This is an introductory guide to help providers discuss and instruct patients for physical therapy who have sexual pain disorders. Sexual pain disorders are now termed under the DSM-5 genitopelvic pain penetration disorders. The physical therapy techniques that we will describe are specifically to treat vaginismus and vulvodynia. Traditional management includes myofascial release of muscle tension and desensitization techniques. Myofascial release addresses the physical component of pain by providing physical manipulation to the muscles and surrounding tissue, while desensitization addresses the cognitive behavioral component in which a dilator is inserted for up to 10 minutes which desensitizes the sympathetic nervous system. The ERASE and PSP program is a simple technique that we have developed that integrates these traditional techniques into a self-treatment guide. The purpose of this video is to assist in provider and patient comfort with discussing physical therapy treatment for sexual pain disorders. We will also provide a program accessible to the community when pelvic floor physical therapy may not be readily available. What is needed for a home program includes a dilator kit, personal lubricant, and a towel. We will start by using the smallest dilator in the kit. We will use this pelvic model to demonstrate physical therapy techniques. First, we will review the pelvic anatomy. The organs include the urethra, vagina, and rectum. The superficial layer of the pelvic floor muscles includes the transverse perineal muscles as well as the bulbospongiosis. We will refer to this as the first layer. The second layer is deeper to this layer and known as levator ani muscles. We will be referring to the pubic symphysis as 12 o'clock and the sacrum as 6 o'clock. For the ease of demonstration, we will be removing the superficial layer of the pelvic floor muscle. ERASE is an easy technique for patients to learn to perform. ERASE stands for insert, release, adjust, and stretch. It is important to make sure the patient is comfortable using a dilator. First, insert the smallest dilator approximately one quarter of an inch into the vaginal opening. Use a dilator that is approximately the circumference of a finger in order to apply the most direct pressure to the muscle. Make sure the tip of the dilator is angled so it presses directly into the trigger point that is about a quarter of an inch into the vaginal canal. Find the most painful area of the trigger point and press with moderate but comfortable pressure. Maintain pressure for at least 60 seconds or until the pain turns to pressure. As the pressure is applied, the pain should not continue to increase. If an additional increase in pain occurs, ease off the pressure point, reposition, and try again. For the next spot, move the dilator so that it is about two inches into the vaginal canal and repeat the previous sequence. Repeat these steps for each trigger point you identify. Adjust the dilator so that it is parallel to your torso and the side of the dilator is flat against the vaginal wall. In this exercise, we will be performing a Kegel contraction and alternating with the stretch. Take a deep breath in as you contract the pelvic muscles and hold the Kegel for three to five seconds. As you exhale, release the Kegel. Then use the dilator to stretch the pelvic floor towards the four o'clock direction. Maintain the stretch on the muscle, inhale, and do another Kegel. Release the Kegel as you exhale into a deeper stretch. Repeat the process for a total of three times or until the stretch becomes painful. Hold the final stretch position for 30 to 45 seconds. Repeat the same process at the eight o'clock and then the six o'clock positions. The PSP exercise sequence is designed to further facilitate pelvic floor muscle relaxation. It stands for perineal massage, strumming, perineal massage. The perineal massage is a scooping side-to-side massage of the pelvic floor muscles. Always use the smallest dilator for this technique. Gently but firmly move the dilator from side to side, massaging the areas between three o'clock and nine o'clock for 15 to 30 seconds. For the strumming massage, stroke the pelvic floor muscles with the tip of the dilator in a deep to superficial, or as patients frequently refer to it, back to front direction. Start with the smallest dilator placed against the vaginal wall at the four o'clock position and gently but firmly strum the muscle from the inner spot in the direction of the entrance, five to six times. Repeat the process at the eight o'clock position. Now repeat the perineal massage technique for 15 to 30 seconds using the smallest dilator at the end of this sequence. Patients should aim to perform these exercise daily, only reducing frequency if there is soreness in between sessions. In summary, start by inserting the smallest dilator, release trigger points by inserting the vaginal dilator a quarter of an inch into the vaginal canal for 60 seconds. Then insert the vaginal dilator two inches into the vaginal canal for 60 seconds. Repeat these steps for each trigger point, then adjust the dilator so that it is parallel to the torso. Then perform the stretch technique approximately three times at four o'clock, eight o'clock, and six o'clock positions, holding the final stretch for 30 to 45 seconds. Then perform the perineal massage technique for 15 to 30 seconds. Then perform the strumming massage five to six times at four o'clock, followed by the eight o'clock position. Then repeat the perineal massage for 15 to 30 seconds. In conclusion, we anticipate this video will assist providers to become more comfortable discussing physical therapy techniques, as well as instructing patients how to perform physical therapy techniques for sexual pain disorders. This is Sherelle Iglesia at Washington, DC. Nice work. I appreciate the attention to detail with the anatomy. I think it will be very educational for a lot of providers and AAPPs, Advanced Practice Practitioners. The one thing I'm concerned about, because in your video, the hand was ungloved, even on the model, and with Larry Nassar at Hashtag Me Too, I think it's also important to add to the video, this has to be done by trained providers. Feel like you have to have a chaperone if needed, you know. It's just a new world order. Do you have comments? And what is the Physical Therapy Association dealing with, I mean, in terms of a public health service message about this? Yeah, so that's a great point. So the reason why there weren't gloves is because these are for the patients to do on themselves, and so that's