Predicting treatment choice for patients with pelvic organ prolapse

The Role of Self-Management in Pessary Therapy for Pelvic Organ Prolapse-A retrospective cohort study

INTRODUCTION AND HYPOTHESIS

This study investigated pessary self-management (PSM). The primary outcome was how often PSM was taught to patients with pelvic organ prolapse (POP). Secondary outcomes were associations of PSM with treatment continuation, side effects, changing to surgery, and number of doctor consultations in the first year after treatment initiation compared with clinical management (CM).

METHODS

A retrospective cohort study was conducted in 300 patients visiting three Dutch medical centres in 2019, and receiving a pessary for POP. The t test, Chi-squared test and logistic regression were performed to compare PSM with CM and to identify factors associated with treatment continuation.

RESULTS

A total of 35% of patients received PSM instructions, of which 92% were able to perform PSM successfully. Treatment was continued by 83% of patients practicing PSM and 75% of patients having CM (p = 0.16), side effects occurred in 26% and 39% respectively (p = 0.18). Pain or discomfort was associated with treatment discontinuation (p < 0.01). In a subgroup analysis of patients who had a pessary suitable for PSM, treatment continuation was significantly higher in the PSM group (97%) than in the CM group (74%; p < 0.01).

CONCLUSIONS

Pessary self-management was only taught to 35% of patients who received a pessary, although the ability to perform PSM was high (92%). Treatment discontinuation was significantly lower in the PSM subgroup, when assessing the subgroup of patients using a pessary suitable for PSM. The large number of patients using a pessary suitable for PSM in the CM group implies that there is a lot to gain by promoting PSM.

The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training

IMPORTANCE

The impact of preoperative pain on outcomes can guide counseling.

OBJECTIVE

The objective of this study was to compare outcomes after vaginal reconstructive surgery and pelvic muscle training between women with and without preoperative pain.

STUDY DESIGN

This is a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial, which randomized patients to a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (pelvic floor muscle training vs usual care). Preoperative pain was defined as a response of "5" or greater on the pain scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question "Do you usually experience pain in the lower abdomen or genital area?"

RESULTS

The OPTIMAL trial included 109 women with preoperative pain and 259 without pain. Although women with pain had worse pain scores and pelvic floor symptoms at baseline and postoperatively, they had greater improvement on pain scores (-2.3 ± 2.4 vs -0.2 ± 1.4, P < 0.001), as well as Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores. Among women with pain who underwent a sacrospinous ligament fixation, those who received pelvic floor muscle training had a greater reduction in pain compared with those in the usual care group (-3.0 ± 2.3 vs -1.3 ± 2.1, P = 0.008). Persistent or worsening pain was present at 24 months in 5 (16%) women with preoperative pain.

CONCLUSIONS

Women with preoperative pain experience significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery. Pelvic floor muscle training perioperatively may be beneficial for select patients.

Vaginal Pessary Use and Management for Pelvic Organ Prolapse: Developed by the joint writing group of the American Urogynecologic Society and the Society of Urologic Nurses and Associates. Individual writing group members are noted in the Acknowledgments section

ABSTRACT

Over the past 50 years, pessary use has increased in popularity and has become an essential pelvic organ prolapse (POP) management tool. However, evidence is lacking to define care standardization, including pessary fitting, routine maintenance, and management of pessary-related complications. This clinical consensus statement (CCS) on vaginal pessary use and management for POP reflects statements drafted by content experts from the American Urogynecologic Society and Society of Urologic Nurses and Associates. The purpose of this CCS is to identify areas of expert consensus and nonconsensus regarding pessary fitting, follow-up, and management of pessary complications to improve the safety and quality of care where evidence is currently limited. The American Urogynecologic Society and Society of Urologic Nurses and Associates' vaginal pessary for POP writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 31 statements were assessed and divided into 3 categories: (1) fitting and follow-up, (2) complications, and 3) quality of life. Of the 31 statements that were assessed, all statements reached consensus after 2 rounds of the Delphi survey. This CCS document hopefully serves as a first step toward standardization of pessary care, but the writing group acknowledges that improved research will grow the base of knowledge and evidence providing clinicians a foundation to manage pessary care effectively and confidently.

