Good evening, everyone, and welcome to this AUGS webinar. Today we are going to focus on common but complex cases in female pelvic health. And what we have tried to do is come up with some relatively common scenarios, but where there may be a little bit of a twist and some extra things to think about as we evaluate these apparently complex cases. The way that the webinar is going to go is we have three cases that we're going to present. We're going to take about 20 minutes per case, and that will leave us with some time at the end for any extra questions if we don't get to those questions during the case presentation. There is a Q&A button down on the bottom of your screen, and please feel free to put any questions that you have into that Q&A. I am Vic Nitti, I'm from UCLA, and I have with me a very distinguished panel of very well-known urogynecologists, Dr. Saia Siegel from Weill Cornell, Dr. Ben Brucker from NYU Langone, and Dr. Catherine Matthews from Wake Forest University. Each of our panelists is going to present a case, and we're going to go in that order that I just introduced our panelists in. And as I said, we'll go about 20 minutes per case. We'll have some questions during and after the cases, and then we have time at the end for questions related to this, or perhaps any other things that come up. So without any further ado, I'd like to introduce Dr. Saia Siegel with our first case, and if we go to the next slide, these are the three cases we're going to talk about, urinary frequency and other discomforts, UTI with a history of radiation, and then finally, recurrent UTIs moving from anti to pro. So without any further ado, Dr. Siegel, we'll let you take over. Hi, welcome, everyone. Sorry, while I start sharing my screen. Okay. Sorry, I've got it minimized. Apologies. I'm going to stop it and share again. Okay, I think we're in business. Okay, good evening. As I said, I'm Saia Siegel. I'm going to start with the first case, urinary frequency and other discomforts. So I have no disclosures. The one-liner for this case, as we like to have in teaching sessions, is a 31-year-old who presents with urinary frequency and urgency for about six weeks. So this patient came in with a six-week history of frequency urgency. She was urinating about one and a half hours or less, but wasn't getting up at night or any voiding. She had no urinary incontinence, bladder pain, or retention. And she reported that she had taken a week of MacroBit after first presenting to an urgent care visit about a month and a half prior presentation with the onset of symptoms and reported no improvement with the MacroBit. This happened before, she said, when she was in college about 10 years ago. And she had no other real urinary or urologic complaints. And she reported she doesn't really check how much water she's drinking, but she is accustomed to carrying around one of these motivational water bottles and drinks quite a bit during the day. Overall, her past medical history, pretty much significant for contraceptive use with condoms and a Mirena IUD. She was sexually active with only one partner. She had a history of IBS as well, constipation, and some intermittent diarrhea tending towards constipation mostly. She had anxiety, mother had a history of uterine cancer. She was on some medications for her anxiety and depression, and otherwise a pretty benign history, social history. Her initial presentation after the urgent care visit was at the end of January when she presented to her primary care doctor. She presented with the same symptoms, frequency, mild dysuria. She had almost same thing, completed this course of MacroBit given to her by the urgent care. And at that time, the PCP did a dipstick analysis, was negative for all and no urine culture was sent. She then presented a few weeks later to her gynecologist, the same complaints of frequency and also had now complaints of vaginal puritis. She had overall normal pelvic exam, and some labs were sent. The sure swab testing was negative for vaginitis, vaginosis, and STD testing, the common STD panel. The urine culture at that time was overall nonspecific. So her presentation to the urogynecologic office was, as we described before, with the urgency and frequency that had been ongoing. At her presentation to the urogynecologic practice, she had really a review of systems which was positive more so for gastrointestinal symptoms, abdominal pain, constipation, and diarrhea. She also reported that she was urinating a lot and some pelvic pain, not sure due to what, and urgency. And overall, she reported herself as having some nervousness. She had a BMI of 29. Her overall physical exam was otherwise pretty normal, nonspecific, and she was able to void to completion when asked to, and followed up with a bladder scan. So at that assessment, in my office, we would just assess her, and as her symptoms, sent some cultures as listed below. And as she was in dire distress, treated her for ureaplasma mycoplasma with a tetracycline and asked her to follow up. And at that point, also recommended a cranberry tablet for the swear history of urinary tract infections. So her testing from her urogynecologic presentation was overall negative in the urinalysis and her urine culture. But her culture was positive, which is what was sent instead of a diversity DNA test for ureaplasma at that time. And her partner at that point was informed to seek treatment. So at this point, you could think, you know, well, we found a cause, we've treated it, and now she should be good, or not. So she had sent a communication saying that she's now finished her doxycycline, I feel a little better, still having symptoms, they're milder, what would you recommend now? So now we're almost at like the eight-week mark. She represented with the same symptoms, frequency, urgency, worse at work, needs to double void, denied any, you know, retention or pain associated with bladder filling. She denied any leakage as well. Had some improvement after the doxycycline course. Also now is having more abdominal, lower abdominal pain. Her last GI appointment or visit for a workup for her IBS was 10 years ago, and then she was also wondering if it was cyclic with her menses. She had started some fiber for her constipation history, and still working on it. At that point, she was reexamined, and overall, there was no discharge, everything looked overall normal, but when the bimanual exam was performed, she had a tender levator ani and pelvic spasms bilaterally, left greater than right tenderness in her pelvic floor. So at that point, we resent some cultures for atypical or anaerobic bacteria, and she was given a recommendation for a GI workup for IBS and a referral to physical therapy for initial management of the second presentation and potential diagnoses of a high tone pelvic floor, and then followed with close follow-up. Her testing from her second urogynecologic presentation, again, was overall benign, negative. So as I presented this case, I just want to touch upon a few things which could have come about at any point in this case, your arthritis picture, dry OAB, cystitis, bladder pain syndrome, high tone pelvic floor, and IBS exacerbation. So. So, Saia, I have a couple of questions. Sure. We'll start off with looking for the atypicals, the urea plasma, the mycoplasma. How, you know, what are your, first, let's start out with what are your indications to look for those organisms? Yeah, that's a great question. So from the 2019 AUA-SUPU document about recurrent UTIs or anyone with, I guess, extended to anyone with a urinary tract infection, it's not really even recommended to do urea plasma or mycoplasma testing. But when patients have these symptoms that don't fit in the IBS, or the bladder pain syndrome, you know, bucket, they don't sound like that. They just have this, like, you know, urgency and frequency, and sometimes they report it's like pain in my urethra. So I think that warrants a little bit of a test at that point. And even on literature searches, trying to do a scoping review of the literature in this arena, there's not much. There's not much known about urea plasma, mycoplasma. So my next question is, and I think that when we test for it and find it, I think most of us generally treat it, but there's always that patient who never quite clears it. And how, you know, how many times do you treat it? And then when will you say, well, maybe that's not what's responsible for the symptoms in a patient who maybe the symptoms don't go away and they just don't clear the organ? Right. So just like with recurrent UTIs or patients like that, if it's within two weeks, I don't retest because it's, it could, you know, again, not be a, it could just be a relapse. You're picking up things like that. But there are, you know, there is some, some difficulty with patients who have multiple partners. They don't know where it actually may have been passed along from. And at that point, you know, I think I treat them once, follow their symptoms because like everything with the bad UTI or bad urethritis, you're going to have some inflammation that that results in is lasting. And at that point you want to use some anti-inflammatories, other conservative measures instead of retreating to improve antibiotic stewardship at that point. Kind of open it up to the, to the other panelists, Ben and Catherine, how do you handle, first of all, when, when do you look for the atypical organisms and how do you handle them? So, you know, I, first of all, hi everyone. How are you doing, Vic? Thanks for hosting and Saya and Catherine. Good to see you guys. I want to thank Augs and Solve Wellness. So I tend to really not look for it upfront. I think a lot of women, and again, sort of as you get into the differential, there are a couple of other things here that I can wrap my head around a little bit more