Real-life after sacral nerve modulation implantation: Rate, reasons, and risk factors for mid-term follow-up discontinuation

OBJECTIVES

To evaluate follow-up after implantation of a sacral nerve modulation implantable pulse generator (IPG) and to investigate the reasons and risk factors for follow-up discontinuation.

MATERIALS AND METHODS

All patients who underwent an IPG implantation to treat lower urinary tract symptoms between 2014-2019 within 6 hospital centers located in the district of "Hauts-de-France" (France) were systematically called during the year 2020 for a standardized (tele)consultation. Patients were divided into 3 distinct profiles according to the regularity of their 5-year postoperative follow-up: "Regular follow-up", "Irregular follow-up" and "Lost to follow-up". The primary outcome was the change in the annual proportion of the 3 follow-up profiles over the 5 years following IPG implantation. As secondary outcomes we described the reasons reported for follow-up discontinuation and looked for risk factors associated with.

RESULTS

Overall, 259 patients were included. At the time of data collection, after a mean follow-up of 28.4 (± 19.8) months, 139 patients (53.7%) had a "Regular follow-up", 54 (20.8%) had an "Irregular follow-up" and 66 (25.5%) were "Lost to follow-up". The proportion of patients with a "Regular follow-up" decreased year by year, representing only 46.2% of patients at five-years. 175 patients (67.6%) underwent a standardized (tele)consultation. In multivariate analysis, only "lack of knowledge of the follow-up protocol" was statistically associated with follow-up discontinuation (OR=5.16; 95% CI [2.12-13.57]).

CONCLUSION

The proportion of patients followed up after IPG implantation decreased steadily over the years, often related to a lack of therapeutic education.

LEVEL OF EVIDENCE: 4

Peak retrograde flow a potential objective management tool to identify young adults with varicocele 'at risk' for a high sperm DNA fragmentation

INTRODUCTION

Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who would benefit most from surgery. Since conventional semen parameters, have been limited in their ability to evaluate the negative effects of varicocele on fertility, specialized laboratory tests have emerged.

OBJECTIVE

To identify clinical and ultrasound parameters (including PRF) which would negatively influence standard and functional semen variables in young adults with a varicocele.

DESIGN

Prospective, cross-sectional observational study.

SETTING

Antwerp University Hospital, Belgium.

PATIENT(S)

Young volunteers between 16 and 26 years, Tanner 5, were recruited.

INTERVENTION(S)

Every participant had a scrotal ultrasound to calculate testicular volumes. If a varicocele was present, the grade, vein diameter, peak retrograde flow (PRF) in supine position and spontaneous reflux in standing position were measured. All participants provided a semen sample. Standard semen parameters were analyzed and sperm DNA fragmentation.

MAIN OUTCOME MEASURE(S)

Of all clinical and ultrasound parameters tested, PRF was an objective tool identifying young adults with a varicocele. PRF was highlighted by the prevalence of SDF, both in the total and vital fractions of the spermatozoa, providing opportunities to manage such 'at-risk' adolescents/young adults.

RESULT(S)

Total SDF was significantly increased in grade 3 varicocele compared to grade 1 and 2 but no significant difference with vital SDF or standard descriptive semen parameters was seen. Total and vital SDF on the other hand were significantly increased when PRF was above 38.4 cm/s. Standard semen analysis showed no difference with PRF as an independent predictor. Testicular atrophy index, varicocele vein diameter and spontaneous reflux revealed no significant differences in both the descriptive and functional semen variables.

DISCUSSION

Descriptive semen parameters showed no significant difference between the non-varicocele controls and the varicocele group with low and high PRF. Increased PRF negatively influenced sperm quality via increased DNA fragmentation both in the total as in the vital fractions of the semen.

CONCLUSION(S)

Of all clinical and ultrasound parameters tested, PRF was an objective non-invasive tool to identify varicocele patients at risk for a high SDF.

The effect of non-surgical weight loss interventions on urinary incontinence in overweight women: a systematic review and meta-analysis

Although the aetiology of urinary incontinence can be multifactorial, in some cases weight loss could be considered as a part of the therapeutic approach for urinary incontinence in people who are overweight. The objective of this study was to review and meta-analyse the effect of non-surgical weight loss interventions on urinary incontinence in overweight women. Web of Science, PubMed, Pedro, SPORTDiscus and Cochrane were systematically searched for clinical trials that met the a priori set criteria. Data of women who participated in non-surgical weight loss interventions (diet, exercise, medication or a combination) were included in the meta-analysis. After removing duplicates, 62 articles remained for screening on title, abstract and full text. Six articles (totalling 2,352 subjects in the intervention groups) were included for meta-analysis. The mean change in urinary incontinence (reported as frequency or quantity, depending on the study) after a non-surgical weight loss intervention, expressed as standardized effect size and corrected for small sample sizes (Hedges' g), was -0.30 (95%CI = -0.47 to -0.12). This systematic review and meta-analysis shows evidence that a non-surgical weight loss intervention has the potential to improve urinary incontinence and should be considered part of standard practice in the management of urinary incontinence in overweight women.

Development and psychometric evaluation of a dutch questionnaire for the assessment of anorectal and lower urinary tract symptoms

BACKGROUND AND STUDY AIMS

Epidemiological studies have shown a frequent coexistence of symptoms and diseases affecting the anorectum and lower urinary tract. To further investigate combined symptoms and pathology of both pelvic viscera we developed a self-reported questionnaire, in Dutch, which extensively evaluates habits, complaints and symptoms of both viscera. We describe the construction and the psychometric properties of this questionnaire.

PATIENTS AND METHODS

This prospective study was conducted in 56 patients with anorectal symptoms, 41 patients with lower urinary tract symptoms and in a control group of 91 people. The following psychometric properties of the questionnaire were evaluated: content validity, construct validity, criterion validity, test-retest reliability and internal consistency.

RESULTS

The questionnaire covered all important domains, was well interpreted and showed good acceptability (content validity). The questionnaire clearly differentiated the patient populations (construct validity). The criterion validity of the questionnaire was excellent. The test-retest reliability of the questionnaire was acceptable in all three the study populations (overall median kappa: 0.64; Inter Quartile Range: 0.56-0.75; mean agreement: 88%). The internal consistency of both anorectal and lower urinary tract symptom questions was high (Crohnbach's alpha of 0.78 and 0.80 respectively).

CONCLUSIONS

This questionnaire is a valid and reliable instrument for the assessment of anorectal and lower urinary tract symptoms. It can provide further insights into the epidemiology of concomitant bowel and bladder disorders and, accordingly, can contribute to a more efficient diagnostic and therapeutic approach in patients with such disorders.

NORMALITY OF BLADDER FILLING STUDIED IN SYMPTOM-FREE MIDDLE-AGED WOMEN

PURPOSE

Data from cystometry and frequency volume charts were evaluated prospectively in symptom-free, middle-aged female volunteers.

MATERIALS AND METHODS

A total of 32 women of the 60 who volunteered could be included with no history, symptoms or signs of urological/neurological disease. They had a mean age +/-SD of 49 +/- 6 years. They completed frequency volume charts during 3 consecutive days and underwent cystometry, including filling sensation evaluation as well as determination of electrosensation thresholds performed using standard techniques.

RESULTS

Four more women had to be excluded because of clearly pathological findings on sensory evaluation. Large bladder capacity and high compliance were seen in the normal group. Data on filling sensation and the electrical sensation threshold were in the normal range.

CONCLUSIONS

To compose a study group of normal volunteers of middle age requires strict inclusion and exclusion. Even then some volunteers must be excluded if pathological examination results are found. Middle-aged women have bladders with large capacity and high compliance, which can be the consequence of retaining urine during daily activities.

Study of the afferent nervous system and its evaluation in women with impaired detrusor contractility treated with bethanechol

OBJECTIVES

To study the effects of subcutaneous bethanechol on the afferent nervous system and correlate these with the efficiency of this treatment in women with impaired detrusor contractility and to evaluate whether patients likely to respond to bethanechol can be identified before treatment through sensation evaluation.

METHODS

Eighteen women with impaired detrusor contractility were given subcutaneous bethanechol for 10 days, and the flow pattern and postvoid residual urine volume were monitored. The afferent nervous system was studied before and after therapy by evaluating the sensation of filling during cystometry and by determining the bladder electrical perception threshold (EPT).

RESULTS

At the end of therapy, 61% voided without a postvoid residual volume. In these women, the sensation of filling and electrical sensitivity were significantly increased compared with before treatment. In women who still voided with a postvoid residual volume, the sensation of filling had increased to a lesser extent and no change in EPT was found. Women in whom bethanechol was unsuccessful had a higher pretreatment EPT than women who were successful. No such difference was found for the sensation of filling.

CONCLUSIONS

An increase in bladder sensitivity correlated with improvement in bladder emptying and can be evaluated by studying the sensation of filling and EPT. Patients likely to respond to bethanechol can be identified before treatment on the basis of the EPT level. Therefore, it would be valuable to initiate EPT measurement in the diagnosis of patients with impaired detrusor contractility.

Value of increase in bladder capacity in treatment of refractory monosymptomatic nocturnal enuresis in children

OBJECTIVES

To evaluate children with refractory monosymptomatic nocturnal enuresis to determine whether detrusor overactivity (DOA) plays a role in 4 weeks of unsuccessful treatment with retention control training (RCT); whether an increase in bladder capacity can eventually be obtained by RCT plus oxybutynin; and whether the increase in capacity is the primary key to success.

METHODS

Sixty-eight children with refractory monosymptomatic nocturnal enuresis were included. They all had a maximal cystometric capacity less than the age-expected value. RCT was done by water loading and retention to the point of urgency once daily. During training, changes in bladder capacity were evaluated by voiding charts. If after 4 weeks of RCT, less than a 10% increase in bladder capacity was noted, oral oxybutynin was added.

RESULTS

The incidence of DOA was 66%. After 4 weeks of RCT, the bladder capacity increased in 20.6%. Combining RCT with oxybutynin led in the end to normalization of the bladder capacity in 79.4%. Older age and high-pressure DOA negatively influenced the ability to increase the bladder capacity. Fifteen children became completely dry, mainly by converting enuresis to nocturia.

CONCLUSIONS

Unsuccessful RCT is often caused by DOA, especially if a bladder capacity rise of at least 10% cannot be achieved within 4 weeks. If oxybutynin is added to the treatment, normalization of bladder capacity can be obtained in most. This increased bladder capacity cures enuresis only in a minority by sharpening their arousal and provoking nocturia.

Cystometrical sensory data from a normal population: comparison of two groups of young healthy volunteers examined with 5 years interval

OBJECTIVE

To describe the pattern of sensations reported during standardized cystometry in a group of healthy young volunteers and compare them with a group examined 5 years before.

METHODS

A group of 50 young healthy volunteers without any symptoms or history reported the sensations they felt during cystometry. These results were compared with those of another group of 38 young healthy volunteers examined in the same lab in 1995 by another investigator.

RESULTS

All participants perceived a first sensation of bladder filling, first desire to void and strong desire to void. Each sensation was easily distinguishable from the others. The volumes at which these sensations came up varied widely. The ratio between volumes at consecutive sensations and at full bladder was fairly constant. All but two parameters were not significantly different from those found in 1995.

CONCLUSIONS

Our data give additional weight to previous findings that there exists a normal pattern of sensations reported during cystometric bladder filling. This sensory pattern probably corresponds with specific physiological mechanisms as suggested before. Deviations from this pattern indicate or illustrate pathology.

Can the sensory threshold toward electrical stimulation be used to quantify the subjective perception of bladder filling? A study in young healthy volunteers

OBJECTIVES

To evaluate whether electrosensation can be used as a quantitative measurement for the sensations felt during bladder distension.

METHODS

A total of 48 healthy volunteers were examined. Sensations of bladder distension were evaluated during medium-fill cystometry. Electrosensation was quantified by obtaining electrical thresholds at different sites in the lower urinary tract with constant current stimulation at 2.5 and 95 Hz.

RESULTS

Both currents were perceived differently. Thresholds at 95 Hz were significantly higher than at 2.5 Hz for each location. With neither current could a significant correlation be found between the parameters of filling perception and electrosensation in the lower urinary tract.

CONCLUSIONS

Although the use of electrical thresholds is a valuable technique in the diagnosis of neuropathic disorders in the lower urinary tract, at the current settings it cannot be used to quantify the perception of bladder filling.

Does bladder tone influence sensation of filling and electro-sensation in the bladder? A blind controlled study in young healthy volunteers using bethanechol

PURPOSE

The influence of bladder tone on filling sensation and electro-sensation in the bladder was studied in young healthy volunteers.

MATERIALS AND METHODS

A total of 22 healthy volunteers 18 to 30 years old were included in our study, of whom 15 received a subcutaneous injection of 5 mg bethanechol and 7 received a subcutaneous injection of water to serve as randomly selected controls. In each group filling perception was evaluated during medium fill cystometry before and 25 minutes after injection. The bladder electrical threshold was determined in each group by constant current stimulation before and 25 minutes after injection.

RESULTS

In the study group there was a marked decrease in the volume at which various filling sensations occurred after bethanechol was given. The pressure at which all filling sensations were perceived was higher after bethanechol than at baseline cystometry. The electrical threshold decreased with bethanechol. In the control group no change was noted in the perception of filling or electro-sensation.

CONCLUSIONS

Bethanechol has a distinct influence on the filling sensation and on electrical bladder stimulation. Each sensation is sharpened after the administration of bethanechol. Several hypotheses are possible to explain these effects.

The relationship between foot structure and intermetatarsal neuromas

Intermetatarsal neuromas are caused by trauma secondary to biomechanical factors. A review of the literature concerning intermetatarsal neuromas is presented. The authors discuss foot structure as a possible cause and present data from 292 radiographs that substantiate the proposed theory. They suggest that intermetatarsal neuromas are caused by a combination of factors.