Characteristics Associated With Recurrent Urinary Tract Infections: A Case-Control Study

IMPORTANCE

Recurrent urinary tract infections (rUTIs) affect 2-10% of adult women and are associated with a significant effect on quality of life, daily activities, and mental health.

OBJECTIVE

The aim of this study was to identify clinical characteristics associated with rUTIs among women seeking care for pelvic floor disorders at an academic tertiary urogynecology clinic.

STUDY DESIGN

A retrospective case-control study of women presenting to an academic tertiary urogynecology clinic was conducted. Cases were women with rUTIs, defined as ≥2 UTIs in 6 months or ≥3 within 1 year. Controls were women with no culture documented UTIs. Cases were matched 2:1 to controls by age and body mass index. Demographic and clinical characteristics were compared between cases and controls, and bivariate characteristics with P values ≤0.2 were assessed for an independent association with rUTIs by multivariable logistic regression.

RESULTS

A total of 285 cases with rUTIs were identified, and 150 matched controls had a mean (SD) age of 72 (11.8) years and a body mass index of 29.6 (6.7; calculated as weight in kilograms divided by height in meters squared). Multivariable analysis revealed that prolapse beyond the introitus (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.13-0.60), parity (OR, 1.33; 95% CI, 1.08-1.64), Charlson Comorbidity Index (OR, 1.66; 95% CI, 1.37-2.03), and postvoid residual volume ≥100 mL (OR, 4.05; 95% CI, 2.01, 8.18) were associated with rUTIs.

CONCLUSIONS

In this ambulatory urogynecologic population, prolapse through the introitus was negatively associated with rUTIs, whereas parity, increased medical comorbidities, and elevated postvoid residual volume were positively associated with rUTI. Future research should seek an increased understanding of these factors associated with rUTI to implement effective preventive strategies.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study

OBJECTIVE

To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery.

DESIGN

Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study.

SETTING

Eight clinical sites in the US Pelvic Floor Disorders Network.

POPULATION OR SAMPLE

Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015.

METHODS

The MRI (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI-based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three-dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position.

MAIN OUTCOME MEASURES

Vaginal angulation (upper, lower and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid-vagina) at rest.

RESULTS

Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid-vagina (p = 0.01) at rest than women with successful surgery.

CONCLUSIONS

Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.

The impact of automated, constant incomplete milking on energy balance, udder health, and subsequent performance in early lactation of dairy cows

Incomplete milking (IM) is one way of mitigating the negative energy balance (NEB) that is characteristic for early lactation and may increase the risk for disease. Our objectives were to test the effects of IM in early lactation on energy balance (EB), metabolic status, udder health, and subsequent performance. To facilitate the practical application, an automated system was used to remove the milking clusters once a predefined amount of milk is withdrawn. Forty-six Holstein cows were equally allocated to either the treatment (TRT, starting on 8 d in milk) or the control group (CON; conventional cluster removal at milk flow rate <0.3 kg/min). Milk removal in the TRT group was limited to the individual cow's milk yield 1 d before IM started and held constant for 14 d. Thereafter, all cows were conventionally milked and records related to EB, performance, and udder health were continued up to 15 wk of lactation. During the 14 d of IM, on average 11.1% less milk was obtained from the TRT cows than from the CON cows. Thereafter, milk yield increased in the TRT group, eliminating the group difference throughout the remaining observation period until wk 15 of lactation. The TRT cows tended to have less dry matter intake and also water intake than the CON cows. The extent of the NEB and the circulating concentrations of fatty acids, β-hydroxybutyrate, insulin-like growth factor-1, and leptin mostly did not differ between the groups. The IM did not affect body condition. Udder health was maintained over the entire observation period in all cows. Our results demonstrate the applicability of the automated cluster removal for limiting milk withdrawal to a defined amount in early lactation. However, it remains to be determined whether the absent effect on energy metabolism was due to the relatively stable energy status of the cows or to the relatively mild IM setting used herein.

Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience

IMPORTANCE

Understanding patients' perceptions of symptoms and outcomes of urogynecologic surgery is essential for providing high-quality care.

OBJECTIVE

The aim of the study was to assess association of pain catastrophizing with pelvic floor symptom distress and impact, postoperative pain, and voiding trial in patients undergoing urogynecologic surgery.

STUDY DESIGN

Individuals whose self-identified gender was female and were undergoing surgery March 2020-December 2021 were included. Participants completed the Pain Catastrophizing Scale (range 0-52), Pelvic Floor Distress Inventory, and Pelvic Floor Impact Questionnaire preoperatively. Pain catastrophizing was score ≥30 and describes the tendency to magnify the overall threat of pain. Voiding trial failure was inability to void ≥2/3 of instilled volume (≤300 mL). The association between pain catastrophizing and symptom distress and impact was assessed with linear regression. A P < 0.05 is significant.

