Sharon Worcester

CHARLESTON, S.C. — Certain vaginal isolates may affect the quantity of HIV RNA in cervicovaginal lavage, Jane Hitti, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Factors affecting the HIV RNA concentrations are important, because genital viral load is a major determinant of sexual and perinatal HIV transmission, noted Dr. Hitti of the University of Washington, Seattle.

She reported on 38 HIV-positive women who completed 163 study visits. Vaginal cultures, cervicovaginal lavage, and plasma were collected at each visit for HIV RNA quantitation.

Hydrogen peroxide-producing lactobacilli were associated with a significant decrease in cervicovaginal lavage HIV RNA concentrations, and Trichomonas vaginalis, Prevotella bivia, Mycoplasma hominis, and other anaerobes were associated with increases in cervicovaginal lavage HIV RNA concentrations.

Of 163 CVL samples, 95 had detectable HIV RNA, and the levels correlated significantly with plasma HIV RNA levels, she said.

After adjustment for log plasma HIV RNA, the log difference in cervicovaginal lavage HIV RNA was significant for H₂O₂ lactobacillus and T. vaginalis. Increased cervicovaginal lavage HIV RNA concentrations also were associated, although not significantly, with M. hominis, P. bivia, black gram-negative rods, Candida albicans, and bacterial vaginosis or intermediate flora.

Also, cervicovaginal lavage HIV RNA concentrations were increased with higher vaginal concentrations of IL-8 in this study, Dr. Hitti noted.

Several vaginal isolates appear to directly influence cervicovaginal lavage viral load, and the effects appear to be independent of plasma viral load, she concluded, noting that an antibiotic treatment trial is underway to determine whether treatment for bacterial vaginosis and associated infections will decrease genital viral load.

“A very logical next step would be looking at ways to augment endogenous lactobacilli and looking at what effects that has,” she said.

The prevalence of H₂O₂-producing lactobacilli is lower than what has been reported among HIV-negative women, even in the presence of bacterial vaginosis, she explained.

CHARLESTON, S.C. — Certain vaginal isolates may affect the quantity of HIV RNA in cervicovaginal lavage, Jane Hitti, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Factors affecting the HIV RNA concentrations are important, because genital viral load is a major determinant of sexual and perinatal HIV transmission, noted Dr. Hitti of the University of Washington, Seattle.

She reported on 38 HIV-positive women who completed 163 study visits. Vaginal cultures, cervicovaginal lavage, and plasma were collected at each visit for HIV RNA quantitation.

Hydrogen peroxide-producing lactobacilli were associated with a significant decrease in cervicovaginal lavage HIV RNA concentrations, and Trichomonas vaginalis, Prevotella bivia, Mycoplasma hominis, and other anaerobes were associated with increases in cervicovaginal lavage HIV RNA concentrations.

Of 163 CVL samples, 95 had detectable HIV RNA, and the levels correlated significantly with plasma HIV RNA levels, she said.

After adjustment for log plasma HIV RNA, the log difference in cervicovaginal lavage HIV RNA was significant for H₂O₂ lactobacillus and T. vaginalis. Increased cervicovaginal lavage HIV RNA concentrations also were associated, although not significantly, with M. hominis, P. bivia, black gram-negative rods, Candida albicans, and bacterial vaginosis or intermediate flora.

Also, cervicovaginal lavage HIV RNA concentrations were increased with higher vaginal concentrations of IL-8 in this study, Dr. Hitti noted.

Several vaginal isolates appear to directly influence cervicovaginal lavage viral load, and the effects appear to be independent of plasma viral load, she concluded, noting that an antibiotic treatment trial is underway to determine whether treatment for bacterial vaginosis and associated infections will decrease genital viral load.

“A very logical next step would be looking at ways to augment endogenous lactobacilli and looking at what effects that has,” she said.

The prevalence of H₂O₂-producing lactobacilli is lower than what has been reported among HIV-negative women, even in the presence of bacterial vaginosis, she explained.

CHARLESTON, S.C. — Certain vaginal isolates may affect the quantity of HIV RNA in cervicovaginal lavage, Jane Hitti, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Factors affecting the HIV RNA concentrations are important, because genital viral load is a major determinant of sexual and perinatal HIV transmission, noted Dr. Hitti of the University of Washington, Seattle.

She reported on 38 HIV-positive women who completed 163 study visits. Vaginal cultures, cervicovaginal lavage, and plasma were collected at each visit for HIV RNA quantitation.

Hydrogen peroxide-producing lactobacilli were associated with a significant decrease in cervicovaginal lavage HIV RNA concentrations, and Trichomonas vaginalis, Prevotella bivia, Mycoplasma hominis, and other anaerobes were associated with increases in cervicovaginal lavage HIV RNA concentrations.

Of 163 CVL samples, 95 had detectable HIV RNA, and the levels correlated significantly with plasma HIV RNA levels, she said.

After adjustment for log plasma HIV RNA, the log difference in cervicovaginal lavage HIV RNA was significant for H₂O₂ lactobacillus and T. vaginalis. Increased cervicovaginal lavage HIV RNA concentrations also were associated, although not significantly, with M. hominis, P. bivia, black gram-negative rods, Candida albicans, and bacterial vaginosis or intermediate flora.

Also, cervicovaginal lavage HIV RNA concentrations were increased with higher vaginal concentrations of IL-8 in this study, Dr. Hitti noted.

Several vaginal isolates appear to directly influence cervicovaginal lavage viral load, and the effects appear to be independent of plasma viral load, she concluded, noting that an antibiotic treatment trial is underway to determine whether treatment for bacterial vaginosis and associated infections will decrease genital viral load.

“A very logical next step would be looking at ways to augment endogenous lactobacilli and looking at what effects that has,” she said.

The prevalence of H₂O₂-producing lactobacilli is lower than what has been reported among HIV-negative women, even in the presence of bacterial vaginosis, she explained.