why they wouldn't be having gloves on. And this is the first time we presented this video, so we have not presented it anywhere else to physical therapists yet. Sherry Palm, APOPS. I'm curious if you have got, we've got quite a few women in our space that have been abused, sexually abused, and have these issues. And I'm curious if you have any kind of, like, flyer type thing on your website that, I mean, obviously patients need to see a physical therapist to teach them how to do these techniques, but I'm just curious if you have any kind of, like, a diagram type thing on your website that we could actually refer patients to so they could actually understand that this tool is available, and they can actually ask their PTs about this if they have not expressed yet that they have been exposed to sexual abuse. Well, I do not have a website. Usually when we see patients in our clinic, for urogyne, it's a multidisciplinary approach, so we always counsel and evaluate that before sending them to physical therapy. So the idea of this is after we counsel them in our clinic that we can provide something until they see the physical therapist, because at least where we are, it takes like three months for them to be able to see anyone. Thank you. I have another question for you. Have you employed videos already as far as patient education, and do you plan to for compliance and education? That's definitely something I'm interested in. One of my thesis is on patient education for consents, but I do not have any currently. Thank you. I'd like to invite our next presenter, Dr. Barnes from the University of New Mexico, on microaggression experiences of female surgeons. Hello. Good morning. These are our disclosures. Even though more women are entering surgical fields, gender bias against women remains a problem in the work environment. This bias is no longer as blatant as it was in the past, but now manifests more commonly as microaggression. So microaggressions are subtle, insulting, or discriminatory actions that communicate a demeaning or hostile message. Though subtle, research supports that the accumulated impact of microaggressions causes negative consequences to psychological health and burnout. So, therefore, our primary aim was to assess the frequency, type, and impact of gender-based microaggressions on female surgeons in the workplace, and we also sought to identify the perpetrators of gender bias and elicit ways to solve this problem. In this qualitative study, we conducted focus groups of female surgeons until saturation was achieved. Focus groups were divided between attending surgeons and trainees in order for everyone to be able to speak freely. We used the same experienced moderator and semi-structured interview guide. All transcripts were audio recorded, de-identified, and transcribed. We used line-by-line coding to identify emerging themes and concepts, and then an iterative process in order to expand on any topics brought out by the focus groups as needed. So, 23 participants were recruited in four focus groups total until thematic saturation was reached. More than half were from OBGYN specialties, and three were urogynecologists. This reflected the overall representation of OBGYN to non-OBGYN female surgeons in our institution. So, four emerging themes were identified. Exclusion, adaptation, increased effort, and resilience. So, exclusion was a common experience that manifested as delayed promotion, limited numbers of female mentors, isolation at conferences, and exclusion from the camaraderie such that can occur in the locker room, after work activities. So, even aspects of the physical environment can act as barriers for women. So, this can include ill-fitting and revealing scrubs and protective equipment that does not fit. So, for women, adaptation was required in order to succeed in surgery. Many adopted masculine pursuits, watching sports, drinking whiskey with their colleagues after work, in order to avoid exclusion. So, some changed their appearance, their voice. They emphasized their title and made sure they were called doctor in order to achieve respect and acceptance. Downplaying femininity was very common, especially in trainees. So, while seeking jobs or promotions, women actually mentioned that they felt the need to hide pregnancies and their family in order to avoid discrimination. So, to achieve a similar level of success as men, increased effort was required. Our participants felt that while male surgical colleagues were automatically assumed to be competent, they had to prove themselves to patients and staff. Female surgeons also felt pressure to conform to gender expectations, having children, smiling, being nice and accommodating, while this was not expected of male colleagues. Being ignored was frequent, requiring female surgeons to ask staff multiple times for needed items in the OR. They were also ignored in a group setting and their ideas dismissed. The nurses and techs are really not okay with you asking for something in a firm voice as a woman. You get a snide response and then they whisper to their colleagues. Our final theme was resilience, which includes both the verbal battering and the stigma that female surgeons face and the defense mechanisms that they develop. Participants often recalled being told that hiring a woman is taking a job away from a man who would be more productive. Home and work balance is judged and commented on in the workplace and overtly hostile comments, condescending body language, eye rolling, all are commonplace, as you can see from the comments above. So, I wanted to say that importantly, gender bias was not perpetrated by just men or just women. It was absolutely between both. And that was noted between all surgical groups and all types. And so, in order to overcome these, in order to defend against them, female surgeons developed defense mechanisms, such as having a thick skin, flying under the radar, deflecting sexist remarks, and using humor. And so, in case you were wondering, this is a tardigrade. They're one of the toughest animals ever discovered and so I thought it was appropriate. So, you know, it doesn't bother me. I'm tough. And I don't go home and cry about it or anything. But it still takes a toll. So, overall, female surgeons, as they enter the field, they fight against a baseline assumption that they are not physically capable and that in some ways they are inferior. In order to overcome that, they have to put in increased effort. They have to prove themselves. They have to balance their work and their home life. They have to represent all women and