Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7)

OBJECTIVE

To develop short forms of 2 valid and reliable condition-specific quality-of-life questionnaires for women with disorders of the pelvic floor including urinary incontinence, pelvic organ prolapse, and fecal incontinence (Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire).

STUDY DESIGN

Data from the 100 women who contributed to the development and validation of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire long forms were used to develop the short-form questionnaires. All subsets regression analysis was used to find the items in each scale that best predicted the scale score on the respective long form. When different items appeared equivalent, a choice was made on item content. After development, the short forms and the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire long forms were administered preoperatively to 45 women with pelvic floor disorders scheduled to undergo surgery to evaluate the correlation between short and long forms in a second independent population. The short forms were readministered 3 to 6 months postoperatively to assess the responsiveness of the instruments.

RESULTS

The short-form version of the Pelvic Floor Distress Inventory has a total of 20 questions and 3 scales (Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal-Anal Distress Inventory). Each short-form scale demonstrates significant correlation with their long-form scales (r=.86, r=.92, and r=.93, respectively, P<.0001). For the Pelvic Floor Impact Questionnaire short form, the previously developed short form for the Incontinence Impact Questionnaire-7 was used as a template. The 7 items identified in the previously developed Incontinence Impact Questionnaire-7 short form correlate highly with the Incontinence Impact Questionnaire long form (r=.96, P<.0001) as well as the long forms of the Colorectal-Anal Impact Questionnaire scale (r=.96, P<.0001) and the Pelvic Organ Prolapse Impact Questionnaire (r=.94, P<.0001). All subsets regression analysis did not identify any items or combination of items that correlated substantially better for any of the 3 scales. The scales of the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 maintained their excellent correlation to the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire long forms in the second independent sample (r=.88 to .94 for scales of Pelvic Floor Distress Inventory-20; r=.95 to .96 for scales of Pelvic Floor Impact Questionnaire-7, P<.0001 for all). The test-retest reliability of each scale was good to excellent (intraclass correlation coefficient 0.70 to 0.93, P<.001 for all scales). The scales and summary scores of the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 demonstrated moderate to excellent responsiveness 3 to 6 months after surgery.

CONCLUSION

The Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 are valid, reliable, and responsive short forms of 2 condition-specific quality-of-life questionnaires for women with pelvic floor disorders.

Duloxetine vs placebo in the treatment of stress urinary incontinence: a four-continent randomized clinical trial

OBJECTIVES

To further assess, in a phase 3 study, treatment with duloxetine for women with stress urinary incontinence (SUI) in other geographical regions, including Argentina, Australia, Brazil, Finland, Poland, South Africa and Spain, as previous trials in North America and Europe provided evidence for the safety and efficacy of duloxetine as a pharmacological treatment for SUI in women.

PATIENTS AND METHODS

The study included 458 women aged 27-79 years enrolled in a double-blind, placebo-controlled trial. The patients with predominantly SUI were identified using a validated clinical algorithm. They were randomly assigned to receive placebo (231) or duloxetine 40 mg twice daily (227) for 12 weeks. The primary outcome variables included the incontinence episode frequency (IEF) and the Incontinence Quality of Life (I-QOL) questionnaire. Van Elteren's test was used to analyse the percentage changes in IEF where the stratification variable was weekly baseline IEF (IEF < 14 and > or = 14). Analysis of covariance was used to analyse I-QOL scores.

RESULTS

The mean baseline IEF was 18.4/week; 55% of patients had a baseline IEF of > or = 14. There was a significantly greater median decrease in IEF with duloxetine with placebo (54% vs 40%, P = 0.05), with comparable significant improvements in quality of life (I-QOL score increases of 10.3 vs 6.4, P = 0.007). The improvements with duloxetine were associated with significantly greater increases in voiding intervals than with placebo (20.4 vs 8.5 min, P < 0.001). The placebo response was 10.7% and 12.5% higher than those reported in two European and North American phase 3 trials. This may have been related to more patients being naïve for incontinence management in the current trial. Discontinuation rates for adverse events were 1.7% for placebo and 17.2% for duloxetine (P < 0.001), with nausea being the most common reason for discontinuation (3.1%); it was the most common adverse event with duloxetine, but was mild or moderate in most (81%), did not worsen in any patient and resolved within 7 days in 60% and within 1 month in 86% of continuing patients; 88% of women who experienced nausea while taking duloxetine completed the trial.

CONCLUSIONS

These results show improvements in incontinence and quality of life with duloxetine 40 mg twice daily for 12 weeks that are in keeping with those reported in two other recently completed phase 3 trials in Europe and North America.

Effects of pelvic floor muscle training on strength and predictors of response in the treatment of urinary incontinence

AIMS

The objectives of this study were (1) to determine the effect of training on pelvic floor muscle strength; (2) to determine whether changes in pelvic floor muscle strength correlate with changes in continence; and (3) to determine whether demographic characteristics, clinical incontinence severity indices, or urodynamic measures predict response to pelvic floor muscle training.

METHODS

One hundred thirty-four women with urinary incontinence (95=genuine stress incontinence [GSI]; 19=detrusor instability [DI]; 20=mixed incontinence [GSI+DI]) were randomized to pelvic floor muscle training (n=67) or bladder training (n=67). Urinary diaries, urodynamic evaluation, and vaginal pressure measurements by using balloon manometry were performed at baseline and after 12 weeks of therapy. Primary outcome measures consisted of incontinent episodes per week and vaginal pressure measurements.

RESULTS

Both treatment groups had a reduction in incontinent episodes (P</=0.004). Vaginal pressures increased more with pelvic floor muscle training than with bladder training (P=0.0003). Other than a weak correlation between a reduction in incontinent episodes/week and an increase in maximum sustained vaginal pressure in women with GSI (r=0.32, P=0.04), there were no significant correlations between increases in pelvic floor muscle strength and improvement in continence status. There were no significant correlations between baseline demographic characteristics, clinical incontinence severity, or urodynamic measures and increases in vaginal pressure or improvement in clinical severity after pelvic floor muscle training.

CONCLUSIONS

Pelvic floor muscle training improves continence and increases vaginal pressure measurements, but the direct correlations between these alterations are weak. A woman's response to behavioral treatment does not depend on her demographic characteristics, clinical incontinence severity, urodynamic measures, or initial pelvic floor muscle strength.

Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders

OBJECTIVE

To evaluate the psychometric properties of the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ).

METHODS

The PFDI and PFIQ are based on the structure and content of two previously validated questionnaires (the Urinary Distress Inventory [UDI] and the Incontinence Impact Questionnaire [IIQ]) and have additional questions regarding pelvic organ prolapse and colorectal dysfunction. The PFDI assesses symptom distress in women with pelvic floor disorders and has 3 scales: UDI (28 items), Colorectal-anal Distress Inventory (17 items), and Pelvic Organ Prolapse Distress Inventory (16 items). The PFIQ assesses life impact and also has 3 scales: IIQ, Colorectal-anal Impact Questionnaire, and the Pelvic Organ Prolapse Impact Questionnaire (31 items each). One hundred women with pelvic floor symptoms were enrolled and completed both the PFDI and PFIQ at baseline and again 1 week later. Patients underwent a comprehensive evaluation that included a structured history, Pelvic Organ Prolapse Quantitation, and a 1-week prospective bowel/bladder diary. Patients with urinary incontinence and stage III or IV pelvic organ prolapse also had a urodynamic evaluation.

RESULTS

Each scale of the PFDI and PFIQ proved to be internally consistent (alphas: PFDI.82-.89; PFIQ.96-.97) and reproducible (interclass correlations: PFDI.86-.87; PFIQ.77-.92). Both the UDI and the IIQ significantly correlated with the number of urinary incontinence episodes per week (rho =.26, P <.05; rho =.46, P <.0001, respectively) and the number of pads used per week (rho =.26, P <.05; rho =.40, P <.0001, respectively). The Pelvic Organ Prolapse Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire significantly correlated with the stage of prolapse (rho =.32 and rho =.33, P <.01 each), and the Colorectal-anal Distress Inventory and Colorectal-anal Impact Questionnaire significantly correlated with the number of fecal incontinence episodes per month (rho =.49, P <.0001 and rho =.30, P <.01) and a diagnosis of defecatory dysfunction (rho =.47, P <.0001 and rho =.29, P <.01). The total time taken to complete both instruments averaged 23 minutes (range, 9-55).

