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The objective was to investigate the impact of mindfulness-based stress reduction therapy on the urinary microbiome of patients with interstitial cystitis/bladder pain syndrome. In this Institutional Review Board-approved prospective cohort study, patients with interstitial cystitis/bladder pain syndrome were recruited to attend an 8-week mindfulness-based stress reduction course involving yoga and meditation. Eligible participants were English-speaking women aged 18 or older with interstitial cystitis/bladder pain syndrome. All participants had a negative urinalysis within 2 months of enrollment and were currently undergoing first- or second-line treatment at the time of recruitment. The mindfulness-based stress reduction course met weekly for 1 h. A straight-catheter urine sample was obtained prior to and following the mindfulness-based stress reduction series. DNA from urine samples underwent bacterial 16S ribosomal gene sequencing at Johns Hopkins University Laboratories followed by taxonomic abundance and diversity analysis by Resphera Biosciences Laboratory. Participants completed validated symptom questionnaires pre- and post-intervention. A total of 12 participants completed the 8-week course and were included in the analysis. The average age was 59 and the majority identified as white. Patient symptoms, measured by the Urogenital Distress Inventory Short Form and Interstitial Cystitis Symptom and Pain Indices, improved significantly (all p

There is little consensus on an effective nonantibiotic agent for the prevention of urinary tract infection (UTI) after pelvic reconstructive surgery.The aim of the study was to investigate the impact of methenamine hippurate with cranberry capsules on rates of UTI after pelvic reconstructive surgery, among patients requiring short-term catheterization.In this randomized, double-blinded placebo-controlled trial, patients discharged with a catheter after pelvic reconstructive surgery were approached to participate. Participants were randomized to receive cranberry with methenamine or cranberry with placebo. Primary outcome was number of UTIs treated within 1 week after surgery. Secondary outcomes included incidence of UTIs treated within 6 weeks postoperatively, bacterial species on culture, urinary pH, catheter duration, patient adherence, and satisfaction. A sample size of 88 participants per arm was planned.From June 2019 to July 2021, 185 patients were randomized and 182 analyzed; 89 received placebo and 93 received methenamine. Both groups were similar. Incidence of UTI at 1 week was significantly higher in the placebo group (79.8%) compared with the methenamine group (66.7%; odds ratio, 1.97; 95% confidence interval, 1.01-3.87; P = 0.048). This difference increased by 6 weeks postoperatively (89.9% vs 72.0%; odds ratio, 3.45; 95% confidence interval, 1.51-7.87; P = 0.003). There were fewer pseudomonal UTIs in the methenamine group (P = 0.041). Duration of catheterization and urinary pH were similar. Overall adherence and level of satisfaction was high.In this high-risk population, methenamine was well tolerated and significantly reduced UTI rates. Methenamine with cranberry should be considered as an effective prophylactic therapy to reduce this common complication after pelvic surgery.

To describe the impact of native tissue vaginal reconstruction on pelvic anatomy using dynamic magnetic resonance imaging. This prospective single-cohort observational study involved women undergoing native tissue reconstruction with intraperitoneal vaginal vault suspension for pelvic organ prolapse. Concomitant procedures such as hysterectomy, midurethral sling, and anterior or posterior colporrhaphy were allowed. Enrolled participants underwent dynamic pelvic imaging pre- and postoperatively. Radiographic and anatomic measurements were compared. Secondary outcomes included validated patient questionnaires. Fourteen participants were included in the analysis. The mean age was 62 years; all participants were Caucasian. Most participants had stage III pelvic organ prolapse. Significant improvements were noted in several radiographic measurements. The average H-line (representing levator hiatus width) with straining maneuvers improved following surgery (7.2 cm preoperatively vs. 6.6 cm postoperatively, p = 0.015). The average M-line (representing levator muscular descent) improved significantly with both straining (4.0 cm preoperatively vs. 3.0 cm postoperatively, p

Objective To determine if women with human immunodeficiency virus (HIV) undergoing pelvic reconstructive surgery (PRS) have an increased risk of perioperative and postoperative complications compared with HIV-negative controls. Study design Multicenter, retrospective matched cohort study of patients with and without HIV infection who underwent PRS between 2006 and 2016. Cases were identified using International Classification of Disease, 9th edition Clinical Modification and 10th edition Clinical Modification and current procedural terminology (CPT) codes encompassing HIV diagnoses and pelvic reconstructive surgeries. Controls were identified as patients without HIV who underwent similar procedures, performed by the same surgeon during the same 1-year period as surgeries performed on patients with HIV. Cases were matched to controls at a ratio of 1:3. The primary outcome was composite complication rate within 1 year of surgery. Results Sixty-three patients with HIV and 187 controls were identified. There was no difference in the composite complication rate between women with HIV and HIV-negative women (36.5% vs 30.0%, P = 0.15) over 1 year. However, 19.1% of patients with HIV compared with 5.4% controls had Clavien Dindo Grade I complications (P = 0.002), and 11.1% of HIV patients had urinary retention within 6 weeks of surgery compared with 3.2% of controls (P = 0.02). After multivariable logistic regression used to adjust for confounders, living with HIV was not associated with an increased risk of complications. Conclusions Patients living with HIV are not at an increased risk of complications within 1 year of PRS compared with patients without HIV.

To evaluate whether self-discontinuation of a transurethral catheter is noninferior to office discontinuation in patients requiring indwelling catheterization for postoperative urinary retention after pelvic reconstructive surgery.In this randomized noninferiority trial, patients with postoperative urinary retention after pelvic reconstructive surgery were assigned to self-discontinuation or office discontinuation of their catheter 1 week after surgery. The primary outcome was a noninferiority comparison of postoperative urinary retention at 1 week. Self-discontinuation patients were instructed on home catheter removal on postoperative day 7. Office discontinuation patients underwent a standard voiding trial on postoperative day 6-8. Postoperative urinary retention at 1 week was defined as continued catheterization on postoperative day 6-8. Secondary outcomes included urinary tract infections (UTI), residual volume at 2 weeks, duration of catheter use, recurrent postoperative urinary retention, number of patient encounters, and visual analog scales (VAS) regarding patient experience. Given a known incidence of postoperative urinary retention at 1 week (16%) and 15% noninferiority margin, a sample size of 74 per group (n=148) was planned.From January 2017 through March 2019, 217 women were screened and 157 were analyzed: 78 self-discontinuation and 79 office discontinuation. Demographic characteristics and surgeries performed were similar. Eleven patients in each group experienced postoperative urinary retention at 1 week (14.1% self-discontinuation vs 13.9% office discontinuation, P=.97), establishing noninferiority (difference 0.2%, 95% CI: -1.00, 0.10). There were significantly fewer patient encounters with self-discontinuation (42/78, 53.8% vs 79/79, 100%). Self-discontinuation patients demonstrated better VAS scores regarding pain, ease, disruption, and likelihood to use the same method again (all P.05). Though the rate of UTI was high, there was no difference between groups (59.0% self-discontinuation vs 66.7% office discontinuation, P=.32). Residual volume at 2 weeks, recurrent postoperative urinary retention, and duration of catheter use were also similar.Self-discontinuation of a transurethral catheter was noninferior to office-based discontinuation in the setting of postoperative urinary retention after pelvic reconstructive surgery. Self-discontinuation resulted in fewer patient encounters and improved patient experience.ClinicalTrials.gov, NCT02996968.

