evaluated with longitudinal models or contingency tables as appropriate. RESULTS A total of 183 participants (mean age, 66 years) were randomized, 175 were included in the trial, and 169 (97%) completed the 3-year follow-up. The primary outcome was not significantly different among women who underwent hysteropexy vs hysterectomy through 48 months (adjusted hazard ratio, 0.62 [95% CI, 0.38-1.02]; P = .06; 36-month adjusted failure incidence, 26% vs 38%). Mean (SD) operative time was lower in the hysteropexy group vs the hysterectomy group (111.5 [39.7] min vs 156.7 [43.9] min; difference, -45.2 [95% CI, -57.7 to -32.7]; P = <.001). Adverse events in the hysteropexy vs hysterectomy groups included mesh exposure (8% vs 0%), ureteral kinking managed intraoperatively (0% vs 7%), granulation tissue after 12 weeks (1% vs 11%), and suture exposure after 12 weeks (3% vs 21%). CONCLUSIONS AND RELEVANCE Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, vaginal mesh hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension did not result in a significantly lower rate of the composite prolapse outcome after 3 years. However, imprecision in study results precludes a definitive conclusion, and further research is needed to assess whether vaginal mesh hysteropexy is more effective than vaginal hysterectomy with uterosacral ligament suspension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01802281.
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Affiliation(s)
- Charles W. Nager
- Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego Health, San Diego, California
| | | | | | | | - Rebecca G. Rogers
- University of New Mexico, Albuquerque
- Dell Medical School, University of Texas at Austin
| | | | - Halina M. Zyczynski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Scott Grey
- Research Triangle International, Research Triangle Park, North Carolina
| | - Amaanti Sridhar
- Research Triangle International, Research Triangle Park, North Carolina
| | - Dennis Wallace
- Research Triangle International, Research Triangle Park, North Carolina
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Sung VW, Borello-France D, Newman DK, Richter HE, Lukacz ES, Moalli P, Weidner AC, Smith AL, Dunivan G, Ridgeway B, Nguyen JN, Mazloomdoost D, Carper B, Gantz MG. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial. JAMA 2019; 322:1066-1076. [PMID: 31529007 PMCID: PMC6749544 DOI: 10.1001/jama.2019.12467] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking. OBJECTIVE To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017. INTERVENTIONS Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207). MAIN OUTCOMES AND MEASURES The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms. RESULTS Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only). CONCLUSIONS AND RELEVANCE Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01959347.
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Affiliation(s)
- Vivian W. Sung
- The Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Diane Borello-France
- Department of Physical Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania
| | - Diane K. Newman
- The Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Holly E. Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Emily S. Lukacz
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, La Jolla
| | - Pamela Moalli
- Women’s Center for Bladder and Pelvic Health, Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alison C. Weidner
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Ariana L. Smith
- The Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia
| | - Gena Dunivan
- The Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque
| | - Beri Ridgeway
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - John N. Nguyen
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, Kaiser Permanente, Downey, California
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Benjamin Carper
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Marie G. Gantz
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, North Carolina
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Richter HE, Dunivan G, Brown HW, Andy U, Dyer KY, Rardin C, Muir T, McNevin S, Paquette I, Gutman RE, Quiroz L, Wu J. A 12-Month Clinical Durability of Effectiveness and Safety Evaluation of a Vaginal Bowel Control System for the Nonsurgical Treatment of Fecal Incontinence. Female Pelvic Med Reconstr Surg 2019; 25:113-119. [PMID: 30807411 DOI: 10.1097/spv.0000000000000681] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to characterize clinical success, impact on quality of life, and durability up to 1 year in women with fecal incontinence (FI) responsive to an initial test period with a trial vaginal bowel control system. METHODS This was a prospective open-label study in subjects with FI and successfully fit who underwent an initial 2-week trial period. Those achieving 50% or greater reduction in FI episodes were provided the long-term system. Primary outcome was success at 3 months defined as 50% or greater reduction in baseline FI episodes, also assessed at 6 and 12 months. Secondary outcomes included symptom impact measured with Fecal Incontinence Quality of Life scale, symptom severity by the St Mark's (Vaizey) questionnaire, Patient Global Impression of Improvement, and satisfaction. Adverse events were collected. Primary analysis was intention to treat (ITT). RESULTS Seventy-three subjects with baseline mean of 14.1 ± 12.15 FI episodes over 2 weeks entered the treatment period. Success rate at 3 months was 72.6% (53/73, P < 0.0001); per-protocol, 84.1% (53/63, P < 0.0001). Significant improvement in all Fecal Incontinence Quality of Life subscales and St Mark's questionnaire meeting minimally important differences was noted. Satisfaction was 91.7%, 89.7%, and 94.4% at 3, 6, and 12 months, respectively; 77.4%, 77.6%, and 79.6% were very much/much better on the Patient Global Impression of Improvement at 3, 6, and 12 months, respectively. Most common adverse event was vaginal wall injury, with most adverse events (90/134, 67%) occurring during fitting period. CONCLUSIONS In women with successful fitting and initial treatment response, durable efficacy was seen at 3, 6, and 12 months by objective and subjective measures, with favorable safety.
