Minimum important differences for scales assessing symptom severity and quality of life in patients with fecal incontinence. Female Pelvic Med Reconstr Surg. 2014;20:342-348. [PMID: 25185630 DOI: 10.1097/spv.0000000000000078]

Silicone Irregular Hexagon Pessary Versus Polyvinyl Chloride Ring Pessary for Pelvic Organ Prolapse: Randomised Controlled Trial

INTRODUCTION AND HYPOTHESIS

Vaginal pessaries are the mainstay of the non-surgical management of pelvic organ prolapse (POP). A flexible silicone irregular hexagonal (SIH) pessary was developed based on the results of a prior vaginal case study. We hypothesised that the SIH pessary would have a higher rate of retention and self-management than the polyvinyl chloride (PVC) pessary.

METHODS

This was a prospective non-blinded, randomised controlled trial with institutional review board approval. Eligible participants were randomised and fitted with the assigned pessary. They were reviewed 1 week, 6 months and 1 year after the initial pessary fitting. Participants who returned for follow-up completed the study questionnaires. The primary outcome was success, defined as continued use of the allocated pessary at 6 months. Secondary outcomes included the ability to perform pessary self-care, treatment satisfaction and pessary-related complications. Statistical tests were performed with alpha or statistical significance defined as a p value of ≤ 0.05, two-tailed.

RESULTS

A total of 104 participants were randomised, with 52 subjects in each arm. Primary outcome data were analysed using per protocol analysis. Continuing pessary usage at 6 months was 68.1% for the PVC pessary group and 65.1% for the SIH group, with no statistically significant differences between the two groups (p = 0.765). Subjects with SIH were more likely to perform pessary self-care. There were no significant differences in subjects' satisfaction, quality-of-life scores or treatment complications between groups.

CONCLUSIONS

The pessary continuation rate between the SIH and the PVC pessary groups was similar at 6 months. Participants with an SIH pessary were more likely to self-manage.

Barbed Versus Nonbarbed Suture for Posterior Colporrhaphy: A Randomized Controlled Trial

IMPORTANCE

There is limited literature or even consensus on the suture material used for posterior vaginal repairs.

OBJECTIVES

This study aimed to compare outcomes of barbed versus nonbarbed delayed absorbable suture used for posterior colporrhaphy.

STUDY DESIGN

This study conducted a randomized controlled trial of 72 women undergoing posterior repair using standardized technique-concurrent procedures permitted with barbed (n = 36) or nonbarbed (n = 36) suture. Standardized examinations, validated questionnaires, and a visual analog scale (VAS) were completed at baseline, 6 weeks, and 12 months, and a telephone interview was conducted at 6 months. The primary outcome was posterior compartment pain at 6 weeks, measured by a VAS.

RESULTS

Seventy-two women enrolled, with follow-up rates 6 weeks (100%), 6 months (90.3%), and 12 months (73.6%). Demographics were similar between groups. A VAS with movement was not different between groups at 6 weeks. The odds of experiencing vaginal pain, having myofascial pain on examination, or being sexually active postoperatively were not different between the groups. There were no differences in the length of posterior colporrhaphy, surgical times, or hospital length of stay between the groups. Suture passes were lower in the nonbarbed group (median, 4 vs 7; P = <0.001), and suture burden was higher in the nonbarbed group (median, 26.9 vs 10.5 cm; P = <0.001). There was overall improvement in Pelvic Floor Distress Inventory Short Form 20 prolapse and colorectal subscores but no differences between groups. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form 12 scores improved, and dyspareunia decreased at 6 and 12 months in both groups. In addition, there were few anatomic recurrences at 6 weeks (0%) and 12 months (3.4%) and few adverse events.

CONCLUSIONS

This study found no differences in primary or secondary outcomes; however, both suture types resulted in clinical improvements in quality-of-life measures and sexual function.

Comparison of the Fecal Incontinence Severity Scores between Self-administration by Patients and an Oral Interview by a Physician

Objectives

To compare patients' self-administered responses to the Fecal Incontinence Severity Index (FISI) questionnaire (A1) with their responses to physician's oral interview (A3).

Methods

Patients (n=100: mean age: 72 years; 66 women) with FI completed the FISI and the modified FISI (with written explanations) questionnaires, followed by a physician interview. To identify a threshold for the rating gap between A1 and A3, we calculated each patient's mean difference in the FISI scores.

Results

There was no significant difference in the FISI scores between A1 and A3. A rating gap existed in the FISI scores (mean difference=8.9). It occurred in 37% of the patients, making its threshold 9. Multivariate analysis revealed that older age and no history of pelvic floor surgery were independently associated with the presence of a rating gap in the FISI scores. The in-coincidence of ticked boxes to all types of leakage between the self-administered responses and those by physician's oral history was 49% (197/400). Older age was associated with the in-coincidence of a ticked box between the assessment results of gas or solid stool leakage.

Conclusions

Some non-negligible discrepancy existed between patients' self-administered responses and their responses to physician's oral interview, especially in older patients.

Natural history of pelvic floor disorders before and after hysterectomy for gynaecological cancer

OBJECTIVE

To investigate the prevalence and severity of pelvic floor disorders (PFD), and the associations between treatment type and PFD, and cancer stage and PFD in patients before and after hysterectomy for gynaecological cancer; and the changes in outcomes over time.

DESIGN

Longitudinal cohort study.

SETTING

Gynaecological oncology outpatient clinics.

POPULATION

Patients undergoing hysterectomy for endometrial, uterine, ovarian or cervical cancer.

METHODS

Participants were assessed before, and 6 weeks and 3 months after hysterectomy. Changes over time were analysed using generalised estimating equations or linear mixed models. Associations were analysed using logistic regression models and analyses of variance.

MAIN OUTCOME MEASURES

Incontinence Severity Index, Pelvic Floor Distress Inventory-short form (PFDI-20), Female Sexual Function Index.

RESULTS

Of 277 eligible patients, 126 participated. Prevalence rates of PFD were high before (urinary incontinence [UI] 66%, faecal incontinence [FI] 12%, sexual inactivity 73%) and after (UI 59%, FI 14%, sexual inactivity 58%) hysterectomy. Receiving adjuvant therapy led to moderate-to-very severe UI 3 months after surgery compared with surgery only (odds ratio 4.98, 95% CI 1.63-15.18). There was no association between treatment type and other PFD, or cancer stage and any PFD.

CONCLUSION

Prevalence of PFD was high before and after hysterectomy for gynaecological cancer. Moderate-to-very-severe UI was associated with adjuvant therapy.

An examination of rectal prolapse surgery patients' quality of life and symptoms using patient-reported outcome instruments: A prospective cohort study

BACKGROUND

We measured changes in self-reported health and symptoms attributable to rectal prolapse surgery using patient-reported outcome (PRO) measures.

METHODS

A prospectively recruited cohort of patients scheduled for rectal prolapse repair in Vancouver, Canada between 2013 and 2021 were surveyed before and 6-months after surgery using seven PROs: the EuroQol Five-Dimension Instrument (EQ-5D-5L), Generalized Anxiety Disorder Scale (GAD-7), Pain Intensity, Interference with Enjoyment of Life and General Activity (PEG), Patient Health Questionnaire (PHQ-9), Fecal Incontinence Severity Index (FISI), Gastrointestinal Quality of Life Index (GIQLI), and the Fecal Incontinence Quality of Life Scale (FIQL).

RESULTS

We included 46 participants who reported improvements in health status (EQ-5D-5L; p ​< ​0.01), pain interference (PEG; p ​< ​0.01), depressive symptoms (PHQ-9; p ​= ​0.01), fecal incontinence severity (FISI; p ​< ​0.01), gastrointestinal quality of life (GIQLI; p ​< ​0.01), and fecal incontinence quality of life (FIQL) related to lifestyle (p ​= ​0.02), coping and behaviour (p ​= ​0.02) and depression and self-perception (p ​= ​0.01).

CONCLUSION

Surgical repair of rectal prolapse improved patients' quality of life with meaningful improvements in fecal incontinence severity and pain, and symptom interference with daily activities.

Pelvic Floor Physical Therapy Attendance Among High-Risk Postpartum Patients

IMPORTANCE

Limited data describe attendance to pelvic floor physical therapy (PFPT) in a postpartum patient population.

