Urogynecology (Hagerstown, Md.)最新文献

Importance: To evaluate and consider how prescribing practices have changed in relation to high-risk overactive bladder (OAB) medications.

Objective: The objective of this study was to evaluate trends in the prevalence of OAB and pharmacologic treatment over time in the United States.

Study design: Data from the National Health and Nutrition Examination Survey (NHANES, 2001-2018, n = 30,478) and the National Ambulatory Medical Care Survey (NAMCS, 2003-2019, n = 251,330) were used to identify women with symptomatic incontinence and overactive bladder (OAB) (NHANES) as well as determine the frequency of prescription use for OAB medications (NHANES and NAMCS) using sampling-based weights. Joinpoint regression was used to determine adjusted annual percent change (APC, adjusting for race, age, body mass index, and insurance status). Trends were assessed overall and by race, age, body mass index, and insurance status.

Results: The prevalence of OAB was 31.2% in the final survey year of NHANES (2017-2018). Women aged >65 years had the highest prevalence of OAB at 54% compared with other age groups. There was an overall increase in OAB (APC 1.24 [0.64, 1.84], P  = 0.002) over time. Overall, only 3.5% of patients with symptoms of OAB reported pharmacologic treatment in NHANES. The NAMCS demonstrated a significant decrease in anticholinergic prescriptions from 2003 until 2019 (APC -6.44 [-9.77, -2.98], P  = 0.001). However, in NHANES, there was no significant change in anticholinergic use (APC 0.62 [-20.2, 26.8], P  = 0.944). There was a stable prevalence of β 3 -adrenergic agonist prescriptions since they were introduced to market (APC 0.65 [-2.24, 3.62], P  = 0.616).

Conclusion: This study demonstrates an increasing prevalence of OAB and highlights the likely undertreatment of symptomatic patients. The high and increasing prevalence coupled with the relative undertreatment of OAB underscores the importance of screening for this condition.

Importance: Obliterative vaginal surgery is often reserved for older patients with prolapse, but the effect of age as an independent risk factor for perioperative complications in this cohort is poorly understood.

Objective: The aim of this study was to assess the association between age and perioperative complications in women undergoing obliterative vaginal surgery.

Study design: This was a retrospective cohort study that included 371 patients undergoing colpocleisis between 2010 and 2013 at a single academic medical center. Seventy demographic and clinical variables, including complications within 12 weeks of surgery, were analyzed. The χ 2 and Fisher exact tests were used for categorical variables. Student t and Mann-Whitney U tests were used for continuous variables. Univariate logistic regression was performed to identify predictors of perioperative complications, and candidate variables with P  < 0.2 were used in multivariate logistic regression.

Results: The mean patient age was 75.4 ± 6.4 years (range, 59-94 years). One hundred ten (29.7%) patients experienced at least 1 complication, the most common of which was urinary tract infection (n = 47, 12.7%). In the final multivariable model, only age (odds ratio, 1.05 per year; 95% confidence interval, 1.01-1.08) remained a significant predictor of perioperative complications. A cut point of age ≥70.5 years maximized sensitivity and specificity for predicting complications.

Conclusions: Among women undergoing obliterative vaginal surgery, age is a predictor of perioperative complications. Each increasing year of age increases the complication likelihood by 1.05-fold, such that an 85-year-old woman is 1.05^20 or 2.65 times more likely than a 65-year-old woman to have a complication. A cut point of ≥70.5 years best predicted complications. Despite this association, severe perioperative complications following obliterative surgery are rare.

Abstract: This Clinical Consensus Statement on the management of asymptomatic bacteriuria (ASB) in adult females reflects statements drafted by content experts within the American Urogynecologic Society Bacteriuria Writing Group. The writing group created 32 clinically relevant topic questions, which were collapsed into 30 questions due to thematic overlap. The group used a modified Delphi process to evaluate the statements for consensus. Eight out of 30 questions did not reach consensus after the first Delphi round. Based on group discussion, several questions were restructured or omitted and 25 were retained. Consensus was reached on all 25 statements after 2 further rounds of discussion. Evidence summaries were developed from a structured literature search and are presented with each topic question and statement. Overall, ASB is common and increases with age in the female population. Treatment of ASB is thought to confer more harm than benefit in most women. For women with chronic lower urinary tract symptoms and bacteriuria, an acute change in symptoms should be evaluated with urinalysis and urine culture to guide decision making for antimicrobial therapy.

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.