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Purpose: With increasing telehealth technology, confirming the validity of non-office administration of questionnaires intended for office use only is important. We studied 3 validated questionnaires: the Urinary Distress Inventory 6-Short Form, the International Incontinence 7-Short Form, and a quality of life survey using a deception model., Materials and Methods: Following Institutional Review Board approval and power calculations, these 3 questionnaires were prospectively administered in women with and without incontinence by phone and then again in person about 2 weeks later. To avoid recall bias, participants were not informed of the study over the phone. After completing their office visit questionnaire scores, they were told about the study and invited to consent for comparison of their phone and in-person questionnaire scores. Non-English speakers and those with an active urinary tract infection, with impaired mental competency, or on a fluid diet were excluded., Results: From June to September 2021, 86 women, including 40 incontinent (30-85 years old) and 46 control (30-85 years old), with similar demographic parameters met all study criteria. Of the 14 questions studied, only 2, ie, Question 1 on the Urinary Distress Inventory 6-Short Form ( P = .033) and Question 7 on the International Incontinence 7-Short Form ( P = .036), showed rather minimal but statistically significant differences in scores. For incontinent women, only Question 7 on the International Incontinence 7-Short Form ( P = .012) showed a significant score difference., Conclusions: The 3 questionnaire scores were overall comparable when obtained over the phone or during office visits. Women with incontinence, who may otherwise be lost to follow-up or only reachable by telehealth calls, can benefit from the remote administration of these 3 questionnaires.

Purpose: We determined whether a custom computer program can improve the extraction and accuracy of key outcome measures from progress notes in an electronic medical record compared to a traditional data recording system for incontinence and prolapse repair procedures., Materials and Methods: Following institutional review board approval, progress notes were exported from the Epic electronic medical record system for outcome measure extraction by a custom computer program. The extracted data (D1) were compared against a manually maintained outcome measures database (D2). This work took place in 2 phases. During the first phase, volatile data such as questionnaires and standardized physical examination findings using the POP-Q (pelvic organ prolapse quantification) system were extracted from existing progress notes. The second phase used a progress note template incorporating key outcome measures to evaluate improvement in data accuracy and extraction rates., Results: Phase 1 compared 6,625 individual outcome measures from 316 patients in D2 to 3,534 outcome measures extracted from progress notes in D1, resulting in an extraction rate of 53.3%. A subset of 3,763 outcome measures from D1 was created by excluding data that did not exist in the extraction, yielding an accuracy rate of 93.9%. With the use of the template in phase 2, the extraction rate improved to 91.9% (273 of 297) and the accuracy rate improved to 100% (273 of 273)., Conclusions: In the field of incontinence and prolapse, the disciplined use of an electronic medical record template containing a preestablished set of key outcome measures can provide the ideal interface between required documentation and clinical research., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Aims: To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms., Methods: 655 women underwent standardized preoperative UDS that included perineal surface EMG prior to undergoing surgery for stress urinary incontinence. Pressure-flow studies were evaluated for abdominal straining and interrupted flow. Quantitative EMG values were extracted from 10 predetermined time-points and compared between fill and void. Qualitative EMG activity was assessed for the percent of time EMG was active during fill and void and for the average amplitude of EMG during fill compared to void. Postoperative voiding dysfunction was defined as surgical revision or catheterization more than 6 weeks after surgery. Fisher's exact test with a 5% two-sided significance level was used to assess differences in EMG activity and postoperative voiding dysfunction., Results: 321 UDS had interpretable EMG studies, of which 131 (41%) had EMG values at all 10 predetermined and annotated time-points. Quantitative and qualitative EMG signals during flow were usually greater than during fill. The prevalence of postoperative voiding dysfunction in subjects with higher preoperative EMG activity during void was not significantly different. Results were similar in the 42 subjects who had neither abdominal straining during void nor interrupted flow., Conclusions: Perineal surface patch EMG did not measure expected pelvic floor and urethral sphincter relaxation during voiding. Preoperative EMG did not predict patients at risk for postoperative voiding dysfunction., (Copyright © 2011 Wiley Periodicals, Inc.)

Purpose: We aimed to explore operational definitions of mixed urinary incontinence (MUI) for use in incontinence outcomes research for non-surgical patient populations., Methods: A secondary analysis of women with urge incontinence or urge predominant MUI enrolled in the Urinary Incontinence Treatment Network BE-DRI randomized clinical trial was performed. Subjects were characterized at baseline for urinary incontinence severity and incontinence subtype (stress or urge) using the Medical, Epidemiologic, and Social Aspects of Aging (MESA) questionnaire, the Urogenital Distress Inventory, and a 7-day urinary diary. Various different definitions of MUI, ranging from low to high threshold, were created using a combination of these baseline incontinence measures. Prevalence of MUI based on each definition was described and compared to treatment response. Logistic regression analysis was used to estimate the association between the study outcomes and the different definitions of MUI., Results: The 307 participants in the BE-DRI study had a mean age of 56.9 (± 13.9) years with a mean total MESA score of 21.7 (± 8.9) and a mean total UDI score of 120.5 (± 49.6). The proportion of women diagnosed with MUI varied significantly by definition ranging from 63.5% to 96.4%. Low threshold symptom-based definitions resulted in nearly universal diagnosis of MUI. No strict cut-off value for these baseline measures was identified to predict clinical outcomes., Conclusions: Current MUI definitions do not adequately categorize clinically relevant UI subgroups. For research purposes we believe it necessary to describe the severity of each incontinence subtype separately in subjects with MUI., (© 2010 Wiley-Liss, Inc.)

