Risk factors for persistent, de novo and overall overactive bladder syndrome after surgical prolapse repair

Impact of Sling at Time of Prolapse Surgery on Overactive Bladder

IMPORTANCE

Prolapse surgery and sling surgery both lead to improvement in overactive bladder. However, less is known regarding how slings performed concurrently with less is know about how overactive bladder symptoms change in patients having prolapse surgery with a sling compared to prolapse surgery without a sling.

OBJECTIVE

The primary aim was to compare change in postoperative overactive bladder symptoms in patients with preoperative overactive bladder who underwent sling placement versus no sling with prolapse surgery.

STUDY DESIGN

This was a secondary analysis of a cohort study evaluating overactive bladder in patients undergoing prolapse surgery. Sling procedures were performed concomitantly for treatment or prevention of stress incontinence. Baseline and 3-month follow-up urinary symptoms were assessed with the Overactive Bladder Questionnaire Short Form (OAB-q SF) and Urinary Distress Inventory-6 (UDI-6).

RESULTS

Of patients with overactive bladder, 26 (40.0%) underwent midurethral sling (MUS) placement and 39 (60.0%) no sling. Preoperative OAB-q SF bother (score [SD], 46.8 [20.2] vs 40.2 [22.1]; P = 0.23) was similar between groups, but UDI-6 scores (59.2 [28.8] vs 43.8 [29.1]; P = 0.04) were higher in the sling group. At 3 months, the change (improvement) in OABq-SF bother (-16.9 [24.1] vs -22.4 [23.0]; P = 0.36), OABq-SF health-related quality of life (22.8 [28.6] vs 22.9 [23.9]; P = 0.99), and UDI-6 (-38.8 [32.9] vs -34.0 [27.8]; P = 0.53) were similar in the MUS and no MUS groups.

CONCLUSION

Patients with prolapse and overactive bladder undergoing prolapse surgery with a sling had similar improvements in OAB-q SF bother scores compared with those who did not have a sling.

Flat Magnetic Stimulation for Urge Urinary Incontinence

Background and Objectives: Strategies for overactive bladder syndrome (OAB) management involve, among others, strengthening the bladder outlet to suppress urgency and neuromodulating the sacral roots. Magnetic stimulation (MS) is a technology that involves an extracorporeal device that is able to provide an electromagnetic field specifically designed to interact with pelvic floor neuromuscular tissue. The resulting tissue electrical activity induces contraction of the pelvic muscle and neuromodulation of the S2-S4 sacral roots. Flat Magnetic Stimulation (FMS) is a relevant advancement involving homogeneous electromagnetic fields, which are able to optimize the effect on the entire pelvic area. However, the benefits of this new technology for OAB syndrome are poorly known. Consequently, the aim of our study is to analyze the outcomes and quality of life (QoL) impact of FMS with Dr. Arnold (DEKA, Calenzano, Italy) in women suffering from OAB syndrome associated with urinary incontinence. Materials and Methods: This prospective study included patients with OAB, urge urinary incontinence, and no ongoing OAB treatments. At baseline (T0), the Incontinence Impact Questionnaire (IIQ-7), the Female Sexual Function Index (FSFI-19), and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) were collected. Patients underwent 8 FMS sessions of 25 min each in one month. At the termination of the therapy (T1), women repeated the ICIQ-UI SF, FSFI-19, and IIQ-7 tools. Moreover, the Patient Global Impression of Improvement (PGI-I) questionnaire was collected to evaluate the cure rate. Results: Our study enrolled a total of 57 consecutive patients. Most women had at least one second- or third-line treatment before FMS, while the remaining naive patients had contraindications to pharmacological treatments. No women reported adverse effects during the treatment. After the treatment, we observed a decrease in the IIQ-7 (p < 0.001) and ICIQ-UI SF scores (p < 0.001) and an improvement in sexual function (p < 0.001) evaluated with FSFI-19. According to PGI-I scores, 42 (73.7%) women referred to some kind of improvement, scoring ≤ 3 points. Specifically, 8.7% of patients considered themselves very much improved, 29.8% much improved, 35.1% minimally improved, and 26.3% found no changes. FMS was effective in treating OAB symptoms without any adverse effects. The mechanism is supposed to be related to suppressing the initiation of micturition. This makes FMS a promising device for treating naive and refractory urge urinary incontinence. Conclusions: The new FMS represents a promising non-pharmacological option for the treatment of naive and refractory OAB.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Italian validation of the Pelvic Floor Distress Inventory (PFDI-20) questionnaire

