Postoperative Urinary Retention.

ABSTRACT: This clinical consensus statement on the management of postoperative (<6 weeks) urinary retention (POUR) reflects statements drafted by content experts from the American Urogynecologic Society's POUR writing group. The writing group used a modified Delphi process to evaluate statements developed from a structured literature search and assessed for consensus. After the definition of POUR was established, a total of 37 statements were assessed in the following 6 categories: (1) incidence of POUR, (2) medications, (3) patient factors, (4) surgical factors, (5) urodynamic testing, and (6) voiding trials. Of the 37 original statements, 34 reached consensus and 3 were omitted.

Performance of Perioperative Tasks for Women Undergoing Anti-incontinence Surgery: Developed by the AUGS Quality Improvement and Outcomes Research Network.

OBJECTIVES: Surgery for the correction of stress urinary incontinence is an elective procedure that can have a dramatic and positive impact on quality of life. Anti-incontinence procedures, like inguinal hernia repairs or cholecystectomies, can be classified as high-volume/low-morbidity procedures. The performance of a standard set of perioperative tasks has been suggested as one way to optimize quality of care in elective high-volume/low-morbidity procedures. Our primary objective was to evaluate the performance of 5 perioperative tasks-(1) offering nonsurgical treatment, (2) performance of a standard preoperative prolapse examination, (3) cough stress test, (4) postvoid residual test, and (5) intraoperative cystoscopy for women undergoing surgery for stress urinary incontinence-compared among surgeons with and without board certification in female pelvic medicine and reconstructive surgery (FPMRS). STUDY DESIGN: This study was a retrospective chart review of anti-incontinence surgical procedures performed between 2011 and 2013 at 9 health systems. Cases were reviewed for surgical volume, adverse outcomes, and the performance of 5 perioperative tasks and compared between surgeons with and without FPMRS certification. RESULTS: Non-FPMRS surgeons performed fewer anti-incontinence procedures than FPMRS-certified surgeons. Female pelvic medicine and reconstructive surgery surgeons were more likely to perform all 5 perioperative tasks compared with non-FPMRS surgeons. After propensity matching, FPMRS surgeons had fewer patients readmitted within 30 days of surgery compared with non-FPMRS surgeons. CONCLUSIONS: Female pelvic medicine and reconstructive surgery surgeons performed higher volumes of anti-incontinence procedures, were more likely to document the performance of the 5 perioperative tasks, and were less likely to have their patients readmitted within 30 days.

PROMIS pain intensity and interference after pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires provide valid comparisons across disciplines. Pain measures can be used to track functional outcomes. Limited PROMIS pain data exist in gynecological surgery. We sought to use pain intensity and pain interference short forms to assess pain and recovery after pelvic organ prolapse surgery. METHODS: The PROMIS pain intensity and pain interference questionnaires were given to patients undergoing uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF) or minimally invasive sacrocolpopexy (MISC) at baseline, 1 week, and 6 weeks postoperatively. Clinical minimally important change was defined as a difference of 2-6 T-score points. Mean pain intensity and pain interference T-scores were compared at baseline, 1 week and 6 weeks with ANOVA. Multiple linear regression assessed 1-week scores adjusted for apical suspension type, advanced prolapse, concurrent hysterectomy, concurrent anterior or posterior repair, and concurrent sling. RESULTS: At 1 week, all apical suspension groups showed minimally important change in pain intensity and pain interference T-scores. Between groups at 1 week, pain interference was higher in USLS (66.3±6.6) and MISC (65.5±5.9) than in SSLF (59.2±9.8), p=0.01. Multiple linear regression showed an association of hysterectomy with increases in pain intensity and pain interference. USLS had a higher proportion of concurrent hysterectomy (100%) than SSLF (0%) and MISC (30.8%), p<0.01. No difference was found based on apical suspension type alone. CONCLUSIONS: No differences were found in PROMIS pain intensity and pain at 1 week postoperatively after apical suspension procedures.

Examining Age and Postoperative Opioid Use in the Urogynecology Population: A Prospective Study.

