Continuing medical edu-mercials.
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Biomedical subjects
Jerry G Blaivas
Publications and source records attributed to Jerry G Blaivas.
Development and validation of a new treatment outcome score for men with LUTS.
AIMS: To develop, validate, and test elements of a new outcome score for men with lower urinary tract symptoms (LUTS). METHODS: Elements of well-established questions from the International Prostate Symptom Score (IPSS) assessment were combined with both established noninvasive objective determinants of voiding function including maximum uroflow (Qmax), postvoid residual urine volume (PVR), total number voids, maximum voided volume (MVV) as well as a subjective patient assessment parameter, to create a new LUTS treatment outcome instrument which we have termed the "LUTS outcome score" (LOS). The LOS is comprised of eight items; each assigned a score of 0, 1, or 2. Thus, the score ranges from 0 (best) to 16 (worst). Patients were divided into surgical/non- surgical (pharmacologic or behavior modification) treatment groups. Content validity and cutoff values for cure/improve/fail were established by an expert panel. Criterion validity was established by comparison to the IPSS. Internal reliability analysis was performed to obtain information about the relationships between individual items in the scale. Individual LOS items were correlated with the subjective outcome score. We also calculated the correlations between the LOS, IPSS, subjective post-treatment response, and age. Internal consistency, based on the average inter-item correlation was calculated using Cronbach's alpha statistic. Associations between continuous variables were examined by calculating the Pearson correlation coefficient, and between ordinal variables, using Spearman's rho. Test-retest analysis was recorded to determine reproducibility of the patient subjective outcome score. Seventy-seven men who underwent treatment for LUTS for at least 6 months participated in the study. All completed a detailed pretreatment and post-treatment clinical evaluation consisting of history/physical, questionnaire, voiding diary, urinalysis, Q, PVR, and videourodynamic study. Subjective responses of cured/improved/failed status following treatment were assessed by independent investigators. RESULTS: A high level of internal consistency was observed among the LOS symptom questions, Cronbach's alpha = 0.81 for the total cohort. The LOS correlated directly and significantly with the patient's subjective post-treatment response (r = 0.75, P < 0.001), age (r = 0.27, P = 0.02), and with the total IPSS (r = 0.62, P < 0.001). The IPSS also correlated directly and significantly with the patient's subjective post-treatment response (r = 0.48, P < 0.001) but did not correlate with the patient's age (r = 0.10, P = 0.41). When the subjective parameter for post-treatment response was subtracted from the LOS, the resulting correlation (r = 0.52, P < 0.001) approximated that obtained using the IPSS. CONCLUSIONS: The LOS is valid and internally consistent. Unlike the IPSS, it combines subjective, semisubjective, and objective parameters. Because of the objective components, it diminishes the possibility of overestimating cure and underestimating improvement relying only on patient's symptoms. Further, we believe it will prove to be useful for post hoc analysis in patients who have not had pre-treatment assessment.
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Pad test by mail for home evaluation of urinary incontinence.
AIMS: To present a simple, cost-effective, and convenient method of home pad test using the mail system and evaluating change in pad weight over time. MATERIALS AND METHODS: A series of nine kinds of commonly available commercial brands of urinary incontinence pads ranging from thin liners less than 10 g in dry weight to large diapers weighing over 100 g each were assembled. Two or three of each variety were individually weighed on an OHAUS LS2000 Portable Standard scale accurate to +/- 1 g. The pads were then wet uniformly with 20 cc of saline, placed individually in sealable plastic bags, sealed, and reweighed. Random groups of three pads were mailed by standard 1st class mail to the Urocenter of New York. The sealed pads were reweighed at 8 and 14 days from the original wetting. Concurrently, ten incontinence pads soiled with urine were similarly examined to confirm that there would be no detectable difference between urine and saline for the purpose of the study. In the second part of the study, 20 pads of the same type (13 inch-long pads with absorbent gel) were divided into 4 groups of 5 pads; each group was uniformly wet with 5, 10, 20, or 50 g of saline. These pads were mailed and reweighed at 7 and 14 days from the initial wetting. RESULTS: Twenty-four pads were used in the first part of the study. The dry weights of 22/24 (92%) of the pads were within 2 g of the average weight for their brand. At the first reweighing, 22 pads (92%) weighed within 2 g of their initial wet weights (Fig. 1). Only two pads on day 8 differed substantially from their initial weights: one pad appeared to have lost 4 g and another one 9 g. On day 14, 23/24 pads remained within 1 g of their day 8 weight and 1 differed by 2 g, and the total weight of the 24 pads on day 14 was only 4 g different from their initial weight (P = 0.71, Fig. 1). The soiled pads exhibited weight changes that were indistinguishable from the saline pads. The average cost of mailing the pads by 1st class mail was $4 and the average length of time in the mail was 5 days +/- 1 day. In the second part of the study, 18/20 pads had lost less than 1 g at 1 week, and at 2 weeks, 19/20 had lost less than 2 g when compared to their initial weights (Fig. 2). One pad had lost 3 g. Pads in the low volume groups (5 and 10 g) lost an average of 1.4 and 1.2 g, respectively, while pads in the high volume groups (20, 50 g) lost an average of 1.8 and 2 g at 2 weeks. CONCLUSIONS: Dry pads of any single brand have a relatively standard weight that varies insignificantly between pads. Up to 2 weeks of delay in the weighing of individually sealed pads does not significantly affect the clinical measurement of weight at a variety of low (5 g) or high (50 g) volumes of simulated incontinence. Home pad test using the mail system is a feasible, inexpensive, and clinically accurate method of evaluating incontinence. Patients can be instructed in techniques for home pad test, allowing for greater compliance, and convenience for both physicians and patients.
