Clinical Focus

  • Obstetrics and Gynecology
  • Urogynecology

Academic Appointments

Administrative Appointments

  • Chair, Department of Obstetrics and Gynecology, Stanford University (2017 - Present)

Honors & Awards

  • Distinction in Mentoring Award Nominee, UCSF Academic Senate (2015, 2016)
  • Outstanding Faculty Award in Medical Student Teaching, UCSF Department of OBGYN&RS (2010, 2011, 2013, 2014)
  • Women's Health Foundation Medical Activist Award, Women's Health Foundation (2009)
  • Mid-Career Investigator Award in Patient Oriented Research (K24) and renewal, NIH/NIDDK (2008, 2015)
  • Honoree, UCSF Chancellor's Committee on the Status of Women, UCSF, Chancellor (2002)
  • UCSF Women’s Reproductive Health Research Career Development Scholar (WRHR K12), UCSF, NIH/NICHD (2000)
  • Rolex Achievement Award for outstanding career achievements and contribution to society, College Golf Foundation (1996)
  • Outstanding Resident Consultant, UCSF Department of Obstetrics, Gynecology & Reproductive Science (1994)
  • Julius R. Krevans Award for Clinical Excellence, UCSF (1991)
  • Green Key Honor Society, Dartmouth College (1982)

Boards, Advisory Committees, Professional Organizations

  • Member, Committee on the Socio-Economic Impact of Urinary Incontinence, WHO and International Continence Society, 1st to 6th International Consultation on Incontinence (1998 - Present)
  • Executive Committee, NIDDK International Collaborative Research Group on Bladder Dysfunction (2003 - 2007)
  • Co-Chair, NIDDK Research Symposium: Urologic Outcomes of Diabetes & Obesity (2008 - 2009)
  • Member, NIH.NIDDK, Urologic Diseases in America External Expert Panel (2016 - Present)
  • Member, Advisory Board, UCSF-Kaiser Permanente Urological Epidemiology Research Career Development Program (K12) (2017 - Present)

Professional Education

  • Board Certified, American Board of Obstetrics and Gynecology (Diplomate) (1997)
  • Fellowship, University of California, San Francisco (UCSF) and San Francisco Veterans Affairs Medical Center (SFVAMC), Epidemiolgy & Clinical Research (1997)
  • Fellowship, UCSF and SFVAMC, Urogynecology and Pelvic Reconstructive Surgery (1997)
  • Certificate, UCSF, Advanced Training in Clinical Research (1996)
  • Fellowship:San Francisco VA Medical Center (1997) CA
  • Residency, University of California, San Francisco, Obstetrics & Gynecology (1995)
  • MD, Stanford University School of Medicine, Medicine (1991)
  • AB, Dartmouth College, Earth Sciences, Economics (1983)

Community and International Work

  • Trustee

    Partnering Organization(s)

    San Francisco Day School Board of Directors


    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


  • Trustee

    Partnering Organization(s)

    Pacific Primary School


    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

My multidisciplinary research program is focused on lower urinary tract function and genitourinary health in women, including (1) the effect of weight loss and physical activity on urinary incontinence (UI) and overactive bladder (OAB), (2) epidemiology of female lower urinary tract and pelvic floor disorders (UI, OAB, pelvic organ prolapse, sexual dysfunction, and fecal incontinence), (3) the association of race/ethnicity with pelvic floor disorders and their treatment, (4) development of novel treatments for UI (weight loss, yoga, slow-paced respiration, mobile health app delivery), and (5) economics, health-related quality of life, and cost-effectiveness of treatments for pelvic floor disorders.

Clinical Trials

  • A Group-Based Therapeutic Yoga Intervention for Urinary Incontinence in Ambulatory Older Women Not Recruiting

    The investigators will conduct a randomized controlled trial to evaluate the efficacy of a group-based yoga intervention to decrease the frequency and impact of urinary incontinence in ambulatory middle-aged and older women and explore potential mediators of improvement in outcomes. Women aged 50 years and older who report daily or more frequent stress-, urgency-, or mixed-type incontinence, are not already engaged in formal yoga or muscle stretching/strengthening programs, are willing to temporarily forgo other clinical treatments for incontinence, are able to walk to and use the bathroom without assistance, and meet other eligibility criteria will be recruited from multiple locations surrounding the San Francisco Bay area.

    Stanford is currently not accepting patients for this trial. For more information, please contact Leslee Subak, MD, 650-723-5533.

    View full details


All Publications

  • A group-based yoga program for urinary incontinence in ambulatory women: feasibility, tolerability, and change in incontinence frequency over 3 months in asingle-center randomized trial. American journal of obstetrics and gynecology Huang, A. J., Chesney, M., Lisha, N., Vittinghoff, E., Schembri, M., Pawlowsky, S., Hsu, A., Subak, L. 2019; 220 (1)


    BACKGROUND: Because of the limitations of existing clinical treatments for urinary incontinence, many women with incontinence are interested in complementary strategies for managing their symptoms. Yoga has been recommended as a behavioral self-management strategy for incontinence, but evidence of its feasibility, tolerability, and efficacy is lacking.OBJECTIVE: To evaluate the feasibility and tolerability of a group-based therapeutic yoga program for ambulatory middle-aged and older women with incontinence, and to examine preliminary changes in incontinence frequency as the primary efficacy outcome after 3 months.MATERIALS AND METHODS: Ambulatory women aged 50 years or older who reported at least daily stress-, urgency-, or mixed-type incontinence, were not already engaged in yoga, and were willing to temporarily forgo clinical incontinence treatments were recruited into a randomized trial in the San Francisco Bay area. Women were randomly assigned to take part in a program of twice-weekly group classes and once-weekly home practice focused on Iyengar-based yoga techniques selected by an expert yoga panel (yoga group), or a nonspecific muscle stretching and strengthening program designed to provide a rigorous time-and-attention control (control group) for 3 months. All participants also received written, evidence-based information about behavioral incontinence self-management techniques (pelvic floor exercises, bladder training) consistent with usual first-line care. Incontinence frequency and type were assessed by validated voiding diaries. Analysis of covariance models examined within- and between-group changes in incontinence frequency as the primary efficacy outcome over 3 months.RESULTS: Of the 56 women randomized (28 to yoga, 28 to control), the mean age was 65.4 (±8.1) years (range, 55-83 years), the mean baseline incontinence frequency was 3.5 (±2.0) episodes/d, and 37 women (66%) had urgency-predominant incontinence. A total of 50 women completed their assigned 3-month intervention program (89%), including 27 in the yoga and 23 in the control group (P= .19). Of those, 24 (89%) in the yoga and 20 (87%) in the control group attended at least 80% of group classes. Over 3 months, total incontinence frequency decreased by an average of 76% from baseline in the yoga and 56% in the control group (P= .07 for between-group difference). Stress incontinence frequency also decreased by an average of 61% in the yoga group and 35% in controls (P= .045 for between-group difference), but changes in urgency incontinence frequency did not differ significantly between groups. A total of 48 nonserious adverse events were reported, including 23 in the yoga and 25 in the control group, but none were directly attributable to yoga or control program practice.CONCLUSION: Findings demonstrate the feasibility of recruiting and retaining incontinent women across the aging spectrum into a therapeutic yoga program, and provide preliminary evidence of reduction in total and stress-type incontinence frequency after 3 months of yoga practice. When taught with attention to women's clinical needs, yoga may offer a potential community-based behavioral self-management strategy for incontinence to enhance clinical treatment, although future research should assess whether yoga offers unique benefits for incontinence above and beyond other physical activity-based interventions.

    View details for DOI 10.1016/j.ajog.2018.10.031

    View details for PubMedID 30595143

  • Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women. JAMA internal medicine Gibson, C. J., Huang, A. J., McCaw, B., Subak, L. L., Thom, D. H., Van Den Eeden, S. K. 2018


    Importance: Little is known about the prevalence of traumatic exposures among midlife and older women and the association of these traumatic exposures with health issues.Objective: To examine the associations of intimate partner violence (IPV), sexual assault, and posttraumatic stress with menopause symptoms among midlife and older women.Design, Setting, and Participants: A cross-sectional analysis of data from a multiethnic cohort of 2016 women 40 to 80 years of age in the Kaiser Permanente Northern California health care system was conducted from November 15, 2008, to March 30, 2012. Statistical analysis was conducted from June 8, 2016, to September 6, 2017.Exposures: Lifetime physical or emotional IPV, sexual assault, and current symptoms of posttraumatic stress disorder, assessed with standardized questionnaires.Main Outcomes and Measures: Difficulty sleeping, vasomotor symptoms, and vaginal symptoms, assessed with standardized questionnaires.Results: Among the 2016 women enrolled, the mean (SD) age was 60.5 (9.5) years, and 792 of 2011 with race/ethnicity data (39.4)% were non-Latina white (403 [20.0%] Latina, 429 [21.3%] black, and 387 [19.2%] Asian). Lifetime emotional IPV was reported by 423 women (21.0%), lifetime physical IPV was reported by 316 women (15.7%), sexual assault was reported by 382 women (18.9%), and 450 of 2000 women (22.5%) had current clinically significant symptoms of posttraumatic stress disorder. In multivariable analyses adjusted for age, race/ethnicity, educational level, body mass index, menopause status, hormone therapy, and parity, symptoms of posttraumatic stress disorder were associated with difficulty sleeping (odds ratio [OR], 3.02; 95% CI, 2.22-4.09), vasomotor symptoms (hot flashes: OR, 1.69; 95% CI, 1.34-2.12; night sweats: OR, 1.72; 95% CI, 1.37-2.15), and vaginal symptoms (vaginal dryness: OR, 1.73; 95% CI, 1.37-2.18; vaginal irritation: OR, 2.20; 95% CI, 1.66-2.93; pain with intercourse: OR, 2.16; 95% CI, 1.57-2.98). Emotional IPV was associated with difficulty sleeping (OR, 1.36; 95% CI, 1.09-1.71), night sweats (OR, 1.50; 95% CI, 1.19-1.89), and pain with intercourse (OR, 1.60; 95% CI, 1.14-2.25). Physical IPV was associated with night sweats (OR, 1.33; 95% CI, 1.03-1.72). Sexual assault was associated with vaginal symptoms (vaginal dryness: OR, 1.41; 95% CI, 1.10-1.82; vaginal irritation: OR, 1.42; 95% CI, 1.04-1.95; pain with intercourse: OR 1.44; 95% CI, 1.00-2.06).Conclusions and Relevance: Lifetime history of IPV or sexual assault and current clinically significant symptoms of posttraumatic stress disorder are common and are associated with menopause symptoms. These findings highlight the need for greater recognition of these exposures by clinicians caring for midlife and older women.

