Overactive bladder syndrome in nulliparous female university students: prevalence and risk factors including waterpipe smoking.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the prevalence of symptoms of overactive bladder syndrome (OAB) among healthy nulliparous female university students, and to evaluate the correlation of these symptoms with a variety of factors, including waterpipe (WP) smoking. METHODS: This is a cross-sectional study. A questionnaire was administered to evaluate symptoms of OAB in healthy nulliparous female university students. Variables assessed included body mass index (BMI), cigarette smoking, WP smoking, consumption of alcohol, coffee, and tea with and without artificial sweeteners, soft drinks, and energy drinks. Adjusted odds ratio were calculated to determine the correlation of these variables with OAB symptoms. RESULTS: A total of 767 out of 2,900 females responded to the questionnaire. Bothersome frequency was reported in 32.3%, and nocturia in 47.5% of the women. Urgency and urgency urinary incontinence (UUI) were present in 25.5 and 24.7% of the study participants respectively. Urgency was associated with WP smoking (p value 0.048). Bothersome frequency was associated with artificial sweeteners used with coffee and tea (p value 0.013). UUI was associated with cigarette smoking (p value 0.034) and elevated BMI (p value < 0.001). OAB symptoms were not found to be significantly associated with soft drink and energy drink consumption. A lower prevalence of nocturia (p value 0.009) and urgency was associated with alcohol consumption (p value 0.017). More than two-thirds (69.2%) of WP smokers expressed readiness to decrease WP smoking if this would improve their lower urinary tract symptoms (LUTS). CONCLUSION: Overactive bladder is common in healthy young nulliparous women and is associated with multiple risk factors, including WP smoking.

The clinical utility of intrapartum screening urinalysis for the prevention of postpartum pyelonephritis.

OBJECTIVES: Urinary tract infection (UTI) is the most common bacterial infection to complicate pregnancy. Medical authorities recommend screening for asymptomatic bacteriuria (ASB) in pregnancy; albeit there is no consensus on ideal timing and frequency for testing. Due to the persistent physiologic changes of pregnancy postpartum, a recent trend to perform urinalysis upon presentation for delivery has been adopted at our institution and various satellite hospitals to putatively minimize cases of postpartum pyelonephritis. The aim of this study is to examine whether routine testing with urinalysis and screening for ASB following suspicious urinalysis with treatment can decrease the incidence of postpartum pyelonephritis, and to determine whether certain urinalysis parameters are more predictive of a positive urine culture. STUDY DESIGN: A retrospective chart review study of all term deliveries was conducted over two years at the American University of Beirut Medical Center, a university teaching hospital. A total of 2359 deliveries of women with no increased susceptibility to UTIs were reviewed. None had urinary symptoms upon presentation. Urinary parameters including time of urinalysis and urine culture collection with respect to time of delivery, corresponding results and mode of urine collection were correlated to intrapartum course, incidence of ASB and of postpartum pyelonephritis. RESULTS: The incidence of ASB among women presenting for delivery was 4.83 %, with Escherichia coli as the most commonly detected pathogen. The presence of nitrite on urinalysis was significantly associated with a positive urine culture (p-value<0.001). Women with history of antenatal ASB or UTI were more likely to have ASB intrapartum with an odds ratio of 3.14 (95 % CI 1.71-5.75, p-value <0.001). Intrapartum urinalysis with subsequent diagnosis and treatment of ASB did not significantly affect the incidence of postpartum pyelonephritis (p-value 0.280). Similarly, intrapartum urinalysis in the setting of positive history of antenatal ASB or UTI did not increase the incidence of postpartum pyelonephritis compared to women with no such history (p-value 0.659). CONCLUSIONS: Urinalysis screening intrapartum does not decrease the incidence of postpartum pyelonephritis. Universal urinalysis screening intrapartum is not warranted and should be reserved for women reporting urinary symptoms and/or women at high risk of UTI.

The Fibromyalgia Bladder Index in 100 consecutive women with fibromyalgia.

