Adherence to Perioperative Behavioral Therapy With Pelvic Floor Muscle Training in Women Receiving Vaginal Reconstructive Surgery for Pelvic Organ Prolapse

OBJECTIVE

The objective of this study was to describe adherence to behavioral and pelvic floor muscle training in women undergoing vaginal reconstructive surgery for organ prolapse and to examine whether adherence was associated with 24-month outcomes.

METHODS

Participants were women ≥18 years of age, with vaginal bulge and stress urinary incontinence symptoms, planning to undergo vaginal reconstructive surgery for stages 2 to 4 vaginal or uterine prolapse. They were randomized to either sacrospinous ligament fixation or uterosacral ligament suspension and to perioperative behavioral and pelvic floor muscle training or usual care. Measurements included anatomic failure, pelvic floor muscle strength, participant-reported symptoms, and perceived improvement. Analyses compared women with lower versus higher adherence.

RESULTS

Forty-eight percent of women performed pelvic floor muscle exercises (PFMEs) daily at the 4- to 6-week visit. Only 33% performed the prescribed number of muscle contractions. At 8 weeks, 37% performed PFMEs daily, and 28% performed the prescribed number of contractions. No significant relationships were found between adherence and 24-month outcomes.

CONCLUSION

Adherence to a behavioral intervention was low following vaginal reconstructive surgery for pelvic organ prolapse. The degree of adherence to perioperative training did not appear to influence 24-month outcomes in women undergoing vaginal prolapse surgery.

IMPACT

This study contributes to the understanding of participant adherence to PFMEs and the impact that participant adherence has on outcomes at 2, 4 to 6, 8, and 12 weeks and 24 months postoperatively. It is important to educate women to follow up with their therapist or physician to report new or unresolved pelvic symptoms.

Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial

IMPORTANCE

Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking.

OBJECTIVE

To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017.

INTERVENTIONS

Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207).

MAIN OUTCOMES AND MEASURES

The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms.

RESULTS

Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only).

CONCLUSIONS AND RELEVANCE

Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01959347.

Structured behavioral treatment research protocol for women with mixed urinary incontinence and overactive bladder symptoms

AIMS

The primary aim is to provide detailed rationale and methodology for the development and implementation of a perioperative behavioral/pelvic floor exercise research protocol for women who self-chose surgical intervention and who may or may not have been offered behavioral treatments initially. This protocol is part of the ESTEEM trial (Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence Trial) which was designed to determine the effect of a combined surgical and perioperative behavioral/pelvic floor exercise intervention versus surgery alone on improving mixed urinary incontinence (MUI) and overactive bladder (OAB) symptoms.

METHODS

As part of a multi-site, prospective, randomized trial of women with MUI electing midurethral sling (MUS) surgical treatment, participants were randomized to a standardized perioperative behavioral/pelvic floor exercise intervention + MUS versus MUS alone. The specific behavioral intervention included: education on voiding habits, pelvic floor muscle training (PFMT), bladder training (BT), strategies to control urgency and reduce/prevent urinary symptoms, and monitoring/promoting adherence to behavioral recommendations. To ensure consistency across all eight research sites in the pelvic floor disorders network (PFDN), selective behavioral treatments sessions were audiotaped and audited for protocol adherence.

RESULTS

The behavioral intervention protocol includes individualization of interventions using an algorithm based on pelvic floor muscle (PFM) assessment, participant symptoms, and findings from the study visits. We present, here, the specific perioperative behavioral/pelvic floor exercise interventions administered by study interventionists.

CONCLUSIONS

This paper details a perioperative behavioral/pelvic floor exercise intervention research study protocol developed for women undergoing surgery for MUI.

Bladder and sexual function among women with multiple sclerosis

Objective: Genitourinary dysfunction is common in women with multiple sclerosis (MS), yet few studies have evaluated the association between bladder and sexual dysfunction in these women. The aim of this study was to determine factors, including demographic and bladder function, associated with sexual dysfunction in a sample of women with MS. Methods: One hundred and thirty-three women with MS completed questionnaires related to overall heath status, bladder function and sexual function. Response frequencies and percentages were calculated for questionnaire responses. Multivariate logistic regression analyses were performed to determine predictors of sexual dysfunction. Results: Sixty-one per cent of the sample indicated that they had a problem with bladder control. Forty-seven per cent of respondents indicated that their neurological problems interfered with their sex life. Over 70% of the sample reported that they enjoyed, felt aroused and experienced orgasm during sexual activity. Not having a sexual partner and the indication of bothersome neurological problems were the best predictors of sexual dysfunction. Interestingly, patients bothered by their urge incontinence had higher levels of orgasm compared to women not bothered by urge incontinence. Conclusions: Although over half of the women reported voiding symptoms, most still enjoyed, felt aroused and could experience orgasm. Neurological symptoms and lacking a sexual partner emerged as the best predictors of sexual dysfunction. Urge incontinence may not be a risk factor for anorgasm. Our findings elucidate the complex nature of sexual dysfunction in women with MS.

Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.

METHODS

ESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.

RESULTS

The final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.

CONCLUSIONS

We describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making.

Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial

IMPORTANCE

More than 300,000 surgeries are performed annually in the United States for pelvic organ prolapse. Sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) are commonly performed transvaginal surgeries to correct apical prolapse. Little is known about their comparative efficacy and safety, and it is unknown whether perioperative behavioral therapy with pelvic floor muscle training (BPMT) improves outcomes of prolapse surgery.

OBJECTIVE

To compare outcomes between (1) SSLF and ULS and (2) perioperative BPMT and usual care in women undergoing surgery for vaginal prolapse and stress urinary incontinence.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, 2 × 2 factorial, randomized trial of 374 women undergoing surgery to treat both apical vaginal prolapse and stress urinary incontinence was conducted between 2008 and 2013 at 9 US medical centers. Two-year follow-up rate was 84.5%.

INTERVENTIONS

The surgical intervention was transvaginal surgery including midurethral sling with randomization to SSLF (n = 186) or ULS (n = 188); the behavioral intervention was randomization to receive perioperative BPMT (n = 186) or usual care (n = 188).

MAIN OUTCOMES AND MEASURES

The primary outcome for the surgical intervention (surgical success) was defined as (1) no apical descent greater than one-third into vaginal canal or anterior or posterior vaginal wall beyond the hymen (anatomic success), (2) no bothersome vaginal bulge symptoms, and (3) no re-treatment for prolapse at 2 years. For the behavioral intervention, primary outcome at 6 months was urinary symptom scores (Urinary Distress Inventory; range 0-300, higher scores worse), and primary outcomes at 2 years were prolapse symptom scores (Pelvic Organ Prolapse Distress Inventory; range 0-300, higher scores worse) and anatomic success.

RESULTS

At 2 years, surgical group was not significantly associated with surgical success rates (ULS, 59.2% [93/157] vs SSLF, 60.5% [92/152]; unadjusted difference, -1.3%; 95% CI, -12.2% to 9.6%; adjusted odds ratio [OR], 0.9; 95% CI, 0.6 to 1.5) or serious adverse event rates (ULS, 16.5% [31/188] vs SSLF, 16.7% [31/186]; unadjusted difference, -0.2%; 95% CI, -7.7% to 7.4%; adjusted OR, 0.9; 95% CI, 0.5 to 1.6). Perioperative BPMT was not associated with greater improvements in urinary scores at 6 months (adjusted treatment difference, -6.7; 95% CI, -19.7 to 6.2), prolapse scores at 24 months (adjusted treatment difference, -8.0; 95% CI, -22.1 to 6.1), or anatomic success at 24 months.

CONCLUSIONS AND RELEVANCE

Two years after vaginal surgery for prolapse and stress urinary incontinence, neither ULS nor SSLF was significantly superior to the other for anatomic, functional, or adverse event outcomes. Perioperative BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00597935.

The effects of drug and behavior therapy on urgency and voiding frequency

INTRODUCTION AND HYPOTHESIS

The objective of this study was to examine the effects of drug therapy alone and combined with behavioral therapy on urgency and 24-voiding frequency in women with urge-predominant incontinence and to identify predictors of change.

METHODS

A planned analysis of data from a multi-site, randomized, controlled trial (N = 307). Bladder diaries were used to document voids, incontinence, and urgency severity.

RESULTS

Urgency scores decreased significantly within both treatment groups, but changes did not differ between groups (p = 0.30). Improvement in urgency was associated with greater baseline urgency (p < 0.0001) and black ethnicity (p = 0.03). Voiding frequency increased with drug alone and decreased slightly with combined therapy (p = 0.009), and improvement was associated with combined treatment (p < 0.0001), higher baseline frequency (p < 0.0001), and lower baseline incontinence episode frequency (p = 0.001).

CONCLUSIONS

Although combined drug and behavioral therapy does not appear to improve urgency more than drug alone, it resulted in better outcomes on voiding frequency.

Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial

BACKGROUND

Women with urge urinary incontinence are commonly treated with antimuscarinic medications, but many discontinue therapy.

OBJECTIVE

To determine whether combining antimuscarinic drug therapy with supervised behavioral training, compared with drug therapy alone, improves the ability of women with urge incontinence to achieve clinically important reductions in incontinence episodes and to sustain these improvements after discontinuing drug therapy.

DESIGN

2-stage, multicenter, randomized clinical trial conducted from July 2004 to January 2006.

SETTING

9 university-affiliated outpatient clinics.

PATIENTS

307 women with urge-predominant incontinence.

INTERVENTION

10 weeks of open-label, extended-release tolterodine alone (n = 153) or combined with behavioral training (n = 154), followed by discontinuation of therapy and follow-up at 8 months.

MEASUREMENTS

The primary outcome, measured at 8 months, was no receipt of drugs or other therapy for urge incontinence and a 70% or greater reduction in frequency of incontinence episodes. Secondary outcomes were reduction in incontinence, self-reported satisfaction and improvement, and scores on validated questionnaires measuring symptom distress and bother and health-related quality of life. Study staff who performed outcome evaluations, but not participants and interventionists, were blinded to group assignment.

RESULTS

237 participants completed the trial. According to life-table estimates, the rate of successful discontinuation of therapy at 8 months was the same in the combination therapy and drug therapy alone groups (41% in both groups; difference, 0 percentage points [95% CI, -12 to 12 percentage points]). A higher proportion of participants who received combination therapy than drug therapy alone achieved a 70% or greater reduction in incontinence at 10 weeks (69% vs. 58%; difference, 11 percentage points [CI, -0.3 to 22.1 percentage points]). Combination therapy yielded better outcomes over time on the Urogenital Distress Inventory and the Overactive Bladder Questionnaire (both P <0.001) at both time points for patient satisfaction and perceived improvement but not health-related quality of life. Adverse events were uncommon (12 events in 6 participants [3 in each group]).

LIMITATIONS

Behavioral therapy components (daily bladder diary and recommendations for fluid management) in the group receiving drug therapy alone may have attenuated between-group differences. Assigned treatment was completed by 68% of participants, whereas 8-month outcome status was assessed on 77%.

CONCLUSION

The addition of behavioral training to drug therapy may reduce incontinence frequency during active treatment but does not improve the ability to discontinue drug therapy and maintain improvement in urinary incontinence. Combination therapy has a beneficial effect on patient satisfaction, perceived improvement, and reduction of other bladder symptoms.

The expectations of patients who undergo surgery for stress incontinence

OBJECTIVE

The purpose of this study was to assess patient expectations of surgical outcome after preoperative counseling of surgical procedures in a randomized trial of 655 women in a comparison of the rectus fascial sling and Burch colposuspension.

STUDY DESIGN

Women who selected surgery for treating stress incontinence and who consented to this randomized, surgical trial completed a preoperative questionnaire to assess expectations for the postsurgical effects of surgery on urinary incontinence-related symptoms, limitations, and emotions. Associations of expectations with a range of preoperative urinary incontinence measures were explored.

RESULTS

The most frequent preoperative symptoms were urine leakage (98%), embarrassment (88%), frequency (74%), physical activity (72%), and urgency (70%). Sexual and social limitations were less frequent (< or = 44%). Treatment expectations were higher for women who reported more symptom bother. As expected, most women (98%) had an expectation that urine leakage would be completely or almost completely eliminated. However, most women (92%) who reported urgency or frequency (83%) expected significant improvement of these symptoms after surgery.

CONCLUSION

Patients who undergo stress incontinence surgery have high expectations regarding the outcome of incontinence surgery, which include the resolution of urgency and frequency.

Test-retest reliability of the Urge-Urinary Distress Inventory and Female Sexual Function Index in women with multiple sclerosis

Test-retest reliability of the Urge-Urinary Distress Inventory (U-UDI) and the Female Sexual Function Index (FSFI) was assessed in women with multiple sclerosis (MS) because it was undetermined whether or not either instrument would yield reliable and valid results in this population. Data from this study suggest that these tools can be reliably used to assess community-dwelling women with mild gait disability and MS-associated symptoms of urinary distress and sexual dysfunction.

Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study

OBJECTIVE

To identify risk factors for postpartum FI and UI.

