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Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.

Groundwater is the most ubiquitous source of liquid freshwater globally, yet its role in supporting diverse ecosystems is rarely acknowledged 1 , 2 . However, the location and extent of groundwater-dependent ecosystems (GDEs) are unknown in many geographies, and protection measures are lacking 1 , 3 . Here, we map GDEs at high-resolution (roughly 30 m) and find them present on more than one-third of global drylands analysed, including important global biodiversity hotspots 4 . GDEs are more extensive and contiguous in landscapes dominated by pastoralism with lower rates of groundwater depletion, suggesting that many GDEs are likely to have already been lost due to water and land use practices. Nevertheless, 53% of GDEs exist within regions showing declining groundwater trends, which highlights the urgent need to protect GDEs from the threat of groundwater depletion. However, we found that only 21% of GDEs exist on protected lands or in jurisdictions with sustainable groundwater management policies, invoking a call to action to protect these vital ecosystems. Furthermore, we examine the linkage of GDEs with cultural and socio-economic factors in the Greater Sahel region, where GDEs play an essential role in supporting biodiversity and rural livelihoods, to explore other means for protection of GDEs in politically unstable regions. Our GDE map provides critical information for prioritizing and developing policies and protection mechanisms across various local, regional or international scales to safeguard these important ecosystems and the societies dependent on them. Mapping of groundwater-dependent ecosystems, which support biodiversity and rural livelihoods, shows they occur on more than one-third of global drylands analysed, but lack protections to safeguard these critical ecosystems and the societies dependent upon them from groundwater depletion.

Women undergoing surgery for vaginal prolapse are at risk for urinary incontinence. In this randomized trial, women who received a midurethral sling had lower rates of incontinence at 3 and 12 months but higher rates of adverse events than those who received sham incisions. One in five women will undergo surgery for pelvic-organ prolapse in her lifetime, 1 and urinary incontinence commonly occurs with pelvic-organ prolapse. In previously continent women with pelvic-organ prolapse, urinary incontinence develops in approximately a quarter of them after prolapse repair; this phenomenon is referred to as occult, latent, de novo, iatrogenic, or potential stress urinary incontinence. 2 In 2006, the Colpopexy and Urinary Reduction Efforts (CARE) trial 2 showed that adding a bladder-neck suspension at the time of abdominal prolapse surgery in women without preoperative stress incontinence significantly reduced the risk of postoperative stress urinary incontinence (23.8%, vs. 44.1% in the control . . .

In a trial comparing onabotulinumtoxinA with an anticholinergic drug, both reduced urgency incontinence episodes. The rates of urinary retention and urinary tract infections were higher with onabotulinumtoxinA, but the rate of dry mouth was higher with anticholinergics. Urgency urinary incontinence is characterized by unpredictable loss of urine; it is a prevalent condition that occurs disproportionately in women, affecting up to 19% of older women in the United States. 1 Anticholinergic medications are used as the primary treatment for this condition. A recent systematic review of trials comparing treatments for urgency urinary incontinence showed that none of the six drugs evaluated was superior to another in treating the condition and that current evidence was insufficient to guide the choice among other therapies, including injections of botulinum toxin. 2 OnabotulinumtoxinA is effective in treating urgency urinary incontinence that is resistant to . . .

Obesity is a modifiable risk factor for urinary incontinence. This study randomly assigned overweight and obese women with urinary incontinence to an intensive 6-month weight-loss program or to a structured education program. More intervention-group participants had clinically relevant reductions in the frequency of episodes of any incontinence, stress incontinence, and urge incontinence. This study randomly assigned overweight and obese women with urinary incontinence to an intensive 6-month weight-loss intervention or to a structured education program. More intervention-group participants had clinically relevant reductions in the frequency of episodes of any incontinence, stress incontinence, and urge incontinence. Urinary incontinence affects more than 13 million women in the United States and has been associated with profound adverse effects on quality of life 1 , 2 ; an increased risk of falls, fractures, 3 and nursing-home admissions 4 ; and more than $20 billion in estimated annual direct health care costs. 5 Observational studies suggest that obesity is a strong risk factor for urinary incontinence, 6 – 9 and preliminary studies suggest that weight loss may have a beneficial effect on urinary incontinence in obese patients. 10 – 14 Reductions in urinary incontinence have been observed in morbidly obese women who have had dramatic weight loss after bariatric . . .

Introduction and hypothesis There are sparse data regarding the long-term efficacy of pelvic floor muscle training (PFMT) for the treatment of urinary incontinence (UI). The objective of this study was to evaluate the impact of an 8-week PFMT program guided by a motion-based intravaginal device versus a standard home program over 24 months. Methods Between October 2020 and March 2021, a total of 363 women with stress or stress-predominant mixed UI were randomized and completed an 8-week PFMT program using a motion-based intravaginal device (intervention group) or a home program following written/video instructions (control group). Participants were not asked to continue training after the 8-week program. At 18 and 24 months’ follow-up, the Urogenital Distress Inventory, short-form (UDI-6) and Patient Global Impression of Improvement (PGI-I) were collected. In the original trial, a total of 139 participants in each arm were needed to detect a 0.3 effect size (alpha = 0.05, power 0.8, one-tailed t test) in the difference in UDI-6 scores. Results A total of 231 participants returned 24-month data. Mean age at 24 months was 51.7 ± 14.5 years, and mean BMI was 31.8 ± 7.4 kg/m 2 . Mean change in UDI-6 scores from baseline to 24 months was greater in the intervention group than the control group (−21.1 ± 24.5 vs −14.8 ± 19.4, p  = 0.04). Reported improvement using PGI-I was greater in the intervention group than in the control group at 24 months (35% vs 22%, p  = 0.03, OR 1.95(95% CI 1.08, 3.57). Conclusions Pelvic floor muscle training guided by a motion-based prescription intravaginal device yielded durable and significantly greater UI symptom improvement than a standard home program, even in the absence of continued therapy.

