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INTRODUCTION: Contemporary US resident exposure to Female Pelvic Medicine and Reconstructive Surgery (FPMRS) faculty during urology residency is unknown. METHODS: Accredited US urology residencies were identified through the American Urological Association (AUA). Accredited, urology-based FPMRS fellowships were identified through the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. The number of faculty and residency positions were obtained from program AUA profiles if they were last modified within the current application cycle; this information was obtained from program websites if AUA profiles were outdated. Data on faculty fellowship training was manually extracted from program websites. A quality control cross-check of program and faculty training characteristics was performed through direct communication with 5% of programs. RESULTS: Of 139 accredited residency programs assessed, 10.8% were affiliated with an accredited, urology-based FPMRS fellowship. In total, 29.5% of residency programs, representing 25% of US urology residents, had neither a FPMRS fellowship nor any FPMRS certified faculty. The national FPMRS faculty-to-resident ratio was 1:10.8, and 7.4% of faculty at all residency programs were FPMRS certified. In comparison, faculty-to-resident ratios for other subspecialties were: 1:4.7 for pediatrics, 1:3.6 for oncology, 1:5.9 for minimally invasive surgery/endourology, 1:14.2 for trauma/reconstruction, and 1:11.8 for andrology or male sexual/reproductive health. The FPMRS faculty-to-resident ratio was 1:5.1 in programs with a urology-based FPMRS fellowship compared with 1:13.4 in programs without a FPMRS fellowship. CONCLUSIONS: 30% of US urology residency programs lack FPMRS trained faculty. Even when FPMRS faculty are on staff, the field is often underrepresented relative to other urologic subspecialties. Further studies are required to ascertain if inadequate exposure to FPMRS cases and mentors during training contribute to the shortage of urology residents who choose to specialize in FPMRS. This link has important implications for the current shortage of FPMRS providers.

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Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.

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PURPOSE/OBJECTIVE: To measure the impact of the placement of a midurethral sling (MUS) on development of urinary tract infections (UTI) in women with stress urinary incontinence. METHODS: This is an analysis of a large managed care organization MUS database from 2005 to 2016. The database was queried to identify UTI and diagnosis of recurrent UTI. The primary outcome was the UTI rate after MUS. Secondary outcomes included the recurrent UTI rate and rates of UTI over time. RESULTS: Over the study period, 13,404 MUS were performed. In the 12 postoperative months, 23% of patients developed a UTI, while 4% developed a de novo recurrent UTI diagnosis. UTIs were most frequently diagnosed in the 1st month, with the 7th postoperative day the most common. Predictors of UTI development included increased age (OR 3.69 [95% CI 2.58-5.26]), being diabetic (OR 1.43 [95% CI 1.28-1.60]), and having urinary retention requiring prolonged catheterization (OR 2.45 [95% CI 2.11-2.85]). UTIs were less likely to be diagnosed in those with transobturator MUS (OR 0.85 [95% CI 0.78-0.94]). Patients who developed a UTI were more likely to have a reoperation (p = 0.0147), including a reoperation for mesh revision/removal (p = 0.0287), and recurrent SUI (p = 0.0394). Patients who developed a UTI were more likely to develop postoperative de novo urgency urinary incontinence (UUI) (p < 0.0001). CONCLUSION: Patients are at risk of UTI and rUTI after MUS. Risk of developing UTIs decreases with time. Predictors of developing UTI can help surgeons in the care of patients after MUS.

