Urogynecology (Hagerstown, Md.)最新文献

Importance: Understanding how race and ethnicity are contextualized as risk factors for obstetric anal sphincter injuries (OASIs) can improve efforts to address maternal health disparities.

Objectives: Our primary aim was to conduct a systematic review and meta-analysis to examine the association between race/ethnicity and OASI incidence. The secondary aim was to critique how included studies contextualized race/ethnicity as risk factors for OASIs.

Study design: This systematic review analyzed observational studies reporting OASI incidence by race and ethnicity. The primary outcome was the overall incidence of OASIs, with odds ratios (OR) calculated using a random effects model. We quantified the racial representation in the included studies using a representation quotient (RQ) analysis and applied the Obstetrics & Gynecology's equity rubric for structured critique.

Results: Out of 3,896 studies, 12 were included. The overall OASI incidence was 4.44% (95% CI, 2.69-6.60%), with Asian American and Pacific Islander (AAPI) individuals having the highest incidence at 5.69% (95% CI, 4.04-7.59%). AAPI individuals had higher odds of OASIs compared with White individuals (OR, 1.61; 95% CI, 1.12-2.31). Two studies provided disaggregated AAPI data by ethnicity. Native American (RQ 0), Black (RQ 0.15), and Hispanic (RQ 0.20) individuals were underrepresented. Among studies that identified racial disparities, 33% attributed findings to systemic factors, 45% did not address disparities, and 22% suggested biological differences without substantiated evidence.

Conclusions: AAPI individuals had 61% higher odds of experiencing OASIs than White individuals. However, most studies aggregated AAPI data, failed to represent the U.S. population, and overlooked system-level factors contributing to the racial disparity in OASI incidence.

Importance: Individuals with non-English primary language (NEPL) have difficulty accessing subspecialty care, and communication barriers can result in suboptimal counseling. Studies investigating the association between primary spoken language (PSL) and pelvic organ prolapse (POP) stage and treatment are lacking.

Objective: The objective of this study was to determine the association between primary language and degree and management of POP.

Study design: This was a retrospective cohort analysis of patients evaluated for POP between 2015 and 2023 at 2 tertiary care centers. Chart review identified patients with a NEPL, and a cohort of English primary language (EPL) patients was randomly selected. Data regarding demographics, Pelvic Organ Prolapse Quantification examination, and treatment within 6 months of initial presentation were collected.

Results: The total cohort included 114 patients (57 per group). The groups were well-matched except that the NEPL group had a significantly higher mean gravidity and parity (4.6 vs 2.8, P < 0.001; 3.8 vs 2.4, P <0.001). The NEPL group had higher rate of Medicaid/Medicare/Self-pay insurance (47 vs 26, P < 0.001) and more diabetes mellitus (19 vs 5, P = 0.002). The rate of advanced-stage POP (stage 3-4) was similar between groups (49.1% vs 56.1%, P = 0.45). The NEPL group had statistically significant higher rates of apical (78.6% vs 59.6%, P = 0.03), anterior (90.9% vs 66.7%, P = 0.002), and posterior prolapse (81.8% vs 45.6%, P < 0.001). The EPL group had statistically significant higher rates of surgical management (43.9% vs 22.8%, P = 0.02). These findings persisted after controlling for age, body mass index, insurance, parity, and diabetes mellitus.

Conclusions: This study highlights inequity in the treatment of POP by primary language. The NEPL population had a similar rate of advanced POP and significantly higher rates of all the subcategories of prolapse. However, they were significantly less likely to undergo surgery. This suggests bias toward conservative measures in those with NEPL.

Importance: The onset of symptom improvement following intravesical onabotulinum toxinA for urgency urinary incontinence is not well known.

Objective: The objective of this study was to evaluate the early efficacy of intradetrusor onabotulinumtoxinA for the treatment of urgency urinary incontinence.

Study design: We performed a prospective observational study of women undergoing intradetrusor onabotulinumtoxinA for the treatment of urgency urinary incontinence. Adult women receiving an initial or subsequent injection of 100 units of intradetrusor onabotulinumtoxinA were included. Participants completed 3-day baseline voiding diaries, the Urinary Distress Inventory-6, and Incontinence Impact Questionnaire-7 before the procedure. Voiding diaries, Urinary Distress Inventory-6, and Incontinence Impact Questionnaire-7 were repeated daily for 14 days postprocedure. Statistical analysis of paired data (preprocedure and postprocedure) was performed using the Wilcoxon signed-rank test.

