Partially Obstructed Longitudinal Vaginal Septum Presenting in Adulthood With Complaint of Urinary Incontinence

A longitudinal vaginal septum can be obstructive or nonobstructive. We report on an adult woman who presented with involuntary fluid loss per vagina and had a partially obstructive longitudinal vaginal septum. A 36-year-old nulliparous female presented with malodorous, clear, leakage per vagina that she described as "urinary incontinence." Examination revealed a fluid-filled fluctuant anterior vaginal wall with a draining sinus. Imaging revealed a solitary right kidney with duplicated ectopic fluid-filled ureters inserting into a partially obstructed left hemivagina with a longitudinal vaginal septum. A longitudinal vaginal septum may present in adulthood with the complaint of urinary incontinence.

Treatment and Prevention of Recurrent Lower Urinary Tract Infections in Women: A Rapid Review with Practice Recommendations

PURPOSE

Recurrent lower urinary tract infections in women are a highly prevalent and burdensome condition for which best practice guidelines for treatment and prevention that minimize harm and optimize well-being are greatly needed. To inform development of practice recommendations, a rapid literature review of original research, systematic reviews, meta-analyses and practice guidelines was conducted.

MATERIALS AND METHODS

PubMed®, Embase®, Opus, Scopus®, Google Scholar, The Cochrane Library and the U.S. National Guideline Clearinghouse electronic databases were searched from inception to September 22, 2017. Articles and practice guidelines were included if they were in English, were peer reviewed, included women, involved treatment or prevention strategies for recurrent urinary tract infection and reported an outcome related to recurrence rates of urinary tract infection. Critical appraisal of original studies was conducted using the Cochrane risk of bias tool, and of systematic reviews using the AMSTAR 2 tool.

RESULTS

Of 1,582 citations identified 74 met our study inclusion criteria. These comprised 49 randomized controlled trials, 23 systematic reviews (16 with meta-analyses) and 2 practice guidelines. No study reported a multi-targeted treatment approach. There was a lack of high quality studies and systematic reviews evaluating prevention strategies for recurrent urinary tract infection.

CONCLUSIONS

We recommend an algorithmic approach to care that includes education on lifestyle and behavioral modifications, and addresses specific populations of women with antimicrobial based and nonantibiotic alternatives. This approach includes the use of vaginal estrogen with or without lactobacillus containing probiotics in postmenopausal women, low dose post-coital antibiotics for recurrent urinary tract infection associated with sexual activity in premenopausal women, low dose daily antibiotic prophylaxis in premenopausal women with infections unrelated to sexual activity, and methenamine hippurate and/or lactobacillus containing probiotics as nonantibiotic alternatives. Future research should involve consistent use of terminology, validated instruments to assess response to interventions and patient perspectives on care. Our treatment algorithm is based on the best available evidence, and fills a gap in the literature and practice regarding effective strategies to prevent recurrent urinary tract infection in women.

A Novel Research Definition of Bladder Health in Women and Girls: Implications for Research and Public Health Promotion

BACKGROUND

Bladder health in women and girls is poorly understood, in part, due to absence of a definition for clinical or research purposes. This article describes the process used by a National Institutes of Health funded transdisciplinary research team (The Prevention of Lower Urinary Tract Symptoms [PLUS] Consortium) to develop a definition of bladder health.

METHODS

The PLUS Consortium identified currently accepted lower urinary tract symptoms (LUTS) and outlined elements of storage and emptying functions of the bladder. Consistent with the World Health Organization's definition of health, PLUS concluded that absence of LUTS was insufficient and emphasizes the bladder's ability to adapt to short-term physical, psychosocial, and environmental challenges for the final definition. Definitions for subjective experiences and objective measures of bladder dysfunction and health were drafted. An additional bioregulatory function to protect against infection, neoplasia, chemical, or biologic threats was proposed.

