Epidemiology of Pelvic Floor Dysfunction

Technologies for Evaluation of Pelvic Floor Functionality: A Systematic Review

Pelvic floor dysfunction is a common problem in women and has a negative impact on their quality of life. The aim of this review was to provide a general overview of the current state of technology used to assess pelvic floor functionality. It also provides literature research of the physiological and anatomical factors that correlate with pelvic floor health. This systematic review was conducted according to the PRISMA guidelines. The PubMed, ScienceDirect, Cochrane Library, and IEEE databases were searched for publications on sensor technology for the assessment of pelvic floor functionality. Anatomical and physiological parameters were identified through a manual search. In the systematic review, 114 publications were included. Twelve different sensor technologies were identified. Information on the obtained parameters, sensor position, test activities, and subject characteristics was prepared in tabular form from each publication. A total of 16 anatomical and physiological parameters influencing pelvic floor health were identified in 17 published studies and ranked for their statistical significance. Taken together, this review could serve as a basis for the development of novel sensors which could allow for quantifiable prevention and diagnosis, as well as particularized documentation of rehabilitation processes related to pelvic floor dysfunctions.

Associated factors of stress, urgency, and mixed urinary incontinence in a geriatric outpatient assessment of older women with hip fracture

PURPOSE

Urinary incontinence (UI) is known to be common among older female hip fracture patients. Little is known about different subtypes of UI among these patients. Our aim was to identify factors associated with subtypes of UI in a cross-sectional design.

METHODS

1,675 female patients aged ≥ 65 and treated for their first hip fracture in Seinäjoki Central Hospital, Finland, during 2007-2019, were included in a prospective cohort study. Of these, 1,106 underwent comprehensive geriatric assessment (CGA), including questions on continence, at our geriatric outpatient clinic 6 month post-fracture. A multivariable-adjusted multinomial logistic regression model was used to examine factors associated with UI subtypes.

RESULTS

Of the 779 patients included, 360 (46%) were continent and 419 (54%) had UI 6-month post-fracture. Of the women with UI, 117 (28%) had stress UI, 183 (44%) had urgency UI and 119 (28%) had mixed UI, respectively. Mean age of the patients was 82 ± 6,91. In multivariable analysis, depressive mood and poor mobility and functional ability were independently associated with stress UI. Fecal incontinence (FI) and Body Mass Index (BMI) over 28 were independently associated with urgency UI. Mixed UI shared the aforementioned factors with stress and urgency UI and was independently associated with constipation.

CONCLUSIONS

Mixed UI was associated with most factors, of which depressive mood and impaired mobility and poor functional ability were shared with stress UI, and FI and higher BMI with urgency UI. CGA is key in assessing UI in older hip fracture patients, regardless of subtype.

Chronic Pelvic Pain: Role of Imaging in the Diagnosis and Management

Chronic pelvic pain (CPP) in women is not uncommon, and it may be difficult to identify the exact cause difficult to manage. It is major health problem for women that affects the quality of their daily lives. The etiology of chronic pelvic pain may be of gynecological or non-gynecological origin and associated with several predisposing and precipitating factors. Psychological and social factors also contribute to the syndrome of CPP and must be evaluated before managing these patients. Due to multifactorial etiology, CPP needs a multidisciplinary approach for diagnosis and management. A detailed history and physical examination supported by appropriate laboratory tests and imaging are the keys to diagnosis. In this paper, the role of imaging in diagnosis and management of CPP is reviewed. Imaging findings should be correlated with detailed clinical examination findings as there are imaging findings that may be unrelated and not the cause of CPP in a particular patient, imaging findings should be correlated with the clinical circumstances.

Minimal Invasive Abdominal Sacral Colpopexy and Abdominal Lateral Suspension: A Prospective, Open-Label, Multicenter, Non-Inferiority Trial

BACKGROUND

Abdominal minimally invasive surgery has become increasingly prominent for the treatment of prolapse. Abdominal sacral colpopexy (ASC) is the gold standard for the treatment of advanced apical prolapse; however, alternative surgical approaches such as the abdominal lateral suspension (ALS) have been developed to improve patient outcomes. This study aims to determine whether ALS improves outcomes compared to ASC in multicompartmental prolapse patients.

METHODS

A prospective, open-label, multicenter, non-inferiority trial was conducted in 360 patients who underwent ASC or ALS for the treatment of apical prolapse. The primary outcome was anatomical and symptomatic cure of the apical compartment at 1-year follow-up; secondary outcomes included prolapse recurrence, re-operation rate, and post-operative complications. A 300-patient cohort was subdivided into 200-patients who underwent ALS and 100-patients who underwent ASC. The confidence interval method was used to calculate the p-value of non-inferiority.

RESULTS

At the 12-months follow-up, the objective cure rate of the apical defect was 92% for ALS and 94% for ASC (recurrence rates were 8% and 6%, respectively, and the p-value for non-inferiority was <0.01). The mMesh complication rates were 1% and 2% for ALS and ASC, respectively.

CONCLUSIONS

This study demonstrated that the ALS technique is not inferior to the gold standard ASC for the surgical treatment of apical prolapse.

Nonoperative Management of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior, posterior, or apical vagina. It is a common condition, with up to 50% of women having prolapse on examination in their lifetimes. This article provides an overview of the evaluation and discussion of nonoperative management of POP for the obstetrician-gynecologist (ob-gyn), with consideration of recommendations from the American College of Obstetricians and Gynecologists, the American Urogynecologic Society, and the International Urogynecological Association. The initial evaluation of POP requires a history documenting whether the patient is experiencing symptoms and what they are, and discovery of which symptoms they believe are attributable to prolapse. Examination determines the vaginal compartment(s) and to what degree prolapse exists. In general, only patients who have symptomatic prolapse or medical indication should be offered treatment. Although surgical options exist, all patients who are symptomatic and desire treatment should be offered nonsurgical treatment first, including pelvic floor physical therapy or a pessary trial. Appropriateness, expectations, complications, and counseling points are reviewed. Educational opportunities between the patient and the ob-gyn include disentangling common beliefs that the bladder is dropping or that concomitant urinary or bowel symptoms are necessarily caused by prolapse. Improving patient education can lead to a better understanding of their condition and better alignment of treatment goals and expectations.

A finite element analysis of different postures and intra-abdominal pressures for the uterine ligaments in maintaining the normal position of uterus

Uterine prolapse is a common gynecological disease, which seriously affects the quality of life and physical and mental health of elderly women. The aim of this study was to analyze the influence of different conditions (intra-abdominal pressure (IAP) and posture) on stress and displacement of uterine ligaments using the finite element method, and evaluate the contribution of uterine ligaments on uterus. The three-dimensional (3D) models of retroverted uterus and its accessory ligaments were established, loads and constraints were set in ABAQUS software, and the stress and displacement of uterine ligaments were calculated. The uterine displacement increased with the increase of IAP, and then the stress and displacement of each uterine ligament also increased. The uterine displacement was in the order of forward < upright < backward with different postures, and USL, CL and RL got larger values when the body was backward, while BL got a larger value when the body was forward. With the same condition, the stress of the uterine ligaments was in the order of USL > BL > CL > RL, and the displacement of the ligaments was in the order of BL > RL > USL > CL. The contribution of each uterine ligament changing with different IAP and postures was studied through finite element analysis, and the research results were consistent with the clinical data, which can provide a basis for exploring the mechanism of uterine prolapse.

Pelvic floor dysfunctions in women with fibromyalgia: A cross-sectional study

BACKGROUND

Fibromyalgia (FM) is a rheumatic syndrome that causes musculoskeletal disorders and is associated with several problems that affect quality of life. As the musculoskeletal system is affected, it can have an impact on the pelvic floor muscles, leading to pelvic floor dysfunction (PFD).

OBJECTIVE

Investigate the occurrence of PFD, such as urinary incontinence (UI) and anal incontinence (AI), sexual problems, and pelvic organ prolapse (POP), in women with FM compared to a control group composed of women without FM; and investigate the association between FM and PFD.

STUDY DESIGN

This was an online cross-sectional survey. Demographic and anthropometric data, the description of PFD (UI, nocturia, AI, genital-pelvic pain/penetration disorder, and POP), and previous obstetric history were collected through a web-based questionnaire. The groups were compared using the independent t-test for quantitative variables and the chi-square test for categorical variables. The association between FM and PFD was tested using logistic regression analysis.

RESULTS

A total of 175 women answered the questionnaire (97 with FM and 78 healthy controls). The women with FM reported significantly more UI, mixed urinary incontinence, AI, POP, and vaginismus than the healthy controls (p ≤ 0.05). FM was associated with mixed urinary incontinence (OR: 2.6; 95 % CI: 1.1-6.4; p = 0.04), anal incontinence (OR: 2.9; 95 % CI: 1.3-6.1; p = 0.01), and flatus incontinence (OR: 2.6; 95 % CI: 1.2-5.4; p = 0.01).

CONCLUSION

The prevalence of PFD was significantly higher in women with FM compared to healthy women. Indeed, the women with FM were 2.6-fold to 2.9-fold more likely to report mixed urinary incontinence, anal and flatus incontinence than those in the control group. The present findings show possible impairment of the pelvic floor musculature in women with FM.

MRI defecography revisited. At-rest pelvic floor measurements with and without rectal gel. Is there a difference?

PURPOSE

The authors sought to test if there was a difference in key pelvic floor measurements obtained during MR defecography at-rest, i.e., H-line, M-line and anorectal angle (ARA), before and after rectal gel administration. The authors also sought to determine if any observed differences would affect the interpretation of the defecography studies.

METHODS

Institutional Review Board approval was obtained. An abdominal fellow retrospectively reviewed the images of all patients who underwent MRI defecography at our institution from January 2018 through June 2021. The H-line, M-line and ARA values were remeasured on T2-weighted sagittal images, with and without rectal gel for each patient.

RESULTS

One hundred and eleven (111) studies were included in the analysis. 18% (N = 20) of patients satisfied the criterion for pelvic floor widening before gel administration based on H-line measurement. This increased to 27% (N = 30) after rectal gel (p = 0.08). 14.4% (N = 16) met the M-line measurement criterion for pelvic floor descent before gel administration. This increased to 38.7% after rectal gel (N = 43) (p < 0.001). 67.6% (N = 75) demonstrated an abnormal ARA prior to administration of rectal gel. This decreased to 58.6% (N = 65) after rectal gel administration (p = 0.07). The overall reporting discrepancies incurred by the presence or absence of rectal gel were 16.2%, 29.7% and 23.4% for H-line, M-line and ARA, respectively.

CONCLUSION

The instillation of gel during MR defecography can cause significant changes to the observed pelvic floor measurements at-rest. This in turn can influence the interpretation of defecography studies.

Effect of the length of the second stage of labor on pelvic floor dysfunction

BACKGROUND

Pelvic floor dysfunction refers to any combination of incontinence, overactive bladder, pelvic organ prolapse, and sexual dysfunction. Pelvic floor dysfunction affects approximately 25% to 30% of women and is linked to parity and age. Some obstetrical risk factors have been highlighted, though the second stage of labor has not been as thoroughly investigated. Allowing a longer second stage has been suggested as a method of reducing the rates of cesarean delivery in nulliparous women, though it has also been linked to pelvic floor injuries.

OBJECTIVE

This study aimed to determine the effect of the length of the second stage of labor on self-reported pelvic floor dysfunction.

STUDY DESIGN

This was a single-center prospective cohort study in a tertiary referral obstetrical unit. Nulliparous women attending routine antenatal clinics were recruited to complete the Australian Pelvic Floor Questionnaire during pregnancy and again 3 months after delivery. The primary outcome in this study was the effect of the length of the second stage of labor on total pelvic floor scores when analyzed using multiple regression. The models were adjusted for the mother's age, mother's body mass index, length of the second stage of labor, fetal birthweight, mode of delivery, and perineal trauma. The secondary outcomes included the comparison of maternal, obstetrical, and functional pelvic floor outcomes based on the mode of delivery and the length of the second stage of labor.

RESULTS

Among the 295 women who were recruited, the length of the second stage of labor and body mass index were associated with self-reported bladder dysfunction on multiple regression, whereas maternal age was protective. Compared with those with 60 to 120 minutes or <60 minutes of second stage of labor, women with that longer than 120 minutes had higher rates of stress incontinence (85.7% [>120 minutes] vs 41.7% [60-120 minutes] or 52.5% [<60 minutes], P=.001), urinary urgency (89.3% [>120 minutes] vs 39.6% [60-120 minutes] or 53.8% [<60 minutes], P<.001), and fecal incontinence (10.7% [>120 minutes] vs 0% [60-120 minutes] or 1.2% [<60 minutes], P=.027). There were no differences in the rates of sexual activity or dyspareunia. Women delivering vaginally had higher rates of stress incontinence (57.6% vs 38.0%, P=.006) than those undergoing cesarean delivery, though there were no differences in other pelvic floor symptoms or pelvic floor scores.

CONCLUSION

A prolonged second stage of labor is associated with more self-reported bladder dysfunction at 3 months postnatal in primiparous women. Women with a longer second stage of labor should be informed about the risk of short-term bladder dysfunction, though the prevalence of long-term sequelae is unknown.

Colonoscopic findings in patients with pelvic floor dysfunction

BACKGROUNDY

Colonoscopy is often performed in the initial workup of pelvic floor dysfunction, even in the absence of red flag symptoms. Current guidelines suggest colonoscopy is only required in the presence of rectal bleeding, diarrhoea or change in bowel habit. The aim of this study was to evaluate the prevalence of significant pathology found at colonoscopy in patients with pelvic floor dysfunction.

METHODS

Retrospective chart review was performed on all patients presenting to a functional colorectal outpatient clinic between May 2018 and August 2019. Information was collected on presenting symptoms, whether colonoscopy had been performed within 5 years, quality of bowel preparation, withdrawal time, number of polyps detected, histology, presence of diverticular disease, colorectal malignancy, inflammatory bowel disease, solitary rectal ulcer or rectal prolapse.

RESULTS

There were 260 patients seen within the study period, of which 67% had undergone recent colonoscopy within the last 5 years. The mean age was 53 and 219 (84%) patients were female. Average withdrawal time was 13 min. Polyps were found in 48.7% and adenomas in 32.4% of all colonoscopies. The adenoma detection rate was 32.7%. None of the colonoscopies found evidence of malignancy. A new diagnosis of inflammatory bowel disease was discovered in two patients.

CONCLUSION

There was low rates of serious pathology such as malignancy or inflammatory bowel disease in patients referred to a functional clinic. However, colonoscopy is still useful in workup of pelvic floor dysfunction, as many patients have erratic bowel habits or vague symptoms, and will have adenomas found.

Who's Posting What? A Qualitative, Cross-Sectional Study Comparing Twitter and Instagram Patterns Between Health Care Professionals and Patients

IMPORTANCE

There is a paucity of evidence-based, physician-authored content available on social media. Data are lacking on physicians use of social media, including intended audience and content.

OBJECTIVE

The aim of this study was to explore the patterns of Twitter and Instagram use for popular urogynecology hashtags between physicians, patients, and allied health professionals (AHPs).

