Female Urology: How dynamic MRI compares with physical exam for evaluating POP

Priya Padmanabhan, MDA study that found that age was more strongly associated with selection of colpocleisis than frailty and a comparison of two common wide pore polypropylene Y meshes were among the noteworthy female urology/incontinence research at the AUA annual meeting in Boston. The take-home messages were presented by Priya Padmanabhan, MD, of the University of Kansas, Kansas City. 

A review of patients who underwent translabial ultrasound prior to mid-urethral sling excision found that at 4.76-year follow-up, 80% of patients with slings outside the mid-urethra were cured, and 20% had refractory SUI. The authors believe that it is the sling’s ability to act as a hammock of support that makes it successful and not necessarily exactly where it lies along the urethra.   

Age was more strongly associated with selection of colpocleisis than frailty, yet frailty was more strongly associated with postoperative complications for all prolapse surgeries.

A series comparing dynamic magnetic resonance imaging with physical exam for the evaluation of pelvic organ prolapse found poor correlation for apical and posterior compartment prolapse but good correlation for anterior prolapse, which was not of diagnostic value. Dynamic MRI was better than physical examination for detection of enterocele and had diagnostic value.

A comparison of two common wide pore polypropylene Y meshes found 100% apical prolapse success for both. De novo stress incontinence was 8% for light and 10% for heavy. There were no significant differences in mesh erosion.

A group comparing a polymer mesh to more a commonly used polypropylene Y mesh found storage and sexual symptoms were better in the polymer group. The polymer group also had excellent biocompatibility, reduced foreign body reaction, and reduced bacterial colonization, yet maintained tensile strength.

Continue to the next page for more take-home messages.

• Two groups presented on pelvic mesh excision and outcomes. The first looked at 47 patients post partial or complete mesh excision with 14 months’ follow-up. Preoperatively, 80% of these patients had pain and 83% had exposure, and postoperatively, 68% were improved. The second group looked at 84 patients post vaginal mesh removal. Of these patients, 83% were deemed better postoperatively, and 35% required at least one reoperation.
• Findings from two randomized placebo-controlled, phase III trials on SER120, a low-dose desmopressin nasal spray for the treatment of nocturia, showed that treatment with SER120 led to significant and durable improvement over 2 years with no evidence of hyponatremia.
• Researchers performed overnight ambulatory urodynamic studies on patients with nocturia and nocturnal enuresis, and found that 80% of patients with nocturia and 88% of patients with nocturnal enuresis demonstrated detrusor overactivity.
• Pioglitazone improved bladder function (capacity and frequency) in cyclophosphamide-induced cystitis.
• A novel research model engaging multiple stakeholders for biomarker development discovered three proteins with highly significant differences between interstitial cystitis with ulcers versus interstitial cystitis without ulcers and controls.
• Three different groups used the National Health and Nutritional Examination Survey to evaluate stress incontinence risk factors. In the first, researchers found that incontinence correlated to vaginal delivery and not age at time of childbirth. The second group reported a significant inverse correlation between serum testosterone and incontinence. Women in the lowest quartile of serum testosterone concentration were more likely to have stress incontinence and mixed urinary incontinence. A third group used bone mineral density data to identify an independent association between osteoporosis and stress incontinence due to connective tissue weakness.
• In a rat model, tramadol enhanced urethral baseline pressure by 79% and was effective for enhancing the active urethral continence reflex during sneezing at the spinal level.
• Bariatric surgery was associated with a significant improvement in pelvic floor disorders and sexual performance. Separately, increased age and abdominal circumference were found to raise the risk of female stress urinary incontinence. Age >52 years and menopause correlated with stress incontinence persistence after weight loss.
• Women who had undergone incontinence surgery but still had stress incontinence receiving autologous muscle-derived cell bulking injections had a >50% reduction in leak frequency at 1 and 2 years. The modality was deemed safe and durable for this population.
• An evaluation of patients in retention after Macroplastique injection found one-third of patients had post-op urinary retention, defined as 24-48 hours of catheterization after bulking. At 2 years, they were dry or significantly improved and declined further stress incontinence therapy more so than patients who had never been in retention.

Next: A comparison of outcomes between simple and complex patients post autologous pubovaginal sling

• A comparison of outcomes between simple and complex patients post autologous pubovaginal sling found overall improvement rates of 96% in simple and 93% in complex patients. The complex patients were most likely to need additional continence procedures. Mesh excision at the time of pubovaginal sling increased postoperative retention and reoperation rates more than pubovaginal slings alone.
• Reproduction of symptoms on urodynamics or symptom score do not correlate with risk of urinary retention in patients with Valsalva voiding or in patients with normal bladder contractility.
• Urodynamics and physical exam are equivalent in demonstrating occult stress incontinence; therefore, urodynamics with or without prolapse reduction is not mandatory.
• A review of video urodynamics as related to patient positioning found that nearly 17% of stress-incontinent patients required video urodynamics to be done in the standing position to demonstrate leakage. The authors recommended video urodynamics be performed in both the lying and standing position.
• In patients undergoing pudendal versus sacral neuromodulation, both groups experienced modest but similar improvements in pelvic pain. Pudendal neuromodulation was effective in those who failed sacral neuromodulation and was used preferentially in patients with a primary pain diagnosis.
• In New York state, InterStim is placed by urologists (60.5%), gynecologists (14.8%), and colorectal surgeons (19.2%). Researchers found no statistical difference in revision or removal rates based on FPMRS fellowship training or those without a surgical specialty.
• Researchers evaluated electrical stimulation of afferent nerves in the foot with transcutaneous adhesive pad electrodes (Footstim) in women with refractory overactive bladder. Durations of 30 minutes daily for 1 week and 3 hours daily for 1 week were compared. Both durations decreased urge urinary incontinence frequencies, but the 3-hour group had better improvement of all OAB symptoms.

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