Cystoscopic findings in women with minimal and maximal lower urinary tract symptoms.

BACKGROUND: Glomerulations are not specific for interstitial cystitis/bladder pain syndrome (IC/BPS). Controversy exists about whether cystoscopic findings differ between patients with and without lower urinary tract symptoms. We sought to compare the prevalence of cystoscopic findings in women with "no or minimal" urinary symptoms to those with a "high" symptom burden. METHODS: This is a secondary analysis of a prospective cohort study performed at a University Educational Facility. Participants in this study were part of a larger prospective study, in which female patients scheduled to undergo routine gynecologic procedures were all consented for cystoscopy with hydrodistension (CWHD). We defined the "minimally symptomatic group" as those with ≤1 on each of the O'Leary/Sant Interstitial Cystitis Symptom Index (ICSI) subscores and without history of IC/BPS. The "highly symptomatic" cohort of women had composite ICSI score ≥12 and a Burning/Pain subscore of 4 or 5. All were non-smokers. RESULTS: A total of 84 women underwent CWHD, with 33 having minimal symptoms and 51 being highly symptomatic. The two groups were not statistically different when assessing for 'any glomerulations' compared to 'no glomerulations.' However, minimally symptomatic women had an eight-fold lower prevalence of significant glomerulations than highly symptomatic women (3.0% minimally symptomatic vs. 23.5% highly symptomatic, P<0.05.). CONCLUSIONS: Extensive glomerulations (≥10 in 3 or 4 quadrants) are rare in women with minimal urinary symptoms. These findings contrast with prior limited prospective data which quoted similar incidence of glomerulations in IC/BPS patients and asymptomatic patients. This study highlights the importance of evaluating objective evidence on CWHD and merits further investigation as part of the ongoing conversation regarding the definition of bladder health and pathology.

Complementary and alternative medications for chronic pelvic pain.

Chronic pelvic pain is common, but rarely cured, thus patients seek both second opinions and alternative means of controlling their pain. Complementary and alternative medicine accounts for 11.2% of out-of-pocket medical expenditures for adults for all conditions in the United States. Although there are many treatments, rigorous testing and well-done randomized studies are lacking. Dietary changes and physical modalities such as physical therapy have often been included in the category of alternative medicine, but their use is now considered mainstream. This article concentrates on other sources of alternative and complementary medicine, such as dietary supplementation and acupuncture.

Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: efficacy and time to response.

OBJECTIVES: : We sought to determine the efficacy of posterior tibial nerve stimulation in patients who had failed anticholinergic medications. A secondary outcome was to determine the time to response for different parameters of overactive bladder. STUDY DESIGN: : The medical records of all patients treated with posterior tibial nerve stimulation from 2000 to 2009 seen in a university urogynecology practice were abstracted. Patients underwent weekly treatments. Patients were asked about the 4 index symptoms at each weekly visit. Descriptive statistics were performed on the data set using SPSS 15. RESULTS: : A total of 141 patients were analyzed. Of these patients, 67.4% were satisfied with treatment results. The median week to improvement was 5 weeks for nocturia, 7 weeks for frequency, 6 weeks for urgency, and 6 weeks for urge incontinence. CONCLUSIONS: : Posterior tibial nerve stimulation is an effective treatment of overactive bladder in patients who have failed anticholinergic therapy. Most patients noted improvement by 6 weeks.

Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder.

PURPOSE: The Overactive Bladder Innovative Therapy Trial during phase 1 was a randomized trial demonstrating comparable effectiveness of percutaneous tibial nerve stimulation and extended-release tolterodine during 12 weeks of therapy for frequency, nocturia, urgency, voided volume and urge incontinence episodes. In this second phase of the Overactive Bladder Innovative Therapy Trial we assessed the sustained therapeutic efficacy of percutaneous tibial nerve stimulation in subjects with overactive bladder during 1 year. MATERIALS AND METHODS: After 12 weeks subjects randomized to weekly percutaneous tibial nerve stimulation with Urgent((R)) PC were offered an additional 9 months of treatment with assessments at 6 and 12 months from baseline. Outcome measures included voiding diary data, overactive bladder questionnaires, global response assessments and safety assessments. RESULTS: A total of 33 percutaneous tibial nerve stimulation responders continued therapy with 32 and 25 subjects completing 6 and 12 months of therapy, respectively. Subjects received a mean of 12.1 treatments during an average of 263 days, with a mean of 21 days (median 17) between treatments. Subject global response assessments showed sustained improvement from 12 weeks at 6 and 12 months, with 94% and 96% of responders, respectively. At 12 months mean improvements from baseline included a frequency of 2.8 voids daily (p <0.001), urge incontinence of 1.6 episodes daily (p <0.001), nocturia with 0.8 voids (p <0.05) and a voided volume of 39 cc (p <0.05). Overactive bladder questionnaire symptom severity was significantly improved from 12 weeks to 12 months (p <0.01) as well as from 6 to 12 months (p <0.01). No serious adverse events occurred. CONCLUSIONS: Statistically significant overactive bladder symptom improvement achieved with 12 weekly percutaneous tibial nerve stimulation treatments demonstrates excellent durability through 12 months. The durability of response demonstrates the effectiveness of percutaneous tibial nerve stimulation as a viable, long-term therapy for overactive bladder.

