try and kind of combine all the talks from today. So with our first case, we have an 88-year-old female that's had prolapse repair and bulkamid. In the post-op period, she develops recurrent UTIs with acute urinary symptoms with each event. All of her samples have been obtained via straight cath and clinic, and resistances have increased with each following injection. Dr. Gray, in this situation, what are some of her options for treatment? Well, we just reviewed some of those. I think the first thing you would want to know is it looks like she's got E. coli intercoccus, and now she's getting some resistance, which again, if you look at recent exposure to ciprofloxacin, technically, is absolutely not that uncommon. She's been given some, okay, she's been given some fosfamycin, and again, she's, oh my goodness, now she's multi-drug resistant, so she's developed that fairly rapidly. So in this case, let's talk about focusing on behavioral interventions. That would include fluid intake. It's very simple. We can recommend that to her. She can certainly try something like Cranberry. I'd suspect that that would give a modest effect at best. She, in terms of antibiotic prophylaxis, I would remind you that you've already got an MDRSO, so I'd be a little bit leery about that, but I certainly would try my antiseptics, and I would see if I, I would certainly consider methamphetamine with someone like her. I think that she also, let's see, so she's had some Volcomed. I mean, would she benefit from something like a cystosamine, just to look around and be sure there's something that you're not anticipating related to any of her previous procedures? I think it's a Hail Mary pass, but it's not, I don't think unreasonable. I'd refer to my physician colleagues for that opinion. At what time would any of you guys consider an antibiotic installation? I mean, what I would do first, and someone, if it's the immediate post-op period, she probably already had this, but check a PBR and just make sure she's emptying. That's less commonly a cause. I mean, in older women, it's more of a cause than in younger women, but that would be the first thing I think I'd do to rule it out. And then before I went into trying to do a lot of complicated treatment regimens, would try her on a prophylactic regimen with some of the things that Dr. Gray brought up. If she's not already on vaginal estrogen, that cranberry, you could consider methenamine or any of those things. So I usually try those. In someone like this that's getting them rapidly, though, and is miserable, since the vaginal estrogen, you gotta tell patients, too, I'm sure everybody knows this, but it takes six to eight weeks to be active. And so a lot of patients will come back three months later and say, oh yeah, I did that for a week and then I had a UTI, so I stopped. So first I tell them that they need to take it. And so for someone that's really miserable like this, I might actually do a month or two of antibiotic prophylaxis just to help them break the cycle. She's 88. Sometimes, like older women, too, the difference between just like genitourinary syndrome and menopause and UTI can be hard. So just break the cycle. I give them some antibiotics daily, like nitrofurantoin for a few months, start vaginal estrogen, and then I see them back in three months, stop the daily, and just see if they're gonna fly on vaginal estrogen alone. So that's what I would do first with this patient. Great, you guys are answering my questions. Dr. Carter-Brooks, given her new UTIs, would you recommend any imaging, given that she hasn't had any microscopic hematuria? I would, I mean, in this patient, I probably would consider some type of evaluation to make sure there's no nidus for the infections and she's not clearing them. And just to add on with the kind of rapid cultures, I'd wanna know after each treatment, did the symptoms clear? You know, do we have a test of cure? I know that's kind of controversial at times, but in this situation, I'd want a culture at the end or at least talk to the patient, bring them in at the end of the course of the treatment, talk to the patient, bring them in at the end of the course of the antibiotics to determine if there's any improvement in symptoms, and also check her culture to make sure it's clearing. If it's not clearing and it's the same antibiotic, there could be a stone, a suture, something like that that's contributing to the infection. So potentially you could do a CT to look for stones and then a cysto, depending on what her symptoms are, to look in the bladder as well. Great, you guys have already answered my next question. So she's using the vaginal estrogen, hydrating adequately, taking D-mannose, PACs, and minimizing risk behaviorally. And we talked about other options for suppressive therapy. Now, would any of you guys refer or think of referrals at this point? Anyone? Would any of you guys consider any sorts of specific types of referrals at this point? So I'm gonna go a little outside the box on this one because we're thinking all pelvic floor here, but what stood out to me is she's 88 years old and she's been through surgeries. And with the symptoms she has, I'd be a little bit concerned that she is low activity and at that age with bone loss and sarcopenia, muscle mass loss, that that might be something for, it doesn't even have to be a pelvic PT, but a PT to help build that back up again. Because I like to look at the whole person, not just necessarily the one symptom she's having. And the great thing is if we've got a collaborative approach and you've