Dysfunctional urinary voiding in women with functional defecatory disorders.

BACKGROUND: While pelvic floor dysfunction may manifest with bladder or bowel symptoms, the relationship between functional defecatory disorders and dysfunctional voiding is unclear. Our hypothesis was that patients with defecatory disorders have generalized pelvic floor dysfunction, manifesting as dysfunctional urinary voiding. METHODS: Voiding was assessed by a symptom questionnaire, a voiding diary, uroflowmetry, and by measuring the postvoid residual urine volume in this case-control study of 28 patients with a functional defecatory disorder (36 ± 2 years, mean ± SEM) and 30 healthy women (36 ± 2 years). KEY RESULTS: Women with a defecatory disorder frequently reported urinary symptoms: urgency (61%), frequency (36%), straining to begin (21%), or finish (50%) voiding, and the sense of incomplete emptying (54%). Fluid intake and output, the minimum voided volume, and the shortest duration between voids measured by voiding diaries were higher (P < 0.05) in patients than in controls. Uroflowmetry revealed abnormalities in seven controls and 22 patients. The risk of abnormal voiding by uroflowmetry was higher in patients (OR 8.0; 95% CI, 2.3-26.9) than in controls. Patients took longer than controls (P < 0.01) to attain the maximum urinary flow rate (12 ± 2 VS 4 ± 0 s) and to empty the bladder (29 ± 4 VS 20 ± 2 s), but the maximum urinary flow rate and postvoid residual volumes were not significantly different. CONCLUSIONS & INFERENCES: Symptoms of dysfunctional voiding and uroflowmetric abnormalities occurred more frequently, suggesting of disordered urination, in women with a defecatory disorder than in healthy controls.

Carbon coated zirconium beads in beta-glucan gel and bovine glutaraldehyde cross-linked collagen injections for intrinsic sphincter deficiency: continence and satisfaction after extended followup.

PURPOSE: The durability of Durasphere (Carbon Medical Technologies, Saint Paul, Minnesota), used to treat stress urinary incontinence, has not been shown beyond 12 months of followup. Women treated with Durasphere and Contigen (Bard, Inc., Covington, Georgia) at 1 institution between 1996 and 2000 were compared to determine patient satisfaction and urinary continence after extended followup. MATERIALS AND METHODS: Between April 1996 and September 2000, 56 women were treated with Durasphere at this institution, of whom 43 were available for extended followup. Aged matched patients treated with Contigen were analyzed for comparison. Patient satisfaction and continence at last followup were subjectively assessed via telephone interview. Survival methods (Kaplan-Meier and Cox proportional hazards model) were used to analyze time to failure as a function of treatment group and other potential predictors. RESULTS: Treatment groups (Contigen and Durasphere) were similar with respect to all baseline factors. Treatment was initially effective in 63% of Durasphere and Contigen cases (p = 1.0). At 24 and 36 months Durasphere remained effective in 33% and 21% of patients compared with 19% and 9% for Contigen, respectively. At last followup only 9 patients (21%) treated with Durasphere and 2 (5%) treated with Contigen (median followup 51 and 62 months, respectively) claimed that treatment was still effective. After controlling for differences in followup time there was no significant difference in time to failure between the treatment groups (p = 0.25). A third of patients in each group believed that treatment was a success. CONCLUSIONS: Neither Contigen nor Durasphere provides durable improvement in continence. Despite this outcome a third of patients in the 2 groups were satisfied with the treatment outcome.

Incidence of physician-diagnosed interstitial cystitis in Olmsted County: a community-based study.

OBJECTIVE: To obtain community-based information about the incidence of interstitial cystitis, a chronic disabling condition of the bladder where knowledge is limited because there are no definitive diagnostic criteria. PATIENTS AND METHODS: All residents of Olmsted County, MN, USA who had received a physician-assigned diagnosis of interstitial cystitis between 1976 and 1996 were identified through the resources of the Rochester Epidemiology Project. The clinical findings at diagnosis and during the follow-up were ascertained from the community medical records for each study subject. RESULTS: In all, 16 women and four men received a diagnosis of interstitial cystitis during the study period. The overall age- and sex-adjusted (95% confidence interval) incidence rate was 1.1 (0.6-1.5) per 100 000 population. The age-adjusted incidence rates were 1.6 per 100 000 in women and 0.6 per 100 000 in men (P = 0.04). The median (range) age at initial diagnosis was 44.5 (27-76) years in women and 71.5 (23-79) years in men (P = 0.26). The median number of episodes of care-seeking for symptoms before the diagnosis was one for women and 4.5 for men (P = 0.03). The median duration from the onset of symptoms until the first diagnosis was 0.06 and 2.2 years in women and men, respectively (P = 0.2). CONCLUSIONS: These findings suggest that the incidence of interstitial cystitis in the community is extremely low. Although the gender difference may be real, the trend toward a later diagnosis in men than in women suggests a potential for missed diagnosis in men. This might explain some of the gender difference in the incidence of interstitial cystitis in men and women.

