Dr. Kavita Mishra is a board-certified urogynecologist who specializes in the treatment of pelvic floor disorders. She has specific training in pelvic organ prolapse and urinary and fecal incontinence, and has expertise in vaginal and minimally invasive reconstructive pelvic surgery, including laparoscopic and robotic approaches.
- Urogynecology & Pelvic Reconstructive Surgery
- Obstetrics and Gynecology
Honors & Awards
Outstanding Faculty Award in Medical Student Teaching, University of California, San Francisco (2017)
Top Fellow Teacher of the Year - Resident Teaching, Brown University, Dept. of Ob-Gyn (2016)
Top Fellow Teacher of the Year - Medical Student Teaching, Brown University, Dept. of Ob-Gyn (2015)
Excellence in Female Pelvic Medicine & Reconstructive Surgery (Resident), American Urogynecologic Society (2012)
Julie Baker Splendid Torch Award (in honor of former resident), Brown University, Dept. of Ob-Gyn (2012)
Boards, Advisory Committees, Professional Organizations
Member, American Urogynecologic Society (2011 - Present)
Associate Member, Society of Gynecologic Surgeons (2014 - Present)
Board Certification: American Board of Obstetrics and Gynecology, Female Pelvic Medicine and Reconstructive Surgery (2018)
Fellowship, Brown University, Women & Infants Hospital, Female Pelvic Medicine and Reconstructive Surgery (Urogynecology) (2016)
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2014)
Residency, Brown University, Women & Infants Hospital, Obstetrics and Gynecology (2013)
Medical Education: University of California at San Francisco School of Medicine (2009) CA
- Surgical Options for Patients Seeking Gender-Affirming Surgery CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020
- A Collaborative Approach to Multicompartment Pelvic Organ Prolapse CLINICS IN COLON AND RECTAL SURGERY 2020
- Delay in Seeking Care for Pelvic Floor Disorders Among Caregivers FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY 2020; 26 (7): 458–63
What to do after a mid-urethral sling fails.
Current opinion in obstetrics & gynecology
After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated.Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling.MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.
View details for DOI 10.1097/GCO.0000000000000658
View details for PubMedID 32833744
Surgical approach, complications, and reoperation rates of combined rectal and pelvic organ prolapse surgery.
International urogynecology journal
Our primary objective was to determine rectal prolapse (RP) and pelvic organ prolapse (POP) reoperation rates and postoperative < 30-day complications after combined RP and POP surgery at a single institution.This was an IRB-approved retrospective cohort study of all female patients who received combined RP and POP surgery at a single tertiary care center from 2008 to 2019. Recurrence was defined as the need for subsequent repeat RP or POP surgery at any point after the index surgery. Surgical complications were separated into Clavien-Dindo classes.Sixty-three patients were identified, and 18.3% (12/63) had < 30-day complications (55% Clavien-Dindo grade 1; 27% Clavien-Dindo grade 2; 18% Clavien-Dindo grade 4). Of patients undergoing combined abdominal RP and POP repair, no postoperative < 30-day complications were noted in the MIS group compared to 37.5% of those patients in the laparotomy group (p < 0.01). Overall, in those patients who underwent combined RP and POP surgery, the need for subsequent RP surgery for recurrent RP was 14% and the need for subsequent POP surgery for recurrent POP was 4.8% (p = 0.25).In this cohort of women undergoing combined RP and POP surgery, a higher proportion required subsequent RP surgery compared to those requiring subsequent POP surgery, although this was not statistically significant. Almost one-fifth of patients undergoing combined RP and POP surgery experienced a < 30-day surgical complication, regardless of whether the approach was perineal or abdominal. For those patients undergoing abdominal repair, < 30-day complications were more likely in those patients who had a laparotomy compared to those who had a minimally invasive surgery.
View details for DOI 10.1007/s00192-020-04394-2
View details for PubMedID 32577789
Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women.
Current opinion in obstetrics & gynecology
PURPOSE OF REVIEW: To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders.RECENT FINDINGS: Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery.SUMMARY: PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.
View details for DOI 10.1097/GCO.0000000000000584
View details for PubMedID 31609735
The impact of frailty on treatment for overactive bladder in older adults.
