The desire for enhancement of the appearance of the genitalia is becoming more in demand, especially with the substantial amount of direct consumer marketing that promises improved sexual experiences. Accordingly, numerous techniques have been devised with varying complexity and variable outcomes especially in regard to cosmesis. Despite the visible enhancements, some techniques may negatively impact the sexual and psychological status of the patient, especially if postoperative complications are encountered. The appropriate selection of the enhancement technique as well as the knowledge of management of complications regarding each technique is crucial for improving patient outcomes and satisfaction.

Purpose/Objective: Mixed urinary incontinence (MUI) is the coexistence of stress urinary incontinence (SUI) and urge urinary incontinence (UUI). MUI can be a challenging condition to treat, and there continues to be a demand for successful nonsurgical interventions if possible. This study evaluates the efficacy of combining bipolar radiofrequency (RF) energy to the vaginal canal, electrical muscle stimulation (EMS) of the pelvic floor, and patient education in the treatment of MUI in females.Methods: A prospective study that evaluates RF and EMS in female patients with moderate MUI. RF and EMS treatments were administered three times, 2 weeks apart. Patients were also educated on exactly what MUI is and how to appropriately utilize their pelvic floor muscles. Outcome measures assessed included both objective (cough stress test to measure pad weight) and subjective (Incontinence Quality of Life [iQOL]; Medical, Epidemiological, and Social Aspects of Aging [MESA] Urge Incontinence [UI], MESA Stress Incontinence [SI], Female Sexual Function Index [FsFI]; and Urogenital Distress Inventory-6 [UDI-6]).Results: In total, 31 women underwent the combination of RF, EMS, and patient education, resulting in significant improvement in MUI symptoms (PGI: 82% indicated feeling improvement) after 3 months of treatment in all measures.Conclusion: RF and EMS in conjunction with patient education via a three-treatment protocol was found to be efficacious and safe for treating women with MUI. Future studies should be done to further elucidate optimal treatment protocols for MUI and patients followed up for longer periods of time to determine the durability of this regimen.

Background: It is difficult to assess if the evaluation and treatment of female sexual dysfunction (FSD) has progressed. In 2003, the American Urogynecology Society (AUGS) surveyed members to measure practice patterns for FSD. Our objective was to administer a similar survey to current members of AUGS and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) to evaluate existing practice patterns. Methods: An electronic survey was administered to SUFU and AUGS members. The results were compared to prior survey results from 2003. Results: A total of 187 physicians responded. The majority were female (75%) and at an academic or university-based practice (54%). Twenty percent of current members consider FSD screening to be extremely important versus 9% in 2003 (P=0.002). The most common reason for not screening was time constraints. Current practitioners report not screening because they do not know how/what to ask, whereas in 2003 physicians were more unsure about therapeutic options (P<0.001). In regards to post residency training, 36% were less than satisfied, significantly improved compared from 50% (P<0.001). Females were more likely to screen for FSD (P=0.012) compared to males. Those who were at least "very satisfied" with their training were more likely to screen (P=0.019). 87% of physicians would refer patients to an interactive phone application about FSD. Conclusions: Screening patterns and barriers to treatment of FSD have minimally improved over the last 20 years. Many trainees continue to feel unsatisfied with FSD education. Phone applications about FSD may be a good resource in the future.

Objective: This study compared the outcomes of the bulking agent polyacrylamide hydrogel (PAHG) with a single-incision sling (SIS) for treating occult stress urinary incontinence (SUI) in association with vaginal prolapse surgery.Methods: This was a retrospective study of patients who underwent transvaginal surgical correction of pelvic organ prolapse and received either SIS or urethral bulking with PAHG for occult SUI. Demographic and perioperative data were extracted from the charts. The primary outcomes were Urinary Distress Inventory-6 (UDI-6) scores, Incontinence Impact Questionnaire-7 (IIQ-7) scores, and incontinence episodes documented by 3-day bladder diaries collected 24 months after surgery. Secondary outcomes included complications such as adverse events, rates of urine retention with prolonged catheterization, and urinary-tract infections.Results: Thirty patients had the bulking agent using PAHG with the prolapse surgery for occult incontinence and 23 patients has SIS. Twenty-two patients from each group completed the postoperative questionnaires. UDI-6 scores were low in both groups with bulking versus SIS value (19 versus 11; p = 0.096). The stress subscale median value for bulking versus SIS was 33 versus 0; p = 0.009. IIQ-7 median value was 0 for both groups. The median Foley catheter duration for the bulking group versus the SIS group was 1 versus 5 days (p = 0.015).Conclusions: SIS and PAHG were equally satisfactory for treating occult SUI with similar total UDI-6 and IIQ-7 scores; yet, the UDI-6 stress subscale was significantly better for the SIS group, but with more short-term voiding dysfunction. (J GYNECOL SURG 20XX:000)

