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Sutcliffe S, Falke C, Fok CS, Griffith JW, Harlow BL, Kenton KA, Lewis CE, Low LK, Lowder JL, Lukacz ES, Markland AD, McGwin G, Meister MR, Mueller ER, Newman DK, Pakpahan R, Rickey LM, Rockwood T, Simon MA, Smith AR, Rudser KD, Smith AL. Lower Urinary Tract Symptoms in US Women: Contemporary Prevalence Estimates from the RISE FOR HEALTH Study. J Urol 2024:101097JU0000000000004009. [PMID: 38703067 DOI: 10.1097/ju.0000000000004009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND To estimate the prevalence of a wide range of lower urinary tract symptoms (LUTS) in US women, and to explore associations with bother and discussion with healthcare providers, friends, and family. MATERIALS AND METHODS We analyzed baseline data collected from 5/2022-12/2023 in the RISE FOR HEALTH study-a large, regionally-representative cohort study of adult female community members. LUTS and related bother were measured by the 10-item Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index and discussion was assessed by a study-specific item. RESULTS Of the 3000 eligible participants, 73% (95% confidence interval [CI] = 71-74%) reported any storage symptoms, 52% (95% CI = 50-53) any voiding or emptying symptoms, and 11% (95% CI = 10-13%) any pain with bladder filling, for an overall LUTS prevalence of 79% (95% CI = 78-81%). This prevalence estimate included 43% (95% CI = 41-45%) of participants with mild-to-moderate symptoms and 37% (95% CI = 35-38%) with moderate-to-severe symptoms. Over one-third of participants reported LUTS-related bother (38%, 95% CI = 36-39%) and discussion (38%, 95% CI = 36-40%), whereas only 7.1% (95% CI = 6.2-8.1%) reported treatment. Urgency and incontinence (including urgency and stress incontinence) were associated with the greatest likelihood of bother and/or discussion (adjusted prevalence ratios = 1.3-2.3), even at mild-to-moderate levels. They were also the most commonly treated LUTS. CONCLUSIONS LUTS, particularly storage LUTS such as urgency and incontinence, were common and bothersome in the RISE study population, yet often untreated. Given this large burden, both prevention and treatment-related interventions are warranted to reduce the high prevalence and bother of LUTS.
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Affiliation(s)
- Siobhan Sutcliffe
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Chloe Falke
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, Minnesota
| | - Cynthia S Fok
- Department of Urology and the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - James W Griffith
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Bernard L Harlow
- Boston University School of Public Health, Boston, Massachusetts
| | - Kimberly A Kenton
- Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Cora E Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Jerry L Lowder
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Emily S Lukacz
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, California
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, and the Geriatric Research, Education, and Clinical Center at the Birmingham Veterans Affairs Health Care System, Birmingham, Alabama
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melanie R Meister
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas
| | - Elizabeth R Mueller
- Departments of Obstetrics and Gynecology, and Urology, Loyola University Medical Center, Loyola University Chicago, Chicago, Illinois
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ratna Pakpahan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Leslie M Rickey
- Department of Urology and the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Todd Rockwood
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Melissa A Simon
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Abigail R Smith
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kyle D Rudser
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, Minnesota
| | - Ariana L Smith
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Lowder JL, Zhao P, Bradley M, Giugale LE, Xu H, Abramowitch S, Bayly P. Pre-operative Prolapse Phenotype is Predictive of Surgical Outcome with Minimally Invasive Sacrocolpopexy. Am J Obstet Gynecol 2024:S0002-9378(24)00523-4. [PMID: 38642697 DOI: 10.1016/j.ajog.2024.04.017] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/31/2024] [Accepted: 04/11/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND The gold standard treatment for advanced pelvic organ prolapse is sacrocolpopexy. However, the pre-operative features of prolapse that predict optimal outcomes are unknown. OBJECTIVES We aimed to develop a clinical prediction model that uses pre-operative scores on the Pelvic Organ Prolapse Quantification examination to predict outcomes after minimally invasive sacrocolpopexy for stages 2, 3, and 4 uterovaginal prolapse and vaginal vault prolapse. STUDY DESIGN A two-institution database of pre- and post-operative variables from 881 cases of minimally invasive sacrocolpopexy was analyzed. Data from patients were analyzed in four groups: stage 2 uterovaginal prolapse, stage 3-4 uterovaginal prolapse, stage 2 vaginal vault prolapse, and stage 3-4 vaginal vault prolapse. Unsupervised machine learning was used to identify clusters and investigate associations between clusters and outcome. The K-means clustering analysis was performed with pre-operative Pelvic Organ Prolapse Quantification points and stratified by prior hysterectomy status. The "optimal" surgical outcome was defined as post-operative Pelvic Organ Prolapse Quantification stage <2. Demographic variables were compared by cluster with Student's t-test and Chi-squared tests. Odds ratios were calculated to determine whether clusters could predict the outcome. Age at surgery, body mass index, and prior prolapse surgery were used for adjusted odds ratios. RESULTS Five statistically distinct prolapse clusters (phenotypes C, A, A>P, P, and P>A) were found. These phenotypes reflected the predominant region of prolapse (apical, anterior, or posterior) and whether or not support was preserved in the non-predominant region. Phenotype A (anterior compartment prolapse predominant, posterior support preserved) was found in all four groups of patients and was considered the reference in analysis. In 111 patients with stage 2 uterovaginal prolapse, phenotypes A and A>P (greater anterior prolapse than posterior prolapse) were found, and patients with phenotype A were more likely than those with phenotype A>P to have an optimal surgical outcome. In 401 patients with stage 3-4 uterovaginal prolapse, phenotypes C (apical compartment predominant, prolapse in all compartments), A, and A>P were found, and patients with phenotype A>P were more likely than those with phenotype A to have ideal surgical outcome. In 72 patients with stage 2 vaginal vault prolapse, phenotypes A, A>P, and P (posterior compartment predominant, anterior support preserved) were found, and those with phenotype A>P were less likely to have an ideal outcome than patients with phenotype A. In 297 patients with stage 3-4 vaginal vault prolapse, phenotypes C, A, and P>A (prolapse greater in posterior compartment than in anterior) were found, but there were no significant differences in rate of ideal outcome between phenotypes. CONCLUSIONS Five anatomic phenotypes based on pre-operative Pelvic Organ Prolapse Quantification scores were present in patients with stages 2 and 3-4 uterovaginal prolapse and vaginal vault prolapse. These phenotypes are predictive of surgical outcome after minimally invasive sacrocolpopexy. Further work needs to confirm the presence and predictive nature of these phenotypes. Additionally, whether the phenotypes represent a progression of prolapse or discrete prolapse presentations resulting from different anatomic and life course risk profiles is unknown. These phenotypes may be useful in surgical counseling and planning.
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Affiliation(s)
- Jerry L Lowder
- St Louis, MO; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine
| | - Peinan Zhao
- St Louis, MO; Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine
| | - Megan Bradley
- Pittsburgh, PA; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School
| | - Lauren E Giugale
- Pittsburgh, PA; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine
| | - Haonan Xu
- St Louis, MO; Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine
| | - Steven Abramowitch
- Pittsburgh, PA; Departments of Bioengineering and Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School
| | - Phillip Bayly
- St Louis, MO; Department of Mechanical Engineering and Materials Science, Washington University in St Louis
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3
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Torosis M, Carey E, Christensen K, Kaufman MR, Kenton K, Kotarinos R, Lai HH, Lee U, Lowder JL, Meister M, Spitznagle T, Wright K, Ackerman AL. A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction. Obstet Gynecol 2024; 143:595-602. [PMID: 38387036 PMCID: PMC10953682 DOI: 10.1097/aog.0000000000005536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients. METHODS A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm. RESULTS A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. CONCLUSION A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.
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Affiliation(s)
- Michele Torosis
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Erin Carey
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Kristin Christensen
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Melissa R. Kaufman
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Kimberly Kenton
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Rhonda Kotarinos
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - H. Henry Lai
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Una Lee
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Jerry L. Lowder
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Melanie Meister
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Theresa Spitznagle
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - Kelly Wright
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
| | - A. Lenore Ackerman
- Department of Obstetrics and Gynecology and the Department of Urology, UCLA, and Cedars-Sinai Medical Center, Los Angeles, California; the Department of Obstetrics and Gynecology, UNC, Chapel Hill, North Carolina; the Department of Urology, Vanderbilt, Nashville, Tennessee; the Department of Obstetrics and Gynecology, University of Chicago, Chicago, and Kotarinos Physical Therapy, Lake Zurich, Illinois; Washington University in St. Louis, the Division of Urologic Surgery, Departments of Surgery and Anesthesiology, and the Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri; the Department of Urology, Virginia Mason, Seattle, Washington; and Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas
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4
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Barker ES, Chiu K, Brown VL, Morsy H, Yaeger LH, Catna A, Pakpahan R, Moldwin R, Shorter B, Lowder JL, Lai HH, Sutcliffe S. Urologic Chronic Pelvic Pain Syndrome Flares: A Comprehensive, Systematic Review and Meta-Analysis of the Peer-Reviewed Flare Literature. J Urol 2024; 211:341-353. [PMID: 38109700 PMCID: PMC11037930 DOI: 10.1097/ju.0000000000003820] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE We sought to systematically review and summarize the peer-reviewed literature on urologic chronic pelvic pain syndrome flares, including their terminology, manifestation, perceived triggers, management and prevention strategies, impact on quality of life, and insights into pathophysiologic mechanisms, as a foundation for future empirical research. MATERIALS AND METHODS We searched 6 medical databases for articles related to any aspect of symptom exacerbations for interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome. A total of 1486 abstracts and 398 full-text articles were reviewed, and data were extracted by at least 2 individuals. RESULTS Overall, we identified 59 articles, including 36 qualitative, cross-sectional, or case-control; 15 cohort-based; and 8 experimental articles. The majority of studies described North American patients with confirmed diagnoses. "Flare" was a commonly used term, but additional terminology (eg, exacerbation) was also used. Most flares involved significant increases in pain intensity, but less data were available on flare frequency and duration. Painful, frequent, long-lasting, and unpredictable flares were highly impactful, even over and above participants' nonflare symptoms. A large number of perceived triggers (eg, diet, stress) and management/prevention strategies (eg, analgesics, thermal therapy, rest) were proposed by participants, but few had empirical support. In addition, few studies explored underlying biologic mechanisms. CONCLUSIONS Overall, we found that flares are painful and impactful, but otherwise poorly understood in terms of manifestation (frequency and duration), triggers, treatment, prevention, and pathophysiology. These summary findings provide a foundation for future flare-related research and highlight gaps that warrant additional empirical studies.
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Affiliation(s)
- Emily S Barker
- Division of Complex Family Planning, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Kimberley Chiu
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Victoria L Brown
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Haidy Morsy
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
- Geisinger, Wilkes Barre, Pennsylvania
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, St Louis, Missouri
| | - Arya Catna
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ratna Pakpahan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Robert Moldwin
- The Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra-Northwell, Lake Success, New York
| | | | - Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - H Henry Lai
- Division of Urological Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Siobhan Sutcliffe
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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5
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Morsy H, Meister M, Spitznagle T, Scott C, Zhang T, Ghetti C, Chu C, Sutcliffe S, Lowder JL. A Pilot Randomized Controlled Trial of Vaginal Cryotherapy for the Treatment of Pelvic Floor Myofascial Pain. Int Urogynecol J 2024; 35:215-225. [PMID: 38133837 DOI: 10.1007/s00192-023-05692-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic floor myofascial pain (PFMP) is a common but underrecognized component of chronic pelvic pain and pelvic floor disorders symptoms with limited, well-studied treatment modalities. Our objective was to determine the effect of vaginal cryotherapy on PFMP with palpation. METHODS Following a standardized PFMP screening examination, individuals with a pain score ≥4/10 in ≥1 of four muscle groups were invited to participate in a randomized controlled trial comparing patients undergoing vaginal cryotherapy with controls. Participants in both arms could choose to participate in a single in-office treatment; a 2-week, at-home daily treatment; or both. RESULTS Between March 2019 and September 2021, a total of 163 participants were enrolled and randomized: 80 to cryotherapy, and 83 to the control group. Sixty-three (28 cryotherapy; 35 controls) completed in-office treatment and 56 (32 cryotherapy; 24 controls) completed at-home therapy. In the in-office comparison, mean pain scores decreased significantly in both arms: cryotherapy (5.13 vs 4.10; p=0.02) and controls (5.60 vs 4.72; p<0.01), with a similar magnitude of reduction between arms (p=0.75). In the at-home comparison, mean pain scores decreased significantly in the cryotherapy arm (6.34 vs 4.75; p<0.01), and nonsignificantly in the control arm (5.41 vs 4.66; p=0.07), resulting in a nonsignificant difference between arms (p=0.14). CONCLUSIONS Pelvic floor myofascial pain with palpation improved following both a single cryotherapy session and 2 weeks of daily cryotherapy. Interestingly, pain scores also improved with room temperature therapy. Whether these findings reflect a therapeutic effect of both cold and room temperature intravaginal therapy or a placebo effect is unclear but should be explored in larger studies.