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Affiliation(s)
| | | | - Heidi W Brown
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Uduak Andy
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Robert E Gutman
- MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | | | - Jennifer Wu
- University of North Carolina, Chapel Hill, NC
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Arbuckle JL, Parden AM, Hoover K, Griffin RL, Richter HE. Prevalence and Awareness of Pelvic Floor Disorders in Female Adolescents Seeking Gynecologic Care. J Pediatr Adolesc Gynecol 2019; 32:288-292. [PMID: 30529498 DOI: 10.1016/j.jpag.2018.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/04/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE To determine the prevalence and awareness of pelvic floor disorder symptoms among female adolescents. DESIGN Cross-sectional study via a written, anonymous survey of adolescents. The survey was composed of validated measures for determination of symptom prevalence. SETTING Pediatric and adolescent gynecology clinic in the southeast United States. PARTICIPANTS Female adolescents ages 14-21 years. INTERVENTIONS None. MAIN OUTCOME MEASURES We used χ2 analyses for categorical variables and t test for continuous variables. RESULTS Two hundred sixteen questionnaires were completed. The mean age of respondents was 17.1 (±2.1) years and most respondents had at least heard about urinary (UI) and fecal incontinence (FI; 62.9%). The prevalence of any UI was 31.5%. Urgency UI (UUI) was reported by 15.7% and stress UI was reported by 6.9% of adolescents; 8.8% of participants experienced UUI and stress UI symptoms. FI and pelvic organ prolapse symptoms were reported by 0.9%. There were no differences in reported prevalence rates of UI (31.7% vs 27.9%), FI (1.4% vs 0%), or pelvic organ prolapse (1.4% vs 0%) between younger (14-17 years) and older (18-21 years) adolescent participants, respectively (all P > .05). Although UI was fairly prevalent among respondents, most stated that it had a minimal effect on daily living. CONCLUSION UI symptoms were common among female adolescents, with UUI being the most reported. Early education regarding pelvic floor disorder symptoms might lead to prevention or empowerment to seek treatment as adolescents age.
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Affiliation(s)
- Janeen L Arbuckle
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Alison M Parden
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kimberly Hoover
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Russell L Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
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Meriwether KV, Lockhart ME, Meyer I, Richter HE. Anal Sphincter Anatomy Prepregnancy to Postdelivery Among the Same Primiparous Women on Dynamic Magnetic Resonance Imaging. Female Pelvic Med Reconstr Surg 2019; 25:8-14. [PMID: 29068801 PMCID: PMC5916743 DOI: 10.1097/spv.0000000000000504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The authors used 2-dimensional images from pelvic 3 T magnetic resonance imaging (MRI) to characterize changes in the internal anal sphincter (IAS) and external anal sphincter (EAS) from prepregnancy to postdelivery in the same cohort. METHODS This secondary analysis studied a prospective cohort of women undergoing 3 T MRI before their first pregnancy and 6 or more months after delivery. Radial thickness was measured at 12, 3, 9, and 6 o'clock from axial proximal and mid views and oblique distal views of the IAS, and at 3 and 9 o'clock from oblique views of the EAS. Measurements were compared prepregnancy to postdelivery; 10 women had 80% power (α = 0.05) to detect a 0.85-mm change. RESULTS Nineteen women completed initial 3 T MRI, 15 achieved pregnancy and birth, and 10 completed postdelivery MRI (4 vaginal birth and 6 Cesarean delivery). Mean change in measurement from prepregnancy to postdelivery was -0.01 mm ± 1.03 mm for the distal 12 o'clock IAS (P = 0.98) and +0.19 ± 0.64 mm for the lateral EAS (P = 0.32). All prepregnancy and postdelivery women had discontinuous EA sphincters at 6 and 12 o'clock. There were no statistically significant changes from prepregnancy to postdelivery in any IAS or EAS location (all >0.05) for the entire cohort, those with vaginal birth, or after Cesarean. CONCLUSIONS Anal sphincter measurements on MRI did not change significantly in nulliparous women prepregnancy to postdelivery at any location, and the EAS was not measurable at 12 o'clock in any women at either time point, challenging classic concepts of EAS anatomy.
