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Background: Building local surgical capacity in low-income and middle-income countries is critical to addressing the unmet global surgical need. Visiting educator programs can be utilized to train local surgeons, but the quantitative impact on surgical capacity has not yet been fully described. The authors' objective was to evaluate the effectiveness of training utilizing a visiting educator program on local reconstructive surgical capacity in Vietnam., Methods: A reconstructive surgery visiting educator program was implemented in Vietnam. Topics of training were based on needs defined by local surgeons, including those specializing in hand surgery, microsurgery, and craniofacial surgery. A retrospective analysis of annual case numbers corresponding to covered topics between the years 2014 and 2019 at each hospital was conducted to determine reconstructive surgical volume and procedures per surgeon over time. Direct costs, indirect costs, and value of volunteer services for each trip were calculated., Results: Over the course of 5 years, 12 visiting educator trips were conducted across three hospitals in Vietnam. Local surgeons subsequently independently performed a total of 2018 operations corresponding to topics covered during visiting educator trips, or a mean of 136 operations annually per surgeon. Within several years, the hospitals experienced an 81.5 percent increase in surgical volume for these reconstructive clinical conditions, and annual case volume continues to increase over time. Total costs were $191,290, for a mean cost per trip of $15,941., Conclusions: Surgical capacity can be successfully expanded by utilizing targeted visiting educator trips to train local reconstructive surgeons. Local providers ultimately independently perform an increased volume of complex procedures and provide further training to others., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: To examine the prevalence, predictors, and effects of nocturia in women and evaluate overlaps with established urinary tract disorders., Methods: This was a cross-sectional analysis of 2,016 women, aged 40 years and older, recruited from Kaiser Permanente Northern California from 2008 to 2012. Nocturia and other urinary symptoms were assessed using structured interviewer-administered questionnaires. Nocturia was defined as patient-reported nocturnal voiding of two or more times per night over a typical week., Results: Thirty-four percent (n=692) reported nocturia, and 40% of women with nocturia reported no other urinary tract symptom. Women with nocturia were older (mean age 58 compared with 55 years) (odds ratio [OR] per 5-year increase 1.21, 95% confidence interval [CI] 1.12-1.31), more likely black (45%) (OR 1.75, 95% CI 1.30-2.35) or Latina (37%) (OR 1.36, 95% CI 1.02-1.83) compared with non-Latina white (30%), have worse depression (mean Hospital Anxiety and Depression Scale score 3.8 compared with 2.8) (OR per 1-point increase in Hospital Anxiety and Depression Scale score 1.08, 95% CI 1.04-1.12), and worse mobility (mean Timed Up-and-Go 11.3 compared with 10 seconds) (OR per 5-second increase in Timed Up-and-Go 1.29, 95% CI 1.05-1.58). Nocturia occurred more among women with hysterectomy (53% compared with 33%) (OR 1.78, 95% CI 1.08-2.94), hot flushes (38% compared with 32%) (OR 1.49, 95% CI 1.19-1.87), and vaginal estrogen use (42% compared with 34%) (OR 1.50, 95% CI 1.04-2.18)., Conclusion: Nocturia is common in women and not necessarily attributable to other urinary tract disorders. Factors not linked to bladder function may contribute to nocturia risk, underlining the need for multiorgan prevention and treatment strategies., Level of Evidence: II.

Objective: To examine relationships among parity, mode of delivery, and other parturition-related factors with women's sexual function later in life., Methods: Self-administered questionnaires examined sexual desire, activity, satisfaction, and problems in a multiethnic cohort of women aged 40 years and older with at least one past childbirth event. Trained abstractors obtained information on parity, mode of delivery, and other parturition-related factors from archived records. Multivariable regression models examined associations with sexual function controlling for age, race or ethnicity, partner status, diabetes, and general health., Results: Among 1,094 participants, mean (standard deviation) age was 56.3 (±8.7) years, 568 (43%) were racial or ethnic minorities (214 African American, 171 Asian, and 183 Latina), and 963 (88%) were multiparous. Fifty-six percent (n=601) reported low sexual desire; 53% (n=577) reported less than monthly sexual activity, and 43% (n=399) reported low overall sexual satisfaction. Greater parity was not associated with increased risk of reporting low sexual desire (adjusted odds ratio [OR] 1.08, confidence interval [CI] 0.96-1.21 per each birth), less than monthly sexual activity (adjusted OR 1.05, CI 0.93-1.20 per each birth), or low sexual satisfaction (adjusted OR 0.96, CI 0.85-1.09 per each birth). Compared with vaginal delivery alone, women with a history of cesarean delivery were not significantly more likely to report low desire (adjusted OR 0.71, CI 0.34-1.47), less than monthly sexual activity (adjusted OR 1.03, CI 0.46-2.32), or low sexual satisfaction (adjusted OR 0.57, CI 0.26-1.22). Women with a history of operative-assisted delivery were more likely to report low desire (adjusted OR 1.38, CI 1.04-1.83)., Conclusions: Among women with at least one childbirth event, parity and mode of delivery are not major determinants of sexual desire, activity, or satisfaction later in life., Level of Evidence: II.

Objectives: : We investigated the prevalence of and risk factors for combinations of urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP) in racially diverse women older than 40 years., Methods: : The Reproductive Risks for Incontinence Study at Kaiser is a population-based study with data from 2106 women older than 40 years. Pelvic floor conditions were determined by self-report. Risk factors were assessed by self-report, interview and record review. Independent risk factors were identified by multinomial logistic regression analysis., Results: : At least one pelvic floor condition was reported by 714 (34%) women. Of these, 494 (69%) had only UI, 60 (8%) only POP, and 46 (6%) only FI. Both UI and FI were reported by 64 (9%) and both UI and POP by 51 (7%). Among women with FI, 60% reported more than one condition. Corresponding figures for POP and UI were 49% and 18%. Estrogen use and constipation were shared risk factors for UI, FI and POP. Body mass index was a unique risk factor UI only, diabetes FI only and parity POP only. No clear pattern could be found to support the hypothesis that risk factors for single conditions are more strongly associated with combined conditions., Conclusions: : Patients with FI or POP often have concomitant UI. These diseases both share and have unique risk factors in a complex pattern.

Objective: To compare the estimated prevalence of, risk factors for, and level of bother associated with subjectively reported and objectively measured pelvic organ prolapse in a racially diverse cohort., Methods: The Reproductive Risks for Incontinence Study at Kaiser 2 is a population-based cohort study of 2,270 middle-aged and older women. Symptomatic prolapse was self-reported, and bother was assessed on a five-point scale. In 1,137 women, prolapse was measured with the Pelvic Organ Prolapse Quantification (POP-Q) system. Multivariable logistic regression analysis was used to identify the independent association of prolapse and race while controlling for risk factors., Results: The participants' mean (standard deviation) age was 55 (9) years, and 44% were white, 20% were African American, 18% were Asian American, and 18% were Latina or other race. Seventy-four women (3%) reported symptomatic prolapse. In multivariable analysis, the risk of symptomatic prolapse was higher in white (prevalence ratio 5.35, 95% confidence interval [CI] 1.89-15.12) and Latina (prevalence ratio 4.89, 95% CI 1.64-14.58) compared with African-American women. Race was not associated with report of moderate to severe bother. Degree of prolapse by POP-Q stage was similar across all racial groups; however, the risk of the leading edge of prolapse at or beyond the hymen was higher in white (prevalence ratio 1.40, 95% CI 1.02-1.92) compared with African-American women., Conclusion: Compared with African-American women, Latina and white women had four to five times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse with leading edge of prolapse at or beyond the hymen., Level of Evidence: II.

Objective: To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States., Methods: We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures., Results: In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars., Conclusion: The annual direct costs of operations for pelvic organ prolapse are substantial.

Objective: To assess specific parturition and reproductive variables as potential risk factors for urinary incontinence in later life., Methods: A mail survey was conducted with a random sample of 1922 women members of a large health maintenance organization. Multivariate analysis was used to estimate the independent association between parturition factors, hysterectomy, hormone use, and incontinence., Results: Completed surveys were returned by 939 women (49%), 682 of whom reported at least one episode of incontinence in the past 12 months or ever having been treated for incontinence. On univariate analysis, women with incontinence were more likely to be white and heavier and to have had a hysterectomy before age 45, at least one live birth, a postdate (at least 42 weeks' gestation) birth, a labor lasting longer than 24 hours, and exposure to oxytocin. The risk of incontinence increased significantly with the number of exposures to oxytocin. In a multivariate model including age, there was a significant association between incontinence and white race (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.2, 2.8), body mass (OR for fourth quartile 3.0, 95% CI 1.8, 5.0), estrogen replacement (OR 1.9, 95% CI 1.3, 2.8) and oxytocin (OR 1.9, 95% CI 1.0, 3.6). Parity was also associated with incontinence (P < .05)., Conclusion: This study supports previous findings of a positive association between urinary incontinence and body mass, parity, and use of estrogen. In addition, we found a significant independent association between exposure to oxytocin during labor and incontinence in later life.