Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence.

INTRODUCTION AND HYPOTHESIS: Despite growing interest in a mobile-app bowel diary to assess fecal incontinence (FI) symptoms, data are limited regarding the correlation between mobile-app diary and questionnaire-based outcomes. The primary aim is to determine whether percentage reduction in FI episodes (FIEs)/week recorded on a mobile-app diary correlates with changes in scores of validated FI-symptom measures from baseline to 12 weeks in women with FI undergoing percutaneous tibial nerve stimulation (PTNS) versus sham. METHODS: This is a planned secondary analysis of a multicenter randomized trial in which women with FI underwent PTNS or sham. FIEs were collected using a mobile-app diary at baseline and after 12 weekly sessions. FI-symptom-validated measures included St. Mark's, Accidental Bowel Leakage Evaluation, FI Severity Index (FISI), Colorectal Anal Distress Inventory, Colorectal Anal Impact Questionnaire, FI Quality of Life, Patient Global Impression of Improvement (PGI-I), and Patient Global Symptom Control (PGSC) rating. Spearman's correlation coefficient (ρ) was computed between %-reduction in FIEs/week and change in questionnaire scores from baseline to 12 weeks. Significance was set at 0.005 to account for multiple comparisons. RESULTS: Baseline characteristics of 163 women (109 PTNS, 54 sham) include mean age 63.4±11.6, 81% white, body mass index 29.4±6.6 kg/m2, 4% previous FI surgeries, 6.6±5.5 FIEs/week, and St. Mark's score 17.4±2.6. A significant correlation was demonstrated between %-reduction in FIEs/week and all questionnaires (p<0.005). A moderate-strength correlation (|ρ|>0.4) was observed for St. Mark's (ρ=0.48), FISI (ρ=0.46), PGI-I (ρ=0.51), and PGSC (ρ=-0.43). CONCLUSIONS: In women with FI randomized to PTNS versus sham, a moderate correlation was noted between FIEs measured via mobile-app diary and FI-symptom-validated questionnaire scores.

Pelvic Floor Disorders in Black Women: Prevalence, Clinical Care, and a Strategic Agenda to Prioritize Care.

Pelvic floor disorders are a group of common conditions affecting women of all racial and ethnic groups. These disorders are undertreated in all women, but this is especially magnified in Black people who have been historically marginalized in the United States. This article seeks to highlight the prevalence of pelvic floor disorders in Black women, evaluate the clinical care they receive, examine barriers they face to equitable care, and present a strategic agenda to prioritize the care of Black women with pelvic floor disorders.

Uterine Prolapse.

This JAMA Insights in the Women's Health series discusses diagnosis of uterine prolapse and available surgical and nonsurgical treatment options.

Barriers to Urogynecologic Care for Racial and Ethnic Minority Women: A Qualitative Systematic Review.

IMPORTANCE: Studies have sought to evaluate factors that have perpetuated disparities in health care, including urogynecologic care. However, there remains a lack of understanding of barriers to care specific to racial/ethnic minority populations. OBJECTIVES: We aimed to report identified barriers to urogynecologic care (eg, care for symptoms/diagnoses of urinary incontinence [UI], accidental bowel leakage [ABL], and pelvic organ prolapse [POP]) for underrepresented racial and ethnic minority (URM) women in the United States. STUDY DESIGN: We conducted a systematic search for studies through 5 electronic bibliographic databases. Inclusion criteria for eligible studies included the following: (1) studies reporting barriers to care for those with urogynecologic symptoms/diagnoses, (2) publication date year 2000 or later. Exclusion criteria included study cohorts with children, exclusively non-U.S. populations, cohorts without URM participants, and studies without qualitative research methodology. Study methodology, characteristics, as well as barriers and facilitators to urogynecologic care were captured using a thematic synthesis approach. RESULTS: There were 360 studies identified. Twelve studies met criteria: 6 had study populations with UI, 3 with POP, 2 on UI and/or POP, and 1 on ABL. There were 7 focus group studies (total 44 groups, n = 330), 4 interview studies (total 160 interviews, n = 160), and 1 had both (10 interviews, 6 groups, n = 39). Most studies reported on patient-associated barriers (n = 10/12) and physician/provider-associated barriers (n = 10/12), whereas only half reported system-associated barriers (n = 6/12). CONCLUSION: Identified barriers to urogynecologic care for URM populations were examined. Findings likely do not fully reflect barriers to urogynecologic care for URM populations. Comprehensive evaluation of social determinants of health and systemic racism within studies is needed to understand the unique barriers present for racially/ethnically diverse populations.