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Affiliation(s)
- Haidy Morsy
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, MSC 8064-37-1005, 4901 Forest Park Avenue, COH, 10th Floor, St. Louis, MO, 63108, USA
- Geisinger, Wilkes Barre, PA, USA
| | - Melanie Meister
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Carter Scott
- Oregon Health Sciences University, Portland, OR, USA
| | - Tianyi Zhang
- Brown School, Washington University, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Sciences, Washington University, St. Louis, MO, USA
| | - Chiara Ghetti
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, MSC 8064-37-1005, 4901 Forest Park Avenue, COH, 10th Floor, St. Louis, MO, 63108, USA
| | - Christine Chu
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina at Chapel-Hill, Chapel Hill, NC, USA
| | - Siobhan Sutcliffe
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, MSC 8064-37-1005, 4901 Forest Park Avenue, COH, 10th Floor, St. Louis, MO, 63108, USA
- Department of Surgery, Division of Public Health Sciences, Washington University, St. Louis, MO, USA
| | - Jerry L Lowder
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, MSC 8064-37-1005, 4901 Forest Park Avenue, COH, 10th Floor, St. Louis, MO, 63108, USA.
- Department of Surgery, Division of Public Health Sciences, Washington University, St. Louis, MO, USA.
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Brown VL, James A, Hunleth J, Bradley CS, Farrar JT, Gupta P, Lai HH, Lowder JL, Moldwin R, Rodriguez LV, Yang CC, Sutcliffe S. Believing women: a qualitative exploration of provider disbelief and pain dismissal among women with interstitial cystitis/bladder pain syndrome from the MAPP research network. Int Urogynecol J 2024; 35:139-148. [PMID: 37991567 PMCID: PMC11019919 DOI: 10.1007/s00192-023-05677-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/10/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Although allusions to the importance of a good physician-patient relationship are present throughout the interstitial cystitis/bladder pain syndrome (IC/BPS) literature, qualitative analysis of patients' perspectives on the clinical encounter is lacking, particularly among women who are most commonly affected by IC/BPS. Therefore, we adopted a patient-centered experiential approach to understanding female patients' perception of clinical encounters. METHODS We re-analyzed previously collected data from a qualitative study on patient flare experiences including eight focus groups of female IC/BPS patients (n = 57, mean = 7/group). Qualitative analysis applied grounded theory to index all physician-patient interactions, then thematically coded these interactions to elucidate common experiences of clinical encounters. RESULTS Women with IC/BPS shared common experiences of provider disbelief and pain dismissal. Discussions with participants demonstrated the extent to which these negative encounters shape patients' health care-seeking behavior, outlook, and psychosocial well-being. Appearing in more than one guise, provider disbelief and dismissal occurred as tacit insinuations, explicit statements, silence, oversimplification, and an unwillingness to listen and discuss alternative treatment. As a result, women adopted several strategies including: rotating specialists; "testing" physicians; self-advocacy; self-management; avoiding the stigma of chronic pain; crying; and opting for alternative medicine over biomedicine. CONCLUSIONS The prevalence of provider disbelief and pain dismissal among women with IC/BPS indicates a need to improve physician-patient communication, informed by the struggles, anxieties, and gendered inequities that female patients with chronic pain experience in their diagnostic journey. Results suggest that further investigation into the power dynamics of clinical encounters might be required.
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Affiliation(s)
- Victoria L Brown
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Aimee James
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jean Hunleth
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jerry L Lowder
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert Moldwin
- The Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra-Northwell, Lake Success, NY, USA
| | | | - Claire C Yang
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Siobhan Sutcliffe
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
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Ackerman AL, Torosis M, Jackson NJ, Caron AT, Kaufman MR, Lowder JL, Routh JC. The Persistency Index: a novel screening tool for identifying myofascial pelvic floor dysfunction in patients seeking care for lower urinary tract symptoms. Am J Obstet Gynecol 2023; 229:667.e1-667.e11. [PMID: 37633575 PMCID: PMC11000817 DOI: 10.1016/j.ajog.2023.08.017] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Patients with myofascial pelvic floor dysfunction often present with lower urinary tract symptoms, such as urinary frequency, urgency, and bladder pressure. Often confused with other lower urinary tract disorders, this constellation of symptoms, recently termed myofascial urinary frequency syndrome, is distinct from other lower urinary tract symptoms and optimally responds to pelvic floor physical therapy. A detailed pelvic floor myofascial examination performed by a skilled provider is currently the only method to identify myofascial urinary frequency syndrome. Despite a high influence on quality of life, low awareness of this condition combined with no objective diagnostic testing leads to the frequent misdiagnosis or underdiagnosis of myofascial urinary frequency syndrome. OBJECTIVE This study aimed to develop a screening measure to identify patients with myofascial urinary frequency syndrome (bothersome lower urinary tract symptoms secondary to myofascial pelvic floor dysfunction) from patient-reported symptoms. STUDY DESIGN A population of patients with isolated myofascial urinary frequency syndrome was identified by provider diagnosis from a tertiary urology practice and verified by standardized pelvic floor myofascial examination and perineal surface pelvic floor electromyography. Least Angle Shrinkage and Selection Operator was used to identify candidate features from the Overactive Bladder Questionnaire, Female Genitourinary Pain Index, and Pelvic Floor Distress Index predictive of myofascial urinary frequency syndrome in a pooled population also containing subjects with overactive bladder (n=42), interstitial cystitis/bladder pain syndrome (n=51), and asymptomatic controls (n=54) (derivation cohort). A simple, summated score of the most discriminatory questions using the original scaling of the Pelvic Floor Distress Index 5 (0-4) and Genitourinary Pain Index 5 (0-5) and modified scaling of Female Genitourinary Pain Index 2b (0-3) had an area under the curve of 0.75. As myofascial urinary frequency syndrome was more prevalent in younger subjects, the inclusion of an age penalty (3 points added if under the age of 50 years) improved the area under the curve to 0.8. This score was defined as the Persistency Index (possible score of 0-15). The Youden Index was used to identify the optimal cut point Persistency Index score for maximizing sensitivity and specificity. RESULTS Using a development cohort of 215 subjects, the severity (Pelvic Floor Distress Index 5) and persistent nature (Female Genitourinary Pain Index 5) of the sensation of incomplete bladder emptying and dyspareunia (Female Genitourinary Pain Index 2b) were the most discriminatory characteristics of the myofascial urinary frequency syndrome group, which were combined with age to create the Persistency Index. The Persistency Index performed well in a validation cohort of 719 patients with various lower urinary tract symptoms, including overactive bladder (n=285), interstitial cystitis/bladder pain syndrome (n=53), myofascial urinary frequency syndrome (n=111), controls (n=209), and unknown diagnoses (n=61), exhibiting an area under the curve of 0.74. A Persistency Index score ≥7 accurately identified patients with myofascial urinary frequency syndrome from an unselected population of individuals with lower urinary tract symptoms with 80% sensitivity and 61% specificity. A combination of the Persistency Index with the previously defined Bladder Pain Composite Index and Urge Incontinence Composite Index separated a population of women seeking care for lower urinary tract symptoms into groups consistent with overactive bladder, interstitial cystitis/bladder pain syndrome, and myofascial urinary frequency syndrome phenotypes with an overall diagnostic accuracy of 82%. CONCLUSION Our study recommends a novel screening method for patients presenting with lower urinary tract symptoms to identify patients with myofascial urinary frequency syndrome. As telemedicine becomes more common, this index provides a way of screening for myofascial urinary frequency syndrome and initiating pelvic floor physical therapy even before a confirmatory pelvic examination.
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Affiliation(s)
- A Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA.
| | - Michele Torosis
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - Nicholas J Jackson
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - Ashley T Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Melissa R Kaufman
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Jonathan C Routh
- Division of Urologic Surgery, Department of Urology, Duke University School of Medicine, Durham, NC
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Ackerman AL, Jackson NJ, Caron AT, Kaufman MR, Routh JC, Lowder JL. Myofascial urinary frequency syndrome is a novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction. Sci Rep 2023; 13:18412. [PMID: 37891217 PMCID: PMC10611808 DOI: 10.1038/s41598-023-44862-5] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
This study describes a novel, distinct phenotype of urinary symptoms named "myofascial urinary frequency syndrome" (MUFS) present in one-third of individuals presenting with urinary frequency. In addition to a characteristic symptom constellation suggestive of myofascial dysfunction, MUFS subjects exhibit "persistency": a persistent feeling of needing to urinate regardless of urine volume. On examination, 97% of MUFS patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. To confirm this symptom pattern was attributable to the pelvic floor musculature, we confirmed the presence of "persistency" in 68 patients with pelvic floor myofascial dysfunction established through comprehensive examination and electromyography and corroborated by improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming MUFS is a distinct LUTS symptom complex.
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Affiliation(s)
- A Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Box 951738, Los Angeles, CA, 90095-1738, USA.
| | - Nicholas J Jackson
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ashley T Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Melissa R Kaufman
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, USA
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Hall EF, Biller DH, Buss JL, Ferzandi T, Halder GE, Muffly TM, Nickel KB, Nihira M, Olsen MA, Wallace SL, Lowder JL. Medium-Term Outcomes of Conservative and Surgical Treatments for Stress Urinary Incontinence: A Medicare Claims Analysis: Developed by the AUGS Payment Reform Committee. Urogynecology (Phila) 2023; 29:536-544. [PMID: 37235803 PMCID: PMC10468831 DOI: 10.1097/spv.0000000000001362] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE This study aimed to evaluate the 3- to 5-year retreatment outcomes for conservatively and surgically treated urinary incontinence (UI) in a population of women 66 years and older. METHODS This retrospective cohort study used 5% Medicare data to evaluate UI retreatment outcomes of women undergoing physical therapy (PT), pessary treatment, or sling surgery. The data set used inpatient, outpatient, and carrier claims from 2008 to 2016 in women 66 years and older with fee-for-service coverage. Treatment failure was defined as receiving another UI treatment (pessary, PT, sling, Burch urethropexy, or urethral bulking) or repeat sling. A secondary analysis was performed where additional treatment courses of PT or pessary were also considered a treatment failure. Survival analysis was used to evaluate the time from treatment initiation to retreatment. RESULTS Between 2008 and 2013, 13,417 women were included with an index UI treatment, and follow-up continued through 2016. In this cohort, 41.4% received pessary treatment, 31.8% received PT, and 26.8% underwent sling surgery. In the primary analysis, pessaries had the lowest treatment failure rate compared with PT (P<0.001) and sling surgery (P<0.001; survival probability, 0.94 [pessary], 0.90 [PT], 0.88 [sling]). In the analysis where retreatment with PT or a pessary was considered a failure, sling surgery had the lowest retreatment rate (survival probability, 0.58 [pessary], 0.81 [PT], 0.88 [sling]; P<0.001 for all comparisons). CONCLUSIONS In this administrative database analysis, there was a small but statistically significant difference in treatment failure among women undergoing sling surgery, PT, or pessary treatment, but pessary use was commonly associated with the need for repeat pessary fittings.
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Affiliation(s)
- Evelyn F Hall
- From the Department of Obstetrics and Gynecology, Tufts University, Boston, MA
| | - Daniel H Biller
- Division of Urogynecology, Department of OBGYN, Vanderbilt University Medical College, Nashville, TN
| | - Joanna L Buss
- Institute for Informatics, Washington University School of Medicine, St Louis, MO
| | - Tanaz Ferzandi
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Keck School of Medicine at University of Southern California, Los Angeles, CA
| | - Gabriela E Halder
- Division of Urogynecology, Department of OBGYN, University of Texas Medical Branch, Galveston, TX
| | - Tyler M Muffly
- Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO
| | - Katelin B Nickel
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St Louis, St Louis, MO
| | - Mikio Nihira
- KPC Healthcare, UC Riverside School of Medicine, Riverside, CA
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St Louis, St Louis, MO
| | - Shannon L Wallace
- Division of Urogynecology, Subspecialty Care for Women's Health, Cleveland Clinic, Cleveland, OH
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO
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Fitzgerald CM, Fok C, Kenton K, Lukacz E, Markland AD, Meister M, Newman DK, Rudser K, Smith EG, Wyman JF, Lowder JL. The RISE FOR HEALTH study: Methods for in-person musculoskeletal assessment. Neurourol Urodyn 2023; 42:1022-1035. [PMID: 36403285 PMCID: PMC10236941 DOI: 10.1002/nau.25086] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To describe the methods for the in-person musculoskeletal (MSK) assessment of the RISE FOR HEALTH (RISE) study, a population-based multicenter prospective cohort study designed to identify factors associated with bladder health (BH) conducted by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). METHODS A subset of RISE participants who express interest in the in-person assessment are screened to ensure eligibility (planned n = 525). Eligible consenting participants are asked to complete a standardized MSK assessment to evaluate core stability (four component core stability test, lumbar spine pain (seated slump test), pelvic girdle pain, (sacroiliac joint, anterior superior iliac spine, pubic symphysis tenderness, and pelvic girdle pain provocation test), hip pain (flexion, abduction, internal rotation and flexion, adduction and external rotation) and pelvic girdle function (active straight leg raise). Participants are also asked to complete the Short Physical Performance Battery to measure balance, gait speed, lower extremity strength, and functional capacity. RESULTS Detailed online and in-person MSK training sessions led by physical therapy were used to certify research staff at each clinical center before the start of RISE in-person assessments. All evaluators exceeded the pre-specified pass rates. CONCLUSIONS The RISE in-person MSK assessment will provide further insight into the role of general body MSK health and dysfunction and the spectrum of BH.
