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Both expert surgeons agree with the following: (1) Surgical mesh, whether placed laparoscopically or transvaginally, is indicated for pelvic floor reconstruction in cases involving recurrent advanced pelvic organ prolapse. (2) Procedural expertise and experience gained from performing a high volume of cases is fundamentally necessary. Knowledge of outcomes and complications from an individual surgeon's audit of cases is also needed when discussing the risks and benefits of procedures and alternatives. Yet controversy still exists on how best to teach new surgical techniques and optimal ways to efficiently track outcomes, including subjective and objective cure of prolapse as well as perioperative complications. A mesh registry will be useful in providing data needed for surgeons. Cost factors are also a consideration since laparoscopic and especially robotic surgical mesh procedures are generally more costly than transvaginal mesh kits when operative time, extra instrumentation and length of stay are included. Long-term outcomes, particularly for transvaginal mesh procedures, are lacking. In conclusion, all surgery poses risks; however, patients should be made aware of the pros and cons of various routes of surgery as well as the potential risks and benefits of using mesh. Surgeons should provide patients with honest information about their own experience implanting mesh and also their experience dealing with mesh-related complications.

OBJECTIVES : This study aimed to examine the risk factors for prevalence and incidence of pelvic organ prolapse (POP) in whites, Hispanics, and blacks. METHODS : This is a secondary analysis of the Women's Health Initiative (WHI) Estrogen plus Progestin Clinical Trial (E + P). Of the original E + P trial population of 16,608, 12,667 women (78.3%; 11,194 whites, 804 blacks, and 669 Hispanics) were included in the final study sample and evaluated during the 5-year period. The outcomes evaluated were any prolapse (WHI prolapse grades 1-3) and WHI prolapse grade 2 or 3. Descriptive analyses, logistic regression, and proportional hazard modeling were performed. RESULTS : Increasing parity correlates with increasing WHI prolapse grades (0-3) in whites and blacks but not Hispanics. The incidence of grade 2 or 3 POP increased by 250% in white women with 1 child (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.68-3.71) in comparison to nulliparous women and grew with higher parity. For blacks, a weak association between the parity and grade 2 or 3 POP was noted only in women who had 5 or more kids (HR, 10.41; 95% CI, 1.38-78.77). Blacks were less likely (HR, 0.53; 95% CI, 0.40-0.71) to develop grade 2 or 3 POP compared with whites. For grade 2 or 3 POP, age was found to be a risk factor in whites (odds ratio [OR], 1.03; 95% CI, 1.02-1.04) only and body mass index (≥25 kg/m

OBJECTIVES : To describe patients' characteristics and anatomic outcome of robotic sacrocolpopexy (RSC) and vaginal mesh colpopexy (VMC). METHODS : Retrospective cohort study involving RSC (n = 17) and VMC (n = 37) procedures performed over an 18 month period in a teaching hospital. The primary outcome was 1 year anatomic cure at the apex and anterior wall. Descriptive and univariate analyses were used to determine statistical significance (P < 0.05). RESULTS : VMC subjects were more likely to be older, menopausal, and had increased BMI and more severe prolapse than the RSC group. At a mean follow-up of 13 and 12.3 months for the VMC and RSC, respectively, both groups showed significant improvement of prolapse (P < 0.001) with a cure rate of 94.1% for RSC and 70.2% for VMC (P = 0.07). Total vaginal length was significantly shorter after VMC. RSC had longer operative time and hospital stay, but lower blood loss. Complication rates were similar among the groups. CONCLUSIONS : RSC and VMC are being offered to different patient populations. These minimally invasive prolapse repair procedures have comparable results with a trend toward higher cure rate in RSC and similar complications rate.

OBJECTIVE : To evaluate the effect of voiding mechanism on cure rate of stress urinary incontinence in patients undergoing midurethral sling procedures. METHODS : Retrospective study of 121 patients who underwent midurethral sling procedures (retropubic or transobturator [TO]) between January 2006 and October 2007. Voiding mechanism was determined by preoperative pressure flow studies. Subjects were dichotomized to either "detrusor voiders" (N = 61) or "Valsalva voiders" (N = 60). Primary outcome was cure of stress urinary incontinence. RESULTS : At a mean follow-up of 6.74 months, the overall success rate was 87.6% (85.7% for retropubic and 89.4% for TO). "Valsalva voiders" had a higher risk of failure compared with "detrusor voiders" (20% vs. 4.9%, respectively; OR = 4.83, 95% CI: 1.29, 18.12, P = 0.012). This effect was significant for TO slings (P = 0.025); however, sling type was not an independent predictor of failure. CONCLUSIONS : Valsalva voiding mechanism is associated with an increased risk of failure of synthetic midurethral slings.

OBJECTIVES : The purpose of this study was to explore resident opinions about vaginal hysterectomy training and to evaluate future practice patterns and impediments to continuing vaginal hysterectomies after graduation. METHODS : An anonymous survey was e-mailed to fourth-year gynecology residents before graduation. The survey assessed opinions on vaginal hysterectomy training and future practice plans. RESULTS : One hundred eighty-three residents responded from 41 states. Most residents (75%) think vaginal hysterectomy training has been adequate to prepare them for future practice. Residents were more likely to respond that their training was adequate if they had performed more than 20 vaginal hysterectomies and if they had learned morcellation techniques. Only 42% of residents report vaginal route as their preferred route for hysterectomy. CONCLUSIONS : Most residents feel that training in vaginal hysterectomy has been adequate to prepare them for their future practice, although they are more likely to feel prepared if they have performed more than 20 vaginal hysterectomies.

Objective The objective of the study was to determine whether reproductive-age women are more likely to perceive their vulva as abnormal compared with older-aged women. Study Design Women aged 18-44 years (group 1) and 45-72 years (group 2) completed a survey on demographics, grooming patterns, vulvar perceptions, and source of information about the vulva. Results There was no difference between group 1 and group 2 in how often women looked at their vulva or their perception of having a normal vulva (91% vs 93%, P = .76). Both groups were satisfied with the appearance of their vulva (81% vs 82%, P = .71). A higher percentage in group 2 would consider cosmetic surgery if cost were not an issue versus group 1 (15% vs 8%, P = .05). Conclusion A woman's age does not have an impact on her perception of a normal vulva. The majority of women perceived their vulva to be normal and were satisfied with its appearance. However, older women are more interested in cosmetic vulvar surgery.

Objective Pessaries are important options for women with pelvic floor disorders, but many pessary users experience bacterial vaginosis (BV). The aim of this study was to evaluate the effect of TrimoSan gel (Milex Pessaries, Cooper Surgical, Trumbull, CT) on BV prevalence among pessary users. Study Design Women presenting for a pessary fitting completed questionnaires on vaginal symptoms and hormone therapy use and underwent a BV BLUE test and slide collection for BV analysis by Nugent's criteria. Following pessary fitting, women were randomized to either standard pessary care with the use of TrimoSan placed vaginally twice weekly or to standard pessary care without TrimoSan gel. Women returned 2 weeks and 3 months later for a repeat slide collection for Gram stain, BV BLUE testing, and completion of questionnaires on vaginal symptoms and desire to continue the pessary. Results There were 184 women randomized after successful fitting (92 to the TrimoSan group), and 147 (79%) presented for 3-month follow up. Mean age was 56 ± 16 years; patients were mostly white (57%) or Hispanic (23%), and 36% were using hormone therapy. The groups did not differ in the prevalence of BV by Nugent's criteria at 2 weeks (20% TrimoSan vs 26% no gel, P = .46) or 3 months (24% TrimoSan vs 23% no gel, P = .82), nor did they differ in BV by BV BLUE testing at 2 weeks (0% TrimoSan vs 4% no gel, P = .12) or 3 months (3% TrimoSan vs 0% no gel, P = .15). The prevalence of at least one vaginal symptom did not differ between groups at 2 weeks (44% TrimoSan vs 45% no gel, P = .98) or 3 months (42% TrimoSan vs 32% no gel, P = .30). The TrimoSan group was equally likely to want to continue their pessary use compared with the standard care group at 2 weeks (90% vs 86%, P = .64) and 3 months (63% vs 60%, P = .76). Conclusion TrimoSan gel in the first 3 months of pessary use does not decrease the prevalence of BV or vaginal symptoms and does not alter the likelihood of a woman desiring to continue pessary use.

To provide data regarding the training, credentialing and use of cystoscopy among recent obstetrics and gynecology (Ob/Gyn) residents.A total of 98 surveys were sent to recent graduates of Ob/Gyn residency programs in the District of Columbia (DC). Questions concerning cystoscopy in residency training, current cystoscopy privileges and utilization of this technique were asked.Of the 98 surveys sent, 34 (35%) were completed. Of the survey respondents 88% reported rotating through a urogynecology or female urology service during residency, and the majority of residents spent at least 2 months on service. A total of 68% of survey respondents reported currently having cystoscopy privileges. Only 12% of those surveyed reported performing routine cystoscopy after hysterectomy. When asked why, most participants reported performing cystoscopy only if urinary tract injury is suspected.The majority of recent graduates of Ob/Gyn residency training programs surveyed in DC are exposed to and receive privileges for cystoscopy. However, few choose to use it after routine hysterectomy. Given the fact that 75% of urinary tract injuries occur during gynecologic surgery and that these injuries are more likely to occur at the hands of newly minted surgeons, a change in this practice may be warranted.

Objective To determine whether blinded and unblinded Pelvic Organ Prolapse Quantification (POP-Q) examinations differ in a randomized trial. Study Design Blinded POP-Q examinations performed at 3 months and 1 year were compared with unblinded examinations performed by the surgeon in a randomized trial of vaginal mesh for pelvic organ prolapse. Results Sixty-five patients were included in the study. Correlations between the blinded and unblinded POP-Q points and stages varied from low to moderate (rho = 0.29-0.78). At 3 months, the blinded overall prolapse recurrence rate was 45.3% compared with 39.1% based on unblinded staging ( P = .34). At 1 year, the blinded overall recurrence rate was significantly higher than the unblinded recurrence rate: 68.3% vs 53.3% ( P = .004). The 1-year blinded anterior wall recurrence rate was also higher than the recurrence based on unblinded staging: 56.7% vs 43.3% ( P = .021). Conclusion Use of unblinded POP-Q staging resulted in underestimation of 1-year overall recurrence after prolapse repair.

Most posterior wall defects occur in combination with other pelvic support disorders. Some patients with rectoceles, the most common posterior wall defect, are asymptomatic, whereas others experience a range of symptoms from a sensation of lower pelvic fullness to defecatory and/or sexual dysfunction. If patients are symptomatic, rectoceles can be treated conservatively with pelvic floor physiotherapy, behavioral therapy, or pessaries. Surgically, the most common rectocele repair is a traditional posterior colporrhaphy which provides excellent cure rates of up to 95%. The studies published to date do not support the use of biologic or synthetic absorbable grafts in reconstructive surgical procedures of the posterior compartment as these repairs have not improved anatomic or functional outcomes over traditional posterior colporrhaphy.

We present a case of urinary retention due to bladder outlet obstruction in a pregnant patient who had a prior transobturator synthetic sling procedure for stress urinary incontinence 2 years earlier. After the sling was released at 19 weeks, the voiding dysfunction resolved, but the patient remained incontinent. This case emphasizes a potential unique complication of suburethral sling in pregnancy.

Thousands of women undergo renal transplantation each year. Many develop pelvic floor conditions after transplantation requiring surgical correction. This study describes our experience with pelvic reconstructive surgery in renal transplant recipients.Retrospective chart review identified five renal transplant patients who had pelvic reconstructive surgery for urodynamic stress incontinence and prolapse between January 2000 and May 2008. Data included medical and surgical history, POP-Q measurements, and classification of perioperative complications.The mean age was 56.5 years (range 50-70). A total of two vaginal hysterectomies with vault suspension, three anterior repairs, two posterior repairs, and three synthetic midurethral slings were performed. No intraoperative or postoperative complications occurred. At a mean follow-up of 12.6 months (range 4-36), all patients were cured of their prolapse and incontinence with no evidence for synthetic mesh infection, rejection, or erosion.Pelvic reconstructive surgery can safely be performed in renal transplant patients.

ContextMenopausal hormone therapy has long been credited with many benefits beyond the indications of relieving hot flashes, night sweats, and vaginal dryness, and it is often prescribed to treat urinary incontinence (UI).ObjectiveTo assess the effects of menopausal hormone therapy on the incidence and severity of symptoms of stress, urge, and mixed UI in healthy postmenopausal women.Design, Setting, and ParticipantsWomen’s Health Initiative multicenter double-blind, placebo-controlled, randomized clinical trials of menopausal hormone therapy in 27 347 postmenopausal women aged 50 to 79 years enrolled between 1993 and 1998, for whom UI symptoms were known in 23 296 participants at baseline and 1 year.InterventionsWomen were randomized based on hysterectomy status to active treatment or placebo in either the estrogen plus progestin (E + P) or estrogen alone trials. The E + P hormones were 0.625 mg/d of conjugated equine estrogen plus 2.5 mg/d of medroxyprogesterone acetate (CEE + MPA); estrogen alone consisted of 0.625 mg/d of conjugated equine estrogen (CEE). There were 8506 participants who received CEE + MPA (8102 who received placebo) and 5310 who received CEE alone (5429 who received placebo).Main Outcome MeasuresIncident UI at 1 year among women without UI at baseline and severity of UI at 1 year among women who had UI at baseline.ResultsMenopausal hormone therapy increased the incidence of all types of UI at 1 year among women who were continent at baseline. The risk was highest for stress UI (CEE + MPA: relative risk [RR], 1.87 [95% confidence interval {CI}, 1.61-2.18]; CEE alone: RR, 2.15 [95% CI, 1.77-2.62]), followed by mixed UI (CEE + MPA: RR, 1.49 [95% CI, 1.10-2.01]; CEE alone: RR, 1.79 [95% CI, 1.26-2.53]). The combination of CEE + MPA had no significant effect on developing urge UI (RR, 1.15; 95% CI, 0.99-1.34), but CEE alone increased the risk (RR, 1.32; 95% CI, 1.10-1.58). Among women experiencing UI at baseline, frequency worsened in both trials (CEE + MPA: RR, 1.38 [95% CI, 1.28-1.49]; CEE alone: RR, 1.47 [95% CI, 1.35-1.61]). Amount of UI worsened at 1 year in both trials (CEE + MPA: RR, 1.20 [95% CI, 1.06-1.36]; CEE alone: RR, 1.59 [95% CI, 1.39-1.82]). Women receiving menopausal hormone therapy were more likely to report that UI limited their daily activities (CEE + MPA: RR, 1.18 [95% CI, 1.06-1.32]; CEE alone: RR, 1.29 [95% CI, 1.15-1.45]) and bothered or disturbed them (CEE + MPA: RR, 1.22 [95% CI, 1.13-1.32]; CEE alone: RR, 1.50 [95% CI, 1.37-1.65]) at 1 year.ConclusionsConjugated equine estrogen alone and CEE + MPA increased the risk of UI among continent women and worsened the characteristics of UI among symptomatic women after 1 year. Conjugated equine estrogen with or without progestin should not be prescribed for the prevention or relief of UI.

Objective The purpose of this study was to evaluate 4 cases of chronic urinary retention and pelvic floor muscle spasms after surgery for endometriosis. Study design These patients underwent a complete history, physical exam, and diagnostic work- up. The results were analyzed with regards to type and extent of inciting surgery, diagnostic findings, postoperative recovery, and treatment success. Results The patients' mean age was 39.5 years and all had undergone various surgical interventions for endometriosis. In addition to urinary retention, all developed debilitating pelvic floor muscle spasm postoperatively. Physical exam revealed pelvic floor hypertonicity and urodynamics indicated hypoactive detrusor contractility. Neurodiagnostic testing gave evidence of neuropathy in all subjects. Conclusion Extensive endometriosis surgery may pose a risk for postoperative bladder dysfunction and pelvic floor muscle spasm.

Stress urinary incontinence is defined as the symptomatic loss of urine related to increases in intra-abdominal pressure. A variety of nonsurgical therapies with varying degrees of effectiveness and patient acceptance are available. If nonsurgical therapies fail, then multiple surgical options exist, including retropubic urethropexy, bulking agents, pubovaginal slings, and sling variants. A surgical algorithm based on the amount of anterior vaginal wall prolapse (including urethrovesical mobility) and urethral sphincter function utilizing these procedures is reported herein.

Objectives: Little is known about involuntary passage of air from the vagina, also known as vaginal wind, garrulous vaginalis, and other slang terms. Similarly, minimal data exist regarding the potential association between abdominal wall striae and pelvic organ prolapse (POP). The objective of this study was to describe the presence of vaginal wind and striae in patients with and without POP. Materials and methods: This was an IRB approved cross-sectional study of women R18 years seeking care at a single academic institution between December 2012 and August 2013. We excluded women with rectovaginal fistulae, prior POP or incontinence surgery, pregnancy, and the inability to complete forms. After obtaining informed consent, all patients completed a questionnaire about vaginal wind and striae, the Pelvic Floor Distress Inventory Short Form (PFDI-20), and the revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-IR). Additionally, POP-Q data, mid-vaginal width, and quantification of abdominal striae were recorded. Women were dichotomized into normal support (POP-Q stage 0-1) or POP (POP-Q stage 2-4) groups for analysis. Forty-six patients were needed in each group to detect a 13% difference in the prevalence of vaginal wind between groups with an a of 0.05 and power of 80%. Results: One hundred thirty-two patients were approached for participation. One hundred twenty-three patients (93%) agreed to participate, of which 110 (83%) completed study questionnaires. The mean age was 55.5 years and mean BMI was 27.5. The majority were white (65%), married (73%), sexually active (71%), and had a college education (76%). Fifty-one of 110 patients (46%) had normal support while 59/110 (54%) had POP. Those with POP had more vaginal deliveries (mean 2.4 vs. 1.3, p \ 0.001). There was no difference in medical comorbidities, smoking status, or steroid use between groups (p > 0.05 for all). Overall, 76/110 (69%) women experienced vaginal wind an average of 2.3 times per week and this was not statistically significant between groups (p = 0.47). Ninety-nine percent of women with vaginal wind experienced it during intercourse. Other activities associated with vaginal wind included cunnilingus (45%), digital stimulation (17%), jogging (45%), and sit-ups (44%). Sixty-four percent of women were at least somewhat bothered by vaginal wind, although only 22% reported a negative effect on quality of life. Women with vaginal wind had a longer mean vaginal length (9.5 vs. 8.8 cm, p = 0.004) and better apical support than those without vaginal wind (C -5.1 vs. -3.0 cm, p = 0.02). There was no difference in midvaginal width or other POP-Q points (p > 0.05 for all). Sixty-five of 110 (59%) women had striae: 23/51 (45%) with normal support and 42/59 (71%) with POP (p = 0.006). Women with POP were more likely to have striae compared to women with normal support, adjusting for skin color and smoking status (OR = 2.5, 95% CI, 1.036.06, p = 0.04). Conclusion: Vaginal wind is a common and bothersome complaint among women with and without POP and is associated with a longer total vaginal length and better apical support. Women with POP are more likely to have striae. Future studies are needed to further investigate these findings with regard to the impact on care-seeking and surgical intervention. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS

Pelvic floor disorders, including pelvic organ prolapse, urinary incontinence, fecal incontinence, and other sensory disorders of the gastrointestinal and genitourinary tract, are common with nearly 1 in 4 US women having at least 1 pelvic floor condition.1 In this issue of JAMA, Nygaard and colleagues2 present findings from the extended Colpopexy and Urinary Reduction Efforts (extended CARE) trial. The original CARE trial3 was a double-blind randomized trial of 322 women mostly with advanced (stage 3-4) prolapse and without stress incontinence symptoms undergoing an open abdominal synthetic mesh sacrocolpopexy procedure either with or without a urethropexy for prevention of stress urinary incontinence.

Objective The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh. Study Design Women with stage ≥2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ≤1 at 12 months. Secondary outcomes included quality of life and complications. Results All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh. Conclusion Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.