Publications

OBJECTIVES: To determine if chemotherapy contributes to the development of overactive bladder (OAB) in female cancer patients.

METHODS: A prospective, longitudinal study was conducted from 2017 to 2023 at Mount Auburn Hospital to assess the effects of chemotherapy on the development of OAB. Sixty-five female patients diagnosed with nonmetastatic breast cancer, lung cancer, or lymphoma were asked to complete 5 validated questionnaires regarding bladder symptoms just before starting chemotherapy and again at 6 weeks, 3 months, 6 months, and 12 months.

RESULTS: Fifty-eight patients completed the study. Overall, we detected no significant increase in OAB symptoms at any time point relative to baseline. However, an analysis of the data according to different chemotherapy regimens revealed that patients being treated with human epidermal growth factor receptor-2 (HER2) monoclonal antibodies, either trastuzumab alone or in combination with pertuzumab, had significantly higher scores on the questionnaires after the start of chemotherapy. When the HER2-treatment group was further subdivided, we found that patients receiving both monoclonal antibodies, trastuzumab, and pertuzumab, reported more significant urinary tract discomfort and changes in quality of life, particularly at the 6-month and 12-month time points.

CONCLUSIONS: We conclude from our study that women receiving both trastuzumab and pertuzumab for HER2-positive breast cancer may experience an increase in OAB symptoms during the course of their treatment.

OBJECTIVE: To conduct a systematic review and meta-analysis of treatments for female sexual desire, arousal, and orgasmic dysfunction in patients without sexual pain conditions.

DATA SOURCE: MEDLINE, Embase, Web of Science, Cochrane Library, PsycINFO, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION: Following the initial search in December 2024, a total of 8994 abstracts were screened, 278 full-text articles were reviewed, and 36 studies met criteria for data abstraction including a patient population with female sexual dysfunction (FSD) of desire, arousal, and/or orgasm (DAO) and outcome measures including the Female Sexual Function Index (FSFI), its DAO subscales, and the Female Sexual Distress Scale (FSDS). Studies including patients with sexual pain conditions were excluded. Two reviewers independently conducted each phase.

TABULATION, INTEGRATION, AND RESULTS: Of the 36 studies, 26 were RCTs and 10 were single-arm trials. Ten studies evaluated cognitive behavioral therapy (CBT), 24 investigated medication therapy, and 2 investigated devices. Meta-analyses were conducted for mindfulness-based CBT, flibanserin, and bremelanotide. Mindfulness-based CBT significantly improved total FSFI and subscales of desire, arousal, and orgasm. Conversely, flibanserin improved total FSFI and desire while bremelanotide improved total FSFI and its desire and arousal subscales. No studies directly compared CBT to pharmacotherapy.

CONCLUSION: In this systematic review of treatments of females with sexual DAO dysfunctions without pain, we found that CBT improves DAO; flibanserin improves desire; and bremelanotide improves both desire and arousal; and all 3 treatments reduce distress. Our findings align with previous literature and expand upon it to include multiple treatment modalities. This broader perspective offers a starting point for clinicians, including gynecologists, who frequently serve as the first point of care for FSD. Conclusions regarding most other treatments could not be drawn due to limited numbers of studies of FSD excluding pain, heterogeneous terminology for DAO disorders, and varying outcome measures across studies.

BACKGROUND: On June 24, 2022, the Supreme Court of the United States' Dobbs v. Jackson Women's Health Organization decision ended constitutional protection for abortion, resulting in severely restricted access to reproductive health care and raising concerns about the repercussions on obstetrics and gynecology trainees.

OBJECTIVE: This qualitative study examines the observed effects of the Dobbs decision on obstetrics and gynecology training and practice one year out.

METHODS: Obstetrics and gynecology physicians involved in patient care and medical education were invited to participate in online focus groups. We attempted to recruit participants from a diversity of subspecialties and regions of the United States. Eighteen physicians participated in five sessions conducted July-October 2023. Using an iterative process, two independent researchers coded transcripts to identify themes and subthemes. An additional reviewer resolved discrepancies.

RESULTS: Eight themes were identified: dichotomy of care in restrictive versus protective states, loss of the patient-physician relationship, moral distress to physicians, legal concerns for physicians, new issues for training programs, loss of patient care experiences for trainees, loss of access to care for patients, and disappointment and frustration with policy makers. Themes were grouped into their effects on patients, trainees, physicians, and society overall, reflecting negative changes in patient care, training, and physician morale.

CONCLUSIONS: This qualitative study found that physicians see the Dobbs ruling as having negative effects on patients, trainees, and physicians. Participants observed that these changes are leading to a dichotomy of care in which patients in restrictive and protective states receive different care and some patients may not receive medically necessary treatment.