INTRODUCTION AND HYPOTHESIS

The use of validated Quality of Life (QoL) questionnaires is useful in the standardization and interpretation process of pelvic floor patient symptoms, due to their functional nature and high prevalence. The Pelvic Floor Distress Inventory QoL questionnaire (PFDI-20) serves both as a symptom inventory and a measure of the degree of bother and distress caused by pelvic floor symptoms. It includes items related to pelvic organ prolapse and lower gastrointestinal and bladder dysfunction.

METHODS

After consensus translation and a comprehension test, the Italian version of the questionnaire was submitted to patients reporting bowel, bladder, or pelvic disorders (cases) and to asymptomatic women (controls). Cases received the questionnaire once again 2 weeks later by email.

RESULTS

A total of 254 patients answered the questionnaire. Construct validity was demonstrated by discriminating between cases and controls. Convergent validity was demonstrated for each domain (F < 0.001). In-ernal consistency reliability showed a satisfactory range (0.816-0.860).

CONCLUSIONS

The PFDI-20 allows a comprehensive assessment of the effect of pelvic floor disorders on the quality of life of women. Moreover, the PFDI-20 represents a very solid QoL tool, since it has been extensively used in literature, and its use is highly recommended by the International Consultation on Incontinence. The present study demonstrated good features for the Italian version of the PFDI-20 questionnaire.

Electrical stimulation plus biofeedback improves urination function, pelvic floor function, and distress after reconstructive surgery: a randomized controlled trial

PURPOSE

This study is aimed at assessing the effect of postoperative electrical stimulation (ES) plus biofeedback therapy on patient rehabilitation after pelvic floor reconstructive surgery.

METHODS

Patients with pelvic organ prolapse (POP) who had received pelvic floor reconstructive surgery were randomly allocated to the intervention group and the control group at a 1:1 ratio. Patients in the control group received routine postoperative nursing care. Patients in the intervention group underwent ES plus biofeedback therapy. The outcomes included the recovery of urination function, the improvement of pelvic floor muscle (PFM) strength, and the change of Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) scores. The study outcomes were evaluated at pre-intervention (T0, 2 months after surgery), 3 months after surgery (T1), and 6 months after surgery (T2).

RESULTS

A total of 60 patients with POP were included in this study. For the urination function evaluation, the intervention group had a higher recovered rate than the control group at the time point of T2 (p = 0.038). For the EMG results, the changes of flick-max and tonic-mean values from T0 to T2 were much higher in the intervention group comparing to the control group. Corresponding to the EMG results, digital palpation showed that intervention group had a much higher proportion of patients who had elevated PFM strength. Furthermore, the intervention group also had more significant PFDI-20 score improvements compared with control group.

CONCLUSIONS

Postoperative ES plus biofeedback therapy could significantly improve urination function, PFM strength, and patient's reported QoL.

TRIAL REGISTRATION

Clinical registration number: hiCTR2000032432.

A Retrospective Cohort Study on the Prevalence, Risk Factors, and Improvement of Overactive Bladder Symptoms in Women with Pelvic Organ Prolapse

Background

Overactive bladder (OAB) symptoms are common in women with pelvic organ prolapse (POP), but the explanation is unclear. It is also uncertain whether OAB symptoms improve or persist after POP reduction. This study aimed to determine the prevalence and risk factors for OAB symptoms in women with POP, and to compare the improvement of OAB symptoms among women in three treatment groups: pelvic floor exercise, pessary, and surgery.