Objective: To develop an empirically derived definition of mixed urinary incontinence (MUI) for use in incontinence outcomes research., Methods: Participants in a randomized trial comparing the fascial sling and. Burch colposuspension were assessed using standardized measures including the Medical, Epidemiologic and Social Aspects of Aging (MESA), UI questionnaire, the Urogenital Distress Inventory (UDI), 3-day urinary diary and urodynamic studies (UDS). Participants were required to have stress incontinence with a MESA stress subscale score > MESA urge subscale score. Several definitions of MUI were considered. Logistic and linear regression analysis methods were used to predict clinical outcomes based on the different MUI definitions. Analyses were carried out using SAS (SAS Institute, Inc., Cary, NC, Version 9.1). Statistical significance was defined at P-value <0.05., Results: In 655 participants, the proportion of women with MUI varied from 8.3% to 93.3% depending on the MUI definition All definitions were associated with severity as measured by the frequency of incontinence episodes at baseline; however little of the variability was explained by any single definition. No strict cut-off value for these baseline measures was identified to predict clinical outcomes., Conclusions: These MUI definitions do not adequately categorize clinically relevant UI subgroups. For research reporting, MUI subcomponents of stress and urge UI should be described separately rather than as a single dimension., ((c) 2009 Wiley-Liss, Inc.)

Objectives: To investigate the relationship between physician-assessed quality-of-life (QOL) parameters obtained from patient interview and patient self-report of QOL by using the short form of the Urogenital Distress Inventory (UDI-6)., Methods: Female patients presenting for the first time at our clinic at two different academic institutions were consecutively evaluated. All patients were asked to fill out the UDI-6 while in the waiting area before their appointment. One additional global QOL question specific to the patient's overall urinary condition was included in the questionnaire. A physician who was unaware of the patient's responses then interviewed all patients. The physicians then filled out the UDI-6 on the basis of their impression of the patient's symptoms from the patient's responses during the medical interview. A statistician unaware of the patient's diagnosis and presenting symptoms compared the physician and patient symptom bother assessments., Results: Seventy-nine patients were analyzed. Statistical analysis with weighted kappas revealed poor concordance between the physician and patient responses. Overall, the physicians at both institutions underestimated the patient's degree of bother 25% to 37% of the time., Conclusions: Reports of outcomes after treatment of urinary incontinence should always include independent patient self-administered questionnaires. Because of interviewer bias, physician assessment of QOL tends to underestimate a patient's bother from urinary symptoms.

Objectives: To report a series of adverse outcomes of urethral sling procedures that used allograft fascia lata and to review the literature regarding the use of this material in genitourinary reconstruction., Methods: Five neurologically normal patients presented to our center between August 1999 and October 1999 with complaints of recurrent incontinence or voiding dysfunction after undergoing urethral sling procedures at outside institutions that used fascia lata allografts. All patients underwent a thorough evaluation, including history and physical examination, voiding cystourethrography, and urodynamic studies. Sections of fascia were removed for histology in 2 patients at the time of operation., Results: Three patients were diagnosed with de novo bladder outlet obstruction, 1 with recurrent urethral hypermobility, and 1 with intrinsic sphincteric deficiency. Histology of cadaveric fascia demonstrated collagen with almost complete absence of cellularity. There was no evidence of capillary or fibroblast ingrowth. All patients underwent reoperation and have had clinical improvement with short-term follow-up., Conclusions: Although distressing, the present series of adverse outcomes may simply reflect an overall increase in the number of sling procedures being performed nationally. Although decreased operative time and morbidity have been attributed to the use of fascia lata in urethral sling procedures, it is essential to ensure that long-term safety and efficacy will not be jeopardized before accepting it as a new standard of care.

T.V.T. is still presented as a minimally invasive operation, but this is not the case in all hands according to the various series reported at the recent EAU congress in Brussels. The indications are also still poorly defined and the long-term effects of a synthetic, suburethral tension tape remain uncertain.

Purpose: We determined the long-term efficacy and quality of life impact of the artificial urinary sphincter., Materials and Methods: We reviewed the medical records of 68 men who underwent artificial urinary sphincter placement for post-prostatectomy incontinence (64) or neurogenic disease (4) between March 1980 and March 1992 (mean followup 7.2 years). Quality of life was assessed in 52 patients who completed the incontinence impact questionnaire and the urogenital distress inventory., Results: At followup 54 men were socially continent (0 or 1 pad per day). Overall, pad score decreased significantly from 2.75 before to 0.97 after artificial urinary sphincter implantation (p < 0.001). The artificial urinary sphincter was permanently removed in 4 patients. Revisions for mechanical failure or urethral atrophy were required in 25% of the patients (mean 1.35 procedures per patient). The mechanical failure rate decreased significantly after 1987 due to device improvements (12.4 versus 44.4%, p < 0.01). Subjective improvement and overall satisfaction were rated as 4.1 and 3.9, respectively (scale 0 to 5). At followup the mean values of the incontinence impact questionnaire and urogenital distress inventory demonstrated the positive impact of the artificial urinary sphincter on quality of life., Conclusions: This long-term study documents the positive impact of the artificial urinary sphincter on patient quality of life with few mechanical failures since 1987.

Complete destruction of the urethra is one of the long-term complications of continuous bladder catheterization in women with advanced neurogenic bladder, resulting in a continuous urine leak around the catheter. This type of incontinence can be treated by closure of the bladder neck associated with suprapubic bladder drainage. Several approaches hve been proposed: abdominal, vaginal and mixed abdominal-vaginal. Each of these techniques is described, together with their results. Closure of the bladder neck decreases the nursing care, reduces the risk of perineal infectious and cutaneous complications and improves the patient's quality of life. Ileal urinary diversion is not always possible in these patients who often have a poor general status. Transvaginal closure of the bladder neck therefore constitutes one of the treatment options.

Background: It has been reported that transurethral resection of the prostate (TURP) after definitive radiation therapy for prostate cancer is associated with a significant risk of incontinence. The presumed reason for incontinence is external sphincter damage from TURP or pre-existing damage from either extension of prostate cancer or radiation therapy., Methods: We reviewed seven recent cases of TURP for bladder outlet obstruction in patients who had undergone radiation therapy for clinical stage T(3-4)M(0)N(0) adenocarcinoma of the prostate. All seven men progressed to either chronic retention or debilitating obstructive symptoms with weak peak flows from 3.4 to 5.1 cc/s (mean 4 cc/s). Each of them subsequently underwent a limited TURP., Results: Voiding symptoms were reduced in all patients and peak flows were improved to 6.3 to 20 cc/s (mean 14.8 cc/s) with mean follow-up 35 m. No patient developed stress urinary incontinence postoperatively., Conclusion: These results suggest that TURP can be performed successfully after radiation therapy with minimal risk of stress incontinence.

