A Mobile Phone Application for Assessing Daily Variation in Pain Location and Pain Intensity in Patients with Urologic Chronic Pelvic Pain Syndrome: A MAPP Network Study.

Introduction: We created and tested a mobile app that facilitates the ecological momentary assessment of pain intensity and pain location and identifies heterogeneous patient pain phenotypes. Methods: A mobile app was created with patient, clinician and researcher input. A sample of 20 participants with urologic chronic pelvic pain syndrome were then asked to complete a 14-day pain assessment using the app. Data were analyzed to assess compliance, usability and the ability for the app to capture variation in pain intensity and pain location. Ecological momentary assessment pain data were then compared to end-of-week pain summary questions to determine construct validity. Results: Mean compliance was 70±8%, higher earlier in the study period (p <0.0005) and better in older individuals (p <0.0001). During the 14-day assessment, 90% of participants reported daily variation in pelvic pain intensity (SD 0.64-3.02; out of 10), 95% reported variation in their nonpelvic pain (SD 0.17-3.63; out of 10) and 100% reported variations in number of sites with pain (SD 0.22-1.44; out of 7). Pelvic pain and nonpelvic pain intensity, as determined by cumulative app scores, were associated with patient reported end-of-week scores; worst pain (r pelvic =0.67; r nonpelvic =0.53) and average pain (r pelvic =0.78; r nonpelvic =0.73). Conclusions: The easy-to-use app captured unique patterns of pain not fully captured by traditional end-of-day/week summary questions or by traditional in-office assessments. Mobile apps for assessing chronic conditions will become increasingly important as telehealth becomes more commonplace.

Development and Validation of A Male Anterior Urethral Stricture Classification System.

OBJECTIVE: To develop and validate a clinical classification system for urethral stricture disease (USD) based on the retrograde urethrogram (RUG), physical exam, and stricture-specific patient history. MATERIALS AND METHODS: Three elements were chosen to be included in the classification system: 1) Length of urethral stricture (L); 2) Stricture segment/location (S); 3) Stricture Etiology (E) (LSE classification system). Each element was divided into clinically relevant sub-categories. A three-step development and validation process then ensued, culminating in an in-person Trauma and Urologic Reconstruction Network of Surgeons (TURNS) meeting, at which the final classification system was unanimously agreed upon by attendees based on interrater reliability data obtained from the classifying of 22 clinical vignettes. A final validation step involved retrospectively classifying cases in the TURNS database to determine if classification influenced surgical technique and was associated with presumed stricture etiology. RESULTS: The final LSE classification system was found to have an interrater reliability of 0.79 (individual components 0.76, 0.70 and 0.93 respectfully). Retrospective classification of the 2162 TURNS strictures revealed the segment (S) to be strongly associated with urethroplasty type (p = 0.0005) and stricture etiology (E) (p = 0.0005). CONCLUSION: We developed and validated a novel, easy to use, urethral stricture classification system. The system's ability to aid in directing treatments, predict treatment outcomes, and facilitate collaborative research efforts will require further study.

Trends in Urethral Stricture Disease Etiology and Urethroplasty Technique From a Multi-institutional Surgical Outcomes Research Group.

OBJECTIVE: To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. METHODS: Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. RESULTS: Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%). CONCLUSION: Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.

Unscheduled Clinical Encounters in the Postoperative Period After Adult and Pediatric Urologic Surgery.

OBJECTIVE: To qualify and quantify unscheduled clinical encounters (UCEs) in postoperative urologic patients and to identify patient and procedural risk factors for UCEs. MATERIALS AND METHODS: All UCEs, including phone calls, emails, patient portal messages, clinic visits, ER visits, and hospital readmissions, were analyzed, including the reason for the interaction (eg, pain, infection, etc) were assessed retrospectively for consecutive surgical patients over a 3-month period. Demographic and perioperative data for each patient and surgery was recorded and risk factors for UCE were determined using uni- and multivariate analyses. RESULTS: Approximately 40% of adult and pediatric patients experienced a UCE, the most common being phone calls (adult-68.2%, pediatric-90.0%) for new medical concerns (adult-67.7%, pediatric-58.1%). Risk factors for UCE in the adult population included lower BMI, living closer to the surgical hospital, discharge with catheter/wound packing, higher discharge pain, and open (vs endoscopic) surgery. In the pediatric population, surgery on the urethra/ureter and discharge with catheters predicted for UCE. UCEs led to changes in clinical management (17%, 21%), unplanned clinic visits (12%, 20%), and hospital readmissions (6%, 3%) for both adult and pediatric patients, respectively. CONCLUSION: Nearly 40% of both adult and pediatric patients experienced an unplanned need for the healthcare system in the postoperative period. The effect that UCEs have on overall costs and patient satisfaction, as well as ways to decrease UCEs, require further study.

Circumcision, Buried Penis and Obesity in a Contemporary Cohort of Patients with Penile Cancer.

INTRODUCTION: We reviewed patient demographics and body morphology in a contemporary cohort of patients presenting to a tertiary care center for treatment of penile cancer. METHODS: The University of Iowa Oncology Registry was retrospectively reviewed for cases of penile cancer managed between 2006 and 2016. The database was queried for cancer specific details, followed by a chart review for body morphology data and comorbidity status. RESULTS: We treated 54 patients for penile cancer in the study period with a mean ± SD age of 64.3 ± 12.9 years and body mass index of 36.2 ± 10 kg/m2. Of these men 31.5% (17) had a clinically buried penis and 50% (27) reported prepubertal circumcision. Patients with a buried penis had a higher body mass index (46.53 ± 10.6 vs 31.48 ± 5.63 kg/m2, p <0.0001) and underwent fewer inguinal lymph node dissections (20% vs 58%, p = 0.05) than patients without a buried penis, but had similar rates of higher stage (2-4) presentation. Stage correlated with penile cancer death. Those with cancer specific mortality had a significantly higher body mass index (41.2 ± 12.4 kg/m2) vs those without penile cancer death (34.6 ± 9.1 kg/m2). CONCLUSIONS: Penile cancer remains relatively rare but contemporary cohorts suggest that circumcision may no longer be protective, especially in the setting of a clinically buried penis that may mimic an intact prepuce. How a buried penis and higher body mass index affect presentation, clinical management, surgical outcomes and disease course deserves further study.

Prevalence of Post-Micturition Incontinence before and after Anterior Urethroplasty.

PURPOSE: In this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence. MATERIALS AND METHODS: We retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, "How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?" Possible answers were never-0 to all the time-3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities. RESULTS: Preoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%. CONCLUSIONS: The prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

The influence of differential response and other factors on parent perceptions of child protection involvement.

As Child Protective Services (CPS) agencies examine how to produce better outcomes with the families they serve, child welfare literature has increasingly focused on the perspectives, emotional responses, and engagement of CPS-involved parents or other primary caregivers. Despite this encouraging trend, the construct of engagement is ill-defined and our understanding of precursors to and factors affecting parent engagement is limited. This article extends the literature by presenting a conceptual framework for examining engagement and associating the identified constructs with parent outcomes. Using data from a survey of parents who were randomly assigned to receive either an assessment response (AR) or investigation response (IR) in two states' Differential Response CPS systems, a factor analysis on 12 commonly assessed emotional responses reported by parents indicated that parents responded with three primary emotions: positive affect, worry, or anger and that these responses varied by their receipt of AR or IR. Further, the results of multivariate analyses indicate that pathway assignment (AR or IR), parents' assessments of the quality of the casework they received, and other parent or household factors contribute to differences observed on the three emotional response factors identified.