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Marlana M Ray,1 Jennifer Yeung,1 Jonathan Hoehn,2 Matthew Valenti,3 Kelsey E Lewis,1 Rachel N Pauls,1 Catrina C Crisp1 1Urogynecology Division, TriHealth, Cincinnati, OH, USA; 2Hatton Research Institute, TriHealth, Cincinnati, OH, USA; 3OB/GYN Department, University of Cincinnati, Cincinnati, OH, USACorrespondence: Marlana M Ray, TriHealth, Urogynecology Division, 3219 Clifton Ave, Medical Office Building Suite 100, Cincinnati, OH, 45220, USA, Email marlana_ray@trihealth.comPurpose: Studies involving minimally invasive hysterectomy and robotic sacrocolpopexy have demonstrated safety and feasibility of same-day discharge. There are limited data, however, on same-day discharge outcomes for vaginal hysterectomy and pelvic reconstruction. This study aimed to compare 30 and 90-day surgical outcomes between same-day discharge versus overnight stay following vaginal hysterectomy and apical suspension.Patients and Methods: This retrospective study evaluated surgeries performed over two time periods. Overnight stay was standard between December 2018 and February 2020. Same-day discharge was standard from December 2020 to February 2022. All patients who underwent vaginal hysterectomy with apical suspension were included. The primary outcome was to determine if there was an increase in 30-day readmission rates. Secondary outcomes included emergency department visits and reoperations within 30 days, the previous variables at 90 days, and the rate for successful same-day discharge.Results: A total of 324 patients were analyzed over the 30 months: 149 (46%) in the overnight stay group and 175 (54%) in the same-day discharge group. At 30 days, no difference was found between groups for readmissions (2.7% vs 4.0%, p = 0.56), emergency department visits (14.8% vs 14.9%, p = 1.0), or reoperations (2.0% vs.1.7%, p = 1.0). At 90 days, outcomes were also similar. Same-day discharge as standard practice was successful in 80% of patients.Conclusion: In this retrospective two cohort study, the safety of same-day discharge following vaginal hysterectomy with apical suspension was demonstrated with no increased risk of 30 or 90-day readmissions, emergency visits, or reoperation rates. The majority (80%) of patients were discharged on the day of surgery, suggesting feasibility of this model.Keywords: female pelvic reconstructive surgery, urogynecology, vaginal prolapse repair, pelvic floor surgery

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

Objective: To describe the ultrasonographic appearance of the post-ablative endometrium to improve knowledge of its sonographic findings., Methods: This was an Institutional Review Board approved prospective study of patients who underwent second-generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized., Results: There were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P = .041), and 6 and 12 months (P = .031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds., Conclusion: After ablation with a second-generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful., (© 2024 American Institute of Ultrasound in Medicine.)

Introduction and Hypothesis: Previous research has not evaluated patient experiences following vaginal reconstructive surgery using a same-day discharge model. The objective of this study was to describe patient experiences following major vaginal reconstructive surgery and same-day discharge., Methods: In this descriptive study, patients undergoing vaginal hysterectomy with pelvic reconstruction were preoperatively enrolled. Questionnaires detailing experience with same-day discharge, surgical recovery, and advice for prospective patients were completed. Our primary outcome was question 7 of the Surgical Satisfaction Questionnaire: Looking back, if you "had to do it all over again" would you have the surgery again? Descriptive statistics were performed, and correlations were performed with Spearman's rank test., Results: Sixty patients were enrolled; 54 underwent surgery. Eighty-seven percent of patients completed the 12-week questionnaire. At 12 weeks, 96% of patients (n = 45) would have the surgery again, and 91% (n = 42) were satisfied with the results of surgery. Twelve weeks postoperatively, the most common patient-reported complications were urinary tract infection (n = 8, 17%), catheter concerns (n = 5, 11%), and constipation (n = 5, 11%). When asked to list the best parts of their surgical experience, half of patients felt that this was the office staff or physician themselves (n = 24, 51%). When asked what advice they would provide to future patients, the most common responses included having a support person at home and taking time for recovery., Conclusions: In this sample of women receiving same-day discharge following vaginal hysterectomy with pelvic reconstruction, we present a unique insight into the most common patient concerns postoperatively. Rates of satisfaction and comfort were high., (© 2023. The International Urogynecological Association.)

