Outcomes of lumbar to sacral nerve rerouting for spina bifida

PURPOSE

Restoring bladder and bowel function in spina bifida by creation of a skin-central nervous system-bladder reflex arc via lumbar to sacral nerve rerouting has a reported success rate of 87% in China. We report 1-year results of the first North American trial on nerve rerouting.

MATERIALS AND METHODS

Nine subjects were enrolled in the study. Intradural lumbar to sacral nerve rerouting was performed. Subjects underwent urodynamic testing with stimulation of the cutaneous dermatome and careful neurological followup. Adverse events were closely monitored along with changes in bowel and bladder function.

RESULTS

At 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle groups at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months.

CONCLUSIONS

At 1 year a novel reflex arc with stimulation of the appropriate dermatome was seen in the majority of subjects. Improvements in voiding and bowel function were noted. Lower extremity weakness was mostly self-limited, except in 1 subject with a persistent foot drop. More patients and longer followup are needed to assess the risk/benefit ratio of this novel procedure.

Effect of amitriptyline on symptoms in treatment naïve patients with interstitial cystitis/painful bladder syndrome

PURPOSE

Amitriptyline is frequently used to treat patients with interstitial cystitis/painful bladder syndrome. The evidence to support this practice is derived mainly from a small, single site clinical trial and case reports.

MATERIALS AND METHODS

We conducted a multicenter, randomized, double-blind, placebo controlled clinical trial of amitriptyline in subjects with interstitial cystitis/painful bladder syndrome who were naïve to therapy. Study participants in both treatment arms received a standardized education and behavioral modification program. The drug dose was increased during a 6-week period from 10 up to 75 mg once daily. The primary outcome was a patient reported global response assessment of symptom improvement evaluated after 12 weeks of treatment.

RESULTS

A total of 271 subjects were randomized and 231 (85%) provided a global response assessment at 12 weeks of followup. Study participants were primarily women (83%) and white (74%), with a median age of 38 years. In an intent to treat analysis (271) the rate of response of subjects reporting moderate or marked improvement from baseline in the amitriptyline and placebo groups was 55% and 45%, respectively (p = 0.12). Of the subgroup of subjects (207) who achieved a drug dose of at least 50 mg, a significantly higher response rate was observed in the amitriptyline group (66%) compared to placebo (47%) (p = 0.01).

CONCLUSIONS

When all randomized subjects were considered, amitriptyline plus an education and behavioral modification program did not significantly improve symptoms in treatment naïve patients with interstitial cystitis/painful bladder syndrome. However, amitriptyline may be beneficial in persons who can achieve a daily dose of 50 mg or greater, although this subgroup comparison was not specified in advance.

The relationship of interstitial cystitis/painful bladder syndrome to vulvodynia

INTRODUCTION

Many patients have interstitial cystitis/painful bladder syndrome (IC/PBS), a condition of frequency, urgency, and pain affecting more than 1 million women in the United States. The vulva, not the urethra or bladder, may actually be the site of some of the reported pain in women with IC/PBS.

PURPOSE

The purpose of this study was to identify the presence of vulvodynia in women diagnosed with IC/PBS.

METHOD

A mailed survey was used to identify women with IC/PBS who also reported vulvar pain. The survey also identified related factors, such as menstrual/hormonal status, sexual function, abuse, and sequence of vulvar and bladder pain from adolescence to adulthood.

RESULTS

Four-hundred-sixteen women with a documented diagnosis of IC/PBS were mailed a survey. The response rate was 49.6%, with 197 completed surveys returned. Results include vulvar pain in adolescence reported by 10.9% of the respondents, while vulvar pain in adulthood was reported by 48.4% of the women. During the last year, 62.7% of the respondents reported vulvar pain. Ninety-five percent (95%) of the women reported having been sexually active in adulthood, but one-third were not currently sexually active; 27% reported fear of pain as the reason. An abuse history was reported by 28.5% of the women. Of the women who were postmenopausal (two-thirds of the group), 38% used hormone replacement therapy. Birth history showed no correlation to vulvar pain.

CONCLUSIONS

The chronic pain that IC/PBS patients feel may not be totally related to their bladder, but instead, may be vulvar pain. The incidence of abuse, past pelvic surgeries, pelvic floor dysfunction, and the chronologic sequence of co-morbid symptoms should be further assessed.

