Urethral bulking agents for female stress urinary incontinence.

Urethral bulking agents (UBAs) to treat stress urinary incontinence was first described in the 1930s, when paraffin was used to increase urethral resistance. Since then, several agents have been introduced to the market, with varying degrees of safety, efficacy, and durability. The agents currently available include calcium hydroxyl apatite (Coaptite®), carbon coated zirconium (Durasphere®); polydimethylsiloxane elastomer (Macroplastique®); and polyacrylamide hydrogel (Bulkamid®). The latest product, PDMS-U (Urolastic ®) is a silicone gel that polymerizes when injected. The short term efficacy of UBAs are generally encouraging; however, longer follow up results show the success rates are reduced and many women will require a repeat treatment. This review looks at the currently available UBAs, application techniques, and the clinical data on their safety and efficacy.

Tolterodine ER reduced increased bladder wall thickness in women with overactive bladder. A randomized, placebo-controlled, double-blind, parallel group study.

AIMS: We evaluated the effect of Tolterodine extended release (TER) versus placebo on bladder wall thickness (BWT) using transvaginal ultrasound in women with overactive bladder (OAB). MATERIALS AND METHODS: We recruited 79 women with symptoms of OAB with a mean age of 47 years who had a BWT of at least 5 mm and a post-micturition volume of less than 50 mL at screening. Subjects received TER 4 mg or placebo once daily for the first 12 weeks of the study. For the subsequent 12 weeks, all subjects received TER 4 mg once daily. BWT was measured at screening, weeks 12 and 24. Subjects recorded number of micturitions, incontinence episodes and urgency episodes, and volume voided per micturition at regular intervals during the study. RESULTS: Treatment with TER for 12 weeks produced a statistically significant decrease from baseline in BWT (mean [SD] = 0.9 [1.4] mm; P < 0.05) that was not evident following treatment with placebo (0.2 [1.6] mm; P = 0.54). However, the treatment difference did not reach statistical significance (LS Mean = -0.4; 95%CI: -1.2, 0.3; P = 0.25). After 12 weeks of treatment, subjects who had taken TER showed an improvement in each bladder diary variable compared to placebo-treated subjects. CONCLUSIONS: TER may have a direct effect on BWT in women with OAB. Larger studies are warranted to further investigate the effect of behavioral interventions and antimuscarinics, such as TER, on BWT in women with OAB and increased BWT.

Urinary Metabolic Phenotyping of Women with Lower Urinary Tract Symptoms.

Lower urinary tract symptoms (LUTS), including urinary incontinence, urgency and nocturia, affect approximately half of women worldwide. Current diagnostic methods for LUTS are invasive and costly, while available treatments are limited by side effects leading to poor patient compliance. In this study, we aimed to identify urine metabolic signatures associated with LUTS using proton nuclear magnetic resonance (1H NMR) spectroscopy. A total of 214 urine samples were collected from women attending tertiary urogynecology clinics (cases; n = 176) and healthy control women attending general gynecology clinics (n = 36). Despite high variation in the urine metabolome across the cohort, associations between urine metabolic profiles and BMI, parity, overactive bladder syndrome, frequency, straining, and bladder storage were identified using KODAMA (knowledge discovery by accuracy maximization). Four distinct urinary metabotypes were identified, one of which was associated with increased urinary frequency and low BMI. Urine from these patients was characterized by increased levels of isoleucine and decreased levels of hippurate. Our study suggests that metabolic profiling of urine samples from LUTS patients offers the potential to identify differences in underlying etiology, which may permit stratification of patient populations and the design of more personalized treatment strategies.

Does the vaginal wall become thinner as prolapse grade increases?

