The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society

Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial

OBJECTIVE

To compare efficacy of transobturator tape with tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence in women with intrinsic sphincter deficiency.

METHODS

One hundred sixty-four women diagnosed with urodynamic stress incontinence and intrinsic sphincter deficiency with or without concomitant pelvic organ prolapse repair were randomized to receive TVT or transobturator tape. The primary outcome was the presence or absence of urodynamic stress incontinence at 6 months postoperatively. Secondary outcomes were the rate of operative complications, symptomatic stress incontinence requiring further surgery, and quality-of-life questionnaires.

RESULTS

Of 180 women eligible to participate, 164 were enrolled and underwent surgery. Of the 138 patients assessed at 6 months with urodynamic studies, 14 of 67 (21%) had urodynamic stress incontinence in the TVT group compared with 32 of 71 (45%) in the transobturator tape group (P=.004), with nine women in the transobturator tape group having repeat sling surgery compared with none in the TVT group. In the intention-to-treat analysis, the incident rate difference for request of repeat surgery was 9.7% (95% confidence interval [CI] 0-19.9); repeat surgery would be requested in one of every six transobturator tape procedures compared with 1 of every 16 TVT procedures. The risk ratio of repeat surgery was 2.6 (95% CI 0.9-9.3) times higher in the transobturator tape group.

CONCLUSION

Retropubic TVT is a more effective operation than the transobturator tape sling in women with urodynamic stress incontinence and intrinsic sphincter deficiency.

CLINICAL TRIAL REGISTRATION

www.actr.org.au, Australian New Zealand Clinical Trials Registry, ACTRN12608000093381

LEVEL OF EVIDENCE

I.

Interstitial cystitis: bladder pain and beyond

BACKGROUND

Interstitial cystitis is characterized by over 6 months of chronic pain, pressure and discomfort felt in the lower pelvis or bladder. It is often relieved with voiding, along with daytime frequency and nocturia in the absence of a urinary tract infection. Interstitial cystitis occurs primarily in females including adolescents and its diagnosis is still one of exclusion. It is now recognized as a serious medical condition associated with significant disability.

OBJECTIVE

The aim of this paper was to review the pathogenesis and treatment of interstitial cystitis with emphasis on new pathogenetic trends and therapeutic modalities.

METHODS

About 713 mostly original papers were reviewed in Medline from 1990 to August. 2008. All authors independently reviewed the literature. Large, double-blind, placebo-controlled, clinical trials were few and the medical histories of the patients used varied considerably making conclusions difficult. Promising pilot trials turned out mostly negative on follow-up.

RESULTS

Increasing evidence of co-morbid diseases, neurogenic inflammation and the effect of stress are promising as new targets for pathophysiology. No new effective treatments have emerged. Oral pentosanpolysulfate, amitriptyline, hydroxyzine and quercetin, as well as intravesical heparin/bicarbonate/lidocaine solutions, are still used with variable success. Some pilot open-label trials presented encouraging findings.

CONCLUSION

Interstitial cystitis contributes substantially to chronic pelvic pain and to poor quality of life. Oral or intravesical administration of solutions containing sodium hyaluronate, chondroitin sulfate and quercetin to both reduce bladder inflammation and 'replenish' the glycosaminoglycan layer should be tried. There is a clear need for therapeutic modalities. New potential translational research areas are suggested.

Operations and pelvic muscle training in the management of apical support loss (OPTIMAL) trial: design and methods

