Emerging Therapies for Incontinence

Meeting Review

8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 44 MEETING REVIEW Emerging Therapies for Incontinence Highlights From the International Continence Society 39th Annual Meeting, September 29-October 3, 2009, San Francisco, CA [Rev Urol. 2010;12(1):44-51 doi: 10.3909/riu0488] © 2010 MedReviews®, LLC Key words: Pelvic floor muscle training • Interstitial cystitis/painful bladder syndrome • Bladder reinnervation • Pudendal neurostimulation he International Continence Society (ICS) is a unique, multidisciplinary society whose members consist of physicians, surgeons, nurses, physiotherapists, physicists, and scientists from across the world. The common bond and theme of this annual event is a special interest in research and care of fecal and urinary incontinence and the function and dysfunction of the pelvic floor, including pelvic, bowel, bladder, and perineal pain. From the first meeting held in 1971, attended by 50 participants, the ICS has grown from strength to strength reaching nearly 2500 participants at this year’s meeting T Reviewed by Cristian P. Ilie, MD, University of Medicine and Pharmacy Bucharest, Romania, and Michael B. Chancellor, MD, William Beaumont Hospital, Royal Oak, MI. 44 VOL. 12 NO. 1 2010 held in San Francisco. “We broke our records,” remarked Dr. Anthony Stone, ICS President, and Professor of Urology, from the University of CaliforniaDavis, with regard to the 39th annual meeting. Dr. Stone noted that the last time the ICS was held in the United States was 10 years ago, in Denver, CO. The reason for being so keen in bringing the ICS meeting back to the United States is that although the ICS is an international society, in terms of membership numbers, he believes there is slightly more emphasis on its European members. Dr. Stone has seen this year’s meeting as a tremendous opportunity to involve and collaborate with clinicians and scientists from the United States. He also remarked on the excellent quality and number of submitted abstracts. In this review we highlight a number of presentations that span the outstanding research for which the ICS is known. REVIEWS IN UROLOGY Pelvic Floor Muscle Training Improves Urgency Incontinence in Women With Multiple Sclerosis Dr. Adélia Correia Lució1 from the University of Campinas (Campinas, Brazil) reported that pelvic floor muscle training (PFMT) is effective in reducing urgency and urgency incontinence, frequency, and nocturia, and in increasing maximum flow rate and reducing postvoid residual volume in women with multiple sclerosis (MS). The effects of PFMT on lower urinary tract symptoms are known, but the authors extended the investigation to the subpopulation of women with MS with relapsing remitting form. Twenty-seven patients with symptoms of urgency, with or without urgency incontinence, frequency, and nocturia are included in this single-blind, prospective, randomized trial. Patients were randomized into 2 groups: treatment (n  13) and 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 45 Emerging Therapies for Incontinence sham (n  14). The intervention was 12 weeks in duration and was performed by a physiotherapist in both groups. The treatment group did PFMT lying supine with the assistance of a Perina (Quark, São Paulo, Brazil) perineometer. Women were instructed to practice the exercises daily at home in other positions (sitting, standing) without the assistance of any device and integrate them into their daily activities. The regimen was reviewed weekly according to the initial vaginal assessment. The sham treatment consisted of the introduction of a perineometer inside the vagina with no contraction being required. Patients from both groups were assessed before and after treatment with 24-hour pad testing, 3-day bladder diary, and urodynamic study (postvoid residual volume, maximum cystometric capacity, detrusor overactivity, and maximum flow rate). The women treated reported a significant reduction in the pad weight, whereas there was no improvement with sham stimulation. Treatment also significantly decreased daytime frequency and nocturia whereas sham therapy did not. The authors reported a significant decrease in postvoid residual volume and a significant increase in maximum flow rate with treatment, whereas in the sham therapy group it remained the same. No difference was observed in maximum voided volumes, in detrusor overactivity, and maximum cystometric capacity in both groups. Dr. Lució concluded that PFMT offers symptomatic relief regarding urgency, frequency, and nocturia in women suffering with MS. By inhibiting the urge to void, treated patients may gain enough time to reach the toilet and thereby prevent urgency incontinence. Enhanced maximum flow rate and decreased postvoid residual volume were also described after PFMT. Interstitial Cystitis/Painful Bladder Syndrome