Humans↗
Treatment of primary bladder neck obstruction in women with transurethral resection of the bladder neck.
PURPOSE: We describe the presentation, clinical characteristics, treatment and followup of a series of women with primary bladder neck obstruction (PBNO). MATERIALS AND METHODS: A patient data base was searched for women who underwent transurethral resection for bladder outlet obstruction diagnosed by videourodynamic study (VUDS) according to the Blaivas-Groutz nomogram for female bladder outlet obstruction between 1993 and 2002. A total of 37 women with obstruction were identified. Patients with neurogenic, traumatic, anatomical or iatrogenic causes of obstruction were excluded. Seven patients remained who had been diagnosed with PBNO, of whom all underwent transurethral bladder neck resection. Office records were reviewed for history, presentation, surgical treatment and clinical outcome. RESULTS: Seven patients were diagnosed with PBNO. Age was 39 to 81 years. Six of 7 patients presented with symptoms of obstruction, including a weak or intermittent stream and urinary hesitancy. These 6 patients had unremarkable physical examination findings with normal perianal sensation, anal sphincter tone and lower extremity reflexes. One patient presented with abdominal swelling, which on physical examination was found to be a markedly distended bladder containing more than 1000 cc urine. All patients had overt urethral obstruction on VUDS. In 6 of 7 patients obstruction was clearly at the vesical neck and in 1 the obstruction site was equivocal. Three patients were treated or had previously been treated pharmacologically with alpha-blockers. All patients were subsequently treated with intermittent self-catheterization. All patients then underwent transurethral bladder neck resection at the vesical neck and proximal urethra. Surgical specimens weighed 1 to 5 gm and showed urethral fragments or fibromuscular tissue without specific pathological findings. Followup was 1 to 10 years (median 3) and it included physical examination, uroflowmetry, post-void residual urine measurement and videourodynamic study. Six patients considered themselves cured of lower urinary tract symptoms and 1 was improved. In 1 patient the obstruction site was not clear. One patient had mild stress incontinence under rare circumstances not severe enough to require protective pads. The average change in flow was 6 +/- 10 vs 30 +/- 17 ml per second (p <0.03). The average change in voided volume was 194 +/- 170 vs 416 +/- 206 ml per second (p <0.06). Average change in post-void residual urine was 680 +/- 445 vs 173 +/- 366 ml (p <0.05). CONCLUSIONS: PBNO is an exceedingly rare condition, which is easily treatable when properly diagnosed by VUDS. The presentation of patients in urinary retention in middle age suggests that PBNO may be more common in less apparent forms than has previously been recognized.
Adult↗
Herding cats part 2: the plight of female pelvic medicine and reconstructive surgery fellowships.
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Female↗
Filling in the blanks.
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Fellowships and Scholarships↗
Nocturia.
This article reviews the state of knowledge and the algorithms for the diagnosis, classification, and treatment of nocturia. The state of the art in diagnosis, classification, and treatment of nocturia is presented. Nocturia has been poorly classified and poorly understood. Multiple factors may result in nocturia, among which are pathologic 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), diminished nocturnal bladder capacity, or a combination of the two. Distinction between these conditions is made by a simple arithmetic analysis of the 24-hour voiding diary. Nocturia has been poorly studied and, only recently, has been classified according to its etiology and pathogenesis. Based on a review of the current state of knowledge, this article presents a scheme for the classification and treatment of patients suffering from loss of sleep resulting from nocturnal micturition.
Adult↗
Urodynamic classification of patients with symptoms of overactive bladder.
