Lessons Learned From the Development of an ABOG Subspecialty.

As I reflect on my 30 years in academic medicine, my professional journey is uniquely intertwined with the growth and development of the field of urogynecology and the ultimate subspecialty recognition by the American Board of Obstetrics and Gynecology (ABOG), the Association of American Medical Colleges (AAMC), and the American Board of Medical Specialties (ABMS). In this article, I will retrace that journey from personal memories and notes, conversations with the leaders in the room, and documents and minutes generously provided by ABOG and the American Urogynecologic Society (AUGS). There were many leadership lessons learned, and I hope sharing them will enable the readers to do this type of transformational work in their own institution and broadly as advocates of women's health.

When Abortion Is Illegal-Profound Effects on Resident Health and Well-being.

This Viewpoint discusses the need for the leadership of hospital systems and graduate medical education programs to address the effects of abortion restrictions on medical residents' health, well-being, and training.

A Randomized Pilot Study to Compare the Effectiveness of a Low FODMAP Diet vs Psyllium in Patients With Fecal Incontinence and Loose Stools.

INTRODUCTION: The aim of the study was to compare the effectiveness of a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet (LFD) vs psyllium on the frequency and severity of fecal incontinence (FI) episodes in patients with loose stools. METHODS: This was a single-center, randomized pilot trial of adult patients with FI (Rome III) with at least 1 weekly FI episode associated with loose stool. Eligible patients were randomized to 4 weeks of either a dietitian-led LFD or 6 g/d psyllium treatment. RESULTS: Forty-three subjects were randomized from October 2014 to May 2019. Thirty-seven patients completed the study (19 LFD and 18 psyllium). There was no statistically significant difference in the proportion of treatment responders (>50% reduction in FI episodes compared with baseline) for treatment weeks 1-4 (LFD 38.9%, psyllium 50%, P = .33). Compared with baseline, mean fecal incontinence severity index score significantly improved with LFD (39.4 vs 32.6, P = .02) but not with psyllium (35.4 vs 32.1, P = .29). Compared with baseline values, the LFD group reported improvements in fecal incontinence quality of life coping/behavior, depression/self-perception, and embarrassment subscales. The psyllium group reported improvement in incontinence quality of life coping/behavior. DISCUSSION: In this pilot study, there was no difference in the proportion of patients who reported a 50% reduction of FI episodes with the LFD or psyllium. Subjects in the psyllium group reported a greater reduction in overall FI episodes, whereas the LFD group reported consistent improvements in FI severity and quality of life. Further work to understand these apparently discrepant results are warranted but the LFD and psyllium seem to provide viable treatment options for patients with FI and loose stools.

Repair of episiotomy and obstetrical perineal lacerations (first-fourth).

Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal trauma is associated with both short- and long-term morbidity, including persistent pain, dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new mother's ability to care for her newborn. The morbidity experienced after perineal injury is dependent on the type of laceration incurred, the technique and materials used for repair, and the skill and knowledge of the birth attendant. After all vaginal deliveries, a systematic evaluation including visual inspection and vaginal, perineal, and rectal exams is recommended to accurately diagnose perineal lacerations. Optimal management of perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique and materials used for repair, providers experienced in perineal laceration repair, and close follow-up. In this article, we review the prevalence, classification, diagnosis, and evidence supporting different closure methods for first- through fourth-degree perineal lacerations and episiotomies. Recommended surgical techniques and materials for different perineal laceration repairs are provided. Finally, best practices for perioperative and postoperative care after advanced perineal trauma are reviewed.

Antibiotic use during repair of obstetrical anal sphincter injury: a quality improvement initiative.