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BACKGROUND: Gender disparities in medicine have been demonstrated in the past, including differences in the attainment of roles in administration and in physician income. OBJECTIVE: Our objective was to determine the differences in Medicare payments based on the provider gender and training track among female pelvic medicine and reconstructive surgeons. STUDY DESIGN: Medicare payments from the Provider Utilization Aggregate Files were used to determine the payments made by Medicare to urogynecologists. This database was merged with the National Provider Identifier registry with information on subspecialty training, years since graduation, and the geographic pricing cost index used for Medicare payment adjustments. Physicians with <90% female patients and those who graduated medical school <7 years ago in obstetrics and gynecology or <8 years ago in urology were excluded. The effects of gender, specialty of training, number of services provided, years of practice, and geographic pricing cost index on physician reimbursement were evaluated using linear mixed modeling. RESULTS: A total of 578 surgeons with female pelvic medicine and reconstructive surgery subspecialty training met the inclusion criteria. Of those, 517 (89%) were trained as gynecologists, whereas 61 (11%) were trained as urologists. Furthermore, 265 (51%) of the gynecology-trained surgeons and 39 (80%) of the urology-trained surgeons were women. Among the urology-trained surgeons, the median female surgeon was paid $85,962 and their male counterparts were paid $121,531 (41% payment difference). In addition, urology-trained female pelvic medicine and reconstructive surgery surgeons performed a median of 1135 services and their male counterparts performed a median of 1793 services (57% volume difference). Similarly, among gynecology-trained surgeons, the median female payment was $59,277 with 880 services performed, whereas male gynecology-trained surgeons received a median of $66,880 with 791 services performed, representing a difference of 12% in payments and 11% in services. With linear mixed modeling, male physicians were paid more than female physicians while controlling for specialty training, number of services performed, years of practice, and geographic pricing cost index (P<.001). CONCLUSION: Although Medicare payments are based on an equation, differences in reimbursement by physician gender exist in female pelvic medicine and reconstructive surgery with female surgeons receiving lower payments from Medicare. The differences in reimbursement could not be solely explained by differences in patient volume, area of practice, or years of experience alone, suggesting that, similar to other fields in medicine, female surgeons in female pelvic medicine and reconstructive surgery are not paid as much as their male counterparts.

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AIM: To evaluate patient satisfaction and savings, and compare visit outcomes based on chief complaint (CC) of women presenting for a televisit to a female pelvic medicine and reconstructive surgery (FPMRS) clinic at an urban academic center. METHODS: A cross-sectional study of women completing a televisit with an FPMRS specialist at our institution from June 19, 2020 to July 17, 2020 was conducted. A telephone questionnaire was administered to patients to assess satisfaction and savings (travel costs/time avoided). Electronic medical records were reviewed to collect patient demographics and comorbidities, CC, and televisit outcomes (e.g., face-to-face (F2F) exam scheduled, orders placed). Logistic regression was used to analyze predictors of satisfaction and need for F2F follow-up. RESULTS: One hundred eighty-seven of 290 (64.5%) women called completed the survey, of whom 168 (89.8%) were satisfied with their televisit. Eighty-eight (48.1%) saved at least an hour and 54 (28.9%) saved more than $25 on transportation. There were no significant associations between patient characteristics, CC, or televisit outcomes and satisfaction. Ninety-nine (52.9%) televisits resulted in F2F follow-up, with CC of prolapse (odds ratio [OR] = 4.2 (1.7-10.3); p = 0.002), new patient (OR = 2.2 (1.2-4.2); p = 0.01), and Hispanic ethnicity (OR = 3.9 (1.2-13.6); p=.03) as significant predictors. CONCLUSION: Most patients were satisfied with FPMRS televisits at our urban academic center. Televisits resulted in patient travel time and cost savings. Women presenting with prolapse and for new patient visits would likely benefit from initial F2F visits instead of televisits. Televisits are an important mode of health care and in some cases can replace F2F visits.