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Affiliation(s)
| | | | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
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Markland AD, Tangpricha V, Beasley TM, Vaughan CP, Richter HE, Burgio KL, Goode PS. Reply to: "Suggestions for Vitamin D Supplementation for Urgency Urinary Incontinence Study". J Am Geriatr Soc 2019; 67:1300-1301. [PMID: 30908591 DOI: 10.1111/jgs.15876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Alayne D Markland
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education and Clinical Center (GRECC).,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Vin Tangpricha
- Department of Medicine, Emory University, Atlanta, Georgia
| | - T Mark Beasley
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education and Clinical Center (GRECC).,School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Camille P Vaughan
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education and Clinical Center (GRECC).,Department of Medicine, Emory University, Atlanta, Georgia
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn L Burgio
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education and Clinical Center (GRECC).,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patricia S Goode
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education and Clinical Center (GRECC).,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Harvie HS, Honeycutt AA, Neuwahl SJ, Barber MD, Richter HE, Visco AG, Sung VW, Shepherd JP, Rogers RG, Jakus-Waldman S, Mazloomdoost D. Responsiveness and minimally important difference of SF-6D and EQ-5D utility scores for the treatment of pelvic organ prolapse. Am J Obstet Gynecol 2019; 220:265.e1-265.e11. [PMID: 30471259 DOI: 10.1016/j.ajog.2018.11.1094] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 11/03/2018] [Accepted: 11/15/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Utility preference scores are standardized, generic, health-related quality of life (HRQOL) measures that quantify disease severity and burden and summarize morbidity on a scale from 0 (death) to 1 (optimal health). Utility scores are widely used to measure HRQOL and in cost-effectiveness research. OBJECTIVE To determine the responsiveness, validity properties, and minimal important difference (MID) of utility scores, as measured by the Short Form 6D (SF-6D) and EuroQol (EQ-5D), in women undergoing surgery for pelvic organ prolapse (POP). MATERIALS AND METHODS This study combined data from 4 large, U.S., multicenter surgical trials enrolling 1321 women with pelvic organ prolapse. We collected condition-specific quality of life data using the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). A subset of women completed the SF6D; women in 2 trials also completed the EQ5D. Mean utility scores were compared from baseline to 12 months after surgery. Responsiveness was assessed using effect size (ES) and standardized response mean (SRM). Validity properties were assessed by (1) comparing changes in utility scores at 12 months between surgical successes and failures as defined in each study, and (2) correlating changes in utility scores with changes in the PFDI and PFIQ. MID was estimated using both anchor-based (SF-36 general health global rating scale "somewhat better" vs "no change") and distribution-based methods. RESULTS The mean SF-6D score improved 0.050, from 0.705 ± 0.126 at baseline to 0.761 ± 0.131 at 12 months (P < .01). The mean EQ-5D score improved 0.060, from 0.810 ± 0.15 at baseline to 0.868 ± 0.15 at 12 months (P < .01). The ES (0.13-0.61) and SRM (0.13-0.57) were in the small-to-moderate range, demonstrating the responsiveness of the SF-6D and EQ-5D similar to other conditions. SF-6D and EQ-5D scores improved more for prolapse reconstructive surgical successes than for failures. The SF-6D and EQ-5D scores correlated with each other (r = 0.41; n = 645) and with condition-specific instruments. Correlations with the PFDI and PFIQ and their prolapse subscales were in the low to moderate range (r = 0.09-0.38), similar to other studies. Using the anchor-based method, the MID was 0.026 for SF-6D and 0.025 for EQ-5D, within the range of MIDs reported in other populations and for other conditions. These findings were supported by distribution-based estimates. CONCLUSION The SF-6D and EQ-5D have good validity properties and are responsive, preference-based, utility and general HRQOL measures for women undergoing surgical treatment for prolapse. The MIDs for SF-6D and EQ-5D are similar and within the range found for other medical conditions.