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Affiliation(s)
- Colleen M. Fitzgerald
- Department of Obstetrics, Gynecology and Urology, Loyola University Chicago, Chicago, IL
| | - Cynthia Fok
- Department of Urology, University of Minnesota, Minneapolis MN
| | - Kim Kenton
- Department of Obstetrics and Gynecology, Northwestern University, Chicago IL
| | - Emily Lukacz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego School of Medicine, University of California San Diego, La Jolla, California
| | - Alayne D. Markland
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care at the University of Alabama at Birmingham, Birmingham, AL
| | - Melanie Meister
- Department of Obstetrics and Gynecology, The University of Kansas, Kansas City, KS
| | - Diane K. Newman
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kyle Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis MN
| | - Elia Gomez Smith
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego School of Medicine, University of California San Diego, La Jolla, California
| | - Jean F. Wyman
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Jerry L. Lowder
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
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Ligon MM, Liang B, Lenger SM, Parameswaran P, Sutcliffe S, Lowder JL, Mysorekar IU. Bladder Mucosal Cystitis Cystica Lesions Are Tertiary Lymphoid Tissues That Correlate With Recurrent Urinary Tract Infection Frequency in Postmenopausal Women. J Urol 2023; 209:928-936. [PMID: 36715657 DOI: 10.1097/ju.0000000000003196] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 01/19/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE We identify correlates and clinical outcomes of cystitis cystica, a poorly understood chronic inflammatory bladder change, in women with recurrent urinary tract infections. MATERIALS AND METHODS A retrospective, observational cohort of women with recurrent urinary tract infections who underwent cystoscopy (n=138) from 2015 to 2018 were identified using electronic medical records. Cystitis cystica status was abstracted from cystoscopy reports and correlations were identified by logistic regression. Urinary tract infection-free survival time associated with cystitis cystica was evaluated by Cox proportional hazards regression. Exact logistic regression was used to identify factors associated with changes to cystitis cystica lesions on repeat cystoscopy. Biopsies of cystitis cystica lesions were examined by routine histology and immunofluorescence. RESULTS Fifty-three patients (38%) had cystitis cystica on cystoscopy. Cystitis cystica was associated with postmenopausal status (OR: 5.53, 95% CI: 1.39-37.21), pelvic floor myofascial pain (6.82, 1.78-45.04), having ≥4 urinary tract infections in the past year (2.28, 1.04-5.09), and a shorter time to next urinary tract infection (HR: 1.54, 95% CI: 1.01-2.35). Forty-two patients (82%) demonstrated improvement or resolution of lesions. Ten/11 (91%) biopsied cystitis cystica lesions were tertiary lymphoid tissue with germinal centers and resembled follicular cystitis. CONCLUSIONS Cystitis cystica lesions were associated with postmenopausal status, pelvic floor myofascial pain, and number of urinary tract infections in the prior year and predicted worse recurrent urinary tract infection outcomes. Cystitis cystica lesions are tertiary lymphoid tissue/follicular cystitis that may improve or resolve over time with treatment. Identifying cystitis cystica in recurrent urinary tract infection patients may be useful in informing future urinary tract infection risk and tailoring appropriate treatment strategies.
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Affiliation(s)
- Marianne M Ligon
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Brooke Liang
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Stacy M Lenger
- Department of Obstetrics & Gynecology and Women's Health, University of Louisville School of Medicine, Louisville, Kentucky
| | - Priyanka Parameswaran
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Siobhan Sutcliffe
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Jerry L Lowder
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Indira U Mysorekar
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
- Department of Medicine, Section of Infectious Diseases and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
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12
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Meister MRL, Osazuwa-Peters OL, Lowder JL, Handa VL. Transition to surgery after pessary among female Medicare beneficiaries with pelvic organ prolapse. Am J Obstet Gynecol 2023; 228:559.e1-559.e9. [PMID: 36627074 PMCID: PMC10149554 DOI: 10.1016/j.ajog.2023.01.006] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists recommends offering a vaginal pessary to women seeking treatment of pelvic organ prolapse. However, single-institution series have suggested that a sizable proportion of women fitted with a pessary will transition to surgery within the first year. OBJECTIVE This study aimed to estimate the proportion of female US Medicare beneficiaries with pelvic organ prolapse who undergo surgery after pessary fitting, to describe the median time to surgery from pessary fitting, and to identify factors associated with the transition from pessary to surgery. STUDY DESIGN The Medicare 5% Limited Data Set was queried from 2011 to 2016 for women aged ≥65 years with a diagnosis of prolapse who underwent pessary fitting. Cases with at least 3 years of follow-up in the Medicare Data Set were followed longitudinally for the primary outcome of surgery for prolapse. The cumulative incidence of prolapse surgery following index pessary fitting was calculated. Characteristics of women who underwent surgery and those who did not were compared using time-varying Cox regression analysis. RESULTS Among 2032 women fitted with a pessary, 608 underwent surgery within 7 years. The median time to surgery was 496 days (interquartile range, 187-1089 days). The cumulative incidence of prolapse surgery was 12.2% at 1 year and 30.9% at 7 years. After adjusting for covariates, factors significantly associated with the transition to surgery included previous prolapse surgery (adjusted hazard ratio, 1.50; 1.09-2.07) and a diagnosis of urinary incontinence at the time of pessary fitting (adjusted hazard ratio, 1.20; 0.62-0.99). Factors associated with a lower hazard of surgery included age (adjusted hazard ratio, 0.96 per year; 95% confidence interval, 0.95-0.97), dual Medicare/Medicaid eligibility (adjusted hazard ratio, 0.75; 95% confidence interval, 0.56-1.00), and pessary fitting by a nongynecologist (adjusted hazard ratio, 0.78; 95% confidence interval, 0.62-0.99). CONCLUSION In this population of Medicare beneficiaries, within 7 years of pessary fitting, almost one-third of women aged >65 years underwent surgery for prolapse. These results add to our current understanding of the demographics of pessary use in an older population and may aid in counseling older patients presenting for treatment of symptomatic pelvic organ prolapse.
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Affiliation(s)
- Melanie R L Meister
- Department of Obstetrics and Gynecology, The University of Kansas, Kansas City, KS.
| | | | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
| | - Victoria L Handa
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
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13
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Constantine ML, Rockwood TH, Rickey LM, Bavendam T, Low LK, Lowder JL, Markland AD, McGwin G, Mueller ER, Newman DK, Putnam S, Rudser K, Smith AL, Stapleton AE, Miller JM, Lukacz ES. Validation of bladder health scales and function indices for women's research. Am J Obstet Gynecol 2023; 228:566.e1-566.e14. [PMID: 36596439 PMCID: PMC10425263 DOI: 10.1016/j.ajog.2022.12.319] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Existing bladder-specific measures lack the ability to assess the full range of bladder health, from poor to optimal health. OBJECTIVE This study aimed to report evidence of validity of the self-administered, multidimensional bladder health scales and function indices for research in adult women. STUDY DESIGN A cross-sectional population-based validation study with random assignment to paper or electronic administration was conducted using national address-based probability sampling supplemented by purposive sampling of women with lower urinary tract symptoms in 7 clinical research centers. Construct validity of the bladder health scales and function indices was guided by a multitrait-multimethod approach using health and condition-specific questionnaires, bladder diaries, expert ratings of bladder health, and noninvasive bladder function testing. Internal dimensional validity was evaluated using factor analysis; internal reliability was assessed using paired t-tests and 2-way mixed-effects intraclass correlation coefficient models. Chi-square, Fisher exact, or t-tests were used for mode comparisons. Convergent validity was evaluated using Pearson correlations with the external construct measures, and known-group validity was established with comparison of women known and unknown to be symptomatic of urinary conditions. RESULTS The sample included 1072 participants. Factor analysis identified 10 scales, with Cronbach's alpha ranging from 0.74 to 0.94. Intraclass correlation coefficients of scales ranged from 0.55 to 0.94. Convergent validity of the 10 scales and 6 indices ranged from 0.52 to 0.83. Known-group validity was confirmed for all scales and indices. Item distribution was similar by mode of administration. CONCLUSION The paper and electronic forms of the bladder health scales and function indices are reliable and valid measures of bladder health for use in women's health research.
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Affiliation(s)
- Melissa L Constantine
- Division of Biostatistics, University of Minnesota, Minneapolis, MN; Patient Centered Research, Evidera, Bethesda, MD.
| | - Todd H Rockwood
- Department of Health Policy, University of Minnesota, Minneapolis, MN
| | - Leslie M Rickey
- Departments of Urology and Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Tamara Bavendam
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, MI
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Alayne D Markland
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Gerald McGwin
- School of Public Health, The University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth R Mueller
- Departments of Urology and Obstetrics and Gynecology, Loyola University Medical Center, Loyola University Chicago, Chicago, IL
| | - Diane K Newman
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sara Putnam
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Kyle Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Ariana L Smith
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann E Stapleton
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Janis M Miller
- School of Nursing, University of Michigan, Ann Arbor, MI
| | - Emily S Lukacz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, La Jolla, CA.
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Ackerman AL, Jackson NJ, Caron AT, Kaufman MR, Routh JC, Lowder JL. Myofascial Frequency Syndrome: A novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction. medRxiv 2023:2023.04.14.23288590. [PMID: 37131628 PMCID: PMC10153318 DOI: 10.1101/2023.04.14.23288590] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Patients presenting with lower urinary tract symptoms (LUTS) are historically classified to several symptom clusters, primarily overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). Accurate diagnosis, however, is challenging due to overlapping symptomatic features, and many patients do not readily fit into these categories. To enhance diagnostic accuracy, we previously described an algorithm differentiating OAB from IC/BPS. Herein, we sought to validate the utility of this algorithm for identifying and classifying a real-world population of individuals presenting with OAB and IC/BPS and characterize patient subgroups outside the traditional LUTS diagnostic paradigm. Methods An Exploratory cohort of 551 consecutive female subjects with LUTS evaluated in 2017 were administered 5 validated genitourinary symptom questionnaires. Application of the LUTS diagnostic algorithm classified subjects into controls, IC/BPS, and OAB, with identification of a novel group of highly bothered subjects lacking pain or incontinence. Symptomatic features of this group were characterized by statistically significant differences from the OAB, IC/BPS and control groups on questionnaires, comprehensive review of discriminate pelvic exam, and thematic analysis of patient histories. In a Reassessment cohort of 215 subjects with known etiologies of their symptoms (OAB, IC/BPS, asymptomatic microscopic hematuria, or myofascial dysfunction confirmed with electromyography), significant associations with myofascial dysfunction were identified in a multivariable regression model. Pre-referral and specialist diagnoses for subjects with myofascial dysfunction were catalogued. Findings Application of a diagnostic algorithm to an unselected group of 551subjects presenting for urologic care identified OAB and IC/BPS in 137 and 96 subjects, respectively. An additional 110 patients (20%) with bothersome urinary symptoms lacked either bladder pain or urgency characteristic of IC/BPS and OAB, respectively. In addition to urinary frequency, this population exhibited a distinctive symptom constellation suggestive of myofascial dysfunction characterized as "persistency": bothersome urinary frequency resulting from bladder discomfort/pelvic pressure conveying a sensation of bladder fullness and a desire to urinate. On examination, 97% of persistency patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. We therefore classified this symptom complex "myofascial frequency syndrome". To confirm this symptom pattern was attributable to the pelvic floor, we confirmed the presence of "persistency" in 68 patients established to have pelvic floor myofascial dysfunction through comprehensive evaluation corroborated by symptom improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming that myofascial frequency syndrome is a distinct LUTS symptom complex. Interpretation This study describes a novel, distinct phenotype of LUTS we classified as myofascial frequency syndrome in approximately one-third of individuals with urinary frequency. Common symptomatic features encompass elements in other urinary syndromes, such as bladder discomfort, urinary frequency and urge, pelvic pressure, and a sensation of incomplete emptying, causing significant diagnostic confusion for providers. Inadequate recognition of myofascial frequency syndrome may partially explain suboptimal overall treatment outcomes for women with LUTS. Recognition of the distinct symptom features of MFS (persistency) should prompt referral to pelvic floor physical therapy. To improve our understanding and management of this as-yet understudied condition, future studies will need to develop consensus diagnostic criteria and objective tools to assess pelvic floor muscle fitness, ultimately leading to corresponding diagnostic codes. Funding This work was supported by the AUGS/Duke UrogynCREST Program (R25HD094667 (NICHD)) and by NIDDK K08 DK118176 and Department of Defense PRMRP PR200027, and NIA R03 AG067993.
