Rahel Nardos

Does the Urinary Microbiome Play a Role in Urgency Urinary Incontinence and Its Severity

Objectives: Traditionally, the urinary tract has been thought to be sterile in the absence of a clinically identifiable infection. However, recent evidence suggests that the urinary tract harbors a variety of bacterial species, known collectively as the urinary microbiome, even when clinical cultures are negative. Whether these bacteria promote urinary health or contribute to urinary tract disease remains unknown. Emerging evidence indicates that a shift in the urinary microbiome may play an important role in urgency urinary incontinence (UUI). The goal of this prospective pilot study was to determine how the urinary microbiome is different between women with and without UUI. We also sought to identify if characteristics of the urinary microbiome are associated with UUI severity. Methods: We collected urine from clinically well-characterized women with UUI (n = 10) and normal bladder function (n = 10) using a transurethral catheter to avoid bacterial contamination from external tissue. To characterize the resident microbial community, we amplified the bacterial 16S rRNA gene by PCR and performed sequencing using Illumina MiSeq. Sequences were processed using the workflow package QIIME. We identified bacteria that had differential relative abundance between UUI and controls using DESeq2 to fit generalized linear models based on the negative binomial distribution. We also identified relationships between the diversity of the urinary microbiome and severity of UUI symptoms with Pearsons correlation coefficient. Results: We successfully extracted and sequenced bacterial DNA from 95% of the urine samples and identified that there is a polymicrobial community in the female bladder in both healthy controls and women with UUI. We found the relative abundance of 14 bacteria significantly differed between control and UUI samples. Furthermore, we established that an increase in UUI symptom severity is associated with a decrease in microbial diversity in women with UUI. Conclusions: Our study provides further characterization of the urinary microbiome in both healthy controls and extensively phenotyped women with UUI. Our results also suggest that the urinary microbiome may play an important role in the pathophysiology of UUI and that the loss of microbial diversity may be associated with clinical severity.

Risk factors that predict failure after vaginal repair of obstetric vesicovaginal fistulae.

OBJECTIVE To identify anatomic characteristics and method of bladder closure that predict failure after repair of obstetric vesicovaginal fistulae. STUDY DESIGN A retrospective analysis of 1045 patients that underwent vaginal repair of vesicovaginal fistulae from January 2006 to December 2007 at the Addis Ababa Hamlin Fistula Hospital. RESULTS The fistulae were midvaginal (26%), adjacent to ureteral orifice (22%), circumferential (6%), had urethral compromise (10%), or had a combination of different locations (17%). Most had fair or good residual bladder size (83%) and minimal or moderate vaginal scarring (85%). Closure was in 1 layer in 48% and 2 layers in 52% with 89% cure, 11% failure, and 17% urethral incontinence. Failures were significantly associated with complete or partial urethral destruction, severe vaginal scarring, small bladders, and circumferential involvement. The 1-layer fistula closure was associated with failure but not after excluding small bladders. CONCLUSION Risk factors for failure include small bladder size, urethral destruction, circumferential involvement, and severe vaginal scarring.

Duration of bladder catheterization after surgery for obstetric fistula

To compare the surgical outcome at discharge and at 6‐months follow up in patients who underwent repair of obstetric fistulae with postoperative bladder catheterization for 10, 12, or 14 days.

Examining mechanisms of brain control of bladder function with resting state functional connectivity MRI

This aim of this study is to identify the brain mechanisms involved in bladder control.

Outcome of obstetric fistula repair after 10-day versus 14-day Foley catheterization

To compare outcome between 10‐day and 14‐day bladder drainage after obstetric fistula repair.

Measuring the levator hiatus with axial MRI sequences: Adjusting the angle of acquisition

We aimed to compare MRI measurements of the female levator hiatus and the most caudal “levator ani” muscles between image slices in a plane axial to the body (AxB) and an axial plane parallel to the direction of the puborectalis muscle (AxPRM).

Obesity and Pelvic Floor Dysfunction: Battling the Bulge

Importance Pelvic floor disorders (PFDs) comprise a broad spectrum of clinical conditions, including urinary incontinence, pelvic organ prolapse, fecal incontinence, and defecatory dysfunction. These disorders are common conditions that generate significant medical, emotional, social, and economic issues for many women. Obese women are disproportionately affected compared with their normal-weight peers, with more than half of women with a body mass index of greater than 35 kg/m2 reporting a PFD, compared with only 32% in women with a normal body mass index. Despite this prevalence, little research is available to help guide and tailor treatment in obese populations. Objective This review outlines current knowledge regarding the relative contribution of obesity to PFDs, as well as its effect on treatment implications. Evidence Acquisition Literature relating to the incidence and treatment of PFDs in obese populations was reviewed. Results Both nonsurgical and surgical weight loss improves all PFDs. Obese women benefit from pelvic floor training, biofeedback, and pharmacologic treatments of urinary and fecal incontinence. Surgical treatments of stress urinary incontinence note increased operative times and perhaps slightly lower cure rates, but overall good treatment success in obese women. No increased risks of complications or treatment failure were noted in obese women treated for prolapse surgically, and pessaries work well for both prolapse and stress urinary incontinence in obese women. Conclusions/Relevance Although literature regarding treatment of PFDs in obese women is limited, the available evidence demonstrates good treatment outcomes in obese populations. Further research into how to best counsel and optimize treatment of obese patients is essential as the obesity epidemic continues. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to understand how obesity may contribute to the etiology of PFDs including urinary incontinence, pelvic organ prolapse, and fecal incontinence; describe the behavioral, medical, and surgical interventions available for treatment of PFDs; and understand how obesity may influence the success of behavioral, medical, and surgical interventions for treatment of PFDs.

