Susan A. Barr

Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: efficacy and time to response.

Objectives: We sought to determine the efficacy of posterior tibial nerve stimulation in patients who had failed anticholinergic medications. A secondary outcome was to determine the time to response for different parameters of overactive bladder. Study Design: The medical records of all patients treated with posterior tibial nerve stimulation from 2000 to 2009 seen in a university urogynecology practice were abstracted. Patients underwent weekly treatments. Patients were asked about the 4 index symptoms at each weekly visit. Descriptive statistics were performed on the data set using SPSS 15. Results: A total of 141 patients were analyzed. Of these patients, 67.4% were satisfied with treatment results. The median week to improvement was 5 weeks for nocturia, 7 weeks for frequency, 6 weeks for urgency, and 6 weeks for urge incontinence. Conclusions: Posterior tibial nerve stimulation is an effective treatment of overactive bladder in patients who have failed anticholinergic therapy. Most patients noted improvement by 6 weeks.

Diagnosis and management of interstitial cystitis.

Interstitial cystitis is a diagnosis of exclusion. The definition has expanded over the years to encompass painful bladder syndrome. It is disease state that is often delayed in its diagnosis and difficult to manage. Treatment options include oral and intravesical therapies as well as both minor and major surgical options. Also, a patient can improve symptoms by following self-management recommendations that focus on both diet and stress management. Treatment options should be periodically evaluated with validated questionnaires to insure they are improving the patients symptoms, and a multidisciplinary approach is best to manage the patient.

Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms.

Objective The study aimed to determine which self-reported vulvovaginal symptoms are most consistent with candidiasis confirmed by yeast culture and to establish guidelines to determine who can be appropriately treated by telephone triage versus office examination for women with vulvovaginal symptoms. Materials and Methods A retrospective chart review of 105 patients seen in the Saint Louis University Vulvar and Vaginal Disorders Specialty Center during a 14-month period was performed after institutional review board approval. Patient’s age, medication use, symptom scores on a Likert rating scale for vaginal/vulvar pain, burning, itching, dyspareunia, wet-mount results, and yeast culture results were recorded. Differences in the occurrence of vaginal/vulvar symptoms of any severity between women with positive and with negative yeast culture results were calculated using &khgr;2 and Fisher exact tests. Differences in symptom scores of any severity were compared between women with positive and with negative yeast culture results using nonparametric Kolmogorov-Smirnov test, owing to a lack of normality of the distributions. Sensitivity of 75% or greater and specificity of 67% or greater were sought for all 9 recorded symptoms. Multiple logistic regression analysis was used to determine which symptoms and their cutoff values were significant independent predictors of a positive yeast culture result. Receiver operating characteristic curve analysis was used to determine the efficacy of individual symptoms and combinations of symptoms for predicting a positive yeast culture result. A value of p < 0.05 was used to denote statistical significance. Results Four vulvovaginal symptoms met cutoff criteria for analysis to predict a positive yeast culture result: vaginal burning, vulvar burning, vulvar itching, and clitoral pain. Vaginal burning with a score of 6 or greater (p < 0.001) and vulvar itching with a score of 5 or greater (p < 0.05) were significant independent predictors of a positive yeast culture result. Women with both a vaginal burning score of 6 or greater and a vulvar itching score 5 or greater had a positive predictive value of 91.7% (22/24). Vaginal discharge was not shown to be predictive of candidiasis. Conclusions Diagnosis of candidiasis using self-reported vulvovaginal symptoms by telephone triage is difficult. Self-reported scores for vaginal burning of 6 or greater and for vulvar itching of 5 or greater are significant indicators of a positive yeast culture result. Vaginal discharge was not predictive of a diagnosis of candidiasis. A symptom chart can aid office staff in telephone triage of symptomatic women.

Imaging of Pelvic Floor Reconstruction

Stress urinary incontinence and pelvic organ prolapse are 2 common pelvic floor disorders that are important causes of pelvic pain and disability. Mesh and sling placement are some of the surgical treatment options available for treatment of these conditions. In addition to clinical assessment, imaging plays an important role in managing postoperative patients with complications such as recurrent organ prolapse and chronic pain. Role of high-resolution pelvic magnetic resonance imaging with additional advanced imaging techniques, such as magnetic resonance neurography that are invaluable in managing such patients, are discussed in this article.

Bladder perforation during tension-free vaginal tape procedures: abdominal versus vaginal approach.

Objective Bladder perforation rates for the tension-free vaginal tape (TVT) are higher with inexperienced surgeons. The purpose of this study was to examine if surgical approach affects this rate. Methods We performed a retrospective cohort study of consecutive patients undergoing a TVT as the sole procedure. All cases were performed by senior residents using 2 different surgical approaches—vaginal or abdominal trocar passage. Power analysis indicated that 103 patients in each group (vaginal and abdominal approach) were required to demonstrate a 50% reduction in perforation rates. Results The rate of perforation was 37.9% (95% confidence interval [CI], 28.5%–47.3%) for the vaginal compared with 6.8% (95% CI, 1.9%–11.7%) for the abdominal technique (P < 0.001). The relative risk that the abdominal technique results in bladder injury compared with the original transvaginal was 0.18 (95% CI, 0.08–0.38). Conclusions Bladder perforation occurs significantly less frequently with abdominal needle placement for the TVT procedure. We recommend this technique to less experienced surgeons.

Acute renal failure caused by prolapsed leiomyoma.

CASE: A 46-year-old multigravid woman with a leiomyomatous uterus was admitted for vaginal bleeding and lightheadedness. She reported soaking up to 6 pads per hour and was clinically orthostatic. The emergency room physician saw a large leiomyoma prolapsing to the level of the introitus, and the cervix could not be palpated or visualized. A pelvic ultrasound examination showed a 26-cm axial length uterus, which at the fundus was 10 cm in depth and 11.4 cm in width. The echopattern was heterogenous, and it was suspected that the uterus was replaced by multiple poorly defined leiomyomas. Endometrial thickness was not seen. Neither ovary was demonstrated. Ultrasonography could be performed using only a transabdominal probe secondary to the prolapsing leiomyoma in the vagina. Endometrial biopsy had been attempted previously, but pathology revealed leiomyomatous tissue. The patient’s medical history included three cesarean deliveries and anemia. Her hematocrit was 33.2%, creatinine level was 0.73 mg/dL, and baseline laboratory results, including coagulation studies, were normal. She was admitted and transfused to be stabilized for hysterectomy. The patient was not started on pharmacologic deep vein thrombosis (DVT) prophylaxis owing to her bleeding risk, but sequential compression devices were placed on her. Just over 24 hours after admission, while the patient was being medically optimized for surgery, she developed acute shortness of breath, confusion, tachycardia, tachypnea, and hypotension and was transferred to the intensive care unit (ICU). Her creatinine level at that time was 1.65 mg/dL. Lower extremity Doppler scans showed multiple DVT, and spiral computed tomography showed multiple pulmonary emboli. The patient was started on a heparin infusion and transfused for persistent anemia (hematocrit 25.4%). A postulated mechanism for the pulmonary embolus was mass effect of the leiomyoma on the pelvic vessels. After the patient’s hypotension was corrected, her creatinine level decreased to 1.2 mg/dL and urine output was adequate. Given the patient’s medical condition, we considered uterine artery embolization for acute treatment of the bleeding. However, by hospital day 6, the leiomyoma delivered itself 3 cm beyond the hymen and the patient experienced difficulty urinating and had borderline urine output (770 cc in 24 hours). The patient initially refused a Foley catheter, but by the afternoon of hospital day 7, she had developed urinary retention, and a Foley catheter was placed. Planned uterine artery embolization was abandoned. An inferior vena cava filter was placed to stabilize the patient for hysterectomy. Over the next 16 hours, the Foley catheter drained blood-tinged watery fluid, with 450-cc output in 8 hours overnight. Clinically, the fluid appeared to be urine, but in retrospect it is evident that this was a combination of urine, vaginal discharge, and blood. At this time, the creatinine level had increased to 2.94 mg/dL and blood urea nitrogen was 25 mg/dL. A renal ultrasound examination revealed a misplaced Foley catheter in the vagina, a 14-cm urinary bladder, mild left hydronephrosis, and moderate right hydronephrosis (Fig. 1). Because the patient’s creatinine level had improved after her episode of hypotension in the ICU and because there was no evidence of brown granular casts on a urine specimen, the likelihood of acute tubular necrosis was presumed low. In the presence of hydronephrosis, the working diagnosis was acute renal failure (ARF) secondary to urinary tract obstruction. On examination, the patient had developed severe edema of her external urethral meatus and vulva with distortion of anatomy due to the prolapsing leiomyoma, and it was thought that this was the reason for the original misplacement of the catheter. The Foley catheter was From the Department of Obstetrics and Gynecology and Women’s Health, the Division of Urogynecology, and the Department of Internal Medicine, Division of Nephrology, Saint Louis University School of Medicine, St. Louis, Missouri.