RESULTS

Three hundred twenty patients were included (mean age, 60 years, 87% White). Forty-six of 320 participants (14%) had a pain catastrophizing score ≥30. The pain catastrophizing group had higher body mass index (33 ± 12 vs 29 ± 5), more benzodiazepine use (26% vs 12%), greater symptom distress (154 ± 58 vs 108 ± 60), and greater urogenital (59 ± 29 vs 47 ± 28), colorectal (42 ± 24 vs 26 ± 23), and prolapse (54 ± 24 vs 36 ± 24) subscale scores, all P ≤ 0.02. The pain catastrophizing group had greater impact (153 ± 72 vs 72 ± 64, P < 0.01) and urogenital (60 ± 29 vs 34 ± 28), colorectal (36 ± 33 vs 16 ± 26), and prolapse (57 ± 32 vs 22 ± 27) subscale scores, P < 0.01. Associations remained controlling for confounders ( P < 0.01). The pain catastrophizing group had higher 10-point pain scores (8 vs 6, P < 0.01) and was more likely to report pain at 2 weeks (59% vs 20%, P < 0.01) and 3 months (25% vs 6%, P = 0.01). Voiding trial failure did not differ (26% vs 28%, P = 0.98).

CONCLUSIONS

Pain catastrophizing is associated with greater pelvic floor symptom distress and impact and postoperative pain but not voiding trial failure.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative Predictors of Sacral Neuromodulation Implantation and Treatment Response: Results From the ROSETTA Trial

PURPOSE

We determined the utility of intraoperative data in predicting sacral neuromodulation outcomes in urgency urinary incontinence.

MATERIALS AND METHODS

Intraoperative details of sacral neuromodulation stage 1 were recorded during the prospective, randomized, multicenter ROSETTA trial, including responsive electrodes, amplitudes, and response strengths (motor and sensory Likert scales). Stage 2 implant was performed for stage 1 success on 3-day diary with 24-month follow-up. An intraoperative amplitude response score for each electrode was calculated ranging from 0 (no response) to 99.5 (maximum response, 0.5 V). Predictors for stage 1 success and improvement at 24 months were identified by stepwise logistic regression confirmed with least absolute shrinkage and selection operator and stepwise linear regression.

RESULTS

Intraoperative data from 161 women showed 139 (86%) had stage 1 success, which was not associated with number of electrodes generating an intraoperative motor and/or sensory response, average amplitude at responsive electrodes, or minimum amplitude-producing responses. However, relative to other electrodes, a best amplitude response score for bellows at electrode 3 was associated with stage 1 failure, a lower reduction in daily urgency urinary incontinence episodes during stage 1, and most strongly predicted stage 1 outcome in logistic modeling. At 24 months, those who had electrode 3 intraoperative sensory response had lower mean reduction in daily urgency urinary incontinence episodes than those who had no response.

CONCLUSIONS

Specific parameters routinely assessed intraoperatively during stage 1 sacral neuromodulation for urgency urinary incontinence show limited utility in predicting both acute and long-term outcomes. However, lead position as it relates to the trajectory of the sacral nerve root appears to be important.

Characteristics associated with subjective and objective measures of treatment success in women undergoing percutaneous tibial nerve stimulation vs sham for accidental bowel leakage

INTRODUCTION AND HYPOTHESIS

In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial.

METHODS

This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Mark's score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p<0.2 for each definition and interaction terms assessed differential effects of PTNS vs sham.

RESULTS

Of 166 women randomized, 160 provided data for at least one success definition. Overall, success rates were 65% (102 out of 158), 57% (90 out of 158), and 46% (73 out of 158) for ≥3-, ≥4-, and ≥5-point St Mark's reduction respectively; 43% (68 out of 157) for PGI-I; and 48% (70 out of 145) for ≥50% FIEs. Of those providing data for all definitions of success, 77% (109 out of 142) met one success criterion, 43% (61 out of 142) two, and 29% (41 out of 142) all three success criteria. No reliable or consistent factors were associated with improved outcomes with PTNS over sham regardless of definition.

CONCLUSIONS

Despite exploring diverse success outcomes, no subgroups of women with ABL differentially responded to PTNS over sham. Success results varied widely across subjective and objective definitions. Further investigation of ABL treatment success definitions that consistently and accurately capture patient symptom burden and improvement are needed.

Association of quality of prenatal care with contraceptive planning in a United States population: a retrospective cohort study

BACKGROUND

Understanding how prenatal care influences planned postpartum contraception can help guide shared decision-making. This study looks to examine the association of the quality of prenatal care with planned postpartum contraception.

METHODS

This is a retrospective cohort study conducted in a single tertiary, academic urban institution in the southwest United States. The institutional review board (IRB) for human research at Valleywise Health Medical Center approved this study. Using a validated measure of prenatal care, the Kessner index, prenatal care was classified as adequate, intermediate, or inadequate. The World Health Organization (WHO) protocol for contraceptive effectiveness was used to classify contraceptives as very effective, effective, and less effective. The planned contraceptive choice was determined at the time of hospital discharge after delivery by discharge summary. Chi-squared testing and logistic regression were used to measure associations between the adequacy of prenatal care and contraceptive planning.

RESULTS

This study included 450 deliveries, 404 (90%) patients with adequate prenatal care, and 46 (10%) patients without adequate (intermediate or inadequate) prenatal care. There was not a statistically significant difference in planning for very effective or effective methods of contraception at hospital discharge between adequate (74%) and non-adequate (61%) prenatal care groups (p = 0.06). There was no association between the adequacy of prenatal care and the effectiveness of contraceptive planning after controlling for age and parity (aOR = 1.7, 95% CI 0.89-3.22).

CONCLUSIONS

Many women chose very effective and effective methods of postpartum contraception; however, there was no statistically significant association between the quality of prenatal care and planned contraception at hospital discharge.

Long-term Urinary Outcomes After Transvaginal Uterovaginal Prolapse Repair With and Without Concomitant Midurethral Slings

IMPORTANCE

Many health care providers place concomitant midurethral slings during pelvic organ prolapse repair, yet growing evidence supports staged midurethral sling placement.

OBJECTIVES

The aim of this study was to compare urinary function after transvaginal uterovaginal prolapse repair with and without midurethral sling.

STUDY DESIGN

Secondary analysis of the Study of Uterine Prolapse Procedures Randomized Trial (hysterectomy with uterosacral ligament suspension vs mesh hysteropexy). Our primary outcome was Urinary Distress Inventory score (UDI-6) through 5 years compared between women with and without a concomitant sling within prolapse repair arms. Sling effect was adjusted for select clinical variables and interaction terms (α = .05).

RESULTS

The sling group included 90 women (43 hysteropexy, 47 hysterectomy), and the no-sling group included 93 women (48 hysteropexy, 45 hysterectomy). At baseline, the sling group reported more bothersome stress (66% vs 36%, P < 0.001) and urgency incontinence (69% vs 48%, P = 0.007). For hysteropexy, there were no significant long-term differences in UDI-6 scores or bothersome urine leakage between sling groups. For hysterectomy, women with sling had better UDI-6 scores across time points (adjusted mean difference, -5.1; 95% confidence interval [CI], -9.9 to -0.2); bothersome stress and urgency leakage were less common in the sling group (stress adjusted odds ratio, 0.1 [95% CI, 0.0-0.4]; urge adjusted odds ratio, 0.5 [95% CI, 0.2-1.0]). Treatment for stress incontinence over 5 years was similar in the sling (7.9%) versus no-sling (7.6%) groups.

CONCLUSIONS

Five-year urinary outcomes of concomitant midurethral sling may vary by type of transvaginal prolapse surgery, with possible benefit of midurethral sling at the time of vaginal hysterectomy with apical suspension but not after mesh hysteropexy.

Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial

BACKGROUND

Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking.

OBJECTIVE

Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed.

STUDY DESIGN

This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile.

RESULTS

The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years.

CONCLUSION

Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.

Improved body image after uterovaginal prolapse surgery with or without hysterectomy

INTRODUCTION AND HYPOTHESIS

The objective was to compare body image and sexual activity and function changes up to 3 years after sacrospinous ligament fixation with graft hysteropexy or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy).

METHODS

This was a planned secondary analysis of a multi-center randomized trial of women undergoing prolapse repair with mesh hysteropexy versus hysterectomy. Women were masked to intervention. The modified Body Image Scale (BIS), sexual activity status, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) scores were reported at baseline and 1.5, 6, 12, 18, 24, and 36 months after surgery. We compared mean BIS and PISQ-IR scores, the proportion of women whose BIS scores met a distribution-based estimate of the minimally important difference (MID), and sexual activity status. Comparisons were analyzed with linear and logistic repeated measures models adjusted for site, intervention, visit, and intervention by visit interaction.

RESULTS

Eighty-eight women underwent mesh hysteropexy; 87 underwent hysterectomy. Women were similar with regard to baseline characteristics, mean age 65.9 ± 7.3 years, and most had stage III or IV prolapse (81%). Baseline mean BIS scores were not significantly different, improved in both groups by 1.5 months, and were sustained through 36 months with no differences between groups (all p > 0.05). The estimated BIS MID was 3; and by 36 months, more women in the mesh hysteropexy group achieved the MID than in the hysterectomy group (62% vs 44%, p = 0.04). The makeup of the sexually active cohort changed throughout the study, making function comparisons difficult.

CONCLUSIONS

Body image improves following prolapse surgery whether or not hysterectomy is performed or transvaginal mesh is used at the time of repair; sexual activity status changes over time following prolapse surgery.

Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management

Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Ischemic stroke on hormonal contraceptives: Characteristics, mechanisms and outcome

Introduction

Systemic contraceptives increase the risk of ischemic stroke but little is known about the characteristics, mechanisms and long-term outcome post stroke of patients on hormonal contraception. We sought to To assess characteristics and outcome of acute ischemic stroke (AIS) in young women using systemic hormonal contraceptives (SHC) and compare them to strokes in non-contraceptive users.

Patients and methods

Using the Acute STroke Registry and Analysis of Lausanne (ASTRAL), we analyzed demographics, risk factors, clinical, radiological and treatment data of consecutive female patients of <50 years between 2003 to 2015. We compared groups with and without SHC in a logistic regression analysis.

Results

Of the 179 female patients of <50 years during the observation period, 57 (39.6%) used SHC, 71.9% of whom, a combined oral contraceptive pill. On logistic regression contraceptive users were significantly younger but had comparable stroke severity. They had less migraine with aura and tobacco use, and more hyperlipidaemia. Also, contraceptive users had significantly less intra and extracranial stenosis and occlusion on arterial imaging, but more focal hypoperfusion on CT-perfusion. Undetermined mechanism of stroke was more frequent with SHC users, whereas rare mechanisms were more frequent in non-users. The contraceptive user group had a more favourable adjusted 12-month outcome with significantly fewer ischemic recurrences after stopping systemic contraception in all.

Conclusion

Contraceptive users with ischemic strokes are younger and have lesser tobacco use and migraine with aura and more hyperlipidemia. Their stroke mechanism is more often undetermined using a standardised work-up, and their adjusted long-term outcome is more favourable with less stroke recurrence.

Comparison of 100 U With 200 U of Intradetrusor OnabotulinumToxinA for Nonneurogenic Urgency Incontinence

OBJECTIVES

The objective of this study was to compare efficacy and adverse events between 100 U and 200 U of onabotulinumtoxinA for 6 months in women with nonneurogenic urgency incontinence.

METHODS

This is a secondary analysis of 2 multicenter randomized controlled trials assessing efficacy of onabotulinumtoxinA in women with nonneurogenic urgency incontinence; one compared 100 U to anticholinergics and the other 200 U to sacral neuromodulation. Of 307 women who received onabotulinumtoxinA injections, 118 received 100 U, and 189 received 200 U. The primary outcome was mean adjusted change in daily urgency incontinence episodes from baseline over 6 months, measured on monthly bladder diaries. Secondary outcomes included perceived improvement, quality of life, and adverse events. The primary outcome was assessed via a multivariate linear mixed model.

RESULTS

Women receiving 200 U had a lower mean reduction in urgency incontinence episodes by 6 months compared with 100 U (-3.65 vs -4.28 episodes per day; mean difference, 0.63 episodes per day [95% confidence interval (CI), 0.05-1.20]). Women receiving 200 U had lower perceptions of improvement (adjusted odds ratio, 0.32 [95% CI, 0.14-0.75]) and smaller improvement in severity score (adjusted mean difference, 12.0 [95% CI, 5.63-18.37]). Upon subanalysis of only women who were treated with prior anticholinergic medications, these differences between onabotulinumtoxinA doses were no longer statistically significant. There was no statistically significant difference in adverse events in women receiving 200 U (catheterization, 32% vs 23%; adjusted odds ratio, 1.4 [95% CI, 0.8-2.4]; urinary tract infection, 37% vs 27%; adjusted odds ratio, 1.5 [95% CI, 0.9-2.6]).

CONCLUSIONS

A higher dose of onabotulinumtoxinA may not directly result in improved outcomes, but rather baseline disease severity may be a more important prediction of outcomes.

Characterization of symptom severity and impact on four fecal incontinence phenotypes in women presenting for evaluation

AIM

To characterize symptom-specific distress and impact on quality of life (QOL) among women with urge, passive, and combined urge/passive fecal incontinence (FI) phenotypes. A secondary aim was to characterize FI symptom-specific distress and impact on women with a novel fourth phenotype, stress FI.

METHODS

Women with at least monthly FI from 2003 to 2017 were included. Participants completed the Modified Manchester Health Questionnaire (MMHQ) including MHQ and Fecal Incontinence Severity Index (FISI). Anorectal manometry (ARM) and endoanal ultrasound (EAUS) testing was performed. Total MHQ and FISI scores were compared across FI subtypes controlling for pertinent baseline covariates.

RESULTS

The cohort included 404 subjects, 220 meeting criteria for urge FI, 67 passive FI, and 117 combined urge/passive FI. On MHQ, women with combined urge/passive FI were most impacted (p < 0.01). FISI scores were significantly different from combined urge/passive FI having the greatest impact (38.1 ± 12.5) and urge FI (31.1 ± 11.3), p < 0.01 having the least. No differences were observed in ARM measurements or anal sphincter defects among the three groups (all p > 0.05). Twenty-nine subjects were identified with stress FI. There were no differences in overall MHQ or FISI scores or anal sphincter evaluation among the urge, passive, and stress FI groups (all p > 0.05).

CONCLUSION

Women with combined urge/passive FI have higher symptom distress and impact on QOL than urge or passive FI alone. Further research is needed to determine the significance of stress FI as a subtype and response to treatment.

Effect of darifenacin on fecal incontinence in women with double incontinence

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION

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

Impact of treatment for fecal incontinence on constipation symptoms

OBJECTIVE

Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment.

STUDY DESIGN

This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks.

RESULTS

At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4).

CONCLUSION

Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.

Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence.

METHODS

This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse.

RESULTS

Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II.

CONCLUSIONS

Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.

Pelvic floor disorder symptoms and bone strength in postmenopausal women

INTRODUCTION AND HYPOTHESIS

The current study is aimed at characterizing the association between pelvic floor disorder symptoms and bone strength reflecting a potential connective tissue pathophysiology in postmenopausal women.

METHODS

A cross-sectional study was conducted in postmenopausal women undergoing osteoporosis evaluation from 2007 to 2010. Urinary incontinence (UI) was defined as urinary leakage ≥2-3 times/week. UI types were defined using the 3 Incontinence Questionnaire. Fecal incontinence was defined as stool leakage ≥1/month, and pelvic organ prolapse as a positive response to "Do you have a bulge or something falling out that you can see or feel in your vaginal area?" Bone quality and quantity were assessed using the trabecular bone score (TBS) and bone mineral density respectively: bone strength was defined by combined quality/quantity index, low strength being equivalent to moderate to severe fracture risk; low quality as TBS ≤ 1.31; low quantity by T-score <-1 or on osteoporosis medication.

RESULTS

Of 681 subjects, 262 had low bone strength whereas 419 were normal using the combined quality/quantity bone assessment. Characteristics were similar except for age (low bone strength: 69.0 ± 8.2 vs normal: 65.0 ± 7.1, p < 0.01) and smoking (8.8% vs 3.3%, p < 0.01). Low bone strength was associated with any UI (adjusted odds ratio [aOR]: 1.48, 1.05-2.10), stress (aOR: 1.53, 1.06-2.21), and mixed (aOR :1.45, 1.02-2.05). Women with low bone quality had increased odds of UI (any, urgency, mixed), whereas none of the pelvic floor disorder symptoms was associated with low bone quantity.

CONCLUSIONS

Low bone strength defined by a combined quantity/quality index, as well as low bone quality alone, were associated with increased risk of UI.

Self-management of accidental bowel leakage and interest in a supportive m-Health app among women

INTRODUCTION

Self-management with clinician guidance is a cornerstone of successful conservative treatment for accidental bowel leakage (ABL). There are currently few resources to assist patients with that essential self-management. The purpose of this study was to describe self-management of ABL and explore interest in a mobile health application (m-Health app) for supporting ABL self-management among community-living women.

METHODS

Using an observational/descriptive design, women (18+ years) previously seen in a urogynecology clinic for ABL were mailed a survey containing eight multiple-choice questions and an open-ended prompt for comments.

RESULTS

Survey responses were received from 161 women (18% response rate). The highest percentage of participants was aged 61-70 years (39%). Nearly half of the participants (47%) "did not know anything" about ABL self-management before visiting a clinician. Only 4% "knew a lot." Of those who have been trying to self-manage their ABL (n = 132), 37% reported that it was not effective, and only 5% thought their self-management was "very effective." Half (50%) of the participants had "a lot of" interest in an m-Health app to support managing ABL, and 30% had "some" interest. The vast majority (89%) thought that it was "very important" to have ongoing guidance and support for self-managing ABL.

CONCLUSIONS

Before visiting a clinician, most women with ABL lacked knowledge about ABL self-management, and their self-management was not very effective. Women thought having guidance to self-manage ABL was important. There would be good interest among women in an m-Health app supporting self-management of ABL if one were created.