in the United States Dr. J.Q. Clemens2 from the University of Michigan, Ann Arbor, presented the RAND Interstitial Cystitis Epidemiology (RICE) study, a rigorous epidemiological research study funded by the National Institutes of Health (NIH) and led by scientists from RAND Corp., Santa Monica, CA. This study was designed to develop a symptom-based case definition of interstitial cystitis/painful bladder syndrome (IC/PBS) for epidemiologic research, to validate the definition in physician-diagnosed cases, to conduct telephone population screening of a sample of women in the United States, and to calculate an estimate of the prevalence of IC/PBS in US women with IC/PBS-like symptoms. There is very little reliable information published on the epidemiology of IC/PBS. The criteria used for diagnosis of IC/PBS by different investigators have been variable. The authors suggested that lack of objective disease markers for IC/PBS is partly to blame for the limited amount of epidemiologic information that exists related to IC/PBS. In this context, it is easy to understand the interest raised by this study. Results showed that 3.4 to 7.9 million women in the United States may single questionnaire-based definition of IC/PBS is able to simultaneously identify all IC/PBS cases and also distinguish these cases from similar conditions such as overactive bladder (OAB), endometriosis, and vulvodynia. Therefore, they recommended the use of 2 definitions: 1 with high sensitivity and 1 with high specificity. This rigorous study provides us with an accurate picture of how many US women are living with IC. Results suggest that the known prevalence of IC/PBS may be underestimated. The authors noted that it is important to continue to study the epidemiology of IC/PBS, as this is of interest to policy makers and physicians who treat women with this very challenging condition. Bladder Reinnervation by Rerouting Improves the Function of the Neurogenic Bladder Dr. William de Groat,3 Professor of Pharmacology at the University of Pittsburgh (Pittsburgh, PA), gave a keynote presentation reviewing the principles and the potential of nerve rerouting to improve bladder function in patients with neural injuries or congenital abnormalities of the spinal cord (spina bifida). Dr. de Groat offered an overview of basic research and clinical practice, spearheaded by Professor Chuan-Guo Results showed that 3.4 to 7.9 million women in the United States may have interstitial cystitis/painful bladder syndrome (IC/PBS), according to the newly released prevalence number presented. Approximately 3% to 6% of women aged  18 years in the United States meet RICE symptom criteria for IC/PBS. have IC/PBS, according to the newly released prevalence number presented. Approximately 3% to 6% of women aged  18 years in the United States meet RICE symptom criteria for IC/PBS. According to the authors, no Xiao from China, which indicated that the normal sacral spinal cord bladder innervation (S2-S4) can be replaced by lumbar (L) 5 motor axons that innervate striated muscles of the legs (Figure 1). VOL. 12 NO. 1 2010 REVIEWS IN UROLOGY 45 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 46 Emerging Therapies for Incontinence continued Scratching the L5 Dermatome L5 innervation S2 reanastomosis Figure 1. Nerve reroute illustration. Crossover nerve surgery was conceptualized by Basil Kilvington in 1907, although his experiment on 3 dogs did not demonstrate any bladder contraction. Afterward, positive results have been reported by bladder reinnervation, establishing new connections by rerouting of lumbar spinal ventral roots or peripheral motor nerves of the hypogastric, obturator, genitofemoral, or intercostal nerves into the bladder. According to Dr. de Groat, there are some basic principles of nerve rerouting: (1) following peripheral nerve injury, axons distal to the injury degenerate and the surviving central axon terminals produce growth cones, (2) denervated target cells express neurotrophic factors that attract regenerating axons, and (3) cholinergic motor axons can innervate decentralized autonomic ganglion cells in the bladder and may directly innervate 46 VOL. 12 NO. 1 2010 bladder smooth muscle to establish new excitatory pathways between the spinal cord and the bladder. In 1989, Xiao and coworkers planned to establish an artificial skincentral nervous system (CNS)-bladder reflex pathway to restore controllable micturition after spinal cord injury. The new concept was tested in rats, cats, and humans. They grafted a lumbar ventral root containing motor fibers projecting to which is basically a somatic reflex arc, was activated by electrical or tactile stimulation of cutaneous afferent axons that normally excite motoneurons in the lumbar spinal cord (Figure 1). Axonal-tracing studies conducted in animals showed that, after spinal root anastomosis, lumbar motoneurons