Recognizing and Managing Common Urogynecologic Disorders.

Many women experience urogynecologic or pelvic floor disorders, especially urinary incontinence and pelvic organ prolapse. The obstetrician/gynecologist is often the first health care professional to evaluate and treat these disorders. Treatments include pelvic floor muscle training, behavioral therapies, oral medications, neuromodulation, intradetrusor medications, and surgery. When approaching the woman with symptomatic prolapse, familiarity with pessaries and various surgical procedures aid in counseling. Referral to a pelvic floor physical therapist or to a female pelvic medicine and reconstructive surgeon should be considered. Increasing attention to data on cost-effectiveness is a necessity.

Stress urinary incontinence and overactive bladder syndrome: current options and new targets for management.

In the United States, office visits for women seeking treatment for urinary incontinence more than doubled between 1994 and 2000, from 1845 per 100 000 women. This review article addresses treatment options for 2 common types of incontinence in women: stress urinary incontinence (SUI) and detrusor overactivity (DO), commonly referred to as urge urinary incontinence (UUI). In the past, those with SUI typically faced limited treatment options, such as Kegel exercises, pessaries, or major surgery (Burch or Marshall-Marchetti-Krantz operations). However, treatment options for women also included anticholinergic medications, behavioral therapy, and implantable neuromodulation. In recent years, more options have become available. For women with SUI, a variety of minimally invasive synthetic midurethral sling approaches (eg, retropubic, transobturator, and single incision) and office-based procedures (eg, periurethral injection of bulking agents and radiofrequency collagen denaturation [Renessa®; Novasys Medical]) are now offered. More outpatient options will hopefully be available soon, including an inflatable, free-floating balloon to act as a shock absorber, and injection of muscle-derived stem cells into the periurethral tissue. Women with UUI now have targeted options, such as posterior tibial nerve stimulation (PTNS) and intravesical injections of onabotulinumtoxinA (Botox®; Allergan, Inc.), in addition to nonoral systemic medications.

Nonsurgical transurethral radiofrequency collagen denaturation: results at three years after treatment.

Objective. To assess treatment efficacy and quality of life in women with stress urinary incontinence 3 years after treatment with nonsurgical transurethral radiofrequency collagen denaturation. Methods. This prospective study included 139 women with stress urinary incontinence due to bladder outlet hypermobility. Radiofrequency collagen denaturation was performed using local anesthesia in an office setting. Assessments included incontinence quality of life (I-QOL) and urogenital distress inventory (UDI-6) instruments. Results. In total, 139 women were enrolled and 136 women were treated (mean age, 47 years). At 36 months, intent-to-treat analysis (n = 139) revealed significant improvements in quality of life. Mean I-QOL score improved 17 points from baseline (P = .0004), while mean UDI-6 score improved (decreased) 19 points (P = .0005). Conclusions. Transurethral collagen denaturation is a low-risk, office-based procedure that results in durable quality-of-life improvements in a significant proportion of women for as long as 3 years.

Nonsurgical transurethral collagen denaturation for stress urinary incontinence in women: 18-month results from a prospective long-term study.

AIMS: To evaluate 18-month safety and durability of efficacy of nonsurgical transurethral collagen denaturation as treatment for stress urinary incontinence (SUI) in women. METHODS: Study comprised women with SUI due to bladder outlet hypermobility for at least 12 months who failed conservative treatment and had not undergone surgery or bulking agent treatment. This one-time procedure was performed in a physician's office or ambulatory treatment center. Patients kept voiding diaries and completed the Incontinence Quality of Life (I-QOL), Urogenital Distress Inventory (UDI-6), and Patient Global Impression of Improvement measures at baseline and at 3, 6, 12, and 18 months posttreatment. RESULTS: At 18 months, intent-to-treat analysis revealed that patients experienced significant reductions in the median number of stress leaks daily (0.43; P < 0.006) and weekly (3.0; P < 0.006) versus baseline, with 46.7% reporting a 50% or greater reduction in leakage. Mean I-QOL score improved 10.9 points (median 8.5; P < 0.0001), with 47.8% having a 10-point or greater improvement and 50.4% reporting improved symptoms versus baseline. Mean UDI-6 improvement was 13.0 points, with a stress incontinence subscore improvement of 17.0 points. Overall, 47.0% of patients were "somewhat" or "very" satisfied, and 52.9% would recommend the procedure to a friend. The procedure was shown to be safe and effective, with no new treatment-related adverse events reported at 18 months. CONCLUSIONS: Transurethral collagen denaturation resulted in significant improvements in stress leaks and quality of life for at least 18 months. This procedure offers a safe, effective, nonsurgical treatment option for women with SUI.

Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics.

OBJECTIVE: The objective of the study was to evaluate the use of urodynamics to determine the need for incontinence surgery at the time of abdominal sacrocolpopexy (ASC). STUDY DESIGN: The records of 441 women undergoing ASC during 2005-2007 were reviewed. Group 1 consisted of 204 women (46.3%) with urodynamic stress incontinence (USI), including occult USI, who underwent incontinence surgery with ASC. Group 2 consisted of 237 women (53.7%) without USI who underwent ASC alone. Primary outcome measures were any complaint of postoperative incontinence (stress or urge) or new-onset urgency/frequency (UF). RESULTS: At a mean follow-up of 46.6 weeks, the overall rate of incontinence was low and similar for both groups (13.4% in group 1 and 13.3% in group 2 [P = .967]), as was new-onset UF: 18.6% in group 1 and 11.5% in group 2 (P = .195). CONCLUSION: Urodynamic evaluation appears to be useful in determining the need for incontinence surgery at the time of ASC.

Pelvic floor muscle function in women presenting with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders. METHODS: Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength. RESULTS: The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores. CONCLUSIONS: Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

Nonsurgical transurethral collagen denaturation for stress urinary incontinence in women: 12-month results from a prospective long-term study.

STUDY OBJECTIVE: To assess efficacy of nonsurgical transurethral collagen denaturation (Renessa) in women with stress urinary incontinence (SUI) caused by bladder outlet hypermobility. DESIGN: Continuing, prospective, 36-month, open-label, single-arm clinical trial. Twelve-month results from intent-to-treat (ITT) analysis are reported. Canadian Task Force classification II-2. SETTING: Thirteen physician offices or ambulatory treatment centers. PATIENTS: Women with SUI secondary to bladder outlet hypermobility for 12 months or longer who failed earlier conservative treatment and had not received earlier surgical or bulking agent therapy. INTERVENTIONS: Women were treated as outpatients and received an oral antibiotic and local periurethral anesthesia before undergoing treatment with transurethral radiofrequency collagen denaturation. MEASUREMENTS AND MAIN RESULTS: Voiding diaries and in-office stress pad weight tests yield objective assessments. Subjective measures include the Incontinence Quality of Life (I-QOL), Urogenital Distress Inventory (UDI-6), and Patient Global Impression of Improvement (PGI-I) instruments. In total, 136 women received treatment (ITT population). Patients experienced significant reductions versus baseline in median number of leaks caused by activity/day and activity/week (p <.0026 for both), with 50% of patients reporting 50% or more reduction. Pad weight tests revealed that 69% of women had 50% or more reduction in leakage (median reduction 15.2 g; p <.0001); 45% were dry (29% no leaks; 16% < 1-g leakage). Significant improvements occurred in median scores on the I-QOL (+9.5 [range -66.0 to 91.0]; p <.0001) and mean scores on the UDI-6 (-14.1 +/- 24.7; p <.0001). Furthermore, 71.2% showed I-QOL score improvement, including 50.3% with 10-point or greater improvement, and 49.6% reported on the PGI-I that they were "a little," "much," or "very much" better. CONCLUSION: At 12 months, treatment of SUI with nonsurgical transurethral collagen denaturation resulted in significant improvements in activity-related leaks and quality of life.

Natural orifice hysterectomy.

