Ten-Year Prevalence and Incidence of Urinary Incontinence in Older Women: A Longitudinal Analysis of the Health and Retirement Study

OBJECTIVES

To measure the incidence of urinary incontinence (UI) over 10 years in older women who did not report UI at baseline in 1998, to estimate the prevalence of female UI according to severity and type, and to explore potential risk factors for development of UI.

DESIGN

Secondary analysis of a prospective cohort.

SETTING

Health and Retirement Study.

PARTICIPANTS

Women participating in the Health and Retirement Study between 1998 and 2008 who did not have UI at baseline (1998).

MEASUREMENTS

UI was defined as an answer of "yes" to the question, "During the last 12 months, have you lost any amount of urine beyond your control?" UI was characterized according to severity (according to the Sandvik Severity Index) and type (according to International Continence Society definitions) at each biennial follow-up between 1998 and 2008.

RESULTS

In 1998, 5,552 women aged 51 to 74 reported no UI. The cumulative incidence of UI in older women was 37.2% (95% confidence interval (CI)=36.0-38.5%). The most common incontinence type at the first report of leakage was mixed UI (49.1%, 95% CI=46.5-51.7%), and women commonly reported their symptoms at first leakage as moderate to severe (46.4%, 95% CI=43.8-49.0%).

CONCLUSION

Development of UI in older women was common and tended to result in mixed type and moderate to severe symptoms.

Outcomes of Surgery for Stress Urinary Incontinence in the Older Woman

As population demographics continue to evolve, specifics on age-related outcomes of stress urinary incontinence interventions will be critical to patient counseling and management planning. Understanding medical factors unique to older women and their lower urinary tract conditions will allow caregivers to optimize surgical outcomes, both physical and functional, and minimize complications within this population.

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic vs laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from study inception to October 9, 2014, using the intersection of the themes "robotic" and "hysterectomy." We included only randomized and quasi-randomized controlled trials of robotic vs laparoscopic hysterectomy in women for benign disease. Four trials met our inclusion criteria and were included in the analyses. We extracted data, and assessed the studies for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RRs) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 complications among 326 patients. Comparing robotic and laparoscopic hysterectomy, revealed no statistically significant differences in the rate of class 1 and 2 complications (RR, 0.66; 95% confidence interval [CI], 0.23-1.89) or in the rate of class 3 and 4 complications (RR, 0.99; 95% CI, 0.22-4.40). Analyses of secondary outcomes were limited owing to heterogeneity, but showed no significant benefit of the robotic technique over the laparoscopic technique in terms of length of hospital stay (weighted mean difference, -0.39 day; 95% CI, -0.92 to 0.14 day), total operating time (weighted mean difference, 9.0 minutes; 95% CI, -31.27 to 47.26 minutes), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were reported inconsistently and were not amenable to pooling. Current evidence demonstrates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

Improving Patient Outcomes in Gynecology: The Role of Large Data Registries and Big Data Analytics

Value-based care is quality health care delivered effectively and efficiently. Data registries were created to collect accurate information on patients with enough clinical information to allow for adequate risk adjustment of postoperative outcomes. Because most gynecologic procedures are elective and preference-sensitive, offering nonsurgical alternatives is an important quality measure. The Center for Medicare and Medicaid Services (CMS), in conjunction with mandates from the Affordable Care Act, passed by Congress in 2010, has developed several initiatives centered on the concept of paying for quality care, and 1 of the first CMS initiatives began with instituting payment penalties for hospital-acquired conditions, such as catheter-associated urinary tract infections, central line-associated bloodstream infections, and surgical site infections. Registries specific to gynecology include the Society for Assisted Reproductive Technology registry established in 1996; the FIBROID registry established in 1999; the Pelvic Floor Disorders Registry established by the American Urogynecologic Society in conjunction with other societies (2014); and the Society of Gynecologic Oncologists Clinical Outcomes Registry. Data from these registries can be used to critically analyze practice patterns, find best practices, and enact meaningful changes in systems and workflow. The ultimate goal of data registries and clinical support tools derived from big data is to access accurate and meaningful data from electronic records without repetitive chart review or the need for direct data entry. The most efficient operating systems will include open-access computer codes that abstract data, in compliance with privacy regulations, in real-time to provide information about our patients, their outcomes, and the quality of care that we deliver.

