Urogynecology (Hagerstown, Md.)最新文献

Importance: Despite evidence emphasizing the necessity of routine care for women with pelvic organ prolapse (POP) using pessaries, the frequency of follow-up is unclear.

Objective: The aim of this study was to compare the presence of complications in women with POP using vaginal pessaries with cleaning and gynecological examination every 3 or 6 months.

Study design: This pilot study was a randomized clinical trial of women with advanced POP using a ring pessary. The women were randomized into 2 groups ("3-month group" and a "6-month group") that returned for evaluation by a health care professional that monitored the vagina, removed the pessary, cleaned it, and reinserted it. Sociodemographic and clinical data were collected. During their follow-up, the women answered a questionnaire regarding the presence of vaginal symptoms and had a physical examination and vaginal sampling for microbiological analysis.

Results: A total of 38 women were randomized into 2 groups: the 3-month group (n = 18) and the 6-month group (n = 20). Baseline characteristics of the groups were similar except for age, which was 70.7 (±7.4) years in the 3-month group and 74.7 (±6.6) years in the 6-month group ( P  = 0.022). Regarding physical examination, after 12 months of follow-up, 4 women in each group presented erosions or ulcers in each group, but without difference ( P  = 1). The presence of bacterial vaginosis was more frequent in the group with cleaning every 6 months ( P  = 0.026).

Conclusions: The prevalence of ulcerations was similar in both groups with cleaning every 3 or 6 months, but the group with cleaning every 6 months showed a higher prevalence of bacterial vaginosis.

Importance: The effect of vaginal bacteria on wound healing is an evolving area of study. Bacterial vaginosis (BV), characterized by an overgrowth of anaerobic bacteria, is linked to increased surgical site infections after pelvic surgery. While BV-associated microbes are known to impair epithelial repair, their effects on fibroblasts, which are crucial for wound healing and prolapse recurrence after pelvic organ prolapsesurgery, are unclear. Understanding these interactions can deepen knowledge of vaginal tissue remodeling.

Objective: This study aimed to compare the effects of BV-associated bacteria and commensal lactobacilli on fibroblast cell number and function, using estradiol as a positive control.

Study design: Fibroblasts were isolated from vaginal wall biopsies of 9 participants undergoing pelvic organ prolapse surgery. Cells were co-cultured in media alone, media containing estradiol, and media with cell-free supernatants (CFS) from Lactobacillus crispatus, Lactobacillus iners , and Gardnerella vaginalis . Intact cell number was assessed using an lactate dehydrogenase assay at 0, 24, and 48 hours, and ELISA measured IL-6, type I collagen, and fibronectin levels.

Results: Fibroblasts exposed to G vaginalis CFS showed significantly reduced cell number and type I collagen production, with increased fibronectin levels. Cell-free supernatants from L crispatus and L iners did not affect fibroblast proliferation. While some donor cells showed an increase in cell number with estradiol, the change was inconsistent and not statistically significant. IL-6 levels showed a nonsignificant increase with any bacterial CFS.

Conclusions: G vaginalis significantly impairs fibroblast cell number and type I collagen production, suggesting BV-associated microbes may alter fibroblast function, emphasizing the vaginal microbiome's role in outcomes.

Importance: A vaginal pessary is a highly effective treatment for patients with pelvic organ prolapse (POP). Patient views of pessaries and how their beliefs affect whether they choose pessary treatment is unknown.

Objective: Our objective of this study was to describe the knowledge, understanding, and patient concerns regarding pessary use for POP management.

Study design: We performed a qualitative study of women presenting with POP who were counseled about pessary use at their initial urogynecology visit. Participants completed interviews, which were recorded, de-identified, and transcribed. Transcriptions were coded for major themes by 2 independent researchers.

Results: Twenty patients with an average age of 63 ± 8.5 years participated. Most identified as sexually active (60%) and the majority had a high school education or less (80%). Thematic saturation was reached with themes of "Failure", "Convenience," "Self-Image," "Sexual Relations," "Cleanliness/Hygiene," "Physical Barriers," "Knowledge Deficits," and "Discomfort." Many patients not only viewed a pessary as a less invasive alternative to surgery but also considered it a temporary treatment. Many patients disliked the idea of having a "foreign body" in place and felt it may affect their hygiene. Although most patients believed it would alleviate their POP symptoms, many had concerns about sexual intercourse, discomfort, and fear that it may fall out. Most participants who were not sexually active thought a pessary would increase their sexual confidence.

Conclusions: Patient opinions about pessaries are often negative with preconceived notions surrounding utilization. Focused counseling addressing concerns and fears may improve a patient's comfort with a pessary as their choice of treatment modality.

Importance: Population-based research is necessary to understand the relationship between the urobiome and bladder health.

Objective: Using advanced contamination controls and ecological metrics, we aimed to evaluate the concordance of microbiota in self-collected urogenital specimens from home versus a clinical research setting.

Study design: A subset of community-dwelling women was enrolled in a longitudinal cohort study, self-collected urogenital samples at 3 time points: 1-day prior, the day of and during an in-person evaluation. Samples were sequenced with V4 16S rRNA and KatharoSeq removed samples indistinguishable from background contamination. Data were matched to Greengenes2-2022.10 and rarefied to 1000 seqs/sample. Intersample concordance pairs above the KatharoSeq threshold were assessed between samples. Unweighted UniFrac distances, Mantel Pearson correlations, Kruskal-Wallis, and chi-square tests were used for comparisons.

