Association of Neighborhood-Level Socioeconomic Status With Prolapse Management Decision

IMPORTANCE

This study identifies how neighborhood-level socioeconomic status (SES) may affect patients' treatment decisions for pelvic organ prolapse (POP).

OBJECTIVE

This study aimed to evaluate the association of neighborhood-level SES with the decision of surgical versus conservative POP management.

STUDY DESIGN

This was a retrospective cohort study of patients newly diagnosed with POP at a tertiary medical center between 2015 and 2021. Patients lost to follow-up or poor surgical candidates were excluded. Patient characteristics, demographics, and treatment selection were abstracted from the electronic health record. Conservative management was defined as expectant, pessary, and/or pelvic floor physical therapy. Five-digit zip codes were linked to the Area Deprivation Index and used as a surrogate for neighborhood-level SES. Area Deprivation Indices were dichotomized at or below the sample median (less disadvantaged area) and above the sample median (more disadvantaged area). Logistic regression models estimated the odds of choosing surgical versus conservative management as a function of the Area Deprivation Index.

RESULTS

A total of 459 patients met the eligibility criteria (non-Hispanic White, 88.2%). The median age was 63 years (interquartile range, 52-70 years), and the majority had stage 2 POP (65.7%). Of all patients, 59.3% had Medicare/Medicaid, 39.9% were privately insured, and 0.9% were uninsured. Furthermore, 74.7% selected surgical management, and 25.3% chose conservative management. Increasing age and higher Pelvic Organ Prolapse Quantification System stage were significantly associated with selecting surgery (P = 0.01). Women residing in a more disadvantaged area had a 67% increased odds of choosing surgical over conservative management (adjusted odds ratio, 1.67; 95% confidence interval, 1.06-2.64) after adjusting for age, race/ethnicity, body mass index, and Pelvic Organ Prolapse Quantification System stage.

CONCLUSIONS

Residing in a more disadvantaged zip code was associated with 67% increased odds of choosing surgical versus conservative POP management.

Characterization of Pain Associated With Pelvic Organ Prolapse: Is Surgery the Answer?

IMPORTANCE

Data on the incidence of pelvic organ prolapse (POP)-related pain, risk factors for its development, and treatment effects of surgery remain sparse.

OBJECTIVES

The aims of the study were to evaluate the incidence and characteristics of POP-related pain in patients presenting with POP and assess the outcome of pain after surgery.

STUDY DESIGN

This was a retrospective study of patients presenting for initial evaluation of POP from May 2019 to May 2020. Using a standardized questionnaire, patients were asked "Do you have pain associated with your prolapse (not pressure or fullness)?" and to indicate pain severity and location(s). Patients who underwent surgery were asked postoperatively if their POP-related pain resolved. Patient and perioperative characteristics were obtained from the medical record and used to evaluate relationships between the presence and resolution of POP-related pain.

RESULTS

Of the 795 patients who met inclusion criteria, 106 (13.3%) reported POP-related pain. The mean age of all patients was 59.9 years, 38.1% had stage 3 or greater POP, and 52.1% were sexually active. Women with POP-related pain reported a median severity of 5 of 10. The most common pain locations were the vagina (46.6%), lower abdomen (27.4%), and back (9.6%). Fifty-seven women with pain (53.8%) underwent surgery, and 40 (70.2%) reported postoperative pain resolution. Of those who did not have resolution, pain improved or remained stable in severity. No patients reported worsening pain after surgery.

CONCLUSIONS

Pain is a symptom experienced by more than 1 in 8 women presenting with POP, with 70% reporting resolution of their pain postoperatively.

Current opinion: postpartum urinary disorders

PURPOSE OF REVIEW

The aim of this study was to describe the common postpartum urinary sequelae including urinary retention and incontinence, and to summarize the management of these conditions.

RECENT FINDINGS

Despite the high frequency of urinary disorders in obstetrics, screening and management protocols are rarely utilized by providers. Large variation exists in the literature regarding assessment of postpartum urinary retention, values of postvoid residuals and management of indwelling catheters in the immediate postpartum population. Recent expert guidance outlines a strategy for managing this condition.Research also highlights that screening for peripartum urinary incontinence is not a routine practice. The diagnosis is made more challenging by the fact that patients commonly understate and over-normalize their symptoms. Emerging studies have found that pelvic floor muscle training is cost-effective, preventive, and may improve symptoms in the postpartum setting.

SUMMARY

Increased awareness of urinary disorders in pregnancy and postpartum is imperative for appropriate diagnosis and management. Instituting standardized voiding protocols postpartum will allow providers to avoid undiagnosed postpartum urinary retention and its repercussions. Improved screening and education regarding urinary incontinence in the peripartum is important for early management, such as pelvic floor muscle training, and improved quality of life.

