Urogynecology We're Not LIKE a Good Neighbor, WE ARE the Good Neighbor Alliance

Volume 92 No. 1 January 2009

Urogynecology We're not LIKE A Good Neighbor, WE ARE The Good Neighbor Alliance

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P.O. Box 1421 Coventry, RI 02816 www.goodneighborall.com UNDER THE JOINT VOLUME 92 NO. 1 January 2009 EDITORIAL SPONSORSHIP OF: Medicine Health The Warren Alpert Medical School of Brown University HODE SLAND Edward J. Wing, MD, Dean of Medicine R I & Biological Science PUBLICATION OF THE RHODE ISLAND M EDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director Quality Partners of Rhode Island Richard W. Besdine, MD, Chief COMMENTARIES Medical Officer 2 Reimbursement for Experience-Based Medicine Rhode Island Medical Society Joseph H. Friedman, MD Diane R. Siedlecki, MD, President 3 I’ve Got a Little List…I’ve Got a Little List EDITORIAL STAFF Stanley M. Aronson, MD Joseph H. Friedman, MD Editor-in-Chief Joan M. Retsinas, PhD CONTRIBUTIONS Managing Editor SPECIAL FOCUS: Urogynecology Stanley M. Aronson, MD, MPH Guest Editor: Deborah L. Myers, MD Editor Emeritus 4 The Role of Urogynecology In Women’s Pelvic Floor Disorders EDITORIAL BOARD Deborah L. Myers, MD Stanley M. Aronson, MD, MPH John J. Cronan, MD 5 Pelvic Organ Prolapse James P. Crowley, MD Brittany Star Hampton, MD Edward R. Feller, MD John P. Fulton, PhD 10 Physical Therapy for Pelvic Floor Dysfunction Peter A. Hollmann, MD Wendy Baltzer Fox, PT, DPT GCS Anthony E. Mega, MD Marguerite A. Neill, MD 12 Minimally Invasive Approaches To Pelvic Reconstructive Surgery Frank J. Schaberg, Jr., MD Charles R. Rardin, MD Lawrence W. Vernaglia, JD, MPH 16 Urinary Incontinence Newell E. Warde, PhD Vivian W. Sung, MD, MPH OFFICERS Diane R. Siedlecki, MD 22 Interstitial Cystitis President Deborah L. Myers, MD Vera A. DePalo, MD President-Elect COLUMNS Gillian Elliot Pearis, MD Vice President 27 ADVANCES IN PHARMACOLOGY – Effect of Zoledronic Acid on Bone Pain Margaret A. Sun, MD Secondary To Metastatic Bone Disease Secretary Porpon Rotjanapan, MD Jerald C. Fingerhut, MD 29 GERIATRICS FOR THE PRACTICING PHYSICIAN – The Practicing Physicians’ Guide Treasurer Nick Tsiongas, MD, MPH To Pressure Ulcers in 2008 Immediate Past President Rachel Roach, MSN, ANP, GNP, WCC, and Clarisse Dexter, MSN, FNP, GNP, WCC

DISTRICT & COUNTY PRESIDENTS 32 HEALTH BY NUMBERS – Rhode Island HEALTH Web Data Query System: Geoffrey R. Hamilton, MD Death Certificate Module Bristol County Medical Society Annie Gjelsvik, PhD, and Karine Monteiro, MPH Herbert J. Brennan, DO Kent County Medical Society 34 PUBLIC HEALTH BRIEFING – Palliative Care – Evolution of a Vision Rafael E. Padilla, MD Anna Wheat Pawtucket Medical Association 37 PHYSICIAN’S LEXICON – Medical Words In Extremis Patrick J. Sweeney, MD, MPH, PhD Stanley M. Aronson, MD Providence Medical Association Nitin S. Damle, MD 37 Vital Statistics Washington County Medical Society Jacques L. Bonnet-Eymard, MD 38 January Heritage Woonsocket District Medical Society 39 2008 Index Cover: “Tender Moment,” is an award- winning watercolor by Antonia Marshall of Foxboro, MA. She is an artist member of the Rhode Island Watercolor Society, Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 the North Shore Arts Association and has Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100 per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island been juried into many national and in- Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postage ternational shows. Following a career in paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St., graphic design, she dedicates her time to Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919, phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected]. painting. E-mail: [email protected] 1 VOLUME 92 NO. 1 JANUARY 2009 Commentaries Reimbursement for Experience-Based Medicine

