Variation in Use of Prophylactic Antibiotics in Gynecologic Procedures Before and After an Educational Intervention.

OBJECTIVES: Guidelines for use of prophylactic antibiotics in gynecologic procedures are outlined by the American Congress of Obstetricians and Gynecologists. There remains, however, a high rate of unindicated administration of antibiotics for surgeries. A retrospective study performed at our institution in 2012-2013 demonstrated that unindicated prophylactic antibiotics were administered over half the time. This study aimed to examine variations in the use of prophylactic antibiotics in patients undergoing gynecologic surgery at Scott and White Memorial Hospital and determine whether an educational intervention to gynecology physicians was associated with a significant decrease in unindicated prophylactic antibiotics. METHODS: A retrospective chart review was performed for all women undergoing gynecologic surgery at Scott and White Memorial Hospital in Temple, Texas for 1 year. An educational intervention regarding prophylactic antibiotic usage was held for obstetricians and gynecologists in the middle of that year. Subjects were included if they had procedures with a Current Procedural Terminology code corresponding to a procedure that does not require prophylactic antibiotics. Subjects were excluded if they had concurrent procedures for which antibiotics are recommended. RESULTS: A total of 500 subjects met inclusion and exclusion criteria, with 243 before the educational intervention and 257 after the intervention. In our study, a significant decrease (P < 0.0001) in unindicated prophylactic antibiotic use was demonstrated: from 45.7% (111/243) preintervention to 24.9% (64/257) postintervention. Before the educational intervention, both the gynecology oncology and reproductive endocrinology and infertility divisions had the highest rates of unindicated antibiotic use-91.7% (44/48) and 91.7% (33/36), respectively. The generalist and urogynecology divisions had the lowest rates for specialists before the intervention: 20.6% (30/146) and 30.8% (4/13), respectively. After the intervention, all of the divisions demonstrated an improvement in their rates of unindicated prophylactic antibiotic use. The urogynecology division demonstrated an improvement that can be considered clinically significant while not meeting statistical significance. The adverse event rates were not different between subjects who received preoperative prophylactic antibiotics (2.9%) and subjects who did not (2.8%). CONCLUSIONS: A simple educational intervention was associated with a significant decrease in unindicated prophylactic antibiotics in gynecologic procedures.

Randomized trial of cesarean vs vaginal delivery for effects on the pelvic floor in squirrel monkeys.

BACKGROUND: Vaginal delivery is a risk factor in pelvic floor disorders. We previously described changes in the pelvic floor associated with pregnancy and parturition in the squirrel monkey, a species with a humanlike pattern of spontaneous age- and parity-associated pelvic organ prolapse. OBJECTIVE: The potential to prevent or diminish these changes with scheduled cesarean delivery (CD) has not been evaluated. In a randomized, controlled trial, we compared female squirrel monkeys undergoing spontaneous vaginal delivery with those undergoing scheduled primary CD for pelvic floor muscle volumes, muscle contrast changes, and dynamic effects on bladder neck position. STUDY DESIGN: Levator ani, obturator internus, and coccygeus (COC) muscle volumes and contrast uptake were assessed by magnetic resonance imaging in 20 nulliparous females examined prior to pregnancy, a few days after delivery, and 3 months postpartum. The position of bladder neck relative to bony reference line also was assessed with abdominal pressure using dynamic magnetic resonance imaging. RESULTS: Baseline measurements of 10 females randomly assigned to scheduled primary CD were not different from those of 10 females assigned to spontaneous vaginal delivery. Levator ani and obturator internus muscle volumes did not differ between groups, while volumes were reduced (P < .05) in the observation immediately after pregnancy. The COC muscles increased (P < .05) immediately after delivery for females in the spontaneous vaginal delivery group, but not for females in the scheduled CD group. Position of the bladder neck descended (P < .05) by 3 months postpartum in both groups. CONCLUSION: Scheduled CD diminishes changes in COC muscle volume and contrast reported to be associated with spontaneous vaginal delivery in squirrel monkeys. However, pelvic support of the bladder was not protected by this intervention suggesting that effects of pregnancy and delivery are not uniformly prevented by this procedure.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension.

