Urogynecology (Hagerstown, Md.)最新文献

Importance: Guideline-recommended medications for overactive bladder and urge urinary incontinence (OAB/UUI) are effective but have high costs and side effects. Little is known about patient concerns regarding these medications when prescribed by their primary care providers (PCPs).

Objective: The aim of the study was to describe PCP-patient interactions when prescribing medications for OAB/UUI, specifically clinical concerns, cost and authorization issues, and mode of communication for these interactions.

Study design: Using electronic health records, we identified a retrospective cohort of women aged 18-89 years who were prescribed a medication for OAB/UUI during a primary care office visit from 2017 to 2018. We examined the electronic health record from initial prescription through 15 subsequent months for documentation of prior authorization requests and patient concerns about cost, side effects, or ineffectiveness. The association of patient demographics, comorbidity, and medication class with these concerns was examined with logistic regression models.

Results: Overall, 46.2% of patients (n = 123) had 1 or more OAB/UUI medication concerns, and 52 reported outside an office visit. Only higher comorbidity was associated with reduced concern of any type. Although the overall percent age of patients reporting concerns was similar by medication type, the patterns of concern type varied. Compared with those taking short-acting antimuscarinics, patients taking long-acting antimuscarinics other than oxybutynin were less likely to have side effect concerns (adjusted odds ratio 0.35, 95% CI 0.16-0.78) and more likely to have cost concerns (adjusted odds ratio 5.10, 95% CI 1.53-17.03).

Conclusions: Patient concerns regarding OAB/UUI medications were common in primary care practices and frequently reported outside of office visits. However, the patterns of concerns (cost vs side effects) varied between medication classes.

Importance: Only 25% of women seek treatment for urinary incontinence. Cost may be a potential barrier. Financial toxicity is the financial stress (ie, direct and indirect costs) associated with treatment of a condition. The subjective financial impact of urinary incontinence has not been previously measured in women.

Objective: This pilot study aimed to characterize the financial toxicity of urinary incontinence in women.

Study design: We performed a cross-sectional study of a convenience sample of women with urinary incontinence presenting to our urban, academic medical center. Surveys capturing degree of financial toxicity and urinary incontinence severity were administered. Descriptive data were analyzed using Student t tests and χ 2 tests for continuous and categorical variables respectively, with a significance threshold of P < 0.05.

Results: A total of 127/132 participants completed the survey. The majority identified as Latin-x (49.6%). Patients with moderate-to-severe financial toxicity due to urinary incontinence also had worse urinary incontinence symptom severity ( P < 0.019), lower levels of education ( P < 0.008), greater reliance on public services including insurance ( P < 0.008), lower household income ( P < 0.046), and a higher number of unmet social needs ( P < 0.001).

Conclusions: Women with moderate-to-severe financial toxicity related to urinary incontinence had worse urinary incontinence symptom severity and more unmet social needs. The COST-FACIT survey administered in women with urinary incontinence for the first time serves to characterize the subjective financial impact. Efforts to increase awareness of the cost burden of urinary incontinence may reveal cost-related barriers to care contributing to health care disparities among women with urinary incontinence.

Importance: Postpartum patients face significant musculoskeletal sequelae of childbirth, which may be compounded by medical characteristics and social determinants of health. These symptoms are treatable with pelvic floor physical therapy, yet postpartum physical therapy referral and adherence rates remain low. The reasons for this are understudied. Furthermore, most current research centers on non-Hispanic, middle- to upper-class White patients, limiting applicability to other populations.

Objectives: The objectives of this study were to evaluate differences in physical therapy referral and adherence rates among medically underserved female patients and determine whether certain variables predicted or moderated adherence to outpatient postpartum physical therapy.

Study design: Data from a retrospective cohort study of electronic health records were analyzed using 2-way t tests, analysis of variance, and logistic regression techniques.

