Cost Effectiveness of Additional Preoperative Telephone Call to Increase Surgical Preparedness: Analysis of a Randomized Clinical Trial

INTRODUCTION AND HYPOTHESIS

There is a need for cost effective interventions that increase surgical preparedness in urogynecology.

METHODS

We performed an ancillary prospective economic evaluation of the Telehealth Intervention to Increase Patient Preparedness for Surgery (TIPPS) Trial, a randomized multicenter trial that evaluated the impact of a preoperative telehealth call on surgical preparedness in women undergoing urogynecologic surgery. A within-trial analysis from the health care sector and societal perspective was performed. Cost-effectiveness was computed from health care sector and societal perspectives, with an 8-week time horizon.

RESULTS

A total of 126 women were included in our analysis. QALYs gained were similar between groups (telehealth 0.1414 + 0.0249; usual care 0.1409 + 0.0179). The cumulative mean per-person costs at 8 weeks from the healthcare sector perspective were telehealth call: $8696 +/- 3341; usual care: $8473 +/- 3118 (p = 0.693) and from the societal perspective were telehealth call: $11,195 + 5191; usual care: $11,213 +/- 4869 (p = 0.944). The preoperative telehealth call intervention was not cost effective from the health care sector perspective with an ICER of $460,091/QALY (95%CI -$7,382,608/QALY, $7,673,961) using the generally accepted maximum willingness to pay threshold of $150,000/QALY (Neumann et al. N Engl J Med. 371(9):796-7, 2014). From the societal perspective, because incremental costs per QALY gained were negative $-35,925/QALY (95%CI, -$382,978/QALY, $317,226), results suggest that preoperative telehealth call dominated usual care.

CONCLUSIONS

A preoperative telehealth call is cost effective from the society perspective.

CLINICAL TRIAL REGISTRATION

Registered with http://ClinicalTrials.gov . Date of registration: March 26, 2019 Date of initial participant enrollment: June 5, 2019 URL: https://clinicaltrials.gov/ct2/show/record/NCT03890471 Clinical trial identification number: NCT03890471.

International urogynecological consultation chapter 4.1: definition of outcomes for pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

This manuscript of Chapter 4 of the International Urogynecological Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature and makes recommendations on the definition of success in the surgical treatment of pelvic organ prolapse.

METHODS

An international group containing seven urogynecologists performed an exhaustive search of the literature using two PubMed searches and using PICO methodology. The first search was from 01/01/2012-06/12/2022. A second search from inception to 7/24/2022 was done to access older references. Publications were eliminated if not relevant to the clinical definition of surgical success for the treatment of POP. All abstracts were reviewed for inclusion and any disagreements were adjudicated by majority consensus of the writing group. The resulting list of articles were used to inform a comprehensive review and creation of the definition of success in the surgical treatment of POP.

OUTCOMES

The original search yielded 12,161 references of which 45 were used by the writing group. Ultimately, 68 references are included in the manuscript. For research purposes, surgical success should be primarily defined by the absence of bothersome patient bulge symptoms or retreatment for POP and a time frame of at least 12 months follow-up should be used. Secondary outcomes, including anatomic measures of POP and related pelvic floor symptoms, should not contribute to a definition of success or failure. For clinical practice, surgical success should primarily be defined as the absence of bothersome patient bulge symptoms. Surgeons may consider using PASS (patient acceptable symptom state) or patient goal attainment assessments, and patients should be followed for a minimum of at least one encounter at 6-12 weeks post-operatively. For surgeries involving mesh longer-term follow-up is recommended.

Surgeon Counseling Regarding Return to Sexual Activity After Pelvic Reconstructive Surgery

IMPORTANCE

Patients highly value surgeon counseling regarding the first sexual encounters after pelvic reconstructive surgery.

OBJECTIVES

We performed a qualitative analysis of usual surgeon counseling regarding return to sexual activity after surgery for pelvic organ prolapse and/or urinary incontinence.

METHODS

Participating surgeons provided a written description of their usual patient counseling regarding return to sexual activity after pelvic organ prolapse or urinary incontinence surgery. Counseling narratives were coded for major themes by 2 independent reviewers; disagreements were arbitrated by the research team. Analysis was performed utilizing Dedoose software and continued until thematic saturation was reached.

RESULTS

Twenty-two surgeons participated, and thematic saturation was reached. Six major themes were identified: "Safety of Intercourse," "Specific Suggestions," "Surgical Sequelae," "Patient Control," "Partner Related," "Changes in Experience," and "No Communication." Nearly all participating surgeons included counseling on the safety of intercourse and reassurance that intercourse would not harm the surgical repair. Specific suggestions included different positions, use of lubrication, vaginal estrogen use, specific products/vendors, alternatives to (vaginal) intercourse, and the importance of foreplay. Surgical sequelae discussion included possible interventions for complications, such as persistent sutures in the vagina, abnormal bleeding, or de novo dyspareunia. Counseling regarding changes to the patient's sexual experience ranged from suggestion of improvement to an anticipated negative experience. Surgeons more commonly advised patients that their sexual experience would be worsened or different from baseline; discussion of improvement was less frequent.

CONCLUSIONS

Surgeon counseling regarding the postoperative return to sexual activity varies among pelvic reconstructive surgeons. Most reassure patients that intercourse is safe after surgery.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review

OBJECTIVE

To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated.

DATA SOURCES

PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines.

METHODS OF STUDY SELECTION

Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded.

TABULATION, INTEGRATION, AND RESULTS

Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes.

CONCLUSION

Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021278796.

The Impact of Language Discordance on Patients' Perception of a Clinical Encounter and Trust in Provider

IMPORTANCE

The impact of language discordance on care for Spanish-speaking patients with pelvic floor disorders is unknown.

OBJECTIVE

The aim of this study was to compare the impact of language concordance with the impact of language discordance on the patient experience and trust in their provider.

METHODS

This cross-sectional cohort study enrolled English- and Spanish-speaking patients during initial evaluation in a urogynecology clinic. English- and Spanish-speaking patients seen by native English- or Spanish-speaking providers were recruited to the language-concordant group. The language-discordant group included Spanish-speaking patients seen with a translator or by nonnative Spanish-speaking providers. Patients completed the Trust in Physician Scale and the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS). Patients and providers rated the provider's Spanish proficiency on a 10-point scale from 0 (low) to 10 (high). Symptom bother questionnaires were completed 4-6 months after enrollment.

RESULTS

Eighty women were recruited, with 40 in each group. Mean age was 55.4 ± 12.9 years. The majority identified as White (75%) and Hispanic (77.5%). Trust in Physician Scale scores were similar between groups (46.2 ± 8.5 vs 44.4 ± 7.5, P > 0.05). The provider communication, provider rating, and recommendation domains of the CG-CAHPS did not differ between groups (all P > 0.05). Provider self-rating of Spanish proficiency was lower than patient ratings (7.5 ± 1.8 vs 9.8 ± 0.5, P < 0.001). There was no difference between groups in symptom bother at 4-6 months (all P > 0.05).

