The "Repeat Colpocleisis": A Literature Review and Case Report.

INTRODUCTION AND HYPOTHESIS: Colpocleisis is a surgical procedure intended to treat pelvic organ prolapse. Compared with other modes of pelvic reconstructive surgery, colpocleisis is associated with lower morbidity and higher satisfaction, and has a success rate of 91-100% and a reoperation rate of less than 2%. However, there is limited information on how to treat recurrent prolapse after colpocleisis. METHODS: We performed a review of the existing literature regarding colpocleisis failure and retreatment. A total of 118 articles were reviewed, with 16 articles suitable for inclusion. We also describe a case from our own institution of a "repeat colpocleisis" for recurrent prolapse after previous colpocleisis. RESULTS: "Repeat colpocleisis" was the most common surgical technique used (18 out of 24 patients, 75.0%). The median follow-up time after the repeat surgery was 12 months, with only 1 patient with recurrence reported owing to recurrent rectocele 2 years after surgery, treated successfully with perineorrhaphy. Other less common techniques included perineorrhaphy, reversal of colpocleisis with native tissue repair, and vaginal hysterectomy with vaginal repair. Our case report describes the surgical management of a patient who had previously undergone LeFort colpocleisis with recurrence of prolapse, subsequently undergoing repeat colpocleisis. CONCLUSIONS: The colpocleisis failure, though rare, presents a surgical challenge owing to both its rarity and the paucity of information in the literature regarding the optimal mode of management. In this review, the most common technique for surgical management of colpocleisis failure was repeat colpocleisis, with good short-term success rates noted. Additional studies with longer-term follow-up are needed.

The Impact of Fellowship Affiliation on Urogynecology Training in Obstetrics & Gynecology Residency.

OBJECTIVE: To compare characteristics of Urogynecology training and number of "Incontinence and Pelvic Floor" cases logged between OB/GYN residencies affiliated and those not affiliated with Urogynecology fellowships. DESIGN: A retrospective descriptive analysis was performed of OB/GYN residency programs, their Urogynecology training, and association with Urogynecology fellowship programs during the 2023-2024 academic year. Program websites for ACGME-accredited OB/GYN residency programs were reviewed to determine availability, timing, and length of Urogynecology training. ACGME data for "Incontinence and Pelvic Floor" cases were analyzed by training year and association with Urogynecology fellowship programs from the 2012-2013 to 2022-2023 academic year. Data was analyzed using SPSS. SETTING: This research was conducted at Harbor-UCLA Medical Center. PARTICIPANTS: None. INTERVENTIONS: None RESULTS: Information was obtained for 85.9% of programs. Nearly all (97.0%) had dedicated Urogynecology rotations, and 64.4% had rotations in > 1 year of training. Association with Urogynecology fellowship did not affect the availability of Urogynecology training overall nor the overall number of rotations. Urogynecology rotations occurred most often in the third (PGY3) year of residency, though 43.6% of programs had training for junior (PGY1, PGY2) residents. Residencies with associated Urogynecology fellowships were more likely to have a rotation for PGY2 residents and for junior residents overall. From 2012-2023, the number of "Incontinence and Pelvic Floor" cases declined by 36.3%, with trainees at residencies not affiliated with Urogynecology fellowships logging more cases than those at a fellowship-affiliated residency. CONCLUSION: While the majority of OB/GYN residencies have dedicated Urogynecology training, most rotations are for senior residents. Training programs associated with Urogynecology fellowships are more likely to expose junior residents to the field, but their trainees log fewer "Incontinence and Pelvic Floor" cases overall. Earlier exposure may enrich surgical training and help residents prepare for their career, whether in Urogynecology or as a generalist.

Randomized trial of an enhanced consultation versus standard consultation for prolapse: impact on patient satisfaction.

INTRODUCTION AND HYPOTHESIS: Optimal counseling techniques for Spanish-speaking patients with low health literacy and pelvic organ prolapse (POP) is unknown. We hypothesize that with use of an enhanced consultation (EC) strategy, patient satisfaction with their knowledge of prolapse will improve compared with a standard consultation (SC). METHODS: We conducted a randomized controlled trial of an EC vs SC in Spanish-speaking women seeking treatment for POP. In addition to receiving the same SC as the SC group, the EC group received consultation using images from an Interactive Pelvic Organ Prolapse Quantification (POPQ) Program and a brief anatomy lesson. Thirty participants per group was calculated to achieve a power of 80% with an alpha of 0.05. The primary outcome was to assess the change in patient satisfaction of prolapse understanding utilizing a visual analog scale. Comparisons between groups were done using Student's t test or Wilcoxon Rank-Sum for continuous variables, Mantel-Haenszel for ordinal variables, and Chi-squared and Fisher's exact tests for categorical variables. RESULTS: A total of 78 patients were enrolled and 64 completed the study. There was no difference in the change in satisfaction with disease understanding on a visual analog scale between the EC and SC groups (45.6 vs 51.7, p = 0.623). There were no differences in the change in factual knowledge scores on the prolapse portion of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) between the EC and the SC groups (19.6 vs 18.9, p = 0.914). CONCLUSIONS: In Spanish-speaking women, an EC using a 2-D prolapse animation did not increase prolapse knowledge satisfaction of disease understanding compared with an SC.

Antibiotic regimen and route of administration do not alter rates of urinary tract infection after intravesical botulinum toxin injection for overactive bladder.

INTRODUCTION AND HYPOTHESIS: Guidelines vary on antibiotic prophylaxis for onabotulinumtoxinA (Botox) treatment for overactive bladder (OAB). Our primary objective was to determine whether any prophylactic regimen is more effective in preventing urinary tract infection (UTI) after Botox. The secondary objective was to identify prophylactic practice patterns among female pelvic medicine and reconstructive surgery (FPMRS) providers of different training backgrounds as well as general urologists. METHODS: This was a secondary analysis of a retrospective cohort study on urinary retention after Botox injection in women with and without diabetes mellitus and OAB. Women > 18 years old who underwent Botox injection for OAB between January 2013 and September 2018 were included. Exclusion criteria were history of urinary retention and neuromuscular bladder dysfunction. RESULTS: A total of 565 patients were included. Two hundred eighty (49.6%) were treated by OB-GYN FPMRS, 209 (37.0%) by urology FPMRS and 76 (13.5%) by general urologists. The majority (92.9%) received antibiotic prophylaxis: 44.4% received intravenous (IV) only, 8.9% received oral (PO) only, and 39.7% received combination IV and PO prophylaxis. Urology FPMRS used antibiotic prophylaxis less frequently (p = 0.003). Within 3 months, 171 patients developed UTI (30.4%). There was no difference in post-procedural UTI for any antibiotic regimen compared to no prophylaxis. No route of antibiotic administration was superior at preventing UTI. CONCLUSIONS: In this cohort, no route of antibiotic administration was more effective in the prevention of UTI. Antibiotic prophylaxis did not lower the rate of post-procedural UTI compared to no antibiotics.

The impact of physician-directed and patient-directed education on screening, diagnosis, treatment, and referral patterns for urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the impact of patient- and physician-directed education in the primary care setting on screening, diagnosis, treatment, and referral patterns to Urogynecology for urinary incontinence (UI). METHODS: This was a prospective, multi-phase, before-and-after study conducted over a 3-year period. New female patients, 40 years and older, seen in the Internal Medicine (IM) clinic of our institution, were included. Phase 1 intervention consisted of UI lectures for IM residents. Phase 2 intervention involved placement of patient-directed posters throughout the IM clinic. Prior to phase 1, charts of new patients were reviewed as the control group to establish a baseline rate of screening, diagnosis, treatment initiation, and referrals. The same data were collected for 4 months after both phase 1 and phase 2. A washout period of 1 year occurred between phase 1 and phase 2. RESULTS: A total of 410 charts were reviewed and included 200 control, 92 phase 1, and 118 phase 2 patients. In the control group, 13% of patients were screened for UI. There was no significant increase in screening after phase 1 (15% vs 13%, p = 0.6); however, there was a significant increase after phase 2 (32.2% vs 13%, p < 0.001). There was no difference in treatment initiation for patients with a positive screen after either phase. CONCLUSION: In our study, providing an informative lecture to an IM referral base did not improve UI screening. Alternatively, directly targeting patients through posters significantly improved screening rates in the primary care setting, demonstrating that simple interventions can improve screening for conditions that are difficult to discuss such as UI.

