Isolated neurofibroma of the urinary bladder incidentally discovered during cystoscopy.

Isolated neurofibromas of the urinary bladder are rare benign tumors typically associated with neurofibromatosis type 1 (NF-1). Herein highlights a bladder neurofibroma incidentally discovered during cystoscopy following midurethral sling removal in a 61-year-old woman without NF-1 sequela. Despite malignancy concerns due to smoking history, histology confirmed a benign neurofibroma. These tumors differ from NF-1-associated neurofibromas in origin and presentation; they are rare, often asymptomatic, and likely stem from somatic mutations. Conservative management is preferred, with surgical intervention indicated only for obstructive masses.

Antibiotic regimen and route of administration do not alter rates of urinary tract infection after intravesical botulinum toxin injection for overactive bladder.

INTRODUCTION AND HYPOTHESIS: Guidelines vary on antibiotic prophylaxis for onabotulinumtoxinA (Botox) treatment for overactive bladder (OAB). Our primary objective was to determine whether any prophylactic regimen is more effective in preventing urinary tract infection (UTI) after Botox. The secondary objective was to identify prophylactic practice patterns among female pelvic medicine and reconstructive surgery (FPMRS) providers of different training backgrounds as well as general urologists. METHODS: This was a secondary analysis of a retrospective cohort study on urinary retention after Botox injection in women with and without diabetes mellitus and OAB. Women > 18 years old who underwent Botox injection for OAB between January 2013 and September 2018 were included. Exclusion criteria were history of urinary retention and neuromuscular bladder dysfunction. RESULTS: A total of 565 patients were included. Two hundred eighty (49.6%) were treated by OB-GYN FPMRS, 209 (37.0%) by urology FPMRS and 76 (13.5%) by general urologists. The majority (92.9%) received antibiotic prophylaxis: 44.4% received intravenous (IV) only, 8.9% received oral (PO) only, and 39.7% received combination IV and PO prophylaxis. Urology FPMRS used antibiotic prophylaxis less frequently (p = 0.003). Within 3 months, 171 patients developed UTI (30.4%). There was no difference in post-procedural UTI for any antibiotic regimen compared to no prophylaxis. No route of antibiotic administration was superior at preventing UTI. CONCLUSIONS: In this cohort, no route of antibiotic administration was more effective in the prevention of UTI. Antibiotic prophylaxis did not lower the rate of post-procedural UTI compared to no antibiotics.

Percutaneous Tibial Nerve Stimulation in Diabetic and Nondiabetic Women With Overactive Bladder Syndrome: A Retrospective Cohort Study.

OBJECTIVES: The primary objective of this study was to compare optimal response ("very much better" or "much better" on the Patient Global Impression of Improvement [PGI-I] index) to posterior tibial nerve stimulation (PTNS) for overactive bladder (OAB) in patients with and without diabetes mellitus. Secondary outcomes included longitudinal data regarding PTNS use in patients with diabetes and controls. METHODS: We performed a retrospective cohort analysis of women in our tertiary care center who completed at least 10 weekly and 1 maintenance PTNS treatments for OAB, excluding patients who were treated with PTNS for a non-OAB primary diagnosis. Participants were grouped into those with diabetes mellitus and those without. Previous research demonstrated a 20% difference in subjective response to anticholinergics in persons with diabetes versus persons without diabetes with OAB. To demonstrate a 20% difference in optimal PGI-I with 80% power, our analysis required 92 patients in each group. RESULTS: We identified 356 patients: 96 with diabetes mellitus, and 260 controls. There was no statistically significant difference in the primary outcome, with 43 (44.8%) of 96 persons with diabetes versus 115 (44.2%) of 260 controls demonstrating optimal PGI-I response (P = 0.92). Among patients with diabetes, no baseline variables were found to predict treatment response, including hemoglobin A1c greater than 7%, diabetes with sequelae, or higher Charlson Comorbidity Index. CONCLUSIONS: In women undergoing PTNS for OAB, the optimal PGI-I response rate is similar in patients with and without diabetes.

