Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial participants with Stage II-IV pelvic organ prolapse (POP) and stress urinary incontinence were randomized to uterosacral ligament suspension (ULS) or sacrospinous ligament fixation (SSLF). In this study, 5 year outcomes were assessed. Ninety-two percent (285/309) of eligible 2-year OPTIMAL trial completers consented to participate in the extended-OPTIMAL study; 273 (96%), 251 (88%), 244 (86%) had assessments at 3, 4, and 5-years, respectively, between 2008 and 2013 at nine US medical centers. The surgical intervention was transvaginal surgery including midurethral sling with randomization to ULS (n = 147) or SSLF (n = 138); the behavioral intervention was randomization to perioperative behavioral therapy with pelvic floor muscle training (PBMT) (n = 141) or usual care (n = 144). The primary surgical outcome was defined as time to anatomic or symptomatic failure or retreatment. Consistent with the primary OPTIMAL study, anatomic failure was defined as apical descent greater than one-third of vaginal length (POPQ C > -2/3TVL) or anterior or posterior vaginal wall beyond the hymen (POPQ Ba or Bp > 0) and symptomatic failure was defined as bothersome vaginal bulge symptoms. The primary outcome for the behavioral intervention was anatomic failure as defined for the surgical intervention and development of POP symptoms measured by the POPDI subscale of the PFDI. By year 5, the estimated probabilities of success from parametric survival modeling (Figure) for the ULS group and the SSLF group, respectively, were 0.44 and 0.33 for the primary outcome (difference of 0.10; 95% CI = -0.06, 0.27), 0.57 and 0.42 for anatomic POP (difference of 0.16; 95% CI = -0.04, 0.35) and 0.64 and 0.62 for symptomatic POP (difference of 0.02; 95% CI = -0.14, 0.18). POP retreatment at 5 years was 12% and 8% (OR = 1.6; 95% CI = 0.6–4.1) including pessary (4.2%) and repeat surgery (5.3%). The 117 anatomic failures involved the apex only (29%), anterior or posterior compartment only (36%), or both apex and anterior or posterior compartment (35%). Quality of life scores improved from baseline to 5 years including: -68.5 and -74.3 for POPDI (adjusted mean difference [AMD] of 5.9; 95% CI = -10.2, 21.9), -76.2, and -80.4 for UDI (AMD of 4.2; 95% CI = -10.6, 19), and -42.4 and -44 for CRADI (AMD of 1.6; 95% CI = -17.3, 20.5). Odds of granulation tissue (6 months to 5 years) were higher in the ULS group (OR = 1.9; 95% CI = 1–3.7) without group differences in suture exposure or mesh erosion/exposure. By year 5, the estimated probabilities of anatomic success for the PBMT group and the usual care group, respectively, were 0.54 and 0.54 (difference of 0.004; 95% CI = -0.21, 0.22) with no treatment difference in improvement of POPDI scores -60 and -62 (AMD of 2.1; 95% CI = -14, 18.1). Five years after vaginal surgery for Stage II-IV POP and SUI, women randomized to ULS and SSLF who consented to extended follow up have similar overall anatomic and subjective surgical cure rates, low rates of retreatment for POP, and significant improvement in quality of life.

Author(s): Lukacz, ES; Warren, LK; Richter, HE; Brubaker, L; Barber, MD; Norton, P; Weidner, AC; Nguyen, JN; Gantz, MG