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INTRODUCTION AND HYPOTHESIS: We sought to examine the change in utilization of the midurethral sling (MUS) for the treatment of stress urinary incontinence (SUI) after the 2011 US FDA communication regarding transvaginal mesh. METHODS: This is a retrospective cohort study evaluating surgical utilization of MUS at a managed care organization of 4.5 million patients from 2008 to 2016. The primary outcome was the change in utilization of synthetic mesh MUS before and after the July 2011 FDA communication. Secondary outcomes were the changes in surgeon level MUS utilization. RESULTS: MUS procedures decreased from 131 to 116 per 100,000 adult women with a decrease of 11.5% from 2010 to 2012. Year over year utilization of MUS was rapidly increasing (p < 0.01) prior the FDA communication from 116 (in 2008) to 131 (in 2010) per 100,000 women and then significantly declined (p < 0.01) after its release from 135 (in 2011) to 75 (in 2016) per 100,000 women (13% increase vs 44% decrease). The number of surgeons performing MUS increased (p < 0.01) from 172/year to 186/year from 2008 to 2010 (Table 1). This decreased (p < 0.01) from 183/year to 121/year from 2011 to 2016. CONCLUSIONS: MUS for SUI drastically declined after the FDA communication. Despite the 2011 FDA communication concerning only transvaginal mesh for pelvic organ prolapse, there was a significant decrease in MUS with synthetic mesh utilization. Our findings support the importance of continued long-term outcome data regarding the safety and efficacy of MUS and highlight the impact of the FDA warning on MUS utilization.

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Obstetrical perineal and anal sphincter lacerations can be associated with considerable sequelae. The diagnosis of short-term bowel, bladder, and healing problems can be delayed if patients are not seen until the traditional postpartum visit at 4 to 6 weeks. Specialized peripartum clinics create a unique opportunity to collaborate with obstetrical specialists to provide early, individualized care for patients experiencing a variety of pelvic floor issues during pregnancy and in the postpartum period. Although implementation of these clinics requires thoughtful planning and partnering with care providers at all levels in the obstetrics care system, many of the necessary resources are available in routine gynecologic practice. Using a multidisciplinary approach with pelvic floor physical therapists, nurses, advanced practice providers, and other specialists is important for the success of this service line and enhances the level of care provided. Overall, these clinics provide a structured means by which pregnant and postpartum women with pelvic floor symptoms can receive specialized counseling and treatment.

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AIMS: Evaluation and treatment of functional conditions of the lower urinary tract (fcLUT), a subset of benign urinary tract conditions, is highly subjective due to overlapping symptomatology. Despite high prevalence and socioeconomic cost, there has been little improvement in their treatment and lack of progress in understanding their pathophysiology. This study investigates trends in quantity, monetary amounts, and awardees' characteristics of federally funded research awards for fcLUT compared to nonurologic benign conditions (NUBCs) and urologic malignancies. METHODS: Data were extracted from the National Institutes of Health (NIH) and federal RePORTER databases in December 2019. We identified currently active awards in fcLUT, NUBC, and malignant urologic conditions and the associated demographic features of awardees. The authors also examined temporal funding trends for such awards. RESULTS: These database searches revealed that there are consistently fewer awards and funding dollars for the study of fcLUT compared to other benign conditions with similar prevalences. While most research topics have received increased funding in awards and overall funding dollars over time, fcLUT funding has remained relatively flat. Urologists are also underrepresented; only 11 of the 86 recipients of NIH R01 awards to study fcLUT have clinical training in urology. CONCLUSIONS: Even when compared to NUBC, funding for the study of fcLUT remains low and has stagnated over time. Further, investigators who are clinicians in the field of urology are in the minority of those doing this study. Given the need for clinical perspectives in fcLUT research, the lack of urologist representation will inhibit discovery and translational advances.