clearly that might be causing symptoms. And if I'm going to test, I need to do a lot of counseling beforehand. So I think when it comes to the idea that I'm treating a sexual partner or gosh, this can be a sexually transmitted sort of, you know, atypical, I get a little nervous because I don't want women to then think, you know, this is a sexually transmitted disease in the same way that other sexually transmitted diseases that you tested are tested for. And to your point, Vic, I think when we don't know if we can clear it and we're not sure if the symptoms get better, you sort of end up in a little bit of a vicious cycle. The thing that I think you had mentioned, the vaginal itching, and if there's a cervicitis or there's inflammation, something on an exam, I might start looking for, you know, other atypical bugs. But this seemed to really be also in the presentation more of that frequency urgency. And I think to your point, I might have done it in the opposite order, which was treat the high pelvic floor tone as that sounded a little bit more, you know, she's had episodes in the past many years ago, and then sort of leave the atypical. I like always trying to find something and treat it and patients want to hang their hat on it. I think I'm a little less inclined to start there in my practice. Yeah. Thanks, Sia and Ben. And I echo my thanks to our hosts. And it's always lovely to get an invitation from Vic to do most anything. Typically, if it's wine tasting, that's the most preferred invitation. But save from that. This was a lovely one as well. You know, Sia, my major discriminating test that I really use in my day to day practice to inform me as to which algorithm and pathway I need to walk down. Is this the anxious high tone of everything kind of patient or is this someone who has an acute infectious inflammatory event that I need to uncover? And the initial urinalysis is so critical to me. Is there pyuria and is there a nitrite that's positive? If somebody has got pyuria, there is something inflammatory or infectious that I've got an obligation to figure out what it is. And I don't just focus on urea plasma. These are patients that I would send a microgen advanced PCR testing, advanced quantification testing so I can learn. Is it another atypical? Is it something weird? Like, you know, we occasionally see, you know, a patient who's immunosuppressed or is an immigrant. They may have TB. You know, there's all kinds of other things that can present this way. That's a weird atypical besides just urea plasma. And all of these people have an abnormal urinalysis. If someone's UA is negative, I'm not looking for the bladder or the urethra as the major offender to the symptoms. I'm looking then to the pelvic floor, the IBS exacerbation. And so that to me is the major discriminator. So when you said to me that her urinalysis was stone cold normal, I really stopped thinking about the bladder and would have been focused on the other things. I think that it's potentially a true, true unrelated. We don't know when you culture around, you know, the vagina, how many people have urea plasma. So, you know, if it's not creating a clinical urethritis in terms of actual presence of white cells, I'm not that interested. Yeah, no, that's a good point. I think in general, that's the issue. We don't know how many of these unless there's, you know, a widespread use of enhanced urine cultures or microgen testing or whatnot, or DNA testing for other, other typical bacteria versus the culture media that we've had since the 1950s, which doesn't really pick up everything. The blood agar is, it is what it is. It's what we have. But it presents a difficult problem because these patients are very uncomfortable. And, you know, my issue is, I mean, I love what you both said, because I think when we go off into, well, she has bladder pain syndrome, that's what makes me even more concerned because then they're going down this route of things that aren't really helping them. They might get instrumented. They're getting bladder installations. There are other things could then present themselves as an issue. And then, you know, now we have issues with Elmer on, too. So but yeah, no, thanks for your input. I think you actually made a good point. And in some ways, maybe it is the anxiety that drives my thought. And I think how I talk to this patient is not that I'm going to give you a specific diagnosis and say it's I see or it's bladder pain or it's, you know, an infectious ideology. But I'm going to say, look, we'll call it syndrome X. We're not sure what it is yet. We're trying to figure it out. And ultimately, the goal here is to get you feeling better. Right. And I think they do want to know that you're doing the testing to look. And that's when you can review the data you have. And is there any value in more data here? I don't know that I get anything else. But then sort of after the exam, sort of having that discussion again. And it's great that you saw her back and you were able to get her in. And it really is about symptom control. And how do I make you feel better? And whether it's nonsteroidals or something for discomfort or an anti-inflammatory, I agree with you. I think the dangerous thing is going, you know, pushing them down a pathway when you're not sure. The nice thing I think about physical therapy here is it's going to really treat many of the non-inflammatory infectious etiology. So even if it is bladder pain syndrome, even if it is overactive bladder, if you get a good physical therapist, you know, it can help. Now maybe another webinar will be about how many of the patients we prescribe physical therapy for go to physical therapy and get good physical therapists and can afford it. But that's sort of how I approach her. So I totally agree with you guys. So in order to put sort of a bow on this case, I'm going to bring up one of the questions that was submitted from the Q&A. And now we have six differentials. What should be our next step in this patient to confirm a diagnosis? And what's the treatment? Yeah. I think just like Dr. Rucker said or Ben said, it's really management of the patient's expectations. Even patients who have a slam dunk recurrent E. coli UTIs, they want to know where is this coming from? Why am I getting it? Why am I prone to it? I have good hygiene. I wipe, you know, whatever. I mean, there are so many ifs, ands, and buts, and that lack of control I think causes the patients to get a little crazy. I mean, at this point, I don't think it's dangerous to approach it full on without, you know, giving any harm. I don't think, you know, addressing her IBS with fiber, you know, an osmotic laxative or sending her to PT is of any danger. I think it's going off in a tangent and then really sticking to the guns, which is hard, and then seeing the subtleties of how her symptoms change, which makes it hard. So again, like I don't know what the prevailing problem is in this patient. We treated one thing. She came back with another. So it is tough. I'm going to give you another one from our Q&A. Let's say you've decided you're going to treat her high-tone pelvic floor. She buys into it. She's ready to go to physical therapy, and of course she goes to make her appointment, and she's told the next available appointment is in six weeks or eight weeks. And now she's all freaked out about that. What would you recommend doing while waiting for the initiation of pelvic floor? Is this panel, is this a question from a New York area? Cause I feel like that's just like, we have exactly the same problem in Los Angeles. I'm sure. I'm sure. So, you know, I don't feel comfortable telling them to, you know, use the wand and things like that because I don't really know how to guide them using the vaginal wands, but I do think it's a lot of stress relief. You know, she has anxiety already maximize everything you're doing wellness things. It's hard. It's like the hard conversation you don't want to have. It adds a lot of time. We're probably not equipped to it, but it's the same as management with bladder pain syndrome, self-care, you know, taking care of, you know, like the other intangibles in life to decrease stress, decrease stress anxiety. So that's. Yeah. So I was just talking with one of our fellows about this, and I don't love vaginal Valium in all patients. I'm sort of selective when using it. But this could be someone, again, with proper counseling saying, look, this is not the fix. This is sort of a way of getting you there. I probably honestly, like Sia was alluding to, would start with non-steroidals, warm baths, massage, whatever else she needs to do. But again, if she's in distress and she's in spasm and it's tight and she's in pain, you know, short course understanding that this is not a forever drug would be something that I might consider to break the cycle. And probably not a good idea to tell her to start doing Kegel exercises. Correct. Probably not, yeah. Yeah, I must say, I really would have, when someone said, you know, how, was tying a bow around this case, I really thought, she sounds like a hydrophobic Florida me. Everything about the case kind of screams that. And, you know, I think that vaginal Valium can be really helpful because they want to be able to do something when they hurt. It gives them this understanding that they're doing something. And we use UraVal and Azo, you know, these are nice bladder anesthetics that are low risk and appropriate hydration. And those bladder analgesics can be really constructive for pain relief. I really try hard to never use bladder pain syndrome. I see in discussing things with these patients, that is a diagnosis of exclusion of six months of, of, of symptoms. These people, you know, it's, it's distressing to them. They're already anxious. They start reading about this chronic disease state. So we really try