CONCLUSION

The PFDI and the PFIQ are reliable, valid, condition-specific quality of life instruments for women with pelvic floor disorders.

Vaginal mesh erosion after abdominal sacral colpopexy

OBJECTIVE

Our goal was to compare the prevalence of vaginal mesh erosion between abdominal sacral colpopexy and various sacral colpoperineopexy procedures.

STUDY DESIGN

We undertook a retrospective analysis of all sacral colpopexies and colpoperineopexies performed between March 1, 1992, and February 28, 1999. The patients were divided into the following 4 groups: abdominal sacral colpopexy, abdominal sacral colpoperineopexy, and 2 combined vaginal and abdominal colpoperineopexy groups, one with vaginal suture passage and the other with vaginal mesh placement. Survival analysis and Cox proportional hazards models were developed to examine erosion rates and time to erosion between groups.

RESULTS

A total of 273 abdominal sacral vault suspensions were performed with the use of permanent synthetic mesh. There were 155 abdominal sacral colpopexies and 88 abdominal sacral colpoperineopexies. Among the 30 combined abdominal-vaginal procedures, 25 had sutures attached to the perineal body and brought into the abdominal field and 5 had mesh placed vaginally and brought into the abdominal field. Overall, mesh erosion was observed in 5.5% (15/273). The prevalence of mesh erosion was 3.2% (5/155) in the abdominal sacral colpopexy group and 4.5% (5/88) in the abdominal sacral colpoperineopexy group (P not significant). The rates of erosion when sutures or mesh was placed vaginally were 16% (4/25) and 40% (2/5), respectively, and were significantly increased in comparison with the rates for abdominal sacral colpopexy (hazard ratio, 5.4; 95% confidence interval, 1.6-18.0; P = .005; vs hazard ratio, 19.7; 95% confidence interval, 3.8-101.5; P < .001). These variables retained their significance after we controlled for other independent variables, including age, concomitant hysterectomy, concomitant posterior repair, and estrogen status. The median time to mesh erosion was 15.6 months for abdominal sacral colpopexy, 12.4 months for abdominal sacral colpoperineopexy, 9.0 months in the suture-only group (P < .005), and 4.1 months in the vaginal mesh group (P < .0001).

CONCLUSIONS

The rate of mesh erosion is higher and the time to mesh erosion is shorter with combined vaginal-abdominal sacral colpoperineopexy with vaginal suture and vaginal mesh placement in comparison with abdominal sacral colpopexy.

Which women with stress incontinence require urodynamic evaluation?

OBJECTIVE

This study was undertaken to determine the predictive value of the symptom of stress urinary incontinence and to evaluate the ability of other factors suggested by a published Agency for Health Care Policy and Research guideline for the discrimination of patients unlikely to require urodynamic testing before surgical management.

STUDY DESIGN

We evaluated 950 consecutive women without advanced (stage III or IV) pelvic organ prolapse who were referred with symptoms of incontinence. Incontinence was recorded by means of standard forms and was characterized as "any stress loss" (76.4%), "primarily stress loss" (58.9%), "stress loss only" (29.8%), "stress and urge loss" (52.2%), "urge loss only" (13.8%), "constant and stress loss" (1.9%), or "constant loss" (2.3%). Other variables were assessed by means of a standardized history, physical examination (including urethral axis determination and stress test), 1-week urinary diary, and postvoid residual volume measurement. A urodynamic diagnosis of pure genuine stress incontinence was used as the criterion standard. Sensitivity, specificity, and positive and negative predictive values were calculated. Logistic regression models incorporating various combinations of stress loss only, previous prolapse or incontinence surgery, nocturia, voiding frequency, urethral hypermobility, and postvoid residual volume <100 mL (the factors recommended by the Agency for Health Care Policy and Research guidelines), along with age and race as predictors of genuine stress incontinence, were constructed to evaluate the predictive ability of the guideline in a subset of 447 patients for whom data on all variables were available.

RESULTS

Of the entire population 480 (50.5%) had pure genuine stress incontinence, 134 (14.1%) had both genuine stress incontinence and detrusor instability, 180 (18.9%) had pure detrusor instability, and 40 (4.2%) had intrinsic sphincter deficiency. Fifty-four (5.7%) had normal study results, and 62 (6.5%) had other nonincontinence diagnoses. Among the subjects with symptoms of stress loss only, 10.8% did not have genuine stress incontinence confirmed on urodynamic examination. Agency for Health Care Policy and Research guideline criteria had excellent discrimination (C statistic of 0.807) compared with the sole criterion of stress urinary incontinence only (C statistic of 0.574), with a positive predictive value of 85.7%. Only 7.8% of subjects met all the criteria, however, and 5.7% of these ultimately had a urodynamic diagnosis of either detrusor instability or normal study result.

CONCLUSION

The predictive value of stress symptoms alone was not high enough to serve as the basis for surgical management. Agency for Health Care Policy and Research guidelines improved the predictive value but were applicable to only a small subset of patients referred with urinary incontinence.

Pelvic muscle electromyography of levator ani and external anal sphincter in nulliparous women and women with pelvic floor dysfunction

OBJECTIVE

The purpose of this study was to compare results of electromyographic assessment of muscular recruitment between nulliparous control subjects without pelvic floor dysfunction and parous subjects with genuine stress urinary incontinence and with pelvic organ prolapse. Interference pattern analysis is an electromyographic technique that reproducibly measures muscular recruitment by detecting both "turns" in the electromyographic signal produced by positive and negative peaks of the motor unit potentials and motor unit potential amplitude. Fewer turns can indicate loss of motor units or failure of central activation of contraction, whereas greater amplitude can indicate reinnervation after nerve damage.

STUDY DESIGN

We performed concentric needle electrode electromyographic examinations of the levator ani and external anal sphincter in 15 nulliparous control subjects and 20 parous subjects with abnormalities (n = 9 with genuine stress urinary incontinence, n = 11 with stage III or IV pelvic organ prolapse). We made digital recordings at multiple sites at rest and with moderate and maximal contraction. Interference pattern analysis yielded the number of turns per second and the mean signal amplitude (in microvolts) for each site at each contraction level. We compared individual patient data with data from the healthy population by means of cloud analysis. Mean values of number of turns per second and mean amplitude in each group were then compared with nonparametric methods and regression models.

RESULTS

Mean ages were 28.7 years (range, 20-49 years) for the control group, 54.3 years (range, 35-75 years) for subjects with genuine stress urinary incontinence, and 65 years (range, 41-77 years) for subjects with pelvic organ prolapse. Median clinical levator ani strengths were 9 (range, 5-9) in the control group, 5 (range, 2-7) in the genuine stress urinary incontinence group, and 5 (range, 2-8) in the pelvic organ prolapse group. Median external anal sphincter strengths were 9 (range, 7-9) in the control group, 5 (range, 3-9) in the genuine stress urinary incontinence group, and 8 (range, 4-9) in the pelvic organ prolapse group. The external anal sphincters of subjects with pelvic organ prolapse had the highest percentage of abnormal study results according to cloud analysis. Mean number of turns per second in levators was greater in control subjects than in subjects with abnormalities (P =.034). We found similar differences in number of turns per second for the external anal sphincter (P =.004). In contrast, we did not find differences between groups in mean amplitude in either the levator ani or the external anal sphincter. Comparison of patients with genuine stress urinary incontinence versus subjects with pelvic organ prolapse showed no significant difference in the number of turns per second in either muscle. Mean amplitude was greater in the pelvic organ prolapse group than in the genuine stress urinary incontinence group for both muscles (levator ani, P =.028; external anal sphincter, P =.048). Neither mean amplitude nor the number of turns per second could be predicted by clinically estimated levator ani strength, age, or fecal incontinence.

CONCLUSION

Compared with nulliparous control subjects, patients with genuine stress urinary incontinence and pelvic organ prolapse had changes in the levator ani and external anal sphincter consistent with either motor unit loss or failure of central activation, or both. Subjects with pelvic organ prolapse had findings consistent with greater recovery than was found in those with genuine stress urinary incontinence. Measures of recruitment by interference pattern analysis correlated better with clinical external anal sphincter strength than with levator ani strength and were independent of age.

Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse

OBJECTIVE

The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described.

STUDY DESIGN

Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms.

RESULTS

After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting.

CONCLUSION

Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.

Quantitative electromyographic analysis of levator ani and external anal sphincter muscles of nulliparous women

OBJECTIVES

Our aims were to introduce a method of digital quantitative electromyography of the levator ani and external anal sphincter muscles and to establish reference values.

STUDY DESIGN

Fifteen nulliparous, symptom-free women underwent concentric needle electromyographic examination of the levator ani and external anal sphincter. We sampled the levator ani transvaginally at 4 sites and the external anal sphincter at 2 sites. The signal was filtered and amplified, and digital recordings were made at 3 levels of voluntary activation at each site. Analyses of motor unit action potentials and interference patterns were performed with the use of these taped signals. Normal ranges were generated and compared with those established for other striated muscles.

RESULTS

The mean age of the subjects was 28.7+/-7.5 years. A median of 24 motor unit action potentials was recorded in each levator ani, and a median of 6 was recorded in each external anal sphincter. Parameters of the levator ani action potentials were significantly greater than those of the external anal sphincter in amplitude (0.48 vs. 0.37 mV; P =.001), duration (10.40 vs. 8.27 ms; P =.002), number of turns per second (2. 80 vs. 2.28; P<.001), and area (0.65 vs. 0.36; P<.001). Parameters of the interference patterns were significantly greater in the levator ani than in the external anal sphincter in number of turns per second (241.6 vs. 183.9; P =.015), amplitude (302.7 vs. 225.3 microV; P<.0001), activity (95.6 vs 61.2; P =.004), envelope size (861.1 vs 567.6 microV; P<.0001), and number of small segments (105. 8 vs 81.4; P =.047). There were no significant differences between levator ani, external anal sphincter, and published parameters from the biceps muscle with regard to amplitude and duration of motor unit action potentials.

CONCLUSIONS

Electromyography of the levator ani and external anal sphincter is feasible and well tolerated. Our findings confirm that the levator ani muscle has larger, more readily recruited motor units than does the external anal sphincter. Ranges for important quantitative electromyographic parameters for these muscles are similar to those published for the biceps.

Effect of patient position on clinical evaluation of pelvic organ prolapse

OBJECTIVE

To compare the severity of pelvic organ prolapse between examinations performed in dorsal lithotomy position and examinations performed upright in a birthing chair using the Pelvic Organ Prolapse Quantification System (POPQ).

METHODS

One hundred eighty-nine consecutive women were evaluated between April 1997 and September 1998. All women were examined in the dorsal lithotomy position and in a birthing chair at a 45 degrees angle. Degree of pelvic organ prolapse was assessed using the POPQ.

RESULTS

When examined upright, 133 patients (70%) had the same stage of prolapse, whereas 49 (26%) had a higher stage and seven (4%) had a lower stage. Of patients who were stage 0 or I when examined in lithotomy position, 23 (36%) were stage II or greater when examined upright. Similarly, of patients who were stage II in lithotomy, 17 (23%) were stage III or higher when examined upright. There was a statistically significant increase in the degree of prolapse at all the POPQ measurements (P <.05 for each point), except for measurement of total vaginal length. Forty-eight percent of patients had at least one measurement increase by 2 cm or more when examined upright. Logistic regression identified no patient characteristics that were independently associated with a significant increase in stage or POPQ values with change in examination position.

CONCLUSION

The degree of pelvic organ prolapse assessed with the patient in the lithotomy position correlates well with assessment performed upright; however, overall there is a higher degree of prolapse with upright examination.

Relationship between urethral and vaginal pressures during pelvic muscle contraction. The Continence Program for Women Research Group

Condensation is the performance of an effective pelvic muscle contraction increases urethral and vaginal pressures and is independent of demographic, clinical, and urodynamic factors. Our objective was to examine the relationship between urethral closure pressure and vaginal pressure during a pelvic muscle contraction in minimally trained women. Our secondary aim was to determine whether demographic, clinical, or urodynamic factors predict pelvic muscle contraction performance. Two hundred two women with urinary incontinence underwent multichannel urodynamic evaluation, including urethral profilometry and measurement of vaginal pressure during pelvic muscle contraction. One hundred forty-four women were diagnosed with genuine stress incontinence, 28 with detrusor instability, and 30 with mixed incontinence. Urethral and vaginal pressures correlated significantly during pelvic muscle contraction (P < or = 0.006). The ability to perform an adequate pelvic muscle contraction was independent of subject age, parity, hormonal or hysterectomy status, clinical severity, urethral support, and urethral profilometry measures (P > or = 0.42).

Pressure transmission ratio reproducibility in stress continent and stress incontinent women

Our objective was to determine the effect of cough strength on pressure transmission ratios and establish quantitative and qualitative intra-observer test-retest reproducibility of pressure transmission ratios calculated from dynamic urethral pressure profilometry. The study included 242 consecutive urodynamic evaluations on women without pelvic organ prolapse. Dynamic urethral pressure profiles were performed in duplicate with coughs of different intensities. The analysis included pressure transmission ratios from the proximal 3 urethral quartiles (Q1 through Q3) and the mean pressure transmission ratio calculated from these quartiles. The final diagnoses were stratified into genuine stress incontinence, 135 (56%), and stress continence, 107 (44%). Correlations were strong for pressure transmission ratios from the first versus the second dynamic urethral pressure profile (K = 0.712 for mean). While the variation in cough intensity between hard and soft coughs averaged 30 cm H2O (P < 0.001), correlation's were equally strong between hard and soft cough pressure transmission ratios (K = 0.712 for mean). When mean pressure transmission ratios were stratified into below 90% and at least 90% categories, 83.5% of subjects had test-retest concordance (K = 0.671). Concordance rates were less for stress continent subjects (80.0%; K = 0.527) than for genuine stress incontinence subjects (86.4%; K = 0.679). Pressure transmission ratios appear to have reasonable quantitative and qualitative reproducibility which is unaffected by cough strength. The degree of individual variability limits the utility of pressure transmission ratios to diagnose genuine stress incontinence independent of other, equally variable clinical and urodynamic parameters, but this measure is sufficiently reproducible to be useful in characterizing stress sphincteric function in population studies.

A survey of pessary use by members of the American urogynecologic society

OBJECTIVE

To describe trends in pessary use for pelvic organ prolapse.

METHODS

An anonymous survey administered to the membership of the American Urogynecologic Society covered indications, management, and choice of pessary for specific support defects.

RESULTS

The response rate was 48% (359 of 748). Two hundred fifty surveys were received at the scientific meeting and 109 were returned by mail. Seventy-seven percent used pessaries as first-line therapy for prolapse, while 12% reserved pessaries for women who were not surgical candidates. With respect to specific support defects, 89% used a pessary for anterior defects, 60% for posterior defects, 74% for apical defects, and 76% for complete procidentia. Twenty-two percent used the same pessary, usually a ring pessary, for all support defects. In the 78% who tailored the pessary to the defect, support pessaries were more common for anterior (ring) and apical defects (ring), while space-filling pessaries were more common for posterior defects (donut) and complete procidentia (Gellhorn). Less than half considered a prior hysterectomy or sexual activity contraindications for a pessary, while 64% considered hypoestrogenism a contraindication. Forty-four percent used a different pessary for women with a prior hysterectomy and 59% for women with a weak pelvic diaphragm. Ninety-two percent of physicians believed that pessaries relieve symptoms associated with pelvic organ prolapse, while 48% felt that pessaries also had therapeutic benefit in addition to relieving symptoms.

CONCLUSION

While there are identifiable trends in pessary use, there is no clear consensus regarding the indications for support pessaries compared with space-filling pessaries, or the use of a single pessary for all support defects compared with tailoring the pessary to the specific defect. Randomized clinical trials are needed to define optimal pessary use.

The urethrodetrusor facilitative reflex in women: results of urethral perfusion studies

OBJECTIVE

This study was undertaken to describe the effects of urethral perfusion on bladder activity, urethral pressure, and sensation in patients with either incontinence or prolapse or both of these.

