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Newberry SJ, Tsuei J, Larkin J, Motala A, Howard K, Dunivan G. Managing Urinary Incontinence for Women in Primary Care: Environmental Scan (Base Year). Rand Health Q 2023; 10:3. [PMID: 37333668 PMCID: PMC10273891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Urinary incontinence (UI) is a highly prevalent condition among women worldwide. Although effective nonsurgical treatments exist, including pharmacological, behavioral, and physical therapies, many women with the condition are never diagnosed because of a lack of information, stigma, and the absence of regular screening in primary care, and those who are diagnosed might not receive or adhere to treatment. In this study, the authors present an environmental scan of studies published from 2012 through 2022 that assess the dissemination and implementation of nonsurgical UI treatment-including screening, management, and referral strategies-for women in primary care. The scan was conducted as part of the RAND's support and evaluation contract for the Agency for Healthcare Research and Quality's Managing Urinary Incontinence initiative. The initiative, which builds on the agency's EvidenceNOW model, funds five grant projects to disseminate and implement improved nonsurgical treatment of UI for women within primary care practices in separate regions of the United States.
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Robison K, Wohlrab K, Howe CJ, Richter HE, Sung V, Bevis KS, Luis C, McCourt C, Lowder J, Occhino J, Glaser G, Lokich E, Dunivan G, Brown A, Tunitsky-Bitton E, Wethington S, Chen CCG, Rahn D, Carlson M, Cram R, Raker C, Clark MA. Endometrial Cancer Surgery With or Without Concomitant Stress Urinary Incontinence Surgery. Obstet Gynecol 2023; 141:642-652. [PMID: 36897162 DOI: 10.1097/aog.0000000000005059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/13/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To compare quality of life (QOL) among patients with endometrial intraepithelial neoplasia or early-stage endometrial cancer and stress urinary incontinence (SUI) who chose to have concomitant surgery with cancer surgery alone. METHODS A multicenter, prospective cohort study was conducted across eight U.S. sites. Potentially eligible patients were screened for SUI symptoms. Those who screened positive were offered referral to urogynecology and incontinence treatment, including concomitant surgery. Participants were categorized into two groups: 1) concomitant cancer and SUI surgery or 2) cancer surgery alone. The primary outcome was cancer-related QOL as measured by the FACT-En (Functional Assessment of Cancer Therapy-Endometrial) (range 0-100; higher score indicates better QOL). The FACT-En and questionnaires assessing urinary symptom-specific severity and effects were assessed before surgery and 6 weeks, 6 months, and 12 months after surgery. Adjusted median regression accounting for clustering was used to examine the relationship between SUI treatment group and FACT-En scores. RESULTS Of 1,322 (53.1%) patients, 702 screened positive for SUI with 532 analyzed; 110 (21%) chose concomitant cancer and SUI surgery, and 422 (79%) chose cancer surgery alone. FACT-En scores increased for both the concomitant SUI surgery and cancer surgery-only groups from the preoperative to the postoperative period. After adjustment for timepoint and preoperative covariates, the median change in FACT-En score (postoperative-preoperative) was 1.2 points higher (95% CI -1.3 to 3.6) for the concomitant SUI surgery group compared with the cancer surgery-only group across the postoperative period. Median time until surgery (22 days vs 16 days; P <.001), estimated blood loss (150 mL vs 72.5 mL; P <.001), and operative time (185.5 minutes vs 152 minutes; P <.001) were all greater for the concomitant cancer and SUI surgery group compared with the cancer-only group, respectively. CONCLUSION Concomitant surgery did not result in improved QOL compared with cancer surgery alone for endometrial intraepithelial neoplasia and patients with early-stage endometrial cancer with SUI. However, FACT-En scores were improved in both groups.