hard not to bring up those words until we've really appropriately treated the other, the other things that are more acute in nature. And this, and this certainly sounds very acute. Yeah. And sadly you can even diagnose it after six weeks with the guidelines. So it is pretty much on that, on that timeframe, but yeah, I agree. And then I think since the, the other studies came out with vaginal Valium, I've kind of come away from it because I think it is like a Band-Aid and a crutch. And then I get requests for, you know, multiple, you know, renewals and things like that. And then they're like skipping over the part, which is the important part, you know, taking care of yourself, taking care of your body and going to PT, but trying to follow that algorithm for high tone. All right. I'm going to finish up the, this with a couple more questions from our audience. What is the dose of vaginal Valium? Ben, what do you typically use? Yeah. It's a compounding pharmacy that I use 10, usually milligrams. Sometimes I'll try to get them to make a five milligram tablet. So usually five to 10 milligrams. And to your point, I will tell them about the potential for systemic effect, usually taking it at night, avoiding alcohol when they're taking it the fact that it can be somewhat, you know, develop a tolerance to it. You know, and in this case, I'd probably use it on an as needed basis if she was having a flare. And I love Catherine's idea of, you know, Urobel, I think that's also a nicer, I know that wasn't the question, but I'll put a check mark next to that one as well. And another suggestion is that since this is a diurnal symptom, it might suggest some sort of diurnal behavioral dietary or non-GU infectious inflammatory etiology. So something that's going on predominantly in the daytime and not at night when the patient's sleeping. You know, Vic, whoever brought that up was really insightful because again, if it's primary bladder and it's not attached to your brain, these people always are getting up all night long. So another important discriminator is, you know, how many hours are you sleeping at a time at night? And so I love that insight. Well, that was Raul Jordan, so we should give him credit for it. Thank you. Thanks, Raul. Okay. Why don't we move on to the next case? Zia, if you could take down your slide share and we'll have Ben go to his case. All right. Let me pull this up. Perfect. All right. Hopefully you guys can see it okay. So again, I think I presented a case that just puzzled me a little bit and brought up a lot of different issues across the board. And I was really hoping to get Vic and Catherine and Zia's input along the way. I'm sure I made some mistakes, but here are my disclosures. So EC is a 68 year old female, history of cervical cancer, had a radical hysterectomy and was treated with radiation therapy. She's presenting now with an increased frequency of what she's calling urinary tract infections, increased frequency of urination and just an overall bladder discomfort. She's voiding about 10 times a day, three times a night. She's not having any leakage. Looking back at her cervical cancer treatment, it was about 30 years ago. She had been followed for a while before essentially being discharged because she had no evidence of disease. She does have a shortened vaginal canal and has had chronic since the radiation or shortly after painful intercourse. She is on oral and topical estrogen and does use a vaginal dilator to maintain an adequate vaginal depth and length for sexual intercourse. In the past, she is someone that's had urinary tract infections. She used to have one or two a year. Someone had actually given her antibiotic to use when she was dilating or sexually active because this seemed to work in reducing her infections. And she's presenting this year having had seven urinary tract infections. I'm sure that you guys will all have these patients in your clinic that come in having urinary tract infections. And as clinicians, we want to know, so what was growing and what did the urine analysis look like? But this patient finds it a lot easier to go to urgent care. And so I don't necessarily have this data, which makes me a little uneasy. We're targeting this and saying it's a urinary tract infection, but, you know, let's sort of try to be a bit objective when possible. She does know when she has these UTI episodes, she gets a bladder pressure and more nocturia. Difficult to say if she has more frequency because she has noticed just a general increase in her frequency and she doesn't have any systemic symptoms, no fever or chills. She gets antibiotics from urgent care. If they send culture, she sometimes gets called back by urgent care and they make sure that she's on a culture appropriate antibiotic. There was at least, I think, one Klebsiella infection that she showed me on her phone. She does have a marginal improvement in urgency and frequency, but she's also feeling just a lot of bladder pressure at baseline. And that's often what's driving her to get the urine check. And then when she gets treated, the bladder pressure, as she calls it, gets better. She does have a sensation of not emptying her bladder. And she does remember when you ask her directly about bladder emptying, that at some point a provider had suggested that she catheterized herself, but she doesn't quite remember why. So remote cervical cancer, now recurrent urinary tract infections, urgency, but really a lot of frequency, no known allergies or medications. She does take some Ativan for anxiety, some Synthroid for hypothyroid. And she does occasionally get a groin cellulitis, which was thought she had seen ID many years ago, maybe a little red herring here, but thought because of a change in lymphatic drainage from radiation, that was the best explanation she had. She has had HSV in the past, but really no active lesions in many years. Vaginal examination consistent with what she tells us about the shortened vagina. She has atrophy, but not a very indurated vaginal canal. So things are fairly supple. She has an orthotopic meatus, no stress incontinence, and her pelvic floor muscles are not very tender. But we have a trusty post-void residual machine and her post-void residual comes back at 270 ML. So I sort of will, I guess, either pause here or give you a little summary. So what's good? What's good for this woman? And I think she's on estrogen, which is good. She's not had pyelonephritis, which is also a big plus. It makes me a little less nervous that I got to get her on an antibiotic right away. And she has catheterized in the past. And it's never an easy conversation to take a woman who's not catheterizing and be the first clinician that says here are catheters you need to catheterize. So I think that makes it a little bit of an easier potential conversation. The bad is her bladder is not emptying, which obviously may or may not be contributing. We don't know really what her bladder emptying status was a few years ago. She has had radiation, which I think makes everything a little more complicated and gives me a little bit more pause to just write her off as a recurrent urinary tract infection without more evaluation. She does have significant overactivity, which we'll talk a little bit about. And if you think about some of the symptoms women have from a UTI will be, let's say, worsening frequency urgency. But she also has that it sounds like a little bit at baseline. And that's where it's a little bit of a common thing, but makes it a bit more complex. And her infection symptoms are not so classic. She's not saying I have dysuria, I have cloudy urine initially when she presents. So what workup do we do at this point? Does she need a cystoscopy? Do I want to get an ultrasound, a urogram? What about urodynamics? Or are there other tests that we would maybe propose? I think because of her history of radiation, I do have some concerns about her compliance of the bladder. I want to make sure that the bladder capacity is adequate enough. I'd say probably even in the absence of the elevated post-void residual, not that I would necessarily start with a urodynamic, but now I have sort of two things on my radar that pop up that say, hey, I may want to find out some information about her bladder function. The other thing that I think is imperative is a cystoscopy. And again, you could argue, two, three, four infections a year, how quickly do you reach for a cystoscope or not? But when someone's been radiated, has sort of a change in her symptoms and has vaginal stenosis that's been dilated, we do want to make sure that there's not anything else anatomically. So my differential, I start thinking about, could she have a stricture of her urethra? Could she have something in the bladder? Could there be a malignancy, increased risk because of her prior radiation? So in the meantime, I'm not terribly worried because she's not had the systemic, she's not been hospitalized, no fever and chills. And I see that her bladder is not emptying. So I actually decide to start her on HIPPREX and vitamin C. In addition, as was mentioned, I think in the last case, Dr. Matthews had brought up hydration and sort of the importance. And when we're talking about UTIs and urinary symptoms, I think having a discussion about fluids and fluid consumption becomes quite important. So I do a cystoscopy, the urethras patent, she has some mild radiation changes, which are shown in this representative image. It's actually not her. But in addition, there is a raised area that's red on the posterior wall of the bladder. It's about two centimeters in size. So the sort of thought that this could be something that is either driving her frequency urgency or infectious, or could it be an oncologic thing? So I take a biopsy of that. It comes back as just ulcerated urothelial mucosa with acute and chronic