Results: Hispanic patients were referred to physical therapy at a disproportionately low rate compared to other racial/ethnic groups (8.8% vs 16.7% and 14.7%, P < 0.0001); older age and higher pain were present in both referred versus nonreferred ( P < 0.0001, both) and adherent versus nonadherent ( P < 0.05 and P < 0.01, respectively) patients; patients who received referrals were significantly more depressed ( P < 0.0001), more educated ( P < 0.0001), had higher rates of grade 3-4 perineal laceration ( P < 0.01), and had higher parity ( P < 0.0001) and gravidity ( P < 0.0001) compared to their nonreferred counterparts; pain, education, race, and age were important predictors of physical therapy adherence (predictor model P = 0.0001); and Asian race moderated the relationship between physical therapy referral and adherence ( P = 0.017).

Conclusions: In a postpartum population, physical therapy referrals were low and ethnic disparities were present. Adherence to physical therapy was also affected by patient demographics and medical history. Interventions to increase postpartum physical therapy referral and adherence should consider the patient's social determinants of health and medical needs.

Importance: Residential segregation influences health outcomes.

Objective: The objective of this study was to examine the relationship between residential segregation and prolapse surgery complications and readmissions among older Black women.

Study design: This retrospective study included non-Hispanic Black women who underwent prolapse surgery from 2011 to 2018 in the Medicare 5% Limited Dataset. The primary outcome was 90-day complications. Other outcomes of interest were 30- and 90-day readmissions. We calculated the Index of Concentration at the Extremes (ICE) for each beneficiary's U.S. county of residence to measure geographic segregation by race, income, and both combined. We stratified the cohort into quintiles based on the ICE measures. Descriptive and comparative analyses were used to compare the demographic and clinical characteristics for each group. Poisson regression models were used to test the association between ICE measures and complications and readmissions.

Results: There were 872 Black women included in the analysis. Black women living in counties with the highest concentrations of Black residents had a 44% and 55% increased relative risk of 90-day complications compared to those in counties with the highest concentrations of White residents. Conversely, Black women living in the least segregated counties by race and income combined experienced 70% and 57% decreased risk of 30- and 90-day readmissions, respectively.

Conclusions: The findings support our hypothesis that structural racism (measured by levels of residential racial and economic segregation) is associated with poorer outcomes after pelvic organ prolapse surgery. Further research is needed to identify neighborhood-level factors that contribute to and protect against inequities in postoperative outcomes after prolapse surgery.

Importance: Little is known regarding patient use of the emergency department for prolapse symptoms and the burden this use places on the health care system.

Objective: The aim of the study was to evaluate the incidence of emergency department visits in the United States for pelvic organ prolapse and associated patient and hospital demographics.

Study design: This was a cross-sectional study of emergency department presentations from 2016 to 2018 associated with a primary diagnosis of pelvic organ prolapse. Data were obtained using International Classification of Diseases, Tenth Revision, Clinical Modification codes from the Healthcare Cost and Utilization Project Nationwide Emergency Department Samples. Descriptive analysis was used to identify sociodemographic and clinical characteristics of the population presenting to the emergency department for prolapse.

Results: Between 2016 and 2018, there were 14,101 annual emergency department visits for prolapse in the United States, which comprised less than 0.01% of all emergency department visits. Overall, 55.5% of patients were <65 years old and 62.5% had a household income of <50th percentile ($0-$58,999). The most common secondary diagnosis was hypertension (12.3%), and the most common secondary urogynecologic diagnosis was urinary tract infection or pyelonephritis (5.7%). No high-risk comorbidities were seen in 78.1% of patients. Most patients with prolapse were discharged (91.8%), although 5.8% were admitted and 1.5% were transferred for further care.

Conclusions: Emergency department presentation for pelvic organ prolapse is uncommon. Disproportionate emergency department use was seen for patients <65 years old and with low household income. Further initiatives can optimize outpatient workflows for urogynecologic care and expand community outreach efforts on prolapse education to reduce emergency department use for nonurgent concerns.