Methods

This retrospective cohort study included patients who visited our urogynecology clinic from January 2016 to December 2020. The Pelvic Floor Bother Questionnaire was used to evaluate selected pelvic floor symptoms (OAB and POP). Demographic characteristics and clinical findings, including Pelvic Organ Prolapse Quantification System and number of prolapsed compartments, were analyzed. Univariate and multivariate analyses were conducted to identify risk factors for OAB symptoms in women with POP. Subgroup analyses were performed in 533 patients to evaluate the improvement of OAB symptoms following POP treatment.

Results

A total of 754 patients were analyzed. The incidence of OAB symptoms was 70% (533/754) and two-thirds (65%) reported moderate to severe bother. The lowest points of the anterior wall (OR 0.60; 95% CI 0.41-0.87; p = 0.01), longer perineal body (OR 0.78; 95% CI 0.21-0.76; p = 0.02), and previous vaginal delivery (OR 2.10; 95% CI 1.14-3.89; p = 0.02) were identified as significant risk factors. In the subgroup analyses, improvement in OAB symptoms was observed in 36.6% (195/533) of women who underwent POP treatment. Compared with pelvic floor exercise, pessary (OR 1.40; 95% CI 0.94-2.07; p = 0.10) and surgery (OR 1.30; 95% CI 0.80-2.12; p = 0.28) had higher odd ratios but the effects were not significant.

Conclusion

The prevalence of OAB symptoms in women with POP was high at 70%. Improvement in OAB symptoms was observed in one-third of women who underwent POP treatment. However, there were no significant differences between the treatment methods.

Flat Magnetic Stimulation for Stress Urinary Incontinence: A 3-Month Follow-Up Study

BACKGROUND

flat magnetic stimulation is based on a stimulation produced by electromagnetic fields with a homogenous profile. Patients with stress urinary incontinence (SUI) can take advantage of this treatment. We aimed to evaluate medium-term subjective, objective, and quality-of-life outcomes in patients with stress urinary incontinence to evaluate possible maintenance schedules.

METHODS

a prospective evaluation through the administration of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the Incontinence Impact Questionnaire (IIQ7), and the Female Sexual Function Index (FSFI) was performed at three different time points: at the baseline (T0), at the end of treatment (T1), and at 3-month follow-up (T2). The stress test and the Patient Global Impression of Improvement questionnaire (PGI-I) defined objective and subjective outcomes, respectively.

RESULTS

25 consecutive patients were enrolled. A statistically significant reduction in the IIQ7 and ICIQ-SF scores was noticed at T1 returned to levels comparable to the baseline at T2. However, objective improvement remained significant even at a 3-month follow-up. Moreover, the PGI-I scores at T1 and T2 were comparable, demonstrating stable subjective satisfaction.

CONCLUSION

despite a certain persistence of the objective and subjective continence improvement, the urinary-related quality of life decreases and returns to baseline values three months after the end of flat magnetic stimulation. These findings indicate that a further cycle of treatment is probably indicated after 3 months since benefits are only partially maintained after this timespan.

Pelvic Organ Prolapse Syndrome and Lower Urinary Tract Symptom Update: What's New?

(1) Background: This narrative review aimed to analyze the epidemiological, clinical, surgical, prognostic, and instrumental aspects of the link between pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS), collecting the most recent evidence from the scientific literature. (2) Methods: We matched the terms "pelvic organ prolapse" (POP) and "lower urinary tract symptoms" (LUTS) on the following databases: Pubmed, Embase, Scopus, Google scholar, and Cochrane. We excluded case reports, systematic reviews, articles published in a language other than English, and studies focusing only on a surgical technique. (3) Results: There is a link between POP and LUTS. Bladder outlet obstruction (BOO) would increase variation in bladder structure and function, which could lead to an overactive bladder (OAB). There is no connection between the POP stage and LUTS. Prolapse surgery could modify the symptoms of OAB with improvement or healing. Post-surgical predictive factors of non-improvement of OAB or de novo onset include high BMI, neurological pathologies, age > 65 years, and the severity of symptoms; predictors of emptying disorders are neurological pathologies, BOO, perineal dysfunctions, severity of pre-surgery symptoms, and severe anterior prolapse. Urodynamics should be performed on a specific subset of patients (i.e., stress urinary incontinence, correct surgery planning), (4) Conclusions: Correction of prolapse is the primary treatment for detrusor underactivity and for patients with both POP and OAB.