OBJECTIVE: To evaluate the effects of a quality improvement initiative regarding the administration of antibiotics at the time of obstetric anal sphincter injury (OASIS) repair. METHODS: At University of Michigan-a tertiary care center in Ann Arbor, MI, USA, we implemented a quality improvement intervention aimed at administering a single dose of broad-spectrum antibiotics at the time of OASIS repair. Best practice recommendations and reminders were presented to the department. Cefazolin plus metronidazole or clindamycin plus gentamycin were the recommended antibiotics. The effects of this intervention were assessed based on a chart review of deliveries between January 4, 2014 and February 13, 2019, which included patient data both pre-initiative and post-initiative to compare the prevalence of antibiotic use at the time of OASIS repair. RESULTS: Recommended antibiotic use increased from 0.3% (1/372) pre-initiative to 75.7% (106/140) post-initiative (P < 0.001), and any antibiotic use increased from 6.5% (24/372) to 82.9% (116/140, P < 0.001). The proportion of cases complicated by wound infection/breakdown decreased by 55% after the quality improvement intervention (3.2% pre-intervention vs 1.4% post-intervention, P = 0.22). CONCLUSION: Following a departmental quality improvement intervention aimed at increasing antibiotic administration at the time of OASIS repair, antibiotic use increased 13-fold. Although underpowered to detect a significant difference in wound complications, our study showed a clinically meaningful decrease in wound infection/breakdown with antibiotic administration.

Promotion of gender equity in obstetrics and gynecology: principles and practices for academic leaders.

The advancement of women leaders in obstetrics and gynecology does not reflect the changes in the physician workforce seen over the last 50 years. A core value of our culture in obstetrics and gynecology must be gender equity. Departmental, institutional, and professional society efforts should explicitly prioritize and demonstrate a commitment to gender equity with tangible actions. This commentary from the American Gynecological and Obstetrical Society synthesizes available information about women holding academic leadership roles within obstetrics and gynecology. We propose specific principles and leadership practices to promote gender equity.

The Fundamentals of Vaginal Surgery pilot study: developing, validating, and setting proficiency scores for a vaginal surgical skills simulation system.

BACKGROUND: Surgical training in the simulation lab can develop basic skills that translate to the operating room. Standardized, basic skills programs that are supported by validated assessment measures exist for open, laparoscopic, and endoscopic surgery; however, there is yet to be a nationally recognized and widely implemented basic skills program specifically for vaginal surgery. OBJECTIVE: Develop a vaginal surgical simulation system; evaluate robust validity evidence for the simulation system and its related performance measures; and establish a proficiency score that discriminates between novice and experienced vaginal surgeon performance. STUDY DESIGN: In this 3-phased study, we developed the Fundamentals of Vaginal Surgery simulation system consisting of (1) the Fundamentals of Vaginal Surgery Trainer, a task trainer; (2) a validated regimen of tasks to be performed on the trainer; and (3) performance measures to determine proficiency. In Phase I, we developed the task trainer and selected surgical tasks by performing a needs assessment and hierarchical task analyses, with review and consensus from an expert panel. In Phase II, we conducted a national survey of vaginal surgeons to collect validity evidence regarding test content, response process, and internal structure relevant to the simulation system. In Phase III, we compared performance of novice (first and second year residents) and experienced (third and fourth year residents, fellows, and faculty) surgeons on the simulation system to evaluate relevant relationships to other variables and consequences. Performance measures were analyzed to set a proficiency score that would discriminate between novice and expert (faculty) vaginal surgical performance. RESULTS: A novel task trainer and 6 basic vaginal surgical skills were developed in Phase I. In Phase II, the survey responses of 48 participants (27 faculty surgeons, 6 fellows, and 14 residents) were evaluated on the dimensions of test content, response process, and internal structure. To support evidence of test content, the participants deemed the task trainer and surgical tasks representative of intended surgical field and supportive of typical surgical actions (mean scores, 3.8-4.4/5). For response process, rater-data analysis revealed high rating variability regarding prototype color. This early evidence confirmed the value of a white prototype. For internal structure, there was high agreement among rater groups (obstetricians and gynecologists generalists vs Female Pelvic Medicine and Reconstructive Surgery specialists: interclass correlation coefficient range, 0.59-0.91; learners vs faculty interclass correlation coefficient range, 0.64-1.0). There were no differences in ratings across institution type, surgeon volume, expertise (P>.14). In Phase III, we analyzed performance from 23 participants (15 [65%] obstetricians and gynecologists residents, 3 [13%] fellows, and 5 [22%] Female Pelvic Medicine and Reconstructive Surgery faculty). Experienced surgeons scored significantly higher than novice surgeons (median, 467.5; interquartile range, [402.5-542.5] vs median, 261.5; interquartile range, [211.5-351.0]; P<.001). Based on these data, setting a proficiency score threshold at 400 results in 0% (0/6) novices attaining the score, with 100% (5/5) experts exceeding it. CONCLUSION: We present validity evidence relevant to all 5 sources which supports the use of this novel simulation system for basic vaginal surgical skills. To complement the system, a proficiency score of 400 was established to discriminate between novices and experts.