OBJECTIVES: To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS). METHODS: A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status. RESULTS: During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses. CONCLUSIONS: In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Incidence and risk factors of postoperative urinary tract infection after uterosacral ligament suspension.

INTRODUCTION AND HYPOTHESIS: We assessed the incidence of and risk factors for developing urinary tract infection (UTI) after uterosacral ligament suspension (USLS). METHODS: Retrospective analysis of patients undergoing USLS in 2008-2009 was performed. Postoperative UTI was defined as a positive urine culture within 1 month following surgery. Factors analyzed were patient age, body mass index, parity, history of UTI before surgery, passing voiding trial, discharge with Foley catheter or intermittent self-catheterization, antibiotics at discharge, history of diabetes or renal disease, and surgeon. RESULTS: Surgical records from 169 patients were reviewed. Twenty-three patients (14%) developed UTI. There were no differences in preoperative factors between patients who developed UTI and those who did not. Subgroup analysis revealed those patients who went home with a Foley catheter and did not receive antibiotics had the highest proportion of UTI. CONCLUSION: Patients requiring Foley catheter at discharge following vaginal prolapse repair are at highest risk for UTI and require prophylactic antibiotics.

A novel transvaginal approach to correct recurrent apical prolapse after failed sacral colpopexy: case series.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to describe the transvaginal approach utilizing the existing sacral colpopexy (SC) graft for recurrent apical prolapse following failed SC. METHODS: Twenty-two patients with recurrent vaginal vault prolapse following a prior SC were treated between January 2000 and December 2009. Twelve patients had a standard uterosacral ligament cuff suspension (USLS) performed. In ten patients, the vaginal cuff was suspended to the left uterosacral ligament and reattached to the graft material from the prior SC. One of these ten subsequently failed and a standard USLS was performed. Patient characteristics, preoperative pelvic floor assessment, operative information, and postoperative follow-up were collected. Cases in which the graft material was used were compared with those undergoing standard USLS. RESULTS: Demographic characteristics and preoperative Baden-Walker scores were similar. Of 23 cases, 21 (91 %) were a consequence of graft separation from the vagina and not the sacrum. Two of nine patients with follow-up where the SC graft was utilized transvaginally had recurrent prolapse. One required reoperation. Of 13 patients in the group that underwent traditional USLS, 2 had asymptomatic recurrent anterior prolapse; neither required additional surgery. CONCLUSIONS: A transvaginal surgical approach for recurrent vaginal prolapse after a history of failed abdominal SC should be considered. If feasible, the SC graft material can be used when performing USLS instead of the right uterosacral ligament for these patients with a prior history of abdominal SC.

Risk factors for late postpartum preeclampsia.

OBJECTIVE: To determine the risk factors for late postpartum preeclampsia. STUDY DESIGN: This was a retrospective case control study of women readmitted in the postpartum period (>48 hours and <4 weeks) with preeclampsia. Inclusion criteria were readmission with confirmed preeclampsia. Variables examined were age, race, parity, gestational hypertension, preeclampsia in labor, mode of delivery and history of preeclampsia in previous pregnancies. RESULTS: Data included 51 women who met the criteria for late postpartum preeclampsia. Initial analysis revealed that antenatal preeclampsia, gestational hypertension, preeclampsia in a prior pregnancy, body mass index (BMI) > 30, African American race and cesarean delivery were all predictive of late postpartum preeclampsia. Asian ethnicity was protective. Final analysis using logistic regression concluded that African American race, cesarean delivery, BMI and hypertensive disease during the incident pregnancy were all significant predicators of late postpartum disease. CONCLUSION: BMI >30, antenatal hypertensive disease, cesarean delivery and African American race were all predictive of readmission for late postpartum preeclampsia. Asian ethnicity appeared to be protective against developing late postpartum preeclampsia.

Design of a Randomized Clinical Trial of Perioperative Vaginal Estrogen Versus Placebo With Transvaginal Native Tissue Apical Prolapse Repair (Investigation to Minimize Prolapse Recurrence of the Vagina using Estrogen: IMPROVE).