Frailty and Acute Postoperative Urinary Retention in Older Women Undergoing Pelvic Organ Prolapse Surgery.

IMPORTANCE: Acute postoperative urinary retention (POUR) is common after pelvic reconstructive surgery, occurring in 15-45% of women. There is a paucity of data on the relationship between frailty and POUR after prolapse surgery. OBJECTIVE: This study aimed to examine the association between frailty and POUR in older women who underwent pelvic organ prolapse surgery. STUDY DESIGN: This secondary analysis of a prospective study of postoperative delirium enrolled women 60 years and older undergoing prolapse surgery. The Fried Frailty Index was used to assess frailty before surgery. Acute POUR was defined as failure to pass a retrograde voiding trial at hospital discharge with postvoid residual volume of greater than 100 mL. RESULTS: Analyses included 165 women, with a mean ± SD age of 72.5 ± 6.1 years and a body mass index of 28.0 ± 4.4 kg/m2. There were 49 laparoscopic/robotic apical suspension procedures (29.7%), 60 vaginal obliterative procedures (36.4%), 47 vaginal apical suspension procedures (28.5%), and 9 isolated anterior and/or posterior colporrhaphies (5.5%), of which 9 had a concomitant incontinence procedure. Seventy-eight women (47.3%) experienced acute POUR. Thirty-one (18.8%) met the criteria for "not frail," 115 (88.5%) were "prefrail," and 19 (11.5%) were "frail." Neither frailty status nor score was associated with POUR. In an analysis of individual Fried Frailty Index components, self-reported unintentional weight loss was significantly associated with POUR (odds ratio, 4.6; 95% confidence interval, 1.23-17.15). This remained significant on multivariable logistic regression (adjusted odds ratio, 4.06; 95% confidence interval, 1.01-16.39). CONCLUSIONS: Frailty was not associated with POUR in older women undergoing prolapse surgery. The observed association between POUR and unintended weight loss before surgery warrants further investigation.

Postoperative delirium in older patients after undergoing pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: To determine the 7-day incidence and risk factors of postoperative delirium (POD) occurring after prolapse surgery in women aged ≥60 years. METHODS: A prospective study of women ≥60 years undergoing prolapse surgery at a large academic center. The primary outcome is positive Confusion Assessment Method delirium screen administered in person or by telephone at the time of hospital discharge and postoperative days 1, 3, 5, and 7. RESULTS: This analysis included 165 patients, mean ± SD age of 72.5 ± 6.1 years, with median (IQR) years of education of 13 (12-16), and baseline Modified Mini-Mental Status (3MS) Exam score of 95 (92-98). Prolapse repair type was vaginal for 70% (n=115) and laparoscopic for 30% (n=50) of patients; most under general anesthesia, 151 (92.1%). The incidence of positive delirium screen during the first week after surgery was 12.1% (n=20). Most of these participants screened positive on postoperative day 0, 8.4% (n=14). In univariate analyses, a positive screen was associated with older age and fewer education years, lower 3MS exam score, greater baseline geriatric depression scale score, and greater frailty score. Lower 3MS score was the only variable that remained significant in the final model (adjusted odds ratio 0.84, 95% CI 0.75-0.95). CONCLUSIONS: One in 12 women ≥60 years deemed eligible for discharge on the day of prolapse surgery screens positive for delirium. The 7-day POD incidence is comparable to other elective non-cardiac surgery cohorts. Given the increasing trend toward same day discharge after major prolapse surgery, more research is needed to determine the impact of universal delirium screening as part of discharge assessments.

Racial Differences in Urinary Catheter Use Among Female Nursing Home Residents.