RESULTS

PLUS proposes that bladder health be defined as: "A complete state of physical, mental, and social well-being related to bladder function and not merely the absence of LUTS. Healthy bladder function permits daily activities, adapts to short-term physical or environmental stressors, and allows optimal well-being (e.g., travel, exercise, social, occupational, or other activities)." Definitions for each element of bladder function are reported with suggested subjective and objective measures.

CONCLUSIONS

PLUS used a comprehensive transdisciplinary process to develop a bladder health definition. This will inform instrument development for evaluation of bladder health promotion and prevention of LUTS in research and public health initiatives.

Specific Changes in Brain Activity during Urgency in Women with Overactive Bladder after Successful Sacral Neuromodulation: A Functional Magnetic Resonance Imaging Study

PURPOSE

The mechanism of sacral neuromodulation is poorly understood. We compared brain activity during urgency before and after sacral neuromodulation in women with overactive bladder and according to the response to treatment.

MATERIALS AND METHODS

Women with refractory overactive bladder who elected sacral neuromodulation were invited to undergo functional magnetic resonance imaging before and after treatment. During imaging the bladder was filled until urgency was experienced. Regions of interest were identified a priori and brain activity in these regions of interest was compared before and after treatment as well as according to the treatment response. Whole brain exploratory analysis with an uncorrected voxel level threshold of p <0.001 was also performed to identify additional brain regions which changed after sacral neuromodulation.

RESULTS

Of the 12 women who underwent a pretreatment functional magnetic resonance imaging examination 7 were successfully treated with sacral neuromodulation and underwent a posttreatment examination. After sacral neuromodulation brain activity decreased in the left anterior cingulate cortex, the bilateral insula, the left dorsolateral prefrontal cortex and the bilateral orbitofrontal cortex (each p <0.05). No new brain regions showed increased activity after sacral neuromodulation. Pretreatment brain activity levels in the bilateral anterior cingulate cortex, the right insula, the bilateral dorsolateral prefrontal cortex, the right orbitofrontal cortex, the right supplementary motor area and the right sensorimotor cortex were higher in women who underwent successful treatment (each p <0.05).

CONCLUSIONS

Brain activity during urgency changes after successful sacral neuromodulation. Sacral neuromodulation may be more effective in women with higher levels of pretreatment brain activity during urgency.

Expression of perforin, granzyme A and Fas ligand mRNA in caecal tissues upon Eimeria tenella infection of naïve and immune chickens

Cytotoxic cells of the immune system may kill infected or transformed host cells via the perforin/granzyme or the Fas ligand (FasL) pathways. The purpose of this study was to determine mRNA expression of perforin, granzyme A and FasL in Eimeria tenella-infected tissues at primary infection and infection of immune chickens as an indirect measure of cytotoxic cell activity. Chickens were rendered immune by repeated E. tenella infections, which were manifested as an absence of clinical signs or pathological lesions and significantly reduced oocyst production upon challenge infection. During primary E. tenella infection, perforin, granzyme A and FasL mRNA expression in caecal tissue was significantly increased at 10 days after infection, compared to uninfected birds. In contrast, at infection of immune birds, perforin and granzyme A mRNA expression in caecal tissue was significantly increased during the early stages of E. tenella challenge infection, days 1-4, which coincided with a substantial reduction of parasite replication in these birds. These results indicate the activation of cytotoxic pathways in immune birds and support a role for cytotoxic T cells in the protection against Eimeria infections.

The use of a mini bypass system (Cobe Synergy) without venous and cardiotomy reservoir in a mitral valve repair: a case report

The use of mini cardiopulmonary bypass circuits is an emerging technology. The venous and cardiotomy reservoir have been excluded from the circuit. This results in a reduction of the blood contact surface area and of the priming volume.

Entrainment of venous air, however, remains a drawback in the widespread acceptance of using these mini circuits.

The technique described resolves this problem by automatic removal of venous air, and explains how this mini cardiopulmonary bypass circuit was utilized on a 64-year-old female presented for a mitral valve repair.

In the absence of a cardiotomy reservoir, an autotrans-fusion cell separator was used to process shed blood and, after CPB, the residual pump blood.

