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Antispasmodics

Category: Pharmacology > Neuropathic & Pelvic Pain

Antispasmodics are drugs used to relax smooth muscle of the bladder, ureter and bowel, and, in pelvic-pain practice, to settle painful pelvic-floor and bladder spasm. Antimuscarinic antispasmodics (hyoscyamine, dicyclomine, hyoscine butylbromide, oxybutynin, tolterodine) and direct smooth-muscle relaxants (flavoxate, drotaverine) act on visceral smooth muscle. Skeletal-muscle relaxants (baclofen, diazepam, tizanidine, cyclobenzaprine, methocarbamol) act on the striated pelvic floor and sphincter. The evidence is strongest for antimuscarinics in overactive bladder and catheter-related bladder discomfort, and weakest for most agents used for pelvic pain or renal colic. Nearly all pelvic-pain uses are off-label.

For skeletal-muscle relaxants, including vaginal diazepam and the trial evidence for it, see Skeletal Muscle Relaxants. For the antimuscarinic OAB drug class in full, see Anticholinergic / Antimuscarinic Agents.

Mechanism of Action​

  • Antimuscarinics block M2/M3 receptors on detrusor and other visceral smooth muscle, reducing involuntary contraction. Their anticholinergic effects (dry mouth, constipation, retention, blurred vision, confusion) are class effects.
  • Flavoxate is a synthetic urinary-tract spasmolytic that acts directly on smooth muscle.[3]
  • Belladonna and opium (B&O) combines belladonna alkaloids (antimuscarinic; atropine and scopolamine) with opium (opioid).[30] The belladonna component targets bladder and ureteral spasm, while the opioid component adds analgesia.
  • Skeletal-muscle relaxants act centrally through different mechanisms. Baclofen inhibits spinal reflexes and may act through GABA-B receptors; tizanidine is an alpha-2 receptor agonist, and diazepam facilitates GABA activity. Animal studies suggest cyclobenzaprine reduces tonic somatic motor activity; methocarbamol's mechanism is unestablished but may involve general CNS depression.[22][23][24][25][26][27]

Agents Used in Urology and Urogynecology​

Doses are from US drug labels; DailyMed lists the cited hyoscyamine tablet and B&O suppository as unapproved products.[1][30] Pelvic-floor and bladder-spasm use is generally off-label.

AgentRouteLabel indicationAdult label dosePractical points
Hyoscyamine sulfatePO (cited tablet); SL (separately labeled formulation)[33]Visceral spasm including spastic bladder, cystitis, neurogenic bladder; peptic ulcer adjunct[1]0.125 mg tablets, 1 to 2 every 4 h as needed; maximum 12 tablets per 24 h[1]Short-acting; contraindicated in glaucoma and obstructive uropathy[1]
DicyclominePOFunctional bowel / irritable bowel syndrome only[2]20 mg four times daily; may increase to 40 mg four times daily after 1 week if tolerated. Discontinue after 2 weeks if ineffective or adverse effects require less than 80 mg/day; safety data above 80 mg/day beyond 2 weeks are unavailable.[2]Bladder or pelvic-pain use is off-label; contraindicated in obstructive uropathy and glaucoma[2]
FlavoxatePOSymptomatic relief of dysuria, urgency, nocturia, suprapubic pain, frequency and incontinence in cystitis, prostatitis, urethritis[3]100 to 200 mg three to four times daily[3]Contraindicated in lower-tract obstructive uropathy; caution in suspected glaucoma; confusion reported, especially in the elderly[3]
Belladonna and opium suppositoryPRDailyMed-listed for ureteral-spasm pain severe enough to require an opioid when alternatives are inadequate; product and label not FDA-approved[30]One suppository rectally once or twice daily as needed; the label allows up to four doses daily or as directed by the prescriber.[30] Trial regimens below.Opioid-containing; use the lowest effective dose for the shortest duration and assess respiratory-depression and sedative co-use risks. Contraindications include significant respiratory depression, acute or severe bronchial asthma in an unmonitored setting or without resuscitative equipment, MAOI use within the prior 14 days, known or suspected gastrointestinal obstruction (including ileus), glaucoma, and severe hepatic or renal disease.[30]
Oxybutynin / tolterodinePOOABTrial dose for prevention of catheter discomfort: oxybutynin 5 mg or tolterodine 2 mg, 1 h before surgery[7]Full OAB dosing in the linked antimuscarinic page
Hyoscine butylbromideIV, PONot an FDA-labeled US productStudied in renal colic (below)No added benefit in renal colic with the studied IV regimens[9][10]
DrotaverineIV, PONot an FDA-labeled US product80 mg IV in the pivotal renal colic RCT[11]Positive placebo-controlled trial