Background: Genitourinary syndrome of menopause (GSM) is a prevalent condition with a constellation of symptoms including burning, dryness, dyspareunia, and irritative lower urinary tract symptoms that result from vulvovaginal atrophic changes. Though hormonal therapy is a mainstay of treatment in GSM, some patients may pursue nonhormonal therapies. Aim: To determine the efficacy of radiofrequency ablation of the vaginal canal with the MorpheusV applicator in reducing the symptoms of GSM. Methods: We conducted a multicenter prospective case series of women with GSM as confirmed by Vaginal Health Index Score (VHIS). Subjects received 3 treatments of radiofrequency ablation similar to 4 weeks apart with follow-up to 6-month posttreatment. Outcomes: The primary endpoint was VHIS at 6-month posttreatment. Secondary endpoints were VHIS at 3 months, Visual analog scale (VAS) pain with each treatment, 3- and 6-month measurements of urogenital distress inventory-6 (UDI-6), and female sexual function index (FSFI) questionnaires. Results: From 2021 to 2023, 71 women were enrolled in the study with 51 followed to the 6-month follow-up time point. Treatments were found to be low in VAS pain score with mean values of 2.13 +/- 2.1, 2.55 +/- 2.38, and 2.18 +/- 2.14 at treatments 1, 2, and 3 respectively. An improvement in VHIS score was seen from baseline to 3 months after the last treatment (15.00 +/- 5.37 vs. 19.62 +/- 4.44) and sustained at 6 months (20.23 +/- 4.12) (P < .001). Significant improvements in both UDI-6 and FSFI were also noted. Between baseline and 6 months after treatment (FSFI: 18.81 +/- 9.57 vs. 22.81 +/- 10.34, P < 0.001; UDI-6: 39.58 +/- 15.98 vs. 22.42 +/- 14.03, P < 0.001). No adverse events were encountered by any subject during this study. Clinical implications: A therapy that is safe and effective in the treatment of both GSM and lower urinary tract symptoms without the use of hormonal methods is clinically impactful for the many patients who cannot receive or do not desire to receive these medications. Strengths and limitations: Strengths of this study include the utilization of 3 treatment sessions, with follow-up of subjects to 6-month posttreatment with a comprehensive assessment of patient symptoms. Limitations include the unblinded nature of the study and the lack of a comparator group. Conclusion: The data from this study suggests that radiofrequency ablation of the vaginal canal by the MorpheusV applicator is a safe and effective intervention for GSM. It also shows subjective improvements in stress urinary incontinence, urge urinary incontinence, and sexual function.

AIMS:This study aimed to determine the efficacy and safety of iltamiocel investigational autologous muscle cell therapy in females with stress urinary incontinence (SUI). METHODS:Adult females were randomized 2:1 to iltamiocel (150 × 106 cells) or placebo and stratified by severity and prior SUI surgery. The primary objective was efficacy based on the frequency of stress incontinence episodes (SIE) recorded in a 3-day diary at 12 months posttreatment. After 12 months, placebo participants could elect to receive open-label iltamiocel. Efficacy and safety analyses were performed using all patients as treated populations. RESULTS:The study enrolled 311 patients, 297 were randomized to either iltamiocel (n = 199) or placebo (n = 98). Of the 295 participants that completed 12 months blinded follow-up, the proportion achieving the primary endpoint of ≥ 50% SIE reduction was not statistically different between treatment groups (52% vs. 53.6%; p = 0.798). A significantly greater proportion of iltamiocel participants in the prior SUI surgery stratum group achieved ≥ 75% SIE reduction compared with placebo, (40% vs. 16%; p = 0.037). Treatment response was maintained at 24 months in 78.4% and 64.9% of iltamiocel participants who achieved ≥ 50% and ≥ 75% SIE reduction, respectively, at Month 12. Adverse events related to the treatment were reported in 19 (9.5%) iltamiocel participants and 6 (6.1%) placebo participants. CONCLUSION:The study did not meet its primary endpoint however, iltamiocel cell therapy is safe and may be ideally suited to female patients who have undergone prior surgery for SUI. Additional study in this group of patients with high unmet medical needs is warranted. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT01893138; EudraCT number: 2014-002919-41.

You have accessJournal of UrologyCME1 Apr 2023PD26-05 FEMALE SEXUAL DYSFUNCTION: PRACTICE PATTERNS & PATIENT EDUCATION AMONG SUFU AND AUGS MEMBERS Poone Shoureshi, Alexandra Dubinskaya, Catherine Bresee, Mickey Karram, and Karyn S. Eilber Poone ShoureshiPoone Shoureshi More articles by this author , Alexandra DubinskayaAlexandra Dubinskaya More articles by this author , Catherine BreseeCatherine Bresee More articles by this author , Mickey KarramMickey Karram More articles by this author , and Karyn S. EilberKaryn S. Eilber More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003304.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The evaluation and treatment of female sexual dysfunction (FSD) has been slow to progress. In 2004, the American Urogynecology Society (AUGS) surveyed its members to assess practice patterns for FSD. The objective of this study was to administer a similar survey to current members of AUGS and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) to evaluate existing practice patterns. METHODS: An electronic survey based on a prior survey administered to AUGS members in 2004 was distributed to current SUFU and AUGS members. The results were compared. RESULTS: 187 physicians responded. The majority were female (75%). Respondent experience was<5 years in practice (25%), 5-10 years (20%), 11-20 years (17%), >20 years (22%), or currently in fellowship (16%). Fifty-four percent were at an academic or university-based practice. Physicians assessed FSD by asking about sexual activity (89%), dyspareunia (89%), arousal (33%), libido (29%), and orgasm (21%), while few reported using validated questionnaires (19%). Most physicians (54%) responded they perceived the overall incidence of FSD ranged 21-50%. Screening practices and barriers are listed in Table 1 and compared to the responses from AUGS members in 2004. The majority of current responders had post-residency training (84% vs. 59% in 2004, p<0.001). 20% of current members consider FSD screening to be extremely important versus 9% in 2004 (p=0.002). Most common reason for not screening was time constraints. Current practitioners also report not screening because they do not know how/what to ask, whereas in 2004 physicians were more unsure about therapeutic options (p<0.001). In regards to post residency training, 52% were less than satisfied, significantly improved compared to 71% in 2004 (p<0.001). Eighty-seven percent of current AUGS/SUFU members would feel comfortable referring patients to an interactive phone application about FSD. CONCLUSIONS: Screening patterns and barriers to treatment of FSD have remained relatively unchanged over the last 18 years, with the most common barrier being time constraints. Many FPMRS/urogynecology trainees continue to feel unsatisfied with FSD training. In the future, phone applications may be a good resource when practitioners are uncomfortable or have a lack of time to discuss FSD. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e736 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Poone Shoureshi More articles by this author Alexandra Dubinskaya More articles by this author Catherine Bresee More articles by this author Mickey Karram More articles by this author Karyn S. Eilber More articles by this author Expand All Advertisement PDF downloadLoading ...

