Wealth of Knowledge and Passion: Patient Perspectives on Vaginal Estrogen as Expressed on Reddit.

OBJECTIVE: To qualitatively analyze the knowledge, attitudes, and beliefs of women regarding genitourinary syndrome of menopause (GSM) and vaginal estrogen therapy as expressed on Reddit, a public, anonymous internet forum for discussion and information sharing. METHODS: "r/menopause," a Subreddit with >30,000 subscribers, was queried for "vaginal estrogen" to collect postings related to vaginal estrogen in October 2022. Posts were analyzed qualitatively by 2 independent researchers. The principles of grounded theory were applied, and preliminary themes were generated. These themes were used to derive emergent concepts. RESULTS: Sixty-seven unique posts with 1101 responses were analyzed. Qualitative analysis revealed 5 preliminary themes: (1) questions regarding medication usage, (2) medication side effects, (3) medication alternatives, (4) frustration with the medical system, and (5) seeking validation for symptoms and experiences. Three emergent concepts were derived: (1) women experience bothersome side effects from menopause, and they desire compassionate and effective medical treatment; (2) women are engaged and active participants in their health and health care decisions; and (3) women perceive that their concerns are not taken seriously and seek validation for their medical conditions. CONCLUSION: Peri- and post-menopausal women have many questions and concerns about the condition of GSM and vaginal estrogen as treatment. They also have a broad range of frustrations including access to health care and questions about the usage of vaginal estrogen. By better understanding patient perspectives, physicians can better meet women's needs and improve care for GSM.

Evidence-based review of nonantibiotic urinary tract infection prevention strategies for women: a patient-centered approach.

PURPOSE OF REVIEW: There is a growing interest in nonantibiotic prevention strategies for recurrent urinary tract infections (rUTIs). Our objective is to provide a focused, pragmatic review of the latest evidence. RECENT FINDINGS: Vaginal estrogen is well tolerated and effective for preventing rUTI in postmenopausal women. Cranberry supplements at sufficient doses are effective in preventing uncomplicated rUTI. Methenamine, d -mannose, and increased hydration all have evidence to support their use, although the evidence is of somewhat variable quality. SUMMARY: There is sufficient evidence to recommend vaginal estrogen and cranberry as first-line rUTI prevention strategies, particularly in postmenopausal women. Prevention strategies can be used in series or in tandem, based on patient preference and tolerance for side effects, to create effective nonantibiotic rUTI prevention strategies.

Workup and conservative management of ileal conduit-vaginal fistulas: review of literature.

Ileal conduit-vaginal fistulas are a rare but challenging complication of urinary diversion. Here we identify risk factors and summarize the workup and conservative management strategies for this complication. We present two cases of elderly women with remote history of cancer who presented with persistent urinary leakage from the vagina several years after ileal conduit creation. Fistulas may be identified using dye or imaging with a loopogram and looposcopy. Correction of obstruction such as stomal stenosis or urinary diversion should be pursued to relieve pressure off the conduit. Minimally invasive management such as fulguration can result temporary relief; however, the recurrence rate is high.

Clinical experience with percutaneous tibial nerve stimulation in the elderly; do outcomes differ by gender?

Objective: To evaluate the use of percutaneous tibial nerve stimulation (PTNS) in an elderly population, as PTNS is a third-line treatment in the management of overactive bladder (OAB) and affects 10-26% of adult males and 8-42% of adult females, increasing in prevalence with age. Patients and methods: We performed a chart review of patients aged ≥ 65 years undergoing PTNS at a single institution over 6 years. We examined clinicopathological variables potentially associated with the outcomes of interest. Results: In total, 52 patients aged ≥ 65 years underwent an induction course of PTNS between 2011 and 2017, comprising 23 men and 29 women. The mean age of the patients was 75.75 years and the mean body mass index (BMI) was 26.33 kg/m2. In all, 36 patients used anticholinergic treatments prior to PTNS, five used a ß3-adrenoceptor agonist, and three had Botox injections. After PTNS, 37 patients reported improvement of their symptoms, with 21 using combined therapy during PTNS. Only seven patients used an anticholinergic after PTNS, six used a ß3-adrenoceptor agonist, five had Botox injections, and two had sacral neuromodulation. When looking at variables such as age, gender, race, BMI, and comorbidities, we found that an obese BMI was the only statistically significant variable predicting failure of response. A sub-analysis of only women did not demonstrate any predictors of failure. Conclusion: Our subjective response rate of 70% was within the success rates reported in literature. In all, 39% of patients used a concomitant treatment during PTNS and 13.2% required alternative treatment after PTNS. Abbreviations: BMI: body mass index; OAB: overactive bladder; PTNS: percutaneous tibial nerve stimulation; UI: urinary incontinence.