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

INTRODUCTION AND HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Can we predict continued pessary use as primary treatment in women with symptomatic pelvic organ prolapse (POP)? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

The objective of this study was creating a prediction model for continued pessary use in patients with symptomatic pelvic organ prolapse (POP) and evaluating the percentage of continued pessary use after 12 months.

METHODS

We performed a prospective cohort study in patients with symptomatic POP stage ≥ 2. All patients received a pessary as primary treatment. Factors for continuation were identified from baseline characteristics and data from validated disease-specific quality of life (DSQOL) questionnaires. Univariate and multivariate analyses for predictors were performed and a prediction model was made. Improvement of POP was measured using the Patient Global Impression of Improvement (PGI-I) and DSQOL at 12 months' follow-up. Primary outcome was factors related to continued use. Secondary outcomes were the percentage continued pessary use after 12 months, improvement of complaints and DSQOL.

RESULTS

Two hundred ninety-one patients were included; 184 (63%) patients continued pessary use after 12 months. Factors related to continuation following the univariate analysis were age, sexual activity, POP-Q point c ≥ 0 and obstructive micturition. GH < 4 was not significant but added significantly to the prediction model. After multivariate analysis, age, point c ≥ 0 and GH < 4 cm remained predictors for continuation. The ROC showed an AUC of 0.65 (95% CI 0.58-0.71). PGI-I showed 83% perceived their prolapse complaints much or very much improved.

CONCLUSIONS

Continued pessary use was found in 63%. Main predictors for continued pessary use were higher age, more prominent apical compartment prolapse (c ≥ 0) and a GH < 4 cm.

Uterus Preservation in Case of Vaginal Prolapse Surgery Acts as a Protector against Postoperative Urinary Retention

Background: The aim of this study was to identify clinical risk factors for increased post-void residual (PVR) volumes in patients undergoing vaginal prolapse surgery and to find out whether uterus preservation or prolapse hysterectomy influences the incidence of postoperative urinary retention. Methods: This retrospective study included women who presented with pelvic organ prolapse (POP) and planned prolapse surgery between January 2017 and July 2019. PVR was assessed postoperatively and increased amounts were defined as incomplete voiding with residual urine volume greater than 150 mL. Results: Increased PVR at the first postoperative day occurred in 31.8% (56/176). Body mass index (BMI) was significantly lower in patients with increased PVR after pelvic floor surgery compared to patients with normal PVR amounts (p = 0.040). Furthermore, during multiple logistic regression analysis, low BMI (p = 0.009) as well as prolapse hysterectomy (p = 0.032) turned out to be the strongest risk factors associated with increased PVR volume. Conclusion: This is the first study identifying prolapse hysterectomy as an independent risk factor for increased PVR after surgical prolapse repair. Our results might be helpful in counseling patients prior to surgery and underline the option of uterus preservation during prolapse surgery in selected cases.

Managing female pelvic floor disorders: a medical device review and appraisal

Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.

Prolapse surgery versus vaginal pessary in women with symptomatic pelvic organ prolapse: which factors influence the choice of treatment?

Objective

To investigate which specific clinical factors influence patients’ choice of prolapse treatment.

Methods

This study includes a total of 510 cases with symptomatic pelvic organ prolapse (POP) of stage II or higher requiring prolapse treatment. Patients were divided into surgery and pessary groups according to their own choice and treatment preference. Primary outcome of interest was to define potential clinical parameters, which contribute to surgical treatment decision.

Results

A total of 252/510 (49%) women decided for prolapse surgery and 258/510 (51%) cases were treated conservatively with vaginal pessary. Hypertension, COPD as well as polypharmacy were parameters, which were statistically significantly more common in the pessary group compared to the surgically managed cases (p <0.05). On the contrary, women undergoing prolapse surgery were significantly younger and showed more advanced POP-Q (pelvic organ prolapse quantification) stages (p < 0.05). Clinical factors, such as BMI (body mass index), parity, mode of delivery and postmenopausal status, did not differ between the two groups (p > 0.05). Multiple logistic regression analysis revealed that advanced POP-Q stage (p < 0.001) as well as the absence of smoking (p < 0.001) were independent factors associated with surgical treatment decision.

Conclusion

Women, who favoured prolapse surgery, were younger and in significant better health condition (less hypertension and COPD), but showed a significantly higher POP-Q stage compared to women choosing pessary treatment. Our data indicate that women with higher POP-Q stage and non-smokers tended to decide for prolapse surgery. This information could help in clinical practice to guide patients for the best possible treatment decision and strengthen individual counselling.

The prevalence and treatment pattern of clinically diagnosed pelvic organ prolapse: a Korean National Health Insurance Database-based cross-sectional study 2009-2015

The study aim was to evaluate the prevalence of pelvic organ prolapse using claim data of South Korea and to evaluate treatment patterns. The Korea National Health Insurance Corporation pay medical costs for most diseases. This study used Health Insurance Review & Assessment Service-National Inpatient Sample (HIRA-NIS) 2009–2015. Pelvic organ prolapse was defined by diagnostic code (N81.x). Of the approximately 4.5 million women included in HIRA-NIS 2009–2015, 10,305 women were selected as having pelvic organ prolapse, and the mean age of the pelvic organ prolapse group was 63.9 ± 0.2 years. The prevalence of pelvic organ prolapse was 180 ± 4 per 100,000 population in women older than 50 years old. In logistic regression analysis, constipation increased the prevalence of all pelvic organ prolapse (odds ratio, 4.04; 95% confidence interval, 3.52–4.63; P < 0.01). The number of women requiring pessary only and surgery only were 26 ± 2 per 100,000 population and 89 ± 1 per 100,000 population, respectively, for women over 50 years of age. The prevalence of pelvic organ prolapse was quite lower than in previous studies. Surgery peaked at approximately 70 years of age. Pessary increased dramatically among women after the age of 65.

Predictors of unsuccessful pessary fitting in women with prolapse: a cross-sectional study in general practice

Introduction and hypothesis

Pelvic organ prolapse is a common condition. There is inconsistency between predictors of unsuccessful pessary fitting in urological/gynaecological clinics. Research in general practice is scarce. The aim was to estimate the proportion of women in general practice with a symptomatic pelvic organ prolapse and unsuccessful pessary fitting, and to identify characteristics associated with unsuccessful pessary fitting.

Methods

A cross-sectional study in general practice (n = 20) was carried out among women (≥55 years) with symptomatic prolapse (n = 78). Multivariate logistic regression analysis was used to identify predictors of unsuccessful pessary fitting.

Results

In total, 33 women (42 %) had unsuccessful pessary fitting. Factors associated with unsuccessful pessary fitting were age (per year, OR 0.93 [95 % CI 0.87–1.00]), body mass index (per kg/m², OR 1.14 [95 % CI 1.00–1.30]), and having underactive pelvic floor muscles (OR 2.60 [95 % CI 0.81–8.36]).

Conclusions

Pessary fitting was successful in 58 %, indicating that pessary treatment may be suitable for many, but not for all women in general practice with symptomatic prolapse. The condition of the pelvic floor probably plays a role in the success of pessary fitting, as demonstrated by the association with underactive pelvic floor muscles, and body mass index. The association with age may reflect the higher acceptance of conservative treatments for prolapse in older women. This is the first study on predictive factors for unsuccessful pessary fitting in general practice. Therefore, further research should seek to confirm these associations before we can recommend the use of this information in patient counselling.

Defining Patient Knowledge and Perceptions of Vaginal Pessaries for Prolapse and Incontinence

OBJECTIVE

The aim of this study was to define patient knowledge and perceptions of pessaries to identify barriers to care and inform physician counseling efforts.

