Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery.

BACKGROUND: Patients with intractable pain in the pudendal nerve distribution may benefit from pudendal neuromodulation; however, some may have previously undergone pudendal nerve entrapment surgery (PNES), potentially altering nerve anatomy and function. AIM: We examined pudendal neuromodulation outcomes in patients with prior PNES. METHODS: Patients with a history of PNES and quadripolar, tined pudendal lead placement for urogenital pain were reviewed. Symptoms and outcomes were collected from existing medical records. OUTCOMES: Patients with pudendal neuromodulation and prior PNES were compared to patients with no prior PNES who had pudendal lead placement. RESULTS: Fifteen patients with a history of 1, 2, or 3 prior PNES (n = 13, 1, and 1, respectively) were evaluated. Most (10; 67%) were female, with bilateral pain (9; 60%), and symptoms of 5-26 years. After trialing the lead, bladder symptoms and pain were improved in 8 of 12 and 9 of 14 patients, respectively, and 80% of patients (12/15) underwent permanent generator implantation. When prior PNES patients were compared to those with no prior PNES (n = 43), gender (67% vs 77% female; P = .50) and age (median 63 vs 58 years; P = .80), were similar; however, BMI differed (mean 24 vs 29; P = .008) and a lower proportion (12/15; 80% vs 42/43; 98%; P = .049) had generator implantation. Importantly, median lead implant time (48 vs 50 minutes; P = .65) did not differ between the 2 groups. CLINICAL IMPLICATIONS: Pudendal neuromodulation has the potential to provide pain relief for a very difficult-to-treat population; furthermore, it does not appear that prior PNES surgery made lead placement significantly more challenging. STRENGTHS & LIMITATIONS: Study strengths include being a tertiary referral center for urogenital pain and having a single surgeon perform all procedures in a regimented way. Limitations include the retrospective study design, small sample size and various approaches to PN CONCLUSION: Chronic pudendal neuromodulation can be a viable option even after prior PNES. Kristen M. Meier, Patrick M. Vecellio, Kim A. Killinger, Judith A. Boura, Kenneth M. Peters. Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery. J Sex Med 2022;19:995-1001.

Small Fiber Polyneuropathy in Hunner Lesion and Non-Hunner Lesion Interstitial Cystitis/Bladder Pain Syndrome.

OBJECTIVE: This study aimed to determine whether small fiber polyneuropathy (SFPN) diagnosis differs between Hunner lesion interstitial cystitis/bladder pain syndrome (HL IC/BPS) and non-Hunner lesion IC/BPS (NHL IC/BPS). METHODS: This was a pilot study of 20 women with IC/BPS. Results from baseline questionnaires, such as Genitourinary Pain Index, Interstitial Cystitis Symptom Index/Interstitial Cystitis Problem Index (ICSI/ICPI), Patient Health Questionnaire-2, were collected.Two punch biopsies were performed on each patient: distal leg and thigh. The samples were evaluated for intraepidermal nerve fiber density. One intraepidermal nerve fiber density less than the fifth percentile, regardless of site, indicated a positive SPFN diagnosis. RESULTS: Twenty patients were enrolled; 10 HL IC/BPS and 10 NHL IC/BPS. The HL IC/BPS group was found to be significantly older than the NHL IC/BPS group (63 vs 48 years, P = 0.007). No significant differences were found in employment or relationship statuses, or in levels of education or comorbidities between the 2 groups.Sixty percent (6/10) of patients had SFPN in the NHL IC/BPS group compared with 40% (4/10) in the HL IC/BPS group. No significant differences were seen in SFPN positivity (P = 0.3) or Genitourinary Pain Index, Patient Health Questionnaire-2, or Interstitial Cystitis Symptom Index/Interstitial Cystitis Problem Index scores between the NHL and HL IC/BPS groups. CONCLUSIONS: Similar to previously published studies, 60% of NHL IC/BPS patients in this cohort were positive for SFPN compared with only 40% of the HL IC/BPS patients. Larger studies may be needed to realize the full impact of SFPN in IC/BPS.

Symptom and Quality of Life Improvements After Pelvic Floor Physical Therapy in a Clinical Population of Women With Pelvic Pain and Other Symptoms.