The editor of Annals of Neurology, the harder, see more patients for less money Should doctors be paid differently publication of the American Neurologi- than we used to. This means less time for based on experience or expertise? Do they cal Association, recently wrote an edito- journal review, attending conferences and do a better job? Evidently not by established rial trying to come to grips with insur- “keeping up” in general. This time-crunch measures. Are they less expensive, able to ance reimbursements being unrelated to means that those more recently trained have rely more on experience than expensive test- experience. As we all know, insurers pay less keeping up to do. Perhaps their skills in ing? We don’t know. In the academic work- flat rates depending on diagnoses, technical areas are better. Or they perform place, pay is based on seniority, and collec- whether the patient gets good care or better on the measuring scales because they tions. In private practice it is not. The Mayo not, so long as it is documented care. were trained with the measuring scales in Clinic, an academic-private practice, has a What I hadn’t realized until I read the mind. One of the major philosophical de- flat payscale that ignores seniority. I don’t article was that there is a body of pub- bates regarding “No child left behind” is think a flat reimbursement is right, again lished data that actually tracks “quality” whether teaching to score better on a stan- perhaps because of my age. Yet that’s what of care in relation to physician’s age and dardized exam is of any value other than insurers pay. One pays more to an experi- duration of practice. improving test performance. Some, but enced famous lawyer than to a newcomer. What surprised me was that these clearly not all, of these outcome studies may Yet if I go to a famous doctor or an un- data, perhaps not the best epidemiology reflect that. But, on the other hand, how known one, the fee is the same, unless the work extant, indicate that “experience” can one measure the physician-patient re- doctor refuses insurance. Yet psychiatric fees is not associated with improved care, and lationship? How can one compare the re- vary enormously in the big cities, with some is often associated with worse outcome. assurance a patient feels from a doctor who doctors charging $600/hr, and some $150. It’s not simply that I’m now an older has helped hundreds of patients cope with They can do this because they refuse insur- physician that makes me respond to this like the same problem to one whose experience ance. The patient pays out of pocket and I’ve heard nails on a chalkboard (a meta- is limited? Is there any way to compare the the insurance company pays whatever per- phor appropriate for an older person) but experience of returning to a doctor who centage they deem “reasonable.” Even rather that I wouldn’t have believed that has had a twenty-year experience with the when the economy was humming along, when I was younger, and don’t now. When patient and his family to that of a younger this would be impossible in most parts of I first started out I used to call my old men- doctor? The doctor-patient relationship is the country. And if we decide that quality tors frequently about troubling cases, refer sometimes more important than choosing is important, how is that to be determined? to the big academic centers for second opin- the first line treatment instead of the sec- I have thought of abandoning accep- ions, and send my EEGs for review. After I ond. These are intangible; and we are lim- tance of insurance, thus reducing overhead got my sea-legs, I reduced my second guess- ited, of course, to measuring what we can enormously and increasing my charges, but ing to a low level, as I learned that when I measure. then my patients, largely Medicare, almost didn’t know something and had an oppor- The various medical disciplines have all insured, would have to pay a lot more; tunity to research the area, chances were tackled the problem of keeping up to date and many of them cannot. Which is why, the other guy didn’t either. by re-credentialing exams every 10 years. of course, medicine is so different than law, The literature indicates that younger While I am an ardent supporter of this I have accounting or other businesses. cardiologists produce better results than not renounced my “grandfather” clause pro- If and when our disaster of a older ones, that younger PCPs follow guide- tection that lets me avoid the process. Am I healthcare system gets straightened out, lines better than older ones, and that by keeping up? How can I tell? In my own nar- this will be another issue that we should any criterion of quality or outcome, younger row subspecialty I’m pretty confident that I confront. physicians do as well or better than the older do and I have a number of objective mea- ones. On the one hand I can believe this, sures to support that. In the wider spectrum – JOSEPH H. FRIEDMAN, MD yet on the other I’m not so sure. Do the of neurology am I up to date? Hard to say. older doctors get the more difficult cases? In the academic sphere where one interacts Disclosure of Financial Interests For some of the studies this is clearly not with neurology residents it’s much easier. Joseph Friedman, MD, Consultant: Acadia true. Patients were tracked by diagnostic They correct you. They quote the expert Pharmacy, Ovation, Transoral; Grant Research codes in very large numbers using insur- with whom they rotated the month before, Support: Cephalon, Teva, Novartis, Boehringer- Ingelheim, Sepracor, Glaxo; Speakers’ Bureau: ance company data. to tell you what is now timely, perhaps work Astra Zeneca, Teva, Novartis, Boehringer- Obviously I wonder if the older doc- not yet published. Out in the “real world” it Ingelheim, GlaxoAcadia, Sepracor, Glaxo Smith tors are out of date. We all have to work is impossible to be sure. Kline, Neurogen, and EMD Serono. 2 MEDICINE & HEALTH/RHODE ISLAND I’ve Got a Little List…I’ve Got a Little List

