Dante Pascali

Effect of childhood dysfunctional voiding on urinary incontinence in adult women.

OBJECTIVE: To determine whether a history of childhood dysfunctional voiding is associated with urinary incontinence in adulthood. METHODS: Using a case-control study, we surveyed patients presenting with or without urinary incontinence. Cases were patients referred to a tertiary urogynecology clinic, and controls were patients referred to a general gynecology clinic. Patients completed a validated childhood questionnaire about dysfunctional voiding. A total score of 6 or more in girls is indicative of dysfunctional voiding, a condition characterized by urgency, frequency, constipation, urinary or fecal incontinence, and/or urinary tract infections. Using an alpha of 0.05, a power of 80%, and a baseline prevalence of dysfunctional voiding of 8%, we determined that 170 patients were needed to show a 3-fold difference between groups. RESULTS: Cases (n = 84) and controls (n = 86) had similar baseline characteristics except for body mass index and incidence of previous pelvic surgery. Although the total dysfunctional voiding score was higher in cases than controls (7.3 versus 5.0, respectively; P = .001), the difference in the number (%) of patients with history of childhood dysfunctional voiding between the 2 groups was not significant (47 [56%] versus 36 [42%], respectively; odds ratio 1.76, 95% confidence interval 0.96–3.24; P = .07). When all patients from both groups were combined, there was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (P = .004), urgency (P = .03), stress incontinence (P = .01), and urge incontinence (P = .009). CONCLUSION: Women with adult lower urinary tract symptoms may have a higher prevalence of history of childhood dysfunctional voiding. LEVEL OF EVIDENCE: II-2

Technical Update on Pessary Use

OBJECTIVE To review the use, care, and fitting of pessaries. OPTIONS Pessaries are an option for women presenting with prolapse and/or urinary incontinence. OUTCOMES Pessaries can be successfully fitted in the majority of women with excellent satisfaction rates and minimal complications. EVIDENCE PubMed and Medline were searched for articles published in English to September 2010, using the key words pessary, prolapse, incontinence, fitting, and complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force (Table 1). BENEFITS, HARMS, AND COSTS Women may choose a pessary for management of their prolapse and/or stress incontinence rather than opt for surgery. Major complications have been seen only with neglected pessaries. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. SUMMARY STATEMENTS AND RECOMMENDATION: Summary Statements 1. Most women can be successfully fitted with a pessary when they present with prolapse. (II-2) 2. Complications of pessary use are usually minor, and vaginal discharge is the most common complaint. (II-3) 3. Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation. (II-2) 4. Satisfaction rates with pessary use are very high. (II-2) Recommendation 1. Pessaries should be considered in all women presenting with symptomatic prolapse and/or urinary stress incontinence. (II-1A).