IMPORTANCE: Surgeons must individualize postoperative pain management while also reducing the amount of unused prescribed opioids. OBJECTIVES: This study compared postoperative opioid use in younger versus older women following urogynecologic surgery. We also assessed the likelihood of women returning unused opioids for safe disposal. STUDY DESIGN: This was a prospective study of women undergoing pelvic reconstructive surgery divided into 2 cohorts: younger (<65 years) and older (≥65 years). Our primary outcome was total opioid use, measured in morphine milligram equivalents (MME). We also assessed the average pain score during the first week after surgery measured by a numerical pain scale (range, 0-10). Our secondary outcome was the rate of return of unused prescribed opioids at the 6-week postoperative visit utilizing a disposable drug deactivation system. RESULTS: From April 2019 to September 2021, 152 participants were enrolled: 92 (61%) in the younger cohort (mean age, 51 ± 8 years) and 60 (39%) in the older cohort (mean age, 72 ± 6 years). For our primary outcome, younger women used significantly more opioids during the first postoperative week compared with older women (49 ± 71 vs 28 ± 40 MME, respectively, P = 0.04), despite no difference in average pain scores (4 ± 2 younger vs 3 ± 2 older, P = 0.05). For our secondary outcome, 23% of participants returned their opioids for disposal with the drug deactivation system. CONCLUSIONS: Younger women had higher postoperative opioid use despite similar pain scores after urogynecologic surgery. Among those prescribed opioids, a quarter of participants returned their opioids for disposal at their postoperative visit.

Length of Stay and 30-Day Postoperative Complications Following Minimally Invasive Apical Prolapse Repair.

IMPORTANCE: Data on the correlation between length of stay and postoperative complications following urogynecologic surgery are limited. OBJECTIVES: The objective of this study was to use a nationwide database to examine the correlation between length of stay and 30-day postoperative complications following minimally invasive apical prolapse repair. STUDY DESIGN: This retrospective cohort study included women in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2018 who underwent laparoscopic/robotic sacrocolpopexy or uterosacral/sacrospinous repair and were discharged on postoperative day 0 (POD0) or 1 (POD1). The primary outcome was 30-day postoperative complication rate. RESULTS: Of the 28,269 women discharged home on POD0/1, 12,663 (45%) underwent laparoscopic/robotic sacrocolpopexy, and 15,606 (55%) underwent uterosacral/sacrospinous repair. Women discharged on POD0 were less likely to be White, less likely to have diabetes or hypertension, had lower mean body mass index, and were less likely to have undergone a hysterectomy ( P < 0.05 for all). Within 30 days of surgery, 7% had a postoperative complication, and 3% had a major complication. Women discharged on POD0 had a lower risk of any complication or any major complication. The most common complication, urinary tract infection, was lower in women discharged on POD0 (3% vs 4%, P < 0.01). Women discharged home on the same day had a higher risk of superficial surgical site infection after undergoing laparoscopic/robotic sacrocolpopexy (1.3% vs 0.5%, P < 0.01) and a higher risk of myocardial infarction/cardiac arrest after uterosacral/sacrospinous repair (0.2% vs 0%, P < 0.04). CONCLUSIONS: In women undergoing minimally invasive reconstructive apical repair, discharge on POD0 is correlated with similar or better (lower) 30-day postoperative complication rates compared with women discharged on POD1.

A Randomized Clinical Trial Comparing the Efficacy and Safety of 2% Versus 4% Chlorohexidine Gluconate for Surgical Preparation of the Vagina.

IMPORTANCE: There have been no studies comparing 2% and 4% chlorhexidine gluconate (CHX) for vaginal surgical site preparation despite both commonly being used. OBJECTIVES: The primary objective was to assess the noninferiority of 2% CHX versus 4% CHX to reduce bacterial contamination rates at 60 minutes after surgical preparation of the vagina. Secondary objectives were to assess differences in colony-forming units and the sensation of postoperative vaginal burning and pain. STUDY DESIGN: This is a single-blinded randomized controlled trial of women who underwent vaginal prolapse surgery. Study participants were randomized into 2 groups: 2% CHX versus 4% CHX. Two vaginal bacterial cultures were collected: (1) preoperatively before vaginal preparation and (2) intraoperatively at 60 minutes. A questionnaire on vaginal pain and burning was administered preoperatively and postoperatively. For our sample size, assuming that 2% CHX would have double the contamination rate of 4% CHX, 26 participants were needed per group to demonstrate noninferiority. RESULTS: Sixty-one women participated in the study. There were no differences in baseline demographics, length of surgery, or surgical procedures. For our primary outcome, the postpreparation contamination rates were 7% for 2% CHX versus 10% for 4% CHX, with a difference of 3% ( P = 0.52). This difference did meet the criteria for noninferiority. Secondary outcomes were not different between groups. CONCLUSIONS: Two percent CHX is noninferior to 4% CHX in reducing vaginal bacterial contamination at 60 minutes after vaginal surgical site preparation, with low rates of postpreparation contamination and vaginal discomfort.