OBJECTIVES: To provide the rationale and design for a randomized, double-blind clinical trial of conjugated estrogen vaginal cream (applied for at least 5 weeks preoperatively and continued twice-weekly through 12 months postoperatively) compared with placebo in postmenopausal women with symptomatic pelvic organ prolapse undergoing a standardized transvaginal native tissue apical repair. METHODS: Study population, randomization process, study cream intervention, masking of participants and evaluators, placebo cream manufacture, standardized surgical intervention, and collection of adverse events are described. The primary outcome of surgical success is a composite of objectively no prolapse beyond the hymen and the vaginal cuff descending no more than one third the vaginal length; subjectively, no sense of vaginal pressure or bulging; and no retreatment for prolapse at 12 months. Time-to-failure postoperatively will be compared in the 2 groups with continued surveillance to 36 months. Secondary outcomes assessed at baseline, preoperatively (ie, after at least 5 weeks of study cream), and postoperatively at 6 month intervals include validated condition-specific and general quality-of-life metrics, overall impression of improvement, sexual function, vaginal atrophy symptoms, and body image. Challenges unique to this study include design and manufacture of placebo and defining and measuring study drug adherence. RESULTS: Recruitment of 204 women is complete with 197 randomized. There have been 174 surgeries completed with 15 more pending; 111 have completed their 12 month postoperative visit. CONCLUSIONS: This trial will contribute evidence-based information regarding the effect of perioperative vaginal estrogen as an adjunct therapy to standardized transvaginal native tissue prolapse surgical repair.

The Certification Process Driving Patient Safety.

In 2016, the American Board of Medical Specialties (ABMS) and the National Patient Safety Foundation issued a joint call encouraging each ABMS member board to integrate patient safety principles and activities into their initial and continuous certification processes. This article describes how the American Board of Obstetrics and Gynecology integrates various aspects of patient safety principles into its initial and continuous certification processes. The authors first describe how they assess patient safety within their initial certification processes. They then describe each component of their maintenance of certification program, and how they intentionally embed patient safety principles within each component.

Grading of squamous dysplasia in endocervical curettage specimens: The case for conservative management of mild endocervical dysplasia.

OBJECTIVE: To determine if the severity of dysplasia in a loop electrical excision procedure (LEEP) specimen is different for women with a preoperative endocervical curettage (ECC) positive for mild dysplasia. STUDY DESIGN: Records from a colposcopy clinic for a 5-year period were reviewed. The subjects were divided into 3 groups: group I, ECC positive for mild dysplasia; group II, mild ectocervical dysplasia; and group III, ECC positive for dysplasia not identified as mild. Outcome variables were a histologic diagnosis on the LEEP specimen and recurrence of dysplasia. Raw data were analyzed. RESULTS: A total of 753 patients underwent a LEEP procedure. One hundred seventy-three (23%) met the inclusion criteria: 37 in group I, 66 group II and 70 group III. Group III had an increased risk of severe dysplasia on LEEP, 68% vs. 25%, over groups I and II. Patients in group III who had minimally abnormal entry cervical cytology had an increased relative risk of 2.13 for severe dysplasia on LEEP as compared to group I. CONCLUSION: Patients with mild dysplasia on ECC appear to have no greater risk of severe dysplasia on subsequent LEEP specimens than have counterparts with isolated ectocervical mild dysplasia. These patients can be offered conservative follow-up with colposcopy rather than initial definitive therapy.

Patterns of care for cervical cancer patients treated in the U.S. military health care system.

OBJECTIVE: To determine whether women diagnosed with cervical cancer within the U.S. Department of Defense (DOD) Military Health Care System received treatment within standard guidelines and whether survival was influenced by implementation of these guidelines. STUDY DESIGN: We identified 621 women treated from 1994 to 2002. Guideline therapy was defined as hysterectomy or radiation for FIGO stage < or = IB, and hysterectomy or chemoradiation for advanced localized FIGO stage > IB. Survival analysis was performed using Cox Proportional Hazards models. RESULTS: Of those 621 women, 25% received no surgery, while 41% received radiation therapy. 6% of all patients received chemoradiation therapy prior to the Clinical Announcement received versus 26% of patients after the announcement. Variables associated with significant increased risk of death were advanced age, advanced stage and poorly differentiated lesions, p < 0.01. The lack of guideline therapy was associated with an increased risk of death, p < 0.005. Those patients who did not receive guideline therapy were twice as likely to die (HR 2.11, p = 0.005). CONCLUSION: Our study suggests that chemoradiation was rapidly introduced in the DOD care system after the 1999 National Cancer Institute's Clinical Announcement. However, some patients did not receive guideline therapy.

