In 2011, the American Board of Medical Specialties (ABMS) approved the Urogynecology and Reconstructive Pelvic Surgery (URPS) fellowship program, a joint initiative by the American Board of Obstetrics and Gynecology (ABOG) and the American Board of Urology (ABU) (1). This fellowship program is accessible to OB-GYNs and urologists, with accreditation by ABOG or ACU varying among individual programs. Despite the URPS fellowship being a joint endeavor, the residency and fellowship curricula for OB-GYNs and urologists exhibit significant variation. In fact, one study found that despite stating that they accept gynecology or urology-trained applicants, few graduates originate from outside their respective specialties (2). Differences in residency education may consequently lead to variations in clinical practice. We propose that such differences in training may lead to specialty-specific differences in the management of pelvic organ prolapse (POP), with urology-trained urogynecologists more inclined towards surgical interventions and gynecology-trained urogynecologists favoring non-surgical approaches such as pessaries. Given the scarcity of data in this area, this study aims to explore trends in both surgical and non-surgical treatments for POP within a Urology/Urogynecology academic practice employing physicians trained in both gynecology and urology.

In our Urology/Urogynecology academic practice, we identified four urogynecologists who treat POP. Two of these physicians completed residency in urology, and two completed residency in gynecology. We then identified patients seen by the 4 aforementioned physicians from January 2011 through September 2022 who had POP ICD 9 and 10 codes and had CPT codes for pessary placement or prolapse surgery. Physician training type, type of prolapse, date(s) of the procedures, and type of treatments (no intervention, pessary alone, surgery alone, or pessary and then surgery) were collected through chart review.  Continuous variables were analyzed using the t-test and categorical variables were analyzed using the chi-squared test. Our study did not receive external funding of the study or grants. Ethical approval was given by our university-affiliated Institutional Review Board.

We identified 1795 patients diagnosed with pelvic organ prolapse treated with either pessary or surgery over a span of 12.75 years. Overall, 1579 (88%) of patients saw gynecology-trained urogynecologists and 216 (12%) saw urology-trained urogynecologists. In our cohort, gynecology-trained urogynecologists had a 92.0% rate of surgical treatment for POP, while urology-trained urogynecologists had an 85.2%  rate of surgical treatment management (p=0.0010). Furthermore, gynecology-trained urogynecologists had a 10.4% rate of pessary use, while urology-trained urogynecologists had a 21.8% rate of pessary use (p<0.0001). Of the 54 patients treated with both pessary and surgery, 47 (87.0%) had pessary first followed by subsequent surgical treatment. Of those treated with pessary followed by surgery, there was no statistically significant difference in rate by provider type (p=0.4139).

Our results indicate that at our Urology/Urogynecology academic practice, patients treated by gynecology-trained physicians were less likely to be managed with pessary than with surgical treatment compared to patients treated by urology-trained physicians. Instead, gynecology-trained urogynecologists had a 6.8% higher rate of surgical management of POP compared to urology-trained urogynecologists and an 11.4% lower rate of pessary use compared to urology-trained urogynecologists. Our results indicate that physicians trained in urology may be more likely to pursue non-surgical management of POP compared to gynecologists. Further research is needed across a wider subset of urology and gynecology-trained physicians to better quantify trends, as our study is limited to four physicians total and may reflect trends specific to individuals as opposed to specialty training.
 
Data is mixed as to whether management of POP with pessary or surgery leads to better outcomes, with some studies citing greater symptom control with surgery and a frequent need for later surgical management after an initial pessary trial (3). These findings align with our conclusion that 22% (47) of our 212 patients who were treated with pessary first subsequently underwent surgical treatment for POP. Despite these results, ample literature underscores significant improvements in POP-related symptoms from baseline with pessary or surgical treatment. Treatment choice therefore should be a collaborative discussion between the patient and their provider. Our results may help patients choose providers who are more likely to meet their individual care goals, whether those be surgical or non-surgical.

In summary, our results indicate that urology-trained urogynecologists may be more likely to offer pessary, a non-surgical treatment for POP, compared to gynecology-trained urogynecologists. Further research is needed across a greater number of urogynecologists to evaluate trends in POP treatment by specialty of residency training. Additionally, the next step in our study is to collect and analyze demographic data to see how this influences treatment pathways.

1.	The American Board of Urology. URPS subspecialty. Charlottesville, VA: The American Board of Urology;(n.d.). Available from: https://www.abu.org/certification/subspecialties/urps-subspeciality. Accessed March 29, 2024.
2.	Gerjevic KA, Brandes E, Gormley EA, Auty SG, Strohbehn K. Trends Among Female Pelvic Medicine and Reconstructive Surgery Fellowships and Graduates. Female Pelvic Med Reconstr Surg. 2022;28(6):e211-e214. doi:10.1097/SPV.0000000000001186
3.	van der Vaart LR, Vollebregt A, Milani AL, et al. Pessary or surgery for a symptomatic pelvic organ prolapse: the PEOPLE study, a multicentre prospective cohort study. BJOG. 2022;129(5):820-829. doi:10.1111/1471-0528.16950

Continence 12S (2024) 101499
DOI: 10.1016/j.cont.2024.101499