Importance: Restricting activity after midurethral slings is an unproven practice.

Objective: The objective of this study was to evaluate the effect of postoperative activity restriction on satisfaction and outcomes after slings.

Study design: This was a multicenter, 2-arm, noninferiority randomized controlled trial. Patients aged 18-85 years undergoing treatment with a midurethral sling were randomized 1:1 to postoperative activity restriction or liberal activity. Restrictions included avoidance of strenuous exercise and heavy lifting. The liberal group was allowed to resume activity at their discretion. Our primary outcome was satisfaction with postoperative instruction at 2 weeks. Secondary outcomes included surgical failure, mesh exposure rates, and other adverse events.

Results: In total, 158 patients were randomized with 80 to the liberal group and 78 to the restricted group. At 2 weeks, 54 (80.6%) of patients in the liberal group and 48 (73.9%) of patients in the restricted group were satisfied. We found statistical evidence supporting the hypothesis that postoperative liberal activity instruction is noninferior to activity restriction with regard to patient satisfaction ( P = 0.0281). There was no significant difference in strenuous activity at 2 weeks ( P = 0.0824). The liberal group reported significantly more moderate activity at 2 weeks ( P = 0.0384) and more strenuous activity at 6 weeks and 6 months ( P = 0.0171, P = 0.0118, respectively). The rate of recurrent or persistent stress incontinence for liberal versus restricted groups was 18.52% versus 23.53% ( P = 0.635). There were no statistically significant differences in complication rates.

Conclusions: Postoperative liberal activity was noninferior to activity restriction with regard to patients' satisfaction. There was no evidence supporting a statistically significant association between postoperative instruction and negative surgical outcomes.

Importance: The importance of this study was to examine treatment patterns and surgical complications for stress urinary incontinence (SUI).

Objectives: The aim of this study was to describe the treatment of SUI and associated complications in a racially and ethnically diverse population.

Study design: This was a retrospective cohort study of patients with a new diagnosis of SUI. We identified patients who received treatment with a pessary, pelvic floor physical therapy, or surgery. Surgical complications were abstracted. Logistic regression was used to examine the association between race/ethnicity and treatment, as well as surgical complications.

Results: A total of 67,187 patients with a new diagnosis of SUI were included. The population was predominately Hispanic (47.5%) followed by White, Asian, Black, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native. Comparing no treatment to any treatment, all racial/ethnic groups, except American Indian/Alaska Native, had decreased odds of receiving treatment compared with White women. Hispanic and Native Hawaiian/Pacific Islander women had increased odds of referral for pelvic floor physical therapy compared with White women. All racial/ethnic groups, except for American Indian/Alaska Native women, had decreased odds of receiving a sling procedure compared with White women. When these racial/ethnic minority groups did receive treatment, it was more likely to be conservative treatment compared with White women. There were no significant differences in individual surgical complications.

Conclusions: Racial minority women were 20-50% less likely to undergo a sling procedure, commonly posited as the gold standard surgical treatment. Racial minority women were 40-100% more likely to receive conservative management and 20-50% less likely to receive any treatment compared with White women.

Importance: Parity and mode of delivery are common risk factors for pelvic floor dysfunction. The prolonged second stage of labor, defined as the time between complete cervical dilation and the expulsion of the fetal head, may be related to these changes and no pooled evidence has been tabulated to seek this association.

Objective: The aim of the study was to carry on a systematic review on the association between pelvic floor dysfunction symptoms and prolonged second stage of labor (PSSL).

Study design: A systematic search was conducted in the databases PubMed, Cochrane Library, Embase, SCOPUS, Web of Science, and LILACS on July and December 2024. Studies involving populations of women who experienced PSSL and in which the analyzed outcomes were symptoms of pelvic floor dysfunction were included. The ROBINS-I scale was used to assess methodological quality for observational studies.