Aim: To identify risk factors for positive preoperative urine cultures in asymptomatic women undergoing urogynecologic surgery.We also sought to identify risk factors for mixed flora clean catch urine cultures.Methods: This is a cross-sectional study.Demographic data and screening preoperative urine cultures were extracted on all women who underwent urogynecologic surgery between 9/2011 and 9/2013.Urine culture results were defined as: negative (no growth), positive (≥100K organisms), and contaminated (mixed flora).Women with <100K colony-forming units of a single organism were excluded.Logistic regression models were constructed to evaluate for differences between groups.Results: 490 women were included.When comparing positive to negative cultures, the positive culture group was more likely to have a history of recurrent urinary tract infections (UTIs) (20% vs. 5%, p=0.001).In a logistic regression model,a history of recurrent UTIs remained a risk factor for a positive preoperative urine culture (OR 6.9, 95% CI 2.3-20.8),whereas vaginal estrogen usage decreased the risk of a positive preoperative culture (OR 0.3, 95% CI 0.1-0.9).When comparing contaminated to negative cultures, the contaminated culture group was more likely to be obese (45% vs. 28%, p=0.001).In a logistic regression model, obesity remained a risk factor for contaminated preoperative urine cultures (OR 2.0, 95% CI 1.3-3.2). Conclusion:A history of recurrent UTIs was a risk factor for a positive preoperative urine culture in asymptomatic women undergoing urogynecologic surgery.Vaginal estrogen therapy was associated with fewer positive preoperative urine cultures.Obesity was an independent risk factor for contaminated (mixed flora) clean catch urine culture results.

Purpose: We evaluated the influence of preoperative urodynamic studies on diagnoses, global treatment plans and outcomes in women treated with surgery for uncomplicated stress predominant urinary incontinence.Materials and Methods: We performed a secondary analysis from a multicenter, randomized trial of the value of preoperative urodynamic studies. Physicians provided diagnoses before and after urodynamic studies and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification and nonoperative therapy. Treatment plan changes and surgical outcomes between office evaluation and office evaluation plus urodynamic studies were compared by the McNemar test.Results: Of 315 subjects randomized to urodynamic studies after office evaluation 294 had evaluable data. Urodynamic studies changed the office evaluation diagnoses in 167 women (56.8%), decreasing the diagnoses of overactive bladder-wet (41.6% to 25.2%, p < 0.001), overactive bladder-dry (31.4% to 20.8%, p = 0.002) and intrinsic sphincter deficiency (19.4% to 12.6%, p = 0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p < 0.001). After urodynamic studies physicians canceled surgery in 4 of 294 women (1.4%), changed the incontinence procedure in 13 (4.4%) and planned to modify mid urethral sling tension (more or less obstructive) in 20 women (6.8%). Nonoperative treatment plans changed in 40 of 294 women (14%). Urodynamic study driven treatment plan changes were not associated with treatment success (OR 0.96, 95% CI 0.41, 2.25, p = 0.92) but they were associated with increased postoperative treatment for urge urinary incontinence (OR 3.23, 95% CI 1.46, 7.14, p = 0.004).Conclusions: Urodynamic studies significantly changed clinical diagnoses but infrequently changed the global treatment plan or influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for postoperative urgency urinary incontinence.