OBJECTIVES: This study aimed to evaluate changes in validated symptom scores at intake and discharge in women undergoing pelvic floor physical therapy (PFPT) for pain and other pelvic floor symptoms. METHODS: Consecutive women starting PFPT during 1 year were reviewed. History, demographics, and Pelvic Floor Distress Inventory Questionnaire - Short Form 20 (PFDI) total and domain scores (Pelvic Organ Prolapse Distress Inventory-6, Urogenital Distress Inventory-6, Colorectal-Anal Distress Inventory-8), Pelvic Floor Impact Questionnaire (PFIQ-7), and pain levels on a numeric rating scale (NRS) were collected at intake and discharge. Data were analyzed with descriptive statistics and sign tests. RESULTS: Of 474 women, mean age was 50.3 ± 16.7 years (range, 18-87 years) and the most common indication for PFPT was pelvic pain (208/474; 43.9%). In women with complete data, pretreatment to posttreatment median scores improved on the PFDI (77.3 vs 41.8; P < 0.0001), Urogenital Distress Inventory (37.5 vs 16.0; P < 0.0001), and PFIQ (58.0 vs 19.0; P < 0.0001), and the minimal clinically important difference was met for the PFDI, PFIQ, and Colorectal-Anal Distress Inventory. Women with primarily pelvic pain (n = 208) achieved significant improvements in PFDI, PFIQ, and NRS scores (P < 0.0001 for all) as well as the minimal clinically important difference for these measures. Pain patients with a history of pelvic surgery (n = 50) also had significant improvements in PFIQ and NRS but not PFDI scores. CONCLUSIONS: Most women referred to PFPT demonstrated symptom improvements as measured by validated instruments.

Pelvic Floor Distress Inventory Scores Improve After Prolapse Surgery Regardless of Surgical Approach but Not After Observation Alone.

OBJECTIVE: To evaluate the effect of different surgical procedures on Pelvic Floor Distress Inventory (PFDI) scores in women with pelvic organ prolapse. MATERIALS AND METHODS: Women with prolapse were enrolled from 2008 to 2014. Baseline data and outcomes at 1 year were collected including subscales of the PFDI. Patients who had surgery (SGY) within the first year were compared to those who did not (N-SGY). Subanalyses of SGY included vaginal vs abdominal, with or without concurrent hysterectomy (HYST, N-HYST), placement of mesh (MESH, N-MESH), and concurrent posterior repair/perineorrhaphy (POST, N-POST). RESULTS: A total of 233/239 patients underwent surgery in the first year. For SGY vs N-SGY, SGY had significant improvements in PFDI and all subscale scores at 1 year while N-SGY did not. When comparing vaginal to abdominal approach, MESH to N-MESH and HYST to N-HYST, there were no differences between any scores at baseline or 1 year between the groups. However, all within group symptom scores improved from baseline to 1 year (P <.0001 for all). In comparing POST to N-POST, there were no differences between groups at 1 year in PFDI and Urogenital Distress Inventory and Pelvic Organ Prolapse Distress Inventory subscale scores. Colorectal-Anal Distress Inventory scores were significantly higher at baseline for POST (P <.0001) but not at 1 year (P = 0.37). All within group scores statistically significant improved at 1 year. CONCLUSION: Women who underwent surgical repair for prolapse had significantly improved overall PFDI and subscale scores regardless of surgical approach and concurrent procedures.

Transvaginal Trigger Point Injections Improve Pain Scores in Women with Pelvic Floor Hypertonicity and Pelvic Pain Conditions.

OBJECTIVES: Chronic pelvic pain in women often requires multimodal treatment regimens. We describe our method of transvaginal trigger point injections (TPIs) and report outcomes using change in pain scores. METHODS: This was a retrospective review of women treated with in-office pelvic floor muscle injections from January 2012 to August 2015. Lidocaine 1% and 2%, bupivacaine 0.5%, or ropivacaine 0.5% with or without the addition of triamcinolone 40 mg was used for the injections. Pain was reported on a 0- to 10-point numerical rating scale before and after injection. Differences in pretreatment and posttreatment pain scores were analyzed after the first injection and after subsequent injections. Repeated-measures analysis was used to determine if any variable affected treatment response. RESULTS: One hundred one women with a mean age of 44 years had a total of 257 separate visits for pelvic floor muscle injections. Triamcinolone was used at 90.2% (230/255) of the TPI visits. After the initial TPI visit, there was significant decrease in total levator numerical rating scale score (maximum score, 20; mean, -6.21 ± 4.7; P < 0.0001), and 77% (70/91) of patients had improved. These significant improvements were noted at all visits 1 through 4 and whether bilateral or unilateral injections were done. Only the total amount of local anesthestic used had a significant effect on the change in total levator pain scores (P = 0.002). Minor adverse effects including leg numbness, dizziness, nausea, bleeding, and headache occurred at 10% of visits. CONCLUSIONS: Pelvic floor muscle injections decrease pain levels in women with pelvic floor dysfunction.