Purpose: We examined urodynamic findings and treatment outcomes in a large population of men with post-prostatectomy incontinence., Materials and Methods: A total of 215 men was referred for evaluation and treatment of significant post-prostatectomy incontinence. Urodynamic evaluation consisted of provocation multichannel medium fill cystometry with vigorous attempts to demonstrate incontinence. Treatment was directed by the results of the urodynamic study. A pad scoring system was used to gauge the severity of incontinence before and after treatment., Results: Based on the results of urodynamic studies 40% of the men had genuine stress incontinence alone and approximately 60% had a major component of bladder dysfunction contributing to incontinence. Treatment results of 135 men demonstrated a significant decrease in pad score (p<0.001) for those treated with anticholinergics, those undergoing artificial sphincter insertion and those treated pharmacologically before sphincter placement., Conclusions: In our large series most men with prostatectomy incontinence did not have genuine stress incontinence alone. Thus, urodynamic studies are critical, not only to define cause of incontinence but to direct effective therapy.

Purpose: We attempt to determine the long-term success rate of the modified Pereyra bladder neck suspension, identify preoperative factors predictive of long-term outcome, and investigate the influence of method and length of followup on reported continence status after modified Pereyra bladder neck suspension., Materials and Methods: The charts of 177 patients who underwent modified Pereyra bladder neck suspension at our institution more than 5 years ago were reviewed. An attempt was made to contact all patients either by mail or telephone to complete a patient survey questionnaire., Results: Of 177 patients 125 (71%) completed the patient survey with a mean followup of 9.8 years. At survey followup 20% of the patients reported no incontinence of any type and 51% reported stress urinary incontinence with or without urge incontinence. Of the patients 71% reported significant improvement in the incontinence and 73% were satisfied with the results of the procedure. No accurate preoperative predictors of long-term outcome were identified. The method and length of followup had significant impact on reported continence status after modified Pereyra bladder neck suspension., Conclusions: This long-term study using outcomes analysis reveals a high rate of recurrent stress incontinence after modified Pereyra bladder neck suspension. However, most patients maintain significant subjective improvement and remain satisfied with the results of the operation.

The 2 major urological objectives in treating the child with myelomeningocele are to preserve renal function and achieve continence. We report our success in managing these cases with nonsurgical therapy. From 1981 to 1991, 45 patients with myelomeningocele 1 to 15 years old were evaluated urodynamically before and after initiating nonsurgical treatment. Pretreatment urodynamics identified 2 groups. Group 1 consisted of 31 patients with leak point pressure of 40 cm. water or more of whom 10 had grades II to V/V vesicoureteral reflux and 4 had moderate or severe hydronephrosis. Group 2 consisted of 14 incontinent patients with leak point pressure of less than 40 cm. water and no reflux or hydronephrosis. Both groups were treated with intermittent catheterization, anticholinergic medications and fluid restriction. Within a mean followup of 5.5 years nonsurgical intervention resulted in lowering maximum detrusor pressure at maximum cystometric capacity to less than 40 cm. water in 22 of 31 group 1 patients (71%), and in resolving vesicoureteral reflux in 7 of 10 (70%) and hydronephrosis in 3 of 4 (75%) group 1 patients. Of 4 patients in group 1 with persistent high grade vesicoureteral reflux or severe hydronephrosis 3 (10%) required augmentation cystoplasty. With nonsurgical management 18 patients (40%) were completely continent, 18 (40%) required 2 or less pads daily and 9 (20%) required more than 2 pads daily. Nonsurgical management alone was effective in preserving the upper urinary tract in 90% of patients and it provided satisfactory continence in 80%. Surgical management should be reserved for the minority of patients whose upper tract changes do not resolve and for those whose degree of continence is not satisfactory with nonsurgical management.

To evaluate the efficacy of intravesical oxybutynin chloride, 42 patients who were incontinent secondary to uninhibited detrusor contractions and had failed oral anticholinergic therapy were begun on intravesical oxybutynin chloride. Indications for intravesical therapy were detrusor hyperreflexia (N = 20), detrusor instability (N = 19), and bowel/bladder overactivity after augmentation cystoplasty (N = 3). A 5-mg tablet dissolved in 30 cc of sterile water was instilled into the bladder two to three times daily via clean self intermittent catheterization. With a mean follow-up of 18.4 months, no patient reported side effects as a result of the intravesical therapy. Nine patients (21%) dropped out of the study due to inability to tolerate the catheterization or difficulty retaining the solution in the bladder. Eighteen of the 33 patients (55%) who followed the protocol experienced elimination or significant improvement of their incontinence. The results of the current study confirm the safety and usefulness of intravesical oxybutynin in treating uninhibited detrusor contractions in a difficult patient population.

Numerous techniques for replacing the urethra have been previously described, but attempts to provide continence have rarely been satisfactory. Urethral replacement using ileum with an ileal intussuscepted valve for continence has been successfully performed in ten female dogs. Eight of them were available for a 1 to 6-month followup. This neo-urethra has provided good continence and can be easily catheterized. The clinical usefulness of this technique in the treatment of total urethral loss in humans needs to be further explored.

The recognition of spinal dysraphism as a potential cause of voiding dysfunction is of the utmost importance if appropriate treatment and followup are to be initiated. We present 2 women with prolonged voiding dysfunction who had spinal dysraphism, intradural lipoma and related urodynamic abnormalities. The importance of initial symptom recognition, physical examination, urodynamic evaluation, appropriate treatment and periodic re-examination to detect progressive neurological impairment is emphasized.

A woman presented with urinary incontinence after traumatic delivery owing to a single right ectopic ureter. The management of this rare condition in adulthood is reviewed.