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Affiliation(s)
- Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
| | | | - Simon J Neuwahl
- Clinical Research Network Coordination, RTI, Research Triangle Park, NC
| | - Matthew D Barber
- Department of Obstetrics and Gynecology, Cleveland, Cleveland, OH
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Brown, Providence, RI
| | - Jonathan P Shepherd
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca G Rogers
- Department of Obstetrics and Gynecology, University of New Mexico and Department of Women's Health, Dell Medical School, University of Texas, Austin, TX
| | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Markland AD, Tangpricha V, Beasley TM, Vaughan CP, Richter HE, Burgio KL, Goode PS. Comparing Vitamin D Supplementation Versus Placebo for Urgency Urinary Incontinence: A Pilot Study. J Am Geriatr Soc 2019; 67:570-575. [PMID: 30578542 PMCID: PMC6403014 DOI: 10.1111/jgs.15711] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To estimate the efficacy of vitamin D supplementation to reduce urgency urinary incontinence (UUI) episodes. DESIGN Pilot, two-arm, randomized trial conducted from 2013 to 2017. Interventions were 12 weeks of weekly oral 50,000 IU vitamin D3 or placebo. SETTING Academic, university-based outpatient clinic. PARTICIPANTS Community-dwelling postmenopausal women, 50 years or older, with at least three UUI episodes on 7-day bladder diary and serum vitamin 25-hydroxyvitamin D (25[OH]D) of 30 ng/mL or less. MEASUREMENTS The primary efficacy estimate was the percentage change in UUI episodes. Secondary estimates included changes in other lower urinary tract symptoms, along with exploratory subgroup analysis by race/ethnicity and obesity. RESULTS We randomized 56 women (aged 50-84 years; mean = 60.5 ± 8.2 years), 28 to vitamin D and 28 to placebo; 51 completed treatments. Mean serum 25(OH)D at baseline (21.2 ± 5.2 and 18.2 ± 5.6, P = .30) improved to 57.9 ± 16.3 ng/mL with vitamin D3 and 21.9 ± 8.2 ng/mL with placebo (P < .001). UUI episodes per 24-hour day decreased by 43.0% with vitamin D3 compared to 27.6% with placebo (P = .22). Among black women (n = 33), UUI episodes decreased by 63.2% with vitamin D3 compared to 22.9% with placebo (P = .03). Among obese women, UUI episodes decreased by 54.1% with vitamin D compared to 32.7% with placebo (P = .29). For all women, changes in voiding frequency (P = .40), nocturia (P = .40), urgency (P = .90), incontinence severity (P = .81), and overactive bladder symptom severity (P = .47) were not different between arms. CONCLUSIONS Postmenopausal women with UUI and vitamin D insufficiency demonstrated a greater than 40% decrease in UUI episodes, which did not reach statistical significance compared to placebo, except in the subset of black women. The results of this pilot study support further investigation of vitamin D3 alone or in combination with other treatments for UUI, particularly for women in higher-risk subgroups. J Am Geriatr Soc 67:570-575, 2019.