Readability and quality of Wikipedia articles on pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: This study is aimed at evaluating the readability and quality of Wikipedia articles on pelvic floor disorders (PFD) and comparing their content with International Urogynecological Association patient education leaflets. METHODS: Readability was assessed using six different readability scales, including the Simple Measure of Gobbledygook (SMOG) Index, which is considered superior for scoring healthcare information. Quality was assessed by three female pelvic medicine and reconstructive surgery fellows using the modified DISCERN instrument. DISCERN is validated to evaluate the quality of written consumer health information; it was subsequently modified by health education researchers to enable the evaluation of Wikipedia articles. RESULTS: We evaluated 30 Wikipedia articles that correlated with 29 International Urogynecological Association leaflets. The mean SMOG score of the Wikipedia articles was 12.0 ± 2.1 (12th-grade reading level) whereas the mean SMOG score of the International Urological Association (IUGA) leaflets was 3.4 ± 0.3 (third-grade reading level, p < 0.001). The mean modified DISCERN score of the Wikipedia articles was 34.43 ± 5.90 (moderate quality); however, the mean modified DISCERN score of the IUGA literature was 45.02 ± 1.36 (good quality, p < 0.001). CONCLUSIONS: Wikipedia articles on PFD are neither readable nor reliable: they require a 12th-grade-level education for comprehension and are merely rated moderate in quality. In comparison, IUGA leaflets require a third-grade education for comprehension and are rated good in quality. Urogynecological providers should provide appropriate health education materials to patients, as Wikipedia is both a popular and sometimes inaccurate resource for patients.

Use of pelvic model-based simulation for sacrospinous ligament fixation education in novice learners: a single-blinded randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: We hypothesize that there will be improvement in a novice learners' confidence and skill level with sacrospinous ligament fixation (SSLF) following a pelvic model-based simulation. METHODS: We performed a single-blinded randomized controlled trial with obstetrics and gynecology residents who were novices at SSLF. The residents were randomly assigned to two groups. The control group received a lecture on the SSLF procedure and anatomy, whereas the intervention group received the same lecture in addition to a pelvic model-based simulation session taught by urogynecologists. The residents' knowledge of SSLF anatomy and confidence level with the procedure were measured via assessments administered before and after the educational interventions. Their technical skills were objectively assessed by one of two fellowship-trained urogynecologists who were blinded to their group allocation. RESULTS: A total of 28 residents were recruited with 14 residents in each group and equal distribution of junior and senior trainees. None of the residents had previously performed the SSLF procedure. There was no difference in anatomical knowledge between the two groups. The intervention group showed a greater increase in their average confidence score compared with the control group: 4.0 ± 1.4 (95% CI 3.1-4.8) versus 2.6 ± 1.6 (95% CI 1.7-3.4) respectively, with p = 0.02. The intervention group also showed better objective scores in specific technical skills, such as instrument handling (p < 0.001), instrument movement/motion (p < 0.001), and speed (p = 0.01). CONCLUSION: Our results demonstrate that inclusion of a pelvic model simulation significantly improves confidence and certain technical skills of novice trainees in performing SSLF.

Randomized controlled trial of the effect of environment on patient embarrassment and anxiety with urodynamics.

