E. Ann Gormley

Clinical assessment of urethral sphincter function

Measurements of urethral pressures, such as maximum urethral pressure, are widely believed to have relevance in the management of urinary incontinence despite evidence to the contrary. In this study maximum urethral pressure and the abdominal pressure required to cause stress incontinence were measured in 125 women with stress incontinence. In women the abdominal pressure required to cause stress incontinence was unrelated to maximum urethral pressure. These findings indicate that maximum urethral pressure has little relationship to urethral resistance to abdominal pressure. In the 9 children with myelodysplasia we compared the detrusor pressure with the abdominal pressure required to induce urethral leakage. These values also were quite different, indicating that as far as the urethra is concerned abdominal pressure and detrusor pressure are not equivalent forces.

Pubovaginal slings for the management of urinary incontinence in female adolescents

A pubovaginal sling is an effective treatment for type III incontinence secondary to poor proximal urethral sphincter function. We used a pubovaginal sling to treat incontinence in 15 female adolescents. The etiology of incontinence was spinal dysraphism in 10 patients and prior trauma in 3. Simultaneous bladder augmentation was performed in the remaining 2 patients for poor bladder compliance. Three patients required additional procedures including repeat slings in 2 and repeat augmentation in 1. Of 13 patients followed for more than 6 months 11 remain dry, 1 leaks small amounts and wears 1 pad per day, and 1 did not achieve acceptable continence and was subsequently managed with bladder augmentation and a Mitrofanoff procedure. The upper urinary tracts have remained normal in all 13 patients. The pubovaginal sling has proved to be safe and successful in these children. The overall continence rate of 92% compares favorably to other available modalities.

The Effect of Terazosin on Bladder Function in the Spinal Cord Injured Patient

We prospectively studied the effect of terazosin on bladder compliance in 12 spinal cord injured patients. All study patients had demonstrated previously poor compliance despite clean intermittent catheterization and maximum anticholinergic therapy. Patients were started on 5 mg. terazosin nightly for 4 weeks. They were evaluated with a history, physical examination, symptom score, and synchronous cystoscopy and cystometry before, during and after terazosin therapy. Detrusor compliance improved in all patients during the treatment phase. The change in bladder pressure and the safe bladder volume were statistically and clinically significant. Patients also reported fewer episodes of incontinence and dysreflexia. The improvement in compliance and continence suggests that in the spinal cord injured patient terazosin may have an effect on alpha receptors in the detrusor muscle or central effects and that improved compliance is not due to decreased outlet resistance.

Early clinical experience with adult bladder auto-augmentation

Five patients 18 to 73 years old underwent auto-augmentation for a small capacity, poorly compliant bladder. The mean operative time and hospital stay were 106 minutes and 6 days, respectively. No postoperative complications occurred. Followup ranged from 12 to 82 weeks. Bladder capacity increased from 75 to 310 cc or 40 to 310%. Compliance also improved in all patients. Three patients had reflux preoperatively, which resolved in 1 and improved in 2. Of 4 patients who were incontinent preoperatively 3 became continent postoperatively and extended the interval between catheterizations. Upper tract function has remained stable. No patient required enterocystoplasty to control bladder pressures.