METHODS

Secondary analysis of data from the CAPS study, which estimated the prevalence of postpartum FI and UI in primiparous women with clinically recognized anal sphincter tears after vaginal delivery, compared with women who delivered vaginally without recognized tears or by cesarean before labor. A total of 921 women were enrolled while in the hospital and 759 (82%) were interviewed by telephone 6 months postpartum. FI was assessed using the FISI and UI using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. FI risk factor analyses were conducted within each group, because of higher prevalence in the tear group. UI analyses were conducted with the groups combined.

RESULTS

In women with sphincter tears, FI at 6 months was associated with white race (OR 6.1, 95% CI 1.3-29.4), antenatal UI (OR 2.2, CI 1.1-4.3), 4th versus 3rd degree tear (OR 2.0, CI 1.0-4.0), older age at delivery (OR 1.6 per 5 yr, CI 1.2-2.1), and higher body mass index (BMI) (OR 1.3 per 5 kg/m(2), CI 1.0-1.7). No factors were associated with FI in the vaginal or cesarean control groups. Across all groups, risk factors for postpartum UI were antenatal UI (OR 3.5, CI 2.4-5.2), less education (OR 2.0, CI 1.4-2.8), and higher BMI (OR 1.2 per 5 kg/m(2), CI 1.1-1.4); cesarean delivery was protective (OR 0.5, CI 0.3-0.9).

CONCLUSIONS

Postpartum FI and UI are associated with few modifiable risk factors. However, the presence of antenatal UI and high BMI may help clinicians target at-risk women for early intervention.

Teaching and practicing of pelvic floor muscle exercises in primiparous women during pregnancy and the postpartum period

OBJECTIVE

The purpose of this study was to describe the teaching and practicing of pelvic floor muscle exercise (PFME) before and after delivery.

STUDY DESIGN

This was a secondary data analysis from a prospective multicenter cohort study, the Childbirth and Pelvic Symptoms study, by the Pelvic Floor Disorders Network. Primiparous women (n = 759) with term singleton delivery were interviewed 6 months after delivery.

RESULTS

Sixty-four percent of the women had been taught PFME, most with verbal (76%) and/or written instructions (55%) and a few (10%) during pelvic examination. Women with anal sphincter tears were not more likely to receive instruction or reminders after delivery. More white women (75%) were taught PFME than were Asian women (48%), African American women (36%), or Hispanic women (39%; P < .0001). More women with college education (74%) were taught, compared with women without a college education (37%; P < .0001). Of those women who were taught, 68% performed PFME after delivery, and 63% were still performing the exercises 6 months after delivery.

CONCLUSION

Results reveal tremendous potential for the improvement of PFME education and targeting at-risk women in the peripartum period.

Non-surgical management of stress urinary incontinence: ambulatory treatments for leakage associated with stress (ATLAS) trial

BACKGROUND

Non-surgical treatment for stress urinary incontinence (SUI) is recommended as first-line therapy, yet few prospective studies and no randomized trials compare the most common non-surgical treatments for SUI.

PURPOSE

To present the design and methodology of the ambulatory treatments for leakage associated with stress (ATLAS) trial, a randomized clinical trial comparing three interventions for predominant SUI in women: intravaginal continence pessary; behavioral therapy (including pelvic floor muscle training and exercise and bladder control strategies); and a combination of the two treatments.

METHODS

Treatment outcome measures, collected at 12 weeks and six and 12 months post randomization, include the Patient Global Impression of Improvement (PGI-I), the Stress Incontinence Scale of the Pelvic Floor Distress Inventory (PFDI), seven-day bladder diaries, Pelvic Floor Impact Questionnaire (PFIQ), Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ-12), Patient Satisfaction Questionnaire (PSQ) and the Medical Outcomes Study Short Form Health Survey (SF-36).

LIMITATIONS

The study design reduces most common biases, but some degree of selection bias may remain.

CONCLUSION

This trial will provide useful information to help counsel women with stress and mixed incontinence about the relative efficacy and satisfaction with pessary, behavioral therapy and both treatments combined.

Fecal and urinary incontinence in primiparous women

OBJECTIVE

To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence.

METHODS

The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site.

RESULTS

Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8-4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2-3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence.

CONCLUSION

Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders.

LEVEL OF EVIDENCE

II-3.