Postpartum urinary retention: an expert review

Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.

Starting a peripartum pelvic floor disorder clinic: what to expect in the first thirty-six months

INTRODUCTION AND HYPOTHESIS

Subspecialty peripartum pelvic floor disorder (PFD) clinics provide care to a unique patient population. We aim to describe the experiences of such a clinic in the first 36 months after its establishment.

METHODS

This is a descriptive case series of all women who presented to a subspecialty PFD clinic at an academic medical center over 36 months (January 2018-December 2020). Patient characteristics, referral patterns, and care plans will be described.

RESULTS

Four hundred eighty-three women presented for care. Women were a mean age of 31.0 ± 4.2 years, most were primiparous (404, 83.6%), and over half (279, 57.8%) had a spontaneous vaginal delivery. Three hundred eighteen women (66.9%) had obstetric anal sphincter injury (OASI), which was also the primary referral indication in 313 (64.8%). Most consultations were from an obstetrician (246, 51.3%), and the median time from delivery to evaluation was 17 days (IQR 11.0-34.0). The majority of women had one additional follow-up visit (330, 68.3%). One hundred forty-one (29.9%) women underwent minor office procedures, and 26 (5.4%) underwent surgery. The number of referrals sequentially increased from year 1 (59, 12.2%) to year 3 (215, 44.5%).

CONCLUSIONS

The 36-month experiences in our growing subspecialty peripartum PFD clinic demonstrate both sustainability and feasibility of this new service line, with consistent clinical growth over time and 483 new consultations, 2/3 of which were for OASI and the other 1/3 for a variety of peripartum pelvic floor indications. Our data outline a model for care, including timeline for follow-up, treatments administered, and number of interventions, both office and surgical.

Impact of Peripartum Antibiotics on Wound Complications in Women with Obstetric Anal Sphincter Injury

OBJECTIVE

To evaluate the role of antibiotics on preventing wound complications following obstetric anal sphincter injuries (OASI).

METHODS

This is a cohort study with retrospective and prospective components of women who sustained an OASI at vaginal delivery. The primary objective of this study was to assess the impact of prophylactic antibiotics at the time of delivery on perineal wound complications. Women were grouped based on peripartum antibiotic administration: no antibiotics (NABX), antibiotics for OASI wound complication prophylaxis (PABX), antibiotics for therapeutic indications (TABX), and antibiotics for any indication (AABX, PABX + TABX).

RESULTS

Four hundred and twenty-five women with OASI were included in this analysis. Most women experienced a third-degree perineal laceration (358, 84.2%). One hundred and sixteen (27.3%) women received NABX, 195 (45.9%) women received PABX, and 114 (26.8%) women received TABX. Cefazolin was the most common antibiotic in the PABX group. Perineal wound complications occurred in 51 (12.0%) women: 14 (12.4%) in NABX, 26 (13.3%) in PABX, 11 (9.6%) in TABX, and 37 (12.0%) in AABX. The incidence of perineal wound complications did not differ between groups.

CONCLUSIONS

In this cohort study, peripartum antibiotics did not reduce wound complication incidence following OASI. It is likely that a first-generation cephalosporin is not the ideal antibiotic in this clinical setting.

Intermediate term outcomes after transvaginal uterine-preserving surgery in women with uterovaginal prolapse

Introduction and hypothesis

There is growing interest in and performance of uterine-preserving prolapse repairs. We hypothesized that there would be no difference in pelvic organ prolapse (POP) recurrence 2 years following transvaginal uterosacral ligament hysteropexy (USLH) and sacrospinous ligament hysteropexy (SSLH).

Methods

This is a retrospective cohort study with a cross-sectional survey of women who underwent transvaginal uterine-preserving POP surgery from May 2016 to December 2017. Patients were included if they underwent either USLH or SSLH. POP recurrence was defined as a composite of subjective symptoms and/or retreatment. A cross-sectional survey was used to assess pelvic floor symptoms and patient satisfaction.

Results

A total of 47 women met the criteria. Mean age was 52.8 ± 12.5 years, and all had a preoperative POP-Q stage of 2 (55.3%) or 3 (44.7%). Thirty (63.8%) underwent SSLH and 17 (36.2%) underwent USLH. There were no differences in patient characteristics or perioperative data. There was no difference in composite recurrence (26.7% [8] vs 23.5% [4]) and retreatment (6.7% [2] vs 0%) retrospectively between SSLH and USLH groups at 22.6 months. Survey response rate was 80.9% (38) with a response time of 30.7 (28.0–36.6) months. The majority of patients (84.2%) reported POP symptom improvement, and both groups reported great satisfaction (89.5%). In respondents, 13.2% (5) reported subjective recurrence and 5.3% (2) underwent retreatment, with no differences between hysteropexy types. There were no differences in other pelvic floor symptoms.

