Urogynecology (Hagerstown, Md.)最新文献

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.

Importance: The Latina population is the largest growing ethnic group in the United States with high levels of health disparities in urinary incontinence (UI) treatment and complications rates, which may be due to disproportionately high barriers to UI care-seeking among Latinas.

Objectives: The objectives of this study were to compare barriers to UI care-seeking among Latina, non-Latina Black, and non-Latina White patients by utilizing the Barriers to Incontinence Care Seeking Questionnaire (BICS-Q) total scores, and to compare specific barriers utilizing BICS-Q subscales.

Study design: In this cross-sectional study, patients accessing primary care were recruited to complete the BICS-Q, International Consultation on Incontinence Questionnaire-Short Form, and Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence. The BICS-Q total and subscale scores were compared among ethnic/racial groups.

Results: A total of 298 patients were included in the study with 83 Black, 144 Latina, and 71 White participants per self-identified ethnicity/race. The total BICS-Q score was highest for Latina participants, followed by White and Black participants (11.2 vs 8.2 vs 4.9, respectively, P  < 0.0001). Latina participants had significantly higher BICS-Q subscale scores compared with Black participants with no significant differences between Latina and White participants. After controlling for potential confounders, Latina ethnicity/race was still associated with a higher BICS-Q score when compared to Black ethnicity/race ( P  = 0.0077), and lower Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence scores remained independently associated with higher BICS-Q scores ( P  = 0.0078).

Conclusions: In our study population, Latina patients and patients with lower UI knowledge experience higher barriers to UI care-seeking compared with Black patients and patients with higher UI knowledge. Addressing these barriers may increase care-seeking and improve health equity in the field.

Importance: There is no consensus on how to define obstetric anal sphincter defects detected by 3-dimensional endoanal ultrasonography (3D-EAUS), and the reported rates vary significantly in the postpartum period.

Objective: The objective of this study was to establish a diagnostic strategy with a high and clinically relevant interrater reliability both early and late postpartum.

Study design: The study was prospective and observational, and 3D-EAUS was performed 10-14 days and 9-12 months postpartum in an unselected cohort of primiparous women with vacuum-assisted deliveries. Two experienced examiners evaluated the ultrasonographic results, which were divided into the categories intact, inconclusive, small, moderate, and large defects based on Starck scores. Three different diagnostic strategies were validated, and the prevalence- and bias-adjusted kappa (PABAK) values calculated.

Results: Of 334 eligible women, 184 (55.1%) completed both examinations. Disagreements involving small defects were predominant and observed in 34 and 39 cases, respectively, at the 2 time points. The highest overall agreement rates (91.3% and 92.4%, respectively) and PABAK values (0.83 and 0.85, respectively) were reached when the disagreements were minimized by dichotomizing the results into Starck scores >4 (designated a significant defect) versus Starck scores 0-4 (all others).

Conclusions: The interrater reliability of detecting small anal sphincter defects by 3D-EAUS was low at both time points for the 2 experienced raters. In contrast, the interrater reliability of detecting a significant defect was classified as almost perfect agreement at both time points.

Importance: Ileus and small bowel obstructions are known but rare complications associated with minimally invasive sacrocolpopexy that can result in variable management.

Objectives: The objectives of this study were to describe the clinical presentation, management and outcomes of ileus or small bowel obstructions after minimally invasive sacrocolpopexy.

Study design: This was a multicenter retrospective case series of postoperative ileus or small bowel obstruction after minimally invasive sacrocolpopexy. Demographics, clinical, surgical, and complication characteristics were manually abstracted. Descriptive statistics were performed via SPSS along with associative and comparative analyses.

Results: Ileus or small bowel obstruction was diagnosed in 2.5%, 95% CI = 1.8,3.3%, of all minimally invasive sacrocolpopexy cases across institutions. Presentation for small bowel complication ranged from 1 to 2,432 days after surgery with 70% presenting within 14 days of the index surgery. Remoteness from the surgery was associated with whether the index team was involved in the management of the bowel complication. Patients who were conservatively managed were admitted for a significantly shorter amount of time with a mean length of stay of 4.52 (±3) days compared to 10.3 (±6, P  < 0.001) days for those who were surgically managed.

Conclusions: Small bowel complication is a known rare risk following minimally invasive sacrocolpopexy. Conservative management resolves the majority of cases and should be considered to reduce the risk of surgical morbidity or disruption of the mesh. Given that multiple clinical teams may encounter and manage these complications, our study highlights the importance of keeping a high index of suspicion and thoughtful communication about these events.

Importance: Dementia and urinary incontinence (UI) have been associated in cross-sectional studies. The temporal relationship between these 2 conditions is not well understood.

Objective: The aim of the study was to investigate the risk of incident dementia in female adults with and without UI using the Medicare 5% Limited Data Set.

Study design: This retrospective cohort study matched females with UI to continent controls by index year, age, and dual Medicare/Medicaid eligibility. A 2-year look back period was used to exclude prevalent dementia and neurologic disorders. The 5-year cumulative incidence of dementia was estimated for women with UI and controls. Cox proportional hazard models assessed the association of variables with dementia, adjusting for age, dual Medicare/Medicaid eligibility, race, and comorbidities.

Results: A total of 8,651 female beneficiaries with UI (n = 8,651) were more likely than matched controls (n = 8,651) to report White race and several medical comorbidities. The 5-year cumulative incidence of dementia diagnosis was lower in the UI versus controls (8.8% vs 10.6%, P  < 0.001). In multivariable analysis with adjustment for covariates, UI diagnosis was associated with a lower hazard of dementia diagnosis (hazard ratio 0.82 [0.74, 0.91], P  < 0.001).

Conclusions: Among female Medicare beneficiaries without baseline neurologic disorders, having any UI diagnosis was associated with a lower risk of dementia diagnosis. Further studies assessing UI symptoms and dementia diagnosis with rigorous and valid assessment tools are needed to confirm this finding.