inflammatory changes and treatment changes. So I make sure to indicate that she's had radiation on the biopsy sample. So they don't come back with something about abnormality seen. And so in some ways, I'm a little bit more reassured to say, okay, bad looking bladder, had this red area, but biopsy looks okay. And she has had at least a few real infections. So maybe this is more of a focal cystitis that we're seeing. I did end up getting a CT urogram. She had showed me some of her lab results, and there was a couple of these questionable UTIs that did show some blood. So she got the hematuria workup. Again, radiation history pushed me a little bit further and quicker to get a CT urogram than I would in a non-radiated patient. Her age was again, above 60, and she had the hematuria. So I think indicated, but things like ureteral strictures and stones and things like that have to come into mind. So as I mentioned, because of the elevated residual, I did get a urodynamic. And what it showed and what I was really looking for was to see if there was an issue with bladder compliance. So we want to make sure that her bladder is a low pressure bladder, and that's not something that over time, the radiation had sort of shrunk the bladder or made the pressures higher and her end fill is low. She does have some small overactivity, small in terms of pressure. And when she goes to Boyd, she really has impaired contractility. She does mount a little bit of a trucer contraction, but it's not really sufficient to empty the bladder all the way. No stress incontinence or urgency incontinence noted. So at this point, I guess the question, and maybe at some point we'll get our panelists' suggestions, but when do you start CIC? When do you not? And in my sort of thought process, she's not doing well as is. So I think a trial of intermittent catheterization is certainly reasonable. I also am wondering if the bladder emptying more completely will maybe reduce her frequency and urgency. So I need to weigh the potential of bringing real bacteria in versus helping symptoms and perhaps getting her to empty her bladder better. So I start her on CIC and I add Elora to the prevention strategy. My thoughts here a little bit in terms of if she's catheterizing, I like things that are non-antibiotic more so than antibiotic because there's always going to be bacteria brought in with catheters. It's not a sterile process. And I think Elora is a great option or a cranberry supplement's a great option because again, I'm not worried about resistance here. I think the thing that also got me was she was sort of suffering. And in my mind is I'm sort of with a little less data than I'd like trying to figure out, hey, do I need to treat her overactive bladder? And I figured that there was probably not a lot of downside to treat her symptoms of frequency with mirabagron. So at this point, does radiation change anything in terms of what I'm doing here? I think it definitely changes my workup and the speed with which I went to that. It does sort of give me a potential reason for why her bladder is not working, a potential reason for why she's having overactive bladder, why symptoms may worsen. And I mentioned again, the HIPPREX and vitamin C, the Elora and suppressive antibiotics are all options. And we can talk a little bit more about when we select each one of these, but in this case, I thought that the cranberry would work. So at this point, she actually starts CIC. She actually took to it very well, didn't really get too worked up about it, as I mentioned before. And at this point, now we start to document all of her urines. And now she's sort of in my grasp and I want to start to put together a story here. And what ends up happening is we start getting these urine analysis and it's sometimes hard when they're done outside, you can't see them all, but now I have them all in my system. And I start seeing that every time she sort of comes in and gives a urine, regardless of whether there's no growth, whether there's lactobacillus or a low colony count, she always has positive looking urines. So she has, and again, is this sort of what was going on before, you know, is this because of catheterization? But I think that, you know, now I realize that the cultures are not really so concerning. She has a mixed flora, a couple of no growths. She does have an E. coli. She does have sort of, again, the lactobacillus, but now at this point, she's still complaining of saying, I constantly feel like I have a UTI, Dr. Brucker. I'm having more frequency urgency. And she actually is worse than when I first met her. So this is where I get a little frustrated. I'm doing everything I think right, treating her infections, preventing them. The cultures are coming back negative, but she's catheterizing 30 times a day, which does seem to be a significant increase. So I guess another sort of topic of discussion is what do we do in terms of other options for her? Is there a role for bladder irrigation? She still thinks they're infectious. I'm trying to tell her, Hey, look, they're not infectious. Betadine gentamicin, we can talk a little bit about whether those are things that you guys use. Suppressive antibiotics, I think, again, may have a role, but I'm not really so convinced because I don't know what bacteria I'm treating at this point. And then the next question is, Hey, maybe this is more of a, we'll call it overactive bladder, but a radiation induced irritable bladder. And is the bladder pain and radiation bladder treatments really what's needed? So I start her on solifenacin. It was easy enough to add it. She's just in distress, even if I want to do something else. And at this point, she continues with CIC. The, the issue that's driving her to catheterize now is just a pressure. And she will get a PVR of about 200 CCs. And we do a long counseling discussion about bacteria colonization, catheterization, so that we're all on the same page. So she finally comes back and she's happy because she realizes she's not having infections after that intervention, explaining to her, Hey, your urine's always dirty. So if you go to urgent care, it comes back dirty. I'm not sure I'm going to treat you. And by the way, you do have overactivity on the urodynamics. Now I use that to help counsel her. She's voiding small amounts. She still can void a couple of ounces on her own, but catheterizes every few hours and gets out a majority of her urine. Nighttime, she just has to catheterize once, but she's still having pressure that's sort of making her catheterize. And I'm wondering if her bladder capacity is really pretty adequate. Should she need to be catheterizing as frequently as she is and voiding? So elect to treat her with Botox. And now it's actually reduced her catheterization. She's doing it about four times a day and that pressure feeling actually is gone. So I guess at this point, to summarize my thoughts on the case, hopefully you guys kept up. But I think that she is someone that illustrates the point that everything's a UTI to a patient. People don't know that radiation affects the bladder. People don't know that bladder emptying needs to happen for you to have normal micturition. So I think that that was sort of one of the points. The symptoms of overactive bladder and UTI overlap quite a bit. And this was a good case because it really seemed real in the beginning and her urines were so nasty looking. But at the same time, finally getting her treated was treating the overactive bladder. Catheterization confuses matters. So thankfully this was a case where I think you guys would agree at 270, we're starting catheterization to see how she does. But I think the education is needed because patients that catheterize will have bacteria. So then even the urine culture in addition to the urinalysis are difficult. Radiation complicates lower urinary tract symptoms. I think some of the treatments and therapies that we may talk a little bit about in the discussion is one better than another for someone that's been radiated. Clear goals are really needed each step of the way. What are we hoping to establish or what are we hoping to get better? And I love this patient because she really is very goal oriented. So each step, each move was pretty useful to sort of set out what we're trying to get better. And also just illustrating the point that use multiple therapies with the hope of really avoiding excessive antibiotic use. So that was the case. And I guess I will open it up, Vic, if there are... Thanks, Ben. First of all, a couple of comments. And what I will tell you, I like you see a lot of patients who have the sequelae of radiation for pelvic cancers. And it is, I think it's something that you have to be very thorough when you think about it. Now, I am generally somebody who likes to stay away from testing. I don't like to do tests unless they're going to help me. But I think in the case of radiation, things are different. This is a patient, her urine's always going to be dirty. It's always going to have some blood in it. I think there comes a point where you need to evaluate that, as you said, cisposcopically, because patients who have had pelvic radiation are at a significantly increased risk for things like bladder cancer. So I think that endoscopic evaluation in this patient is very important. Whereas I think for most patients with quote unquote recurrent UTIs, it's not very helpful. Also, I think the aerodynamic testing that you did really to determine her compliance and make sure she's not at risk was also critically important. And in this case, turns out she wasn't at risk. Turns out she had some detrusor under activity likely secondary to radiation. We can talk about how we can deal with that as well. And then the other thing I just wanted to mention was that, you know, if you evaluate a patient who's been radiated