Contraception and Cardiovascular Effects: What Should the Cardiologist Know?

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of death in women. This review highlights contraceptive options and their effects on the cardiovascular system (CVS). It provides guidance to cardiologists to make informed decisions regarding the safety of contraceptive use and cardiovascular risk stratification in the care of women of childbearing age. RECENT FINDINGS: Approximately 44% of American women live with some type of CVD. Many women use hormonal contraception during their lifetime. It is imperative that cardiologists have a robust understanding of the forms of contraception in current use and their cardiovascular effects. This contemporary review provides a comprehensive summary of available contraceptive methods to practicing cardiologists and aims to be used as a resource to guide cardiovascular specialists on contraception in the context of cardiovascular disease.

Urethral Diverticulum following Polypropylene Mesh Midurethral Slings: A Literature Review.

AIMS: It is currently unknown whether an association exists between polypropylene mesh and urethral diverticulum formation following placement of polypropylene midurethral slings (MUS) for the treatment of stress urinary incontinence (SUI). We aimed to examine the literature associating MUS with the occurrence of urethral diverticula. METHODS: Multiple online research databases, including PubMed, Google Scholar, EBSCOhost, and the Cochrane Library, were searched, from January 2019 to February 2019, for evidence related to the occurrence of urethral diverticula following polypropylene MUS procedures. RESULTS: Four case reports were published demonstrating the occurrence of urethral diverticula following the use of polypropylene mesh for surgical treatment of SUI. Subjects of these cases were menopausal and had an elevated body mass index (BMI), recurrent urinary tract infections (UTIs), autoimmune conditions, or prior pelvic floor surgeries. A thorough urologic workup, including imaging prior to sling placement, was not always performed. CONCLUSION: No clear association exists between polypropylene MUS placement and subsequent urethral diverticulum formation. Factors that diminish polypropylene mesh biocompatibility include elevated BMI, menopause, recurrent UTIs, prior pelvic surgeries, and preexisting medical conditions. Symptoms associated with urethral diverticula should prompt a complete urologic workup prior to MUS placement.

Comparing postoperative voiding dysfunction after mid-urethral sling using either a Babcock or Kelly clamp tensioning technique.

INTRODUCTION AND HYPOTHESIS: The objective was to compare postoperative urinary retention using the Babcock and Kelly clamps for retropubic midurethral sling (RPS) tensioning. METHODS: This was a retrospective cohort of isolated RPS procedures from December 2010 through April 2016 by five fellowship-trained surgeons at two institutions. Slings were tensioned with a Babcock clamp by grasping a 3-mm midline fold of mesh (RPS-B) or a Kelly clamp as a spacer between the sling and suburethral tissue (RPS-K). Assessment of urinary retention included the primary outcome of postoperative catheterization and several secondary outcomes, including discharge home with a catheter, within 1 year of surgery. Analysis of covariance was used to compute the mean difference in duration of catheterization and log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI). RESULTS: We included 240 patients. The RPS-B group had a lower body mass index and was more likely to be menopausal, have had pelvic organ prolapse surgery, and have a lower maximum urethral closure pressure than the RPS-K group. The mean duration of catheterization was similar, as demonstrated by the crude (0.21 days [-0.30-0.71]) and BMI-adjusted (0.07 days [-0.41-0.55]) mean difference in duration of catheterization. The incidence of postoperative OAB symptoms was comparable between the groups (BMI-adjusted RR: 0.95 (0.80-1.1)), and the incidence of revision did not differ (p = 0.7). CONCLUSIONS: The Babcock and Kelly clamp tensioning techniques appear comparable, with a low incidence of prolonged postoperative catheterization. Most catheters were removed on the day of the surgery. It is reasonable to tension retropubic midurethral slings with either method.

