Ethnicity as an independent predictor of incontinence care seeking when theoretical modeling is used.

Urinary incontinence is a major public health problem affecting 30% of community dwelling women aged 35-85. Urinary incontinence may have a significant impact on activities of daily living depending on the severity of symptoms. Women with urinary incontinence suffer from psychological distress associated with the self-imposed social isolation required to hide their disorder from friends and family. The annual health care costs for managing urinary incontinence has been estimated at nearly 26 million dollars and 70% of these costs are attributed to remedies that are not covered by healthcare insurance. Yet, only 25-50% of incontinence sufferers seek professional care for symptoms. The prevalence rate of urinary incontinence is similar for women from varying ethnic backgrounds. Yet health care disparities may exist amongst incontinent women from varying ethnic backgrounds for a number of reasons including access to care differences. Recently, one study identified ethnicity as an independent predictor of incontinence care seeking during bivariate analysis. However measures of symptom severity explained the association between ethnicity and incontinence care seeking during multivariate analysis. The purpose of this study was to determine if ethnicity was an independent predictor of incontinence care seeking using the Theory of Care Seeking Behavior to guide our research. Both Blacks and Hispanics were less likely to seek incontinence care than Whites, independent of socioeconomic status and measures of symptom severity. None of the measured psychosocial (affect, utility, norms and habits) and barrier variables from the Theory of Care Seeking Behavior explained the association between ethnicity and incontinence care seeking. The social construct of ethnicity includes bias, stereotyping, cultural competence, religiosity, spirituality, and lay illness which could explain the between ethnic group differences in incontinence care seeking identified in my study. Measurement of these variables, in conjunction with clinical and demographic, or psychosocial and barrier variables from the Theory of Care Seeking Behavior may explain the within ethnic group differences in incontinence care seeking, if they truly exist. Researchers should be able to develop modifiable predictor-specific interventions aimed at reducing health care disparities between ethnic groups by increasing the percentage of all incontinent women who seek care

A model for explaining differences in incontinence care seeking (MEDICS) project.

The broad long-term objectives of this research project are to increase the percentage of women who seek care for urinary incontinence. The specific aims of this research project are: (1) Use Lauver\u27s Theory of Care Seeking Behavior to identify predictors of incontinence care seeking for African American and Caucasian women. (2) Determine if previously studied predictors explain incontinence care seeking for African-American and Caucasian women, after controlling for predictors in Lauver\u27s Theory of Care Seeking Behavior. (3) Develop and compare theoretical models for explaining differences in incontinence care seeking for African American and Caucasian women. The health relatedness of the project is that our models for incontinence care seeking will guide behavioral interventions which may increase the percentage of women who seek care and reduce any health disparities between African American and Caucasian women

Urinary Biomarkers Under Investigation for Overactive Bladder Syndrome

Overactive bladder (OAB) is a symptom syndrome of urinary urgency, frequency, nocturia, and urge incontinence suggestive of lower urinary tract dysfunction. Detrusor overactivity (DO) during urodynamic testing may be the cause of symptoms in 54–70 % of OAB study participants. The identification of urinary biomarkers is warranted due to the high false negative rate of urodynamic testing results for the diagnosis of DO and for the evaluation of treatment response in study participants with OAB symptoms. We reviewed the published literature on urinary biomarkers under investigation for OAB with Pub Med up to June 2015 using search keywords that included “overactive bladder,” “nerve growth factor (NGF),” “brain-derived nerve growth factor (BDNF),” “prostaglandins,” “cytokines,” and “CRP.” Current evidence suggests that NGF and BDNF appear to be most promising candidates for urinary biomarkers for the diagnosis and the evaluation treatment response

Increasing Anteroposterior Genital Hiatus Widening Does Not Limit Apical Descent for Prolapse Staging during Valsalva’s Maneuver: Effect on Symptom Severity and Surgical Decision Making