Functional disability among older women with fecal incontinence

OBJECTIVE

The prevalence of functional disability for basic activities of daily living (ADLs) in older women with fecal incontinence (FI) is not well characterized. Our objective was to determine the prevalence of functional disability among community-dwelling older women with FI.

STUDY DESIGN

We conducted a secondary database analysis of the 2005-2006 National Social Life, Health and Aging Project, a cross-sectional study of community-dwelling older adults that had been conducted by single in-home interviews. FI was defined as an affirmative answer to the question, "Have you lost control of your bowels (stool incontinence or anal incontinence)?" with a frequency of "at least monthly." We then examined functional status. Women were asked about 7 basic ADLs. Statistical analyses with percentage estimates and 95% confidence intervals (CIs) were performed.

RESULTS

We included 1412 women in our analysis. FI, at least monthly, was reported by 5.5% of community-dwelling older women (n = 77); 63.2% (95% CI, 50.1-76.4) of the women with FI reported difficulty or dependence with ≥1 ADLs, and 31.2% (95% CI, 18.9-43.6) of the women specifically reported difficulty or dependence with using the toilet. After adjustment for age category, race/ethnicity, education level, women with FI had 2.6 increased odds (95% CI, 1.26-5.35) of difficulty or dependence compared with women with no FI. Other significant risk factors for increased functional difficulty/dependence included obesity (body mass index, ≥30 kg/m(2)) and depressive symptoms.

CONCLUSION

Consistent with other large epidemiologic studies, we found monthly FI was reported by 5.5% of older women (n/N = 77/1412). More than 60% of community-dwelling older women with FI report functional difficulty or dependence with ≥1 ADL and specifically; more than 30% of women with FI report difficulty or dependence using/reaching the toilet. Because of the high prevalence of functional disability in older women with FI, we purpose that initial evaluation and treatment of FI may be improved by considering functional status.

Frailty, cognitive impairment, and functional disability in older women with female pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

There is a growing body of evidence demonstrating frailty as an important predictor of surgical outcomes in older adults undergoing major surgeries. The age-related onset of many symptoms of female pelvic floor dysfunction (PFD) in women suggests that many women seeking treatment for PFD may also have a high prevalence of frailty, which could potentially impact the risks and benefits of surgical treatment options. Our primary objective was to determine the prevalence of frailty, cognitive impairment, and functional disability in older women seeking treatment for PFD.

METHODS

We conducted a cross-sectional study with prospective recruitment between September 2011 and September 2012. Women, age 65 years and older, were recruited at the conclusion of their new patient consultation for PFD at a tertiary center. A comprehensive geriatric screening including frailty measurements (Fried Frailty Index), cognitive screening (Saint Louis University Mental Status score), and functional status evaluation for activities of daily living (Katz ADL score) was conducted.

RESULTS

Sixteen percent (n/N = 25/150) of women were categorized as frail according to the Fried Frailty Index score. After adjusting for education level, 21.3 % of women (n/N = 32/150) screened positive for dementia and 46 (30.7 %) reported functional difficulty or dependence in performing at least one Katz ADL. Sixty-nine women (46.0 %) chose surgical options for treatment of their PFD at the conclusion of their new patient visit with their physician.

CONCLUSIONS

Frailty, cognitive impairment, and functional disability are common in older women seeking treatment for PFD.

Surgical site infection after hysterectomy

OBJECTIVE

Our objective was to estimate the occurrence of surgical site infections (SSI) after hysterectomy and the associated risk factors.

STUDY DESIGN

We conducted a cross-sectional analysis of the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze hysterectomies. Different routes of hysterectomy were compared. The primary outcome was to identify the occurrence of 30-day superficial SSI (cellulitis) after hysterectomy. Secondary outcomes were the occurrence of deep and organ-space SSI after hysterectomy. Logistic regression models were conducted to further explore the associations of risks factors with SSI after hysterectomy.

RESULTS

A total of 13,822 women were included in our final analysis. The occurrence of postoperative cellulitis after hysterectomy was 1.6% (n = 221 women). Risk factors that were associated with cellulitis were route of hysterectomy with an adjusted odds ratio (AOR) of 3.74 (95% confidence interval [CI], 2.26-6.22) for laparotomy compared with the vaginal approach, operative time >75th percentile (AOR, 1.84; 95% CI, 1.40-2.44), American Society of Anesthesia class ≥ 3 (AOR, 1.79; 95% CI, 1.31-2.43), body mass index ≥40 kg/m(2) (AOR, 2.65; 95% CI, 1.85-3.80), and diabetes mellitus (AOR, 1.54; 95% CI, 1.06-2.24) The occurrence of deep and organ-space SSI was 1.1% (n = 154 women) after hysterectomy.