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.

The relationship between subjective and objective assessments of sacral neuromodulation effectiveness in patients with urgency-frequency

AIMS

Global response assessment (GRA) has been used to evaluate patients' perceptions of treatment effectiveness. However, few studies have scrutinized the relationship between GRAs and objective voiding diary outcomes data. This study explores the relationship between self-reported symptom-specific GRA responses and objective changes in frequency, urgency and pelvic pain in patients with urgency-frequency with or without pelvic pain after implantation of a prosthetic sacral nerve stimulation device.

METHODS

Patients scheduled for a staged procedure were enrolled in a prospective, observational, longitudinal study. Post implantation, patietns were grouped into "responders" or "non-responders" based on their answers to symptom-specific GRAs at three and six months. Treatment responders were defined as those reporting "moderately" or "markedly improved" on a 7-point scale, and all others were considered non-responders. Pre- and post-implant changes in mean 24-hour voiding frequency, voided volume, urgency and pelvic pain scores as recorded on voiding diaries were compared between groups using paired t-test.

RESULTS

At three months, responders demonstrated corresponding statistically significant improvement in voiding frequency (P < 0.001), average voided volume (P = 0.003), urgency (P = 0.022) and pelvic pain (P = 0.039). At six months, responders demonstrated statistically significant improvements in frequency (P = 0.025) and urgency (P = 0.006). None of the symptom changes were statistically significant in treatment non-responders.

CONCLUSIONS

The GRA non-responders groups' perceptions of treatment response agreed with their objective changes in bothersome symptoms and responders' changes agreed with their perception of improvement in the majority of symptoms. Further study is needed to standardize the GRA, and explore its potential for use in clinical practice.

Childhood symptoms and events in women with interstitial cystitis/painful bladder syndrome

OBJECTIVES

To explore the prevalence of recurrent urinary tract infection and elimination difficulties experienced in childhood and adolescence in adult women with interstitial cystitis/painful bladder syndrome (IC/PBS) and community controls. The relationship between dysfunctional voiding and bowel symptoms in early life and the development of IC/PBS is not clear.

METHODS

A questionnaire was developed and mailed to 406 women with IC/PBS (patients) and 5000 community-dwelling controls. The demographic, personal, and family health history data and the urinary and bowel symptoms experienced in childhood, adolescence, and adulthood were collected. The data were analyzed using the Student t test and multiple logistic regression analysis.

RESULTS

A total of 215 patients (53%) and 823 controls (16%) returned the questionnaires (controls with a previous IC/PBS diagnosis or not meeting the inclusion criteria for either group were excluded from analysis). The 215 patients, 126 controls reporting IC/PBS symptoms but no diagnosis, and 464 asymptomatic controls were compared regarding symptoms and events experienced in childhood and adolescence. Statistically significant differences were seen among the groups for recurrent urinary tract infection (P < .0001) and frequent antibiotic use (P < .0001) in childhood and for all symptoms in childhood and adolescence, including trouble starting the urinary stream (P < .0001 for both), urgency (P < .0001 for both), retention (P = .0038 and P < .0001, respectively), constipation (P = .0006 and P = .0001, respectively), and painful defecation (P < .0001 for both). Multiple logistic regression analyses showed statistically significant differences between the patients and asymptomatic controls in childhood bladder infections (P = .006) and urinary urgency (P = .001) in adolescence.

CONCLUSIONS

These results support the need for longitudinal prospective assessment of children with dysfunctional elimination symptoms to determine whether these symptoms progress to IC/PBS. Additional research will contribute to our understanding of the natural history of IC/PBS, promote its earlier diagnosis, and potentially prevent disease progression.

Efficacy and safety of extended-release oxybutynin in combination with tamsulosin for treatment of lower urinary tract symptoms in men: randomized, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the efficacy and tolerability of extended-release oxybutynin in combination with the alpha1-blocker tamsulosin in reducing lower urinary tract symptoms in men.