s 237 O14. 015. 016. 017. 018. 019. 020. 020. 021. 022. C. Sultana, P. Young, Thomas Jefferson 023. University, Philadelphia, PA and Case Western Reserve University, Cleveland, OH. Double-blinded randomized evaluation of nitrofurantion prophylaxis for combined 024. urodynamics and cystourethroscopy G. W. Cundiff. M. T. McLennan, A. E. Bent, Greater Baltimore Medical Center, Baltimore, MD. The effects of patient position and pelvic organ prolapse on vesical leak point pressures J. C. Portera, S. G. Portera, R. L. Summitt, Jr., University of Tennessee, Memphis 025. Description of the Squirrel Monkey Pelvis using three-dimensional computed tomography (3-D CT). R. Scow, K. W. Coates, B. L. Shull, M. Klouda, D. Piper~ T. J. Kuehl. Scott & White Clinic-Texas 026. A & M Univesity, Temple TX and Duke University, Durham NC. Does provocative exercise predispose to future incontinence?: a retrospective cohort study of 027. female olympic athletes I. Nygaard, University of Iowa College of Medicine, Iowa City, IA. Societal costs of urinary incontinence L. L. Subak, L. Wilson, G. E. Park, K-O Luc, and J. S. Brown. Departments of Obstetrics, 028. Gynecology, and Reproductive Sciences and Pharmacology, University of California, San Francisco Objectively demonstrable de novo stress urinary incontinence in primiparas C. M. Sampselle, J. O. L. DeLancey, J. A. AshtonMiller, & C. L. Antonakos. University of 028. Michigan, Ann Arbor, MI. Randomized prospective trial of posterior colporrhaphy vs transanal repair of rectocele: preliminary findings M. A. Kahn, S. L. Stanton, D. A. Kumar. St George's Hospital, London, UK. Anorectal physiological effects of rectocele 029. correction by posterior colporrhaphy or the transanal approach M. A. Kahn, D. A. Kumar, S. L. Stanton. St George's Hospital, London, UK. Defining Urinary Incontinence (UI) for population 030. prevalence studies V. T. Mallett, D. E. Fenner, M. Kuchibhatia, R. C. Bump. Wayne State University, Detroit, MI; Rush Medical College, Chicago, IL; and Duke University, Durham, NC. O31. Urine from interstitial cystitis patients contains a low molecular weight, heat stable antiproliferative factor S. Keay, C-O Zhang, A. L. Trifillis, M. K. Hise, S.C. Jacobs, S. Bodison, N. Gordon, D. Gordon, K.E. Whitmore, J. R. Hebel and J. W. Warren, Baltimore, MD, College Park, MD, and Philadelphia, PA. Interstitial cystitis and pregnancy G. S. Singh, K. E. Whitmore, D. A. Gordon, S. Moma. University of Pennsylvania, Philadelphia, PA. Use of a stainless steel thimble to reduce needle stick injuries and to maximize depth of vaginal suture passes when performing the Burch Colposuspension L. R. Lind, N. N. Bhatia. North Shore University Hospital New York University School of Medicine, and HarborAJCLA Medical Center UCLA School of Medicine. Vaginal Flap Abdominal Sacral Colpopexy (ASCP): a preliminary report R. J. Scotti, J. Hutchinson-Colas, W. M. Greston. Monefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. The omental J-flap: a simple technique to repair complex bladder injuries A. D. Garely, T. E. Elkins, Louisiana State University Medical Center, New Orleans, LA. Dysfunctional bowel symptoms in women with urinary incontinence and pelvic organ prolapse K. W. Coates, A. C. Weidner, G. W. Cundiff, D. Elser, R. C. Bump. Duke University, Durham NC and Medical College of Virginia, Richmond VA. Recurrent pelvic organ prolapse after sacrospinous ligament vaginal vault suspension: the anterior versus posterior approach J. E. Tomezsko, P. K. Sand. Evanston Continence Center, Northwestern University, Evanston, IL. The effect of anterior approach sacrospinous vaginal vault suspension on recurrent cystocele rates when performed with transvaginal needle suspension J. E. Tomezsko, P. K. Sand. Evanston Continence Center, Northwestern University, Evanston, IL. Managing advanced prolapse in patient's with bladder exstrophy M. M. Karram, N. Kohli, R. G. Owens, G. Cundiff, P. Walsh, Good Samaritan Hospital, Cincinnati, Ohio Mesh erosion followikng abdominal sacrocolpopexy N. Kohli, P. M. Walsh, T. W. Roat and M. M. Karram, Good Samaritan Hospital, Cincinnati, OH. Full thickness permanent suture passes including vaginal mucosa in pelvic support surgery: complications and endoscopic examination of suture sites J. Y. Cboe, L. R. Lind, M. Dainer, N. N. Bhatia. Harbor/UCLA Medical Center, UCLA School of Medicine, Torrance, CA, and North Shore University Hospital New York University Medical Center, Manhasset, NY. 238 Abstracts 032. 033. 034. 035. 036. 037. 038. 039. 040. 041. 042. The empiric treatment of lower urinary tract 043. infections in a urogynecology practice: is it cost effective? R. Caputo, J. Evans. The Ohio State University, 044. Columbus, OH. Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse M. D. Barber, G. W. Cundiff, A. C. Weidner, K.W. Coates, R. C. Bump, W. A. Addison, Duke University Medical Center, Durham, North 045. Carolina Sphincteric assessment is augmented by quantitative needle urethral sphincter electromyography (EMG) Cheryl B. Iglesia, Jason Kane, Susan Shott and Linda Brubaker. Rush Medical College, Chicago, 045. IL. Urge-Incontinence Impact Questionnaire (U-IIQ): a measure for women with urge incontinence J. Brown, S. Posner, M. Kuppermann, E. Mozaffari and A. Stewart. University of California, San Francisco and Alza Corportation, Palo Alto, California 046. Relationship of cystocele grade to bladder volume status and patient position K. L. Noblett, J. K. Jensen, M. M. Germain, D. R. Ostergard: Long Beach Memorial Medical Center 047. Detrusor overactivity effects on urethral resistance in women with GSI A. C. Weidner, C. W. Coates, G. W. Cundiff, R. C. Bump. Duke University Medical Center, Durham, NC. The effect of rectocele on urodynamic parameters 048. D. Myers, C. LaSala, P. Rosenblatt. Brown University, Providence, RI. Multichannel urodynamics have limited reproducibility L. Brubaker, J. T. Benson, A. Clark, A. Bent, S. Shott. Rush Medical College, Chicago, IL; Indiana University, Indianapolis, IN; Oregon Health 049. Sciences University, Portland, OR; and Greater Baltimore Medical Center, Baltimore, MD. Intrauretrhral ultrasound: correlation of urethral sphincter morphology with funcitonal urodynamic parameters in stress incontinent women M. Heit, L. J. Goldsmith and M. Newton. University of Louisville HSC, Louisville, KY. Combined rectocele repair and abdominal sacralcolpopexy. A new method for repair of Denonvillier's fascia J. Fischer, D. Hale, J. T. Benson, D. Maglinte. Indiana University/Methodist Hospital of Indiana, Indianapolis, IN. Pit falls in the diagnosis of vesico intestinal fistula in females V. Ali, A. Guthrie, Univesity of Texas Medical School, Houston, Texas Mersilene mesh sling erosion: a problem? S. B. Young. University of Massachusetts Medical Center, Worcester, MA. Clinical efficacy and safety of tolterodine vs oxybutyn and placebo in patients with unstable bladder H. P. Drutz and R. A. Appetl. Section of Urogynecology, Mount Sinai Hospital, Toronto, Ontario, Canada. Dept. of Urology, The Cleveland Foundation, Cleveland, Ohio, USA An experimental intervention for mild sui: urination diary results differ from standing clinical stress test results James A. Ashton-Miller, Janis M. Miller, Lisa Carchidi, John O. L. DeLancey, University of Michigan, Ann Arbor, Michigan, Ann Arbor, MI Does a three-month pelvic muscle exercise intervention improve the effectiveness of the knack in reducing cough-induced urine loss on a standing stress test? Janis M. Miller, James A. Ashton-Miller, Lisa Carchidi, John O. L. DeLancey, University of Michigan, Ann Arbor, MI. Femassist: a new non-invasive external antiincontinence device E. Versi, D. J. Griffiths, D. Giovannini. Brigham % Women's Hospital, Harvard University, Boston, MA. A levator ani precontraction significantly reduces bladder neck descent during coughing in women with sui. Daniele Perucchini, John O. L. DeLancey, Janis M. Miller, Lisa Carchidi, Kathy Krajewski and James A. Ashton-Miller, University of Michigan, Ann Arbor, MI The effect of behavioral therapy on urinary incontinence in older women: a randomized, controlled trial K. Soghikian, L. L. Subak, E. Cattolica and S. F. Posner. Kaiser Permanente Medical Center, Oakland, CA and the University of California, San Francisco The relationship between pelvic muscle strength and incontinence severity following behavioral treatment of urinary incontinence J. P. Theofrastous, J. F. Wyman, D. K. McClish, D. M. Elser, D. Robinson, J. A. Fantl, R. C. Bump. Duke University, Durham, NC, Virginia Commonwealth University, Richmond, VA, Bowman Gray School of Medicine, WinstonSalem, NC. Poster Presentations P1. Prevalence of Urinary Incontinence in Asian American Women in the Seattle Area R. Chang, I. Rothman and J. Miller. University of Washington, Seattle, WA.

In Brief Objectives: To assess long-term fecal incontinence symptoms after combined perineoplasty with overlapping anal sphincteroplasty using the Fecal Incontinence Severity Index (FISI) questionnaire. Methods: A retrospective review identified all 22 subjects who had undergone perineoplasty with overlapping anal sphincteroplasty by 1 surgeon over a 6-year period. Sixteen subjects returned FISI questionnaires via mail, and demographics on all 22 were recorded. Results: Only 1 of 22 subjects reported fecal incontinence 6 weeks postoperatively. Sixteen of 22 (72%) individuals returned the FISI questionnaires with mean postoperative follow-up period of 37 months (range, 6–67 months). Of these 16, 12 patients experienced only 1 to 3 episodes of fecal incontinence of liquid and solid stool per month or less. Only 1 patient reported daily incontinence of solid stool. Conclusion: Long-term follow-up by FISI questionnaire revealed continued satisfaction with symptom control and overall bowel function. Combined perineoplasty with overlapping anal sphincteroplasty for fecal incontinence may be an effective method for decreasing symptom frequency. Long-term follow-up with the Fecal Incontinence Severity Index questionnaire suggests continued satisfaction with symptom control in patients who had undergone perineoplasty and overlapping anal sphincteroplasty for fecal incontinence.

OBJECTIVE:We measured levator ani neuromuscular function before and after first delivery to identify the location, timing, and mechanism of injury. STUDY DESIGN:Fifty-eight primiparous women underwent electromyographic examination of the levator ani antepartum at 6 weeks and 6 months after the delivery. Antepartum turns/amplitude data were pooled to create a normal range. We calculated each woman's percentage of outliers from this range and assessed relationships between delivery and extent of injury. RESULTS:At 6 weeks, 14 of 58 women (24.1%) had neuropathy, with 9 of those 14 women recovering by 6 months. At 6 months, 17 of 58 women (29.3%) were neuropathic, which included 12 new injuries. Women who had elective cesarean delivery had virtually no injury, but all other modes of delivery had similar injury rates. CONCLUSION:Obstetric delivery is associated frequently with electromyographic evidence of neuropathic injury to the levator ani. The entire levator complex is at risk, and cesarean delivery while in labor is not protective.

1OBGYN, Duke University Medical Center, Durham, NC; 2Urology, Duke University Medical Center, Durham, NC Disclosure - Nothing to disclose.

Loyola University Medical Center, Maywood, IL Disclosure – Speakers Bureau: L. Hoyte, Odyssey/Indevus Pharm; Advisory Board: L. Hoyte, Volugraphics Inc.

Objective: Compare pelvic morphology between asymptomatic African-American and white nulliparous women.Study design: Resting Supine T2-weighted magnetic resonance (MR) images were obtained in 12 African-American (AA) and 10 white American (WA) women Without pelvic floor dysfunction. Three-dimensional models were reconstructed from the MR images by a masked investigator, and predefined bony and Soft tissue pelvic floor parameters were measured and compared. Nonparametric statistics were used, with significance considered at P < .05.Results: Subjects were similar in age and body mass index. Levator ani volume was significantly greater in the AA versus the WA group (mean = 26.8 vs 19.8 cm(3), P = .002). The levator-symphysis gap was smaller in the AA (left-18.2, right-18.8 mm) versus the WA group (22.4, 22.6 mm, P = .003, .048) on the left and right. Significant differences were seen in bladder neck position, urethral angle, and the pubic arch angle.Conclusion: The increased muscle bulk and closer puborectalis attachment seen among the African-American nulliparous women may impact the development of pelvic floor dysfunction. These findings need further study. (c) 2005 Mosby, Inc. All rights reserved.

OBJECTIVE: To evaluate the possibility that genetic alterations may predispose women to pelvic organ prolapse (POP) by studying specific single nucleotide polymorphisms (SNPs). METHODS: Women with POP-Q ≥ stage III and controls POP-Q stage ≤ 1 were recruited. All subjects were matched for race, age, parity and BMI; additional information included medical history, surgical history and family history of POP. Blood DNA was genotyped using TaqMan Assays-on-Demand SNP Genotyping for 7 SNPs including MMP2, MMP3, MMP8, MMP9, MMP11, TIMP1 and TIMP 3. Genotypic data was tested for Hardy-Weinberg Equilibrium (HWE) and gene frequencies were computed for both cases and controls. Genotypic frequencies for each SNP were compared between cases and controls using Chi Square analysis. RESULTS: Thirty-six Caucasian women with POP and 36 controls were recruited, mean age was 65 (45–83) years, mean parity 2 (0–6) and mean BMI 27.2 (18–37). The mean weight of the largest infant vaginally was 3707 (3175–4536) and 3523 (3005–4649) grams respectively, among cases and controls. 62% and 38% respectively, of cases and controls had a history of hysterectomy (P<0.00). There was no significant evidence that cases were not under HWE. Genotypic frequencies for both cases and controls are shown in Table 1.TABLE 1CONCLUSIONS: There does not appear to be any difference in genotypic frequencies between our prolapse population and controls for the specific SNPs analyzed.

Journal of Pelvic Medicine and Surgery: March 2005 - Volume 11 - Issue 2 - p 84-85 doi: 10.1097/01.spv.0000156033.61858.36

OBJECTIVE:This study was undertaken to determine the prevalence of nocturnal polyuria in women complaining of nocturia and overactive bladder (OAB) symptoms and to identify clinical and health characteristics associated with nocturnal polyuria. STUDY DESIGN:Women presenting to a urogynecology clinic with complaints of nocturia and OAB symptoms were asked to participate. They completed a health characteristic summary, 3-day voiding diary, Nordic sleep questionnaire, urinary distress inventory (UDI), and a nocturia distress visual log (NDVL). The 24-hour urine production, nighttime urine volume, and maximum bladder capacity were calculated from the bladder diary. Nocturnal polyuria was defined as production of greater than 33% of the 24-hour urine volume during an 8-hour sleep period. A histogram was performed to analyze at what age the prevalence of nocturnal polyuria increased. Women were then divided by presence or absence of nocturnal polyuria and compared by the health and clinical characteristics. RESULTS:Fifty-five women met the qualifications and participated in the study. Average age of the cohort was 65.8 +/- 13.5 years. The risk of nocturnal polyuria increased with age 65 years or older (prevalence for age 65-74 = 0.86 [0.62-1.00]) and with white race. On the basis of the mean population values for UDI, NDVL, sleepiness scores, and insomnia scores, all women were bothered by their nocturia. Median number of nighttime voids, 24-hour urine production, maximum bladder capacity, nocturnal index, UDI, NDVL, sleepiness scores, and insomnia scores did not differ, based on presence or absence of nocturnal polyuria. CONCLUSION:Among women complaining of nocturia and overactive bladder symptoms, age 65 years or older and white race appear to be risk factors for nocturnal polyuria.

Non-Oral Presentations: AUGS-SGS Abstracts: 2004 Joint Scientific Meeting The American Urogynecologic Society and The Society of Gynecologic Surgeons

Oral Poster Presentations: AUGS-SGS Abstracts: 2004 Joint Scientific Meeting The American Urogynecologic Society and The Society of Gynecologic Surgeons