Faculty Bibliography

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: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.

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.

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.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:Social media content related to patient experiences and education continues to grow. Information on how obstetric perineal lacerations are represented on social media is limited. Our goal is to characterize available social media content on obstetric perineal lacerations. METHODS:This is an IRB-exempt study using publicly available data on commonly searched topics about perineal lacerations to create a list of queries for Instagram and TikTok. The ten queries and "keyword" searches with the highest number of posts were identified from this list. The 50 most recent posts were reviewed for relevance, quality of content, and authorship. Topic-relevant posts were analyzed. RESULTS:The search yielded 427 posts on Instagram and 500 on TikTok. Instagram yielded more topic-relevant posts than TikTok (94.1% vs 44.8%). Almost 50% of posts were categorized as educational. Instagram identified more patient experience-related posts (29.6%) whereas TikTok provided more humorous content (26.3%). Patients produced 27.6% of content on Instagram and 43.3% on TikTok. Physical therapists produced 18.9% of posts on Instagram and 21.9% on TikTok. They constituted the largest group of health professionals to post overall. Physician-created educational content accounted for 10.3% of posts on Instagram and 6.0% on TikTok. CONCLUSIONS:Compared with TikTok, Instagram may be a more informative social media platform for educational or patient experience-related content. Given the paucity of physician-created content and given that only half of all posts are educational, providers should encourage social media engagement for community and networking purposes, while encouraging caution with regard to cosmetic products and advertisements.

BACKGROUND:The efficacy of intradetrusor onabotulinumtoxinA injections for the management of idiopathic overactive bladder has been well-established. The injections are typically performed in the office setting using local analgesia, most commonly a 20 to 30-minute intravesical instillation of lidocaine. There are limited data evaluating alternative bladder analgesics. OBJECTIVE:To compare pain scores with preprocedure oral phenazopyridine vs intravesical lidocaine in women undergoing intradetrusor onabotulinumtoxinA injections for idiopathic overactive bladder. STUDY DESIGN/METHODS:Nonpregnant adult females with idiopathic overactive bladder, scheduled for office injection of 100 units of intradetrusor onabotulinumtoxinA were randomized to either 200 mg of oral phenazopyridine taken 1 to 2 hours preprocedure or a 20-minute preprocedure intravesical instillation of 50 mL of 2% lidocaine. We excluded participants with neurogenic bladders, and those who had received intradetrusor onabotulinumtoxinA injections in the previous 12 months. The primary outcome was pain measured by a 100-mm visual analog scale. Demographic characteristics and overall satisfaction with the procedure were also recorded. Providers answered questions about cystoscopic visualization, ease of procedure, and perception of participant comfort. Prespecified noninferiority margin was set to equal the anticipated minimum clinically important difference of 14 mm. A planned sample of 100 participants, 50 in each treatment arm, provided 80% power to detect noninferiority at a significance level of.05. We performed a modified intention-to-treat analysis and compared variables with the t test or the Fisher exact test. RESULTS:A total of 111 participants were enrolled, and complete data were obtained for 100 participants; 47 participants were randomized to phenazopyridine and 53 to lidocaine. Baseline characteristics did not differ between groups. There were 19.6% and 20.8% of participants in the phenazopyridine and lidocaine groups, respectively, who previously underwent intradetrusor onabotulinumtoxinA injections. The mean postprocedure pain was 2.7 mm lower in the phenazopyridine group than in the lidocaine group (95% confidence interval, -11.3 to 10.7), demonstrating noninferiority. More than 90% of participants in both groups stated that the pain was tolerable. Slightly more participants reported being "very satisfied" in the lidocaine group, although this was not statistically significant (50.0% vs 40.4%; P=.34). Providers reported clear visualization in 89.4% of participants in the phenazopyridine group and in 100% of participants in the lidocaine group (P=.02). Provider perception of participant comfort and overall ease of procedure were not different between groups. Length of time in the exam room was significantly shorter in the phenazopyridine than in the lidocaine group (44.4 vs 57.5 minutes; P=.0003). CONCLUSION/CONCLUSIONS:In women receiving intradetrusor onabotulinumtoxinA injections for idiopathic overactive bladder, oral phenazopyridine was noninferior to intravesical lidocaine for procedural pain control. Phenazopyridine is well-tolerated by participants, allows for the procedure to be performed with similar ease, and is associated with shorter appointment times.