Objective: Tamoxifen complicates management of conditions such as urinary tract infections (UTIs), urinary incontinence (UI), and/or pelvic organ prolapse (POP) that traditionally benefit from hormonal intake; thus, we reviewed our experience in managing these hormonally deprived women. Materials and Methods: After IRB approval, electronic medical records from women with current use or history of tamoxifen use and referred to a tertiary care center with female pelvic medicine and reconstructive surgery expertise for UTI, UI, and/or POP were reviewed. Results: From 2015 to 2020, 32 women treated with tamoxifen 10?40?mg for a median of 4 years were referred for UTIs (9), UI (10), symptomatic POP (8), or for a combination of these (5). Participants with UTI treated with antibiotics, prophylactic supplements, and/or electrofulguration had satisfactory response at median follow-up of 1 year (interquartile range [IQR]: 0.5?1). Ten of 15 women with UI chose intervention, with no self-reported UI recurrence at median follow-up of 2.5 years (IQR: 1?3). All but one participant with POP underwent vaginal or open/robotic mesh repairs, with satisfactory outcomes at median follow-up of 3 years (IQR: 2?7). Conclusions: The management of UTIs, UI, and POP in women on tamoxifen or unable to benefit from hormonal intake is challenging, but traditional interventions can be considered with satisfactory results.

BackgroundFemale urinary microbiota are associated with urgency urinary incontinence and response to medication. The urinary microbiota of women with stress urinary incontinence has not been described.ObjectiveWe sought to study the cross-sectional relationships between urinary microbiota features and demographic and clinical characteristics of women undergoing stress urinary incontinence surgery.Study designPreoperative urine specimens were collected from women without urinary tract infection and were available from 197 women (174 voided, 23 catheterized) enrolled in a multicenter prospective randomized trial, the Value of Urodynamic Evaluation study. Demographic and clinical variables were obtained including stress and urgency urinary incontinence symptoms, menopausal status, and hormone use. The bacterial composition of the urine was qualitatively assessed by sequencing the bacterial 16S ribosomal RNA gene. Phylogenetic relatedness and microbial alpha diversity were compared to demographics and symptoms using generalized estimating equation models.ResultsThe majority of 197 urine samples (86%) had detectable bacterial DNA. Bacterial diversity was significantly associated with higher body mass index (P = .02); increased Medical, Epidemiologic, and Social Aspects of Aging urge index score (P = .04); and hormonal status (P < .001). No associations were detected with stress urinary incontinence symptoms. Increased diversity was also associated with a concomitant lower frequency of Lactobacillus in hormone-negative women.ConclusionWomen undergoing stress urinary incontinence surgery have detectable urinary microbiota. This cross-sectional analysis revealed that increased diversity of the microbiota was associated with urgency urinary incontinence symptoms, hormonal status, and body mass index. In contrast, the female urinary microbiota were not associated with stress urinary incontinence symptoms.

AimsTo examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow-up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures.MethodsWe performed a secondary analysis of the SISTER and ToMUS trials of participants who underwent primary stress urinary incontinence (SUI) treatment (without prior SUI surgery or concomitant procedures). Using Kaplan-Meier analysis, retreatment-free survival rates by initial surgical procedure were compared. Mean MESA (Medical Epidemiologic and Social Aspects of Aging) stress index was also compared between those retreated for rSUI compared to those not retreated.ResultsHalf of the women in the SISTEr trial met inclusion criteria for this analysis (329/655, 174 Burch and 155 fascial sling), as did 444/597 (74%) of subjects in ToMUS (221 transobturator midurethral sling (TMUS), and 223 retropubic midurethral sling (RMUS). Types of surgical retreatment included autologous fascial sling (19), synthetic sling (1), and bulking agent (18). Five-year retreatment free survival rates (and standard errors) were 87% (3%), 96% (2%), 97% (1%), and 99% (0.7%) for Burch, autologous fascial sling, TMUS, and RMUS groups respectively (P

ABSTRACT Objective To evaluate the subjective and objective outcomes of Macroplastique® (MPQ) in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD). Materials and Methods Following Institutional Review Board (IRB) approval, charts of non-neurogenic women with SUI secondary to ISD who underwent MPQ injection and had 6 months minimum follow-up were reviewed from a prospectively maintained database. Patients were divided into 3 groups: Naïve (Group I), Prior Anti-Incontinence Surgery (Group II), and combined Prior Bulking Agent and Anti-Incontinence Surgery (Group III). Data collected included SUI self-report, Urogenital Distress Inventory (UDI-6) Question 3, and VAS Quality of Life (QoL) Questionnaire scores at baseline and in follow-up. Three-dimensional ultrasound (3DUS) evaluated volume/configuration of MPQ. Success was defined after the last MPQ injection as a UDI-6 Question 3 score of 0 (dry) or 1, and no reoperation for SUI. Results From 2011-2017, 106 of 142 women met study criteria. At a median follow-up of 20 months (mean=26 months; range: 6-71), success rate was 41% for Group I, 40% for Group II, and 65% for Group III (p = 0.22). QoL scores were significantly improved over baseline in all groups. There was no significant difference in clinical outcome between the asymmetrical and symmetrical group on 3DUS. The completely dry rate was highest in Group III at 29%, compared to 4% for Group I and 15% for Group II (p = 0.05). Conclusion Macroplastique® improved subjective and objective outcome measures for SUI secondary to ISD as both a primary and secondary treatment option in women.

Abstract The University of Texas Southwestern Aging and Geriatrics Education's Urinary Incontinence (UI) resource is a comprehensive core curriculum on UI in the elderly which can be incorporated into existing undergraduate medical education courses at both the preclinical and clinical levels. After completion of the program, medical students will have been trained in the basic evaluation and treatment of UI in the elderly. The program and learning platforms are created in sequential modules so that components can be utilized as a clinical relevance link to basic science courses (e.g., anatomy, physiology, pharmacology) and for different levels of learners (e.g., third- and fourth-year students), and is required during a 2-week geriatrics rotation for all internal medicine and general psychiatry interns. It is also utilized in the family medicine clerkship. The resource utilizes a narrated, self-paced, interactive medium using high quality visual renditions. Each section includes a mini-quiz and a section on clinical cases for review is also provided.

