Health inequities within the field of urogynecology.

PURPOSE OF REVIEW: To summarize some of the most recent evidence on disparities in the prevalence, treatment and outcomes of pelvic floor disorders (PFDs), and to address potential interventions to dismantle these inequities. RECENT FINDINGS: There is a paucity of data on the prevalence and treatment of PFDs in racial minority women. The existing studies are limited and poor quality. These studies suggest that racial and ethnic minorities may be at a higher risk of PFDs, however the epidemiologic data regarding prevalence varies by disorder and at times are conflicting. Nevertheless, the data on treatment and complications is clear. Racial and ethnic minorities are less likely to receive gold-standard treatment and are more likely to experience treatment related complications. SUMMARY: We discuss the lack of racially inclusive research that perpetuates ongoing health inequities.

Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse.

BACKGROUND: There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery. OBJECTIVE: This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity. STUDY DESIGN: This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity. RESULTS: A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02). CONCLUSION: There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.

Treatment of Stress Urinary Incontinence: Does Race Matter?

IMPORTANCE: The importance of this study was to examine treatment patterns and surgical complications for stress urinary incontinence (SUI). OBJECTIVES: The aim of this study was to describe the treatment of SUI and associated complications in a racially and ethnically diverse population. STUDY DESIGN: This was a retrospective cohort study of patients with a new diagnosis of SUI. We identified patients who received treatment with a pessary, pelvic floor physical therapy, or surgery. Surgical complications were abstracted. Logistic regression was used to examine the association between race/ethnicity and treatment, as well as surgical complications. RESULTS: A total of 67,187 patients with a new diagnosis of SUI were included. The population was predominately Hispanic (47.5%) followed by White, Asian, Black, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native. Comparing no treatment to any treatment, all racial/ethnic groups, except American Indian/Alaska Native, had decreased odds of receiving treatment compared with White women. Hispanic and Native Hawaiian/Pacific Islander women had increased odds of referral for pelvic floor physical therapy compared with White women. All racial/ethnic groups, except for American Indian/Alaska Native women, had decreased odds of receiving a sling procedure compared with White women. When these racial/ethnic minority groups did receive treatment, it was more likely to be conservative treatment compared with White women. There were no significant differences in individual surgical complications. CONCLUSIONS: Racial minority women were 20-50% less likely to undergo a sling procedure, commonly posited as the gold standard surgical treatment. Racial minority women were 40-100% more likely to receive conservative management and 20-50% less likely to receive any treatment compared with White women.

Prolapse Treatment-Related Decisional Conflict After New Patient Visits.

IMPORTANCE: Patients with pelvic organ prolapse are often tasked with deciding between treatments. Decisional conflict is a measure of factors that go into effective decision making. OBJECTIVE: This study aimed to compare prolapse treatment-related decisional conflict reported by underrepresented patients (URPs) to non-URPs after new patient visits. STUDY DESIGN: A multicenter cohort study of new patients counseled regarding management of prolapse from July 2021 to December 2022 was performed. Participants completed the Decisional Conflict Scale (DCS), a validated measure of modifiable factors in decision making. Higher scores indicate feeling less comfortable with decisions. Race and ethnicity were viewed as social constructs. A URP was defined as self-identification with a non-White race or Hispanic ethnicity. Alpha was set at 0.05, power 80%, to detect an effect size of 0.4 between mean DCS scores. RESULTS: A total of 207 participants (103 URPs, 49.8%), with a mean age of 63.4 ± 11.9 years and mean body mass index of 29.7 ± 6.9 (calculated as weight in kilograms divided by height in meters squared), completed the study. Much of the URP group self-identified as Hispanic (50/103, 48.5%) and/or Black (39/103, 37.9%), and 30 of 103 (29.1%) had an interpreter at their visit. A greater proportion of non-URPs had a prior hysterectomy (16.1% difference; P = 0.017) and prolapse surgery (18/204, 10.5% difference; P = 0.020). A greater proportion of URPs had hypertension (23.6% difference; P = <0.001). There were no differences in the other pelvic floor disorders, prolapse stage, or treatments selected (all P > 0.05). The mean DCS scores were not different between groups (URP, 12.9 ± 12.3 vs non-URP, 11.6 ± 14.9; P = 0.31). Household income, education, and insurance were not associated with DCS scores (all P > 0.05). CONCLUSIONS: Decisional Conflict Scale scores were not significantly different between groups. Possible differences between subgroups warrant further investigation.

Pregnancy and Outcomes After Prolapse Surgery: A Case Series.

IMPORTANCE: There are limited data on whether pelvic organ prolapse (POP) surgery is durable after subsequent delivery. OBJECTIVES: The aims of this study were to evaluate the safety and durability of POP surgery after delivery and to describe the medical decision-making and clinical outcomes of patients who gave birth after POP surgery. STUDY DESIGN: This study is a retrospective case series of patients who underwent surgery for symptomatic POP between 2007 and 2017, and subsequently had a live birth. RESULTS: Twenty patients were identified. Seventeen patients underwent posterior colporrhaphy, 10 anterior colporrhaphy, and 5 apical suspensions. The mean interval between POP surgery and the first delivery was 28.6 months. One patient endorsed recurrent POP symptoms before pregnancy, and none of the remaining 19 patients reported recurrent POP symptoms before or during pregnancy. There were no pregnancy complications related to the POP surgery. Nine patients underwent cesarean delivery (CD). Four patients were counseled to have a CD due to their prior POP surgery, 3 patients had an elective primary CD due to the POP surgery, 1 patient chose an elective repeat CD, and 1 patient had a CD due to obstructed labor. Urogynecologists were consulted for delivery recommendations for 6 patients and recommended CD for 3 of them. Eleven patients had spontaneous vaginal delivery. Three patients reported recurrent POP symptoms after delivery. CONCLUSIONS: Our findings corroborate previous case series demonstrating the safety and durability of POP surgery during and after pregnancy. More than 75% of patients gave birth by CD, which was due to physician or patient concerns regarding the prior POP surgery.

Interpersonal Trauma as a Marker of Risk for Urinary Tract Dysfunction in Midlife and Older Women.

OBJECTIVE: To examine relationships between interpersonal trauma exposures and urinary symptoms in community-dwelling midlife and older women. METHODS: We analyzed cross-sectional data from a multiethnic cohort of women aged 40-80 years enrolled in an integrated health care system in California. Lifetime history of intimate partner violence (IPV) and sexual assault, current posttraumatic stress disorder (PTSD) symptoms, and current urinary symptoms were assessed using structured-item questionnaires. Multivariable-adjusted logistic regression models examined associations between traumatic exposures and PTSD symptoms with any weekly urinary incontinence, stress-type incontinence, urgency-type incontinence, and nocturia two or more times per night. RESULTS: Of the 1,999 participants analyzed, 21.7% women reported lifetime emotional IPV, 16.2% physical IPV, 19.7% sexual assault, and 22.6% reported clinically significant PTSD symptoms. Overall, 45% reported any weekly incontinence, 23% stress-type incontinence, 23% urgency-type incontinence, and 35% nocturia. Exposure to emotional IPV was associated with any weekly incontinence (odds ratio [OR] 1.33, 95% CI 1.04-1.70), stress-type incontinence (OR 1.30, 95% CI 1.00-1.65), urgency-type incontinence (OR 1.30, 95% CI 1.00-1.70), and nocturia (OR 1.73, 95% CI 1.36-2.19). Physical IPV exposure was associated with nocturia (OR 1.35, 95% CI 1.04-1.77), but not incontinence. Sexual assault history was not associated with weekly incontinence of any type or nocturia. Symptoms of PTSD were associated with all urinary symptoms assessed, including any weekly incontinence (OR 1.46, 95% CI 1.15-1.85), stress-type incontinence (OR 1.70, 95% CI 1.32-2.20), urgency-type incontinence (OR 1.60, 95% CI 1.24-2.06), and nocturia (OR 1.95, 95% CI 1.55-2.45). CONCLUSION: More than 20% of women in this multiethnic, community-based cohort reported a history of IPV, PTSD symptoms, or both, which were associated with symptomatic urinary tract dysfunction. Findings highlight the need to provide trauma-informed care of midlife and older women presenting with urinary symptoms.

Fungal Lumbosacral Osteomyelitis After Robotic-Assisted Laparoscopic Sacrocolpopexy.

Sacral osteomyelitis is a rare complication after robotic sacrocolpopexy, with previous reports of enteric and skin flora as inciting organisms. We report a patient who presented with severe low back pain and fever 6 weeks after a robotic sacrocolpopexy, who was subsequently diagnosed as having lumbosacral discitis and osteomyelitis with thoracic intervertebral extension. Empiric antibiotic therapy was initially administered. After laparoscopic mesh excision and abdominal wash out, Candida albicans was isolated from the excised mesh. Postoperatively, the patient was treated with a 12-month course of oral fluconazole with significant clinical improvement. To our knowledge, this is the second reported case of fungal osteomyelitis, providing further recommendations for the management of postoperative sacral osteomyelitis using a minimally invasive surgical technique and guidance by a multidisciplinary team.