ATLANTA — Most activity restrictions recommended for preventing the progression or recurrence of pelvic floor disorders are unwarranted, results of a small study suggest.

Several daily activities, such as lifting and exercising, are often restricted in patients with pelvic floor disorders and in those who undergo pelvic floor surgery, because there is concern that the activities can increase intraabdominal pressure and thereby exacerbate the disorder, Larissa F. Weir, M.D., explained during the annual meeting of the American Urogynecologic Society.

In fact, of 23 physical activities tested in 30 women who were not undergoing treatment for pelvic floor disorders, most had no greater effect on intraabdominal pressure than unavoidable or typically unrestricted activities had, said Dr. Weir, who was a medical student at the University of Iowa, Iowa City, at the time of the study, but who currently is a first-year resident at the San Antonio Uniformed Services Health Education Consortium.

Lifting technique with higher-weight items did, however, have an effect on intraabdominal pressure, she noted.

Activity restrictions can have a significant impact on daily life, so it is important that they are based on evidence, Dr. Weir said.

These findings lay a foundation for evidence-based revisions of current activity restriction recommendations, but prospective long-term studies of the impact of intraabdominal pressure on pelvic floor function and of the effects of physical activity on intraabdominal pressure are needed, she added.

Women who participated in the study performed three repetitions of each activity, and intraabdominal pressures were measured using a microtip rectal catheter. The mean peak and net intraabdominal pressures associated with the repetitions were calculated and compared with the baseline values in each patient.

The peak values for activities such as coughing, climbing stairs, and lowering to and rising from the floor, and for exercises such as jumping jacks, abdominal crunches, walking, and jogging on a treadmill were not significantly different than those for rising from a chair. Rising from a chair produced significantly higher abdominal pressures than lifting 8–10 pounds, Dr. Weir said.

The activities that produced the highest peak and net pressures included lifting 20 and 35 pounds off the ground, and forceful coughing; those that produced the lowest peak and net pressures were lifting 8 pounds from a low table, from counter height, and overhead.

As weight increased, lifting technique became more important: Compared with rising from a chair, lifting 8 or 13 pounds from the floor produced less intraabdominal pressure, while lifting 20 pounds from the floor did not. But lifting 20 pounds from counter height did produce less intraabdominal pressure.

Furthermore, lying supine on the ground—an unrestricted activity—produced intraabdominal pressure not significantly different from lifting 35 pounds off a counter. And lifting 35 pounds off a counter produced pressure significantly less than lifting 20 pounds off the ground.

In this study, body mass index and abdominal circumference were positively correlated with peak abdominal pressures—but not net abdominal pressures—for many of the activities studied, Dr. Weir noted. No such trend was observed with grip strength (which was used as a proxy for overall strength) or grip pressure. That suggests that overall strength has no impact on the effect of various activities on intraabdominal pressure, she said.

ATLANTA — Most activity restrictions recommended for preventing the progression or recurrence of pelvic floor disorders are unwarranted, results of a small study suggest.

Several daily activities, such as lifting and exercising, are often restricted in patients with pelvic floor disorders and in those who undergo pelvic floor surgery, because there is concern that the activities can increase intraabdominal pressure and thereby exacerbate the disorder, Larissa F. Weir, M.D., explained during the annual meeting of the American Urogynecologic Society.

In fact, of 23 physical activities tested in 30 women who were not undergoing treatment for pelvic floor disorders, most had no greater effect on intraabdominal pressure than unavoidable or typically unrestricted activities had, said Dr. Weir, who was a medical student at the University of Iowa, Iowa City, at the time of the study, but who currently is a first-year resident at the San Antonio Uniformed Services Health Education Consortium.

Lifting technique with higher-weight items did, however, have an effect on intraabdominal pressure, she noted.

Activity restrictions can have a significant impact on daily life, so it is important that they are based on evidence, Dr. Weir said.

These findings lay a foundation for evidence-based revisions of current activity restriction recommendations, but prospective long-term studies of the impact of intraabdominal pressure on pelvic floor function and of the effects of physical activity on intraabdominal pressure are needed, she added.

Women who participated in the study performed three repetitions of each activity, and intraabdominal pressures were measured using a microtip rectal catheter. The mean peak and net intraabdominal pressures associated with the repetitions were calculated and compared with the baseline values in each patient.

The peak values for activities such as coughing, climbing stairs, and lowering to and rising from the floor, and for exercises such as jumping jacks, abdominal crunches, walking, and jogging on a treadmill were not significantly different than those for rising from a chair. Rising from a chair produced significantly higher abdominal pressures than lifting 8–10 pounds, Dr. Weir said.

The activities that produced the highest peak and net pressures included lifting 20 and 35 pounds off the ground, and forceful coughing; those that produced the lowest peak and net pressures were lifting 8 pounds from a low table, from counter height, and overhead.

As weight increased, lifting technique became more important: Compared with rising from a chair, lifting 8 or 13 pounds from the floor produced less intraabdominal pressure, while lifting 20 pounds from the floor did not. But lifting 20 pounds from counter height did produce less intraabdominal pressure.

Furthermore, lying supine on the ground—an unrestricted activity—produced intraabdominal pressure not significantly different from lifting 35 pounds off a counter. And lifting 35 pounds off a counter produced pressure significantly less than lifting 20 pounds off the ground.

In this study, body mass index and abdominal circumference were positively correlated with peak abdominal pressures—but not net abdominal pressures—for many of the activities studied, Dr. Weir noted. No such trend was observed with grip strength (which was used as a proxy for overall strength) or grip pressure. That suggests that overall strength has no impact on the effect of various activities on intraabdominal pressure, she said.

ATLANTA — Most activity restrictions recommended for preventing the progression or recurrence of pelvic floor disorders are unwarranted, results of a small study suggest.

