Unilateral and Bilateral Transcutaneous Tibial Nerve Stimulation in Women With Overactive Bladder Syndrome: A Randomized Controlled Study (UBTTNS-OAB Study).

INTRODUCTION: The efficacy of unilateral versus bilateral Transcutaneous Tibial Nerve Stimulation (TTNS) for women with Overactive Bladder Syndrome (OAB) remains uncertain. OBJECTIVE: To compare the efficacy of unilateral and bilateral TTNS in the tibial region in women with OAB. METHODS: This randomized, controlled, triple-blind clinical trial included women with OAB or urgency-predominant urinary incontinence (UUI). Participants were randomized (1:1) into the Unilateral Tibial Group or Bilateral Tibial Group. Before treatment, they underwent a pre-assessment including peripheral sensitivity examination and completion of sociodemographic data and seven validated questionnaires on urinary symptoms, quality of life, sleep, and psycho-emotional aspects. TTNS interventions were administered twice weekly (12 sessions, 30 min each). Posttreatment, participants underwent another physical examination and completed the same questionnaires, with a 30-day follow-up. Categorical variables were analyzed using Chi-square or Fisher's Exact Test, while numerical variables were assessed with the Mann-Whitney test. Group comparisons over time utilized intention-to-treat ANOVA (p < 0.05). RESULTS: Thirty-five women participated: 17 in the unilateral group and 18 in the bilateral group. Mean ages were 55.1 (±14.7) years and 52.7 (±12.6) years, respectively (p = 0.680). Initial OAB severity (ICIQ-OAB) did not differ significantly between groups (p = 0.561). Both groups showed significant improvement in ICIQ-OAB scores: unilateral group from 10.1 (±3.4) to 5.8 (±3.4) (p < 0.001), bilateral group from 9.3 (±3.3) to 5.1 (±4) (p < 0.001), with no intergroup difference (p = 0.395). Improvement in UUI symptoms was observed: unilateral group from 2.2 (±1.4) to 0.7 (±1.5), bilateral group from 1.5 (±1.9) to 0.2 (±0.5), without significant intergroup difference (p = 0.645). Quality of life scores improved similarly between groups (p = 0.055). CONCLUSION: TTNS appears to be effective in improving bladder storage and UUI symptoms in women with OAB, with no difference between unilateral and bilateral applications. CLINICAL TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (REBEC) (RBR: 96f2fgkn).

Use of a Mobile Application for Pelvic Floor Muscle Training in Women With Urinary Incontinence: a Randomized Control Trial.

INTRODUCTION AND HYPOTHESIS: This study was aimed at evaluating the impact of a mobile app-guided pelvic floor muscle training (PFMT) program on urinary symptoms and quality of life in women suffering from urinary incontinence. METHODS: The study included women with stress urinary incontinence (SUI), who underwent a structured interview and completed validated questionnaires, including the Questionnaire for Urinary Incontinence Diagnosis (QUID), the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), and the Incontinence Quality of Life Questionnaire (I-QOL). These women were randomly assigned to one of two groups: the app group, which received a visual depiction on the expected contraction pattern through a mobile app to support their PFMT exercises, and the control (paper) group. Both groups were instructed to perform PFMT exercises twice daily for 30 days. Data were collected at baseline and at 30, 60, 90, and 120 days after completing the exercises. RESULTS: A total of 154 women participated, with 76 in the app group and 78 in the paper group. The mean ages were 61 (± 6.1) and 60.6 (± 6.8) in the app and paper groups respectively (p = 0.644). Both groups showed significant improvements in QUID SUI scores (p < 0.001), overactive bladder (OAB; p < 0.001), ICIQ-SF scores (p < 0.001), and quality-of-life scores (p < 0.001). When comparing the two groups, the app group exhibited a more substantial reduction in OAB (p = 0.017) as assessed by QUID and total (p = 0.042), psychosocial (p = 0.032) and social embarrassment (p = 0.006) I-QOL scores. CONCLUSIONS: The study findings suggest that PFMT guided by a mobile app with visual guidance leads to greater improvements in storage symptoms and quality of life than the home-based PFMT guidance.