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Affiliation(s)
- Alayne D. Markland
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL and Atlanta, GA
- University of Alabama at Birmingham, Department of Medicine, Birmingham, AL
| | | | - T. Mark Beasley
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL and Atlanta, GA
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL
| | - Camille P. Vaughan
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL and Atlanta, GA
- Department of Medicine, Emory University, Atlanta, GA
| | - Holly E. Richter
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, AL
| | - Kathryn L. Burgio
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL and Atlanta, GA
- University of Alabama at Birmingham, Department of Medicine, Birmingham, AL
| | - Patricia S. Goode
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL and Atlanta, GA
- University of Alabama at Birmingham, Department of Medicine, Birmingham, AL
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Komesu YM, Richter HE, Carper B, Dinwiddie DL, Lukacz ES, Siddiqui NY, Sung VW, Zyczynski HM, Ridgeway B, Rogers RG, Arya LA, Mazloomdoost D, Gantz MG. The urinary microbiome in women with mixed urinary incontinence compared to similarly aged controls. Int Urogynecol J 2018; 29:1785-1795. [PMID: 29909556 PMCID: PMC6295358 DOI: 10.1007/s00192-018-3683-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/28/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION & HYPOTHESIS Previous studies have suggested that women with urinary incontinence have an altered urinary microbiome. We hypothesized that the microbiome in women with mixed urinary incontinence (MUI) differed from controls and tested this hypothesis using bacterial gene sequencing techniques. METHODS This multicenter study compared the urinary microbiome in women with MUI and similarly aged controls. Catheterized urine samples were obtained; v4-6 regions of the 16S rRNA gene were sequenced to identify bacteria. Bacterial predominance (> 50% of an individual's genera) was compared between MUI and controls. Bacterial sequences were categorized into "community types" using Dirichlet multinomial mixture (DMM) methods. Generalized linear mixed models predicted MUI/control status based on clinical characteristics and community type. Post-hoc analyses were performed in women < 51 and ≥ 51 years. Sample size estimates required 200 samples to detect a 20% difference in Lactobacillus predominance with P < 0.05. RESULTS Of 212 samples, 97.6% were analyzed (123 MUI/84 controls, mean age 53 ± 11 years). Overall Lactobacillus predominance did not differ between MUI and controls (45/123 = 36.6% vs. 36/84 = 42.9%, P = 0.36). DMM analyses revealed six community types; communities differed by age (P = 0.001). A High-Lactobacillus (89.2% Lactobacillus) community had a greater proportion of controls (19/84 = 22.6%, MUI 11/123 = 8.9%). Overall, bacterial community types did not differ in MUI and controls. However, post-hoc analysis of women < 51 years found that bacterial community types distinguished MUI from controls (P = 0.041); Moderate-Lactobacillus (aOR 7.78, CI 1.85-32.62) and Mixed (aOR 7.10, CI 1.32-38.10) community types were associated with MUI. Community types did not differentiate MUI and controls in women ≥ 51 years (P = 0.94). CONCLUSIONS Women with MUI and controls did not differ in overall Lactobacillus predominance. In younger women, urinary bacterial community types differentiated MUI from controls.
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Affiliation(s)
- Yuko M Komesu
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA.
| | - Holly E Richter
- Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin Carper
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, NC, USA
| | - Darrell L Dinwiddie
- Pediatrics and Clinical Translational Science Center, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, University of California San Diego, San Diego, CA, USA
| | | | - Vivian W Sung
- Obstetrics & Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Halina M Zyczynski
- Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Beri Ridgeway
- Obstetrics & Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca G Rogers
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA
- Obstetrics & Gynecology, Dell Medical School University of Texas Austin, Austin, TX, USA
| | - Lily A Arya
- Obstetrics & Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Donna Mazloomdoost
- Gynecologic Health and Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) National Institutes of Health (NIH), Bethesda, MD, USA
| | - Marie G Gantz
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, NC, USA
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Chen GD, Rizk DEE, Richter HE. Surgical repair of vesico-vaginal fistula: the need for an evidence-based approach. Int Urogynecol J 2018; 30:169-170. [PMID: 30467761 DOI: 10.1007/s00192-018-3828-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Gin-Den Chen
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, 110, Jianguo N Rd, Section 1, Taichung, 402, Taiwan.
