Randomized Trial of 3 Techniques of Perineal Skin Closure During Second‐Degree Perineal Laceration Repair

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151863/1/jmwh13020.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151863/2/jmwh13020_am.pd

Self-report of difficult defecation is associated with overactive bladder symptoms

Aims The association of dysfunctional bowel elimination with lower urinary tract symptoms is well known in children, but not in adults. It was our objective to assess lower urinary tract symptoms (LUTS) in women who report difficult defecation (DD). Methods This is a secondary analysis of 2,812 women, aged 35–64, who participated in a telephone interview. All subjects were asked “When you move your bowels, does the stool come out easily?” DD was considered present in those answering “no.” All subjects were queried regarding LUTS, urinary infections in the past year, self-perceived health status, medical history, and demographics. Symptoms of stress incontinence (five items), urge incontinence (five items), and the impact of these symptoms on their quality of life were solicited from subjects reporting more than 12 episodes of incontinence in 1 year. Results DD was reported by 10.4% (290/2,790) of women. Women with DD had higher LUTS than those who did not: nocturia (mean 1.8 ± 0.1 vs. 1.3 ± 0.0), urgency (47.6% vs. 29.2%), increased daytime frequency (mean 8.2 ± 0.3 vs. 7.2 ± 0.1), dysuria (22.9% vs. 13.7%), and a sensation of incomplete bladder emptying (55.6% vs. 28.2%). DD women were more often menopausal, reported a fair or poor self-reported health status, and had a higher number of comorbidities, less formal education, and lower annual household income. Conclusions Women with symptoms of DD have an increased rate of LUTS, consistent with the diagnosis of overactive bladder without incontinence. The pathophysiology underlying this association is worthy of future research. Neurourol. Urodynam. 29:1290–1294, 2010. © 2009 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78056/1/20839_ftp.pd

Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse

ObjectiveTo evaluate whether major levator ani muscle defects were associated with differences in postoperative vaginal support after primary surgery for pelvic organ prolapse (POP).MethodsA retrospective chart review of a subgroup of patients in the Organ Prolapse and Levator (OPAL) study. Of the 247 women recruited into OPAL, 107 underwent surgery for prolapse and were the cohort for the present analysis. Major levator ani defects were diagnosed when more than 50% of the pubovisceral muscle was missing on MRI. Postoperative vaginal support was assessed via POPâ quantification system. Postoperative anatomic outcome was analyzed according to levator ani defect status, as determined by MRI.ResultsSupport of the anterior vaginal wall 2 cm above the hymen occurred among 62% of women with normal levator ani muscles/minor defects and 35% of those with major defects. Support of the anterior wall 1 cm above the hymen occurred among 32% women with normal muscles /minor defects and 59% of those with major defects. Levator ani defects were not associated with differences in postoperative apical/posterior vaginal support.ConclusionSix weeks after primary surgery for prolapse, women with normal levator ani muscles/minor defects had better anterior vaginal support than those with major levator defects.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135557/1/ijgo141.pd

Racial differences in self‐reported healthcare seeking and treatment for urinary incontinence in community‐dwelling women from the EPI study

Aims Objectives of this study are: (1) to examine the prevalence of healthcare seeking among black and white women with self‐reported urinary incontinence (UI), (2) to investigate barriers to treatment for incontinence, and (3) To investigate commonly used therapeutic modalities for UI. Methods This is a planned secondary analysis of responses from 2,812 black and white community‐dwelling women living in southeastern Michigan, aged 35–64 years, who completed a telephone interview concerning UI, healthcare‐seeking behaviors and management strategies. The study population was 571 subjects (278 black, 293 white) who self‐identified as having urinary incontinence. Results Of these women with UI, 51% sought healthcare with no statistically significant difference between the two races (53% black, 50.6% white, P  = 0.64). In multivariate logistic regression analysis, a higher likelihood of seeking healthcare was associated with increased age, body mass index lower than 30 kg/m 2 , prior surgery for UI, having regular pelvic exams, having a doctor, and worsening severity of UI. There was no significant association between hypothesized barriers to care seeking and race. Almost 95% of the subjects identified lack of knowledge of available treatments as one barrier. Black and white women were similar in percentage use of medications and some self‐care strategies, for example, pad wearing and bathroom mapping, but black women were significantly more likely to restrict fluid intake than white women and marginally less likely to perform Kegels. Conclusions Black and white women seek healthcare for UI at similar, low rates. Improved patient‐doctor relationships and public education may foster healthcare seeking behavior. Neurourol. Urodynam. Neurourol. Urodynam. 30: 1442–1447, 2011. © 2011 Wiley Periodicals, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87061/1/21145_ftp.pd