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Affiliation(s)
- Katina Robison
- Women & Infants Hospital and Brown University, Providence, Rhode Island; the University of Alabama at Birmingham, Birmingham, Alabama; Washington University of St. Louis Hospital, St. Louis, Missouri; Mayo Clinic, Rochester, Minnesota; the University of New Mexico Hospital, Albuquerque, New Mexico; Hartford Hospital, Hartford, Connecticut; Johns Hopkins Hospital, Baltimore, Maryland; and the University of Texas Southwestern Medical Center, Dallas, Texas
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Cadena M, Dunivan G. Obliterative Surgery for Vaginal Prolapse: An Update. Curr Geri Rep 2023. [DOI: 10.1007/s13670-023-00382-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Halder G, Ishag T, Lewis K, Gallo M, Ellsworth K, Kilic S, Meriwether K, Dunivan G. Examining surgical preparedness in elderly women undergoing urogynecologic surgery. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.12.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Meriwether K, Jansen S, Abudushalamu F, Griego J, Dunivan G, Komesu Y, Page-Reeves J. Beliefs and narratives associated with the treatment of chronic pelvic pain in women. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Dao A, Dunivan G. Patient-Centered Goals for Treatment of Pelvic Floor Disorders. Curr Bladder Dysfunct Rep 2022; 17:210-218. [PMID: 36258780 PMCID: PMC9562075 DOI: 10.1007/s11884-022-00668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/28/2022]
Abstract
Purpose of review To review the current literature on patient centered goals for the treatment of pelvic floor disorders (PFDs). Recent findings Patients have a poor understanding of their PFDs, regardless if they had prior PFD treatments or received counseling, emphasizing the need for improved education from healthcare providers. Understanding the patient perspective provides insights into identifying patient goals, which facilitates communication and allows for tailored counseling, management of expectations, and assessment of treatment response. Functional outcomes are consistently important to patients, often listed as their main treatment goals. The achievement of these goals is fundamental to satisfaction. IMPACT and PROMIS are examples of PCO measures that can be utilized in both research and clinical settings. Finally, telemedicine has emerged as a viable alternative to clinic visits that offers improved access to care with no increase in adverse events or dissatisfaction, in order to aid in monitoring and meeting patient treatment goals. Summary Patient involvement is fundamental to providing value-based care. Provider understanding of the patient perspective is necessary to guide counseling and treatment. Patient-centered goals offer a way to engage patients, facilitate communication, and improve patient satisfaction. Although there are multiple validated PCO tools, further development and research involving patient input is needed.
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Affiliation(s)
- Angela Dao
- Division of Urogynecology, Department of OBGYN, University of New Mexico, MSC 10-5580, Albuquerque, NM 87131-0001 USA
| | - Gena Dunivan
- Division of Urogynecology, Department of OBGYN, University of Alabama at Birmingham, Birmingham, AL USA
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Rockefeller NF, Petersen TR, Komesu YM, Meriwether K, Dunivan G, Ninivaggio C, Jeppson PC. Chlorhexidine gluconate vs povidone-iodine vaginal antisepsis for urogynecologic surgery: a randomized controlled noninferiority trial. Am J Obstet Gynecol 2021; 227:66.e1-66.e9. [PMID: 34973179 DOI: 10.1016/j.ajog.2021.12.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/29/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although povidone-iodine (iodine) is the only Food and Drug Administration-approved vaginal antiseptic solution, there is a lack of comparative data evaluating alternatives. Chlorhexidine gluconate is readily accessible, recommended by multiple societies as an alternative for patients with iodine allergy, and preliminary data indicate that it may provide superior antisepsis. OBJECTIVE This study aimed to compare the effectiveness of chlorhexidine and iodine as presurgical vaginal antiseptic solutions in preventing the most common surgery-associated infection after gynecologic surgery, urinary tract infections. STUDY DESIGN We conducted a randomized controlled noninferiority trial among women undergoing urogynecologic surgery. The primary outcome measure was symptomatic urinary tract infection within 2 weeks after surgery. The secondary outcomes included culture-proven urinary tract infection at 2 and 6 weeks after surgery, symptomatic urinary tract infections at 6 weeks after surgery, any surgical site infection at 2 weeks after surgery, and patient-reported vaginal irritation after surgery. We required 58 participants per arm to demonstrate noninferiority of chlorhexidine vs iodine (margin of relative risk of <1.5 for the upper