Impact of Weight Gain on Surgical Outcomes and Quality of Life among Women after Sling Surgeries

STUDY OBJECTIVE

To investigate the impact of body weight gain after sling surgeries on outcomes in women with stress urinary incontinence.

DESIGN

A single-center, retrospective study.

SETTING

Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taiwan.

PATIENTS

A total of 248 women who underwent sling surgeries from 2010 to 2015 were reviewed. Patients who gained more than 10% body weight were compared with those with stable body weight.

INTERVENTIONS

Midurethral sling surgery with single-incision, transobturator, or retropubic slings.

MEASUREMENTS AND MAIN RESULTS

Objective success was defined as no urine leakage during the stress test in the filling phase of urodynamic studies. De novo overactive bladder (OAB) was defined as the appearance of urgency, frequency, and/or nocturia, with or without urinary incontinence after midurethral sling surgery persisting after 6 months. Quality of life evaluations included the short forms of the Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7. A total of 248 women who underwent sling surgeries and had complete weight measurement and evaluation data before and after the surgeries were included, of whom 47 gained body weight, and 201 had a stable body weight. The median follow-up duration was 18 months (range, 6-47 months). There were no significant differences in surgical outcomes between the 2 groups regarding objective cure rate (86% vs 87%, p = .834), 1-hour pad test (4.5 ± 17.8 vs 3.6 ± 18.6 g, p = .770), or postoperative quality of life (Urogenital Distress Inventory-6: 1.9 ± 2.8 vs 2.8 ± 3.2, p = .122; Incontinence Impact Questionnaire-7: 1.8 ± 3.9 vs 2.6 ± 4.3, p = .307). A trend toward increased de novo OAB rate was observed, although this finding was not adequately powered.

CONCLUSION

Weight gain after sling surgeries did not influence surgical outcomes, but there was a nonsignificant trend toward increased OAB in the weight gain group. It may be beneficial to counsel patients with regard to body weight maintenance after sling surgeries.

Urinary Biomarkers and Overactive Bladder Symptoms Before and After Prolapse Surgery

IMPORTANCE

Women with pelvic organ prolapse (POP) have increased prevalence of overactive bladder (OAB) and the evaluation of urinary biomarkers associated with OAB in the setting of POP is limited.

OBJECTIVE

The objective is to determine whether associations exist between urinary biomarkers measured before POP surgery with postoperative OAB symptoms.

STUDY DESIGN

In this prospective cohort study, women with anterior and/or apical POP beyond the hymen undergoing POP surgery were assessed using the OAB Questionnaire Short Form (OAB-q SF) and the Urogenital Distress Inventory 6 (UDI-6) preoperatively and 3 months postoperatively. A first morning voided urine specimen was collected preoperatively and 3 months postoperatively. Urinary biomarkers for inflammation, neuroinflammation, and tissue remodeling were measured. Univariate generalized linear models measured the relationship between biomarkers and symptoms. Between- and within-cohort assessments were made using 2-sample paired and unpaired t tests, respectively.

RESULTS

Seventy-seven participants with OAB (n = 67, 87.0%) and without OAB (n = 10, 13.0%) were enrolled. Seventy-four participants (96%) completed 3-month follow up. The OAB-q SF and UDI-6 scores significantly improved between preoperative and postoperative measures. Preoperative urinary biomarkers did not demonstrate significant correlations with postoperative OAB-q SF or UDI-6 scores. No significant differences were measured in preoperative biomarkers between patients with and without OAB or when comparing preoperative and postoperative biomarkers in patients with OAB.

CONCLUSIONS

Urinary biomarkers for tissue remodeling, inflammation, and neuroinflammation were not significantly correlated with OAB symptoms in a population of patients with OAB and POP.

Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse

OBJECTIVE

The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery.

METHODS

This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery.

RESULTS

A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P = 0.008) and more frequently had overactive bladder compared with controls (P = 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P = 0.034).

CONCLUSION

POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.

Feasibility and clinical implications of 3-day bladder diary derived classification of female storage lower urinary tract symptoms

Our aim was to assess the feasibility of a bladder diary (BD) classification as a surrogate for urodynamic studies in women with storage lower urinary tract symptoms. A total of 3823 women who underwent urodynamic studies were reviewed. Nearly the scores of Patient Perception of Bladder Condition, Indevus Urgency Severity Scale and Overactive Bladder Symptom Score decreased gradually from the overactive bladder (OAB) wet-BD, OAB dry-BD, hypersensitive bladder (HSB) -BD, nocturia-BD to normal-BD groups (all p < 0.001). In addition, there is a trend that the rates of bladder oversensitivity decreased gradually from the OAB wet-BD, OAB dry-BD, HSB-BD, nocturia-BD to normal-BD groups (chi-square test, p < 0.001). Moreover, almost the volumes of first desire to void, normal desire to void, strong desire to void, and urgency increased gradually from the OAB wet-BD, OAB dry-BD, HSB-BD, nocturia-BD to normal-BD groups (all p < 0.001). Thus, this BD classification is correlated significantly with symptom severity, the rate of bladder oversensitivity, and bladder capacity. Nonetheless, a combination of urodynamics, clinical history, and BD is still needed for a thorough diagnosis, but that BD provides an efficient diagnosis in a proportion of patients.

Coexistent Detrusor Overactivity-Underactivity in Patients with Pelvic Floor Disorders

Introduction and Hypothesis: Pelvic floor disorders represent a series of conditions that share, in part, the same etiological mechanisms, so they tend to be concomitant. Recently, awareness of a new lower urinary tract clinical syndrome has risen, namely the coexisting overactive–underactive bladder (COUB). The etiopathogenetic process, prevalence, and related instrumental findings of COUB are not well-established. We aimed to evaluate the prevalence, clinical features, and urodynamic findings of patients with COUB in a large cohort of patients with pelvic floor disorders. Methods: A cohort of 2092 women was retrospectively analyzed. A clinical interview, urogenital examination, and urodynamic assessment were performed by a trained urogynecologist. Based on baseline symptoms, patients were divided into COUB and non-COUB groups, and the degree of concordance between COUB and urodynamic findings, and other parameters related to the clinical aspects of these patients were measured and analyzed. Results: 18.8% of patients were classified as COUB. The association between COUB and patients with coexisting detrusor overactivity–underactivity (DOU) was statistically significant and there were substantial similarities in terms of population characteristics, symptoms, and urodynamic findings. Conclusions: Our study showed a high prevalence of COUB, and a link between this clinical syndrome and DOU was demonstrated. They showed substantial similarities in terms of clinical and urodynamics correlates. Based on these findings, we do think that urodynamic tests can be useful to improve knowledge on COUB and may be of help in the management of this condition.

Native Tissue Posterior Compartment Repair for Isolated Posterior Vaginal Prolapse: Anatomical and Functional Outcomes

Background and Objectives: Posterior compartment prolapse is associated with constipation and obstructed defecation syndrome. However, there is still a lack of consensus on the optimal treatment for this condition. We aim to investigate functional, anatomical, and quality-of-life outcomes of native tissue transvaginal repair of isolated symptomatic rectocele. Materials and Methods: We retrospective analyzed patients who underwent transvaginal native tissue repair for stage ≥ II and symptomatic posterior vaginal wall prolapse between January 2018 and June 2021. Anatomical and functional outcomes were evaluated. Wexner constipation score was used to assess bowel symptoms, while the Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Results: Twenty-eight patients were included in the analysis. The median age was 64.5 years, and half of them underwent a previous hysterectomy for benign reasons. The median follow-up time was 33.5 months. A significant anatomical improvement in the posterior compartment was noticed compared with preoperative assessment (p < 0.001 for Ap and Bp), with only two (7.1%) anatomical recurrences. Additionally, obstructed defecation symptoms decreased significantly compared to baseline (p < 0.001), as well as vaginal bulging, with no new-onset cases of fecal incontinence or de novo dyspareunia. PGI-I resulted in 89.2% of patients being satisfied (PGI-I ≥ 2), with a median score of 1.5. Conclusions: Transvaginal native tissue repair for isolated posterior prolapse is safe and effective in managing bowel symptoms, with excellent anatomical and functional outcomes and satisfactory improvement in patients’ quality of life.

Correlation between urinary symptoms and urodynamic findings: Is the bladder an unreliable witness?

OBJECTIVE

The role of urodynamics as the gold standard to investigate bladder function has recently been questioned. We aimed to evaluate the agreement of lower urinary tract symptoms and urodynamic diagnosis and to build predictive models.

STUDY DESIGN

Patients who underwent urodynamics for pelvic floor disorders between 2008 and 2016 were retrospectively analyzed. Clinical evaluation investigated the presence of genital prolapse, stress urinary incontinence (SUI), overactive bladder (OAB), urge urinary incontinence (UUI), voiding symptoms (VS), and bulging symptoms. The degree of concordance/agreement between symptoms and corresponding urodynamic findings was measured. Multivariate models to predict specific urodynamic findings were built.

RESULTS

1972 women were analyzed. The best agreement was found for SUI and urodynamic SUI, with a proportion of agreement of 0.68 and a Cohen's Kappa of 0.37. Very poor agreement was found for OAB/UUI and detrusor overactivity, voiding dysfunction, and positive post-void residuals. Multivariate models resulted in poor accuracy for all urodynamic findings (AUC range 0.64-0.72).

CONCLUSION

Lower urinary tract symptoms and gynecological examination are poor predictors of urodynamic findings. This confirms the role of urodynamic assessment in defining bladder function and providing precious information to counsel patients and establishing optimal clinical guidance.

Learning Curve of Botulinum Toxin Bladder Injection for the Treatment of Refractory Overactive Bladder

PURPOSE

Intradetrusor botulinum toxin injections is an established second-line treatment for patients with refractory overactive bladder syndrome (OAB). We aimed to evaluate the learning curve of intradetrusor injections with botulinum toxin for the treatment of refractory OAB.

PATIENTS AND METHODS

This retrospective study analyzed all women with idiopathic and refractory OAB who underwent botulinum toxin bladder injections performed by residents with no previous experience with operative cystoscopy under consultant supervision. Baseline International Consultation on Incontinence Questionnaire-Short Form questionnaire (ICIQ-SF) and Euroqol (EQ-5D) questionnaires were collected. Procedural data (operative time, number of valid injections, complications, subjective easiness, perceived tolerability) and patients' outcomes (Patients Global Impression of Improvement (PGI-I), ΔICIQ-SF, ΔEQ-5D, need for self intermittent catheterization, duration of efficacy) were considered as markers to evaluate learning curves for each resident.

RESULTS

Twenty-seven patients underwent intravesical injection of botulinum toxin performed by residents. Only a grade 1 Clavien-Dindo complication occurred, and none of the patients had urinary retention. PGI-I was very satisfactory, scoring 1.4 ± 0.9. Both ICIQ-SF and EQ-5D 2-2 were statistically improved (p < 0.00001 and p = 0.04, respectively). The mean duration of efficacy resulted to be 8.0±4.3 months. A positive effect of the learning curve was observed only for operative time, subjective easiness, and perceived tolerability.

CONCLUSION

Intradetrusor botulinum toxin injection for the treatment of refractory OAB is characterized by high efficacy and very low complications even at the very beginning of the learning curve when performed under proper mentorship.

[Non-neurological overactive bladder and pelvic-perineal pathology in women]

INTRODUCTION

The aim was to synthesize current knowledge on overactive bladder (OAB) and female pelvic-perineal diseases.

METHOD

A systematic literature review based on PubMed, Embase and Google Scholar was conducted in April 2020.

