No abstract

Idiopathic overactive bladder (OAB) is a chronic condition that negatively affects quality of life, and oral medications are an important component of the OAB treatment algorithm. Recent literature has shown that anticholinergics, the most commonly prescribed oral medication for the treatment of OAB, are associated with cognitive side effects including dementia. β3-adrenoceptor agonists, the only alternative oral treatment for OAB, are similar in efficacy to anticholinergics with a more favorable side effect profile without the same cognitive effects. However, there are marked cost variations and barriers to access for OAB medications, resulting in expensive copays and medication trial requirements that ultimately limit access to β3-adrenoceptor agonists and more advanced procedural therapies. This contributes to and perpetuates health care inequality by burdening the patients with the least resources with a greater risk of dementia. When prescribing these medications, health care professionals are caught in a delicate balancing act between cost and patient safety. Through multilevel collaboration, we can help disrupt health care inequalities and provide better care for patients with OAB.

Background Vulvovaginal involvement in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is common, likely underdiagnosed, and can result in severe sequelae if not managed acutely. There are few studies on acute management of vulvovaginal SJS/TEN. Current recommendations are predominantly based on expert opinion. We aimed to determine the frequency of vulvovaginal involvement in SJS/TEN at a single institution, identify treatment modalities, and assess outcomes at a tertiary care burn center.Methods This is a retrospective review of vulvovaginal SJS/TEN cases between 2009 and 2019. Demographic and clinical data including exam findings, treatment regimens, and outpatient follow-up were collected from the electronic medical record.Results Vulvovaginal involvement was observed in 12.7% (19/149) of cases of female patients with SJS/TEN. The mean age was 38.7 years (SD 23.6), and 21% (4/19) of patients were pediatric (age 9-18). Vulvar involvement was seen in 47.3% (9/19), and vulvar plus vaginal involvement was reported in 42.1% (8/19). Treatment regimens were variable until 2017, at which time institutional guidelines were implemented including application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression.Gynecology follow-up occurred in 15.7% (3/19) of cases. One complication of superficial vaginal agglutination was noted and was successfully treated in the office with blunt dissection. ConclusionThe most common treatment modalities employed at our institution included application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression.While follow-up was limited for our patient population, we propose an algorithm to prevent long-term sequalae of vulvovaginal SJS/TEN. Gynecologic surveillance is recommended to reduce urogynecologic sequelae.

It is estimated that more than 30 million women in the United States are affected by pelvic floor disorders. Of these, 3 million experience pelvic organ prolapse. A robust surgical option for treatment of vaginal vault prolapse is sacrocolpopexy (SC).A rare but life-threatening possible sequela of SC is bowel obstruction. There are only limited data on its prevention, prevalence, detection, and management.Previous studies reported rates of bowel obstruction after SC ranging from 1.9% to 2.5%. A comprehensive review found that bowel obstruction after SC was managed surgically in 0.6%-8.6% of cases. Few studies have described the diagnosis, therapeutic options, and long-term consequences of bowel obstruction. Although early detection and treatment can prevent patient morbidity and mortality from adverse events of obstruction such as bowel incarceration and ischemia, presenting symptoms can be mistakenly attributed to other diagnoses. Especially in the immediate postoperative period, common symptoms of bowel obstruction are often indistinguishable from those of ileus. Bowel obstruction can occur from 5 days to 14 years after surgery, further challenging its diagnosis.The aim of this study was to identify clinical and surgical factors associated with occurrence of bowel obstruction after SC and to describe its presentation, management strategies (medical vs surgical), and long-term sequelae. The authors obtained data from a retrospective case series of patients who underwent open, laparoscopic, or robotic SC between January 1, 2009 and December 31, 2019 at hospitals within a large health maintenance organization and a single academic medical center in Southern California.Of 3231 patients, 32 (1.0%) who underwent SC experienced a subsequent bowel obstruction. Thirteen (40.6%) of the 32 patients underwent SC using an open abdominal approach, and 19 (59.4%) via laparoscopic or robotic approach. Among the 32 patients experiencing bowel obstruction, medical management was undertaken in 19 (59.4%). Of the 13 patients managed surgically, 8 (61.5%) had severe bowel obstruction requiring bowel resection, and 3 (23.1%) had partial mesh excision. Two (10.5%) of the medically managed, and 2 (15.4%) of the surgically managed cases had recurrent obstruction.Findings in this small case series suggest that the type of hysterectomy may not be a risk factor for bowel obstruction. The timing of occurrence of this complication spans from days to nearly a decade after SC, which emphasizes the need for surveillance in the immediate postoperative period as well as long-term. Conservative management may be effective long-term as shown by similar rates of recurrence between medically and surgically managed patients. The data provide information to guide surgeons in patient selection, informed counseling, surgical planning before SC, and may aid in diagnosis and management of bowel obstruction after SC. The study is limited by its small sample size secondary to the low prevalence of bowel obstruction.

