I'm presenting these findings on behalf of my colleagues at the Pelvic Floor Disorders Network. The vaginal and urinary lactobacillus may be associated with health. Vaginal lactobacillus supplementation may decrease urinary infections, suggesting that the vaginal and urinary environments may influence one another. Are the vaginal and urinary microbiomes related? Our objective was to describe the relationship between urinary and vaginal microbiomes using 16S sequencing. We compared similarities and differences in vaginal and urinary bacteria as described by genus and abundance, using canonical correlation analysis, multidimensional scaling, and linear discriminant analysis of effect size. We analyzed the variable regions 1 through 3 and compared matched vaginal and urine samples. Two hundred and ten participants, those with mixed incontinence and controls, contributed specimens. Of these, for the final analysis, we had 197 matched samples. There were no significant differences between MUI and control samples, so the findings are presented in the aggregate. With respect to this last statement, we used canonical correlation analysis, which correlates clinical characteristics against bacterial taxa, noted in yellow. Long lines represent strong correlation. Short lines, poor correlation. MUI and control status had a short line, meaning they correlated poorly with the taxa. Or looking at CCA differently, the left ellipse represents MUI, the right one controls, and as you can see, the ellipses largely overlap. Thus, we aggregated the samples and using multidimensional scaling, we found that the urinary and vaginal microbiomes were similar. The urinary results are in yellow, the vaginal in blue, and although there's more scatter or diversity within the urine, the vaginal ellipse certainly resides within the urinary one. This is confirmed also using canonical correlation, wherein the left ellipse represents urine and the right one, vagina, and again, the two largely overlap. So what is responsible for the similarities between the vagina and urine? In a word, lactobacillus. On this log transform scale with increased bacterial counts at the top of the slide in the vagina and increased counts of bacteria in the urine on the right of the slide, lactobacillus represented in purple resides in the right upper quadrant, meaning that there's a lot of lactobacillus in the vagina and urine. Or illustrated differently in these paired urinary and vaginal samples, wherein an individual's urine sample is at the top and her match sample is directly below, lactobacillus is represented in pink, and there's a lot of pink on these slides. So that for these individual samples of the bacteria represented in this slide, lactobacillus contributed a mean of 53% to the urine and a mean of 64% to the vaginal samples. This is in contrast to the other bacteria represented in this slide, which contributed quite a bit less to both urine and vaginal samples. And indeed, the majority or at least half of the bacteria on these slides contributed only on average 2% to 3% to the individual samples. We also looked at the bacteria that correlated in their presence in vagina and urine. Lactobacillus correlated fairly well, Gardnerella, Prevotella, and Ureaplasma did too. But lactobacillus, by its sheer abundance, largely drove the similarities between the vagina and urine. Although lactobacillus was responsible for the similarities between the two environments, it also differentiated the two, as there was more lactobacillus present in the vagina than in the urine. Tapetomonas and Flavobacterium also differentiated the urinary environment from the vaginal one by their virtual absence in the vagina. So the vaginal and urinary bacterial genera overlap, and the vaginal and urinary microbiomes are related. Lactobacillus is largely responsible for this interrelatedness, although other bacteria contribute as well. Lactobacillus also contributes to the differences, as do Tapetomonas and Flavobacterium. So perhaps the presence and abundance of specific bacteria in the urine and vaginal microbiomes may tip the balance between health and disease in specific individuals. Thank you. Thank you. We have no financially relevant disclosures. So Wang et al. looked at the effect of estrogen on UTI pathogenesis, and a mouse model of UTI was used in which UPEC was instilled into the bladder. The effect of overectomy on clearance of bacteria from the urine was measured. OVX decreased the clearance of bacteria from urine compared to sham at day three after infection. Our lab is interested in the urothelial defense mechanisms against urinary tract infections, and the urothelial cells are the sentinel cells that respond to UPEC. These responses include release of chemokines and cytokines, pyroptosis via inflammasones, which results in the shedding of urothelial cells, and uroplaquin 1A binding to UPEC fimbriae. In our lab, we have created a transgenic mouse, and this mouse has the estrogen receptor beta overexpression at the urothelial level. This was done by a transgene which encodes the UP2 promoter, which is only turned on in the urothelial tissue, with the estrogen receptor gene linked downstream to this gene. What this means is that only the urothelium will overexpress the estrogen receptor beta. Once we created this transgenic animal, which we've designated as UER beta OE positive, we performed anatomic phenotyping. This showed on the graph, the first graph on the left, that the estrogen receptor beta transcripts in the urothelial tissue are significantly higher in the transgenic animal compared to the wild type. Then looking at the graph on the right, we can see that within that animal, there are no other tissues, including the bladder lamina propria, bladder smooth muscle, kidney, liver, and uterus, had increased estrogen receptor beta transcript expression. It was previously demonstrated in our lab that the UER beta OE plus, so that they're transgenic animal, depicted as the red circles, cleared UPEC significantly faster than negative littermates. Negative littermates are siblings that do not carry the transgene, and they are designated as the UER beta OE negative, or minus. The wild type animals behave similarly to the negative littermates, and this work was presented at last year's PFD week. My hypothesis is that estrogen is a necessary component in the estrogen receptor beta upregulated mouse's resistance to urinary tract infection, and that estrogen acts in concert with the ER beta protein as a key contributor to the innate immune response against urinary tract infections at the urothelial level. So I want to talk about the experimental design. We had three groups of mice. Each one