OBJECTIVE: To assess racial differences in prevalence of indwelling urinary catheterization and intermittent catheterization among female NH residents in the United States (US). METHODS: We performed a cross-sectional analysis using the 2019 Minimum Data Set 3.0 and developed a multivariable logistic regression model to examine the association between catheter use and race. Moderation analyses were performed to clarify significant associations. RESULTS: Our study cohort was composed of 597,966 women, who were predominantly of White race with a median age of 80 years. Eight percent (n=47,799) of female residents had indwelling catheters, and 0.5% (n=2,876) used intermittent catheterization. Black residents had a 7% lower odds of having an indwelling catheter (aOR 0.93, 95% CI 0.90-0.96), and a 38% lower odds of utilizing intermittent catheterization (aOR 0.62, 95% CI 0.54-0.71) compared to White residents when controlling for common factors associated with catheter use. In moderation analyses, Black residents with age under 80 years and BMI of 35 kg/m2 or greater were less likely to have an indwelling catheter than age- and BMI-matched White residents. CONCLUSION: Racial differences in both indwelling and intermittent catheterization prevalence exist in female NH residents. These disparities should be further clarified to reduce bias in NH care.

Overactive Bladder and Cognitive Impairment: The American Urogynecologic Society and Pelvic Floor Disorders Research Foundation State-of-the-Science Conference Summary Report.

IMPORTANCE: Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications. OBJECTIVES: The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment. STUDY DESIGN: The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets. RESULTS: Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk. CONCLUSIONS: The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment.

Evidence-Informed, Interdisciplinary, Multidimensional Action Plan to Advance Overactive Bladder Research and Treatment Initiatives: Directives From State-of-the-Science Conference on Overactive Bladder and Cognitive Impairment.

ABSTRACT: This article outlines an evidence-informed, interdisciplinary, multidimensional, comprehensive action plan for the American Urogynecologic Society to improve care of women with overactive bladder (OAB) while minimizing treatment-related adverse events, including cognitive impairment. It is a "call to action" to advance basic, translational, and clinical research and summarizes initiatives developed at the State-of-the-Science Conference on OAB and Cognitive Impairment to (1) develop framework for a new OAB treatment approach in women, (2) define research gaps and future research priorities, (3) champion health equity and diversity considerations in OAB treatment, (4) foster community and promote education to remove stigma surrounding OAB and urinary incontinence, and (5) elevate visibility and impact of OAB, by creating partnerships through education and engagement with health care professionals, industry, private and public payers, funding agencies, and policymakers.

Patient Preparedness for Pelvic Organ Prolapse Surgery: A Randomized Equivalence Trial of Preoperative Counseling.

OBJECTIVE: Preoperative counseling can affect postoperative outcomes and satisfaction. We hypothesized that patient preparedness would be equivalent after preoperative counseling phone calls versus preoperative counseling office visits before prolapse surgery. METHODS: This was an equivalence randomized controlled trial of women undergoing pelvic organ prolapse surgery. Participants were randomized to receive standardized counseling via a preoperative phone call or office visit. The primary outcome was patient preparedness measured on a 5-point Likert scale by the Patient Preparedness Questionnaire at the postoperative visit. A predetermined equivalence margin of 20% was used. Two 1-sided tests for equivalence were used for the primary outcome. RESULTS: We randomized 120 women. The study was concluded early because of COVID-19 and subsequent surgery cancellations. There were 85 participants with primary outcome data (43 offices, 42 phones). Mean age was 62.0 years (±1.0) and 64 (75.3%) had stage III or stage IV prolapse. The primary outcome, patient preparedness measured at the postoperative visit, was equivalent between groups (office, n = 43 [97.7%]; phone, n = 42 [97.6%], P < 0.001). Most women reported they would have preferred a phone call (n = 66, 65.5%) with more women in the phone group expressing this preference than the office group (office 40.5% vs phone 90.5%, P < 0.001). Ultimately, nearly all women (96.5%) were satisfied with their method of counseling. CONCLUSIONS: Preoperative counseling phone calls were equivalent to office visits for patient preparedness for pelvic organ prolapse surgery. This study demonstrates patient acceptance of phone calls for preoperative counseling. Telehealth modalities should be considered as an option for preoperative patient counseling.

