Prescription Opioid Use for Acute Pain and Persistent Opioid Use After Gynecologic Surgery: A Systematic Review.

OBJECTIVE: To assess the amount of opioid medication used by patients and the prevalence of persistent opioid use after discharge for gynecologic surgery for benign indications. DATA SOURCES: We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from inception to October 2020. METHODS OF STUDY SELECTION: Studies with data on gynecologic surgical procedures for benign indications and the amount of outpatient opioids consumed, or the incidence of either persistent opioid use or opioid-use disorder postsurgery were included. Two reviewers independently screened citations and extracted data from eligible studies. TABULATION, INTEGRATION, AND RESULTS: Thirty-six studies (37 articles) met inclusion criteria. Data were extracted from 35 studies; 23 studies included data on opioids consumed after hospital discharge, and 12 studies included data on persistent opioid use after gynecologic surgery. Average morphine milligram equivalents (MME) used in the 14 days after discharge were 54.0 (95% CI 39.9-68.0, seven tablets of 5-mg oxycodone) across all gynecologic surgery types, 35.0 (95% CI 0-75.12, 4.5 tablets of 5-mg oxycodone) after a vaginal hysterectomy, 59.5 (95% CI 44.4-74.6, eight tablets of 5-mg oxycodone) after laparoscopic hysterectomy, and 108.1 (95% CI 80.5-135.8, 14.5 tablets of 5-mg oxycodone) after abdominal hysterectomy. Patients used 22.4 MME (95% CI 12.4-32.3, three tablets of 5-mg oxycodone) within 24 hours of discharge after laparoscopic procedures without hysterectomy and 79.8 MME (95% CI 37.1-122.6, 10.5 tablets of 5-mg oxycodone) from discharge to 7 or 14 days postdischarge after surgery for prolapse. Persistent opioid use occurred in about 4.4% of patients after gynecologic surgery, but this outcome had high heterogeneity due to variation in populations and definitions of the outcome. CONCLUSION: On average, patients use the equivalent of 15 or fewer 5-mg oxycodone tablets (or equivalent) in the 2 weeks after discharge after major gynecologic surgery for benign indications. Persistent opioid use occurred in 4.4% of patients who underwent gynecologic surgery for benign indications. Our findings could help surgeons minimize overprescribing and reduce medication diversion or misuse. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020146120.

Fluids affecting bladder urgency and lower urinary symptoms: results from a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Caffeinated, alcoholic, artificially sweetened, carbonated, and acidic beverages are pervasive and consumed in large quantities. Reputedly, these beverages are "irritating to the bladder" and result in heightened void frequency, but prior studies lack control for intake volume. We tested the null hypothesis that women recruited from the community who demonstrate overactive bladder symptoms will show no difference by groups in void frequency when one group is instructed to replace listed beverages by substituting non-irritants (emphasis on water or milk) and the other group is instructed in healthy eating. METHODS: This was a parallel-group randomized controlled trial design with a three-period fixed sequence (baseline and 2 and 6 weeks post-baseline). We recruited 105 community women with overactive bladder symptoms. INCLUSION CRITERIA: >7 voids per day or 2 voids per night, daily intake of ≥16 oz. (473 ml) of beverages containing the ingredients listed above, and ≥ 32 oz. (946 ml) of total fluid intake. Stratified randomization was conducted. The primary outcome was average daily void frequency on a 3-day diary. RESULTS: Participants were 86% white, mean (SD) age was 46.6 (17.6) years, and baseline void frequency was 9.2 (2.9) voids per day. At 2 and 6 weeks, estimated average (SD) difference in void frequency between group 1 and group 2 was -0.46 (0.57) and -0.31 (0.57) voids per day (p > 0.05); the null hypothesis was not rejected. CONCLUSIONS: Women who reduce potentially irritating beverages while maintaining total fluid volume intake is not predictive of void frequency. Further research on type and volume of beverage intake is recommended.

Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women.

