Antibiotics for UTI Prevention After Intradetrusor OnabotulinumtoxinA Injections.

IMPORTANCE: Urinary tract infections (UTIs) occur in 8.6% to 48.1% of patients after intradetrusor onabotulinumtoxinA injections. OBJECTIVE: The objective of this study was to evaluate both choice and duration of antibiotic prophylaxis on the incidence of UTI within 30 days after in-office onabotulinumtoxinA injections. STUDY DESIGN: We included a single-site, retrospective cohort of 305 patients with overactive bladder or bladder pain syndrome receiving postprocedure prophylactic antibiotics for in-office, 100-unit intradetrusor onabotulinumtoxinA injections from 2019 to 2023. Categories of antibiotic prophylaxis compared included (1) nitrofurantoin 100 mg twice daily for 3 days, (2) nitrofurantoin 100 mg twice daily for 5 days, (3) trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily for 3 days, and (4) "other regimens." Primary outcome was incidence of UTI within 30 days. Variables were compared via χ2 test. Crude/adjusted odds were estimated using binary logistic regression. RESULTS: Incidence of UTI was 10.4% for 3-day nitrofurantoin, 20.5% for 5-day nitrofurantoin, 7.4% for 3-day trimethoprim-sulfamethoxazole, and 25.7% among "other regimens" (P = 0.023). Differences among primary regimens were substantial but not statistically significant: 3-day trimethoprim-sulfamethoxazole had 31% lower odds of UTI versus 3-day nitrofurantoin (odds ratio [OR], 0.689; P = 0.518). Compared with 3-day nitrofurantoin regimen, the 5-day nitrofurantoin regimen had twice the odds of UTI (OR, 2.22; P = 0.088). Those receiving "other regimens" had nearly 3 times the odds of UTI (OR, 2.98; P = 0.018). Results were similar adjusting for age and race. Overall urinary retention rate was 1.97%. CONCLUSIONS: Prophylactic antibiotic choice and duration of treatment potentially affect UTI incidence after in-office, intradetrusor onabotulinumtoxinA injections. Nitrofurantoin and trimethoprim-sulfamethoxazole for 3 days have the lowest UTI incidence.

Association of Pelvic Floor Disorders, Perceived Psychological Stress, and Military Service in U.S. Navy Servicewomen: A Cross-Sectional Survey.

IMPORTANCE: Pelvic floor disorders (PFDs) are linked to psychological stress and decreased work performance in civilian populations. Higher psychological stress is reported in female active-duty servicewomen (ADSW), which affects military readiness. OBJECTIVE: This study sought to associate PFDs, work-related challenges, and psychological stress in ADSW. STUDY DESIGN: We conducted a single-site, cross-sectional survey of ADSW seeking care in the urogynecology, family medicine, and women's health clinics between December 2018 and February 2020 using validated questionnaires to determine the prevalence of PFDs and the association with psychological stress, performance of military duties, and continued military service. RESULTS: One hundred seventy-eight U.S. Navy ADSW responded; most were seeking care for PFDs. The reported prevalence rates of PFDs were as follows: urinary incontinence, 53.7%; pelvic organ prolapse, 16.3%; fecal incontinence, 73.2%; and interstitial cystitis/bladder pain syndrome, 20.3%. Active-duty servicewomen with PFDs were more likely to have higher psychological stress scores (22.5 ± 3.7 vs 20.5 ± 4.2, P = 0.002) and body composition failures (22.0% vs 7.3%, P = 0.012), yet more strongly consider remaining on active service if they reported urinary incontinence (22.8% vs 1.8%) or interstitial cystitis/bladder pain syndrome (19.5% vs 1.8%; all P ≤ 0.001). No significant differences were noted in physical fitness failures or other military duties. CONCLUSIONS: For these U.S. Navy ADSW with PFDs, there was no significant difference in duty performance but reported psychological stress levels were higher. The presence of PFD was associated with women more strongly considering ongoing military service compared with other factors such as family, job, or career path.

Reduced versus standard intradetrusor OnabotulinumtoxinA injections for treatment of overactive bladder.

BACKGROUND: Intradetrusor onabotulinumtoxinA injection is an effective advanced treatment for overactive bladder. While the effective dosages have been well studied, very little data exist on treatment efficacy using differing injection techniques. The objective of this study was to determine whether the efficacy of a reduced injection technique of 5 injection sites was noninferior to the standard technique of 20 injection sites of intradetrusor onabotulinumtoxinA for treatment of overactive bladder. METHODS: In this randomized noninferiority trial, men and women seeking treatment of overactive bladder with intradetrusor onabotulinumtoxinA injections were randomized to receive 100 units administered via either a reduced injection technique of 5 injection sites or a standard injection technique of 20 injection sites. Subjects completed a series of standardized questionnaires at baseline and at 4-12 weeks postprocedure to determine symptom severity and treatment efficacy. The primary outcome was treatment efficacy as determined by Overactive Bladder Questionnaire-Short Form with a noninferiority margin of 15 points. Secondary outcomes were incidence of urinary tract infection and urinary retention requiring catheterization. RESULTS: Data from 77 subjects were available for analysis with 39 in the control arm (20 injections) and 38 in the study arm (5 injections). There was a significant improvement in both arms from baseline to follow-up in Overactive Bladder Questionnaire-Short Form and International Consultation on Incontinence Questionnaire scores (p < 0.001). Overall treatment success was 68% with no statistically significant difference between arms. A significant difference between arms was found on the Overactive Bladder Questionnaire-Short Form quality of life survey favoring the control arm (confidence interval [CI]: 0.36-20.5, p = 0.04). However, there were no significant differences between arms in the remaining validated questionnaires. The study arm did not demonstrate noninferiority to the control arm. Subjects in the study arm were significantly more likely to express a willingness to undergo the procedure again (odds ratio = 3.8, 95% CI: 1.42-10.67, p = 0.004). Adverse events did not differ between arms. CONCLUSIONS: A reduced injection technique for administration of intradetrusor onabotulinumtoxinA demonstrates similar efficacy to the standard injection technique but did not demonstrate noninferiority. Subjects preferred the reduced injection technique over the standard technique. A reduced injection technique is a safe and effective alternative to the standard technique.

Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial.

BACKGROUND: Pelvic reconstructive surgery may cause significant postoperative pain, especially with posterior colporrhaphy, contributing to a longer hospital stay and increased pain medication utilization. Regional blocks are being increasingly utilized in gynecologic surgery to improve postoperative pain and decrease opioid usage, yet preoperative pudendal blocks have not been used routinely during posterior colporrhaphy. OBJECTIVE: This study aimed to compare the effect of preoperative regional pudendal nerve block using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and 3. We hypothesized that there would be a reduction in vaginal pain scores for the study group vs the control group over the first 72 hours. STUDY DESIGN: This was a double-blinded, randomized controlled trial that included patients undergoing a posterior colporrhaphy, either independently or in conjunction with other vaginal or abdominal reconstructive procedures. Patients were block randomized to receive 20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study) or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before the start of surgery. Double blinding was achieved by covering four 5-mL syringes containing the randomized local anesthetic. After induction of anesthesia, a pudendal nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary outcomes included total analgesic medication usage through postoperative day 3, postoperative voiding and defecatory dysfunction, and impact of vaginal pain on quality of life factors. RESULTS: A total of 120 patients were enrolled (60 in each group). There were no significant differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined liposomal and bupivacaine group at all time points vs the plain bupivacaine group. Median pain scores for the study and control groups, respectively, were 0 (0-2) and 2 (0-4) for postoperative day 1 (P=.03), 2 (1-4) and 3 (2-5) for postoperative day 2 (P=.05), and 2 (1-4) and 3 (2-5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days 2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%, P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity). CONCLUSION: Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine provided more effective vaginal pain control than plain bupivacaine alone for reconstructive surgery that included posterior colporrhaphy. Given the statistically significant decrease in vaginal pain in the study group, this block may be considered as a potential adjunct for multimodal pain reduction in this patient population.

Head-to-Head Comparison of Three Virtual-Reality Robotic Surgery Simulators.

BACKGROUND AND OBJECTIVES: There are several different commercially available virtual-reality robotic simulators, but very little comparative data. We compared the face and content validity of 3 robotic surgery simulators and their pricing and availability. METHODS: Fifteen participants completed one task on each of the following: dV-Trainer (dVT; Mimic Technologies, Inc., Seattle, Washington, USA), da Vinci Skills Simulator (dVSS; Intuitive Surgical Inc., Sunnyvale, California, USA), and RobotiX Mentor (RM; 3D Systems, Rock Hill, South Carolina, USA). Participants completed previously validated face and content validity questionnaires and a demographics questionnaire. Statistical analysis was then performed on the scores. RESULTS: Participants had a mean age of 29.6 (range, 25-41) years. Most were surgical trainees, having performed a mean of 8.6 robotic primary surgeries. For face validity, ANOVA showed a significant difference favoring the dVSS over the dVT (P = .001), and no significant difference between the RM, dVSS, and dVT. Content validity revealed similar results, with a significant difference between the dVSS and dVT (P = .021), a trend toward a difference between the RM and dVT (P = .092), and no difference between the dVSS and RM (P = .99). CONCLUSION: All simulators demonstrated evidence of face and content validity, with significantly higher scores for the dVSS; it is also the least costly ($80,000 for the simulator), although it is frequently unavailable because of intra-operative use. The dVT and RM have similar face and content validity, are slightly more expensive, and are readily available.

The use of magnetic resonance imaging for studying female sexual function: A review.

Many would agree that there are two quintessential sexual organs in the female: the clitoris and the brain. Using non-invasive techniques of magnetic resonance imaging (MRI), investigators have gained insight into the mental and physical factors involved in female sexual function. Since only the external clitoral glans is easily accessible for direct measurement, the complete anatomy of the clitoris (including the internal components-paired corpora, crura, and bulbs) has only recently been described, with MRI providing the most sensitive way of distinguishing among the various soft tissue planes. Average sizes of clitoral structures and average distances between the clitoral complex and other pelvic landmarks have been measured. These measurements have been correlated with female sexual function: a longer distance between the clitoral complex and the vaginal lumen correlates with poorer sexual function, consistent with prior imaging studies. However, whether clitoral size influences function is debatable, so further studies are needed. Physiological investigations have demonstrated that female arousal disorder is unlikely to be due to inadequate genital engorgement. Some consider the brain to be the ultimate sexual organ, and several recent studies have used functional MRI (fMRI) to reveal sexual excitability in the brain. The normal sexual response requires deactivation of the frontal lobe and activation of the instinctual limbic system of the midbrain. As MR technology continues to improve, the mysteries of female sexuality will be further unraveled.

Female sexual function and the clitoral complex using pelvic MRI assessment.

OBJECTIVE: To report basic measurements of clitoral anatomy, and explore potential relationships between the clitoral complex and female sexual function using MRI assessment. STUDY DESIGN: In this retrospective descriptive study, 20 sexually active women (≥18 years) who had a recent pelvic MRI for various gynecologic concerns were invited to participate. Outcome measures included demographic data, medical and sexual history, quality of life questionnaires: Female Sexual Function Index (FSFI), Body Exposure during Sexual Activities Questionnaire (BESAQ), and Short Form Quality of Life Questionnaire (SF-12). These data were then compared to detailed clitoral MRI measurements and analyzed using the Pearson correlation and Chi square test. RESULTS: FSFI domains of desire, arousal, lubrication, and orgasm were inversely correlated with clitoral size (p=0.01-0.04), as were SF-12 physical composite scores (p=0.003), suggesting improved sexual function and physical health in women with smaller clitoral structures (specifically the clitoral body and crus). CONCLUSION: Sexual function was improved in women with a smaller-sized clitoris, specifically the clitoral body and crus.

Clitoral size and location in relation to sexual function using pelvic MRI.

INTRODUCTION: The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of orgasm. AIM: The aim of this study is to evaluate the clitoral size and location with regard to female sexual function. METHODS: This cross-sectional TriHealth Institutional Board Review approved study compared 10 sexually active women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12), Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short Form Health Survey-12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast; measurements of the clitoris were calculated. MAIN OUTCOME MEASURES: Our primary outcomes were clitoral size and location as measured by noncontrast MRI imaging in sagittal, coronal, and axial planes. RESULTS: Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7), mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ-12 (P < 0.001) and total FSFI (P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral glans in coronal view was significantly smaller for the anorgasmic group (P = 0.005). A larger distance from the clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer scores on the PISQ-12 (r = -0.44, P = 0.02), FSFI (r = -0.43, P = 0.02), and BESAQ (r = -0.37, P = 0.04). CONCLUSION: Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function.

Robotic virtual reality simulation plus standard robotic orientation versus standard robotic orientation alone: a randomized controlled trial.

OBJECTIVE: The objective of this study was to compare the effect of virtual reality simulation training plus robotic orientation versus robotic orientation alone on performance of surgical tasks using an inanimate model. METHODS: Surgical resident physicians were enrolled in this assessor-blinded randomized controlled trial. Residents were randomized to receive either (1) robotic virtual reality simulation training plus standard robotic orientation or (2) standard robotic orientation alone. Performance of surgical tasks was assessed at baseline and after the intervention. Nine of 33 modules from the da Vinci Skills Simulator were chosen. Experts in robotic surgery evaluated each resident's videotaped performance of the inanimate model using the Global Rating Scale (GRS) and Objective Structured Assessment of Technical Skills-modified for robotic-assisted surgery (rOSATS). RESULTS: Nine resident physicians were enrolled in the simulation group and 9 in the control group. As a whole, participants improved their total time, time to incision, and suture time from baseline to repeat testing on the inanimate model (P = 0.001, 0.003, <0.001, respectively). Both groups improved their GRS and rOSATS scores significantly (both P < 0.001); however, the GRS overall pass rate was higher in the simulation group compared with the control group (89% vs 44%, P = 0.066). CONCLUSIONS: Standard robotic orientation and/or robotic virtual reality simulation improve surgical skills on an inanimate model, although this may be a function of the initial "practice" on the inanimate model and repeat testing of a known task. However, robotic virtual reality simulation training increases GRS pass rates consistent with improved robotic technical skills learned in a virtual reality environment.

Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial.

INTRODUCTION AND HYPOTHESIS: Intra-vaginal diazepam suppositories are commonly prescribed as a treatment option for high-tone pelvic floor myalgia. This triple-blinded placebo-controlled randomized trial sought to determine if 10 mg diazepam suppositories improve resting pelvic floor electromyography (EMG) compared with placebo. METHODS: Women ≥18 years of age with hypertonic pelvic floor muscles on examination, confirmed by resting EMG ≥2.0 microvolts (µv), administered vaginal suppositories containing either diazepam or placebo for 28 consecutive nights. Outcomes included vaginal surface EMG (four measurements), the Female Sexual Function Index (FSFI), the Short Form Health Survey 12 (SF-12), four visual analog scales (VAS), the Patient Global Impression of Severity (PGI-S), and the Patient Global Impression of Improvement (PGI-I). A priori sample size calculation indicated that 7 subjects in each group could detect a 2-µv difference in resting EMG tone with 90% power. RESULTS: Twenty-one subjects were enrolled. The mean age was 36.1 (SD 13.9) years, mean body mass index was 28.56 (SD 9.4), and the majority (85.7%) was Caucasian. When evaluating response to therapy, no difference was seen in any of the resting vaginal EMG assessments at any time point within subjects or between groups, nor was an interaction found. Additionally, no differences were noted in any of the validated questionnaires. CONCLUSIONS: When used nightly over 4 weeks, 10 mg of vaginal diazepam was not associated with improvement in resting EMG parameters or subjective outcomes compared with placebo. This suggests such that therapy alone may be insufficient in treating high-tone pelvic floor dysfunction.

Histologic and cytologic effects of vaginal estrogen in women with pelvic organ prolapse: a randomized controlled trial.

OBJECTIVE: This study aimed to evaluate the histologic and cytologic effects of preoperative vaginal estrogen in women with atrophic vaginitis and pelvic organ prolapse. METHODS: Forty-two women with atrophic vaginitis and stage greater than or equal to 2 prolapse were enrolled in this assessor-blinded randomized controlled trial comparing daily vaginal estrogen cream use for 2 to 12 weeks preoperatively versus no intervention. Data were analyzed using t test and analysis of variance. RESULTS: Of these 42 women, 22 received treatment and 20 were controls. After a mean 7 (3) weeks of use, the vaginal maturity index increased 15.5% in the treatment group and declined 1.5% in the control group (P < 0.001). The vaginal epithelial thickness was 339 (96) µm in the treatment group compared to 302 (119) µm (P = 0.275) in the controls. CONCLUSIONS: Preoperative vaginal estrogen application for 2 to 12 weeks restores vaginal cytology to premenopausal levels, but does not increase vaginal epithelial thickness in women with prolapse.

Is female sexual dysfunction related to personality and coping? An exploratory study.

