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Enhanced counseling with an educational video does not improve patient adherence to pelvic floor physical therapy attendance when compared with an educational handout.

To describe the characteristics of pain experienced by patients with interstitial cystitis (IC) in terms of pain site, severity, and character, we performed a secondary analysis of data from the IC database (ICDB), which was a prospective, longitudinal, cohort study of IC patients. We analyzed the cross-sectional baseline data from 629 patients who had a completed baseline symptom questionnaire. Patients answered questions about whether they had pain or discomfort associated with urinary symptoms over the past 4 weeks and if so, about the location, characteristics, intensity, and frequency of their pain. Logistic regression examined associations between pain location and the presence of urinary symptoms. Analyses were performed using SAS version 8.2 (SAS Institute, Cary, NC, USA) and considered significant at the 5% level. Five hundred and eighty-nine (94%) patients with a mean age of 45 years (SD 14 years) reported baseline pain or discomfort associated with their urinary symptoms. The most common baseline pain site was lower abdominal (80%), with urethral (74%) and low back pain (65%) also commonly reported. The majority of patients described their pain as intermittent, regardless of the pain site. Most patients reported moderate pain intensity, across all pain sites. There was a statistically significant link between pain in the urethra, lower back, and lower abdomen, and urinary symptoms. Patients with IC report pain at several sites other than the bladder, possibly arising from the previously well-described myofascial abnormalities of pelvic floor and abdominal wall present in patients with IC and other chronic pelvic pain syndromes.

Abstract:  Injured nerves and their motor units may undergo enhanced recovery when exposed to recombinant human insulin-like growth factor-I (rhIGF-I). The external anal sphincter muscle in the female rat was denervated to model incontinence. The treatment-group muscle was injected with rhIGF-1 plasmid, whereas in the control group the plasmid lacked the cDNA insert and the normal group received neither surgery nor treatment. Electromyography data at 56 days post surgery indicated more reinnervation without fibrillation potentials in the treatment group (2 of 6) than in the control group (0 of 6). The histology of the regenerated axons in the pudendal nerve distal to the crush site also suggested an improved recovery in the treatment group. The number of motor neurons retrogradely labeled with horseradish peroxidase was decreased by 50% following pudendal nerve crush in both experimental groups compared to the normal group. We conclude from these preliminary results that rhIGF-I gene therapy may improve the distal recovery of structure and function.

Patients commonly express bother with the symptom of frequent urination. The relationship between actual voiding frequency and this symptom is undocumented. We reviewed records of 200 women who had completed 24‐hour frequency‐volume charts, and had indicated their degree of bother with urinary frequency utilizing the short form of the Urogenital Distress Inventory. The degree of bother was correlated with daytime and nighttime voiding frequency, maximum functional capacity, mean voided volume, and demographic variables. Among 200 women, 180 (90%) indicated at least a minor degree of bother with urinary frequency. A voiding frequency of eight or more times in 24 hours was reported by 166 (83%) of women. Among the 34 women voiding fewer than eight times/24 hours, 26 (76%) reported bother with urinary frequency. There was large variation in the degree of bother reported at a given voiding frequency. Postmenopausal women without hormone replacement therapy (HRT) recorded more nighttime voids than those on HRT. Among postmenopausal women without HRT, mean voided volume and maximum functional capacity were inversely related to patient age. Our study suggests that the currently utilized cutoff value of eight daily voids to define urinary frequency, may not be helpful in the management of women in this country. A racially diverse study of the voiding habits of asymptomatic North American women is mandated. Neurourol. Urodynam. 21:36–41, 2002. © 2002 Wiley‐Liss, Inc.