Treatments for Overactive Bladder: Focus on Pharmacotherapy

OBJECTIVE To provide guidelines for pharmacotherapy to treat overactive bladder syndrome (OAB). OPTIONS Pharmacotherapy for OAB includes anticholinergic (antimuscarinic) drugs and vaginal estrogen. Both oral and transdermal anticholinergic preparations are available. OUTCOMES To provide understanding of current available evidence concerning safety and clinical efficacy of pharmacotherapy for OAB; to guide selection of anticholinergic therapy based on individual patient characteristics. EVIDENCE The Cochrane Library and Medline were searched for articles published from 1950 to the present related to individual anticholinergic drugs. Review articles on management of refractory OAB were also examined. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to 2010. VALUES The quality of evidence is rated and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Anticholinergics are the mainstay of pharmacotherapy for OAB. EVIDENCE for their efficacy is mostly derived from short-term phase III randomized drug trials. Placebo response is strong, and long-term follow-up and patient subjective outcome data are lacking. Care providers need to be well acquainted with the side effects of anticholinergics and select therapy based on individual patient parameters. Recommendations 1. Behavioural management protocols and functional electrical stimulation should be offered in the spectrum of effective primary treatments for overactive bladder syndrome. (I-A) 2. Oral oxybutynin, immediate and extended release, as well as transdermal oxybutynin, may be offered as treatment for overactive bladder syndrome, as they are associated with significant objective clinical improvement at 12 weeks. (I-A) Oxybutynin immediate release has superior cost-effectiveness but more side effects than other anticholinergics. (I-A) Adverse events associated with transdermal oxybutynin are fewer than with oral oxybutynin. (I-A) 3. Tolterodine, immediate and extended release, may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) 4. Trospium, immediate and extended release, may be offered as treatment for overactive bladder syndrome as it is associated with significant clinical improvement at 12 weeks. (I-A) Trospium is an adequate anticholinergic choice for overactive bladder syndrome patients with pre-existing cognitive impairment (II-B) and for overactive bladder syndrome patients taking concurrent CYP450 inhibitors. (III-B) 5. Solifenacin may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) Solifenacin may be an adequate anticholinergic choice for elderly overactive bladder syndrome patients or patients with pre-existing cognitive dysfunction. (I-B) 6. Darifenacin may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) Darifenacin is an adequate anticholinergic choice for overactive bladder syndrome patients with pre-existing cardiac concerns or cognitive dysfunction. (I-B) 7. Overactive bladder syndrome patients should be offered a choice between bladder training, functional electric stimulation, and anticholinergic therapy, as there is no difference in cure rates. Combination therapy does not have a clear advantage over one therapy alone. (I-A) 8. The choice of anticholinergic therapy should be guided by individual patient comorbidities, as objective efficacy of anticholinergic drugs is similar. (I-A) Dose escalation does not improve objective parameters and causes more anticholinergic adverse effects. It is, however, associated with improved subjective outcomes. (I-A) To decrease side effects, switching to a lower dose or using an extended release formulation or a transdermal delivery mechanism should be considered. (I-A) 9. Education on treatment efficacy, realistic expectations, and length of treatment should be offered to patients upon initiation of anticholinergic therapy, as continuation rates for anticholinergic therapy are low. (III-B) 10. Oral or transdermal estrogen supplementation should not be recommended for treatment of overactive bladder syndrome as its effects are comparable to placebo. (I-E) Vaginal estrogen can be suggested for subjective improvements in overactive bladder syndrome symptoms. (III-B) 11. Intravesical botulinum toxin injection and sacral nerve and posterior tibial nerve stimulation are clinically effective options for patients with overactive bladder syndrome unresponsive to conservative options, anticholinergics, or vaginal estrogen. (I-A).

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair

OBJECTIVE To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. OPTIONS Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. OUTCOMES The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. EVIDENCE Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Randomized Trial of Oxybutynin Extended Versus Immediate Release for Women Aged 65 and Older with Overactive Bladder: Lessons Learned from Conducting a Trial

OBJECTIVE This trial was designed to investigate the effectiveness of extended release versus immediate release oxybutynin in reducing symptoms of overactive bladder in a community-dwelling female population over the age of 65. METHODS This was a prospective randomized 12-week, open-label study. The primary outcome was number of micturitions per 24 hours, 12 weeks after treatment. The a priori sample size estimate was 60 patients per group. RESULTS Of the 318 women approached, only 72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely because of recruitment difficulties and an interim analysis revealing the need for a much larger sample than had been estimated to show a significant difference between treatments. After 12 weeks of treatment, there was no difference between the oxybutynin extended release and immediate release groups in the number of micturitions per 24 hours or in other outcomes. CONCLUSION This study did not demonstrate differences between oxybutynin extended release and immediate release and in reducing symptoms of overactive bladder or quality of life, possibly because the study did not reach the necessary sample size. The difficulty in recruiting subjects for the trial likely resulted from the onerous study requirements (4 study visits required over 12 weeks) and the downtown location of the study centres: these factors would cause particular difficulties for women over age 65 with overactive bladder, for whom travelling may be a problem. Evidence is needed to guide prescribing for older patients, but designing research to obtain adequate sample sizes is difficult. Studies in older subjects should ensure that a much larger budget is allocated for recruitment than would be allocated for studies in younger subjects, that meticulous attention is paid to issues of transport and access, and that support is provided for subjects who agree to take part research.

