Kim A. Killinger

Chronic pudendal neuromodulation: Expanding available treatment options for refractory urologic symptoms†

Chronic pudendal nerve stimulation (CPNS) is a logical alternative particularly in those who fail sacral stimulation. We evaluated symptoms, complications, and satisfaction after CPNS.

Childhood Symptoms and Events in Women With Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVES To explore the prevalence of recurrent urinary tract infection and elimination difficulties experienced in childhood and adolescence in adult women with interstitial cystitis/painful bladder syndrome (IC/PBS) and community controls. The relationship between dysfunctional voiding and bowel symptoms in early life and the development of IC/PBS is not clear. METHODS A questionnaire was developed and mailed to 406 women with IC/PBS (patients) and 5000 community-dwelling controls. The demographic, personal, and family health history data and the urinary and bowel symptoms experienced in childhood, adolescence, and adulthood were collected. The data were analyzed using the Student t test and multiple logistic regression analysis. RESULTS A total of 215 patients (53%) and 823 controls (16%) returned the questionnaires (controls with a previous IC/PBS diagnosis or not meeting the inclusion criteria for either group were excluded from analysis). The 215 patients, 126 controls reporting IC/PBS symptoms but no diagnosis, and 464 asymptomatic controls were compared regarding symptoms and events experienced in childhood and adolescence. Statistically significant differences were seen among the groups for recurrent urinary tract infection (P < .0001) and frequent antibiotic use (P < .0001) in childhood and for all symptoms in childhood and adolescence, including trouble starting the urinary stream (P < .0001 for both), urgency (P < .0001 for both), retention (P = .0038 and P < .0001, respectively), constipation (P = .0006 and P = .0001, respectively), and painful defecation (P < .0001 for both). Multiple logistic regression analyses showed statistically significant differences between the patients and asymptomatic controls in childhood bladder infections (P = .006) and urinary urgency (P = .001) in adolescence. CONCLUSIONS These results support the need for longitudinal prospective assessment of children with dysfunctional elimination symptoms to determine whether these symptoms progress to IC/PBS. Additional research will contribute to our understanding of the natural history of IC/PBS, promote its earlier diagnosis, and potentially prevent disease progression.

Are Ulcerative and Nonulcerative Interstitial Cystitis/Painful Bladder Syndrome 2 Distinct Diseases? A Study of Coexisting Conditions

OBJECTIVES Coexisting conditions associated with interstitial cystitis/painful bladder syndrome (IC/PBS) have not been fully explored by IC/PBS subtypes. We compared comorbid diagnoses/symptoms in women with ulcerative (ULC) and nonulcerative (N-ULC) IC/PBS and controls. METHODS Adult women with IC/PBS and controls without IC/PBS completed a mailed survey assessing for 21 diagnoses. IC/PBS subtype was determined by hydrodistention reports. Standardized questionnaires assessed IC/PBS symptoms (Interstitial Cystitis Symptom/Problem Indexes [ICSI-PI]) and for undiagnosed fibromyalgia, irritable bowel syndrome, and depression (Symptom Intensity Score [SIS]; Rome III Functional Bowel Questionnaire; Center for Epidemiologic Studies Depression Scale [CES-D]). Data were analyzed using the Pearson chi-square, Fisher exact, Wilcoxon rank test, or Spearman rank correlation coefficient. RESULTS Of 178 N-ULC IC/PBS patients, 36 ULC IC/PBS patients, and 425 controls, ULC IC/PBS subjects were older (median 63 years; P < .01) and less employed (P < .01), but groups were similar on other demographic characteristics. N-ULC reported more chronic diagnoses (mean 3.5 ± 2.3) than ULC (2.3 ± 2.0) and controls (1.2 ± 1.5) (P < .01). When N-ULC and ULC IC/PBS patients were compared, more N-ULC IC/PBS patients had fibromyalgia (P = .03), migraines (P = .03), temporomandibular joint disorder (P < .01), and higher CES-D (P = .02) and SIS scores (P = .01). The ULC IC/PBS group voided more frequently during the daytime (P = .03) and nighttime (P < .01) and had smaller mean bladder capacity than N-ULC (P < .01). No significant differences were seen between N-ULC and ULC IC/PBS patients on the ICSI-PI and Rome III. CONCLUSIONS Notable differences in the number of comorbid diagnoses and symptoms were seen between IC/PBS subtypes and controls. Subtypes should continue to be evaluated individually to ascertain other similarities and differences.

Electrosurgical Management of Hunner Ulcers in a Referral Center's Interstitial Cystitis Population

OBJECTIVE To characterize electrocautery (EC) as a valid treatment option in interstitial cystitis (IC) patients with Hunner ulcers (HUs). METHODS From 1997 to 2013, a single urologists IC population was retrospectively reviewed to identify HU patients as well as their demographics, operative characteristics, and response to a 2-page questionnaire evaluating parameters of their experience with EC. Descriptive statistics, Pearson chi-square test, Student t test, and Pearson coefficient were used. RESULTS Two hundred fourteen EC procedures were performed in 76 patients (87% women; mean age, 66 ± 1.67 years). Fifty-one patients (69%) who underwent multiple EC had mean initial bladder capacity of 438.62 ± 27.90 mL and final bladder capacity of 422.40 ± 30.10 mL. Mean number of EC procedures was 2.98 ± 0.25 (range, 1-11). Mean time between sessions was 14.52 ± 1.34 months (range, 1-121 months). Fifty-two patients (68%) completed our questionnaire, with 13.54 ± 1.28 years of symptoms and 10.66 ± 0.96 years since diagnosis. Ranking IC treatments, 37 patients (84%) reported EC most beneficial. On a 0-10 (none to worst possible) scale before and after EC, frequency improved from 9.04 ± 1.30 to 3.65 ± 2.75 (P <.001), urgency from 8.40 ± 2.38 to 3.28 ± 2.71 (P <.001), and pain from 8.62 ± 2.36 to 2.68 ± 2.55 (P <.001). Overall, 89.6% of patients noted some degree of symptom improvement after EC; 56.3% of patients had marked improvement. A total of 98% of patients would undergo EC again. CONCLUSION EC of HU is an effective and safe procedure with high patient satisfaction that does not diminish bladder capacity.

Exploring Predictors of Mesh Exposure After Vaginal Prolapse Repair

Objectives To evaluate clinical, demographic, and surgical factors that may be associated with mesh exposure after vaginal repair of pelvic organ prolapse (POP). Methods Records of women who underwent POP repair with Elevate or Prolift were retrospectively reviewed. Body mass index (BMI), prolapse grade, smoking history, diabetes, steroid and estrogen use, parity, compartment repaired, concurrent hysterectomy, operative time, postoperative pain, change in hemoglobin (&Dgr;Hgb) and other characteristics were evaluated for associations with mesh exposure. Categorical variables were examined using Pearson &khgr;2 test where appropriate, or the Fisher exact test was used. The continuous variables were examined using Wilcoxon rank tests. A multivariable logistic regression analysis was completed to examine predictors of mesh exposure. All analyses used SAS for Windows version 9.2 (Cary, NC). Results Three hundred thirty-five women underwent repair from 2006 to 2011. Vaginal mesh exposure was identified in 27 (8.1%) of the 335 women. Patients with exposure had longer median follow-up than the group with no exposure (357 vs 145 days; P = 0.0003). The median time to exposure was 96 days (15–1129 days). Mesh exposure was associated with lower BMI (25.2 ± 2.5 vs 27.4 ± 5.1; P = 0.020) and greater &Dgr;Hgb (−3.7 ± 1.7 mg/dL vs −2.5 ±1.3; P = 0.0011). Change in hemoglobin decreased over time (P = 0.0005). Exposure rates also decreased over time (17% in 2005 to 12% in 2006, then 5%–8% in 2006–2011) but were not statistically significant (P = 0.49). Conclusions In this study, vaginal mesh exposure was only associated with &Dgr;Hgb and lower BMI.

