The Incidence of Pelvic and Low Back Pain in Patients with Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: To define the prevalence and incidence of pelvic/low back pain in patients with pelvic organ prolapse (POP). METHODS: Patients presenting for POP to three urogynecology centers in the US, UK, and Chile were enrolled in an IRB-approved cross-sectional study assessing pain, GU, GI and sexual function symptoms. For prevalence, symptoms were noted as present if the participant recorded the symptom and reported the degree of bother as "somewhat," "a moderate amount," or "a lot." For incidence, participants were queried if the symptom's onset concurred with the POP. We also queried if they perceived the symptom was worsened by their POP. RESULTS: Two hundred five participants were recruited: 100 from the US, 46 from the UK, and 59 from Chile. One US participant was excluded due a missing examination. The prevalence of pelvic pain was 42%. Seventy-three percent of these participants reported the onset of pelvic pain coinciding with prolapse onset, and 81% endorsed worsening pelvic pain with POP. The prevalence of low back pain was 46%, with 30% reporting the onset coincided with the onset of POP and 44% responded that prolapse worsened their pain. CONCLUSION: A higher proportion of participants than expected endorsed pelvic/low back pain. Among patients with pelvic pain, the majority experienced symptom onset with POP onset and a worsening of pain with POP. While roughly half of participants reported low back pain; a minority correlated this to their POP. These findings highlight a high incidence of pelvic pain, challenging the perception of POP as a painless condition.

Dropped abdominal pressure at void in women.

INTRODUCTION AND HYPOTHESIS: "Dropped pabd at void" occurs when pabd decreases below the previous resting pressure during voiding time. We sought clinical factors associated with this phenomenon and evaluated whether its correction modifies the urodynamic diagnosis. METHODS: Retrospective cross-sectional study of non-neurological consecutive symptomatic women. The following definitions were used: "dropped pabd at void": decrease in pabd at Qmax ≥ 5 cmH2O; bladder outflow obstruction (BOO) (pdetQmax ≥ 25 cmH2O + Qmax ≤ 12 ml/s and female BOO index (pdetQmax - 2.2*Qmax) > 18; "low detrusor contraction strength": PIP1 (pdetQmax + Qmax) < 30. In patients with "dropped pabd at void", pdetQmax was corrected. RESULTS: A total of 360 women were analyzed. Ninety-five percent of the women had a variation in pabd at Qmax between -13 and 53 cmH2O. "Dropped pabd at void" was found in 100 women (27.8%). History of stress urinary incontinence (SUI) surgery was significantly higher (p = 0.016) and symptoms of mixed urinary incontinence were significantly lower (p = 0.030) in patients with "dropped pabd at void". On multivariate analysis only the history of SUI surgery maintained its significance (OR = 1.787 [95% CI: 1.058, 3.017], p = 0.030). When correcting pdetQmax in women with "dropped pabd at void", 2 or 5 patients lost BOO diagnosis (depending on how it was diagnosed) and 7 patients gained a "low detrusor contraction strength" diagnosis. CONCLUSIONS: Approximately one-quarter of women had "dropped pabd at void", which was associated with a history of SUI surgery. Correction of pdetQmax would lead to a 2.5% to 3.33% diagnostic modification.

Subjective versus objective determination of bladder emptying following urogynecological surgery: "do you feel that you completely emptied your bladder?"

INTRODUCTION AND HYPOTHESIS: We tested the hypothesis that women can subjectively determine if they have emptied their bladder after a spontaneous voiding attempt following urogynecological surgery to rule out post-operative urinary retention as determined by a voiding trial. METHODS: This is a prospective observational study of women undergoing urogynecological surgery at two academic institutions from June 2016 to March 2019. Following surgery, subjects underwent a voiding trial followed by measurement of the PVR via ultrasound bladder scan or straight catheterization. A successful voiding trial was defined as a PVR of ≤150 ml. Subjects were queried about their subjective sensation of bladder emptying; "Do you feel that you completely emptied your bladder?" Their responses were either "Yes", "No" or "I don't know". Their subjective responses were correlated with the voiding trial results using a Chi-squared analysis for sensitivity, specificity, and positive (PPV) and negative predictive values (NPV). RESULTS: A total of 266 subjects were included in the final evaluation. The screening subjective question had a sensitivity of 85.7% (CI 71.46 to 94.57%), a specificity of 91.5% (CI 87.01 to 94.79%), a PPV of 65.4% (CI 54.78 to 74.77%), and an NPV of 97.14% (CI 94.18 to 98.62%) to detect a failed voiding trial. CONCLUSIONS: The NPV of the subjective question regarding bladder emptying in the post-operative urogynecological setting is high at >97%, suggesting that it might be reasonable to forgo a formal voiding trial in patients who subjectively feel that they have emptied their bladder.

Voiding symptoms obtained by open versus directed anamnesis as predictors of voiding dysfunction in women

ABSTRACT Objectives To determine the differences between voiding symptoms obtained by open anamnesis (VS-Open) versus voiding symptoms obtained by directed anamnesis (VS-Directed) to predict voiding dysfunction in women. Materials and Methods Retrospective study of women with prior anti-incontinence surgery evaluated during 5 years. In a standardized clinical history taking, each patient was asked to answer question number five of the UDI-6 questionnaire ("Do you experience any difficulty emptying your bladder?"). If the answer was positive, the following voiding symptoms spontaneously described by the patient were documented: slow urine stream, straining to void, intermittent stream and feeling of incomplete bladder emptying, which were considered VS-Open. If the answer to this question was negative or if the patient had not reported the four voiding symptoms, she was asked in a directed manner about the presence of each o Ninety-one women are analyzed. Eighteen patients presented voiding dysfunction (19.8%), There was a statistical association between voiding dysfunction and the presence of any VS-Open (p = 0.037) and straining to void obtained by open anamnesis (p = 0.013). Sensitivity, specificity, PPV, NPV, positive likelihood ratio and negative likelihood ratio, respectively, were 44.4% and 27.8%, 80.8% and 94.5%, 36.3% and 55.6%, 85.5% and 84.1%, 2.324 and 5.129, and 0.686 and 0.764. There was no statistical association between voiding dysfunction and VS-Directed. Conclusions VS-Open may predict better voiding dysfunction than VS-Directed in women.

Voiding symptoms obtained by open versus directed anamnesis as predictors of voiding dysfunction in women.

OBJECTIVES: To determine the differences between voiding symptoms obtained by open anamnesis (VS-Open) versus voiding symptoms obtained by directed anamnesis (VSDirected) to predict voiding dysfunction in women. MATERIALS AND METHODS: Retrospective study of women with prior anti-incontinence surgery evaluated during 5 years. In a standardized clinical history taking, each patient was asked to answer question number fi ve of the UDI-6 questionnaire ("Do you experience any difficulty emptying your bladder?"). If the answer was positive, the following voiding symptoms spontaneously described by the patient were documented: slow urine stream, straining to void, intermittent stream and feeling of incomplete bladder emptying, which were considered VS-Open. If the answer to this question was negative or if the patient had not reported the four voiding symptoms, she was asked in a directed manner about the presence of each of them, which were considered VS-Directed. Voiding dysfunction was considered the presence of a maximum fl ow ≤ 12 mL/s and/ or a postvoid residual > 100 mL. RESULTS: Ninety-one women are analyzed. Eighteen patients presented voiding dysfunction (19.8%), There was a statistical association between voiding dysfunction and the presence of any VS-Open (p = 0.037) and straining to void obtained by open anamnesis (p = 0.013). Sensitivity, specificity, PPV, NPV, positive likelihood ratio and negative likelihood ratio, respectively, were 44.4% and 27.8%, 80.8% and 94.5%, 36.3% and 55.6%, 85.5% and 84.1%, 2.324 and 5.129, and 0.686 and 0.764. There was no statistical association between voiding dysfunction and VS-Directed. CONCLUSIONS: VS-Open may predict better voiding dysfunction than VS-Directed in women.

Incontinencia urinaria en el adulto mayor / Urinary incontinence in the elderly

RESUMEN Antecedentes: La incontinencia urinaria (IU) corresponde a la pérdida involuntaria de orina. En la medida en que la población envejece, aumenta su prevalencia y severidad. Objetivo: Describir el impacto de la incontinencia de orina en la población adulto mayor, así como conocer su fisiopatología e implicancias en la calidad de vida. Método: Revisión de la literatura disponible en PubMed, Embase y Medline utilizando los términos "urinary incontinence" y "elderly" entre los años 1990 y 2018. Resultados: La IU en el adulto mayor impacta negativamente en la calidad de vida de esta población, teniendo una multiplicidad de causas subyacentes que implican un tratamiento integral y multidisciplinario de esta patología. Conclusión: Dado el incremento de la edad en la población, conocer y manejar esta patología es importante para el clínico y el especialista para que de esta forma mejore la calidad de vida en este grupo etario.

ABSTRACT Background: Urinary incontinence (UI) is the involuntary loss of urine. The prevalence and severity of this condition increase as population ages. Objective: To describe the impact urinary incontinence in the elderly population, as well as to know its pathophysiology and implications in the quality of life. Method: Review of the literature available in PubMed, Embase and Medline using the keywords "urinary incontinence" and "elderly" between 1990 and 2018. Results: UI in the elderly has a negative impact on their quality of life, having a multiplicity of underlying causes that imply a comprehensive and multidisciplinary treatment of this pathology. Conclusion: Given the age increase in general population, knowing and managing this pathology is important for the clinician and the specialist to improve the quality of life in this age group.

Transcutaneous posterior tibial nerve stimulation versus extended release oxybutynin in overactive bladder patients. A prospective randomized trial.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the effectiveness of transcutaneous posterior tibial nerve stimulation (T.C. PTNS) versus extended release oxybutynin (E.R.O.) in patients with overactive bladder. MATERIALS AND METHODS: Seventy female patients were randomized to receive either 10mg E.R.O. daily or T.C. PTNS, using a TENS machine program with the 20Hz, 200 cycles/s, and normal stimulation setting for two 30-min sessions, each week for a 12-week period. Pre-treatment and after the 12-week intervention, each patient completed a 3-day voiding diary and a self-report quality of life questionnaire (OAB-q). Statistical analysis was performed using Stata V12.1. RESULTS: Sixty-four patients completed the treatment protocol. There were no significant differences between study groups in terms of age, body mass index, past hormone replacement therapy, smoking habits, menopause status, and parity. Prior to treatment, there were also no significant differences in the analysis of the 3-day voiding diary or in the OAB-q questionnaire results. Following the 12-week study, there was a statistically significant reduction in frequency of urination, urgency episodes, and urge incontinent episodes compared to pre-treatment values. However, there were no significant differences in these values between intervention groups after 12-weeks of therapy. There was a similar improvement in OAB-q scores in both treatment groups following therapy, and the T.C. PTNS group showed a statistically significant improvement over the E.R.O. in domain 2 of the OAB-q questionnaire. The other two domains showed similar improvement in both study groups. CONCLUSION: T.C. PTNS and E.R.O. demonstrated similar improvements in subjects with OAB in a 12-week study.

First evidence of neosaxitoxin as a long-acting pain blocker in bladder pain syndrome.

