Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023).

PURPOSE: The purpose of this guideline is to provide a clinical structure with which to approach the diagnosis, counseling, and treatment of female patients with stress urinary incontinence (SUI). MATERIALS/METHODS: The primary source of evidence for the 2017 version of the SUI guideline was the systematic literature review conducted by the ECRI Institute. The initial search spanned literature from January 2005 to December 2015, with an additional updated abstract search through September 2016. The current amendment represents the first update to the 2017 iteration and includes updated literature published through February 2022. RESULTS: This guideline has been amended to reflect changes in and additions to the literature since 2017. The Panel maintained that the differentiation between index and non-index patients remained important. The index patient is a healthy female with minimal or no prolapse who desires surgical therapy for treatment of pure SUI or stress-predominant mixed urinary incontinence. Non-index patients have factors that may affect their treatment options and outcomes, such as high grade prolapse (grade 3 or 4), urgency-predominant mixed incontinence, neurogenic lower urinary tract dysfunction, incomplete bladder emptying, dysfunctional voiding, SUI following anti-incontinence treatment, mesh complications, high body mass index, or advanced age. CONCLUSION: While gains have been made in the field to support new methods for the diagnosis, treatment, and follow-up of patients with SUI, the field continues to expand. As such, future reviews of this guideline will take place to stay in keeping with the highest levels of patient care.

A qualitative analysis of female Reddit users' experiences with low libido: how do women perceive their changes in sexual desire?

BACKGROUND: The true prevalence of low sexual desire among women is disputed among researchers due to the complex nature and presentation of women's sexual problems. AIM: To qualitatively analyze the aspects of libido/sexual desire frequently discussed by Reddit users and compare them with the current understanding of female sexual well-being and sexual desire disorders. METHODS: By using the Reddit application programming interface, the TwoXChromosomes subreddit was queried for posts with the keywords libido and sex drive. Posts that were deleted or unrelated to themes of libido/sex drive were excluded. A total of 85 threads-63 queried from the keyword libido and 22 from sex drive-and approximately 2900 comments were qualitatively analyzed per the grounded theory approach. Five independent researchers read and coded each thread to identify dominant themes and emergent concepts. OUTCOMES: Outcomes of interest included codes related to sexual dysfunction, libido, orgasm, masturbation, types of sex, psychology, relationships, intimacy, treatment, medications, and health care. RESULTS: Posters were primarily heterosexual women in their 20s and 30s. The code categories with the highest frequency were relationships (22.7%, n = 272), libido (22.2%, n = 210), psychological (20.2%, n = 191), medications (7.29%, n = 69), and intimacy (6.0%, n = 57). Users frequently described a decrease in libido secondary to medications, particularly antidepressants and hormonal birth control. Many users discussed the challenges of navigating a relationship with low sexual desire and the resulting sexual distress. Posters described feelings of sadness, anxiety, and guilt due to their low desire. Additionally, users discussed the role that sex plays in relationships, whether as a way to develop intimacy between partners or to achieve orgasm. Finally, posters expressed dissatisfaction with health care addressing their concerns surrounding sexual desire. CLINICAL IMPLICATIONS: The study findings-namely, the impact of medications on sexual health, the interaction of sexual desire and mental health, and cited examples of inadequate sexual health care-can help guide sexual well-being research, diagnosis, and public policy. STRENGTHS AND LIMITATIONS: Using Reddit as a data source allowed for the analysis of women's experiences outside the preestablished concepts of female sexual desire. Limitations to the study include the potential for posts to be deleted by moderator guidelines, the young demographic distribution of Reddit users, and the popularity-based structure of subreddit threads. CONCLUSION: Our results emphasize the psychosocial aspects of sexual desire and the need to redefine sexual problems to encompass the complex nature of female sexual well-being.

Vaginal Hormone Therapy for Conditions of the Lower Urinary Tract.

PURPOSE OF REVIEW: Up to half of postmenopausal women experience genitourinary symptoms secondary to hormone deficiency, and there is little consensus on the use of vaginal hormone therapy (VHT) for lower urinary tract symptoms (LUTS) in these patients. This is a review of the scientific literature in the last decade evaluating the use of VHT for disorders of the lower urinary tract including overactive bladder (OAB), stress urinary incontinence (SUI), recurrent urinary tract infections (UTI), and interstitial cystitis/bladder pain syndrome (ICS/BPS). RECENT FINDINGS: Vaginal estrogen therapy improves OAB symptoms in postmenopausal women, but results are mixed when VHT is used in combination with other treatments. There is inconclusive or limited data for the use of VHT to treat SUI and IC/BPS. Vaginal estrogen and prasterone (DHEA) therapies have demonstrated efficacy as treatment modalities for patients who experience recurrent UTIs. VHT preparations show efficacy for the treatment of certain LUTS and can be considered in carefully selected patients when clinically indicated.