The primary aims of this trial are: 1) to compare surgical outcomes following sacrospinous ligament fixation to uterosacral vaginal vault suspension in women undergoing vaginal surgery for apical or uterine pelvic organ prolapse and stress urinary incontinence and 2) to examine the effects of a structured perioperative program consisting of behavioral techniques and pelvic floor muscle training compared to usual care. This trial is performed through the Pelvic Floor Disorders Network (PFDN), which is funded by National Institute of Child Health and Human Development. Subjects will be enrolled from hospitals associated with seven PFDN clinical centers across the United States. A centralized biostatistical coordinating center will oversee data collection and analysis. Two approaches will be investigated simultaneously using a 2x2 randomized factorial design: a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (behavioral and pelvic floor muscle training versus usual care). Surgeons have standardized essential components of each surgical procedure and have met specific standards of expertise. Providers of the behavioral intervention have undergone standardized training. Anatomic, functional, and health-related quality of life outcomes will be assessed using validated measures by researchers blinded to all randomization assignments. Cost-effectiveness analysis will be performed using prospectively collected data on health care costs and resource utilization. The primary surgical endpoint is a composite outcome defined by anatomic recurrence, recurrence of bothersome vaginal prolapse symptoms and/or retreatment and will be assessed 2 years after the index surgery. Endpoints for the behavioral intervention include both short-term (6-month) improvement in urinary symptoms and long-term (2-year) improvement in anatomic outcomes and prolapse symptoms. This article describes the rationale and design of this randomized trial, focusing on several key design features of potential interest to researchers in the field of female pelvic floor disorders and others conducting randomized surgical trials.

SOGC Committee opinion on urodynamics testing

OBJECTIVE

To provide a description of the components of urodynamic testing for the evaluation of urinary tract dysfunction and the indications for these tests.

OPTIONS

Urodynamic testing is useful in investigating of urinary incontinence.

EVIDENCE

A search of PubMed and the Cochrane Library identified the relevant literature. The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

VALUES

This is a consensus opinion of the Society of Obstetricians and Gynaecologists of Canada Sub-Committee on Urogynaecology.

BENEFITS, HARMS, AND COSTS

Urinary incontinence is a pervasive problem that can be treated effectively once properly diagnosed.

Diagnostic options for early identification and management of interstitial cystitis/painful bladder syndrome

AIMS

The aims of this article were to discuss options for diagnosing interstitial cystitis (IC), to compare approaches and to encourage early diagnosis of this disorder in the primary care setting.

METHODS

Experts discussed the tools available to diagnose IC and the advantages and disadvantages of each approach. Treatment options, both pharmacological and non-pharmacological, were also discussed. The importance of patient follow-up was emphasised.

RESULTS

Diagnostic options for IC include a thorough history and physical examination, laboratory evaluations, symptom screening tools, cystoscopy with hydrodistention, bladder biopsy, potassium sensitivity testing, intravesical anaesthetic challenges, urodynamics and urinary markers. Treatment options include oral and intravesical medications, dietary modification and physical therapy. Patient follow-up can be an opportunity to educate and empower patients to participate in their treatment.

DISCUSSION

A thorough patient history, physical examination and laboratory evaluations are keys to the diagnosis of IC. Optional diagnostic approaches may help increase physician confidence in prescribing therapy for this disorder. Multimodal therapy with an emphasis on patient education can help ensure success in treating IC.

CONCLUSION

Understanding the options available to diagnose IC may result in earlier identification and treatment for some patients.

Risk factors associated with failure 1 year after retropubic or transobturator midurethral slings

OBJECTIVE

The objective of the study was to identify predictors of recurrent urinary incontinence (UI) 1 year after treatment with tension-free vaginal tape (TVT) and transobturator tape (TOT).

STUDY DESIGN

One hundred sixty-two women with urodynamic stress urinary incontinence (SUI) were included in a clinical trial comparing TVT with TOT with at least 1 year of follow-up were included in this analysis. Potential clinical and urodynamic predictors for development of "any recurrent UI" or "recurrent SUI" 1 year after surgery were evaluated using logistic regression models.

RESULTS

Subjects who received concurrent prolapse surgery and those taking anticholinergic medications preoperatively were more likely to develop any recurrent UI. Increasing age was independently associated with recurrent SUI. Risk factors were similar for TVT and TOT for both definitions of treatment failure.

CONCLUSION

Concurrent prolapse surgery and preoperative anticholinergic medication use are associated with increased risk of developing recurrent UI 1 year after TVT or TOT. Increasing age is specifically associated with the recurrence of SUI symptoms.

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.

Postprostatectomy incontinence: all about diagnosis and management

CONTEXT

The ever-increasing number of radical prostatectomies entails an increasing number of patients suffering from postprostatectomy stress incontinence despite improved surgical techniques. We provide an overview of the current diagnosis and treatment of postprostatectomy stress incontinence.

OBJECTIVE

To review previous and recent literature on this subject and to assess the current standards of diagnosis and management of postprostatectomy incontinence.

