Omission of Pelvic Examination Before Gender-Affirming Hysterectomy and Vaginectomy.

Surgeons may be performing pelvic examinations on transgender patients before gender-affirming pelvic surgery (hysterectomy and vaginectomy) without a clinically significant indication. A retrospective cohort study was conducted at a single-institution academic referral center comparing 30-day perioperative outcomes of all 62 gender-affirming pelvic surgeries, including hysterectomy alone, hysterectomy with vaginectomy, and vaginectomy alone, between April 2018 and March 2022. More than half (53.2%, n=33) of the 62 patients did not have an in-office, preoperative, internal pelvic examination within 1 year of gender-affirming surgery. There were no significant differences in patient characteristics nor 30-day perioperative outcomes between the examined and examination-omitted groups, suggesting that omission of a preoperative pelvic examination is probably safe before gender-affirming hysterectomy and vaginectomy, minimizing barriers to gender-affirming surgical care.

Vaginal and urinary evaluation of lactobacilli quantification by qPCR: Identifying factors that influence urinary detection and the quantity of Lactobacillus.

Vaginal colonization with lactobacilli has been linked to the health of the lower urinary tract in women. There is growing evidence that the bladder has its microbiome related closely to the vagina. In this study, we compared the three common vaginal Lactobacillus species (L. jensenii, L. iners and L. crispatus) in vaginal and urine samples to identify factors that influence urinary detection and the quantity of Lactobacillus. We used quantitative real-time PCR (qPCR) assays to measure the concentration of Lactobacillus jensenii, L. iners and L. crispatus in paired vaginal swabs and clean-catch urine samples from pre-and post-menopausal women. We compared demographic variables and vaginal Lactobacillus quantity between women with vaginal detection of at least one of the three species, detection in both vagina and urine, or urine only. We performed Spearman correlation between vaginal and urinary quantities of each species. We used multivariable logistic regression models to determine predictors of detectable Lactobacillus species in both samples (vs. vagina only or urine only). Models were adjusted for variables selected a priori: age, BMI, condom use, and recent sexual activity. Ninety-three paired vaginal fluid, and urine samples were included in the final analysis. 44 (47%) had no detectable Lactobacillus species in their urine samples, and 49 (53%) had at least one of the three Lactobacillus species (L. jensenii, L. iners and L. crispatus) detected in urine. Most women were white (91.4%), with a mean age of 39.8 ±13.8 years. The two groups were similar in demographics, gynecologic history, sexual history, recent use of antibiotics or probiotics within 7 days of sample collection, Nugent scores, and urine-specific gravity. Among the three Lactobacillus species, L. jensenii was more commonly detected in urine than the other two. For all three species, detection in the urine sample alone was infrequent. The concentrations of all three species were higher in vaginal samples than in urine samples. For all three Lactobacillus spp., vaginal abundance was associated with the urinary abundance of the same species even after adjusting for the Nugent score. In Spearman correlation analysis, urinary and vaginal Lactobacillus concentrations were positively correlated within the same species, with the most significant correlation coefficient for L. jensenii (R = 0.43, p<0.0001). Vaginal quantities were positively correlated between the three species, as were urinary quantities to a lesser extent. There was no meaningful correlation between the urinary quantity of one Lactobacillus sp. and the vaginal quantity of another species. In summary, the vaginal quantity of Lactobacillus was the most significant predictor of concurrent detection of the same species in the bladder, confirming the close relationship between these environments. Strategies to promote vaginal Lactobacillus colonization may also bring urinary colonization and the health of the lower urinary tract.

Incidence of de novo stress urinary incontinence following minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the incidence and risk factors of postoperative de novo stress urinary incontinence (SUI) in stress-continent women following minimally invasive sacrocolpopexy without an anti-incontinence procedure. METHODS: We completed a multicenter, retrospective cohort study of women undergoing laparoscopic sacrocolpopexy without concurrent anti-incontinence procedures from October 2006 through January 2021. RESULTS: Of the 169 women who underwent minimally invasive sacrocolpopexy, 17.1% (n=30) developed de novo SUI, and 7.1% eventually underwent a midurethral sling placement. On logistic regression, BMI, preoperative urinary urgency, and history of transvaginal mesh repair were found to be significantly associated with and predictive of de novo SUI. When the concordance index (C-index) was calculated with the model published by Jelovsek et al. for women who developed de novo SUI within 12 months of the prolapse surgery, the current de novo SUI calculator was able to discriminate de novo SUI outcome (C-index = 0.71). CONCLUSIONS: The incidence of de novo SUI after minimally invasive sacrocolpopexy without anti-incontinence procedure correlates directly with higher BMI, preoperative urinary urgency, and transvaginal mesh history for POP. Preoperative counseling for minimally invasive sacrocolpopexy should include discussing the risk of de novo SUI and preoperative factors that may increase this risk.