Preoperative Counseling Method and Postoperative Opioid Usage: A Secondary Analysis of the PREOP Study.

OBJECTIVE: The purpose of this analysis is to determine if postoperative opioid usage differs among women randomized to office or phone preoperative counseling for pelvic organ prolapse surgery. METHODS: This was a planned exploratory analysis of the Patient Preparedness for Pelvic Organ Prolapse Surgery study, which randomized women to standardized preoperative counseling by office visit or phone call before prolapse surgery. Inclusion criteria were the completion of the assigned counseling intervention and submission of a 7-day postoperative pain and medication diary. Multivariable logistic regression was done to assess the association between counseling method and total opioid use while controlling for variables significant on univariate analysis (surgery type and county of residence). RESULTS: There were 84 participants with postoperative data (41 office, 43 phone). Median total number of 5-mg oxycodone tablets used was higher for the office group (5 [interquartile range, 0-10]) than the phone group (0 [interquartile range, 0-2], P = 0.002). On multivariable logistic regression, women who underwent phone counseling were less likely to be in the highest third of opioid use when controlling for surgery type and county of residence (odds ratio, 0.23; P = 0.012; 95% confidence interval, 0.07-0.72). Daily pain scores and nonopioid medication use (nonsteroidal anti-inflammatory medications and acetaminophen) were similar between groups (P > 0.05). CONCLUSIONS: Despite similar pain scores, women who received preoperative phone counseling before pelvic organ prolapse surgery had lower opioid utilization than those with office counseling. Further research is needed to determine the optimal method of preoperative counseling and its role in postoperative pain management.

Postoperative Opioid Utilization in Older Women Undergoing Pelvic Organ Prolapse Surgery.

OBJECTIVES: The objective of this study was to determine total postoperative opioid consumption by women 60 years and older during the first week after pelvic organ prolapse surgery. We secondarily aimed to describe opioid prescribing patterns in this cohort. METHODS: This is a secondary analysis of a prospective cohort study assessing changes in cognition in women 60 years and older undergoing prolapse surgery. Postoperative opioid use at home during the first week was collected through daily self-reported diary entries. Total postoperative opioid consumption was calculated by adding opioid administration in the postoperative anesthesia recovery unit, inpatient setting, and home opioid use (as documented in diary). Regression models were used to identify demographic and clinical factors associated with total postoperative opioid consumption in the top quartile of this cohort and home opioid use. RESULTS: Data from 80 women were analyzed. Mean ± SD age was 71.78 ± 6.14 years (range, 60-88 years). Fifty women (62.5%) underwent vaginal surgery, and 30 (7.5%) underwent laparoscopic/robotic surgery, with concomitant hysterectomy in 47 (58.8%). The median (interquartile range) total morphine milligram equivalents used during the first week after surgery was 30 (7.5-65.75). The median (interquartile range) total morphine milligram equivalents prescribed was 225 (150-225). CONCLUSIONS: Opioid consumption after prolapse surgery in older women is very modest and equates to a median (interquartile range) of 4 (1-9) oxycodone (5 mg) tablets. Opioid prescribing patterns should be adjusted accordingly.

The Complexity of the Retropubic Midurethral Sling: A Cognitive Task Analysis.

OBJECTIVE: The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon's internal thought processes during the surgery. METHODS: Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery. RESULTS: Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps). CONCLUSIONS: The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.