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BACKGROUND: As a result of the vaginal mesh controversy, surgeons are performing more nonmesh, autologous fascia pubovaginal slings to treat stress urinary incontinence in women. The rectus abdominis fascia is the most commonly harvested site for autologous pubovaginal slings, so it is crucial that surgeons are familiar with the relationship between this graft harvest site and the ilioinguinal and iliohypogastric nerves, which can be injured during this procedure. OBJECTIVE: The aims of this study were as follows: (1) to estimate the safest area between the bilateral courses of the ilioinguinal and iliohypogastric nerves in which a rectus abdominis fascia graft could be harvested with minimal risk of injury to these nerves and (2) to determine the location and dimensions of a graft harvest site that maximized graft length while remaining close to the pubic symphysis. STUDY DESIGN: The ilioinguinal and iliohypogastric nerves were dissected bilaterally in 12 unembalmed female anatomical donors. The distances of these nerves to a 10 × 2 cm rectus abdominis fascia graft site located 4 cm above the pubic symphysis were measured. Nerve courses inferior to the graft site were determined for each donor by linearly extrapolating measurement points; analysis was performed with and without extrapolation. Average nerve trajectories were estimated assuming a linear regression function to predict the horizontal measurement as a quadratic function of the vertical distance; 95% confidence bands were also estimated. An estimated safety zone was determined to be the region between all credible nerve bounds. RESULTS: The largest safety zone that was closest to the pubic symphysis was located at 5.4 cm superior to the pubic symphysis. At this location, the inferior border of the graft could measure 9.4 cm in length (4.7 cm bilaterally from the midline). Extrapolated nerve courses below the study graft site yielded a smaller safety zone located 2.7 cm superior to the pubic symphysis, allowing for the inferior border of the graft to be 4.8 cm (2.4 cm bilaterally from the midline). CONCLUSION: A rectus abdominis fascia graft harvested 5.4 cm superior to the pubic symphysis with the inferior border of the graft measuring 9.4 cm in length should minimize injury to the ilioinguinal and iliohypogastric nerves. These dimensions allow for the longest graft while remaining relatively close to the pubic symphysis. The closer a graft is harvested to the pubic symphysis, the smaller in length the graft must be to avoid injury to the ilioinguinal and iliohypogastric nerves.

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INTRODUCTION AND HYPOTHESIS: Understanding demographic and opioid utilization patterns of preoperative opioid users compared with opioid-naïve patients undergoing surgical treatment for pelvic organ prolapse (POP) better informs opioid prescribing. METHODS: A cohort of preoperative opioid users undergoing surgery for POP from 1 January 2012 through 30 May 2017 was identified. Electronic medical records were utilized to obtain pain scores and prescription data. The cohort was organized by surgical approach, number of concomitant procedures, and patient age. These factors were then matched to pain scores, opioid quantity prescribed at discharge, and subsequent refills. Pain scores and opioid use were evaluated for correlation. Results were then compared with similar data previously published for opioid-naïve patients undergoing surgical treatment of POP. RESULTS: Preoperative opioid users were younger (55.5 [14.7] vs 59.5 [12.7]; p = 0.002), of higher body mass index (BMI; 29.2 [5.4] vs 28.6 [10.3]; p = 0.04), and less likely Caucasian (90.3% vs 95.9%; p = 0.002) than opioid-naïve patients. After matching for these differences, opioid users reported higher pain scores (3.5 [2.2] vs 2.6 [1.8]; p = <0.0001), but received similar opioid quantities (324.4 [395] vs 296 [158] oral morphine equivalents [OME]; p = 0.27; 16.8% vs 10.4% refill rates; p = 0.07). In preoperative opioid users, neither surgical approach nor the number of concomitant procedures influenced pain scores. Increasing mean pain scores (1.8 [2.0] to 4.2 [2.4]; p < 0.002) and OME prescribed (226 [170.2] to 541 [902.5] p = 0.056; 0% to 22.2% refill rates; p = 0.02), were seen with decreasing patient age. Pain scores correlated directly with the opioid amount prescribed. CONCLUSIONS: Patient age and preoperative opioid utilization should be factored into urogynecological postoperative opioid-prescribing protocols.

