Vesicovaginal fistula and other Obstetric complications
BelleJAR Foundation
women in the developing world
International
Yes
No
Obstetric Fistula Projects:
1. Preoperative ultrasound evaluation to detect ureteric involvement in vesicovaginal fistulas
2. Patient narrative study to identify key medical, social and economic factors that lead to fistula formation
3. Study of urinary continence after fistula repair
Pelvic pain: investigation into role of pelvic floor in chronic pelvic pain
We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes.We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods.There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03).We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study.
View details for DOI 10.1016/j.juro.2012.11.018
View details for PubMedID 23234638
We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes.We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods.There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03).We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study.
View details for DOI 10.1016/j.juro.2012.11.018
View details for Web of Science ID 000312100000019
View details for PubMedID 23234638
Cyclosporine A is a fifth-tier treatment option in the American Urological Association guidelines for interstitial cystitis/bladder pain syndrome. It was more effective than pentosanpolysulfate in a Finnish trial, but experience elsewhere is limited. Some centers use cyclosporine A off label for carefully selected patients but the number of patients in each center is small. We performed a retrospective review combining data from 3 tertiary centers that focus on interstitial cystitis/bladder pain syndrome.Charts were reviewed for patients with interstitial cystitis/bladder pain syndrome who received cyclosporine A. Response was defined as markedly improved on the 7-point global response assessment (2 centers) or as at least a 50% decrease in Interstitial Cystitis Symptom Index score (1 center).The study included 14 men and 30 women. Mean patient age was 55.5 years (range 27 to 75) and mean followup was 20.8 months (range 3 to 81). A total of 34 patients had Hunner lesions. Of these patients 29 (85%) responded but 6 eventually stopped cyclosporine A for adverse events, resulting in a success rate of 68% (23 of 34) for patients with Hunner lesions. In contrast, only 3 of 10 patients without Hunner lesions responded (30%). For all responders, the response occurred within 4 months.Cyclosporine A had a high success rate for patients with Hunner lesions in whom more conservative options, including endoscopic treatment, had failed. The success rate was low for patients without Hunner lesions. A 3 to 4-month trial is sufficient time to assess response. Adverse events were common and led to discontinuation of cyclosporine A for some patients. Close monitoring is needed, especially for blood pressure and renal function.
View details for DOI 10.1016/j.juro.2012.06.023
View details for Web of Science ID 000308745400037
View details for PubMedID 22901569
The overlap between interstitial cystitis-painful bladder syndrome and overactive bladder can present a diagnostic challenge to the treating practitioner. Both can present with similar patient symptoms. Further compounding this dilemma is the fact that no gold standard test exists to differentiate one from the other. This review will serve to highlight their similarities and distinguishing features.
View details for DOI 10.1007/s11934-012-0264-y
View details for PubMedID 22965225
We determined the efficacy and safety of pelvic floor myofascial physical therapy compared to global therapeutic massage in women with newly symptomatic interstitial cystitis/painful bladder syndrome.A randomized controlled trial of 10 scheduled treatments of myofascial physical therapy vs global therapeutic massage was performed at 11 clinical centers in North America. We recruited women with interstitial cystitis/painful bladder syndrome with demonstrable pelvic floor tenderness on physical examination and a limitation of no more than 3 years' symptom duration. The primary outcome was the proportion of responders defined as moderately improved or markedly improved in overall symptoms compared to baseline on a 7-point global response assessment scale. Secondary outcomes included ratings for pain, urgency and frequency, the O'Leary-Sant IC Symptom and Problem Index, and reports of adverse events. We compared response rates between treatment arms using the exact conditional version of the Mantel-Haenszel test to control for clustering by clinical center. For secondary efficacy outcomes cross-sectional descriptive statistics and changes from baseline were calculated.A total of 81 women randomized to the 2 treatment groups had similar symptoms at baseline. The global response assessment response rate was 26% in the global therapeutic massage group and 59% in the myofascial physical therapy group (p=0.0012). Pain, urgency and frequency ratings, and O'Leary-Sant IC Symptom and Problem Index decreased in both groups during followup, and were not significantly different between the groups. Pain was the most common adverse event, occurring at similar rates in both groups. No serious adverse events were reported.A significantly higher proportion of women with interstitial cystitis/painful bladder syndrome responded to treatment with myofascial physical therapy than to global therapeutic massage. Myofascial physical therapy may be a beneficial therapy in women with this syndrome.
View details for DOI 10.1016/j.juro.2012.01.123
View details for Web of Science ID 000303821300051
View details for PubMedID 22503015
View details for PubMedCentralID PMC3351550
View details for DOI 10.1016/j.pain.2011.10.005
View details for PubMedID 22153018
Abdominal sacrocolpopexy is considered a standard of care operation for apical vaginal vault prolapse repair. Using outcomes at our center we evaluated whether the robotic approach to sacrocolpopexy is as cost-effective as the open approach.After obtaining institutional review board approval we performed cost-minimization analysis in a retrospective cohort of patients who underwent sacrocolpopexy at our institution between 2006 and 2010. Threshold values, that is model variable values at which the most cost effective approach crosses over to an alternative approach, were determined by testing model variables over realistic ranges using sensitivity analysis. Hospital billing data were also evaluated to confirm our findings.Operative time was similar for robotic and open surgery (226 vs 221 minutes) but postoperative length of stay differed significantly (1.0 vs 3.3 days, p <0.001). Base case analysis revealed an overall 10% cost savings for robot-assisted vs open sacrocolpopexy ($10,178 vs $11,307). Tornado analysis suggested that the number of institutional robotic cases done annually, length of stay and cost per hospitalization day in the postoperative period were the largest drivers of cost. Analysis of our hospital billing data showed a similar trend with robotic surgery costing 4.2% less than open surgery.A robot-assisted approach to sacrocolpopexy can be equally or less costly than an open approach. This depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo the robot-assisted procedure.
View details for DOI 10.1016/j.juro.2011.09.160
View details for PubMedID 22177180
To provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome.A systematic review of the literature using the MEDLINE® database (search dates 1/1/83-7/22/09) was conducted to identify peer reviewed publications relevant to the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Insufficient evidence-based data were retrieved regarding diagnosis and, therefore, this portion of the Guideline is based on Clinical Principles and Expert Opinion statements. The review yielded an evidence base of 86 treatment articles after application of inclusion/exclusion criteria. These publications were used to create the majority of the treatment portion of the Guideline. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. See text and algorithm for definitions, and detailed diagnostic management, and treatment frameworks.The evidence-based guideline statements are provided for diagnosis and overall management of interstitial cystitis/bladder pain syndrome as well as for various treatments. The panel identified first through sixth line treatments as well as developed guideline statements on treatments that should not be offered.Interstitial cystitis/bladder pain syndrome is best identified and managed through use of a logical algorithm such as is presented in this Guideline. In the algorithm the panel identifies an overall management strategy for the interstitial cystitis/bladder pain syndrome patient. Diagnosis and treatment methodologies can be expected to change as the evidence base grows in the future.
