Urogynecology (Hagerstown, Md.)最新文献

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.

Importance: Vaginal fibroblast function is altered in people with pelvic organ prolapse. Thus, it is important to study vaginal fibroblasts to better understand the pathophysiology of prolapse.

Objective: This study aimed to compare 3 culturing methods of primary vaginal fibroblasts.

Study design: This was an in vitro study. Patients who were undergoing surgery for vaginal prolapse were recruited. Excess vaginal epithelial tissue that would have otherwise been discarded was collected. The vaginal fibroblasts from each participant were cultured via (1) 3-hour digest, (2) coverslip, and (3) gelatin-coat methods. Differences in the efficiency of cell isolation, expression of known fibroblast-associated genes, and cellular function were compared between the 3 methods using one-way analysis of variance and Tukey test for post hoc pairwise comparisons ( P  < 0.05).

Results: Five patients with pelvic organ prolapse were recruited. Fibroblasts cultured via the 3-hour digest method became confluent within 3-5 days in a 100-mm dish compared to 2-3 weeks in a 6-well dish for the coverslip and gelatin-coat methods. Cells from all culture methods expressed similar amounts of vimentin and α smooth muscle actin. There were no significant differences in morphology; gene expression levels of MMP1 , MMP2 , ACTA2 , COL1A1 , COL3A1 , and LOXL1 on qPCR; cell viability; proliferation; and migration between the 3 culturing methods.

Conclusion: Culturing primary vaginal fibroblasts via the 3-hour digest, coverslip, and gelatin-coat methods similarly resulted in reliable primary vaginal fibroblast growth and function.

Importance: The U.S. health care system has an enormous carbon footprint made worse by the escalating use of single-use supplies. Emerging evidence suggests that smaller surgical fields ("green" draping) may represent a safe alternative to traditional draping.

Objectives: The aim of the study was to determine if the proportion of cases treated for culture-proven urinary tract infection (UTI) within 2 weeks of operating room cystoscopy after the green draping protocol implementation is noninferior to preprotocol cases. Secondary objectives included risk factors for UTI and waste and cost savings.

Study design: A pre-post implementation noninferiority study was performed from 2021 to 2023 in a urogynecology division at an academic medical center. The green draping protocol eliminated the use of top drapes, leg drapes, and gowns; blue towels were permitted per the surgeon's discretion. All minor cystoscopy cases were included.

Results: The cohort included 240 patients. Treatment of culture-proven UTI in the green cohort was noninferior to the preprotocol group (9 [7.5%] vs 7 [5.8%], P  < 0.05). The odds of a culture-proven UTI were higher with history of recurrent UTI (odds ratio = 7.02), interstitial cystitis/bladder pain syndrome (odds ratio = 4.33), and older age (odds ratio per 5-year increase = 1.21). Approximately $1,403.92 (2023 USD) was saved, and 165 pounds of waste was diverted from the landfill.

Conclusions: A green draping protocol is noninferior to standard draping with respect to rates of postoperative culture-positive UTIs. Clinicians may use a smaller operating room field to decrease the carbon footprint without compromising quality of care.

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.