Polypharmacy and Multimorbidity in the Urogynecology Population and Their Effect on Pelvic Floor Symptoms.

IMPORTANCE: Polypharmacy and multimorbidity are common in older adults but has not been well studied in the urogynecologic patient population. OBJECTIVES: The objective of this study was to determine the prevalence of polypharmacy and multimorbidity in a diverse outpatient urogynecologic population and to examine whether polypharmacy and/or multimorbidity were associated with lower urinary tract symptoms, pelvic organ prolapse, defecatory distress, and/or female sexual dysfunction. STUDY DESIGN: This is a secondary analysis of a dual-center cross-sectional study of new patients presenting for evaluation of pelvic floor disorders at 2 urban academic outpatient urogynecology clinics. Baseline demographics and clinical characteristics were obtained from the electronic medical record. Validated surveys were administered to determine severity of lower urinary tract symptoms (Overactive Bladder Validated 8-Question Screener, Urogenital Distress Inventory-6), pelvic floor dysfunction (Pelvic Organ Prolapse Distress Inventory-6, Colorectal-Anal Distress Inventory-8), and sexual dysfunction (6-item Female Sexual Function Index). Standard statistical techniques were used. RESULTS: One hundred ninety-seven women with mean age 58.8 years (SD, 13.4 years) were included, and most were of minority race/ethnicity (Black, 34.0%; Hispanic, 21.8%). The majority of participants met criteria for polypharmacy (58.4%) and multimorbidity (85.8%), with a mean prescription number of 6.5 (SD, ± 4.9) and mean number of medical comorbidities of 4.9 (SD, ± 3.3). Polypharmacy and multimorbidity were significantly associated with higher CRADI-8 scores. Specifically, polypharmacy was associated with straining with bowel movements and painful stools, whereas multimorbidity was associated with incomplete emptying and fecal urgency. There was no significant association between polypharmacy and multimorbidity with urinary symptoms, prolapse, or sexual dysfunction. CONCLUSIONS: Polypharmacy and multimorbidity are common in the urogynecologic population. There is a relationship between greater defecatory distress and polypharmacy and multimorbidity.

Adapting to Challenging Circumstances: Pessary Care in a Racially Diverse Urban Population Within a U.S. Epicenter of the COVID-19 Pandemic.

OBJECTIVES: The aim of the study was to describe time intervals between pessary maintenance visits in racially diverse women receiving care in a U.S. epicenter of the COVID-19 pandemic. We secondarily aimed to determine whether time interval between pessary changes is associated with adverse outcomes and to identify factors associated with adverse pessary outcomes. METHODS: We performed a retrospective study of women undergoing pessary care after the COVID-19 pandemic began. Time between the most recent visit before the pandemic and first visit after the pandemic began was recorded. Pessary care data were collected from the latter visit, including vaginal bleeding, vaginal discharge, and erosion. Patient-reported symptoms and demographics were also recorded. The relationship between time interval between pessary visits and adverse outcomes as well as between adverse outcomes and demographic data was assessed. RESULTS: We identified 104 women undergoing pessary care, of which 35.6% were Hispanic and 32.7% were Black and 26.2% ± 10.5% lived in poverty. The median time to in-person visit was 4.5 months (interquartile range, 3.7-5.3 months). Seven women (8.7%) had vaginal bleeding, 15 (14.6%) had vaginal discharge, and 7 (6.8%) had erosions. There was no significant association between time interval between pessary visits and adverse outcomes or between adverse outcomes and patient characteristics (all P > 0.05). CONCLUSIONS: Longer duration of time between pessary maintenance visits is not associated with increased adverse outcomes in this group of racially diverse women. Extended intervals between pessary visits can be considered to minimize risk and maintain patient safety during challenging circumstances, such as the COVID-19 pandemic.

Sex-Based Language Differences in Female Pelvic Medicine and Reconstructive Surgery Fellowship Recommendation Letters.

INTRODUCTION: Letters of recommendation (LORs) are a significant component of residency and fellowship applications. Applicant sex may play a role in the language used in letters, which could hinder progress in academic fields, particularly for women. Although differences in language based on applicant sex have been identified in other fields, no prior studies have evaluated LORs for female pelvic medicine and reconstructive surgery (FPMRS) fellowships. METHODS: Letters of recommendations for applicants to an urban, tertiary care academic medical FPMRS fellowship from 2017 to 2019 were collected. Using the Linguistic Inquiry and Word Count program, a licensed text analysis software for academic purposes, we analyzed LORs based on 16 categories. The Wilcoxon rank sum test, Fisher exact test, and a generalized linear mixed model were used for statistical analyses. RESULTS: A total of 97 fellowship applications were analyzed, yielding 354 LORs; 32 applicants were male, whereas 65 were female. Letters written for male applicants contained significantly more power words (P = 0.022) and significantly less affiliation words (P = 0.025) compared with female counterparts. Differences were maintained after adjusting for age, race/ethnicity, step 1 to step 3 scores, Phi Beta Kappa status, Alpha Omega Alpha status, and writer's sex. CONCLUSIONS: Significant linguistic differences based on applicant sex exist in FPMRS fellowship LORs. Differences are consistent with previous analyses within science and medical fields. These findings did not show a significant association with an applicant's ability to match; however, we did not analyze whether the matched institution was the preferred choice for each applicant.