Readability and quality of Wikipedia articles on pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: This study is aimed at evaluating the readability and quality of Wikipedia articles on pelvic floor disorders (PFD) and comparing their content with International Urogynecological Association patient education leaflets. METHODS: Readability was assessed using six different readability scales, including the Simple Measure of Gobbledygook (SMOG) Index, which is considered superior for scoring healthcare information. Quality was assessed by three female pelvic medicine and reconstructive surgery fellows using the modified DISCERN instrument. DISCERN is validated to evaluate the quality of written consumer health information; it was subsequently modified by health education researchers to enable the evaluation of Wikipedia articles. RESULTS: We evaluated 30 Wikipedia articles that correlated with 29 International Urogynecological Association leaflets. The mean SMOG score of the Wikipedia articles was 12.0 ± 2.1 (12th-grade reading level) whereas the mean SMOG score of the International Urological Association (IUGA) leaflets was 3.4 ± 0.3 (third-grade reading level, p < 0.001). The mean modified DISCERN score of the Wikipedia articles was 34.43 ± 5.90 (moderate quality); however, the mean modified DISCERN score of the IUGA literature was 45.02 ± 1.36 (good quality, p < 0.001). CONCLUSIONS: Wikipedia articles on PFD are neither readable nor reliable: they require a 12th-grade-level education for comprehension and are merely rated moderate in quality. In comparison, IUGA leaflets require a third-grade education for comprehension and are rated good in quality. Urogynecological providers should provide appropriate health education materials to patients, as Wikipedia is both a popular and sometimes inaccurate resource for patients.

Use of pelvic model-based simulation for sacrospinous ligament fixation education in novice learners: a single-blinded randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: We hypothesize that there will be improvement in a novice learners' confidence and skill level with sacrospinous ligament fixation (SSLF) following a pelvic model-based simulation. METHODS: We performed a single-blinded randomized controlled trial with obstetrics and gynecology residents who were novices at SSLF. The residents were randomly assigned to two groups. The control group received a lecture on the SSLF procedure and anatomy, whereas the intervention group received the same lecture in addition to a pelvic model-based simulation session taught by urogynecologists. The residents' knowledge of SSLF anatomy and confidence level with the procedure were measured via assessments administered before and after the educational interventions. Their technical skills were objectively assessed by one of two fellowship-trained urogynecologists who were blinded to their group allocation. RESULTS: A total of 28 residents were recruited with 14 residents in each group and equal distribution of junior and senior trainees. None of the residents had previously performed the SSLF procedure. There was no difference in anatomical knowledge between the two groups. The intervention group showed a greater increase in their average confidence score compared with the control group: 4.0 ± 1.4 (95% CI 3.1-4.8) versus 2.6 ± 1.6 (95% CI 1.7-3.4) respectively, with p = 0.02. The intervention group also showed better objective scores in specific technical skills, such as instrument handling (p < 0.001), instrument movement/motion (p < 0.001), and speed (p = 0.01). CONCLUSION: Our results demonstrate that inclusion of a pelvic model simulation significantly improves confidence and certain technical skills of novice trainees in performing SSLF.

The Anatomical Distribution of the Pudendal Nerve Block Injection: A Cadaveric Study.

OBJECTIVE: The objective of this study was to assess the accuracy of commonly used injection locations of the pudendal nerve block by examining the proximity of the injected dye to the pudendal nerve in a cadaveric model. METHODS: Pudendal block injections at 4 sites were placed transvaginally on 5 cadaveric pelvises. These sites were 1 cm proximal to the ischial spine (black dye), at the ischial spine (red dye), 1 cm distal to the ischial spine (blue dye), and 2 cm lateral and 2 cm distal to the ischial spine (green dye). The cadavers were dissected via a posterior approach. RESULTS: We measured the shortest distance from the center of the dye-stained tissue to the pudendal nerve. As expected, the injections at the ischial spine (red) resulted in a distribution of dye closest to the pudendal nerve, averaging 3.0 ± 0.95 mm. Dyes at other sites were close to the nerve: 3.1 ± 1.00 mm (black), 3.6 ± 1.14 mm (blue), and 4.05 ± 1.28 mm (green). CONCLUSIONS: Regardless of the injection site, all dyes were close the pudendal nerve, indicating accuracy. We observed wide variation in the dye distribution even though all injections were performed by the same provider, implicating lack of precision. Based on our findings, we propose that the most effective injection location is at the ischial spine because it is the closest to the pudendal nerve; however, all injections were within 4 mm of the pudendal nerve, suggesting that only 1 to 2 injections may be sufficient.

Urinary Incontinence: Evaluation and Management.