Urinary tract infection following intradetrusor onabotulinumtoxina injection for non-neurogenic urgency incontinence: single- vs. multi-dose prophylactic antibiotic treatment regimens.

INTRODUCTION AND HYPOTHESIS: Urinary tract infection is one of the most common adverse events following onabotulinumtoxinA injection for urgency incontinence. Our hypothesis was that those undergoing injection for urgency incontinence who received more than one dose of prophylactic antibiotics have lower post-procedure urinary tract infection rates compared to those who receive a single dose. METHODS: We conducted a multi-center retrospective cohort study in females who underwent onabotulinumtoxinA injection for non-neurogenic urgency incontinence to evaluate the effect of single- vs. multi-dose prophylactic antibiotic regimens on the risk of post-procedure urinary tract infection. The primary outcome was the rate of urinary tract infection within 30 days of injection. Our sample size calculation required 136 subjects per group. RESULTS: Two hundred eighty-one patients were included from four centers. The single-dose cohort included 145 patients (51.6%), and the multi-dose cohort included 136 patients (48.4%). The mean age was 65 years, and patients were primarily Caucasian (81.4%). There was no difference in the rate of urinary tract infections diagnosed within 30 days of injection between the cohorts (single dose 13.8% vs. multi-dose 10.3%, p = 0.369). Those with a positive urine culture within 30 days of injection had a 15.2 times greater odds of having a post-procedure infection than those who did not (95% CI 3.19-72.53). There was no significant difference between the two cohorts in terms of adverse health events following injection. CONCLUSIONS: In females with non-neurogenic urgency incontinence undergoing onabotulinumtoxinA injection, multi-dose prophylactic antibiotic regimens were not associated with lower post-procedure urinary tract infection rates.

Postoperative complications and pelvic organ prolapse recurrence following combined pelvic organ prolapse and rectal prolapse surgery compared with pelvic organ prolapse only surgery.