OBJECTIVE The American College of Obstetricians and Gynecologists does not provide a recommendation regarding the preferred vaginal preparation solution. We intended to compare the effectiveness of chlorhexidine versus iodine in decreasing vaginal bacterial counts. METHODS In this institutional review board-approved study, participants undergoing total hysterectomy via vaginal or laparoscopic approach were randomized to 4% chlorhexidine or 10% iodine for presurgical vaginal preparation. Swabs were collected from the vaginal mucosa before, then 30, 60, and 90 minutes after preparation. Our primary outcome was the number of positive cultures (≥5,000 bacteria) at 90 minutes. The secondary outcomes included the presence of selected pathogens, postoperative complications, and infections. The sample size of 71 per arm was calculated using P = 0.05, 80% power, and anticipating a 22% difference in positive cultures. RESULTS Between May 2018 and August 2019, 85 participants were randomized. The average age was 59.8 years (SD, 11.4), and the median Charlson Comorbidity Index score was 2 (minimum, 0; maximum, 6). Baseline bacterial counts were similar in both groups. Chlorhexidine demonstrated a lower percentage of positive cultures at 90 minutes (47.6% vs 85.4%; odds ratio, 10.6; P = 0.001). In addition, the median bacterial count in the chlorhexidine group was significantly lower than the iodine group (3,000 vs 24,000 colony-forming units, P < 0.001) at 90 minutes. No surgical site infections were identified in either group during the 30-day postoperative period, and there were no reported adverse reactions to either solution. CONCLUSIONS Chlorhexidine resulted in substantially lower bacterial counts after preparation compared with iodine. Gynecologic surgeons may consider switching to 4% chlorhexidine for vaginal preparation before hysterectomy.

Patients undergoing vaginal hysterectomy with native tissue pelvic reconstruction typically have low pain levels overall in the postoperative period. Notwithstanding, pain control immediately after surgery may be more challenging and a barrier to same-day discharge. Intrarectal diazepam has been used for acute and chronic pelvic pain and has a pharmacokinetic profile ideal for intermittent use. However, its use has not been investigated after the surgical intervention.This study aimed to evaluate the effect of diazepam rectal suppositories on early postoperative pain after hysterectomy and vaginal reconstruction for pelvic organ prolapse.This was a double-blind, randomized, placebo-controlled trial comparing postoperative pain scores after vaginal hysterectomy with native tissue prolapse repairs. Patients were randomized to receive either an intrarectal 10-mg diazepam suppository or an identical placebo. Moreover, the participants completed the questionnaires at baseline, the morning of postoperative day 1, and 2 weeks after the operation. Surveys included visual analog scales for pain, a validated Surgical Satisfaction Questionnaire, and queries regarding medication side effects and postoperative recovery. The primary outcome was pain scores based on a visual analog scale approximately 3 hours after surgery. The secondary outcomes included total morphine equivalents after surgery, patient satisfaction with pain control, same-day discharge outcome, and overall satisfaction. The chi-square, Fisher exact, and Mann-Whitney tests were used. Based on a 10-mm difference in postoperative vaginal pain using the visual analog scale, sample size was calculated to be 55 patients in each arm to achieve 80% power with an alpha of.05.From February 2020 to August 2021, 130 participants were randomized. Of those participants, 7 withdrew, and 123 were analyzed: 60 in the diazepam group and 63 in the placebo group. The median age was 65 years (interquartile range, 27-80), the median body mass index was 27.9 kg/mThe placement of a 10-mg diazepam rectal suppository immediately after pelvic reconstructive surgery did not improve pain or narcotic usage in the early postoperative period. Although the placebo group reported slightly higher satisfaction with pain control 2 weeks after surgery, overall pain levels were low. Therefore, we do not believe that the addition of diazepam to the postoperative regimen is warranted.

We aimed to systematically review the literature on pelvic organ prolapse (POP) surgery with uterine preservation (hysteropexy). We hypothesized that different hysteropexy surgeries would have similar POP outcomes but varying adverse event (AE) rates. MEDLINE, Cochrane, and clinicaltrials.gov databases were reviewed from inception to January 2018 for comparative (any size) and single-arm studies (n ≥ 50) involving hysteropexy. Studies were extracted for participant characteristics, interventions, comparators, outcomes, and AEs and assessed for methodological quality. We identified 99 eligible studies: 53 comparing hysteropexy to POP surgery with hysterectomy, 42 single-arm studies on hysteropexy, and four studies comparing stage ≥2 hysteropexy types. Data on POP outcomes were heterogeneous and usually from

OBJECTIVE The aim of the study was to compare long-term outcomes of uterosacral ligament suspension (USLS) versus robotic sacrocolpopexy (RSC) in patients with pelvic organ prolapse. METHODS This was an institutional review board-approved retrospective cohort study. Women 3 to 7 years after USLS or RSC were contacted for enrollment. Participants were asked to complete validated questionnaires and physical examinations. The primary outcomes were no symptoms of bulge or retreatment for prolapse (subjective) and POP-Q examination demonstrating prolapse above or equal to -1 (objective). For the subjective outcome, a noninferiority calculation with 10% noninferiority margin deemed 91 subjects in each group were required. RESULTS We identified the following 770 eligible subjects: 205 were contacted, 19 declined, 186 subjects agreed to participate, and 2 were excluded. There were 92 subjects per group in the analysis for the primary subjective outcome, and 84% underwent examinations for the objective outcome. Baseline characteristics were overall similar; however, previous prolapse surgery was more common in the RSC group (P < 0.001). Subjective success was achieved in 83 subjects in the USLS group and 78 subjects in the RSC group (90.2% vs 84.4%, respectively, P = 0.265 [95% confidence interval = -0.036 to 1.000]). Objective success was noted in 93.2% and 91.3% of the USLS and RSC groups, respectively (P = 0.869). Postoperative complication rates were low and did not differ between groups. Mesh complications were noted in 6.6% of the RSC group. One subject in the USLS group reported pain related to surgery. CONCLUSION Uterosacral ligament suspension was noninferior to RSC at 3- to 7-year postsurgery for subjective symptoms and similar for objective outcomes. Both approaches showed high success rates and strong patient satisfaction.

OBJECTIVE This study was conducted to assess the utility of a mirror in improving pain and vulnerability during a pelvic examination. METHODS In this prospective, institutional review board-approved, 2-cohort trial, all "new" patients presenting to a urogynecology office were offered to have a mirror or no-mirror present during their pelvic examination. Patients completed 100-mm visual analog scales regarding pain, anxiety, knowledge, control, embarrassment, and vulnerability before and after examination. The primary outcome was difference in level of pain and vulnerability between groups. Secondary outcomes included comparisons from baseline to postexamination scores within groups, patient satisfaction, and examination duration. A sample size of 68 participants in each arm was planned. RESULTS From April 2019 to May 2020, 147 participants were enrolled. Two participants were excluded, 145 were included in the final analysis; 74 in the no-mirror group and 71 in the mirror group. The average age was 55.9 (±13) years, and the groups were overall similar. There was no difference in primary outcomes of pain or vulnerability, but the mirror group showed improved levels of control (P = 0.006) and knowledge (P = 0.018) following examination. All participants reported high satisfaction, and those that selected a mirror reported strong preference for future use. CONCLUSIONS Patients who chose to use the mirror did not demonstrate a difference in pain or vulnerability scores; however, they exhibited benefit to their sense of control and knowledge after the pelvic examination. Although the mirror did not benefit all patients, this is a simple option that could improve the examination experience for some.Clinical Trial Registration:ClinicalTrials.gov, NCT03785548.

The objective was to investigate the impact of mindfulness-based stress reduction therapy on the urinary microbiome of patients with interstitial cystitis/bladder pain syndrome.In this Institutional Review Board-approved prospective cohort study, patients with interstitial cystitis/bladder pain syndrome were recruited to attend an 8-week mindfulness-based stress reduction course involving yoga and meditation. Eligible participants were English-speaking women aged 18 or older with interstitial cystitis/bladder pain syndrome. All participants had a negative urinalysis within 2 months of enrollment and were currently undergoing first- or second-line treatment at the time of recruitment. The mindfulness-based stress reduction course met weekly for 1 h. A straight-catheter urine sample was obtained prior to and following the mindfulness-based stress reduction series. DNA from urine samples underwent bacterial 16S ribosomal gene sequencing at Johns Hopkins University Laboratories followed by taxonomic abundance and diversity analysis by Resphera Biosciences Laboratory. Participants completed validated symptom questionnaires pre- and post-intervention.A total of 12 participants completed the 8-week course and were included in the analysis. The average age was 59 and the majority identified as white. Patient symptoms, measured by the Urogenital Distress Inventory Short Form and Interstitial Cystitis Symptom and Pain Indices, improved significantly (all p 0.05). Overall composition of the urinary microbiome changed significantly (p 0.01) and demonstrated an increase in diversity following the intervention.Mindfulness-based stress reduction therapy improves patient symptoms and was associated with significant changes in the urinary microbiome in patients with interstitial cystitis/bladder pain syndrome.

To describe the impact of native tissue vaginal reconstruction on pelvic anatomy using dynamic magnetic resonance imaging.This prospective single-cohort observational study involved women undergoing native tissue reconstruction with intraperitoneal vaginal vault suspension for pelvic organ prolapse. Concomitant procedures such as hysterectomy, midurethral sling, and anterior or posterior colporrhaphy were allowed. Enrolled participants underwent dynamic pelvic imaging pre- and postoperatively. Radiographic and anatomic measurements were compared. Secondary outcomes included validated patient questionnaires.Fourteen participants were included in the analysis. The mean age was 62 years; all participants were Caucasian. Most participants had stage III pelvic organ prolapse. Significant improvements were noted in several radiographic measurements. The average H-line (representing levator hiatus width) with straining maneuvers improved following surgery (7.2 cm preoperatively vs. 6.6 cm postoperatively, p = 0.015). The average M-line (representing levator muscular descent) improved significantly with both straining (4.0 cm preoperatively vs. 3.0 cm postoperatively, p 0.001) and defecatory maneuvers (6.2 cm preoperatively vs. 5.2 cm postoperatively, p = 0.001). The average size of cystocele improved from 5.6 cm (moderate) preoperatively to 0.7 cm (absent descent) postoperatively (p 0.001). The average descent of the vaginal apex with defecation preoperatively was 3.0 cm (moderate) and 0 cm (absent descent) postoperatively (p = 0.003). Posterior compartment descent with defecation did not change following surgical intervention (5.8 cm preoperatively vs. 5.2 cm postoperatively, p = 0.056). Pelvic Organ Prolapse Quantification measurements improved in all compartments, and Pelvic Floor Distress Inventory-20 scores improved significantly following surgery (102 preoperatively vs. 30 postoperatively, p 0.001).Native tissue reconstruction with intraperitoneal vaginal vault suspension resulted in significant anatomic improvements, as defined by physical examination and dynamic magnetic resonance imaging.

To determine if women with human immunodeficiency virus (HIV) undergoing pelvic reconstructive surgery (PRS) have an increased risk of perioperative and postoperative complications compared with HIV-negative controls.Multicenter, retrospective matched cohort study of patients with and without HIV infection who underwent PRS between 2006 and 2016. Cases were identified using International Classification of Disease, 9th edition Clinical Modification and 10th edition Clinical Modification and current procedural terminology (CPT) codes encompassing HIV diagnoses and pelvic reconstructive surgeries. Controls were identified as patients without HIV who underwent similar procedures, performed by the same surgeon during the same 1-year period as surgeries performed on patients with HIV. Cases were matched to controls at a ratio of 1:3. The primary outcome was composite complication rate within 1 year of surgery.Sixty-three patients with HIV and 187 controls were identified. There was no difference in the composite complication rate between women with HIV and HIV-negative women (36.5% vs 30.0%, P = 0.15) over 1 year. However, 19.1% of patients with HIV compared with 5.4% controls had Clavien Dindo Grade I complications (P = 0.002), and 11.1% of HIV patients had urinary retention within 6 weeks of surgery compared with 3.2% of controls (P = 0.02). After multivariable logistic regression used to adjust for confounders, living with HIV was not associated with an increased risk of complications.Patients living with HIV are not at an increased risk of complications within 1 year of PRS compared with patients without HIV.

To describe national practice patterns regarding apical support procedures at time of hysterectomy for prolapse prior to the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on pelvic organ prolapse. This retrospective descriptive study analyzed 24 months of data from the National Surgical Quality Improvement Program (NSQIP) database, from 2015 and 2016. Patients undergoing hysterectomy for the indication of pelvic organ prolapse were included. Surgical details, diagnostic codes, subspecialty, patient demographics, and postoperative complications were collected. Comparisons were conducted between those who did and did not undergo apical support procedures. Further comparisons, including logistic regressions, were performed using subspecialty designation. During the study period, 3458 hysterectomies were performed for the indication of pelvic organ prolapse. Of this population, 76% were White, with an average age of 61 years, BMI of 27.6, and parity of 2, and 90.5% carried the diagnosis of apical prolapse. Slightly over half (51.8%) had a concurrent procedure to support the vaginal apex. When performed by Female Pelvic Medicine and Reconstructive Surgery (FPMRS) physicians, 65.7% underwent an apical suspension at time of hysterectomy for prolapse compared with 40.2% of non-FPMRS (p

Objectives Appropriate perineal protection may reduce rates of obstetric anal sphincter injuries (OASIS). We sought to investigate the knowledge and attitudes of obstetrics and gynecology residents concerning perineal protection, OASIS, and episiotomy before and after an educational workshop. Methods This was an institutional review board-approved cross-sectional survey study of obstetrics and gynecology residents. Two experts in perineal protection, whose methods have been shown to reduce OASIS by 50%, provided 1 week of education. Residents were taught in hands-on workshops and labor and delivery wards. Residents were surveyed regarding experiences, knowledge, and opinions of perineal protection, OASIS, and episiotomy. Surveys were administered immediately before and after the workshop and at 3 months following. Results All 31 residents participated. Almost all (97%) felt it was possible to reduce the incidence of OASIS prior to the workshop. Statistically significant increases were noted following training in the number that felt it was "very effective" to use the 2-handed technique taught in the workshop (P = 0.002), as well as those that reported most commonly performing a mediolateral episiotomy (protective against OASIS, if used selectively) when episiotomy was indicated (P = 0.001). The percent that reported feeling "comfortable" or "very comfortable" performing episiotomies increased from 45% to 77% immediately after the workshop (P = 0.002); this declined to 55% at 3 months. A large majority (77%) reported that the workshop was beneficial; 65% described an impact to patient care. Conclusions A workshop targeting perineal protection improved awareness and changed clinical practice in this group of residents. Ongoing education regarding perineal protection and episiotomy may reinforce behavior modifications.

Objectives Obstetric anal sphincter injuries (OASISs) are a devastating postpartum complication; reducing rates is paramount to improving quality of care. In Norway, implementation of a perineal protection program decreased the incidence of OASIS by 48%. We sought to assess impact on OASIS rates following a similar program. Methods This institutional review board-approved, retrospective cohort study was performed in an academic hospital system. The periods of analysis were November 2014 through October 2015 for the preintervention arm and November 2015 through October 2016 for the postintervention arm. From November 2 to 6, 2015, 2 Norwegian experts conducted a didactic and hands-on, on-site workshop focusing on perineal protection. The experts were then present on labor and delivery wards to reinforce perineal protection in live deliveries. Teachings were emphasized at departmental meetings for the remainder of the year. Data were extracted from electronic medical records and manually audited. Results The rate of vaginal delivery was similar among both periods (6504 and 6650; P = 0.059). Obstetric anal sphincter injury rates decreased from 211 (3.2%) preintervention to 189 (2.8%) after the workshop. Although this represented 32 fewer injuries, it was not statistically significant (P = 0.179). Obstetric anal sphincter injuries following forceps-assisted deliveries did decline significantly from 103 (28%) to 81 (21%) (P = 0.014). In addition, incidence of fourth-degree lacerations during resident deliveries decreased significantly from 10 (0.6%) to 3 (0.2%) (P = 0.047). Conclusions An educational workshop focusing on perineal support was not associated with a significant reduction in overall OASIS rates. Nevertheless, decreased forceps-related OASIS and fourth-degree lacerations rates support positive influence of the intervention.

