This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada. SIUJ • Volume 4, Number 3 • May 2023 SIUJ.ORG Key Words Competing Interests Article Information Concurrent surgery, rectal prolapse, vaginal prolapse, multidisciplinary care None declared. Received on July 19, 2022 Accepted on October 18, 2022 This article has been peer reviewed. Soc Int Urol J. 2023;4(3):180–186 DOI: 10.48083/KUPV7345 180 ORIGINAL RESEARCH Age- and Population-Adjusted Trends in Inpatient Surgical Management of Vaginal Prolapse, Rectal Prolapse, and Concurrent Vaginal and Rectal Prolapse Surgery Justina Tam,1 Hannah G. Koenig,2 Celine R. Soriano,3 Alvaro Lucioni,1 Jennifer A. Kaplan,3 Kathleen C. Kobashi,1,* Vlad V. Simianu, 3 Una J. Lee1 1 Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, United States 2 Research and Academics, Virginia Mason Medical Center, Seattle, United States 3 Department of Surgery, Virginia Mason Medical Center, Seattle, United States * Present address: Department of Urology, Houston Methodist, Houston, United States Previous presentation: This study was previously presented at the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction (SUFU) 2021 Virtual Winter Meeting as a non-moderated poster and the abstract was published in the SUFU 2021 Abstracts Issue of Neurourology and Urodynamics: Tam J, Soriano C, Koeniga H, Lucioni A, Kaplan J, Kobashi K, et al. Age and population adjusted trends in inpatient surgical management of vaginal prolapse, rectal prolapse, and concurrent vaginal and rectal prolapse surgery in Washington State. Neurourol Urodyn.2021;40:S229–S229. Abstract Objective To report age- and population-adjusted trends in the prevalence of inpatient vaginal prolapse (VP), rectal prolapse (RP), and concurrent VP/RP surgical procedures in women in Washington State over a 12-year period. Methods The Comprehensive Hospital Abstract Reporting System, an inpatient claims database, was queried for female patients aged 20 years or older with a diagnosis of VP and/or RP and associated surgical procedures from 2008 to 2019. Rates for female patients were adjusted by age and population based on census results. Results Between 2008 and 2019, inpatient admissions for concurrent VP/RP surgery remained stable, with adjusted rates ranging from 1.42 to 3.38 per 100 000, with a majority performed in patients < 80 years old. The population- adjusted rate of inpatient RP repairs remained stable at 3.12 to 5.14 per 100 000. The population-adjusted rate of inpatient VP repairs decreased dramatically, from 81.79 to 6.96 per 100 000. Conclusions The rate of inpatient RP and combined RP/VP surgical procedures was low and remained stable, while inpatient VP surgical repairs decreased substantially. Since the dataset is limited to inpatient surgery, this trend may reflect a shift to outpatient settings for VP surgeries. Nationally in the United States, there has been a trend toward multidisciplinary surgical management of concurrent VP/RP. However, this same trend does not appear to be reflected in Washington State, suggesting that nationwide trends may not be reflective of trends within each state. Further study is needed to understand how and why local trends in the management concurrent VP/RP may differ from national trends, and potentially improve concurrent VP/RP management using multidisciplinary approaches. Introduction Vaginal (VP) and rectal prolapse (RP) in women share a common pathophysiology and similar surgical approaches. The incidence of concomitant uterine/VP with RP is variable and has been reported to be ~38% in some analyses[1]. http://SIUJ.org https://orcid.org/0000-0002-1069-0901 https://orcid.org/0000-0003-2215-0301 https://orcid.org/0000-0003-0440-9439 https://orcid.org/0000-0002-9188-677X