Anatomic relation between single-incision slings and the obturator vessels.

The risk of arterial vascular injury within the retropubic space is a potentially life-threatening complication associated with mid-urethral sling placement for the treatment of female stress urinary incontinence. To determine the relationship between the major blood vessels and a single incision sling, these slings were placed in 12 fresh female cadavers. Following the insertion of each sling, the retropubic space was dissected and sling placement was observed relative to the obturator neurovascular bundle bilaterally. The distance between the most distal aspect of each sling arm, or the point of anchoring, was measured from the most medial aspect of the obturator vessels bilaterally. The mean distance between each sling arm and the medial portion of the obturator vessels was an average of 3.4 cm (range 2.0-6.0 cm) in 24 observations. Placement of the single incision sling may have a lower risk of injuring major vessels within the retropubic space compared to full-length mid-urethral slings.

Inappropriate use of antibiotics in patients undergoing gynecologic surgery.

We retrospectively examined prophylactic antibiotic use and documentation of wound classification in patients having gynecologic surgery at a tertiary hospital. Of the 326 cases reviewed, 175 (54%) received prophylactic antibiotics when not indicated according to guidelines of the American College of Obstetricians and Gynecologists. Antibiotic administration varied significantly (P < 0.02) among the different types of surgery, being given in 82% of laparoscopic cases, 35% of nonobstetrical dilation and curettage and operative hysteroscopy procedures, and 51% of open abdominal procedures. There were no recorded episodes of anaphylaxis or pseudomembranous colitis. In conclusion, antibiotic use is high among gynecologic surgeons at a tertiary hospital, but this use was unnecessary.

Iatrogenic Bladder Diverticulum 11 Years After Sacrospinous Ligament Fixation for Apical Prolapse.

INTRODUCTION: In this case, we describe a bladder diverticulum due to apical vaginal suspension to the sacrospinous ligament presenting 11 years after surgery. This case report explores her signs and symptoms, diagnostic work-up, surgical intervention, and postoperative course. CASE DESCRIPTION: A 71-year-old G2P2 presented with symptoms of urinary urgency. Work-up including cystoscopy and retrograde fistulogram revealed a bladder diverticulum extending to the level of the sacrospinous ligament. Her surgical history was significant for a sacrospinous ligament fixation 11 years before her symptoms. The iatrogenic bladder diverticulum was removed via robotic-assisted laparoscopic excision. Her postoperative course was benign beyond a urinary tract infection. Her urgency symptoms resolved after treatment. CONCLUSIONS: Iatrogenic injuries can present distant from initial surgery. Permanent foreign material, including suture, may increase the risk of complications. A high level of suspicion is necessary to diagnose complications given the subtle presentation.

Incidence of Bladder Injury During Retropubic Midurethral Sling Placement After Prior Burch Colpopexy.

OBJECTIVES: To elucidate if prior Burch changes the risk of bladder injury or rates of voiding dysfunction and continence in the immediate postoperative period when undergoing retropubic midurethral sling (MUS) placement. METHODS: In this retrospective case control, charts were selected by Current Procedural Terminology codes for MUS placement. Women undergoing retropubic MUS placement with history of Burch urethropexy were considered. For every case, 2 age-matched and parity-matched controls without prior Burch were selected. RESULTS: In total, 538 charts were reviewed from 2010 to 2014. Twenty cases were found. There was a difference (P = 0.023) in trocar penetration of the bladder. Twenty-five percent (5/20) of women with prior Burch had a 9-fold (odds ratio [OR], 9.0; 95% confidence interval [CI], 1.0-82) higher chance of bladder penetration compared with women without prior retropubic surgery as calculated with Mantel-Haenszel paired test. Women with prior Burch had more success passing their voiding trials (OR, 7.5; 95% CI, 1.1-49.2). At 6 weeks, there was no difference in voiding dysfunction. Cure of stress incontinence at 6 weeks occurred more in controls than cases (P = 0.044) with match pairs manifesting an OR of 0.20 and 95% CI of 0.04-1.1. DISCUSSION: This study shows a significant increase risk of trocar penetration of the bladder during retropubic MUS placement in women with a history of Burch urethropexy. Despite this, MUS placement was successful in all women. Women with prior surgery were much more likely to pass their voiding trials. There was no difference in voiding dysfunction at 6 weeks between the 2 groups. CONCLUSIONS: This indicates that though bladder penetration with a trocar is more common in the setting of previous retropubic surgery, it does not impact a woman's short-term intraoperative or postoperative course.