Experiences during the first four years of a postpartum perineal clinic in the USA

ObjectiveTo assess the characteristics of patients seen at a postpartum perineal clinic in the USA during the first 4 years of its existence, and to identify factors contributing to the clinic’s success.MethodsIn a retrospective study, the charts of patients presenting to the clinic between July 1, 2007, and June 30, 2011, were reviewed for presenting complaint, findings, treatment, number of visits, and referral source. Strategies that led to successful clinic implementation were reviewed.ResultsA total of 247 patients were seen during the 4‐year period. Indications for referral included lacerations, pain, urinary and fecal incontinence, and fistulas. The most common referral indication was a third‐ or fourth‐degree laceration, which affected 154 (62.3%) patients. Overall, 53 (21.5%) patients required a procedure, of whom 20 (8.1%) underwent surgery. Most women were counseled about pelvic floor exercises, and 39 (15.8%) were referred for pelvic floor physical therapy. Nurse‐led triage, patient education, and follow‐up were key to the success of the program.ConclusionThe postpartum perineal clinic is sustainable and offers an opportunity for early assessment and treatment of pelvic floor dysfunction after a complicated vaginal delivery.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135192/1/ijgo68.pd

Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures

The aim of this study was to document longer-term follow-up of patients in a previously reported series who underwent either sacrocolpopexy (SCP) or suburethral sling procedures utilizing freeze-dried, irradiated donor fascia. Subjects from the initial series of 67 SCPs and 35 slings were included in this retrospective chart review of postoperative follow-up where surgical follow-up longer than 3 months from the procedure was available. Subjects undergoing SCP were examined at the time of any clinical visit and their pelvic organ support evaluated utilizing the POP-Q system. The SCP procedure was considered to be unsuccessful if any anterior vaginal wall point (Aa or Ba) was at the hymen or beyond, or if the vaginal apical point (C or D) descended to a point at least halfway to the hymen from a position of perfect apical support. Subjects who did not return for clinical examination after their 3-month postoperative visit but who had been in telephone contact with the clinic stating that they had experienced symptomatic recurrence of their POP were also included as having unsuccessful SCP procedures. Those similarly in contact with the office by telephone, but not clinically examined, who indicated no subjective return of their POP, were coded as successful. The outcome of the sling procedure was primarily evaluated subjectively, with the patient indicating that stress incontinence symptoms were present or absent. Follow-up was available for 75 patients, who had undergone 54 SCP and 27 sling procedures (6 patients had undergone both SCP and sling procedures). When failure was defined according to any of the criteria listed in the methods section, 45 (83%) patients experienced SCP failure at a median of 12 months after surgery. A total of 14 (52%) sling procedures were failures, with recurrent SUI symptoms experienced from 2 weeks to 24 months (median 3 months) after the procedure. One year after surgery, 23 (43%) SCPs were known to be failures, and 11 (41%) slings were known to be failures. The remaining 13 (48%) slings were subjectively successful when last seen 7–51 months after surgery. We reoperated on 21 (40%) patients. At the time of repeat SCP (chosen by 16 patients) we found graft between the sacrum and vagina in just 3 patients (19%). The use of freeze-dried, irradiated donor fascia for both SCP and sling procedures was associated with an unacceptably high failure rate in our series.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/45893/1/192_2004_Article_1146.pd