STUDY DESIGN

Among 76 consecutive patients who were seen for urodynamic evaluations, 63 had vesical, abdominal, and urethral pressures measured while the urethra was perfused with fluid. A perfusion study result was considered positive if the perfusion provoked a detrusor contraction.

RESULTS

Of the 63 women 9 (14%) had a positive urethral perfusion study result, and all of them had detrusor instability independent of perfusion. Among the women with detrusor instability 53% (n = 9/17) had positive study results, versus none of the 46 women without detrusor instability (P =. 000001). Women with mixed incontinence were more likely to have a positive perfusion test result (n = 4/7; 57%) than were those without mixed incontinence (n = 5/56; 10%; P =.006), although urethral hypermobility was not significantly associated with a positive test result. Among the subjects 60% experienced urgency during perfusion, and in half of these urethral pressure was concurrently increased. Among those who had no urgency 84% demonstrated decreased urethral pressure (P =.01).

CONCLUSIONS

Positive perfusion study results were more common among women with detrusor instability but did not discriminate any patient with detrusor instability whose condition was not diagnosed by standard urodynamic studies. The association of positive perfusion study results with mixed incontinence seems primarily related to poor central inhibition of detrusor activity rather than to urethral stimulation.

Observed patient compliance with a structured outpatient bladder retraining program

OBJECTIVE

Our purpose was to determine patient compliance with a telephone-based retraining program.

STUDY DESIGN

This was a retrospective study of 123 women with urinary urgency or urge incontinence who were offered bladder retraining with facsimile machine submission of a retraining diary and weekly telephone feedback.

RESULTS

Completion was defined as having >/=4 follow-up sessions and >/=6 weeks of retraining. Seventy-one percent (87/123) began the retraining program; 63% (55/87) of them completed it, for an overall compliance rate of 45% (55/123). When we compared those who completed retraining with those who started but did not complete it, only concurrent use of pharmacologic therapy was significantly different (87% vs 53%, respectively; P <.001). This difference remained significant after we controlled for other independent variables, including urodynamic diagnosis and physician.

CONCLUSIONS

A total of 55% of women to whom telephone-based bladder retraining was recommended either never started or were noncompliant with the treatment. Bladder retraining success in the "real world" may be substantially lower than that described in well-funded labor-intensive clinical trials.

Understanding lower urinary tract function in women soon after bladder neck surgery. Continence Program for Women Research Group

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty-seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6-week and 6-month postoperative status was assessed with urodynamic testing, physical examination, and condition-specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR >/= 90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR </= 110% (P = .006 and P = .04). At 6 months, subjects with excessive obstruction were more likely to have EPD than other subjects (75% vs. 27%, P = .001). Those with optimal dynamic obstruction (PTR >/= 90% but </= 110%) were more likely to have normal function (no GSI, no DI, and no EPD) than those with higher or lower PTRs (59% vs. 34%, P = .04). Urethral axis measurements did not correlate with functional status at either follow-up session. The magnitude of dynamic urethral obstruction is related to function after bladder neck surgery. Excessive obstruction is associated with DI and EPD, inadequate obstruction with GSI, and optimal obstruction with normal function. Neurourol. Urodynam. 18:629-637, 1999.

The effect of bladder training, pelvic floor muscle training, or combination training on urodynamic parameters in women with urinary incontinence. Continence Program for Women Research Group

The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral closure pressure, mean urethral closure pressure, maximum Kegel urethral closure pressure, mean Kegel urethral closure pressure, functional urethral length, pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.

Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse

OBJECTIVE

The objective of this study was to determine the accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse.

STUDY DESIGN

A retrospective chart review of all women undergoing surgery for anterior vaginal wall prolapse during the years of 1994 to 1996 identified operative notes that described the surgical assessment of paravaginal support. These surgical findings were compared with the preoperative clinical assessment. Clinical parameters that predicted poor correlation were identified. Statistical analysis used the chi(2) test.

RESULTS

One hundred seventeen patients had surgery for anterior vaginal prolapse. Seventy had documentation of an intraoperative paravaginal support evaluation. Of these, 44 patients had vaginal procedures, and 26 had abdominal procedures. All patients had at least stage 2 prolapse before surgery, and all were noted to have excellent pelvic support 4 to 6 weeks after surgery. The prevalence of paravaginal defects at surgery was 47% on the right and 41% on the left. The sensitivity and negative predictive value for the clinical assessment for paravaginal defects were good on both the right and left sides, whereas the specificity and positive predictive values were poor. Stage of prolapse, previous hysterectomy, or previous anterior colporrhaphy did not significantly affect the accuracy of the clinical examination in predicting fascial defects. However, previous retropubic urethropexy did significantly decrease the accuracy of the clinical examination in predicting right paravaginal defects (P <.01) but not left.

CONCLUSION

Although preoperative clinical assessment for paravaginal defects is useful, it does not substitute for careful intraoperative evaluation for endopelvic fascial defects.

Urinary incontinence and pelvic organ prolapse in nulliparous women

OBJECTIVE

To determine differences between vaginally parous and nulliparous women presenting with urinary incontinence and pelvic organ prolapse.

METHODS

Seven hundred forty eight consecutive referrals with urinary incontinence or pelvic organ prolapse, 62 of whom were nulliparous, were included in the analysis. Five hundred thirty-seven (72%) had urinary incontinence and 235 (31%) had at least stage III pelvic organ prolapse. Each subject had standard history, physical examination, and multichannel urodynamic testing. Differences between parous and nulliparous women were compared using parametric and nonparametric analysis of variance and the chi2 test with Yates correction where appropriate.

RESULTS

The only significant demographic difference between the groups was that parous women had more previous continence and prolapse surgery. There were significant differences in distribution of diagnoses according to parity, with the nulliparas much less likely to have pelvic organ prolapse. Among incontinent women without prolapse, nulliparas were significantly more likely to have pure detrusor instability. Of those with pure genuine stress incontinence, nulliparas were older, had less anterior vaginal wall descent, less bladder neck mobility, narrower genital hiatus and perineal body measurements, and lower maximum urethral closure pressures. Of those with pure detrusor instability, the only difference was that nulliparas were significantly younger. For women with stage III pelvic organ prolapse or worse, no significant difference in any measured characteristic was noted.

CONCLUSION

Nulliparous women were less likely to present with pelvic organ prolapse and those with urinary incontinence differed little from incontinent parous women.

An anatomic and functional assessment of the discrete defect rectocele repair

OBJECTIVE

The aim of this study was to describe the anatomic and functional results of the discrete fascial defect rectocele repair.

STUDY DESIGN

Sixty-nine women underwent rectocele repair at Duke University Medical Center during a 3-year period beginning January 1, 1994. Repair was limited to reapproximation of discrete defects in the rectovaginal fascia, without levator plication or perineorrhaphy. Outcome measures included Pelvic Organ Prolapse Quantitation measurements, prolapse stage, and a symptom questionnaire. Univariate and nonparametric tests were used as appropriate.

RESULTS

Before the operation 46% patients (32/69) reported constipation, 39% (27/69) reported splinting, 32% (22/69) reported tenesmus, and 13% (9/69) reported fecal incontinence. The median preoperative posterior Pelvic Organ Prolapse Quantitation stage was 2 (1-4). Pelvic Organ Prolapse Quantitation stage had improved for all but 2 women at 6 weeks. Eighteen percent (8/43) had recurrent rectoceles at 12 months. Mean values for the points describing the posterior vaginal wall improved >2 cm (P <.0001). Although perineorrhaphy was not performed, the genital hiatus decreased by 2. 3 cm (P <.0001), with no significant change in the length of the perineal body. Functional results mirrored anatomic results, with statistically significant improvements for all symptoms.

CONCLUSIONS

The discrete defect rectocele repair provides anatomic correction of rectoceles with alleviation of associated symptoms for most women.

Epidemiology and natural history of pelvic floor dysfunction

Pelvic floor dysfunction, including urinary incontinence, anal incontinence, and pelvic organ prolapse, is extremely common, affecting at least one-third of adult women. A minority of patients sustaining these conditions volunteer their symptoms. Risk factor identification and the development of tactics for prevention are significant priorities for future research. Understanding both the specific predisposing factors that place an individual woman at risk and the precise events of the labor and delivery process that initiate injury and dysfunction is important for primary prevention. Defining the relative importance of various promoting and decompensating factors is essential for secondary prevention.

