Assessing the Impact of Overactive Bladder Medications on Cognition.

IMPORTANCE: Emerging literature has associated the use of anticholinergic medications to cognitive decline. OBJECTIVE: The aim of this study was to evaluate the association of overactive bladder medications on cognitive function with prospective longitudinal cognitive assessments. STUDY DESIGN: A population-based cohort of individuals 50 years and older who had serial validated cognitive assessment, in accordance with the Mayo Clinic Study of Aging, was evaluated from October 2004 through December 2021. Anticholinergic overactive bladder medications were grouped by traditional anticholinergic medications and central nervous system (CNS)- sparing anticholinergic medications and compared to no medication exposure. A linear mixed effects model with time-dependent exposures evaluated the association between overactive bladder anticholinergic medication exposure and subsequent trajectories of cognitive z-scores. RESULTS: We included 5,872 participants with a median follow-up of 6.4 years. Four hundred forty-three were exposed to traditional anticholinergic medications, 60 to CNS-sparing medications, and 5,369 had no exposure. On multivariable analyses, exposure to any anticholinergic overactive bladder medication was significantly associated with deterioration in longitudinal cognitive scores in the language and attention assessments compared to the control cohort. Traditional anticholinergic medication exposure was associated with worse attention scores than nonexposed participants. Exposure to CNS-sparing anticholinergic medications was associated with a deterioration in the language domain compared to those unexposed. Among women, traditional anticholinergic medication exposure was associated with worse global and visuospatial scores than nonexposed participants, but this association was not identified in the CNS-sparing group. CONCLUSION: Exposure to anticholinergic overactive bladder medications was associated with small but significantly worse decline in cognitive scoring in the language and attention domains when compared to nonexposed individuals.

Robotic repair of a branching vesicouterine and vesicovaginal fistula.

INTRODUCTION AND HYPOTHESIS: We present technical considerations and tips for repairing a complex branching vesicouterine and vesicovaginal fistula via a robotic approach. METHODS: A 31-year-old female presented with constant urinary leakage following a vaginal birth after prior cesarean section. Evaluation with cystoscopy and cross-sectional imaging demonstrated a branching vesicouterine and vesicovaginal fistula. Repair with robotic-assisted approach was carried out. An intentional cystotomy was made with a tear-drop incision around the fistula tracts. The vesicouterine and vesicovaginal planes were dissected and mobilized. The vaginotomy and cystotomy were closed in a running two-layer fashion with absorbable suture and the uterine defect closed with interrupted absorbable suture. Retrograde bladder filling confirmed a watertight repair. A broad peritoneal flap was created, positioned, and secured with care to ensure it covered past the apex of the fistula closure. RESULTS: Following overnight observation she had an uneventful recovery, including catheter removal at 3 weeks after cystogram confirmed resolution of the fistula. At 6 weeks the fistula and her leakage remained resolved, with no de novo voiding or incontinence symptoms. CONCLUSIONS: A robotic approach to complex branching vesicouterine and vesicovaginal fistula is technically feasible. Careful attention to surgical technique and the use of tissue interposition may improve fistula resolution rates.

Influenza and Tdap Vaccines: Practices and Perception among Hispanic Women attending Tertiary Center in Puerto Rico.

OBJECTIVE: Explore influenza and Tdap immunization knowledge, attitudes, and practices among Hispanics patients attending prenatal care in a tertiary hospital in Puerto Rico as well as barriers encountered by patients regarding vaccination practices during pregnancy. METHODS: Descriptive study conducted at the University District Hospital prenatal care clinics in the Medical Sciences Campus of Puerto Rico from September 2016 to June 2017. RESULTS: A total of 189 pregnant women were recruited. Regarding Influenza vaccine: 75.6% were offered or oriented about Influenza vaccination, 51.8% had received the vaccine at least once (only 12.2% during current pregnancy) and, 57.1% reported receiving information about influenza infection risks in pregnancy, mainly from health care professionals and media. For Tdap only 20.6% of women were offered or oriented about the vaccine and 7.4% received the vaccine during pregnancy. 55.6% of patients had not been oriented about potential dangers of the pertussis infection; for the few oriented, health professionals were their predominant source. In terms of barriers, lack of information about vaccination and its benefits during pregnancy were the most frequent. CONCLUSION: Our study identifies the existing gap of information regarding Influenza and Tdap vaccine. Physicians play a pivotal role in preventive care and new strategies are needed to optimize education to our patients.

Cost-effectiveness Analysis of Early Sling Loosening Versus Delayed Sling Lysis in the Management of Voiding Dysfunction After Midurethral Sling Placement.

OBJECTIVE: The aim of this study was to perform a cost-effectiveness analysis comparing the management for ongoing voiding dysfunction after midurethral sling placement, including early sling loosening and delayed sling lysis. METHODS: A Markov model was created to compare the cost-effectiveness of early sling loosening (2 weeks) versus delayed sling lysis (6 weeks) for the management of persisting voiding dysfunction/retention after midurethral sling placement. A literature review provided rates of resolution of voiding dysfunction with conservative management, complications, recurrent stress urinary incontinence, or ongoing retention, as well as quality-adjusted life years (QALYs). Costs were based on 2020 Medicare reimbursement rates. Incremental cost-effectiveness ratios were compared using a willingness-to-pay threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS: At 1 year, early sling loosening resulted in increased costs ($3,575 vs $1,836) and higher QALYs (0.948 vs 0.925) compared with delayed sling lysis. This translated to early sling loosening being the most cost-effective strategy, with an incremental cost-effectiveness ratio of $74,382/QALY. The model was sensitive to multiple variables on our 1-way sensitivity analysis. For example, delayed sling lysis became cost-effective if the rate of voiding dysfunction resolution with conservative management was greater than or equal to 57% or recurrent stress urinary incontinence after early loosening was greater than or equal to 9.6%. At a willingness-to-pay threshold of 100,000/QALY, early sling loosening was cost-effective in 82% of microsimulations in probabilistic sensitivity analysis. CONCLUSIONS: Early sling loosening represents a more cost-effective management method in resolving ongoing voiding dysfunction after sling placement. These findings may favor early clinical management in patients with voiding dysfunction after midurethral sling placement.

Vaginal symptoms in women who are affected by gynecologic cancer.

PURPOSE OF REVIEW: Pelvic floor disorders are common among gynecologic cancer survivors. With improvements in survivorship, quality of life conditions in these women need greater attention and care. This review focuses specifically on vulvovaginal symptoms, which are common and have a negative impact on sexual health and quality of life in women affected by gynecologic cancer. RECENT FINDINGS: We review publications on treatment-specific sexual health outcomes, screening and treatment of vulvovaginal symptoms and sexual pain, and surgical management options. Recent evidence regarding the safety of concomitant prolapse repair at the time of surgery for gynecologic malignancies and CO2 laser therapy is discussed and areas needing further research and innovation are highlighted. SUMMARY: Pelvic floor disorders, including vaginal and sexual health concerns, are common in women affected by gynecologic cancer due to both common risk factors and as a side effects of cancer treatment. Gynecologists play a critical role in screening, treatment, and collaboration with other specialists to provide comprehensive care for these women throughout their lifetime.