View details for DOI 10.1016/j.juro.2011.03.064
View details for Web of Science ID 000290389600044
View details for PubMedID 21497847
In order to better understand provider treatment patterns for interstitial cystitis (IC)/painful bladder syndrome, we sought to document the therapies utilized and their associated expenditures using a national dataset.A cohort was created by applying the ICD-9 diagnosis of IC (595.1) to INGENIX claims for the year 1999. Subjects were followed for 5 years, and patterns of care and related expenditures were evaluated.Of 553,910 adults insured in 1999, 89 subjects had a diagnosis of IC with 5-year follow-up data. All subjects were treated with oral medication(s), 26% received intravesical treatments, and 22% underwent hydrodistension. Total expenditures per subject were $2,808.The majority of IC expenditures were attributable to oral medical therapy. Hydrodistension and intravesical instillations were utilized in less than 25% of patients. Hydrodistension was used more frequently among subjects with a new diagnosis; this may reflect its utilization as part of a diagnostic algorithm.
View details for DOI 10.1007/s00192-010-1252-8
View details for Web of Science ID 000288173700004
View details for PubMedID 20811877
View details for PubMedCentralID PMC3051069
We evaluated the efficacy and tolerability of mycophenolate mofetil in patients with treatment refractory interstitial cystitis/painful bladder syndrome.A total of 210 patients with interstitial cystitis/painful bladder syndrome were to be randomized into a multicenter, placebo controlled trial using a 2:1 randomization. Participants in whom at least 3 interstitial cystitis/painful bladder syndrome specific treatments had failed and who had at least moderately severe symptoms were enrolled in a 12-week treatment study. The primary study end point was the global response assessment. Secondary end points were general and disease specific symptom questionnaires, and voiding diaries.Only 58 subjects were randomized before a black box warning regarding mycophenolate mofetil safety was issued by the manufacturer in October 2007. The trial was halted, and interim analysis was performed and presented to an independent data and safety monitoring board. Six of the 39 subjects (15%) randomized at study cessation were considered responders for mycophenolate mofetil compared to 3 of 19 controls (16%, p=0.67). Secondary outcome measures reflected more improvement in controls.In a randomized, placebo controlled trial that was prematurely halted mycophenolate mofetil showed efficacy similar to that of placebo to treat symptoms of refractory interstitial cystitis/painful bladder syndrome. The results of this limited study cannot be used to confirm or refute the hypothesis that immunosuppressive therapy may be beneficial to at least a subgroup of patients with interstitial cystitis/painful bladder syndrome. Despite study termination lessons can be gleaned to inform future investigations.
View details for DOI 10.1016/j.juro.2010.10.053
View details for Web of Science ID 000287133900050
View details for PubMedID 21238993
View details for PubMedCentralID PMC3408599
View details for DOI 10.1016/j.juro.2010.04.026
View details for PubMedID 20478598
Current measurement tools have difficulty identifying the automatic physiologic processes maintaining continence, and many questions still remain about pelvic floor muscle (PFM) function during automatic events.To perform a feasibility study to characterise the displacement, velocity, and acceleration of the PFM and the urethra during a cough.A volunteer convenience sample of 23 continent women and 9 women with stress urinary incontinence (SUI) from the general community of San Francisco Bay Area was studied.Methods included perineal ultrasound imaging, motion tracking of the urogenital structures, and digital vaginal examination. Statistical analysis used one-tailed unpaired student t tests, and Welch's correction was applied when variances were unequal.The cough reflex activated the PFM of continent women to compress the urogenital structures towards the pubic symphysis, which was absent in women with SUI. The maximum accelerations that acted on the PFM during a cough were generally more similar than the velocities and displacements. The urethras of women with SUI were exposed to uncontrolled transverse acceleration and were displaced more than twice as far (p=0.0002), with almost twice the velocity (p=0.0015) of the urethras of continent women. Caution regarding the generalisability of this study is warranted due to the small number of women in the SUI group and the significant difference in parity between groups.During a cough, normal PFM function produces timely compression of the pelvic floor and additional external support to the urethra, reducing displacement, velocity, and acceleration. In women with SUI, who have weaker urethral attachments, this shortening contraction does not occur; consequently, the urethras of women with SUI move further and faster for a longer duration.
View details for DOI 10.1016/j.eururo.2009.06.011
View details for PubMedID 19560261
Amitriptyline is frequently used to treat patients with interstitial cystitis/painful bladder syndrome. The evidence to support this practice is derived mainly from a small, single site clinical trial and case reports.We conducted a multicenter, randomized, double-blind, placebo controlled clinical trial of amitriptyline in subjects with interstitial cystitis/painful bladder syndrome who were naïve to therapy. Study participants in both treatment arms received a standardized education and behavioral modification program. The drug dose was increased during a 6-week period from 10 up to 75 mg once daily. The primary outcome was a patient reported global response assessment of symptom improvement evaluated after 12 weeks of treatment.A total of 271 subjects were randomized and 231 (85%) provided a global response assessment at 12 weeks of followup. Study participants were primarily women (83%) and white (74%), with a median age of 38 years. In an intent to treat analysis (271) the rate of response of subjects reporting moderate or marked improvement from baseline in the amitriptyline and placebo groups was 55% and 45%, respectively (p = 0.12). Of the subgroup of subjects (207) who achieved a drug dose of at least 50 mg, a significantly higher response rate was observed in the amitriptyline group (66%) compared to placebo (47%) (p = 0.01).When all randomized subjects were considered, amitriptyline plus an education and behavioral modification program did not significantly improve symptoms in treatment naïve patients with interstitial cystitis/painful bladder syndrome. However, amitriptyline may be beneficial in persons who can achieve a daily dose of 50 mg or greater, although this subgroup comparison was not specified in advance.
