Antegrade endoscopic removal of retained urethral sling mesh in the bladder.

The midurethral sling has emerged as an effective, minimally invasive treatment for patients with stress urinary incontinence. Bladder penetration is a known complication that, if unrecognized, may result in retained intravesical mesh. This rare complication can cause patient discomfort as well as become a nidus for infection and bladder calculi. Because of the technique of sling passage, the site of retained sling material is often along the anterior bladder wall, making evaluation and treatment via traditional retrograde cystoscopy prohibitively difficult. We describe a novel and minimally invasive method to remove the sling material using antegrade access into the bladder in conjunction with holmium laser vaporization. In our series of six patients in whom retrograde cystoscopic treatment had failed, all were successfully treated with antegrade cystoscopy and reported improved urinary symptoms. This new technique provides a simple, minimally invasive, and effective method for removal of exposed sling mesh.

Effects of combined behavioral intervention and tolterodine on patient-reported outcomes.

OBJECTIVE: To assess the effects of tolterodine extended release (ER) plus behavioral intervention on urgency and other patient-reported outcomes in subjects with overactive bladder (OAB) who were previously dissatisfied with antimuscarinic treatment. METHODS: In this 16-week, multicenter, open-label study, eligible adults (aged > or = 18 y) reported dissatisfaction with their most recent antimuscarinic OAB medication; > or = 8 micturitions and > or = 2 urgency episodes per 24 hours and > or = 1 UUI episode in 5 day bladder diaries; and OAB symptoms for > or = 3 months. Subjects received tolterodine ER plus a behavioral educational handout with verbal reinforcement of behavioral intervention content for 8 weeks. Those satisfied with treatment at week 8 continued with this therapy; those dissatisfied received tolterodine ER plus individualized behavioral intervention (pelvic floor muscle training, tailored behavioral techniques) for 8 weeks. Endpoints were changes from baseline in daytime and nocturnal micturition-related urgency episodes and frequency-urgency sum (a measure of urgency severity and frequency) reported in 5 day bladder diaries at weeks 4, 8, 12, and 16; Patient Perception of Bladder Condition (PPBC), Overactive Bladder Questionnaire (OAB-q), and Urgency Perception Scale (UPS) scores at weeks 8 and 16. RESULTS: Daytime and nocturnal urgency episodes and frequency-urgency sum were significantly reduced at all time points (all p < 0.0001). Significant improvements were also observed in PPBC, OAB-q Symptom Bother and Health-Related Quality of Life, and UPS scores at weeks 8 and 16 (all p < 0.0001). CONCLUSIONS: Patients with OAB who are dissatisfied with antimuscarinic therapy may experience improved treatment outcomes by adding a self-administered behavioral intervention to their drug regimen.

Contributors to satisfaction with combined drug and behavioral therapy for overactive bladder in subjects dissatisfied with prior drug treatment.

PURPOSE: To assess contributors to treatment satisfaction with a focused, self-administered behavioral intervention combined with tolterodine extended release (ER) in subjects from an open-label study who had reported dissatisfaction with antimuscarinic treatment for overactive bladder (OAB) before that study. METHODS: Cognitive debriefing interviews were conducted with a convenience sample of 15 participants 7 to 10 months after completing the open-label trial. Reasons that contributed to participants' satisfaction with tolterodine ER treatment combined with behavioral intervention were assessed in the context of their dissatisfaction with prior antimuscarinic treatment. Also assessed were participants' treatment expectations and experiences with specific aspects of study participation and the self-administered behavioral intervention. RESULTS: Among the 15 participants (median age, 57 years; 13 women, 2 men), 12 attributed dissatisfaction with prior antimuscarinics to lack of efficacy. Only 7 participants had positive expectations of tolterodine ER treatment, 5 did not expect it to work, and 3 did not know what to expect. Reasons given for satisfaction with combined treatment were improved OAB symptoms (n = 13), attention of clinic staff (n = 8), review of educational materials on OAB symptoms and treatment (n = 14), and keeping a bladder diary (n = 13). One-third of participants (n = 5) continued to take tolterodine ER for 7 to 10 months after completing the open-label study. CONCLUSION: In addition to antimuscarinic therapy, treatment satisfaction and OAB symptoms may be improved in many patients by using a focused educational pamphlet with verbal reinforcement that increases awareness of OAB causes, treatments, and strategies for improving bladder control, including behavioral interventions and keeping bladder diaries.