INTRODUCTION AND HYPOTHESIS: The Fibromyalgia Bladder Index (FBI) is a validated instrument to quantify bothersome bladder symptoms specifically in women with fibromyalgia syndrome (FMS). The FBI includes two sub-scales: one addressing urinary urgency and bladder pain (UP), the other addressing urinary frequency and nocturia (FN). The objectives of this study are to evaluate the FBI in a cohort of patients with FMS, to correlate it with certain characteristics in this cohort, and to compare it with controls. METHODS: We performed a case-control study of 100 women with FMS and 155 controls. Demographic data, comorbidities, and other characteristics were registered. Comparison between FBI scores of participants with and without FMS, as well as correlation of FBI scores with the characteristics of FMS patients, were undertaken using independent two-sample t test for continuous outcomes and Pearson's Chi-squared test for categorical outcomes. RESULTS: The mean UP subscale score of the FBI was significantly higher in the FMS group (10.29 ± 5.61) compared with the controls (1.65 ± 2.65; (p = 0.001). The mean FN subscale score was significantly higher in the FMS group (9.93 ± 5.37) compared with the controls (2.95 ± 3.27; p = 0.001). FMS patients diagnosed >3 years ago had a higher UP subscale score and a higher FN subscale score compared with FMS patients diagnosed <3 years ago (p = 0.020 and p = 0.024 respectively). Menopause and parity significantly increased the FBI scores. Smoking and a history of depression did not significantly affect any of the FBI subscale scores in the FMS group. CONCLUSION: Women with FMS suffer from bothersome bladder symptoms that can be readily identified and quantified.

Pelvic examination: an iatrogenic cause of microscopic hematuria in women?

INTRODUCTION AND HYPOTHESIS: Microscopic hematuria (MH) in women is a common incidental finding that can trigger morbid and costly investigation. Identifying non-pathologic etiologies of MH may help limit unnecessary investigation. Our study aimed to determine whether pelvic examination (PE) increases the prevalence of MH in women. METHODS: Between May 2018 and October 2018, 157 women > 18 years of age and presenting to the Obstetrics and Gynecology private clinics at a tertiary care center were approached and asked to provide two urine samples: one before PE and one after. Samples were then analyzed to asses for the presence of MH. The McNemar test was used to evaluate whether the conversion from no MH to MH could be attributed to PE rather than to chance. An associated p < 0.05 was determined to be significant. Chi-square test was used to determine whether this conversion is influenced by age and menopausal status. RESULTS: Thirteen women (8.3%) had MH before PE. Of 144 participants with no initial MH, 22 (15.3%) had MH after PE. PE was significantly correlated with the conversion from no MH to MH (p = 0.002). The conversion from no MH to MH following PE was not correlated with age (p = 0.451) or menopausal status (p = 0.411). CONCLUSIONS: PE performed within an hour before urinalysis was found to be a risk factor for MH in women.

Peer review: single-blind, double-blind, or all the way-blind?

A scholarly peer review is the process whereby referees scrutinize research work or a manuscript within their field of expertise and decide on its acceptability for publication in a journal or scientific proceeding. Ideally, peer review is impartial. Among the many models of peer review, the single blind is currently the most adopted model in scientific journals. The double-blind model has been claimed to decrease bias, despite some difficulty in implementation.

International authorship in leading world journals on incontinence and pelvic floor disorders: Is it truly international?

OBJECTIVE: The primary aim of this study is to compare the authorship in the Journal of Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ) across two categories: country members of the Organization for Economic Co-operation and Development (OECD) and non-members of OECD (non-OECD). The secondary aim is to explore the obstacles in publishing in these two journals. STUDY DESIGN: NAU and IUJ articles between June 2014 and June 2018 were manually screened and divided into 2 categories depending on the country of affiliation of the corresponding author: OECD versus non-OECD. They were then divided into seven different types depending on the scope of the article. An online anonymous lime survey was then used to get the opinions of corresponding authors from non-OECD countries regarding obstacles to publishing. RESULTS: The OECD countries, representing 17.0% of the world population contributed to 85.4% of the 1885 articles evaluated, whereas only 14.6% originated from non-OECD countries. The distribution of the article types was comparable between the 2 groups. Out of 194 corresponding authors from non-OECD countries, 35 (18.7%) returned a completely filled survey that could be included in the analysis. Lack of funding, language barrier, and perceived bias were acknowledged as barriers to research and publishing. The majority of corresponding authors believed that international collaboration can improve the quality of research. CONCLUSIONS: The majority of NAU and IUJ articles originate from countries belonging to the OECD group. The uneven representation could be due to gaps in research activity, to obstacles in submission or both.

The underutilization of obliterative and constrictive surgery in the surgical treatment of pelvic organ prolapse.

Vaginal length and caliber are necessary for satisfactory vaginal coitus. Surgical treatment of pelvic organ prolapse (POP) can include preservation of vaginal length and caliber, or shortening and narrowing of the vagina (constrictive and obliterative surgery). The latter option is proven to have fewer complications and a lower risk of recurrence of POP. Women undergoing surgical intervention for POP who are not coitally active and choose not to be coitally active for the rest of their lives should be offered constrictive and obliterative surgery.

Correlates of vaginal laxity symptoms in women attending a urogynecology clinic in Saudi Arabia.

OBJECTIVE: To evaluate the prevalence of vaginal laxity (VL) and its correlates in a cohort of women attending a urogynecology clinic in a tertiary referral center in Saudi Arabia. METHODS: In this retrospective study, demographic information, clinical characteristics, and POP-Q system measurements for women attending the King Fahad Medical City Urogynecology Clinic (January 2013 to April 2015) were analyzed. Women with and without VL were compared across these variables. RESULTS: Out of 376 women attending the clinic for various reasons, 135 (35.9%) reported VL. VL was more common in younger women (P<0.001). Parity, menopausal status, and diabetes were not associated with this symptom. A history of cesarean delivery was protective (aOR 0.39; 95% CI, 0.17-0.90). A bulge symptom and "vaginal wind" were predictors (aOR 3.25; 95% CI, 1.46-7.23 and aOR 15.48; 95% CI, 6.93-34.56, respectively). There was no correlation between VL and POP-Q measurements. VL was not associated with the presence of clinically significant prolapse (stage 2-4), compared with nonsignificant prolapse (stage 0-1) (P=0.869, P=0.152, and P=0.783 for anterior, posterior, and central vaginal compartment, respectively). CONCLUSIONS: In this cohort, VL was common, more prevalent in younger women, and had poorly defined clinical correlates.

IUGA committee opinion: laser-based vaginal devices for treatment of stress urinary incontinence, genitourinary syndrome of menopause, and vaginal laxity.

This committee opinion reviews the laser-based vaginal devices for treatment of genitourinary syndrome of menopause, vaginal laxity, and stress urinary incontinence. The United States Food and Drug Administration has issued a warning for unsubstantiated advertising and use of energy-based devices. Well-designed case-control studies are required to further investigate the potential benefits, harm, and efficacy of laser therapy in the treatment of genitourinary syndrome of menopause, vaginal laxity, and stress urinary incontinence. The therapeutic advantages of nonsurgical laser-based devices in urogynecology can only be recommended after robust clinical trials have demonstrated their long-term complication profile, safety, and efficacy.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion.

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.

Clinical epidemiological insights into urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is very common and heterogeneous among women with limited knowledge of progression or prognosis. Evidence based on clinical epidemiology can help to better understand the natural history of UI. METHODS: We examine the challenges of UI definition and its subtypes, its impact on quality of life and health-seeking behavior. We review the proposed pathophysiology of UI subtypes and known risk factors as they relate to our current knowledge of the disease state. Finally, we emphasize the role of epidemiology in the process of acquiring new insight, improving knowledge, and translating this information into clinical practice. RESULTS: Stress UI is most common overall, but mixed UI is most prevalent in older women. The three UI subtypes have some common risk factors, and others that are unique, but there remains a significant gap in our understanding of how they develop. Although the pathophysiology of stress UI is somewhat understood, urgency UI remains mostly idiopathic, whereas mixed UI is the least studied and most complex subtype. Moreover, there exists limited information on the progression of symptoms over time, and disproportionate UI health-seeking behavior. We identify areas of exploration (e.g., epigenetics, urinary microbiome), and offer new insights into a better understanding of the relationship among the UI subtypes and to develop an integrated construct of UI natural history. CONCLUSION: Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Prevalence and degree of bother of pelvic floor disorder symptoms among women from primary care and specialty clinics in Lebanon: an exploratory study.

INTRODUCTION AND HYPOTHESIS: The prevalence of pelvic floor disorders (PFD) and their impact on quality of life of women vary among different populations. The purpose of this study was to assess the prevalence of symptoms of PFD, and their degree of bother in a convenience sample of Lebanese women, and to evaluate health-care seeking (HCS) behavior related to PFD. METHODS: Women visiting clinics in a University Medical Center in Beirut, Lebanon, completed the self-filled validated Arabic version of the Global Pelvic Floor Bother Questionnaire (PFBQ). Data covering demographics, comorbidities, and HCS behavior related to PFD were collected. Total individual PFBQ scores, individual PFD symptom scores and HCS behavior were correlated to demographic data and comorbidities. RESULTS: The study participants included 900 women. PFBQ scores were significantly higher in women of older age, women with a lower level of education, women with higher vaginal parity, and women who engaged in heavy lifting/physical activity. BMI >25 kg/m2 was the strongest independent risk factor for the presence of PFD symptoms. The overall prevalence of urinary incontinence was 42 %. Anal incontinence was the most bothersome PFD. Almost two thirds of the women reported HCS due to any aspect of PFD. Among symptomatic women who believed that their PFD warranted HCS, financial concern was the most common obstacle irrespective of age and educational level. CONCLUSIONS: In this convenience sample of Lebanese women, PFD symptoms were common and were significantly correlated with demographic characteristics and self-reported comorbidities. The key reason for not seeking health care related to PFD was financial concern.

Female genital mutilation: the role of medical professional organizations.

Female genital mutilation (FGM) refers to alteration of the external genitalia of girls without medical benefit. It is estimated by United Nations agencies that 200 million living girls and women have been subjected to different forms of FGM worldwide. Despite the criminalization of the procedure in the vast majority of countries where it is practiced, the decline in the incidence of this ritual is far from satisfactory. Immediate and long-term ill effects are well documented. Most publications of relevance originate from countries outside the map of FGM. In addition, there are major gaps in research related to this issue, considering the magnitude of the problem. International medical organizations and societies should assume their responsibility by providing a platform to professionals engaged in the prevention and treatment of the consequences of FGM, especially those living in the communities where the practice is endemic.

Variability in practice patterns in stress urinary incontinence and pelvic organ prolapse: results of an IUGA survey.

INTRODUCTION AND HYPOTHESIS: Members of the International Urogynecological Association (IUGA) come from different geographic locations and practice settings. A member survey regarding practice patterns provides valuable information for practitioners and researchers alike, and allows the IUGA to discover areas to focus on education and information dissemination. METHODS: A questionnaire was developed by the IUGA Research and Development committee and distributed electronically to IUGA surgeons. Answers were analyzed in reference to demographics, geographic distribution, and academic affiliation. RESULTS: Five hundred sixty-four members answered the questionnaire, representing a 28 % response rate, and closely reflecting the geographic distribution of IUGA membership. Preferred surgical treatment for uncomplicated SUI was the mid-urethral trans-obturator sling (49.7 %). Vaginal mesh was mainly used for repair of recurrent POP (20.4 %). Pessary use was offered "always" or "frequently" by 61.5 %, with no difference in academic affiliation, but significant differences based on region of practice. Compared to practitioners in non-academic centers, those with academic affiliation utilized Urodynamic studies (UDS) and Magnetic Resonance Imaging (MRI) more frequently in the evaluation of POP. Regions of practice significantly influenced the majority of practice patterns, with the highest impact found in the use of robotic assistance. CONCLUSIONS: Many practice patterns in the evaluation and treatment of POP and SUI depend on academic affiliation and geographic location. Practice patterns are not always based on most recent evidence-based data.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs. RESULTS: This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations. CONCLUSIONS: Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

Mixed urinary incontinence: international urogynecological association research and development committee opinion.

BACKGROUND AND AIM: The definition as well as the treatment of women with mixed urinary incontinence (MUI) is controversial. Since women with MUI are a heterogeneous group, the treatment of MUI requires an individual assessment of the symptom components: stress urinary incontinence, urinary urgency, urgency urinary incontinence, urinary frequency, and nocturia. The purpose of this paper is to summarize the current literature and give an evidence-based review of the assessment and treatment of MUI. METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the diagnosis and management of MUI was drafted based on a literature review. After evaluation by the entire IUGA R&D Committee, revisions were made, and the final document represents the IUGA R&D Committee Opinion on MUI. RESULTS: This R&D Committee Opinion reviews the literature on MUI and summarizes the assessment and treatment with evidence-based recommendations. CONCLUSIONS: The diagnosis of MUI encompasses a very heterogeneous group of women. The evaluation and treatment requires an individualized approach. The use of validated questionnaires is recommended to assess urinary incontinence symptoms and effect on quality of life. Conservative therapy is suggested as a first-line approach; if surgery is contemplated, urodynamic investigation is recommended. Women undergoing surgical treatment for MUI need to be counselled about the possibility of persistence of urinary urgency, frequency and urge incontinence even if stress urinary incontinence is cured.