Use of Electronic Medical Records to Estimate Changes in Pregnancy and Birth Rates During the COVID-19 Pandemic.

Importance: The influence of the COVID-19 pandemic on fertility rates has been suggested in the lay press and anticipated based on documented decreases in fertility and pregnancy rates during previous major societal and economic shifts. Anticipatory planning for birth rates is important for health care systems and government agencies to accurately estimate size of economy and model working and/or aging populations. Objective: To use projection modeling based on electronic health care records in a large US university medical center to estimate changes in pregnancy and birth rates prior to and after the COVID-19 pandemic societal lockdowns. Design, Setting, and Participants: This cohort study included all pregnancy episodes within a single US academic health care system retrospectively from 2017 and modeled prospectively to 2021. Data were analyzed September 2021. Exposures: Pre- and post-COVID-19 pandemic societal shutdown measures. Main Outcomes and Measures: The primary outcome was number of new pregnancy episodes initiated within the health care system and use of those episodes to project birth volumes. Interrupted time series analysis was used to assess the degree to which COVID-19 societal changes may have factored into pregnancy episode volume. Potential reasons for the changes in volumes were compared with historical pregnancy volumes, including delays in starting prenatal care, interruptions in reproductive endocrinology and infertility services, and preterm birth rates. Results: This cohort study documented a steadily increasing number of pregnancy episodes over the study period, from 4100 pregnancies in 2017 to 4620 in 2020 (28 284 total pregnancies; median maternal [interquartile range] age, 30 [27-34] years; 18 728 [66.2%] White women, 3794 [13.4%] Black women; 2177 [7.7%] Asian women). A 14% reduction in pregnancy episode initiation was observed after the societal shutdown of the COVID-19 pandemic (risk ratio, 0.86; 95% CI, 0.79-0.92; P < .001). This decrease appeared to be due to a decrease in conceptions that followed the March 15 mandated COVID-19 pandemic societal shutdown. Prospective modeling of pregnancies currently suggests that a birth volume surge can be anticipated in summer 2021. Conclusions and Relevance: This cohort study using electronic medical record surveillance found an initial decline in births associated with the COVID-19 pandemic societal changes and an anticipated increase in birth volume. Future studies can further explore how pregnancy episode volume changes can be monitored and birth rates projected in real-time during major societal events.

Establishing a reproductive biorepository for basic and translational research: experience developing the reproductive subjects registry and sample repository.

PURPOSE: To report experience designing and establishing a reproductive registry and sample biorepository and to describe initial subject characteristics and biospecimens. METHODS: Beginning in December 2017, patients presenting for reproductive care at the University of Michigan were approached for study enrollment. Following consent, subjects completed detailed reproductive and health questionnaires. A variety of reproductive specimens and tissues were collected and processed for multiple downstream applications. RESULTS: Subject enrollment began in December of 2017. There are currently 1798 subjects enrolled. Female participants report a variety of reproductive disorders. Available samples include semen, sperm, follicular fluid, granulosa cells, immature oocytes, ovarian and uterine tissue, and blood samples. CONCLUSION: We report the successful establishment of a reproductive registry and sample biorepository. Furthermore, we describe methods for collection and storage of a variety of reproductive tissue processed for multiple downstream translational applications.

Structural failure sites in posterior vaginal wall prolapse: stress 3D MRI-based analysis.