STUDY DESIGN

Twelve hashtags derived from the Urogynecology Tag Ontology project were used as search terms to select Twitter and Instagram posts. Up to 5 top posts per hashtag per author type (physician, patient, or AHP) were included. Posts were analyzed using Dedoose qualitative analytic software by author, hashtag, intended audience, and themes.

RESULTS

On Twitter, 109 posts met inclusion criteria: 41% written by physicians, 40% patients, and 18.3% AHPs. For Instagram, 72 posts were included: 50% written by patients, 39% AHPs, and 11% physicians. Twitter physician posts were mainly intended for health professionals (64%) with only 18% for patients. Patients posted to the general public (57%) and patients (36%). Instagram physician posts were intended for health professionals (49%), whereas 62% of AHPs posted to patients. Most patient posts were directed to other patients (90%). Physicians posted about academic peer discussions, medical education, and advocacy. Patients posted about personal experiences, treatments, or dissatisfaction.

CONCLUSIONS

Physicians are more likely to post on Twitter than Instagram, with content focused primarily on their peer group, and physicians/patients are unlikely to engage with each other. There is an opportunity to improve social media interactions between physicians and the public while increasing high-quality patient education.

Pelvic floor dysfunctions in women with systemic lupus erythematosus: A cross-sectional study

INTRODUCTION AND HYPOTHESIS

As a result of the impairment of the musculoskeletal system, the pelvic floor muscles are likely compromised in women with systemic lupus erythematosus (SLE). We hypothesized that women with SLE would report more symptoms of pelvic floor dysfunction (PFD) and there will be an association between SLE and PFD.

METHODS

An online cross-sectional survey was conducted. Data were collected on demographic and anthropometric characteristics, PFD (urinary incontinence, nocturia, anal incontinence, genital-pelvic pain/penetration disorder and pelvic organ prolapse) and obstetric history using a web-based questionnaire. The groups were compared using the Mann-Whitney test for quantitative variables and the chi-squared test for categorical variables. The association between SLE and PFD was tested using logistic regression analysis.

RESULTS

A total of 196 women answered the questionnaire (102 with SLE and 94 healthy controls). Women with SLE reported significantly more urinary incontinence, nocturia, anal incontinence, pelvic organ prolapse and genital-pelvic pain/penetration disorder than the healthy controls (p ≤ 0.05). Women with SLE were 2.8- to 3.0-fold more likely to report genital-pelvic pain/penetration disorder than healthy women.

CONCLUSIONS

The prevalence of PFD was significantly higher in women with SLE compared to healthy women. Thus, PFD seems to be an important problem in women with this disease. An in-depth investigation of these disorders could contribute to the understanding of how SLE impacts pelvic floor function.

Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors

Determine the prevalence of pelvic floor disorders (PFD) stratified by age, race, body mass index (BMI), and parity in adult women attending family medicine and general internal medicine clinics at an academic health system. The medical records of 25,425 adult women attending primary care clinics were queried using International Classification of Diseases-10th Revision codes (ICD-10 codes) for PFD [urinary incontinence (UI), pelvic organ prolapse (POP), and bowel dysfunction (anal incontinence (AI) and difficult defecation)]. Prevalence and odds ratios were calculated using univariate and multivariate analysis for age, race, BMI, and parity when available. Multivariate logistic regression models were used to assess the impact of age, race, BMI, and parity on the likelihood of being diagnosed with a PFD. A separate model was constructed for each of the three PFD categories (UI, POP, and bowel dysfunction) as well as a model assessing the likelihood of occurrence for any type of PFD. The percentage of women with at least one PFD was 32.0% with bowel dysfunction the most common (24.6%), followed by UI (11.1%) and POP (4.4%). 5.5% had exactly two PFD and 1.1% had all 3 categories of PFD. Older age and higher BMI were strongly and significantly associated with each of the three PFD categories, except for BMI and prolapse. Relative to White patients, Asian patients were at significantly lower risk for each category of PFD, while Black patients were at significantly lower risk for UI and POP, but at significantly greater risk for bowel dysfunction and the presence of any PFD. Higher parity was also significantly associated with pelvic organ prolapse. Using multivariate analyses, age, race, and BMI were all independently associated with PFD. PFD are highly prevalent in the primary care setting and should be screened for, especially in older and obese women. BMI may represent a modifiable risk factor.

Investigating the Efficacy of an 18-Week Postpartum Rehabilitation and Physical Development Intervention on Occupational Physical Performance and Musculoskeletal Health in UK Servicewomen: Protocol for an Independent Group Study Design

Background

Postpartum women are at an increased risk of pelvic floor dysfunction, musculoskeletal injury, and poor psychological health and have reduced physical fitness compared to before pregnancy. There is no formal, evidence-based rehabilitation and physical development program for returning UK servicewomen to work following childbirth.

Objective

This study aims to examine the efficacy of a rehabilitation and physical development intervention for returning postpartum UK servicewomen to occupational fitness.

Methods

Eligible servicewomen will be assigned to a training or control group in a nonrandomized controlled trial 6 weeks after childbirth. Group allocation will be based on the location of standard pregnancy and postpartum care. The control group will receive standard care, with no prescribed intervention. The training group will start an 18-week core and pelvic health rehabilitation program 6 weeks post partum and a 12-week resistance and high-intensity interval training program 12 weeks post partum. All participants will attend 4 testing sessions at 6, 12, 18, and 24 weeks post partum for the assessment of occupational physical performance, pelvic health, psychological well-being, quality of life, and musculoskeletal health outcomes. Occupational physical performance tests will include vertical jump, mid-thigh pull, seated medicine ball throw, and a timed 2-km run. Pelvic health tests will include the Pelvic Organ Prolapse Quantification system, the PERFECT (power, endurance, repetitions, fast, every contraction timed) scheme for pelvic floor strength, musculoskeletal physiotherapy assessment, the Pelvic Floor Distress Inventory–20 questionnaire, and the International Consultation on Incontinence Questionnaire–Vaginal Symptoms. Psychological well-being and quality of life tests will include the World Health Organization Quality of Life questionnaire and the Edinburgh Postnatal Depression Scale. Musculoskeletal health outcomes will include body composition; whole-body areal bone mineral density; tibial volumetric bone mineral density, geometry, and microarchitecture; patella tendon properties; muscle architecture; muscle protein and collagen turnover; and muscle mass and muscle breakdown. Data will be analyzed using linear mixed-effects models, with participants included as random effects, and group and time as fixed effects to assess within- and between-group differences over time.

Results

This study received ethical approval in April 2019 and recruitment started in July 2019. The study was paused in March 2020 owing to the COVID-19 pandemic. Recruitment restarted in May 2021. The results are expected in September 2022.

Conclusions

This study will inform the best practice for the safe and optimal return of postpartum servicewomen to physically and mentally demanding jobs.