of these mice were surgically overectomized, or ooverectomized. After four weeks, the mice were inoculated with uropathogenic E. coli, and after that, the urine and organ CFU measurements were done. The red bar graph is the transgenic animal. The black and the gray are the two negative control mice. On days one, two, three, and four, there was no difference in CFU counts between animals. If you can recall, the graph on the left, which is the data that I just showed, and the one on the right, which was the previous data that we had shown that the mouse clears the urinary tract infections faster, we see that, compared to mitopausal overectomized mice, there was no difference between the three cohorts of animals. However, with estrogen present in the right graph, the estrogen receptor positive animal behaved statistically different than the two controls. What this means is that the removal of estrogen negated this significant difference. So how can we interpret this? First of all, it appears that estrogen is necessary for the estrogen receptor beta's protective effect against urinary tract infections at the urothelial level, and this may be a preliminary step in elucidating another pathophysiologic mechanism as to why post-metapausal females are prone to urinary tract infections compared to pre-metapausal females. I'd like to thank Dr. Chai and Dr. Yeh for their help. Thank you. Thank you. We're open for questions. My question is for Dr. Burns. From your study, you said there were six patients that had a post-operative UTI. Did those patients have any difference in their surgeries? Did they have anti-incontinence procedures at the time? There were no differences as far as their pelvic reconstructions. All had vaginal hysterectomy with or without adenectomy, and then anterior posterior repair and uterine sacral ligament suspension. About half of them had an anti-incontinence procedure at the same time. My name is Ian Field, second year fellow at OHSU. This question is for Dr. Komesu. Good study. It's really important, I think, as we look for, as we're doing more microbiome research to look at the sort of similarity between the two environments, especially in terms of how we capture these samples and looking at the urinary microbiome. I was just curious as to your thoughts on, you know, clean catch versus straight catheterized specimens moving forward in sort of physicians who want to do these kinds of studies, whether that will be important to differentiate between the two or whether it doesn't make much of a difference. Thank you. Based on the literature, our group decided to use the catheterized specimens as the clean catch because you pick up so much, so many, millions of bacteria that others have shown that the clean catch and suprapubic catheterized specimens are superior, at least at this stage in our study. Thank you. I would have to agree. If you want to study the bladder, you need to get urine from the bladder. And it's kind of like if you want to know what's going on in the highlands of Minnesota, the headwaters of Mississippi, you really don't want to be sampling the Mississippi Delta. So until we figure out how to interpret voided urine, I think if you really want to know what's happening in the bladder, use cath urine. So this is for Dr. Burns. Have you taken the OTUs from the lactobacillus OTUs, so that's sequences, for those that don't know what an OTU is, those are sort of proxies for species, and looked, like blasted them to see which of those OTUs are assigned to which species? We do have that data and it will be in the manuscript. As far as looking at characterizing a urinary microbiome, we didn't have enough data to be able to say what would be normal and not normal in our patients who had UTI and didn't, but we will be able to report which species of lactobacillus we saw most commonly. So these are surgery patients, right? Correct. I would venture to guess that you'll find that if you have lactobacillus inners, you're unlikely to get a postoperative UTI, and if you are depleted for inners, you're more likely to, especially if there's a uropathogen present. Thank you. Hey, Alan, can you stay on the mic so you can make a general comment for us? Sure. Can you give us an idea, after you do all extensive cataloging and describing everything, all different conditions, what would be the next approach of taking this data to help us in the world of what we do every day? I know it's not an answerable question, obviously, but can you give us some idea? Well, I can tell you what our approach is. First, we're doing a lot of what you guys have done, which is to catalog who's there under what condition, trying to figure out associations. But an association is an association, it's not a cause or effect. Another thing that you have to do is to figure out the best way to collect urine for answering a question that you want to ask. So we just talked about cath urines, if you want to know what's in the bladder, but you can't go out on the street corner and grab somebody and throw them down and put a catheter in. So if you want to do community studies, you want to do longitudinal studies, you want to study pregnant women, you need to figure out how to use voided urine, and that requires understanding how to interpret the data. We're working on that. And then you need to identify which organisms are most commonly together, so consortia. These are communities of bacteria, the bacteria work together or work against each other. So you need to understand the interactions between those bacteria and between the community and the urothelial cells and the innate immune response. So that's to understand how they work. And for clinicians, I think what we need to do is to identify those organisms that are most likely to either be positive or negative, figure out how to put them on a panel on a lab on a chip so the patient goes in for surgery, and during the pre-op, you take a little bit of urine, you put it on the chip, and out comes an if-then statement, an algorithm that says, well, there's a lot of bacillus inners here in large amounts. This person's unlikely to get a urinary tract infection post-surgery. But if there's a depletion of inners and there's, let's say, E. coli or Klebsiella or Pseudomonas, then this person's likely to. And then there's the question of, what do you do at that moment? And I can't tell you what to do, right? But the first thing we have to know is which organisms are critical for most individuals given whatever set of symptoms they have and whatever procedure's going to happen to determine how you proceed. We have to move on. I'm sorry. We are running a little bit behind. But I want to thank the first... Good