INTRODUCTION AND HYPOTHESIS: Neosaxitoxin is a phycotoxin whose molecular mechanism of action shows a reversible inhibition of voltage-gated sodium channels at the axonal level, impeding nerve impulse propagation. This study was designed to evaluate the clinical efficacy of neosaxitoxin as a long-acting pain blocker in the treatment of bladder pain syndrome (BPS). METHODS: Five patients with a diagnosis of BPS received a total dose of 80 µg of neosaxitoxin in an isoosmotic solution of 0.9 % NaCl, pH 6.5. Infiltration was performed via cystoscopy under spinal anesthesia. Questionnaires were administered immediately before and 7, 30 and 90 days after the procedure to measure the patients' reported pain severity and quality of life. RESULTS: This study, for the first time, showed the effect of blocking the neuronal transmission of pain by local infiltration of neosaxitoxin into the bladder submucosa. All five patients successfully responded to the treatment. Furthermore, the analgesic effect lasted for the entire 90 days of follow-up without the need for a second infiltration, and no adverse reactions to neosaxitoxin were detected. CONCLUSIONS: Neosaxitoxin infiltration was shown to be a safe and effective intervention to control pain related to BPS. It was well tolerated by patients, who experienced extended pain relief and associated beneficial effects over a follow-up of 90 days. These results confirm the effectiveness of neosaxitoxin as a long-acting local pain blocker.

Efectos del embarazo y el parto sobre el piso pélvico / Effects of pregnancy and childbirth on the pelvic floor

Las disfunciones del piso pélvico comprenden la incontinencia urinaria de esfuerzo, el prolapso de órganos pélvicos y la incontinencia anal. Una de cada diez mujeres tendrá que ser sometida a una intervención quirúrgica por disfunciones del piso pélvico durante su vida. Además, entre el 30 por ciento y el 50 por ciento tendrá una recidiva de estas intervenciones. La maternidad es un factor que contribuye de manera importante en la presentación de estas disfunciones pelvianas. Aún no existe evidencia probada de que el parto vaginal sea un factor completamente decisivo para la presencia de disfunciones del piso pélvico. Existe intensa investigación acerca del embarazo y el parto y sus efectos sobre el piso pélvico, y acerca de si algunas de las acciones obstétricas pueden ser modificadas con el fin de protegerlo de los potenciales daños.

The pelvic floor dysfunctions include urinary incontinence, pelvic organ prolapsed and anal incontinence. One in ten women will be subjected to surgery for pelvic floor dysfunction during their lifetime. In addition, between 30 percent and 50 percent will have a recurrence of these interventions. Motherhood is a factor that contributes significantly to the submission of pelvic dysfunctions. There is still no proven evidence that vaginal delivery is an absolutely crucial factor for the presence of pelvic floor dysfunction. There is extensive research on pregnancy and child birth and their effects on the pelvic floor and if some of the obstetric action scan be modified in order to protect it from potential damage.

Optimal waist circumference cutoff value for defining the metabolic syndrome in postmenopausal Latin American women.

OBJECTIVE: The aim of this study was to determine an optimal waist circumference (WC) cutoff value for defining the metabolic syndrome (METS) in postmenopausal Latin American women. METHODS: A total of 3,965 postmenopausal women (age, 45-64 y), with self-reported good health, attending routine consultation at 12 gynecological centers in major Latin American cities were included in this cross-sectional study. Modified guidelines of the US National Cholesterol Education Program, Adult Treatment Panel III were used to assess METS risk factors. Receiver operator characteristic curve analysis was used to obtain an optimal WC cutoff value best predicting at least two other METS components. Optimal cutoff values were calculated by plotting the true-positive rate (sensitivity) against the false-positive rate (1 - specificity). In addition, total accuracy, distance to receiver operator characteristic curve, and the Youden Index were calculated. RESULTS: Of the participants, 51.6% (n = 2,047) were identified as having two or more nonadipose METS risk components (excluding a positive WC component). These women were older, had more years since menopause onset, used hormone therapy less frequently, and had higher body mass indices than women with fewer metabolic risk factors. The optimal WC cutoff value best predicting at least two other METS components was determined to be 88 cm, equal to that defined by the Adult Treatment Panel III. CONCLUSIONS: A WC cutoff value of 88 cm is optimal for defining METS in this postmenopausal Latin American series.