Rebecca J. McCrery

The safety and efficacy of ethylene vinyl alcohol copolymer as an intra-urethral bulking agent in women with intrinsic urethral deficiency.

Abstract The purpose of this post-marketing case-series is to report the short-term safety and effectiveness of ethylene vinyl alcohol (EVA) copolymer (TegressTM; C.R. Bard, Covington, GA, USA) in the treatment of intrinsic sphincter deficiency (ISD). The charts of all female patients who received ethylene vinyl alcohol (EVA) copolymer between 2005 and 2006 were reviewed for demographics, physical exam, urodynamic findings, outcomes and complications.Nineteen of twenty women who received EVA during this period completed follow-up. After an average of 1.4 injections, ∼58% of the patients had a complication related to the procedure with 37% experiencing urethral erosion. Of the patients, 10.5% reported at least a 50% subjective improvement in their symptoms. Intra-urethral bulking for the treatment of SID is meant to be minimally invasive and safe with minimal reports of complications. This series of 19 patients show significant percentage of patients experiencing serious complications with TegressTM. Additionally, TegressTM may be less efficacious than reported in the FDA trials, especially those with prior injections. A long-term prospective study needs to be performed in women with ISD before treatment can be recommended for general use by all gynecologists and urologists.

Transvaginal urethrolysis for obstruction after antiincontinence surgery

Our objective was to determine our success in relieving bladder outlet obstruction (BOO) with a transvaginal urethrolysis (TVU). This was a chart review that included 55 patients who underwent 61 TVU procedures between 2001 and 2005. Twenty-three patients had at least one prior TVU. Outcomes evaluated included obstructive symptoms, need for catheterization, postvoid residual (PVR), irritative symptoms, and stress urinary incontinence (SUI). Of the 46 patients with obstructive voiding preoperatively, 87% were cured. Of the 47 patients with irritative symptoms, 45% were cured, 34% improved, and 21% were left unchanged. SUI, generally mild, was noted postoperatively in 16% patients. Similar success was seen among patients with prior procedures. Aggressive TVU is very successful in relieving urinary retention and improving or curing overactive bladder symptomatology due to iatrogenic obstruction, even when a prior urethrolysis had been unsuccessful. SUI is an infrequent complication.

Current trends in the evaluation and management of female urinary incontinence

Despite its common occurrence and often seemingly obvious causes, female urinary incontinence requires a thorough and thoughtful evaluation for its proper diagnosis and treatment. With rare exceptions, urinary incontinence is the result of failure of the sphincter mechanism to resist bladder pressures encountered during daily activities. This may be the result of sphincter failure, overactivity of the bladder detrusor muscle or both. In uncomplicated cases, the diagnosis is usually based on an evaluation in the office. Urodynamic and cystoscopic study may be helpful in complex, resistant and recurring cases of urinary incontinence of any cause. Most cases of incontinence may be classified as stress, urge or mixed urinary incontinence. Treatment of stress urinary incontinence focuses on supplementing the urethral continence mechanisms, particularly the urethral supports and periurethral striated muscle function. The current paradigm for the treatment of urge incontinence centres on pharmacologic therapy, primarily by correcting detrusor overactivity with antimuscarinic drugs. Other therapies aimed at altering sensorimotor function may be used in resistant cases. The treatment of mixed urinary incontinence requires consideration of the contribution of each of its components. With proper diagnosis, effective treatment is possible for most patients.

Complications of ethylene vinyl alcohol copolymer as an intraurethral bulking agent in men with stress urinary incontinence.

OBJECTIVES To report the short-term safety and efficacy of ethylene vinyl alcohol (EVA) copolymer (Tegress; C.R. Bard, Inc., Covington, GA) in the off-label treatment of male stress urinary incontinence. METHODS We reviewed the charts of all adult male patients who received EVA copolymer between 2005 and 2006 for demographics, physical examination findings, urodynamic findings, outcomes, and complications. RESULTS A total of 17 of 18 men completed follow-up after receiving EVA during this time period. With an average of 1.4 injection sessions, 58.8% of patients experienced a complication related to the procedure, with 41.1% of these complications being urethral erosion of the material and 22% experiencing severe pain on injection. Subjective improvement of at least 50% was reported by 41.1% of patients. The mean follow-up period was 4.2 months. CONCLUSIONS Intraurethral bulking agents are meant to be a minimally invasive procedure with lower complication rates than alternatives such as the artificial urinary sphincter and male sling. The off-label use of EVA in men in this case series resulted in a significant complication rate. Urethral erosion was the most common complication causing dysuria, precluding further bulking in others, and resulting in loss of benefit with passage of material. In addition, EVA used in men may be less efficacious than the Food and Drug Administration data reported in women, especially with prior injectable therapy. In December 2006, EVA was voluntarily taken off the marketplace by CR Bard owing to reports from clinicians.