CONCLUSION

Our finding of the decreased occurrence of superficial SSI after the vaginal approach for hysterectomy reaffirms the role for vaginal hysterectomy as the route of choice for hysterectomy.

Cost-effectiveness of endometrial evaluation prior to morcellation in surgical procedures for prolapse

OBJECTIVE

The objective of the study was to compare the cost-effectiveness of 3 screening options for endometrial cancer in asymptomatic, postmenopausal women prior to undergoing morcellation in minimally invasive supracervical hysterectomy and minimally invasive sacral colpopexy for the treatment of pelvic organ prolapse.

STUDY DESIGN

A decision tree model was constructed to compare no screening, endometrial biopsy, and transvaginal ultrasound for asymptomatic, postmenopausal women prior to surgery. Effectiveness was measured by life-years. The incremental cost-effectiveness ratio, defined as the difference in cost between 2 screening options divided by the difference in life-years between the 2 options, was calculated in 2012 US dollars for endometrial biopsy and transvaginal ultrasound, in comparison with no screening.

RESULTS

Using an endometrial cancer prevalence of 0.6% and a 40% risk of upstaging after morcellation, the expected per-patient cost was $8800, $9023, and $9112 over 5 years for no screening, endometrial biopsy, and transvaginal ultrasound, respectively. The expected life-years saved compared with no screening were 0.00108 for endometrial biopsy and 0.00105 for transvaginal ultrasound, ie, 0.39 and 0.38 days, respectively. The estimated incremental cost-effectiveness ratio was $207,348 for endometrial biopsy and $298,038 for transvaginal ultrasound compared with no screening. A sensitivity analysis showed that the prevalence of endometrial cancer and the risk of endometrial cancer upstaging after morcellation had the greatest impact on the cost-effectiveness of screening.

CONCLUSION

For asymptomatic, postmenopausal women, preoperative endometrial evaluation via endometrial biopsy or transvaginal ultrasound helps improve the preoperative detection of endometrial cancer, but universal screening is not cost effective.

The association between urinary and fecal incontinence and social isolation in older women

OBJECTIVE

To describe the association between social isolation and urinary incontinence and fecal incontinence in older women.

METHODS

We conducted a secondary database analysis of the National Social Life, Health and Aging Project for women aged 57 to 85 years old. Our primary outcome was self-report of often feeling isolated. We explored self-report of daily urinary incontinence and weekly fecal incontinence. Two logistic regression analyses were performed to assess the association between often feeling isolated and (1) daily urinary incontinence and (2) weekly fecal incontinence.

RESULTS

A total of 1412 women were included in our analysis. Daily urinary incontinence was reported by 12.5% (177/1412) of community-dwelling older women. More women with daily urinary incontinence reported often feeling isolated (6.6%; 95% confidence interval [CI], 1.3-11.9 vs 2.6%; 95% CI, 1.7-3.5; P = .04) compared with women without daily urinary incontinence. Women with daily urinary incontinence had 3.0 (95% CI, 1.1-7.6) increased odds of often feeling isolated after adjusting for depressive symptoms, age, race, education, and overall health. Weekly fecal incontinence was reported by 2.9% (41/1412) of women. Weekly fecal incontinence and often feeling isolated were associated on univariable analysis (crude odds ratio, 4.6; 95% CI, 1.4-15.1). However, after adjusting for depressive symptoms, age, race, education, and overall health the association between weekly fecal incontinence and often feeling isolated was not significant (adjusted odds ratio, 0.65; 95% CI, 0.1-5.3; P = .65).

CONCLUSION

After adjusting for confounders, daily urinary incontinence was significantly associated with often feeling isolated. Weekly fecal incontinence was not found to be associated with often feeling isolated on multivariable logistic regression.

Sexual function in older women after oophorectomy

OBJECTIVE

To compare the sexual function of older women who had bilateral oophorectomy with that of older women who had retained their ovaries.

METHODS

This cross-sectional study involved analysis of 1,352 women aged 57 to 85 years from the National Social Life, Health, and Aging Project. Women with previous bilateral oophorectomy were compared with women who retained their ovaries. The primary outcome of interest was self-report of sexual ideation, chosen because having thoughts about sexual experiences is not prohibited by either a partner or a woman's own physical limitations.

RESULTS

Three hundred fifty-six (25.8%) women reported previous bilateral oophorectomy. Our analysis achieved 90% power to detect a difference of 10% in sexual ideation. No significant difference in the report of sexual ideation was found between women with previous bilateral oophorectomy and women who retained their ovaries (54.5% and 95% confidence interval [CI] 48.1-61.0 compared with 49.9% and 95% CI 45.3-54.5, P=.230), even after adjusting for current hormone therapy, age, education, and race (adjusted odds ratio 1.32, 95% CI 0.96-1.80).

CONCLUSION

Bilateral oophorectomy may not play a pivotal role in sexual ideation and function among older women.

LEVEL OF EVIDENCE

II.

Maternal postoperative complications after nonobstetric antenatal surgery

OBJECTIVE

Our primary objective is to estimate the occurrence of major maternal 30 day postoperative complications after nonobstetric antenatal surgery.

METHODS

We analyzed the 2005-2009 data files from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for pregnant women undergoing nonobstetric antenatal surgery during any trimester of pregnancy as classified by CPT-4 codes. t Tests, χ(2), logistic regression and other tests were used to calculate composite 30-day major postoperative complications and associations of preoperative predictors with 30 day postoperative morbidity.

RESULTS

The most common nonobstetric antenatal surgical procedure among the 1969 included women was appendectomy (44.0%). The prevalence of composite 30-day major postoperative complications was 5.8% (n = 115). This included (not exclusive categories): return to the surgical operating room within 30 days of surgery 3.6%, infectious morbidity 2.0%, wound morbidity 1.4%, 30 day respiratory morbidity 2.0%, venous thromboembolic event morbidity 0.5%, postoperative blood transfusion 0.2%, and maternal mortality 0.25%.

CONCLUSION

Major maternal postoperative complications following nonobstetric antenatal surgery were low (5.8%). Maternal postoperative mortality was rare (0.25%).

Pay-for-performance: a survey of specialty providers in urogynecology

OBJECTIVE

The objective of this study was to develop and implement a web-based survey to collect information on the reported knowledge, attitudes and practice impact of pay-for-performance (P4P) among providers in the specialty of urogynecology.

STUDY DESIGN

All members of the American Urogynecologic Society were invited to participate in a web-based survey. The questionnaire focused on reported knowledge, attitudes and practice impact of P4P.

RESULTS

Complete responses were obtained from 212 members for a survey response rate of 17.6%. A minority of participants (9.0%) reported having "a lot of knowledge" of the P4P reimbursement model. Fifty-five (25.9%) participants reported that the hospital or healthcare system where they worked had some involvement with P4P reimbursement.

CONCLUSION

A minority of participants reported having a lot of knowledge of P4P, even though current involvement with some type of P4P reimbursement was reported by >25% of participants.

Ambulatory procedures for female pelvic floor disorders in the United States

OBJECTIVE

The aim of this study was to estimate the number of women undergoing ambulatory surgical procedures for female pelvic floor disorders (PFDs) in the United States and to compare age-adjusted ambulatory surgical case rates between 1996 and 2006.

STUDY DESIGN

We analyzed data from the 1996 and 2006 National Survey of Ambulatory Surgery, a federal public access de-identified database. Procedures for PFDs were identified using International Classification of Diseases-9th revision Clinical Modification procedure codes for urinary incontinence, fecal incontinence, and pelvic organ prolapse.

RESULTS

The number of women undergoing ambulatory surgical procedures for urinary incontinence increased from 34,968 (95% confidence interval, 25,583-44,353) in 1996 to 105,656 (95% confidence interval, 79,033-132,279) in 2006. The age-adjusted ambulatory surgical case rates for all PFDs increased from 7.91 per 10,000 in 1996 to 12.10 per 10,000 in 2006 (P = .0006).

CONCLUSION

Ambulatory procedures for urinary incontinence increased between 1996 and 2006, as well as the age-adjusted ambulatory case rate for all PFDs.

The association between obesity and stage II or greater prolapse

OBJECTIVE

We sought to evaluate the association between obesity and vaginal prolapse as well as pelvic organ prolapse symptoms.

STUDY DESIGN

This was a cross-sectional study of women referred for urogynecologic care. The exposure was obesity and outcome, stage>or=II prolapse. Secondary outcomes were symptom bother and disease-specific quality of life.

RESULTS

Our study included 721 women. No difference in stage>or=II prolapse was observed between obese (n/N 58/721 [35.8%]) and nonobese (n/N=463/721 [64.2%]) women (50.8% vs 52.7%; P=.62). Obesity was associated with increased distress on the Pelvic Floor Distress Inventory-20 (100 [+/-57.3] vs 87.4 [+/-53.1]; P=.003) due to higher scores on the Colorectal-Anal Distress Inventory-8 (22.9 [+/-21.5] vs 18.3 [+/-19.7]; P=.003) and the Urinary Distress Inventory-6 (48.8 [+/-27] vs 42.4 [+/-26.1]; P=.002).

CONCLUSION

Obesity was not associated with stage>or=II prolapse but was associated with increased pelvic floor symptoms secondary to urinary and anal incontinence subscales.

Socioeconomic indicators and hysterectomy status in the United States, 2004

OBJECTIVE

To examine the association between socioeconomic indicators and hysterectomy.

STUDY DESIGN

We performed a cross-sectional analysis of the 2004 Behavioral Risk Factor Surveillance Survey database. The effect of multiple socioeconomic exposures (education level, annual income and employment status) on hysterectomy status was evaluated. Logistic regression was used to estimate ORs between the multiple exposures and the outcome of hysterectomy status.

RESULTS

Our analytic sample included 180,982 women. Prior hysterectomy was reported by 26.4%. After adjusting for confounders, women who had not graduated from high school had 1.75 times higher odds (95% CI 1.68-1.83) of having a hysterectomy as compared to women who were college graduates, and women with an annual household income of < $15,000 had 1.06 times higher odds (95% CI 1.02 to 1.10) of having a hysterectomy as compared to women who reported an income of > $50,000/year. Women who were unemployed did not have higher odds of having a hysterectomy than women who were employed.

CONCLUSION

Socioeconomic indicators of education level and income are associated with hysterectomy status; however, employment status is not.

Uterosacral colpopexy at the time of vaginal hysterectomy: comparison of laparoscopic and vaginal approaches

OBJECTIVE

To compare the risk of ureteral compromise and of recurrent vault prolapse following vaginal vs. laparoscopic uterosacral vault suspension at the time of vaginal hysterectomy.

STUDY DESIGN

In this retrospective, cohort study, uterosacral ligament suspension was performed using either a vaginal or laparoscopic approach. The primary outcome was intraoperative ureteral compromise; secondary outcomes were postoperative anatomic result and recurrent prolapse. The Canadian Task Force Classification was II-2.

RESULTS

One hundred eighteen patients were included: 96 patients in the vaginal group and 22 patients in the laparoscopic group. Ureteral compromise was identified intraoperatively in 4 (4.2%) cases in the vaginal group; no ureteral compromise was observed in the laparoscopic group (p = 0.33). Failure at the apex, defined as stage > or = II for point C, was seen in 6.3% of patients in the vaginal group as compared with 0% in the laparoscopic group; this difference did not achieve statistical significance. Similarly, trends toward lower recurrent symptomatic vault prolapse (10% vs. 0%), any symptomatic prolapse recurrence (12.5% vs. 4.6%), and higher postoperative Pelvic Organ Prolapse Quantification point C were observed in the laparoscopic group (p > 0.05 for all).

CONCLUSION

Laparoscopic uterosacral vault suspension following vaginal hysterectomy is a safe alternative to the vaginal approach.

The association between regional anesthesia and acute postoperative urinary retention in women undergoing outpatient midurethral sling procedures

OBJECTIVE

The objective of the study was to estimate the association between regional anesthesia and acute postoperative urinary retention in women undergoing outpatient midurethral sling procedures.

STUDY DESIGN

We performed a retrospective cohort study of women undergoing outpatient midurethral sling procedures. Exposure was defined as the type of anesthesia, categorized as regional (spinal or combined spinal/epidural) or nonregional (general endotracheal, monitored anesthesia care with sedation, or local). The outcome, acute postoperative urinary retention, was defined as a failed voiding trial prior to discharge.

