Showing papers in "International Urogynecology Journal in 2003"
TL;DR: The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire –12 is a validated and reliable short form that evaluates sexual function in women with urinary incontinence and/or pelvic organ prolapse and predicts PISQ-31 scores.
Abstract: The aim of this study was to develop the short form of a condition-specific, reliable, validated and self-administered instrument to evaluate sexual function in women with pelvic organ prolapse and/or urinary incontinence. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire -12 (PISQ-12) was developed from the data of 99 of 182 women surveyed to create the long form (PISQ-31). An additional 46 patients were recruited for further validation. All subsets regression analysis identified 12 items likely to predict PISQ-31 scores. Short form scores underwent correlation analysis with long form, Incontinence Impact Questionnaire - 7 (IIQ-7), Sexual History Form -12 (SHF-12) and Symptom Questionnaire (SQ) scores. Test-retest reliability was checked with a subset of 20 patients. All subsets regression analysis with R>0.92 identified 12 items that predicted PISQ-31 scores. Short form scores were highly correlated with long form scores ( R=0.75-0.95). Correlations of the PISQ-12 with SHF-12 ( R=-0.66 and -0.68) and IIQ-7 ( R=-0.38 and -0.54) scores were similar to correlation of the PISQ-31 with these other measures. Reliability was moderate to high, with weighted kappa values from 0.56 to 0.93. PISQ-12 scores were lower in patients with low sexual function as measured on the SHF-12 ( P <0.001), and lower in women with depression as measured on the SQ ( P <0.001). The PISQ-12 is a validated and reliable short form that evaluates sexual function in women with urinary incontinence and/or pelvic organ prolapse and predicts PISQ-31 scores. It is able to distinguish women with poor sexual function as measured on the SHF-12.
647 citations
TL;DR: Allogenic MDSC significantly improved the LPP in sciatic nerve-transected animals after both 1 and 4 weeks compared to denervated animals injected with saline.
Abstract: Our goal was to determine whether periurethral injection of allogenic muscle-derived stem cells (MDSC) could increase the leak point pressure (LPP) in a denervated female rat model of stress urinary incontinence. Cells isolated from the gastrocnemius muscle of normal female rats were purified for a myogenic population by the preplate technique. Three experimental groups were established: a control group (C) had a sham operation without injections; a sciatic nerve transection group (D) had periurethral saline injections; and a sciatic nerve transsection group had periurethral MDSC injections (M). One week following treatment the LPP of groups C, D and M were 25.2±1.9 cmH2O, 28.6±0.8 cmH2O and 36.7±2.3 cmH2O, respectively. At 4 weeks the LPP of groups C, D and M were 25.8±2.5 cmH2O, 18.6±5.2 cmH2O and 44.1±6.6 cmH2O, respectively. Allogenic MDSC significantly improved the LPP in sciatic nerve-transected animals after both 1 and 4 weeks compared to denervated animals injected with saline.
183 citations
TL;DR: The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity.
Abstract: The authors review the literature concerning all types of synthetics implants used in prolapse repair or the treatment of stress urinary incontinence, and analyze the mechanical properties of and the tolerance to the various products used. Various synthetic implants are also studied, including their advantages and disadvantages, as well as outcome following implantation and tolerance by the host, with respect to the type of product and the type of intervention. A review of current implant products demonstrated that the perfect product does not exist at present. The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity. Their properties of resistance are undisputed, but it remains to be shown whether they are well tolerated when inserted by the vaginal route. The technical modalities for their use are still under evaluation, which should enable a better identification of the respective indications for these products in prolapse repair and treatment of urinary incontinence by the vaginal route.
177 citations
TL;DR: It was concluded that symptoms from all domains were frequent and reported generally and with little relation to prolapse in a specific compartment or POP-Q value.
Abstract: The aim of this study was to evaluate symptoms and bother in patients with pelvic organ prolapse (POP) and to compare symptoms with POP-Q grading and measurements. One hundred and ten women with POP filled in a symptom–bother questionnaire concerning frequency of mechanical, bladder, bowel and sexual problems, and a 4-point bother score. The POP was grouped grade 0–1 versus grade ≥2 in each compartment. Symptoms more than once per week were associated with a higher bother score. Mechanical symptoms, reported in 70%, were the most troublesome. Various bladder, bowel and sexual symptoms were reported in 5%–52%, 5%–39%, and 35%–57%, respectively. We concluded that symptoms from all domains were frequent and reported generally and with little relation to prolapse in a specific compartment or POP-Q value.
164 citations
TL;DR: The obturator approach shows identical urinary results to the classic retropubic approach and, because of the nature of the procedure, major hemorrhage and bowel perforation are excluded in the TOT procedure.
Abstract: Suburethral meshes can be implanted via the classic retropubic route (TVT) or by a new insertion technique that passes the tape into the obturator foramen (TOT). In a retrospective study we compared one 18-month period of 94 TOT (tension-free obturator tape) and one 18-month period of 99 TVT (tension-free vaginal tape), which preceded the change in the approach route. All operations were performed by the same surgeon using the same Prolene mesh and withno other surgical procedure associated. These two series were similar in terms of patient age, previous surgical history, degree of incontinence and preoperative urethral closure pressure. The analysis shows morehemorrhagic complications in the TVT group (10%) than in the TOT group (2%), but the difference was not significant. Bladder injuries were more frequent in the TVT group (10%) than in the TOT group (0%), but there was one urethral injury in the TOT group. The mean follow-up was 29.5 months in the TVT group and 12.8 months in the TOT group. The urinary results were the same, with 90% and 95% cured, respectively. In conclusion, the obturator approach shows identical urinary results to the classic retropubic approach. Because of the nature of the procedure, major hemorrhage and bowel perforation are excluded in the TOT procedure. Thus simplicity, safety and continence result mean that the obturator approach represents the best method of suburethral tape insertion for the treatment of urinary stress incontinence.
161 citations
TL;DR: It is concluded that the TVT and other wide-weave Prolene tapes have unique biomechanical characteristics and may be at least partly responsible for the apparent clinical success of the implants.
Abstract: Synthetic suburethral slings have recently become popular despite the risk of erosion commonly associated with synthetic implants. Some of these materials seem to have unexpectedly low erosion rates. Based on the hypothesis that erosion is due, in part, to biomechanical properties, we undertook an in vitro study. The biomechanical properties of eight non-resorbable synthetic implant materials, stiffness (slope, N/mm) and peak load (N) were determined from load vs. displacement curves. Open-weave Prolene mesh showed unique biomechanical properties compared to other tested materials. The tension- free vaginal tape had the lowest initial stiffness (0.23 N/mm), i.e. low resistance to deformation at forces below the elastic limit, whereas the stiffest implant tested, a nylon tape, reached 6.83 N/mm. We concluded that the TVT and other wide-weave Prolene tapes have unique biomechanical characteristics. These properties may be at least partly responsible for the apparent clinical success of the implants.
155 citations
TL;DR: Vascular and nerve structures are within 1–3 cm of the path of any device passed through the obturator foramen, although the small caliber of the vessels and the confined space in which they would bleed make the consequences of injury uncertain.
Abstract: Our objective was to determine the relationships between a trans-obturator sling and anatomic structures within the obturator region. The obturator regions of six cadavers were dissected and distances from the mid-point of the ischiopubic ramus to the muscles, nerves, and vessels of the region were measured. A trans-obturator sling was placed and distances from the device to the same anatomic structures were determined. Four additional cadavers were dissected to determine the device route of passage. The obturator canal is on average 4.4 cm from the midpoint of the ischiopubic rami. The trans-obturator sling passes on average 2.4 cm inferior-medial to the obturator canal. The anterior and posterior divisions of the obturator nerve are on average 3.4 and 2.8 cm, respectively, from a passed trans-obturator device. The device passed on average 1.1 cm from the most medial branch of the obturator vessels. Vascular and nerve structures are within 1–3 cm of the path of any device passed through the obturator foramen. A trans-obturator sling risks injury to these structures, although the small caliber of the vessels and the confined space in which they would bleed make the consequences of injury uncertain.
128 citations
TL;DR: Clinically, the pelvic floor musculature is found to be short, tender, and therefore weak, and there are associated trigger points and characteristic extrapelvic connective tissue abnormalities.
Abstract: Pelvic floor physical therapists have traditionally focused on rehabilitation of the weak pelvic floor of normal length. With the recognition that many urogynecologic symptoms arise from the presence of a short, painful pelvic floor, the role of the physical therapist is expanding. Clinically, the pelvic floor musculature is found to be short, tender, and therefore weak. There are associated trigger points and characteristic extrapelvic connective tissue abnormalities. We report the characteristic patterns of myofascial and connective tissue abnormalities in 49 patients presenting with this syndrome.
122 citations
TL;DR: It is concluded that sacral nerve modulation can treat refractory IC symptoms and the response to therapy and the reoperation rate are dependent on the technique used to test and implant the device.
