BBI Contributing Editor

ATLANTA – Most of the scientific sessions during the annual meeting of the American Urogynecological Society (AUGS; Washington), held here in mid-September, were “standing room only” and often overflowing into the halls of the CNN Omni Hotel.

The society is dedicated to research and education in female pelvic medicine and reconstructive surgery and to improved care for women with lower urinary tract disorders. AUGS members continue to perform research that can be used to help determine better pelvic health outcomes, whether the research points toward a surgical event or lifestyle adaptation.

Although most pelvic floor disorders are treated surgically by this specialty group of surgeons, the meeting highlighted research that supports lifestyle changes and prevention. AUGS has helped developed federal legislation called the “Quality of Life for Women Act,” which aims to educate the public and primary care providers about women’s pelvic floor disorders, treatment options and the advantages of seeking proper care.

The objective of the legislation is both to strengthen awareness programs at the Centers for Disease Control and Prevention (Atlanta) and to prioritize research at the National Institutes for Health (NIH; Bethesda, Maryland) in order to encourage more women to seek treatment for pelvic floor disorders and to provide better, more scientific-based care. Since most pelvic floor disorders are not life threatening, many think this area of medicine has been overlooked in terms of funding and research.

The fact that 11% of the U.S. adult female population has had surgery for a pelvic floor disorder indicates that this is a large issue to be addressed. Estimates are that there are 275,000 pelvic prolapse surgeries and about 200,000 hysterectomies performed annually because of pelvic floor problems.

For those who don’t seek treatment, studies have shown that pelvic floor disorders lead to depression, disability and poor quality of life. Those conditions often lead to isolation, followed by obesity.

“So many women live with pelvic floor disorders,” said Dr. Stephen Young, AUGS president, “and yet, most do not know that they are treatable. The Quality of Life for Women Act will provide the education and research necessary to change that status.”

An important focus for AUGS is to perform research that can translate into disease prevention or treatment improvement for pelvic floor disorders.

Since between 8% and 60% of all continent patients having surgery to repair prolapse will develop de novo incontinence following surgery, Linda Brubaker, MD, professor of obstetrics/gynecology and urology at Loyola University Medical Center (Chicago), posed the question of whether or not to perform incontinence surgery at the same time as scheduled prolapse surgery.

She studied patients who did not have incontinence prior to prolapse surgery to see if they could predict which ones would develop incontinence following such surgery. In her study, Brubaker randomized 157 patients to receive a Burch (incontinence procedure) along with their prolapse repair surgery and 165 patients having identical demographics to receive the prolapse repair surgery alone. Both groups received urodynamic testing prior to surgery, but the results were not shown to any of the surgeons.

The Loyola study found that by performing a Burch at the same time as the prolapse surgery (sacrocolpopexy), the incidence of de novo incontinence following the surgery could be reduced by 50%. In the study, those patients who had a sacrocolpopexy alone had a 40% chance of developing incontinence post-operatively, while only 20% of the patients who received a Burch procedure along with the sacrocolpopexy developed incontinence.

The urodynamic testing that had been performed pre-operatively showed no statistical difference between the groups and no predictive evidence of which patients would most likely develop incontinence.

Brubaker told The BBI Newsletter that she encourages surgeons to counsel their patients using the data from her study and “allow those patients who choose to do so to have the combination procedure.”

In another study looking for causal associations for pelvic floor disorders, Emily Lukacz, MD, assistant professor of clinical reproductive medicine at the University of California, San Diego, studied the impact of pregnancy and delivery on the development of disorders such as urinary incontinence, fecal incontinence and pelvic organ prolapse.

She said, “There is much debate surrounding the causes of pelvic floor disorders. Past studies on the impact of pregnancy and method of delivery have not successfully established the risks of pregnancy and delivery on the development of these disorders.”

Although obesity, aging and other medical conditions have been implicated, many researchers feel that pregnancy and method of delivery are major contributing factors to the development of pelvic floor dysfunction.

Lukacz’s study was conducted by mailing surveys to 12,000 women enrolled in the Southern California Kaiser Permanente healthcare system. Of the more than 4,000 surveys completed, the study found that 15% had stress urinary incontinence, 13% had overactive bladder, 25% had fecal or gas incontinence and 7% had pelvic organ prolapse. A total of 37% had one or more of these conditions.

However, women who had given birth only by Caesarian section had these conditions at the same rate as women who had never given birth. Women who had given birth vaginally developed one or more of these disorders 42% of the time, as opposed to 27% for women who had never delivered vaginally. Lukasz cautioned that these results do not establish cause and effect but rather an “association.”

Although the results show a near doubling of the rates of pelvic floor disorders in women who delivered vaginally, 58% of women who delivered vaginally did not have a pelvic floor disorder.

Lukacz again cautioned against a universal call to increase C-section rates, as the surgery may carry risks of its own. She said, “Caesarean section should [include] careful consideration of the risks to mother and baby.”

Following her presentation, BBI conducted its own mini-survey, polling nearby surgeons at the meeting on the topic. The majority said that if a patient requests a primary C-section, they may grant those wishes upon certain conditions: 1) The patient desires three or fewer children in total, 2) the patient is educated and well-informed of the risks and benefits of C-section vs. vaginal delivery; and 3) the patient has good reasoning for wanting the C-section (i.e., to avoid pelvic floor disorders).

What are women willing to pay for help in treating their incontinence? In a first-time study, conducted by Leslee Subak, MD, associate professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, economic costs associated with routine care of urinary incontinence were examined.

The study included more than 300 women from around the country and was ethnically and economically diverse. Besides determining what it costs for pads, additional laundry and other health-related issues that result from urinary incontinence, the study also determined women’s willingness to pay to achieve a 25%, 50%, 75% and 100% improvement in their incontinence symptoms.

“Ninety percent of the women in this study reported some economic costs associated with incontinence,” Subak said. “The estimated annual cost was more than $880 per year for resolution of incontinence, which is similar to willingness to pay for improvement of other chronic medical conditions, such as migraine headaches and acid reflux.”

She also found that willingness to pay increased linearly with the expected amount of improvement. For instance, women were willing to pay twice as much for a 50% improvement in their incontinence than they were for a 25% improvement. Willingness to pay also was associated with household income. Those with incomes over $60,000 were willing to pay twice as much for improvement in their incontinence as those households with lower incomes.