Trial Registration

ClinicalTrials.gov NCT04332757; https://clinicaltrials.gov/ct2/show/NCT04332757

International Registered Report Identifier (IRRID)

DERR1-10.2196/32315

Improving the Technique of Pelvic Floor Muscle Contraction in Active Nulliparous Women Attending a Structured High-Low Impact Aerobics Program-A Randomized Control Trial

Learning the correct technique of performing pelvic floor muscle (PFM) exercises is a very important factor influencing the effectiveness of this muscle group training. Correctly performed PFM contractions are involved in the urinary continence mechanism. In this study, we tested the hypothesis that a six-week high-low impact aerobics program, supported by one EMG biofeedback session and pelvic floor muscle training, improves the technique of PFM contraction. Participants were 42 active nulliparous women (age 22 ± 2 years, mean ± SD), randomly allocated into intervention (n = 18) and control (n = 24) groups. We analyzed the technique of PFM contractions, taking into account the order in which selected muscle groups were activated, so called 'firing order'. In both groups, we assessed the PFM contraction technique using surface electromyography (sEMG) and intravaginal probes, before and after six weeks of intervention. The intervention group received one biofeedback session on how to properly contract PFM and afterwards participated in a high-low impact aerobics program supplemented by PFM training. The control group did not receive any intervention. In the pre-test, 67% of the intervention group activated PFM first in order in short, quick contractions. After six weeks of training, this task was correctly performed by 100% of this group (p = 0.04). The proper performance of PFM short contraction in the control group was 75% and 67%, before and after intervention, respectively. In the intervention group we also observed statistically significant improvement in the PFM contraction technique in 10-s contractions. The presented intervention was beneficial for the improvement of PFM contraction. High-low impact aerobics, supplemented by one EMG biofeedback session and pelvic floor muscle training can be recommended for active nulliparous women.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Development of a prediction model in female pure or predominant urge urinary incontinence: a retrospective cohort study

Background:

Urinary incontinence is a prevalent form of pelvic floor dysfunction, with a non-negligible impact on a patient’s quality of life. There are several treatment options, varying from conservative to invasive. The aim of this study is to predict treatment outcomes of pure or predominant urge urinary incontinence (UUI) in women to support shared decision-making and manage patient expectations.

Methods:

Data on patient characteristics, disease history, and investigations of 512 consecutive women treated for UUI in three hospitals in the Netherlands were retrospectively collected. The predicted outcome was the short-term subjective continence outcome, defined as patient-reported continence 3 months after treatment categorized as cure (no urinary leakage), improvement (any degree of improvement of urinary leakage), and failure (no improvement or worsening of urinary leakage). Multivariable ordinal regression with backward stepwise selection was performed to analyze association between outcome and patient’s characteristics. Interactions between patient characteristics and treatment were added to estimate individual treatment benefit. Discriminative ability was assessed with the ordinal c-statistic.

Results:

Conservative treatment was applied in 12% of the patients, pharmacological in 62%, and invasive in 26%. Subjective continence outcome was cure, improvement, and failure in 20%, 49%, and 31%, respectively. Number of incontinence episodes per day, voiding frequency during the day, subjective quantity of UI, coexistence of stress urinary incontinence (SUI), night incontinence, and bladder capacity and the interactions between these variables were included in the model. After internal validation, the ordinal c-statistic was 0.699.

Conclusions:

Six variables were of value to predict pure or predominant UUI treatment outcome in women. Further development into a comprehensive set of models for the use in various pelvic floor disorders and treatments is recommended to optimize individualized care. This model requires external validation before implementation in clinical practice.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature

Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Impact of urinary incontinence on quality of life in female CrossFit practitioners: A cross-sectional study

OBJECTIVE

Investigate the impact of urinary incontinence (UI) on quality of life (QoL) in female CrossFit practitioners and to verify the strategies used by them to minimize the occurrence of urine leakage. In addition, to verify whether anthropometric and clinical characteristics increase the UI impact on QoL of female CrossFit practitioners.

STUDY DESIGN

This was an online cross-sectional survey. The impact of UI on QoL was investigated by International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF). Associations between the impact of UI on QoL and the clinical (age, BMI, gestations, mode of delivery, practice of other physical activities) and the others pelvic floor dysfunctions (PFD) related independent variables were tested using logistic regression analysis.

RESULTS

A total of 828 female CrossFit practitioners answered the questionnaire and 36% reported UI symptoms. The women who obtained the highest score on the ICIQ-SF have high UI interference in QoL. Previous history of two or more gestations and sexual dysfunctions (dyspareunia or vaginismus) or pelvic organ prolapse increase 2.65 and 1.82 times the risk of female CrossFit practitioners with UI having a high impact of UI on their QoL, respectively (OR = 2.65 95% CI 1.30-5.40, p = 0.01; and OR = 1.82 95% CI 1.04-3.21, p = 0.04, respectively). The most strategies used by them to minimize the occurrence of urine leakage were emptying the bladder before training (77.5%) and use absorbent (17.8%).

CONCLUSIONS

Women who had higher scores on the ICIQ-SF reported greater impact on QoL, and the previous history of two or more gestations and sexual dysfunction/pelvic organ prolapse increase the risk of women with UI who practice CrossFit to have a greater impact on QoL. Multigravida and women with sexual dysfunction/pelvic organ prolapse who practice CrossFit could have more attention on the UI symptoms due to the high impact on their QoL.

High-impact aerobics programme supplemented by pelvic floor muscle training does not impair the function of pelvic floor muscles in active nulliparous women: A randomized control trial

BACKGROUND

We aimed to test the hypothesis that high-impact aerobics programme, combined with pelvic floor muscle training does not impair pelvic floor muscle function in young active women.

METHODS

A randomized control trial was conducted among active nulliparous, sport university students (age 23 ± 3 years, mean ± SD). Experimental group (n = 13) attended high-impact aerobics programme, supplemented by pelvic floor muscle training with one biofeedback session, for 6 weeks. The control group (n = 19) did not get any intervention. Before and after the experiment, we assessed pelvic floor muscle function in both groups with surface electromyography using vaginal probes. In both groups, we assessed the participants' quality of life related to pelvic floor functions with the Incontinence Impact Questionnaires.

RESULTS

We recorded no impairments in neuromuscular activity of pelvic floor muscles and in quality of life in women regularly performing high-impact aerobics. What is even more positive, after 6 weeks, experimental group presented better skills both in contracting and relaxing their pelvic floor muscles, although the pre-post intervention EMG change was not statistically significant. All participants maintained good quality of life related to pelvic floor functions.

CONCLUSIONS

High-impact aerobics, supplemented by pelvic floor muscle training can be recommended for active nulliparas.

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.

Prevalence of pelvic organ prolapse among US racial populations: A systematic review and meta-analysis of population-based screening studies

AIMS

To determine the differences in pooled prevalence rates of symptomatic pelvic organ prolapse (POP) across different US racial/ethnic groups using existing screening-based epidemiologic studies.

METHODS

A systematic search of MEDLINE, EMBASE, Cochrane, and Scopus was conducted to retrieve eligible studies. We included studies that identified POP by either physical exam or questionnaire, conducted in non-gynecologic care-seeking settings, and had a representative sample of US community-dwelling women from more than one racial/ethnic group with prevalence rates reported for each population. Meta-analysis was performed with the pooled estimates calculated, and χ ² tests were performed to examine the associations between race and POP prevalence.

RESULTS

Of the 2604 studies reviewed, 5 were included. One study used physical exam findings while others used questionnaires to identify POP. All but one study demonstrated statistically significant differences in POP prevalence rates based on race/ethnicity. The overall pooled POP prevalence rates were determined for each racial/ethnic group-White women: 10.76% (95% confidence interval [CI], 10.30%-11.22%); Hispanic women: 6.55% (95% CI, 5.83%-7.28%); Black women: 3.80% (95% CI, 3.22%-4.38%); and Asian American women: 3.40% (95% CI, 2.09%-4.71%). There was a significant difference in the pooled prevalence rates among these four racial/ethnic groups (p < 0.01).

CONCLUSIONS

Our study found that White women had the highest pooled POP prevalence rate overall, while Hispanic women had the highest pooled prevalence among minority women. Additionally, American Indians and Pacific Islanders were absent from the current prolapse epidemiologic literature.

Prolonged second stage effect on pelvic floor dysfunction: a follow up survey to a randomized controlled trial

BACKGROUND

Pelvic floor dysfunction is a group of disorders that can significantly impact quality of life due to persistent urinary and anal incontinence. Data evaluating the effect of prolonged second stage of labor and postpartum pelvic floor dysfunction is heterogenous and limited.