limit of 95% confidence interval) between groups for the primary outcome. RESULTS A total of 119 participants (61 in the chlorhexidine group and 58 in the iodine group) completed the primary outcome and were included in the analyses. There was no difference in the groups' demographic characteristics, medical history, operations performed, or perioperative factors. Chlorhexidine was not inferior to iodine concerning the primary outcome, symptomatic urinary tract infection at 2 weeks after surgery (10% vs 17%; relative risk, 0.6; 95% confidence interval [-∞, 1.3]). Furthermore, chlorhexidine was not inferior to iodine for the secondary urinary tract infection outcomes (culture-proven urinary tract infection at 2 and 6 weeks after surgery and symptomatic urinary tract infection at 6 weeks after surgery). Groups were similar in terms of surgical site infection (overall 3/119 [2.5%]) and presence of any vaginal irritation (4/54 [7.4%], for both groups). CONCLUSION Chlorhexidine was not inferior to iodine for vaginal antisepsis before urogynecologic surgery concerning urinary tract infection. Given the similar postoperative urinary tract infection rates demonstrated in this study and the lack of difference in vaginal irritation, chlorhexidine seemed to be a safe and reasonable option for vaginal antisepsis before surgical procedures. Additional studies are needed to further examine surgical site infection.
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Affiliation(s)
- Nicholas F Rockefeller
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.
| | - Timothy R Petersen
- Department of Anesthesia and Critical Care Medicine, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM
| | - Yuko M Komesu
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Kate Meriwether
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Gena Dunivan
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Cara Ninivaggio
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Peter C Jeppson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
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Jelovsek JE, Gantz MG, Lukacz ES, Zyczynski HM, Sridhar A, Kery C, Chew R, Harvie HS, Dunivan G, Schaffer J, Sung V, Varner RE, Mazloomdoost D, Barber MD. Subgroups of failure after surgery for pelvic organ prolapse and associations with quality of life outcomes: a longitudinal cluster analysis. Am J Obstet Gynecol 2021; 225:504.e1-504.e22. [PMID: 34157280 PMCID: PMC8578254 DOI: 10.1016/j.ajog.2021.06.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment outcomes after pelvic organ prolapse surgery are often presented as dichotomous "success or failure" based on anatomic and symptom criteria. However, clinical experience suggests that some women with outcome "failures" are asymptomatic and perceive their surgery to be successful and that other women have anatomic resolution but continue to report symptoms. Characterizing failure types could be a useful step to clarify definitions of success, understand mechanisms of failure, and identify individuals who may benefit from specific therapies. OBJECTIVE This study aimed to identify clusters of women with similar failure patterns over time and assess associations among clusters and the Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, Patient Global Impression of Improvement, patient satisfaction item questionnaire, and quality-adjusted life-year. STUDY DESIGN Outcomes were evaluated for up to 5 years in a cohort of participants (N=709) with stage ≥2 pelvic organ prolapse who underwent surgical pelvic organ prolapse repair and had sufficient follow-up in 1 of 4 multicenter surgical trials conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Surgical success was defined as a composite measure requiring anatomic success (Pelvic Organ Prolapse Quantification system points Ba, Bp, and C of ≤0), subjective success (absence of bothersome vaginal bulge symptoms), and absence of retreatment for pelvic organ prolapse. Participants who experienced surgical failure and attended ≥4 visits from baseline to 60 months after surgery were longitudinally clustered, accounting for similar trajectories in Ba, Bp, and C and degree of vaginal bulge bother; moreover, missing data were imputed. Participants with surgical success were grouped into a separate cluster. RESULTS Surgical failure was reported in 276 of 709 women (39%) included in the analysis. Failures clustered into the following 4 mutually exclusive subgroups: (1) asymptomatic intermittent anterior wall failures, (2) symptomatic intermittent anterior wall failures, (3) asymptomatic intermittent anterior and posterior wall failures, and (4) symptomatic all-compartment failures. Each cluster had different bulge symptoms, anatomy, and retreatment associations with quality of life outcomes. Asymptomatic intermittent anterior wall failures (n=150) were similar to surgical successes with Ba values that averaged around -1 cm but fluctuated between anatomic success (Ba≤0) and failure (Ba>0) over time. Symptomatic intermittent anterior wall failures (n=82) were anatomically similar to asymptomatic intermittent anterior failures, but women in this cluster persistently reported bothersome bulge symptoms and the lowest quality of life, Short-Form Six-Dimension health index scores, and perceived success. Women with asymptomatic intermittent anterior and posterior wall failures (n=28) had the most severe preoperative pelvic organ prolapse but the lowest symptomatic failure rate and retreatment rate. Participants with symptomatic all-compartment failures (n=16) had symptomatic and anatomic failure early after surgery and the highest retreatment of any cluster. CONCLUSION In particular, the following 4 clusters of pelvic organ prolapse surgical failure were identified in participants up to 5 years after pelvic organ prolapse surgery: asymptomatic intermittent anterior wall failures, symptomatic intermittent anterior wall failures, asymptomatic intermittent anterior and posterior wall failures, and symptomatic all-compartment failures. These groups provide granularity about the nature of surgical failures after pelvic organ prolapse surgery. Future work is planned for predicting these distinct outcomes using patient characteristics that can be used for counseling women individually.
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Affiliation(s)
- J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, NC
| | - Emily S Lukacz
- Department of Obstetrics and Gynecology, University of California San Diego, San Diego, CA
| | - Halina M Zyczynski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, NC
| | - Caroline Kery
- Division for Statistical and Data Sciences, Research Triangle Institute International, Research Triangle Park, NC
| | - Rob Chew
- Division for Statistical and Data Sciences, Research Triangle Institute International, Research Triangle Park, NC
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Gena Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - Joseph Schaffer
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vivian Sung
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, the Warren Alpert Medical School, Brown University, Providence, RI
| | - R Ed Varner
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Matthew D Barber
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
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Kulkarni A, Proussaloglou E, Beffa L, Miller K, Bevis K, Wohlrab K, Lokich E, McCourt C, Glaser G, Brown A, Wethington S, Carlson M, DiSilvestro P, Occhino J, Dunivan G, Tunitsky E, Chen G, Raker C, Luis C, Robison K. Does adjuvant treatment increase risk of midurethral sling complications after concomitant surgery for endometrial cancer and stress urinary incontinence? Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2020.05.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Proussaloglou E, Kulkarni A, Beffa L, Miller K, Wohlrab K, Lokich E, McCourt C, Glaser G, Brown A, Wethington S, Carlson M, DiSilvestro P, Lowder J, Rahn D, Occhino J, Dunivan G, Chen G, Raker C, Robison K. Sexual dysfunction in women with endometrial cancer and stress urinary incontinence. Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2020.06.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Barnes KL, Dunivan G, Sussman AL, McGuire L, McKee R. Behind the Mask: An Exploratory Assessment of Female Surgeons' Experiences of Gender Bias. Acad Med 2020; 95:1529-1538. [PMID: 33006870 DOI: 10.1097/acm.0000000000003569] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Though overt sexism is decreasing, women now experience subtle, often unconscious, gender bias as microaggressions. The authors sought to explore the prevalence and impact of the sexist microaggressions female surgeons experience, using a sequential exploratory mixed methods approach (January 2018-April 2018), to identify opportunities for education and prevention. First, all resident, fellow, and attending female surgeons at the University of New Mexico Health Sciences Center (UNM HSC) were invited to participate in focus groups conducted by experienced moderators using a semistructured interview guide based on the 7 Sexist Microaggressions Experiences and Stress Scale (Sexist MESS) domains. Qualitative analysis was performed using line-by-line manual coding to identify themes aligned with the Sexist MESS domains as well as other gender bias experiences of female surgeons. Next, a survey was sent to all resident, fellow, and attending female surgeons at the UNM HSC, which included the Sexist MESS questionnaire and questions related to surgeon-specific experiences of gender bias that the authors developed based on major thematic categories from the focus groups.Four focus groups of 23 female surgeons were conducted, revealing 4 themes: exclusion, increased effort, adaptation, and resilience to workplace slights. The survey response rate was 64% (65/101 surgeons). Across Sexist MESS domains, the frequency and severity of microaggressions was higher for trainees than attendings. The variables of non-White race/ethnicity, having children under 18, and fellowship training generally did not demonstrate statistical significance. This exploratory study adds to the growing body of evidence that gender bias in surgery continues and frequently manifests as microaggressions. Trainees reported the highest rates and severity of microaggressions and bias experiences. Further research should investigate how to address microaggressions, the experiences of male surgeons, the perspectives of medical students and groups who were reported as often perpetuating gender bias, and the efficacy of possible interventions.
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Affiliation(s)
- K Lauren Barnes
- K.L. Barnes is a female pelvic medicine and reconstructive surgery fellow, Department of Obstetrics and Gynecology, Division of Urogynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Gena Dunivan
- G. Dunivan is associate professor, Department of Obstetrics and Gynecology, Division of Urogynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Andrew L Sussman
- A.L. Sussman is associate professor, Department of Family and Community Medicine and University of New Mexico Comprehensive Cancer Center, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Lauren McGuire
- L. McGuire is a first-year general surgery resident, University of Utah School of Medicine, Salt Lake City, Utah
| | - Rohini McKee
- R. McKee is associate professor, Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Barnes KL, McGuire L, Dunivan G, Sussman AL, McKee R. Gender Bias Experiences of Female Surgical Trainees. J Surg Educ 2019; 76:e1-e14. [PMID: 31601487 DOI: 10.1016/j.jsurg.2019.07.024] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/24/2019] [Accepted: 07/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Medical schools now average approximately 50% female students, yet a disproportionate number of women continue to choose nonsurgical over surgical specialties. Once in training, studies indicate that pervasive gender stereotypes, sexism and harassment negatively affect female surgeons. The aim of this study is to describe female surgeons' experiences with gender bias and microaggressions in the workplace during residency and fellowship training, and understand if differences exist in the experiences of trainees in male-dominant vs female-dominant surgical specialties. DESIGN A mixed methods approach was used to explore the experiences of female surgical trainees. Participants were recruited from all surgical disciplines at an academic center. Initially, focus groups were used to explore themes that trainees face related to gender bias. A trained moderator conducted all focus groups, which were audio recorded and transcribed. Qualitative analysis of de-identified transcripts was performed to identify emerging themes. We then created an online survey using the validated 44-question Sexist Microaggression Experiences and Stress Scale to assess frequency and psychologic impact of these events with additional questions developed from the focus groups. The survey was sent to all female residents and fellows at one academic institution. SETTING University of New Mexico Hospital, a tertiary care academic medical center. PARTICIPANTS Fifteen female surgical trainees participated in focus groups. Thirty-three female surgical trainees participated in the online survey. RESULTS Two focus groups including 15 female trainees were conducted, revealing 4 themes: Exclusion, Adaptation, Increased effort, and Development of Resilience Strategies. All participants had experienced gender bias or discrimination during medical school or surgical training. The quantitative survey had a 66% response rate (33/50 female trainees). Significant differences were found in the experience of female trainees in male-dominant vs female-dominant specialties, with those in male-dominant fields often reporting more frequent, severe, and stressful microaggression experiences. When describing how gender bias would affect their future in medicine, trainees in male-dominant specialties were more likely to report that due to gender bias, they "may leave medicine/retire early" (33% vs 6%, p = 0.040) and that they "would not recommend my profession to trainees or family members" (40% vs 6%, p = 0.015)." CONCLUSIONS Female surgical trainees continue to experience gender bias. A culture of sexism leads to physical and social adaptations to fit into the role of surgeon. Participants expressed significant effort to sustain this level of adaptation, leading to fatigue and creation of resilience mechanisms. The environment in which a trainee operates (male-dominant vs female-dominant) significantly impacts their experience. Those experiencing more bias were less likely to recommend their specialty and reported plans to leave medicine earlier. Culture change across institutions and system-level interventions are necessary to create meaningful and sustainable change that improves the experience of female surgical trainees.