INTRODUCTION: Most causes of microscopic hematuria (MH) are benign but may indicate an underlying malignancy. Current MH evaluation guidelines are reflective of male urologic malignancy risks. The objective of this systematic review was to evaluate whether the finding of MH predicts subsequent urologic malignancy in women. METHODS: MEDLINE was searched between January 1990 and June 8, 2018. The positive predictive value (PPV) of MH as a screening tool for urologic malignancy was calculated for each study individually and collectively. The pooled relative risk of urologic malignancy associated with MH was calculated. RESULTS: Seventeen studies were included. Eight studies included only women. In total, 300 urinary tract cancers were identified in 110,179 women with MH. The PPV of MH as a screening tool for cancer ranged from approximately 0.6% to 2.8%; confidence intervals (CIs) suggested this is a relatively unstable performance indicator because of small sample sizes. Average PPV across all studies was 2.13%, but the weighted average PPV was 0.24%. The risk of urologic malignancies among women with relative those without MH was 2.01 (95% CI, 1.61-2.51). Based on these limited data, we estimate that 859 (95% CI, 654-1250) women with MH would require complete evaluation to identify 1 urinary tract malignancy. CONCLUSIONS: A very small proportion of women with MH are likely to have a urologic malignancy. Approximately 859 women require full screening to identify 1 malignancy. Current evidence is limited, and further studies, specifically in women, are needed.

Stigma Associated With Pelvic Floor Disorders.

OBJECTIVES: Although the impact of stigma is known for women with urinary incontinence, it has not been well studied among the full spectrum of pelvic floor disorders. This study quantifies the level of stigma among women presenting for urogynecologic care and tests the hypothesis that stigma related to pelvic floor disorders results in a delay in care seeking for these problems. METHODS: Women presenting for new patient visits (N = 523) in university medical center-based urogynecology clinics completed 2 anonymous questionnaires (Stigma Scale for Chronic Illnesses 8-item version and Pelvic Floor Bother Questionnaire) before their visit. The Kruskal-Wallis test was used to compare the distributions of stigma scores. Logistic regression was used to model factors associated with a delay in seeking care. Spearman correlation was used to determine whether there was an association between stigma and bother scores. RESULTS: Median stigma score was significantly higher for those presenting with complaints of urine leakage (P = 0.015), accidental bowel leakage (P < 0.001), and constipation (P < 0.001) compared with women without these symptoms. Women presenting with accidental bowel leakage had the highest median stigma score, and those presenting with pelvic organ prolapse had the lowest. Total stigma score had a moderately positive correlation (r = 0.5, P < 0.001) with bother score. In a logistic regression model, higher stigma score was associated with a decreased likelihood of waiting 1 year or more to seek care (odds ratio = 0.92, 95% confidence interval = 0.86-0.98). CONCLUSIONS: Pelvic floor disorders carry varying levels of stigma. Women who feel more stigmatized by pelvic floor disorders seem to seek care earlier.

Comparison of Serum Vitamin D Levels in Relation to Bowel and Bladder Symptoms in Women with Vulvar Diseases.

Objectives: We sought to investigate associations between vitamin D levels and bowel and bladder disorders in women with vulvar diseases. Methods: This is a planned sub-analysis of a cross-sectional study comparing the prevalence of bowel and bladder symptoms in women with biopsy-proven vulvar lichen sclerosus (LS) to a control group of women with non-lichenoid vulvar diseases. All subjects were recruited from a tertiary referral vulvar care clinic in a university-based practice. Serum vitamin D levels were measured and subjects self-completed questionnaires during study recruitment. Pelvic floor disorders were determined from the following questionnaires: Rome III Functional Bowel Disorders Questionnaire, the Bristol stool scale, the Medical, Social and Epidemiologic Aspects of Aging Questionnaire, and the Overactive Bladder-8 Question Version. Results: 181 women with vulvar diseases were included: 88 with LS and 93 with non-LS vulvar diseases. The mean age was 52.5 ± 15.3 years, and 94.5% were Caucasian. Vitamin D levels (26.8 ± 13.1 vs 29.5 ± 19.0 ng/mL), prevalence of low vitamin D levels (51.1% vs 45.2%), and vitamin D supplementation (42.0% vs 47.8%) were similar in women with and without LS (p ≥ 0.27). These factors did not differ between women with and without overactive bladder (OAB) (vitamin D levels 30.1 ± 17.8 vs 26.3 ± 14.8 ng/mL), urinary incontinence (27.9 ± 15.2 vs 26.4 ± 11.0 ng/mL), constipation (26.7 ± 14.8 vs 28.5 ± 16.8 ng/mL), or irritable bowel syndrome (IBS) (30.8 ± 22.1 vs 27.6 ± 13.4 ng/mL). Conclusions: In this cohort of women with vulvar diseases, vitamin D levels and supplementation were not significantly different amongst women with vulvar lichen sclerosus or other non-lichenoid vulvar diseases. Furthermore, vitamin D levels are not serum biomarkers for OAB, urinary incontinence, constipation, or IBS.

