Biomedical subjects
J G Blaivas
Publications and source records attributed to J G Blaivas.
A simplified urinary incontinence score for the evaluation of treatment outcomes.
There are no standardized definitions for anti-incontinence therapy outcomes. The present study was conducted to evaluate whether the incorporation of several non-invasive outcome measures into a new score may serve as a meaningful outcome instrument. Ninety-four consecutive sphincteric incontinent women who underwent a pubovaginal sling by a single surgeon were enrolled. All patients underwent a full clinical evaluation, including pre- and post-operative questionnaires, 24-hour voiding diary, and 24-hour pad test. Surgery outcomes were classified twice: First, by analyzing the patient questionnaire, voiding diary, and pad test separately, according to previously published criteria, and second, by combining the three outcome tools into a new response score. The new score was constructed in a simple, easy-to-remember format and divided into five categories: cure, good response, fair response, poor response, and failure. All patients were evaluated at least 1 year post-operatively. Comparison of the old and new classifications suggests that the new response score provides a more accurate evaluation of the surgical outcomes. Although 64 to 69% of the patients were originally classified as cure according to the old classification, only 44.7% were re-classified as cure by the strict criteria employed in the new score. Furthermore, the response score also differentiates between various degrees of clinical improvement (i.e., good, fair, or poor response). Twenty-five (26.6%) patients, most of whom were previously classified as cure, were re-classified as good response, whereas 20 others were re-classified as fair (13. 9%), or poor (7.4%) response. Seven (7.4%) patients were re-classified as surgical failures. All were diagnosed pre-operatively as having complex sphincteric incontinence. Specific failure rates were therefore 11.3% for complex and 0% for simple cases. In conclusion, the suggested post-operative response score incorporates in a user-friendly format three popular outcome tools (i.e., 24-hour diary, 24-hour pad test, and patient questionnaire) and seems to reflect the surgical results more accurately. Further studies are needed to assess its validity and reproducibility in other treatment modalities. Neurourol Urodynam. 19:127-135, 2000.
Bladder outlet obstruction in women: definition and characteristics.
The prevalence of bladder outlet obstruction in women is unknown and most probably has been underestimated. Moreover, there are no standard definitions for the diagnosis of bladder outlet obstruction in women. Our study was conducted to define as well as to examine the clinical and urodynamic characteristics of bladder outlet obstruction among women referred for evaluation of voiding symptoms. Bladder outlet obstruction was defined as a persistent, low, maximum "free" flow rate of <12 mL/s in repeated non-invasive uroflow studies, combined with high detrusor pressure at a maximum flow (p(det.Q)(max) >20 cm H(2)O) during detrusor pressure-uroflow studies. A urodynamic database of 587 consecutive women identified 38 (6.5%) women with bladder outlet obstruction. The mean age of the patients was 63.9 +/- 17.5 years. The mean maximum "free" flow, voided volume, and residual urinary volume were 9.4 +/-3.9 mL/s, 144. 9 +/- 72.7 mL, and 86.1 +/- 98.8 mL, respectively. The mean p(det. Q)(max) was 37.2 +/- 19.2 cm H(2)O. Previous anti-incontinence surgery and severe genital prolapse were the most common etiologies, accounting for half of the cases. Other, less common, etiologies included urethral stricture (13%), primary bladder neck obstruction (8%), learned voiding dysfunction (5%), and detrusor external sphincter dyssynergia (5%). Symptomatology was defined as mixed obstructive and irritative in 63% of the patients, isolated irritative in 29%, and isolated obstructive in other 8%. In conclusion, bladder outlet obstruction in women appears to be more common than was previously recognized, occurring in 6.5% of our patients. Micturition symptoms relevant to bladder outlet obstruction are non-specific, and a full urodynamic evaluation is essential in making the correct diagnosis and formulating a treatment plan.
The litigation lottery: tort reform.
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Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology.