Anal Sphincter Anatomy Prepregnancy to Postdelivery Among the Same Primiparous Women on Dynamic Magnetic Resonance Imaging

OBJECTIVES

The authors used 2-dimensional images from pelvic 3 T magnetic resonance imaging (MRI) to characterize changes in the internal anal sphincter (IAS) and external anal sphincter (EAS) from prepregnancy to postdelivery in the same cohort.

METHODS

This secondary analysis studied a prospective cohort of women undergoing 3 T MRI before their first pregnancy and 6 or more months after delivery. Radial thickness was measured at 12, 3, 9, and 6 o'clock from axial proximal and mid views and oblique distal views of the IAS, and at 3 and 9 o'clock from oblique views of the EAS. Measurements were compared prepregnancy to postdelivery; 10 women had 80% power (α = 0.05) to detect a 0.85-mm change.

RESULTS

Nineteen women completed initial 3 T MRI, 15 achieved pregnancy and birth, and 10 completed postdelivery MRI (4 vaginal birth and 6 Cesarean delivery). Mean change in measurement from prepregnancy to postdelivery was -0.01 mm ± 1.03 mm for the distal 12 o'clock IAS (P = 0.98) and +0.19 ± 0.64 mm for the lateral EAS (P = 0.32). All prepregnancy and postdelivery women had discontinuous EA sphincters at 6 and 12 o'clock. There were no statistically significant changes from prepregnancy to postdelivery in any IAS or EAS location (all >0.05) for the entire cohort, those with vaginal birth, or after Cesarean.

CONCLUSIONS

Anal sphincter measurements on MRI did not change significantly in nulliparous women prepregnancy to postdelivery at any location, and the EAS was not measurable at 12 o'clock in any women at either time point, challenging classic concepts of EAS anatomy.

The Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing

Seventy four Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) have been recognised by the European Commission in 2016 for their commitment to excellence in investing and scaling up innovative solutions for active and healthy ageing. The Reference Site Collaborative Network (RSCN) brings together the EIP on AHA Reference Sites awarded by the European Commission, and Candidate Reference Sites into a single forum. The overarching goals are to promote cooperation, share and transfer good practice and solutions in the development and scaling up of health and care strategies, policies and service delivery models, while at the same time supporting the action groups in their work. The RSCN aspires to be recognized by the EU Commission as the principal forum and authority representing all EIP on AHA Reference Sites. The RSCN will contribute to achieve the goals of the EIP on AHA by improving health and care outcomes for citizens across Europe, and the development of sustainable economic growth and the creation of jobs.

Impact of age on mid- to long-term outcomes of transvaginal native tissue repair for apical vaginal prolapse

AIMS

To compare surgical success rates in older versus younger women a minimum of 3 years post transvaginal native tissue repair for apical prolapse. Post-operative symptom severity and quality of life improvement, surgical complications and retreatment were also examined.

METHODS

Women who underwent transvaginal native tissue repair for apical prolapse between 2011 and 2013 were eligible. Subjects completed the pelvic floor distress inventory (PFDI-20), pelvic floor impact questionnaire (PFIQ-7), and patient global impression of improvement (PGI-I), and were categorized as "younger" (age <70) or "older" (age ≥70). The primary outcome of surgical success was defined as the absence of bulge symptoms and no re-treatment for prolapse.

RESULTS

Of 641 eligible patients, response rate was 51.0%. 62.7% of subjects had hysterectomy prior to index surgery. Surgical success was noted in 72.9% of younger and 82.2% of older subjects (Adjusted odds ratio [aOR] 1.72, 95% CI [0.93, 3.17]). Older women had greater improvement from baseline in PFDI-20 score (-87.5 [IQR 74.0] vs -54.2 [IQR 80.2], P = 0.01). Retreatment rate and surgical complication rates were similar between groups (both P > 0.05).

CONCLUSIONS

Older and younger women had similar surgical success rates a minimum of 3 years post-operative; however, older women had a greater overall symptom severity improvement. This information may be helpful in counseling older women regarding surgical expectations and decision-making.