Neurourology and urodynamics
To examine the impact of frailty on treatment outcomes for overactive bladder (OAB) in older adults starting pharmacotherapy, onabotulinumtoxinA, and sacral neuromodulation.This is a prospective study of men and women age ≥60 years starting pharmacotherapy, onabotulinumtoxinA, or sacral neuromodulation. Subjects were administered questionnaires at baseline and again at 1- and 3-months. Frailty was assessed at baseline using the timed up and go test (TUGT), whereby a TUGT time of ≥12 seconds was considered to be slow, or frail. Response to treatment was assessed using the overactive bladder symptom score (OABSS) and the OAB-q SF (both Bother and HRQOL subscales). Information on side effects/adverse events was also collected. Mixed effects linear modeling was used to model changes in outcomes over time both within and between groups.A total of 45 subjects enrolled in the study, 40% (N = 18) of whom had a TUGT ≥12 seconds. Both TUGT groups demonstrated improvement in OAB symptoms over time and there were no statistically significant differences in these responses per group (all P-values >.05). Similar trends were found for both OAB-q SF Bother and OAB-q SF HRQOL questionnaire responses. Side effects and adverse events were not significantly different between groups (all P's >.05).Adults ≥60 years of age starting second- and third-line treatments for OAB, regardless of TUGT time, demonstrated improvement in OAB symptoms at 3 months. These findings suggest that frail older adults may receive comparable benefit and similar rates of side effects compared with less frail older individuals.
View details for DOI 10.1002/nau.24093
View details for PubMedID 31286561
Standardized Terminology of Apical Structures in the Female Pelvis Based on a Structured Medical Literature Review.
American journal of obstetrics and gynecology
To review the published literature and selected textbooks, compare existing usage to Terminologia Anatomica, and compile standardized anatomic nomenclature for the apical structures of the female pelvis.MEDLINE was searched from inception until May 30, 2017 based on 33 search terms generated by group consensus. Resulting abstracts were screened by eleven reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures.From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified of which 184 had Terminologia Anatomica accepted terms. Inclusion of several widely-used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, and presacral) not included in Terminologia Anatomica is proposed. Further, two controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication.This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and promote consistency among multiple academic, clinical, and surgical disciplines.
View details for DOI 10.1016/j.ajog.2019.11.1262
View details for PubMedID 31805273
Evaluation and management of defecatory dysfunction in women.
Current opinion in obstetrics & gynecology
PURPOSE OF REVIEW: To summarize the current recommendations for the evaluation and management of defecatory dysfunction in women and highlight key relationships between defecatory dysfunction and other pelvic floor disorders, including pelvic organ prolapse, fecal incontinence, and voiding dysfunction.RECENT FINDINGS: Conservative measures including lifestyle modifications, pharmacotherapy, and biofeedback continue to be the mainstay of treatment with newer therapies emerging. Physiologic testing and/or radiologic imaging should be considered for those who fail conservative therapy or are clinically complex. Surgical management is appropriate for carefully selected patients with anatomic causes of defecatory dysfunction. Further research is needed on surgical outcomes and patient expectations.SUMMARY: Pelvic floor disorders, including defecatory dysfunction, have a significant societal impact and are highly prevalent among women. Given its potential complexity, a broader focus is needed when evaluating women with defecatory symptoms and effective treatment may require multidisciplinary care.
View details for PubMedID 30247166
Fungal Lumbosacral Osteomyelitis After Robotic-assisted Laparoscopic Sacrocolpopexy.
Female pelvic medicine & reconstructive surgery
Sacral osteomyelitis is a rare complication after robotic sacrocolpopexy, with previous reports of enteric and skin flora as inciting organisms. We report a patient who presented with severe low back pain and fever 6 weeks after a robotic sacrocolpopexy, who was subsequently diagnosed as having lumbosacral discitis and osteomyelitis with thoracic intervertebral extension. Empiric antibiotic therapy was initially administered. After laparoscopic mesh excision and abdominal wash out, Candida albicans was isolated from the excised mesh. Postoperatively, the patient was treated with a 12-month course of oral fluconazole with significant clinical improvement. To our knowledge, this is the second reported case of fungal osteomyelitis, providing further recommendations for the management of postoperative sacral osteomyelitis using a minimally invasive surgical technique and guidance by a multidisciplinary team.
View details for DOI 10.1097/SPV.0000000000000612
View details for PubMedID 30059439
Delay in Seeking Care for Pelvic Floor Disorders Among Caregivers.