Results: Thirty-one participants completed baseline and follow-up questionnaires. The median (range) baseline Urinary Distress Inventory-6 was 33 (8-71) and the Incontinence Impact Questionnaire-7 was 38 (0-100). The median baseline daily voids, urgency urinary incontinence episodes, urgency episodes, and nocturia episodes were 13 (8-20), 5 (2-15), 8 (3-17), and 4 (0-6), respectively. For all measures, day 1 outcomes were significantly improved from baseline. Day 1 median Urinary Distress Inventory-6 was 25 (0-67), Incontinence Impact Questionnaire-7 was 24 (0-81), daily voids were 10 (5-20), daily urgency urinary incontinence episodes were 2 (0-15), daily urgency episodes were 3 (0-20), and daily nocturia episodes were 2 (0-4). Significant improvement persisted over the 14-day follow-up.

Conclusions: Women undergoing intradetrusor onabotulinumtoxinA for urgency urinary incontinence had significant subjective and objective improvement 1 day postprocedure.

Importance: Urine samples are part of urogynecologic evaluation, but limited data exist on the optimal urine collection technique in obese female patients.

Objective: The objective of this study was to compare dipstick urinalysis and culture results obtained from obese females via midstream clean-catch and straight catheterization.

Study design: We performed a prospective cross-sectional study of obese females aged ≥18 years with a body mass index (BMI) ≥30 presenting for urogynecologic consult. Women with symptoms of acute urinary tract infection were excluded. Midstream clean-catch and straight catheterization urine samples were collected from all participants. Dipstick urinalysis and urine cultures were performed on both specimens to compare results using contingency tables, Cohen's Kappa, and logistic regression.

Results: Two hundred one patients were included with a mean age of 59.61±13.42 years and a median (IQR) BMI of 35.8 (33.0-40.3). Agreement between collection methods was moderate for nitrites (κ=0.65). There was weak agreement between the collection methods for blood, leukocytes, and bacteria (all κ<0.60). Nearly half of the midstream clean-catch cultures were contaminated with ≥3 mixed bacteria versus catheterized specimens (42.3% vs 3.5% respectively, P<0.001). Culture contamination was not more likely with increasing BMI for clean-catch or catheterized specimens (odds ratio [OR]=1.0, 95% CI, 0.96-1.10 and OR=1.0, 95% CI, 0.94-1.16, respectively). Culture contamination was not associated with age by decade in clean-catch or catheterized specimens (OR=1.0, 95% CI, 0.83-1.27 and OR=1.3, 95% CI, 0.72-2.40, respectively).

Conclusions: Agreement between midstream clean-catch and catheterized specimens among obese female patients is poor. Midstream clean-catch urine cultures were more likely to be contaminated, though increasing BMI does not appear to influence the odds of contamination among obese patients.

Importance: Asymptomatic bacteriuria (ASB) is common, particularly among women as they age, yet awareness is low and patient education materials are often limited in quality.

Objectives: We conducted a qualitative study to assess patient feedback on existing ASB information and identify gaps in understanding to guide future educational efforts.

Study design: We convened 5 focus groups among postmenopausal women with previous experience of treatment for urinary tract infections. Participants were asked to describe their experiences of urinary symptoms, reflect on a handout describing ASB, and make recommendations on how to improve patient education. Three team members read deidentified transcripts of the focus groups, developed a thematic codebook following Conventional Content Analysis guidelines, and coded the data using NVivo software.

Results: Twenty women participated in 5 focus groups. The average age of participants was 69.1 years (SD 10.8). Three participants (15.0%) identified as Black and the remaining participants identified as White. Many had postsecondary education, 12 with some college (60.0%) and 7 with graduate-level education (35.0%). Five overarching themes emerged: (1) ASB confusion, (2) presence of bacteria must indicate infection, (3) diagnosis requires treatment, (4) antibiotics as a "cure-all," and (5) in favor of antimicrobial stewardship. Quotations illustrated both persistent misconceptions and openness to learning, highlighting opportunities to improve communication and reduce inappropriate antibiotic use.