two years ago and now they come back and things have changed, don't think it's the same. Because radiation, as I tell my patients all the time, is the gift that keeps on giving and things change and things can get dramatically worse two, three, four years down the line. And you can have the ill effects of radiation 20 and 30 years after the patient's been radiated. So I think we always have to keep that in mind. And that makes this somewhat simple, but clearly complex case, I think really very important. And I think the one question that I wanna throw out to the panel, and this can be related to this patient or any patient, is the patient with the modestly elevated post-void residual, not in any danger, quote unquote recurrent UTIs, is intermittent catheterization a good thing, a bad thing, or it depends on the patient? And I'll let any of you, Saia, you can take it first and then we'll go to Katherine. I'll start, I think the approach I use is definitely in this patient. I think the straight catheterization with her symptoms, taking into the fact that she's skimming off the top, potentially had UTIs, has detrusor underactivity, a whole host of issues, is somewhat in her treatment plan and can't be avoided. However, when you take patients that are like post-Botox and they're just kind of like running, towing the line above 150, 200s, PVRs, I let them go a little bit because I've done their urodynamics workup for the most part in most patients. And we're not so concerned with their upper tract and it's a medication that wears off over time. And if they're not getting recurrent UTIs and not too much bothered by it, I'm not either. And the second group of patients I think I think that way is the patients who are coming in that are 80, 90 years old and they're potentially maybe not in the same realm as the patient with a radiation history, but their upper tracts look okay, we've imaged them, and they're not having too many lower urinary tract symptoms. And they're just like, as an aside, found this one small glitch in their history with a slightly elevated PVR. Outside of prolapse and things like that, I think those can be watched as well. Catherine, any thoughts on catheterization for modestly elevated residuals? And let's just say recurrent UTIs now and take symptoms out of the picture, only those related to the UTIs. The people that Ben described here, the DODU group, have such a small functional capacity. And I feel like their constant leaking and the wet pads that they're in creates this horrible milieu that is worse than the catheterization piece. And so, I find DODU like one of the hardest conditions to manage because very commonly it's associated with recurrent UTIs related to this whole leaking, just like messy perineum situation. And in those people, I really do think that Botox and CIC results in less symptomatic infections, particularly if they're on heparex and vitamin C. The people that I am not in favor of doing CIC for are those people that have retention related to antivaginal prolapse, of which we see that a lot. And that's a person that I love to operate on. And it's very rare that I'm excited to do a surgery for a UTI indication, but I really do find that these people that are pooling, that dependent bladder portion, that even if they're catheterized, they don't empty it well because it's sitting down and outside the entroitis. Those people I love to either manage with a pessary or with surgery. So, the catheterization question is, I don't, it's not a one-fit-all thing at all. I think that people that don't have UTI that have an elevated residual, I certainly don't institute it for those people that are in neurogenics and I'm worried about the upper tracks. So, I think that the answer is very nuanced as to the particular patient presentation. Yeah, I think I have two patients that came to mind as you were speaking. One was an MS patient actually, who her issue was she was really getting infections and she had had C. diff and she was someone actually, I let her residual ride and she's 200, 250 CCs because in her, it was really just trying to, again, sterilize the urine and keep it sterile and do what she can, hydration and time voiding. And she's actually okay now, because I was so nervous. Her culture is always positive. She was always getting antibiotics. So, she was one that I let go. And then there's that prolapse patient who happened to have had elevator residual, 300 CCs. I did a urodynamic and she had underactive bladder. Bladder didn't squeeze. And I had trialed her with a pessary during the urodynamic with and without. She emptied a little bit better, but it wasn't much better. And I said, look, I'm not sure what to do, but let's fix your prolapse because she was symptomatic enough and it was anterior. And she came back the other day and her PBR is zero now. And she's dry. And I mean, that was the success story, but I think you're right. It is tricky depending on what you're dealing with. And so, it's not, as Saya was saying, the Botox patient is very different than this radiated patient. The MS patient, very different than that prolapse patient. So, I think it is a topic that we all see and you really do need to tailor it. Well, Ben, one question before we move on to the next case that comes from the audiences. It seems that her elevated PVR is the culprit and caused by, it says neurogenic lower urinary tract dysfunction. I guess that would mean after her radical pelvic surgery. Since her compliance is normal and she has non-obstructive urinary retention, would SNS be an option? Yeah. So, I think in some ways, when we think about the success stories of non-obstructive urinary retention, she doesn't fit into my picture of what that is. I think it's probably reasonable if you sort of have that discussion with the patient. I don't know, Catherine and Saya, if you'd sort of rush to do that. In her, she actually was okay with the catheters and was doing so well. The only problem she had was this pressure feeling. She wasn't even wet at this point. It was just more of a frequency and a pressure. And so for her, the idea of Botox really was more appealing. She didn't like the idea of sacro neuromodulation. At some point we had had the discussion. So again, if I really convinced myself she was non-obstructive and I said this was truly, I wouldn't say a neurogenic in terms of how I described it, but I think it's an option. I don't think it's gonna really work for her, but reasonable. I mean, here's how I look at that. And it's not to say I'm necessarily right on this, but if it's neurogenic, then you're gonna have a disruption of your innervation to the bladder. Why would sacro neuromodulation work? If it's radiation, is sacro neuromodulation really gonna change the intrinsic changes to the bladder that the radiation did? And I think, we've come up with this term, non-obstructive urinary retention, but to me, the patients who don't empty their bladder well, that do the best with sacro neuromodulation are really those that have essentially Fowler syndrome. I think that those are the ones that sacro neuromodulation really works best on. Yeah, I totally agree. And even if it's a high pelvic floor tone patient that doesn't empty, I think they do better, right? That's sort of the pain patient. I think it works better on, but yeah, I agree with you. Okay, let's move on to case number three. And then if we have some time at the end, we'll get to some of the other questions. Catherine. Thanks so much, Vic. My one disclosure that I have that's relevant to this case presentation is that I really hate to lose. And when it comes to recurrent UTIs, I was in past years losing a lot, and I really hated that. So I took it upon myself to try to understand a paradigm shift in how I was doing things. And I'm gonna share a little bit about that paradigm shift with you all. So I want you to meet Mrs. M. This is an 84-year-old lady, run-of-the-mill, comes in with recurrent UTI. And what she describes is her symptoms of UTI, worsening urgency, frequency, incontinence. And truly, she comes in and her daughter is with her. They're very prepared, and they have multiple E. coli UTI cultures affirming this diagnosis. She shared with me that she had been admitted with C. diff. colitis the year prior because of the innumerable courses of antibiotics that she's been given by innumerable providers, Cipro being at the very top of the list of the flavors that are chosen from the shelf. And of course, on the day that I see her, my clinic is already running behind, and she walks with a walker, and it took her half an hour to get roomed because she walks that slowly down the hallway, has trouble getting undressed, getting mobilized, and was not particularly excited about having to undergo a pelvic examination in her investigation. And I got frustrated with patients like this, both because I was losing and treating them, and it was taking me an hour and a half to get them through my clinic. And so I decided to investigate, do we really need to do pelvic examinations on women like Mrs. M? And so we did a retrospective study looking at patients who came in with the diagnosis and tried to understand in the findings that were listed on pelvic examination, what was relevant, what was new information that I was not able to glean by simply asking the questions, do you have a bulge of the vagina? And doing an assessment of post-foid residual volume measurements. We assumed that any woman over 50 had some degree of vaginal atrophy, and that it would benefit from topical vaginal estrogen. We never thought that having to visually evaluate the vagina was going to be a reason that we would withhold or give someone vaginal estrogen. And what we found from this retrospective analysis was that there was absolutely no benefit in doing a pelvic exam. If we merely asked the questions