overcome being ignored. The Boys Club is still happening in surgery, unfortunately. And it creates barriers in academia, a hostile environment, and it manifests as a lack of female mentorship. And due to this, women are excluded. They feel like they have delayed promotion. They struggle to find mentorship. And it's difficult to get on the national stage, though I'm glad I'm here. Some find that this pressure to conform is intense. And so women adapt in order to avoid exclusion. They downplay their femininity. They hide their personality. They change their physical appearance and their voice. There is still overt verbal and sexual harassment that is going on and that was in every surgical field. And so women became resilient. Due to all of this negativity and additive wear and tear, they create defense mechanisms. But it still culminates in burnout. So inherent to all qualitative work, this study was hypothesis generating. Our limitations are a small sample size and a single institution. Our strengths are that most surgical subspecialties were actually represented and data on both trainees and attendings was collected. They all had a diverse training background from multiple parts of the country. And they wanted to let us know that it was not just in the region that we're working in. It was something that's pervasive in all of the training that they've done across the country. So in conclusion, gender bias is common in surgical fields regardless of specialty. Verbal harassment and pressure to conform seems more prevalent in training. And both men and women perpetrate this gender bias. More research is needed to determine the interventions to change this culture. Thank you and I look forward to your questions. I don't want to minimize the gender bias, but I think that there is actually a culture of bullying that is in the OR. And felt by really all people who are entering that. And I'm wondering, do you think that addressing the gender issue, which is certainly part of it, is a way to change the culture overall? I think it can change a good portion of it. I think the concept of bullying as you're entering the surgical field in medical school and in residency, I think that is integrated in this, but it's sort of a separate problem altogether. Because I think that whole culture is slowly changing, but it needs to be changed as well. But I think doing implicit bias training would be very helpful. Yes. Good work. Thanks. Dr. Merriweather? Hi, Dr. Barnes. Really cool work. Disturbing, but very interesting. And I can't wait to see more data from this. I was wondering if you could comment on, many of those of us in my vintage often feel this guilt, like we didn't have it as bad as our female mentors who went through 20, 30, whatever years before. And so sometimes there's this sort of female surgeon on female surgeon crime that occurs when we don't understand each other's eras, and even though both of us have faced these biases, we're not growing up in the same time frame. Did you get any themes like that in your focus groups? Yes, we did. We had one older female surgeon that made it very clear that things have gotten better, which is wonderful, but was very critical of the victimhood complex that she felt that was being seen in the younger generations. But in contrast to that, there has been a wealth of literature, especially on racially based microaggressions, that has shown that even if it's not overt anymore, it is so damaging to people and to their careers and their mental health. So I do think it's still a problem, even though it's not as out in the open as it was at one point. Thank you. Yeah, thanks. I work in New Zealand, and I'm one of the first generations, or probably the second generation, of gynecologists in my country that I've adopted. But I've worked in a few different places. The gender bias in the UK was terrible. I was thinking about doing urology and was asked, would your husband put the clothes in the washing machine? But nowadays, certainly in New Zealand and Australia, 90% of our trainings are women, and that's similar to the comment, you know, is there a difference in age groups? I'm a generation above you, and I got a bit of it. The generation below me, definitely not. But one of the things I've noticed about the US is you have to go back to work six weeks after having a baby, and I think that's incredibly abusive. Or two weeks. Two weeks. So I think that needs to be addressed, yes. I think we have time for one more question. I was just wondering if any of the women in your study did talk about maybe more racial microaggressions and how that combines being an ethnic or racial minority and also being a woman surgeon or female surgeon. I think it just compounds it. We had a, our group was mixed in their ethnicity, but not really enough to determine kind of big themes. We are doing, we did do some further work that quantified that, and we didn't find any differences at that point, though. We did a validated survey afterwards, after all this, so that'll be coming next. Thank you. Thank you. I'd like to invite Dr. Turner for the next presentation, The Impact of Preoperative IV Acetaminophen on Postoperative Pain in Women Undergoing Pelvic Organ Prolapse Repair in Multi-Center Randomized Double Bi-Placebo Controlled Trial. Thank you for the opportunity to present our research. We have no relevant financial disclosures. I would like to take this opportunity to thank the American Heart Association and I'd like to take this opportunity to thank the Augs Public Floor Disorders Research Foundation for their generous support of our study. Opioids are the standard of care for postoperative pain and have side effects that can be especially problematic in the elderly, including cognitive impairment, urinary retention, and constipation. Preemptive analgesia involves introduction of pain medications prior to surgical incision to prevent that amplification of pain by the central nervous system and thereby reduce postoperative pain. Although it has been widely studied in postoperative pain, IV acetaminophen has not been well studied as preemptive analgesia and studies in the OBGYN literature report conflicting impact on reduction of pain and narcotic use. Therefore, our objective was to compare the impact of preop IV acetaminophen compared to saline on postoperative pain scores following pelvic organ prolapse repair. Secondary outcomes included narcotic use, quality of life, patient satisfaction, and side effects. We hypothesized that preemptive IV acetaminophen prior to pelvic organ prolapse correction would result in lower