Year in review: Female pelvic medicine and reconstructive surgery 2022 highlights

"The field of FPRMS needs to continue to better understand barriers to care for patients with PFDs, and I anticipate continued research and innovation in this space in 2023 and beyond," says Dr. Van Kuiken.

The past year has brought about some incredible strides in urology, spanning everything from advances in treatments to changes in practice management. To celebrate these achievements, Urology Times® is closing out 2022 by highlighting some of the clinical and research milestones from different areas of urology over the past year.

In this iteration, Michelle E. Van Kuiken, MD, discusses some of the clinical and research highlights in female pelvic medicine and reconstructive surgery (FPMRS) over the past year and looks ahead to what might be on the horizon for the field 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 specializes in female pelvic medicine and reconstructive surgery, also known as urogynecology. My clinical practice is about 70% women and 30% men. I focus on all aspects of lower urinary tract and pelvic floor dysfunction such as 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 year, what have been some clinical and research highlights regarding FPMRS?

One of the areas that has gotten more attention this year is female sexual medicine. Issues with female sexual dysfunction (FSD) have been highlighted more, both in the media and at our clinical meetings. There's been a historical paucity of data in regard to female sexual dysfunction, along with the question of who owns female sexual dysfunction as a specialty. Is it gynecologists? Is it urologists? Is it primary care?

There was a great article that came out recently in The New York Times that featured Dr. Rachel Rubin and focused on the issue of disparities in sexual health care between men and women.¹ At recent clinical meetings, there's been increasing discussion about how to address and treat female sexual dysfunction. Additionally, we’re starting to recognize that not a lot of clinicians are getting training in this area, and clearly there needs to be an increase in both education and research surrounding female sexual dysfunction. A recent study by Dr. Shoureshi et al presented at 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.Additionally, clinicians cited not knowing what or how to ask about FSD and uncertainty of therapeutic options as barriers to screening for FSD.

Another important area of focus is health care disparities and how patients with pelvic floor disorders (PFDs) access care. A recent systematic review and metanalysis by Mou et al published in Urogynecology³ highlighted both promoters and barriers to care for 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 knowledge or embarrassment surrounding PFDs, or were of Black or Asian race were less likely to seek care. Importantly, the authors noted that only about 1/3 of all women with symptomatic PFDs sought care.

This study and many others highlight how access to care in this country may vary depending on race/ethnicity, geographic location, socioeconomic status, insurance type, and more. This is an extremely important topic of conversation that's fortunately being addressed more and more at meetings, in publications, and remains an area of ongoing research that we’ll continue to see more of in 2023 and beyond.

Another area of focus is continuing to evaluate and innovate treatment offerings that we have for patients with PDFs. While there haven’t been any sweeping changes to how we perform pelvic floor surgeries over the past year, there are a couple of new innovative technologies and treatments that have seen increasing popularity. One example is the single-incision sling for stress urinary incontinence. A recent trial published in 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 new to the market, home pelvic floor muscle training devices remain popular with patients due to 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 among users of these 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 idea 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 care for patients with OAB is often dictated by insurance companies, especially in regard to choice of medications and treatments offered. The American Urological Association and the Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU), have a guideline statement that outlines a tiered treatment algorithm for patients with OAB. Currently, however, this guideline is in the process of being revised.One possible outcome of this revision may be to change the “tiered” strategy, which could allow patients to more easily access certain medications and more advanced therapies earlier in the treatment pathway.

Ultimately, as discussed above, the field of FPMRS needs to continue to better understand barriers to care for patients with PFDs, and I anticipate continued research and innovation in this space in 2023 and beyond.

Could you describe your own research interests?

I am interested in Health Services Research, e.g. how patients access care. Currently, I am working with the American Urological Association’s AQUA Registry, which is a database of practicing urologists in the United States, to examine practice trends in OAB management. Using this dataset, we’re assessing how patients with OAB access care based on a variety of different factors including race/ethnicity, gender, age, geographic location, and insurance type.We’re also examining what leads to lack of progression or delays in progression through the OAB pathway.We're hoping to use these data to develop a baseline of how patients are accessing care by urologists in the US so that we can better inform interventions in the future.

References

1. Gross RE. Half the world has a clitoris. Why don’t doctors study it? The New 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 at 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 the United States: 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 New 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