    View details for DOI 10.1001/jamainternmed.2018.5233

    View details for PubMedID 30453319

  • Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women A Randomized Clinical Trial JAMA INTERNAL MEDICINE Diokno, A. C., Newman, D. K., Low, L. K., Griebling, T. L., Maddens, M. E., Goode, P. S., Raghunathan, T. E., Subak, L. L., Sampselle, C. M., Boura, J. A., Robinson, A. E., McIntyre, D., Burgio, K. L. 2018; 178 (10): 1333–41


    Urinary incontinence (UI) guidelines recommend behavioral interventions as first-line treatment using individualized approaches. A one-time, group-administered behavioral treatment (GBT) could enhance access to behavioral treatment.To compare the effectiveness, cost, and cost-effectiveness of GBT with no treatment for UI in older women.Multisite randomized clinical trial (the Group Learning Achieves Decreased Incidents of Lower Urinary Symptoms [GLADIOLUS] study), conducted from July 7, 2014, to December 31, 2016. The setting was outpatient practices at 3 academic medical centers. Community-dwelling women 55 years or older with UI were recruited by mail and screened for eligibility, including a score of 3 or higher on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), symptoms of at least 3 months' duration, and absence of medical conditions or treatments that could affect continence status. Of 2171 mail respondents, 1125 were invited for clinical screening; 463 were eligible and randomized; 398 completed the 12-month study.The GBT group received a one-time 2-hour bladder health class, supported by written materials and an audio CD.Outcomes were measured at in-person visits (at 3 and 12 months) and by mail or telephone (at 6 and 9 months). The primary outcome was the change in the ICIQ-SF score. Secondary outcome measures assessed UI severity, quality of life, perceptions of improvement, pelvic floor muscle strength, and costs. Evaluators were masked to group assignment.Participants (232 in the GBT group and 231 in the control group) were aged 55 to 91 years (mean [SD] age, 64 [7] years), and 46.2% (214 of 463) were African American. In intent-to-treat analyses, the ICIQ-SF scores for GBT were consistently lower than control across all time points but did not achieve the projected 3-point difference. At 3 months, the difference in differences was 0.96 points (95% CI, -1.51 to -0.41 points), which was statistically significant but clinically modest. The mean (SE) treatment effects at 6, 9, and 12 months were 1.36 (0.32), 2.13 (0.33), and 1.77 (0.31), respectively. Significant group differences were found at all time points in favor of GBT on all secondary outcomes except pelvic floor muscle strength. The incremental cost to achieve a treatment success was $723 at 3 months; GBT dominated at 12 months.The GLADIOLUS study shows that a novel one-time GBT program is modestly effective and cost-effective for reducing UI frequency, severity, and bother and improving quality of life. Group-administered behavioral treatment is a promising first-line approach to enhancing access to noninvasive behavioral treatment for older women with identifier: NCT02001714.

    View details for DOI 10.1001/jamainternmed.2018.3766

    View details for Web of Science ID 000446453500009

    View details for PubMedID 30193294

  • Association of Pharmacologic Treatment of Urgency Urinary Incontinence With Sleep Quality and Daytime Sleepiness EDITORIAL COMMENT OBSTETRICAL & GYNECOLOGICAL SURVEY Warsi, Q. A., Huang, A. J., Hess, R., Arya, L. A., Richter, H. E., Bradley, C. S., Rogers, R. G., Myers, D. L., Johnson, K. C., Winkelman, W. D., Gregory, W., Kraus, S. R., Schembri, M., Brown, J. S., Stone, K. L., Subak, L. L. 2018; 73 (5): 273–74
  • Sleep Quality and Daytime Sleepiness Among Women With Urgency Predominant Urinary Incontinence Winkelman, W. D., Warsi, A., Huang, A. J., Schembri, M., Rogers, R. G., Richter, H. E., Myers, D. L., Kraus, S. R., Johnson, K. C., Hess, R., Gregory, T., Bradley, C. S., Arya, L. A., Brown, J. S., Stone, K. L., Subak, L. L. LIPPINCOTT WILLIAMS & WILKINS. 2018: 76–81


    The objective of this study was to examine the strength and direction of the association between urinary symptoms and both poor quality sleep and daytime sleepiness among women with urgency urinary incontinence.A planned secondary analysis of baseline characteristics of participants in a multicenter, double-blinded, 12-week randomized controlled trial of pharmacologic therapy for urgency-predominant urinary incontinence in ambulatory women self-diagnosed by the 3 Incontinence Questions was performed. Urinary symptoms were assessed by 3-day voiding diaries. Quality of sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness using the Epworth Sleepiness Scale.Of the 640 participants, mean (SD) age was 56 (±14) years and 68% were white. Participants reported an average of 3.9 (±3.0) urgency incontinence episodes per day and 1.3 (±1.3) episodes of nocturia per night. At baseline, 57% had poor sleep quality (PSQI score, >5) and 17% reported daytime sleepiness (Epworth Sleepiness Scale score, >10). Most women (69%) did not use sleeping medication during the prior month, whereas 13% reported use of sleeping medication 3 or more times per week. An increase in total daily incontinence episodes, total daily urgency incontinence episodes, total daily micturitions, and moderate to severe urge sensations were all associated with higher self-report of poor sleep quality according to the PSQI (all P ≤ 0.01). Higher scores on the Bother Scale and the Health-Related Quality of Life for overactive bladder on the Overactive Bladder Questionnaire were similarly associated with higher rates of poor sleep quality (both P ≤ 0.01). In subgroup analysis of those who took sleeping medications less than twice a week, there was still a significant relationship between incontinence measures and quality of sleep as measured by the PSQI. In multivariable analyses, greater frequency of nighttime urgency incontinence was associated with poor sleep quality (P = 0.03).Among ambulatory women with urgency urinary incontinence, poor sleep quality is common and greater frequency of incontinence is associated with a greater degree of sleep dysfunction. Women seeking urgency urinary incontinence treatment should be queried about their sleeping habits so that they can be offered appropriate interventions.

    View details for DOI 10.1097/SPV.0000000000000547

    View details for Web of Science ID 000426823700003

    View details for PubMedID 29300259

    View details for PubMedCentralID PMC5909832

  • Association of Pharmacologic Treatment of Urgency Urinary Incontinence With Sleep Quality and Daytime Sleepiness Warsi, Q. A., Huang, A. J., Hess, R., Arya, L. A., Richter, H. E., Bradley, C. S., Rogers, R. G., Myers, D. L., Johnson, K. C., Winkelman, W. D., Gregory, W., Kraus, S. R., Schembri, M., Brown, J. S., Stone, K. L., Subak, L. L. LIPPINCOTT WILLIAMS & WILKINS. 2018: 204–11


    To evaluate the association between pharmacologic therapy for urgency urinary incontinence (UUI) and sleep quality.We conducted a planned secondary data analysis of sleep outcomes in a previously conducted multicenter, double-blind, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence among community-dwelling women self-diagnosed using the 3-Incontinence Questions questionnaire. Participants (N=645) were assigned randomly to 4-8 mg antimuscarinic therapy daily or placebo. At baseline and 12 weeks, participants completed a validated voiding diary to evaluate incontinence and voiding symptoms, the Pittsburgh Sleep Quality Index to evaluate sleep quality, and the Epworth Sleepiness Scale to evaluate daytime sleepiness.Mean (SD) age was 56 (±14) years, 68% were white, and 57% had poor sleep quality (Pittsburgh Sleep Quality Index score greater than 5). Mean frequency of any urinary incontinence and UUI was 4.6 and 3.9 episodes/d, respectively. After 12 weeks, women randomized to the antimuscarinic group reported greater decrease compared with the placebo group in UUI frequency (0.9 episodes/d; P<.001) and diurnal and nocturnal voiding frequency (P<.05). As compared with the placebo group, women in the antimuscarinic group also reported greater improvement in sleep quality (total Pittsburgh Sleep Quality Index score 0.48; P=.02) with greater improvement in sleep duration and sleep efficiency subscales (P<.05). The intervention did not affect daytime sleepiness.Pharmacologic treatment of UUI is associated with decreased incontinence frequency and nocturia and improvement in overall sleep quality, sleep duration, and sleep, NCT00862745.

    View details for DOI 10.1097/AOG.0000000000002443

    View details for Web of Science ID 000428989700004

    View details for PubMedID 29324595

  • RANDOMIZED CONTROLLED TRIAL OF GROUP-ADMINSITERED BEHAVIORAL TREATMENT IN REDUCING URINARY INCONTINENCE IN ADULT WOMEN Newman, D., Diokno, A., Burgio, K., Low, L., Griebling, T., Maddens, M., Subak, L., Goode, P., Sampselle, C., Robinson, A., Raghunathan, T., Boura, J., McIntyre, D., Magno, A., Stambakio, H. WILEY. 2018: S564–S565
  • TRAINING FIDELITY AND QUALITY CONTROL IN CLINICAL BEHAVIORAL RESEARCH FOR URINARY INCONTINENCE: THE GLADIOLUS TRIAL Griebling, T. L., Diokno, A., Newman, D., Burgio, K., Low, L., Maddens, M., Subak, L., Goode, P., Sampselle, C., Robinson, A., Raghunathan, T., Boura, J., McIntyre, D., Gladiolus Res Team WILEY. 2018: S633–S634
  • A Behavioral Weight Loss Program and Nonurinary Incontinence Lower Urinary Tract Symptoms in Overweight and Obese Women with Urinary Incontinence: A Secondary Data Analysis of PRIDE JOURNAL OF UROLOGY Breyer, B. N., Creasman, J. M., Richter, H. E., Myers, D., Burgio, K. L., Wing, R. R., West, D., Kusek, J. W., Subak, L. L., PRIDE 2018; 199 (1): 215–21


    We sought to determine whether a behavioral weight reduction intervention would improve nonurinary incontinence lower urinary tract storage symptoms at 6 months, including urinary frequency, nocturia and urgency, compared to a structured education program serving as the control group among overweight and obese women with urinary incontinence.PRIDE (Program to Reduce Incontinence by Diet and Exercise) was a randomized clinical trial performed in 338 overweight or obese women with urinary incontinence. Participants were randomized, including 226 to 6-month behavioral weight loss intervention and 112 to the control group. All participants received a self-help behavioral treatment booklet to improve bladder control. On this secondary data analysis we examined changes in nonurinary incontinence lower urinary tract storage symptoms from baseline to 6 months and the impact of treatment allocation (intervention vs control), weight loss and physical activity.Nonurinary incontinence lower urinary tract storage symptoms were common at baseline, varying from 48% to 62%. In the 2 groups combined women experienced significant improvement in nocturia, urgency and International Prostate Symptom Score at 6 months (all p <0.001). However, lower urinary tract storage symptom outcomes at 6 months did not differ between the intervention and control groups. Similarly no difference was observed in the amount of weight lost (5% or greater vs less than 5%) or physical activity (1,500 kcal or greater expenditure per week compared to less than 1,500 kcal).Lower urinary tract storage symptoms were common among overweight and obese women with urinary incontinence. The prevalence decreased significantly after 6 months independent of treatment group assignment, amount of weight lost or physical activity. These improvements may have been due to self-help behavioral educational materials, trial participation or repeat assessment of symptoms.

    View details for DOI 10.1016/j.juro.2017.07.087

    View details for Web of Science ID 000419429700094

    View details for PubMedID 28807645

  • Search Images and Extrapolation Risk Reply JAMA INTERNAL MEDICINE Grady, D., Subak, L. 2017; 177 (12): 1870
  • Interpersonal Violence, Posttraumatic Stress Disorder, and Menopause-Related Sexual Dysfunction in an Ethnically-Diverse, Community-Based Sample of Women Gibson, C., Huang, A., McCaw, B., Shan, J., Subak, L., Thom, D., Van den Eeden, S. LIPPINCOTT WILLIAMS & WILKINS. 2017: 1433
  • Characterizing the Functional Decline of Older Women With Incident Urinary Incontinence Parker-Autry, C., Houston, D. K., Rushing, J., Richter, H. E., Subak, L., Kanaya, A. M., Kritchevsky, S. B. LIPPINCOTT WILLIAMS & WILKINS. 2017: 1025–32


    To characterize change in physical performance and differential prevalence of low skeletal muscle mass and strength (sarcopenia) and lower 25-hydroxyvitamin D concentrations among older women who developed urinary incontinence (UI) symptoms.This is a secondary analysis of the Health, Aging, and Body Composition Study. Urinary incontinence symptoms were assessed using validated questions. The Short Physical Performance Battery measured physical performance. Sarcopenia, defined by low muscle mass and strength, was determined using validated cutoffs for gait speed, grip strength, and appendicular skeletal muscle mass. All parameters were evaluated at baseline and year 4. Serum 25-hydroxyvitamin D concentrations were assessed at year 2. The primary outcome was change in Short Physical Performance Battery total scores. Sarcopenia and lower serum 25-hydroxyvitamin D concentrations have been independently associated with poor physical performance and UI and were therefore included as secondary outcomes. Univariate and multivariate analyses were used to characterize the associations of change in physical performance from baseline to year 4, incidence of sarcopenia, and lower serum 25-hydroxyvitamin D on the development of UI symptoms.Of the 1,583 women enrolled, 910 were excluded (730 had baseline UI; 180 with missing data). Six hundred seventy-three women were continent at baseline; 223 (33%) developed UI symptoms at year 4. SPPB total scores significantly declined in women with UI versus continent women (mean difference continent-incident UI 0.32, 95% CI 0.04-0.60, P=.02). Of subscale measures, standing balance showed the greatest decline at 0.20 (0.05-0.36; continent-incident UI, respectively; P=.009). Sarcopenia developed at a higher rate with incident UI (adjusted odds ratio [OR] 1.7, 95% CI 1.0-2.9). Low 25-hydroxyvitamin D was not associated with incident UI (adjusted OR 1.1, 95% CI 0.7-1.6 and 1.1, 95% CI 0.7-1.6 for deficient or insufficient versus sufficient status, respectively).We observed a significant decline in standing balance among older women who developed UI symptoms. This decline may be associated with coinciding development of sarcopenia.

    View details for DOI 10.1097/AOG.0000000000002322

    View details for Web of Science ID 000417651200025

    View details for PubMedID 29016492

  • Asymptomatic Microscopic Hematuria-Rethinking the Diagnostic Algorithm JAMA INTERNAL MEDICINE Subak, L. L., Grady, D. 2017; 177 (6): 808–9
  • Modifiers of Response to Treatment With Fesoterodine for Urgency-Predominant Urinary Incontinence in a Randomized Controlled Trial Winkelman, W. D., Huang, A. J., Schembri, M., Rogers, R. G., Richter, H., Myers, D. L., Kraus, S. R., Johnson, K. C., Hess, R., Gregory, T., Bradley, C. S., Arya, L., Brown, J. S., Subak, L. L. LIPPINCOTT WILLIAMS & WILKINS. 2017: 151–56


    The aim of this study was to identify clinical and demographic characteristics that moderate response to treatment with fesoterodine among women with a diagnosis of urgency-predominant urinary incontinence.A multicenter, double-blinded, 12-week randomized controlled trial of pharmacologic therapy for urgency-predominant urinary incontinence in community-dwelling women diagnosed by the 3-item Incontinence Questionnaire (3IQ) was previously performed. Participants (N = 645) were randomized to fesoterodine therapy (4-8 mg daily; n = 322) or placebo (n = 323). Urinary incontinence was assessed by 3-day voiding diaries. In this secondary analysis, a "responder" was defined as reduction of 50% or greater in overall incontinence episode frequency compared with baseline. Clinical and demographic characteristics that may moderate treatment response were assessed by testing for interaction between characteristics and intervention in logit models of responders, adjusting for clinical site.Participants' ages were a mean of 56 (SD, 14) years, 68% were white race, and they had a mean of 3.9 (SD, 3.0) urgency incontinence episodes per day. There were no baseline differences in demographic, clinical, or incontinence characteristics between treatment and placebo groups or between responders and nonresponders. There was an increase in the proportion of responders to fesoterodine with increasing age (P = 0.04) and parity (0.04) and among married women (P = 0.03), but no effect modification was observed by race/ethnicity, body mass index, education, employment status, or alcohol or tobacco use.In ambulatory women with urgency-predominant urinary incontinence, older age, being married, and higher parity significantly moderated and potentiated the effects of pharmacologic therapy on incontinence frequency. This study identifies certain populations who may have increased responsiveness to treatment with antimuscarinic therapy and may be used to inform and guide future therapy.

    View details for DOI 10.1097/SPV.0000000000000396

    View details for Web of Science ID 000395579800017

    View details for PubMedID 28118174

    View details for PubMedCentralID PMC5323297

  • Urinary Incontinence in Older Women: The Role of Body Composition and Muscle Strength: From the Health, Aging, and Body Composition Study JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Suskind, A. M., Cawthon, P. M., Nakagawa, S., Subak, L. L., Reinders, I., Satterfield, S., Cummings, S., Cauley, J. A., Harris, T., Huang, A. J., Hlth ABC Study 2017; 65 (1): 42–50


    To evaluate prospective relationships between body composition and muscle strength with predominantly stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) in older women.Prospective community-dwelling observational cohort study (Health, Aging, and Body Composition study).Women initially aged 70 to 79 recruited from Pittsburgh, Pennsylvania, and Memphis, Tennessee (N = 1,475).Urinary incontinence was assessed using structured questionnaires. Body mass index (BMI), grip strength, quadriceps torque, and walking speed were assessed using physical examination and performance testing. Appendicular lean body mass (ALM) and whole-body fat mass were measured using dual-energy X-ray absorptiometry.At baseline, 212 (14%) women reported at least monthly predominantly SUI and 233 (16%) at least monthly predominantly UUI. At 3 years, of 1,137 women, 164 (14%) had new or persistent SUI, and 320 (28%) had new or persistent UUI. Women had greater odds of new or persistent SUI if they demonstrated a 5% or greater decrease in grip strength, (adjusted odds ratio (AOR) = 1.60, P = .047) and lower odds of new or persistent SUI if they demonstrated a 5% or greater decrease in BMI (AOR = 0.46, P = .01), a 5% or greater increase in ALM corrected for BMI (AOR = 0.17, P = .004), or a 5% or greater decrease in fat mass (AOR = 0.53, P = .01). Only a 5% or greater increase in walking speed was associated with new or persistent UUI over 3 years (AOR = 1.54, P = .04).In women aged 70 and older, changes in body composition and grip strength were associated with changes in SUI frequency over time. In contrast, changes in these factors did not influence UUI. Findings suggest that optimization of body composition and muscle strength is more likely to modify risk of SUI than of UUI in older women.

