The past 12 months has led to some incredible strides in urology, spanning every thing from advances in treatments to changes in practice management. To rejoice these achievements, Urology Times® is closing out 2022 by highlighting among the clinical and research milestones from different areas of urology over the past 12 months.
On this iteration, Michelle E. Van Kuiken, MD, discusses among the clinical and research highlights in female pelvic medicine and reconstructive surgery (FPMRS) over the past 12 months and appears ahead to what is perhaps on the horizon for the sphere in 2023. Van Kuiken is a urologist at University of California, San Francisco Health, specializing in FPMRS.
Could you describe your clinical practice?
I’m a urologist who focuses on female pelvic medicine and reconstructive surgery, also generally known as urogynecology. My clinical practice is about 70% women and 30% men. I concentrate on all facets of lower urinary tract and pelvic floor dysfunction equivalent to urinary incontinence, neurogenic bladder, pelvic organ prolapse, and bladder/pelvic pain syndromes. I also perform complex reconstruction surgeries for fistulae, pelvic radiation injuries, vaginal mesh complications, and perform urinary diversion surgery.
Over the past 12 months, what have been some clinical and research highlights regarding FPMRS?
One among the areas that has gotten more attention this 12 months is female sexual medicine. Issues with female sexual dysfunction (FSD) have been highlighted more, each within the media and at our clinical meetings. There’s been a historical paucity of information in regard to female sexual dysfunction, together with the query of who owns female sexual dysfunction as a specialty. Is it gynecologists? Is it urologists? Is it primary care?
There was an ideal article that got here out recently in The Recent York Times that featured Dr. Rachel Rubin and focused on the problem of disparities in sexual health care between men and girls.1 At recent clinical meetings, there’s been increasing discussion about the way to address and treat female sexual dysfunction. Moreover, we’re starting to acknowledge that not a number of clinicians are getting training on this area, and clearly there must be a rise in each education and research surrounding female sexual dysfunction. A recent study by Dr. Shoureshi et al presented on the AUA Western Section Meeting2 found that only 14% of FPMRS trained clinicians considered FSD training to be extremely or very satisfactory, and 25% found it to be somewhat satisfactory.Moreover, clinicians cited not knowing what or the way to ask about FSD and uncertainty of therapeutic options as barriers to screening for FSD.
One other vital area of focus is health care disparities and the way patients with pelvic floor disorders (PFDs) access care. A recent systematic review and metanalysis by Mou et al published in Urogynecology3 highlighted each promoters and barriers to look after patients with PDFs.They found that increased knowledge and awareness of PFDs, increased symptom severity, access to primary/secondary care, and good social support were promoters for seeing care.Conversely, patients who were employed, had lack of expertise or embarrassment surrounding PFDs, or were of Black or Asian race were less more likely to seek care. Importantly, the authors noted that only about 1/3 of all women with symptomatic PFDs sought care.
This study and lots of others highlight how access to care on this country may vary depending on race/ethnicity, geographic location, socioeconomic status, insurance type, and more. That is a particularly vital topic of conversation that is fortunately being addressed an increasing number of at meetings, in publications, and stays an area of ongoing research that we’ll proceed to see more of in 2023 and beyond.
One other area of focus is continuous to guage and innovate treatment offerings that we have now for patients with PDFs. While there haven’t been any sweeping changes to how we perform pelvic floor surgeries over the past 12 months, there are a pair of recent revolutionary technologies and coverings which have seen increasing popularity. One example is the single-incision sling for stress urinary incontinence. A recent trial published within the NEJM4 showed that there was non-inferiority of single-incision slings compared with traditional TVT [tension-free vaginal tape] slings for treatment of stress incontinence. While not recent to the market, home pelvic floor muscle training devices remain popular with patients as a result of heavy direct-to-consumer marketing. Fortunately, a recent meta-analysis by Pennycuff et all in Obstetrics and Gynecology5 found an overall reduction in urinary incontinence episodes and improvement in quality of life amongst users of those devices. While unable to state which device is superior, clinicians can feel comfortable recommending these devices to patients especially when access to pelvic floor PT is lacking.
What advances in FPMRS are you anticipating in 2023?
Going back to the concept of how patients access care, one area of increased interest and focus is how we treat patients with overactive bladder (OAB) and urge incontinence. Unfortunately, the plan of look after patients with OAB is commonly dictated by insurance firms, especially in regard to selection of medicines and coverings offered. The American Urological Association and the Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU), have a tenet statement that outlines a tiered treatment algorithm for patients with OAB. Currently, nonetheless, this guideline is within the means of being revised.One possible final result of this revision could also be to alter the “tiered” strategy, which could allow patients to more easily access certain medications and more advanced therapies earlier within the treatment pathway.
Ultimately, as discussed above, the sphere of FPMRS must proceed to higher understand barriers to look after patients with PFDs, and I anticipate continued research and innovation on this space in 2023 and beyond.
Could you describe your individual research interests?
I’m involved in Health Services Research, e.g. how patients access care. Currently, I’m working with the American Urological Association’s AQUA Registry, which is a database of practicing urologists in america, to look at practice trends in OAB management. Using this dataset, we’re assessing how patients with OAB access care based on quite a lot of various factors including race/ethnicity, gender, age, geographic location, and insurance type.We’re also examining what results in lack of progression or delays in progression through the OAB pathway.We’re hoping to make use of these data to develop a baseline of how patients are accessing care by urologists within the US in order that we are able to higher inform interventions in the longer term.
References
1. Gross RE. Half the world has a clitoris. Why don’t doctors study it? The Recent York Times. October 26, 2022. Accessed November 15, 2022. https://www.nytimes.com/2022/10/17/health/clitoris-sex-doctors-surgery.html
2. Shoureshi P, Dubinskaya A, Karram M, et al. Female sexual dysfunction: Practice patterns then and now. Presented on the Western Sectional Meeting of the American Urological Association in Los Angeles, California. Accessed November 29, 2022. https://virtual.oxfordabstracts.com/#/event/3112/submission/234
3. Mou T, Gonzalez J, Gupta A, et al. Barriers and promotors to health service utilization for pelvic flood disorders in america: Systematic review and meta-analysis of qualitative and quantitative studies. Urogynecology. September 2022. Accessed November 29, 2022. doi: 10.1097/SPV.0000000000001215
4. Abdel-Fattah M, Cooper D, Davidson T, et al. Single-incision mini-slings for stress urinary incontinence in women. The Recent England Journal of Medicine. March 31, 2022. Accessed November 29, 2022. doi: 10.1056/NEJMoa2111815
5. Pennycuff JF, Borazjani A, Wang H, et al. Commercially available home pelvic training devices for the treatment of pelvic floor disorders. Obstetrics and Gynecology. August 2022. Accessed November 29, 2022. doi: 10.1097/AOG.0000000000004860