Conclusions

Although 1 in 4 women experienced subjective POP recurrence after transvaginal uterine-preserving prolapse repair and <5% underwent retreatment at 2 years, our results must be interpreted with caution given our small sample size. No differences in outcomes were identified between hysteropexy types; however, additional studies should be performed to confirm these findings. Both hysteropexy approaches were associated with great patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04987-5

Peripartum pelvic floor disorder clinics inform obstetric provider practices

INTRODUCTION AND HYPOTHESIS

The objective of this study is to evaluate obstetric providers' knowledge and practice patterns since the establishment of a peripartum pelvic floor disorder clinic.

METHODS

This is a prospective, cross-sectional survey study of obstetric providers at an academic tertiary care health system. A 22-question survey was designed to collect provider demographic data, indications for and barriers to referrals, provider satisfaction, and impact of the clinic's existence on peripartum pelvic floor dysfunction diagnosis and management. Eligibility criteria included obstetrics and gynecology trainees, attending physicians, certified nurse midwives, and advanced practice providers.

RESULTS

There were 86 survey responses yielding a response rate of 72.1%. The majority of respondents were staff obstetricians (57.0%) or trainees (26.7%). Most commonly reported referral indications were third- and fourth-degree lacerations (94.9%), complex lacerations (70.5%), wound breakdown (57.7%), and urinary retention (53.8%). Regarding satisfaction with the peripartum pelvic floor disorder clinic, of referring providers, 77 (98.7%) agreed or strongly agreed that evaluations were useful for patients and 78 (100%) agreed or strongly agreed that evaluations were useful for themselves. Seventy-six (97.4%) respondents reported that they were very satisfied with the peripartum pelvic floor disorder clinic overall. The majority of respondents agreed or strongly agreed that the clinic increased their awareness of both obstetric anal sphincter injuries and their impact on maternal health (84.6%).

CONCLUSION

The introduction of a peripartum pelvic floor disorder clinic results in high obstetric provider satisfaction and positively impacts patient care through increased provider knowledge and awareness on the management of obstetric anal sphincter injuries.

Accurate diagnosis and repair of obstetric anal sphincter injuries: why and how

Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.

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Fertility and fertility preservation: knowledge, awareness and attitudes of female graduate students

PURPOSE

To evaluate the general knowledge of female graduate students on reproductive aging and fertility preservation options, as well as to investigate the perceptions, personal beliefs, and desires regarding fertility and preservation modalities.

MATERIALS AND METHODS

A cross-sectional online survey study of female graduate students and medical trainees from academic institutions in Ohio was performed. Women were excluded if the online survey was incomplete or if they were >45 years.

RESULTS

Analysis of 590 surveys was performed (response rate of 26.3%). Ninety-four percent (557/590) of subjects were between 20 and 35 years. Our respondents tended to be nulliparous (87%), married or in a relationship (51%) and interested in future fertility (77%). The reasons cited for delaying childbearing were multi-factorial, with career building noted most commonly (69%). Nearly 60% of women reported they would consider fertility preservation in the future; however, the majority (87%) cited two or more barriers. When asked about their desire for information on fertility preservation, 28% desired to receive education on their choices and 36% wanted their Ob/Gyn to discuss fertility preservation options. Women >30 years were significantly more likely to desire future fertility, want more fertility preservation education and consider pursuing fertility preservation in the future.

CONCLUSIONS

Graduate-level women often delay childbearing for professional pursuits. This study demonstrates a need for increased fertility preservation awareness and education, especially by Ob/Gyn providers.

Preservation of gonadal function in women undergoing chemotherapy: a systematic review and meta-analysis of the potential role for gonadotropin-releasing hormone agonists

PURPOSE

To evaluate the available randomized controlled trials (RCTs) in the literature investigating the use of gonadotropin-releasing hormone agonist (GnRHa) co-treatment for ovarian preservation in women receiving chemotherapy.

METHODS

A systematic review of the literature was performed from 1960 through 2017 to identify relevant RCTs. Included patients had lymphoma, ovarian cancer, or breast cancer. The primary outcome was the proportion of women who retained ovarian function after chemotherapy. Extracted data points included study design, patient characteristics, and proportion of women who developed premature ovarian failure (POF). A risk of bias assessment was performed according to the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The pooled odds ratio was calculated, and outcomes of individual studies were compared using the random-effects model with the inverse-variance method and the DerSimonian-Laird estimator.

