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Treatment options are limited for the approximately 40% of postmenopausal women worldwide who suffer from female sexual dysfunction (FSD). Neural stimulation has shown potential as a treatment for genital arousal FSD, however the mechanisms for its improvement are unknown. One potential cause of some cases of genital arousal FSD are changes to the composition of the vaginal microbiota, which is associated with vulvovaginal atrophy. The primary hypothesis of this study was that neural stimulation may induce healthy changes in the vaginal microbiome, thereby improving genital arousal FSD symptoms. In this study we used healthy rats, which are a common animal model for sexual function, however the rat vaginal microbiome is understudied. Thus this study also sought to examine the composition of the rat vaginal microbiota. Treatment rats (n = 5) received 30 minutes of cutaneous electrical stimulation targeting the genital branch of the pudendal nerve, and Control animals (n = 4) had 30-minute sessions without stimulation. Vaginal lavage samples were taken during a 14-day baseline period including multiple estrous periods and after twice-weekly 30-minute sessions across a six-week trial period. Analysis of 16S rRNA gene sequences was used to characterize the rat vaginal microbiota in baseline samples and determine the effect of stimulation. We found that the rat vaginal microbiota is dominated by Proteobacteria, Firmicutes, and Actinobacteria, which changed in relative abundance during the estrous cycle and in relationship to each other. While the overall stimulation effects were unclear in these healthy rats, some Treatment animals had less alteration in microbiota composition between sequential samples than Control animals, suggesting that stimulation may help stabilize the vaginal microbiome. Future studies may consider additional physiological parameters, in addition to the microbiome composition, to further examine vaginal health and the effects of stimulation.

Objectives. To estimate the proportion of US adults who identify as transgender and to compare the demographics of the transgender and nontransgender populations. Methods. We conducted a secondary analysis of data from states and territories in the 2014 Behavioral Risk Factor Surveillance System that asked about transgender status. The proportion of adults identified as transgender was calculated from affirmative and negative responses (n = 151 456). We analyzed data with a design-adjusted χ 2 test. We also explored differences between male-to-female and nontransgender females and female-to-male and nontransgender males. Results. Transgender individuals made up 0.53% (95% confidence interval = 0.46, 0.61) of the population and were more likely to be non-White (40.0% vs 27.3%) and below the poverty line (26.0% vs 15.5%); as likely to be married (50.5% vs 47.7%), living in a rural area (28.7% vs 22.6%), and employed (54.3% vs 57.7%); and less likely to attend college (35.6% vs 56.6%) compared with nontransgender individuals. Conclusions. Our findings suggest that the transgender population is a racially diverse population present across US communities. Inequalities in the education and socioeconomic status have negative implications for the health of the transgender population.

The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.

PurposeFollowing radiation therapy (RT), women with gynecologic malignancies report high rates of sexual dysfunction, but little is known regarding sexual health communication between these patients and health-care providers. This study assessed these patients’ beliefs/attitudes toward providers’ sexual history taking.MethodsSurveys were administered to women who presented for follow-up care for gynecologic cancers in an academic radiation oncology department. The surveys assessed patient sexual health beliefs and inquiry preferences. Sexual functioning was assessed using the Female Sexual Function Index (FSFI). Ordered logistic regressions were performed to assess for correlations between survey responses, FSFI, and demographic characteristics.ResultsSeventy-five subjects participated. Most (89.8%) had FSFI scores indicating sexual dysfunction. Most patients agreed that sexual function is an important component of overall health (78.7%) and that providers should inquire regularly (62.8%). Few (12.0%) reported embarrassment around provider discussions. Most (62.7%) preferred discussion with female providers, especially married patients (p = 0.03). Half (53.4%) agreed that sexual problems are an unavoidable part of aging, a view that was more common as education level decreased (p = 0.01). Most (62.7%) patients agreed that providers should regularly ask about their sexual history, with patients having significant differences in education level. Patients with low FSFI scores were less likely to report inquiry from their OB/Gyn (p = 0.03).ConclusionsGynecologic cancer radiotherapy patients want to discuss sexual health, but report suboptimal provider inquiry. Patient views and experiences varied based on marital status, education level, and FSFI score. This work highlights the need for improved sexual health communication between cancer patients and providers.