Are Electronic and Paper Questionnaires Equivalent to Assess Patients with Overactive Bladder?

PURPOSE: Overactive bladder syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence in the absence of urinary tract infection or another obvious pathological condition. Electronic questionnaires have been used in a few specialties with the hope of improving treatment outcomes and patient satisfaction. However, they have not been widely used in the urological field. When treating overactive bladder, the main outcome is to improve patient quality of life. The primary objective of this study was to evaluate whether electronic questionnaires would be equally accepted as or preferred to paper questionnaires. The secondary objective was to look at the preference in relation to patient age, education and iPad® tablet familiarity. MATERIALS AND METHODS: We prospectively evaluated the iList® electronic questionnaire application using a friendly iPad tablet in patients with overactive bladder who presented to the urology clinic at our institution. Each of the 80 patients who were recruited randomly completed the validated OABSS (Overactive Bladder Symptom Score) and the PPBC (Patient Perception of Bladder Condition) questionnaires in paper and electronic format on the tablet. Variables potentially associated with the outcomes of interest included demographic data, questionnaire method preference, patient response rate and iPad familiarity. We used the 2-sided Z-test to determine whether the proportion of patients who considered the tablet to be the same, better or much better than paper was significantly greater than 50%. The 2-sided chi-square test was applied to assess whether the intervention effect significantly differed among the demographic subgroups. RESULTS: A total of 80 patients 21 to 87 years old were enrolled in the study from November 2015 to August 2016. Of the patients 53% were female and 49% were 65 years or younger. The incidence of those who considered the tablet to be the same or better than paper was 82.5% (95% CI 74.2-90.8, p <0.001). The incidence of patients who considered the tablet to be the same or better than paper ranged from 76% to 97% regardless of age, gender and education subgroup as well as in those with any familiarity with the tablet (each p <0.001). Of the 20 patients who were not familiar with the tablet 45% preferred the electronic questionnaire (p = 0.654). CONCLUSIONS: We found that the proportion of patients who considered electronic questionnaires to be equivalent to or better than paper versions was higher than those who preferred paper questionnaires regardless of age, gender or education level.

Urethral Foreign Bodies: Clinical Presentation and Management.

OBJECTIVE: To review a single institution's 15-year experience with urethral foreign bodies, including evaluation, clinical findings, and treatment. MATERIALS AND METHODS: In total, 27 patients comprising 35 episodes of inserted urethral foreign bodies were reviewed at Cook County Hospital between 2000 and 2015. Retrospective chart review was performed to describe the clinical presentation, rationale for insertion, management, recidivism, and sequelae. RESULTS: Median patient age was 26 (range 12-60). Twenty-six patients (97 %) were male, 1 was female (3%). Items inserted included pieces of plastic forks, spoons, metal screws and aluminum, pieces of cardboard or paper, staples, writing utensils such as pens and pencils, as well as coaxial cable and spray foam sealant. Reported reasons for insertion were self-stimulation, erectile enhancement, and attention seeking. Presenting symptoms included dysuria, gross hematuria, urinary retention, urinary tract infection, and penile discharge. The most common technique for removal was manual extraction with extrinsic pressure (n = 19, 54%). Other methods include endoscopic retrieval (n = 8, 23%), open cystotomy (n = 1, 3%), and voiding to expel the foreign body (n = 7, 20%). Postremoval complications included urinary tract infection (n = 7), sepsis (n = 4), urethral false passage (n = 5), laceration (n = 5), and stricture (n = 1). CONCLUSION: We present the largest single-institutional series of urethral foreign bodies to date. Urethral foreign body insertion is a relatively rare occurrence and, commonly, is a recurrent behavior. Urethral trauma related to foreign body insertion is associated with significant risk of infection and urethral injury with long-term sequelae.

