Antibiotic Duration and UTI Outcomes in Recurrent UTI Patients.

IMPORTANCE: Little evidence is available to inform management of acute urinary tract infections (UTIs) in women with recurrent urinary tract infection (rUTI). OBJECTIVE: This study aimed to compare the proportion of acute UTIs with persistence/relapse or recurrence based on duration of treatment antibiotics (acute UTI guideline-consistent versus extended). STUDY DESIGN: A retrospective noninferiority study of women with rUTI was performed at an academic tertiary referral center from January 2016 to December 2020. Exposure was UTI treatment with acute UTI guideline-consistent versus extended antibiotics. Outcomes were persistent/relapsed UTI (subsequent culture with the same pathogen requiring additional antibiotics within 4 weeks), recurrent UTI (culture with different pathogen), or resolution. Sample size was calculated under the null hypothesis that the proportion of acute UTIs with persistence/relapse or recurrence after acute UTI guideline-consistent antibiotics would be within a 10% noninferiority margin of extended duration (α = 0.05, ß = 0.20, 2-sided tests, P < 0.05 significant). RESULTS: We included 219 patients with 553 acute UTIs. The mean ± SD number of UTIs per patient was 2.53 ± 1.88, the mean ± SD age was 68.60 ± 16.29 years, and the mean ± SD body mass index was 29.73 ± 7 (calculated as weight in kilograms divided by height in meters squared). There were no differences in prior surgical procedures postvoid residual volume, pelvic floor disorders, or preventive treatments between groups. Two-hundred sixty UTIs (260 of 553 [47%]) were treated with acute UTI guideline-consistent antibiotics. Overall, 86 of 553 UTIs (15.6%) persisted/relapsed, and 29 of 553 (5.2%) recurred. The difference in the proportions of UTIs with persistence/relapse or recurrence excluded the noninferiority margin (4.4%; 95% confidence interval, -0.04 to 6.80%). In total, 115 of 553 UTIs (20.8%) had persistence/relapse or recurrence. CONCLUSION: In this cohort of patients with rUTI experiencing acute UTIs, acute UTI guideline-consistent duration of antibiotics was noninferior.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction. METHODS: An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed. RESULTS: The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP. CONCLUSIONS: The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Underrepresentation in Pelvic Floor Disorder Patient-Reported Outcomes: Whose Outcomes Are We Measuring?

IMPORTANCE: Patient-reported outcome (PRO) instruments measure the patient's perspective. It is unclear whether commonly used PRO measures were tested in populations that had racial and ethnic distributions comparable with those reported in U.S. census data. OBJECTIVE: The aim of this study was to compare the proportion of non-White race and Hispanic ethnicity participants with their expected proportion based on U.S. census data for PRO instruments with U.S.-based validation studies. STUDY DESIGN: This was a retrospective review of PRO measures considered by the Pelvic Floors Disorders Consortium Working Group on Patient-Reported Outcomes in their 2020 consensus publication. Study and participant information were abstracted from PRO validation studies. Racial and ethnic representation in U.S.-based studies were compared with U.S. census data. The primary outcome was the representation quotient of reported races and ethnicities, calculated as the reported percentage of the study population identifying with a race and/or ethnicity divided by the proportion of the U.S. population identifying with that race and/or ethnicity when the study was published. RESULTS: Forty-five studies with 21,080 total participants were included. Race was reported in 17 of 45 studies (37.8%), and ethnicity was reported in 7 of 45 (15.6%). Most studies did not specify how race and ethnicity information was collected. For U.S.-based studies, the representation quotient of White participants from 1995 to 2019 was 1.15. Indigenous American/Native American/American Indian/Alaska Natives had the lowest representation quotient (0.22). Reporting of ethnicity increased over time (P = 0.001), although there was no significant change in the reporting of race or the representation of various races and ethnicities (P > 0.05). CONCLUSION: Non-White and Hispanic patients may be underrepresented in U.S.-based validation studies for PRO instruments in pelvic floor disorders.

Cystoscopy at the time of incontinence and prolapse surgery.