The personal experience of female obstetricians and gynaecologists with contraceptive use influences the guidance and prescription of contraceptive methods: a web-survey.

OBJECTIVE: To evaluate the influence of the personal experience of female obstetricians and gynaecologists (Obst/Gyns) who utilise contraceptive methods on the provision of these methods. METHODS: An anonymous online web-based survey was carried out with female Obst/Gyns. The instrument contained questions about their current and previous contraceptive methods use, factors that influenced the choice and satisfaction with the ongoing method, as well as the occurrence of adverse events. They were also asked whether the experience of any adverse events influenced their decision in prescribing any particular contraceptive method. RESULTS: 476/9000 (5.3%) female Obst/Gyns answered the survey. The most common contraceptive in use was the 52-mg levonorgestrel-intrauterine device (52-mg LNG-IUD) (34%), followed by non-Long-Acting Reversible Contraception hormonal methods (21.2%). More than half of the respondents (57.6%) reported having some adverse effects and 18.7% reported that the personal experience of an adverse effect with the use of a contraceptive method influenced the prescription of that method. CONCLUSION: Half of female Obst/Gyns encountered adverse events linked to contraceptive usage. Additionally, almost one-fifth believe that their own encounter with adverse effects from a contraceptive method impacts their decision to prescribe the same method.

Almost one-fifth of the female obstetrics and gynaecologists that answered the online survey reported that the personal experience of an adverse effect with the use of a contraceptive method influenced the prescription of that method.

Sexual function after energy-based treatments of women with urinary incontinence. A systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) affects approximately 50% of adult women worldwide and is associated with declining sexual function (SF). Energy-based devices emerged as a minimally invasive alternative treatment. Nevertheless, their effect on sexuality is uncertain. We hypothesize that the UI energy treatment can lead to sexual function improvement. METHODS: A search was performed in PubMed, Cochrane Library, Web of Science, Embase, and Scopus for randomized clinical trials (RCTs) and nonrandomized studies of intervention, which treated incontinent women using energy, with UI and sexual function (SF) as outcomes. Severe comorbidities, pelvic organ prolapse (POP)> grade 2, and use of medication to treat UI or that affects SF were excluded. Quality assessment and meta-analysis were performed. RESULTS: From 322 articles, 11 RCTs were included for qualitative analysis. UI symptoms improved in all studies. Regarding SF, RCT with premenopausal women showed improvement in SF in the Er:Yag group (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 and Female Sexual Function Index). A prospective study showed improvement in SF independent of the grade of SUI. RF showed benefits for SF but was not superior to pelvic floor muscle training. One nonrandomized study of intervention with a High-Intensity Focused Electromagnetic Field showed significant improvement of SF in the Golombok Rust Inventory of Sexual Satisfaction total score, a decline in pain and dissatisfaction domains. Meta-analysis with 4 RCTs and 2 nonrandomized studies found no difference between groups (0.26 (95% CI -0.67 to 1.20, and -0.74 (95% CI -3.78 to 2.30) respectively). CONCLUSIONS: This meta-analysis did not confirm that energy equipment improved the SF of women with UI.

Provision of contraceptives by Brazilian general gynaecologists: a nationwide online survey.

OBJECTIVE: To assess the provision of contraceptives by Brazilian obstetricians and gynaecologists (Obst/Gyns) during medical consultation and associated factors. METHODS: An anonymous online survey was conducted with Obst/Gyns regarding age, gender, training, method counselling about and provision of long-acting reversible contraception (LARC). RESULTS: Of 16,000 Obst/Gyns, 610 (3.8%) answered the survey. After multiple regression analysis, female Obst/Gyns (reference) (OR male was 0.53 [95%CI 0.28-0.98], p = 0.044) and Obst/Gyns aged between 20 and 39 were more likely to provide an IUD. For hormonal-IUDs, Obst/Gyns who had had theoretical training in hormonal-IUD insertion (reference no training) (OR = 2.13 [95%CI 1.14-3.99], p = 0.018), those who work in a private facility or public hospital, and those that allowed more time during consultations (reference) (OR short time = 0.33 [95%CI 0.17-0.63], p < 0.001) were more likely to provide them. Obst/Gyns who were hands-on trained were more likely to provide subdermal implant (OR = 2.04 [95%CI 1.45-2.87], p < 0.001). CONCLUSIONS: There is a gap between theoretical and practical training received by this cohort of Obst/Gyns regarding LARCs, mainly contraceptive implants and hormonal-IUDs. The identification of barriers to offering contraceptives is essential to providing client-centred contraceptive care.

There is a gap between the theoretical and practical training received by Brazil-based Obst/Gyns regarding LARC methods, mainly subdermal implants and hormonal-IUDs. The identification of barriers is essential to providing client-centred contraceptive care.

Depression, anxiety, and stress in women with urinary incontinence with or without myofascial dysfunction in the pelvic floor muscles: A cross-sectional study.

AIMS: To compare the prevalence of psychological symptoms (depression, anxiety, and stress) in women with urinary incontinence (UI), according to the presence or absence of myofascial dysfunction (MD) in the pelvic floor muscles (PFMs). METHODS: Cross-sectional study, with women with UI who are 18 years old and over. The diagnosis of MD was defined by the pain of any intensity during the palpation of PFM. All participants answered the International Consultation on Incontinence Questionnaire-Short Form and the International Consultation on Incontinence Questionnaire Overactive Bladder for urinary symptoms and the Depression Anxiety and Stress Scale-Short Form-21 to check for the presence and degrees of depression, anxiety, and stress. RESULTS: Two hundred-thirty-four women with a mean age of 52.5 (±9.2) years were included. Almost half (51.7%) of women had MD. Women with MD showed higher mild and moderate anxiety scores (p = .005) and higher mild, moderate, and severe stress scores (p = .027) than women without MD. Depression scores were not associated with MD; however, women with and without MD reported severe or extremely severe depression, anxiety, and stress. CONCLUSIONS: The risk for depression, anxiety, and stress is high among women with UI regardless of the presence of MD. However, women with MD had higher scores for anxiety and stress than women with UI without MD.

Tilapia Skin for Neovaginoplasty after Sex Reassignment Surgery.

STUDY OBJECTIVE: To describe a new technique of neovaginoplasty after a female sex reassignment surgery using a tilapia skin as a graft. DESIGN: Stepwise demonstration of a new technique with narrated video of a single case report. The patient provided oral and written informed consent. Moreover, this video report is part of a multicenter, Investigational Review Board-approved study. SETTING: Women's university hospital in Campinas, Brazil. INTERVENTIONS: Neovaginoplasty technique using tilapia skin with the following key strategies: (1) corpus cavernosum removal, (2) vagina tunnel creation, (3) mold coating with tilapia skin, (4) mold fixation, and (5) postoperative care. The patient remained with the mold coated with tilapia skin for 5 days; after this time, the mold was removed, and the tissue graft was adhered and incorporated in the new vaginal canal. After 2 months, the tissue resembled a vaginal mucosa, and the vaginal length was 8 cm. The patient has not had intercourse yet. CONCLUSION: We introduce an alternative for low-morbidity neovaginoplasty based on the experience of plastic surgery in burned grafts. The procedure described offers an alternative option to develop an anatomic neovagina with tissue similar to mucosa tissue by a simple, low-morbidity minimally invasive procedure.

Does sacrocolpopexy present heterogeneity in its surgical technique? A systematic review.

AIMS: Sacrocolpopexy (SCP) is an extensively studied and highly efficacious treatment for female pelvic organ prolapse (POP). We aimed to analyze the technical steps for performance of a SCP among all RCTs in the literature that compared it with different procedures, or that studied different routes for performing SCP. METHODS: Systematic review searching electronic databases for RCTs only. We extracted data for 13 points of interest; main outcomes were procedure standardization; depth of vaginal dissection; number of sutures in the vaginal wall; type of suture in the vaginal wall; type of mesh fixation to the sacrum; and type and shape of mesh used. RESULTS: Twenty-two RCTs were included. Most of them did not provide a full standardized description of the procedure steps. There was great heterogeneity in almost all steps of the operation, including the choice of materials for attaching the mesh to the vagina and sacrum-with both absorbable and non-absorbable sutures being used-and the extent of vaginal dissection for mesh fixation, with some studies dissecting only the apex, superficially, while others performed a full-length dissection. Choice of mesh material was more consensual, with polypropylene mesh being the most commonly used. CONCLUSIONS: SCP is a highly unstandardized procedure in the literature, albeit being used as a major comparator. Various RCTs compared alternative procedures with SCP, but the technical aspects have varied greatly, and studied outcomes could have been potentially influenced by these technical choices.

Does pelvic floor muscle maximum voluntary contraction improve after vaginal pelvic organ prolapse surgery? A prospective study.

AIMS: to assess pelvic floor muscle maximum voluntary contraction (MVC) before and after surgical treatment for pelvic organ prolapse (POP). METHODS: This was a prospective observational study with women scheduled for surgical correction of POP. Assessments occurred 15 days before and 40 days after surgery. The primary outcome was pelvic floor muscle (PFM) MVC measured using the manometer Peritron™. The average strength of PFM contraction was also measured. Secondary outcomes were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) score. The Student paired t-test was used for quantitative data. For the pre and postsurgery comparisons of PFM strength in relation to POP-Q value we used the nonparametric Kruskal-Wallis test for dependent variables. The level of significance adopted was P < 0.05. RESULTS: Sixty-seven women were recruited, 65 (97%) completed the study. The mean age of participants was 62 ± 10.2. There was no difference (1.9 cm H2 O ± 12.9; P = 0.22) between MVC before (27.1 cm H2 O ± 17.0) and after surgery (29 cm H2 O ± 17.8). The average contraction was higher after surgery (2.3 cmH2 O ± 8.6; P = 0.03). The higher the severity of pre and postsurgery POP, the worse the MVC. CONCLUSION: There was no difference in MVC pre and postsurgery, however we found an improvement in PFM average contraction strength postsurgery.

Trastuzumab use during pregnancy: long-term survival after locally advanced breast cancer and long-term infant follow-up.

Here, we describe the case of a patient diagnosed with locally advanced breast cancer 8 years ago. Her treatment course was neoadjuvant chemotherapy, followed by mastectomy and then adjuvant radiotherapy and trastuzumab (TTZ). During the use of adjuvant targeted therapy, an incidental pregnancy was diagnosed. Four years later, she developed bone and cerebral metastases, and since then, she has received courses of TTZ, capecitabine, lapatinib, and radiotherapy with intermittent control of the disease. Her 7-year-old son presents a normal physical and long-term neurological developmental curve according to specialized evaluation. This case is unique for several reasons: the patient received the highest dose of TTZ yet described during pregnancy (4400 mg); there has been a long period of disease-free survival after treatment for locally advanced breast cancer and long overall survival despite successive disease progressions during the metastatic phase of the disease (97 months), and there was a monitored pediatric follow-up period (7 years).

How We Do It: Student Perspectives on Changes to the Obstetrics and Gynecology Residency Application Process.

