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Primary care physicians (PCPs) play a major role in patient access to appropriate health care. This study examines PCPs' perceptions and management of female pelvic floor disorders. Surveys were mailed to family medicine and internal medicine physicians associated with the Hawai'i Medical Service Association. A total of 150 respondents were included. Only 34%, 38%, and 9% of respondents correctly identified the prevalence of urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP), respectively. For disease-specific screening, the highest response was that PCPs "sometimes" screen for UI (36%) and OAB (45%) but "hardly ever" screen for POP (43%). With regards to management of UI and OAB, respondents would either treat (30% UI, 39% OAB) or start treatment then refer (53% UI, 49% OAB). For POP, nearly all of respondents (81%) would immediately refer. When consultation is necessary, there was a similar rate of referral to urology and urogynecology for UI (38% urology, 42% urogynecology), and a similar rate of referral to gynecology and urogynecology for POP (47% gynecology, 48% urogynecology). For OAB, PCPs would refer to urology (54.0%), then urogynecology (31%), and lastly gynecology (13%). A majority of respondents were "somewhat familiar" (56%) with urogynecology as a subspecialty, while 27% were "very familiar", 13% were "slightly unfamiliar", and 3% were "very unfamiliar". This study shows that most PCPs are not comfortable managing common urogynecologic problems and would likely benefit from education on how to diagnose, treat, and refer for these conditions in order to optimize patient care.

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OBJECTIVE: To quantify and compare intraabdominal pressures (IAPs) in women with pelvic floor dysfunction during standard activities. STUDY DESIGN: Eligible subjects were women with pelvic organ prolapse and/or urinary incontinence presenting for urodynamic evaluation. IAPs were recorded for the following tasks: (1) standing up from a chair, (2) coughing, (3) lifting 10 lb (4.54 kg), (4) lifting 20 ;b (9.07 kg), and (5) pushing 20 lb (9.07 kg). Net pressures were compared by activity, age, and body mass index (BMI). RESULTS: We enrolled 147 subjects. The mean net IAPs generated were as follows: pushing 20 lb (11.6 cm H2O), lifting 10 lb (11.9 cm H2O), lifting 20 lb (19.6 cm H2O), standing up (36.8 cm H2O), and coughing (80.4 cm H2O). Coughing and standing up generated significantly more pressure than lifting either 10 or 20 lb (p < 0.001). IAPs were significantly lower for standing up in patients > or = 70 years old (p = 0.01) but otherwise did not vary by age. Obese subjects (BMI > or = 30.0) generated significantly more pressure than did normal-weight subjects (BMI 18.5-24.9) during all activities. CONCLUSION: Common activities such as standing up and coughing generate significantly more IAP than lifting up to 20 lb. This may have implications for postoperative restrictions in patients with pelvic floor dysfunction.

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PURPOSE: To compare leak point volumes and cost-effectiveness of a variety of adult incontinence products. METHODS: Adult incontinence products were purchased from local retail stores and categorized into moderate absorbency pads, moderate absorbency briefs, maximum absorbency pads, and maximum absorbent briefs. The leak point for each product was determined by applying fluid to the pad until the first drop of leakage from the pad or brief occurred. Cost-effectiveness was calculated by dividing the cost per product by the amount of fluid absorbed prior to the leak point. The leak points and cost-effectiveness of incontinence products were compared within and between categories. RESULTS: Significant differences in leak point volumes were present within all product categories except moderate absorbency pads. When comparing product categories, moderate absorbency pads were the least cost-effective, followed by maximum absorbency pads and absorbent briefs (P < .01). CONCLUSIONS: As a group, absorbent briefs are more cost-effective than incontinence pads, although products of similar absorbency category and design demonstrated varying leak points and cost-effectiveness. These findings may influence physician assessment of urinary incontinence as well as patient selection of incontinence products.