PATIENTS AND METHODS

In this multicenter, double-blind trial performed between March 29, 2004, and June 22, 2005, 420 men aged 45 years or older with a total International Prostate Symptom Score (IPSS) of 13 or more and IPSS for storage of 8 or more were randomized to receive tamsulosin (0.4 mg/d) with either extended-release oxybutynin (10 mg/d) or placebo for 12 weeks. Eligibility requirements included a maximum flow rate of 8 mL/s or more with voided volume of 125 mL or more and a postvoid residual volume of 150 mL or less on 2 occasions. Postvoid residual volume and peak flow rates at weeks 4, 8, and 12 were measured. The primary end point was change from baseline in total IPSS after 12 weeks of treatment. Secondary outcomes included change in IPSSs for storage and quality of life.

RESULTS

Tamsulosin combined with extended-release oxybutynin resulted in significantly greater improvement in total IPSS compared with tamsulosin and placebo after 8 (P=.03) and 12 (P=.006) weeks of treatment, and improved IPSS for storage and quality of life at all assessment points (P<.01). The incidence of postvoid residual volume higher than 300 mL was 2.9% (6/209) in patients receiving combination therapy compared with 0.5% (1/209) in patients receiving tamsulosin alone (P=.12). Occurrence of peak flow rates below 5 mL/s was 3.8% (8/209) for combination therapy and 5.7% (12/209) for tamsulosin alone (P=.49).

CONCLUSION

In men with substantial storage symptoms, combination therapy with tamsulosin and extended-release oxybutynin demonstrated greater efficacy than and comparable safety and tolerability to tamsulosin monotherapy.

Sacral neuromodulation reprogramming: is it an office burden?

Our objective was to evaluate the burden of sacral neuromodulation (SNM) reprogramming and the reasons for reprogramming, and to correlate these with the underlying diagnosis. A retrospective review of 50 consecutive subjects implanted with SNM was completed from November 2002 through December 2005. Of the 50 SNM implants, 47 subjects had adequate follow-up. The mean age was 53.1 (22-90 years) with 83% women. Of the SNM performed, 91.5% were done for urinary urgency, frequency, or incontinence and 47.4% of those had interstitial cystitis. Overall, 239 programming visits were recorded, and subjects on average had two reprogramming visits per year. There was no correlation with number of reprogramming events and patient age, sex, reason for implantation, or diagnosis. These data suggest that the number of reprogramming episodes is small, and the majority is done as part of routine follow-up. No additional burden was seen in subjects with interstitial cystitis.

A prospective, single-blind, randomized crossover trial of sacral vs pudendal nerve stimulation for interstitial cystitis

OBJECTIVE

To compare sacral nerve stimulation (SNS) with pudendal nerve stimulation (PNS) for interstitial cystitis (IC).

PATIENTS AND METHODS

Twenty-two patients with well-documented, refractory IC had a tined lead placed at S3 and a second electrode implanted at the pudendal nerve via a posterior approach. In a blinded, randomized design, each lead was tested for 7 days. The best lead was implanted to a pulse generator and patients were followed at 1, 3 and 6 months.

RESULTS

The time required to place a sacral lead was 27.4 min, and a pudendal lead 19.6 min (P = 0.039). Of the 22 patients, 17 (77%) responded and had a permanent implant placed. PNS was chosen as the better lead in 77% and SNS in 24%. The order in which the lead was stimulated had no effect on the final lead implanted and there was no 'carry-over' effect. The overall reduction in symptoms was 59% for PNS and 44% for SNS (P = 0.05). At 6 months after implantation, voids improved by 41% (PNS) and 33% (SNS), and mean voided volume increased 95% and 21%, respectively; validated IC questionnaires improved markedly and complications were minimal.

CONCLUSIONS

This is the first 'blinded' study of SNS vs PNS for IC. A pudendal lead was implanted successfully in all patients, and most chose PNS as better than SNS; the improvement was sustained over time.

Dilemmas in diagnosing pelvic pain: multiple pelvic surgeries common in women with interstitial cystitis

We determined the prevalence of pelvic surgeries in women with interstitial cystitis (IC) compared to community-based controls through responses to a survey from 215 women with IC and 823 controls. Women with IC had a statistically higher prevalence of hysterectomies (cases=42.3%, controls=21.4%), bladder suspensions (cases=21.9%, controls=5.7), pelvic or genital surgeries other than cystoscopy (cases=26.5%, controls=16.2%), and laparoscopic pelvic surgeries (cases=22.8%, controls=8.3%). Women with IC more commonly had been diagnosed with endometriosis (cases=25.6%, controls=9.8%) and fibroids (cases=24.2%, controls= 16.3%). Of women with IC who had hysterectomies, 68% of the hysterectomies were done before their diagnosis of IC, and only 21% were done after their IC diagnosis. The diagnosis of IC occurred 1-5 years after hysterectomy in most cases. Women with IC have significantly more pelvic surgeries than controls. The majority of these surgeries were done before the diagnosis of IC and may be performed for pain related to undiagnosed IC.

Sexual Function and Sexual Distress in Women with Interstitial Cystitis: A Case-Control Study

OBJECTIVES

To evaluate female sexual dysfunction (FSD) in women with interstitial cystitis (IC) versus a control group. Specific areas of FSD in women with IC have not been reported.

METHODS

A mailed survey was sent to 5000 randomly selected women from the United States (controls) and 407 women with IC from a large referral center (cases). The Female Sexual Distress Scale and questions about sexual function, desire, orgasm, and pain were included. The Student t test was used to compare the mean values, and the chi-square test was used to compare the proportions between the cases and controls.

RESULTS

During adolescence (the start of menstruation through age 18), having had intercourse, levels of sexual desire, and orgasm frequency did not differ significantly between the cases and controls. However, a significantly greater proportion of cases reported fear of pain (P = 0.018) and pain with intercourse (P = 0.001). In adulthood, a significantly greater proportion of cases reported having pelvic pain, fear of pain during intercourse, and dyspareunia (P <0.001 for all). Furthermore, after the diagnosis of IC, the number of cases reporting moderate to high desire (P <0.001) and orgasm frequently and very frequently declined significantly (P <0.001). The mean value of the Female Sexual Distress Scale was greater among established IC cases (18.5 +/- 14.3) compared with controls (8.3 +/- 10.2; P <0.001). A score of 15 or greater on the Female Sexual Distress Scale has been associated with sexual distress.

CONCLUSIONS

Women with IC have significantly more FSD and sexual distress than women without IC. Additional study is needed to explore the multiple factors contributing to FSD in IC.

Fact or fiction--is abuse prevalent in patients with interstitial cystitis? Results from a community survey and clinic population

PURPOSE

We determined whether abuse is associated with interstitial cystitis by surveying patients with interstitial cystitis and controls. We corroborated this association in a clinic population.

MATERIALS AND METHODS

A survey was mailed to 406 women diagnosed with interstitial cystitis and 5,000 age matched, randomly selected women in the United States. Similar data were collected from our interstitial cystitis clinic population by interviews in person.

RESULTS

We evaluated surveys from 464 symptom-free controls, 215 established patients with IC and 121 respondents with a history suggestive of interstitial cystitis. A higher proportion of patients with interstitial cystitis reported a history of abuse than controls (37% vs 22%, p <0.001). Sexual, physical and emotional abuse were also reported by a higher proportion of patients with interstitial cystitis. In our clinic population 76 women diagnosed with interstitial cystitis were evaluated, of whom 49% reported a history of abuse. Of those reporting abuse 92% reported emotional abuse, 78% reported physical abuse, 68% reported sexual abuse and 49% reported domestic violence.

CONCLUSIONS

Our study demonstrates an association between interstitial cystitis and abuse. Thus, it is important for clinicians to assess for abuse in women with interstitial cystitis or pelvic pain and provide appropriate referral to psychologists or other health care workers to provide comprehensive care for managing their symptoms. Further research is needed to evaluate the role of biopsychosocial therapies, in addition to traditional interstitial cystitis medical therapies for women with a history of abuse and interstitial cystitis.

Did patients with interstitial cystitis who failed to respond to initial treatment with bacillus Calmette-Guerin or placebo in a randomized clinical trial benefit from a second course of open label bacillus Calmette-Guerin?

PURPOSE

We evaluated safety and efficacy outcomes in a case series of subjects who received open label intravesical bacillus Calmette-Guerin after failing to respond to bacillus Calmette-Guerin or intravesical placebo in a randomized clinical trial.