of the bulge and assess the PVR, that that was equivalent in women without a history of pelvic mesh. And of course, pelvic mesh changes everything. Those people all did have examination findings that potentially were contributory. So this was, I think, important information that changed my practice about not initially doing a pelvic exam on all of the patients like Mrs. M. So what do I do? Well, terminal dysuria, of course, is our best historical discriminator. Symptoms of random urgency frequency are not nearly as discriminating. And if a woman's telling me that she's having terminal dysuria, I think very, very long and hard about finding an infectious etiology. We've talked about my passion for the initial urinalysis. I rely on that microscopic examination so intently in terms of how I investigate someone further. We, of course, know that urine is not sterile and a culture of more than 1,000 CFUs of a particular bug in a symptomatic patient can be rational for treatment. But in somebody like this patient, I absolutely don't mind if she's got more than 100,000 of E. coli. In fact, we very much introduced the idea that she legitimately has infections, but these are infections much like C. diff of the bladder that have come about because of the disruption in the microbiome. We've talked about assessment of the PVR volume. The only people that it's not reliable on, of course, are people that have bulges beyond the introitus. And so if someone's telling you they've got a bulge, you need to evaluate them anyway and assess that residual volume. But otherwise, that's a reasonable discriminator to assess if there is indeed incomplete bladder emptying. There are a fair number of false positives we all know from the PVR assessment, but then that warrants additional investigation. We, of course, do a lot of work reviewing the prior UA results in conjunction with the cultures looking for pyuria with negative cultures. So what are the things not to miss on a pelvic exam? If somebody is describing a bulge or they've got other vaginal symptoms, vaginal discharge, itching, irritation, we, of course, want to ensure that we're not missing the urethral diverticulum, bladder prolapse, and, of course, anyone with prior pelvic mesh. We need to investigate for mesh exposure in the vagina that can be a major contributor to abnormalities in the vaginal microbiome. And if there's mesh exposure, is there also something in terms of mesh erosion that's going on that requires further investigation? We speak passionately about the use of topical vaginal estrogen, and I think that this is still an underutilized adjunct for many, many practices, particularly amongst urologists who don't feel that comfortable using vaginal estrogen creams. So these are the kinds of things that we are looking to not miss, the classic urethral diverticulum. I promise you, a woman with this kind of pathology has symptoms. They're not gonna be diagnosed on a blind pelvic exam as just a cause of recurrent UTI. And the one thing that I will say definitively about diverticula is they can masquerade as just stress incontinence, but they never masquerade as just having UTI. So what is my spiel about antibiotics? Well, we know from evidence that antibiotics are spectacular at killing the good guys. Yes, they kill the bad guys, but they mow down all the good guys too, which sets up this problem of recurrent infection. Because once the bug is colonized in the GI tract, there is no eradicating it from the system. And so we can temporarily eradicate it from the bladder, but then we set up this whole problem because we don't have the good guys, and then the bad guys can set up shop on this recurring UTI basis. So I spend all my time in the visit, not getting old ladies naked, but rather spending the time in the visit introducing the paradigm shift of the pro. So lactobacillus is the woman's best pal, and it's what really can take somebody who's in this terrible cycle of recurrent infection and then get them back on track. Lactobacillus produces lactic acid, lowers the vaginal pH and makes it less hospitable to all those pathogenic E. coli, which set up for these recurring infections. So I think that evidence is really helpful. Patients sometimes look at you like you're completely nuts when you say, look, we're gonna move away from the antibiotics until someone has suffered from C. diff, and then they're actually very willing to listen. And some trials in the Netherlands have showed that lactobacillus supplementation is almost equivalent to antibiotics for prevention of UTI. Antibiotics went out a little bit, but it's a very, very small margin. And so of course there's very little harm in using lactobacillus. And so I really wanna make a passionate plea to think about supplementation of this probiotic as opposed to resorting to antibiotic. So what are our options? The best name on the page, of course, is the happy hoo-ha. But there's a whole host of options that you have. And so I say to you, use whichever compound is most affordable and most accessible to patients, but they need to be using one of these. Whenever somebody is in the recurrent UTI paradigm, getting them on probiotic therapy is really, really fundamental. Now, how these are administered and what the absorption profile is in the bladder certainly is variable. We wanna get it into the vagina. And so supplements that can be placed in the vagina I think are really helpful. Ultimately, I don't have a true understanding when things are taken orally and they go through the gastric juices and through the colon, to what extent these remain alive in the vagina and the bladder. So I do like formulations that can be introduced vaginally. The other paradigms that are major shifts away from antibiotics is doing the things that compete locally in the bladder. And huge fan of D-mannose and Allura, or other supplements that compete with the attachment of the pili. So the D-mannose makes the lining of the bladder slippery. And of course, Allura competes with a pili binding to the lining of the bladder. So these don't work if somebody has got recurrent Klebsiella or has got recurrent Enterococcus. This is for your E. coli people. And nothing makes me happier when I see a culture that has E. coli because that's one of the agents that we can use these supplements for that's really, really helpful. Again, we focus our approach on not spending time on the exam, but talking about hydration. You know, there's evidence that 64 ounces of water is again, almost as effective as a course of antibiotic therapy. And I used to think women were absolutely crazy when they would tell me that they could sort of drink through an infection. But I turned out to be the crazy one because when I looked up some of the evidence, there is indeed truth that in women enrolled in randomized trials of antibiotics versus placebo, that simply with hydration, we are able to clear those positive cultures. We use the combination of the D-menace and cranberry and there's evidence that the combination together is more effective than each one in isolation. And so we do that very commonly. Estrogen for everybody who's over 50, we talked about the probiotics and then important to Ben's point, ensuring that the bladder is indeed emptying. So Mrs. M left my office without any more antibiotics ever. We checked her PVR, we did time voiding, we avoided dehydration in her, did the estrogen, did the supplements. And the only reason we said we would give her antibiotics was that if she had a febrile UTI with upper tract damage or upper tract involvement, I should say. And after, you know, it takes a lot of counseling to walk these people back from a treatment path that they've been on sometimes for 20 plus years. But I think that ultimately, you know, she was delighted with that intervention and has not had to be treated for an upper tract infection. And we've relied on Tylenol, Urobel, some anti-inflammatories if she does have dysuria, which does intermittently pop up, but have not had to resort to any antibiotics for her case. So I'd be delighted to take additional questions and hear your thoughts about that patient. So I think it would be great to get the input from the other panelists as we think about how important a pelvic exam is in a patient with recurrent urinary tract infection. Sia, do you take a similar approach? I have. And so Catherine, I love that you mentioned that part. So I, since the pandemic and we started telehealth more robustly, In our practice, in my practice specifically, every patient with the primary complaint of dysuria or recurrent UTIs, or even sometimes pelvic pain, are offered a telehealth visit. That is simply because the same scenario, I think you may have presented this and I was in the audience at one point, and thought, yeah, of course, why would we want to also potentially induce another UTI in a patient who has uncontrolled UTIs by doing her pelvic exam for little or minimal clinical utility. So yes, I 100% agree with that and take that approach as well. What makes me nervous about this case is some patients, and the older patients who, I just want to know how Katherine or any of the panelists approach this, when they're patients with subtle symptoms, of course, the C. diff is a worry, but the elderly patient who you're worried about landing up with urosepsis, how do we mitigate those patients? So that is what I'd love to know about anything that you're doing differently before the fever. Yeah, I think that that's why all of those preventative strategies is to try and minimize an infection that basically then overwhelms the bladder and starts to ascend. So I'm trying to use all this local control. That's what I'm focusing all my energy on. And I may add hip wrecks to some of these patients, not those with renal impairment, which is problematic in those people, but it's