Trainee Perspectives Regarding the Effect of the Dobbs v. Jackson Women's Health Organization Supreme Court Decision on Obstetrics and Gynecology Training.

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

Cognitive Behavioral Therapy for Chronic Pelvic Pain: What Is It and Does It Work?

PURPOSE: Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome in women and men and chronic prostatitis/chronic pelvic pain syndrome in men, is a common, often disabling urological disorder that is neither well understood nor satisfactorily treated with medical treatments. The past 25 years have seen the development and validation of a number of behavioral pain treatments, of which cognitive behavioral therapy (CBT) is arguably the most effective. CBT combines strategies of behavior therapy, which teaches patients more effective ways of behaving, and cognitive therapy, which focuses on correcting faulty thinking patterns. As a skills-based treatment, CBT emphasizes "unlearning" maladaptive behaviors and thoughts, and replacing them with more adaptive ones that support symptom self-management. MATERIALS AND METHODS: This review describes the rationale, technical procedures, and empirical basis of CBT. RESULTS: While evidence supports CBT for treatment-refractory chronic pain disorders, there is limited understanding of why or how CBT might work, for whom it is most beneficial, or the specific UCPPS symptoms (eg, pain, urinary symptoms) it effectively targets. This is the focus of EPPIC (Easing Pelvic Pain Interventions Clinical Research Program), a landmark NIH trial examining the efficacy of low-intensity, home-based CBT for UCPPS relative to a nonspecific comparator featuring self-care recommendations of AUA guidelines. CONCLUSIONS: Systematic efforts to increase both the efficiency of CBT and the way it is delivered (eg, home-based treatments) are critical to scaling up CBT, optimizing its therapeutic potential, and reducing the public health burden of UCPPS.

De Quervain's Tenosynovitis in Primary Caregivers.

INTRODUCTION: The purpose of this study is to evaluate the incidence of de Quervain's tenosynovitis in newborn caregivers - both male and female - as well as potential associated factors, such as child's age or weight and lactation status. METHODS: Surveys were administered from August 2014 to April 2015 to parents with young children in the greater Buffalo, New York area. Parents were asked to report wrist pain symptoms and location, number of hours spent caregiving, child's age, and lactation status. Participants who reported wrist pain performed a self-guided Finkelstein test and completed a QuickDASH questionnaire. RESULTS: One-hundred twenty-one surveys were returned: 9 from males and 112 from females. Ninety respondents reported no wrist/hand pain (group A), 11 reported wrist/hand pain and a negative Finkelstein test (group B), and 20 reported wrist/hand pain and a positive Finkelstein test (group C). The mean QuickDASH score in group B was significantly smaller than that of group C. On average, child age was statistically significantly different across categories of pain with the oldest population in the positive Finkelstein group (group C) (272.8 ± 196.5 vs 481.9 ± 488.9, P = 0.007). CONCLUSIONS: This study supports the hypothesis that mechanical components of newborn caregiving play a major role in the development of postpartum de Quervain's tenosynovitis. It also supports the concept that hormonal changes in the lactating female are not an important contributor to the development of postpartum de Quervain's tenosynovitis. Our results, as well as previous studies, suggest a high index of suspicion for the condition must be maintained when seeing primary caregivers with wrist pain.

Pelvic Floor Pressures Differ Based on Location in the Pelvis and Body Position: A Cadaver Mode.

BACKGROUND: The pelvic floor is a bowl-shaped complex of multiple muscles and fascia, which functions to support the pelvic organs, and it aids in controlling continence. In pelvic floor disease, this complex becomes weakened or damaged leading to urinary, fecal incontinence, and pelvic organ prolapse. It is unclear whether the position of the body impacts the forces on the pelvic floor. PURPOSE: The primary objective of this work is to measure force applied to the pelvic floor of a cadaver in sitting, standing, supine, and control positions. The secondary objective is to map the forces across the pelvic floor. METHODS: An un-embalmed female cadaver without pelvic floor dysfunction was prepared for pelvic floor pressure measurement using a pressure sensory array placed on top of the pelvic floor, and urodynamic catheters were placed in the hollow of the sacrum, the retropubic space, and at the vaginal apex. Pressure measurements were recorded with the cadaver in the supine position, sitting cushioned without external pelvic floor support, and standing. Pressure array data were analyzed along with imaging of the cadaver. Together, these data were mapped into a three-dimensional reconstruction of the pressure points in pelvic floor and corresponding pelvic organs. RESULTS: pressures were higher at the symphysis than in the hollow of the sacrum in the standing position. Pressure array measurements were lowest in the standing position and highest in the sitting position. Three-dimensional reconstruction confirmed the location and accuracy of our measurements. CONCLUSIONS: The findings of increased pressures behind the symphysis are in line with the higher incidence of anterior compartment prolapse. Our findings support our hypothesis that the natural shape and orientation of the pelvis in the standing position shields the pelvic floor from downward forces of the viscera.

Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS).