Objective: Determine if anteroposterior genital hiatus (GH) widening obscures rather than facilitates signs and symptoms, inadvertently altering management decisions for women with pelvic organ prolapse (POP) during Valsalva's Maneuver, at a given total vaginal length (TVL). Methods: We performed a retrospective cohort with nested cross-sectional study of patients who underwent POP surgery. Data from obstetric and gynecologic history, preoperative and postoperative physical examinations, and 20-item Pelvic Floor Distress Inventory (PFDI-20) and 7-item Pelvic Floor Impact Questionnaire (PFIQ-7) scores were extracted. Study participants were compared in 2 groups: anteroposterior widened (>3 cm) and not widened (<=3 cm) GH, for baseline leading edge and POP stage, while controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were evaluated within GH groups. Delta GH, PFDI-20, and PFIQ-7 scores after apical suspension with and without posterior colporrhaphy were compared to assess the clinical value of the procedure. Results: Study participants with anteroposterior GH widening during Valsalva maneuver had greater baseline leading edge descent and higher POP stage compared with those without anteroposterior GH widening after controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were similar within both GH categories controlling for prolapse severity. Adding posterior colporrhaphy to apical suspension resulted in a greater anteroposterior GH reduction without improving delta PFDI-20 or PFIQ-7 scores. Conclusions: Facilitation through herniation rather than obscuration from anteroposterior GH widening explains why patients will not be undertreated based on signs and symptoms of disease. Adding posterior colporrhaphy to apical suspension more effectively reduces anteroposterior GH widening without differential improvement in symptoms rendering the operation to no more than a cosmetic procedure

Polypropylene Mesh Predicts Mesh/Suture Exposure After Sacrocolpopexy Independent of Known Risk Factors

Objective(s) The aim of this study was to determine if ultralightweight polypropylene mesh reduced the risk of mesh/suture exposure after sacrocolpopexy compared with heavier-weighted polypropylene. Methods Bivariate and multivariate analyses were used to interpret data from 133 cases and 261 control subjects to evaluate independent predictors of mesh/suture exposure after sacrocolpopexy from 2003 to 2013. Results Multivariate logistic regression revealed that prior surgery for incontinence (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.19–6.96), porcine acellular cross-linked collagen matrix with medium-weight polypropylene mesh (OR, 4.95; 95% CI, 1.70–14.42), other polypropylene mesh (OR, 6.73; 95% CI, 1.12–40.63), nonabsorbable braided suture for vaginal mesh attachment (OR, 4.52; 95% CI, 1.53–15.37), and immediate perioperative complications (OR, 3.64; 95% CI, 1.53–13.37) were independent risk factors for mesh/suture exposure. After multivariate analysis, ultralightweight polypropylene mesh was no longer associated with decreased rates of mesh/suture exposure after controlling for known risk factors identified during bivariate analysis (P = 0.423). Conclusions Both mesh choice and suture selection remained independent predictors of mesh/suture exposure, with heavier meshes increasing and monofilament suture decreasing rates of mesh/suture exposure. Based on this study, surgeons may consider use of delayed-absorbable, monofilament suture over nonabsorbable braided suture for attachment of vaginal mesh to reduce the risk of mesh/suture exposure when using mesh

30 Years of Cystocele/Rectocele Repair in the United States

Objective: A growing body of evidence suggests an increased role for apical support in the treatment of pelvic organ prolapse regardless of phenotype. The objective of this study was to determine whether changes in cystocele/rectocele diagnosis and surgical management for the last 30 years reflect this changing paradigm. Methods: Data from the National Hospital Discharge Survey were mined from 1979 to 2009 for diagnosis and procedure codes. Records were categorized according to predefined combinations of diagnosis and procedure codes and weighted according to the National Hospital Discharge Survey data set. Pearson [chi]2 test was used to evaluate the changes in population proportions during the study interval. Results: The proportion of isolated cystocele/rectocele diagnoses decreased from 1979 to 2009 (56.5%, n = 88,548, to 34.8%, n = 31,577). The proportion of isolated apical defect diagnoses increased from 1979 to 2009 (38.4%, n = 60,223, to 60.8%, n = 55,153). There was a decrease in the frequency of isolated cystocele/rectocele repair procedures performed from 1979 to 2009 (96.3%, n = 150,980, to 67.7%, n = 61,444), whereas there was an increase in isolated apical defect repair procedures (2.5%, n = 3929, to 22.5%, n = 20,450). The proportion of cystocele/rectocele plus apical defect procedures also increased (1.2%, n = 1879, to 9.7%, n = 8806). Furthermore, 87.0% of all studied diagnostic groups were managed by cystocele/rectocele repair alone. Conclusions: Surgeons have responded to the increased contribution of apical support defects to cystocele/rectocele by modifying their diagnostic coding practices. Unfortunately, their surgical choices remain largely rooted in an older paradigm