Exploring Racial Differences Surrounding Prostate Cancer Screening: Beliefs and Attitudes in Community Dwelling Men Attending an Urban Men's Health Event.

The purpose of the study was to explore attitudes/beliefs in men attending an urban health fair to explore barriers to prostate cancer (PCa) screening. Five hundred and forty-four men attending the PCa booth at the fair in 2014 or 2015 completed questionnaires about PCa. Data were examined using Pearson's χ2, Fisher's Exact, and Wilcoxon rank tests after grouping men by African American (AA) and non-African American ethnicity. Three hundred and twenty-six (60%) men were AA and two hundred and eighteen (40%) were non-AA (89% white). Median age (54 vs. 56 years) and prior PCa screening were similar between AA and non-AA; income ( p = .044) and education ( p = .0002) differed. AA men were less likely to have researched prostate-specific antigen (PSA) on the internet ( p = .003), but more used TV ( p = .003) and media ( p = .0014) as information sources. Family members had a stronger influence over screening decisions for AA men ( p = .005). After reading PSA information, AA men were more likely to still be confused ( p = .008). A higher proportion of AA men were less worried about dying from PCa ( p = .0006), but would want treatment immediately instead of watchful waiting ( p < .0001). Interestingly, a higher proportion of AA men indicated that they would prefer not to know if they had PCa ( p = .001). Ultimately, more AA men had a PSA done (98.4% vs. 95.1%; p = .031). When considering screening eligible men, a higher proportion of AA men had an abnormal PSA (13.1% vs. 5.3%; p = .037). AA men's beliefs surrounding PCa differ from non-AA men, and should be considered when developing culturally appropriate education, screening, and treatment strategies for this group.

Does sex matter? A matched pairs analysis of neuromodulation outcomes in women and men.

AIMS: To evaluate whether baseline symptoms and outcomes are influenced by gender in a matched cohort undergoing neuromodulation. METHODS: Patients in our prospective neuromodulation database that had a tined lead placed were reviewed. Those that had implantable pulse generator (IPG) placed were matched on age and urologic diagnosis. History, voiding diaries, satisfaction, Interstitial Cystitis Symptom/Problem Index (ICSIPI), and overactive bladder symptom severity (OABq ss)/health-related quality of life (HRQOL) preimplant and over 3 years were evaluated using descriptive statistics, repeated measures, and matched pair GEE or mixed analyses. RESULTS: Of 590 patients in the database, more women than men received an IPG (450/488; 92.2 vs. 84/102; 82.4%; p = 0.0011). Eighty matched pairs (n = 160; 81% ≥ 50 years old; 56.25% had urgency/frequency with urge incontinence-UI) were identified and evaluated. On voiding diaries, volume/void was greater in women only at baseline (p = 0.040); both groups improved over time (p < 0.0001). Urinary frequency improved in both women and men (p = 0.0010; p = 0.0025). Over 3 years, UI episodes/day improved only in men (p = 0.017) and UI severity improved only in women (p < 0.0001). ICSIPI, OABq ss, and HRQOL scores improved similarly in both groups (p < 0.0001 for all measures in both groups), and although more women were satisfied at 3 months (p = 0.027), groups did not differ at other time points. CONCLUSIONS: More women undergo neuromodulation and have initial success and subsequent IPG implantation. UI episodes improved only in men, and UI severity improved only in women. Both women and men experienced similar levels of symptom improvement on other measures.

Additional treatments, satisfaction, symptoms and quality of life in women 1 year after vaginal and abdominal pelvic organ prolapse repair.

OBJECTIVES: To evaluate additional treatments, symptoms, satisfaction and quality of life 1 year after vaginal and abdominal pelvic organ prolapse (POP) repair. METHODS: Adult women enrolled in a prospective POP database were reviewed. Baseline and outcomes data 1 year after surgery were collected including the Pelvic Floor Distress Inventory (PFDI) and mailed surveys. Data were analyzed with descriptive statistics, Fisher's exact tests and t tests. RESULTS: Of 222 women, 147 (66%) had vaginal and 75 (34%) had abdominal repair. Vaginal group patients were older (64.1 vs. 59.7 years; p = 0.003), but other demographic characteristics did not differ. Vaginal group patients had lower baseline anterior and apical prolapse grades (anterior 2.7 vs. 3.1, p = 0.003; apical 2.1 vs. 3.1, p < 0.001). Baseline PFDI scores were similar. Scores improved significantly for both groups after 1 year, but 1-year PFDI scores were significantly higher in the vaginal group (45.6 vs. 32.6, p = 0.032). Scores were not different when adjusted for age and prolapse grade (p = 0.24). At 1 year, most patients in the vaginal and abdominal groups reported moderately/markedly improved overall symptoms (72/108 vs. 50/60, p = 0.030) and quality of life (89/101 vs. 54/59, p = 0.601). Most were satisfied with surgery (68/101 vs. 48/59, p = 0.067). Retreatment rates (pelvic floor physical therapy, medications, coping strategies, surgical procedures) were similar (34/109 vs. 15/62, p = 0.381). Vaginal mesh use did not affect additional treatments, patient satisfaction or symptoms. CONCLUSIONS: Although symptoms improve and most women are satisfied with surgery, about one in four women have additional therapy in the first year after POP repair.

Percutaneous Tibial Nerve Stimulation in the Office Setting: Real-world Experience of Over 100 Patients.

OBJECTIVE: To examine the outcomes and compliance with percutaneous tibial nerve stimulation (PTNS) for overactive bladder (OAB) symptoms. METHODS: Adults who had PTNS from June 30, 2011, to October 8, 2015, were retrospectively reviewed for demographics, copay, travel distance, employment status, history, symptoms, and treatments used before, during, and after PTNS. Pearson chi-square test, Fisher exact test, Wilcoxon rank and paired t test were performed. RESULTS: Of 113 patients (mean age 75 ± 12 years), most were women (65.5%), married (78.1%), and retired or unemployed (80.2%). The median distance to the clinic was 8.1 mi, and the median copay was $0. The most common indication for PTNS was nocturia (92.9%) followed by OAB with urgency urinary incontinence (75.2%) and urinary urgency and/or frequency (24.8%). Prior treatments included anticholinergics (75.2%), mirabegron (36.6%), behavioral modification (29.2%), pelvic floor physical therapy (18.6%), and others (19.5%). Patients completed a mean of 10.5 ± 3 of 12 planned weekly PTNS treatments. Of 105 patients, 40 (38.1%) used concomitant treatments (most commonly anticholinergics). Of 87 patients, 62 (71.3%) had decreased symptoms at 6 weeks, and of 85 patients, 60 (70.6%) had decreased symptoms at 12 weeks. The majority (82; 75.6%) completed all 12 weekly treatments and 45 (54.9%) completed 3 (median) monthly maintenance treatments. The most common reason for noncompliance was lack of efficacy. Visit copay, employment status, and distance to the clinic were not associated with failure to complete weekly treatments or progression to monthly maintenance. CONCLUSION: Although most patients' symptoms decreased after weekly PTNS, nonadherence to maintenance and lack of efficacy may limit long-term feasibility. Copay and distance traveled were not associated with noncompliance.

Pudendal Neuromodulation as a Treatment for Persistent Genital Arousal Disorder-A Case Series.

BACKGROUND: Persistent genital arousal disorder (PGAD) is a rare life-altering condition characterized by unwanted, uncomfortable genital sensations or spontaneous orgasms without physical or emotional stimulation. Its etiology remains unclear, and a variety of treatments have been attempted with incomplete resolution. We propose that chronic pudendal neuromodulation (CPN) may be a useful treatment for PGAD symptoms. METHODS: A retrospective chart review was performed for women older than 18 years with a diagnosis of PGAD that had staged neuromodulation with placement of a tined lead at the pudendal nerve. Demographic, operative, and postoperative data were collected. A survey was then sent to these women to assess additional demographic data, preoperative and postoperative symptoms, and patient satisfaction. Descriptive statistics were performed. RESULTS: Six women underwent CPN for PGAD. Mean age was 52 (SD, 9) years. Five (83%) of 6 were still implanted at time of survey, at a mean of 38 months after implantation; 1 device was removed for nonuse. Four of 6 completed surveys and were still using their device. Three of 4 had met their treatment goals and were satisfied with CPN; 3 of 4 felt CPN was the most useful treatment modality they had used overall. Chronic pudendal neuromodulation also improved chronic pelvic pain (4/4), bowel function (3/4), and bladder function (3/4). CONCLUSIONS: Chronic pudendal neuromodulation can be an effective treatment for decreasing frequency of PGAD symptoms and providing symptom relief.

Coexisting depressive symptoms do not limit the benefits of chronic neuromodulation: A study of over 200 patients.

AIMS: To examine the relationship between coexisting depressive symptoms and outcomes after staged neuromodulation procedures for refractory urological symptoms. METHODS: Adults who enrolled in a prospective database and completed a Personal Health Questionnaire Depression Scale (PHQ-8) at baseline were reviewed. The PHQ-8 and Generalized Anxiety Disorder (GAD-7) assessed depressive/anxiety symptoms pre and 6 months post device implant. Urological symptoms were assessed with The Interstitial Cystitis Symptom Index/Problem Index (ICSI-PI) and Overactive Bladder Questionnaire (OAB-q) at baseline, 3 and 6 months, and Global Response Assessments (GRA) post implant. Subjects, grouped by PHQ <10 and PHQ ≥10, were compared with Pearson's Chi-square, Fisher's Exact or Wilcoxon rank test, and Spearman's correlations. RESULTS: In 117 PHQ <10 and 84 PHQ ≥10 patients, age differed (mean 59 vs 52 years; P = 0.001), and PHQ <10 had lower GAD-7, ICSI-PI, and OAB-q scores at baseline (P < 0.0001, P = 0.0003, and P < 0.0008, respectively). Implantation rates were similar between groups. Reoperation and complication rates within the first 6 months did not differ, similar proportions (majority) were improved on the GRA at each time point, and ICSI-PI and OAB-q scores improved significantly. PHQ scores only improved significantly for those with baseline PHQ ≥10. Baseline PHQ strongly correlated with GAD-7 at baseline and 6 months, and baseline ICSI-PI. Change in PHQ positively correlated with the change in GAD-7, 6 month ICSI-PI, and change in ICSI-PI from baseline to 6 months. CONCLUSIONS: Coexisting depressive symptoms do not limit the efficacy of neuromodulation and PHQ improvements correlate with improved anxiety and bladder symptoms.

Perioperative Outcomes, Complications, and Efficacy of Robotic-Assisted Prolapse Repair: A Single Institution Study of 196 Patients.

Abdominal pelvic organ prolapse repair is efficacious for uterovaginal and apical prolapse. We describe the safety and efficacy of robotic prolapse repair in a large teaching institution. METHODS: Consecutive robotic-assisted prolapse repairs at a single institution between 2006 and 2014 were retrospectively reviewed for patient characteristics, operative information, and outcomes. RESULTS: A total of 196 women (mean age, 61 ± 9 years) underwent robotic prolapse repair (189 sacrocolpopexy, 6 sacrohysteropexy, 1 enterocele repair). Concomitant procedures included hysterectomy (88), midurethral sling (84), and/or Burch colposuspension (7). Mean odds ratio time was 242 ± 69.9 minutes, and median length of stay was 1 day. Intraoperative complications were as follows: cystotomy (4), vaginotomy (4), conversion to open (2), bowel injury/aborted (1), adhesions/aborted (1), and ureteral injury (1). Women with complications had greater blood loss than those without complications (P = 0.0015). Immediate (<30 days) postoperative complications were rare: port-site hernia (2), discitis (1), ileus (1), and ulnar neuropraxia (3). At median follow-up of 9 months (range, 0-85 months), 14 women had recurrent grade 3 prolapse, and 4 had grade 2 apical prolapse. Nine of 14 women had additional prolapse repair at a mean of 9.5 ± 6.3 months. Vaginal mesh exposure was detected in 12 (6.3%) of 192 women. There were 6 procedures for mesh exposure and 2 procedures for exposed sutures. One mesh erosion into the bladder required open excision. CONCLUSIONS: In this large series of robotic prolapse repair, complications are infrequent. Short-term apical outcomes are excellent. Few women required additional compartment repairs within 1 year with 6% rate of mesh exposure.

The Impact of Baseline Functional Bladder Capacity on Short-term Neuromodulation Outcomes.

