Anita H. Chen

Sacral neuromodulation: new applications in the treatment of female pelvic floor dysfunction.

Purpose of review The first sacral nerve stimulators implanted by Tanagho and Schmidt (1981) were performed for the indications of urinary urge incontinence, urgency-frequency, and nonobstructive urinary retention. Since that time, observations have been made for benefits beyond voiding disorders. These additional benefits have included re-establishment of pelvic floor muscle awareness, resolution of pelvic floor muscle tension and pain, decrease in vestibulitis and vulvadynia, decrease in bladder pain (interstitial cystitis), and normalization of bowel function. Recent findings Therapy for fecal incontinence in patients with a structurally intact sphincter mechanism appears to be very promising. Investigators agree that there is a role for sacral nerve stimulation in patients with urge fecal incontinence that have failed conservative efforts. Objective manovolumetric testing shows an increase in resting pressure, an increase in voluntary contraction pressure, a decrease in rectal volumes which cause first urge, a decrease in rectal volume to initiate first urge to defecate, and an increase in duration of maximum squeeze pressure. Intractable interstitial cystitis is defined as patients that have failed conventional therapy. Historically, the only option remaining was extirpative surgery or diversion. Maher et al. reported on patients with intractable interstitial cystitis who had undergone sacral nerve stimulation. They found that 73% of these patients had a reduction in pelvic pain, daytime frequency, nocturnal urgency and an increase in average voided volumes. The final area of interest concerns refractory pelvic pain. Siegal et al. reported a decrease in severity, number of hours of pain, and improved quality of life measures in patients who underwent transforamenal sacral nerve stimulations. These patients had all failed conventional pain therapy. Summary While the data are encouraging in these new arenas of pelvic floor disorders, investigators acknowledge the need for multicenter, statistically powered studies to evaluate the validity of these findings.

Transvaginal Trigger Point Injections for Pelvic Floor Myofascial Spasm: A Retrospective Review of Pain Assessment and Development of a Treatment Algorithm.

Study Objective: To determine the safety and feasibility of single incision sling procedures (SIS) performed in an office based surgical setting among patients with stress urinary incontinence (SUI). Design: Retrospective study. Setting: Urogynecology office based Class A ASU. Patients: Women who underwent SIS procedures in an office setting. Intervention: SIS procedures were performed under local anesthesia with or without oral sedation. Measurements and Main Results: A total of 27 patients underwent a SIS procedure from 01/2011 to 02/2015 for the treatment of SUI. 9/ 27 patients (33.3%) had SUI with urethral hypermobility as the primary diagnosis, 1/27 patients (3.7%) had intrinsic sphincter deficiency (ISD) with urethral hypermobility, and 17/27 patients (63%) had stress-predominant mixed urinary incontinence. 27/27 (100%) of patients received administration of a local anesthetic, 24/27 patients (89%) also received oral sedation 1 hour prior to the procedure. There were no intraoperative complications. The estimated blood loss ranged from minimal to 50 cc. 9/27 patients (33.3%) reported minimal immediate postoperative pain, while 18/27 patients (66.7%) experienced no postoperative pain. No patients experienced urinary retention/voiding dysfunction post-procedure. 27/27 patients (100%) were discharged without a catheter. All the patients tolerated the procedure well, with no procedures having to be aborted for any reason. The last postoperative visit ranged from 6 weeks to 11 months. 1/27 patients (3.7%) complained of dyspareunia. 1/27 (3.7%) had mesh exposure/ revision; 1/27 (3.7%) had de novo overactive bladder symptoms. The one patient with preoperative ISD, experienced mild persistent SUI. 26/27 patients (96%) reported resolution of the SUI. Conclusion: We demonstrated the safety and feasibility of performing SIS procedures in an office-based setting. Clinical outcomes were comparable to those procedures performed in a traditional hospital or ambulatory surgical care setting. Larger clinical trials may be necessary before SIS placement in the ASU setting can be considered to be the standard setting for this procedure.

Trigger Point Injections for Pelvic Floor Myofascial Spasm Refractive to Primary Therapy

Introduction A retrospective chart review was conducted of visual analog scale (VAS) scores completed before and after trigger point injections (TPIs) for pelvic floor myofascial spasm to evaluate response. Methods Sixty-eight female patients who underwent TPIs from October 9, 2007 to March 12, 2015 were included. The primary end point was the difference between scores. Secondary analyses were conducted for patients who needed repeat TPIs. Descriptive and paired t test analyses were used. Results The key result was an improvement in VAS scores for 65% (44/68) of patients (p<0.0001). The median pre-injection VAS score was 7 (1 to 10), (mean 6.3). The median post-injection VAS score was 4 (0 to 9), (mean 4.3). The median difference between scores in patients who improved was 3 (1 to 8), (mean 3.6). Seventeen of 68 (25%) patients needed repeat TPI, and the median time between injections was 1.5 months (1 to 7 months), (mean 2.2 months). When analyzing pre-injection VAS scores in patients who underwent subsequent repeat injection when compared to patients who did not require repeat injection, there was no difference (p = 0.32). In addition, the differences between pre- and post-injection VAS scores in the patients who underwent repeat injection and those who did not was not significant (p = 0.26). Conclusions We report on 68 women who underwent TPIs, with an improvement in VAS pain scores in 65%. It appears that TPIs for pelvic floor myofascial spasm are successful in reducing pain scores for patients who are refractory to primary therapy.

Robotic Placement of the FENIX Continence Restoration System in a Patient with Previous Radiation to the Pelvis: A Case Report

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patients risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patients quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.