Biomedical subjects

Victoria L Handa

Publications and source records attributed to Victoria L Handa.

14 recordsLinked to original sources

PubMed2006

Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve.

We describe the anatomy of the uterosacral ligament with respect to the sacral plexus. In six adult female embalmed cadavers, we identified the uterosacral ligament and its lateral nerve relations. Using the ischial spine as the starting point and measuring along the axis of the uterosacral ligament, we noted that the S1 trunk of the sacral plexus passes under the ligament 3.9 cm [95% confidence interval (CI), 2.1-5.8 cm] superior to the ischial spine. The S2 trunk passes under the ligament at 2.6 cm (95% CI; 1.5, 3.6 cm), the S3 trunk passes under the ligament at 1.5 cm (95% CI; 0.7, 2.4 cm), and the S4 trunk passes under the ligament at 0.9 cm (95% CI; 0.3, 1.5 cm) superior to the ischial spine. The pudendal nerve forms lateral to the uterosacral ligament. Our data demonstrate that the S1-S4 trunks of the sacral plexus, not the pudendal nerve, are vulnerable to injury during uterosacral ligament suspension.

Female↗

PubMed2006

Simulators and virtual reality in surgical education.

This article explores the pros and cons of virtual reality simulators, their abilities to train and assess surgical skills, and their potential future applications. Computer-based virtual reality simulators and more conventional box trainers are compared and contrasted. The virtual reality simulator provides objective assessment of surgical skills and immediate feedback further to enhance training. With this ability to provide standardized, unbiased assessment of surgical skills, the virtual reality trainer has the potential to be a tool for selecting, instructing, certifying, and recertifying gynecologists.

Clinical Competence↗

PubMed2006

Sexual function and childbirth.

OBJECTIVE: This manuscript reviews the potential impact of cesarean delivery on maternal sexual function. FINDING: The majority of new mothers resume intercourse within the first 3 months after delivery. However, during the first year after delivery, the majority of women experience at least one problem related to sexual function. The question with respect to maternal-choice cesarean is whether this obstetrical intervention affects maternal sexual function. We review the available evidence regarding sexual function after cesarean delivery and present several plausible mechanisms by which route of delivery could impact long-term postpartum sexual function. CONCLUSION: Further research is needed to investigate whether maternal-choice cesarean delivery affects female sexual function.

Cesarean Section↗

PubMed2006

Fecal and urinary incontinence in primiparous women.

OBJECTIVE: To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence. METHODS: The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site. RESULTS: Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8-4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2-3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence. CONCLUSION: Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders. LEVEL OF EVIDENCE: II-3.

Adult↗

PubMed2006

Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears.

OBJECTIVE: To estimate whether endoanal ultrasound findings are more prevalent in primiparous women with a history of anal sphincter tear than in women without this history and whether the findings are associated with fecal incontinence symptoms. METHODS: A total of 251 primiparous women at seven clinical sites underwent standardized ultrasound assessment of the internal and external anal sphincter 6-12 months after delivery. Participants were women in the three cohorts of the Childbirth and Pelvic Symptoms Study: 1) women with clinically evident third- or fourth-degree tear at vaginal delivery (n=106); 2) no tear at vaginal delivery (n=106); and 3) cesarean delivery without labor (n=39). Women completed the Fecal Incontinence Severity Index to assess fecal incontinence symptoms. RESULTS: Thirty-five percent of the sphincter tear group exhibited internal sphincter gaps compared with 3% of vaginal controls (odds ratio [OR] 18.4, 95% confidence interval [CI] 5.5-62.1) and 10% of cesarean controls. External sphincter gaps were identified in 51% of the tear group compared with 31% of vaginal controls (OR 2.3, 95% CI 1.3-4.0) and 28% of cesarean controls. In the tear group, fecal incontinence severity was greater in those with internal sphincter gaps compared with those with no internal sphincter gaps (Fecal Incontinence Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well as in those with external sphincter gaps (6.1+/-8.4 compared with 2.7+/-5.0, P=.01), and greatest in those with both internal and external sphincter gaps compared with at least one gap not present (7.2+/-8.1 compared with 3.4+/-6.4, P=.003). CONCLUSION: Anal sphincter gaps detected by ultrasonography are prevalent in postpartum primiparous women with a history of sphincter tear and are associated with fecal incontinence severity. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed2005

Effects of estrogen with and without progestin on urinary incontinence.