OBJECTIVE

To evaluate whether extending the length of labor in nulliparous women with prolonged second stage affects the presence of self-reported pelvic floor dysfunction after a randomized controlled trial of prolonged second stage.

STUDY DESIGN

We conducted a planned follow up survey to our randomized controlled trial of prolonged second stage of labor using the Pelvic Floor Distress Inventory-20 (PFDI-20). The primary outcome was the PFDI-20 summary score. Secondary outcomes included urinary and fecal incontinence, prolapse, and patient satisfaction. Women surveyed were nulliparous patients with epidural anesthesia, previously enrolled in a randomized controlled trial that assigned them to extended labor, at least 1 additional hour in the second stage if they were undelivered after three hours, or to usual labor, defined as expedited delivery after three hours in the second stage. Women were surveyed at 12 - 36 months postpartum.

RESULTS

Thirty-four of the seventy-eight women responded to the survey (43.6%). 17 women (50.0%) were from the extended labor group and 17 from the usual labor group (50.0%). Maternal demographic data were not significantly different between groups. The PFDI-20 summary score was 13.8 ± 23.3 in the extended labor group and 13.1 ± 20.9 in the usual labor group (p = 0.9). The Pelvic Organ Prolapse Distress Inventory-6 was 1.2 ± 2.9 in the extended labor group and 2.7 ± 6.4 in the usual labor group (p = 0.4). The Colorectal-Anal Distress Inventory-8 was 0.8 ± 2.8 in the extended labor group and 2.1 ± 4.0 in the usual labor group (p = 0.6). The Urinary Distress Inventory-6 was 11.8 ± 21.1 in the extended labor group and 8.3 ± 14.5 in the usual labor group (p = 0.6). Maternal and neonatal outcomes, as well as patient satisfaction, were not statistically significantly different between groups.

CONCLUSION

Extending the length of labor in nulliparas with singleton gestations, epidural anesthesia, and prolonged second stage did not have an impact on PFDI-20 scores at 12-36 months postpartum. However, our study was underpowered to detect small, but potentially clinically important, differences.

CLINICAL TRIAL NUMBER

NCT02101515 (Study Registration Date March 28, 2014) https://clinicaltrials.gov/ct2/show/NCT02101515.

Barium Defaecating Proctography: Experience from a Tertiary Referral Center

Objective Pelvic floor dysfunction (PFD) is a major health care problem predominately affecting the elderly female. It impairs quality of life and patients increasingly expect a solution. Barium defaecating proctography (BDP) is frequently used in the assessment of patients with PFD. The aim of this study was to present our findings from BDP and to look at the proportion of patients who went on to have surgery following their investigations.

Methods All patients who underwent BDP in a tertiary referral center were identified retrospectively from the computerized radiology information system. Demographic data and radiologic findings were extracted. Data regarding those who had surgery were retrieved from the anonymized patient registry.

Results A total of 671 patients had a BDP during the study period. The main symptoms investigated were obstructed defecation or chronic constipation (64%). Complete barium evacuation was observed in 70% of the patients, while 17% were noted to have incomplete and 13% no evacuation. A large rectocele (>5 cm) was noted in 38% while nearly 5% had frank prolapse. There was no significant association between a rectocele and any of the presenting symptoms. Seventy-eight (12%) patients went on to have operation, of which 17 (22%) had multiple procedures. Three patients ended up with a permanent stoma.

Conclusion BDP contributes to decision making in patients with PFD. However, results need to be interpreted with caution and in conjunction with other tests and clinical examination to maintain a low rate of operation and reduce the risk of adverse outcomes for these patients.

Pelvic floor dysfunctions and associated factors in female CrossFit practitioners: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

It is known that high-impact exercises can cause an increase in intra-abdominal pressure and provide overload in the pelvic floor structures. We hypothesized that female CrossFit practitioners would report symptoms of pelvic floor dysfunction (PFD) and that there will be factors associated with these dysfunctions.

METHODS

The study design is an online cross-sectional survey. Demographic and anthropometric data, the characterization of CrossFit activity, the description of PFD and previous obstetric history were collected through a structured web-based questionnaire. Associations between PFD and the clinical and CrossFit-related independent variables were tested using logistic regression analysis.

RESULTS

A total of 828 female CrossFit practitioners answered the questionnaire. The most prevalent symptom was anal incontinence (AI) (52.7%), with flatus incontinence (FI) being the most reported (93.3%). Women who reported constipation are 1.7 times more likely to have FI, and women who practice CrossFit more than five times a week are 3.0 times more likely to have FI. Urinary incontinence(UI) affected 36% of women, and 84.2% of participants reported urinary loss during CrossFit practice. The occurrence of dyspareunia was reported by 48.7% and showed an inverse association with age and body mass index. POP was reported by only 1.4% of the sample.

CONCLUSION

There is a high prevalence of PFD in female CrossFit practitioners, with AI being the most reported symptom, especially FI. In addition, constipation and weekly training frequency were significantly associated with FI. UI occurred primarily in CrossFit exercises, and dyspareunia was the most prevalent sexual symptom.

Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women

PURPOSE OF REVIEW

To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders.

RECENT FINDINGS

Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery.

SUMMARY

PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.

Urotherapist activities in caring for patients with pelvic floor disorders: a prospective single-center observational study

Purpose

Patients with pelvic floor disorders are growing in number. The aim of this study is to outline the main activities of a urotherapist, an advanced nurse practitioner, in the care of patients with pelvic floor disorders and to evaluate patient satisfaction with the service urotherapists provide.

Methods

The prospective single-center observational study was carried out from July 2016 to June 2018. Parameters used to assess the urotherapist activities included the number of consultations, type of counselling, time frame of consultations and therapy and patient satisfaction. In a subgroup of 38 patients, satisfaction with the urotherapy sessions was evaluated by a questionnaire.

Results

Totally, 1709 patients were examined by urogynecologists. Five hundred and fourteen (30%) with chronic pelvic floor disorders were subsequently referred to a urotherapist. Of these patients, 60% were at least 65 years old. The most common pelvic floor disorders (221 patients; 43%) were an overactive bladder, recurrent urinary tract infections, chronic cystitis and pelvic pain syndrome; the second most common pelvic floor disorder was pelvic organ prolapsed (151 patients; 29%). Of the study subgroup comprising 38 patients, 32 (84%) returned the patient satisfaction questionnaire. All 32 patients specified their level of agreement with the urotherapist’s professional competence, empathy, temporal availability and quality of advice as “agree to strongly agree.”

Conclusions

Management by a urotherapist was highly appreciated. The role of the urotherapist as a care coordinator, their level of autonomy and barriers to the implementation in primary care requires further exploration.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05810-0) contains supplementary material, which is available to authorized users.

Impact of pelvic floor ultrasound in diagnosis of postpartum pelvic floor dysfunction: A protocol of systematic review

BACKGROUND

This study will appraise the impact of pelvic floor ultrasound (PFU) in diagnosis of postpartum pelvic floor dysfunction (PPPFD).

METHODS

Studies that report the impact of PFU in diagnosis of PPPFD will be examined in Cochrane Library, MEDLINE, EMBASE, PSYCINFO, Scopus, Web of Science, Allied and Complementary Medicine Database, CNKI, and WANGFANG up to June 1, 2020. Grey literature sources will also be searched. All potential case-controlled studies (CCSs) exploring the impact of PFU in diagnosis of PPPFD will be considered for inclusion in this study. Data will be extracted from eligible CCSs for data pooling and meta-analysis. Whenever necessary, we will also perform summary effect size, heterogeneity across studies, study quality assessment, and reporting bias.

RESULTS

The present study will estimate pooled outcome effects regarding the impact of PFU in diagnosis of PPPFD.

CONCLUSION

This study may provide robust evidence to judge the impact of PFU on PPPFD SYSTEMATIC REVIEW REGISTRATION:: PROSPERO CRD42020187623.

Factors affecting patient choice for continued observation versus intervention for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

To analyze the reasons for eventual choice of a therapeutic intervention in subjects who initially chose observation for bothersome pelvic organ prolapse (POP) over therapeutic intervention at their first urogynecology clinic visit.

METHODS

This is a retrospective cohort study of women with bothersome POP who initially chose observation over therapeutic intervention at one institution from 2002 to 2015. Subjects were followed over time with sequential pelvic organ prolapse quantification examinations (POP-Q) and assessments of symptoms and bother utilizing non-validated standard questions. Subjects were divided into two groups: (1) those who chose continued observation versus (2) those who chose therapeutic intervention with either pessary or surgery. Demographic information, POP-Q examinations, and POP symptoms and bother were collected. We analyzed which clinical variables influenced patient decision to elect for therapeutic intervention.

RESULTS

A total of 111 subjects were enrolled. The distribution of initial POP-Q stage was: stage 2 = 54%; stage 3 = 45%; stage 4 = 1%. Median follow-up was 24 months (range 6 and 110 months). At their last recorded visit, 73 subjects (66%) continued observation and 38 subjects (34%) chose pessary or surgical intervention. We investigated clinical factors for choosing intervention. Increase in POP symptom bother was the only variable that remained significant in determining patient choice of a therapeutic intervention (p < 0.001) after confounding factors were controlled for using multivariate regression analysis.

CONCLUSION

In subjects with bothersome POP who initially choose observation and subsequently elect to pursue a therapeutic intervention, worsening symptom bother is the most important factor.

Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes

BACKGROUND

Rapid increase in number of male-to-female vaginoplasties emphasizes the need for preoperative measures to optimize final surgical and patient-reported outcomes. Hormonal therapy and socioeconomic factors may contribute to a higher incidence of pelvic floor dysfunction in patients undergoing male-to-female vaginoplasty. The purpose of this study was to evaluate the incidence of pelvic floor dysfunction in this population and the role of physical therapy in its treatment.

METHODS

From July 2016 to July 2018, patients scheduled to undergo male-to-female vaginoplasty were evaluated by a physical therapist for pelvic floor dysfunction. Patient charts were reviewed for demographics, comorbidities, and length of hormonal therapy. Those with and without symptoms were compared. Symptomatic patients underwent therapy. Assessment of symptom severity and its impact on daily living were completed at 2- to 3-month intervals with physical therapy using the 6-item Urinary Distress Index 6 and 8-item Colorectal Anal Distress Index components of the 20-item Pelvic Floor Distress Inventory (PFDI-20) before and after surgery. A third component of the PFDI-20, the 6-item Pelvic Organ Prolapse Distress Inventory, was also included in the postoperative assessment.

RESULTS

Over a 24-month period, a total of 40 patients with a mean age of 40.7 (19-72) years and body mass index of 27.1 kg/m (22-39 kg/m) were enrolled. Comorbidities included 4 patients (10%) with diabetes and 6 patients (15%) with hypertension. Patients with symptoms had a significantly higher mean age (P < 0.01). Only 1 patient (2.5%) had new-onset pelvic floor dysfunction after surgery, and there was no significant increase in severity of symptoms in those with a previous pelvic floor dysfunction postoperatively. Physical therapy significantly (P < 0.01) reduced severity of symptoms and its impact on daily living as assessed by the Urinary Distress Index and Colorectal Anal Distress Index before and after surgery and by the PFDI-20 and 7-item Pelvic Floor Dysfunction Index postoperatively.

CONCLUSIONS

A high incidence of pelvic floor dysfunction may exist in patients undergoing male-to-female vaginoplasty preoperatively. Screening at this early stage with both preoperative and postoperative therapy can significantly reduce pelvic floor dysfunction and improve symptoms and quality of life for this population.

Pelvic floor disorders in women who consult primary care clinics: development and validation of case definitions using primary care electronic medical records

BACKGROUND

To date, there has been no validated method to identify cases of pelvic floor disorders in primary care electronic medical record (EMR) data. We aimed to develop and validate symptom-based case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse in women, for use in primary care epidemiologic or clinical research.

METHODS

Our retrospective study used EMR data from the Southern Alberta Primary Care Research Network (SAPCReN) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in southern Alberta. Trained researchers remotely reviewed a random sample of EMR charts of women aged 18 years or older from 6 rural and urban clinics to validate case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and estimated SAPCReN prevalence as appropriate.

RESULTS

Charts of 900 women were included. Sensitivity was 81.9% (95% confidence interval [CI] 75.1-87.2) for urinary incontinence, 61.2% (95% CI 46.2-74.5) for fecal incontinence, and 51.8% (95% CI 40.6-62.8) for pelvic organ prolapse. Corresponding specificity values were 71.9% (95% CI 68.4-75.1), 99.2% (95% CI 98.2-99.6) and 98.8% (95% CI 97.7-99.4), PPVs 40.6% (95% CI 35.4-46.0), 81.1% (95% CI 64.3-91.4) and 81.1% (95% CI 67.6-90.1), and NPVs 94.4% (95% CI 92.1-96.1), 97.8% (95% CI 96.5-98.6) and 95.3% (95% CI 93.6-96.6). The SAPCReN-observed prevalence for urinary incontinence was 29.7% (95% CI 29.3-30.0), but the adjusted prevalence was 2.97%.

INTERPRETATION

The case definition for urinary incontinence met our standard for validity (sensitivity and specificity > 70%), and the case definitions for fecal incontinence and pelvic organ prolapse had PPVs greater than 80%. The urinary incontinence definition may be used in epidemiologic research, and those for fecal incontinence and pelvic organ prolapse may be used in quality-improvement studies or creation of disease registries. Our symptom-based case definitions could also be adapted for research in other EMR settings.

Prevalence of Screening High Risk of Obstructive Sleep Apnea Among Urogynecology Patients

OBJECTIVES

There is limited knowledge on the prevalence of obstructive sleep apnea (OSA) among urogynecology patients. The aim of this study was to determine the prevalence of screening high risk of OSA (HR-OSA) in an ambulatory urogynecology clinic.

METHODS

Women presenting for a new patient visit to a single outpatient urogynecology clinic for any indication were screened for eligibility. Patients were included if they were 18 years or older, English speaking, nonpregnant, and not using treatment for OSA. Participants completed the STOP-BANG questionnaire to screen for OSA and additional questionnaires to assess the presence and classification of nocturia and urinary incontinence.

RESULTS

Among 130 participants, the prevalence of screening HR-OSA was 38.5%. Characteristics associated with screening HR-OSA included hypertension (P < 0.001), diabetes (P=0.003), untreated sleep apnea (P < 0.001), body mass index ≥30 kg/m (P < 0.001), and age >50 years (P < 0.001). Participants who screened HR-OSA were more likely to have bothersome bladder symptoms of nocturia (P < 0.001), nocturnal enuresis (P < 0.001), higher urinary distress inventory scores (P < 0.001), and incontinence severity index scores (P < 0.001). On multivariable analysis, age >50 years (odds ratio [OR], 7.54), hypertension (OR, 4.04), body mass index ≥30 kg/m (OR, 3.98), and nocturial enuresis (OR, 2.26) remained significantly associated with screening HR-OSA. Average time to complete the STOP-BANG was 1.2 minutes.

CONCLUSIONS

The prevalence of OSA among urogynecology patients is high, and screening is not time prohibitive. Patients who screen HR-OSA have more bothersome bladder symptoms. Providers should consider screening urogynecology patients for OSA, especially patients who are 50 years or older, are obese, and have nocturnal enuresis.

Prevalence of symptomatic urinary incontinence and pelvic organ prolapse among women in rural Nepal

INTRODUCTION AND HYPOTHESIS

Although pelvic floor disorders (PFDs) are a significant public health issue in higher income countries, less is known about these disorders and associated risk factors in low income countries. We aimed to determine prevalence and associated risk factors for stress urinary incontinence (SUI), urge urinary incontinence (UUI), and pelvic organ prolapse (POP) in reproductive age women in Sarlahi District in rural Nepal.

METHODS

We conducted a community-based cross-sectional survey of parous, reproductive age women in rural Nepal and screened for pelvic floor disorders using validated screening questions for PFDs. Overall frequency of self-reported symptoms for SUI, UUI, and POP was estimated and compared across demographic and pregnancy history information.

RESULTS

Of 14,469 women available for analysis, the mean (SD, range) age was 33.5 (8.2, 13-52) years, and median (range) number of pregnancies was 4 (1-15). The prevalence of SUI was 24.1% (95% CI: 23.3-24.8), of UUI was 13.5% (95% CI: 13.0-14.1), and of POP was 8.0% (95% CI: 7.5-8.4). Bivariate analysis identified the risk of PFD increased incrementally with age and number of vaginal deliveries; these covariates were highly correlated. Multivariable logistic regression revealed age, vaginal deliveries, and previous pelvic surgeries were independently associated with PFD.

CONCLUSIONS

PFDs are common in a community of parous, reproductive age women in rural Nepal. Risk factors for these conditions are similar to risk factors found in higher income countries.

Association of race with anal incontinence in parous women

INTRODUCTION AND HYPOTHESIS

To investigate the relationship between race and anal incontinence (AI). Our hypotheses were (a) AI symptoms are similar between white and black women and (b) asymptomatic black and white women are equally likely to develop AI over one year of prospective observation.

METHODS

Parous women enrolled in a longitudinal cohort study were assessed for AI symptoms annually using Epidemiology of Prolapse and Incontinence Questionnaire. An AI score > 0 indicated any bother from AI; a score > 22.8 indicated clinically significant AI. We compared the odds of AI scores >0 at the visit level between white vs black women with logistic regression models using generalized estimating equations. We also estimated the odds of new AI symptoms at time T + 1(one year later) among women free of AI symptoms at time T comparing white vs black women. In the latter analysis, we considered new AI symptoms to be represented by scores above 11.4. Covariates included in the adjusted models were: mode of delivery, obstetrical anal sphincter injuries, body mass index, age at the first delivery, and parity at enrollment.

RESULTS

Among 1256 participants, 189 (15.0%) were black. AI score = 0 was observed at 74.2% (= 5122/6902) person-visits. The adjusted odds ratio of AI score > 0 was 1.83 (95% CI 1.24, 2.70) for white vs black women. Across 4364 visit pairs with AI score = 0 at time T, 203 (4.7%) had AI score > 11.4 at visit T + 1 and white race significantly increased the odds of developing symptoms at time T + 1 (adjusted OR = 2.26, 95% CI 1.28, 3.98).

CONCLUSIONS

In an analysis that controlled for mode of delivery, obstetrical anal sphincter injuries, obesity, age at first delivery, and parity, white race was significantly associated with AI symptoms at any point in time as well as to the development of AI over one year of observation.

Pelvic floor dysfunctions in female cheerleaders: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

Cheerleaders perform high-impact maneuvers that can be associated with pelvic floor dysfunction. We hypothesized that female cheerleaders would report more symptoms of pelvic floor dysfunction and fewer symptoms of premenstrual syndrome than nonathletic women.

METHODS

This cross-sectional study included high-performance female cheerleaders and young nonathletic, nulliparous, and normal-weight females. Demographics, sports practices, and pelvic floor dysfunction data were collected through an electronic questionnaire. Urinary symptoms were collected through the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and King's Health Questionnaire. Intestinal symptoms were collected through the use of Criterion F of item C3, referring to functional constipation of Rome III and Fecal Incontinence Severity Index. Data on sexual function were collected through the Female Sexual Function Index. Data on pelvic organ prolapse were obtained through the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS). In addition, questions about premenstrual syndrome-dysmenorrhea, irritability, headache, tiredness, fluid retention, and constipation-were collected through the Menstrual Symptom Questionnaire. The comparison between groups of the quantitative variables was performed using the Mann-Whitney U test. Odds ratios (OR) and 95% confidence intervals (CI) were estimated for comparison between groups on the occurrence of pelvic floor muscle dysfunction symptoms. A significance level of 5% was adopted.

RESULTS

A total of 156 women (78 cheerleaders and 76 nonathletes) completed the electronic questionnaire. Anal incontinence was the most prevalent symptom of pelvic floor muscle dysfunction. Cheerleaders were 2.3 times more likely to report symptoms regarding anal incontinence than nonathletic women. For the other symptoms of pelvic floor dysfunction, no statistical differences between the groups were found. Cheerleaders reported fewer symptoms of tiredness and constipation during the premenstrual period than did nonathletic women.

CONCLUSION

Pelvic floor dysfunction, particularly anal incontinence, appears to be more prevalent among cheerleaders than among nonathletic women. In addition, cheerleaders demonstrated fewer symptoms of tiredness and constipation during the premenstrual period.

Pelvic floor disorders and health-related quality of life in older women: Results from the Women's Gynaecological Health study in Lieto, Finland

OBJECTIVE

The aim of this study was to analyse the prevalence of pelvic floor disorders and to describe health-related quality of life (HRQoL) among older women. We also compared participants' HRQoL with the age-matched general female population and analysed factors associated with HRQoL.

STUDY DESIGN

This is a population-based study of a cohort of women born in 1948 and in 1950 (n = 143) which is also part of the Women's Gynaecological Health study in Lieto, Finland.

METHODS

The data were collected by questionnaires which pertained to socio-demographics, health-related variables, pelvic floor disorders and HRQoL (15D). Linear model was conducted to estimate a model of factors that associated with HRQoL.

RESULTS

The prevalence of urinary incontinence, faecal incontinence and pelvic organ prolapse was 50%, 13% and 12%, respectively. The overall HRQoL score of the study cohort is broadly similar to that of the agematched general Finnish female population (mean±SD15D scores 0.905±0.084 vs 0.912±0.077). Higher number of medications was the most important explanatory factor for lower HRQoL.

CONCLUSION

Urinary incontinence was common; however, the impact on HRQoL was minor. The overall HRQoL score of the study cohort was broadly similar to that of age-matched general female population. Women who used a higher number of medications had lower HRQoL compared to women who used fewer medications.

Depression symptoms in women with pelvic floor dysfunction: a case-control study

Purpose

In this study, we aimed to estimate the prevalence of depression symptoms in women with pelvic floor dysfunction (PFD) and to assess their quality of life (QOL).

Patients and methods

A case-control study assessing depression and its severity in women with PFD (urinary incontinence, pelvic organ prolapse, and fecal incontinence) was conducted. Patients attending the Urogynecology Department of the Women's Specialized Hospital, King Fahad Medical City, were requested to complete the self-reported Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and Beck Inventory Scale for Depression. Women presenting with no PFD symptoms were recruited from other clinics as controls.

Results

Data of 100 women diagnosed with PFD (mean age, 45.18±10.50 years) and 100 control participants (mean age, 45.14±13.03 years; P=0.644) were collected. Patients with PFD showed significantly higher (7.3%) body mass index (BMI) (32.59±6.22 kg/m²) than controls (30.37±8.08 kg/m²) (OR, 1.044, 95% CI: 1.001-1.091; P=0.043). Patients with PFD exhibited a threefold higher prevalence of depression symptoms than controls (43% vs 14%, respectively; P<0.001). QOL scores in patients with PFD were significantly higher in patients with depression (P-values, 0.024 to <0.001).

Conclusion

There is a significant association between depression and PFD, and QOL scores in patients with PFD were significantly higher in patients with depression.

Clinical Significance of Neuropeptide Y Expression in Pelvic Tissue in Patients with Pelvic Floor Dysfunction

OBJECTIVES

To investigate the neuropeptide Y (NPY) expression in the tissue of pelvic floor ligament and anterior vaginal wall in female patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

METHOD

Seventeen patients with POP, 6 with SUI, 13 with POP and SUI (POP&SUI), and 10 controls were included in this study from First Affiliated Hospital of JiNan University. Immunohistochemical assay was used to examine NPY expression in the tissue of round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall. NPY expression were compared between POP, SUI, POP&SUI and controls.

RESULTS

NPY was positive expressed in the round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal subepithelial connective tissue. Compared with the control group, NPY expression in the round, cardinal, and uterosacral ligaments in patients with POP&SUI group was decreased with significant statistical difference (p<0.05). NPY expression in anterior vaginal wall was significantly decreased in POP, SUI, and POP&SUI groups compared to normal group (p<0.05). Compared to POP group, NPY expression in SUI and POP&SUI groups were significantly decreased (p<0.05), however the difference was not statistical different between SUI and POP&SUI groups (p>0.05). In POP and POP&SUI groups, the NPY expression in the cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall were negatively correlated with age (p<0.05), however, was not correlated with number of pregnancy, number of delivery, and BMI (p>0.05).

CONCLUSIONS

NPY expression was reduced in the round ligament, cardinal ligament of uterus, Uterosacral ligament, and vaginal anterior wall of the patients with POP and SUI. The decreased NPY expression may play an important role in the development of pelvic floordysfunction.

How to report electrotherapy parameters and procedures for pelvic floor dysfunction

Electrical stimulation is widely used for pelvic floor muscle dysfunctions (PFMDs), but studies are not always clear about the parameters used, jeopardizing their reproduction. As such, this study aimed to be a reference for researchers and clinicians when using electrical stimulation for PFMD. This report was designed by experts on electrophysical agents and PFMD who determined all basic parameters that should be described. The terms were selected from the Medical Subject Headings database of controlled vocabulary. An extensive process of systematic searching of databases was performed, after which experts met and discussed on the main findings, and a consensus was achieved. Electrical stimulation parameters were described, including the physiological meaning and clinical relevance of each parameter. Also, a description of patient and electrode positioning was added. A consensus-based guideline on how to report electrical stimulation parameters for PFMD treatment was developed to help both clinicians and researchers.

Pelvic floor dysfunction in women with fibromyalgia and control subjects: Prevalence and impact on overall symptomatology and psychosocial function

AIMS

To evaluate the prevalence, distress, and impact of pelvic floor dysfunction (PFD) symptomatology in women with fibromyalgia and control women. We also aimed to evaluate the impact of PFD symptomatology on several psychosocial measures such as mood, sleep, pain, and quality of life.

METHODS

We conducted a cross-sectional study in women with fibromyalgia and control women from the general population. Using a structured survey, we collected sociodemographic and clinical data, assessed the prevalence of PFD and evaluated the distress (PFDI-20) and the impact (PFIQ-7) caused by its symptomatology. Using Spanish-validated questionnaires, we also evaluated mood and sleep disturbances, bodily pain, and quality of life in subjects with and without PFD. In participants with fibromyalgia, we assessed the severity and impact of the disease using the Fibromyalgia Impact Questionnaire (FIQR).

RESULTS

Two hundred and twenty-six patients with fibromyalgia and 222 control women completed the surveys. Two hundred and twenty patients (93%) and 140 controls (63%) reported PFD-related symptoms. Both the scores of distress (143.1 ± 5.7 vs 96.1 ± 4.8, P < 0.0001) and impact (122.4 ± 5.6 vs 100.6 ± 6.4, P < 0.0001) caused by PFD symptoms were significantly higher in women with fibromyalgia than in controls. There was a significant positive relationship between fibromyalgia severity and both PFDI-20 (r²  = 0.32, P < 0.0001) and PFIQ-7 scores (r²  = 0.375, P < 0.0001). Depression severity, sleep disturbances, bodily pain, and low quality of life were highest in women with fibromyalgia and PFD and lowest in control women without PFD.

CONCLUSIONS

PFD-related symptoms were significantly more frequent in women with fibromyalgia than in controls. PFD symptomatology, when present, negatively influenced mood, sleep quality, and quality of life of both patients with fibromyalgia and controls.

Predictors for adherence to a home-based pelvic floor muscle exercise program for treating female urinary incontinence in Brazil

Objective: To assess predictors for adherence to a home-based pelvic floor muscle exercise (PFME) program supplemented with three physical therapy sessions in women with urinary incontinence (UI). Design: Secondary analysis of a randomized controlled trial of interventions to enhance self-efficacy with respect to PFME. Setting: Patients were referred from public primary or secondary care providers in Florianópolis, Brazil. Participants: Adult women with UI. Intervention: Three supervised physiotherapy sessions for the treatment of UI combined with home-based PFME program. Treatment groups were combined for predictive modelling because there was no difference after intervention between groups regarding UI and adherence rates. Main Outcome Measures: Adherence to PFME at 3-month follow-up (structured questionnaire). Baseline Predictors: self-efficacy and outcome expectation scales; severity of UI (ICIQ-SF), pelvic floor muscle strength, age, body mass index (BMI), and educational level. Results: 86 women with UI of whom 72 completed the study. An intention-to-treat analysis was performed. Forty-three women reported carrying out PFME every day. Adherence was correlated to: baseline self-efficacy (r = 0.299); age (r = 0.242); and educational level (r = -0.273). Hierarchical regression analyses incorporating treatment group, age, education, disease-related factors (severity of UI; pelvic floor muscle strength; BMI), and outcome expectations and self-efficacy showed that only baseline self-efficacy predicted adherence (R² = 0.217). Conclusions: Adherence to home-based PFME is a complex phenomenon. Assessing self-efficacy may help physiotherapists to detect patients' confidence in performing home-based exercises and, when necessary, give patients additional incentives.

Do moderate aerobic exercise and strength training influence electromyographic biofeedback of the pelvic floor muscles in female non-athletes?

[Purpose] To assess the influence of moderate physical exercise on pelvic floor muscle electromyographic (EMG) biofeedback signal in female non-athletes. [Subjects and Methods] A prospective, non-randomized study of 90 adult females (age ≥18 years) divided into three groups: Intervention (I), which began physical exercise upon study enrollment; Moderate Exercise (ME), comprising those who already engaged in physical activity; and Sedentary (S), comprising those who had a sedentary lifestyle. All participants underwent EMG biofeedback of the pelvic floor muscles upon study enrollment (T1) and at the end of the third subsequent month (T2). [Results] Mean age was 35.7 (SD: 7.5) years, with no significant difference between groups. T1 values in groups I and S were significantly lower than in group ME. There was no statistically significant difference between groups S and I. On comparison between groups at T2, values were highest in group I (18.5 µV vs. 15.3 µV in group S, vs. 16.1 µV in group ME). There was no significant difference between groups S and ME. On age-adjusted analysis, group I exhibited the greatest change between T1 and T2 (I, 4.7 µV; ME, 2.1 µV; S, 1.5 µV). [Conclusion] Females who exercise exhibit better pelvic floor muscle function than those who do not engage in physical activity.