OBJECTIVE The aims of this study are to identify screening, treatment, and referral practices of primary care physicians (PCPs) for patients with pelvic floor disorders (PFDs) and evaluate awareness of the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) subspecialty. METHODS We conducted a cross-sectional survey of PCPs using a random sample of 1005 American College of Physicians members, stratified by demographic region. Electronic survey content included awareness of FPMRS certification, comfort diagnosing and treating PFDs, and PFD referral patterns for PCPs. RESULTS The 399 survey respondents were predominately male and of diverse ages, geographic distribution, and experience level.Forty-eight percent were aware of the FPMRS subspecialty, 31% of FPMRS board certification, and 25% of American Urogynecologic Society. Less than one third screened for PFDs, only two thirds were comfortable diagnosing urinary complaints, and even fewer felt comfortable diagnosing pelvic organ prolapse and fecal incontinence (FI).Eighty-five percent recommended pelvic floor exercises for stress urinary incontinence and referred to urology (29%) or FPMRS (25%) as second-line therapy, whereas 55% recommended medication/fiber for FI and referred to gastroenterology/colorectal surgery (31%) and FPMRS (2%) as second-line therapy.Primary care physicians referred to colorectal surgery for FI (60%), to Ob/Gyn for obstetric anal sphincter injury (38%) and pelvic organ prolapse (57%), and to urology for microscopic hematuria (80%), overactive bladder (60%), recurrent urinary tract infection (75%), stress urinary incontinence (48%), and voiding dysfunction (84%). CONCLUSIONS Most PCPs do not routinely screen for PFDs, and fewer feel comfortable treating. The majority is unaware of FPMRS and American Urogynecologic Society and more commonly refers PFD patients to other specialists.

Objective The aims of this study were to describe the characteristics of women presenting with mesh-related complications and evaluate postoperative quality of life, sexual functioning, and patient-perceived outcomes. Methods This institutional review board-approved study included a retrospective chart review and a cross-sectional follow-up with validated questionnaires. Demographics and medical histories were collected from charts of women treated for mesh-related complaints between 2010 and 2014. Subjects completed follow-up validated questionnaires regarding health, sexual functioning, postoperative symptom improvement/severity, satisfaction, and regret with the decision to pursue treatment. Results Ninety-three charts were analyzed. Mean subject age was 55 years, median body mass index was 28.7 kg/m, and median time from mesh placement to presentation was 2.7 years. Forty-nine had midurethral sling mesh only, 30 had prolapse-related mesh, and 14 had both. Forty-two subjects (48.9%) had mesh exposures, 19 involving prolapse-related mesh (52.4% transvaginal and 47.4% sacrocolpopexy). Surgical revisions were most often for exposure and pain. Seventy-five women were reached for follow-up; 71 agreed to participate, 53 (75%) returned the questionnaires. Thirty had sling revision, 22 had prolapse mesh revision, and 1 had both. Questionnaire results revealed no changes in health or sexual function after treatment. Postoperatively, subjects reported symptom improvement, low symptom severity, as well as high satisfaction and low regret with the decision to pursue surgical intervention. Conclusions Women with mesh complications presented 2 years after initial placement, most often complaining of exposure or pain/dyspareunia. Although no changes in health or sexual functioning were noted postoperatively, participants reported symptom improvement after revision and satisfaction with the decision to pursue treatment.

Study Objective Historically, surgery was learned in the operating room after first reading step-by-step instructions in a well-respected and well-illustrated text-book. Today, with technology at their fingertips, young surgeons seek and utilize video for learning surgical procedures. Often however, the more important “why” behind many surgical steps is left out. Our objective therefore, was to marry the demonstration of the anatomy with the why in order to provide a more complete experience for the learner. Design N/A Setting Operating room. Patients or Participants Patients undergoing planned hysterectomy for pelvic organ prolapse repairs who provided consent for filming. Interventions We carefully walk through performing the steps of a complete vaginal hysterectomy. We begin with identifying the cervix, and finish demonstrating how to check the pedicles for occult bleeding once the uterus and cervix are removed. We include tips and tricks within the video with specific benefits related to each suggestion, to help provide the "why". We cover many of the most challenging areas for new surgeons in completing a successful vaginal hysterectomy. We cover plane development, efficient tying technique, aids for visualization, introduction of a modified Heaney stitch, which brings each pedicle together, closing the gaps between them and greatly reducing blood loss, and provide and demonstrate other pearls throughout. Measurements and Main Results N/A Conclusion If performed correctly, utilizing the techniques and tips included in this instructional video, the gynecologic trainee will enter the operating room for their first hysterectomy, empowered with knowledge and understanding that typically are learned during their first five to ten cases. Thus, empowering them with a framework for not only success in their first case, but one they can carry with them through their career.

Background Activity tracking devices can reinforce physical fitness and may be beneficial to resident physicians. To date, their use has not been evaluated. Objective To determine if use of an activity tracking device increases residents' activity, measured as steps per day. Methods A prospective, crossover study involved residents at 1 academic hospital system. Participants were weighed and completed a baseline survey. All participants were asked to wear an activity tracking device for 8 weeks. Residents were blinded to feedback from the device on activity level during the first 4 weeks. During the second 4-week period, participants were given access to data on activity level and were invited to join a voluntary activity tracking group. Results Of 104 residents invited to participate, 86 enrolled. The majority of participants were female and did not have experience using activity trackers. Almost half (49%, 51 of 104) had a body mass index greater than 25 kg/m2. The median steps per day of all participants during the blinded period was 7260. This increased to 8266 steps per day during the unblinded period. Surgical residents recorded significantly more steps than nonsurgical specialties (7938 versus 6724, P = .018). The 26 residents who joined the voluntary activity tracking group registered higher median steps per day, and wore their activity tracker more consistently. Conclusions Providing residents with activity trackers, increasing feedback, and providing comparisons to peers may enhance residents' physical activity levels.

Background Vaginal and urethral histology is important to understanding the pathophysiology of the pelvic floor. Methods En bloc removal of 4 female cadaveric pelvises was performed, with 18 to 25 serial sections obtained from each. The vaginal and urethral lengths were divided into distal and proximal sections; urethra was divided into anterior and posterior segments as well. Innervation and vasculature were qualified as small and large and quantified per high-power field. Results The mean vaginal length was 7.45 cm, and the mean urethral length was 3.38 cm. A distinct vaginal fibromuscular layer was noted, without evidence of a dense sheet of continuous collagen. An epithelial, lamina propria, and muscular layer surrounded the urethral lumen. Adipose and loose fibroconnective tissue separated the urethra from the anterior vagina in 41% of slides. Nerves and vasculature were concentrated in the lamina propria. More small nerves and vessels were grossly seen compared with larger counterparts in both the vagina and urethra. No significant differences in layer thickness, innervation, or vasculature were observed along the vaginal length. The posterior urethra had greater innervation than did the anterior (P = 0.012). The distal posterior urethra had more large vessels than did the proximal posterior urethra (P = 0.03). No other differences were noted in urethral sections. Conclusions A vaginal fibromuscular layer was confirmed, refuting a true fascia. Innervation and vasculature were quantitatively the same along the anterior vagina. However, the posterior urethra had greater innervation than did anterior and is most innervated proximally. Nerve and vascular histology may relate to pelvic floor disorder etiology.

