Urogynecology (Hagerstown, Md.)最新文献

Importance: Sacral neuromodulation (SNM) is a procedure with the advantage of reprogramming for discomfort or inadequate symptom control.

Objectives: The aims of this study were to investigate the rates of office-based SNM programming in a large multisite cohort and to examine differences based on implantation indication.

Study design: The TriNetX database was utilized for retrospective cohort comparison using International Classification of Diseases, Tenth Revision, and Current Procedural Terminology (CPT) codes. Cohort selection included female adults with a diagnosis of urinary retention, urgency urinary incontinence, and/or fecal incontinence (FI) at time of implantation. The primary outcome was the rate of SNM reprogramming CPT per individual from 6 weeks to 5 years postimplantation. Secondary outcomes included demographic comparisons, incidence, and survival curves for patients with SNM reprogramming identified with CPT codes. Further comparisons were completed between implantation diagnoses of grouped urinary (urgency and retention) versus fecal indications.

Results: A total of 9,501 patients meet inclusion criteria with a mean of age 62.1 ± 14.9 years (range, 18-90). Office-based SNM reprogramming was identified in 31.5%. The probability of never having reprogramming at 5 years was 52.5%. The mean number of reprogramming sessions was 2.5 ± 2.1. Approximately half (48%) of the patients with FI also had a diagnosis of urgency urinary incontinence, and approximately 25% had urinary retention. The probability of never having reprogramming was 55% and higher in patients with a fecal incontinence indication than those with only urinary indications at 50%, P < 0.001.

Conclusions: Office-based SNM reprogramming occurs in 31.5% of patients with implants, and rates are likely underreported. Patients with any FI diagnosis have a higher risk of requiring reprogramming.

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: Wound complications after obstetric anal sphincter injury (OASI) can amplify morbidity and affect quality of life.

Objective: The objective of this study was to evaluate for characteristics associated with wound complications after OASI.

Study design: This was a retrospective cohort study of patients with an OASI who were evaluated in a postpartum pelvic floor healing clinic between November 1, 2020, and May 16, 2023. Our primary outcome was to identify factors associated with wound complications (wound infection or breakdown, antibiotic treatment, or surgical intervention). We hypothesized that operative vaginal delivery would be associated with wound complications and that peripartum antibiotics would be protective. Statistical analyses included t tests, chi-square test, Fisher exact test, and multivariable logistic regression.

Results: Of 332 patients with an OASI, 74 (22.3%) experienced a wound complication. There were 31 (9.3%) wound infections and 62 (18.7%) wound breakdowns; 50 (15.1%) patients received additional antibiotics, and 20 (6.0%) underwent additional surgical intervention. On univariate analysis, those with wound complications were older (31.9 vs 30.6 years, P = 0.01) and more likely to have had an episiotomy (23.0% vs 12.5%, P = 0.03). On multivariable logistic regression, older maternal age was associated with wound complication (odds ratio, 1.1, 95% CI, 1.01-1.13, P = 0.03), and peripartum antibiotics were associated with decreased odds of wound complication (odds ratio, 0.57, 95% CI, 0.33-0.97, P = 0.04). Patients with wound complications were more likely to undergo in-office procedures (P < 0.001) and report postpartum pain (P < 0.001), urinary incontinence (P = 0.02), fecal urgency (P = 0.02), and other symptoms (P = 0.04).

Conclusions: Older maternal age was associated with wound complications after OASI, while peripartum antibiotics were protective. Patients with wound complications were more likely to report symptoms of pelvic floor disorders.

Importance: Documentation of symptoms in the medical record before prescribing antibiotics for urinary tract infection (UTI) could promote antibiotic stewardship.

Objective: The aim of this study was to describe the number and type of symptoms documented across specialties during encounters where an antibiotic was prescribed to older women with recurrent UTI.

Study design: We conducted a retrospective cohort study of women aged 65 years or older with a diagnosis of recurrent UTI. Patients were included if they had been prescribed an antibiotic for UTI at least twice in 6 months or 3 times in 1 year. Data on number and type of symptoms and urine culture results were extracted and compared across encounters and specialties.

Results: A total of 454 encounters from 175 patients were analyzed. The majority of encounters were in primary care (61.8%), followed by urology/urogynecology (24%), obstetrics and gynecology (9.2%), and emergency department/urgent care (4.8%). The median number of UTI-specific symptoms recorded across specialties was 1 (interquartile range, 0-2) and declined in subsequent encounters. The number of UTI-specific symptoms documented was none in 25%, 1 in 26%, and 2 or more in 49% of encounters. Of the 337 encounters with positive cultures, 19% had no documented UTI-specific symptoms and 9% had no documented symptoms of any kind.

Conclusions: Documentation of urinary symptoms during encounters where antibiotics are prescribed is sparse across specialties for older patients with recurrent UTI. The gap in care identifies an opportunity for improving antibiotic stewardship through improved documentation of urinary symptoms.

Importance: Enterococcus faecalis urinary tract infection (UTI) is common in postmenopausal females and these bacteria create biofilms that may reduce treatment efficacy. The role of local vaginal estrogen therapy in susceptibility to E. faecalis infection is unclear.

Objective: The aim of the study was to evaluate differences in the treatment of relapsing E. faecalis UTIs in postmenopausal women using vaginal estrogen compared to premenopausal women.

Study design: This was a secondary analysis of a retrospective cohort study of 71 female ambulatory patients seen within the gynecology or urogynecology practices between 2011 and 2020. Patients included had symptomatic E. faecalis UTI and a diagnosis of recurrent UTI. Patients with asymptomatic bacteriuria and concurrent pregnancy were excluded. Data was retrieved by chart review, stored, and analyzed utilizing descriptive statistics. A 2-sided Fisher exact test was performed to compare outcomes between postmenopausal and premenopausal patients and the prescription of additional rounds of antibiotics for relapse.

Results: Within this cohort, 57.8% were postmenopausal and 42.2% were premenopausal. There was no statistically significant difference in the need for additional antibiotics between postmenopausal and premenopausal patients (10.8% vs 14.3%, P = 0.72), postmenopausal patients not using vaginal estrogen and premenopausal patients (0% vs 14.3%, P = 0.28), postmenopausal patients using vaginal estrogen and premenopausal patients (20% vs 14.3%, P = 0.70), and among postmenopausal vaginal estrogen users and nonusers (20% vs 0%, P = 0.11).

Conclusions: A small percentage of premenopausal and postmenopausal patients with recurrent UTI required additional antibiotics for E. faecalis relapse. However, there are no statistically significant differences between our estrogen-deficient or estrogenized postmenopausal patients, and premenopausal patients.

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: Pelvic organ prolapse recurrence following native tissue repair occurs with composite failure rates of 9-19% within 12 months, predominantly involving apical/anterior compartments. Objective The objective of this study was to develop a novel vaginal orthosis (NVO) device prototype through an iterative design process based on investigator and user feedback.

Study design: The NVO was designed based on pelvic floor biomechanical principles to mitigate unopposed intra-abdominal pressure of the anterior vagina by absorbing and redirecting intra-abdominal forces to the levator ani and tailored to accommodate postoperative vaginal caliber and axis. Prototypes were fabricated by 3D-printing negative molds, cast, and cured with medical-grade biocompatible silicone. Ten healthy volunteers were recruited to provide qualitative feedback for iterative design refinement (phase 0).

Results: Through an iterative engineering design process, initial concepts were refined to align with the natural, resting H-shape of the vagina. Key features included a distal self-retaining feature, posterior curvature, proximal taper, and apical/anterior contact areas for support. A more rigid material to withstand intra-abdominal forces without folding was required; therefore, Shore A60 (medium soft) instead of A40 (soft) silicone was used. Based on participant feedback, the NVO retaining feature width range was reduced (47.5-63 mm to 45-50 mm) to decrease pressure on lateral vaginal walls and levator ani distally maintaining self-retaining function. Updates to the fitting and education process also provided increased descriptive instructions for insertion and removal.

Conclusions: A novel vaginal orthosis was designed specifically tailored to facilitate wound healing using an orthomedical model, improving the design through iterative feedback.

Importance: Exposure to the surgical management of obstetric anal sphincter injuries (OASIS) is limited during obstetrics training.

Objectives: The objective of this study was to quantify residents' exposure to OASI repair during 4-year obstetrics and gynecology (OBGYN) residency and examine temporal trends over a 16-year period.

Study design: This was a retrospective cohort study of residents' exposure to OASIS at a community academic hospital from 2007 to 2022. Individuals with documented OASIS (third- or fourth-degree laceration) by International Classification of Diseases, Ninth and Tenth Revisions, codes during vaginal delivery (VD), spontaneous vaginal delivery (SVD), or operative vaginal delivery (OVD), were included. Delivery rates and OBGYN resident positions were examined. Temporal trends in OASIS were analyzed in 4-year epoch to determine average resident exposure during OBGYN residency.

