Complications after pelvic floor repair surgery (with and without mesh): short-term incidence after 1873 inclusions in the French VIGI-MESH registry.

Abstract: Assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse.Prospective longitudinal cohort study by using a surgical registry.13 public hospitals in France.1873 women […]

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Antibiotic Prophylaxis During Catheter-Managed Postoperative Urinary Retention After Pelvic Reconstructive Surgery: A Randomized Controlled Trial.

Abstract: To estimate whether nitrofurantoin prophylaxis decreases the incidence of culture-documented urinary tract infection for women with catheter-managed urinary retention after pelvic reconstructive surgery.This double-blind, placebo-controlled, randomized trial was conducted […]

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Body mass index, abdominal fatness, weight gain and the risk of urinary incontinence: A systematic review and dose-response meta-analysis of prospective studies.

Abstract: Adiposity has been associated with elevated risk of urinary incontinence in epidemiological studies, however, the strength of the association has differed between studies.To conduct a systematic literature review and […]

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Do we need reminders of the precautionary principle?

In July 2018, Baroness Julia Cumberlege and her Review Team advised The Department of Health and NHS England to suspend the use of mesh tape procedures for incontinence. At the end of one of the Review’s oral hearings this April, her views were challenged as they were suspected to be skewed, because she was ‘only speaking to women who had poor outcome’. The answer came quick. ‘We certainly believe in precautionary principle…First do no harm’. This article is protected by copyright. All rights reserved.

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A systematic review on outcome reporting in randomized controlled trials on surgical interventions for female stress urinary incontinence. A call to develop a core outcome set.

Several meta-analyses have identified methodological limitations in female stress urinary incontinence (SUI) trials, precluding synthesis of primary studies and high-quality evidence.Evaluation of outcome measure selection and outcome reporting in randomised controlled trials (RCTs) on surgery for SUI.Systematic review of RCTs identified from bibliographical databases including Medline, Cochrane and EMBASE.RCTs evaluating the efficacy and safety of surgical interventions for the management of female SUI.Two researchers independently assessed the included studies and documented outcomes.Overall, 108 studies were identified that included 422 reported outcomes and 119 outcome measures. The three most common outcomes were cure rates (87 studies), quality of life (85 studies) and overactive bladder (78 studies). The median methodological quality was 3 (range 0-3) and outcome reporting quality 3 (range 0-5). Multinomial logistic regression analysis revealed that the methodological quality and use of validated questionnaire were significant predictors of outcome reporting quality. (?=0.538; p<.001, ?=0.218; p=.011, respectively).Outcome reporting in SUI trials is highly variable Until a core outcome set is developed and implemented, we propose an interim use of 3 commonly reported outcomes in each domain (treatment success rate: complete cure, partial improvement, failure of response; urodynamic evaluation outcomes: OAB, voiding dysfunction, urodynamic stress incontinence; patient-reported outcomes: quality of life, sexual dysfunction, patient satisfaction) with use of validated questionnaires for patient reported outcomes and subjective success rates. Complications should be also explicitly and comprehensively reported using validated outcome measures. This article is protected by copyright. All rights reserved.

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Pelvic floor myofascial pain severity and pelvic floor disorder symptom bother: Is there a correlation?

