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Chronic pelvic pain (CPP) is a medically complex, multifaceted gynecological condition associated with psychological comorbidities and sexual trauma among women. Low rates of positive treatment outcomes underscore the need to better understand complex relationships between CPP, trauma exposure, and the psychosocial context of patients' lives. We conducted a secondary analysis of English and Spanish qualitative interviews with female-identity patients (N = 48) about CPP's impact on psychosocial well-being. Interviews were coded and analyzed in accordance with reflexive thematic analysis. We generated 4 themes regarding CPP and psychosocial well-being: navigating pain-filled relationships, multiple burdens of mental health challenges and marginalization, sexual trauma exposure embedded in illness experience, and harnessing hope in healing and dealing with CPP. We used insights from these findings to generate a list of treatment recommendations for trauma-informed, CPP-specific integrated care. Patients described the importance of social support and how psychological comorbidities and trauma exposure contributed to CPP's psychosocial toll. Findings provide insight into the burden of CPP-related minority stress and the role of hope on patients' well-being. Patients with CPP endorse the integration of psychosocial support into their CPP treatment plans. The authors encourage the incorporation of behavioral health providers into integrated care teams to deliver trauma-informed, culturally responsive methods for engaging patients with CPP in psychosocial interventions addressing multiple domains of well-being., Competing Interests: Declarations. Conflict of Interest: The fifth author (K.V.M.) receives book editing royalties from Elsevier publishing, is an Editorial Board member of the journals Obstetrics & Gynecology as well as Urogynecology, is an Executive Board member for the Society of Gynecologic Surgeons, an unpaid investigator for Caldera medical, and serves as a consultant for RBI Medical. The other authors have no relevant funding or conflicts of interest to disclose., (© 2024. National Council for Mental Wellbeing.)

Introduction and Hypothesis: This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018., Methods: The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes., Results: We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12., Conclusion: Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery., (© 2021. The International Urogynecological Association.)

Introduction and Hypothesis: The COVID-19 pandemic and the desire to "flatten the curve" of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic., Methods: We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19., Results: Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission., Conclusions: We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

Introduction and Hypothesis: The objective of this study was to utilize objective citation analyses to describe the 100 most cited articles in the field of Female Pelvic Medicine & Reconstructive Surgery (FPMRS) and to review their characteristics., Methods: We searched the Thomas Reuters Web of Science database for the most cited articles within all journals classified as Obstetrics and Gynecology (Ob/Gyn), Urology (Uro), Colorectal Surgery (CRS), and vital General Medicine (GM) journals (New England Journal of Medicine; Journal of the American Medical Association; Lancet; The BMJ). We reviewed search results for FPMRS content and compiled a list of the top 100 most cited articles relevant to FPMRS., Results: We screened 34,934 articles yielded by the initial search and compiled the 100 most cited articles relevant to FPMRS. Of these 100 titles, 40% (42 out of 105) were published in Ob/Gyn, 46.7% (49 out of 105) in Uro, 1.9% (2 out of 105) in CRS, and 11.4% (12 out of 105) in GM journals. The most cited FPMRS article was "The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society" (3,810 total and 242 citations per year). Over half the articles were observational in nature and the majority (58%) of them were related to urinary incontinence in women., Conclusions: Highly cited FPMRS articles come from a variety of journals, and nearly 50% of the 100 most cited FPMRS articles are from the urology literature. The most cited articles were largely observational rather than interventional studies and mostly related to female urinary incontinence.

Introduction and Hypothesis: We aimed to systematically review the literature on pelvic organ prolapse (POP) surgery with uterine preservation (hysteropexy). We hypothesized that different hysteropexy surgeries would have similar POP outcomes but varying adverse event (AE) rates., Methods: MEDLINE, Cochrane, and clinicaltrials.gov databases were reviewed from inception to January 2018 for comparative (any size) and single-arm studies (n ≥ 50) involving hysteropexy. Studies were extracted for participant characteristics, interventions, comparators, outcomes, and AEs and assessed for methodological quality., Results: We identified 99 eligible studies: 53 comparing hysteropexy to POP surgery with hysterectomy, 42 single-arm studies on hysteropexy, and four studies comparing stage ≥2 hysteropexy types. Data on POP outcomes were heterogeneous and usually from <3 years of follow-up. Repeat surgery prevalence for POP after hysteropexy varied widely (0-29%) but was similar among hysteropexy types. When comparing sacrohysteropexy routes, the laparoscopic approach had lower recurrent prolapse symptoms [odds ratio (OR) 0.18, 95% confidence interval (CI) 0.07-0.46), urinary retention (OR 0.05, 95% CI 0.003-0.83), and blood loss (difference -104 ml, 95% CI -145 to -63 ml) than open sacrohysteropexy. Laparoscopic sacrohysteropexy had longer operative times than vaginal mesh hysteropexy (difference 119 min, 95% CI 102-136 min). Most commonly reported AEs included mesh exposure (0-39%), urinary retention (0-80%), and sexual dysfunction (0-48%)., Conclusions: Hysteropexies have a wide range of POP recurrence and AEs; little data exist directly comparing different hysteropexy types. Therefore, for women choosing uterine preservation, surgeons should counsel them on outcomes and risks particular to the specific hysteropexy type planned.

Introduction and Hypothesis: One in 2900 genotypical men report gender dysphoria, and many undergo gender confirmation surgery to match their physical phenotype to their identity. A variety of surgical techniques are used in male-to-female transgender patients, one of which is bowel vaginoplasty, and postoperative stenosis of the colonic neovagina is common. Extracellular matrix grafts have been used in vaginal reconstruction. with porcine urinary bladder matrix (UBM) acting as a scaffold for smooth-muscle tissue and matrix regeneration. The aim of this surgical video is to describe the use of a UBM biological graft in repair of introital stenosis due to recurrent granulation tissue in the colonic neovagina of a male-to-female transgender patient., Methods: A 32-year-old male-to-female transgender patient with a history of rectosigmoid neovagina formation for genital gender confirmation surgery 12 months prior presented with genital granulation tissue and stenosis of her neovaginal introitus. Despite two surgical revisions, the patient developed recurrence of granulation tissue and obliteration of the neovaginal introitus, preventing sexual function of the neovagina., Results: Reconstruction of the neovaginal introitus was performed using UBM. The patient noted improvement in comfort, hygiene, and quality of life following the procedure. This video describes our surgical technique and perioperative clinical findings., Conclusions: We report the novel use of UBM biological graft in the revision of a neovaginal introitus after former rectosigmoid vaginoplasty in a male-to-female transgender patient.

Introduction and Hypothesis: The goal of this study was to evaluate whether the addition of an iPad™ application to the informed consent process for pelvic organ prolapse (POP) surgery improves patient understanding and retention of information compared with standard verbal counseling (SVC) alone., Methods: Patients scheduled for POP surgery were randomized to SVC alone or SVC augmented with an iPad™ application. Prior to counseling, immediately following counseling, and 6 weeks after surgery, patients completed a written quiz testing their understanding of POP and surgical repair (worst score 0; best score 20). Primary outcome was score change from pre- to immediately postcounseling. Secondary outcomes were patient satisfaction and score change from postcounseling to 6 weeks after surgery. Twenty-six patients per group were needed to detect a 2.8-point difference in score change between groups (80% power; α = 0.05)., Results: Sixty patients were randomized, and 57 patients (29 SVC; 28 iPad) were included in the final analysis. There was no significant difference in score change between groups immediately postcounseling. Six weeks after surgery, patients in the iPad group had more deterioration of score (iPad -4.0 ± 2.8 vs. SVC -0.6 ± 2.3 points; p = 0.02). Both groups reported similar satisfaction with counseling., Conclusions: The addition of a POP-based iPad™ application to the informed consent process for POP surgery did not improve patient comprehension immediately postcounseling and resulted in poorer retention of information 6 weeks after surgery compared with SVC alone.

Introduction and Hypothesis: The objective of this study was to describe surgeons' current practices in InterStim® programming after initial implantation and their knowledge of programming parameters. We hypothesized that surgeons performing their own reprogramming would have increased knowledge., Methods: We administered a written survey to attendees at the Society of Gynecologic Surgeons Scientific Meeting and analyzed those on which surgeons indicated they offer InterStim® care. The survey queried surgeon characteristics, experience with InterStim® implantation and programming, and clinical opinions regarding reprogramming and tested six knowledge-based questions about programming parameters. Correct response to all six questions was the primary outcome., Results: One hundred and thirty-five of 407 (33%) attendees returned the survey, of which 99 met inclusion criteria. Most respondents (88 of 99; 89%) were between 36 and 60 years, 27 (73%) were women, 76 (77%) practiced in a university setting, and 76 (77%) were trained in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). Surgeons who had InterStim® programming training were more likely to perform their own programming [15/46 (32%) vs 6/47 (13%), p = 0.03]. Most answered all knowledge-based questions correctly (62/90, 69%); no surgeon characteristics were significantly associated with this outcome. Most surgeons cited patient comfort (71/80, 89%) and symptom relief (64/80, 80%) as important factors when reprogramming, but no prevalent themes emerged on how and why surgeons change certain programming parameters., Conclusions: Surgeons who had formal InterStim® programming training are more likely to perform programming themselves. No surgeon characteristic was associated with improved programming knowledge. We found that surgeons prioritize patient comfort and symptoms when deciding to reprogram.

Introduction and Hypothesis: A variety of factors affect the amount of bother experienced by different women with equivalent pelvic organ prolapse (POP). The goal of this study was to describe the relationship between age and bother experienced from objectively equivalent stages of POP., Methods: Records of all patients presenting to a pelvic floor subspecialty clinic between January 2014 and March 2015 were reviewed. Women with POP stage ≥ 2 were included. The level of bother experienced from prolapse symptoms was defined as the score on the validated Pelvic Organ Prolapse Distress Inventory (POPDI). Multiple linear regression was performed to examine the relationship between age and the POPDI score. A sample size of 150 patients was determined to have 80 % power to detect an effect of age equivalent to an increase in R2 of 0.05., Results: A total of 229 charts were reviewed and 165 patients were included in the final analysis. The effect of age on prolapse bother in the entire population was quadratic (p = 0.0497). Women at both ends of the spectrum were less bothered by prolapse, whereas women in the 6th and 7th decades of life demonstrated the highest level of bother, irrespective of stage. This same quadratic relationship remained in women with stage 2 prolapse (p = 0.019)., Conclusions: Women in the 6th and 7th decades of life experience higher levels of bother from POP than older or younger women with the same stage of prolapse. This suggests that women in these decades of life might be at a higher risk for impairment of quality of life from POP.

Introduction and Hypothesis: The perineum stretches naturally during obstetrical labor, but it is unknown whether this stretch has a negative impact on pelvic floor outcomes after a vaginal birth (VB). We aimed to evaluate whether perineal stretch was associated with postpartum pelvic floor dysfunction, and we hypothesized that greater perineal stretch would correlate with worsened outcomes., Methods: This was a prospective cohort study of primiparous women who had a VB. Perineal body (PB) length was measured antepartum, during labor, and 6 months postpartum. We determined the maximum PB (PBmax) measurements during the second stage of labor and PB change (ΔPB) between time points. Women completed functional questionnaires and had a Pelvic Organ Prolapse Quantification (POP-Q) system exam 6 months postpartum. We analyzed the relationship of PB measurements to perineal lacerations and postpartum outcomes, including urinary, anal, and fecal incontinence, sexual activity and function, and POP-Q measurements., Results: Four hundred and forty-eight women with VB and a mean age of 24 ± 5.0 years with rare (5 %) third- or fourth-degree lacerations were assessed. During the second stage of labor, 270/448 (60 %) had perineal measurements. Mean antepartum PB length was 3.7 ± 0.8 cm, with a maximum mean PB length (PBmax) during the second stage of 6.1 ± 1.5 cm, an increase of 65 %. The change in PB length (ΔPB) from antepartum to 6 months postpartum was a net decrease (-0.39 ± 1.02 cm). PB change and PBmax were not associated with perineal lacerations or outcomes postpartum (all p > 0.05)., Conclusions: PB stretch during labor is unrelated to perineal laceration, postpartum incontinence, sexual activity, or sexual function.

Introduction and Hypothesis: We aimed to determine whether anal sphincter complex (ASC) measurements on translabial ultrasound (TL-US) were related to anal incontinence (AI) or fecal incontinence (FI) symptoms 6 months postpartum., Methods: A prospective cohort of primiparous women underwent TL-US 6 months after a vaginal birth (VB) or cesarean delivery (CD). Muscle thickness was measured at 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS), the same four quadrants of the internal anal sphincter (IAS) at proximal, mid, and distal levels, and at the bilateral pubovisceralis muscle (PVM). Measurements were correlated to AI and FI on the Wexner Fecal Incontinence Scale, with sub-analyses by mode of delivery. The odds ratio (OR) of symptoms was calculated for every 1 mm increase in muscle thickness (E1MIT)., Results: A total of 423 women (299 VB, 124 CD) had TL-US 6 months postpartum. Decreased AI risk was associated with thicker measurements at the 6 o'clock (OR 0.74 E1MIT) and 9 o'clock proximal IAS (OR 0.71 E1MIT) in the entire cohort. For CD women, thicker measurements of the 9 o'clock proximal IAS were associated with decreased risk of AI (OR 0.56 E1MIT) and thicker distal 6 o'clock IAS measurements were related to a decreased risk of FI (OR 0.37 E1MIT). For VB women, no sphincter measurements were significantly related to symptoms, but thicker PVM measurements were associated with increased risk of AI (right side OR 1.32 E1MIT; left side OR 1.21 E1MIT)., Conclusions: ASC anatomy is associated with AI and FI in certain locations; these locations vary based on the patient's mode of delivery.

Introduction and Hypothesis: Women may experience anal sphincter anatomy changes after vaginal birth (VB) or Cesarean delivery (CD). Therefore, accurate and acceptable imaging options to evaluate the anal sphincter complex (ASC) are needed. ASC measurements may differ between translabial (TLUS) and endoanal (EAUS) ultrasound imaging and between 2D and 3D US. The objective of this analysis was to describe measurement variation between these modalities., Methods: Primiparous women underwent 2D and 3D TLUS imaging of the ASC 6 months after VB or CD. A subset of women also underwent EAUS measurements. Measurements included internal anal sphincter (IAS) thickness at proximal, mid, and distal levels and the external anal sphincter (EAS) at 3, 6, 9, and 12 o'clock positions, as well as bilateral thickness of the pubovisceralis muscle (PVM)., Results: There were 433 women presenting for US: 423 had TLUS and 64 had both TLUS and EAUS of the ASC. All IAS measurements were significantly thicker on TLUS than EAUS (all p < 0.01), while EAS measurements were significantly thicker on EAUS (p < 0.01). PVM measurements with 3D or 2D imaging were similar (p > 0.20). On both TLUS and EAUS, there were multiple sites where significant asymmetry existed in left versus right measurements., Conclusions: US modality used to image the ASC introduces small but significant changes in measurements, and the direction of the bias depends on the muscle and location being imaged.

Introduction and Hypothesis: Risk of pelvic floor disorders increases after menopause and may be linked to estrogen deficiency. We aimed to systematically and critically assess the literature on vaginal estrogen in the management of pelvic floor disorders in postmenopausal women and provide evidence-based clinical practice guidelines., Methods: MEDLINE and Cochrane databases were searched from inception to July 2014 for randomized controlled trials of commercially available vaginal estrogen products compared with placebo, no treatment, or any medication for overactive bladder or urinary incontinence. We double-screened 1,805 abstracts and identified 12 eligible papers. Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality and strength of evidence., Results: Evidence was generally of poor to moderate quality. Vaginal estrogen application before pelvic organ prolapse surgery improved the vaginal maturation index and increased vaginal epithelial thickness. Postoperative vaginal estrogen use after a midurethral sling resulted in decreased urinary frequency and urgency. Vaginal estrogen and immediate-release oxybutynin were similar in improvement of urinary urgency, frequency, and urgency urinary incontinence in women with overactive bladder, but oxybutynin had higher rates of side effects and discontinuation. Conversely, the addition of vaginal estrogen to immediate or extended-release tolterodine did not improve urinary symptoms more than tolterodine alone. One study reported an improvement in stress urinary incontinence with use of vaginal estrogen., Conclusion: Vaginal estrogen application may play a useful role as an adjunct in the management of common pelvic floor disorders in postmenopausal women.

Introduction and Hypothesis: Consensus on normal translabial ultrasound (TL-US) anal sphincter complex measurements for postpartum women is lacking. We aimed to evaluate normative measurements in 2D and 3D TL-US for the anal sphincter complex (ASC) at 6 months postpartum and compare these measurements in women who had a vaginal birth (VB) and in those who had a Cesarean delivery (CD)., Methods: A large, prospective cohort of primiparous women underwent 2D and 3D TL-US 6 months after their first delivery. For normative sphincter measurements, we excluded women with third- or fourth-degree lacerations or with sphincter interruption on TL-US. Measurements included the sphincter thickness at the 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS) and the internal anal sphincter (IAS) at proximal, mid, and distal levels. We also measured the mean coronal diameter of the pubovisceralis muscle (PVM)., Results: 696 women consented to participate, and 433 women presented for ultrasound imaging 6 months later. Women who sustained a third- or fourth-degree laceration had significantly thicker EAS measurements at 12 o'clock. Sphincter asymmetry was common (69 %), but was not related to mode of delivery. Only IAS measurements at the proximal and distal 12 o'clock position were significantly thicker for CD patients. There were no significant differences in the EAS or PVM measurements between VB and CD women., Conclusions: There appear to be few differences in normative sphincter ultrasound measurements between primiparous patients who had VB or CD.