INTRODUCTION AND HYPOTHESIS: The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements. METHODS: We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size. RESULTS: We identified three primary factors with large effect sizes of 2 or greater: two attachment factors-posterior paravaginal descent and perineal height; and one hiatal factor-genital hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60-76% of cases; and highly correlated with one another (r = 0.72-0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani hiatus had smaller effect sizes and were less likely to fall outside the norm (20-24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size. CONCLUSIONS: Lower perineal and lateral posterior vaginal location and enlarged genital hiatus size were strong predictors of rectocele occurrence and size and correlated highly.

Musculoskeletal findings on MRI among postpartum women with persistent pelvic pain.

INTRODUCTION AND HYPOTHESIS: Persistent postpartum pelvic pain affects one in six women, and its source is often unexplained in the absence of obvious clinical findings. Musculoskeletal injuries during childbirth are common and can be detected using MRI or US; however, pelvic imaging is not standard of care in evaluating women with persistent pain. We hypothesize that clinical symptoms in women with unexplained persistent postpartum pelvic pain will correlate with musculoskeletal abnormalities identified on MRI in > 50% of cases. METHODS: Retrospective cohort study of women with persistent postpartum pelvic pain who underwent a pelvic MRI for this indication. Chart review was performed. MRI findings were classified as major (bone fracture, levator ani avulsion) or minor (edema, inflammation or partial levator ani defect). Descriptive statistics were used to describe the study population. RESULTS: Of the 252 women seen for postpartum pelvic pain, 18 patients met our study criteria. Half of women were primiparous (55.6%, n = 10). Operative delivery occurred in 27.8% (n = 5), 22.2% (n = 4) had anal sphincter lacerations, and 38.9% (n = 7) had prolonged second stage of labor. Median time from delivery to MRI was 4.5 ± 5.13 (IQR) months. Musculoskeletal abnormalities were found in 94.4% (n = 17) of cases; 38.8% (n = 7) were major and 55.6% (n = 10) were minor abnormalities. All findings correlated with presenting symptoms. CONCLUSION: Of women with persistent postpartum pelvic pain, 94.4% had musculoskeletal abnormalities supporting their clinical symptoms. Pelvic floor imaging should be considered in women with unexplained persistent postpartum pelvic pain to accurately manage the source of their pain.

Galvanizing for the future: a bottom-up departmental approach to diversity, equity, and inclusion.

As an academic department, we sought to identify effective strategies to engage our faculty and staff in diversity, equity, and inclusion initiatives and programs to build an inclusive department that would address our needs and those of our community and partners. Over a 4-year period, our faculty and staff have participated in town hall meetings, focus group discussions, surveys, and community-building activities to foster stakeholder engagement that will build a leading academic department for the future. We noted that our faculty and staff were committed to building diversity, equity, and inclusion, and our mission and vision were reflective of this. However, communication and transparency may be improved to help support a more inclusive department for all. In the future, we hope to continue with the integration of diversity, equity, and inclusion into our department's business processes to achieve meaningful, sustained change and impact through continued focus on recruitment, selection, retention, development, and wellness of faculty and staff-in addition to the continued recruitment of faculty and staff from underrepresented minority groups. Our findings should serve as a call to action for other academic obstetrics and gynecology departments to improve the health and well-being of the individuals we serve.

Indications for surgical intervention in a postpartum pelvic floor specialty clinic.

OBJECTIVE: To determine the prevalence and type of surgical procedures undergone by postpartum women seen in a specialty postpartum pelvic floor clinic over 11 years. METHODS: This study was a retrospective chart review of patients requiring surgical intervention within a 1-year period after their initial visit to the Michigan Healthy Healing After Delivery (MHHAD) clinic at the University of Michigan from July 2007 through January 2019. Chart review was performed to abstract demographics, obstetric data, indication for postpartum clinic visit, primary and secondary indications for surgery, and procedures performed. Descriptive analyses were used to describe the cohort. RESULTS: Of the 1138 new MHHAD patients seen during the study period, 9.1% (n = 103) underwent surgical management. Anal incontinence was the primary or secondary indication for surgery in 51.5% (n = 53) of women. The most common surgical interventions were anal sphincteroplasty (37.9%, n = 39), perineal laceration revision (33.0%, n = 34), and rectovaginal fistula repair/fistulotomy (19.4%, n = 20). Of the women who had a sphincteroplasty, 61.5% (24/39) had a prior fourth-degree perineal laceration. CONCLUSIONS: Anal sphincteroplasty was the most common surgical intervention undergone by women seen in a postpartum pelvic floor specialty clinic. Postpartum pelvic floor clinics, such as the Michigan Healthy Healing After Delivery Clinic, provide the expertise and specialized resources required to ensure the early diagnosis and treatment of pelvic floor conditions related to childbirth thus improving women's quality of life and preventing potential life-long sequelae.