Minimally invasive surgery (MIS) such as natural orifice surgery is perceived as a relatively recent development partly because many MIS techniques utilize new technology and devices. However, a natural orifice/MIS approach for hysterectomy (vaginal hysterectomy, VH) has existed for over a century. VH is typically thought of in the realm of the urogynecologist as a component of reconstructive pelvic surgery for pelvic organ prolapse. However, current evidence supports the use of VH in women with other benign conditions such as uterine fibroids and abnormal bleeding. Despite the evidence and availability of several MIS options for hysterectomy, the majority of hysterectomies continue to be performed via laparotomy. VH is the least invasive approach to hysterectomy, and its use should be encouraged as the preferred MIS option for women requiring uterine removal for benign conditions.

Stress urinary incontinence in women: what options lie between traditional therapies and surgery?

Stress urinary incontinence affects women of all ages, becoming more prevalent with increasing age. While many nonsurgical therapies are available for the treatment of stress urinary incontinence, options are limited for women who fail to respond to these therapies yet may not be candidates for, or wish to avoid, surgery. This limitation prompted efforts to develop less-invasive procedures for treating stress urinary incontinence patients, including bulking-agent injections and a new transurethral, radiofrequency collagen-denaturation system. This new treatment (Renessa((R))) reduces tissue compliance without necrosis or stricture, thus differentiating it from a surgical radiofrequency treatment, transvaginal radiofrequency tissue ablation. The advent of new treatment options for stress urinary incontinence allows physicians to offer their patients a broader choice of treatment options, underscoring the importance of educating patients regarding all available therapies, including success rates and risk for complications. This is particularly important for women who have not responded to prior treatment strategies.

Systemic hypertension among women with uterine leiomyomata: potential final common pathways of target end-organ remodeling.

The uterus and the heart share a common structure and may remodel in a similar fashion, albeit temporally distinct. The authors investigated the prevalence of systemic hypertension in women with uterine leiomyomata (fibroids) and compared the prevalence in women undergoing hysterectomy for other reasons as well as in age-matched women from the National Health and Nutrition Examination Survey III (NHANES III). A total of 584 women, 205 with leiomyomata in 1999 (group A) and 379 who underwent hysterectomy for a variety of reasons in 2000 (group B) at Advocate Christ Medical Center were included. Presence of leiomyomata was confirmed by pathology. Hypertension was defined as blood pressure > or = 140/90 mm Hg or history of hypertension with or without medication use. The prevalence of hypertension in group A and B patients with leiomyomata compared with NHANES III overall was 48.6% vs. 24% (p<0.001), in African Americans 55.5% vs. 32.4% (p<0.001), and in Caucasians 51.1% vs. 23.3% (p<0.001). Leiomyomata were more frequent among hypertensive than normotensive women (57% vs. 27%). Caucasian and African-American women with leiomyomata were significantly younger and more likely to use hormone replacement therapy than others. Thus there appears to be an association between leiomyomata and hypertension, which needs to be explored in future prospective trials.

A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence.

PURPOSE: We primarily compared the effectiveness of combined pelvic floor muscle training (PFMT) and duloxetine with imitation PFMT and placebo for 12 weeks in women with stress urinary incontinence (SUI). In addition, we compared the effectiveness of combined treatment with single treatments, single treatments with each other and single treatments with no treatment. MATERIALS AND METHODS: This blinded, doubly controlled, randomized trial enrolled 201 women 18 to 75 years old with SUI at 17 incontinence centers in the Netherlands, United Kingdom and United States. Women averaged 2 or more incontinence episodes daily and were randomized to 1 of 4 combinations of 80 mg duloxetine daily, placebo, PFMT and imitation PFMT, including combined treatment (in 52), no active treatment (in 47), PFMT only (in 50) and duloxetine only (in 52). The primary efficacy measure was incontinence episode frequency. Other efficacy variables included the number of continence pads used and the Incontinence Quality of Life questionnaire score. RESULTS: The intent to treat population incontinence episode frequency analysis demonstrated the superiority of duloxetine with or without PFMT compared with no treatment or with PFMT alone. However, pad and Incontinence Quality of Life analyses suggested greater improvement with combined treatment than single treatment. A completer population analysis demonstrated the efficacy of duloxetine with or without PFMT and suggested combined treatment was more effective than either treatment alone. CONCLUSIONS: The data support significant efficacy of combined PFMT and duloxetine in the treatment of women with SUI. We hypothesize that complementary modes of action of duloxetine and PFMT may result in an additive effect of combined treatment.