INTRODUCTION AND HYPOTHESIS: In previous survey studies, women undergoing urodynamic testing (UDT) have reported bother and embarrassment and have provided suggestions for improving the experience. The suggestions include audio distraction and increased privacy, neither of which have been prospectively examined. We report a prospective randomized controlled trial to evaluate the hypothesis that an improved ambience can decrease UDT-related embarrassment and anxiety. METHODS: A total of 60 participants were recruited to achieve an 80% power to detect a conservative 20-point difference with a significance level of 0.05. Eligible participants were randomized to one of two conditions: dim lighting with light instrumental music (modified group, 30 patients), or no music and standard lighting (standard group, 30 patients). The aim of the dim lighting and music was to provide an increased sense of privacy and audio distraction based on participant feedback in previous studies. RESULTS: The study was complete with 60 participants. Patients in both groups reported less embarrassment after UDT. However, patients in the modified group showed a greater decrease in embarrassment scores (9.72 mm) than patients in the standard group (1.3 mm; p = 0.33). Although the study was under-powered, the difference found approached clinical significance. CONCLUSIONS: Simply dimming the lights and providing music during UDT resulted in a decrease in embarrassment scores of almost ten points. This low-cost and simple measure improved patient experience.

Urinary Incontinence Care in the Academic and Safety-Net Primary Care Settings: Opportunities to Improve Quality of Care.

OBJECTIVE: To compare the quality of urinary incontinence (UI) care for women in the safety-net and nonsafety-net settings prior to referral to a specialist. METHODS: We performed a retrospective review of 200 women from two nonsafety-net hospitals and 188 women from two safety-net hospitals who were referred to Urogynecology and Reconstructive Surgery specialists for bothersome UI between March 2017 and March 2020. We evaluated the care that women received 12 months prior to referral, by measuring adherence to a set of previously developed quality indicators (QIs), for example, the performance of a urinalysis or pelvic exam. RESULTS: Women seen in safety-net hospitals were more likely to receive QI-compliant care than women in the nonsafety-net hospitals prior to referral, with 55.53% of appropriate care given in the safety-net vs 40.3% in the nonsafety-net setting (P <.01). Clinicians in the safety-net hospitals were more likely to adhere to QIs in patients with general, stress, and urgency incontinence. CONCLUSION: Women were more likely to receive timely, quality-based UI care in the safety net compared to the nonsafety-net setting. This may be in part due to aspects unique to the safety-net system, including an eConsult referral system, which guides referring clinicians in appropriate management steps that should be taken prior to the specialist visit, as well as women's health-focused primary care clinics.

Gender Representation in U.S. Urogynecology Fellowship Program Leadership.

IMPORTANCE: The proportion of female physicians in the workforce has been steadily increasing, but the proportion of women in department leadership roles across the United States remains low. Urogynecology has the highest representation of women in leadership roles across obstetrics and gynecology and urology subspecialties; however, the proportion of women in leadership roles within urogynecology fellowship programs has not been described previously. OBJECTIVES: Our objective was to investigate gender representation within urogynecology fellowship program leadership positions. STUDY DESIGN: This was a cross-sectional observational study where urogynecology fellowship program websites were queried for the geographic state as well as the gender expression of the program director and division chair. RESULTS: A total of 68 American Council for Graduate Medical Education-accredited urogynecology fellowship programs were queried. Of these, 53 are obstetrics and gynecology-based programs and 15 are urology-based programs. Overall, women represent 67.6% of fellowship directors and 59.2% of division directors. One in 4 female fellowship directors concurrently hold the role of division chair. Women are significantly more likely to be fellowship directors in obstetrics and gynecology-based programs compared with urology-based urogynecology programs (75.4% versus 40.0%; odds ratio, 4.1; 95% confidence interval, 1.20-14.0). Women are also more likely to be division chairs in obstetrics and gynecology-based compared with urology-based urogynecology programs, although this did not reach statistical significance (63.4% versus 37.5%; odds ratio, 2.9, 95% confidence interval, 0.60-13.8). CONCLUSIONS: Across urogynecology fellowship programs, women are the majority of division chairs and fellowship directors. However, female representation in leadership roles is lagging at urology-based urogynecology programs.

