Posterior Tibial Nerve Stimulation With versus Without Mirabegron: A Randomized Controlled Trial.

INTRODUCTION AND HYPOTHESIS: To compare change in urgency urinary incontinence episodes (UUIEs) in women undergoing posterior tibial nerve stimulation (PTNS) plus mirabegron versus PTNS plus placebo for the treatment of refractory urgency urinary incontinence (UUI). The primary hypothesis was that combination therapy is superior to monotherapy. METHODS: A randomized controlled trial was performed in individuals identifying as female aged ≥ 18 years with UUI symptoms refractory to second-line treatment or who could not tolerate antimuscarinic medications. Both participants and providers were blinded to medication treatment allocation. Participants were randomized (1:1) to PTNS plus mirabegron or PTNS plus placebo. Participants completed a 3-day bladder diary prior to and after 12-week treatment. Validated symptom distress and impact questionnaires were obtained pre- and post-treatment. The primary outcome was change in mean number of UUIEs on a 3-day bladder diary pre- versus post-treatment between arms. Primary and secondary outcomes were analyzed via sample t tests. RESULTS: Fifty-four subjects were randomized, mean ± SD baseline age 56.2±15.6 years and body mass index 35.0±9.4 (kg/m2); no differences were noted in any clinical-demographic characteristics. There was a significant difference between arms in mean pre- to post-treatment UUIEs, 9.4±3.9, mirabegron versus 5.3±5.5, placebo (p=0.007). Significant differences were found pre- compared with post-treatment in urinary frequency, Overactive Bladder Questionnaire Short Form Symptom Bother and Symptom Health-Related Quality of Life scores. CONCLUSIONS: In subjects undergoing PTNS treatment for refractory UUI and OAB-wet symptoms, the addition of a ß-3 agonist produced significant improvement in both objective and subjective overactive bladder symptom outcomes compared with PTNS plus placebo.

Urine staining intensity and observation of intraoperative ureteral jets among oral agents.

INTRODUCTION AND HYPOTHESIS: To determine if administration of a standard 400 mg oral dose of riboflavin (vitamin B2) was comparable to phenazopyridine (pyridium) for evaluating ease of visualization of ureteral jets at the time of cystoscopy. METHODS: A three-arm double-blinded, randomized controlled study was performed consisting of thiamine as placebo, phenazopyridine, and riboflavin. Agents were administered the morning of surgery prior to surgical procedure. The primary outcome was the ease of visualization of the ureteral jets based on a grading of urine stain intensity on a 7-point color scale, where 1-2 were minimal yellow staining, 3-4 were moderate yellow staining, and 5-7 defined as intense yellow staining. Analysis of covariance (ANCOVA) was used with pairwise comparison to characterize urine stain intensity as a continuous variable among the three groups controlling for age, BMI, creatinine, and time from ingestion of medication to first cystoscopy. RESULTS: Eighty-four subjects were randomized with a mean ± SD age of 46.25 + 11.36 and BMI of 32.46 + 6.59. Riboflavin did have moderate or intense staining in 57% of cases; however, there was no significant difference between urine staining intensity compared to placebo (p = 0.21). There was a statistically significant increased urine staining intensity for phenazopyridine compared to placebo (p = 0.001) and for phenazopyridine compared to riboflavin (p = 0.001). CONCLUSIONS: Phenazopyridine provided statistically significantly greater urine staining compared to both riboflavin and placebo and should be considered primarily for ease of ureteral jet visualization.

Colorectal Cancer Screening: Role of Family Physicians.

The purpose of this study was to look at the differences in colorectal cancer screening awareness between two rural communities in Texas. In Clifton, patients have access to colonoscopies in their local hospital, while in Haskell, patients have to travel to a tertiary center. A 24-question survey pertaining to colon cancer from the Behavior Risk Factor Surveillance System (BRFSS) was given to patients at primary care clinics in Clifton and Haskell. To take the survey, participants had to have been patients for at least 1 year in either Clifton or Haskell clinic and be at least age 50 years or older. A total of 168 surveys were collected, 92 at Clifton and 76 at Haskell. A higher odds ratio (OR=3.61; CI = [1.11, 11.69]) was seen in Clifton compared with Haskell for patient colon cancer screening awareness. Also, a higher odds ratio (OR=2.50; CI = [1.13, 5.54]) was found of knowing at what age a person should be screened for colon cancer in Clifton compared with Haskell. A higher odds ratio (OR=3.61; CI = [1.42, 9.20]) was seen in Clifton compared with Haskell for patients ever having a colonoscopy or sigmoidoscopy. This study supports the idea that providing colorectal cancer screening and screening procedures locally in the rural community by family medicine physicians helps to contribute to an improved awareness of colorectal cancer screening guidelines as opposed to communities that do not offer screening locally.

Bladder calculi causing irreducible urogenital prolapse.

Over 200 000 surgeries for vaginal prolapse are done annually, and these are rarely urgent. However, when the rare event of bladder stones causes incarcerated procidentia, surgical intervention should not be delayed, due to unrelenting pain and end-organs effects. We present such a case below. A 71-year-old woman presents to our department with massive uterovaginal and rectal procidentia. This massive prolapse was found to be irreducible due to numerous dahllite stones in the bladder, and was causing obstructive uropathy with left-sided hydronephrosis. A multidisciplinary approach was necessary to surgically correct the prolapse and implement complete removal of all the stones. The simultaneous occurrence of uterovaginal prolapse, rectal prolapse and urolithiasis is uncommon. Stone formation is a result of chronically infected urine presenting a nidus for stone formation. This presentation has occurred very rarely over the last 70 years of the world's literature. Surgical cures can be achieved by either the vaginal or abdominal routes but should be treated emergently to alleviate pain, prevent renal impairment from obstructive uropathy and decrease infectious morbidity.

Spontaneous ovarian heterotopic pregnancy.

Heterotopic pregnancy is a simultaneous intrauterine and ectopic pregnancy. We report a case of a spontaneous ovarian heterotopic pregnancy. A 36-year-old woman, gravida 7 para 4-1-1-5 at 4 weeks gestation (spontaneous conception), presented to the emergency department with vaginal spotting, lower abdominal cramps with human chorionic gonadotropin(hCG) 10 772 mIU/mL (hCG at T0). Abdominal and pelvic examinations were benign. Transvaginal sonogram (TVS) showed an intrauterine gestational sac and yolk sac, no fetal pole visualised. She was discharged home with a diagnosis of threatened abortion. The patient returned to the emergency department 3 weeks later (T1) at 7 weeks gestation with recurrent vaginal bleeding and lower abdominal pain. Her TVS showed an empty uterus with small amount of free fluid in the cul-de-sac. A small 2 cm round mass noted in the adnexa with hCG of 4663 mIU/mL (hCG at T1). Laparoscopy revealed normal fallopian tubes bilaterally and a ruptured right ovarian ectopic pregnancy. Pathology was consistent with ectopic pregnancy. Abnormal hCG patterns should raise suspicion for heterotopic pregnancy.