I have practiced and taught gynecology in 4 states and 5 institutions for >3 decades. While this experience does not constitute a nationwide survey, I have observed that the most common word associated with the phrase “pelvic examination” in medical charting by nongynecologists is “deferred.” This is undoubtedly a misuse of “defer” (“to put off to a future time”), since generally “defer” is actually a euphemism for “never.”See related article, page 109 See related article, page 109 In this issue of the American Journal of Obstetrics and Gynecology, Henderson et al1Henderson J.T. Harper C.C. Gutin S. Saraiya M. Chapman J. Sawaya G.F. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists.Am J Obstet Gynecol. 2013; 208 (109.e1-7)Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar present the results of a nationwide survey of US obstetrician-gynecologists with 2 objectives: (1) to determine how many would complete a bimanual pelvic examination on 4 asymptomatic patients not requiring a Pap test; and (2) to determine when the examination was performed, how important it was, and why it was done. The authors demonstrate most respondents would perform the examination but the importance attached to it and the reasons for performing it varied. They also discuss why the need for the examination is not supported by evidence in any of the scenarios. This is similar to conclusions of other recent publications2Westhoff C.L. Jones H.E. Guiahi M. Do new guidelines and technology make the routine pelvic examination obsolete?.J Womens Health. 2011; 20: 5-10Crossref Scopus (46) Google Scholar, 3Stormo A. Cooper C.P. Hawkins N.A. Saraiya M. Physician characteristics and beliefs associated with use of pelvic examinations in asymptomatic women.Prev Med. 2012; 54: 415-421Crossref PubMed Scopus (37) Google Scholar, 4Stormo A. Hawkins N.A. Cooper C.P. Saraiya M. Less is more–the pelvic examination as a screening tool: practices of US physicians.Arch Intern Med. 2011; 171: 2053-2054Crossref PubMed Scopus (27) Google Scholar that challenge the value of the routine pelvic examination as part of well-women visits in the face of lengthened screening intervals for cervical cancer. The bias of such reports is that they have a very narrow view of the indications for and components of the gynecological physical examination. For example, Henderson et al1Henderson J.T. Harper C.C. Gutin S. Saraiya M. Chapman J. Sawaya G.F. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists.Am J Obstet Gynecol. 2013; 208 (109.e1-7)Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar define the components of the examination to be a Pap test, human papillomavirus test, visual inspection of the external genitalia, speculum examination, and bimanual examination with or without a rectal examination, while Westhoff et al2Westhoff C.L. Jones H.E. Guiahi M. Do new guidelines and technology make the routine pelvic examination obsolete?.J Womens Health. 2011; 20: 5-10Crossref Scopus (46) Google Scholar limit the putative justifications for a pelvic examination to screening for sexually transmitted disease (Chlamydia or gonorrhea), evaluation before starting hormonal contraception, cervical cancer screening, and early detection of ovarian cancer. The latter authors concluded that “eliminating the speculum examination from most visits and the bimanual examination from all visits of asymptomatic women will free resources to provide services of proven benefit. Overuse of the pelvic examination contributes to high healthcare costs without any compensatory health benefit.” I would agree that if one has a limited ability to make pertinent observations during the performance of the pelvic examination, the examination is better deferred. If a provider believes the only value of the pelvic examination is to obtain cervical cytology every 3-5 years, then, predictably, many potentially useful observations are never made because the examiner's mind is not prepared to make them. As Pasteur famously observed, “chance favors the prepared mind” (In French, the quotation is: Dans les champs de l'observation le hasard ne favorise que les esprits prepares); one who approaches the pelvic examination with only the goal of exposing the cervix misses the opportunity to make pertinent observations that may benefit the patient. Such tunnel vision allows vulvar cancers to be overlooked for years, evidence of embarrassing vaginal infections to be ignored, and an appreciation of advancing pelvic organ prolapse to be missed. Findings during the pelvic examination may lead to further questions regarding conditions such as urinary incontinence, fecal incontinence, dyspareunia and other sexual dysfunction, and physical abuse, all of which are frequently not volunteered by women but have substantial impact on their quality of life. A pelvic examination by a qualified professional includes inspection of the external genitalia, a visual assessment of vaginal and cervical secretions with a conscious assessment as to whether they are appropriate for the individual patient and with a microscopic evaluation as indicated, an assessment of pelvic support and of the trophic status of the vaginal epithelium, an assessment of introital and vaginal pain and levator muscle tenderness, and a determination of the patient's ability to contract and relax the pelvic floor. The recommendation to educate clinicians about the inappropriateness of a pelvic examination for women who had a total abdominal hysterectomy–bilateral salpingo-oophorectomy ignores the fact that hysterectomy is one of the primary risk factors for pelvic organ prolapse and that detection of early prolapse may lead to simple interventions (eg, physical therapy to optimize pelvic muscle tone; fiber therapy to correct constipation and excessive straining with bowel movements) that may allow the patient to avoid surgery in the future. Before declaring the obsolescence of the pelvic examination (and for that matter, most or all of the general physical examination) for asymptomatic women (and men), I agree with Henderson et al1Henderson J.T. Harper C.C. Gutin S. Saraiya M. Chapman J. Sawaya G.F. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists.Am J Obstet Gynecol. 2013; 208 (109.e1-7)Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar that other aspects of the examination deserve study to assess their value and importance. At the same time, we need to train students that the pelvic examination should be more than a Pap smear and bimanual examination. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologistsAmerican Journal of Obstetrics & GynecologyVol. 208Issue 2PreviewLess-than-annual cervical cancer screening is now recommended for most US women, raising questions about the need for routine annual bimanual pelvic examinations. Little is known about clinicians' bimanual pelvic examination practices, their beliefs about its importance, or the reasoning underlying its performance in asymptomatic women. Full-Text PDF