Patient Frustration with Pelvic Organ Prolapse Education Met with Resilient Response.

INTRODUCTION: Limited patient understanding due to challenges in physician-patient communication and inadequate patient education materials (PEMs) can result in poor outcomes after pelvic organ prolapse (POP) repair. Our objective was to identify how patients learned about POP and review their perception of available educational tools. METHODS: Patients with a history of POP were recruited using ResearchMatch and invited to participate in a virtual semi-structured interview where they were shown a website, brochure, and video pertaining to POP. Information regarding patient preference for PEMs was obtained. The interviews were transcribed, coded, and qualitative data analysis was performed using grounded theory methodology. RESULTS: Qualitative analysis of interviews of 13 participants averaging 58 years old yielded several preliminary themes including: insufficient information to guide treatment decisions, preference for multimodal, dynamic, and comprehensive materials, and lack of support leading to avoidance of care, misinformation, and self-advocacy mechanisms. Emerging concepts included: lack of complete information regarding POP treatment resulted in misinformation, stress and desperation, distrust of healthcare providers leading to feelings of isolation, desire of support groups, and loss of follow up, and a desire for well-organized, detailed, multimodal, and destigmatizing materials as a guide to their disease process, prevention and risk factors, its natural progression, and treatment decisions. Participants developed self-reliant strategies for making treatment decisions, including the use of online resources, advice from friends, and independent search for more specialized physicians. CONCLUSIONS: Women with POP reported a lack of information and support which resulted in the generation of self-coping mechanisms. This led to significant anxiety surrounding their diagnosis and treatment and poor satisfaction. Developing a reproducible methodology to create evidence-based PEMs will significantly decrease patient misinformation, apprehension, and use of inaccurate sources of information.

Sigmoid conduit-neovaginal fistula: a case report and literature review.

Total pelvic exenterations (TPE) are high morbidity procedures, with up to 38% of patients experiencing a major complication after TPE surgery. We report the case of a 69-year-old woman with a sigmoid conduit-neovaginal fistula who presented with new onset continuous vaginal leakage and decreased urostomy output 3 months post-op from a TPE. We highlight the presentation, diagnosis, conservative management, and surgical management of conduit-vaginal fistulas.

Characteristics of pelvic organ prolapse content available on social media.

AIMS: To analyze the quality, understandability, and actionability of pelvic organ prolapse (POP) content and to characterize creators of content and treatment options discussed on social media platforms YouTube, Instagram, and Pinterest. METHODS: A cross-sectional, qualitative study was conducted for each platform. A search for "pelvic organ prolapse" was conducted and the first 100 relevant results analyzed. Data collected include source characteristics, treatments discussed, and scores for each criterion of validated Patient Education Materials and Assessment Tool and DISCERN metrics to evaluate quality, actionability, and understandability. The χ 2 analysis, univariate and multivariate logistic regressions were done to assess correlations and the impact of variables on outcomes of interest across platforms. RESULTS: Low to moderate quality was present in 74.1% of posts. Poor understandability was seen in 37.1% of posts, and 56.1% had poor actionability. The most common publisher of content overall was health and wellness or physical therapy groups (44.6%). The most common YouTube publisher was doctors, hospitals, or clinics (49%). Pelvic floor muscle training was the most discussed treatment overall (57.4%). On YouTube surgery was discussed more frequently than Instagram or Pinterest (58% vs. 11% vs. 43%, p < 0.001. Pinterest posts had better understandability ratings than YouTube videos (odds ratio = 0.19; 95% confidence interval: [0.10-0.36]; p < 0.001). CONCLUSION: Information on popular platforms regarding POP demonstrates inconsistent quality and poor understandability and actionability. There is an opportunity for health care providers to direct patients to curated lists of high-quality educational content on these platforms. Awareness of information available on social media is an increasingly important aspect of patient care.

Readability of pelvic floor dysfunction questionnaires.