Background: 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., Objective: This study aimed to evaluate the effect of diazepam rectal suppositories on early postoperative pain after hysterectomy and vaginal reconstruction for pelvic organ prolapse., Study Design: 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., Results: 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/m 2 (interquartile range, 18.70-45.90), and 119 of 123 participants (96.7%) were White. There was no difference in the baseline characteristics, prolapse stage, or types of procedures performed between groups. Most participants had concurrent uterosacral ligament suspension with anterior and posterior repairs. Of note, 50 of 123 participants (41%) had midurethral slings. Moreover, 61 of 123 participants (50%) were discharged on the day of surgery. There was no difference in the primary outcome of vaginal pain 3.5 to 6.0 hours postoperatively (25 vs 21 mm; P=.285). In addition, the amount of rescue narcotics used in the immediate postoperative period (19.0 vs 17.0 MME; P=.202) did not differ between groups. At 2-weeks postoperatively, patients in the placebo group reported higher satisfaction with pain control in the hospital (31 vs 43 mm; P=.006) and pain control at home (31 vs 42 mm; P=.022). No difference was noted between same-day discharges and those who were admitted overnight., Conclusion: The 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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: There is little consensus on an effective nonantibiotic agent for the prevention of urinary tract infection (UTI) after pelvic reconstructive surgery., Objective: 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., Study Design: 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., Results: 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., Conclusions: 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., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2022 American Urogynecologic Society. All rights reserved.)

Introduction and Hypothesis: 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., Methods: 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., Results: 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., Conclusions: 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., (© 2021. The International Urogynecological Association.)

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 ɑP = 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., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 American Urogynecologic Society. All rights reserved.)

Introduction and Hypothesis: To describe the impact of native tissue vaginal reconstruction on pelvic anatomy using dynamic magnetic resonance imaging., Methods: 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., Results: 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)., Conclusions: Native tissue reconstruction with intraperitoneal vaginal vault suspension resulted in significant anatomic improvements, as defined by physical examination and dynamic magnetic resonance imaging.

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., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2021 American Urogynecologic Society. All rights reserved.)

Objective: This study aimed to assess anatomy relative to sacral sutures 20 to 24 months after robotic sacrocolpopexy., Methods: This was an institutional review board-approved prospective anatomy study of women undergoing robotic sacrocolpopexy. After placement of suture into the anterior longitudinal ligament, a small vascular clip was secured on the base of the suture. Subjects were imaged at 6 weeks and between 20 and 24 months after surgery. Measurements were calculated by the primary investigator and radiologist coinvestigator., Results: Of the 11 subjects enrolled in the initial 6-week postoperative study, 5 (45%) completed the long-term follow-up. Regarding the vascular anatomy, no significant changes were documented. Similarly, the major urologic structure, the right ureter, was stable at 16 mm from the clip. A significant change was noted, however, in the distance from the apex of the vagina to the sacral suture. At 6 weeks postoperatively, the mean (SD) distance from the vaginal apex to the clip was 69.3 (14) mm; this increased to 85.2 (11.3) mm at the long-term follow-up (P = 0.004)., Conclusions: Reassuringly, the position of the clip remained stable, which is reflected in the constancy of the measurements to the vascular landmarks. Nevertheless, alteration in the distance to the vaginal apex suggests elongation of the mesh or vaginal tissue with time. Although the increase in length was greater than 1.5 cm, it may bear clinical relevance in certain patients. This information may help guide surgeons regarding appropriate mesh tensioning during this critical step of the procedure., Competing Interests: The authors have declared that there are no conflicts of interest., (Copyright © 2019 American Urogynecologic Society. All rights reserved.)

Objectives: We sought to understand practice patterns of non-female pelvic medicine and reconstructive surgery (FPMRS) clinicians regarding concurrent apical support procedures during hysterectomies when primarily performed for the treatment of pelvic organ prolapse. We also sought to describe differences between those receiving and not receiving apical support., Methods: This retrospective study analyzed medical records of individuals undergoing hysterectomy for the primary indication of pelvic organ prolapse between 2012 and 2017 at all locations within the TriHealth system. Surgeries performed by board-certified FPMRS physicians were excluded. Comparisons were drawn between those who did and did not receive apical support., Results: A total of 236 charts met the inclusion criteria. Of these, 66 (28%) received concurrent apical suspension, and 94 (39.8%) underwent no reconstructive procedures. The annual proportion of those receiving apical suspension did not differ over the course of the study period. On average, the addition of apical support added 39.9 minutes (P < 0.001) to the length of surgery. There was, however, no difference noted in estimated blood loss. Risk factors for recurrent prolapse including chronic constipation, pulmonary disease, and connective tissue disorders were similar between groups., Conclusion: When excluding FPMRS surgeons, data from our institution showed that most patients undergoing hysterectomy for prolapse did not receive concurrent apical support. This suggests areas of potential improvement for adopting into clinical practice the new American College of Obstetricians and Gynecologists recommendations regarding the treatment of prolapse. Furthermore, this may represent an important opportunity for peer outreach and education by FPMRS surgeons., Competing Interests: The authors have declared that there are no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This study aimed to describe uterosacral ligament suspension (USLS) suture location relative to the surrounding anatomy in a living model using computed tomographic imaging., Methods: 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., Results: 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., Conclusions: 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.

Background: Improving the patient experience, controlling pain with nonopiate therapies, and preparing for value-based reimbursement are increasingly important foci for both physicians and hospitals., Objective: We aimed to determine whether 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 randomized controlled trial was approved by an Institutional Review Board. Eligible candidates were 18-85 years old, English speaking, and scheduled to undergo native tissue vaginal vault suspension for symptomatic pelvic organ prolapse. Patients with history of a chronic pain or substance abuse were excluded. Subjects were advised that the purpose of the study was to assess the effect 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 and access to a speaker with preprogrammed music selections. The intervention group was instructed to listen to their preferred music for a minimum of 2 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 analog scale for pain in the morning of postoperative day 1. 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 to detect a difference of 10 mm in visual analog scale pain score., Results: A total of 133 subjects were enrolled; primary outcome data were available for 92 (46 per arm). The mean age was 63.8 (standard deviation, 9.5) years, median Charlson comorbidity score was 2 (min, 0; max, 7), and 94.6% of subjects were white. On postoperative day 1, median visual analog scale pain scores were low (28.8 mm [0, 86]; 24.5 mm [0, 81]) and did not differ between intervention and control, respectively (P=.57). Total morphine equivalents (P=.817) and nursing pain scores (P=.774) were also similar. However, the intervention group displayed a higher likelihood to refer family members to the hospital (98 mm (47, 100); 96 mm (65, 100); P=.037). At postoperative 2 weeks, the intervention group indicated higher satisfaction with their care (98 mm, (34, 100); 95 mm (42, 100); P=.032), the hospital (98 mm (71, 100); 94 mm (6, 100); P=.004), and the healing environment provided during their stay (98 mm; 92 mm (19, 100); P=.020) than those in the standard hospital rooms., Conclusion: In this randomized trial, we found music and landscape imagery did not substantially affect postoperative pain scores; however, they had a positive effect on the postoperative experience. Furthermore, this effect appeared to broaden 2 weeks after surgery. Given the importance of value-based care, interventions such as these should be emphasized to enhance patient satisfaction, quality scores, and overall well-being., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: 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., Methods: 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., Results: 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 < 0.001). Annual rates of apical support procedures showed significant improvement from 49.5% in 2015 to 55.2% in 2016 (P < 0.001). Regarding surgical data, addition of apical support procedures increased operative time by 33 min, and reoperation was 1.3% higher (0.3% vs 1.6%)., Conclusion: Our results demonstrate that in the 2 years prior to ACOG's recommendation only 51.8% of women undergoing hysterectomy for pelvic organ prolapse received concurrent procedures to address apical support.

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.

Introduction and Hypothesis: The COVID-19 pandemic and the desire to "flatten the curve" of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic., Methods: We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19., Results: Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission., Conclusions: We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

Objective: 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., Methods: 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., Results: 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., Conclusion: 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., Clinical Trial Registration: ClinicalTrials.gov, NCT02996968.