We think of obsessions as emotions so intense as to nullify Alpine altitudes. Peter, still an infant, stayed in London with rectitude or reason. Admittedly, obsessions can be narrowly his mother’s family. focused, such as the building of the world’s biggest sandcastle These were troubled times for the Roget child: his father or collecting the most diversified display of butterflies, but most was dying in Switzerland, while his surrogate family in England, are broader and pertain to unrequited human passions. Ob- the Romillys, were distracted by widespread mental disorder sessions may come in all sizes and durations; they may be trivial, within their ranks. Following his father’s death, his mother’s pos- short-lived, or enduring and magnificent in their grandeur and sessive dependency made his childhood extremely difficult. He sweep. Generally though, they are persistent, phobic, haunt- learned to cope, however, with a compulsive habit of classifying ing, anxiety-producing and sometimes maniacal. things; and he maintained a series of notebooks containing all of Then there is the word compulsion or its adjective, com- his revelations on the orderliness of life around him. His great pulsive. Dictionaries define this word as the fulfillment of an hero was Carolus Linnaeus [1707 – 1778] the great Swedish act, usually initiated by an irresistible impulse which is con- physician-botanist who organized all living matter, whether plant trary to the individual’s conscious agenda. While most com- or animal, in a great binomial classification used, virtually unal- pulsions stem from the psyche of the individual, some compul- tered, to this day. Young Peter marveled at the genius of Linnaeus sions are extracorporeal, established through legislation or so- to reduce the immensity of life, from the smallest to the largest, cietal regulation. Compulsory gymnasium attendance or com- into a systematized regimen which replaced an unsettling vision pulsory military service, for example, representing things re- of life with an idyllic and structured sense of order: every plant, quired by society but not arising, necessarily, from the inner every creature in proper relation to each other, a tranquil tapes- emotional needs of the individual. Compulsive behaviors, gen- try in accord with God’s concept of order. erally, are repetitive, on the surface illogical, and in reaction to And so young Peter went through childhood constantly obsessive moods. These inciting obsessions may be blasphemous making lists of things as his way of transforming chaos into a thoughts, unbidden aggressive feelings or, frequently, inappro- serene, symmetrical visage of life. Peter began his University priate sexual ideation. education in Edinburgh in 1793. His medical studies went And the synergy of obsession and compulsion? Obsessive feel- well and he was awarded his doctoral degree in medicine on ings often initiate unreasonable, compulsive responses. Unreasoned June 25, 1798. fear of bacterial contamination, for example, may be so distressful Despite intervals of intense anxiety, obsessive ideation re- that only repetitive hand-washing offers any relief. garding cleanliness, and depression, the next few decades saw Obsessive-compulsive disorder is now a defined psychiat- Dr. Roget practicing in Manchester and finally establishing a ric condition afflicting about two percent of the adult popula- commendable practice of medicine in London. He achieved tion. Obsessive-compulsive behavior, on the other hand, is far prominence not only in the clinical arts but as the inventor of more pervasive, tends to be more narrowly idiosyncratic, epi- the log-log slide rule, as Secretary of the Royal Society, as an sodic rather than continuous and does not overwhelm or para- esteemed lecturer in medical physiology, and as the author of lyze its victims. that century’s most authoritative text on comparative and hu- It is sometimes stated that Professor X, despite being a vic- man physiology. tim of Disease Z, nonetheless succeeded in elucidating the cause These were also difficult years for Roget: he witnessed the of Disease Y. The operative word in the preceding sentence, ‘de- suicide of his father-in-law; saw the emotional deterioration of spite’, suggests that were it not for the oppressive effects of Dis- his mother, his sister, and later, even his daughter. His ultimate ease Z, Professor X would have accomplished yet more during professional goal in life, however, was fulfilled, namely, the gath- his lifetime. Perhaps. But sometimes there are clinical features ering of his many verbal lists into a single, memorable lexico- inherent in Disease X that might enhance rather than restrain graphic text of synonyms. He remembered the words of his the creative impulses of someone with the temperament of Pro- professor at Edinburgh: “As it is by language alone that we are fessor X. Consider the lengthy and creative life of Peter Mark rendered capable of general reasoning, one of the most valu- Roget, physician, teacher, lexicographer and scientist. able branches of logic is that which relates to the use of words.” The SoHo district of London, during the 18th Century, And Peter’s compulsive habit of listing things evolved finally was heavily populated with Huguenot refugees from France. into “Roget’s Thesaurus.” Declaring that adherence to the Protestant faith was illegal, Louis XIV expelled the Huguenots [followers of Hugues, a dis- – STANLEY M. ARONSON, MD ciple of Calvin] from Catholic France. In 1775, the French Protestant Church in London, in need of a pastor, recruited Disclosure of Financial Interests Reverend Jean Roget of Geneva. In 1778 he married Catherine Stanley M. Aronson, MD, has no financial interests to Romilly, daughter of a prominent British family. On January disclose. 18, 1779, their first child, Peter Mark, was born. Later that year Pastor Roget took ill with tuberculosis. He and Catherine CORRESPONDENCE fled to Switzerland in hopes of finding a rest cure in the high e-mail: [email protected] 3 VOLUME 92 NO. 1 JANUARY 2009 The Role of Urogynecology In Women’s Pelvic Floor Disorders Deborah L. Myers, MD