| | - Diaa E E Rizk
- Department of Obstetrics and Gynecology, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
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Cahill AG, Srinivas SK, Tita ATN, Caughey AB, Richter HE, Gregory WT, Liu J, Woolfolk C, Weinstein DL, Mathur AM, Macones GA, Tuuli MG. Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial. JAMA 2018; 320:1444-1454. [PMID: 30304425 PMCID: PMC6583005 DOI: 10.1001/jama.2018.13986] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE It is unclear whether the timing of second stage pushing efforts affects spontaneous vaginal delivery rates and reduces morbidities. OBJECTIVE To evaluate whether immediate or delayed pushing results in higher rates of spontaneous vaginal delivery and lower rates of maternal and neonatal morbidities. DESIGN, SETTING, AND PARTICIPANTS Pragmatic randomized clinical trial of nulliparous women at or beyond 37 weeks' gestation admitted for spontaneous or induced labor with neuraxial analgesia between May 2014 and December 2017 at 6 US medical centers. The interim analysis suggested futility for the primary outcome and recruitment was terminated with 2414 of 3184 planned participants. Follow-up ended January 4, 2018. INTERVENTIONS Randomization occurred when participants reached complete cervical dilation. Immediate group participants (n = 1200) began pushing immediately. Delayed group participants (n = 1204) were instructed to wait 60 minutes. MAIN OUTCOMES AND MEASURES The primary outcome was spontaneous vaginal delivery. Secondary outcomes included total duration of the second stage, duration of active pushing, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, chorioamnionitis, endometritis, perineal lacerations (≥second degree), and a composite outcome of neonatal morbidity that included neonatal death and 9 other adverse outcomes. RESULTS Among 2414 women randomized (mean age, 26.5 years), 2404 (99.6%) completed the trial. The rate of spontaneous vaginal delivery was 85.9% in the immediate group vs 86.5% in the delayed group, and was not significantly different (absolute difference, -0.6% [95% CI, -3.4% to 2.1%]; relative risk, 0.99 [95% CI, 0.96 to 1.03]). There was no significant difference in 5 of the 9 prespecified secondary outcomes reported, including the composite outcome of neonatal morbidity (7.3% for the immediate group vs 8.9% for the delayed group; between-group difference, -1.6% [95% CI, -3.8% to 0.5%]) and perineal lacerations (45.9% vs 46.4%, respectively; between-group difference, -0.4% [95% CI, -4.4% to 3.6%]). The immediate group had significantly shorter mean duration of the second stage compared with the delayed group (102.4 vs 134.2 minutes, respectively; mean difference, -31.8 minutes [95% CI, -36.7 to -26.9], P < .001), despite a significantly longer mean duration of active pushing (83.7 vs 74.5 minutes; mean difference, 9.2 minutes [95% CI, 5.8 to 12.6], P < .001), lower rates of chorioamnionitis (6.7% vs 9.1%; between-group difference, -2.5% [95% CI, -4.6% to -0.3%], P = .005), and fewer postpartum hemorrhages (2.3% vs 4.0%; between-group difference, -1.7% [95% CI, -3.1% to -0.4%], P = .03). CONCLUSIONS AND RELEVANCE Among nulliparous women receiving neuraxial anesthesia, the timing of second stage pushing efforts did not affect the rate of spontaneous vaginal delivery. These findings may help inform decisions about the preferred timing of second stage pushing efforts, when considered with other maternal and neonatal outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02137200.
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Affiliation(s)
- Alison G. Cahill
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, Perelman School of Medicine, Maternal and Child Health Research Center, University of Pennsylvania, Philadelphia
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham
- Center for Women’s Reproductive Health, University of Alabama, Birmingham
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Holly E. Richter
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham
- Center for Women’s Reproductive Health, University of Alabama, Birmingham
| | - W. Thomas Gregory
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Jingxia Liu
- Division of Public Health Sciences, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Candice Woolfolk
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - David L. Weinstein
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Amit M. Mathur
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - George A. Macones
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St Louis, St Louis, Missouri
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Kissane LM, Meyer I, Martin KD, Tan JC, Miller K, Richter HE. Impact of age on mid- to long-term outcomes of transvaginal native tissue repair for apical vaginal prolapse. Neurourol Urodyn 2018; 37:2860-2866. [PMID: 30168627 DOI: 10.1002/nau.23803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022]
Abstract
AIMS To compare surgical success rates in older versus younger women a minimum of 3 years post transvaginal native tissue repair for apical prolapse. Post-operative symptom severity and quality of life improvement, surgical complications and retreatment were also examined. METHODS Women who underwent transvaginal native tissue repair for apical prolapse between 2011 and 2013 were eligible. Subjects completed the pelvic floor distress inventory (PFDI-20), pelvic floor impact questionnaire (PFIQ-7), and patient global impression of improvement (PGI-I), and were categorized as "younger" (age <70) or "older" (age ≥70). The primary outcome of surgical success was defined as the absence of bulge symptoms and no re-treatment for prolapse. RESULTS Of 641 eligible patients, response rate was 51.0%. 62.7% of subjects had hysterectomy prior to index surgery. Surgical success was noted in 72.9% of younger and 82.2% of older subjects (Adjusted odds ratio [aOR] 1.72, 95% CI [0.93, 3.17]). Older women had greater improvement from baseline in PFDI-20 score (-87.5 [IQR 74.0] vs -54.2 [IQR 80.2], P = 0.01). Retreatment rate and surgical complication rates were similar between groups (both P > 0.05). CONCLUSIONS Older and younger women had similar surgical success rates a minimum of 3 years post-operative; however, older women had a greater overall symptom severity improvement. This information may be helpful in counseling older women regarding surgical expectations and decision-making.