Results: During the 16-year study period, there were 103,234 deliveries (62% VD, 4% OVD, 34% cesarean delivery). Among VDs, there were 2,344 (3.4%) OASIS with 88.5% classified as third-degree and 11.5% as fourth degree. The OASI rate decreased from 4.2% (2007-2010) to 2.9% (2019-2022), whereas OBGYN residents increased by 49% (67 to 99; P < 0.001). Average resident exposure to OASIS decreased from 11 (2007-2010) to 5 (2019-2022; P = 0.55). Subclassification revealed that residents were exposed to 5 third-degree repairs and less than 1 fourth-degree repair, on average, during 2019-2022.

Conclusions: During 4 years of training, average resident exposure was to 7 OASIS, 6 third degree, and 1 fourth degree. Limited exposure to OASIS during residency may be detrimental, as surgical treatment is a complicated yet essential obstetric procedure that carries significant risk of patient morbidity and potential long-term sequelae. Therefore, reliance on supplementation with simulation may improve surgeon competence in OASI management.

Importance: Little is known about reasons behind missed appointments in subspecialty settings, particularly in urogynecology practices.

Objective: The aim of the study was to understand patient-perceived barriers to appointment attendance at an academic urban multisite urogynecology practice.

Study design: This was a prospective, qualitative study of patients who missed their appointments at a urogynecology practice from April to September 2023. Patients were invited to participate in semistructured interviews. Nonrandom, purposive sampling ensured a reflective sample. The interview guide addressed attendance barriers, reasons for missed appointments, and clinic accessibility. Inductive coding was applied to interview text fragments and a codebook was developed.

Results: Of the 230 eligible patients, 110 (48%) were contacted and 26/110 (24%) consented and completed interviews. Patients identified the following 3 major barriers to appointment attendance: (1) community and environmental barriers, (2) patient-related factors, and (3) clinic-related factors. Community and environmental barriers (n = 20 [77%]) included unforeseen circumstances and transportation issues, with 52% citing transportation difficulties. Patient-related factors (n = 16 [62%]) included family obligations, personal illness, mental health concerns, confusion with appointments, or competing job responsibilities. Clinic-related factors (n = 9 [35%]) included scheduling and timing issues. Participants proposed changes to facilitate attendance, which included clinics offering transportation assistance, providing interpersonal support through support groups, and improving the internet-based portal to make patient communication easier.

Conclusions: Identifying the reasons why patients miss appointments is pivotal to providing patient-centered care. Our findings provide a deeper understanding of issues underlying missed urogynecology appointments. Future research to develop an algorithm to identify barriers to attending appointments and provide interventions such as transportation support could result in more accessible, equitable care.

Importance: Functional near-infrared spectroscopy (fNIRS) is a noninvasive technique used to quantify prefrontal cortex (PFC) neuroexcitation. The PFC is involved in the decision to void, and dysfunction in the region has been associated with overactive bladder (OAB). This study demonstrates neuroexcitation differences in the brain region associated with the decision to void (prefrontal cortex) using noninvasive fNIRS.

Objective: The objective of this study was to compare PFC neuroexcitation during natural filling in female participants with and without OAB.

Study design: Female participants with OAB were cross-sectionally compared with controls without urinary urgency. The fNIRS signals were continuously recorded during an oral hydration protocol. Simultaneously, recordings of real-time bladder sensation of fullness were completed. A period of "high sensation" was defined as the time from first desire to 100% sensation. Signal analysis included removal of motion artifact, low pass filtering, and interpolated to standardize reporting bladder filling time.

Results: A total of 25 female participants were enrolled and had complete analyzable data, including 14 with OAB and 11 controls without OAB. Change in O2Hb during the high sensation period was significantly lower in all PFC regions in the OAB group compared with controls (P < 0.001). The majority of OAB participants had a constant or decreasing neuroexcitation pattern, which differenced in comparison to normal controls who displayed an increasing pattern.

Conclusions: This study demonstrates that fNIRS PFC excitation during a period of high sensation is consistently lower in women with OAB as compared with controls. These data support the hypothesis that the PFC plays an inhibitory role in voiding function and that there may be a lack of inhibitory control in women with OAB.