Laura Nguyen

Outcomes for Intermittent Neuromodulation as a Treatment for Overactive Bladder

Purpose of ReviewIn this review, we describe the history and basic science behind intermittent neuromodulation, specifically of the tibial nerve and its neuroanatomic suitability for this approach, as well as the logistics, efficacy, and advantages of peripheral tibial nerve stimulation (PTNS) in both idiopathic and neurogenic overactive bladder (OAB) populations. We also discuss the less commonly used sacral, pudendal, and genital nerves as a means of intermittent neuromodulation for the management of OAB.Recent FindingsIntermittent neuromodulation in the form of PTNS is approved as a third-line treatment of OAB, which affects upwards of 16% of the population of the USA.SummarySeveral studies and clinical trials have demonstrated the effectiveness of PTNS in treating OAB, with the benefit of decreased cost and invasiveness compared to chronic, implantable neurostimulators. This has been explored in various patient populations including patients with idiopathic and neurogenic detrusor overactivity.

Current best practice management of interstitial cystitis/bladder pain syndrome

Introduction: Over the last 100 years, the terminology and diagnosis criteria for interstitial cystitis have evolved. Many therapeutic options have changed, but others have endured. This article will review the idea of separating ‘classic’ Hunner lesion interstitial cystitis (HL IC) from non-Hunner lesion interstitial cystitis and bladder pain syndrome (N-HL IC/BPS) and their respective treatment algorithms. Methods/Results: A literature search was performed to identify articles and research on HL IC and N-HL IC/BPS including definitions, etiological theories, and treatments. This article is an overview of the existing literature. We also offer insight into how HL IC and N-HL IC/BPS are approached at our tertiary referral center. Additionally, American Urological Association guidelines have been integrated and newer treatment modalities and research will be introduced at the conclusion. Conclusion: The AUA guidelines have mapped out a stepwise fashion to treat IC/BPS; at our institution we separate patients with HL IC from those with N-HL IC/BPS prior to them entering a treatment pathway. We identify the rarer patient with HL as having classic ‘IC’; this cystoscopic finding is critical in guiding treatment. We believe HL IC is a distinct disease from N-HL IC/BPS and therapy should focus on the bladder. The vast majority of patients with N-HL IC/BPS need management of their pelvic floor muscles as the primary therapy, complemented by bladder-directed therapies as needed as well as a multidisciplinary team to manage a variety of other regional/systemic symptoms. Ongoing research into IC/BPS will help us better understand the pathophysiology and phenotypes of this complex disease while exciting and novel research studies are developing promising treatments.

The Future of Neuromodulation

Neuromodulation for the treatment of urological conditions including overactive bladder symptoms has been available for decades but minimal advances have been made to improve efficacy, decrease cost and decrease morbidity. In the past few years, however, many novel devices that take advantage of new technologies have been developed and are currently in testing phases. These new devices address current limitations by using wireless battery charging, external power source technology and minimally invasive percutaneous implantation techniques. In addition to innovative devices, neuromodulation is also expanding for use for broader patient indications and targeting novel nerve targets including the dorsal genital and cavernous nerves.

PD44-01 CHARACTERISTICS AND OUTCOMES OF WOMEN PRESENTING TO A MULTIDISCIPLINARY WOMEN'S UROLOGY CLINIC

INTRODUCTION AND OBJECTIVES: We report on women with a variety of complex, often pain-based pelvic floor conditions managed in a comprehensive multidisciplinary Women’s Urology Center (WUC) that offers urological, gynecological, colorectal, psychological, pelvic floor physical therapy and integrative medicine treatments. METHODS: Women presenting 2011-2015 were reviewed. Descriptive statistics were performed. A mailed survey to patients presenting in 2013-2014 assessed current status and satisfaction with treatment. Baseline and follow up Pelvic Floor Distress Inventory (PFDI20) overall and subscale scores (Pelvic Organ Prolapse Distress Inventory (POPDI-6), Colorectal and Anal Distress Inventory (CRADI-8) and Urinary Distress Inventory (UDI-6)) were analyzed. RESULTS: 693 new patients were seen in the specified time period. Mean age was 51 (range 17-91). Most common chief complaints were pelvic pain (219/687, 32%), urine incontinence (110/687, 16%), and overactive bladder (75/687, 11%). WUC treats women with complicated pelvic floor issues, provides 30-90 minute appointments including multidisciplinary care, yet even with this careful, tailored personal management only 89/567 (16%) patients returned the follow up survey. 85% (71/84) of responders were satisfied with the care and 35% (31/88) were still managed at the WUC. Of those who did not return, 44% (19/43) were improved / satisfied and did not need to return, 49% (21/43) had logistical reasons (live out of area, insurance issues, or inconvenient appointment times) and only7% (3/43) were unhappy with their care. Compared to non-responders, survey respondents had similar age and chief complaint, were more educated (p1⁄40.02), and were less likely to smoke (p<0.01) but more likely to have diabetes (p1⁄40.04). Rates of anxiety and depression were similar between groups (p1⁄40.25, p1⁄40.67). Most common treatments included pelvic floor physical therapy (55%), pelvic floor trigger point injections (15%), medications (24%), and coping strategies (58%). Mean PFDI-20 scores improved (82 to 64), all subscale scores improved (POPDI-6 from 24 to 17, CRADI-8 from 19 to 17 UDI-6 from 37 to 29) however, only the CRADI-8 met the minimally important difference. CONCLUSIONS: Complex pelvic floor issues are difficult. Many patients were outside our catchment area, had seen multiple providers and were refractory to standard therapies. Although survey response was low, the majority of patients were pleased with their care. A multidisciplinary clinic providing individualized, comprehensive care is effective for pelvic floor symptoms.

PD02-11 ADDITIONAL TREATMENTS, SATISFACTION, AND QUALITY OF LIFE IN WOMEN AFTER TRANSVAGINAL AND ABDOMINAL PELVIC ORGAN PROLAPSE REPAIR

INTRODUCTION AND OBJECTIVES: We evaluated satisfaction, quality of life, and additional treatments after transvaginal (TV) and abdominal (ABD) pelvic organ prolapse (POP) repair. METHODS: Adult women enrolled in a prospective POP database were reviewed. Baseline and outcomes data one year after surgery were collected from medical records, validated Pelvic Floor Distress Inventory (PFDI), and mailed surveys, and analyzed with descriptive statistics, Fishers Exact, and two sample t tests. RESULTS: Two hundred twenty-two patients were identified from the database, of whom 147 (66%) had TV and 75 (34%) had ABD repair. TV patients were older (mean 64.1 vs. 59.7 years; p1⁄40.003) but no differences in BMI, race, marital status or other demographics were identified. Preoperative mean anterior (TV 2.7 vs. ABD 3.1; p1⁄40.003) and apical (TV 2.1 vs. ABD 3.1; p<0.001) POP grades were more severe in the ABD patients compared to the TV patients. Baseline PFDI scores however were similar between groups (TV 115.8 vs. ABD 111.6, p1⁄40.605). At one year PFDI scores were improved in both groups, though were significantly higher in the TV group (45.6 vs. 32.6; p1⁄40.032). Absolute score improvement from baseline to 1-year did not differ (TV -67.6 vs. ABD -76.1, p1⁄40.353). The majority of patients in both groups reported moderately or markedly improved overall symptoms (TV 79/101; 78% and ABD 51/59; 86% p1⁄40.199) and quality of life (80/101; 79% and 51/59; 87% p1⁄40.252). Similar proportions of patients in both groups (TV 52/109; 48% vs. ABD 21/62; 34%, p1⁄40.108) had additional POP treatments including pelvic floor physical therapy, medications, coping strategies, and surgical procedures. Specifically, there was no difference in rates of additional surgical treatments for prolapse between groups (TV 32/109; 29% vs. ABD 10/62; 11%, p1⁄40.053). Most TV and ABD patients were satisfied (68/101; 68% and 48/59; 81%, p1⁄40.055, respectively) and would recommend to a friend (85/99; 86% and 55/57; 96%, p1⁄40.052). CONCLUSIONS: This study suggests that although symptoms, satisfaction and quality of life improve after both TV and ABD prolapse repair, women seek additional treatments as early as the first year after POP repair.

PD39-07 PELVIC FLOOR PHYSICAL THERAPY SIGNIFICANTLY IMPROVES PAIN AND VOIDING SYMPTOMS IN WOMEN WITH PELVIC PAIN

Frequency of urination is the most commonly reported symptom at 12 months (62%) followed by difficulty postponing urination (40%), leakage (35%) and nocturia (3.7%). Younger men (median 61 vs 59 year, p1⁄40.032) and those with a higher BMI (27.5 vs 28.2, p1⁄40.049) are more likely to report worsening symptoms. However, differences between groups are small. For example, the probability of storage dysfunction is 23% for a patient with a BMI of 25 compared to 26% for a patient with a BMI of 30. No significant association was identified between prostate volume, prior TURP, EBL, operative time, postoperative leakage or hematoma, ASA, Charlson comorbidity index score or pathologic tumor characteristics. CONCLUSIONS: There is a subgroup of patients post-RP who will experience de novo storage symptoms in the absence of an anastomotic stricture. Younger patients and those with a higher BMI may be at a higher risk, reflecting a broader clinical picture where patients with little to no urinary bother may be more acutely aware of new storage symptoms and those with a higher preoperative weight may more commonly develop urinary leakage that stimulates a reflex detrusor contraction. At risk patients should be counseled on the incidence of de novo storage symptoms in the perioperative period.

Clinical Factors to Decide Between Sacral Neuromodulation and Onabotulinum Toxin—When Is One Clearly Better?

Purpose of ReviewThis article provides a review of the current literature on the applicability of each treatment for OAB, as well as unique clinical scenarios. In addition, the authors provide their own practical insight on how to approach third-line therapies for OAB.Recent FindingsThe treatment of overactive bladder (OAB) is increasingly common amongst specialists. OnabotulinumtoxinA and sacral neuromodulation are both highly effective third-line therapies for OAB, but work via very different mechanisms. The differences between the two are associated with potential benefits and complications unique for each.SummaryThe OAB clinician must account for several clinical and personal factors in counseling patients on options.