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Affiliation(s)
- K Lauren Barnes
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, New Mexico
| | - Lauren McGuire
- University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Gena Dunivan
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, New Mexico
| | - Andrew L Sussman
- Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, New Mexico
| | - Rohini McKee
- Department of Surgery, University of New Mexico Health Science Center, Albuquerque, New Mexico.
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Sung VW, Borello-France D, Newman DK, Richter HE, Lukacz ES, Moalli P, Weidner AC, Smith AL, Dunivan G, Ridgeway B, Nguyen JN, Mazloomdoost D, Carper B, Gantz MG. 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. JAMA 2019; 322:1066-1076. [PMID: 31529007 PMCID: PMC6749544 DOI: 10.1001/jama.2019.12467] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Vivian W. Sung
- The Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Diane Borello-France
- Department of Physical Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania
| | - Diane K. Newman
- The Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Holly E. Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Emily S. Lukacz
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, La Jolla
| | - Pamela Moalli
- Women’s Center for Bladder and Pelvic Health, Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alison C. Weidner
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Ariana L. Smith
- The Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia
| | - Gena Dunivan
- The Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque
| | - Beri Ridgeway
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - John N. Nguyen
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, Kaiser Permanente, Downey, California
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Benjamin Carper
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Marie G. Gantz
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, North Carolina
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14
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Richter HE, Dunivan G, Brown HW, Andy U, Dyer KY, Rardin C, Muir T, McNevin S, Paquette I, Gutman RE, Quiroz L, Wu J. A 12-Month Clinical Durability of Effectiveness and Safety Evaluation of a Vaginal Bowel Control System for the Nonsurgical Treatment of Fecal Incontinence. Female Pelvic Med Reconstr Surg 2019; 25:113-119. [PMID: 30807411 DOI: 10.1097/spv.0000000000000681] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to characterize clinical success, impact on quality of life, and durability up to 1 year in women with fecal incontinence (FI) responsive to an initial test period with a trial vaginal bowel control system. METHODS This was a prospective open-label study in subjects with FI and successfully fit who underwent an initial 2-week trial period. Those achieving 50% or greater reduction in FI episodes were provided the long-term system. Primary outcome was success at 3 months defined as 50% or greater reduction in baseline FI episodes, also assessed at 6 and 12 months. Secondary outcomes included symptom impact measured with Fecal Incontinence Quality of Life scale, symptom severity by the St Mark's (Vaizey) questionnaire, Patient Global Impression of Improvement, and satisfaction. Adverse events were collected. Primary analysis was intention to treat (ITT). RESULTS Seventy-three subjects with baseline mean of 14.1 ± 12.15 FI episodes over 2 weeks entered the treatment period. Success rate at 3 months was 72.6% (53/73, P < 0.0001); per-protocol, 84.1% (53/63, P < 0.0001). Significant improvement in all Fecal Incontinence Quality of Life subscales and St Mark's questionnaire meeting minimally important differences was noted. Satisfaction was 91.7%, 89.7%, and 94.4% at 3, 6, and 12 months, respectively; 77.4%, 77.6%, and 79.6% were very much/much better on the Patient Global Impression of Improvement at 3, 6, and 12 months, respectively. Most common adverse event was vaginal wall injury, with most adverse events (90/134, 67%) occurring during fitting period. CONCLUSIONS In women with successful fitting and initial treatment response, durable efficacy was seen at 3, 6, and 12 months by objective and subjective measures, with favorable safety.