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Affiliation(s)
- A. Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Nicholas J. Jackson
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Ashley T. Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Melissa R. Kaufman
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan C. Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC
| | - Jerry L. Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
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15
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Tuuli MG, Gregory WT, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita ATN, Macones GA, Cahill AG, Richter HE. Effect of Second-Stage Pushing Timing on Postpartum Pelvic Floor Morbidity: A Randomized Controlled Trial. Obstet Gynecol 2023; 141:245-252. [PMID: 36603202 DOI: 10.1097/aog.0000000000005031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/07/2022] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Methodius G Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, and Women & Infants Hospital of Rhode Island, Providence, Rhode Island; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; the Department of Obstetrics and Gynecology and the Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; the Department of Obstetrics and Gynecology and the Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, Texas
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Newman DK, Lowder JL, Meister M, Low LK, Fitzgerald CM, Fok CS, Geynisman-Tan J, Lukacz ES, Markland A, Putnam S, Rudser K, Smith AL, Miller JM. Comprehensive pelvic muscle assessment: Developing and testing a dual e-Learning and simulation-based training program. Neurourol Urodyn 2023. [PMID: 36626146 DOI: 10.1002/nau.25125] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/04/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium launched the RISE FOR HEALTH (RISE) national study of women's bladder health which includes annual surveys and an in-person visit. For the in-person exam, a standardized, replicable approach to conducting a pelvic muscle (PM) assessment was necessary. The process used to develop the training, the products, and group testing results from the education and training are described. METHODS A comprehensive pelvic muscle assessment (CPMA) program was informed by literature view and expert opinion. Training materials were prepared for use on an electronicLearning (e-Learning) platform. An in-person hands-on simulation and certification session was then designed. It included a performance checklist assessment for use by Clinical Trainers, who in collaboration with a gynecology teaching assistant, provided an audit and feedback process to determine Trainee competency. RESULTS Five discrete components for CPMA training were developed as e-Learning modules. These were: (1) overview of all the clinical measures and PM anatomy and examination assessments, (2) visual assessment for pronounced pelvic organ prolapse, (3) palpatory assessment of the pubovisceral muscle to estimate muscle integrity, (4) digital vaginal assessment to estimate strength, duration, symmetry during PM contraction, and (5) pressure palpation of both myofascial structures and PMs to assess for self-report of pain. Seventeen Trainees completed the full CPMA training, all successfully meeting the a priori certification required pass rate of 85% on checklist assessment. CONCLUSIONS The RISE CPMA training program was successfully conducted to assure standardization of the PM assessment across the PLUS multicenter research sites. This approach can be used by researchers and healthcare professionals who desire a standardized approach to assess competency when performing this CPMA in the clinical or research setting.
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Affiliation(s)
- Diane K Newman
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Melanie Meister
- Department of Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas, USA
| | - Lisa K Low
- School of Nursing, University of Michigan, Ann Arbor Michigan, USA
| | - Colleen M Fitzgerald
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois, USA
| | - Cynthia S Fok
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Julia Geynisman-Tan
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Emily S Lukacz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alayne Markland
- Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, Alabama, USA
| | - Sara Putnam
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kyle Rudser
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ariana L Smith
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Janis M Miller
- School of Nursing, University of Michigan, Ann Arbor Michigan, USA
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Saucedo AM, Richter HE, Gregory WT, Woolfolk C, Tuuli MG, Lowder JL, Caughey AB, Srinivas SK, Tita ATN, Macones GA, Cahill AG. Intrapartum risk factors associated with pelvic organ prolapse at 6 months postpartum. Am J Obstet Gynecol MFM 2022; 4:100692. [PMID: 35853583 DOI: 10.1016/j.ajogmf.2022.100692] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pregnancy and childbirth are known risk factors associated with the development of pelvic organ prolapse; specific intrapartum risk factors are not well characterized. OBJECTIVE This study aimed to determine intrapartum factors associated with increased risk of pelvic organ prolapse identified after delivery. STUDY DESIGN A planned secondary analysis of a multicenter randomized clinical trial of delayed vs immediate pushing among nulliparous women at ≥37 weeks of gestation in labor with neuraxial analgesia was conducted at 6 academic and community hospitals in the United States. Intrapartum characteristics were identified, and Pelvic Organ Prolapse Quantification assessments at 6 weeks and 6 months after delivery were performed. The primary outcome was pelvic organ prolapse, defined as stage 2 or greater prolapse using the Pelvic Organ Prolapse Quantification assessment at 6 months. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, macrosomia, and maternal age. RESULTS Among the 941 women participating in the pelvic floor follow-up, 793 women had Pelvic Organ Prolapse Quantification assessments at 6 weeks with 91 of 793 women (11.5%) demonstrating stage 2 or greater prolapse. Of the 728 women followed up at 6 months, stage 2 or greater prolapse was identified in 58 of 728 women (8.0%). Prostaglandin use for induction of labor was associated with an increased risk at 6 months (adjusted odds ratio, 2.15; 95% confidence interval, 1.18-3.91; P<.01). The length and type (spontaneous vs induced) of the first stage of labor were not significantly associated with stage 2 or greater prolapse. Moreover, increased length of the second stage of labor and duration of pushing were not associated with stage 2 or greater prolapse. After adjusting for confounding factors, cesarean delivery was protective of pelvic organ prolapse at 6 months (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.90). CONCLUSION The management of the first and second stages of labor, including time length, was not associated with stage 2 or greater prolapse at 6 months. The findings that prostaglandin exposure was associated with increased risk likely were not directly affecting the risk of prolapse but may be surrogates for other labor features that deserve exploration. Cesarean delivery was associated with protection from stage 2 or greater pelvic organ prolapse at 6 months, consistent with previous literature.
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Gregory WT, Cahill AG, Woolfolk C, Lowder JL, Caughey AB, Srinivas SK, Tita AT, Tuuli MG, Richter HE. Impact of pushing timing on occult injury of levator ani: secondary analysis of a randomized trial. Am J Obstet Gynecol 2022; 226:718.e1-718.e10. [PMID: 35202591 PMCID: PMC9064971 DOI: 10.1016/j.ajog.2022.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Evidence of detachment of the levator ani muscle system is seen more frequently in patients with pelvic floor disorders. It has been suggested that passive descent of the fetus before pushing could be used to decrease operative vaginal delivery and levator ani muscle injury. OBJECTIVE This planned analysis aimed to determine whether immediate or delayed pushing was associated with an increased proportion of injury to the levator ani muscle system after the first delivery among nulliparous women. STUDY DESIGN The Optimizing Management of the Second Stage study was a multicenter randomized trial. Nulliparous women with term pregnancies and neuraxial analgesia were randomly assigned at complete cervical dilation to either immediate pushing or delayed pushing for 1 hour. A subset of participants consented to longitudinal objective pelvic floor assessments: (1) during postpartum stay (initial), (2) at 6 weeks (postpartum 1), and (3) at 6 months (postpartum 2) with transperineal 3-dimensional ultrasound. Following the completion of all visits by all subjects, saved 3-dimensional ultrasound volumes were assessed in a masked fashion. The outcome was "occult" levator ani muscle injury on the right or left, defined as a widening of the attachment of the levator ani to its origin utilizing the levator-urethra gap measurement. Measurements and proportions were compared between the 2 groups by study visit using the χ2 test or Fisher exact test for categorical variables and the t test or Mann-Whitney U test for continuous variables as appropriate. RESULTS Here, 941 of 2414 randomized subjects (39.0%) participated in the pelvic floor assessments: 452 in the immediate pushing group and 489 in the delayed pushing group. We obtained sonograms on 67%, 83%, and 77% of the pelvic floor assessment participants at the initial, postpartum 1, and postpartum-2 visits, respectively. Demographic and labor characteristics were comparable between the 2 groups; 94% of participants were non-Hispanic, and 50% of participants were Black. Levator ani muscle injury was noted in 77 participants (13.6%) at the initial visit, 99 (13.1%) at PP1, and 72 (10.6%) at PP2. There was no difference in injury between women in the immediate pushing group and women in the delayed pushing group. These findings did not change when the threshold (sensitivity) of levator ani muscle injury was adjusted to a less conservative measure. CONCLUSION Among nulliparous women at term with neuraxial analgesia, the rates of occult levator ani muscle injury were not different between women undergoing immediate pushing and women undergoing delayed pushing in the second stage of labor. Further research efforts are needed to understand the development and potential prevention of subsequent pelvic floor disorders.
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Foster SN, Spitznagle TM, Tuttle LJ, Lowder JL, Sutcliffe S, Steger-May K, Ghetti C, Wang J, Burlis T, Meister MR, Mueller MJ, Harris-Hayes M. Pelvic Floor Mobility measured by Transperineal Ultrasound Imaging in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms. J Womens Health Phys Therap 2022; 46:100-108. [PMID: 35757164 PMCID: PMC9216208 DOI: 10.1097/jwh.0000000000000224] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Women with urgency/frequency predominant lower urinary tract symptoms (UF-LUTS) may have elevated pelvic floor muscle (PFM) position at rest and limited mobility with PFM contraction and bearing down, but this has not been quantified. OBJECTIVES To compare PFM position and mobility using transperineal ultrasound (TPUS) at rest, maximal PFM contraction (perineal elevation), and bearing down (perineal descent) in women with and without UF-LUTS. We hypothesized that women with UF-LUTS would demonstrate elevated resting position and decreased excursion of pelvic landmarks during contraction and bearing down as compared to women without UF-LUTS. STUDY DESIGN Case-control study. METHODS Women with UF-LUTS were matched 1:1 on age, body mass index and vaginal parity to women without UF-LUTS. TPUS videos were obtained during 3 conditions: rest, PFM contraction, and bearing down. Levator plate angle (LPA) and puborectalis length (PR length), were measured for each condition. Paired t-tests or Wilcoxon signed rank tests compared LPA and PR length between cases and controls. RESULTS 21 case-control pairs (42 women): Women with UF-LUTS demonstrated greater LPA at rest (66.8 ± 13.2 degrees vs 54.9 ± 9.8 degrees; P=0.006), and less PR lengthening from rest to bearing down (0.2 ± 3.1 mm vs 2.1 ± 2.9 mm; P=.03). CONCLUSION Women with UF-LUTS demonstrated more elevated (cranioventral) position of the PFM at rest and less PR muscle lengthening with bearing down. These findings highlight the importance of a comprehensive PFM examination and possible treatment for women with UF-LUTS to include PFM position and mobility.
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Affiliation(s)
- Stefanie N Foster
- Program in Physical Therapy, Washington University in St. Louis, St Louis, MO
| | - Theresa M Spitznagle
- Program in Physical Therapy, Washington University in St. Louis, St Louis, MO
- Department Obstetrics and Gynecology, Washington University in St. Louis, St Louis, MO
| | - Lori J Tuttle
- Doctor of Physical Therapy Program, San Diego State University, San Diego, CA
| | - Jerry L Lowder
- Department Obstetrics and Gynecology, Washington University in St. Louis, St Louis, MO
- Division of Female Pelvic Medicine & Reconstructive Surgery, Washington University in St. Louis, St Louis, MO
| | - Siobhan Sutcliffe
- Department of Surgery, Washington University in St. Louis, St Louis, MO
- Department Obstetrics and Gynecology, Washington University in St. Louis, St Louis, MO
| | - Karen Steger-May
- Division of Biostatistics, Washington University in St. Louis, St Louis, MO
| | - Chiara Ghetti
- Department Obstetrics and Gynecology, Washington University in St. Louis, St Louis, MO
- Division of Female Pelvic Medicine & Reconstructive Surgery, Washington University in St. Louis, St Louis, MO
| | - Jinli Wang
- Division of Biostatistics, Washington University in St. Louis, St Louis, MO
| | - Taylor Burlis
- Program in Physical Therapy, Washington University in St. Louis, St Louis, MO
| | - Melanie R Meister
- Department Obstetrics and Gynecology, Washington University in St. Louis, St Louis, MO
- Division of Female Pelvic Medicine & Reconstructive Surgery, Washington University in St. Louis, St Louis, MO
| | - Michael J Mueller
- Program in Physical Therapy, Washington University in St. Louis, St Louis, MO
- Department of Radiology, Washington University in St. Louis, St Louis, MO
| | - Marcie Harris-Hayes
- Program in Physical Therapy, Washington University in St. Louis, St Louis, MO
- Department Orthopedic Surgery, Washington University in St. Louis, St Louis, MO
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Gregory T, Cahill AG, Woolfolk C, Arya LA, Lowder JL, Caughey AB, Srinivas SK, Tita AT, Tuuli MG, Richter HE. Impact of Pushing Timing on Occult Injury of Levator Ani: a Multicenter Randomized Controlled Trial. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.151] [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: 11/17/2022]
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21
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Gregory T, Cahill AG, Woolfolk C, Arya LA, Lowder JL, Caughey AB, Srinivas SK, Tita AT, Tuuli MG, Richter HE. Association of lower degree perineal lacerations at delivery and occult injury of levator ani muscles. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.570] [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: 11/24/2022]
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Saucedo AM, Tuuli MG, Gregory T, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita AT, Macones GA, Richter HE, Cahill AG. Intrapartum Risk Factors for Pelvic Organ Prolapse Postpartum. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.423] [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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Lenger SM, Chu CM, Ghetti C, Hardi AC, Lai HH, Pakpahan R, Lowder JL, Sutcliffe S. Adult female urinary incontinence guidelines: a systematic review of evaluation guidelines across clinical specialties. Int Urogynecol J 2021; 32:2671-2691. [PMID: 33881602 DOI: 10.1007/s00192-021-04777-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/01/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To systematically review evaluation guidelines of uncomplicated urinary incontinence (UI) in community-dwelling adult women to assess guidance available to the full range of providers treating UI. METHODS Systematic literature search of eight bibliographic databases. We included UI evaluation guidelines written for medical providers in English after January 1, 2008. EXCLUSION CRITERIA guidelines for children, men, institutionalized women, peripartum- and neurologic-related UI. A quantitative scoring system included assessed components and associated recommendation level and clarity. RESULTS Twenty-two guidelines met the criteria. All guidelines included: history taking, UI characterization, physical examination (PE) performance, urinalysis, and post-void residual volume assessment. At least 75% included medical and surgical history assessment, other disease process exclusion, medication review, impact on quality of life ascertainment, observing stress UI, mental status assessment, performing a pelvic examination, urine culture, bladder diary, and limiting more invasive diagnostics procedures. Fifty to 75% included other important evaluation components (i.e., assessing obstetric history, bowel symptoms, fluid intake, patient expectations/preferences/values, obesity, physical functioning/mobility, other PE [abdominal, rectal, pelvic muscle, and neurologic], urethral hypermobility, and pad testing. Less than 50% of guidelines included discussing patient treatment goals. Guidelines varied in level of detail and clarity, with several instances of unclear or inconsistent recommendations within the same guideline and evaluation components identified only by inference from treatment recommendations. Non-specialty guidelines reported fewer components with a lesser degree of clarity, but this difference was not statistically significant (p = 0.20). CONCLUSIONS UI evaluation guidelines varied in level of comprehensiveness, detail, and clarity. This variability may lead to inconsistent evaluations in the work-up of UI, contributing to missed opportunities for individualized care.