Pelvic floor disorders (PFD) include men. Symptoms are highly associated with urogynecologist provides overall care of urinary incontinence (UI), fecal/ anal in- anal sphincter injury following vaginal the pelvic floor through a complete ap- continence (AI), and pelvic organ pro- delivery. A recent multi-center survey proach and one that is often multi-disci- lapse (POP). An estimated one third of study by Boreham, et al found that up to plinary. The urogynecologist does not women will experience at least one of these 28% of women presenting for routine work alone since many pelvic floor disor- disorders in her lifetime. A prevalence rate gynecologic care reported AI in the pre- ders are affected by other conditions. of all PFD combined is not available, but ceding year.3 Sensory and emptying abnormalities of estimates of each of these dysfunctions The US Census Bureau projects that the lower urinary tract and bowel, pelvic have been reported in epidemiologic stud- by the year 2030, the population over age and abdominal pain, musculoskeletal ies. UI is the 8th most prevalent chronic 65 will double to over 70 million in the dysfunction of the pelvic muscles/ liga- medical condition. It affects approximately US, and over 1 billion worldwide. With ments, and constipation and diarrheal 13 million Americans: 50% of nursing the increase in the aging population, the states all affect PFD. Therefore, home residents, and 15-30% of the com- prevalence of pelvic floor disorders will urogynecologists work in conjunction munity elderly. POP is a common condi- likely increase. Over these next 30 years, with physical therapists, gastroenterolo- tion amongst women. The exact preva- growth in demand for services to treat fe- gists, urologists and colorectal special- lence rate of the condition is not known, male pelvic floor disorders will increase at ists. The urogynecologist is best positioned but a study by Henrdrix et al of 16,616 twice the rate of growth of the same popu- to diagnose and provide a comprehen- women with a uterus found the rate of lation. These findings have broad impli- sive treatment plan for this group of uterine prolapse to be 14.2%; the rate of cations for those responsible for adminis- women. cystocele 34.3%, and the rate of rectocele tering programs that care for women, al- 18.6%. In the same study 10,727 women locating research funds in women’s health REFERENCES who had undergone hysterectomy had and geriatrics, and training physicians to 1. Hendrix SL, Clark A, et al. Pelvic organ prolapse similar rates of prolapse, the prevalence of meet this escalating demand.4 in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6. cystocele was 32.9% and of rectocele was A urogynecologist is an obstetrician/ 2. Olsen AL, Smith VJ, et al. Epidemiology of surgi- 18.3%.1 Olsen et al found that American gynecologist who has specialized in the cally managed pelvic organ prolapse and urinary women have an 11% lifetime risk of un- care of women with pelvic floor disorders. incontinence. Obstet Gynecol 1997;89:501-6. dergoing surgery before the age of 80 for Urogynecologic training is achieved 3. Boreham MK, Richter HE, et al. Anal incontinence in women presenting for gynecologic care. either urinary incontinence or prolapse through three-year fellowship programs Am J Obstet Gynecol 2005;192:1637-42. with 30% of women undergoing repeat in Female Pelvic Medicine and Recon- 4. Luber KM, Boero S, Choe JY. The demographics surgery.2 AI may have the most devastat- structive Surgery (FPM&RS), under the of pelvic floor disorders. Am J Obstet Gynecol ing effects on quality of life, self-image, and auspices of both the American Board of 2001;184:1496-501; discussion 1501-3. social functioning of all pelvic floor disor- Obstetrics and Gynecology (ABOG) Deborah L. Myers, MD, is Associate ders. It is defined by the International and the American Board of Urology Professor, Obstetrics and Gynecology,The Consultation on Incontinence as the in- (ABU). There are currently 32 accred- Warren Alpert Medical School of Brown voluntary loss of gas, liquid, or solid stool ited fellowship programs within the University, and Director, Division of that causes a social or hygienic problem. United States. Urogynecology fellow- Urogynecology and Reconstructive Pelvic Women are twice as likely to report AI as ships provide comprehensive training in Surgery, Women & Infants Hospital of pelvic floor disorders for women; train- Rhode Island. ees are needed to meet future clinical, research, and educational demands. The Disclosure of Financial Interests The author has no financial interests to disclose.