Objective: The goal of this research was to determine the efficacy of fractionated carbon dioxide (CO2) laser therapy for reducing symptoms of vulvar lichen sclerosus (LS).Materials and Methods: This was a prospective case series. The study participants were 23 women with active vulvar LS, confirmed via biopsy, who were abstaining from topical and systemic treatments for at least 4 weeks before enrollment. Subjects received 3-5 treatments with the CO2 laser, based on symptom improvements. The primary endpoint was a reduction by >50%, as shown by a composite examination-based and symptom-based score at 6 months post-treatment. A secondary endpoint was changes in the Vulvar Quality of Life Questionnaire and patient-supplied Patient Global Impression of Improvement (PGI) scores. A t-test was used to contrast pre-treatment and post-treatment changes in symptomsResults: From 2015 to 2020, 23 women participated in the study. The primary endpoint of >50% reduction in the composite symptom score was not significant; p = 0.08, although a reduction was significant at that time point; p = < 0.01. At 12 months a >50% reduction was significant; p = 0.03. Secondary outcomes were remarkable for significant reductions in symptoms that did not meet the >50% threshold at 6 and at 12 months. Mean satisfaction was 2.47 & PLUSMN; 0.61 on a 3-point scale and significantly positive PGI scores through the post-treatment follow-up time point.Conclusions: Exploration of fractionated CO2 for treating vulvar LS should be continued. (J GYNECOL SURG 20XX:000)

BackgroundThe United States currently faces a public health crisis with regarding to antibiotic-resistant bacteria, and new urinary tract infection (UTI) diagnostics are needed. Women with recurrent UTI (rUTI) and complicated UTI (cUTI) are at particular risk given their complexity and the paucity of adequate testing modalities. The standard urine culture (SUC) is the cornerstone for diagnosis, but it has many shortcomings. These pitfalls lead to dissatisfaction and frustration among women afflicted with rUTI and cUTI, as well as overuse of antibiotics. One innovation is PCR UTI testing, which has been shown to outperform SUC among symptomatic women.AimsThis article discusses UTI PCR testing, as well as a possible role in clinical practice.Materials and MethodsPublished literature was reviewed and summarized.ResultsManagement of rUTI and cUTI is complex, and providers should have all diagnostics available to facilitate providing optimal care. Urine PCR testing faces reimbursement issues despite fulfilling clinical indication parameters as described by insurance companies.DiscussionThe role of UTI PCR testing remains unclear. Reimbursement issues have led to underuse and limited real-world outcomes reinforcing benefit.ConclusionThis study proposes an algorithm for PCR testing among women with rUTI and cUTI.

Purpose: To describe the effects of consistent levels of testosterone in a pellet form and it's potential to reverse osteoporosis. Methods: This is a descriptive case report of a 54 year male with a spontaneous fracture and osteoporosis in the presence of what many consider a normal male testosterone level. Results: After discovering and documenting osteoporosis by DXA scan, the patient was shown to reverse the diagnosis of osteoporosis in a year on pelleted testosterone therapy. Consistent levels of 943 ng/dL were achieved; the patient also experienced improvements in quality of life and sleep apnea. Conclusion: Testosterone deficiency (TD) is a clinical syndrome and osteoporosis can be found in levels above standard "criteria" of 300. This patient did not realize a benefit on injections both physical and clinically and both improved on pelleted testosterone. This should be further studied and considered for TD in men.

INTRODUCTION:Radiofrequency (RF) energy application stimulates collagen and elastin remodeling to restore the elasticity, and moisture of the superficial vaginal mucosa. This is the first study to report on the use of microneedling to deliver RF energy to the vaginal canal. Microneedling increases the response of the collagen contraction and neocollagenesis in deeper layers of tissue, thus increasing the support to the surface. The novel intravaginal microneedling device used in this study allows penetration of the needles to 1, 2, or 3 mm.OBJECTIVE:A prospective study to evaluate the safety and short-term outcome of a single fractional RF treatment of the vaginal canal in a series of women with coexistent stress or mixed incontinence (MUI) and genitourinary syndrome of menopause (GSM).METHODS:Twenty women who had symptoms of SUI and or MUI in conjunction with GSM were given a single vaginal treatment that consisted of fractional bipolar RF energy using the EmpowerRF platform with the Morpheus8V applicator (InMode). RF energy was delivered into the vaginal walls via 24 microneedles, at a depth of 1, 2, and 3 mm. Outcomes were evaluated by "cough" stress test, questionnaires (MESA SI, MESA UI, iQoL, UDI-6) and evaluation of vaginal tissue through the VHI scale at 1-, 3-, and 6-months post-treatment compared to baseline. Biopsies were performed at baseline and 3-months on five patients for histological reference and tissue evaluation.RESULTS:Eight out of eight outcomes measured from baseline to 6-months post-treatment showed improvement. The parameters scored in the questionnaires including frequency, urgency, nocturia, urge incontinence, and stress incontinence showed significant improvement in all areas at the 1-, 3-, and 6-month follow-up sessions compared to baseline.CONCLUSIONS:The results showed evidence that fractional RF energy delivered vaginally is safe, well tolerated, and provide short term improvement of SUI and or MUI in conjunction with GSM.

Single-incision mini-slings are anchored into the obturator internus muscles or connective tissues of the endopelvic fascia of the retropubic space behind the pubic bone, and more recently, some are anchored directly into the obturator membrane. Tension-free vaginal tape Secur was the first popular device that was used as a single incision mini slings. Indications for SIMS are similar to the indications for the more traditional MUS in that they can be offered as an initial, definitive treatment of SUI. Because single-incision mini-sling procedures can be done under local anesthesia, they can also be considered in patients with significant comorbidities in whom general anesthesia is contraindicated. Complications related to surgical techniques that can occur with SIS are similar to the complications that can occur with retropubic and transobturator MUS. In theory, the rate of complications with SIS should be less than the complication rate with MUS, as the surgical technique is simpler.

This chapter discusses the various complications and how best to manage them. Proper patient selection is essential when considering the use of mesh for POP repair and may minimize mesh-related complications. Amid type II (e.g., microporous materials) and type III (e.g., grafts with microporous components or with multifilament weave) synthetic meshes should be avoided because of the increased risk of mesh-related complications. Mesh-related complications associated with these materials require complete excision of the mesh and are not the focus of this chapter. The AUGS-IUGA 2020 joint position statement on the management of mesh-related complications divides the management of women with MUS mesh exposure into those without pain and those with pain. The American Urological Association IUGA 2020 joint position statement on the management of mesh-related complications similarly divides the management of women with SCP mesh exposure into those without pain and those with pain.

Objective: The goal of this study was to compare patient-reported efficacy of suburothelial versus intradetrusor onabotulinumtoxin A (BTX-A) in patients with refractory overactive bladder (OAB). Materials and Methods: This single-center, retrospective cohort study was a retrospective chart review of patients who received BTX-A injections to address refractory idiopathic OAB. The study was performed from 2014 to 2019 for 2 providers. Provider 1 used a suburothelial technique, while Provider 2 used an intradetrusor technique. Patients were excluded for lack of follow-up, co-injection with a urethral-bulking agent, and/or a diagnosis of neurogenic bladder. Patients included were BTX-A-naive and all received a starting dose of 100 units. Results: After cases were excluded, 133 patient charts were analyzed (Provider 1, n = 83; Provider 2, n = 50). Provider 1 had 65% (n = 54) of patients report improvement, while Provider 2 had 82% (n = 41) of patients report improvement. This difference was statistically different (p = 0.036). There was no statistical difference between the 2 groups for postprocedure urinary retention (p = 0.749). The prevalence of urinary tract infections (UTIs) within 30 days following the procedure was not significantly different between the 2 providers' groups (p = 0.329). Conclusion: In this patient population, intradetrusor injection was more effective than suburothelial injection and there was no statistical difference in the secondary outcomes of urinary retention and UTIs.

INTRODUCTION AND HYPOTHESIS:Radiofrequency (RF) energy has been delivered in a variety of methods to the vagina, bladder, and periurethral tissue to improve myriad genitourinary complaints. Currently, practitioners are promoting transvaginal RF treatments with a minimal understanding of the various platforms and data to support or refute their utilization. This review explores how various RF technologies create desired tissue effects, review the published literature reporting outcomes of various treatment regimes, and peer into potential future uses of this technology in urogynecology.METHODS:A comprehensive literature review was performed for articles pertaining to RF energy use in women for genitourinary complaints with regard to stress urinary incontinence (SUI), genitourinary syndrome of menopause (GSM), female sexual dysfunction (FSD), and overactive bladder (OAB).RESULTS:Radiofrequency energy devices heat tissues via direct or micro-needling applications with the goal of stimulating collagen remodeling, neovascularization, and potentially modulation of nerve function. By altering the approach and location of energy application, many new devices have been marketed for treatment of conditions such as SUI, GSM, FSD, and OAB. Available studies demonstrate promising efficacy and favorable safety; however, interpretation of studies is greatly limited by poor study quality and reporting.CONCLUSIONS:Despite a lack of high-quality evidence for efficacy, safety, and durability in the literature, practitioners around the world continue to promote RF technology for a variety of genitourinary complaints. Currently, it appears that RF energy can potentially treat a variety of genitourinary conditions, but more robust data are needed to substantiate evidence-based use.