BACKGROUND: The National Institutes of Health and Center for Disease Control recommend the readability of self-administered patient questionnaires to be written at or below a sixth to eight grade reading level. The aim of this study is to evaluate the readability of commonly used urinary incontinence (UI), pelvic organ prolapse (POP), overactive bladder (OAB), and benign prostate hyperplasia (BPH) questionnaires. METHODS: Eighteen validated urologic questionnaires were analyzed using four readability assessment tools. A mean grade-level needed to comprehend each questionnaire was calculated. RESULTS: For UI questionnaires, three out of five questionnaires required a reading level of 10th grade or higher, two grade levels above recommendations. Only one POP questionnaire met recommendations with a mean readability score of 5.9, whereas the other questionnaires required a ninth-grade reading level or higher. For the OAB questionnaires, three out of five questionnaires met reading recommendations. Readability scores for BPH questionnaires ranged from 6.4 to 11.2, with only the International Prostate Symptom Score questionnaire in compliance with recommendations. CONCLUSIONS: The majority of currently available pelvic floor dysfunction questionnaires do not comply with recommended reading levels, suggesting that these questionnaires are written at a level too advanced for a large proportion of the population. This limits their effectiveness in accurately assessing symptom severity and impact on quality of life.

A systematic review of best practices for the perioperative management of abdominal sacrocolpopexy.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have been shown to reduce surgical morbidity and length of stay across various procedures. Our objective was to systematically evaluate the literature for best practices of ERAS elements in abdominal sacrocolpopexy (ASC), to determine if there is sufficient evidence to create best practice guidelines for this procedure. MATERIALS AND METHODS: Following the preferred reporting items for systematic review and meta-analysis (PRISMA) statement, we performed a review using Pubmed, Embase, and Cochrane Library. Eligible articles contained ERAS components and postoperative outcomes of ASC published in English since 1997. Thirty-five full-text articles were selected for final qualitative analysis. RESULTS: Poor functional status before ASC was associated with a longer length of hospital stay. Laparoscopic ASC was associated with a shorter postoperative hospital stay, with no difference between laparoscopic and robotic approaches. Epidural analgesia in addition to spinal anesthesia lowered levels of pain throughout the postoperative stay in laparoscopic ASC. A multimodal bowel regimen shortened time to first bowel movement compared to a single agent regimen. Removing a Foley catheter may lead to sooner first spontaneous void but may result in higher rates of urinary retention and urinary tract infection. Studies investigating preoperative bowel preparation, preanesthesia medication, and multidose antimicrobial prophylaxis did not show significant benefit. CONCLUSIONS: Best practices for ASC can be developed based on current findings from the literature and extrapolation of evidence from other surgeries where ASC-specific elements are missing, with the ability to modify the pathways as new data become available.

Bethanechol: Is it still being prescribed for bladder dysfunction in women?

PURPOSE: Few medical treatment options exist for detrusor underactivity or urinary retention in women. Bethanechol, a cholinergic agonist, may improve detrusor contractility in these conditions; however, its clinical efficacy is limited. We sought to examine the patterns of Bethanechol use by physicians in an ambulatory care setting using a national database to determine if it is still prescribed for patients with bladder dysfunction. MATERIALS AND METHODS: The National Ambulatory Medical Care Survey (NAMCS) database was queried for a sample of patient visits to office-based physicians from 2003-2013. Visits were included for women aged 18 years or older with diagnosed lower urinary tract symptoms (LUTS), neurogenic bladder, or urinary retention based on ICD-9-CM codes. Visits in which Bethanechol was prescribed were analysed with descriptive statistics. Sampling weights were adjusted for nonresponders to yield an unbiased national estimate of ambulatory care visits. RESULTS: Out of a weighted sample of 17 321 630 included patient visits, 132 281 (0.8%) visits included a prescription for Bethanechol. Patients prescribed Bethanechol had a mean age of 62.3 ± 2.1 and were predominantly Caucasian (67%) followed by African American (18%). The primary diagnosis associated with Bethanechol was atony of bladder (35%), urinary retention (20%), neurogenic bladder (18%), urinary incontinence (16%), and incomplete bladder emptying (10%). Visits were primarily for chronic conditions (63%). It was typically prescribed as a continued medication (79%) most often by urologists (92%) followed by internal medicine clinicians (8%). CONCLUSIONS: Bethanechol continues to be prescribed in elderly women primarily for detrusor atony, urinary retention, or incomplete bladder emptying.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence.

PURPOSE: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. MATERIALS AND METHODS: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. RESULTS: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74-0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4-186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3-161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3-72.1), p<0.001). CONCLUSIONS: 24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Outcomes following Thulium vapoenucleation of large prostates.