OBJECTIVES

The objective was describe attendance to PFPT in a cohort of postpartum women at high-risk of pelvic floor concerns. We secondarily compared attendance between patients with and without evaluation in a postpartum pelvic floor healing clinic (PPFHC).

STUDY DESIGN

This was a retrospective cohort study of 2 convenience samples from an academic hospital. The PPFHC cohort comprised all postpartum vaginal delivery patients evaluated in the PPFHC from July 2021 to July 2022. The historical pre-PPFHC cohort comprised patients with third/fourth-degree obstetrical lacerations from December 2019 to January 2021. We abstracted attendance to PFPT, number of visits, Pelvic Floor Distress Inventory-20 (PFDI-20) scores, Pelvic Floor Impact Questionnaire (PFIQ) scores, and discharge status.

RESULTS

Our cohort contained 464 patients, 195 (42.0%) from pre-PPFHC and 269 (58.0%) from PPFHC. Among all patients 302 (65.1%) were referred to PFPT and 170 (56.3%) attended at least 1 visit, 82 (48.2%) were discharged from PFPT with goals met, and the median number of visits was 6 (3-10). The majority of patients (97.0%, n = 261) seen in the PPFHC were referred to PFPT, compared with 22.0% (n = 41) of pre-PPFHC patients (P < 0.01). More patients in the pre-PPFHC cohort attended PFPT than in those the PPFHC cohort (75.6% vs 53.5%, P ≤ 0.01). Most patients exhibited improved PFDI and PFIQ scores after PFPT (n = 88, 80.0%, and n = 89, 81.7% respectively).

CONCLUSIONS

Patients attending postpartum PFPT demonstrated high therapy completion rates. A dedicated PPFHC had more referrals, however, lower PFPT attendance rates, when compared with a historical cohort.

Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence

INTRODUCTION AND HYPOTHESIS

Despite growing interest in a mobile-app bowel diary to assess fecal incontinence (FI) symptoms, data are limited regarding the correlation between mobile-app diary and questionnaire-based outcomes. The primary aim is to determine whether percentage reduction in FI episodes (FIEs)/week recorded on a mobile-app diary correlates with changes in scores of validated FI-symptom measures from baseline to 12 weeks in women with FI undergoing percutaneous tibial nerve stimulation (PTNS) versus sham.

METHODS

This is a planned secondary analysis of a multicenter randomized trial in which women with FI underwent PTNS or sham. FIEs were collected using a mobile-app diary at baseline and after 12 weekly sessions. FI-symptom-validated measures included St. Mark's, Accidental Bowel Leakage Evaluation, FI Severity Index (FISI), Colorectal Anal Distress Inventory, Colorectal Anal Impact Questionnaire, FI Quality of Life, Patient Global Impression of Improvement (PGI-I), and Patient Global Symptom Control (PGSC) rating. Spearman's correlation coefficient (ρ) was computed between %-reduction in FIEs/week and change in questionnaire scores from baseline to 12 weeks. Significance was set at 0.005 to account for multiple comparisons.

RESULTS

Baseline characteristics of 163 women (109 PTNS, 54 sham) include mean age 63.4±11.6, 81% white, body mass index 29.4±6.6 kg/m2, 4% previous FI surgeries, 6.6±5.5 FIEs/week, and St. Mark's score 17.4±2.6. A significant correlation was demonstrated between %-reduction in FIEs/week and all questionnaires (p<0.005). A moderate-strength correlation (|ρ|>0.4) was observed for St. Mark's (ρ=0.48), FISI (ρ=0.46), PGI-I (ρ=0.51), and PGSC (ρ=-0.43).

CONCLUSIONS

In women with FI randomized to PTNS versus sham, a moderate correlation was noted between FIEs measured via mobile-app diary and FI-symptom-validated questionnaire scores.

Effects of Pure Barre Exercise on Urinary Incontinence Symptoms: A Prospective Observational Cross-Sectional Study

IMPORTANCE

Pure Barre is a form of physical exercise using low-impact, high-intensity, pulsatile isometric movements that may serve as a treatment option for urinary incontinence.

OBJECTIVE

The objective of this study was to measure the effects of the Pure Barre workout on urinary incontinence symptoms and sexual function.

STUDY DESIGN

This was a prospective observational study of new, female Pure Barre clients with urinary incontinence. Eligible participants completed 3 validated questionnaires at baseline and at follow-up after 10 Pure Barre classes within 2 months. Questionnaires included the Michigan Incontinence Symptoms Index (M-ISI), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index-6. Matched differences in domain questionnaire scores between baseline and follow-up were analyzed.

RESULTS

All questionnaire domains significantly improved for all 25 participants after 10 Pure Barre classes. Median M-ISI severity domain scores decreased from 13 (interquartile range, 9-19) at baseline to 7 at follow-up (interquartile range, 3-10; P < 0.0001). Mean ± SD M-ISI urgency urinary incontinence domain scores decreased from 6.40 ± 3.06 to 2.96 ± 2.13 ( P < 0.0001). Mean ± SD M-ISI stress urinary incontinence scores decreased from 5.24 ± 2.71 to 2.48 ± 1.58 ( P < 0.0001). Mean ± SD Urinary Distress Inventory domain scores decreased from 42.17 ± 17.15 to 29.67 ± 13.73 ( P < 0.0001). Matched rank sum analysis indicated increasing Female Sexual Function Index-6 scores from baseline to follow-up ( P = 0.0022).

CONCLUSION

The Pure Barre workout may be an enjoyable, conservative management option that improves symptoms of urinary incontinence and sexual function.

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.

Five-year surgical outcomes of transvaginal apical approaches in women with advanced pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

In women with advanced prolapse, differences in vaginal apex anchoring sites may impact surgical outcomes over time. The primary aim was to compare 5-year surgical outcomes of uterosacral ligament suspension (ULS) versus sacrospinous ligament fixation (SSLF) in women with advanced (stage III-IV) prolapse.

METHODS

A secondary analysis was conducted in a subset of women with advanced prolapse from a multicenter randomized trial comparing ULS versus SSLF and its extended follow-up, using publicly accessible de-identified datasets. The primary outcome was time to failure, defined as any one of (1) apical descent > 1/3 into the vaginal canal or anterior/posterior compartment beyond the hymen, (2) bothersome vaginal bulge symptoms, or (3) re-treatment. Secondary outcomes include symptom severity measured by the Pelvic Organ Prolapse Distress Inventory (POPDI) and adverse events.

RESULTS

Of 285 women, 90/147 (61.2%) in ULS and 88/138 (63.8%) in SSLF had advanced prolapse. Baseline characteristics did not differ between groups except for median-vaginal deliveries (3.0 [2.0, 5.0] versus 3.0 [2.0, 4.0], p < 0.01). The median time to failure was 1.7 years ULS versus 2.0 years SSLF (p = 0.42). Surgical failure increased over time in both groups with no intergroup difference; by year 5, the estimated failure rate was 67.7% ULS versus 71.5% SSLF (adjusted difference -3.8; 95%CI [-21.9, 14.2]). No differences were noted in individual failure components (p > 0.05). POPDI scores improved over 5 years without intergroup difference (ULS -68.0 ± 61.1 versus SSLF -69.9 ± 60.3, adjusted difference -0.1 [-20.0, 19.9]). No difference in adverse events were observed (p > 0.05).

CONCLUSION

In women with advanced prolapse, surgical failure, symptom severity, and adverse events did not differ between ULS and SSLF over 5 years.

Comparison of outcomes of laparoscopic sacrocolpopexy with concomitant supracervical hysterectomy or uterine preservation

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy was traditionally performed for post-hysterectomy prolapse or during concurrent hysterectomy. Sacrocolpopexy outcome with uterine preservation is poorly investigated. This study compared outcomes of laparoscopic sacrocolpopexy with concurrent supracervical hysterectomy or uterine preservation.

METHODS

This retrospective study compared data of patients with pelvic organ prolapse who underwent laparoscopic sacrocolpopexy with uterine preservation with the data of controls who underwent laparoscopic sacrocolpopexy with supracervical hysterectomy. We analyzed composite failure in uterine preservation versus concurrent supracervical hysterectomy (primary objective) and evaluated factors associated with the primary outcome of composite failure after laparoscopic sacrocolpopexy with preservation or supracervical hysterectomy (secondary objective). Composite failure was defined as subjective bulge symptoms, reoperation, or anatomical prolapse. Cox models indicated time to composite failure as an endpoint.