This mini bypass circuit, with the safety feature to remove automatically venous air, provided an additional degree of protection.

In our experience, mini bypass circuits allow us safely to perform cardiopulmonary bypass during valve procedures.

A standardized surgical technique for removal of the Interstim tined lead

INTRODUCTION

Explantation of the Interstim sacral neuromodulation (SNM) device is occasionally necessary. Removing the tined lead can put strain on the lead, resulting in a possible break and retained fragments. The Food and Drug Administration (FDA) released a notification regarding health consequences related to retained lead fragments. We describe a novel and safe surgical technique for removing the Interstim device and permanent lead.

MATERIALS AND METHODS

We searched the Manufacturer and User Facility Device Experience (MAUDE) database for complications related to tined lead removal and searched the database of a single surgeon at our institution. Our standardized technique for tined lead removal is as follows. An incision is made over the previous lead insertion site and the lead is isolated and externalized. The fibrous encapsulation is dissected off the lead to expose the tines and ensure the lead is free from adhesions. The lead is removed by wrapping it around a curved hemostat and turning it under tension. If the lead breaks, the incision is extended and dissection is carried down to the sacral body to remove all fragments.

RESULTS

Twenty-eight patients had their tined lead removed between 2009 and 2015 after being in place a median of 2.00 years (IQR 1.32-3.32 years). One lead broke (3.6%) during removal over the 6 years using our standardized approach.

CONCLUSION

Permanent tined leads can break on removal and retained fragments can pose significant health consequences. Our technique standardizes the approach for removal and is safe and effective in our series.

Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.

METHODS

ESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.

RESULTS

The final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.

CONCLUSIONS

We describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making.

The Impact of Treatment of Overactive Bladder on Physical Activity Limitations

PURPOSE

To determine if treatment of overactive bladder (OAB) can improve self-reported limitations in physical activity in women.

MATERIALS AND METHODS

This is a prospective study of women with OAB treated with flexible-dose fesoterodine therapy and standardized behavioral counseling. Subjects were evaluated at baseline and 8 weeks post-treatment. Physical activity scores were assigned using two questions of the Short Form 12 (SF-12) and categorized into three levels of physical activity (no limitations, moderate limitations, severe limitations). Response of urinary symptoms to treatment at 8 weeks was measured using the Patient Global Impression of Improvement. Physical activity limitations at baseline and 8 weeks were compared.

RESULTS

We recruited 137 women. At baseline, 71 (52%) women had no limitations, 34 (25%) had moderate, and 32 (23%) had severe physical limitations. Eight weeks after treatment, the proportion of women reporting severe limitations in physical activity was significantly lower with 71 (52%) women reporting no limitations, 50 (36%) reporting moderate, and 16 (12%) reporting severe limitations in physical activity (p = 0.001). At 8 weeks, the proportion of women with no limitations in physical activity was higher in responders than nonresponders (52% vs. 33%), and the proportion of women with severe restriction was lower in responders (13% vs. 17%), although there was no significant difference between the groups (p = 0.24), which both showed overall improvement in physical activity limitations.

CONCLUSION

Treatment of OAB is associated with a decrease in perceived physical activity limitations; however, this is not directly associated with improvement in urinary symptoms.

Viral Reservoirs in Lymph Nodes of FIV-Infected Progressor and Long-Term Non-Progressor Cats during the Asymptomatic Phase

Background

Examination of a cohort of cats experimentally infected with feline immunodeficiency virus (FIV) for 5.75 years revealed detectable proviral DNA in peripheral blood mononuclear cells (PBMCs) harvested during the asymptomatic phase, undetectable plasma viral RNA (FIV gag), and rarely detectable cell-associated viral RNA. Despite apparent viral latency in peripheral CD4+ T cells, circulating CD4+ T cell numbers progressively declined in progressor animals. The aim of this study was to explore this dichotomy of peripheral blood viral latency in the face of progressive immunopathology. The viral replication status, cellular immunophenotypes, and histopathologic features were compared between popliteal lymph nodes (PLNs) and peripheral blood. Also, we identified and further characterized one of the FIV-infected cats identified as a long-term non-progressor (LTNP).