The Correlation of Diabetes Mellitus and Urinary Retention From Intravesical OnabotulinumtoxinA Injection for Overactive Bladder.

IMPORTANCE AND OBJECTIVES: The objective was to determine whether patients with diabetes mellitus (DM) treated with intravesical onabotulinumtoxinA (BoNT) injection for overactive bladder (OAB) had increased urinary retention requiring clean intermittent catheterization (CIC), as well as the impact of disease duration and severity. We hypothesize that patients with DM will have higher rates of retention after BoNT injection. STUDY DESIGN: We performed a retrospective cohort analysis of women in the Kaiser Permanente Southern California Health System who underwent BoNT injection for OAB, excluding women with a history of urinary retention or neurogenic bladder. RESULTS: We identified 565 patients, 410 in the control group and 155 in the DM group. No significant difference was found in the rate of CIC (9% in the control group versus 5.8% in the DM group, P = 0.2), voiding dysfunction, and peak postprocedure postvoid residual volume (PVR). Patients with diabetes had a significantly increased rate of postprocedure urinary tract infection (UTI; 27.6% versus 38.1%, P = 0.02). Urinary tract infection was significantly associated with urinary retention (adjusted odds ratio [OR], 2.26; 95% confidence interval [CI], 1.02-4.99; P = 0.045) and peak PVR ≥200 mL (adjusted OR, 2.42; 95% CI, 1.15-5.06; P = 0.019). Diabetic disease duration and severity were not a predictor of urinary retention, elevated PVR, or voiding dysfunction; however, the presence of ≥1 disease-related complication was a predictor of UTI (adjusted OR, 2.81; 95% CI, 1.34-5.91; P = 0.006). CONCLUSIONS: Diabetic patients had a similar rate of urinary retention requiring CIC after BoNT injection for OAB compared with nondiabetic patients. Diabetic patients had an increased risk of UTI based on disease severity.

Urinary retention and voiding dysfunction in women with uterine leiomyoma: a case series.

OBJECTIVE: To examine urinary retention as an underreported complication of uterine leiomyoma. Reproductive-aged women with uterine leiomyoma often describe pelvic pressure and menorrhagia, however few complain of complete urinary retention. STUDY DESIGN: We dis-cuss the cases of 8 women who presented to our emergency room with acute urinary retention over a 4-year period. RESULTS: Patients had a mean age of 39 (range, 25-51) and median parity of 1 (range, 0-5). Seven of 8 patients (88%) had posterior-fundal leiomyomas. All patients underwent either myomectomy or hysterectomy with resolution of their urinary retention. CONCLUSION: Incarceration of the posterior or fundal leiomyoma beyond the pelvic brim can push the cervix against the pubic bone, resulting in compression of the bladder neck or urethra. This may explain the etiology of retention and/or voiding dysfunction in some cases. Urinary retention, as a result of leiomyoma, may be overlooked in the initial management of symptomatic patients.

Vulvar Angioleiomyoma.

Vulvar angioleiomyoma is a very rare neoplasm. We describe the case of a 49-year-old woman who presented with a small, firm, tender labial mass. Intraoperatively, the lesion appeared hypervascular and was excised using sharp dissection. Histological and immunohistochemical analyses were necessary to make the diagnosis. The report of this extremely uncommon gynecologic lesion is important to make clinicians aware of the possibility of vulvar angioleiomyoma.

Music in the Operating Room: Comparing the Opinions of Surgeons, Anesthesiologists, and Nurses.

BACKGROUND: Music is part of operating room (OR) culture; however, some personnel may perceive music as a distraction. METHODS: A single institution survey of surgeons (SURG), anesthesia (ANES), and nursing (NURS) regarding attitudes on music in the OR. RESULTS: There were 222 responses (67% response rate) agreeing that music in the OR should be allowed (91%), is calming (75%), and helps with focus (63%). Most did not feel music was distracting (63%) or unsafe (80%). SURG were more likely to state that surgeons should decide (46.7%) if music should be played, whereas ANES and NURS (81%) were more likely to feel decisions should be made collaboratively (P < .001). CONCLUSION: Most OR personnel feel positively towards music. Surgeons were more likely to believe the decision to play music should be the surgeon's choice. The majority of OR staff agreed with collaborative decision-making, aligning with creating a safe OR culture.

