Risk factors for the failure of antimuscarinic treatment with solifenacin in women with overactive bladder.

OBJECTIVE: To evaluate the outcomes of women treated with Solifenacin 5 mg once a day for overactive bladder (OAB) to identify the factors associated with the risk of treatment failure. METHODS: Women with OAB symptoms for at least 3 months were considered for this study. At visit 0, patients received a 3-day voiding diary. Eligibility was determined at visit 1, 2 weeks later, on the basis of the results recorded in the 3-day voiding diary. To be included, patients had to have experienced at least 3 episodes of urgency during the 3-day voiding diary period. Eligible women received a 12-week antimuscarinic therapy with oral Solifenacin 5 mg once a day. At the follow-up examination, objective outcomes included changes from baseline in the 3-day voiding diary data. Subjective efficacy was evaluated using the Overactive Bladder Questionnaire Short Form (OABq-SF), the Indevus urgency severity scale (USS) questionnaire, and the Patient Global Impression of Improvement. RESULTS: A total of 675 (69.3%) women met the inclusion criteria and were directed to Solifenacin therapy. After a 12-week treatment, 632 (93.6%) women were assessed for office evaluation, and 101 (16%) patients were considered as nonresponders. The antimuscarinics were effective both in terms of improvement of questionnaires scores and in terms of reduction of episodes of urgency/24 hour (P <.0001). In multivariable analysis, the number of episodes of urgency/24 hour, baseline OABq-SF symptom severity score, and baseline USS were independent predictors of Solifenacin failure. CONCLUSION: Some markers of OAB severity, such as the higher number of episodes of urgency/24 hour and the higher OABq-SF symptom severity score and USS at baseline, were associated with a lower therapeutic efficacy of Solifenacin.

Deep endometriosis and bladder and detrusor functions in women without urinary symptoms: a pilot study through an unexplored world.

OBJECTIVE: To evaluate the impact of deep endometriosis (DE) on bladder function, focusing on detrusor pattern, in patients without preoperative urinary symptoms. DESIGN: Prospective study. SETTING: Academic research center. PATIENT(S): A total of 25 asymptomatic patients: 12 patients with DE (group 1) and 13 patients with ovarian endometriosis (group 2, control group). INTERVENTION(S): Preoperative urodynamic evaluation. MAIN OUTCOME MEASURE(S): The impact of DE on urodynamic parameters. RESULT(S): For the first time, a urodynamic diagnosis of detrusor overactivity was correlated with the presence of deep infiltrating endometriosis (group 1, 91.7% [11/12] vs. group 2, 7.7% [1/13]). All involuntary detrusor contractions were detected only during the filling phase. All cystometry parameters were found to be altered in group 1 and statistically different between the two groups. No pressure/flow study parameter significantly differed between the two groups, besides maximal detrusor pressure (46 cmH2O [33-79] vs. 29 cmH2O [15-40]), which was significantly higher in group 1. Therefore, all detrusor-related parameters are statistically different between the two groups. Postvoid residual does not reach a statistically significant difference. CONCLUSION(S): DE could significantly impair detrusor functions. A preoperative urodynamic evaluation allows the attainment of important functional information, even in asymptomatic patients.

Urodynamic evaluation: can it prevent the need for surgical intervention in women with apparent pure stress urinary incontinence?

OBJECTIVES: To identify how many patients with symptoms of pure stress urinary incontinence (SUI) do not require any surgical treatment on the basis of urodynamics (UDS) and how many patients still do not require surgery 1 year after UDS. To assess the outcomes of these patients at 12-month follow-up. PATIENTS AND METHODS: Women with pure SUI received UDS and were prospectively divided into four groups, comprising women with: urodynamic stress incontinence (USI); detrusor overactivity (DO); USI + DO; and inconclusive UDS. Women with USI underwent a Tension Free Vaginal Tape (Obturator) (TVT-O) procedure (Gynecare; Ethicon Inc., Somerville, NJ, USA), whereas women with DO ±/- USI were recommended 24-week antimuscarinic therapy. Follow-up was scheduled at 3 and 12 months. To define subjective outcomes, all patients completed the International Consultation on Incontinence Questionnaire - short form, the Patient Global Impression - Improvement and the Urinary Distress Inventory. Patients were considered cured if they presented a negative stress test, a score reduction of at least 80% on the Urinary Distress Inventory and a response of 'much better' or 'very much better' on the Patient Global Impression - Improvement. RESULTS: Of the 263 women with pure SUI, 74.5% had a urodynamic diagnosis of USI, 10.6% had DO, 8% had USI + DO and 6.8% had inconclusive UDS. At 12-month follow-up, 165/181 (91.6%) women in group 1 were considered cured post-TVT-O; in the other groups, 33/67 (49.2%) patients were considered cured simply as a result of taking antimuscarinics; 13 of these 67 patients required TVT-O. CONCLUSIONS: UDS is able to show that several patients with symptoms of pure SUI present an underlying DO and do not require surgery, even 1 year after UDS. In these patients, antimuscarinic treatment appears to ensure a good rate of cure; thus, UDS could lead to the avoidance of several surgical procedures.