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Affiliation(s)
- Stacy M Lenger
- Department of Obstetrics, Gynecology, and Women's Health, Division of Female Pelvic Medicine and Reconstructive Surgery, The University of Louisville School of Medicine, Louisville, KY, USA.,Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA
| | - Christine M Chu
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA
| | - Chiara Ghetti
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA
| | - Angela C Hardi
- Washington University School of Medicine, Becker Medical Library, St. Louis, MO, USA
| | - H Henry Lai
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ratna Pakpahan
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA.
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Lukacz ES, Constantine ML, Kane Low L, Lowder JL, Markland AD, Mueller ER, Newman DK, Rickey LM, Rockwood T, Rudser K. Rationale and design of the validation of bladder health instrument for evaluation in women (VIEW) protocol. BMC Womens Health 2021; 21:18. [PMID: 33413284 PMCID: PMC7789348 DOI: 10.1186/s12905-020-01136-w] [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] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/24/2020] [Indexed: 12/04/2022]
Abstract
Background Bladder health is an understudied state and difficult to measure due to lack of valid and reliable instruments. While condition specific questionnaires assess presence, severity and degree of bother from lower urinary tract symptoms, the absence of symptoms is insufficient to assume bladder health. This study describes the methodology used to validate a novel bladder health instrument to measure the spectrum of bladder health from very healthy to very unhealthy in population based and clinical research.
Methods Three samples of women are being recruited: a sample from a nationally representative general population and two locally recruited clinical center samples—women with a targeted range of symptom severity and type, and a postpartum group. The general population sample includes 694 women, 18 years or older, randomly selected from a US Postal delivery sequence file. Participants are randomly assigned to electronic or paper versions of the bladder health instrument along with a battery of criterion questionnaires and a demographic survey; followed by a retest or a two-day voiding symptom diary. A total of 354 women around 7 clinical centers are being recruited across a spectrum of self-reported symptoms and randomized to mode of completion. They complete the two-day voiding symptom diary as well as a one-day frequency volume diary prior to an in-person evaluation with a standardized cough stress test, non-invasive urine flowmetry, chemical urine analysis and post void residual measurement. Independent judge ratings of bladder health are obtained by interview with a qualified health care provider. A total of 154 postpartum women recruited around 6 of the centers are completing similar assessments within 6–12 weeks postpartum. Dimensional validity will be evaluated using factor analysis and principal components analysis with varimax rotation, and internal consistency with Cronbach’s alpha. Criterion validity will be assessed using multitrait-multimethod matrix including correlations across multiple data sources and multiple types of measures. Discussion We aim to validate a bladder health instrument to measure the degree of bladder health within the general population and among women (including postpartum) recruited from local clinical centers.
Trial registration NCT04016298 Posted July 11, 2019 (https://www.clinicaltrials.gov/ct2/show/NCT04016298?cond=bladder+health&draw=2&rank=1).
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Affiliation(s)
- Emily S Lukacz
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of California San Diego, San Diego, CA, USA. .,Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego Health, 9500 Gilman Dr. #0971, La Jolla, CA, 92093, USA.
| | | | - Lisa Kane Low
- Practice and Professional Graduate Programs, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama At Birmingham, Birmingham, AL, USA.,Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham, AL, USA
| | - Elizabeth R Mueller
- Division of Female Pelvic Medicine and Reconstructive Surgery, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leslie M Rickey
- Departments of Urology and Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT, USA
| | - Todd Rockwood
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Kyle Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
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Meister MR, Brubaker A, Sutcliffe S, Lowder JL. Effectiveness of Botulinum Toxin for Treatment of Symptomatic Pelvic Floor Myofascial Pain in Women: A Systematic Review and Meta-analysis. Female Pelvic Med Reconstr Surg 2021; 27:e152-e160. [PMID: 32301801 PMCID: PMC7793632 DOI: 10.1097/spv.0000000000000870] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aims of the study were to systematically review the literature and to synthesize the evidence for the effectiveness of botulinum toxin injection to the pelvic floor muscles for treating pelvic floor myofascial pain in female patients. METHODS This systematic literature search was performed in February 2018 and updated in September 2019. Articles were screened based on predefined criteria: (1) adult population, (2) female patients, (3) treatment of pelvic pain by transvaginal botulinum toxin injection into the pelvic floor, (4) published in English or English translation available, (5) study design including randomized controlled trials, cohort studies, and case series with more than 10 participants, and (6) quantitative report of pain scores. Nine studies were included in the primary analysis, and an unpublished study was included in a sensitivity analysis. A random effects model with robust variance estimation was used to estimate the pooled mean difference in patient-reported pain scores after botulinum toxin injection. RESULTS A statistically significant reduction in patient-reported pain scores was noted at 6 weeks after botulinum toxin injection (mean difference, 20.3; 95% confidence interval, 11.7-28.9) and continued past 12 weeks (mean difference, 19.4; 95% confidence interval, 14.6-24.2). Significant improvement was noted in secondary outcomes including dyspareunia, dyschezia, and quality of life. CONCLUSIONS This systematic review and meta-analysis support the conduct of future, large-scale randomized controlled trials to determine the efficacy and optimize administration of botulinum toxin injections for treatment of pelvic floor myofascial pain and associated symptoms in women.
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Affiliation(s)
- Melanie R Meister
- From the Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Kansas School of Medicine
| | - Allison Brubaker
- Department of Obstetrics & Gynecology, Washington University in St. Louis
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis
| | - Jerry L Lowder
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO
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Pollack LM, Lowder JL, Keller M, Chang SH, Gehlert SJ, Olsen MA. Racial/Ethnic Differences in the Risk of Surgical Complications and Posthysterectomy Hospitalization among Women Undergoing Hysterectomy for Benign Conditions. J Minim Invasive Gynecol 2021; 28:1022-1032.e12. [PMID: 33395578 DOI: 10.1016/j.jmig.2020.12.032] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/25/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Evaluate whether 30- and 90-day surgical complication and postoperative hospitalization rates after hysterectomy for benign conditions differ by race/ethnicity and whether the differences remain after controlling for patient, hospital, and surgical characteristics. DESIGN Retrospective cohort study using administrative data. The exposure was race/ethnicity. The outcomes included 5 different surgical complications/categories and posthysterectomy inpatient hospitalization, all identified through 30 and 90 days after hysterectomy hospital discharge, with the exception of hemorrhage/hematoma, which was only identified through 30 days. To examine the association between race/ethnicity and each outcome, we used logistic regression with clustering of procedures within hospitals, adjusting for patient and hospital characteristics and surgical approach. SETTING Multistate, including Florida and New York. PATIENTS Women aged ≥18 years who underwent hysterectomy for benign conditions using State Inpatient Databases and State Ambulatory Surgery Databases. INTERVENTIONS Hysterectomy for benign conditions. MEASUREMENTS AND MAIN RESULTS We included 183 697 women undergoing hysterectomy for benign conditions from January 2011 to September 2014. In analysis, adjusting for surgery route and other factors, black race was associated with increased risk of 30-day digestive system complications (multivariable adjusted odds ratio [aOR], 1.98; 95% confidence interval [CI], 1.78-2.21), surgical-site infection (aOR, 1.34; 95% CI, 1.18-1.53), posthysterectomy hospitalization (aOR, 1.31; 95% CI, 1.22-1.40), and urologic complications (aOR, 1.16; 95% CI, 1.01-1.34) compared with white race. Asian/Pacific Islander race was associated with increased risk of 30-day urologic complications (aOR, 1.48; 95% CI, 1.08-2.03), intraoperative injury to abdominal/pelvic organs (aOR, 1.46; 95% CI, 1.23-1.75), and hemorrhage/hematoma (aOR, 1.33; 95% CI, 1.06-1.67) compared with white race. Hispanic ethnicity was associated with increased risk of 30-day posthysterectomy hospitalization (aOR, 1.11; 95% CI, 1.02-1.20) compared with white race. All findings were similar at 90 days. CONCLUSION Black and Asian/Pacific Islander women had higher risk of some 30- and 90-day surgical complications after hysterectomy than white women. Black and Hispanic women had higher risk of posthysterectomy hospitalization. Intervention strategies aimed at identifying and better managing disparities in pre-existing conditions/comorbidities could reduce racial/ethnic differences in outcomes.
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Affiliation(s)
- Lisa M Pollack
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert).
| | - Jerry L Lowder
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Matt Keller
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Sarah J Gehlert
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Margaret A Olsen
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
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Lenger SM, Bradley MS, Thomas DA, Bertolet MH, Lowder JL, Sutcliffe S. D-mannose vs other agents for recurrent urinary tract infection prevention in adult women: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 223:265.e1-265.e13. [PMID: 32497610 DOI: 10.1016/j.ajog.2020.05.048] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [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: 12/28/2019] [Revised: 05/23/2020] [Accepted: 05/28/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We performed a systematic review and meta-analysis to determine whether D-mannose reduces urinary tract infection recurrence (ie, cumulative incidence) in adult women with recurrent urinary tract infection compared with other prevention agents. Secondary outcomes included side effects and compliance with D-mannose use. DATA SOURCES Ovid Medline 1946-, Embase 1947-, Scopus 1823-, Cochrane Library, Web of Science 1900-, and ClinicalTrials.gov were searched through 4/15/2020. STUDY ELIGIBILITY CRITERIA Systematic review inclusion: randomized controlled trials, prospective cohorts, and retrospective cohorts written in English of women ≥18 years old with recurrent urinary tract infection in which D-mannose was utilized as an outpatient prevention regimen. Systematic review exclusion: lab or animal-based research, study protocols only, and conference abstracts. Meta-analysis inclusion: stated D-mannose dose, follow-up time ≥6 months, a comparison arm to D-mannose, and data available from women ≥18 years of age. STUDY APPRAISAL AND SYNTHESIS METHODS Two independent reviewers made abstract, full text, and data extraction decisions. Study methodologic quality was assessed using the Cochrane Risk of Bias tool. Relative risks, confidence intervals, and heterogeneity were computed. RESULTS Searches identified 776 unique citations. Eight publications met eligibility: 2 using D-mannose only; 6 using D-mannose combined with another treatment. Seven studies were prospective: 2 randomized controlled trials, 1 randomized cross-over trial, and 4 prospective cohort studies. One retrospective cohort study was included. Three studies met meta-analysis eligibility (1 randomized controlled trial, 1 randomized cross-over trial, and 1 prospective cohort). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to placebo was 0.23 (95% confidence interval, 0.14-0.37; heterogeneity=0%; D-mannose n=125, placebo n=123). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to preventative antibiotics was 0.39 (95% confidence interval, 0.12-1.25; heterogeneity=88%; D-mannose n=163, antibiotics n=163). Adverse side effects were reported in 2 studies assessing D-mannose only (1 study (n=10) reported none; the other reported a low incidence (8/103 participants) of diarrhea). Two studies reported compliance, which was high. CONCLUSION D-mannose appears protective for recurrent urinary tract infection (vs placebo) with possibly similar effectiveness as antibiotics. Overall, D-mannose appears well tolerated with minimal side effects-only a small percentage experiencing diarrhea. Meta-analysis interpretation must consider the small number of studies with varied study design and quality and the overall small sample size.