afternoon, and thank you for the opportunity to present our work. As we all know, bladder function is dependent on a complex interaction of multiple neural pathways in the central and peripheral nervous system. Most of this process can lead to abnormal bladder function, including overactive bladder. It is well known that the beta-3 adrenergic receptor plays a critical role in this process. As a reminder, sympathetic stimulation via the hypogastric nerve leads to the release of norepinephrine, which stimulates the beta-3 receptor in the bladder. This ultimately results in detrusor muscle relaxation and bladder filling. You can imagine if something changed in the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor and the beta-3 adrenergic receptor There are multiple genotypes at this site, the wild type and two variants. Interestingly, two genetic association studies have found that the variant genotypes occur more often in patients with overactive bladder. Although the mutation appears to be more common in this population, no studies have elucidated the relationship between the presence of the SNP and OAB severity. We hypothesize that in women with overactive bladder, those with the variant genotype would have more severe OAB symptoms than those with the wild type genotype. With that in mind, our primary objective was to determine if the presence of the variant genotype is associated with higher OABQ summary scores. Secondarily, we wanted to know if the presence of the variant genotype is associated with the number of anticholinergic medication failures. I know you may be wondering why we're looking at anticholinergics as opposed to mirabegron, which is a beta agonist, and the answer is twofold. One, we didn't have any mirabegron data for these patients, and two, the beta-3 receptor has been implicated in the inhibition of cholinergic nerve signaling, which does make it feasible or plausible that we should look at this in terms of the function of the SNP. We performed a retrospective cohort study of women with pelvic floor disorders who had previously been enrolled in biorepositories at two academic institutions. All women had urgency urinary incontinence based on a response of somewhat or greater bother to question 16 of the PFDI-20 and had available OABQ data. Previously banked blood samples were thawed, DNA extraction was performed, the SNP was identified by DNA sequencing, and patients were divided into cohorts based on their genotype. Bladder function was then compared using OABQ summary scores. The following data analysis was performed. 303 women with bothersome OAB were included in our study. Nearly 84% of them had the wild-type genotype and 16% were found to be heterozygotes. Our data was in Hardy-Weinberg equilibrium. As shown here, there were no differences in baseline characteristics between our cohort. With regard to AIM-1, OABQ symptom severity and quality of life summary scores were not significantly different between our cohorts. There remained no significant differences between cohorts after controlling for covariance in a linear regression model. We had anticholinergic trial data on 98 patients, 81 wild-types and 17 heterozygotes. There was no difference between our cohorts with the number of medication trials. The strengths of this study include the novel examination of the HIV-3 SNP genotype and its relationship to OAB severity. This is also the first study to look at the SNP in a predominantly non-Hispanic Caucasian population of women with OAB. The limitations of our study include the lack of a non-OAB control group as well as limitations in our medication data. These samples were collected prior to 2012 when mirror background was FDA approved and only 32% of our patients had medication data available. Based on our findings, OAB severity as indicated by OABQ summary scores is not related to the beta-3 codon 64 variant genotype. Given the complexity of bladder physiology, more work is needed to establish the relationship between ADRB3 gene function and OAB. We did not find a relationship between genotype and response to anticholinergic medication, but these conclusions are limited by the small number of patients and medication data available. Thank you and I look forward to questions. Good afternoon and thank you for giving me the opportunity to present our study. Pelvic floor three-dimensional manometry is an established method that can be useful in the evaluation of pelvic floor disorders. When a woman delivers vaginally, one in five sustains levator anae injury with each birth and the effect of these injuries results in increasing of the risk for developing pelvic floor disorders, so in designing a study investigating the effect of aging, it's important to remove vaginal birth as confounding factor. Our objectives were to investigate the correlation between age and three-dimensional pelvic floor manometry pressure measurements and to correlate age and pressure measurements with pelvic floor symptoms. It was a pilot cross-sectional study that was approved by our IRB in Nova Fairfax, Virginia. We had recruited two groups of women, volunteers between March 2017 and December 2017. The younger group there were volunteers, healthy volunteers between 18 and 40 years old of age and the older group between 52 to 85 years old. All of them were nulliparous and we excluded participants with prior incontinence or prolapse surgery with reproductive anomalies, pelvic radiation in the past or inability to complete written questionnaire. All participants were consented by our research team and we obtained the demographic variables including age, height, weight, body mass, index, race and ethnicity. Then participants completed the pelvic floor distress inventory, female sexual function inventory. They all underwent gynecological examination including perspeculum and POPQ and then they had undergone vaginal manometry to obtain the pressure measurements at wrist, squeezing and pushing and the values were obtained at the anterior, posterior, left and right vaginal wall. As we can see here in this slide, this is the map that we obtained when we performed vaginal manometry. If we look in this slide, here are the legs and here is the head and we can see the anterior wall so this is the pubic bone and this area is the levator plate so during squeeze we can see that the color changes to red which indicates the higher pressure. So this is the map that we get when we perform manometry. For our results we had a total of 9 participants with a mean age of 28.6 years old. This were the participants in the younger group and for the older group we had a total of 10 participants with a mean age of 62 years old. All of them were