that normally innervate limb-striated muscles send axons to the bladder. Pharmacological experiments were conducted and showed suppression of the new skin-CNS-bladder reflex by a ganglionic blocking agent or by atropine, indicating that the motor axons established cholinergic synapses with bladder parasympathetic ganglion cells that release acetylcholine which then activates muscarinic receptors in bladder smooth muscle. In 1995, clinical trials began of the artificial somatic-CNS-autonomic reflex arc procedure on adult male patients with upper motoneuron lesions and in children with spina bifida. The reflex arc was realized by unilateral anastomosis of the L5 and sacral 2-3 spinal ventral roots. Electrical or tactile stimulation of the cutaneous receptors in the leg ipsilateral to the spinal root anastomosis resulted in voiding. Patients underwent urodynamic evaluation which exhibited improvement in neurogenic detrusor overactivity, detrusor sphincter dyssynergia, and postvoid residual volumes. The results appeared Axonal-tracing studies conducted in animals showed that, after spinal root anastomosis, lumbar motoneurons that normally innervate limb-striated muscles send axons to the bladder. the hind limb to a transected sacral ventral root carrying the efferent axons to the bladder, creating a new pathway that could evoke bladder contractions. The new reflex pathway, REVIEWS IN UROLOGY approximately 12 to 18 months after the procedure. Bladder capacity increased and incontinence was reduced in children suffering from spina bifida. 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 47 Emerging Therapies for Incontinence A fascinating and unexpected result of this procedure was that, according to Dr. de Groat, some of the children gained bladder sensory function. In his opinion, the major adverse effect was partial loss of L4-L5 motor function on one side. Occurrence rate of partial loss of the left L4 or L5 motor function after surgery, the only complication for 25% of the first 20 cases, has been dramatically reduced to 5%, by Xiao and coworkers, by using only half of the lumbar ventral root. Dr. de Groat summarized that the effects of bladder nerve rerouting in animal experiments have been confirmed in clinical studies in patients with neurogenic storage and voiding symptoms. One of the major criticisms that can be raised about this procedure is that most of the clinical studies have been performed by a single research group in China. So, in agreement with Dr. de Groat’s remarks, more detailed urodynamic and neurologic studies with long-term follow-up are needed. New data have been added to the existing evidence and the first series of spina bifida children treated in the United States has been completed at the William Beaumont Hospital in Michigan. Dr. Kenneth Peters and associates are advancing the research with an NIH-sponsored study. In the final part of the presentation, Dr. de Groat reviewed possible directions for future studies. The emergence of bladder sensations after rerouting motor nerves to the bladder is difficult to explain and may reflect plasticity in central neural pathways. This supposition is based on the detection of a similar mechanism of circuitry reorganization in the sensorimotor cerebral cortex with brainimaging techniques after rerouting of nerves to striated muscles. Another unexpected result is the conversion of dyssynergic voiding to synergic Sacral lead Pudendal lead Figure 2. Radiograph of pudendal nerve leads versus sacral leads. voiding after unilateral nerve rerouting because the normal innervation of the lower urinary tract is intact on the contralateral side of the spinal cord and should continue to induce dyssynergia. Partial denervation of the sphincter after unilateral transection of the sacral roots may contribute to a reduction in dyssynergia, but plasticity in spinal pathways may also be an important factor. Dr. de Groat concluded that bladder reinnervation is a promising area for research but many questions remain. Pudendal Neurostimulation as an Alternative to Sacral Nerve Stimulation Dr. Kenneth Peters4 and associates from the William Beaumont Hospital (Royal Oak, MI) reported the use of chronic pudendal neurostimulation (PNS) as an alternative form of treatment for patients with voiding dysfunction, particularly in those who fail to respond to sacral stimulation. Dr. Peters explained that they began offering PNS to patients who had failed sacral stimulation as well as for other difficult-to-treat patients. These patients represented some of the most complex patients in Dr. Peters’ practice. For the majority of these patients, PNS represented a last resort for managing symptoms and improving quality of life. The pudendal lead was placed using the ischial-rectal approach (Figure 2). The Beaumont team’s aim was to evaluate patients after PNS to determine