Patients commonly express bother with the symptom of frequent urination. The relationship between actual voiding frequency and this symptom is undocumented. We reviewed records of 200 women who had completed 24-hour frequency-volume charts, and had indicated their degree of bother with urinary frequency utilizing the short form of the Urogenital Distress Inventory. The degree of bother was correlated with daytime and nighttime voiding frequency, maximum functional capacity, mean voided volume, and demographic variables. Among 200 women, 180 (90%) indicated at least a minor degree of bother with urinary frequency. A voiding frequency of eight or more times in 24 hours was reported by 166 (83%) of women. Among the 34 women voiding fewer than eight times/24 hours, 26 (76%) reported bother with urinary frequency. There was large variation in the degree of bother reported at a given voiding frequency. Postmenopausal women without hormone replacement therapy (HRT) recorded more nighttime voids than those on HRT. Among postmenopausal women without HRT, mean voided volume and maximum functional capacity were inversely related to patient age. Our study suggests that the currently utilized cutoff value of eight daily voids to define urinary frequency, may not be helpful in the management of women in this country. A racially diverse study of the voiding habits of asymptomatic North American women is mandated. Neurourol. Urodynam. 21:36–41, 2002. © 2002 Wiley-Liss, Inc.

Abstract:: The aim of this study was to identify factors in patients with symptoms of urgency/frequency or urge incontinence that predict that the postvoid residual urine volume (PVR) will be elevated. A restrospective chart review was carried out of all patients new to our urogynecology practice between June 1998 and May 1999, with symptoms of urgency, frequency and/or urge incontinence. Demographic variables, symptoms and physical findings were correlated with the presence of an elevated PVR (>100 ml) using logistic regression analysis. An elevated PVR was found in 10% (33/336) of patients with urge incontinence (UI), and in 5% (3/57) of patients with urgency/frequency without UI. In patients with UI the presence of pelvic organ prolapse (POP) ≥stage II, symptoms of voiding difficulty and the absence of the symptom of stress incontinence, predicted 82% of patients with an elevated PVR.

The lack of standardized terminology in pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and fecal incontinence) is a major obstacle to performing and interpreting research. The National Institutes of Health convened the Terminology Workshop for Researchers in Female Pelvic Floor Disorders to: (1) agree on standard terms for defining conditions and outcomes; (2) make recommendations for minimum data collection for research; and (3) identify high priority issues for future research. Pelvic organ prolapse was defined by physical examination staging using the International Continence Society system. Stress urinary incontinence was defined by symptoms and testing; ‘cure’ was defined as no stress incontinence symptoms, negative testing, and no new problems due to intervention. Overactive bladder was defined as urinary frequency and urgency, with and without urge incontinence. Detrusor instability was defined by cystometry. For all urinary symptoms, defining ‘improvement’ after intervention was identified as a high priority. For fecal incontinence, more research is needed before recommendations can be made. A standard terminology for research on pelvic floor disorders is presented and areas of high priority for future research are identified.

The aim of this study was to document the relative proportions of two isoforms of myosin heavy chain in detrusor smooth muscle of women with detrusor overactivity and in asymptomatic controls. Women aged 35–65 with documented detrusor overactivity and without a history of neurologic disease, prior incontinence surgery, elevated post‐void residual urine volume, or indwelling urinary catheter were eligible for the study. Full‐thickness biopsies of extraperitoneal bladder dome were obtained at the time of laparotomy in six patients with documented detrusor overactivity and in a control group of eight continent patients. Biopsies were frozen in liquid nitrogen, crushed with a frozen mortar and pestle at −80°C, and homogenized in buffer, and the extracts were electrophoresed on 6% polyacrylamide sodium dodecyl sulfate gels and stained with Coomassie blue. The gels were de‐stained and then the protein bands were scanned with a densitometer. The mean patient age was 48 years (range, 36–59). Seven patients were Caucasian and seven patients were African American. Detrusor smooth muscle contains a mean of 34% (range, 27–43%) SM1 and 66% (range, 57–73%) SM2 isoforms. There was no difference in isoform composition when patients were compared according to urogynecologic diagnosis or according to race. In detrusor biopsies from women, approximately 34% of myosin is of the SM1 isoform and approximately 66% is of the SM2 isoform. This ratio is relatively constant in the two races studied and unchanged in women with detrusor overactivity. Animal models utilizing outlet obstruction of the bladder to provoke detrusor instability and detrusor hypertrophy are known to alter myosin isoform distribution and may not be appropriate models of detrusor instability in human females. Neurourol. Urodynam. 20:23–29, 2001. © 2001 Wiley‐Liss, Inc.

Transient postoperative urinary retention after stress incontinence surgery is common, and there is no widely accepted method of hastening the return to normal voiding. The etiology of this retention is poorly understood. Failure of the relaxation of the striated external urethral sphincter has been proposed as an etiologic agent, but has not been documented. Ten patients about to undergo a Burch colposuspension or sub‐urethral sling, who demonstrated normal preoperative voiding, were recruited to a study of postoperative retention. Hook‐wire electromyographic (EMG)probes were placed into the external urethral sphincter while the patients were under anesthesia, and a suprapubic catheter was placed. We performed instrumented voiding trials 1 or 2 days after surgery while continuously recording urethral EMG and intravesical pressure. Two patients demonstrated normal voiding. Two patients were able to void but demonstrated no EMG silencing. Six patients were unable to void and demonstrated persistent EMG activity. Four of these demonstrated no detrusor contraction, whereas two demonstrated detrusor contractions. All patients resumed normal voiding by clinical parameters within 14 days of surgery. Our study supports other research that suggests that failure of relaxation of the striated urethral sphincter contributes to postoperative urinary retention. Neurourol. Urodynam. 20:13–21, 2001. © 2001 Wiley‐Liss, Inc.

Complex repetitive discharges (CRDs) are a form of abnormal needle electromyographic (EMG) activity associated with a variety of neuromuscular disorders, including chronic denervation. Urethral CRDs have also been associated with symptoms of voiding dysfunction. We reviewed the findings of 351 consecutive urethral sphincter EMG studies to characterize the patients with CRDs in our patient population and further to characterize the peri-operative course of any patient with urethral CRDs who underwent surgery for genuine stress incontinence (GSI). Among the 351 women studied, a subgroup of 27 (8%) women demonstrated CRDs during their study. Patients with CRDs were more likely to report the symptom of strain voiding (48% of patients with CRDs, 18% of patients without CRDs; χ²(1) = 17.6, P < 0.001). Patients with CRDs were also more likely to have undergone prior urethral dilation (15% of patients with CRDs versus 2% of patients without CRDs, χ²(1) = 9.5, P < 0.01). Patients with CRDs were similar to patients without CRDs with respect to symptoms of incontinence and history of hysterectomy or surgery for incontinence. Ten patients who had urethral CRDs underwent surgery for their GSI with a 90% success rate. The duration of post-operative catheterization did not differ from that of our general population of patients undergoing similar procedures. Urethral CRDs appear to be a non-specific finding, and it is premature to alter the approach to patients with lower urinary tract dysfunction for this reason. Neurourol. Urodynam. 19:577–583, 2000. © 2000 Wiley-Liss, Inc.

Complex repetitive discharges (CRDs) are a form of abnormal needle electromyographic (EMG) activity associated with a variety of neuromuscular disorders, including chronic denervation. Urethral CRDs have also been associated with symptoms of voiding dysfunction. We reviewed the findings of 351 consecutive urethral sphincter EMG studies to characterize the patients with CRDs in our patient population and further to characterize the peri‐operative course of any patient with urethral CRDs who underwent surgery for genuine stress incontinence (GSI). Among the 351 women studied, a subgroup of 27 (8%) women demonstrated CRDs during their study. Patients with CRDs were more likely to report the symptom of strain voiding (48% of patients with CRDs, 18% of patients without CRDs; χ2(1)= 17.6, P < 0.001). Patients with CRDs were also more likely to have undergone prior urethral dilation (15% of patients with CRDs versus 2% of patients without CRDs, χ2(1)= 9.5, P< 0.01). Patients with CRDs were similar to patients without CRDs with respect to symptoms of incontinence and history of hysterectomy or surgery for incontinence. Ten patients who had urethral CRDs underwent surgery for their GSI with a 90% success rate. The duration of post‐operative catheterization did not differ from that of our general population of patients undergoing similar procedures. Urethral CRDs appear to be a non‐specific finding, and it is premature to alter the approach to patients with lower urinary tract dysfunction for this reason. Neurourol. Urodynam. 19:577–583, 2000. © 2000 Wiley‐Liss, Inc.

Abstract:: Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.