MP51-03 OLDER AND WISER? CHANGES IN UNPROFESSIONAL CONTENT ON UROLOGISTS' SOCIAL MEDIA FROM RESIDENCY TO PRACTICE

INTRODUCTION AND OBJECTIVES: The AUA has encouraged social media use and published online professionalism guidelines. We previously found that at the completion of residency, 40% of recent urology graduates’ public social media contained unprofessional (UP) or potentially objectionable (PO) content. This study examines changes in urologists’ unprofessional social media content as they transition from residency to practice. METHODS: Facebook was queried with the names of all 2015 U.S. urology graduates 1 year after completion of residency. We determined UP/PO content using a rubric based on professionalism guidelines by the ACGME, AMA, and AUA. We noted users who publicly identified as a urologist or affiliated with the AUA. 3 reviewers conducted assessments with strong concordance (k>0.90). Comparisons were made with data from this cohort collected at the completion of training. RESULTS: Of 281 urologists, 198 (70%) had publicly-identifiable Facebook profiles. Of these, 85 (43%) contained any UP or PO content, including 35 (18%) with UP content. Common examples included images of and references to intoxication, explicit profanity, unprofessional behavior at work, and offensive comments about patients. Of the 201 public profiles in this cohort at completion of residency 1 year prior, most profiles (183, 91%) have remained public; of the 18 that were no longer publicly accessible, 9 (50%) had previously had UP/ PO content, indicating greater adherence by some urologists to the guidelines. Similarly, of the 80 urologists without public profiles 1 year prior, most (64, 80%) have remained unidentifiable; but of the 16 that have become publicly accessible since then, half had UP/PO content, suggesting parallel changes by other urologists against the guidelines. Of note, among the public profiles in the present analysis, 11 (6%) had posted new UP/PO content since entering practice. Comparing this cohort at present vs at completion of residency, there was minimal difference overall in how many had public profiles (70% vs 71%) or public UP/PO content (43% vs 40%). While more users now self-identified on Facebook as being a urologist (109 vs 85 one year prior), the proportion of them posting public UP/PO content increased (53% vs 47% one year prior). CONCLUSIONS: Most urologists who recently entered practice continue to have public Facebook profiles, and about half of these contain unprofessional content. Amidst a steady rise in users identifying as urologists online, the majority now have public UP/PO content, raising concern about their professional identities and public perceptions of the specialty.

PD46-08 FOLLOWING THE CROWD: PATTERNS OF CROWDSOURCING ON SOCIAL MEDIA AMONG UROLOGISTS

INTRODUCTION AND OBJECTIVES: One proposed advantage of urologists’ use of social media is efficient knowledge exchange by “crowdsourcing” clinical advice and community solutions to local challenges. This study examines patterns and functions of Twitterbased crowdsourcing among urologists. METHODS: A sample of Twitter users was developed using a list of U.S. urologists on Twitter from the AUA. Twitter feeds were reviewed for primary (ie, not in reply to another post) posts seeking clinical advice or input, as well as reply posts linked to primary posts of this nature. Posts by trainees and posts using the poll function were excluded. Authors’ 50 most recent posts were reviewed, and eligible posts were included for analysis. Authors’ demographic data were collected from public sources. When patient data was posted, we noted whether permission was cited. Content analysis was conducted by 2 reviewers; differences were resolved by consensus among all authors. RESULTS: After review of 98 urologists’ Twitter feeds, 276 posts in 23 crowdsourcing threads were collected for analysis. The reasons for crowdsourcing fell into 4 categories: urologists requesting ideas or solutions to a clinical dilemma (82 posts, 30%); urologists requesting advice about a surgical plan (77 posts, 28%); urologists requesting colleagues’ experiences with a device, medication, or finding (64 posts, 23%); and urologists wondering if colleagues would agree with a specific course of action (53 posts, 19%). Topics spanned oncology, stone disease, endourology, and reconstructive surgery. A bidirectional exchange was achieved in most queries; mean number of replies per thread was 11 (range 0-30), and mean number of authors replying to each thread was 5 (range 0-10). In threads with 1 reply, the author of the primary post wrote a followup question or comment 82% of the time. Recent completion of training (as a proxy for inexperience) did not appear to disproportionately motivate crowdsourcing; median time in practice among authors of primary posts was 7 years (range 1-22), and authors with 7 years in practice initiated 13 (57%) requests. Most requests were prompted by a specific patient; of the 23 threads, 15 (65%) referenced a patient or case. Among these patient-specific threads, 7 (47%) also included photos or radiographs, yet only 1 (7%) mentioned having obtained the patient’s permission. CONCLUSIONS: Urologists are now leveraging social media to crowdsource clinical guidance and experiential knowledge. As urologists’ Twitter use expands, these exchanges may grow in breadth and sophistication. Public dissemination of patient data remains a concern.

Are urodynamics needed before surgery for straightforward female stress incontinence

Detrusor overactivity. Detrusor overactivity may be detected on urodynamics. In a healthy woman with straightforward SUI this incidental discovery would not change the surgical plan. It does not reproduce the symptoms and may be an artifact of unphysiological fluid temperature or filling rate. If urge incontinence did occur on urodynamics, the diagnosis would change to stress predominant mixed incontinence. Assuming stress incontinence also is confirmed and is the predominant symptom, discovery of urge incontinence would not change the plan. The urge component often improves after stress incontinence surgery, and this improvement is not predicted by the presence or absence of urodynamic detrusor overactivity before surgery.