Sexual function in patients presenting to a urogynecology practice

The purpose of this study was to evaluate sexual function in women referred to a urogynecology practice. All new patients were mailed an optional female sexual function index (FSFI) in conjunction with their history forms; other sexual function information was obtained during the physician interview. Over 6 months, four hundred fifty new patients were enrolled. Of these, 243 (54%) were not sexually active. Reasons listed for sexual inactivity included partner problems/no partner (32%), low desire (14%), prolapse (10%), and pain (10%). There were several differences between sexually active and non-sexually active participants; however, after a multivariate analysis, only age, marital status, and stage/grade 1–2 of prolapse remained significant. One hundred nine sexually active patients completed the FSFI; the majority was sexually active two to four times per month. Female sexual dysfunction was noted in 70 (64%) patients. Lowest scores were noted for the domain of desire, followed by arousal, orgasm, lubrication, satisfaction, and pain. Reduced frequency of intercourse was the only factor significantly associated with dysfunction. Ninety-four percent were not embarrassed by the survey. Overall, sexual inactivity is common in patients presenting for urogynecologic care. Those that are sexually active report low rates of sexual activity and high rates of sexual dysfunction. Most sexually active patients will accept a sexual function questionnaire as part of their routine assessment.This research was presented at the American College of Obstetricians and Gynecologists annual clinical meeting, May 10, 2005, San Francisco, CA, USA.     

Attitudes and perceptions regarding subspecialty training in female pelvic medicine and reconstructive surgery

The objective of the study was to evaluate perceptions regarding subspecialty training in female pelvic medicine and reconstructive surgery (FPMRS) in the United States. A 57-item questionnaire was anonymously mailed to fellows and applicants to FPMRS fellowship. Seventy-four American fellowship interviewees and current fellows completed the entire questionnaire (56% response rate). Key factors associated with higher interest in FPMRS compared to general obstetrics and gynecology (OBG) included competitiveness to get into fellowship and new developments. Key factors associated with higher interest in FPMRS compared to other subspecialties in obstetrics and gynecology (SUB) were lower risk of malpractice and higher sense of career satisfaction. Commonly cited attributes of FPMRS that attract to the field relate to the complexity of cases and the quantity of time spent in the operating room. Majority of responders preferred academics over private practice or a mixture (55.4%, 17.6%, and 27%, respectively). The most important reason for interest in FPMRS compared to OBG and SUB is quality time in the operating room and lower risk of malpractice, respectively. Results of this study may help attract medical students to OBG and help mentors with career counseling.     

Definition of normal female pelvic floor anatomy using ultrasonographic techniques.

Urogynecology deals with anatomic and physiologic defects of the female pelvic floor, including urinary and anal incontinence. Ultrasonographic investigation of the female pelvic floor may be helpful in diagnosis and management of both symptom complexes. To interpret pelvic floor ultrasound studies, normal parameters are necessary. Ten asymptomatic control subjects were studied for internal and external anal closing pressures, anal-rectal angles, puborectalis muscle movement, position of urethral egress, and amount and direction of urethrovesical junction mobility. Means and standard deviations for each parameter were obtained. Comparison to studies performed during the same time interval on patients symptomatic for urinary or anal incontinence is discussed.     

Sexual satisfaction in the elderly female population: A special focus on women with gynecologic pathology

Sexual function in aging women

Sexuality is an integral part of human expressions. Mental health plays a major role in sexuality. Several psychological interventions are proposed to increase the sexual quality of life in older women with diverse gynecologic pathology. A biopsychosocial approach utilizing brief strategies can be easily implemented in clinics to help women of all ages increase their sexual quality of life.

The impact of female pelvic floor disorders on sexual function in older women

Female pelvic floor disorders include urinary incontinence, pelvic organ prolapse, and fecal incontinence. These disorders increase dramatically with increasing age. Urinary incontinence has been demonstrated to have a negative impact on a woman's sexual function. Among sexually active older women with urinary incontinence, 22% report being moderately or extremely worried that sexual activity would cause urine loss. An increased prevalence of sexual distress [9% (6/76) vs. 1.3% (2/216), p = 0.005] has been reported in sexually active women over 40 years old with urinary incontinence. Treatment of urinary incontinence can improve sexual function in older women. Among sexually active women (N = 53) who underwent midurethral slings procedures for the correction of urinary incontinence, increased coital frequency, decrease fear of incontinence with coitus, decreased embarrassment due to incontinence was reported six months after surgery. Pelvic organ prolapse, a hernia of the vagina resulting in a visible vaginal bulge, has also been associated with a negative impact on sexual function. Women with advanced pelvic organ prolapse (POP-Q stage III or IV) have been demonstrated to have decreased body image reporting that they are more self-conscious about their appearance [adjusted odds ratio (AOR) 4.7; 95% confidence interval (CI) 2.9, 51], feel less feminine (AOR 4.0; 95% CI 1.2, 15) and less sexually attractive (AOR 4.6; 95% CI 1.4, 17) compared with women who have normal pelvic support. Both vaginal and abdominal approaches to surgical correction of pelvic organ prolapse have been demonstrated to improve sexual function.