CONCLUSIONS

Patient-provider language discordance does not affect patient trust in the provider or perception of the encounter as measured by the Trust in Physician Scale and CG-CAHPS questionnaires.

Dissociation Among Women with Chronic Pelvic Pain: Relation to Surgical Treatment, Pelvic Pain Severity, and Health-Related Quality of Life

Chronic pelvic pain (CPP) is associated with a history of trauma and symptoms of somatoform dissociation. We aimed to describe how somatoform dissociation impacts CPP symptoms, surgical treatment, and health-related quality of life (HRQOL). Patients (N = 133) diagnosed with CPP presenting for an appointment at a women's health clinic between November, 2019 - July, 2021 were recruited to participate in a cross-sectional study and complete a survey assessing symptoms of somatoform dissociation, post-traumatic stress disorder (PTSD), pelvic pain severity, history of CPP-related surgeries, and mental and physical HRQOL. We also conducted a post-hoc analysis assessing correlations of individual symptom items on the Somatoform Dissociation Questionnaire (SDQ-20) with HRQOL outcomes. We did not find a relationship between somatoform dissociation and pelvic pain severity or surgical history. Physical HRQOL outcomes were related to somatoform dissociation, PTSD symptoms, and pelvic pain severity, while mental HRQOL outcomes were connected to somatoform dissociation and PTSD symptoms. Our study reveals preliminary evidence suggesting that among CPP patients, HRQOL outcomes are affected by unique profiles of positive and negative symptoms of somatoform dissociation, including sensory disturbances, localized genital pain, and generalized numbness and bodily analgesia. Addressing specific symptoms of somatoform dissociation may enhance HRQOL among trauma-exposed women with CPP. Replication studies are needed to validate our findings. Integrating trauma-informed approaches, including standardized evaluations of trauma exposure and symptoms of somatoform dissociation into routine care for women with CPP is encouraged.

An evidence-based microscopic hematuria care pathway optimizes decision-making among providers

INTRODUCTION AND HYPOTHESIS

Microscopic hematuria (MH) has many etiologies in women and requires specific gynecologic evaluation. We created a standardized MH pathway to serve as an evidence-based decision aid for providers in our practice.

METHODS

Using a modified Delphi process, a multidisciplinary team reviewed existing guidelines for MH diagnosis and treatment to reach consensus on care pathway components.

RESULTS

Entry into the care pathway by an advanced practice provider is determined by the finding of ≥3 red blood cells per high-power field (RBC/HPF) on microscopic urinalysis. Initial evaluation includes history and physical exam. If there are signs of a gynecologic cause of MH, the conditions are treated and repeat urinalysis is performed in 6 months. If repeat urinalysis shows persistent MH or there are no other apparent causes for MH, we proceed with risk stratification. Through shared decision-making, low-risk patients may undergo repeat urinalysis in 6 months or cystoscopy with urinary tract ultrasound. For intermediate-risk patients, cystoscopy and urinary tract ultrasound are recommended. For high-risk patients, cystoscopy and axial upper urinary tract imaging are recommended. If evaluation is positive, urology referral is provided. If evaluation is negative, low-risk patients are released from care, but intermediate-risk or high-risk patients undergo repeat urinalysis in 12 months. If repeat urinalysis is positive, shared decision-making is used to determine a plan.

CONCLUSIONS

We developed an MH care pathway to standardize care of women with MH across a multidisciplinary group. This pathway serves as a component of value-based care and supports evidence-based care by providers.

International Urogynecology Consultation: Patient Reported Outcome Measures (PROs) use in the evaluation of patients with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients.

METHODS

This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP).

RESULTS

The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations.

CONCLUSIONS

All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.

Childhood betrayal trauma, dissociation, and shame impact health-related quality of life among individuals with chronic pelvic pain

BACKGROUND

High betrayal trauma (HBT), or interpersonal trauma perpetrated by someone close, is linked to dissociation and shame, while trauma perpetrated by someone less close, low betrayal trauma (LBT) is associated with post-traumatic stress disorder (PTSD).

OBJECTIVE

Child interpersonal trauma is common among women with chronic pelvic pain (CPP) and can negatively impact physical and mental health-related quality of life (HRQOL). Our study investigates unexplored connections between these variables.

PARTICIPANTS & SETTING

Survey data were analyzed from 96 English-speaking female patients with CPP at a women's health clinic (mean age = 33, 59 % White non-Hispanic, 62 % married or cohabitating, 61.5 % completed post-high school degree); prevalence of HBT and LBT were 65.2 % and 45.6 %, respectively.

METHODS

Multiple regression analyzed relationships between mental and physical HRQOL and dissociation, shame, and PTSD. Parallel mediation analyses examined indirect relationships between mental and physical HRQOL and exposure to childhood HBT and LBT.

RESULTS

Dissociation was related to worse physical HRQOL, while shame was related to worse physical and mental HRQOL. Dissociation and shame mediated relationships between childhood HBT and current mental (R² = 0.08, p = .01) and physical (R² = 0.11, p = .002) HRQOL. Shame, but not PTSD, mediated relationships between childhood LBT and current mental (R² = 0.14, p < .001) and physical (R² = 0.16, p < .001) HRQOL.

CONCLUSIONS

Our study provides preliminary evidence that dissociation and shame negatively impact HRQOL among individuals with CPP in the context of exposure to different types of childhood betrayal trauma. Replication studies to validate our results with larger samples and longitudinal designs are encouraged.

3D quantitative analysis of normal clitoral anatomy in nulliparous women by MRI

INTRODUCTION AND HYPOTHESIS

We present a 3D computational approach for automated clitoral measurements. We hypothesized that computationally derived measurements would be comparable and less variable than reported manual measures.

METHODS

In this retrospective study, MRIs of 22 nulliparous women age 20-49 years with normal vaginal and clitoral anatomy were collected. Manual segmentations were performed to reconstruct 3D models of the whole clitoris (glans, body, crura, and bulbs) and vagina. The length, width, and volume of the clitoral structures and the distance between the vagina and clitoral structures were calculated. Computed clitoral morphometrics (length, width) were compared to median [range] values from a previously published cadaver study (N = 22) using the median test and Moses extreme reaction test. Calculated distances were compared to mean (± SD) reported by a 2D MRI study (N = 20) using independent t-test and Levene's test.

RESULTS

Overall, computed clitoral morphometrics were similar to manual cadaver measurements, where the majority of length and width measures had ~1-2 mm difference and had less variability (smaller range). All calculated distances were significantly smaller and had smaller SDs than manual 2D MRI values, with two-fold differences in the means and SDs. Large variation was observed in clitoral volumetric measures in our cohort.

CONCLUSIONS

The proposed 3D computational method improves the standardization and consistency of clitoral measurements compared to traditional manual approaches. The use of this approach in radiographic studies will give better insight into how clitoral anatomy relates to sexual function and how both are impacted by gynecologic surgery, where outcomes can assist treatment planning.