postmenopausal. Regarding the questionnaire and the symptoms, so it was interesting that all the participants were so-called healthy participants that didn't seek any Uruguayan evaluation but they had higher, as we can see here, they had higher scores in the PFDI and despite the fact that they were asymptomatic and for the sexual activity we found that 60% of the older group were sexually active versus 89% of the younger group but regarding the function the scores were not significantly different. For the manometry measurement we found that during Valsalva all the measurements were higher among the older group as we can see here so the red columns represent the measurements of the older group and the blue columns represent the measurements of the younger group so all the measurements were higher regarding the older age. What about resting and squeezing? So it was interesting that despite the fact that the measurements were not significantly different between both groups as we see here but the trend was interesting because at rest pressures were lower in the younger group versus the older group and the trend during squeezing was that the measurements were higher in the younger group versus the older group. So how can we explain our results? So going back to the lens's levels of support so if we look on this slide that represents what happens when a woman pairs down or during rest so the first level that the pressure that is obtained during pushing will pass through the level 1 support which are the ligaments, the uterus sacral ligament and the cardinal ligament and then to level 2 support which is the fascial support of the pubocervical fascia and rectovaginal fascia and the archostendinous levator ani. So if we look at this slide so when a woman pairs down so the first thing that the pressure can pass through is level 1 and then level 2 so if the transducer is here in the vagina during manometry most of the pressure if those levels are intact will be absorbed here and then less pressure will be absorbed in the vaginal transducer versus here in this slide we can see for the older patients that there is a problem already in the level 1 and 2 so we can see that part of the pressure is absorbed here and more pressure is sensed via the transducer so during squeezing we expect the younger group to have higher pressure because it represents the muscles strength as we this is an example comparing the older versus the younger group one of the participants from the older patients so we can see that in the levator plate and the pubic synthesis the pressure was higher during valsalva if I compare it to the younger patient we also the two groups were merged for logistic and linear regression analysis of age versus other variables and the important findings were that age was positively correlated with PFDI scores and with valsalva pressure measurements and linear regression analysis revealed positive trends between the scores, the symptoms of pelvic floor and the valsalva pressure measurements to conclude postmenopausal older nulliparous women have more pelvic floor symptoms when compared with young premenopausal nulliparous women pressure measurements assessed by 3D manometry during valsalva increases significantly with aging pelvic floor symptoms were associated with higher valsalva pressure measured by 3D manometry thank you applause thank you Dr. Chai thank you Dr. Floreira Rodriguez good afternoon all I'm excited to present our work I have no relevant financial disclosures so let me tell you a story in 2007 the maternal fetal medicine networks published a large multi-center study that introduced a now widely used calculator to estimate the probability of a vaginal delivery in women who had a prior cesarean section the calculator shown here uses several factors obstetric history to generate an actual percent probability that someone will successfully complete a VBAT so for example in this test patient after inputting her age her obstetric history it's predicted that she has about a 36.2% chance of actually having a vaginal delivery in 2009 same investigators in a follow up study found that when that predicted probability of VBAT was less than 70% women who opted for a trial of labor were more likely to experience maternal morbidity they described morbidity as uterine rupture wound and infectious complications hysterectomy but didn't include OASIS and everyone in this room knows that there's significant long term and short term morbidity associated with OASIS in addition we know that women who undergo VBAT are at increased risk for OASIS so this led us to wonder if this already published calculator could also be useful in predicting OASIS as a result our aims were to determine the association between the probability of VBAT and OASIS as well as re-evaluate already known risk factors with the goal of generating models to predict OASIS at the time of VBAT so this is a retrospective study at our institution that included all VBATs over this five year period after excluding IUFDs, multi-fetal gestations, women who had pre-viral deliveries we then stratified into two groups based on the presence of OASIS we abstracted obstetric, medical and demographic data and then calculated the predicted probability of VBAT for each of these patients using the aforementioned calculator we then created logistic regression models using variables that were statistically significant on univariate analysis so our final cohort consisted of about 1400 VBATs 73 of whom sustained OASIS making the incidence of OASIS in our cohort about 5.2% mean age of the cohort was about 32 and the mean BMI was 30 and if you look at the graph here those two things age and BMI did not differ between groups most women in our cohort self-identified as Caucasian I do want to draw your attention to the mode of delivery because I do think it's important if you take a look at the women who sustained OASIS a little under half of those women were delivered by forceps delivery in addition if you take a look at the predicted probability of VBAT which we divided into quartiles women who sustained OASIS were less likely to have a high predicted probability of VBAT so in the last column you can see only about 11% of women in the OASIS group had a predicted probability of VBAT that was greater than 75% compared to about a third of women who did not sustain OASIS When we looked at our regression model, we found that the predicted probability of VBAC was independently associated with OASIS. In particular, relative to the women with the highest predicted probability of VBAC, women who had a predicted chance of VBAC between 25 and 50 percent had three times the odds of OASIS. And not surprisingly, similar