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BACKGROUND: This report aims to describe urethral mesh erosion after a single-incision synthetic midurethral sling placement and to discuss possible causes for this complication. CASE: A 41-year-old woman presented with recurrent stress urinary incontinence after an anchored single-incision midurethral sling placement. Cystourethroscopy and translabial pelvic ultrasonography demonstrated the size and location of the injury. Mesh removal, urethral reconstruction, and Martius transposition flap were performed. The entire mesh removed was 24% shorter than the product before insertion. CONCLUSION: Mesh contraction may play an important role in delayed urinary tract injury especially after anchored synthetic midurethral sling placements.

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OBJECTIVE: Anatomic differences among racial groups may contribute to observed differences in the occurrence of severe perineal lacerations at the time of vaginal delivery. The purpose of this study was to identify differences in perineal body length between racial groups. METHODS: Perineal body length was measured in primigravid women aged 18 to 45 years who were admitted in labor. Women were classified into 1 of 6 racial groups: White, Filipino, Japanese, Chinese, Native Hawaiian, or Micronesian. The primary outcome, perineal body length, was compared using analysis of variance. RESULTS: A total of 200 women were recruited. There were no significant differences in perineal body length (P = 0.42) and severe perineal lacerations (P = 0.82) between the different racial groups. The mean (SD) perineal body length of women who had a severe laceration was 3.9 (0.5) versus 3.9 (0.6) cm in women who did not have a severe laceration (P= 0.98). CONCLUSION: Perineal body length does not seem to differ among the different racial groups studied and therefore an unlikely cause of racial variation in rates of severe perineal lacerations.

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OBJECTIVE: This study aimed to determine whether the Pelvic Organ Prolapse Quantification (POPQ) system should be simplified based on its use in the peer-reviewed literature. METHODS: The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and International Urogynecology Journal were used for this study. All articles relating to pelvic organ prolapse published in these journals from January 2005 to December 2010 were reviewed for their use of the POPQ system. The POPQ points described in the Materials and/or Results sections of these articles were recorded. RESULTS: Two hundred eighty-three articles using the POPQ system were identified. One hundred thirty-two (47%) articles used the POPQ system but only to determine the stage of prolapse. Specific points were not mentioned. One hundred two (36%) articles evaluated specific POPQ points (Aa, Ba, Ap, Bp, C, D). Forty-nine (17%) articles evaluated points Gh, Pb, and Tvl. CONCLUSIONS: The POPQ system, based on its use in the peer-reviewed literature, may need revisions. An abbreviated version of the system may be considered, allowing for more widespread use.

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OBJECTIVE: This study aimed to establish descriptive data on the content, accuracy, and relevance of Internet-based information regarding pelvic organ prolapse and urinary incontinence. METHODS: Using the search terms, urinary incontinence, uterine prolapse, dropped uterus, cystocele, and dropped bladder, the first 20 Web sites that appeared in each of 3 highly used search engines were identified. Two experienced reviewers independently evaluated each site for specific content, relevance, and accuracy. RESULTS: A total of 220 individual sites were identified: government-, university-, and/or society-sponsored sites represented 14.1% of the identified sites. Private parties, community groups, or unknown sponsors represented 73.2% of the sites. Industry represented 12.7% of the sites. The year the site was created was displayed in 45.9% of the sites, although 66.4% of the sites contained a year of update. Overall, 45% of the sites were rated as mostly/completely relevant to the search term and 44% of the sites were rated as mostly/completely accurate. Government-, university-, and/or society-sponsored sites were significantly more likely to be rated mostly/completely relevant and mostly/completely accurate compared with all other site sponsors with P = 0.05 and P = 0.0003, respectively. CONCLUSIONS: Government, university, and/or medical societies sponsor a minority of Web sites compared with other sponsors but provide more comprehensive content that is more relevant and accurate to the topics of pelvic organ prolapse and urinary incontinence.

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OBJECTIVE: The purpose of this study was to calculate the number of cesarean deliveries needed to prevent 1 case of obstetric anal sphincter laceration associated with operative vaginal delivery in an at-risk cohort. STUDY DESIGN: An institutional, computerized database was used to analyze women with obstructed labor who could have been managed by either operative vaginal or cesarean delivery from September 2006 to March 2008. Women with 1 or more of the following diagnoses comprised the cohort: cephalopelvic disproportion (CPD), arrest of descent, maternal exhaustion, and fetal distress. RESULTS: Fifty (23.9%) out of a total of 209 women managed by operative vaginal delivery experienced an anal sphincter laceration compared to none of 254 women in the cesarean delivery group (P < .0001). The ARR therefore was 23.9% (95% confidence interval, 18.1-29.7) and the NNT was 4.2 (95% confidence interval, 3.4-5.5). CONCLUSION: Five cesarean deliveries are needed to prevent 1 anal sphincter laceration associated with operative vaginal delivery in this cohort.

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OBJECTIVE: Obstetric anal sphincter injury (ASI) is associated with significant morbidity We conducted an ASI workshop for 20 obstetrics and gynecology residents and assessed its impact. Our goal was to determine and enhance residents' knowledge using a multimedia presentation, hands-on simulator and tests. We comment on trends regarding residents' knowledge bases and their retention of the material. STUDY DESIGN: The workshop consisted of a pretest, lecture with slideshow, DVD, and 20 simulator stations. The porcine tongue simulator represented the human perineum, bungee cord the anal sphincter and a laceration created in each tongue an obstetrical ASI. Faculty members supervised the residents' suture repairs. We analyzed responses from identical immediate posttests and delayed posttests. RESULTS: Out of a possible 18 points, the average scores were: pretest 9.1 (SD 2.32), posttest 17 (SD 1.34; P < .001), and delayed posttest 15.1 (SD 1.52; P < .001). On a 10 cm visual analog scale (VAS) evaluating the helpfulness of this exercise, the average respondent marked 9.0 (SD 0.95). On a VAS evaluating the comfort level in repairing ASI, the average pre-simulator score was 3.9 (SD 3.13) and the average post-simulator score 5.2 (SD 2.96; P < .001). CONCLUSION: Relevant structured workshops with simulators for ASI repair could help improve residents' background knowledge and skills in repairing such injuries.

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OBJECTIVES: To show the value of placing bilateral sacral nerve stimulators in patients diagnosed with interstitial cystitis with the symptoms of frequency, urgency, and pain. METHODS: A retrospective chart review was performed of patients who had had bilateral S3 stimulators placed during a 6-month period. At consultation immediately before undergoing the procedure and on subsequent postoperative visits, these patients completed the Urinary Distress Inventory short form and voiding diaries. Patients were excluded if sacroneuromodulation had been attempted to be placed previously, if patients had any identifiable neurologic deficits, or if they had any evidence of urinary retention. RESULTS: The mean age of the 15 patients was 43.2 years, with a mean follow-up of 14.1 months. Student's t test was used to compare the preoperative and postoperative values. The mean decrease in frequency and nocturia was 10.4 voids (P <0.001) and 2.6 voids (P <0.001), respectively. The change in the Urinary Distress Inventory short form showed that patients had satisfaction postoperatively (P <0.001). Four patients also noted improvement in fecal incontinence after the procedure, with a mean decrease in episodes of 2.75 (P <0.01). CONCLUSIONS: The results of this study have demonstrated that patients with bilateral stimulator placement have a significant decrease in frequency and nocturia with postoperative satisfaction. Also, evidence of possible improvement in the daily episodes of fecal incontinence was demonstrated.

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OBJECTIVE: The purpose of this study was to evaluate the use of local capsaicin cream as an effective treatment for patients with documented vulvar vestibulitis syndrome. STUDY DESIGN: A retrospective chart review was performed for patients who received a diagnosis of vulvar vestibulitis syndrome that was treated with capsaicin. Patients performed local application of capsaicin 0.025% cream for 20 minutes daily for 12 weeks. A comparison was made between the pre- and posttreatment Kaufman touch test to evaluate discomfort. The Marinoff dyspareunia scale was also used to assess pre- and posttreatment. RESULTS: The sum of the Kaufman touch test scores before the treatment (13.2 +/- 4.9) compared with the scores after treatment (4.8 +/- 3.8) was statistically improved (P < .001). A significant improvement was also observed at each individual site (P < .001). The Marinoff dyspareunia scale also showed a significant improvement (P < .001). CONCLUSION: Vulvar vestibulitis syndrome that is treated with capsaicin significantly decreases discomfort and allows for more frequent sexual relations.