Evidence-based pelvic floor disorder care pathways optimize shared decision making between patients and surgeons

Introduction and hypothesis

Evidence-based care pathways improve care standardization and patient outcomes. We created pelvic organ prolapse (POP) and stress urinary incontinence (SUI) care pathways as decision aids for our multidisciplinary team to use when counseling patients.

Methods

Using a modified Delphi process, an expert team reviewed existing guidelines and literature to reach consensus on pathway definitions and components.

Results

Entry to the care pathways occurs via an advanced practice provider visit. Symptom and quality-of-life questionnaires as well as open-ended patient goals are used to guide patient–provider shared decision making. All treatment choices, including surgical and nonsurgical management, are presented to patients by advanced practice providers. Patients electing nonsurgical management follow-up by telehealth (preferred) or in-person visits as determined by the care pathway. Surgeon consultations are scheduled for patients desiring surgery. Surgical patients undergo urodynamics, simple cystometrics or deferred bladder testing according to the urodynamics clinical pathway. Postoperative follow-up includes telehealth visits and minimizes in-person visits for women with uncomplicated postoperative courses. Patients with resolution of symptoms are graduated from clinic and return to their referring physician. The pathways are revised following publication of new compelling evidence.

Conclusions

We developed POP and SUI care pathways to standardize care across a diverse provider group. Advanced practice providers use care pathways with patients as shared decision-making tools for initial evaluation of patients with prolapse and incontinence. These pathways serve as components of value-based care and encourage team members to function independently while utilizing the full scope of their training.

Sexual function after pelvic organ prolapse surgery: a systematic review comparing different approaches to pelvic floor repair

OBJECTIVE

Women consider preservation of sexual activity and improvement of sexual function as important goals after pelvic organ prolapse surgery. This systematic review aimed to compare sexual activity and function before and after prolapse surgery among specific approaches to pelvic organ prolapse surgery including native tissue repairs, transvaginal synthetic mesh, biologic grafts, and sacrocolpopexy.

DATA SOURCES

MEDLINE, Embase, and ClinicalTrials.gov databases were searched from inception to March 2021.

STUDY ELIGIBILITY CRITERIA

Prospective comparative cohort and randomized studies of pelvic organ prolapse surgeries were included that reported the following specific sexual function outcomes: baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Notably, the following 4 comparisons were made: transvaginal synthetic mesh vs native tissue repairs, sacrocolpopexy vs native tissue repairs, transvaginal synthetic mesh vs sacrocolpopexy, and biologic graft vs native tissue repairs.

METHODS

Studies were double screened for inclusion and extracted for population characteristics, sexual function outcomes, and methodological quality. Evidence profiles were generated for each surgery comparison by grading quality of evidence for each outcome across studies using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Screening of 3651 abstracts was performed and identified 77 original studies. The overall quality of evidence was moderate to high. There were 26 studies comparing transvaginal synthetic mesh with native tissue repairs, 5 comparing sacrocolpopexy with native tissue repairs, 5 comparing transvaginal synthetic mesh with sacrocolpopexy, and 7 comparing biologic graft with native tissue repairs. For transvaginal synthetic mesh vs native tissue repairs, no statistical differences were found in baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, persistent dyspareunia, and de novo dyspareunia. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form change scores were not different between transvaginal synthetic mesh and native tissue repairs (net difference, -0.3; 95% confidence interval, -1.4 to 0.8). For sacrocolpopexy vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, de novo dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form score differences were not different. For biologic graft vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form changes were also not different. For transvaginal synthetic mesh vs sacrocolpopexy, there was no difference in sexual activity and sexual function score change. Based on 2 studies, postoperative total dyspareunia was more common in transvaginal synthetic mesh than sacrocolpopexy (27.5% vs 12.2%; odds ratio, 2.72; 95% confidence interval, 1.33-5.58). The prevalence of postoperative dyspareunia was lower than preoperative dyspareunia after all surgery types.

CONCLUSION

Sexual function comparisons are most robust between transvaginal synthetic mesh and native tissue repairs and show similar prevalence of sexual activity, de novo dyspareunia, and sexual function scores. Total dyspareunia is higher after transvaginal synthetic mesh than sacrocolpopexy. Although sexual function data are sparse in the other comparisons, no other differences in sexual activity, dyspareunia, and sexual function score change were found.

Inadequacy and underreporting of study subjects' race and ethnicity in federally funded pelvic floor research

BACKGROUND

The inclusion of participants who are Black, Indigenous people of color, and participants of various ethnicities is a priority of federally sponsored research.

OBJECTIVE

This study aimed to describe the reporting of race and ethnicity in federally funded research published by the Eunice Kennedy Shriver National Institute of Child Health and Human Development-funded Pelvic Floor Disorders Network.

STUDY DESIGN

Pelvic Floor Disorders Network publications were reviewed to determine whether race or ethnicity was reported. The number of participants included in each manuscript who were identified as White, Black, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and "other," and the number of participants who identified as having Hispanic ethnicity were recorded. Data were analyzed by publication and by the pelvic floor disorder investigated, including urinary incontinence, pelvic organ prolapse, fecal incontinence, pregnancy-related pelvic floor disorders, and multiple pelvic floor disorders. Many publications reported on overlapping patient populations, which included primary trials and secondary analyses and studies. Data were analyzed both by counting participants every time they were reported in all papers and by counting the unique number of participants in only the original trials (primary paper published).

RESULTS

A total of 132 Pelvic Floor Disorders Network publications were published between 2003 and 2020. Of these, 21 were excluded because they were methods papers or described research without participants. Of the 111 remaining articles, 90 (81%) included descriptions of race and 55 (50%) included descriptions of ethnicity. All 13 primary trials described race and 10 of 13 (76.9%) described ethnicity. Of those publications that described race, 50 of 90 (56%) included only the categories of "White," "Black," and "Other," and 14 of 90 (16%) only described the percentage of White patients. Of the 49,218 subjects, there were 43,058 (87%) with reported race and 27,468 (56%) with reported ethnicity. Among subjects with race and ethnicity reported, 79% were reported as White, 9.9% as Black, 0.4% as Asian, 0.1% as American Indian or Alaska Native, and 4% as "other," whereas 13% were reported to be of Hispanic ethnicity. The racial and ethnic diversity varied based on the pelvic floor disorder studied (P<.01), which was driven by pregnancy-related and fecal incontinence studies because these had lower proportions of White patients than studies of other pelvic floor disorders.

CONCLUSION

Federally funded Pelvic Floor Disorders Network research does not consistently report the race and ethnicity of participants. Even in the publications that report these characteristics, Black, Indigenous people of color, and people of Hispanic ethnicity are underrepresented. Consistent reporting and recruitment of a diverse population of women is necessary to address this systemic inequity.

Peer-Centered Versus Standard Physician-Centered Video Counseling for Midurethral Sling Surgery: A Randomized Controlled Trial

OBJECTIVES

Peer counseling may improve upon provider counseling and enhance patient preparedness for midurethral sling (MUS) surgery. We aimed to compare the impact of peer-centered versus standard preoperative video counseling by assessing patient preparedness for MUS surgery.

METHODS

Women undergoing MUS were randomized to view either a peer-centered (PEER) or standard physician preoperative counseling video (PHYS). The PEER video featured a woman who had undergone MUS surgery and included the standard risks and benefits as well as additional information identified in prior work as important to patients. The PHYS video featured a surgeon discussing risks and benefits. Patients viewed either video at their preoperative visit and completed the Patient Preparedness Questionnaire (PPQ), Surgical Decision Satisfaction, Decisional Regret Scale, and the Urogenital Distress Inventory Short Form. Patients then underwent standard in-person surgeon counseling. Sessions were timed and compared with historical timed sessions. Our primary outcome was between-group differences in 6-week postoperative PPQ scores.

RESULTS

Patient Preparedness Questionnaire scores did not differ between groups (postoperative PPQ scores: median [interquartile range], 95 [84, 100] vs 92 [80, 100]; P=0.50). The PEER group reported higher decisional regret (15 [0, 28.75] vs 0 [0, 10], P=0.02) and less symptom improvement on Urogenital Distress Inventory Short Form change scores compared with the PHYS group (47.2 [37.2, 62.5] vs 36.1 [16.5, 50], P=0.03); secondary outcomes were not different between groups. In-person counseling times decreased after watching either video compared with the institution's historical standard (8:27 minutes [08:56, 17:14] vs 11:34 minutes [5:22, 13:07]; P < 0.005).

CONCLUSION

Patient preparedness did not differ between groups. Decision regret did not differ between groups once adjusted for urinary symptoms.

Improved body image after uterovaginal prolapse surgery with or without hysterectomy

INTRODUCTION AND HYPOTHESIS

The objective was to compare body image and sexual activity and function changes up to 3 years after sacrospinous ligament fixation with graft hysteropexy or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy).

METHODS

This was a planned secondary analysis of a multi-center randomized trial of women undergoing prolapse repair with mesh hysteropexy versus hysterectomy. Women were masked to intervention. The modified Body Image Scale (BIS), sexual activity status, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) scores were reported at baseline and 1.5, 6, 12, 18, 24, and 36 months after surgery. We compared mean BIS and PISQ-IR scores, the proportion of women whose BIS scores met a distribution-based estimate of the minimally important difference (MID), and sexual activity status. Comparisons were analyzed with linear and logistic repeated measures models adjusted for site, intervention, visit, and intervention by visit interaction.

RESULTS

Eighty-eight women underwent mesh hysteropexy; 87 underwent hysterectomy. Women were similar with regard to baseline characteristics, mean age 65.9 ± 7.3 years, and most had stage III or IV prolapse (81%). Baseline mean BIS scores were not significantly different, improved in both groups by 1.5 months, and were sustained through 36 months with no differences between groups (all p > 0.05). The estimated BIS MID was 3; and by 36 months, more women in the mesh hysteropexy group achieved the MID than in the hysterectomy group (62% vs 44%, p = 0.04). The makeup of the sexually active cohort changed throughout the study, making function comparisons difficult.

CONCLUSIONS

Body image improves following prolapse surgery whether or not hysterectomy is performed or transvaginal mesh is used at the time of repair; sexual activity status changes over time following prolapse surgery.

A telehealth intervention to increase patient preparedness for surgery: a randomized trial

INTRODUCTION AND HYPOTHESIS

Methods to increase surgical preparedness in urogynecology are lacking. Our objective was to evaluate the impact of a preoperative provider-initiated telehealth call on surgical preparedness.

METHODS

This was a multicenter randomized controlled trial. Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence were randomized to either a telehealth call 3 (± 2) days before surgery plus usual preoperative counseling versus usual preoperative counseling alone. Our primary outcome was surgical preparedness, as measured by the Preoperative Prepardeness Questionnaire. The Modified Surgical Pain Scale, Pelvic Floor Distress Inventory-20, Patient Global Impressions of Improvement, Patient Global Impressions of Severity, Satisfaction with Decision Scale, Decision Regret Scale, and Clavien-Dindo scores were obtained at 4-8 weeks postoperatively and comparisons were made between groups.

RESULTS

Mean telehealth call time was 11.1 ± 4.11 min. Women who received a preoperative telehealth call (n = 63) were significantly more prepared for surgery than those who received usual preoperative counseling alone (n = 69); 82.5 vs 59.4%, p < 0.01). A preoperative telehealth call was associated with greater understanding of surgical alternatives (77.8 vs 59.4%, p = 0.03), complications (69.8 vs 47.8%, p = 0.01), hospital-based catheter care (54 vs 34.8%, p = 0.04) and patient perception that nurses and doctors had spent enough time preparing them for their upcoming surgery (84.1 vs 60.9%, p < 0.01). At 4-8 weeks, no differences in postoperative and patient reported outcomes were observed between groups (all p > 0.05).

CONCLUSIONS

A short preoperative telehealth call improves patient preparedness for urogynecological surgery.

Relationship of postoperative vaginal anatomy and sexual function: a systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018.

METHODS

The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes.

RESULTS

We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12.

CONCLUSION

Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery.

Mind-body (hypnotherapy) treatment of women with urgency urinary incontinence: changes in brain attentional networks

BACKGROUND

Prior study of patients with urgency urinary incontinence by functional magnetic resonance imaging showed altered function in areas of the brain associated with interoception and salience and with attention. Our randomized controlled trial of hypnotherapy for urgency urinary incontinence demonstrated marked improvement in urgency urinary incontinence symptoms at 2 months. A subsample of these women with urgency urinary incontinence underwent functional magnetic resonance imaging before and after treatment.

OBJECTIVE

This study aimed to determine if hypnotherapy treatment of urgency urinary incontinence compared with pharmacotherapy was associated with altered brain activation or resting connectivity on functional magnetic resonance imaging.

STUDY DESIGN

A subsample of women participating in a randomized controlled trial comparing hypnotherapy vs pharmacotherapy for treatment of urgency urinary incontinence was evaluated with functional magnetic resonance imaging. Scans were obtained pretreatment and 8 to 12 weeks after treatment initiation. Brain activation during bladder filling and resting functional connectivity with an empty and partially filled bladder were assessed. Brain regions of interest were derived from those previously showing differences between healthy controls and participants with untreated urgency urinary incontinence in our prior work and included regions in the interoceptive and salience, ventral attentional, and dorsal attentional networks.

RESULTS

After treatment, participants in both groups demonstrated marked improvement in incontinence episodes (P<.001). Bladder-filling task functional magnetic resonance imaging data from the combined groups (n=64, 30 hypnotherapy, 34 pharmacotherapy) demonstrated decreased activation of the left temporoparietal junction, a component of the ventral attentional network (P<.01) compared with baseline. Resting functional connectivity differed only with the bladder partially filled (n=54). Compared with pharmacotherapy, hypnotherapy participants manifested increased functional connectivity between the anterior cingulate cortex and the left dorsolateral prefrontal cortex, a component of the dorsal attentional network (P<.001).

CONCLUSION

Successful treatment of urgency urinary incontinence with both pharmacotherapy and hypnotherapy was associated with decreased activation of the ventral (bottom-up) attentional network during bladder filling. This may be attributable to decreased afferent stimuli arising from the bladder in the pharmacotherapy group. In contrast, decreased ventral attentional network activation associated with hypnotherapy may be mediated by the counterbalancing effects of the dorsal (top-down) attentional network.

Creating a bundled care payment model for treatment of pelvic floor disorders: introducing value into urogynecology

Ineffective healthcare delivery and expenditures associated with the traditional fee for service in-person models have turned attention toward alternative payment models as a means of enhancing healthcare quality in the United States. Bundled care payment models are a form of alternate payment models that provide a single reimbursement for all services rendered for an episode of care and have been developed extensively in primary care settings with limited literature in urogynecology. We describe the process used to create a bundled care payment model for women seeking care in a subspecialty clinic for pelvic floor disorders in partnership with our safety net insurer. The process included estimation of prior average spend, the design of an integrated practice unit, creation of pelvic floor pathways, approximation of utilization rates, and estimation of reimbursement and expenses.

Management of Fecal Incontinence

Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.

Sacral neuromodulation for symptomatic chronic urinary retention in females: do age and comorbidities make a difference?

OBJECTIVES

To evaluate if age and medical comorbidities are associated with progression to implantation of sacral neuromodulation devices in women with symptomatic chronic urinary retention.

METHODS

This multisite retrospective cohort included women with symptomatic chronic urinary retention who had a trial phase of sacral neuromodulation. The primary outcome was progression to implantation. Post-implantation outcomes were assessed as stable response versus decreased efficacy. A sub-analysis of catheter-reliant (intermittent-self catheterization or indwelling) patients was performed. Age was analyzed by 10-year units (decades of age). Multivariate logistic regression determined odds ratios for outcomes of implantation and for post-implantation stable response.

RESULTS

Implantation occurred in 86% (243/284) women across six academic institutions. Most patients (160/243, 66%) were catheter reliant at the time of trial phase. Increased decade of age was associated with reduced implantation in all women [OR 0.54 (95% CI 0.42, 0.70)] and in the subgroup of catheter-reliant women [OR 0.52 (95% CI 0.37, 0.73)]. Post-implantation stable response occurred in 68% (193/243) of women at median follow-up of 2 years (range 0.3-15 years). Medical comorbidities present at the time of trials did not impact progression to implantation or post-implantation success.

CONCLUSIONS

Increasing decade of age is associated with reduced implantation in women with symptomatic chronic urinary retention. There is no age cutoff at which outcomes change. Post-implantation stable response was not associated with age or medical comorbidities.

The responsiveness and minimally important difference for the Accidental Bowel Leakage Evaluation questionnaire

INTRODUCTION AND HYPOTHESIS

We describe the responsiveness and minimally important difference (MID) of the Accidental Bowel Leakage Evaluation (ABLE) questionnaire.

METHODS

Women with bowel leakage completed ABLE, Patient Global Impression of Improvement, Colo-Rectal Anal Distress Inventory, and Vaizey questionnaires pretreatment and again at 24 weeks post-treatment. Change scores were correlated between questionnaires. Student's t tests compared ABLE change scores for improved versus not improved based on other measures. The MID was determined by anchor- and distribution-based approaches.

RESULTS

In 266 women, the mean age was 63.75 (SD = 11.14) and 79% were white. Mean baseline ABLE scores were 2.32 ± 0.56 (possible range 1-5) with a reduction of 0.62 (SD = 0.79) by 24 weeks. ABLE change scores correlated with related measures change scores (r = 0.24 to 0.53) and differed between women who improved and did not improve (all p < 0.001). Standardized response means for participants who improved were large ranging from -0.89 to -1.12. Distribution-based methods suggest a MID of -0.19 based on the criterion of one SEM and -0.28 based on half a standard deviation. Anchor-based MIDs ranged from -0.10 to -0.45. We recommend a MID of -0.20.

CONCLUSIONS

The ABLE questionnaire is responsive to change, with a suggested MID of -0.20.

Impact of treatment for fecal incontinence on constipation symptoms

OBJECTIVE

Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment.

STUDY DESIGN

This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks.

RESULTS

At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4).

CONCLUSION

Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.

Small-Group, Community-Member Intervention for Urinary and Bowel Incontinence: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of Mind Over Matter: Healthy Bowels, Healthy Bladder, a small-group intervention, on urinary and bowel incontinence symptoms among older women with incontinence.

METHODS

In this individually randomized group treatment trial, women aged 50 years and older with urinary, bowel incontinence, or both, were randomly allocated at baseline to participate in Mind Over Matter: Healthy Bowels, Healthy Bladder immediately (treatment group) or after final data collection (waitlist control group). The primary outcome was urinary incontinence (UI) improvement on the Patient Global Impression of Improvement at 4 months. Validated instruments assessed incontinence, self-efficacy, depression, and barriers to care-seeking. Intent-to-treat analyses compared differences between groups. Target sample size, based on an anticipated improvement rate of 45% in treated women vs 11% in the control group, 90% power, type I error of 0.05, with anticipated attrition of 25%, was 110.

RESULTS

Among 121 women randomized (62 treatment group; 59 control group), 116 (95%) completed the 4-month assessment. Most participants were non-Hispanic white (97%), with a mean age of 75 years (SD 9.2, range 51-98); 66% had attended some college. There were no significant between-group differences at baseline. At 4 months, 71% of treated women vs 23% of women in the control group reported improved UI on Patient Global Impression of Improvement (P<.001); 39% vs 5% were much improved (P<.001). Regarding bowel incontinence, 55% of treated women vs 27% of women in the control group improved on Patient Global Impression of Improvement (P<.005), with 35% vs 11% reporting much improvement (P<.005). Treated women improved significantly more than women in the control group on all validated instruments of incontinence severity, quality of life, and self-efficacy. Care-seeking rates were similar between groups.

CONCLUSION

Participation in a small-group intervention improves symptoms of both urinary and bowel incontinence in older women. Mind Over Matter is a feasible model with potential to bring effective behavioral solutions to the community.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03140852.

Hypnotherapy or medications: a randomized noninferiority trial in urgency urinary incontinent women

BACKGROUND

Urgency urinary incontinence afflicts many adults, and most commonly affects women. Medications, a standard treatment, may be poorly tolerated, with poor adherence. This warrants investigation of alternative interventions. Mind-body therapies such as hypnotherapy may offer additional treatment options for individuals with urgency urinary incontinence.

OBJECTIVE

To evaluate hypnotherapy's efficacy compared to medications in treating women with urgency urinary incontinence.

MATERIALS AND METHODS

This investigator-masked, noninferiority trial compared hypnotherapy to medications at an academic center in the southwestern United States, and randomized women with non-neurogenic urgency urinary incontinence to weekly hypnotherapy sessions for 2 months (and continued self-hypnosis thereafter) or to medication and weekly counseling for 2 months (and medication alone thereafter). The primary outcome was the between-group comparison of percent change in urgency incontinence on a 3-day bladder diary at 2 months. Important secondary outcomes were between-group comparisons of percent change in urgency incontinence at 6 and 12 months. Outcomes were analyzed based on noninferiority margins of 5% for between group differences (P < 0.025) (that is, for between group difference in percentage change in urgency incontinence, if the lower bound of the 95% confidence interval was greater than -5%, noninferiority would be proved).

RESULTS

A total of 152 women were randomized to treatment between April 2013 and October 2016. Of these women, 142 (70 hypnotherapy, 72 medications) had 3-day diary information at 2 months and were included in the primary outcome analysis. Secondary outcomes were analyzed for women with diary data at the 6-month and then 12-month time points (138 women [67 hypnotherapy, 71 medications] at 6 months, 140 women [69 hypnotherapy, 71 medications] at 12 months. There were no differences between groups' urgency incontinence episodes at baseline: median (quartile 1, quartile 3) for hypnotherapy was 8 (4, 14) and medication was 7 (4, 11) (P = .165). For the primary outcome, although both interventions showed improvement, hypnotherapy did not prove noninferior to medication at 2 months. Hypnotherapy's median percent improvement was 73.0% (95% confidence interval, 60.0-88˖9%), whereas medication's improvement was 88.6% (95% confidence interval, 78.6-100.0%). The median difference in percent change between groups was 0% (95% confidence interval, -16.7% to 0.0%); because the lower margin of the confidence interval did not meet the predetermined noninferiority margin of greater than -5%, hypnotherapy did not prove noninferior to medication. In contrast, hypnotherapy was noninferior to medication for the secondary outcomes at 6 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 75.0-100%; medications, 83.3% improvement, 95% confidence interval, 64.7-100%; median difference in percent change between groups of 0%, 95% confidence interval, 0.0-6.7%) and 12 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 66.7-94.4%; medications, 80% improvement, 95% confidence interval, 54.5-100%; median difference in percent change between groups of 0%, 95% confidence interval, -4.2% to -9.5%).

CONCLUSION

Both hypnotherapy and medications were associated with substantially improved urgency urinary incontinence at all follow-up. The study did not prove the noninferiority of hypnotherapy compared to medications at 2 months, the study's primary outcome. Hypnotherapy proved noninferior to medications at longer-term follow-up of 6 and 12 months. Hypnotherapy is a promising, alternative treatment for women with UUI.

Defining the relationship between vaginal and urinary microbiomes

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.

Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial

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.

Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial

BACKGROUND

Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo.

METHODS

In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565.

FINDINGS

Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group).

INTERPRETATION

In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.

Postpartum Weight Retention in Primiparous Women and Weight Outcomes in Their Offspring

INTRODUCTION

To explore the effect of prepregnancy body mass index (BMI) and gestational weight gain on postpartum weight retention in nulliparous women and weight-for-length percentiles of offspring to 2 years following birth.

METHODS

A retrospective secondary analysis of a large, prospective longitudinal study of women conducted during pregnancy and after their first birth was completed to examine outcomes associated with postpartum weight retention. A chart review of the offspring of these women was completed to explore the relationship between maternal prepregnancy BMI and gestational weight gain on offspring weight-for-length percentiles.

RESULTS

Data from 652 woman-infant dyads were available for analysis. Average postpartum weight retention was 4.0 kg at one year for all groups. At 6 weeks postpartum, women who were obese prior to pregnancy retained significantly less weight than did women who were normal weight prior to pregnancy (P < .05). Women who were normal weight or overweight at the onset of pregnancy and had gestational weight gain within Institute of Medicine recommendations retained significantly less weight at 6 weeks, 6 months, and 1 year postpartum (P < .01) when compared with women in those same weight groups who had a gestational weight gain in excess of the recommended guideline. Women who entered pregnancy obese and who had a gestational weight gain within the recommended weight range during pregnancy retained significantly less weight compared with women who were obese and who gained in excess of the guideline at 6 weeks postpartum only (P < .05). No statistically significant differences were seen in offspring weight-for-length percentiles at any time point based on maternal prepregnancy BMI or weight gain within guidelines.

DISCUSSION

Many women retained weight up to one year postpartum. In this study, we saw no statistically significant differences between the prepregnant BMI groups or between gestational weight gain within guidelines or in excess of guidelines on offspring weight-for-length percentiles.

A longitudinal qualitative evaluation of patient perspectives of adverse events after pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

Patient perception of adverse events (AEs) after pelvic floor disorder surgery is incompletely understood and may differ from providers' views of AEs. Our objective is to describe patient perceptions of AEs related to pelvic floor disorder surgery and how perceptions change over time.

METHODS

Mixed-method study of longitudinal patient interviews and surveys. Women planning pelvic floor disorder surgery completed three one-on-one interviews: preoperatively (< 12 weeks before surgery), 6-8 weeks postoperatively, and 6 months postoperatively. Interviews explored the patient experience of surgery and their perception of AEs over time. Participants ranked self-identified AEs by severity. De-identified transcripts of audio recordings were coded and analyzed using an iterative, thematic, team-based process using NVivo software (QSR International).

RESULTS

Twenty women each completed three separate interviews for a total of 60 interviews. Their mean age was 55.3 (± 12.7) years, and 50% were Non-Hispanic white. Women's perceptions of AEs changed as more time passed from surgery. Women identified potential problems related to surgery such as anesthesia complications, pain, injury, catheter issues, and an unsuccessful surgery as the most concerning AEs preoperatively. Postoperatively (6-8 weeks), women expressed concern about functional outcomes (e.g., performing daily activities, symptom reduction). Late postoperatively (6 months), the majority identified unsuccessful surgery, incontinence, and sexual dysfunction as severe AEs. These findings are consistent with prior work that suggests women perceive functional outcomes as fundamental to their recovery.

CONCLUSIONS

These findings contribute to a more nuanced understanding of patient-centered perspectives on AEs. Patients view poor functional outcomes as severe AEs.

A 10-yr Analysis of Chronic Pelvic Pain and Chronic Opioid Therapy in the Women Veteran Population

Introduction

Chronic pelvic pain (CPP) affects an estimated 30% of women Veterans. Previous research shows high rates of narcotic abuse in the women Veteran population. Narcotics are not recommended for the treatment of CPP. Understanding how CPP impacts narcotic prescribing in the women Veteran population is critical to addressing the public health crisis of opioid abuse. Our objective was to compare chronic opioid therapy (COT) prescribed 5 yr prior to and following CPP diagnosis and to identify predictors of COT as well as adverse events associated with COT. We choose to look at 10 yr of data because we thought this time period would provide unique insight into the longitudinal associations of CPP and COT and was available in the database.

Materials and Methods

Women with non-cancer CPP were included for analyses from the Veteran's Affairs Corporate Database Warehouse. COT was defined as 90 d of opiates/calendar year for each of the 5 yr proceeding and following the diagnosis of CPP. Patient characteristics and potential variables influencing COT were collected. We compared baseline demographics between the women who received COT to the women who did not receive COT to find additional demographic predictors of COT in association with CPP. Multivariable analysis identified predictors of COT in this population of women with CPP. We utilized an interrupted time series analysis to understand the impact of the diagnosis of CPP on COT.