Pelvic floor myofascial pain, which is predominantly identified in the muscles of the levator ani and obturator internus, has been observed in women with chronic pelvic pain and other pelvic floor disorder symptoms, and is hypothesized to contribute to their symptoms.To describe the prevalence of pelvic floor myofascial pain in patients presenting with pelvic floor disorder symptoms and to investigate whether severity of pelvic floor myofascial pain on examination correlates with degree of pelvic floor disorder symptom bother.All new patients seen at one tertiary referral center between 2014 and 2016 were included in this retrospectively-assembled cross-sectional study. Pelvic floor myofascial pain was determined by transvaginal palpation of the bilateral obturator internus and levator ani muscles, and scored as a discrete number on an 11-point verbal pain rating scale (range 0-10) at each site. Scores were categorized as none (0), mild (1-3/10), moderate (4-6/10), and severe (7-10/10) for each site. Pelvic floor disorder symptom bother was assessed by the Pelvic Floor Distress Inventory short form (PFDI-20) scores. The correlation between these two measures was calculated using Spearman’s rank and partial rank correlation coefficients.912 new patients were evaluated. After excluding 79 with an acute urinary tract infection, 833 patients were included in the final analysis. Pelvic floor myofascial pain (pain rated >0 in any muscle group) was identified in 85.0% of patients: 50.4% rated as severe, 25.0% moderate, and 9.6% mild. In unadjusted analyses and those adjusted for postmenopausal status, severity of pelvic floor myofascial pain was significantly correlated with subjective prolapse symptoms such as pelvic pressure and heaviness but not with objective prolapse symptoms (seeing or feeling a vaginal bulge or having to push up on a bulge to start or complete urination) or leading edge. Severity of myofascial pain at several individual pelvic floor sites was also independently correlated with lower urinary tract symptoms, including pain in the lower abdomen (myofascial pain at all sites) and difficulty emptying the bladder (right obturator internus and left levator ani); and with defecatory dysfunction, including sensation of incomplete rectal emptying (pain at all sites combined and the right obturator internus), anal incontinence to flatus (pain at all sites combined), and pain with defecation (pain at all sites combined, and the right obturator internus and left levator ani).Pelvic floor myofascial pain was common in patients seeking evaluation for pelvic floor disorder symptoms. Location and severity of pelvic floor myofascial pain was significantly correlated with degree of symptom bother, even after controlling for postmenopausal status. Given the high prevalence of pelvic floor myofascial pain in these patients and correlation between pain severity and degree of symptom bother, a routine assessment for pelvic floor myofascial pain should be considered for all patients presenting for evaluation of pelvic floor symptoms.

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Long-Term Assessment of a Prospective Cohort of Patients Undergoing Laparoscopic Sacrocolpopexy.

To report long-term outcomes after laparoscopic sacrocolpopexy.We conducted a prospective descriptive cohort study on 331 consecutive patients who underwent laparoscopic sacrocolpopexy for symptomatic prolapse (Pelvic Organ Prolapse Quantification [POP-Q] system stage 2 or greater) at one center, with minimum 1.5 years of follow-up by April 30, 2014. Primary outcome measures were Patient Global Impression of Change score and failure at the apex (C?-1 cm; POP-Q stage 2 or greater). Secondary outcomes were anatomical failure in other compartments, duration of follow-up, occurrence and time point of complications, reinterventions, and functional outcomes by response to a standardized 24-question interview on prolapse and bladder, bowel, and sexual function. Assessment was by an experienced clinician not involved in patient management.The follow-up rate was 84.6% (280/331); 185 of 331 (55.9%) patients were both physically examined and interviewed, and 95 of 331 (25.7%) were interviewed only. The median age at interview was 72 years (interquartile range 13 years), with a follow-up period of 85.5 months (interquartile range 46 months). Approximately 83% (231/280) reported improvement; 5.7% (16/280) were unchanged, 5.7% (16/280) felt slightly worse, and 6.8% (17/280) reported clear deterioration. Anatomical failure at point-C was 8.6% (16/185); anterior (22.2%, 41/185) and posterior (28.6%, 53/185) prolapse were more common than apical prolapse. Of those with level-I anatomical cure, 10.1% (17/185) felt worse; half of them (9/17) because of prolapse in another compartment. The others had urinary problems (41.2%, 7/17), obstructive defecation (11.8%, 2/17), or dyspareunia (11.8%, 2/17). Conversely, the majority of patients with recurrence at the vault (62.5%, 10/16) self-reported to be improved. The reoperation rate was 17.8% (48/270), including 19 (7.0%) for graft-related complications and nine (3.3%) for prolapse.More than four out of five patients (82.5%) felt improved 86 months after laparoscopic sacrocolpopexy. Of those not improved, two thirds had recurrent prolapse; however, typically mid-vaginal. The other third reported urinary or bowel problems or dyspareunia. Reintervention for prolapse was 3.3%. The most common reasons for reoperation were graft-related complications (7.0%) and urinary incontinence (6.7%).