The American Urogynecologic Society Action Plan on Diversity, Equity, and Inclusion: Developed by the Diversity, Equity, and Inclusion Task Force.

ABSTRACT: The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVE: This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. METHODS: A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. RESULTS: A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. CONCLUSIONS: For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

A Systematic Review of Randomized Trials Investigating Methods of Postoperative Void Trials Following Benign Gynecologic and Urogynecologic Surgeries.

OBJECTIVE: To perform a systematic review of randomized controlled trials (RCTs) studying postoperative void trials (VTs) following gynecologic and urogynecologic surgery to investigate (1) the optimal postoperative VT methodology and (2) the optimal time after surgery to perform a VT. DATA SOURCES: PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHOD OF STUDY SELECTION: We systematically searched the aforementioned data sources from inception to November 22, 2019, using a combination of subject headings and keywords for the following 3 concepts: gynecologic surgery (prolapse, benign gynecologic, and incontinence surgery), postoperative period, and voiding. We identified any RCT in English that studied VT methodology or timing in patients undergoing benign gynecologic or urogynecologic surgery. Discrepancies were adjudicated by a third reviewer. We followed the standard systematic review methodology and used the Jadad scoring system to assess bias. Extracted study outcomes included the following: proportion of patients discharged home with catheter, proportion of VT failure, surgery for retention, retention after initial VT, postoperative calls and visits, time in postanesthesia care unit (PACU), time to discharge, time to spontaneous void, duration of catheterization, patient and provider burden, and urinary tract infection (UTI). TABULATION, INTEGRATION, AND RESULTS: We double screened 618 abstracts and clinical trial descriptions, assessed 56 full-text articles, and ultimately included 21 RCTs. The evidence was of low to moderate quality overall. The studies were divided into the following 2 categories: VT methodology (10 studies) and VT timing (11 studies). VT methodology included backfill-assisted (in operating room vs PACU), autofill, and force of stream studies. One RCT compared backfill-assisted with and without postvoid residual volume check. Outcomes were similar for all VT methods, except backfill-assisted decreased time to spontaneous void compared with autofill. In the VT timing category, earlier VT performance correlated with a shorter time to discharge, time to spontaneous void, duration of catheterization, and lower patient burden and UTI rate but had a higher rate of retention after initial VT. There was no difference between earlier vs later VT timing for proportion of discharged home with catheter or rate of VT failure. No studies reported outcomes of provider burden or postoperative calls. CONCLUSION: In comparing VT methodologies, VT by backfill-assisted (in operating room vs PACU, ± postvoid residual volume), autofill, and force of stream resulted in similar outcomes with no one method being superior. Performing VT at an earlier postoperative time point results in shorter time to discharge and spontaneous void, shorter duration of catheterization, lower patient burden, and lower UTI risk, but it may increase the risk of retention after initial VT.

Is a Postvoid Residual Necessary? A Randomized Trial of Two Postoperative Voiding Protocols.

OBJECTIVES: This study aimed to compare a backfill-assisted voiding trial (VT) with and without a postvoid residual (PVR) after pelvic reconstructive surgery. METHODS: This was a nonblinded randomized controlled trial of women undergoing pelvic organ prolapse and/or stress incontinence surgery. Participants were randomized immediately after surgery to either a PVR VT or a PVR-free VT. Our primary outcome was the rate of VT failure at discharge. Secondary outcomes included days of catheterization, urinary tract infection (UTI), and prolonged voiding dysfunction. With a power of 80% and an α of 0.05, we needed 126 participants to detect a 25% difference in VT failure (60% in PVR VT vs 35% in PVR-free VT). RESULTS: Participants were enrolled from March 2017 to October 2017. Of the 150 participants, mean age was 59 years, and 33% underwent vaginal hysterectomy, 48% underwent anterior repair, and 75% underwent midurethral sling. Seventy-five (50%) were randomized to PVR VT and 75 (50%) to PVR-free VT, with no differences in baseline demographic or intraoperative characteristics between the 2 groups. Our primary outcome, VT failure, was not significantly different (53% PVR VT vs 53% PVR-free VT, P = 1.0). There were no significant differences in days of postoperative catheterization (1 [0, 4] in PVR VT vs 1 [0, 4] in PVR-free VT, P = 0.90), UTI (20% PVR VT vs 20% PVR-free VT, P = 1.0), or postoperative voiding dysfunction (4% PVR VT vs 5% PVR-free VT, P = 1.0). CONCLUSIONS: When performing a backfill-assisted VT, checking a PVR does not affect VT failure, postoperative duration of catheterization, UTI, or voiding dysfunction.