postoperative pain scores and reduce narcotic requirements, which would consequently result in improved patient satisfaction, better quality of life, and less side effects. We conducted a multi-center trial at two large hospital systems between 2014 and 2017. We included women who were aged 18 and older, planning to undergo a minimally invasive prolapse repair surgery with an anticipated hospital stay of 24 hours or more. We excluded those with an allergy or intolerance to Tylenol, hepatic dysfunction, or significant alcohol use. We performed randomization in a one-to-one ratio on the day of surgery. Acetaminophen 1000 milligrams or normal saline was administered in matching 250 cc glass bottles by our preoperative nurses approximately 10 to 30 minutes prior to surgical incision. Since pain intensity and type likely differs by the route of surgery, we planned a stratified randomization by surgical route with a group of vaginal and a group of laparoscopic and robotic women. Patients, investigators, surgical and anesthesia teams were blinded to the allocation. Our primary outcome was change from baseline and visual analog scale pain scores at 24 hours. Secondary outcomes included narcotic requirements measured in milligram morphine equivalents, which was abstracted from the inpatient electronic medical record, as well as through a seven-day pain diary, which asked patients to complete every dose and time that they took a medication for pain throughout the seven days post-op. We also queried patient satisfaction through the American Pain Society questionnaire at 24 hours post-operatively, as well as through the promised pain interference short form at seven days post-op. We measured side effects including nausea, drowsiness, dizziness, and itchiness through the American Pain Society questionnaire. We also queried constipation through the use of a seven-day bowel diary, which measured type and timing of all bowel movements. We also looked at the urinary retention rates in the electronic medical record. We calculated that we would require 102 subjects to detect a 12-millimeter difference in VIS pain score with an 80 percent power and alpha of .05, adjusted for a five percent loss to follow up. Ultimately then, we had 204 subjects, 102 in each route, for both vaginal and laparoscopic robotic. This is our study flow diagram. As you can see, 366 subjects were assessed for eligibility and ultimately 204 were enrolled. After two subjects were withdrawn, this left us with 101 in the vaginal arm and 101 in the laparoscopic robotic arm. Based on our discrete analysis, we had 202 subjects that were analyzed. At baseline, patients were predominantly Caucasian, postmenopausal, had an average age of 65 and a mean BMI of 28. At baseline in the vaginal arm, there were no significant differences between groups with the exception of more posterior repairs in the placebo arm. In the laparoscopic group, there were no significant differences between IV acetaminophen and placebo groups in the overall or route-specific groups. Similarly, there was no difference in narcotic requirements between IV acetaminophen and placebo in either the first 24 hours postoperatively or throughout the seven-day pain diary. In the postoperative group, there were no significant differences in quality of life or patient satisfaction with pain between groups as measured by the PROMIS and American Pain Society questionnaires. There was no difference in side effects of nausea, drowsiness, itchiness or dizziness and constipation was similar between groups with median time to first bowel movement of three days. Interestingly, urinary retention did differ. In the laparoscopic surgery group, there was no difference. There was an increased risk in the acetaminophen arm with 59% of women having urinary retention as compared with 33% in the placebo group. Strengths of the study include its multicenter design, double-blind, placebo-controlled study that included both a vaginal and laparoscopic group. Additionally, the pragmatic design with multiple institutions, multiple surgeons and few exclusion criteria leads to its generalizability. Limitations include postoperative opioid administration was not standardized and therefore may have blunted differences in observed outcomes. In conclusion, women undergoing minimally invasive pelvic reconstructive surgery preemptive IV acetaminophen did not impact 24-hour BAS pain scores, narcotic requirements, satisfaction or quality of life. Side effects were similar between groups with the exception of increased urinary retention amongst women receiving acetaminophen in the vaginal arm. Routine use of IV acetaminophen as the sole preemptive agent is not supported by this study. I now welcome your questions. Thank you. Considering that you did have difference in your group with regards to posterior coporaphy which may have an impact on pain and retention, did you do your analysis correcting for that adjusting for this difference in baseline? We did an unplanned regression analysis looking at the urinary retention rates. We did include the posterior coporaphy which did not result in any differences. We also looked at in that regression model urine output and IV fluids to see if that potentially influenced anything and it did not. And it didn't have any impact on pain as well? We did not perform a regression on the pain since there were no differences in the two groups in overall or route specific. A question from the right. Just one little comment. You mentioned robotic and laparoscopic approaches. So you lumped them together. I wonder if you teased that out? There were no significant differences. We did have a much smaller robotic arm as part of the laparoscopic group. Only 25 subjects out of the 101 had robotic surgery but there were no differences within that small group. Great. Thanks. Hi, Michelle Morrell, San Francisco. As I was sitting there thinking, so many of my colleagues have said it feels like IV Tylenol is beneficial in my patient. I was wondering, and it seemed like you had trends, although because the confidence intervals were so wide there was obviously no significant difference. Was there maybe a type of patient that did respond to the IV Tylenol? For instance, patients with more pain were more likely to feel better, or less pain were more likely to feel better. Did you look at that at all? We didn't. You know, most of our patients had very low preoperative pain scores, but we didn't tease out if there was a difference between those with higher postoperative scores that would be interesting to look at. On the left. Vicki Hander