Pallavi Latthe

Background: Female genital mutilation is an important UK health-care challenge. There are no health benefits of female genital mutilation, and it is associated with lifelong physical, psychological and sexual impacts. The annual cost to the NHS to care for survivors is £100M. Deinfibulation may improve the health and well-being of some women, but there is no consensus on the optimal timing of surgery for type 3 survivors. UK care provision is reportedly suboptimal. Objectives: We aimed to explore the views of survivors, men and health-care professionals on the timing of deinfibulation surgery and NHS service provision. Methods: This was a qualitative study informed by the Sound of Silence framework. This framework is useful for researching sensitive issues and the health-care needs of marginalised populations. A total of 101 interviews with 44 survivors, 13 men and 44 health-care professionals were conducted, supplemented by two workshops with affected communities (participants, n = 10) and one workshop with stakeholders (participants, n = 30). Data were analysed using a hybrid framework method. Results: There was no clear consensus between groups on the optimal timing of deinfibulation. However, within groups, survivors expressed a preference for deinfibulation pre pregnancy; health-care professionals preferred antenatal deinfibulation, with the caveat that it should be the survivor’s choice. There was no consensus among men. There was agreement that deinfibulation should take place in a hospital setting and be undertaken by a suitable health-care professional. Decision-making around deinfibulation was complex. Deficiencies in professionals’ awareness, knowledge and understanding resulted in impacts on the provision of appropriate care. Although there were examples of good practice and positive care interactions, in general, service provision was opaque and remains suboptimal, with deficiencies most notable in mental health. Deinfibulation reportedly helps to mitigate some of the impacts of female genital mutilation. Interactions between survivors and health-care professionals were disproportionately framed around the law. The way in which services are planned and provided often silences the perspectives and preferences of survivors and their families. Limitations: Only a minority of the interviews were conducted in a language other than English, and the recruitment of survivors was predominantly through maternity settings, which meant that some voices may not have been heard. The sample of men was relatively small, limiting interpretation. Conclusions: In general, service provision remains suboptimal and can silence the perspectives and preferences of survivors. Deinfibulation services need to be widely advertised and information should highlight that the procedure will be carried out in hospital by suitable health-care professionals and that a range of time points will be offered to facilitate choice. Future services should be developed with survivors to ensure that they are clinically and culturally appropriate. Guidelines should be updated to better reflect the needs of survivors and to ensure consistency in service provision. Future work: Research is needed to (1) map female genital mutilation service provision; (2) develop and test effective education to address deficits in awareness and knowledge for affected communities and health-care professionals; and (3) develop, monitor and evaluate clinically and culturally competent female genital mutilation services. Trial registration: Current Controlled Trials ISRCTN14710507. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 27, No. 3. See the NIHR Journals Library website for further project information.

The field of urogynecology and female pelvic medicine and reconstructive surgery (FPMRS) is dedicated entirely to the goal of improving the lives of women who suffer from pelvic floor disorders, while both minimizing risks and maximizing efficacious treatments. Differences between local, regional, national, and even international surgical settings can have impacts on the well-documented catabolic state caused by patient stress surrounding surgical procedures. Although this state can include relative tissue hypoxia, increased insulin resistance, increased cardiac demand, and altered pulmonary and gastrointestinal function, the postsurgical paradigm shift through the cost-effective strategy Enhanced Recovery After Surgery (ERAS) is intended to promote rapid recovery, shorten hospital stay length, and decrease both the cost of particular surgical interventions and rates of complications. Multiple caretakers are involved in implementing an ERAS program. Anesthetists, surgeons, nursing staff from units caring for the patient, and an ERAS coordinator (typically a nurse or physician assistant) are all involved in counseling preoperatively, using primarily minimally invasive surgery routes, managing nutrition, avoiding opioid use and standardizing analgesia, and minimizing fluid and electrolyte imbalance. An adoption of ERAS protocols in urogynecology could potentially benefit patients by reducing pain and hastening recovery. Therefore, the primary objective of this report is an evaluation of existing evidence in gynecology and urogynecology (as well as additional fields such as colorectal or general surgery) to develop recommendations for the implementation and practice of an ERAS pathway. For this analysis, a collaboration between the review team and a research librarian allowed for the creation of a search in PubMed, which was also translated into various databases: Web of Science (Clarivate), CINAHL (EBSCO), Scopus (Elsevier), and Cochrane Central Register of Controlled Trials (Wiley). English language publications dated between January 1, 2001, and March 22, 2021, were included, with the application of 2 exclusion filters: an age filter to adapt to adult populations and a publication filter to eliminate editorials, case reports, and commentaries. Reference lists of acquired studies were cross-checked for additional relevant studies. Finally, the evidence base of each item was reviewed by 2 authors. Reviews of each study assessed the conclusions and strength of evidence for each article using the Grading of Recommendations, Assessment, Development, and Evaluation system. Following are various recommendations from the writing group on the application of ERAS in various circumstances: (1) ERAS specifically for the older population Standard ERAS protocol is both feasible and safe for patients undergoing colorectal resection, providing advantages such as shorter hospital stays and lower rates of postoperative morbidity. Although consensus is lacking for definitions of the terms “elderly” or “older,” consensus does exist for a strong recommendation in favor of ERAS for improving the care of this group. (2) Preadmission information, education, and counseling Clear communication between patient and physician about ERAS is critical to its success. Preoperative-visit discussions of ERAS can both reduce anxiety and increase patient satisfaction. It can also reduce pain and nausea, along with improve well-being. The recommendation is to give the patient information both in written and oral format. (3) Prehabilitation This aspect encompasses 4 principles: (1) resistance and aerobic exercises, (2) targeted functional exercises, (3) dietary interventions, and (4) psychological stress-reducing interventions that support behavior change for the benefit of overall well-being. The primary recommendation of prehabilitation is a multimodal approach encompassing dietary interventions, exercise, and psychological interventions for improving overall well-being. (4) Preoperative fasting and carbohydrate treatment and perioperative nutritional care Current evidence-based guidelines recommend a decrease in preoperative fasting time, allowing for the consumption of clear liquids and carbohydrate-rich beverages up to 2 hours before surgery. This recommendation has been associated with improved well-being, insulin resistance, and decreased nausea. The overall recommendation is to encourage patients to consume a light meal up to 6 hours preoperatively and clear fluids up to 2 hours before surgery. (5) Preoperative bowel preparation Evidence reports very little benefit to mechanical bowel preparation or rectal enema across surgery specialties. The recommendation is to avoid routine preoperative bowel preparation before urogynecologic surgery. (6) Standardized anesthetic protocol These protocols are a cornerstone of ERAS pathways and should be designed with the facilitation of rapid recovery in mind. Administration of sedatives for anxiety reduction purposes should be avoided. Local anesthesia plus sedation, regional anesthesia, and general anesthesia have all been used successfully for urogynecologic surgery. The recommendation is to use short-acting anesthetics and monitoring of neuromuscular block depth (and complete reversal). Protective strategies should be used with ventilation. Every use of anesthetic should facilitate a rapid recovery. (7) Perioperative management of intravenous fluids The overall goal of intraoperative fluid administration should be euvolemia, and the use of balanced salt solutions takes precedence over saline. Once a patient has resumed and tolerated oral hydration, intravenous fluid use should cease. (8) Antithrombotic prophylaxis Thorough evaluation of individual and surgical risk factors for VTE should take place as part of the preoperative assessment. Intermittent pneumatic compression is recommended for outpatient urogynecologic procedures. (9) Surgical site...

Background: Pelvic organ prolapse (POP) negatively affects many women’s quality of life. The ability to develop improved therapeutic approaches for POP patients is hampered by low patient recruitment and retention rates in clinical trials. Objective: Our objective was to explore the motivational factors and barriers to recruitment and participation in clinical trials among postmenopausal women with POP who are intending to have surgical management. Design: Qualitative study based on in-depth face-to-face interviews with postmenopausal women attending urogynaecology clinics in the UK intending to have surgical management for pelvic organ prolapse. These women were eligible to participate in the on-going clinical trial on the use of local vaginal oestrogen as an adjunct to surgical treatment. Twenty-two postmenopausal women aged 52–76 years were interviewed. Interviews were analysed using thematic analysis method. Results: Many women participated because of altruistic motivations; however, we found that clarity of information provided, timing of approach and acceptability of study design played a pivotal role in women. Of the women who declined participation, the following themes emerged: uncertainty of the investigational product, fear of experimentation, logistical concerns and regret that their condition was trivialised at an early stage. Conclusion: We have gained a valuable insight into women’s views and experience in the decision making process. Understanding the elements that will enhance trial participation such as clarity of information provided, balance between professional guidance whilst maintaining equipoise, easy access to trial teams and timing of approach will ultimately enable us to improve our recruitment to clinical trials.

Evidence suggests that OAB (overactive bladder) can occur alongside disorders of the colon, such as irritable bowel syndrome (IBS). Moreover, patients with constipation are more likely to develop OAB symptoms than those without. Anticholinergic medications (AcH) are commonly used for treating OAB, and can result in the unwanted side effects of constipation. We aimed to study the relationship of AcH, and their effects on quality of life using the electronic Personal Assessment Questionnaire (ePAQ) by assessing changes in the bowel and bladder domains, pre- and post-AcH treatment. Ninety patients completed the ePAQ pre- and post-AcH treatment from January 2011 to April 2014. Data were collected retrospectively and prospectively, and analysed using a paired t test. Effect size (ES) was calculated for OAB and bowel domains to quantify the effect on QoL. There was a significant improvement in the OAB (p = 0.0005) and bowel domains (p = 0.0005). In the bowel domains, the largest effect size was seen for IBS (0.5) followed by continence (0.4), evacuation (0.375) and a small ES was seen for constipation (0.2). There was a reduction in the "degree of bother" in OAB and bowel domains. Patients may benefit from the possible effects of AcH on their bowels, and assessment of all aspects of pelvic floor function is important before commencing AcH. This may help to counsel patients, with possibly improved compliance with therapy.

Quality of life can be seriously affected by pelvic floor disorders and a range of other coexisting symptoms. The electronic patient assessment questionnaire (ePAQ®) is a validated tool that can be used for the assessment of pelvic floor disorders. The authors aimed to systematically review all the studies that had used ePAQ for assessment of pelvic-floor-related quality of life. The delivery of evidence-based care is paramount and dependent on a precise, detailed clinical history. A pelvic floor questionnaire is an effective way of assessing the effect of pelvic floor dysfunction on quality of life. A thorough literature search was conducted in November 2013 using various search engines. A total of 15 articles were found. Four of these articles were excluded as ePAQ had not been used and the remaining 11 articles summarised. The main themes drawn from the studies were: screening and diagnostic uses, treatment prioritisation, treatment response and miscellaneous/qualitative data. The findings illustrate that the pelvic floor assessment version of ePAQ is a useful tool in assessing patients before and after receiving pelvic floor treatment.