Mental health

Mental health plays a major role in older woman's sexuality. Sexual interest and satisfaction is tied to emotional expressivity, women's self-worth, feelings of depression and loneliness as well as cognitive function. Research has shown that both general practitioners and specialists lack training in sexual assessments. Behavioral health specialists, such as a psychologist, can play an integral role in helping to facilitate communication between the patient and the provider. A main focus of communication training is to facilitate open and genuine conversation between the provider and the patient. Providers are encouraged to ask open ended questions while patients are encouraged to discuss symptoms while coping with an internal state of anxiety.Despite the known prevalence of sexual dysfunction among older women, few studied empirically based interventions have been published with these women. This speaks to the general assumption among medical professionals that having the “sex talk” in older women with gynecological pathology is not important or relevant. A biopsychosocial approach utilizing some of the aforementioned brief strategies can be easily implemented in comprehensive gynecology clinics in order to help women of all ages increase their sexual quality of life.     

Do preoperative cytokine levels offer a prognostic factor for polypropylene mesh erosion after suburethral sling surgery for stress urinary incontinence?

When polypropylene meshes are used in reconstructive urogynecological surgery, the erosion rates vary from 3.3% to 14% and causative factors for such erosions are still unknown in many cases. Therefore, the aim of our study was to establish the role of immunologic factors in the process of polypropylene tapes erosions after suburethral sling procedures. Serum concentrations of tumor necrosis factor α, interleukin (IL)-2, IL-4, IL-5, IL-10, and interferon (IFN)-γ were estimated in 123 patients suffering from stress urinary incontinence preoperatively and during 12 months follow-up using Human Th1/Th2 Cytokine Cytometric Bead Array I kit. The same immunological assessment was performed in each case of detected tape erosion. Statistical calculation was performed using UNIVARIATE, CORR, and NPAR1WAY procedures from Statistical Analysis System. The unpaired Student’s t test, nonparametric Mann–Whitney U test, and Wilcoxon tests were used. Preoperative IFN-γ concentration was significantly higher in women with subsequent polypropylene mesh erosion when compared to women with successful outcome (p < 0.05). Th1 cytokine profile may be related to the risk of the vaginal erosions following placement of polypropylene meshes. The way to lower erosion rate may involve exclusion of the patients immunologically prone to synthetic material erosion. The factor which can help to select such patients could be preoperative level of IFN-γ.     

Urodynamic follow-up after radical hysterectomy

Two groups of patients treated for cervical cancer stage Ib with radical Wertheim-Meigs hysterectomy, in two periods (1957–1966 and 1981–1986) were compared. To avoid urological complications after the Wertheim-Meigs operation the experience of the surgeon is very important. Only mild disturbances of the lower urinary tract function were found in 36% of patients in the second group. In those patients treated subsequently by irradiation the bladder compliance is significantly lower compared to the control group.     

Pelvic Floor Dysfunction Management Practice Patterns: A Survey of Members of the International Urogynecological Association

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.     

The state of resident education in urogynecology and pelvic floor disorders

To determine the state of resident education in the areas of pelvic floor dysfunction and urogynecology a survey was sent to program directors (or their designees) of United States residency training programs. A six-page 14-question survey was sent to 274 approved residency programs. The response rate was 46.4%. Program directors were queried on educational objectives and materials, diagnostic and therapeutic techniques and evaluation of resident performance. To confirm results, the responses were checked against data published in the APGO/CIBA Directory of Residencies in Obstetrics and Gynecology. Eighty per cent of programs used the objectives established by the American Uro-Gynecologic Society or the Council on Resident Education in Obstetrics and Gynecology. Resident lectures or textbooks were the most frequent sources of educational information used. The annual CREOG in-training exam was the most frequently utilized evaluation process. Ninety-three per cent of residents obtained hands-on experience with urodynamics and all residents were exposed to retropubic techniques for the surgical treatment of incontinence. Resident education in non-surgical techniques to treat urinary incontinence, however, was lacking in approximately 50% of programs. The survey suggests that the basic foundation may be in place to provide residents with adequate exposure to diagnostic and therapeutic measures for dealing with pelvic floor disorders and urogynecology. There are, however, many aspects which need attention in our educational objectives for resident education. A broader focus on the non-surgical management of incontinence needs to be encouraged.Editorial Comment: As underscored by the authors, a great deal of continued emphasis will need to be focused on the standardized educational experience in the area of urogynecology/pelvic floor disorders, particularly as the lifespan of the female population increases. Despite the recent swell of interest in educating residents as well as practicing gynecologists in this area, it is disconcerting to learn from this study that eight of the 126 responding programs had no evaluation process of resident knowledge/performance in place. This paper highlights that, while the majority of programs offer urodynamics and lower urinary tract endoscopy, other diagnostic (e.g. ultrasonography) and therapeutic (e.g. biofeedback, behavior modification) modalities need to be expanded further. In addition, the training of residents in more sophisticated anti-incontinence and corrective genitourinary prolapse surgery needs to be more consistent between the residency programs. As the speciality of obstetrics and gynecology now pronounces itself as one of the primary care specialties, it is paramount that intensive efforts be made to standardize as much as possible the educational experience of residents.