The aim of our study was to construct a bladder outlet obstruction nomogram for women with lower urinary tract symptoms. A urodynamic database of 600 consecutive women was reviewed. Bladder outlet obstruction, utilizing strict diagnostic criteria, was diagnosed in 50 (8.3%) patients. A comparison of patient characteristics, uroflowmetry, and detrusor pressure-uroflow studies was carried out between the obstructed patients (mean age, 64.4 +/- 17.6 years) and 50 age-matched unobstructed controls (mean age, 64.8 +/- 10.7 years). Maximum flow rates were significantly higher in free uroflow studies (free Qmax) than in pressure-flow studies (Qmax), in both obstructed (9.3 +/- 3.7 versus 5.7 +/- 3.6 mL/s, respectively. P = 2. 6 10(-6)) and unobstructed (25.6 +/- 11.2 versus 11.8 +/- 5.9 mL/s, respectively. P = 8.7 10(-12)) patients. Comparison of detrusor pressure at maximum flow (pdet.Qmax) and maximum detrusor pressure during voiding (pdet.max) values did not reveal significant differences, in both obstructed (39.3 +/- 18.4 versus 49.7 +/- 25.5 cm H(2)O, respectively) and unobstructed (16.5 +/- 8.4 versus 20.6 +/- 9.2 cm H(2)O, respectively) patients. Further statistical analysis was carried out to construct bladder outlet obstruction nomogram. The nomogram classifies any pair of values of free Qmax and pdet.max into one of the following four zones: no obstruction, mild obstruction, moderate obstruction, and severe obstruction. Of the 50 obstructed women, 34 (68%) were classified by the nomogram as mildly, 12 (24%) as moderately, and 4 (8%) as severely obstructed. A positive correlation was found between subjective severity of the symptoms (assessed by the AUA Symptom Index score) and the four nomogram zones. In conclusion, the nomogram makes it possible to differentiate between obstructed and unobstructed women and between various degrees of obstruction. We believe the nomogram may also serve as an instrument to assess treatment outcomes.
Female pelvic medicine and reconstructive surgery fellowships.
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Issues of uroselectivity in male and female LUTS. Summary of the meeting.
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Noninvasive outcome measures of urinary incontinence and lower urinary tract symptoms: a multicenter study of micturition diary and pad tests.
PURPOSE: We assessed the test-retest reliability of a 24, 48 and 72-hour micturition diary and pad test in patients referred for the evaluation of urinary incontinence and lower urinary tract symptoms. MATERIALS AND METHODS: We prospectively enrolled 109 patients referred for the evaluation of lower urinary tract symptoms in our multicenter study. Patients were requested to complete a 72-hour micturition diary and pad test, and repeat each test during a 1-week interval. The test-retest reliability of various parameters of the 72-hour micturition diary and pad test was analyzed and compared. Further analysis was done to compare the test-retest reliability of 24, 48 and 72-hour studies performed on the same days after a 1-week interval. Reliability was assessed by Lin's concordance correlation coefficient (CCC) with a cutoff value of 0.7 indicating test-retest reliability. RESULTS: Of the 109 patients 106 (97%) with a median age of 64 years completed the study. The number of pads and total weight gain appeared to be reliable measures of the 24, 48 and 72-hour pad tests. For the 24-hour diary the total number of incontinence episodes was a reliable measure, while the total number of voiding episodes was marginally reliable (mean CCC 0.785 and 0. 689, respectively). For the 48-hour diary the number of incontinence episodes and total number of voiding episodes were reliable measures (mean CCC 0.78 and 0.83, respectively), while for the 72-hour diary each parameter was highly reliable (CCC 0.86 and 0.826, respectively). However, an increased test period was associated with decreased patient compliance. CONCLUSIONS: The 24-hour pad test and micturition diary are reliable instruments for assessing the degree of urinary loss and number of incontinent episodes, respectively. Increasing test duration to 48 and 72 hours increases reliability but is associated with decreased patient compliance.