got referral sources, I would definitely use that. So I know it's a little bit outside the box, like I said, but it's something just to think about. The other thing you wanna think about in older patients like this is constipation and or fecal incontinence, which could be contributing to the UTIs as well. Yeah, and I guess the only other thing is, do any of you guys work with allergists that do antibiotic exposure therapy? Yeah, especially because she's allergic to so many things. This is a great question. We don't, there's some allergists in the community that I have sent patients to who have multiple antibiotic allergies. And that's actually coming up more and more. And in those instances, I will try to partner with outside allergists, but also our infectious disease folks to help with more of the medicine aspect. I was just gonna say, I naively sent somebody, like not that long ago in the last several years, thinking like, oh, they're allergists, they can test for everything. They can't, like they're not an allergy test for every medicine apparently. So, you know, they came back with like, oh, there's no penicillin allergy. But I do think it's a great idea to bring them in and ID when it gets more complicated, especially because unfortunately, every now and then you run into somebody who either can't take or is resistant to all oral antibiotics. And it seems like a lot to say, oh, you need IV antibiotics, but I mean, they're really symptomatic, you know? And I do have one lady like that who ended up just, she was able to get the symptoms tolerable and sort of work through it with non-antibiotic treatment. But if they're super, you know, if you're really convinced it's bacteria causing the symptoms, then sometimes they do need the IV antibiotics, which is just a complete flail right now in our healthcare system. Like that is just dreadful that patients have to go to the ED and go inpatient when they could just get it done at home. But that's when we really have to partner with our ID group, which is also a problem because it's like all inpatient, very little outpatient. So yeah, I don't know if it's like that in everybody's healthcare system. So I sometimes just try to, if I think anybody may be getting into that situation, I try to refer them to their group just to at least get them seen as a patient. But it can be a problem. Anyone want to add anything else or should we go to the next case? So case number two, we have a 35-year-old female that recently had a stent placed for a left kidney stone and had transient urgency and frequency while it was in place. Six weeks after, she had an L5 to S1 fusion and she had severe dyspareunia followed by pelvic pain. She then developed the following symptoms as time progressed. And so, Dr. Carter-Brooks, what are some things you would suspect at this point? Can you go back to the last slide too, please? You know, that is concerning and I would definitely want her to follow up with her neurosurgeon or orthopedic surgeon who did the surgery. She's pretty young for a spinal fusion. And then with the stone, I'd want to rule out some underlying kind of neurologic compromise from her surgery. And we talked about our neurologic exam. I'm not doing exams in these patients very often, so I definitely want to partner with my neuro colleagues for that or neurosurgery colleagues to make sure there's not something going on, some cord compression. But it could be, yes, nerve compression and or pelvic floor related at this point. Plus once that chronic pain kind of cycle, if she had a fusion, I'm guessing there's some underlying chronic pain, like acute on chronic pain exacerbation. So sometimes with these patients, I'll also pair with PMNR, pain medicine and rehab, along with PT to work on these symptoms. And potentially, I forget how, you can go to the next slide, how far out she is from surgery. You consider your neurodynamics as well to evaluate her bladder symptoms. But if it's really close to surgery, it just might not be great timing. Great. And so now that we've referred her to pelvic floor PT, Beth, how would you approach this patient's care? I think I would definitely start, this patient had a lot of things happen to her in one fell swoop, it sounds like. So really a lot of patient education to start with. It seems like she has the high tone. She probably needs a lot of information that these muscles are reacting. They've possibly overreacted at this point. So I'd probably start with her homework being awareness, starting to get some healthy movement back for her. It seems like she can't walk. So starting to have her really start to work on stretching, yoga-type movements, probably breathing exercises to try to get some core kind of motor control back would be how I start. Ingrid, would you add any other kinds of homework for this patient? Well, I think when we're looking at, she's had the history of pain. Even though she's shown up as a weak floor, there may need to be a concentration on relaxation and working through that process to help her get to the point where she can find her pelvic floor and use it right, because that's extremely weak, her pelvic floor. I also would like to make sure she's not developed scar tissue or anything from the procedure she's been through that can definitely affect some of these symptoms. But I'm really worried about that extreme weakness that she has that kind of concerns me. So I would agree that I would send her to neuro, probably knowing the surgeries that she's been through. Yeah, go ahead. Back to the prior slide real quick. Also, if I see a patient like this, I don't chase their LUTs at this point. Like, she has a lot going on. It's not like a bladder issue, per se. It looks like sort of a lower myofascial, musculoskeletal neuro something going on that's affecting a lot of, her lower extremities, sitting, all of that. So I wouldn't say, oh, let's do some urodynamics and figure out your incontinence, especially it depends on how close it is to her surgery. But I totally agree. I'd send her to like PMNR, pelvic floor PT, just to try to get a hint and let her know this may just take some time. But it's complicated. She's got a lot of different organ systems that are affected. I'll very briefly say that, and this is anecdotal, so let me just call it. But you've got a patient who had L5-S1 surgery, is that correct? Yes. And now is all of a sudden worse and weaker than they were beforehand. I think that neurosurgery kind of needs to be, have their feet held to the fire on this one. I had this, and I'll just be perfectly honest, and my sister and a PA, so well done APPs in this audience, a PA said, I don't like the way that that MRI looks. You're lighting up on the MRI after treatment for the postoperative osteomyelitis of her spine was properly diagnosed. She suddenly became exactly at the point in her rehab that we would have expected. She kept coming to me and saying, do that magic you do, PP doctor. And I said, no, no, no, no, no, that's neurosurgery's issue. So I agree that I think this is, I think neurosurgery needs to follow up here because this, to me, sounds like a post-op complication. So if we're kind of hitting a standstill in like a pelvic floor PT, is there anything you guys would say to like a provider saying like, I'm hitting a roadblock, can you think of doing X, Y, and Z? Yeah, usually, I usually tell patients, you know, muscle changes fairly predictably. So if they are not tolerating first-line intervention, which is gentle breathing movement, trying to control the pelvic floor, if that's not working in a fairly short period of time measured in a small number of weeks, then I would definitely circle back to, at this case I agree I'd probably go back to whoever did the spine surgery and say that I have some concerns that they're not tolerating even my first-line physical therapy. »» And this is just an overall question, but how quickly would you guys move to like a muscle relaxer, vaginal valium if you feel like PT needs a little bit more help? »» I think in this case I would not move towards that because I do think this is related to the surgery that she had. I think if this was a different patient that didn't have this post-operative course or say it was after a prolapse procedure and they had a high-tone pelvic floor, and maybe we knew beforehand some of that was there and it was a risk after, then I would probably start with an oral muscle relaxer instead of a vaginal one because of the incisions in the vagina for a short course along with the PT. But probably in this patient I would not feel comfortable prescribing something like that. And that's what I'd work with my other colleagues. I think when I have patients who have pain, as you guys talked about earlier, it really needs to be a multidisciplinary approach because you alone, it's really hard to manage all of those symptoms. So I try to form a team around that patient so that we can make sure we're each addressing the issue that's specific to us and then staying in communication, which I think helps the patient and obviously it helps me too because I don't feel like I have to manage everything. And so that is probably the approach that I would take for this. »» Great. And then you kind of alluded to this, but if her symptoms included fecal incontinence, or urgent incontinence, incontinence without sensory awareness, and like lower extremity weakness and numbness, you kind of alluded to maybe looking up cauda kina, right? Okay. Next case. So we have a 38-year-old female preparing for a HYST for menorrhagia, dysmenorrhea and pelvic pain. She has some urinary symptoms and bothersome leakage with running. Her urodynamic study findings are as follows. Dr. Ricci, what are some key interpretations from her studies and pressure flow findings? »» She has the symptoms of stress urinary incontinence. I would say even though she has urgency frequency, she has what looks like a pretty reasonable maximum systematic capacity. She demonstrates urodynamic stress incontinence with no, which for somebody that doesn't have urgency urinary incontinence and has more of a sensory urgency frequency, I'm not sure how often we actually see detrusor overactivity. But nonetheless, there's no concerning findings on her system metrogram. When you look at the pressure flow, it looks like she voids to completion without any abdominal straining by this, and pretty normal Qmax. And we don't have the P-DET on there necessarily, but she would have no real reason to be obstructive or obstructed at this point. »» And so based on that, would you guys kind of modify your options for SUI management or would she be free to do any of them? Anyone can answer that. »» I'll just say that earlier in my career, like I was super reluctant to do any kind of, especially slings, you know, on anybody that had urgency frequency, because I was just, because having either de novo or worsening urgency frequency is a major driver of patient dissatisfaction. However, like I've sort of learned now, I see some people with almost like bladder pain syndrome and stress incontinence, and they have really, and I had to have a few patients talk me into it. And they are usually pretty happy to have the incontinence part taken care of. But you just have to be really careful about your pre-op assessment. Like do they have myofascial pain, do they have dyspareunia? She has a lot of little signals about some sensory things going on, the urgency, the frequency, the dyspareunia, the anal fissures. So maybe some pelvic floor dysfunction. So you know, it kind of depends. I think you don't not do the surgery, but you just have to let them know they're at higher risk for these things, and keep a close eye on them afterwards. Would bulking be better than a sling? Maybe. It doesn't work as well. It's less obstructive. But it could be like good enough for what she has. So I think those are just some things to consider when I see somebody like this. I do a very careful exam. I really carefully document their symptoms, any myofascial findings, and then go from there. »» I think I also, like you said, I do my pelvic exam feeling for pelvic floor tension of those muscles. I've transitioned to doing a lot of the single incision slings. So I'm feeling the obturator, and if that's tender or not. And I'm very frank with patients. I talk a lot about prehab and posthab for pelvic floor after surgery. Like I have some patients, like you need to do pelvic floor PT before. I'm fortunate to have a lot of pelvic floor PTs in the D.C. area that take insurance. So I get them in beforehand, start the PT, work on your hypertonic pelvic floor and your pain. Because a hysterectomy, maybe it does fix pain. I have not found hysterectomy to fix pain alone for many patients. So I'm like, you have pain before, you're probably going to have pain in a hypertonic pelvic floor after. But at least if we get you started in PT before, we can do your surgery to treat your stress incontinence. And then as soon as you're healed, like six weeks after, we can get you back into pelvic floor PT. And I think having a plan and an approach helps the patient, but also sets realistic expectation that's going to happen after the surgery. »» I think you're right on target. Because what has bothered me is the suprapubic pressure and the worsening leakage with running. So that's telling there's a lot more going on pelvically. The puberectalis can create a lot of pressure suprapubically. And if you're doing sling surgery and it's going right through that area, that person might be worse with the surgery afterwards because he didn't realize there was tension to begin with. So I just think it takes really looking at the musculoskeletal system and determining what's going on. Is the obturator internus tight, which is causing some of the problems with runners. I've seen so many patients after hip replacement surgery have horrible problems with incontinence. So it's just something to think about that our hips are intimately connected with our pelvic floor and it's all an integral structure, our abdominals, our back. So to me, this just speaks of looking at, again, the whole, like I was saying before, but really thinking these very specific muscles as possible problems with this. One other thing is, you know, I get a fair number of referrals from gynecologists, like the patient's having surgery next week and oh, by the way, she has incontinence, you know. And so there's not really a lot of other context with the referral. Sometimes it's just overactive bladder, you know. And sometimes it is leakage and they did report leakage. But when you talk to them, it's like when I'm very, very full and I cough, I leak, you know. And sometimes even if it's more than that, I talk to them, I try to assess, like, would you have come for this incontinence alone? Just because they're having a surgery, I know there's some, you know, desire to save them another anesthesia. But like we said, like you might start with pelvic floor PT in this person, right? Like rehab the muscles, like first treat the pain, then get them stronger, like triage that a little bit. So some patients are still going to want it treated and it's warranted. But some patients are like, you know what, let me just treat this. And then I say, then come back to me, see how you're doing. Sometimes hysterectomy will change their bladder symptoms, like their LUTs. Come back to me when you're about eight weeks out, 12 weeks, we'll see what you have. And then we'll go from there with the normal thing. So you don't also have to feel, because you guys probably get, we probably all get those, feel pressured into doing something just because it's convenient. Because you do these surgeries and you can make long-lasting or permanent side effects with them. So make sure you have always great indication for doing whatever you're doing, so that if there are any side effects, you at least feel good about the indication. Now she's come back two and a half years later after her hyst and sling, and now she's reporting dysfunctional voiding. She's been to PT for defecatory dysfunction. She denies urgency, frequency, or incontinence, and her exam demonstrated normal pelvic floor function. She did repeat urodynamic studies, and they were as follows, comparing, well I don't know if you remember the first, but how would you interpret these findings, Dr. Rickey? Okay, let's do Dr. Gray. Okay. Well, the maximum systematic capacity is 332, normal. No detrusor overactivity is noted, normal compliance. So let's look at her voiding pressure flow. She voids 552 mLs, her Qmax is well within normal limits at 29, or average should be half of that. That just gives me an idea that it's a continuous flow pattern without having the pattern to look at. The PVR is unchanged at 80 mLs, fluctuations really don't tell me that much. Appears to void with detrusor contraction, no abdominal straining. Do you have a UD, a PDET max, do you have any kind of detrusor pressures, am I missing it? No. It's all I got. I would need to know, I would be highly doubtful that she has any kind of obstruction given that Qmax at 29. I would be equally doubtful that she probably has significant underactive detrusor given that PVR and given that Qmax. I remind you, what is an adequate detrusor contraction in a female? The answer is never how much is the pressure. The answer is always an adequate detrusor contraction in a female, and this is much more difficult to interpret than males, is one that is sufficient to create a continuous flow with at least a maximum, with a minimum, maximum value of 15, and empty the bladder with a reasonable residual, 80 mLs is a reasonable residual. Even if she's voiding at 2 mLs per second, even if she's contracting at 2 cm, excuse me, of water, that is still, that would still be an adequate contraction for her. My residents, they struggle with that. Even the Uruguayan residents struggle with that. They say, no, Dr. Gray, that is too low a pressure. It's a bad contraction. Not if it has a good outcome. If I lift 5 pounds, that's all I need to lift. If I lift 50 pounds because I have a huge prostate and I'm a male, then that means I'm going to have to do a lot more work. Just like the detrusor only does the minimum work it needs to get its job done, which is to empty the bladder with a reasonable stream. Having said all those things, the issue is that she says she's got hesitancy and slow stream. This is a classic when the urodynamic findings significantly disagree with what the patient is telling you. Hesitancy, I need to know more about that. Not looking at the study, I can't tell you when permission was given to void versus when the voiding event actually happened. I can tell you that it's listed as a pressure flow, so she appeared to be able to void with catheters and EMG patches in place. If EMG patches are reused, that's kind of irrelevant. So in this case, I would more likely be reassuring in my counseling that that is a good bladder and it is emptying itself. I would always tell her that we're listening to what you're having to say, but it may be better than you think it is. Often women will notice some difference in voiding after hysterectomy. Sometimes it's just a difference in the pelvic anatomy. I call it a myth, but I think it kind of works to reassure patients. »» She was in pelvic floor PT for her GI issues. So I would be using a lot of these kind of findings to reassure her that maybe some things have changed, but kind of going over normal voiding mechanics, what's supposed to be happening, what she is doing right. And then maybe just reinforcing some pelvic floor kind of coordination. Can she use it appropriately for her function? Can she relax appropriately with something like biofeedback to give her some strategies in the bathroom? But a lot of reassurance. »» Any other comments on this? »» Anybody in this situation where she has symptoms, would anybody in the room, does anybody ever use Flomax off-label for female voiding dysfunction? I mean, I do sometimes, yeah. This was actually one of my patients. So didn't do the first surgery, but now she's seeing me. And so she didn't want to take any medicines, but I think it's reasonable to try a trial. There's a question in the back. Do you have any thoughts? »» I think this comes up somewhat often. I think it depends on the size of the uterus. So if it's probably 10 centimeters or less, I wouldn't think so. But as the uterus gets bigger, it's definitely a consideration. And I would talk probably more about bulking or a staged procedure. Something in this patient too, she's a G0, we didn't comment on urethral hypermobility, but it's something that I would think I would want to look at on my examination when placing a sling too. Because if she has no mobility in her urethra, you're placing the sling, it might have been a retropubic if the flow is slower subjectively after a retropubic sling, like you may just have to tension a little bit more to get the impact that you want. And so all of these things I'd be kind of thinking about before the surgery and counseling about so that they'd be aware, like I may have to tension this a little bit more tightly so that you don't leak. And your stream will be slower after, but we're expecting that to happen. But yes, I think if the uterus is probably 10, 11 centimeters or more, I would think about a staged procedure for that reason. Oh, not necessarily. I would say, you know, at least six weeks or so to heal. I would love them to do some PT after, so then maybe somewhere between three to six months after I'd consider doing a sling. And you know, it's really, I do slings under sedation. It's a 20-minute surgery. People are pretty much awake when they're leaving the operating room. I know there's different ways to do it, but it really is a minor surgery. So I try to reassure patients it's not going to be the same process you went through with your hysterectomy. Most people only need ibuprofen or Tylenol after for pain and can get back to like normal activities within a couple of weeks. So I try to frame it in that way so they're not as scared of having a second surgery done.

recurrent UTIs

prophylactic antibiotics

pelvic physical therapy

multidisciplinary approach

patient education

post-operative complications