Background/AimsThere is currently no gold standard for evaluating stool burden in the colon for patients with gastrointestinal symptoms. We aim to examine the relationship between fecal loading on single view abdominal X-ray imaging and gastrointestinal symptoms such as constipation, diarrhea, bloating, and accidental bowel leakage in adult outpatients.MethodsThis retrospective, cross-sectional study examined patients seen at University of Michigan from 2005 to 2017. Chart review of demographic information, reported gastrointestinal symptoms, past medical history, and abdominal radiographic imaging was performed. Bivariate analysis was performed to assess associations between these characteristics and fecal loading. Factors independently associated with fecal loading were identified using logistic regression. Significance was established at p < 0.05.ResultsIn total, 319 patients who had an X-ray were included in the final analysis, with 84.0% demonstrating fecal loading on the initial X-ray and most reporting constipation as a symptom (n = 214, 84.3%, p = 0.0334). In logistic regression, a chief complaint of constipation had higher odds of being associated with fecal loading on X-ray compared to diarrhea (adjusted OR 6.41; CI 1.51–27.24, p = 0.0118). Bloating as a reported symptom was statistically significant with an adjusted OR of 2.56 (CI 1.10–5.96, p = 0.0286).ConclusionsConstipation (as a chief complaint) and bloating (as a symptom) were associated with fecal loading on X-ray imaging, while accidental bowel leakage and diarrhea were not.

Introduction and hypothesisValidated questionnaires are commonly used in research, but successful completion rates in clinical settings are largely unknown. The primary goal of this study was to assess the frequency of appropriate completion of a validated research survey. We secondarily examined relationships between demographics and successful questionnaire completion.MethodsNew patients completed a paper form of the Pelvic Floor Bother Questionnaire (PFBQ) to assess pelvic floor symptoms and level of bother. Various aspects of successful survey completion were assessed, including unanswered questions, affirmative responses without selection of a level of bother, or choosing a level of bother despite reporting not having a symptom. Relationships between self-reported demographic characteristics and completion of the survey were also evaluated.ResultsFive hundred and fourteen questionnaires were completed by a cohort of women with a mean age of 57.5 ± 14.4 years (range 19–97). Overall, 45.3% of women (n = 233) completed the entire PFBQ properly as originally described. Women skipped at least one entire question 16.5% of the time. On logistic regression, older age was significantly associated with improper questionnaire completion (55.0 years ±14.9 successful vs 59.6 years ±13.6 unsuccessful completion, p < 0.001 for overall completion). Age was significantly associated with proper completion of every individual PFBQ question, except question 8 concerning fecal incontinence (p = 0.06). Education level was not significantly associated with successful questionnaire completion.ConclusionsOverall successful completion of the survey as designed and validated was low, even in a highly educated population. Ways to simplify the instrument to enhance completion, such as electronic smart questionnaires, should be further investigated.

Introduction and hypothesis We compared two hypotheses as to why obesity is associated with stress urinary incontinence (SUI): (1) obesity increases demand on the continence system (e.g. higher cough pressure) and (2) obesity compromises urethral function and urethrovaginal support. Methods A secondary analysis was performed using data from a case–control study of SUI in women. Measurements of urethrovaginal support (POP-Q point Aa, urethral axis), urethral function (maximal urethral closure pressure, MUCP), and measures of continence system demand (intravesical pressures at rest and during maximal cough) were analyzed. Cases and controls were divided into three body mass index (BMI) groups: normal (18.5–24.9 kg/m 2 ); overweight (25.0–29.9 kg/m 2 ); and obese (≥30 kg/m 2 ). Logistic regression models where created to investigate variables related to SUI for each BMI group. Structural equation modeling was used to test the direct and indirect relationships among BMI, SUI, maximal cough pressure, MUCP, and POP-Q point Aa. Results The study included 108 continent controls and 103 women with SUI. MUCP was the factor most strongly associated with SUI in all BMI groups. Maximal cough pressure was significantly associated with SUI in obese women (OR 3.191, 95% CI 1.326, 7.683; p  < 0.01), but not in normal weight or overweight women. Path model analysis showed a significant relationship between BMI and SUI through maximal cough pressure (indirect effect, p  = 0.038), but not through MUCP (indirect effect, p  = 0.243) or POP-Q point Aa (indirect effect, p  = 0.410). Conclusions Our results support the first hypothesis that obesity is associated with SUI because of increased intravesical pressure, which therefore increases demand on the continence mechanism.