Background: Transvaginal synthetic mesh and mesh sling placement for the treatment of stress urinary incontinence and pelvic organ prolapse can yield adverse outcomes, including pelvic pain and dyspareunia, that persist after implant removal. Objective: To describe the clinical presentations of women with residual pelvic pain or dyspareunia after synthetic vaginal mesh and/or mesh sling removal and the effectiveness of treatments using a multidisciplinary approach. Study Design: After receiving institutional review board approval, a neutral reviewer retrospectively analyzed a prospectively maintained database of women who experienced pelvic pain/dyspareunia after implant removal and were referred to a physiatrist specializing in pelvic rehabilitation medicine. Methods: Included were women who were evaluated by a physiatrist following implant removal. Excluded were women seen for symptoms other than pain or pending subsequent resection procedures. Primary outcome was pelvic pain score assessed by a Numeric Pain Rating Scale obtained at each physiatrist and physical therapy visit. Success was defined as a 50% or greater reduction in pain score. All patients underwent pelvic floor physical therapy, with medications and injections as necessary. Results: From 2010 to 2015, 37 women were included in the analysis. Of these, 4 had isolated dyspareunia and the remaining 33 had general pelvic pain. Eight of these 33 (24%) achieved a successful outcome. When evaluating compliance, half (14 of 28) of the compliant patients achieved improvement in pain scores. Compliant patients treated for isolated dyspareunia experienced more than 80% improvement. Conclusion: Pelvic pain-focused interventions are a worthwhile recommendation in women with refractory pelvic pain after vaginal mesh or mesh sling removal. [ABSTRACT FROM AUTHOR]

Purpose We sought to determine the types and frequency of presenting symptoms in women undergoing suburethral mid urethral sling removal to improve outcome reporting after removal. Materials and Methods Following institutional review board approval women who underwent suburethral mid urethral sling removal of 1 mid urethral sling were evaluated for their presenting symptoms and correlation with the UDI-6 (Urogenital Distress Inventory-Short Form) questionnaire. Demographic data were recorded. Patient reported presenting symptoms were categorized into 5 domains, including storage symptoms, voiding symptoms, pain, recurrent urinary tract infections or urinary incontinence. The UDI-6 was reviewed preoperatively and 6 to 12 months postoperatively. We also calculated an ideal outcome, defined as resolution of incontinence, pain, resumption of sexual activity and no need for further anti-incontinence procedures. Results A total of 230 women from 2006 to 2017 met study inclusion criteria, including 116 who completed the UDI-6 postoperatively. Of the women 80% had 3 or more presenting symptoms with pain as the most common symptom. The most common combination of symptoms was all 5 domains, which was noted in 46 of the 230 women (20%). An increasing number of symptoms correlated with the total preoperative UDI-6 score. Symptom domains were associated with the corresponding UDI-6 subdomain questions. Domains not covered by the UDI-6, ie recurrent urinary tract infections and dyspareunia, accounted for 27% of reported symptoms. Due to limited data on sexual activity an ideal outcome was reached in 10% of patients but this rate was 40% after sexual activity information was excluded. Conclusions In this series the presenting symptoms were manifold in women undergoing suburethral mid urethral sling removal. The UDI-6 questionnaire correlated with many of these complaints. It may be used in outcome analysis in conjunction with self-reported symptoms. [ABSTRACT FROM AUTHOR]

Purpose We evaluated urinary incontinence outcomes following synthetic suburethral sling removal in women. Materials and Methods We reviewed a prospectively maintained database of 360 consecutive women who underwent transvaginal suburethral sling removal from 2005 to 2015. We excluded patients with neurogenic bladder, nonsynthetic or multiple slings, prior mesh for prolapse, concomitant surgery during sling excision, urethral erosion or fistula, postoperative retention or less than 6-month followup. Demographics, sling type, indications for removal, time to removal and patient reported outcomes were recorded. Outcomes were stratified by incontinence type, including stress predominant, urge predominant and mixed urinary incontinence. Subsequent management was evaluated, including observation, minimally invasive outpatient interventions (bulking agents, neuromodulation or onabotulinumtoxinA) or more invasive surgery (autologous fascial sling or bladder suspension). No patients elected to receive a subsequent synthetic sling. Success was defined by responses to UDI-6 (Urogenital Distress Inventory) questions 2 and 3, self-reported satisfaction with continence at the last visit and no further intervention. Results Of the 99 patients who met inclusion criteria 27 denied any subjective leakage after suburethral sling removal alone while 72 experienced some degree of incontinence after removal. Stress predominant urinary incontinence occurred in 26 patients, which was persistent in 7 and de novo in 19, urge predominant incontinence was noted in 14, which was persistent in 6 and de novo in 8, and mixed urinary incontinence occurred in 32, which was persistent in 13 and de novo in 19. Mean followup was 23 months (range 6 to 114). The success rate following a single minimally invasive intervention after suburethral sling removal was 81%, 86% and 75% in patients with stress predominant, urge predominant and mixed urinary incontinence, respectively. Conclusions Patients who undergo suburethral sling removal may show urinary control, or de novo or persistent incontinence with a higher predilection for stress predominant or mixed urinary incontinence. However, after a single minimally invasive intervention following suburethral sling removal the success rate reached 75% to 86%. [ABSTRACT FROM AUTHOR]

Purpose We report our experience with anterior vaginal wall suspension for moderate anterior vaginal compartment prolapse and uterine descent less than stage 2. Materials and Methods Data on patients who underwent anterior vaginal wall suspension with uterine preservation by hysteropexy and had a 1-year minimum followup were extracted from a long-term, prospective, institutional review board approved, surgical prolapse database. The indication for uterine preservation was uterine descent not beyond the distal third of the vagina with traction with the patient under anesthesia, and negative Pap smear and pelvic ultrasound preoperatively. The upper suture of the anterior vaginal wall suspension secures the cardinal ligament complex, allowing for uterine suspension once the suture is transferred suprapubically. Failure was defined as prolapse recurrence greater than stage 2 on physical examination or the need for reoperation for uterine descent. Outcome measures at serial intervals included validated questionnaires, physical examination, standing voiding cystourethrogram at 6 months postoperatively and complications. Results From May 1996 to March 2012, 52 of 739 patients met inclusion criteria. Mean followup was 55 months (range 12 to 175, median 44). Mean patient age was 62 years (range 38 to 81), mean body mass index was 26.7 kg/m 2 (range 18.3 to 49.4) and mean parity was 2.7. There were no transfusions or intraoperative complications. Overall 7 (13%) patients underwent subsequent hysterectomy for uterine prolapse recurrence at 7 months to 6 years postoperatively. Conclusions The anterior vaginal wall suspension procedure offers a simple, mesh-free surgical alternative with acceptable long-term followup in patients with moderate uterine prolapse who wish for uterine preservation. However, patients should be appropriately counseled about the low risk of subsequent hysterectomy. [ABSTRACT FROM AUTHOR]