Perineal body length and perineal lacerations during delivery in primigravid patients.

This study assessed the relation between perineal body length and the risk of perineal laceration extending into the anal sphincter during vaginal delivery in primigravid patients at an institution with a low utilization of episiotomy. This was a prospective study of primigravid patients in active labor. Primigravid women with singleton pregnancies who were in the first stage of labor at 37 weeks gestation or greater were recruited, and the admitting physician measured the length of the perineal body. The degree of perineal laceration and other delivery characteristics were recorded. Data were analyzed using univariate analyses, receiver-operator curve analyses, and multiple logistic regression for factors associated with increased severity of vaginal lacerations. The perineal body length, duration of second stage of labor, type of delivery, and patient age were associated (P < 0.1) with third- and fourth-degree (severe) perineal lacerations in primigravid women using receiver-operator curve analysis. Using logistic regression, only the duration of second stage of labor and length of the perineal body were significant (P < 0.04) predictors of third- and fourth-degree lacerations, with odds ratios of 32 (1.3 to 807 as 95% CI) and 24 (1.3 to 456), respectively. Both a perineal body length of ≤3.5 cm and a duration of second stage of labor >99 minutes were associated with an increased risk of third- and fourth-degree lacerations in primigravid patients.

Far forward gynecologic care of the female soldier.

OBJECTIVE: To evaluate the value, unit cost and medical effectiveness of providing specialized obstetric and gynecologic care far forward, at echelon III, the combat support hospital (CSH), in the operating theater of Afghanistan during Operation Enduring Freedom (OEF), rotation 5. STUDY DESIGN: Between April 2004 and September 2004, records were reviewed from the outpatient gynecology clinic at Bagram Air Field (BAF), in Afghanistan, through an approved protocol request. Cohort analysis was performed on all gynecologic patients. Significant differences in distribution of clinical factors were determined by Student's t test. RESULTS: A total of 62 cases were extracted for analysis over the 6-month period. Fifty-seven total patients were seen at echelon III, the CSH at BAF, while 5 were sent to level IV or V echelon care in Landstuhl, Germany. The average distance traveled for the patients coming to BAF was 158 km, while those sent to Germany averaged 5,204 km. The mean travel time in days was significantly lower among patients seen at BAF, 0.5 versus 7 days for patients sent to Germany. The time to appointment was also significantly lower among those patients seen at BAF: 0.04 versus 13 days for patients sent to Germany. CONCLUSION: We devised and implemented the concept of far forward specialized gynecologic care for women participating in OEF. This substantially decreased the woman-hours lost by their individual units. The far forward availability of gynecologic care and the supplies to evaluate and treat abnormal Pap smears should be considered by all military services in their plans for providing health care for the modern female soldier.

Treatment of metastatic gestational choriocarcinoma with oral methotrexate in a combat environment.