Introduction and hypothesis The goal of this study was to use a well-described system of quantifying levator ani defect (LAD) severity using magnetic resonance imaging (MRI) to examine the relationship between defect severity and the presence or absence of prolapse. Methods This is a secondary analysis of two case–control studies comparing 284 cases (with prolapse) to 219 controls (normal support) defined by using Pelvic Organ Prolapse Quantification (POP-Q) exams. LAD were assessed on MRI, with scores from 0 (no defects) to 6 (complete, bilateral defects). The number of cases and controls at each score were compared. Logistic regression and receiver operating characteristic (ROC) analyses were used to quantify relationships between LAD and prolapse. Results The proportion of cases exceeds the overall prolapse rate in this study at LAD scores ≥3, with higher rates of prolapse at higher LAD scores ( p  < 0.0000001). Prolapse risk stratifies into low risk at LAD scores 0–2, moderate at 3–5, and high at 6. ROC analysis for classification of prolapse based on LAD scores has an area under the curve of 69.9 % ( p  < 0.001), suggesting LAD alone can discriminate between normal support and prolapse for nearly 70 % of patients. Logistic regression identified higher parity and higher LAD scores as independent predictors of prolapse. Conclusions There are three clusters of prolapse risk: low (0–2), moderate (3–5), and high (6). Although LAD have a dose-response-like effect for prolapse, other factors are clearly involved.

Introduction and hypothesis It is commonly believed that pelvic organ prolapse (POP) is associated with cervical elongation. However, cervical lengths have not been formally compared between women with prolapse and those with normal support. Methods Cervix and uterine corpus lengths were measured on magnetic resonance images in a case-control study of 51 women with prolapse and 46 women with normal support determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Group matching ensured similar demographics in both groups. Ranges for normal cervical lengths were determined from the values in the control group in order to evaluate for cervical elongation amongst women with prolapse. Results The cervix is 36.4 % (8.6 mm) longer in women with prolapse than in women with normal pelvic support ( p  < 0.001). Linear regression modeling suggests the feature most highly associated with cervical length is the degree of uterine descent (POP-Q point C). Approximately 40 % of women with prolapse have cervical elongation; 57 % of cervical elongation in prolapse can be explained by a logistic regression-based model including POP-Q point C, body mass index, and menopausal status. Conclusions Cervical elongation is found in one third of women with POP, with the extent of elongation increasing with greater degrees of uterine descent.

Introduction and hypothesis Bony pelvis dimensions have been shown to differ in women with and without pelvic floor dysfunction. The goal of this study was to determine whether bony pelvis dimensions are different when comparing women with severe bilateral levator ani defects (LAD) with those with normal muscles. Methods This is a secondary analysis of a case–control study comparing women with and those without pelvic organ prolapse. Subjects underwent pelvic organ prolapse quantification (POP-Q) examination and were classified as either having prolapse or being normal. All underwent pelvic magnetic resonance imaging (MRI). Levator defects were assessed based on the muscles’ appearance on imaging and subjects were stratified into two groups—women with normal muscles ( n  = 99) and women with severe bilateral LAD ( n  = 50). Bony pelvis dimensions were measured via MRI pelvimetry. The subpubic angle, interspinous and intertuberous diameters, and the sacrococcygeal joint-to-infrapubic point (SCIPP) lengths were compared. Results Both groups had similar demographics. The SCIPP length was 2.5 % (3 mm) shorter in women with severe LAD than in those without defects ( P  = 0.02). The SCIPP measured 4 % (5 mm) less in women with prolapse and severe LAD than in subjects with prolapse but normal muscles ( P  = 0.01). Logistic regression identified SCIPP length and history of forceps delivery as being independent predictors of severe bilateral LAD. Conclusions Severe bilateral LAD are associated with shorter SCIPP length and forceps-assisted vaginal delivery.