Faculty Bibliography

IMPORTANCE/OBJECTIVE:Pelvic floor physical therapy (PFPT) is a first-line treatment for pelvic floor disorders, though it is frequently an uncovered benefit. Data on insurance acceptance among PFPT offices is limited; therefore, its true accessibility is unknown. OBJECTIVES/OBJECTIVE:Our primary objective was to characterize the effect of insurance coverage on access to PFPT in a national sample. Our secondary objective was to identify factors associated with Medicaid acceptance. STUDY DESIGN/METHODS:This cross-sectional analysis utilized a "secret shopper" methodology. Investigators contacted 200 PFPT offices across 8 states, 4 with expanded Medicaid access, using a script to evaluate insurance acceptance, wait times, and cost. The agreement between Medicaid and commercial insurance acceptance was tested using the McNemar test. Logistic regression identified factors associated with Medicaid acceptance. RESULTS:Of 200 PFPT offices, 141 (70%) accepted commercial insurance and 94 (47%) accepted Medicaid (χ2=35.8, P<0.001); 53 accepted neither (26.6%). Factors associated with Medicaid acceptance included location in nonexpansion states (adjusted odds ratio [aOR], 2.0; 95% CI, 1.02-4.00, P=0.045), acceptance of commercial insurance (aOR, 6.72, 95% CI; 2.22-20.38, P<0.001), academic affiliation (aOR, 17.54; 95% CI, 6.93-44.36, P<0.001), and nonurban location (aOR, 3.10, 1.23-7.18, P=0.016). Mean wait time for Medicaid was 4.6 weeks versus 3.1 weeks for non-Medicaid offices (P=0.004). In all, 117 PFPTs (58.5%) reported a cash cost for an initial visit: median cost was $190.62 (SD=73.77), range $70-$450. CONCLUSIONS:Our analysis reveals significant PFPT disparities for Medicaid beneficiaries, underscores barriers to access for Medicaid patients, and highlights opportunities for policy interventions to promote equity.

OBJECTIVES/OBJECTIVE:To examine how media, geography, race, and social factors shaped patient experiences to inform strategies for improving trust and care. DESIGN/METHODS:We conducted a cross-sectional online survey of experiences and perceptions of OB/GYN care and medical mistrust using a stratified, randomised sampling approach. SETTING/METHODS:The survey was distributed through Prolific. POPULATION/METHODS:Inclusion criteria included assigned female at birth, age between 18 and 40 years, and residing in the United States. MAIN OUTCOME MEASURES/METHODS:Gender preference of OB/GYN clinician, demographic association with negative OB/GYN experiences, and degree of medical mistrust. RESULTS:Of 579 respondents, 93% identified as women, 33.9% as LGBTQIA+, and 45.2% had a history of pregnancy. Anxiety was the most common (46.4%) emotion experienced when receiving OB/GYN care, and 25.8% reported negative experiences, primarily from minimization of concerns (68.5%). A majority (65.3%) preferred receiving care from a female OB/GYN. Identifying as Republican was associated with higher odds of having had a negative experience with an OB/GYN, whereas Asian race and lower education were linked to lower odds. Black, Asian, and multiracial participants were more likely to have a racial preference for clinicians. Medical mistrust was higher among Black respondents and those with lower education. Feeling heard by a clinician was the strongest predictor of care satisfaction. CONCLUSION/CONCLUSIONS:Anxiety and negative experiences were prevalent among participants. Feeling heard was the strongest predictor of patient satisfaction, highlighting the importance of patient-centred OB/GYN care to reduce mistrust and improve patient experiences, particularly for marginalised groups.