BACKGROUND: There is a growing interest in combined pelvic organ prolapse and rectal prolapse surgery for concomitant pelvic floor prolapse despite a paucity of data regarding complications and clinical outcomes of combined repair. OBJECTIVE: The primary objective of this study was to compare the <30-day postoperative complication rate in women undergoing combined POP + RP surgery with that of women undergoing pelvic organ prolapse-only surgery. The secondary objectives were to describe the <30-day postoperative complications, compare the pelvic organ prolapse recurrence between the 2 groups, and determine the preoperative predictors of <30-day postoperative complications and predictors of pelvic organ prolapse recurrence. STUDY DESIGN: This was a multicenter, retrospective cohort study at 5 academic hospitals. Patients undergoing combined pelvic organ prolapse and rectal prolapse surgery were matched by age, pelvic organ prolapse stage by leading compartment, and pelvic organ prolapse procedure compared with those undergoing pelvic organ prolapse-only surgery from March 2003 to March 2020. The primary outcome measure was <30-day complications separated into Clavien-Dindo classes. The secondary outcome measures were (1) subsequent pelvic organ prolapse surgeries and (2) pelvic organ prolapse recurrence, defined as patients who complained of vaginal bulge symptoms postoperatively. RESULTS: Overall, 204 women underwent combined surgery for pelvic organ prolapse and rectal prolapse, and 204 women underwent surgery for pelvic organ prolapse only. The average age (59.3±1.0 vs 59.0±1.0) and mean parity (2.3±1.5 vs 2.6±1.8) were similar in each group. Of note, 109 (26.7%) patients had at least one <30-day postoperative complication. The proportion of patients who had a complication in the combined surgery group and pelvic organ prolapse-only surgery group was similar (27.5% vs 26.0%; P=.82). The Clavien-Dindo scores were similar between the groups (grade I, 10.3% vs 9.3%; grade II, 11.8% vs 12.3%; grade III, 3.9% vs 4.4%; grade IV, 1.0% vs 0%; grade V, 0.5% vs 0%). Patients undergoing combined surgery were less likely to develop postoperative urinary tract infections and urinary retention but were more likely to be treated for wound infections and pelvic abscesses than patients undergoing pelvic organ prolapse-only surgery. After adjusting for combined surgery vs pelvic organ prolapse-only surgery and parity, patients who had anti-incontinence procedures (adjusted odds ratio, 1.85; 95% confidence interval, 1.16-2.94; P=.02) and perineorrhaphies (adjusted odds ratio, 1.68; 95% confidence interval, 1.05-2.70; P=.02) were more likely to have <30-day postoperative complications. Of note, 12 patients in the combined surgery group and 15 patients in the pelvic organ prolapse-only surgery group had subsequent pelvic organ prolapse repairs (5.9% vs 7.4%; P=.26). In the combined surgery group, 10 patients (4.9%) underwent 1 repair, and 2 patients (1.0%) underwent 2 repairs. All patients who had recurrent pelvic organ prolapse surgery in the pelvic organ prolapse-only surgery group had 1 subsequent pelvic organ prolapse repair. Of note, 21 patients in the combined surgery group and 28 patients in the pelvic organ prolapse-only surgery group reported recurrent pelvic organ prolapse (10.3% vs 13.7%; P=.26). On multivariable analysis adjusted for number of previous pelvic organ prolapse repairs, combined surgery vs pelvic organ prolapse-only surgery, and perineorrhaphy at the time of surgery, patients were more likely to have a subsequent pelvic organ prolapse surgery if they had had ≥2 previous pelvic organ prolapse repairs (adjusted odds ratio, 6.06; 95% confidence interval, 2.10-17.5; P=.01). The average follow-up times were 307.2±31.5 days for the combined surgery cohort and 487.7±49.9 days for the pelvic organ prolapse-only surgery cohort. Survival curves indicated that the median time to recurrence was not statistically significant (log-rank, P=.265) between the combined surgery group (4.2±0.4 years) and the pelvic organ prolapse-only surgery group (5.6±0.4 years). CONCLUSION: In this retrospective cohort study, patients undergoing combined pelvic organ prolapse and rectal prolapse surgery had a similar risk of <30-day postoperative complications compared with patients undergoing pelvic organ prolapse-only surgery. Furthermore, patients who underwent combined surgery had a similar risk of recurrent pelvic organ prolapse and subsequent pelvic organ prolapse surgery compared with patients who underwent pelvic organ prolapse-only surgery.

Synchronous Telemedicine Model in Urogynecology: Are Patients Willing to Continue Telemedicine in the Post-COVID-19 Pandemic Era?

IMPORTANCE: Following the recent expansion of telemedicine during the COVID-19 pandemic, this remote model of care in female pelvic medicine and reconstructive surgery will likely remain and continue to evolve. OBJECTIVE: This study was conducted to assess patients' perceptions of and willingness to participate in a synchronous telemedicine visit beyond the COVID-19 pandemic for women with pelvic floor disorders. STUDY DESIGN: We conducted a cross-sectional study of women who completed a synchronous telemedicine visit from March 16 through May 22, 2020, at a urogynecology practice in an academic medical center. An electronic survey was distributed to women after all telemedicine visits. Demographic data, visit type, and survey responses were analyzed. RESULTS: Two hundred two women received the survey, and 135 women completed it (response rate of 66.8%). The mean age of the respondents was 62.9 ± 16.4 years, and the 3 most common visit diagnoses were overactive bladder (43.7%), stress urinary incontinence (22.2%), and pelvic organ prolapse (21.4%). Most survey participants (88.9%) found that the quality of their telemedicine visits was better than expected, and 89.6% reported that they would like to continue telemedicine care. Our survey showed that 19.4% of women reported difficulty with technology. CONCLUSIONS: We found that most women presenting for synchronous telemedicine urogynecology care had a positive visit experience and would continue to use telemedicine for their care. Further developmental work needs to be done on improving the ease of technology as well as availability of telemedicine in the care of women affected by pelvic floor disorders.

Can sonographic fetal head circumference measurement help predict obstetric anal sphincter injury?