complications, changes in symptoms, and satisfaction with treatment. They completed a retrospective review of the patients who had a tined lead placed at the pudendal nerve between 2003 and 2008. The authors collected demographic, history voiding diary, and complications data. Patients who had  50% improvement in symptoms were considered treatment responders. Questionnaires assessing symptom changes, treatment satisfaction, and Interstitial Cystitis Symptom and Problem Indices (ICSI-PI) were then mailed to patients. Data were compiled from a total of 84 patients, mostly female (78.6%), mean age 52 years. Diagnoses included IC/PBS (42 patients), urgency/ frequency or urge incontinence (26 patients), nonobstructive urinary retention (13 patients), pelvic pain (2 patients), and tethered sacral nerve (1 patient). Twelve subjects also had VOL. 12 NO. 1 2010 REVIEWS IN UROLOGY 47 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 48 Emerging Therapies for Incontinence continued a neurologic diagnosis and 3 had pudendal nerve pathology. Ninetythree percent (41/44) of the patients who had previously failed sacral neuromodulation responded to PNS. A total of 55 out of the 84 patients (65.5%) responded to treatment and had an implantable pulse generator placed. Five out of 55 patients had complications requiring revision. A total of 40 out of 55 (72.7%) responded to the questionnaires with a mean follow-up of 23.3 months. The researchers reported that over time, frequency, voided volume, incontinence episodes, urgency, and ICSI-PI scores significantly improved. Patients also reported improvement in overall bladder, pelvic pain, incontinence, urgency, and frequency symptoms. The majority still had a device (35/40; 87.5%) continuously in use (27/35; 77%). Of note is that, although treatment satisfaction was reported by 14/30 (46.7%), 31/37 (83.8%) would recommend neuromodulation to a friend. The authors concluded that PNS is a reasonable alternative for complex patients refractory to other therapies although more research is needed to fully assess long-term outcomes and identify predictors of success. Outcome of OAB Symptoms After Surgery for Pelvic Organ Prolapse Urogenital prolapse is a common condition that affects many women, in particular those who have borne chil- has been calculated that about 33 million adults in the United States and 100 million adults worldwide suffer from OAB. Dr. Tiny de Boer5 from Radboud University Nijmegen Medical Centre, the Netherlands, began with the premise that both pelvic organ prolapse (POP) and OAB are frequently seen in elderly women and it is typical that both conditions are often encountered in the same patient. Taking into consideration that currently it is unclear whether there is a causal relationship between the 2 conditions, the authors supposed that if there is a causal relationship it can be expected that OAB symptoms will improve after successful treatment of POP. The goal of this review was to research if OAB symptoms improved after pelvic surgery for POP. To achieve their goal the authors searched Medline and Embase for studies with the following terms: “overactive bladder” OR “urgency” OR “frequency” OR “nocturia” OR “urge incontinence” OR “micturition,” AND “prolapse” AND “repair” OR “operation” OR “surgery.” From a total of 328 studies collected, they selected 43 on the basis of the abstract. After studying those in further detail, the authors identified 12 studies with relevant and analyzable data. Patients with concomitant incontinence surgery were excluded because it was a risk factor for de novo OAB symptoms. In all published studies, the authors found an improvement in the OAB Urogenital prolapse is a common condition that affects many women, in particular those who have borne children. It has been estimated that 50% of parous women have some degree of urogenital prolapse, and 20% of those are symptomatic. dren. It has been estimated that 50% of parous women have some degree of urogenital prolapse, and 20% of those are symptomatic. However, it 48 VOL. 12 NO. 1 2010 symptoms after pelvic organ surgery. There was no relationship between the compartment of the prolapse, method of surgery, parameter or stage REVIEWS IN UROLOGY of prolapse, and the results after POP surgery. The results suggested that there is a relationship between OAB and POP. Published materials concurred that, in the majority of cases, OAB symptoms improved or disappeared after POP surgery. The authors noted that the literature review suggests that it is likely that OAB symptoms will resolve after surgery for POP. The Effect of Stress on IC/PBS This interesting animal physiology research was based on the hypothesis that stress appears to play a role in the exacerbation and possibly even the development of functional urinary tract disorders including OAB and IC/PBS. In patients with IC/PBS, stress may affect quality