An evaluation of pelvic floor disorders in a public and private healthcare setting.

INTRODUCTION AND HYPOTHESIS: The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans. METHODS: A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type. RESULTS: A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size. CONCLUSIONS: Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries. DATA SOURCES: PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included. METHODS: Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals. RESULTS: Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures. CONCLUSION: Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Neural control properties of the external anal sphincter in young and elderly women.

AIMS: The prevalence of fecal incontinence (FI) increases with age and affects more than 15% of the elderly population. Sarcopenia, skeletal muscle structural, and functional decline with aging, is known to be caused by neuromuscular dysfunction. However, age-related alterations of the neuromuscular function of the external anal sphincter (EAS) have not been studied. This study aims to quantitatively characterize the effect of aging on the EAS by assessing the firing patterns and size of motor unit action potential (MUAP) using high-density surface electromyography (HD-sEMG) recording and analysis techniques. METHODS: Thirteen young (31.0 ± 3.6 years) and 14 elderly (64.3 ± 6.2 years) healthy women were recruited for this study. EMG activity of the EAS during maximal voluntary contraction was recorded by a 64-Channel, HD-sEMG intra-rectal probe. HD-sEMG signals were decomposed into MUAP spike trains to extract the firing rate and amplitudes thereof. RESULTS: HD-sEMG decomposition was successfully performed. For the young and elderly groups, mean motor unit (MU) firing rates of 11.4 ± 2.1 pulses per second (PPS) and 9.6 ± 2.3 PPS, and mean MUAP amplitudes of 45.2 ± 14.3 µV and 61.9 ± 21.2 µV were respectively obtained. Both the MU firing rate and MUAP amplitude were significantly different between two groups (P < .05). Moreover, the MUAP firing rate and amplitude correlated with age with a linear regression model (P < .05). CONCLUSIONS: This study represents the first effort to examine the effect of aging on the neuromuscular function of EAS. Results suggest an age-related impairment of lower motor neuron descending excitation to the EAS with a compensatory increase in mean MU size.

Improving Documentation of Obstetric Anal Sphincter Injuries (OASIS) Using a Standardized Electronic Template at Two University-Affiliated Institutions.

OBJECTIVES: Adequate repair is vital to reduce the long-term sequelae of obstetric anal sphincter injuries (OASIS). Sufficient documentation is necessary to reflect the quality of care provided, to guide future management, and to reduce medicolegal liability. With the advent of electronic health records, proper methods of documentation can be more easily disseminated and applied for general use. The objectives of our study were to assess whether documentation of OASIS management is improved by introducing a standardized electronic operative report, determining rates of readmission due to complications, and measuring adherence to practice guidelines. METHODS: A pre- and postintervention study was conducted by auditing electronic charts of patients affected by OASIS at two university-affiliated delivery units throughout the 2016 calendar year. Unit A is a safety-net hospital and unit B is private. A standardized electronic template was created in the electronic health records of both units. The primary outcome was the quality of repair documentation, which was quantified using a scale that included all relevant aspects of the repair. RESULTS: Analyzing both units separately, baseline characteristics including operator training level, episiotomy rate, and operative delivery were similar pre- and postintervention. The quality of documentation measured by the scale score improved significantly postintervention. Proper use of antibiotics and bowel regimen significantly increased after the intervention at both units. CONCLUSIONS: The use of a standardized electronic template for reporting the diagnosis and repair of OASIS improves the thoroughness of documentation and appears to promote the implementation of best practice guidelines.

Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum. METHODS: In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate. RESULTS: From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2). CONCLUSION: The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.

Nonantimuscarinic treatment for overactive bladder: a systematic review.

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE: Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN: We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS: For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION: Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Trainee Perspectives Regarding the Effect of the Dobbs v. Jackson Women's Health Organization Supreme Court Decision on Obstetrics and Gynecology Training.

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review.

OBJECTIVE: To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM). DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators. METHODS OF STUDY SELECTION: We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group. TABULATION, INTEGRATION, AND RESULTS: Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function. CONCLUSION: Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVE: To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated. DATA SOURCES: PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines. METHODS OF STUDY SELECTION: Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded. TABULATION, INTEGRATION, AND RESULTS: Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes. CONCLUSION: Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021278796.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review.

OBJECTIVE: To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION: The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS: Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION: Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021234511.

The time factor in the assessment of prolapse and levator ballooning.

INTRODUCTION AND HYPOTHESIS: The goal of the study was to define the time needed to obtain maximal organ descent and hiatal distension during Valsalva measured by transperineal ultrasound. Secondarily, we aimed to describe the timing of these events in relationship to each other. METHODS: We undertook a retrospective review of the stored ultrasound volume datasets of 50 patients with pelvic organ prolapse. Data on organ descent and hiatal distension were obtained in 10 volumes from rest to maximal Valsalva. RESULTS: On average, a Valsalva maneuver lasted 9.4 s (range 5 to 18). It took patients on average about six volumes (approximately 5-6 s) to reach 80% of maximum organ descent. The time to maximum organ descent was 8.9 s and the time to maximum distension of the levator hiatus was 8.2 s, p = 0.031. CONCLUSIONS: In order to obtain adequate assessment of pelvic organ prolapse, a Valsalva maneuver should last at least 6 s. Hiatal distension seems to precede pelvic organ descent.

Emotional intelligence and selection to administrative chief residency.