EVIDENCE ACQUISITION

The PubMed database was searched, and all articles published since 2000 were evaluated.

EVIDENCE SYNTHESIS

This review presents the current recommended diagnostic tools and available noninvasive and invasive treatment options.

CONCLUSIONS

The European Association of Urology (EAU) recommends a two-stage assessment for diagnosis of postprostatectomy incontinence. Noninvasive therapy, pelvic floor-muscle training and biofeedback, is recommended in early postoperative and mild incontinence. Pharmacological treatment with duloxetine is especially effective in combination with physiotherapy, where it synergistically improves the continence rate. For surgical treatment, the insertion of an artificial urinary sphincter, AS-800, is still the gold standard. In recent years, several minimal invasive treatment options have been introduced with different rates of success, but they have not yet surpassed the results of the artificial sphincter.

Urodynamic evaluation of the bladder and pelvic floor

Pelvic floor disorders including lower urinary tract dysfunction are common, and may be evaluated by urodynamic tests, such as cystometry, uroflowmetry, pressure flow studies, electromyography, and video-urodynamics. These urodynamic tests provide objective information regarding the normal and abnormal function of the urinary tract and pelvic floor, and provide a better understanding of the pathophysiologic processes that cause lower urinary tract symptoms. This article describes typical urodynamic studies and their roles in the evaluation of common pelvic floor disorders, including stress urinary incontinence, overactive bladder, and pelvic organ prolapse.

The Hordaland Women's Cohort: a prospective cohort study of incontinence, other urinary tract symptoms and related health issues in middle-aged women

Background

Urinary incontinence (UI) is a prevalent symptom in middle-aged women, but data on incidence is limited and rarely reported. In order to analyze incidence, remission, or development patterns of severity and types of UI, we have established a 15-year prospective cohort (1997–2012).

Methods

The Cohort is based on the national collection of health data gathered from county studies (CONOR). Hordaland Health Study (HUSK) is one of them from Hordaland County. Each of the county studies may have local sub-studies and our Cohort is one of them. The Cohort included women aged 40–45 in order to have a broad approach to women's health including UI and other lower urinary tract symptoms (LUTS). A onefifth random sampling from HUSK was used to create the Cohort in 1997–1999. For the necessary sample size a preliminary power calculation, based on a 70% response rate at inclusion and 5% annual attrition rates was used. The Cohort is planned to collect data through questionnaires every second year for the 15-year period from 1997–2012.

Discussion

The Cohort represents a relatively large random sample (N = 2,230) of about 15% of the total population of women born between 1953–57 in the county of Hordaland. Our data shows that the cohort population is very similar to the source population. The baseline demographic, social and medical characteristics of the Cohort are compared with the rest of women in HUSK (N = 7,746) and there were no significant differences between them except for the level of education (P = 0.001) and yearly income (P = 0.018), which were higher in the Cohort population. Urological characteristics of participants from the Cohort (N = 1,920) were also compared with the other participants (N = 3,400). There were no significant statistical differences except for somewhat more urinary continence (P = 0.04), more stress incontinence (P = 0.048) and smaller amount of leakage (P = 0.015) in the Cohort. In conclusion, the Cohort ispopulation-based, with little selection bias, and thus is a rather unique study forinvestigating UI and LUTS in comparison with many other projects with similar purposes.

Urodynamic characterization of obese women with urinary incontinence undergoing a weight loss program: the Program to Reduce Incontinence by Diet and Exercise (PRIDE) trial

The purpose of this study was to describe urodynamic characteristics of overweight or obese women with urinary incontinence and explore the relationship between urodynamic parameters, body mass index (BMI), and abdominal circumference (AC). One hundred ten women underwent a standardized cough stress test and urodynamic study. Eighty-six percent of women had urodynamic stress incontinence and 15% detrusor overactivity. Intra-abdominal pressure (Pabd) at maximum cystometric capacity (MCC) increased 0.4 cm H(2)O per kg/m(2) unit of BMI (95% confidence interval [CI] = 0.0,0.7, p = 0.04) and 0.4 cm H(2)O per 2 cm increase in AC (CI = 0.2, 0.7, p < 0.01). Intravesical pressure (Pves) at MCC increased 0.4 cm H(2)O per 2 cm increase in AC (CI = 0.0, 0.8, p = 0.05) but was not associated with BMI (p = 0.18). BMI and AC had a stronger association with Pabd than with Pves, suggesting a possible mechanism for the association between obesity and urinary incontinence.

Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency

OBJECTIVE

The aim of this study was to compare the treatment outcome of 3 sling procedures for stress urinary incontinence with intrinsic sphincter deficiency.

STUDY DESIGN

This retrospective study included 253 patients who underwent incontinence surgery (pubovaginal sling [PVS] = 87, tension-free vaginal tape [TVT] = 94, and transobturator tape [TOT] = 72) for urodynamic stress incontinence with intrinsic sphincter deficiency. Analysis of variance, chi(2) test, Fisher's exact test, Kaplan-Meier survival analysis, and Cox proportional hazard regression were used for statistical analysis.

RESULTS

Overall complication rates were not significantly different. At 2 years postoperatively, the cumulative cure rates of the PVS, TVT, and TOT groups were significantly different (87.25%, 86.94%, and 34.89%, respectively; P < .0001). The risk of treatment failure in women who received TOT was 4.6 times higher than in women who underwent PVS. The 7-year cumulative cure rates of PVS and TVT groups were 59.10% and 55.09%, respectively.

CONCLUSION

PVS and TVT were more efficacious, but the long-term cure rates were low.

The loss and progressive recovery of voiding after spinal cord interruption in rats is associated with simultaneous changes in autonomous contractile bladder activity

BACKGROUND

Autonomous contractile activity (ACA) is a well-known phenomenon in isolated bladders from different species and seems to be important in the physiology of both normal and dysfunctional voiding.

OBJECTIVE

To determine whether ACA is changed in bladders from paraplegic rats at different periods post-spinal cord injury (post-SCI).

DESIGN, SETTING, AND PARTICIPANTS

ACA was studied in bladders (at least six per group) from normal and paraplegic female Wister rats at different times post-SCI (2 h, 24 h, 1 wk, and 3 wk). A group of normal rats was used as a control group. For measurements bladders were incubated in organ baths under standardised conditions.

MEASUREMENTS

ACA was measured as pressure change, which was defined as either a transient change or a spiked change according to its characteristics. The effects of intravesical volume load and muscarinic agonists were studied.

RESULTS AND LIMITATIONS

Following spinal cord injury (SCI) a clear evolution in ACA was observed. In bladders from SCI rats in the acute areflexive voiding phase (1 wk post-SCI), we observed decreased ACA associated with a highly increased compliance and a changed response to muscarinic agonists. ACA in bladders from SCI rats with renewed voiding reflexes (3 wk post-SCI) was increased, together with a moderately increased compliance and a (moderately) changed response to muscarinic agonists.

CONCLUSIONS

From these observations it is apparent that SCI leads to alterations in the behaviour and muscarinic response of ACA in the isolated bladder. These changes in ACA may play an important role in the pathophysiology of overactive bladder disease (OAB), and interacting with changed ACA might be promising in the search for newer treatments for OAB.

Chronic pelvic pain in women: still a challenge

Chronic pelvic pain (CPP), a common condition particularly in reproductive-aged women, causes disability and distress, and significantly compromises quality of life and affects healthcare costs. The pathogenesis of CPP is still poorly understood and consequently poorly managed. Furthermore, the lack of a consensus on the definition of CPP greatly hinders epidemiological studies. Patients present with various associated problems, including bladder or bowel dysfunction, gynaecological pathologies or sexual dysfunction, and other systemic or constitutional symptoms. Other conditions, e.g. depression, anxiety and drug addiction, can also coexist. Effective management presupposes an integrated knowledge of all pelvic organs and other systems, including musculoskeletal, neurological and psychiatric systems. The key to treating CPP is to treat it as the complex disease it is. Treatment options range from conservative medical therapy to surgical intervention, and are primarily directed towards symptom relief. Unsatisfactory results of treatment render this condition a frustrating problem for both patients and physicians.