Introduction and Hypothesis: 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., Methods: 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., Results: 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 <3 years of follow-up. Repeat surgery prevalence for POP after hysteropexy varied widely (0-29%) but was similar among hysteropexy types. When comparing sacrohysteropexy routes, the laparoscopic approach had lower recurrent prolapse symptoms [odds ratio (OR) 0.18, 95% confidence interval (CI) 0.07-0.46), urinary retention (OR 0.05, 95% CI 0.003-0.83), and blood loss (difference -104 ml, 95% CI -145 to -63 ml) than open sacrohysteropexy. Laparoscopic sacrohysteropexy had longer operative times than vaginal mesh hysteropexy (difference 119 min, 95% CI 102-136 min). Most commonly reported AEs included mesh exposure (0-39%), urinary retention (0-80%), and sexual dysfunction (0-48%)., Conclusions: Hysteropexies have a wide range of POP recurrence and AEs; little data exist directly comparing different hysteropexy types. Therefore, for women choosing uterine preservation, surgeons should counsel them on outcomes and risks particular to the specific hysteropexy type planned.

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: 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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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.

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.

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.

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.

Introduction and Hypothesis: Primary care physicians can impact womens' access to care. We assessed primary care providers' experience and management regarding pelvic floor disorders., Methods: 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., Results: 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 <10% of women, and often referred POP to Gynecology. Only 25% reported being 'very familiar' with urogynecology, and 46% were unaware of such providers in their area. Female providers were more likely to screen for OAB (p = .018) and POP (p = .004) and be familiar with urogynecology (p = 0.038). Providers practicing in the Midwest were most likely, while those in the West were least likely, to be aware of urogynecologists for referral, (p = < .001)., Conclusions: Primary care providers nationally are familiar with UI and OAB, but less familiar with POP. Nearly half were uncertain of urogynecologists to whom they could refer. Outreach to these providers may improve patient access to care.

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: 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.

Background: Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively., Objective: The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement., Study Design: This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed "current level of pain"; the evening items queried "current level of pain," "most intense pain today," "average pain today with activity," and "average pain today with rest." Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed., Results: One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m 2 . Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m 2 ; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted., Conclusion: Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful., (Published by Elsevier Inc.)

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.

Background: Cesarean delivery is a common surgery in the United States, with 1.3 million performed during 2009. 1 Obstetricians must balance the growing concern with opioid abuse, dependence, and side effects with optimal postoperative pain control. Intravenous acetaminophen may represent an additional method to decrease the reliance on opioid medications and improve postoperative pain following cesarean delivery., Objective: The objective of the study was to determine whether the administration of intravenous acetaminophen following routine scheduled cesarean delivery would decrease the need for narcotic medications to control postoperative pain., Study Design: This was an institutional review board-approved, double-blind, placebo-controlled, randomized trial, registered on clinicaltrials.gov (number 02046382). Women scheduled to undergo cesarean delivery with regional anesthesia at term were recruited. All perioperative and postpartum care was standardized via study order sets. Study patients were given all medications in a standardized manner receiving either acetaminophen 1000 mg intravenously or 100 mL saline (placebo) every 8 hours for 48 hours for a total of 6 doses. The pharmacy prepared intravenous acetaminophen and saline in identical administration bags labeled study drug to ensure blinding. The initial dose of study drug was given within 60 minutes of skin incision. Quantity of breakthrough and scheduled analgesic medications and self-reported pain levels on the Faces Pain Scale (0-10) before and after study drug administration were collected. Patient demographics were extracted from the chart. Power calculation determined that 45 patients per arm were required to detect a 30% reduction in postcesarean narcotic requirement with 80% power and a significance level of P = .05., Results: A total of 133 patients were consented for the study. Twenty-nine were excluded and 104 patients completed the study: 57 received intravenous acetaminophen and 47 received placebo. There were no differences in baseline demographic characteristics including patient age, body mass index, gravidity, parity, race, comorbidities, or number of prior cesarean deliveries. There were no differences between groups in estimated blood loss or length of stay. The total amount of oral narcotic medications consumed by patients receiving intravenous acetaminophen was significantly reduced when compared with the placebo group (47 mg vs 65 mg of oxycodone; P = .034). The total amount of ibuprofen used between groups was not different. There was no difference in pain scores between groups before and after study dose administration. There was no significant difference in narcotic side effects (nausea/emesis, respiratory depression, constipation) in either study arm., Conclusion: Intravenous acetaminophen in the postoperative period following cesarean delivery resulted in a significant decrease in oral narcotic consumption for pain control., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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/m 2 . 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., Competing Interests: Conflict of interest: The authors declare they have no competing interests. These data were previously presented at the ACGME Annual Educational Conference, National Harbor, Maryland, February 25–28, 2016.

