"O" no: a Reddit analysis of orgasmic dysfunction

Background

Female Reddit users frequently discussed potential causes of orgasm difficulties and its implications on mental health and relationships.

Aim

This study aimed to evaluate the experiences of women discussing orgasms on the Internet site Reddit. We sought to qualitatively analyze the topics that arose in users' discussions to better understand the potential causes of orgasm difficulties and its implications on quality of life.

Methods

Posts on the subreddit r/TwoXChromosomes containing the keywords "orgasm" and "climax" were included in the dataset. Posts and their associated comments were qualitatively analyzed using the grounded theory approach. Two independent researchers coded each thread to identify dominant themes and emergent concepts.

Outcomes

The most frequently coded primary topics included: (1) orgasm (32.2% [n = 337]), (2) psychological (17.8% [n = 186]), (3) relationships (15.4% [n = 161]), and (4) treatment (10.7% [n = 112]).

Results

Qualitative analysis of 107 threads and approximately 6300 comments resulted in 5 major categories: psychological aspect of orgasms, difficulty orgasming with partners, partners' responses to orgasmic dysfunction, types of orgasms, and treatments for orgasmic dysfunction. Preliminary themes included (1) the presence of an emotional component or history of trauma related to orgasmic difficulty, (2) difficulty orgasming with a partner regardless of ability to orgasm during masturbation and a variety of stimulation required to orgasm, (3) mixed partner responses to orgasmic dysfunction, (4) the definition of a normal orgasm, and (5) self-motivated treatment for orgasmic dysfunction, including clitoral stimulation devices and masturbation techniques. Notably, few posters discussed their orgasmic dysfunction with healthcare providers.

Clinical Translation

The study reveals insights into the possible causes, psychosocial implications, and treatment of orgasm difficulties from a patient perspective, and can guide future research on female orgasms in a more precise, patient-oriented direction.

Strengths and Limitations

The anonymous nature of the forum allowed for insight into sensitive topics related to female orgasms and sexual trauma. Limitations include the demographic distribution of Reddit users, which was primarily younger women in their 20s and 30s, which restricts generalizability.

Conclusion

Reddit provides a medium for individuals with orgasm difficulties to discuss their experiences. Posts addressed users' inability to orgasm, their mental health and relationships, the stimulation required for orgasm, and treatments for orgasmic dysfunction. Interestingly, very few posts discussed healthcare, potentially suggesting that women do not classify their orgasmic dysfunction as a health issue.

The Gender Gap in Promotions: Inhibitors and Catalysts, Strategies to Close the Gap

The gender gap is an amalgam of gender disparity issues in the workplace ranging from fewer opportunities to network, decreased funding for research, microaggressions, nebulous promotional criteria and difficulty achieving the perception of professionalism because of inherent gender bias. Contributing home factors include more substantial household duties for women typically, spouses who also have a career, and the inherent delay associated with maternity leave for those who choose to have children. This article subdivides gender disparity that impedes promotion into experiences inside and outside the workplace. Disparities within the workplace are divided into directly quantified versus qualitative differences.

Patient and Clinician Challenges with Anticholinergic Step Therapy in the Treatment of Overactive Bladder: A Narrative Review

Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β3-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β3-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.

Social Media and Apps in Urology

Purpose of Review

In this study, we aimed to review the common social media (SoMe) apps used and how they have impacted the practice and exchange of information, as well as the challenges of using SoMe in urology.

Recent Findings

SoMe has become increasingly popular in the urology community. Lay users often turn to SoMe to learn about urological health and share their own experiences, while medical professionals may use it for career development, networking, education, and research purposes.

Summary

It is important to recognize the power of SoMe and to use it responsibly and ethically, particularly given the potential risks of encountering low-quality or misleading information.

#Coronavirus on TikTok: user engagement with misinformation as a potential threat to public health behavior

Coronavirus disease (COVID)-related misinformation is prevalent online, including on social media. The purpose of this study was to explore factors associated with user engagement with COVID-related misinformation on the social media platform, TikTok. A sample of TikTok videos associated with the hashtag #coronavirus was downloaded on September 20, 2020. Misinformation was evaluated on a scale (low, medium, and high) using a codebook developed by experts in infectious diseases. Multivariable modeling was used to evaluate factors associated with number of views and presence of user comments indicating intention to change behavior. One hundred and sixty-six TikTok videos were identified and reviewed. Moderate misinformation was present in 36 (22%) videos viewed a median of 6.8 million times (interquartile range [IQR] 3.6-16 million), and high-level misinformation was present in 11 (7%) videos viewed a median of 9.4 million times (IQR 5.1-18 million). After controlling for characteristics and content, videos containing moderate misinformation were less likely to generate a user response indicating intended behavior change. By contrast, videos containing high-level misinformation were less likely to be viewed but demonstrated a nonsignificant trend towards higher engagement among viewers. COVID-related misinformation is less frequently viewed on TikTok but more likely to engage viewers. Public health authorities can combat misinformation on social media by posting informative content of their own.

A qualitative analysis of female Reddit users' experiences with low libido: how do women perceive their changes in sexual desire?