from Johns Hopkins. I think this is a really interesting and important study, and heavy Tylenol is so expensive that it's important to really assess its value. One concern I have, though, I think what you said was that your power calculation was for the whole group, but then you presented your groups, you stratified the randomization but then you analyzed the two groups separately, am I understanding that? Sorry if that was confusing. We actually powered the study to have full power for both groups. So it was a hundred... For each group independently? Correct. So a hundred and two were needed total, so we basically took a hundred and two and made that a laparoscopic arm, and then another hundred and two and made that a vaginal arm. So it was powered to detect a difference for each route. Okay. And then the one other point I'll make, just again, because I want to make sure that everyone gets this message, can you say anything about why you picked that 12-point difference or any post-hoc analysis that you might have, just to make sure we're not missing something that we would criticize as, oh, well, that difference is still clinically meaningful even though not statistically meaningful? Sure. That number was chosen from three prior studies that have looked at the minimally important difference of VIS pain score changes. Most of these were done in a population of emergency room patients, so we chose the median of those studies, which was 12 millimeters. Thank you very much. Thank you. I'd like to move on to our next paper by Dr. Carter Brooks, Outcomes by Age in a Urogynecology Enhanced Recovery After Surgery Program. Good morning. Thank you for the opportunity to present our research. We have no disclosures. Enhanced recovery after surgery is a multidisciplinary approach to patient perioperative care. At our institution, we developed a discipline and gender-specific protocol for women undergoing prolapse repair surgeries. We found in early data that ERAS increased same-day discharge and decreased opioid requirements. While we know overall from our studies and other data that ERAS improves outcomes for patients having prolapse surgery, data is lacking on the impact of age on ERAS perioperative outcomes after prolapse surgery. Therefore, our objective was to evaluate the impact of patient age on same-day discharge before and after implementation of an ERAS pathway. Our null hypothesis was there's no difference in same-day discharge among age groups after ERAS implementation. And for our secondary aims, we assessed length of stay, opioid administration, and pain scores before and after ERAS implementation by age group. This study is a retrospective analysis of an observational cohort. Women included had major prolapse surgery by seven FPRMS surgeons. Consecutive cases were included from January 2016 through October 2017, and ERAS was implemented February 2017. For our analyses, we divided age into three groups based on age percentiles. Women who were in the 25th percentile for age or less were young, the 26th to 74th percentile were middle-aged, and over the 75th percentile were considered old age. For our primary aim to determine the impact of age on ERAS and same-day discharge, we performed regression analyses and we tested interaction terms to determine the impact of age on same-day discharge in ERAS. For our secondary aims, we used chi-squared t-tests and Kruskal-Wallis tests for changes for pre- to post-ERAS, and we used mixed-effect regression modeling for PACU pain scores over time. We estimated 82 women were required in each group to detect a 20% difference in same-day discharge between young and middle-aged women and a 22% difference between middle-aged and old women. For our baseline data, we found the mean age for young women was 52, for middle-aged women was 68, and for old women was 80 years old. Old women are more likely to have more comorbidities. In terms of ERAS, there was no difference between the age groups for women enrolled in ERAS. Older women had more severe prolapse and were more likely to undergo a copolysis. Notably, there were no differences pre- or post-ERAS in any age group. When we assessed age in same-day discharge before and after ERAS implementation, we found a significant increase in same-day discharge for all age groups. Overall, same-day discharge increased by 125% after ERAS implementation. For our primary outcome, we performed a regression analysis for the impact of age on the association between ERAS and same-day discharge in our whole cohort, and we found that there was a significant association between ERAS and same-day discharge, increasing by 14-fold. However, there was no association between age and same-day discharge in this cohort. We tested it for an interaction term. This was not significant, indicating that the effect of ERAS on same-day discharge was not conditional on the age categories. Next, we assessed age and length of stay before and after ERAS implementation, and again found overall that length of stay decreased for all age groups, approximately 58% or 14 hours. We were unable to perform a regression analysis for this group, as length of stay had a bimodal distribution. Next, we assessed age and oral morphine equivalence, which were intra-op and PACU oral morphine equivalence before and after ERAS implementation, and again we found that opioid administration was reduced in all age groups significantly, and overall this was a 90% decrease after ERAS implementation. Notably, this data was not normally distributed, and so we assessed the number of women who received zero opioids intraoperatively and in the PACU, and found that after ERAS, opioid-free anesthesia increased from 8.6% to 32%. And due to, again, the non-normal data, in order to perform a regression analysis to determine the impact of age, we excluded women who received zero intra-op and PACU opioids. And for our regression on the impact of age and association between ERAS and mean oral morphine equivalence, we found that ERAS was independently associated with a decrease in oral morphine equivalence, and age was also associated with oral morphine equivalence. However, young women received more, and older women received less. And when we tested our interaction term, we found there was a significant difference, or significant p-value, indicating that the effect we see here from ERAS is actually conditional on age. And lastly, we assessed PACU pain scores over time by age category. Notably, we found no difference in pain scores for women pre- or post-ERAS. So this figure represents pain scores for our young, middle-aged, and