OBJECTIVE: To describe the perspectives of obstetrics and gynecology (OBGYN) residency applicants regarding new standards for the 2019 to 2020 application cycle. DESIGN: An anonymous electronic survey was sent to all OBGYN residency applicants to US programs retrospectively evaluating 5 new recommended standards for the application process. This 15-item survey assessed the importance of the proposed standards and their impact on applicants' anxiety. SETTING: The OBGYN residency application process is marked by increasing application numbers and no standardization for managing interview offers. The Association of Professors of Gynecology and Obstetrics (APGO) received a 5-year Reimagining Residency grant from the American Medical Association to improve the transition from undergraduate medical education (UME) to graduate medical education (GME) within OBGYN. The multiphase project, "Transforming the UME to GME Transition for Obstetrics and Gynecology- Right Resident, Right Program, Ready Day One (RRR)," began with Standardizing the OBGYN Application and Interview Process (SOAIP). This group recommended 5 new standards for all US OBGYN residency programs and applicants. PARTICIPANTS: Applicants for US OBGYN residency programs for the 2019 to 2020 application cycle completed the survey, with a 904/2508 (36.0%) response rate, including 762 complete responses (30.4%). RESULTS: Applicants reported that all 5 of the new standards would cause the least self-perceived anxiety (range 76.8% - 96.5%). The impact of the standards on perceived anxiety varied by student group, with International Medical Graduates (IMGs) and students with USMLE Step I scores <200 describing lesser impact compared to others. Despite these differences, all 5 standards were consistently noted to cause the least anxiety for all groups. Despite varying degrees of effects in different groups, the new OBGYN residency application standards caused the least anxiety for all subgroups of applicants. CONCLUSIONS: Implementing universal standards for the OBGYN residency application process was favorably perceived by applicants and caused the least anxiety for applicants.

Risk Factors for Dislodgment of Vaginal Pessaries in Women With Pelvic Organ Prolapse: A Cohort Study.

OBJECTIVE: The aim of the study was to evaluate the associated factors associated with pessary dislodgment in women with advanced pelvic organ prolapse (POP). METHODS: A cohort study with women (N = 98) with advanced POP who chose conservative treatment with ring pessary between December 2016 and 2018 identified by screening. Demographic data, history of POP, urinary, and/or bowel symptoms were collected. A medical visit was scheduled 3 and 6 months after pessary insertion to evaluate symptoms (vaginal discharge, bleeding, pain, discomfort, new-onset urinary, or fecal problems) and any pessary dislodgment. Two groups were created (women who were able to retain the pessary versus who were not able), and univariate and multivariate analysis were performed to look for risk factors for pessary dislodgment. Women who requested to have their pessaries removed during the 6-month follow-up were excluded. RESULTS: Ninety-three women included in the study, 78 successfully continued to use the pessary at 6 months, and 15 had pessary dislodgment (16.1%). Demographic characteristics were similar between the treatment group and the control group. After multivariate analysis, women who had their pessaries dislodged presented higher rates of previous surgery (odds ratio = 8.11; 95% confidence interval = 2.09-31.58; P = 0.003) with advanced Pelvic Organ Prolapse Quantification system staging (odds ratio, 13.41; confidence interval, 1.97-91.36; P = 0.008). CONCLUSIONS: The presence of advanced apical POP and previous POP surgery are risk factors for ring pessary dislodgment. This information should guide physicians for counseling patients before pessary insertion.

Randomized double-blind placebo-controlled trial of the effect of Morus nigra L. (black mulberry) leaf powder on symptoms and quality of life among climacteric women.

OBJECTIVE: To test the efficacy of Morus nigra L. (MN) leaf powder for treating climacteric symptoms by comparison with hormone therapy (HT) and placebo. METHODS: A randomized controlled trial among 62 climacteric women attending Hospital of the Federal University of Maranhão, Brazil. Women were divided into MN, HT, and placebo groups, and received 250 mg of MN leaf powder, 1 mg of estradiol, or placebo for 60 days. Primary outcomes were the Blatt-Kupperman index (BKI) for climacteric symptoms and SF-36 health questionnaire scores. RESULTS: Baseline sociodemographic variables, BKI scores, symptoms, and SF-36 domains did not differ among the groups. There was a reduction in mean BKI in the MN (17.5 vs 9.7, P<0.001), HT (15.4 vs 8.6, P=0.001), and placebo (16.1 vs 12.4, P=0.040) groups. Analysis of quality of life (QoL) showed that functional capacity (P=0.006), vitality (P=0.031), mental health (P=0.017), and social aspect (P<0.01) improved after treatment in the MN group. The HT group showed improvement in emotional limitation (P=0.040), and the placebo group showed better functional capacity (P=0.030) after treatment. CONCLUSIONS: Climacteric symptoms and QoL improved after administration of 250 mg of MN leaf powder for 60 days, similar to the effects of HT. The trial is registered in the Brazilian Registry of Clinical Trials (REBEC) under registration number RBR-9t4xxk.