View details for DOI 10.1016/j.juro.2009.12.106
View details for Web of Science ID 000276747600068
View details for PubMedID 20303115
View details for PubMedCentralID PMC2861998
View details for DOI 10.1002/nau.20870
View details for Web of Science ID 000273439200030
View details for PubMedID 20025020
We report the clinical characteristics and the principles of laparoscopic management of ureteral endometriosis at our institution.We retrospectively reviewed the charts of patients with ureteral endometriosis.Preoperatively 97% of patients complained of pain but only a third had urinary symptoms. The left ureter was affected in 64% of cases and disease was bilateral in 10%. Four patients had hydroureter and 2 had hydronephrosis.To our knowledge this report represents the largest series of laparoscopically treated, pathologically confirmed ureteral endometriotic cases to date. It confirms that laparoscopic diagnosis and management of ureteral endometriosis are safe and efficient. All patients who undergo laparoscopy for endometriosis should be evaluated for possible ureteral involvement regardless of the presence or absence of urinary symptoms, or prior radiological evaluation since undiagnosed ureteral disease may result in loss of renal function.
View details for DOI 10.1016/j.juro.2009.08.019
View details for PubMedID 19837436
To determine whether Zuidex using a non-cystoscopy mid-urethral injection technique produces as good a result (i.e. was not inferior) as Contigen injected endoscopically at the bladder neck in the treatment of urinary stress incontinence secondary to intrinsic sphincter deficiency in adult women.A prospective 2:1 randomized trial of mid-urethral injections of Zuidex-Implacer vs proximal urethral cystoscopic injections of Contigen was performed in 344 women with intrinsic sphincter deficiency at 23 North American sites, and followed up for >1 year from last treatment.Outcomes at 12 months from last treatment failed to demonstrate that mid-urethral injected Zuidex was equivalent to cystoscopically injected Contigen in primary and secondary outcome variables. The primary outcome, the proportion of women who achieved a 50% reduction in urinary leakage on provocation testing, was achieved in 84% of Contigen-treated women vs 65% of Zuidex-treated women.Confounding multiple variables inherent in the study design make a detailed analysis of study outcomes difficult.
View details for DOI 10.1016/j.urology.2009.05.034
View details for Web of Science ID 000270797900018
View details for PubMedID 19660800
We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes.We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods.There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03).We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study.
View details for DOI 10.1016/j.juro.2009.04.022
View details for Web of Science ID 000267850300056
View details for PubMedID 19535099
View details for PubMedCentralID PMC2872169
We conducted a retrospective analysis to determine associations among symptoms, sleep disturbances and quality of life in responder and nonresponder groups of patients with interstitial cystitis.Patients in a multidose pentosan polysulfate sodium clinical trial with a diagnosis of interstitial cystitis who were randomized to 300 mg pentosan polysulfate sodium per day (128) completed the Interstitial Cystitis Symptom Index, an adapted Medical Outcomes Study Sleep scale and the Medical Outcomes Study Short Form-12 Health Survey at baseline, and at weeks 8, 16, 24 and 32. Responders were defined as those achieving a 30% or greater reduction in Interstitial Cystitis Symptom Index score from baseline to study end point (week 32 or last observation carried forward).A positive correlation at baseline was observed between sleep scores and Short Form-12 physical and mental components (r = 0.43 and 0.37, respectively, p <0.0001). Patients showed statistically significant improvement in Interstitial Cystitis Symptom Index and sleep scores by week 32. Responders (48, 43%) had a mean change in sleep score of 11.8 +/- 22.4 while nonresponders (64, 57%) had a mean change of 1.6 +/- 15.7 (p = 0.0055 between groups). The reduction in Interstitial Cystitis Symptom Index score correlated with improvement in sleep score from baseline to study end point (r = -0.33, p = 0.0003). At the study end point responders demonstrated a significant improvement in the Short Form-12 physical component compared with baseline (p <0.0001).Reduction in interstitial cystitis symptoms may be associated with patient reported improvement in sleep and quality of life.
View details for DOI 10.1016/j.juro.2009.02.030
View details for Web of Science ID 000266020500055
View details for PubMedID 19375108
A 79-year-old woman with a history of chronic back pain and urinary urgency presented to a spine center for treatment and evaluation for axial low back pain. The patient described the back pain as severe with intermittent radiation into the right leg; her pain intensity was 7 out of 10 on a visual analog scale. She described her sense of urgency as severe, and could delay urination for 10 min or less. She described her bladder control as 6 out of 10 on the urgency perception score (with 0 being perfect control).Physical examination, including manual muscle testing, test for sensation to fine touch, reflex assessment and assessment of gait pattern, and MRI of the lumbar spine.Overactive bladder associated with severe central-canal stenosis at L4-5, in the setting of anterolisthesis.Fluoroscopically guided caudal epidural steroid injection; 60 mg of triamcinolone, 3 ml of 1% lidocaine hydrochloride and 3 ml of normal saline, injected in increments.
View details for DOI 10.1038/ncpuro1293
View details for PubMedID 19153571
Goal Assessment Scaling (GAS), wherein patients specify goals then evaluate treatments with regard to goal achievement, has proven utility in assessing treatment of complex conditions such as chronic pain, rheumatoid arthritis, and incontinence. We used surveys and focus groups to characterize the goals of patients with interstitial cystitis/painful bladder syndrome (IC/PBS) in order to create a pilot GAS.37 patients with IC/PBS recorded and ranked their treatment goals which were pooled and analyzed for emergent domains and priority rankings. 15 patients participated in 3 separate focus groups. Focus group audiotapes were transcribed and reviewed to identify major themes and goals domains.140 separate goals were collected. Mean number of goals 4+/-2.73% had pain goals and 56% had frequency and/or nocturia goals. Focus groups revealed that urgency is a separate entity from pain or frequency and any of these may take priority. The groups defined urgency for IC/PBS patient as "the need to urinate due to an unpleasant sensation that prevents attention to any other task." Additional goal domains of control, predictability, and information were explored. Unsatisfactory aspects of common urological surveys were discussed as well as positive and negative aspects of GAS.Patients have individualized treatment goals. GAS holds promise for addressing individuality in a standardized format. A new instrument developed from this work is being piloted in a multicenter RCT. We also suggest that questionnaires investigating urgency in IC/PBS clarify the definition in a way more applicable to the specific condition.
View details for DOI 10.1002/nau.20616
View details for Web of Science ID 000262038700004
View details for PubMedID 19089894
Historically dilation of the female urethra was thought to be of value in the treatment of a variety of lower urinary tract symptoms. Subsequent work has more accurately classified these complaints as parts of various diseases or syndromes in which scant data exist to support the use of dilation. Yet Medicare reimbursement for urethral dilation remains generous and we describe practice patterns regarding female urethral dilation to characterize a potential quality of care issue.Health care use by females treated with urethral dilation was compiled using a complementary set of databases. Data sets were examined for relevant inpatient, outpatient and emergency room services for women of all ages.Female urethral dilation is common (929 per 100,000 patients) and is performed almost as much as treatment for male urethral stricture disease. Approximately 12% of these patients are subjected to costly studies such as retrograde urethrography. The overall national costs for treatment exceed $61 million per year and have increased 10% to 17% a year since 1994. A diagnosis of female urethral stricture increases health care expenditures by more than $1,800 per individual per year in insured populations.Urethral dilation is still common despite the fact that true female urethral stricture is an uncommon entity. This scenario is likely secondary to the persistence of the mostly discarded practice of dilating the unstrictured female urethra for a wide variety of complaints despite the lack of data suggesting that it improves lower urinary tract symptoms.
