Asymptomatic Microscopic Hematuria in Women Abstract: Asymptomatic microscopic hematuria is an important clinical sign of urinary tract malignancy. Asymptomatic microscopic hematuria has been variably defined over the years. In addition, the evidence primarily is based on data from male patients. However, whether the patient is a man or a woman influences the differential diagnosis of asymptomatic microscopic hematuria, and the risk of urinary tract malignancy (bladder, ureter, and kidney) is significantly less in women than in men. Among women, being older than 60 years, having a history of smoking, and having gross hematuria are the strongest predictors of urologic cancer. In low-risk, never-smoking women younger than 50 years without gross hematuria and with fewer than 25 red blood cells per high-power field, the risk of urinary tract malignancy is less than or equal to 0.5%. Furthermore, the evaluation may result in more harm than benefit and is unlikely to be cost effective. Thus, data support changing current hematuria recommendations in this low-risk group. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society encourage organizations producing future guidelines on the evaluation of microscopic hematuria to perform sex-specific analysis of the data and produce practical sex-specific recommendations. In the meantime, the American College of Obstetricians and Gynecologists and the American Urogynecologic Society recommend that asymptomatic, low-risk, never-smoking women aged 35–50 years undergo evaluation only if they have more than 25 red blood cells per high-power field.
Development and Validation of a Quantitative Measure of Adaptive Behaviors in Women With Pelvic Floor Disorders Purpose: To establish validity for the Pelvic Floor Disorders Network (PFDN) self-administered Adaptive Behavior Index (ABI) and to assess whether ABI assesses known discordance between severity of pelvic floor symptoms and self-reported bother.
Methods: In addition to the ABI questionnaire, participants in 1 of 6 Pelvic Floor Disorders Network trials completed condition-specific measures of pretreatment symptom severity (including Pelvic Floor Distress Inventory; PFDI) and health-related quality of life (Pelvic Floor Impact Questionnaire; PFIQ). The final survey was developed from an iterative process using subject and expert endorsement, factor analyses, and response distributions. Domains were created using a development cohort (n = 304 women), reliability and validity were established using a validation cohort (n = 596 women), and test-retest reliability was assessed (n = 111 women).
Results: Factor analyses supported an 11-item avoidance domain and a 6-item hygiene domain. Cronbach' alphas were 0.88 and 0.68, respectively. Test-retest reliability was 0.84 for both domains. Construct validity was demonstrated in correlations between the ABI domains and baseline PFDI and PFIQ (r values, 0.43–0.79 with all P values <0.0001). Moreover, the ABI accounted for 8% to 26% of unexplained variance between the symptoms severity measure and the impact on health related quality of life. After treatment, avoidance domain scores improved for urinary and fecal incontinence groups and hygiene scores improved for the fecal incontinence group.
Conclusions: The ABI is a reliable and valid measure in women with pelvic floor disorders. Adaptive behaviors account in part for discordance between pelvic floor symptom severity and bother.
Relationship of Anatomy and Function: External Anal Sphincter on Transperineal Ultrasound and Anal Incontinence Objective: The aim of this study was to investigate the association of the anatomic integrity of the external anal sphincter (EAS) detected on transperineal ultrasound (TPUS) with symptoms of anal incontinence (AI) as measured by St Mark’s Incontinence Score (SMIS) and the visual analog scale (VAS).
Methods: This is an observational, cross-sectional analysis of 486 women who presented to a tertiary urogynecological center between May 2013 and August 2014. They underwent a standardized interview and an examination that involved 3-dimensional/4-dimensional TPUS. The SMIS and VAS were administered if they answered positively to a question on AI. The association between defects of the EAS and symptoms of AI was evaluated using bivariate tests, as well as adjusting for pertinent covariates using multiple linear regression modeling.
Results: Of the included patients, 17.1% reported AI, and 15.2% had significant EAS defects (≥4 slices) on TPUS imaging. A significant sonographic defect was diagnosed in 23% of women with AI versus 14% of those without (P = 0.033). Women with symptoms of AI were more likely to have a significant defect on TPUS (odds ratio, 1.878; 95% confidence interval, 1.05–3.37). No significant findings were seen when analyzing SMIS, its components, and VAS against sonographic EAS defects.