CORRESPONDENCE: Deborah L. Myers, MD Women and Infants Hospital of RI 695 Eddy Street Providence, Rhode Island 02903 Phone: (401) 453-7560 e-mail:dmyers @wihri.org

4 MEDICINE & HEALTH/RHODE ISLAND Pelvic Organ Prolapse Brittany Star Hampton, MD

The levator ani pelvic muscles and chronic cough. Nulliparity does not pro- Awareness or palpation of an actual pro- surrounding connective tissues provide tect against prolapse: one fifth of the nul- trusion usually occurs when prolapse is at support for the pelvic organs. Disrup- liparous women in the Women’s Health or below the hymen, but women with pro- tion of this natural anatomic system re- Initiative had some degree of prolapse.5 lapse above the hymen may complain of sults in descent or prolapse of one or more pelvic pressure or heaviness. of the pelvic structures: bladder and ure- DIAGNOSTIC APPROACH The patient interview should address thra, rectum, uterus and cervix, and small History all of the above. Additionally, questions bowel. Patients with prolapse often In evaluating a patient with pelvic regarding conditions that may contrib- present with associated urinary, organ prolapse, it is important to ascertain ute to the progression of pelvic prolapse defecatory, and sexual dysfunction, al- symptoms and bother, because many pa- should be asked, such as gravidity and though many women who have prolapse tients with prolapse are asymptomatic. parity, menopausal status, conditions or on examination are clinically not af- Patients who are symptomatic will present activities contributing to elevated intra- fected.1 The finding of prolapse on exam with complaints in at least one of four cat- abdominal pressure, and prior surgery. is not well correlated with symptoms. egories: lower urinary tract dysfunction, Again, the interview should assess how Thus, pelvic organ prolapse encompasses defecatory dysfunction, sexual dysfunc- much bother the symptoms are creating a wide range of disorders, from asymp- tion, or feeling and /or seeing a “bulge”. for the patient. Several validated ques- tomatic altered anatomy to complete Symptoms of lower urinary tract dysfunc- tionnaires are available to quantify and eversion of the vagina. The lifetime risk tion may include hesitancy, slow stream, qualify symptoms. Finally, it is important that a woman in the United States will need for position change to void, or in- to ascertain patient treatment goals. Pa- have surgery for prolapse and urinary complete bladder emptying. Some tients will benefit from reassurance and incontinence is estimated at 11%.2 The women with advanced prolapse may reeducation regarding their condition. direct cost of prolapse surgery is greater count a history of stress incontinence that than $1 billion per year.3 has improved over time. This is likely due Physical Examination The pathophysiology of prolapse is to the urethral obstruction or “kinking” Physical exam begins with visual in- multifactorial. Risk factors can be predis- caused by the advancing prolapse. Symp- spection of the vulva and vagina. The pro- posing, inciting, promoting, and decom- toms of defecatory dysfunction include vider can assess the patient’s