Urogynecology (Hagerstown, Md.)最新文献

Importance: Patients with pelvic organ prolapse (POP) are 6 times more likely to experience overactive bladder and/or urgency urinary incontinence (UUI). Given the high prevalence of concomitant urinary symptoms, evaluating the effect of surgical prolapse repair on urinary urgency is critical for surgical counseling.

Objective: The objective of this study was to evaluate changes in UUI symptoms in women after performance of apical and/or anterior wall repair for the management of POP.

Study design: This secondary analysis included all women participating in the SUPeR, OPTIMAL, and OPUS trials. The primary outcome of urge incontinence symptoms was evaluated with the Pelvic Floor Distress Inventory (PFDI). Pelvic Organ Prolapse Quantification (POP-Q) measurements were evaluated at baseline and 12 months postoperatively. The secondary outcome of overall urinary function was assessed using the Urogenital Distress Inventory-6 (UDI-6) subscore of the Pelvic Floor Distress Innventory (PFDI) and Urinary Impact Questionnaire-7 (UIQ-7) subscore of the Pelvic Floor Impact Questionnaire (PFIQ).

Results: Seven hundred thirty-five women were included for analysis, of which 82.3% of the cohort underwent a native tissue repair, 13.6% a mesh-augmented hysteropexy, 69.1% an anterior repair (AR), and 68.8% a midurethral sling (MUS). Postoperative improvement in UUI and bladder emptying was demonstrated across the cohort, with greater improvements in UDI-6 and UIQ-7 subscores among women with pre-existing UUI (P<0.001). Greatest improvement was seen for the combination of either uterosacral ligament suspension or sacrospinous ligament fixation with AR and concomitant MUS placement. Undergoing MUS placement (with or without AR) resulted in greater improvement in UDI-6 and UIQ-7 subscores than undergoing an AR alone (P<0.001).

Conclusions: POP surgery improves UUI with the greatest improvements in women undergoing native tissue repair with AR and concomitant MUS placement.

Importance: Although useful to drive prevention efforts, awareness of family history (FH) of pelvic organ prolapse (POP) or urinary incontinence (UI) may be influenced by factors other than the actual presence or absence of POP/UI in a family member. This analysis identifies demographic and clinical factors associated with positive self-reported family history (FHPOP/UI+) during the first pregnancy and through 1-year postpartum (1-yr PP).

Objectives: Based on self-reported FH during the third trimester, the objectives were to evaluate differences between nulliparous women with and without FHPOP/UI+, identify factors associated with FHPOP/UI+, and explore whether FHPOP/UI+ is associated with anatomic POP or moderate/severe UI at 1-yr PP.

Study design: In this secondary analysis of a prospective cohort study, multiple logistic regression models tested associations between FHPOP/UI+ and data collected during the third trimester (n=962), following vaginal delivery at 8 weeks postpartum (8-wk PP, n=659), and 1-yr PP (n=543).

Results: Adjusted odds of FHPOP/UI+ increased with higher education level and decreased if the participant's mother delivered via cesarean at all 3 time points, increased with moderate/severe UI symptoms during pregnancy and at 1-yr PP (not assessed at 8-wk PP), and increased with enlarged genital hiatus and prepregnancy body mass index during pregnancy and at 8-wk PP, but not 1-yr PP. In exploratory analysis, FHPOP/UI+ was associated with moderate/severe UI (P<0.001) but not anatomic POP (P=0.12) at 1-yr PP.

Conclusions: FHPOP/UI is multifactorial in nature, and future studies could investigate the relative contribution of genetics, cultural, and environmental factors to better characterize this as a risk factor for POP/UI.

Importance: While vaginal estrogen (VE) is a common treatment option for women with genitourinary syndrome of menopause, VE can be cost-prohibitive, causing medication nonadherence.

Objective: The objective of this study was to compare trends in VE pricing through retail pharmacies, Medicare Part D, the Mark Cuban Cost Plus Drug Company (CPD), and with the application of GoodRx coupons.

Study design: For this economic study, data from CPD and GoodRx were reviewed to obtain listed prices for various VE types and formulations, including conjugated estrogen cream (Premarin), estradiol 0.01% cream (Estrace), and estradiol 10 mcg tablets (Vagifem). GoodRx prices were obtained from 4 retail pharmacies within the most populous zip code from each U.S. state. Prices were adjusted to account for dosage and prescribed quantity to estimate an average cost per dosage unit ($/adu).

Results: Within zip codes, the mean $/adu of Premarin, Estrace, and Vagifem were $9.03, $3.45, and $9.86, with a standard deviation of 0.45 $/adu, 0.48 $/adu, and 0.56 $/adu. Comparing GoodRx to retail pricing, cost reductions were seen for all 3 medications, with an average saving of $7.45, $1.34, and $6.00 per dosing unit. Reduced prices for all medications were available through CPD versus GoodRx, with cost reduction of $0.35, $0.89, and $2.31 for each unit of Premarin, Estrace, and Vagifem.

Conclusions: While significant price variations for prescriptions were seen on a regional level within zip codes and between pharmacies, notable price savings were consistently seen with CPD and GoodRx, offering a solution to the financial strain that these prescriptions may impose.

Importance: Patient preferences regarding medical decision making are central to prolapse treatment discussions.

Objective: The objective of this study was to compare control preferences scale (CPS) and autonomy preference index (API) scores reported by underrepresented patients (UPs) to non-UPs after new patient consultations with urogynecology providers.

Study design: This was a planned secondary analysis of patients counseled regarding treatment of pelvic organ prolapse at 8 academic medical centers from July 2021 to December 2022. Participants completed the CPS (5-point scale, 1="I prefer to make the final decision" to 5="I prefer my doctor to make the decision"; scores 1-2 were considered preferring an "active" role). Participants also completed the API, which has 2 subscales (information seeking, 8 items; decision making, 6 items; scored 0-100) and 2 clinical vignettes (scored 0-20). Higher scores indicate stronger preferences for participation. P<0.05 is considered significant.

Results: Two hundred seven participants were included; 103 (49.8%) identified as UP and 122 (59%) pursued surgery. The mean CPS scores were not different between UPs versus non-UPs (2.0 ± 1.0 vs 2.1 ± 0.8, P=0.35), and most participants preferred an active role in decision making (145/194, 74.7%). The mean API scores were different between groups (UP, 149.2 ± 27.7 vs non-UP, 159.4 ± 22.5, P=0.008). When adjusting for education, income, insurance, and prior prolapse surgery, self-identification with non-Hispanic Black race was associated with lower API scores compared with non-UPs (adjusted difference of 12.4, SE±5.1, P=0.023).

Conclusions: Autonomy preferences may vary, and most participants prefer an active role in prolapse treatment decision making.

Importance: Urinary incontinence (UI) can negatively affect sexual function in women. Although many women with UI seek complementary strategies such as pelvic floor yoga techniques to improve sexual functioning, evidence of their efficacy is limited.

Objective: The objective of this study was to evaluate the effects of a pelvic floor yoga program versus a general physical conditioning program on multidimensional sexual function in women with UI.

Study design: Ambulatory women aged 45 and older with daily UI were enrolled in a multicenter randomized trial in 2019-2022. Participants were randomized to a 12-week program of group instruction and self-practice of Hatha yoga techniques tailored to pelvic floor function (pelvic yoga) or a time-equivalent program of general skeletal muscle exercises (physical conditioning). Intervention effects on sexual function, a prespecified secondary trial outcome, were examined using linear mixed models of change in Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) scores over 6 and 12 weeks of intervention instruction.

Results: Among 240 participants (121 pelvic yoga, 119 physical conditioning; ages 45-90 years), UI frequency averaged 3.4±2.2 episodes/day, and 129 (54.7%) participants were sexually active at baseline. Compared with physical conditioning, pelvic yoga did not result in significantly greater improvements in any PISQ-IR domain over 6 and 12 weeks. Within-group analyses showed that sexually active participants in the yoga group had a 3.7 (95% CI: 1.4-6.1) point improvement in condition-specific impact on sexual activity.

Conclusions: Among midlife and older women with daily UI, a 12-week pelvic yoga intervention did not result in meaningfully greater improvements in sexual function compared with nonspecific physical conditioning exercise.

Importance: Little is known about the effect of weight change following surgery on midurethral sling outcomes.

Objective: The objective of this study was to determine the effect of body weight change after midurethral sling on the 24-month subjective outcome. We hypothesized that body weight gain would increase the chance of subjective failure.

Study design: This was a secondary analysis of the Trial of Mid-Urethral Slings. The primary outcome was subjective failure at 24 months postoperatively. Secondary outcomes include objective failure and combined (objective/subjective) failure at 24 months. Weight change was categorized as no change (if ±5 lb of baseline), gain (>5 lb above), and loss (>5 lb below) at baseline. In addition, we categorized for percentage weight change of baseline body weight (±5%, 5-10%, and >10%). The association between weight change and outcomes was evaluated using logistic regression.

Results: Four hundred thirty-two participants were included. Weight loss or gain of >5 lb was not significantly associated with 24-month subjective failure (weight loss odds ratio [OR]: 1.54, 95% CI: 0.96-2.49; weight gain OR: 1.51, 95% CI: 0.96-2.36). In addition, no significant association was observed with 24-month objective or combined failure (Objective: weight loss OR: 1.23, 95% CI: 0.73-2.08; weight gain OR: 1.11, 95% CI: 0.67-1.82; Combined failure: weight loss OR: 1.32, 95% CI: 0.82-2.13, weight gain OR: 1.47, 95% CI: 0.94-2.31). Participants with weight gain >10% baseline body weight had significantly increased odds of combined failure at 24 months (OR: 2.75, 95% CI: 1.13-6.69).

Conclusions: Significant body weight gain (>10%) following midurethral sling placement is associated with increased odds of combined failure of the surgery at 24 months.

Importance: Only a fraction of women with overactive bladder (OAB) receive effective treatment for this condition; inequities in access to OAB care must be understood.

Objective: The objective of this study was to explore features associated with intradetrusor chemodenervation treatment for OAB among female Medicare beneficiaries from different racial and ethnic groups.

Study design: This was a retrospective cohort study of females ≥65 years old from the Center for Medicare & Medicaid Services' 5% Limited Data Set with a diagnosis of OAB between 2012 and 2020. The cumulative incidence of beneficiaries who received intradetrusor chemodenervation within 5 years following OAB diagnosis was compared between race and ethnicity groups. Cox regression analysis was performed to determine predictors for the likelihood of intradetrusor chemodenervation treatment and to adjust for potential confounders.

Results: In total, 232,366 females with a new OAB diagnosis were identified. The cumulative incidence of intradetrusor chemodenervation treatment within 5 years of OAB diagnosis was low at 1.4%, with lower rates among Asian (0.6%), Black (0.7%), Hispanic (0.7%), and Other groups (0.9%) (P < 0.001). After adjustments, non-White race and Hispanic ethnicity (Asian: adjusted hazard ratio [aHR] 0.51, 95% CI: 0.33-0.80; Black: aHR 0.56, 95% CI: 0.45-0.69; Hispanic: aHR 0.62, 95% CI: 0.40-0.96; Other: aHR 0.58, 95% CI: 0.37-0.91) were associated with a lower relative hazard of receiving intradetrusor chemodenervation.

Conclusions: Overall utilization of intradetrusor chemodenervation was low in this national cohort. Women from non-White racial and ethnic groups had lower rates of utilization compared with White women. Further research should evaluate barriers patients face in accessing this effective OAB treatment and explore potential interventions that facilitate access to care.

Importance: Understanding the current practice patterns regarding recurrent urinary tract infection (rUTI) can help providers better manage this burdensome condition.

Objectives: The objective was to describe and compare preferences in the management of acute UTI and rUTI in women among primary care providers, and to determine whether various national practice guidelines are being followed.

Study design: Physicians and advanced practice providers in family medicine, general internal medicine, general obstetrics and gynecology, and geriatric medicine at a state-wide academic institution and a community health system were invited to complete an online survey that included questions about management of a postmenopausal patient with rUTI. Comparisons were made between demographic groups, including gender, specialty, practice years, patients with rUTI per month, and practice setting.