Perioperative opioid prescriptions associated with stress incontinence and pelvic organ prolapse surgery.

BACKGROUND: There is an opioid epidemic in the United States with a contributing factor of opioids being prescribed for postoperative pain after surgery. OBJECTIVE: Among women who underwent stress urinary incontinence and pelvic organ prolapse surgeries, our primary objective was to determine the proportion of women who filled perioperative opioid prescriptions and to compare factors associated with these opioid prescriptions. We also sought to assess the risk of prolonged opioid use through 1 year after stress urinary incontinence and pelvic organ prolapse surgeries. STUDY DESIGN: Using a population-based cohort of commercially insured individuals in the 2005-2015 IBM MarketScan databases, we identified opioid-naive women ≥18 years who underwent stress urinary incontinence and/or pelvic organ prolapse procedures based on Current Procedural Terminology codes. We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. For our primary outcome, we reported the proportion of opioid-naive women who filled a perioperative opioid prescription and reported the median quantity dispensed in the perioperative period. We also assessed demographic and perioperative factors associated with perioperative opioid prescription fills. Previous studies have defined prolonged use as the proportion of women who fill an opioid prescription between 90 and 180 days after surgery. We report this estimate as well as continuous opioid use, defined as the proportion of women with ongoing monthly opioid prescriptions filled through 1 year after stress urinary incontinence and/or pelvic organ prolapse surgery. RESULTS: Among the 217,460 opioid-naive women who underwent urogynecologic surgery, 61,025 (28.1%) had pelvic organ prolapse and stress urinary incontinence surgeries, 85,575 (39.4%) had stress urinary incontinence surgery without pelvic organ prolapse surgery, and 70,860 (32.6%) had pelvic organ prolapse surgery without stress urinary incontinence surgery. Overall, 167,354 (77.0%) filled a perioperative opioid prescription, and the median quantity was 30 pills (interquartile range, 20-30). In a multivariate regression model, younger age, pelvic organ prolapse surgery with or without stress urinary incontinence surgery, abdominal route, hysterectomy, and mesh use remained significantly associated with opioid prescriptions filled. Among those with a filled perioperative opioid prescription, the risk of prolonged use defined as an opioid prescription filled between 90 and 180 days was 7.5% (95% confidence interval, 7.3-7.6). However, the risk of prolonged use defined as continuous use with at least 1 monthly opioid prescription filled after surgery was significantly lower: 1.2% (1.13-1.24), 0.32% (0.29-0.35), 0.06% (0.05-0.08), and 0.04% (0.02-0.05) at 60, 90, 180, and 360 days after surgery, respectively. CONCLUSION: Among privately insured, opioid-naive women undergoing stress urinary incontinence and/or pelvic organ prolapse surgery, 77% of women filled an opioid prescription with a median of 30 opioid pills prescribed. For prolonged use, 7.5% (95% confidence interval, 7.3-7.6) filled an opioid prescription within 90 to 180 days after surgery, but the rates of continuously filled opioid prescriptions were significantly lower at 0.06% (95% confidence interval, 0.05-0.08) at 180 days and 0.04% (95% confidence interval, 0.02-0.05) at 1 year after surgery.

Lidocaine Use in Vaginal Surgery and Risk of Toxicity.

