Faculty Bibliography

INTRODUCTION/UNASSIGNED:Anticholinergic (Ach) medications, a mainstay in the treatment of overactive bladder (OAB), are increasingly linked to incident dementia. Beta-3 agonists (B3A) have emerged as an alternative with a more favorable side-effect profile, especially in elderly patients. This study evaluated whether treating OAB with B3A instead of Ach is cost-effective, accounting for the long-term clinical and economic impact of Ach-associated dementia. METHODS/UNASSIGNED:A cost-effectiveness analysis was conducted from the health care sector perspective using a Markov microsimulation model comparing Ach and B3A over a 15-year horizon. Model inputs included costs, utilities, and probabilities of health states and adverse events associated with untreated OAB, pharmacotherapy, and minimally invasive therapies. Health states transitioned between untreated OAB, Ach or B3A, minimally invasive therapy, and dementia. Analysis was performed with TreeAge. RESULTS/UNASSIGNED:Over 15 years, total health care costs were $97,000 for Ach versus $90,961 for B3A, and total QALYs were 8.65 versus 8.79, respectively. Sensitivity analysis revealed that B3A alone, compared to Ach alone or Ach followed by B3A, is the dominant strategy, and this held when inputs were varied across their ranges. CONCLUSIONS/UNASSIGNED:B3A are cost-saving and more effective than Ach for OAB, largely driven by the elevated dementia risk associated with Ach exposure and the substantial costs and diminished quality of life inherent to dementia. Although clinical guidelines favor eliminating step therapy, many payers still mandate an Ach trial before approving B3A. The long-term burden of Ach-associated dementia exceeds the lower upfront cost of Ach, making B3A more cost-effective overall.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:To evaluate current literature on uterine-sparing surgery for pelvic organ prolapse (POP) with respect to subsequent obstetric outcomes and POP recurrence. METHODS:A comprehensive search was conducted through MEDLINE and PubMed from 1993 to November 2025 using PRISMA guidelines for studies exploring patients who had subsequent deliveries after undergoing surgical management of POP. Articles were evaluated by three independent reviewers for quality, relevance, and outcomes assessment. RESULTS:Eighteen studies (six prospective, nine retrospective, and three case series) that included follow-up data on 126 patients with pregnancy after POP surgery were included in data analysis. The mean follow-up period was 37.2 months. The majority of patients had previously undergone native tissue POP repair, 64.3%, vs 35.7% who had undergone mesh-augmented repairs. Nearly all (94.8%) deliveries after POP surgery occurred at term. Cesarean delivery (CD) was common (65.8%). No neonatal complications were reported. POP recurrence rate was 11.7% with the majority (71.4%) occurring after native tissue repair. Analyzed separately, among 14 case reports of pregnancies following mesh-based sacrohysteropexy, cesarean delivery was common (85.7%) and prolapse recurrence rate was low. CONCLUSION/CONCLUSIONS:Current evidence suggests that uterine-sparing prolapse surgery, whether mesh-augmented or native tissue, is associated with favorable obstetric outcomes, low neonatal risk, and low rates of POP recurrence; however, longitudinal data is limited in the absence of randomized controlled trials.