of life by increasing the symptoms of pain and urgency. Dr. Ariana L. Smith6 and associates from the University of California Los Angeles, aimed to characterize changes in micturition frequency, interval and anxiety-related behavior in an animal study to better understand the mechanism underlying this relationship. Twenty-four adult female Wistar rats were subjected to water avoidance, a potent psychologic stressor, or sham, for 1 hour per day for 10 consecutive days. The method included a colonic assessment, a voiding assessment after day 1 (acute stress) and on day 10 (chronic stress), urine norepinephrine levels (days 1 and 10), lightdark box transition test, histologic examination (4 animals from each group), and repeat voiding assessment (the remaining animals underwent voiding assessment every 3 days for 1 month). The authors found that rats exposed to stress developed a significant increase in anxiety-like behavior, voiding frequency and decrease in latency to first void, voiding interval, and volume of first void when compared 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 49 Emerging Therapies for Incontinence with sham group animals and with baseline voiding parameters. Alteration in micturition parameters persisted for at least 1 month. Stressed rats also showed increased fecal pellet excretion and their bladder specimens revealed increased angiogenesis when compared with those of sham group animals. In the authors’ opinion, the response may be related to hypothalamicpituitary axis activation secondary to stress, resulting in a functional impact on the end organ. Similar effects on the gastrointestinal system, in accordance with those previously reported, suggested that this response may be initiated centrally. Although this study did not review pain or urgency, it made an advancing step in understanding the pathophysiology of these complex disorders. Risk Factors of De Novo OAB and Stress Incontinence After Urethral Diverticulectomy The most recognized complications after surgical removal of urethral diverticulum are diverticula recurrence, urethrovaginal fistula, and de novo urinary incontinence. The incidence of de novo urinary incontinence is reported in the literature to occur in 1.7% to 20.3% of patients, but only a few research papers debate whether it is required to perform a preventive retrospective review of past history, and findings of pelvic magnetic resonance (MR) imaging of patients with urethral diverticulum. The method consisted of reviewing the 28 patients who underwent surgical removal of urethral diverticulum between 2002 and 2007 regarding medical history, physical examination, pelvic MR imaging, changes of voiding symptoms (by Bristol female lower urinary tract symptoms), and occurrence of SUI. The authors also analyzed risk factors of OAB and SUI including age, body mass index (BMI), number of deliveries, size and location of diverticulum, and history of pelvic surgery. Mean age of patients was 38 (range, 20 to 59 years). OAB was present before surgery in 4 patients and occurred afterward in another 5 patients (20.8%). De novo SUI occurred in 4 of 28 patients (14.3%) after surgical procedure—one of them having both SUI and OAB. Age, BMI, number of deliveries, and history of pelvic surgery did not statistically relate to occurrence of SUI or OAB. The authors found a relationship between diverticulum size and position and de novo SUI or OAB. SUI occurred in 3 and OAB in 5 out of the 7 patients with diverticulum  3 cm. Among 11 patients with diverticulum located in proximal urethra, SUI The incidence of de novo urinary incontinence is reported in the literature to occur in 1.7% to 20.3% of patients, but only a few research papers debate whether it is required to perform a preventive surgery in those patients at risk. surgery in those patients at risk. In this study, Dr. Young-Ho Kim7 and colleagues from the Department of Urology, SCH University Bucheon Hospital (Bucheon, South Korea) assessed risk factors related to de novo stress urinary incontinence (SUI) and OAB by occurred in 4 patients and OAB in 5 patients. In patients with urethral diverticulum  3 cm in diameter and located in proximal urethra on pelvic MR imaging, incidence of SUI and OAB was significantly higher. The authors reported that 3 out of 28 pa- tients had a large defect of urethra after removal of urethral diverticulum or weakened periurethral fascia by repeated inflammation and simultaneously underwent Martius labial fat pad interposition. None of them complained about any symptom of SUI or OAB after surgery. In 6 out of 8 patients with urgency or frequency, symptoms improved and none presented with dysuria after surgery. Dr. Kim and associates concluded that size of urethral diverticulum  3 cm and location in proximal urethra are significant risk factors of postoperative development of SUI and OAB. The Optimal