Nocturia.
PURPOSE: We review the current state of knowledge of nocturia and present algorithms for diagnosis, classification and treatment. MATERIALS AND METHODS: We reviewed the recent literature on nocturia, and state-of-the-art methods of diagnosis, classification and treatment. RESULTS: Nocturia, which is among the most bothersome of all urological symptoms, has heretofore been poorly classified and understood. Multiple factors may result in nocturia, including pathological conditions, such as cardiovascular disease, diabetes mellitus, lower urinary tract obstruction, anxiety or primary sleep disorders, and behavioral and environmental factors. Nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction) and/or diminished nocturnal bladder capacity. Distinction between these conditions is made by a simple arithmetic analysis of a 24-hour voiding diary. CONCLUSIONS: Nocturia has been poorly studied, and its etiology and pathogenesis have been classified only recently. We present a scheme for diagnosis and care of patients suffering from loss of sleep due to nocturnal voiding.
The significance of the American Urological Association symptom index score in the evaluation of women with bladder outlet obstruction.
PURPOSE: The American Urological Association (AUA) symptom index was originally designed to assess the severity of lower urinary tract symptoms in men with benign prostatic hyperplasia. Data concerning the clinical application of the AUA symptom index to women are sparse. We evaluated the significance of the AUA symptom index in women with urodynamically defined bladder outlet obstruction. MATERIALS AND METHODS: From a urodynamic database of 587 consecutive women 38 (6.5%) were identified with bladder outlet obstruction, defined as a maximum flow rate of less than 12 ml. per second on repeat noninvasive uroflowmetry studies with a detrusor pressure at a maximum flow of greater than 20 cm. water on pressure flow study. All patients underwent a complete clinical and urodynamic evaluation, and completed the AUA symptom index questionnaire. Results in women with urodynamic obstruction were compared with those in 2 control groups, including women without obstruction but with sphincteric incontinence and asymptomatic healthy women. RESULTS: Mean symptom score was significantly higher in women with obstruction than in those with sphincteric incontinence or no symptoms (15.8+/-8.4 versus 10.3+/-6.4 and 2.1+/-2.7, respectively). Likewise, scores were classified as severe in 34% of women with obstruction compared with only 7% of those with sphincteric incontinence. However, no correlation was noted between symptom index scores and objective urodynamic parameters, which is similar to data already reported in male populations. CONCLUSIONS: The AUA symptom index score may be useful as a bothersomeness index in women with bladder outlet obstruction. However, subjective symptoms associated with bladder outlet obstruction are nonspecific and a complete urodynamic evaluation is essential for making the diagnosis.
Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse.
PURPOSE: We determined the indications for anti-incontinence surgery in continent women undergoing surgical repair of severe urogenital prolapse. MATERIALS AND METHODS: We prospectively evaluated 24 continent women referred for evaluation of severe urogenital prolapse. All patients underwent a meticulous clinical evaluation, including a complete history and physical examination, urinary questionnaire, voiding diary, pad test, cotton swab test, video urodynamics and cystoscopy. The urodynamic evaluation was repeated with prolapse repositioning by a fitted vaginal pessary. Surgical intervention was tailored according to urodynamic findings. RESULTS: Reduction of prolpase with a pessary unmasked sphincteric incontinence in 14 women (58%). Ten women with no urodynamic evidence of sphincteric incontinence underwent anterior colporrhaphy and no additional anti-incontinence procedure was performed. Mean followup was 44 months (range 12 to 96). None had postoperative stress incontinence but 1 (10%) had a recurrent grade 2 cystocele. The 14 remaining women with sphincteric incontinence after prolapse reduction underwent anterior colporrhaphy with a pubovaginal sling procedure. Mean followup in these cases was 47 months (range 12 to 108). In 2 patients (14%) stress incontinence developed postoperatively and 1 (7%) had a recurrent grade 3 cystocele. The incidence of urge incontinence did not appear to be significantly influenced by either surgical intervention. Overall 12 patients had preoperative urge incontinence, of whom 9 (75%) had persistent urge incontinence postoperatively. In another woman new onset urge incontinence developed. CONCLUSIONS: Preoperative urodynamic evaluation with and without prolapse reduction is essential for making the correct diagnosis of masked stress incontinence in women with urogenital prolapse. The decision to perform a concomitant prophylactic anti-incontinence procedure should be tailored to individual urodynamic findings. Larger series and longer followup are needed to establish the most effective preventive procedure for this troublesome clinical problem.