American Urogynecologic Society Systematic Review: The Impact of Weight Loss Intervention on Lower Urinary Tract Symptoms and Urinary Incontinence in Overweight and Obese Women.

OBJECTIVE: Obesity can contribute to urinary symptoms such as urgency, frequency, and incontinence. In addition to classic treatments, weight loss interventions offer a unique clinical opportunity to improve these symptoms. STUDY DESIGN: The American Urogynecologic Society Systematic Review Group conducted a review of articles on the impact of surgical and behavioral weight loss (BWL) interventions on urinary symptoms in overweight and obese women. The certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: The review group identified 43 publications from 39 studies, including 10 reports that used data from 5 randomized trials. Overall, there is high-certainty evidence that BWL, such as diet and exercise, decreases the prevalence of stress urinary incontinence 15% to 18% and overall urinary incontinence (UI) by 12% to 17% at 1 to 2.9 years. The certainty of evidence on the long-term impact of these interventions was lower. The certainty of the evidence was moderate to low regarding the benefit of BWL on urgency UI and overactive bladder symptoms. No randomized trials evaluated the impact of surgical weight loss on urinary symptoms, and the certainty of evidence of other study types was very low. CONCLUSIONS: There is high-certainty evidence that BWL results in modest improvements in stress and overall UI in overweight and obese women at 1 to 2.9 years after the intervention. Robust studies with low risk of bias are needed to assess whether these benefits are maintained over the long term and are associated with adverse events and to assess the impact of surgical weight loss interventions on urinary outcomes in overweight and obese women.

Fluids affecting bladder urgency and lower urinary symptoms (FABULUS): methods and protocol for a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: We present the design of a randomized controlled trial, Fluids Affecting Bladder Urgency and Lower Urinary Symptoms (FABULUS), with the purpose of testing the common clinical advice of treating overactive bladder by eliminating potentially irritating beverages (PIBs) that are caffeinated, artificially sweetened, citric, or alcoholic. The primary hypothesis is that women taught to reduce PIBs will show less void frequency compared with a control group instructed in diet/exercise recommendations. Secondary outcomes include change in urgency symptoms and volume per void. METHODS: We report the methods for FABULUS and discuss how challenges presented in the literature and from a prior proof-of-concept feasibility trial are addressed by strengthening study design, procedures, and instruments. We introduce the concept of standardized automated tutorials for assisting participants in compliance from study start to finish. The tutorials contain a detailed explanation of the study, including tips for complying with the extensive diary requirements, and parallel tutorials to intervention and control groups for consistency in format and time of instructional content. The intervention tutorial on eliminating PIBs places emphasis on maintaining steady fluid intake volume, as fluctuations have been a confounder in prior work. RESULTS: Study results promise to inform about both the tutorial approach and specific PIB reduction for effectively treating overactive bladder. CONCLUSIONS: OAB can have a negative impact on quality of life, and current medical treatments carry costs and side-effect risks. If simple lifestyle changes can improve or prevent these bladder symptoms, multiple medical and public health advances could result.

Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations.

INTRODUCTION AND HYPOTHESIS: Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches. METHODS: A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery. RESULTS: Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia. CONCLUSIONS: Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.

Completion of a validated pelvic floor symptom and bother instrument in real-life practice.

INTRODUCTION AND HYPOTHESIS: Validated questionnaires are commonly used in research, but successful completion rates in clinical settings are largely unknown. The primary goal of this study was to assess the frequency of appropriate completion of a validated research survey. We secondarily examined relationships between demographics and successful questionnaire completion. METHODS: New patients completed a paper form of the Pelvic Floor Bother Questionnaire (PFBQ) to assess pelvic floor symptoms and level of bother. Various aspects of successful survey completion were assessed, including unanswered questions, affirmative responses without selection of a level of bother, or choosing a level of bother despite reporting not having a symptom. Relationships between self-reported demographic characteristics and completion of the survey were also evaluated. RESULTS: Five hundred and fourteen questionnaires were completed by a cohort of women with a mean age of 57.5 ± 14.4 years (range 19-97). Overall, 45.3% of women (n = 233) completed the entire PFBQ properly as originally described. Women skipped at least one entire question 16.5% of the time. On logistic regression, older age was significantly associated with improper questionnaire completion (55.0 years ±14.9 successful vs 59.6 years ±13.6 unsuccessful completion, p < 0.001 for overall completion). Age was significantly associated with proper completion of every individual PFBQ question, except question 8 concerning fecal incontinence (p = 0.06). Education level was not significantly associated with successful questionnaire completion. CONCLUSIONS: Overall successful completion of the survey as designed and validated was low, even in a highly educated population. Ways to simplify the instrument to enhance completion, such as electronic smart questionnaires, should be further investigated.

Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines.

OBJECTIVE: The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. DATA SOURCES: Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY ELIGIBILITY: We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. STUDY APPRAISAL AND SYNTHESIS METHODS: Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. RESULTS: Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. CONCLUSION: Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

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 χ 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.

Patient Satisfaction With Nurse-Led Telephone Follow-up in an Ambulatory Setting.

OBJECTIVES: We studied our practice of using nurse telephone follow-up under physician direction to assess symptom improvement and patient satisfaction. METHODS: Women were recruited when their clinical care merited nurse telephone follow-up in the opinion of the attending physician. Women specified a preferred telephone number and completed a symptom questionnaire at the time of enrollment. Nursing telephone follow-up was completed at an interval prescribed by the attending physician to answer specified clinical questions. Approximately 3 months after the initial in-office visit, a satisfaction questionnaire and repeat symptom measure were mailed to the subjects. RESULTS: A convenience sample of 83 women was analyzed. Of those, 91.6% were reached by telephone, and 47.0% returned the follow-up questionnaire. Mean (SD) age was 56.8 (16.6) years (range, 20-89 years). Younger women were less likely to be able to be contacted by telephone (P = 0.02) and less likely to return the questionnaire (P = 0.02). Most common diagnoses were overactive bladder and mixed urinary incontinence. Satisfaction rates were high, and level of convenience for patients was high. Women indicated an ease of speaking over the telephone about their condition and confidence in the treatment plan. Satisfaction with telephone follow-up did not significantly differ based on age or diagnosis. CONCLUSIONS: Patient satisfaction was high for nurse telephone follow-up to replace in-office visits for selected diagnoses. This care strategy deserves further consideration for reimbursement purposes as health care evolves.

Graft and Mesh Use in Transvaginal Prolapse Repair: A Systematic Review.

OBJECTIVE: To update clinical practice guidelines on graft and mesh use in transvaginal pelvic organ prolapse repair based on systematic review. DATA SOURCES: Eligible studies, published through April 2015, were retrieved through ClinicalTrials.gov, MEDLINE, and Cochrane databases and bibliography searches. METHODS OF STUDY SELECTION: We included studies of transvaginal prolapse repair that compared graft or mesh use with either native tissue repair or use of a different graft or mesh with anatomic and symptomatic outcomes with a minimum of 12 months of follow-up. TABULATION, INTEGRATION, AND RESULTS: Study data were extracted by one reviewer and confirmed by a second reviewer. Studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic absorbable, synthetic nonabsorbable), and outcome (anatomic, symptomatic, sexual function, mesh complications, and return to the operating room). We found 66 comparative studies reported in 70 articles, including 38 randomized trials; quality of the literature has improved over time, but some outcomes still show heterogeneity and limited power. In the anterior vaginal compartment, synthetic nonabsorbable mesh consistently showed improved anatomic and bulge symptom outcomes compared with native tissue repairs based on meta-analyses. Other subjective outcomes, including urinary incontinence or dyspareunia, generally did not differ. Biologic graft or synthetic absorbable mesh use did not provide an advantage in any compartment. Synthetic mesh use in the posterior or apical compartments did not improve success. Mesh erosion rates ranged from 1.4-19% at the anterior vaginal wall, but 3-36% when mesh was placed in multiple compartments. Operative mesh revision rates ranged from 3-8%. CONCLUSION: Synthetic mesh augmentation of anterior wall prolapse repair improves anatomic outcomes and bulge symptoms compared with native tissue repair. Biologic grafts do not improve prolapse repair outcomes in any compartment. Mesh erosion occurred in up to 36% of patients, but reoperation rates were low.

Defining Patient Knowledge and Perceptions of Vaginal Pessaries for Prolapse and Incontinence.