BACKGROUND: Gestational trophoblastic neoplasia (GTN) is a rare neoplastic complication of pregnancy. This disease can be successfully treated with parenteral intravenous or intramuscular chemotherapy. We present a case of metastatic gestational choriocarcinoma following a term pregnancy that was treated successfully with oral methotrexate therapy. CASE: A 25-year-old, G4 P4, native Afghani with a history of irregular menses since the birth of her son 6 months ago received a physical examination that was within normal limits. Pelvic examination revealed minimal blood in the vault and slight bleeding from a closed cervical os. The uterus was slightly enlarged, 5 weeks in size, and without any adnexal masses. Laboratory evaluation was significant for a positive urine and serum beta-HCG. Pelvic ultrasound examination revealed a 5-cm uterus with a 2-cm endometrial stripe. Chest radiograph revealed multiple bilateral ill-defined pulmonary nodules confirmed by computerized tomography. The patient underwent dilation and curettage productive of a moderate amount of tissue. The patient continued to have positive serum beta-HCGs and was given the presumptive diagnosis of FIGO stage III gestational choriocarcinoma. Because of the lack of intravenous chemotherapeutic agents, the patient was begun on methotrexate 0.40 mg/kg orally on days 1-5, with 9 days off. The patient completed one course of chemotherapy, followed by an interval total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient had a complete response to therapy and was treated with oral methotrexate for 2 courses after a negative serum beta-HCG. The patient tolerated the chemotherapy without any complication. CONCLUSION: Methotrexate is routinely used in a parenteral intramuscular fashion for the treatment of gestational choriocarcinoma. Physicians should be aware that, in very limited situations, oral methotrexate in combination with hysterectomy still could offer a patient successful treatment for stage III GTN.

Can laparoscopic cholecystectomy be performed with a positive margin at medicaid reimbursement rates?

BACKGROUND: The Affordable Care Act provides health care coverage to an increasing segment of the population at Medicaid reimbursement rates. Health care systems currently offset lower Medicaid reimbursement through higher payers. The ability to "cost shift" will be diminished as the Medicaid population increases. STUDY DESIGN: A financial cost and revenue analysis of outpatient laparoscopic cholecystectomy at our institution was performed. Cost was defined as actual expense to the health care institution. Fixed and variable costs were identified to calculate a break-even point. Time spent from check in to dismissal was based on historic averages. When actual costs could not be pinpointed, estimates from industry experts were used. Reimbursement included surgeon and anesthesia professional fees and facility fees. RESULTS: A total of 501 laparoscopic cholecystectomies were performed at the main operating room facility in 2012. Annual fixed costs were $252,637. Variable costs were $1,860/case. Personnel and single-use equipment made the largest contribution to variable costs. Reimbursement for professional and facility fees totaled $2,444/case. The break-even point occurred at 454 cases. Based on historic volume, the break-even point for the calendar year would occur on November 27. CONCLUSIONS: Our analysis demonstrates that laparoscopic cholecystectomy can be performed with a positive margin at Medicaid reimbursement rates with sufficient volume. The minimal margin, however, could substantially limit the ability of lower-volume hospitals to provide these services and negatively impact access to care in this patient population.

Comparison of urodynamic volume measurements using room and body temperature saline: a double-blinded randomized crossover study design.

INTRODUCTION: Urodynamic studies, routinely performed in women with lower urinary tract symptoms, have a large impact on clinical decision making. Unfortunately, these studies are insensitive in reproducing idiopathic detrusor overactivity (IDO). We set out to examine whether serial cystometry with different distending fluid temperatures could better reproduce symptoms. METHODS: Eighty-six women were enrolled in a double-blinded, randomized, crossover study. Two cystometries were performed in series, starting with either body temperature fluid (BTF) or room temperature fluid (RTF) and then repeating cystometry with the other temperature fluid. Primary outcomes included first sensation, first urge, and maximum cystometric capacity. Secondary outcomes included subjective sensation of bladder discomfort and the incidence of IDO. RESULTS: In aggregate, the temperature of the fluid did not affect volumes of bladder sensation. There were no differences in self-reported bladder irritation or IDO between the different temperature fluids. There was a significant carryover effect with BTF. BTF administered first reached sensory thresholds at lower volumes than when it was administered second after RTF. Room temperature fluid cystometry showed no statistical difference in volume between first fill and second fill. Idiopathic detrusor overactivity contractions were seen in 9% of studies and were not affected by period or temperature. CONCLUSIONS: These data suggest that BTF and RTF independently do not affect bladder sensory thresholds. The periodicity in combination with varying fluid temperature is of greater impact. This study documents that changes in temperature of the distending fluid from BTF to RTF or vice versa likely do not provoke IDO contractions.