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INTRODUCTION AND HYPOTHESIS:The aim of this study was to determine the reoperation rate for sling placement or revision in patients who had primary continence procedures based on prolapse reduction stress testing (RST) prior to laparoscopic sacral colpoperineopexy (LSCP).METHODS:This was a retrospective cohort study of women who had RST prior to LSCP for symptomatic pelvic organ prolapse. Patients with positive test (Pos RST) had a concomitant midurethral sling procedure and those with negative test (Neg RST) did not. Variables were compared with either Student's t test or Fisher's exact test.RESULTS:In Neg RST group (n = 70), the rate of surgery for de novo urodynamic stress incontinence was 18.6%. In Pos RST group (n = 82), the rate of sling revision for bladder outlet obstruction was 7.3%. Overall, 88% of patients did not require a second surgery.CONCLUSIONS:The use of RST to recommend concomitant continence procedures during LSCP results in a single surgery for the majority of our patients.

OBJECTIVE: The primary objective was to estimate the incidence of de novo stress urinary incontinence after total vaginal mesh procedures in women with negative preoperative urodynamics with prolapse reduction. Secondary objective was to identify associated risk factors.STUDY DESIGN: A retrospective cohort study with a nested case-control study of women who underwent total vaginal mesh procedures without midurethral sling after a negative preoperative urodynamics.RESULT: Sixty patients were included in the final analysis. Fifteen (25%) patients were diagnosed with de novo stress urinary incontinence. Although no significant associated risk factors were identified, there was a trend for higher gravidity and better anterior wall support among women who had stress urinary incontinence develop.CONCLUSION: The incidence of de novo stress urinary incontinence after total vaginal mesh procedures in this cohort was 25%. Patients should be appropriately counseled regarding the same.

OBJECTIVE: The purpose of this study was to evaluate the association between smoking and vaginal mesh erosion after abdominal sacral colpoperineopexy with the use of type 1 polypropylene mesh.STUDY DESIGN: All cases of mesh erosion (n = 27) that were diagnosed between October 2003 and June 2006 were identified and compared with matched control cases (n = 81). Control cases were matched for age, diabetes mellitus status, hypoestrogenic state enopausal status, chronic steroid use, use of hormone therapy), abdominal-vaginal rectocele repair, culdoplasty, and concomitant hysterectomy. Demographic data, surgical characteristics, and postoperative complications were also compared between groups. Continuous data were compared using 2-sample Student t tests. Categoric data were compared with the use of Pearson Chi-square tests.RESULTS: The odds of experiencing mesh erosion was significantly greater in smokers than in nonsmokers (odds ratio, 4.4 95% Cl, 1.3, 14.4 P =.010) when potential confounders were similar between groups.CONCLUSION: Tobacco use is a risk factor for vaginal mesh erosion after abdominal sacral colpoperineopexy with the use of type 1 polypropylene mesh.