RESULTS

Twenty-nine RCTs were identified, and 10 met criteria for inclusion in the meta-analysis. An analysis of patients who did not develop POF after chemotherapy revealed eight studies supporting the use of GnRHa (OR 1.83; 95% CI 1.34-2.49). The duration of benefit of GnRHa is unclear. An analysis of three studies with outcome data at 2 years revealed a non-significant OR of 0.53 (95% CI 0.22-1.30) for the preservation of ovarian function with GnRHa treatment.

CONCLUSION

GnRHa may have a protective effect against the development of POF after gonadotoxic chemotherapy; however, the duration of benefit is unclear and requires further study.

Preservation of gonadal function in women undergoing chemotherapy: a review of the potential role for gonadotropin-releasing hormone agonists

A cancer diagnosis in women of reproductive age has unique medical and psychosocial ramifications, especially with treatments that are known to cause gonadal toxicity. For patients who undergo chemotherapy, a multidisciplinary team approach is essential to ensure that the patients' reproductive wishes are addressed. Currently, embryo and oocyte cryopreservation are the standard of care for those who wish to preserve their fertility. The use of gonadotropin-releasing hormone agonists has been a source of debate with numerous studies that have investigated the efficacy on both fertility and ovarian function preservation. This review evaluates the current literature on the use of gonadotropin-releasing hormone agonists for preservation of gonadal function. Assisted reproductive technology is excellent for preservation of fertility but will not protect gonadal function. Protection of gonadal function is critical for the broader issues of health and quality of life as a result of a hypogonadal state. At this moment, gonadotropin-releasing hormone agonists are the only drug class available to protect gonadal function.

Do we need a robot in endometriosis surgery?

Since the initial approval of robotic surgery for gynecologic procedures in 2005, its use has been widely adopted, and its application has been expanded beyond hysterectomies and myomectomies. The role of robotics in endometriosis surgery remains controversial, as no randomized control trials have been conducted to evaluate its use over conventional laparoscopy, the current gold standard for diagnosis and treatment. The advantage of robotic surgery in early stage endometriosis remains unclear, whereas several case reports and retrospective studies have suggested a role for robotics in treating advanced stage and deep infiltrating endometriosis. Advantages in advanced stage endometriosis include lower blood loss and possible reduction in length of hospital stay, compared to conventional laparoscopy; however, operative times are consistently longer in robotic surgery with no differences in quality of life and fertility outcomes. Randomized control trials comparing robotic to conventional laparoscopy for endometriosis surgery are needed to more clearly define the role for this promising technology.

Ovarian Tissue Cryopreservation for Benign Gynecologic Disease: A Case of Ovarian Torsion and Review of the Literature

Ovarian tissue cryopreservation (OTC) is an emerging method for fertility preservation. Although OTC has been previously proposed for benign indications, to our knowledge this is the first report highlighting the use of OTC for the indication of ovarian torsion. A 36-year-old nulligravid woman with a history of recurrent ovarian torsion presented with an acute episode of ovarian torsion confirmed by ultrasound. She requested a laparoscopic oophorectomy because her previous oophoropexy had failed, and in light of this was counseled to undergo concurrent OTC. On laparoscopy, 10 strips of ovarian cortex were obtained. A portion of this tissue was sent for pathological analysis, which revealed a primordial follicle density of 167 follicles/mm(3), a primary follicle density of 38 follicles/mm(3), and minimal ischemic damage. Although the clinical application of OTC continues to evolve and requires further investigation, the possibility of expanding the indications for benign gynecologic conditions is promising.

A distraction technique for control of burn pain

Research has indicated that analgesics alone do not adequately relieve pain for 75% of patients with burns. The purpose of this study was to determine the effects of a distraction therapy, in which videos were used in combination with administration of analgesics, on intensity and quality of pain and on levels of anxiety in adults during burn dressing changes. The sample consisted of 17 patients who were randomly assigned to the treatment or the control group. The treatment group viewed video programs that were composed of scenic beauty accompanied by music. Each was asked to score his or her present pain intensity and pain rating index with the McGill questionnaire and anxiety with the Spielberger questionnaire before and after the dressing change. A nested general linear model using the "F" test in multiple regression analysis was adjusted for age, percent partial-thickness burn, and choice of topical agent demonstrated that the use of videos during the dressing changes significantly reduced pain and anxiety: present pain intensity (F = 8.69; p = 0.01), pain rating index (F = 5.57; p = 0.03), anxiety (F = 9.10; p = 0.01). It is recommended that the use of pain medication be augmented by use of videos during burn dressing changes.