METHODS

An anonymous survey was distributed to a convenience sample of new patients presenting to the urogynecology clinic at a single academic medical center. Data analysis was performed using standard bivariate and logistic regression models.

RESULTS

A total of 254 women completed the survey. Only half of respondents indicated prior knowledge of pessaries. The most common source of prior knowledge was a physician or other health care provider (100/130, 76.9%); comparatively few women had heard about pessaries from any other source. Patients presented with a negative view of pessaries, 3.6 ± 2.2 on a 0- to 10-point Likert scale, and only a third of patients indicated they would consider pessary use as a treatment option for their condition. On multivariable logistic regression, having previously seen a gynecologist (P = 0.03) and a lower level of education (P = 0.05) independently predicted aversion to pessary use.

CONCLUSIONS

Only half of patients presenting to a referral-based practice had previous knowledge of vaginal pessaries. Few patients had heard about pessaries from any source other than a physician or other health care provider. Patients presented with a negative impression of pessaries and a high level of aversion to pessary use. Patients who indicated they would decline pessary use reported a lower level of education and were more likely to have previously seen a gynecologist for evaluation of their condition. These data may inform physician counseling efforts.

Changes in the rheological behavior of the vagina in women with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is a common condition impacting the quality of life of millions of women worldwide. Although vaginal estrogen is widely used in women with prolapse, little is known regarding estrogen's benefits on the biomechanical properties of vaginal tissue. Here, we aimed to examine the effect of prolapse on the biomechanical properties of the vagina and determine alterations in vaginal mechanics in the presence and absence of hormone therapy (HT).

METHODS

We characterized the viscoelastic properties of vaginal biopsies from age-matched premenopausal women without (n = 12) and with prolapse (n = 8) and postmenopausal women with prolapse on (n = 18) and off HT (n = 9). Utilizing a single-lap shear testing protocol, full-thickness anterior vaginal biopsies were subjected to ±10% shear strain over a range of frequencies (1-90 Hz). This applied energy is either dissipated (viscous) or stored (elastic) as a function of frequency due to compositional or structural differences in the tissue.

RESULTS

Prolapsed tissue was more stiff (higher complex modulus) under shear deformation resulting from increases in both elastic (elastic modulus) and viscous (loss modulus) contributions, with non-prolapsed premenopausal women being the least stiff. Postmenopausal women with prolapse currently on HT were the most stiff of all the groups.

CONCLUSIONS

These data suggest that prolapsed tissue has an increased elastic contribution likely resulting from changes in biochemical constituents, and hormones increase the viscous contribution of prolapsed tissue. Overall, this study design characterized the viscoelastic properties of vaginal biopsies and may be utilized to conduct longitudinal studies to better understand the mechanisms of prolapse development and progression.

Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050

OBJECTIVE

We sought to estimate the number of women who will undergo inpatient and outpatient surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP) in the United States from 2010 through 2050.

STUDY DESIGN

Using the 2007 Nationwide Inpatient Sample and the 2006 National Survey of Ambulatory Surgery, we calculated the rates for inpatient and outpatient SUI and POP surgery. We applied the surgery rates to the US Census Bureau population projections from 2010 through 2050.

RESULTS

The total number of women who will undergo SUI surgery will increase 47.2% from 210,700 in 2010 to 310,050 in 2050. Similarly, the total number of women who will have surgery for prolapse will increase from 166,000 in 2010 to 245,970 in 2050.

CONCLUSION

If the surgery rates for pelvic floor disorders remain unchanged, the number of surgeries for urinary incontinence and POP will increase substantially over the next 40 years.

Lower abdominal and pelvic pain with advanced pelvic organ prolapse: a case-control study

OBJECTIVE

The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP).

STUDY DESIGN

This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support.

RESULTS

Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7-20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6-3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3-4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8-4.1).