BACKGROUND: Urologic chronic pelvic pain syndrome (UCPPS) encompasses several common, costly, diagnoses including interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome that are poorly understood and inadequately treated with conventional medical therapies. Behavioral strategies, recommended as a first-line treatment for managing symptoms, are largely inaccessible, time and labor intensive, and technically complex. The Easing Pelvic Pain Interventions Clinical Research Program (EPPIC) is a clinical trial examining the efficacy of low-intensity cognitive behavioral therapy (Minimal Contact CBT or MC-CBT) for UCPPS and its durability 3 and 6 months post treatment. Additional aims include characterizing the operative processes (e.g., cognitive distancing, context sensitivity, coping flexibility, repetitive negative thought) that drive MC-CBT-induced symptom relief and pre-treatment patient variables that moderate differential response. METHODS: UCPPS patients (240) ages 18-70 years, any gender, ethnicity, and race, will be randomized to 4-session MC-CBT or a credible, non-specific education comparator (EDU) that controls for the generic effects from simply going to treatment. Efficacy assessments will be administered at pre-treatment, 2 weeks, and 3 and 6 months post treatment-week acute phase. A novel statistical approach applied to micro-analytic mediator assessment schedule will permit the specification of the most effective CBT component(s) that drive symptom relief. DISCUSSION: Empirical validation of a low-intensity self-management therapy transdiagnostic in scope has the potential to improve the health of chronic pelvic pain patients refractory to medical therapies, reduce social and economic costs, conserve health care resources, as well as inform evidence-based practice guidelines. Identification of change mechanisms and moderators of treatment effects can provide proactive patient-treatment matching fundamental to goals of personalized medicine. TRIAL REGISTRATION: Clinicaltrials.gov NCT05127616. Registered on 9/19/21.

The effect of solifenacin on postvoid dribbling in women: results of a randomized, double-blind placebo-controlled trial.

INTRODUCTION AND HYPOTHESIS: To determine the effectiveness of the muscarinic receptor antagonist solifenacin (VESIcare®) in the treatment of postvoid dribbling (PVD). METHODS: We carried out a multicenter, 12-week, double-blind, randomized, placebo-controlled, parallel design study. Between 2012 and 2015, a total of 118 women (age 18-89 years) with PVD at least twice/weekly, were randomized to receive solifenacin (5 mg; n = 58) or placebo (n = 60) once daily. The primary outcome was the percentage reduction in PVD episodes. Secondary outcomes included the percentage of patients with ≥50% reduction in PVD episodes and changes in quality of life. RESULTS: There were no differences in either the primary or secondary outcome variables. Subgroup analysis, based on those with more severe disease (>10 PVD episodes/week), showed a greater and significant percentage reduction in the frequency of PVD episodes per day (60.3% vs 32.1%; p = 0.035) and a higher percentage of patients showing ≥50% reduction in the frequency of PVD episodes with solifenacin (68.1% vs 45.8%; p = 0.0476). A significant solifenacin effect occurred at week 2 and continued through week 12 for the subgroup. For solifenacin, PVD reduction was the same for the entire cohort and subgroup, whereas for placebo, it was 10% lower in the subgroup, declining from 42% to 32%. CONCLUSION: There were no differences in PVD outcomes between the solifenacin and placebo groups. Solifenacin may play a role in treating women with the most severe symptoms. Because of the powerful placebo response seen in this study, behavior-based interventions may be useful for treating PVD.

Body mass index continues to accurately predict percent body fat as women age despite changes in muscle mass and height.

OBJECTIVE: Body mass index (BMI) is commonly used to predict obesity in clinical practice because it is suggested to closely correlate with percent body fat (%BF). With aging, women lose both lean mass and height. Because of this, many clinicians question whether BMI is an accurate predictor of obesity in aging women. In evaluating the equation for BMI (weight/height(2)), it is clear that both variables can have a dramatic effect on BMI calculation. We evaluated the relationship between BMI and %BF, as measured by dual-energy x-ray absorptiometry, in the setting of age-related changes in height loss and body composition in women. Our objective is to determine whether BMI continues to correlate with %BF as women age. METHODS: Study participants were identified using data from five osteoporosis clinical trials, where healthy participants had full-body dual-energy x-ray absorptiometry scans. Deidentified data from 274 women aged between 35 and 95 years were evaluated. %BF, weight, age, tallest height, actual height, and appendicular lean mass were collected from all participants. BMI was calculated using the actual height and the tallest height of each study participant. %BF was compared with BMI and stratified for age. RESULTS: BMI calculated using the tallest height and BMI calculated using actual height both had strong correlations with %BF. CONCLUSIONS: Surprisingly, the effects of changes in height and lean body mass balance each other out in BMI calculation. There continues to be a strong correlation between BMI and %BF in adult women as they age.

Prevention of recurrent urinary tract infections by intravesical administration of heparin: a pilot study.

OBJECTIVE: To assess the effect of bladder instillations using heparin on the rate of urinary tract infections in women resistant to standard therapy. PATIENTS AND METHODS: The medical records of all women who received bladder instillations between May 2009 and January of 2010 at the University of Wisconsin urogynecology clinic were reviewed. Eighteen women (mean age 67 years) with a history of recurrent urinary tract infections received intravesical instillations (heparin 40,000 U, 2% lidocaine 8 ml, sodium bicarbonate 4 ml) once weekly for 6 weeks. Patients were considered resistant to standard therapy if their condition failed to respond to chronic suppression antibiotic therapy; they had chronic infections and for this reason could not be placed on chronic suppression; or they were not candidates for chronic suppression due to drug allergies. The number of urinary tract infections was monitored during treatment and for 6 months after therapy. The urinary tract infection rates were compared with the rates of urinary tract infection in the 6 months before treatment. RESULTS: Seventy-eight percent of patients responded to therapy. Subjects were thought to have responded to therapy if there was a greater than 50% reduction in the rate of urinary tract infection. Other variables reviewed included evidence of chronic infection, hormonal status, glomerular filtration rate, age, body mass index, antibiotic allergies, diabetes, hypertension, and chronic antibiotic therapy during bladder instillations. None of these variables were found to be statistically significant. CONCLUSION: Bladder instillations decreased the rate of urinary tract infection in this pilot study; this effect persisted into the post-treatment period. More research is needed to confirm these preliminary findings.

Post void dribbling: incidence and risk factors.

AIMS: The primary aim of this study was to determine the incidence of post void dribbling (PVD) in women being evaluated for pelvic floor dysfunction. The secondary aim was to identify other conditions present in women with symptoms of PVD. MATERIALS AND METHODS: 163 consecutive women with complaints of PVD who underwent urodynamic testing were studied. Testing was performed to evaluate women scheduled for surgery for incontinence, irritative bladder, urinary retention and pelvic organ prolapse. Subjects completed a medical history and voiding diary. A complete pelvic exam was performed. Patients were questioned regarding symptoms of PVD, stress incontinence, urge incontinence and insensible urine loss. Menopausal status, hormone replacement therapy status, age, body mass index, residual urine volume, genital hiatus length, and evidence of pelvic organ prolapse were recorded. Maximal urethral closure pressure, urethral length, pressure transmission ratio, and documentation of detrusor overactivity or urodynamic stress incontinence were determined by urodynamic testing. RESULTS: 42% of patients had symptoms of PVD. The incidence of PVD decreased with age. In pre- and peri-menopausal women, there was an association between PVD and urge incontinence. In post-menopausal women, there was an association between age, body mass index, and genital hiatus length. CONCLUSIONS: There was a significant correlation between PVD and urge incontinence in pre-menopausal patients. The overall incidence and causes of PVD relative to age require further study. Body mass index and genital hiatus length may play an important role in PVD, especially in post-menopausal women.

Prevalence of carpal tunnel syndrome in pregnant women.

Carpal tunnel syndrome (CTS) is a frequent complication of pregnancy, with a prevalence reported as high as 62%. The most typical symptoms are numbness and tingling in the thumb, index finger, middle finger, and radial half of the ring finger. Other common manifestations include burning dysesthetic wrist pain, as well as the loss of grip strength and dexterity. Proximal radiation along the volar forearm, medial arm, and shoulder, while not as common, is not unusual. Symptoms are often worse at night and can be exacerbated by forceful activity and extreme wrist positions. It can be diagnosed to a high degree of specificity via history and physical examination. Median nerve function is impaired in virtually all pregnant women during the third trimester, even in the absence of symptoms. Treatment is symptomatic and usually consists of activity modification, splinting, edema control, and, if necessary, steroid injections. While most women experience symptomatic improvement following delivery, a significant percentage may still have some complaints up to at least 3 years post-partum and continue to wear splints. A high level of vigilance should be maintained in the management of these patients.

Effects of endogenous ovarian estrogen versus exogenous estrogen replacement on blood flow and ERßα and ERß levels in the bladder.

OBJECTIVE: Determine the effect of endogenous estrogen versus estrogen replacement therapy (ERT) on bladder blood flow (BBF) and estrogen receptors (ERs). METHODS: BBF was determined with radiolabeled microspheres in luteal, follicular, pregnant, oophorectomized (Ovx) sheep, and Ovx sheep with ERT. Estrogen receptors (ERalpha, ERbeta) were quantified using Western blot analysis. RESULTS: Compared to luteal and follicular ewes, BBF was reduced in pregnancy and following oophorectomy. Estrogen replacement therapy in Ovx sheep restored BBF to luteal levels. Estrogen receptor alpha predominated, whereas ERbeta was not detectable. Estrogen receptor-alpha levels were unaffected by the ovarian cycle and increased in pregnancy, as well as in Ovx sheep with and without chronic ERT. CONCLUSION: The combination of diminished BBF and elevated ERalpha levels in both pregnant and Ovx sheep suggests an inverse relationship between BBF and ERalpha in the bladder. Although chronic ERT in Ovx sheep restored BBF, it did not restore ERalpha back to luteal levels.