Evidence-based criteria for pain of interstitial cystitis/painful bladder syndrome in women

OBJECTIVES

No diagnostic physical signs, urologic findings, or laboratory tests are available for interstitial cystitis/painful bladder syndrome (IC/PBS). Its diagnosis is determined by symptoms and the exclusion of mimicking diseases. We hypothesized that certain pain characteristics are sensitive criteria for diagnosing IC/PBS.

METHODS

In women with recent-onset IC/PBS recruited in 2004 to 2006 for the case-control study, "Events Preceding Interstitial Cystitis," we identified the locations of each patient's pain and in a nonleading way asked about the effects of 17 different experiences (criteria) on the pain. We identified a set of criteria that described the largest number of patients in the Events Preceding Interstitial Cystitis study. In a secondary analysis of another cohort recruited by others in 1993 to 1997, the Interstitial Cystitis Database, we determined the proportion of patients captured by these same criteria.

RESULTS

In the Events Preceding Interstitial Cystitis study, pain that worsened with a certain food or drink and/or worsened with bladder filling and/or improved with urination was reported by 151 (97%) of 156 patients. These were the only three criteria that applied directly to the bladder. The same three criteria described the pain of 262 (97%) of 270 women in the Interstitial Cystitis Database who "definitely" had IC/PBS.

CONCLUSIONS

An hypothesis generated in one IC/PBS patient group and tested in another--pain that worsened with certain food or drink and/or worsened with bladder filling and/or improved with urination--was described by 97% of the patients with IC/PBS in each cohort. This triad might describe the pain of IC/PBS and contribute to a sensitive case definition. Estimating specificity awaits comparison with other diseases with similar symptoms.

Urodynamic leak point pressures weakly correlate with subjective urinary incontinence severity

OBJECTIVE

To evaluate preoperative abdominal leak point pressures (ALPP) with pre- and postoperative Incontinence Severity Index (ISI) scores.

METHODS

A review of women who underwent a midurethral sling procedure between August 2004 and April 2006 was conducted. Eligible women completed preoperative urodynamic testing with ALPP determination and subjective incontinence severity assessment using the ISI before and 6 weeks after surgery. The ISI and ALPP relationship was analyzed using a Spearman rank correlation (Rho).

RESULTS

Ninety-nine women met the inclusion criteria. Mean ALPP was 77.7 (25-172 cm H2O). Mean improvement in ISI following surgery was 4 (-8 to 12). ALPP correlated with preoperative ISI (Spearman Rho -0.28, P=0.01), preoperative leakage frequency (ISI question 1) (Spearman Rho -0.32, P=0.001), and the ISI change 6 weeks postoperatively (ISI-delta) (Spearman Rho -0.23, P=0.002).

CONCLUSION

ALPP is associated with subjective incontinence severity. Women with the lowest ALPP improved most following a midurethral sling procedure.

Restoration of continence by pessaries: magnetic resonance imaging assessment of mechanism of action

OBJECTIVE

The objective of the study was to determine incontinence pessaries' mechanism of action by measuring changes on urodynamic studies (UDS) and dynamic magnetic resonance imaging (MRI) with and without pessaries in place.

STUDY DESIGN

Women with stress incontinence had UDS and MRI performed with and without incontinence dish pessaries.

RESULTS

Fifteen women were evaluated. Pessary insertion resulted in increased urethral resistance; detrusor pressures increased (33-45 cm H(2)O) and maximal flow rates decreased (30 to 19 mL/second). With Valsalva on MRI, pessaries were associated with decreased posterior urethrovesical angles (175-130 degrees), bladder neck elevation (0.3 below to 0 .8 cm above the pubococcygeal line) and increased urethral lengths (2.4 to 2.97 cm). Bladder neck funneling with cough occurred in 14 patients without pessaries and 3 with pessaries.

CONCLUSION

On UDS and MRI following pessary placement, continence restoration was associated with decreased posterior urethrovesical angles, bladder neck descent and funneling, and increased urethral lengths and resistance to urine flow.

Endopelvic fascia in women: shape and relation to parietal pelvic structures

OBJECTIVE

The endopelvic fascia is a confluent suspensory apparatus of the female pelvic organs. The aim of the study was to construct a three-dimensional model of the endopelvic fascia, defining its shape and its connections to the surrounding parietal structures.