Conclusions: Among postmenopausal women, there is a lack of awareness surrounding ASB and the concept that bacteriuria could exist without requiring antibiotics. While misconceptions are common, willingness to learn suggests potential for targeted, plain-language educational materials as we seek to improve understanding of ASB and support antibiotic stewardship.

Importance: Midurethral sling (MUS) is a common procedure to correct stress urinary incontinence but carries a risk of postoperative urinary retention (POUR).

Objective: The objective of this study was to evaluate the efficacy of perioperative tamsulosin for reducing the incidence of POUR in patients undergoing MUS placement, with or without concomitant pelvic organ prolapse (POP) surgery.

Study design: This was a retrospective cohort study of female patients who underwent MUS placement, with or without concomitant gynecologic surgery. Patients were excluded if they underwent transobturator or autologous sling placement or had an intraoperative injury requiring prolonged catheterization. Patients who received perioperative tamsulosin were compared with those who did not. Multivariable logistic regression was performed to assess factors associated with POUR. The primary outcome was the incidence of POUR.

Results: A total of 423 patients who underwent MUS placement were eligible for analysis. Of these, 131 (31.0%) patients received perioperative tamsulosin and 292 (69.0%) did not. In the unadjusted analysis, the incidence of POUR was significantly higher in the no-tamsulosin group (18.8% vs 10.6%, P=0.04). However, the multivariable logistic model demonstrated that perioperative tamsulosin was not significantly associated with decreased POUR (OR, 0.61; 95% CI, [0.29-1.28], P=0.19). Patients with a higher body mass index had a reduced likelihood of POUR (OR, 0.94; 95% CI, [0.89-0.99], P=0.02), while patients who underwent a concomitant POP surgical procedure trended toward increased likelihood of POUR (OR, 2.15; 95% CI, [0.97-4.73], P=0.06).

Conclusions: These findings suggest that patient and procedural characteristics may play a more significant role in POUR risk than perioperative tamsulosin use for patients undergoing MUS placement.

Importance: Colpocleisis is an obliterative procedure for pelvic organ prolapse commonly offered to medically complex patients who may not be candidates for reconstructive surgery. Although frailty is a well-established predictor of surgical morbidity, its effect on colpocleisis outcomes is not well defined. The 5-factor Modified Frailty Index (mFI-5) is a validated tool for surgical risk prediction.

Objective: This study evaluated the association between mFI-5 and 30-day postoperative complications after colpocleisis.

Study design: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2006 to 2022. We defined frailty as an mFI-5 score ≥2 based on 5 ACS NSQIP-captured items: (1) functional dependence, (2) diabetes, (3) chronic obstructive pulmonary disease, (4) congestive heart failure, and (5) hypertension. Demographic, perioperative variables, and postoperative complications were compared between frail and nonfrail patients. The primary outcome was a composite of any 30-day complication. Secondary outcomes included individual complications, reoperation, and length of stay. Multivariable logistic regression adjusted for prespecified clinical covariates.

Results: Of 5,213 patients undergoing colpocleisis, 93 (1.8%) were frail. Overall, 495 (9.3%) experienced a postoperative complication. More frail patients were Black, had higher body mass index, smoked tobacco, and were assigned American Society of Anesthesiologists classification 3-4. In adjusted models, frailty was independently associated with composite complications (adjusted odds ratio [aOR], 2.04; 95% CI, 1.21-3.48), pneumonia (aOR,15.94; 95% CI, 4.51-56.37), and stroke (aOR, 14.72; 95% CI, 2.74-79.08).

Conclusion: Frailty is an independent predictor of morbidity after colpocleisis with disproportionately elevated risks of pulmonary and cerebrovascular events. Incorporating frailty screening into preoperative evaluation may improve perioperative counseling, stratification, and management.

Objective: This study aimed to determine the effect of a run-in period on fecal incontinence (FI) symptom severity.

Study design: This study conducted a planned secondary analysis of the run-in period to a study evaluating the effect of 12-week treatment with percutaneous tibial nerve stimulation versus sham in reducing FI severity in women. All participants completed a 4-week run-in period designed to exclude from randomization women whose symptoms reduced below the eligibility threshold after receiving education on FI and completing bowel diaries. Change in St Mark's (Vaizey) score and weekly FI episodes during the run-in period (week 1 vs week 4) was assessed.

Results: One hundred and eighty-five women completed the run-in period. The mean St Mark's (Vaizey) score was 17.8 ± 2.6 and 16.9 ± 3.5 at week 1 and week 4, respectively. There was no significant change in the St Mark's (Vaizey) score from week 1 to week 4 (mean change, -0.93 [95% CI, -1.56 to -0.31]). The average number of FI episodes per week did not change significantly between week 1 and week 4, nor did other bowel diary measures. Only 11 (6%) women became ineligible for the trial following the run-in period, all of whom had baseline St Mark's (Vaizey) scores of 18 or lower.

Conclusions: Completion of a bowel diary and receiving education on FI during the 4-week run-in period did not significantly affect symptom severity in women with FI. Only 6% of women became ineligible for participation following the run-in period, suggesting that, in a refractory population, a run-in period may have minimal effect.

Importance: Postoperative activity restrictions can affect patient satisfaction after midurethral sling (MUS) surgery.

Objective: The aim of the study was to assess the effect of a duration of postoperative activity restrictions on patient satisfaction and surgical outcomes after MUS surgery for stress urinary incontinence.

Study design: Women undergoing MUS surgery alone for stress urinary incontinence were enrolled in this provider-blinded, randomized clinical trial. Randomization to either 3- or 6-weeks' duration of activity restrictions was assigned. Restrictions included abstaining from lifting greater than 20 pounds, high-impact activity, or strenuous exercise. Primary outcome was patient satisfaction with surgery, using a 5-point Likert patient satisfaction scale. Satisfaction scores were analyzed in a "complete satisfaction" ("completely" satisfied only) and a "higher satisfaction" approach (both "completely" and "mostly" satisfied). Secondary outcomes included objective and subjective assessment of incontinence symptoms and activity assessment.

Results: Ninety-eight women underwent MUS surgery between July 2021 and September 2022, and 88 were randomized. Of them, 41 and 43 women with 3- and 6-week restrictions had patient satisfaction data, respectively. Baseline characteristics did not differ between groups. At the 6-month postoperative visit, overall patient satisfaction ("completely" and "mostly" satisfied) was very high at 92%. Complete satisfaction was significantly higher in the 3-week (73.2%) versus the 6-week restriction group (51.2%) ( P  = 0.04). "Higher satisfaction" did not reach a statically significant difference between groups ( P  = 0.11). Subjective urinary incontinence indices did not differ between groups.

Conclusions: Return to normal activities 3 weeks after MUS surgery resulted in significantly higher satisfaction scores at 6 months compared to a 6-week restriction without compromising subjective and objective surgical success.

Importance: Pharmacogenetics could address the challenge of predicting an individual's response to anticholinergic medications for urgency urinary incontinence (UUI).

Objectives: Our objectives were to evaluate whether the metabolizer status of cytochrome p450 2D6 (CYP2D6), the drug metabolizing enzyme for fesoterodine, is associated with effectiveness or moderate/severe adverse events (AEs) from fesoterodine fumarate in women with UUI.

Study design: In this pilot pharmacogenetics study, 58 women aged ≥50 with ≥3 UUI episodes on a 3-day bladder diary were treated with fesoterodine. Participants were categorized as normal metabolizers (NM), intermediate (IM), or poor metabolizers (PM) based on their genetic CYP2D6 sequence. Effectiveness was measured by Treatment Benefit Scale (responders were "improved" or "greatly improved" versus nonresponders were "not changed" or "worsened"). Moderate and severe AEs were defined by the National Cancer Institute Common Terminology Criteria for Adverse Events.

Results: Among 58 women, 34 (58.6%) were NM, 22 (37.9%) were IM, and 2 (3.4%) were PM. Given the small proportion of PM, we compared the NM and IM groups. Regarding effectiveness for UUI, there was no significant difference between metabolizer cohorts at 4 weeks (82.8% vs 94.4%, P  = 0.38 for NM vs IM, respectively). Metabolizer status was also not associated with moderate-severe AEs (14.7% vs 13.6% for NM vs IM, P  = 1.0).

Conclusions: In this pilot study with limited sample size, CYP2D6 normal and IM metabolizer status was not associated with effectiveness or moderate-severe AEs to fesoterodine fumarate. The proportion of poor metabolizers was low; thus, further investigation in this population is warranted.