Pelvic Floor Disorders in Black Women: Prevalence, Clinical Care & A Strategic Agenda to Prioritize Care

Introduction

Pelvic floor disorders (PFD) are a group of chronic conditions that include pelvic organ prolapse (POP) and urinary incontinence (UI). PFDs are prevalent, with 25% of women in the United States (US) experiencing at least one PFD in their lifetime ^1,2. While PFD conditions are benign, they can negatively impact quality of life ³. In addition, PFDs are often underreported and subsequently undertreated in women due to embarrassment, normalization, and downplaying of symptoms by patients and healthcare professionals ^4–6.

Women from racial backgrounds that have been historically marginalized in the US experience differences in PFD treatment and outcomes. In some instances, these differences constitute health care inequities ^{7, 8, 9}. Studies focusing on these differences often compare outcomes of Black and Hispanic women against the outcomes of White women. Research solely approached in this manner can be problematic as White women are made the reference group or “gold standard” for comparison. Women from historically marginalized groups require research performed through their own lens to increase understanding of their experiences with care and disease states, and improve their outcomes.

This chapter will focus on PFDs, specifically POP and UI, in Black women in the US. We will explore what is known about PFDs in Black women, the clinical care they receive, and the associated outcomes and barriers they face to equitable care. Finally, we will present action items to prioritize the care of Black women with PFDs in the US.

Prevalence of Pelvic Floor Disorders in Black Women

UI and POP are the most common PFDs in women, and their prevalence increases with age ^{2, 1}. There are various subtypes of urinary incontinence. Urgency urinary continence (UUI) is characterized by a sudden compelling desire to pass urine that is difficult to defer ¹⁰. Overactive bladder is defined as urinary urgency, with or without UUI, usually with frequency and nocturia. In contrast, stress urinary incontinence (SUI) refers to involuntary loss of urine with increases in intra-abdominal pressure such as exercise or coughing. POP is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina through the pelvic floor to the level of the hymen or beyond ¹¹.

The prevalence and subtype of UI in Black women may vary based on severity of leakage and screening methodology. Several studies report varied prevalence rates of UI among Black women with rates ranging from 3.3 to 45.9% (Table 1, 2). A study of women aged 35 to 64 in Michigan from 2002–2004 found that the prevalence of UI was 14.6% for Black women. Of women with UI, Black women reported high frequency of urge symptoms (23.8%) ¹². Another study of women aged 40 to 69 years found the prevalence of UI was 64.8% in Black women. In a cross-sectional, population internet-based survey, the prevalence of UUI among Black women was 14.2%. In another study of women aged 66 years and older, overactive bladder was diagnosed in 5.5% of Black women. Overall rates of SUI in Black women range from 3 to 25% compared to 6 to 40% in White women in cross-sectional studies based on patient-reported symptoms ^12–17; ¹⁸. Notably, these studies overwhelmingly show Black women have similar rates of UI as White women yet Black women are more likely to report urge symptoms than SUI.

Table 1 :

Prevalence of Overactive Bladder/ Urgency Urinary Incontinence by Patient-Reported Symptoms in Validated Questionnaires

Author	Year	Type of study	Age (years)	N Total Study	N= Black Women*	N= White Women*	Overall OAB/ UUI Prevalence	OAB/UUI in Black Women*	OAB/ UUI in White Women*
Fenner	2008	Phone questionnaire	35–64	2814	892	1,922	26.5%	23.8%	11%
Jackson	2004	Interview	70–79	1,558	717	841	11.6%	7%	11%
Thom	2006	Interview	Middle aged	2109	383	1003	--	13.6%	8.8%
Coyne	2013	Internet questionnaire	18–70	5,023	1,026	3,032	20.0%	19.0%	19%
Coyne	2012	Internet questionnaire	18–70	4,482	514	3,499	--	45.9%	43.4%
Townsend	2010	Mailed questionnaires	37–79	76,724	1,138	74,734	--	0.5	0.4
Tennstedt	2008	In-person interview/questionnaire	37–79	3,205	1,070	1,024	10.4%	3.3%	13.4%
Akbar	2021	Questionnaire	Mean 70	1749	443	641	--	10.2%	7.6%

OAB: overactive bladder

UUI: urgency urinary incontinence

Table 2 :

Prevalence of Stress Urinary Incontinence by Patient-Reported Symptoms in Validated Questionnaires

Author	Year	Type of study	Age (years)	Total N in study	N = Black Women*	N = White Women*	Overall SUI Prevalence	SUI in Black Women*	SUI in White Women*
Fenner	2008	Phone questionnaire	35– 64	2,814	892	1,922	26.50%	25%	39.2%
Jackson	2004	Interview	70– 79	1,558	717	841	12%	5%	12%
Thom	2006	Interview	Middle-aged	2109	383	1003	--	7.5%	15.1%
Coyne	2013	Internet questionnaire	18– 70	5,023	1,026	3,032	--	24.8%	40.15%
Townsend	2010	Mailed questionnaires	37–79	76,724	1,138	74,734	--	0.1	0.8
Tennstedt	2008	In-person interview/questionnaire	37–79	3,205	1,070	1,024	26.4%	9.4%	35.4%
Akbar	2021	Questionnaire	Mean 70	1749	443	641	--	3.1%	6.2%

SUI: stress urinary incontinence

POP is also prevalent among Black women. Population based studies found that prevalence in Black women ranged from 1% to 7.6%. In a systematic review, the pooled prevalence rates of symptomatic POP was 3.8% (95% CI, 3.22%−4.38%) for Black women ¹⁹.

