STOMp: sexual function trial of overactive bladder medication.

Background: Female sexual function has been shown to improve with overactive bladder (OAB) treatment. Aim: The objective of this study was to evaluate the effects of anticholinergics (ACHs) or a beta-agonist (BAG) on female sexual function. Methods: This was a prospective multicenter cohort study. Sexually active women with OAB completed the Overactive Bladder questionnaire (OAB-q) and Female Sexual Function Index (FSFI) prior to and after 12 weeks of therapy. Sample sizes of 63 per group were calculated to detect a clinically relevant difference in the FSFI. Outcomes: The primary outcome was FSFI change from baseline at 12 weeks. Results: A total of 157 patients were recruited, and 91 completed follow-up (58/108, ACH; 31/49, BAG). There were within-group FSFI differences from pre- to posttreatment: a worsening of arousal in the ACH group (P = .046) and an improvement in overall FSFI (P = .04) and pain (P = .04) in the BAG group. After treatment, postmenopausal women in the BAG group had significantly better overall FSFI (P = .01), desire (P = .003), arousal (P = .009), and orgasm (P = .01). Clinical Implications: While further research is necessary, this study provides information about the comparative effects of OAB treatments on female sexual function, which may ultimately lead to better patient selection and outcomes. Strengths and Limitations: While there was no difference between the subjects who completed the study and those who did not, the study remained underpowered after the loss to follow-up. The multicenter cohort design allows for generalizability of results. Conclusion: Although this study was underpowered, an improvement in overall sexual function was seen with BAGs, while ACHs were associated with worsening aspects of sexual function.

Longitudinal urinary microbiome characteristics in women with urgency urinary incontinence undergoing sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the stability of the urinary microbiome communities in women undergoing sacral neuromodulation (SNM) for urgency urinary incontinence (UUI). We hypothesized that clinical response to SNM therapy would be associated with changes in the urinary microbiome. METHODS: Women completed the Overactive Bladder Questionnaire Short-Form, the International Consultation on Incontinence Questionnaire Short Form, and the Female Sexual Function Index at baseline and 3 months post-SNM implantation. Transurethral urinary specimens were obtained for microbiome analysis at baseline and 3 months postoperatively. The V4 region of the 16S rRNA gene (515F-806R) was amplified with region-specific primers, and Amplicon Sequence Variants (ASVs) were identified with a closed-reference approach of taxonomic classification. Alpha-diversity was calculated using the phylogenetic (i.e., Faith's phylogenetic diversity) and nonphylogenetic metrics (i.e., Shannon diversity, and Pielou's evenness) using the QIIME2 plugin. Longitudinal paired volatility analysis was performed using the DEICODE and Gemelli plugin to account for host specificity across both time and space. RESULTS: Nineteen women who underwent SNM and provided both baseline and 3-month urine samples were included in this analysis. Women reported improvement in objective (number of UUI episodes) and subjective (symptom severity and health-related quality of life) measures. Ninety percent of the bacteria were classified as Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. No significant differences were observed in each subject's beta-diversity at 3 months compared with their baseline microbiome. CONCLUSIONS: Our descriptive pilot study of a cohort of women who had achieved objective and subjective improvements in UUI following SNM therapy demonstrates that the urinary microbiome remains relatively stable, despite variability amongst the cohort.

Characterization of the GU microbiome in women with self-perceived bladder health over the life course.

