Urogynecology (Hagerstown, Md.)最新文献

Importance: Evidence regarding the effect of pudendal nerve blockade during vaginal surgery is conflicting. Previous studies compared pudendal nerve blockade to either normal saline placebo injection or no injection, demonstrating small or no difference in pain outcomes. Studies investigating nerve blocks at the time of vaginal surgery have not evaluated the effect of infiltration of the space around the pudendal nerve.

Objective: The aim of the study was to determine whether intraoperative pudendal nerve injection (bupivacaine or normal saline) will result in improved pain scores and satisfaction compared with patients who receive no pudendal injection.

Study design: We performed a secondary analysis of 2 randomized controlled trials investigating postoperative pain after vaginal reconstructive surgery, comparing the outcomes of the following 3 groups: control (no pudendal injection), intervention (bilateral pudendal nerve blockade), and placebo (bilateral normal saline pudendal injections). The primary outcome was postoperative pain scores. Secondary outcomes were opioid use, patient satisfaction, and postoperative complications. Linear mixed effects models were applied to outcomes, and treatment effects with 95% confidence intervals were estimated at each time point from the model.

Results: One hundred four patients who underwent vaginal surgery were included: 36 pudendal nerve block, 35 normal saline pudendal injection, and 33 no injection. The groups were well-matched. Linear mixed effects models demonstrated no significant differences between treatment groups for postoperative pain severity scores, opioid use, and patient-reported satisfaction at each time point.

Conclusions: Normal saline injection and no injection seem to have no clinically meaningful difference in effect, and either could reasonably serve as control for pudendal blockade during vaginal surgery.

Importance: Pessaries are commonly used to manage pelvic organ prolapse. Pessary management can be done by a medical professional or the patient themselves. Pessary complications are rare. However, pessaries can be difficult to track, and patients who are lost to follow-up are at an increased risk of complications such as vaginal ulceration, pessary embedment, and fistulization.

Objectives: To create and implement a quality improvement initiative focusing on preventing neglected pessaries.

Study design: Through the electronic medical record, we implemented a quality improvement initiative focused on creating a workflow where a pessary can be designated as an implant when inserted. A year after implementation, data was gathered.

Results: We identified 37% (55/147) of patients without follow-up in the 3 months after pessary placement. Of those, 24% were no longer using pessaries, 24% were self-maintaining or having surveillance with their primary OB/GYN, 16% had surgery for pelvic organ prolapse since placement of the pessary, 15% were lost to follow-up and were considered to be patients "at risk," and 12% did not have a pessary placed to begin with. Review showed 53% of patients with proper documentation and designation of pessary as an implant.

Conclusions: This quality improvement initiative can identify patients lost to follow-up, leading to improved patient care and potential to prevent complications.

Importance: Women with cystic fibrosis (CF) historically experience a high prevalence of urinary incontinence (UI). However, this area is understudied, especially in the modern era of highly effective modulator therapy (HEMT).

Objective: This study aimed to explore the UI experiences, knowledge, care-seeking behavior, and treatment preferences of women with CF.

Study design: We recruited women aged ≥18 years through the CF Foundation's Community Voice national registry if they had a diagnosis of CF and reported UI. Participants underwent individual, semistructured interviews exploring their experiences, attitudes, and preferences toward UI that were audiorecorded and transcribed. Two coders performed thematic analysis using deductive and inductive coding approaches.

Results: Twenty-six participants completed interviews (average age, 45.1 years; range, 24-61 years). Key themes included the following: (1) most women with CF and UI report low bother from symptoms likely related to stress UI, and HEMT has greatly improved UI symptoms and decreased bother; (2) most women with CF and UI had previously discussed UI symptoms with family and/or peers but had not sought care due to stigma or low priority; (3) women with CF and UI had minimal knowledge about UI in general and how it relates to CF; (4) most desired broad screening for UI from their CF team and improved multidisciplinary care; and (5) highly effective UI treatment options with low-time commitment and easily accessible resources are desired.

Conclusions: Women with CF and UI report low knowledge and care-seeking behavior related to this condition and desire improved care provision. Importantly, HEMT may improve UI symptoms among people with CF.

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: It is crucial to understand the racial and ethnic disparities that exist in nocturia prevalence to appropriately manage nocturia.

Objectives: Nocturia is associated with increased body mass index (BMI) and is most prevalent in Black and Hispanic women, who also have the highest and second highest prevalence of obesity, respectively. We sought to better understand the association of nocturia with BMI category by race and ethnicity in U.S. women.