BACKGROUND:Varicocele severity has traditionally been associated with larger testicular vein size, but the true relationship to decreased fertility remains debatable. In clinical practice, the largest testicular vein diameter is an often-used parameter to screen for potential surgical intervention, even though current research provides weak support for this. More recent studies have found venous reflux patterns and total testicular volume (TTV) to be significantly associated with total motile sperm count (TMSC). This study compares largest testicular vein size and arterial flow rates, assessing the predictive value of each for identifying patients at risk for reduced semen analysis (SA) parameters. METHODS:We conducted a retrospective, single-institution chart review over 14 years of 487 Tanner V adolescents. Patients were included if they had a palpable, primary left-sided varicocele and underwent at least one SA and scrotal Doppler ultrasound (SDUS) to assess vein diameter and arterial blood flow including peak systolic and end-diastolic velocities. Abnormal TMSC was defined by WHO 2010 criteria. Descriptive statistics, ROC analysis and univariate as well as multivariate logistic regression analyses were performed using SPSS. RESULTS:148 Tanner V adolescent males were included. Mean age ± SD was 18.24 ± 1.38 years. Median diameter of largest vein on US was 3.5 mm (IQR 3.1-4.6), median peak systolic velocity (PSV) of the left testicular artery was 10.4 cm/s (IQR 9.1-12.5), median end-diastolic velocity (EDV) of the left testicular artery was 5.1 cm/s (IQR 4.3-5.9), and median value of PSV/EDV was 2.1 (IQR 1.8-2.3), with a median TMSC of 37.4 million sperm (IQR 15.8-84.2). On ROC analysis regarding prediction of abnormal TMSC (<9 million sperm/ejaculate), left testicular PSV was found to have the greatest AUC at 0.73 (95 % CI 0.62-0.85) with Youden index analysis determining an ideal cutoff of 10.22 cm/s. Based on this cutoff, the positive predictive value for identifying a patient with abnormal TMSC was 23.6 %, corresponding to a number needed to screen of approximately 4 patients to identify one with abnormal sperm parameters. Left testicle largest vein diameter was found to have an AUC of 0.48. On univariate logistic regression, PSV <10.22 cm/s was predictive of abnormal TMSC (OR: 5.51 [1.84-16.46], p = 0.002, which persisted on multivariate logistic regression with adjustment for age (OR: 5.49 [1.83-16.43], p = 0.002). CONCLUSION/CONCLUSIONS:Left testicular PSV was the parameter most significantly correlated with TMSC in this cohort. A PSV <10.22 cm/s was found to be predictive of an abnormally low TMSC. There was no significant predictive value of larger veins for abnormal TMSC. When assessing varicocele severity by US, left testicular artery PSV should be measured to help stratify future fertility risk and provide important context regarding shared decision making about potential surgical intervention.

Childhood adversity is increasingly recognized as a critical modifier of neurologic disorder development and disease severity, including in the neuroimmune disorder multiple sclerosis (MS). While previous studies have linked early-life adversity to increased MS susceptibility and more severe disease, the underlying biological mechanisms remain poorly understood. This study investigated associations between childhood adversity and MS clinical features, with a focus on two potential pathogenic mechanisms: allostatic load and epigenetic modifications. We evaluated 60 consecutively enrolled young adults with MS; 30 with paediatric-onset MS (POMS) and 30 with adult-onset MS (AOMS). At time of enrolment in this cross-sectional study, participants had MS disease duration of 6 years on average. POMS participants were mean 22.09 (2.66) years and AOMS participants were mean 32.41 (2.19) years old. 62% of participants were female. Childhood adversity was defined using a composite index of individual, family and socioeconomic measures captured by the adverse childhood experiences questionnaire, parental education level and estimated household income during childhood. Clinical outcomes included patient-reported SymptoMScreen questionnaire regarding MS symptom burden and MS neurologist-assessed disability using the Expanded Disability Status Scale (EDSS) of the participant's neurologic exam at the time of enrolment. Circulating biomarkers of allostatic load and genome-wide epigenetic profiles (DNA methylation via RRBS; reduced representation bisulfite sequencing) were also assessed. A history of high childhood adversity was associated with significantly greater patient-reported MS symptom burden (P = 0.001) and higher neurologist-reported EDSS disability scores (P = 0.028), independent of disease duration or timing of treatment initiation. There were no differences between childhood adversity and circulating biomarkers of allostatic load. While childhood adversity was not associated with global epigenetic changes across the entire cohort, stratified analysis revealed divergent methylation patterns by age of MS onset: POMS participants with childhood adversity had increased DNA methylation, whereas AOMS participants with childhood adversity showed decreased methylation compared to individuals without childhood adversity. None of the observed clinical and biologic differences were explained by differences in disease duration or the interval between symptom onset and treatment initiation. Our findings suggest that childhood adversity is associated with increased MS symptom burden and neurologic disability in young adults with MS. Childhood adversity may differentially shape the epigenome, depending on the age of MS onset, with potential implications for disease trajectory and therapeutic vulnerability. These results support the biological embedding of childhood adversity in MS and highlight the need for age- and exposure-sensitive approaches to understanding MS pathogenesis across the lifespan.