INTRODUCTION AND HYPOTHESIS: Achieving adequate pain relief is crucial for intradetrusor onabotulinumtoxinA treatments for idiopathic overactive bladder in office settings. The objective of this study was to determine whether buffered lidocaine bladder instillation provides better pain control than standard lidocaine prior to intradetrusor onabotulinumtoxinA injections.

METHODS: We conducted a prospective, double-blind, randomized controlled trial comparing two protocols. The standard protocol used a pre-procedure instillation of 50 ml of 1% lidocaine and 50 ml of 0.9% saline. The buffered lidocaine protocol used 50 ml of 1% lidocaine, 45 ml of 0.9% saline, and 5 ml of 8.4% sodium bicarbonate. Both protocols were administered 20 min before onabotulinumtoxinA injections. Female patients with a primary diagnosis of idiopathic overactive bladder were randomized. The primary outcome was procedural pain using a visual analog scale (VAS) measured in millimeters, with secondary outcomes of patient satisfaction and willingness to repeat the procedure.

RESULTS: Of the 76 patients enrolled, 38 were randomized to each group. Data were analyzed for 37 patients in the buffered lidocaine group, and 36 in the standard lidocaine group. Both groups had comparable baseline characteristics. There was no difference in median pain measured by VAS between the buffered (16 [9-40]) and standard (25 [15-55]) protocols (p = 0.21). The buffered group reported a higher, though not statistically significant, satisfaction rate (68% vs 39%, p = 0.08).

CONCLUSION: Intradetrusor onabotulinumtoxinA injections are generally well tolerated among women with idiopathic overactive bladder. No difference was found between protocols, suggesting that buffered lidocaine instillation may not improve pain control among women with idiopathic overactive bladder, although we had insufficient power to detect a difference of the observed magnitude.

IMPORTANCE: Tobacco smoking is linked to poor surgical outcomes, leading many physicians to avoid synthetic implants like mesh in smokers due to concerns about impaired healing. While long-term outcomes for smokers have been studied, the effect of smoking on 30-day postoperative complications, especially related to surgical mesh, is less understood.

OBJECTIVES: This study aimed to quantify the association between tobacco smoking and risk of postoperative infection, readmission, and reoperation within 30 days of minimally invasive apical prolapse repair. We also examined whether these associations differed based on whether mesh was used.

STUDY DESIGN: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database for patients who underwent minimally invasive apical pelvic organ prolapse repair from 2012 to 2022. Smoking in the last year was the exposure. Outcomes included postoperative infection, unplanned readmission, and reoperation within 30 days. We calculated adjusted risk ratios for complications and stratified results based on mesh use.

RESULTS: Of 67,235 cases, 5,518 (8.2%) patients smoked in the past year. Smokers had a significantly higher likelihood of infection and unplanned readmission. Smoking did not increase the risk of unplanned reoperation. The association between smoking and 30-day complications did not differ based on mesh use (all P for interaction ≥0.24).

CONCLUSIONS: Tobacco use was associated with an increase in postoperative complications within 30 days, though the absolute risk was low. There was no evidence of effect modification by mesh use; suggesting that mesh-augmented repairs could be considered in smokers who receive appropriate counseling.

IMPORTANCE: Improving patients' recall and understanding of their planned surgery is essential for fully informed consent.

OBJECTIVE: The objective of this study was to assess if the addition of an information handout to the standard preoperative consent process for the transobturator midurethral sling procedure improved patient understanding, recall, and satisfaction.

STUDY DESIGN: This is a randomized controlled trial of adult women undergoing a transobturator midurethral sling procedure for the treatment of stress urinary incontinence. After standard counseling, participants were randomly assigned to either the control or the intervention group, with the latter receiving an extra informational handout detailing surgical information. Before surgery, all participants filled out a questionnaire assessing key points discussed during the surgical consent, which was used to calculate a knowledge score, the primary endpoint. Secondary outcomes included perception of the consent process and patient satisfaction.

RESULTS: Of 98 randomized participants (50 control, 48 intervention), knowledge scores were 43% for controls and 57% for the intervention group ( P = 0.015). Despite low scores, high self-rated understanding and satisfaction were noted across both groups (78% control, 71% intervention, P = 0.4). Notably, younger individuals, those with some college education, and patients undergoing additional prolapse surgery benefited most from the handout.

CONCLUSIONS: The informational handout improved knowledge scores, though overall knowledge scores were low in both groups. High satisfaction and perceived understanding of the planned procedure persisted, but the addition of a handout was not associated with a significant difference in knowledge scores.

