Changes in sexual functioning in women after neuromodulation for voiding dysfunction

INTRODUCTION

Sacral neuromodulation is a well-established treatment for urinary and bowel disorders with potential use for other disorders such as sexual dysfunction.

AIM

To evaluate changes in sexual functioning in women undergoing neuromodulation for voiding symptoms.

METHODS

Patients enrolled in our prospective, observational neuromodulation database study were evaluated. Data were collected from medical records, and patient-completed Female Sexual Function Index (FSFI) and Interstitial Cystitis Symptom-Problem Indices (ICSI-PI) at baseline, 3, 6, and 12 months post-implant. Patients rated overall change in sexual functioning on scaled global response assessments (GRA) at 3, 6, and 12 months post-implant. We grouped women by baseline FSFI scores: less (score<26) and more sexually functional (score≥26). Data were analyzed with Pearson's Chi-square or Fisher's Exact test and repeated measures.

MAIN OUTCOMES MEASURES

Changes in FSFI and ICSI-PI scores in women grouped by baseline FSFI score<26 and ≥26.

RESULTS

Of 167 women evaluated, FSFI scores improved overall from preimplant (mean 13.5±8.5) to 12 months (N=72; mean 15.9±8.9, P=0.004). At baseline and each follow-up point, ICSI-PI scores were similar between groups and improved through time. For patients in the FSFI<26 group there was improvement from baseline to 12-month scores (N=63; 11.9±6.9 to 14.8±8.7; P=0.0006). Improved FSFI domains included desire, orgasm, satisfaction, and pain. Furthermore, of the 74 subjects in this group not sexually active at baseline, 10 became sexually active during follow-up. In the FSFI≥26 group there was slight but statistically significant decline in mean scores between baseline and 12 months (N=9; 27.4±1.1 to 24.5±3.4; P=0.0302); however one had become sexually inactive. A significant decrease was seen in the satisfaction domain.

CONCLUSIONS

Many factors affect sexual functioning in women; however sexual function may improve along with urinary symptoms after neuromodulation.

Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes

PURPOSE

We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes.

MATERIALS AND METHODS

We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods.

RESULTS

There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03).

CONCLUSIONS

We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study.

Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care

Overactive bladder affects millions of adults, with profound personal and economic costs. Although antimuscarinic drugs can cause a reduction in voiding symptoms, the effect is modest, and many patients are intolerant of the side effects, or do not experience sufficient relief. For these patients, the modulation of bladder reflex pathways via percutaneous tibial nerve stimulation (PTNS) or via implanted sacral nerve stimulation (SNS) has been acknowledged as a logical next step in the algorithm of care. This review examines the mechanism of action, the relative benefits, adverse effects, and costs of percutaneous nerve stimulation compared to other treatment modalities.

Pain in interstitial cystitis/bladder pain syndrome: do characteristics differ in ulcerative and non-ulcerative subtypes?

INTRODUCTION AND HYPOTHESIS

Key differences between interstitial cystitis/bladder pain syndrome (IC/BPS) subtypes (with and without Hunner's ulcer) have been noted. We hypothesized that pain characteristics in women grouped by IC/BPS subtype would differ.

METHODS

A survey was mailed to 749 women to assess IC/BPS pain and other characteristics. Cystoscopy/hydrodistention reports were reviewed for presence/absence of Hunner's ulcer. The McGill Pain Questionnaire Short Form© (MPQ-SF), Brief Pain Inventory (BPI), and Interstitial Cystitis Symptom and Problem Indices (ICSI-PI) assessed symptoms. Data were analyzed with Pearson's chi-square, Fisher's exact, t tests, and Wilcoxon rank tests.

RESULTS

Of the 214 women that returned a survey (36 ulcerative and 178 non-ulcerative IC/BPS), similar proportions in each group reported that certain foods, exercise, and/or stress triggered symptoms. Fewer ulcerative patients reported pain with vaginal penetration than non-ulcerative (5/33, 15.2 % vs 76/160, 47.5 %; p = 0.0006). On the BPI, the ulcerative and non-ulcerative groups reported similar numbers of painful areas (mean 4.1 ± 6.1 and 4.1 ± 3.8; p = 0.33), and lower abdominal/pelvic pain was reported most (13/35, 37 % vs 79/172, 46 %; p = 0.34) followed by lower back pain (12/35, 34 % vs 69/172, 40 %; p = 0.52). Even though ICSI-PI, MPQ-SF, and BPI scores/responses did not differ, on the MPQ-SF the three words most frequently used by ulcerative patients to describe their pain were sharp, stabbing, and hot burning, and in non-ulcerative were aching, cramping, and tender.

