Urogynecology (Hagerstown, Md.)最新文献

Importance: Urinary retention is a common adverse effect after intravesical injection of onabotulinum toxin A (BTX) for overactive bladder (OAB). Reported retention rates range from 1.6% to more than 40%. This variation may be due to varying definitions of retention in the literature.

Objective: We aimed to assess the variation in definitions of urinary retention across studies of BTX for the treatment of OAB.

Study design: We performed a systematic review of studies of BTX for OAB by querying MEDLINE and EMBASE according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included original research studies on adults with overactive bladder treated with BTX and urinary retention reported as an outcome from January 2000 to December 2020.

Results: From 954 results, we identified 53 articles that met inclusion criteria. There were 6 definitions for urinary retention. The majority of studies (60.4%) reported initiating clean intermittent catheterization (CIC) as the metric for retention. Five (9.5%) studies provided no definition despite reporting retention as an adverse event. Twenty studies (37.7%) specified a postvoid residual volume (PVR) threshold for initiating CIC in asymptomatic patients; 19 (35.8%) specified a PVR threshold for CIC in symptomatic patients. The PVR thresholds ranged from 100 to 400 mL. Twenty-three studies (43.4%) did not address asymptomatic elevation of PVR, and 22 (41.5%) did not address how symptomatic patients were managed.

Conclusions: Urinary retention after BTX injection is inconsistently defined in the literature. Lack of standardization in reporting retention after intravesical BTX prevents accurate assessment of the risk of urinary retention and comparison of outcomes between studies.

Importance: Routine screening for urinary incontinence (UI) by primary care providers (PCPs) is recommended.

Objectives: We aimed to describe the rate of incident UI diagnosed at annual PCP visits, the prevalence of UI in a large primary care population, and estimate the rate of screening for UI during primary care preventive and annual wellness visits. Secondary aims were to describe PCP knowledge and behavior as they relate to UI screening and diagnosis.

Study design: The electronic health record was used to abstract the number of adult female patients seen by PCPs within a regional health system with a diagnosis of UI before our study period and with a new diagnosis over a 2-year period. Additional new diagnoses and screening practices were found on chart review of an additional 824 representative charts. Primary care providers within the health system were surveyed about their screening practices and knowledge about UI.

Results: There were 192,053 women primary care patients seen over 2 years. A total of 5.7% had a UI diagnosis preceding the study period and 3.4% had a UI diagnosis during the study period. A total of 42% of PCPs reported that they screen for UI at least half the time and none were completely satisfied with their ability to screen for UI. Sixteen percent of annual wellness visits had any documentation of screening for UI.

Conclusion: In a large primary care population, screening for and detection of UI in women was low.

Importance: Pelvic floor disorders are common and burdensome. Data on the effect of induction of labor on pelvic floor disorders are sparse and results are mixed.

Objective: Our aim was to evaluate whether elective labor induction in nulliparous women increases the risks of symptomatic urinary incontinence (UI), anal incontinence (AI), or pelvic organ prolapse (POP) 4 years after delivery.

Study design: In this single-site follow-up study of "A Randomized Trial of Induction Versus Expectant Management" (ARRIVE) that randomized low-risk nulliparous women with a singleton fetus to elective induction of labor versus expectant management, we compared pelvic floor symptoms between groups at a median of 4 years (interquartile range, 3.5-5.3) after first delivery using validated questionnaires.

Results: Seventy hundred sixty-six of 1,042 (74%) original participants responded, and 647 participants (62%) were included in the analysis after exclusions. The overall prevalence rates of symptomatic moderate to severe UI, AI, and POP were 21%, 14%, and 8%, respectively. There were no significant differences in any of the outcomes between women randomized to induction of labor and those to expectant management, either in unadjusted or adjusted analyses. There were also no differences in secondary outcomes, including subtypes of UI or flatal versus stool incontinence.

Conclusions: In this single-site study, we found no significant differences in any UI, AI, and POP symptoms between nulliparous women randomized to elective induction of labor and to expectant management; however, for the least frequent outcome (POP), meaningful differences cannot be ruled out.

Importance: Dementia and urinary incontinence (UI) have been associated in cross-sectional studies. The temporal relationship between these 2 conditions is not well understood.

Objective: The aim of the study was to investigate the risk of incident dementia in female adults with and without UI using the Medicare 5% Limited Data Set.

