Sangeeta T. Mahajan

Refractory Idiopathic Urge Urinary Incontinence and Botulinum A Injection

PURPOSE We compared 200 U intradetrusor botulinum toxin A vs placebo in women with refractory idiopathic urge incontinence. MATERIALS AND METHODS This institutional review board approved, multicenter registered trial randomized women with refractory urge incontinence, detrusor overactivity incontinence and 6 or greater urge incontinence episodes in 3 days to botulinum toxin A or placebo at a 2:1 ratio. Refractory was defined as inadequate symptom control after 2 or more attempts at pharmacotherapy and 1 or more other first line therapies for detrusor overactivity incontinence. The primary outcome measure was time to failure, as evidenced by a Patient Global Impression of Improvement score of 4 or greater at least 2 months after injection, or changes in treatment (initiation or increase) at any time after injection. Safety data, including increased post-void residual volume, defined as more than 200 ml irrespective of symptoms, was obtained at specified time points. RESULTS Approximately 60% of the women who received botulinum toxin A had a clinical response based on the Patient Global Impression of Improvement. The median duration of their responses was 373 days, significantly longer than the 62 days or less for placebo (p <0.0001). In the botulinum toxin A group increased post-void residual urine (12 of 28 women or 43%) and urinary tract infection in those with increased post-void residual urine (9 of 12 or 75%) exceeded expected ranges. Further injections were stopped after 43 patients were randomized, including 28 to botulinum toxin A and 15 to placebo. CONCLUSIONS Local injection of 200 U botulinum toxin A was an effective and durable treatment for refractory overactive bladder. However, a transient post-void residual urine increase was experienced in 43% of patients. Botulinum toxin A for idiopathic overactive bladder is still under investigation.

Under Treatment of Overactive Bladder Symptoms in Patients With Multiple Sclerosis: An Ancillary Analysis of the NARCOMS Patient Registry

PURPOSE We describe the prevalence of overactive bladder symptoms in patients with multiple sclerosis as well as the rates of evaluation and treatment of urinary complaints. MATERIALS AND METHODS Data from the fall 2005 North American Research Committee On Multiple Sclerosis survey were examined, including the Urogenital Distress Inventory plus a nocturia question, the SF-12, and inquiries regarding urological care and treatments. Data were analyzed using descriptive statistics, chi-square and Students t tests, ANOVA and multivariable logistic regression. RESULTS Of 16,858 surveys distributed 9,702 (58%) were completed. Participants with a surgically altered bladder were excluded from analysis (21). At least 1 moderate to severe urinary symptom (score of 2 or greater) was reported by 6,263 (65%) respondents. Increasing overactive bladder symptoms were correlated with longer disease duration (r = 0.135) and increasing physical disability (r = 0.291) (both p <0.001). Decreased quality of life was associated with increasing disability (p <0.001) and overactive bladder symptom score (p <0.001). Of patients with moderate to severe overactive bladder symptoms only 2,710 (43.3%) were evaluated by urology and 2,361 (51%) were treated with an anticholinergic medication. Treated patients more frequently reported leakage (p <0.001) and newer treatments were significantly underused (less than 10% total use). Catheter use was reported by 2,309 (36.8%) respondents, and was associated with greater disability, higher overactive bladder symptom score and reduced quality of life (all p <0.001). CONCLUSIONS This large scale study identified high rates of overactive bladder symptoms in patients with MS, and correlations with increasing disease duration and physical disability. Despite an increasing awareness of overactive bladder symptoms and the need for evaluation and treatment, many patients remain underserved.

Concentric needle electrodes are superior to perineal surface‐patch electrodes for electromyographic documentation of urethral sphincter relaxation during voiding

To compare interpretations of electromyographic (EMG) recordings from perineal surface patch electrodes (PSPEs) to those from urethral concentric needle electrodes (CNEs) during voiding.

The prevalence of urinary catheterization in women and men with multiple sclerosis