Abstract: Patients with refractory interstitial cystitis (IC) underwent testing with sacral nerve modulation via either a traditional percutaneous approach or a staged procedure. Implanted patients were followed with scaled questionnaires and voiding diaries. Twenty-six patients who had a permanent InterStim placed had a reduction in 24-h voids of 51%. More than two-thirds of patients reported a moderate or marked improvement in urinary frequency, urgency, pelvic pain, pelvic pressure, incontinence and overall quality of life. The test to implant rate of a traditional percutaneous procedure was 52%, compared to a staged procedure of 94%. Assessing sensory response at the time of implant reduced the reoperation rate from 43% to 0%. Ninety-six per cent stated they would undergo an implant again and recommend the therapy to a friend. We concluded that sacral nerve modulation can treat refractory IC symptoms. The response to therapy and the reoperation rate are dependent on the technique used to test and implant the device.
114 citations
TL;DR: It is found that vaginal hysterectomy is associated with a three times higher risk for urge incontinence and overactive bladder symptoms, and sacrospinous hysteropexy appears to be promising for the correction of descensus uteri.
Abstract: One hundred and three women underwent sacrospinous hysteropexy (n=54) or vaginal hysterectomy with a vaginal vault suspension (n=49) for the management of descensus uteri. They were sent a postal questionnaire. Logistic regression analysis was used to obtain crude and adjusted odds ratios. Seventy-four (72%) women responded. The adjusted odds ratios for urge incontinence is 3.4 (1.0–12.3) and for overactive bladder 2.9 (0.5–16.9) greater after vaginal hysterectomy. The women recovered significantly more quickly after sacrospinous hysteropexy. There were no differences in anatomical outcome or recurrence rate. When performed to correct a descensus uteri of grade 2 or more we found that vaginal hysterectomy is associated with a three times higher risk for urge incontinence and overactive bladder symptoms. In addition, the women who underwent sacrospinous hysteropexy also reported a quicker recovery from surgery. Sacrospinous hysteropexy, therefore, appears to be promising for the correction of descensus uteri.
111 citations
TL;DR: Techniques for rehabilitation include the avoidance of perpetuating factors, rehabilitation of extrapelvic musculoskeletal abnormalities, the use of manual techniques and needling to promote resolution of connective tissue problems, closure of any diastasis recti, and transvaginal/transrectal manual release of muscular trigger points and contractures.
Abstract: Several urogynecologic syndromes are associated with the clinical finding of a short, painful, tender and weak pelvic floor and a variety of connective tissue abnormalities. Techniques for rehabilitation include the avoidance of perpetuating factors, rehabilitation of extrapelvic musculoskeletal abnormalities, the use of manual techniques and needling to promote resolution of connective tissue problems, closure of any diastasis recti, and transvaginal/transrectal manual release of muscular trigger points and contractures. Therapy can be facilitated by pudendal or epidural nerve block. Patients contribute to their success through home maintenance programs.
TL;DR: Subacute PNS appears to be effective in reducing symptom severity and increasing voided volumes in patients with interstitial cystitis previously unresponsive to standard therapy.
Abstract: Female patients with interstitial cystitis (IC) unresponsive to standard oral and intravesical therapy were enrolled at three clinical sites for percutaneous sacral nerve root stimulation (PNS) in a prospective, observational pilot study. Evaluation was in the form of a 3-day voiding diary completed both prior to and following the commencement of sacral nerve root stimulation. Symptoms were also assessed by the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indices (ICSI and ICPI). Baseline and test stimulation values for voiding diary parameters and O'Leary-Sant scores were compared to determine treatment efficacy. A total of 33 patients were enrolled. Statistically significant improvements were seen in frequency, pain, average voided volume and maximum voided volume. Significant improvements were also seen in ICSI and ICPI scores. Subacute PNS appears to be effective in reducing symptom severity and increasing voided volumes in patients with IC previously unresponsive to standard therapy.
TL;DR: When women with long-term urinary incontinence sought professional help they did so because they were afraid of the odor of urine and that they perceived the leakage as shameful and embarrassing, and felt that the healthcare service offered appropriate care for their condition.