    View details for DOI 10.1111/jgs.14545

    View details for Web of Science ID 000394551300012

    View details for PubMedID 27918084

    View details for PubMedCentralID PMC5258849

  • The FDA and the Vaginal Mesh Controversy-Further Impetus to Change the 510(k) Pathway for Medical Device Approval JAMA INTERNAL MEDICINE Jacoby, V. L., Subak, L., Waetjen, L. 2016; 176 (2): 277–78
  • Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Duralde, E. R., Walter, L. C., Van den Eeden, S. K., Nakagawa, S., Subak, L. L., Brown, J. S., Thom, D. H., Huang, A. J. 2016; 214 (2): 266.e1–266.e9


    More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated.We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women.We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment.Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician.Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

    View details for DOI 10.1016/j.ajog.2015.08.072

    View details for Web of Science ID 000369518200019

    View details for PubMedID 26348382

    View details for PubMedCentralID PMC4830485

  • Urinary Incontinence Before and After Bariatric Surgery JAMA INTERNAL MEDICINE Subak, L. L., King, W. C., Belle, S. H., Chen, J., Courcoulas, A. P., Ebel, F. E., Flum, D. R., Khandelwal, S., Pender, J. R., Pierson, S. K., Pories, W. J., Steffen, K. J., Strain, G. W., Wolfe, B. M., Huang, A. J. 2015; 175 (8): 1378–87


    Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking.To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery.The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012).Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter.The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up.Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation.Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery.

    View details for DOI 10.1001/jamainternmed.2015.2609

    View details for Web of Science ID 000361057700027

    View details for PubMedID 26098620

    View details for PubMedCentralID PMC4529061

  • The Impact of Multimorbidity on Sexual Function in Middle-Aged and Older Women: Beyond the Single Disease Perspective JOURNAL OF SEXUAL MEDICINE Appa, A. A., Creasman, J., Brown, J. S., Van den Eeden, S. K., Thom, D. H., Subak, L. L., Huang, A. J. 2014; 11 (11): 2744–55


    Little is known about sexual activity and function in women with multiple chronic health conditions.To examine the impact of multimorbidity on sexual activity and function in middle-aged and older women.Multiethnic cross-sectional cohort of 1,997 community-dwelling women (mean age of 60.2 [±9.5] years) in California. Structured questionnaires assessed prior diagnoses of common cardiometabolic, colorectal, neuropsychiatric, respiratory, musculoskeletal, and genitourinary conditions.Sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (i.e., difficulty with arousal, lubrication, orgasm, and pain) were assessed by structured questionnaires.Seventy-one percent of women had two or more diagnosed chronic conditions. Fifty-nine percent reported low sexual desire, 53% reported less than monthly sexual activity, and 47% reported low overall sexual satisfaction. Multimorbidity was associated with increased odds of reporting low sexual desire (OR = 1.11, 95% CI = 1.06-1.17, per each additional chronic condition), less than monthly sexual activity (OR = 1.11, 95% CI = 1.05-1.17 per each additional condition), and low sexual satisfaction (OR = 1.10, 95% CI = 1.04-1.16 per each additional condition), adjusting for age, race/ethnicity, and partner status. Depression and urinary incontinence were each independently associated with low desire (OR = 1.53, 95% CI = 1.19-1.97, and OR = 1.23, 95% CI = 1.00-1.52, respectively), less than monthly sexual activity (OR = 1.39, 95% CI = 1.06-1.83, and OR = 1.29, 95% CI = 1.02-1.62, respectively), and low sexual satisfaction (OR = 1.49, 95% CI = 1.14-1.93, and OR = 1.38, 95% CI = 1.11-1.73, respectively), adjusting for other types of conditions. After adjustment for total number of chronic conditions, age remained a significant predictor of low desire and less than monthly sexual activity, but not sexual satisfaction.Women with multiple chronic health conditions are at increased risk for decreased sexual function. Depression and incontinence may have particularly strong effects on sexual desire, frequency of activity, and satisfaction in women, independent of other comorbid conditions. Women's overall sexual satisfaction may be more strongly influenced by multimorbidity than age.

    View details for DOI 10.1111/jsm.12665

    View details for Web of Science ID 000344473800013

    View details for PubMedID 25146458

    View details for PubMedCentralID PMC4309673

  • Urinary incontinence management costs are reduced following Burch or sling surgery for stress incontinence AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Subak, L. L., Goode, P. S., Brubaker, L., Kusek, J. W., Schembri, M., Lukacz, E. S., Kraus, S. R., Chai, T. C., Norton, P., Tennstedt, S. L., Urinary Incontinence Treatment Net 2014; 211 (2): 171.e1–7


    The objective of the study was to estimate the effect of Burch and fascial sling surgery on out-of-pocket urinary incontinence (UI) management costs at 24 months postoperatively and identify predictors of change in cost among women enrolled in a randomized trial comparing these procedures.Resources used for UI management (supplies, laundry, dry cleaning) were self-reported by 491 women at baseline and 24 months after surgery, and total out-of-pocket costs for UI management (in 2012 US dollars) were estimated. Data from the 2 surgical groups were combined to examine the change in cost for UI management over 24 months. Univariate and bivariate changes in cost were analyzed using the Wilcoxon signed rank test. Predictors of change in cost were examined using multivariate mixed models.At baseline mean (±SD) age of participants was 53 ± 10 years, and the frequency of weekly UI episodes was 23 ± 21. Weekly UI episodes decreased by 86% at 24 months (P < .001). The mean weekly cost was $16.60 ± $27.00 (median $9.39) at baseline and $4.57 ± $15.00 (median $0.10) at 24 months (P < .001), a decrease of 72%. In multivariate analyses, cost decreased by $3.38 ± $0.77 per week for each decrease of 1 UI episode per day (P < .001) and was strongly associated with greater improvement in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores (P < .001) and decreased 24-hour pad weight (P < .02).Following Burch or fascial sling surgery, the UI management cost at 24 months decreased by 72% ($625 per woman per year) and was strongly associated with decreasing UI frequency. Reduced out-of-pocket expenses may be a benefit of these established urinary incontinence procedures.

    View details for DOI 10.1016/j.ajog.2014.03.012

    View details for Web of Science ID 000340259300025

    View details for PubMedID 24631433

    View details for PubMedCentralID PMC4349353

  • Adding Evidence-Based Behavioral Weight Loss Strategies to a Statewide Wellness Campaign: A Randomized Clinical Trial AMERICAN JOURNAL OF PUBLIC HEALTH Leahey, T. M., Thomas, G., Fava, J. L., Subak, L. L., Schembri, M., Krupel, K., Kumar, R., Weinberg, B., Wing, R. R. 2014; 104 (7): 1300–1306


    We determined the efficacy and cost-effectiveness of adding an evidence-based Internet behavioral weight loss intervention alone or combined with optional group sessions to ShapeUp Rhode Island 2011 (SURI), a 3-month statewide wellness campaign.We randomized participants (n = 230; body mass index = 34.3 ±6.8 kg/m(2); 84% female) to the standard SURI program (S) or to 1 of 2 enhanced programs: SURI plus Internet behavioral program (SI) or SI plus optional group sessions (SIG). The primary outcome was weight loss at the end of the 3-month program.Weight losses differed among all 3 conditions (S: 1.1% ±0.9%; SI: 4.2% ±0.6%; SIG: 6.1% ±0.6%; Ps ≤ .04). Both SI and SIG increased the percentage of individuals who achieved a 5% weight loss (SI: 42%; SIG: 54%; S: 7%; Ps < .001). Cost per kilogram of weight loss was similar for S ($39) and SI ($35); both were lower than SIG ($114).Although weight losses were greatest at the end of SURI with optional group sessions, the addition of an Internet behavioral program was the most cost-effective method to enhance weight losses.

    View details for DOI 10.2105/AJPH.2014.301870

    View details for Web of Science ID 000341809500047

    View details for PubMedID 24832424

    View details for PubMedCentralID PMC4056209

  • A Group-Based Yoga Therapy Intervention for Urinary Incontinence in Women: A Pilot Randomized Trial FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Huang, A. J., Jenny, H. E., Chesney, M. A., Schembri, M., Subak, L. L. 2014; 20 (3): 147–54


    The aim of this study is to examine the feasibility, efficacy, and safety of a group-based yoga therapy intervention for middle-aged and older women with urinary incontinence.We conducted a pilot randomized trial of ambulatory women aged 40 years and older with stress, urgency, or mixed-type incontinence. Women were randomized to a 6-week yoga therapy program (n = 10) consisting of twice weekly group classes and once weekly home practice or a wait-list control group (n = 9). All participants also received written pamphlets about standard behavioral self-management strategies for incontinence. Changes in incontinence were assessed with 7-day voiding diaries.The mean (SD) age was 61.4 (8.2) years, and the mean baseline frequency of incontinence was 2.5 (1.3) episodes/d. After 6 weeks, the total incontinence frequency decreased by 70% (1.8 [0.9] fewer episodes/d) in the yoga therapy versus 13% (0.3 [1.7] fewer episodes/d) in the control group (P = 0.049). Participants in the yoga therapy group also reported an average of 71% decrease in stress incontinence frequency (0.7 [0.8] fewer episodes/d) compared with a 25% increase in controls (0.2 [1.1] more episodes/d) (P = 0.039). No significant differences in reduction in urgency incontinence were detected between the yoga therapy versus control groups (1.0 [1.0] versus 0.5 [0.5] fewer episodes/d; P = 0.20). All women starting the yoga therapy program completed at least 90% of the group classes and practice sessions. Two participants in each group reported adverse events unrelated to the intervention.Findings provide preliminary evidence to support the feasibility, efficacy, and safety of a group-based yoga therapy intervention to improve urinary incontinence in women.

    View details for DOI 10.1097/SPV.0000000000000072

    View details for Web of Science ID 000347114400007

    View details for PubMedID 24763156

    View details for PubMedCentralID PMC4310548

  • What constitutes an adequate evaluation of device-guided breathing? JAMA internal medicine Huang, A. J., Subak, L. L. 2014; 174 (4): 637

    View details for DOI 10.1001/jamainternmed.2013.13791

    View details for PubMedID 24711181

  • Childbirth and Female Sexual Function Later in Life OBSTETRICS AND GYNECOLOGY Fehniger, J. E., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Thom, D. H., Subak, L. L., Huang, A. J. 2013; 122 (5): 988–97


    To examine relationships among parity, mode of delivery, and other parturition-related factors with women's sexual function later in life.Self-administered questionnaires examined sexual desire, activity, satisfaction, and problems in a multiethnic cohort of women aged 40 years and older with at least one past childbirth event. Trained abstractors obtained information on parity, mode of delivery, and other parturition-related factors from archived records. Multivariable regression models examined associations with sexual function controlling for age, race or ethnicity, partner status, diabetes, and general health.Among 1,094 participants, mean (standard deviation) age was 56.3 (±8.7) years, 568 (43%) were racial or ethnic minorities (214 African American, 171 Asian, and 183 Latina), and 963 (88%) were multiparous. Fifty-six percent (n=601) reported low sexual desire; 53% (n=577) reported less than monthly sexual activity, and 43% (n=399) reported low overall sexual satisfaction. Greater parity was not associated with increased risk of reporting low sexual desire (adjusted odds ratio [OR] 1.08, confidence interval [CI] 0.96-1.21 per each birth), less than monthly sexual activity (adjusted OR 1.05, CI 0.93-1.20 per each birth), or low sexual satisfaction (adjusted OR 0.96, CI 0.85-1.09 per each birth). Compared with vaginal delivery alone, women with a history of cesarean delivery were not significantly more likely to report low desire (adjusted OR 0.71, CI 0.34-1.47), less than monthly sexual activity (adjusted OR 1.03, CI 0.46-2.32), or low sexual satisfaction (adjusted OR 0.57, CI 0.26-1.22). Women with a history of operative-assisted delivery were more likely to report low desire (adjusted OR 1.38, CI 1.04-1.83).Among women with at least one childbirth event, parity and mode of delivery are not major determinants of sexual desire, activity, or satisfaction later in life.II.

    View details for DOI 10.1097/AOG.0b013e3182a7f3fc

    View details for Web of Science ID 000330448500010

    View details for PubMedID 24104776

    View details for PubMedCentralID PMC3813451

  • Fecal Incontinence Decreases Sexual Quality of Life, But Does Not Prevent Sexual Activity in Women DISEASES OF THE COLON & RECTUM Imhoff, L. R., Brown, J. S., Creasman, J. M., Subak, L. L., Van den Eeden, S. K., Thom, D. H., Varma, M. G., Huang, A. J. 2012; 55 (10): 1059–65


    The impact of anal incontinence on women's sexual function is poorly understood.The aim of this study was to investigate the relationship between anal incontinence and sexual activity and functioning in women.This is a cross-sectional study.This investigation was conducted in a community-based integrated health care delivery system.Included were 2269 ethnically diverse women aged 40 to 80 years.Self-administered questionnaires assessed accidental leakage of gas (flatal incontinence) and fluid/mucus/stool (fecal incontinence) in the past 3 months. Additional questionnaires assessed sexual activity, desire and satisfaction, as well as specific sexual problems (difficulty with arousal, lubrication, orgasm, or pain). Multivariable logistic regression models compared sexual function in women with 1) isolated flatal incontinence, 2) fecal incontinence (with or without flatal incontinence), and 3) no fecal/flatal incontinence, controlling for potential confounders.Twenty-four percent of women reported fecal incontinence and 43% reported isolated flatal incontinence in the previous 3 months. The majority were sexually active (62% of women without fecal/flatal incontinence, 66% with isolated flatal incontinence, and 60% with fecal incontinence; p = 0.06). In comparison with women without fecal/flatal incontinence, women with fecal incontinence were more likely to report low sexual desire (OR: 1.41 (CI: 1.10-1.82)), low sexual satisfaction (OR: 1.56 (CI: 1.14-2.12)), and limitation of sexual activity by physical health (OR: 1.65 (CI: 1.19-2.28)) after adjustment for confounders. Among sexually active women, women with fecal incontinence were more likely than women without fecal/flatal incontinence to report difficulties with lubrication (OR: 2.66 (CI: 1.76-4.00)), pain (OR: 2.44 (CI: 1.52-3.91)), and orgasm (OR: 1.68 (CI: 1.12-2.51)). Women with isolated flatal incontinence reported sexual functioning similar to women without fecal/flatal incontinence.The cross-sectional design prevented evaluation of causality.Although most women with fecal incontinence are at high risk for several aspects of sexual dysfunction, the presence of fecal incontinence does not prevent women from engaging in sexual activity. This indicates that sexual function is important to women with anal incontinence and should be prioritized during therapeutic management.

    View details for DOI 10.1097/DCR.0b013e318265795d

    View details for Web of Science ID 000308797600020

    View details for PubMedID 22965405

    View details for PubMedCentralID PMC3720983

  • Diabetes Mellitus and Sexual Function in Middle-Aged and Older Women OBSTETRICS AND GYNECOLOGY Copeland, K. L., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Subak, L. L., Thom, D. H., Ferrara, A., Huang, A. J. 2012; 120 (2): 331–40


    Diabetes mellitus is an established risk factor for sexual dysfunction in men, but its effect on female sexual function is poorly understood. We examined the relationship of diabetes to sexual function in middle-aged and older women.Sexual function was examined in a cross-sectional cohort of ethnically diverse women aged 40-80 years using self-administered questionnaires. Multivariable regression models compared self-reported sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (difficulty with lubrication, arousal, orgasm, or pain) among insulin-treated diabetic, non-insulin-treated diabetic, and nondiabetic women. Additional models assessed relationships between diabetic end-organ complications (heart disease, stroke, renal dysfunction, and peripheral neuropathy) and sexual function.Among the 2,270 participants, mean±standard deviation age was 55±9.2 years, 1,006 (44.4%) were non-Latina white, 486 (21.4%) had diabetes, and 139 (6.1%) were taking insulin. Compared with 19.3% of nondiabetic women, 34.9% of insulin-treated diabetic women (adjusted odds ratio [OR] 2.04, 95% confidence interval [CI] 1.32-3.15) and 26.0% of non-insulin-treated diabetic women (adjusted OR 1.42, 95% CI 1.03-1.94) reported low overall sexual satisfaction. Among sexually active women, insulin-treated diabetic women were more likely to report problems with lubrication (OR 2.37, 95% CI 1.35-4.16) and orgasm (OR 1.80, 95% CI 1.01-3.20) than nondiabetic women. Among all diabetic women, end-organ complications such as heart disease, stroke, renal dysfunction, and peripheral neuropathy were associated with decreased sexual function in at least one domain.Compared with nondiabetic women, diabetic women are more likely to report low overall sexual satisfaction. Insulin-treated diabetic women also appear at higher risk for problems such as difficulty with lubrication and orgasm. Prevention of end-organ complications may be important in preserving sexual activity and function in diabetic women.II.

    View details for DOI 10.1097/AOG.0b013e31825ec5fa

    View details for Web of Science ID 000306713100020

    View details for PubMedID 22825093

    View details for PubMedCentralID PMC3404429

  • Decrease in Urinary Incontinence Management Costs in Women Enrolled in a Clinical Trial of Weight Loss to Treat Urinary Incontinence OBSTETRICS AND GYNECOLOGY Subak, L. L., Pinto, A., Wing, R. R., Nakagawa, S., Kusek, J. W., Herman, W. H., Kuppermann, M., Program Reduce Incontinence Diet 2012; 120 (2): 277–83


    To estimate the effect of a decrease in urinary incontinence (UI) frequency on UI management costs among women enrolled in a clinical trial of a weight loss intervention and to identify factors that predict change in cost.This is a secondary cohort analysis of 338 obese and overweight women with 10 or more weekly episodes of UI enrolled in an 18-month randomized clinical trial of a weight loss intervention compared with a structured education program to treat UI. Quantities of resources used for incontinence management, including pads, additional laundry, and dry cleaning, were reported by participants. Direct costs for UI management ("cost") were calculated by multiplying resources used by national resource costs (in 2006 U.S. dollars). Randomized groups were combined to examine the effects of change in incontinence frequency on cost. Possible predictors of change in cost were examined using generalized estimating equations controlling for factors associated with change in cost in univariable analyses.Mean age±standard deviation was 53±10 years and baseline weight was 97±17 kg. Mean weekly UI frequency was 24±18 at baseline and decreased by 37% at 6 months and 60% at 18 months' follow-up (both P<.001). At baseline, adjusted mean cost was $7.76±$14 per week, with costs increasing significantly with greater incontinence frequency. Mean cost decreased by 54% at 6 months and 81% at 18 months (both P<.001). In multivariable analyses, cost independently decreased by 23% for each decrease of seven UI episodes per week and 21% for each 5 kg of weight lost (P<.001 for both).In obese and overweight women enrolled in a clinical trial of weight loss for UI, incontinence management cost decreased by 81% at 18 months ($327 per woman per year) and was strongly and independently associated with decreasing incontinence frequency.II.