Abstract Context/objective To determine the prevalence of urinary catheterization in patients with multiple sclerosis (MS). Design/intervention After obtaining Institutional Review Board exemption, results from the Fall 2005 North American Research Committee on Multiple Sclerosis (NARCOMS) survey were reviewed. Participants Respondents to the fall 2005 NARCOMS survey. Outcome measures Responses to the Urogenital Distress Inventory (UDI-6), the Short Form-12 (SF-12), the Patient Determined Disease Steps measure of physical disability, and urologic history were analyzed using descriptive statistics, the χ2 and Students t-tests, and multivariable logistic and linear regression. Results Of 9702 (58%) responses were returned, excluding respondents with prior bladder surgery, 9676 participants were reviewed: primarily white (92.9%), women (75.3%), with average age of diagnosis of 30.2 (SD 10.0) years. Urinary catheterization was reported by 2514 (26%) respondents, with 1091 (11%) reporting current and 1423 (15%) past catheter use. Among all catheter types (possibly ≥1), intermittent self-catheterization was most common (81%), followed by transurethral Foley catheterization (43%) and suprapubic catheterization (8%). Males were more likely to catheterize than females (32 versus 24%, P < 0.001) and use indwelling methods (P < 0.001). Catheterizing patients reported longer disease duration, greater physical disability, increased overactive bladder symptoms, and reduced quality of life (QoL) scores (all P < 0.001). Conclusions This is the first study to demonstrate significant rates (1 in 4) of urinary catheterization in patients with MS. Although thought to be common, the true rates of catheter use among MS patient were previously unknown. Urinary catheterization appears to be associated with reduced QoL, increased physical disability and longer disease duration as well.

The Impact of Training Residents on the Outcome of Robotic-Assisted Sacrocolpopexy

Objective. To evaluate the surgical outcomes of robotic-assisted sacrocolpopexy (RASCP) before and after the incorporation of hands-on training for urology and gynecology residents. Study Design. Forty-one patients underwent RASCP between December 2008 and March 2010 with one surgeon. RASCP was performed in the context of surgical repair of complex pelvic organ prolapse and/or stress urinary incontinence. The first 20 cases (group I) were performed exclusively by the attending surgeon. In the last 21 cases (group II), the urology resident performed a 50% or more of the RASCP while the gynecology resident performed the supracervical hysterectomy. The primary outcome measure was vaginal vault support at 24 weeks postoperatively based on pelvic organ prolapse quantification (POP-Q). Results. Mean ± SD operative time for the entire surgery including RASCP was 282.3 ± 51.3 min and median EBL was 83.1 ± 50.4 mL. Patient demographics and stage of disease did not differ between groups. Procedure time, PACU time, blood loss, and intraoperative complications were similar between groups. Follow-up POP-Q evaluations demonstrated significant correction of all points on vaginal examination for both groups (P < 0.001). Conclusions. Incorporation of resident training during RASCP allows teaching of robotic surgery techniques in an effective manner without prolonging operative time or affecting the overall surgical outcome.

Uterus Didelphys and Longitudinal Vaginal Septum Coincident with an Obstructive Transverse Vaginal Septum

A wide variety of Müllerian anomalies has been described in the literature. Various combinations of anomalies may coexist in a single subject. Precise identification of the various components of the anomaly is paramount in choosing and planning the appropriate conservative and surgical treatment. In this report, we present a rare case of combined vertical fusion and transverse canalization defects in a single subject. A review of the literature along with an overview of the pertinent embryologic processes and management concepts for such cases are presented.

Sexual dysfunction in patients with multiple sclerosis.

BACKGROUND Sexual dysfunction (SD) is a common complaint in female and male patients with multiple sclerosis (MS) and can arise at anytime during the course of the disease even in patients with low disability. Increasing neurological and physical impairment, psychological factors, and medication side effects are thought to increase rates of SD. OBJECTIVE To determine the prevalence of various SD symptoms among MS patients, their impact on patient self-reported sexual activity and satisfaction (SAS), and to examine the rates at which symptomatic patients utilize therapies for their complaints. METHODS Results from the Spring, 2006 North American Research Committee on Multiple Sclerosis (NARCOMS) Project were reviewed. Participants were asked to answer the Multiple Sclerosis Intimacy and Sexuality Questionaire-19 (MSISQ-19) and to indicate which symptomatic therapy they used to alleviate SD. Symptoms were grouped as severe (they impacted SAS always or almost always), moderate (occasionally), and mild (never or almost never). Primary end point was the prevalence of SD symptoms and their impact on patient SAS. RESULTS Of 17,883 surveys mailed, 9861 (55.1%) responses were returned. Of these, 6739 (68.3%) answered the questions on sexuality. Respondents were primarily female (76.7%), Caucasian (87.8%), with average age of 38.4 (±9.6), and time since diagnosis of 13.9 years (±9.3). 38.6% of male subjects and 34.8% of female subjects experienced at least 5 different types of severe symptoms. Also, 14.3% of males and 12.9% of females complained of at least 10 severe symptoms that affected their SAS. The most common severe symptoms were shared by both sexes: too long to achieve orgasm/climax (37.8%), inadequate lubrication/difficult erection (36.5%), less intense or pleasure with orgasm/climax (35.2%), lack of interest or desire (32.1%), problems moving the body (29.1%), less feeling or numbness in genitals (28.8%), feeling less confident (25.5%), and body less attractive (24.8%). The severe symptoms positively correlated with time since diagnosis, Patient Determined Disease Steps Score, bladder disability score, and spasticity score. Few patients with at least one severe symptom used therapies to improve their SD (vibrators 19.1%, phosphodiesterase-5 enzyme inhibitors 14.2%, other medications 0.6%, counseling 4.1%, penile device 1.0%, intracorporeal therapy 0.7%, sex surgery 0.5%, and clitoral device 0.3%). CONCLUSION SD in patients with MS is multifactorial and very similar in men and women. Despite increasing therapeutic options, many patients with MS do not seek treatment for their SD complaints. It is very important for the physicians caring for patients with MS to initiate discussion of potential SD to allow earlier diagnosis and treatment.

