American Urogynecologic Society

Five Things Physicians and Patients Should Question

Released May 5, 2015; Last reviewed 2019

  1. 1

    Avoid using a fluoroquinolone antibiotic for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.

    For women with uncomplicated UTIs (defined as premenopausal, non-pregnant women with no known urologic abnormalities or comorbidities), fluoroquinolone antibiotics should not be considered first-line treatment. Although fluoroquinolones are efficacious in three-day regimens, they have a higher risk of ecological adverse events, such as increasing multidrug resistant organisms. Thus, fluoroquinolones should only be used for the treatment of acute UTIs for women who should not be prescribed nitrofurantoin, trimethoprim-sulfamethoxazole or fosfomycin.

  2. 2

    Don’t perform cystoscopy, urodynamics or diagnostic renal and bladder ultrasound in the initial work-up of an uncomplicated overactive bladder (OAB) patient.

    The initial evaluation of an uncomplicated patient presenting with symptoms should include history, physical examination and urinalysis. In some cases, urine culture, post-void residual urine assessment and bladder diaries may be helpful. More invasive testing should be reserved for complex patients, patients who have failed initial therapies (i.e., behavioral therapies and medications), or patients who have abnormal findings on their initial evaluation.

  3. 3

    Don’t exclude pessaries as a treatment option for pelvic organ prolapse.

    Nonsurgical treatment options for pelvic organ prolapse include pessaries, which are removable devices that are placed into the vagina to support the prolapsed organs (i.e., uterus, vagina, bladder and/or rectum). A pessary trial can be offered to almost all women with pelvic organ prolapse. Exceptions include women with an active vaginal infection and those who would be noncompliant with follow-up.

  4. 4

    Avoid using synthetic or biologic grafts in primary rectocele repairs.

    Posterior vaginal repair of rectocele is performed for women with symptoms of a posterior vaginal wall bulge or difficulty with defecation. The repair involves suturing the posterior vaginal wall and perineal tissue. The addition of synthetic or biologic grafts to this repair does not improve patient outcomes.

  5. 5

    Avoid removing ovaries at hysterectomy in pre-menopausal women with normal cancer risk.

    For women with an average risk of ovarian cancer (defined as women who do not have a document germline mutation or who do not have a strong family history suspicious for a germline mutation) who are undergoing a hysterectomy for benign conditions, the decision to perform bilateral salpingo-oophorectomy (BSO) should be individualized after appropriate informed consent, including a careful analysis of personal risk factors. There is evidence from observational studies that surgical menopause may negatively impact cardiovascular health and all-cause mortality. Ovarian conservation before menopause is particularly important in patients with a personal or strong family history of cardiovascular disease or stroke.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Urogynecologic Society (AUGS) is proud to partner with the Choosing Wisely® campaign. Founded in 1979, AUGS is the premier non-profit organization representing more than 1,800 members including practicing physicians, nurse practitioners, physical therapists, nurses and health care professionals, as well as researchers from many disciplines, all dedicated to treating female pelvic floor disorders. As the leader in female pelvic medicine and reconstructive surgery, AUGS promotes the highest quality patient care through excellence in education, research and advocacy. Participation in Choosing Wisely® complements AUGS’ commitment to quality improvement, and improving patient care practices and outcomes.

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How This List Was Created

The Clinical Practice Committee of the American Urogynecologic Society (AUGS) reviewed clinical evidence to identify possible topics along with suggestions for possible topics from the AUGS Board of Directors. By consensus, the Clinical Practice Committee selected the top five most overused tests within specified parameters. Additional input was sought from the AUGS Board of Directors and incorporated. The final list was reviewed and approved by the AUGS Board of Directors.

AUGS’ listing of board and committee members and conflict of interest policy can be found at


  1. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.

    Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012 Mar 15;366(11):1028-37.

  2. Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemens JQ, Culkin DJ, Das AK, Foster HE Jr, Scarpero HM, Tessier CD, Vasavada SP; American Urological Association; Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Diagnosis and treatment of overactive bladder (non neurognic) in adults: AUA/SUFU guideline. J Urol. 2012 Dec 1;188(6 Suppl):2455-63.

  3. Culligan PJ. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol. 2012 Apr;119(4):852-60.

    ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. 2007 Sep;110(3):717-29.

    Bugge C, Adams EJ, Gopinath D, Reid F. Pessaries (mechanical devices) for pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004010.

  4. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30;4:CD004014.

    Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol. 2006 Dec;195(6):1762-71.

    Sung VW, Rardin CR, Raker CA, LaSala CA, Myers DL. Porcine subintestinal submucosal graft augmentation forrectocele repair: a randomized controlled trial. Obstet Gynecol, 2012 Jan;119(1):125-33.

  5. Berek JS, Chalas E, Edelson M, Moore DH, Burke WM, Cliby WA, Berchuck A; Society of Gynecologic Oncologists Clinical Practice Committee. Prophylactic and risk-reducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer. Obstet Gynecol. 2010 Sep;116(3):733-43.