Results

PLN-derived leukocytes from FIV-infected cats during the chronic asymptomatic phase demonstrated active viral gag transcription and FIV protein translation as determined by real-time RT-PCR, Western blot and in situ immunohistochemistry, whereas viral RNA in blood leukocytes was either undetectable or intermittently detectable and viral protein was not detected. Active transcription of viral RNA was detectable in PLN-derived CD4+ and CD21+ leukocytes. Replication competent provirus was reactivated ex vivo from PLN-derived leukocytes from three of four FIV-infected cats. Progressor cats showed a persistent and dramatically decreased proportion and absolute count of CD4+ T cells in blood, and a decreased proportion of CD4+ T cells in PLNs. A single long-term non-progressor (LTNP) cat persistently demonstrated an absolute peripheral blood CD4+ T cell count indistinguishable from uninfected animals, a lower proviral load in unfractionated blood and PLN leukocytes, and very low amounts of viral RNA in the PLN.

Conclusion

Collectively our data indicates that PLNs harbor important reservoirs of ongoing viral replication during the asymptomatic phase of infection, in spite of undetectable viral activity in peripheral blood. A thorough understanding of tissue-based lentiviral reservoirs is fundamental to medical interventions to eliminate virus or prolong the asymptomatic phase of FIV infection.

The impact of pontine disease on lower urinary tract symptoms in patients with multiple sclerosis

AIMS

To investigate the relationship between pontine lesion characteristics on MRI and lower urinary tract symptoms (LUTS) in patients with multiple sclerosis (MS).

METHODS

We performed a prospective cohort study of patients with MS and LUTS who were undergoing brain/spine MRI. Patients were administered the American Urological Association Symptom Score (AUA-SS), Medical, Epidemiologic, and Social Aspects of Aging questionnaire (MESA), and Urogenital Distress Inventory questionnaire (UDI-6), underwent Kurtzke Expanded Disability Status Scale (EDSS) scoring by a neurologist, and had their MRIs reviewed by a neuroradiologist. The relationships between symptom scores and lesion number, size, and location were analyzed.

RESULTS

There were 42 patients that completed the study and 20 (48%) had one or more pontine lesions. Total AUA-SS and UDI-6 were related to multiple Short Form Health Survey (SF-36) scales and not EDSS scoring. Weak urinary stream measured on the AUA-SS (P = 0.028), and urgency incontinence measured on the MESA questionnaire (P = 0.034) were related to pontine lesion diameter. There was no difference in urinary symptoms according to the presence or absence of a pontine lesion, or according to lesion location within the pons.

CONCLUSIONS

Pontine lesion size appears to be related to lower urinary tract symptoms (weak stream and urgency incontinence) in patients with MS. Therefore, CNS lesion characteristics may be able to phenotype voiding symptoms in patients with MS. Neurourol. Urodynam. 36:453-456, 2017. © 2016 Wiley Periodicals, Inc.

Impact of Dry Mouth on Fluid Intake and Overactive Bladder Symptoms in Women taking Fesoterodine

PURPOSE

We investigated the long-term relationships between dry mouth, fluid intake and overactive bladder symptoms in women undergoing treatment with fesoterodine. We hypothesized that women who experienced dry mouth would increase their fluid intake and worsen their urinary symptoms.

MATERIALS AND METHODS

We conducted a prospective ancillary study to a 9-month open-label trial of fesoterodine for women with urgency urinary incontinence. Fluid intake was measured and compared according to reported dry mouth. Multivariable analysis was used to study the interaction between dry mouth, fluid intake and urinary symptoms.

RESULTS

During the study 407 women without dry mouth significantly reduced their fluid intake (mean decrease 172.1 ml, median 118.3 ml, p = 0.02), while 91 women with dry mouth did not (mean decrease 95.8 ml, median 118.3 ml, p = 0.54). On univariable analysis a greater proportion of women who experienced dry mouth reported improvement in their urinary symptoms compared to women without dry mouth (60.5% vs 47.2%, p = 0.03). On multivariable analysis black women were less likely to report dry mouth (OR 0.4, 95% CI 0.2-0.9, p = 0.03) and older women were less likely to report improvement in urinary symptoms (OR 0.98, 95% CI 0.96-0.99, p = 0.003). Factors not associated with improvement in urinary symptoms on multiple regression were dry mouth, baseline fluid intake volume, change in fluid intake volume and caffeine intake volume.

CONCLUSIONS

In women with overactive bladder receiving fesoterodine dry mouth may prevent restriction of fluid intake but does not diminish treatment efficacy.

The female urinary microbiome in urgency urinary incontinence

OBJECTIVE

The purpose of this study was to characterize the urinary microbiota in women who are planning treatment for urgency urinary incontinence and to describe clinical associations with urinary symptoms, urinary tract infection, and treatment outcomes.

STUDY DESIGN

Catheterized urine samples were collected from multisite randomized trial participants who had no clinical evidence of urinary tract infection; 16S ribosomal RNA gene sequencing was used to dichotomize participants as either DNA sequence-positive or sequence-negative. Associations with demographics, urinary symptoms, urinary tract infection risk, and treatment outcomes were determined. In sequence-positive samples, microbiotas were characterized on the basis of their dominant microorganisms.

RESULTS

More than one-half (51.1%; 93/182) of the participants' urine samples were sequence-positive. Sequence-positive participants were younger (55.8 vs 61.3 years old; P = .0007), had a higher body mass index (33.7 vs 30.1 kg/m(2); P = .0009), had a higher mean baseline daily urgency urinary incontinence episodes (5.7 vs 4.2 episodes; P < .0001), responded better to treatment (decrease in urgency urinary incontinence episodes, -4.4 vs -3.3; P = .0013), and were less likely to experience urinary tract infection (9% vs 27%; P = .0011). In sequence-positive samples, 8 major bacterial clusters were identified; 7 clusters were dominated not only by a single genus, most commonly Lactobacillus (45%) or Gardnerella (17%), but also by other taxa (25%). The remaining cluster had no dominant genus (13%).

CONCLUSION

DNA sequencing confirmed urinary bacterial DNA in many women with urgency urinary incontinence who had no signs of infection. Sequence status was associated with baseline urgency urinary incontinence episodes, treatment response, and posttreatment urinary tract infection risk.

Is self-reported adherence associated with clinical outcomes in women treated with anticholinergic medication for overactive bladder?

AIM

To determine the association between self-reported adherence to anticholinergic medication and clinical outcomes in women with overactive bladder (OAB).

METHODS

A prospective study of women with OAB treated with fesoterodine for 8 weeks. Adherence to medication was measured using the Medication Adherence Self-report Inventory (MASRI). A self reported adherence rate of ≥80% was considered adherent. The association between self-reported adherence and clinical outcomes (Global Index of Improvement, Global impression of Severity, urinary symptom and quality of life scores) was examined. We hypothesized that adherent women would have greater improvement in urinary symptoms and quality of life than non-adherent women.

RESULTS

Based on the MASRI, 115 (62.5%) women were adherent and 69 (37.5%) were non-adherent to anticholinergic medication at 8weeks. Adherent women were more likely to report overall improvement in their symptoms compared to non-adherent women (84% vs. 24%, P < 0.001). Significantly more non-adherent women described their bladder symptoms as "moderate" or "severe" at 8 weeks compared to adherent women (74% vs. 44%, P = 0.03). At 8 weeks, adherent women reported significantly greater improvement (change) in urinary symptoms from baseline to 8 weeks than non-adherent women (-13.3 ± 25.8 vs. 2.5 ± 14.4, P = 0.04). Similarly, adherent women reported greater improvement in quality of life scores than non-adherent women (- 7.9 ± 24.0 vs. -1.8 ± 11.9, P = 0.003).