RESULTS

Of 274 patients, 232 underwent laparoscopic sacrocolpopexy with supracervical hysterectomy and 42 underwent laparoscopic uterine preservation. After propensity score matching (ratio: 2, for the laparoscopic sacrocolpopexy with supracervical hysterectomy group), 56 patients (24.1%) were in the supracervical hysterectomy group and 28 (66.7%) in the uterine preservation group. All patients underwent 24 months of follow-up. The composite failure rates were 10.7% for supracervical hysterectomy and 3.6% for preservation (p=0.87). The mean estimated blood loss was 10 ml (preservation, 10.0 ml [5.0-10.0] versus supracervical hysterectomy, 10.0 ml [10.0-15.0]; p=0.007). In the Cox proportional hazards model, higher preoperative body mass index and the point Ba increased composite failure risk.

CONCLUSIONS

Although not statistically significant, composite failure in the two techniques is likely clinically meaningful.

The Impact of Pelvic Floor Physical Therapy on Bladder and Bowel Function After Obstetric Anal Sphincter Injury

IMPORTANCE

Women with obstetric anal sphincter injury (OASI) are at increased risk of pelvic floor disorders. No standard of care exists for management of pelvic floor dysfunction after OASI.

OBJECTIVES

The aims of this study were to evaluate the impact of pelvic floor physical therapy (PFPT) on bladder and bowel function after OASI and to describe adherence to PFPT.

STUDY DESIGN

A retrospective cohort study of women with OASI presenting at a postpartum care clinic from 2017 to 2021 was conducted. Women were grouped according to PFPT attendance. Urinary Distress Inventory 6 (UDI-6) and Fecal Incontinence Severity Index (FISI) were administered at baseline and 6 months.

RESULTS

A total of 430 women with OASI presented to a postpartum care clinic, of which 137 (31.9%) attended PFPT, and 293 (68.1%) did not attend. Baseline and 6-month questionnaires were completed by 169 women: 52 (30.8%) in the PFPT group and 117 (69.2%) in the non-PFPT group. Baseline UDI-6 and FISI scores were higher in the PFPT group. Improvement in UDI-6 was not different between groups (-5.8 ± 14.9 vs -3.7 ± 10.8, P = 0.36). The non-PFPT group had greater worsening of FISI compared with PFPT group (9.8 ± 15.2 vs 1.1 ± 11.5, P < 0.001). Sixty-six percent (n = 136) of women referred to PFFT attended at least 1 session, of which 32.4% (n = 44) completed all sessions. Completely adherent women were referred to PFPT earlier (18.5 vs 28.5 days postpartum, P = 0.027).

CONCLUSIONS

Women in both the PFPT and non-PFPT groups reported improvement in bladder leakage 6 months after OASI. Women who did not attend PFPT had significant worsening of bowel leakage. Early referral to PFPT in women with pelvic floor dysfunction following OASI should be considered.

Effect of Second-Stage Pushing Timing on Postpartum Pelvic Floor Morbidity: A Randomized Controlled Trial

OBJECTIVE

To assess whether immediate or delayed pushing in the second-stage results in higher risk of pelvic floor morbidity.

METHODS

This study was a planned secondary aim of a multicenter randomized clinical trial that included nulliparous patients at 37 weeks of gestation or greater in labor with neuraxial analgesia. Participants were randomized in the second stage to initiate pushing immediately or wait 60 minutes before pushing. Participants had pelvic floor assessments at 1-5 days postpartum, 6 weeks postpartum, and 6 months postpartum. Rates of perineal lacerations, pelvic organ prolapse quantification (POP-Q) measures, and scores on validated symptom-specific distress and quality-of-life questionnaires (PFDI-20 [Pelvic Floor Distress Inventory], PFIQ [Pelvic Floor Impact Questionnaire], FISI [Fecal Incontinence Severity Index], and MMHQ [Modified Manchester Health Questionnaire]) were compared. It was estimated that 630 participants would provide more than 80% power to detect a 40% difference in second-degree or greater perineal lacerations and approximately 80% power to detect a 40% difference in stage 2 or greater pelvic organ prolapse (POP).

RESULTS

Among 2,414 participants in the primary trial conducted between May 19, 2014, and December 16, 2017, 941 (39%) had pelvic floor assessments: 452 immediate pushing and 489 delayed pushing. The mean age was 24.8 years, and 93.4% had vaginal delivery. There were no significant differences in perineal lacerations at delivery and POP at 6 weeks and 6 months postpartum. Changes from baseline in total and subscale scores for the PFDI-20, the PFIQ, and the MMHQ were not significantly different at 6 weeks postpartum and 6 months postpartum. The change in FISI score was higher in the immediate pushing group at 6 months (2.9±5.7 vs 2.0±4.5, difference 0.9, P =.01), but less than the minimum important difference of 4.

CONCLUSION

Among nulliparous patients in the second stage with neuraxial analgesia, immediate pushing, compared with delayed pushing, did not increase perineal lacerations, POP-Q measures, or patient-reported pelvic floor symptoms at 6 weeks and 6 months postpartum.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT02137200.

Reproxalap Activity and Estimation of Clinically Relevant Thresholds for Ocular Itching and Redness in a Randomized Allergic Conjunctivitis Field Trial

INTRODUCTION

This clinical trial assessed the activity of reproxalap, a novel reactive aldehyde species modulator, and estimated clinically relevant thresholds for changes in ocular itching and redness in an allergic conjunctivitis field trial.

METHODS

This was a randomized, double-masked, vehicle-controlled phase 2 trial. Patients with ragweed-associated allergic conjunctivitis were assessed over 28 days in an environmental setting with approximately four doses per day of either 0.25% reproxalap, 0.5% reproxalap, or vehicle. Patients recorded ocular itching, redness, tearing, and eyelid swelling scores (each with a 0-4 scale, except for a 0-3 scale for swelling), and completed the Allergic Conjunctivitis Quality of Life Questionnaire at the beginning and end of the trial.

RESULTS

Mixed model of repeated measures analysis demonstrated statistically lower itching and tearing scores (pooled P = 0.026 and P < 0.001, respectively) and numerically lower redness and eyelid swelling scores than vehicle on days when pollen exceeded the 95th percentile value. Using three anchor-based and three distribution-based approaches, the meaningful within-patient change and the between-group meaningful difference for patient-reported ocular itching and redness was estimated to be approximately 0.5. The most common treatment-emergent adverse event associated with reproxalap was transient irritation upon instillation.

CONCLUSION

In a field clinical trial, reproxalap was well tolerated and superior to vehicle in reducing ocular itching on high-pollen days. The clinical meaningfulness threshold estimates of 0.5 units are among the first such calculations generated for the standard ocular itching and redness scores, providing important context for the clinical interpretation of clinical trials in allergic conjunctivitis.

Do resistance exercises during biofeedback therapy enhance the anal sphincter and pelvic floor muscles in anal incontinence?

AIM

To determine if a biofeedback therapy that includes concentric resistance exercise for the anal sphincter muscles can improve muscle strength/function and improve AI symptoms compared to the traditional/non-resistance biofeedback therapy.

BACKGROUND

Biofeedback therapy is the current gold standard treatment for patients with anal incontinence (AI). Lack of resistance exercise biofeedback programs is a limitation in current practice.

METHODS

Thirty-three women with AI (mean age 60 years) were randomly assigned to concentric (resistance) or isometric (non-resistance) biofeedback training. Concentric training utilized the Functional Luminal Imaging Probe to provide progressive resistance exercises based on the patient's ability to collapse the anal canal lumen. Isometric training utilized a non-collapsible 10 mm diameter probe. Both groups performed a biofeedback protocol once per week in the clinic for 12 weeks and at home daily. High definition anal manometry was used to assess anal sphincter strength; symptoms were measured using FISI and UDI-6. 3D transperineal ultrasound imaging was used to assess the anal sphincter muscle integrity.

RESULTS

Concentric and isometric groups improved FISI and UDI-6 scores to a similar degree. Both the concentric and isometric groups showed small improvement in the anal high-pressure zone; however, there was no difference between the two groups. Ultrasound image analysis revealed significant damage to the anal sphincter muscles in both patient groups.