The American Journal of Obstetrics & Gynecology (AJOG) became the premier journal of our discipline in the 20th century after publishing many groundbreaking discoveries that changed the practice of medicine and the lives of women. The stature and reputation of the Journal, coupled with advances in the technologies through which information is conveyed, have compelled us to examine the role that a scholarly clinical journal must play in the first part of the 21st century. This question has implications for the readers, contributors, patients, and professional societies that we serve.

La incontinencia urinaria es un problema de salud de alta prevalencia que puede alterar significativamente la calidad de vida. A pesar de ello, los pacientes con incontinencia de orina suelen aceptar sus sintomas durante anos antes de consultar con su medico. Un porcentaje desproporcionadamente alto de aquellos que consultan es remitido al especialista. Aunque la fisiopatologia de la incontinencia urinaria sea compleja, al poseer conocimientos basicos sobre la anatomia y fisiologia del tracto urinario inferior, esta puede ser eficazmente tratada en el marco de la asistencia primaria. En esta revision se describen los recientes hallazgos sobre la neurofisiologia del tracto urinario inferior (TUI), con especial atencion en el papel del sistema nervioso central y del sistema nervioso periferico autonomo y somatico durante el llenado y vaciamiento vesical

Objectives. To determine the clinically relevant reference points for the Incontinence Quality of Life (I-QOL) questionnaire scores in women with stress urinary incontinence and compare them with the treatment effects observed with duloxetine and placebo.Methods. Using data from 1133 women with predominant stress urinary incontinence in two randomized, placebo-controlled duloxetine studies, the within-treatment and between-treatment minimal clinically important differences (MCIDs) were obtained by anchoring the I-QOL scores to the validated Patient Global Impression of Improvement scale (PGI-I). The within-treatment MCID (mean I-QOL for women rating their condition "a little better" with treatment) and between-treatment MCID (difference in scores between the group ratings of "no change" and "a little better") were derived. The treatment effects were compared with these MODS. Real-time urinary diaries were completed, along with the I-QOL and PGI-I.Results. The within-treatment and between-treatment MCID for the I-QOL total score was 6.3 and 2.5, respectively. The total and subscale scores had almost identical MCIDs. Duloxetine 80 mg significantly improved the I-QOL total and subscale scores. Treatment differences in the I-QOL scores exceeded the between-treatment MCID and the duloxetine I-QOL treatment effect exceeded the within-treatment MCID. The number of patients needed to treat to gain an additional I-QOL responder was 6.8.Conclusions. Improvements in I-QOL scores should be greater than the within-treatment MCID, and differences between two treatments should be greater than the between-treatment MODS, for statistically significant differences to be considered clinically meaningful. We propose 2.5 points as a reasonable guide for the I-QOL between-treatment MCID and 6.3 points for the within-treatment MCID.

Objective: The purpose of this study is to evaluate whether the use of medications with urological activity (UA) is associated with self-reported difficulty in control of urination. Methods: This is a cross-sectional study using data from the Duke Established Populations for Epidemiologic Studies of the Elderly. Results: Difficulty holding urine was reported by 49.5% of men and 54.0% of the women. Overall, 50.9% of men and 72.7% of the women took one or more medications with UA. Multivariable logistic regression for men revealed that neither use of any medication with UA (Adjusted [Adj.] Odds Ratio [OR] 1.12, 95% confidence interval [CI] 0.84-1.50) nor the number of medications with UA used was associated with urinary difficulties (Adj. OR 1.08, 95% CI 0.97-1.21). For women, there was a significant association (p < .05) between use of any medication with UA and reported urinary difficulty (Adj. OR = 1.31, 95% CI = 1.05-1.62). Discussion: Medications with UA may be related to difficulty in controlling urine among community-dwelling elderly women.