Reliability and correlation of measurements during and after bladder neck surgery. The Continence Program for Women Research Group

OBJECTIVES

To assess the reliability of seven intraoperative measurements of the effects of bladder neck suspension and correlate these measurements with postoperative dynamic urethral obstruction, quantified as the cough-pressure transmission ratio.

PATIENTS AND METHODS

Sixty women undergoing surgery for bladder neck hypermobility had seven measurements performed in duplicate: (i) the endoscopic appearance of the bladder neck: (ii) the bladder neck-retropubic surface distance (BN-RP distance); (iii) urethral axis; (iv) slow urethral pressure profilometry (UPP); (v) fast UPP; (vi) straining UPP; and (vii) dynamic UPP. Reliabilities were assessed by computing the intraclass correlation coefficient (R) for continuous data or Kappa statistic (K) for ordinal data. Pearson correlation coefficients were used to assess the relationships between the intra-operative measures and postoperative pressure transmission.

RESULTS

The intra-operative reliabilities for maximum pressure, length and area from the three UPP techniques were high (R=0.88-0.98) as were those for urethral axis measurements (R=0.98). In contrast, reliabilities were poor for pressure transmission ratios (R=0.15-0.33), BN-RP distance (R=0.55), and endoscopic appearance (K=0.10). There were significant correlations of the pressures from the UPPs and intra-operative pressure transmission ratios with postoperative pressure transmission ratios; however, the poor intra-operative reliability of intra-operative pressure transmission limits their usefulness. None of the other measures correlated significantly with postoperative pressure transmission ratios.

CONCLUSIONS

Of the measures studied, only intra-operative UPPs had both high reliability and good postoperative correlations.

Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Continence Program for Women Research Group

OBJECTIVE

We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes.

STUDY DESIGN

A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests.

RESULTS

The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site.

CONCLUSIONS

Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.

Urethral prolapse after collagen injection

A woman who was treated for intrinsic urethral sphincteric deficiency with periurethral injection of glutaraldehyde cross-linked collagen had prolapse of the urethral mucosa and recurrence of incontinence. She subsequently required surgical resection and a fascia lata sling. This is the first known occurrence of this postinjection complication.

Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse

OBJECTIVE

Our purpose was to assess a modification of abdominal sacral colpopexy in 19 patients.

STUDY DESIGN

The rectovaginal space was dissected to the superior aspect of the posterior vaginal fascia still contiguous with the perineal body. Mersilene (Ethicon, Somerville, N.J.) mesh was sutured to this fascia and along the entire posterior vaginal wall. Patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles are reported. Outcome measures included bowel symptoms and pelvic organ prolapse staging. Defecography was performed in three patients. Wilcoxon signed rank analysis was used for comparison of prolapse measures.

RESULTS

Mean follow-up was 11 weeks. Bowel symptoms improved in 8 of 11 women. No subjects had greater than stage II prolapse postoperatively and median improvement in stage was 3 (range 2 to 4). The mean decrease in the genital hiatus measurement was 3.13 +/- 1.25 (range 2 to 6) cm. Postoperative defecography documented correction of rectoceles and enteroceles and improvement in perineal descent with straining.

CONCLUSIONS

Abdominal sacral colpoperineopexy is effective surgery for vaginal vault prolapse associated with perineal descent and posterior vaginal defects.

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery

OBJECTIVE

Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence.

STUDY DESIGN

Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed.

RESULTS

Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters.

CONCLUSIONS

The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.

Terminology of pelvic organ prolapse

Pelvic organ prolapse is a common gynecologic condition, yet until recently no standard classification system to describe prolapse existed. A validated and standardized terminology system is now in use that allows accurate description of physical findings as well as meaningful communication between clinicians and comparisons of published series.

Diagnosing intrinsic sphincteric deficiency: comparing urethral closure pressure, urethral axis, and Valsalva leak point pressures

OBJECTIVES

Our purpose was to compare three measures proposed to diagnose intrinsic sphincteric deficiency: maximum urethral closure pressure, Valsalva leak point pressure, and straining urethral axis.

STUDY DESIGN

A total of 159 women with pure genuine stress incontinence had the three measures determined in a standardized fashion. Critical cutoff values for the Valsalva leak point pressure (52 cm) and urethral axis (22 degrees) were established by examining relative frequency distribution curves, using closure pressure of 20 as the arbitrary benchmark value for the prevalence of intrinsic sphincteric deficiency. The distribution of cutoff values is described and differences among the measures with respect to risk factors for intrinsic sphincteric deficiency and incontinence severity were determined.

RESULTS

Half the subjects fell below at least one cutoff value, but only 10% fell below all three. Sixty-four percent of subjects with either low closure pressure or leak point pressure had low values for the other, whereas 21% had discordance between them. Only 53% of subjects with low closure pressure and 40% with low leak point pressure had an axis < or = 22 degrees. Conversely, a substantial portion (36%) of subjects with pure genuine stress incontinence without urethral hypermobility had neither low urethral or leak point pressures. All three cutoff-values were associated with risk factors for intrinsic sphincteric deficiency, but only low closure and leak point pressures had significant associations with the severity of incontinence.

CONCLUSIONS

Intrinsic sphincteric deficiency should be diagnosed by a composite of historic, urodynamic, anatomic, and clinical severity criteria. We would include a maximum urethral closure pressure < or = 20, a Valsalva leak point pressure < or = 50, and a stress urethral axis < or = 20 in this composite.

Clinical predictors of urinary incontinence in women

OBJECTIVE

Our purpose was to characterize historic and clinical parameters in incontinent women to determine the predictive value for urodynamic diagnoses.

STUDY DESIGN

The analysis includes 535 consecutive women with final diagnoses of genuine stress incontinence, detrusor instability, or both. Evaluations included a standardized history, examination, urinary diary, quantitation test, and urodynamics. The analysis used one-way analysis of variance, chi 2 analysis with Yates' correction, and Fisher's exact test.

RESULTS

A total of 351 (66%) women were diagnosed with genuine stress incontinence, 102 (19%) with detrusor instability, and 82 (15%) with both. Half had symptoms of both stress incontinence and urge incontinence, of whom only 21% had both genuine stress incontinence and detrusor instability. Fewer than half of women diagnosed with genuine stress incontinence or detrusor instability had just symptoms of stress incontinence or urge incontinence, respectively. Evaluation of historic, examination, and urinary diary data for their influences on the predictive value of pure stress incontinence or urge incontinence revealed statistical differences for urethral hypermobility, estrogen deficiency, and incontinent episodes, yet they were not clinically practical predictors.

CONCLUSIONS

Pure symptoms identify fewer than half of patients with pure genuine stress incontinence or detrusor instability; historic and clinical parameters do not improve the sensitivity of these symptoms.

Uroflowmetry in women with urinary incontinence and pelvic organ prolapse

OBJECTIVE

To characterize uroflowmetry parameters in women with pelvic organ prolapse (POP) and urinary incontinence (UI) and to assess the effects of clinical and urodynamic variables on these parameters.

PATIENTS AND METHODS

The study comprised 655 consecutive women who presented with UI or POP and who had interpretable uroflowmetry values. Normal uroflowmetry values were defined as a maximum flow (Q(max)) > or = 15 mL/s, a mean flow (Q(mean)) > or = 10 mL/s, a post-void residual volume (PVR) < or = 100 mL and a continuous, single-peak waveform. Parametric and non-parametric analysis of variance and chi-square analysis were used to compare differences between diagnostic groups. Multiple linear regression models were developed to evaluate factors considered to influence uroflowmetry.