CONCLUSIONS

These measures did not reveal any significant differences in pain between subtypes. More research is needed in larger samples to determine whether differences exist.

Does patient age impact outcomes of neuromodulation?

AIMS

We evaluated whether patients stratified by age have the same level of risks/benefits after a staged neuromodulation procedure for refractory voiding symptoms.

METHODS

Urologic diagnosis, complications, and revisions were collected from medical records of adults enrolled in our prospective observational study. Symptoms were assessed over 2 years with diaries, Interstitial Symptom-Problem Indices (ICSI-PI), and the Overactive Bladder Questionnaire-SF (OAB-q SF). 12-item Short-Form Health Survey (SF-12v2®) mental (MCS) and physical (PCS) component summaries evaluated quality of life. Data were examined with Pearson Chi-square or Fisher's Exact test, Kruskal-Wallis tests, and repeated measures analyses.

RESULTS

Patients (83% female) were grouped by age (years): <40 (n = 46), 40-64 (n = 146), and ≥65 (n = 136). Urge incontinence was predominant in the older groups and more patients <40 had interstitial cystitis/painful bladder syndrome (IC/PBS). In the <40, 40-64, and ≥65 groups, respectively, generator implant (91%, 88%, and 89%) and explant (15%, 12%, and 10%) rates were similar. Complications (24%, 14%, and 9%; P = 0.031) and revisions (20%, 5%, and 6%; P = 0.0025) differed. For the three respective groups, urinary frequency (P < 0.0001 for all), nocturia (P < 0.0001 for all), incontinence episodes (P < 0.0001 for all), urgency (P = 0.0474, P < 0.0001, P = 0.0020), ICSI-PI (P = 0.0015, P < 0.0001, P < 0.0001), and OAB-q scores improved over time. Incontinence severity improved in those >65 (P = 0.0015). SF-12 PCS improved in those 40-64 (P = 0.0482) and MCS scores improved in the <40 and 40-64 age groups (P = 0.013 and P = 0.0440, respectively).

CONCLUSIONS

These data suggest that neuromodulation success is not age dependent, however continued study is needed to confirm findings.

Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness

PURPOSE

We determined the efficacy and safety of pelvic floor myofascial physical therapy compared to global therapeutic massage in women with newly symptomatic interstitial cystitis/painful bladder syndrome.

MATERIALS AND METHODS

A randomized controlled trial of 10 scheduled treatments of myofascial physical therapy vs global therapeutic massage was performed at 11 clinical centers in North America. We recruited women with interstitial cystitis/painful bladder syndrome with demonstrable pelvic floor tenderness on physical examination and a limitation of no more than 3 years' symptom duration. The primary outcome was the proportion of responders defined as moderately improved or markedly improved in overall symptoms compared to baseline on a 7-point global response assessment scale. Secondary outcomes included ratings for pain, urgency and frequency, the O'Leary-Sant IC Symptom and Problem Index, and reports of adverse events. We compared response rates between treatment arms using the exact conditional version of the Mantel-Haenszel test to control for clustering by clinical center. For secondary efficacy outcomes cross-sectional descriptive statistics and changes from baseline were calculated.

RESULTS

A total of 81 women randomized to the 2 treatment groups had similar symptoms at baseline. The global response assessment response rate was 26% in the global therapeutic massage group and 59% in the myofascial physical therapy group (p=0.0012). Pain, urgency and frequency ratings, and O'Leary-Sant IC Symptom and Problem Index decreased in both groups during followup, and were not significantly different between the groups. Pain was the most common adverse event, occurring at similar rates in both groups. No serious adverse events were reported.

CONCLUSIONS

A significantly higher proportion of women with interstitial cystitis/painful bladder syndrome responded to treatment with myofascial physical therapy than to global therapeutic massage. Myofascial physical therapy may be a beneficial therapy in women with this syndrome.

Urinary chemokines as noninvasive predictors of ulcerative interstitial cystitis

PURPOSE

Based on basic research findings an increase in chemokines and cytokines (CXCL-1 and 10, nerve growth factor and interleukin-6) is considered responsible for inflammation and afferent sensitization. In this cross-sectional study we tested the hypothesis that select chemokines are increased in the urine of patients with ulcerative and nonulcerative interstitial cystitis/painful bladder syndrome.