Female pelvic medicine & reconstructive surgery
OBJECTIVE: In 2015, 44 million adults were informal, unpaid caregivers to an adult or child. Caregiving (CG) is associated with poor self-care, higher depression rates, and decreased quality of life. Our primary objective was to determine if CG is associated with a delay in seeking care for pelvic floor disorders (PFDs).METHODS: We performed a cross-sectional survey of new urogynecology patients from September 2015 to January 2016. Subjects completed the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, Patient Reported Outcomes Measurement Information System-Depression surveys, and a survey of care-seeking practices. Caregiving was defined as considering one's self a primary caregiver and assisting with 2 or more activities and instrumental activities of daily living. Multiple logistic regression identified variables associated with delayed care-seeking for 1 or more year.RESULTS: Two hundred fifty-six patients completed the survey, 82 caregivers (32%) and 174 noncaregivers (NCGs). Sixty-seven percent of caregivers cared for a child and 33% for an adult. There was no difference between caregivers and NCGs in PFD symptom duration, Pelvic Floor Distress Inventory, or Patient Reported Outcomes Measurement Information System depression scores. Caregiving had higher mean Pelvic Floor Impact Questionnaire scores (69.6 vs 51.0, P = 0.02). There was no difference in proportion of patients who delayed care for 1 year or more (42% vs 54%, P = 0.08). A higher proportion of caregivers for an adult waited for 1 year or more (75% vs 42% NCG, P = 0.001). On multiple logistic regression, CG for adults only was associated with delaying care for 1 year or more (adjusted odds ratio, 3.73; confidence interval, 1.33-10.44; P = 0.01).CONCLUSIONS: One third of patients presenting to a urogynecology practice are caregivers. Caregiving for an adult was associated with a delay in seeking care for PFDs.
View details for PubMedID 30045052
Prevalence of occult pre-malignant or malignant pathology at the time of uterine morcellation for benign disease
INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS
2017; 137 (2): 123–28
To determine the prevalence of occult pre-malignant or malignant uterine pathology at the time of laparoscopic surgery with open power morcellation for benign gynecologic disease.The present multicenter, retrospective cohort study included women who underwent open power morcellation for benign indications between January 1, 2007, and February 28, 2014, at three academic medical centers in the USA. The primary outcome was pre-malignant or malignant pathology at the time of open power morcellation, and was determined from the patients' pathology reports.During the study period, 1214 women underwent open power morcellation for benign indications. Similar preoperative characteristics were observed between patients with normal pathology and those with pre-malignant or malignant uterine pathology, including body mass index, parity, hypertension, diabetes, breast cancer, and smoking (all P>0.129). Among patients who underwent open power morcellation, 14 (1.2%) had occult pre-malignant or malignant pathology; 5 (0.4%) women had endometrial adenocarcinoma and 1 (0.1%) had low-grade endometrial stromal sarcoma. There were eight patients with malignant pathology who underwent additional surgical exploration and were disease free at their final clinical visit, with a median follow-up time of 42.0 months (interquartile range 5.0-62.0 months).Endometrial adenocarcinoma and low-grade endometrial stromal sarcoma were rare in the present study and there were no reports of leiomyosarcoma.
View details for PubMedID 28170091
View details for PubMedCentralID PMC5934613
Global Health Interest Among Female Pelvic Medicine and Reconstructive Surgery Fellows
JOURNAL OF REPRODUCTIVE MEDICINE
2015; 60 (11-12): 501-506
To determine interest in global health (GH) work among Female Pelvic Medicine and Reconstructive Surgery (FPMRS)fellows.An anonymous, online survey was sent to FPMRS fellows in March 2012. All fellows at accredited and nonaccredited U.S. FPMRS programs were eligible. Of at least 123 fellows, 58 (47%) completed the survey and met inclusion criteria. Survey questions included demographics, GH interest and experience, barriers to GH experience, and career goals.Of those 58 fellows, 79% of respondents graduated from Ob-Gyn residencies, 41% were first year fellows, 45% spoke another language fluently, and 62% had previously worked and/or studied in a developing country. Of the respondents 74% desired GH experience during fellowship, 78% desired GH experience after fellowship, and 40% reported seeing themselves integrating GH into their career. Top barriers to GH work in fellowship were lack of elective time (74%), cost (70%), and personal commitments (67%). A total of 39% of respondents said the ability to work in GH somewhat or strongly affected their decision to pursue FPMRS, and 26% said the availability of GH opportunities affected their fellowship rank list. Family (88%), clinical commitments (78%), and cost (67%) were the biggest reported hurdles to future GH work.Nearly three-quarters of FPMRS fellows are interested in GH work in fellowship. Almost half would like to include it in future practice. Barriers in fellowship include elective time, cost, and personal commitments.