RESULTS

Of the 655 patients, 471 (72%) had UI of whom 16% had pure detrusor instability (DI), 69% pure genuine stress incontinence (GSI) and 15% with both, and 184 (28%) had POP, 26% of whom also had DI. Of all patients, 72% had normal uroflowmetry patterns, 13% had multiple peaks and 15% had patterns with interrupted flow; 56% had completely normal uroflowmetry. There were significant differences in uroflowmetry values between the POP and UI groups, with the former having a lower Q(max) and Q(mean) (P < 0.001), larger PVRs (P < 0.001) and a lower percentage of totally normal uroflowmetry (33% and 64%, respectively, P < 0.001). Of patients with POP, 30% had a PVR > 100 mL. Because of the differences, the POP and UI groups were evaluated separately in the regression analysis. In both groups, the most important determinants of flow rate were the volume voided and pressure transmission ratio (PTR). However, when several factors (including age, voided volume, PTR and maximum detrusor pressure with flow and at Q(max)) were included in the model, they accounted for only 23-26% of the variability of flow in the patients with UI and 36-39% of the variability in patients with POP. The subsets of patients with pure DI in both the UI and POP groups had higher PVR volumes than the other subsets.

CONCLUSIONS

These results show that the positive correlation between flow rate and voided volume described in normal populations is also observed in women with UI and POP. However, most of the variability in urine flow was not attributable to factors such as age, voided volume and PTR, confirming the complexity of the micturition mechanism. Women with POP had more objective evidence of emptying-phase dysfunction than women with UI, although most emptied their bladders efficiently. Finally, the results suggest that women with DI exhibit dysfunction of both inhibitory and facilitory detrusor control.

Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system

OBJECTIVE

Our purpose was to determine the intraobserver and interobserver reliability of site-specific measurements and stages with the proposed international Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society 1994 draft prolapse terminology document.

STUDY DESIGN

Women who completed informed consent procedures underwent pelvic examinations by two investigators, each blinded to the results of the other's examination. The reproducibility of the nine site-specific measurements and the summary stage and substage were analyzed with Spearman's correlation coefficient (rs) and Kendel tau B Correlation Coefficient (tau b), respectively. Similar analyses were performed on supine and upright examinations performed at two different times by one examiner.

RESULTS

Experienced examiners averaged 2.05 minutes per examination and new examiners averaged 3.73 minutes. In the study of interobserver reliability, 48, subjects, mean age 61 +/- 14 years, parity 3 +/- 2, weight 74 +/- 31 kg, comprised the study population. Correlations for each of the nine measurements were substantial and highly significant (rs 0.817, 0.895, 0.522, 0.767, 0.746, 0.747, 0.913, 0.514, and 0.488, p = 0.0008 to < 0.0001). Staging and substaging were highly reproducible (tau b 0.702 and 0.652). In no subject did the stage vary by more than one; in 69% stages were identical. In the study of intraobserver reliability, for 25 subjects correlations for each of the nine measurements were equally strong (rs 0.780, 0.934, 0.765, 0.759, 0.859, 0.826, 0.812, 0.659, 0.431). Measurements from the upright examinations reflected greater prolapse. Staging and substaging were highly reproducible (tau b 0.712 and 0.712). In no subject did the stage vary by more than one; in 64% stages were identical. All stage discrepancies represented an increase in the upright position.

CONCLUSIONS

There is good reproducibility of measures with the proposed system. The data suggest that the reliability is independent of examiner experience. Patient position is likely important in maximizing the severity of the prolapse.

Efficacy of estrogen supplementation in the treatment of urinary incontinence. The Continence Program for Women Research Group

OBJECTIVE

To assess the efficacy of cyclic postmenopausal hormone replacement in treating urinary incontinence in hypoestrogenic women.

METHODS

Eighty-three hypoestrogenic women complaining of urinary incontinence were included. All patients were community-dwelling, age 45 years or older, with involuntary loss of urine occurring at least once a week and urodynamic evidence of genuine stress incontinence and/or detrusor instability. Evaluation consisted of a comprehensive clinical and urodynamic research protocol. The hypoestrogenic entry criterion was a plasma estradiol level of 30 pg/mL or less. Parabasal cells on vaginal smears were also monitored. The primary outcome was the number of incontinent episodes per week, as documented on a standardized urinary diary. Secondary outcomes were the quantity of fluid loss, voluntary diurnal and nocturnal micturition frequency, generic and condition-specific health-related quality of life measurements, and patient satisfaction. A randomized, placebo-controlled, double-blind design was used. Subjects in the treatment group were given conjugated equine estrogens (0.625 mg) and medroxyprogesterone (10 mg) cyclically for 3 months. Controls received placebo tablets.

RESULTS

(All results are presented as mean +/- standard deviation.) Subjects were 67 +/- 9 years old. The menopause duration was 18 +/- 11 years. The duration of incontinence was 9 +/- 9 years. Estradiol level at baseline was 9 +/- 9 pg/mL, and the parabasal cell count was 42 +/- 44%. The number of incontinent episodes at baseline was 13 +/- 10 for the treatment group and 16 +/- 4 for controls. No significant changes occurred in the number of incontinent episodes after treatment: 10 +/- 10 for the treatment group, and 13 +/- 14 for the controls (P = .7). Also, fluid loss was not changed: 176 +/- 106 g for the treatment group and 64 +/- 88 g for the control group at baseline, and 101 +/- 150 and 51 +/- 69 g after treatment, respectively (P = .7). There were no significant differences for either diurnal or nocturnal voluntary micturition, quality of life measures, or patient's perception of improvement.

CONCLUSION

Three-month cyclic hormone replacement therapy did not affect either clinical or quality of life variables of incontinent, hypoestrogenic women. Long-term effects are unlikely to be substantially different. The use of estrogen supplementation as preventive or adjuvant therapy was not evaluated in this study.

Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group

OBJECTIVE

Severe prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not.

STUDY DESIGN

This prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years.

RESULTS

Needle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patient's function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support.

CONCLUSIONS

Preoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension.

The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction

This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.

The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction

This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.

The effect of vesical volume on Valsalva leak-point pressures in women with genuine stress urinary incontinence

OBJECTIVE

To determine the effect of increasing vesical volume on the Valsalva leak-point pressure, examine the relationship between leakage at a given volume and clinical incontinence severity, and evaluate the relationships between leakage at a given volume and other measures of urethral resistance.

METHODS

One hundred twenty women with genuine stress urinary incontinence (GSI) underwent serial Valsalva leak-point pressure determinations at vesical volumes of 100, 200, and 300 mL, and at maximum cystometric capacity. Urinary diary data, quantitative pad testing, and passive and dynamic urethral profilometry were also performed.

RESULTS

Thirty-three women had leakage starting at a vesical volume of 100 mL, 18 at 200 mL, and 19 at 300 mL, and 17 had leakage only at maximum cystometric capacity. The mean first positive Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures at maximum capacity in all groups: in women who began to leak at 100 mL, 57 versus 36 cm H2O (P < .001); at 200 mL, 59 versus 45 cm H2O (P < .001); and at 300mL, 61 versus 47 cm H2O (P = .01). Women who had leakage at lower vesical volumes had worse measures of clinical incontinence severity and lower maximum urethral closure pressure less than or equal to 20 cm H2O) and pure intrinsic sphincteric deficiency (low urethral pressure and the lack of urethral hypermobility), but the specificities were 63 and 50%, respectively.

CONCLUSIONS

Women with GSI are more likely to leak during Valsalva with increasing vesical volume. Valsalva leak-point pressures decrease significantly with bladder filling. The volume at which leakage occurs correlates inversely with clinical severity and directly with maximum urethral closure pressure. A negative Valsalva leak-point pressure at 300 mL excludes the presence of low urethral pressure and pure intrinsic sphincteric deficiency; however, the specificity and positive predictive value are inadequate for making a clinical diagnosis of either condition.

Comparison between urinary diaries completed with and without intensive patient instructions

The evaluation of the incontinent patient relies on accurate assessment of urinary symptoms. Although the 7 day urinary diary is a reproducible method of data collection, the optimal means of implementing this diary is unknown. The urinary diary is usually employed after the initial clinical pathophysiologic evaluation has been performed and the patient has received intensive instructions on the correct method of diary completion. This study aims to determine if a urinary diary provided to the patient prior to the initial clinical evaluation along with minimal instructions will provide symptom data comparable with that obtained by conventional methods. Two hundred seventy-eight women were recruited to participate in one of three clinical trials for urinary incontinence treatment. All subjects completed a diary prior to the initial clinical evaluation, the Minimal Instruction Diary, and a second diary after clinical evaluation, the Intensive Instruction Diary. The Minimal and the Intensive Instruction Diaries were compared for number of episodes of diurnal and nocturnal voluntary micturition and incontinence. Pearsons' correlation coefficients ranged from 0.67 to 0.78 for each of the urinary symptoms. Intra-subject comparison indicated a decline in reports of nocturnal voluntary micturitions from the Minimal to the Intensive Instruction Diary. No demographic or urodynamic parameters could account for the difference. The 7 day urinary diary is a reliable tool to asses urinary symptoms, which can be utilized prior to the initial clinical evaluation. Its case of use and practicality make this diary promising for use in a wider patient population.

