the National Overactive BLadder Evaluation (NOBLE) Program was initiated to better understand the prevalence and burden of overactive bladder in a broad spectrum of the United States population.
to ...estimate the prevalence of overactive bladder with and without urge incontinence in the US, assess variation in prevalence by sex and other factors, and measure individual burden.
US national telephone survey using a clinically validated interview and a follow-up nested study comparing overactive bladder cases to sex- and age-matched controls.
noninstitutionalized US adult population.
a sample of 5,204 adults >/=18 years of age and representative of the US population by sex, age, and geographical region.
prevalence of overactive bladder with and without urge incontinence and risk factors for overactive bladder in the US. In the nested case-control study, SF-36, CES-D, and MOS sleep scores were used to assess impact.
the overall prevalence of overactive bladder was similar between men (16.0%) and women (16.9%), but sex-specific prevalence differed substantially by severity of symptoms. In women, prevalence of urge incontinence increased with age from 2.0% to 19% with a marked increase after 44 years of age, and in men, increased with age from 0.3% to 8.9% with a marked increase after 64 years of age. Across all age groups, overactive bladder without urge incontinence was more common in men than in women. Overactive bladder with and without urge incontinence was associated with clinically and significantly lower SF-36 quality-of-life scores, higher CES-D depression scores, and poorer quality of sleep than matched controls.
the NOBLE studies do not support the commonly held notion that women are considerably more likely than men to have urgency-related bladder control problems. The overall prevalence of overactive bladder does not differ by sex; however, the severity and nature of symptom expression does differ. Sex-specific anatomic differences may increase the probability that overactive bladder is expressed as urge incontinence among women compared with men. Nonetheless, overactive bladder, with and without incontinence, has a clinically significant impact on quality-of-life, quality-of-sleep, and mental health, in both men and women.
Objective
To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery.
Design
Population‐based, retrospective ...cohort study.
Setting
British Columbia, Canada.
Population
Term, singleton deliveries (2004–2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery (n = 10 901 deliveries; 5057 indicated for dystocia, 5844 for fetal distress).
Methods
Multinomial propensity scores and mulitvariable log‐binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (95% CI).
Main outcome measures
Composite severe perinatal morbidity/mortality (e.g. convulsions, severe birth trauma and perinatal death) and severe maternal morbidity (e.g. severe postpartum haemorrhage, shock, sepsis and cardiac complications).
Results
Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46–3.07; vacuum ARR 2.71, 95% CI 1.49–3.15; sequential ARR 4.68, 95% CI 3.33–6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05–2.36; vacuum ARR 2.29, 95% CI 1.57–3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04–1.61) and in severe maternal morbidity following attempted midcavity forceps delivery (ARR 2.34, 95% CI 1.54–3.56).
Conclusion
Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument.
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Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery.
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Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery.
Objective: The aim of this study was to describe the anatomic and functional results of the discrete fascial defect rectocele repair.
Study Design: Sixty-nine women underwent rectocele repair at Duke ...University Medical Center during a 3-year period beginning January 1, 1994. Repair was limited to reapproximation of discrete defects in the rectovaginal fascia, without levator plication or perineorrhaphy. Outcome measures included Pelvic Organ Prolapse Quantitation measurements, prolapse stage, and a symptom questionnaire. Univariate and nonparametric tests were used as appropriate.
Results: Before the operation 46% patients (32/69) reported constipation, 39% (27/69) reported splinting, 32% (22/69) reported tenesmus, and 13% (9/69) reported fecal incontinence. The median preoperative posterior Pelvic Organ Prolapse Quantitation stage was 2 (1-4). Pelvic Organ Prolapse Quantitation stage had improved for all but 2 women at 6 weeks. Eighteen percent (8/43) had recurrent rectoceles at 12 months. Mean values for the points describing the posterior vaginal wall improved >2 cm (
P < .0001). Although perineorrhaphy was not performed, the genital hiatus decreased by 2.3 cm (
P < .0001), with no significant change in the length of the perineal body. Functional results mirrored anatomic results, with statistically significant improvements for all symptoms.
Conclusions: The discrete defect rectocele repair provides anatomic correction of rectoceles with alleviation of associated symptoms for most women. (Am J Obstet Gynecol 1998;179:1451-7.)
The objective was to study the effect of colpocleisis on pelvic support, symptoms, and quality of life and report-associated morbidity and postoperative satisfaction. Women undergoing colpocleisis ...for treatment of pelvic organ prolapse (POP) were recruited at six centers. Baseline measures included physical examination, responses to the Pelvic Floor Distress Inventory, and Pelvic Floor Impact Questionnaire. Three and 12 months after surgery we repeated baseline measures. Of 152 patients with mean age 79 (±6) years, 132 (87%) completed 1 year follow-up. Three and 12 months after surgery, 90/110 (82%) and 75/103 (73%) patients following up had POP stage ≤1. All pelvic symptom scores and related bother significantly improved at 3 and 12 months, and 125 (95%) patients said they were either ‘very satisfied’ or ‘satisfied’ with the outcome of their surgery. Colpocleisis was effective in resolving prolapse and pelvic symptoms and was associated with high patient satisfaction.
