Urogynecology (Hagerstown, Md.)最新文献

Importance: Understanding the risk of urinary retention with different prolapse repair surgical procedures is important for perioperative counseling.

Objective: The study compared postoperative urinary retention rates between robotic sacrocolpopexy and robotic uterosacral ligament suspension.

Study design: This institutional review board-exempt retrospective cohort study compared patients who underwent pelvic organ prolapse repair with robotic sacrocolpopexy (RSCP) and robotic uterosacral ligament suspension (RUSLS) between June 2018 and March 2022. Our primary outcome was the rate of acute postoperative urinary retention (POUR) in these groups. Secondary outcomes were the number of days needed to resolve urinary retention and persistent voiding dysfunction.

Results: Out of 298 patients, 258 underwent RSCP and 40 underwent RUSLS. Acute POUR was found in 73 patients (24%): 46 patients (18%) in the RSCP group versus 26 patients (65%) in the RUSLS group ( P < 0.001). Multivariate analysis demonstrated a significantly higher rate of acute POUR after RUSLS (odds ratio [OR] = 17.92, confidence interval [CI] = 3.06-104.86; P = 0.001). Patients with an elevated preoperative postvoid residual volume >100 mL or concomitant midurethral sling were more likely to develop POUR (OR = 2.93, CI = 1.43-5.98; P = 0.003 and OR = 2.19, CI = 1.16-4.14; P = 0.016, respectively). While patients with higher parity were less likely to have urinary retention (OR = 0.71, CI = 0.53-0.96; P = 0.024), age, body mass index, prolapse stage, and concurrent posterior repair did not affect the urinary retention rate significantly. The number of days needed to resolve POUR and persistent voiding dysfunction were similar.

Conclusions: Acute POUR appears more likely to develop after RUSLS compared to RSCP. Elevated preoperative postvoid residual volume and concomitant midurethral sling surgery independently increase the risk of POUR.

Importance: Disparities research in Black women with pelvic floor disorders (PFDs) has primarily focused on epidemiology or surgical outcomes, but little is known about the patient perspective on seeking PFD care.

Objective: To provide quality and equitable care to Black women with PFDs, we conducted a qualitative study to hear their perspectives and lived health care experiences.

Study design: Black women seeking care for PFDs at a tertiary care institution were invited to participate in qualitative interviews. Open-ended questions explored participants' knowledge, attitudes, and health care experiences. Interviews were transcribed verbatim and coded line-by-line. Inductive content analysis was performed to identify key themes, and consensus was achieved among the research team.

Results: Eight Black women aged 21-83 years consented to participate. Patients noted a stigma surrounding PFDs, both among health care professionals and their community. They noted several barriers to care: financial, logistical, and racial bias. They cited difficulties in patient-health care professional communication, including not feeling heard or treated as an individual. They preferred gender and racial concordance with their physicians. These women expressed both a desire for more knowledge and to share this knowledge and advocate for other women.

Conclusions: Black women expressed distinct obstacles in their PFD health care. They reported not feeling heard or treated as a unique individual. The themes derived from this study identify complex patient-centered needs that can serve as the basis for future quality improvement work and/or hypothesis-driven research. By grounding health disparities research in patient perspectives, we can improve the health care experiences of Black women.

Importance: The genital hiatus (GH) has been identified as a predictor of pelvic organ prolapse. An enlarged preoperative GH is a risk factor for recurrent prolapse after surgery.

Objective: The objective of this study was to determine the changes in preoperative and postoperative GH size compared with the intraoperative resting GH at 6 weeks and 12 months after native-tissue pelvic organ prolapse surgery.

Study design: This was a descriptive analysis of a prospective cohort study of women undergoing native-tissue prolapse repair with apical suspension. Resting GH was obtained at the start and conclusion of surgery. Measurements were obtained preoperatively, and 6 weeks and 12 months postoperatively under Valsalva maneuver. Comparisons were made using paired t tests for the following time points: (1) preoperative measurements under Valsalva maneuver to resting presurgery measurements under anesthesia, and (2) resting postsurgery measurements under anesthesia to 6 weeks and 12 months postoperatively under Valsalva maneuver.

Results: Sixty-seven patients were included, with a median age of 66 years and median body mass index (calculated as weight in kilograms divided by height in meters squared) of 29.1. There was no significant difference in GH when measured preoperatively to resting presurgical measurements under anesthesia ( P = 0.60). For all, the median GH was 3.0 cm at the conclusion of surgery and remained at 3.0 cm at 6 weeks and 12 months postoperatively. In patients who had a concurrent posterior colporrhaphy, the median resting postsurgery GH was 3.0 cm, then decreased to 2.5 cm at 6 weeks then 3.5 cm at 12 months under Valsalva.

Conclusions: Preoperative GH size under Valsalva maneuver and resting under anesthesia were comparable. For all patients undergoing native-tissue pelvic organ prolapse repair, the genital hiatus size remains the same from the intraoperative final resting measurements to the 6-week and 12-month measurements under Valsalva maneuver.

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.