- Email: [email protected]
Risk factors for surgically managed pelvic organ prolapse and urinary incontinence
BRIEF COMMUNICATIONS The heparin infusion was stopped during labor. Treatment with 15,000 IU of tinzaparin twice daily was initiated after delivery and changed to warfarin treatment after a week. The filter was removed uneventfully on the 14th day under local anesthesia through a right subclavian puncture. Venous thrombo-embolism remains the most common cause of direct maternal deaths [1]. Adequate management in pregnancy requires prompt and accurate diagnosis as well as a standardized anticoagulant regimen. In instances where the thrombus is unstable, surgical management with an IVC filter is effective. An IVC filter was used temporarily to facilitate induction of labor and allow for vaginal delivery, a safer option for this patient with extensive and mobile bilateral deep-vein thrombosis involving both common femoral veins. There was a previous report on the use of an IVC filter in a twin pregnancy of 26 weeks. The patient entered spontaneous labor at 36th weeks and underwent forceps delivery [3]. When the clot involves the common iliac veins or lower IVC, the risk of pulmonary embolism is high [2] and surgical interruption of the IVC prevents a large and often fatal thrombo-embolism [3].
63 The transvenous placement of filters provides a simple method of interrupting the IVC, and in combination with standard anticoagulation therapy, is an effective management in high-risk patients. The multidisciplinary approach was the key to successful outcome in this patient.
References [1] Confidential Enquiries Into Maternal and Child Health. Why Mothers Die 2000–2002: Executive Summary and Key Findings of the Sixth Report on the Confidential Enquiries Into Maternal and Child Deaths in the United Kingdom; 2004. Available at: http:// www.cemach.org.uk/publications/WMD2000_2002_ExecSumm. pdf. [2] Nicolaides AN, editor. Thromboembolism: Aetiology, Advances in Prevention and Management. Baltimore, Md, USA: University Park Press; 1975. p. 274. [3] Scurr J, Stannard P, Wright J. Extensive thrombo-embolic disease in pregnancy treated with a Kimray Greenfield vena cava filter. BJOG 1981;88(7):778–80.
Risk factors for surgically managed pelvic organ prolapse and urinary incontinence C. Ghetti a,⁎, W.T. Gregory b , A.L. Clark b a b
University of Pittsburgh, Pittsburgh, PA, USA Oregon Health and Science University, Portland, OR, USA
Received 17 October 2006; received in revised form 8 March 2007; accepted 8 March 2007
KEYWORDS Pelvic organ prolapse; Risk factors; Surgery; Urinary incontinence
Pelvic floor disorders are common in women, and they disrupt their quality of life. The present study continues a previous study on surgically managed pelvic organ prolapse and urinary incontinence (POPUI) in a large managed-care population in the United States [1]. In that study, the lifetime ⁎ Corresponding author. University of Pittsburgh, Magee Womens Hospital, Pittsburgh, PA, USA. Tel.: +1 412 641 1440; fax: +1 412 641 1133. E-mail address: [email protected] (C. Ghetti). doi:10.1016/j.ijgo.2007.03.039
risk for women to undergo surgery for prolapse or incontinence was estimated at 11%. Using a case–control design and a sampling from the same population, the present study investigates risk factors for POPUI. The study sample was recruited in 1995 among female members of Kaiser Permanente Northwest, a large health care organization. The cases were women who underwent primary surgical treatment for POPUI as described by Olsen and colleagues [1]. Age-matched controls were randomly selected among adult women who had a detailed history taking and physical examination in 1995 with no record of POPUI surgery. Sample size required to provide 90% power to detect a 2-fold difference in parity between groups was 245 participants in each group. Data were abstracted from the complete inpatient and outpatient medical records. The variables examined included patient age, self-reported race, height, weight, parity, route of delivery, estrogen status, smoking history, and aspects of the patient's medical and
64 Table 1
BRIEF COMMUNICATIONS Multivariate logistic regression (age-matched)
Mean Parity Nulliparous CSs only Vaginal deliveries Age b 50 years Age ≥ 50 years Smoking Currently Ever Never Lung disease BMI
OR (95% CI)
P value
Reference (1.0) 1.5 (0.4–5.6) 4.1 (1.7–9.4) 8 (2.3–29.1) 1.9 (0.6–6.3)
0.56 0.001 0.001 0.3
Reference (1.0) 0.9 (0.5–1.6) 1.5 (0.9–2.6) 2.4 (1.4–4.2) 1 (0.96–1.01)
0.75 0.15 0.002 0.23
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); CI, confidence interval; CS, cesarean section; OR, odds ratio.
