Omar Felipe Dueñas-Garcia

Patient-focused websites related to stress urinary incontinence and pelvic organ prolapse: a DISCERN quality analysis

Introduction and hypothesisThe quality of information related to pelvic floor disorders is varied and understudied. Using a validated instrument we evaluated the quality of selected websites addressing treatment options for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).MethodsEnglish-language, patient-focused professional, governmental, and consumer websites related to POP and SUI were identified using the International Urogynecology Association (IUGA) list of continence societies worldwide, search terms, and provider nomination. Websites were evaluated by 10 providers at an academic medical center, representing urogynecology (6), urology (3), and general gynecology (1). Quality assessment utilized the DISCERN instrument, a validated instrument consisting of 16 questions addressing the quality of consumer health information.ResultsWebsites of 13 organizations met inclusion criteria and were assessed, 12 relating to SUI and 8 to POP. The websites with the highest mean total DISCERN score for POP were those of the IUGA, the American Society of Colon and Rectal Surgeons, and the American Urogynecologic Association, and for SUI, the National Association For Continence, the American Urological Association, and the IUGA. High correlations were obtained for the total DISCERN score and the overall quality scores for POP (0.76) and SUI (0.82). The most commonly omitted components of the DISCERN instrument were a clear statement of the content objectives, references or sources of the content, and a discussion of what patients could expect if they opted for no intervention.ConclusionsAvailable English-language professional websites written to inform patients about management choices for SUI and POP miss key components of quality patient information.

Pharmacological Agents to Decrease New Episodes of Recurrent Lower Urinary Tract Infections in Postmenopausal Women. A Systematic Review.

Objectives The purpose of this systematic review was to evaluate and summarize pharmacological interventions evaluated in randomized clinical trials designed to prevent recurrent episodes of urinary tract infections (UTIs) in postmenopausal women. Methods Excerpta Medica dataBASE, Pubmed, Medline, and Cochrane Library were accessed to search for nonexperimental drugs evaluated in randomized clinical trials published in peer reviewed journals from January 1, 1970, to August 1, 2015, to reduce the number of recurrent UTIs in postmenopausal women. Results A systematic search yielded 9 articles that met eligibility criteria. Five articles involved the use of systemic or vaginal estrogen therapy and the remainder used oral antibiotics, lactobacilli, or a combination of interventions. Antibiotics were the most efficacious therapy but with a higher incidence of systemic side effects. Oral lactobacillus was noninferior to sulfamethoxazole with trimethoprim with a safer profile in 1 small study. Vaginal estrogen appeared to be inferior to continuous oral antibiotic suppression; however, use of multiple formulations of both treatment options precludes meta-analysis. Oral estrogen use did not decrease UTI recurrence and resulted in local and systemic side effects in up to nearly 30% of the patients. Conclusions This review supports the use of antibiotic suppression, vaginal estrogen, and oral lactobacillus for prevention of recurrent UTIs in postmenopausal women. However, the overall dearth of data suggests that this is an important but understudied population. Because the effectiveness and safety of available treatments are not well understood, they should be used with caution in older populations, pending further study.

Voiding Function After Midurethral Slings With and Without Local Anesthetic: Randomized Controlled Trial

Objectives This study aimed to compare the effect of periurethral infiltration of bupivacaine versus normal saline on postoperative voiding function and pain in patients undergoing retropubic midurethral sling Methods A randomized double-blind placebo-controlled study was performed at the University of Massachusetts from March 2012 to June 2015. Ninety patients were randomized to receive 0.5% bupivacaine with epinephrine or normal saline with epinephrine solution for periurethral hydrodissection. Postoperative pain was assessed at 2 to 3 and 6 to 7 hours using a visual analog scale. Voiding function was determined by the proportion of subjects passing or failing a voiding trial. Descriptive statistics and percentages were used to compare the rate of voiding dysfunction. A logistic regression analysis was performed adjusting for possible covariates. Results Ninety subjects enrolled and 45 were randomized to each group. Thirty-nine subjects received the normal saline and 41 received bupivacaine. The remaining 10 withdrew before the procedure. Pain scores at 2 to 3 hours did not differ between the groups (P = 0.837), but at 6 to 7 hours, patients who received bupivacaine had less pain (P = 0.028). There was no difference in voiding dysfunction between the study and placebo groups (17.9% and 24.4%, respectively; P = 0.481). Because of the unavailability of indigo carmine midway through the study, 36 of 80 subjects received preoperative phenazopyridine for the assessment of ureteral patency. Three (8%) of these subjects failed their voiding trial compared with 19 (30%) of the patients who did not receive phenazopyridine (P = 0.010). Conclusions The use of bupivacaine did not affect postoperative voiding function but had lower pain scores at 6 to 7 hours postoperatively. Preoperative phenazopyridine may reduce postoperative urinary retention.