PFD prevalence studies also suggest racial differences in PFD prevalence. In particular, studies suggest lower overall UI prevalence, higher UUI prevalence and lower POP prevalence for Black women compared to White women ^2,12–24. It is noteworthy that there have been studies aimed at understanding differences in prevalence of PFD in Black women compared to White women by examining biological and anatomic differences including differences in genetic loci, pelvic floor musculature, and urodynamic parameters ^25,26. Giri et al. evaluated the association of specific genetic loci and POP across races. This study demonstrated that being of European ancestry did not increase the risk of POP ²⁵. Derpapas et al. assessing pelvic floor musculature using translabial sonography found that nulliparous Black women had larger rhabdosphincters than White women (8.88 cm³ ± 1.65 vs. 5.97 cm³ ± 1.82, p = 0.001). Black women also had a significantly wider transverse diameter at rest (levator hiatal dimension) than White women ²⁶. However, the reported findings from these studies did not examine how these differences relate to associated PFDs. The caution and critique of genetic and anatomic studies is that the data can be misinterpreted to infer that Black women have protective factors against certain PFDs. Yet, it is well established that race does not denote genetics or biology. Race is a social political construct that has biological consequences but does indicate inherent biological differences ²⁷. Hence, the focus on biological differences to explain racial differences in prevalence is flawed and detracts from social and structural determinants of health that may impact a population’s manifestation of symptoms and attitudes towards reporting of PFD symptoms. Furthermore, an assumption of inherent biological differences by race that explain the discrepancies in PFD prevalence could place Black women at risk for inequities in care such as not being asked about PFD symptoms by providers, leading to subsequent underdiagnosis and undertreatment.

The prevalence data for PFD in Black women obtained from questionnaires should also be interpreted with caution as there is a possibility for underreporting. A mixed methods study involved surveying participants on knowledge and experience of PFDs, followed by a focus group. The investigators found that Black women were less likely to report having PFD in the initial questionnaire; however, in the follow up focus group discussion, many women reported incidence of UI and indecision whether to classify UI as a health problem ²⁸.

Clinics Care Points:

• Prevalence of UI in Black women ranges from 3.3 to 45.9%

• Prevalence of POP in Black women ranges from 1% to 7.6%

• There is little evidence to attribute biologic, anatomic, or genetic variation to account for differences in prevalence of POP by race

• Underreporting of PFD symptoms may occur among Black women

Knowledge and Experience of PFDs Among Black Women

Overall, studies estimate that at least 50% of women do not seek care for UI ^29,30. In particular, the data on care-seeking for PFD treatment for Black women are sparse and conflicting. A study of Black and White community-dwelling women (not residing in nursing homes) in Michigan with UI previously identified there were no differences in care-seeking for PFDs (53% Black versus 50.6% White, P = 0.64) ²⁹. Another study assessing treatment seeking behavior for POP found no difference between Black and White community-dwelling women ²¹. However, in a large study from an integrated healthcare system in California, women with at least moderate bother from UI were less likely to discuss their incontinence with a healthcare provider,. Race and income were influencing factors (Black race adjusted Odds Ratio (aOR) 0.45, 95%CI [0.25–0.81]) compared to White race, and income < $30,000 per year aOR 0.37, 95% CI [0.17–0.81] compared to ≥ $120,000 per year) ³¹. A systematic review and meta-analysis of studies on care seeking behavior found that Black race was predictive of decreased healthcare utilization for women with PFDs (OR 0.77; 95% CI [0.55–1.08]) ³². Other factors associated with decreased utilization were normalization of symptoms due to aging, fear, and misinformation. As race is an indicator of sociopolitical conditions and is not in of itself a risk factor, a critical step to understanding this data would be determining how social and structural determinants of health including systemic racism impact healthcare utilization and care-seeking for Black women with PFD. Of note, this dynamic is not well elaborated in prior PFD research.

Insufficient knowledge and misconceptions about PFD are often suggested as potential reasons for lower healthcare utilizations and care-seeking among populations. There are few studies that examine PFD knowledge among women from different racial groups. One study found no differences in knowledge of UI when controlling for relevant confounders between Black and White women ³³. Another analysis of community-dwelling women found differences in knowledge about modifiable risk factors and treatment options for UI and POP ³⁴. Black women in this study were less likely to recognize childbirth as a risk factor for UI, less likely to know that pelvic floor exercises could help control leakage, and less likely to recognize pessaries as a treatment for UI ³⁴. While there may be opportunities to enhance knowledge about PFD among Black women, knowledge proficiency alone is insufficient to optimize care utilization for Black women with PFD.

Understanding barriers to care can provide insights to improving care-seeking and health care utilization. There is a paucity of data examining barriers to PFD care among Black women. One study by Willis-Gray et al. utilized a validated barrier assessment questionnaire, known as the Barriers to Incontinence Care-Seeking Questionnaire (BICS-Q), to assess barriers to care for PFDs between Black, White, and Latina women. Barrier scores were higher in Black women compared to White women (2.9 vs 7.3, p<0.0001) ³⁵. However, when adjusting for demographics such as age, income, and education, there were no differences in barrier scores between Black and White women. Only one published study has examined barriers to PFD care specific to Black women and not in comparison to another racial group. The study found that insurance concerns were a significant barrier for Black community-dwelling women when adjusting for health status and embarrassment (aOR, 3.80; 95%CI [1.39,10.33]) ³⁶.

A significant gap in the literature on knowledge and care seeking for PFDs is comprehensive data focused on the lived experiences of Black women with PFDs and their perceptions of treatment options (not in comparison to other racial groups). Such data would highlight opportunities for interventions in improving knowledge and care-seeking for Black women with PFD.

Clinics Care Points:

• Data suggests that Black women with PFDs underutilize PFD care

• Our understanding of the drivers of lower PFD care utilization among Black women is limited

• There is a paucity of literature to increase our understanding of barriers to care of PFDs specifically in Black women

• Data suggests that Black women with PFDs underutilize PFD care

Treatment and Outcomes in Black Women with PFDs

For both UI and POP, pelvic floor physical therapy (PFPT) is the cornerstone of conservative therapy and is a first-line treatment for UUI. While PFPT can improve urinary symptoms by up to 50%, there is little data on PFPT utilization, responsiveness, and outcomes in Black women. Regarding referrals, utilization, and adherence, data is conflicting concerning race, with some showing lower rates ³⁹ and others showing higher rates among Black women. ^{38, 39, 40} In all studies, except for one, Black women were largely underrepresented (2%, 10.3 % vs. 33.4%) ^37–39.

UI Treatment

Second-line therapies for UUI/ OAB diverge from stress UI treatment, and include medical management of symptoms with anticholinergic and beta-3-agonist medications. Globally, medical management of UI/OAB is low, with some studies showing only 1.6% of Medicare visits being associated with OAB medication prescribing. ⁴⁰. Data suggests that Black women receive anticholinergics at similar rates to White women; however, they are less likely to receive the newer beta-3-agonists ^{9 41 42 40}. Data regarding medication continuation is controversial as only two studies showed Black race was associated with decreased adherence compared to White race ^{43 44}, while another large cross-sectional study found overall drug use was low with no difference in adherence by race ⁴⁵.

Third-line therapies for UUI/ OAB include percutaneous nerve stimulation (PTNS), chemodenervation of the bladder with onabotulinum, and sacral neuromodulation (SNM). Overall SNM and PTNS are utilized infrequently (<1%), but began increasing in the early 2000s ^46,47. However, in a recent study by Edge et al. using medical claims data from 2010 to 2020, SNM actually decreased from 2010 onward. Conversely, intradetrusor onabotulinum utilization increased, accounting for 50% of third-line therapies in women with OAB (^46,47). Laudano et al. found that racially minoritized Medicare patients were less likely to receive third-line treatments compared to White patients ⁴⁸. Similar findings were noted in a commercially insured population ⁴⁹. For SNM specifically, a study using California state ambulatory surgery data from 2005 to 2011, found that Black patients had similar sacral neuromodulation treatment success compared to White patients ⁵⁰. However, only 4.5% of total study participants were Black. There is a paucity of research specifically assessing drivers of advanced OAB/UUI treatment (PTNS, intradetrusor onabotulinum, SNM) utilization in Black women.

Patients who demonstrate SUI on examination in the office are candidates for surgical based treatments. Notably, SUI procedures have decreased over time by at least 25%, with sling procedures (fascial and synthetic) decreasing by 50% ^51,52. Most studies using large hospital-based or insurance databases demonstrate that Black women undergo SUI or sling procedures less than White women, yet they experience higher rates of post-operative complications including unplanned readmissions, urinary obstruction, and new onset POP ^51–55.

Overall, the data suggests that Black women are less likely to receive beta agonist medications, advanced UI therapies, and surgical management of UI. For SUI procedures, Black women experience worse outcomes than White women.

POP Treatment

Quality of life (QoL) is an important surgical outcome to evaluate the long-term impact of surgery. There are no specific data assessing QoL after POP or UI surgery using validated measures in Black women in the US. A prospective observational study of Ugandan women showed a significant improvement in physical, social, sexual, emotional and sleep quality of life domains after surgical repair at 1 year ⁵⁶. In addition, we know that after surgery and incontinence procedures, most women across race and ethnicity have improvement in various areas including sexual function, bladder function, prolapse symptoms ⁵⁷. However, quality of life improvement among Black women after POP/UI procedures is an area that has not been largely or explicitly studied to date, and represents a significant research gap.

There is emerging evidence that Black women are less likely to receive surgery for their POP. When they do receive surgery, the approach and procedures vary by race. A large cohort study using an administrative database found that Black women were less likely to have surgery for POP than White women (5.6 vs 14.8 per 10,000 women) ⁵⁸. Black women in this study were more likely to be on public assistance (27% vs 5.9%) and have surgery at a government hospital (20.2% vs 11.9%) than White women ⁵⁸ suggesting that socioeconomic status may influence the receipt of surgery for POP. A limitation of this study however is that the investigators could not evaluate other potential drivers of this observation such as clinicians recommendations for surgery among all women presenting for prolapse management.