amazing if you get local control, how upper tracts don't tend to be as affected as often. So many of these elderly patients are under hydrated. It's really remarkable. A lot of these intimate mental status changes I think are related to hyponatremia and poor fluid management. So spending time on that, as opposed to just another antibiotic, I really, I recognize that urosepsis happens, but I think that C diff induced colitis that's iatrogenic is far more common than urosepsis related to ignored UTIs. Yeah. So I love the concept of having, to be able to say to a patient, look, I don't need to examine you. I'm not being a bad doctor by not examining you. What am I going to find? The thing about M that makes me a little nervous not to do an exam is I'm going to think I do the exam on M, I get her up in stirrups. I'm now two hours behind in clinic. And she has a huge stool ball in her rectum, right? Or she has something on the GI front or an abdominal mass. And so in some ways, I think I probably hear and do what you do. And probably for that younger patient, I'm a little bit more willing to forego the visit or do the telemedicine visit. Older patient, you know, the constipation, I probably could screen them with constipation questionnaires. I'm sure Catherine, you have questionnaires that they get beforehand anyway. And then sort of the other thing that you had mentioned before was that sort of that wet diaper of, you know, the, the sort of the perfect milieu for infections. I like seeing what's going on. Do they have stool smearing on their, on their buttock? Is there sort of feces near the vaginal opening? So I think M, I'm giving her a pelvic exam, but I think it's actually nice to realize, hey, what are you really looking for in anything? To Saia's point about the fear factor, you know, I think what I would tell M was you've had these infections for years, right? Or months or whatever it ended up being. And, and I'll ask them, how many times have you been admitted to the hospital with sepsis? And they say, well, never. So there's something about M, I think that she's just not genetically programmed or the bacteria is not virulent enough or whatever it is where she's not going to get infections. Then you talk to the other patient. And even if it's a 22 year old woman say, you know, otherwise same story, but she actually was hospitalized twice during college with flank pain and fever. That's a patient I'm more nervous about. But I think that the paradigm shift that you're talking about, Catherine is actually, it's great. I'm thinking it, I'm doing it all the time. I actually wrote a piece for something or got quoted in something. And I don't want to say it was hate mail, but the comments back about, well, this could develop into sepsis. I was overwhelmed saying, oh gosh, maybe I was off base. But, but I think the answer is yes, we can really manage this, the hydration, the sort of not treating if they're not symptomatic. And I love my patients that come in now that have positive urines. The MA says, yeah, per urine's positive. And we're not, and the patient says, I know we're not treating it. And now I've done my job in terms of that education. So I think it's an awesome case for that reason. I'd still probably do a pelvic exam on him, but call me old fashioned. Well, I'll play devil's advocate for a moment and just say, you're already two hours behind. Would your time have been better spent counseling? It's going to take you 15, 20 minutes to examine the patient. Is that 15 or 20 minutes better spent counseling the patient and her family? And I think that's kind of the message that Catherine was trying to get through is we, you know, we have a limited amount of time and, you know, you can even, you know, you could make an, and I am not saying that I support this view, but I would like to throw this out to the panelists is that this, you know, we are highly trained surgical specialists. We have spent seven or eight years of training. Are we, and I understand that we are responsible for pelvic health in women, are, are, are urogynecologists, the folks that should be taking care of these patients, or should they only be coming to a urogynecologist when they have a problem that can be fixed? You know, do we need, do we need to educate our colleagues outside of urogynecology or is it best to say that, you know what, we'll just continue to do this. You know what, we'll just continue to manage these patients. And I'm not saying a pro or con on my part. I'd like to get the input from our panelists and see what they think. I really think that we need to ask people the right discriminating questions. And the hard thing is not missing the diverticulum and knowing what that looks like and not missing the bulge. But honestly, I think a cookbook, I mean, internists are good at cookbook medicine and we say, look, you know, if someone's got a recurrent UTI, we've got a screen for these conditions. They don't have PBR machines in their offices, which is problematic. And for a lot of the older people, incomplete bladder emptying is a major contributor as an issue. So, you know, I think that that piece is hard, but there's obviously so much education that needs to happen. I mean, how many times are we seeing the recurrent UTI person who's 56, new infections after menopause, and has been on Cipro, you know, five times in the last year. It's like everything is wrong with that. And so, you know, I feel like if we started small with the easy stuff and manage the more difficult stuff, it would make a lot more sense. Yeah, no, I agree. I mean, I think in some ways, and your point about the exam and those expertise, and frankly, even all the therapies you selected for her, even if she has a diverticulum, so what, right? If she still starts getting infections beyond what that first line of therapy was, well, then you're going to sort of need to refer, right? But I think it's a great question, Vic. I'm not sure that, I mean, the primary carers are probably having online lectures with their, you know, educational and professional societies where they're saying they're overwhelmed with the amount of stuff they need to do. So I can tell you that most of my colleagues at NYU would say, hey, if I could choose one condition not to see any longer, you know, in urogynecology, what would it be? And I think recurrent UTIs might be that. But unfortunately, I think at least for the time being, we're stuck with it. But we should continue to educate and algorithmize and sort of guideline this so others can really start to pitch in because it's overwhelming. I mean, at least get the message to not treat asymptomatic bacteria would be, that would be, and I think slowly it's breaking through slowly. I was going to add to that. So I think, yes, of course, there's an enormous amount of calls to our practice for recurrent UTIs. But the amount of people I've seen that come from the community or PCPs that have not, have been calling around in different venues, like we all saw the urgent care visits, the primary care visits, they're going around and not getting any help. And then just not, you know, no one's going back and saying, oh, you just had, you just had antibiotics, let's give you another, you know, or not give you another round, but putting it together, giving them a prevention, whatever it needs to be in their, you know, armamentarium, starting slow, supplements, then moving up, ratcheting up as needed, even to like an antibiotic. I think it is kind of in our role at this point. I'll get Catherine, like, you know, I echo Catherine, like we have, we can do the workup in the office easily. Are you in retention? Are we now diagnosing you like a new onset neurogenic blotter with MS, a young, you know, ambulatory population? So I think it is going to, it's not going anywhere. Well, I don't disagree with anything that you all have said. A couple of questions from our audience. Inpatient to have recurrent UTIs, is there any utility in performing a cystoscopy during symptomatic episodes to rule out infection, i.e. if the urophilium looks normal, she doesn't have cystitis. And this may be a diagnostic educational tool for a patient who always thinks she has true infections. Any comments on that? Showing them your bladder looks pristine, you don't have an infection. I will. Yes. Sometimes I think there is potentially a role for it. I mean, you try to explain it away without an invasive test, but sometimes you want to know, or you have that patient that, you know, you were supposed to do a Botox injection on them and they're nitrate positive. And then you look in and it's not injected. And then you wonder, hey, maybe they're just nitrate positive and maybe they don't have anything else going on. So I think, yes, sometimes I think you need to be selective. And again, because it goes against many guidelines that say don't instrument during, I think you need to counsel the patient appropriately, but not an unreasonable thing. The question is, does that UA really, you know, look positive with a bladder that looks perfectly normal? And, and Catherine's favorite urine analysis may, you know, again, that patient that has the positive urinalysis may not be doing that. It might be the negative urine analysis with the positive culture that I'm doing it for. Yeah, I agree. I stick to the guidelines a little bit in that setting because it's easy enough to see if they fail and they really get to the point where I'm out of ideas, then instrument them. But until then, I think it's just ratcheting up every form of prevention. Another question and this is certainly, I found this to be the case. The problem with the elderly is it's not easy to get them to properly hydrate. This has been documented in the geriatric literature as well. And it's an issue we face day to day in our practice. What is your approach to this