Maternal IL-6 during pregnancy can be estimated from newborn brain connectivity and predicts future working memory in offspring

Several lines of evidence support the link between maternal inflammation during pregnancy and increased likelihood of neurodevelopmental and psychiatric disorders in offspring. This longitudinal study seeks to advance understanding regarding implications of systemic maternal inflammation during pregnancy, indexed by plasma interleukin-6 (IL-6) concentrations, for large-scale brain system development and emerging executive function skills in offspring. We assessed maternal IL-6 during pregnancy, functional magnetic resonance imaging acquired in neonates, and working memory (an important component of executive function) at 2 years of age. Functional connectivity within and between multiple neonatal brain networks can be modeled to estimate maternal IL-6 concentrations during pregnancy. Brain regions heavily weighted in these models overlap substantially with those supporting working memory in a large meta-analysis. Maternal IL-6 also directly accounts for a portion of the variance of working memory at 2 years of age. Findings highlight the association of maternal inflammation during pregnancy with the developing functional architecture of the brain and emerging executive function.The authors show that maternal inflammation during pregnancy, indexed by IL-6, can be estimated from the newborn brain connectome and predicts future working memory performance in offspring at two years of age.

Pelvic floor levator hiatus measurements: MRI versus ultrasound.

Objective The objective of this study is to compare levator hiatus measurements between pelvic magnetic resonance imaging (MRI) and pelvic ultrasound (US) imaging modalities. Methods We performed pelvic MRI and 3-dimensional US in 37 asymptomatic nulliparous women. For the MRI protocols, we performed axial and sagittal sequences at rest. We then obtained sagittal sequences during Kegel squeeze and Valsalva maneuvers. Blinded to the findings of the MRI, we obtained 3-dimensional pelvic US images using a perineal approach at rest, Kegel and Valsalva maneuvers. Finally, we measured the levator hiatus in both sagittal and axial planes. Results For the resting sagittal measurements, the mean levator hiatus measurement using MRI (5.0 cm; SD, 0.8) is significantly greater than that using US (4.4 cm; SD, 0.6; P < 0.05). Although the absolute mean levator measurements between the 2 modalities are significantly different, this difference is not influenced by the magnitude of the measurements as noted in Bland-Altman plots of the limits of agreement. Conclusions We found that the MRI measurements obtained from the sagittal images were consistently greater than the corresponding US images. In contrast, there was not the same consistency of difference between MRI and US for the axial images. This suggests possible variation in acquisition planes for axial images or interpretation of landmarks for the sagittal images.

Reference lines in dynamic magnetic resonance imaging of the pelvic floor

Objective: To compare the variability in two commonly used reference lines in pelvic magnetic resonance imaging (MRI), the pubococcygeal line (PCL) and the sacrococcygeal to inferior pubis (SCIPP) line, with respect to their distance from pelvic floor points of interest. Methods: We obtained pelvic MR images of 20 asymptomatic nulliparous women who are part of an ongoing pelvic floor nerve injury postpartum study. The subjects underwent a high-resolution two-dimensional, T2-weighted sagittal pelvic MRI in the supine position using a GE Signa scanner with a body phased-array coil. We also obtained dynamic T2-weighted sagittal MR images in supine position during Kegel and Valsalva maneuvers. Using the midsagittal image, we measured the length of two reference lines: the PCL and the more cephalad SCIPP line. From each line, we then measured the perpendicular distance to the bladder neck and to the posterior margin of the anorectal angle (M-line). We compared the mean values of all measurements between the two reference lines with paired Student t tests. Result: The SCIPP line (mean [SD], 11.60 [0.91] cm) is longer than the PCL (mean [SD], 10.54 [0.85] cm) at rest (P < 0.001). There is no significant change in length from resting to Kegel maneuver or from resting to Valsalva maneuver in either reference line. Only the resting to Valsalva maneuver for the M-line was significantly different between the 2 reference lines (P = 0.02). The resting to Kegel for the perpendicular distance to the bladder neck and the M-line was not significantly different between the two lines. Conclusions: Both reference lines remain stable during pelvic floor maneuvers.