Henk W. Elzevier

Can Advance Transobturator Sling Suspension Cure Male Urinary Postoperative Stress Incontinence

PURPOSE In a prospective 2-center study we confirmed and extended published results of the positive effect on post-prostatectomy stress incontinence of transobturator sling suspension using an Advance male sling. MATERIALS AND METHODS From September 2007 to June 2008 a male sling was placed and evaluated in 36 men according to the Rehder and Gozzi method. Diagnosis was based on 24-hour urine loss measured by a pad test, a 24-hour micturition frequency volume chart and cystoscopy. A visual analog scale for continence and bother, and a pad test were used preoperatively and postoperatively to objectively evaluate operative results. RESULTS At 1-year followup cure was achieved in 9.0% of patients and improvement was achieved in 45.5%. No effect on incontinence was seen in 36.5% of patients and 9.0% experienced worsening incontinence by pad test. The mean +/- SD visual analogue scale score of 6.1 +/- 2.2 (range 0 to 10) preoperatively improved significantly to 4.6 +/- 3.0 at 3 months (p = 0.024) and not significantly to 4.9 +/- 3.1 by 1 year postoperatively (p = 0.39). Improved incontinence did not correlate with patient age or incontinence severity. Complications developed in 2 patients, including sling infection and postoperative urinary retention in 1 each. CONCLUSIONS The transobturator sling suspension operation is a minimally invasive, safe procedure for male postoperative stress incontinence. Significantly improved continence was not observed on pad test but significant improvement in continence and bother was seen on the visual analog scale at 3 months.

Intraoperative Near Infrared Fluorescence Guided Identification of the Ureters Using Low Dose Methylene Blue: A First in Human Experience

PURPOSE Near infrared fluorescence imaging is a promising technique that offers real-time visual information during surgery. In this study we report the first clinical results to our knowledge of ureteral imaging using near infrared fluorescence after a simple peripheral infusion of methylene blue. Furthermore, we assessed the optimal timing and dose of methylene blue. MATERIALS AND METHODS A total of 12 patients who underwent lower abdominal surgery were included in this prospective feasibility study. Near infrared fluorescence imaging was performed using the Mini-FLARE™ imaging system. To determine optimal timing and dose, methylene blue was injected intravenously at doses of 0.25, 0.5 or 1 mg/kg after exposure of the ureters. Imaging was performed for up to 60 minutes after injection. RESULTS In all patients both ureters could be clearly visualized within 10 minutes after infusion of methylene blue. The signal lasted at least up to 60 minutes after injection. The mean signal-to-background ratio of the ureter was 2.27 ± 1.22 (4), 2.61 ± 1.88 (4) and 3.58 ± 3.36 (4) for the 0.25, 0.5 and 1 mg/kg groups, respectively. A mixed model analysis was used to compare signal-to-background ratios among dose groups and times, and to assess the relationship between dose and time. A significant difference among time points (p <0.001) was found. However, no difference was observed among dose groups (p = 0.811). CONCLUSIONS This study demonstrates the first successful use of near infrared fluorescence using low dose methylene blue for the identification of the ureters during lower abdominal surgery.

Sexual Function Improvement Following Surgery for Stress Incontinence: The Relevance of Coital Incontinence

INTRODUCTION Little is known about the impact of surgery for stress urinary incontinence (SUI) on female sexual function, and results are conflicting. AIMS We aimed to clarify the impact of surgery for SUI on female sexual function. METHODS We analyzed data collected from two studies evaluating sexual function in women after placement of the tension-free vaginal tape, tension-free vaginal tape obturator, or transobturator suburethral tape. A nonvalidated sexual questionnaire developed by Lemack, translated into Dutch, was mailed to all patients 3-12 months after the procedure. MAIN OUTCOME MEASURES Pre- and postoperative results of a nonvalidated sexual questionnaire. RESULTS A total of 136 sexually active women completed the questionnaires. Compared with preoperative responses, we observed no significant changes postsurgical regarding frequency of sexual intercourse or satisfaction of sexual intercourse, although a significant postoperative decrease in urinary coital incontinence (P < or = 0.001) was found. Postoperatively, 29 women (21.3%) reported improved sexual intercourse, and eight women (5.9%) complained of a worsening. There was a significant higher rate of preoperative coital incontinence (86.2% women with coital incontinence) in the group of women who reported improved intercourse (P = 0.01). CONCLUSION Women with coital incontinence show a significant higher improvement in sexual function after surgery for SUI compared to women without coital incontinence. Our results suggest that improvement in coital incontinence results in improvement of sexual function. Therefore, coital incontinence is a prognostic factor for improvement of sexual function following incontinence surgery.

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.

A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice.

Several antihypertensive drugs, such as diuretics and β-blockers, can negatively affect sexual function, leading to diminished quality of life and often to noncompliance with the therapy. Other drug classes, however, such as angiotensin II receptor blockers (ARBs) are able to improve patients’ sexual function. Sufficient knowledge about the effects of these widely used antihypertensive drugs will make it possible for cardiologists and general practitioners to spare and even improve patients’ sexual health by switching to different classes of cardiac medication. Nevertheless, previous data (part I) indicate that most cardiologists lack knowledge about the effects cardiovascular agents can have on sexual function and will thus not be able to provide the necessary holistic patient care with regard to prescribing these drugs. To be able to improve healthcare on this point, we aimed to provide a practical overview, for use by cardiologists as well as other healthcare professionals, dealing with sexual dysfunction in their clinical practices. Therefore, a systematic review of the literature was performed. The eight most widely used classes of antihypertensive drugs have been categorised in a clear table, marking whether they have a positive, negative or no effect on sexual function.

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.

Multiple Pelvic Floor Complaints Are Correlated with Sexual Abuse History

INTRODUCTION The relationship between sexual abuse and urinary tract symptoms, sexual abuse and gastrointestinal symptoms, or sexual abuse and sexual dysfunction has been described before. A correlation between all these symptoms and sexual abuse has not yet been reported. AIMS The first aim of this study was to document the prevalence rates of reported sexual abuse in a large sample of female patients with complaints of the pelvic floor. The second aim was to evaluate the frequency of complaints in the different domains of the pelvic floor, such as complaints of micturition, defecation, and sexual function, in female patients reporting sexual abuse, and comparing these data with female patients without a history of sexual abuse. METHODS Female patients with pelvic floor complaints were evaluated in a tertiary referral center. History taking was assessed by a pelvic-floor clinician. The number of domains with complaints of patients with a history of sexual abuse was compared with the number of domains with complaints of patients without sexual abuse. MAIN OUTCOME MEASURES The number of patients who reported sexual abuse and the frequency of complaints in the different domains of the pelvic floor. The number of domains of patients with a history of sexual abuse was compared with patients without a history of sexual abuse. RESULTS Twenty-three percent (42/185) of the patients reported a history of sexual abuse. The female patients with a history of sexual abuse had significantly more complaints in three domains of the pelvic floor (35/42) compared with the nonabused (69/143) (83% vs. 48%, P < 0.001). CONCLUSIONS Twenty-three percent of the female patients in a pelvic floor center evaluated by a pelvic-floor clinician reported a history of sexual abuse. This is comparable with the percentage of sexual abuse observed in the population at large. In our sample, the patients with multiple pelvic floor complaints (micturition, defecation, and sexual function) related to pelvic floor dysfunction were more likely to have a history of sexual abuse than the patients with isolated complaints.

The place of female sexual dysfunction in the urological practice: results of a Dutch survey.

INTRODUCTION Female sexual dysfunction (FSD) is a highly prevalent and often underestimated problem. There is a strong association between urological complaints and FSD. AIMS The purpose of this survey was to evaluate how Dutch urologists address FSD in their daily practice. METHODS We performed an anonymous survey study. A 17-item anonymous questionnaire was mailed to all 405 registered members of the Dutch Urology Association (urologists and residents in urology). MAIN OUTCOME MEASURES The survey results. RESULTS. One hundred eighty-six complete surveys of eligible respondents were returned (45.9% response rate). Ten respondents (5.5%) stated that they ask each female patient for sexual function; 87.1% stated that they ask for sexual function when a patient complains about lower abdominal pain (87.2%), incontinence (75.8%), urgency or frequency (70.5%), or urinary tract infections (65.8%). Many respondents (40.3%) do not think that FSD is meaningful in a urological practice. The majority of respondents (91%) underestimate the frequency of FSD in a urological clinic. Respondents who believe the frequency of FSD to be at least 30% tend to ask more often for sexual function than the rest of the group (P = 0.08). CONCLUSION Overall, many urologists do not consistently ask each female patient for sexual function and underestimate the prevalence of FSD. For the majority of the members of the Dutch Urological Association, FSD is not part of routine urological practice. There is, therefore, a need for better implementation of education and training at both undergraduate and postgraduate levels.

ORIGINAL RESERACH—OUTCOMES ASSESSMENT: How Reliable is a Self‐administered Questionnaire in Detecting Sexual Abuse: A Retrospective Study in Patients with Pelvic‐Floor Complaints and a Review of Literature

INTRODUCTION: Sexual abuse and sexual functioning are topics that health professionals find difficult to discuss. Women who present with pelvic-floor complaints often experience sexual difficulties; therefore, questions regarding sexual function should be a routine part of screening. Furthermore, pelvic-floor complaints are correlated with sexual abuse and asking about abuse should be a routine part of screening as well. Considering the fact that many practitioners have difficulty enquiring about abuse, we have suggested that a questionnaire may be helpful in improving the recognition and management of patients who have a history of sexual abuse. AIM: The efficiency of detecting sexual abuse by a self-administered questionnaire. METHODS: Report of sexual abuse in a self-administered pelvic-floor questionnaire before visiting our outpatient pelvic-floor department was evaluated with the Pelvic Floor Leiden Inventories (PelFIs) administered by a pelvic- floor clinician in a later stage. MAIN OUTCOME MEASURES: The percentage of sexual abuse detected by a taken questionnaire administered by a pelvic-floor clinician not confessed during a previous self-administered questionnaire. RESULTS: Sexual abuse was reported in 20 patients with pelvic-floor dysfunction during administration of the PelFIs and were also evaluated on our pelvic-floor department. Only six of the patients (30%) did not note in the self-administered questionnaire that they had a history of sexual abuse. CONCLUSION: A self-administered questionnaire for pelvic-floor complaints is reliable in detecting sexual abuse and can be helpful in daily practice. Language: en

Intravesical gentamicin for recurrent urinary tract infection in patients with intermittent bladder catheterisation

Clean intermittent catheterisation (CIC) of the bladder is used to imitate normal bladder emptying in patients with bladder dysfunction. CIC is associated with urinary tract infection (UTI) that may be difficult to treat in the case of antimicrobial resistance. The aim of this study was to establish the effect and safety of intravesical gentamicin treatment in such settings. In 2009, intravesical gentamicin treatment was started in selected patients. Here we describe our experience with two patients treated until March 2010. Two patients using CIC suffering recurrent UTI with multiresistant Escherichia coli were treated with daily administration of 80 mg intravesical gentamicin. On treatment they appeared asymptomatic. During 8- and 9-month follow-up they were free of UTI, urine cultures were negative and there were no side effects. A systematic review was conducted through searches of PubMed and other databases. Clinical trials that met the eligibility criteria and displayed the efficacy or safety of intravesical aminoglycoside treatment in patients using CIC were studied. Study selection was performed by two independent reviewers. Eight studies were included for review. Owing to study heterogeneity, a meta-analysis could not be performed. Of four controlled studies using neomycin or kanamycin, two demonstrated a significant reduction in bacteriuria, whilst two other trials did not. One case series on neomycin/polymyxin showed that the majority of patients still developed bacteriuria. Three case series using gentamicin all pointed towards a significant reduction in bacteriuria and UTIs. There were no clinically relevant side effects reported but follow-up in all studies was limited. Although data are limited, intravesical treatment with gentamicin might be a reasonable treatment option in selected patients practicing CIC who suffer recurrent UTIs with highly resistant microorganisms.