    View details for DOI 10.1097/AOG.0b013e31825dd268

    View details for Web of Science ID 000306713100012

    View details for PubMedID 22825085

    View details for PubMedCentralID PMC3404427

  • Pharmacologic treatment for urgency-predominant urinary incontinence in women diagnosed using a simplified algorithm: a randomized trial AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Huang, A. J., Hess, R., Arya, L. A., Richter, H. E., Subak, L. L., Bradley, C. S., Rogers, R. G., Myers, D. L., Johnson, K. C., Gregory, W., Kraus, S. R., Schembri, M., Brown, J. S. 2012; 206 (5): 444.e1–11


    The purpose of this study was to evaluate clinical outcomes associated with the initiation of treatment for urgency-predominant incontinence in women diagnosed by a simple 3-item questionnaire.We conducted a multicenter, double-blinded, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence in ambulatory women diagnosed by the simple 3-item questionnaire. Participants (N = 645) were assigned randomly to fesoterodine therapy (4-8 mg daily) or placebo. Urinary incontinence was assessed with the use of voiding diaries; postvoid residual volume was measured after treatment.After 12 weeks, women who had been assigned randomly to fesoterodine therapy reported 0.9 fewer urgency and 1.0 fewer total incontinence episodes/day, compared with placebo (P ≤ .001). Four serious adverse events occurred in each group, none of which was related to treatment. No participant had postvoid residual volume of ≥ 250 mL after treatment.Among ambulatory women with urgency-predominant incontinence diagnosed with a simple 3-item questionnaire, pharmacologic therapy resulted in a moderate decrease in incontinence frequency without increasing significant urinary retention or serious adverse events, which provides support for a streamlined algorithm for diagnosis and treatment of female urgency-predominant incontinence.

    View details for DOI 10.1016/j.ajog.2012.03.002

    View details for Web of Science ID 000303211100029

    View details for PubMedID 22542122

    View details for PubMedCentralID PMC3570031

  • Summary of Research Recommendations From the Inaugural American Urogynecologic Society Research Summit FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Nygaard, I., Chai, T. C., Cundiff, G. W., Delancey, J. L., FitzGerald, M., Heit, M., Moalli, P., Richter, H. E., Subak, L., Swift, S. 2011; 17 (1): 4–7

    View details for DOI 10.1097/SPV.0b013e3182042168

    View details for Web of Science ID 000209176000002

    View details for PubMedID 22453666

  • Incidence of and Risk Factors for Change in Urinary Incontinence Status in a Prospective Cohort of Middle-Aged and Older Women: The Reproductive Risk of Incontinence Study in Kaiser JOURNAL OF UROLOGY Thom, D. H., Brown, J. S., Schembri, M., Ragins, A. I., Subak, L. L., Van Den Eeden, S. K. 2010; 184 (4): 1394–1401


    Urinary incontinence is a dynamic condition that can progress and regress but few groups have examined risk factors for change in incontinence status.We used stratified random sampling to construct a racially and ethnically diverse, population based cohort of 2,109 women 40 to 69 years old. Data were collected by questionnaires and medical record review. A second survey approximately 5 years later was completed by 1,413 women (67%) from the original cohort. The frequency of urinary incontinence was categorized as less than weekly, weekly and daily. Change in incontinence status was defined as new onset incontinence, incontinence progression or regression between frequency categories and resolution of incontinence. Predictor variables were demographics, body mass index and other medical conditions. We used logistic regression to estimate the adjusted OR and 95% CI.Compared to white nonHispanic women, black women were less likely to have incontinence progression (OR 0.46, 95% CI 0.24-0.88). New onset incontinence was more common in women with a higher body mass index at baseline (p = 0.006) and those who experienced increased body mass index (p = 0.03) or decreased general health (p = 0.007) during the study. Participants with chronic obstructive pulmonary disorder at baseline were more likely to report incontinence progression (OR 2.64, 95% CI 1.22-5.70). Baseline incontinence type was not significantly associated with the risk of change in continence status independent of frequency.Identifying risk factors for change in incontinence status may be important to develop interventions to decrease the burden of incontinence in the general population.

    View details for DOI 10.1016/j.juro.2010.05.095

    View details for Web of Science ID 000282615400056

    View details for PubMedID 20727544

    View details for PubMedCentralID PMC2939171

  • Urinary incontinence, fecal incontinence and pelvic organ prolapse in a population-based, racially diverse cohort: prevalence and risk factors. Female pelvic medicine & reconstructive surgery Rortveit, G., Subak, L. L., Thom, D. H., Creasman, J. M., Vittinghoff, E., Van Den Eeden, S. K., Brown, J. S. 2010; 16 (5): 278–83


    OBJECTIVES: : We investigated the prevalence of and risk factors for combinations of urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP) in racially diverse women older than 40 years.METHODS: : The Reproductive Risks for Incontinence Study at Kaiser is a population-based study with data from 2106 women older than 40 years. Pelvic floor conditions were determined by self-report. Risk factors were assessed by self-report, interview and record review. Independent risk factors were identified by multinomial logistic regression analysis.RESULTS: : At least one pelvic floor condition was reported by 714 (34%) women. Of these, 494 (69%) had only UI, 60 (8%) only POP, and 46 (6%) only FI. Both UI and FI were reported by 64 (9%) and both UI and POP by 51 (7%). Among women with FI, 60% reported more than one condition. Corresponding figures for POP and UI were 49% and 18%. Estrogen use and constipation were shared risk factors for UI, FI and POP. Body mass index was a unique risk factor UI only, diabetes FI only and parity POP only. No clear pattern could be found to support the hypothesis that risk factors for single conditions are more strongly associated with combined conditions.CONCLUSIONS: : Patients with FI or POP often have concomitant UI. These diseases both share and have unique risk factors in a complex pattern.

    View details for DOI 10.1097/SPV.0b013e3181ed3e31

    View details for PubMedID 22453506

  • An Intensive Behavioral Weight Loss Intervention and Hot Flushes in Women ARCHIVES OF INTERNAL MEDICINE Huang, A. J., Subak, L. L., Wing, R., West, D., Hernandez, A. L., Macer, J., Grady, D., Program Reduce Incontinence Diet 2010; 170 (13): 1161–67


    Higher body mass index is associated with worse hot flushes during menopause but the effect of weight loss on flushing is unclear.Self-administered questionnaires were used to assess bothersome hot flushes in a 6-month randomized controlled trial of an intensive behavioral weight loss program (intervention) vs a structured health education program (control) in 338 women who were overweight or obese and had urinary incontinence. Weight, body mass index, abdominal circumference, physical activity, calorie intake, blood pressure, and physical and mental functioning were assessed at baseline and at 6 months. Repeated-measures proportional odds models examined intervention effects on bothersome hot flushes and potential mediating factors.Approximately half of participants (n = 154) were at least slightly bothered by hot flushes at baseline. Among these women, the intervention was associated with greater improvement in bothersome flushes vs control (odds ratio [OR] for improvement by 1 Likert category, 2.25; 95% confidence interval [CI], 1.20-4.21). Reductions in weight (OR, 1.32; 95% CI, 1.08-1.61; per 5-kg decrease), body mass index (1.17; 1.05-1.30; per 1-point decrease), and abdominal circumference (1.32; 1.07-1.64; per 5-cm decrease) were each associated with improvement in flushing, but changes in physical activity, calorie intake, blood pressure, and physical and mental functioning were not related. The effect of the intervention on flushing was modestly diminished after adjustment for multiple potential mediators (OR, 1.92; 95% CI, 0.95-3.89).Among women who were overweight or obese and had bothersome hot flushes, an intensive behavioral weight loss intervention resulted in improvement in flushing relative to control. Trial Registration Identifier: NCT00091988.

    View details for DOI 10.1001/archinternmed.2010.162

    View details for Web of Science ID 000279797700015

    View details for PubMedID 20625026

    View details for PubMedCentralID PMC3030922

  • Talking About Incontinence The First Step Toward Prevention and Treatment JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wagner, T. H., Subak, L. L. 2010; 303 (21): 2184–85

    View details for DOI 10.1001/jama.2010.747

    View details for Web of Science ID 000278182100028

    View details for PubMedID 20516420

    View details for PubMedCentralID PMC4445834

  • An Innovative Program to Train Health Sciences Researchers to Be Effective Clinical and Translational Research Mentors ACADEMIC MEDICINE Johnson, M. O., Subak, L. L., Brown, J. S., Lee, K. A., Feldman, M. D. 2010; 85 (3): 484-489


    The creation of the Clinical Translational Science Awards for academic health sciences campuses in 2006 was implicitly accompanied by a call for a new paradigm of faculty development and mentoring to train the next generation of researchers and leaders in this new approach to research. Effective mentoring is critical to help early-career investigators become successful, independent researchers, and a new approach to mentoring is vital to recruit, advance, and retain fellows and junior faculty engaged in clinical and translational research. However, in addition to the many rewards of mentoring, there are numerous substantive barriers to effective mentoring. These barriers include a lack of training in how to be a mentor, lack of time and structural and financial support for mentoring, and competing personal, administrative, and clinical demands. The authors describe an innovative program, the University of California, San Francisco Mentor Development Program (MDP), established in 2006 and designed to train midcareer academic health sciences researchers to be more effective as clinical and translational research mentors. Using a framework for presenting innovations in academic research, they present the rationale, design, implementation, and mechanisms being used to evaluate and sustain the MDP. Specific details of the objectives and content of the MDP sessions are provided as well as evaluation criteria and a link to specific curriculum materials.