Several daily activities, such as lifting and exercising, are often restricted in patients with pelvic floor disorders and in those who undergo pelvic floor surgery, because there is concern that the activities can increase intraabdominal pressure and thereby exacerbate the disorder, Larissa F. Weir, M.D., explained during the annual meeting of the American Urogynecologic Society.

In fact, of 23 physical activities tested in 30 women who were not undergoing treatment for pelvic floor disorders, most had no greater effect on intraabdominal pressure than unavoidable or typically unrestricted activities had, said Dr. Weir, who was a medical student at the University of Iowa, Iowa City, at the time of the study, but who currently is a first-year resident at the San Antonio Uniformed Services Health Education Consortium.

Lifting technique with higher-weight items did, however, have an effect on intraabdominal pressure, she noted.

Activity restrictions can have a significant impact on daily life, so it is important that they are based on evidence, Dr. Weir said.

These findings lay a foundation for evidence-based revisions of current activity restriction recommendations, but prospective long-term studies of the impact of intraabdominal pressure on pelvic floor function and of the effects of physical activity on intraabdominal pressure are needed, she added.

Women who participated in the study performed three repetitions of each activity, and intraabdominal pressures were measured using a microtip rectal catheter. The mean peak and net intraabdominal pressures associated with the repetitions were calculated and compared with the baseline values in each patient.

The peak values for activities such as coughing, climbing stairs, and lowering to and rising from the floor, and for exercises such as jumping jacks, abdominal crunches, walking, and jogging on a treadmill were not significantly different than those for rising from a chair. Rising from a chair produced significantly higher abdominal pressures than lifting 8–10 pounds, Dr. Weir said.

The activities that produced the highest peak and net pressures included lifting 20 and 35 pounds off the ground, and forceful coughing; those that produced the lowest peak and net pressures were lifting 8 pounds from a low table, from counter height, and overhead.

As weight increased, lifting technique became more important: Compared with rising from a chair, lifting 8 or 13 pounds from the floor produced less intraabdominal pressure, while lifting 20 pounds from the floor did not. But lifting 20 pounds from counter height did produce less intraabdominal pressure.

Furthermore, lying supine on the ground—an unrestricted activity—produced intraabdominal pressure not significantly different from lifting 35 pounds off a counter. And lifting 35 pounds off a counter produced pressure significantly less than lifting 20 pounds off the ground.

In this study, body mass index and abdominal circumference were positively correlated with peak abdominal pressures—but not net abdominal pressures—for many of the activities studied, Dr. Weir noted. No such trend was observed with grip strength (which was used as a proxy for overall strength) or grip pressure. That suggests that overall strength has no impact on the effect of various activities on intraabdominal pressure, she said.

ATLANTA — Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest.

The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Cecilia K. Wieslander, M.D., reported at the annual meeting of the American Urogynecologic Society.

Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers), and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas.

Even among nulliparous smokers, the prevalence of prolapse was significantly greater compared with nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers.

The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study is needed to look at dose-response to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.

ATLANTA — Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest.

The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Cecilia K. Wieslander, M.D., reported at the annual meeting of the American Urogynecologic Society.

Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers), and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas.

Even among nulliparous smokers, the prevalence of prolapse was significantly greater compared with nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers.

The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study is needed to look at dose-response to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.

ATLANTA — Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest.

The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Cecilia K. Wieslander, M.D., reported at the annual meeting of the American Urogynecologic Society.

Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers), and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas.

Even among nulliparous smokers, the prevalence of prolapse was significantly greater compared with nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers.

The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study is needed to look at dose-response to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.

CHARLESTON, S.C. — A combination of intralesional steroids, antifungal therapy, and physical therapy may be effective for the treatment of vulvar vestibulitis syndrome, Carolyn Gardella, M.D., reported in a poster at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Of 21 women treated with intralesional steroids after failing treatment with topical steroids, 68% had complete resolution of symptoms, and all patients had at least 80% improvement.

Twelve of the 21 women also were treated with yeast suppressive therapy, and 14 underwent physical therapy for levator muscle hypertonus, noted Dr. Gardella of the University of Washington, Seattle.

Of the 12 women who also received yeast suppressive therapy, 10 (83%) had complete resolution of symptoms, but only 4 of the 9 (44%) who did not receive yeast suppressive therapy had symptom resolution, Dr. Gardella noted.

All patients were seen by a single clinician at a vulvovaginal specialty clinic during a 5-month period. A chart review showed that the women were symptomatic for a mean of 27 months before presenting at the clinic.

Eleven of the 21 had yeast by culture despite a lack of clinical evidence of yeast vaginitis, and all had failed treatment with 0.25% desoximetasone ointment applied twice daily for an average of 11 weeks.

The intralesional injections included 4-mg of betamethasone and 4 cc of 0.5% bupivacaine with epinephrine; the women received a mean of nine injections.

A randomized controlled trial of a regimen using intralesional steroids, antifungal treatment, and physical therapy for vulvar vestibulitis syndrome is warranted, Dr. Gardella wrote.

Her poster also indicated that the high prevalence of yeast by culture in the study population supports the “biologic plausibility” of empiric yeast suppressive therapy for women with vulvar vestibulitis syndrome.

CHARLESTON, S.C. — A combination of intralesional steroids, antifungal therapy, and physical therapy may be effective for the treatment of vulvar vestibulitis syndrome, Carolyn Gardella, M.D., reported in a poster at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Of 21 women treated with intralesional steroids after failing treatment with topical steroids, 68% had complete resolution of symptoms, and all patients had at least 80% improvement.

Twelve of the 21 women also were treated with yeast suppressive therapy, and 14 underwent physical therapy for levator muscle hypertonus, noted Dr. Gardella of the University of Washington, Seattle.

Of the 12 women who also received yeast suppressive therapy, 10 (83%) had complete resolution of symptoms, but only 4 of the 9 (44%) who did not receive yeast suppressive therapy had symptom resolution, Dr. Gardella noted.

All patients were seen by a single clinician at a vulvovaginal specialty clinic during a 5-month period. A chart review showed that the women were symptomatic for a mean of 27 months before presenting at the clinic.

Eleven of the 21 had yeast by culture despite a lack of clinical evidence of yeast vaginitis, and all had failed treatment with 0.25% desoximetasone ointment applied twice daily for an average of 11 weeks.

The intralesional injections included 4-mg of betamethasone and 4 cc of 0.5% bupivacaine with epinephrine; the women received a mean of nine injections.

A randomized controlled trial of a regimen using intralesional steroids, antifungal treatment, and physical therapy for vulvar vestibulitis syndrome is warranted, Dr. Gardella wrote.

Her poster also indicated that the high prevalence of yeast by culture in the study population supports the “biologic plausibility” of empiric yeast suppressive therapy for women with vulvar vestibulitis syndrome.

CHARLESTON, S.C. — A combination of intralesional steroids, antifungal therapy, and physical therapy may be effective for the treatment of vulvar vestibulitis syndrome, Carolyn Gardella, M.D., reported in a poster at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Of 21 women treated with intralesional steroids after failing treatment with topical steroids, 68% had complete resolution of symptoms, and all patients had at least 80% improvement.

Twelve of the 21 women also were treated with yeast suppressive therapy, and 14 underwent physical therapy for levator muscle hypertonus, noted Dr. Gardella of the University of Washington, Seattle.

Of the 12 women who also received yeast suppressive therapy, 10 (83%) had complete resolution of symptoms, but only 4 of the 9 (44%) who did not receive yeast suppressive therapy had symptom resolution, Dr. Gardella noted.

All patients were seen by a single clinician at a vulvovaginal specialty clinic during a 5-month period. A chart review showed that the women were symptomatic for a mean of 27 months before presenting at the clinic.

Eleven of the 21 had yeast by culture despite a lack of clinical evidence of yeast vaginitis, and all had failed treatment with 0.25% desoximetasone ointment applied twice daily for an average of 11 weeks.

The intralesional injections included 4-mg of betamethasone and 4 cc of 0.5% bupivacaine with epinephrine; the women received a mean of nine injections.

A randomized controlled trial of a regimen using intralesional steroids, antifungal treatment, and physical therapy for vulvar vestibulitis syndrome is warranted, Dr. Gardella wrote.

Her poster also indicated that the high prevalence of yeast by culture in the study population supports the “biologic plausibility” of empiric yeast suppressive therapy for women with vulvar vestibulitis syndrome.

ATLANTA — Advanced age is an independent risk factor for in-hospital mortality and perioperative complications in women undergoing urogynecologic surgery, Vivian W. Sung, M.D., reported at the annual meeting of the American Urogynecologic Society.

In a retrospective cohort study of 264,340 women who underwent inpatient urogynecologic procedures from 1998 to 2002, the in-hospital mortality rate was 2.8% in those aged 80 and older, compared with 0.9% in those 70–79 years old, 0.5% in those aged 60–69, and 0.1% in those younger than 60, said Dr. Sung of Brown University, Providence, R.I.

The findings have important implications for counseling older women about urogynecologic surgery options, because elective surgeries to improve quality of life in these patients are increasingly common. “Elderly women should not be excluded from procedures that may improve their quality of life; however, it is appropriate to consider age alone when counseling women,” Dr. Sung said.

Of the study participants, 19% were aged 60–69 years, 16% were aged 70–79 years, and 4% were at least 80 years old.

The perioperative complication rate was 20% in those ages 80 and older, 16% for those aged 70–79, 13% for those aged 60–69, and 14% for those under age 60.

Mean length of stay in the hospital also was increased in the oldest group of patients (3.2 days among those 80 and older, vs. 2.4 days for the other groups).

Even after adjusting for comorbidity status, increased age was significantly associated with increased risk of in-hospital death and complications. For example, the adjusted odds ratio for in-hospital death was 13.8 among those aged 80 and older without comorbidities, and a similar trend was seen in women with any comorbidities, Dr. Sung noted.

The risk of complications was significantly lower among those aged 80 and older undergoing obliterative procedures, such as colpocleisis or colpectomy, compared with reconstructive procedures, such as vaginal vault suspension with or without hysterectomy (17% vs. 25% complication rate). The risk of in-hospital death with obliterative procedures also was lower in this population, though not significantly, she said.

Women included in the study were part of the National Inpatient Sample. Urogynecologic discharge diagnoses and procedural ICD-9 codes were used to identify those undergoing urogynecologic procedures. The patients had a mean of 2.8 procedures per admission, and this was similar across the age groups.

ATLANTA — Advanced age is an independent risk factor for in-hospital mortality and perioperative complications in women undergoing urogynecologic surgery, Vivian W. Sung, M.D., reported at the annual meeting of the American Urogynecologic Society.

In a retrospective cohort study of 264,340 women who underwent inpatient urogynecologic procedures from 1998 to 2002, the in-hospital mortality rate was 2.8% in those aged 80 and older, compared with 0.9% in those 70–79 years old, 0.5% in those aged 60–69, and 0.1% in those younger than 60, said Dr. Sung of Brown University, Providence, R.I.

The findings have important implications for counseling older women about urogynecologic surgery options, because elective surgeries to improve quality of life in these patients are increasingly common. “Elderly women should not be excluded from procedures that may improve their quality of life; however, it is appropriate to consider age alone when counseling women,” Dr. Sung said.

Of the study participants, 19% were aged 60–69 years, 16% were aged 70–79 years, and 4% were at least 80 years old.

The perioperative complication rate was 20% in those ages 80 and older, 16% for those aged 70–79, 13% for those aged 60–69, and 14% for those under age 60.

Mean length of stay in the hospital also was increased in the oldest group of patients (3.2 days among those 80 and older, vs. 2.4 days for the other groups).

Even after adjusting for comorbidity status, increased age was significantly associated with increased risk of in-hospital death and complications. For example, the adjusted odds ratio for in-hospital death was 13.8 among those aged 80 and older without comorbidities, and a similar trend was seen in women with any comorbidities, Dr. Sung noted.

The risk of complications was significantly lower among those aged 80 and older undergoing obliterative procedures, such as colpocleisis or colpectomy, compared with reconstructive procedures, such as vaginal vault suspension with or without hysterectomy (17% vs. 25% complication rate). The risk of in-hospital death with obliterative procedures also was lower in this population, though not significantly, she said.

Women included in the study were part of the National Inpatient Sample. Urogynecologic discharge diagnoses and procedural ICD-9 codes were used to identify those undergoing urogynecologic procedures. The patients had a mean of 2.8 procedures per admission, and this was similar across the age groups.

ATLANTA — Advanced age is an independent risk factor for in-hospital mortality and perioperative complications in women undergoing urogynecologic surgery, Vivian W. Sung, M.D., reported at the annual meeting of the American Urogynecologic Society.

In a retrospective cohort study of 264,340 women who underwent inpatient urogynecologic procedures from 1998 to 2002, the in-hospital mortality rate was 2.8% in those aged 80 and older, compared with 0.9% in those 70–79 years old, 0.5% in those aged 60–69, and 0.1% in those younger than 60, said Dr. Sung of Brown University, Providence, R.I.

The findings have important implications for counseling older women about urogynecologic surgery options, because elective surgeries to improve quality of life in these patients are increasingly common. “Elderly women should not be excluded from procedures that may improve their quality of life; however, it is appropriate to consider age alone when counseling women,” Dr. Sung said.

Of the study participants, 19% were aged 60–69 years, 16% were aged 70–79 years, and 4% were at least 80 years old.

The perioperative complication rate was 20% in those ages 80 and older, 16% for those aged 70–79, 13% for those aged 60–69, and 14% for those under age 60.

Mean length of stay in the hospital also was increased in the oldest group of patients (3.2 days among those 80 and older, vs. 2.4 days for the other groups).

Even after adjusting for comorbidity status, increased age was significantly associated with increased risk of in-hospital death and complications. For example, the adjusted odds ratio for in-hospital death was 13.8 among those aged 80 and older without comorbidities, and a similar trend was seen in women with any comorbidities, Dr. Sung noted.

The risk of complications was significantly lower among those aged 80 and older undergoing obliterative procedures, such as colpocleisis or colpectomy, compared with reconstructive procedures, such as vaginal vault suspension with or without hysterectomy (17% vs. 25% complication rate). The risk of in-hospital death with obliterative procedures also was lower in this population, though not significantly, she said.

Women included in the study were part of the National Inpatient Sample. Urogynecologic discharge diagnoses and procedural ICD-9 codes were used to identify those undergoing urogynecologic procedures. The patients had a mean of 2.8 procedures per admission, and this was similar across the age groups.

CHARLESTON, S.C. — The association between maternal periodontal disease and increased risk for preterm birth is strongest among black women with moderate or severe periodontal disease, Kim A. Boggess, M.D., reported at the annual meeting of the Infectious Disease Society for Obstetrics and Gynecology.

In a longitudinal observational study of 958 women, 30% had no periodontal disease at enrollment, 60% had mild periodontal disease, and 14% had moderate/severe periodontal disease. Of those with moderate/severe disease, 79% were black, suggesting that the rate of periodontal disease in the pregnant population mirrors that of the nonpregnant population, said Dr. Boggess of the University of North Carolina at Chapel Hill.

The literature shows that, compared with white women, black women have a higher rate of periodontal disease, she noted.

Black women also have a higher rate of preterm birth, and this was true in the current study, as well. Preterm birth occurred in 23% of the 471 black women in the study, compared with 6% of the 487 white women.

Furthermore, the study supports previous research that suggests periodontal disease is associated with preterm delivery. Delivery before 37 weeks' gestation occurred in 29% of those with moderate/severe disease, compared with 19% of those with mild disease, and 11% of those with periodontal health, Dr. Boggess said.

A multivariable logistic regression model that adjusted for maternal age, parity, marital status, insurance use, smoking, and prior preterm birth showed that, taken together, the risk ratios for preterm birth before 37 weeks' and 35 weeks' gestation were highest for those who were black and had moderate or severe periodontal disease. (See box.)

The rate of preterm birth in this population was much higher than would have been expected if race and disease were acting independently. “It looks like race and periodontal disease are acting together in a multiplicative way,” she said.

Possible mechanisms for the differences between black and white women in this study include access to care issues and differences between black and white women in oral microbiology, maternal host response to oral microbes, and stress levels (which have been identified as a risk factor for periodontal disease), Dr. Boggess said, noting that further study is warranted.

Teasing out the mechanisms for the findings in this study could help in the development—and appropriate targeting—of intervention strategies, she said.

CHARLESTON, S.C. — The association between maternal periodontal disease and increased risk for preterm birth is strongest among black women with moderate or severe periodontal disease, Kim A. Boggess, M.D., reported at the annual meeting of the Infectious Disease Society for Obstetrics and Gynecology.

In a longitudinal observational study of 958 women, 30% had no periodontal disease at enrollment, 60% had mild periodontal disease, and 14% had moderate/severe periodontal disease. Of those with moderate/severe disease, 79% were black, suggesting that the rate of periodontal disease in the pregnant population mirrors that of the nonpregnant population, said Dr. Boggess of the University of North Carolina at Chapel Hill.

The literature shows that, compared with white women, black women have a higher rate of periodontal disease, she noted.