Incidence of postoperative cognitive dysfunction in older women undergoing pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Postoperative cognitive dysfunction (POCD), a transient impairment of memory, concentration, and information processing, has been reported after 7-26% of non-cardiac surgeries with associated increase in morbidity and death. Our primary aim was to determine the incidence of POCD 2 weeks after prolapse surgery in women ≥ 60 years old. Our secondary aim was to identify risk factors for POCD. METHODS: Prospective cohort study of women ≥ 60 years old scheduled for pelvic organ prolapse surgery. Exclusion criteria included cognitive impairment history, major neurologic disorder, and abnormal cognition screen. A comprehensive neuropsychologic (NP) battery (eight tests), administered 2 weeks pre- and post-surgery, assessed premorbid IQ and domains of attention, memory, and executive function. The primary outcome was defined as decline of ≥ 1 SD on ≥ 2 NP tests or decline of ≥ 2 SD on ≥ 1 test. Raw scores were transformed to Z-scores. RESULTS: NP testing was completed by 72 women, median age 72 (IQR 69-77) years. Procedures included 16 (22.9%) laparoscopic sacrocolpopexies, 23 (32.9%) transvaginal reconstructions, and 29 (41.4%) obliterative surgeries, performed under general (63, 90%), regional (5, 7.1%), or sedation (2, 2.9%) anesthesia with a median hospital stay of 0.6 (IQR 0.6-0.75) days. POCD incidence was 33.3% (n = 24). POCD was associated with greater frailty (p = 0.006) and higher baseline depression (p = 0.05) but not with older age (p = 0.77) or inhalational gas use (p = 1.0). CONCLUSION: In this cohort, one in three women manifested POCD 2 weeks after prolapse surgery. Preoperative counseling should include discussions on POCD given its detrimental impact on postoperative recovery and independence.

Sporadic compared to recurrent urinary tract infections: Considerations for urogynecologic patients.

AIMS: To describe the uropathogens and antimicrobial resistance patterns in women with singular, sporadic urinary tract infection (UTI) vs those with recurrent UTI (rUTI) in a urogynecologic population. METHODS: This was a cross-sectional analysis of women treated for a UTI by a urogynecologic provider in a 1-year timeframe. Subjects were divided into two groups: (a) sporadic UTI-no history of rUTI and a single infection in the study timeframe and (b) rUTI-history of rUTI and ≥2 UTIs in the study timeframe. Our primary outcome was the difference in uropathogens between groups. Secondary aims were to investigate host characteristics associated with recurrent Escherichia coli infections and resistant uropathogens in the rUTI cohort. RESULTS: We had 265 women with 163 (61.5%) in the sporadic UTI group and 102 (38.5%) in the rUTI group. The most common uropathogens were E. coli (57.3%) and Klebsiella (11.7%). In the rUTI group, only 27 of 102 (26.5%) had all E. coli infections. There were differences between groups regarding age (P = .03) and proportion of neurogenic bladder (P = .01), intermittent self-catheterization (P < .01), antibiotic suppression (P < .01), and vaginal estrogen therapy (P < .01). In the rUTI cohort, there were no risk factors that were significantly associated with recurrent E.coli UTIs and vaginal estrogen therapy was associated with a higher odds of sensitive uropathogens (adjusted odds ratio, 3.12; confidence interval, 1.28-7.56). CONCLUSIONS: In those with rUTI, it was uncommon to have recurring E. coli UTIs and consistently sensitive uropathogens. Pretreatment urine cultures are important to verify causative uropathogens in this population.

Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence. METHODS: This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse. RESULTS: Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II. CONCLUSIONS: Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.

Refractory urgency urinary incontinence treatment in women: impact of age on outcomes and complications.

BACKGROUND: Women with refractory urgency urinary incontinence (ie, unresponsive to behavioral and pharmacological interventions) are treated with onabotulinumtoxinA or sacral neuromodulation. OBJECTIVE: The objective of the study was to compare treatment efficacy and adverse events in women <65 and ≥65 years old treated with onabotulinumtoxinA or sacral neuromodulation. STUDY DESIGN: This study was a planned secondary analysis of a multicenter, randomized trial that enrolled community-dwelling women with refractory urgency urinary incontinence to onabotulinumtoxinA or sacral neuromodulation treatments. The primary outcome was a change in mean daily urgency urinary incontinence episodes on a bladder diary over 6 months. Secondary outcomes included ≥75% urgency urinary incontinence episode reduction, change in symptom severity/quality of life, treatment satisfaction, and treatment-related adverse events. RESULTS: Both age groups experienced improvement in mean urgency urinary incontinence episodes per day following each treatment. There was no evidence that mean daily urgency urinary incontinence episode reduction differed between age groups for onabotulinumtoxinA (adjusted coefficient, -0.127, 95% confidence interval, -1.233 to 0.979; P = .821) or sacral neuromodulation (adjusted coefficient, -0.698, 95% confidence interval, -1.832 to 0.437; P = .227). Among those treated with onabotulinumtoxinA, women <65 years had 3.3-fold greater odds of ≥75% resolution than women ≥65 years (95% confidence interval, 1.56 -7.02). Women <65 years had a greater reduction in Overactive Bladder Questionnaire Short Form symptom bother scores compared with women ≥65 years by 7.49 points (95% confidence interval, -3.23 to -11.74), regardless of treatment group. There was no difference between quality of life improvement by age. Women ≥65 years had more urinary tract infections following onabotulinumtoxinA and sacral neuromodulation (odds ratio, 1.9, 95% confidence interval, 1.2-3.3). There was no evidence of age differences in sacral neuromodulation revision/removal or catheterization following onabotulinumtoxinA treatment. CONCLUSION: Younger women experienced greater absolute continence, symptom improvement, and fewer urinary tract infections; both older and younger women had beneficial urgency urinary incontinence episode reduction, similar rates of other treatment adverse events, and improved quality of life.

Incidence of Occult Uterine Pathology in Women Undergoing Hysterectomy With Pelvic Organ Prolapse Repair.

OBJECTIVES: The objectives of this study are to determine the incidence of and associated risk factors for occult uterine pathology in patients undergoing hysterectomy with pelvic organ prolapse (POP) repair. METHODS: Medical records were reviewed from all cases of hysterectomy with POP surgery at a tertiary medical center from January 2007 through July 2014. Exclusion criteria included known endometrial hyperplasia or malignancy. A power calculation determined that 1000 subjects would demonstrate a lower rate of leiomyosarcoma in a urogynecology population compared to the rate of 1:352 reported by the Food and Drug Administration. RESULTS: There were 1196 cases identified with a mean age of 62.3 ± 11.3 years and body mass index of 27.8 ± 5.7. Most patients were white (95.5%) and postmenopausal (81.6%). Malignancy was present in 3 (0.3%) specimens. Seven (0.6%) specimens had endometrial hyperplasia. This overall abnormal pathology incidence of 0.8%, with 95% confidence interval of 0% to 1.4% is significantly lower than published rates of 2.6% (P < 0.001). There were no specimens with sarcoma (rate of 0%; 95% confidence interval, 0%-0.2%). There were no associations between demographic or clinical variables with the presence of hyperplasia and/or malignancy. CONCLUSIONS: The incidence of uterine hyperplasia/malignancy and sarcoma in women undergoing hysterectomy with POP were both significantly lower than previously published values in other populations. The use of power morcellation in urogynecologic populations should be revisited as the incidence of occult pathology is lower than the general population, and a condition-specific risk profile should be considered in the informed consent process.

Single versus multi-dose antibiotic prophylaxis for pelvic organ prolapse surgery with graft/mesh.

OBJECTIVE: To compare the risk of postoperative infections in women who receive single-dose versus multi-dose prophylactic antibiotic regimen during prolapse surgery with mesh/graft. STUDY DESIGN: Retrospective cohort study of 460 women who underwent prolapse surgery with mesh/graft. We compared women who received a single-dose prophylactic antibiotic regimen to those who received a multi-dose regimen. The primary outcome was the presence of any postoperative infection, defined as the presence of any of the following infections: urinary tract infection (UTI), fever, wound or trocar site infection, mesh infection or pelvic abscess. Associations between prophylactic antibiotic regimen and postoperative infections were estimated using univariable and multivariable analysis. RESULTS: Rate of any postoperative infection was similar between the single- and multi-dose groups (19% vs. 16%, p=0.50). Rate of UTI was significantly higher in the single-dose compared to the multi-dose group (13% vs. 7%, p=0.03). On multivariable analysis, after controlling for vaginal route of surgery, the odds of UTI was not significantly different between groups (OR 0.59, 95% CI 0.27, 1.26). CONCLUSION: A single-dose antibiotic regimen is sufficient for prophylaxis against postoperative infections in women undergoing prolapse surgery with graft/mesh.