OBJECTIVE: The authors sought to determine whether emotional intelligence, as measured by the BarOn emotional quotient inventory (EQ-i), is associated with selection to administrative chief resident. METHOD: Authors invited senior-year residents at the University of Texas Health Science Center at Houston to participate in an observational cross-sectional study using the BarOn EQ-i. In October 2009 they sent an invitation e-mail to 66 senior residents, with a reminder e-mail 1 month later. The study was designed to detect a 15-point difference in EQ-i scores with 80% power. RESULTS: Of the 66 invited residents, 69.6% participated in the study. Average total EQ-I score was 104.9. Among senior-year residents, there were no statistically significant differences in EQ-i scores between administrative chief residents (at 109) and non-administrative chief residents (at 103.2). CONCLUSION: Administrative chief residents do not demonstrate higher Emotional Intelligence, as measured by the EQ-i, than other senior-year residents.

Rate of Mesh Erosion After Sacrocolpopexy With Concurrent Supracervical Compared With Total Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of concomitant supracervical hysterectomy compared with total hysterectomy during abdominal sacrocolpopexy on the rate of mesh erosion by performing a systematic review and meta-analysis of the existing literature. DATA SOURCES: From database inception through January 2022, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov , and Cochrane Central Register of Controlled Trials. Studies comparing the rate of mesh erosion in women undergoing abdominal sacrocolpopexy who had concomitant supracervical hysterectomy compared with total hysterectomy were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of mesh erosion was compared, and odds ratios (ORs) with 95% CIs were estimated. TABULATION, INTEGRATION, AND RESULTS: Nineteen studies with 10,572 women who underwent abdominal sacrocolpopexy were identified, including 4,285 women in the supracervical group and 6,287 women in the total hysterectomy group. The overall mean postprocedure follow-up time was 30.7±15.1 months (median 12.4, range 1.5-44.2). The median (95% CI) point prevalence of mesh erosion was 0.36% (0-1.9%) in women who had supracervical hysterectomy compared with 3.8% (1.8-8.7%) in women who had total hysterectomy. The overall rate of mesh erosion in women who had supracervical hysterectomy was lower compared with women who had total hysterectomy (pooled OR 0.26, 95% CI 0.18-0.38, I 2 0%). CONCLUSION: In women with symptomatic apical pelvic organ prolapse who undergo abdominal sacrocolpopexy with concomitant hysterectomy, supracervical hysterectomy is associated with a lower risk of mesh erosion compared with total hysterectomy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022301862.

Postoperative Pain and Urinary Retention After Vaginal Reconstructive Surgery.

OBJECTIVE: The objective of this study was to evaluate the effect of patients' immediate prevoiding pain level after vaginal pelvic reconstructive surgery on their ability to void. METHODS: We conducted a retrospective cohort study of women with and without urinary retention after urogynecologic procedures. Postoperative pain, measured by a visual analog scale, was recorded for each patient before a voiding trial. Demographic, surgical characteristics, prevoiding trial pain, and rate of postoperative urinary retention were compared. Multiple-logistic regression analysis was used with all analyses controlled for univariate variables with a P value of ≤0.1 to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Two-tailed tests were used, with P < 0.05. RESULTS: A total of 458 patients were identified, of which 21% (97/458) failed their voiding trial. In our study, 62% (284/458) of women had a voiding trial on postoperative day 1, and 38% (174/458) underwent a same-day voiding trial. No differences were noted between groups comparing race, ethnicity, hysterectomy, urinary sling, estimated surgical blood loss, utilization of intraoperative or postoperative narcotics, or the proportion of same-day voiding trials. Women with postoperative urinary retention had higher mean prevoiding pain when compared with women without urinary retention (pain visual analog scale, 25 mm vs 12 mm [P < 0.001], respectively). After multiple-logistic regression analysis, a significant association between postoperative urinary retention persisted for prevoiding trial pain score (aOR, 1.02; 95% CI, 1.01-1.03), age (aOR, 1.05; 95% CI, 1.02-1.02), and anterior colporrhaphy (aOR, 2.13; 95% CI, 1.18-3.8). CONCLUSIONS: Prevoiding pain after pelvic surgery is significantly associated with increased rates of postoperative urinary retention.

Barriers to Care Affecting Presentation to Urogynecologists in a Community Setting.

OBJECTIVE: To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings. METHODS: Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care. RESULTS: One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01). CONCLUSION: This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care.

Factors complicating surgical management of the vulvar abscess.

OBJECTIVE: To delineate risk factors and demographics in those patients with vulvar abscess that required surgical intervention, identify the most common bacterial isolate present at the time of surgery and comment on the progression to necrotizing fasciitis and the need for reoperation. STUDY DESIGN: Retrospective chart review. RESULTS: A total of 47 vulvar abscesses with cellulitis were managed surgically. The most common isolate was methicillin-resistant Staphylococcus aureus (MRSA), which comprised 43% of the total. The median length of stay was 4 days (1-66), and 17% had stays >7 days. Diabetes was significantly related to hospitalization >7 days (38% vs. 6%, p<0.01), reoperation (25% vs. 3%, p=0.02) and progression to necrotizing fasciitis (19% vs. 0%, p=0.01). CONCLUSION: When treating abscess of the vulva with cellulitis, antibiotic coverage of MRSA should be undertaken. Inpatient management with aggressive treatment for abscess of the vulva in those patients with concomitant diabetes is recommended.

Intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy: a practice survey.

OBJECTIVE: To assess practice patterns concerning intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy among members of the Association of Professors of Gynecology and Obstetrics (APGO). STUDY DESIGN: A 16-question survey regarding intraoperative fetal heart rate monitoring during nonobstetric surgery was delivered to the 1300 APGO members via email. Descriptive statistics were used to determine the reasons for fetal monitoring during nonobstetric surgery in pregnancy. RESULTS: Concerning intraoperative monitoring during nonobstetric surgery, 98% of respondents recorded the fetal heart rate pre-and post-surgery, and 43% of respondents reported they usually monitor intraoperatively. Of the 1151 physicians surveyed, 16% completed the survey. CONCLUSION: The majority of APGO members surveyed do not employ intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy.