Introduction and hypothesis The objective of our study is to compare patient self-reported urinary incontinence symptoms based on the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-SF) question number 6 (When...
moreIntroduction and hypothesis The objective of our study is to compare patient self-reported urinary incontinence symptoms based on the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-SF) question number 6 (When does urine leak?) with physician-assessed interpretation of the patient’s urinary incontinence symptoms. Methods This trial is a cross-sectional study of patients who presented to a tertiary urogynecology center with symptoms of urinary incontinence between January 2014 and August 2016. We compared patient-reported symptoms on the ICIQ-SF with physician interpretation of urinary complaints during their initial visit. The urinary incontinence symptoms included stress urinary incontinence (SUI), urgency urinary incontinence (UUI), insensible urine loss, nocturnal enuresis, and post-micturition dribbling. Results A total of 432 patients with a mean age of 61 were included in this evaluation. The most common urinary incontinence symptoms according to the physician were UUI ( n = 357, 83%), followed by SUI ( n = 308, 71%). Of the patients who were diagnosed by a physician with the symptom of UUI, only 61% self-identified as having this symptom based on the ICIQ-SF, and for SUI, only 66% self-identified as having SUI symptoms based on the ICIQ-SF. Overall UUI (κ = 0.30) appears to have poor agreement, as does nocturnal enuresis (κ = 0.39), when compared with physician historical assessment. Conclusion There is a discrepancy between patient-reported urinary incontinence symptoms on the ICIQ-SF and physician-assessed symptoms. Symptomatology entered into electronic medical records by patients is often inaccurate. Physician validation is essential in understanding the underlying the precise symptomatology.
Objective: The objective of this study is to determine the prevalence and correlation of urinary incontinence symptoms to diagnoses made on urodynamic testing among women older than 65 when compared to women less than age 65. Methods:...
moreObjective: The objective of this study is to determine the prevalence and correlation of urinary incontinence symptoms to diagnoses made on urodynamic testing among women older than 65 when compared to women less than age 65. Methods: This is a cross-sectional study of patients with complaints of urinary incontinence between January, 2014 and August, 2016, who underwent urodynamic testing. The cohort was split by age over 65 versus those less than or equal to 65. Baseline demographics, and the prevalences of both urinary symptoms and diag-noses on urodynamic testing were compared. The proportion of patients with high pressure detrusor overactivity or a maximum detrusor pressure over 40 cm H2O and low pressure urethra, defined as a urethral closure pressure less than 28 cm H2O were also compared between groups. Results: Baseline demographics other than age did not differ between groups. Patients over 65 more often com-plained of urgency urinary incontinence while those less than 65 m...
Surgical treatments used for pelvic organ prolapse (POP) and urinary incontinence (UI) have markedly changed in recent years. Concomitant with these changes, the patient-physician relationship has evolved over the last several years in...
moreSurgical treatments used for pelvic organ prolapse (POP) and urinary incontinence (UI) have markedly changed in recent years. Concomitant with these changes, the patient-physician relationship has evolved over the last several years in large part due to patients asking for more information about their conditions as well as their desire to play an active role in the treatment decision-making process. Increasing reports of adverse outcomes in patients undergoing POP and UI surgery have prompted several scientific societies and researchers to emphasize the need to provide patients with thorough counseling before surgery. A Swedish National Register study documented the lack of adequate information provided before urogynecological surgery and also found that counseling is rarely provided. The criterion standard for excellence in clinical care has become patientcentered communication. To reach a shared understanding with patients of the risks and possible outcomes of surgery, clinicians must be cognizant of their patients' perspectives, expectations, motivations, fears, concerns, and social contexts. Many patients believe that their urge urinary incontinence (UUI) is actually stress UI and may be confused and disappointed when SUI surgery does not successfully treat overactive bladder. The clinical aspects of the intended procedure must be clearly explained to help balance patients' expectations with realities of what is achievable during the procedure. Although it is clear that well-informed patients are more satisfied with results of surgery and recover faster, women with vaginal POP are poorly informed about their treatment options and potential outcomes. Urogynecology counseling is a crucial process through which patients can gain a clear understanding of their clinical condition, and the risks and benefits of potential treatment options. A patient-centered approach (providing information and allowing patients to participate in the decision-making process) is associated with better patient coping skills and treatment adherence as well as better care and outcomes. Many urogynecologists still believe that a proposed treatment plan and providing only enough detail to secure informed consent constitutes counseling. This article describes good counseling practice for female patients undergoing urogynecological surgery and suggests optimal methodologies for implementation.