There are six studies using the National Surgical Quality Improvement Program (NSQIP) Database and two additional studies using the National Inpatient Sample (NIS) database to assess surgical treatment of POP and associated outcomes in Black women ^{7,8,59–62,63,64, 57}. Black women underwent disproportionately less surgery for POP than White women ^7,8,59–62. While NSQIP studies demonstrate similar rates of vaginal apical suspensions and sacrocolpopexy between Black and White women ^60–62, Cardenas-Trowers et al. found that Black women were also more likely to have a hysterectomy without a concomitant prolapse procedure than White women ⁶¹. This is an important finding, as current practice guidelines recommend apical procedures at the time of surgery for symptomatic prolapse. Hysterectomy alone or with anterior and posterior repairs alone are rarely the correct procedure for women with symptomatic POP. Not only are Black women receiving surgical treatment less often, but they are also undergoing surgeries that may not appropriately treat their symptoms. These conflicting data need to be further explored to better understand why treatment disparities exist.

Finally, Black women were more likely to have obliterative procedures (i.e., colpocleisis), which have the lowest rates of surgical failure but preclude women from being able to have penetrative intercourse postoperatively ^7,59,61. Though these surgeries are associated with low risk of regret, we must critically examine this finding to ensure that Black women’s desires for future coital function is being supported.

Black women experience more morbidity after surgery for POP than White women. Using the same databases that determined differential surgical approaches, Shah et al. found that Black women had higher rates of postoperative complications compared to White women (34.1% vs 19.4%, respectively), even though they were less likely to have surgery for POP ⁵⁸. Numerous studies have found increased perioperative morbidity including increased surgical injury, blood transfusion, venous thromboembolic event, and longer operative times ^8,60–64.

It is difficult to extrapolate why Black women have worse outcomes than White women after surgery for POP. The data is limited to large national databases with limited meaningful variables and underrepresentation of Black women. In addition, Black women in these databases have more medical comorbidities than White women which predisposes them to higher perioperative morbidity, a factor that may influence a surgeon to choose a different surgical/management approach ^7,8,59–62.

Much of the current disparities research has focused on patient factors associated with poor outcomes including obesity, large uteri, and markers of poor health. When the focus is on these types of patient factors, it implies that the population is in part responsible for their poor outcomes. This is problematic and inhibits our ability to understand other variables, such as the contribution of bias, racism, and discrimination. Future research is needed to evaluate these outcomes through a health equity lens, specifically understanding how racism impacts Black women in the healthcare system. Tables 3 and 4 outline key findings related to SUI and POP outcomes.

Table 3:

Summary of Urinary Incontinence Treatment Data

Author Journal Year	Database N(%) Black Women	Methods	Relevant Findings
Mckellar Neuro Uro 2019	Single healthcare system 2013–2016 39,933 (33.4%)	Cohort Study Prevalence and Treatment SUI	Pessary placement was the least utilized form of active treatment (2.31%) and was more likely in White women* (P = 0.03) Black women were less likely to consult with a specialist and undergo active treatment (physical therapy, pessary placement, and sling surgery) compared to all other racial groups Rates of sling surgery were similar between Black and White women (2.15 vs 2.04%)
Anger Urology 2007	Medicare Claims 1999–2001 1,789,155 (8.7%)	Cohort Study Prevalence and Surgical Treatment SUI	7.1% of Black women underwent a sling compared to 13.1% of White women (p <0.01) Non-white women had more non-urologic complications (aOR 2.02 95%CI [1.22–3.34]), new onset pelvic prolapse (aOR 2.04 95%CI [1.19–3.50]), and urinary obstruction (aOR 2.30 95%CI [1.07–4.91])
Waetjen Obstet Gyn 2003	National Hospital Discharge Survey 1998 x	Cohort Study Prevalence and Surgical Treatment SUI	Black women were less likely to have a surgery for SUI (2.6 per 10000 vs 11.6 per 10000). Black women higher rate of complications (20.6% vs 9.7%)
Shah Int Urogyn 2008	National Hospital Discharge Survey 2003 4,352 (3.4%)	Cohort Study Prevalence and Surgical Treatment SUI	12 surgical procedures per 10,000 women were performed in the U.S, for SUI, the majority were 10 per 10,000 in White women (66.7%) vs 3 per 10,000 women (3.4%) in Black women Surgical complications were not different in Black versus White women Women in the other group (26.8% of surgeries) had the highest rates of complications
Dallas Urology 2017	California State Ambulatory Surgery Database 2005–2011 474 (1.7%)	Cohort Study Surgical Treatment SUI: Sling Surgery	Increased postoperative complications within 30 days in Black women Black race increased the odds of unplanned hospital visits (OR 1.8) Black women had more unplanned events (10.5%, P < .01), including higher surgical revision rates than all other groups (0.6%, P < .05) even in adjusted models
Luchristt JAMA Open 2023	Medical Expenditure Panel Survey 2019 x	Cross- sectional Analysis Assessing OAB Prescriptions Filled	Black women were 90% less likely to fill a β3-agonist prescription (adjusted OR, 0.10; 95%CI [0.04–0.27]) compared with White women
Ju Int Urogyn 2014	Ambulatory Medical Care Survey database (NAMCS) 2009 x	Cross-sectional Analysis Assessing OAB Prescriptions Filled	1.6% of Medicare visits in women were associated with an anticholinergic (ACh) prescription No differences between Black and White women in prescriptions for ACh
Mckellar Urology 2019	Single Healthcare System 2013– 2016 41,710 (34.02%)	Retrospective cohort Prevalence and Treatment OAB	No difference in treatment of OAB with medication prescriptions between Black and White women (21.5% vs 23.9%) Black women were less likely to consult with a specialist
Benner BJU Int 2010	Survey of USA Households 2009 453 (8.4%) ^	Cross-sectional study Discontinuation OAB meds	Overall OAB drug use was low, 24.5% reported discontinuing prescription OAB medication within the last 12 months No difference in discontinuation by race
Shaya Am J Manag 2005	Medicaid Managed Care 2000–2003 737 (45%) ^	Retrospective Cohort Study Continuation OAB meds	Black women had decreased adherence compared to white race (continuation 15% of Black vs 27% White)
Rashid J Mang Care Spec Pharm 2017	Kaiser Permanente Southern California (KPSC) Electronic Medical Records (EMR) 977 (10.8%) ^	Retrospective Cohort Study Prescribing new OAB med prescriptions	Black women had increased odds of nonadherence after OAB medication was prescribed (aOR 1.56 95%CI [1.24–1.96])
Lee Urology 2021	CDM (Optum® de-identified Clinformatics® Data Mart) for women 18 to 64 years old and the CMS (Centers for Medicare and Medicaid Services) Medicare 5% Sample 2004– 2013 x	Retrospective Cohort Study Surgical Management of Urinary Incontinence	Decline in the percent of women with UI who underwent surgical treatment according to the CMS from 4.7% in 2004 to 2.7% in 2013 and the CDM from 12.5% in 2004 to 9.1% in 2013 Slings decreased by 50% over study period Younger and older white women were more likely than Black women to have surgery for UI Slings were also more common in white women UI surgery prevalence of 1% or less among Black Women
Laudano J Uro 2015	Medicare Claims Data 2001, 2004, 2007, 2010 x	Retrospective Cohort Study Sacral Neuromodulation (SNM) Trends	SNM implantation increased from 0.03% to 0.91% (p <0.0001) for a total of 13,360 (0.58%) Minority patients (OR 0.38, p <0.0001) were less likely to receive SNM
Syan Urology 2020	Optum, a national claims database 2003– 2017 368,568 (9%) ^	Retrospective Cohort Study Treatment of OAB/UUI	SNM was no different between Black and white patients Onabotulinum was similar between races/ethnicities (P < 0.05) Non-white race was associated with decreased odds of receiving advanced therapies for OAB/UUI (OR 0.89, 95% CI [0.87,0.91])
Dobberfuhl FPMRS 2018	California State Ambulatory Surgery Database 2005 – 2011 124 (4.5%) ^	Retrospective Cohort Study Sacral Neuromodulation (SNM) Success Rates	Race was not associated with SNM treatment success

^x- Race numerators not given

^{^}- Includes population numbers where males are included

SUI – Stress Urinary Incontinence

OAB – Overactive Bladder

UUI – Urgency Urinary Incontinence

UI – Urinary Incontinence

SNM – Sacral Neuromodulation

Table 4:

Summary Pelvic Organ Prolapse Treatment Data

Author Journal Year	Database N(%) Black Women	Methods	Relevant Findings
Cardenas-Trowers FPMRS 2021	National Surgical Quality Improvement Project 2005–2015 2,299 (4.7%)	Cohort Study Surgical Treatment POP	Minority women* were less likely to undergo an apical suspension than White women (aOR 0.78 95%CI [0.71–0.86]) Obliterative procedures were more likely to be performed in Black women (aOR, 1.53 95%CI [1.20–1.92]) compared to White women Black women experienced higher complication rates (10.7%) compared to White women (8.9%, p < 0.01) including higher rates of major complications, blood transfusion surgical site infection, sepsis, and readmission
Winkleman FPMRS 2021	National Surgical Quality Improvement Project 2010– 2018 2,353 (5%)	Cohort Study Surgical Treatment POP	Black patients were more likely to undergo obliterative procedures compared with White patients (RR 1.2 95% CI [1.03 – 1.3]), which persisted in adjusted models Black patients had increased risk of a postoperative complication (RR, 1.2 95% CI [1.1 – 1.4]); in the adjusted model, this difference was not statistically significant
Roberts FPMRS 2020	National Surgical Quality Improvement Project 2010– 2015 738 (5.5%)	Cohort Study Sacrocolpopexy for Treatment POP	Overall complications were higher in Black patients 15.0% vs 11.5% (P = 0.006), persisted on multivariable regression (aOR 1.29) Most common complication for Black patients was postoperative transfusion
Yadav FPMRS 2022	National Inpatient Sample 2008– 2018 3,404 (4.8%)	Cohort Study Surgical Treatment POP	Non-white (Black, Hispanic, and other races), Medicaid patients and patients at urban teaching hospitals were less likely to receive reconstructive prolapse repairs compared to obliterative procedures in adjusted analyses Non-white (Black, Hispanic, and “other” races), uninsured/Medicaid patients, and patients in the midwest, south, and west were more likely to receive a native tissue repair compared to a sacrocolpopexy in adjusted analyses
Rodriguez Urology 2023	National Surgical Quality Improvement Project 2012–2017 2,776 (5.5%)	Cohort Study Surgical Treatment POP	Black patients were more likely to undergo apical repair procedures (p <.001) and less likely to undergo combination POP procedures (p <.001) than White or other patients Black were more likely to undergo POP repair with a concomitant hysterectomy as compared to White patients (p <.001) Blood transfusion was more common in Blacks (2.4% vs 1.1%, p <.001) Black patients were more often readmitted (3.2%; p = .014) Operative time was longer for Black patients (146 min vs 132 min, p <.001)
Brown Int Urogyn 2022	National Surgical Quality Improvement Project 2012– 2014 1,460 (5.0%)	Cohort Study Surgical Treatment POP & Cost Analysis	Postoperative complications were significantly higher among Black women (20%) compared to White women of other races (16%, p < 0.01) Black race had an increased odds of complications compared to white women (aOR 1.21) controlling for confounders
Ringel Urology 2022	National Surgical Quality Improvement Project 2010– 2018 3756 (5%)	Cohort Study Surgical Treatment POP	Black women had the highest complication rates (11%, vs 9% for both White women, p<0.01) In adjusted models, Black women still experienced higher odds of any complication (aOR 1.15, 95% CI [1.03– 1.29]) and vascular complication (aOR 2.50, 95% CI [2.05– 3.04]) Trends in vascular complications showed a decrease from 2010–2018 in non-Black women after prolapse repair, the same decrease was not seen in Black women
Shah AJOG 2007	National Hospital Discharge Survey & National Census 2003 7,668 (3.8%)	Cohort Study Surgical Treatment POP	5.5 per 10,000 Black women had surgery for POP in 20023 compared to 14.1 per 10,000 White women Of Black women, 27% were on public assistance, compared with 5.9% White women Complications were higher in Black women (34.1% vs 19.4%) of White women
Boyd AJOG 2021	National Surgical Quality Improvement Project 2014–2017 1,281 (6%)	Cohort Study Sacrocolpopexy and Vaginal Colpopexy for Treatment POP	No differences in sacrocolpopexy vs vaginal colpopexy performed between Black and White women in adjusted analyses Black women were more likely to need a blood transfusion after vaginal colpopexy (OR 3.04; 95% CI [1.95–4.73], p ≤.001) and have a deep vein thrombosis or pulmonary embolus (OR 2.46; 95% CI [1.10–5.48], p =.028) than White women in multivariable regression models

POP – Pelvic Organ Prolapse

aOR – adjusted Odds Ratio

CI – Confidence Interval

POP – Pelvic Organ Prolapse

OR – Odds Ratio

RR – Relative Risk

Clinics Care Points:

• There are disparities in the receipt of evidence-based treatments for PFDs for Black women

• Outcome data for urgency UI advanced treatments in Black women are limited

• Black women experience poorer outcomes after surgeries for PFD and SUI

• Studies moving beyond identifying disparities in treatment are limited, yet necessary to improve outcomes

Representation of Black Women in Biomedical Research and The Impact of Evidence-Based Guidelines

Research

There is a paucity of research on Black women with PFDs, their lived experiences, how they perceive their symptoms, at what threshold they would seek treatment, barriers to treatment, how they view conservative versus surgical treatment options, and perceptions of how racism directly impacts the care they receive. Not only are Black women underrepresented in the research, they are also underrepresented in the teams performing the research.

Recent research has focused on the lack of Black women in research studies used to create evidence-based guidelines. Brown et al. analyzed 387 studies referenced in the 2019 American Urologic Association (AUA) and Society of Urodynamics and the Female Pelvic Medicine & Urogenital Reconstruction (SUFU) nonneurogenic OAB Diagnosis and Treatment Guidelines ⁶⁵. Notably, only 35% of all studies reported the patient’s race. They found White and Asian patients were overrepresented (representation quotients 1.06, 1.62), while Black, Hispanic, and Native American/Alaska Native patients were underrepresented (representation quotients 0.85, 0.56, and 0.02, respectively). There was no change in representation over the study period of 1990 to 2019 ⁶⁵. A similar study by Gonzalez et al. evaluated racial and ethnic representation in the evaluation and management of SUI. They found less than half of studies were from populations within the U.S. (17/52 studies) and even fewer reported race of the study participants (9/52 studies). Of these 9 studies, 80% of participants were non-Hispanic White women ⁶⁶.

A similar study by Grimes and McKay reviewed racial representation in the PFD NIH-funded research network including the Pelvic Floor Disorders Network (PFDN) and Urinary Incontinence Treatment Network (UITN) ^67,68. Data demonstrate that 90/111 studies reported race. Overall 9.9% of patients were Black compared to 79% White. Notably, racial and ethnic representation varied, with higher representation of non-White participants in pregnancy-related and fecal incontinence studies ⁶⁷. McKay et al. found that White women comprised 70%−89% of total participants, while Black women represented 6%−16% of participants in pelvic floor disorder trials. White women were overrepresented in 13 of 18 PFDN studies, while Black women were underrepresented or absent in 10 of 18 studies ⁶⁸.

Notably, in all NSQIP and large administrative database studies, Black women are underrepresented (3–6% total cohort) and missing race data was common (up to 25%). While this could be due to lower rates of bothersome or symptomatic POP among this population, there is also the possibility that these large databases are unable to capture disparities in the symptom reporting, diagnosis, and treatment of this particular patient population.

Despite numerous studies describing disparities for women from minoritized racial groups, our understanding of how to alleviate these disparities remains limited. This is further highlighted by the fact that women from minoritized racial groups remain underrepresented in PFD research ⁶⁸; ^63,67. Underrepresentation of Black communities in PFD research poses missed opportunities for a deeper understanding of how non-clinical factors (such as systemic racism) may impact clinical outcomes. There is an opportunity to reimagine how we approach and study PFDs for women from minoritized racial groups. Further, while it is important to identify disparities, the transformative work lies in designing care delivery that optimizes outcomes for historically marginalized populations.

Risk Calculators

Studies published from the Pelvic Floor Disorders Network (PFDN) and Urinary Incontinence Treatment Network (UITN) were not only used to create guidelines for management of PFDs. Treatment recommendations are often created and supported based on these research findings, which would be more generalizable if all races/ethnicities were represented in these large trials ⁶⁹. Data from these large network trials are also used to create decisions calculators for risk stratification and treatment. Risk calculators have been used throughout medicine to stratify severity of an illness or risk associated with a treatment based on patient and hospital-level factors.

Getaneh et al. called attention to a calculator created to predict success of treatment with intradetrusor onabotulinumtoxinA, which uses race as a factor⁷⁰. Black and other non-White women in this model have a decreased risk of treatment success. This model and the studies from which it is derived do not provide insight into why or how Black race— a social construct— could decrease treatment efficacy. Authors postulated that including race may be harmful for non-White patients by exacerbating treatment disparities that are already present. In addition, it perpetuates the ideology that Black race denotes genetic differences leading to treatment disparities, which is false. Similar editorials have been published in the obstetric and urology literature critiquing the vaginal birth after cesarean delivery (VBAC) calculator, the estimated glomerular filtration rate (eGFR) calculator and STONE Score for Uncomplicated Ureteral Stone for their inclusion of race as a mitigating factor ^71,72.

Clinics Care Points:

• Black women are underrepresented in major clinical trials guiding treatment decisions and algorithms for UI and POP

• Calculators driving treatment for PFDs may introduce bias when including race as variable

• Black women are underrepresented in major clinical trials guiding treatment decisions and algorithms for UI and POP

• Calculators driving treatment for PFDs may introduce bias when including race as a variable

Strategic Agenda to Prioritize the Care of Black Women with PFDs

There remains a gap in alleviating inequities in Black women’s outcomes and experiences with care and treatment for pelvic floor disorders. To address this gap, health care professionals and advocates alike must be intentional in our actions to improve PFD care for Black women. Impact plans to address health inequities should incorporate elements that both address individual and population level needs ⁷³. The following incorporates our proposed impact plan “Strategic Agenda to Prioritize the Care of Black Women with PFDs”, which includes a multi-level approach to minimizing health inequity in Black women with PFDs (Table 5).

Table 5:

Strategic Agenda to Prioritize the Care of Black Women with Pelvic Floor Disorders (PFDs)

Strategy 1: Enhance knowledge and awareness of the existence and impact of PFDs in health care professionals, patients and the community

Strategy 2: Optimize the quality of clinical care for Black women with PFDs Educating healthcare providers Facilitation and promotion of connections between medical community and Black women by Supporting programs/patient navigators Improving access and insurance coverage Diversification of workforce Advocacy Policy Changes

Strategy 3: Expand representation of Black women in biomedical research

Strategy 4: Dismantle structural racism in PFD care to achieve health equity

Strategy 1: Enhance knowledge and awareness of the existence and impact of PFDs among healthcare professionals, patients, and the community

One element that impedes the narrowing of health inequities for Black women with PFDs are variations in awareness of PFDs and PFD treatment not only among patients but also among healthcare practitioners. In order to enhance knowledge and awareness of the existence and impact of PFDs among healthcare professionals, patients, and the community, we propose increasing efforts to help patients improve reporting of symptoms by increasing clinician screening and inquiry during health assessments in various healthcare settings ⁷⁴. Black women may under report their PFD symptoms due to personal and cultural beliefs. In addition, healthcare professionals may minimize or ignore their symptoms leading to underdiagnosis. Targeting these phenomena is key to eradicating these care disparities.

Strategy 2: Optimize the quality of clinical care for Black women with PFDs

Significant efforts must be made to optimize the quality of clinical care for Black women with PFDs. Perpetuation of public education and community awareness of PFDs is an essential element of optimizing clinical care, but it is insufficient to eliminate racial health disparities. Facilitation and promotion of connections between the medical community and Black communities are critical to the achieving equitable PFD care for Black women. Authentic community partnerships ensure that the efforts of professionals that treat PFDs are aligned with the needs of the communities, for which there is a dearth of community-based partnerships and initiatives.

Efforts should also be made to identify and address structural barriers to healthcare professional PFD screening and referrals for Black women. At both the individual and institutional levels, equitable patient counseling on PFD management options must be prioritized. Additionally, efforts should be made to mitigate the effects of differential care through insurance access and universal coverage for PFD treatment. Insurance status/coverage is a known barrier to PFD treatment for underrepresented racial and ethnic minority women and should be addressed ⁷⁵. The use of patient navigators can help address these barriers. There should be collective efforts to advocate for policy changes at state and federal levels with outputs that directly improve access to healthcare and health care quality ⁷⁶.

Diversification of the healthcare/ medical workforce is also an actionable step that can directly improve the quality of care for Black women ^74,76. There should be intentional efforts to increase racial and ethnic diversity at the trainee level by program leadership, specifically for OB/GYN residency and urogynecology and reconstructive surgery fellowship programs. In addition, once trainees are accepted into the program they should be supported with the knowledge that those underrepresented in medicine face unique challenges that may not be readily apparent. Mentorship programs that increase exposure to urogynecology as a sub-specialty should also be considered.

Strategy 3: Expand representation of Black women in biomedical research

Approaches to clinical care are often developed through evidence-based medicine supported by research. Given that research findings greatly influence recommendations for clinical care as well as insurance coverage and policy guidelines, it is essential to expand representation of Black women in biomedical research. This strategy can be achieved through focus on community-based participatory research efforts, promotion of Black researchers to lead scientific efforts, and inclusion of appropriate honorariums for participation in research studies ⁷⁶. In addition, efforts should be made to report race and ethnicity in study populations, understanding the limitations of underrepresentation and required reporting of such limitations. Larger databases should reflect the diversity of our communities and report the demographic breakdown of the entire population to minimize bias in case selection.

Strategy 4: Dismantle structural racism in PFD care to achieve health equity

Finally, efforts must be made to dismantle structural racism in PFD care to achieve health equity. We acknowledge that this is a grand task. However, we also appreciate the fact that structural racism is not well measured nor appreciated in efforts to understand and reduce health disparities. Actions made towards dismantling structural racism directly influences all of the proposed strategies, which emphasizes its importance in developing a plan to improve health equity for Black women. There is currently a dearth of research models that actually highlight the role of racism in sexual and reproductive health, with many studies focused on the reproductive (i.e., perinatal) health of African American women ⁷³. The lived experiences of Black women should be acknowledged and measured through research to capture the impact of racism. Additionally, other suggested efforts include professional development that addresses anti-Black racism in the medical profession as well as efforts to fight against anti-Black interpersonal racism ⁷⁷. All women, including Black women themselves, may benefit from opportunities that increase their own understanding of the historical impact of racism and its links to contemporary health outcomes. Subsequently, this interaction should promote further learning and support individual and community advocacy opportunities ⁷³.

In summary, white PFDs are prevalent in Black women, their experiences with those PFDs are lacking in the literature. Black women deserve dedicated efforts to optimize their PFD care and representation in PFD research.

Clinics Care Points.

• The prevalence of UI in Black women ranges from 3.3 to 45.9%.

• The prevalence of POP in Black women ranges from 1% to 7.6%.

• There is little evidence to attribute biologic, anatomic, or genetic variation to account for differences in prevalence of POP by race.

• Data suggests that Black women with PFDs underutilize PFD care; there is a paucity of literature to increase our understanding of barriers to care of PFDs specifically in Black communities.

• There are disparities in the receipt of evidence-based treatments for PFDs for Black women.

• Black women experience poorer outcomes after surgeries for PFD and SUI.

• Studies moving beyond identifying disparities in treatment are limited, yet necessary to improve outcomes.

Key Points.

1. Urinary incontinence (UI) and pelvic organ prolapse (POP) are common among Black women, with the prevalence of these disorders ranging from 3.3 to 45.9% for UI and 1% to 7.6% for POP.

2. Studies show underutilization of evidence-based treatments for pelvic floor disorders (PFDs) among Black women. There is limited data on barriers to PFD care for this population.

3. Large database studies consistently demonstrate that Black women experience poor outcomes after surgeries for UI and POP.

4. Studies moving beyond identifying disparities in treatment are limited, yet necessary to improve outcomes.

5. A strategic agenda to prioritize the care of Black women with PFDs should aim to address multiple influences on PFD care by increasing awareness of PFDs and treatments, optimizing clinical care, expanding representation of Black women in PFD research, and dismantling structural racism to achieve health equity.

Synopsis:

Pelvic floor disorders are a group of common conditions affecting women of all racial and ethnic groups. These disorders are undertreated in all women, but this is especially magnified in Black people who have been historically marginalized in the U.S. This chapter seeks to highlight the prevalence of pelvic floor disorders in Black women, evaluate the clinical care they receive, examine barriers they face to equitable care, and present a strategic agenda to prioritize the care of Black women with pelvic floor disorders.