IMPORTANCE/OBJECTIVE:A cost analysis model of supracervical (SCH) versus total hysterectomy (TH) at the time of minimally invasive sacrocolpopexy (SCP) has not been established. OBJECTIVES/OBJECTIVE:Minimally invasive sacrocolpopexy (SCP), a mesh-augmented pelvic organ prolapse (POP) repair, is frequently performed with concomitant hysterectomy, either a supracervical hysterectomy (SCH) or total hysterectomy (TH), with comparable POP outcomes with either approach. However, for SCH versus TH, there are important implications on cervical cancer screening and reported complication rates. Clinical outcomes data have not identified a clear preferred hysterectomy type at the time of SCP. This study aimed to perform a cost analysis to compare SCH versus TH at the time of SCP for POP. STUDY DESIGN/METHODS:A health care sector-perspective analysis was performed using a 10-year time horizon. Our model assumes that there is similar efficacy and patient satisfaction for SCH and TH, and that the age of patients undergoing SCP is 55 years (median age in the literature). The average cost of procedures and complications were estimated from publicly available data sources. Base-case probabilities for various complications were estimated through a PubMed literature search. RESULTS:TH-SCP is $654 less costly per treatment case compared with SCH-SCP ($26,101 vs. $26,754). Three model variables have the potential to reverse this cost advantage when varied across their ranges: SCH-SCP surgery, TH-SCP surgery, and the cost of cervical screening. Based on our model assumptions, SCH-SCP was 2.5% more costly than TH-SCP in relative terms. CONCLUSION/CONCLUSIONS:SCH-SCP was found to be more costly over a 10-year time horizon than TH-SCP in our study population.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:Patients with stage 3 or 4 pelvic organ prolapse (POP) may concurrently have hydronephrosis. Consequences of hydronephrosis, such as acute kidney injury and chronic kidney disease, have significant costs to patients and healthcare facilities. In this study, we evaluate the cost-effectiveness of renal ultrasound to screen for hydronephrosis in patients with stage 3 or 4 POP. METHODS:We designed a decision tree model comparing screening renal ultrasound versus usual care for patients with stage 3 or 4 POP. In the screening strategy, patients undergo ultrasound and subsequently proceed with pessary or surgery should they screen positive for hydronephrosis or proceed with expectant management, pessary, or surgery should they screen negative. In the non-screening strategy, patients choose treatment as they normally would and those with underlying hydronephrosis either continue to have hydronephrosis or have resolution of hydronephrosis. We modeled a time horizon of 5 years, with a 3% discount rate annually for future costs and quality-adjusted life-years (QALY). This was an IRB-exempt study. RESULTS:At a willingness to pay threshold of $150,000/QALY, renal ultrasound was cost-effective when the majority of patients who screen positive for hydronephrosis choose pessary instead of surgery. Screening renal ultrasound is cost-effective if less than 36.3% of patients with hydronephrosis choose surgery. At 5 years, screening renal ultrasound was cost-effective regardless of the prolapse treatment chosen by patients with hydronephrosis. CONCLUSION/CONCLUSIONS:Routine renal ultrasound screening of patients with stage 3 or 4 POP is a cost-effective strategy to identify hydronephrosis and guide treatment that mitigates risk of permanent renal damage.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:Perineal wound breakdown is a rare but important complication following childbirth-related perineal trauma. Though many providers manage wound breakdown via expectant management, the optimal strategy remains debated. In this review, we systematically compile a comprehensive overview of existing data on management of perineal wound dehiscence with emphasis on timing, surgical technique and personnel, outcomes, and considerations to obstetric anal sphincter injuries (OASIS). METHODS:Our literature search utilized PubMed, SCOPUS, and EMBase databases. RESULTS:Thirteen relevant articles were included in our review. The majority of studies reported resuturing within 2 weeks of diagnosis (11/13), utilizing intraoperative antibiotics (10/13) and polyglactin suture (13/13). Repairs were largely completed in the operating room by an Ob/Gyn; Urogynecology and Reconstructive Pelvic Surgery (URPS) subspecialists were specified in two studies. Complete healing occurred in 57.1-92.9% of patients, typically by 3 months postoperatively, but also reported up to 1 year after repair. Dyspareunia was the most common complication (5.6-27.8%). Minor complications included superficial separation (14.3%) and surgical site infection (9.5%). Four studies focused on OASIS, and repair in these settings often required an URPS consultation and was associated with fecal urgency, flatal and/or fecal incontinence (13.6-37.0%). CONCLUSIONS:Evidence supports early resuturing within 2 weeks of perineal wound breakdown, demonstrating good short-term outcomes. Optimal management includes intraoperative cephalosporin administration, polyglactin sutures, and URPS consultation, especially if breakdown of OASIS is suspected. Future studies should examine long-term outcomes, such as rates of persistent anal incontinence, and overall patient satisfaction regarding the timing and techniques of perineal laceration repair revision.

Stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) and symptoms of urgency, frequency, and nocturia are prevalent during pregnancy and the postpartum period but often are underestimated. Overactive bladder, including UUI, affects nearly 65% of patients during pregnancy. Postpartum SUI particularly is associated with mood disorders. Despite the association, many women delay seeking care. Effective treatments for urinary incontinence are available, and timely peripartum screening supports early intervention and enhances quality of life.

IMPORTANCE/OBJECTIVE:Postpartum patients generally have limited knowledge of urinary incontinence (UI) and pelvic organ prolapse (POP). However, it is unclear what differences exist in knowledge level between English- and Spanish-speaking postpartum patients for each condition. OBJECTIVE:The objective of this study was to report rates of knowledge proficiency on UI and POP in English- and Spanish-speaking postpartum patients. STUDY DESIGN/METHODS:In this cross-sectional study of postpartum patients at a tertiary care center, knowledge was assessed using the English and Spanish language-validated Prolapse and Incontinence Knowledge Questionnaire. Knowledge proficiency on UI was defined as answering correctly ≥80% of the questions and for POP as answering correctly ≥50% of the questions, based on cutoffs implemented by Geynisman-Tan et al previously. Pelvic floor disorder symptom severity was assessed using the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7. RESULTS:Fifty English- and 50 Spanish-speaking patients completed the survey questionnaires. Spanish-speaking patients had lower rates of UI proficiency compared to English-speaking patients (10.0% vs 40.0%, P < 0.001) and were less likely to identify childbirth to be a risk factor for UI compared to English-speaking patients. For POP, proficiency levels were low but similar between English and Spanish speakers. Pelvic floor disorder symptom severity and impact on quality of life were low, did not differ between the 2 groups, and did not correlate with knowledge scores. CONCLUSION/CONCLUSIONS:English- and Spanish-speaking postpartum patients have low knowledge of both UI and POP. Postpartum patients need educational resources to understand the risks and treatments for pelvic floor disorders.

IMPORTANCE/OBJECTIVE:This is the first systematic review on female sexual dysfunction (FSD) in patients who sustained obstetric anal sphincter injury (OASI). OBJECTIVE:The aim of the study was to characterize FSD following OASI. STUDY DESIGN/METHODS:Between January and April 2024, we conducted a literature search of studies that explored outcomes of FSD following OASI, reporting on rates of dyspareunia and/or using questionnaires that measured female sexual function. RESULTS:Fourteen studies with 1,907 OASI patients met inclusion criteria. Rates of dyspareunia in the first year after OASI ranged from 27% to 35% with only 40%-57% of women having resumed sexual activity at 3 months postpartum. The Female Sexual Function Index (FSFI) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were the most utilized questionnaires. Using the FSFI, the range of FSD was 47%-81% among patients with OASI. The FSFI subdomain scores (maximum 6) for desire and arousal had the least improvement with time, ranging from 1.3-2.1 at 2 months to 3-3.1 at 4 months. Pain, lubrication, and orgasm domains showed greater improvement with time, ranging from 1.4-1.6 at 2 months and up to 3.5-3.8 at 4 months. Five studies used the PISQ-12 with mean scores of 34.1-39 (range 0-48), 3 of which included a non-OASI control group and found similar PISQ-12 scores between groups. Physical therapy did not significantly impact FSD. CONCLUSIONS:One-third of patients with OASI experience dyspareunia in the first year postpartum, 1in 2 patients do not resume intercourse at 3 months postpartum, and FSD, measured by the FSFI, may be present in 80% of women with OASI at 3 months postpartum.

INTRODUCTION/UNASSIGNED:Office administration of intradetrusor onabotulinumtoxinA is commonly used to treat overactive bladder. For preprocedure analgesia, either 50 mL 2% intravesical lidocaine instillation for 20 to 30 minutes or 200 mg oral phenazopyridine can be used. Phenazopyridine is associated with shorter appointment times and is noninferior to lidocaine for pain control in this setting. We performed a cost analysis of phenazopyridine vs lidocaine for analgesia before office intradetrusor onabotulinumtoxinA injection for the treatment of idiopathic overactive bladder. METHODS/UNASSIGNED:A health care sector-perspective cost analysis was performed. The following assumptions were made: (1) similar efficacy of each medication in providing adequate analgesia, (2) similar physician ease of performing the procedure with either analgesic, and (3) similar patient satisfaction with either analgesic. Average cost of medications, adverse reactions, nursing tasks, and office visit time were found in publicly available data. Sensitivity analyses were performed using TreeAge Pro 2021, R1 software. RESULTS/UNASSIGNED:Phenazopyridine is less costly compared to lidocaine per visit for office intradetrusor onabotulinumtoxinA injection ($827 vs $925). A difference of $98 per procedure provides a total annual cost savings of over $24 million if all procedures are performed with phenazopyridine instead of lidocaine. Sensitivity analysis showed that phenazopyridine remained less costly under most circumstances, and threshold analysis provided exact circumstances under which phenazopyridine is no longer cost saving. CONCLUSIONS/UNASSIGNED:Phenazopyridine provides cost savings compared to lidocaine for analgesia before office intradetrusor onabotulinumtoxinA injection for the treatment of idiopathic overactive bladder. If adopted by providers nationwide, phenazopyridine may reduce health care spending and minimize office visit time while maintaining patient pain control and satisfaction.