Study design: This was a cross-sectional study using publicly available data from the National Health and Nutrition Examination Survey data from 2005 to 2018. We estimated the prevalence of moderate to severe nocturia (defined as 2 or more episodes of nighttime urination) by BMI category within each racial and ethnic (Black, White, Hispanic, and other) group of adult women. Logistic regression was performed to determine the odds ratio of nocturia by race.

Results: The odds of nocturia was 2.25 (2.04-2.49) for Black women, 1.27 (1.15-1.4) for Hispanic women and 0.96 (0.82-1.13) for other women compared to White women. After accounting for BMI, socioeconomic status and comorbidities, the adjusted odds ratio was 1.76 (1.42-2.16) for Black women, 1.1 (.0.88-1.38) for Hispanic women, and 0.81 (0.5-1.29) for other women compared to White women.

Conclusions: Black women were nearly twice as likely to have nocturia than White women. The increased odds of nocturia, while not sustained for Hispanic women, persisted for Black women regardless of socioeconomic status, BMI, and comorbidities. Our study suggests that there are factors other than weight driving the prevalence of nocturia in Black women that require further investigation.

Importance: Recent articles have highlighted the existence of pelvic floor myofascial dysfunction in women presenting with pelvic floor disorders.

Objective: The aim of the study was to evaluate whether younger age is associated with pelvic floor muscle dysfunction in women with lower urinary tract symptoms, including urinary urgency, frequency, nocturia, and urinary incontinence.

Study design: This retrospective cohort study included women seeking an initial outpatient urogynecology evaluation for urinary symptoms from 8/2018 to 2/2022. The primary outcome was the presence of pelvic floor muscle dysfunction, defined as a diagnosis of levator myalgia/spasm. Multivariable logistic regression was used to evaluate the association.

Results: Four hundred twenty-one women with lower urinary tract symptoms were included, and 115 (27.3%) were diagnosed with pelvic floor muscle dysfunction. Women with pelvic floor dysfunction were 13 years younger, less likely to report any incontinence (60% vs 71.9%, P  = 0.026) and urgency incontinence (8.7% vs 17.3%, P  = 0.04). There was no difference in reported urgency, frequency, or nocturia. Women with pelvic floor dysfunction were more likely to report dysuria (19.1% vs 9.5%, P  = 0.012), dyspareunia (39% vs 7.5%, P  < 0.001), vulvodynia (11.3% vs 2.3%, P  < 0.001), and pelvic pain (25.2% vs 7.2%, P  < 0.001). The odds of pelvic floor muscle dysfunction in women <40 years old was 2.34 times greater than women ≥40 years old, after adjusting for other factors (adjusted odds ratio 2.341, 95% confidence interval [1.102, 4.972]).

Conclusions: Younger women with lower urinary tract symptoms were significantly more likely to have pelvic floor muscle dysfunction compared to older women with similar symptoms, even after controlling for other associated characteristics.

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: Genitourinary fistula is a rare complication of obstetric cerclage with limited evidence to guide prevention and management.

Objective: The aim of the study was to describe 5 new cases of vesicovaginal fistula (VVF) after cerclage and evaluate existing cases, including shared features, to generate hypothesis for future etiologic research.

Study design: Case series and scoping review.

Results: Five patients presented with VVF symptoms after cerclage placement; 4 were diagnosed during pregnancy, 1 postpartum. Two patients had prior cervical procedures and were noted to have difficult cerclage placements. Three cerclages remained until delivery, 1 was removed antepartum, and another was replaced. All VVFs were diagnosed by cystoscopy and were repaired postpartum transvaginally. In the scoping review, 14 studies met inclusion criteria, and 19 cases were identified. Compiled cases had a history of cervical procedure(s), shortened cervix, McDonald technique, anterior knot placement, and Mersilene tape use. Fistulas were identified by cystoscopy when performed. Most reports described VVFs near the bladder trigone and midline of the vagina. All VVFs required surgical repair.

Conclusions: Genitourinary fistula after cerclage is rare but may be more common after prior cervical surgery, shortened cervix, and McDonald cerclage. Methods to mitigate morbidity associated with fistula after cerclage placement include cystoscopy if bladder injury is suspected at the time of cerclage placement and consideration of abdominal cerclage when intravaginal access to the cervix is limited. Patients with urinary leakage after cerclage should be evaluated for genitourinary fistula, not just incontinence. Postpartum surgical repair remains the primary treatment for VVF, ideally by a vaginal approach.