Purpose We investigated age related changes in urodynamic parameters in 2 large cohorts of women planning stress urinary incontinence surgery. Materials and Methods Using a standardized protocol we obtained urodynamic parameters for participants in SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) and TOMUS (Trial of Mid-Urethral Slings) undergoing baseline noninvasive flow followed by filling cystometrogram and pressure flow study. The bladder contractility index (defined as detrusor pressure at maximum flow + 5 x maximum flow) and detrusor hypocontractility (defined as detrusor pressure at maximum flow less than 10 cm H2O) were also characterized. Patients excluded from analysis had undergone prior stress urinary incontinence surgery or had prolapse stage greater than II. Propensity score analysis controlled for the potential bias of combining participants from 2 clinical trials. Linear and logistic regression analysis adjusting for propensity score quintile was done to assess the association of age and an age cutoff (less than 65 vs 65 or greater years) with urodynamic parameters. Results A total of 945 women (468 in SISTEr and 477 in TOMUS) were included in analysis. Mean age was 50 years in SISTEr (range 27 to 75) and 51 years (range 24 to 82) in TOMUS. Noninvasive maximum urinary flow decreased significantly with age (26.2 vs 22 ml per second, p = 0.002). Noninvasive flow voiding time increased 2.7 seconds for each 10-year age increment and detrusor pressure at maximum flow decreased 2.1 cm H2O for each 10-year increase in age (each p = 0.003). Hypocontractility was more likely in women 65 years old or older (OR 2.89, 95% CI 1.59, 5.27). The bladder contractility index was inversely related to age, decreasing a mean ± SD of 7.68 ± 1.96 cm H2O for each 10-year age increase (p <0.001). Conclusions In these 2 cohorts the observed changes in voiding parameters suggest that detrusor contractility and efficiency decrease with age. [ABSTRACT FROM AUTHOR]

This review aims to provide an overview of complications associated with surgical treatment for urinary incontinence and pelvic organ prolapse relating to synthetic mesh, as well as review the new International Urogynecologic Association (IUGA)/ International Continence Society (ICS) classification of complications for insertion of prosthesis or grafts in female pelvic floor surgery and the recent Food and Drug Administration (FDA) notifications. [ABSTRACT FROM AUTHOR]

Purpose: We examined preoperative and postoperative patient related factors associated with continence status up to 7 years after surgery for stress urinary incontinence. Materials and Methods: Women randomized to Burch colposuspension or fascial sling surgery and assessed for the primary outcome of urinary continence 2 years after surgery were eligible to enroll in a prospective observational study. Survival analysis was used to investigate baseline and postoperative factors in the subsequent risk of stress urinary incontinence, defined as self-report of stress urinary incontinence symptoms, incontinence episodes on a 3-day diary or surgical re-treatment. Results: Of the women who participated in the randomized trial 74% (482 of 655) were enrolled in the followup study. Urinary continence rates decreased during a period of 2 to 7 years postoperatively from 42% to 13% in the Burch group and from 52% to 27% in the sling group, respectively. Among the baseline factors included in the first multivariable model age (p = 0.03), prior stress urinary incontinence surgery (p = 0.02), menopausal status (0.005), urge index (0.006), assigned surgery (p = 0.01) and recruiting site (p = 0.02) were independently associated with increased risk of incontinence. In the final multivariable model including baseline and postoperative factors, Burch surgery (p = 0.01), baseline variables of prior urinary incontinence surgery (p = 0.04), menopausal status (p = 0.03) and postoperative urge index (p <0.001) were each significantly associated with a greater risk of recurrent urinary incontinence. Conclusions: Preoperative and postoperative urgency incontinence symptoms, Burch urethropexy, prior stress urinary incontinence surgery and menopausal status were negatively associated with long-term continence rates. More effective treatment of urgency urinary incontinence in patients who undergo stress urinary incontinence surgery may improve long-term overall continence status. [Copyright &y& Elsevier]

Purpose: We characterized continence, satisfaction and adverse events in women at least 5 years after Burch urethropexy or fascial sling with longitudinal followup of randomized clinical trial participants. Materials and Methods: Of 655 women who participated in a randomized surgical trial comparing the efficacy of the Burch and sling treatments 482 (73.6%) enrolled in this long-term observational study. Urinary continence status was assessed yearly for a minimum of 5 years postoperatively. Continence was defined as no urinary leakage on a 3-day voiding diary, and no self-reported stress incontinence symptoms and no stress incontinence surgical re-treatment. Results: Incontinent participants were more likely to enroll in the followup study than continent patients (85.5% vs 52.2%) regardless of surgical group (p <0.0001). Overall the continence rates were lower in the Burch urethropexy group than in the fascial sling group (p = 0.002). The continence rates at 5 years were 24.1% (95% CI 18.5 to 29.7) vs 30.8% (95% CI 24.7 to 36.9), respectively. Satisfaction at 5 years was related to continence status and was higher in women undergoing sling surgery (83% vs 73%, p = 0.04). Satisfaction decreased with time (p = 0.001) and remained higher in the sling group (p = 0.03). The 2 groups had similar adverse event rates (Burch 10% vs sling 9%) and similar numbers of participants with adverse events (Burch 23 vs sling 22). Conclusions: Continence rates in both groups decreased substantially during 5 years, yet most women reported satisfaction with their continence status. Satisfaction was higher in continent women and in those who underwent fascial sling surgery, despite the voiding dysfunction associated with this procedure. [ABSTRACT FROM AUTHOR]