Results: A total of 92 articles were fully analyzed, and 6 articles were selected. A meta-analysis could not be performed because of the heterogeneity of the primary outcome and the definition for PSSL. Two of 6 studies considered PSSL over 3 hours. Among the 6 studies, 3 showed no association between PSSL and pelvic floor dysfunction, 2 indicated an association with urinary incontinence, and one suggested a partial association. All studies presented a moderate overall risk of bias.

Conclusions: Half of the studies did not demonstrate an association between PSSL and pelvic floor dysfunction and the other half suggested an association. Further studies with PSSL as primary outcomes with cohort design are needed to clarify this question.

Importance/study objectives: The aim of this study was to determine whether the Social Vulnerability Index (SVI) is associated with the type of surgery for pelvic organ prolapse (POP) focusing on sacrocolpopexy (SCP) and uterosacral ligament suspension (USLS).

Study design: This was a retrospective case-control study that included patients from 8 hospitals within a large academic health system in New York between January 1, 2018 and January 1, 2023. All patients 15-85 years of age with a preoperative diagnosis of POP who underwent a hysterectomy with an SCP or USLS were included. Home addresses were linked to census tracts and SVI scores. Multiple logistic regression analyses were performed to evaluate the association between SVI quartiles and POP surgical management (SCP vs USLS).

Results: Six hundred one patients who underwent reconstructive surgery for POP were included in the study. The Social Vulnerability Index was not statistically significantly associated with POP surgical management ( P = 0.26). After adjusting for potential confounders, there continued to be no association between SVI and POP management ( P = 0.40). The adjusted model illustrated that age 65 years or greater was associated with decreased odds (adjusted odds ratio, 0.24; 95% confidence interval, 0.14-0.40) of SCP ( P < 0.0001), whereas patients with hypertension were found to be at increased odds (adjusted odds ratio, 2.60; 95% confidence interval, 1.01-6.71).

Conclusions: There was no statistically significant association between SVI and POP surgical management for SCP versus USLS. However, advanced patient age (65 years and greater) was associated with decreased odds, and hypertension was associated with greater odds of SCP.

Importance: Safe surgery requires an understanding of the anatomic boundaries and neurovascular structures of the presacral space.

Objective: The aim of the study was to characterize anatomy of the presacral space applicable to sacrocolpopexy or rectopexy while highlighting cadaveric findings of the lateral border of the space.

Study design: Structures and boundaries of the presacral space of 18 unembalmed female cadavers were studied. Anatomic relationships and distances to landmarks were established.

Results: A dense connective tissue layer ≤1 mm thick on the piriformis muscle's medial surface attaches to the anterior sacrum just medial to the sacral foramina, separating the lateral sacral vein and sacral nerves laterally from the presacral space contents medially. Median transverse distance from midsacral promontory to right sympathetic trunk was 19.5 (range, 15-31) mm. Distances from right S1, S2, S3, and S4 foramina to midsacral promontory were 28.8 (22-47.5), 48.3 (38.5-72.5), 65.8 (54.5-89.5), and 80.8 (65-104.5) mm and to midline sacrum were 16.5 (14-22), 15.3 (13-20.5), 13.5 (10.5-19.5) and 13.3 (10.5-19.5) mm, respectively. Transverse communicating veins, measuring 3 (2-4) mm in width, penetrated the piriformis fascia, joining the lateral sacral vein to form the sacral venous plexus. Vertical distance from midsacral promontory to the most cephalad communicating vein was 38.3 (7.5-60.5) mm.

Conclusions: During presacral space surgical procedures, avoiding suture placement and mesh fixation beyond 1.5 cm from the sacrum midline should prevent injury to the sacral sympathetic trunk, sacral nerves, and lateral sacral vein. Transverse communicating vessels of the sacral venous plexus are usually encountered below the S1 foramina level. The piriformis fascia is the lateral boundary of the presacral space over the greater sciatic foramen.