Results: Detectable sequences were obtained in 261 samples from the 114 participants with 186 (71%) above the KatharoSeq threshold. Escherichia_710834, Lactobacillus, and Prevotella were most prevalent. Intersample concordance was determined for samples above the threshold from 38 participants with 2 home samples and 47 with home and clinic samples. Correlations between 2 home and between home and clinic were significant (r = 0.43, P = 0.001; r = 0.362, P = 0.001, respectively). There were no significant differences across time points (X2 = 2.72, P = 0.256).

Conclusions: Home-collected urine samples for urogenital microbiome ecological analysis have sufficient short-term similarity and concordance with self-collected urine samples from a research clinic setting for use in population-based research, which may facilitate inclusion of participants with limited access to clinic-based research.

Importance: Studies characterizing pain and pain management following obstetric anal sphincter injury (OASI) are limited.

Objectives: Our primary objective was to analyze time to pain resolution following OASI. Secondary objectives included analyzing pain severity, location, triggers, and patterns of pain medication use.

Study design: This was a prospective cohort study of patients with OASIs seen in a postpartum care clinic at a tertiary referral center between 2017 and 2022. We analyzed data on pain resolution, visual analog scale pain scores, pain triggers, pain location, and pain medications.

Results: A total of 362 patients were included in this study. In the Kaplan-Meier estimator, 58.5% of patients showed resolution of pain by 3 months following their initial postpartum care clinic visit, and 73.3% showed resolution of pain by 6 months. The median months to pain resolution was 2.2 (95% confidence interval: 1.6-3.0) for patients with third-degree lacerations and 2.3 (95% confidence interval: 1.6-6.8) for patients with fourth-degree lacerations. Visual analog scale scores showed the most improvement in the first 2 months. Common pain triggers included sitting and bowel movements in the first few months, as well as intercourse during later recovery. Pain location varied over time; bilateral pain in the levator ani muscles and obturator internus were most prevalent at each time point. Pain appeared to be predominantly managed by acetaminophen and ibuprofen.

Conclusions: Half of patients who experience OASI will have pain resolution by 2-3 months postpartum. Most patients will have resolution of their pain by 6 months postpartum.

Purpose: Genitourinary syndrome of menopause (GSM) describes the symptoms and physical changes that result from declining estrogen and androgen concentrations in the genitourinary tract during the menopausal transition. This guideline provides information to clinicians regarding identification, diagnosis, counseling, and treatment for patients with GSM to optimize symptom control and quality of life while minimizing adverse events.

Methods: The systematic review used in the creation of this guideline is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality and funded by the Patient Centered Outcomes Research Institute. The EPC synthesized effectiveness and/or harms outcomes from 68 publications. An additional 66 articles evaluating 46 nonhormonal interventions were described in an evidence map.

Results: Clinicians diagnose GSM based on symptoms, with or without related physical findings, and after ruling out other etiologies or co-occurring pathologies. There is a large body of evidence examining the use of hormonal and nonhormonal treatment options to manage the symptoms of GSM; however, the local low-dose vaginal estrogen has the most robust evidence base.

Conclusion: The strategies defined in this document were derived from evidence-based and consensus-based processes. Given that there is insufficient information to recommend one hormonal therapy over another, this guideline is not meant to support a stepwise progression through different hormonal approaches. The clinician should make treatment decisions in the context of shared decision-making, considering patient goals and preferences, using the evidence of efficacy and adverse events of each possible intervention as a guide.

Abstract: Vaginal dehiscence with evisceration is a surgical emergency where all cases are surgically managed. However, identifying the optimal approach in a patient with a history of prior chemoradiation and multiple native-tissue pelvic reconstructive surgical procedures may be challenging. We present here a multidisciplinary case of a 74-year-old patient where flap and graft material placement were utilized as part of her management. She presented as a transfer from an outside hospital for vaginal evisceration of small bowel contents. She was hemodynamically stable, and physical examination revealed 14 cm of edematous, nonreducible, hyperemic bowel protruding beyond her introitus. General surgery and plastic surgery services were consulted for multidisciplinary management. She underwent urgent exploratory laparotomy with an oblique rectus abdominus flap (performed by plastic surgery), small bowel resection and right hemicolectomy (by general surgery), and closure of the distal posterior vaginal wall dehiscence site with placement of a saline-reconstituted decellularized fish skin xenograft within the vaginal defect (by urogynecology). Her postoperative course was uncomplicated, and she was discharged home on postoperative day (POD) 11. She was recovered and asymptomatic at her 4-week postoperative follow-up visit, where she declined scheduling further follow-up appointments. In conclusion, vaginal incision dehiscence with evisceration is best approached early on in a multidisciplinary manner. Select patients, such as those with an extensive pelvic surgical history, multiple vulnerable vaginal incision lines, and history of recurrent prolapse may benefit from consideration of flap placement and application of graft material for wound healing and surgical site integrity at the time of repair.