Self‐reported natural history of recurrent prolapse among women presenting to a tertiary care center

ObjectiveTo describe the characteristics of recurrent pelvic organ prolapse (POP).MethodsA convenience sample of patients presenting with recurrent POP symptoms between October 2007 and February 2010 completed questionnaires. The survey focused on timing of recurrence(s), symptoms, and demographics.ResultsNinety‐seven women completed questionnaires. Thirty‐four (35.1%) had undergone multiple prior treatments. Overall, 23 of 76 (30.3%) women had not informed their surgeon of the recurrence. Twenty‐seven of 59 (45.8%) women reported that their symptoms were the same as before treatment, whereas 23 of 59 (39.0%) reported more severe symptoms. POP was considered to be persistent if symptoms returned within 3 months, and recurrent if symptom relief exceeded 3 months. After primary surgery, 28 of 79 (35.4%) cases were considered to be persistent, whereas 51 (64.6%) cases were recurrent. Similar percentages were seen after second and third treatments.ConclusionOverall, 35% of participants experienced early return of symptoms. Almost one‐third of participants had not informed their surgeon of the recurrence, indicating that there may not be an accurate self‐assessment of outcome in the absence of careful follow‐up.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135685/1/ijgo53.pd

Fecal incontinence in pregnancy and post partum

ObjectiveTo assess the prevalence of fecal incontinence (FI) during pregnancy and post partum, and to determine any associations with demographic and birth variables.MethodsSecondary analysis of 240 primiparous women conducted during pregnancy and post partum. Women were asked at various time points if they had lost control over their stool or bowel movements, and if they were practicing Kegel exercises. Associations of bowel symptoms with demographic and birth data were evaluated.ResultsMost participants were white (87%), with a median age of 30 years (range, 18â 42 years). Women who reported fecal incontinence at 1 year were more educated than those who did not report it. No other demographic or birth data were associated with fecal incontinence at 1 year.ConclusionsPrevalence of FI during pregnancy and post partum is low and not linked to lowâ risk birth. Furthermore, when FI occurs it is often sporadic. This should be reassuring to patients and providers alike.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135542/1/ijgo236.pd

Antibiotic use during repair of obstetrical anal sphincter injury: a quality improvement initiative

ObjectiveTo evaluate the effects of a quality improvement initiative regarding the administration of antibiotics at the time of obstetric anal sphincter injury (OASIS) repair.MethodsAt University of Michigan—a tertiary care center in Ann Arbor, MI, USA, we implemented a quality improvement intervention aimed at administering a single dose of broad‐spectrum antibiotics at the time of OASIS repair. Best practice recommendations and reminders were presented to the department. Cefazolin plus metronidazole or clindamycin plus gentamycin were the recommended antibiotics. The effects of this intervention were assessed based on a chart review of deliveries between January 4, 2014 and February 13, 2019, which included patient data both pre‐initiative and post‐initiative to compare the prevalence of antibiotic use at the time of OASIS repair.ResultsRecommended antibiotic use increased from 0.3% (1/372) pre‐initiative to 75.7% (106/140) post‐initiative (P < 0.001), and any antibiotic use increased from 6.5% (24/372) to 82.9% (116/140, P < 0.001). The proportion of cases complicated by wound infection/breakdown decreased by 55% after the quality improvement intervention (3.2% pre‐intervention vs 1.4% post‐intervention, P = 0.22).ConclusionFollowing a departmental quality improvement intervention aimed at increasing antibiotic administration at the time of OASIS repair, antibiotic use increased 13‐fold. Although underpowered to detect a significant difference in wound complications, our study showed a clinically meaningful decrease in wound infection/breakdown with antibiotic administration.SynopsisFollowing implementation of a quality improvement intervention aimed at increasing antibiotic administration at the time of obstetric anal sphincter injury repair, antibiotic use increased 13‐fold.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/171227/1/ijgo13623_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171227/2/ijgo13623-sup-0001-AppendixS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171227/3/ijgo13623.pd