Results: A total of 50 surveys were completed. Most respondents (78%) followed guidelines when choosing an antibiotic for empiric treatment of UTI. Notably, 28% would recommend long-term antibiotic prophylaxis for an uncomplicated patient with rUTI. While a majority (62%) would consider vaginal estrogen as their first option for UTI prophylaxis, few providers would also consider other evidence-based nonantibiotic options such as methenamine hippurate (26%) or D-mannose (17%). Primary care providers with "focused" training in menopause care were more comfortable prescribing vaginal estrogen in various clinical scenarios. Providers who saw 6+ patients with rUTI per month were more likely to prescribe methenamine hippurate.

Conclusions: While those surveyed generally followed standard practice in the management of UTI in postmenopausal women, our study identified opportunities for improvement. These include prioritizing nonantibiotic prophylaxis and first-line treatments for acute UTI.

Importance: Perioperative gabapentin is widely used in gynecology ERAS protocols, but evidence for its use for vaginal prolapse procedures is very limited.

Objective: The objective of this study was to evaluate the effect of preoperative gabapentin on postoperative opioid use in patients undergoing vaginal apical suspension procedures for pelvic organ prolapse.

Study design: This was a double-blind, randomized, placebo-controlled clinical trial conducted at a tertiary care center. Participants received either 300 mg of gabapentin or placebo 1 hour before surgery, along with 975 mg of acetaminophen and 400 mg of celecoxib. The primary outcome was total opioid consumption in the first 24 hours postoperatively in morphine milligram equivalents. Secondary outcomes included pain scores, time to discharge, adverse events, and adequacy of pain control. Statistical analysis included the Wilcoxon rank sum and Fisher exact tests. A sample size of 46 per group was planned to achieve 80% power.

Results: From January 2023 through October 2024, 110 participants were enrolled, and 100 were randomized and received the intervention (50 per group). Demographics and patient characteristics were similar between groups except for preoperative/intraoperative opioids. There were no significant differences between the placebo and gabapentin groups in postoperative 24-hour opioid use (P=0.15) or any secondary outcomes. After correcting for the difference in preoperative/intraoperative opioid use with regression models, there were still no significant differences in the primary or secondary outcomes. The same results held true for a per-protocol analysis, which excluded 5 participants.

Conclusions: A single 300-mg preoperative dose of gabapentin did not significantly reduce opioid use or improve pain control in patients undergoing vaginal apical suspension. These findings suggest limited utility for the routine use of gabapentin in this clinical context.

Importance: Idiopathic normal pressure hydrocephalus (iNPH) is characterized by dementia, gait disturbance, and urinary incontinence (UI). While gait and cognitive impairments trigger a focused workup, UI is often excused by female patients and doctors as normal aging in women.

Objectives: The objectives of this study were to evaluate sex differences in time from UI documentation to iNPH diagnosis and describe differences in postoperative UI outcomes following ventriculoperitoneal shunt placement.

Study design: This was a single-center, retrospective study of patients treated for iNPH who presented with the complete triad of symptoms. The primary outcome was the time from UI documentation to iNPH diagnosis compared between sexes with a 2-tailed Student t test. Sex differences in diagnostic timing and 3-month postoperative outcomes (gait, cognition, and UI) were analyzed with χ 2 tests.

Results: Eighty-two patients (38 male and 44 female) were included in the analysis. Females experienced a longer time to diagnosis than males (40.3 vs 16.8 mo; P =0.001). Following surgery, no significant sex differences were observed in gait ( P =0.32), cognitive ( P =0.17), or UI improvement ( P =0.11), but females had lower rates of complete UI resolution (13.6% vs 36.8%; P =0.020). In females, but not males, 3-month UI improvement (12.5 vs 46.8 mo; P =0.02) and resolution (1.7 vs 35.4 mo; P =0.002) correlated with shorter time to diagnosis.

Conclusions: Females with UI face a longer time to iNPH diagnosis and lower rates of complete symptom resolution. Increased awareness of iNPH in this population is essential for timely screening and improved outcomes.