OBJECTIVE: To evaluate the impact of functional bladder capacity (FBC) on clinical outcomes after a staged neuromodulation procedure. MATERIALS AND METHODS: Adults in our prospective neuromodulation database were evaluated. Data were collected from medical records, voiding diaries (FBC defined as average volume per void), Interstitial Cystitis Symptom Index-Problem Index, Overactive Bladder Questionnaire, and Global Response Assessment over 3 months. Descriptive statistics, Pearson's chi-square tests, Wilcoxon rank sum tests, logistic regression, repeated measures analyses, and Spearman correlation coefficients were performed. RESULTS: Of the 216 patients (mean age 59 years; 84% female), most had urinary urgency and frequency with or without urge incontinence (71%), a sacral lead placement (82%), and implantable pulse generator (IPG) implantation (92%). Baseline FBC was similar between implanted and not implanted patients (P = .17); however implanted patients had a median 19 mL increase in FBC after lead placement compared to a 2.7 mL decrease in explanted patients (P = .0014). There was a strong association between percent change in FBC after lead placement and IPG implantation (P = .021; C-statistic 0.68), but baseline FBC (mL) was not associated. Baseline FBC (mL), or percent change in FBC after lead placement, was not related to symptom improvement. When grouped by baseline FBC < 150 mL and FBC ≥ 150 mL, FBC only improved significantly in the <150 group but both demonstrated significant improvements in symptoms. CONCLUSION: FBC improvements were associated with IPG implantation but not other symptom measures. Patients with low FBC (baseline FBC < 150) also achieved significant improvements in symptoms.

The impact of prior back surgery on neuromodulation outcomes: A review of over 500 patients.

AIMS: To evaluate neuromodulation outcomes in patients with prior back surgery. METHODS: Adults in our prospective observational sacral/pudendal neuromodulation study were retrospectively evaluated. History and operative details were reviewed, and outcomes were measured at 3, 6, 12, and 24 months with overactive bladder questionnaire (OAB q) symptom severity (SS)/health related quality of life (HRQOL), interstitial cystitis symptom/problem indices (ICSI - PI), voiding diaries, and global response assessments (GRA). Data were examined with Pearson's χ2 , Fisher's exact, Wilcoxon rank sum tests, and logistic regression multivariate analysis. RESULTS: Five hundred and sixty patients were evaluated (mean age 58.8 ± 17 years; 83% female; 79% had a sacral lead placed), 109 (19%) had history of back surgery; 66 surgeries were lumbar. Back surgery patients were older (mean 63 ± 15 vs. 58 ± 17 years; P = 0.003) and a higher proportion had urge urinary incontinence (UUI) (64% vs. 50% P = 0.008). Generator implant rates were similar (94% vs. 91%; P = 0.34). OABq-SS and HRQOL and ICSI - PI composite scores did not differ between groups at any time point. On bladder diaries, median incontinence episodes daily at baseline and between stages were worse in the prior back surgery group but all bladder diary parameters improved significantly in both groups with the exception of mean voided volume which only improved significantly in the non-back surgery group. Most patients in both groups reported moderate/marked improvement in overall bladder symptoms. CONCLUSIONS: This study suggests that prior back surgery does not appear to impact clinical outcomes; therefore, neuromodulation may be offered in this patient population.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

AIMS: To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM). METHODS: Patients enrolled in our longitudinal neuromodulation database were reviewed. Medical records data, and voiding diaries, Interstitial Cystitis Symptom-Problem Indices (ICSI-PI), and Overactive Bladder Questionnaires (OAB-q) at baseline and 3 months were analyzed with Pearson's χ2 , Fisher's Exact test, Wilcoxon rank tests, and multivariable logistic regression. RESULTS: Of 407 patients, 134 (33%) had at least one reoperation over median 28.9 months follow-up (range 1.6-121.7); 78/407 (19%) were revised, and 56/407 (14%) were explanted. The most common reason for reoperation was lack of efficacy/worsening symptoms (n = 87). The reoperations group had a higher proportion of women (P = 0.049), lower mean body mass index (BMI; P = 0.010), more reprogramming events (P < 0.0001), longer median follow-up (P = 0.0008), and higher proportions with interstitial cystitis (P = 0.013), using hormone replacement therapy (P = 0.0004), and complications (P < 0.0001). Both reoperations/no reoperations groups had similar improvements in ICSI-PI (P < 0.0001 for both), OAB-q severity (P < 0.0001 for both) and quality of life (P < 0.0001 for both). On multivariate analysis, only longer follow-up (P = 0.0011; OR 1.048; CI 1.019, 1.078) and having a complication (P < 0.0001; OR 23.2; CI 11.47, 46.75) were significant predictors of reoperations. In women only, using HRT at time of implant was also predictive of reoperation (P = 0.0027; OR 3.09; CI 1.48, 6.46). CONCLUSIONS: In this largest known series to date, one third of the patients required reoperation and the most common reason was lack of efficacy/worsening symptoms. Ongoing study is needed as the technology continues to evolve. Neurourol. Urodynam. 36:354-359, 2017. © 2015 Wiley Periodicals, Inc.

Outcomes of Sacral Neuromodulation in Patients with Prior Surgical Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse.

OBJECTIVES: The aim of this study was to evaluate the efficacy of sacral neuromodulation in patients with prior stress urinary incontinence (SUI) or pelvic organ prolapse (POP) surgery. METHODS: Women in our prospective neuromodulation database were evaluated. Patients with a history of prior SUI/POP surgery were compared to those without. Medical records at baseline were reviewed, and primary outcome was defined as moderate/marked improvement on Global Response Assessment (GRA) at 3 months. Secondary outcomes were measured using bladder diaries and Overactive Bladder Symptom Severity (OABq-SS)/health-related quality of life (HRQOL). Data were analyzed with Pearson χ test, Fisher exact test, Wilcoxon rank-sum test, and repeated-measures analyses. RESULTS: Of 210 subjects, 108 (51%) had prior SUI/POP surgery. Patients with SUI/POP surgery had more prior hysterectomies. At 3 months, there was no difference between groups on GRA outcomes. On the bladder diary, both groups had improvement in median voids per 24 hours, urgency severity, and urge incontinence over 2 years. On the GRA, fewer patients in the SUI/POP group were treatment responders at 12 and 24 months. For urinary urgency, a few in this group were moderately/markedly improved at 6 months, and a higher proportion are reported still leaking urine at 6 and 12 months. Similar proportions in each group reported moderate/marked improvement in leaking. Satisfaction was similar between groups. The OABq-SS/HRQOL scores improved, and there was no difference between the groups. CONCLUSION: Sacral neuromodulation improves bladder symptoms in women with prior SUI/POP surgery, but response may be slightly less in those with prior surgery due to underlying bladder or pelvic floor issues.

Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches.

INTRODUCTION AND HYPOTHESIS: To examine changes in sexual function after abdominal and transvaginal pelvic organ prolapse repair. METHODS: Women enrolled in our prospective, longitudinal prolapse database with abdominal sacrocolpopexy (ASC) or transvaginal (TVR) pelvic organ prolapse (POP) repair with or without mesh, between 19 December 2008 through 4 June 2014. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory (PFDI -20) were mailed preoperatively, and at 6 and 12 months postoperatively. Patients completed Global Response Assessments to rate their overall satisfaction. RESULTS: Two hundred and four of the 300 women met the inclusion criteria: 74 out of 204 (36 %) had ASC and 130 out of 204 (64 %) had TVR. Seventy-two out of seventy-four ASCs were performed robotically and 2 were open. Baseline demographics were similar except that the ASC patients were significantly younger (60 vs 63, P = 0.019) and had a higher rate of apical repair (77 % vs 55 %). Thirty-six out of seventy-four ASC (48.7 %) and 63 out of 128 TVR patients (49.2 %) were sexually active at baseline (P = 0.94). Sixteen out of thirty-eight ASC (42.1 %) and 18 out 63 TVR patients (28.6 %; P = 0.16) reported dyspareunia at baseline. Seventy-two out of seventy-four ASC (97 %) and 86 out of 130 TVR patients (66 %) had mesh-augmented repairs. There was no difference in sexual activity or dyspareunia between the groups at the 6- or 12-month follow-up. PISQ and PFDI scores improved significantly in both the ASC and TVR groups over time compared with the baseline (p < 0.0001). Most women in the ASC (77.5 %) and TVR (64.8 %) groups were satisfied with the results of prolapse surgery at 12 months. CONCLUSIONS: Sexual function and pelvic floor symptoms improved in a similar manner in patients after abdominal and transvaginal POP surgery.

Clinical Comparison of 2 Trial-of-Void Methods After Outpatient Midurethral Sling Placement.

