Sexual dysfunction among women of low-income status in an urban setting.

OBJECTIVE: To determine demographic and clinical conditions associated with sexual dysfunction among women of low-income status living in an urban setting. METHODS: Cross-sectional study of 102 consecutive women attending an urban gynecology clinic. Women were given validated questionnaires to measure sexual function, depression, urinary incontinence, and erectile dysfunction in the partner. The association of sexual dysfunction with demographic variables, depression, urinary incontinence, and sexual function in the partner was assessed by the respondent. RESULTS: The prevalence of sexual dysfunction was 37.3% (n=38). Women with sexual dysfunction reported significantly lower scores on all subscales of sexual function compared with women without sexual dysfunction. Women with sexual dysfunction were more likely to be older (33±11.2 vs 28.7±8.6; P<0.04), unemployed (68% vs 47%; P<0.03), and report depression (OR 4.4; 95% CI, 1.7-11.3), urinary urge incontinence (OR 2.7; 95% CI, 1.2-7.3), and intake of multiple medications (OR 5.4; 95% CI, 1.6-20.1). On multivariate analysis, depression and urge urinary incontinence were independently associated with sexual dysfunction. CONCLUSION: Female sexual dysfunction is associated with the presence of depression and urge urinary incontinence in women of low-income status living in an urban setting.

Cryptococcosis of the upper genital tract.

Upper genital tract infection by Cryptococcus neoformans has not previously been reported. We describe such a case, in order to alert clinicians to the existence of this rare infection. A 34-year-old woman with AIDS presented with chronic menorrhagia, fever, anemia, and thrombocytopenia. Despite blood transfusions and hormonal therapy, her vaginal bleeding could not be controlled and she became hemodynamically unstable. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed, at which time granulomatous peritonitis and prominent myometrial blood vessels were found. Histologic examination revealed cryptococcal infection of all upper genital organs. This case demonstrates that disseminated cryptococcosis may involve the upper genital tract in women, and may be associated with profuse vaginal bleeding.

Discontinuation rates of anticholinergic medications used for the treatment of lower urinary tract symptoms.

OBJECTIVE: To estimate the discontinuation rates of anticholinergic medications used for the treatment of lower urinary tract symptoms in women. METHODS: A large administrative database was used for this study. Women aged 18 years and older who were prescribed anticholinergic medications were included. An overall and drug-specific discontinuation rate for nine different anticholinergic medications was estimated. Covariates examined included number of prior drug classes used, number of switches performed, number of prior drug episodes, year of initiation, age, and history of smoking. The Kaplan-Meier method was used to estimate an overall discontinuation rate. A Cox multivariable regression was performed for the drug-specific analysis. RESULTS: There were 49,419 episodes of anticholinergic therapy available for analysis from 29,369 women. The average number of treatment episodes and number of drug classes prescribed per patient were 1.65+/-1.31 and 1.54+/-0.57, respectively. The median time for overall anticholinergic drug discontinuation was 4.76 months. The 6-month unadjusted cumulative incidence of discontinuation was 58.8% (95% confidence interval [CI] 58.4-59.3). The percentage of episodes in which women switched to another medication was 15.8% (95% CI 15.4-16.1). At 6 months, the adjusted cumulative incidence of discontinuation was as follows: oxybutynin 71% (95% CI 68.4-73.5), tolterodine tartrate 61% (59.4,64.3), extended-release oxybutynin 57% (95% CI 55.1-59.4), and extended-release tolterodine tartrate 54% (95% CI 52.3-57.7). CONCLUSION: Discontinuation rates for anticholinergic medications are high regardless of the class of medication used. LEVEL OF EVIDENCE: II.

Association of change in estradiol to lower urinary tract symptoms during the menopausal transition.

OBJECTIVE: To estimate the relationship between changes in estradiol (E2) levels over time and lower urinary tract symptoms in premenopausal women as they transition to menopause. METHODS: A self-administered validated questionnaire to measure lower urinary tract symptoms was administered to 300 women at the 11th assessment period on an ongoing longitudinal Penn Ovarian Aging cohort study. The association between the change in E2 over time through the menopausal transition and lower urinary tract symptoms (urinary incontinence, filling symptoms, voiding dysfunction) was determined. Risk factors associated with lower urinary tract symptoms were determined by univariable analysis and multivariable linear regression. RESULTS: Estradiol levels and menopausal stage at one point in time were not associated with lower urinary tract symptoms. Women with a sharp decline in E2 levels over time had significantly lower urinary incontinence scores in comparison with women without a change in E2 levels through the study period (mean+/-standard deviation 3.11+/-2.86 compared with 2.08+/-2.43, adjusted mean difference -0.93, 95% confidence interval [CI] -1.8 to -0.02). Women between the ages of 45 years to 49 years had significantly higher urinary incontinence scores than women woman age older than 55 years (1.59+/-1.86 compared with 3.04+/-2.93, adjusted mean difference 1.0, 95% CI 0.01-2.1). Women with a body mass index greater than 35 also had significantly higher urinary incontinence scores than women in the normal weight range, (3.53+/-3.16 compared with 1.98+/-2.52, adjusted mean difference 1.5, 95% CI 0.59-2.3) after adjusting for changes of E2 through the menopausal transition. High anxiety was associated with worsening scores in all three lower urinary tract symptoms domains (incontinence, filling, voiding). CONCLUSION: Women with a sharp decline in E2 through the menopausal transition have significantly lower urinary incontinence scores. Urinary filling symptoms and voiding dysfunction were not associated with changes in E2 through the menopausal transition. LEVEL OF EVIDENCE: II.