Our aim was to examine the effects of denervation on urethral anatomy and urine voiding pattern. Rats usually void at one end of their cage, which gives a behavioral index of continence. The voiding preference for denervated rats was decreased to 88.8+4.7%,n=32,P<0.001, compared to improvements with time for unoperated (117±10%,n=16) or sham-operated rats (105±8%,n=5). The volume of urine or the frequency of voidings between denervated, unoperated or sham-operated rats did not differ significantly. Urethral sections were analyzed immunochemically and quantified morphometrically. Smooth muscle volume remained constant but skeletal muscle volume decreased after denervation, from 43±2% to 36±3% (P<0.05,n=5). Fiber diameter decreased from 14.3±1.4 μm to 8.5±0.7 μm (P<0.005). We concluded that pudendal nerve transection in female rats causes behavioral alterations in voiding and muscular atrophy of the striated sphincter.

The aim of this review was to compare properties of the most commonly used synthetic meshes and describe their use in gynecologic procedures. An Ovid search of the English literature from 1966 to the present was carried out, together with a hand search ofIndex Medicusfrom 1950 to 1965. Articles involving the use of mesh in surgical procedures or comparative studies of the different mechanical properties of mesh are included. Overviews from urogynecologic texts and surgical texts are also included. All studies in this review consisted of retrospective case series (21 suburethral sling articles, 15 sacrocolpopexy articles, and five pelvic sling articles). No randomized prospective trials were available. Outcome variables, including cure rates and mesh-related complications, are reviewed and compared. Conclusions show that long-term success of the suburethral sling with synthetic mesh ranges from 61% to 100%, and the success rate of the abdominal sacrocolpopexies using mesh ranges from 68% to 100%. Mesh-related complications rates are frequent, with up to a 35% removal rate and 10% sinus tract formation for suburethral slings and 9% erosion rate for sacrocolpopexy. The ideal synthetic mesh material for pelvic surgery, one that induces minimal foreign-body reaction with minimal risk of infection, rejection and erosion, has yet to be developed.

Electrical stimulation has been widely used in Europe to treat incontinence, but original studies and overall use of the device has been limited in North America. Forty-five patients with documented genuine stress incontinence, detrusor instability or mixed incontinence had self-administered therapy for 15 minutes twice daily, for a duration of 6 weeks. Treatment was delivered by a new stimulation device with an attached vaginal probe. Patients recorded treatment times, leak episodes and pad use. Objective measures included a pad test, standing stress test, standing CMG, and resting and dynamic urethral closure pressure profiles. The subjective success rates based on a questionnaire were 71% for genuine stress incontinence, 70% for detrusor instability, and 52% for combined incontinence. Objective testing for both types of incontinence did not show significant improvement after treatment. Four patients reported pain during use of the device, but most wished to continue the device in preference to other therapy.

Our objective was to determine whether voiding diary non-compliance was an important clinical predictor for the absence of urinary symptoms. History questionnaires and voiding diaries are mailed to all patients before initial visits. The study included 349 patients capable of filling out the history questionnaire and voiding diary prior to their initial visit. The control group (n=261) consisted of patients who filled out both forms. The study group (n=88) consisted of patients who filled out their history questionnaire yet left their voiding diary blank. Study variables were extracted by chart review to determine the clinical significance of non-compliance with voiding diary completion. Non-Caucasian patients were less likely to complete their diary (P=0.008). Patients presenting for treatment of pelvic organ prolapse (no urinary symptoms) were also less likely to complete their diary (P=0.01, OR 0.41, 0.20–0.85). These patients should be counseled about the importance of the voiding diary in validating urinary symptoms. Urodynamic diagnosis were similar in patients considering surgical correction of pelvic organ prolapse, independent of diary non-compliance.