Long-term results of the FemSoft urethral insert for the management of female stress urinary incontinence.

A 5-year ongoing, controlled multicenter study enrolled 150 women. Outcome measures included pad weight tests (PWT), voiding diary (VD), quality of life (QOL) and satisfaction questionnaires. Outcome measures during the baseline period were compared to evaluations during follow-up. Concurrent evaluations with and without device use were also performed. Safety evaluations included urinalysis and culture, leak-point pressure (LPP) and cystoscopy. Adverse events (AE) were recorded throughout the study. One to 2 years of follow-up were collected on all study participants (mean 15 months). Statistically significant reductions in overall daily incontinence episodes (P<0.001) and PWT urine loss (P<0.001) were observed with the device at all follow-up intervals, and 93% of women had a negative PWT at 12 months. Women were satisfied with ease of use of the device, comfort and dryness, and significant improvements in QOL were observed (P<0.001). Subgroup analysis revealed that the insert was effective, despite the presence of urgency, low LPP, failed surgery and advanced age. AE included symptomatic urinary tract infection in 31.3%, mild trauma with insertion in 6.7%, hematuria in 3.3%, and migration in 1.3% of women. The results of PWT and VD demonstrated device efficacy. Women were satisfied and significant improvements in QOL were observed. AE were transient and required minimal or no treatment. The urethral insert should be considered as an option for the management of SUI.

Treatment options for women with stress urinary incontinence.

About one-quarter million surgical procedures are performed each year in the United States for stress urinary incontinence. After outlining the presentation and diagnostic evaluation of stress urinary incontinence, this review concentrates specifically on the numerous conservative management strategies and minimally invasive surgical options for women with this common complaint. In the evaluation of nursing home residents with incontinence, the Minimum Data Set and Resident Assessment Protocol facilitate nonspecialist evaluation and management. In healthy adults, the therapeutic implications of the physical examination of the pelvic floor, assessing for the presence and strength of the voluntary contraction of the pelvic floor muscles, are detailed as the basis for all conservative management strategies. Reports on the effectiveness of pelvic floor muscle reeducation and pelvic floor electrical stimulation vary substantially, as do long-term results of surgical interventions. Surgical management is highly effective in the appropriate candidate. The current theory and practice of surgical treatment of stress urinary incontinence are outlined, with certain caveats regarding the lack of long-term follow-up for newer less invasive techniques.

A new temporary catheter (ContiCath) for the treatment of temporary, reversible, postoperative urinary retention.

OBJECTIVES: To describe the initial experience of a newly designed temporary urethral catheter, ContiCath, as an aid in the management of postoperative or temporary outflow obstruction. In patients with normal detrusor and sphincter function, this catheter allows volitional voiding while maintaining an open prostatic urethra. METHODS: In a pilot study, 64 nonconsecutive patients with postoperative or temporary urinary retention, at eight clinical trial sites, were enrolled for the placement of this temporary catheter. Three patients did not have the catheter placed because of placement failure because of either a large median lobe or a urethral stricture. The remaining 61 patients were divided into three groups: those with non-neuropathic causes of retention and retention for 1 week or less (37 patients), those with non-neuropathic causes of retention and retention for longer than 1 week (19 patients), and those with neuropathic causes of retention and retention for longer than 1 week (5 patients). The ContiCath is placed in the office setting, in the same fashion as a Foley catheter. A blue prolene tether extends from the bulbar urethra to the meatus to assist in the removal of the device. Patients were then reassessed at 3 hours, and at 7, 14, 21, and 28 days, at which point the device was removed. RESULTS: In patients with a neuropathic cause for their retention (5 patients) and those with non-neuropathic causes of retention and retention for longer than 1 week (19 patients), only 3 patients were able to void after the catheter was placed. Of the 37 patients with a non-neuropathic cause and retention 1 week or less, controlled voiding was seen in 33 patients (89%). Controlled voiding was defined as the patient's volitional ability to initiate and stop his urinary stream. There were no complications with catheter placement; however, 8 patients (24.2%) had minor adverse experiences of frequency/urgency (n = 3), incontinence (n = 3), migration of the catheter (n = 1), and pain (n = 1). CONCLUSIONS: ContiCath offers an alternative to an indwelling Foley catheter in men with temporary bladder outlet obstruction and urinary retention.