Black women also have a higher rate of preterm birth, and this was true in the current study, as well. Preterm birth occurred in 23% of the 471 black women in the study, compared with 6% of the 487 white women.

Furthermore, the study supports previous research that suggests periodontal disease is associated with preterm delivery. Delivery before 37 weeks' gestation occurred in 29% of those with moderate/severe disease, compared with 19% of those with mild disease, and 11% of those with periodontal health, Dr. Boggess said.

A multivariable logistic regression model that adjusted for maternal age, parity, marital status, insurance use, smoking, and prior preterm birth showed that, taken together, the risk ratios for preterm birth before 37 weeks' and 35 weeks' gestation were highest for those who were black and had moderate or severe periodontal disease. (See box.)

The rate of preterm birth in this population was much higher than would have been expected if race and disease were acting independently. “It looks like race and periodontal disease are acting together in a multiplicative way,” she said.

Possible mechanisms for the differences between black and white women in this study include access to care issues and differences between black and white women in oral microbiology, maternal host response to oral microbes, and stress levels (which have been identified as a risk factor for periodontal disease), Dr. Boggess said, noting that further study is warranted.

Teasing out the mechanisms for the findings in this study could help in the development—and appropriate targeting—of intervention strategies, she said.

CHARLESTON, S.C. — The association between maternal periodontal disease and increased risk for preterm birth is strongest among black women with moderate or severe periodontal disease, Kim A. Boggess, M.D., reported at the annual meeting of the Infectious Disease Society for Obstetrics and Gynecology.

In a longitudinal observational study of 958 women, 30% had no periodontal disease at enrollment, 60% had mild periodontal disease, and 14% had moderate/severe periodontal disease. Of those with moderate/severe disease, 79% were black, suggesting that the rate of periodontal disease in the pregnant population mirrors that of the nonpregnant population, said Dr. Boggess of the University of North Carolina at Chapel Hill.

The literature shows that, compared with white women, black women have a higher rate of periodontal disease, she noted.

Black women also have a higher rate of preterm birth, and this was true in the current study, as well. Preterm birth occurred in 23% of the 471 black women in the study, compared with 6% of the 487 white women.

Furthermore, the study supports previous research that suggests periodontal disease is associated with preterm delivery. Delivery before 37 weeks' gestation occurred in 29% of those with moderate/severe disease, compared with 19% of those with mild disease, and 11% of those with periodontal health, Dr. Boggess said.

A multivariable logistic regression model that adjusted for maternal age, parity, marital status, insurance use, smoking, and prior preterm birth showed that, taken together, the risk ratios for preterm birth before 37 weeks' and 35 weeks' gestation were highest for those who were black and had moderate or severe periodontal disease. (See box.)

The rate of preterm birth in this population was much higher than would have been expected if race and disease were acting independently. “It looks like race and periodontal disease are acting together in a multiplicative way,” she said.

Possible mechanisms for the differences between black and white women in this study include access to care issues and differences between black and white women in oral microbiology, maternal host response to oral microbes, and stress levels (which have been identified as a risk factor for periodontal disease), Dr. Boggess said, noting that further study is warranted.

Teasing out the mechanisms for the findings in this study could help in the development—and appropriate targeting—of intervention strategies, she said.

ATLANTA — Women with postpartum depression are more likely than are nondepressed women to have urge urinary incontinence, according to findings presented in a poster at the annual meeting of the American Urogynecologic Society.

Of 146 women in the cross-sectional study, 12% had postpartum depression at the 6-week visit as measured by the Edinburgh Postnatal Depression Scale. At that time, those with depression had a fourfold increase in overall and subscale scores on the Urge-Incontinence Impact Questionnaire (UIIQ), compared with nondepressed women.

This finding suggests depressed patients have more symptoms and a greater impact on their lives from urge urinary incontinence, Dee Fenner, M.D., said.

Depressed and nondepressed patients were similar in age, race, parity, and body mass index. On multivariate analysis, depression scores were shown to be affected by UIIQ score, smoking, and infant feeding mode (bottle vs. breast). But urge incontinence symptoms had the greatest effect on depression scores.

In addition, depressed patients were more than twice as likely to have had a cesarean delivery, Dr. Fenner said.

That finding amplifies the association between urinary incontinence and postpartum depression because studies have shown women who have a C-section are less likely to develop urge urinary incontinence than are those who deliver vaginally, Dr. Fenner noted.

“We hope this will serve for future studies as a model to predict the onset of depression and to actually work out whether or not this is the depression causing the incontinence or the incontinence causing the depression,” she said.

The model could also aid in assessing the role of various markers, such as cortisol levels, hormone fluctuations, and neurotransmitters in depression and incontinence.

ATLANTA — Women with postpartum depression are more likely than are nondepressed women to have urge urinary incontinence, according to findings presented in a poster at the annual meeting of the American Urogynecologic Society.

Of 146 women in the cross-sectional study, 12% had postpartum depression at the 6-week visit as measured by the Edinburgh Postnatal Depression Scale. At that time, those with depression had a fourfold increase in overall and subscale scores on the Urge-Incontinence Impact Questionnaire (UIIQ), compared with nondepressed women.

This finding suggests depressed patients have more symptoms and a greater impact on their lives from urge urinary incontinence, Dee Fenner, M.D., said.

Depressed and nondepressed patients were similar in age, race, parity, and body mass index. On multivariate analysis, depression scores were shown to be affected by UIIQ score, smoking, and infant feeding mode (bottle vs. breast). But urge incontinence symptoms had the greatest effect on depression scores.

In addition, depressed patients were more than twice as likely to have had a cesarean delivery, Dr. Fenner said.

That finding amplifies the association between urinary incontinence and postpartum depression because studies have shown women who have a C-section are less likely to develop urge urinary incontinence than are those who deliver vaginally, Dr. Fenner noted.

