Dominique El-Khawand

Botulinum Toxin A Injections Into Pelvic Floor Muscles Under Electromyographic Guidance for Women With Refractory High-Tone Pelvic Floor Dysfunction: A 6-Month Prospective Pilot Study.

Objectives High-tone pelvic floor dysfunction (HTPFD) is a debilitating chronic pain disorder for many women with significant impact on their quality of life (QoL). Our objective was to determine the efficacy of electromyography-guided onabotulinumtoxinA (Botox; Allergan, Irvine, Calif) injections in treating patient’s perception of pelvic pain and improving QoL measurement scores. Methods This is a prospective pilot open-label study of women with chronic pelvic pain and HTPFD who have failed conventional therapy between January 2011 and August 2013. Botox injections (up to 300 U) were done using needle electromyography guidance, from a transperineal approach, to localize spastic pelvic floor muscles (PFMs). Data were collected at baseline, 4, 8, 12, and 24 weeks after injections. This included demographics; Visual Analog Scale (VAS) scores for pain and dyspareunia; validated questionnaires for symptoms, QoL, and sexual function; Global Response Assessment scale for pelvic pain; digital examination of PFM for tone and tenderness; and vaginal manometry. Side effects were also recorded. Results Out of 28 women who enrolled in the study, 21 completed the 6-month follow-up and qualified for analysis. The mean (SD) age was 35.1 (9.4) years (range, 22–50 years), and the mean (SD) body mass index was 25 (4.4). Comorbidities included interstitial cystitis/bladder pain syndrome (42.9%) and vulvodynia (66.7%). Overall, 61.9% of subjects reported improvement on Global Response Assessment at 4 weeks and 80.9% at 8, 12, and 24 weeks post injection, compared with baseline. Of the subjects who were sexually active at baseline, 58.8% (10/17), 68.8% (11/16), 80% (12/15), and 83.3% (15/18) reported less dyspareunia at 4, 8, 12, and 24 weeks, respectively. Dyspareunia Visual Analog Scale score significantly improved at weeks 12 (5.6, P = 0.011) and 24 (5.4, P = 0.004) compared with baseline (7.8). Two of the 4 patients who avoided sexual activity at baseline secondary to dyspareunia resumed and tolerated intercourse after Botox. Sexual dysfunction as measured by the Female Sexual Distress Scale significantly improved at 8 weeks (27.6, P = 0.005), 12 weeks (27.9, P = 0.006), and 24 weeks (22.6, P < 0.001) compared with baseline (34.5). The Short-Form 12 Health Survey (SF-12) showed improved QoL in the physical composite score at all post injections visits (42.9, 44, 43.1, and 45.5 vs 40 at baseline; P < 0.05), and in the mental composite score at both 12 and 24 weeks (44.3 and 47.8 vs 38.5, P = 0.012). Vaginal manometry demonstrated significant decrease in resting pressures and in maximum contraction pressures at all follow-up visits (P < 0.05). Digital assessment of PFM (on a scale from 0 to 4) showed decreased tenderness on all visits (mean of 1.9, 1.7, 1.8, 1.9; P < 0.001) compared with baseline (2.8). Reported postinjection adverse effects included worsening of the following preexisting conditions: constipation (28.6%), stress urinary incontinence (4.8%), fecal incontinence (4.8%), and new onset stress urinary incontinence (4.8%). Conclusions Electromyography-guided Botox injection into PFM could be beneficial for women with refractory HTPFD who have failed conservative therapy.

Sacral nerve stimulation during pregnancy: case report and review of the literature.

Background The use of sacral nerve stimulation during pregnancy is not recommended because of the unknown effects on the offspring. There is a paucity of literature on the subject. Case A 25-year-old woman who had a sacral nerve stimulator for severe interstitial cystitis/bladder pain syndrome had 2 successful pregnancies. Against medical advice, she kept the stimulator activated for symptom control during the pregnancies. The first child was later diagnosed with chronic motor tic disorder, and the second had a pilonidal sinus at birth. Whether this outcome is related to the neurostimulator is unknown. The efficacy of sacral nerve stimulation decreased after each pregnancy. Conclusion The safety of sacral nerve stimulation in pregnancy has not been well established. Until further research is done, we recommend that women of reproductive age with a sacral nerve stimulator be advised about contraception and that the device should be deactivated before or as soon as pregnancy is confirmed.

Risk factors for vaginal mesh exposure after mesh-augmented anterior repair: a retrospective cohort study.