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Affiliation(s)
- Stacy M Lenger
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.
| | - Megan S Bradley
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Debbie A Thomas
- Becker Library, Washington University School of Medicine, St. Louis, MO
| | - Marnie H Bertolet
- Departments of Epidemiology, Biostatistics, and the Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
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Brady SS, Brubaker L, Fok CS, Gahagan S, Lewis CE, Lewis J, Lowder JL, Nodora J, Stapleton A, Palmer MH. Development of Conceptual Models to Guide Public Health Research, Practice, and Policy: Synthesizing Traditional and Contemporary Paradigms. Health Promot Pract 2020; 21:510-524. [PMID: 31910039 PMCID: PMC7869957 DOI: 10.1177/1524839919890869] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Indexed: 11/16/2022]
Abstract
This applied paper is intended to serve as a "how to" guide for public health researchers, practitioners, and policy makers who are interested in building conceptual models to convey their ideas to diverse audiences. Conceptual models can provide a visual representation of specific research questions. They also can show key components of programs, practices, and policies designed to promote health. Conceptual models may provide improved guidance for prevention and intervention efforts if they are based on frameworks that integrate social ecological and biological influences on health and incorporate health equity and social justice principles. To enhance understanding and utilization of this guide, we provide examples of conceptual models developed by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. PLUS is a transdisciplinary U.S. scientific network established by the National Institutes of Health in 2015 to promote bladder health and prevent lower urinary tract symptoms, an emerging public health and prevention priority. The PLUS Research Consortium is developing conceptual models to guide its prevention research agenda. Research findings may in turn influence future public health practices and policies. This guide can assist others in framing diverse public health and prevention science issues in innovative, potentially transformative ways.
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Affiliation(s)
| | | | | | | | - Cora E Lewis
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jerry L Lowder
- Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Jesse Nodora
- University of California San Diego, La Jolla, CA, USA
| | | | - Mary H Palmer
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Brady SS, Berry A, Camenga DR, Fitzgerald CM, Gahagan S, Hardacker CT, Harlow BL, Hebert-Beirne J, LaCoursiere DY, Lewis JB, Low LK, Lowder JL, Markland AD, McGwin G, Newman DK, Palmer MH, Shoham DA, Smith AL, Stapleton A, Williams BR, Sutcliffe S. Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women. Neurourol Urodyn 2020; 39:1185-1202. [PMID: 32119156 PMCID: PMC7659467 DOI: 10.1002/nau.24325] [Citation(s) in RCA: 12] [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: 10/04/2019] [Accepted: 01/23/2020] [Indexed: 01/18/2023]
Abstract
AIMS Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts. METHODS Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span. RESULTS Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research. CONCLUSIONS This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.
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Affiliation(s)
- Sonya S Brady
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Amanda Berry
- Department of Surgery, Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deepa R Camenga
- Department of Emergency Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Colleen M Fitzgerald
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Sheila Gahagan
- Department of Pediatrics, Division of Academic General Pediatrics, University of California San Diego School of Medicine, San Diego, California
| | | | - Bernard L Harlow
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Jeni Hebert-Beirne
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - D Yvette LaCoursiere
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego School of Medicine, San Diego, California
| | - Jessica B Lewis
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Lisa K Low
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Alayne D Markland
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, School of Medicine, University of Alabama, Birmingham, Alabama
- Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, Alabama
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
| | - Diane K Newman
- Department of Surgery, Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary H Palmer
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - David A Shoham
- Department of Public Health Sciences, Loyola University Chicago, Maywood, Illinois
| | - Ariana L Smith
- Department of Surgery, Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann Stapleton
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, Washington
| | - Beverly R Williams
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, School of Medicine, University of Alabama, Birmingham, Alabama
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri
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Smith AL, Rickey LM, Brady SS, Fok CS, Lowder JL, Markland AD, Mueller ER, Sutcliffe S, Bavendam TG, Brubaker L. Laying the Foundation for Bladder Health Promotion in Women and Girls. Urology 2020; 150:227-233. [PMID: 32197984 DOI: 10.1016/j.urology.2020.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 02/27/2020] [Accepted: 03/05/2020] [Indexed: 01/03/2023]
Abstract
Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement. Important foundational work of PLUS includes development of clear definitions of both BH and disease, as well as a BH measurement instrument that will be validated for use in the general population, adolescents, and Latinx and Spanish-speaking women.1 The BH measurement instrument will be used in an upcoming nationally-representative cohort study that will measure BH and investigate risk and protective factors. PLUS investigators also developed a conceptual framework to guide their research agenda; this framework organizes a broad array of candidate risk and protective factors that can be studied across the life course of girls and women.1 As PLUS begins to fill existing knowledge gaps with new information, its efforts will undoubtedly be complemented by outside investigators to further advance the science of LUTS prevention and BH across additional populations. Once the BH community has broadened its understanding of modifiable risk and protective factors, intervention studies will be necessary to test LUTS prevention strategies and support public health efforts. LUTS providers may be able to translate this evolving evidence for individual patients under their care and act as BH advocates in their local communities.
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Affiliation(s)
- Ariana L Smith
- Department of Surgery, University of Pennsylvania's Perelman School of Medicine, Philadelphia, PA.
| | - Leslie M Rickey
- Department of Urology, Yale University School of Medicine, New Haven, CT
| | - Sonya S Brady
- Department of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
| | - Cynthia S Fok
- Department of Urology, University of Minnesota, Minneapolis MN
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Washington University, St Louis, MO
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham and the Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL
| | - Elizabeth R Mueller
- Departments of Obstetrics and Gynecology & Urology, Stritch School of Medicine, Loyola University Chicago, Chicago IL
| | | | | | - Linda Brubaker
- Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego, San Diego, CA
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Tuuli MG, Gregory T, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita AT, Cahill AG, Richter HE. 7: Impact of second stage pushing timing on maternal pelvic floor morbidity: Multicenter randomized controlled trial. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Meister MR, Sutcliffe S, Badu A, Ghetti C, Lowder JL. Pelvic floor myofascial pain severity and pelvic floor disorder symptom bother: is there a correlation? Am J Obstet Gynecol 2019; 221:235.e1-235.e15. [PMID: 31319079 DOI: 10.1016/j.ajog.2019.07.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/26/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pelvic floor myofascial pain, which is predominantly identified in the muscles of the levator ani and obturator internus, has been observed in women with chronic pelvic pain and other pelvic floor disorder symptoms, and is hypothesized to contribute to their symptoms. OBJECTIVES To describe the prevalence of pelvic floor myofascial pain in patients presenting with pelvic floor disorder symptoms and to investigate whether severity of pelvic floor myofascial pain on examination correlates with degree of pelvic floor disorder symptom bother. STUDY DESIGN All new patients seen at 1 tertiary referral center between 2014 and 2016 were included in this retrospectively assembled cross-sectional study. Pelvic floor myofascial pain was determined by transvaginal palpation of the bilateral obturator internus and levator ani muscles and scored as a discrete number on an 11-point verbal pain rating scale (range, 0-10) at each site. Scores were categorized as none (0), mild (1-3), moderate (4-6), and severe (7-10) for each site. Pelvic floor disorder symptom bother was assessed by the Pelvic Floor Distress Inventory short form scores. The correlation between these 2 measures was calculated using Spearman rank and partial rank correlation coefficients. RESULTS A total of 912 new patients were evaluated. After exclusion of 79 with an acute urinary tract infection, 833 patients were included in the final analysis. Pelvic floor myofascial pain (pain rated >0 in any muscle group) was identified in 85.0% of patients: 50.4% rated as severe, 25.0% moderate, and 9.6% mild. In unadjusted analyses and those adjusted for postmenopausal status, severity of pelvic floor myofascial pain was significantly correlated with subjective prolapse symptoms such as pelvic pressure and heaviness but not with objective prolapse symptoms (seeing or feeling a vaginal bulge or having to push up on a bulge to start or complete urination) or leading edge. Severity of myofascial pain at several individual pelvic floor sites was also independently correlated with lower urinary tract symptoms, including pain in the lower abdomen (myofascial pain at all sites) and difficulty emptying the bladder (right obturator internus and left levator ani); and with defecatory dysfunction, including sensation of incomplete rectal emptying (pain at all sites combined and the right obturator internus), anal incontinence to flatus (pain at all sites combined), and pain with defecation (pain at all sites combined, and the right obturator internus and left levator ani). CONCLUSION Pelvic floor myofascial pain was common in patients seeking evaluation for pelvic floor disorder symptoms. Location and severity of pelvic floor myofascial pain was significantly correlated with degree of symptom bother, even after controlling for postmenopausal status. Given the high prevalence of pelvic floor myofascial pain in these patients and correlation between pain severity and degree of symptom bother, a routine assessment for pelvic floor myofascial pain should be considered for all patients presenting for evaluation of pelvic floor symptoms.
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Lowder JL, Bavendam TG, Berry A, Brady SS, Fitzgerald CM, Fok CS, Goode PS, Lewis CE, Mueller ER, Newman DK, Palmer MH, Rickey L, Stapleton A, Lukacz ES. Terminology for bladder health research in women and girls: Prevention of Lower Urinary Tract Symptoms transdisciplinary consortium definitions. Neurourol Urodyn 2019; 38:1339-1352. [PMID: 30957915 PMCID: PMC6581588 DOI: 10.1002/nau.23985] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 10/19/2018] [Revised: 02/22/2019] [Accepted: 03/14/2019] [Indexed: 12/20/2022]
Abstract
AIM To report research terminology and definitions for describing healthy bladder function among women and girls. METHODS The Prevention of Lower Urinary tract Symptoms (PLUS) Consortium developed research terminology and definitions for elements of healthy bladder function based on existing understanding of storage and emptying functions of the bladder and accepted definitions of lower urinary tract symptoms (LUTS). The novel concept of a bladder "bioregulatory" function was also proposed. Elements of bladder function corresponding to bladder health (BH) and LUTS were developed and refined using an iterative process. A comprehensive reference table structured by bladder function (Storage, Emptying, and Bioregulatory) and elements of each function was created to document proposed research terminology and definitions. RESULTS The BH research definitions for each bladder function are: (1) Storage: the ability to hold urine for a reasonable duration of time and sense bladder fullness without fear of or concern about urgency, discomfort or leakage; (2) Emptying: the ability to empty the bladder completely in a timely, efficient, effortless, comfortable manner; and (3) Bioregulatory: the bladder barrier protects the individual/host from pathogens, chemicals, and malignancy. Research definitions for seven Storage, seven Emptying, and three Bioregulatory elements of function are presented. Novel LUTS research definitions were developed when gaps in existing definitions were identified or nonclinical language was desired. CONCLUSIONS PLUS BH definitions reflect a transdisciplinary approach to standardizing research definitions for elements of bladder function from a perspective of health rather than dysfunction and provide a framework for studying BH in clinical practice, public health promotion, and LUTS prevention.
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Affiliation(s)
- Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Tamara G Bavendam
- Division of Kidney, Urologic and Hematologic Disease, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Amanda Berry
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sonya S Brady
- Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Colleen M Fitzgerald
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Loyola University Stritch School of Medicine, Chicago, Illinois
- Department of Physical Medicine and Rehabilitation, Loyola University Stritch School of Medicine, Chicago, Illinois
| | - Cynthia S Fok
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Patricia S Goode
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham, Alabama
| | - Cora E Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth R Mueller
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Loyola University Stritch School of Medicine, Chicago, Illinois
| | - Diane K Newman
- Department of Urology, Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary H Palmer
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Leslie Rickey
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Urology and Obstetrics & Gynecology, Yale University, New Haven, Connecticut
| | - Ann Stapleton
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Emily S Lukacz
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, California
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Meister MR, Sutcliffe S, Ghetti C, Chu CM, Spitznagle T, Warren DK, Lowder JL. Development of a Standardized, Reproducible Screening Examination for Assessment of Pelvic Floor Myofascial Pain. Obstet Gynecol Surv 2019. [DOI: 10.1097/01.ogx.0000559834.14388.b5] [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: 11/25/2022]
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Meister MR, Shivakumar N, Sutcliffe S, Spitznagle T, Lowder JL. Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. Am J Obstet Gynecol 2018; 219:497.e1-497.e13. [PMID: 29959930 DOI: 10.1016/j.ajog.2018.06.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Myofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles in men and women. Pelvic floor myofascial pain in the absence of local or referred pain has also been observed in patients with lower urinary tract symptoms, and we have found that many patients report an improvement in these symptoms after receiving myofascial-targeted pelvic floor physical therapy. OBJECTIVE We sought to systematically review the literature for examination techniques used to assess pelvic floor myofascial pain in women. STUDY DESIGN We performed a systematic literature search using strategies for the concepts of pelvic floor disorders, myofascial pain, and diagnosis in Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Database of Systematic Reviews. Articles were screened by 3 authors and included if they contained a description of a pelvic myofascial physical examination. RESULTS In all, 55 studies met our inclusion criteria. Overall, examination components varied significantly among the included studies and were frequently undefined. A consensus examination guideline was developed based on the available data and includes use of a single digit (62%, 34/55) to perform transvaginal palpation (75%, 41/55) of the levator ani (87%, 48/55) and obturator internus (45%, 25/55) muscles with a patient-reported scale to assess the level of pain to palpation (51%, 28/55). CONCLUSION Physical examination methods to evaluate pelvic musculature for presence of myofascial pain varied significantly and were often undefined. Given the known role of pelvic floor myofascial pain in chronic pelvic pain and link between pelvic floor myofascial pain and lower urinary tract symptoms, physicians should be trained to evaluate for pelvic floor myofascial pain as part of their physical examination in patients presenting with these symptoms. Therefore, the development and standardization of a reliable and reproducible examination is needed.