INTRODUCTION: Thulium laser VapoEnucleation of the prostate (ThuVEP) is an evolving surgical technique for BPH. Most studies have focused on outcomes in small to médium sized prostates and have originated from Europe and Asia. We sought to describe our experience with ThuVEP for very large prostates in a North American cohort. MATERIALS AND METHODS: From December 2010 to October 2014, 25 men underwent Thu-VEP using the CyberTM® (Quantastem, Italy) thulium laser, all with prostate volume >75mL. Data collected included patient demographics, comorbidities, intraoperative parameters, complications, and post-operative outcomes including maximum flow rate (Qmax), post-void residual (PVR), International Prostate Symptom Score (IPSS), and quality of life score (QoL) in one year of follow-up. Statistical analysis was done using Wilcoxon signed-rank test. RESULTS: At baseline, mean age was 70±9 years and prostate size was 163±62g. Most patients (84%) were in retention and 10 (40%) patients were on anticoagulation. Seven (28%) patients went home the day of surgery (mean hospital stay: 1.2±1.2d). There were 2 intraoperative complications (8%), both cystotomies related to morcellation. Nine patients (36%) experienced a complication, all within 30 days. There were no Clavien III complications. Significant improvements were seen in Qmax, PVR, IPSS, and QoL score at each time interval to 12-months following surgery (all p<0.05). Of 21 patients initially in retention, all were voiding at last follow-up. CONCLUSIONS: Our findings suggest that ThuVEP is an effective treatment for BPH in patients with large prostates with sustained results for one year.

Are we testing appropriately for low testosterone?: Characterization of tested men and compliance with current guidelines.

INTRODUCTION: Direct-to-consumer ads for testosterone replacement therapies have significantly increased over the past several years. Subsequently, testing for low serum testosterone has correspondingly increased. AIMS: We sought to determine the testing behaviors of practitioners as well as the characteristics of men who are undergoing testing for low testosterone. METHODS: Men aged 18-85 years were queried from the institutional electronic data warehouse from 2009 to 2012. Men were considered "tested" if their serum total testosterone level had been measured for any purpose. Tested men (TM) were compared with those not tested (NT). MAIN OUTCOME MEASURES: The frequency and timing of testing for low testosterone as well as patient demographics and clinical characteristics were compared between TM and NT using multivariable logistic regression models. RESULTS: Of the 321,674 total men, 10,133 (3.2%) underwent testing with a serum total testosterone (mean age of 55.2 ± 14.1 years). The frequency of testing increased from 2.5% to 3.6% during the study period (P < 0.001). Multivariable analysis demonstrated that TM were significantly (P < 0.001) more likely to be Caucasian and have increased body mass index. In addition, TM were significantly more likely to have comorbid conditions including decreased libido (adjusted odds ratio [aOR] 10.0, 95% confidence interval [CI] 8.5, 11.7), infertility (aOR 4.8, 95% CI 3.6, 6.6), erectile dysfunction (aOR 3.6, 95% CI 3.4, 3.8), osteoporosis (aOR 3.3, 95% CI 2.8, 3.8), depression (aOR 1.7, 95% CI 1.6, 1.8), prostate cancer (aOR 1.7, 95% CI 1.5, 1.8), hypertension (aOR 1.3. 95% CI 1.2, 1.4), chronic obstructive pulmonary disease (aOR 1.2, 95% CI 1.0, 1.4), and benign prostatic hyperplasia (aOR 1.2, 95% CI 1.1, 1.2). Among TM, only 889 (9%) men underwent testing between 7 am and 12 pm. CONCLUSIONS: The rate of testosterone testing is increasing with most testing practices directed toward a subset of men with comorbidities that are associated with hypogonadism. Compliance of physicians obtaining early morning serum testosterone levels is low. Further education of practitioners is required to appropriately test patients for hypogonadism.

Urinary retention in elderly women: diagnosis & management.

The management of urinary retention in the elderly female can present a challenging conundrum for primary care physicians, geriatricians, and urologists. It is often difficult to diagnose due to concomitant comorbidities and potential cognitive impairments. Evaluation should include a comprehensive history and physical examination, post-void residual, and urinalysis with consideration given to urodynamic testing in select patients. Management varies from conservative to invasive and should be tailored to the individual patient. Primary goals of care include symptom reduction, prevention of urinary tract infection, and upper tract deterioration. This presents an up-to-date review of the presentation, diagnosis, and management options available for elderly women with urinary retention.