PURPOSE: We describe a new classification of patients with overactive bladder symptoms. MATERIALS AND METHODS: The office records of 132 patients who presented for evaluation of symptoms of urinary frequency, urinary urgency and/or urge incontinence, and who underwent videourodynamics were identified. All patients completed a 24-hour voiding diary and 24-hour pad test. Data collection included age, sex, hormone status, number of voids and incontinence episodes per 24 hours, functional bladder capacity, pad weight and associated genitourinary conditions. Videourodynamics were reviewed and patients were divided into 4 clinical categories, including type 1-no evidence of involuntary detrusor contractions on videourodynamics, type 2-involuntary detrusor contractions present, and patient aware and able to abort them, type 3-contractions present, patient aware and able to contract the sphincter but not abort contractions and type 4-contractions present and patient unaware but unable to contract the sphincter or abort contractions. RESULTS: Average patient age +/- SD was 64 years +/- 13. There were an average of 13 +/- 5 voids and 3 +/- 5 incontinence episodes per 24 hours. Average functional bladder capacity was 306 +/- 146 cc and average pad weight was 94 +/- 165 gm. Associated diagnoses included benign prostatic hypertrophy in 28% of cases, sphincteric incontinence in 17%, idiopathic urge incontinence in 29% and uterovaginal or bladder prolapse in 17%. Another 11% of patients had bladder outlet obstruction, impaired detrusor contractility or neurogenic bladder conditions. Of the cases 72 (55%), 32 (25%), 23 (17%) and 5 (4%) were categorized as classes 1 to 4, respectively. ANOVA revealed no statistically significant differences in the number of voids or incontinence episodes, functional bladder capacity or pad test when individual categories were compared to each other. CONCLUSIONS: This overactive bladder classification stratifies patients according to degrees of awareness, and control of bladder and sphincter function. It may prove useful as a guide for prognosis and therapy. Patients can be stratified into clinical groups based on the presence or absence of involuntary detrusor contractions, the ability to abort contractions and the ability to contract the urinary sphincter in response to contractions. Limiting the definition of overactive bladder to apply only to patients with no proved infection or other pathological condition would have eliminated more than 75% of those in this sample with symptoms of urinary urgency, frequency and/or urge incontinence.
Humans↗
Sphincteric urinary incontinence: relationship of vesical leak point pressure, urethral mobility and severity of incontinence.
PURPOSE: We examined the relationships among urethral hypermobility, intrinsic sphincter deficiency and incontinence in women. MATERIALS AND METHODS: A total of 65 consecutive women with stress urinary incontinence and 28 with lower urinary tract symptoms not associated with stress urinary incontinence were evaluated with videourodynamics, 24-hour voiding diaries and pad tests, vesical leak point pressure measurement and the cotton swab test. RESULTS: A total of 93 patients with a mean age +/- SD of 63 +/- 13 years were studied, including 65 who presented with stress urinary incontinence and 28 who presented with lower urinary tract symptoms without stress urinary incontinence. The incidence of urethral hypermobility was 32% in the stress urinary incontinence group and 36% in the lower urinary tract symptoms group (p = 0.46). When stress urinary incontinence cases were stratified according to a vesical leak point pressure of 0 to 60, 60 to 90 and greater than 90 cm. H2O, urethral hypermobility was noted in 25%, 31% and 41%, respectively, a difference that was not statistically significant (p = 0.6). Overall incontinent patients with and without urethral hypermobility had the same median number of incontinence episodes (5, range 1 to 13 versus 7, range 1 to 15, p = 0.39) and median pad weight (39.5 range 1 to 693 gm. versus 33.5, range 1 to 751, p = 0.19). When patients with intrinsic sphincter deficiency, defined as vesical leak point pressure less than 60 cm. H2O, were divided into those with and without urethral hypermobility, there were no differences in the mean number of incontinence episodes (9.4 +/- 3 versus 6 +/- 3.6, p = 0.17) or median pad weight (90 gm., range 10 to 348 versus 86, range 30 to 81, p = 0.76). The degree of change in the urethral angle did not correlate with vesical leak point pressure (r = 0.16, p = 0.24) or with pad weight (r = -0.23, p = 0.1). CONCLUSIONS: Urethral hypermobility was equally common in this group of women with lower urinary tract symptoms and stress urinary incontinence. Intrinsic sphincteric deficiency and urethral hypermobility may coexist and they do not define discrete classes of patients with stress urinary incontinence. Urethral hypermobility did not appear to have an independent effect on the frequency or severity of incontinence. Patients with stress urinary incontinence can still be characterized by vesical leak point pressure and change in the urethral angle, although these variables do not always define discrete classes.