PURPOSE OF REVIEW: This article provides an update on the use of cystoscopy at the time of prolapse and incontinence surgery. RECENT FINDINGS: Iatrogenic lower urinary tract injury is a known complication of antiincontinence procedures and surgical repair of pelvic organ prolapse. Intraoperative cystoscopy improves detection of lower urinary tract injuries in women undergoing pelvic floor surgery. The pelvic surgeon has a number of agents available to aid in the cystoscopic visualization of ureteral efflux. When injuries of the urinary tract are identified and treated intraoperatively, there is decreased morbidity, lower healthcare costs, and a lower risk of litigation than when detection is delayed. Therefore, many organizations, including the American College of Obstetricians and Gynecologists (ACOG), the American Urogynecologic Society (AUGS), and the American Urological Association (AUA) recommend cystoscopy at the time of pelvic floor surgery. SUMMARY: Cystoscopy should be universally employed at the time of prolapse and incontinence surgery, except in instances of isolated repair of the posterior compartment.

American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair.

Injury to the urinary tract is a known risk of surgical repair of anterior and apical pelvic organ prolapse. Cystoscopy at the time of surgical prolapse repair is a low-risk procedure that can identify genitourinary tract injury by inspecting the bladder and urethra as well as by visualizing the ureters and ureteral efflux. There are several techniques to assist with visualization of ureteral efflux. Identifying injury intraoperatively may allow for mitigation of the morbidity of the injury. Universal cystoscopy should be performed at the time of all pelvic reconstructive surgeries, with the exception of operations solely for posterior compartment defects.

Metabolites and microbial composition of stool of women with fecal incontinence: Study design and methods.

AIMS: This paper aims to report the rationale, design, and the specific methodology of an ongoing nested observational study that will determine the association of the metabolite and microbial composition of stool with fecal incontinence (FI). METHODS: Eligible cases are participants with FI enrolled in the Controlling Anal Incontinence in women by Performing Anal Exercises with Biofeedback or Loperamide (CAPABLe) trial, a Pelvic Floor Disorders Network trial across eight clinical centers in the United States. Women of similar age without FI in the last year served as controls. All subject collected stool samples at the baseline and 24-week visit at home using a standardized collection method. Samples were shipped to and stored at centralized laboratories. RESULTS: Specimen collection commenced December 2014 and was completed in May 2016. Fecal water and DNA has been extracted and is currently being analyzed by targeted metabolic profiling for stool metabolites and 16S rRNA gene sequencing for stool microbiota. CONCLUSIONS: This article describes the rationale and design of a study that could provide a paradigm shift for the treatment of FI in women.

Vaginal estrogen use in postmenopausal women with pelvic floor disorders: systematic review and practice guidelines.

INTRODUCTION AND HYPOTHESIS: Risk of pelvic floor disorders increases after menopause and may be linked to estrogen deficiency. We aimed to systematically and critically assess the literature on vaginal estrogen in the management of pelvic floor disorders in postmenopausal women and provide evidence-based clinical practice guidelines. METHODS: MEDLINE and Cochrane databases were searched from inception to July 2014 for randomized controlled trials of commercially available vaginal estrogen products compared with placebo, no treatment, or any medication for overactive bladder or urinary incontinence. We double-screened 1,805 abstracts and identified 12 eligible papers. Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality and strength of evidence. RESULTS: Evidence was generally of poor to moderate quality. Vaginal estrogen application before pelvic organ prolapse surgery improved the vaginal maturation index and increased vaginal epithelial thickness. Postoperative vaginal estrogen use after a midurethral sling resulted in decreased urinary frequency and urgency. Vaginal estrogen and immediate-release oxybutynin were similar in improvement of urinary urgency, frequency, and urgency urinary incontinence in women with overactive bladder, but oxybutynin had higher rates of side effects and discontinuation. Conversely, the addition of vaginal estrogen to immediate or extended-release tolterodine did not improve urinary symptoms more than tolterodine alone. One study reported an improvement in stress urinary incontinence with use of vaginal estrogen. CONCLUSION: Vaginal estrogen application may play a useful role as an adjunct in the management of common pelvic floor disorders in postmenopausal women.

Vaginal estrogen for genitourinary syndrome of menopause: a systematic review.