MATERIALS AND METHODS

Midstream urinary specimens were collected from 10 patients with ulcerative and nonulcerative interstitial cystitis/painful bladder syndrome, respectively, and from 10 asymptomatic controls. Urinary levels of 7 cytokines were measured by a human cytokine/chemokine assay. Nerve growth factor was measured by enzyme-linked immunosorbent assay.

RESULTS

Urinary levels of most chemokines/cytokines were tenfold to 100-fold lower in asymptomatic controls vs patients with ulcerative and nonulcerative interstitial cystitis/painful bladder syndrome. Univariate comparison of 8 tested proteins in the ulcerative vs nonulcerative groups revealed a significant fivefold to twentyfold increase in CXCL-10 and 1, interleukin-6 and nerve growth factor (ANOVA p<0.001).

CONCLUSIONS

Differential expression of chemokines in ulcerative and nonulcerative subtypes of interstitial cystitis/painful bladder syndrome suggests differences in paracrine signaling between the 2 entities.

Apremilast in the Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Pilot Study

OBJECTIVE

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a disease with an uncertain cause and limited effective treatments. Apremilast (Celgene Corporation, Summit, NJ, USA) is a selective phosphodiesterase type 4 (PDE4) inhibitor that modulates the immune system. An open-label, one-arm, pilot study was conducted to explore its potential for improving CP/CPPS symptoms.

METHODS

Males ≥ 18 years of age were treated with 20 mg oral apremilast twice daily for up to 12 weeks. Outcomes were measured with Global Response Assessment (GRA), pain visual analog scale (VAS), Chronic Prostatitis Symptom Index (CPSI), Pittsburgh Sleep Quality Index (PSQI), SF-12 mental (MCS) and physical (PCS) health-related quality of life subscales, and voiding diaries. Repeated measures and paired t-tests evaluated changes from baseline to end of treatment, and at a final visit 4 weeks off the drug.

RESULTS

Seventeen men (94% Caucasian; mean age 48.2 ± 10 years) were treated (mean 115.8 ± 56.1 doses). Mean VAS (3.4 ± 2.0 vs 1.8 ± 1.7; P = 0.0011), PSQI (9.4 ± 4.4 vs 7.4 ± 4.2; P = 0.037) and CPSI (26.1 ± 5.0 vs 17.2 ± 8.3; P = 0.0016) scores improved from baseline to end of treatment. Incontinence episodes per day improved slightly (P = 0.042). When only those completing at least 8 weeks of treatment were examined (n = 9), significant changes in CPSI, VAS, and PSQI were still observed. At the final visit, 8/9 (88.9%) men also reported some improvement in pain related to sex. Side-effects were generally mild and well tolerated.

CONCLUSION

These results suggest that apremilast may improve CP/CPPS symptoms with only mild side-effects. However, placebo controlled studies are necessary to determine efficacy.

Novel Therapy with Intravesical Liposomes for Ulcerative Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVES

A Federal Drug Administration-approved, compassionate-use, investigational new drug single-subject trial was conducted to evaluate the safety and clinical outcomes of intravesical instillation of liposomes in a woman with ulcerative interstitial cystitis/painful bladder syndrome (IC/PBS).

METHODS

After obtaining informed consent, the 48-year-old woman, diagnosed with ulcerative IC/PBS, received four weekly instillations of intravesical liposomes. Subsequently she was evaluated for 8 weeks post bladder instillation.

RESULTS

No side effects or adverse events were reported during the 12 week study period. Voids per day decreased from a baseline of 18 voids per 24 h to 11.3 voids per 24 h at week 3, and 12.6 voids per 24 h at 8 weeks after final instillation. Urgency score also decreased from a pre-instillation mean of 1.75 (out of 10) to 1.07 8 weeks after the final instillation. Bladder ulcers noted by cystoscopy at baseline were absent at the 8 weeks post-treatment and no evidence of bladder inflammation was noted.

CONCLUSION

Intravesical liposome instillation is minimally invasive and presents an appealing new treatment for IC/PBS. Prospective trials are needed to assess intravesical liposomes for IC/PBS.

Vaginal diazepam use with urogenital pain/pelvic floor dysfunction: serum diazepam levels and efficacy data

Vaginal diazepam is used off-label for pelvic floor dysfunction and urogenital pain, but serum levels with efficacy have not been reported until now. One clinician evaluated 21 women for overall, levator, and vulvar pain pre- and one-month post-daily diazepam treatment. One-month post-treatment assessments and serum diazepam levels were done; 62% were moderately or markedly improved. Levator examination pain scores were significantly improved, and vulvar pain scores decreased post-treatment. Serum diazepam levels were within normal limits. Vaginal diazepam may be helpful in treating pelvic floor/urogenital pain conditions.

Are ulcerative and nonulcerative interstitial cystitis/painful bladder syndrome 2 distinct diseases? A study of coexisting conditions

OBJECTIVES

Coexisting conditions associated with interstitial cystitis/painful bladder syndrome (IC/PBS) have not been fully explored by IC/PBS subtypes. We compared comorbid diagnoses/symptoms in women with ulcerative (ULC) and nonulcerative (N-ULC) IC/PBS and controls.

METHODS

Adult women with IC/PBS and controls without IC/PBS completed a mailed survey assessing for 21 diagnoses. IC/PBS subtype was determined by hydrodistention reports. Standardized questionnaires assessed IC/PBS symptoms (Interstitial Cystitis Symptom/Problem Indexes [ICSI-PI]) and for undiagnosed fibromyalgia, irritable bowel syndrome, and depression (Symptom Intensity Score [SIS]; Rome III Functional Bowel Questionnaire; Center for Epidemiologic Studies Depression Scale [CES-D]). Data were analyzed using the Pearson chi-square, Fisher exact, Wilcoxon rank test, or Spearman rank correlation coefficient.

RESULTS

Of 178 N-ULC IC/PBS patients, 36 ULC IC/PBS patients, and 425 controls, ULC IC/PBS subjects were older (median 63 years; P < .01) and less employed (P < .01), but groups were similar on other demographic characteristics. N-ULC reported more chronic diagnoses (mean 3.5 ± 2.3) than ULC (2.3 ± 2.0) and controls (1.2 ± 1.5) (P < .01). When N-ULC and ULC IC/PBS patients were compared, more N-ULC IC/PBS patients had fibromyalgia (P = .03), migraines (P = .03), temporomandibular joint disorder (P < .01), and higher CES-D (P = .02) and SIS scores (P = .01). The ULC IC/PBS group voided more frequently during the daytime (P = .03) and nighttime (P < .01) and had smaller mean bladder capacity than N-ULC (P < .01). No significant differences were seen between N-ULC and ULC IC/PBS patients on the ICSI-PI and Rome III.

CONCLUSIONS

Notable differences in the number of comorbid diagnoses and symptoms were seen between IC/PBS subtypes and controls. Subtypes should continue to be evaluated individually to ascertain other similarities and differences.

Early termination of a trial of mycophenolate mofetil for treatment of interstitial cystitis/painful bladder syndrome: lessons learned

PURPOSE

We evaluated the efficacy and tolerability of mycophenolate mofetil in patients with treatment refractory interstitial cystitis/painful bladder syndrome.

MATERIALS AND METHODS

A total of 210 patients with interstitial cystitis/painful bladder syndrome were to be randomized into a multicenter, placebo controlled trial using a 2:1 randomization. Participants in whom at least 3 interstitial cystitis/painful bladder syndrome specific treatments had failed and who had at least moderately severe symptoms were enrolled in a 12-week treatment study. The primary study end point was the global response assessment. Secondary end points were general and disease specific symptom questionnaires, and voiding diaries.

RESULTS

Only 58 subjects were randomized before a black box warning regarding mycophenolate mofetil safety was issued by the manufacturer in October 2007. The trial was halted, and interim analysis was performed and presented to an independent data and safety monitoring board. Six of the 39 subjects (15%) randomized at study cessation were considered responders for mycophenolate mofetil compared to 3 of 19 controls (16%, p=0.67). Secondary outcome measures reflected more improvement in controls.

CONCLUSIONS

In a randomized, placebo controlled trial that was prematurely halted mycophenolate mofetil showed efficacy similar to that of placebo to treat symptoms of refractory interstitial cystitis/painful bladder syndrome. The results of this limited study cannot be used to confirm or refute the hypothesis that immunosuppressive therapy may be beneficial to at least a subgroup of patients with interstitial cystitis/painful bladder syndrome. Despite study termination lessons can be gleaned to inform future investigations.