FACE: Female Pelvic Medicine and Reconstructive Surgery Awareness Campaign: Increasing Exposure

Objective The aims of this study are to identify screening, treatment, and referral practices of primary care physicians (PCPs) for patients with pelvic floor disorders (PFDs) and evaluate awareness of the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) subspecialty. Methods We conducted a cross-sectional survey of PCPs using a random sample of 1005 American College of Physicians members, stratified by demographic region. Electronic survey content included awareness of FPMRS certification, comfort diagnosing and treating PFDs, and PFD referral patterns for PCPs. Results The 399 survey respondents were predominately male and of diverse ages, geographic distribution, and experience level. Forty-eight percent were aware of the FPMRS subspecialty, 31% of FPMRS board certification, and 25% of American Urogynecologic Society. Less than one third screened for PFDs, only two thirds were comfortable diagnosing urinary complaints, and even fewer felt comfortable diagnosing pelvic organ prolapse and fecal incontinence (FI). Eighty-five percent recommended pelvic floor exercises for stress urinary incontinence and referred to urology (29%) or FPMRS (25%) as second-line therapy, whereas 55% recommended medication/fiber for FI and referred to gastroenterology/colorectal surgery (31%) and FPMRS (2%) as second-line therapy. Primary care physicians referred to colorectal surgery for FI (60%), to Ob/Gyn for obstetric anal sphincter injury (38%) and pelvic organ prolapse (57%), and to urology for microscopic hematuria (80%), overactive bladder (60%), recurrent urinary tract infection (75%), stress urinary incontinence (48%), and voiding dysfunction (84%). Conclusions Most PCPs do not routinely screen for PFDs, and fewer feel comfortable treating. The majority is unaware of FPMRS and American Urogynecologic Society and more commonly refers PFD patients to other specialists.

Urethral Diverticulum Presenting as a Large Vaginal Mass Complicating Pregnancy and Delivery

Patient: Female, 25 Final Diagnosis: Urethral diverticulum Symptoms: Large anterior vaginal mass Medication: — Clinical Procedure: Primary cesarean section Specialty: Obstetrics and Gynecology Objective: Unusual presentation Background: A case report of urethral diverticulum complicating pregnancy is presented. The diagnosis and management are challenging because of the rare nature of this condition, the varied presentations and differential diagnoses, and the possibility of misdiagnosis. Case Report: A 25-year-old primigravida with scheduled induction of labor at 39 weeks gestation due to gestational diabetes mellitus presented for a routine antenatal appointment at 38 weeks and four days. On digital cervical examination, she was found to have a large semi-solid anterior vaginal mass, shown by trans-vaginal ultrasound to have a nearly solid appearance of a 5×7 cm mass with septation. Maternal Fetal Medicine and Gynecologic Oncology consultations were obtained primary cesarean section with vaginal biopsy in the Operating Room were recommended. Following an uncomplicated cesarean delivery and with the patient still under spinal anesthesia, the anterior vaginal mass was examined and found to contain 200 ml of purulent material. Because a diagnosis of urethral diverticulum was made, a biopsy was not performed. The patient was placed on antibiotic prophylaxis for the remainder of her hospital course. Follow-up CT scan confirmed a large urethral diverticulum, and she was referred to the Fetal Pelvic Medicine and Reconstructive Surgery (FPMRS) and Urogynecology units for treatment. Conclusions: Early identification of urethral diverticulum during the pregnancy may allow for treatment and a trial of labor with vaginal delivery. MRI is the recommended imaging modality in identifying urethral diverticulum.