CONCLUSION

Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review

Pessaries have been used to treat women with pelvic organ prolapse (POP) since the beginning of recorded history. This review aims to assess the effect of pessary treatment on the disease-specific, health-related quality of life in women with pelvic organ prolapse. After a Medline search using the Mesh term ‘pessary’ and critical appraisal, 41 articles were selected and used in this review. Pessaries are widely used to treat pelvic organ prolapse. It is minimally invasive and appears to be safe. Although there is evidence that the use of pessaries in the treatment of pelvic organ prolapse is effective in alleviating symptoms and that patient satisfaction is high, the follow-up in many published papers is short, and the use of validated urogynaecological questionnaires is limited. Comparison with surgical treatment of pelvic organ prolapse is rare and not assessed in a randomised controlled trial.

Validation, reliability, and responsiveness of Prolapse Quality of Life Questionnaire (P-QOL) in a Brazilian population

INTRODUCTION AND HYPOTHESIS

The aim of this study was to translate and validate a Brazilian version of the "Prolapse Quality of Life Questionnaire" (P-QOL) an instrument to assess quality of life of women with genital prolapse.

METHODS

Sixty-five patients answered the P-QOL twice. The reliability was assessed using Cronbach's alpha coefficient and validity was assessed comparing symptom scores between affected and asymptomatic women and comparing symptom scores with prolapse stages. Responsiveness was obtained with patients who underwent to genital prolapse surgical corrections.

RESULTS

The results have showed that the Brazilian Portuguese version of P-QOL has had very good psychometric properties. All items achieved a Cronbach's alpha greater than 0.70. The test-retest reliability confirmed that the questionnaire was able to detect changes in quality-of-life after treatment.

CONCLUSIONS

We concluded that the Portuguese version of the P-QOL is a very good instrument to assess quality-of-life in women with genital Prolapse.

Body image in women before and after reconstructive surgery for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This study seeks to determine the impact of prolapse surgery on body image in women with pelvic organ prolapse.

METHODS

Case-control study of 76 sexually active women with greater than or equal to stage II prolapse planning reconstructive surgery and 67 women with lesser than or equal to stage I prolapse. Questionnaires/examinations were completed at baseline and 6 months postoperatively for cases and at baseline for controls: Body Exposure During Sexual Activity Questionnaire (BESAQ), Body Image Quality of Life Inventory (BIQLI), Pelvic Floor Distress Inventory (PFDI)/Pelvic Floor Impact Questionnaire (PFIQ), and Pelvic Organ Prolapse-Incontinence Sexual Function Questionnaire-12 (PISQ-12), and the Pelvic Organ Prolapse Quantification (POPQ) examination.

RESULTS

Baseline and 6-month data were available for 64 case women with mean age of 60 +/- 8 years, mean body mass index of 28 +/- 5 kg/m(2), 96% Caucasian, and 83% postmenopausal. Baseline POPQ stage distribution was: stage II 14%, stage III 78%, and stage IV 8%. BESAQ, BIQLI, PFDI/PFIQ, and PISQ-12 postoperative scores significantly improved compared to preoperatively (all p <or= 0.001).

CONCLUSIONS

Body image, sexual function, and pelvic floor symptoms improve after prolapse surgery.

Factors influencing long-term pessary use

INTRODUCTION AND HYPOTHESIS

We aimed to identify factors contributing to successful pessary use for over 1 year.

METHODS

A chart review was conducted composed of 150 women at Montefiore Medical Center, using a pessary for over 1 year. Characteristics of those who continued pessary usage were compared with those who discontinued use by using Chi-square, Fisher's exact test, logistic regression model, receiver-operator characteristic curve, and Kaplan-Meier survival curves.

RESULTS

Thirty-five women (23%) discontinued using pessaries (DP) after a year, while 115 women (77%) continued (CP). There was no difference in multiple characteristics. The DP group had more patients with stress incontinence, p = 0.17. Older age at pessary insertion showed higher continued use (OR = 1.083, CI: 1.033-1.136). Patients with a history of prolapse repair surgery were more likely to discontinue pessary use.