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.

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.

Introduction and Hypothesis: 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., Methods: 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., Results: 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 < 0.001). Only a minority (35.2 %) described being 'very familiar' with urogynecology, and 19.4 % were unaware of such providers within the system., Conclusions: Primary care providers within a large healthcare system were more familiar with UI and OAB than POP, often underestimating the prevalence of POP. Nearly one-fifth were unaware of urogynecologists within their system. Educational outreach regarding pelvic floor disorders and the urogynecology specialty would likely improve patient access to care.

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., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

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: 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.

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.

Objective: Placement of vaginal packing after pelvic reconstructive surgery is common; however, little evidence exists to support the practice. Furthermore, patients have reported discomfort from the packs. We describe pain and satisfaction in women treated with and without vaginal packing., Methods: This institutional review board-approved randomized-controlled trial enrolled patients undergoing vaginal hysterectomy with prolapse repairs. The primary outcome was visual analog scales (VASs) for pain on postoperative day 1. Allocation to "packing" ("P") or "no-packing" ("NP") arms occurred intraoperatively at the end of surgery. Visual analog scales regarding pain and satisfaction were completed early on postoperative day 1 before packing removal. Visual analog scale scores for pain, satisfaction, and bother attributable to packing were recorded before discharge. All packing and perineal pads were weighed to calculate a "postoperative vaginal blood loss." Perioperative data were collected from the hospital record. Our sample size estimation required 74 subjects., Results: Ninety-three women were enrolled. After exclusions, 77 were randomized (P, 37; NP, 40). No differences were found in surgical information, hemoglobin levels, or narcotic use between groups. However, "postoperative vaginal blood loss" was greater in packed subjects (P < 0.001). Visual analog scale scores for pain before removal of packing (P, 41.6 vs NP, 46.3; P = 0.43] and before discharge (P, 35.0 vs NP, 40.0; P = 0.43] were not significantly different between treatment arms. Likewise, VAS scores for satisfaction before removal of packing (P, 81.0 vs NP, 90.0; P = 0.08] and before discharge (P, 90.0 vs NP, 90.5; P = 0.60] were not significantly different. Packed patients noted lower nursing verbal pain scores (P = 0.04) and used less ketorolac (P = 0.01). Bother from packing was low overall., Conclusions: Although there was no difference based on VAS, women receiving vaginal packing had lower nursing documented pain and used less ketorolac than packed women. Vaginal packing may provide benefit and can remain part of the surgical practice.

Objective: This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging., Methods: A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging., Results: Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%., Conclusions: We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.