Urinary incontinence is a major public health issue in the United States with physical, mental, social, and economic repercussions. History and in-office evaluation are paramount to diagnosis and formation of an appropriate treatment plan. Lifestyle modifications, which include pelvic floor muscle training and behavioral changes, are appropriate for initial management. Patients with overactive bladder syndrome whose symptoms are not adequately controlled with conservative treatment can be offered medical or procedural management. Stress urinary incontinence refractory to first-line treatment can be treated with surgical options such as mesh midurethral slings.

Referral Patterns for the Evaluation of Asymptomatic Microscopic Hematuria in Women in a Single Health Care System: Room for Improvement.

OBJECTIVE: To identify patterns of care for women referred for asymptomatic microhematuria in a single, hospital-based health care system and estimate the cost of unindicated evaluation. METHODS: We conducted a retrospective study of 100 women with a diagnosis of asymptomatic microhematuria referred to a tertiary female pelvic medicine and reconstructive surgery practice. Our analysis focused on referral patterns by obstetrician-gynecologists and primary care physicians. Data analyzed included whether asymptomatic microhematuria was documented using urine microscopy (vs urine dipstick) and whether the urine microscopy correctly identified asymptomatic microhematuria with three red blood cells (RBCs). RESULTS: Forty-six patients were referred who met the American Urological Association's guidelines for asymptomatic microhematuria with a workup estimated at $8,298 per patient. Fifty-four were referred to a female pelvic medicine and reconstructive surgery specialist despite clearly not meeting the American Urological Association's definition of asymptomatic microhematuria. Of these, 33 patients were referred based on dipstick-positive results only, 11 were referred based on microscopic urinalysis demonstrating fewer than three RBCs per high-power field (HPF), and the remaining 10 patients were referred with urine microscopy demonstrating at least 3 RBC/HPF but in the setting of a clearly benign cause, such as infection or menstruation. The total estimated cost of the unnecessary asymptomatic microhematuria workup in patients who did not meet American Urological Association criteria for referral was $1,213 per patient. CONCLUSION: Fewer than half of the referrals for asymptomatic microhematuria were appropriate, leading to wasted and entirely preventable health care expenditures. This study highlights the need for education of health care providers making these referrals.

How do maternal views of delivery outcomes vary by demographics and preferred mode of delivery?

OBJECTIVE: To investigate how maternal views of delivery outcomes vary by demographic characteristics and preference toward mode of delivery (MOD). STUDY DESIGN: Survey of 719 pregnant women in outpatient clinics at an academic institution during their third trimester. Women ranked outcomes such as vaginal delivery (VD), cesarean delivery (CD), urinary incontinence, perineal lacerations, and induction of labor (IOL) on a visual analog scale (VAS) in order of worst imaginable (0) to best possible (100) outcomes. RESULTS: Women of all ages ranked VD as more desirable than CD. However, women ≥ 35 years of age had greater valuations of both MOD compared with women <35 years, with mean VAS scores of 88.4 versus 86.4 for VD (p < 0.001) and 61.5 versus 51.9 for CD (p < 0.001). Women with a college education or higher also rated both MOD as more desirable than women with less than a college education. Additionally, women who preferred VD rather than CD had greater valuations of perineal laceration (43.3 vs. 31.5, p = 0.001) and urinary incontinence (40.7 vs. 30.1, p = 0.002). CONCLUSION: Significant differences exist in women's views toward MOD and peripartum outcomes, by demographics and preferred MOD. Understanding delivery preferences better enables clinicians to counsel women about labor and management options.

Racial/ethnic variations in perineal length and association with perineal lacerations: a prospective cohort study.

OBJECTIVE: To examine the association between race/ethnicity, perineal length and the risk of perineal laceration. METHODS: This is a prospective cohort study of a diverse group of women with singleton gestations in the third trimester of pregnancy. Perineal length was measured and mean values calculated for several racial/ethnic groups. Chi-squared analyses were used to examine rates of severe perineal laceration (third or fourth degree laceration) by race/ethnicity among women considered to have a short perineal length. Further, subgroup analyses were performed comparing nulliparas to multiparas. RESULTS: Among 344 study participants, there was no statistically significant difference in mean perineal length by race/ethnicity (White 4.0 ± 1.1 cm, African-American 3.7 ± 1.0 cm, Latina 4.1 ± 1.1 cm, Asian 3.8 ± 1.0 cm, and other/unknown 4.0 ± 0.9 cm). Considering parity, more multiparous Asian and African-American women had a short perineal length (20.7 and 23.5%, respectively, p = 0.05). Finally, the rate of severe perineal lacerations in our cohort was 2.6% overall, but was 8.2% among Asian women (p = 0.04). CONCLUSIONS: We did not find a relationship between short perineal length and risk of severe perineal laceration with vaginal delivery, or a difference in mean perineal length by maternal race/ethnicity. However, we did find that women of different racial/ethnic groups have varying rates of severe perineal laceration, with Asian women comprising the highest proportion.