“We hope this will serve for future studies as a model to predict the onset of depression and to actually work out whether or not this is the depression causing the incontinence or the incontinence causing the depression,” she said.

The model could also aid in assessing the role of various markers, such as cortisol levels, hormone fluctuations, and neurotransmitters in depression and incontinence.

ATLANTA — Women with postpartum depression are more likely than are nondepressed women to have urge urinary incontinence, according to findings presented in a poster at the annual meeting of the American Urogynecologic Society.

Of 146 women in the cross-sectional study, 12% had postpartum depression at the 6-week visit as measured by the Edinburgh Postnatal Depression Scale. At that time, those with depression had a fourfold increase in overall and subscale scores on the Urge-Incontinence Impact Questionnaire (UIIQ), compared with nondepressed women.

This finding suggests depressed patients have more symptoms and a greater impact on their lives from urge urinary incontinence, Dee Fenner, M.D., said.

Depressed and nondepressed patients were similar in age, race, parity, and body mass index. On multivariate analysis, depression scores were shown to be affected by UIIQ score, smoking, and infant feeding mode (bottle vs. breast). But urge incontinence symptoms had the greatest effect on depression scores.

In addition, depressed patients were more than twice as likely to have had a cesarean delivery, Dr. Fenner said.

That finding amplifies the association between urinary incontinence and postpartum depression because studies have shown women who have a C-section are less likely to develop urge urinary incontinence than are those who deliver vaginally, Dr. Fenner noted.

“We hope this will serve for future studies as a model to predict the onset of depression and to actually work out whether or not this is the depression causing the incontinence or the incontinence causing the depression,” she said.

The model could also aid in assessing the role of various markers, such as cortisol levels, hormone fluctuations, and neurotransmitters in depression and incontinence.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause is simple.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, she said, noting that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not. Motivated patients are going to have better success, Dr. Sands said.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results. One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, Dr. Sands said. Try medical management, but consider surgery in patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery.

Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

For rectal prolapse, it's important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted.

In the most severe cases of constipation, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause is simple.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, she said, noting that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not. Motivated patients are going to have better success, Dr. Sands said.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results. One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, Dr. Sands said. Try medical management, but consider surgery in patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery.

Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

For rectal prolapse, it's important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted.

In the most severe cases of constipation, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause is simple.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, she said, noting that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not. Motivated patients are going to have better success, Dr. Sands said.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results. One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, Dr. Sands said. Try medical management, but consider surgery in patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery.

Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

For rectal prolapse, it's important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted.

In the most severe cases of constipation, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said.

ST. PETE BEACH, FLA. — Maternal infection with the Epstein-Barr virus does not appear to represent a major teratogenic risk, Meytal Avgil, M.D., reported at the annual meeting of the Teratology Society.

The herpes virus—and the cause of infectious mononucleosis—has not been well studied in pregnancy, but in a recent prospective study, the rate of major anomalies was 5% in a group of more than 200 EBV-exposed pregnancies, and 3% in a group of nearly 1,200 controls. The difference between groups was not statistically significant, and the rates were within the expected baseline risk for the general population, said Dr. Avgil of Hebrew University, Jerusalem.

Furthermore, the anomalies did not follow any specific pattern in the EBV group, and were similar in the two groups, she noted.

There also were no differences in the rate of live births, miscarriages, or elective terminations of pregnancy between the two groups; the median birth weight of infants was similar in both groups, ranging from about 3,200 g to 3,300 g. The median gestational age at delivery was 40 weeks in both groups.

ST. PETE BEACH, FLA. — Maternal infection with the Epstein-Barr virus does not appear to represent a major teratogenic risk, Meytal Avgil, M.D., reported at the annual meeting of the Teratology Society.

The herpes virus—and the cause of infectious mononucleosis—has not been well studied in pregnancy, but in a recent prospective study, the rate of major anomalies was 5% in a group of more than 200 EBV-exposed pregnancies, and 3% in a group of nearly 1,200 controls. The difference between groups was not statistically significant, and the rates were within the expected baseline risk for the general population, said Dr. Avgil of Hebrew University, Jerusalem.

Furthermore, the anomalies did not follow any specific pattern in the EBV group, and were similar in the two groups, she noted.

There also were no differences in the rate of live births, miscarriages, or elective terminations of pregnancy between the two groups; the median birth weight of infants was similar in both groups, ranging from about 3,200 g to 3,300 g. The median gestational age at delivery was 40 weeks in both groups.

ST. PETE BEACH, FLA. — Maternal infection with the Epstein-Barr virus does not appear to represent a major teratogenic risk, Meytal Avgil, M.D., reported at the annual meeting of the Teratology Society.

The herpes virus—and the cause of infectious mononucleosis—has not been well studied in pregnancy, but in a recent prospective study, the rate of major anomalies was 5% in a group of more than 200 EBV-exposed pregnancies, and 3% in a group of nearly 1,200 controls. The difference between groups was not statistically significant, and the rates were within the expected baseline risk for the general population, said Dr. Avgil of Hebrew University, Jerusalem.

Furthermore, the anomalies did not follow any specific pattern in the EBV group, and were similar in the two groups, she noted.

There also were no differences in the rate of live births, miscarriages, or elective terminations of pregnancy between the two groups; the median birth weight of infants was similar in both groups, ranging from about 3,200 g to 3,300 g. The median gestational age at delivery was 40 weeks in both groups.

Clostridium sordellii has been confirmed as the cause of sepsis in four women who died in the United States following the use of Mifeprex (mifepristone) for medical abortion, the Food and Drug Administration reported.

The product's package insert—and a related public health advisory released in July after two of the cases were confirmed to be due to C. sordellii—have been updated to reflect the new information. The updates also note that FDA tests of manufacturing lots of mifepristone and misoprostol, which is used along with mifepristone for medical abortion, showed no signs of contamination with the bacteria.