The purpose of this document is to update the 2013 AUGS Position Statement based on subsequent decisions made by the U.S. Food and Drug Administration, published clinical data, and relevant society and national guidelines related to the use of surgical mesh. Urogynecologists specialize in treating pelvic floor disorders, such as pelvic organ prolapse (POP) and urinary incontinence, and have been actively involved and engaged in the national and international discussions and research on the use of surgical mesh in the treatment of POP and stress urinary incontinence. In 2019, the U.S. Food and Drug Administration ordered manufacturers of transvaginally placed mesh kits for prolapse to stop selling and distributing their devices, stating that the data submitted did not provide a reasonable assurance of safety and effectiveness. Evidence supports the use of mesh in synthetic midurethral sling and abdominal sacrocolpopexy. The American Urogynecologic Society (AUGS) remains opposed to any restrictions that ban currently available surgical options performed by qualified and credentialed surgeons on appropriately informed patients with pelvic floor disorders. The AUGS supports the U.S. Food and Drug Administration's recommendations that surgeons thoroughly inform patients seeking treatment for POP about the risks and benefits of all potential treatment options, including nonsurgical options, native tissue vaginal repairs, or abdominally placed mesh. There are certain clinical situations where surgeons may assert that the use and potential benefit of transvaginal mesh for prolapse outweighs the risk of other routes/types of surgery or of not using mesh. The AUGS recommends that surgeons utilize a shared decision-making model in the decision-making process regarding surgical options, including use of transvaginally placed mesh.

OBJECTIVE: To understand women's views of and values placed on the uterus.

METHODS: This was a multicenter, mixed methods, prospective cohort study at seven medical centers across the United States involved with the Society of Gynecologic Surgeons' Collaborative Research in Pelvic Surgery Consortium network. Adults with a uterus and a benign gynecologic condition with no intention for pregnancy were recruited. Chart review and patient questionnaires, including the validated VALUS (Value of Uterus) instrument, were completed. Semi-structured audio interviews were performed in a subset of participants to identify themes associated with values of the uterus. Interview transcripts were thematically analyzed using the grounded theory approach until saturation was reached.

RESULTS: Qualitative data were collected from 40 participants; 36 (90.0%) completed the VALUS questionnaire, and 20 (50.0%) completed semi-structured interviews. The median age was 51 years, and patients mostly identified as White race (75.0%). Participants' gynecologic conditions included urinary incontinence (57.5%), pelvic pain (42.5%), pelvic organ prolapse (40.0%), and various other gynecologic conditions. Based on the VALUS score, 55.6% (20/36) placed a high value on the uterus and 44.4% (16/36) placed a low value on the uterus. When asked about the value of the uterus, some participants viewed it as an organ for reproduction and fertility and their personhood or womanhood, whereas others thought of it as an organ of no value. Recurring themes around considerations before a hysterectomy procedure included a lack of knowledge regarding the physiologic role of the uterus beyond reproduction, the desire for more knowledge to make informed decisions and to understand the purpose of the hysterectomy procedure and alternatives.

CONCLUSION: In this multicenter, mixed methods analysis, more than half the participants placed a high value on the uterus. The values of the uterus included fertility, personhood, and womanhood, which often was described as changing with patient's age or life circumstances. Our findings highlight the need to include the patient's values of the uterus to foster person-centered care in the treatment of gynecologic disorders when uterine preservation is an option.

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.

OBJECTIVES: Sexual function is an important component of women's health that has not been traditionally emphasized during medical training, suggesting that further education is needed to provide comprehensive patient care. The purpose of this study was to describe education and interest in female sexual function among urogynecology providers.

METHODS: Conducted in 2020, this was a cross-sectional survey of American Urogynecologic Society members assessing educational and clinical experience with female sexual function.

RESULTS: Of 642 members who opened the survey, 123 (19%) completed it. Most of the respondents were fellowship trained (70%), and 74% reported ≥10% of their patients had sexual function questions or concerns unrelated to prolapse or incontinence. Most (71%) of the members strongly agreed/agreed that they were comfortable evaluating and managing these patients. This was more common in providers who saw more patients (≥25%) with sexual function concerns (83%) compared with those who saw <25% (65%; P = 0.04). Most of the respondents reported receiving ≤1 lecture on normal sexual function (82%) or sexual dysfunction (85%) during medical training. Most (67%) would expand their practice if they received additional education. The most requested topics were disorders of desire (72%), orgasm (71%), and arousal (67%). The most common reasons for not expanding practice even with additional education were female sexual function not being of significant interest (30%) and time and interruption of practice flow (28%).

CONCLUSIONS: Most of the respondents felt comfortable caring for patients with sexual function concerns, but reported that they would expand their practice with additional education. The majority reported having received ≤1 female sexual function/dysfunction lecture during their medical training. This highlights a critical need and desire for more female sexual function education among the urogynecologic provider population.