old women across the entire time frame of our study. Young women are in orange, and we found that they had the highest pain scores overall in the PACU compared to middle-aged women in blue and old women in the green. Notably, by about 60 minutes, pain scores were three or less in all groups. So in conclusion, we found women of any age benefit from ERAS. We found a marked increase in same-day discharge and reduction in length of stay and overall oral morphine equivalence. In our regression analyses for opioid administration, we did find an interaction existed between age and ERAS, which indicated that the effect of ERAS on oral morphine equivalent reduction is conditional on age. In addition, young women required more opioids, while older women required less. And even though we saw a decrease in opioid administration, there was no effect with ERAS on pain scores. Thank you. They even have surgery and who's able to take care of them. And we also post-operatively have nursing calls the day after discharge for all patients to pick up any signs that the patient may need to come back in for evaluation. Vicky Handa from Johns Hopkins. Since you've done a lot of work in this area, which is an important area, I wonder if you can comment on kind of a philosophical question, which is whether our patients value same-day discharge and decreased length of stay. And we value that. We use that as a marker of success. And certainly our hospitals value that. But I don't always feel that patients view that as an outcome that they are seeking. And similarly, I think because your analysis, the morphine equivalents would be linked to length of stay, right? If they didn't stay, they wouldn't get the morphine. So maybe it all boils down to length of stay. And that's my philosophical question, too. Is that something our patients are seeking? Sure. So for the first question, that is a really good point. And I think that when we first introduced the idea of same-day discharge, there was resistance from patients. When we implemented a questionnaire after surgery the day after discharge on that nursing call, we found patients were satisfied with their experience in going home. However, we don't have pre-ERAS data to compare that to. And just anecdotally, which I know is not evidence-based or data-driven, patients do report being happy to go home. And we've had patients who would not have had surgery because they did not want to stay in the hospital. Also, there's increasing exposure that patients know there's increased risk of infection, clot risk, et cetera, in the hospital. And so many patients actually are happy to be able to go home and avoid some of that risk. But you're right, I don't have data necessarily to support that. And in terms of the second question, so when we looked at oral morphine equivalents in this study, we looked at just intraoperative and PAC use. So all patients were assessed during that timeframe. We didn't look at post-op, floor, or at home. Thank you. Take the middle microphone. Thank you. Maggie Mueller, Chicago. One really quick question. How did you define length of stay? Was that from admission to the PACU? Length of stay was from the time the patient checked into the hospital to the time that they were physically discharged from PACU or from the hospital. And do you have the amount of time that patients, like the average amount of time that patients stayed in the PACU? We do. And the average time is between three and four hours. I think it's like three and a half hours. Thank you. You're welcome. I think we can take one more. Kara Elmer from Iowa. I was just wondering, maybe I missed this, but did you guys do any sort of frailty screening for the older patients? And were they included in this study? We didn't do frailty screening. We do have the RAE frailty score that generates for all patients in our system. We tended to rely on preoperative clearance for all of our patients to have the PCP assess frailty. We do have ongoing studies right now assessing frailty and what that actually means. There's a number of different scores. And how they actually relate to outcomes in patients varies depending on what you read. So we didn't actually use frailty in our evaluation. Thank you. You're welcome. Thank you very much. Our next presenter is Dr. Bono, presenting evaluation of postoperative opioid prescriptions following urogynecologic surgery. How much are we prescribing? Good morning. Thank you to Dr. Rogers, Dr. Van Relt, and the Ogg Scientific Committee for allowing my co-authors and I to have the opportunity to present our research. Turn the slides off. Hang on. Green. Thank you. There we go. We have no relevant financial relationships to disclose. One avenue to curb the national opioid epidemic is to optimize postoperative prescriptions. As previous studies have demonstrated, that the majority of postoperative opioids are not consumed by the surgical patient. Surgeons need to be aware of our own prescribing patterns in order to optimize future postoperative prescriptions. Our primary objective was to assess the quantity of morphine milligram equivalents prescribed postoperatively for patients undergoing different urogynecologic surgeries for the indication of pelvic organ prolapse or stress urinary incontinence. Our secondary objectives were to determine the frequency of concurrent non-opioid postoperative analgesic prescriptions, such as Tylenol or NSAIDs, assess for individual patient and surgical factors that were associated with higher postoperative morphine milligram equivalent doses, and determine the frequency of additional opioid prescriptions within 90 days after surgery. This was a retrospective cohort study of patients who underwent surgery for the indication of pelvic organ prolapse or stress urinary incontinence within the Southern California Permanente Medical Group. A convenient sample of patients who underwent surgery between July and December of 2016 were selected for inclusion. CPT coding for reconstructive or obliterative surgeries, as well as mid-urethral sling insertions, were used to identify the initial cohort and the charts were reviewed by physicians to confirm eligibility. Several surgical exclusion criteria were applied in order to specifically evaluate patients who underwent traditional combinations of urogynecologic surgery. Patients were excluded if their hysterectomy was performed for an indication other than prolapse or if it was performed at the same time as a vaginal obliterative procedure. Additionally, vaginal or laparoscopic surgeries that were converted to laparotomy were excluded from the analysis. A patient was excluded if she had a concomitant laparoscopic surgery, often for the indication of sterilization or adnexal pathology during an otherwise vaginal surgery for prolapse or stress urinary incontinence. Finally, patients who did not remain within the healthcare system for 90 days after their surgery were also excluded. 