Anterior Repair Study: Standard Colporrhaphy Versus Vaginal Paravaginal Repair Anterior vaginal wall prolapse repair is followed by a high rate of recurrence. The use of graft-reinforced repairs has superior results; however, the optimal graft material is not known. The objective of the study by Dr. Keisha Dyer8 and associates at Kaiser Permanente in San Diego, CA, was to compare cure rates of traditional anterior colporrhaphy with graft augmented vaginal paravaginal repairs using porcine dermis or polypropylene mesh to define the best repair technique. The authors designed a randomized, double-blind clinical trial including women age  18 years with at least stage II anterior vaginal wall prolapse (as measured by POP-Q point Ba  1). They have obtained International Review Board approval and the study was performed at 2 clinical sites by 1 of 4 fellowship-trained urogynecologists. A total of 99 subjects were randomized to 1 of 3 treatment arms: (1) standard anterior colporrhaphy, (2) vaginal paravaginal repair with porcine dermis graft (Pelvicol; CR Bard, Murray Hill, NJ), or (3) vaginal paravaginal repair with VOL. 12 NO. 1 2010 REVIEWS IN UROLOGY 49 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 50 Emerging Therapies for Incontinence continued polypropylene mesh (PolyformTM; Boston Scientific, Natick, MA). A CapioTM device (Boston Scientific) was used to secure the graft material to the arcus tendineus fascia. Concomitant procedures were performed at the surgeon’s discretion. Baseline characteristics and validated quality-of-life instruments were obtained. Sexual function was also assessed using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PSIQ-12). The primary outcome was anatomic success defined as anterior vaginal wall prolapse of stage I or less with a minimum of 1-year follow-up. Secondary outcomes included impact on quality of life and degree of bother as measured using the Pelvic Floor Impact Questionnaire (PFIQ-7) and Pelvic Floor Function (PFDI-20). Authors assessed outcomes at 6 weeks and again at 12 and 24 months, postoperatively. Seventy-eight women (mean age, 63 years with a median of stage III [range, II-IV] anterior prolapse) had completed a minimum 1-year follow-up at the time of this interim analysis. The mean follow-up period was 20 months. The authors reported that there were no differences in terms of clinical history or demographic data among the groups. Concomitant procedures were common: 40% hysterectomy, 56% midurethral sling, and 67% apical prolapse procedure. The anatomic success rates were 54%, 63%, and 89% in the anterior colporrhaphy, porcine dermis graft, and polypropylene mesh groups, respectively. Authors noted symptomatic recurrence of the anterior vaginal wall in 7% overall; with 3 (12%) in the colporrhaphy group, 3 (12%) in the porcine dermis group, and 1 (4%) in the synthetic mesh group. With regard to blood loss, it was higher in the graft-augmented group (227 mL) compared with the anterior colporrhaphy group (171 mL). No deaths or serious adverse events were reported. Graft erosion rates in the mesh group were 14%, and in the porcine group were 4%. One in the mesh group required excision. Authors reported a reduction in prolapse and urinary symptoms in all groups without statistically significant differences between groups. In all groups, researchers noticed improvements in urinary and prolapse symptoms but no significant difference between groups. Polypropylene mesh had the highest anatomic success rate of all 3 therapeutic options studied. The authors concluded that, with careful patient education, synthetic mesh placement may be considered for primary or recurrent prolapse repair in patients willing to accept the risk of erosion to achieve a higher anatomic success rate. References 1. 2. 3. Lucio AC, Campos R, Perissinoto MC, et al. Pelvic floor muscle training in the treatment of lower urinary tract symptoms in women with multiple sclerosis. Presented at: International Continence Society 39th Annual Meeting; September 29October 3, 2009; San Francisco, CA. Abstract 193. Clemens JQ, Stoto MA, Elliott M, et al. Prevalence of interstitial cystitis/painful bladder syndrome in the United States. Presented at: International Continence Society 39th Annual Meeting; September 29-October 3, 2009; San Francisco, CA. Abstract 261. de Groat WC. Bladder reinervation: can new nerves improve the function of the neurogenic bladder? Presented at: International Continence Society 39th Annual Meeting; September 29-October 3, 2009; San Francisco, CA. State of the Art 2. Global Alliance Toward Improvement of Health • The International Continence Society announced the designation of June 22-28, 2009, as the First World Continence Week. World Continence Week will help promote global awareness of continence by providing contact points for those seeking treatments and information, creating