The influence of national society annual scientific meetings on publication in general obstetrics and gynecology literature: a urogynecology perspective.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to determine urogynecology publication rates in obstetrics and gynecology literature. METHODS: Original scientific articles from American Journal of Obstetrics and Gynecology (AJOG) and Obstetrics and Gynecology (Obstet Gynecol) from 1996-2007 were reviewed. RESULTS: A total of 10,192 articles were evaluated. Two trends were noted in the AJOG: percentage of urogynecology articles increased (correlation with year r = 0.845; p < 0.05) and percentage of obstetric articles decreased (negative correlation r = -0.589; p < 0.05). Similarly for Obstet Gynecol, the number of urogynecology articles increased with time with a strong positive correlation of r = 0.743 and p < 0.05. There was a significant difference in the number of articles published in the AJOG in months with an annual scientific meeting compared to months without (t = -6.34; p < 0.001). CONCLUSIONS: The numbers of urogynecology articles published in the general literature has increased and may be related to presentation at national meetings.

Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial.

PURPOSE: The Overactive Bladder Innovative Therapy trial was a randomized, multicenter, controlled study that compared the effectiveness of percutaneous tibial nerve stimulation to extended-release tolterodine. The reduction in overactive bladder symptoms along with global response assessments was evaluated. MATERIALS AND METHODS: A total of 100 adults with urinary frequency were randomized 1:1 to 12 weeks of treatment with weekly percutaneous tibial nerve stimulation or to 4 mg daily extended-release tolterodine. Voiding diaries and an overactive bladder questionnaire were completed at baseline and at the end of therapy to compare 24-hour voiding frequency, urinary urge incontinence episodes, voids causing waking, volume voided, urgency episodes and quality of life indices. Global response assessments were completed by subjects and investigators after 12 weeks of therapy. RESULTS: The global response assessment demonstrated that subject assessment of overactive bladder symptoms compared to baseline was statistically significant in the percutaneous tibial nerve stimulation arm with 79.5% reporting cure or improvement compared to 54.8% of subjects on tolterodine (p = 0.01). Assessments by investigators were similar but did not reach statistical significance (p = 0.05). After 12 weeks of therapy objective measures improved similarly in both groups for reductions in urinary frequency, urge urinary incontinence episodes, urge severity and nighttime voids, as well as for improvement in voided volume. There were no serious adverse events or device malfunctions. CONCLUSIONS: This multicenter, randomized trial demonstrates that percutaneous tibial nerve stimulation is safe with statistically significant improvements in patient assessment of overactive bladder symptoms, and with objective effectiveness comparable to that of pharmacotherapy. Percutaneous tibial nerve stimulation may be considered a clinically significant alternative therapy for overactive bladder.

Solifenacin succinate for the treatment of overactive bladder.

UNLABELLED: Solifenacin succinate, a competitive muscarinic receptor antagonist, is one of the newer options for the treatment of overactive bladder in men and women. OBJECTIVE: To review the pharmacology, efficacy and tolerability for the treatment of overactive bladder with solifenacin succinate. METHODS: A literature search was done using the keywords YM905 and solifenacin succinate. CONCLUSION: Solifenacin succinate was shown to be effective for symptom control with an increase in volume voided, improvement in quality of life and a decrease in a common side effect of dry mouth compared to other medications.

Elective primary cesarean section: weighing the risks and benefits.

The increasing understanding of the nature and extent of pelvic floor injury during childbirth, coupled with an increasing medico-legal demand to present a flawless baby at the completion of the birth process, has helped fuel the rising cesarean section rate. As more women become educated in the controversies surrounding the protective benefits of cesarean, they may increasingly elect to undergo cesarean delivery primarily. Evidence concerning maternal, fetal, and ethical considerations in this decision is presented.

Self-reported yeast symptoms compared with clinical wet mount analysis and vaginal yeast culture in a specialty clinic setting.