Conclusions: The symptom of AI is associated with significant EAS defects detected on TPUS. However, this study failed to show an association between significant EAS defects and the SMIS and VAS.
Effect of Concurrent Prolapse Surgery on Stress Urinary Incontinence Outcomes After TVTO Objectives: A variety of pelvic organ prolapse (POP) surgeries are performed concomitant to midurethral sling (MUS) placement. It is unknown whether differing POP surgeries may affect stress urinary incontinence outcomes after MUS placement.
Methods: We performed a retrospective cohort analysis of patients undergoing TVT obturator system in conjunction with a variety of POP repair (cystocele with mesh graft, cystocele with cadaveric fascia, colpocleisis, and sacrocolpopexy). Primary outcomes included validated measures of stress urinary incontinence (International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms), measured preoperatively and at 6 week, 1 year, and 2 years postoperatively. Secondary outcomes included validated questionnaire items focused on obstructive and irritative symptoms. Multivariate analyses using mixed-effects regressions were used to assess for differences in outcomes based on POP repair type.
Results: A total of 102 patients were identified for study analysis (cystocele with mesh graft, n = 45; cystocele with cadaveric fascia, n = 37; sacrocolpopexy, n = 16; colpocleisis, n = 4). Four patients undergoing colpocleisis were excluded from primary analysis given lack of sufficient cohort size. When adjusted for effects of covariates, significant improvements in primary and secondary outcomes were seen throughout follow-up in comparison with baseline. In general, multivariate analysis demonstrated no significant differences between surgeries when assessing primary and secondary outcomes. The only statistically significant difference in change over time comprised CM, which demonstrated superior improvement in International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (preoperative vs 2 year, P = 0.04).
Conclusions: Regardless of POP surgery type, patients demonstrate improvements in validated SUI outcomes through 2 years. Multivariate analysis suggests that there is little difference in SUI outcomes after TVT obturator system across several different POP repair types.
Trends in Ambulatory Management of Urinary Incontinence in Women in the United States Objectives: Urinary incontinence (UI) is a common condition, but despite the availability of guidelines, variations exist in the care of patients. We sought to assess the changes in assessment and management of women with UI over time in the United States.
Methods: The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey are annual surveys from a nationally representative sample of visits to physicians. From 1999 through 2010, we identified visits by women to physicians where the chief complaint was UI using reason-for-visit and International Classification of Diseases, Ninth Revision codes.
Results: Using 2-year intervals between 1999–2000 and 2009–2010, the number of visits by women with UI to physicians increased (5.3 million to 6.8 million). There was no difference in patient age, race/ethnicity, or physician specialty (primary care, urology, gynecology). The majority did not have their incontinence characterized (42.4%–47.4%). The use of urinalysis significantly decreased (53%–37.2%, P = 0.02), whereas antimuscarinic use significantly increased (16.7%–35%, P = 0.006). There was an overall increased trend in number of referrals to another physician (5.8%–14.7%, P = 0.06). Urologists had a significant increase in antimuscarinic use (23.5%–44.2%, P = 0.003). All physician specialties demonstrated a decreased trend in use of urinalysis between 1999 and 2010. Although imaging rates were low, they were at highest rates among urologists.
Conclusions: The majority of women do not have the type of UI characterized, whereas there is underutilization of urinalysis. Given the widespread prevalence of UI and its implications on quality of life, greater adherence to guidelines is warranted.
The Effects of a Genital Vibratory Stimulation Device on Sexual Function and Genital Sensation Objective: The aim of this study was to evaluate the effectiveness of a genital vibratory stimulation device in improving sexual function in women with arousal and orgasm disorders.
Methods: In this single-arm, prospective study, baseline and 1- and 3-month assessments were performed to evaluate women with sexual arousal and/or orgasmic disorders, who received therapy using a genital vibratory stimulation device. Sexual function, satisfaction, and distress were evaluated using the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale, and the Female Intervention Efficacy Index questionnaires. Genital sensation was evaluated using quantitative sensory testing.