BACKGROUND

The true prevalence of low sexual desire among women is disputed among researchers due to the complex nature and presentation of women's sexual problems.

AIM

To qualitatively analyze the aspects of libido/sexual desire frequently discussed by Reddit users and compare them with the current understanding of female sexual well-being and sexual desire disorders.

METHODS

By using the Reddit application programming interface, the TwoXChromosomes subreddit was queried for posts with the keywords libido and sex drive. Posts that were deleted or unrelated to themes of libido/sex drive were excluded. A total of 85 threads-63 queried from the keyword libido and 22 from sex drive-and approximately 2900 comments were qualitatively analyzed per the grounded theory approach. Five independent researchers read and coded each thread to identify dominant themes and emergent concepts.

OUTCOMES

Outcomes of interest included codes related to sexual dysfunction, libido, orgasm, masturbation, types of sex, psychology, relationships, intimacy, treatment, medications, and health care.

RESULTS

Posters were primarily heterosexual women in their 20s and 30s. The code categories with the highest frequency were relationships (22.7%, n = 272), libido (22.2%, n = 210), psychological (20.2%, n = 191), medications (7.29%, n = 69), and intimacy (6.0%, n = 57). Users frequently described a decrease in libido secondary to medications, particularly antidepressants and hormonal birth control. Many users discussed the challenges of navigating a relationship with low sexual desire and the resulting sexual distress. Posters described feelings of sadness, anxiety, and guilt due to their low desire. Additionally, users discussed the role that sex plays in relationships, whether as a way to develop intimacy between partners or to achieve orgasm. Finally, posters expressed dissatisfaction with health care addressing their concerns surrounding sexual desire.

CLINICAL IMPLICATIONS

The study findings-namely, the impact of medications on sexual health, the interaction of sexual desire and mental health, and cited examples of inadequate sexual health care-can help guide sexual well-being research, diagnosis, and public policy.

STRENGTHS AND LIMITATIONS

Using Reddit as a data source allowed for the analysis of women's experiences outside the preestablished concepts of female sexual desire. Limitations to the study include the potential for posts to be deleted by moderator guidelines, the young demographic distribution of Reddit users, and the popularity-based structure of subreddit threads.

CONCLUSION

Our results emphasize the psychosocial aspects of sexual desire and the need to redefine sexual problems to encompass the complex nature of female sexual well-being.

Assessment of Stress Urinary Incontinence-Related Podcasts on Stitcher

OBJECTIVE

To assess the quality, understandability, actionability, accuracy and commercial bias of podcasts regarding stress urinary incontinence (SUI).

METHODS

The first 100 Stitcher podcasts from the search, "Stress urinary incontinence" were evaluated using the validated DISCERN criteria, PEMAT tool, and a Misinformation Likert Scale. The accuracy of information was assessed by comparison to the American Urological Association (AUA) SUI Guidelines.

RESULTS

Common publisher types included health/wellness channels (66%). Low-moderate quality, poor understandability and misinformation was seen in 67% (DISCERN ≤3), 69% (PEMAT understandability ≤75%) and 17% of podcasts, respectively. Treatments discussed included pelvic floor muscle training (PFMT) (89%) and surgery (47%). Health and wellness channels had the most evidence of commercial bias (44%). Podcasts that discussed surgery more often emphasized shared decision-making (DISCERN15).

CONCLUSION

SUI-related podcasts on Stitcher are mostly published by health/wellness channels and skewed toward discussing PFMT. Podcasts are often low-moderate quality, poorly understandable and often have commercial bias.

A Contemporary Evaluation of Urological Outcomes After Renal Transplantation

INTRODUCTION

Urological surgery after renal transplantation leaves patients at risk of infection and further urological complications. Our objective was to discern patient factors associated with adverse outcomes following renal transplantation to identify patients who would benefit from close urological follow-up.

METHODS

Retrospective chart review was conducted for patients undergoing renal transplantation between August 1, 2016 and July 30, 2019 at a tertiary care academic center. Data on patient demographics, medical history, and surgical history were collected. Primary outcomes observed were urinary tract infection, urosepsis, urinary retention, unexpected urology visit, and urological procedures within 3 months of transplant. Variables determined significant by hypothesis testing were used in logistic regression modeling for each primary outcome.

RESULTS

Of the 789 renal transplant patients, 217 (27.5%) developed postoperative urinary tract infection and 124 (15.7%) developed postoperative urosepsis. Patients with postoperative urinary tract infection were more likely to be female (OR 2.2, P < .01), have pre-existing prostate cancer (OR 3.1, P < .01), and recurrent urinary tract infections (OR 2.1, P < .01). After renal transplant, unexpected urology visits were observed in 191 (24.2%) patients, and urological procedures were performed in 65 (8.2%) patients. Postoperative urinary retention was noted in 47 (6.0%) patients and seen more often in patients with benign prostatic hyperplasia (OR 2.8, P = .033) and prior prostate surgery (OR 3.0, P = .072).

CONCLUSIONS

Identifiable risk factors associated with urological complications after renal transplantation include benign prostatic hyperplasia, prostate cancer, urinary retention, and recurrent urinary tract infections. Female renal transplant patients are at increased risk of postoperative urinary tract infection and urosepsis. These patient subsets would benefit from establishing urological care and pre-transplant urological evaluation including urinalysis, urine cultures, urodynamic studies, and close follow-up post-transplant.

Association of lower urinary tract symptoms and diuretic adherence

OBJECTIVE

To assess whether more severe urinary symptoms and poorer quality of life among patients on diuretic therapy are associated with decreased adherence to the diuretic regimen.

METHODS

Participants were recruited via ResearchMatch.org and sent a REDCap survey. The Overactive Bladder Questionnaire-Short Form (OAB-q SF) was used to assess urinary symptom bother and health-related quality of life (HRQL). Participants were asked if they skip diuretic doses due to urinary symptoms with a bivariate (yes or no) outcome. Subgroup analyses of loop vs non-loop diuretic and those taking the diuretic for a cardiovascular indication (hypertension or heart failure) were performed.

RESULTS

A total of 4029 surveys were sent, 285 were returned (7.1% response rate), and 279 were included in the study. Fifty-three participants admitted to skipping diuretic doses due to urinary symptoms. Lower HRQL scores were significantly associated with poorer adherence scores among all participants (P < .001), among participants taking a loop diuretic (P < .001), and among participants with hypertension and heart failure (P < .039). Association between symptoms and adherence remained significant after adjustment in the multivariate model for the whole cohort and loop diuretic subgroup but lost significance in the hypertension and heart failure subgroup.

CONCLUSIONS

Worsening quality of life due to urinary symptoms may be associated with poorer adherence to diuretics, particularly loop diuretics.

Sigmoid conduit-neovaginal fistula: a case report and literature review

Total pelvic exenterations (TPE) are high morbidity procedures, with up to 38% of patients experiencing a major complication after TPE surgery. We report the case of a 69-year-old woman with a sigmoid conduit-neovaginal fistula who presented with new onset continuous vaginal leakage and decreased urostomy output 3 months post-op from a TPE. We highlight the presentation, diagnosis, conservative management, and surgical management of conduit-vaginal fistulas.

Identifying Patient-Centered Research Priorities in Overactive Bladder by Crowdsourcing and Targeted Recruitment

INTRODUCTION

Patient perspectives in quality-of-life improvement are critical to measuring treatment outcomes. We aimed to identify patient priorities for overactive bladder (OAB) research.

METHODS

Participants were recruited utilizing the Amazon Mechanical Turk database, an online marketplace where individuals receive payment for completing tasks. Those who scored 4 or higher on the OAB-V3, a simple 3-question screening survey, were requested to complete an "OAB-q and Prioritization Survey," which identified preferences for future OAB research priorities, demographic and clinical data, and symptom severity via the OAB-q. Participants must have correctly answered an attention-confirming question to have their responses included in the final analysis.

RESULTS

Of 555 responders, 352 screened positive on the OAB-V3 and 232 completed the followup survey and met study criteria. The top 3 research preferences were: discovering the etiology of OAB (31%); individualized treatment based on age, race, gender and comorbidities (19%); and identifying the fastest OAB treatments (15%). Participants who selected etiology of OAB in the top 3 research priorities (56%) were older (38.7±2.1 vs 33.9±1.5 years, p=0.05) and had significantly lower mean health-related quality of life scores than those who did not (25.1±2.5 vs 35.5±3.9, p=0.02).

CONCLUSIONS

Using Amazon Mechanical Turk, we present the first report of OAB research priorities identified by patients experiencing OAB symptoms. Crowdsourcing offers a timely and cost-effective manner to learn directly from people with OAB symptoms. Few participants sought treatment for OAB despite having bothersome symptoms.

Women in Academic Urology: A Qualitative Analysis of the Relationship Between Pregnancy, Parenting and Delayed Promotion

OBJECTIVE

To determine the role that the burden of childbearing, including pregnancy and maternity leave, play in academic promotion for women in urology, which has been shown to be delayed as compared to their male counterparts.

METHOD

Female academic urologists of varying academic rank who have children were invited to participate in a semi-structured interview. A representative sample from multiple subspecialties and geographic locations were targeted. Topics addressed included pregnancy, maternity leave, parenting, and promotion in academic urology. Transcripts of the interview were analyzed using grounded theory methodology.

RESULTS

Eleven participants were interviewed, including 3 assistant, 5 associate, and 3 full professors. The majority of participants chose to time pregnancy with training either during less strenuous portions or avoiding residency altogether. Nearly half endorsed self-inflicted hardships during pregnancy or early postpartum to prevent inconveniencing colleagues or to "pull their weight" in accordance with surgical culture. Outsourcing of childcare and household duties, along with spousal support, were discussed as contributing to success. Lack of transparency for promotional criteria was identified as a significant obstacle to promotion. Sponsorship and self-motivated information gathering were identified as critical components to success in promotion.

CONCLUSION

A culture of support created by administration and colleagues is critical for a positive experience with childbearing, and return to clinical practice or training postpartum. Explicit promotional criteria that are accessible in early career development and sponsorship from members of the academic department or subspecialty community are crucial for all urologists, but for women in particular.

Exploring Urological Malignancies on Pinterest: Content Analysis (Preprint)

Background

Pinterest is a visually oriented social media platform with over 250 million monthly users. Previous studies have found misinformative content on genitourinary malignancies to be broadly disseminated on YouTube; however, no study has assessed the quality of this content on Pinterest.

Objective

Our objective was to evaluate the quality, understandability, and actionability of genitourinary malignancy content on Pinterest.

Methods

We examined 540 Pinterest posts or pins, using the following search terms: “bladder cancer,” “kidney cancer,” “prostate cancer,” and “testicular cancer.” The pins were limited to English language and topic-specific content, resulting in the following exclusions: bladder (n=88), kidney (n=4), prostate (n=79), and testicular cancer (n=10), leaving 359 pins as the final analytic sample. Pinterest pins were classified based on publisher and perceived race or ethnicity. Content was assessed using 2 validated grading systems: DISCERN quality criteria and the Patient Education Materials Assessment Tool. The presence of misinformation was evaluated using a published Likert scale ranging from 1=none to 5=high.

Results

Overall, 359 pins with a total of 8507 repins were evaluated. The primary publisher of genitourinary malignancy pins were health and wellness groups (n=162, 45%). Across all genitourinary malignancy pins with people, only 3% (n=7) were perceived as Black. Additionally, Asian (n=2, 1%) and Latinx (n=1, 0.5%) individuals were underrepresented in all pins. Nearly 75% (n=298) of the pins had moderate- to poor-quality information. Misinformative content was apparent in 4%-26% of all genitourinary cancer pins. Understandability and actionability were poor in 55% (n=198) and 100% (n=359) of the pins, respectively.

Conclusions

On Pinterest, the majority of the urological oncology patient-centric content is of low quality and lacks diversity. This widely used, yet unregulated platform has the ability to influence consumers’ health knowledge and decision-making. Ultimately, this can lead to consumers making suboptimal medical decisions. Moreover, our findings demonstrate underrepresentation across many racial and ethnic groups. Efforts should be made to ensure the dissemination of diverse, high-quality, and accurate health care information to the millions of users on Pinterest and other social media platforms.

Urologic dermatology: a comprehensive foray into the noninfectious etiologies of balanitis

Balanitis is classically defined as inflammation of the glans penis, often also encompassing the prepuce (balanoposthitis). Several investigations have found that a sizable proportion of urology clinic visits are due to balanitis or related complaints. Balanitis can have numerous complications, including severe pain, urethral stenosis, phimosis, sexual dysfunction, and if untreated, malignancy. Unfortunately, there is no recent or comprehensive review that describes the various etiologies, clinical workup, and treatments for balanitis. Herein this review, we attempt to provide the reader with a complete and updated guide to balanitis in an attempt to improve clinical outcomes.

Patient Frustration with Pelvic Organ Prolapse Education Met with Resilient Response

INTRODUCTION

Limited patient understanding due to challenges in physician-patient communication and inadequate patient education materials (PEMs) can result in poor outcomes after pelvic organ prolapse (POP) repair. Our objective was to identify how patients learned about POP and review their perception of available educational tools.

METHODS

Patients with a history of POP were recruited using ResearchMatch and invited to participate in a virtual semi-structured interview where they were shown a website, brochure, and video pertaining to POP. Information regarding patient preference for PEMs was obtained. The interviews were transcribed, coded, and qualitative data analysis was performed using grounded theory methodology.

RESULTS

Qualitative analysis of interviews of 13 participants averaging 58 years old yielded several preliminary themes including: insufficient information to guide treatment decisions, preference for multimodal, dynamic, and comprehensive materials, and lack of support leading to avoidance of care, misinformation, and self-advocacy mechanisms. Emerging concepts included: lack of complete information regarding POP treatment resulted in misinformation, stress and desperation, distrust of healthcare providers leading to feelings of isolation, desire of support groups, and loss of follow up, and a desire for well-organized, detailed, multimodal, and destigmatizing materials as a guide to their disease process, prevention and risk factors, its natural progression, and treatment decisions. Participants developed self-reliant strategies for making treatment decisions, including the use of online resources, advice from friends, and independent search for more specialized physicians.

CONCLUSIONS

Women with POP reported a lack of information and support which resulted in the generation of self-coping mechanisms. This led to significant anxiety surrounding their diagnosis and treatment and poor satisfaction. Developing a reproducible methodology to create evidence-based PEMs will significantly decrease patient misinformation, apprehension, and use of inaccurate sources of information.

Medical malpractice in stress urinary incontinence management: A 30-year legal database review

BACKGROUND

The purpose of this study is to investigate the most common reasons for and judicial outcomes of malpractice claims related to stress urinary incontinence (SUI) management.

MATERIALS AND METHODS

Using the Westlaw database, a search was performed using the terms "medical malpractice" or "negligence" in combination with "stress incontinence" or "stress urinary incontinence" between January 1, 1990 and January 1, 2020. Extracted information included trial date, demographic information, defendant profession, procedure performed, procedure complications, alleged malpractice, trial outcome, and monetary award. Data were analyzed using descriptive statistics.

RESULTS

The Westlaw search yielded 79 case results. Of the cases, 70.4% (n = 38/54) had a defense verdict, 22.2% (n = 12/54) had a plaintiff verdict, and 7.4% (n = 4/54) were settled. The most commonly implicated procedure was mid-urethral sling (63.2%, n = 36/57). Among the plaintiffs, 48.4% (n = 61/126) claimed negligence in preoperative care, 33.3% (n = 42/126) claimed negligence in surgical performance, and 18.3% (n = 23/126) claimed negligence in postoperative care. Lack of informed consent was the most common complaint related to negligence in preoperative care (42.6%, n = 26/61). The average indemnity payment was $1,253,644 for preoperative care negligence, $1,254,491 for surgical performance negligence, and $2,239,198 for postoperative care negligence. Of the defendants, 63.4% (n = 52) were gynecologists and 36.6% (n = 30) were urologists.

CONCLUSIONS

Negligent preoperative care, with a particular emphasis on failure to obtain informed consent, and negligent surgical performance are the leading causes of malpractice claims during SUI management. Mid-urethral sling was the most commonly litigated procedure. This study highlights key factors to consider in minimizing malpractice risk during SUI management.

Characteristics of pelvic organ prolapse content available on social media

AIMS

To analyze the quality, understandability, and actionability of pelvic organ prolapse (POP) content and to characterize creators of content and treatment options discussed on social media platforms YouTube, Instagram, and Pinterest.

METHODS

A cross-sectional, qualitative study was conducted for each platform. A search for "pelvic organ prolapse" was conducted and the first 100 relevant results analyzed. Data collected include source characteristics, treatments discussed, and scores for each criterion of validated Patient Education Materials and Assessment Tool and DISCERN metrics to evaluate quality, actionability, and understandability. The χ ² analysis, univariate and multivariate logistic regressions were done to assess correlations and the impact of variables on outcomes of interest across platforms.

RESULTS

Low to moderate quality was present in 74.1% of posts. Poor understandability was seen in 37.1% of posts, and 56.1% had poor actionability. The most common publisher of content overall was health and wellness or physical therapy groups (44.6%). The most common YouTube publisher was doctors, hospitals, or clinics (49%). Pelvic floor muscle training was the most discussed treatment overall (57.4%). On YouTube surgery was discussed more frequently than Instagram or Pinterest (58% vs. 11% vs. 43%, p < 0.001. Pinterest posts had better understandability ratings than YouTube videos (odds ratio = 0.19; 95% confidence interval: [0.10-0.36]; p < 0.001).

CONCLUSION

Information on popular platforms regarding POP demonstrates inconsistent quality and poor understandability and actionability. There is an opportunity for health care providers to direct patients to curated lists of high-quality educational content on these platforms. Awareness of information available on social media is an increasingly important aspect of patient care.

A systematic review of best practices for the perioperative management of abdominal sacrocolpopexy

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been shown to reduce surgical morbidity and length of stay across various procedures. Our objective was to systematically evaluate the literature for best practices of ERAS elements in abdominal sacrocolpopexy (ASC), to determine if there is sufficient evidence to create best practice guidelines for this procedure.

MATERIALS AND METHODS

Following the preferred reporting items for systematic review and meta-analysis (PRISMA) statement, we performed a review using Pubmed, Embase, and Cochrane Library. Eligible articles contained ERAS components and postoperative outcomes of ASC published in English since 1997. Thirty-five full-text articles were selected for final qualitative analysis.

RESULTS

Poor functional status before ASC was associated with a longer length of hospital stay. Laparoscopic ASC was associated with a shorter postoperative hospital stay, with no difference between laparoscopic and robotic approaches. Epidural analgesia in addition to spinal anesthesia lowered levels of pain throughout the postoperative stay in laparoscopic ASC. A multimodal bowel regimen shortened time to first bowel movement compared to a single agent regimen. Removing a Foley catheter may lead to sooner first spontaneous void but may result in higher rates of urinary retention and urinary tract infection. Studies investigating preoperative bowel preparation, preanesthesia medication, and multidose antimicrobial prophylaxis did not show significant benefit.

CONCLUSIONS

Best practices for ASC can be developed based on current findings from the literature and extrapolation of evidence from other surgeries where ASC-specific elements are missing, with the ability to modify the pathways as new data become available.

Contemporary use of prescription medications for neurogenic lower urinary tract dysfunction

OBJECTIVES

First-line treatment for patients with neurogenic detrusor overactivity (NDO) is anticholinergic or beta-3 agonist medication. The addition of a secondary medication in patients with NDO may avoid progression to third- and fourth-line therapies. We aim to identify patterns of medication use for patients with neurogenic lower urinary tract dysfunction (NLUTD) using a national database.

METHODS

The National Ambulatory Medical Care Survey (NAMCS) database was queried for a sample of ambulatory patient visits from 2003 to 2015. Outpatient visits were included for all patients aged 18 years or older diagnosed with NLUTD. Dual therapy was defined as prescription of two anticholinergics or one anticholinergic + beta-3 agonist on the same visit. Visits in which medications were prescribed were analyzed with descriptive statistics.

