Cystoscopic findings in women with minimal and maximal lower urinary tract symptoms.

BACKGROUND: Glomerulations are not specific for interstitial cystitis/bladder pain syndrome (IC/BPS). Controversy exists about whether cystoscopic findings differ between patients with and without lower urinary tract symptoms. We sought to compare the prevalence of cystoscopic findings in women with "no or minimal" urinary symptoms to those with a "high" symptom burden. METHODS: This is a secondary analysis of a prospective cohort study performed at a University Educational Facility. Participants in this study were part of a larger prospective study, in which female patients scheduled to undergo routine gynecologic procedures were all consented for cystoscopy with hydrodistension (CWHD). We defined the "minimally symptomatic group" as those with ≤1 on each of the O'Leary/Sant Interstitial Cystitis Symptom Index (ICSI) subscores and without history of IC/BPS. The "highly symptomatic" cohort of women had composite ICSI score ≥12 and a Burning/Pain subscore of 4 or 5. All were non-smokers. RESULTS: A total of 84 women underwent CWHD, with 33 having minimal symptoms and 51 being highly symptomatic. The two groups were not statistically different when assessing for 'any glomerulations' compared to 'no glomerulations.' However, minimally symptomatic women had an eight-fold lower prevalence of significant glomerulations than highly symptomatic women (3.0% minimally symptomatic vs. 23.5% highly symptomatic, P<0.05.). CONCLUSIONS: Extensive glomerulations (≥10 in 3 or 4 quadrants) are rare in women with minimal urinary symptoms. These findings contrast with prior limited prospective data which quoted similar incidence of glomerulations in IC/BPS patients and asymptomatic patients. This study highlights the importance of evaluating objective evidence on CWHD and merits further investigation as part of the ongoing conversation regarding the definition of bladder health and pathology.

Incidence of successful voiding and predictors of early voiding dysfunction after retropubic sling.

INTRODUCTION AND HYPOTHESIS: There is a paucity of literature on resumption of normal voiding predictors after synthetic retropubic sling insertion and lack of a standardized method of determination. Our goals were to determine the incidence of a successful voiding trial; whether clinical, operative, or urodynamic variables predict discharge with a catheter; and incidence of later retention in those who were initially successful. METHODS: We performed an internal-review-board (IRB)-approved retrospective chart review of 229 consecutive patients who underwent retropubic sling (TVT, Boston Scientific, Natick, MA, USA)) from 2001 to 2010. Exclusions were concomitant surgery or cystotomy at the time of retropubic sling insertion. All participants underwent a voiding trial in recovery consisting of 300 cc sterile-water retrograde fill and were discharged home without a catheter after single void of at least 200 cc following catheter removal. RESULTS: Of 170 patients, 136 (80 %) passed the voiding trial the same day, with 165 (97 %) passing within 1 day. Factors associated with delayed voiding were age ≥65 years (p < 0.05), presence of Valsalva voiding (p < 0.01), lower body mass index (BMI) (p < 0.05), and higher gravidity (p < 0.05) and parity (p < 0.01). Age ≥65 years [adjusted odds ratio (aOR) 3.72, 95 % confidence interval (CI) 1.40-9.90, p < 0.01] and Valsalva voiding (aOR 3.89, 95 % CI 1.56-9.69, p < 0.01) remained significant independent predictors in multivariate analysis. CONCLUSIONS: The majority of patients with retropubic sling can be safely discharged home the same day without a catheter after retrograde fill. Women >65 years or Valsalva voiders had nearly four times the odds of being discharged with a catheter. Most patients resume normal voiding within 24 h after retropubic sling insertion, but >65 years and Valsalva voiding are risk factors for voiding inability at discharge.

Interstitial cystitis: epidemiology, pathophysiology, and clinical presentation.

Interstitial cystitis, or painful bladder syndrome, can present with lower abdominal pain/discomfort and dyspareunia, and pain in any distribution of lower spinal nerves. Patients with this condition experience some additional symptoms referable to the bladder, such as frequency, urgency, or nocturia. It can occur across all age groups, although the specific additional symptoms can vary in prevalence depending on patient age. It should be considered in patients who have other chronic pain conditions such as fibromyalgia, chronic fatigue, irritable bowel, and vulvodynia. The cause is still largely not understood, although there are several postulated mechanisms.

Bladder perforation during tension-free vaginal tape procedures: abdominal versus vaginal approach.