Results: Seventy women, aged 19 to 64 years, were evaluated from October 2009 to August 2013. Forty-seven (67.1%) and 37 (52.9%) women completed 1- and 3-month follow-ups, respectively. The FSFI arousal and orgasm domain scores and total FSFI scores improved at 1 and 3 months (P < 0.001 for all outcomes). Mean (SD) total FSFI scores increased from 20.04 (4.65) (baseline) to 25.03 (5.21) (1 month) to 26.66 (5.42) (3 months; both Ps < 0.0001). Female Sexual Distress Scale scores reflected significantly decreased distress at 1 (P = 0.0006) and 3 (P < 0.0001) months compared with baseline and at 3 months compared with 1 month (P = 0.03). Neurological sensation was increased at all genital sites at 1 and 3 months (P < 0.0001 for all). After adjustment for age, there was a significant interaction between arousal domain scores and clitoral and right labial sensation. At 3 months, perceptions of increased vaginal lubrication, orgasm, and genital sensation were reported by 67.5%, 65.0%, and 82.5% of the participants. No major adverse events were noted.
Conclusions: Genital vibratory stimulation device use resulted in uniform improvements in sexual function, satisfaction, sexually related distress and genital sensation.
Resident Education in Female Pelvic Medicine and Reconstructive Surgery Objective: The aim of this study was to evaluate whether obstetrics and gynecology trainees feel satisfied with the female pelvic medicine and reconstructive surgery (FPMRS) education received in residency.
Methods: This is a survey study of obstetrics and gynecology residents in the United States and Puerto Rico during the 2015–2016 academic year. The anonymous 29-question survey was approved by the Hartford HealthCare institutional review board. Responses were included only if the trainee had ever rotated on the FPMRS service. Descriptive analyses were performed using mean and SD for continuous data; categorical data were described using frequencies, expressed as percentages. The results were analyzed for statistical significance using χ2 for categorical variables and Student t test for continuous variables. All results yielding P < 0.05 were deemed statistically significant.
Results: Of the 333 responses received, 172 met criteria for inclusion. Regarding amount of training in FPMRS, 126 trainees (73.3%) reported satisfaction, 40 (23.3%) reported too little training, and 6 trainees (3.5%) reported too much. Residents in programs with a board-certified FPMRS surgeon more commonly reported satisfaction with training (75.0 vs 28.6%, P = 0.02). When fourth-year residents were asked if they would feel comfortable performing specific surgical procedures independently after graduation, the percentage answering affirmatively ranged from 23.6% to 98.8%.
Conclusions: Satisfaction with training in FPMRS has improved, but poor confidence performing surgical procedures compared with previous reports demonstrates that improvements in resident training are still needed.
Ultrasonographic Evaluation of the Urethral Rhabdosphincter Morphology in Female Patients With Urodynamic Stress Incontinence Objectives: During the last 2 decades, ultrasonography has been proposed for the morphologic evaluation of the urethral rhabdosphincter. The aims of this study were to evaluate the feasibility of a simple sonographic technique for the assessment of the urethral rhabdosphincter morphology by using a 2-dimensional (2D) transvaginal transducer and to evaluate any associations between the sonographic parameters of rhabdosphincter morphology with the presence of urodynamic stress incontinence (USI).
Methods: This was a prospective study of women who underwent urodynamic studies and an introital 2D ultrasonography and divided in 2 groups based on the presence or absence of USI. Measurements included rhabdosphincter thickness at the 3-o’clock (right) and 9-o’clock (left) positions and the rhabdosphincter outer (Π) and inner circumference (π). Based on these values, the mean thickness of the rhabdosphincter (R + L / 2), the rhabdosphincter differential perimeter (Π − π), and area (A − α) were also calculated.
Results: Statistical analysis showed that women with a rhabdosphincter area of less than 0.65 cm2, mean thickness of less than 0.24 cm, and differential perimeter of less than 1.08 cm had 3.98, 5.67, and 5.41 times greater odds for USI, respectively. Receiver operating characteristic curve analysis results showed that the optimal cutoff values for the prediction of USI from rhabdosphincter thickness, differential perimeter. and surface area were 0.24 cm (79.6% sensitivity, 63.4% specificity), 1.08 cm (70.8% sensitivity and 69.1% specificity), and 0.65 cm2 (71.9% sensitivity, 57.1% specificity), respectively.
Conclusions: Introital ultrasonography with a 2D transvaginal probe allowed the visualization of the urethral rhabdosphincter morphology in greater than 90% of the cases. Sonographic measurements showed that patients with USI had a thinner urethral rhabdosphincter than did women with a normal sphincteric mechanism.
Impact of Case Order on Laparoscopic Sacrocolpopexy: Do Surgeons Need a Warm-Up? Objectives: Warm-up is defined as a preparatory activity or procedure. Using case order as a surrogate for surgeon warm-up, first cases were compared with second or later cases for intraoperative complications, operative time, and length of stay (LOS) among women undergoing laparoscopic sacrocolpopexy.
Methods: This is a retrospective study of laparoscopic sacrocolpopexies performed from 2009 through 2014 at a large academic center. Any surgery preceding laparoscopic sacrocolpopexy was considered a surrogate for surgeon warm-up. Logistic and linear regression analyses were used to identify predictors of complications, operative time, and LOS.
Results: Of 480 procedures, 192 (40%) were first cases and 288 (60%) were second or later. Baseline characteristics were similar between groups. Intraoperative complication rate was not different between groups (6.3% vs 3.1%, P = 0.50) even after controlling for risk factors. Operative times were comparable on initial analysis (231.2 ± 55.2 vs 225.9 ± 51.2 minutes, P = 0.28l), but a small difference was detected after adjusting for confounding factors (body mass index, menopausal status, surgeon experience, intraoperative complications, and concomitant hysterectomy or midurethral sling; adjusted β = 8.44 minutes, P = 0.037). Length of stay was longer for first case patients (1.44 ± 0.67 vs 1.24 ± 0.50 days, P < 0.001) even after adjusting for age, medical comorbidities, operative time, conversion to laparotomy, ileus/bowel obstruction, and postoperative urinary retention (adjusted β = 0.183 days, P = 0.001) as well as after accounting for delayed start time of second or later cases.
Conclusions: Laparoscopic sacrocolpopexy performed first case of the day without preoperative surgeon warm-up conferred no significant increase in intraoperative complications. Second or later cases were associated with small decreases in operative time and in LOS.
Colpocleisis: A Survey of Current Practice Patterns Background: Currently, there are no standard treatment guidelines for colpocleisis. Clinical practice varies widely for this safe and effective procedure.
Objective: The aim of this study was to evaluate the current practice patterns in the United States among surgeons who perform colpocleisis.
Methods: A 27-item anonymous Web-based survey was sent to all practicing physicians affiliated with the American Urogynecologic Society. It consisted of questions regarding the demographic background of the physicians and their current practice as it relates to colpocleisis.
Results: Of the 1422 physicians contacted, 322 responded (23%) to the questionnaire. Slightly more than half were female with an average time of 15 years in practice. The majority of respondents (79%) were urogynecologists. Most surgeons chose colpocleisis for its high success rate, short operating time, and low risk of complications. Approximately half of the providers performed both LeFort and total colpocleisis. Only 18% performed a routine hysterectomy at the time of surgery. Routine preoperative endometrial evaluation was preferred by 68% of the respondents, with 81% utilizing a transvaginal ultrasound first. Almost all providers would perform concomitant incontinence procedures, with 54% requiring a positive cough stress test and normal postvoid residual.
Conclusions: There is variation in the current practice of colpocleisis in the United States. LeFort colpocleisis is most commonly performed, and routine hysterectomy is uncommon. Two thirds of surgeons evaluate the endometrium prior to surgery. Concomitant anti-incontinence procedures appear to be standard.
Retroperitoneal Hemorrhage After Sacral Neurostimulator Placement for Urgency Urinary Incontinence Abstract: Sacral neuromodulation (SNM) is an effective therapy for patients who experience urinary incontinence, idiopathic urinary retention, and fecal incontinence. Although typically a low-risk procedure, rarely, it can be associated with significant hemorrhage. A 61-year-old woman on chronic anticoagulation underwent uncomplicated implantation of SNM for refractory urgency urinary incontinence. Anticoagulation was held on the day of surgery and resumed on postoperative day 1. On postoperative day 2, the patient developed an extensive retroperitoneal hemorrhage. This was successfully treated by angioembolization of the left lateral sacral artery with the InterStim device left in situ. At 6-month follow-up, the device was functioning properly, and the patient's urinary symptoms were well controlled. Retroperitoneal hemorrhage is a rare complication after SNM placement. Conservative management with angioembolization should be considered as a first-line approach.
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