Objective: The purpose of this study was to compare the symptoms that are related to pelvic floor dysfunction with the location and severity of the coexisting prolapse. Study Design: Two hundred ...thirty-seven consecutive patients with symptomatic pelvic organ prolapse came to Johns Hopkins Medicine during a 24-month period beginning in July 1998 and completed a symptom-specific Likert scale questionnaire that included standardized questions that were compiled from commonly used validated instruments. All questionnaires were completed by the patients before they were seen by a physician. Further evaluation included a standardized physical examination that included the International Continence Society's system for grading uterovaginal prolapse. Symptoms were categorized according to both severity and associated anatomic compartment. Symptoms that were related to urinary and anal incontinence and voiding, defecatory, sexual, and pelvic floor dysfunction were analyzed with respect to location and severity of pelvic organ prolapse with the use of the nonparametric correlation coefficient, Kendall's tau-b. Results: The mean age of the women was 57.2 years (range, 23-93 years); 109 of the women (46%) had undergone hysterectomy. Overall, stage II was the most common pelvic organ prolapse (51%) that was encountered. In 77 patients (33%), anterior compartment pelvic organ prolapse predominated; 46 patients (19%) demonstrated posterior compartment prolapse, whereas 26 patients (11%) had apical prolapse. In 88 patients (37%), no single location was more severe than another. Voiding dysfunction that was characterized by urinary hesitancy, prolonged or intermittent flow, and a need to change position was associated with the increasing severity of anterior and apical pelvic organ prolapse. Pelvic pressure and discomfort along with visualization of prolapse were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Defecatory dysfunction characterized by incomplete evacuation and digital manipulation was associated with worsening posterior compartment pelvic organ prolapse. Impairment of sexual relations and duration of abstinence were strongly associated with worsening pelvic organ prolapse. An inverse correlation was observed between increasing severity of pelvic organ prolapse and urinary incontinence and enuresis. Conclusion: Women with pelvic organ prolapse experience symptoms that do not necessarily correlate with compartment-specific defects. Increasing severity of pelvic organ prolapse is weakly to moderately associated with several specific symptoms that are related to urinary incontinence and voiding, defecatory, and sexual dysfunction. (Am J Obstet Gynecol 2001;185:1332-8.)
The rate of obstetric anal sphincter injury has increased in recent years, particularly among operative vaginal deliveries. We sought to characterize temporal trends in episiotomy use and to quantify ...the association between episiotomy and obstetric anal sphincter injury.
Using a population-based retrospective cohort study design of hospital data from 2004 to 2017, we studied all vaginal deliveries of singleton infants at term gestation in Canada (excluding Quebec). Rates of obstetric anal sphincter injury were contrasted between women who had an episiotomy and those who did not. Log-binomial regression was used to estimate the association between episiotomy and obstetric anal sphincter injury among women with spontaneous and operative vaginal deliveries after controlling for confounders.
The study population included 2 570 847 deliveries. Episiotomy use declined significantly among operative vaginal deliveries (53.1% in 2004 to 43.2% in 2017,
< 0.0001) and spontaneous vaginal deliveries (13.5% in 2004 to 6.5% in 2017,
< 0.0001). Episiotomy was associated with higher rates of obstetric anal sphincter injury among spontaneous vaginal deliveries (4.8 with episiotomy v. 2.4% without; adjusted rate ratio RR 2.06, 95% confidence interval CI 2.00-2.11) and this association remained after stratification by parity and obstetric history. In contrast, episiotomy was associated with lower rates of obstetric anal sphincter injury among forceps deliveries in nulliparous women (adjusted RR 0.63, 95% CI 0.61-0.66), and women with vaginal birth after cesarean (adjusted RR 0.71, 95% CI 0.60-0.85), but not among parous women without a previous cesarean (adjusted RR 1.16, 95% CI 1.00-1.34).
Episiotomy use has declined in Canada for all vaginal deliveries. The protective association between episiotomy and obstetric anal sphincter injury among women who gave birth by operative vaginal delivery (especially forceps) warrants reconsideration of clinical practice among nulliparous women and those attempting vaginal birth after cesarean.
To describe trends in pessary use for pelvic organ prolapse.
An anonymous survey administered to the membership of the American Urogynecologic Society covered indications, management, and choice of ...pessary for specific support defects.