ObjectiveThe aims of this study were to describe the fecal relative abundance of potentially uropathogenic bacteria and to analyze antibiotic resistance genes before and after fecal microbiota transplantation in women with recurrent urinary tract infection (UTI).MethodsShotgun sequencing was performed on fecal samples from 3 donors and 4 women with recurrent UTI who underwent transplantation. Recipient samples were sequenced at baseline and at 4 time points through 6 months postintervention. Relative fecal uropathogen abundance was analyzed by species and participant using descriptive statistics. Antibiotic resistance gene abundance was assigned, normalized, and compared between donors and recipients at baseline and postintervention using an abundance bar plot, nonmetric multidimensional scaling, and pairwise permutational multivariate analysis of variance.ResultsThe median (range) relative abundance of Escherichia coli in all fecal samples from women with recurrent UTI was 0% (0%–5.10%); Enterococcus faecalis, 0% (0%–0.20%); Enterococcus faecium, 0% (0%–1.90%); Klebsiella pneumoniae, 0% (0%–0.10%); and Pseudomonas aeruginosa, 0% (0%–0.10%). Gut microbes carried genes conferring resistance to antibiotics used for UTI. No significant difference was seen in antibiotic resistance gene carriage after transplantation compared with baseline (P=0.22, R2=0.08 at 3 months). Antibiotic gene composition and abundance were significantly associated with the individual from whom the sample came (P=0.004, R2=0.78 at 3 months).ConclusionsExploratory analysis of gut microbiomes in women with recurrent UTI identifies no or low relative putative uropathogen abundance for all species examined. Antibiotic resistance gene carriage persisted after fecal microbiota transplantation, although conclusions are limited by small sample size.

ImportanceThere is a lack of consensus regarding the clinical applicability of fluoroscopic defecography in evaluation of pelvic organ prolapse.ObjectivesThe aim was to evaluate the association between rectocele on defecography and posterior vaginal wall prolapse (PVWP) on physical examination. The secondary objective was to describe radiologic and clinical predictors of surgical intervention and outcomes.Study DesignThis was a retrospective review of patients enrolled in a large health maintenance organization who underwent defecography and were examined by a urogynecologist within 12 months. The electronic medical record was reviewed for demographic and clinical variables, including pelvic organ prolapse and defecatory symptoms, physical examination, and surgical intervention through 12 months after initial urogynecologic examination or 12 months after surgery if applicable.ResultsOne hundred eighty-six patients met inclusion criteria. Of those, 168 (90.3%) had a rectocele on defecography and 31 (16.6%) had PVWP at or beyond the hymen. Rectocele size on defecography was poorly correlated with PVWP stage (spearman ρ = 0.18). Forty patients underwent surgical intervention. Symptoms of splinting, digitation, and stool trapping were associated with surgical intervention (odds ratio, 4.24; 95% confidence interval, 1.59–11.34; P < 0.01) as was advanced PVWP stage (P < 0.01), while rectocele presence and size on defecography were not. Large rectocele size on defecography was correlated with persistent postoperative defecatory symptoms (P = 0.02).ConclusionsWe demonstrated a poor correlation between rectocele size on defecography and PVWP stage. Defecatory symptoms (splinting, digitation, stool trapping) and higher PVWP stage were associated with surgical intervention, while rectocele on defecography was not.