Universal access to contraception: women, families, and communities benefit.

Universal access to contraception benefits society: unintended pregnancies, maternal mortality, preterm birth, abortions, and obesity would be reduced by increasing access to affordable contraception. Women should be able to choose when and whether to use contraception, choose which method to use, and have ready access to their chosen method. State and national government should support unrestricted access to all contraceptives. As obstetrician-gynecologists, we have a critical mandate, based on principle and mission, to step up with leadership on this vital medical and public health issue, to improve the lives of women, their families, and society. The field of Obstetrics and Gynecology must provide the leadership for moving forward. The American Gynecological and Obstetrical Society (AGOS), representing academic and public policy leaders from across all disciplines of Obstetrics and Gynecology, is well positioned to serve as a unifying organization, focused on developing a strong unified advocacy voice to fight for accessible contraception for all in the United States.

Deliberate Practice: Applying the Expert Performance Approach to Gynecologic Surgical Training.

Surgical training is shifting from the historical Halstedian apprenticeship model to outcomes-based methods. Surgical residents can reach a higher level of performance when utilizing deliberate practice and the expert performance approach. This article discusses methods for implementing deliberate practice and the expert performance approach into gynecologic surgical training programs.

Defining "normal recovery" of pelvic floor function and appearance in a high-risk vaginal delivery cohort.

INTRODUCTION AND HYPOTHESIS: Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and patterns of normal recovery in women sustaining high-risk labor events. METHODS: We completed a prospective cohort study comparing women undergoing vaginal births involving risk factors for pelvic floor injury with women undergoing cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size. RESULTS: Eighty-two women post-vaginal delivery and 30 women post-cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, 6 weeks (p < 0.001), and 6 months (p = 0.001). POP-Q points did not change between any time point (all p > 0.05). Measures of strength improved between each time point (all p < 0.002). When compared with cesarean delivery, women post-vaginal birth had longer genital hiatus and lower anterior and posterior vaginal walls (all p < 0.05). Based on theoretical considerations and effect sizes, those with Bp ≥0 cm, Kegel force ≤1.50 N, and/or an LA tear on imaging were considered to have significant pelvic floor injury. Using this definition, at 6 weeks, 27 (46.4%) women were classified as injured. At 6 months, 13 (29.6%) remained injured. CONCLUSIONS: We propose that pelvic floor muscle strength, posterior vaginal wall support, and imaging consistent with LA tear are potential indicators of abnormal or prolonged recovery in this cohort with high-risk labor events.

Randomized Trial of 3 Techniques of Perineal Skin Closure During Second-Degree Perineal Laceration Repair.

INTRODUCTION: Perineal lacerations during childbirth are common, and suturing the perineal skin during repair has been associated with increased postpartum pain. This study sought to test the hypothesis that no difference in postpartum perineal pain exists between 3 methods of skin closure for second-degree repair: suture, no suture, and surgical glue. METHODS: A single-blind randomized controlled trial of women after vaginal birth who had a second-degree perineal laceration was conducted at a tertiary care teaching hospital from August 2014 to April 2017. Women were randomized to perineal skin closure with suture, no suture, or surgical glue using a 1:1:1 allocation. Pain was assessed using the short-form McGill Pain Questionnaire, a 100-mm visual analog scale (VAS), and Present Pain Index (PPI) at one day, 2 weeks, 6 weeks, and 3 months postpartum. Wound healing was assessed at 6 weeks using the Redness, Edema, Ecchymosis, Drainage, Approximation (REEDA) scale. Pain scores were compared across groups using a chi-square test, Mann-Whitney U test, or analysis of variance where appropriate. RESULTS: A total of 35 women were randomized: 14 received suture, 11 had no suture, and 10 received surgical glue for perineal skin repair. Demographic characteristics were similar between groups. At 2 weeks postpartum, women with suture had higher median pain scores on the short-form McGill Pain Questionnaire (15.0 suture vs 2.0 glue vs 2.0 no suture, P = .03) and VAS (50.0 suture vs 3.0 glue vs 7.0 no suture, P = .02). Significant differences in pain were not seen on the PPI. At 3 months, women in the suture group had higher median pain scores on the short-form McGill Pain Questionnaire compared with surgical glue (1.0 vs 0, P = .04). Wound healing was similar across groups (REEDA score: 0 suture vs 1.0 no suture, vs 0 surgical glue, P = .24). DISCUSSION: Compared with no suture and surgical glue, suturing the perineal skin was associated with the highest postpartum pain scores.