CONCLUSIONS

Concentric resistance biofeedback training did not improve the anal sphincter muscle function or AI symptoms beyond traditional biofeedback training. Anal sphincter muscle damage may be an important factor that limits the success of biofeedback training.

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy.

METHODS

In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum.

RESULTS

Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index.

CONCLUSION

At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.

Adding Insult to Injury: Levator Ani Avulsion in Women With Obstetric Anal Sphincter Injuries

OBJECTIVE

In women with obstetric anal sphincter injuries, we compared the rate of major levator ani avulsion after forceps-assisted delivery versus spontaneous vaginal delivery.

METHODS

Prospective cohort of primiparous women with obstetric anal sphincter injuries. The primary outcome was the rate of major levator ani avulsion as measured by 3-dimensional transvaginal ultrasonography performed between 1 and 2 weeks postpartum. Secondary outcomes included ultrasonographic anteroposterior hiatal diameter, levator hiatal area, and levator-urethra gap, and differences in validated pelvic disorder questionnaires scores at 1 to 2 and 13 weeks postpartum.

RESULTS

Sixty-two women (30 spontaneous deliveries, 32 forceps deliveries) were included in the final analysis. After controlling for delivery variables, women who underwent forceps-assisted delivery were more likely to experience a major avulsion as compared with those who underwent spontaneous delivery (21/32, [65.6%] vs 8/30 [26.7%]; odds ratio, 5.9; 95% confidence interval, 1.5-24.5; P = 0.014). They were also more likely to have larger levator-urethra gaps bilaterally (P = 0.012, 0.016). After controlling for potential confounders, levator ani avulsion was independently associated with persistent anal incontinence symptoms at 13 weeks postpartum (P = 0.02).

CONCLUSIONS

In women with obstetric anal sphincter injuries, the risk of levator ani avulsion is almost 6 times higher after forceps-assisted vaginal delivery as compared with spontaneous vaginal delivery. In those with avulsion, recovery of anal continence is compromised, suggesting that adding insult (avulsion) to injury (obstetric anal sphincter injury) may have negative functional consequences.

Symptom and Quality of Life Improvements After Pelvic Floor Physical Therapy in a Clinical Population of Women With Pelvic Pain and Other Symptoms

OBJECTIVES

This study aimed to evaluate changes in validated symptom scores at intake and discharge in women undergoing pelvic floor physical therapy (PFPT) for pain and other pelvic floor symptoms.

METHODS

Consecutive women starting PFPT during 1 year were reviewed. History, demographics, and Pelvic Floor Distress Inventory Questionnaire - Short Form 20 (PFDI) total and domain scores (Pelvic Organ Prolapse Distress Inventory-6, Urogenital Distress Inventory-6, Colorectal-Anal Distress Inventory-8), Pelvic Floor Impact Questionnaire (PFIQ-7), and pain levels on a numeric rating scale (NRS) were collected at intake and discharge. Data were analyzed with descriptive statistics and sign tests.

RESULTS

Of 474 women, mean age was 50.3 ± 16.7 years (range, 18-87 years) and the most common indication for PFPT was pelvic pain (208/474; 43.9%). In women with complete data, pretreatment to posttreatment median scores improved on the PFDI (77.3 vs 41.8; P < 0.0001), Urogenital Distress Inventory (37.5 vs 16.0; P < 0.0001), and PFIQ (58.0 vs 19.0; P < 0.0001), and the minimal clinically important difference was met for the PFDI, PFIQ, and Colorectal-Anal Distress Inventory. Women with primarily pelvic pain (n = 208) achieved significant improvements in PFDI, PFIQ, and NRS scores (P < 0.0001 for all) as well as the minimal clinically important difference for these measures. Pain patients with a history of pelvic surgery (n = 50) also had significant improvements in PFIQ and NRS but not PFDI scores.

CONCLUSIONS

Most women referred to PFPT demonstrated symptom improvements as measured by validated instruments.

Risk Factors for Surgical Failure and Worsening Pelvic Floor Symptoms Within 5 Years After Vaginal Prolapse Repair

OBJECTIVE

To assess independent risk factors for surgical failure and worsening pelvic floor symptoms within 5 years after vaginal prolapse surgery.

METHODS

This secondary analysis includes OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) (n=374) and E-OPTIMAL (Extended) (n=285) trial participants. Surgical failure was defined as apical descent greater than one third of the total vaginal length, anterior or posterior vaginal wall past the hymen, subsequent surgery or bothersome vaginal bulge. Worsening pelvic floor symptoms were defined as increases from baseline as large as the minimally important difference for subscale scores of the Pelvic Floor Distress Inventory: 11 for the Urinary Distress Inventory and Colorectal-Anal Distress Inventory and 34.3 for the Pelvic Organ Prolapse Distress Inventory. Outcomes were measured at 6 months then 1, 2, 3, 4, and 5 years. Chi-square and t test results from bivariate models and clinical relevance were used to inform final models.

RESULTS

Baseline risk factors for surgical failure were Hispanic ethnicity (adjusted odds ratio [aOR] 1.92, 95% CI 1.17-3.15), perineal body (aOR 1.34, 95% CI 1.09-1.63), and pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 1.16, 95% CI 1.05-1.28). Risk factors for worsening of pelvic floor symptoms were pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 0.75, 95% CI 0.60-0.94) for worsening Pelvic Organ Prolapse Distress Inventory score, vaginal deliveries (aOR 1.26, 95% CI 1.10-1.44) and pretreatment Urinary Distress Inventory score (aOR 0.86, 95% CI 0.80-0.93) for worsening Urinary Distress Inventory score, and age (aOR 1.03, 95% CI 1.01-1.05) and pretreatment Colorectal-Anal Distress Inventory score (aOR 0.95, 95% CI 0.92-0.98) for worsening Colorectal-Anal Distress Inventory score.

CONCLUSIONS

Hispanic ethnicity, larger preoperative perineal body, and higher pretreatment Pelvic Organ Prolapse Distress Inventory scores were risk factors for surgical failure up to 5 years after vaginal prolapse repair. Participants with higher baseline Pelvic Floor Distress Inventory scores were less likely to worsen. Risk factors for worsening Urinary Distress Inventory and Colorectal-Anal Distress Inventory scores included more vaginal deliveries and increased age, respectively.

CLINICAL TRIAL REGISTRATION

NCT00597935, NCT01166373.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of darifenacin on fecal incontinence in women with double incontinence

INTRODUCTION AND HYPOTHESIS

To evaluate change in fecal incontinence symptom severity after 8 weeks of darifenacin therapy in patients with double incontinence-urgency urinary incontinence (UUI) and fecal incontinence. Important secondary outcomes included fecal incontinence symptom distress and impact on quality of life, fecal incontinence episodes, global impression of improvement and overactive bladder symptom distress and impact.

METHODS

Prospective open-label cohort study of women presenting primarily with UUI, diagnosed with double incontinence and electing antimuscarinic therapy for UUI. Women ≥ 18 years with moderate or greater bothersome UUI and fecal incontinence of liquid/solid stool with St. Marks (Vaizey) score ≥ 12 were included. Subjects were treated with darifenacin 15 mg daily for 8 weeks. The primary outcome was change in fecal incontinence symptom severity using the St. Marks (Vaizey) score after 8 weeks. Sample size was based on the minimally important difference of the St. Marks, -5, and standard deviation, ± 8.5; 30 subjects provided 80% power and type I error of 0.05, including a 15% attrition rate.

RESULTS

Thirty-two women were consented with mean baseline St. Marks (Vaizey) score of 18.0 ± 3.0. Mean age was 66.5 ± 10.3 years. Twenty-eight subjects (29/32, 87.5%) completed assessments. St. Marks (Vaizey) score significantly improved from 18.0 to 11.0 [mean difference - 7.0, 95% confidence interval (CI): -8.7, -5.3], and 19 subjects (19/32,67.9%) met the minimally important difference. Statistically significant improvements were also noted in fecal incontinence frequency, quality of life, and overactive bladder symptom bother and quality of life (all p < 0.01).

CONCLUSIONS

Darifenacin can be considered a highly effective early intervention in women suffering from double incontinence.

CLINICAL TRIAL REGISTRATION

Bladder Antimuscarinic Medication and Accidental Bowel Leakage (BAMA), https://clinicaltrials.gov/ct2/show/NCT03543566 , NCT03543566.

