American Urogynecologic Society

Ten Things Physicians and Patients Should Question

tems 1–5 Released May 5, 2015; Items 6–10 Released June 24, 2020

  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.

  6. 6

    Do not perform surgery for asymptomatic vaginal exposure of monofilament mesh.

    Vaginal exposure of mesh used in surgery for the treatment of pelvic organ prolapse or urinary incontinence is a known complication of such surgeries. Although symptomatic exposure may require treatment, evidence suggests that asymptomatic mesh exposure can be safely watched without surgery to avoid the risks and complications associated with surgery for mesh exposure. Longitudinal expectant management is a reasonable alternative.

  7. 7

    Avoid presumptive antibiotic treatment of recurrent UTIs in women without first obtaining a UA C&S

    Supporting statement: Although women with uncomplicated, infrequent UTIs can be treated empirically based on symptoms, women with recurrent
    UTIs (≥3 UTIs in one year, or ≥2 in 6 months) should have a pretreatment urine specimen to document episodes and guide treatment. The use of vaginal, but not oral, estrogen in postmenopausal women is effective in reducing recurrent cystitis and should be used whenever possible. Infectious
    Diseases Society of America guidelines regarding cystitis should dictate treatment, accounting for antimicrobial resistance and potential ecological
    adverse effects.

  8. 8

    Do not routinely perform cystoscopy or imaging in asymptomatic, never-smoking women younger than 50 years with microscopic hematuria who have less than 25 RBC/HPF.

    Asymptomatic hematuria in women is common but less likely to be associated with a urinary tract malignancy compared to men. Data support
    changing the evaluation requirements for microscopic hematuria in this low-risk group of women. Organizations which do not risk-stratify based
    on gender may continue to recommend more aggressive diagnostic evaluation in low-risk women.

  9. 9

    Avoid using anticholinergic medication to treat overactive bladder in women older than 70.

    Anticholinergic medications block acetylcholine at muscarinic receptors, which are present throughout the body. These medications have many side
    effects, including impaired cognition, drowsiness and constipation.” Several cohort studies have raised concern regarding an association between
    higher exposure to anticholinergics and increased risk of dementia. Given this, beta-3 agonists or 3rd line therapies should be preferentially utilized
    when possible. When anticholinergics cannot be avoided, the lowest effective dose of anticholinergic should be used, and consideration should be
    given to decreasing the dose of other concurrent anticholinergic medications

  10. 10

    Do not perform multichannel urodynamics in women with uncomplicated stress urinary incontinence.

    Women with uncomplicated stress urinary incontinence should undergo a thorough evaluation and screening that includes the following: a comprehensive history and physical, demonstration of stress incontinence, urinalysis, assessment of urethral mobility, and measurement of post
    void residual. If results of that screening are normal, and conventional non-surgical treatment fails, then mid-urethral sling surgery can be performed
    without further testing. Multichannel urodynamics have not been shown to affect surgical treatment outcomes in women with uncomplicated stress
    urinary incontinence.

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.

For more information or questions, please visit www.augs.org.

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 www.augs.org/about.

Sources

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

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  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.

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    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.

  6. American College of Obstetrics & Gynecology Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstetrics & Gynecology.2017 Apr;129(4):e102-8.

    Deffieux X, Thubert T, de Tayrac R, Fernandez H, Letouzey V. Long-term follow-up of persistent vaginal polypropylene mesh exposure for transvaginally placed mesh procedures. International Urogynecology Journal 2012 Oct; 23:1387-90.

    Kobashi KC, Govier FC. Management of vaginal erosion of polypropylene mesh slings. Journal of Urology. 2003 Nov;169: 2242-3.

  7. ResourcesBrubaker L, Carberry C, Nardos R, Carter-Brooks C, Lowder JL. American Urogynecologic Society Best-Practice Statement: Recurrent Urinary Tract Infection in Adult Women. Female Pelvic Medicine & Reconstructive Surgery 2018 Sep/Oct:24(5):321-335.

    Anger J, Lee U, Ackerman AL, Chou R, Chughtai B, Clemons JQ, Hickling D, Kapoor A, Kenton KS, Kaufman MR, Rondanina MA, Stapleton A, Stothers L, Chai TC. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. 2019 Aug:202(2):282-89.

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    Gupta K, Hooton TM, Naber K, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases 2011 Mar;52(5):e103–e120.

  8. Committee Opinion No. 703: Asymptomatic Microscopic Hematuria in Women. Obstetrics & Gynecology 2017 Jun;129(6):1153-4.

    American Urogynecologic Society Systematic Review: Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women. Jeppson PC, Jakus-Waldman S1, Yazdany T2, Schimpf MO3, Ferzandi TR4, Yurteri-Kaplan LA5, Knoepp L6, Mamik M7, Resnick HE8, Ward RM9; American Urogynecologic Society Systematic Review Committee.Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, Messing EM, Miller SD, Peterson AC, Turk TM, Weitzel W; American Urological Association. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. Journal of Urology. 2012 Dec;188(6 Supplement):2473-81. (reviewed and reaffirmed in 2016)

    Lippmann QK, Slezak JM, Menefee SA, Ng CK, Whitcomb EL, Loo RK. Evaluation of microscopic hematuria and risk of urologic cancer in female patients. American Journal of Obstetrics & Gynecology 2017 Feb;216:146.e1–7.

    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CAL Cancer Journal for Clinicians 2017 Jan;67:7–30.

  9. ResourcesAmerican Association of Urogynecologic Surgery Consensus Statement: Association of Anticholinergic Medication Use and Cognition in Women with Overactive Bladder. Female Pelvic Medicine & Reconstructive Surgery. 2017 May/June;23(3):177-178.

    Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R, Yu O, Crane PK, Larson EB. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. Journal of the American Medical Association Internal Medicine 2015 Mar;175:401–407.

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    Coupland CAC1, Hill T1, Dening T2, Morriss R2, Moore M3, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study.

    JAMA Intern Med. 2019 Jun 24. doi: 10.1001/jamainternmed.2019.0677.

    Welk B, McArthur E. Increased risk of dementia among patients with overactive bladder treated with an anticholinergic medication compared to a beta-3 agonist: a population-based cohort study. BJU Int. 2020 Mar 13. doi: 10.1111/bju.15040.

    Wang YC, Chen YL, Huang CC.Cumulative use of therapeutic bladder anticholinergics and the risk of dementia in patients with lower urinary tract symptoms: a nationwide 12-year cohort study. BMC Geriatr. 2019 Dec 30;19(1):380. doi: 10.1186/s12877-019-1401-y.

    Andre L, Gallini A, Montastruc F. Association between anticholinergic drug exposure and cognitive function in longitudinal studies among individuals over 50 years old: a systematic review.Eur J Clin Pharmacol. 2019 Dec;75(12):1631-1644. doi: 10.1007/s00228-019-02744-8. Epub 2019 Aug 29.

  10. Committee Opinion No. 603: Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment. Obstetrics & Gynecology. 2014 Jun;123(6):1403-7.

    Nager CW, Brubaker L, Litman HJ, Zyczynski HM, Varner RE, Amundsen C, Sirls LT, Norton PA, Arisco AM, Chai TC, Zimmem P, Barber MD, Dandreo KJ, Menafee SA, Kenton K, Lowder J, Richter HE, Khandwala S, Nygaard I, Kraus SR, Johnson HW, Lemack GE, Mihova M, Albo ME, Mueller E, Sutkin G, Wilson TS, Hsu Y, Rozanski TQ, Rickey LM, Rahn D, Tennstedt S, Kusek JW, Gormley EA: Urinary Incontinence Treatment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. New England Journal of Medicine 2012 May;366(21):1987-97.