OBJECTIVES: This study aimed to assess the efficacy, efficiency, and costs of 2 methods of trial of void (TOV) after midurethral sling (MUS) placement. METHODS: A retrospective chart review was performed on women who underwent outpatient MUS between January 2013 and April 2014 by 3 urologists. Patients were excluded if they had a concomitant prolapse repair, hysterectomy, bladder/urethral injury, or any procedure that may prolong recovery room (RR) stay. Trial of void was performed by either (1) bladder instillation, catheter removal in the operating room (OR) fill with attempted void in RR, or (2) bladder instillation and catheter removal with immediate attempted void in the RR fill. Intraoperative, postoperative, and cost data were analyzed. RESULTS: Ninety-one of 183 women (mean age, 55.9 ± 12 years; mean body mass index, 28.8 ± 5.8 kg/m) met inclusion criteria. Eighty-three had a transobturator sling. Forty-nine (54%) had an OR fill and 42 (46%) had an RR fill; age and body mass index were similar between groups. The OR fill group had shorter median operative time (15 vs 22 minutes; P = 0.003) and median RR time (138 vs 161, P = 0.033). The OR fill and RR fill groups did not differ in TOV failure rate (3/49 vs 6/42; P = 0.29), overall mean LOS (4.96 vs 5.51 hours; P = 0.055), and median RR costs ($627 vs $678; P = 0.065). No patient had urinary retention after successful TOV. CONCLUSIONS: After MUS placement, both OR fill and RR fill TOV methods are effective and efficient with similar TOV failure rates.

Pilot Study Exploring Chronic Pudendal Neuromodulation as a Treatment Option for Pain Associated with Pudendal Neuralgia.

OBJECTIVES: Pudendal neuralgia can cause significant voiding and pain symptoms. We explored the effects of chronic pudendal neuromodulation (CPN) and nerve blocks on pain associated with pudendal neuralgia. METHODS: Patients with pudendal neuralgia and tined lead placed at the pudendal nerve were reviewed. History and initial improvement after lead placement were collected from medical records. Demographics, symptom characteristics and changes after various treatments were assessed by mailed survey. Descriptive statistics were performed. RESULTS: Of 19 patients (mean age 54.8 years, 63% female), 6/19 (32%) had previous sacral neuromodulation. Before CPN, 18 patients had 77 nerve blocks (median six blocks per patient); most blocks (60/77; 78%) provided at least some relief. After lead placement, pain relief was complete in three patients, almost complete in three, significant/remarkable in 10, and small/slight in three. All 19 patients had a permanent generator placed. Five were ultimately explanted at (mean) 2.95 years: one had total symptom resolution, one had stopped using the device, and three lost efficacy. Survey respondents (n = 10) indicated that they had been experiencing pain for (median) 4.42 years before CPN. The most helpful pain treatment cited was medication for 6/10 and neuromodulation for 4/10; 8/9 rated neuromodulation as more helpful than nerve block, while one subject felt that the two treatments were equally helpful. Compared to sacral neuromodulation, 3/4 rated CPN as more effective for pain. Overall, 8/10 were satisfied with CPN; only 1/9 was mildly satisfied with nerve block. CONCLUSIONS: Chronic pudendal neuromodulation can improve pain in patients with pudendal neuralgia.

Contemporary diagnosis and management of Fournier's gangrene.

Fournier's gangrene, an obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the overlying skin, is a rare but severe infective necrotizing fasciitis of the external genitalia. Mainly associated with men and those over the age of 50, Fournier's gangrene has been shown to have a predilection for patients with diabetes as well as people who are long-term alcohol misusers. The nidus for the synergistic polymicrobial infection is usually located in the genitourinary tract, lower gastointestinal tract or skin. Early diagnosis remains imperative as rapid progression of the gangrene can lead to multiorgan failure and death. The diagnosis is often made clinically, although radiography can be helpful when the diagnosis or the extent of the disease is difficult to discern. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be used to stratify patients into low, moderate or high risk and the Fournier's Gangrene Severity Index (FGSI) can also be used to determine the severity and prognosis of Fournier's gangrene. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics. After initial radical debridement, open wounds are generally managed with sterile dressings and negative-pressure wound therapy. In cases of severe perineal involvement, colostomy has been used for fecal diversion or alternatively, the Flexi-Seal Fecal Management System can be utilized to prevent fecal contamination of the wound. After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for satisfactory functional and cosmetic results.