Sacrospinous ligament fixation for pelvic organ prolapse in the era of vaginal mesh kits.

PURPOSE OF REVIEW: To examine the sacrospinous ligament as a point of attachment for pelvic organ prolapse procedures, including vaginal mesh kits. RECENT FINDINGS: Pelvic surgeons are increasingly employing the sacrospinous ligament as a point of attachment for biologic grafts and synthetic mesh kits during uterovaginal prolapse repairs. These techniques may have introduced a novel set of complications (mesh extrusion, erosion) in addition to those already known to occur in traditional sacrospinous ligament fixations. Except for limited short-term results, little data are available in the literature regarding surgical outcomes and complications for mesh and graft augmented repairs attached to the sacrospinous ligament. SUMMARY: The sacrospinous ligament fixation is a well tolerated and effective procedure for suspension of the vaginal apex. Mesh augmentation using the sacrospinous ligament may improve objective prolapse recurrence, but complications still occur, including those specific to mesh placement.

Determining outcomes, adverse events, and predictors of success after sacral neuromodulation for lower urinary disorders in women.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to determine the predictors of successful treatment of lower urinary tract disorders with sacral nerve stimulation (SNS) and the rate of adverse events and reoperations. METHODS: A retrospective case series of patients who underwent SNS at a single institution was analyzed. RESULTS: Seventy-six patients underwent stage I trial of SNS. Fifty-eight (76%) patients experienced improvement and underwent placement of an implantable pulse generator with a mean follow-up of 23.7 months (SD ± 22.3). Surgical revisions occurred in 14/58 (24%) patients and 15/58 (26%) patients had the device explanted after a mean of 2.8 years (SD ± 1.7). Patients with greater than ten incontinence episodes per day were more likely to have a successful stage I trial compared to those with less than five (OR = 10.3; 95% CI 2.1 to 50.60). CONCLUSIONS: Although SNS is a safe and effective therapy for lower urinary tract disorders, it is associated with a high reoperation rate.

Uterosacral ligament vaginal vault suspension using delayed absorbable monofilament suture.

INTRODUCTION AND HYPOTHESIS: We investigated the incidence of suture complications and recurrent prolapse following uterosacral ligament suspension (USLS) using delayed absorbable polyglyconate monofilament suture (Maxon). METHODS: We reviewed the medical records of subjects who underwent vaginal USLS using polyglyconate suture. Primary outcomes were suture complications and anatomic failures defined as recurrent apical prolapse stage 1 or greater. Secondary outcomes were subjective failures and reoperation rate for apical prolapse. RESULTS: Fifty-seven out of 68 subjects who underwent USLS with polyglyconate suture over the study period were included in analysis. At median follow-up of 12 months, 3.5% had suture complications. The anatomic and symptomatic failure rate was 7%. One subject underwent repeat surgery for prolapse. CONCLUSIONS: Suture complications are uncommon using polyglyconate suture for USLS, and failure rates are low. This is in comparison to a 44.6% suture erosion rate with permanent suture reported by our institution using the same surgical technique.

Percutaneous Tibial Nerve Stimulation in Diabetic and Nondiabetic Women With Overactive Bladder Syndrome: A Retrospective Cohort Study.