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Urologic Injury and Fistula After Hysterectomy for Benign Indications.

To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications.In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005-2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed.Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14-0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16-0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30-1.58), an incontinence procedure (OR 1.40, 95% CI 1.21-1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31-1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36-1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01-1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53-0.64) or laparoscopic (OR 0.80, 95% CI 0.75-0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach.Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

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Reoperation for Urinary Incontinence After Retropubic and Transobturator Sling Procedures.

To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures.We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure.We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups.Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.

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Anatomy, Histology, and Nerve Density of Clitoris and Associated Structures: Clinical Applications to Vulvar Surgery.

Precise understanding of structures comprising female external genitalia is essential in obstetric and gynecologic practice.To further characterize anatomy, histology, and nerve density of the clitoris and associated structures and to provide clinical correlations to vulvar surgery.Unembalmed female cadavers were examined. Length and width of body, glans and crura of clitoris were measured. Distances from glans to urethra and from dorsal surface of clitoral body to mid pubic arch were recorded. Path of dorsal nerve of clitoris was examined and nerve width was measured as it emerged from lateral surface of crura and at distal clitoral body. Distances from where dorsal nerve emerged from perineal membrane to posterior surface of membrane and to mid pubic arch were measured. Connective tissue layers associated with clitoris were examined. Tissue was harvested from additional unembalmed cadavers and nerve density of labia minora, glans, and clitoral body were analyzed. Histological examination was performed on vulvar structures to clarify tissue composition. Descriptive statistics were used for data analyses.27 cadavers (ages 48 to 96) were examined, 22 grossly and 5 histologically. Median length and width of clitoral body were 29 mm (range, 13-59 mm) and 9 (5-14) mm, respectively. Glans was 8 (5-12) mm long and 4 (3-10) mm wide. Length of crura was 50 (25-68) mm and width at anterior portion was 9 (2-13) mm. Closest distance from glans to urethra was 25 (14-37) mm and from clitoral body to mid pubic arch was 29 (14-46) mm. Widths of dorsal nerve at lateral crura and at distal clitoral body were 3 (2-4) mm and 1 (1-2) mm, respectively. Distance from dorsal nerve as it emerged from perineal membrane to mid pubic arch was 34 (20-48) mm and to posterior surface of membrane was 20 (8-31) mm. Dorsal nerve and artery of clitoris coursed adjacent to medial surface of inferior pubic ramus surrounded by a dense fibrous capsule adherent to periosteum. Nerve and artery then coursed deep to dense connective tissue layers, which were contiguous with suspensory ligament and fascia of clitoris. Histologic examination revealed presence of erectile tissue in clitoral body, crura and vestibular bulbs but such tissue was absent in glans and labia minora. Nerve density analysis revealed statistically significant greater density in the dorsal, compared with ventral half of the clitoral body. Although not statistically significant, there was increased nerve density in the distal compared to proximal half of the labia minora.Precise knowledge of clitoral anatomy and associated neurovascular structures is essential to safely complete partial vulvectomies, clitoral and vulvar reconstructive procedures, anti-incontinence surgeries and repair of obstetric lacerations. Understanding range of anatomic variations and awareness of areas of increased nerve density is important during counseling and surgical planning. Though the dorsal nerve of clitoris courses deep to dense connective tissue layers, inadvertent injury may occur in setting of deep dissection or suture placement. The dorsal nerve seems most vulnerable with surgical entry or lacerations that extend from the midline of the prepuce to the inferior pubic rami.

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A randomized, double-blind, placebo-controlled trial of onabotulinumtoxinA trigger point injections for myofascial pelvic pain.