Cervix removal at the time of hysterectomy: factors affecting patients' choice and effect on subsequent sexual function.

OBJECTIVES: To identify factors that influence the decision-making process on the type of hysterectomy (total or supracervical) and the impact of surgery of subsequent sexual function. STUDY DESIGN: A cross-sectional survey was undertaken on 212 women who underwent total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for benign conditions at the Division of Minimally Invasive Gynecology at Brigham and Women's Hospital in Boston, MA, USA. We analyzed the factors that patients considered in their decision-making process, their sexual function after surgery and their satisfaction with the surgery overall. Demographic and perioperative outcomes were also collected. RESULTS: A total of 115 women answered the survey, for a response rate of 54.24%. The patients who underwent LSH (n=54) and TLH (n=61) were overall similar in terms of baseline factors and perioperative outcomes. Patients reported that the physician was the main source of information regarding decision to remove or retain the cervix (79.13%). The physicians' recommendation was viewed as very or extremely important (83.68%) to the decision-making process, followed by concerns regarding their future sex life (51.09%). Almost half of the women reported that hysterectomy had no impact on sexual function. No statistically significant differences were seen between groups regarding satisfaction with sexual function (p=.822), impact on sexual function (p=.753) or recommendation of this surgery to other women (p=.505). CONCLUSION: Concerns about sexual health were important to women when considering the type of hysterectomy to undergo. Cervix removal or retention at the time of hysterectomy did not impact women's sexual function after mean follow-up of 15.2 months.

Why are the low birthweight rates in Brazil higher in richer than in poorer municipalities? Exploring the epidemiological paradox of low birthweight.

Socio-economic disadvantage is usually associated with low birthweight (LBW). However, it has been shown that Mexican Americans, despite being economically less advantaged, present LBW rates that are similar to or lower than those found among white women in the US. This fact has been called 'the epidemiological paradox of low birthweight'. Natality data from Brazil revealed the existence of a similar paradox: LBW rates are higher in more developed than in less developed regions within the country. In this study, data from two population-based cohort studies carried out in the nineties, including 2439 births in Sao Luis, a poor city in north-eastern Brazil, and 2839 births in Ribeirao Preto, a socio-economically well-off city in south-eastern Brazil, were used to explore this paradox. The method proposed by Wilcox and Russell and a graphic analysis of the frequency distribution of birthweight according to gestational age were used to provide indirect information about possible gestational age misclassification. Contrary to expectations, the LBW rate was higher in Ribeirao Preto than in Sao Luis (10.7 vs. 7.6%, P <0.001), while preterm birth (PTB) rate (12.7 vs. 12.1%, P=0.520) and percentage of small-for-gestational-age (SGA) infants (12.5 vs. 13.5%, P=0.290) were similar for the two cities. However, SGA rate among preterm infants was higher in Ribeirao Preto (16.4 vs. 9.8%, P=0.014). A bimodal distribution of birthweight was observed for children with less than 32 weeks in Sao Luis. As estimated by the Wilcox and Russell method, the residual distribution was greater in Ribeirao Preto than in Sao Luis (3.4 vs. 2.4%). Part of the LBW paradox observed for the two cities was due to the higher PTB rate and higher number of preterm SGA infants in Ribeirao Preto. Factors such as greater medical intervention in preterm newborns close to the end of pregnancy in more developed municipalities, artefacts in the determination of gestational age, and the under-registration of livebirths and registration of livebirths as stillbirths in less developed municipalities may explain why LBW rates in Brazil are higher in richer than in poorer municipalities.