View details for DOI 10.1016/j.juro.2008.07.037
View details for Web of Science ID 000260102000054
View details for PubMedID 18804232
View details for PubMedCentralID PMC2630407
We evaluated the longer term response in patients with interstitial cystitis who initially responded to intravesical bacillus Calmette-Guerin or placebo in a randomized clinical trial.Patients with interstitial cystitis who responded positively to treatment with bacillus Calmette-Guerin or placebo after 34 weeks of followup in a double-blind clinical trial were followed for an additional 34 weeks in an observational study to assess response durability. Outcomes at 68 weeks included a patient reported global response assessment, 24-hour voiding diary, and pain, urgency and validated interstitial cystitis symptom indexes.Of responders to bacillus Calmette-Guerin or placebo in the clinical trial 38 continued extended followup in the observational study. A total of 12 (75%) responders who received placebo and 19 (86%) who received bacillus Calmette-Guerin considered themselves to remain moderately or markedly improved at week 68. Improved symptom outcomes were also generally maintained during followup in the 2 groups.Most patients who respond to therapy with intravesical bacillus Calmette-Guerin or placebo maintain improved symptoms for up to 68 weeks after the initiation of therapy. However, initial response rates are low and placebo responders demonstrated essentially the same durability of response as bacillus Calmette-Guerin responders. These results argue against the routine use of bacillus Calmette-Guerin in this patient group.
View details for DOI 10.1016/j.juro.2007.09.035
View details for Web of Science ID 000252369600044
View details for PubMedID 18082224
View details for PubMedCentralID PMC2694727
View details for Web of Science ID 000259114800097
We measured candidate urine biomarkers and bladder cell DNA cytometry in interstitial cystitis (IC) patients randomized to receive intravesical Bacillus Calmette Guerin (BCG) or placebo in a multicenter trial. Participants received 6 weekly instillations and were followed for 34 weeks. Urine was collected at baseline, prior to fourth treatment, and at study end. Antiproliferative factor (APF) activity was determined by 3H-thymidine incorporation assay; heparin-binding epidermal growth factor-like growth factor (HB-EGF) and epidermal growth factor-like growth factor (EGF) levels were determined by ELISA. Cellular DNA content was measured by image analysis to determine the mean hyperdiploid fraction (HDF) of the urine cell pellet. Associations between marker levels, and treatment or symptoms, were examined. Baseline APF positivity rate and mean levels of the other biomarkers were similar to previous smaller studies. During the week 34 follow-up, mean HDF decreased (P = 0.0003) and HB-EGF increased (P < 0.0001); both correlated weakly with decreased urgency. There was no difference in any biomarker between symptom responders and non-responders, but the percentage of responders was low and not significantly different for BCG versus placebo. APF positivity, decreased HB-EGF, increased EGF, and increased HDF were confirmed at baseline in IC patients. Changes in HDF and HB-EGF levels correlated weakly with changes in urgency, but the low BCG response rate prevented identification of additional associations between biomarker changes and treatment or symptoms.
View details for DOI 10.1007/s00345-007-0205-4
View details for Web of Science ID 000249636000007
View details for PubMedID 17694391
We evaluated safety and efficacy outcomes in a case series of subjects who received open label intravesical bacillus Calmette-Guerin after failing to respond to bacillus Calmette-Guerin or intravesical placebo in a randomized clinical trial.Subjects who met National Institutes of Health-National Institute of Diabetes and Digestive and Kidney Diseases criteria for IC and reported at least moderate pain and frequency were initially randomized to 6 weekly intravesical instillations of bacillus Calmette-Guerin or placebo and followed for a total of 34 weeks. At 34 weeks subjects who reported that they had not responded to treatment were offered treatment with open label bacillus Calmette-Guerin, using the same course of treatment and followup. Outcomes included a patient reported global response assessment, a 24-hour voiding diary, pain, urgency, validated interstitial cystitis symptom indexes and adverse events.A total of 156 subjects elected open label bacillus Calmette-Guerin, of whom 18 (12%) withdrew during the open label series. The response rate based on the global response assessment was 18% and it was identical between those initially randomized to placebo (first course of bacillus Calmette-Guerin in the open label series) and those initially randomized to bacillus Calmette-Guerin (second course). Small improvements were observed for most secondary efficacy outcomes. Most participants reported at least 1 adverse event, primarily pain, genitourinary symptoms and gastrointestinal disturbances. However, there was no difference in adverse events between those who received the first course of bacillus Calmette-Guerin in this series compared to those who received 2 courses.The low response rate for bacillus Calmette-Guerin in this open label case series further argues against the routine use of bacillus Calmette-Guerin as treatment for interstitial cystitis.
View details for DOI 10.1016/j.juro.2007.05.052
View details for Web of Science ID 000248641300042
View details for PubMedID 17631335
We quantified the burden of interstitial cystitis/painful bladder syndrome on the health care system in the United States.The analytical methods used to generate these results were described previously. Interstitial cystitis was defined based on International Classification of Diseases, 9th revision code 595.1 (interstitial cystitis). For painful bladder syndrome we used the definition International Classification of Diseases, 9th revision code 788.41 (urinary frequency) with code 625.8 (other specified symptoms associated with female genital organs) or 625.9 (unspecified symptoms associated with female genital organs).Between 1992 and 2001 there was a 2-fold increase in the rate of hospital outpatient visits and a 3-fold increase in the rate of physician office visits related to interstitial cystitis. The annualized rate was 102 office visits per 100,000 population. Ambulatory surgery for interstitial cystitis decreased. A diagnosis of interstitial cystitis was associated with a 2-fold increase in direct medical costs. Between 1994 and 2000 annual national expenditures for interstitial cystitis were stable at $37 million but annual costs for painful bladder syndrome increased from $481 million to $750 million.Although interstitial cystitis accounts for a small percent of health care visits, its economic burden is substantial. Because of misdiagnosis, the true burden of interstitial cystitis/painful bladder syndrome on the health care system in the United States is probably underestimated in administrative data that rely only on physician coding to identify the disorder. The greatest part of the disease burden is likely not captured in this economic analysis.