    View details for DOI 10.1097/ACM.0b013e3181cccd12

    View details for Web of Science ID 000276132100023

    View details for PubMedID 20182122

    View details for PubMedCentralID PMC2856696

  • Pelvic floor disorders and quality of life in women with self-reported irritable bowel syndrome ALIMENTARY PHARMACOLOGY & THERAPEUTICS Wang, J., Varma, M. G., Creasman, J. M., Subak, L. L., Brown, J. S., Thom, D. H., van den Eeden, S. K. 2010; 31 (3): 424–31


    Quality of life among women with irritable bowel syndrome may be affected by pelvic floor disorders.To assess the association of self-reported irritable bowel syndrome with urinary incontinence, pelvic organ prolapse, sexual function and quality of life.We analysed data from the Reproductive Risks for Incontinence Study at Kaiser Permanente, a random population-based study of 2109 racially diverse women (mean age = 56). Multivariate analyses assessed the association of irritable bowel syndrome with pelvic floor disorders and quality of life.The prevalence of irritable bowel syndrome was 9.7% (n = 204). Women with irritable bowel had higher adjusted odds of reporting symptomatic pelvic organ prolapse (OR 2.4; 95% CI, 1.4-4.1) and urinary urgency (OR 1.4; 95% CI, 1.0-1.9); greater bother from pelvic organ prolapse (OR 4.3; 95% CI, 1.5-11.9) and faecal incontinence (OR 2.0; 95% CI, 1.3-3.2); greater lifestyle impact from urinary incontinence (OR 2.2; 95% CI, 1.3-3.8); and worse quality of life (P < 0.01). Women with irritable bowel reported more inability to relax and enjoy sexual activity (OR 1.8; 95% CI, 1.3-2.6) and lower ratings for sexual satisfaction (OR 1.8; 95% CI, 1.3-2.5), but no difference in sexual frequency, interest or ability to have an orgasm.Women with irritable bowel are more likely to report symptomatic pelvic organ prolapse and sexual dysfunction, and report lower quality of life.

    View details for DOI 10.1111/j.1365-2036.2009.04180.x

    View details for Web of Science ID 000273300700009

    View details for PubMedID 19863498

    View details for PubMedCentralID PMC2807921

  • Obesity and Urinary Incontinence: Epidemiology and Clinical Research Update Subak, L. L., Richter, H. E., Hunskaar, S. ELSEVIER SCIENCE INC. 2009: S2–S7


    We reviewed the epidemiological literature on the association of obesity and urinary incontinence, and summarized clinical trial data on the effect of weight loss on urinary incontinence.We systematically searched for published community based prevalence studies with bivariate or multivariate analysis of the association of urinary incontinence and overweight/obesity in women. Case series and randomized controlled trials of the effect of surgical, behavioral and pharmacological weight loss on urinary incontinence are summarized.Epidemiological studies showed that obesity is a strong independent risk factor for prevalent and incident urinary incontinence. There was a clear dose-response effect of weight on urinary incontinence with each 5-unit increase in body mass index associated with about a 20% to 70% increase in the urinary incontinence risk, and the maximum effect of weight rarely exceeded an OR of greater than 4 to 5 on well controlled analyses. The odds of incident urinary incontinence during 5 to 10 years increased by approximately 30% to 60% for each 5-unit increase in body mass index. There may be a stronger association of increasing weight with prevalent and incident stress incontinence, including mixed incontinence, than with urge incontinence and overactive bladder syndrome. Weight loss studies indicated that surgical and nonsurgical weight loss led to significant improvements in urinary incontinence symptoms.Epidemiological studies document overweight and obesity as important risk factors for urinary incontinence. Weight loss by surgical and more conservative approaches is effective to decrease urinary incontinence symptoms and should be strongly considered a first line treatment in this patient population.

    View details for DOI 10.1016/j.juro.2009.08.071

    View details for Web of Science ID 000271668800002

    View details for PubMedID 19846133

    View details for PubMedCentralID PMC2866035

  • Sexual Function Among Overweight and Obese Women With Urinary Incontinence in a Randomized Controlled Trial of an Intensive Behavioral Weight Loss Intervention JOURNAL OF UROLOGY Huang, A. J., Stewart, A. L., Hernandez, A. L., Shen, H., Subak, L. L., Program Reduce Incontinence Diet & 2009; 181 (5): 2235–42


    We examined sexual function in overweight and obese women with urinary incontinence, and evaluated the effects of an intensive behavioral weight reduction intervention on sexual function in this population.A total of 338 overweight and obese women reporting 10 or more incontinence episodes weekly were randomized to an intensive behavioral change (226) or structured education program (112) for 6 months. Sexual function was assessed using self-administered questionnaires. Multivariate regression was used to examine factors associated with baseline and 6-month change in sexual function as well as intervention effects.Two-thirds of participants (233) were sexually active at baseline but more than half (188) reported low desire and a quarter (91) were sexually dissatisfied. More than half of sexually active participants (123) reported problems with arousal, lubrication, orgasm or incontinence during sex. Compared to controls women in the intervention group demonstrated a borderline increase in frequency of sexual activity at 6 months (OR 1.34, 95% CI 0.99-1.81, p = 0.06) but no differences in satisfaction (OR 1.28, 95% CI 0.83-1.99, p = 0.26), desire (OR 1.12, 95% CI 0.79-1.61, p = 0.52) or problems (beta +/- SE 0.03 +/- 0.07, p = 0.68 for intervention effects on problems score). Neither clinical incontinence severity nor body mass index was independently associated with baseline or 6-month change in function (p >0.10 for all).Sexual dysfunction is common in overweight and obese women with incontinence but the severity of this dysfunction may not be directly related to the severity of incontinence or obesity. An intensive 6-month behavioral weight reduction intervention did not significantly improve sexual function in this population relative to controls.

    View details for DOI 10.1016/j.juro.2009.01.046

    View details for Web of Science ID 000265074800100

    View details for PubMedID 19296980

    View details for PubMedCentralID PMC2744348

  • Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women. NEW ENGLAND JOURNAL OF MEDICINE Subak, L. L., Wing, R., West, D., Franklin, F., Vittinghoff, E., Creasman, J. M., Richter, H. E., Myers, D., Burgio, K. L., Gorin, A. A., Macer, J., Kusek, J. W., Grady, D., PRIDE Investigators 2009; 360 (5): 481–90


    Obesity is an established and modifiable risk factor for urinary incontinence, but conclusive evidence for a beneficial effect of weight loss on urinary incontinence is lacking.We randomly assigned 338 overweight and obese women with at least 10 urinary-incontinence episodes per week to an intensive 6-month weight-loss program that included diet, exercise, and behavior modification (226 patients) or to a structured education program (112 patients).The mean (+/-SD) age of the participants was 53+/-11 years. The body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) and the weekly number of incontinence episodes as recorded in a 7-day diary of voiding were similar in the intervention group and the control group at baseline (BMI, 36+/-6 and 36+/-5, respectively; incontinence episodes, 24+/-18 and 24+/-16, respectively). The women in the intervention group had a mean weight loss of 8.0% (7.8 kg), as compared with 1.6% (1.5 kg) in the control group (P<0.001). After 6 months, the mean weekly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group (P=0.01). As compared with the control group, the intervention group had a greater decrease in the frequency of stress-incontinence episodes (P=0.02), but not of urge-incontinence episodes (P=0.14). A higher proportion of the intervention group than of the control group had a clinically relevant reduction of 70% or more in the frequency of all incontinence episodes (P<0.001), stress-incontinence episodes (P=0.009), and urge-incontinence episodes (P=0.04).A 6-month behavioral intervention targeting weight loss reduced the frequency of self-reported urinary-incontinence episodes among overweight and obese women as compared with a control group. A decrease in urinary incontinence may be another benefit among the extensive health improvements associated with moderate weight reduction. ( number, NCT00091988.)

    View details for DOI 10.1056/NEJMoa0806375

    View details for Web of Science ID 000262812400007

    View details for PubMedID 19179316

    View details for PubMedCentralID PMC2877497

  • High costs of urinary incontinence among women electing surgery to treat stress incontinence OBSTETRICS AND GYNECOLOGY Subak, L. L., Brubaker, L., Chai, T. C., Creasman, J. M., Diokno, A. C., Goode, P. S., Kraus, S. R., Kusek, J. W., Leng, W. W., Lukacz, E. S., Norton, P., Tennstedt, S., Urinary Incontinence Treatment Ne 2008; 111 (4): 899–907


    To estimate costs for incontinence management, health-related quality of life, and willingness to pay for incontinence improvement in women electing surgery for stress urinary incontinence.A total of 655 incontinent women enrolled in the Stress Incontinence Surgical Treatment Efficacy Trial, a randomized surgical trial. Baseline out-of-pocket costs for incontinence management were calculated by multiplying self-report of resources used (supplies, laundry, dry cleaning) by national resource costs (USD2,006). Health-related quality of life was estimated with the Health Utilities Index Mark 3. Participants estimated willingness to pay for 100% improvement in incontinence. Potential predictors of these outcomes were examined by using multivariable linear regression.Mean age was 52+/-10 years, and mean number of weekly incontinence episodes was 22+/-21. Mean and median (25%, 75% interquartile range) estimated personal costs for incontinence management among all women were USD14+/-USD24 and USD8 (interquartile range USD3, USD18) per week, and 617 (94%) women reported any cost. Costs increased significantly with incontinence frequency and mixed compared with stress incontinence. The mean and median Health Utilities Index Mark 3 scores were 0.73+/-0.25 and 0.84 (interquartile range 0.63, 0.92). Women were willing to pay a mean of USD118+/-USD132 per month for complete resolution of incontinence, and willingness to pay increased significantly with greater expected incontinence improvement, household income, and incontinent episode frequency.Urinary incontinence is associated with substantial costs. Women spent nearly USD750 per year out of pocket for incontinence management, had a significant decrement in quality of life, and were willing to pay nearly USD1,400 per year for cure.