The response rate was 48% (359 of 748). Two hundred fifty surveys were received at the scientific meeting and 109 were returned by mail. Seventy-seven percent used pessaries as first-line therapy for prolapse, while 12% reserved pessaries for women who were not surgical candidates. With respect to specific support defects, 89% used a pessary for anterior defects, 60% for posterior defects, 74% for apical defects, and 76% for complete procidentia. Twenty-two percent used the same pessary, usually a ring pessary, for all support defects. In the 78% who tailored the pessary to the defect, support pessaries were more common for anterior (ring) and apical defects (ring), while space-filling pessaries were more common for posterior defects (donut) and complete procidentia (Gellhorn). Less than half considered a prior hysterectomy or sexual activity contraindications for a pessary, while 64% considered hypoestrogenism a contraindication. Forty-four percent used a different pessary for women with a prior hysterectomy and 59% for women with a weak pelvic diaphragm. Ninety-two percent of physicians believed that pessaries relieve symptoms associated with pelvic organ prolapse, while 48% felt that pessaries also had therapeutic benefit in addition to relieving symptoms.
While there are identifiable trends in pessary use, there is no clear consensus regarding the indications for support pessaries compared with space-filling pessaries, or the use of a single pessary for all support defects compared with tailoring the pessary to the specific defect. Randomized clinical trials are needed to define optimal pessary use.
We designed this trial to assess whether the addition of standardized Burch colposuspension to abdominal sacrocolpopexy for the treatment of pelvic-organ prolapse decreases postoperative stress ...urinary incontinence in women without preoperative symptoms of stress incontinence.
Women who did not report symptoms of stress incontinence and who chose to undergo sacrocolpopexy to treat prolapse were randomly assigned to concomitant Burch colposuspension or to no Burch colposuspension (control) and were evaluated in a blinded fashion three months after the surgery. The primary outcomes included measures of stress incontinence (symptoms, stress testing, or treatment) and measures of urge symptoms. Enrollment was stopped after the first interim analysis because of a significantly lower frequency of stress incontinence in the group that underwent the Burch colposuspension.
Of 322 women who underwent randomization, 157 were assigned to Burch colposuspension and 165 to the control group. Three months after surgery, 33.6 percent of the women in the Burch group and 57.4 percent of the controls met one or more of the criteria for stress incontinence (P<0.001) Corrected. There was no significant difference between the Burch group and the control group in the frequency of urge incontinence (32.7 percent vs. 38.4 percent, P=0.48). After surgery, women in the control group were more likely to report bothersome symptoms of stress incontinence than those in the Burch group who had stress incontinence (24.5 percent vs. 6.1 percent, P<0.001).
In women without stress incontinence who are undergoing abdominal sacrocolpopexy for prolapse, Burch colposuspension significantly reduced postoperative symptoms of stress incontinence without increasing other lower urinary tract symptoms.
This study was undertaken to evaluate the responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women with pelvic organ prolapse undergoing ...surgical and nonsurgical management.
The responsiveness of the prolapse, urinary and colorectal scales of the PFDI and PFIQ were assessed in 2 independent populations: (1) 42 women with stage II or greater prolapse enrolled in an ongoing multicenter randomized trial comparing 2 different pessaries (Pessary group) and (2) 64 women with stage III or greater prolapse who underwent vaginal reconstructive surgery (Surgery group). All subjects completed the PFDI and PFIQ at baseline and again either 3 months (Pessary group) or 6 months (Surgery group) after initiation of treatment. Responsiveness was assessed with standardized response mean (SRM), effect size (ES), and the paired t test.
In the Pessary group, there was a significant improvement in the prolapse and urinary scales of the PFDI, with each demonstrating moderate responsiveness (prolapse: SRM 0.69, ES 0.68; urinary: SRM 0.57, ES: 0.50, P < .001 for each). The colorectal scale of the PFDI and each of the 3 scales of the PFIQ demonstrated no significant change in scores with pessary use. In the Surgery group, there was a significant improvement in the prolapse, urinary, and colorectal scales of both the PFDI and PFIQ (P < .01 for each). The prolapse and urinary scales of the PFDI demonstrated excellent responsiveness with SRM and ES 1.20 or greater for the prolapse scale and equal to1.05 for the urinary scales. The colorectal scale of the PFDI and the urinary and prolapse scales of the PFIQ demonstrated moderate responsiveness (SRM 0.61-0.70 and ES 0.56-0.60) after surgery. Subjects who had a recurrence of their prolapse develop after surgery (6%) had significantly less improvement in the prolapse scale of the PFDI than those who did not. After controlling for preoperative prolapse stage and baseline quality of life scores, subjects in the Surgery group had significantly greater improvement in each of the scales of the PFDI and the prolapse and urinary scales of the PFIQ than did the Pessary group (P < .05 for each).
The PFDI and PFIQ are responsive to change in women undergoing surgical and nonsurgical treatment for pelvic organ prolapse. The PFDI is more responsive than the PFIQ.
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