The objective of this study was to determine whether anterior colporrhaphy plus insertion of anterior dermal allograft reduces anterior prolapse recurrence at 1 and 7 to 10 years postoperatively compared with anterior colporrhaphy alone....
moreThe objective of this study was to determine whether anterior colporrhaphy plus insertion of anterior dermal allograft reduces anterior prolapse recurrence at 1 and 7 to 10 years postoperatively compared with anterior colporrhaphy alone. We present a nonblinded randomized controlled trial with 1- and 7- to 10-year follow-up. Subjects were randomized between 2005 and 2008 to anterior colporrhaphy or ultralateral anterior colporrhaphy plus insertion of a dermal allograft spanning the anterior compartment between the arcus tendineus fascia pelvis on each side. Eligible subjects had anterior prolapse to the hymen or beyond, were bothered by their prolapse, and were planning to undergo surgical correction. Subjects completed a pelvic organ prolapse quantification system (POPQ) examination and Pelvic Floor Distress Inventory (PFDI)/PFDI-20 before surgery; a POPQ, PFDI, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire at 1 year postoperatively; and a POPQ, PFDI-20, Pelvic Organ ...
Oxybutynin chloride has been effectively used for treating overactive bladder syndrome for more than three decades. The evolution of different delivery systems led first to intravesical administration, anal suppositories, and then to the...
moreOxybutynin chloride has been effectively used for treating overactive bladder syndrome for more than three decades. The evolution of different delivery systems led first to intravesical administration, anal suppositories, and then to the commercial development of an extended-release oral formulation of oxybutynin chloride to improve its tolerability while maintaining efficacy. These modes of delivery were associated with decreased antimuscarinic side effects and N-desethyloxybutynin serum levels by avoiding first-pass metabolism in the upper gut and liver. The development of transdermal delivery has carried this evolution even further, with serum levels of desethyloxybutynin < or = oxybutynin and dry mouth rates of 7%, with little constipation. The new development of a transdermal oxybutynin gel has decreased these application site reactions to low levels while maintaining good efficacy.
To compare the incidence of postoperative pain after suture‐ or mesh‐based sacrospinous ligament suspension (SSLS).
Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic and debilitating condition. Our objective was to compare two different bladder instillation treatments in patients with BPS/IC: dimethyl sulfoxide with triamcinolone (DMSO)...
moreBladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic and debilitating condition. Our objective was to compare two different bladder instillation treatments in patients with BPS/IC: dimethyl sulfoxide with triamcinolone (DMSO) vs. bupivacaine with heparin and triamcinolone (B/H/T). Our hypothesis was that both treatments are equally effective. A retrospective cohort study of instillation-naïve patients was conducted comparing responses to either DMSO or B/H/T at our tertiary urogynecology center from 2012 to 2014. The primary outcome was patient-reported percent of overall improvement from baseline. Secondary outcomes were change in patient-reported daytime voiding frequency (hours) and change in number of nighttime voiding episodes. Variables analyzed as potential confounders included pelvic pain, cystoscopy findings, levator spasm, and fibromyalgia. The two-sided Student's t test, chi-squared test, Poisson regression, and repeated-measure analysis of variance (ANOV...