https://orcid.org/0000-0002-5668-251X https://orcid.org/0000-0003-1255-0221 https://orcid.org/0000-0003-1128-5083 mailto:Una.Lee%40virginiamason.org?subject=SIUJ SIUJ.ORG SIUJ • Volume 4, Number 3 • May 2023 Both VP and RP occur more commonly in women over the age of 65 years[2,3], and traditionally have been treated as separate entities. However, there has been a trend toward a multidisciplinary approach, with concomitant procedures being performed by colorectal surgeons and urologists or g y necologists[1,4,5]. Multidisciplinary approaches have been demonstrated to be safe and efficacious[1] and may improve surgical outcomes and patient symptoms[4,6–9]. Prior work has demonstrated that the national rate of multidisciplinary repair in women diagnosed with VP and RP increased from 0.7% in 2003 to 1.9% in 2017[5]. However, a more detailed analysis of these trends on a statewide level has not been reported. The objective of this study is to report age- and population-adjusted trends in the prevalence of inpatient VP, RP, and concurrent VP/RP surgical procedures in women in Washington State over a contemporary 12-year period. Materials and Methods The Comprehensive Hospital Abstract Reporting System (CHARS), a Washington State administrative inpatient claims database that captures all inpatient hospitalizations from all hospitals in the state, and includes data such as age, sex, zip code, diagnosis and procedure codes, billing codes, and procedure dates, regardless of insurance type, was queried for female patients 20 years of age or older with both a diagnosis of VP and/or R P and associated VP and/or R P surgical procedures from 2008 to 2019. The CHARS data dictionary is publicly available at https://www. doh.wa.gov/ and includes diagnosis and procedural codes based on the Ninth revision of the International Classification of Diseases (ICD-9) and ICD-10 for admissions. The CHARS database does not utilize Current Procedural Terminology (CPT®) codes. Using the International Classification of Diseases Ninth and Tenth edition (ICD-9 and ICD-10) codes, women ≥ 20 years of age with VP and/or RP diagnosis codes were identified (Appendix 1). ICD procedural codes for VP and RP operations were used to identify patients who had undergone treatment for prolapse (Appendix 1). Surgical procedures that were performed on the same date were considered concurrent, while those with different dates were considered staged. Demographic characteristics and rates of concurrent surgica l repair were analyzed. Rates were adjusted by age, and population of women, based on Washington State Census results for 2008 to 2019 using the direct method. The study was submitted for Institutional Review Board (IRB) review and was found to not constitute human subjects research and did not require IRB approval. Results Query of the CHARS database identified 17 840 female inpatient admissions with a diagnosis of VP and/or RP who had also undergone a VP and/or RP procedure. Of those, 15 279 (85.6%) underwent VP-only and 918 (5.1%) underwent combined VP/RP repair. The majority of women identified in our query were < 80 years old, 52.03% were identified as white, and 4.83% of the population were identified as minority groups (Table 1). Notably, there was no information provided on ethnicity in the database for 43.14% of the population. Seventy-five percent of all VP-only, RP-only, or concurrent VP/RP inpatient surgeries were performed in the 7 most populated Washington State counties. The majority of all combined VP/RP procedures were performed in 10 facilities in a single county (King County, which includes the Seattle metropolitan area). The majority of patients identified in the query were residents of 5 counties (Table 2), and 75% of patients lived within 20 miles of their treating facilities. Among the top 15 centers performing VP and/or RP prolapse surgery, 2 centers were noted to have patient populations composed of nearly 95% of patients who resided less than 20 miles away (Figure 1). Between 2008 and 2019, inpatient admissions for concurrent VP/RP surgery remained stable, with adjusted rates ranging from 1.42 to 3.38 per 100 000 women (Figure 2), and 95% of combined procedures were performed in patients < 80 years old. The adjusted rate of inpatient RP-only repairs also remained stable, 3.12 to 5.14 per 100 000 women, with 82% being performed in women < 80 years old. The adjusted rate of inpatient VP-only repairs decreased markedly, from 81.79 per 100 000 women in 2008 to 6.96 per 100 000 women in 2019, with 94% of these surgeries being performed in women < 80 years old. Discussion Prior work has demonstrated that there has been a nationw ide trend of increasing utilization of multidisciplinary approaches toward treating VP/ RP concurrently, increasing from 0.7% of all surgeries performed for rectal prolapse or pelvic organ prolapse in 2003 to 1.9% in 2017[5]. However, the same trend for concurrent VP/RP surgery has not been clearly identified in Washington State. These data suggest that despite a nationwide trend toward multidisciplinary Abbreviations CHARS Comprehensive Hospital Abstract Reporting System ICD International Classification of Diseases IRB Institutional Review Board RP rectal prolapse VP vaginal prolapse 181 Trends in Vaginal and Rectal Prolapse Surgery http://SIUJ.org https://www.doh.wa.gov/ https://www.doh.wa.gov/ http://SIUJ.org http://SIUJ.org SIUJ • Volume 4, Number 3 • May 2023 SIUJ.ORG approaches, this trend may not be occurring at similar rates in each state. Additionally, the previously reported rates[5] were not adjusted for population, age, or gender, which may affect the ability to compare the results. Although there was a significant nationwide increase in the number of concurrent VP/RP procedures, whether this increase is due to a growing and aging population with a higher incidence for pelvic organ prolapse has not been well studied. The procedure rates described herein were obtained using the CHARS database, which collects record- level information on inpatient and observation-patient community hospital stays. While limited to adminis- trative data, this database has the advantage of captur- ing all procedures performed provided that the patient was hospitalized, regardless of insurance status. We acknowledge the limitations of using this inpatient state- wide database. However, the information captured adds to our knowledge of trends in the utilization of concur- rent RP/VP surgery overall. Although some studies with small patient cohorts have suggested that rectal prolapse procedures such as laparoscopic rectopexy may be feasibly performed as outpatient procedures[10–13], the majority of RP surgeries are performed as inpatient procedures and concurrent VP/RP surgeries are there- fore captured in this dataset, allowing for analysis of trends in this procedure. However, VP surgery can be performed either in an inpatient or outpatient setting, depending on many factors. The reporting of only inpatient VP surgeries is a limitation that prevents an accurate analysis of broader trends in VP and its proce- dures. We acknowledge this limitation as it relates to the capture of all vaginal prolapse surgeries. The focus of this study is concurrent VP/RP surgery, which is captured in this dataset. Between 2008 and 2019, the rate of inpatient VP surgery decreased substantially in Washington State from 81.79 per 100 000 women in 2008 to 6.96 per 100 000 women in 2019. Previously published literature has demonstrated an increasing utilization of outpa- tient urologic procedures[14], suggesting that this trend could represent an increase in utilization of outpatient VP surgeries or a true decrease in VP surgery over time. The shift of surgery from inpatient to outpatient possi- TABLE 1. Demographics by prolapse type for female inpatient admissions 2008–2019 in Washington State Prolapse type Total prolapse n = 17 840 Vaginal and rectal combination n = 918 Vaginal only n = 15 279 Rectal only n = 1643 n % n % n % n % Age group < 50 years 4078 22.86 266 28.98 3485 22.81 327 19.90 50–64 years 6421 35.99 355 38.67 5557 36.37 509 30.98 65–79 years 6025 33.77 250 27.23 5270 34.49 505 30.74 80+ years 1316 7.38 47 5.12 967 6.33 302 18.38 Ethnicity* American Indian/Alaskan Native 78 0.44 2 0.22 62 0.41 14 0.85 Asian 209 1.17 15 1.63 167 1.09 27 1.64 Black/African American 98 0.55 7 0.76 78 0.51 13 0.79 Hispanic origin 435 2.44 13 1.42 395 2.59 27 1.64 Native Hawaiian/Pacific Islander 40 0.22 0 0.00 36 0.24 4 0.24 White 9283 52.03 582 63.40 7561 49.49 1140 69.39 Excluded/Not provided 7697 43.14 299 32.57 6980 45.68 418 25.44 *All ethnicity categories/labels taken directly from the Comprehensive Hospital Abstract Reporting System database. 182 ORIGINAL RESEARCH http://SIUJ.org SIUJ.ORG SIUJ • Volume 4, Number 3 • May 2023 TABLE 2. Female inpatient admissions for top 15 facility counties and residential counties by prolapse type Facility county of care Total prolapse (n = 17 840) Combination vaginal and rectal prolapse (n = 918) Vaginal only (n = 15 278) Rectal only (n = 1643) County (n*) Ads. % County (n*) Ads. % County (n*) Ads. % County (n*) Ads. % King (17) 6136 34.39 King (10) 808 88.02 King (17) 4487 29.37 King (12) 841 51.19 Spokane (4) 1965 11.01 Spokane (4) 53 5.77 Spokane (4) 1656 10.84 Spokane (4) 256 15.58 Pierce (5) 1590 8.91 Pierce (4) 35 3.81 Pierce (5) 1381 9.04 Pierce (5) 174 10.59 Snohomish (4) 1290 7.23 Snohomish (2) 9 0.98 Snohomish (4) 1211 7.93 Snohomish (3) 70 4.26 Benton (3) 887 4.97 Benton (1) 6 0.65 Benton (3) 815 5.33 Benton (3) 66 4.02 Yakima (4) 761 4.27 Kitsap (1) 4 0.44 Yakima (4) 755 4.94 Thurston (2) 54 3.29 Clark (2) 759 4.25 Chelan (1) 1 0.11 Clark (2) 747 4.89 Kitsap (1) 41 2.50 Whatcom (1) 538 3.02 Clark (1) 1 0.11 Whatcom (1) 516 3.38 Chelan (1) 29 1.77 Kitsap (1) 482 2.70 Thurston (1) 1 0.11 Kitsap (1) 437 2.86 Skagit (2) 28 1.70 Cowlitz (1) 414 2.32 Cowlitz (1) 402 2.63 Whatcom (1) 22 1.34 Thurston (2) 399 2.24 Clallam (1) 370 2.42 Cowlitz (1) 12 0.73 Clallam (1) 380 2.13 Thurston (2) 344 2.25 Clark (2) 11 0.67 Skagit (3) 361 2.02 Walla Walla (2) 339 2.22 Clallam (1) 10 0.61 Walla Walla (2) 342 1.92 Skagit (3) 333 2.18 Whitman (2) 8 0.49 Grays Harbor (1) 302 1.69 Greys Harbor (1) 301 1.97 Jefferson (1) 7 0.43 Patient residential county Total prolapse (n = 17 840) Combination vaginal and rectal prolapse (n = 918) Vaginal only (n = 15 278) Rectal only (n = 1643) County Ads. % County Ads. % County Ads. % County Ads. % King 6136 34.39 King 356 38.78 King 2919 19.10 King 841 51.19 Spokane 1965 11.01 Snohomish 311 33.88 Snohomish 1762 11.53 Spokane 256 15.58 Pierce 1590 8.91 Spokane 30 3.27 Pierce 1322 8.65 Pierce 174 10.59 Snohomish 1290 7.23 Pierce 28 3.05 Spokane 1265 8.28 Snohomish 70 4.26 Benton 887 4.97 Kitsap 23 2.51 Yakima 794 5.20 Benton 66 4.02 Yakima 761 4.27 Thurston 19 2.07 Clark 656 4.29 Thurston 54 3.29 Clark 759 4.25 Island 15 1.63 Benton 653 4.27 Kitsap 41 2.50 Whatcom 538 3.02 Skagit 14 1.53 Whatcom 603 3.95 Chelan 29 1.77 Kitsap 482 2.70 Whatcom 13 1.42 Kitsap 589 3.85 Skagit 28 1.70 Cowlitz 414 2.32 Clallam 11 1.20 Clallam 432 2.83 Whatcom 22 1.34 Thurston 399 2.24 Yakima 11 1.20 Thurston 397 2.60 Cowlitz 12 0.73 Clallam 380 2.13 Benton 9 0.98 Cowlitz 363 2.38 Clark 11 0.67 Skagit 361 2.02 Mason 6 0.65 Grays Harbor 330 2.16 Clallam 10 0.61 Walla Walla 342 1.92 Kittitas 5 0.54 Skagit 279 1.83 Whitman 8 0.49 Grays Harbor 302 1.69 Kootenai (Idaho) 5 0.54 Franklin 228 1.49 Jefferson 7 0.43 Note: Percentages calculated out of total prolapse type sample. *Denotes number of facilities within that county. Ads.: Admissions. 