Study design: This retrospective cohort study matched females with UI to continent controls by index year, age, and dual Medicare/Medicaid eligibility. A 2-year look back period was used to exclude prevalent dementia and neurologic disorders. The 5-year cumulative incidence of dementia was estimated for women with UI and controls. Cox proportional hazard models assessed the association of variables with dementia, adjusting for age, dual Medicare/Medicaid eligibility, race, and comorbidities.

Results: A total of 8,651 female beneficiaries with UI (n = 8,651) were more likely than matched controls (n = 8,651) to report White race and several medical comorbidities. The 5-year cumulative incidence of dementia diagnosis was lower in the UI versus controls (8.8% vs 10.6%, P < 0.001). In multivariable analysis with adjustment for covariates, UI diagnosis was associated with a lower hazard of dementia diagnosis (hazard ratio 0.82 [0.74, 0.91], P < 0.001).

Conclusions: Among female Medicare beneficiaries without baseline neurologic disorders, having any UI diagnosis was associated with a lower risk of dementia diagnosis. Further studies assessing UI symptoms and dementia diagnosis with rigorous and valid assessment tools are needed to confirm this finding.

Importance: There is no consensus on how to define obstetric anal sphincter defects detected by 3-dimensional endoanal ultrasonography (3D-EAUS), and the reported rates vary significantly in the postpartum period.

Objective: The objective of this study was to establish a diagnostic strategy with a high and clinically relevant interrater reliability both early and late postpartum.

Study design: The study was prospective and observational, and 3D-EAUS was performed 10-14 days and 9-12 months postpartum in an unselected cohort of primiparous women with vacuum-assisted deliveries. Two experienced examiners evaluated the ultrasonographic results, which were divided into the categories intact, inconclusive, small, moderate, and large defects based on Starck scores. Three different diagnostic strategies were validated, and the prevalence- and bias-adjusted kappa (PABAK) values calculated.

Results: Of 334 eligible women, 184 (55.1%) completed both examinations. Disagreements involving small defects were predominant and observed in 34 and 39 cases, respectively, at the 2 time points. The highest overall agreement rates (91.3% and 92.4%, respectively) and PABAK values (0.83 and 0.85, respectively) were reached when the disagreements were minimized by dichotomizing the results into Starck scores >4 (designated a significant defect) versus Starck scores 0-4 (all others).

Conclusions: The interrater reliability of detecting small anal sphincter defects by 3D-EAUS was low at both time points for the 2 experienced raters. In contrast, the interrater reliability of detecting a significant defect was classified as almost perfect agreement at both time points.

Importance: Up to 50% of patients report not readily seeking treatment for pelvic floor disorders (PFDs). The increase in phone applications (apps) for health care information is an opportunity to increase access to care.

Objective: The aim of the study was to systematically evaluate content and function of apps for patients with PFDs.

Study design: Apps were screened using PFD-related search terms. Included apps were on the Apple store, in English, and targeted patients with PFDs. The primary outcome was app quality based on the APPLICATIONS scoring system (scored 0-16). Secondary outcomes included professional medical involvement, iTunes rating details, the presence of a voiding/bowel diary, tracking of diet, pain/symptoms, exercise, and medication, graphing or social functions, reminders, disease information, and decision support. Data was reported with descriptive statistics (medians (ranges) and n (percentages).

Results: Eight hundred forty apps were identified and 83 were analyzed. The top 3 PFD categories represented were defecatory dysfunction (29), overactive bladder (28), and stress incontinence (27). The median APPLICATIONS score was 7 (3-12). Most apps (78%) were developed without professional medical involvement. Most apps were free, while the remainder ranged from $1.99 to $4.99. No app had all features. Twenty-five apps (30%) included a voiding diary, 33 (40%) had a bowel diary, 27 (33%) included exercise tracking, and 44 (53%) had reminder systems.

Conclusions: Most apps had reasonable, but not high, functionality. Current apps provide varying degrees of overall utility, with limited disease information and decision support. Further collaboration with medical providers in app development would support better integration of clinician and patient needs.

Importance: The pregnancy safety and teratogenicity of overactive bladder (OAB) anticholinergic medications in humans are unknown.

Objective: The aim of this study was to determine if the use of OAB anticholinergics during pregnancy was associated with adverse pregnancy outcomes or congenital malformation.

Study design: Using routinely collected health care data from Ontario, Canada, we conducted a retrospective cohort study and identified women aged 18-45 years who gave birth between 2004 and 2022 and were eligible for provincial drug benefits. We used gestational age and birth dates to approximate conception dates. The primary exposure was filling a prescription for an OAB anticholinergic during pregnancy (compared with nonusers). The coprimary outcomes were pregnancy complication (which included preterm birth or low birth weight) and congenital malformation. Poisson regression models with generalized estimating equations and inverse probability of treatment weighting were used to estimate risk ratios (RRs).