Risks and Associations of Third- and Fourth-Degree Lacerations: An Urban Single Center Experience.

OBJECTIVE: Obstetric anal sphincter injuries (OASIs) are severe tears involving the external and internal anal sphincters. We aimed to document the incidence of OASIs within a racially and ethnically diverse institution to elucidate which maternal, fetal, and parturition factors may be associated with OASIs in minority subgroups. METHODS: This was a retrospective unmatched case-control study of reproductive aged women who delivered between January 1, 2014, and December 31, 2017, at our institution. Data for maternal, fetal, and parturition factors were gathered through chart review. We also investigated the expertise level of the surgeon performing repairs and complications that developed in the postpartum period. Logistic regression analysis was used to compare women with third- and fourth-degree lacerations against the control group of women with first-degree, second-degree, or no lacerations. RESULTS: Of the 23,362 deliveries between January 1, 2014, and December 31, 2017, the incidence of OASIs was 1%. Of our patients, 38% self-identified as Hispanic, 32% as Black, 13% as White, and 3.5% as Asian. Risk for OASIs was significantly increased in nulliparity, Pitocin use, operative deliveries, episiotomy, and prolonged second stage of labor. Black race and obesity were protective for OASIs. There was no significant difference in complication rates based on type of repair nor the provider level of training. CONCLUSIONS: The incidence of OASIs at our institution is similar to current published literature. Our study population is unique in its overrepresentation of minority groups, offering insight into potentially distinctive risk and protective factors associated with OASIs.

Racial and Ethnic Differences in Urodynamic Parameters in Women With Overactive Bladder Symptoms.

OBJECTIVES: This study aimed to identify differences in severity of overactive bladder (OAB) symptoms in women of different races and ethnicities using urodynamic study (UDS) parameters. METHODS: We performed a 5-year retrospective chart review from January 2014 to January 2019 of women 18 years and older who endorsed OAB symptoms and underwent UDS at a racially and ethnically diverse academic urban medical center. Logistic and linear regressions were used to examine the associations of various UDS parameters between racial/ethnic groups, after adjusting for age, diabetes, and parity. RESULTS: A total of 161 women with an average age of 59 years were included in the study. The racial/ethnic composition of the group was Hispanic (62%), black (24%), and white (11%). Symptoms on presentation included urgency and/or frequency (11.8%), urge incontinence (23.0%), or mixed urinary symptoms (65.2%). Black and Hispanic women presented with differing symptoms (urgency/frequency vs mixed urinary symptoms). Half of the patients (n = 82) had detrusor overactivity. Compared with whites, blacks were 3.4-fold more likely to have detrusor overactivity (95% confidence interval, 0.99-11.40) and had lower volumes at time of "strong desire" (-102.6 mL, P = 0.003). Hispanics had on average 75.88 mL less volume at sensation of "strong desire" (P = 0.016) than did whites. CONCLUSIONS: Our study suggests that minority race and ethnicity may be associated with worse performance on certain UDS parameters. Future studies should aim to understand if these differences are due to genetic, disease-related, behavioral, and/or socioeconomic factors and whether these differences are associated with worse subjective OAB.

Female Urethral Diverticula: Diagnosis, Pathology, and Surgical Outcomes at an Academic, Urban Medical Center.

OBJECTIVE: To describe the outcomes of a series of women diagnosed with a urethral diverticulum at an urban tertiary care center. METHODS: An Institutional Review Board-approved review of a series of 78 women with a diagnosis of urethral diverticulum from 2009 to 2015 was performed. Clinical, radiographic, and pathologic data was collected by retrospective review of patient medical records. Data regarding treatment selection and postoperative outcomes were collected. A multivariable logistic regression was performed to identify preoperative variables that were associated with undergoing surgical resection. RESULTS: Of the 78 patients reviewed, the median age was 45.5 years (interquartile range (IQR) 36.0-53.8), median body mass index was 30.4 (IQR 24.8-34.4). The most common presenting symptoms included: incontinence (39%), recurrent urinary tract infections (23%), dysuria (18%), discharge (13%), dyspareunia (12%), and hematuria (9%). Additionally, 16 (21%) women were asymptomatic. Of these 78 cases, 40 underwent surgical excision (51%). Of the remaining 38, 13 were symptomatic and lost to follow-up, 23 were managed expectantly, and 2 underwent surgery after the study period. Review of the pathology results revealed that the most common finding was squamous metaplasia (31%). There was 1 adenocarcinoma in the series (2.5%). Of the 40 patients who had surgery, 3 (7.5%) had a diverticular recurrence and 5 (12.5%) developed stress urinary incontinence. The median follow-up was 7.5 months (IQR 1-20.25 months). CONCLUSION: A variety of presenting symptoms existed for women with a urethral diverticulum seeking medical care at an urban medical center. When controlling for age, body mass index, and race, the presence of preoperative symptoms was associated with undergoing surgical resection.