RESULTS

Out of a weighted sample of 5 391 680 patient visits with a primary diagnosis of NLUTD, 1 602 705 (30%) were prescribed medical therapy. Of included patients prescribed NDO medications, the majority were white (80%), located in the Northeast (71%), and of a mean age of 51 ± 3. Of these patients, at least 93% of patients were prescribed anticholinergics, and 37% were prescribed dual therapy. Patients 65 years and older were more likely to initiate a new NDO medication at their visit (43%) than patients under 65 (7%).

CONCLUSIONS

This is the first study to analyze the use of medical therapy for NLUTD in a large outpatient setting. Further prospective evaluation of patient satisfaction and efficacy of both single anticholinergic medication and dual therapy is needed.

Readability of pelvic floor dysfunction questionnaires

BACKGROUND

The National Institutes of Health and Center for Disease Control recommend the readability of self-administered patient questionnaires to be written at or below a sixth to eight grade reading level. The aim of this study is to evaluate the readability of commonly used urinary incontinence (UI), pelvic organ prolapse (POP), overactive bladder (OAB), and benign prostate hyperplasia (BPH) questionnaires.

METHODS

Eighteen validated urologic questionnaires were analyzed using four readability assessment tools. A mean grade-level needed to comprehend each questionnaire was calculated.

RESULTS

For UI questionnaires, three out of five questionnaires required a reading level of 10th grade or higher, two grade levels above recommendations. Only one POP questionnaire met recommendations with a mean readability score of 5.9, whereas the other questionnaires required a ninth-grade reading level or higher. For the OAB questionnaires, three out of five questionnaires met reading recommendations. Readability scores for BPH questionnaires ranged from 6.4 to 11.2, with only the International Prostate Symptom Score questionnaire in compliance with recommendations.

CONCLUSIONS

The majority of currently available pelvic floor dysfunction questionnaires do not comply with recommended reading levels, suggesting that these questionnaires are written at a level too advanced for a large proportion of the population. This limits their effectiveness in accurately assessing symptom severity and impact on quality of life.

Posterior Compartment Prolapse Occurrence After Anterior Vaginal Wall Suspension

OBJECTIVE

To determine the long-term rate of posterior compartment prolapse (PCP) occurrence after native tissue repair of the anterior compartment with anterior vaginal wall suspension (AVWS) procedure.

METHODS

An institutional review board approved surgical prolapse database was reviewed for women who underwent AVWS for any degree of anterior compartment prolapse with minimum of 6-month follow-up and no history of apical or posterior compartment repair. Demographic data, smoking status, parity, and uterine status were collected. The primary outcome was need for secondary PCP repair.

RESULTS

A total of 300 women met inclusion criteria with a mean age of 63.8 ± 10.8 years, mean BMI of 26.1 ± 6.2 kg/m², and a mean parity of 2.5 ± 1.4. At the time of AVWS 46 women (15%) had uterine-sparing AVWS, 74 (25%) had concomitant hysterectomy, and 180 (60%) had prior hysterectomy. Forty-eight women (16%) had secondary posterior compartment repair for PCP (60% abdominal route, 40% done vaginally) over a mean follow-up of 7.1 ± 4.4 years.

CONCLUSION

At long-term follow-up, less than 20% of women undergoing AVWS underwent PCP repair.

Bethanechol: Is it still being prescribed for bladder dysfunction in women?

PURPOSE

Few medical treatment options exist for detrusor underactivity or urinary retention in women. Bethanechol, a cholinergic agonist, may improve detrusor contractility in these conditions; however, its clinical efficacy is limited. We sought to examine the patterns of Bethanechol use by physicians in an ambulatory care setting using a national database to determine if it is still prescribed for patients with bladder dysfunction.

MATERIALS AND METHODS

The National Ambulatory Medical Care Survey (NAMCS) database was queried for a sample of patient visits to office-based physicians from 2003-2013. Visits were included for women aged 18 years or older with diagnosed lower urinary tract symptoms (LUTS), neurogenic bladder, or urinary retention based on ICD-9-CM codes. Visits in which Bethanechol was prescribed were analysed with descriptive statistics. Sampling weights were adjusted for nonresponders to yield an unbiased national estimate of ambulatory care visits.

RESULTS

Out of a weighted sample of 17 321 630 included patient visits, 132 281 (0.8%) visits included a prescription for Bethanechol. Patients prescribed Bethanechol had a mean age of 62.3 ± 2.1 and were predominantly Caucasian (67%) followed by African American (18%). The primary diagnosis associated with Bethanechol was atony of bladder (35%), urinary retention (20%), neurogenic bladder (18%), urinary incontinence (16%), and incomplete bladder emptying (10%). Visits were primarily for chronic conditions (63%). It was typically prescribed as a continued medication (79%) most often by urologists (92%) followed by internal medicine clinicians (8%).

CONCLUSIONS

Bethanechol continues to be prescribed in elderly women primarily for detrusor atony, urinary retention, or incomplete bladder emptying.

Current policies and practicing surgeon perspectives on parental leave

BACKGROUND

The aim of this study is to evaluate the components of current parental leave policies in surgical practice and evaluate surgeon perceptions of parental leave.

METHODS

Practicing surgeons were recruited to complete a survey via social media outlets and e-mail. Participants were asked questions regarding existing policies and their perspectives towards parental leave.

RESULTS

The survey was completed by 431 surgeons, of which 90% were female and 45% in academics. The majority (84%) of women took <12 weeks leave, and 24% were fully funded. All male respondents took <4 weeks, of which 55% was fully paid. Discrimination was experienced by 31%. The majority support paid parental leave (94%) without impact on time to promotion (87%) or partnership (85%).

CONCLUSIONS

There is variance in current parental leave policies regarding length and compensation. Most respondents support paid parental leave and are in favor of policies that support new parents during and after pregnancy.

Prospective Evaluation of Urodynamic Utility in a Subspecialty Tertiary Practice

OBJECTIVE

To prospectively evaluated the utility of urodynamic evaluations (UDS) ordered in a tertiary referral center as part of a quality improvement project.

METHODS

Patients with UDS ordered by 3 subspecialty physicians were included. Physicians were surveyed when ordering UDS and at the post-UDS clinic visit to assess indications for UDS, pre- and post-UDS diagnosis, treatment plan, confidence level, and perceived helpfulness of UDS. UDS trained nurses conducting studies were surveyed on patient reported reproducibility of their symptoms and perceived difficulty of UDS.

RESULTS

From April 2017 to October 2017, 127 UDS were included of which 102 met study criteria. UDS were done for neurogenic (23%) and non-neurogenic lower urinary tract symptoms (76%). The majority were conducted for incontinence evaluation (79%), or after prior lower urinary tract surgery (33%). UDS nurses reported 90% of UDS fully or partially reproduced patient symptoms. Nurses found 18% of UDS difficult due to catheter malfunctions, physical limitations, and communication abilities. Post-UDS, providers found 97% of UDS interpretable. UDS resulted in a change in treatment plan in 78% of patients. On a Likert scale, mean pre-UDS confidence level was 2.9 ± 0.8 (range 0-5). This increased to 4.1 ± 0.6 post-UDS with 76% of evaluations having a change of at least 1 point.

CONCLUSION

UDS in a tertiary referral center result in change in patient treatment plans over three-fourths of the time with high rates of interpretability.

Outcomes following Thulium vapoenucleation of large prostates

INTRODUCTION

Thulium laser VapoEnucleation of the prostate (ThuVEP) is an evolving surgical technique for BPH. Most studies have focused on outcomes in small to médium sized prostates and have originated from Europe and Asia. We sought to describe our experience with ThuVEP for very large prostates in a North American cohort.

MATERIALS AND METHODS

From December 2010 to October 2014, 25 men underwent Thu-VEP using the CyberTM® (Quantastem, Italy) thulium laser, all with prostate volume >75mL. Data collected included patient demographics, comorbidities, intraoperative parameters, complications, and post-operative outcomes including maximum flow rate (Qmax), post-void residual (PVR), International Prostate Symptom Score (IPSS), and quality of life score (QoL) in one year of follow-up. Statistical analysis was done using Wilcoxon signed-rank test.

RESULTS

At baseline, mean age was 70±9 years and prostate size was 163±62g. Most patients (84%) were in retention and 10 (40%) patients were on anticoagulation. Seven (28%) patients went home the day of surgery (mean hospital stay: 1.2±1.2d). There were 2 intraoperative complications (8%), both cystotomies related to morcellation. Nine patients (36%) experienced a complication, all within 30 days. There were no Clavien III complications. Significant improvements were seen in Qmax, PVR, IPSS, and QoL score at each time interval to 12-months following surgery (all p<0.05). Of 21 patients initially in retention, all were voiding at last follow-up.

CONCLUSIONS

Our findings suggest that ThuVEP is an effective treatment for BPH in patients with large prostates with sustained results for one year.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence

Purpose:

Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity.

Materials and Methods:

25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used.

Results:

Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001).

Conclusions:

24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Perspectives on International Urological Volunteerism: A Survey of IVUmed Resident Scholar Alumni

INTRODUCTION

The primary intentions of international surgical programs are to directly benefit those receiving medical care, educate local physicians and staff, and improve care delivery models. IVUmed, a nonprofit organization dedicated to providing urological care to resource poor areas of the world, provides scholarship opportunities for urology trainees. We assessed the motivations and barriers of IVUmed traveling resident scholars regarding continuing international surgical work after completion of the program.

METHODS

An Internet based survey was sent to all previous IVUmed resident scholars assessing potential factors associated with repeat international service. Logistic regression was used to examine the association between survey responses and the likelihood of repeating an international service trip after completion of training.

RESULTS

Of 196 IVUmed resident scholar participants 100 (51%) responded to the survey. Of the 69 attending surgeons 17 (25%) had repeated an international service trip. Altruism (100%), personal fulfillment (99%) and practicing in a resource limited setting (94%) were the most frequently cited motivating factors for repeat participation, while lack of time (96%) was the most commonly reported barrier. Respondents in private practice were less likely to participate in a subsequent trip compared to those in an academic setting (OR 0.16, CI 0.03-0.80, p = 0.03). No other factors were associated with the likelihood of repeating an international service trip.

CONCLUSIONS

Among urologists who participated in a funded international scholarship program during residency repeat participation during the subsequent 7 years was modest. Private practitioners were less likely to repeat international service compared to academic urologists.