183 Trends in Vaginal and Rectal Prolapse Surgery http://SIUJ.org SIUJ • Volume 4, Number 3 • May 2023 SIUJ.ORG bly reflects the US health care system’s shift toward more cost-effective outpatient settings and insurance reim- bursement patterns[15]. The prevalence of VP has been found to vary across racial groups[16,17], and racial disparities have been identified in women undergoing pelvic organ prolapse surgery[18]. For this reason, we were interested in evalu- ating the trends in multidisciplinary approaches in treat- ing prolapse across racial groups. Low rates of VP and/or RP surgery have been noted in minority groups[16,17]. However, this observation could not be clearly assessed using the CHARS database, as racial information was not provided for 43.14% of the patient population. The majority of all inpatient VP-only, RP-only, and concurrent VP/RP surgeries were performed in the most populated counties in Washington State, and the majority of patients lived within a 20-mile radius of their treating facilities. Indeed, in 2 facilities, the patient population was nearly entirely composed of patients who resided less than 20 miles away (Figure 1). It should also be noted that the distances described here are straight- line distances and may not be an accurate reflection of the time or actual distance required to travel to treat- ment centers, particularly in Washington State, where patients may need to utilize ferry services in order to reach the more densely populated regions where high- FIGURE 1. Proportion of patients receiving care locally (within 20 miles) at top 15 Washington State facilities from 2008 to 2019 by average annual volume of vaginal prolapse, rectal prolapse, or concurrent vaginal and rectal prolapse surgeries. Centers sorted in descending order of average number of prolapse procedures per year for each center. FIGURE 2. Female inpatient prolapse procedures by prolapse type for Washington State from 2008 to 2019. Total prolapse is combined total of vaginal, rectal, and concurrent vaginal and rectal prolapse surgeries. De-identi�ed treatment centers, by number of prolapses per year 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% A 110 B 100 C 93 D 81 E 74 F 58 G 57 H 50 I 48 J 48 K 45 L 42 M 41 N 40 O 39 Local Non-Local N um be r o f P ro la ps e Pr oc ed ur es P er fo rm ed Year of inpatient admission Total* Prolapse Vaginal Prolapse Only Rectal Prolapse Only Rectal and Vaginal Prolapse 3500 3000 2500 2000 1500 1000 500 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 184 ORIGINAL RESEARCH http://SIUJ.org SIUJ.ORG SIUJ • Volume 4, Number 3 • May 2023 er-volume facilities are located. Patients electing surgi- cal management are more likely to travel farther, as do patients travelling from areas with fewer women and older people[19,20]. Distance travelled to reach care may be a barrier to patient care, and longer distances travelled have been associated with later presentation to care, and greater likelihood of planning surgery at presentation[19]. There may be a multitude of reasons for this, including patients electing treatments that require fewer follow-ups due to the long distances required for follow-up, lack of available services in less-populated counties, or patients who have failed conservative thera- pies at facilities closer to their homes. Overall, our study showed that VP and/or RP surgical care was concen- trated in the most populated areas of Washington State. Additional limitations of this database include the lack of recorded clinical variables, including outcomes, complications, recurrence, and patient-specific vari- ables such as degree of prolapse or comorbid diseases. These results may not be generalizable, as the data are specific to Washington State. Strengths of the analysis include the ability to adjust surgery rates by gender, state population, and age. In addition, all patients undergo- ing inpatient VP-only, RP-only, and concurrent VP/RP procedures in Washington State are included, and not limited by insurance status. National trends have shown an increase in utiliza- tion of concurrent VP/RP surgery. To assess this trend on a more local level, these procedures were examined in Washington State over a 12-year time period and were found to have remained stable. The reasons for this cannot be clearly identified using the CHARS data- base. Future directions may include investigations into contributing factors that may play a role in increasing awareness of the prevalence of concurrent VP and RP as well as supporting integrated and collaborative treat- ment for women with concurrent VP and RP. Conclusion The rates of inpatient RP and combined VP/RP surgical procedures between 2008 and 2019 were low and remained stable in Washington State. Inpatient VP surgical repairs decreased from 81 to 6 per 100 000 women over the same time period, which may represent an increase in outpatient VP procedures. Although previously published data suggest that a multidisciplinary approach to VP and RP is increasing nationwide, the trend seen here does not seem to reflect the same increase, suggesting that nationwide trends may not be reflective of local trends within each state. Further study is needed to understand how and why local trends in the management concurrent VP/RP may differ from national trends, and potentially improve concurrent VP/RP management using multidisciplinary approaches. Acknowledgements We thank Virginia M. Green, PhD, for editorial assistance. Financial Disclosure No funding or other financial support was received. Ethics Statement The Institutional Review Board of Benaroya Research Institute at Virginia Mason determined that this study did not constitute human subjects research and thus this study did not require IRB approval. 185 Trends in Vaginal and Rectal Prolapse Surgery http://SIUJ.org SIUJ • Volume 4, Number 3 • May 2023 SIUJ.ORG References 1. Geltzeiler CB, Birnbaum EH, Silviera ML, Mutch MG, Vetter J, Wise PE, et al. Combined rectopexy and sacrocolpopexy is safe for correction of pelvic organ prolapse. Int J Colorectal Dis.2018;33(10):1453–1459. doi: 10.1007/s00384-018-3140-5. PMID: 30076441. 2. Azpuru CE. Total rectal prolapse and total genital prolapse: a series of 17 cases. Dis Colon Rectum.1974;17(4):528–531. doi: 10.1007/ BF02587029. PMID: 4855224. 3. Jurgeleit HC, Corman ML, Coller JA, Veidenheimer MC. Symposium: Procidentia of the rectum: teflon sling repair of rectal prolapse, Lahey Clinic experience. Dis Colon Rectum.1975;18(6):464–467. doi: 10.1007/ BF02587211. PMID: 1181148. 4. Jallad K, Gurland B. Multidisciplinary approach to the treatment of concomitant rectal and vaginal prolapse. Clin Colon Rectal Surg.2016;29(2):101–105. doi: 10.1055/s-0036-1580721. PMID: 27247534; PMCID: PMC4882172. 5. Speed JM, Zhang CA, Gurland B, Enemchuk wu E. Trends in the diagnosis and management of combined rectal and vaginal pelvic organ prolapse. Urology.2021;150:188–193. doi: 10.1016/j. urology.2020.05.010. PMID: 32439552. 6. Boccasanta P, Venturi M, Spennacchio M, Buonaguidi A, Airoldi A, Roviaro G. Prospective clinical and functional results of combined rectal and urogynecologic surgery in complex pelvic floor disorders. Am J Surg.2010;199(2):144–153. doi: 10.1016/j.amjsurg.2008.11.040. PMID: 19362286. 7. Lim M, Sagar PM, Gonsalves S, Thekkinkattil D, Landon C. Surgical management of pelvic organ prolapse in females: functional outcome of mesh sacrocolpopexy and rectopexy as a combined procedure. Dis Colon Rectum.2007;50(9):1412–1421. doi: 10.1007/s10350-007-0255- 0. PMID: 17566828. 8. González-Argenté FX, Jain A, Nogueras JJ, Davila GW, Weiss EG, Wexner SD. Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse. Dis Colon Rectum.2001;44(7):920–926. doi: 10.1007/BF02235476. PMID: 11496068. 9. van Zanten F, van der Schans EM, Consten ECJ, Verheijen PM, Lenters E, Broeders IAMJ, et al. Long-term anatomical and functional results of robot-assisted pelvic floor surgery for the management of multicompartment prolapse: a prospective study. Dis Colon Rectum.2020;63(9):1293–1301. doi: 10.1097/DCR.0000000000001696. PMID: 32618619. 10. Trilling B, Sage PY, Reche F, Barbois S, Waroquet PA, Faucheron JL. Early experience with ambulatory robotic ventral rectopexy. J Visc Surg.2018;155:5 –9. doi: 10.1016/j.jviscsurg.2017.05.005. PMID: 29396113. 11. Powar MP, Ogilvie JW, Jr, Stevenson AR. Day-case laparoscopic ventral rectopexy: an achievable reality. Colorectal Dis.2013;15(6):700– 706. doi: 10.1111/codi.12110. PMID: 23320615. 12. Faucheron JL, Trilling B, Barbois S, Sage PY, Waroquet PA, Reche F. Day case robotic ventral rectopexy compared with day case laparoscopic ventral rectopexy: a prospective study. Tech Coloproctol.2016;20(10):695–700. doi: 10.1007/s10151-016-1518-3. PMID: 27530905. 13. Vijay V, Halbert J, Zissimopoulos A, Siddiqi S, Warren S. Day case laparoscopic rectopexy is feasible, safe, and cost effective for selected patients. Surg Endosc.2008;22(5):1237–1240. doi: 10.1007/s00464- 007-9598-9. PMID: 17943362. 14. Kobashi KC, Ward JB, Feinstein L, Abbott KC, Bavendam T, Kirkali Z, et al. MP27-03 Economic cost of urinary incontinence for insured adult women in the United States, 2004-2013. J Urol.2020;203(suppl 4):e410. doi: 10.1097/JU.0000000000000866.03. 15. Lee UJ, Ward JB, Feinstein L, Matlaga BR, Martinez-Miller E, Bavendam T, et al.; Urologic Diseases in America Project. National trends in neuromodulation for rrinary incontinence among insured adult women and men, 2004-2013: The Urologic Diseases in America Project. Urology.2021;150:86–91. doi: 10.1016/j.urology.2020.11.043. PMID: 33296698; PMCID: PMC8601400. 16. Whitcomb EL, Rortveit G, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK, et al. Racial differences in pelvic organ prolapse. Obstet Gynecol.2009;114(6):1271–1277. doi: 10.1097/AOG.0b013e3181bf9cc8. PMID: 19935029. 17. Abdool Z, Dietz HP, Lindeque BG. Interethnic variation in pelvic floor morphology in women with symptomatic pelvic organ prolapse. Int Urogynecol J.2018;29(5):745–750. doi: 10.1007/s00192-017-3391-7. PMID: 28624916. 18. Shah AD, Kohli N, Rajan SS, Hoyte L. Racial characteristics of women undergoing surgery for pelvic organ prolapse in the United States. Am J Obstet Gynecol.2007;197(1):70.e71–70.e78. doi: 10.1016/j. ajog.2007.02.042. PMID: 17618763. 19. English E, Rogo-Gupta L. Impact of distance to treatment center on care seeking for pelvic floor disorders. Female Pelvic Med Reconstr Surg.2017;23(6):438–443. doi: 10.1097/SPV.0000000000000411. PMID: 28430729. 20. Dunivan GC, Fairchild PS, Cichowski SB, Rogers RG. The association between distances traveled for care and treatment choices for pelvic floor disorders in a rural southwestern population. J Health Dispar Res Pract.2014;7(4):23–32. PMID: 26925308; PMCID: PMC4765380. 186 ORIGINAL RESEARCH http://SIUJ.org