Complications of sterile abscess formation and pulmonary embolism following periurethral bulking agents.

PURPOSE: Agents currently used in the treatment of urinary incontinence secondary to intrinsic sphincter deficiency are effective and minimally invasive. Ensuring a lack of sensitivity to the product or use of autologous material, such as fat, minimizes significant problems. However, local and systemic complications can occur with any bulking agent. We describe rare complications of periurethral bulk injections. MATERIALS AND METHODS: Three cases of sterile abscess formation and 1 of pulmonary embolism after periurethral bulk injections were reviewed. Two patients with intrinsic sphincter deficiency were treated with transurethral injection of glutaraldehyde cross-linked collagen at the Mayo Clinic, 1 also treated with collagen for intrinsic sphincter deficiency was referred from elsewhere and 1 underwent periurethral injection of autologous fat for intrinsic sphincter deficiency elsewhere. Clinical information and patient followup were obtained from medical records and discussion with treating physicians. RESULTS: Three patients treated with collagen presented with sterile abscesses at the injection site after routine transurethral injection. Documentation of the abscesses included cystoscopic findings, magnetic resonance imaging of the pelvis and/or transvaginal ultrasound. Drainage procedures for relief of obstructive and irritative voiding symptoms were required in 2 patients. In 1 of these patients transurethral unroofing failed, and transvaginal incision and drainage were required while the other had slow spontaneous improvement but a mass remained at the injection site 3 months later. Repeat skin testing was negative in 2 of 3 cases. Currently, these 3 patients are asymptomatic except for continued urinary incontinence. Pulmonary embolism was documented in 1 patient who underwent periurethral autologous fat injection. This patient survived without long-term consequences but was maintained on ventilatory support for a short time. CONCLUSIONS: In general, periurethral injection of bulk agents is safe and effective. However, injectable bulk agents are not without risk of complications, some of which are life threatening and others of considerable morbidity that may require operative intervention.

Principles of urodynamics pressure measurement and its implication to female continence function.

Urodynamic pressure measurements using catheters have been widely used among clinicians. More often objective interpretation of urodynamic pressure measurements requires fundamental understanding of pressure measurement techniques due to many measurement artifacts. In this study we developed a simplified compound thick-walled cylinder model to investigate the mechanical nature of urodynamic pressure measurement as well as pressure transmission. Efficacy of collagen implantation was also explored. Lamé's formulation was used to find analytical solutions. Pressure transmission can be related to catheter caliber and the compressibility of the urethral tissue (poisson ratio) in a simple mathematical form. The theoretical pressure transmission ratio will be 133% with the additional incompressibility assumption, reflecting the passive structural transmission of intraabdominal pressure increase. The relationship between the pressure measurement error and the catheter caliber was found to be linear (r2 = 0.94 +/- 0.04) and two or more pressure measurements need to be used to find the uninstrumented pressure. It was predicted that collagen implantation treatment might improve the pressure transmission ratio maximally by 33%.

Contemporary urologic management of patients with spinal cord injury.

Urologic management strategies in patients with spinal cord injury are discussed herein, and the underlying pathophysiology and urodynamic principles are emphasized. Contemporary management of the spinal cord-injured bladder has allowed for near-elimination of renal failure as the primary cause of long-term morbidity in these patients; low urine storage, sterile urine, and effective emptying are imperative for good long-term results.

Prostate biopsy indices: toward efficient use of transrectal ultrasound.

With increasing use of transrectal ultrasonography (TRUS) it becomes important to establish guidelines for its appropriate utilization. Three hundred and twenty-two patients with either an abnormal digital rectal examination (DRE) or prostate-specific antigen (PSA), or both, were evaluated further for cancer by means of prostatic ultrasonography. Two hundred and twenty-five (70%) of these underwent ultrasound-guided biopsy, cancer was detected in 74 (23%), and 33 percent of all biopsy specimens were positive. Thus, the indices of biopsy: TRUS (Bx:T), cancer: TRUS (Ca:T), and cancer: biopsy (Ca:Bx) were 70 percent, 23 percent, and 33 percent, respectively. Comparing these indices with other earlier series (TRUS used less selectively) and with more recent series (TRUS used more selectively), suggest that ratios in the range of biopsy: TRUS of 70 percent to 75 percent, cancer: TRUS of 25 percent to 30 percent, and cancer: biopsy of 30 percent to 40 percent may be expected with appropriate use of this imaging modality.

Prostate specific antigen and local recurrence after radical prostatectomy.