We compared persistence on overactive bladder (OAB) pharmacotherapy in patients treated in the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) department compared with patients treated in the Internal Medicine (IM) and General...
moreWe compared persistence on overactive bladder (OAB) pharmacotherapy in patients treated in the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) department compared with patients treated in the Internal Medicine (IM) and General Urology (GU) departments within an integrated health-care system. We hypothesized that persistence would be higher among FPMRS patients. This was a retrospective cohort study. Patients with at least one prescription for OAB between January 2003 and July 2014 were identified. Demographic, prescription and treatment specialty data and data on the use of third-line therapies were collected. The primary outcome was persistence, defined as days on continuous pharmacotherapy. Discontinuation was defined as a treatment gap of ≥45 days. Discontinuation-free probabilities were calculated using the Kaplan-Meier method and compared among the specialties. Predictors of persistence were estimated using logistic regression with adjustment for covariates. Pearson c...
To provide an overview of interstitial cystitis (IC), including the presentation of patients with the disorder, and to explore diagnostic and treatment options. Current literature concerning the history, etiology, diagnosis and treatment...
moreTo provide an overview of interstitial cystitis (IC), including the presentation of patients with the disorder, and to explore diagnostic and treatment options. Current literature concerning the history, etiology, diagnosis and treatment of IC was used to support expert recommendations regarding patient management. Experts discussed the literature surrounding IC, focusing on diagnostic tools and currently available treatment modalities. Diagnosis of IC may often be delayed or missed due to the similarity of symptoms with a number of other conditions. A detailed medical history and careful physical examination are key for diagnosis, and a variety of screening and diagnostic tools are also available. Once a patient is diagnosed with IC, multimodal treatment through pharmacological and nonpharmacological approaches is recommended. The involvement of both the patient and physician in determining the therapeutic approach, the use of multimodal therapies, regular follow-up and staff involvement in care can bring relief to a substantial number of patients with this condition.
These are the final results from the prospective, multicenter, long-term (3.5 years) study of the efficacy/safety of onabotulinumtoxinA for treatment of overactive bladder syndrome. Patients completing either phase 3 trial could enter a...
moreThese are the final results from the prospective, multicenter, long-term (3.5 years) study of the efficacy/safety of onabotulinumtoxinA for treatment of overactive bladder syndrome. Patients completing either phase 3 trial could enter a 3-year extension and continue treatment with onabotulinumtoxinA 100U as needed for control of overactive bladder symptoms. Data were analyzed by treatment(s) received (up to 6) and within discrete subgroups who received 1, 2, 3, 4, 5 or 6 treatments (to evaluate consistency of response after repeat treatments in the same groups of patients). Assessments included change from baseline in urinary incontinence episodes/day and proportion of patients reporting improvement/great improvement in their urinary symptoms on the Treatment Benefit Scale at week 12 (co-primary endpoints); change from baseline in Incontinence Quality of Life, urgency and micturition episodes/day; duration of effect; adverse events; and initiation of intermittent catheterization. Co...
Certain patients will present with irritative lower urinary tract symptoms that defy conventional therapies. Under these circumstances, urodynamic evaluation may reveal a marked elevation of the urethral closure pressure suggesting...
moreCertain patients will present with irritative lower urinary tract symptoms that defy conventional therapies. Under these circumstances, urodynamic evaluation may reveal a marked elevation of the urethral closure pressure suggesting over-activity of one of the components of the urethral sphincteric mechanism. Frequently it is the voluntary skeletal muscle component which is responsible. By performing a bilateral pudendal block, the contribution of the skeletal muscle to the urethral sphincteric mechanism can be determined.
Dynamic urethral closure pressure profiles are useful tests in the establishment of the diagnosis of genuine stress incontinence. By definition, genuine stress incontinence is a condition where an increase in intra-abdominal pressure...
moreDynamic urethral closure pressure profiles are useful tests in the establishment of the diagnosis of genuine stress incontinence. By definition, genuine stress incontinence is a condition where an increase in intra-abdominal pressure leads to an increase in bladder pressure that is greater than urethral pressure in the absence of a bladder contraction. This condition is represented by a dynamic change in urethral closure pressure to zero or below known as pressure equalization during dynamic urethral closure pressure profiles.
