All Publications

  • Pelvic organ prolapse recurrence after pregnancy following uterine-sparing prolapse repair: a systematic review and meta-analysis. International urogynecology journal Andebrhan, S. B., Caron, A. T., Szlachta-McGinn, A., Parameshwar, P. S., Jackson, N. J., Rosenman, A. E., Anger, J. T., Ackerman, A. L. 2022


    INTRODUCTION: We sought to determine rates of pelvic organ prolapse (POP) recurrence following pregnancy and delivery in reproductive-age women with prior hysteropexy.METHODS: Scopus, MEDLine, EMBASE, Cochrane Library, and databases were searched from inception to May 2020 for combinations of any of the keywords: "pregnancy", "delivery", "fertility", or "cesarean" with a comprehensive list of uterine-sparing surgical procedures for POP repair. Using approach, 1,817 articles were identified describing surgical, uterine-sparing POP repair techniques and subsequent pregnancy and deliveryoutcomes in reproductive-age women. RESULTS: Twenty-seven studies describing 218 pregnancies, including 215 deliveries and 3 abortions, were summarized using narrative review and descriptive statistics. Successful pregnancies were reported following a diverse range of uterine-sparing prolapse repairs, both native tissue and mesh-augmented, that utilized vaginal, open abdominal, and laparoscopic approaches. We observed shifts from native tissue repairs to mesh-augmented laparoscopic repairs over time. POP recurrence occurred in 12% of subjects overall, 15% after vaginal and 10% after abdominal prolapse repairs. While meta-analysis identified higher recurrence rates after vaginal delivery (15%) than cesarean section (10%), due to small study numbers, multiple confounders, and heterogeneity between studies, no significant differences in recurrence rates could be identified between vaginal and abdominal surgical approaches, utilization of mesh augmentation, or mode of delivery.CONCLUSION: Although literature on pregnancy following uterine-sparing POP repair is limited, available data suggest that prolapse recurrence after pregnancy and delivery remains similar to that after prolapse repair without subsequent pregnancies with few documented perinatal complications.SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021247722.

    View details for DOI 10.1007/s00192-022-05306-2

    View details for PubMedID 35920935

  • Mixed methods evaluation of simulation-based training for postpartum hemorrhage management in Guatemala. BMC pregnancy and childbirth Parameshwar, P. S., Bianco, K., Sherwin, E. B., Meza, P. K., Tolani, A., Bates, P., Sie, L., Lopez Enriquez, A. S., Sanchez, D. E., Herrarte, E. R., Daniels, K. 2022; 22 (1): 513


    BACKGROUND: To assess if simulation-based training (SBT) of B-Lynch suture and uterine balloon tamponade (UBT) for the management of postpartum hemorrhage (PPH) impacted provider attitudes, practice patterns, and patient management in Guatemala, using a mixed-methods approach.METHODS: We conducted an in-country SBT course on the management of PPH in a governmental teaching hospital in Guatemala City, Guatemala. Participants were OB/GYN providers (n=39) who had or had not received SBT before. Surveys and qualitative interviews evaluated provider knowledge and experiences with B-Lynch and UBT to treat PPH.RESULTS: Multiple-choice surveys indicated that providers who received SBT were more comfortable performing and teaching B-Lynch compared to those who did not (p=0.003 and 0.005). Qualitative interviews revealed increased provider comfort with B-Lynch compared to UBT and identified multiple barriers to uterine balloon tamponade implementation.CONCLUSIONS: Simulation-based training had a stronger impact on provider comfort with B-Lynch compared to uterine balloon tamponade. Qualitative interviews provided insight into the challenges that hinder uptake of uterine balloon tamponade, namely resource limitations and decision-making hierarchies. Capturing data through a mixed-methods approach allowed for more comprehensive program evaluation.

    View details for DOI 10.1186/s12884-022-04845-2

    View details for PubMedID 35751071

  • Using Prompted Reflective Writing to Demonstrate Learning of Physician Competencies during Global Clinical Rotations. The American journal of tropical medicine and hygiene Wells, T., Parameshwar, P., Marais, H., Hoffman, R., Arora, G. 2022


    Global health education programs have grown in number and rigor with the development of learning objectives, competency frameworks, and assessment tools. This study aimed to assess whether prompted reflective writing could demonstrate medical student learning of physician competencies during global clinical rotations. From 2014 to 2018, 135 medical students who participated in global health clinical rotations responded to four reflective writing prompts. We conducted qualitative content analysis of 487 individual responses using grounded theory and an iterative process to identify themes associated with the eight American Association of Medical College physician competency domains. In response to prompted reflective writing assignments, students demonstrated learning related to all eight competencies. They reflected on systems-based practice while also sharing their growth in knowledge and skills related to personal and professional development, knowledge for practice, interprofessional collaboration, and patient care. In demonstrating practice-based learning and improvement, students additionally reflected on how the experiences during their global clinical rotations might influence their future careers as physicians. Our findings suggest that prompted reflective writing during global clinical rotations allows medical students to demonstrate learning in the competency domains expected of all physician trainees and to reflect on the application of this learning to current and future patient care. In reading students' writings, we found that prompted reflective writing during global clinical rotations offers an opportunity for students to illustrate the knowledge and skills they have acquired as physicians in training.