RESULTS

Women with pelvic organ prolapse very often have OAB. Prolapse surgery should be considered if the prolapse is symptomatic and never be indicated in case of overactive bladder symptoms solely. In case of symptomatic prolapse and OAB, pessary and surgical treatments are effective on both pathologies up to 71 % of the cases. OAB may occur in parallel or as part of a menopausal genitourinary syndrome. In the latter case, only local estrogen therapy is effective. OAB may occur alongside stress urinary incontinence (SUI) or be integrated into mixed urinary incontinence. The initial treatment should be based on the most troublesome symptoms. In case of SUI, the outcome of surgical treatment on OAB remains uncertain. De novo, OAB follows prolapse or SUI surgery. It requires investigations to exclude urinary tract infection, bladder outlet obstruction or erosion. The treatment is the same as OAB.

CONCLUSION

The clinician's challenge is to draw a balance between the OAB and a pelvic-perineal pathology in order to adapt the treatment.

Pelvic organ prolapse surgery and overactive bladder symptoms-a population-based cohort (FINPOP)

Introduction and hypothesis

It is unclear how compartment of pelvic organ prolapse (POP) impacts overactive bladder (OAB) symptom severity or improvement after POP surgery. We hypothesized that anterior and apical prolapse are more strongly associated with OAB symptoms than posterior compartment prolapse.

Methods

A total of 2933 POP surgeries from a prospective population-based cohort were divided into two groups: (1) anterior and/or apical compartment surgery (± posterior repair), N = 2091; (2) posterior repair only, N = 478. Urinary frequency and urgency urinary incontinence (UUI) were evaluated using PFDI-20 (bothersome symptom: score 3–4) at baseline, 6, and 24 months. Association between degree of POP in specific compartments and symptoms at baseline was estimated with generalized linear models and between compartment of surgery and symptom improvement with generalized estimating equations.

Results

At least one bothersome symptom was reported by 40% at baseline, 14% at 6, and 19% at 24 months. At baseline, urinary frequency was associated with degree of anterior and apical and UUI with anterior compartment prolapse. Women undergoing surgery for anterior/apical compartment started with worse symptoms and experienced greater improvement than women undergoing posterior compartment surgery. Bothersome frequency resolved in 82% after anterior/apical and in 63% after posterior compartment surgery. Bothersome UUI resolved in 75% after anterior/apical and in 61% after posterior compartment surgery. After surgery, symptom severity was comparable between groups. Bothersome de novo symptoms occurred in 1–3%.

Conclusions

OAB symptoms are more strongly related to anterior and apical than to posterior compartment prolapse, but improvement is seen after surgery for any vaginal compartment.

The association of symptoms of overactive bladder with pelvic organ prolapse and its improvement after pelvic reconstructive surgery

Objectives

This study asseses the association of overactive bladder symptoms and pelvic organ prolapse severity and evaluates the effect of pelvic reconstructive surgery on overactive bladder (OAB) symptoms in women with pelvic organ prolapse (POP). It also looks into any pre and post-operative factors responsible for persistent postoperative OAB symptoms.

Methods

This was a retrospective cross-sectional study conducted at the Aga Khan University Hospital, Karachi between 1st January 2014 and 31st December 2018. In this study women presenting with POP and concommitent OAB who underwent surgery for site specific defects, measured using Pelvic Organ Prolapse Quantification (POP-Q) staging system. OAB was defined as presence of urinary frequency, urinary urgency incontinence (UUI) and an affirmative response to item #15 and/or item #16 of the Pelvic Floor Distress Inventory (PFDI), which was used both pre and postoperatively. Primary outcome of the study was to find complete resolution or improvement of urinary frequency and UUI on the PFDI, 24 months after surgery. The secondary outcome was to see persistent OAB postoperatively and the factors associated with it.

Results

Overactive bladder (OAB) symptoms improved significantly regardless of the severity of prolapse at 24 months postoperative period. Body mass index (BMI) and postoperative constipation were the only statistically significant variables associated with persistent OAB symptoms postoperatively.

Conclusions

Surgical correction of POP results in significant improvement in symptoms of OAB, in all stages of POP and co-existing OAB. However women with high BMI and post-operative constipation may be prone to persistent frequency and/or UUI.