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OBJECTIVE This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. METHODS A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. RESULTS A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. CONCLUSIONS For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

Pelvic floor disorders affect up to 24% of adult women in the United States, and many patients with pelvic organ prolapse (POP) choose to undergo surgical repair to improve their quality of life. While a variety of surgical repair approaches and techniques are utilized, including mesh augmentation, there is limited comparative effectiveness and safety outcome data guiding best practice. In conjunction with device manufacturers, federal regulatory organizations, and professional societies, the American Urogynecologic Society developed the Pelvic Floor Disorders Registry (PFDR) designed to improve the quality of POP surgery by facilitating quality improvement and research on POP treatments. The PFDR will serve as a resource for surgeons interested in benchmarking and outcomes data and as a data repository for Food and Drug Administration-mandated POP surgical device studies. Provider-reported clinical data and patient-reported outcomes will be collected prospectively at baseline and for up to 3 years after treatment. All data elements including measures of success, adverse events, and surgeon characteristics were identified and defined within the context of the anticipated multifunctionality of the registry, and with collaboration from multiple stakeholders. The PFDR will provide a platform to collect high-quality, standardized patient-level data from a variety of nonsurgical (pessary) and surgical treatments of POP and other pelvic floor disorders. Data from this registry may be used to evaluate short- and longer-term treatment outcomes, patient-reported outcomes, and complications, as well as to identify factors associated with treatment success and failure with the overall goal of improving the quality of care for women with these conditions.

The objective of this study was to identify factors associated with new onset of postpartum fecal incontinence in primiparous women. A population-based study was conducted that surveyed all women delivering between 2002 and 2003 in Oregon. Factors associated with fecal incontinence were identified using logistic regression analysis. A total of 6,152 primiparous women completed the survey 3–6 months postpartum with 2,482 reporting a new onset of fecal incontinence (FI) after childbirth. Vaginal delivery was associated with a greater risk of FI compared to cesarean (odds ratio = 1.45; 95% confidence interval, 1.29 to 1.64). However, vaginal delivery without laceration or instrument assistance did not increase the risk of FI over cesarean. Being overweight (body mass index ≥30 kg/m2), pushing for greater than 2 h, and constipation were independently associated with postpartum FI (p < 0.05) regardless of route of delivery. This study provides important data to inform counseling and management of primiparous women.

Significant nerve injury to a muscle can be associated with muscle atrophy and volume loss. Three-dimensional (3D) ultrasound can measure muscle volume, but the reproducibility of the technique has not been established for the anal sphincter.Using a 10 MHz 360-degree rotating endoanal probe, we performed 3D endoanal ultrasounds on 9 nulliparous and 23 asymptomatic primiparous subjects at 12 weeks' postpartum. Two blinded examiners measured the length of the external anal sphincter (EAS) from a midsagittal image, and the width of the EAS and internal anal sphincter (IAS) from axial images at mid anal canal. The EAS volume was calculated by repetitively outlining only the EAS in each sequential axial view. Both examiners measured the EAS volumes twice, blinded to previous calculations.The intrarater reliability for EAS volume was 0.79 to 0.89 (intraclass coefficient). The mean difference of the EAS volume between the 2 examiners was 0.5 mL (P = .3, t test). Correlation between the 2 examiners for measuring EAS volume was r = 0.77 (P.001, Pearson's). The "limits of agreement" (between 2 examiners) varied by as much as 40% of the mean volume.Quantitative 3D ultrasound of the anal sphincter is moderately reproducible.

Objective The objective of our study was to describe the national rates of ambulatory surgery for urinary incontinence in women. Study design We used the National Survey of Ambulatory Surgery, a federal database that samples outpatient surgery in the United States. Data from 1994 to 1996 were analyzed for diagnoses and procedures coded using the International Classification of Diseases, 9th revision, Clinical Modification, classification system. Age-adjusted rates were calculated with use of the 1990 census population and compared for change over time by using the score test for linear trend. Results The estimated number of women undergoing outpatient surgery for urinary incontinence increased from 7,200 in 1994 to 15,900 in 1996 ( P =.3), whereas the age-adjusted rate remained stable at approximately 10 procedures per 100,000 women per year. The procedures performed included "other repair of the bladder" (ICD-9-CM code 57.89), "other repair of urinary stress incontinence" (code 59.7), plication of the urethrovesical junction, suprapubic sling operation, retropubic urethral suspension, paraurethral suspension, and levator muscle operation. The mean age of women undergoing these procedures was 58±14.5 years. Women undergoing incontinence procedures were 76% white, 0.3% African American, and 24% other (including unknown). Ninety-two percent of the procedures were completed at hospitals, whereas 8% were performed at free-standing ambulatory surgery centers. Conclusion Between 1994 and 1996, the number of ambulatory surgeries for urinary incontinence in women doubled.

Objective: The objective of our study was to describe the national rates of surgery for urinary incontinence in women. Study Design: We used the National Hospital Discharge Survey, a federal database that samples inpatient hospitals in the United States. Data from 1979 to 1997 were analyzed for diagnoses and procedures coded by using the International Classification of Diseases, 9th revision, Clinical Modification, classification system. Age-adjusted rates were calculated by using the 1990 census population and compared for change over time with the score test for linear trend. Results: The number of women undergoing inpatient surgery for urinary incontinence has varied from 33,000 in 1979 to 85,000 in 1993. The rate of surgeries for incontinence has almost doubled, from 0.32 procedures per 1000 women per year in 1979 to 0.60 procedures per 1000 women per year in 1997 ( P =.02). The number of suprapubic slings performed increased over time. Approximately 2100 slings were performed per year until 1996, when 7348 were performed, followed by 10,192 in 1997 (rate increase from 12 to 75.2 per 1,000,000 women per year, P =.03). Women undergoing incontinence procedures were 79% white, 3% African American, and the remaining 18% other (including unknown). Thirty-seven percent of cases were performed in the South, 25% in the Midwest and West, and 12% in the Northeast. From 1979 to 1997, the mean age of women at the time of surgery increased from 50.5 ± 12.1 years to 56.6 ± 13.3 years; mean length of hospital stay decreased from 9.9 ± 4.5 days to 2.7 ± 1.4 days ( P Conclusion: The rate of surgery for urinary incontinence in women has nearly doubled from 1979 to 1997. (Am J Obstet Gynecol 2003;189:·70-5.)

Objective: The objective of our study was to describe national rates of surgery for pelvic organ prolapse. Study Design: We used the National Hospital Discharge Survey, a federal database that samples inpatient hospitals in the United States. Data from 1979 to 1997 were analyzed for diagnoses and procedures coded with the ICD-9-CM classification system. Age-adjusted rates were calculated by using the 1990 census population and compared for change over time by using the Score test for linear trend. Results: Approximately 200,000 women undergo inpatient procedures for prolapse in the United States each year, ranging from 165,000 in 1988 to 226,000 in 1979. There was a significant decrease in the overall age-adjusted rate of procedures performed over the study period, from 2.2 to 1.5 procedures per 1000 women ( P = .01). The rate of prolapse procedures for women younger than 50 years decreased by more than half (1.9 to 0.8 per 1000 women, P P = .5). Conclusion: Prolapse procedures are performed very frequently in the United States, although the rate has decreased slightly over time. (Am J Obstet Gynecol 2003;188:108-15.)

Objective To evaluate whether antepartum pelvic floor muscle strength, as measured by the Brink scale, predicts postpartum anal incontinence. Study Design This prospective cohort study of primigravid women used validated questionnaires and standardized pelvic examinations to evaluate subjects during the third trimester and at 2 postpartum time points. Results Of the initial 129 subjects, 102 and 81 completed 2 week and 6 month postpartum visits. 35% had cesarean deliveries. The antepartum prevalence of fecal incontinence (14%) did not differ significantly from the postpartum (17% at 2 weeks, 11% at 6 months). However, the prevalence of flatal incontinence fell from antepartum (65%) to postpartum (47% at 2 weeks, P = .001; 49% at 6 months, P = .012). Mean Brink score decreased postpartum; no correlations were found between Brink score and questionnaire scores. Conclusion Anal incontinence symptoms are common in the third trimester of a first pregnancy and may regress or resolve after delivery. Brink score did not predict postpartum anal incontinence.

To estimate the effect of mode of delivery on the incidence of urinary incontinence in primiparous women.A population-based survey was mailed to all Oregon women who delivered a liveborn neonate in a 1-year period. Data were collected on urinary incontinence, childbirth experience, and other risk factors for incontinence at 3-6 months postpartum. Univariable analyses were conducted using t tests and Wilcoxon rank-sum tests for continuous variables and chi tests for categorical variables. Logistic regression analyses were used to estimate odds ratios and 95% confidence intervals for demographic and clinical risk factors.A total of 15,787 women completed the survey, for a response rate of 39%. Of these women, 5,599 were primiparous, completed the survey in the desired timeframe, submitted information on their urinary continence, and did not have incontinence before pregnancy. A total of 955 (17.1%) reported leakage of urine. Women who had vaginal deliveries were more likely to have urinary incontinence than women who had cesarean deliveries (odds ratio 4.96 [95% confidence interval 3.82-6.44], P.001). This risk increased with assisted delivery and perineal laceration. No statistical difference in the incidence of urinary incontinence was found among women who had elective cesarean deliveries (6.1%), women who had cesarean deliveries after laboring (5.7%), and women who had cesarean deliveries after laboring and pushing (6.4%).Urinary incontinence is common in the immediate postpartum period after a woman's first pregnancy. Although vaginal delivery increases the risk of urinary incontinence, labor and pushing alone without vaginal delivery do not appear to increase this risk significantly.II.

We describe the presacral space and its potential impact on sacral neuromodulator implantation and bowel injury.Parasagittal images containing bilateral sacral foramina (S2-S4) were examined on 45 pelvic magnetic resonance images. Images were excluded from analysis if they were poor quality or had any history causing distortion of normal anatomy. We measured the natural angle between the foramina and the dorsal skin to approximate the needle angulation during neuromodulator electrode placement. Using these angles we measured the distance from the skin to any bowel (D1), the skin to the dorsal sacrum (D2) and then calculated the distance from the dorsal sacrum to any bowel (D3).Mean subject age was 45 years (range 19 to 78) and body mass index was 27.9 kg/m(2) (range 18.6 to 56.2). At S3 the mean foraminal angle and D3 were 46 +/- 8.4 degrees and 27.4 +/- 11.7 mm, respectively. Increasing age was moderately correlated to widening D3 at each foramina (r = 0.3, Pearson's p0.05). Body mass index did not consistently vary with D3 at any foramina.Our measurements suggest that the presacral space can be expected to be approximately 27 mm at the level of S3 where the neuromodulator electrode is implanted. It is possible to encounter bowel while performing this implantation using standard techniques and equipment. We recommend the standard use of fluoroscopy during placement.

Objective This study measured the 10-year risk of reoperation for surgically treated pelvic organ prolapse and urinary incontinence (POPUI) in a community population. Study Design We conducted a prospective cohort analysis of 374 women who were > 20 years old and who underwent surgery for POPUI in 1995. Results The 10-year reoperation rate was 17% by Kaplan Meier analysis. Previous POPUI surgery at the time of index surgery conferred a hazard ratio of 1.9 (95% CI, 1.1-3.2; P = .018). The abdominal approach was protective against reoperation compared with the vaginal approach (hazard ratio, 0.37; 95% CI, 0.17-0.83; P = .02) With the use of Cox regression, no association was observed for age, vaginal parity, previous hysterectomy, body mass index, prolapse severity, ethnicity, chronic lung disease, smoking, estrogen status, surgical indication, or anatomic compartment. Conclusion A reoperation rate of 17% is unacceptably high and likely represents an underestimate of the true rate. Most of the factors that influence reoperation have not yet been identified.

This study aims to determine the complications associated with trans-obturator slings as reported to a national database. We required "MAUDE", a database that collects reports of complications associated with medical devices and which is maintained by the Food and Drug Administration. We searched for complications associated with three different, commercially available trans-obturator slings. We then tabulated the results by type of complication, by date of occurrence, and by type of sling. Between January 2004 and July 2005, 140 reports of 173 complications associated with trans-obturator tapes were reported to the MAUDE database. Previously unreported injuries, such as obturator nerve injuries, large blood losses (or=600cc), and ischiorectal fossa abscesses, were documented. Serious complications occur with the trans-obturator tape systems, but the rates are unknown due to database limitations. The type of complication appears to differ between devices and this may reflect different implantation systems and different polypropylene mesh formulations. Improved tracking of device complications is necessary to maximize patient safety.

OBJECTIVE: To assess the impact of two programs at the University of Pittsburgh, one that requires and one that encourages volunteer activity. In the program that requires primary care interns to spend 15 hours in a homeless clinic, we measured volunteer service after the requirement was fulfilled. In the program that encourages and provides the structure for first- and second-year medical students to volunteer, we assessed correlates of volunteering. MEASUREMENTS AND MAIN RESULTS: When primary care interns were required to spend time at homeless clinics, all (13/13) volunteered to work at the same clinic in subsequent years. Categorical interns without this requirement were less likely to volunteer (24/51; x2=12.7, p>.001). Medical students who volunteered were more likely to be first-year students, have previously volunteered in a similar setting, have positive attitudes toward caring for indigent patients, and have fewer factors that discouraged them from volunteering (p

We evaluate the interrater reliability of levator hiatus (LH) size and correlate size to other measures of muscle function.Participants were examined independently by 2 examiners. During maximal contraction of the levator ani, the muscle was assessed by using Brink's scale. The LH was measured in the transverse and sagittal dimensions by digital palpation. The paired t test was used to compare continuous variables and Spearman's coefficient was used for correlations.The mean LH transverse was 4.5 cm and the mean LH sagittal was 3 cm. The inter-rater correlation for the LH transverse measurement was 0.6 (P.01) and 0.8 (P.01) for the LH sagittal measurement. The correlations between the LH size and Brink's scale were moderate (correlation coefficient -0.4 to -0.5, P.01). Eighty-three percent of measurements were within 1 cm.This technique for clinical measurement of levator hiatus size shows good interrater reliability.