a network of events and organizations, and promoting a multidisciplinary approach to treatment. Vision • World Continence Day is a global initiative to address the increasing needs of 200 million people across the world suffering from the often silent problem of incontinence. The campaign’s main purpose is to globally facilitate continence awareness and promotion to improve health, wellness, and quality of life. Mission • To allow innovative country- or organization-specific programs to help plan strategies and create awareness. • To allow active participation of the public sector, governmental/nongovernmental, charitable, and other organizations to share common resources and facilitate a common path approach in creating awareness and support for incontinence sufferers. • To create a network of events and organizations that will be recognized as leading authorities of continence and bladder health information. • To further establish continence awareness and promote a multidisciplinary approach to treatment and management. 50 VOL. 12 NO. 1 2010 REVIEWS IN UROLOGY 8. RIU0488_03-16.qxd 3/16/10 9:31 PM Page 51 Emerging Therapies for Incontinence 4. 5. Peters KM, Killinger KA, Boguslawski BM. Pudendal nerve stimulation is a viable alternative to sacral nerve stimulation in voiding dysfunction. Presented at: International Continence Society 39th Annual Meeting; September 29-October 3, 2009; San Francisco, CA. Abstract 14. De Boer T, Vierhout M. Do OAB symptoms improve after surgery for POP? Presented at: International Continence Society 39th Annual Meeting; September 29-October 3, 2009; San 6. 7. Francisco, CA. Abstract 8. Smith AL, Leung J, Harper SK, et al. The effect of acute and chronic stress and anxiety-like behaviour on bladder motor and sensory function. Presented at: International Continence Society 39th Annual Meeting; September 29-October 3, 2009; San Francisco, CA. Abstract 11. Kim YH, Park SJ, Hong J. Risk factors of de nove overactive bladder and stress incontinence following surgical removal of urethral diverticulum. Presented at: International Continence 8. Society 39th Annual Meeting; September 29-October 3, 2009; San Francisco, CA. Abstract 168. Dyer K, Nguyen J, Lukacz E, et al. The optimal anterior repair study (OARS): a triple arm randomized double blinded clinical trial of standard colporhaphy, porcine dermis or polyprolylene mesh augmented anterior vaginal wall repair. Presented at: International Continence Society 39th Annual Meeting; September 29-October 3, 2009; San Francisco, CA. Abstract 252. Main Points • Pelvic floor musle training (PFMT) offers symptomatic relief regarding urgency, frequency, and nocturia in women suffering with multiple sclerosis. By inhibiting the urge to void, treated patients may gain enough time to reach the toilet and thereby prevent urgency incontinence. In addition, enhanced maximum flow rate and decreased postvoid residual volume were described as occurring after PFMT. Results of the RAND Interstitial Cystitis Epidemiology (RICE) study showed that 3.4 to 7.9 million women in the United States may have interstitial cystitis/painful bladder syndrome (IC/PBS), although this may be an underestimate. Approximately 3% to 6% of women aged  18 years in the United States meet RICE symptom criteria for IC/PBS, although no single questionnaire-based definition of IC/PBS is able to identify all cases; therefore, the use of 2 definitions was recommended: 1 with high sensitivity and 1 with high specificity. • The use of chronic pudendal neurostimulation (PNS) is an alternative form of treatment for patients with voiding dysfunction, particularly in those who fail to respond to sacral stimulation. PNS was offered to patients who had failed sacral stimulation as well as for other difficult-to-treat patients. For the majority, PNS represented a last resort for managing symptoms and improving quality of life. • A literature review found an improvement of overactive bladder (OAB) symptoms after pelvic organ surgery. No relationship was found between the compartment of the prolapse, method of surgery, parameter or stage of prolapse, and the results after pelvic organ prolapse (POP) surgery. Published materials support that, in the majority of cases, OAB symptoms improved or disappeared after POP surgery. • In comparing cure rates for traditional anterior colporrhaphy with graft-augmented vaginal repairs using porcine dermis or polypropylene mesh, researchers noticed improvements in urinary and prolapse symptoms but no significant difference between groups. Polypropylene mesh had the highest anatomic success rate and it was concluded that, with careful patient education, synthetic mesh placement may be considered for primary or recurrent prolapse repair in patients willing to accept the risk of erosion to achieve a higher anatomic success rate. VOL. 12 NO. 1 2010 REVIEWS IN UROLOGY 51