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INTRODUCTION AND HYPOTHESIS: Understanding patient preferences regarding provider characteristics is an under-explored area in urogynecology. This study aims to describe patient preferences for urogynecologic care, including provider gender, age, experience, and presence of medical trainees. METHODS: This was a multicenter, cross-sectional, survey-based study assessing patient preferences with a voluntary, self-administered, anonymous questionnaire prior to their first urogynecology consult. A 5-point Likert scale addressing provider gender, age, experience, and presence of trainees was used. Descriptive statistics summarized patient characteristics and provider preferences. Chi-squared (or Fisher's exact) test was used to test for associations. RESULTS: Six hundred fifteen women participated from eight sites including all geographic regions across the US; 70.8% identified as white with mean age of 58.5 ± 14.2 years. Urinary incontinence was the most commonly reported symptom (45.9%); 51.4% saw a female provider. The majority of patients saw a provider 45-60 years old (42.8%) with > 15 years' experience (60.9%). Sixty-five percent of patients preferred a female provider; 10% preferred a male provider. Sixteen percent preferred a provider < 45 years old, 36% preferred 45-60 years old, and 11% of patients preferred a provider > 60 years old. Most patients preferred a provider with 5-15 or > 15 years' experience (49% and 46%, respectively). Eleven percent preferred the presence of trainees while 24% preferred trainee absence. CONCLUSION: Patient preferences regarding urogynecologic providers included female gender and provider age 45-60 years old with > 5 years' experience. Further study is needed to identify qualitative components associated with these preferences.

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INTRODUCTION AND HYPOTHESIS: The objective of this study was to utilize objective citation analyses to describe the 100 most cited articles in the field of Female Pelvic Medicine & Reconstructive Surgery (FPMRS) and to review their characteristics. METHODS: We searched the Thomas Reuters Web of Science database for the most cited articles within all journals classified as Obstetrics and Gynecology (Ob/Gyn), Urology (Uro), Colorectal Surgery (CRS), and vital General Medicine (GM) journals (New England Journal of Medicine; Journal of the American Medical Association; Lancet; The BMJ). We reviewed search results for FPMRS content and compiled a list of the top 100 most cited articles relevant to FPMRS. RESULTS: We screened 34,934 articles yielded by the initial search and compiled the 100 most cited articles relevant to FPMRS. Of these 100 titles, 40% (42 out of 105) were published in Ob/Gyn, 46.7% (49 out of 105) in Uro, 1.9% (2 out of 105) in CRS, and 11.4% (12 out of 105) in GM journals. The most cited FPMRS article was "The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society" (3,810 total and 242 citations per year). Over half the articles were observational in nature and the majority (58%) of them were related to urinary incontinence in women. CONCLUSIONS: Highly cited FPMRS articles come from a variety of journals, and nearly 50% of the 100 most cited FPMRS articles are from the urology literature. The most cited articles were largely observational rather than interventional studies and mostly related to female urinary incontinence.

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INTRODUCTION AND HYPOTHESIS: The urogynecology subspecialty relies on appropriate referrals from their referral base. We sought to provide guidance for optimizing appropriate referrals to urogynecology by comparing pre-referral characteristics between appropriate and inappropriate referrals. METHODS: This retrospective cohort study examined predictors of appropriate urogynecology referrals. Appropriateness categorization was based upon pelvic floor disorder (PFD) symptoms and signs provided by the referring provider. Patients with both a PFD symptom and sign were considered "appropriate." Patients with neither a PFD symptom nor sign were considered "inappropriate." PFD symptoms were: vaginal bulge, voiding or defecatory dysfunction. PFD signs were: vaginal vault prolapse, urethral hypermobility, mesh/sling exposure, elevated post-void residual, positive standing stress test, abnormal urinalysis or urine culture-proven infection. Continuous and categorical data were analyzed with ANOVA and chi-square test, respectively. A logistic regression model to predict appropriateness was developed from variables identified from the bivariate analysis. RESULTS: Bivariate predictors of an appropriate referral for 1716 study subjects were older age, prior overactive bladder medication use, MD/DO referrer source and OBGYN, urogynecology or urology referrer specialty. Our logistic regression model correctly classified referrals as appropriate in 93.6% of cases. CONCLUSIONS: Age, anti-cholinergic medication use, referrer source and specialty are pre-initial visit predictors of urogynecology referral appropriateness. The predictor-generated model was successful in predicting referral appropriateness. Potential bias from information transfer issues, lack of pre-referral evaluation and referring provider unfamiliarity with urogynecology are possible reasons for inappropriate referrals and potential areas for improvement.