METHODS

We created a three-dimensional multiple-source computer model to simultaneously visualize and analyze all the structures within the female pelvic floor. This model integrates data from magnetic resonance imaging of 15 nulliparas under age 30 with no symptoms of pelvic floor dysfunction. The model also includes data from direct observation in the dissection laboratory and in surgical rooms, together with the relevant scientific literature.

RESULTS

The endopelvic fascia has the shape of a semifrontally oriented septum, which surrounds the vagina and part of the uterine cervix and divides the pelvic floor into the anterior and posterior compartments. This confluent septum has specific connections to the pubic bone, anterior perineal membrane, perineal body, and superior fascia of the levator ani muscle. Additionally, the uterosacral part of the septum has three subdivisions- the "vascular part," the "neural part," and the true uterosacral ligament. Each of these subdivisions has a different physical link to the parietal structures. Three-dimensional illustrations and schemes were created to facilitate the understanding of the anatomy of these complex structures.

CONCLUSION

Connecting descriptions of the geometry of the organs visible by magnetic resonance imaging with descriptions of their individual connections to the endopelvic fascia gave us unique information about the three-dimensional representation of the anatomy of the female lesser pelvis. The endopelvic fascia divides the lesser pelvis in a manner that is similar to the way the urorectal septum divides the embryonic cloaca.

Does the tension-free vaginal tape procedure (TVT) affect the voiding function over time? Pressure-flow studies 1 year and 3(1/2) years after TVT

AIM

The aim was to evaluate the voiding function over time after the TVT procedure for stress incontinence.

MATERIALS AND METHODS

Thirty-eight women with urodynamic stress urinary incontinence were included in the study. For voiding function assessment the patients were asked if voiding had changed postoperatively, and objectively uroflowmetry, residual urine measurement and pressure-flow were performed preoperatively, 1 year and 3(1/2) years postoperatively.

RESULTS

At 1/3(1/2) years follow-up 87%/69% were subjectively cured and 13%/26% improved, respectively. The objective cure rate was 89%/74%. Subjectively 77%/63% of the patients felt an altered voiding function towards more difficult voiding one and 3(1/2) years after surgery, respectively. Objectively all the uroflowmetry variables deteriorated and residual urine volume increased over time although the changes were not statistically significant between the 1 and 3(1/2) years follow-up. Pressure-flow variables were essentially unchanged.

CONCLUSION

The changes in voiding function after a TVT do not reverse over time. This may imply a potential risk of development of clinically important impaired emptying function.

Maximal functional electrical stimulation as a single treatment: is it cost-effective?

OBJECTIVE

The ideal electrical parameters for maximal functional electrical stimulation (MFES) in the treatment of an overactive bladder have not yet been well established. It has been speculated that unsatisfactory results may be due to a low stimulation intensity and that the number of sessions may also be an outcome-determining factor. Herein, we present the results obtained in a group of consecutively treated patients who were given 10 sessions of MFES at the highest tolerable amplitude.

MATERIAL AND METHODS

A total of 60 patients (29 females, 31 males) with an overactive bladder were treated. All subjects underwent a urodynamic assessment and completed a 48-h micturition chart prior to treatment, immediately after the last session and 3 months after termination of treatment. The patients were thoroughly informed that the result of the treatment depended on the amplitude that they could endure; there was a gradual increase in amplitude to the maximum level that did not cause painful discomfort.

RESULTS

Immediately after termination of the stimulation, almost half of the subjects reported an improvement in their condition. However, few subjects experienced sustained symptom amelioration 3 months post-stimulation. Decreases in micturition frequency and the number of leakage episodes were noted immediately after cessation of treatment but these decreases were no longer significant 3 months post-treatment.

CONCLUSIONS

In this series, although MFES was effective in the short term, the long-term treatment outcome was unsatisfactory. A critical review suggests that outcome success is proportional to the patient's ability and willingness to accept quite a high stimulation intensity or, alternatively, follow-up home treatment. Hence, the implementation of strict primary as well as secondary selection criteria can hopefully identify patients most suitable for MFES. Another lesson to be learnt is that the identification of crucial prerequisites of successful treatment is mandatory before embarking on controlled studies.