TVT-O for the treatment of pure urodynamic stress incontinence: efficacy, adverse effects, and prognostic factors at 5-year follow-up.

BACKGROUND: Inside-out tension-free vaginal transobturator tape (TVT-O) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI), but data reporting long-term outcomes are scarce. OBJECTIVE: To evaluate the efficacy and safety of TVT-O 5-yr implantation for management of pure SUI in women. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study was conducted in four tertiary reference centers. Consecutive women presenting with urodynamically proven, pure SUI treated by TVT-O were included. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. INTERVENTION: TVT-O implantation without any associated procedure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Data regarding subjective outcomes (International Consultation on Incontinence-Short Form [ICIQ-SF], Patient Global Impression of Improvement, patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Multivariable analyses were performed to investigate outcomes. RESULTS AND LIMITATIONS: Of the 191 women included, 21 (11.0%) had previously undergone a failed anti-incontinence surgical procedure. Six (3.1%) patients were lost to follow-up. The 5-yr subjective and objective cure rates were 90.3% and 90.8%, respectively. De novo overactive bladder (OAB) was reported by 24.3% of patients at 5-yr follow-up. Median ICIQ-SF score significantly improved from 17 (interquartile range [IQR]:16-17) preoperatively to 0 (IQR: 0-2) (p<0.0001). Failure of a previous anti-incontinence procedure was the only independent predictor of subjective recurrence of SUI (hazard ratio [HR]: 4.4; p = 0.009) or objective (HR: 3.7; p = 0.02). No predictive factor of de novo OAB was identified. CONCLUSIONS: TVT-O implantation is a highly effective option for the treatment of women with pure SUI, showing a very high cure rate and a low incidence of complications after 5-yr follow-up.

Transobturator vaginal tape for the treatment of stress urinary incontinence in elderly women without concomitant pelvic organ prolapse: is it effective and safe?

OBJECTIVE: To evaluate the efficacy and safety of the transobturator approach (TVT-O) for the surgical management of stress urinary incontinence (SUI) in older women. STUDY DESIGN: Between 2007 and 2010, all consecutive women with SUI undergoing an isolated TVT-O procedure were prospectively enrolled in this study. Patients were divided into two groups by age: older women (≥ 70 years old) were included in group 1, while younger women (< 70 years old) in group 2. Intra- and post-operative outcomes were compared between the groups. RESULTS: During the study period 181 women met the inclusion criteria and were included for final analysis. Among these women, 60 (33.1%) and 121 (66.9%) were included in groups 1 and 2 respectively. After a median follow-up of 26 (IQR 15-41) months for the younger and 25 (IQR 18-40) months for older patients (p>0.99), no differences were observed between the two groups in terms of cure rate (92.5% vs. 88.3%; p=0.40). No differences were observed in terms of voiding dysfunction, vaginal erosion and persistent groin pain, or in terms of onset of de novo overactive bladder (9.0% vs. 13.3%; p=0.44). CONCLUSIONS: TVT-O appears to be a safe and effective procedure for the management of stress urinary incontinence also in elderly population.

Tension-free vaginal tape for the treatment of urodynamic stress incontinence: efficacy and adverse effects at 10-year follow-up.

