Women Who Avoid or Stop Exercise Due to Lower Urinary Tract Symptoms: Prevalence, Symptom Profile, and Associated Factors.

OBJECTIVE: To determine the prevalence of women who report avoiding exercise or stopping a workout due to lower urinary tract symptoms (LUTS) in a community population, characterize symptoms in these women, and identify clinical and demographic factors associated with exercise cessation due to LUTS. METHODS: A cross-sectional online survey was administered to community-based women. The prevalence of having avoided exercise or stopped a workout due to LUTS was calculated. Clinical and demographic variables along with comprehensive urinary symptoms assessed by the Lower Urinary Tract Research Network-Symptom Index (LURN-SI 29) were compared between women with and without the outcome. Multivariable logistic regression and random forest models were used to identify variables associated with the outcome. RESULTS: Out of 1707 women who completed the survey, 18.9% reported avoiding exercising or stopping a workout due to LUTS. For these women, multiple domains of LUTS were noted, including incontinence, pain, voiding difficulty, urgency, and nocturia. Multivariable logistic regression identified LURN SI-29 score, White race, and prior vaginal delivery as significantly associated with the outcome, while the random forest model identified LURN SI-29 score, age, and body mass index (BMI) as most important. CONCLUSION: In a population-based study, 1 in 5 women reported avoiding exercise or stopping a workout due to LUTS. Their reported LUTS span multiple symptom domains, and factors associated with stopping exercise include symptom severity, older age, higher BMI, White race, and prior vaginal delivery. Addressing LUTS may improve the resumption and continuation of exercise in women.

Urinary Incontinence in Elite Female Athletes.

PURPOSE OF REVIEW: To summarize the current understanding on the epidemiology, pathophysiology, and management strategies of urinary incontinence (UI) in female athletes, highlighting findings specific to nulliparous elite athletes. RECENT FINDINGS: UI occurs in about 20-50% of female athletes of all ages and parity status, around 40% for younger nulliparous athletes, and is more prevalent in high-impact sports. Possible contributing factors to UI in female elite athletes include pelvic floor laxity and bladder neck descent, pelvic floor muscle fatigue, low energy availability, and hypermobility syndrome. In female elite athletes, urinary symptoms negatively affect quality of life, although the effects of symptoms on exercise participation are not well understood. Current management strategies are primarily conservative and centered on behavioral modifications and pelvic floor muscle physiotherapy. UI in female elite athletes appears to be multifactorial. Clarifying how individual factors influence UI in this population will inform athlete counseling, prevention, and treatment strategies.

Role of Hysteropexy in the Management of Pelvic Organ Prolapse.

PURPOSE OF REVIEW: To discuss considerations for hysteropexy for apical pelvic organ prolapse (POP) and summarize available literature comparing various hysteropexy techniques to analogous procedures involving hysterectomy. RECENT FINDINGS: Hysteropexy for apical POP has increased in popularity in recent years, although anatomic factors and gynecologic cancer risk must be taken into account. Native tissue hysteropexy options include the LeFort colpocleisis, sacrospinous hysteropexy, and uterosacral hysteropexy. Although vaginal mesh was banned by the Food and Drug Administration in 2019, abdominal mesh sacrohysteropexy done either open or laparoscopically remains an option in the USA. Overall, short-term prolapse outcomes appear to be comparable between uterus-sparing approaches and hysterectomy, with less blood loss and shorter operating room time observed with the uterine-sparing approaches, although long-term outcome data remains variable and limited. Uterine-sparing apical POP repair may be offered to appropriate patients without certain risk factors, although longer-term data will be required to evaluate durability.

Urologic emergencies before and after COVID-19: a retrospective chart review.

INTRODUCTION During the coronavirus disease 2019 (COVID-19) pandemic, decreased presentations for various emergent conditions have been observed. Our objective was to compare the volume of patients with urologic emergencies presenting to emergency departments (EDs) within a single health system before and after the onset of the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective chart review was performed for 3 EDs within a single health system in the United States to identify all ED consults to urology from January 1, 2019 to May 31, 2020. For emergent consults, covariates were extracted, including demographic information, insurance status, Charlson Comorbidity Index (CCI) score, travel distance from home to the ED, and whether the patient had seen a provider in the hospital system before. Data were compared between COVID-19 months (March-May 2020) and corresponding months in 2019. RESULTS: The study period encompassed 1,179 consults and 373 urologic emergencies. We observed not only a 22% decrease in urologic presentations to the ED compared to corresponding months in 2019, but also a 54% decrease in the proportion of urologic presentations that were truly emergent. For patients with emergent diagnoses, April 2020 saw an increase in Medicare/Medicaid coverage and a decrease in private insurance, May 2020 saw a decreased travel distance from home to the ED, and March and May 2020 saw an increase in patients who had previously seen a health system provider outside of the ED. No changes were seen in demographic characteristics or CCI. CONCLUSIONS: During the early COVID-19 pandemic, urologic emergencies within a single health system decreased by 54% compared to the corresponding months pre-pandemic. Those who do present for care may be influenced by both locality and provider familiarity.