Efficacy of Supervised Pelvic Floor Muscle Training and Biofeedback vs Attention-Control Treatment in Adults With Fecal Incontinence

BACKGROUND & AIMS

Pelvic floor muscle training (PFMT) in combination with conservative treatment is recommended as first-line treatment for patients with fecal incontinence, although its efficacy is unclear. We investigated whether supervised PFMT in combination with conservative treatment is superior to attention-control massage treatment and conservative treatment in adults with fecal incontinence.

METHODS

We performed a randomized, controlled, superiority trial of patients with fecal incontinence at a tertiary care center at a public hospital in Denmark. Ninety-eight adults with fecal incontinence were randomly assigned to groups that received supervised PFMT and biofeedback plus conservative treatment or attention-control treatment plus conservative treatment. The primary outcome was rating of symptom changes, after 16 weeks, based on scores from the Patient Global Impression of Improvement scale. Secondary outcomes were changes in the Vaizey incontinence score (Vaizey Score), Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life Scale.

RESULTS

In the intention-to-treat analysis, participants in the PFMT group were significantly more likely to report improvement in incontinence symptoms based on Patient Global Impression of Improvement scale scores (unadjusted odds ratio, 5.16; 95% CI, 2.18-12.19; P = .0002). The PFMT group had a larger reduction in the mean Vaizey Score (reduction, -1.83 points; 95% CI, -3.57 to -0.08; P = .04). There were no significant differences in condition-specific quality of life. In the per-protocol analyses, the superiority of PFMT was increased. No adverse events were reported.

CONCLUSIONS

This randomized controlled trial of adults with fecal incontinence provides support for a superior effect of supervised PFMT in combination with conservative treatment compared with attention-control massage treatment and conservative treatment. We found that participants who received supervised PFMT had 5-fold higher odds of reporting improvements in fecal incontinence symptoms and had a larger mean reduction of incontinence severity based on the Vaizey Score compared with attention control massage treatment. Clinicaltrials.gov no: NCT01705535.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Fecal Incontinence Symptoms and Impact in Older Versus Younger Women Seeking Care

BACKGROUND

The differential impact of aging on fecal incontinence symptom severity and condition-specific quality of life remains unclear.

OBJECTIVE

The purpose of this study was to characterize differences in symptom distress, quality of life, and anorectal physiology assessments in older versus younger women with fecal incontinence.

DESIGN

This was a cross-sectional study.

SETTINGS

This study was conducted at a tertiary genitorectal disorder clinic.

PATIENTS

Women presenting for fecal incontinence evaluation between 2003 and 2016 were classified as older or younger based on age ≥65 or <65 years.

MAIN OUTCOME MEASURES

The main outcomes were symptom-specific quality of life and distress measured by validated questionnaires (the Modified Manchester Health Questionnaire containing the Fecal Incontinence Severity Index); anorectal physiology and anatomy were assessed by manometry and endoanal ultrasound.

RESULTS

Of 879 subjects, 286 and 593 were classified as older and younger (mean ages, 71.4 ± 5.3 y and 51.3 ± 10.5 y). Solid stool leakage was more frequent in older women (83.2% vs 76.7%; p = 0.03), whereas liquid stool leakage (83.2% vs 82.8%; p = 0.88) and fecal urgency (76.9% vs 78.8%; p = 0.54) did not differ between groups. Mean symptom severity scores were similar between groups (28.0 ± 11.9 and 27.6 ± 13.5; p = 0.69); however, there was greater negative impact on quality of life among younger women (46.3 ± 22.0 vs 51.8 ± 21.8; p < 0.01). Multivariable linear regression controlling for pertinent covariates revealed younger age as an independent predictor for worse condition-specific quality-of-life scores (p < 0.01). Squeeze pressures were similar between groups, whereas younger women had greater resting pressures and higher rates of sphincter defects (external, 7.7% vs 20.2%; internal, 12.2% vs 26.8%; both p < 0.01).

LIMITATIONS

This study was limited by its lack of patient obstetric history and the duration of their incontinence symptoms.

CONCLUSIONS

Characteristics differ between older and younger women seeking care for fecal incontinence. The differential impact and age-related phenotypes may provide useful information for patient counseling and developing management algorithms for women with fecal incontinence. See Video Abstract at http://links.lww.com/DCR/A910.

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

BACKGROUND

Utility preference scores are standardized, generic, health-related quality of life (HRQOL) measures that quantify disease severity and burden and summarize morbidity on a scale from 0 (death) to 1 (optimal health). Utility scores are widely used to measure HRQOL and in cost-effectiveness research.

OBJECTIVE

To determine the responsiveness, validity properties, and minimal important difference (MID) of utility scores, as measured by the Short Form 6D (SF-6D) and EuroQol (EQ-5D), in women undergoing surgery for pelvic organ prolapse (POP).

MATERIALS AND METHODS

This study combined data from 4 large, U.S., multicenter surgical trials enrolling 1321 women with pelvic organ prolapse. We collected condition-specific quality of life data using the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). A subset of women completed the SF6D; women in 2 trials also completed the EQ5D. Mean utility scores were compared from baseline to 12 months after surgery. Responsiveness was assessed using effect size (ES) and standardized response mean (SRM). Validity properties were assessed by (1) comparing changes in utility scores at 12 months between surgical successes and failures as defined in each study, and (2) correlating changes in utility scores with changes in the PFDI and PFIQ. MID was estimated using both anchor-based (SF-36 general health global rating scale "somewhat better" vs "no change") and distribution-based methods.

RESULTS

The mean SF-6D score improved 0.050, from 0.705 ± 0.126 at baseline to 0.761 ± 0.131 at 12 months (P < .01). The mean EQ-5D score improved 0.060, from 0.810 ± 0.15 at baseline to 0.868 ± 0.15 at 12 months (P < .01). The ES (0.13-0.61) and SRM (0.13-0.57) were in the small-to-moderate range, demonstrating the responsiveness of the SF-6D and EQ-5D similar to other conditions. SF-6D and EQ-5D scores improved more for prolapse reconstructive surgical successes than for failures. The SF-6D and EQ-5D scores correlated with each other (r = 0.41; n = 645) and with condition-specific instruments. Correlations with the PFDI and PFIQ and their prolapse subscales were in the low to moderate range (r = 0.09-0.38), similar to other studies. Using the anchor-based method, the MID was 0.026 for SF-6D and 0.025 for EQ-5D, within the range of MIDs reported in other populations and for other conditions. These findings were supported by distribution-based estimates.

CONCLUSION

The SF-6D and EQ-5D have good validity properties and are responsive, preference-based, utility and general HRQOL measures for women undergoing surgical treatment for prolapse. The MIDs for SF-6D and EQ-5D are similar and within the range found for other medical conditions.

Pelvic Floor Distress Inventory Scores Improve After Prolapse Surgery Regardless of Surgical Approach but Not After Observation Alone

OBJECTIVE

To evaluate the effect of different surgical procedures on Pelvic Floor Distress Inventory (PFDI) scores in women with pelvic organ prolapse.

MATERIALS AND METHODS

Women with prolapse were enrolled from 2008 to 2014. Baseline data and outcomes at 1 year were collected including subscales of the PFDI. Patients who had surgery (SGY) within the first year were compared to those who did not (N-SGY). Subanalyses of SGY included vaginal vs abdominal, with or without concurrent hysterectomy (HYST, N-HYST), placement of mesh (MESH, N-MESH), and concurrent posterior repair/perineorrhaphy (POST, N-POST).

RESULTS

A total of 233/239 patients underwent surgery in the first year. For SGY vs N-SGY, SGY had significant improvements in PFDI and all subscale scores at 1 year while N-SGY did not. When comparing vaginal to abdominal approach, MESH to N-MESH and HYST to N-HYST, there were no differences between any scores at baseline or 1 year between the groups. However, all within group symptom scores improved from baseline to 1 year (P <.0001 for all). In comparing POST to N-POST, there were no differences between groups at 1 year in PFDI and Urogenital Distress Inventory and Pelvic Organ Prolapse Distress Inventory subscale scores. Colorectal-Anal Distress Inventory scores were significantly higher at baseline for POST (P <.0001) but not at 1 year (P = 0.37). All within group scores statistically significant improved at 1 year.

CONCLUSION

Women who underwent surgical repair for prolapse had significantly improved overall PFDI and subscale scores regardless of surgical approach and concurrent procedures.

Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial

IMPORTANCE

Uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) are commonly performed pelvic organ prolapse procedures despite a lack of long-term efficacy data.

OBJECTIVE

To compare outcomes in women randomized to (1) ULS or SSLF and (2) usual care or perioperative behavioral therapy and pelvic floor muscle training (BPMT) for vaginal apical prolapse.

DESIGN, SETTING, AND PARTICIPANTS

This 2 × 2 factorial randomized clinical trial was conducted at 9 US medical centers. Eligible participants who completed the Operations and Pelvic Muscle Training in the Management of Apical Support Loss Trial enrolled between January 2008 and March 2011 and were followed up 5 years after their index surgery from April 2011 through June 2016.

INTERVENTIONS

Two randomizations: (1) BPMT (n = 186) or usual care (n = 188) and (2) surgical intervention (ULS: n = 188 or SSLF: n = 186).

MAIN OUTCOMES AND MEASURES

The primary surgical outcome was time to surgical failure. Surgical failure was defined as (1) apical descent greater than one-third of total vaginal length or anterior or posterior vaginal wall beyond the hymen or retreatment for prolapse (anatomic failure), or (2) bothersome bulge symptoms. The primary behavioral outcomes were time to anatomic failure and Pelvic Organ Prolapse Distress Inventory scores (range, 0-300).

RESULTS

The original study randomized 374 patients, of whom 309 were eligible for this extended trial. For this study, 285 enrolled (mean age, 57.2 years), of whom 244 (86%) completed the extended trial. By year 5, the estimated surgical failure rate was 61.5% in the ULS group and 70.3% in the SSLF group (adjusted difference, -8.8% [95% CI, -24.2 to 6.6]). The estimated anatomic failure rate was 45.6% in the BPMT group and 47.2% in the usual care group (adjusted difference, -1.6% [95% CI, -21.2 to 17.9]). Improvements in Pelvic Organ Prolapse Distress Inventory scores were -59.4 in the BPMT group and -61.8 in the usual care group (adjusted mean difference, 2.4 [95% CI, -13.7 to 18.4]).

CONCLUSIONS AND RELEVANCE

Among women who had undergone vaginal surgery for apical pelvic organ vaginal prolapse, there was no significant difference between ULS and SSLF in rates of surgical failure and no significant difference between perioperative behavioral muscle training and usual care on rates of anatomic success and symptom scores at 5 years. Compared with outcomes at 2 years, rates of surgical failure increased during the follow-up period, although prolapse symptom scores remained improved.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01166373.

Perioperative Behavioral Therapy and Pelvic Muscle Strengthening Do Not Enhance Quality of Life After Pelvic Surgery: Secondary Report of a Randomized Controlled Trial

BACKGROUND

There is significant need for trials evaluating the long-term effectiveness of a rigorous program of perioperative behavioral therapy with pelvic floor muscle training (BPMT) in women undergoing transvaginal reconstructive surgery for prolapse.

OBJECTIVE

The purpose of this study was to evaluate the effect of perioperative BPMT on health-related quality of life (HRQOL) and sexual function following vaginal surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

DESIGN

This study is a secondary report of a 2 × 2 factorial randomized controlled trial.

SETTING

This study was a multicenter trial.

PARTICIPANTS

Participants were adult women with stage 2-4 POP and SUI.

INTERVENTION

Perioperative BPMT versus usual care and sacrospinous ligament fixation (SSLF) versus uterosacral ligament suspension (ULS) were provided.

MEASUREMENTS

Participants undergoing transvaginal surgery (SSLF or ULS for POP and a midurethral sling for SUI) received usual care or five perioperative BPMT visits. The primary outcome was change in body image and in Pelvic Floor Impact Questionnaire (PFIQ) short-form subscale, 36-item Short-Form Health Survey (SF-36), Pelvic Organ Prolapse-Urinary Incontinence Sexual Questionnaire short form (PISQ-12), Patient Global Impression of Improvement (PGII), and Brink scores.

RESULTS

The 374 participants were randomized to BPMT (n = 186) and usual care (n = 188). Outcomes were available for 137 (74%) of BPMT participants and 146 (78%) of the usual care participants at 24 months. There were no statistically significant differences between groups in PFIQ, SF-36, PGII, PISQ-12, or body image scale measures.

LIMITATIONS

The clinicians providing BPMT had variable expertise. Findings might not apply to vaginal prolapse procedures without slings or abdominal apical prolapse procedures.

CONCLUSIONS

Perioperative BPMT performed as an adjunct to vaginal surgery for POP and SUI provided no additional improvement in QOL or sexual function compared with usual care.

Factors Associated With Timing of Return to Intercourse After Obstetric Anal Sphincter Injuries

INTRODUCTION

The impact of obstetric perineal trauma on timing of return to intercourse is unclear, although sexual desire is clearly decreased in these women. In addition, studies examining timing of return to intercourse are cross-sectional and therefore cannot delineate potential reasons that patients might delay return to intercourse.

AIM

To identify factors associated with delayed return to intercourse after obstetric anal sphincter injuries.

METHODS

This was a planned secondary analysis of a prospective cohort study of women sustaining obstetric anal sphincter injuries during delivery of a full-term singleton infant. Patients completed the Fecal Incontinence Severity Index at every postpartum visit (1, 2, 6, and 12 weeks) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 once resuming vaginal intercourse. Intercourse was considered "delayed" if patients did not resume intercourse by the 12-week visit. This cutoff was chosen because it was subsequent to the 6-week visit, when patients were instructed to return to normal pelvic activity. Continuous variables were compared using the Student t-test (parametric) or Mann-Whitney U-test (non-parametric). The χ(2) test was used for categorical variables. Statistical significance was assigned with a P value less than .05.

MAIN OUTCOME MEASURES

Primary outcome measurements were differences in pelvic floor symptoms on validated surveys between the "delayed" and "not-delayed" groups at the first postpartum visit and at the time the subjects returned to intercourse. We used the Patient Health Questionnaire-9 for depression, the Urinary Distress Inventory-6 and Incontinence Impact Questionnaire-7 for urinary symptoms, the visual analog scale for pain, the Fecal Incontinence Severity Index for bowel symptoms, and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 at the return to intercourse visit only.

RESULTS

One hundred ninety-nine women were included in this analysis. Most were Caucasian (77%) and primiparous (86%). One hundred nineteen women (60%) did not resume vaginal intercourse until after the 12-week visit and were deemed "delayed." Patients who delayed intercourse scored higher on the Fecal Incontinence Severity Index (more anal incontinence) than those who resumed intercourse before 12 weeks (15.4 ± 12.3 vs 12.0 ± 12.8, P = .02). The delayed group also had worse sexual function, shown as lower Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 scores (35.4 ± 5.9 vs 38.4 ± 4.1, P ≤ .001) and persistently higher Fecal Incontinence Severity Index scores (4.1 ± 7.3 vs 1.6 ± 4.4, P = .001), at the first visit after returning to intercourse.

CONCLUSION

Patients with obstetric anal sphincter injuries who do not resume intercourse by 12 weeks postpartum report more severe anal incontinence symptoms and worse sexual function after return to coitus.

Endpoints for therapeutic interventions in faecal incontinence: small step or game changer

Faecal incontinence (FI) is common and its pathophysiology and treatments continue to evolve. However, a standard measure(s) for assessing its clinical outcome has been elusive. Consequently, over 100 measures and scoring systems, each with intrinsic biases have been reported. These include adequate relief or global satisfaction, ≥50% reduction in episodes or days without FI, quality of life (QOL), FI severity scales and composite indices. Earlier scales relied on the frequency and type of solid, liquid or flatus incontinence and effects on life style whereas newer scales have incorporated urgency, use of pads, antidiarrhoeals and amount of leakage, using prospective daily stool diaries or retrospective weekly or single point assessments. Such a plethora of measures have negatively impacted the assessment and outcome of clinical trials, and have made comparisons difficult. So, how does one sort out the grain from the chaff? In a provocative, post-hoc analysis published in this issue, the minimal clinically important difference, i.e. the smallest change detected by an instrument that is associated with a clinically meaningful change was used to assess FI endpoint. Based on this a ≥50% reduction in FI episodes is recommended as a clinically meaningful outcome measure when assessed by prospective stool diary, and it correlates with symptoms and severity. However, this requires further validation in multi-centre, longer duration and therapeutically effective clinical trial(s). Simultaneous assessment of coping strategies, QOL and psychosocial domains can provide further insights regarding the overall impact of treatments. This mini-review discusses the advances and controversies in defining meaningful FI endpoints.

Quality of Life and Sexual Function 2 Years After Vaginal Surgery for Prolapse

OBJECTIVE

To longitudinally assess the effect of native tissue vaginal apical prolapse repair with anti-incontinence surgery on quality of life, sexual function, and body image between uterosacral and sacrospinous suspensions.

METHODS

A planned secondary analysis was performed on 374 women enrolled in a randomized trial of the two types of native tissue repair for apical prolapse. Condition-specific and generic quality of life, sexual function, overall and de novo dyspareunia, and body image were assessed using validated instruments at baseline; 6, 12, and 24 months postoperatively; and changes from baseline were assessed and compared between surgical groups. General linear mixed models were used for comparisons and clinically significant differences were assessed using minimum important differences.

RESULTS

Of the women randomized, 82% had outcomes available at 2 years. Overall, clinically and statistically significant improvements in generic and condition-specific quality of life and sexual function were observed after surgery. Dyspareunia rates decreased from 25% to 16% by 24 months with only 3% of all women undergoing treatment. De novo dyspareunia occurred in 5% and 10% by 12 and 24 months, respectively. Body image scores also significantly improved from baseline. There were no clinically meaningful or statistically significant differences between groups for any of these outcomes (all P>.05).

CONCLUSION

Native tissue vaginal prolapse surgery results in statistically and clinically significant improvements in quality of life, sexual function, and body image at 24 months with no significant differences between uterosacral and sacrospinous suspensions. One in 10 women experience de novo dyspareunia but few requested treatment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00597935.

Adverse events of sacral neuromodulation for fecal incontinence reported to the federal drug administration

AIM: To investigate the nature and severity of AE related to sacral neurostimulation (SNS).

METHODS: Based on Pubmed and Embase searches, we identified published trials and case series of SNS for fecal incontinence (FI) and extracted data on adverse events, requiring an active intervention. Those problems were operationally defined as infection, device removal explant or need for lead and/or generator replacement. In addition, we analyzed the Manufacturer and User Device Experience registry of the Federal Drug Administration for the months of August - October of 2015. Events were included if the report specifically mentioned gastrointestinal (GI), bowel and FI as indication and if the narrative did not focus on bladder symptoms. The classification, reporter, the date of the recorded complaint, time between initial implant and report, the type of AE, steps taken and outcome were extracted from the report. In cases of device removal or replacement, we looked for confirmatory comments by healthcare providers or the manufacturer.

RESULTS: Published studies reported adverse events and reoperation rates for 1954 patients, followed for 27 (1-117) mo. Reoperation rates were 18.6% (14.2-23.9) with device explants accounting for 10.0% (7.8-12.7) of secondary surgeries; rates of device replacement or explant or pocket site and electrode revisions increased with longer follow up. During the period examined, the FDA received 1684 reports of AE related to SNS with FI or GI listed as indication. A total of 652 reports met the inclusion criteria, with 52.7% specifically listing FI. Lack or loss of benefit (48.9%), pain or dysesthesia (27.8%) and complication at the generator implantation site (8.7%) were most commonly listed. Complaints led to secondary surgeries in 29.7% of the AE. Reoperations were performed to explant (38.2%) or replace (46.5%) the device or a lead, or revise the generator pocket (14.6%). Conservative management changes mostly involved changes in stimulation parameters (44.5%), which successfully addressed concerns in 35.2% of cases that included information about treatment results.

CONCLUSION: With reoperation rates around 20%, physicians need to fully disclose the high likelihood of complications and secondary interventions and exhaust non-invasive treatments, including transcutaneous stimulation paradigms.

Risk Factors Associated With Neurogenic Bowel Complications and Dysfunction in Spinal Cord Injury

OBJECTIVES

To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling.

DESIGN

Cross-sectional observational study.

SETTING

A Spinal Cord Injury Model System, with additional participants recruited from other sites.

PARTICIPANTS

Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling.

RESULTS

Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake.

CONCLUSIONS

These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Psychometric evaluation of an online and paper accidental bowel leakage questionnaire: The ICIQ-B questionnaire

AIMS

To evaluate the psychometric properties of an online versus paper US-English version of the International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B).

METHODS

The ICIQ-B includes 17 items under 3 domains: bowel pattern (5 items), bowel control (7 items), and quality of life (5 items). We recruited community-dwelling adults seeking treatment for ≥monthly bowel leakage from specialty clinics within a VA medical center and university affiliate. An online versus paper version was evaluated at baseline, 2 weeks later, and 3 months after nonsurgical treatments per usual care. We assessed test-retest reliability (Pearson correlations) at 2 weeks, internal consistency (Cronbach's alpha), and convergent validity (Pearson correlations). Sensitivity to change was the difference between the baseline and post-treatment (3-month) scores.

RESULTS

Mean age was 58.0 ± 11.9; 36% Veterans, 52% women. At baseline, 2 weeks, and 3 months, we found no differences in the online vs paper scores for the bowel control and quality of life domains. The ICIQ-B demonstrated fair internal consistency for the bowel pattern domain (Cronbach's α = 0.36-0.54). Internal consistency on the bowel pattern domain was better with the paper version than the online version at 2 weeks (P < 0.05) and 3 months (P < 0.01) with no difference at baseline. All other domains had good internal consistency (Cronbach's α > 0.80), good retest reliability (r ≥ 0.70, P < 0.001), domain-specific convergent validity for stool consistency (P < 0.05), incontinence severity (P ≤ 0.002), and quality of life impact (P < 0.05). After nonsurgical treatments, we found a reasonable response to change (P ≤ 0.05).

CONCLUSIONS

Online and paper versions had robust psychometric data for use among U.S. men and women, including Veterans. Neurourol. Urodynam. 36:166-170, 2017. © 2015 Wiley Periodicals, Inc.

Loperamide Versus Psyllium Fiber for Treatment of Fecal Incontinence: The Fecal Incontinence Prescription (Rx) Management (FIRM) Randomized Clinical Trial

BACKGROUND

Fecal incontinence is a devastating condition with few US Food and Drug Administration-approved pharmacologic treatment options. Loperamide and psyllium, both first-line treatments, have different mechanisms of action without any comparative data.

OBJECTIVE

The purpose of this study was to examine the effectiveness and tolerability of loperamide compared with psyllium for reducing fecal incontinence. We hypothesized that psyllium fiber supplementation would be more effective than loperamide for reducing fecal incontinence episodes and have fewer adverse effects.

DESIGN

We conducted a randomized, double-blind, placebo-controlled crossover trial comparing loperamide (followed by psyllium) with psyllium (followed by loperamide).

SETTINGS

Our sites included outpatient clinics within a Veterans Affairs medical center and university affiliate.

PATIENTS

Participants included community-dwelling adults (n = 80) with at least 1 fecal incontinent episode on a 7-day bowel diary.

INTERVENTION

Participants received either daily loperamide (plus placebo psyllium powder) or psyllium powder (plus loperamide placebo) for 4 weeks. After a 2-week washout, participants crossed over to 4 weeks of alternate treatment.

MAIN OUTCOME MEASURES

The primary outcome was the number of fecal incontinence episodes from 7-day bowel diaries. Secondary outcomes included symptom severity, quality of life, and tolerability.

RESULTS

Mean age was 60.7 ± 10.1 years; 68% were men. After determining nonsignificant carryover effects, combined analyses showed no differences between the loperamide and psyllium groups for reducing fecal incontinent episodes, symptom severity, or quality of life. Within each group, both loperamide and psyllium reduced fecal incontinent episodes and improved symptom severity and quality of life. Constipation occurred in 29% of participants for loperamide vs 10% for psyllium.

LIMITATIONS

Limitations include the washout period length and dropout rate after crossing over to the second intervention.

CONCLUSIONS

Both loperamide and psyllium improve fecal incontinence. Loperamide was associated with more adverse effects, especially constipation.

