Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital.

Objective: To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications. Methods: A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022. Results: Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I. Conclusion: SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

Adherencias del capuchón del clítoris al glande: una condición poco estudiada y poco examinada / Clitoral hood adhesions to the glans penis: an understudied and under-examined condition

INTRODUCCIÓN: El clítoris es una de las estructuras vulvares menos examinadas, pese a su relevancia en la vida sexual y sus importantes relaciones anatómicas. Las adherencias del capuchón del clítoris han sido descritas y clasificadas según la exposición del glande, siendo relacionadas con trastornos del deseo sexual. La inervación del clítoris depende de raíces de S3-S4, siendo posible que síntomas frecuentes del piso pélvico tengan relación con esta condición. Realizamos un análisis retrospectivo de pacientes de policlínico de piso pélvico entre noviembre de 2021 y abril de 2022. Se incluyeron 100 pacientes con adherencias al ingreso. RESULTADOS: Promedio de edad 45,8 ± 15,5 años. Las adherencias fueron el 19% leves, el 62% moderadas y el 18% graves. Los principales síntomas eran mal vaciado vesical (38%), dolor (28%), disfunción sexual (39%) y síntomas irritativos vesicales (43%); solo una paciente fue asintomática. El área visible promedio del clítoris era de 20,7 ± 13,7 mm2. CONCLUSIONES: Las adherencias del capuchón del clítoris son un hallazgo común, muchas veces no diagnosticadas, por lo que su evaluación debe ser parte de la exploración física. Pueden asociarse a sintomatología de piso pélvico.

INTRODUCTION: The clitoris is one of the least examined vulvar structures despite its relevance in sexual life and important anatomical relationships. Clitoral hood adhesions have been described in the literature, classified based on glans exposure, and related to sexual desire disorders. The innervation of the clitoris depends on the roots of S3-S4, and frequent pelvic floor symptoms may be associated with this condition. We retrospectively analyzed the clinical record of patients admitted to a pelvic floor clinic between November 2021 and April 2022. One hundred patients with adhesions at the time of admission were registered. RESULTS: Average 45.8 ± 15.5 years. Clitoral hood adhesions were mild (19%), moderated (62%), or severe (18%). The main symptoms were voiding dysfunction symptoms (38%), pain (28%), sexual dysfunction (39%), and irritative bladder symptoms (43%); only one patient was asymptomatic. The visible area of the clitoris was 20.7 ± 13.7 mm2. CONCLUSIONS: Adhesions of the clitoral hood are often undiagnosed, and its analysis should be part of the physical exam. Clitoral hood adhesions could be associated with pelvic floor symptoms.

Defining bladder outlet obstruction and detrusor underactivity in females with overactive bladder: Are we forgetting about the free uroflowmetry?

INTRODUCTION: Both detrusor underactivity (DU) and bladder outlet obstruction (BOO) can coexist in patients with overactive bladder. Definitions of both DU and BOO are based on pressure-flow study (PFS) data. However, invasive urodynamics study can differ from a natural micturition, in fact, discrepancies between free uroflowmetry (UFM) and PFS have been largely described. Our goal is to assess the correlation of free-flowmetry and PFS among patients with OAB and to evaluate how different definitions of DU/BOO are able to discriminate patients with different free UFMs. METHODS: A retrospective review of urodynamics performed at a single institution was conducted. Females with OAB who voided more than 150 mL in both UFM and PFS were included. Parameters from both voiding episodes were compared with nonparametric test. Two definitions of DU were applied; PIP1: Pdet@Qmax+Qmax < 30 and Gammie: Pdet@Qmax < 20 cmH2 O, Qmax < 15 mL/s, and BVE < 90% (Bladder voiding efficiency). Also, two definitions of obstruction were chosen; Defretias: Pdet@Qmax ≥25 cmH2 O and Qmax ≤ 12 mL/s and Solomon-Greenwell female BOO index ≥ 18. Patients who matched with each definition were compared to those who did not, to assess if any definitions were able to discriminate different noninvasive uroflowmetries. RESULTS: A total of 195 patients were included. Overall, mean age was 55 ± 12 years, 90.8% had mixed urinary incontinence, and 39% complained of at least one voiding symptom. Globally, Qmax and BVE correlated poorly between UFM and PFS, showing that most of the variation corresponded to a systematic error. Twenty-two individuals were found to have DU, they had a difference of 13 mL/s on both maximum flows. Fifty-four patients showed BOO, with a difference between their Qmax of 19 mL/s. Among the four definitions analyzed, only PIP1 and Defreitas were able to discriminate patients with actually a lower Qmax on the free UFM. CONCLUSIONS: Patients with overactive bladder seem to have a systematic discordance between the urine flow of the free and invasive studies. Current definitions of DU and BOO, which are based on the PFS parameters, are not consistently able to discriminate patients who actually void deficiently on the free UFM.

Agentes de abultamiento en incontinencia de orina de esfuerzo femenina: una alternativa a las mallas suburetrales / Bulking agents in female stress urinary incontinence: an alternative to suburethral mesh

OBJETIVO: Presentar una serie de casos de agentes de abultamiento (AA) de nuestro centro. MATERIAL Y MÉTODOS: Estudio retrospectivo. Se evaluaron todos los casos operados con AA entre 2017 y 2022. La inyección de AA se realizó en quirófano, bajo sedación con anestesia local periuretral o raquídea. La inyección se realizó con uretroscopia, 0,5 cc en 4 puntos periuretrales (horas 2, 5, 7 y 10). Se analizaron datos demográficos, quirúrgicos y de seguimiento. RESULTADOS: 15 casos. 13/15 presentaron incontinencia urinaria mixta. Solo dos casos tenían incontinencia de orina de esfuerzo pura. El procedimiento fue ambulatorio. La mediana del tiempo operatorio fue 15 minutos (15-20). La mediana de seguimiento fue 5 meses (1-9). El índice de severidad preoperatorio promedio fue 10,6 y en el seguimiento fue 2,79. La Escala de Mejoría Global mostró mejoría en 12/15, y 12/15 estaban satisfechas con la cirugía con mejoría en la calidad de vida. CONCLUSIÓN: Los AA son una opción quirúrgica efectiva, con una tasa de éxito del 80% en otros reportes, siendo similar con nuestra casuística. Ofrecer esta opción es posible a la hora de hablar de terapias alternativas.

OBJECTIVE: To present a case series of bulking agents (BA) from our center. MATERIAL AND METHODS: Retrospective study. All cases operated with BA between 2017 and 2022 were evaluated. A BA injection was performed in the operating room, under periurethral local anesthesia sedation or spinal anesthesia. The injection was performed with urethroscopy, 0.5 cc in 4 periurethral points (hours 2, 5, 7 and 10). Demographic, surgical, and follow-up data were analyzed. RESULTS: 15 cases were reported. 13/15 patients presented with mixed urinary incontinence. Only 2 cases had pure stress urinary incontinence. The procedure was ambulatory. Median operative time was 15 minutes (15-20). Median follow-up was 5 months (1-9). The average preoperative Sandvik Severity Index was 10.6 and in follow-up was 2.79. The PGI showed improvement in 12/15, and 12/15 were satisfied with the surgery with quality-of-life improvement. CONCLUSION: BA are an effective surgical option, with a success rate of 80%, according to other reports, being similar with our casuistry. Offer this option is possible at the moment of discussing alternative therapies.