to previously published studies, forceps, which we do do a lot of at our institution, shame, and episiotomy carried about a 13-fold and 3-fold increase in OASIS. We tested the predicted capability of our model that included race, predicted probability of VBAC, operative delivery, and episiotomy, and we found that the error under the curve was about 0.8, which suggests robust prediction for OASIS. So in conclusion, women with a low likelihood of VBAC, particularly less than 50 percent, have three times the odds of OASIS at the time of VBAC. And I do acknowledge some limitations in our study, particularly in terms of generalizability. We know that obstetric patterns vary widely across the country and the world. In addition, our model is not yet externally validated, which we are working on securing a much larger database from various centers so that we can see if these findings are still true in a different population. Thank you, and I will end by giving a clap. All right. Good afternoon, everyone. I would like to thank the conference organizers as well as the session organizers for allowing me to share my work with you today. In terms of disclosures, this research was supported by grants from the NSF as well as the tobacco settlement funds. So pelvic organ prolapse is a physical, or the POP-Q exam is a physical exam that is performed in order to characterize pelvic organ support. And this system actually relies on the hymenal ring, which is shown in blue. And this is one of the externally visible reference points from which measurements are able to be obtained. And this landmark was chosen not only due to its visibility during clinical examinations, but also because it is assumed to be a fixed point of reference. And so we already know that prolapse significantly impacts the position of the hymenal ring, especially during strain maneuvers. However, here we're illustrating a computational model that was created from a multi-planar MRI of the vagina of a nulliparous woman on the left and a woman with prolapse on the right. And so here we see both models are presented from a sagittal perspective with the anterior bony pelvis on the left and the posterior bony pelvis to the right. And what we'll see is the vagina is shown in green and the hymenal ring position is depicted in blue. And so when we look at the nulliparous patient relative to the parous patient, or the patient with prolapse, what we see is the patient's vagina moves posteriorly and inferiorly. And so it's illustrated here in this image. And so we also hypothesize that because the hymenal ring is a soft tissue, its position may also change even in the absence of prolapse. And so that's what we are emphasizing here with our parous patient. And it's depicted with the similar movement of the posterior and inferior. And so therefore, our objective was to determine if age and parity, which are two of the greatest risk factors for the development of prolapse, impacts the position of the hymenal ring at rest. And so we hypothesize that both parity and age are contributing to that inferior and posterior movement of the hymenal ring. And so we included women or patients who had multi-planar MRI volumes. And these MRI volumes had to provide detailed female pelvic anatomy while at rest. And parous women also had to be vaginally parous. But most importantly, the scans that we used had to show healthy pelvic anatomy, so anatomy without abnormalities that may impact our planes of measurement. And so women were excluded from our study if they had cancers that were related to or within the pelvic region, things like endometriosis or pelvic surgery. And it was due to the unknown impact that these different unknown factors could have on the pelvic tissues and regions of interest. And so our patient cohorts were made. They were characterized by age primarily. And then we also characterized them by parity status, which is shown here. So we have nulliparous and parous for our younger group. And for our older group, we also have nulliparous and parous. And so when we look at the hymenal ring position in the axial view, we were able to take the most inferior and the most anterior and posterior points of the hymenal ring. And when we look at our sagittal view, we're able to take the most inferior—sorry, we were able to take the most inferior aspect of the pubic symphysis and then from there measure the distance to the anterior hymenal ring and the posterior hymenal ring, as shown in this picture. And so when we're considering the impact of age on the hymenal ring position, what we'll end up seeing is that with nulliparous women, both the anterior and the posterior borders are moving away from the pubic symphysis with age at approximately the same distance, and this distance is in millimeters. And so what we see is this is indicating that the borders are moving together. And then when we consider for parous women, while the hymenal ring is positioned further away from the pubic symphysis, in older women, the distance between the anterior and posterior border actually is decreasing with age, and it appears to be driven by the movement of the anterior border away from the pubic symphysis. And this finding actually corroborates with what we see in clinical observations of older women. So when we talk about parity and we're considering that impact on the hymenal ring position, what we see are the young nulliparous women maintain the shortest distance from the pubic symphysis in both the anterior and posterior borders. However, when we look at younger parous women, the posterior border of the hymenal ring moves, and it's a significant distance from the pubic symphysis, and this increase in distance between the hymenal ring borders. So this finding actually supports how the hymenal ring is described in parous women, and when we look at the older parous women, the anterior border shifts away from the pubic symphysis, which ultimately decreases that distance. And so our conclusions were the data supports that the hymenal ring is not a fixed landmark. The POPQ could potentially be underestimating the degree of prolapse, which could impact our surgical outcomes. More investigation is needed to establish clinical relevance and also may be used as a marker for restoration of pelvic organ support. Thank you very much for your time. I probably have time for one, two questions max. Very nice presentations. I have a question for Dr. Brown. So the predictor for OASIS was very interesting. I have a question about how well you think people were at identifying those OASIS, because we know it's underdiagnosed, and whether you've done any sensitivity analyses to see how that would impact it? Yeah, that was