Purpose: We determined the rate of patients lost to followup in level I/II evidence-based studies of surgical management of stress urinary incontinence in women. Materials and Methods: Randomized clinical trials (level I) or nonrandomized but prospective studies (level II) related to surgical treatment of stress urinary incontinence in women from January 1995 to November 2009 were searched on PubMed®. Data reviewed included study type, number of participating centers or hospitals, sample size calculation, surgical techniques, power calculation, estimated dropout rate, followup duration, and rate of and reasons for loss to followup. Results: A total of 47 randomized clinical trials and 24 nonrandomized prospective studies, representing a total of 11,007 women, met study inclusion criteria. Of the articles 33 provided details on sample size calculation and 16 explained the lost to followup rate after contacting patients lost to followup by mail or telephone. The incidence of patients lost to followup was 8.1% (587 of 7,213) at 12 months or less in 58 articles, 28% (813 of 2,890) at 24 months in 13, 36% (248 of 694) at 36 months in 5, 33% (233 of 708) at 36 to 60 months in 5 and 32.4% (722 of 2,227) at 60 months or greater in 10. A total of 11 articles reported no missing data due to small sample size or short followup. Only 7 articles defined cases lost to followup as treatment failures and reported outcomes accordingly. Conclusions: In this contemporary literature review we found an important attrition rate of followup with time that directly affects the strength of the conclusions on the remaining patient population. [ABSTRACT FROM AUTHOR]

Purpose: We retrospectively compared preoperative characteristics in patients with new onset lower urinary tract symptoms after receiving a mid urethral sling who did (group 1) and did not (group 2) have radiographically confirmed urethral distortion during voiding. Materials and Methods: After receiving institutional review board approval we reviewed the charts of patients who underwent mid urethral sling excision for new onset lower urinary tract symptoms between January 2003 and July 2009. We collected demographic and questionnaire data, including the Urogenital Distress Inventory, Incontinence Impact Questionnaire and visual analog scale (score 0 to 10) for quality of life, and preoperative urodynamics data, including maximum flow, detrusor pressure at maximum flow and post-void residual urine. Lateral voiding cystourethrogram was done with the patient standing. Results: Of 87 operable patients 23 were excluded from analysis due to lack of a voiding cystourethrogram (16) or of the voiding phase on voiding cystourethrogram (7). Groups 1 and 2 consisted of 51 and 13 patients, respectively. Age, time to sling excision, and Urogenital Distress Inventory, Incontinence Impact Questionnaire and quality of life scores were not significantly different between the groups. Preoperative urodynamic parameters in 37 group 1 and 7 group 2 patients revealed a mean detrusor pressure at maximum flow of 31.1 and 22.2 cm H2O, respectively (p = 0.25). Mean preoperative maximum flow was 13.4 and 15.4 ml per second (p = 0.59), and median post-void residual urine was 45.5 and 8.3, ml respectively (p = 0.16). Conclusions: Despite similar baseline symptoms and uroflow characteristics patients with urethral distortion had 50% higher detrusor pressure and greater post-void residual urine than those without urethral distortion. Flow rate alone may be insufficient to predict the impact of the mid urethral sling on bladder function in patients with new onset lower urinary tract symptoms. [Copyright &y& Elsevier]

Purpose: We evaluated the result of periurethral collagen injection in incontinent patients after prior urethral surgery. Materials and Methods: We reviewed the charts of patients who underwent periurethral collagen injection between January 2000 and December 2006 for persistent stress urinary incontinence after a failed suspension procedure or urethral repair. Preoperative assessment included the validated Urogenital Distress Inventory-6 symptom questionnaire, a single global quality of life score, history and physical examination, cystogram while standing and multichannel urodynamics. All patients had a well supported urethra and intrinsic sphincteric deficiency. Outcome measures included questionnaires and 3-dimensional urethral ultrasound at 6 weeks, 6 to 12 months and yearly thereafter. In patients who were still symptomatic after the first injection a repeat injection was considered when there was asymmetrical or low collagen volume on ultrasound, and another therapy was considered when ultrasound findings were adequate. Results: In 31 consecutive patients Urogenital Distress Inventory-6 question 3 and quality of life scores decreased after collagen injection (mean volume 5.5 cc). Baseline postoperative collagen volume on ultrasound was 2.6 cc (range 0.8 of 4.8). Of the patients 93% considered themselves clinically improved or cured, 17 of 31 required only 1 injection with a symmetrical configuration in 83%, while 8 received 1 or 2 more injections because of an asymmetrical configuration (75%) and/or low volume. Despite a mean collagen volume of 3.2 cc (range 2 to 4.3) 6 women with persistent stress urinary incontinence underwent a pubovaginal sling procedure. Eight of 25 patients requiring only collagen had stable collagen volume for 2 years without repeat injection. Conclusions: Collagen injection is a viable option with satisfactory results in this complex population. [Copyright &y& Elsevier]

Purpose: We identified baseline demographic and clinical factors associated with treatment failure after surgical treatment of stress urinary incontinence. Materials and Methods: Data were obtained from 655 women randomized to Burch colposuspension or autologous rectus sling. Of those, 543 (83%) had stress failure status assessed at 24 months (269 Burch, 274 sling). Stress failure (261) was defined as self-report of stress urinary incontinence by the Medical, Epidemiological, and Social Aspects of Aging questionnaire, positive stress test or re-treatment for stress urinary incontinence. Nonstress failure (66) was defined as positive 24-hour pad test (more than 15 ml) or any incontinent episodes by 3-day voiding diary with none of the 3 criteria for stress failure. Subjects not meeting any failure criteria were considered a treatment success (185). Adjusting for surgical treatment group and clinical site, logistic regression models were developed to predict the probability of treatment failure. Results: Severity of urge incontinence symptoms (p = 0.041), prolapse stage (p = 0.013), and being postmenopausal without hormone therapy (p = 0.023) were significant predictors for stress failure. Odds of nonstress failure quadrupled for every 10-point increase in Medical, Epidemiological, and Social Aspects of Aging questionnaire urge score (OR 3.93 CI 1.45, 10.65) and decreased more than 2 times for every 10-point increase in stress score (OR 0.36, CI 0.16, 0.84). The associations of risk factors and failure remained similar regardless of surgical group. Conclusions: Two years after surgery, risk factors for stress failure are similar after Burch and sling procedures and include greater baseline urge incontinence symptoms, more advanced prolapse, and menopausal not on hormone replacement therapy. Higher urge scores predicted failure by nonstress specific outcomes. [Copyright &y& Elsevier]