BACKGROUND: One of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings. OBJECTIVE: To evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. INTERVENTION: Standard retropubic TVT. MEASUREMENTS: Patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes. RESULTS AND LIMITATIONS: A total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p>0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9cm H(2)O (hazard ratio [HR]: 16.2; p=0.01) and maximum detrusor pressure during the voiding phase ≤29cm H(2)O (HR: 8.0; p=0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p=0.01) and of USI (HR: 8.9; p=0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred. CONCLUSIONS: The 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.

The impact of mid-urethral slings for the treatment of urodynamic stress incontinence on female sexual function: a multicenter prospective study.

INTRODUCTION: Urinary incontinence is a common condition that negatively impacts on female sexuality (FS). AIM: To evaluate FS before and after a mid-urethral sling (MUS) procedure using the Female Sexual Function Index (FSFI). We included women that were both sexually and nonsexually active at baseline. METHODS: One hundred fifty-seven women complaining of urodynamic stress incontinence underwent a MUS procedure and were enrolled in the study. All patients answered the Italian translation of FSFI, before and 12 months after surgery. To understand the real impact of the MUS on female sexual function, for the first time in the literature, we also monitored and included in the final analysis all the women who are nonsexually active at baseline. We evaluated the prevalence of female sexual dysfunction according to the FSFI cutoff point (26.55). MAIN OUTCOME MEASURES: FSFI total score, pads use, and stress test presurgery and postsurgery. RESULTS: One hundred thirty-three patients completed the study protocol: 105 out of 133 underwent to a trans-obturator procedure, while 28 out of 133 had a retropubic procedure. After the 12-month follow up, 115 out of 133 patients (86%) were dry, 10 improved their symptoms, and the remaining 8 were unchanged. Seventy-nine out of 133 (59%) patients reported an active sexual life before surgery. Fifty-four (41%) reported they were not sexually active before surgery. Twelve months after surgery, 22 out of 54 nonsexually active women (40%) reestablished sexual activity, whereas only 6 out of 79 (7.5%) patients, sexually active at baseline, were not sexually active 1 year after surgery (P < 0.05). After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score postsurgery as independent variables. Conclusions. Our data showed that after a MUS procedure, female sexual function improves. We also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after MUS.

Female urinary incontinence at orgasm: a possible marker of a more severe form of detrusor overactivity. Can ultrasound measurement of bladder wall thickness explain it?

INTRODUCTION: Coital incontinence (CI) during orgasm is a form of urinary incontinence possibly because of detrusor overactivity (DO), as the underlying pathophysiological condition. Women with this symptom usually show a pharmacological lower cure rate than those with DO alone. The ultrasound measurement of the bladder wall thickness (BWT) allows an indirect evaluation of detrusor muscle thickness, giving a potential index of detrusor activity. AIM: We wanted to understand if CI at orgasm could be a marker of severity of DO by comparing BWT in women with both DO and CI at orgasm vs. women with DO alone. In addition we aimed to confirm if CI during orgasm is related to antimuscarinics treatment failure. METHODS: This is a prospective cohort study performed in two tertiary urogynecological referral departments, recruiting consecutive patients seeking treatment for symptomatic DO. MAIN OUTCOME MEASURES: All patients were thoroughly assessed including physical examination, urodynamic evaluation, and BWT measurement according to the International Continence Society/International Urogynecological Association and ICI recommendations. Solifenacine 5 mg once daily was then prescribed and follow-up was scheduled to evaluate treatment. Multiple logistic regression (MLR) was performed to identify risk factors for treatment failure. RESULTS: Between September 2007 and March 2010, 31 (22.6%) and 106 (77.4%) women with DO with and without CI at orgasm were enrolled. Women complaining of CI at orgasm had significantly higher BWT than the control group (5.8 ± 0.6 mm vs. 5.2 ± 1.2 mm [P=0.007]). In patients with CI at orgasm, the nonresponder rate to antimuscarinics was significantly higher than controls (P=0.01). After MLR, CI at orgasm was the only independent predictor decreasing antimuscarinics efficacy (odds ratio [OR] 3.16 [95% CI 1.22-8.18], P=0.02). CONCLUSIONS: Women with DO and CI at orgasm showed a significantly higher BWT values and worse cure rates than women with DO alone. CI at orgasm could be a marker of a more severe form of DO.

Urinary symptoms and urodynamic findings in women with pelvic organ prolapse: is there a correlation? Results of an artificial neural network analysis.

BACKGROUND: International official guidelines recommend urodynamic (UDS) evaluation in patients with pelvic organ prolapse (POP). However, the real benefit of this examination is still the subject of heated and controversial debate. Therefore, we aimed to assess the correlation between urinary symptoms and UDS findings in women with POP through the implementation of a sophisticated computer-based technology in the outpatient workup. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was performed in a single, tertiary, urogynaecologic referral department, enrolling consecutive women seeking care for pelvic floor dysfunctions. INTERVENTION: Patients underwent clinical and urodynamic evaluation. Data regarding baseline characteristics, symptoms, anatomic, and urodynamic findings were gathered for each patient. Multiple linear regression (MLR) and artificial neural networks (ANNs) were performed to design predicting models. RESULTS AND LIMITATIONS: A total of 802 women with POP were included. POP quantification stages and baseline data poorly correlated to final UDS findings. Stress urinary incontinence and overactive bladder were both independently associated to each UDS diagnosis, including detrusor overactivity (DO), urodynamic stress incontinence (USI), and mixed urinary incontinence (USI plus DO). Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLR in identifying predictors of UDS diagnosis, but none of these methods could successfully overcome UDS. Case-control studies are needed to confirm our findings. CONCLUSIONS: Despite the current debate based on the actual value of UDS in women with POP, even the implementation of ANN, a sophisticated computer-based technology, does not permit an accurate diagnosis just on the basis of symptoms or avoiding UDS. Therefore, in women with POP, especially if scheduled for surgery, UDS should be considered as mandatory, since misleading counselling could result in unpleasant unexpected events.

Urinary tract infections in women.

Urinary tract infections (UTIs) are conditions frequently complained by women both in the general population and in the hospital setting. Indeed it has been estimated that one woman out of three will experience at least an episode of UTI during lifetime. A comprehensive literature review of published experimental and clinical studies of UTI was carried out at the University of Insubria electronic library (SFX Bicocca-Insubria) with cross-search of seven different medical databases (AMED, BIOSIS Previews on Web of Knowledge, Cochrane Library, Embase and Medline on Web of Knowledge, OvidSP and PubMed). We aimed to draw a clinical guideline addressed to the management of UTI, based on the most recent evidence.

Correlation between anatomical findings and symptoms in women with pelvic organ prolapse using an artificial neural network analysis.

INTRODUCTION AND HYPOTHESIS: The aim of the present study was to assess the relationship between lower urinary tract symptoms, anatomical findings, and baseline characteristics in women with pelvic organ prolapse (POP). METHODS: A cross-sectional observational study was performed, enrolling consecutive women seeking cares for lower urinary tract symptoms (LUTS) with evidence of POP. Data regarding baseline characteristics, LUTS, and physical examination were gathered for each patient. Multivariate analysis (multiple linear regression (MLR)) and artificial neural networks (ANNs) were performed to design predicting models. RESULTS: A total of 1,344 women were included. Age, BMI, pelvic organ prolapse quantification (POP-Q) stage I, and previous surgery for urinary incontinence resulted predictors of urgency and stress incontinence. POP-Q stages III-IV were related to voiding dysfunction and POP symptoms. Age, BMI, and menopausal status resulted predictors for sexual dysfunction. Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLRs in identifying predictors of LUTS. CONCLUSIONS: LUTS result from a fine interaction between baseline characteristics and anatomical findings. ANNs are valuable instrument for better understanding complex biological models.

Female sexual function during pregnancy and after childbirth.

INTRODUCTION: Healthy sexual function during pregnancy and after childbirth is one of the cornerstones for couples to evolve from partners to parents. AIM: The aim of our review is to evaluate the available evidence and define present knowledge about female sexual function during pregnancy and after childbirth. METHODS: PubMed was searched for articles on sexual function during pregnancy and after childbirth, published from 1960 up to date. The most relevant articles have been reviewed and included. MAIN OUTCOME MEASURES: The main outcome is the review of the effect of pregnancy, delivery, and postpartum on female sexuality. RESULTS: A total of 48 articles which specifically addressed this topic were included. Sexual function was found to have a significant global decline during pregnancy, particularly in the third trimester and this persisted for 3-6 months following delivery. The lack of adequate information about sex in pregnancy and concerns about the possible adverse obstetric outcomes are the most relevant factors responsible for the avoidance of sexual activity during pregnancy. Breast-feeding, dyspareunia, and postpartum pelvic floor dysfunction were reported as possible causes for the delay in resuming sexual intercourses after childbirth. CONCLUSIONS: Couples should be informed about the decline of libido, desire and orgasm, commonly encountered during pregnancy, particularly in the last trimester, and puerperium which may lead to reduction in sexual intercourse frequency.

Ultrasound measurement of bladder wall thickness in different forms of detrusor overactivity.

INTRODUCTION AND HYPOTHESIS: Aims of this study were to compare the ultrasound measurement of bladder wall thickness (BWT) in women with different urodynamic diagnosis and to correlate BWT to the different urodynamic findings of detrusor overactivity (DO). METHODS: Two hundred forty seven women with urinary symptoms have been prospectively enrolled. Urodynamics and transvaginal ultrasound BWT were performed. Patients were divided into four urodynamic subgroups. BWT of women with DO was compared with the BWT of any other subgroup. RESULTS: Women with DO had a BWT value significantly higher (p < 0.0001). A cut-off of 6.5 mm for BWT had a positive predictive value of 100% for all DO. We use ROC curves to analyze the BWT for urgency urinary incontinence (AUC 0.645 95% CI 0.57-0.72) and the BWT for "pure DO" (AUC 0.702 95% CI 0.64-0.76) and for "all DO" (AUC 0.704 95% CI 0.64-0.77) vs other urodynamic diagnoses. CONCLUSIONS: The ultrasound BWT showed a highly significant association with DO. However, the performance of this test cannot currently replace urodynamic testing.

The impact of the loop electrosurgical excisional procedure for cervical intraepithelial lesions on female sexual function.

INTRODUCTION: Very limited knowledge exists concerning the impact of Loop Electrosurgical Excisional Procedure (LEEP) on female sexual function in women with cervical intraepithelial neoplasia AIM: To investigate sexual function in women who underwent LEEP for the treatment of cervical intraepithelial lesions, using a validated questionnaire (Female Sexual Function Index [FSFI]). MAIN OUTCOME MEASURES: FSFI questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, and pain). METHODS: Consecutive sexually active women, who underwent LEEP for the treatment of cervical intraepithelial neoplasia were enrolled in this study. All women were asked to complete a copy of FSFI questionnaire, at the time of LEEP and after 6 months. We finally compared the results of the pre-LEEP questionnaire and the post-LEEP questionnaire for each patient. RESULTS: A total of 67 sexually active women undergoing LEEP for the treatment of cervical intraepithelial lesions were enrolled. Nine of these patients (13.4%) completed only the questionnaire regarding their sexual function before LEEP; thus we did not include them for final analysis. In our study population, data showed a sexual function overall unchanged after LEEP; only the variable "desire" (sexual interest) became significantly worse (P = 0.02). CONCLUSIONS: LEEP for the treatment of cervical intraepithelial lesions doesn't affect women's sexuality, when compared with sexual function before surgery. In our study, all FSFI sexual function domains but desire, did not show significant change after LEEP.

The impact of the mid-urethral slings for the treatment of stress urinary incontinence on female sexuality.

INTRODUCTION: No available review has been specifically designed to analyze the relationship between mid-urethral slings for stress urinary incontinence (SUI) and female sexual function. AIM: The aim of our review has been to go through the available evidence and define the present state of the art about the effects of this specific type of surgery for SUI on female sexuality. METHODS: PubMed was searched for reports about the impact of mid-urethral slings on female sexual function that were published from 1995 to 2008, and the most relevant papers were reviewed. MAIN OUTCOME MEASURES: Review on the effect of mid-urethral slings on sexuality. RESULTS: A total of 14 papers including 904 women have been published about the relationship between mid-urethral slings and female sexual function. The main mechanism accounting for improved sexuality is the cure of coital incontinence, while the most common symptom related to worsened sexual life is dyspareunia. CONCLUSIONS: In the majority of cases, women undergoing mid-urethral sling procedures for SUI report that their sexual function is improved or unchanged by this type of surgery, although a not negligible risk of developing dyspareunia (<15%) exists. There are no sufficient data to draw definitive conclusions about possible differences between retropubic vs. transobturator procedures.