CONCLUSIONS

Age greater than 72 years was associated with continued pessary use and history of hysterectomy or prolapse surgery, and stress incontinence were associated with discontinuation.

Assessment of preferences for treatment: validation of a measure

Systematic measurement of treatment preferences is needed to obtain well-informed preferences. Guided by a conceptualization of treatment preferences, a measure was developed to assess treatment acceptability and preference. The purpose of this study was to evaluate the psychometric properties of the treatment acceptability and preferences (TAP) measure. The TAP measure contains a description of each treatment under evaluation, items to rate its acceptability, and questions about participants' preferred treatment option. The items measuring treatment acceptability were internally consistent (alpha > .80) and demonstrated validity, evidenced by a one-factor structure and differences in the scores between participants with preferences for particular interventions. The TAP measure has the potential for the assessment of acceptability and preferences for various behavioral interventions.

The role of nurses in the management of women with pelvic organ prolapse

Pelvic organ prolapse is a common female complaint, with 50% of women experiencing some degree of pelvic relaxation, although not all have any symptoms. Prolapse is found most commonly in the anterior vaginal walls. Posterior vaginal wall and apical prolapse are the other, less common, categories. There are a large number of potential risk factors, but increased age, parity and body mass index are most consistently reported. A variety of symptoms may be experienced, including a feeling of something coming down, pelvic heaviness, urinary, bowel and sexual dysfunction. Two main treatment options exist, conservative management (pessary or pelvic floor rehabilitation) or surgical repair, however the evidence-base for treatment is weak. The specialist nurse is well-placed to contribute to the initial assessment, management and ongoing support of women with prolapse.

Relationships between personal beliefs and treatment acceptability, and preferences for behavioral treatments

BACKGROUND

The literature on preferences for behavioral interventions is limited in terms of understanding treatment-related factors that underlie treatment choice. The objectives of this study were to examine the direct relationships between personal beliefs about clinical condition, perception of treatment acceptability, and preferences for behavioral interventions for insomnia.

METHODS

The data set used in this study was obtained from 431 persons with insomnia who participated in a partially randomized clinical trial and expressed preferences for treatment options. The data were collected at baseline. Logistic regression was used to examine the relationships between personal beliefs and treatment acceptability, and preferences. The relationships between personal beliefs and perception of treatment acceptability were explored with correlational analysis.

RESULTS

Perception of treatment acceptability was associated with preferences. Persons viewing the option as convenient tended to choose that option for managing insomnia. Personal beliefs were not related to preferences. However, beliefs about sleep promoting behaviors were correlated with perceived treatment effectiveness.

CONCLUSIONS

Perception of treatment acceptability underlies expressed preferences for behavioral interventions. Personal beliefs about insomnia are not directly associated with preferences. Importance is highlighted for providing information about treatment options and exploring perception of each option's acceptability during the process of treatment selection.

Conservative versus surgical management of prolapse: what dictates patient choice?

INTRODUCTION AND HYPOTHESIS

The aim of this study is to establish whether the presence of severe symptoms influences women's choice of pessaries or surgery for uterovaginal prolapse.

METHODS

This is a prospective study using the validated Sheffield Prolapse Symptoms Questionnaire.

RESULTS

Women choosing surgery (n = 251) were younger (58 versus 66 years), more bothered by dragging lower abdominal pain (33% versus 25%, P = 0.04), need for vaginal digitation (8% versus 3%, P = 0.02), and incomplete bowel emptying (27% versus 19%, P = 0.01) than women choosing pessaries (n = 429). More women opting for surgery were sexually active (51% versus 29%, P < 0.0001), perceived avoidance of sex due to prolapse (28% versus 17%, P = 0.000), and perceived prolapse interfering with sexual satisfaction as a severe problem (26% versus 15%, P = 0.000).

CONCLUSIONS

Nearly two thirds of women with symptomatic prolapse initially opted for conservative management. Women choosing surgery over pessaries for treatment of prolapse describe more severe symptoms related to bowel emptying, sexual function, and quality of life and are bothered by them.