Results: We identified 138,271 births, of which 479 (0.3%) had exposure to an OAB anticholinergic, for a median of 60 (interquartile range, 30-120) days. The most common OAB anticholinergic was oxybutynin (84%). In the weighted cohort, the risk of a pregnancy complication was significantly elevated (RR, 1.65; 95% confidence interval [CI], 1.40-1.95; P < 0.01; absolute risk difference + 9.9% [95% CI, +5.9, +13.9]), with a dose-response relationship close to statistical significance (P = 0.07). The risk of congenital malformations with OAB anticholinergic use was not significant (RR, 1.24; 95% CI, 0.85-1.80; P = 0.26).

Conclusions: Pregnant women who take OAB anticholinergic medications have a higher risk of pregnancy complications, but not congenital malformations, compared with non-OAB anticholinergic users. This information can be used when counseling women of child-bearing age about these medications.

Importance: There are no definitive guidelines for use of postoperative antibiotics after sacral neuromodulation (SNM) leading to practice pattern variation among health care professionals.

Objectives: The objectives of this study were to determine if additional antibiotics beyond preoperative intravenous antibiotics and surgical preparation decrease postoperative infections and to determine if additional antibiotics are associated with other postoperative complications.

Study design: This was a single-center, retrospective cohort study of all SNM procedures from 2014 to 2023 performed by 12 surgeons. Cohorts were stratified between patients who received preoperative antibiotics only (OnlyPreAbx) and patients who received both preoperative antibiotics and postoperative antibiotics (PrePostAbx) after either insertion of tined lead and/or after insertion of a neurostimulator.

Results: There were 212 patients included in this study: 70 (33.0%) in the OnlyPreAbx group and 142 (67.0%) in the PrePostAbx group. Of patients receiving postoperative antibiotics, 76 (53.5%) received cephalexin, 49 (34.5%) received sulfamethoxazole-trimethoprim, and 17 (12.0%) received alternative antibiotics. Six patients overall (2.8%) experienced infections after SNM. There was no difference in the rates of infection between groups (4 [1.9%] PrePostAbx vs 2 [0.9%] OnlyPreAbx, P = 0.99). Of the 4 patients with postoperative infections in the PrePostAbx group, 2 had cellulitis requiring antibiotics and 2 required full explantation. Of the 2 patients with postoperative infections in the OnlyPreAbx group, both patients required explantation. In a subanalysis comparing infected and noninfected patients, infected patients (n = 6) had higher rates of hypertension (n = 6, 100%; P = 0.02) and diabetes mellitus (n = 3, 50%; P = 0.05).

Conclusions: Additional postoperative antibiotics did not decrease infection rates in patients undergoing SNM. Similar comparative analyses should be performed with larger sample sizes.

Importance: Adherence to overactive bladder (OAB) therapy is low among the general population. Prior studies suggest that OAB is more prevalent among Hispanic women compared with other ethnicities.

Objectives: The aims of this study were to analyze nonadherence to OAB therapy among Hispanic compared with non-Hispanic women and identify potential barriers to treatment to reduce disparities in care.

Study design: All patients who received treatment for OAB between 2018 and 2022 were included in this retrospective study. Race and ethnicity were self-reported. Nonadherence was defined as failure to initiate therapy within 1 year. Non-Hispanic women were selected at random to form a control group. The study was powered to detect a 50% difference in treatment nonadherence. Comparisons were made using the Fisher exact test or χ2 test as appropriate for nominal variables, and the Mann-Whitney test for continuous variables.

Results: The analysis included 126 Hispanic and 126 non-Hispanic women. Both cohorts were similar in demographics. Nonadherence to OAB therapy was more frequent among Hispanic women (44.0 vs 20.9%, P < 0.0001). After adjusting for age, body mass index, primary language, parity, insurance type, and treatment offered, Hispanic women were at a 2.54-fold increased risk of nonadherence (P = 0.007). A subanalysis of only Hispanic women found that younger age (P = 0.033), higher parity (P = 0.035) underinsured status (P = 0.027), and fewer office visits (P = 0.0002) were associated with nonadherence.

Conclusions: Nonadherence to OAB therapy was greater among Hispanic women despite no difference in treatment patterns. Younger age, greater parity, lack of insurance, and fewer office visits may be barriers for Hispanic women.