F-18-FDG-hybrid-camera-PET in patients with postoperative fever

Aim: Evaluation of F-18-FDG-hybrid-camera-PET imaging in patients with undetermined postoperative fever (POF). Methods: Prospective study of 18 patients (9 women, 9 men; age 23-85 years) suffering from POF with 2-fluoro-2’-deoxyglucose (F-18-FDG) using a dual headed coincidence camera (DHCC). Surgery had been performed 5-94 days prior to our investigation. 13 of the 18 patients received antibiotic therapy during the time of evaluation. Ten (55%) had an infectious and eight (45%) a non infectious cause of fever. Results: Increased F-18-FDG-uptake outside the surgical wound occurred in 13 regions (infection n = 11, malignancy n = 2). The sensitivity of F-18-FDG-hybrid-camera-PET in imaging infection in areas outside the surgical wound was 86% and the specificity 100%, respectively. Antibiotic therapy did not negatively influence the results of F-18-FDG-scanning. Increased F-18-FDG-uptake within the surgical wound was seen in 8 of 18 patients. The sensitivity of F-18-FDG-hybrid-camera-PET in imaging infection within the surgical wound was 100% and the specificity 56%, respectively. The interval between surgery and F-18-FDG-scanning was significantly shorter in patients with false positive results compared with patients showing true negative results (median 34 vs. 54 days; p = 0,038). Conclusion: In POF-Patients, F-18-FDG transaxial tomography performed with a F-18-FDG-hybrid-camera-PET is sensitive in the diagnosis of inflammation and malignant disease within and outside the surgical wound. Because of the accumulation of the tracer both in granulation tissue and infection, the specificity in detecting the focus of fever within the surgical wound is poor.

Dermatological moulage collections in the Nordic countries

BACKGROUND

The art of producing and acquiring dermatological wax models, moulages, flourished all over Europe in the beginning of the twentieth century, whereas very little is known about the existence of moulage collections in the Nordic countries.

OBJECTIVE

The aim of this study was to elucidate the presence, the origin, the production place, the use and the condition of dermatological moulage collections in the Nordic countries.

METHODS

In each Nordic country, an extensive survey was undertaken during spring 2016. Dermatological departments, museums with medical collections, persons assumed to have specific information about wax moulages as well as secondary sources were contacted and interviewed.

RESULTS

Several hitherto undescribed collections have survived in each country, most, however, damaged and in disrepair. One Danish and part of a Finnish collection have been restored. Only few moulages are exhibited and some have been photographed and digitalized. Denmark and Sweden have had a local moulage production. Responses to the survey indicate that the result covers all collections of dermatological moulages in the Nordic countries, though some moulages may remain in private collections unknown to the authors, or uncatalogued in museums.

CONCLUSION

Moulages are medical gems from bygone days before modern technology facilitated new means of communication. Restoration and appropriate storing should be considered for at least selected items from the Nordic collections.

Vaginal Changes Due to Varying Degrees of Rectocele Prolapse: A Computational Study

Pelvic organ prolapse (POP), downward descent of the pelvic organs resulting in a protrusion of the vagina, is a highly prevalent condition, responsible for 300,000 surgeries in the U.S. annually. Rectocele, a posterior vaginal wall (PVW) prolapse of the rectum, is the second most common type of POP after cystocele. A rectocele usually manifests itself along with other types of prolapse with multicompartment pelvic floor defects. To date, the specific mechanics of rectocele formation are poorly understood, which does not allow its early stage detection and progression prediction over time. Recently, with the advancement of imaging and computational modeling techniques, a plethora of finite element (FE) models have been developed to study vaginal prolapse from different perspectives and allow a better understanding of dynamic interactions of pelvic organs and their supporting structures. So far, most studies have focused on anterior vaginal prolapse (AVP) (or cystocele) and limited data exist on the role of pelvic muscles and ligaments on the development and progression of rectocele. In this work, a full-scale magnetic resonance imaging (MRI) based three-dimensional (3D) computational model of the female pelvic anatomy, comprising the vaginal canal, uterus, and rectum, was developed to study the effect of varying degrees (or sizes) of rectocele prolapse on the vaginal canal for the first time. Vaginal wall displacements and stresses generated due to the varying rectocele size and average abdominal pressures were estimated. Considering the direction pointing from anterior to posterior side of the pelvic system as the positive Y-direction, it was found that rectocele leads to negative Y-direction displacements, causing the vaginal cross section to shrink significantly at the lower half of the vaginal canal. Besides the negative Y displacements, the rectocele bulging was observed to push the PVW downward toward the vaginal hiatus, exhibiting the well-known "kneeling effect." Also, the stress field on the PVW was found to localize at the upper half of the vaginal canal and shift eventually to the lower half with increase in rectocele size. Additionally, clinical relevance and implications of the results were discussed.