Pelvic pain is estimated to effect 15% of women, and onabotulinumtoxinA is used to treat a variety of pain disorders. However, the data on the use of onabotulinumtoxinA for the treatment of women with myofascial pelvic pain is limited.To compare the effect of onabotulinumtoxinA versus placebo injections to the pelvic floor muscles in women with myofascial pelvic pain.This was a double-blind, randomized, placebo-controlled trial in women with myofascial pelvic pain. Women ?18 years were eligible if they reported pain ?6 on a 10-point visual analog scale (VAS) ?50% of the time and had pain on palpation ?6 on the VAS in ?1 of 6 pelvic floor muscle groups. Participants were randomly allocated to a pelvic floor injection of 200 units of onabotulinumtoxinA or 20 mLs of saline. All participants started 8 weeks of physical therapy 4 weeks after the injection. Participants completed validated questionnaires at baseline, 2, 4, and 12 weeks after injection. At each visit, a urogynecologist who was blinded to treatment arm performed a clinical examination with palpation of the left and right sides of 6 pelvic floor muscle groups. The primary outcome was change in participant-reported pain on palpation of the most painful pelvic floor muscle at 2 weeks. Analyses were intention-to-treat.We consented 60 women. One participant was lost to follow-up after she was consented; therefore, we randomized 59 women. The groups had similar demographic and clinical characteristics. With regard to the primary outcome, there was no significant difference between the intervention and placebo groups in the change in participant-reported pain on palpation of the most painful pelvic floor muscle at 2 weeks. There were no significant differences in participant-reported pain on palpation for any muscle group at 4 or 12 weeks. At 4 and 12 weeks, participants in the intervention group reported greater declines in overall pelvic pain on the VAS compared to the placebo group, though these differences were not statistically significant (both p=0.16). Using the Patient Global Impression of Improvement index, participants in the intervention group were more likely to report their symptoms were improved at 4 and 12 weeks compared to the placebo group, though this difference was significant only at 4 weeks (p=0.03 and p=0.10, respectively). At 2 weeks, the placebo group had a significant improvement in the Pelvic Floor Distress Inventory score compared to the intervention group (p=0.01); however, this difference did not persist at 4 (p=0.19) or 12 weeks (p=0.11). At 2 weeks, the most common adverse event was constipation in the intervention and placebo groups, with 10.1% reporting de novo constipation. This was followed by urinary incontinence in the intervention group (22%) and urinary tract infection (9%) in the placebo group.Pelvic floor onabotulinumtoxinA injections for myofascial pelvic pain were not more effective than saline injections at decreasing muscle pain on palpation. Despite this, participants who received onabotulinumtoxinA were more likely than those who received saline to report improvement, albeit not statistically significant, in their overall pelvic floor pain at 4 and 12 weeks.

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Sacral Neuromodulation versus OnabotulinumtoxinA for refractory urgency urinary incontinence: impact on fecal incontinence symptoms and sexual function.

Women with refractory urgency urinary incontinence can be treated with onabotulinumtoxinA or sacral neuromodulation. Little data exists on the comparative effects of treatment of refractory UUI on other pelvic floor complaints, such as bowel and sexual function.The objective of this study was to compare the impact of these treatments on fecal incontinence and sexual symptoms.This was a planned supplemental analysis of a randomized trial in women with refractory UUI treated with onabotulinumtoxinA (n=190) or sacral neuromodulation (n=174). Fecal Incontinence and sexual symptoms were assessed at baseline, 6, 12, and 24 months. Fecal incontinence symptoms were measured using the St Mark’s (Vaizey) Fecal Incontinence severity scale. Sexual symptoms were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The PISQ-IR allows measurement of sexual symptoms in both sexually active and non-sexually active adults. Primary outcomes were change in Vaizey and PISQ-12 scores between baseline and 6 months. Secondary outcomes were change in PISQ-IR total and subscores between baseline and 6 months and change in Vaizey, PISQ-12 and PISQ-IR scores between baseline and 12 and 24 months. Intent to treat analysis was performed using repeated measures mixed model to estimate change in all parameters from baseline while adjusting for the baseline score. A subgroup analysis of women with clinically significant bowel symptoms was conducted based on baseline Vaizey score of ?12.At baseline, mean Vaizey scores were indicative of mild fecal incontinence symptoms and were not different between onabotulinumtoxinA and sacral neuromodulation groups (7.6+5.3 v 6.6+4.9, p=0.07). The proportion of sexually active women (56% v 63%, p=0.25), mean PISQ-12 score (33.4+7.5 v 32.7+6.7, p=0.55), or PISQ-IR subscores were also not different between the BTX and SNM groups at baseline. There was no difference between women treated with BTX and SNM at 6 months in improvement in fecal incontinence symptom score (Vaizey: -1.9, 95% CI -2.6 to -1.2 v -0.9, 95% CI -1.7 to -0.2, p=0.07) or sexual symptoms score (PISQ-12: 2.2, 95% CI 0.7 to 3.7 v 2.2, 95% CI 0.7 to 3.7, p=0.99). There was no difference in improvement between groups in the sexual symptom subscores in sexually active and non-sexually active women at 6 months. Similar findings were noted at 12 and 24 months. In a subgroup (onabotulinumtoxinA =33 and sacral neuromodulation =22) with clinically significant fecal incontinence at baseline (Vaizey score ?12), there was a clinically meaningful improvement in symptoms in both groups from baseline to 6 months with no difference in improvement between the onabotulinumtoxinA and sacral neuromodulation groups (-5.1, 95% CI -7.3 to -2.8 v -5.6, 95% CI -8.5 to -2.6, p=0.8).There were no differences in improvement of fecal incontinence and sexual symptoms in women with urgency urinary incontinence treated with onabotulinumtoxinA or sacral neuromodulation. Women with significant fecal incontinence symptoms at baseline had clinically important improvement in symptoms with no difference between the treatments. Our findings can help clinicians counseling women considering treatment for refractory urgency urinary incontinence.

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Characterizing Anxiety at the First Encounter in women presenting to the urogynecology clinic: the CAFÉ Study.

Clinically based anxiety questionnaires measure 2 forms of anxiety known as state anxiety and trait anxiety. State anxiety is temporary and is sensitive to change, while trait anxiety is a generalized propensity to be anxious.Our study aims to characterize the reasons for anxiety among women presenting for an initial consultation for their pelvic floor disorders, to measure change in participant state anxiety after the visit, and to correlate improvement in anxiety with visit satisfaction.All new patients presenting to our tertiary Urogynecology clinic were invited to participate. Following consent, participants completed pre- and post-visit questionnaires. Providers were blinded to pre and post-visit questionnaire responses. The pre-visit questionnaires included the Pelvic Floor Distress Inventory (PFDI), Generalized Anxiety Disorder-7 (GAD-7) and the 6 item short form of the Spielberg State Trait Anxiety Inventory (STAI-Y6). Participants were also asked to list their pre-visit anxieties. The post-visit questionnaires comprised of the STAI-Y6, patient global impression of improvement (PGI-I) of participant anxiety, patient satisfaction, and the participant’s perception of whether her anxiety was address during the visit. The anxieties listed by participants were then reviewed independently by 2 of the authors and categorized. A separate panel arbitrated when there were disagreements among anxiety categories.Fifty primarily Caucasian (66%) women with a median age of 53 years (IQR: 41-66) completed the study. The visit diagnoses included: stress urinary incontinence (54%), urge urinary incontinence (46%), myofascial pain (28%), pelvic organ prolapse (20%), and recurrent urinary tract infection (12%). Less than a quarter (22%) of participants had a history of anxiety diagnosis. The average pre-visit STAI-Y6 score was 42.9 (SD=11.98) which decreased by an average of 12.60 points post-visit (95% CI: -16.56 to -8.64, p<.001). Post-visit decreased anxiety was associated with improvements in the PGI-I anxiety (p<.001) and participants' perception that their anxiety symptoms were completely addressed (p=.045). The most reported causes for consultation related anxiety were: lack of knowledge of diagnosis and ramifications, personal or social issues, and fear of the physical exam. Participants reported that improvements in anxiety were related to patient education and reassurance, medical staff appreciation and acceptable treatment plan. Participants reporting complete satisfaction demonstrated a greater decrease in post-visit STAI scores compared to participants not reporting complete satisfaction (p=.045). Changes in the STAI-Y6 score were not associated with the PFDI (p=.35) or GAD-7 scores (p=.78).Women with the highest satisfaction following their initial Urogynecology visit also demonstrate the largest decreases in anxiety following the visit. Changes in anxiety scores were not correlated with the PFDI or with measures of generalized anxiety (GAD-7). Recognizing and addressing patient anxiety may help physicians better treat their patients and improve overall patient satisfaction.