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Brady SS, Bavendam TG, Berry A, Fok CS, Gahagan S, Goode PS, Hardacker CT, Hebert-Beirne J, Lewis CE, Lewis JB, Kane Low L, Lowder JL, Palmer MH, Wyman JF, Lukacz ES. The Prevention of Lower Urinary Tract Symptoms (PLUS) in girls and women: Developing a conceptual framework for a prevention research agenda. Neurourol Urodyn 2018; 37:2951-2964. [PMID: 30136299 DOI: 10.1002/nau.23787] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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: 03/11/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022]
Abstract
AIMS The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was established by the National Institutes of Health in 2015 to expand research beyond the detection and treatment of lower urinary tract symptoms (LUTS) to the promotion and preservation of bladder health and prevention of LUTS in girls and women. While many multi-disciplinary scientific networks focus on pelvic floor dysfunction and LUTS, the PLUS Consortium stands alone in its focus on prevention. This article describes the PLUS approach to developing a conceptual framework to guide the Consortium's initial prevention research agenda. METHODS The conceptual framework was informed by traditional social ecological models of public health, biopsychosocial models of health, Glass and McAtee's Society-Behavior-Biology Nexus, and the World Health Organization's conceptual framework for action on the social determinants of health. RESULTS The PLUS conceptual framework provides a foundation for developing prevention interventions that have the greatest likelihood of promoting and preserving bladder health among diverse populations. CONCLUSIONS PLUS Consortium work is premised on the notion that programs, practices, and policies designed to promote health will have optimal impact if the conceptual foundation upon which efforts are based is comprehensive and informed by multiple disciplines. The PLUS conceptual framework is broadly applicable to domains of health that have historically focused on the treatment of illness and symptoms rather than the promotion of health. It is also applicable to domains of health that have been examined from a predominantly biological or social ecological perspective, without integration of both perspectives.
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Affiliation(s)
- Sonya S Brady
- Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Tamara G Bavendam
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Amanda Berry
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia S Fok
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Sheila Gahagan
- Division of Academic General Pediatrics, University of California San Diego, San Diego, California
| | - Patricia S Goode
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama.,Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham, Alabama
| | - Cecilia T Hardacker
- Howard Brown Health, Chicago, Illinois.,Rush University College of Nursing, Chicago, Illinois
| | - Jeni Hebert-Beirne
- Division of Community Health Sciences, University of Illinois at Chicago, School of Public Health, Chicago, Illinois
| | - Cora E Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Lisa Kane Low
- School of Nursing, Women's Studies, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Mary H Palmer
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jean F Wyman
- School of Nursing, University of Minnesota, Minneapolis, Minnesota
| | - Emily S Lukacz
- Division of Female Pelvic Medicine & Reconstructive Surgery, University of California San Diego, San Diego, California
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- Division of Female Pelvic Medicine & Reconstructive Surgery, University of California San Diego, San Diego, California
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Chu CM, Lowder JL. Diagnosis and treatment of urinary tract infections across age groups. Am J Obstet Gynecol 2018; 219:40-51. [PMID: 29305250 DOI: 10.1016/j.ajog.2017.12.231] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/18/2017] [Accepted: 12/27/2017] [Indexed: 01/20/2023]
Abstract
Urinary tract infections are the most common outpatient infections, but predicting the probability of urinary tract infections through symptoms and test results can be complex. The most diagnostic symptoms of urinary tract infections include change in frequency, dysuria, urgency, and presence or absence of vaginal discharge, but urinary tract infections may present differently in older women. Dipstick urinalysis is popular for its availability and usefulness, but results must be interpreted in context of the patient's pretest probability based on symptoms and characteristics. In patients with a high probability of urinary tract infection based on symptoms, negative dipstick urinalysis does not rule out urinary tract infection. Nitrites are likely more sensitive and specific than other dipstick components for urinary tract infection, particularly in the elderly. Positive dipstick testing is likely specific for asymptomatic bacteriuria in pregnancy, but urine culture is still the test of choice. Microscopic urinalysis is likely comparable to dipstick urinalysis as a screening test. Bacteriuria is more specific and sensitive than pyuria for detecting urinary tract infection, even in older women and during pregnancy. Pyuria is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms such as incontinence. Positive testing may increase the probability of urinary tract infection, but initiation of treatment should take into account risk of urinary tract infection based on symptoms as well. In cases in which the probability of urinary tract infection is moderate or unclear, urine culture should be performed. Urine culture is the gold standard for detection of urinary tract infection. However, asymptomatic bacteriuria is common, particularly in older women, and should not be treated with antibiotics. Conversely, in symptomatic women, even growth as low as 102 colony-forming unit/mL could reflect infection. Resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole. Most uropathogens still display good sensitivity to nitrofurantoin. First-line treatments for urinary tract infection include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%). These antibiotics have minimal collateral damage and resistance. In pregnancy, beta-lactams, nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole can be appropriate treatments. Interpreting the probability of urinary tract infection based on symptoms and testing allows for greater accuracy in diagnosis of urinary tract infection, decreasing overtreatment and encouraging antimicrobial stewardship.
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Lukacz ES, Bavendam TG, Berry A, Fok CS, Gahagan S, Goode PS, Hardacker CT, Hebert-Beirne J, Lewis CE, Lewis J, Low LK, Lowder JL, Palmer MH, Smith AL, Brady SS. A Novel Research Definition of Bladder Health in Women and Girls: Implications for Research and Public Health Promotion. J Womens Health (Larchmt) 2018; 27:974-981. [PMID: 29792542 DOI: 10.1089/jwh.2017.6786] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Bladder health in women and girls is poorly understood, in part, due to absence of a definition for clinical or research purposes. This article describes the process used by a National Institutes of Health funded transdisciplinary research team (The Prevention of Lower Urinary Tract Symptoms [PLUS] Consortium) to develop a definition of bladder health. METHODS The PLUS Consortium identified currently accepted lower urinary tract symptoms (LUTS) and outlined elements of storage and emptying functions of the bladder. Consistent with the World Health Organization's definition of health, PLUS concluded that absence of LUTS was insufficient and emphasizes the bladder's ability to adapt to short-term physical, psychosocial, and environmental challenges for the final definition. Definitions for subjective experiences and objective measures of bladder dysfunction and health were drafted. An additional bioregulatory function to protect against infection, neoplasia, chemical, or biologic threats was proposed. RESULTS PLUS proposes that bladder health be defined as: "A complete state of physical, mental, and social well-being related to bladder function and not merely the absence of LUTS. Healthy bladder function permits daily activities, adapts to short-term physical or environmental stressors, and allows optimal well-being (e.g., travel, exercise, social, occupational, or other activities)." Definitions for each element of bladder function are reported with suggested subjective and objective measures. CONCLUSIONS PLUS used a comprehensive transdisciplinary process to develop a bladder health definition. This will inform instrument development for evaluation of bladder health promotion and prevention of LUTS in research and public health initiatives.
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Affiliation(s)
- Emily S Lukacz
- 1 Division of Female Pelvic Medicine and Reconstructive Surgery, University of California San Diego , San Diego, California
| | - Tamara G Bavendam
- 2 National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health , Bethesda, Maryland
| | - Amanda Berry
- 3 Division of Urology, Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Cynthia S Fok
- 4 Department of Urology, University of Minnesota , Minneapolis, Minnesota
| | - Sheila Gahagan
- 5 Division of Academic General Pediatrics, University of California San Diego , San Diego, California
| | - Patricia S Goode
- 6 Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham , Birmingham, Alabama.,7 Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center , Birmingham, Alabama
| | - Cecilia T Hardacker
- 8 Howard Brown Health, Rush University College of Nursing , Chicago, Illinois
| | - Jeni Hebert-Beirne
- 9 Division of Community Health Sciences, University of Illinois at Chicago , School of Public Health, Chicago, Illinois
| | - Cora E Lewis
- 10 Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Jessica Lewis
- 11 Yale School of Public Health , New Haven, Connecticut
| | - Lisa Kane Low
- 12 University of Michigan School of Nursing , Ann Arbor, Michigan
| | - Jerry L Lowder
- 13 Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Mary H Palmer
- 14 School of Nursing, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Ariana L Smith
- 15 Division of Urology, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Sonya S Brady
- 16 Division of Epidemiology and Community Health, University of Minnesota School of Public Health , Minneapolis, Minnesota
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Ross WT, Meister MR, Shepherd JP, Olsen MA, Lowder JL. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol 2017; 217:436.e1-436.e8. [PMID: 28716634 DOI: 10.1016/j.ajog.2017.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 06/09/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports reestablishment of apical support at time of hysterectomy, regardless of whether the hysterectomy is performed for prolapse. National rates of apical support procedure performance at time of inpatient hysterectomy have not been well described. OBJECTIVE We sought to estimate trends and factors associated with use of apical support procedures at time of inpatient hysterectomy for benign indications in a large national database. STUDY DESIGN The National (Nationwide) Inpatient Sample was used to identify hysterectomies performed from 2004 through 2013 for benign indications. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to select both procedures and diagnoses. The primary outcome was performance of an apical support procedure at time of hysterectomy. Descriptive and multivariable analyses were performed. RESULTS There were 3,509,230 inpatient hysterectomies performed for benign disease from 2004 through 2013. In both nonprolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (P < .0001). There were 2,790,652 (79.5%) hysterectomies performed without a diagnosis of prolapse, and an apical support procedure was performed in only 85,879 (3.1%). There was a significant decrease in the proportion of hysterectomies with concurrent apical support procedure (high of 4.0% in 2004 to 2.5% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically assisted vaginal) were associated with performance of an apical support procedure. During the study period, 718,578 (20.5%) inpatient hysterectomies were performed for prolapse diagnoses and 266,743 (37.1%) included an apical support procedure. There was a significant increase in the proportion of hysterectomies with concurrent apical support procedure (low of 31.3% in 2005 to 49.3% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (medium and large), and hysterectomy type (total laparoscopic and laparoscopic supracervical) were associated with performance of an apical support procedure. CONCLUSION This national database study demonstrates that apical support procedures are not routinely performed at time of inpatient hysterectomy regardless of presence of prolapse diagnosis. Educational efforts are needed to increase awareness of the importance of reestablishing apical vaginal support at time of hysterectomy regardless of indication.
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Lowder JL. Apical Vaginal Support: The Often Forgotten Piece of the Puzzle. Mo Med 2017; 114:171-175. [PMID: 30228575 PMCID: PMC6140207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Pelvic organ prolapse is common among women who have delivered vaginally or had a hysterectomy. In a total hysterectomy, the apical vaginal support is transected. Although evidence supports re-establishment of apical support, our research showed that this rarely occurs in hysterectomies. To address our lack of definitions of "significant" apical support loss and recommendations to guide surgeons as to when they should perform an apical support procedure, we analyzed patient data and found that a simple assessment of the genital hiatus can effectively screen for significant apical support loss. Our work will hopefully highlight the importance of apical support loss and current deficits in research and clinical guidelines.