INTRODUCTION: Sexual disorders impact up to 43% of women. However, the relationship between sexual dysfunction and psychological variables such as personality traits and coping mechanisms is not well understood. AIM: To examine personality domains and coping strategies utilized by women with sexual dysfunction in a clinical sample. METHODS: Patients seeking care for female sexual dysfunction (FSD) from a sexual medicine specialist were identified using International Classification of Diseases, Ninth Revision codes. Packets containing informed consent, Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), Ten Item Personality Index (TIPI), and Brief COPE were mailed to subjects. MAIN OUTCOME MEASURES: Correlations among FSFI, FSDS-R, TIPI, and Brief COPE. RESULTS: Of 79 eligible subjects, 50 (63.2%) returned completed questionnaires. The mean age was 40 years (standard deviation 14). Total FSFI and FSDS-R scores confirmed FSD. Correlations between the FSFI and TIPI illustrated trends with the domain of extraversion, suggesting better function in those exhibiting more of this trait (r = 0.285, P = 0.079). Similarly, FSDS-R scores correlated with openness to experience (r = -0.305, P = 0.037) and approached significance for extraversion (r = -0.258, P = 0.080), indicating lower distress in such personality types. When assessing the Brief COPE, use of emotional support, a positive coping strategy, correlated with better orgasm (r = 0.303, P = 0.048) and higher satisfaction (r = 0.331, P = 0.03). Finally, when evaluating TIPI with COPE scores, several significant associations were noted, establishing that personality may influence these adaptive behaviors. CONCLUSION: Many notable relationships between sexual function, personality, and coping are presented. These support a role for consideration of psychological variables when evaluating women presenting for sexual dysfunction. Crisp CC, Vaccaro CM, Pancholy A, Kleeman S, Fellner AN, and Pauls R. Is female sexual dysfunction related to personality and coping? An exploratory study. Sex Med 2013;1:69-75.

Patient-controlled versus scheduled, nurse-administered analgesia following vaginal reconstructive surgery: a randomized trial.

OBJECTIVE: To determine whether patient-controlled analgesia or scheduled intravenous analgesia provides superior pain relief and satisfaction with pain control after vaginal reconstructive surgery. STUDY DESIGN: Fifty-nine women scheduled for vaginal reconstructive surgery were enrolled in this randomized trial. Operative procedures and postoperative orders were standardized. Visual analog scales for pain and satisfaction with pain control were recorded during the hospital stay and 2 weeks after surgery. RESULTS: Patients receiving patient-controlled analgesia had less pain on postoperative day 1, 25 mm vs 39 mm, on visual analog scales (P = .007). Although this group used twice as much hydromorphone (3.57 mg vs 1.48 mg, P < .001), there was no difference in side effects, length of hospital stay, or complications. For the sample overall, larger amounts of narcotic used correlated with higher pain scores (r = 0.364, P = .009) and worse satisfaction scores (r = -0.348, P = .012). CONCLUSION: In patients undergoing vaginal surgery, patient-controlled analgesia offers superior pain relief on postoperative day 1 when compared with scheduled, nurse-administered hydromorphone.

Sexual function in a woman with congenital bladder exstrophy and multiple pelvic reconstructive surgeries: a case report.

INTRODUCTION: Bladder exstrophy is a rare congenital anomaly isolated to the fetal genitourinary tract. In our patient, this defect necessitated removal of her bladder in her childhood and a distal neovaginoplasty in adolescence. Despite these surgeries, as well as several procedures for pelvic organ prolapse, the patient reports excellent sexual function and ability to achieve vaginal orgasms. AIM: (i) To report on the sexual function of a woman without a bladder or urethra who has undergone multiple pelvic reconstructive surgeries; and (ii) to correlate her self-reported erotic areas with magnetic resonance imaging (MRI) assessment. METHODS: The patient completed a detailed sexual history, the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and the Health Survey Short Form (SF-12). Photodocumentation of her erotic tissue was correlated with a pelvic MRI with contrast. RESULTS: The patient reports ability to achieve vaginal orgasms 100% of the time. Her FSFI score was 29.4/36 with maximum scores noted in arousal, lubrication, orgasm and satisfaction. Her FSDS score was 7/48, which implies no sexually related distress. Her PISQ-12 score was 10/48, demonstrating a small impact on her sexual function related to her pelvic organ prolapse. Her SF-12 scores were 36.6 and 57.9. Photography and mapping of her erotic areas illustrated the superficial and anterior locations of the vaginal opening to be the sites of orgasm. MRI correlated these exact locations with clitoral tissue. CONCLUSION: Intact sexual function is possible in patients after reconstructive surgery for congenital bladder exstrophy. Due to the superficial location of her clitoris and separation of the pubic rami associated with this anatomic variant, sexual function may be enhanced.