Urodynamics in pelvic organ prolapse: when are they helpful and how do we use them?

The routine use of preoperative urodynamics in the woman considering surgery for pelvic organ prolapse is a topic of much debate. This article addresses the use of urodynamics in patients with pelvic organ prolapse. It specifically discusses the utility of urodynamics in the evaluation stress incontinence on prolapse reduction (occult stress urinary incontinence) as well as concomitant storage and voiding symptoms in these patients.

The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study.

OBJECTIVE: The objective of this study was to investigate the association between chronic back pain and urinary incontinence in women. STUDY DESIGN: This study was a cross-sectional, observational study. BACKGROUND: There are numerous factors associated with the development of back pain, yet little consideration has been given to the pelvic floor musculature and dysfunction of this musculature which may also cause urinary incontinence. Currently, limited research exists evaluating the relationship between back pain and urinary incontinence. METHODS AND MEASURES: Data from a sample of 2,341 women from the Kentucky Women's Health Registry were used for analysis. The primary variables of interest were self-reported chronic back pain (CBP) and stress urinary incontinence (SUI), with stress urinary incontinence serving as the primary dependent variable. Simple comparisons were performed using chi-square tests and two-sample t-tests, and multivariable associations were assessed using binary logistic regression. RESULTS: Reports of stress urinary incontinence were higher in women reporting CBP than those not reporting CBP (49.0% vs. 35.2%, p<0.01). After controlling for potential confounders, the adjusted SUI odds ratio for CBP versus not was 1.44 (95% CI 1.11, 1.86). CONCLUSION: Women who report CBP have an increased odds of having SUI. Therefore, clinicians must consider this association and the relationship of relevant trunk muscles, including pelvic floor musculature, in patients presenting with CBP and/or UI.

Outcomes of patients lost to followup after mid urethral synthetic slings--successes or failures?

PURPOSE: We classified patients lost to followup after mid urethral synthetic sling placement as examples of treatment success or failure based on the Patient Global Impression of Improvement, and compared the outcomes of those who followed up to the outcomes of those who did not. MATERIALS AND METHODS: We reviewed the charts of 217 patients who underwent mid urethral synthetic sling placement. Telephone interviews including the Patient Global Impression of Improvement and the Medical, Epidemiological, and Social Aspects of Aging questionnaires were conducted for patients lacking 3-month followup. RESULTS: Based on the Patient Global Impression of Improvement of the 48 patients who responded 13 (27.1%) were failures. The overall failure rate of patients with at least 3-month followup was 19% (23 of 124). CONCLUSIONS: In our study success rates for patients lost to followup were similar to the rates for those who had routine followup. However, it is uncertain if these data can be applied to other study populations, especially in a randomized controlled trial.

Association between detrusor overactivity and postoperative outcomes in patients undergoing male bone anchored perineal sling.

PURPOSE: In this study we determined if there was an association between the presence of preoperative detrusor overactivity and patient outcomes after bone anchored perineal sling. MATERIALS AND METHODS: A total of 85 men underwent a male perineal sling procedure for urodynamically proven stress urinary incontinence. Preoperative history and physical examination were performed, and patients completed self-assessment questionnaires. Based on urodynamics patients were divided into 2 groups of those with and those without detrusor overactivity. Questionnaires including the Patient Global Impression of Improvement Scale were readministered postoperatively. Success was defined by the Patient Global Impression of Improvement as very much better or much better. Failure was defined by the responses of a little better, no change, a little worse or much worse. Successes and failures were compared to the presence of detrusor overactivity. Preoperative parameters, preoperative and postoperative questionnaire scores, and postoperative pad and anticholinergic use were compared between the 2 groups. RESULTS: A total of 72 patients were included in the analysis, and of these 22 (30.6%) had detrusor overactivity and 50 (69.4%) did not. All patients completed the Patient Global Impression of Improvement. There was no statistical difference in the number of cases classified as successes or failures in the 2 groups (p = 0.4213). A significantly higher percentage of patients with detrusor overactivity required postoperative anticholinergics. There was no statistical difference in the number of patients using pads postoperatively. CONCLUSIONS: Preoperative detrusor overactivity was not associated with worse postoperative outcomes. Men with urodynamic stress urinary incontinence and detrusor overactivity may be considered for a male sling procedure. However, they may require postoperative anticholinergics and should be counseled accordingly.

Fistulization between ectopic ureteral stump and uterus following nephroureterectomy: case report.

Ureterouterine fistulas are rare surgical complications with fewer than 30 reported cases in the literature to date. Rarer yet is a fistula between an ectopic ureter and the uterus, with only one case described previously (Shibata et al. in J Urol 153: 1208-1210, 1995). Herein, we present the first case, to our knowledge, of a fistula between an ectopic ureteral stump (from a prior nephroureterectomy) and the uterus.

Artificial urinary sphincter versus male sling for post-prostatectomy incontinence--what do patients choose?

PURPOSE: Early outcomes of the male sling to correct post-prostatectomy incontinence have been promising in select patients. Long-term data are lacking to determine whether the male sling is as effective as the artificial urinary sphincter, which is the current gold standard. Because the male sling offers the significant advantage of avoiding a mechanical device but without established success, we determined the patient preference for the male sling vs the artificial urinary sphincter. MATERIALS AND METHODS: We reviewed the charts of 133 men with post-prostatectomy incontinence who underwent the first procedure to correct incontinence. After urodynamics the surgeon recommended an artificial urinary sphincter or a male sling and patients were told the artificial urinary sphincter satisfaction rate and shorter term data on the male sling. Patients with high grade post-prostatectomy incontinence (pad weight greater than 400 gm/24 hours) were recommended to receive an artificial urinary sphincter, those with moderate post-prostatectomy incontinence (pad weight 100 to 400 gm/24 hours) were recommended to receive an artificial urinary sphincter or a male sling and those with mild post-prostatectomy incontinence (pad weight less than 100 gm/24 hours) were recommended to receive a male sling. RESULTS: A total of 84 male sling (63%) and 49 artificial urinary sphincter (37%) procedures were performed. The surgeon recommendation was an artificial urinary sphincter in 63 men (47%) and a male sling in 46 (35%). A total of 24 men (18%) were given the option of either procedure. All patients recommended to receive a male sling chose it. When an artificial urinary sphincter was recommended, 75% of patients chose it, while 25% chose a male sling. When given a choice, 92% of patients chose a male sling and 8% chose an artificial urinary sphincter. CONCLUSIONS: Most patients adhere to the surgeon recommendation. When men with post-prostatectomy incontinence are offered the choice of an artificial urinary sphincter vs a male sling, the opportunity to avoid using a mechanical device is preferable to undergoing a well established procedure. Men who strongly wish to avoid a mechanical device are willing to go against the surgeon recommendation for an artificial urinary sphincter.

Managing the urethra at transvaginal pelvic organ prolapse repair: a urodynamic approach.

PURPOSE: We evaluated the protocol that we use to determine whether a mid urethral synthetic sling will be placed at transvaginal pelvic organ prolapse repair. MATERIALS AND METHODS: A total of 140 patients underwent transvaginal repair for stage 2 to 4 pelvic organ prolapse, of whom 105 were treated according to the protocol and had a minimum 3 months of followup or required earlier intervention. Urodynamics were performed without prolapse reduction. When stress urinary incontinence was not identified, a pessary was placed and the study was repeated. Patients were designated as having urodynamic, occult or no stress urinary incontinence. Patients with urodynamic or occult stress urinary incontinence underwent a simultaneous mid urethral synthetic sling procedure, while those without urodynamic or occult stress urinary incontinence did not. Charts were reviewed to determine whether further intervention was required for stress urinary incontinence or obstruction. RESULTS: The risk of intervention due to obstruction after receiving a mid urethral synthetic sling was 8.5%. The risk of intervention for stress urinary incontinence in patients with no clinical, urodynamic or occult stress urinary incontinence and no mid urethral synthetic sling was 8.3%. The risk of intervention for stress urinary incontinence in patients with clinical stress urinary incontinence but no urodynamic or occult stress urinary incontinence and no mid urethral sling was 30%. CONCLUSIONS: Using our urodynamic protocol to manage the urethra at transvaginal pelvic organ prolapse repair the risk of intervention due to obstruction is essentially equal to the risk of intervention due to stress urinary incontinence when no clinical, urodynamic or occult stress urinary incontinence was present and no mid urethral synthetic sling was placed. In patients who report clinical stress urinary incontinence preoperatively despite no urodynamic or occult stress urinary incontinence there is a much higher rate of further intervention for stress urinary incontinence.

Patient-reported outcomes for tension-free vaginal tape-obturator in women treated with a previous anti-incontinence procedure.

Our purpose was to evaluate the outcome of a subset of patients that had a tension-free vaginal tape-obturator (TVT-O) placed following a previous anti-incontinence procedure. We performed a retrospective analysis of 27 consecutive women who had a TVT-O placed from January 2004 to December 2007. Patients were given the Patient Global Impression of Improvement (PGI-I) questionnaire starting at the 3-month follow-up. Of 174 women who had a TVT-O placed, 27 (15.5%) had a prior failed anti-incontinence procedure or surgery performed. The mean age was 63.8 years (range 43-87). Mean follow-up was 25.7 months (range 12-47 months). Based on the PGI-I, the overall success rate was 80% (20/25). In the properly selected patients with prior intervention for stress urinary incontinence (SUI), the success rate for TVT-O of 80% appears to be comparable to that of patients who never had a previous surgical or minimally invasive treatment for SUI.

Effect of tension-free vaginal tape and TVT-obturator on lower urinary tract symptoms other than stress urinary incontinence.

Variable effects on lower urinary tract symptoms (LUTS) other than stress urinary incontinence (SUI) have been reported after tension-free vaginal tape (TVT). We measured the effect of TVT on LUTS using the American Urological Association Symptom Index (AUASI). Patients undergoing TVT completed the AUASI pre- and post-operatively. Total scores (TS), storage scores (SS), and voiding scores (VS) were compared overall and among patients with SUI vs mixed urinary incontinence (MUI) and those who underwent TVT vs TVT-obturator (TVT-O). The mean change in TS and SS was -3.6 and -3.0. Mean reductions in TS and SS were significant in all patient subsets with no change in VS. There was no significant difference in the mean changes in TS between patients with SUI vs MUI or those undergoing TVT vs TVT-O. LUTS are improved after TVT in most patients. In general, voiding symptoms were not adversely affected.