Tissue mechanics, animal models, and pelvic organ prolapse: a review

Pelvic floor disorders such as pelvic organ prolapse, urinary incontinence, and fecal incontinence affect a large number of women each year. The pelvic floor can be thought of as a biomechanical structure due to the complex interaction between the vagina and its supportive structures that are designed to withstand the downward descent of the pelvic organs in response to increases in abdominal pressure. Although previous work has highlighted the biochemical changes that are associated with specific risk factors (i.e. parity, menopause, and genetics), little work has been done to understand the biomechanical changes that occur within the vagina and its supportive structures to prevent the onset of these pelvic floor disorders. Human studies are often limited due to the challenges of obtaining large tissue samples and ethical concerns. Therefore, it is necessary to investigate the use of animal models and their importance in understanding how different risk factors affect the biomechanical properties of the vagina and its supportive structures. In this review paper, we will discuss the different animal models that have been previously used to characterize the biomechanical properties of the vagina: including non-human primates, rodents, rabbits, and sheep. The anatomy and preliminary biomechanical findings are discussed along with the importance of considering experimental conditions, tissue anisotropy, and viscoelasticity when characterizing the biomechanical properties of vaginal tissue. Although there is not a lot of biomechanics research related to the vagina and pelvic floor, the future is exciting due to the significant potential for scientific findings that will improve our understanding of these conditions and hopefully lead to improvements in the prevention and treatment of pelvic disorders.

Patients' pelvic goals change after initial urogynecologic consultation

OBJECTIVE

The objective of the study was to determine the effect of initial urogynecologic consultation on the number and type of patient goals.

STUDY DESIGN

Charts of women who underwent initial urogynecology consultation were reviewed. Patient goals were collected before and after their consultation. Investigators categorized goals into 6 categories. Category and number of goals were compared before and after their first visit. Predictors of change and clinical associations were assessed.

RESULTS

Sixty-three women with a mean age of 53 (range, 18-83) years reported a total number of 313 goals. The number of patients' postconsultation goals was higher than the number of preconsultation goals, (median of 3 +/- 1.2 vs 2 +/- 1.2, respectively; P < .003). Women were less likely to report" symptom" and "information-seeking" goals (P < .002 and P < .03, respectively) but more likely to report treatment goals after consultation (P < .001).

CONCLUSION

Urogynecologic consultation affects patients' goals. It is important to reassess goals following initial consultation.

Presentation of a device used by elderly women with prolapse in eastern part of Turkey

OBJECTIVE

Presentation of a device used by three elderly women with prolapse in eastern part of Turkey.

METHOD

Information about device is obtained by face to face interview technique. Microbiologic examination of the device and vaginal cultures were performed.

RESULTS

Three women with genital polapse using an ancient device were found incidentally and information about device, their knowledge about genital prolapse, and solutions were obtained.

CONCLUSION

By the help of related media and women health organizations the women especially who live in rural area should be educated about reproductive health care and if necessary health policies revisions should be considered.

Traitement chirurgical du prolapsus génital chez les femmes âgées de plus de 80 ans

OBJECTIVES

The aim of this study was to assess the morbidity and the effectiveness of the vaginal surgical treatment for women over 80 years of age with genital prolapse.

MATERIALS AND METHODS

All the women over 80 years operated in our institution between 1996 and 2003 were reviewed retrospectively. We examined the risk and the effectiveness of this surgery.

RESULTS

Forty-eight women underwent surgery during this period. No colpocleisis was performed. The most frequent surgery was a combination of vaginal patch plastron, Richter's spinous fixation and posterior perineorrhaphy. No major intra- or post-operative complication occurred. One woman required blood transfusion. The most frequent postoperative complication was voiding difficulties (12%), which had disappeared 3 months later. A partial stenosis of a left ureter with ureterohydronephrosis occurred, requiring endoscopic dilatation. At 3 months, anatomic and functional outcome was good in 92% of women. The number of patients lost to follow-up at one year was to large to draw any conclusion.