Pelvic Floor and Urinary Distress in Women with Fibromyalgia

Fibromyalgia (FM) patients were recently found to have more symptom burden from bothersome pelvic pain syndromes that women seeking care for pelvic floor disease at a urogynecology clinic. We sought to further characterize pelvic floor symptoms in a larger sample of FM patients using of validated questionnaires. Female listserv members of the Fibromyalgia Information Foundation completed an online survey of three validated questionnaires: the Pelvic Floor Distress Inventory 20 (PFDI-20), the Pelvic Pain, Urgency and Frequency Questionnaire (PUF), and the Revised Fibromyalgia Impact Questionnaire (FIQR). Scores were characterized using descriptive statistics. Patients (n = 204 with complete data on 177) were on average 52.3 ± 11.4 years with a mean parity of 2.5 ± 1.9. FM severity based on FIQR score (57.2 ± 14.9) positively correlated with PFDI-20 total 159.08 ± 55.2 (r = .34, p < .001) and PUF total 16.54 ± 7 (r = .36, p < .001). Women with FM report significantly bothersome pelvic floor and urinary symptoms. Fibromyalgia management should include evaluation and treatment of pelvic floor disorders recognizing that pelvic distress and urinary symptoms are associated with more severe FM symptoms. Validated questionnaires, like the ones used in this study, are easily incorporated into clinical practice.

A vaginal bowel-control system for the treatment of fecal incontinence

OBJECTIVE

To evaluate the effectiveness and safety of a vaginal bowel-control device and pump system for fecal incontinence treatment.

METHODS

Women with a minimum of four fecal incontinence episodes over 2 weeks were fit with the intravaginal device. Treatment success, defined as a 50% or greater reduction of incontinent episodes, was assessed at 1 month. Participants were invited into an optional extended-wear period of another 2 months. Secondary outcomes included symptom improvement measured by the Fecal Incontinence Quality of Life, Modified Manchester Health Questionnaire, and Patient Global Impression of Improvement. Adverse events were collected. Intention-to-treat analysis included participants who were successfully fit entering treatment. Per protocol, analysis included participants with a valid 1-month treatment diary.

RESULTS

Sixty-one of 110 (55.5%) participants from six clinical sites were successfully fit and entered treatment. At 1 month, intention-to-treat success was 78.7% (48/61, P<.001); per protocol success, 85.7% (48/56, P<.001) and 85.7% (48/56) considered bowel symptoms "very much better" or "much better." There was significant improvement in all Fecal Incontinence Quality of Life (P<.001) and Modified Manchester (P≤.007) subscales. Success rate at 3 months was 86.4% (38/44; 95% confidence interval 73-95%). There were no serious adverse events; the most common study-wide device-related adverse event was pelvic cramping or discomfort (25/110 participants [22.7%]), the majority of events (16/25 [64%]) occurring during the fitting period.

CONCLUSION

In women successfully fit with a vaginal bowel-control device for nonsurgical treatment for fecal incontinence, there was significant improvement in fecal incontinence by objective and subjective measures.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01655498.

LEVEL OF EVIDENCE

: II.

Symptom improvement in women after fecal incontinence treatments: a multicenter cohort study of the pelvic floor disorders network

OBJECTIVES

The study aims were to characterize women with fecal incontinence (FI) and measure changes in FI severity and quality of life 3 and 12 months after treatment.

METHODS

This study is a secondary analysis of a multicenter study measuring adaptive behaviors among women with FI. Women included had a primary complaint of at least monthly FI over 3 consecutive months and planned FI treatment. Demographic and medical history data were obtained at baseline. Data were collected at baseline, 3 months, and 12 months after clinically selected, nonstandardized treatment. Validated questionnaires were as follows: Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire, Pelvic Floor Disorders Inventory's Colorectal and Anal Distress Inventory, Pelvic Floor Impact Questionnaire's Colorectal and Anal Impact Questionnaire, and Medical Outcomes Study Short Form. Questionnaire score changes from baseline were compared using paired t tests at 3 and 12 months after treatment.

RESULTS

Of the 133 women enrolled, 90 women had treatment data at 3 months and 77 at 12 months. Nonsurgical therapies were the most common (78%) with anal sphincter repair in 22%. Fecal Incontinence Severity Index scores and Modified Manchester Health Questionnaire scores significantly improved 3 months after nonsurgical and surgical treatments (-8.8 ± 12.0 and -12.6 ± 19.2, respectively, P < 0.001), as did Colorectal-Anal Distress Inventory and Colorectal-Anal Impact Questionnaire scores (-52.7 ± 70.0 and -60.6 ± 70.0, respectively, P < 0.001) and Medical Outcomes Study Short Form mental health scores (4.2 ± 9.4, P = 0.001). Improvement persisted 12 months posttreatment.

CONCLUSIONS

In women seeking care for FI, symptom severity and condition-specific quality of life significantly improve within the first 3 months after FI treatment and are maintained up to 12 months.

PELVIC FLOOR SYMPTOMS AND QUALITY OF LIFE ANALYSES IN WOMEN UNDERGOING SURGERY FOR RECTAL PROLPASE

OBJECTIVE

Characterize pelvic floor symptom distress and impact, sexual function and quality of life in women who underwent rectal prolapse surgery.

METHODS

Subjects undergoing rectal prolapse surgery from 2004-2009 completed questionnaires including the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Prolapse/Urinary Incontinence Sexual Questionnaire. Baseline demographic, medical, and surgical characteristics were extracted by chart review. Demographic and clinic outcomes of women undergoing transperineal and abdominal approaches were compared. Wilcoxon rank-sum test was used for continuous variables and Fisher's exact test for categorical measures.

RESULTS

45 were identified; two deceased at follow-up. 28/43 subjects (65.1%) responded to the questionnaires. Mean time from original procedure was 3.9 ± 3.1 years. No differences in median total Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and subscale scores, and Prolapse/Urinary Incontinence Sexual Questionnaire scores in women undergoing open rectopexy versus transperineal proctectomy were seen (all p>0.05). 26 (60%) participants answered the Prolapse/Urinary Incontinence Sexual Questionnaire, nine reported sexual activity within the last month. All underwent abdominal procedures.

CONCLUSION

There are few colorectal or other pelvic floor symptoms after rectal prolapse repair. Robust prospective studies are needed to more fully characterize and understand issues associated with rectal prolapse surgery in women.

Posterior vaginal compartment prolapse and defecatory dysfunction: are they related?

While posterior vaginal compartment prolapse and defecatory dysfunction are highly prevalent conditions in women with pelvic floor disorders, the relationship between anatomy and symptoms, specifically obstructed defecation, is incompletely understood. This review discusses the anatomy of the posterior vaginal compartment and definitions of defecatory dysfunction and obstructed defecation. A clinically useful classification system for defecatory dysfunction is highlighted. Available tools for the measurement of symptoms, physical findings, and imaging in women with posterior compartment prolapse are discussed. Based on a critical review of the literature, we investigate and summarize whether posterior compartment anatomy correlates with function. Definitions of obstructed defecation and significant posterior compartment prolapse are proposed for future exploration.

Anal sphincter repair for fecal incontinence: effect on symptom severity, quality of life, and anal sphincter squeeze pressures

INTRODUCTION AND HYPOTHESIS

The objective of this study was to determine the effect of external anal sphincter repair on fecal incontinence symptoms, quality of life, and anal sphincter squeeze pressures.

METHODS

The fecal incontinence symptoms and impact on quality of life, patient satisfaction, and anorectal manometry were assessed pre- and post-operatively.

RESULTS

One hundred four women were eligible and 74/104 (71%) returned post-operative questionnaires. Fifty-four of 74 (73%) had pre- and post-operative questionnaires. Twenty-five of 74 (34%) had pre- and post-operative anorectal manometry measures. Mean length of follow-up for participants (n = 54) was 32 ± 19 months. Modified Manchester Health Questionnaire scores decreased from 47.3 ± 21.9 to 28.4 ± 24.3 (p < 0.01) and Fecal Incontinence Severity Index scores from 30.6 ± 13.0 to 21.6 ± 15.5 (p < 0.01). Seventy-seven percent of the participants was satisfied. Sphincter squeeze pressures increased from 53.4 ± 25.0 to 71.8 ± 29.1 mmHg (p < 0.01).

CONCLUSIONS

External anal sphincter repair resulted in sustained improvements in fecal incontinence severity and quality of life along with improved anal sphincter squeeze pressures.