Why do people buy dogs with potential welfare problems related to extreme conformation and inherited disease? A representative study of Danish owners of four small dog breeds

A number of dog breeds suffer from welfare problems due to extreme phenotypes and high levels of inherited diseases but the popularity of such breeds is not declining. Using a survey of owners of two popular breeds with extreme physical features (French Bulldog and Chihuahua), one with a high load of inherited diseases not directly related to conformation (Cavalier King Charles Spaniel), and one representing the same size range but without extreme conformation and with the same level of disease as the overall dog population (Cairn Terrier), we investigated this seeming paradox. We examined planning and motivational factors behind acquisition of the dogs, and whether levels of experienced health and behavior problems were associated with the quality of the owner-dog relationship and the intention to re-procure a dog of the same breed. Owners of each of the four breeds (750/breed) were randomly drawn from a nationwide Danish dog registry and invited to participate. Of these, 911 responded, giving a final sample of 846. There were clear differences between owners of the four breeds with respect to degree of planning prior to purchase, with owners of Chihuahuas exhibiting less. Motivations behind choice of dog were also different. Health and other breed attributes were more important to owners of Cairn Terriers, whereas the dog’s personality was reported to be more important for owners of French Bulldogs and Cavalier King Charles Spaniels but less important for Chihuahua owners. Higher levels of health and behavior problems were positively associated with a closer owner-dog relationship for owners of Cavalier King Charles Spaniels and Chihuahuas but, for owners of French Bulldogs, high levels of problems were negatively associated with an intention to procure the same breed again. In light of these findings, it appears less paradoxical that people continue to buy dogs with welfare problems.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Parturition pit: the bony imprint of vaginal birth

PURPOSE

To retrospectively evaluate for pits along the dorsum of the pubic body in females and compare the presence/absence of these pits to vaginal birth data.

MATERIALS AND METHODS

We retrospectively reviewed females with vaginal birth data who underwent pelvic CT. The presence of pits along the dorsum of the pubic body, pit grade (0 = not present; 1 = faintly imperceptible; 2 = present; 3 = prominent), and the presence of osteitis condensans ilii, preauricular sulcus, and sacroiliac joint vacuum phenomenon were assessed on imaging. Musculoskeletal radiologists who were blinded to the birth data evaluated the CTs. 48 males were also evaluated for the presence of pits.

RESULTS

482 female patients underwent CT pelvis and 171 were excluded due to lack of vaginal birth data. Of the 311 study patients, 262 had prior vaginal birth(s) and 194 had pits on CT. Only 7 of the 49 patients without prior vaginal birth had pits. There was a statistically significant association between vaginal birth and presence of pits (p < 0.0001). Patients with more prominent pits (grades 2/3) had a greater number of vaginal births. As vaginal deliveries increased, the odds of having parturition pits greatly increased, adjusting for age and race at CT (p < 0.0001). No males had pits.

CONCLUSION

Our study indicates that parturition pits are associated with prior vaginal birth and should be considered a characteristic of the female pelvis. The lytic appearance of prominent pits on imaging can simulate disease and create a diagnostic dilemma for interpreting radiologists.

Synthetic Graft Augmentation in Vaginal Prolapse Surgery: Long-Term Objective and Subjective Outcomes

OBJECTIVE

To report long-term objectives and subjective outcomes in women who underwent prolapse surgery with a synthetic graft augmentation.

DESIGN

Retrospective analysis (Canadian Task Force classification II-3).

SETTING

University hospital in the southeastern United States.

PATIENTS

Women with symptomatic pelvic organ prolapse who underwent transvaginal graft augmentation using the Prolift mesh system between July 2006 and December 2008 for a minimum 5-year follow-up.

INTERVENTIONS

Subjects completed the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), and the Patient Satisfaction Questionnaire. Subjects also underwent postoperative physical examination with Pelvic Organ Prolapse Quantification (POP-Q) and vaginal pain/stricture assessment. Long-term postoperative findings were compared with preoperative baseline data.

MEASUREMENTS AND MAIN RESULTS

Of 208 eligible subjects, 70 completed the questionnaires only, and 48 of these 70 provided both postoperative examination and questionnaire data. The mean duration of follow-up was 7.0 ± 0.7 years (range, 5.8-8.1 years). POP-Q measurements of Ba (point B anterior), Bp (B posterior), C (cervix), GH (genital hiatus), PB (perineal body), and overall pelvic organ prolapse stage were significantly improved (all p < .001 except for PB, p = .006). PFIQ-7 (total, Urinary Impact Questionnaire, and Pelvic Organ Prolapse Impact Questionnaire) and PFDI-20 (total, Urinary Distress Inventory, and Pelvic Organ Prolapse Distress Inventory) scores significantly improved (all p < .001). No differences were noted in the colorectal-anal subscales (Colorectal-Anal Impact Questionnaire and Colorectal-Anal Distress Inventory) and PISQ scores at >5-year follow-up (all p > .05). Satisfaction rates were 15.7% for not at all, 35.7% for somewhat, and 48.6% for completely satisfied. Complications included graft exposure (n = 3; 6%) and dyspareunia (n = 25; 36%).

CONCLUSION

Women undergoing transvaginal prolapse surgery using a synthetic graft continue to have positive objective and subjective outcomes, leading to significantly improved quality of life at a minimum 5-year follow-up.

Impact of fecal incontinence and its treatment on quality of life in women

Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.