Systematic Review and Meta-Analysis of Cycling and Erectile Dysfunction.

INTRODUCTION: Conflicting evidence exists on the relationship between bicycle riding and erectile dysfunction (ED). A major limitation to several prior studies is the lack of a validated measure of ED. OBJECTIVE: To assess the relationship between cycling and clinically validated ED based on existing literature. METHODS: We searched several major databases from database inception through 2018 using a variety of search terms relating to "cycling" and "erectile dysfunction." Studies were included if they were written in English, reported original data, compared ED between cyclists and non-cycling controls, and used a validated measure of ED, such as the International Index of Erectile Function or the subset Sexual Health Inventory for Men (SHIM). Age, SHIM score, and comorbidities were extracted for all groups. Primary outcomes for each group were mean SHIM score and presence of ED (SHIM ≤ 21). A generalized linear mixed-effects model was used to fit the collected data for meta-analysis. Main outcome measures were unadjusted odds ratios of ED for cyclists and non-cyclists, mean SHIM score difference between cyclists and noncyclists, and both of these measures adjusted for age and comorbidities. RESULTS: After a systematic evaluation of 843 studies, 6 studies met our inclusion criteria, encompassing 3,330 cyclists and 1,524 non-cycling controls. When comparing cyclists to non-cyclists in an unadjusted analysis, there were no significant differences in the odds of having ED or mean SHIM score. However, when controlling for age and comorbidities, cyclists had significantly higher odds of having ED (odds ratio: 2.00; 95% confidence interval: 1.57, 2.55). CONCLUSIONS: Limited evidence supports a positive correlation between cycling and ED when adjusting for age and several comorbidities. Heterogeneity among studies suggests that further investigation into certain populations of cyclists that may be more vulnerable to ED may be beneficial. Gan ZS, Ehlers ME, Lin FC, et al. Systematic Review and Meta-Analysis of Cycling and Erectile Dysfunction. Sex Med 2021;9:304-311.

Outpatient Panniculectomy and Skin Graft for Adult Buried Penis.

OBJECTIVE: To demonstrate a technique for performing panniculectomy and skin graft for a patient with adult buried penis, highlighting a number of technical modifications that allow for the procedure to be performed as an outpatient. METHODS: Pannus is mobilized with a modified trapezoid incision, leaving superior attachments intact for skin graft harvest. Diseased penile skin is removed, defect is measured, and an appropriately sized split thickness skin graft is harvested from the pannus in 2-inch sections at a depth of 18/1000. The unmeshed graft is applied to the penis and covered with a bolster that is secured to the penis for 5-7 days. Patients are discharged postoperative day 0 or 1. RESULTS: From 2017 to 2019, 19 patients underwent outpatient adult-buried penis repair. Median follow-up was 11.5 months. Median age was 70 years, median body mass index was 43.4, 9 (47%) patients had pathologically confirmed lichen sclerosus. Graft take was ≥95% in all patients. Complications included cellulitis (5, 26%) and minor dehiscence (3, 16%). No patients experienced deep vein thrombosis. CONCLUSION: Outpatient panniculectomy and skin graft is an effective treatment option for patients with adult buried penis.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload in Urology.

OBJECTIVE: To define the relationship between urology relative value units (RVUs) and measures of surgical complexity and physician workload. Secondary objectives include: (1) identifying procedures with outlying RVU values for their measures of surgical complexity and workload; and (2) calculating projected RVU values for these procedures. METHODS: We obtained surgical case data for 71 urology current procedural terminology (CPT) codes from the 2017 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Pearson correlation coefficients were calculated to measure the association between mean total work RVU and operative time, length of hospital stay, serious adverse events, readmissions, and mortality. We developed a multivariable regression model to predict mean total work RVU from these measures. Studentized residuals were used to identify outlying CPT codes for both bivariable and multivariable regression models, and empirically derived RVU values from complexity and work effort metrics were estimated. RESULTS: We analyzed 71 urology CPT codes encompassing 55,068 cases. RVUs correlated well with median length of hospital stay (R = 0.81), median operative time (R = 0.92), serious adverse events (R = 0.83), and readmissions (R = 0.74). RVUs were poorly correlated with mortality (R = 0.34). Outlying procedures identified using the multivariable model were retroperitoneal lymph node dissection (projected +21.09 RVUs), laparoscopic ureteroneocystotomy (projected -12.34 RVUs), and cystectomy with bilateral pelvic lymphadenectomy (projected +9.37 RVUs). CONCLUSION: Urology work RVUs correlate more with operative time than other measures of surgical complexity and physician workload. There exist several significant outlying procedures for various work measures. Incorporating objective work data may improve RVU assignments in the future.

Gender Preferences of Patients When Selecting Orthopaedic Providers.