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Affiliation(s)
- Jerry L Lowder
- Jerry L. Lowder, MD, MSc, is Associate Professor and Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine
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Meister MRL, Sutcliffe S, Lowder JL. Definitions of apical vaginal support loss: a systematic review. Am J Obstet Gynecol 2017; 216:232.e1-232.e14. [PMID: 27640944 DOI: 10.1016/j.ajog.2016.09.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 04/20/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to identify and summarize definitions of apical support loss utilized for inclusion, success, and failure in surgical trials for treatment of apical vaginal prolapse. BACKGROUND Pelvic organ prolapse is a common condition affecting more than 3 million women in the US, and the prevalence is increasing. Prolapse may occur in the anterior compartment, posterior compartment or at the apex. Apical support is considered paramount to overall female pelvic organ support, yet apical support loss is often underrecognized and there are no guidelines for when an apical support procedure should be performed or incorporated into a procedure designed to address prolapse. STUDY DESIGN A systematic literature search was performed in 8 search engines: PubMed 1946-, Embase 1947-, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Proquest Dissertations and Theses, and FirstSearch Proceedings, using key words for apical pelvic organ prolapse and apical suspension procedures through April 2016. Searches were limited to human beings using human filters and articles published in English. Study authors (M.R.L.M., J.L.L.) independently reviewed publications for inclusion based on predefined variables. Articles were eligible for inclusion if they satisfied any of the following criteria: (1) apical support loss was an inclusion criterion in the original study, (2) apical support loss was a surgical indication, or (3) an apical support procedure was performed as part of the primary surgery. RESULTS A total of 4469 publications were identified. After review, 35 articles were included in the analysis. Prolapse-related inclusion criteria were: (1) apical prolapse (n = 20, 57.1%); (2) overall prolapse (n = 8, 22.8%); or (3) both (n = 6, 17.1%). Definitions of apical prolapse (relative to the hymen) included: (1) apical prolapse >-1 cm (n = 13, 50.0%); (2) apical prolapse >+1 cm (n = 7, 26.9%); (3) apical prolapse >50% of total vaginal length (-[total vaginal length/2]) (n = 4, 15.4%); and (4) cervix/apex >0 cm (n = 2, 7.7%). Sixteen of the 35 studies (45.7%) required the presence of symptoms for inclusion. A measurement of the apical compartment (relative to the hymen) was used as a measure of surgical success or failure in 17 (48.6%) studies. Definitions for surgical success included: (1) prolapse stage >2 in each compartment (n = 5, 29.4%); (2) prolapse >-[total vaginal length/2] (n = 2, 11.8%); (3) apical support >-[total vaginal length/3] (n = 1, 5.9%); (4) absence of prolapse beyond the hymen (n = 1, 5.9%); and (5) point C at ≥-5 cm (n = 2, 11.8%). Surgical failure was defined as: (1) apical prolapse ≥0 cm (n = 2, 11.8%); (2) apical prolapse ≥-1 cm (n = 2, 11.8%); (3) apical prolapse >-[total vaginal length/2] (n = 3, 17.6%); and (4) recurrent apical prolapse surgery (n = 1, 5.9%). Ten (28.6%) of the 35 studies also included symptomatic outcomes in the definition of success or failure. CONCLUSION Among randomized, controlled surgical trials designed to address apical vaginal support loss, definitions of clinically significant apical prolapse for study inclusion and surgical success or failure are either highly variable or absent. These findings provide limited evidence of consensus and little insight into current expert opinion.
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Affiliation(s)
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University, St Louis, MO
| | - Jerry L Lowder
- Obstetrics and Gynecology, Washington University, St Louis, MO; Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University, St Louis, MO
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Meister MR, Cahill AG, Conner SN, Woolfolk CL, Lowder JL. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol 2016; 215:310.e1-7. [PMID: 26902989 DOI: 10.1016/j.ajog.2016.02.041] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/21/2016] [Accepted: 02/16/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. OBJECTIVE The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. STUDY DESIGN This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. RESULTS Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury. CONCLUSIONS Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks.
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Lowder JL, Oliphant SS, Shepherd JP, Ghetti C, Sutkin G. Genital hiatus size is associated with and predictive of apical vaginal support loss. Am J Obstet Gynecol 2016; 214:718.e1-8. [PMID: 26719211 DOI: 10.1016/j.ajog.2015.12.027] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/13/2015] [Accepted: 12/16/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1) Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely. OBJECTIVE The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support. STUDY DESIGN This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz et al. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated. RESULTS Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was +2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models). CONCLUSIONS Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery.
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Abstract
OBJECTIVES To describe the introduction of robotic sacrocolpopexy (RSC) in a urogynecology fellowship program, including operative times and patient outcomes. METHODS Data were retrospectively extracted from all women who underwent RSC between May 1, 2009 and December 31, 2011 by a single urogynecologist with fellow and resident assistance. Patient demographics, operative times, intraoperative complications, length of hospital stay, and postoperative course were analyzed. Cases were grouped chronologically in blocks of 10 for analysis. Trend analysis of operative time was done with linear and negative binomial regression. Fisher's exact test was used to compare complications among blocks. RESULTS Fifty-two patients (mean age 58.5±8.4 years) underwent RSC. The majority (75%) had stage III prolapse. Forty-one patients (79%) had concomitant procedures, including supracervical hysterectomy (44%), bilateral salpingo-oophorectomy (9.6%), midurethral sling (9.6%), and lysis of adhesions (40.4%). There was no trend toward decreased operative time with increased surgical experience (linear regression P=.453, negative binomial regression P=.998). Mean operative time was 301.1±53.1 minutes (range 205-440). Overall complication rate was not associated with number of robotic cases performed (P=.771). Nine cases (17.3%) were converted to laparotomy. Five of these occurred in the first 15 cases. There were 2 bladder injuries (3.8%) and no bowel injuries. CONCLUSIONS Although a learning curve was not demonstrated, the adoption of RSC into a urogynecology fellowship program yields similar rates of bladder/bowel injuries, postoperative complications, and operative times when compared with other published studies.
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Affiliation(s)
- Megan S Bradley
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Kelly L Kantartzis
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Jerry L Lowder
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Dan Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan P Shepherd
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania
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Ghetti C, Lee M, Oliphant S, Okun M, Lowder JL. Sleep quality in women seeking care for pelvic organ prolapse. Maturitas 2014; 80:155-61. [PMID: 25465518 DOI: 10.1016/j.maturitas.2014.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 07/15/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To identify the prevalence of sleep disturbance in women seeking treatment for pelvic organ prolapse (POP) and identify correlates of poor sleep quality in this population by using a validated sleep scale. STUDY DESIGN This is a cohort study of female patients with pelvic organ prolapse. MAIN OUTCOME MEASURES Pittsburgh Sleep Quality Index (PSQI), Pelvic Floor Disorders Inventory (PFDI), and Pelvic Floor Impact Questionnaire (PFIQ) measures were completed. Demographic data, medical comorbidities, medications, and physical examinations were also recorded. RESULTS 407 Women were enrolled. Analysis was performed on the 250 subjects who completed all PSQI components. Subjects were predominantly white, with a mean age of 61 ± 11 years and mean BMI of 28 ± 5 kg/m(2). The majority (71%) had Stage III prolapse. Half (N=127) had poor sleep quality (PSQI > 5). Women with poor sleep quality were younger, had more medical comorbidities, more pelvic floor symptoms, more nocturia, more depressive symptoms, and took more time to fall asleep. Factors associated with sleep quality were evaluated using multivariable linear regression models. Worse sleep scores were associated with each of the PFDI subscores (urinary, prolapse, bowel), depressive symptoms, severe nocturia symptoms, and number of comorbidities. CONCLUSIONS Poor sleep is prevalent in women with prolapse. Pelvic floor symptoms as measured by PFDI sub-scales, were associated with poor sleep quality. Future studies are needed to better understand how sleep disturbances may contribute to the impact of pelvic floor symptoms on quality of life.
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Affiliation(s)
- Chiara Ghetti
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States; Department of Obstetrics and Gynecology, Washington University, St. Louis, MO, United States.
| | - MinJae Lee
- Biostatistics/Epidemiology/Research Design (BERD) Core Center for Clinical and Translational Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sallie Oliphant
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States; Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Michele Okun
- Western Psychiatric Institute and Clinic, Pittsburgh, PA, United States; University of Colorado, Colorado Springs, CO, United States
| | - Jerry L Lowder
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
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Kantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. Int Urogynecol J 2014; 26:207-12. [PMID: 25182150 DOI: 10.1007/s00192-014-2474-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/26/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. METHODS Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. RESULTS A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1%) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8% vs 9.4%, p < 0.001), but less likely to have rectocele (3.4% vs 12.2%, p < 0.001) or combined cystocele/rectocele repair (16.4% vs 25.6%, p < 0.001). Of those without apical procedures, 95.7% were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1% and 88.8% vs 23.6%, p < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95% CI 3.127-8.304). Surgeons practicing for 10-14 years and >20 years were less likely to perform apical procedures than those practicing <5 years (p < 0.001 vs. p = 0.01). CONCLUSIONS At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.
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Affiliation(s)
- Kelly L Kantartzis
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Hospital, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA,
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Lowder JL, Ghetti C, Switzer GE. Reply: To PMID 24631437. Am J Obstet Gynecol 2014; 211:311. [PMID: 24727106 DOI: 10.1016/j.ajog.2014.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/06/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Chiara Ghetti
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Galen E Switzer
- Departments of Medicine and Psychiatry, University of Pittsburgh School of Medicine, and the VA Center for Health Equity Research and Promotion, Pittsburgh, PA
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Lowder JL, Ghetti C, Oliphant SS, Skoczylas LC, Swift S, Switzer GE. Body image in the Pelvic Organ Prolapse Questionnaire: development and validation. Am J Obstet Gynecol 2014; 211:174.e1-9. [PMID: 24631437 DOI: 10.1016/j.ajog.2014.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/18/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to develop and validate a prolapse-specific body image questionnaire. STUDY DESIGN Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability. RESULTS Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbach's α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high. CONCLUSION We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.
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Oliphant SS, Ghetti C, McGough RL, Wang L, Bunker CH, Lowder JL. Inpatient procedures in elderly women: an analysis over time. Maturitas 2013; 75:349-54. [PMID: 23707727 PMCID: PMC3713166 DOI: 10.1016/j.maturitas.2013.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 12/26/2012] [Revised: 04/12/2013] [Accepted: 04/28/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To describe inpatient surgical and diagnostic/therapeutic procedures in women ≥65 years old and assess procedure trends over time. STUDY DESIGN Procedure data for all women ≥65 years was collected using the National Hospital Discharge Survey, a federal dataset drawn from a representative sampling of U.S. inpatient hospitals which includes patient and hospital demographics and ICD-9-CM diagnosis and procedure codes for admissions from 1979 to 2006. MAIN OUTCOME MEASURES Age-adjusted rates (AAR) per 1000 women were created using 1990 U.S. Census data to compare trends over time. RESULTS Over 96 million procedures were performed in women age≥65 years from 1979 to 2006. Women age≥65 years constituted 17% of women with ≥1 inpatient procedure in 1979, rising to 32% in 2006. The most common surgical procedures were lower extremity joint replacement, open reduction internal fixation, and cholecystectomy. The most common concurrent diagnosis was femoral neck fracture. Women with femoral neck fracture were more likely to undergo open reduction internal fixation compared to joint replacement. AARs for ORIF fell from 4.3 to 3.2 (p=.02) from 1979 to 2006, while AARs for joint replacement increased from 0.2 to 3.4 (p≤.001, 1979-1988; p=.14, 1990-2006). CONCLUSIONS The rate of women age≥65 years undergoing inpatient procedures has increased dramatically in the last 30 years. Hip fracture was the most common diagnosis for elderly women, highlighting the impact of osteoporosis and falls and the importance of prevention strategies and optimization of peri-operative care in this population. Further comparative study of hip fracture treatment strategies in this population is needed.
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Affiliation(s)
- Sallie S Oliphant
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh-School of Medicine, Pittsburgh, PA 15213, United States
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Turner LC, Shepherd JP, Wang L, Bunker CH, Lowder JL. Hysterectomy surgery trends: a more accurate depiction of the last decade? Am J Obstet Gynecol 2013; 208:277.e1-7. [PMID: 23333543 DOI: 10.1016/j.ajog.2013.01.022] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/09/2013] [Accepted: 01/14/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of the study was to describe trends in hysterectomy route at a large tertiary center. STUDY DESIGN We reviewed all hysterectomies performed at Magee-Womens Hospital from 2000 to 2010. This database was chosen over larger national surveys because it has been tracking laparoscopic procedures since 2000, well before laparoscopic hysterectomy International Classification of Diseases, ninth revision (ICD-9) procedure codes were developed. RESULTS There were 13,973 patients included who underwent hysterectomy at Magee-Womens Hospital. In 2000, 3.3% were laparoscopic (LH), 74.5% abdominal (AH), and 22.2% vaginal hysterectomy (VH). By 2010, LH represented 43.5%, AH 36.3%, VH 17.2%, and 3.0% laparoscopic converted to open (LH→AH). Hysterectomies performed for gynecological malignancy represented 24.4% of cases. The average length of stay for benign LH and VH, 1.0 ± 1.0 and 1.6 ± 1.0 days respectively, was significantly shorter than the average 3.1 ± 2.3 day stay associated with AH (P < .001). The average patient age was 46.9 ± 10.9 years for LH, 51.5 ± 12.1 years for AH, and 51.7 ± 14.1 years for VH, and over the study period there was a significant trend of increasing patient age (b1 = 0.517, 0.583, and 0.513, respectively [P < .001 for all]). CONCLUSION The percentage of LH increased over the last decade and by 2010 had surpassed AH. The 43.4% LH rate in 2010 is much higher than previously reported in national surveys. This likely is due to an increase in the number of laparoscopic procedures being performed over the last few years as well as the ability of our study to capture LH prior to development of appropriate ICD-9 procedure codes. Our unique ability to determine hysterectomy route, which predates appropriate coding, may provide a more accurate characterization of hysterectomy trends.
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Affiliation(s)
- Lindsay C Turner
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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