Forgotten ureteral stents: who's at risk?

The sequelae from forgotten stents carry significant morbidity and costs. In this study, we attempt to identify potential risk factors that may make patients less likely to follow up for stent removal so that more effective prevention efforts may be directed at these persons. A single-institution retrospective analysis of 187 consecutive patients who had stents placed between January 2010 and December 2010 was performed. Chart review was conducted to see if patients had undergone stent removal beyond the intended maximal stent life (MSL). Patients who were lost to follow-up were contacted to determine if stents were overdue. Logistic regression was performed to determine risk factors. Of the 187 patients who had stents placed, 147 had the stent removed before MSL and 28 had stents removed after the MSL. Twelve patients could not be contacted and were excluded from the analysis. Within our cohort of 175 patients, 48% were males, 73% were minorities (33% Latino, 30% Black, 8% Asian, and 2% Native American), 39% did not speak English, 79% were unemployed, 73% were uninsured, and 35% were married. Among the patients with forgotten stents, 68% were male, 64% were minorities (32% Latino, 29% Black, 4% Native American, and 0% Asian), 82% were unemployed, 39% did not speak English, 93% were uninsured, and 43% were married. Multivariate regression analysis demonstrated that uninsured patients (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.4-28.2; P value 0.01) and males (OR, 2.8; CI, 1.2-6.8; P=0.02) had statistically significant associations with forgotten stents. Men were 2.8 times more likely to have forgotten stents than females. Patients without health insurance were six times more likely to have forgotten stents than patients with insurance. As efforts are made to prevent forgotten stents, increased attention should be given to these higher-risk patient populations.

Clinical characteristics and surgical outcomes of penetrating external genital injuries.

BACKGROUND: Penetrating external genital injuries, although uncommon, may present complex problems for the urologic and trauma surgeon. A paucity of data exists on the incidence, clinical characteristics, and management outcomes of these injuries because few institutions have the volume to report their experience. METHODS: Penetrating external genital trauma presenting from 2004 to 2011 was retrospectively reviewed. Patient characteristics, operative and nonoperative management, and outcomes were analyzed while validating current guidelines. Surgical management is described in detail, and overall incidence and trends were calculated. RESULTS: A total of 28,459 trauma patients were reviewed, of which 8,076 sustained penetrating injuries and 162 sustained penetrating external genital trauma. Penetrating external genital trauma was 0.57% of all trauma and 2.0% among penetrating trauma. Gunshot wounds accounted for the most common mechanism of injury (93%). Injury to the scrotum occurred in 78% and of these injuries, 63% resulted in a testicular injury, with bilateral testicular injuries occurring in 8%. Testicular reconstruction was performed in 65%. Penile injuries occurred in 28%, and urethral injuries occurred in 13%. For penile injuries, 62% were explored immediately. Urethral injuries were managed by immediate primary urethral repair (43%) or urinary diversion with delayed reconstruction (57%). In total, nonoperative management was performed in 26% of scrotal and 38% of penile injuries. The incidence of penetrating external genital injuries has remained constant during our study period, averaging 20.2 cases per year (R(2) = 0.99). The testicular salvage rate varied from 55% to 75% per year (R(2) = 0.06). CONCLUSION: Penetrating external genital injuries occur at an incidence of 0.57% where scrotal injury from gunshot wounds is the most common form. Testicular preservation is possible in the majority of testicular injuries. Penile injuries were less likely to require surgical exploration compared with scrotal injuries likely because physical examination is better at confirming only superficial injury. Select patients with superficial scrotal or penile injuries may undergo nonoperative management with minimal morbidity. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level IV.