View details for DOI 10.1016/j.juro.2007.01.124
View details for PubMedID 17509284
Interstitial cystitis significantly negatively impacts quality of life. The demographic and clinical factors associated with decreased quality of life in these patients have not been well studied.Women with moderate/severe interstitial cystitis enrolled in a clinical trial of intravesical bacillus Calmette-Guerin were studied. Demographic data and responses to questionnaires were evaluated at baseline, including the O'Leary-Sant Interstitial Cystitis Symptom Index and Problem Index, University of Wisconsin Interstitial Cystitis Inventory, Medical Outcomes Study sexual functioning scale, and the physical composite and mental composite scales of the Medical Outcomes Study Short Form Health Status Survey. Three composite indexes were constructed (from the O'Leary-Sant Interstitial Cystitis Symptom Index, O'Leary-Sant Interstitial Cystitis Problem Index, pain/urgency Likert scales and 24-hour voiding diary) to document the severity, frequency and bother of pain, urinary urgency and frequency (frequency composite index). Linear and multivariate regression models were used to examine predictors of the physical composite and mental composite scales of the Medical Outcomes Study Short Form Health Status Survey. Medical Outcomes Study sexual functioning scale data were available for 163 of the 217 women in the trial.Physical composite scale (median 36) and mental composite scale (median 42) were lower than the standard population value of 50. Multivariate models showed that employment, pain composite index and Medical Outcomes Study sexual functioning scale (all p<0.001) predicted physical composite scale, while only Medical Outcomes Study sexual functioning scale (p<0.001) remained a strong predictor of mental composite scale.Sexual functioning, employment and pain issues predict mental and physical quality of life. In particular, this study identifies sexual functioning as a primary predictor of mental quality of life in women with long-standing interstitial cystitis. It is suggested that sexual functioning may be a salient therapeutic target in the multifaceted treatment of patients with interstitial cystitis.
View details for DOI 10.1016/j.juro.2007.01.060
View details for Web of Science ID 000245764900066
View details for PubMedID 17437831
To evaluate three potential definitions of treatment response in overactive bladder (OAB) syndrome, based on the International Continence Society (ICS) definition of OAB, using pooled data from two large clinical trials of the antimuscarinic agent solifenacin succinate.As the ICS definition of OAB does not rely on urodynamic observations for a diagnosis, the use of composite endpoints, such as in the definitions examined here, might provide a more relevant measure of patient benefits. Each definition was tested to assess the impact of pharmacotherapy, comparing treatment response rates based on composite endpoints. Responder definitions were validated based on the impact on quality of life (QoL). Pooled data from two 12-week multinational, multicentre, double-blind randomized studies of solifenacin, a once-daily oral antimuscarinic for treating OAB symptoms, were used for this analysis. Based on the symptom data from these studies (episodes of urgency, incontinence, nocturia and voiding frequency per 24 h), response was defined as being: (i) a reduction by half or more in all baseline symptoms; (ii) a reduction by half or more in urgency and at least one other symptom; or (iii) resolution of urgency episodes and at least one other symptom. Health-related QoL changes were recorded using the King's Health Questionnaire (KHQ).Solifenacin at 5 mg or 10 mg once daily resulted in significantly higher response rates than with placebo, irrespective of the definition of a responder (P < or = 0.001). When assessing the most challenging definition of response (resolution of urgency and at least one other symptom), solifenacin at 5 mg and 10 mg resulted in 20% and 25% of patients, respectively, meeting the response criteria, vs 12% of placebo-treated patients (P < or = 0.001 for both solifenacin doses). For all three definitions of response, responders showed greater improvements in all KHQ domains than did nonresponders, and the differences were statistically significant.The two strictest definitions of response (halving or more in all baseline symptoms or resolution of urgency and more than one other symptom) appeared to capture QoL changes most effectively. Establishing the most appropriate definition to assess treatment-related changes in OAB will require further investigation, but it is clear from this analysis that composite clinical endpoints, based on the ICS definition of OAB, are a valid approach for assessing the effect of treatments for OAB.
View details for DOI 10.1111/j.1464-410X.2007.06517.x
View details for PubMedID 17227496
Bladder hydrodistention is used to diagnose and treat patients with interstitial cystitis. This procedure has been shown to have minimal morbidity and provide symptomatic relief in a subset of patients with interstitial cystitis. We report our experience with almost total bladder necrosis after hydrodistention at 2 institutions. To our knowledge this rare complication has not been previously reported in the literature. We also reviewed the literature regarding complications of hydrodistention and discuss their possible etiology.We report 3 cases of bladder necrosis after therapeutic hydrodistention for interstitial cystitis at 2 institutions. All records were reviewed, and the clinical presentation, findings and treatments are discussed. A literature review was performed to evaluate the effectiveness and complications of hydrodistention for interstitial cystitis.There were 2 female and 1 male patient between ages 29 and 46. All patients had a previous diagnosis of interstitial cystitis and had been previously treated with hydrodistention. All patients presented with severe abdominal pain and had necrosis of the entire bladder wall with sparing of the trigone. Two patients were treated with supratrigonal cystectomy. A review of the literature revealed little data on the effectiveness of hydrodistention for interstitial cystitis.Vesical necrosis is a rare but devastating complication of hydrodistention. It can occur in young patients in the absence of a contracted bladder and it usually presents as severe postoperative abdominal pain. At exploration bladder necrosis with sparing of the trigone was observed. All patients required enterocystoplasty.
View details for DOI 10.1016/j.juro.2006.08.095
View details for Web of Science ID 000242843200037
View details for PubMedID 17162025
Overactive bladder (OAB) syndrome is a prevalent condition, increasingly recognised as a cause of reduced quality of life that places a substantial economic burden on healthcare provision. While antimuscarinic agents are the therapy of choice for OAB, their use is associated with a number of drawbacks, not least of which is the high rate of adverse events, which is intimately linked with poor compliance with treatment. Solifenacin succinate is a novel antimuscarinic agent approved in Europe and the US for the treatment of men and women with OAB. The recommended starting dose of solifenacin is 5 mg once daily and, if needed, the dose may be increased to 10 mg once daily. In multiple clinical trials, solifenacin treatment has been associated with statistically significant reductions in all key symptoms of OAB (notably frequency, urgency and incontinence) as well as increases in volume voided. Solifenacin has been shown to be well tolerated, producing few adverse effects, which are usually mild in nature. Furthermore, possibly because of this favourable efficacy and tolerability, solifenacin treatment has been associated with a high rate of patient persistence with therapy, with 81% of 1802 patients who completed 12-week, double-blind trials enrolling in and completing a 40-week open-label extension study. Solifenacin has been shown to display selectivity for bladder versus salivary tissue in vitro, and studies in healthy men have shown that absorption is slow but extensive with an absolute bioavailability of 88%. Solifenacin is a well tolerated and efficacious agent for the treatment of OAB, significantly reducing symptoms and improving patients' quality of life.