Abstract: The aims of this study were to investigate the reasons why some women with long-term urinary incontinence (UI) seek professional help whereas others do not, their experiences and satisfactions with the healthcare services, and how women deal with their incontinence. In total, 95 women aged 23–51 years with persistent UI (median 10 years, range 6–20 years) were included in this telephone interview survey. Seventy-four percent of the women with long-term UI had not sought help. The most common reason given was that the disorder was considered a minor problem, which they felt they could cope with on their own. When women did consult professional help they did so because they were afraid of the odor of urine and that they perceived the leakage as shameful and embarrassing. These women felt that the healthcare service offered appropriate care for their condition. Pelvic floor exercises were the most commonly used management methods for all participants.
TL;DR: Subjects who depressed the LP when instructed to elevate it appeared to adopt straining strategies via the generation of intra-abdominal pressure, which may have long-term negative implications for prolapse and incontinence.
Abstract: Transabdominal ultrasound was used to assess 104 women with incontinence and prolapse. The bladder was used as a marker of levator plate (LP) movement. The women were asked to draw in and lift the pelvic floor muscles (PFM) and a change in position of the LP in a cranial or caudal direction during contraction was documented. Three different patterns of movement of the LP were identified, with 38% of subjects elevating and 43% of subjects depressing the LP; 19% had no change in LP movement. In the stress incontinence group there was a higher than expected number that elevated the LP. In the urgency and prolapse groups there was a higher than expected number of subjects that depressed the LP (P=0.008).The results highlight three different subgroups based on the patients' attempt to initiate elevation of the LP. Subjects who depressed the LP when instructed to elevate it appeared to adopt straining strategies via the generation of intra-abdominal pressure. Depression of the LP may have long-term negative implications for prolapse and incontinence.
TL;DR: The current literature suggests that uterine preservation during surgery for uterovaginal prolapse may be an option in appropriately selected women who desire it; prospective, randomized trials are needed to corroborate this.
Abstract: The traditional surgical treatment for uterovaginal prolapse has been vaginal hysterectomy. For many reasons, women may request uterine preservation at the time of prolapse surgery. The purpose of this paper is to review the medical literature pertaining to the role of uterine preservation during reconstructive surgery for uterovaginal prolapse. A MEDLINE search of literature in the English language (1966 to current) was carried out using the keywords ‘hysterectomy’, ‘hysteropexy’, ‘uterine preservation’, ‘uterine suspension’ and ‘uterovaginal prolapse.’ Fourteen articles primarily addressing the surgical repair of uterovaginal prolapse with uterine preservation were included in this review. Papers primarily addressing other forms of pelvic organ prolapse, incontinence or obliterative procedures were excluded. Existing procedures and their clinical outcomes were reviewed. The current literature suggests that uterine preservation during surgery for uterovaginal prolapse may be an option in appropriately selected women who desire it; prospective, randomized trials are needed to corroborate this.
TL;DR: The results highlight some of the concerns regarding the complex nature of the POPQ system and its acceptance and use by specialists worldwide and suggest the need for a simplified version of the classification system that is user-friendly and can be adopted by all practitioners.
Abstract: The authors performed a web-based questionnaire survey of 667 members of the ICS and AUGS to determine the current use of the pelvic organ prolapse quantification (POPQ) system by members of the professional societies which have advocated its use. Three hundred and eighty (57%) gynecologists responded. This international survey shows that only 40.2% of ICS and AUGS members who responded routinely use the POPQ system in their clinical practice and provides information on the most common reasons for not using it. The results highlight some of the concerns regarding the complex nature of the system and its acceptance and use by specialists worldwide. It also suggests the need for a simplified version of the classification system that is user-friendly and can be adopted by all practitioners.
TL;DR: The program for detecting and treating patients with postpartum urinary retention seemed to work efficiently and the incidence of instrumental delivery, sphincter rupture, and larger lacerations of the perineum was significantly increased in the group with urinary retention.
Abstract: The aim of this clinical study was to examine the incidence of postpartum urinary retention, to investigate the relationship between different obstetric parameters, and to find out whether our proposed treatment program fulfilled our needs. The incidence of urinary retention postpartum was 0.7%. The incidence of instrumental delivery, sphincter rupture, and larger lacerations of the perineum was significantly increased in the group with urinary retention. Our program for detecting and treating patients with postpartum urinary retention seemed to work efficiently.
TL;DR: The Pelvicol™ implant sling had a comparable patient- determined success rate with TVT and should be considered in the surgical treatment of women with genuine stress incontinence.
Abstract: The objective of this study was to compare porcine dermal sling (Pelvicol™ implant, Bard) with tension-free vaginal tape (TVT) in the surgical treatment of stress incontinence. One hundred and forty-two women with genuine stress incontinence (GSI) were randomly assigned to either Pelvicol™ implant pubovaginal sling (n=74) or TVT (n=68). They were followed up at a minimum of 6 months (range 6–24 months), with a median follow-up of 12 months. The majority (n=109) of procedures were carried out in a day surgery unit. The median operation time was 35 minutes (range 15–60) in the TVT group and 30 minutes (range 20–80) in the Pelvicol™ implant group; 81% of the TVT group and 77% of the Pelvicol™ implant group were able to void urine within 24 hours, and had insignificant residual bladder volumes. The prevalence of postoperative symptomatic voiding dysfunction was 3.4% after TVT and 1.4% after Pelvicol™ implant. Nine percent of the TVT group developed de novo urge incontinence and 6% of the Pelvicol™ implant group had de novo urge incontinence 6 months after the procedure. Postoperative evaluation was done at the outpatient department, and a postal questionnaire was also completed to determine subjective continence status. The patient-determined cure rate was 85% in the TVT group and 89% in the Pelvicol™ implant group. The Pelvicol™ implant sling had a comparable patient- determined success rate with TVT and should be considered in the surgical treatment of women with genuine stress incontinence.
TL;DR: This study shows that both SUI and the TVT procedure negatively affect sexual function in women, and postoperative scores significantly worsened, except for desire and arousal.
Abstract: The aim of this study was to evaluate the effects of tension-free vaginal tape (TVT) on sexual function in women with stress urinary incontinence (SUI) by questionnaire. Thirty-two sexually active and married women who were planned for TVT to treat SUI constituted the patient group, and 25 women who were healthy, sexually active and married, were selected as the control group; the ages of both groups matched. Sexual functions (desire, arousal, orgasm, pain and satisfaction) were evaluated with the Index of Female Sexual Function (IFSF), and continence status during sexual intercourse was asked about both preoperatively and postoperatively in the 6th month. The mean domain scores of sexual functions such as desire, arousal, orgasm, pain and overall satisfaction preoperatively and postoperatively were 3.37+/-0.69, 3.82+/-0.62, 3.40+/-0.95, 3.41+/-0.98, 3.16+/-1.09 and 3.32+/-0.79, 3.71+/-0.53, 3.06+/-1.04, 2.75+/-1.29, 2.88+/-0.63, respectively, and postoperative scores insignificantly decreased. Also, these scores in the control group were 3.64+/-0.66, 3.96+/-0.73, 4.12+/-0.78, 3.96+/-1.14 and 3.68+/-0.92. In comparison with the control group, whereas all of the preoperative domain scores were found to be decreased but were statistically insignificant except orgasmic function, postoperative scores significantly worsened, except for desire and arousal. However, preoperatively nine patients explained that they had incontinence during sexual intercourse, and this problem persisted in two postoperatively ( p = 0.043). This study shows that both SUI and the TVT procedure negatively affect sexual function in women.
TL;DR: A new technique in the surgical treatment of rectocele using a dermal allograft to augment site-specific fascial defect repair of the rectovaginal fascia is described, associated with high cure rates and minimal complications.
Abstract: We describe a new technique in the surgical treatment of rectocele using a dermal allograft to augment site-specific fascial defect repair of the rectovaginal fascia. The posterior vaginal wall is opened and discrete defects in the rectovaginal fascia are repaired in a site-specific fashion using delayed absorbable suture. A second layer of support is created using a rectangular dermal allograft placed over the site-specific repair and secured to the normal anatomic attachments of the rectovaginal fascia using permanent sutures. The vagina is then closed and routine perineorrhaphy performed as indicated. Forty-three women with advanced posterior vaginal wall prolapse underwent dermal graft augmentation of site-specific rectocele repair over a 1-year period. No major intraoperative or postoperative complications were reported. Thirty women were available for follow-up examination at an average of 12.9 months (range 8–17). The average patient age in the follow-up group was 63.6 ± 10.9 years (range 33–79) and average parity was 2.8 ± 1.5 (range 0–7). Using the Pelvic Organ Prolapse Quantification score, the average measurement of point Ap was 0.25 preoperatively and −2.4 postoperatively, whereas point Bp was 0.9 preoperatively and −2.5 postoperatively. Using a point Ap measurement of −0.5 or greater to define surgical failure, 28/30 (93%) of women were noted to have surgical cure on follow-up. Site-specific rectocele repair augmented with dermal allograft is associated with high cure rates and minimal complications. It recreates normal anatomic support and is easily adapted into current surgical procedures for rectocele repair.
TL;DR: An improvement in sexual desire, performance during coitus and achievement of orgasm were observed in women who received pelvic floor muscle rehabilitation.
Abstract: The aim of this study was to determine the effects of improvements in urinary incontinence resulting from pelvic floor rehabilitation on the sexual function of patients. The study involved 42 clinic patients who received pelvic floor rehabilitation treatment. Their sexual histories were obtained through face-to-face interviews. Pelvic muscle strength was measured with a perineometer. Improvement in incontinence was measured with the pad test. Seventeen women reported decreased sexual desire before the treatment; 5 of these indicated improvement after treatment. Nine of 17 women who experienced dyspareunia prior to treatment reported an improvement afterwards, and four women reported complete relief from pain. Five of 15 women who complained of difficulty in reaching climax before the treatment experienced improvement in this area. In conclusion, an improvement in sexual desire, performance during coitus and achievement of orgasm were observed in women who received pelvic floor muscle rehabilitation. No change was seen in the arousal and resolution stages of sexual activity.
TL;DR: Overall POPQ stage was significantly higher in the third trimester than in the first (P=0.001); individual POPQ points which showed significant differences between the first and third trimesters include Aa, PB, Ap, Ba, Bp, TVL and GH.
Abstract: Little is known about the anatomic and physiologic changes in the pelvic floor that occur during pregnancy. The purpose of this study was to prospectively document pelvic organ support throughout pregnancy using the standardized system of the International Continence Society, also known as the Pelvic Organ Prolapse Quantification (POPQ) Staging System. Pelvic organ support evaluations were performed in nulliparous pregnant women presenting for routine obstetric care during each trimester. POPQ stage assignments and POPQ component measurements were compared for first-, second- and third-trimester examinations. Overall POPQ stage was significantly higher in the third trimester than in the first (P=0.001). Individual POPQ points which showed significant differences between the first and third trimesters include Aa, PB, Ap, Ba, Bp, TVL and GH. These findings probably represent normal physiologic changes of the pelvic floor during pregnancy, but suggest that significant changes may be objectively demonstrated prior to delivery.
TL;DR: The conclusion was that negative cystoscopy cannot be solely relied on to rule out ureteral injury, as cases with partial obstruction and ureTERal patency can be missed.
Abstract: Our objective was to review our experience and attempt to identify risk factors for ureteral injury during gynecologic surgery for benign conditions. A retrospective chart review was performed of all cases of ureteral injury during gynecologic surgery for benign conditions, at Temple University Hospital, from January 1992 to September 2002. We analyzed hospital records to determine whether the injury was diagnosed intraoperatively, with postprocedure cystoscopy, or if cystoscopy was ineffective in diagnosing the injury. There were nine ureteral injuries during the study period. Of these, two were diagnosed during the procedure, two were discovered by immediate postprocedure cystoscopy, and the other five were discovered during the postoperative period. Of these five, three patients had immediate postprocedure cystoscopy and the injuries were not detected. Risk factors associated with ureteral injury included: a large uterus (5), high-grade cystocele (3), ectopic insertion of the ureter into the bladder (1), and previous surgeries (4). Our conclusion was that negative cystoscopy cannot be solely relied on to rule out ureteral injury, as cases with partial obstruction and ureteral patency can be missed.
TL;DR: It is felt the use of botulinum toxin type B to treat patients with overactive bladder warrants further study.
Abstract: The purpose of this study was to determine the efficacy and safety of botulinum toxin type B (BTX-B/Myobloc) in the treatment of patients with overactive bladder. This open-label dose-escalation study enrolled 15 female patients with urinary frequency with or without incontinence. The BTX-B doses used in this study were 2500, 3750, 5000, 10 000 and 15 000 units. Response was defined as a subjective improvement in frequency, urgency and incontinence symptoms. A paired t-test of the pre/post frequency difference indicates that these 15 patients experienced an average of 5.27 fewer frequency episodes per day after treatment with BTX-B. The p value for the paired t-test was <0.001. The longest duration effect was 3 months using 10 000–15 000 units of BTX-B. The correlation between dose and duration was very significant, with a correlation coefficient = 0.96, p<0.001. Based on these findings, we feel the use of botulinum toxin to treat patients with overactive bladder warrants further study.
TL;DR: It is concluded that both periurethral and transurethrals methods of bulking agent injection for stress urinary incontinence are equally efficacious, with minimal morbidity.