Comparison of measurement systems for posterior vaginal wall prolapse on magnetic resonance imaging.

INTRODUCTION AND HYPOTHESIS: A wide variety of reference lines and landmarks have been used in imaging studies to diagnose and quantify posterior vaginal wall prolapse without consensus. We sought to determine which is the best system to (1) identify posterior vaginal wall prolapse and its appropriate cutoff values and (2) assess the prolapse size. METHODS: This was a secondary analysis of sagittal maximal Valsalva dynamic MRI scans from 52 posterior-predominant prolapse cases and 60 comparable controls from ongoing research. All eight existing measurement lines and a new parameter, the exposed vaginal length, were measured. Expert opinions were used to score the prolapse sizes. Simple linear regressions, effect sizes, area under the curve, and classification and regression tree analyses were used to compare these reference systems and determine cutoff values. Linear and ordinal logistic regressions were used to assess the effectiveness of the prolapse size. RESULTS: Among existing parameters, "the perineal line-internal pubis," a reference line from the inside of the pubic symphysis to the front tip of the perineal body (cutoff value 0.9 cm), had the largest effect size (1.61), showed the highest sensitivity and specificity to discriminate prolapse with area under the curve (0.91), and explained the most variation (68%) in prolapse size scores. The exposed vaginal length (cutoff value 2.9) outperformed all the existing lines, with the largest effect size (2.09), area under the curve (0.95), and R-squared value (0.77). CONCLUSIONS: The exposed vaginal length performs slightly better than the best of the existing systems, for both diagnosing and quantifying posterior prolapse size. Performance characteristics and evidence-based cutoffs might be useful in clinical practice.

Biomarkers Implicated in Lower Urinary Tract Symptoms: Systematic Review and Pathway Analyses.

PURPOSE: Lower urinary tract symptoms are prevalent and burdensome, yet methods to enhance diagnosis and appropriately guide therapies are lacking. We systematically reviewed the literature for human studies of biomarkers associated with lower urinary tract symptoms. MATERIALS AND METHODS: PubMed®, EMBASE® and Web of Science® were searched from inception to February 13, 2018. Articles were included if they were in English, performed in benign urological populations without neurological disorders or interstitial cystitis/bladder pain syndrome, and assessed a biomarker's association with or ability to predict specific lower urinary tract symptoms or urological conditions. Bioinformatic pathway analyses were conducted to determine whether individual biomarkers associated with symptoms are present in unifying pathways. RESULTS: Of 6,150 citations identified 125 met the inclusion criteria. Most studies (93.6%) assessed biomarkers at 1 time point and were cross-sectional in nature. Few studies adjusted for potentially confounding clinical variables or assessed biomarkers in an individual over time. No individual biomarkers are currently validated as diagnostic tools for lower urinary tract symptoms. Compared to controls, pathway analyses identified multiple immune response pathways that were enriched in overactive bladder syndrome and cell migration/cytoskeleton remodeling pathways that were enriched in female stress incontinence. CONCLUSIONS: Major deficiencies in the existing biomarker literature include poor reproducibility of laboratory data, unclear classification of patients with lower urinary tract symptoms and lack of adjustment for clinical covariates. Despite these limitations we identified multiple putative pathways in which panels of biological markers need further research.