1,028 patients were originally identified by CPT coding and of those, 173 were excluded, which resulted in a final cohort of 855 patients. Table 1 demonstrates the distribution of urogynecologic surgeries, and notably, isolated mid-uterus sling insertions can pose the largest surgical category. Seventy-two percent of patients who underwent a vaginal or laparoscopic apical suspension had a concomitant hysterectomy. The median quantity of morphine milligram equivalents ranged between 135 to 200 milligrams. Patients undergoing an isolated mid-uterus sling insertion or a vaginal obliterative procedure were prescribed the lowest average doses, while patients undergoing a laparoscopic utero-sacral ligament suspension received the highest average dose. Not only was their variability within the quantity of morphine milligram equivalents prescribed to patients undergoing different surgeries, but the range of morphine milligram equivalents prescribed by surgeons within a single surgical category was notable. For example, the interquartile range of morphine milligram equivalents prescribed to patients undergoing a vaginal utero-sacral ligament suspension ranged between 135 and 300 milligrams, which is the equivalent of 27 to 60 tablets of oral hydrocodone 5 milligrams. The presence of a postoperative NSAID prescription varied widely between different surgical categories. Interestingly, when comparing different types of surgeons who performed isolated mid-uterus sling insertions, FPMRS surgeons were more likely to prescribe a postoperative NSAID than a non-FPMRS urologic surgeon. While this was a secondary outcome, we found this result to be surprising and may be worth further investigation. Based on prior literature that demonstrated that urogynecologic surgical patients who consumed more opioids postoperatively were more likely to be prescribed a higher dose at the time of discharge, we compared patients whose opioid prescriptions were in the top quartile to those who were at or below the 75th percentile to assess for identifiable risk factors. The factors in Table 4 were found to be significantly different between the two groups. Additionally, the type of surgery varied between the two groups, and patients who underwent vaginal or laparoscopic utero-sacral ligament suspensions were more likely to be prescribed higher morphine milligram equivalent doses postoperatively. Of note, the lack of a postoperative NSAID prescription remained a significant in a multivariable linear regression. 136 patients, which constituted 16 percent of the cohort, received an additional postoperative opioid prescription within 90 days after surgery. Of these, 39 patients were prescribed additional opioids specifically for the indication of persistent postoperative pain, which resulted in an overall refill rate of 4.6 percent. Notable findings from this study included the marked variability in the quantity of morphine milligram equivalents that were prescribed to patients within the same surgical category, with some patients receiving more than twice the dose of another patient who underwent a similar operation. The only modifiable clinical factor that was correlated with the quantity of morphine milligram equivalents prescribed was the absence of a postoperative NSAID prescription. Finally, less than 5 percent of urogynecologic patients received opioid refills specifically for the indication of persistent postoperative pain within 90 days of surgery. Further evaluation of opioid and non-opioid analgesic prescriptions, as well as consumption among postoperative patients, is needed. Formal multidisciplinary guidelines regarding optimal opioid dosing after urogynecologic surgery are necessary to reduce excessive postoperative prescriptions. Thank you, and I look forward to answering your questions at this time. So this is for the system? Yes. Right. So are there any order sets or things within the EMR to help prompt people in terms of their prescribing patterns, or is it just, you know, individual choice? That's a great question. So at the time that this data was collected in 2016, there were no formal guidelines for the physicians within this healthcare system, and that's why we chose this time period to kind of set a baseline before formal recommendations had come into play. Since that time, in the earlier part of 2018, within the Southern California Kaiser Permanente Medical Group, there's now been guidelines that have come out that have said that it's requested that the surgeons prescribe only a five-day postoperative prescription dose. So if you're prescribing a tablet that's to be used every six hours as needed, that would limit a physician to a 20-tablet supply. Okay. Thank you. Thank you for this great work. Were you able to query either your database or to find out if the lack of NSAID prescriptions was due to their wide availability over the counter? No, I often will tell patients just take three and I'll tell them how to do it. I'm pro-fit, or take two a week, and I'll tell them how to do it on a schedule, but I don't write a prescription. That's a great question. We did not specifically, since it was a secondary analysis, we did not specifically look into the exact reasons why NSAIDs were or were not being prescribed. From reviewing the preoperative documentation, if that counseling was being performed, there was not a lot of documentation that was going into it, but we didn't specifically look into each indication regarding NSAID prescriptions. Hi, Elliot Greenberg from Springfield, Massachusetts. I think this is really helpful information to be able to share with our colleagues and help us look at ways to reduce opioid usage. One of the things I was curious about is anecdotally we found that when we added acetaminophen to the NSAID postoperatively, it reduced opioid consumption significantly. I'm wondering why you didn't look at acetaminophen in combination with NSAIDs and if that's something you're looking towards in the future. Yes, so we did look at acetaminophen. The rates of plain acetaminophen prescription were less than 1%. The reason why, I believe, is that 80% of the opioids were often combination medications, so 60% were Norco 5, 13% were Tylenol No. 3, 7% were Percocet 5. The other 20% were either altering dosages of those medications, but we found that overwhelmingly it seems that physicians within this healthcare system were prescribing an NSAID and usually a combination medication, so the rates of pure acetaminophen prescription were quite low. Thank you. Thank you. Okay. Our next paper will be presented by Dr. Buono, evaluation of postoperative opioid prescriptions following urogynecologic surgery, how much are we prescribing? Oops, sorry, my bad. All right, I was definitely up too late last night. I apologize for that. It did seem to loosen up the audience to ask more questions, so great. Sorry, you don't have to present again. This is, oh, my goodness, I'm going to not pronounce your name right. This is Dr. Rameseshan. Thank you. She is going to talk about predictive factors of post-discharge narcotic use after female pelvic reconstructive surgery, so thank you for allowing me to fumble around here. Thank you. Okay. Good morning. I'd like to thank the society for allowing us to present our research. Due to the ongoing opioid epidemic in the United States, drug overdose deaths have nearly tripled over the last 15 years. Prescription opioids play a significant role, contributing to 40% of all opioid-related deaths. By the year 2012, we as providers prescribed nearly a quarter of a billion opioid prescriptions, which is sufficient for every American adult to have his or her own bottle of pills. Studies across various surgical specialties have shown that patients underuse the number of pills prescribed after surgery. A recent study in obstetrics showed that after cesarean delivery, most women were prescribed opioids in excess of what they needed. Therefore, providers now face an important task of decreasing excess opioid prescriptions while ensuring optimal pain control in the post-operative period. To find this balance, it is important that surgeons understand key patient factors that may drive prescription opioid use after surgery. The objective of this study is to evaluate post-discharge narcotic use, or PDNU, and identify clinical factors that may be predictive of patient opioid consumption after pelvic reconstructive surgery. This is a secondary analysis of a previously published randomized controlled trial at our hospital by Reagan et al., where standard post-operative pain management was compared to multimodal pain pathway. Participants in this study were stratified into three surgery types, laparoscopic, total vaginal surgery, and abdominal surgery. The time that this study was done, patients were discharged home with 50 tablets of a narcotic. Only participants in the multimodal arm were included in this analysis. Patient demographics, clinical, and surgical factors were evaluated. In-hospital and post-discharge narcotic use was calculated and converted to morphine milligram equivalent. The number of tablets remaining post-discharge was collected via telephone interviews between post-operative days 7 through 10, where patients were asked to count the number of pills remaining in their respective bottles. Validated brief pain inventory was used to assess pain levels at different time points, including preoperatively, post-operative day 1, and between post-operative days 7 through 10 via telephone interviews. In the brief pain inventory, questions 3 through 6 were of interest. It involved patients rating their pain in the last 24 hours on a scale from 0 to 10 to describe their worst, least, average, and now pain. Standard statistical tests were applied. Univariate and multivariate analysis was performed to evaluate demographic and clinical factors. Correlations were used to examine the relationships between post-discharge narcotic use, amount of narcotics used in hospital, and brief pain inventory scores. Logistic regression analysis was performed to evaluate contributions of factors associated with non-narcotic versus narcotic users post-discharge. Sample size in the multimodal arm was 68. Increasing age and menopausal status greater than 1 year was associated with increased post-discharge narcotic use on multivariate analysis. All other clinical and patient characteristics, including route of surgery, were not predictive of post-discharge narcotic use. Looking at post-discharge narcotic use, we found that 34.8% of patients used no narcotics post-discharge. Of the patients who underwent vaginal surgery, almost 50% did not use any narcotics after hospital discharge. After excluding patients who took zero narcotics, the median MME across all routes of surgery was 127.5, which equals about 17 5-milligram oxycodone tablets. The median MME after vaginal surgery was 37.5, which is only 5 5-milligram oxycodone tablets that patients used post-discharge after vaginal reconstructive surgery. Correlational analysis between in-hospital and post-discharge narcotic use revealed a linear relationship across all routes of surgery, suggesting that patients who used more narcotics in hospital typically used more after discharge. After controlling for baseline differences, higher BPI scores for questions regarding worst, least, average, and now pain on post-operative day one and post-operative week one were positively correlated with post-discharge narcotic use. In conclusion, when a multimodal pain regimen is used, almost 35% of patients did not use narcotics. In-hospital narcotic use predicts post-discharge narcotic use in patients undergoing minimally invasive reconstructive surgeries. Surprisingly, vaginal surgery utilized the lowest amount of post-discharge narcotic use. High BPI scores suggest higher narcotic use after discharge. Strengths of our study are that the data is from a well-designed randomized controlled trial with robust data collection due to which there is a minimal recall bias. It also included most common urogynecology procedures. The limitations are the small sample size and were not powered to examine the impact of these characteristics on post-discharge narcotic use. In summary, post-discharge opioid consumption after pelvic reconstructive surgery is lower compared to the amount of narcotic medications typically prescribed. In-hospital narcotic use and brief pain inventory scores may allow surgeons to individualize pain control. Future prospective studies on individualized pain regimens are currently underway. Thank you and I look forward to your questions.

post-discharge narcotic use

pelvic reconstructive surgery

predictive factors

patient opioid consumption

randomized controlled trial

multimodal pain pathway

in-hospital narcotic use

pain levels

morphine milligram equivalent