View details for PubMedID 16451092
Interstitial cystitis is a painful bladder condition of unknown etiology and poorly understood pathophysiology. Current therapies have met with limited success. Vanilloid receptor agonists such as resiniferatoxin (RTX) desensitize C-fibers that transmit pain; it is hypothesized that such drugs will be effective in the treatment of interstitial cystitis and painful bladder syndrome by decreasing the pain that leads to urinary frequency and urgency.A randomized, double-blind, placebo controlled study was conducted in 163 patients with interstitial cystitis. Participants were randomly assigned to receive a single intravesical dose of 50 ml of either RTX 0.01 microM, 0.05 microM, 0.10 microM, or placebo. Safety and efficacy was evaluated over 12 weeks. The primary efficacy endpoint was the Global Response Assessment, a 7-point scale rating overall change in symptoms of interstitial cystitis after 4 weeks. Secondary efficacy endpoints included reduction in pain, urgency, frequency, nocturia, average void volume, and the O'Leary-Sant Symptom and Problem Indexes.RTX did not improve overall symptoms, pain, urgency, frequency, nocturia, or average void volume during 12 weeks followup. RTX resulted in a dose-dependent increase in the incidence of instillation pain, but was otherwise generally well tolerated.In the largest prospective, randomized clinical trial reported to date with intravesical vanilloid therapy, single administration of RTX at doses of 0.01 microM to 0.10 microM was not effective in patients with interstitial cystitis.
View details for DOI 10.1097/01.ju.0000154631.92150.ef
View details for PubMedID 15821499
We compared intravesical bacillus Calmette-Guerin (BCG) to placebo instillations in patients with treatment refractory interstitial cystitis (IC).Subjects who met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC, and reported at least moderate pain and frequency for a minimum of 6 months before study entry, were randomized to 6 weekly double-blinded intravesical instillations of either BCG or placebo, and then followed for a total of 34 weeks. The primary outcome was a patient reported global response assessment at week 34, supplemented with medications for IC during weeks 31 to 34. Secondary outcomes included a 24-hour voiding diary, pain, urgency, validated IC symptom indexes and adverse events. The target sample size was 260 participants, designed to detect a difference in response rates between placebo and BCG of 30% and 50%, respectively.A total of 265 participants were randomized and 17 (6%) patients withdrew from study. The response rates for the primary outcome were 12% for placebo and 21% for BCG (p = 0.062). Small improvements were observed for all secondary outcomes, some more so with BCG, but these differences were of borderline statistical significance. Although a large number of adverse events were reported in the BCG arm, there was no statistically significant difference between the treatment arms in overall adverse event rates.Although the BCG safety profile was acceptable, the response rate for the primary outcome was low. Effective medical treatment for patients with moderate to severe interstitial cystitis remains elusive.
View details for DOI 10.1097/01.ju.0000152337.82806.e8
View details for Web of Science ID 000227687600027
View details for PubMedID 15758738
Two statistically validated interstitial cystitis (IC) symptom instruments have been used in clinical research. In this study we report what is to our knowledge the first direct comparison of the University of Wisconsin Symptom Instrument (UWI) with the O'Leary-Sant instruments, that is the IC Symptom Index (ICSI) and IC Problem Index (ICPI).A convenience sampling of 107 patients with IC evaluated at the urology clinic at our institution from March through August 2000 were asked to complete ICSI, ICPI and UWI. The scores were analyzed and graphed.Mean ICSI, ICPI and UWI scores +/- SD were 12.6 +/- 4.3, 10.5 +/- 3.8 and 25.5 +/- 10.8, respectively. UWI and ICSI scores correlated at r = 0.80 (p <0.01) and ICSI/ICPI scores correlated at r = 0.83 (p <0.01). ICSI and ICPI contain 4 symptom-problem pairs. There are relevant differences in the correlation of symptom severity (ICSI question) and its associated problem (ICPI question). The symptom of urgency correlated best with the associated problem (r = 0.84), followed by nocturia (r = 0.82), pain (r = 0.70) and frequency (r = 0.68).The ICSI and UWI symptom instruments correlate strongly in a large population of patients with IC. The data presented will aid in interpreting the literature. A relatively poor correlation between pain symptom-problem pairs in the O'Leary-Sant instruments is probably an artifact of wording. The word pressure appears in ICPI but not in ICSI. We suggest using parallel wording of the pain symptom-problem pair containing the identical phrase, burning, pain, discomfort or pressure, to improve the ICSI/ICPI correlation and more accurately reflect the clinical condition.
View details for DOI 10.1097/01.ju.0000152672.83393.61
View details for PubMedID 15711285
Cystoscopic bladder distention is an important tool in the diagnosis and treatment of interstitial cystitis (IC). We investigated the feasibility of performing bladder distention in the office using two different anesthetic strategies: simple instillation of alkalized lidocaine and electromotive drug administration (EMDA) of lidocaine.Patients presenting with urinary frequency, urgency, and bladder pain were recruited for an office evaluation protocol which included bladder distention under local anesthesia. An initial group of 10 patients underwent bladder distention after instillation of 5 mg/kg alkalized lidocaine. A second group of 11 patients had lidocaine EMDA anesthesia prior to distention.In the alkaxlized lidocaine group, 6 of the 10 distentions were aborted after less than 5 minutes at only 40 cm H(2)O. In the EMDA group, 7 of 11 of the distentions were completed using 60 cm H(2)O for 7 minutes. EMDA afforded a more effective distention as manifest by a greater percent increase in distention capacity over cystometric capacity compared to alkalized lidocaine (135% vs. 70%). Despite the lower pressure used in the alkalized lidocaine group, the median distention time was only 3 minutes compared to 7 minutes using EMDA.These results represent the first study of the efficacy of EMDA as local anesthesia for bladder distention compared to another method of anesthesia. Lidocaine EMDA is superior to alkalized lidocaine in that it allows for a greater distention of the bladder for a longer period of time but does not eliminate the pain of bladder distention.
View details for DOI 10.1002/nau.20106
View details for PubMedID 15747341
View details for Web of Science ID 000234296500027
View details for DOI 10.1007/s11195-005-8927-y
View details for Web of Science ID 000234464600001
Extragenital endometriosis is an uncommon condition that can affect almost any organ system and tissue in the human body. Disease involving multiple distant sites is extremely uncommon.We report a rare case of synchronous rectovaginal, urinary bladder, and pulmonary endometriosis. We performed a Medline literature search using keywords "endom etriosis," "recto vaginal," "pulmonary," "bladder," "ureteral," "bowel," "extrapelvic," and "extragenital" and were unable to find any prior case reports of such findings. A 31-year-old female presented with catamenial dysuria of 1-year duration, pleurisy associated with spontaneous pneumothoraces of 7 months' duration and a long-standing history of pelvic pain. A multispecialty team with experience in endoscopic techniques was assembled, consisting of a thoracic, a urologic, and a gynecologic surgeon. Video-assisted thoracoscopic surgery with fulguration of all visible pleural endometriosis and pleurodesis was performed, followed by laparoscopic segmental bladder wall endometrioma excision and resection of rectovaginal endometriosis. Twelve months after surgery and without additional hormonal treatment, the patient is symptom free.Extragenital endometriosis may coexist in multiple sites. A high index of suspicion aids in the diagnosis. A multidisciplinary approach in a tertiary center, followed by appropriate surgical eradication of visible disease, can successfully treat endometriosis even in such extreme cases.
View details for PubMedID 15791976
Bladder distention is commonly used in diagnosis and treatment of interstitial cystitis (IC). Traditionally performed in the operating room under general or spinal anesthesia (GA), it is expensive and associated with short term morbidity. Office bladder distention using electromotive drug administration (EMDA) has been suggested as an alternative that is well tolerated by patients. We report the first comparative findings of patients undergoing both office distention with EMDA and distention in the operating room (OR) with GA.This retrospective chart review identified 11 patients participating in two protocols of EMDA bladder distention who also underwent bladder distention under GA either prior to or after the EMDA procedure.The median absolute difference in bladder capacity between GA and EMDA was only 25 cc; the median percent difference was 5%. Cystoscopic findings, while not prospectively compiled, appear to have been similar.This study represents the first comparison between distention with EMDA versus GA and confirms the technical feasibility of performing bladder distention in an office setting. The distention capacity achieved in the office was nearly identical to that in the OR and the cystoscopic findings very similar. Further investigation into the comparative morbidity, cost, and other outcome measures is warranted to define the ultimate role of EMDA bladder distention in the clinical evaluation and care of patients with IC.
View details for PubMedID 16300684
Overactive bladder (OAB) is described as urinary urgency, with and without urge incontinence and usually with frequency and nocturia. Most attention to OAB's impact on health-related quality of life (HRQL), however, has focused on urge incontinence. The objective of this study was to evaluate the burden of OAB, specifically urinary urgency and frequency on HRQL.In the National Overactive Bladder Evaluation Program (NOBLE), a computer-assisted telephone interview survey was conducted to assess the prevalence of OAB in the United States. Based on interview responses, respondents were classified into three groups: continent OAB, incontinent OAB, and controls. To evaluate the HRQL impact of OAB, HRQL questionnaires were mailed to all respondents with OAB and age- and sex-matched controls as a performed nested case-control study. Continuous data were compared using Student's t tests and analysis of variance with post hoc pairwise comparisons; results were adjusted for age, sex, and comorbid conditions. Multivariable regressions were performed to assess the impact of each urinary variable on symptom bother and HRQL.A total of 919 participants responded to the questionnaires (52% response rate) with a mean age of 54.2 years (SD 16.4 years); 70.4% were female and 85% were white. Continent OAB participants comprised 24.8% of the sample, incontinent OAB 18.3%, and controls 56.9%. In each regression analysis, urinary urge intensity accounted for the greatest variance for increases in symptom bother and decreases in HRQL.The experience of urinary urgency has a significant negative effect on HRQL and increases symptom bother, an effect that, in this community sample, is greater than that of incontinence, frequency, or nocturia.
View details for Web of Science ID 000222801900008
View details for PubMedID 15449637
View details for Web of Science ID 000231546800005
View details for Web of Science ID 000223051900149
Female patients with interstitial cystitis (IC) unresponsive to standard oral and intravesical therapy were enrolled at three clinical sites for percutaneous sacral nerve root stimulation (PNS) in a prospective, observational pilot study. Evaluation was in the form of a 3-day voiding diary completed both prior to and following the commencement of sacral nerve root stimulation. Symptoms were also assessed by the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indices (ICSI and ICPI). Baseline and test stimulation values for voiding diary parameters and O'Leary-Sant scores were compared to determine treatment efficacy. A total of 33 patients were enrolled. Statistically significant improvements were seen in frequency, pain, average voided volume and maximum voided volume. Significant improvements were also seen in ICSI and ICPI scores. Subacute PNS appears to be effective in reducing symptom severity and increasing voided volumes in patients with IC previously unresponsive to standard therapy.
View details for DOI 10.1007/s00192-003-1080-1
View details for Web of Science ID 000187826500004
View details for PubMedID 14618305
In March 2003 experts on interstitial cystitis (IC) from around the world met in Kyoto, Japan for a series of workshops intended to define areas of agreement and difference in the approach to this disease. This workshop explored the diagnostic criteria IC in the clinical and research settings. The NIDDK criteria are used almost universally for research but there is tremendous disparity in the clinics and no consensus at all as to the best practice in diagnosing IC for clinical purposes. Throughout the world many physicians use the NIDDK research criteria for clinical diagnosis; in some countries this is standard. Undoubtedly, this mandates under-diagnosis and denies treatment to many patients. Still, a majority feel that one diagnostic system is mandatory to promote clarity in communication. The group called for two initiatives to help advance this area of controversy: (1) a large-scale, prospective study critically examining the role of cystoscopy, bladder distention, and biopsy in the diagnosis of IC; (2) a concerted effort to develop a single evidence-based guideline or algorithm that would be flexible enough to meet the needs of clinicians, researchers, and patients.
View details for PubMedID 14641406
This study evaluated the efficacy and tolerability of new extended-release (ER) tolterodine for the treatment of overactive bladder in women. In this subpopulation analysis of a double-blind multicenter trial, 1235 female patients were randomized to oral therapy with tolterodine ER 4 mg once daily (n=417), tolterodine IR 2 mg twice daily (n=408) or placebo (n=410) for 12 weeks. Both formulations reduced the mean number of urge incontinence episodes per week (both P=0.001 vs placebo); tolterodine ER was more effective than tolterodine IR (P=0.036). Both formulations significantly improved all other micturition chart variables compared to placebo. Dry mouth was the most common adverse event. There were no safety concerns. Toltrodine ER 4 mg once daily is effective and well tolerated in the treatment of women with overactive bladder, and reduces urge incontinence episodes more than the existing IR twice-daily formulation.