Quality of life in women with stress urinary incontinence

The objective of this study was to identify clinical and demographic factors associated with incontinence-related quality of life (QoL) in 655 women with stress urinary incontinence who elected surgical treatment. The following factors were examined for their association with QoL as measured with the Incontinence Impact Questionnaire (IIQ): number of incontinence (UI) episodes/day; self-reported type of UI symptoms (stress and urge); sexual function as measured by the Prolapse/Urinary Incontinence Sexual Questionnaire; symptom bother as measured by the Urogenital Distress Inventory; as well as other clinical and sociodemographic factors. A stepwise least-squares regression analysis was used to identify factors significantly associated with QoL. Lower QoL was related to the greater frequency of stress UI symptoms, increasing severity, greater symptom bother, prior UI surgery or treatment, and sexual dysfunction (if sexually active). Health and sociodemographic factors associated with lower incontinence-related QoL included current tobacco use, younger age, lower socioeconomic status, and Hispanic ethnicity.

The relationship between overactive bladder and sexual activity in women

PURPOSE

We assessed the relationships between bladder symptoms, demographic, and medical history variables and sexual dysfunction in women with overactive bladder (OAB) disorder.

MATERIALS AND METHODS

Seventy-eight women diagnosed with OAB completed self-administered questionnaires related to overall heath status, bladder function, and sexual function. Data were compiled for questionnaire responses, and multivariate logistic regression analyses were performed to determine predictors of sexual dysfunction.

RESULTS

Bothersome bladder symptoms were reported by > or = 60% of the sample. Sixty-percent of the sample was sexually active in the past month. Difficulty with sexual arousal, orgasm, and sexual enjoyment were reported by about 25% of the women. Sexual partner status was the best predictor of sexual arousal, orgasm, and sexual enjoyment. Menopausal status emerged as an important predictor of arousal and sexual enjoyment.

CONCLUSION

The majority of women with symptoms of OAB viewed these symptoms as bothersome. However, the extent of symptom bother did not predict aspects of female sexual dysfunction (FSD). Instead, menopausal and partner status emerged as the best predictors of FSD in our sample.

Physical activity in women planning sacrocolpopexy

This study describes preoperative physical activity in 314 stress-continent women with prolapse planning sacrocolpopexy. Seventy-six percent reported that they engaged in mild, 60% in moderate, and 26% in strenuous exercise (counts are not mutually exclusive). Activity frequencies did not generally differ by prolapse stage. Prolapse substantially interfered with exercise or recreation in 27% of women, household work or yard work in 19%, and work outside the home in 8%. Compared to women with less symptom distress, more women with greater symptom distress reported that prolapse interfered with household/yard work (43 vs 5%, p<0.0001), working outside the home (29 vs 8%, p<0.005), and recreation/exercise (51 vs 10%, p<0.0001). Prolapse stage was not associated with interference with household/yard work (p=0.28) or work outside home (p=0.89). Although prolapse stage is associated with interference with recreation (p=0.02), this association is not consistently positive : stage II, 42%; stage III, 22%; and stage IV, 32%.

Functional outcome of vestibular rehabilitation in patients with abnormal sensory-organization testing

A goal of vestibular rehabilitation is to improve the functional status of patients with balance disorders. Despite the focus of vestibular rehabilitation on function, few objective data describe the outcome of vestibular rehabilitation in terms of balance function. In this prospective observational study, we tested a well-defined patient cohort (n = 67) with abnormal pretreatment sensory-organization testing who were undergoing vestibular rehabilitation. Patient outcomes were determined by using objective and subjective measures of function before and after rehabilitation. Overall, 60% of patients showed objective improvement of balance function; 25% of patients improved to normal. Analysis of success and failure of vestibular rehabilitation is important as an aid to appropriate patient counseling and efficient use of rehabilitation resources.

Gait comparison of subjects with hemiplegia walking unbraced, with ankle-foot orthosis, and with Air-Stirrup brace

The effects of the Air-Stirrup (AS) standard ankle brace on the gait of 19 subjects with hemiplegia resulting from a cerebrovascular accident who exhibited excessive subtalar joint motion were studied. Videotaped trials and footprint analyses were used to measure subjects' hip, knee, and ankle sagittal plane angles; inversion and eversion of the calcaneus; and time-distance gait characteristics. A one-way analysis of variance for repeated measures was used to compare the gait of 19 subjects with the AS brace and unbraced and 11 subjects with the AS brace, unbraced, and with an ankle-foot orthosis. The AS brace was associated with more calcaneal stability during standing than the unbraced condition. The ankle-foot orthosis was associated with less plantar flexion at foot-strike than either the AS brace or unbraced condition. Both the AS brace and the ankle-foot orthosis were associated with less mid-swing plantar flexion and increased step length on the paretic side compared with no brace. These results support the effectiveness of the AS brace in controlling inversion and eversion instability in patients with hemiplegia.