INTRODUCTION/BACKGROUND:Parental refusal of intramuscular (IM) vitamin K in newborns poses challenges, particularly for pediatric urologists assessing the safety of neonatal circumcision. Vitamin K deficiency bleeding (VKDB) is a known risk, with lack of prophylaxis increasing bleeding complications. This study evaluates the safety of neonatal circumcision without IM vitamin K, reviews guidelines, and explores alternative prophylaxis options. OBJECTIVE:To assess if neonatal circumcision can be safely performed on infants lacking IM vitamin K and to identify both optimal timing and alternative prophylactic approaches. METHODS:We conducted a literature review using PubMed and Google Scholar to gather data on neonatal circumcision and VKDB in the context of IM vitamin K refusal. Additionally, we searched for relevant guidelines from the American Urological Association (AUA), American Academy of Pediatrics (AAP), and other organizations. Our study included analysis of ten recent cases of neonatal circumcision without IM vitamin K, focusing on safety outcomes and timing. RESULTS:IM vitamin K is the most effective prophylaxis against VKDB, significantly reducing bleeding risk up to sixfold in neonatal circumcision. Oral vitamin K, sometimes used as an alternative in Europe, shows variable effectiveness and lacks standardization in the U.S. Newborn prothrombin (PT) levels fluctuate significantly in the first week: PT levels are high at birth, drop within 24 h, reach a nadir at 24-72 h, then rebound. Circumcisions performed at 14 days on ten patients without IM vitamin K showed no bleeding complications, suggesting that timing circumcisions after PT stabilization may be safer. CONCLUSIONS:IM vitamin K prophylaxis should remain standard care. In cases of refusal, alternative prophylaxis and timing circumcision after the PT nadir may improve safety. This study underscores the need for updated guidelines from professional organizations, including the AUA, to address the growing trend of IM vitamin K refusal and its implications for neonatal circumcision.

INTRODUCTION/BACKGROUND:It is known the prevalence of varicoceles in adolescent men is 14-29% but there is debate surrounding implications on fertility. As obtaining a semen analysis (SA) may be challenging, there is need for objective tests as measures of fecundity. Our aim was to investigate the relationship between testicular volume differential (TVD), varicocele grade, and total testicular volume (TTV) on seminal parameters including total motile sperm count (TMSC). MATERIALS AND METHODS/METHODS:We conducted a retrospective single-center chart review over 14 years of 486 Tanner V adolescent males. Three hundred and four met inclusion of palpable, non-operated left-sided varicocele who underwent at least one SA and ultrasound. Abnormal TMSC was defined by World Health Organization 2010 criteria for minimal reference ranges. Multivariate logistic regression, receiver operating characteristic analysis with Youden J-statistic and descriptive statistics were performed. RESULTS:Three hundred and four Tanner V adolescents with median age of 18.0 years (18.0-19.0), median TTV of 34.5 cc (28.9, 40.2) and median TMSC of 62.5 million/ejaculate (25.4, 123.4) were evaluated. TTV cutoff of 29.5 cc was found to predict TMSC of <9 million/ejaculate with negative predictive value of 96.2% and odds ratio of 6.08 ([2.13-17.42], p < 0.001). TVD greater than 20% did not reach statistical significance with an odds ratio of 1.66 ([0.41-6.62], p = 0.50). DISCUSSION/CONCLUSIONS:In clinical practice, each patient will need to have an individualized plan. Based on our data, for older adolescents (17 or 18 years) with varicocele and an abnormal TTV, clinicians may have a lower threshold for advising SA, and if unable to obtain, surgical intervention and/or closer surveillance should be stressed. Patients should be informed of their six-fold increase in abnormal SA. Patients with normal TTV should be advised they are at lower risk of having abnormal SA. Younger patients with varicocele and an initial TVD>20%, should be followed closely but intervention delayed until 17 or 18 to better assess TTV. The importance of trending patient data should be emphasized as a single measurement has low predictive value for developing adolescents. Limitations of our study include a retrospective design and the lack of uniform correlation between adolescent SA and paternity. CONCLUSIONS:Total testicular volume less than 29.5 cc increased odds of abnormal semen analysis by over six times and had a negative predictive value of 96.2%. Ultrasound results may be useful for risk stratification and counselling on appropriateness of surgical intervention.

INTRODUCTION/BACKGROUND:There are currently no clinical criteria for obstructed urinary flow after hypospadias repair surgery. Previous studies have utilized adult and pediatric nomograms and flow shapes to define obstruction, however these methods are limited by a lack of standardization and lack of interrater reliability when determining flow shapes, respectively. The idealized voider derived flow indexes offer a way to track uroflowmetry results in a volume and age agnostic manner. OBJECTIVE:We sought to evaluate all our hypospadias patients over a 10-year period and identify patients without complications and those with complications and determine their respective flow parameters. Our secondary objective is to identify which uroflowmetry parameters are the most significant predictors of urethral stricture and meatal stenosis at the time of the uroflowmetry study. STUDY DESIGN/METHODS:Retrospective chart review was used to compile demographic information, details of hypospadias repair surgeries, and uroflowmetry results from pediatric hypospadias repair patients. Subjects were divided into distal, midshaft, and proximal groups based on the initial location of their urethral meatus. Flows from the hypospadias repair groups were compared to flows from normal age matched controls from a previous study. We compared flows from hypospadias repair patients with no complications present with those who had urethral stricture or meatal stenosis present at the time of uroflowmetry. Binary logistic regression and ROC analysis was used to assess different uroflowmetry parameters' ability to detect the presence of obstructed urine flow. RESULTS:467 uroflowmetry studies from 200 hypospadias repair patients were included in the database. Compared to controls, the hypospadias repair groups tended to have significantly lower Qmax, Qavg, Qmax FI, Qavg FI, and longer ttQmax. Significant differences in flow parameters were observed when comparing hypospadias repair patients with and without flow obstructing complications at the time of uroflowmetry. Binary logistic regression including various uroflowmetry parameters showed Qmax FI had a significant effect on the odds of observing the absence of a stricture in proximal and distal hypospadias cases. DISCUSSION/CONCLUSIONS:Of the uroflowmetry parameters analyzed, binary logistic regression and the likelihood ratio of a positive result all point to Qmax FI as the better parameter to use to detect the presence of complications in patients who have undergone distal or proximal hypospadias repair surgery. CONCLUSION/CONCLUSIONS:We have established normal parameters for post-operative hypospadias repair patients which can be used to follow patients over time and allow for the identification of complications by keeping track of flow indexes which are volume and age agnostic.

INTRODUCTION AND OBJECTIVE/OBJECTIVE:Desmopressin is well accepted as first-line medical therapy for enuresis. If ineffective, combination therapy of desmopressin + oxybutynin or desmopressin + imipramine has been used. This study assessed the efficacy of adjunct therapy with either imipramine or oxybutynin in the management of enuresis patients who failed desmopressin treatment. STUDY DESIGN/METHODS:A retrospective chart review of our database for patients with enuresis was performed. Patients who were prescribed desmopressin, oxybutynin, and imipramine over 14 years for enuresis were included. Two cohorts of patients were examined; group OXY was treated with desmopressin and oxybutynin, and group IMP received desmopressin and imipramine. Pretreatment measurement of Vancouver Symptom Scores (VSS) were used to compare groups using the VSS question "I wet my bed at night" where 4: every night, 3: 4-5 nights per week, 2: 1-2 nights per week, 1: 3-4 nights per month, and 0: never. International Children's Continence Society (ICCS) criteria for continence success was utilized to determine outcomes. RESULTS:2521 patients prescribed one of the 3 medications were identified. Among them, 81 patients (mean age: 10.5 ± 2.8 years) received combination therapy. Of which, 55 were male and 26 female. Specifically, 58 were prescribed both desmopressin and imipramine (group IMP), 23 desmopressin and oxybutynin (group OXY), and 4 transitioned from OXY to IMP. Mean pretreatment VSS showed no difference between groups. Both groups experienced minimal drops in wet nights with desmopressin alone. A comparison revealed that group IMP reduced wet nights significantly more than group OXY (VSS wet night score 0.7 ± 1.2 vs. 2.3 ± 1.1 respectively, p < 0.0001). Non-intent-to-treat complete response rate was 68% vs 5% (OR = 42.5, p < 0.001) (IMP vs. OXY respectively). Intent-to-treat response rates were 58%. DISCUSSION/CONCLUSIONS:Although first-line desmopressin treatment for enuresis is effective, it does not work for all patients, and many parents and children desire nighttime dryness. Clinicians have combined desmopressin with oxybutynin or imipramine for improved results, but research comparing these modalities is scarce. Our study suggests that the desmopressin and imipramine combination is superior at reducing nights wet compared to desmopressin and oxybutynin, attributed to imipramine's probable central mechanism rather than its secondary anticholinergic properties. Limitations include a modest sample size, retrospective design, and subjective responses to the Vancouver questionnaire. CONCLUSION/CONCLUSIONS:A combination of desmopressin and imipramine was more effective in reducing wet nights and had a complete response rate that was 42.5 times greater than desmopressin and oxybutynin.

OBJECTIVE:To present our experience in a single pediatric urology practice over a 10-year period with bladder tumors in the pediatric population in an effort to add to the relatively small amount of existing data. We hope to expand the community's knowledge of presentations, management and natural history of pediatric bladder tumors. METHODS:We retrospectively queried our electronic medical records for International Classification of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT) codes relevant for bladder tumors. Patients with underlying bladder pathology, such as neurogenic bladder, history of bladder exstrophy, and history of bladder augmentation, were excluded. RESULTS:We identified 30 patients with bladder tumors from 2011 to 2021. There were 21 males and 9 females. Age at diagnosis ranged from 16 months to 19 years. Tumors identified were: 11 of various inflammatory subtypes; 4 papillomas; 4 rhabdomyosarcomas; 3 papillary urothelial neoplasms of low malignant potential and 8 of other types. Treatment included transurethral resection of bladder tumor, chemoradiation and laparoscopic partial cystectomy. Twenty nine patients had disease limited to the bladder and 1 had disease outside the bladder. Follow-up ranged from 2 weeks to 13 years (median 19 months). All patients had no evidence of disease at most recent follow-up. CONCLUSION:Pediatric bladder tumors range from aggressive rhabdomyosarcomas to more benign urothelial lesions. Fortunately, the latter type of tumor is the more prevalent lesion. Knowledge of the treatment options and natural history of these tumors will hopefully be of benefit to clinicians and parents alike.

Background/UNASSIGNED:Testicular torsion is surgical emergency. Prompt diagnosis and treatment of testicular torsion is essential for testicular viability. At surgical exploration, the spermatic cord is seen twisted a variable number of times around its longitudinal axis. There is scant data regarding the degree of twisting and its association with testis outcomes. The purpose of our study is to explore how the degree of torsion factors into testicular outcome using follow-up data. Methods/UNASSIGNED:We retrospectively reviewed the records of adolescent males who presented with testicular torsion to our institution, looking at duration of pain symptoms, degree of torsion documented in the operative note, procedure performed (orchiopexy versus orchiectomy), and follow-up clinic data for whether testicular atrophy after orchiopexy was present. A non-salvageable testis was defined as orchiectomy or atrophy. Receiver operator characteristics (ROC), multivariate, and logistic regression analyses were performed to determine the probability of a non-salvageable torsed testis based on time and degree of twisting. Results/UNASSIGNED:Eighty-one patients met our study criteria, with 55 testes deemed viable and 26 non-salvageable. We found a 25.7% atrophy rate after orchiopexy. Cut-off values of 8.5 h and 495 degrees of torsion would provide sensitivities of 73% and 53%, respectively, with specificity of 80% for both. Only duration and age were correlated with the risk of non-salvage on multivariate analysis. Logistic regression generated linear probability formulas of 4 + (3 ¡Á hours) and 7 + (0.05 ¡Á degrees) in calculating the probability of non-salvage with strong correlation. Conclusions/UNASSIGNED:We were able to derive separate formulas to determine the viability of the torsed testis based on symptom duration and degrees of twisting. Fifteen h of symptoms and 860 degrees of torsion gives testes a 50% salvage rate. Interestingly, we also found that about 1 out of every 4 testes undergoes atrophy after orchiopexy.