Urethral closure pressure will be affected by position changes in both the normal, continent woman and the woman suffering from genuine stress incontinence. Typically, as shown in Fig. 18.1, the continent woman will respond to the...
moreUrethral closure pressure will be affected by position changes in both the normal, continent woman and the woman suffering from genuine stress incontinence. Typically, as shown in Fig. 18.1, the continent woman will respond to the increasing stress of a more upright position by increasing skeletal muscle activity within the wall of the urethra as well as within the pelvic floor musculature to lead to an increase in urethral closure pressure. In Fig. 18.1, this is demonstrated by an increased urethral pressure and urethral closure pressure in the sitting position when compared to the supine position. This recruitment of skeletal muscle is a normal compensating response reflected in the periurethral EMG activity.
Electrical stimulation of the pelvic muscles has been used for over 25 years to control detrusor overactivity and genuine stress incontinence. From studies in cats, it is believed that the mechanism of detrusor inhibition is through...
moreElectrical stimulation of the pelvic muscles has been used for over 25 years to control detrusor overactivity and genuine stress incontinence. From studies in cats, it is believed that the mechanism of detrusor inhibition is through reflex inhibition of the pelvic nerve after stimulating afferently along the pudendal nerve. This mechanism takes advantage of the vesicoinhibitory reflexes which allow one to stop a bladder contraction at the end of micturition by contracting the periurethral skeletal muscle. Transvaginal and transanal electrical stimulation has been reported to be successful in improving or curing detrusor overactivity in up to 90% of patients.
Pelvic floor stimulation (as discussed in Appendix A) can be utilized to treat not only detrusor overactivity but also genuine stress incontinence. It is believed that the primary effect of electrical stimulation for treatment of genuine...
morePelvic floor stimulation (as discussed in Appendix A) can be utilized to treat not only detrusor overactivity but also genuine stress incontinence. It is believed that the primary effect of electrical stimulation for treatment of genuine stress incontinence is to cause activation of the pelvic floor and periurethral musculature via the pudendal nerve. Repetitively contracting the skeletal muscle around the urethra should create muscular hypertrophy with increasing muscle strength. This translates into an increase in intraluminal urethral pressure with intra-abdominal pressure elevations. Similar to physiotherapy with progressive resistance exercises, it allows patients to develop strong guarding reflexes to prevent leakage of urine with anticipated voluntary increases in intra-abdominal pressure.
Augmenting urethral closure pressure profiles are used to identify the voluntary ability of the patient to contract her periurethral and pelvic striated musculature around the urethra to effect an increase in intraurethral pressure. This...
moreAugmenting urethral closure pressure profiles are used to identify the voluntary ability of the patient to contract her periurethral and pelvic striated musculature around the urethra to effect an increase in intraurethral pressure. This effort is identical to that of progressive resistance exercise or Kegel’s maneuver and represents the urodynamic measure of this activity. In the prior chapter in Figure 15.2 we noted that the patient was not able to augment her urethral closure pressure nor functional length by contracting the pelvic floor. The absence of an increase in closure pressure and functional length during these profiles may represent a failure of the patient to understand the maneuver, partial or total denervation of the pelvic skeletal muscles, or a rigid fibrotic urethra which cannot respond to extrinsic efforts to increase intraurethral pressure.
Dr. Charles Butrick from the Urogynecology Center, Overland Park, KS moderated the topic "Overactive Bladder: Evaluation and Diagnosis" with Drs. Linda Cardozo from King's College Hospital and Peter Sand from the Evanston...
moreDr. Charles Butrick from the Urogynecology Center, Overland Park, KS moderated the topic "Overactive Bladder: Evaluation and Diagnosis" with Drs. Linda Cardozo from King's College Hospital and Peter Sand from the Evanston Continence Center, Chicago, IL. The discussion focused primarily on: The definition, prevalence, and symptoms of overactive bladder (OAB) syndrome; the risk factors for and comorbidities associated with OAB; the importance of the differential diagnosis of OAB; combined use of behavioral modification and medication or a combination of medications as first-line therapy; pharmacological treatment of OAB, focusing on antimuscarinic medications, and its outcomes; treatment of patients with mixed symptoms and/or nocturia; the importance of ensuring patient compliance; and second-line and emerging therapies for patients who fail to respond. Med Roundtable Gen Med Ed. 2014;1(3):212–221.