Investigating the associations between nocturia and sleep disorders in perimenopausal women.

PURPOSE: We determined the associations between nocturia and sleep disorders in perimenopausal women. MATERIALS AND METHODS: A total of 100 women with nocturia were compared to 200 without nocturia. Obstructive sleep apnea, insomnia, anxiety and menopausal stage were assessed using validated questionnaires. Comorbidities associated with nocturia were determined by bivariate analysis and multivariate logistic regression. RESULTS: Independent associations for nocturia were anxiety (OR 2.11, 95% CI 1.08-4.13), black American race (OR 2.00, 95% CI 1.06-3.85), obstructive sleep apnea symptoms (OR 1.73, 95% CI 1.18-2.53) and insomnia (OR 1.11, 95% CI 1.05-1.12). CONCLUSIONS: Nocturia is associated with sleep disorders in perimenopausal women.

Development and testing of a new instrument to measure fluid intake, output, and urinary symptoms: the questionnaire-based voiding diary.

OBJECTIVE: The purpose of this study was to develop a validated self-administered questionnaire to measure fluid intake, output, behavior, and urinary symptoms. STUDY DESIGN: Factor analysis identified 4 subscales in the new questionnaire. Ninety-two women completed the questionnaire, comprised of a 48-hour voiding diary and the Bristol Female Lower Urinary Tract Symptom-Scored form. The questionnaire was readministered after a 2-week period with no change in treatment and 2-3 months later after treatment of urinary symptoms. RESULTS: Correlation of items of the questionnaire with the 48-hour voiding diary in the 4 subscales was high (r = 0.55, 0.74. 0.68, and 0.47; P < .01). Subscale scores also correlated with the Bristol Lower Urinary Tract Symptom score (r = 0.68 and =0.87; P < .001). Comparisons of scores before and after treatment showed the ability of the questionnaire to respond to change. CONCLUSION: The new questionnaire is a valid and reliable means to assess fluid intake, output, behavior, and urinary symptoms.

Clinical symptoms predictive of recurrent urinary tract infections.

OBJECTIVE: The purpose of this study was to evaluate clinical predictors that will help diagnose women with recurrent urinary tract infections among women with irritative voiding symptoms. STUDY DESIGN: A case control study was performed. Cases were women with the diagnosis of recurrent urinary tract infection and controls were women with irritative voiding symptoms. Symptoms predictive for recurrent urinary tract infection were evaluated. RESULTS: Report of symptoms following intercourse (OR 12.4, 95% CI 3, 59), prior history of pyelonephritis (OR 7.4, 95% CI 2.1; 29), prompt resolution of symptoms with antibiotics (OR 3.9, 95 % CI 1.4, 11), and absence of nocturia (OR 0.22, 95% CI 0.05, 0.87) are significant predictors for women with recurrent urinary tract infection. CONCLUSION: Among women with irritative voiding symptoms, clinical symptoms can help to identify women with recurrent urinary tract infections at the initial presentation even if urine culture reports are not available.

Nighttime call in house vs. out of house: a comparison of obstetric procedure rates.

OBJECTIVE: To evaluate the effect of in-house vs. out-of-house nighttime call coverage on obstetric practice. STUDY DESIGN: A retrospective analysis was performed on nighttime deliveries. Included were deliveries by 2 faculty groups that equally shared in-house and out-of-house call coverage. Included patients had an equal chance of delivering with a physician on call covering in house or out of house. Patient demographics and obstetric outcomes were compared between in-house and out-of-house call status for the delivering physician by ANOVA and chi2. RESULTS: Of eligible nighttime deliveries, 230 were identified, 120 with in-house and 110 with out-of-house call coverage. Demographic features were not statistically different between the groups. A comparison of in-house and out-of-house deliveries yielded rates for episiotomy (28.3% vs. 30.0%), cesarean delivery (26.7% vs. 21.8%), operative vaginal delivery (11.7% vs. 18.2%), total operative delivery (38.4% vs. 40.0%) and nonoperative vaginal delivery (61.7% vs. 60.0%) that did not significantly differ by physician call status. CONCLUSION: The nighttime call status of physicians, whether in house or out of house, did not affect cesarean delivery, operative vaginal delivery, overall (total) operative delivery or episiotomy rates.

Embolization of a uterine arteriovenous malformation followed by a twin pregnancy.

BACKGROUND: Uterine arteriovenous malformation is a lesion that can cause recurrent pregnancy loss. Very few successful pregnancies have been reported after selective embolization of an arteriovenous malformation. CASE: A 42-year-old gravida 6 para 0 with a history of four first-trimester spontaneous abortions was found to have a uterine arteriovenous malformation by hysterosalpingogram, which was confirmed by magnetic resonance angiography. She underwent selective transcatheter embolization of the arteriovenous malformation. A twin gestation was later conceived via in vitro fertilization. The twins were delivered by cesarean at term. CONCLUSION: Uterine arteriovenous malformation can be successfully treated with selective embolization, with good obstetric outcome.