INTRODUCTION AND HYPOTHESIS: The pathophysiology of prolapse is not well understood. However, two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated. The aim of this study was to assess how vaginal wall thickness (VWT) is related to vaginal prolapse. METHODS: The study group comprised 243 women with symptomatic prolapse recruited from the Outpatient Department of a tertiary referral centre for urogynaecology. A history was taken and women were examined to determine their POP-Q score. Using a previously validated technique, ultrasonography was used to measure the mean VWT at three anatomical sites on the anterior and posterior walls. Scores were then compared using t tests, the Kruskal-Wallis test and the Friedman test. RESULTS: The mean age of the patients was 59.7 years (SD 12.0 years range 38 - 84 years). For each measurement VWT reduced as prolapse grade increased until the prolapse extended beyond the hymen. Women with grade 3 prolapse had a significantly higher mean VWT than women with grade 1 or 2 contained prolapse. Menopause status did not have a significant effect on the VWT. CONCLUSIONS: VWT is lower in women with vaginal prolapse until the prolapse extends beyond the hymen and then VWT is thicker and comparable with women without prolapse. This may be explained by changes in the vaginal tissue including reduction of collagen, elastin and smooth muscle, as well as fibrosis in exposed tissues, rather than by defects in the vagina.

A randomised controlled trial comparing immediate versus delayed catheter removal following vaginal prolapse surgery.

OBJECTIVE: It is unclear if any catheterisation is necessary after vaginal surgery for pelvic organ prolapse. The aim of this study was to determine if indwelling catheterisation is necessary after these procedures. STUDY DESIGN: A randomised controlled trial of immediate post-operative removal of catheter compared to a suprapubic catheter (SPC) after vaginal prolapse surgery. In the Suprapubic group the catheter was left on free drainage until a voiding trial was commenced at 48h. Women in the immediate removal group underwent in/out catheterisation only if they had not voided by 8h after surgery to ensure the bladder did not over-distend. RESULTS: 55% (n=17) of patients in the immediate removal group did not require catheterisation postoperatively. A further 13 (42%) patients only required one in/out catheterisation 8h post operatively. In the immediate removal group duration of catheterisation was significantly shorter (median 0h, IQR 0-8h, range 0-16h) vs (6days (IQR 2-8days, range 2-19h) p=0.001). The duration of hospital stay (7days (range 3-16) vs. 9 (range 3-27) p=0.014), day of first mobilisation (Day 1, range 0-2, vs. Day 2, range 1-4, p=0.001), and rate of Symptomatic bacturia (16% vs. 52%, p<0.01) were all significantly better with immediate catheter removal. CONCLUSIONS: After vaginal surgery for pelvic organ prolapse, the majority of patients do not require extended catheterisation. Early removal of a catheter reduces urinary tract infection and significantly decreases hospital stay. Such a policy should result in improved patient satisfaction and reduced hospital costs.

The pelvic floor muscle hyperalgesia (PFMH) scoring system: a new classification tool to assess women with chronic pelvic pain: multicentre pilot study of validity and reliability.

OBJECTIVE: The contribution of pelvic floor muscle tenderness to chronic pelvic pain (CPP) is well established in the literature. However pelvic floor muscle hyperalgesia (PFMH) is often missed during vaginal examination of women with CPP. To our knowledge criteria for diagnosing PFMH has not been established or validated so far. The aim of this study is to assess the validity and reliability of the PFMH scoring system. STUDY DESIGN: Women with and without PFMH were recruited prospectively. Digital pelvic examination was performed to detect any pain. All women were asked to report of any discomfort or pain evoked by digital palpation of the PFMs and to rate the severity of pain/discomfort as none (grade 0), mild (grade I) moderate (grade II) or severe (grade III). All women were also asked to describe the severity of the pain/discomfort using a visual analogue scale (VAS). Following examination a PFMH score was given according to each patient's reactions. Intra-observer and inter-observer reliability was assessed. Construct and content validity was also determined. RESULTS: 111 (44 symptomatic and 67 controls) were recruited. Intraobserver reliability had ICCs between 0.426 and 0.804. Interobserver reliability had ICCs between 0.724 and 0.917. There was a good correlation between PFMH scores and VAS scores (rho 0.994, p<0.01). Total scores between symptomatic and controls were significantly different (p<0.01 Mann-Whitney U test). CONCLUSION: The PFMH scoring system is a simple, reliable, valid and easy screening tool for in the assessment of women with CPP.