OBJECTIVES: The primary objective of this study was to compare the amount of lidocaine administered for vaginal reconstruction with versus without hysterectomy. The secondary objective was to assess the risk of lidocaine toxicity. METHODS: This retrospective cohort study compares lidocaine dose in 2 cohorts: women who underwent vaginal hysterectomy with additional vaginal reconstruction (VH + VR) versus those who underwent vaginal reconstruction without hysterectomy (VR only). Total intraoperative lidocaine dose included the intravenous dose from anesthesia and the vaginally injected dose from the surgeon. The risk of toxicity was defined as total dose greater than 7 mg/kg. The primary outcome was the difference in total lidocaine dose for VH + VR versus VR only. RESULTS: Among 372 women included, 140 (37.6%) were in the VH + VR group, and 232 (62.4%) in the VR-only group. For the primary outcome of total lidocaine dose between groups, VH + VR received more total lidocaine than did VR only (228 ± 105 vs 168 ± 78 mg, P < 0.001). This difference was due to the vaginal lidocaine dose (P < 0.001), with no significant difference in the intravenous lidocaine dose (P = 0.68). In a logistic regression model controlling for age, anesthesia type, sling, and anterior repair, posterior repair, and anesthesia type, VH remained an independent risk factor for increased lidocaine dose (P < 0.001). Two women received a toxic dose of lidocaine, and both were in the VH + VR group. CONCLUSIONS: Women undergoing vaginal hysterectomy with additional vaginal reconstructive procedures are more likely to receive a higher dose of lidocaine compared with women undergoing vaginal reconstruction alone. The risk of lidocaine toxicity is increased with concomitant procedures.

Transfusion Rates and the Utility of Type and Screen for Pelvic Organ Prolapse Surgery.

OBJECTIVES: Limited data exist directly comparing the likelihood of blood transfusion by route of apical pelvic organ prolapse (POP) surgery. In addition, limited evidence is available regarding the risk of not ordering preoperative type and screen (T&S) in apical POP surgery. The objectives of the study are to (1) provide baseline data regarding the current need for preoperative T&S by comparing perioperative blood transfusion rates between 3 routes of apical POP surgery and (2) determine the rate of a positive preoperative antibody screen in women who underwent apical POP surgery. METHODS: This was a retrospective cohort study of women who underwent apical POP surgery by 3 different routes: abdominal (abdominal sacrocolpopexy), robotic (robotic sacrocolpopexy), or vaginal (uterosacral or sacrospinous ligament fixation). RESULTS: Among 610 women who underwent apical POP surgeries between May 2005 and May 2016, 24 women (3.9%) received a perioperative blood transfusion. The rate of transfusion was higher in the abdominal group (11.1%) compared with robotic (0.5%, P < 0.001) and vaginal (0.5%, P < 0.001). In a logistic regression model, abdominal route of POP surgery remained significantly associated with transfusion (odds ratio, 20.7; 95% confidence interval, 2.7-156.6). Among the 572 women who had a preoperative T&S performed, 9 (1.5%) had a positive antibody screen. CONCLUSIONS: Blood transfusion was significantly more common in abdominal compared with robotic and vaginal apical POP surgeries. The rate of a positive antibody screen was low, suggesting that type O blood is low risk if cross-matched blood is not available. Thus, it may be reasonable to not order a preoperative T&S prior to robotic or vaginal apical POP surgery.

Catheter burden following urogynecologic surgery.

