Change in Overactive Bladder Symptoms After Surgery for Stress Urinary Incontinence in Women.

OBJECTIVE: To assess change in overactive bladder (OAB) symptoms up to 5 years after surgery and to identify associated predictors of change from baseline. METHODS: This is a secondary analysis of data from three multicenter urinary incontinence (UI) surgical trials of women with stress-predominant mixed UI assigned to Burch colposuspension, autologous fascial sling, or retropubic or transobturator midurethral slings. The primary outcome was improvement of 70% or greater from baseline in symptoms measured by the Urinary Distress Inventory-Irritative subscale. Surgical groups were compared within respective trials. Generalized linear models were fit using 1-year and up to 5-year data. RESULTS: Significant improvements in Urinary Distress Inventory-Irritative scores were reported by each surgical group 1 year after surgery (P<.001). Most women (50-71%) reported improvement in OAB symptoms. Improvements were similar between midurethral sling groups at 1 year (65.5% compared with 70.7%, P=.32; odds ratio [OR] 0.83, 95% confidence interval [CI] 0.57-1.20 for retropubic compared with transobturator sling) and throughout the 5-year follow-up period. More women reported OAB symptom improvement after Burch compared with pubovaginal sling (67.9% compared with 56.6%, P=.01; OR 1.59, 95% CI 1.10-2.31 for Burch compared with sling); this group difference at 1 year persisted throughout the 5-year follow-up. At 1-year, 50.0-64.3% of patients reported 70% greater improvement in UI. This proportion declined to 36.5-54.1% at 5 years (P<.001). Preoperative use of anticholinergics and urodynamic parameters was not predictive of OAB symptom change after surgery. CONCLUSION: Most women with stress-predominant mixed UI experienced significant improvement in OAB symptoms after incontinence surgery although this initial improvement diminished over time. Obesity blunted symptom improvement. LEVEL OF EVIDENCE: II.

A psychophysical study of discomfort produced by repeated filling of the urinary bladder.

Psychophysical studies were performed in 10 healthy, female volunteers using urinary bladder distension (UBD) as a visceral stimulus. Stimulus methodology was similar to that used clinically for obtaining cystometrograms with a fixed-rate (100 cc/min normal saline) filling of the urinary bladder, occasional pauses and simultaneous measure of bladder pressure using a catheter-transducer assembly. During bladder filling, subjects were asked to report sensations by verbal report and by using an electronic, hand-held, visual-analog-scale device. Sensations evoked by UBD were generally localized to the suprapubic region. UBD produced cardiovascular responses which increased with repeated trials. Sensation intensity increased with repeated UBDs as indicated by global pain ratings. Intravesical pressure and volume correlated with sensation intensity. The volume of distending fluid needed to produce a report of discomfort was highly variable from trial to trial and did not change significantly with repeated UBDs. The intravesical pressure which produced a report of discomfort was less variable and significantly decreased with repeated UBDs. The change in intravesical pressure and volume needed to produce discomfort was inversely correlated with initial intravesical pressure measures. Similar to findings in other organ systems, these findings demonstrate that repeated presentations of a visceral stimulus may lead to an increase in physiological and perceptual responses to pain.

Uterine herpes virus infection with multifocal necrotizing endometritis.

A case of herpes simplex virus (HSV) infection was diagnosed by biopsy of the cervix and endometrium in a 28-year-old woman with abnormal uterine bleeding. The cervical biopsy demonstrated surface ulceration and underlying patchy necrosis of endocervical clefts and stroma. The endometrium was late secretory, with striking patchy necrosis of gland epithelium and stromal cells. Both sites contained occasional epithelial and stromal cells with nuclear inclusions consistent with HSV infection. Viral culture further confirmed the presence of HSV. Immunohistochemistry demonstrated the presence of HSV antigens in the tissue, and ultrastructural study of the endometrium revealed viral particles within epithelial and stromal cells. The results suggest endometrial involvement via an ascending infection from the cervix. Recognition of this unusual pattern of endometrial inflammation may facilitate diagnosis of additional cases.

Hyperandrogenic state associated with a mucinous cystadenoma.

A case of mucinous cystadenoma associated with androgen secretion is presented to add to the growing body of literature concerning hormone secretion by ovarian neoplasms regarded as "nonfunctional." The theorized mechanisms of hormone production in these tumors also are reviewed.

Ovarian cancer screening.

For populations in which preventive measures have been applied for the more common causes of death, the early detection of ovarian cancer becomes the next focus of efforts to reduce premature death among women. Data regarding the effectiveness of ultrasonography in detecting early-stage ovarian cancer are reviewed. Ultrasonography is more sensitive than pelvic examination in detecting ovarian abnormalities but lacks specificity in distinguishing benign from malignant ovarian lesions. Combined with serum CA 125 levels, ultrasonography may provide an effective screening tool, although cost-effectiveness has not been demonstrated and its effectiveness in reducing mortality from ovarian cancer has not been completely evaluated. Guidelines are presented for the use of ultrasonography in evaluating the postmenopausal ovary.

Transvaginal sonography of the endometrium in postmenopausal women.

The purposes of this study were to compare transvaginal sonographic scanning of the uterus and endometrium with histology obtained by endometrial biopsy or curettage and to determine whether the sonographic technique might be useful in the evaluation of postmenopausal women. Eighty postmenopausal women were studied. Of these, 65 were asymptomatic (38 on no hormone therapy and 27 on hormone replacement). Fifteen women underwent evaluation because of postmenopausal bleeding. In both groups, endometrial thickness of 4 mm or less as depicted by sonography correlated well with endometrial characteristics of decreased estrogen stimulation. However, in women with measured endometrial thickness between 5-8 mm, proliferative endometrium could not be distinguished from hyperplastic endometrium or, in one case, low-grade carcinoma. Large polyps and invasive carcinoma with myometrial extension were easily recognized.

The short-term effect of pelvic irradiation for gynecologic malignancies on bladder function.

Urinary symptoms and urodynamic studies were evaluated prospectively in 33 women undergoing radiation therapy for cervical cancer. Patients were evaluated during treatment, after one to two months, and after five to six months. Significant reductions in peak urinary flow, volume at first desire to void, cystometric capacity, and bladder compliance were evident during and immediately after therapy. Bladder symptoms and urodynamic alteration did not correlate with age, race, or stage of disease. Bladder compliance was significantly reduced in those patients receiving more than 3000 rads to the entire bladder from external beam irradiation.

Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group.

OBJECTIVE: To determine the prevalence of stress, urge, and mixed urinary incontinence and associated risk factors in postmenopausal women. METHODS: Before enrollment in a 4-year, randomized trial of combination hormone therapy to prevent coronary heart disease, 2763 participants completed questionnaires on prevalence and type of incontinence. We measured factors potentially associated with incontinence including demographics, reproductive and medical histories, height, weight, and waist-to-hip circumference ratio. We used multivariate logistic models to determine independent associations between those factors and weekly incontinence by type. RESULTS: The mean (+/- standard deviation [SD]) age of the participants was 67+/-7 years; 89% were white and 8% were black. Fifty-six percent reported weekly incontinence. In multivariate analyses, the prevalence of weekly stress incontinence was higher in white than black women (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1), in women with higher body-mass index (BMI) (OR 1.1 per 5 units, 95% CI 1.0, 1.3), and higher waist-to-hip ratio (OR 1.2 per 0.1 unit, 95% CI 1.0, 1.4). The prevalence of weekly urge incontinence was higher in older women (OR 1.2 per 5 years, 95% CI 1.1, 1.3), diabetic women (OR 1.5, 95% CI 1.1, 2.0) and women who had reported two or more urinary tract infections in the prior year (OR 2.0, 95% CI 1.1, 3.6). CONCLUSION: Stress and urge incontinence are common in postmenopausal women and have different risk factors, suggesting that approaches to risk-factor modification and prevention also might differ and should be specific to types of incontinence.

Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse.

BACKGROUND: Multiple studies have shown sacrospinous ligament fixation to be highly effective therapy for vaginal vault prolapse. Several authors have suggested that the marked vaginal retroversion subsequent to sacrospinous ligament fixation may predispose to recurrent pelvic support defects in the anterior fascial segment, resulting in cystocele or urethrocele, or both. STUDY DESIGN: Thirty-six patients, 46 to 86 years of age, were examined at six weeks postoperatively and at long-term follow-up evaluation 15 to 79 months (median of 42 months) after sacrospinous ligament fixation and repair of associated pelvic support defects. The examinations, by an unbiased examiner, were done to identify and grade recurrent pelvic support defects. RESULTS: At the six week postoperative visit, one patient had a small enterocele, and none of the patients demonstrated vaginal vault prolapse. At the long-term follow-up visit, 33 (92 percent) of the patients had cystoceles, six (17 percent) had rectoceles, two (6 percent) had enteroceles, and three (8 percent) demonstrated recurrent vaginal vault prolapse. Most cystoceles were small and asymptomatic. CONCLUSIONS: A high rate of success in the treatment of prolapse of the upper vagina by sacrospinous ligament fixation was observed. Pelvic support defects at long-term follow-up evaluation occurred more commonly in the anterior fascial segment. Retroversion and fixation of the upper vagina predisposes the anterior fascial segment to excess pressure and a higher incidence of cystocele than could be attributed to the effects of aging and menopause.