IMPORTANCE/OBJECTIVE:Diabetes is an independent risk factor for urinary incontinence, and its impact on rates of postoperative incontinence after pelvic reconstructive surgery remains unexplored. OBJECTIVE:The aim of the study was to compare the incidence of postoperative stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence in patients with diabetes mellitus undergoing surgery for pelvic organ prolapse (POP) with or without SUI surgery. STUDY DESIGN/METHODS:This is a secondary analysis of a multicenter retrospective cohort study involving 10 diverse medical centers that identified a cohort of women with diabetes who had prolapse and/or anti-incontinence surgery. We compared rates of postoperative urinary incontinence among patients who had surgery for prolapse and incontinence versus surgery for prolapse only. RESULTS:Three hundred five patients had surgery for prolapse and incontinence, 330 had surgery for prolapse only, and 189 had anti-incontinence surgery only. De novo UUI was higher among those who underwent surgery for POP and SUI compared with surgery for POP alone (26.4% vs 14.1%, P < 0.01). Rates of persistent SUI (21% vs 4.9%, P < 0.01) and mixed urinary incontinence (15.9% vs 2.7%, P < 0.01) were higher for those who underwent prolapse surgery alone versus prolapse and an incontinence procedure. No differences were seen in hemoglobin A1C levels between those who did and did not report postoperative UI. CONCLUSIONS:We found that postoperative de novo UUI rates were high among patients with diabetes after pelvic reconstructive surgery, with the incidence being significantly higher for those who had surgery for prolapse and incontinence compared with surgery for prolapse only.

STUDY OBJECTIVE/OBJECTIVE:To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. DESIGN/METHODS:A multicenter prospective cohort study. SETTING/METHODS:Ten institutions in the United States. PATIENTS/METHODS:Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. INTERVENTIONS/METHODS:Benign gynecologic surgery. MEASUREMENTS AND MAIN RESULTS/RESULTS:The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4-50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). CONCLUSION/CONCLUSIONS:In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.

OBJECTIVES:Poor control of diabetes mellitus is a known predictor of perioperative and postoperative complications. No literature to date has established a hemoglobin A1c (HbA1c) cutoff for risk stratification in the urogynecology population. We sought to identify an HbA1c threshold predictive of increased risk for perioperative and postoperative complications after pelvic reconstructive surgery. METHODS:This multicenter retrospective cohort study involving 10 geographically diverse U.S. female pelvic medicine and reconstructive surgery programs identified women with diabetes who underwent prolapse and/or stress urinary incontinence surgery from September 1, 2013, to August 31, 2018. We collected information on demographics, preoperative HbA1c levels, surgery type, complications, and outcomes. Sensitivity analyses identified thresholds of complications stratified by HbA1c. Multivariate logistic regression further evaluated the association between HbA1c and complications after adjustments. RESULTS:Eight hundred seven charts were identified. In this diabetic cohort, the rate of overall complications was 44.1%, and severe complications were 14.9%. Patients with an am HbA1c value of 8% or greater (reference HbA1c, <8%) had an increased rate of both severe (27.1% vs 12.8%, P < 0.001) and overall complications (57.6% vs 41.8%, P = 0.002) that persisted after multivariate logistic regression (odds ratio, 2.618; 95% confidence interval, 1.560-4.393 and odds ratio, 1.931; 95% confidence interval, 1.264-2.949, respectively). Mesh complications occurred in 4.6% of sacrocolpopexies and 1.7% of slings. The average HbA1c in those with mesh exposures was 7.5%. CONCLUSIONS:Preoperative HbA1c of 8% or higher was associated with a 2- to 3-fold increased risk of overall and severe complications in diabetic patients undergoing pelvic reconstructive surgery that persisted after adjustments.

OBJECTIVE:The aim of the study was to compare the racial/ethnic representation in studies supporting the 2019 American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction overactive bladder diagnosis and treatment guideline to the racial/ethnic distribution of the U.S. population. METHODS:We analyzed the race and ethnicity of participants in the articles cited in the 2019 American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction nonneurogenic overactive bladder guidelines. The primary outcome was the representation quotient, the ratio of the proportion of a racial/ethnic group in the guideline studies relative to the estimated proportion of that group in the U.S. population. Data were analyzed using descriptive statistics and Pearson χ2 test. RESULTS:There were 387 studies included, 35% of which reported participants' race. Of the studies that included U.S. participants, 111 (61%) reported race and 44 (24%) reported Hispanic ethnicity. The representation quotient for White and Asian participants was 1.06 and 1.62, indicating overrepresentation relative to the U.S. population, respectively. The representation quotient for Black, Hispanic, and American Indian/Alaska Native participants was 0.85, 0.56, and 0.02, respectively, indicating underrepresentation for these groups. Evaluation of the representation quotients over time revealed no meaningful change in representation from 1990 to 2019 for any racial/ethnic group. CONCLUSIONS:The evidence based on the overactive bladder guidelines is derived from studies that frequently failed to report race/ethnicity and is not reflective of the U.S. population. Black, Hispanic, and American Indian/Alaska Native participants that are underrepresented in U.S.-based studies, highlighting the need for more inclusive recruitment strategies in overactive bladder research.