Comparison of Pelvic Floor Physical Therapy Attendance Based on Referring Provider Specialty.

OBJECTIVE: The objective of this study was to determine whether pelvic floor physical therapy (PFPT) attendance differs based on referring provider specialty and identify factors related to PFPT initiation and completion. METHODS: This was an institutional review board-approved retrospective cohort study examining referrals from female pelvic medicine and reconstructive surgery (FPMRS) and non-FPMRS providers at a single academic medical center to affiliated PFPT clinics over a 12-month period. Demographics, referring specialty and diagnoses, prior treatment, and details regarding PFPT attendance were collected. Characteristics between FPMRS and non-FPMRS referrals were compared and multivariate logistic regression analyses were performed to identify factors associated with PFPT initiation and completion. RESULTS: A total of 497 referrals were placed for PFPT. Compared with non-FPMRS referrals, FPMRS referrals were for patients who were older (54.7 years vs 35.6 years), and had higher parity; more were postmenopausal (56% vs 18%) and had Medicare insurance (22% vs 10%) (all P < 0.001). Most FPMRS referrals were for patients with urinary incontinence (69% vs 31%), whereas non-FPMRS referrals were for patients with pelvic pain (70% vs 27%) (both P < 0.0001). Pelvic floor physical therapy attendance was similar in both groups when comparing rates of initiation (47% vs 45%) and completion (13% vs 16%). In multivariate analysis, factors associated with initiation were age 65 years or older, additional therapy provided at referring visit, private insurance, Asian race, pregnant or postpartum at time of referral, and more than 1 referring diagnosis (all P < 0.05). No factors were associated with completion. CONCLUSIONS: Less than half of the patients referred to PFPT initiate therapy, and only 15% complete PFPT. The populations referred by FPMRS and non-FPMRS providers are different, but ultimately PFPT utilization is similar.

Unsupervised Machine Learning Approaches Reveal Distinct Phenotypes of Perceived Bladder Pain: A Pilot Study.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is defined as an unpleasant sensation perceived to be related to the bladder with associated urinary symptoms. Due to difficulties discriminating pelvic visceral sensation, IC/BPS likely represents multiple phenotypes with different etiologies that present with overlapping symptomatic manifestations, which complicates clinical management. We hypothesized that unique bladder pain phenotypes or "symptomatic clusters" would be identifiable using machine learning analysis (unsupervised clustering) of validated patient-reported urinary and pain measures. Patients (n = 145) with pelvic pain/discomfort perceived to originate in the bladder and lower urinary tract symptoms answered validated questionnaires [OAB Questionnaire (OAB-q), O'Leary-Sant Indices (ICSI/ICPI), female Genitourinary Pain Index (fGUPI), and Pelvic Floor Disability Index (PFDI)]. In comparison to asymptomatic controls (n = 69), machine learning revealed three bladder pain phenotypes with unique, salient features. The first group chiefly describes urinary frequency and pain with the voiding cycle, in which bladder filling causes pain relieved by bladder emptying. The second group has fluctuating pelvic discomfort and straining to void, urinary frequency and urgency without incontinence, and a sensation of incomplete emptying without urinary retention. Pain in the third group was not associated with voiding, instead being more constant and focused on the urethra and vagina. While not utilized as a feature for clustering, subjects in the second and third groups were significantly younger than subjects in the first group and controls without pain. These phenotypes defined more homogeneous patient subgroups which responded to different therapies on chart review. Current approaches to the management of heterogenous populations of bladder pain patients are often ineffective, discouraging both patients and providers. The granularity of individual phenotypes provided by unsupervised clustering approaches can be exploited to help objectively define more homogeneous patient subgroups. Better differentiation of unique phenotypes within the larger group of pelvic pain patients is needed to move toward improvements in care and a better understanding of the etiologies of these painful symptoms.

Risk Factors for Incomplete Bladder Emptying After Prolapse Repairs and Slings.

OBJECTIVE: The aim of this study was to determine the risk factors for catheter use and incomplete bladder emptying (IE) more than 1 week after prolapse repairs and slings. METHODS: This is a case-control study of women with prolapse repairs and/or sling from June 2011 to April 2016. All underwent standardized postoperative voiding trial before discharge. Controls and cases of IE were identified by codes and chart review; cases were defined as those needing any postoperative catheterization. We excluded patients with preoperative catheter use or postvoid residual (PVR) greater than 150 mL and those needing postoperative catheterization for reasons other than IE. Univariate and multivariate analyses were performed. RESULTS: A total of 475 (30.6%) cases and 478 controls were identified from 1552 eligible patients. Any catheter use was associated with higher uroflow PVR (71.2 vs 54.1 mL, P = 0.006), lower uroflow maximum flow (19.4 vs 25.4 mL/s, P < 0.001), and less detrusor overactivity (DO) (22.0% vs 28.7%, P = 0.03). Seventy-seven (5.0%) patients used catheters more than 1 week, and 15 patients (1.5%) required sling revision.Factors on multivariate analysis associated with any catheter use include office PVR [odds ratio (OR), 1.004; 1.00-1.008], uroflow maximum flow (OR, 0.96; 0.94-0.98), sling (OR, 2.40; 1.51-3.81), and anterior repair (OR, 1.81; 1.15-2.85). Factors associated with IE more than 1 week include uroflow maximum flow (OR, 0.90; 0.84-0.95), DO (OR, 0.21; 0.05-0.83), sling (OR, 3.68; 1.32-10.20), and uterosacral suspensions (OR, 3.43; 1.23-9.54). CONCLUSIONS: Overall, the incidence of short-term catheter use was 31%, prolonged IE more than 1 week was 5%, and 1.5% required sling revision. Sling placement, lower maximum flow, and higher preoperative PVR, anterior repair, and uterosacral ligament suspension are risk factors for IE, and presence of DO is protective.