Spanish language translation of pelvic floor disorders instruments

The purpose of the study is to translate existing measures of pelvic symptoms and quality of life from English into Spanish, facilitating research participation of Hispanic/Latina women. The forward–backward translation protocol was applied then adjudicated by a concordance committee. The measures included the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), Medical, Epidemiological, and Social Aspects of Aging (MESA) Questionnaire, Hunskaar Severity Measure, Fecal Incontinence Severity Index and modified Manchester Questionnaire, Pelvic Organ Prolapse/Urinary Incontinence Sexual Functioning Questionnaire (PISQ), and the Life Orientation Test (LOT). English and Spanish versions were administered to 50 Hispanic/Latina women with pelvic symptoms. Kappa correlations of items and correlation coefficients for scales were computed. Psychometric testing for translations demonstrated good (0.80–0.89), very good (0.90–0.95), or excellent (>0.95) correlations for primary scales of the PFDI, PFIQ, MESA, Hunskaar, PISQ, and LOT. Strict translation techniques and testing yielded valid Spanish translations of instruments assessing pelvic symptoms/functional life impact in women with pelvic floor disorders.

The emergence of new drugs for overactive bladder

Overactive bladder is a common and distressing problem. Standard therapy is directed towards modifying the detrusor motor sensitivity and response via anticholinergic medication. Currently available medications are reviewed and alternative targets for treatment are presented.

Rodney A. Appell.

The field of Female Urology and Urogynecology has experienced a huge loss with the passing of Dr. Rodney Appell. Often, a physician is remembered by their contributions in a particular specialty. Many already know of his many publications in journals and textbooks. He was well known as an editor, his involvement with the NAFC and SUFU. He was an exceptional educator for many residents and fellows of which some have now become leaders in Urology and Urogynecology. For those who knew him well, he was much more. He was a man of integrity and brutal honesty. He was the person who was willing to take a stand for others. Whether it was for strangers being treated rudely by another passenger on a train or for his fellows caught in a political battle with university administration, he fought for what he believed was right and just. Everything he achieved was through his own merits and hard work. Many do not know that he did road construction during the summers to pay for medical school. To him, a half-day of work was from 6 AM to 6 PM. He had a strong belief in educating good surgeons and clinicians specifically in his area of focus of voiding dysfunction, incontinence, and pelvic organ prolapse. He happened to be one of the first Urologists to cross the specialty line by taking in Gynecologists as Fellows and training them in a Urology department. Prior to that, he taught the first Gynecologist to perform insertion of artificial urinary sphincters in women and later on men as well. We could elaborate on how much he taught us about surgery, clinical practice and urodynamics but this was just the academic aspect. For those who knew him best however, it was personal side that made him so unique. When you committed to him as a Fellow, he committed himself to you as a mentor in medicine and life. He was always ready to give advice about work and most importantly family. We learned of his sacrifices that he made that cost him precious time with his loved ones. He adored his sons, daughter-in-law, and his wife. We knew so much about them before we ever met them. When you earned his trust, you became a colleague and a friend where your input was expected and appreciated. His other loves included his dogs, fine restaurants, and the Houston Texans. He always had a good story from a fight breaking out on a salmon fishing trip to golfing with alligators (most involved many of the editors of prominent Urological journals). He had a great sense of humor with too many lines to quote, though often quoted by those who heard them. He also was generous with his time whether it was discussing physiology, research projects, or your spouse. He will be particularly missed by those of us fortunate enough to have been his Fellows. We owe him a great deal for his mentoring and friendship. He shaped us each uniquely as people and physicians which gave us the opportunity to obtain the careers that we currently have. Our hearts are with his family who loved him so very much. May he rest in peace and be remembered as a great physician, colleague, and friend.

Female neurogenic vesicourethral dysfunction: Evaluation and management

This paper outlines the evaluation and management of neurogenic vesicourethral dysfunction (NVUD). The anatomy and neurophysiology involved with lower urinary tract functions are reviwed. Multiple sclerosis, diabetes, lumbar disc prolapse, and Parkinson’s disease are specifically addressed. Proper evaluation of patients suspected of having NVUD, which is fundamental to making an accurate diagnosis, is discussed. This is followed by options for initiating individualized management plans that focus on protecting and preserving renal function, in addition to relieving the symptoms of NVUD.