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Affiliation(s)
| | | | - Heidi W Brown
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Uduak Andy
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Robert E Gutman
- MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | | | - Jennifer Wu
- University of North Carolina, Chapel Hill, NC
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15
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Robison K, Bevis K, Howe C, Wohlrab K, Sung V, Richter H, Lokich E, McCourt C, Glaser G, Brown A, Wethington S, Carlson M, DiSilvestro P, Lowder J, Rahn D, Occhino J, Dunivan G, Tunitsky E, Chen G, Luis C, Raker C, Clark M. Concurrent surgical treatment of urinary incontinence at the time of endometrial cancer surgery is associated with improved quality of life 6 months after cancer surgery: Cancer of the uterus and treatment of incontinence (CUTI) study. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Glassman D, Wohlrab K, Bevis K, Sung V, Richter H, Howe C, Lokich E, McCourt C, Glaser G, Brown A, Wethington S, DiSilvestro P, Lowder J, Occhino J, Dunivan G, Chen G, Luis C, Raker C, Clark M, Robison K, Carlson M, Tunitsky E. Adverse outcomes among women after concurrent surgery for endometrial cancer and pelvic floor disorders: The cancer of the uterus and treatment of incontinence (CUTI) trial. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Cichowski S, Ashley M, Ortiz O, Dunivan G. Female Veterans' Experiences With VHA Treatment for Military Sexual Trauma. Fed Pract 2019; 36:41-47. [PMID: 30766417 PMCID: PMC6366579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Provider validation and support for females' experiences as well as a range of therapies are essential treatments for female veterans with military sexual trauma.
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Affiliation(s)
- Sara Cichowski
- is a Female Pelvic Medicine and Reconstructive Surgeon at New Mexico VA Health Care System and University of New Mexico. is a Medical Student, is a Resident Physician in psychiatry, and is a Female Pelvic Medicine and Reconstructive Surgeon, all at the University of New Mexico in Albuquerque
| | - Malia Ashley
- is a Female Pelvic Medicine and Reconstructive Surgeon at New Mexico VA Health Care System and University of New Mexico. is a Medical Student, is a Resident Physician in psychiatry, and is a Female Pelvic Medicine and Reconstructive Surgeon, all at the University of New Mexico in Albuquerque
| | - Orlando Ortiz
- is a Female Pelvic Medicine and Reconstructive Surgeon at New Mexico VA Health Care System and University of New Mexico. is a Medical Student, is a Resident Physician in psychiatry, and is a Female Pelvic Medicine and Reconstructive Surgeon, all at the University of New Mexico in Albuquerque
| | - Gena Dunivan
- is a Female Pelvic Medicine and Reconstructive Surgeon at New Mexico VA Health Care System and University of New Mexico. is a Medical Student, is a Resident Physician in psychiatry, and is a Female Pelvic Medicine and Reconstructive Surgeon, all at the University of New Mexico in Albuquerque
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18
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Robison K, Bevis K, Howe C, Wohlrab K, Sung V, Richter H, Lokich E, McCourt C, Glaser G, Brown A, Wethington S, Carlson M, Rahn D, Lowder J, Occhino J, Dunivan G, Tunitsky E, Chen G, Luis C, Raker C, DiSilvestro P, Clark M. Characteristics of women with endometrial cancer and stress urinary incontinence (SUI) that desire concurrent cancer and SUI surgery: Cancer of the uterus and treatment of incontinence (CUTI) study. Gynecol Oncol 2018. [DOI: 10.1016/j.ygyno.2018.04.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Thompson J, Dunivan G, Jeppson P, Cichowski S, Komesu Y, Rogers R, Mazurie A, Nestsiarovich A, Lambert C. 09: Trends in postoperative opioid prescribing practices and route of hysterectomy in the United States from 2003 to 2014. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.12.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Krantz T, Thompson J, Popek S, Rogers R, Komesu Y, Dunivan G, Cichowski S, Jeppson P. 16: Vaginal evisceration remote from pelvic surgery. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.12.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Connolly A, Donnellan N, Lutz E, Buys E, Lane F, Gecsi K, Adams K, Kenton K, Amundsen C, Gregory T, Botros S, Blanchard A, Dunivan G, Gosman G. Real-Time Feedback – Trying Something New – What Works? What Gets in the Way? Program Directors’ Perspectives on the myTIPreport Rollout Experience. J Minim Invasive Gynecol 2016. [DOI: 10.1016/j.jmig.2016.08.572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Connolly A, Donnellan N, Lutz E, Goepfert A, Blanchard A, Buys E, Galvin S, Litwiller A, Gosman G, Amundsen C, Gerber S, Dunivan G, Gregory T, Gecsi K, Botros S, Lane F, Higgins R, Major C, Frishman G, Bienstock J, Cantrell L, Parviainen K, Kenton K. “Real-Time” Feedback for Milestones and Procedural Skills: A Multi-Center Trial of “myTIPreport”. J Minim Invasive Gynecol 2016. [DOI: 10.1016/j.jmig.2016.08.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Sung VW, Borello-France D, Dunivan G, Gantz M, Lukacz ES, Moalli P, Newman DK, Richter HE, Ridgeway B, Smith AL, Weidner AC, Meikle S. Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial. Int Urogynecol J 2016; 27:1479-90. [PMID: 27287818 DOI: 10.1007/s00192-016-3031-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Vivian W Sung
- The Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA. .,Women and Infants Hospital of Rhode Island Division of Urogynecology and Reconstructive Pelvic Surgery, Warren Alpert Medical School of Brown University, 101 Plain Street 5th floor, Providence, RI, 02903, USA.
| | - Diane Borello-France
- Department of Physical Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA
| | - Gena Dunivan
- The Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA
| | - Marie Gantz
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, NC, USA
| | - Emily S Lukacz
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Reproductive Medicine, UC San Diego Health System, San Diego, CA, USA
| | - Pamela Moalli
- Women's Center for Bladder and Pelvic Health, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Diane K Newman
- The Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Beri Ridgeway
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ariana L Smith
- The Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Alison C Weidner
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Susan Meikle
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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24
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Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SS, Hamilton FA. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015; 110:127-36. [PMID: 25533002 PMCID: PMC4418464 DOI: 10.1038/ajg.2014.396] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 11/01/2014] [Indexed: 12/11/2022]
Abstract
In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Gena Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Patricia S. Goode
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Emily S. Lukacz
- Department of Reproductive Medicine, UC San Diego Health Systems, La Jolla, CA
| | - Alayne D. Markland
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Catherine A. Matthews
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Louise Mott
- Simon Foundation, Langley, British Columbia, Canada
| | - Rebecca G. Rogers
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Alan R. Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - William E. Whitehead
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC,Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC
| | - Satish S.C. Rao
- Department of Gastroenterology, Georgia Regents University, Augusta, GA
| | - Frank A. Hamilton
- National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, MD
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25
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McFadden B, Rogers R, Dunivan G, Qualls C, Cichowski S, Fairchild P, Komesu Y. Do Measurements of External Genitalia Correlate with Body Image among Women with Pelvic Floor Dysfunction? J Minim Invasive Gynecol 2014. [DOI: 10.1016/j.jmig.2013.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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