    View details for DOI 10.1097/AOG.0b013e31816a1e12

    View details for Web of Science ID 000254433700013

    View details for PubMedID 18378749

    View details for PubMedCentralID PMC2593129

  • Pelvic organ prolapse surgery in the United States, 1997 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Brown, J. S., Waetjen, L. E., Subak, L. L., Thom, D. H., Van den Eeden, S., Vittinghoff, E. 2002; 186 (4): 712-716


    Our purpose was to describe the prevalence, regional rates and demographic characteristics, morbidity, and mortality of pelvic organ prolapse surgeries in the United States.We used data from the 1997 National Hospital Discharge Survey and the 1997 National Census to calculate rates of pelvic organ prolapse surgeries by age, race, and regional trends.In 1997, 225,964 women underwent surgery for prolapse (22.7 per 10,000 women). The mean age of these women was 54.6 years (+/-15.2). The South had the highest rate of surgery (29.3 per 10,000) and the Northeast had the lowest (16.1 per 10,000). The surgery rate for whites (19.6 per 10,000) was 3 times greater than that for African Americans (6.4 per 10,000). Although 16% of surgeries had complications, mortality was rare (0.03%).Pelvic organ prolapse surgery is common. Regional and racial differences in rates of surgery may reflect physician practice, patient preferences, and gynecologic care utilization.

    View details for DOI 10.1067/mob.2002.121897

    View details for Web of Science ID 000175545300018

    View details for PubMedID 11967496

  • Does weight loss improve incontinence in moderately obese women? INTERNATIONAL UROGYNECOLOGY JOURNAL Subak, L. L., Johnson, C., Whitcomb, E., Boban, D., Saxton, J., Brown, J. S. 2002; 13 (1): 40-43


    The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (+/-SD) baseline BMI of 38.3 (+/-10.1) kg/m2 and 13 (+/-10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (+/-6.2) kg/ m2 (P < 0.03). Among women achieving a weight loss of > or = 5%, 6/6 had > or = 50% reduction in incontinence frequency compared to 1 in 4 women with < 5% weight loss (P < 0.03). Incontinence episodes decreased to 8 (+/-10) per week following weight reduction (P < 0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.

    View details for Web of Science ID 000174940100009

    View details for PubMedID 11999205

  • Cost of pelvic organ prolapse surgery in the United States OBSTETRICS AND GYNECOLOGY Subak, L. L., Waetjen, L. E., Van den Eeden, S., Thom, D. H., Vittinghoff, E., Brown, J. S. 2001; 98 (4): 646-651


    To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.The annual direct costs of operations for pelvic organ prolapse are substantial.

    View details for Web of Science ID 000171374400021

    View details for PubMedID 11576582



    We evaluated the efficacy of fresh versus frozen sperm in therapeutic donor insemination.Fifty-seven women underwent 72 courses of treatment (a maximum of six therapeutic donor insemination cycles--three fresh and three frozen) totaling 198 cycles. Each woman served as her own control and was prospectively randomized to receive a single, timed insemination of either fresh or frozen sperm.Fecundity was 20.6% for fresh sperm cycles and 9.4% for frozen (p less than 0.03, by chi 2 analysis). Fresh cervical cap insemination fecundity was 20.3%; frozen was 7.8% (p less than 0.03, by chi 2 analysis). Fresh intrauterine insemination fecundity was 21.2%; frozen was 15.8% (p = 0.63, by chi 2 analysis). Fresh 3-month life-table pregnancy rates were 48% +/- 10%; frozen rates were 22% +/- 8% (p = 0.05 by Breslow analysis). Survival analysis with fixed covariates showed a positive association with the use of fresh sperm (p = 0.04).Cycle fecundity was significantly greater with fresh sperm in women undergoing cervical cap insemination or intrauterine insemination and in women undergoing only cervical cap insemination. These results have important implications for contemporary management of patients undergoing therapeutic donor insemination with frozen sperm.

    View details for Web of Science ID A1992JA20600002

    View details for PubMedID 1615966



    To assess the effectiveness of laparoscopy versus laparotomy in the treatment of endometriomata.Controlled study using data prospectively tabulated.Treatment performed by senior author in a referral reproductive endocrinology and surgery private practice.One hundred infertile women were diagnosed with endometriomata.Forty-eight women were treated with CO2 laser laparoscopy (laparoscopy group) and 52 women were treated with CO2 laser or nonlaser laparotomy (laparotomy group).The hypothesis that laparoscopy group pregnancy rates (PRs) would be equal to or greater than laparotomy group was formulated before data analysis but after data tabulation.The 1 and 3-year life table estimated cumulative PRs +/- SE were 0.30 +/- 0.07 and 0.52 +/- 0.09 for laparoscopy group and 0.23 +/- 0.06 and 0.46 +/- 0.09 for laparotomy group (Breslow P = 0.48). Monthly fecundity over 3 years was 2.4% for laparoscopy group and 2.0% for laparotomy group.Laparoscopy with CO2 laser can be a safe and effective modality for treating endometriomata.

    View details for Web of Science ID A1992HR34300003

    View details for PubMedID 1533375



    The study was designed to compare five opioid analgesic regimens administered after cesarean delivery in a routine hospital setting with respect to patients' perceptions of their pain relief and the impact of analgesic technique on recovery and hospital costs. After cesarean delivery, 684 patients received one of the following: epidural morphine, alone (EM,n = 128), or with fentanyl (EM + F,n = 245); subarachnoid morphine (n = 48); intramuscular meperidine (n = 165), or patient-controlled analgesia using meperidine (PCA, n = 98). On the first three postoperative days (Days 1-3; day of operation is Day 1) patients were surveyed regarding their impressions of their analgesia, the incidence of side effects, times to resume normal activities and satisfaction with their technique. Information regarding drug interventions and costs was obtained from anesthetic records and nursing charts. Patients receiving intramuscular and PCA opioids reported significantly more severe pain during the first 16 hours than those receiving intraspinal opioids (p less than 0.05); differences were minimal for the remainder of Day 1. Among the intraspinal groups, analgesia was best overall with EM; specifically, fentanyl did not decrease early postoperative pain. Analgesia with PCA and intramuscular opioids was similar during the first 16 hours; however, PCA patients felt they had less pain thereafter. Side effects were common in all intraspinal groups and were least frequent with PCA (p less than 0.05 versus all intraspinal groups). Times to sit, walk and drink were similar in all patients except those receiving intramuscular opioids after general anesthesia, who experienced a several-hour delay. Other aspects of recovery did not differ among the groups. Satisfaction parallelled pain relief and was better with intraspinal than with systemic opioids. Costs were greatest with PCA, although differences were small (less than 1%) relative to total hospital charges.

    View details for Web of Science ID A1991FX19600006

    View details for PubMedID 1883771



    The use of basal body temperature (BBT) recording and a single progesterone (P) level at the time of the endometrial biopsy in the late luteal phase improved our ability to predict the onset of the next menstrual period (NMP) and determine the postovulatory day (POD) in 124 regularly menstruating infertile women. We determined BBT shift using a microcomputer program, analyzed P levels by radioimmunoassay, and evaluated endometrial biopsies both prospectively (blinded) and retrospectively (with knowledge of the other variables). Serum P levels were within the normal range for the luteal phase and prospective and retrospective histological diagnoses closely agreed (82% within 2 days). The best correlation with the NMP was the BBT shift (r = 0.493) followed by P (r = 0.426) and prospective histologic dating (r = 0.390). Multiple regression analysis confirmed that use of all of the variables markedly improved the ability to estimate the POD (R2 = 0.51).

    View details for Web of Science ID A1990CX65500005

    View details for PubMedID 2318322



    This study reports on 108 infertile patients with endometriosis diagnosed at laparoscopy. Sixty-four patients had endometriosis and adhesions vaporized with a CO2 laser (LAS) and were prospectively compared with a control group (CON) of 44 patients who had laparoscopy. The 6- and 12-month estimated cumulative pregnancy rates for LAS were 0.32 +/- 0.07 and 0.55 +/- 0.09 respectively, and for CON 0.17 +/- 0.06 and 0.43 +/- 0.09 (Breslow P = 0.10). Monthly fecundity rates were 6.7% in LAS and 4.5% in CON. Survival analysis with fixed covariates showed that pregnancy rates were increased in patients with adhesions (P = 0.002) and other pelvic disease (P = 0.0001). Pregnancy rates were reduced by age (P = 0.02), previous adhesiolysis (P = 0.0000) and post-laparoscopy medical treatment (P = 0.0002). Our findings indicate that CO2 laser laparoscopy vaporization of endometriosis can be a safe, effective, and possibly improved modality for treating endometriosis.

    View details for Web of Science ID A1988Q917200003

    View details for PubMedID 2972565