The Effect of Preoperative Phenazopyridine on Urinary Retention Following Midurethral Sling

Objective The aim of this study was to determine the effect of preoperative oral phenazopyridine on short-term voiding dysfunction in patients undergoing a retropubic midurethral sling. Methods We conducted a retrospective cohort study in subjects undergoing a retropubic midurethral sling comparing those who received preoperative oral phenazopyridine with those who did not. We included all women who underwent a retropubic midurethral sling without concomitant procedures under general anesthesia at our institution. Slings were placed by either suprapubic or transvaginal approach, per surgeon’s preference. Demographics and intraoperative data on preoperative dose of phenazopyridine and medications linked to voiding dysfunction were captured. Results One hundred seventy-four subjects were identified. Twenty-five subjects failed to meet inclusion and exclusion criteria and were excluded, and 149 subjects comprised the final groups. Eighty-two subjects (55.03%) received phenazopyridine, and 67 (44.97%) did not. Most subjects received a 200-mg dose (97.6%). Except for surgical approach, both groups receiving and not receiving phenazopyridine had similar demographic characteristics. Eighty-eight percent of the subjects who received phenazopyridine passed the voiding trial versus 73.1% (odds ratio, 2.98; 95% confidence interval, 1.23–7.17). After adjusting for medications, estimated blood loss, number of trocar passages, or bladder perforation, the patients receiving phenazopyridine were still more likely to pass the postoperative voiding trials compared with those who did not (odds ratio, 2.97; 95% confidence interval, 1.10–7.98). Conclusions Our findings suggest that the preoperative administration of phenazopyridine may improve postoperative voiding function after a retropubic midurethral sling. Additional prospective trials are needed to confirm this finding.

Vaginal ectopic ureter simulating preterm premature rupture of membranes

Preterm premature rupture of membranes (PPROM) is defined as the rupture ofmembranes before labor and before 37weeks’ gestation. Usual differential diagnosis includes urinary incontinence, cervical mucus, excessive vaginal physiological secretions, malignancy, and vaginal infections [1]. The authors report a case in which a patient presented with spontaneous passage of copious vaginal fluid in the third trimester secondary to the presence of an ectopic ureter draining in the vagina.

A Randomized Controlled Trial of Patient-Controlled Valve Catheter and Indwelling Foley Catheter for Short-term Bladder Drainage.

Objective The purpose of this study was to compare catheter-related pain and quality-of-life scores between 2 catheters used after failed voiding trials following urogynecologic surgery. Methods Women failing an inpatient voiding trial requiring short-term catheterization after urogynecologic surgery were randomized to receive either a standard FC or a patient-controlled VC. Subjects completed a 6-item, visual analog scale–based postoperative questionnaire (POQ) and an outpatient voiding trial 3 to 7 days after surgery. Baseline demographic, surgical data, and results of the outpatient voiding trial were recorded. The primary outcome was the difference in mean score for catheter-related pain on the POQ, based on intent to treat. Secondary outcomes included between-group differences in means for individual POQ items and a calculated composite satisfaction score. The statistician was blinded to group assignment. Results Forty-nine subjects were randomized to FC (n = 24) and VC (n = 25). Two subjects, one in each group, were excluded from the primary analysis because of missing data. Mean age was 60.6 (SD, 12.5) years. Baseline characteristics were similar. Valve catheter users had a lower median catheter-related pain score (1.25 vs 2.3), but not significantly (P = 0.153). Valve catheter users had significantly lower median scores for frustration (1.2 vs 3.8; P = 0.018) and limitation on social activities (0 vs 7.6; P < 0.001). Mean composite satisfaction score was statistically significantly lower for the VC group (2.23 [SD, 1.83] vs 3.62 [SD, 1.95]; P < 0.01), suggesting greater satisfaction. Conclusions Valve catheter and FC users report similar catheter-related pain. Valve catheter users scored better in overall satisfaction, frustration, and limitations on social activities.

Urogynecology digest : presented by Omar F. Dueñas-Garcia.

This analysis of survey data obtained in the 2008 Swedish Pregnancy, Obesity and Pelvic Floor Study (SWEPOP) was performed to compare prevalence, severity, and bother of subtypes of urinary incontinence (UI), including stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) in women 20 years after a singleton birth either by vaginal delivery (VD) or elective cesarean delivery (CD). A Medical Birth Registry search yielded 10,117 potential participants, of whom 9,423 could be contacted. Mailed questionnaires comprised 31 questions regarding demographics, current symptoms of pelvic organ prolapse (sPOP) or UI subtypes, and a validated UI severity index (Sandvik). Likert responses to a UI-related bother question were dichotomized as minimal or bothersome. Of the 6,148 (65.8 %) who responded, 5,236 (55.5 % of potential participants) met inclusion criteria (e.g., no subsequent pregnancy or multiple birth). Overall prevalence of SUI was 15.3 %, UUI 6.1 %, and MUI 14.4 %. Prevalence of moderate to severe UI was 21.3 % and 13.5 % for VD and CD respectively, odds ratio (OR) 1.68; [95 % confidence interval (CI) 1.40–2.03], with severe UI reported by 19 % after both modes of birth. Bothersome UI was reported by 27.2 % of women with UI, with prevalence higher post-VD vs CD (11.2 % vs 6.3 %, OR 1.85; 95 % CI 1.42–2.39). Number-needed-to-treat to avoid one case of bothersome UI was 20 CD. Bothersomeness post-VD vs CD was only greater for MUI (difference 10.1 %, OR 1.65; 95 % CI 1.07–2.54). Linear regression demonstrated risk factors for overall UI severity to be any UUI, sPOP, long-term UI, and increased body mass index (BMI) (p<0.0001). In this cohort, primiparas with no subsequent birth were more likely to develop any UI subtype 20 years following a VD than those having delivered by CD. The prevalence of bothersome UI, severity of UI, and severity of each UI subtype were also higher for those who had VD vs CD. Strengths of the study include the differentiation of UI subtypes; measurement of occurrence, severity, and bother; control for maternal age, BMI, and infant weight; and calculation of need-to-treat statistics. Weaknesses include limits of a large database (e.g., unknown UI rates in general population, birth parameters, incorrect identification of nearly 10 % of potential participants). Study results highlight several areas for future research, including high bother reported with MUI, low numbers of bothered women seeking and receiving medical care, and cost analysis of surgical birth for UI prevention.