Bladder compliance in neurologically intact women

No data currently exist to define normal bladder compliance (C) in women. This study was undertaken to establish normative data for C in neurologically intact women and to determine if detrusor instability (DI) is associated with changes in C. The multichannel urodynamic tracings of 270 patients (195 stable, 75 unstable) were reviewed according to a standard written protocol. Vesical and abdominal pressures (Pves, Pabd) were measured during retrograde filling after a stable baseline was established (< 50 ml) and just prior to cessation of infusion. If a detrusor contraction occurred, measurements were taken during a 5-sec window preceding onset of contraction. The vesical volume used to calculate C was the total bladder volume determined by completely emptying the bladder at the end of cystometry. Compliance was calculated by dividing this volume by the change in detrusor pressure (Pdet). For the purpose of some analyses, infinite C, i.e., no observed rise in Pdet, was arbitrarily assigned a value of 1,000. Overall, 47.6% of women had no increase in Pdet with filling to maximum cystometric capacity (MCC) and had infinite C. Women with instability were significantly less likely to have infinite C than those with stable bladders (32% vs. 53%; P = 0.003). In 75% of women, C was > 130 ml/cm; in 90%, C was > 60 ml/cm; and in 95%, C was > 40 ml/cm. There were significant differences between the distribution of stable and unstable bladders above and below each of these percentile cutoffs. Only 2 women, both of whom had unstable bladders, had C < 20 ml/cm water. Ninety-five percent of neurologically intact women have C > 40 ml/cm, and nearly half have no increase in Pdet during filling to MCC. Patients with DI have significantly less compliant bladders than do those with stable bladders. If C is < 40 ml/cm, a woman is 16 times more likely to have DI. Decreased C may suggest the diagnosis of DI in patients with urge incontinence whose symptoms are not reproduced in the laboratory.

Wound infection after abdominal hysterectomy: effect of the depth of subcutaneous tissue

OBJECTIVE

Our purpose was to determine the effect of the depth of the subcutaneous tissue at the operative site on abdominal wound infection after hysterectomy.

STUDY DESIGN

A prospective study was performed of women undergoing abdominal hysterectomy and not receiving antibiotic prophylaxis who underwent maximum vertical measurement of their subcutaneous incisions before the abdominal cavity was surgically entered. Additional demographic and perioperative data previously associated with wound infection were collected and analyzed. Surgical technique was standardized among the three attending surgeons involved.

RESULTS

Wound infection occurred in 17 of 150 (11.3%) women undergoing abdominal hysterectomy. Univariate analysis identified the following risk factors as being significantly associated with wound infection: depth of subcutaneous tissue (p = 0.0004), preoperative serum albumin (0.0015), weight (p = 0.0029), and body mass index (p = 0.0032). Logistic regression analysis confirmed the thickness of the subcutaneous tissue as the only significant risk factor for wound infection (p = 0.04) (odds ratio 1.37, 95% confidence interval 1.01 to 1.86). No patients with a maximum depth of subcutaneous tissue < 3 cm had a wound infection.

CONCLUSION

We conclude that the depth of subcutaneous tissue is the most significant risk factor associated with abdominal wound infection after hysterectomy.

Wound infection after abdominal hysterectomy: effect of the depth of subcutaneous tissue

OBJECTIVE

Our purpose was to determine the effect of the depth of the subcutaneous tissue at the operative site on abdominal wound infection after hysterectomy.

STUDY DESIGN

A prospective study was performed of women undergoing abdominal hysterectomy and not receiving antibiotic prophylaxis who underwent maximum vertical measurement of their subcutaneous incisions before the abdominal cavity was surgically entered. Additional demographic and perioperative data previously associated with wound infection were collected and analyzed. Surgical technique was standardized among the three attending surgeons involved.

RESULTS

Wound infection occurred in 17 of 150 (11.3%) women undergoing abdominal hysterectomy. Univariate analysis identified the following risk factors as being significantly associated with wound infection: depth of subcutaneous tissue (p = 0.0004), preoperative serum albumin (0.0015), weight (p = 0.0029), and body mass index (p = 0.0032). Logistic regression analysis confirmed the thickness of the subcutaneous tissue as the only significant risk factor for wound infection (p = 0.04) (odds ratio 1.37, 95% confidence interval 1.01 to 1.86). No patients with a maximum depth of subcutaneous tissue < 3 cm had a wound infection.

CONCLUSION

We conclude that the depth of subcutaneous tissue is the most significant risk factor associated with abdominal wound infection after hysterectomy.

Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence. The Continence Program for Women Research Group

OBJECTIVE

Our aim was to correlate multiple measures of urethral resistance with five clinical measures of incontinence severity in women with pure genuine stress incontinence.

STUDY DESIGN

Seventy-five women with pure genuine stress incontinence underwent passive and dynamic urethral pressure profilometry and Valsalva leak point pressure determinations. The standardized and validated measures of incontinence severity included (1) the number of incontinent episodes, (2) the number of continence pads used recorded in a prospective 1-week urinary dairy, (3) grams of fluid loss on a pad quantitation test, and (4) two condition-specific quality-of-life scales, the urogenital distress inventory and the incontinence impact questionnaire. The urodynamic and severity measures were compared with Pearson product-moment correlation analysis.

RESULTS

There were no significant correlations between dynamic urethral pressure profile pressure transmission ratios and any measure of incontinence severity. Passive urethral pressure profile variables correlated significantly with incontinence episodes and pad use. Valsalva leak point pressures correlated significantly with pad use and quantitation testing. None of the urodynamic measurements was significantly correlated with either of the quality-of-life scales, but our power to demonstrate a correlation was limited.

CONCLUSIONS

Both passive urethral pressure profile measures and Valsalva leak point pressures correlate with some severity measures of genuine stress incontinence. Although inefficient pressure transmission during stress is critical to the pathogenesis of genuine stress incontinence, the severity of the pressure transmission defect is not related to clinical severity. Conversely, impairment of intrinsic urethral resistance is not essential to the pathogenesis of genuine stress incontinence, but the degree of sphincteric impairment is related to severity once the condition exists.

Valsalva leak point pressures in women with genuine stress incontinence: reproducibility, effect of catheter caliber, and correlations with other measures of urethral resistance. Continence Program for Women Research Group

OBJECTIVES

The Valsalva leak point pressure has been promoted as an alternative to urethral pressure profilometry as a measure of urethral resistance in women with genuine stress incontinence. Our aims were to evaluate the reproducibility of the Valsalva leak point pressure, to assess the effect of catheter caliber on the Valsalva leak point pressure, and to compare vesical Valsalva leak point pressure to other measures of urethral resistance.

STUDY DESIGN

Sixty consecutive women with genuine stress incontinence underwent duplicate Valsalva leak point pressure determinations by use of 8F and 3F vesical and 8F vaginal catheters. Subjects also underwent a standard resting urethral pressure profilometry, cough leak point pressure determinations, and pressure-flow micturition studies.

RESULTS

Leakage was demonstrated on both Valsalva maneuvers in approximately 80% of subjects with both catheters. In subjects who leaked with both strains there was an extremely high correlation between the test-retest Valsalva leak point pressure within both catheters. The intercatheter correlation between the 8F and 3F Valsalva leak point pressures was significant but much weaker than the intracatheter correlations; 8F Valsalva leak point pressures were significantly higher than 3F Valsalva leak point pressures, although there were individual exceptions to this observation. Urethral pressure profilometry measures and micturition opening pressures were poorly correlated with Valsalva leak point pressure. Cough and vaginal Valsalva leak point pressures were significantly correlated with vesical Valsalva leak point pressure, but cough leak point pressures were significantly higher and vaginal Valsalva leak point pressures were significantly lower than the vesical Valsalva leak point pressure.

CONCLUSIONS

Valsalva leak point pressure is a simple and reproducible technique for evaluating urethral resistance in women with genuine stress incontinence. However, variations in Valsalva leak point pressure measurement must be precisely described, standardized, and validated before a technique can be advocated for clinical use.

The epidemiology of female pelvic floor dysfunction

Pelvic floor dysfunction, specifically urinary and fecal incontinence, is thought to be widespread. Prevalence figures for these disorders vary greatly. This review highlights the accepted prevalence and incidence figures for pelvic floor dysfunction and their relative age distribution in women. Remission and natural history is examined with an emphasis on gaps in our knowledge. The limited data on racial differences in the epidemiology of this disorder are also reviewed.

Cigarette smoking and pure genuine stress incontinence of urine: a comparison of risk factors and determinants between smokers and nonsmokers

OBJECTIVES

The aim of this case-control study was to examine differences in risk factors and determinants of genuine stress incontinence between smokers and nonsmokers.

STUDY DESIGN

Seventy one smokers and 118 nonsmokers with pure genuine stress incontinence underwent a complete urogynecologic evaluation. Differences in risk factors and determinants of genuine stress incontinence were analyzed by means of chi 2 and nonparametric techniques.

RESULTS

Smokers had stronger urethral sphincters and generated greater increases in bladder pressure with coughing but had equivalent urethral mobility and pressure transmission ratios compared with nonsmokers. Smokers were significantly younger than nonsmokers, tended to be less often hypoestrogenic, but were of equivalent vaginal parity and weight.

CONCLUSIONS

Genuine stress incontinence develops in smokers in spite of their stronger urethral sphincter and lower risk profile than nonsmokers. More violent coughing by smokers likely promotes the earlier development of the anatomic and pressure transmission defects that allow genuine stress incontinence and overcomes any protective advantage of a stronger urethral sphincter.

Antiestrogenic potency of toremifene and tamoxifen in postmenopausal women

In this nonblinded, controlled multicenter trial, postmenopausal women were randomly assigned to receive graded doses of toremifene and tamoxifen or no antiestrogen to assess dose-response levels and evaluation methodology. For standardization, transdermal estradiol (Estraderm-Ciba Geigy) was applied to all women for 38 days. The antiestrogens were added on days 29-38. For control and all treatment groups, there were no significant changes in serum chemistries or serum hormone levels, nor were there differences in adverse effects. The use of continuous estradiol precluded any meaningful assessment of the estrogenicity of tamoxifen or toremifene. As measured by vaginal superficial cytologic cell count changes, the antiestrogenic activity of toremifene doses ranging from 20 to 200 mg/day could not be distinguished from that of 20 mg/day of tamoxifen, the clinically recommended dose in North America.

Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse

OBJECTIVE

To compare black and white women with regard to urinary incontinence and prolapse.

METHODS

Two hundred consecutive women referred for evaluation of urinary incontinence or severe prolapse, 54 of whom were black, were evaluated. Each had a comprehensive standardized evaluation. Qualitative and quantitative data were analyzed for significant differences between the groups.

RESULTS

The symptoms of pure stress, pure urge, and mixed incontinence were described by 7, 56, and 37% of black subjects, respectively, compared to 31, 28, and 41% of white subjects (P = .001). The conditions of pure genuine stress incontinence (GSI), pure motor incontinence, and mixed incontinence were diagnosed in 27, 56, and 17% of black subjects, respectively, compared to 61, 28, and 11% of whites (P = .0008). Black women with mixed symptoms were significantly less likely than white women to have pure GSI (47 versus 74%; P = .05). Blacks with GSI were significantly heavier, had higher parity, more often took a diuretic, were more often diabetic, and had better passive urethral closure pressure but greater urethral axis mobility than whites. Blacks with motor incontinence were significantly younger, heavier, less likely to have had prior continence surgery or hysterectomy, and had better passive urethral closure pressure but smaller bladder capacities than whites. The prevalence of severe prolapse in this referral population was the same for blacks and whites (24 and 23%), although blacks had significantly more vaginal deliveries. No other significant racial differences were noted in the prolapse group.

CONCLUSIONS

Black women with urinary incontinence have a different distribution of symptoms, different conditions causing their incontinence, and different risk profiles for these conditions than do whites. The significantly lower prevalence of pure GSI in black women compared to white women makes the clinical evaluation for GSI appreciably less accurate in the individual black patient. Until further epidemiologic information regarding incontinence in black women is available, such women should be considered candidates for more accurate, sophisticated urodynamic testing before continence surgery.

Cigarette smoking and urinary incontinence in women

OBJECTIVE

The goal of this case control study was to evaluate the relationship between smoking and female urinary incontinence.

STUDY DESIGN

The study included 606 women whose smoking histories were known; 322 were incontinent and 284 were continent. The condition(s) causing each subject's incontinence was determined by urodynamic testing; 40% of the continent subjects had the same testing.

RESULTS

There were highly significant overall differences (p = 0.000009) in the distribution of current, former, and never smokers between incontinent (35%, 16%, 49%) and continent (24%, 8%, 68%) groups. The odds ratio for genuine stress incontinence was 2.20 for former (95% confidence interval 1.18 to 4.11) and 2.48 for current smokers (95% confidence interval 1.60 to 3.84); for motor incontinence it was 2.92 for former (95% confidence interval 1.58 to 5.39) and 1.89 (95% confidence interval 1.19 to 3.02) for current smokers. Increasing daily and lifetime cigarette consumption was associated with an increasing odds ratio for genuine stress incontinence but not for motor incontinence. The increased risk for incontinence was not due to differences in age, parity, weight, or hypoestrogenic status.

CONCLUSION

The data establish a strong statistical relationship between current and former cigarette smoking and both stress and motor urinary incontinence in women.

Obesity and lower urinary tract function in women: effect of surgically induced weight loss

OBJECTIVE

The subjective and objective effects of massive weight loss on lower urinary tract function in morbidly obese women were examined.

STUDY DESIGN

Thirteen subjects underwent a comprehensive evaluation of lower urinary tract function before and 1 year after surgically induced weight loss.

RESULTS

We demonstrated significant improvements in lower urinary tract function after weight loss. Of 12 subjects who complained of incontinence before surgery only three complained of incontinence (p = 0.004) and only one requested treatment after weight loss. Objective and subjective resolution of both stress and urge incontinence was documented. Statistically significant changes were seen in measures of vesical pressure, the magnitude of bladder pressure increases with coughing, bladder-to-urethra pressure transmission with cough, urethral axial mobility, number of incontinence episodes, and the need to use absorptive pads.

CONCLUSION

Weight reduction is desirable for obese women complaining of urinary incontinence and may obviate the need for further incontinence therapy.

Ectopic pregnancy in an urban teaching hospital: can tubal rupture be predicted?

We evaluated the medical history, physical examination, and laboratory tests done on 245 patients with laparoscopically proven ectopic pregnancies. The absence of abdominal pain was the only clinically useful negative predictive value (91%) regarding tubal rupture. Although mean levels of serum human chorionic gonadotropin (hCG-beta subunit) were significantly higher in patients with ruptured versus unruptured ectopic pregnancies (16,612 mIU/mL vs 6406 mIU/mL), no breakpoint excluded the possibility of tubal rupture. In fact, one third of ectopic pregnancies in patients with a serum beta-hCG level below 100 mIU/mL were ruptured. We conclude that clinical symptoms and signs are poor predictors of tubal rupture. In addition, absolute values of serum beta-hCG are not helpful in excluding the possibility of rupture.

Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction

Forty-seven women had urethral pressure profile determinations performed at rest and during a Kegel pelvic muscle contraction, after brief standardized verbal instruction. Twenty-three (49%) had an ideal Kegel effort--a significant increase in the force of urethral closure without an appreciable Valsalva effort. Twelve subjects (25%) displayed a Kegel technique that could potentially promote incontinence. Age, parity, weight, estrogen deprivation, prior continence surgery or hysterectomy, and passive urethral function did not predict a successful effort. We concluded that simple verbal or written instruction does not represent adequate preparation for a patient who is about to start a Kegel exercise program.