problem? So Catherine, how do you get an elderly person to be relatively well hydrated without ending her up in the bathroom all day? Yeah, you know, Vic, I, I set goals and we try to get liquid meals in addition to drinks. And, you know, I think that the problem with the hydration is the free water. Like if you check a random sodium, all these people, I mean, they start off at 132, you try to get them to drink a whole bunch of water. Their sodiums are like 128. They feel bad doing it. They have mild nausea. So, you know, I think that having some sort of Gatorade like substance several times a week is helpful for these people. And so we try to set some of those goals and just talk about not drinking a whole lot of free water. I think you have to get them size water bottles that really like will motivate them to drink. Yeah. On that note, I heard this at a talk that someone had mentioned like the American obsession with hydration. And I feel like it does go in the opposite direction for some people, you know, hyponatremia feeling poorly sitting in the toilet all day. But I think asking that second question to the elderly, why aren't you drinking? And then often I feel like they'll tell you because I'm leaking because I get up a million times at night and then tailoring it to that patient saying, okay, we'll drink between these hours, maybe stop three hours before bedtime, and then try that out. But I think when you ask why you get a little bit more of an answer and then can work with that. Right. Well, we had a couple of questions that were submitted ahead of time that may not necessarily have anything to do with the topics that we discussed tonight. But I think since there may be some folks listening that were interested in this, I'm just going to pull up one that I think we can chat about. When you have a patient with mixed incontinence, what is your approach? So patient has stress and urgency incontinence. How are you going to approach that patient? It's a very general question. We'll start with Siam. How do you approach the mixed incontinence patient? So the mixed incontinence patient, I mean, besides, I'm assuming now you've given them all the conservative management, key goals, what have you checked for others, things like incomplete bladder emptying, prolapse, etc. And then when you work them up, I usually, these people are ending up in my office getting aerodynamics testing because after they failed the initial conservative things, you're left with that. And then that's not even the most straightforward because I oftentimes pick up stress incontinence, but they're not bothered by the stress incontinence. So I think it's taking the tests that we see objective data on and then corroborating it with their symptoms. And what's bothering you the most? That's like my most favorite question in my office. What's bothering you the most? Let's tack that first. And then going down the algorithm, I don't think we need to, the details, but. No, for me, Vic, when women have mixed incontinence, I find that the empty cough stress test is a really helpful thing for me to understand the degree of the stress incontinence. If someone's got such a low pressure urethra, they're leaking with a relatively empty bladder lying down. That's a major component of the problem. And I'm going to really tackle that first. For somebody that's got a negative cough stress test in the office and has emptied well, then we will, you know, really try to focus on when is she subjectively having most bother and tackle both simultaneously if it really is equal bother. So that's kind of just, if I, you know, if they've shown me that they leak with a relatively empty bladder with stress, then I definitely will go down that road first. Yeah, I agree. I love, you know, I love the topic and I love when I see the patient that just, you know, they say, ah, the stress is not so bad. And then they're laying there and the floor is soaking wet because now I know what I'm treating first. I think I was always a respect the urge person first. And more recently, I think with more and more data about resolution of urgency symptoms with sling, I pro or with treatment of anti-continence surgeries, I probably am leaning a little more in that direction. But I think it depends, right? There are the patients that hate the idea of medication, then it's an easy answer, right? There are patients that, you know, are, you know, not exercising because of the stress incontinence component. And it's an easy answer. And then there's the patient you look at and they don't look to be the best surgical candidate. And you sort of get a sense that their cough stress test is negative. And at that point, you know, why not just try a little overactive bladder medication again, assuming they've done the conservative things. So I think when I start to look a little deeper and maybe consider the aerodynamics would be, you know, we're at the point where we're, you know, considering a third line therapy and we're still not sure their bladders never full when they come into clinic to know. But I think cough stress test is useful. And I will tell you, you know, I've done Botox and neuromodulation on these patients without bladder testing. So it's not a must. I think it's, it's something that I probably today do more stress incontinence treatment in that pure 50-50 patient than I did five years ago. So Ben, are you bulking them or are you putting a sling in? Both. Yeah, both. So I think that the data is there for, for sling, not quite there for bulking yet, but mechanistically, I think it'll work. And sometimes even an anti-incontinence pessary to sort of say, Hey, you know, how much better does it get? It's a little harder to interpret that. And not every woman loves that idea, but you know, the patients that I'm thinking of are those 50 year old patients that are at the gym that have the mixed incontinence, frequency, urgency, similar questionnaire looks, you know, pretty even. And those are patients that I think gravitate a little more towards sling. But I'll offer both. The hypermobile urethras, I don't think do as well with bulking and they do really great with sling. So I, that, that is my discriminator for, you know, what I'm going to push for in that scenario. Yeah. The reason I ask is sometimes it's a hard sell when someone's saying, well, I'm not really bothered by the incontinence. Now you want me to be down and out for like a few days or a week or whatever you tell your patients, sling patients. And then let's hope that the urgency gets better. So it is, it is interesting. Those patients actually I send for PT, try an OAB if I see, you know, to choose for rect or, you know, something beforehand before they undergo their urethral treatment of whatever flavor we choose. Yeah. But this is one place where I also do think it is important to let the patient decide, right. We, we talk about sort of, you know, that, that patient decision-making process and shared decision-making, but Cy, I think it's a good point. If someone says, Hey, I don't want to be off of work or I don't want to be out from the gym, then it's pretty obvious we can go down that overactive bladder pathway. Yeah. With, with reasonable expectations about the uses of other treatments. Yeah. Yeah. I mean, I think one thing that I've learned from some of the more recent data and the data on resolution of overactive bladder symptoms with treatment of significant stress incontinence is I've become much less reliant on urodynamic testing and much more reliant on just talking to the patient and listening to the patient. I think that's all, you know, you, you can have a dilemma when the urodynamics and what the patient's telling you don't agree. And in a case of a non-neurogenic patient, as long as what I'm going to do is not going to potentially cause harm, I'm more likely to listen to the patient than I am to a urodynamics test. In the non-radiated, non-neurogenic type patient, where you are, you know, your urodynamics is more critically important. But I think some of the more recent data has, has helped with that. And I've become much less, as Catherine said, I'm much less fearful about treating stress incontinence in the patient who also has urgency incontinence than I used to be. I think that's something we've learned. Well, I think we are just about out of time. I'd like to, first of all, thank the panelists. I think those were excellent cases, thought-provoking, and we certainly got, we got a lot out of them, got a lot of questions out of them, got a lot of audience participation out of them. I would like to thank Solve Wellness for sponsoring this. They have been really great throughout this process. None of the content that you heard tonight was contributed by anybody from Solve Wellness. It was all from our three, our three panelists, but yet they were here to support this event. I think that's really great. I'd like to thank Augs for allowing us to do this and hopefully you all enjoyed it and can go back to it on the web and look at it again or tell your friends about it and they can look about it as, look at it as well. It'll be around on the website for a while. Any closing thoughts from our panelists? No, thank you, Vic, for hosting and thank Augs and Solve Wellness, Catherine and Saya. I learned a lot from you guys, so let's do it again soon. Yeah, thank you very much. Yeah, and thanks Solve Wellness for doing some direct-to-consumer advertising. Every patient that you treat outside of our offices is one less long, difficult patient conversation, so we are very grateful. Thanks, everybody. Bye, everybody. I hope you enjoyed it.

AUGS webinar

female pelvic health

urinary frequency

urinary urgency

bladder discomfort

radiation therapy

recurrent urinary tract infections

diagnoses

tests

recommended treatments

panel discussion

mixed incontinence