Results

A total of 49,601 women met inclusion criteria with an average age of 40.1 ± 11.5 yr; 37.3% self-characterized as being a racial minority and 24% had a history of military sexual trauma. Chronic use increased significantly (p < 0.001) in the 5 yr preceding the diagnosis of CPP from 6.3% (n = 3124) of women at time -5 to 13.6% (n = 6746) at time 0. In the first year following the diagnosis of CPP, 16.8% (n = 8,333) of women with CPP met the criteria for COT (p < 0.001) and 15% (n = 7440) of women with CPP remained in the COT group for the remaining 5 yr following the diagnosis. On average women in the COT group had 250-292 d of opioids/year. When comparing women who received chronic narcotics following the diagnosis of CPP versus those who did not receive chronic narcotics, women who received COT were older, more likely to smoke and more frequently diagnosed with other pain conditions such as back pain, headaches, and fibromyalgia. (All p < 0.001). In the multivariable model, predictors of COT following CPP diagnosis included prior COT (OR = 10.0 (95% CI 9.4, 10.6), a positive history of military sexual trauma, smoking, and other chronic pain conditions.

Conclusions

The distinct pattern of prescribing shown in this cohort may mean COT is prescribed for CPP and this prescribing pattern contributes to the adverse events associated with COT. As COT is not recommended for CPP, physicians need more education on the therapies available to help CPP patients.

Responsiveness and minimally important difference of SF-6D and EQ-5D utility scores for the treatment of pelvic organ prolapse

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.

Gaining the patient perspective on pelvic floor disorders' surgical adverse events

BACKGROUND

The Institute for Healthcare Improvement defines an adverse event as an unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization or that results in death. The majority of research has focused on adverse events from the provider's perspective.

OBJECTIVE

The objective of this qualitative study was to describe patient perceptions on adverse events following surgery for pelvic floor disorders.

STUDY DESIGN

Women representing the following 3 separate surgical populations participated in focus groups: (1) preoperative (women <12 weeks prior to surgery); (2) short-term postoperative (women up to 12 weeks after surgery); and (3) long-term postoperative (women 1-5 years after surgery). Deidentified transcripts of audio recordings were coded and analyzed with NVivo 10 software to identify themes, concepts, and adverse events. Women were asked to rank patient-identified and surgeon-identified adverse events in order of perceived severity.

RESULTS

Eighty-one women participated in 12 focus groups. Group demographics were similar between groups, and all groups shared similar perspectives regarding surgical expectations. Women commonly reported an unclear understanding of their surgery and categorized adverse events such as incontinence, constipation, nocturia, and lack of improvement in sexual function as very severe, ranking these comparably with intensive care unit admissions or other major surgical complications. Women also expressed a sense of personal failure and shame if symptoms recurred.

CONCLUSION

Women consider functional outcomes such as incontinence, sexual dysfunction, and recurrence of symptoms as severe adverse events and rate them as similar in severity to intensive care unit admissions and death.

The urinary microbiome in women with mixed urinary incontinence compared to similarly aged controls

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.

Trends in patient procurement of postoperative opioids and route of hysterectomy in the United States from 2004 through 2014

BACKGROUND

The opioid epidemic in the United States is a public health emergency. Minimally invasive surgical technology has decreased length of hospital stay, improved postoperative recovery, and decreased postoperative pain. Hysterectomy is one of the most commonly performed surgeries in the United States. Increasing trends in minimally invasive gynecologic surgery are expected to reduce patients' postoperative pain. It is unclear whether this assumption has resulted in decreasing postoperative opioid prescriptions or patient need for these prescriptions, as prescribing patterns may be contributing to the current opioid public health emergency.

OBJECTIVE

We sought to describe opioid prescribing and patient procurement practices for postoperative pain at time of discharge for benign hysterectomy from 2004 through 2014 using the Truven Health Analytics MarketScan Research Database. The trends of the route of hysterectomy over this time period were concomitantly described to reflect the movement toward more minimally invasive approaches.

STUDY DESIGN

The Truven Health Analytics MarketScan Research Database including the Commercial Claims and Encounters Database, and the Medicare Supplemental and Coordination of Benefits Database were utilized. Current Procedural Terminology, 4th Edition, and International Classification of Diseases, Ninth Revision, codes identified all patients who underwent a hysterectomy for benign indications from 2004 through 2014. Hysterectomy routes were categorized into abdominal, laparoscopic, and vaginal. The MarketScan database captures prescriptions filled at a retail or mail-order pharmacy and does not capture prescriptions filled within the inpatient, hospital facility. The days of opioids procured by patients at the time of discharge were identified for each encounter. Descriptive statistics were used to summarize data within the entire study period. Although this article is purely descriptive, further analyses were conducted for exploratory purposes only. analysis of variance and χ² analyses were used for continuous and categorical variables, respectively. Multiple linear regression models were used to describe associations between variables of interest and postoperative opioid prescriptions.

RESULTS

We identified 793,016 patients who underwent a hysterectomy for benign indications from 2004 through 2014. Of these, 96% were identified from the Commercial Claims and Encounters Database. During the study period, the overall route of hysterectomy was categorized into 40.5% abdominal, 42.0% laparoscopic, and 17.5% vaginal hysterectomy. The route of hysterectomy changed from 60.2-25.6% (a decrease of Δ = 34.58; 95% confidence interval, 33.96-35.20) for abdominal, 17.0-61.9% (an increase of Δ = 44.83; 95% confidence interval, 44.21-45.44) for laparoscopic, and 22.8-12.6% (a decrease of Δ = 10.25; 95% confidence interval, 9.77-10.73) for vaginal. At discharge, the percentage of patients who were prescribed opioids and filled them increased from 25.6-82.1% (an increase of Δ = 56.50; 95% confidence interval, 55.88-57.13 with P < .001) from 2004 through 2014 for all hysterectomy routes. Additionally, the quantity of opioids prescribed also increased.

CONCLUSION

Opioid prescriptions filled for postoperative pain after hysterectomy substantially increased from 2004 through 2014. Opioid prescription procurement has increased despite a concomitant increase in minimally invasive hysterectomy routes. In light of the current opioid epidemic, physicians must recognize that postoperative prescribing practices may contribute to chronic opioid use. Heightened awareness of opioid prescribing practices following surgery is critically important to decrease risk of development of chronic opioid dependence.

Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications

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.

Universal cystoscopy at the time of benign hysterectomy: a debate

Injury to the bladder and/or ureters is the cause of significant morbidity, and efforts to reduce these injuries are important. This debate presents arguments that both support, and refute, the value of routine cystoscopy at the time of benign hysterectomy. Proponents of routine cystoscopy state that injuries are more likely to be detected and repaired when cystoscopy is routinely performed. Dissenters counter that the available evidence does not support routine cystoscopy at the current rates of lower urinary tract injury, and the cystoscopy should be performed only when injury is suspected or when performing hysterectomy with concurrent procedures that increase the risk of lower urinary tract injury.

