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Este mes en... Female Pelvic Medicine & Reconstructive Surgery

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Este mes en... Female Pelvic Medicine & Reconstructive Surgery:

  • Are You Ready for Payment Reform?
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  • Pelvic Organ Prolapse
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  • Trends in Hysteropexy and Apical Support for Uterovaginal Prolapse in the United States from 2002 to 2012
    imageObjectives Our objective was to describe trends in hysteropexy and apical support for uterovaginal prolapse (UVP) from 2002 to 2012 in the United States. We identified patient and hospital variables associated with hysteropexy and apical support. Methods We used the Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes to identify a population of women 18 years or older with UVP undergoing pelvic organ prolapse surgery from January 1, 2002, to December 31, 2012. Procedures were categorized as (1) hysteropexy, (2) obliterative with uterine preservation, (3) hysterectomy with apical support, (4) hysterectomy without apical support, and (5) other reconstruction without apical support. Categories were dichotomized into those with and without apical support. We used survey weights to obtain nationally representative estimates; χ2 and linear and logistic regression compared procedure groups. Results An estimated 815,184 hospital discharges of pelvic organ prolapse procedures for UVP occurred from 2002 to 2012. During this time, hysteropexies increased from 1.81% to 5.00% (P < 0.0001). From 2002 to 2012, hysterectomies with apical support increased (10.07% to 32.51%, P < 0.0001), hysterectomy without apical support decreased (27.14% to 17.12%, P < 0.0001), and reconstruction without apical support decreased (59.07% to 40.48%, P < 0.0001). In most recent years 2011 to 2012, 60% of women with UVP underwent inpatient surgery without an apical procedure. Age 52 years or older, Medicare payment, Northeast region, and urban teaching hospitals were associated with increased odds of apical support for UVP (P < 0.001 for all). Conclusions Hysteropexy significantly increased in the United States from 2002 to 2012, although the overall proportion remains low. While hysterectomy without apical support is decreasing, approximately 60% of inpatient procedures performed for UVP do not address the apex.
  • Outcomes in Pelvic Organ Prolapse Surgery in Women Using Chronic Antithrombotic Therapy
    imageIntroduction Chronic antithrombotic therapy is common among patients requiring surgery for pelvic organ prolapse because of age and comorbidities. The impact of chronic anticoagulation on postoperative complications in pelvic organ prolapse surgery has not been investigated. This study aims to determine if patients on chronic antithrombotic therapy are at increased risk for postoperative complications. Methods This retrospective cohort study included women having prolapse surgery from 2012 to 2015, identified by Current Procedural Terminology codes, excluding patients undergoing concomitant major nonurogynecologic procedures. Baseline characteristics were compared and all procedures performed, operative duration, estimated blood loss, and length of hospitalization. Complications (blood transfusion, intensive care unit admission, reoperation, readmission, hematoma, thromboembolic event, and infection) were compared in women on chronic antithrombotic therapy and controls. Logistic regression determined odds ratio (OR) for complications in patients on chronic antithrombotics. Complications were graded by the Clavien-Dindo classification. Results A total of 388 charts were reviewed, and 386 patients met inclusion criteria. Twenty-one of the 386 patients were on chronic antithrombotic therapy. Chronic antithrombotic therapy increased overall complications (OR, 6.8; P < 0.0005), blood transfusion (OR, 165; P < 0.001), intensive care unit admission (OR, 19.10; P < 0.004), hospital readmission (OR, 20.7; P < 0.0005), vaginal hematoma (OR, 554.1; P < 0.001), infection (OR, 22.44; P < 0.004), and complications that required specific additional follow-up (OR, 9.42; P < 0.0005). There were no thromboembolic events. Antithrombotic therapy did not significantly increase reoperation rates (OR, 3.8; P = 0.275). Findings were maintained when adjusting for covariates of age and body mass index. Conclusions Postoperative surgical complications after prolapse repair procedures are increased in patients who use chronic antithrombotic medication, the majority of cases are successfully managed conservatively.
  • Patient-Reported Impact of Pelvic Organ Prolapse on Continence and Sexual Function in Women With Exstrophy-Epispadias Complex
    imageObjective This study aimed to characterize long-term urogynecologic issues of women with a history of bladder exstrophy and pelvic organ prolapse (POP) and to assess the impact of POP repair on continence and sexual function. Design Patient demographics and surgical history related to exstrophy and POP were collected through chart review. Patient perceptions regarding sexual function, urinary continence, and quality of life were assessed through Web-based administration of validated questionnaires: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and POP-Urinary Incontinence Sexual Questionnaire. Setting Maryland, United States. Participants Review of a single-institution exstrophy-epispadias complex database resulted in 25 adult female patients with a history of POP treated at the authors' institution. Eleven patients participated and were included in the analysis. Main Outcome Measures Urinary continence and sexual function. Results All participants underwent surgical repair for prolapse, with 7 (63.6%) experiencing unsuccessful initial repair and subsequent recurrence. Median total number of POP repairs was 2.5 (1–4). After correction of POP, patients reported a median improvement in International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form scores of 11 (21 to −1) of 21 and in POP-Urinary Incontinence Sexual Questionnaire scores of 9.5 (6.5–33.0) of 48.0. With regard to urinary continence, 6 (54.5%) patients presently reported no incontinence, 3 (27.3%) reported mild incontinence, and 2 (18.2%) reported continuous incontinence. Conclusions Pelvic organ prolapse poses significant reductions in quality of life for women born with exstrophy, with effects on urinary continence and sexual function. Identification and correction of prolapse seems to result in notable improvements in the lives of these patients.
  • Vaginal Mesh Removal Outcomes: Eight Years of Experience at an Academic Hospital
    imageObjectives The purpose of this study is to describe the clinical history leading up to and the outcomes after vaginal mesh removal surgery at an academic hospital. Methods A retrospective case series of patients who underwent vaginal mesh removal from 2008 to 2015 was conducted. Demographics, clinical history, physical examination, pre- and postoperative symptoms, and number and type of reoperations were abstracted. Results Between February 2008 and November 2015, 83 patients underwent vaginal mesh removal surgery at our hospital. The median time interval from initial mesh placement to removal was 58 months (range, 0.4–154 months). The most common preoperative symptoms were vaginal pain (n = 52, 62%), dyspareunia (n = 46, 55%), and pelvic pain (n = 42, 50%). Intraoperative complications were infrequent (n = 3, 4%). Of patients presenting for follow-up within 4 to 6 weeks postoperatively, the most common symptoms were urinary incontinence (n = 15, 28%), vaginal pain (n = 7, 13%), buttock pain (n = 5, 9%), and urinary tract infection (n = 5, 9%). There were no identifiable risk factors to predict which patients would have persistent postoperative symptoms or who would require more than 1 mesh removal surgery. After vaginal mesh removal, 29 patients (35%) required 1 or more reoperations, with 3 being the highest number of reoperations per patient. The total number of reoperations was 43, with a total of 63 individual procedures performed. Forty-four percent (n = 28) of the procedures were graft removals, 40% (n = 25) were pelvic organ prolapse surgeries (only native tissue repairs), and 16% (n = 10) were stress incontinence surgeries. More than 1 procedure was performed in 49% (n = 21) of the reoperations. Conclusions Vaginal mesh removal surgery is safe; however, some patients require more than 1 procedure, and the risk factors for reoperations are unclear.
  • The Effect of Resident Involvement in Pelvic Prolapse Surgery: A Retrospective Study From a Nationwide Inpatient Sample
    imageObjective The primary aim of this study was to assess the effect of resident involvement on perioperative complication rates in pelvic organ prolapse surgery using the National Surgical Quality Improvement database. Methods All pelvic organ prolapse operations from 2006 to 2012 were identified and dichotomized by resident participation. Preoperative characteristics and 30-day perioperative outcomes were compared using χ2 and Student t test. To control for nonrandomization of cases, propensity scores representing the probability of resident involvement as a function of a case's comorbidities were calculated. They were then divided into quartiles, and because of equal probabilities for the first and second quartiles, 3 groups were created (Q1/2, Q3, and Q4), followed by substratification and analysis. As a control, complications of transurethral resection of prostate and nephrectomy were dichotomized by resident involvement. Results We identified 2637 cases. Resident involvement was associated with increased postoperative urinary tract infections, perioperative complications, and procedure length. After stratification by propensity scoring, the following unique findings occurred in each group: in the first group, resident involvement was associated with increased rates of readmission, pulmonary embolism, and sepsis; in the second and third groups, resident involvement was associated with increased rates of superficial surgical site infection. Resident involvement in nephrectomy observed increased perioperative complications and procedural length. In prostate resection, increased procedure lengths and decreased postoperative length of stay were observed. Conclusions Resident involvement in pelvic organ prolapse surgery was associated with an increased risk of adverse outcomes. A similar effect was seen with nephrectomy but not with a more simple endoscopic urologic procedure.
  • Resident Knowledge, Surgical Skill, and Confidence in Transobturator Vaginal Tape Placement: The Value of a Cadaver Laboratory
    imageObjectives The objective of this study is to examine the effect of additional cadaver laboratory use in training obstetrics and gynecology (OBGYN) residents on transobturator vaginal tape (TOT) insertion. Methods Thirty-four OBGYN residents were randomized into 2 groups (group 1, control; group 2, intervention; 17 in each group). Before and after the interventions, written knowledge and confidence levels were assessed. Both groups received didactic lectures using a bony pelvis and an instructional video on TOT insertion; group 2 participated in a half day cadaver laboratory. Surgical skills were assessed by placing 1 arm of the TOT trocar on a custom-designed pelvic model simulator while being graded by an Female Pelvic Medicine and Reconstructive Surgery (FPMRS) board-certified proctor. Results Demographics were comparable. Baseline knowledge and confidence level before interventions were similar. After interventions, knowledge scores improved for both groups (8.8% for group 1; 14.1% for group 2); TOT insertion scores were significantly higher in group 2 (6.76/15 ± 2.54 group 1; 10.24/15 ± 2.73 group 2, P < 0.01); confidence scores improved in both groups. The pelvic model simulator was rated as the most useful method to learn TOT placement by group 1. Group 2 rated TOT simulation (47%) and cadaver laboratory (41%). All trainees reported that the pelvic model was highly realistic. Conclusions Cadaver laboratory exposure, along with other educational interventions (lectures and video), improves OBGYN residents' confidence, knowledge, and surgical skills regarding TOT placement. The custom-designed pelvic model allows for a realistic simulation of TOT placement: it can be used to assess resident surgical skills and also aid the training of OBGYN residents.
  • Ready or Not? Obstetrics and Gynecology Resident Preparedness for Female Pelvic Medicine and Reconstructive Surgery Training
    imageObjective The aim of this study was to assess the perception of female pelvic medicine and reconstructive surgery (FPMRS) program directors (PDs) and obstetrics and gynecology (OG) FMPRS fellows regarding the adequacy of OG residency as preparation for FPMRS fellowship. Methods Electronic invitations to complete a modified version of a validated survey were extended to FPMRS PDs and their second- and third-year OG FPMRS fellows who had just completed their first or second year of FPMRS fellowship, respectively. The survey consisted of 5 domains; qualitative questions and recommendations for improvement were elicited. Results Program directors (33%, 16/48) and second-year (64%, 29/45) and third-year (53%, 26/49) fellows completed the surveys. While incoming fellows were deemed professional, serious surgical skill competency issues were identified: (1) PDs felt they could not leave their incoming fellow to operate independently on a major case for 30 minutes while in the next room compared with fellow responses (PDs: 33.3% vs second-year fellows: 67.9%; P = 0.03); (2) no PDs felt their fellows could suture laparoscopically; and (3) there was group consensus that incoming fellows were not proficient at cystoscopy (PDs: 40.0%, second-year fellows: 39.3%, third-year fellows: 32.0%; P = 0.82). Mostly, fellows could clinically evaluate and manage patients. Program directors thought their fellows had better understanding of statistics than fellows believed of themselves (P = 0.05). Increasing FPMRS exposure during residency was favored as the method to better prepare OG residents for fellowship. Conclusions Quantitative and emerging qualitative outcomes highlight that fellows are professional and are largely able to evaluate and care for patients but that achieving independence, surgical skills, and scholarship requires further training.
  • Trends in Fellowship Training for Female Pelvic Medicine and Reconstructive Surgery
    Objective The aim of this study was to characterize distinguishing features among gynecology, urology, and combined female pelvic medicine and reconstructive surgery (FPMRS) fellowship programs and practices. Methods A 32-item Web-based survey was sent to fellowship directors of FPMRS programs accredited by the Accreditation Council for Graduate Medical Education. The survey assessed the structure of the fellowship, as well as the degree to which gynecology and urology are integrated into the fellowship training. In addition to descriptive statistics, Fisher exact test and Mann-Whitney U test were used for statistical analysis. Results Forty-one program directors (PDs) completed the survey for a 76% response rate. Of the respondents, 78% were gynecologists, and 22% were urologists. Sixty-five percent of the respondents considered their program gynecology based, 7.5% considered their program urology based, 22.5% considered their program fully integrated (urology and gynecology equal sharing), and 5% have separate tracks for urology fellows and gynecology fellows. Sixty-one percent of the programs accept both urology and gynecology fellows in their fellowship programs. Approximately two thirds of the PDs are happy with the fellowship model at their institution, whereas the remaining one third would like greater integration of gynecology and urology in fellowship training. Almost 90% of the respondents felt that there were benefits to an integrated program. The top benefits were reported as more exchange of information, better relationships, more comprehensive training, exposure to different treatment approaches, and improved care for women. For those PDs who desire a more integrated program, the top barriers listed were departmental competition/politics, lack of formally trained urology faculty, and expense. Conclusions There are several FPMRS fellowship models. A significant proportion of PDs would like a more integrated fellowship program, and an overwhelming majority note benefits for themselves and their fellows that result from increased contact with a diverse FPMRS faculty.
  • Direct and Indirect Effects of Personality Traits on Psychological Distress in Women With Pelvic Floor Disorders
    imageObjectives The diagnosis and treatment of pelvic floor disorders may involve subjective self-report symptom measures that may be related to personality traits. We aimed to construct a model that integrates pelvic floor disorders, personality variables (optimism and neuroticism), psychological distress, and related demographic variables. Methods In a cross-sectional study, conducted between August 2014 and June 2015, 155 women following an intake to an urogynecology outpatient clinic of a tertiary health center completed personality questionnaires of optimism and neuroticism (Life Orientation Test–Revised, 10-item Big Five Inventory), pelvic floor symptoms (Pelvic Floor Distress Inventory Short Form), psychological distress (18-item Brief Symptom Inventory), and a demographic questionnaire. Results A path analysis mediation model showed that patients who had more pelvic floor symptoms felt more psychological distress and that psychological distress increased as the level of neuroticism increased. As for optimism, the correlation to pelvic floor symptoms was nearly significant. Optimism and neuroticism had indirect effects on psychological distress through pelvic floor symptoms in women with urinary incontinence and pelvic organ prolapse. Neuroticism had a direct effect on psychological distress in these women as well. Conclusions Our suggested statistical path analysis model supports the important role of personality traits in pelvic floor disorder self-reports and the effect of these traits on psychological distress. Therefore, the optimal treatment for pelvic floor symptoms should include psychological interventions in addition to traditional medical or surgical therapy in hope of reducing psychology distress associated with urinary incontinence and pelvic organ prolapse.
  • Women's Perception of Their Vulvar Appearance in a Predominantly Low-Income, Minority Population
    imageObjectives The aim of this study was to investigate the effect of certain predictors, such as age and media exposure, on a woman's perception of her vulva anatomy. Methods We recruited 346 female visitors from a county teaching hospital to complete questionnaires that determine the following: demographics, satisfaction with their vulvar appearance, whether they consider their vulvar anatomy to be normal, exposure to media (namely having had Internet access or learned about genitalia from the Internet or any type of pornography), and consideration of cosmetic vulvar surgery for themselves. The participants were divided into 2 age groups; group I (45 years or older) and group II (18–44 years). Personal satisfaction, self-perceived normality, and one's consideration of cosmetic vulvar surgery were then compared between the 2 groups. Results A large percentage of women considered their vulva to be “normal,” 93.1% of group I versus 96.0% of group II (P = 0.24). For group I, 87.5% were satisfied with their vulva versus 91.5% of group II (P = 0.24). The participants with media exposure report self-perceived normal-appearing vulvas at higher rates than those not exposed to media (96.7% vs 90.8%, respectively; P = 0.03). Of those who were satisfied with their vulvar appearance, 92.3% were exposed to media, whereas 84.5% were not exposed (P = 0.03). However, of the participants who reported consideration of vulvar surgery, 74.4% of them had exposure to media, whereas 25.6% had no media exposure (P = 0.034). Conclusions Age does not play a significant role in determining a woman's acceptance of the appearance of her vulvar anatomy. However, media exposure was a significant determinant for self-perception, satisfaction, and desire for cosmetic vulvar surgery.
  • Diagnostic Accuracy and Clinical Implications of Translabial Ultrasound for the Assessment of Levator Ani Defects and Levator Ani Biometry in Women With Pelvic Organ Prolapse: A Systematic Review
    imageObjective The aim of this study was to assess the diagnostic accuracy and clinical implications of translabial 3-dimensional (3D) ultrasound for the assessment of levator ani defects and biometry in women with pelvic organ prolapse (POP). Methods We performed a systematic literature search through computerized databases including MEDLINE (via PubMed), EMBASE (via OvidSP), and the Cochrane Library using both medical subject headings and text terms from January 1, 2003, to December 25, 2015. We included articles that reported on POP status and diagnostic accuracy measurements with translabial 3D ultrasound or transperineal ultrasound for the detection of levator ani defects or for measuring pelvic floor biometry, that is, levator ani hiatus, or reported on the clinical relevance of using translabial 3D ultrasound for levator ani defects or measuring pelvic floor biometry in women with POP. Results Thirty-one articles were selected in accordance with parts of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines that can be applied to studies of diagnostic accuracy. Twenty-two articles (71%) are coauthored by 1 expert in this field. Detecting levator ani defects with translabial 3D ultrasound compared with magnetic resonance imaging showed a moderate to good agreement, whereas measuring hiatal biometry on translabial 3D ultrasound compared with magnetic resonance imaging showed a moderate to very good agreement. The interobserver agreement for diagnosing levator ani defects and measuring the levator hiatal area showed a moderate to very good agreement. Furthermore, levator ani defects increase the risk of cystocele and uterine prolapse, and levator ani defects are associated with recurrent POP. Finally, a larger hiatus was associated with POP and recurrent POP. Conclusions Translabial 3D ultrasound is reproducible for diagnosing levator ani defects and ballooning hiatus. Both levator ani defects and a larger hiatal area are, in a selected population of patients with pelvic floor dysfunction, associated with POP and recurrent POP. More research is needed concerning external validation because most data in this article are coauthored by 1 expert in this field.
  • Twenty-Four–Hour Voiding Diaries Versus 3-Day Voiding Diaries: A Clinical Comparison
    imageObjective This study aimed to determine if 24-hour versus 3-day voiding diary affects medical decision making for women with urinary incontinence. Methods A retrospective chart review was conducted of patients presenting to the OhioHealth Urogynecology Physician group for urinary incontinence from 2009 to 2011. Practice protocol includes patient completion of a 3-day voiding diary before their appointment. Diagnostic and treatment plans were extracted based on the initial patient encounter and 3-day voiding diary. A chart review was then completed with the first 24 hours of the same diaries, principal history, and physical examination data compiled into a separate chart. These charts were then reevaluated by the same physician who initially provided care to the patient but were blinded to their previous orders, impressions, and plans. New plans were then created based on the 24-hour diaries and compared with the original plans. Results One hundred eighty-six charts were reviewed. There was good agreement between 24-hour and 3-day diaries in recommendations for first-line behavioral modifications (Κ > 0.6) and moderate agreement between diaries in initiation of medical therapy or trial of incontinence pessary (Κ > 0.4). However, 24-hour diaries resulted in a statistically significant increase in invasive diagnostic tests (P < 0.019) and other treatment recommendations when compared with 3-day diaries. Conclusions Use of 24-hour diaries may result in increased testing when compared with 3-day diaries. It may be prudent to postpone invasive testing in those patients who initially are noncompliant with a longer diary until a more complete history can be obtained.
  • Correlation Between Transperineal 3-Dimensional Ultrasound Measurements of Levator Hiatus and Female Sexual Function
    imageObjective The aim of this study is to investigate the association of sexual functions with levator hiatus biometry measurements and levator ani muscle defect. Methods In 62 heterosexual, sexually active premenopausal women without pelvic floor disorders or urinary incontinence, 3-dimensional transperineal ultrasound imaging was used. Two 3-dimensional volumes were recorded, one at rest and one on Valsalva maneuver. Levator biometry measurements and levator defect were evaluated in an axial plane. Sexual function was assessed by a validated questionnaire, Female Sexual Function Index (FSFI). The primary outcome measure was correlation of sexual functions with the levator hiatus area, transverse and anteroposterior diameters, levator ani muscle thickness, vaginal length, and changes in measurements with Valsalva and levator defect. Results Forty-two women (67.7%) had low total FSFI scores (<26.55). Levator defect rates were similar in female sexual dysfunction (7/42, 16.7%) and women without female sexual dysfunction (5/20, 25%). The FSFI was negatively and weakly correlated with Δhiatal anteroposterior diameter (r = −0.33, P < 0.009) in the study population. There was a weak and inverse correlation between Δhiatal anteroposterior diameter and arousal (r = −0.35, P < 0.002), desire (r = −0.38, P < 0.001), and orgasm (r = −0.33, P < 0.007). Pain and lubrication did not correlate with any measurement. Conclusions Hiatal area and diameters at rest are not related to sexual functions. Changes in anteroposterior diameter of the levator hiatus during Valsalva, which may be a sign of pelvic floor laxity or levator muscle weakness, are weakly associated with sexual functions, particularly desire, arousal, and orgasm domains.
  • Impact of Distance to Treatment Center on Care Seeking for Pelvic Floor Disorders
    imageObjective The aim of this study was to evaluate the impact of distance from residence to treatment center on access to care for female pelvic floor disorders at an academic institution. Methods A retrospective cross-sectional study was conducted of women seen for pelvic floor disorders at an academic institution from 2008 to 2014. Patient characteristics were extracted from charts. Geographical and US census data was obtained from public records and used to calculate distance from patient residence to physician office. Statistical analysis was performed using R Software (Version 0.98.1102) and Microsoft Excel (Version 14.4.7). Statistical significance was defined as a 2-sided P value of less than 0.05, and the χ2 test was used to determine associations of categorical variables. Results A total of 3015 patients were included in the analysis. The mean distance traveled was 93 miles. Thirty percent of patients traveled more than 50 miles. Many patients (43%) reported having the symptoms for more than 2 years. Patients who traveled farther were significantly more likely to be white, English-speaking, and with pelvic organ prolapse as primary complaint. These patients were more likely to plan surgery at the first visit than patients who traveled less far (29% vs 14%). Patients who traveled farther were also more likely to live in counties with a low percentage of persons older than 65 years and low percentage of female inhabitants. Conclusions Women who travel the farthest for treatment of pelvic floor disorders have experienced the symptoms for longer duration and are more willing to plan surgery at presentation. These women also come from counties with fewer elderly women, suggesting future outreach care should focus on similar geographic areas.
  • Barriers to Pelvic Floor Physical Therapy Regarding Treatment of High-Tone Pelvic Floor Dysfunction
    imageObjective Chronic pelvic pain is a prevalent and debilitating condition with a wide range of etiologies. An estimated 30% to 70% of chronic pelvic cases involve musculoskeletal component pain including high-tone pelvic floor dysfunction (HTPFD). Pelvic floor physical therapy has been shown to be a beneficial treatment for HTPFD, yet many patients do not have access to this treatment. The objective of this study was to identify the barriers preventing patients from following through with the first-line management, physical therapy. Methods Participants with a diagnosis of HTPFD (n = 154) were identified from the list of referrals sent from the obstetrics and gynecology department to an affiliated PFPT center. Participants were contacted and asked to complete a phone survey addressing demographics and perceived barriers to care. Responses were collected in REDCap. Univariate and bivariate analyses were performed using a statistical analysis software. Results Seventy surveys were completed. The top barriers identified by participants were financial constraints (51.4%), perceived lack of utility (37.1%), time constraints (30.0%), and travel issues (18.6%); 84.4% of participants had 1 or more comorbid pain condition. Whereas 51.4% expressed some level of anxiety regarding the PFPT option, only 9.6% of participants did not start treatment because of fear of treatment. Conclusions The majority of treatment barriers identified were concrete restraints, with insurance noncoverage and time constraints being the top issues. A fair number of participants expressed anxiety about the treatment or felt they received unclear explanations of the treatment. These are areas in which providers can potentially alleviate some barriers to care.
  • Effect of Pregnancy and Delivery on Cytokine Expression in a Mouse Model of Pelvic Organ Prolapse
    imageObjectives The aim of this study was to determine the effect of pregnancy and delivery mode on cytokine expression in the pelvic organs and serum of lysyl oxidase like-1 knockout (LOXL1 KO) mice, which develop pelvic organ prolapse after delivery. Methods Bladder, urethra, vagina, rectum, and blood were harvested from female LOXL1 KO mice during pregnancy, after vaginal or cesarean delivery, and from sham cesarean and unmanipulated controls. Pelvic organs and blood were also harvested from pregnant and vaginally delivered wild-type (WT) mice and from unmanipulated female virgin WT controls. Specimens were assessed using quantitative real-time reverse transcription polymerase chain reaction and/or enzyme-linked immunosorbent assay. Results Both CXCL12 and CCL7 mRNA were significantly up-regulated in the vagina, urethra, bladder, and rectum of pregnant LOXL1 KO mice compared with pregnant WT mice, suggesting systemic dysregulation of both of these cytokines in LOXL1 KO mice as a response to pregnancy. The differences in cytokine expression between LOXL1 KO and WT mice in pregnancy persisted after vaginal delivery. CCL7 gene expression increases faster and to a greater extent in LOXL1 KO mice, translating to longer lasting increases in CCL7 in serum of LOXL1 KO mice after vaginal delivery, compared with pregnant mice. Conclusions Lysyl oxidase like-1 KO mice have an increased cytokine response to pregnancy perhaps because they are less able to reform and re–cross-link stretched elastin to accommodate pups, and this resultant tissue stretches during pregnancy. The up-regulation of CCL7 after delivery could provide an indicator of level of childbirth injury, to which the urethra and vagina seem to be particularly vulnerable.
  • The Effect of Lithotomy Position on Nerve Stretch: A Cadaveric Study
    imageObjective The objective of our study was to design a method to measure nerve stretch in cadaveric subjects and then use the method to assess femoral nerve stretch in the lithotomy position with varying degrees of flexion and extension. Methods A university-based, cadaveric observational study of femoral nerve stretch was conducted. In 6 cadaveric subjects, femoral nerve near the inguinal ligament was dissected in each cadaveric subject. The nerve was marked, and digital images of the nerve were obtained in the supine position and lithotomy position in both flexion and extension. Distances were calculated using the ratio of pixels to millimeter specific for each image. The average distance for each set of images was then used to calculate the percent change from supine for each position. Results We were able to assess nerve stretch using photo-editing software. For extended position, all nerves showed some degree of stretch with the mean percent change in nerve length being 10.35%. For all other positions, most showed a decrease of nerve length. There was not a significant relation between degree of extension and stretch (Pearson r, P < 0.05). Conclusions Hip extension between 10 and 20 degrees consistently stretches the femoral nerve greater than 5%. The potential for femoral nerve stretch and avoiding hip extension should be considered when positioning a patient in lithotomy for surgical procedures.


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