It is estimated that more than 30 million women in the United States are affected by pelvic floor disorders. Of these, 3 million experience pelvic organ prolapse. A robust surgical option for treatment of vaginal vault prolapse is sacrocolpopexy (SC).A rare but life-threatening possible sequela of SC is bowel obstruction. There are only limited data on its prevention, prevalence, detection, and management.Previous studies reported rates of bowel obstruction after SC ranging from 1.9% to 2.5%. A comprehensive review found that bowel obstruction after SC was managed surgically in 0.6%-8.6% of cases. Few studies have described the diagnosis, therapeutic options, and long-term consequences of bowel obstruction. Although early detection and treatment can prevent patient morbidity and mortality from adverse events of obstruction such as bowel incarceration and ischemia, presenting symptoms can be mistakenly attributed to other diagnoses. Especially in the immediate postoperative period, common symptoms of bowel obstruction are often indistinguishable from those of ileus. Bowel obstruction can occur from 5 days to 14 years after surgery, further challenging its diagnosis.The aim of this study was to identify clinical and surgical factors associated with occurrence of bowel obstruction after SC and to describe its presentation, management strategies (medical vs surgical), and long-term sequelae. The authors obtained data from a retrospective case series of patients who underwent open, laparoscopic, or robotic SC between January 1, 2009 and December 31, 2019 at hospitals within a large health maintenance organization and a single academic medical center in Southern California.Of 3231 patients, 32 (1.0%) who underwent SC experienced a subsequent bowel obstruction. Thirteen (40.6%) of the 32 patients underwent SC using an open abdominal approach, and 19 (59.4%) via laparoscopic or robotic approach. Among the 32 patients experiencing bowel obstruction, medical management was undertaken in 19 (59.4%). Of the 13 patients managed surgically, 8 (61.5%) had severe bowel obstruction requiring bowel resection, and 3 (23.1%) had partial mesh excision. Two (10.5%) of the medically managed, and 2 (15.4%) of the surgically managed cases had recurrent obstruction.Findings in this small case series suggest that the type of hysterectomy may not be a risk factor for bowel obstruction. The timing of occurrence of this complication spans from days to nearly a decade after SC, which emphasizes the need for surveillance in the immediate postoperative period as well as long-term. Conservative management may be effective long-term as shown by similar rates of recurrence between medically and surgically managed patients. The data provide information to guide surgeons in patient selection, informed counseling, surgical planning before SC, and may aid in diagnosis and management of bowel obstruction after SC. The study is limited by its small sample size secondary to the low prevalence of bowel obstruction.

ObjectiveThe primary objective was to evaluate the use of a novel video for enhancing patient knowledge of midurethral sling compared with standard handout.MethodsParticipants scheduled for midurethral sling were randomized to 1 of 2 preoperative educational interventions, either video or standard handout. The primary outcome was change in knowledge measured via a 15-question questionnaire completed immediately before and after the intervention. Secondary outcomes were knowledge retention, urinary symptoms, decision satisfaction, and regret measured via validated questionnaires at 2 and 6 weeks postoperatively. Data are presented as median (interquartile range) and comparisons between intervention groups made using non-parametric statistics. A sample size of 16 per arm was calculated to detect a 20% effect size.ResultsThirty-eight participants, 19 per site, were randomized from August 2019 to October 2020 and 37 (97%) completed the primary outcome per protocol. Median age was 51 years (18 years), and there were no significant demographic differences between groups. Participants randomized to video demonstrated greater change in knowledge than those randomized to handout (+8.5 (3) vs +2.0 (4), P < 0.0001). Those randomized to video demonstrated improved 6 week postoperative urinary symptoms (Urogenital Distress Inventory-6, 0.0 [8.3] vs 14.6 [26.0]; P = 0.02; Incontinence Severity Index, 0.0 [2] vs 3.0 [4]; P = 0.005). There were no differences in satisfaction with decision (5.0 [0] video vs 5.0 [0.9] handout; P = 0.48) or decision regret (1.0 [0.5] video vs 1.0 [0.8] handout; P = 0.80) at 6 weeks postoperatively.ConclusionsA preoperative educational video improved knowledge and urinary symptoms after midurethral sling compared with a standard handout.