    View details for DOI 10.4269/ajtmh.21-0485

    View details for PubMedID 35292590

  • Writing in the Margins of Sexual Function Questionnaires: A Qualitative Analysis of Data From Women With Pelvic Floor Disorders. The journal of sexual medicine Parameshwar, P. S., Borok, J. F., Jung, E. E., Thum, L. W., Ackerman, A. L., Eilber, K. S., Anger, J. T. 2020


    BACKGROUND: The impact of pelvic floor disorders (PFDs) on female sexual function is not well understood, partly due to difficulties in measurement and evaluation.AIM: We sought to assess how women with PFDs respond to sexual function questionnaires through an analysis of survey marginalia, or the comments written in the margins of fixed-choice surveys.METHODS: 94 women with PFDs completed validated written sexual function questionnaires (Global Study of Sexual Attitudes and Behaviors survey, Female Sexual Function Index, and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised). Marginalia, or the additions, eliminations, and changes subjects made (by hand) to survey items, were collected. Data were coded and analyzed qualitatively using grounded theory methodology.OUTCOMES: Themes and emergent concepts related to the content of survey marginalia were the primary outcomes of this study.RESULTS: We observed 177 instances of marginalia across all questionnaires. Qualitative analysis revealed 7 preliminary themes and 2 emergent concepts. Preliminary themes included partner-related topics, loss, problems during intercourse, emotional problems, other medical problems, and survey answer choices failing to capture the spectrum of patient experiences. Emergent concepts revealed highly diverse sexual function in this population and a wide range of factors that influence sexual function.CLINICAL IMPLICATIONS: Conducting qualitative studies alongside sexual function questionnaires can allow for a more meaningful assessment of the sexual function of women with various underlying conditions, such as PFDs.STRENGTHS & LIMITATIONS: This is the first study of its kind to analyze survey marginalia from sexual function questionnaires among women with PFDs. The limitations of this study include the inherently spontaneous nature of marginalia data. In addition, the ways in which study participants responded to sexual function questionnaires in our study may not be reflective of all potential subjects.CONCLUSION: Analysis of survey marginalia from sexual function questionnaires amongst women with PFDs revealed new information regarding patients' histories, concerns, and thoughts. Over half of the women in this study felt the need to expand, explain, or eliminate responses from the questionnaires. Many subjects were no longer sexually active, which accounted for a large majority of participants leaving questions blank or responding with "N/A." Standard sexual evaluation tools may fail to capture the complexity, spectrum, and depth and breadth of patient experiences. Parameshwar PS, Borok J, Jung E, etal. Writing in the Margins of Sexual Function Questionnaires: A Qualitative Analysis of Data From Women With Pelvic Floor Disorders. J Sex Med 2020;XX:XXX-XXX.

    View details for DOI 10.1016/j.jsxm.2020.06.003

    View details for PubMedID 32694067

  • World Health Organization Guidance on Ethical Considerations in Planning and Reviewing Research Studies on Sexual and Reproductive Health in Adolescents JOURNAL OF ADOLESCENT HEALTH Singh, J., Siddiqi, M., Parameshwar, P., Chandra-Mouli, V. 2019; 64 (4): 427–29

    View details for PubMedID 30904091

  • Outcomes of pregnancy following surgery for pelvic organ prolapse: a systematic review Caron, A., Ackerman, A., Parameshwar, P., Eilber, K., Anger, J. WILEY. 2019: S226
  • Overuse of specialty care for women with urinary incontinence Burton, C. S., Gonzalez-Alabastro, C., Choi, E., Parameshwar, P., Gonzalez, G., Bresee, C., Eilber, K., Ackerman, A., Anger, J. T. WILEY. 2019: S72–S73
  • Symptomatic overlap in overactive bladder and interstitial cystitis/bladder pain syndrome: development of a new algorithm. BJU international Ackerman, A. L., Lai, H. H., Parameshwar, P. S., Eilber, K. S., Anger, J. T. 2018


    To address challenges in the diagnosis and classification of storage lower urinary tract symptoms (LUTS), we sought to define the fundamental features of overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), two conditions with considerable symptomatic overlap. Through retrospective comparison of self-reported symptoms in women with a range of clinical presentations and symptom severities, we have attempted to refine the diagnostic features of OAB and IC/BPS and to develop a novel clinical nomogram to improve patient screening and classification.We performed a univariate analysis comparing responses to the female Genitourinary Pain Index (fGUPI), the OAB Questionnaire and O'Leary-Sant Indices (the Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index) in an initial cohort of 50 patients with OAB, patients with IC/BPS and control subjects. Only eight questions differed significantly between the IC/BPS and OAB groups; we used five unique questions and three measuring bother to generate a novel composite scoring system and nomogram that included urgency incontinence, bladder pain and symptomatic bother domains to differentiate these populations, which was validated in a second cohort of 150 patients. The addition of a self-reported bother index resulted in the creation of a diagnostic algorithm to identify and classify LUTS clusters across the total population.While all validated questionnaires could distinguish between controls and patients with storage LUTS, no combined symptom scores differed significantly between the IC/BPS and OAB groups. These results are reflective of the prevalence of significant bladder pain (35%) in patients with OAB and the presence of urge incontinence (25%) in patients with IC/BPS. Only the fGUPI pain domain scores differed between patients in the OAB and IC/BPS groups, but it was not accurate enough for diagnostic evaluation (68% accuracy). Our composite scores and nomogram gave a much-improved diagnostic accuracy (94%) and demonstrated utility as a screening tool to identify storage LUTS in patients presenting for unrelated complaints, e.g. microhaematuria.There is significant overlap of urinary tract symptoms between OAB and IC/BPS. We present a novel algorithm that provides a binary output capable of guiding clinical diagnosis. Future studies aimed at assessing the diagnostic value of novel classification schemes that address symptoms rather than specific diagnoses may improve patient prognosis.

    View details for DOI 10.1111/bju.14568

    View details for PubMedID 30253040

  • Is it Safe to Reduce Water Intake in the Overactive Bladder Population? A Systematic Review. The Journal of urology Wood, L. N., Markowitz, M. A., Parameshwar, P. S., Hannemann, A. J., Ogawa, S. L., Anger, J. T., Eilber, K. S. 2018; 200 (2): 375-381


    Overactive bladder imposes a significant socioeconomic burden on the health care system. It is a commonly held belief that increased fluid intake (8 glasses of water per day) is beneficial for health. However, increased fluid intake exacerbates overactive bladder symptoms. Thus, it is imperative that clinicians appropriately educate patients for whom increased water intake may be detrimental (women with overactive bladder), in contrast to patients with comorbidities that necessitate increased water intake (nephrolithiasis). We systematically reviewed the literature to determine the potential health advantages of increased water intake and identify specific subpopulations that need increased hydration.We systematically reviewed published articles from 1972 through 2017 on PubMed® and the Cochrane Library. The data were reviewed independently by 2 individuals. Studies were included if they explored water intake in relation to the risk of a particular disease.Level 1 evidence supported increased fluid intake in patients with nephrolithiasis. There was no available evidence to support increased fluid intake in patients with cardiovascular disease, constipation, venous thromboembolism, headaches, cognitive function or bladder cancer. Dehydration may exacerbate some conditions, specifically chronic constipation and headache intensity. Increased fluid intake may have a role in preventing stroke recurrence but not in preventing primary stroke.The available reviewed literature suggests no benefit to drinking 8 glasses of water per day in patients without nephrolithiasis. Also, excess fluid intake can exacerbate symptoms of overactive bladder.

    View details for DOI 10.1016/j.juro.2018.02.3089

    View details for PubMedID 29499207

  • THEMATIC CONTENT ANALYSIS OF ONLINE PHYSICIAN REVIEWS IN UROLOGY Moradzadeh, A., Parameshwar, P., Houman, J., Daskivich, T., Anger, J. ELSEVIER SCIENCE INC. 2018: E1180
  • Online Physician Reviews in Female Pelvic Medicine and Reconstructive Surgery: What Do Patients Really Want? Female pelvic medicine & reconstructive surgery Asanad, K., Parameshwar, P. S., Houman, J., Spiegel, B. M., Daskivich, T. J., Anger, J. T. 2018; 24 (2): 109-114


    This study aimed to qualitatively analyze online reviews of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialists to better understand patients' experiences and improve patient satisfaction.Fifty urologists and urogynecologists were randomly sampled from the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction membership website. We evaluated patient ratings and reviews of physicians from 4 websites: Yelp, Healthgrades, Vitals, and UCompareHealthCare. Qualitative data analysis was performed using grounded theory methodology, as described by Charmaz (Constructing Grounded Theory, 2014).Across the four websites, the mean number of stars per physician ranged from 3.6 to 4.1 and the mean number of reviews per physician ranged from 1.3 to 7.6. Qualitative analysis revealed several preliminary themes: patient-physician experience, medical and surgical treatment, office staff, and analysis of worth. Physicians who developed strong connections with patients through empathetic communication were likely to receive a positive review, regardless of wait times. Bedside manner was found to be multidimensional and included physician competence and understanding patients' concerns. Failure to meet several expectations led to dissatisfaction of care and negative patient reviews.Patients' perspectives of quality of care in FPMRS are weighted heavily toward establishing personal connections with physicians. Accurate diagnosis and effective management of urological conditions, especially after negative experiences with previous providers, were associated with satisfaction of care. It seems that the concept of good bedside manner is multifactorial and requires the provider to demonstrate not one but several different sets of communication skills.