Purpose: We compared 2 measures of urethral hypermobility, the Q-tip test and voiding cystourethrogram, preoperatively in women recruited in 1 center participating in a multicenter randomized clinical trial comparing Burch colposuspension with autologous rectus fascia sling. Materials and Methods: Following institutional review board approval, women with stress urinary incontinence and pelvic organ prolapse stage 2 or less underwent a standardized standing voiding cystourethrogram and a Q-tip test at a 45 degree angle reclining position preoperatively. Urethral angle at rest and straining were measured with a radiological ruler (voiding cystourethrogram) or goniometer (Q-tip) by 2 different investigators blinded to each other findings. Results: In 43 patients the mean urethral angle at rest and UAS were 20 degrees ± 12 and 51 degrees ± 20, by voiding cystourethrogram compared to 16 degrees ± 9 and 58 degrees ± 10 by Q-tip test, respectively. The mean angle difference (urethral angle with straining minus urethral angle at rest) was greater for the Q-tip test (42 degrees ± 9) than that for the voiding cystourethrogram test (32 degrees ± 17; p <0.05). Fewer patients (14% by Q-tip, 28% by voiding cystourethrogram) had urethral hypermobility using the definition of urethral angle at rest greater than 30, while almost all patients (91% by voiding cystourethrogram, 100% by Q-tip) had urethral hypermobility using the definition of urethral angle with straining greater than 30. However, using the definition of urethral angle with straining minus urethral angle at rest greater than 30, only 58% of patients had urethral hypermobility by voiding cystourethrogram compared to 98% by Q-tip. Conclusions: The voiding cystourethrogram and the Q-tip test measure urethral hypermobility differently. This may affect which patients are classified as having urethral hypermobility, and the choice of anti-incontinence surgery. [Copyright &y& Elsevier]

Purpose: As part of a continuous quality control effort to measure the interrater reliability of urodynamic studies performed at multiple centers, we compared agreement levels for urodynamic studies between central and local physician reviewers. We report interrater reliability findings for the filling cystometrogram. Materials and Methods: Following a satisfactory interrater reliability study among 4 central physician reviewers in 33 tracings 36 urodynamic study tracings from 9 Urinary Incontinence Treatment Network continence treatment centers and 13 Urinary Incontinence Treatment Network certified urodynamic study testers were randomly selected for review. These tracings were originally interpreted by 11 local physician reviewers using standardized Urinary Incontinence Treatment Network interpretation guidelines. Each of the 4 central physician reviewers reviewed 9 randomly assigned tracings and none reviewed tracings from his or her center. Local and central physician reviewers were instructed to categorize values as invalid if specified technical quality assurance standards were not met or the signal pattern suggested implausible values because of technical deficiencies. An intraclass correlation coefficient was calculated for continuous (numerical) variables and a κ statistic was calculated for qualitative values with acceptable agreement defined a priori as an intraclass correlation coefficient of greater than 0.6. Results: Filling cystometrogram baseline pressure, Valsalva leak point pressure, and volume and pressure measurements at maximum cystometric capacity had excellent intraclass correlation coefficients of 0.74 to 0.99. There were no significant differences between local and central physician reviewer means, indicating excellent agreement. Conclusions: With proper quality control measures in place and a set of standardized interpretive guidelines excellent interrater reliability between local and central physician reviewer can be achieved for numerical cystometrogram variables. [Copyright &y& Elsevier]

Perineal and pelvic floor muscles play an important role in continence by providing mechanical support to pelvic organs. It is also known that the pubococcygeus muscle (PcM) contracts in the storage phase and is inactive during voiding, while the bulbospongiosus muscle (BsM) is active during the voiding phase. Recent evidence suggested an additional role of these muscles in supporting urethral closure in rabbits. However, the individual role of perineal and pelvic muscles as urethral sphincters is not well-defined. Here we evaluated the individual, sequential and synergistic roles of the PcM and BsM in assisting urethral closure and defined the optimal electrical stimulation parameters that can effectively contract these muscles and increase the urethral pressure (Pura) in young nulliparous animals (n = 11). Unilateral stimulation of either the BsM or PcM at 40 Hz induced modest increases in average Pura (0.23 ± 0.10 and 0.07 ± 0.04 mmHg, respectively). Investigation on the changes in Pura evoked by stimulation frequencies between 5 and 60 Hz show that sequential contralateral PcM-BsM activation at 40 Hz induced a 2-fold average Pura increase (0.23 ± 0.07 mmHg) compared to that evoked by PcM stimulation. Simultaneous activation of PcM and BsM at 40 Hz also showed an increased average Pura (0.26 ± 0.04 mmHg), with a 2-fold increase in average Pura observed during the unilateral sequential PcM-BsM stimulation at 40 Hz (0.69 ± 0.2 mmHg). Finally, stimulation at 40 Hz of the bulbospongiosus nerve (BsN) induced an approximate 4-fold increase in average Pura (0.87 ± 0.44 mmHg; p < 0.04) compared to that elicited by BsM stimulation, confirming that direct nerve stimulation is more effective. Together, this study shows that in the female rabbit, both perineal and pelvic muscles support of the urethral function during continence, and that unilateral stimulation of the BsN at 40–60 Hz is sufficient to achieve maximal secondary sphincter activity. The results also support the potential clinical value of neuromodulation of pelvic and perineal nerves as bioelectronic therapy for stress urinary incontinence.

This review aims to provide an overview of complications associated with surgical treatment for urinary incontinence and pelvic organ prolapse relating to synthetic mesh, as well as review the new International Urogynecologic Association (IUGA)/ International Continence Society (ICS) classification of complications for insertion of prosthesis or grafts in female pelvic floor surgery and the recent Food and Drug Administration (FDA) notifications.