The objective was to determine whether vaginal topography accurately predicts the location of the pelvic viscera on fluoroscopy in women with pelvic organ prolapse. Eighty-nine women undergoing preoperative evaluation for reconstructive pelvic surgery at a tertiary care referral practice formed the study population. Each woman completed a comprehensive urogynecologic history and physical examination, which included a quantified (POP-Q) assessment of her vaginal topography, as described by Bump et al. In addition each woman underwent pelvic floor fluoroscopy (PFF). Visceral sites were selected which corresponded clinically to the vaginal sites measured by the POP-Q. The most dependent portion of the bladder, small intestine, rectum and urethrovesical junction was measured. Twenty-five (28%) women had stage II prolapse, 34 (38%) had stage III prolapse, and 28 (32%) had stage IV prolapse. The remaining 2 women were symptomatic, with stage I prolapse. For the entire study population there was no correlation between the fluoroscopic position of the small bowel and/or rectum and any apical or posterior wall POP-Q site (C, Ap or Bp). There was no correlation with the fluoroscopic position of the UVJ at rest or with straining and the corresponding POP-Q site (Aa). The fluoroscopic position of the most dependent portion of the bladder correlated only modestly with the upper (Ba,ρ=0.51) and lower Aa,ρ=0.68) anterior vaginal wall POP-Q sites. In women without prior surgery (n=33) there was only modest correlation between the fluoroscopic position of the bladder and the corresponding POP-Q site (Aa,ρ=0.71). In this unoperated subpopulation there was no correlation with PFF and any other POP-Q site. In women who had undergone prior hysterectomy (n=25) or hysterectomy with anterior and/or posterior colporrhaphy (n=17), there was only a modest correlation of the most dependent portion of the bladder and the upper anterior vaginal wall site (Bb,ρ=0.67 andρ=0.55, respectively). It was concluded that vaginal topography does not reliably predict the position of the associated viscera on PFF in women with primary or recurrent pelvic organ prolapse.

Our objective was to use an alternative statistical approach to identify clinical and urodynamic predictors of prolonged catheterization following Burch colposuspension. Seventy women with genuine stress incontinence underwent Burch colposuspension with suprapubic catheter placement at Rush Presbyterian-St. Luke’s Medical Center from 1 July 1992 to 1 October 1993. Patient charts were retrospectively reviewed to extract pertinent variables from their history, examination and preoperative urodynamic evaluation. The day of suprapubic catheter removal was considered the endpoint ‘event’ for the purposes of survival analysis. This statistical model allowed us to identify preoperative clinical parameters important in determining the percentage of patients requiring catheters as a function of time. The need for defining prolonged postoperative catheterization was eliminated. Aging (P=0.01), increasing maximal urethral pressures (P=0.02) and menopausal status (P=0.02) were important in determining the percentage of patients requiring catheters as a function of time. Data from our preoperative voiding studies were not predictive of prolonged catheterization following Burch colposuspension.

We determine whether urinary diary values are stable over time among women without lower urinary tract symptoms.

To validate the clinically obtained bulbocavernosus reflex (BCR) by comparing it to the results of clitoroanal reflex (CAR) electrodiagnostic testing. Thirty three women with detrusor overactivity underwent clinical examination and electrodiagnostic testing including evaluation of CAR latency using a Nicolet Viking IIe electrodiagnostic instrument, stimulating the paraclitoral area on each side in turn with paired stimuli while recording anal sphincter compound muscle action potentials bilaterally using surface patch electrodes. The results of clinical and electrodiagnostic testing were compared. The BCR was clinically present on at least one side in 26 (79%) women, and thought to be clinically bilaterally absent in 7 (21%). Electrophysiologic testing revealed CARs to be at least unilaterally present in 30 (91%) patients. When the BCR was clinically present, a CAR was recorded in 92% of patients. Of the seven women with clinically absent BCR, just one had absent CARs. In this sample of women with detrusor overactivity, the clinical BCR did not have strong correlation with the electrically obtained reflex. Neurourol. Urodynam. 22:589–592, 2003. © 2003 Wiley-Liss, Inc.

Abstract:: The use of bone anchors as a superior fixation for suburethral slings is becoming popular. We present a case report of pubic osteomyelitis and granuloma after bone anchor placement. A 71-year-old woman underwent placement of a vaginal wall sling using pubic bone anchors placed through a suprapubic incision. Recurrent swelling of the mons pubis required re-exploration and removal of the anchors from an infected pubic bone. When symptoms persisted over the following 10 months, the patient underwent repeat surgery and excision of a pubic bone granuloma. The use of bone anchors in suburethral sling surgery is associated with possible increase in patient morbidity, and no benefit to the patient has been shown.

Urodynamic testing is often performed preoperatively for stress urinary incontinence. However, previous studies have not demonstrated improved surgical outcomes with such testing. No randomized controlled trials have addressed this issue.