The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study.
PURPOSE: We examine various mechanisms of post-radical prostatectomy incontinence. MATERIALS AND METHODS: A total of 83 consecutive men (mean age 68 +/- 6.6 years) referred for evaluation of persistent post-radical prostatectomy incontinence were enrolled in the study. All patients underwent clinical and urodynamic evaluation. Final diagnosis was based on clinical judgment considering patient history, pad test, voiding diary, free (unintubated) uroflow measurements, video urodynamics and linear passive urethral resistance relation curves. We compared free uroflow and pressure flow obtained with a 7Fr urethral catheter in place, and empirically defined low urethral compliance as at least 10 ml. per second difference between these measurements. RESULTS: Sphincteric incontinence was the most common urodynamic finding, occurring in 73 patients (88%). Detrusor instability was identified in 28 patients (33.7%) and in 6 (7.2%) was the main cause of incontinence. In 2 other patients bladder outlet obstruction (1.2%) or impaired detrusor contractility (1.2%) was the only urodynamic finding. Impaired detrusor contractility was diagnosed by linear passive urethral resistance relation in 82% of cases but considered to be clinically relevant in only a third. In 25 cases (30.1%) low urethral compliance was noted, which we consider nearly synonymous with urethral scarring. CONCLUSIONS: Sphincteric incontinence is the most common urodynamic finding in patients with post-radical prostatectomy incontinence, although other findings may coexist. The most accurate diagnosis is attained when all objective measures are put in perspective with the clinical setting.
Detrusor pressure uroflowmetry studies in women: effect of a 7Fr transurethral catheter.
PURPOSE: We evaluated whether a 7Fr transurethral catheter affects urinary flow in women undergoing pressure flow studies for voiding symptoms. MATERIALS AND METHODS: We reviewed a urodynamic database of 600 consecutive women referred for the evaluation of voiding symptoms. Before urodynamics all patients voided privately using a standard toilet and free flow was recorded. Urodynamics were performed using a 7Fr double lumen transurethral catheter. At functional bladder capacity patients were asked to void in the sitting position and pressure flow studies were performed. All uroflowmetry tracings were inspected and analyzed manually. Only patients who voided similar volumes varying by less than 20% on the free and pressure flow studies were assessed. Free and pressure flow parameters were compared according to voided volume category, main urodynamic diagnosis, uroflowmetry pattern and pre-void bladder volume. RESULTS: A similar volume was voided on the free and pressure flow studies of 100 women. In each voided volume category and urodynamic diagnosis pressure flow parameters were significantly different from the equivalent free flow parameters in all but 4 cases. Specifically the maximum flow rate was significantly less and flow time was significantly longer on pressure versus free flow studies (each p <0.01). An intermittent flow pattern was more common on pressure than in free flow measurements (43% versus 9%). CONCLUSIONS: A 7Fr transurethral catheter may adversely affect uroflowmetry parameters in women undergoing pressure flow studies for lower urinary tract symptoms. This finding may have further clinical implications regarding the interpretation of these parameters as well as establishment of an accurate diagnosis.
Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement.