Ureteral Stent Pain and Post-Procedure Bladder Spasm​

Stent symptoms combine bladder irritation, flank pain on voiding and urgency. A 2023 Bayesian network meta-analysis of 26 randomized studies found the best drug class differed by symptom domain. Combined alpha-blocker plus anticholinergic ranked best for urinary symptoms, and combined anticholinergic plus pregabalin ranked best for pain. The ranking rests largely on indirect comparisons.[12] A 2024 network meta-analysis of 16 randomized trials (2,002 patients) found that mirabegron, solifenacin, and tamsulosin each improved urinary symptoms versus placebo; the five-trial adverse-event analysis associated solifenacin with more adverse events than mirabegron or tamsulosin.[34] See NSAIDs & Analgesics for the analgesic options for stent-related pain.

Belladonna and opium suppositories​

Trials of B&O across three settings gave divergent results, so its benefit is setting-specific.

SettingDesignRegimenResult
Ureteral stent after ureteroscopyRCT, 71 randomized; 69 received a stent[4]Suppository (16.2 mg belladonna / 30 mg opium) after induction, before stent placementAmong day-3 questionnaire respondents (about 75% of stented participants), better quality-of-life and work scores and less pain with urination by postoperative day 3; no difference in analgesic use; no retention[4]
Vaginal hysterectomy with uterosacral suspension or posthysterectomy prolapse repairRCT, n = 90 (51% with prolapse)[5]B&O 16A (16.2 mg / 60 mg) after surgery and every 8 h for 3 dosesPain scores and morphine use did not differ significantly from placebo; adverse effects (constipation, retention) were similar[5]
In-office intravesical onabotulinumtoxinARCT, n = 26[6]Belladonna alkaloids 16.2 mg/morphine 7.5 mg suppository with lidocaine instillationNo significant reduction in injection pain; postvoid residual >200 mL did not differ significantly immediately or at 2 weeks[6]

Practical position: consider a single B&O suppository before ureteroscopy with planned stent placement in selected patients; the cited trial did not test treatment after stent symptoms developed.[4] Do not add it routinely after vaginal surgery or for office bladder injections, where the RCTs were negative. Confirm current formulation and opioid-stewardship requirements locally, because it is an opioid-containing product.

Catheter-related bladder discomfort (CRBD) is an urgency-like burning and pressure sensation from the indwelling catheter, and it is common on emergence from anesthesia. Antimuscarinics are the most direct pharmacologic answer.

  • In an RCT of 234 patients undergoing percutaneous nephrolithotomy, discomfort occurred in 58% with placebo, 35% with oxybutynin 5 mg and 33% with tolterodine 2 mg given 1 h preoperatively, with lower severity in both drug groups.[7]
  • A 2022 systematic review and meta-analysis of 45 randomized trials found that tolterodine, oxybutynin, gabapentin, pregabalin, dexmedetomidine, tramadol, ketamine, nefopam and pudendal nerve block were effective. Dexmedetomidine and gabapentin ranked best when efficacy and adverse effects were considered together. Evidence for butylscopolamine was insufficient.[8]

Anticholinergic exposure is short in this setting. Retention after catheter removal, sedation and dry mouth are the main adverse effects to anticipate.

Renal Colic​

NICE NG118 recommends NSAIDs first-line for suspected renal colic and explicitly advises against antispasmodics (recommendations 1.2.1 and 1.2.4).[31] Antispasmodics have been tested as adjuncts with disappointing results for the antimuscarinic agents.

  • Hyoscine butylbromide. In a 192-patient RCT (178 analyzed), adding hyoscine butylbromide to morphine did not reduce opioid requirement (median 0.12 versus 0.11 mg/kg) or the need for further morphine (33% versus 38%).[9] In a 128-patient trial in colic not responding to oral NSAIDs, continuous IV butylscopolamine 100 mg/24 h was no better than placebo, and the authors concluded there is no role for continuous infusion.[10]
  • Drotaverine: a placebo-controlled RCT enrolled 140 patients, but 38 withdrew. Among 102 analyzed (48 drotaverine, 54 placebo), 79% versus 46% met a response definition of at least a 50% fall on the pain-intensity scale and/or a 40% fall on VAS 40 minutes after the first or repeat 80 mg IV dose. There were 20 versus 4 minor adverse events, most often transient hypotension, vertigo, and nausea or vomiting.[11] It is not an FDA-labeled US product.

This section addresses analgesia only. Whether antispasmodics improve stone passage is a separate question, and alpha-blocker medical expulsive therapy is covered on its own page.

Bladder and Pelvic-Floor Spasm in Pain Syndromes​

  • Hypertonic pelvic floor and levator spasm. Pelvic-floor physical therapy is the foundation. For men with pelvic-floor or abdominopelvic myalgia, AUA 2025 permits individualized internal and external manual physical therapy .[29] Systemic skeletal-muscle relaxants and vaginal diazepam are used off label for pelvic-floor spasm, with limited trial support; the trials and safety details are on the Skeletal Muscle Relaxants page. For women with pelvic floor dysfunction, NICE NG210 recommends against offering vaginal diazepam even with high muscle tone (recommendation 1.6.33).[32] Within that evidence, a triple-blinded RCT found no improvement with nightly 10 mg vaginal diazepam over 4 weeks,[13] and a 2020 systematic review found that the randomized trials showed no significant benefit in pain scores.[14]
  • IC/BPS: the 2022 AUA guideline does not list smooth-muscle antispasmodics among its oral options (Statement 14), and it no longer uses numbered treatment tiers.[36] See Oral IC/BPS Agents and Intravesical Agents.
  • Flavoxate carries a label indication for suprapubic pain and dysuria in cystitis and prostatitis, but the supporting literature is older, and a review of the drug in urogynecology noted that no randomized trials had been done in the preceding decade.[3][15]

Antimuscarinics and Beta-3 Agonists for OAB​

For idiopathic OAB, the 2024 AUA/SUFU guideline states that clinicians should offer an antimuscarinic or a beta-3 agonist to improve urgency, frequency and urgency incontinence .[16] Treatment is chosen by side-effect profile through shared decision-making.[16] In the 2023 Cochrane review of 104 trials, oral anticholinergics were probably better than placebo for perceived cure or improvement (RR 1.38, 95% CI 1.15 to 1.66), with possible increases in dry mouth (RR 3.50) and urinary retention (RR 3.52), both based on low-certainty evidence.[17] Drug selection, dosing and the beta-3 agonists are covered in Anticholinergic / Antimuscarinic Agents and Beta-3 Agonists.

Cognitive Risk and Anticholinergic Burden​

Chronic antimuscarinic use has been associated with incident dementia in observational studies, but the comparator affects the estimate. A 2025 Danish nested case-control study reported an adjusted incidence rate ratio of 1.44 (95% CI 1.40 to 1.48) versus non-use in the general-population cohort; among new bladder-drug users, the ratio was 0.82 versus mirabegron. Neither association establishes causation; confounding by indication remains possible.[35]

  • The AUA/SUFU guideline states that clinicians should discuss the potential risk of dementia and cognitive impairment with patients taking or prescribed antimuscarinics , and should use them with extreme caution in narrow-angle glaucoma, impaired gastric emptying or a history of urinary retention .[16] The guideline cites a meta-analysis of 14 studies (1,564,181 subjects) reporting an association with all-cause dementia (RR 1.20, 95% CI 1.15 to 1.26).[16][18]
  • The 2022 SUFU white paper concluded that chronic use (longer than 3 months) is likely associated with new-onset dementia and short-term use (under 4 weeks) of most OAB anticholinergic medications is likely safe in most people.[19]
  • In a French nested case-control study, OAB anticholinergic use was associated with dementia (adjusted OR 1.23, 95% CI 1.10 to 1.37), with a dose-response pattern: 1.07 (0.91 to 1.25) for 1 to 90 daily doses, 1.29 for 91 to 365 and 1.48 for more than 365. Risk was marked for oxybutynin and solifenacin and not increased for trospium.[20] A large English nested case-control study reported an adjusted OR of 1.18 overall, with oxybutynin, solifenacin and tolterodine most strongly associated and no significant increase for darifenacin, fesoterodine, flavoxate, propiverine or trospium.[21]

Each additional anticholinergic (hyoscyamine, dicyclomine, tricyclics, cyclobenzaprine, diphenhydramine) adds to total burden. Before adding an antispasmodic in an older patient, review the whole medication list.

Contraindications and Precautions​

  • Hyoscyamine and dicyclomine labels contraindicate glaucoma, obstructive uropathy, gastrointestinal obstruction and myasthenia gravis; hyoscyamine also lists paralytic ileus. Flavoxate contraindicates lower-tract obstructive uropathy and specified gastrointestinal conditions, including intestinal obstruction or ileus, and advises caution in suspected glaucoma.[1][2][3] Check post-void residual before starting in patients at risk of retention.[16]
  • Oral baclofen. Hallucinations and seizures have occurred with abrupt withdrawal, so taper slowly.[22] Renal impairment causes accumulation. The FDA boxed warning is for intrathecal baclofen (Lioresal, Gablofen): abrupt discontinuation, from any cause, has led to high fever, altered mental status, rebound spasticity, muscle rigidity, and in rare cases rhabdomyolysis, multiple organ failure and death.[23]
  • Diazepam: the boxed warning covers concomitant opioid use (profound sedation, respiratory depression, coma, death), abuse, misuse and addiction, and dependence and withdrawal reactions.[24] This applies to vaginal use when absorption is systemic, and to co-prescription with B&O or postoperative opioids.
  • Tizanidine is contraindicated with strong CYP1A2 inhibitors, including ciprofloxacin and fluvoxamine.[25] It can cause hepatocellular liver injury (aminotransferases at baseline and 1 month after reaching maximum dose) and hypotension, especially with antihypertensives.[25]
  • Cyclobenzaprine: contraindicated during MAO inhibitor use or within 14 days after stopping it, during acute recovery from myocardial infarction, with arrhythmias, heart block or other conduction disturbances, heart failure, and hyperthyroidism.[26] Serotonin syndrome has been reported with serotonergic drugs. The label does not recommend use beyond two or three weeks.[26]
  • Methocarbamol: labeled for acute painful musculoskeletal conditions, with sedation and additive CNS depression.[27] Its pelvic-floor use has no trial support.

Evidence Summary​

IndicationEvidenceKey sourceNotes
OABStrong recommendation (Grade A); modest effect size, moderate-certainty for cure or improvementAUA/SUFU 2024 ; Cochrane 2023[16][17]Antimuscarinic or beta-3 agonist; cognitive counseling
CRBD preventionMultiple RCTs and meta-analysisAgarwal 2006; Li 2022[7][8]Oxybutynin and tolterodine effective; short exposure
Stent symptomsNetwork meta-analysis (indirect)Hinojosa-Gonzalez 2023[12]Combination therapy ranks highest
B&O before ureteroscopy and stentingOne RCT: selected quality-of-life, work and dysuria outcomes favored B&O at postoperative day 3; overall urinary and pain-domain scores and analgesic use did not differLee 2017[4]71 randomized; 51 completed day-3 USSQ; opioid-containing
B&O after vaginal surgery / office BotoxRCTs, negativeButler 2017; LeClaire 2018[5][6]—
Renal colic, hyoscine butylbromideRCTs, negativeHoldgate 2005; Weltings 2021[9][10]NICE NG118: NSAIDs first-line for suspected renal colic when appropriate[31]
Renal colic, drotaverineSingle RCT, positive among 102 analyzed after 38 withdrawalsRomics 2003[11]Not an FDA-labeled US product; NICE NG118 advises against antispasmodics for suspected renal colic.[31]
Hypertonic pelvic floor (vaginal diazepam)Two small RCTs found no significant between-group pain-score difference; a third trial in women with vestibulodynia and high-tone pelvic floor dysfunction found less dyspareunia at 60 days with diazepam plus TENS than placebo plus TENS, but no VAS pain differenceCrisp 2013; Stone 2020[13][14]Off-label; see SMR page
Female functional BOO (oral baclofen)One crossover RCTEAU 2026: weak recommendation[28]Improved Qmax and PdetQmax; not a pain indication

Practical Pearls​

  • Match the drug to the condition. Antimuscarinics improve OAB symptoms and, in a perioperative RCT, reduced catheter-related bladder discomfort.[16][7] Hyoscine butylbromide did not reduce analgesic use in two renal-colic RCTs.[9][10] Pelvic-floor myalgia calls for separate assessment; for affected men, AUA 2025 says clinicians may offer individualized manual physical therapy .[29]
  • A bladder-spasm plan after reconstruction should say how long the antimuscarinic runs and when to check for retention, particularly after urethral or bladder-neck surgery.
  • Avoid stacking anticholinergics. Hyoscyamine plus oxybutynin plus a tricyclic multiplies dry mouth, constipation, retention and cognitive effects.
  • Do not pair a benzodiazepine with an opioid-containing suppository without a clear reason.
  • Never stop intrathecal baclofen abruptly, including during pump-related or reconstructive surgery.[23] Confirm pump function and refill dates.

See Also​

References​

1. Hyoscyamine sulfate tablets prescribing information. DailyMed. Accessed September 26, 2026.

2. Dicyclomine hydrochloride tablets prescribing information. DailyMed. Accessed September 26, 2026.

3. Flavoxate hydrochloride tablets prescribing information. DailyMed. Accessed September 26, 2026.

4. Lee FC, Holt SK, Hsi RS, et al. "Preoperative Belladonna and Opium Suppository for Ureteral Stent Pain: A Randomized, Double-blinded, Placebo-controlled Study." Urology. 2017;100:27-32. doi:10.1016/j.urology.2016.07.035

5. Butler K, Yi J, Wasson M, et al. "Randomized controlled trial of postoperative belladonna and opium rectal suppositories in vaginal surgery." Am J Obstet Gynecol. 2017;216(5):491.e1-491.e6. doi:10.1016/j.ajog.2016.12.032

6. LeClaire EL, Duong J, Wykes RM, et al. "Randomized controlled trial of belladonna and opiate suppository during intravesical onabotulinum toxin A injection." Am J Obstet Gynecol. 2018;219(5):488.e1-488.e7. doi:10.1016/j.ajog.2018.06.004

7. Agarwal A, Dhiraaj S, Singhal V, et al. "Comparison of efficacy of oxybutynin and tolterodine for prevention of catheter related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study." Br J Anaesth. 2006;96(3):377-380. doi:10.1093/bja/ael003

8. Li S, Li P, Wang R, et al. "Different interventions for preventing postoperative catheter-related bladder discomfort: a systematic review and meta-analysis." Eur J Clin Pharmacol. 2022;78(6):897-906. doi:10.1007/s00228-021-03251-5

9. Holdgate A, Oh CM. "Is there a role for antimuscarinics in renal colic? A randomized controlled trial." J Urol. 2005;174(2):572-575. doi:10.1097/01.ju.0000165337.37317.4c

10. Weltings S, Buddingh KT, van Diepen DC, et al. "The BUSCOPAN study: a randomized-controlled non-inferiority trial of a continuous butylscopolamine infusion versus placebo in patients with a renal colic not responding to oral non-steroidal anti-inflammatory drugs." World J Urol. 2021;39(7):2747-2752. doi:10.1007/s00345-020-03460-0

11. Romics I, Molnár DL, Timberg G, et al. "The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones." BJU Int. 2003;92(1):92-96. doi:10.1046/j.1464-410x.2003.04262.x

12. Hinojosa-Gonzalez DE, Segall MR, Eisner BH. "Pharmacological Management of Ureteral Stent-related Symptoms: A Systematic Review, Bayesian Network Meta-analysis, and Meta-regression." J Urol. 2023;210(5):739-749. doi:10.1097/JU.0000000000003616

13. Crisp CC, Vaccaro CM, Estanol MV, et al. "Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial." Int Urogynecol J. 2013;24(11):1915-1923. doi:10.1007/s00192-013-2108-9

14. Stone RH, Abousaud M, Abousaud A, et al. "A Systematic Review of Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder." J Clin Pharmacol. 2020;60(Suppl 2):S110-S120. doi:10.1002/jcph.1775

15. Zor M, Aydur E, Dmochowski RR. "Flavoxate in urogynecology: an old drug revisited." Int Urogynecol J. 2015;26(7):959-966. doi:10.1007/s00192-014-2585-5

16. Cameron AP, Chung DE, Dielubanza EJ, et al. "The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder." J Urol. 2024;212(1):11-20. doi:10.1097/JU.0000000000003985

17. Stoniute A, Madhuvrata P, Still M, et al. "Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults." Cochrane Database Syst Rev. 2023;5(5):CD003781. doi:10.1002/14651858.CD003781.pub3

18. Zheng YB, Shi L, Zhu XM, et al. "Anticholinergic drugs and the risk of dementia: A systematic review and meta-analysis." Neurosci Biobehav Rev. 2021;127:296-306. doi:10.1016/j.neubiorev.2021.04.031

19. Zillioux J, Welk B, Suskind AM, Gormley EA, Goldman HB. "SUFU white paper on overactive bladder anticholinergic medications and dementia risk." Neurourol Urodyn. 2022;41(8):1928-1933. doi:10.1002/nau.25037

20. Malcher MF, Droupy S, Berr C, et al. "Dementia Associated with Anticholinergic Drugs Used for Overactive Bladder: A Nested Case-Control Study Using the French National Medical-Administrative Database." J Urol. 2022;208(4):863-871. doi:10.1097/JU.0000000000002804

21. Iyen B, Coupland C, Bell BG, et al. "Risk of dementia associated with anticholinergic drugs for overactive bladder in adults aged ≥55 years: nested case-control study." BMJ Med. 2024;3(1):e000799. doi:10.1136/bmjmed-2023-000799

22. Baclofen tablets prescribing information. DailyMed. Accessed September 26, 2026.

23. Gablofen (baclofen injection, intrathecal) prescribing information. DailyMed. Accessed September 26, 2026.

24. Diazepam tablets prescribing information. DailyMed. Accessed September 26, 2026.

25. Tizanidine tablets prescribing information. DailyMed. Accessed September 26, 2026.

26. Cyclobenzaprine hydrochloride tablets prescribing information. DailyMed. Accessed September 26, 2026.

27. Methocarbamol tablets prescribing information. DailyMed. Accessed September 26, 2026.

28. European Association of Urology. Management of Non-neurogenic Female LUTS, limited update March 2026, section 4.5.4.b.2.b (striated muscle relaxants). Guideline.

29. Lai HH, Pontari MA, Argoff CE, et al. Male Chronic Pelvic Pain: AUA Guideline: Part II Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Urol. 2025;214(2):127-137. doi:10.1097/JU.0000000000004565 Full 2025 guideline

30. Padagis US LLC. Belladonna and opium suppositories, for rectal use: prescribing information. DailyMed. Updated April 1, 2023.

31. National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management (NG118). 2019. Guideline.

32. National Institute for Health and Care Excellence. Pelvic floor dysfunction: prevention and non-surgical management (NG210). 2021. Guideline

33. Granulation Technology, Inc. Hyoscyamine sulfate sublingual tablets, 0.125 mg: drug label. DailyMed. Updated April 10, 2026.

34. Xiang N, Hu Y, Peng W, Luo M, Yang Y, Zhang Q. "Comparing efficacy and safety of mirabegron, tamsulosin, and solifenacin in ureteral stent-related symptoms: outcomes from a network meta-analysis." Transl Androl Urol. 2024;13(5):699-707. doi:10.21037/tau-23-642

35. Pourhadi N, Janbek J, Gasse C, et al. "Bladder drugs and risk of dementia: Danish nationwide active comparator study." BMJ Med. 2025;4(1):e001125. doi:10.1136/bmjmed-2024-001125

36. Clemens JQ, Erickson DR, Varela NP, Lai HH. "Diagnosis and treatment of interstitial cystitis/bladder pain syndrome." J Urol. 2022;208(1):34–42. doi:10.1097/JU.0000000000002756