Una J. Lee

Health literacy and disease understanding among aging women with pelvic floor disorders.

Objectives Few studies on health literacy and disease understanding among women with pelvic floor disorders have been published. We conducted a pilot study to explore the relationship between disease understanding and health literacy, age, and diagnosis type among women with urinary incontinence and pelvic organ prolapse. Methods The study subjects were recruited from urology and urogynecology specialty clinics based on a chief complaint suggestive of urinary incontinence or pelvic prolapse. Subjects completed questionnaires to assess symptom severity, and health literacy was measured using the Test of Functional Health Literacy in Adults. Patient-physician interactions were audiotaped during the office visit. Immediately afterward, patients were asked to describe diagnoses and treatments discussed by the physician and record them on a checklist, with follow-up phone call, where the same checklist was administered 2 to 3 days later. Results A total of 36 women with pelvic floor disorders, aged 42 to 94 years, were enrolled. We found that health literacy scores decreased with increasing age. However, all patients had low percentage recall of their pelvic floor diagnoses and poor understanding of their pelvic floor condition despite high health literacy scores. Patients with pelvic prolapse seemed to have worse recall and disease understanding than patients with urinary incontinence. Conclusions High health literacy as assessed by the Test of Functional Health Literacy in Adults may not correlate with patients’ ability to comprehend complex functional conditions such as pelvic floor disorders. Lack of understanding may lead to unrealistic treatment expectations, inability to give informed consent for treatment, and dissatisfaction with care. Better methods to improve disease understanding are needed.

Women in Urology Residency, 1978-2013: A Critical Look at Gender Representation in Our Specialty.

OBJECTIVE To evaluate changes over time in female representation among urology residents compared to those within other specialties. MATERIALS AND METHODS Urology match data were obtained from the American Urological Association from 1996 to 2015. Trends in match rates of male and female urology applicants were assessed. Data for gender representation among residencies were extracted from reports in the Journal of the American Medical Association from 1978 to 2013. We compared the annual percentage of women among urology residents vs residents of other specialties over time. RESULTS Mean number of male vs female urology applicants per year was 285.0 ± 27.1 vs 76.5 ± 21.8 (P < .001). There was no statistically significant difference in the mean successful match rate of male vs female applicants (68.2% vs 66.6%, P = .36). From 1978 to 2013, the proportion of female residents across all specialties rose from 15.4% to 46.1%, whereas female residents in urology rose from 0.9% to 23.8%. Between 2009 and 2013, obstetrics and gynecology and orthopedics had the highest and lowest average proportion of women, respectively (80.7% and 13.5%). The largest growth occurred in urology among all other specialties (P < .001), with an 11-fold increase seen during the study period. CONCLUSION Male and female applicants to urology residency have similar match rates. Although urology demonstrated the greatest fold-increase in proportion of women among all specialties during the study period, women have remained a minority among urology residents. Gender representation within urology is a reflection of many factors and demonstrates a need for further improvement.

The Role of Mindfulness in Urinary Urgency Symptoms

Stress, anxiety, depression and patient perception play critical roles in bothersome urinary urgency and related syndromes overactive bladder and bladder pain syndrome. A robust body of brain imaging literature has identified brain changes that occur in patients with urinary urgency and urgency incontinence, and conversely, brain changes that occur after successful treatment of urinary urgency. In an effort to directly target the role central nervous system (CNS) abnormalities in urinary urgency, which occur in regions for high-order function areas for attention, awareness, emotion, and interoception, mindfulness therapies have emerged as a promising treatment option. Mindfulness is the practice of nonreactive awareness of thoughts and sensations, which may reorient cognitive and emotional responses to bladder sensations. Recent studies examining mindfulness therapy for urinary urgency show promising results for a conservative intervention that directly targets the relevant CNS mechanisms now being elucidated.