OBJECTIVE: The aim of this study was to define patient knowledge and perceptions of pessaries to identify barriers to care and inform physician counseling efforts. METHODS: An anonymous survey was distributed to a convenience sample of new patients presenting to the urogynecology clinic at a single academic medical center. Data analysis was performed using standard bivariate and logistic regression models. RESULTS: A total of 254 women completed the survey. Only half of respondents indicated prior knowledge of pessaries. The most common source of prior knowledge was a physician or other health care provider (100/130, 76.9%); comparatively few women had heard about pessaries from any other source. Patients presented with a negative view of pessaries, 3.6 ± 2.2 on a 0- to 10-point Likert scale, and only a third of patients indicated they would consider pessary use as a treatment option for their condition. On multivariable logistic regression, having previously seen a gynecologist (P = 0.03) and a lower level of education (P = 0.05) independently predicted aversion to pessary use. CONCLUSIONS: Only half of patients presenting to a referral-based practice had previous knowledge of vaginal pessaries. Few patients had heard about pessaries from any source other than a physician or other health care provider. Patients presented with a negative impression of pessaries and a high level of aversion to pessary use. Patients who indicated they would decline pessary use reported a lower level of education and were more likely to have previously seen a gynecologist for evaluation of their condition. These data may inform physician counseling efforts.

Does Instruction to Eliminate Coffee, Tea, Alcohol, Carbonated, and Artificially Sweetened Beverages Improve Lower Urinary Tract Symptoms?: A Prospective Trial.

PURPOSE: Common advice for lower urinary tract symptoms (LUTS) such as frequency, urgency, and related bother includes elimination of potentially irritating beverages (coffee, tea, alcohol, and carbonated and/or artificially sweetened beverages). The purpose of this study was to determine compliance with standardized instruction to eliminate these potentially irritating beverages, whether LUTS improved after instruction, and whether symptoms worsened with partial reintroduction. DESIGN: The 3-phase fixed sequence design was (1) baseline, (2) eliminate potentially irritating beverages listed above, and (3) reintroduce at 50% of baseline volume, with a washout period between each 3-day phase. We asked participants to maintain total intake volume by swapping in equal amounts of nonpotentially irritating beverages (primarily water). SUBJECTS AND SETTING: The study sample comprised 30 community-dwelling women recruited through newspaper advertisement. METHODS: Quantification measures included 3-day voiding diaries and detailed beverage intake, and LUTS questionnaires completed during each phase. RESULTS: During Phase 2, we found significant reduction in potentially irritating beverages but complete elimination was rare. Despite protocol demands, total beverage intake was not stable; mean (± standard deviation) daily total intake volume dropped by 6.2 ± 14.9 oz (P = .03) during Phase 2. In Phase 3, the volume of total beverage intake returned to baseline, but the intake of potentially irritating beverages also returned to near baseline rather than 50% as requested by protocol. Despite this incomplete adherence to study protocols, women reported reduction in symptoms of urge, inability to delay voiding, and bother during both phases (P ≤ .01). The number of voids per day decreased on average by 1.3 and 0.9 voids during Phases 2 and 3, respectively (P = .002 and P = .035). CONCLUSIONS: Education to reduce potentially irritating beverages resulted in improvement in LUTS. However, eliminating potentially irritating beverages was difficult to achieve and maintain. Study findings do not allow us to determine whether LUTS improvement was attributable to intake of fewer potentially irritating beverages, reduced intake of all beverages, the effect of self-monitoring, or some combination of these factors.

Left-sided sacrospinous ligament suspension for treating recurrent sigmoid neovagina prolapse.

Numerous techniques for surgical creation of a neovagina have been described for treating Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. Sigmoid vaginoplasty is one well-described technique with satisfactory long-term outcomes. However, there are several case reports of subsequent prolapse of the sigmoid neovagina, which presents a unique challenge for surgical repair, as the associated mesentery can also be involved and is at risk during repair. We present a patient with MRKH syndrome and recurrent sigmoid neovagina prolapse who had undergone four prior attempts at repair. In all prior attempts, recurrence of her prolapse occurred within 3 months of the antecedent surgery. We describe the first report and successful long-term treatment of recurrent sigmoid neovagina prolapse using a left-sided sacrospinous ligament suspension.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE: Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN: We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS: For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION: Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature.

Pyogenic spondylodiscitis includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. This is a rare complication of sacral colpopexy, but can lead to devastating consequences for the patient. We present two cases of pyogenic spondylodiscitis following sacral colpopexy. In addition, we discuss 26 cases of pyogenic spondylodiscitis reported in the literature from 1957 to 2012. Techniques to decrease rates of infection include proper identification of the S1 vertebra, awareness of the suture placement depth at the level of the sacrum and at the vagina, and early treatment of post-operative urinary tract and vaginal infections. Awareness of symptoms, timely diagnosis and multidisciplinary approach to management is essential in preventing long-term complications.