Introduction and Hypothesis To compare change in urgency urinary incontinence episodes (UUIEs) in women undergoing posterior tibial nerve stimulation (PTNS) plus mirabegron versus PTNS plus placebo for the treatment of refractory urgency urinary incontinence (UUI). The primary hypothesis was that combination therapy is superior to monotherapy. Methods A randomized controlled trial was performed in individuals identifying as female aged ≥ 18 years with UUI symptoms refractory to second-line treatment or who could not tolerate antimuscarinic medications. Both participants and providers were blinded to medication treatment allocation. Participants were randomized (1:1) to PTNS plus mirabegron or PTNS plus placebo. Participants completed a 3-day bladder diary prior to and after 12-week treatment. Validated symptom distress and impact questionnaires were obtained pre- and post-treatment. The primary outcome was change in mean number of UUIEs on a 3-day bladder diary pre- versus post-treatment between arms. Primary and secondary outcomes were analyzed via sample t tests. Results Fifty-four subjects were randomized, mean ± SD baseline age 56.2±15.6 years and body mass index 35.0±9.4 (kg/m 2 ); no differences were noted in any clinical–demographic characteristics. There was a significant difference between arms in mean pre- to post-treatment UUIEs, 9.4±3.9, mirabegron versus 5.3±5.5, placebo ( p =0.007). Significant differences were found pre- compared with post-treatment in urinary frequency, Overactive Bladder Questionnaire Short Form Symptom Bother and Symptom Health-Related Quality of Life scores. Conclusions In subjects undergoing PTNS treatment for refractory UUI and OAB-wet symptoms, the addition of a β-3 agonist produced significant improvement in both objective and subjective overactive bladder symptom outcomes compared with PTNS plus placebo.

Introduction and hypothesis In women with advanced prolapse, differences in vaginal apex anchoring sites may impact surgical outcomes over time. The primary aim was to compare 5-year surgical outcomes of uterosacral ligament suspension (ULS) versus sacrospinous ligament fixation (SSLF) in women with advanced (stage III–IV) prolapse. Methods A secondary analysis was conducted in a subset of women with advanced prolapse from a multicenter randomized trial comparing ULS versus SSLF and its extended follow-up, using publicly accessible de-identified datasets. The primary outcome was time to failure, defined as any one of (1) apical descent > 1/3 into the vaginal canal or anterior/posterior compartment beyond the hymen, (2) bothersome vaginal bulge symptoms, or (3) re-treatment. Secondary outcomes include symptom severity measured by the Pelvic Organ Prolapse Distress Inventory (POPDI) and adverse events. Results Of 285 women, 90/147 (61.2%) in ULS and 88/138 (63.8%) in SSLF had advanced prolapse. Baseline characteristics did not differ between groups except for median-vaginal deliveries (3.0 [2.0, 5.0] versus 3.0 [2.0, 4.0], p  < 0.01). The median time to failure was 1.7 years ULS versus 2.0 years SSLF ( p  = 0.42). Surgical failure increased over time in both groups with no intergroup difference; by year 5, the estimated failure rate was 67.7% ULS versus 71.5% SSLF (adjusted difference −3.8; 95%CI [−21.9, 14.2]). No differences were noted in individual failure components ( p  > 0.05). POPDI scores improved over 5 years without intergroup difference (ULS −68.0 ± 61.1 versus SSLF −69.9 ± 60.3, adjusted difference −0.1 [−20.0, 19.9]). No difference in adverse events were observed ( p  > 0.05). Conclusion In women with advanced prolapse, surgical failure, symptom severity, and adverse events did not differ between ULS and SSLF over 5 years.

Introduction & hypothesisPrevious studies have suggested that women with urinary incontinence have an altered urinary microbiome. We hypothesized that the microbiome in women with mixed urinary incontinence (MUI) differed from controls and tested this hypothesis using bacterial gene sequencing techniques.MethodsThis multicenter study compared the urinary microbiome in women with MUI and similarly aged controls. Catheterized urine samples were obtained; v4–6 regions of the 16S rRNA gene were sequenced to identify bacteria. Bacterial predominance (> 50% of an individual’s genera) was compared between MUI and controls. Bacterial sequences were categorized into “community types” using Dirichlet multinomial mixture (DMM) methods. Generalized linear mixed models predicted MUI/control status based on clinical characteristics and community type. Post-hoc analyses were performed in women < 51 and ≥ 51 years. Sample size estimates required 200 samples to detect a 20% difference in Lactobacillus predominance with P < 0.05.ResultsOf 212 samples, 97.6% were analyzed (123 MUI/84 controls, mean age 53 ± 11 years). Overall Lactobacillus predominance did not differ between MUI and controls (45/123 = 36.6% vs. 36/84 = 42.9%, P = 0.36). DMM analyses revealed six community types; communities differed by age (P = 0.001). A High-Lactobacillus (89.2% Lactobacillus) community had a greater proportion of controls (19/84 = 22.6%, MUI 11/123 = 8.9%). Overall, bacterial community types did not differ in MUI and controls. However, post-hoc analysis of women < 51 years found that bacterial community types distinguished MUI from controls (P = 0.041); Moderate-Lactobacillus (aOR 7.78, CI 1.85–32.62) and Mixed (aOR 7.10, CI 1.32–38.10) community types were associated with MUI. Community types did not differentiate MUI and controls in women ≥ 51 years (P = 0.94).ConclusionsWomen with MUI and controls did not differ in overall Lactobacillus predominance. In younger women, urinary bacterial community types differentiated MUI from controls.