Prostate cancer and podcasts: an analysis and assessment of the quality of information about prostate cancer available on podcasts.

Podcasts represent a new source of information for patients and families dealing with prostate cancer, but no studies have been conducted evaluating the quality of information in them. Evaluating for: (1) quality based on the validated DISCERN criteria, (2) understandability and actionability based on the Patient Education Materials Assessment Tool (PEMAT), (3) misinformation, and (4) commercial bias, we concluded that podcasts are currently not good sources of information for lay health consumers.

The Gender Gap in Promotions: Inhibitors and Catalysts, Strategies to Close the Gap.

The gender gap is an amalgam of gender disparity issues in the workplace ranging from fewer opportunities to network, decreased funding for research, microaggressions, nebulous promotional criteria and difficulty achieving the perception of professionalism because of inherent gender bias. Contributing home factors include more substantial household duties for women typically, spouses who also have a career, and the inherent delay associated with maternity leave for those who choose to have children. This article subdivides gender disparity that impedes promotion into experiences inside and outside the workplace. Disparities within the workplace are divided into directly quantified versus qualitative differences.

Social Media and Apps in Urology.

Purpose of Review: In this study, we aimed to review the common social media (SoMe) apps used and how they have impacted the practice and exchange of information, as well as the challenges of using SoMe in urology. Recent Findings: SoMe has become increasingly popular in the urology community. Lay users often turn to SoMe to learn about urological health and share their own experiences, while medical professionals may use it for career development, networking, education, and research purposes. Summary: It is important to recognize the power of SoMe and to use it responsibly and ethically, particularly given the potential risks of encountering low-quality or misleading information.

Assessment of Stress Urinary Incontinence-Related Podcasts on Stitcher.

OBJECTIVE: To assess the quality, understandability, actionability, accuracy and commercial bias of podcasts regarding stress urinary incontinence (SUI). METHODS: The first 100 Stitcher podcasts from the search, "Stress urinary incontinence" were evaluated using the validated DISCERN criteria, PEMAT tool, and a Misinformation Likert Scale. The accuracy of information was assessed by comparison to the American Urological Association (AUA) SUI Guidelines. RESULTS: Common publisher types included health/wellness channels (66%). Low-moderate quality, poor understandability and misinformation was seen in 67% (DISCERN ≤3), 69% (PEMAT understandability ≤75%) and 17% of podcasts, respectively. Treatments discussed included pelvic floor muscle training (PFMT) (89%) and surgery (47%). Health and wellness channels had the most evidence of commercial bias (44%). Podcasts that discussed surgery more often emphasized shared decision-making (DISCERN15). CONCLUSION: SUI-related podcasts on Stitcher are mostly published by health/wellness channels and skewed toward discussing PFMT. Podcasts are often low-moderate quality, poorly understandable and often have commercial bias.

TikTok and YouTube Videos on Overactive Bladder Exhibit Poor Quality and Diversity.

INTRODUCTION: We sought to assess the quality, understandability, actionability, and diversity of speakers in videos on TikTok and YouTube regarding overactive bladder. METHODS: Using Application Program Interface, the top 500 TikTok and 120 YouTube videos on overactive bladder were retrieved. Videos unrelated to overactive bladder, those not in English, longer than 10 minutes, or lacking both text and audio were excluded. Surgical technique videos for providers were also excluded. Videos were scored by trained raters using 2 validated instruments: PEMAT (Agency for Healthcare Research and Quality's Patient Education Materials Assessment Tool) for actionability and understandability, and the DISCERN instrument for quality of consumer health information. We also examined for evidence of misinformation and commercial bias. RESULTS: One hundred thirty-six TikTok videos and 75 YouTube videos met inclusion criteria. Eighty-eight percent of TikTok videos had poor PEMAT actionability scores (a score below 75%), as compared to 60% of YouTube videos. Both YouTube and TikTok videos scored low on PEMAT understandability. Ninety-eight percent of TikTok videos and 65% of YouTube videos were poor quality (DISCERN score <3). YouTube videos had higher actionability and quality than TikTok videos (P < .001) but did not differ on understandability (P = .769). Twenty-three percent of TikTok and 11% of YouTube videos had high misinformation (score >3). Commercial bias was present in 10% of TikTok and 19% of YouTube videos. CONCLUSIONS: Actionability, understandability, and quality for overactive bladder-related content is poor on YouTube and TikTok. With increasing access to social media, it is important that health care providers and organizations invest resources in patient education on health literacy.