As with position change, the urethra will also respond to the stress of changes in the bladder volume. Increased bladder volume will lead to increased hydrostatic pressure within the bladder as well as an increased response from stretch...
moreAs with position change, the urethra will also respond to the stress of changes in the bladder volume. Increased bladder volume will lead to increased hydrostatic pressure within the bladder as well as an increased response from stretch receptors in the bladder and the trigone. The normal response to this is further to augment urethral pressure and closure pressure. Fig. 19.1 shows a normal urethrocystometry study where there is increasing urethral pressure during filling. This is associated with augmentation of EMG activity near the end of the study (curved open arrow) and thus reflects increasing skeletal muscle activity in the pelvic floor musculature during bladder filling. In patients who have genuine stress incontinence, although there may be augmentation of EMG activity during filling, there is usually a progressive decrease in urethral pressure and urethral closure pressure which facilitates eventual urinary leakage with increased intra-abdominal pressure.
When all medical therapies for detrusor instability have failed partial denervation of the detrusor by surgical hypogastric nerve resection may be indicated for some patients. Although good results may be obtained in up to 90% of selected...
moreWhen all medical therapies for detrusor instability have failed partial denervation of the detrusor by surgical hypogastric nerve resection may be indicated for some patients. Although good results may be obtained in up to 90% of selected patients initially, recurrences are frequent in these and other nerve resections or neurologic procedures. If hypogastric nerve resection or phenol injection is to be considered, preliminary evaluation of the patient with unilateral and bilateral hypogastric nerve blocks is indicated to determine the anticipated response of the detrusor muscle to surgical resection or phenol injection of these nerves. Assessment of detrusor function during filling and micturition is accomplished after anesthetic nerve block to look for resolution of detrusor overactivity and to rule out detrusor areflexia.
The therapeutic potential of magnetic energy has been a subject of long-standing interest within both conventional and alternative medical practice. Numerous devices utilizing magnetic fields, ranging from the dubious to truly innovative,...
moreThe therapeutic potential of magnetic energy has been a subject of long-standing interest within both conventional and alternative medical practice. Numerous devices utilizing magnetic fields, ranging from the dubious to truly innovative, have claimed a wide variety of clinical benefits. The electric field effect induced by a changing magnetic field appears to be more valuable in research and therapy than the magnetic field effects described from permanent magnets. Magnetic stimulation of the sacral nerve roots continues to evolve as an alternative to transcutaneous electrical neuromodulation for the diagnosis and treatment of bladder and pelvic floor dysfunction. The conduction characteristics of magnetic energy confer several practical advantages for its use as a non-invasive treatment modality. Moreover, its clinical application may provide theoretical insight into the neurobiology of the lower urinary tract. This chapter examines the use of extracorporeal electromagnetic stimulation for the treatment of urinary incontinence and bladder disease, and provides a historical overview of the therapeutic application of electromagnetic energy.
In recent years, more attention has turned to the use of patient-reported outcomes in clinical trials to assess treatment efficacy in overactive bladder syndrome (OAB). The challenge for investigators and clinicians is how to choose among...
moreIn recent years, more attention has turned to the use of patient-reported outcomes in clinical trials to assess treatment efficacy in overactive bladder syndrome (OAB). The challenge for investigators and clinicians is how to choose among the many available health-related quality-of-life questionnaires. This article provides an overview of the patient-reported outcome instruments available specific to OAB and their validation for clinical use.
Urethroscopy, cystoscopy and dynamic cystourethroscopy are valuable diagnostic and therapeutic tools which are essential to the practice of urogynecology.