Objectives The aim of this study is to identify risk factors for vaginal mesh exposure after mesh-augmented repair of anterior prolapse. Methods We performed a retrospective cohort study of all patients who had mesh-augmented anterior repair by 1 surgeon between January 2007 and February 2012. Data were extracted from medical records. The primary outcome was the rate of anterior or apical vaginal mesh exposure. Both univariate and multivariate analyses were performed. Results A total of 201 subjects were included. The mean (SD) follow-up was 14.3 (12.4) months. All cases were done using a type 1 macroporous monofilament polypropylene mesh. The overall mesh exposure rate was 8.5% (17/201). Univariate analysis showed a statistically significant positive association between exposure rates and the following risk factors: lower body mass index (BMI) (P = 0.016), menopause in combination with the use of hormone replacement therapy (P = 0.023), midline sagittal vaginal incision (compared with distal transverse incision) (P = 0.026), concurrent total hysterectomy (P < 0.001), surgery time (P = 0.002), and worse apical prolapse at baseline (P = 0.007). After multivariate analysis using logistic regression, only BMI (P < 0.001) and concomitant total hysterectomy (odds ratio, 48; P < 0.001) remained relevant. The exposure rate was 23.5% (16/68) when concomitant hysterectomy was performed compared with 0.8% (1/133) when no hysterectomy was done. Exposure rates stratified by BMI class were 12.9% (8/62) for BMI less than 25 kg/m2, 9.5% (8/84) for BMI of 25 to 29.9 kg/m2, 3.1% (1/32) for BMI of 30 to 34.9 kg/m2, and 0% (0/23) for BMI greater than or equal to 35 kg/m2. Conclusions Concomitant total hysterectomy is an independent risk factor for mesh exposure after mesh-augmented anterior repair, whereas BMI may negatively correlate with exposure rates.

Botulinum toxin for conditions of the female pelvis

Introduction and hypothesisBotulinum toxin has recently been approved by the Food and Drug Administration (FDA) for the treatment of urinary incontinence associated with neurogenic detrusor overactivity. However, it has also been used off-label for a multitude of other conditions in the female pelvis, including urological, gynecological, and colorectal. This article reviews the most recent data regarding its efficacy and safety, and administration techniques for those conditions.MethodsA literature review of the most relevant reports published between 1985 and 2012.ResultsUrinary incontinence related to neurogenic detrusor overactivity is currently the only approved indication in the female pelvis. Other supported off-label uses include: idiopathic detrusor overactivity, interstitial cystitis/bladder pain syndrome, detrusor sphincter dyssynergia, high-tone pelvic floor dysfunction, anal fissure, anismus, and functional anal pain.ConclusionsBotulinum toxin may effectively and safely be used in many conditions of the female pelvis. More high quality research is needed to better clarify its role in the therapeutic algorithm for those indications.

Kenalog Injection into Hunner's Lesions as a Treatment for Interstitial Cystitis/Bladder Pain Syndrome

Introduction: This study aims to evaluate the effectiveness of kenalog injection into Hunners lesions. Materials and Methods: All patients had cystoscopy and bladder hydrodistention with corticosteroid injection into Hunners lesions over a 2.5-year period. Data include patient characteristics and pre- and post-operative validated questionnaires. Spearman Correlation and Wilcoxon t-tests were used for analysis. Results: One hundred patients were reviewed retrospectively. There was a 1.1 point decrease in pain at 12 weeks post-operation (p = 0.435). Urinary frequency decreased from a mean of 11.7 to 9.1 daily episodes (p = 0.05), and nocturia from a mean of 3 to 1.6 nightly episodes (p = 0.008). Conclusion: The use of a corticosteroid may be beneficial to symptom control and improvement in the quality of life of interstitial cystitis/painful bladder syndrome patients. Patients had improved frequency and nocturia 12 weeks post injection.

Neurostimulation for Bladder Pain Syndrome

Bladder pain syndrome (BPS) can be a debilitating disorder with limited treatment options. Recently, neuromodulation has emerged as a viable therapeutic option for patients with intractable symptoms, improving the pain and the urgency–frequency, as well as the quality of life. The most commonly used approach is sacral nerve stimulation (SNS), although pudendal and posterior tibial nerve stimulations have also been described. This chapter details the mechanism of action, patient selection, and procedure technique of SNS. It also reviews the latest scientific literature addressing its use for BPS, and provides a summary of the reported related adverse events. Furthermore, it sheds some light on the current research regarding pudendal, posterior tibial, and caudal epidural sacral nerve stimulations.