Objective This study aimed to determine the effect of intravenous acetaminophen versus placebo on postoperative pain, satisfaction with pain control, and narcotic use after vaginal reconstructive surgery. Methods This was an institutional review board-approved, double-blind placebo-controlled randomized trial. Women scheduled for reconstructive surgery including vaginal hysterectomy and vaginal vault suspension were enrolled. Subjects received 1000 mg of intravenous acetaminophen or 100 mL placebo every 6 hours for 24 hours. Pain and satisfaction with pain control were assessed using visual analog scales and a numeric rating scale. Visual analog scales were collected at 18 and 24 hours postoperatively and at discharge. A sample size calculation determined 90 subjects would be required to detect a 30% reduction in postoperative narcotic use with 80% power and significance level of 0.05. Results One hundred subjects were enrolled. There were no differences in demographics or surgical data and no difference in narcotic consumption at multiple evaluation points. At 18 hours postoperative, median pain scores at rest were 27.0 (interquartile range, 35.0) for acetaminophen and 35.0 (interquartile range, 44.5) for placebo, finding no difference (P = 0.465). Furthermore, pain with activity and numeric rating scale-assessed pain scales were similar (P = 0.328; P = 0.597). Although satisfaction with pain control was high overall (91.5), no difference was noted. Conclusions Patients undergoing vaginal reconstructive surgery receiving perioperative intravenous acetaminophen did not experience a decrease in narcotic requirements or postoperative pain when compared with placebo. Reassuringly, pain scores were low and satisfaction with pain control was high for all subjects. The general use of this medication is not supported in these surgical patients.

The novel coronavirus (COVID-19) pandemic has had a major impact on how patients are evaluated and treated for diseases and conditions in normal patient care Due to lack of effective treatments for this virus or vaccines to prevent infection, focus is placed on infection prevention through use of social distancing, quarantine, and face masks To prevent COVID-19 infections in healthcare settings, the Centers for Disease Control and Prevention has recommended decreasing or eliminating nonurgent office visits Telehealth has emerged as an alternative way to deliver effective patient care, while reducing patient and physician exposure to the virus Telehealth is any remote healthcare process, including provider training or team meetings, whereas telemedicine refers to use of specific technology to connect a patient to a provider High quality of care can and must be provided by Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) as well as other specialists and health professionals using telemedicine Because of the health care emergency during the pandemic, the Centers for Medicare and Medicaid Services have broadened access to and reimbursement for telemedicine services Rapid advances in communications technology and widespread wireless access in many modern households have allowed the adoption and integration of telemedicine into urogynecology and other health practices There are no clear guidelines for the use of telemedicine in FPMRS The aim of this study was to conduct an expedited review of the evidence and to provide guidance for managing common outpatient FPRMS conditions during the COVID pandemic using telemedicine FPMRS conditions were grouped into those that likely to require different treatment with virtual management compared with in-person visits, and those that could use accepted behavioral counseling and not deviate from current management paradigms Rapid systematic review methodology was used to screen for articles related to 4 topics: (1) telemedicine in FPMRS, (2) pessary management, (3) urinary tract infections, and (4) urinary retention In addition, 4 other topics were addressed (based on past systematic reviews and national or international society guidelines): (1) urinary incontinence, (2) vaginal prolapse, (3) fecal incontinence, and (4) defecatory dysfunction Finally, clinical experience and expertise were pooled to reach consensus on 4 remaining areas: (1) FPMRS conditions amenable to virtual management, (2) urgent care scenarios requiring in-person visits, (3) symptoms that should alert providers to a possible COVID infection, and (4) special consideration for managing patients with known or suspected COVID-19 Overall, behavioral, medical, and conservative management provided in a virtual setting (via phone or Internet communication) will be valuable as first-line treatments Certain situations were identified that require different treatments in the virtual setting than in person, whereas others were shown to require an in-person visit despite risks of COVID-19 exposure and spread of infection This study presents guidance for treating FPMRS conditions via telemedicine in a format that can be actively referenced The strengths of the study include use of an expedited review method, extensive experience of the authors in conducting systematic reviews, as well as being seasoned FPMRS practitioners Main limitations include the rapid methodology, lack of data regarding many of the pertinent questions, and missed salient studies, because of the expedited evidence methods

OBJECTIVES There is no standard of care for women sustaining an obstetric anal sphincter injury (OASIS). We sought to determine whether pelvic floor physical therapy (PFPT) would improve the quality of life and function in women 12 weeks after OASIS. METHODS This institutional review board-approved randomized trial enrolled primiparous women 2 weeks after delivery complicated by OASIS. After informed consent, all subjects underwent vaginal electromyography and anorectal manometry and completed validated questionnaires; measures were repeated for all subjects at 12 weeks after delivery. The intervention arm completed 4 PFPT sessions. The primary outcome was a change in the Fecal Incontinence Quality of Life. RESULTS Three hundred four women were screened; 250 were excluded, and 54 were randomized. After four were lost to follow-up, analysis included 27 in the intervention arm and 23 in the control arm. Overall, mean age was 29.8 ± 4.7 years, and there were no demographic differences between groups.Fecal Incontinence Quality of Life domain scores showed improvement for both groups from baseline to 12 weeks for coping (P = 0.006) and depression (P = 0.009); however, there was no difference in domain scores between groups. For the secondary outcome of anorectal manometry, squeezing pressure improved for all subjects (P = 0.035) from baseline to 12 weeks. Vaginal EMG strength (microvolts) increased for all subjects in measures of rest average (P < 0.000), rapid peak (P = 0.006), and work average (P < 0.000), with no difference based on therapeutic arm. CONCLUSIONS All women showed improvements in quality of life and function at 12 weeks after delivery, regardless of treatment allocation. Further study is needed to determine whether PFPT provides a significant benefit to women having OASIS.

OBJECTIVE To evaluate the impact of colpocleisis on body image, regret, satisfaction, and pelvic floor symptoms 24 weeks after surgery. METHODS This was a prospective multicenter study conducted through the Society of Gynecologic Surgeons' Fellows' Pelvic Research Network with 7 sites across the United States. Women undergoing colpocleisis were enrolled. Outcomes assessed at 24 weeks included body image, regret, satisfaction, and pelvic floor symptoms. The Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory, the modified Body Image Scale, the Decision Regret Scale, and the Satisfaction with Decision Scale were administered. A sample size of 88 subjects was calculated for a significant change in the Body Image Scale. RESULTS Ninety subjects were enrolled. Two did not undergo surgery, and 7 were deceased at the time of 24-week follow-up. Significant improvements in all pelvic floor symptoms were noted 6 weeks postoperatively, and 24-week data showed sustained improvement. In addition, mean and total body image scores showed lasting significant improvement when compared with preoperative scores (P < 0.001 and P < 0.001, respectively). Finally, patients continued to be satisfied with their decision to undergo surgery (mean [SD] 4.6, [0.6]) and had a very low level of regret regarding this decision (mean [SD], 1.5 [0.7]). CONCLUSIONS Colpocleisis is a highly effective surgical treatment option for pelvic organ prolapse with improvements in both pelvic floor symptoms and body image. Furthermore, high satisfaction and low regret seen 24 weeks after surgery provide reassurance that colpocleisis is an excellent option for appropriate patients.