definitely something we were concerned about, because even when we got our data, like when we had an institution pull that, we were surprised at the number, 73 in our cohort. So the sensitivity analysis is definitely something that we plan on doing. It was also one of the impetus for us saying that we wanted to do this study again in a much larger database. Our next presentation is Evaluation of Postpartum Pelvic Floor Physical Therapy on Obstetrical Anal Sphincter Injury by Dr. Von Bergen. Thank you. I wanted to thank the scientific committee for allowing us to present our work. These are our disclosures. Pelvic floor dysfunction is a multifactorial condition with risk factors including childbirth. Seventy-five percent of women with pelvic organ prolapse attributed to childbirth and pregnancy. And we know that 30 to 40 percent of women with pelvic organ prolapse experience sexual dysfunction, anal incontinence, and urinary incontinence. Pelvic floor physical therapy is a minimally invasive therapy. However, there's little evidence on the effect of pelvic floor physical therapy in women undergoing primary perineal repair after an obstetrical anal sphincter injury. The objective of our study was to evaluate the effect of a short course of postpartum pelvic floor physical therapy among women with an obstetrical anal sphincter injury. This was a multi-centered randomized controlled trial. We recruited 50 women to take part in this pilot study. Potential participants were identified through daily sign-out logs and approached on the postpartum floor. Participants were randomized in a one-to-one fashion to pelvic floor physical therapy or no treatment. Women were included if they were at least 18 years of age, were able to read and speak English, had a vaginal delivery complicated by OASIS. They were excluded if they had a history of a previous vaginal delivery after 24 weeks. Women in the pelvic floor physical therapy group completed 12 weeks of pelvic floor therapy. These were weekly sessions that were 60 minutes in length and started at one week postpartum. Participants completed five validated questionnaires at the following time point. Women in the control group were considered to be the standard of care. However, they did complete the same validated questionnaires as those in the physical therapy group. The five validated quality of life questionnaires are listed. The outcome was changed in the pelvic floor distress inventory or PFDI-20 at 12 weeks postpartum. Eighty-nine women were assessed for eligibility. Fifty women were enrolled. Eighteen women underwent physical therapy and 25 received the standard of care. Nine women in the physical therapy group were lost to follow-up and seven in the control group were lost to follow-up. Twenty-five women in each group were analyzed and attend to treat analysis. The maternal age at delivery in the physical therapy group was 32 and 33 in the control group. There was no difference between the two groups in regards to body mass index, gestational age at delivery, rate of episiotomy or rate of instrumented vaginal delivery. Eighty percent of women had a third-degree laceration in both groups and 20 percent had a fourth-degree laceration. Over the next few slides, you will see the quality of life questionnaires represented in a graphical presentation. For each group, you will see that the participant's scores during their pregnancy is separated from their scores during the follow-up visit. This is to represent how a woman felt their pelvic floor condition was during their pregnancy. The control group is in red and the intervention group is in blue. On the pelvic floor, on the PFDI-20, higher scores indicate more bother and distress caused by the pelvic floor dysfunction. At 12 weeks postpartum, women in both groups reported improvement in their symptoms and there was found to be no difference between the group. The pelvic floor physical therapy group reported a median decrease of 11.5 compared to the control arm which reported a difference of 6.9. When looking at the pelvic floor impact questionnaire, again you can see from the immediate postpartum period to 12 weeks, women had an improvement in their pelvic floor symptoms. On the female sexual function index, higher scores indicate better sexual function. There was no difference seen between the two groups. And they both had a total score that was less than or equal to 26.55 which indicates persistent sexual dysfunction. Now when women were asked in the global impression improvement how they felt compared to how they felt immediately after delivery, we found that at 12 weeks postpartum, 73% of women felt like they felt better in the intervention group or the PT group compared to the control group which reported that 47.1% felt better. So in conclusion, at 12 weeks postpartum, both groups showed an improvement in pelvic floor symptoms based on quality of life questionnaires. More women felt their pelvic floor symptoms were better in the pelvic floor physical therapy arm compared to our control arm, although these results were not statistically significant. Given that this is a pilot study, larger studies with longer term follow-up are needed. Thank you. Thank you for the opportunity to present this work. You can see here our disclosures. The objective of this study was to evaluate the impact of breastfeeding on postpartum lower urinary tract, vaginal, and sexual function symptoms. We hypothesized that women who were breastfeeding would have worse scores on the urinary distress inventory six or UDI six than women who were not breastfeeding at three months postpartum. For our secondary outcomes, we wanted to look at impact on quality of life. We used the IIQ-7, or incontinence impact questionnaire seven. For vaginal symptoms, we used the most bothersome symptom score, or MBS. And for sexual function, we used the pelvic organ prolapse incontinence sexual questionnaire, i.e. revised or PISQ-IR. This was a prospective cohort study, and we included primiparous women who had singleton deliveries after 34 weeks who could complete the questionnaire in English. Here you can see the flow of our study. At baseline, women were offered a paper questionnaire in the hospital to complete questions about their breastfeeding habits, the UDI six, the IIQ-7, and the MBS. And at this time point, they were asked to recall their pre-pregnancy symptoms. At six weeks, three months, and six months, they completed similar questionnaires with the addition of the PISQ-IR at three and six months. At those time points, they were asked to reflect on their current symptoms within the preceding two weeks, and they completed all of these online using the REDCap system. For our cohorts, we defined them based upon their three-month responses. The breastfeeding group were those who self-reported as primarily breastfeeding at three months, and that was defined as greater than 75% of the babies' feeds were coming from the mother's milk. The non-breastfeeding cohort were those who self-reported as not breastfeeding at three months, and also had not been breastfeeding since at least six weeks postpartum. For our sample size calculation, we considered a minimum important difference of 11.6 points for the UDI six, and to achieve 80% power, we needed 74 participants per arm. We completed bivariate and multivariable analyses and controlled for age, race, BMI, diabetes, and infant-weighted delivery. We screened over 6,000 women. Nearly 1,200 were eligible and were offered participation. 361 participated, and 183 met our cohort definitions and were included in the analysis. 110 of those were breastfeeding, and 73 were non-breastfeeding. Our overall demographics, the population was about 27 years old, 53% Caucasian, and 62% had a vaginal delivery. The breastfeeding cohort were more likely to be older, white, married, and have higher education. Here you can see the UDI six scores, and at three months, they were similar between the groups. There was no significant difference between IQ scores between the breastfeeding and non-breastfeeding groups at three months either. Here are the vaginal symptom scores. The breastfeeding group were more likely to have vaginal dryness, with an odds ratio of 2.82. As far as sexual function, the not sexually active breastfeeding participants had lower partner-related scores than their non-breastfeeding counterparts, and lower means less impact for that instrument. The sexually active breastfeeding group had higher condition impact scores than their non-breastfeeding counterparts, indicating higher impact. At six months, we did not see any significant differences between UDI six, IQ seven, or MBS between groups. And in the PISQ-IR, the breastfeeding group had lower scores in the not sexually active partner-related, sexually active arousal orgasm, and sexually active condition-specific domains. They also had higher scores in the not sexually active global quality domain. This study is limited by inherent differences between the cohorts of women who choose to breastfeed and those who do not, and the fact that we did not have any physical exam or laboratory components. However, it's a large prospective cohort using validated measures in a significantly understudied and clinically relevant population. Breastfeeding impacts vaginal dryness and sexual function symptoms postpartum. However, we did not see any effect on lower urinary tract symptoms. Breastfeeding women were almost three times more likely to have vaginal dryness at three months, and we found mixed impact on sexual function at three and six months. Thank you. Fibrillin V, a cellular matrix protein that promotes elastogenesis and inhibits MMP9, an enzyme involved in extracellular matrix degradation, has been studied extensively due to its role in development of pelvic organ prolapse in animal models. Previous work indicated that vaginal injury-induced degradation of Fibrillin V was rescued by the protease inhibitor actinonin. Further rescue of Fibrillin V was accompanied by improvement in biomechanics of the vaginal wall after injury. Here we aimed to investigate the effect of pregnancy, vaginal delivery, and vaginal laceration on postpartum recovery of vaginal Fibrillin V. Also, we compared the dynamics of Fibrillin V synthesis and degradation, as well as its effect on protease inhibition with actinonin in both nonpregnant and pregnant rat models. Nonpregnant, antepartum day 21, the day prior to delivery, and parturent sprogdoli rats at 12 hours, 24 hours, and 7 days postpartum were studied after posterior vaginal wall surgical injury. At the time of injury, which was performed near delivery in the pregnant group, animals were injected with either phosphate-buffered saline, a neutral buffer acting as control agent, or a neutral buffer acting as a control agent. A neutral buffer acting as control, or 200 microliters of actinonin. Nonpregnant, uninjured animals were used as controls. The bar graph on the left depicts relative Fibrillin V content per milligram of protein in nonpregnant animals. As indicated by the blue bars, injury resulted in loss of Fibrillin V that recovered on postpartum day 7. In this nonpregnant model, the protease inhibitor actinonin in red completely rescued injury-induced loss of Fibrillin V. In pregnant animals, Fibrillin V was already downregulated significantly. This is a long-term adaptation of pregnancy, not due to proteolysis. Aside from a transient burst at 24 hours, Fibrillin V did not recover 7 days after obstetrical injury. The red bars indicate that injection of the protease inhibitor actinonin of obstetrical injury improved vaginal Fibrillin V levels, but the rescue was only partial in stark contrast to the rather dramatic effects in nonpregnant animals. Rings of distal vaginal tissue were evaluated biomechanically. This graph depicts changes in stiffness, or resistance to deformation, at 7 days after injury in both the nonpregnant and pregnant groups. The yellow bar represents uninjured nonpregnant controls, and the blue bars are injured controls, whereas the red bars represent animals injected with actinonin at the time of vaginal injury. Although actinonin increased rate of recovery of biomechanical properties in the postpartum rat vagina at 72 hours postpartum, the comparative time point of 7 days did not demonstrate rescue of stiffness in the pregnant animals as it did in the nonpregnant animals. This work indicates that the mechanism of injury-induced loss of vaginal Fibrillin V in nonpregnant animals differs significantly from pregnant animals. Our data support the idea that in the nonpregnant injury model, Fibrillin V is regulated by proteolysis, and a local administration of actinonin, a protease inhibitor, completely rescued injury-induced loss. In contrast, in the pregnant injury model, loss of Fibrillin V is only partially mediated by proteolysis with other remodeling factors likely playing a more significant role. Further study is needed to determine optimal dosing and timing of actinonin administration and the role of other factors that contribute to the rescue of the vaginal matrix after vaginal delivery. Thank you. Transvaginal Surgical Management of Advanced Prolapse, the case of the 22 cm prolapse. We have no disclosures. The objective of this video is to demonstrate a transvaginal surgical technique for the reduction of an advanced case of pelvic organ prolapse, measuring 22 cm. The patient is a 58-year-old Caucasian woman with a history of five prior vaginal deliveries who presented with complaints of bothersome vaginal bulge and vaginal bleeding. She had recently been evaluated at an outside hospital for vaginal bleeding and was referred to Houston Methodist Hospital for management of irreducible prolapse. The patient initially noticed the bulge 10 years ago and reported that it had been worsening. However, it was not bothersome until she began having vaginal bleeding three months prior. She stated that secondary to her prolapse, she had difficulty sitting down and ambulating. She also reported urinary incontinence for the past five years. She reported leak with urgency and also voiding dysfunction with slow bladder emptying and need for Valsalva, Creed Assist and positional voiding to improve her flow. She denied history of hematuria and urinary tract infections. She reported regular bowel movements daily. She was not sexually active due to the presence of prolapse. However, she desired to be sexually active in the future. She had no significant past medical or surgical history. On exam, the cervix was noted to be fungating and friable. POPQ exam demonstrated a total vaginal length of 20.5 cm and the cervix measuring 18.5 cm outside of the hymen. The patient was counseled on management options. Due to the presence of severe non-reducible Procedentia that was impeding her daily life, she desired to proceed with surgical management. She was then referred to Gynecologic Oncology for cervical and endometrial biopsies and imaging given the irregularity of her cervix. On Gynecologic Oncology evaluation, three biopsies were performed of the fungating cervical mass. The biopsy results showed proliferative squamous epithelium. However, no high-grade dysplasia or invasive malignancy were seen. An MRI of the pelvis was obtained which demonstrated a total descent of 22 cm with distal colon, loops of small bowel, bladder, and uterus contained within the prolapse. There was mild left-sided hydronephrosis. The uterus measured 6.5 x 4.4 x 4.6 cm with the endometrial stripe measuring 4 mm. Bilateral ovaries were unremarkable. The decision was made to proceed with surgical management via transvaginal approach with a total vaginal hysterectomy, bilateral self-injectomy, utero-sacral ligament suspension, anterior and posterior repair, and cystoscopy. On exam under anesthesia, the prolapse was noted to measure greater than 20 cm outside of the hymen and was unable to be reduced. At the most distal edge of the prolapse, there was noted to be hypertrophy of the vaginal epithelium into a fungating and fibril mass measuring 6 cm in width. The prolapse was noted to weigh approximately 15 lbs. Therefore, the decision was made to proceed with placing the prolapse on a Mayo stand in order to decrease the vaginal pressure and operative strain. Upon surgeon examination, the uterus was palpable within the prolapse sac measuring 6 cm in length. Also within the prolapse, multiple loops of bowel were palpable. During the examination, the friable cervix tissue began to slough off. Alice clamps were placed on the vaginal epithelium at the level of the cervix and the skin was incised with Mayo scissors. The underlying connective tissue was then continually grasped with Alice clamps and sharp dissection was performed for 30 minutes. The peritoneum was then entered sharply and the posterior peritoneal edge was incorporated into the vaginal epithelium with a running vicral suture to improve hemostasis. The uterus was then everted to better visualize the anatomy and the utero ovarian ligament was visible. The hysterectomy and bilateral self-injectomy were then performed in a standard fashion. After removal of the uterus and bilateral fallopian tubes, the bowel was then packed with two moist laparotomy sponges. The excess vaginal epithelium was measuring at least 22 cm anteriorly and posteriorly. The vaginal epithelium was then injected with diluted lidocaine with epinephrine. The epithelium was then dissected off of the underlying connective tissue using sharp and blunt dissection. Due to the inability to access the utero sacral ligaments, due to the inability to access the utero sacral ligaments, decision was made to proceed with sacrospinous ligament fixation. The right sacrospinous ligament was dissected off of the posterior wall. The right ischial spine was palpable. The CAPIO device was then used with OPDS to place two sutures within the right sacrospinous ligament. The same procedure was then carried out on the left side. The remaining prolapse was then manually reduced. The fibromuscularis of the anterior vaginal wall was then placated in a vertical fashion using a running suture of 2-O-PDS. Three total layers of placation were performed in order to reduce the prolapse. The vaginal epithelium was then trimmed. The sacrospinous ligament sutures were then tied, thus further reducing the prolapse. Additional placation of the fibromuscularis layer was then performed. Additional vaginal epithelium was then removed. The anterior vaginal epithelium was then closed with a running suture of 3-O monocryl. The anterior vaginal epithelium was then removed. The anterior vaginal epithelium was then removed. Cystoscopy was then performed, revealing over 100 small bladder calculi. Urology was then consulted for stone removal. The ureters were then visualized with bilateral efflux seen. The bladder was otherwise unremarkable. The levator ani muscles were noted to be significantly separated, therefore they were re-approximated with a running suture of O-Vicol. An additional layer of O-Vicol was then placed for further perineal support. The remainder of the posterior repair was then carried out in a standard fashion. This photo demonstrates the amount of vaginal epithelium that was removed throughout the case. After completion of the procedure, the total vaginal length measured 7-7.5 inches. The total vaginal length measured 7-7.5 inches. The total vaginal length measured 7-7.5 inches. After completion of the procedure, the total vaginal length measured 7 centimeters, with the genital hiatus measuring 4 centimeters, and the perineal body measuring 2.5 centimeters. Excellent apical suspension was noted. In conclusion, this video demonstrates the management of a unique case of advanced prolapse measuring 22 centimeters. It also demonstrates the vaginal surgical technique for the detection of an advanced prolapse.

transvaginal surgical management

pelvic organ prolapse

vaginal deliveries

vaginal bulge

vaginal bleeding

total vaginal hysterectomy

self-injectomy

utero-sacral ligament suspension

anterior and posterior repair

cystoscopy