Current state of bladder diary: a survey and review of the literature.

INTRODUCTION AND HYPOTHESIS: The objectives of this study are (1) to assess practice patterns among urogynecology/female pelvic medicine and reconstructive surgery (FPMRS) providers regarding the use of bladder diaries (BD) and (2) to review the literature regarding BD. METHODS: For the first objective, a survey was emailed to United States-based urogynecology providers in 2019 querying frequency of use of bladder diaries (FBD), indications, problems, patient education methods, and perception of utility. Chi-square tests and multiple logistic regression were performed. For the second objective, we reviewed literature published in English by searching the terms "voiding," "bladder," or "incontinence," in combination with "diary," "log," or "questionnaire." RESULTS: A total of 371 of 851 (43.5%) contacted providers responded. Nearly 80% were attending physicians, 75.5% of whom completed the FPMRS fellowship; 20.8% of all respondents and nearly 25% of fellowship-trained attendings reported FBD <20% in the last year. FPMRS providers were more likely to report FBD >80%. A total of 97.5% of respondents cited difficulty in using BD. Most (71.6%) taught patients to use BD themselves or shared responsibility with a nonphysician staff member (53.4%). BD is a validated and valuable instrument; however, there are obstacles to its use. Despite recent innovations including electronic and automated BD, there is a paucity of data regarding the provider-viewed challenges in implementing BD. CONCLUSIONS: The literature supports the use of BD; however, many survey respondents, including fellowship-trained attendings, never or rarely use BD. Most respondents reported difficulty in using BD. More research is needed to improve the ease, accuracy, and widespread adaptation of BD use in clinical practice.

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.

Circumferential urethral diverticulum: a surgical conundrum.

INTRODUCTION AND HYPOTHESIS: Excision of a circumferential diverticulum may be challenging as its extension into the dorsal aspect of the urethra makes access complicated. METHODS: A 69-year-old woman with a history of Stage 3C ovarian cancer on chemotherapy presented with a 3-week history of severe dysuria and suprapubic pain. T2-weighted pelvic magnetic resonance imaging (MRI) showed a circumferential diverticulum extending over the dorsal midurethra without evidence of urethral communication. As conservative measures including bladder instillations failed, she underwent surgical excision of this multilocular circumferential diverticulum. The diverticulum was identified and excised in segments. To achieve optimal excision, we incised around and dorsal to the urethral meatus into the retropubic area. Finally, a communicating tract from the ventral loculation of the diverticulum to the urethra was identified. The communication was obliterated, and the urethra was repaired in two layers and reinforced with a fibromuscular flap. The fluid tight seal was confirmed by retrograde filling of the bladder and cystourethroscopy. RESULTS: The patient was symptom free at 6-week and 6-month visits. CONCLUSION: This video highlights the steps required to successfully excise a complex circumferential diverticulum that extends over the dorsal midurethra and has a communication with the urethral lumen.

Transdermal light neuromodulation: Optogenetics in the murine urinary tract.

BACKGROUND: Optogenetics is a biologic technique that uses light to control living neurons, which have been genetically modified to express light-sensitive ion-channels. OBJECTIVES: Using an adenovirus to modify the sciatic nerves of mice, we aim to demonstrate peripheral neuromodulation of bladder pain using transdermal light. STUDY DESIGN: This pilot study is divided into: A) Confirmation and Application and B) Behavioral Step. A) Six mice were injected with AAV6-hSyn-ChR2(H134R)-eYFP virus into their sciatic nerves. This encoded an excitatory opsin, enabling light-inducible stimulation. At 4-6 weeks after injection, we induced foot pain responses with an activating blue 475 nm wavelength of light. B) Two optogenetically primed mice and two control mice underwent anesthesia and capsaicin was instilled into their bladders via catheter. The catheters were removed and the mice awoke in a chamber that exposed them to either blue 475 nm light or no light. Groin licking was scored in a binary fashion by two blinded observers. RESULTS: A) All six mice exhibited pain response to 475 nm blue light either by licking of foot or avoidance of light. B) The optogenetically primed mice had a 48% reduction in bladder pain behavior when exposed to blue 475 nm light whereas the control mice had a 18% reduction. CONCLUSION: To our knowledge this is the first demonstration of the application of optogenetics to modulate sensation in the lower urinary tract. It suggests that the process of priming peripheral nerves for optogenetic modulation is possible and can be used to study bladder pain response in mice.

