Ga Digesu

Percutaneous posterior tibial nerve stimulation as an effective treatment of refractory lower urinary tract symptoms in patients with multiple sclerosis: preliminary data from a multicentre, prospective, open label trial

Background: Percutaneous tibial nerve stimulation (PTNS) has been proposed as a new, minimally invasive neuromodulation technique to treat lower urinary tract symptoms (LUTS). Objective: To evaluate efficacy, safety and impact on quality of life (QoL) of PTNS on patients with multiple sclerosis (MS) who have LUTS. Methods: 21 patients (5 men, 16 women) with MS and LUTS unresponsive to anticholinergics were treated with 12 sessions of PTNS. Assessment of LUTS was by validated, self-administered chart and questionnaires, testing the subjective and objective relevance of LUTS for patients and their impact on QoL before and after treatment; the mean post-micturition residual was assessed by trans-abdominal ultrasound scanning. Analysis was by intention to treat. Results: There was a significant reduction of daytime frequency (from 9 to 6, p = 0.04), nocturia (from 3 to 1, p = 0.002) and mean post-micturition residual (from 98 ± 124 ml to 43 ± 45 ml, p = 0.02). The mean voided volume increased from 182 ± 50 ml to 225 ± 50 ml (p = 0.003). Eighty-nine percent of patients reported a treatment satisfaction of 70%. Significant improvement in QoL was seen in most domains of the King’s Health QoL questionnaire (p < 0.05). No adverse events were reported. Conclusions: PTNS is an effective, safe and well-tolerated treatment for LUTS in patients with MS.

Rectal distension: The effect on bladder function

To assess how rectal distension affects urodynamics parameters and diagnosis.

Pre-operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre-operative mixed urinary incontinence†

To determine if specific pre‐operative urodynamic parameters could predict detrusor overactivity following TVT in patients with urodynamic mixed incontinence.

Preoperative pressure‐flow studies: useful variables to predict the outcome of continence surgery

To determine whether the acceleration of flow rate (AFR), pressure flow variables and urethral pressure profilometry (UPP) measurements might have a role in evaluating women with urodynamic stress incontinence (USI), to predict the surgical outcome and de novo detrusor overactivity after Burch colposuspension.

Changes in detrusor muscle oxygenation during detrusor overactivity contractions

OBJECTIVE To investigate changes in the oxygenated and deoxygenated haemoglobin (Hb) of the bladder wall during voluntary and involuntary detrusor contractions. STUDY DESIGN Women with lower urinary tract symptoms were recruited from a urodynamics clinic. Near infra-red spectroscopy, a non-invasive optical technique which monitors changes in tissue oxygenation, was used to measure oxygenated and deoxygenated haemoglobin simultaneously while the women underwent urodynamics. All data were compared using paired sample t-test. RESULTS Fifty-five women with a mean age of 52 years were enrolled into the study. In the 23 women with detrusor overactivity (15 with isolated detrusor overactivity and 8 with mixed urinary incontinence) there was a statistically significant rise in deoxygenated Hb during involuntary detrusor contractions at maximum detrusor pressure compared to the start of filling (p=0.02). There was no statistically significant change between Hb parameters measured at the start of the filling phase and those measured during voluntary detrusor contraction at pdetQmax (detrusor pressure at maximum flow rate). The mean detrusor pressure measured during voiding, however, was significantly higher than the maximum pressure during involuntary detrusor contractions (p=0.03). CONCLUSION There is a significant rise in the deoxygenated Hb in the detrusor muscle during detrusor overactivity, which is not seen during voiding even when the pdetQmax was higher than the peak detrusor pressure during involuntary contractions. These interesting changes in detrusor muscle oxygenation during involuntary detrusor contraction need to be explored further to assess if deoxygenation plays a role in the pathogenesis of detrusor overactivity.

Racial differences in female urethral morphology and levator hiatal dimensions: an ultrasound study.

To compare the urethral sphincter morphology and levator hiatal dimensions between white and black premenopausal nulliparous asymptomatic women using 3D/4D translabial ultrasonography.

Imaging in urogynaecology.

The assessment of patients with pelvic floor dysfunction necessitates a combination of clinical skills and adjunct investigations, including detailed imaging. This article reviews a variety of static and dynamic imaging modalities available in the field of urogynaecology, with an emphasis on their clinical implication in identifying the structural and functional causes of pelvic floor disorders. A number of different modalities have been used including X-rays, ultrasound and magnetic resonance imaging. Their place and value are discussed with comments on the validity of the various techniques.

Re: Ultrasound bladder wall thickness and detrusor overactivity: a multicentre test accuracy study

Sir, We read with interest the paper by Latthe et al. on ultrasound bladder wall thickness (BWT) and detrusor overactivity (DO). The authors included women with symptoms of frequency, urgency and post-void residual of <100 ml. The authors excluded from the study women with urodynamic pure or predominant stress incontinence, pregnancy, prolapse, recent surgery, Botox, urinary tract infection and women on anti-muscarinics for over 6 months, which may have affected the bladder wall thickness. There were no normal controls. All participants that met the inclusion and exclusion criteria had urodynamics and a BWT scan. This resulted in a group of women with symptoms of overactive bladder (OAB), some of whom had DO on urodynamics. It is not clear which provocation tests were done; 33% (226/687) reported only urgency and frequency, 61% had urgency-predominant urinary incontinence. BWT > 5 mm, as a test for DO diagnosis in women with OAB, showed a sensitivity of 0.43 (0.38–0.48), specificity 0.62 (0.55–0.68), positive predictive value 0.63 (0.57–0.69), negative predictive value 0.41 (0.36–0.47). A systematic review of 23 studies (6282 women) found that urodynamics for women with symptoms of OAB and urinary incontinence had a sensitivity of 0.76 (0.73–0.78), specificity 0.57 (0.55– 0.59), positive predictive value 0.48 (0.46–0.50) and negative predictive value 0.82 (0.80–0.84) for DO. Urodynamics and BWT > 5 mm performed similarly in predicting DO in women with OAB. A meta-analysis of 16 studies (1404 women), showed that the position during filling or the change of position with a full bladder during the test, such as from supine to standing or standing to sitting, increased the diagnostic rate of DO by 33–100%. The most provocative manoeuvre found was asking the woman to sit on the commode with the instruction ‘not to void’, which increased the detection of DO by 53%. Handwashing increased the detection of DO by 25%. A study of 126 women in whom ambulatory urodynamics was performed as a second-line test after inconclusive or normal urodynamics in symptomatic women, as recommended by the International Continence Society and the National Institute for Health and Care Excellence (NICE), reached a diagnosis in 86% of that cohort. The diagnosis of DO was made in 60% (76 women); 57/ 71 improved with an anti-cholinergic. Overall, laboratory urodynamics have been shown to have a poor diagnostic rate for DO. This puts into question the use of laboratory urodynamics as a reference standard. A multicentre double-blind randomised study, 307 women with OAB showed a similar response to anti-cholinergic therapy regardless of the urodynamic findings. The routine use of urodynamics has been questioned in the management of women with OAB. NICE recommends empirical treatment of OABwith an anti-cholinergic, without the need for urodynamics before medical therapy. A better test would be to assess the outcome of treatment guided by ultrasound BWT or urodynamics. Therefore, as there is no adequate valid standard of assessing bladder function, BWT cannot be said to be ‘of no value in clinical practice’.& References

OC30.07: The fascial defect theory for vaginal prolapse is not supported by ultrasound measurement of vaginal wall thickness

to age, BMI, parity, time from delivery, episiotomy, epidural anesthesia, birth weight, or delivery mode, but there was a trend towards higher TUI scores with a prolonged second stage (0.061). Women with a higher BMI had larger levator hiatal area dimensions (P=0.05), whereas shorter women tended to have more severe avulsion defects on TUI (P=0.027). Women with an avulsion defect in addition to the perineal tear were also more likely to have anorectal symptoms, although this was statistically significant only for fecal urgency (< 0.05). We observed a decrease in the incidence (61.4% vs. 29.5%, P<0.001) and TUI score of avulsion defects (6.18 ± 6.4 vs. 2.43 ± 4.8, (P<0.001), for the enrolment and last visits, respectively. Conclusion: There seems to be a change in the appearance of levator ani trauma during long term follow-up in women with 3rd and 4th degree perineal tears suggesting the need for continued evaluation.

OC30.01: Vaginal wall thickness is related to the degree of vaginal prolapse

acquisition. Aim of this study was to compare the performance of the AN24 with Doppler FHR monitoring in high risk patients requiring prolonged testing. Study design: Prospective observational study of singletons admitted for fetal monitoring. Each AN24 session was matched 2 : 1 for gestational age (GA), body mass index (BMI), and time of day with a control recording using external Doppler. Percentage of FHR capture was compared for both methods. Results: 93 monitoring sessions (31 cases, 62 controls) were analyzed after verifying proper matching by ANOVA. GA median was 29.0wks [23.1–39.5], median BMI 26.6 [20.1–42.2] and mean monitoring duration 751 minutes [73-1410]. Rate of good capture recordings (> 60%) was similar p>0.05. Overall percentage capture of the FHR was better with Doppler (88% vs 58%, Mann Whitney < 0.001). This difference was primarily due to sessions with low AN24 capture between 26–33.6wks (** =p<0.001, table). Outside this gestational age window both devices perform similar. Conclusion: Monica AN24 fetal ECG monitoring is equivalent Doppler technology early and late in gestation. For extended monitoring between 26–34 weeks, the AN24 technology requires improvement to overcome FHR capture limitations that are most likely due to increased vernix caseosa formation.