A Telephone Call to Decrease Patient Anxiety Before Urodynamic Testing: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to determine if a telephone call before undergoing urodynamic study (UDS) would decrease test-related anxiety compared with standard care. METHODS: We performed a randomized controlled trial at a single practice from April 2016 to June 2017. Patients at least 18 years old with lower urinary tract dysfunction and undergoing UDS for the first time were eligible. All participants received standard counseling; participants randomized to the intervention group also received a telephone call before their UDS appointment to answer any questions regarding their upcoming test. All participants completed surveys before and after testing to assess anxiety, preparedness, and satisfaction. The primary outcome was anxiety level immediately before UDS. Secondary outcomes included self-reported patient preparedness, pain, and satisfaction with counseling. Data were compared using χ, Fisher exact, and Wilcoxon rank sum tests. RESULTS: One hundred two participants were included in this as-treated analysis: 52 in the intervention group and 50 in the standard care group. The 2 groups were similar in age, ethnicity, and the proportion seeking additional information before testing. There were no statistically significant differences between groups with respect to overall anxiety, anxiety regarding specific elements of the test, or anticipated pain (all P ≥ 0.19). Participant satisfaction with pre-UDS counseling was significantly higher in the intervention group (80.8%) compared with the standard care group (54.0%; P = 0.002). CONCLUSIONS: Our study showed that a telephone call before undergoing UDS did not decrease anxiety compared with standard care; however, the telephone call was associated with higher satisfaction with pre-UDS counseling.

Opioid use following gynecologic and pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Opioid use, addiction, and overdose are a growing epidemic in the USA. Our objective was to determine whether the amount of opioid medication prescribed following gynecologic and pelvic reconstructive surgery is insufficient, adequate, or in excess. We hypothesized that we were overprescribing postoperative opioids. METHODS: Participants who were at least 18 years old and underwent gynecologic and/or pelvic reconstructive surgery from April through August 2016 were eligible to participate. Routine practice for pain management is to prescribe 30 tablets of opioids for major procedures and ten to 15 tablets for minor procedures. At the 2-week postoperative visit, participants completed a questionnaire regarding the number of tablets prescribed and used, postoperative pain control, and relevant medical history. Fisher's exact test was used to compare data. RESULTS: Sixty-five participants completed questionnaires. Half (49.1%) reported being prescribed more opioids than needed, while two (3.5%) felt the amount was less than needed. Though not significant, participants who underwent major surgeries were more likely to report being prescribed more than needed (53.5%) compared with participants who underwent minor surgeries (35.7%; p = 0.47). Though not significant, participants with anxiety were less likely to report being prescribed more tablets than needed compared with participants without anxiety (44.4% vs. 57.1%; p = 0.38). This was also true of participants with depression compared with those without (37.5% vs. 58.3%; p = 0.17), and those with chronic pain compared with those without (33.3% vs. 60.0%; p = 0.10). CONCLUSIONS: Our current opioid prescription practice for postoperative pain management may exceed what patients need.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial.

OBJECTIVE: To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. METHODS: We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. RESULTS: One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P≤0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0-4.0) days. CONCLUSIONS: Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE: I.

Effect of vaginal estrogen on pessary use.

INTRODUCTION AND HYPOTHESIS: Many providers recommend concurrent estrogen therapy with pessary use to limit complications; however, limited data exist to support this practice. We hypothesized that vaginal estrogen supplementation decreases incidence of pessary-related complications and discontinuation. METHODS: We performed a retrospective cohort study of women who underwent a pessary fitting from 1 January 2007 through 1 September 2013 at one institution; participants were identified by billing code and were eligible if they were postmenopausal and had at least 3 months of pessary use and 6 months of follow-up. All tests were two sided, and P values < 0.05 were considered statistically significant. RESULTS: Data from 199 women were included; 134 used vaginal estrogen and 65 did not. Women who used vaginal estrogen had a longer median follow-up time (29.5 months) compared with women who did not (15.4 months) and were more likely to have at least one pessary check (98.5 % vs 86.2 %, P < 0.001). Those in the estrogen group were less likely to discontinue using their pessary (30.6 % vs 58.5 %, P < 0.001) and less likely to develop increased vaginal discharge than women who did not [hazard ratio (HR) 0.31, 95 % confidence interval (CI) 0.17-0.58]. Vaginal estrogen was not protective against erosions (HR 0.93, 95 % CI 0.54-1.6) or vaginal bleeding (HR 0.78, 95 % CI 0.36-1.7). CONCLUSIONS: Women who used vaginal estrogen exhibited a higher incidence of continued pessary use and lower incidence of increased vaginal discharge than women who did not.