The use of botulinum toxin for the treatment of overactive bladder syndrome.

Over the last 50 years, botulinum toxin has been transformed from a cause of life-threatening disease to an effective medical therapy. It has been used in a variety of specialties for different indications, significantly improving patient quality of life. A recent growing body of evidence suggests that intra-detrusor injection of botulinum toxin may have beneficial effects in patients with medication refractory detrusor overactivity and may offer a new minimally invasive alternative to patients with severe overactive bladder symptoms. To review current data regarding the effects of botulinum toxin in patients with overactive bladder, a MEDLINE®/PubMed® literature search was carried out. The mechanism of action, clinical usage, adverse effects, and treatment efficacy were reviewed and the results are presented in this paper.

Urinary Catheterization May Not Adversely Impact Quality of Life in Multiple Sclerosis Patients

Background. Multiple sclerosis (MS) healthcare providers (HCP) have undergone considerable educational efforts regarding the importance of evaluating and treating pelvic floor disorders, specifically, urinary dysfunction. However, limited data are available to determine the impact of catheterization on patient quality of life (QoL). Objectives. To describe the use of urinary catheterization among MS patients and determine the differences between those who report positive versus negative impact of this treatment on QoL. Methods. Patients were queried as part of the 2010 North American Research Committee On Multiple Sclerosis survey; topics included 1) urinary/bladder, bowel, or sexual problems; 2) current urine leakage; 3) current catheter use; 4) catheterizing and QoL. Results. Respondents with current urine leakage were 5143 (54.7%), of which 1201 reported current catheter use (12.8%). The types of catheters (intermittent self-catheterization and Foley catheter (indwelling and suprapubic)) did not differ significantly. Of the current catheter users, 304 (25.35%) respondents reported catheterization negatively impacting QoL, 629 (52.4%) reported a positive impact on QoL, and 223 (18.6%) reported neutral QoL. Conclusions. A large proportion of catheterized MS patients report negative or positive changes in QoL associated with urinary catheterization. Urinary catheterization does not appear to have a universally negative impact on patient QoL.

Interstitial Cystitis - Elucidation of Psychophysiologic and Autonomic Characteristics (the ICEPAC Study): design and methods.

Background and purpose Interstitial cystitis/bladder pain syndrome (IC/BPS) is relatively common and associated with severe pain, yet effective treatment remains elusive. Research typically emphasized the bladder’s role, but given the high presence of systemic comorbidities, the authors hypothesized a pathophysiologic nervous system role. This paper reports the methodology and approach to study the nervous system in women with IC/BPS. The study compares neurologic, urologic, gynecologic, autonomic, gastrointestinal, and psychological features of women with IC/BPS, their female relatives, women with myofascial pelvic pain (MPP), and healthy controls to elucidate the role of central and peripheral processing. Methods and results In total, 228 women (76 IC/BPS, 76 MPP, 38 family members, and 38 healthy controls) will be recruited. Subjects undergo detailed screening, structured neurologic examination of limbs and pelvis, tender point examination, autonomic testing, electrogastrography, and assessment of comorbid functional dysautonomias. Interpreters are blinded to subject classification. Psychological and stress response characteristics are examined with assessments of stress, trauma history, general psychological function, and stress response quantification. As of December 2012, data collection is completed for 25 healthy controls, 33 IC/BPS ± MPP, eight MPP, and three family members. Recruitment rate is accelerating and strategies emphasize maintaining and encouraging investigator participation in study science, internet advertising, and presentations to pelvic pain support groups. Conclusion The study represents a comprehensive, interdisciplinary approach to sampling autonomic and psychophysiologic characteristics of women with IC/BPS. Despite divergent opinions on study methodologies based on specialty experiences, the study has proven feasible to date and different perspectives have proved to be one of the greatest study strengths.