BACKGROUND: A variety of factors influence bladder health, including environmental factors, life experiences, biologic foundations, and coexistent medical conditions. A biologically diverse microbial community exists in the urine that is likely influenced by the microbial inhabitants of the vagina. The relationship between the genitourinary (GU) microbiome and self-perceived bladder health is unknown. OBJECTIVE: To longitudinally define the GU microbiome in women with self-percieved bladder health sampled across multiple time points over a year. STUDY DESIGN: Women with no reported lower urinary tract dysfunction or symptoms (LUTS) were recruited from six clinical sites and assessed every 6 weeks for 1 year. Voided urine and vaginal samples were longitudinally collected. Self-perceived bladder health was assessed with select items from the LURN comprehensive assessment of self-reported urinary symptoms (CASUS) tool. We defined four life phases as follows: young (18-34 years, nulliparous), midlife (35-45 years, menstruating), transitional (46-60 years, perimenopausal), mature (>60 years, not using vaginal and/or systemic hormone replacement therapy). DNA was extracted from samples, and the V4 region of the 16S rRNA gene was amplified with region-specific primers. The 16S rRNA sequencing on an Illumina NovaSeq. Microbial beta-diversity was calculated using DEICODE to identify microbial taxa that cluster in the samples. Longitudinal volatility analysis was performed using the gemelli plugin. Log-abundance ratios of microbial features were explored and visualized in Qurro. RESULTS: Fifty-four (N = 16 young, N = 16 midlife, N = 15 transitional, N = 7 mature) women were enrolled and provided baseline data. Most women in each life phase (93%-98%) continued to report self-perceived bladder health throughout the 1-year follow-up as assessed by CASUS items. Temporal-based microbial diversity of urinary and vaginal microbiome remained relatively stable over 1 year in all subjects. The GU microbiomes of mature women were distinct and microbially diverse from that of young, midlife, and transitional women, with genera of Gardnerella, Cupriavidus, and Dialister contributory to the microbial features of the mature microbiome. The mature GU microbiome was statistically different (p < 0.0001) from the midlife, transitional, and young microbiome for the log ratio of Gardnerella and Cupriavidus (in the numerator) and Lactobacillus (in the denominator) for voided samples and Gardnerella and Dialister (in the numerator) and Lactobacillus (in the denominator) for vaginal samples. Differences in the GU microbiome were also demonstrated via longitudinal beta-diversity between women developing urinary frequency as reported by CASUS responses or objectively on bladder diary compared to women without urinary frequency. CONCLUSION: In women with a self-perceived healthy bladder, the GU microbiome remained stable in all age groups over a 1 year period. Differences were seen with respect to life phase, where mature women were distinct from all other groups, and with respect to self-reported LUTS.

Baseline Characteristics, Evaluation, and Management of Women With Complaints of Recurrent Urinary Tract Infections.

OBJECTIVE: The aims of this study were to determine the proportion of women presenting for recurrent urinary tract infections (UTIs) who met the diagnostic criteria (culture-proven UTI ≥3 in 1 year or ≥2 in 6 months) and to assess advanced testing utilization, preventive therapy use, and risk factors. METHODS: This is a retrospective chart review of women seen as new urogynecology consults for recurrent UTI (rUTI) between April 1, 2017, and April 1, 2018, followed through April 1, 2019. Exclusion criteria included catheter use, cancer treatment within 2 years, and prior organ transplant, urinary diversion, conduit, or bladder augmentation. RESULTS: Of 600 women, 71% had follow-up with a median of 179 days. Urinary tract infection symptoms included frequency (50%), dysuria (46%), urgency (43%), and malodorous urine (7%). One third met the rUTI diagnostic criteria. Two hundred thirty-four (39%) underwent advanced testing, and 9% (21/234) of women who underwent advanced testing had a change in clinical care. Preventive therapy use increased after consultation (P < 0.001), with vaginal estrogen (47%) being most common. Compared with women not meeting the rUTI criteria, women meeting the rUTI criteria were more likely to be older (adjusted odds ratio [aOR], 1.03/year; 95% confidence interval [CI], 1.02-1.04), have a prior history of gynecologic cancer (aOR, 4.07; 95% CI, 1.02-16.25), or report UTI symptoms of dysuria (aOR, 2.27; 95% CI, 1.57-3.27), or malodorous urine (aOR, 2.96; 95% CI, 1.47-5.94) and, while equally likely to be receiving preventive treatment prior to consultation, were more likely after consultation (OR, 3.06; 95% CI, 2.05-4.55). DISCUSSION: Thirty-seven percent of women seen for rUTI met the diagnostic criteria. Advanced imaging rarely changed care. Education about diagnostic criteria and preventive therapy is warranted.

