Kristene E. Whitmore

Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: A multicenter, placebo-controlled trial

OBJECTIVE Our purpose was to determine the efficacy of transvaginal electrical stimulation in treating genuine stress incontinence. STUDY DESIGN This was a multicenter, prospective, randomized, double-blind, placebo-controlled 15-week trial comparing the use of an active pelvic floor stimulator with a sham device. Thirty-five women used an active unit and 17 control subjects used sham devices. Weekly and daily voiding diaries were recorded throughout the trial. Urodynamic testing, including pad test and subtracted cystometry, was done before and at the end of device use. Pelvic muscle strength was measured at baseline and at the end of the trial. Patients scored their symptoms on visual analog scales and completed quality-of-life questionnaires before and after therapy. RESULTS Significant improvements from baseline were found in patients using active devices but not in controls. Comparisons of changes from baseline between active-device and control patients showed that active-device patients had significantly greater improvement in weekly (p = 0.009) and daily (p = 0.04) leakage episodes, pad testing (p = 0.005), and vaginal muscle strength (p = 0.02) when compared with control subjects. Significantly greater improvement was also found for both visual analog scores of urinary incontinence (p = 0.007) and stress incontinence (p = 0.02), as well as for subjective reporting of frequency of urine loss (p = 0.002), and urine loss with sneezing, coughing, or laughing (p = 0.02), when compared with controls. Pad testing showed that stress incontinence was improved by at least 50% in 62% of patients using an active device compared with only 19% of patients using sham devices (p = 0.01). Voiding diaries showed at least 50% improvement in 48% of active-device patients compared with 13% of women using the sham device (p = 0.02). No irreversible adverse effects were noted in either group. CONCLUSIONS Transvaginal pelvic floor electrical stimulation was found to be a safe and effective therapy for genuine stress incontinence.

Hydrogel/silver ion-coated urinary catheter reduces nosocomial urinary tract infection rates in intensive care unit patients: a multicenter study.

OBJECTIVES Indwelling urinary catheters are the leading source of nosocomial urinary tract infections (NUTIs). The Bardex I.C. catheter is a hydrogel latex Foley catheter with a monolayer of silver metal applied to the inner and outer surfaces of the catheter. We investigated the Bardex I.C. catheter for its ability to decrease the NUTI rate in critical care units. METHODS Five hospitals participated in a blind prospective study, exchanging the standard latex Foley catheter for the Bardex I.C. Foley catheter. The device use rate and NUTI rate were monitored. Data were collected and analyzed using Wilcoxon rank sum test and four-way analysis of variance. A cost analysis was also performed. RESULTS The baseline period, intervention period, and number of device days was similar for both periods. The unadjusted catheter-associated infection rate during the baseline and intervention periods was 7.1 and 4.5 infections per 1000 catheter days, respectively (P <0.01). The adjusted catheter-associated infection rate during the baseline and intervention periods was 8.1 and 4.9 infections per 1000 catheter days, respectively. This was not statistically significant (P = 0. 13). CONCLUSIONS A trend toward a reduction in NUTIs with the use of the hydrogel/silver-coated catheter was noted in all intensive care units at each institution as shown by the unadjusted and adjusted catheter-associated infection rates. One hospital demonstrated a statistically significant reduction in NUTIs. However, statistical significance was not met when the results were adjusted. The cost analysis at one institution demonstrated cost savings with the use of the silver-coated catheter. Future analysis may require a double-blind, prospective-controlled study of longer duration to reach statistical significance.

ORIGINAL RESEARCH—SEXUAL PAIN DISORDERS: Interstitial Cystitis/Painful Bladder Syndrome as a Cause of Sexual Pain in Women: A Diagnosis to Consider

INTRODUCTION Sexual pain, or dyspareunia, is a common symptom among women. Dyspareunia presents in many ways, and arises from a range of causes. Interstitial cystitis/painful bladder syndrome (IC/PBS) is one potential cause that may frequently be overlooked by clinicians. Interstitial cystitis is increasingly recognized as more common than was once thought. However, it can be difficult to identify, as the symptoms of IC/PBS (urinary urgency and frequency, dyspareunia, nocturia, and pelvic pain) overlap with other urogynecologic conditions. AIM This article will review the association between dyspareunia and IC/PBS, and will provide an approach to the diagnosis and treatment of IC/PBS in women with sexual pain. METHODS AND MAIN OUTCOME MEASURES Review of the medical literature and expert medical opinion. RESULTS Many women with IC/PBS experience dyspareunia, often in conjunction with chronic pelvic pain. When IC/PBS is suspected, there are simple measures to aid in the diagnosis of this condition, and treatments are readily available. CONCLUSIONS When a woman presents with the symptoms of urinary urgency and frequency, dyspareunia, nocturia, and/or pelvic pain, IC/PBS should be part of the diagnostic evaluation.