OBJECTIVE: To determine the validity of patients' self-reported symptoms of vulvovaginal candidiasis and the accuracy of clinical wet mount examinations compared with vulvovaginal yeast culture results in a specialty clinic. STUDY DESIGN: A retrospective chart review of new patients seen at the Saint Louis University Vulvar and Vaginal Disease Clinic from January 2005 to March 2006 was performed. Patients' age, medication use, symptom scores on a rating scale for vaginal/vulvar pain, burning, itching, dyspareunia and wet mount analyses were compared with yeast culture results. RESULTS: Of 153 patients, 40 had positive yeast cultures (prevalence rate 26.1%). Compared with yeast cultures, self-reported symptom scores >4 resulted in high sensitivity (90%) and low specificity (7%). Positive wet mount result showed low sensitivity (18%) and high specificity (99%). Patient symptom scores were a poor predictor of yeast infections based on yeast culture results. No correlation was found among wet mount, self-reported symptoms and yeast culture results. No significant difference between age or symptom scores to culture result was found. CONCLUSION: Wet mount analysis for recurrent or persistent patient symptoms should be reevaluated. Self-reported symptoms are not reliable for diagnosis. Wet mount analysis resulted in low sensitivity. Yeast cultures should be considered the gold standard for identification of vulvovaginal candidiasis in persistent or recurrent cases.

The influence of industry sponsorship on the acceptance of abstracts and their publication.

OBJECTIVE: The purpose of this study was to determine whether abstracts with industry sponsorship are more likely to be oral presentations, be published, and the effect of nonspecific author disclosure on identification of sponsorship. STUDY DESIGN: We reviewed abstracts accepted for the urogynecology scientific meeting from 1998-2006 and subanalyzed publication status of studies from 2002-2004. RESULTS: One hundred twenty-four of 1091 abstracts (11.4%) and 45/376 (11.9%) of oral presentations had industry sponsorship. Industry-sponsored was not significantly more likely than nonindustry sponsored research (RR, 1.06; 95% CI, 0.33-1.36) to be an oral presentation or be published (RR, 0.85; 95% CI, 0.53-1.34). Twelve of 36 studies (34%) were correctly identified as sponsored with the use of a nonspecific author disclosure compared to 22/22 (100%) when sponsorship was disclosed separately. CONCLUSION: Researchers without sponsorship can be reassured their work is as likely to be accepted for oral presentation and publication. A policy of full author disclosure makes identification of sponsored studies difficult, and specific sponsorship statement is necessary.

Short-term efficacy and complications of posterior intravaginal slingplasty.

This study was performed to evaluate the efficacy and complications of the posterior intravaginal slingplasty (IVS). A retrospective chart review was performed. Ninety IVS procedures were performed from January 2004 to June 2005. The group consisted of predominantly nonsmoking, Caucasian, postmenopausal women with a median age of 62 years and a median parity of 3. The mean follow-up was 33 +/- 23.2 weeks with a median of 31.9 weeks. There were no intraoperative bladder, bowel, or vascular injuries. Overall, 11 out of 90 patients developed recurrent or de novo prolapse; 4.4% of these had recurrent apical prolapse. There was a 17.8% incidence of mesh erosion. Only 1 of the 11 patients with recurrent prolapse had concomitant mesh erosion. The procedure demonstrated an unacceptably high erosion rate. The adoption of newer mesh techniques based on the slingplasty concept or the use of the multifilament polypropylene tape should be scrutinized.

Neuromodulation for the treatment of urinary incontinence.

The prevalence of overactive bladder (OAB) in the United States ranges from 10% - 30%. The mainstay of treatment is anticholinergic medication. All agents have significant side effects and at least 30% of patients fail to respond. This paper reviews neuromodulation which involves the use of electrical stimulation of either the sacral or peripheral nerves to modify the behavior of the bladder. It is an option for patients who either cannot tolerate medications or fail therapy.

Evaluation of urinary incontinence and voiding dysfunction in women.

Urinary incontinence currently affects 33 million American women. In the next 30 years the population over 60 years will increase by 80-90%. This will result in a tremendous increase in patients suffering this condition. It is therefore not feasible for evaluation and treatment to be limited to specialists. Primary care physicians must be comfortable performing basic evaluations which will enable them to formulate a diagnosis and conservative treatment plan. This article outlines a practical approach.

Vulvodynia.

Vulvar pain and discomfort are common conditions which can truly make the patient's life miserable. It is relatively common, but can be a difficult condition to evaluate and treat. This article serves to give the primary care physician a basic framework with which to begin treatment for such patients.

Prevalence of diastasis recti abdominis in a urogynecological patient population.

A urogynecologist's examination typically includes assessment of the abdominal musculature, including the determination of whether a diastasis recti abdominis (DRA) is present. The purposes of the current study were to examine the (1) prevalence of DRA in a urogynecological population, (2) differences in select characteristics of patients with and without DRA, and (3) relationship of DRA to support-related pelvic floor dysfunction diagnoses. A retrospective chart review was conducted by an independent examiner. Fifty-two percent of the patients examined presented with DRA. Patients with DRA were older, reported higher gravity and parity, and had weaker pelvic floor muscles than patients without DRA. Sixty-six percent of all the patients with DRA had at least one support-related pelvic floor dysfunction (SPFD) diagnosis. There was a relationship between the presence of DRA and the SPFD diagnoses of stress urinary incontinence, fecal incontinence, and pelvic organ prolapse.