The deaths occurred in California between Sept. 2003 and June 2005. All followed the off-label use of oral mifepristone and vaginal misoprostol given as 200 mg mifepristone orally followed the next day by 800 mcg misoprostol inserted vaginally, rather than the FDA-approved regimen of 600 mg of oral mifepristone followed by 400 mcg of oral misoprostol. An additional death in Canada in 2001 also was linked with C. sordellii infection following medical abortion with the off-label regimen of oral mifepristone followed by vaginal misoprostol.

The absence of any evidence of product contamination with C. sordellii provides support for some experts' belief that mifepristone alters innate immunity, predisposing recipients to potentially lethal infections. This theoretical mechanism of mifepristone-induced sepsis remains under investigation, but the FDA's advisory warns health care providers and patients of the potential risks of Mifeprex use.

Sepsis is a known risk associated with any type of abortion. The presentation in the cases for which medical information is available was not typical, however, according to the FDA.

“All providers of medical abortion and [emergency department] health care providers should investigate the possibility of sepsis in patients who are undergoing medical abortion and present with nausea, vomiting, or diarrhea and weakness with or without abdominal pain, and without fever or other signs of infection more than 24 hours after taking misoprostol,” the advisory states.

A complete blood count should be considered in these patients, and immediate antibiotic treatment that includes coverage for C. sordellii is recommended if infection is suspected.

Danco Laboratories LLC did not immediately respond to a request for comment from this newspaper regarding the recent update to the Mifeprex labeling, but following the labeling change and FDA advisory in July, the company released a statement noting that Mifeprex has been used by more than 460,000 women since its approval in 2000.

Clostridium sordellii has been confirmed as the cause of sepsis in four women who died in the United States following the use of Mifeprex (mifepristone) for medical abortion, the Food and Drug Administration reported.

The product's package insert—and a related public health advisory released in July after two of the cases were confirmed to be due to C. sordellii—have been updated to reflect the new information. The updates also note that FDA tests of manufacturing lots of mifepristone and misoprostol, which is used along with mifepristone for medical abortion, showed no signs of contamination with the bacteria.

The deaths occurred in California between Sept. 2003 and June 2005. All followed the off-label use of oral mifepristone and vaginal misoprostol given as 200 mg mifepristone orally followed the next day by 800 mcg misoprostol inserted vaginally, rather than the FDA-approved regimen of 600 mg of oral mifepristone followed by 400 mcg of oral misoprostol. An additional death in Canada in 2001 also was linked with C. sordellii infection following medical abortion with the off-label regimen of oral mifepristone followed by vaginal misoprostol.

The absence of any evidence of product contamination with C. sordellii provides support for some experts' belief that mifepristone alters innate immunity, predisposing recipients to potentially lethal infections. This theoretical mechanism of mifepristone-induced sepsis remains under investigation, but the FDA's advisory warns health care providers and patients of the potential risks of Mifeprex use.

Sepsis is a known risk associated with any type of abortion. The presentation in the cases for which medical information is available was not typical, however, according to the FDA.

“All providers of medical abortion and [emergency department] health care providers should investigate the possibility of sepsis in patients who are undergoing medical abortion and present with nausea, vomiting, or diarrhea and weakness with or without abdominal pain, and without fever or other signs of infection more than 24 hours after taking misoprostol,” the advisory states.

A complete blood count should be considered in these patients, and immediate antibiotic treatment that includes coverage for C. sordellii is recommended if infection is suspected.

Danco Laboratories LLC did not immediately respond to a request for comment from this newspaper regarding the recent update to the Mifeprex labeling, but following the labeling change and FDA advisory in July, the company released a statement noting that Mifeprex has been used by more than 460,000 women since its approval in 2000.

Clostridium sordellii has been confirmed as the cause of sepsis in four women who died in the United States following the use of Mifeprex (mifepristone) for medical abortion, the Food and Drug Administration reported.

The product's package insert—and a related public health advisory released in July after two of the cases were confirmed to be due to C. sordellii—have been updated to reflect the new information. The updates also note that FDA tests of manufacturing lots of mifepristone and misoprostol, which is used along with mifepristone for medical abortion, showed no signs of contamination with the bacteria.

The deaths occurred in California between Sept. 2003 and June 2005. All followed the off-label use of oral mifepristone and vaginal misoprostol given as 200 mg mifepristone orally followed the next day by 800 mcg misoprostol inserted vaginally, rather than the FDA-approved regimen of 600 mg of oral mifepristone followed by 400 mcg of oral misoprostol. An additional death in Canada in 2001 also was linked with C. sordellii infection following medical abortion with the off-label regimen of oral mifepristone followed by vaginal misoprostol.

The absence of any evidence of product contamination with C. sordellii provides support for some experts' belief that mifepristone alters innate immunity, predisposing recipients to potentially lethal infections. This theoretical mechanism of mifepristone-induced sepsis remains under investigation, but the FDA's advisory warns health care providers and patients of the potential risks of Mifeprex use.

Sepsis is a known risk associated with any type of abortion. The presentation in the cases for which medical information is available was not typical, however, according to the FDA.

“All providers of medical abortion and [emergency department] health care providers should investigate the possibility of sepsis in patients who are undergoing medical abortion and present with nausea, vomiting, or diarrhea and weakness with or without abdominal pain, and without fever or other signs of infection more than 24 hours after taking misoprostol,” the advisory states.

A complete blood count should be considered in these patients, and immediate antibiotic treatment that includes coverage for C. sordellii is recommended if infection is suspected.

Danco Laboratories LLC did not immediately respond to a request for comment from this newspaper regarding the recent update to the Mifeprex labeling, but following the labeling change and FDA advisory in July, the company released a statement noting that Mifeprex has been used by more than 460,000 women since its approval in 2000.