Vaccination attitudes and mobile readiness: A survey of expectant and new mothers

Sub-optimal vaccination coverage and recent outbreaks of vaccine-preventable diseases serve as a reminder that vaccine hesitancy remains a concern. ImmunizeCA, a new smartphone app to help track immunizations, may address several reasons for not vaccinating. We conducted a study to describe demographic variables, attitudes, beliefs and information sources regarding pediatric vaccination in a sample of childbearing women who were willing to download an immunization app. We also sought to measure their current mobile usage behaviors and determine if there is an association between participant demographics, attitudes, beliefs and information sources regarding pediatric vaccination and mobile usage. We recruited participants using a combination of passive and active methods at a tertiary care hospital in Ottawa, Canada. We used surveys to collect demographic information, examine attitudes, behavior, and information sources regarding immunization and self-reported mobile phone usage. A total of 54 women participated. The majority had positive attitudes toward vaccination (96%) and intended to vaccinate their children (98%). Participants were interested in information on pediatric vaccination (94%), and found information from public health the most reliable and accessible (78%). Participants also trusted immunization information from their doctor or nurse and public health (83%) more than other sources. There was variability in participant use of mobile apps for other purposes. The median participant mobile readiness score was 3.2. We found no significant associations between participant age, behavior and attitudes regarding vaccination and mobile readiness scores. This is the first evaluation of mobile readiness for a smartphone app to track immunizations. Our findings suggest that there exists an opportunity to provide reliable information on vaccination through mobile devices to better inform the public, however predictors of individual engagement with these technologies merits further study.

Deep Endometriosis Infiltrating the Bladder Mucosa

A 29-year-old G1A1 woman presented with symptoms of dysmenorrhea, dyspareunia, dysuria, and dyschezia. She also complained of a sensation of bladder pressure and postvoiding discomfort unrelated to her menses. An advanced gynecologic ultrasound performed for endometriosis at our center showed a 2-! 1.9-cm vascular nodule with papillary projections infiltrating into the bladder wall (Fig. 1A), along with other findings indicative of endometriosis. However, malignancy could not be excluded due to the vascular appearance and papillary projections. Cystoscopy revealed an irregular-shaped papillary mass over the upper trigone with no active bleeding (Fig. 1B). A transurethral resection of the lesion was performed, and pathology confirmed endometriosis. Following resection, medical management with dienogest provided complete relief of symptoms. Urinary tract endometriosis can occur in up to 52% of women presenting with deep endometriosis [1]. Transvaginal ultrasound is sensitive in diagnosing bladder endometriosis [2]. Management options include partial cystectomy [3] or medical treatment with dienogest [4].

Water-Related Vaginal Injury: A Case Report and Review of the Literature

BACKGROUND Vaginal injury can result from entry of water into the vagina under high pressure. Previously reported cases describe water-jet vaginal injuries in women participating in water-related activities, including: water skiing, personal watercraft use, waterslides, water hose and fountains, with and without foreign body in situ. CASE We describe the case of a severe vaginal laceration and hemorrhage in a 44-year-old female from a high-pressure water-jet generated during a water-ski fall requiring operative repair. Timely management resulted in excellent patient outcome. CONCLUSION A literature review demonstrated that, although uncommon, watersport-related gynaecologic injuries can be life-threatening, and women who regularly engage in watersports can be counselled regarding potential preventative measures. Physicians encountering patients with these injuries should rule out intraperitoneal injury and consider benefits of antibiotics.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes

STUDY OBJECTIVE Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Predictors of sling revision after mid-urethral sling procedures: a case-control study

To identify patient characteristics and surgical factors predictive of complications requiring mid‐urethral sling (MUS) revision/removal.