surgical history. Univariate and multivariate logistic regression analyses were performed. Cases (n = 245) and controls (n = 287) were similar in smoking status, postmenopausal status, prior surgical history, and estrogen use. Variables associated with POPUI surgery in the multivariate analysis were parity (OR, 4.1 [95% CI, 1.7–9.4]; P= 0.001) and chronic lung disease (OR, 2.4 [95% CI, 1.4–4.2]; P= 0.002). The first vaginal birth conferred a risk of 2.6 (95% CI, 1.0–7.0). Each subsequent vaginal birth increased the risk of surgery. Women younger than 50 years had a higher risk
associated with vaginal parity (OR, 8.0 [95% CI, 2.3–29.1]; P= 0.001) than women aged 50 years or older. In the latter, the risk was not statistically significant (OR 1.9 [95% CI, 0.6–6.3]; P= 0.3) (Table 1). This age-matched, case–control study demonstrates that women who underwent surgery for POPUI were nearly 4 times more likely to have been delivered vaginally, and twice as likely to have chronic lung disease. Parity is a greater risk factor for women younger than 50 years than for older women. The present study encompasses the adult lifespan and links prior studies of disparate age groups. These findings are in agreement with previous reports that parturition injury is a stronger risk factor for women during midlife [2], and that age-associated changes in pelvic floor function become stronger as women age [3,4].
References [1] Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89(4):501–6. [2] Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997;104(5):579–85. [3] Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186(6):1160–6. [4] MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000;107(12):1460–70.
Perineometer and digital examination for assessment of pelvic floor strength Y. Uyar ⁎, Y.B. Baytur, U. Inceboz Department of Obstetrics and Gynecology, Celal Bayar University School of Medicine, Manisa, Turkey Received 4 December 2006; received in revised form 10 March 2007; accepted 13 March 2007
KEYWORDS Digital examination; Perineometer; Pelvic floor strength
⁎ Corresponding author. 166 Clock House Road, Beckenham /Kent, BR3 4LA London, UK. Tel.: +44 2086584026 (home), +44 7837933983 (mobile). E-mail address: [email protected] (Y. Uyar). doi:10.1016/j.ijgo.2007.03.015
Pelvic floor muscle dysfunction may cause severe problems in women such as fecal and urinary incontinence and anorgasm, which decrease quality of life [1]. Vaginal palpation is commonly used to evaluate pelvic floor strength and to teach patients correct pelvic floor muscle contraction [2]. Vaginal palpation provides subjective data in evaluating pelvic floor muscle strength; however, instruments such as a perineometer may yield objective data [3]. In this study, results from palpation test were compared with measurements of vaginal squeezing pressure using a perineometer and the role of digital examination in the assessment of pelvic floor muscle strength and correlation of simple techniques were investigated.
63 The transvenous placement of filters provides a simple method of interrupting the IVC, and in combination with standard anticoagulation therapy, is an effective management in high-risk patients. The multidisciplinary approach was the key to successful outcome in this patient.
References [1] Confidential Enquiries Into Maternal and Child Health. Why Mothers Die 2000–2002: Executive Summary and Key Findings of the Sixth Report on the Confidential Enquiries Into Maternal and Child Deaths in the United Kingdom; 2004. Available at: http:// www.cemach.org.uk/publications/WMD2000_2002_ExecSumm. pdf. [2] Nicolaides AN, editor. Thromboembolism: Aetiology, Advances in Prevention and Management. Baltimore, Md, USA: University Park Press; 1975. p. 274. [3] Scurr J, Stannard P, Wright J. Extensive thrombo-embolic disease in pregnancy treated with a Kimray Greenfield vena cava filter. BJOG 1981;88(7):778–80.
Risk factors for surgically managed pelvic organ prolapse and urinary incontinence C. Ghetti a,⁎, W.T. Gregory b , A.L. Clark b a b
University of Pittsburgh, Pittsburgh, PA, USA Oregon Health and Science University, Portland, OR, USA
Received 17 October 2006; received in revised form 8 March 2007; accepted 8 March 2007
KEYWORDS Pelvic organ prolapse; Risk factors; Surgery; Urinary incontinence
Pelvic floor disorders are common in women, and they disrupt their quality of life. The present study continues a previous study on surgically managed pelvic organ prolapse and urinary incontinence (POPUI) in a large managed-care population in the United States [1]. In that study, the lifetime ⁎ Corresponding author. University of Pittsburgh, Magee Womens Hospital, Pittsburgh, PA, USA. Tel.: +1 412 641 1440; fax: +1 412 641 1133. E-mail address: [email protected] (C. Ghetti). doi:10.1016/j.ijgo.2007.03.039
risk for women to undergo surgery for prolapse or incontinence was estimated at 11%. Using a case–control design and a sampling from the same population, the present study investigates risk factors for POPUI. The study sample was recruited in 1995 among female members of Kaiser Permanente Northwest, a large health care organization. The cases were women who underwent primary surgical treatment for POPUI as described by Olsen and colleagues [1]. Age-matched controls were randomly selected among adult women who had a detailed history taking and physical examination in 1995 with no record of POPUI surgery. Sample size required to provide 90% power to detect a 2-fold difference in parity between groups was 245 participants in each group. Data were abstracted from the complete inpatient and outpatient medical records. The variables examined included patient age, self-reported race, height, weight, parity, route of delivery, estrogen status, smoking history, and aspects of the patient's medical and
64 Table 1
BRIEF COMMUNICATIONS Multivariate logistic regression (age-matched)
Mean Parity Nulliparous CSs only Vaginal deliveries Age b 50 years Age ≥ 50 years Smoking Currently Ever Never Lung disease BMI
OR (95% CI)
P value
Reference (1.0) 1.5 (0.4–5.6) 4.1 (1.7–9.4) 8 (2.3–29.1) 1.9 (0.6–6.3)
0.56 0.001 0.001 0.3
Reference (1.0) 0.9 (0.5–1.6) 1.5 (0.9–2.6) 2.4 (1.4–4.2) 1 (0.96–1.01)
0.75 0.15 0.002 0.23
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); CI, confidence interval; CS, cesarean section; OR, odds ratio.
surgical history. Univariate and multivariate logistic regression analyses were performed. Cases (n = 245) and controls (n = 287) were similar in smoking status, postmenopausal status, prior surgical history, and estrogen use. Variables associated with POPUI surgery in the multivariate analysis were parity (OR, 4.1 [95% CI, 1.7–9.4]; P= 0.001) and chronic lung disease (OR, 2.4 [95% CI, 1.4–4.2]; P= 0.002). The first vaginal birth conferred a risk of 2.6 (95% CI, 1.0–7.0). Each subsequent vaginal birth increased the risk of surgery. Women younger than 50 years had a higher risk
associated with vaginal parity (OR, 8.0 [95% CI, 2.3–29.1]; P= 0.001) than women aged 50 years or older. In the latter, the risk was not statistically significant (OR 1.9 [95% CI, 0.6–6.3]; P= 0.3) (Table 1). This age-matched, case–control study demonstrates that women who underwent surgery for POPUI were nearly 4 times more likely to have been delivered vaginally, and twice as likely to have chronic lung disease. Parity is a greater risk factor for women younger than 50 years than for older women. The present study encompasses the adult lifespan and links prior studies of disparate age groups. These findings are in agreement with previous reports that parturition injury is a stronger risk factor for women during midlife [2], and that age-associated changes in pelvic floor function become stronger as women age [3,4].
References [1] Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89(4):501–6. [2] Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997;104(5):579–85. [3] Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186(6):1160–6. [4] MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000;107(12):1460–70.
Perineometer and digital examination for assessment of pelvic floor strength Y. Uyar ⁎, Y.B. Baytur, U. Inceboz Department of Obstetrics and Gynecology, Celal Bayar University School of Medicine, Manisa, Turkey Received 4 December 2006; received in revised form 10 March 2007; accepted 13 March 2007
KEYWORDS Digital examination; Perineometer; Pelvic floor strength
⁎ Corresponding author. 166 Clock House Road, Beckenham /Kent, BR3 4LA London, UK. Tel.: +44 2086584026 (home), +44 7837933983 (mobile). E-mail address: [email protected] (Y. Uyar). doi:10.1016/j.ijgo.2007.03.015
Pelvic floor muscle dysfunction may cause severe problems in women such as fecal and urinary incontinence and anorgasm, which decrease quality of life [1]. Vaginal palpation is commonly used to evaluate pelvic floor strength and to teach patients correct pelvic floor muscle contraction [2]. Vaginal palpation provides subjective data in evaluating pelvic floor muscle strength; however, instruments such as a perineometer may yield objective data [3]. In this study, results from palpation test were compared with measurements of vaginal squeezing pressure using a perineometer and the role of digital examination in the assessment of pelvic floor muscle strength and correlation of simple techniques were investigated.