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OBJECTIVE: The aim of this study was to compare the symptomatic change in urinary symptom distress before and after treatment with pelvic floor biofeedback and electrical stimulation in women with mixed urinary incontinence (MUI) and stress urinary incontinence (SUI). METHODS: We conducted a retrospective cohort study of women who underwent supervised pelvic floor biofeedback therapy and electrostimulation for the treatment of MUI and SUI. Our primary outcome was change in the Urinary Distress Inventory-6 (UDI-6) score before and after therapy. RESULTS: Overall, a significant drop in UDI-6 score was seen in women with MUI (mean decrease, 29.1 [27.5]; P < 0.001), and a nonsignificant drop was seen in women with SUI (mean decrease, 6.8 [20.3]; P = 0.07) after treatment. Significantly greater change in UDI-6 score from baseline to follow-up was noted in women with MUI compared with those with SUI (P = 0.002). CONCLUSIONS: Women with MUI have greater urinary distress symptoms than women with SUI. Both women with MUI and SUI experienced significant improvement in their urinary distress symptoms after pelvic floor biofeedback and electrostimulation.

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OBJECTIVE: The objective of this descriptive study was to quantify the personal hygiene habits/practices of, as well as the over-the-counter (OTC) products used by, postmenopausal women. Specifically, we were interested in any product that would contact the vulva or vagina. METHODS: We performed a cross-sectional study of postmenopausal women seeking routine gynecologic care. We developed a questionnaire on their personal hygiene habits/practices and the OTC products that they use that would contact the vulva or vagina. We recruited postmenopausal women seeking gynecologic care from two separate gynecology practices. Descriptive statistics were performed as appropriate to characterize the frequency of reported treatments and practices. RESULTS: The questionnaire on OTC treatments and perineal hygiene was completed by 114 postmenopausal women. Fifty-eight women (50.9%) reported using at least one OTC vulvovaginal treatment in the last 3 months, including barrier treatments, topical anesthetics, powders, and antifungals. Women often used more than one OTC product. Thirty-seven women (32.5%) reported the use of two or more OTC products. Powders were used by 34 women (29.8%). Talcum powder was the most commonly used powder (26 of 34; 76.5%). Nine postmenopausal women (7.9%) reported douching in the last 3 months. CONCLUSIONS: We found that more than half of postmenopausal women seeking gynecologic care have used an OTC product for vulvovaginal symptoms in the last 3 months and that one third of women use two or more products. Because the use of OTC products is very common, our study highlights the need for a detailed history inquiry about OTC product use and perineal hygiene practices.

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Objective Acquired clitoromegaly is rare and may result from hormonal and nonhormonal causes, and evaluation of the pregnant patient with clitoromegaly invokes a specific set of differential diagnoses. Methods Case report. Results We describe the case of a young woman with pregnancy-associated clitoral enlargement whose hormonal evaluation proved negative. Further investigation concluded that an epidermoid cyst was the culprit of her pseudoclitoromegaly. The patient underwent successful surgical resection and has had no recurrence at her subsequent pregnancy. Conclusion We review the differential diagnosis of clitoromegaly, including hormonal and nonhormonal causes, with focus on the evaluation of pregnancy-associated clitoromegaly.

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OBJECTIVE: The purpose of this study was to describe patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse symptoms and to describe predictors of preference for uterine preservation. STUDY DESIGN: This multicenter, cross-sectional study evaluated patient preferences for uterine preservation vs hysterectomy in women with prolapse symptoms who were being examined for initial urogynecologic evaluation. Before meeting the physician, the women completed a questionnaire that asked them to indicate their prolapse treatment preference (uterine preservation vs hysterectomy) for scenarios in which the efficacy of treatment varied. Patient characteristics that were associated with preferences were determined, and predictors for uterine preservation preference were identified with multivariable logistic regression. RESULTS: Two hundred thirteen women participated. Assuming outcomes were equal between hysterectomy and uterine preservation, 36% of the women preferred uterine preservation; 20% of the women preferred hysterectomy, and 44% of the women had no strong preference. If uterine preservation was superior, 46% of the women preferred uterine preservation, and 11% of the women preferred hysterectomy. If hysterectomy was superior, 21% of the women still preferred uterine preservation, despite inferior efficacy. On multivariable logistic regression, women in the South had decreased odds of preferring uterine preservation compared with women in the Northeast (odds ratio [OR], 0.17; 95% CI, 0.05-0.66). Women with at least some college education (OR, 2.87; 95% CI, 1.08-7.62) and those who believed that the uterus is important for their sense of self (OR, 28.2; 95% CI, 5.00-158.7) had increased odds for preferring uterine preservation. CONCLUSION: A higher proportion of women with prolapse symptoms who were examined for urogynecologic evaluation preferred uterine preservation, compared with hysterectomy. Geographic region, education level, and belief that the uterus is important for a sense of self were predictors of preference for uterine preservation.

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OBJECTIVE: The objective of the study was to describe the basic knowledge about prolapse and attitudes regarding the uterus in women seeking care for prolapse symptoms. STUDY DESIGN: This was a cross-sectional study of English-speaking women presenting with prolapse symptoms. Patients completed a self-administered questionnaire that included 5 prolapse-related knowledge items and 6 benefit-of-uterus attitude items; higher scores indicated greater knowledge or more positive perception of the uterus. The data were analyzed using descriptive statistics and multiple linear regression. RESULTS: A total of 213 women were included. The overall mean knowledge score was 2.2 ± 1.1 (range, 0-5); 44% of the items were answered correctly. Participants correctly responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises (34.3%) were prolapse treatment options. Prior evaluation by a female pelvic medicine and reconstructive surgery specialist (beta = 0.57, P = .001) and higher education (beta = 0.3, P = .07) was associated with a higher mean knowledge score. For attitude items, the overall mean score was 15.1 (4.7; range, 6-30). A total of 47.4% disagreed with the statement that the uterus is important for sex. The majority disagreed with the statement that the uterus is important for a sense of self (60.1%); that hysterectomy would make me feel less feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%). Previous consultation with a female pelvic medicine and reconstructive surgery specialist was associated with a higher mean benefit of uterus score (beta = 1.82, P = .01). CONCLUSION: Prolapse-related knowledge is low in women seeking care for prolapse symptoms. The majority do not believe the uterus is important for body image or sexuality and do not believe that hysterectomy will negatively affect their sex lives.

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OBJECTIVE: This study aims to develop a Vulvovaginal Symptoms Questionnaire (VSQ) to determine the symptoms, emotions, life impact, and sexual impact of vulvovaginal symptoms on postmenopausal women. METHODS: We developed a questionnaire that focuses on vulvovaginal symptoms based on modifications to Skindex-16, a validated questionnaire for measuring the impact of skin disease. We recruited postmenopausal women seeking routine gynecologic care to test the psychometric properties of the VSQ. Test-retest reliability was assessed 2 to 4 weeks after their initial recruitment and measured using intraclass coefficients. Four distinct a priori scales of the VSQ were developed: symptoms, emotions, life impact, and sexual impact. Confirmatory factor analysis was performed to verify the four a priori scales by evaluating the goodness of fit of a final confirmatory factor analysis model. The internal consistency of the scales was assessed by calculating Cronbach's α coefficients. RESULTS: The VSQ is a 21-item written questionnaire with four scales: symptoms, emotions, life impact, and sexual impact. One hundred twenty postmenopausal women participated in the psychometric validation of the VSQ. The test-retest reliability measured by intraclass coefficients was 0.75, 0.60, 0.55, and 0.65 for the symptoms, emotions, life impact, and sexual impact scales, respectively. The goodness of fit of the confirmatory factor response model was confirmed. The Cronbach's α coefficients were 0.76, 0.87, 0.83, and 0.82 for the respective scales. CONCLUSIONS: The VSQ is a reliable and internally consistent instrument for measuring vulvovaginal symptoms in postmenopausal women.

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OBJECTIVE: To describe the association between social isolation and urinary incontinence and fecal incontinence in older women. METHODS: We conducted a secondary database analysis of the National Social Life, Health and Aging Project for women aged 57 to 85 years old. Our primary outcome was self-report of often feeling isolated. We explored self-report of daily urinary incontinence and weekly fecal incontinence. Two logistic regression analyses were performed to assess the association between often feeling isolated and (1) daily urinary incontinence and (2) weekly fecal incontinence. RESULTS: A total of 1412 women were included in our analysis. Daily urinary incontinence was reported by 12.5% (177/1412) of community-dwelling older women. More women with daily urinary incontinence reported often feeling isolated (6.6%; 95% confidence interval [CI], 1.3-11.9 vs 2.6%; 95% CI, 1.7-3.5; P = .04) compared with women without daily urinary incontinence. Women with daily urinary incontinence had 3.0 (95% CI, 1.1-7.6) increased odds of often feeling isolated after adjusting for depressive symptoms, age, race, education, and overall health. Weekly fecal incontinence was reported by 2.9% (41/1412) of women. Weekly fecal incontinence and often feeling isolated were associated on univariable analysis (crude odds ratio, 4.6; 95% CI, 1.4-15.1). However, after adjusting for depressive symptoms, age, race, education, and overall health the association between weekly fecal incontinence and often feeling isolated was not significant (adjusted odds ratio, 0.65; 95% CI, 0.1-5.3; P = .65). CONCLUSION: After adjusting for confounders, daily urinary incontinence was significantly associated with often feeling isolated. Weekly fecal incontinence was not found to be associated with often feeling isolated on multivariable logistic regression.

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OBJECTIVE: The objective of this study was to create a clinical prediction tool to differentiate women at risk for postoperative complications after benign gynecologic surgery. METHODS: We utilized the 2005 to 2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to perform a secondary data-set analysis of women older than 16 years who underwent benign gynecologic procedures. We then temporally divided women into 2 similar cohorts. Our derivation cohort included all women undergoing benign gynecologic procedures in 2005 to 2008. Our validation cohort included all women undergoing benign gynecologic procedures in 2009. The primary outcome, composite 30-day major postoperative complications, was analyzed as a dichotomous variable. A prediction tool was then constructed to predict the occurrence of postoperative complications built from the logistic regression model by rounding the value of each estimated ß coefficient to the nearest integer. An individual's risk score was then computed by summing the number of points based on her preoperative characteristics. This risk score was then used to categorize women into low-, medium-, and high-risk groups. RESULTS: A prediction tool for benign gynecologic procedures identified women at low (2.7% and 2.4%), medium (6.3% and 6.8%), and high (29.5% and 23.8%) risk of complications in the derivation and validation cohorts, respectively. CONCLUSIONS: A prediction tool can differentiate women at risk for postoperative complications after benign gynecologic surgery.

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OBJECTIVE: To estimate the association of age, medical comorbidities, functional status, and unintentional weight loss (as a marker of frailty) with postoperative complications in women undergoing major gynecologic surgery. METHODS: We conducted a cross-sectional analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 participant use data files to analyze gynecologic procedures. The primary outcome was a composite of 30-day major postoperative complications. RESULTS: A total of 22,214 women were included in our final analysis. The overall prevalence of composite 30-day major postoperative complications was 3.7% (n=817). Age 80 years or older (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.25-2.58), dependent functional status (adjusted OR 2.37, 95% CI 1.53-3.68), and unintentional weight loss (adjusted OR 2.49, 95% CI 1.48-4.17) were significantly associated with postoperative morbidity after adjusting for diabetes mellitus (adjusted OR 1.44, 95% CI 1.15-1.79), known bleeding disorder (adjusted OR 2.29, 95% CI 1.49-3.52), morbid obesity (adjusted OR 1.77, 95% CI 1.45-2.17), ascites (adjusted OR 3.27, 95% CI 2.18-4.90), preoperative systemic infection (adjusted OR 3.02, 95% CI 2.03-4.48), procedures for gynecologic cancer (adjusted OR 1.60, 95% CI 1.27-2.0), disseminated cancer (adjusted OR 2.57, 95% CI 1.64-4.03), emergency procedures (adjusted OR 1.82, 95% CI 1.18-2.79), operative time more than 4 hours compared with less than 1 hour (adjusted OR 2.91, 95% CI 2.18-3.89), and wound class 4 compared with wound class 1 (adjusted OR 4.28, 95% CI 1.82-10.1). CONCLUSION: Age 80 years or older, medical comorbidities, dependent functional status, and unintentional weight loss are associated with increased major postoperative complications after gynecologic procedures. LEVEL OF EVIDENCE: III.

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INTRODUCTION AND HYPOTHESIS: Our study aimed to identify the rate of suture complications over a 5-year period using braided permanent suture for uterosacral ligament suspension (USLS) surgery. METHODS: We reviewed the medical records of patients who underwent vaginal uterosacral ligament suspensions using braided polyester suture. Outcome measures included rate and timing of suture complications, patient symptoms post-operatively, efficacy of treatment modalities and surgical success. RESULTS: Eighty-three patients had undergone USLS with braided, polyester suture over the study period that met inclusion criteria. Thirty-seven patients (44.6%) had suture-related complications post-operatively with a mean follow-up of 10.4 months. When only silver nitrate was applied, 16.7% improved, and when the suture was cut in clinic, 77.8% resolved. CONCLUSIONS: Permanent polyester braided suture for suspension of vaginal vault may lead to an unacceptably high suture erosion rate, cutting the suture in clinic results in the highest resolution.

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PURPOSE OF REVIEW: This review discusses published data of the recent advances in understanding lower urinary tract dysfunctions in women with diabetes mellitus. RECENT FINDINGS: Many studies have shown a relationship between diabetes mellitus and lower urinary tract dysfunctions. Although the pathophysiology of these disorders is multifactorial, microvascular damage and neuropathy causing dysfunctions of smooth muscle, urothelium, and neuronal components in the lower urinary tract are the most likely etiologies. SUMMARY: Lower urinary tract dysfunctions are common in diabetes mellitus. Screening and effective management of these disorders should be promoted in an effort to decrease morbidity and improve quality of life.

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In an effort to understand the olfactory code of rats, we collected more than 1,500,000 measurements of glomerular activity in response to 54 odorants selected to provide differences in functional groups and hydrocarbon structure. Each odorant evoked a unique response pattern by differentially stimulating clusters of glomeruli, called modules. Odorants sharing specific aspects of their structure activated the same modules, allowing us to relate responses to structure across approximately 80% of the glomerular layer. The most obvious relationship was between the presence of particular oxygen-containing functional groups and the activity of glomeruli within dorsal modules. Functional group-specific responses were observed for odorants possessing a wide range of hydrocarbon structure, including aliphatic, cyclic, and aromatic features. Even formic acid and acetone, the simplest odorants possessing acid or ketone functional groups, respectively, stimulated modules specific for these functional groups. At the same time, quantitative analysis of pattern similarities revealed relationships in activation patterns between odorants of similar hydrocarbon structure. The odorant responses were reliable enough to allow us to predict accurately specific aspects of odorant molecular structure from the evoked glomerular activity pattern, as well as predicting the location of glomerular activity evoked by novel odorants.

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