Effect of Educational Video on Patient Adherence and Completeness of Voiding Diaries: A Randomized Trial.

IMPORTANCE: Voiding diaries are clinically useful tools for elucidating the etiology of lower urinary tract symptoms. The utility of voiding diaries is challenged by low return rate and incomplete or inaccurate data entry. OBJECTIVE: The objective was to determine the effect of the use of an educational video on patient adherence, completeness of intake and voiding diaries, and patient satisfaction. STUDY DESIGN: In this trial, patients who were asked to complete an intake and voiding diary in a urogynecology clinic were randomized to receive standard education or enhanced education with an instructional video on how to complete the diary. Patients returned the diaries at their follow-up visits in the clinic. The primary outcome was the return rate of the diaries. Upon follow-up, patients filled out a survey reporting their satisfaction with instructions received. Diaries were graded by 3 blinded experts. RESULTS: Eighty-five patients were enrolled, 42 in the standardized instructions arm and 43 in the video arm. A total of 26 patients (30.6%) filled out and returned an intake and voiding diary. Between groups, there was no difference in the rate of return of the diaries ( P = 0.59) or in completeness of the returned voiding diaries ( P = 0.60). The educational video did not change satisfaction between the groups; patients reported identical satisfaction between groups. CONCLUSIONS: The addition of an instructional video on how to complete an intake and voiding diary did not increase patients' rate of return, completeness of diaries, or satisfaction with instructions provided to complete the diary.

Rethinking Second-Line Therapy for Overactive Bladder to Improve Patient Access to Treatment Options.

Idiopathic overactive bladder (OAB) is a chronic condition that negatively affects quality of life, and oral medications are an important component of the OAB treatment algorithm. Recent literature has shown that anticholinergics, the most commonly prescribed oral medication for the treatment of OAB, are associated with cognitive side effects including dementia. ß3-adrenoceptor agonists, the only alternative oral treatment for OAB, are similar in efficacy to anticholinergics with a more favorable side effect profile without the same cognitive effects. However, there are marked cost variations and barriers to access for OAB medications, resulting in expensive copays and medication trial requirements that ultimately limit access to ß3-adrenoceptor agonists and more advanced procedural therapies. This contributes to and perpetuates health care inequality by burdening the patients with the least resources with a greater risk of dementia. When prescribing these medications, health care professionals are caught in a delicate balancing act between cost and patient safety. Through multilevel collaboration, we can help disrupt health care inequalities and provide better care for patients with OAB.

In Search of Mobile Applications for Urogynecology Providers.

INTRODUCTION: Thousands of medical applications (apps) are available for mobile devices. Finding accurate, health care provider-centered apps may be time consuming and frustrating for urogynecologists. The objective of this study was to identify and evaluate urogynecology (urogyn) apps using a modified APPLICATIONS scoring system. MATERIALS AND METHODS: Urogyn apps were identified from the Apple iTunes and Google Play Stores using the following 10 MeSH terms: urogynecology, incontinence, prolapse, urinary tract infection, pelvic surgery, fecal incontinence, defecation disorder, voiding disorder, urethral diverticulum, and fistula. Patient-centered and inaccurate apps were excluded. The remaining apps were evaluated with a modified APPLICATIONS scoring system, which included both objective and subjective criteria to determine each app's ability to aid in clinical decision making and to provide informational data. Objective rating components were price, paid subscription, literature referenced, in-app purchases, Internet connectivity, advertisements, text search field, interplatform compatibility and incorporated images, figures, videos, and special features. Subjective rating components were ease of navigation and presentation. RESULTS: Our search yielded 133 and 235 apps in the Apple iTunes and Google Play Stores, respectively. Only 8 apps (4 of which were in both stores) were determined to be accurate and useful; these were evaluated using the modified APPLICATIONS scoring system. The top-rated app was Practical Urology. CONCLUSION: Few accurate clinical decision-making and informational apps exist for urogynecologists. Apps varied by comprehensiveness and quality. This study highlights the importance of systematically reviewing and rating medical apps. It also emphasizes the need for developing accurate apps for urogynecologists that improve health care provider performance and patient outcomes.

Squamous cell carcinoma of the vulva arising in the setting of chronic hidradenitis suppurativa: A case report.

•Highlights the sheer mass of tumor encountered with hidradenitis suppurativa.•Reviews the complexity of wound healing with hidradenitis suppurativa.•Overview of multi-team approach to a vulvar cancer.