Abstract: The purpose of our study was to compare the two standard routes of urethral bulking injection in a prospective randomized trial. Forty women with genuine stress incontinence (n=36), or mixed incontinence with a minor and controlled urge component (n=4), participated in a urethral bulking agent trial. All patients had a standardized preoperative evaluation which included history, physical examination, assignment of incontinence status on a Stamey grading scale, postvoid residual (PVR) determination, Valsalva leak-point pressure, maximal urethral closure pressure, functional urethral length, Q-tip excursion angle, quantitative pad test, and completion of a quality of life questionnaire. On the day of injection they were randomly assigned to a periurethral or transurethral route of injection based on a computer-generated block randomization scheme. An ultrasound-determined PVR was obtained on all patients after injection. If self-catheterization was necessary, and the PVR was >200 ml, urinary retention was diagnosed. Postoperative assessment included a patient interview, subjective assessment of improvement, PVR, voiding diary, and assignment of incontinence grade. At the screening visit there were no significant differences between the groups for any variables except type of stress incontinence. With short-term follow-up both transurethral and periurethral routes of injection seem to be equally efficacious. In the periurethral injection group there was a higher rate of postoperative retention; this group had a significantly higher volume of injectable agent used. There was no significant difference in risk of urinary tract infections between the two groups. We conclude that both periurethral and transurethral methods of bulking agent injection for stress urinary incontinence are equally efficacious, with minimal morbidity.
TL;DR: Conclusions were that both tapes appear to be equally effective in the surgical treatment of SUI and the higher incidence of postoperative urinary retention in the monofilament group was most likely caused by the elastic feature of this tape.
Abstract: Our objective was to compare monofilament and multifilament tapes positioned without tension at the midurethra for postoperative complications and cure rate. One hundred patients with stress urinary incontinence were randomly allocated into two study groups. Using identical surgical methodology, 50 patients had a monofilament tape inserted at the midurethra using the TVT delivery instrument, and another 50 a multifilament tape using the IVS delivery instrument. The only significant difference between the groups was in the incidence of postoperative urinary retention (p=0.023). Ten patients from the monofilament group required longer than normal (‘normal’ means to the morning of the next day) catheterization, in contrast to only two from the multifilament group. The clinical efficacy of both procedures was equally high. Conclusions were that both tapes appear to be equally effective in the surgical treatment of SUI. The higher incidence of postoperative urinary retention in the monofilament group was most likely caused by the elastic feature of this tape.
TL;DR: It is concluded that women with LUT dysfunction are more likely to have symptoms of obstructive defecation than are community controls.
Abstract: It has been suggested that, apart from obstetric trauma, chronic straining at stool may also result in pudendal nerve damage, contributing to the etiology of genuine stress incontinence (GSI). The benign joint hypermobility syndrome (BJHS) has been associated with rectal as well as uterovaginal prolapse, suggesting that connective tissue abnormalities may also be implicated. This study was undertaken in order to further investigate whether - and if so, why - an association may exist between symptoms of obstructive defecation, lifetime constipation, chronic heavy lifting and lower urinary tract (LUT) dysfunction. Cases were female patients referred for urodynamic assessment with symptoms of LUT dysfunction. Controls were age-, sex- and postcode-matched community controls. Both cases and controls were assessed using a detailed questionnaire that also asked about symptoms of BJHS. Cases were also divided into their urodynamic classification of LUT dysfunction. All symptoms of obstructive defecation (52.3% vs 33.6%, P=0.00003), as well as chronic straining at stool (38.6% vs 23.4%, P=0.0005), were significantly more common in women with LUT dysfunction than in community controls. BJHS, chronic heavy lifting and a history of uterovaginal prolapse were significantly associated with patients with LUT and obstructive defecation compared to those with LUT dysfunction alone. Overall, symptoms of obstructed defecation were not more prevalent in any one urodynamic diagnostic group than in others. However, childhood constipation and current constipation were significantly more prevalent in women with voiding dysfunction than in those with other urodynamic diagnoses (16.7% vs 5.5%, P = 0.0030 and 13.0% vs 5.7%, P = 0.017). We concluded that women with LUT dysfunction are more likely to have symptoms of obstructive defecation than are community controls. Connective tissue disorders such as BJHS may be an important factor in this association.
TL;DR: Two points seem to be important for the functioning of the tension-free vaginal tape: a dynamic kinking of the urethra during stress, and the movement of the tape against the symphysis, compressing the tissue between the tape and the Symphysis.
Abstract: Forty patients who underwent a single tension-free vaginal tape procedure were evaluated by perineal ultrasound both pre- and postoperatively in a prospective observational clinical study. The positions of the tape, bladder neck and urethra were sonographically documented at rest and during Valsalva maneuvers. During Valsalva the tape rotated towards the symphysis in all patients. Postoperative urethral angulation could be demonstrated in 36 of 40 patients. Bladder neck mobility remained unchanged after the tension-free vaginal tape procedure, and 36 of the 40 were dry according to patient questionnaires. Postoperative cough test was negative in all patients. Two points seem to be important for the functioning of the tension-free vaginal tape: a dynamic kinking of the urethra during stress, and the movement of the tape against the symphysis, compressing the tissue between the tape and the symphysis. Mobility of the bladder neck is unaffected by the single tension-free vaginal tape procedure.
TL;DR: Treatment of urinary stress incontinence by intravaginal electrical stimulation (IES) and pelvic floor physiotherapy represents an alternative to other therapies and Satisfactory results can be achieved with patients who are reluctant to undergo surgery because of personal or clinical problems.
Abstract: Treatment of urinary stress incontinence (USI) by intravaginal electrical stimulation (IES) and pelvic floor physiotherapy represents an alternative to other therapies. The purpose of this work was to evaluate the effectiveness of this treatment inpatients with urinary incontinence. From January 1998 to May 2000, 30 women (mean age 54 years) were studied. All patients had USI and 70% urge incontinence; average follow-up was 7 months. Selection criteria were based on clinical history, objective evaluation of perineal musculature by perineometry, and urodynamics. The treatment protocol consisted of three sessions of IES per week for 14 weeks using INNOVA equipment. Physiotherapy was initiated in the fifth week of IES. A significant decrease in the number of micturitions and urgency was observed after treatment ( P<0.01). The pad test showed a reduction in urinary leakage from 13.9 to 5.9 g after treatment ( P<0.01). Objective evaluation of perineal muscle strength showed a significant improvement in all patients after treatment ( P<0.01). A positive correlation was observed between maximum flow rate (Qmax) and all three variables: urethral pressure profile at rest and on straining (stop test), and abdominal leak-point pressure (ALPP). A positive correlation was also observed between ALPP and the stop test. Over 100 different surgical and conservative treatments have been tried to manage USI. The majority of these procedures reveal that despite progress already made in this area, there is no ideal treatment. Satisfactory results can be achieved with this method, especially with patients who are reluctant to undergo surgery because of personal or clinical problems.
TL;DR: The use of freeze-dried, irradiated donor fascia for both sacrocolpopexy and sling procedures was associated with an unacceptably high failure rate in this series.
Abstract: The aim of this study was to document longer-term follow-up of patients in a previously reported series who underwent either sacrocolpopexy (SCP) or suburethral sling procedures utilizing freeze-dried, irradiated donor fascia. Subjects from the initial series of 67 SCPs and 35 slings were included in this retrospective chart review of postoperative follow-up where surgical follow-up longer than 3 months from the procedure was available. Subjects undergoing SCP were examined at the time of any clinical visit and their pelvic organ support evaluated utilizing the POP-Q system. The SCP procedure was considered to be unsuccessful if any anterior vaginal wall point (Aa or Ba) was at the hymen or beyond, or if the vaginal apical point (C or D) descended to a point at least halfway to the hymen from a position of perfect apical support. Subjects who did not return for clinical examination after their 3-month postoperative visit but who had been in telephone contact with the clinic stating that they had experienced symptomatic recurrence of their POP were also included as having unsuccessful SCP procedures. Those similarly in contact with the office by telephone, but not clinically examined, who indicated no subjective return of their POP, were coded as successful. The outcome of the sling procedure was primarily evaluated subjectively, with the patient indicating that stress incontinence symptoms were present or absent. Follow-up was available for 75 patients, who had undergone 54 SCP and 27 sling procedures (6 patients had undergone both SCP and sling procedures). When failure was defined according to any of the criteria listed in the methods section, 45 (83%) patients experienced SCP failure at a median of 12 months after surgery. A total of 14 (52%) sling procedures were failures, with recurrent SUI symptoms experienced from 2 weeks to 24 months (median 3 months) after the procedure. One year after surgery, 23 (43%) SCPs were known to be failures, and 11 (41%) slings were known to be failures. The remaining 13 (48%) slings were subjectively successful when last seen 7–51 months after surgery. We reoperated on 21 (40%) patients. At the time of repeat SCP (chosen by 16 patients) we found graft between the sacrum and vagina in just 3 patients (19%). The use of freeze-dried, irradiated donor fascia for both SCP and sling procedures was associated with an unacceptably high failure rate in our series.