OBJECTIVE: Bladder perforation rates for the tension-free vaginal tape (TVT) are higher with inexperienced surgeons. The purpose of this study was to examine if surgical approach affects this rate. METHODS: We performed a retrospective cohort study of consecutive patients undergoing a TVT as the sole procedure. All cases were performed by senior residents using 2 different surgical approaches-vaginal or abdominal trocar passage. Power analysis indicated that 103 patients in each group (vaginal and abdominal approach) were required to demonstrate a 50% reduction in perforation rates. RESULTS: The rate of perforation was 37.9% (95% confidence interval [CI], 28.5%-47.3%) for the vaginal compared with 6.8% (95% CI, 1.9%-11.7%) for the abdominal technique (P < 0.001). The relative risk that the abdominal technique results in bladder injury compared with the original transvaginal was 0.18 (95% CI, 0.08-0.38). CONCLUSIONS: Bladder perforation occurs significantly less frequently with abdominal needle placement for the TVT procedure. We recommend this technique to less experienced surgeons.

Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: efficacy and time to response.

OBJECTIVES: : We sought to determine the efficacy of posterior tibial nerve stimulation in patients who had failed anticholinergic medications. A secondary outcome was to determine the time to response for different parameters of overactive bladder. STUDY DESIGN: : The medical records of all patients treated with posterior tibial nerve stimulation from 2000 to 2009 seen in a university urogynecology practice were abstracted. Patients underwent weekly treatments. Patients were asked about the 4 index symptoms at each weekly visit. Descriptive statistics were performed on the data set using SPSS 15. RESULTS: : A total of 141 patients were analyzed. Of these patients, 67.4% were satisfied with treatment results. The median week to improvement was 5 weeks for nocturia, 7 weeks for frequency, 6 weeks for urgency, and 6 weeks for urge incontinence. CONCLUSIONS: : Posterior tibial nerve stimulation is an effective treatment of overactive bladder in patients who have failed anticholinergic therapy. Most patients noted improvement by 6 weeks.

The influence of national society annual scientific meetings on publication in general obstetrics and gynecology literature: a urogynecology perspective.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to determine urogynecology publication rates in obstetrics and gynecology literature. METHODS: Original scientific articles from American Journal of Obstetrics and Gynecology (AJOG) and Obstetrics and Gynecology (Obstet Gynecol) from 1996-2007 were reviewed. RESULTS: A total of 10,192 articles were evaluated. Two trends were noted in the AJOG: percentage of urogynecology articles increased (correlation with year r = 0.845; p < 0.05) and percentage of obstetric articles decreased (negative correlation r = -0.589; p < 0.05). Similarly for Obstet Gynecol, the number of urogynecology articles increased with time with a strong positive correlation of r = 0.743 and p < 0.05. There was a significant difference in the number of articles published in the AJOG in months with an annual scientific meeting compared to months without (t = -6.34; p < 0.001). CONCLUSIONS: The numbers of urogynecology articles published in the general literature has increased and may be related to presentation at national meetings.

Incontinence pads: recommending the best product-based wetback performance and price.

Incontinence pads are available in the USA without a prescription and are commonly the first treatment option a patient with incontinence uses. The goal of this study was to examine the difference in the performance and cost of commercially available incontinence pads with the intention of providing recommendations to women. Ten different urinary incontinence products were selected. A modified wetback test was used to test product performance. For the small volume leaks, the Walgreen's Extra pad generally performed worse on the wetback test than the three other pads tested (p = 0.001-0.012), but four tests were not statistically significant. At larger leak volumes, the Walgreen's underwear generally performed worse than other products (p < or = 0.001-0.046), with some exceptions. Brand name products generally performed better than generic products, but cost more. Undergarments and underwear do the worst job of keeping moisture inside the pad.

Family history as a risk factor for pelvic organ prolapse.

The aim of this study was to determine whether a family history of prolapse and/or hernia is a risk factor for prolapse. A cohort of 458 women seeking gynecological care was classified as exposed (family history) or unexposed (without family history). We used chi2 to assess confounding and logistic regression to determine risk. Nearly half (47.3%) of the 458 participants reported a positive family history. Of these, 52.5% had prolapse. This was significantly higher than the 28.9% rate of prolapse in women without a family history (p<0.001). The crude risk ratio for family history of prolapse and/or hernia and prolapse was 1.8 (95% CI 1.4-2.3). After adjusting for vaginal deliveries, incontinence, and hysterectomy, the risk of prolapse was 1.4 (95% CI 1.2-1.8) times higher in women with a family history of prolapse and/or hernia. Heredity is a risk factor for prolapse. History taking should include both male and female family members.

Short-term efficacy and complications of posterior intravaginal slingplasty.

This study was performed to evaluate the efficacy and complications of the posterior intravaginal slingplasty (IVS). A retrospective chart review was performed. Ninety IVS procedures were performed from January 2004 to June 2005. The group consisted of predominantly nonsmoking, Caucasian, postmenopausal women with a median age of 62 years and a median parity of 3. The mean follow-up was 33 +/- 23.2 weeks with a median of 31.9 weeks. There were no intraoperative bladder, bowel, or vascular injuries. Overall, 11 out of 90 patients developed recurrent or de novo prolapse; 4.4% of these had recurrent apical prolapse. There was a 17.8% incidence of mesh erosion. Only 1 of the 11 patients with recurrent prolapse had concomitant mesh erosion. The procedure demonstrated an unacceptably high erosion rate. The adoption of newer mesh techniques based on the slingplasty concept or the use of the multifilament polypropylene tape should be scrutinized.

Neuromodulation for the treatment of urinary incontinence.

The prevalence of overactive bladder (OAB) in the United States ranges from 10% - 30%. The mainstay of treatment is anticholinergic medication. All agents have significant side effects and at least 30% of patients fail to respond. This paper reviews neuromodulation which involves the use of electrical stimulation of either the sacral or peripheral nerves to modify the behavior of the bladder. It is an option for patients who either cannot tolerate medications or fail therapy.

The painful bladder: urinary tract infection and interstitial cystitis in women.

Irritative voiding symptoms in women are most often due to uncomplicated urinary tract infection. A cost-effective approach to the treatment of urinary tract infections is a reasonable first step. However, in patients who have persistent or frequently recurrent symptoms, a more thorough evaluation is warranted. These women may be found to have interstitial cystitis, requiring further evaluation. While interstitial cystitis remains a difficult disease to treat, a multi-modality therapy provides excellent symptom relief.

Evaluation of urinary incontinence and voiding dysfunction in women.

Urinary incontinence currently affects 33 million American women. In the next 30 years the population over 60 years will increase by 80-90%. This will result in a tremendous increase in patients suffering this condition. It is therefore not feasible for evaluation and treatment to be limited to specialists. Primary care physicians must be comfortable performing basic evaluations which will enable them to formulate a diagnosis and conservative treatment plan. This article outlines a practical approach.

Spontaneous extrusion of sacral nerve implant secondary to massive weight loss.

Sacral neuromodulation (Interstim, Medtronic, Minneapolis, Minnesota) is a recognized treatment for refractory urgency, frequency, and urge incontinence. Revision rates range from 10-33% mainly for pain over the implantable pulse generator site (IPG) or lead migration [Hassouna et al. J Urol 163:1849-1854, 2000; Schmidt et al. J Urol 162:352-357, 1999; Spinelli et al. J Urol 166:541-545, 2001; Swinn et al. Eur Urol 38:439-443, 2000; Weil et al. Eur Urol 37:161-171, 2000; Evaraert et al. Int Urogynecol J Pelvic Floor Dysfunct 11:231-236, 2000]. We report a case of spontaneous extrusion of the IPG through the subcutaneous fat and skin secondary to marked weight loss after gastric bypass surgery. Continued weight loss resulted in multiple surgical interventions and eventual removal of the device.

Patients' knowledge of potential pelvic floor changes associated with pregnancy and delivery.

Physicians cite pelvic floor injury as a major reason for Cesarean section as their personal preferred delivery mode. This study was undertaken to determine whether patients receive information about possible pelvic floor complications of pregnancy/delivery. Day 1 post-partum women completed a 52-item questionnaire assessing information given during routine antenatal care. Pelvic floor and general questions were intermixed. Of the 232 patients, the mean age was 26.9 years, with 59.5% white, 32.8% African-American and 7.7% other. Most (84.5%) had at least grade 12 education. The following percentage of patients reported receiving no information about: Kegel exercises 46.1%; episiotomy 51.3%; urinary incontinence 46.6%; fecal incontinence 80.6%; change in vaginal caliber 72.8%; neuropathy 84.9%. Counseling on all of these issues occurred significantly less frequently than education on general pregnancy topics. Our results suggest that knowledge and instruction of pelvic floor risks is very much lacking and provide us with an impetus to develop educational tools.

Patients' satisfaction with and attitudes toward vaginal delivery.

OBJECTIVE: To determine patient satisfaction with delivery mode and whether information on urinary incontinence would modify their decision. STUDY DESIGN: Postpartum women completed an anonymous questionnaire regarding their delivery, complications, types of information received during pregnancy, and delivery and satisfaction with their mode of delivery. Various risk scenarios for urinary incontinence ranging from 10-50% were presented. RESULTS: One hundred ninety-two ethnically and economically diverse patients responded: 86.4% reported receiving sufficient information on the risks of delivery, and 61.5% thought that cesarean section would not help prevent urinary/fecal incontinence. Irrespective of the magnitude of risk, few patients (5.7-21.9%) chose cesarean section to prevent urinary incontinence. CONCLUSION: Patients were happy with their delivery mode. Most thought that they obtained sufficient information on the various types of delivery available. They would not have chosen a cesarean section over a vaginal delivery even if the risks of urinary incontinence were much higher than currently reported.

Bladder perforation during tension-free vaginal tape procedures: analysis of learning curve and risk factors.

OBJECTIVE: To estimate whether rates of bladder perforation decrease with increasing surgical experience. METHODS: We performed a review of all patients undergoing a tension-free vaginal tape procedure performed by senior resident physicians under the guidance of a single surgeon. Physician experience was assessed by sequentially assigning case numbers to each procedure for each resident. For analysis of learning curve, cases were grouped in fives (ie, first five representing cases 1 to 5, second five cases 6 to 10). RESULTS: Twenty-three residents performed 278 procedures. The median number of cases performed was 13 (range 3 - 22); mean number was 12.1 (sd = +/- 5.6). The rate of perforation was 34.2% (95/278, 95% confidence interval 28.8-39.9%). Age and weight were significantly associated with perforation. The cystotomy group was, on average 4.5 years younger (P = .007) and 7.86 kg (17.3 lb) lighter (P < .001). Rate of injury in the first five series was 40.9%, 30.7% in second series of five, and 25.9% in the third series of five and was statistically significant (linear-by-linear association chi(2) = 4.286, df = 1, P = .038). The relationship between the incidence of cystotomy and the cumulative number of cases performed was inversely correlated. As the number of cases a resident completed increased, there was a slight tendency for cystotomy to decrease (P.033). On cystoscopic examination, residents missed 35 of the 95 injuries (37%, 95% confidence interval 27.8-46.9%). CONCLUSION: A learning curve exists for tension-free vaginal tape procedures. Many injuries are missed on initial resident cystoscopic inspection, highlighting the need for comprehensive cystoscopic training during residency. LEVEL OF EVIDENCE: II-3.

Transurethral resection of transvaginal tape.

Urethral erosion is an uncommon complication after tension-free vaginal tape (TVT) procedure. However, management is a challenge and morbidity significant because of the necessity to incise the urethra to gain access to the material. This is a report of a case of transurethral resection of such mesh. A 77-year-old women presented at 7 months postoperatively with complaints of incomplete emptying and persistent incontinence. Urodynamic testing and cystoscopy revealed intrinsic sphincter deficiency, an elevated post void residual and erosion of the TVT tape into the urethral lumen. The tape was removed without any incisions via an operative cystoscope and hysteroscopic scissors. All urinary symptoms resolved. Partial urethral transection can be managed successfully with transurethral resection of the material. This diagnosis should be considered in patients with incomplete emptying and recurrent incontinence.

The position of the urethrovesical junction after incontinence surgery: early postoperative changes.

This study prospectively evaluated the position of the urethrovesical junction using the Q-tip angle to assess early postoperative changes for different anti-incontinence surgeries. All procedures resulted in a statistically significant change in resting angle from the intraoperative value. The mean change for the transvaginal tape was 25.74 degrees (27.43 to 3.28); Burch 11.18 degrees (-20.44 to -10.0) and fascia sling 13.9 degrees (26.57 to 15.68). The mean change in Q-tip angle was greater after transvaginal tape placement than after Burch ( p=0.000) and fascial sling ( p=0.022) procedures. These findings show that the resting position of the urethrovesical junction after surgery is different for all procedures. The transvaginal tape results in the greatest change in angle. This may help to negate the so-called 'tension-free' nature of the procedure. Surgeons need to be aware of this, as it may be an etiological factor in cases of late urinary retention and urethral erosion.

The role of electrodiagnostic techniques in the reprogramming of patients with a delayed suboptimal response to sacral nerve stimulation.

Sacral neuromodulation is an approved therapy for frequency, urgency, urge incontinence and non-obstructive urinary retention. There are several recent reports on a subgroup of patients who are 'Iate failures' to therapy. This descriptive study aimed to determine whether the use of electrodiagnosis during reprogramming could provide objective data on device function in these patients and help direct therapy. We employed electrodiagnostic techniques to differentiate between those patients who could be reprogrammed in the office to a site of maximal response, those that required reoperation, and those in whom reoperation was unlikely to be successful. Our findings suggest that electrodiagnostic monitoring may help to direct future therapy in this group of patients who currently present a management challenge.