OBJECTIVES: The primary objective of this study was to compare optimal response ("very much better" or "much better" on the Patient Global Impression of Improvement [PGI-I] index) to posterior tibial nerve stimulation (PTNS) for overactive bladder (OAB) in patients with and without diabetes mellitus. Secondary outcomes included longitudinal data regarding PTNS use in patients with diabetes and controls. METHODS: We performed a retrospective cohort analysis of women in our tertiary care center who completed at least 10 weekly and 1 maintenance PTNS treatments for OAB, excluding patients who were treated with PTNS for a non-OAB primary diagnosis. Participants were grouped into those with diabetes mellitus and those without. Previous research demonstrated a 20% difference in subjective response to anticholinergics in persons with diabetes versus persons without diabetes with OAB. To demonstrate a 20% difference in optimal PGI-I with 80% power, our analysis required 92 patients in each group. RESULTS: We identified 356 patients: 96 with diabetes mellitus, and 260 controls. There was no statistically significant difference in the primary outcome, with 43 (44.8%) of 96 persons with diabetes versus 115 (44.2%) of 260 controls demonstrating optimal PGI-I response (P = 0.92). Among patients with diabetes, no baseline variables were found to predict treatment response, including hemoglobin A1c greater than 7%, diabetes with sequelae, or higher Charlson Comorbidity Index. CONCLUSIONS: In women undergoing PTNS for OAB, the optimal PGI-I response rate is similar in patients with and without diabetes.

The Anatomical Distribution of the Pudendal Nerve Block Injection: A Cadaveric Study.

OBJECTIVE: The objective of this study was to assess the accuracy of commonly used injection locations of the pudendal nerve block by examining the proximity of the injected dye to the pudendal nerve in a cadaveric model. METHODS: Pudendal block injections at 4 sites were placed transvaginally on 5 cadaveric pelvises. These sites were 1 cm proximal to the ischial spine (black dye), at the ischial spine (red dye), 1 cm distal to the ischial spine (blue dye), and 2 cm lateral and 2 cm distal to the ischial spine (green dye). The cadavers were dissected via a posterior approach. RESULTS: We measured the shortest distance from the center of the dye-stained tissue to the pudendal nerve. As expected, the injections at the ischial spine (red) resulted in a distribution of dye closest to the pudendal nerve, averaging 3.0 ± 0.95 mm. Dyes at other sites were close to the nerve: 3.1 ± 1.00 mm (black), 3.6 ± 1.14 mm (blue), and 4.05 ± 1.28 mm (green). CONCLUSIONS: Regardless of the injection site, all dyes were close the pudendal nerve, indicating accuracy. We observed wide variation in the dye distribution even though all injections were performed by the same provider, implicating lack of precision. Based on our findings, we propose that the most effective injection location is at the ischial spine because it is the closest to the pudendal nerve; however, all injections were within 4 mm of the pudendal nerve, suggesting that only 1 to 2 injections may be sufficient.

Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women.

INTRODUCTION: Most causes of microscopic hematuria (MH) are benign but may indicate an underlying malignancy. Current MH evaluation guidelines are reflective of male urologic malignancy risks. The objective of this systematic review was to evaluate whether the finding of MH predicts subsequent urologic malignancy in women. METHODS: MEDLINE was searched between January 1990 and June 8, 2018. The positive predictive value (PPV) of MH as a screening tool for urologic malignancy was calculated for each study individually and collectively. The pooled relative risk of urologic malignancy associated with MH was calculated. RESULTS: Seventeen studies were included. Eight studies included only women. In total, 300 urinary tract cancers were identified in 110,179 women with MH. The PPV of MH as a screening tool for cancer ranged from approximately 0.6% to 2.8%; confidence intervals (CIs) suggested this is a relatively unstable performance indicator because of small sample sizes. Average PPV across all studies was 2.13%, but the weighted average PPV was 0.24%. The risk of urologic malignancies among women with relative those without MH was 2.01 (95% CI, 1.61-2.51). Based on these limited data, we estimate that 859 (95% CI, 654-1250) women with MH would require complete evaluation to identify 1 urinary tract malignancy. CONCLUSIONS: A very small proportion of women with MH are likely to have a urologic malignancy. Approximately 859 women require full screening to identify 1 malignancy. Current evidence is limited, and further studies, specifically in women, are needed.