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Pain and activity after vaginal reconstructive surgery for pelvic organ prolapse and stress urinary incontinence.

Little is known about short- and long-term pain and functional activity after surgery for pelvic organ prolapse.To describe postoperative pain and functional activity after transvaginal native tissue reconstructive surgery with apical suspension and retropubic synthetic midurethral sling and to compare these outcomes between patients receiving two common transvaginal prolapse repairs, uterosacral ligament and sacrospinous ligament vaginal vault suspension.This planned secondary analysis of a 2×2 factorial randomized trial included 374 women randomized to receive uterosacral (n=188) or sacrospinous (n=186) vaginal vault suspension to treat both Stages 2-4 apical vaginal prolapse and stress urinary incontinence between 2008 and 2013 at 9 medical centers. Participants were also randomized to receive perioperative pelvic muscle therapy or usual care. All patients received transvaginal native tissue repairs and a midurethral sling. Participants completed the Surgical Pain Scales (0-10 numeric rating scales; higher scores = greater pain) and Activity Assessment Scale (0-100; higher score = higher activity) prior to surgery and at 2 weeks, 4-6 weeks, and 3 months postoperatively. The SF-36 was completed at baseline, 6, 12 and 24 months after surgery; the Bodily Pain, Physical Functioning and Role-Physical subscales were used for this analysis (higher scores = less disability). Self-reported pain medication use was also collected.Before surgery, average pain at rest and during normal activity were (adjusted mean ± standard error) 2.24 + 0.23 and 2.76 + 0.25; both increased slightly from baseline at 2 weeks (+0.65, p<0.001 and +0.74, p=0.007 respectively) then decreased below baseline at 3 months (-0.87 and -1.14 respectively, p<0.001), with no differences between surgical groups. Pain during exercise/strenuous activity and worst pain decreased below baseline levels at 4-6 weeks (-1.26, p=0.014 and -0.95, p=0.002) and 3 months (-1.97 and -1.50, p<0.001) without differences between surgical groups. Functional activity as measured by the Activity Assessment Scale improved from baseline at 4-6 weeks (+9.24, p<0.001) and 3 months (+13.79, p<0.001). SF-36 Bodily Pain, Physical Functioning, and Role-Physical Scales demonstrated significant improvements from baseline at 6, 12 and 24 months (24 months: +5.62, +5.79, and +4.72 respectively, p<0.001 for each) with no differences between groups. Use of narcotic pain medications was reported by 14.3% of participants prior to surgery, 53.7% at 2 and 26.1% at 4-6 weeks post-operatively; thereafter, use was similar to baseline rates until 24 months when it decreased to 6.8%. Use of non-narcotic pain medication was reported by 48.1% of participants prior to surgery, 68.7% at 2 weeks and similar to baseline at 3 months; thereafter use dropped steadily to 26.6% at 2 years. Uterosacral ligament suspension resulted in less new or worsening buttock pain than sacrospinous suspension at 4-6 weeks postoperatively (4.6% vs. 10.5%, p=0.043) but no difference in groin or thigh pain.Pain and functional activity improve for up to 2 years after native tissue reconstructive surgery with uterosacral or sacrospinous vaginal vault suspension and midurethral sling for stage 2-4 pelvic organ prolapse. On average, immediate postoperative pain is low and improves to below baseline levels by 4-6 weeks.

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