PURPOSE: We describe various clinical presentations of urethral diverticulum, which may mimic other pelvic floor disorders and result in diagnostic delay. Management and outcome results are reported. MATERIALS AND METHODS: We reviewed retrospectively 46 consecutive cases of urethral diverticulum. Patient characteristics, history, clinical evaluation, management and long-term followup are reported. RESULTS: Mean patient age plus or minus standard deviation was 36.3 +/- 11.7 years. Most (83%) cases were referred as diagnostic dilemmas with symptoms present for 3 months to 27 years. Mean interval between onset of symptoms to diagnosis was 5.2 years. The most common symptoms were pain (48% of cases), urinary incontinence (35%), dyspareunia (24%) and frequency/urgency (22%). The number of physicians previously consulted ranged from 3 to 20 and prior therapies included oral and/or vaginal medications, anti-incontinence surgery and psychotherapy. The diverticulum was palpable on examination in 24 patients (52%), in only 6 of whom was it possible to "milk" contents per meatus. Of these 24 palpable diverticula 2 contained malignancy, and 2 others contained endometriosis and stones, respectively. Diagnosis was made by voiding cystourethrography in 30 cases (65%), double balloon urethrography in 5 (11%) and transvaginal ultrasound or magnetic resonance imaging in 7 (15%). Diverticula were incidental findings during vaginal surgery in 4 cases (9%). Treatment consisted of diverticulectomy and/or Martius flap, pubovaginal sling and urethral reconstructive procedures when indicated in 35 cases (76%), and 2 other patients underwent radical surgery for diverticular malignancy. Subsequently all but 2 patients with pain were cured. In another patient de novo stress incontinence developed postoperatively. None of the patients who underwent concomitant pubovaginal sling had postoperative incontinence. CONCLUSIONS: The symptoms of urethral diverticulum may mimic other disorders. This condition should be considered in women with pelvic pain, urinary incontinence and irritative voiding symptoms not responding to therapy. Surgical treatment is usually effective in alleviating associated symptoms.
Outcome results of transurethral collagen injection for female stress incontinence: assessment by urinary incontinence score.
PURPOSE: We assessed the results of collagen injection for female sphincteric incontinence using strict subjective and objective criteria. MATERIALS AND METHODS: We evaluated 63 consecutive women with sphincteric incontinence who underwent a total of 131 transurethral collagen injections. Sphincteric incontinence was confirmed by urodynamics. All patients were treated with 1 to 5 transurethral collagen injections and treatment outcome was classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence documented by a 24-hour diary and pad test, and patient assessment that cure was achieved. Failure was defined as poor objective results and patient assessment that treatment failed. Cases that did not fulfill these cure and failure criteria were considered improved and further classified as a good, fair or poor response. RESULTS: Mean patient age plus or minus standard deviation was 67.7 +/- 12.8 years. All women had a long history of severe stress urinary incontinence, 18 (29%) underwent previous anti-incontinence surgery, and 41% had combined stress and urge incontinence. Preoperatively diary and pad tests revealed a mean of 7.5 +/- 4.6 incontinence episodes and 152 +/- 172 gm. of urine lost per 24 hours. Overall 1 to 5 injections were given in 26, 17, 13, 3 and 4 patients, respectively. Mean interval between injections was 4.4 +/- 5.7 months, mean followup was 12 +/- 9.6 months, and mean interval between the final injection and outcome assessment was 6.4 +/- 4.9 months. There was a statistically significant decrease in the total number of incontinence episodes per 24-hour voiding diary after each injection session. Although there was a clear trend toward decreased urinary loss per 24-hour pad test, statistical significance was not established. Using the strict criteria of our outcome score overall 13% of procedures were classified as cure, 10%, 17% and 42% as good, fair and poor, respectively, and 18% as failure. CONCLUSIONS: As defined by strict subjective and objective criteria, we noted a low short-term cure rate after collagen injection in women with severe sphincteric incontinence. It remains to be determined how patients with less severe incontinence would fare using our outcome assessment instruments.
Protracted urinary retention necessitating urethrolysis following tension-free vaginal tape surgery.
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Making doctors.
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Classifying stress urinary incontinence.
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