MATERIALS AND METHODS

Subjects who met National Institutes of Health-National Institute of Diabetes and Digestive and Kidney Diseases criteria for IC and reported at least moderate pain and frequency were initially randomized to 6 weekly intravesical instillations of bacillus Calmette-Guerin or placebo and followed for a total of 34 weeks. At 34 weeks subjects who reported that they had not responded to treatment were offered treatment with open label bacillus Calmette-Guerin, using the same course of treatment and followup. Outcomes included a patient reported global response assessment, a 24-hour voiding diary, pain, urgency, validated interstitial cystitis symptom indexes and adverse events.

RESULTS

A total of 156 subjects elected open label bacillus Calmette-Guerin, of whom 18 (12%) withdrew during the open label series. The response rate based on the global response assessment was 18% and it was identical between those initially randomized to placebo (first course of bacillus Calmette-Guerin in the open label series) and those initially randomized to bacillus Calmette-Guerin (second course). Small improvements were observed for most secondary efficacy outcomes. Most participants reported at least 1 adverse event, primarily pain, genitourinary symptoms and gastrointestinal disturbances. However, there was no difference in adverse events between those who received the first course of bacillus Calmette-Guerin in this series compared to those who received 2 courses.

CONCLUSIONS

The low response rate for bacillus Calmette-Guerin in this open label case series further argues against the routine use of bacillus Calmette-Guerin as treatment for interstitial cystitis.

Prevalence of Pelvic Floor Dysfunction in Patients with Interstitial Cystitis

OBJECTIVES

To evaluate the prevalence of pelvic floor dysfunction in women with interstitial cystitis (IC).

METHODS

Women with IC and pelvic pain were referred to the Beaumont Women's Initiative for Pelvic Pain and Sexual Health program. A comprehensive patient history and pelvic examination were completed by a certified women's health nurse practitioner.

RESULTS

Seventy women with a mean age of 45 years were evaluated. Of these 70 women 87% had levator pain consistent with pelvic floor dysfunction. The mean levator pain score was 4.48 out of 10. Nearly two thirds of these women (64%) had their pain for 5 years or more, whereas one quarter (24%) had their pain for 1 to 3 years. Half of the women reported irritable bowel syndrome, and more than one third (36%) reported urge urinary incontinence.

CONCLUSIONS

Women with IC may have pelvic floor dysfunction, as noted in this population in which 87% had levator pain upon examination. If pelvic floor dysfunction is diagnosed in IC patients, then therapy targeting the pelvic floor musculature may be considered as part of a multimodality approach to treating IC.

Sexual Function is a Determinant of Poor Quality of Life for Women With Treatment Refractory Interstitial Cystitis

PURPOSE

Interstitial cystitis significantly negatively impacts quality of life. The demographic and clinical factors associated with decreased quality of life in these patients have not been well studied.

MATERIALS AND METHODS

Women with moderate/severe interstitial cystitis enrolled in a clinical trial of intravesical bacillus Calmette-Guerin were studied. Demographic data and responses to questionnaires were evaluated at baseline, including the O'Leary-Sant Interstitial Cystitis Symptom Index and Problem Index, University of Wisconsin Interstitial Cystitis Inventory, Medical Outcomes Study sexual functioning scale, and the physical composite and mental composite scales of the Medical Outcomes Study Short Form Health Status Survey. Three composite indexes were constructed (from the O'Leary-Sant Interstitial Cystitis Symptom Index, O'Leary-Sant Interstitial Cystitis Problem Index, pain/urgency Likert scales and 24-hour voiding diary) to document the severity, frequency and bother of pain, urinary urgency and frequency (frequency composite index). Linear and multivariate regression models were used to examine predictors of the physical composite and mental composite scales of the Medical Outcomes Study Short Form Health Status Survey. Medical Outcomes Study sexual functioning scale data were available for 163 of the 217 women in the trial.

RESULTS

Physical composite scale (median 36) and mental composite scale (median 42) were lower than the standard population value of 50. Multivariate models showed that employment, pain composite index and Medical Outcomes Study sexual functioning scale (all p<0.001) predicted physical composite scale, while only Medical Outcomes Study sexual functioning scale (p<0.001) remained a strong predictor of mental composite scale.

CONCLUSIONS

Sexual functioning, employment and pain issues predict mental and physical quality of life. In particular, this study identifies sexual functioning as a primary predictor of mental quality of life in women with long-standing interstitial cystitis. It is suggested that sexual functioning may be a salient therapeutic target in the multifaceted treatment of patients with interstitial cystitis.