OBJECTIVE: To investigate whether sonographic fetal head circumference (sfHC) size assessed by ultrasound prenatally could help predict OASIS. METHODS: This study is a retrospective cohort study between 2005 and 2016. Antenatal sfHC assessment, maternal demographics, and labor and delivery data were abstracted and compared in women with and without OASIS. RESULTS: Of 2057 pregnant women that had sfHC assessment, 121 (5.8%) had OASIS. In the unadjusted analysis, sfHC above the 90th centile was associated with OASIS (odds ratio [OR] 1.12; 95% confidence interval [CI] 1.02-1.23; P = 0.015). When adjusted for gestational age at delivery, maternal age, race, prolonged second stage, body mass index, infant gender, and intrapartum oxytocin use, sfHC above the 90th centile remained significantly associated with OASIS (OR 1.13, 95% CI 1.00-1.27, P = 0.050). CONCLUSION: In our cohort, sfHC above the 90th centile was associated with a greater risk of OASIS. As OASIS significantly impacts both short-term and long-term health outcomes, such as perineal pain, dyspareunia, and urinary and fecal incontinence, sfHC could be an additional prenatal marker to help clinicians counsel pregnant women about the risk of OASIS.

Urinary symptoms in women with faecal incontinence.

AIM: Faecal incontinence (FI) is estimated to affect 8.9% of women in the United States, with a significant impact on quality of life. Our aim was to compare urinary symptoms in patients with and without FI with different degrees of severity. METHODS: This prospective cohort of women presented for care at a pelvic floor disorder centre between May 2007 and January 2019. We excluded women with a history of bowel resection, prior history of pelvic organ prolapse surgery or existing prolapse symptoms reported by the patient during intake. The primary outcome was the presence of urinary symptoms in women with and without FI by validated questionnaires. A logistic regression model for association of urinary symptoms with FI was performed, adjusting for age, smoking, diabetes, prior hysterectomy and irritable bowel syndrome. RESULTS: A total of 2932 met inclusion criteria, and of these 1404 (47.89%) reported FI. In the univariate analysis, patients with FI were more likely to have urgency urinary incontinence (P = 0.01) or mixed urinary incontinence (P < 0.001), report nocturnal enuresis (P < 0.001) or have leakage of urine during sex (P < 0.001). In an adjusted model, FI was associated with concurrent stress (adjusted OR 1.28, P = 0.034), urgency (adjusted OR 1.52, P < 0.001) and mixed incontinence (adjusted OR 1.94, P < 0.001). CONCLUSION: In women with pelvic floor disorders, the presence of FI is associated with a higher prevalence of urinary incontinence. Pelvic floor specialists should assess urinary incontinence symptoms along with the presence and severity of FI to provide comprehensive care and guide appropriate therapy.

Updates in treating fecal incontinence in women.

PURPOSE OF REVIEW: Fecal incontinence is a chronic condition that can significantly affect a woman's quality of life. The pathogenesis of fecal incontinence is multifaceted and management ranges from supportive care, medical therapy to more invasive surgical procedures. This review will discuss the recent advancements in treating fecal incontinence. RECENT FINDINGS: The pelvic floor disorder consortium has created a consensus document with recommendations on pelvic floor symptom measurement tools, patient-reported instruments, and questionnaires that should be used when evaluating fecal incontinence. There is new robust data reinforcing the importance of conservative management prior to proceeding with more invasive treatment. Lastly, several novel therapies that were developed in the past decade now have longer term data on safety and efficacy. SUMMARY: Management of fecal incontinence is challenging, as no one therapy has been proven to be predominately effective. We should continue to first optimize patients with conservative therapy followed by induction of more advanced therapies. There needs to be continued efforts to develop and evaluate effective treatment guidelines and therapies for fecal incontinence.

Optimizing Perioperative Pain Control After Ambulatory Urogynecologic Surgery.