CONTEXT: Menopausal hormone therapy has long been credited with many benefits beyond the indications of relieving hot flashes, night sweats, and vaginal dryness, and it is often prescribed to treat urinary incontinence (UI). OBJECTIVE: To assess the effects of menopausal hormone therapy on the incidence and severity of symptoms of stress, urge, and mixed UI in healthy postmenopausal women. DESIGN, SETTING, AND PARTICIPANTS: Women's Health Initiative multicenter double-blind, placebo-controlled, randomized clinical trials of menopausal hormone therapy in 27,347 postmenopausal women aged 50 to 79 years enrolled between 1993 and 1998, for whom UI symptoms were known in 23,296 participants at baseline and 1 year. INTERVENTIONS: Women were randomized based on hysterectomy status to active treatment or placebo in either the estrogen plus progestin (E + P) or estrogen alone trials. The E + P hormones were 0.625 mg/d of conjugated equine estrogen plus 2.5 mg/d of medroxyprogesterone acetate (CEE + MPA); estrogen alone consisted of 0.625 mg/d of conjugated equine estrogen (CEE). There were 8506 participants who received CEE + MPA (8102 who received placebo) and 5310 who received CEE alone (5429 who received placebo). MAIN OUTCOME MEASURES: Incident UI at 1 year among women without UI at baseline and severity of UI at 1 year among women who had UI at baseline. RESULTS: Menopausal hormone therapy increased the incidence of all types of UI at 1 year among women who were continent at baseline. The risk was highest for stress UI (CEE + MPA: relative risk [RR], 1.87 [95% confidence interval {CI}, 1.61-2.18]; CEE alone: RR, 2.15 [95% CI, 1.77-2.62]), followed by mixed UI (CEE + MPA: RR, 1.49 [95% CI, 1.10-2.01]; CEE alone: RR, 1.79 [95% CI, 1.26-2.53]). The combination of CEE + MPA had no significant effect on developing urge UI (RR, 1.15; 95% CI, 0.99-1.34), but CEE alone increased the risk (RR, 1.32; 95% CI, 1.10-1.58). Among women experiencing UI at baseline, frequency worsened in both trials (CEE + MPA: RR, 1.38 [95% CI, 1.28-1.49]; CEE alone: RR, 1.47 [95% CI, 1.35-1.61]). Amount of UI worsened at 1 year in both trials (CEE + MPA: RR, 1.20 [95% CI, 1.06-1.36]; CEE alone: RR, 1.59 [95% CI, 1.39-1.82]). Women receiving menopausal hormone therapy were more likely to report that UI limited their daily activities (CEE + MPA: RR, 1.18 [95% CI, 1.06-1.32]; CEE alone: RR, 1.29 [95% CI, 1.15-1.45]) and bothered or disturbed them (CEE + MPA: RR, 1.22 [95% CI, 1.13-1.32]; CEE alone: RR, 1.50 [95% CI, 1.37-1.65]) at 1 year. CONCLUSIONS: Conjugated equine estrogen alone and CEE + MPA increased the risk of UI among continent women and worsened the characteristics of UI among symptomatic women after 1 year. Conjugated equine estrogen with or without progestin should not be prescribed for the prevention or relief of UI.

Aged↗

PubMed2005

Anatomic relationship between the vaginal apex and the bony architecture of the pelvis: a magnetic resonance imaging evaluation.

OBJECTIVE: This study was undertaken to define anatomic relationships between the vaginal apex and the ischial spines and sacrum for nulliparous women with normal support. STUDY DESIGN: We retrospectively evaluated the magnetic resonance images of 11 consecutive women who underwent pelvic imaging at Johns Hopkins. Coordinates were recorded for the posterior fornix, sacrum, ischial spines, and cervical vaginal junctions. We calculated vector distances with means, SDs, and 95% CIs. Intraclass correlation coefficients tested interobserver reliability and the Wilcoxon signed rank test compared right- and left-sided measurements. RESULTS: Mean age was 30.4 +/- 9.1 years. The cervical vaginal junction was 1.6 +/- 0.5 cm superior, 1.1 +/- 0.5 cm anterior, and 4.7 +/- 0.4 cm medial to the ipsilateral ischial spine. The posterior fornix was 1.0 +/- 1.0 cm anterior and 5.3 +/- 0.8 cm inferior to the second sacral vertebra. There was excellent interobserver reliability (interclass correlation coefficients = 0.997, P < .001) and no detectable difference between sides. CONCLUSION: Consistent relationships exist between the vaginal apex and ischial spines and sacrum, which may be useful in reconstructive pelvic surgery.

Adult↗

PubMed2005

Perioperative complications of surgery for genital prolapse: does concomitant anti-incontinence surgery increase complications?

OBJECTIVES: To establish whether the short-term risks of prolapse surgery are increased by a concomitant anti-incontinence procedure. METHODS: Using data from the past 4 years of the National Hospital Discharge Survey, we identified women admitted for surgery for pelvic organ prolapse (specifically, suspension of the vagina or obliteration of the cul-de-sac, with or without concomitant hysterectomy or vaginal repairs). We identified women diagnosed with complications (including infections, bleeding complications, surgical injuries, pulmonary complications, and cardiovascular complications). We used multiple logistic regression analysis to compare women with and without complications with respect to concurrent continence procedures, controlling for demographic characteristics, concurrent procedures, and medical comorbidity (using the Charlson index). RESULTS: Of the 1931 women who underwent prolapse surgery, concomitant anti-incontinence procedures were performed in 514 (26.6%). Complications were reported in 288 patients (14.9%) and were associated with medical comorbidity (odds ratio 11.2) and concomitant hysterectomy (odds ratio 1.5). Concomitant surgery for incontinence was not associated with an increased risk of complications. CONCLUSIONS: These data suggest that medical comorbidity is strongly associated with complications after surgery for pelvic organ prolapse. A concomitant anti-incontinence procedure did not significantly increase the immediate morbidity of prolapse surgery.

Aged↗

PubMed2004

Measuring the severity of stress urinary incontinence using the Incontinence Impact Questionnaire.

AIMS: Questionnaires, including the Incontinence Impact Questionnaire (IIQ), have been used to assess the severity of urinary incontinence in clinical trials. However, the summed score derived from the IIQ does not have any inherent clinical meaning. Also, a summed score does not have interval properties, complicating the interpretation of changes in severity. The purpose of this study is to test the hypothesis that incontinence-related disability is a measurable variable and that the IIQ can measure that variable accurately. METHODS: We used Rasch analysis, a logistic regression technique, to estimate an interval scale of incontinence severity. Rasch analysis is based on the mathematical assumption that each subject's response to any given item is a function of (a) the individual's inherent level of disability and (b) the inherent difficulty of that item. RESULTS: Twenty-seven women with urodynamic stress urinary incontinence (USUI) completed the IIQ. Using Rasch analysis, we found that women with USUI had the most difficulty engaging in "physical recreational activities" and the least difficulty participating in "relationship with family." We also assessed the ability of the IIQ to discriminate between individuals with respect to disease severity. We found that most of the items in the IIQ are useful for discriminating incontinence severity among women with mild or moderate incontinence, but very few IIQ items distinguish among women with severe incontinence. CONCLUSIONS: Our results have important implications for clinical trials using the IIQ: among women treated for severe incontinence, the standard IIQ summed score will underestimate the magnitude of any change in incontinence severity.

Aged↗

PubMed2004

Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women.

OBJECTIVE: The purpose of this study was to describe the natural history of pelvic organ prolapse after menopause. STUDY DESIGN: Over 2 to 8 years, participants in the estrogen plus progestin trial of the Women's Health Initiative at the University of California Davis had annual pelvic examinations, with an assessment of uterine prolapse, cystocele, and rectocele. The findings from these examinations were used to describe the incidence of pelvic organ prolapse, the probability of progression or regression, and the associated risk factors. RESULTS: At baseline, 31.8% of women had pelvic organ prolapse (n=412 women). The annual incidences of cystocele, rectocele, and uterine prolapse were 9.3, 5.7, and 1.5 cases per 100 women-years, respectively. Incident prolapse was associated with increasing parity and waist circumference. The progression rates for grade 1 pelvic organ prolapse (per 100 women-years) were 9.5 for cystocele, 13.5 for rectocele, and 1.9 for uterine prolapse. The annual rates of regression (per 100 women-years) was 23.5, 22, and 48, respectively. CONCLUSION: Our data suggest that pelvic organ prolapse is not always chronic and progressive as traditionally thought. Spontaneous regression is common, especially for grade 1 prolapse.

Disease Progression↗

PubMed2004

Sexual function among women with urinary incontinence and pelvic organ prolapse.