    View details for DOI 10.1097/SPV.0000000000000503

    View details for PubMedID 29474282

  • Diagnosis and treatment of patients with prostatic abscess in the post-antibiotic era. International journal of urology : official journal of the Japanese Urological Association Ackerman, A. L., Parameshwar, P. S., Anger, J. T. 2018; 25 (2): 103-110


    We reviewed the pathogenesis, clinical presentation, treatment options and outcomes of prostatic abscess in the post-antibiotic era, focusing on how patient risk factors and the emergence of multidrug-resistant organisms influence management of the condition. A MEDLINE search for "prostate abscess" or "prostatic abscess" was carried out. Prostate abscess is no longer considered a consequence of untreated urinary infection; now, men with prostatic abscess are typically debilitated or immunologically compromised, with >50% of patients having diabetes. In younger men, prostatic abscess can be the initial presentation of such chronic conditions. In older men, prostatic abscess is increasingly a complication of benign prostatic hyperplasia or prostate biopsy. Diagnosis is based on a physical examination, leukocytosis, leukocyturia and transrectal ultrasound, with magnetic resonance imaging serving as the preferred confirmatory imaging modality. Treatment of prostatic abscess is changing as a result of the emergence of atypical and drug-resistant organisms, such as extended-spectrum β-lactamase-producing enterobacteriaceae and methicillin-resistant Staphylococcus aureus. As many as 75% of infections are resistant to first-generation antibiotics, necessitating aggressive therapy with broad-spectrum parenteral antibiotics, such as third-generation cephalosporins, aztreonam or antibiotic combinations. A total of 80% of patients require early surgical drainage, frequently through a transurethral approach. In the post-antibiotic era, prostatic abscess is evolving from an uncommon complication of urinary infection to a consequence of immunodeficiency, growing antibiotic resistance and urological manipulation. This condition, primarily affecting patients with chronic medical conditions rendering them susceptible to atypical, drug-resistant organisms, requires prompt aggressive intervention with contemporary antibiotic therapy and surgical drainage.

    View details for DOI 10.1111/iju.13451

    View details for PubMedID 28944509

  • A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it. Reproductive health Chandra-Mouli, V., Parameshwar, P. S., Parry, M., Lane, C., Hainsworth, G., Wong, S., Menard-Freeman, L., Scott, B., Sullivan, E., Kemplay, M., Say, L. 2017; 14 (1): 85


    Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a "never-before" opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights.In this commentary, we call for action in several key areas to address adolescents' persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a 'condoms-only' mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents.This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.

    View details for DOI 10.1186/s12978-017-0347-9

    View details for PubMedID 28728586

    View details for PubMedCentralID PMC5520341

  • Cystathionine: A novel oncometabolite in human breast cancer. Archives of biochemistry and biophysics Sen, S., Kawahara, B., Mahata, S. K., Tsai, R., Yoon, A., Hwang, L., Hu-Moore, K., Villanueva, C., Vajihuddin, A., Parameshwar, P., You, M., Bhaskar, D. L., Gomez, O., Faull, K. F., Farias-Eisner, R., Chaudhuri, G. 2016; 604: 95-102


    In this study, we have identified cystathionine (CTH), a sulfur containing metabolite, to be selectively enriched in human breast cancer (HBC) tissues (∼50-100 pmoles/mg protein) compared with undetectable levels in normal breast tissues. The accumulation of CTH, specifically in HBC, was attributed to the overexpression of cystathionine beta synthase (CBS), its synthesizing enzyme, and the undetectable levels of its downstream metabolizing enzyme, cystathionine gamma lyase (CGL). Interestingly both CBS and CGL could not be detected in normal breast tissues. We further observed that CTH protected HBC cells against excess reactive oxygen species (ROS) and chemotherapeutic drug-induced apoptosis. Moreover, CTH promoted both mitochondrial and endoplasmic reticulum homeostasis in HBC cells. As both the mitochondria and the endoplasmic reticulum are key organelles regulating the onset of apoptosis, we reasoned that endogenous CTH could be contributing towards increasing the apoptotic threshold in HBC cells. An increased apoptotic threshold is a hallmark of all cancer types, including HBC, and is primarily responsible for drug resistance. Hence this study unravels one of the possible pathways that may contribute towards drug resistance in HBC.

    View details for DOI 10.1016/

    View details for PubMedID 27311614