Transvaginal radiofrequency energy for the treatment of urinary stress incontinence: A comparison of monopolar and bipolar technologies in both pre- and post-menopausal patients.

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.

Serial Echocardiographic Follow-up of Structural Heart Interventions Performed During Pacific Partnership Interventional Cardiology Subject Matter Exchanges From 2015 to 2017 in Da Nang, Vietnam.

INTRODUCTION: The U.S. Navy Medicine has a long history of conducting global health missions that foster international diplomacy through medical knowledge exchange with a goal of increasing partner nation's health care capacity. Pacific Partnership is an annual U.S. Navy-sponsored joint operation that enhances medical collaboration with participating nations throughout the Indo-Asia-Pacific region. Since 2015, a U.S. Navy Cardiology team has conducted a structural heart disease interventional workshop focused on congenital heart disease with the cardiologists at the Da Nang General Hospital, Da Nang, Vietnam. Herein, we describe the multinational collaborative project including the patient registry we developed to monitor the short- and long-term outcomes of structural heart disease interventions preformed during Pacific Partnership 2015 and 2016. MATERIALS AND METHODS: Our team developed a sustainable procedural registry with the goal of following the long-term outcomes of cardiac interventions for congenital heart disease in Vietnamese patients. Specifically, the registry was designed to record the changes in symptoms referable to the cardiovascular system and for device placement-associated complications for devices placed in 2015 and 2016 and has been updated annually thereafter. RESULTS: Twelve patients (age range, 7 months to 31 years) underwent successful atrial septal defect closure in 2015 without procedural complications. The follow-up rate was 75% at 1 year and 67% at 2 years, and all devices were in appropriate position with no complications identified. Fifteen patients (age range, 20-66 years) underwent successful atrial septal defect closure in 2016. The follow-up rate was 62.5% at 1 year, and all devices were in appropriate position with no complications identified. Three patients (age range, 5-25 months) underwent successful device closure of the patent ductus arteriosus in 2015 without complications. The follow-up rate was 67% in 2016 and again in 2017. Six patients (age range, 9-74 years) underwent successful patent ductus arteriosus closure in 2016 without complications. The follow-up rate was 67% in 2017, and all devices were in appropriate position with no device-related complications identified. CONCLUSIONS: The development of a patient registry during these missions allowed for the longitudinal monitoring of outcomes for cardiac interventions. Notably, treated patients experienced symptomatic improvement without significant long-term procedural complications. Following patients longitudinally across medical missions is of recognized importance but remains a difficult objective to achieve for a multitude of factors including administrative and financial burdens on both the medical systems and the patients of host nations. Despite these limitations, longitudinal follow-up of patient care facilitated by a patient registry has a vital role in monitoring the quality of care provided and should be an integral part of all future global medical missions.

Fractional CO2 laser of the vagina for genitourinary syndrome of menopause: Is the out-of-pocket cost worth the outcome of treatment?

OBJECTIVES: The purpose of this study is to assess patient's satisfaction treatment outcomes and out-of-pocket expense for the fractional CO2 laser (SmartXide) in the treatment of genitourinary symptoms of menopause (GSM). MATERIALS AND METHODS: A multicenter retrospective cohort study of patients who completed a course of three vaginal treatments with the SmartXide11 Fractional CO2 laser. Patients contacted via telephone and asked to participate in questionnaires to evaluate for adverse outcomes since last treatment, symptom severity before and after treatment, patient satisfaction with treatment, patient satisfaction with out-of-pocket expense, and sexual function. RESULTS: Of the 368 patients contacted, 122 agreed to be interviewed. No patients reported seeking emergent medical treatment. Patient reported vaginal dryness significantly improved following treatment (P < 0.05). The frequency of intercourse increased from "once a month" to "few times a month" (P < 0.001). The vast majority of patients reported being satisfied with their treatment results (86%) and with the cost of treatment (78%). Satisfaction with the out-of-pocket expense did not correlate with household income (P = 0.07). CONCLUSION: The SmartXide Fractional CO2 laser is a safe and efficacious treatment for GSM. This treatment is associated with a high level of patient satisfaction with both treatment results and out-of-pocket expense. Lasers Surg. Med. 49:882-885, 2017. © 2017 Wiley Periodicals, Inc.

Differentiating interstitial cystitis from similar conditions commonly seen in gynecologic practice.

Interstitial cystitis is a syndrome characterized by pelvic pain, urinary urgency/frequency, nocturia, and dyspareunia, with no other identifiable etiology. The clinical presentation of interstitial cystitis is similar to that of many other conditions commonly seen in female patients, including recurrent urinary tract infections, endometriosis, chronic pelvic pain, vulvodynia, and overactive bladder. In addition, interstitial cystitis may exist concurrently with these conditions. Correct diagnosis is necessary for appropriate treatment and improved outcomes. Tools to assist in the diagnosis of interstitial cystitis, as well as effective therapies for this condition, are available. A diagnosis of interstitial cystitis should be considered in patients with irritative voiding symptoms and/or pelvic pain complaints.

Evolving trends in the successful management of interstitial cystitis/painful bladder syndrome.

OBJECTIVE: To provide an overview of interstitial cystitis (IC), including the presentation of patients with the disorder, and to explore diagnostic and treatment options. STUDY DESIGN: Current literature concerning the history, etiology, diagnosis and treatment of IC was used to support expert recommendations regarding patient management. Experts discussed the literature surrounding IC, focusing on diagnostic tools and currently available treatment modalities. RESULTS: Diagnosis of IC may often be delayed or missed due to the similarity of symptoms with a number of other conditions. A detailed medical history and careful physical examination are key for diagnosis, and a variety of screening and diagnostic tools are also available. Once a patient is diagnosed with IC, multimodal treatment through pharmacological and nonpharmacological approaches is recommended. CONCLUSION: The involvement of both the patient and physician in determining the therapeutic approach, the use of multimodal therapies, regular follow-up and staff involvement in care can bring relief to a substantial number of patients with this condition.

Interstitial cystitis/painful bladder syndrome: appropriate diagnosis and management.

Interstitial cystitis/painful bladder syndrome (IC/PBS) is characterized by urinary frequency, urgency, and pelvic pain in the absence of any other identifiable pathology. Initial identification of IC/PBS is challenging, as patients may have a range of symptoms that overlap with other disorders, including urinary tract infection (UTI). These patients may be treated empirically with antibiotics; however, many patients with such symptoms are actually culture negative and are later diagnosed with IC/PBS. This review describes the importance of recognizing the symptom overlap between IC/PBS and UTI and focuses on approaches to the diagnosis and management of IC/PBS. Physicians can improve patient care by considering IC/PBS early in the differential diagnosis.

The emerging presence of interstitial cystitis in gynecologic patients with chronic pelvic pain.

Emerging data are changing the pelvic pain paradigm for gynecologic patients. Historically, interstitial cystitis (IC) was rarely considered as a cause of chronic pelvic pain (CPP), but recent data suggest that IC is a common cause of CPP in gynecologic patients and perhaps is even the most common cause. It is important to consider the bladder as a generator of symptoms early in the evaluation of the gynecologic patient with CPP. New tools have been developed to aid the gynecologist in ruling out IC in patients with CPP, including a new IC symptom questionnaire and the Potassium Sensitivity Test (PST). By determining whether the pain is of bladder origin, the physician can more successfully treat the patient with CPP.

Successful management of interstitial cystitis in clinical practice.

Primary care physicians, urologists, and gynecologists have the opportunity to detect interstitial cystitis (IC) in its early stages in symptomatic patients and provide effective treatment before the disease progresses. In this article, we present guidelines for clinical practice management and coding for reimbursement for the care of patients with IC. Important issues in the management of IC are presented, including appropriate Current Procedural Terminology (CPT) coding for office visits and procedures associated with diagnosis and treatment of the disease. Excellent IC care can be integrated into a successful clinical practice with appropriate clinical management and coding for reimbursement.

Multimodal therapy for painful bladder syndrome/interstitial cystitis.

Most patients who suffer from PBS/IC can now be simply and effectively treated. The first step to successful management is accurate and timely diagnosis, which has become easier with available and validated screening and diagnostic tools such as PUF and PST. Once PBS/IC is correctly diagnosed, prompt treatment should address the main components of the disease, a dysfunctional urothelium, mast cell activation and neural upregulation. Multimodal treatment that has shown benefit includes oral PPS plus an antihistamine, such as hydroxyzine, and a TCA, such as amitriptyline. Behavioral interventions and intravesical instillation therapy are adjunctive measures that will promote symptom relief. Intravesical "rescue" solutions using lidocaine and heparin or PPS (dissolved in water or in the instillation solution [off-label use of PPS]) can provide immediate relief while patients develop a response to oral PPS. Patient education and support are critical in managing this complex but treatable disorder.

TVT erosion secondary to a twist in tape.

Mesh erosions through vaginal mucosa as well as the urethra following TVT procedures have been reported but are rare. We report a case of a 50-year-old woman who was found to have mesh erosion through vaginal mucosa 8 weeks after her TVT procedure, apparently secondary to a twist in the tape. Excision of approximately 5 mm of tape encompassing the twist was accomplished without difficulty, and allowed for complete healing of the vaginal mucosa and resolution of the patient's pain and irritative voiding symptoms.

PelviSoft BioMesh augmentation of rectocele repair: the initial clinical experience in 35 patients.

Graft materials have been utilized in the repair of posterior vaginal wall defects to enhance anatomical and functional results, and to improve long-term outcomes. We report on our initial series of 35 patients treated with porcine dermal acellular collagen matrix BioMesh (PelviSoft BioMesh, CR Bard, Cranston, R.I., USA), which has alleviated problems with early postoperative vaginal mucosal dehiscence and delayed healing experienced with the use of other graft materials in the posterior vaginal wall.

Multimodal therapy for interstitial cystitis.

Gynecologists have been challenged by the diversity in treatment approaches and the historical absence of effective therapy for interstitial cystisis (IC). Until recently, the only Food and Drug Administration (FDA)-approved treatment was bladder instillation with dimethyl sulfoxide, a moderately effective and safe, albeit invasive, process. The approval in 1996 of pentosan polysulfate sodium (PPS) provided IC patients with an effective and safe oral regimen that specifically targets and repairs the damaged urothelium. Intravesical administration of heparin sulfate or PPS, while not FDA indicated, has also been shown to provide symptom relief. Patients with moderate to severe disease may require a multimodal therapeutic approach utilizing PPS as the foundation. Oral PPS can be combined with antihistamines, analgesics, antispasmodics or antidepressants to provide enhanced pain and symptom relief. Patients with severe disease or flares may benefit from instillation of an anesthetic therapeutic relief solution composed of heparin or PPS combined with sodium bicarbonate and lidocaine. Nonpharmacologic approaches, such as bladder training, biofeedback and dietary changes, can provide supplemental relief. Acute and chronic pain associated with IC can now be effectively managed using a multimodal approach with PPS as the basis.

Chronic pelvic pain of bladder origin: a focus on interstitial cystitis.

Chronic pelvic pain afflicts some 9,000,000 women in the United States. Of these, perhaps 10%-although the true number of those affected is actually much greater-are found to have interstitial cystitis (IC), that is, pain of bladder origin. The etiology is multifactorial, but a fairly good marker is dysfunction of the glycosaminoglycan/mucus/mucin layer of the bladder as detected by a potassium (KCl) sensitivity test. A cascade starting with Substance P seems to be involved in generating inflammation, and even ulceration, which is the focus of pain. This article describes means of diagnosis, including the KCl test and cystoscopy, and both U.S. FDA-approved and extended-use medical treatment options which are always to be attempted before the final step of surgery.

The prevalence of interstitial cystitis in gynecologic patients with pelvic pain, as detected by intravesical potassium sensitivity.

OBJECTIVE: The purpose of this study was to determine the prevalence of interstitial cystitis in a large number of gynecologic patients with pelvic pain versus control subjects, as indicated by a positive result on a potassium sensitivity test. STUDY DESIGN: Gynecologists at four US medical centers administered the potassium sensitivity test to consecutive unselected patients with pelvic pain and control subjects. Before testing, each patient with pelvic pain was given an initial clinical diagnosis on the basis of the chief symptomatic complaint(s) and was surveyed for urologic symptoms. RESULTS: Of 244 patients with pelvic pain, 197 patients (81 %) had a positive result from a potassium sensitivity test. Positive potassium sensitivity test rates were comparable across all four sites and all clinical diagnoses that included endometriosis, vulvodynia (vulvar vestibulitis), and pelvic pain. Urologic symptoms were reported by 84% of patients, but only 1.6% of the patients had received an initial diagnosis of interstitial cystitis. None of the 47 control subjects were tested positive with the potassium sensitivity test. CONCLUSION: Interstitial cystitis may be a common unrecognized cause of pelvic pain in gynecologic patients and deserves greater, if not primary, consideration in the differential diagnosis of pelvic pain.

Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity.

OBJECTIVES: Most individuals with interstitial cystitis (IC) have both pelvic pain and urinary urgency/frequency, and many have dyspareunia. Existing questionnaires designed to assess bladder-origin pelvic pain (IC) give little attention to pelvic pain or dyspareunia, however. On the basis of our clinical experience with more than 5000 patients with IC, we have designed a pelvic pain and urgency/frequency (PUF) symptom scale that gives balanced attention to urinary urgency/frequency, pelvic pain, and symptoms associated with sexual intercourse. METHODS: We used the intravesical potassium sensitivity test (PST) to validate the PUF scale in urologic patients suspected of having IC, gynecologic patients with pelvic pain, controls, and women attending lectures given by one of us (C.L.P.). Positive potassium sensitivity is known to be associated with a bladder epithelial dysfunction present in most individuals with IC. RESULTS: The PST was positive in 74% of patients with a PUF score of 10 to 14, 76% of those scoring 15 to 19, and 91% of those scoring 20 or higher. All controls' PUF scores were less than 3, and the rate of positive PST in controls was 0%. The PUF scores in women screened at lectures suggested that 1 in 4.5 women have IC. CONCLUSIONS: High PUF scores appear to correlate directly with a higher likelihood of positive PST in both urologic patients suspected of having IC and gynecologic patients with pelvic pain. The PUF appears to be a valid tool for detecting IC in these two populations, as well as in the general population. Use of the PUF alone may prove to be an accurate method for detecting IC. The IC prevalence may be as high as 1 in 4.5 women.