Comparing Ketorolac With Ibuprofen for Postoperative Pain: A Randomized Clinical Trial.

OBJECTIVES: The objective of this study was to identify differences in pain perception and satisfaction with pain control in women receiving nonsteroidal anti-inflammatory drugs postoperatively. METHODS: This was a prospective, randomized controlled trial including urogynecology surgical patients. After surgery, all patients were randomized to receive either intravenous (IV) ketorolac or ibuprofen. The patients completed 3 visual analog scales (VAS) assessing pain at rest, pain with ambulation, and satisfaction with pain control. Postoperative opioid use was also measured. RESULTS: A total of 224 patients (112 in each arm) were included. Pain scores (SD) at rest in all patients who received ketorolac versus those who received ibuprofen was 2.30 (2.1) versus 2.68 (2.34) (P = 0.20). Pain scores (SD) with ambulation was 3.94 (2.57) versus 4.16 (2.73) (P = 0.57) in patients who received ketorolac and ibuprofen, respectively. Patients who received ketorolac rated their satisfaction with their pain regimen similarly to those who received ibuprofen (P = 0.50). The average amount (SD) of hydromorphone used in the ketorolac and ibuprofen arm was 3.68 (4.58) mg and 4.04 (4.97) mg, respectively (P = 0.58). A subgroup analysis based on type of surgery showed decreased pain at rest (VAS, 2.77 vs 4.88; P = 0.04) and increased satisfaction (VAS, 1.69 vs 4.67; P = 0.003) in patients who had laparotomy and received ketorolac. CONCLUSIONS: There was no difference in pain and satisfaction with IV ketorolac compared with IV ibuprofen in patients who underwent all modalities of urogynecologic surgery. A subgroup of patients who underwent laparotomy had less pain with ketorolac.

Opioid Pain Medication Use in New Urogynecology Patients.

OBJECTIVES: The aim of this study was to determine the prevalence of opioid pain medication use among patients presenting for a new visit to the urogynecology clinic compared with those presenting to general gynecology. METHODS: We identified all patients who presented for new patient visits to the urogynecology and gynecology clinics between January 1, 2016, and December 31, 2016. Any previous or current opioid use was extracted from the electronic medical record medication list. Statistical analysis was performed using χ and Fisher exact tests for comparisons of categorical variables. Modified Poisson regression models were used to estimate prevalence proportion ratios (PPRs). RESULTS: There were 1835 (955 gynecology, 880 urogynecology) patients included. Median age was 47 years (interquartile range, 29 years), and median body mass index was 28.15 kg/m (interquartile range, 9.96 kg/m). Prevalence of opioid use was lowest among women who identified as Asian or other race and highest among black and Native American women; however, when compared by ethnicity, use was lowest among Hispanic women (P = 0.01). Among new urogynecology patients, 14% had self-reported opioid pain medication usage. Opioid use was almost twice as likely in the urogynecology group (PPR, 1.86; 95% confidence interval, 1.4-2.4). When adjusted for confounders, the urogynecology group was 1.3 times as likely to report opioid use (PPR 1.29; 95% confidence interval, 1.0-1.8), with this result approaching statistical significance. CONCLUSIONS: Opioid use is greater in patients presenting to the urogynecology clinic compared with general gynecology. Urogynecologists need to know this information for planning and optimizing pain management in this population.

Novel Use of Three-Dimensional Ultrasonography to Locate a Retained Needle in the Vaginal Wall.

BACKGROUND: The occurrence of retained surgical instruments in vaginal surgery, although low, carries unique complications. Appropriate imaging to find retained surgical instruments allows for timely diagnosis and retrieval of the vaginal foreign body. CASE: The patient is a 33-year-old woman with recurrent cervical cancer who was undergoing radiation therapy. During interstitial implantation, a reverse cutting needle was broken into the anterior vaginal wall. Three-dimensional endoluminal ultrasonography allowed for timely retrieval with minimal surgical exploration in the operating room. CONCLUSION: Intraoperative three-dimensional endoluminal ultrasonography allows for accurate visualization and mapping of a vaginal foreign body. This highlights an innovative and highly useful feature of this imaging technique.