Inconsistency in the definition of urinary tract infection after intravesical botulinum toxin A injection: a systematic review

Purpose: To more accurately examine the rate of urinary tract infection following onabotulinumtoxinA injection of the bladder we systematically reviewed the literature for definitions of urinary tract infection in studies of onabotulinumtoxinA injections. We assessed the studies for consistency with guideline statements defining urinary tract infections. Materials and Methods: We systematically reviewed the literature by querying MEDLINE® and Embase®. We included original studies on adult patients with idiopathic overactive bladder and/or neurogenic detrusor overactivity who underwent cystoscopy with onabotulinumtoxinA injection and in whom urinary tract infection was a reported outcome. Results: We identified 299 publications, of which 50 met study inclusion criteria. In 27 studies (54%) urinary tract infection diagnostic criteria were defined with a total of 10 definitions among these studies. None of the overactive bladder studies used a definition which met the EAU (European Association of Urology) criteria for urinary tract infection. Only 2 of the 10 studies on patients with neurogenic bladder used a urinary tract infection definition consistent with the NIDRR (National Institute on Disability and Rehabilitation Research) standards. Conclusions: Definitions of urinary tract infection are heterogeneous and frequently absent in the literature on onabotulinumtoxinA to treat overactive bladder and/or neurogenic bladder. Given the potential for post‐procedure urinary symptoms in this setting, explicit criteria are imperative to establish the true urinary tract infection rate following treatment with onabotulinumtoxinA.

Selection of Concomitant Vaginal Procedures

Robotic sacrocolpopexy (RASC) is a minimally invasive abdominal apical suspension procedure for women with pelvic organ prolapse (POP); however, there is controversy and a diversity of expert opinions as to the best management of defects in other vaginal compartments at the time of RASC, as the coexistence of multiple defects is common. Some surgeons feel that the apical support of RASC alone is adequate to restore anatomy and resolve prolapse and associated urinary, defecatory, and sexual symptoms. Some advocate a technique of distal anchoring of the sacrocolpopexy mesh to achieve this restoration. Other surgeons routinely perform concomitant vaginal repairs to address anterior and/or posterior compartment prolapse. There are few, if any, comparative studies of these approaches to evaluate success, recurrence, or impact on associated symptomatology. Existing observational evidence of both approaches and impact on outcomes is reviewed. The pelvic floor surgeon may utilize available data as an aid in discussing patient goals of treatment and surgical options for concomitant vaginal procedures, including risks and benefits of various approaches, to reach a shared decision with the patient.

PD54-03 OPTIMIZING LEAD PLACEMENT DURING STAGED SACRAL NEUROMODULATION (SNM): FACTORS ASSOCIATED WITH PROGRESSION TO STAGE 2

INTRODUCTION AND OBJECTIVES: Sacral neuromodulation (SNS) is an effective therapy; however, these devices are not approved to undergo magnetic resonance imaging (MRI) of sites other than the brain. Therefore, when non-brain MRIs are required, devices are often removed prior to imaging. We assessed the frequency of device removal for MRI and the subsequent clinical course of these patients. METHODS: A retrospective review of all SNS procedures in the urology department at a tertiary care center from 2010-2015 was performed and explants identified. Cases explanted for MRI were analyzed to collect demographics, clinical characteristics, and postremoval management. Descriptive statistics were calculated and presented as mean(standard deviation) or median[interquartile range] as appropriate. RESULTS: A total of 90 patients underwent SNS device removal, with 21(23%) occurring for MRI, of which all devices were implanted in 2012 or before. At explant, patients were 95%(N1⁄420) female, 66[52-72] years of age, and had a 29.6[23.8-34.6] kg/m2 body mass index. Suboptimal symptom control from SNS was noted in 7(33%) patients prior to explantation and 4 patients in the cohort (19%) had Multiple Sclerosis. Of those explanted, 24% required MRI for neurologic and 57% for orthopedic concerns. The remaining MRI indications included abdominal masses (10%), genitourinary disease (5%), surveillance for prior spinal cord malignancy (5%), and cardiac disease (5%). Only 16 (76%) patients explanted ultimately underwent MRI, a median of 13[3-16] days after device removal. MRI results actively impacted clinical management in half of the imaged patients, with no pharmacologic interventions, but instead surgical evaluation (5), physical therapy/rehabilitation (1), an outpatient procedure (1), and a headache diary (1) being recommended. Only 10%(N1⁄42) of explanted patients underwent device replacement, while 7 patients resumed medical therapy, 3 utilized intermittent self-catheterization or an indwelling catheter, 2 patients pursued Botulinum toxin, 1 sought care with a local urologist, and 1 underwent cystectomy and ileal conduit urinary diversion. Of the remainder, 1 is deceased and 4 were lost to follow-up. CONCLUSIONS: In patients receiving SNS therapy, device removal for MRI is a rare event, most commonly due to orthopedic and neurologic pathologies. About half of the MRIs performed impacted clinical management. As SNS replacement was rare in this cohort, research is needed on the safety of various MRI types with SNS devices in vivo.