OBJECTIVE: To comprehensively review and critically assess the literature on vaginal estrogen and its alternatives for women with genitourinary syndrome of menopause and to provide clinical practice guidelines. DATA SOURCES: MEDLINE and Cochrane databases were searched from inception to April 2013. We included randomized controlled trials and prospective comparative studies. Interventions and comparators included all commercially available vaginal estrogen products. Placebo, no treatment, systemic estrogen (all routes), and nonhormonal moisturizers and lubricants were included as comparators. METHODS OF STUDY SELECTION: We double-screened 1,805 abstracts, identifying 44 eligible studies. Discrepancies were adjudicated by a third reviewer. Studies were individually and collectively assessed for methodologic quality and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant, intervention, comparator, and outcomes data, including patient-reported atrophy symptoms (eg, vaginal dryness, dyspareunia, dysuria, urgency, frequency, recurrent urinary tract infection (UTI), and urinary incontinence), objective signs of atrophy, urodynamic measures, endometrial effects, serum estradiol changes, and adverse events. Compared with placebo, vaginal estrogens improved dryness, dyspareunia, urinary urgency, frequency, and stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). Urinary tract infection rates decreased. The various estrogen preparations had similar efficacy and safety; serum estradiol levels remained within postmenopausal norms for all except high-dose conjugated equine estrogen cream. Endometrial hyperplasia and adenocarcinoma were extremely rare among those receiving vaginal estrogen. Comparing vaginal estrogen with nonhormonal moisturizers, patients with two or more symptoms of vulvovaginal atrophy were substantially more improved using vaginal estrogens, but those with one or minor complaints had similar symptom resolution with either estrogen or nonhormonal moisturizer. CONCLUSION: All commercially available vaginal estrogens effectively relieve common vulvovaginal atrophy-related complaints and have additional utility in patients with urinary urgency, frequency or nocturia, SUI and UUI, and recurrent UTIs. Nonhormonal moisturizers are a beneficial alternative for those with few or minor atrophy-related symptoms and in patients at risk for estrogen-related neoplasia. CLINICAL TRIAL REGISTRATION: PROSPERO International prospective register of systematic reviews, http://www.crd.york.ac.uk/PROSPERO/, CRD42013006656.

Antibiotic prophylaxis for selected gynecologic surgeries.

BACKGROUND: Antibiotic prophylaxis for surgery is commonly used and is recommended by multiple organizations. OBJECTIVE: To critically review gynecology-specific data regarding surgical antibiotic prophylaxis in selected benign gynecologic surgeries. SEARCH STRATEGY: MEDLINE and Cochrane databases were searched from inception to July 2010. SELECTION CRITERIA: Randomized controlled trials of benign vaginal, cervical, transcervical, abdominal, or laparoscopic procedures other than hysterectomy comparing prophylactic antibiotic use with placebo or with another antibiotic. Outcomes of interest were postoperative infections, additional treatments, and adverse events. DATA COLLECTION AND ANALYSIS: In total, 19 trials met the inclusion criteria. Studies were individually assessed for methodologic quality, then grouped by procedure and evaluated for evidence quality. MAIN RESULTS: There was no difference in infectious outcome for loop electrosurgical excision, hysteroscopic ablation, or laparoscopy, although evidence quality was poor. Fair evidence supports antibiotic prophylaxis for suction curettage or laparotomy. There were insufficient data regarding vaginal surgery prophylaxis. CONCLUSION: Antibiotic prophylaxis may be beneficial in first-trimester suction curettage and laparotomy. No advantage was found for loop electrosurgical excision, hysteroscopy, or laparoscopic gynecologic surgery. Newer procedures and vaginal surgery lack research and merit study.

The effect of pelvic organ prolapse severity on improvement in overactive bladder symptoms after pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: This study evaluates the effect of baseline pelvic organ prolapse (POP) severity on improvement in overactive bladder (OAB) symptoms after pelvic reconstructive surgery. METHODS: We performed a retrospective cohort study of women with POP and OAB who underwent surgical correction of symptomatic apical and/or anterior POP. OAB was defined as an affirmative response to item #15 (urinary frequency) and/or item #16 (urge incontinence) of the Pelvic Floor Distress Inventory (PFDI). POP severity was dichotomized as Pelvic Organ Prolapse Quantification (POP-Q) stage 1-2 versus stage 3-4. Our primary outcome was complete resolution or improvement of urinary frequency or urge incontinence on the PFDI 12 months postoperatively. RESULTS: At 12 months postoperative, 41 (89%) women with stage 1-2 POP versus 47 (85 %) with stage 3-4 POP reported improvement in urinary frequency (p = 0.58). Thirty five (90 %) with stage 1-2 and 34 (85 %) with stage 3-4 POP reported improvement in urge incontinence (p = 0.74). On multiple logistic regression, women with stage 3-4 POP had a decreased odds of improvement in frequency or urge incontinence compared with women with stage 1-2 POP (adjusted odds ration [AOR] = 0.06 [95 % CI 0.01-0.67]), after adjusting for confounders. CONCLUSIONS: Women with coexisting POP and OAB who undergo surgical correction of POP experience improvement in OAB symptoms after surgery, although women with more severe POP may be at a higher risk of persistent frequency or urge incontinence.

Surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery.

OBJECTIVE: To assess surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery. METHODS: A survey was distributed at the 2011 annual scientific meeting of the Society of Gynecologic Surgeons regarding antibiotic prophylaxis practices. RESULTS: The response rate was 51%. Most surgeons did not use antibiotic prophylaxis for dilation and curettage without products of conception, hysteroscopy, and loop electrocautery excision procedure/cone biopsy. For laparoscopy without graft placement, 45.9% did not use prophylaxis. Prophylaxis was common for hysterectomy. For midurethral slings, 8.2% did not use prophylaxis. When graft material was used in prolapse surgery, at least 93% of surgeons administered some form of antibiotic prophylaxis. Only 70% of respondents prescribe antibiotic prophylaxis for hysterectomy consistent with recommendations from the American College of Obstetricians and Gynecologists, whereas 78% are consistent with specifications from the Joint Commission. CONCLUSIONS: Wide variability exists in antibiotic prophylaxis in gynecologic surgery. Surgeon preference or local hospital policies affect choice of prophylaxis less than 14.9% of the time.

Sexual function is related to body image perception in women with pelvic organ prolapse.

INTRODUCTION: A previous study demonstrated that women seeking treatment for advanced pelvic organ prolapsed (POP) reported decreased self-perceived body image and decreased quality of life. AIMS: To determine the relationship between: (i) sexual function and POP, (ii) self-perceived body image and POP; and (iii) sexual function and self-perceived body image in women with prolapse. METHODS: After IRB approval, consecutive women with POP stage II or greater presenting for urogynecologic care at one of eight academic medical centers in the United States were invited to participate. In addition to routine urogynecologic history and physical examination, including pelvic organ prolapse quantification (POPQ), consenting participants completed three validated questionnaires: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to assess sexual function; Modified Body Image Perception Scale (MBIS) to assess self-perceived body image; Prolapse subscale of Pelvic Floor Distress Inventory (POPDI-6) to assess condition specific bother from POP. Pearson's correlations were used to investigate the relationship between independent variables. MAIN OUTCOME MEASURES: Sexual function and modified body image score and its correlation with symptoms of POP. RESULTS: Three hundred eighty-four participants with a mean age of 62 +/- 12 years were enrolled. Median POPQ stage was 3 (range 2-4). 62% (N = 241) were sexually active and 77% (N = 304) were post-menopausal. Mean PISQ-12, MBIS, and POPDI scores were (33 +/- 7, 6 +/- 5, 39 +/- 23, respectively). PISQ-12 scores were not related to stage or compartment (anterior, apical, or posterior) of POP (P > 0.5). Worse sexual function (lower PSIQ-12 scores) correlated with lower body image perception (higher MBIS scores) (rho = -0.39, P < 0001) and more bothersome POP (higher POPDI scores) (rho = -0.34, P < 0001). CONCLUSIONS: Sexual function is related to a woman's self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a woman's perception of her body image than to actual topographical changes from POP.

Pyometra necessitating hysterectomy after colpocleisis in an extremely elderly patient.

As the number of women more than the age 65 increases, so will the need for treatment of pelvic organ prolapse and the comorbidities that come with surgical treatment of an aging population gain significance. Colpocleisis is an option for women failing or refusing conservative prolapse management and not desiring sexual function. The advantages of colpocleisis are decreased operative time, low complication rate, and ability to use local or regional anesthesia. We report a case of a 95-year-old woman whose procidentia was treated with colpocleisis. Endometrial evaluation with dilation and curettage was performed at the time of colpocleisis. Postoperative course was complicated by pyometra necessitating total abdominal hysterectomy and bilateral salpingoopherectomy, leading to further complications including deep vein thrombosis, anemia, atrial fibrillation, and pleural effusions. Preoperative versus intraoperative endometrial evaluation may decrease the risk of developing pyometra after colpocleisis and, therefore, diminish the possibility of multiple complications.