TVT-Secur (Hammock) versus TVT-Obturator: a randomized trial of suburethral sling operative procedures.

OBJECTIVES: This study aimed to compare TVT-Secur (TVT-S) and TVT-Obturator (TVT-O) suburethral slings for treatment of stress urinary incontinence (SUI). METHODS: This was a single-center, nonblinded, randomized trial of women with SUI who were randomized to TVT-S or TVT-O from May 2007 to April 2009. The primary outcome, SUI on cough stress test (CST), and quality-of-life and symptom questionnaires (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) were assessed at 12 weeks and 1 year. RESULTS: Forty-three women were randomized to TVT-S and 44 to TVT-O. There were no differences in median baseline PFDI-20 and PFIQ-7. Twenty-two (52.4%) of 42 participants randomized to TVT-S had a positive CST result at evaluation after 12 weeks or 1 year, whereas 4 (9.1%) of the 44 in the TVT-O group had a positive CST result. The intent-to-treat analysis showed that the risk of a positive CST result was 6 times higher after TVT-S than TVT-O (risk ratio, 6.0; 95% confidence interval [CI], 2.3-16.0). Among women not lost to follow-up, the risk ratio for a positive CST result after TVT-S compared with TVT-O was 17.9 (95% CI, 2.5-128.0) at 12 weeks and 3.5 (95% CI, 1.1-11.0) at 1 year. Both TVT-S and TVT-O resulted in improved quality of life and symptoms at 12 weeks. There was no difference between the groups for PFDI-20 (P = 0.40) or PFIQ-7 (P = 0.43). A similar pattern was seen at 1 year (P = 0.85 and P = 0.36). CONCLUSIONS: The TVT-S seems to have a higher risk of positive postoperative CST result; however, the procedures result in similar improvements in quality of life and symptoms.

Association of body mass index with hip and thigh pain following transobturator midurethral sling placement.

OBJECTIVE: We sought to investigate the incidence of hip and proximal lower extremity pain following transobturator midurethral sling and evaluate the association between pain and body mass index (BMI). STUDY DESIGN: This was a retrospective cohort study of all transobturator midurethral sling procedures from July 2008 through June 2009. The primary outcome was postoperative hip or proximal lower extremity pain. RESULTS: Four urogynecologists performed 226 procedures. The incidence of postoperative hip or proximal lower extremity pain was 15.5%. Women of normal BMI had a higher risk of developing pain than obese women (risk ratio, 2.51; 95% confidence interval, 1.01-6.22). While not statistically significant, overweight women were twice as likely as obese women to develop the primary outcome (risk ratio, 1.99; 95% confidence interval, 0.79-4.99). CONCLUSION: Women of normal BMI have an increased risk of hip and proximal lower extremity pain following transobturator midurethral sling compared with obese women.

Use of synthetic mesh in pelvic reconstructive surgery: a survey of attitudes and practice patterns of urogynecologists.

This study surveyed attitudes and practice patterns of urogynecologists regarding the use of synthetic mesh in pelvic reconstructive surgery. A web-based survey was administered to members of the American Urogynecologic Society. The survey evaluated the use of the mesh for sacrocolpopexy, suburethral sling, and vaginal pelvic reconstructive surgery. The survey had a 30.5% response rate. One hundred one (39%) respondents were women, and 158 (61%) were men. One hundred forty-seven (56.8%) participated in fellowship training. Two hundred forty-seven (99.5%) currently perform procedures using synthetic mesh, including 93% who perform sacrocolpopexy and 93% who perform suburethral slings. In a logistic regression model including gender, fellowship training, and practice setting, male surgeons and those who had not undergone fellowship training were more likely to use the mesh than those who were fellowship trained. Respondents use the mesh most commonly when performing sacrocolpopexies and suburethral slings. The use of the mesh for anterior and posterior colporrhaphy is less common.