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BACKGROUND: There are approximately 25% of women in the United States suffering from pelvic floor disorders (PFDs) and this number is predicted to rise. The potential complications and increasing healthcare costs that exist with an operation indicate the importance of conservative treatment options prior to attempting surgery. Considering the prevalence of PFDs, it is important for primary care physician and specialists (obstetricians and gynecologists) to be familiar with the initial work-up and the available conservative treatment options prior to subspecialist (urogynecologist) referral. AIM: To assess the types of treatments that specialists attempted prior to subspecialty referral and determine the differences in referral patterns. METHODS: This is a retrospective cohort study of 234 patients from a community teaching hospital referred to a single female pelvic medicine and reconstructive surgery (FPMRS) provider for PFD. Specialist vs primary care provider (PCP) referrals were compared. Number, length and treatment types were studied using descriptive statistics. RESULTS: There were 184 referrals (78.6%) by specialists and 50 (21.4%) by PCP. Treatment (with Kegel exercises, pessary placements, and anticholinergic medications) was attempted on 51% (n = 26) of the PCP compared to 48% (n = 88) of the specialist referrals prior to FPMRS referral (P = 0.6). There was no significant difference in length of treatment prior to referral for PCPs vs specialists (14 mo vs 16 mo, respectively, P = 0.88). However, there was a significant difference in the patient's average time with the condition prior to referral (35 mo vs 58 mo for PCP compared to specialist referrals) (P = 0.02). CONCLUSION: One half of the patients referred to FPMRS clinic received treatment prior to referral. Thus, specialists and generalists can benefit from education regarding therapies for PFD before subspecialty referral.

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PURPOSE OF REVIEW: There are advantages and disadvantages of subspecialty certification for physicians, trainees, patients, and society at large. As female pelvic medicine and reconstructive surgery (FPMRS) became the second subspecialty of urology to offer subspecialty certification, understanding the effects of FPMRS subspecialty certification on the healthcare system is important. RECENT FINDINGS: While subspecialty certification may improve training, identify experts, and ultimately lead to improved patient outcomes, certification might also be unnecessary for some physicians, weaken residency training, and limit the number of physicians who are deemed qualified to offer certain treatments. As pelvic floor disorders can considerably affect quality of life, and their prevalence is expected to increase with the aging population, high-quality FPMRS care is needed. In this article, we describe the history of FPMRS subspecialty certification as well as its potential advantages and disadvantages as suggested by literature. There are advantages and disadvantages of FPMRS subspecialty certification. Further research is needed to assess the effect of FPMRS subspecialty certification on patient outcomes.

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OBJECTIVE: In this review I describe the history leading to the creation of the subspecialty of female pelvic medicine and reconstructive surgery and its fellowships, the process involved in the current requirements for subspecialty certification and fellowship applications, and the implications for urological training. RESULTS AND CONCLUSIONS: The route to subspecialty certification and fellowships for female urology in the USA is a lesson in politics, education, medical rivalries and perseverance, with the goal of improving care for women. This decade-long journey culminated in the recognition of a separate subspecialty by the American Board of Medical Specialties in 2011, accreditation by the American Council for Graduate Medical Education in 2012, and certification to be awarded by the Boards of Obstetrics and Gynecology and Urology in 2013. It remains to be seen whether this effort will improve resident education and patient care, or represent a marketing tool in the competitive USA healthcare environment. While many of the details and regulatory issues are specific to the USA, elements of the curriculum and procedures should be relevant to other countries.