Aim Overactive bladder (OAB) is a common and troublesome condition that can significantly impair quality of life. This review aims to educate providers of obstetrics and gynecology services about available therapies for OAB and what to expect following treatment. Methods Here, we review published data from studies that have evaluated available treatments for OAB. Relevant articles published over the past 2 decades, including large multicenter trials, were identified through a literature search using , and the references in those articles were also manually searched to find additional articles. Treatment guidelines and product labels were also reviewed. Results Behavioral therapy is recommended as a first choice for OAB management; pharmacologic treatment (anticholinergics, beta(3)-adrenoceptor agonists) as second-line treatment; and onabotulinumtoxinA, peripheral tibial nerve stimulation, and sacral nerve stimulation as third-line therapy for patients refractory or intolerant to first- and second-line treatments. A stepwise approach to treatment through first-, second-, and third-line therapies is recommended, recognizing this may not be appropriate for all patients. Conclusions To optimize symptom control and set realistic expectations, patients should be carefully monitored and counseled appropriately on available treatment options.

AIM:A study to compare the effect of two different radio frequency energy models (mono polar and bipolar) for the treatment of urinary stress incontinence.METHODS:Retrospective chart review, which was conducted at 2 sites, 69 patients received treatment with a bipolar radiofrequency device. Out of those 69 patients, 13 patients received bipolar in conjugation with CO2 laser treatment, while 32 patients received monopolar frequency. The study protocol normally consists of three sessions of treatment. Each session was four weeks apart with a whole 6-month duration follow-up. Results were evaluated by urogenital distress inventory (UDI)-6 questionnaire before and after treatment.RESULTS:The bipolar group improved UDI-6 scores across time more so than did the monopolar group with some evidence suggesting that the bipolar radiofrequency treatment was more effective compared to the monopolar radiofrequency. Three months after treatment, the bipolar group UDI-6 values were lower than those of the monopolar group. Six months after treatment, the UDI-6 scores increased in both groups, suggesting decrease efficacy with time however, the bipolar group's UDI-6 scores were consistently lower than the monopolar group's scores.CONCLUSION:This study shows benefit of both monopolar and bipolar radiofrequency device in patients with stress urinary incontinence and mixed UI, with bipolar RF more efficacious than monopolar RF. More randomized prospective studies are needed to confirm these findings.

Background: Diastasis of recti abdominis muscle (DRAM) is a common condition occurring postpartum and thought to be a cause for back pain and pelvic instability. Electrical muscle stimulation (EMS) had been used in abdominal muscle rehabilitation in combination with exercises in DRAM. This study looks at the effect of EMS in treating DRAM in comparison to a control group receiving no treatment. Methods: This is a prospective randomized clinical trial. A total of 51 patients were included in the study, including group A (28 patients) that was treated with EMS, and a control group B (23 patients) that did not receive any treatment. Pre-treatment baseline, 1-, 3-, and 6-month follow-up data were collected. Results were evaluated through ultrasound measurements of inter-rectal distance (IRD), investigator assessments, patient subjective improvement and satisfaction and Pelvic Floor Distress Inventory (PFDI) questionnaire. Results: Ultrasound IRD measurements demonstrated improvement from baseline to the 3-month and 6-month follow-up in the treatment group. Investigator assessment favored the treatment group with significant difference at all study points. Subjective assessments by patients demonstrated a significant difference between the two groups at 1-month while continued to show improvement at 3- and 6-months follow-up. PFDI questionnaire favored the treatment group over the control group in three PFDI subscales at all study points. Progress of the EMS effect over time was shown. Conclusions: The current study supports potential efficacy of the EMS device as a stand- alone treatment modality for the improvement of DRAM in postpartum women. J Clin Gynecol Obstet. 2021;10(3):59-66 doi: https://doi.org/10.14740/jcgo755

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