OBJECTIVE: The objective of this research was to determine whether sexual complaints, such as dyspareunia, are associated with pelvic floor disorders. STUDY DESIGN: We used data collected for the Maryland Women's Health Study. Among adult women scheduled for hysterectomy, we used multiple logistic regression analysis to identify characteristics associated with 4 sexual complaints: decreased libido, vaginal dryness, dyspareunia, and anorgasmia. RESULTS: Among 1299 participants, 495 (38.1%) had evidence of pelvic floor disorders. Sexual complaints were significantly more common among women with pelvic floor disorders (53.2% vs 40.4%, P < .01). In the multiple regression model, urinary incontinence was significantly associated with low libido (odds ratio [OR] 1.96), vaginal dryness (OR 2.11), and dyspareunia (OR 2.04), independent of age, educational attainment, and race. In contrast, pelvic organ prolapse was not associated with any sexual complaint. CONCLUSION: In a cohort of women planning hysterectomy, women with urinary incontinence were significantly more likely to report sexual complaints.

Adult↗

PubMed2004

Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life?

OBJECTIVE: This study was undertaken to investigate the impact of reproductive factors on the prevalence of urinary symptoms. STUDY DESIGN: Participants were women scheduled for hysterectomy (n=1299). Before surgery, urinary symptoms were assessed by questionnaire. Multiple logistic regression analysis was used to investigate the association between bladder symptoms and parity, route of delivery, and other characteristics. RESULTS: Stress incontinence and urinary urgency were more prevalent among parous than nulliparous women (P <.01). Controlling for parity and other characteristics, women who had a history of cesarean delivery were significantly less likely to report stress incontinence than women with a history of vaginal delivery (odds ratio 0.60; 95% CI 0.39-0.93). CONCLUSION: Women who have undergone vaginal delivery are more likely to report stress incontinence than women who have delivered by cesarean section. Although this suggests that cesarean delivery might reduce incontinence later in life, further research is needed to clarify the long-term risks, benefits, and costs of cesarean delivery.

Cesarean Section↗

PubMed2003

Effects of examination technique modifications on pelvic organ prolapse quantification (POP-Q) results.

The pelvic organ prolapse quantification system (POP-Q) is currently the most quantitative, site-specific system for describing pelvic organ prolapse. To ensure that anatomic outcomes can be optimally assessed, investigators in the Pelvic Floor Disorders Network evaluated the impact of specific technique variations on POP-Q measurements performed on 133 patients by 16 examiners at seven sites. Values for genital hiatus and perineal body were higher when measured with maximal strain than on resting. With the exception of TVL, internal points did not differ significantly when measured with or without a speculum. The maximum extent of prolapse was best seen with the patient standing. These results suggest that genital hiatus and perineal body should be measured at rest and during straining, as the measurements may assess different aspects of pelvic floor function, and that internal points can be measured with or without a speculum. They also emphasize the value of the standing examination to observe the maximum extent of pelvic organ prolapse.

Adult↗

PubMed2003

Architectural differences in the bony pelvis of women with and without pelvic floor disorders.

OBJECTIVE: To investigate the hypothesis that the architecture of the bony pelvis differs between women with and without pelvic floor disorders. METHODS: We designed a case-control study of women who had undergone magnetic resonance imaging (MRI) of the pelvis at our institution. Records were reviewed to identify women with and without pelvic floor disorders (urinary or anal incontinence, other symptoms of urinary tract dysfunction, or pelvic organ prolapse). Pelvimetry techniques were standardized. Relevant measures included transverse diameter of the inlet, angle of the pubic arch, intertuberous diameter, interspinous diameter, sacrococcygeal length, depth of sacral curvature, anteroposterior conjugate, obstetrical conjugate, and anteroposterior outlet. Multiple logistic regression analysis was used to identify women with pelvic floor disorders as a function of their pelvic dimensions, controlling for potentially confounding variables. RESULTS: Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with pelvic floor disorders had a wider transverse inlet, wider intertuberous diameter, wider interspinous diameter, greater sacrococcygeal length, deeper sacral curvature, and narrower anteroposterior outlet. When controlling for the confounding effects of age, race, and parity, we found that a wider transverse inlet (odds ratio 3.425) and a shorter obstetrical conjugate (odds ratio 0.233) were significantly associated with pelvic floor disorders. CONCLUSION: A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may predispose the patient to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.

Adult↗