Suppression of lysyl oxidase gene expression by methylation in pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: We measured promoter methylation in the LOX gene in women with pelvic organ prolapse and in women without prolapse. METHODS: Genomic DNA was isolated from the uterosacral ligaments of eight women with prolapse and eight women without prolapse as controls. Genomic DNA was digested with BamHI and underwent sodium bisulfite modification. The LOX gene promoter region of -246 to +74 was then amplified by PCR, cloned into PCR2.1-TOPO and transformed into an Escherichia coli DH5alpha strain. Amplified plasmid DNA samples containing the LOX gene promoter region from each woman were sequenced and methylated CpG islands were identified by sequence comparison. RESULTS: A total of 66 methylated CpG sites were found in the group of patients with prolapse, while only one methylated CpG site was found in the non-prolapse control group. CONCLUSIONS: Methylation in the promoter region may suppress LOX gene expression in women with pelvic organ prolapse.

Transobturator midurethral sling: surgical technique and outcomes.

Transobturator tape midurethral sling is the latest method for treatment of female urinary incont-inence. The authors describe their technique via an outside-in approach under local anesthetic to ensure proper tightening of the sling. Placement through the obturator foramen is straightforward and virtually eliminates risk of serious intraoperative major organ or vessel injury. Although outcome data lack the long-term follow-up of colposuspension and tension-free vaginal tape, similar short-term continence results are encouraging with less associated operative morbidity.

Assessment of patient outcomes following submucosal injection of triamcinolone for treatment of Hunner's ulcer subtype interstitial cystitis.

INTRODUCTION AND OBJECTIVE: Hunner's ulcer subtype interstitial cystitis (IC) is characterized by the presence of circumscribed inflammatory ulcerations in the bladder wall identified during endoscopic examination of individuals with irritative voiding symptoms and pelvic pain. We present our experience with management of this subgroup with intralesional submucosal injection of corticosteroid. METHODS: Prospective analysis of patients presenting with Hunner's ulcer subtype IC was performed between November 2006 to April 2008. All patients underwent flexible cystoscopy and biopsy confirming the presence of Hunner's ulcer(s). Under general anesthesia, 10 ml of triamcinolone acetonide (40 mg/ml) was injected in 0.5 ml aliquots into the submucosal space of the center and periphery of ulcer(s) using an endoscopic needle. Patient symptoms and quality of life was assessed using two validated questionnaires, the International Prostate Symptom Score (IPSS) and the Pelvic Pain and Urgency/Frequency (PUF) symptom scale. Each questionnaire was administered prior to therapy and 4 weeks postoperatively. The postoperative interview included the Patient Global Impression of Change (PGIC). RESULTS: Thirty patients with Hunner's ulcer subtype IC underwent endoscopic submucosal injection of triamcinolone. The mean preoperative and postoperative IPSS were 21.1 and 11.3, respectively. The mean preoperative and postoperative PUF scores were 20.0 and 11.0, respectively. PGIC assessment revealed 21 of 30 patients (70%) very much improved. No perioperative complications were noted. CONCLUSION: In Hunner's ulcer IC, submucosal injection of triamcinolone is well tolerated. This treatment offers significant improvement in symptoms and quality of life based on responses from validated questionnaires administered before and after therapy.

Combined effects of behavioral intervention and tolterodine in patients dissatisfied with overactive bladder medication.

PURPOSE: We assessed the effect of tolterodine extended release plus behavioral intervention on treatment satisfaction and bladder diary variables in patients with overactive bladder who had been previously treated and were dissatisfied with tolterodine or other antimuscarinics. MATERIALS AND METHODS: This 16-week, multicenter, open label study included eligible patients 18 years old or older who reported overactive bladder symptoms 3 months or greater in duration, 8 or greater micturitions and 2 or greater urgency related micturitions per 24 hours, and 1 or greater urgency urinary incontinence episodes in a 5-day bladder diary at baseline as well as dissatisfaction with prior antimuscarinic medication. Patients received tolterodine extended release plus self-administered behavioral intervention, consisting of an educational pamphlet with verbal reinforcement, for 8 weeks. Satisfied patients continued with this therapy and dissatisfied patients received tolterodine extended release plus individualized behavioral intervention, consisting of in-depth interaction with a clinician to refine behavioral techniques, for 8 weeks thereafter. Patients rated treatment satisfaction at weeks 8 and 16, and completed a 5-day bladder diary at weeks 4, 8, 12 and 16, respectively. RESULTS: At weeks 8 and 16, 346 and 357 patients or 91% of the total cohort reported being at least a little satisfied with tolterodine extended release plus behavioral intervention, including 201 (53%) and 252 (64%), respectively, who were very satisfied. Of the 33 patients who were dissatisfied at week 8, 25 (76%) reported treatment satisfaction at week 16 after individualized behavioral intervention. Compared with baseline all bladder diary variables were significantly improved by week 4 (p <0.0001). Patients who were dissatisfied with prior tolterodine or other antimuscarinic treatment reported similar results. CONCLUSIONS: Tolterodine extended release plus behavioral intervention resulted in high treatment satisfaction and improved bladder diary variables in patients who had previously been treated and were dissatisfied with tolterodine or other antimuscarinics.

Interstitial cystitis/painful bladder syndrome for the primary care physician.

Interstitial cystitis also known as painful bladder disorder refers to individuals with chronic bladder inflammation of unknown cause. The presentation of disabling symptoms of urgency, frequency, nocturia, and varying degrees of suprapubic discomfort, is one that the primary care physician will encounter frequently as the prevalence of interstitial cystitis ranges from 10.6 cases per 100,000 to as high as one in 4.5 women, depending upon the criteria used for its diagnosis. Many etiologies are possible. The disorder can be divided clinically into two groups-ulcerative and non-ulcerative-based on cystoscopic findings and response to treatment. In general the diagnosis is made by excluding known treatable causes of bladder irritation. Criteria for the disease are lacking. Management follows an approach of applying the least invasive therapy that affords sufficient relief of symptoms. This monograph attempts to guide the practicing primary care physician from the clinical presentation to a sensible diagnostic work-up and reviews the present management strategies in patients with interstitial cystitis.

Transobturator sling with intraoperative cough test is effective for patients with low valsalva leak point pressure.

OBJECTIVE: The transobturator sling (TOS) is safe and effective for the treatment of female stress urinary incontinence (SUI). Controversy exists regarding its efficacy in patients with low valsalva leak point pressure (VLPP), a marker of intrinsic sphincter deficiency (ISD). We review our experience of TOS in the treatment of women with SUI and low VLPP. METHODS: Patients diagnosed with stress or mixed incontinence treated with TOS were identified by retrospective review. All procedures were performed with local anesthesia and intravenous sedation. Stress incontinence and VLPP were determined preoperatively with urodynamic testing. Chart review identified demographics, perioperative variables, complications, and subjective cure. Low VLPP was defined as VLPP less than 60 cm H2O. RESULTS: From November 2003 to February 2006, 151 consecutive women underwent TOS. Twenty-seven patients were excluded who exhibited incontinence with cough but not valsalva on preoperative urodynamic testing. Of the remaining 124 patients, 29% had low VLPP and 71% had higher VLPP. There was no difference in subjective cure between patients with low (94%) and higher VLPP (84%) overall (p = 0.12) or in patients with 12 months or more of follow-up (93% versus 79%, p = 0.40). Patients with low VLPP were more likely to be older (p = 0.036), and have pure SUI (p = 0.019). CONCLUSIONS: TOS is effective for patients with low VLPP. Women with SUI and ISD without a fixed urethra should be considered candidates for TOS. The use of intravenous sedation during sling placement allows the surgeon to perform an intraoperative cough test, permitting tensioning of the TOS in relation to the patient's ISD.

Stress urinary incontinence: the evolution of the sling.

Stress urinary incontinence is one of the most prevalent and costly problems encountered by the international medical community. The exact mechanism of stress incontinence remains elusive. Early management relied on behavioral modification but, as more advanced anatomic and urodynamic research surfaced, the focus shifted to surgical correction. Initial innovations provided a compressive force/hammock to support the urethra and bladder neck. For almost a century, the pubovaginal sling provided this support, with 70-90% cure rates at the expense of significant voiding dysfunction. Later work has highlighted the interaction of muscles and ligaments as a midurethral kinking mechanism to prevent leakage. With this knowledge came the advent of tension-free vaginal taping. Further modifications led to the development of other midurethral slings, producing similar cure rates while minimizing complications.

Pelvic hematoma following transobturator tape procedure: case report and review of literature.

OBJECTIVE: The transobturator tape (TOS) procedure is rapidly becoming a preferred treatment for female stress urinary incontinence due to excellent outcomes and minimal morbidity. Though rare, significant bleeding complications can occur. MATERIAL AND METHODS: We review our experience and available literature of pelvic hematoma formation after TOS placement. RESULTS: A 56-year-old woman underwent a TOS procedure for stress incontinence. She returned on postoperative day three with nausea and vague suprapubic discomfort, though voiding without difficulty. Office ultrasound and computed tomographic imaging revealed a bi-lobed 8 cm x 10 cm x 11 cm hematoma in the Space of Retzius. She was treated conservatively with intravenous pain medication and antiemetics and without blood transfusion. Four weeks after the procedure, the patient had no voiding, pain, or bowel complaints. Literature review yielded two other reports of five patients with similar presentations who were successfully treated conservatively. CONCLUSIONS: Pelvic hematoma formation after the TOS procedure is a rare event and can usually be managed conservatively.

Decreased endopelvic fascia elastin content in uterine prolapse.

BACKGROUND: Genital prolapse is a debilitating manifestation of pelvic floor dysfunction. The cause of this condition has not been elucidated. The purpose of this study was to determine elastin content and RNA expression of related enzymes of elastin synthesis in uterosacral ligament biopsies from women with severe prolapse, and controls with normal pelvic support. METHODS: Biopsies were taken from the uterosacral ligament tissue of 31 women with Grade III or greater prolapse and 29 women with normal pelvic support. Elastin content was assessed by measuring desmosine using radioimmunoassay, and quantitative real time PCR was performed to quantify mRNA levels of lysyl oxidase (LOX), lysyl oxidase like-1 (LOXL1), LOXL2 and fibulin-5 (FIB-5). RESULTS: The mean desmosine concentration found in uterosacral ligaments of women with prolapse (n =26) was 103.3+/-59.3 pmolD/mgP compared to controls (n =29) 120.5+/-47.4 pmolD/mgP (p =0.1943). In the subgroup of subjects with complete procidentia (n =8), mean desmosine concentration was 50.6+/-25.8 and 127.1+/-42.2 pmolD/mgP in age-matched controls (n =12) (p <0.05). In tissue from subjects with more than 2 vaginal deliveries (n =18), the mean desmosine concentration was 99.9+/-60.7 and 133.0+/-44.0 pmolD/mgP in controls (n =17) (p <0.05). Expression of LOX, LOXL1 and LOXL2 decreased 8.2-fold+/-3.4, 5.0-fold+/-1.7 and 15.2-fold+/-5.2, respectively (mean+/-SD) in cases versus controls (p<0.05). Expression of FIB-5 was increased 3.1-fold+/-0.7 compared to controls (p<0.05). CONCLUSIONS: Significantly decreased desmosine content was measured in the uterosacral ligament tissue from women with prolapse versus controls in women with parity >2 and in women with complete procidentia. Suppression of mRNA for LOX and two LOX isoenzymes was correspondingly present. These results suggest that altered elastin metabolism is present in women with uterine prolapse.

Small intestinal bacterial overgrowth in patients with interstitial cystitis and gastrointestinal symptoms.

PURPOSE: Interstitial cystitis (IC) often coexists with irritable bowel syndrome (IBS). IBS may be explained by small-intestinal bacterial overgrowth (SIBO), which increases immune activation and visceral hypersensitivity. This prospective pilot study tested hypotheses that IC patients with gastrointestinal (GI) symptoms have SIBO, that nonabsorbable antibiotic use improves symptoms, and that improvement is sustained by prokinetic therapy. METHODS: Consecutive IC patients with GI symptoms had lactulose breath testing (LBT). Those with abnormal results received rifaximin 1,200-1,800 mg/day for 10 days then tegaserod 3 mg/nightly. Questionnaires addressed IC and GI global improvement. RESULTS: Of 21 patients, 17 (81%) had abnormal LBTs. Of 15 patients treated, GI global improvement was moderate to great in 11 (73%) and sustained in ten (67%). IC global improvement was moderate to great in six (40%) and sustained in seven (47%). CONCLUSIONS: A majority of IC patients and GI symptoms had an abnormal LBT suggesting SIBO. Rifaximin improved symptoms, which was sustained by tegaserod.

Duloxetine compared with placebo for the treatment of women with mixed urinary incontinence.