Introduction Female sexual dysfunction affects up to 43% of women in the United States and hypoactive sexual desire disorder (HSDD) is the most common type; however, we lack treatment options showing improvement for this condition. Aims To investigate whether acupuncture therapy could improve HSDD. Methods Premenopausal women with a primary diagnosis of HSDD were included in a single-arm prospective pilot study that was approved by the institutional review board. After providing informed consent, subjects completed validated questionnaires. Participants underwent 25-minute twice-weekly acupuncture sessions for 5 weeks with one certified acupuncturist. Questionnaires were completed again 6 weeks after onset of treatment. Main Outcome Measures Based on a statistically significant change in the desire domain of the Female Sexual Function Index from 2.0 (at baseline) to 2.4 (after intervention with a specialist) in our population of patients diagnosed with HSDD, a sample of 13 was determined, with 90% power and α 0.05. Results Fifteen women were enrolled and 13 completed the study. Mean age was 36.9 ± 11.4 years. Most were white (n = 9, 60%), heterosexual (n = 15, 100%), and non-smokers (n = 14, 93%). Most were sexually active more than four times per month (n = 8, 53%) and none had a history of sexual abuse (n = 15, 100%). Participants received a mean acupuncture needle application of 17 ± 2 at each session. Sexual function improved after intervention, particularly desire (2.1 ± 0.6 to 3.3 ± 1.2, P < .0001), arousal (P < .0001), lubrication (P = .03), and orgasm (P = .005). Conclusion In this cohort of premenopausal women with HSDD, 5 weeks of acupuncture therapy was associated with significant improvements in sexual function, particularly desire. This supports a role for acupuncture as a therapeutic option for women with low desire.

Background Improving the patient experience, controlling pain with non-opiate therapies, and preparing for value based reimbursement are increasingly important foci for both physicians and hospitals. Objectives We sought to determine if the addition of music and a natural landscape image to postoperative hospital rooms would result in improved pain and satisfaction scores among inpatients undergoing pelvic reconstructive surgery. Study Design This was an Institutional Review Board approved, randomized controlled trial. Eligible candidates were 18-85 years old, English speaking, and scheduled to undergo native tissue vaginal vault suspension for symptomatic pelvic organ prolapse. Exclusions included history of a chronic pain or substance abuse. Subjects were advised the purpose of the study was to assess the impact of changes to the hospital environment on patient experience, but were blinded to their group and intervention details. Changes included a landscape image mounted to the wall, as well as access to a speaker with preprogrammed music selections. The intervention group was instructed to listen to their preferred music for a minimum of two 30-minute sessions postoperatively. The control group had a standard hospital room, without music or landscape. All patient rooms were private. The primary outcome was the Visual Analogue Scale (VAS) for pain on the morning of post-operative day one. Secondary outcomes included narcotic use, likelihood to refer family to the same hospital facility, satisfaction with care and the hospital, and perception of a healing environment. A sample size of 43 subjects per arm was calculated in order to detect a difference of 10mm in VAS pain score. Results One hundred thirty-three subjects were enrolled; primary outcome data was available for 92 (46 per arm). The mean age was 63.8 (SD 9.5) years, median Charlson Comorbidity score was 2 (min=0,max=7), and 94.6% were Caucasian. On postoperative day one, median VAS scores for pain were low (28.8mm (0,86), 24.5mm (0,81)), and did not differ between intervention and control, respectively (p=0.57). Total morphine equivalents (p=0.817) and nursing pain scores (p=0.774) were also similar. However, the intervention group displayed a higher likelihood to refer family members to the hospital (98mm(47, 100), 96mm(65, 100), p=0.037). At 2 weeks postoperative, the intervention group demonstrated higher satisfaction with their care (98mm (34, 100), 95mm (42, 100), p=0.032), the hospital (98mm (71, 100), 94mm (6, 100), p=0.004), and the healing environment provided during their stay (98mm (52, 100), 92mm (19, 100), p=0.020), than those in standard hospital rooms. Conclusion In this randomized trial, we demonstrated music and landscape imagery did not significantly impact post-operative pain scores, however they had a positive impact on the postoperative experience. Further, this impact appeared to broaden two weeks following surgery. Given the importance of value-based care, interventions such as these should be emphasized in an effort to enhance patient satisfaction, quality scores and overall well-being.

This study aimed to describe uterosacral ligament suspension (USLS) suture location relative to the surrounding anatomy in a living model using computed tomographic imaging.This was an institutional review board-approved prospective descriptive study. Women aged 18 to 85 years undergoing vaginal hysterectomy with USLS were eligible. A size 'small' titanium vascular clip was applied to the base of each USLS suture. Computed tomography of the pelvis was performed on postoperative day 1. Preoperative and postoperative neurologic questionnaires and physical examinations were performed. A sample size of 15 subjects was deemed appropriate for this pilot study.Seventeen subjects were enrolled: 2 excluded and 15 analyzed. The median (interquartile range) age of the subjects was 57 (22) years. The closest branch of the internal iliac complex was 2.6 (0.9) cm (median [interquartile range]) from the proximal suture on the right and 2.6 (0.5) cm on the left. The right ureter was 2.1 (0.7) cm from the right proximal suture. The left ureter was 2.3 (1.0) cm from the left proximal suture. The rectal lumen were 3.0 (1.6) cm from the right proximal suture and 2.8 (1.4) cm from the left proximal suture. No subjects were found to have neurologic involvement of the sutures based on neurologic questionnaire responses and physical examination.In live subjects, our study confirms that the vasculature, ureter, and rectum of the pelvic side wall are near suture placement for USLS. This information highlights the importance of careful dissection and awareness of anatomic landmarks.

The aims of this study are to identify screening, treatment, and referral practices of primary care physicians (PCPs) for patients with pelvic floor disorders (PFDs) and evaluate awareness of the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) subspecialty.We conducted a cross-sectional survey of PCPs using a random sample of 1005 American College of Physicians members, stratified by demographic region. Electronic survey content included awareness of FPMRS certification, comfort diagnosing and treating PFDs, and PFD referral patterns for PCPs.The 399 survey respondents were predominately male and of diverse ages, geographic distribution, and experience level.Forty-eight percent were aware of the FPMRS subspecialty, 31% of FPMRS board certification, and 25% of American Urogynecologic Society. Less than one third screened for PFDs, only two thirds were comfortable diagnosing urinary complaints, and even fewer felt comfortable diagnosing pelvic organ prolapse and fecal incontinence (FI).Eighty-five percent recommended pelvic floor exercises for stress urinary incontinence and referred to urology (29%) or FPMRS (25%) as second-line therapy, whereas 55% recommended medication/fiber for FI and referred to gastroenterology/colorectal surgery (31%) and FPMRS (2%) as second-line therapy.Primary care physicians referred to colorectal surgery for FI (60%), to Ob/Gyn for obstetric anal sphincter injury (38%) and pelvic organ prolapse (57%), and to urology for microscopic hematuria (80%), overactive bladder (60%), recurrent urinary tract infection (75%), stress urinary incontinence (48%), and voiding dysfunction (84%).Most PCPs do not routinely screen for PFDs, and fewer feel comfortable treating. The majority is unaware of FPMRS and American Urogynecologic Society and more commonly refers PFD patients to other specialists.

OBJECTIVES An ability to anticipate individuals at increased risk of postoperative pain would improve coordination of care and patient satisfaction. We sought to describe predictive factors of postoperative pain following vaginal reconstructive surgery. METHODS This institutional review board-approved, retrospective study used previously collected data from research performed at 1 center from 2009 to 2015. Eligible trials enrolled subjects undergoing vaginal reconstructive surgery for pelvic organ prolapse. All studies used a validated visual analog scale (VAS) for pain on postoperative day 1. Other information collected included pain medication use, medical and surgical history, and demographics. Linear regression analyses, multiple regression analyses, Mann-Whitney U, and Kruskal-Wallis tests were used to analyze the relationship between VAS scores and other variables. RESULTS Six studies were analyzed with a total of 364 patients. The median age was 60 years (interquartile range, 16 years), and the median pain score on postoperative day 1 was 35 mm on a 100-mm VAS. Patients younger than 60 years (P < 0.001), those who used tobacco (P = 0.014), those who used pain medication prior to surgery (P = 0.007), and those who did not have a concomitant midurethral sling (P = 0.018) had significantly higher pain scores postoperatively. A trend was also noted with operating times greater than 210 minutes (P = 0.057) and preexisting history of depression (P = 0.065). Multiple regression was performed, and age, depression, tobacco use, and concomitant sling were found to be independent factors predictive of postoperative pain scores. CONCLUSIONS Age, depression, tobacco use, and concomitant midurethral sling are significant independent factors predictive of postoperative pain following vaginal reconstructive surgery.

