The demographics of pelvic floor disorders: current observations and future projections.

OBJECTIVE: Our aim was to assess current demand for care of pelvic floor disorders and create projections for future demand for care. We also sought to better understand the characteristics of women seeking care. STUDY DESIGN: Current demand for care was calculated by comparing those women seeking care through the female pelvic floor disorders clinic with those women of the same age range at risk within an integrated health care delivery program. Patients underwent complete urogynecologic evaluation including cystometry. Women seeking care were compared with regard to age, distribution of conditions (pelvic organ prolapse, stress conditions, urge conditions), and probability of undergoing surgery. Modeling the study population by use of data from the US Census Bureau, which projects population changes over the next 30 years, created predictions of future demand. RESULTS: Data were available on 2070 consecutive patients with an age range of 30 to 89 years normally distributed around a median age of 61.5 years drawn from an at-risk population of 149,000 women aged 30 to 89 years. Older women generated more consults per 1000 woman years than did the younger cohorts (1.7 vs 18.6 consults per 1000 woman years for those 30-39 years old vs those 70-79 years old; P <.05). Estimates of growth in demand at 30 years indicate a 45% increase in demand while net growth of the same population segment should be 22%. Stress conditions were more common among younger women and urge conditions were more common among older women. Pelvic organ prolapse was equally distributed throughout the age ranges. CONCLUSIONS: Over the next 30 years, growth in demand for services to care for female pelvic floor disorders will increase at twice the rate of growth of the same population. Demand for care for pelvic floor disorders comes from a wide age range of women, although mature age groups generate 10 times the number of consults per 1000 woman years as do their younger counterparts. Age plays a major role in the distribution of conditions with which patients present. These findings have broad implications for those responsible for administering programs to care for women, allocating research funds in women's health and geriatrics, and training physicians to meet this rapidly escalating demand.

Overactive bladder: special considerations in the geriatric population.

Overactive bladder (OAB) is a highly prevalent condition among older patients, and its presence is associated with the use of substantial healthcare resources and economic costs. Within the next 30 years, it is expected that the demand for services related to OAB will increase dramatically. Treatment of OAB is challenging and depends on several factors, including the age of the patient, cognitive functioning, and the degree of mobility. Pharmacotherapy, such as the use of tolterodine and oxybutynin, is a viable option for the treatment of OAB, and muscarinic antagonists are commonly used. The efficacy of an agent may differ in older patients compared with younger ones. In addition, certain side effects can be particularly troublesome in the geriatric population. A retrospective analysis of a large managed care database showed an age-related increase in the number of women seeking care for OAB. Caring for incontinent patients in the long-term care setting was shown to result in substantial additional costs, which were higher in those with more frequent incontinent episodes. Prompted voiding may be effective in reducing the number of incontinent episodes for those in institutionalized care; however, this practice is labor intensive and generally is only effective in 40% of cases. Moreover, assistance with prompted voiding must be maintained continuously. Future research should focus on defining the most cost-effective methods of treating OAB in the long-term care setting.

Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association.

PURPOSE: The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data. MATERIALS AND METHODS: The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures. RESULTS: The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings. CONCLUSIONS: The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

Efficacy of functional electrical stimulation in treating genuine stress incontinence: a randomized clinical trial.

Our objective was to determine the efficacy of functional electrical stimulation as a stand-alone therapy for female stress incontinence. The study was conducted as a prospective, double-blind, randomized controlled trial using subjective and objective outcome criteria. Patients enrolled in this study had stress incontinence consistent with International Continence Society criteria. Patients with significant pelvic prolapse or detrusor instability were excluded. Patients underwent twice-daily treatment sessions for a total of 3 months. Results were analyzed for confounding variables between the treatment and control groups. Statistical analysis was performed utilizing Fisher's exact test and the paired t-test. Of the 54 patients enrolled in this study, 44 completed the program. The dropout rate was similar for both the treatment and control groups. There was no statistically significant difference between the treatment and control groups with regard to age, gravity, parity, previous antiincontinence surgery, menopausal status, or previous hysterectomy. Objective success for the treatment group was 15% and for the control group, 12.5% (NS). The subjective success for the treatment group was 25% and for the control group, 29% (NS). There was no relationship demonstrated between age, parity, previous surgery, hysterectomy, or menopausal status and the successful treatment of genuine stress incontinence with functional electrical stimulation. In this patient population, functional electrical stimulation was no more effective at improving or eliminating the symptoms of genuine stress incontinence than was the daily retention of the control probe.

Integrin-dependent protein dephosphorylation on tyrosine induced by activation of the thrombin receptor in human platelets.

Activation of human platelets by thrombin or a thrombin receptor-activating peptide (TRAP) resulted in a decrease in tyrosine phosphorylation of two proteins, P38 and P140. Preincubation of platelets with the tyrosine phosphatase inhibitor orthovanadate prevented the tyrosine dephosphorylation of P38 and P140, and reduced platelet aggregation induced by thrombin receptor activation. When platelets were stimulated under conditions that precluded the activation of glycoprotein IIb/IIIa (dissociation of the complex by EGTA at 37 degrees C) or the binding of fibrinogen (preincubation of platelets with RGDS), tyrosine dephosphorylation of P38 and P140 was not observed. The results indicate that protein tyrosine phosphatase stimulation (a) occurs during platelet activation induced by a physiological stimulus, (b) is a positive regulatory signal for platelet aggregation and (c) is dependent on the activation of the integrin alpha IIb beta 3.

Platelet signal transduction mechanisms induced by eicosanoids.

Platelets are in many ways involved in the pathogenesis of artherosclerosis and the development of coronary heart disease, and play a role in acute myocardial infarction (8). They are also an useful model to study cellular activation mechanisms: their isolation from peripheral venous blood is simple and rapid and their physiological responses such as shape change, aggregation and secretion can be easily measured (10). This chapter is focused on our results on the mechanisms of platelet activation and inhibition induced by eicosanoids.

Cloning and sequencing of rat plectin indicates a 466-kD polypeptide chain with a three-domain structure based on a central alpha-helical coiled coil.

We have determined the complete cDNA sequence of rat plectin from a number of well-characterized overlapping lambda gt11 clones. The 4,140-residue predicted amino acid sequence (466,481 D) is consistent with a three-domain structural model in which a long central rod domain, having mainly an alpha-helical coiled coil conformation, is flanked by globular NH2- and COOH-terminal domains. The plectin sequence has a number of repeating motifs. The rod domain has five subregions approximately 200-residues long in which there is a strong repeat in the charged amino acids at 10.4 residues that may be involved in association between plectin molecules. The globular COOH-terminal domain has a prominent six-fold tandem repeat, with each repeat having a strongly conserved central region based on nine tandem repeats of a 19-residue motif. The plectin sequence has several marked similarities to that of desmoplakin (Green, K. J., D. A. D. Parry, P. M. Steinert, M. L. A. Virata, R. M. Wagner, B. D. Angst, and L.A. Nilles. 1990. J. Biol. Chem. 265:2,603-2,612), which has a shorter coiled-coil rod domain with a similar 10.4 residue charge periodicity and a COOH-terminal globular domain with three tandem repeats homologous to the six found in plectin. The plectin sequence also has homologies to that of the bullous pemphigoid antigen. Northern blot analysis indicated that there is a significant degree of conservation of plectin genes between rat, human, and chicken and that, as shown previously at the protein level, plectin has a wide tissue distribution. There appeared to be a single rat plectin gene that gave rise to a 15-kb message. Expression of polypeptides encoded by defined fragments of plectin cDNA in E. coli has also been used to localize the epitopes of a range of monoclonal and serum antibodies. This enabled us to tentatively map a sequence involved in plectin-vimentin and plectin-lamin B interactions to a restricted region of the rod domain.

Results of microsurgical treatment of tubal infertility and early second-look laparoscopy in the post-pelvic inflammatory disease patient: implications for in vitro fertilization.

Sixty-nine patients with tubal infertility secondary to pelvic inflammatory disease were surgically treated by one of three infertility surgeons, who used microsurgery for repair of the tubal pathologic condition and early second-look laparoscopy 6 to 30 days postoperatively for lysis of postoperative adhesions. No patient was included in this group whose disease was thought to have originated from endometriosis or prior abdominal surgery. The average follow-up time was 43.1 months (range 12 to 85.9). Nine patients were excluded from the analysis. Pregnancy outcome by procedure, expressed as the percentage of patients conceiving, was as follows: adhesiolysis, 69% (61% term, 8% ectopic); fimbrioplasty, 35% (25% term, 10% ectopic); salpingostomy, 30% (18% term, 12% ectopic); and cornual implantation, 60% (40% term, 20% ectopic). No added therapeutic value could be attributed to the use of early second-look laparoscopy. Given the relatively poor outcome of fimbrioplasty and salpingostomy, it may be prudent to advise patients with bilateral partial and/or total tubal occlusion against tuboplasty in favor of in vitro fertilization and embryo transfer.