RESULTS

A total of 131 women met our inclusion criteria. Forty-two women (32%) had regional anesthesia and 89 (68%) women had non-regional anesthesia. Overall, 48 women (36.6%) had acute postoperative urinary retention. Women who had regional anesthesia had an increased odds (adjusted odds ratio, 4.4; 95% confidence interval, 1.9-10.2) of acute postoperative urinary retention compared with women receiving nonregional anesthesia.

CONCLUSION

Regional anesthesia is a risk factor for acute postoperative urinary retention following outpatient midurethral slings.

Urinary symptoms and impact on quality of life in women after treatment for endometrial cancer

The primary objective of our study is to describe urinary symptoms in women treated for endometrial cancer. We performed a cross-sectional survey of women who had undergone surgical treatment for endometrial cancer. Three validated questionnaires were utilized: the Sandvik Severity Index, the Urinary Distress Inventory-6 (UDI-6), and Incontinence Impact Questionaire-7 (IIQ-7). Our study included 70 women treated for endometrial cancer; 35.7% (25/70) of women reported adjuvant radiation therapy after surgical staging. Urinary incontinence was reported in over 80% of women. Mean UDI-6 and IIQ-7 scores for women treated with adjuvant radiation therapy were higher compared to women with no adjuvant radiation therapy [47(+/-26.8) vs. 35.6(+/-21.7; p = 0.05)] and [24.4(+/-28.5) vs. 8.1(+/-16.4; p = 0.004)], respectively. Treatment with adjuvant radiation therapy was associated with more severe incontinence symptoms and impact on quality of life.

Pay for performance: what the urogynecologist should know

As urogynecologists, we should educate ourselves about pay for performance and be proactive in the development of outcome measures.

Effect of body mass index on the risk of anal incontinence and defecatory dysfunction in women

OBJECTIVE

The primary objective was to estimate the effect of body mass index on the risk of anal incontinence and defecatory dysfunction in a tertiary referral urogynecologic population.

STUDY DESIGN

This was a cross-sectional study, including 519 new patients. Exposure was defined as body mass index. The primary outcome was any reported anal incontinence. The secondary outcome was any defecatory dysfunction. We used multiple logistic regression to estimate odds ratios and 95% confidence intervals for the effect of body mass index on anal incontinence and defecatory dysfunction.

RESULTS

After adjusting for confounders, every 5 unit increase in body mass index was associated with a significantly increased odds of anal incontinence (odds ratio 1.25; 95% confidence interval, 1.09 to 1.44) and a trend toward an increased odds of defecatory dysfunction (odds ratio 1.13; 95% confidence interval, 0.98 to 1.31), although this was not statistically significant.

CONCLUSION

Increasing body mass index is significantly associated with anal incontinence, but not defecatory dysfunction in women.

A new insertion technique for the transcervical Foley catheter used for cervical ripening

OBJECTIVE

To describe a new placement technique for the transcervical Foley catheter that may succeed when other methods have failed.

STUDY DESIGN

Sixteen patients were identified as candidates for placement of a transcervical Foley catheter for cervical ripening, but all had failed attempted placement using the classically described methods. Our new placement technique involved the use of a 5 French rigid catheter guide inserted into the Foley catheter to make the catheter rigid and to ease insertion. RESLLTS: Placement was 100% successful in all 16 patients using the new insertion technique.

CONCLUSION

The use of a rigid stylet during insertion increases the chances of success. The ease of insertion using this technique makes the use of a Foley catheter for cervical ripening a valuable option.

Ethylene vinyl alcohol copolymer erosions after use as a urethral bulking agent

BACKGROUND

Ethylene vinyl alcohol copolymer was approved for use by the U.S. Food and Drug Administration (FDA) in December 2004 for the treatment of stress urinary incontinence.

CASE

We report on two patients who underwent injection with ethylene vinyl alcohol copolymer who were later found to have urethral erosions.

CONCLUSION

Information regarding complications after ethylene vinyl alcohol copolymer urethral injections is currently limited. We performed a search of the FDA labeling information, Manufacturer and User Facility Device Experience database, and abstracts presented at scientific meetings regarding complications with this material. Symptomatic and asymptomatic erosions of ethylene vinyl alcohol copolymer in the urethra, bladder, and vaginal mucosa are possible complications after this procedure.