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The incidental finding of cancer in a hernial sac is rare, but there are many case reports in the literature. There has never been a report of carcinoma found in an enterocele sac. We present the case of a 77-year-old female with symptomatic pelvic organ prolapse who presented for reconstructive pelvic surgery and was found to have metastatic adenocarcinoma contained within an enterocele sac. Incidental diagnosis of asymptomatic carcinoma found on typically discarded tissue from surgical procedures is rare. However, routine pathologic review of all tissue removed from a patient may save a life if carcinoma is found early.

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Clitoral reduction, especially in an adult, is a rare procedure which often leaves the glans clitoris without the capacity for tactile sensation. We present the case of a 34-year-old woman with symptomatic clitoromegaly since puberty who underwent a clitoral reduction procedure designed to preserve the neurovascular supply of the glans clitoris. The surgical technique presented here removes the corpora cavernosa of the clitoris, but conserves important neurovascular attachments. While this procedure was done on an adult, it could just as easily be performed on children or adolescents with clitoromegaly, typically the at-risk group for this condition.

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OBJECTIVES: To evaluate the effectiveness of transvaginal manual therapy of the pelvic floor musculature (Thiele massage) in symptomatic female patients with interstitial cystitis and high-tone dysfunction of the pelvic floor. METHODS: A total of 21 women with documented interstitial cystitis and high-tone pelvic floor dysfunction underwent transvaginal massage using the Thiele technique twice a week for 5 weeks. Symptoms were evaluated before massage, at protocol conclusion, and at a mean of 4.5 months after therapy completion (long-term follow-up). The response to treatment was evaluated through the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indexes, Likert Visual Analogue Scales for urgency and pain, and Short-Form 12-item (SF-12) Quality-of-Life Scale, and through changes in the physical examination findings using a 5-point modified Oxford Scale to document pelvic floor tenderness. RESULTS: A statistically significant improvement was seen in the Symptom and Problem Indexes of the O'Leary-Sant Questionnaire (P = 0.015 and P = 0.039, respectively), Likert Visual Analogue Scales for urgency and pain (P = 0.001 and P = 0.005, respectively), the Physical and Mental Component Summary from the SF-12 Quality-of-Life Scale (P = 0.049 and P = 0.044, respectively), and the modified Oxford Scale (P <0.05) after protocol completion. At long-term follow-up, the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indexes (P = 0.049 and P = 0.02, respectively), Likert Visual Analogue Scales for urgency and pain (P = 0.004 and P = 0.005, respectively), and modified Oxford Scale for three of four muscles in the pelvic floor (P <0.05) remained significantly improved. CONCLUSIONS: Thiele massage appears to be very helpful in improving irritative bladder symptoms in patients with interstitial cystitis and high-tone pelvic floor dysfunction in addition to decreasing pelvic floor muscle tone.

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OBJECTIVE: This study was undertaken to determine whether administration of local anesthetic reduces pain associated with colposcopically directed cervical biopsies. STUDY DESIGN: Fifty-six patients undergoing colposcopically directed cervical biopsies were randomly selected prospectively to receive a 1% lidocaine injection or no injection before the biopsy procedure. Pain was assessed by using a 10-cm visual analog scale at various points during the procedure. Data were analyzed with the Student t test. RESULTS: Injection of lidocaine resulted in a reduction in pain scores for cervical biopsies (4.004 to 1.166, P: <.001), endocervical curettage (5.757 to 3.900, P =.0018), and overall procedure scores (4.911 to 3.145, P =.0013). CONCLUSION: This pilot study demonstrates that injection of local anesthetic at the site of colposcopically direct cervical biopsies decreases the pain perceived by patients.

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