Background: Orthopaedic surgery is a male-dominated specialty associated with many stereotypes, despite the increased representation of females compared to 30 years ago. Numerous studies have examined medical student and resident perceptions regarding females in orthopaedic surgery to explain the disparity, but there are few studies that analyze whether patients have a gender preference in their orthopaedic surgeon. Our study sought to determine whether patients have a preference for the gender of their orthopaedic surgeon, and what traits in orthopaedic surgeons are important to their patients. Methods: A total of 191 new patients seen in the emergency department and orthopaedic urgent care clinic were administered a 22-question survey regarding preferences in their orthopaedic provider. Patients were asked questions regarding preferred gender of their provider, as well as preferences in characteristics exhibited. Results: The majority of patients did not have a preference for the gender of their orthopaedist (83.9%); however, 14.5% of patients preferred a female surgeon and 1.6% of patients preferred a male surgeon. Female patients had a preference for the same gender compared to male patients and preferred females (p=0.04). Of the patients that had a preference, 90% preferred a female provider. There were trends towards preference for gender that varied depending on subspecialty. There was a statistically insignificant trend towards preference for male providers in total joint replacements and spine surgery, and conversely a preference for female providers in hand surgery and pediatric orthopaedics. 48.6% of patients cited the single most important trait to be board certification, followed by years in practice (27.1%), then reputation or prestige (16.7%). Over one-third of patients found physical appearance, gender, racial background and age to be important traits. Conclusions: The majority of patients did not have a preference for the gender of their orthopaedic surgeon. 16.1% of patients had a preference, and the majority of these patients preferred female surgeons. Preferences for a specific gender were seen that varied based on the subspecialty. Efforts at increasing gender diversity in orthopaedics should continue to be a major goal.Level of Evidence: III.

Blood Biomarkers for Traumatic Brain Injury: A Quantitative Assessment of Diagnostic and Prognostic Accuracy.

Blood biomarkers have been explored for their potential to provide objective measures in the assessment of traumatic brain injury (TBI). However, it is not clear which biomarkers are best for diagnosis and prognosis in different severities of TBI. Here, we compare existing studies on the discriminative abilities of serum biomarkers for four commonly studied clinical situations: detecting concussion, predicting intracranial damage after mild TBI (mTBI), predicting delayed recovery after mTBI, and predicting adverse outcome after severe TBI (sTBI). We conducted a literature search of publications on biomarkers in TBI published up until July 2018. Operating characteristics were pooled for each biomarker for comparison. For detecting concussion, 4 biomarker panels and creatine kinase B type had excellent discriminative ability. For detecting intracranial injury and the need for a head CT scan after mTBI, 2 biomarker panels, and hyperphosphorylated tau had excellent operating characteristics. For predicting delayed recovery after mTBI, top candidates included calpain-derived αII-spectrin N-terminal fragment, tau A, neurofilament light, and ghrelin. For predicting adverse outcome following sTBI, no biomarker had excellent performance, but several had good performance, including markers of coagulation and inflammation, structural proteins in the brain, and proteins involved in homeostasis. The highest-performing biomarkers in each of these categories may provide insight into the pathophysiologies underlying mild and severe TBI. With further study, these biomarkers have the potential to be used alongside clinical and radiological data to improve TBI diagnostics, prognostics, and evidence-based medical management.

From the Cover: Volatile Anesthetics Transiently Disrupt Neuronal Development in Neonatal Rats.

Volatile anesthetics can cause neuronal and glial toxicity in the developing mammalian brain, as well as long-term defects in learning and memory. The goals of this study were to compare anesthetics using a clinically relevant exposure paradigm, and to assess the anesthetic effects on hippocampal development and behavior. Our hypothesis was that volatile anesthetics disrupt hippocampal development, causing neurobehavioral defects later in life. Bromodeoxyuridine (BrdU) was administered to rats on postnatal day (P)1, and the rats were exposed to volatile anesthetics (isoflurane, sevoflurane, or desflurane) for 2 h on P2. On days P7 and P14, the BrdU-labeled cells were quantified in the hippocampal dentate gyrus using immunohistochemical assays and fluorescent microscopy. Caspase-3 positive cells were quantified on P2 to evaluate apoptosis. The remaining animals underwent behavioral testing at ages 6 weeks and 6 months, using the Morris Water Maze. Significantly fewer BrdU-positive cells were detected in the hippocampal dentate gyrus in both isoflurane and desflurane-treated animals compared with controls at P7, but there were no changes in cell numbers after sevoflurane exposure. Cell counts for all three anesthetics compared with controls were equivalent at P14. Isoflurane or desflurane exposure yielded slight differences in the behavioral tests at 6 weeks, but no differences at 6 months post-exposure. We conclude that a single 2-h exposure at P2 to either isoflurane or desflurane causes a transient disruption of hippocampal neuronal development with no significant detectable long-term effects on learning and memory, whereas the same exposure to sevoflurane has no effects.