CONCLUSION

Self-reported non-adherence, as measured by the MASRI, is associated with clinically meaningful outcomes in women with OAB. This further validates the MASRI as a clinically useful tool for measuring adherence to anticholinergic medications in women with OAB. Neurourol. Urodynam. 35:738-742, 2016. © 2015 Wiley Periodicals, Inc.

Establishing a clinic-based pancreatic cancer and periampullary tumour research registry in Quebec

BACKGROUND

Enrolling patients in studies of pancreatic ductal adenocarcinoma (pdac) is challenging because of the high fatality of the disease. We hypothesized that a prospective clinic-based study with rapid ascertainment would result in high participation rates. Using that strategy, we established the Quebec Pancreas Cancer Study (qpcs) to investigate the genetics and causes of pdac and other periampullary tumours (pats) that are also rare and underrepresented in research studies.

METHODS

Patients diagnosed with pdac or pat were introduced to the study at their initial clinical encounter, with a strategy to enrol participants within 2 weeks of diagnosis. Patient self-referrals and referrals of unaffected individuals with an increased risk of pdac were also accepted. Family histories, epidemiologic and clinical data, and biospecimens were collected. Additional relatives were enrolled in families at increased genetic risk.

RESULTS

The first 346 completed referrals led to 306 probands being enrolled, including 190 probands affected with pdac, who represent the population focus of the qpcs. Participation rates were 88.4% for all referrals and 89.2% for pdac referrals. Family history, epidemiologic and clinical data, and biospecimens were ascertained from 91.9%, 54.6%, and 97.5% respectively of patients with pdac. Although demographics and trends in risk factors in our patients were consistent with published statistics for patients with pdac, the qpcs is enriched for families with French-Canadian ancestry (37.4%), a population with recurrent germ-line mutations in hereditary diseases.

CONCLUSIONS

Using rapid ascertainment, a pdac and pat research registry with high participation rates can be established. The qpcs is a valuable research resource and its enrichment with patients of French-Canadian ancestry provides a unique opportunity for studies of heredity in these diseases.

Force chains in monodisperse spherical particle assemblies: three-dimensional measurements using neutrons

The full triaxial stress state within individual particles in a monodisperse spherical granular assembly has been measured. This was made possible by neutron imaging and computed tomography combined with neutron diffraction strain measurement techniques and associated stress reconstruction. The assembly in question consists of 549 precision steel ball bearings under an applied axial load of 85 MPa in a cylindrical die. Clear evidence of force chains was observed in terms of both the shape of the probability distribution function for normal stresses and the network formed by highly loaded particles. An extensive analysis of the source and magnitude of uncertainty in these measurements is also presented.

Bacterial septicaemia in prerecruit edible crabs, Cancer pagurus L

Juvenile edible crabs, Cancer pagurus L., were surveyed from Mumbles Head and Oxwich Bay in South Wales, UK, and the number of heterotrophic bacteria and vibrios in the hemolymph was determined. The percentage of crabs with hemolymph containing bacteria was variable over the survey with higher numbers of animals affected in summer than in winter. Post-moult crabs contained significantly higher numbers of heterotrophic bacteria in the hemolymph than pre- and intermoult animals. Crabs with cuticular damage to the gills also had significantly higher numbers of bacteria in the hemolymph. Crabs were found to have a high prevalence of infection by the dinoflagellate, Hematodinium. Such animals had significantly fewer bacteria in the blood in comparison with Hematodinium-free animals. Of the 463 crabs surveyed, only 3 individuals had hemolymph containing 2000 + CFU mL(-1). Based on 16S rRNA gene sequences, two of these crabs contained a Vibrio pectenicida-like isolate, while the other had a mixed assemblage of vibrios. Although 59% of the crabs surveyed had culturable bacteria in the hemolymph, the majority only had small numbers (<2000 CFU mL(-1) ), suggesting that such infections may be of limited importance to the sustainability of the crab fishery in this region.