Neurourology and Urodynamics (vol 29, issue 8) - 2010 winter issue

This issue, as usual, has a number of very interesting papers.  The editorial gives an update on the journal itself.  Time to print is decreasing and the number of pages will be increased this year.

Pelvic floor muscle training in the treatment of lower urinary tract dysfunction in women with multiple sclerosis (Lucio)  This RTC is supportive of PFM exercises in patient with MS.  Treatment group received pressure biofeedback treatment twice per week for 12 weeks.   They were asked to perform 30 long holds and 3 minutes of fast twitch exercises 3 times per day without feedback.  Unfortunately the PERFECT scale was used to measure muscle function – not very reliable.  Even so, post treatment measurements showed improvements in endurance, number of repetitions and fast twitch contractions with little change in “power” a trend that I see clinically with many patient populations. 

Minimum standards for urodyanmic practice in the UK (G Singh et al) approaches a subject very important to me – education and training.  The paper is obviously very specific to the practice of urpdynamics but it begins to discuss issues of inconsistent education and set standards.  I believe the days of learning Pelvic PT via on-the-job-training are fading away.  We can no longer accept a 2 day course as adequate preparation for treating this patient population.  When I started treating OB GYN patients over 20 years ago there were very few traini9ngs offered and little research to base our training on.  That is clearly not the case now.  There are many evidenced based learning opportunities available to PTs.  It is time to set the bar higher for quality education with the goal of more qualified professional and more successful outcomes.   This article describes and template for developing minimum educational standards in Pelvic PT.

Usage of International Continence Society Standardized Terminology: A bibliometric and questionnaire study (Cartwright and Cardozo) The ICS has published several version of standardized terminology.  Indeed it is a living document with regular arguments among professionals as to the proper term.   This study looked at the usage of word pairs in published literature between 2 time periods (1996-2002 and 2003-2009).  Of interest is the continued usage of terms deemed obsolete in the 2002 ICS terminology document.  The chart below outlines the most significant changes.

Obsolete term	Preferred term
Genuine stress incontinence	Urodynamic stress incontinence
Detrusor instability	Detrusor overactivity
Detrusor hyperreflexia	Neurogenic detrusor overactivity

The standardization guidelines also recommended use of “stress urinary incontinence” and “urge urinary incontinence” instead of “stress incontinence” and “urge incontinence”.  The addition of the word “urinary” to these 2 phrases did increase but not as significantly as the change in the above terms.   

Of note was the lack of change in usage of terms outside of basic urinary incontinence.  The terms  “urethral pain” instead of “dysuria” and “vulval pain syndrome”  instead of “vulvodynia”. In fact the standardization committee has reinstated the term “dysuria” in the 2009 standards.  It seems to me that other groups are better situed to establish pain terminology.  Personally I would use the ISSVD terminology for vulvodyia.   Overall it is interesting to witness the shift in urology terms.  I would encourage all PTs in this fields to adopt the ICS standardized terminology.   This paper also calls for journals to require usage of standardized terms.  It seems to follow that our journal should adopt this position also. 

Patient satisfaction with stress incontinence surgery (K Burgio, L Brubaker et al)  This study looks at pre operative and post operative variables in relation to patient satisfaction.  Lower odds of satisfaction was associated with higher urge incontinence symptoms at baseline and higher detrussor overactivity 24 months after surgery.  It seems patients are not clearly counseled in reasonable expectation.  In other words, patients expect urgency to be solved with SUI surgery.  While research has shown some improvement in OAB symptoms with SUI surgery, it is not the primary goal.   In addition it seems prudent to provide conservative treatment (bladder training) before surgery to maximize the surgical outcome. 

Demographic and urodynamic factors associated with persistent OAB after anterior compartment prolapsed repair (Fletcher, SG)  This is another article looking at the issues of urgency / frequency and UUI surrounding a pelvic surgery.  In this retrospective study all patients one of two surgeries for anterior vaginal vault prolapse (anterior repair with polypropylene mesh or anterior vaginal wall suspension).   Researchers documented post operative improvement in frequency (33%), UUI (49%) and retention symptoms (75%).  This means symptoms of frequency persisted for 67% percent of patients and UUI persisted for 51% of patients.  Again I wonder if preoperative behavioral treatment would improve these outcomes and patient satisfaction.  The point of the study was to identify pre operative demographics or measurements which would predict less than desirable outcomes.  They found age, parity, BMI, and degree of prolapse was not related to negative outcomes.  Improvements in retention were correlated with greater pre operative PVR.  On the other hand lack of improvement in UUI was related to higher preoperative detrusor pressures on urodynamics.   Authors note that there is no consensus at to the pathophysiology of OAB symptoms with POP.  The Cochrane Review of POP surgery was unable to complete a meta analyses on the urinary symptoms . 10% of patients developed new urinary sx after surgery.  Maher 27:3-12 (2008) ICS journal. 

Effects of anterior trocar guided tranvaginal mesh surgery on lower urinary tract symptoms (Ek, M et al)  This study is somewhat contradictory to the one above.  In this study there was a significant decrease in all OAB measures (using the UDI outcomes measure).  SUI was resolved in 56% of patients after surgery for POP and denovo SUI occurred in 11%.  

A Re-adjustable sling for female recurrent stress incontinence and sphincter deficiency: outcomes and complications in 125 patients using Remeex sling system (Errando C, et al) Another surgery paper, just a few interesting points.  Cure rates (after 38 months) are 87%, in line with many research papers that quote 80 to 90% success with surgery.  Readjustment of sling was done for 17 cases that were too loose and 4 cases that were too tight.

New strategies of pelvic nerves stimulation for recovery of pelvic visceral functions and locomotion in paraplegics (Possover, M, et al)  This is the stuff of the future.  Three SCI patients (T5, T7, T10) underwent implantation of electrodes to the sciatic, pudendal nerves and sacral nerve roots S3 and S4.  The procedure is described in some detail in the article.  With a variety of parameters and combinations of nerves stimulated these researchers were able to completely control spasticity of the LE and reflex incontinence, improve bladder empting.  They also note functional electrical stimulation of the femoral nerve allowed one patient to ride a stationary bike and two others to stand and perform “alternative locomotion”.    This is truly a view of the future.