The Association Between Distances Traveled for Care and Treatment Choices for Pelvic Floor Disorders in a Rural Southwestern Population

OBJECTIVES: To determine if distance traveled for care influenced patient choice for conservative vs. surgical treatment for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI). METHODS: Retrospective chart review of all new patients seen in the Urogynecology clinic at the University of New Mexico Hospital (UNMH) from January 2007 through September 2011. Data collected included medical history, Pelvic Organ Prolapse Quantification (POPQ) examination, and validated quality of life questionnaires. RESULTS: 1384 women were identified with POP and/or SUI. Women traveled an average of 50 miles to receive care at UNMH. After multivariable analysis, greater distance traveled was associated with increased likelihood of choosing surgery, OR 1.45 [1.18-1.76]. More advanced disease as measured by higher stage of prolapse, OR 3.43 [2.30-5.11], and positive leak with empty supine cough test, OR 1.94 [1.45-2.59] were also associated with choosing surgical management. CONCLUSIONS: Women who travel further for care and women with more advanced pelvic organ prolapse and/or stress urinary incontinence are more likely to choose surgical management for pelvic floor disorders

Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization

To estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare healthcare costs and utilization in patients with different severities of FI to those without FI

Risk factors for lower urinary tract injury at the time of hysterectomy for benign reasons

None of the authors has any conflicts of interest to report except for Dr. Rebecca G. Rogers, who is DSMB chair for American Medical Systems Transform Trial, UptoDate royalties, ACOG royalties, and is on the executive board of the ACOG. Dr. Gena Dunivan is a member of the AUGS Education Committee

Epidemiology, Pathophysiology and Classification of Fecal Incontinence: State of the Science Summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Workshop

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but is often underreported as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (co-morbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multi-faceted anorectal dysfunctions. The type (urge, passive or combined); etiology (anorectal disturbance, bowel symptoms or both); and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI

Gender Bias Experiences of Female Surgical Trainees

Objective Medical schools now average approximately 50% female students, yet a disproportionate number of women continue to choose nonsurgical over surgical specialties. Once in training, studies indicate that pervasive gender stereotypes, sexism and harassment negatively affect female surgeons. The aim of this study is to describe female surgeons’ experiences with gender bias and microaggressions in the workplace during residency and fellowship training, and understand if differences exist in the experiences of trainees in male-dominant vs female-dominant surgical specialties. Design A mixed methods approach was used to explore the experiences of female surgical trainees. Participants were recruited from all surgical disciplines at an academic center. Initially, focus groups were used to explore themes that trainees face related to gender bias. A trained moderator conducted all focus groups, which were audio recorded and transcribed. Qualitative analysis of de-identified transcripts was performed to identify emerging themes. We then created an online survey using the validated 44-question Sexist Microaggression Experiences and Stress Scale to assess frequency and psychologic impact of these events with additional questions developed from the focus groups. The survey was sent to all female residents and fellows at one academic institution. Setting University of New Mexico Hospital, a tertiary care academic medical center. Participants Fifteen female surgical trainees participated in focus groups. Thirty-three female surgical trainees participated in the online survey. Results Two focus groups including 15 female trainees were conducted, revealing 4 themes: Exclusion, Adaptation, Increased effort, and Development of Resilience Strategies. All participants had experienced gender bias or discrimination during medical school or surgical training. The quantitative survey had a 66% response rate (33/50 female trainees). Significant differences were found in the experience of female trainees in male-dominant vs female-dominant specialties, with those in male-dominant fields often reporting more frequent, severe, and stressful microaggression experiences. When describing how gender bias would affect their future in medicine, trainees in male-dominant specialties were more likely to report that due to gender bias, they “may leave medicine/retire early” (33% vs 6%, p = 0.040) and that they “would not recommend my profession to trainees or family members” (40% vs 6%, p = 0.015).” Conclusions Female surgical trainees continue to experience gender bias. A culture of sexism leads to physical and social adaptations to fit into the role of surgeon. Participants expressed significant effort to sustain this level of adaptation, leading to fatigue and creation of resilience mechanisms. The environment in which a trainee operates (male-dominant vs female-dominant) significantly impacts their experience. Those experiencing more bias were less likely to recommend their specialty and reported plans to leave medicine earlier. Culture change across institutions and system-level interventions are necessary to create meaningful and sustainable change that improves the experience of female surgical trainees

Perineal body stretch during labor does not predict perineal laceration, postpartum incontinence, or postpartum sexual function: a cohort study.

INTRODUCTION AND HYPOTHESIS: The perineum stretches naturally during obstetrical labor, but it is unknown whether this stretch has a negative impact on pelvic floor outcomes after a vaginal birth (VB). We aimed to evaluate whether perineal stretch was associated with postpartum pelvic floor dysfunction, and we hypothesized that greater perineal stretch would correlate with worsened outcomes. METHODS: This was a prospective cohort study of primiparous women who had a VB. Perineal body (PB) length was measured antepartum, during labor, and 6 months postpartum. We determined the maximum PB (PBmax) measurements during the second stage of labor and PB change (ΔPB) between time points. Women completed functional questionnaires and had a Pelvic Organ Prolapse Quantification (POP-Q) system exam 6 months postpartum. We analyzed the relationship of PB measurements to perineal lacerations and postpartum outcomes, including urinary, anal, and fecal incontinence, sexual activity and function, and POP-Q measurements. RESULTS: Four hundred and forty-eight women with VB and a mean age of 24 ± 5.0 years with rare (5 %) third- or fourth-degree lacerations were assessed. During the second stage of labor, 270/448 (60 %) had perineal measurements. Mean antepartum PB length was 3.7 ± 0.8 cm, with a maximum mean PB length (PBmax) during the second stage of 6.1 ± 1.5 cm, an increase of 65 %. The change in PB length (ΔPB) from antepartum to 6 months postpartum was a net decrease (-0.39 ± 1.02 cm). PB change and PBmax were not associated with perineal lacerations or outcomes postpartum (all p \u3e 0.05). CONCLUSIONS: PB stretch during labor is unrelated to perineal laceration, postpartum incontinence, sexual activity, or sexual function

Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial.

Introduction and hypothesisMixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.MethodsESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.ResultsThe final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.ConclusionsWe describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making