Preference toward future mode of delivery: how do antepartum preferences and prior delivery experience contribute?

OBJECTIVE: Examine postpartum preferences toward future mode of delivery (MOD), considering recent MOD, antepartum preferences, and demographics. STUDY DESIGN: Prospective cohort study where a survey was distributed in outpatient obstetrics clinics to pregnant women over 18 years at 28 weeks gestation or later. Surveys gathered demographics, obstetric history, and preference toward vaginal delivery (VD) versus cesarean delivery (CD). Women were again surveyed at 6-8 weeks postpartum. Chi-square test compared proportions, and logistic regression controlled for potential confounders. RESULTS: A total of 299 women returned postpartum surveys and expressed preferences. Comparing women who experienced VD versus CD, the majority who had a VD (92.1%) would choose this again, while only 1.9% preferred CD. Among the CD group, preferences were mixed: 29.4% desired repeat CD, 34.1% preferred VD, and 36.5% were undecided (p < 0.001). Adjusted odds were 34.4 (95% CI 9.4-126.1) for preferring VD over CD among women who experienced a recent VD, adjusting for parity, age, ethnicity, education, possible depression, and type of provider. CONCLUSIONS: The majority of women preferred VD postpartum. Of the minority who desired CD, antenatal preference for cesarean and prior experience with CD were important factors. This highlights the impact of individual desires and experience, and underscores importance of antenatal counseling.

Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery?

OBJECTIVE: Obstetrics is one of the most sued subspecialties in the US. This study aimed to examine clinicians' medical-legal experience and its association with recommending cesarean delivery. DESIGN: Cross-sectional convenience survey. POPULATION OR SAMPLE: This is a survey study of clinicians in the US. METHODS: Survey included eight common obstetric clinical vignettes and 27 questions regarding clinicians' practice environment. Chi-square test, multivariable logistic regression models were used for statistical comparisons. MAIN OUTCOME MEASURES: Likelihood of recommending cesarean delivery. RESULTS: There were 1486 clinicians who completed the survey. Clinicians were categorized based on answers to clinical vignettes. Having had lawsuits and daily worry of suits were associated with higher likelihood of recommending cesarean, compared to those without lawsuits (17.2 versus 11.3%, respectively; p = 0.008) as was frequent worry of lawsuits (every day, 20.3% more likely; every week/month, 12.3%; few times a year/never, 11.4%, p < 0.001). CONCLUSION: Obstetric malpractice lawsuit and frequent worry about lawsuit are associated with higher propensity of recommending cesarean delivery in common obstetric settings.

PAMUS: placenta accreta management across the United States.

OBJECTIVE: There is lack of consensus regarding the optimal strategy for management of abnormal placentation. We set out to determine the actual practices of providers across the United States (U.S.). METHODS: This was a cross-sectional survey of maternal-fetal medicine providers in the U.S. registered with the Society for Maternal Fetal Medicine (SMFM). Questions regarding management strategies for placenta accreta were addressed by the survey. Both univariable and multivariable analyses were performed to determine if a relationship between demographic factors and management strategies exists. RESULTS: Approximately 64% of responders were male and 62% had been in practice less than or equal to 20 years. The respondents represented all the major regions of the U.S. and the majority had performed one to five cases in the past year. The gestational age at delivery varied by both the number of years in practice and by geographic location. About 35% of providers report the use of ureteral stents and 36% of providers use internal femoral artery balloons though this varied by region. Regional differences and recent experience play a role in whether to attempt placental removal first. Though the majority of providers believe hysterectomy is the only management option for accreta, 32% of providers have attempted conservative management. CONCLUSIONS: There is wide variation in the actual practices of physicians in the U.S. with regard to management of placenta accreta.