OBJECTIVES: The objective of this study was to determine the impact of a multimodal protocol on opiate use and postoperative pain after ambulatory urogynecologic surgery. METHODS: This was a retrospective cohort study comparing ambulatory urogynecologic surgery patients treated under a standard perioperative pain protocol with those treated under a multimodal perioperative pain protocol. The multimodal protocol consisted of preoperative gabapentin and acetaminophen and postoperative scheduled doses of acetaminophen and nonsteroidal anti-inflammatory drugs. Pain scores were obtained from nursing records and assessed on the Numeric Rating Scale 11 per hospital protocol. All opioid dosages were converted into morphine milligram equivalents using standardized conversion tables. RESULTS: We treated 109 patients under the standard protocol and 112 under the multimodal protocol. Patients had similar baseline characteristics. Overall, a minority of patients (39%) used postoperative opioids; this was similar in the 2 groups (P=0.45). The 2 groups also were similar with regard to the total postoperative morphine milligram equivalents (P=0.35). Postoperatively, patients treated under the standard protocol had higher mean pain scores (2.2 vs 1.4, P=0.002). Patients treated under the standard protocol were also significantly more likely to report postoperative pain (69%) than those treated under the multimodal protocol (52%; P=0.01), and the multimodal protocol was associated with a 25% lower risk of postoperative pain (risk ratio, 0.75; 95% confidence interval, 0.60-0.94) than the standard protocol. CONCLUSIONS: Patients infrequently use opiates after ambulatory urogynecologic surgery. The use of a multimodal pain protocol was associated with lower pain scores, and patients in a multimodal pain protocol were more likely to report no pain.

Accuracy of Bladder Scanner for the Assessment of Postvoid Residual Volumes in Women With Pelvic Organ Prolapse.

OBJECTIVES: The aim of the study was to evaluate the accuracy of the bladder scanner in assessing postvoid residual (PVR) volumes in patients with pelvic organ prolapse (POP). METHODS: We performed a prospective parallel cohort study evaluating the accuracy of the BVI 3000 bladder scanner in patients with POP. Patients with POP to the hymen were offered inclusion. Primary outcome was the absolute difference between bladder scanner and catheterization PVR. We also investigated the effect of prolapse stage on bladder scanner accuracy. A prevoid bladder volume was obtained by bladder scan. Subjects voided volume was then collected. A PVR was obtained by bladder scan, followed by a PVR by catheterization. Descriptive statistics, Wilcoxon signed-rank test, linear regression analysis, and sensitivity/specificity analysis were performed. RESULTS: We enrolled 87 subjects. There was a statistically significant difference between catheter and bladder scan PVR, with an absolute median difference of 20 mL (SD = 37.7), P < 0.001. Linear regression analysis showed a difference between mild and advanced prolapse groups. The regression coefficients of the mild prolapse group and advanced prolapse were 0.91 (confidence interval = 0.75-1.06) and 0.66 (confidence interval = 0.54-0. 78), P = 0.015, respectively, indicating a deterioration of accuracy of the bladder scanner for advanced prolapse. The sensitivity of the bladder scanner identifying catheterized PVR volumes less than 100 mL was 93.7%. For catheter PVRs greater than 100 mL, the specificity of the bladder scanner was 72.7%. CONCLUSIONS: Bladder scanner PVRs are less accurate in advanced prolapse, and PVRs of greater than 100 mL should be confirmed by catheterization.

Vascular anatomical relationships of the retropubic space and the sacrospinous ligament, using three-dimensional imaging.

INTRODUCTION AND HYPOTHESIS: Pelvic anatomy is complex and intimate knowledge of variabilities in anatomical relationships is critical for surgeons to safely perform surgical procedures. Three-dimensional Imaging provides the opportunity to analyze undisturbed anatomical relationships. The authors hypothesized that three-dimensional models created from pelvic computed tomography angiograms could be used to obtain vascular anatomical measurements, and that the measurements obtained from three-dimensional models would be similar to those from cadaver studies. METHODS: We included all pelvic computed tomography angiograms that were acquired in female patients older than 18 years at our institution within the previous 5 years. Three-dimensional models were created using the Invivo5 software based on the Digital Imaging and Communications in Medicine files. Structures of interest were virtually dissected and measured replicating previous cadaver studies. Statistical analysis of demographics and measurements was performed. RESULTS: The final analysis included 87 studies. The average age of the subjects was 66.9 years and their average BMI was 26.1 kg/m2. Of the 87 subjects, 12.6% had a history of hysterectomy, 2.3% a history of a continence procedure, and 1.1% a history of a prolapse procedure. The range of distance between the ischial spine and the pudendal artery was 3-17 mm. The closest vessels to the lower edge of the symphysis pubis were the obturator vessels. The aberrant corona mortis vessel was present in 27.9% of the subjects. Prior hysterectomy was associated with changes in the measurements of the obturator arteries with minimal changes in other measurements. CONCLUSIONS: Our results indicate that this technology provides similar measurements to those found in previous unembalmed cadaver studies. This technology offers a great opportunity to study anatomical relationships in a native undisturbed state.