Objective: Dexamethasone is a corticosteroid with minimal side effects that may improve quality of recovery. We sought to evaluate standard use of this medication prior to vaginal reconstructive surgery., Study Design: This was a double-blind, randomized, placebo-controlled trial of women undergoing vaginal reconstructive surgery for pelvic organ prolapse. Patients scheduled for an intraperitoneal vaginal vault suspension, with general anesthesia and an overnight stay, were enrolled. The intervention arm received dexamethasone 60 minutes prior to surgery, and controls received placebo. Postoperative pain medications, antiemetics, and voiding trials were standardized. Our primary outcome was the difference in Quality of Recovery (QoR-40) scores on postoperative day 1. Secondary measures included Postoperative Nausea and Vomiting Intensity scores, and visual analog scales for nausea/vomiting, and pain. Our power calculation demonstrated 31 subjects in each group would be necessary to document difference in QoR-40 scores; to allow for attrition, a goal of 74 subjects was set., Results: Seventy-four women were enrolled and randomized. Two withdrew, 9 were excluded, and 63 were analyzed (36 placebo, 27 dexamethasone). The mean age was 63 years. No significant differences were noted among demographics other than American Society for Anesthesiologists class; there were greater numbers of dexamethasone subjects that were class 3 (5 vs 11; P = .030). Postoperatively, more patients in the placebo group required promethazine as a rescue antiemetic for control of their nausea/vomiting (11 vs 2; P = .029). Placebo subjects also failed their voiding trials more frequently, which remained following a logistic regression controlling for suburethral sling (30 vs 15; P = .037). Regarding the QoR-40 following surgery, the emotional state domain declined less in dexamethasone patients (-14.3, interquartile range [IQR], 16.8 vs -4.6, IQR, 20.1; P = .042), indicating better symptoms. Whereas pain scales were similar, the visual analog scales for nausea/vomiting was lower in dexamethasone subjects (0.7; IQR, 4.1 vs 0.4; IQR, 1.4; P = .042). Postoperative Nausea and Vomiting Intensity scores were not significantly different; nevertheless, twice as many placebo subjects had severe range symptoms (4 vs 2; P = .47). No adverse effects from the dexamethasone were noted., Conclusion: Use of dexamethasone prior to vaginal reconstructive surgery was associated with less nausea/vomiting and need for antiemetics as well as greater success with voiding trials. Furthermore, quality of recovery was enhanced, suggesting use of dexamethasone should be considered for these patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to characterize male preferences of vulvar appearance, their awareness of labiaplasty, and their knowledge of genital anatomy., Study Design: Men 18-80 years old were recruited via emails sent by an Internet provider to participate in a 27-question web-based survey. The questionnaire included images and queried demographics, men's familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. Two deployments to >150,000 email addresses were sent. Demographic data were described using frequencies for categoric variables and mean measures of central tendency for continuous variables. Logistic regression models were used to analyze associations between demographics and responses., Results: Two thousand four hundred three men responded to the survey. After excluding incomplete and ineligible surveys, 1847 surveys were analyzed. The median age of respondents was 55 years. The majority was white (87%), married (68%), employed (69%), and had completed high school or beyond (97%). One-third of the respondents lived in the South, with the other regions nearly equally represented. A significant majority, 95%, reported having been sexually active with women, and 86% felt comfortable labeling the vulvar anatomy. With regard to preferences, more respondents considered smaller labia attractive compared to large labia; yet 36% of the men remained neutral. Men also showed a preference for partially or completely groomed genitals compared to natural hair pattern. Whereas 51% of participants believed the appearance of a woman's labia influenced their desire to engage in sexual activity, 60% denied it affected sexual pleasure. Only 42% of men were familiar with labiaplasty, and 75% of all respondents would not encourage a female partner to change her genital appearance. Multivariable analysis revealed younger age to be associated with preferences for small labia and complete genital hair removal, as well as familiarity with labiaplasty., Conclusion: In this national survey, men demonstrated familiarity with the female anatomy, but many did not feel it impacted sexual desire or pleasure. Moreover, the majority lacked strong preferences for a specific vulvar appearance and would not encourage a female partner to alter her genital appearance surgically., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: 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., Methods: 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., Results: 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 < 0.001., Conclusions: Web-based administration of the FSFI is a valid alternative to the paper-based version.

Introduction and Hypothesis: The objective was to document adherence with 24-h voiding diaries in the evaluation of routine urogynecology patients., Methods: This was a cross-sectional study of 200 patients presenting for initial urogynecological consultation. All were mailed a standardized packet prior to their visit, including a 24-h voiding diary. Upon arrival, subjects were asked to complete a brief survey. Eight questions targeted those that completed the diary ("completers"); 3 targeted those that did not ("noncompleters"). "Completers" were further sub-classified based on survey responses. Those recording each void immediately were termed "appropriate completers." Others were considered "inappropriate completers." Demographics and other data were obtained from the medical records., Results: Eleven women were excluded for recording more than 24 h of data. Of the 189 remaining subjects, 157 (83 %) completed the diary. Many "noncompleters" were unaware of the diary (54 %). Others chose not to complete it, most commonly citing "don't think it applies" (25 %). On univariate analysis "completers" were older (p = 0.049), with more complaints of mixed incontinence (p = 0.001). Fifty-four percent of "completers" were deemed "appropriate." "Appropriate completers" voided more frequently (p = 0.024) than "inappropriate completers." After multivariate analyses, however, only lower parity and unemployed status were associated with appropriate diary completion. Reassuringly, the majority, 77 %, believed that the diary responses were reflective of their typical behavior, and voiding frequency on the diary correlated with self-report during their medical history (rs = 0.483, p < 0.001)., Conclusions: Although compliance with voiding diaries is reasonably high in the office setting, adherence to instructions is less optimal. Strategies to improve ease of use could benefit future patient care.