AIMS: Evaluate duloxetine in the treatment of women with mixed urinary incontinence (MUI). MATERIALS AND METHODS: 588 women, 19-85 years old with >or=4 incontinence episodes/week were randomly assigned to duloxetine 80 mg/day (N = 300) or placebo (N = 288). Patients were classified into three symptom subgroups: stress or urge predominant MUI (SPMUI or UPMUI) or balanced MUI (BMUI) based on their responses to the validated Stress/Urge Incontinence Questionnaire. Half the population was randomly assigned to have urodynamics; SPMUI, UPMUI, and BMUI condition diagnoses were based on signs, symptoms, and urodynamic observations. The primary outcome measure was the change in incontinence episode frequency (IEF). Secondary outcome measures included the Incontinence Quality of Life (I-QOL) scores, the ICI Quality of Life (ICIQ-SF) score, and the Patient Global Impression of Improvement (PGI-I) rating. RESULTS: At baseline, women with SPMUI averaged 15.9 IEF/week (61% stress), those with UPMUI averaged 13.2 (70% urge), and those with BMUI averaged 16.5 (52% urge). Overall IEF decreases were significantly greater with duloxetine than placebo (median percent reduction 60% vs. 47%, P < 0.001); both UUI and SUI episodes were significantly decreased with duloxetine (median SUI IEF reduction 59% vs. 43%, P = 0.001; UUI IEF reduction 58% vs. 40%, P < 0.001). Duloxetine IEF decreases were significantly greater for patients with SPMUI conditions and symptoms and for those with UPMUI conditions but not symptoms. Significant benefits were also demonstrated with duloxetine for improvements in I-QOL total score (11.5 points vs. 8.1 points, P = 0.002), all three I-QOL subscale scores, and for the ICIQ-SF score (-2.6 vs. -1.7, P = 0.002) as well as for PGI-I ratings (much/very much better 44.2% vs. 27.3%, P = 0.001). CONCLUSION: Duloxetine demonstrated significant efficacy in this population of women with MUI.

Female pelvic prolapse.

This article gives the practicing physician a summary of normal female pelvic and vaginal support structures and the etiology of pelvic prolapse. The most recent grading system for pelvic prolapse is reviewed. Changes on the various organ systems in the pelvis follow and concentrate on urinary incontinence, dyspareunia and bowel dysfunction. A review of the various non-surgical and surgical corrective procedures and a summary of the literature conclude the presentation.

Transobturator approach to suburethral sling placement in the treatment of stress urinary incontinence in women.

Minimally invasive suburethral sling procedures have become a mainstay for the surgical treatment of stress urinary incontinence in women. The transvaginal tape sling is the urethral sling most commonly used today. Although the transvaginal tape procedure is safe and efficacious, complications such as bladder, bowel and blood vessel injury have been reported. The most promising recent innovation in minimally invasive surgery for stress urinary incontinence is the transobturator approach for sling placement. This review will cover the mechanism of continence, rationale for the use of suburethral slings in the treatment of stress urinary incontinence, characteristics of polypropylene, comparison of the slings that are commercially available and early data on the efficacy of the transobturator approach in the treatment of stress urinary incontinence.

Validation of a two-item quantitative questionnaire for the triage of women with urinary incontinence.

OBJECTIVE: To evaluate the reproducibility, construct validity, and preferences for the 2-item Stress/Urge Incontinence Questionnaire. METHODS: The questionnaire asks a patient to recall the number of stress urinary incontinence and urge urinary incontinence episodes she experienced during the preceding week. The 4-week prospective study included 3 office visits and enrolled women with stress, urge, or mixed urinary incontinence symptoms. The test-retest reproducibility was assessed after 3 days, and the construct validity of the questionnaire was evaluated against a diary and other measures of incontinence severity and effect. The bother associated with completing (patients) or analyzing (physicians) the diary was assessed. Both groups also reported their time requirements and preferences for the questionnaire or diary. RESULTS: Reproducibility for the classification of symptoms was moderately strong (kappa = .536). Test-retest agreement was good (64-80%) for all but balanced mixed incontinence (38%). Intraclass correlations revealed good reproducibility for the number of stress (.694), urge (.703), and total (.726) incontinence episodes. Significant (P < .01) correlations with other measures of incontinence established construct validity. Patients and physicians reported it took less time to complete the questionnaire than the diary, but the majority said the completion or analysis of the diary was of little or no bother and preferred the diary. CONCLUSION: The Stress/Urge Incontinence Questionnaire is a valid tool that can be used in clinical practice to differentiate between symptoms of stress and urge urinary incontinence to make an initial diagnosis, especially in primary care where incontinence is not a focus of the practice.

Urethral slings placed by the transobturator approach: evolution in the technique and review of the literature.

Midurethral slings have proven to be efficacious in the surgical treatment of stress urinary incontinence (SUI) in women. A relatively new approach to the midurethral sling technique is the transobturator route for placement of the sling. This approach offers the theoretical safety advantage of avoiding the retroperitoneal space. The procedure has been pioneered in Europe and is now being practiced in the United States. In this article, we describe the theory behind urethral slings for SUI, the anatomy of the obturator canal, and early data on the safety and efficacy of transobturator urethral slings in the treatment of SUI.