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Affiliation(s)
- Lindsay M Kissane
- University of Alabama at Birmingham, Division of Urogynecology and Pelvic Reconstructive Surgery, Birmingham, Alabama
| | - Isuzu Meyer
- University of Alabama at Birmingham, Division of Urogynecology and Pelvic Reconstructive Surgery, Birmingham, Alabama
| | - Kimberly D Martin
- University of Alabama at Birmingham, Department of Epidemiology, Birmingham, Alabama
| | - Jubilee C Tan
- University of Alabama at Birmingham, Division of Urogynecology and Pelvic Reconstructive Surgery, Birmingham, Alabama
| | - Kathryn Miller
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama
| | - Holly E Richter
- University of Alabama at Birmingham, Division of Urogynecology and Pelvic Reconstructive Surgery, Birmingham, Alabama
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50
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Rogers RG, Nolen TL, Weidner AC, Richter HE, Jelovsek JE, Shepherd JP, Harvie HS, Brubaker L, Menefee SA, Myers D, Hsu Y, Schaffer JI, Wallace D, Meikle SF. Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications. Int Urogynecol J 2018; 29:1101-1110. [PMID: 29802413 PMCID: PMC6046257 DOI: 10.1007/s00192-018-3666-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/25/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We compared treatment success and adverse events between women undergoing open abdominal sacrocolpopexy (ASC) vs vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. METHODS Participants underwent apical repair of stage 2-4 prolapse. Vaginal repair included uterosacral, sacrospinous, and iliococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen, and no retreatment up to 24 months. Adverse events were collected at multiple time points. Outcomes were analyzed using longitudinal mixed-effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, body mass index (BMI), initial Pelvic Organ Prolapse Quantification (POP-Q) stage, baseline scores, prior prolapse repair, and concurrent repairs. RESULTS Of women who met inclusion criteria (1022 of 1159 eligibile), 701 underwent vaginal repair. The ASC group (n = 321) was older, more likely white, had prior prolapse repairs, and stage 4 prolapse (all p < 0.05). While POP-Q measurements and symptoms improved in both groups, treatment success was higher in the ASC group [odds ratio (OR) 6.00, 95% confidence interval (CI) 3.45-10.44). The groups did not differ significantly in most questionnaire responses at 12 months and overall improvement in bowel and bladder function. By 24 months, fewer patients had undergone retreatment (2% ASC vs 5% VAR); serious adverse events did not differ significantly through 6 weeks (13% vs 5%, OR 2.0, 95% CI 0.9-4.7), and 12 months (26% vs 13%, OR 1.6, 95% CI 0.9-2.9), respectively. CONCLUSIONS Open sacrocolpopexy resulted in more successful prolapse treatment at 2 years.
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Affiliation(s)
- Rebecca G Rogers
- Department of Women's Health, Dell Medical School, University of Texas, 1301 W 38th Street, Suite 705, Austin, TX, 78756, USA.
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
| | | | - Alison C Weidner
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Eric Jelovsek
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jonathan P Shepherd
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda Brubaker
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Maywood, IL, USA
| | - Shawn A Menefee
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA, USA
| | - Deborah Myers
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Yvonne Hsu
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Joseph I Schaffer
- Department of Obstetrics and Gynecology, University of Texas, Southwestern, Dallas, TX, USA
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