OBJECTIVE: To estimate the prevalence and trends of these pelvic floor disorders in U.S. women from 2005 to 2010. METHODS: We used the National Health and Nutritional Examination Survey from 2005–2006, 2007–2008, and 2009–2010. A total of 7,924 nonpregnant women (aged 20 years or older) were categorized as having: urinary incontinence (UI)—moderate to severe (3 or higher on a validated UI severity index, range 0–12); fecal incontinence—at least monthly (solid, liquid, or mucus stool); and pelvic organ prolapse—seeing or feeling a bulge. Potential risk factors included age, race and ethnicity, parity, education, poverty income ratio, body mass index ([BMI] less than 25, 25-29, 30 or greater), comorbidity count, and reproductive factors. Using appropriate sampling weights, weighted χ analysis and multivariable logistic regression models with odds ratios and 95% confidence intervals (95% CIs) were reported. RESULTS: The weighted prevalence rate of one or more pelvic floor disorders was 25.0% (95% CI 23.6–26.3), including 17.1% (95% CI 15.8–18.4) of women with moderate-to-severe UI, 9.4% (95% CI 8.6–10.2) with fecal incontinence, and 2.9% (95% CI 2.5–3.4) with prolapse. From 2005 to 2010, no significant differences were found in the prevalence rates of any individual disorder or for all disorders combined ( P >.05). After adjusting for potential confounders, higher BMI, greater parity, and hysterectomy were associated with higher odds of one or more pelvic floor disorders. CONCLUSION: Although rates of pelvic floor disorders did not change from 2005 to 2010, these conditions remain common, with one fourth of adult U.S. women reporting at least one disorder. LEVEL OF EVIDENCE: III

Midurethral slings are increasingly used for the treatment of stress incontinence, but there are limited data comparing types of slings and associated complications. We performed a multicenter, randomized equivalence trial comparing outcomes with retropubic and transobturator midurethral slings in women with stress incontinence. The primary outcome was treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). The predetermined equivalence margin was ±12 percentage points. A total of 597 women were randomly assigned to a study group; 565 (94.6%) completed the 12-month assessment. The rates of objectively assessed treatment success were 80.8% in the retropubic-sling group and 77.7% in the transobturator-sling group (3.0 percentage-point difference; 95% confidence interval [CI], −3.6 to 9.6). The rates of subjectively assessed success were 62.2% and 55.8%, respectively (6.4 percentage-point difference; 95% CI, −1.6 to 14.3). The rates of voiding dysfunction requiring surgery were 2.7% in those who received retropubic slings and 0% in those who received transobturator slings (P=0.004), and the respective rates of neurologic symptoms were 4.0% and 9.4% (P=0.01). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life. The 12-month rates of objectively assessed success of treatment for stress incontinence with the retropubic and transobturator approaches met the prespecified criteria for equivalence; the rates of subjectively assessed success were similar between groups but did not meet the criteria for equivalence. Differences in the complications associated with the two procedures should be discussed with patients who are considering surgical treatment for incontinence. (ClinicalTrials.gov number, NCT00325039.)

More than 225 000 surgeries are performed annually in the United States for pelvic organ prolapse (POP). Abdominal sacrocolpopexy is considered the most durable POP surgery, but little is known about safety and long-term effectiveness. To describe anatomic and symptomatic outcomes up to 7 years after abdominal sacrocolpopexy, and to determine whether these are affected by concomitant anti-incontinence surgery (Burch urethropexy). Long-term follow-up of the randomized, masked 2-year Colpopexy and Urinary Reduction Efforts (CARE) trial of women with stress continence who underwent abdominal sacrocolpopexy between 2002 and 2005 for symptomatic POP and also received either concomitant Burch urethropexy or no urethropexy. Ninety-two percent (215/233) of eligible 2-year CARE trial completers were enrolled in the extended CARE study; and 181 (84%) and 126 (59%) completed 5 and 7 years of follow-up, respectively. The median follow-up was 7 years. Symptomatic POP failure requiring retreatment or self-reported bulge; or anatomic POP failure requiring retreatment or Pelvic Organ Prolapse Quantification evaluation demonstrating descent of the vaginal apex below the upper third of the vagina, or anterior or posterior vaginal wall prolapse beyond the hymen. Stress urinary incontinence (SUI) with more than 1 symptom or interval treatment; or overall UI score of 3 or greater on the Incontinence Severity Index. By year 7, the estimated probabilities of treatment failure (POP, SUI, UI) from parametric survival modeling for the urethropexy group and the no urethropexy group, respectively, were 0.27 and 0.22 for anatomic POP (treatment difference of 0.050; 95% CI, -0.161 to 0.271), 0.29 and 0.24 for symptomatic POP (treatment difference of 0.049; 95% CI, -0.060 to 0.162), 0.48 and 0.34 for composite POP (treatment difference of 0.134; 95% CI, -0.096 to 0.322), 0.62 and 0.77 for SUI (treatment difference of -0.153; 95% CI, -0.268 to 0.030), and 0.75 and 0.81 for overall UI (treatment difference of -0.064; 95% CI, -0.161 to 0.032). Mesh erosion probability at 7 years (estimated by the Kaplan-Meier method) was 10.5% (95% CI, 6.8% to 16.1%). During 7 years of follow-up, abdominal sacrocolpopexy failure rates increased in both groups. Urethropexy prevented SUI longer than no urethropexy. Abdominal sacrocolpopexy effectiveness should be balanced with long-term risks of mesh or suture erosion. clinicaltrials.gov Identifier: NCT00099372.

Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes. We performed a multicenter, randomized, noninferiority trial involving women with uncomplicated, demonstrable stress urinary incontinence to compare outcomes after preoperative office evaluation and urodynamic tests or evaluation only. The primary outcome was treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of “much better” or “very much better” on the Patient Global Impression of Improvement. The predetermined noninferiority margin was 11 percentage points. A total of 630 women were randomly assigned to undergo office evaluation with urodynamic tests or evaluation only (315 per group); the proportion in whom treatment was successful was 76.9% in the urodynamic-testing group versus 77.2% in the evaluation-only group (difference, −0.3 percentage points; 95% confidence interval, −7.5 to 6.9), which was consistent with noninferiority. There were no significant between-group differences in secondary measures of incontinence severity, quality of life, patient satisfaction, rates of positive provocative stress tests, voiding dysfunction, or adverse events. Women who underwent urodynamic tests were significantly less likely to receive a diagnosis of overactive bladder and more likely to receive a diagnosis of voiding-phase dysfunction, but these changes did not lead to significant between-group differences in treatment selection or outcomes. For women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00803959.)

Female pelvic floor disorders are a spectrum of conditions including pelvic organ prolapse and urinary incontinence. Pelvic organ prolapse occurs when the uterus descends into the lower vagina or vaginal walls protrude beyond the vaginal opening. Approximately 300 000 surgeries for prolapse are performed annually in the United States.¹ Most surgery for pelvic organ prolapse (80%-90%) is performed transvaginally, with the remainder performed abdominally.^1-4 Increasingly, surgeons recognize that adequate apical (upper vaginal) support is an essential component of a durable repair.^5-7 The sacrospinous ligament fixation (SSLF) and the uterosacral ligament vaginal vault suspension (ULS) are the 2 most widely used vaginal procedures for correcting apical prolapse. The SSLF procedure suspends the vaginal apex to the sacrospinous ligament using an extraperitoneal approach whereas the ULS suspends the vaginal apex bilaterally to the proximal remnants of the uterosacral ligaments using an intraperitoneal approach. To date, no comparative data exist about the relative efficacy and safety of these 2 procedures.⁸