View details for DOI 10.1007/s00192-002-1009-0
View details for Web of Science ID 000221039900010
View details for PubMedID 12601517
View details for Web of Science ID 000179188700003
View details for PubMedID 12429288
View details for PubMedID 11378111
View details for PubMedID 11378115
View details for PubMedID 11378097
View details for PubMedID 11378114
What is behavioral therapy? On the one hand there is no consensus in the literature as to the definition of the treatment or the optimal mode of delivery. On the other hand, it is possibly the "best" single treatment for urinary incontinence when viewed from a risk:benefit analysis. There is general agreement that within this framework wide variations exist in intensity of treatment, expertise required to deliver the treatment, and the subsequent cost of therapy. A definition of behavioral therapy should include at least the following techniques: first, education and explanation of normal lower urinary tract function; second, micturition charts and diaries; and finally, timed voiding/bladder training regimens. All of the behavioral methods are demonstrably effective, with improvement rates in incontinence episodes uniformly in excess of 50%. Our challenge is to define the critical parts of behavioral therapy and develop algorithms that can be delivered to the incontinent population in the most cost-effective manner.
View details for PubMedID 10767442
Urethral sling procedures have become increasingly popular in the treatment of female stress incontinence. Until recently, the use of this procedure in the urologic community has been limited by technical difficulties and complications (e.g., urinary retention, urethral injury, urge frequency). Many modifications of the original sling procedure recently have been described to decrease surgical morbidity. This article describes a minimally invasive sling procedure performed completely through the vagina, with the aid of bone anchor fixation. The potential advantages of this operation include a rapid return to full activity and normal voiding. It should be noted that neither the long-term safety nor the efficacy has been established.
View details for PubMedID 10361564
View details for Web of Science ID 000073746500044
View details for PubMedID 9609656
To present an overview of current knowledge regarding the epidemiology, pathophysiology, and evaluation of urinary incontinence (UI) with a focus on the problem of the overactive bladder.The most recent data on the epidemiology of UI are presented. The literature on the pathophysiology of urinary urge incontinence (UUI) is reviewed, and key concepts related to patient evaluation are summarized.The prevalence of UI depends on the population being surveyed. The overactive bladder constitutes a substantial percentage of the overall problem, ranging from > 50% of incontinent men to only 10% to 15% of incontinent younger women. Few data are available on the incidence of the disorder or on racial/ethnic trends. Overactive bladder or urge incontinence is called detrusor hyperreflexia when a neurologic cause is known and detrusor instability when there is no neurologic abnormality. Although the pathophysiology of idiopathic instability is not well understood, some evidence suggests that this condition may result from subclinical neurologic disease or primary smooth muscle disease. Most patients with UUI can be adequately evaluated with a history, physical examination, determination of postvoid residual volume, and urinalysis. When neurologic disease or other complicating factors are present, or if initial treatment fails, sophisticated urodynamic testing is appropriate.Urinary incontinence is prevalent in all strata of the population, although it affects women and the elderly disproportionately. With the exception of cases in which a neurologic lesion can be demonstrated, the etiology of UUI remains elusive. A thorough history, physical examination, determination of postvoid residual, and urinalysis will be adequate to classify and treat the majority of patients.
View details for PubMedID 9495728
To review the role of biofeedback in the management of community-dwelling individuals with urge urinary incontinence (UUI), and to present a practical approach to patient evaluation and treatment selection.In view of a lack of objective published information, perspectives on the use of biofeedback in UUI are derived from extrapolation of studies in patients with stress incontinence as well as from the author's personal experience.Through the use of careful baseline evaluations, appropriate exercise and biofeedback treatment for UUI can be selected for specific patients. Office-based biofeedback is preferred for patients who have no or minimal ability to isolate and contract the levator muscles at baseline. Such individuals cannot be expected to exercise effectively without instruction but can be converted to home-based treatment once responses have been achieved. Patients with weak contractions but appropriate muscle isolation are appropriate candidates for Kegel exercises; biofeedback has not been conclusively demonstrated to be superior to exercise therapy alone in this group. Vaginal cones or simple home biofeedback units may be useful adjuncts in these cases. Patients who have good muscle isolation and strong pelvic contractions at baseline generally have more severe bladder dysfunction and require aggressive treatment aimed at the detrusor. Instruction in "quick flicks" may assist in inhibiting urgency, and motivated patients may be offered vaginal cones.Pelvic floor muscle dysfunction is an important but often-overlooked component of UUI. The algorithm presented here can assist in tailoring exercise and biofeedback therapy to the individual patient. However, more research is needed to help stratify patients according to the degree of detrusor dysfunction and status of pelvic floor muscles before intervention.
View details for PubMedID 9495734
View details for Web of Science ID A1996TU66800064
View details for PubMedID 8583553
View details for Web of Science ID A1995QL42200055
View details for PubMedID 7533462
Dramatic advances across several fronts have provided a marked improvement in the quality of life for the elderly urologic patient. Radical surgery for cancer is much safer than in the past, and our focus is on preservation of function or complete functional reconstruction. In other areas we strive to continue to deliver excellent treatment while minimizing patient morbidity. This is seen most dramatically in the treatment of urinary stone disease. Ongoing work in patients with BPH promises to provide similar benefits to this population in the coming years. At the same time, we must remember that our abundance of therapeutic options imposes a responsibility to individualize treatment so as to best serve each patient.
View details for PubMedID 7513086
We describe a modification of gastrocystoplasty using the GIA stapler to harvest the segment for augmentation without opening the stomach. This simplification reduces operative time and blood loss without introducing complication specific to it and has been successfully used in our first 5 patients.
View details for Web of Science ID A1993LM76700036
View details for PubMedID 8326631
Fifty-nine males with bladder outlet obstruction were treated with transurethral ultrasonic aspiration of the prostate. Utilizing a 26.5F urethral sheath, surgery was accomplished with a 10F, 0-700-micron-vibration-level ultrasonic tip with an excursion rate of 39 kHz. Complete removal of the adenoma was accomplished followed by transurethral electrocautery biopsies of both lateral lobes to compare pathologic specimens. One year follow-up revealed satisfactory voiding patterns in 57 of 59 men (96%). Bladder neck contractures developed in 2 men. Pathologic comparisons showed 100 percent correlation between aspirated and TUR specimens (56 BPH, 3 adenocarcinoma). Forty-seven men were active sexually preoperatively (6 with inflatable penile prostheses). Post ultrasonic aspiration, 46 men had erectile function similar to preoperative levels with 1 patient suffering erectile dysfunction. Forty men (85%) had antegrade ejaculation while 7 (15%) experienced retrograde or retarded ejaculation. No patients were incontinent.
View details for Web of Science ID A1991FQ19200002
View details for PubMedID 1710082