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Outcome of urethral reconstructive surgery in a series of 74 women.
PURPOSE: We evaluated the results of vaginal flap reconstructive surgery of the female urethra. MATERIALS AND METHODS: A series of 74 consecutive women who presented with urethral pathology requiring surgical reconstruction were assessed for anatomical and functional outcome. Followup was 1 to 15 years (median 1.5). Outcome assessment included success or failure of the anatomical repair based on physical examination as well as voiding habits and continence assessed by voiding diary, questionnaire and patient self-assessment. RESULTS: A total of 74 procedures were performed, including 72 vaginal flap repairs (56 with a concomitant pubovaginal sling). Five vaginal flap repairs were performed with a concomitant modified Pereyra procedure and 1 was done with Kelly plication. A patient in whom vaginal flap repair was planned underwent a Tanagho anterior bladder flap procedure, 1 underwent extensive lysis of urethral and periurethral scarring with primary urethral repair and 12 underwent vaginal flap repair without an incontinence procedure. A total of 72 women with an average age +/- SD of 54 +/- 13 years were followed a median of 1.5 years after vaginal flap reconstruction and 2 were lost to followup. Of the 62 patients with preoperative incontinence 54 (87%) considered themselves cured or improved. Successful anatomical repair by single procedure vaginal flap repair was achieved in all except 5 patients (93%). CONCLUSIONS: Single stage vaginal flap reconstruction with concurrent pubovaginal sling and Martius flap graft has a high degree of anatomical and functional success for treating a difficult surgical problem.
Adult↗
Effective treatment for mixed urinary incontinence with a pubovaginal sling.
PURPOSE: We assessed the results of autologous fascia pubovaginal sling (PVS) in women with mixed incontinence using a validated outcome score and identified risk factors for failure. MATERIALS AND METHODS: A total of 131 women who received a PVS for sphincteric incontinence (SUI) confirmed by history, physical examination and/or videourodynamic study (VUDS) were identified from a database during the accrual dates 1995 to 2001. Patients with a urethral diverticulum, neoplasm or urinary fistula were excluded. Patients with SUI who also complained of urinary urge incontinence (UUI) and/or had detrusor instability that reproduced incontinence symptoms during VUDS were diagnosed with mixed incontinence (MUI). Patients completed a urological questionnaire, 24-hour voiding diary, pad test, VUDS and cystoscopy preoperatively. The diagnosis of SUI and UUI was further confirmed by physician interview. In patients with MUI detrusor overactivity was classified according to urodynamic criteria. At least 1 year postoperatively the validated Urinary Incontinence Outcome Score (UIOS) was calculated from a 24-hour diary, pad test and questionnaire, and outcomes in patients with SUI and those with MUI were compared. The study was powered a priori to detect a 20% difference in outcome score. Cured patients (UIOS 0) were compared with those who were not cured (UIOS 1 or greater) and univariate analysis was applied to identify the correlates of failed PVS. RESULTS: Of the 131 patients evaluated 33 with a diverticulum or fistula were excluded and 98 underwent PVS. Patient age was 45 to 84 years (median 66). Followup was 1 to 7 years (median 3). A total of 46 patients (48.5%) had simple SUI and 52 (51.5%) had MUI. Two patients were lost to followup (2%) and the procedure was presumed to have failed. There were no differences in age, hormone status, previous surgery or pelvic organ prolapse between patients with SUI and MUI. The cure/improved rate was 97% in 44 SUI cases and 93% in 47 MUI cases, which was a nonsignificant difference (p = 0.33). Analysis of the MUI group showed that patients who were cured and not cured had similar age, parity, urethral angle, bladder capacity, leak point pressure and pad tests. Patients with MUI who were cured had a higher number of voids in 24 hours on preoperative voiding diary (12 vs 8, p = 0.01), while those who were improved or in whom treatment failed had a greater number of urgency (5.6 vs 4.1, p <0.05) and UUI (5.1 vs 3.0, p <0.01) episodes. Univariate analysis of MUI cases showed that an increasing number of preoperative urgency and urge incontinence episodes correlated directly with PVS failure (r = 0.33, p = 0.038 and r = 0.35, p = 0.048, respectively). In contrast, an increasing number of voids correlated with successful PVS (r = 0.4, p = 0.01). CONCLUSIONS: Women with SUI and concurrent urge incontinence or detrusor instability have a successful PVS outcome at a rate comparable to that in women with simple SUI, in contrast to our previous findings. Increasing episodes of urgency and urge incontinence on the preoperative voiding diary correlated directly with surgical failure, while voiding frequently was associated with cure.
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