Current management of interstitial cystitis

The management of patients with IC remains a challenge because no single agent has proven universally effective. DMSO and PPS have been evaluated through early placebo-controlled trials, and these two agents are FDA approved treatments for IC. BCG is currently undergoing a large placebo-controlled trial, and hyaluronic acid is receiving similar clinical evaluation. Sacral nerve root stimulation shows promise with early favorable results. As with any treatment algorithm, it is reasonable to begin with conservative treatment using time-dependent milestones, allowing adequate trials of successive therapy while ensuring an appropriate pace for timely symptom resolution.

Traumatic Rupture of the Corpus Cavernosum: Evaluation and Management

Rupture of the corpus cavernosum is a rare but probably under-reported entity. It truly represents a urological emergency and current recommendations are for early surgical intervention. We review 5 cases with evaluation, treatment and followup. Delays in treatment lead to long-term complications, such as erectile dysfunction and penile curvature.

Depression, abuse and its relationship to interstitial cystitis

This study evaluated the prevalence of depression, sexual abuse, and physical abuse among women diagnosed with interstitial cystitis (IC). One hundred forty-one subjects completed the validated Becks Depression Inventory II Questionnaire (BDI-II) and the validated Drossman Abuse Questionnaire. Ninety-seven (69%) subjects scored 14 or higher on the BDI-II, corresponding to depression. When compared to the US prevalence of 9%, this was significantly higher. Fifty-one subjects (36%) reported sexual abuse which is higher than the US average. The prevalence of childhood sexual abuse in the sample was not significantly different than the US average. The prevalence of physical abuse in the sample was not statistically different than the US average. Women with IC appear to have a higher prevalence of depression and sexual abuse than the general population. Women with IC should be screened for depression and abuse and referred to a mental health expert as necessary for treatment.

Pelvic floor muscle re-education treatment of the overactive bladder and painful bladder syndrome

Normal function of the pelvic floor musculature is essential in maintaining appropriate function of the pelvic viscera. Low-tone pelvic floor dysfunction, as may be seen in patients with pelvic floor musculature denervation, can contribute to pelvic organ prolapse, transurethral urinary incontinence, vaginal laxity, or transrectal fecal incontinence. High-tone pelvic floor dysfunction, as may occur in patients with overactive bladder or painful bladder syndrome (interstitial cystitis), can manifest as voiding dysfunction, sexual dysfunction with dyspareunia, or fecal retention. Pelvic floor rehabilitation for patients with pelvic floor dysfunction is performed in an effort to restore normal tone and function to the muscles of the pelvic floor, and in patients with overactive bladder may provide an additional element of reflex bladder inhibition. Muscle reeducation techniques, typically preceded by a trial of behavioral therapy, include pelvic floor musculature exercises, pelvic floor musculature exercises with biofeedback, and electrical stimulation. The purpose of this chapter is to discuss the use of pelvic floor musculature rehabilitation to treat overactive bladder and to correct high-tone pelvic floor dysfunction.

Xanthogranulomatous Pyelonephritis and Amyloidosis: A Rare Association

The coincidence of systemic amyloidosis and xanthogranulomatous pyelonephritis has been reported previously only once. Clinical findings, such as the nephrotic syndrome, cardiac and autonomic nervous system dysfunction, and adrenal insufficiency, are suggestive and a thorough investigation to rule out other causes of secondary amyloidosis is warranted. We report a case of xanthogranulomatous pyelonephritis associated with secondary systemic amyloidosis and the nephrotic syndrome. Treatment consisted of nephrectomy and intensive supportive care. The unique clinical, radiographic and pathological aspects of this case are discussed.

Lack of effect following repeated in vivo exposure of the rabbit urinary bladder to urine from interstitial cystitis patients at low infusion volumes

We reported previously that substances in interstitial cystitis urine, when infused into the rabbit bladder, induce changes that resemble bladders of interstitial cystitis (IC) patients. Here we report our investigation of the effect of additional molecular weight subfractions of IC urine and lower infusion volume in this rabbit bladder bioassay. Urine was pooled from symptomatic IC patients, asymptomatic IC patients (in remission), and normal volunteers. Two fractions of 20× concentrated urine were obtained for each of the 3 groups: a 10–100‐kD fraction and a fraction > 100 kD but <0.22 μm. Six rabbits per group were infused twice per week with 6 ml of 1 of these 6 urine fractions or saline as a control. After 6 weeks, each rabbit was cystoscoped before and after hydrodistension, bladder capacity and urea permeability were determined, and the bladder was removed for histologic examination. A questionnaire revealed a significant difference (P < 0.01) regarding voiding symptom severity between symptomatic IC patients and both normal volunteers and IC patients in remission. There was no statistically significant difference among groups of rabbits in cystoscopic bladder appearance, bladder capacity, urea permeability, or bladder histology. If a urine‐borne factor is in part responsible for IC symptoms, the rabbit bladder must be filled with urine to near capacity to be able to detect a difference between IC and normal urine in this rabbit bladder bioassay. Neurourol. Urodynam. 17:147–152, 1998.