OBJECTIVE To evaluate the effect of liposomal bupivacaine on postoperative pain among patients undergoing robotic sacrocolpopexy with posterior repair. METHODS This was a randomized, patient-blinded, placebo-controlled trial of women undergoing robotic sacrocolpopexy with posterior repair. Liposomal bupivacaine or normal saline placebo was injected into laparoscopic and vaginal incisions at completion of surgery. Perioperative care was standardized. Visual analog scales were collected at 4, 18, and 24 hours postoperatively in hospital. Starting on postoperative day 1, participants completed twice-daily pain scales and a pain medication diary up until the evening of postoperative day 3. The primary outcome was a 20-mm change in the visual analog scale 18 hours postoperatively. Secondary measures included additional pain scores, satisfaction, and narcotic use. Sample size calculation revealed that 32 patients per arm were required to detect the 20-mm difference with 90% power and an α of 0.05. To allocate for dropout, a goal of 70 was set. RESULTS Between March 2015 and April 2016, 100 women were screened and 70 women were enrolled: 35 women were randomized to liposomal bupivacaine and 35 to placebo, of whom 64 (91%) were included in the final analysis: 33 liposomal bupivacaine and 31 placebo. No difference in demographics, surgical data, or satisfaction between groups was noted. Median VAS at 18 hours after surgery was not statistically different in those who received liposomal bupivacaine compared with normal saline (15 mm compared with 20 mm; P=.52). Other pain scales and total morphine equivalents were also similar (P=.90). CONCLUSION In this study of robotic sacrocolpopexy with posterior repair, there were no differences in pain scores or narcotic use between liposomal bupivacaine and placebo injected into laparoscopic and vaginal incisions. Given its lack of clinical benefit, routine use of liposomal bupivacaine is not supported for this surgical intervention. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02449915.

Objective We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines. Data Sources The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017. Study Eligibility Criteria We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy. Study Appraisal and Synthesis Methods Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed. Results We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation. Conclusion Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.

Objective To evaluate systemic markers of collagen metabolism and vitamin C in female smokers with pelvic organ prolapse (POP). Secondary aims were to compare these levels in women based on prolapse or smoking history alone. Study design This was a cross-sectional study with four groups: smokers with POP, non-smokers with POP, smokers without POP and non-smokers without POP. Subjects were age-matched based on smoking history and presence of POP. All underwent a fasting blood panel, including plasma procollagen 1-N propeptide (P1NP), matrix metalloproteinase 9 (MMP-9), and vitamin C. Results Ninety-six subjects were enrolled. There were no differences for any demographics other than stage of prolapse, which was highest in non-smokers with POP. Significant variations in the levels of vitamin C and MMP-9 were noted among the four groups. Smokers with POP had lower levels of vitamin C and higher levels of MMP-9, compared to non-smokers with POP, but this relationship was not statistically significant. However, when contrasting smokers without POP to non-smokers without POP, significant differences in both vitamin C and MMP-9 were documented, confirming an impact of smoking on these markers. Notwithstanding, when evaluated independent of smoking status, vitamin C and MMP-9 levels in women with POP were similar to those of women without POP. Conclusion Lower vitamin C and higher MMP-9 among smokers confirms the usefulness of such markers in documenting the smoking's impact on collagen. However, the lack of a difference based on POP suggests these are poor measures for understanding the pathophysiology of this disorder.

Introduction Female sexual dysfunction (FSD) is a common disorder with limited data investigating relationships with psychological influences, such as personality traits and coping mechanisms. Aim To investigate the relationship and impact of personality traits and coping strategies on female sexual function. Methods A web-based survey was distributed to a sample of women representative of the area’s demographic distribution. Main Outcome Measures Participants completed the Female Sexual Function Index (FSFI), the Ten Item Personality Index (TIPI), and the Brief COPE. Results Five hundred twenty-six females responded. The mean total FSFI score was 24.56 (SD 6.77) with lowest scores in the desire domain. Personality scores were similar to published normative values. Subjects displaying stronger tendencies for introversion (r = 0.246, P Conclusion Personality and coping are linked to sexual function with introversion, not being open to new experiences, emotional instability, and the utilization of negative coping strategies being significantly associated with poor sexual function. Women presenting with sexual function complaints may need further evaluation of their personality and coping strategies in order to mitigate any negative impact of these tendencies.

BACKGROUND In this study of patients undergoing vaginal hysterectomy with either robotic or vaginal prolapse repair, there was no difference in quality of life in the weeks following surgery; however, less narcotics were used, less pain was documented by nurses and Surgical Pain Scale (SPS), and better performance on voiding trials was noted in those undergoing robotic sacrocolpopexy. OBJECTIVES Minimally invasive surgery for pelvic organ prolapse is the preferred surgical route for optimal recovery. However, information regarding patient-centered outcomes among various techniques is lacking. We sought to describe pain and quality of life in patients undergoing vaginal hysterectomy with uterosacral ligament suspension (USLS) compared with robotic-assisted sacrocolpopexy (RSC). METHODS This institutional review board-approved prospective cohort study enrolled consecutive patients undergoing vaginal hysterectomy with USLS or with RSC. The primary outcome was pain on postoperative day 1 using the SPS. Nursing verbal pain scores, narcotic usage, surgical data, and Short-Form Health Survey 12 at baseline and 2 and 6 weeks after surgery were collected. A sample size calculation revealed 37 subjects per group would be required. RESULTS Seventy-eight women were enrolled (USLS, n = 39; RSC, n = 39). There were no significant differences in scores on the SPS between groups. Subjects undergoing RSC had lower nursing verbal pain scores (P = 0.04), less narcotic consumption (P = 0.02), and lower estimated blood loss (P = 0.01) and were less likely to fail voiding trials (P < 0.001); however, surgery duration was longer (P < 0.001). After controlling for age, regression analysis revealed SPS "worst pain" was lower in the robotic arm (P = 0.01), but not in other scales of the SPS. At 2 and 6 weeks postoperatively, Short-Form Health Survey 12 scores were not different between cohorts. CONCLUSIONS Both USLS and RSC are minimally invasive, with similar quality-of-life scores after surgery. However, the robotic approach may be associated with less pain, less narcotic use, and better performance in voiding trials. Surgeons should consider these findings when counseling patients regarding treatment options.

Web-based questionnaires are becoming increasingly valuable for clinical research. The Female Sexual Function Index (FSFI) is the gold standard for evaluating female sexual function; yet, it has not been validated in this format. We sought to validate the Female Sexual Function Index (FSFI) for web-based administration. Subjects enrolled in a web-based research survey of sexual function from the general population were invited to participate in this validation study. The first 151 respondents were included. Validation participants completed the web-based version of the FSFI followed by a mailed paper-based version. Demographic data were collected for all subjects. Scores were compared using the paired t test and the intraclass correlation coefficient. One hundred fifty-one subjects completed both web- and paper-based versions of the FSFI. Those subjects participating in the validation study did not differ in demographics or FSFI scores from the remaining subjects in the general population study. Total web-based and paper-based FSFI scores were not significantly different (mean 20.31 and 20.29 respectively, p = 0.931). The six domains or subscales of the FSFI were similar when comparing web and paper scores. Finally, intraclass correlation analysis revealed a high degree of correlation between total and subscale scores, r = 0.848–0.943, p

Introduction The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of orgasm. Aim The aim of this study is to evaluate the clitoral size and location with regard to female sexual function. Methods This cross‐sectional TriHealth Institutional Board Review approved study compared 10 sexually active women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire‐12 (PISQ‐12), Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short Form Health Survey‐12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast; measurements of the clitoris were calculated. Main Outcome Measures Our primary outcomes were clitoral size and location as measured by noncontrast MRI imaging in sagittal, coronal, and axial planes. Results Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7), mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ‐12 ( P P P = 0.005). A larger distance from the clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer scores on the PISQ‐12 ( r = −0.44, P = 0.02), FSFI ( r = −0.43, P = 0.02), and BESAQ ( r = −0.37, P = 0.04). Conclusion Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function. Oakley SH, Vaccaro CM, Crisp CC, Estanol MV, Fellner AN, Kleeman SD, and Pauls RN. Clitoral size and location in relation to sexual function using pelvic MRI. J Sex Med 2014;11:1013–1022.

Objective The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. Data Sources Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. Study Eligibility We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. Study Appraisal and Synthesis Methods Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. Results Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. Conclusion Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

Primary care physicians can impact womens’ access to care. We assessed primary care providers’ experience and management regarding pelvic floor disorders. This Institutional Review Board approved study invited internal and family Medicine Program Directors to complete and distribute to faculty an online survey designed to query demographics, perceptions, management, and referral patterns regarding urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP) in females. A total of 872 residency Program Directors were invited: 74 emails were incorrect; 391 physicians responded. Respondents were evenly distributed with respect to age, gender, and region. The majority practiced family Medicine, identified their practice as community/academic, and practiced >10 years. Forty-one percent perceived UI and 54% believed OAB prevalence to be 11–30%. Most initiated treatment for UI (97%) and OAB (96%), referring to urology when consultation was necessary. Half believed POP prevalence to be

Objective To describe practice preferences for the diagnosis and management of ileus and small-bowel obstruction (SBO) following benign gynecologic surgery. Methods A secondary descriptive analysis was performed on data from a multicenter case–control study of patients who underwent gynecologic surgery and subsequently developed ileus or SBO. Information was collected regarding interventions such as type of imaging ordered for diagnosis, diet alterations, antiemetic administration, and need for reoperation. Results In total, 144 cases were identified. Abdominal X-ray was the most common imaging modality, occurring in 54 (37.5%) cases. Sixty-nine (65.1%) of the 106 women who underwent imaging were given definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]); 57.9% (n = 11) of the SBO diagnoses and 90.0% (n = 45) of the ileus diagnoses were managed conservatively. Eighteen (12.5%) patients underwent reoperation for bowel obstruction. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P = 0.18), or between diet statuses on postoperative day 1 (P = 0.08). Conclusion Most study centers initially performed an abdominal X-ray for diagnostic purposes. The majority used a multimodal treatment approach. None of the management options decreased the likelihood of reoperation.

Background/Aims: The Accreditation Council for Graduate Medical Education (ACGME) requires that all Ob/Gyn residents accomplish scholarly activity. We hypothesize resident productivity is poor. Methods: This was a web-based two-survey study using SurveyMonkey®. Surveys queried both program directors and residents regarding their adherence to ACGME guidelines. All 233 accredited Ob/Gyn programs were targeted. Results: 70 program directors responded (30.4%). The majority (99%) felt research was a goal of their program and stated their residents are taught to read current literature (99%), design basic studies (99%), and interpret simple statistics (89%). 17% (53/313) of the residents did not agree that their training environment promoted research, 25% did not feel comfortable discussing basic study designs, and 54% did not feel comfortable interpreting basic statistics. Urban programs demonstrated improved resident attitudes toward research (p = 0.025), better research environments (p = 0.007) and curricula (p = 0.001) compared to rural programs. Furthermore, residents intending to pursue an academic career were more likely to be working with a research mentor (p = 0.038). Conclusion: The ACGME clearly delineates residency research requirements. A dichotomy exists between program director perception and resident compliance. Notwithstanding, it is reassuring that the majority of programs appear to promote scholarly activity and provide necessary support.

Physicians-in-training play a role in guiding patient care, and their contributions may improve adherence to clinical practice guidelines. However, there is scant information in the literature assessing this impact on perioperative decision-making. The purpose of this study was to determine whether involvement of urogynecology fellows results in closer adherence to guidelines regarding perioperative management of gynecological patients.Retrospective analysis of patients undergoing major gynecological surgery between 1 July 2009 and 30 June 2010. Charts were identified using surgical procedure codes (SPT) and subdivided into: urogynecology (fellow co-managed) or private gynecology patients. Information was collected regarding pre- and postoperative deep venous thrombosis (DVT) prophylaxis, preoperative antibiotic type, dose, and timing.Included were 699 women: 564 (81.2%) private and 135 (19.4%) urogynecology patients. Significant differences were noted in preoperative DVT prophylaxis, with the fellow-managed group being treated appropriately more often (p=0.001). Postoperative management of thromboprophylaxis, however, was not found to be significant (p=0.163). When evaluating antibiotic utilization, both groups were similar with regard to the timing of cephalosporins. However, fellows were significantly superior in dosing antibiotics correctly (p=0.023), and their selection of appropriate antibiotics for penicillin-allergic subjects approached significance (p=0.052).Fellow contributions toward clinical decisions resulted in more appropriate DVT prophylaxis and antibiotic administration prior to gynecological surgery.

Understanding barriers to seeking care for pelvic floor disorders is necessary. We sought to assess familiarity with pelvic floor disorders, as well as identify screening and referral patterns among primary care providers. This Institutional Review Board approved study was distributed through a secure online server (SurveyMonkey®). Primary care providers within a large healthcare system were invited to participate in a 14-question survey regarding the prevalence, diagnosis, and treatment of urinary incontinence (UI), overactive bladder (OAB) syndrome, and pelvic organ prolapse (POP). Demographic information was collected. Descriptive statistics and associations were calculated. A total of 360 emails were delivered, 108 responded (response rate 30.0 %). Respondents were evenly distributed with respect to age and years in practice. Providers correctly estimated the prevalence of UI and OAB, and most reported treating these conditions themselves (92.6 % and 88.9 %, respectively). If treatment failed, however, referral was most often (68.1 %) to urology. The majority reported not screening for POP, and 50.9 % believed the prevalence to be rare. Referrals for POP were most often (61.1 %) to urogynecology. Male providers were less likely to screen for POP than female providers (p

Objective The aim of this study was to describe gynecologists' attitudes toward labial hypertrophy and explore possible differences among providers for pediatric/adolescent patients. Methods This was an institutional review board-approved, cross-sectional survey of physician attendees at 2 national meetings in 2014: the Society of Gynecologic Surgeons (SGS) and the North American Society for Pediatric and Adolescent Gynecology (NASPAG). The survey was designed to query demographics and impressions regarding labial hypertrophy and labiaplasty. Results Three hundred sixty-five surveys were completed (response rate, 50%); 268 were analyzed: 55% from SGS and 45% from NASPAG. Most were older than 41 years; 170 (63%) were women, and 93 (35%) were men. More men than women attended SGS (60%); however, women were the majority at NASPAG (94%).Most respondents believed labial hypertrophy to be infrequently reported and "a condition that impacts body image." Common symptoms were "discomfort with exercise" and "dissatisfaction with appearance naked." The majority felt this to impact sexual function "in some cases," citing "self-esteem" and "comfort" most often.Concerning therapies for provided labial hypertrophy, 83% of practitioners provide reassurance, whereas 77% would offer labiaplasty. Expertise with labiaplasty varied; 28% felt "very comfortable," and 11% felt "very uncomfortable."Provider preference for treatment differed based on meeting attendance. After logistic regression controlling for sex and age, attendance at SGS remained associated with offering labiaplasty (P = 0.001; odds ratio, 4.1; 95% confidence interval, 1.8-9.3), whereas NASPAG attendance was associated with providing reassurance (P = 0.008; odds ratio, 0.30; 95% confidence interval, 0.10-0.70). Conclusions Although the majority surveyed view labial hypertrophy to be bothersome, gynecologists caring for our youngest patients are more likely to provide reassurance. Consensus guidelines are needed to aid practitioners in appropriate management of labial hypertrophy.