Reliability and validity of the Tigrigna version of the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7)

INTRODUCTION AND HYPOTHESIS

This study adapted the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) into the Tigrigna language of northern Ethiopia and validated the their reliability and validity through patient interviews.

METHODS

Expert translation, cognitive interviewing, and patient interviews using translated questionnaires were conducted. A subset of women was reinterviewed 1 week later. Intraclass correlation coefficients (ICC), Bland-Altman analysis, and Cronbach's alpha values were assessed. Total and subscale scores were compared between women with and without pelvic floor disorders (PFDs) using the Mann-Whitney U test. Spearman's correlation coefficients were used to compare severity of pelvic organ prolapse (POP) stage according to the POP Quantification (POP-Q) system and PFDI-20 and PFIQ-7 and subscale scores.

RESULTS

Ten women participated in cognitive interviewing and 118 age 49 ± 10 years, mean ± standard deviation (SD) with and without PFDs were interviewed using the translated questionnaires, both of which presented adequate face validity and test-retest reliability [intraclass correlation coefficient (ICC) 0.765-0.969, p < 0.001]. Construct validity was significant between clinical symptoms and full forms (p <0.001) and their subscales (p <0.001), except for the Pelvic Organ Prolapse Impact Questionnaire (POPIQ). Differences between first and second scores on total PFDI-20 and PFIQ-7 and subscales largely fell within 0 ± 1.96 SD. Cronbach's alpha values were 0.891-0.930 for PFDI-20 and 0.909-0.956 for PFIQ-7 (p < 0.001). Analysis of known groups showed differences PFDI-20 and PFIQ-7 scores between women with and without PFDs (p <0.001 for full forms and subscales, except for anal incontinence (AI) and the Urinary Impact Questionnaire (UIQ)/POPIQ.

CONCLUSION

The translated Tigrigna versions of the PFDI-20 and PFIQ-7 questionnaires are reliable, valid, and feasible tools to evaluate symptoms and quality of life (QoL) of Tigrigna-speaking Ethiopian women with PFDs.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Developing Best Clinical Practices Through Outcomes Improvement: An Ongoing Quality Improvement Curriculum for Faculty and Residents

Introduction

Practice patterns in clinical learning environments are an important predictor of the patient care quality that residents will deliver after training. The Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review Evaluation Committee reported that from 2012-2015, residents and fellows rarely engaged in quality improvement (QI) activities. A QI curriculum was created for OB-GYN faculty and trainees to develop and implement best practices and study the resulting improvement in patient outcomes.

Methods

Educational leadership in the Dell Medical School Department of Women's Health designed a five-stage curriculum: (1) learning module describing the curriculum's rationale, (2) clinical practice proposal development, (3) implementation/data analysis for selected proposals, (4) dissemination of proposals and outcomes during a live forum, and (5) evaluation. PGY1 and PGY4 OB-GYN residents collaborated in dyads with selected faculty mentors to draft evidence-based proposals. Dyads identified suggested outcomes measures to be analyzed postimplementation. Remaining faculty analyzed outcomes from the previous year's proposals with PGY2 and PGY3 OB-GYN residents.

Results

Forum participants, including faculty, residents, nursing staff, and private obstetrician-gynecologists, evaluated the activity. In 2017, 15 (35%) completed the evaluation. All respondents intended to change their practice based on findings. In addition, the 2016 ACGME survey indicated significant increases in faculty perception of resident QI from 58% in 2014-2015 to 89% in 2015-2016 (p = .01) and in collaboration in scholarly activity from 50% to 85% (p < .01).

Discussion

This curriculum was effective in engaging OB-GYN faculty and residents in formalized problem-based learning to address QI.

Methodology for a vaginal and urinary microbiome study in women with mixed urinary incontinence

INTRODUCTION AND HYPOTHESIS

We describe the rationale and methods of a study designed to compare vaginal and urinary microbiomes in women with mixed urinary incontinence (MUI) and similarly aged, asymptomatic controls.

METHODS

This paper delineates the methodology of a supplementary microbiome study nested in an ongoing randomized controlled trial comparing a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone for MUI. Women in the parent study had at least "moderate bother" from urgency and stress urinary incontinence symptoms (SUI) on validated questionnaire and confirmed MUI on bladder diary. Controls had no incontinence symptoms. All participants underwent vaginal and urine collection for DNA analysis and conventional urine culture. Standardized protocols were designed, and a central lab received samples for subsequent polymerase chain reaction (PCR) amplification and sequencing of the bacterial16S ribosomal RNA (rRNA) gene. The composition of bacterial communities will be determined by dual amplicon sequencing of variable regions 1-3 and 4-6 from vaginal and urine specimens to compare the microbiome of patients with controls. Sample-size estimates determined that 126 MUI and 84 control participants were sufficient to detect a 20 % difference in predominant urinary genera, with 80 % power and 0.05 significance level.

RESULTS

Specimen collection commenced January 2015 and finished April 2016. DNA was extracted and stored for subsequent evaluation.

CONCLUSIONS

Methods papers sharing information regarding development of genitourinary microbiome studies, particularly with control populations, are few. We describe the rigorous methodology developed for a novel urogenital microbiome study in women with MUI.

Validation of an instrument to assess barriers to care-seeking for accidental bowel leakage in women: the BCABL questionnaire

INTRODUCTION AND HYPOTHESIS

Fewer than 30% of women with accidental bowel leakage (ABL) seek care, despite the existence of effective, minimally invasive therapies. We developed and validated a condition-specific instrument to assess barriers to care-seeking for ABL in women.

METHODS

Adult women with ABL completed an electronic survey about condition severity, patient activation, previous care-seeking, and demographics. The Barriers to Care-seeking for Accidental Bowel Leakage (BCABL) instrument contained 42 potential items completed at baseline and again 2 weeks later. Paired t tests evaluated test-retest reliability. Factor analysis evaluated factor structure and guided item retention. Cronbach's alpha evaluated internal consistency. Within and across factor item means generated a summary BCABL score used to evaluate scale validity with six external criterion measures.

RESULTS

Among 1,677 click-throughs, 736 (44%) entered the survey; 95% of eligible female respondents (427 out of 458) provided complete data. Fifty-three percent of respondents had previously sought care for their ABL; median age was 62 years (range 27-89); mean Vaizey score was 12.8 (SD = 5.0), indicating moderate to severe ABL. Test-retest reliability was excellent for all items. Factor extraction via oblique rotation resulted in the final structure of 16 items in six domains, within which internal consistency was high. All six external criterion measures correlated significantly with BCABL score.

CONCLUSIONS

The BCABL questionnaire, with 16 items mapping to six domains, has excellent criterion validity and test-retest reliability when administered electronically in women with ABL. The BCABL can be used to identify care-seeking barriers for ABL in different populations, inform targeted interventions, and measure their effectiveness.