Guus Lycklama à Nijeholt

Diagnostic Investigation of the Pelvic Floor: A Helpful Tool in the Approach in Patients with Complaints of Micturition, Defecation, and/or Sexual Dysfunction

INTRODUCTION Pelvic floor dysfunction is recognized to be related to lower urinary tract dysfunction and to lower gastrointestinal symptoms, and is an influential factor in dysfunction and subsequent behavior of the genital system in both men and women. Caregivers should be informed regarding normal pelvic floor function in general and should be able to identify specific aspects of pelvic floor dysfunction in patients with related symptoms. In our hospital, this diagnostic consultation is indicated as Diagnostic Investigation of Pelvic Floor Function (DIPFF). AIM This study looked at pelvic floor dysfunction related to specific complaints. METHODS DIPFF consists of a medical history, a physical examination, including the International Continence Society (ICS) pelvic organ prolapse quantification system in female patients, and a biofeedback registration using a vaginal or anal probe. Based on our experience, we defined an elevated rest tone as greater than 2 microV using intravaginal or intra-anal electromyography. MAIN OUTCOME MEASURES Stratification of patients with a single complaint, a combination of two or three complaints of the micturition, defecation or sexual (all compartments of the pelvic floor) resulted in subgroups of respectively 30, 74, and 133 patients. RESULTS A total of 238 patients with complaints of micturition, defecation, and/or sexual function were included in this study. Electromyographic analysis revealed an elevated rest tone of the pelvic floor in 141 patients. In 184 patients, we found an involuntary relaxation of the pelvic floor. CONCLUSION In our retrospective study, we found that 77.2% of patients who presented to the clinic with urinary, gastro or sexual complaints had measurable pelvic floor dysfunction (69.3% overactive rest tone and 7.9% under active rest tone). In relation to the ICS terminology, there is a need for a well-defined normal vs. elevated rest tone of the pelvic floor.

Effects of magnetic stimulation in the treatment of pelvic floor dysfunction

To correlate, in a pilot study, the clinical results of extracorporeal magnetic innervation therapy (ExMI) of the pelvic floor muscles with functional changes in the pelvic floor musculature, urodynamics and quality of life.

Strontium-89 (Metastron) and the bisphosphonate olpadronate reduce the incidence of spinal cord compression in patients with hormone-refractory prostate cancer metastatic to the skeleton

Abstract. Spinal cord compression (SCC) is a devastating complication of metastatic cancer. We investigated the potential beneficial effect of two palliative therapies – strontium-89 (Metastron) and the nitrogen-containing bisphosphonate olpadronate – on the incidence of SCC in hormone-refractory prostate cancer (HRPC) metastatic to the skeleton. We retrospectively studied 415 patients with histologically proven prostate cancer who underwent bone scintigraphy at the time of diagnosis and were followed up at the Leiden University Medical Center between 1990 and 1999. Medical or surgical castration was undertaken in 172 patients with evidence for skeletal metastases. Within 2 years, 147 of these patients (85%) developed HRPC associated with severe progressive bone pain. Palliative treatment was given to 131 patients in the form of local radiotherapy (n=10), 89Sr (n=46) or intravenous olpadronate (n=66), with (n=57) or without (n=9) maintenance oral olpadronate. Nine patients received both 89Sr and olpadronate at various intervals. Sixteen patients who did not receive any of these treatments were used as historical controls. There was no significant difference in baseline characteristics between treatment modalities. The incidence of SCC was 17% in the whole group, and highest in controls receiving no palliation (50%). None of the patients treated with local radiotherapy, only 4% of patients receiving 89Sr and 21% of patients given olpadronate developed this complication. Our findings suggest a significant reduction in SCC in patients with symptomatic HRPC metastatic to the skeleton who receive palliative therapies. Local radiotherapy completely prevents the incidence of SCC, 89Sr leads to an important decrease in this complication and olpadronate induces a significant, albeit smaller decrease in the incidence of SCC. The use of these agents opens new avenues in the difficult management of patients with advanced prostate cancer who are most at risk of developing SCC.

Placement of probes in electrostimulation and biofeedback training in pelvic floor dysfunction

Background. We examined the positioning of five commonly used probes in electrostimulation and biofeedback training.

Bone scintigraphy predicts the risk of spinal cord compression in hormone-refractory prostate cancer

In prostate cancer, confirmation of metastatic involvement of the skeleton has traditionally been achieved by bone scintigraphy, although the widespread availability of prostate-specific antigen (PSA) measurements has tended to eliminate the need for this investigation. The potential of bone scintigraphy to predict skeletal-related events, particularly spinal cord compression, after the onset of hormone refractoriness has never been investigated. The aim of this study was to establish whether a new method of evaluating bone scintigraphy would offer a better predictive value for this complication of the metastatic process than is achieved with currently available grading methods. We studied 84 patients with hormone-refractory prostate cancer who had undergone bone scintigraphy at the time of hormone escape. Tumour grading and parameters of tumour load (PSA and alkaline phosphatase activity) were available in all patients. The incidence of spinal cord compression was documented and all patients were followed up until death. Bone scintigraphy was evaluated by the conventional Soloway grading and by an additional analysis determining total or partial involvement of individual vertebrae. In contrast to the Soloway method, the new method was able to predict spinal cord compression at various spinal levels. Our data suggest that there is still a place for bone scintigraphy in the management of hormone-refractory prostate cancer.