Is sensory testing during lead placement crucial for achieving positive outcomes after sacral neuromodulation

Motor and sensory responses help guide lead placement during staged neuromodulation procedures. However, eliciting sensory responses requires lighter anesthesia. We evaluated the impact of assessing sensory responses during quadripolar tined lead placement on outcomes in subjects with refractory voiding symptoms.

Does patient age impact outcomes of neuromodulation

We evaluated whether patients stratified by age have the same level of risks/benefits after a staged neuromodulation procedure for refractory voiding symptoms.

Contemporary diagnosis and management of Fournier's gangrene.

Fournier’s gangrene, an obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the overlying skin, is a rare but severe infective necrotizing fasciitis of the external genitalia. Mainly associated with men and those over the age of 50, Fournier’s gangrene has been shown to have a predilection for patients with diabetes as well as people who are long-term alcohol misusers. The nidus for the synergistic polymicrobial infection is usually located in the genitourinary tract, lower gastointestinal tract or skin. Early diagnosis remains imperative as rapid progression of the gangrene can lead to multiorgan failure and death. The diagnosis is often made clinically, although radiography can be helpful when the diagnosis or the extent of the disease is difficult to discern. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be used to stratify patients into low, moderate or high risk and the Fournier’s Gangrene Severity Index (FGSI) can also be used to determine the severity and prognosis of Fournier’s gangrene. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics. After initial radical debridement, open wounds are generally managed with sterile dressings and negative-pressure wound therapy. In cases of severe perineal involvement, colostomy has been used for fecal diversion or alternatively, the Flexi-Seal Fecal Management System can be utilized to prevent fecal contamination of the wound. After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for satisfactory functional and cosmetic results.

Changes in Sexual Functioning in Women after Neuromodulation for Voiding Dysfunction

INTRODUCTION Sacral neuromodulation is a well-established treatment for urinary and bowel disorders with potential use for other disorders such as sexual dysfunction. AIM To evaluate changes in sexual functioning in women undergoing neuromodulation for voiding symptoms. METHODS Patients enrolled in our prospective, observational neuromodulation database study were evaluated. Data were collected from medical records, and patient-completed Female Sexual Function Index (FSFI) and Interstitial Cystitis Symptom-Problem Indices (ICSI-PI) at baseline, 3, 6, and 12 months post-implant. Patients rated overall change in sexual functioning on scaled global response assessments (GRA) at 3, 6, and 12 months post-implant. We grouped women by baseline FSFI scores: less (score<26) and more sexually functional (score≥26). Data were analyzed with Pearsons Chi-square or Fishers Exact test and repeated measures. MAIN OUTCOMES MEASURES Changes in FSFI and ICSI-PI scores in women grouped by baseline FSFI score<26 and ≥26. RESULTS Of 167 women evaluated, FSFI scores improved overall from preimplant (mean 13.5±8.5) to 12 months (N=72; mean 15.9±8.9, P=0.004). At baseline and each follow-up point, ICSI-PI scores were similar between groups and improved through time. For patients in the FSFI<26 group there was improvement from baseline to 12-month scores (N=63; 11.9±6.9 to 14.8±8.7; P=0.0006). Improved FSFI domains included desire, orgasm, satisfaction, and pain. Furthermore, of the 74 subjects in this group not sexually active at baseline, 10 became sexually active during follow-up. In the FSFI≥26 group there was slight but statistically significant decline in mean scores between baseline and 12 months (N=9; 27.4±1.1 to 24.5±3.4; P=0.0302); however one had become sexually inactive. A significant decrease was seen in the satisfaction domain. CONCLUSIONS Many factors affect sexual functioning in women; however sexual function may improve along with urinary symptoms after neuromodulation.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM).