Urogynecology (Hagerstown, Md.)最新文献

Importance: Adherence to overactive bladder (OAB) therapy is low among the general population. Prior studies suggest that OAB is more prevalent among Hispanic women compared with other ethnicities.

Objectives: The aims of this study were to analyze nonadherence to OAB therapy among Hispanic compared with non-Hispanic women and identify potential barriers to treatment to reduce disparities in care.

Study design: All patients who received treatment for OAB between 2018 and 2022 were included in this retrospective study. Race and ethnicity were self-reported. Nonadherence was defined as failure to initiate therapy within 1 year. Non-Hispanic women were selected at random to form a control group. The study was powered to detect a 50% difference in treatment nonadherence. Comparisons were made using the Fisher exact test or χ 2 test as appropriate for nominal variables, and the Mann-Whitney test for continuous variables.

Results: The analysis included 126 Hispanic and 126 non-Hispanic women. Both cohorts were similar in demographics. Nonadherence to OAB therapy was more frequent among Hispanic women (44.0 vs 20.9%, P  < 0.0001). After adjusting for age, body mass index, primary language, parity, insurance type, and treatment offered, Hispanic women were at a 2.54-fold increased risk of nonadherence ( P  = 0.007). A subanalysis of only Hispanic women found that younger age ( P  = 0.033), higher parity ( P  = 0.035) underinsured status ( P  = 0.027), and fewer office visits ( P  = 0.0002) were associated with nonadherence.

Conclusions: Nonadherence to OAB therapy was greater among Hispanic women despite no difference in treatment patterns. Younger age, greater parity, lack of insurance, and fewer office visits may be barriers for Hispanic women.

Importance: Although parturients report few postpartum symptoms, birth is clearly associated with future symptom development. The ability to identify asymptomatic at-risk women would facilitate prevention.

Objective: The aim of the study was to develop a model predicting abnormal recovery in women at risk for childbirth-associated pelvic floor injury.

Study design: Women undergoing first vaginal birth at high risk of pelvic floor injury underwent examinations and ultrasound imaging and completed 6-week and 6-month postpartum questionnaires. We defined "abnormal" recovery as having ≥1 of the following 3 findings: (1) levator ani injury, (2) decreased objective pelvic floor strength, and (3) Pelvic Organ Prolapse Quantification point Bp ≥0. Descriptive statistics and bivariate analyses compared "normal" and "abnormal" recovery. Birth characteristics, 6-week examinations, and questionnaires potentially predicted abnormal recovery at 6 months. Significant variables were included as candidates in the multivariable logistic regression predicting "abnormal" recovery after birth.

Results: Fifty-four women (63.5%) had normal and 31 (36.5%) had abnormal recovery at 6 months. At 6 weeks, women with abnormal recovery had decreased pelvic floor strength by Oxford scores (3 [2-5], 6 [2-8]; P  = 0.002), lower point Bp (-1 [-3 to 0], -2 [-3 to -1]; P  = 0.02), larger genital hiatus (4 [3 to 4], 3 [3 to 3.5]; P  = 0.02), and higher levator ani injury rate (76.7%, 22.4%; P  < 0.001). Between-group questionnaire differences were not clinically significant. Our final model included postpartum examination findings or birth characteristics: Oxford Scale, 6-week Pelvic Organ Prolapse Quantification GH strain, infant head circumference, and second stage ≥120 minutes. The area under the curve for predicting abnormal recovery at 6 months was 0.84, indicating a good sensitivity and specificity balance.

Conclusion: The model identifies women at risk for an abnormal recovery trajectory.

Importance: Urinary incontinence is a common postpartum morbidity that negatively affects quality of life.

Objective: This study aimed to identify factors associated with persistent (ie, 12 months postpartum) bothersome urinary symptoms, including stress urinary incontinence (SUI) and urgency urinary incontinence (UUI), and explore their association with mental health in medically underserved communities.

Study design: This was a cross-sectional analysis of a prospective study of individuals enrolled into "extending Maternal Care After Pregnancy," a program providing 12 months of postpartum care to individuals with health disparities. Patients were screened at 12 months for urinary dysfunction, anxiety, and depression using the Urinary Distress Index-6, Generalized Anxiety Disorder-7, and Edinburgh Postnatal Depression Scale, respectively. Bivariate and multivariable logistic regression analyses were performed for at-least-somewhat-bothersome SUI versus no-SUI, UUI versus no-UUI, and for bothersome versus asymptomatic urinary symptoms, using demographic and peripartum and postpartum variables as associated factors.

Results: Four hundred nineteen patients provided data at median 12 months postpartum. Patients were 77% Hispanic White and 22% non-Hispanic Black. After multivariable analysis, SUI (n = 136, 32.5%) was significantly associated with increasing body mass index at the time of delivery and greater depression screening scores. Fetal birthweight, mode of delivery, degree of laceration, and breastfeeding status were not associated. Urgency urinary incontinence (n = 69, 16.5%) was significantly associated with increasing parity and higher anxiety screening scores. Similarly, participants with urinary symptom bother had significantly greater parity and higher anxiety screening scores.

Conclusions: At 12 months postpartum, bothersome urinary symptoms and incontinence were quite common. Since these are treatable, postpartum screening for urinary complaints-and associated anxiety and depression-is essential, as is assisting patients in achieving a healthy weight.

Importance: Despite growing popularity in medicine, data on large language models in urogynecology are lacking.

Objective: The aim of this study was to compare the performance of ChatGPT-3.5, GPT-4, and Bard on the American Urogynecologic Society self-assessment examination.

Study design: The examination features 185 questions with a passing score of 80. We tested 3 models-ChatGPT-3.5, GPT-4, and Bard on every question. Dedicated accounts enabled controlled comparisons. Questions with prompts were inputted into each model's interface, and responses were evaluated for correctness, logical reasoning behind answer choice, and sourcing. Data on subcategory, question type, correctness rate, question difficulty, and reference quality were noted. The Fisher exact or χ 2 test was used for statistical analysis.

Results: Out of 185 questions, GPT-4 answered 61.6% questions correctly compared with 54.6% for GPT-3.5 and 42.7% for Bard. GPT-4 answered all questions, whereas GPT-3.5 and Bard declined to answer 4 and 25 questions, respectively. All models demonstrated logical reasoning in their correct responses. Performance of all large language models was inversely proportional to the difficulty level of the questions. Bard referenced sources 97.5% of the time, more often than GPT-4 (83.3%) and GPT-3.5 (39%). GPT-3.5 cited books and websites, whereas GPT-4 and Bard additionally cited journal articles and society guidelines. Median journal impact factor and number of citations were 3.6 with 20 citations for GPT-4 and 2.6 with 25 citations for Bard.

Conclusions: Although GPT-4 outperformed GPT-3.5 and Bard, none of the models achieved a passing score. Clinicians should use language models cautiously in patient care scenarios until more evidence emerges.

Importance: Urinary incontinence can be a barrier to performing physical activities for many women. A midurethral sling (MUS) has shown symptom improvement for women experiencing stress urinary incontinence (SUI), suggesting the hypothesis that physical activity rates should increase after treatment.

Objective: The aim of this study was to determine the change in objectively measured physical activity levels in women following placement of MUS for SUI.

Study design: In this prospective cohort study, patients undergoing MUS placement, with or without concomitant pelvic reconstructive surgery, were provided a commercial activity tracker. Physical activity was tracked for at least 1 week preoperatively and up to 6 months postoperatively. Participants were required to wear the tracker for at least 2 weeks in the postoperative period. The primary outcome, mean caloric daily expenditure (MCDE), was compared preoperatively and postoperatively.

Results: Seventy-two patients met criteria for data inclusion. The device was worn for a mean of 18.4 ± 12.1 days preoperatively and 91.7 ± 53.3 days postoperatively. Mean participant age was 51.9 ± 9.4 years. The MCDE was significantly higher postoperatively (preoperatively: 1,673 kcal/d vs postoperatively: 2,018 kcal/d; P < 0.01). There were no significant differences in postoperative MCDE in participants who had only MUS as the primary procedure versus participants who also had a concomitant procedure (2,020 ± 216 kcal/d vs 2,015 ± 431 kcal/d; P = 0.95). Of participants with class II/III obesity, 45% had at least a 500 kcal/d increase postoperatively.

