Pelvic Floor Physical Therapy Research Articles

A randomized trial comparing vaginal laser therapy and pelvic floor physical therapy for treating women with stress urinary incontinence.

Female stress urinary incontinence (SUI) is considered a major public health issue. Physical therapy is an important conservative treatment; however, it is primarily limited by poor long-term compliance. Furthermore, surgical treatment entails significant risks. Therefore, new treatment techniques must be identified. To compare the use of laser therapy and pelvic floor (PF) physical therapy for treating postmenopausal women with SUI. This pilot study enrolled 40 women with a clinical and urodynamic diagnosis of SUI who were randomized into two groups: those who received erbium-doped yttrium-aluminum-garnet (Er:YAG) laser therapy implemented over three sessions with a 1-month interval (n = 20) and those who received physical therapy with supervision twice a week for 3 months (n = 20). In total, 16 women completed the treatment in each group. The patients were assessed for PF function using the modified Oxford scale and for pelvic organ prolapse using the Pelvic Organ Prolapse Quantification System. The 1-h pad test and quality of life questionnaires, King's Health Questionnaire (KHQ), and Incontinence Quality of Life (IQOL) were also administered. Patients were re-evaluated at 1, 3, 6, and 12 months after treatment. The mean patient age was 62.7 ± 9.1 and 57.9 ± 6.1 years, median Oxford score at baseline was 3 (2-4.5) and 4 (3-4), mean IQOL score was 79.8 ± 17 and 74.6 ± 18 for physical therapy group (PTG) and laser group (LG), respectively. For the amount of urine leak in the 1-hpad test evaluation, we found significance for the interaction of group and time points only for the Laser intragroup. The cure rate, that is, the rate of reaching an insignificant score in the pad test, at 6 and 12 months was 43.75% and 50% in PTG and 62.5% and 56.25% in the LG, respectively (p > 0.05). IQOL scores demonstrated considerable improvement in both groups (p > 0.05). Upon comparing the initial and follow-up results, the LG showed an improvement at all consultations, whereas the PTG showed improvements at 1, 3, and 6 months but not at 12 months after treatment. KHQ analysis revealed a considerable improvement in the quality of life (QOL) of patients over time, with no substantial difference between the groups. QOL comparison before and after treatment revealed that the vaginal LG improved more consistently in some domains. Only the PTG showed a significant increase in the mean Oxford score from pretreatment to 1 and 3 months after treatment (p < 0.001 and p = 0.002, respectively). However, no statistically significant difference was observed between the groups. Both treatments are safe and have a positive influence on the impact of UI on patients'QOL. The laser caused a greater reduction in the urinary loss, as measured using the weight of pad test, at 6-month and 12-month after treatment without difference with PTG at the end of the follow-up.

Effectiveness of telehealth physical therapy for patients with pelvic floor disorders in a community hospital setting.

To examine whether there are differences in meeting treatment goals between pelvic floor physical therapy (PFPT) patients who participated in a majority of telehealth visits versus those who participated in mostly traditional office visits at a community hospital. Retrospective chart review was performed among patients who received PFPT from April 2019 to February 2021. Cohorts were defined as "Mostly Office Visits" (> 50% office visits) and "Mostly Telehealth" (> / = 50% telehealth visits). Primary outcome measures included demographic data, number/type of visit for each patient, number of no-show/cancelation appointments, and number of patients discharged meeting PFPT goals. Statistical significance was defined as p < 0.05. 234 subjects met criteria for the "Mostly Office Visit" cohort and 48 subjects met criteria for the "Mostly Telehealth" cohort. There were no significant differences observed in age (p = 0.919), BMI (p = 0.817), race/ethnicity (p = 0.170) or insurance type (p = 0.426) between cohorts. There was no significant difference in meeting PFPT goals between the "Mostly Office Visit" cohort (24.4%) and the "Mostly Telehealth" cohort (35.4%) (p = 0.113). There was no difference in the number of canceled visits per patient (mean cancelations "Office visit" 1.98; "Telehealth" 1.63; p = 0.246) and the number of no-show visits per patient (mean no-show's "Office visit" 0.23; "Telehealth" 0.31; p = 0.297) between cohorts. There was no difference in meeting discharge goals regardless of whether a patient participated in mostly telehealth visits versus mostly traditional office visits. Therefore, we can conclude that participating in mostly provider-led telehealth visits can be equally efficacious at providing competent PFPT care.

ID: 210631 Case Report: Peripheral Nerve Stimulation of the Pudendal Nerve for Pudendal Neuralgia

Pudendal neuralgia is an incapacitating condition that causes pelvic pain, disability and dysfunction along the pudendal nerve and can be difficult to treat. Usual treatment includes pelvic floor physical therapy, neuropathic and pain medications, biofeedback and cognitive behavioral therapy, nerve blocks, sympathetic blocks, and spinal cord or DRG stimulation.

(087) Why Should Pelvic Floor Physical Therapy be Included in Treatment of Vestibulodynia?

Abstract Introduction Vestibulodynia, vulvar pain localized to the vestibule without an identifiable cause, has a multifactorial etiology including neurologic, hormonal, inflammatory, psychologic, and musculoskeletal factors. Key pathophysiologic drivers likely vary from patient to patient. Published studies demonstrate that compared to controls, patients with provoked vestibulodynia are more likely to have pelvic floor hypertonicity and decreased pelvic floor strength, as measured by dynamometric speculum and ultrasound. Further, observational studies describe improvement of vestibulodynia symptoms with pelvic floor physical therapy, suggesting a causal relationship between pelvic floor hypertonicity and vestibulodynia. Objective To describe the pathophysiologic mechanism by which pelvic floor dysfunction and myofascial trigger point development could cause vestibuoldynia, with a focus on pelvic floor anatomy. Methods Literature about vestibulodynia, pelvic floor dysfunction, and pelvic floor anatomy was reviewed and synthesized in conjunction with expert clinical experience of pelvic floor physical therapists and gynecologists. Results The pelvic floor consists of the levator ani muscles (iliococcygeus, pubococcygeus, and puborectalis) and ischiococcygeus, which form a basket to support the pelvic organs. The puborectalis inserts in the posterior vestibule, and hypertonicity can cause allodynia in this region. The levator ani are innervated by the levator ani nerve, which originates from S3-S5 and traverses the visceral surface of the muscles. Some cadaveric studies suggest dual innervation of the levator ani by the pudendal nerve, which originates from S2-S4 and courses over the inferior surface of the muscles. Pelvic floor hypertonicity, increased resting tone of the pelvic floor muscles, can result from many factors including stress, bladder and rectum voiding habits, and painful pelvic processes (i.e. interstitial cystitis, endometriosis). Increased muscle tone can promote sensitization of muscle afferent fibers and neuropathic upregulation. This may be perceived as vestibulodynia because the vestibule contains visceral and somatic sensory nerve fibers, whose signals are integrated at the same spinal levels as those from the levator ani. This anatomy allows for somatovisceral convergence of afferent signals, and thus perception of vestibular pain. Hypertonicity of the pelvic floor muscles decreases circulation creating localized hypoxia that can promote development of myofascial trigger points (tender nodules) in the pelvic floor. These trigger points can cause allodynia, perceived in the vestibule. In some cases, vestibulodynia may develop first and promote pelvic floor hypertonicity. Conclusions As pelvic floor hypertonicity can contribute to the pathogenesis of vestibulodynia, it is imperative for clinicians to include pelvic floor tone evaluation in their assessment of vestibulodynia. If pelvic floor hypertonicity is present, it should be treated concurrently with vestibular pain through a combination of pelvic floor physical therapy, trigger point injections, and botulinum toxin injections as pelvic floor hypertonicity and vestibulodynia may each perpetuate the other. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson &amp; Johnson.

(016) Outpatient, Multimodal Neuromuscular Treatment Reduces Pain and Improves Functionality for Patients with Chronic Pelvic Pain and Vulvodynia

Abstract Introduction Characterized by chronic pain and/or discomfort around the opening of the vulva, Vulvodynia is known to affect up to 16% of adult women. Vulvodynia may present as constant or intermittent pain which negatively impacts patients’ personal and working lives, as well as mental health and relationships. The cause of Vulvodynia is unknown, and treatment is not widely agreed upon. Objective The purpose of this study was to test the effectiveness of a multimodal neuromuscular treatment protocol in treating the symptoms of Chronic Pelvic Pain and Vulvodynia, improving pain and function. Methods 59 patients ages 20-79 who presented to an outpatient clinic for treatment of pelvic pain and Vulvodynia symptoms. These symptoms had persisted for an average of 6 years. All patients underwent a once weekly, six-week treatment consisting of ultrasound-guided pelvic floor musculature trigger-point injections and peripheral nerve blocks. To measure the effects of this treatment, a 0-10 Visual Analogue Scale (VAS) was used to measure pelvic pain intensity, and the Functional Pelvic Pain Scale (FPPS) was used to measure function across multiple areas. These measures were taken at patients’ first visit to a clinic, and three months after treatment began. Results VAS scores improved by an average of 51%. Before treatment, the mean VAS score was 7.93 (SD=1.61) (a=0.05; CI 7.52-8.34) and the posttreatment mean VAS score was 3.9 (SD=2.19) (a=0.05; CI 3.34-4.46) (P&amp;lt;0.0001). Pelvic pain functionality improved by 23% after three months. Pretreatment FPPS scores averaged at 12.34 (SD=5.8) (a=0.05; CI 10.86-13.82), decreasing to 9.53 (SD=5.43) (a=0.05; CI 8.14-10.91) after treatment (P&amp;lt;0.0001). FPPS functions which showed the greatest improvement were Sleep, which improved by 39%, Intercourse, which improved by 28%, and Walking, which improved by 28%. Conclusions These results indicate that a six-week treatment consisting of once-weekly ultrasound-guided pelvic floor musculature trigger-point injections and peripheral nerve blocks combined with once-weekly pelvic floor physical therapy was very effective at relieving pain and improving function for patients with Vulvodynia. Disclosure No

(065) Let’s Talk about Sex: Resident Run Didactic Curriculum

Abstract Introduction The Council on Resident Education in Obstetrics and Gynecology (CREOG) includes sexual health learning objectives as part of the core education for Ob/Gyn training. Residents are expected to gain understanding of normal sexual function as well as common areas of sexual dysfunction. Unfortunately, several studies have demonstrated a lack of knowledge in this area by Ob/Gyn residents and that educational didactic programs are not standardized on this topic. In 2010, over 90% of post graduate year (PGY)3 and PGY4 residents reported attending fewer than 5 didactic activities on sexual function/dysfunction, with only 50% feeling able to perform a targeted physical exam. Over the past decade, there has not been substantial improvement in this subject matter. In a 2021 survey evaluating the sexual health CREOG objectives showed that more than half of Ob/Gyn residents were not able to describe the disorders of sexual function or list common medications that effect sexual function. This is not isolated to the US, with studies in other countries including Singapore and Brazil, showing residents lack formal training and residents want increased didactic time focused on sexual health. Objective Our hypothesis was that at our institution the baseline knowledge of sexual dysfunction among Ob/Gyn residents would be low. The primary objective was formulating a needs assessment through implementation of a pre/post survey with a curriculum component. The secondary objective was to determine what areas of sexual medicine are most commonly areas of confusion or where residents lack comfort in regard to patient care. Methods The resident-designed curriculum was built with collaboration from a pelvic floor physical therapist. The journal club format was based on American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins, the International Society for the Study of Women’s Sexual Health (ISSWSH) clinical pearls, and the North American Menopausal Society (NAMS) position statements. The pelvic floor physical therapy component focused on pelvic pain, perinatal considerations, and incontinence. The WCG IRB deemed this study exempt. After the pre-curriculum assessment was used to identify knowledge gaps, a month of one-hour weekly sexual health sessions were implemented followed by a post-curriculum survey. Results Due to small sample size, (N=14) there was no way to establish significance in our results. In general, areas that residents were weak and the curriculum focused on were: 1) Pelvic floor/vulvar/vestibular disorders. 2) Genitourinary syndrome of menopause and vasomotor symptoms of menopause. 3) Sexual medicine disorders (hypoactive sexual desire disorder, female sexual arousal disorder, persistent genital arousal disorder, female orgasm disorders, genitopelvic pain penetration dysfunction). Conclusions The baseline knowledge of sexual dysfunction and menopausal concerns among Ob/Gyn residents was low. However, implementation of a structured curriculum after a formal needs assessment improved comfort with these topics. Now that the baseline curriculum is designed it is imperative to expand to further residency programs (in Ob/Gyn as well as other specialties) to disseminate the knowledge to providers in training who require competency in sexual health concerns. Disclosure No

(432) Efficacy of Low-Intensity Shockwave Therapy on Hard Flaccid Syndrome: Initial Report of Three Cases

Abstract Introduction Hard flaccid syndrome (HFS) is characterized by chronic pain in the penis and perineum and firmness or rigidity of the penis even while not erect and may have a devastating impact on patient sexual quality of life. Although this syndrome has been discussed in myriad patient forums, there is no established evidence-based definition nor specific standard established treatment modalities in the literature. Current treatment options may include a combination of medical pain management, pelvic floor physical therapy, biofeedback, and stress reduction. In patients with other chronic pain conditions who fail traditional therapies, low-intensity shock wave therapy (LiSWT) has been increasingly utilized as management with positive response. We report a series of three patients with managed with LiSWT. Objective To report our initial experience of men with HFS managed with LiSWT. Methods Three patients, aged 36, 24, and 20 diagnosed with HFS were treated with LiSWT for a course of six sessions. In each session, LiSWT settings were: energy flux density of 0.13 mJ/mm2 and frequency of 3 Hz. While penis was held in stretched position, 600 shocks were delivered to each of the dorsum, left, ventral, and right aspects of penis along the shaft. The scrotum was then held up, and 600 shocks were delivered to each of the right and left crural areas, adding up to 3600 total number of shocks that were allocated evenly. All patients answered a questionnaire to assess improvement in symptoms after completion of the treatment sessions (Table 1). Results All patients reported initially alleviated symptoms after 3 treatment sessions, particularly with respect to penile rigidity in the flaccid state. Patient 1 elected for a combination of LiSWT and tadalafil. 5 months after treatment completion, Patient 1 has had complete resolution of HFS symptoms. Patient 2 had no response with tadalfil alone before he elected for LiSWT only, and patient 3 opted for LiSWT alone. After each LiSWT session, patient 2 reported relieved symptoms for 3-4 days, while patient 3 reported significant improvement lasting for 24 hours. Both patients 2 and 3 reported gradually returning to their pre-treatment baseline in 5 months’ follow-up. Conclusions While HFS is becoming increasingly recognized amongst sexual medicine clinicians, there are currently no established efficacious treatment options. LiSWT shows potential as a treatment modality and may have increased efficacy if used in combination with PDE5 inhibitors, as demonstrated in this pilot study. Nevertheless, a larger case series is necessary to establish LiSWT as a standardized treatment option and may require a more comprehensive approach to properly manage this condition. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Clarus Therapeutics, Antares Pharma, Acerus.

Objective Changes in Pelvic Floor Muscle Strength and Length in Women With High-Tone Pelvic Floor Dysfunction After Pelvic Floor Physical Therapy (RELAX Trial)

Although pelvic floor physical therapy (PFPT) is effective in treating high-tone pelvic floor dysfunction (HTPFD), data on the mechanism of improvement are limited. This study aimed to compare squeeze intravaginal closure force after 6 weeks of PFPT in women affected by HTPFD and, secondarily, to describe changes in levator dimensions and short-term effects of PFPT on bladder, bowel, and pain symptoms. We conducted a prospective cohort study of patients undergoing 6 sessions of PFPT for the diagnosis of HTPFD. At baseline, we measured intravaginal closure force using an instrumented speculum, levator hiatal dimension using a 3-dimensional endovaginal ultrasonography, and symptom severity using 3 validated questionnaires. Intravaginal closure force and symptoms were reevaluated after the second, fourth, and sixth PFPT sessions, and levator hiatus was reevaluated at the sixth session. Twenty-six women were enrolled and 22 completed 6 sessions and are included in the analysis. Contrary to our hypothesis, mean ± SD vaginal closure force (N) did not demonstrate a significant change (3.27 ± 2.34 vs 3.67 ± 2.02 N, P = 0.18). However, mean levator hiatal area (cm2) increased between visit 1 (13.71 ± 1.77 cm2) and visit 6 (14.43 ± 2.17 cm2, P = 0.05), as did the transverse diameter (3.83 ± 0.03 vs 3.95 ± 0.03 cm, P = 0.04). Survey responses demonstrated significant improvements across all measures of genitourinary symptoms, pain, lower gastrointestinal symptoms and quality-of-life measures after 6 sessions of PFPT. Although the levator hiatal area increased after 6 sessions of PFPT (suggesting muscle lengthening), we were unable to demonstrate that this changed the force generated by pelvic floor muscles as measured by a speculum.

Sexual Function in Women at 6 and 12 Months After Obstetric Anal Sphincter Injury: Is Pelvic Floor Physical Therapy Associated With Improved Outcomes?

Women with obstetric anal sphincter injury (OASI) are at increased risk of postpartum sexual dysfunction. Risk persists beyond 3 years after perineal trauma in up to half of patients with OASI. The aims of this study were to determine if postpartum pelvic floor physical therapy (PFPT) is associated with improved sexual function after vaginal delivery with OASI and to describe sexual function in patients with OASI at 6 and 12 months postpartum. This is a retrospective cohort study of patients with OASI. Women were grouped according to PFPT attendance. The Postpartum Pelvic Floor and Birth Questionnaire (PPFBQ), which compares current sexual function to baseline prepregnancy sexual function, and the Female Sexual Function Index (FSFI) were administered at 6 and 12 months, respectively, to evaluate postpartum sexual function. Two hundred women were included. Sixty-four (32%) women attended PFPT; 136 (68%) did not attend PFPT. Patients reported worse-than-baseline sexual function at 6 months postpartum in the PPFBQ sexual activity domain, but the PFPT group had lower median score than the non-PFPT group (2.3 [2.0, 2.8] vs 2.7 [2.1, 3.1], P = 0.034), with scores <3.0 indicating worse-than-baseline functioning. The FSFI composite scores were similar between groups and showed 80.7% of the patients with OASI meeting the criteria for female sexual dysfunction at 12 months postpartum. Attendance of PFPT was not significantly associated with composite FSFI scores and most domains of PPFBQ. Attendance of PFPT did not significantly impact overall sexual function in OASI patients at 6 and 12 months postpartum. Sexual function is complex and may be more effectively addressed in the postpartum period using a multidimensional approach.

The patient with obstructed defecatory symptoms: Management differs considerably between physicians and surgeons.

Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be impacted by this choice of referral. An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient. A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre-treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele. Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines.

Prevalence and Normalization of Stress Urinary Incontinence in Female Strength Athletes.

Mahoney, K, Heidel, RE, and Olewinski, L. Prevalence and normalization of stress urinary incontinence in female strength athletes. J Strength Cond Res 37(9): 1877-1881, 2023-Strength training is increasing in popularity in women but is also a potential risk factor for stress urinary incontinence (SUI). There is potential for normalization of SUI in sports with high rates of SUI. Pelvic floor physical therapy is an effective treatment for SUI in both athletes and nonathletes, but female strength athletes may not be aware of this option. Our study sought to assess prevalence, normalization, rates of treatment, and preferred sources of information about SUI in female strength athletes. A novel cross-sectional survey was distributed online through social media groups dedicated to female strength athletes with 425 women responding within 4 days. Statistical significance of results was assumed at a 2-sided alpha value of 0.05. 43.5% of athletes experienced incontinence with daily tasks, 59.1% experienced incontinence with normal strength training, and 50.2% experienced incontinence during competition. Of the athletes who experienced incontinence, 61.4% did not have incontinence before starting their sport and only 9.4% had ever sought treatment. 67.9% of all athletes surveyed believed that urinary incontinence was a normal part of their sport. Our findings indicate that SUI is common in female strength athletes and may be a consequence of the sport itself. Normalization of SUI is common, and few athletes seek treatment.

PD05-03 BLADDER-DIRECTED VERSUS PELVIC FLOOR THERAPY IN WOMEN WITH INTERSTITIAL CYSTITIS/BLADDER PAIN SYNDROME: PRELIMINARY RESULTS

You have accessJournal of UrologyCME1 Apr 2023PD05-03 BLADDER-DIRECTED VERSUS PELVIC FLOOR THERAPY IN WOMEN WITH INTERSTITIAL CYSTITIS/BLADDER PAIN SYNDROME: PRELIMINARY RESULTS Bernadette Zwaans, Lydia Kosovich, Larry Sirls, Jason Gilleran, Christoper Smith, Priya Padmanabhan, Michael Chancellor, and Kenneth Peters Bernadette ZwaansBernadette Zwaans More articles by this author , Lydia KosovichLydia Kosovich More articles by this author , Larry SirlsLarry Sirls More articles by this author , Jason GilleranJason Gilleran More articles by this author , Christoper SmithChristoper Smith More articles by this author , Priya PadmanabhanPriya Padmanabhan More articles by this author , Michael ChancellorMichael Chancellor More articles by this author , and Kenneth PetersKenneth Peters More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003229.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Interstitial cystitis/bladder pain syndrome (IC/BPS) symptoms appear bladder related, though little solid evidence exists linking IC/BPS symptoms to dysfunctional bladder epithelium unless ulcers are present. Growing evidence suggests IC/BPS may be a more diffuse syndrome. The study objective is to compare IC/BPS symptom improvement in pelvic floor versus bladder directed therapies. METHODS: Women 18 to 85 years with history of IC/BPS were randomized to one of two treatment arms: 1. Pelvic Floor Physical Therapy (PFPT), 2. Bladder directed instillation of lidocaine, heparin sulphate, sodium bicarbonate, and Kenalog. All participants received twice weekly treatments for 8 consecutive weeks. Symptom improvement was assessed using 3-day voiding diary, pain assessment, and validated questionnaires: global response assessment (GRA), Interstitial cystitis symptom index (ICSI) and Interstitial cystitis problem index (ICPI), at baseline, treatment mid- and end-points (V8 and V17), and 6 months follow-up (V18). Statistical analysis was performed using ANOVA followed by Dunnett’s multiple comparison. RESULTS: 31 women were enrolled and randomized to PFPT (n=15) or Instillation (n=16) arm with average age of 46.8 and 48.7 respectively. By end of treatment 67% in PFPT versus 54% in instillation group reported significant improvement of symptoms (GRA). Urinary frequency was significantly reduced in PFPT group at all time points (Figure 1) and was resolved or improved in 75% of patients in PFPT compared to 33% in instillation group. Both treatments significantly improved Maximum pelvic pain, but reduction in pain was no longer significant in PFPT group by V18 (Figure 1). Pain Catastrophizing Scale scores followed the same trend. Urgency did not improve with either treatment. ICSI and ICPI scores were significantly reduced by V8 and remained constant up to V18. No severe adverse events were reported. Four patients developed urinary tract infections during treatment, 1 in PFPT and 3 in instillation group. CONCLUSIONS: Both treatments significantly improved IC/BPS symptoms, with patients in PFPT reporting higher GRA scores and frequency improvement. In contrast, instillation appeared superior in reducing maximum pelvic pain long-term. Source of Funding: DoD clinical research grant (W81XWH 16-10) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e149 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bernadette Zwaans More articles by this author Lydia Kosovich More articles by this author Larry Sirls More articles by this author Jason Gilleran More articles by this author Christoper Smith More articles by this author Priya Padmanabhan More articles by this author Michael Chancellor More articles by this author Kenneth Peters More articles by this author Expand All Advertisement PDF downloadLoading ...

MP49-04 PILOT PELVIC FLOOR THERAPY PROGRAM FOR THE TREATMENT OF FEMALE URINARY INCONTINENCE IN BELIZE

You have accessJournal of UrologyCME1 Apr 2023MP49-04 PILOT PELVIC FLOOR THERAPY PROGRAM FOR THE TREATMENT OF FEMALE URINARY INCONTINENCE IN BELIZE David Rapp, Jacqueline Zillioux, Fionna Sun, Michelle Little, and Jeanice Mitchell David RappDavid Rapp More articles by this author , Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Fionna SunFionna Sun More articles by this author , Michelle LittleMichelle Little More articles by this author , and Jeanice MitchellJeanice Mitchell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003297.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary incontinence (UI) is highly prevalent in low- and middle-income countries (LMIC). Concurrently, the availability of surgical or conservative UI treatments in LMIC is limited. METHODS: We conducted a prospective feasibility study of women in Belize with UI treated with pelvic floor physical therapy (PFPT) and education (PFE). This study is part of a larger initiative to establish a PFPT program in Belize in conjunction with the charity Global Surgical Expedition. Patients were recruited during a 7-day visiting trip. Enrolled patients received individual PFPT/PFE over the course 2 days (1 hour per day), consisting of biofeedback-enhanced PFMT including pelvic floor activation training (dynamic and functional activities) in addition to behavioral, dietary, and general pelvic education. Patients then completed a daily 6-month home regimen including 7 PFMT exercises (total 70 repetitions) comprising both endurance and quick flick exercises across supine, seated, and standing positions. Patients also performed comprehensive dietary and behavioral modification activities. Comprehensive outcomes were assessed at baseline and 6-months, including validated symptom (ICIQ-FLUTS) and QOL (IIQ-7) questionnaires, strength testing (PEFECT score, perineometry), and items assessing PFPT comprehension. RESULTS: Ten patients were enrolled and underwent baseline PFMT. One patient was lost to follow-up, leaving nine patients for interim analysis. The mean patient age, BMI, and parity were 51.4 (±6.6) years, 30.9 (±6.3), and 2.7 (±1.5). The mean duration of UI was 104.7 (±92.2) months. Provider assessment demonstrated patient comprehension of basic, endurance, and quick flick pelvic floor contractions in 9 (100%), 8 (89%), and 7 (78%) patients, respectively. At 6-month follow-up, significant improvements were seen across validated questionnaire and strength measurement assessments (Table 1). Patient reported improvement level was 8.1 (±1.6) on a 10-point Likert scale. CONCLUSIONS: Our interim analysis demonstrates that women in Belize demonstrate good understanding of PFMT/PFE. In addition, women in our study demonstrated significant improvements across subjective incontinence and QOL outcomes, as well as strength testing. Study recruitment is ongoing as part of a scaled effort to develop pelvic floor services in Belize. Source of Funding: University of Virginia Center for Global Inquiry and Innovation; Global Surgical Expedition © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e679 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Rapp More articles by this author Jacqueline Zillioux More articles by this author Fionna Sun More articles by this author Michelle Little More articles by this author Jeanice Mitchell More articles by this author Expand All Advertisement PDF downloadLoading ...

HF01-10 EVOLUTION TO EXTINCTION?: THE SAGA OF FEMALE URETHRAL DILATION

You have accessJournal of UrologyCME1 Apr 2023HF01-10 EVOLUTION TO EXTINCTION?: THE SAGA OF FEMALE URETHRAL DILATION Jasmine Kashkoush and Brant Fulmer Jasmine KashkoushJasmine Kashkoush More articles by this author and Brant FulmerBrant Fulmer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003243.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Historically, many women have reported bothersome urinary symptoms and recurrent urinary tract infections (UTIs). The challenge in managing these symptoms led to the practice of urethral dilation in the 1920s, despite the rarity of a female urethral stricture. With little scientific data to support its efficacy, this practice should have gone to extinction; however, it is still very common. This represents a historical review of urethral dilation in women and its penetration in modern day practice patterns. METHODS: A literature review was performed to evaluate the history of female urethral dilation. RESULTS: In 1923, Stevens theorized the culprit behind bothersome urinary symptoms was a narrow urethral meatus, initially presenting the idea of urethral dilation/incision. He advocated for urethral meatotomy with a scalpel up to 30 Fr. This was refined by Davis in the 1950s with the use of an Otis urethrotome to incise the urethra up to 45 Fr. This was popularized in the 1960s when Keitzer, Lyon, and Kerr thought persistent UTIs were due to a “contraction ring in the distal urethra of little girls.” They used sounds and Otis urethrotomes in infants to dilate and/or incise the entire urethra. Eventually, this practice lost scientific backing due to complications of urinary incontinence as well as favorable outcomes with less invasive options. In fact, the last reference to using urethral dilation without a urethral stricture was in 1970. Interestingly, despite the lack of data to support its use, Medicare reimbursement still shows high utilization and cost expenditures. Almost $70 million was spent in 2000 despite only ∼40 documented cases of female urethral stricture. Furthermore, when surveying urologists, those who completed residency after 1989 rarely performed urethral dilation when compared to their predecessors who find it a useful practice. CONCLUSIONS: A wide variety of treatment modalities have been used to manage recurrent UTIs and irritative lower urinary tract symptoms. Female urethral dilation was common despite the rarity of a female urethral stricture. Urinary incontinence and a better understanding of bladder function have decreased the data in favor of female urethral dilation, putting into question its practice. Evidence based medicine supports medical management, vaginal estrogen, and pelvic floor physical therapy more favorably. One would hope that this practice would go into extinction; however, Medicare data still shows high utilization. Perhaps updated guideline statements and better education of patients that have had prior dilations will help in debunking this practice. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e259 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jasmine Kashkoush More articles by this author Brant Fulmer More articles by this author Expand All Advertisement PDF downloadLoading ...

MP37-09 DEVELOPMENT OF URINARY INCONTINENCE CLINICAL DECISION SUPPORT TOOLS FOR USE IN PRIMARY CARE

MP37-09 DEVELOPMENT OF URINARY INCONTINENCE CLINICAL DECISION SUPPORT TOOLS FOR USE IN PRIMARY CARE

V12-03 StimWAVE ® FOR PUDENDAL NEURALGIA

You have accessJournal of UrologyCME1 Apr 2023V12-03 StimWAVE® FOR PUDENDAL NEURALGIA Hailey Eisner, Nataljia Kovacevic, and Kenneth Peters Hailey EisnerHailey Eisner More articles by this author , Nataljia KovacevicNataljia Kovacevic More articles by this author , and Kenneth PetersKenneth Peters More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pudendal neuralgia is an often debilitating chronic pain condition. Up to 25% of these patients are refractory to the current treatments including medications, pelvic floor physical therapy, nerve blocks, sacral neuromodulation, and pudendal nerve entrapment surgery, thus indicating a need for alternative treatment modalities. StimWave® is a novel wireless powered nerve stimulator approved for implantation at any peripheral nerve. On demand adjustable frequency stimulation is performed by the patient in order to control peripheral nerve pain. We have developed a minimally invasive percutaneous technique to place the lead adjacent to the pudendal nerve for the treatment of pudendal neuralgia. This video describes the step-by-step technique of transgluteal StimWave® placement at the pudendal nerve. METHODS: The video was recorded during both the trial and permanent implant stages of transgluteal StimWave® placement for the treatment of bilateral pudendal neuralgia. RESULTS: Our institution recently published the results of this novel technique of placing a peripheral nerve stimulator at the pudendal nerve in order to treat pudendal neuralgia (Hoang Roberts 2021). Of the thirteen treatment refractory patients, 10/13 (76.9%) had >50% improvement in pain with 6/13 (46.1%) reporting 100% pain improvement. Post-operatively the patient in this video had an almost 100% resolution of her symptoms. CONCLUSIONS: In this video we demonstrated the step-by-step guide for a surgeon to perform this procedure. When implanted, patients with pudendal neuralgia refractory to the current treatment options can have a significant improvement in pain and increased quality of life. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1065 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hailey Eisner More articles by this author Nataljia Kovacevic More articles by this author Kenneth Peters More articles by this author Expand All Advertisement PDF downloadLoading ...

PD14-11 PERCUTANEOUS URETHRAL SPHINCTER STIMULATION: SWINE MODEL FOR FEASIBILITY OF USE IN STRESS URINARY INCONTINENCE

You have accessJournal of UrologyCME1 Apr 2023PD14-11 PERCUTANEOUS URETHRAL SPHINCTER STIMULATION: SWINE MODEL FOR FEASIBILITY OF USE IN STRESS URINARY INCONTINENCE Kyle Waisanen, Tyler Maiers, Peter Natalzia, and Teresa Danforth Kyle WaisanenKyle Waisanen More articles by this author , Tyler MaiersTyler Maiers More articles by this author , Peter NatalziaPeter Natalzia More articles by this author , and Teresa DanforthTeresa Danforth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003261.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current treatment modalities for stress urinary incontinence (SUI) include pelvic floor physical therapy, urethral bulking agents, and urethral sling support. We aim to assess direct electrical external urethral sphincter stimulation as a means for treating SUI patients with intrinsic sphincter deficiency. The objective of this study was to assess the feasibility of percutaneous external urethral sphincter access and urethral pressure profiles associated with direct electric sphincteric stimulation. METHODS: An IACUC-approved swine model study was performed under general anesthesia. The urinary bladder was accessed by open cystotomy for placement of antegrade 7F urethral pressure catheter. Stimulation leads were deployed into the external urethral sphincter under transvaginal ultrasound guidance and antegrade urethroscopy was performed to confirm urethral integrity. Leads were then stimulated with serial increases in amplitude from an external pulse generator from 0.1 mA to 3.6 mA with pressure monitoring of the external urethral sphincter. RESULTS: Three swine subjects were utilized in the study. All subjects underwent successful percutaneous insertion of stimulation leads into the EUS without urethral violation. External urethral sphincter pressures recorded with electric stimulation amplitudes of 0 mA, 1.8 mA, and 3.6 mA were found to exhibit increased urethral pressures of 6-10 cm H2O, 16-20 cm H2O, and 31-36 cm H2O, respectfully. EMG capture was achieved in each subject with a corresponding increase in EMG activity with pulse generator amplitude increase represented in the urodynamic strip from subject #2 (Figure 1). CONCLUSIONS: Direct external urethral sphincter stimulation with increased urethral closure pressures is achievable by an ultrasound-guided percutaneous approach. Further studies are required to assess long-term effects and success of the stimulation in SUI modeled subjects with promising results seen in this preliminary proof-of-concept study. Source of Funding: Lent Foundation, University at Buffalo © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e416 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Waisanen More articles by this author Tyler Maiers More articles by this author Peter Natalzia More articles by this author Teresa Danforth More articles by this author Expand All Advertisement PDF downloadLoading ...

Nonoperative Management of Pelvic Organ Prolapse.

Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior, posterior, or apical vagina. It is a common condition, with up to 50% of women having prolapse on examination in their lifetimes. This article provides an overview of the evaluation and discussion of nonoperative management of POP for the obstetrician-gynecologist (ob-gyn), with consideration of recommendations from the American College of Obstetricians and Gynecologists, the American Urogynecologic Society, and the International Urogynecological Association. The initial evaluation of POP requires a history documenting whether the patient is experiencing symptoms and what they are, and discovery of which symptoms they believe are attributable to prolapse. Examination determines the vaginal compartment(s) and to what degree prolapse exists. In general, only patients who have symptomatic prolapse or medical indication should be offered treatment. Although surgical options exist, all patients who are symptomatic and desire treatment should be offered nonsurgical treatment first, including pelvic floor physical therapy or a pessary trial. Appropriateness, expectations, complications, and counseling points are reviewed. Educational opportunities between the patient and the ob-gyn include disentangling common beliefs that the bladder is dropping or that concomitant urinary or bowel symptoms are necessarily caused by prolapse. Improving patient education can lead to a better understanding of their condition and better alignment of treatment goals and expectations.

Cost-effectiveness of Prophylactic Retropubic Sling at the Time of Vaginal Prolapse Surgery

ABSTRACT The increasing proportion of elderly Americans has brought about an anticipation of 50% rise in prolapse surgeries by 2050. It is anticipated that 25% to 40% of patients undergoing surgeries will develop de novo stress urinary incontinence (SUI) after prolapse repair. The Outcomes Following Vaginal Prolapse Repair with Midurethral Sling (OPUS) found a 36% reduction in the risk for de novo SUI, but also demonstrated increased risk of bladder perforations, urinary tract infections, and incomplete bladder emptying symptoms (N Engl J Med. 2012;366:2358–2367). As a result, pelvic reconstructive surgeons often vary their approach toward prophylactic MUS at the time of vaginal prolapse repair (VPR). Although a cost-effectiveness analysis found universal MUS placement to be the most cost-effective strategy over both selective and staged strategies (J Urol. 2013;190:1306–1312), this analysis did not include an arm for the less-costly option of using a selective approach via a prolapse-reduced cough stress test (CST). In addition, Richardson analysis of patients undergoing sacral colpopexy lacks generalizability for VPR surgeries (which account for two thirds of all prolapse surgeries). The manuscript described here therefore tested the cost-effectiveness of 3 generalizable MUS utilization strategies for preventing de novo SUI within 1 year post-VPR. Three approaches were compared: (1) staged strategy performing VPR with later MUS placement only for de novo SUI; (2) universal sling placement at the time of VPR; and (3) selective sling placement with MUS at the time of VPR when occult SUI was observed at the time of preoperative prolapse-reduced CST. A representative population of women with symptomatic pelvic organ prolapse (at least stage II) was modeled. Included in the VPR model was colpocleisis, apical suspension, or anterior colporrhaphy, with or without hysterectomy. The base assumption was that all VPRs were uncomplicated and anatomically successful. Subsequent treatment pathways were formed based on the 3 aforementioned options if de novo SUI was to occur. A 2017 systematic review by van der Ploeg was used for obtaining literature to gain point estimates concerning the risk for postoperative SUI (Int Urogynecol J. 2016;27:1029–1038). The search was performed via PubMed through January 2017, and exclusionary criteria were as follows: studies examining urodynamics preoperatively, abdominal prolapse repairs, duplicate studies, and studies lacking clear definitions for VPR, MUS, or SUI. Using data from 3 previous studies, for a selective MUS, the authors estimated the rate of de novo SUI after VPR with a negative preoperative CST to be 33.6%. The authors determined the existence of 4 possible adverse outcomes following MUS: (1) persistent SUI, (2) sling lysis required for voiding dysfunction, (3) mesh exposure requiring excision, and (4) anticholinergic medications required for de novo overactive bladder. Information on costs was gathered Physician Fee Schedules from the 2020 Centers for Medicare and Medicaid Services. Incremental cost-effectiveness ratio was the primary outcome modeled, defined as the ratio of the cost difference compared with the difference in quality-adjusted life years between scenarios. Results indicated that costs were as follows for various approaches: $1051.70 per patient for staged strategy, $1093.75 for selective MUS, and $1125.54 for universal MUS. The incremental cost-effectiveness ratio value for selective MUS calculated at $2664/quality-adjusted life years, rendering it the most cost-effective and preferred strategy. The variable with the greatest effect on model cost was the proportion of patients experiencing postoperative SUI electing to undergo repeat surgical intervention via MUS placement. Strengths of the study include its use of high-quality Centers for Medicare and Medicaid Services data for costs and point estimates. Because these data hails from the large portion of older Americans covered by Medicare (the most at risk for prolapse surgery), it avoids the inclusion of large variabilities innate to individual hospital systems. In addition, a 1-way sensitivity analysis was performed based on all case assumptions, thereby demonstrating the robustness of the study model. Limitations of the study included the expected hindrance of estimations and assumptions about event incidences. A 1-year time horizon was analyzed, although this may be reasonable because risks of complications dwindle over time. Furthermore, the study only considered women with de novo SUI to have the options of no treatment or MUS placement, disregarding costs of alternative procedures such as pelvic floor physical therapy, pessary, repeat MUS, urethral bulking, or other surgical interventions. Finally, all possible common outcomes after VPR were not included, such as urinary tract infections, pain, or postoperative urinary retention requiring short-term catheterization. In this study, the overall preference for treating de novo SUI via vaginal prolapse surgeries was the selective prophylactic midurethral sling. Patient counseling should occur to inform about the risks and benefits related to prophylactic sling surgeries (including the possibility of de novo SUI after VPR). Decisions regarding treatment strategy ought to be made using each patient’s priorities and treatment goals in discussion with her surgeon.

A randomized trial comparing perioperative pelvic floor physical therapy to current standard of care in transgender women undergoing vaginoplasty for gender affirmation: the flower trial

A randomized trial comparing perioperative pelvic floor physical therapy to current standard of care in transgender women undergoing vaginoplasty for gender affirmation: the flower trial