View details for Web of Science ID 000366243600007
View details for PubMedID 26775458
Outcomes following treatment for pelvic floor mesh complications
INTERNATIONAL UROGYNECOLOGY JOURNAL
2014; 25 (6): 745–49
Our aim was to determine symptoms and degree of improvement in a cohort of women who presented following treatment for vaginal mesh complications.This study was a follow-up to a multicenter, retrospective study of women who presented to four tertiary referral centers for management of vaginal-mesh-related complications. Study participants completed a one-time follow-up survey regarding any additional treatment, current symptoms, and degree of improvement from initial presentation.Two hundred and sixty women received surveys; we had a response rate of 41.1 % (107/260). Complete data were available for 101 respondents. Survey respondents were more likely to be postmenopausal (p = 0.006), but otherwise did not differ from nonrespondents. Fifty-one percent (52/101) of women underwent surgery as the primary intervention for their mesh complication; 8 % (4/52) underwent a second surgery; 34 % (17/52) required a second nonsurgical intervention. Three patients required three or more surgeries. Of the 30 % (30/101) of respondents who reported pelvic pain prior to intervention, 63 % (19/30) reported improvement, 30 % (9/30) were worse, and 7 % (2/30) reported no change. Of the 33 % (33/101) who reported voiding dysfunction prior to intervention, 61 % (20/33) reported being at least somewhat bothered by these symptoms.About 50 % of women with mesh complications in this study underwent surgical management as treatment, and <10 % required a second surgery. Most patients with pain preintervention reported significant improvement after treatment; however, almost a third reported worsening pain or no change after surgical management. Less than half of patients with voiding dysfunction improved after intervention.
View details for DOI 10.1007/s00192-013-2282-9
View details for Web of Science ID 000336388800007
View details for PubMedID 24318564
Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study
MOSBY-ELSEVIER. 2014: 163.e1–8
The purpose of this study was to describe the evaluation and management of synthetic mesh-related complications after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP).We conducted a multicenter, retrospective analysis of women who attended 4 US tertiary referral centers for evaluation of mesh-related complications after surgery for SUI and/or POP from January 2006 to December 2010. Demographic, clinical, and surgical data were abstracted from the medical record, and complications were classified according to the Expanded Accordion Severity Classification.Three hundred forty-seven patients sought management of synthetic mesh-related complications over the study period. Index surgeries were performed for the following indications: SUI (sling only), 49.9%; POP (transvaginal mesh [TVM] or sacrocolpopexy only), 25.6%; and SUI + POP (sling + TVM or sacrocolpopexy), 24.2%. Median time to evaluation was 5.8 months (range, 0-65.2). Thirty percent of the patients had dyspareunia; 42.7% of the patients had mesh erosion; and 34.6% of the patients had pelvic pain. Seventy-seven percent of the patients had a grade 3 or 4 (severe) complication. Patients with TVM or sacrocolpopexy were more likely to have mesh erosion and vaginal symptoms compared with sling only. The median number of treatments for mesh complications was 2 (range, 1-9); 60% of the women required ≥2 interventions. Initial treatment intervention was surgical for 49% of subjects. Of those treatments that initially were managed nonsurgically, 59.3% went on to surgical intervention.Most of the women who seek management of synthetic mesh complication after POP or SUI surgery have severe complications that require surgical intervention; a significant proportion require >1 surgical procedure. The pattern of complaints differs by index procedure.
View details for DOI 10.1016/j.ajog.2013.10.012
View details for Web of Science ID 000330126100027
View details for PubMedID 24126300
Variables Impacting Care-Seeking for Pelvic Floor Disorders Among African American Women
FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY
2013; 19 (2): 98–102
This study aimed to identify variables impacting care-seeking for pelvic floor disorders (PFDs) among (1) a general population of professional African American (AA) women and (2) professional AA women with prevalent PFD symptoms.A cross-sectional survey of women registered for the 37th National Assembly of the Links, Inc, a volunteer service organization of professional AA women, was conducted. Our de-identified questionnaire addressed several domains including PFD symptoms, history of PFD diagnoses, attitudes regarding PFDs, and help-seeking. We asked what respondents would do if they experienced PFD symptoms and defined our outcome as the response "I would not seek care." Barriers were covariates associated with not seeking care.Of 568 questionnaires distributed, 362 (64%) with complete data were returned; 6.4% (23/362) of respondents reported they "would not seek care" if experiencing a PFD symptom. On logistic regression, attitude that PFDs are a normal part of aging [adjusted odds ratio (AOR), 5.56; 95% confidence interval (CI), 1.46-21.23] and concerns about insurance (AOR, 3.80; 95% CI, 1.39-10.33) were barriers to care-seeking, adjusting for health status and embarrassment about discussing PFDs.Thirty percent (110/362) of women reported having current PFD symptoms. In this subset, only 26% had accessed care. On logistic regression, prolapse symptoms in the previous 3 months and age 65 years or older were negatively associated with not seeking care (ie, were predictors of care-seeking) (AOR, 0.11; 95% CI, 0.02-0.67) and (AOR, 0.17; 95% CI, 0.03-0.85), respectively, adjusting for pelvic floor distress inventory scores.Among educated and insured AA women, attitudes about aging and insurance complexity are barriers to care-seeking for PFDs. In women with current PFD symptoms, recent prolapse symptoms and age 65 years or older were predictors of care-seeking.
View details for DOI 10.1097/SPV.0b013e31827bfee8
View details for Web of Science ID 000209178800008
View details for PubMedID 23442507
Providers' Perspectives on Provision of Family Planning to HIV-Positive Individuals in HIV Care in Nyanza Province, Kenya
AIDS RESEARCH AND TREATMENT
Objective. To inform an intervention integrating family planning into HIV care, family planning (FP) knowledge, attitudes and practices, and perspectives on integrating FP into HIV care were assessed among healthcare providers in Nyanza Province, Kenya. Methods. Thirty-one mixed-method, structured interviews were conducted among a purposive sample of healthcare workers (HCWs) from 13 government HIV care facilities in Nyanza Province. Structured questions and case scenarios assessed contraceptive knowledge, training, and FP provision experience. Open-ended questions explored perspectives on integration. Data were analyzed descriptively and qualitatively. Results. Of the 31 HCWs interviewed, 45% reported previous FP training. Few providers thought long-acting methods were safe for HIV-positive women (19% viewed depot medroxyprogesterone acetate as safe and 36% viewed implants and intrauterine contraceptives as safe); fewer felt comfortable recommending them to HIV-positive women. Overall, providers supported HIV and family planning integration, yet several potential barriers were identified including misunderstandings about contraceptive safety, gendered power differentials relating to fertility decisions, staff shortages, lack of FP training, and contraceptive shortages. Conclusions. These findings suggest the importance of considering issues such as patient flow, provider burden, commodity supply, gender and cultural issues affecting FP use, and provider training in FP/HIV when designing integrated FP/HIV services in high HIV prevalence areas.
View details for DOI 10.1155/2013/915923
View details for Web of Science ID 000215095600035
View details for PubMedID 23738058
View details for PubMedCentralID PMC3659431
Analgesia/Pain Management in First Trimester Surgical Abortion
CLINICAL OBSTETRICS AND GYNECOLOGY
2009; 52 (2): 160–70
Management of pain during abortion is a critical aspect of patient care. Although it is not always possible to offer a range of pain control options in every setting, individualizing pain medications as much as possible for patients' preferences is likely to improve satisfaction with the abortion experience. Evidence suggests that higher volume (at least 200 mg lidocaine) and deeper injections are beneficial for cervical block. Adding intravenous sedation with a moderate dose of fentanyl and midazolam reduces the pain scores. Oral benzodiazepines may improve satisfaction and anxiety. Deep sedation and general anesthesia are important options for women with significant medical conditions or complicated procedures.
View details for DOI 10.1097/GRF.0b013e3181a2b0e8
View details for Web of Science ID 000266136400006
View details for PubMedID 19407522