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., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Pelvic floor physical therapy (PFPT) is often used as a treatment of pelvic floor disorders and may improve function after pelvic reconstructive surgery. However, the long-term impact of this modality is not understood., Methods: This randomized controlled trial compared PFPT to the standard care in women undergoing vaginal reconstruction. The intervention group received PFPT biweekly until 12 weeks postoperatively, in conjunction with a physician assessment. Control subjects underwent a physician assessment alone at all postoperative intervals. The final follow-up was at 24 weeks. Physical examinations (pelvic organ prolapse quantification assessment), intravaginal electromyography, voiding diaries, and validated questionnaires were completed by all subjects. The primary outcome was change in the World Health Organization Quality of Life-BREF., Results: Forty-nine women completed the study, 24 in the PFPT group and 25 in the control group. Although electromyography measures showed better muscular function in PFPT subjects after 12 weeks, at 6 months after surgery, this was no longer noted. However, quality of life parameters improved for the entire sample at 24 weeks, with no difference between groups. Positive change from 12 to 24 weeks was also documented in scores on the Pelvic Floor Distress Inventory-20 (P = 0.04) and Pelvic Floor Impact Questionnaire-7 (P = 0.018), corresponding with continued improvement in bladder symptoms. Finally, Prolapse and Incontinence Sexual Questionnaire-12 and Female Sexual Function Index scores improved between 12 and 24 weeks, suggesting better sexual function overall with time elapsed from surgery., Conclusions: Quality of life improves in all subjects after vaginal reconstructive surgery, with ongoing benefit between 3 and 6 months. Nevertheless, standardized PFPT was not associated with differences at 24 weeks in this cohort of women.

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 < 0.001) and total FSFI (P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral glans in coronal view was significantly smaller for the anorgasmic group (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., (© 2014 International Society for Sexual Medicine.)

Introduction: Sexual disorders impact up to 43% of women. However, the relationship between sexual dysfunction and psychological variables such as personality traits and coping mechanisms is not well understood., Aim: To examine personality domains and coping strategies utilized by women with sexual dysfunction in a clinical sample., Methods: Patients seeking care for female sexual dysfunction (FSD) from a sexual medicine specialist were identified using International Classification of Diseases, Ninth Revision codes. Packets containing informed consent, Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), Ten Item Personality Index (TIPI), and Brief COPE were mailed to subjects., Main Outcome Measures: Correlations among FSFI, FSDS-R, TIPI, and Brief COPE., Results: Of 79 eligible subjects, 50 (63.2%) returned completed questionnaires. The mean age was 40 years (standard deviation 14). Total FSFI and FSDS-R scores confirmed FSD. Correlations between the FSFI and TIPI illustrated trends with the domain of extraversion, suggesting better function in those exhibiting more of this trait (r = 0.285, P = 0.079). Similarly, FSDS-R scores correlated with openness to experience (r = -0.305, P = 0.037) and approached significance for extraversion (r = -0.258, P = 0.080), indicating lower distress in such personality types. When assessing the Brief COPE, use of emotional support, a positive coping strategy, correlated with better orgasm (r = 0.303, P = 0.048) and higher satisfaction (r = 0.331, P = 0.03). Finally, when evaluating TIPI with COPE scores, several significant associations were noted, establishing that personality may influence these adaptive behaviors., Conclusion: Many notable relationships between sexual function, personality, and coping are presented. These support a role for consideration of psychological variables when evaluating women presenting for sexual dysfunction. Crisp CC, Vaccaro CM, Pancholy A, Kleeman S, Fellner AN, and Pauls R. Is female sexual dysfunction related to personality and coping? An exploratory study. Sex Med 2013;1:69-75.