Operationalizing the Measurement of Socioeconomic Position in Our Urogynecology Study Populations: An Illustrative Review

Objectives The purpose of this illustrative review is to provide guidance for the measurement of socioeconomic position when conducting health disparities research in urogynecology study populations. Methods Deidentified data were extracted from existing investigational review board–approved research databases for illustrative purposes. Attributes collected included the study participant's marital status, level of educational attainment (in number of years of school completed) and occupation as well as the study participant's last/only spouses' level of education and occupation. Average household and female socioeconomic position scores were calculated using two established composite indices: (1) Hollingshead Four Factor Index of Social Position, (2) Green's Socioeconomic Status scores, and 2 single-item indices: (1) Hauser-Warren Socioeconomic Index of Occupation, (2) level of educational attainment. Results The Hollingshead Four Factor Index of Social Position more than the Hauser-Warren Socioeconomic Index of Occupation provides researchers with a continuous score that is normally distributed with the least skew from the dataset. Their greater standard deviations and low kurtotic values increase the probability that statistically significant differences in health outcomes predicted by socioeconomic position will be detected compared with Green's socioeconomic status scores. Conclusions Collection of socioeconomic data is an important first step in gaining a better understanding of health disparities through elimination of confounding bias, and for the development of behavioral, educational, and legislative strategies to eliminate them. We favor average household socioeconomic position scores over female socioeconomic position scores because average household socioeconomic position scores are more reflective of overall resources and opportunities available to each family member

Obliterative surgery for the treatment of pelvic organ prolapse: A patient survey on reasons for surgery selection and post-operative decision regret and satisfaction

Objectives: To identify patient-reported reasons for selecting obliterative surgery for the purpose of predicting decision regret and satisfaction. Methods: We created a deidentified database of patients who underwent an obliterative procedure for prolapse from 2006 to 2013. Patients were excluded if they declined study participation, were deceased, or had dementia. Participants completed a survey regarding reasons for selecting obliterative surgery and a modified version of validated questionnaires on decision regret (Decision Regret Scale-Pelvic Floor Disorder) and satisfaction (Satisfaction with Decision Scale-Pelvic Floor Disorder). Parsimonious multivariate linear regression models were constructed to determine if any of the reasons given for choosing obliterative surgery were independent predictors of decision regret and satisfaction after controlling for significant sociodemographic, clinical, and surgical outcome data identified by bivariate analysis. Results: Seventy-seven women completed the surveys. "To follow my doctor's recommendations" and "no longer sexually active," and/or "did not plan to be" as reasons for selecting obliterative surgery made the most difference; however, these reasons were not identified as independent predictors of decision regret or satisfaction after controlling for confounders. The regret linear regression models identified preoperative sexual activity rather than the patient-reported reason "no longer sexually active and/or did not plan to be," as the only independent predictor of more decision regret after obliterative surgery (B coefficient 1.68, P < 0.01). The satisfaction linear regression models identified reoperation for any reason as an independent predictor of lower satisfaction ([beta], -0.24; P = 0.04) and the patient-reported reason for choosing obliterative surgery "not interested in pessary" as a predictor of higher satisfaction ([beta], 0.30, P = 0.01). Conclusions: This study advances our knowledge about the obliterative surgical decision making process. Behavioral and educational interventions directed at improving patient and physician communications concerning the dynamics of sexual health issues in an aging population will likely decrease regret when obliterative surgery is chosen. Minimizing reoperation after obliterative surgery through increased experience, knowledge, and improved surgical skills and patient validation when pessary is declined will likely improve satisfaction when obliterative surgery is chosen