BACKGROUND: Data on the experience that women who undergo urogynecologic surgery have with postoperative catheterization are severely limited. As the importance of our patients' perioperative experience becomes more valued, assessment of the burden of postoperative catheterization, which has not yet been performed, is increasingly needed. OBJECTIVE: The aim of this study was to compare catheter burden in women who self-selected use of an indwelling Foley catheter vs clean intermittent self-catheterization for voiding dysfunction after reconstructive pelvic surgery. STUDY DESIGN: This is a nested study within a nonblinded randomized controlled trial of 2 different voiding trial protocols that was conducted from March to October 2017. Women who underwent pelvic organ prolapse and/or stress urinary incontinence surgery who were English speaking and ≥18 years old with a preoperative postvoid residual <100 mL were included. Participants who did not pass their voiding trial were discharged with an indwelling Foley catheter or self-catheterization per participant preference. Our primary outcome was catheter burden at 1 week after surgery assessed by the Short-Term Catheter Burden Questionnaire, which is a validated 6-item survey comprised of 2 subscales: difficulty of use and embarrassment. Scores range from 3-15 with higher scores indicating greater difficulty and/or embarrassment, and the sum of the 2 subscale scores measures total catheter burden with a higher score indicating greater burden. Secondary outcomes included the rate of urinary tract infection, the number of postoperative clinic visits, and the number of postoperative phone calls. RESULTS: Of 150 participants, 77 women (51%) did not pass their voiding trial; of those, 47 women (61%) were discharged home with an indwelling catheter and 30 women (39%) with self-catheterization. Baseline demographics were similar, except that women who chose an indwelling Foley catheter were older (62±11 vs 55±11 years; P<.01). There were no significant differences between indwelling Foley catheter and self-catheterization in total catheter burden score (18±5 vs 18±6; P=.77), difficulty of use subscale score (8±3 vs 9±3; P=.20), or embarrassment subscale score (10±4 vs 9±4; P=.12). For secondary outcomes, there were no significant differences in rate of urinary tract infection (23% indwelling vs 30% self-catheterization; P=.60). Consistent with study protocol, women who were discharged with an indwelling Foley catheter did have more postoperative clinic visits (2±1 vs 1±1 visits; P<.01), and those women who were discharged with self-catheterization had more postoperative phone calls (2±3 vs 5±3 phone calls; P<.01). Otherwise there was no significant difference in nonvoiding-related clinic visits (1±1 visits for indwelling and self-catheterization; P=.15) or postoperative phone calls (1±2 indwelling vs 2±3 self-catheterization calls; P=.31). CONCLUSION: In women who used either an indwelling Foley catheter or clean intermittent self-catheterization for management of postoperative voiding dysfunction after pelvic reconstructive surgery, there were no differences in difficulty of use, embarrassment, or overall catheter burden. There were also no differences in nonvoiding-related postoperative phone calls or clinic visits, with similar rates of urinary tract infection between the 2 groups.

Variation in bony landmarks and predictors of success with sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: We assessed variations in sacral anatomy and lead placement as predictors of sacral neuromodulation (SNM) success. Based solely on bony landmarks, we also assessed the accuracy of the 9 and 2 protocol for locating S3. METHODS: This is a retrospective cohort study performed from October 2008 to December 2016 at the University of North Carolina at Chapel Hill. Fluoroscopic images were used to assess sacral anatomy and lead location. Success was defined as >50% symptom improvement after stage I and clinical response at most recent follow-up. RESULTS: Of 249 procedures, 209 were primary implants and 40 were revisions among 187 (89.5%) women and 22 (10.5%) men. Success rate was 83.3% for primary implants and 89.4% for revisions. Success was associated with shorter implant duration (21.3 ± 22.2 vs 33.6 ± 25.8 months), higher body mass index (30.3 ± 7.8 vs 27.6 ± 6.1 kg/m2), and straight vs curved lead (90.5% vs 80.5%) (all p = .05), but not with sacral anatomy or lead placement. In assessing the 9 and 2 protocol, mean distance from coccyx to S3 did not equal 9 cm: 7.4 ± 1.0 vs 7.2 ± 0.8 cm (p = .26), while mean distance from midline to S3 did equal 2 cm: 1.9 ± 0.4 vs 2.0 ± 0.7 cm (p = .37). CONCLUSIONS: Variations in sacral anatomy and lead placement did not predict SNM success. The 2-cm protocol was verified while the 9-cm protocol was not, although neither was predictive of success, which may obviate the need to mark bony landmarks prior to fluoroscopy.

Predictors of Opioid Administration in the Acute Postoperative Period.

OBJECTIVES: Our primary objective was to evaluate age as a predictor of postanesthesia care unit (PACU) opioid administration in women undergoing reconstructive pelvic surgery. Our secondary objective was to identify additional predictors of PACU opioid administration. METHODS: We conducted a retrospective cohort study of women undergoing outpatient urogynecologic surgery for pelvic organ prolapse and/or stress urinary incontinence between September 2015 to October 2016 at 1 academic medical center. We compared 2 cohorts (1) women older than 65 years and (2) women older than 65 years. Our primary outcome was any opioid medication administered during the PACU admission. RESULTS: A total of 183 women were included in the study; 124 (68%) were younger than 65 years, and 59 (32%) were 65 years or older. For our primary outcome, women younger than 65 years were more likely to be given any opioids in PACU than women 65 years (70% vs 54%, P = 0.04, respectively). Women younger than 65 years were also given higher total amounts of opioid narcotics postoperatively (9.0 ± 8.3 vs 5.1 ± 6.0 mg, P < 0.05). For our secondary outcome, we found that PACU opioid administration was associated with midurethral sling (MUS) surgery (70% MUS vs 30% no MUS, P = 0.04) and high maximum PACU pain score (97% high vs 3% low, P < 0.01). CONCLUSIONS: In women undergoing urogynecologic surgery, age younger than 65 years is a predictor of high PACU pain score and resultant PACU opioid dispensation. This population should be targeted in future studies addressing the use of nonopioid multimodal therapies in the treatment of postoperative pain.