We evaluated the location of recurrent disease in 63 patients with carcinoma of the prostate who had abnormal levels of prostate specific antigen (greater than 0.4 ng./ml., Tandem-R assay) 6 to 240 months after radical prostatectomy but who were otherwise considered to be without evidence of disease. The evaluation involved physical examination including digital rectal examinations by 3 urologists, isotopic bone scans, computerized tomography scans of the abdomen and pelvis, cystoscopy, and random needle biopsies of the urethrovesical anastomotic area. In 6 patients metastatic disease to the bone and/or lymph nodes was found and local prostate cancer was discovered in 5. Among 57 patients without evidence of disease by the usual methods of evaluation needle biopsies of the anastomosis revealed local disease in 42%. No local disease was discovered in 30 post-radical prostatectomy patients with normal prostate specific antigen levels. There was a wide range of transrectally palpable contours after radical prostatectomy in patients with and without elevated prostate specific antigen levels. We conclude that prostate specific antigen but not digital rectal examination is an excellent early indicator of possible local recurrence after radical prostatectomy. Whether the prevalence of local disease after radical prostatectomy using prostate specific antigen levels and needle biopsies of the anastomosis is greater than heretofore has been appreciated will require further study.

The effect of radiation therapy after radical prostatectomy in patients with elevated prostate specific antigen levels.

We analyzed the effects of pelvic radiation therapy given to patients who had an elevated prostate specific antigen level after radical prostatectomy. Among men who previously received adjuvant radiation therapy and had appropriately stored serum 15 had elevated prostate specific antigen levels after radical prostatectomy but before radiation therapy. After radiation therapy the prostate specific antigen level decreased by more than 50% in 80% and to female levels in 53% of the patients. We also prospectively treated 29 men who had increasing levels of prostate specific antigen 9 to 95 months after radical prostatectomy but who were otherwise without evidence of disease by the usual criteria. However, 19 of the patients had local disease as evidenced by random needle biopsy of the urethrovesical anastomosis. Complications of radiation therapy were minimal and maximal prostate specific antigen decrease occurred by 6 months after treatment. In 82% of the patients prostate specific antigen levels decreased by more than 50% and in 43% they decreased to female levels. Female levels were achieved after radiation therapy given many years postoperatively even in stage D1 cancer patients but some of the patients subsequently had increasing prostate specific antigen levels. These data suggest that local-regional disease may be the only site of disease persistence after radical prostatectomy in some of the patients who subsequently have distant metastasis. We conclude that radiation therapy after radical prostatectomy can cause elevated prostate specific antigen to decrease to undetectable levels in many patients but the durability and ultimate therapeutic value of this effect are unknown.

The value of serum prostate specific antigen determinations before and after radical prostatectomy.

We evaluated serum prostate specific antigen before and after radical prostatectomy. In 100 consecutive patients who underwent radical prostatectomy, preoperative prostate specific antigen levels tended to increase with the increasing severity of pathological stage. However, even at levels of greater than 10 ng. per ml. the positive and negative predictive values (78 and 61 per cent, respectively) of prostate specific antigen to predict extracapsular disease were not sufficient to make this test useful alone for staging. In theory, after radical prostatectomy prostate specific antigen should be zero if no remaining prostatic tissue is present. Tests of precision and analytical sensitivity in our laboratory using a commercial prostate specific antigen assay revealed that a value of 0.4 ng. per ml. or more is different from zero at a greater than 95 per cent confidence level. With this guideline we evaluated the meaning of prostate specific antigen levels 3 to 6 months after radical prostatectomy in 59 men. Among men whose prostate specific antigen level was less than 0.4 ng. per ml. only 9 per cent demonstrated recurrence as evidenced by the development of positive bone scan or progressively elevated prostate specific antigen levels within 6 to 50 months. Alternatively, in men whose 3 to 6-month prostate specific antigen level was 0.4 ng per ml. or more there was evidence of recurrence in 100 per cent within 6 to 49 months (p less than 0.0001). Progressively elevated (more than 0.4 ng. per ml.) prostate specific antigen levels preceded recurrence from 12 to 43 months in all 6 patients who had positive bone scans, while increasing prostate specific antigen levels since radical prostatectomy have continued from 9 to 65 months in the 11 patients who have no radiological evidence of recurrent disease to date. Prostatic acid phosphatase serum values after radical prostatectomy were not useful to predict persistent disease. Prostate specific antigen values 3 to 6 months after radical prostatectomy are a sensitive indicator of persistent disease after radical prostatectomy and often precede other evidence of this occurrence by many years. This fact may alter concepts about surgical results, and possibly shorten and sharpen clinical studies involving adjuvant therapy after radical prostatectomy.