Metabolic Evaluation in Stone Patients in Relation to Extracorporeal Shock Wave Lithotripsy Treatment

No information exists in the literature about the optimal time for metabolic evaluation of stone patients in relation to extracorporeal shock wave lithotripsy (ESWL) treatment. It is uncertain whether the presence of a stone, ESWL treatment itself or subsequent colic episodes influence the urinary risk factors. A prospective study was performed to determine the optimal period for metabolic evaluation. Two 24-hour urine samples were collected directly before, and 1 week, 1 month and 3 months after therapy in an outpatient setting and tested for total volume, calcium, uric acid, oxalate, citrate and creatinine levels. A total of 66 patients was available for evaluation. Comparison of the 4 subsequent collecting periods showed no statistically significant differences in the excretion values. Also, in subgroups of patients with colic (16%), on a calcium oxalate restricted diet (12%) and with repeated treatments within 3 months (33%) no differences were noted. This means that the presence of a stone, treatment itself or subsequent colic episodes have no adverse effect on the urinary risk factors. For practical reasons metabolic evaluation directly before ESWL treatment seems most attractive. In the pre-ESWL samples hypercalciuria (greater than 7.5 mmol./24 hours), hyperuricosuria (greater than 6 mmol./24 hours), hyperoxaluria (greater than 0.5 mmol./24 hours) and hypocitraturia (less than 2 mmol./24 hours) were found in 31%, 12%, 18% and 27%, respectively, of the patients. It is concluded that metabolic evaluation before ESWL is practical, applicable and reliable.

Validation of the pelvic floor inventories Leiden (PelFIs) in English

To evaluate the validity and reliability of the English translation of an interviewer‐administered pelvic floor questionnaire, the “Pelvic Floor Inventories Leiden” (PeLFIs) for women, which addresses complaints of prolapse, bladder, and bowel dysfunction, pelvic floor pain and/or sexual dysfunction related to pelvic floor dysfunction.

The effect of EMG biofeedback assisted pelvic floor muscle therapy on symptoms of the overactive bladder syndrome in women: A randomized controlled trial

The overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence. Biofeedback‐assisted pelvic muscle therapy (BAPFMT) is a first‐line treatment option for OAB. The aims of this study were to determine the efficacy and effectiveness of BAPFMT on symptoms of OAB after 9 weeks of treatment and to detect changes EMG activity of individual pelvic floor muscles (PFM) with the MAPLe.

DEVELOPMENT AND VALIDATION OF THE PELVIC FLOOR INVENTORIES LEIDEN (PELFIS)

AIMS To evaluate the validity and reliability in Dutch of the Pelvic Floor Inventories Leiden (PelFIs) for men and women, an administered questionnaire, developed to create a condition-specific pelvic floor questionnaire addressing all symptoms of micturition, defecation and sexual dysfunction related to pelvic floor dysfunction. METHODS The PelFIs is an 83-item instrument for women and 76-item instrument for men measuring the degree of pelvic floor dysfunction, containing nine different domains. Questions have been selected which, from a clinical point of view, should configure a domain. The PelFIs was administered to healthy volunteers (N = 120), and to patients (N = 100). Reliability of the PelFIs was assessed by internal consistency and test-retest reliability. Construct validity was established comparing healthy volunteers and patients by intercorrelating the domains. RESULTS A total of 220 questionnaires were completed; by 147 women and 73 men. Some domains in the mens questionnaire had a low alpha (alpha) although the overall alpha was good. The overall of the domains for men ranged from 0.53 to 0.90. The internal consistency for the total scale of mens questionnaire was 0.84. The overall of the domains in women ranged from 0.60 to 0.85. The internal consistency of the womens questionnaire was 0.88 for the total scale. Intraclass correlation ranged from 0.65 to 0.88. Differences between healthy volunteers and patients were statistically significant for all domains. CONCLUSION The PelFIs is a new, practical and conceptually clear questionnaire, which focus on micturition, defecation and/or sexual dysfunction related to pelvic floor dysfunction.

Reoperation Rate in Patients with a Continent Urinary Diversion or Neobladder Is Influenced by the Oncological or Functional Indication for Cystectomy

Purpose: Continent urinary diversion following a cystectomy has become a standard procedure in suitable patients, because of its potentially favorable aspects. Reports concerning long-term complications necessitating reoperation are mainly based on patients with cystectomy for carcinoma. We reviewed the reoperation rate in patients with a continent diversion for both oncological and interstitial cystitis. Materials and Methods: A retrospective study was performed at our department on 63 patients in whom a continent diversion was created in the period from 1984 to 2002. Mean follow-up period was 73.9 months. Statistical analysis for the postoperative complication rate was performed using a multivariate linear stepwise regression, and Cox proportional hazard model. Results: Mean patient-age for the whole group was 53.8 years. Types of diversion used were Indiana (n = 31), Hautmann (n = 21) and Kock (n = 11). The group with an oncological indication for cystectomy consisted of 40 patients (31 male, 9 female) with a mean age of 58.5 years. Reasons for cystectomy were transitional cell carcinoma of the bladder (n = 39) and clear cell vaginal carcinoma (n = 1). The cystitis group was comprised of 23 patients (2 male, 21 female) with a mean age of 45.7 years. Cystectomy was performed for interstitial cystitis (n = 20) and chronic cystitis (n = 3). Multivariate linear stepwise regression of the summed side-effect score yielded a significant association, with the oncological group having less postoperative complications. The Cox proportional hazard model yielded a highly significant difference in revision of the urinary diversion. Reoperation rate in functional patients was 78.3 vs. 22.5% in oncological patients (p < 0.001). Conclusions: Postoperative complication and reoperation rates of continent diversion (or orthotopic neobladder) were significantly higher in patients with non-oncological indications for cystectomy. Therefore, results of continent diversion based on studies with oncological patients should not be used in counselling patients who may need a urinary diversion because of functional reasons such as interstitial cystitis.