The Utility of Preoperative Laboratory Testing Before Urogynecologic Surgery.

OBJECTIVES: National guidelines for preoperative laboratory testing are based on limited, low-quality evidence. The role of age as a risk factor for testing is unclear. We sought to compare the prevalence of abnormal preoperative laboratory results in older vs younger urogynecologic surgical patients. METHODS: In this retrospective cohort study of women undergoing urogynecologic surgery, we compared older (age, ≥65 years) with younger (age, 50-64 years) women. Our primary outcome was the prevalence of an abnormal preoperative laboratory result. RESULTS: We included 317 women, with 167 (52.7%) in the older cohort (ages, 65-91 years; mean, 73.3 ± 5.6 years) and 150 (47.3%) in the younger cohort (ages, 50-64 years; mean, 57.3 ± 4.1 years). Overall, 18.3% of participants had at least one abnormal preoperative laboratory, with older women more likely to have an abnormal result (28.7% vs 10.7%, P < 0.001). Compared with the younger cohort, older women had higher rates of abnormal hemoglobin (13.8% vs 6.0%, P = 0.02) and creatinine values (10.8% vs 2.7%, P = 0.005), with no significant differences for platelets (3.0% vs 1.3%, P = 0.53), sodium (3.0% vs 0.7%, P = 0.22), or potassium (6.0% vs 3.3%, P = 0.27). After adjusting for potential confounders, older age remained associated with an abnormal preoperative result (odds ratio, 3.6; 95% confidence interval, 1.9-7.1). CONCLUSIONS: In our sample, women 65 years or older had a greater than 25% chance of having an abnormal preoperative laboratory result and were at higher risk compared with younger women. Age 65 years or greater should be considered as a criterion for preoperative laboratory testing in urogynecologic patients.

Self-reported toileting behaviors in employed women: Are they associated with lower urinary tract symptoms?

AIMS: To describe toileting behaviors working women habitually use and investigate behaviors associated with lower urinary tract symptoms (LUTS), especially urinary urgency with or without leakage. METHODS: Non-pregnant female employees of a large academic medical center 18 years and over were eligible to complete an online survey about bladder health and toileting behaviors. RESULTS: One hundred eighty-two women participated in the survey. The majority were white (83.52%), married (52.49%), had ≥1 pregnancy (54.40%), and in excellent health (93.41%). The average age and body mass index were 47.28 ± 13.56 years and 27.92 ± 6.78, respectively. The sample was further sub-divided into two groups: urinary urgency (N = 119) or no urinary urgency symptoms (N = 51). Habitual toileting behaviors for these groups (N = 170) included: sitting to urinate at home (98.24%), emptying the bladder completely (88.82%), emptying the bladder before leaving home (80.00%), and sitting to urinate when away from home (68.82%). Logistic regression analysis showed age increased the odds of urinary urgency (aOR 1.06, 95%CI 1.02-1.09). Women who waited too long to urinate at work (aOR 7.85, 95%CI 1.57-39.24) and wore panty liners for urinary leakage (aOR 2.86, 95%CI 1.25-6.56) had greater odds of urinary urgency than women who did neither. CONCLUSIONS: Most habitual toileting behaviors were not associated with urinary urgency except waiting too long to urinate when at work. Logistic regression revealed significant relationships among health-related factors, personal characteristics, behaviors, and urinary urgency. LUTS in women is both a women's health and occupational health issue.

CE: Overactive Bladder in Women.

: Overactive bladder is a term used to describe a group of lower urinary tract symptoms that are prevalent in women, particularly as they age. Those with overactive bladder often experience related physical and psychological symptoms or conditions and report a poorer quality of life than other women. Many factors that increase the risk of developing overactive bladder are modifiable; therefore, lifestyle and behavioral interventions are first-line treatments. More treatment options are becoming available to women as research provides new information about the underlying pathophysiology of overactive bladder. Nurses play a major role in its screening, assessment, and management in women, many of whom do not seek help and try to self-manage symptoms, leading to a continuing cycle of unpredictable urgency and incontinence.