Outcomes in Pediatric Robot-Assisted Laparoscopic Heminephrectomy Compared with Contemporary Open and Laparoscopic Series

PURPOSE

To compare our renal and clinical outcomes for robot-assisted laparoscopic heminephrectomy (RAL-HN) in the pediatric population with duplicated systems with those of current contemporary open and laparoscopic series.

PATIENTS AND METHODS

Sixteen children underwent RAL-HN from 2009 to 2014. Data were collected via retrospective chart review including demographics, preoperative and postoperative imaging, operative time, estimated blood loss (EBL), length of stay (LOS), complications, and renal outcomes.

RESULTS

Mean age at surgery was 37.5±49.2 months. Mean operative time was 135±36 minutes with an EBL of 10±5 mL. Mean LOS was 2±0.8 days, and no major perioperative complications were observed. Mean follow-up was 22.1±17.2 months. Two patients needed secondary ureterectomy for recurrent urinary tract infection in the setting of a refluxing ureteral stump. One of these patients also underwent a ureteral reimplantation of the ipsilateral normal ureter. No patients lost their remaining healthy moiety. Asymptomatic cyst formation was seen in four (25%) patients, and self- limited postoperative urinoma was seen in 2 (13%) patients. Postoperative perinephric abscess did not develop in any patient. Mean change in renal function based on nuclear renography of the duplex kidney was -2.7%±4.6%.

CONCLUSIONS

Compared with previously published literature evaluating open and laparoscopic heminephrectomy, RAL-HN provides comparable outcomes in regard to complication rate and renal function of the remnant moiety.

Are we testing appropriately for low testosterone?: Characterization of tested men and compliance with current guidelines

INTRODUCTION

Direct-to-consumer ads for testosterone replacement therapies have significantly increased over the past several years. Subsequently, testing for low serum testosterone has correspondingly increased.

AIMS

We sought to determine the testing behaviors of practitioners as well as the characteristics of men who are undergoing testing for low testosterone.

METHODS

Men aged 18-85 years were queried from the institutional electronic data warehouse from 2009 to 2012. Men were considered "tested" if their serum total testosterone level had been measured for any purpose. Tested men (TM) were compared with those not tested (NT).

MAIN OUTCOME MEASURES

The frequency and timing of testing for low testosterone as well as patient demographics and clinical characteristics were compared between TM and NT using multivariable logistic regression models.

RESULTS

Of the 321,674 total men, 10,133 (3.2%) underwent testing with a serum total testosterone (mean age of 55.2 ± 14.1 years). The frequency of testing increased from 2.5% to 3.6% during the study period (P < 0.001). Multivariable analysis demonstrated that TM were significantly (P < 0.001) more likely to be Caucasian and have increased body mass index. In addition, TM were significantly more likely to have comorbid conditions including decreased libido (adjusted odds ratio [aOR] 10.0, 95% confidence interval [CI] 8.5, 11.7), infertility (aOR 4.8, 95% CI 3.6, 6.6), erectile dysfunction (aOR 3.6, 95% CI 3.4, 3.8), osteoporosis (aOR 3.3, 95% CI 2.8, 3.8), depression (aOR 1.7, 95% CI 1.6, 1.8), prostate cancer (aOR 1.7, 95% CI 1.5, 1.8), hypertension (aOR 1.3. 95% CI 1.2, 1.4), chronic obstructive pulmonary disease (aOR 1.2, 95% CI 1.0, 1.4), and benign prostatic hyperplasia (aOR 1.2, 95% CI 1.1, 1.2). Among TM, only 889 (9%) men underwent testing between 7 am and 12 pm.

CONCLUSIONS

The rate of testosterone testing is increasing with most testing practices directed toward a subset of men with comorbidities that are associated with hypogonadism. Compliance of physicians obtaining early morning serum testosterone levels is low. Further education of practitioners is required to appropriately test patients for hypogonadism.

Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias

OBJECTIVE

To better characterize the current state of testosterone use in the surgical correction of hypospadias among pediatric urologists.

METHODS

An email was sent via the pedsurology research listserv through the American Academy of Pediatrics, inviting members to participate in an anonymous survey regarding their use of preoperative testosterone in hypospadias correction.

RESULTS

Twenty-seven responses were obtained for a response rate of 53%. Almost all responders practiced in North America, had exclusively pediatric patients in their practice, and had been in practice for 30 years or less. 55% were classified as high-volume surgeons, completing >50 cases yearly, 87% of whom use preoperative androgen therapy currently, compared with 67% of low-volume surgeons. Testosterone was prescribed primarily for a small appearing penis, reduced glans circumference, reduced urethral plate width, and/or proximal hypospadias. The effect of testosterone was determined primarily by evaluating penile appearance (59%). However, the majority (56%) of physicians stopped giving testosterone when they completed a predetermined regimen.

CONCLUSIONS

While many pediatric urologists use testosterone prior to hypospadias repair, the practice patterns are variable. It appears that the use of testosterone is primarily limited to patients with proximal hypospadias, small appearing penis, reduced glans circumference or reduced urethral plate.