Conclusions: Treatment of SUI with MUS is associated with a significantly greater caloric expenditure in the postoperative period.

Importance: Knowledge on the interpregnancy interval (IPI) among women with an obstetric anal sphincter injury (OASI) is both limited and not well understood.

Objectives: The objectives of this study were to describe the IPI among women with OASI and to compare women with OASI based on the route of subsequent obstetric delivery and OASI recurrence.

Study design: This was a retrospective single-cohort study of women who had an OASI between 2013 and 2015 at a tertiary academic medical center. Demographics, obstetric delivery data, postpartum sequelae, and subsequent pregnancy delivery data from 2013 to 2021 were collected. The IPI was defined as the time from date of first vaginal delivery to date of conception of the subsequent pregnancy. Women without a subsequent pregnancy were censored at the date of last contact. The IPI was evaluated using a survival analysis (Kaplan-Meier estimator).

Results: A total of 287 women experienced an OASI, and subsequent pregnancy occurred for 178 (62.0%) women. The median IPI was 26.4 months (95% confidence interval: 23.7-29.9) for women with a prior OASI. Of the 97 women who did not have a subsequent pregnancy documented during the study, the median follow-up was 64.0 months (interquartile range: 5.7-80.0). Subsequent delivery route data were available for 171 women; of those, 127 (74.3%) experienced a subsequent vaginal delivery and 44 (25.7%) experienced a cesarean delivery. Of the 127 women who experienced a subsequent vaginal delivery, 3 (2.4%) experienced a recurrent OASI.

Conclusion: The IPI among women with OASI is similar to the IPI for all women in Ohio and in the United States.

Importance: Improving patients' recall and understanding of their planned surgery is essential for fully informed consent.

Objective: The objective of this study was to assess if the addition of an information handout to the standard preoperative consent process for the transobturator midurethral sling procedure improved patient understanding, recall, and satisfaction.

Study design: This is a randomized controlled trial of adult women undergoing a transobturator midurethral sling procedure for the treatment of stress urinary incontinence. After standard counseling, participants were randomly assigned to either the control or the intervention group, with the latter receiving an extra informational handout detailing surgical information. Before surgery, all participants filled out a questionnaire assessing key points discussed during the surgical consent, which was used to calculate a knowledge score, the primary endpoint. Secondary outcomes included perception of the consent process and patient satisfaction.

Results: Of 98 randomized participants (50 control, 48 intervention), knowledge scores were 43% for controls and 57% for the intervention group ( P = 0.015). Despite low scores, high self-rated understanding and satisfaction were noted across both groups (78% control, 71% intervention, P = 0.4). Notably, younger individuals, those with some college education, and patients undergoing additional prolapse surgery benefited most from the handout.

Conclusions: The informational handout improved knowledge scores, though overall knowledge scores were low in both groups. High satisfaction and perceived understanding of the planned procedure persisted, but the addition of a handout was not associated with a significant difference in knowledge scores.

Importance: Understanding the risk of urinary retention with different prolapse repair surgical procedures is important for perioperative counseling.

Objective: The study compared postoperative urinary retention rates between robotic sacrocolpopexy and robotic uterosacral ligament suspension.

Study design: This institutional review board-exempt retrospective cohort study compared patients who underwent pelvic organ prolapse repair with robotic sacrocolpopexy (RSCP) and robotic uterosacral ligament suspension (RUSLS) between June 2018 and March 2022. Our primary outcome was the rate of acute postoperative urinary retention (POUR) in these groups. Secondary outcomes were the number of days needed to resolve urinary retention and persistent voiding dysfunction.

Results: Out of 298 patients, 258 underwent RSCP and 40 underwent RUSLS. Acute POUR was found in 73 patients (24%): 46 patients (18%) in the RSCP group versus 26 patients (65%) in the RUSLS group ( P < 0.001). Multivariate analysis demonstrated a significantly higher rate of acute POUR after RUSLS (odds ratio [OR] = 17.92, confidence interval [CI] = 3.06-104.86; P = 0.001). Patients with an elevated preoperative postvoid residual volume >100 mL or concomitant midurethral sling were more likely to develop POUR (OR = 2.93, CI = 1.43-5.98; P = 0.003 and OR = 2.19, CI = 1.16-4.14; P = 0.016, respectively). While patients with higher parity were less likely to have urinary retention (OR = 0.71, CI = 0.53-0.96; P = 0.024), age, body mass index, prolapse stage, and concurrent posterior repair did not affect the urinary retention rate significantly. The number of days needed to resolve POUR and persistent voiding dysfunction were similar.

Conclusions: Acute POUR appears more likely to develop after RUSLS compared to RSCP. Elevated preoperative postvoid residual volume and concomitant midurethral sling surgery independently increase the risk of POUR.

Importance: Disparities research in Black women with pelvic floor disorders (PFDs) has primarily focused on epidemiology or surgical outcomes, but little is known about the patient perspective on seeking PFD care.

Objective: To provide quality and equitable care to Black women with PFDs, we conducted a qualitative study to hear their perspectives and lived health care experiences.

Study design: Black women seeking care for PFDs at a tertiary care institution were invited to participate in qualitative interviews. Open-ended questions explored participants' knowledge, attitudes, and health care experiences. Interviews were transcribed verbatim and coded line-by-line. Inductive content analysis was performed to identify key themes, and consensus was achieved among the research team.

Results: Eight Black women aged 21-83 years consented to participate. Patients noted a stigma surrounding PFDs, both among health care professionals and their community. They noted several barriers to care: financial, logistical, and racial bias. They cited difficulties in patient-health care professional communication, including not feeling heard or treated as an individual. They preferred gender and racial concordance with their physicians. These women expressed both a desire for more knowledge and to share this knowledge and advocate for other women.

Conclusions: Black women expressed distinct obstacles in their PFD health care. They reported not feeling heard or treated as a unique individual. The themes derived from this study identify complex patient-centered needs that can serve as the basis for future quality improvement work and/or hypothesis-driven research. By grounding health disparities research in patient perspectives, we can improve the health care experiences of Black women.

Importance: The genital hiatus (GH) has been identified as a predictor of pelvic organ prolapse. An enlarged preoperative GH is a risk factor for recurrent prolapse after surgery.

Objective: The objective of this study was to determine the changes in preoperative and postoperative GH size compared with the intraoperative resting GH at 6 weeks and 12 months after native-tissue pelvic organ prolapse surgery.

Study design: This was a descriptive analysis of a prospective cohort study of women undergoing native-tissue prolapse repair with apical suspension. Resting GH was obtained at the start and conclusion of surgery. Measurements were obtained preoperatively, and 6 weeks and 12 months postoperatively under Valsalva maneuver. Comparisons were made using paired t tests for the following time points: (1) preoperative measurements under Valsalva maneuver to resting presurgery measurements under anesthesia, and (2) resting postsurgery measurements under anesthesia to 6 weeks and 12 months postoperatively under Valsalva maneuver.

Results: Sixty-seven patients were included, with a median age of 66 years and median body mass index (calculated as weight in kilograms divided by height in meters squared) of 29.1. There was no significant difference in GH when measured preoperatively to resting presurgical measurements under anesthesia ( P = 0.60). For all, the median GH was 3.0 cm at the conclusion of surgery and remained at 3.0 cm at 6 weeks and 12 months postoperatively. In patients who had a concurrent posterior colporrhaphy, the median resting postsurgery GH was 3.0 cm, then decreased to 2.5 cm at 6 weeks then 3.5 cm at 12 months under Valsalva.

Conclusions: Preoperative GH size under Valsalva maneuver and resting under anesthesia were comparable. For all patients undergoing native-tissue pelvic organ prolapse repair, the genital hiatus size remains the same from the intraoperative final resting measurements to the 6-week and 12-month measurements under Valsalva maneuver.