CONCLUSION

Complete transvaginal surgical treatment is a safe procedure for elderly women which provides good short-term effectiveness.

Surgery for pelvic organ prolapse in women of 80 years of age and older

BACKGROUND

To investigate the long-term results of women over 80 years of age following surgery for pelvic organ prolapse. Design. Retrospective, descriptive study.

METHODS

We reviewed all records of women of 80 years and older operated for pelvic organ prolapse; all patients alive were contacted through a postal questionnaire.

RESULTS

A total of 2058 operations for pelvic organ prolapse were performed in the study period. One hundred and twenty-eight patients were 80 years and older with the mean age of 83 years (range 80-92 years). In three cases, serious complications occurred, and one of them died shortly after the operation. Follow-up was done with a postal questionnaire. Eighty-eight percent of patients who were alive at the time of data analysis returned the questionnaire. The mean duration of follow-up was 28 months (range 1-80 months). There were no patients who reported a relapse of prolapse. Urinary incontinence, urge, stress, or mixed incontinence, was present in almost half of the cases. The time to full recovery after the operation was experienced to be less than 3 months for 48%. General satisfaction with the procedure was high with 88% being (very) satisfied.

CONCLUSION

The operative correction of a pelvic organ prolapse in a group of women 80 years and older is a successful operation, with an acceptable morbidity and a high satisfaction of the patients.

Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction

Pelvic organ prolapse is a common and growing condition for which women seek help and frequently undergo surgical management. Prolapse of the posterior vaginal wall, alone or in combination with other compartment defects, can be a challenge for the pelvic surgeon. A clear understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship or lack of relationship between anatomy and function is required. Vaginal support defects occur with and without symptoms, and many of the symptoms attributed to pelvic organ prolapse can result from other causes. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been correlated with rectoceles. Whether the prolapse is the cause of these symptoms or is a result of straining and stretching of support tissues in women with defecation disorders is still unknown. We will present the current literature on these relationships and what evaluations are useful when caring for a woman with a rectocele and defecation disorders. Either pessaries or surgery can be used for treating rectoceles. Several surgical techniques have been described, including transvaginal, transanal, abdominal, and the use of graft materials to treat both anatomical defects and functional symptoms. The success, rationale, and complications of each approach, including anatomic cure, impact on defecation, and sexual function, are presented.

Patient characteristics that are associated with continued pessary use versus surgery after 1 year

OBJECTIVE

The purpose of this study was to identify patient characteristics in women with symptomatic pelvic organ prolapse that is associated with continued pessary use versus surgery after 1 year.

STUDY DESIGN

Fifty-nine women with symptomatic pelvic organ prolapse who were satisfied with their pessary at 2 months were evaluated prospectively at 1 year. Characteristics of women who continued to use a pessary were compared with women who underwent pelvic reconstructive surgery to identify predictors for continued pessary use versus surgery.

RESULTS

Forty-three women (73%) continued pessary use, and 16 women (27%) underwent surgery. Characteristics that were associated with continued pessary use were older age (76 vs 61 years; p <.001) and poor surgical risk (26% vs 0%; P =.03). Characteristics that were associated with surgery were sexual activity (81% vs 26%; P <.001), stress incontinence (44% vs 16%; P =.03), stage III-IV posterior vaginal wall prolapse (44% vs 16%; P =.03), and desire for surgery at the first visit (63% vs 12%; P <.001). Age >or=65 years was the best cut-off value for continued pessary use, with sensitivity of 95% (95% CI, 84%, 99%) and a positive predictive value of 87% (95% CI, 74%, 94%). Logistic regression demonstrated that age >or=65 years ( P <.001), stage III-IV posterior vaginal wall prolapse ( P =.007), and desire for surgery ( P =.04) were independent predictors.

CONCLUSION

Age >or=65 years was associated highly with continued pessary use. Desire for surgery and stage III-IV posterior vaginal wall prolapse were associated with discontinued pessary use and pelvic reconstructive surgery.