Pregnancy and Sexual Relationships Study Involving wOmen and meN (PASSION Study).

INTRODUCTION: Sexual satisfaction is believed to decrease during pregnancy; however, the effect of pregnancy on the sexual relationship in a couple is not well studied. AIM: To assess for sexual dysfunction in heterosexual couples during pregnancy. METHODS: We performed a cross-sectional study of heterosexual pregnant women in the third trimester and their cohabitating partners. MAIN OUTCOME MEASURES: Sexual satisfaction in heterosexual couples during pregnancy was assessed with a self-reported questionnaire, the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) questionnaire. RESULTS: A total of 53 couples met eligibility criteria, and nearly all of those approached participated (52 of 53 couples). All couples were enrolled at or after 35 weeks' gestation. The mean age was 29.0 ± 6.4 and 31.3 ± 6.9 years for women and men, respectively. 60% of couples were married, and the remainder were cohabitating and in a committed relationship. When analyzing the results of the GRISS questionnaire for both partners, a significant difference was seen in mean avoidance of sex between women and men (3.31 vs 2.63; P = .047) and non-sensuality (3.54 vs 2.75; P = .040). Women reported more of a decrease in communication about sex when compared with their partners (3.79 vs 3.23; P = .047). Vaginismus was more problematic during pregnancy than before (mean = 4.17), and frequency of intercourse was decreased (mean = 4.93) based on calculated GRISS scores. CLINICAL IMPLICATIONS: Pregnant couples reported decreased frequency of intercourse and more pain with intercourse in women. Women were more likely to avoid intercourse and reported more problems with communication regarding sexual needs. STRENGTH & LIMITATIONS: This study is the first to assess both partners in pregnancy. Due to the nature of the study, we were unable to assess other factors affecting the relationship that may result in sexual dysfunction, there was no control group, and the results are limited to heterosexual couples. CONCLUSION: Overall sexual satisfaction and function were not problematic for these couples during pregnancy based on the GRISS scale. Dwarica DS, Garbe Collins G, Fitzgerald C, et al. Pregnancy and Sexual Relationships Study Involving WOmen and MeN (PASSION Study). J Sex Med 2019;16:975-980.

Comparison of dysplastic and benign endocervical polyps.

OBJECTIVE: This study aimed to estimate dysplasia rate in histologically evaluated endocervical polyps and to compare histological and clinical characteristics of dysplastic (D) polyps with those displaying representative benign changes. MATERIALS AND METHODS: Endocervical polyps removed at Mayo Clinic from January 1994 to December 2010 were categorized as polyp without other descriptors, benign polyp variants, adenomatous or reactive atypical (AR) polyps, and D polyps. Clinical characteristics, cervical cytological result, and polyp histological result of patients in the latter 2 categories were compared. RESULTS: Among the 4,328 patients with endocervical polyps, 3,656 were classified as polyp without other descriptors, 628 as benign polyp variants, 34 as AR polyps, and 9 as D polyps. Dysplasia was mild in 4 polyps, moderate in 1 polyp, and severe in 4 polyps. Overall risk of dysplasia was 0.2%. Patients with D polyps were younger (mean = 40.3 vs. 49.8 years, p = .009) and more likely to have abnormal cervical cytological result before polyp removal (67% vs. 21%, p = .014) as compared with those with AR. Patients with D polyps tended to have a polyp greater than 20 mm (44% vs. 15%, p = .074) compared with those with AR polyps. Associated endometrial pathological diagnosis was limited to a prolapsed endometrial polyp in 1 patient and submucosal endometriosis in 1 patient. CONCLUSIONS: Patients with D polyps were younger and had a greater likelihood of abnormal cytological result before polyp removal. No polyp size threshold below which dysplasia could be excluded was identified. No primary cervical cancer, endometrial hyperplasia, or cancer was identified.