Resident Knowledge, Surgical Skill, and Confidence in Transobturator Vaginal Tape Placement: The Value of a Cadaver Laboratory.

OBJECTIVES: The objective of this study is to examine the effect of additional cadaver laboratory use in training obstetrics and gynecology (OBGYN) residents on transobturator vaginal tape (TOT) insertion. METHODS: Thirty-four OBGYN residents were randomized into 2 groups (group 1, control; group 2, intervention; 17 in each group). Before and after the interventions, written knowledge and confidence levels were assessed. Both groups received didactic lectures using a bony pelvis and an instructional video on TOT insertion; group 2 participated in a half day cadaver laboratory. Surgical skills were assessed by placing 1 arm of the TOT trocar on a custom-designed pelvic model simulator while being graded by an Female Pelvic Medicine and Reconstructive Surgery (FPMRS) board-certified proctor. RESULTS: Demographics were comparable. Baseline knowledge and confidence level before interventions were similar. After interventions, knowledge scores improved for both groups (8.8% for group 1; 14.1% for group 2); TOT insertion scores were significantly higher in group 2 (6.76/15 ± 2.54 group 1; 10.24/15 ± 2.73 group 2, P < 0.01); confidence scores improved in both groups. The pelvic model simulator was rated as the most useful method to learn TOT placement by group 1. Group 2 rated TOT simulation (47%) and cadaver laboratory (41%). All trainees reported that the pelvic model was highly realistic. CONCLUSIONS: Cadaver laboratory exposure, along with other educational interventions (lectures and video), improves OBGYN residents' confidence, knowledge, and surgical skills regarding TOT placement. The custom-designed pelvic model allows for a realistic simulation of TOT placement: it can be used to assess resident surgical skills and also aid the training of OBGYN residents.

Transforming growth factor ß1 and extracellular matrix protease expression in the uterosacral ligaments of patients with and without pelvic organ prolapse.

OBJECTIVES: This study was undertaken to evaluate the expression of transforming growth factor ß1 (TGF-ß1) and matrix metalloproteinase 9 (MMP-9), key regulators of the extracellular matrix composition, in the uterosacral ligaments (USLs) of women with pelvic organ prolapse (POP) compared with controls. METHODS: Under an institutional review board approval, USL samples were obtained from women undergoing vaginal hysterectomy for stage 2 or greater POP (cases, n = 21) and from women without POP undergoing vaginal hysterectomy for benign indications (controls, n = 19). Hematoxylin and eosin and trichrome staining were performed on the USL sections, and the distribution of smooth muscle and fibrous tissue were quantified. Immunohistochemical staining was performed using anti-TGF-ß1 and anti-MMP-9 antibodies. The expressions of TGF-ß1 and MMP-9 were evaluated by the pathologist, who was blinded to all clinical data. RESULTS: Transforming growth factor ß1 expression positively correlated with MMP-9 expression (R = 0.4, P = 0.01). The expressions of TGF-ß1 and MMP-9 were similar in subjects with POP versus controls. There was a significant increase in fibrous tissue (P = 0.008) and a corresponding decrease in smooth muscle (P = 0.03), associated with increasing age. The TGF-ß1 expression, but not MMP-9 expression, also significantly increased with age (P = 0.02). DISCUSSION: Although our study uncovered age-related alterations in USL composition and TGF-ß1 expression, there was no difference in the expression of TGF-ß1 or MMP-9 in the subjects with POP versus controls.

Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder.

OBJECTIVE: The aim of this study was to compare the efficacy of the ultralow-dose estradiol vaginal ring with that of oral oxybutynin in the treatment of overactive bladder in postmenopausal women. METHODS: Postmenopausal women with an overactive bladder were recruited from the general gynecology clinic. Participants were randomized to receive either the ultralow-dose estradiol vaginal ring or oral oxybutynin for 12 weeks. The primary outcome was a decrease in the number of voids in 24 hours. The secondary outcomes were quality-of-life questionnaires, vaginal pH levels, and vaginal maturation index. RESULTS: Fifty-nine women were enrolled. Thirty-one were randomized to receive oxybutynin, whereas 28 received the estradiol vaginal ring. Women who received oxybutynin had a mean decrease of 3.0 voids per day, and women who received the vaginal ring had a mean decrease of 4.5 voids per day, with no significant difference between the groups. There was a significant improvement in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores in both groups, with no significant difference in improvement between the two groups. CONCLUSIONS: Ultralow-dose estradiol-releasing vaginal ring and oral oxybutynin seem to be similarly effective in decreasing the number of daily voids in postmenopausal women with overactive bladder.