Surgery for stress urinary incontinence.

Stress urinary incontinence is a common problem, with various degrees of disability. Its etiology may be defective external or internal urethral sphincter mechanisms. Evaluation of the patient with symptoms of stress incontinence requires objective testing for diagnostic accuracy. Patient management may be individualized to conservative measures or to one of the various surgical approaches, which produce success rates between 80% and 95%. Retropubic suspension or long needle procedures should be considered for patients with stress incontinence and evidence of bladder neck detachment. Sling procedures, artificial sphincters, and periurethral injections should be considered for patients with minimal bladder neck mobility or low urethral pressures and for those with a high risk of failing other procedures.

Pelvic-floor musculature exercises in treatment of anatomical urinary stress incontinence.

The purpose of this study was to investigate the effects of pelvic-floor musculature exercises in the treatment of women with anatomical urinary stress incontinence. Fourteen female subjects, ranging in age from 33 to 67 years, participated in a four-week pelvic-floor musculature exercise program. Subjects underwent a pretraining urodynamic evaluation and were reexamined after four weeks of exercise training. Paired t tests of subjects' pretraining and posttraining values of bladder capacity, functional urethral length, and static urethral pressure profile showed no significant differences. Multivariate regression analysis demonstrated that the covariates of weight, motivation, and age did not significantly influence subjects' bladder capacity, functional urethral length, or static urethral pressure profile. Nine of the 14 subjects had a negative result on the posttraining urinary stress test (R = 0, p less than .01). The urinary stress test result was the only variable to change significantly from pretraining to posttraining measurements. All subjects reported posttraining improvement in control of urinary incontinence. A short-term exercise program for pelvic-floor musculature produced positive changes in subjects with anatomical urinary stress incontinence.

Transcutaneous electrical nerve stimulation in the relief of primary dysmenorrhea.

The purpose of this study was to replicate a previous study to determine the effectiveness of acupuncture-like transcutaneous electrical nerve stimulation in treating primary dysmenorrhea. Twenty-one women with dysmenorrhea received a placebo pill or 30 minutes of acupuncture-like TENS. All subjects completed two pain questionnaires before treatment; immediately posttreatment; 30, 60, 120, and 180 minutes posttreatment; and the next morning upon awakening. Each woman also participated in a separate study measuring electrical resistance at four auricular acupuncture points before and immediately after treatment. The data were analyzed with a two-factor repeated-measures analysis of variance, which revealed statistical significance over time but not for group or interaction between group and time. Results revealed an average pain relief of at least 50% immediately posttreatment, indicating that acupuncture-like TENS may be useful for dysmenorrheic pain. This study also suggests that auriculotherapy via acupressure may relieve the pain of primary dysmenorrhea.

Müllerian dysgenesis.

The multifaceted syndrome of müllerian dysgenesis appears to represent a defect in mesodermal organization and is often associated with renal and skeletal anomalies. This report discusses the embryology, multifactorial etiology, clinical presentation and management of the syndrome from a historical standpoint and details our experience with 35 affected patients. Both Frank dilatation and McIndoe vaginoplasty appear to be acceptable means of therapy. The therapeutic success depends to a large extent on the psychosocial adaptation of the patient.

Sexual function after sacrospinous ligament fixation for vaginal vault prolapse.

OBJECTIVE: To determine if sacrospinous ligament fixation predisposes to dyspareunia or if vaginal narrowing secondary to repair of associated defects is causative. STUDY DESIGN: We interviewed and examined 36 heterosexual patients preoperatively and at follow-up 15-79 months postoperatively. We inquired specifically as to sexual activity or inactivity and whether sexual function had improved or declined since surgery. RESULTS: Postoperatively, sexually active patients reported either an improvement or no change in sexual function unless vaginal narrowing occurred. Vaginal narrowing caused apareunia in three postoperative patients. Death of the partner was the most common reason for sexual inactivity preoperatively or postoperatively. CONCLUSION: Sacrospinous ligament fixation did not predispose to dyspareunia unless vaginal narrowing due to repair of associated defects was present.

Retropubic long-needle suspension procedures for stress urinary incontinence.

A brief review of the Pereyra and the Stamey procedures and their modifications, including success rates and potential problems, is presented. A new modified technique is described that has potential advantages of ease, rapidity, less dissection, and less blood loss than may be seen with the modified Pereyra procedure and less chance of foreign body reaction than may be seen with the Stamey procedure. Twenty patients with significant stress urinary incontinence (14 with concurrent severe pelvic relaxation) underwent the procedure with an 80% cure plus 5% significant improvement rate noted 12 to 39 months after operation. All failures occurred in patients who were obese and involved apparent suture pull-through. Complications were minimal. Suggested causes for failures are discussed.

Force production decay rate in Alastik modules.

The production and decay of forces produced by Alastik modules was studied under conditions simulating clinical usage over time period of 2 hr to 4 weeks. Force decay was moderate and all Kx modules tested produced approximately 1 lb of force at the end of the 4-week test period. Therefore, from a clinical standpoint, modules need not be changed more frequently than once every 4 weeks.

Urinary complaints after modified Burch urethropexy: an analysis.

OBJECTIVE: Postoperative bladder complaints after incontinence procedures are well known to the pelvic surgeon, but there are few reports comparing subjective complaints with objective data. Thirty of 68 patients who underwent a modified Burch urethral suspension were interviewed and examined by the first author. Four-channel urodynamics were then performed. STUDY DESIGN: Of the 30 patients, eight (27%) complained of postoperative urinary leaking, and three of eight (10%) said they leaked worse than before surgery. Four patients (13%) had objective evidence of detrusor instability on cystometrogram. Two patients (6%) had recurrent genuine stress incontinence. No patients had bladder spams or symptoms of retention. Univariate and multivariate analyses were performed on the following preoperative patient factors in relation to surgical success: age, height, hormonal status, and concurrent pelvic relaxation. Only preoperative hormone use had statistical significance in relation to surgical success. RESULTS: The eight patients with leaking were treated on the basis of subjective complaints plus objective findings. The patients with detrusor instability had improvement with medication and bladder drills, but two of the four still had mild leakage. Of the other four patients, one required a urethral sling and is now dry. The other three patients had significant improvement or cure of symptoms after modifications were made in their voiding techniques. CONCLUSION: Our study suggests that preoperative and postoperative estrogen use is significantly correlated with surgical success of the Burch procedure, whereas age, weight, and postoperative pelvic relaxation have little influence. We also found that surgical success could be improved by close evaluation and individual management of patients with voiding complaints.

Long-term failure of pelvic floor musculature exercises in treatment of genuine stress incontinence.

This report evaluates the motivation of a group of patients to continue a program of pelvic floor musculature exercises as conservative therapy for genuine stress incontinence. Fourteen women with urodynamically documented genuine stress incontinence had subjective improvement; nine of them showed objective improvement after 4 weeks of supervised pelvic floor musculature exercises. These patients were questioned 5 years later as to continence status, performance of pelvic floor musculature exercises, and subsequent surgery for incontinence. Ten of 14 patients responded: four have had anti-incontinence surgery and remain continent; five have not had surgery, do not perform pelvic floor musculature exercises, and continue to have stress incontinence. One patient continues to perform pelvic floor musculature exercises and has stress incontinence with a full bladder. Thus, only one patient out of 10 remained sufficiently motivated to perform pelvic floor musculature exercises after 5 years, even though all patients in this series had improvement after a 4-week course of supervised exercises.

Cefotetan versus cefoxitin as prophylaxis in hysterectomy.

Seventy hospitalized women were entered into an open, randomized, parallel study of antimicrobial prophylaxis for abdominal and vaginal hysterectomy with the use of either cefotetan, a new long-acting cephalosporin, or cefoxitin. Ninety-four percent of cefotetan recipients and 83% of cefoxitin recipients did not develop clinical signs or symptoms of infection. The satisfactory bacteriologic response rates were significantly different: 91% satisfactory (43 of 47 patients) for cefotetan and 74% satisfactory (17 of 23 patients) for cefoxitin. The two treatment groups demonstrated no significant differences in postoperative temperature changes, duration of hospitalization, or grading of surgical wounds. Neither drug was associated with significant side effects.