neurologic pensating.4 Risk factors include family incomplete evacuation and the need for function in the pelvis by testing for an anal history, connective tissue disorders, race, application of manual pressure to the wink (bulbocavernosus reflex) and the gravidity and parity, prior prolapse sur- perineum or posterior vagina to complete dermatomes of the perineum and upper gery, myopathy, neuropathy, advancing a bowel movement, commonly called leg. Efficiency of bladder emptying can age, menopause, and elevated “splinting.” Pelvic prolapse may interfere be assessed by measuring a voided volume intrabdominal pressure from obesity, with sexual activity secondary to embar- and the post void residual by either cath- constipation, occupational activities, or rassment, concern, or fear of incontinence. eterization or ultrasound. The extent of

Table 1. Pelvic Organ Prolapse Quantification Staging (6)

Stage 0 No prolapse is demonstrated.

Stage I The criteria for stage 0 are not met, but the most distal portion of the prolapse is >1 cm above the level of the hymen

Stage II The most distal portion of the prolapse is =1 cm proximal to or distal to the plane of the hymen

Stage III The most distal portion of the prolapse is >1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters

Stage VI Essentially, complete eversion of the total length of the lower genital tract is demonstrated. The Figure 1. Six sites (points Aa, Ba, C, D, Bp, and Ap), genital distal portion of the prolapse protrudes to at least hiatus (gh), perineal body (pb), and total vaginal length (tvl) (TVL-2) cm used for pelvic organ support quantitation. (6) 5 VOLUME 92 NO. 1 JANUARY 2009 pelvic organ prolapse should then be sys- nation is performed to assess rectal becomes compromised or impossible sec- tematically evaluated and with Valsalva sphincter tone and its voluntary contrac- ondary to prolapse, emergent treatment efforts. If the prolapse is advanced this is tion. Rectal prolapse and defects in the is needed for reduction of the prolapse. often not difficult. However, if prolapse is rectovaginal septum may be appreciated If bladder emptying is compromised, re- not obvious, the use of a “split” vaginal more fully at this time as well. sulting in increased post void residuals, speculum is needed to determine which patients should be counseled on the pos- vaginal supports (anterior, apical, poste- Adjunctive testing sible risk of recurrent urinary tract infec- rior) are affected by prolapse. Retraction Women with prolapse who are seek- tions and upper urinary tract damage. In of the posterior wall of the vagina with the ing treatment should undergo bladder addition, the protruding vaginal epithe- single blade of a speculum will help iden- testing to unmask any bladder dysfunc- lium is at risk for erosion and/ or abra- tify anterior prolapse, and vice versa, re- tion. Occult stress incontinence and sion with advanced prolapse; it can rarely traction of the anterior wall of the vagina voiding dysfunction are often seen in become infected. with the single blade of a speculum will women with prolapse.7,8 Bladder testing If a woman chooses to move forward help identify posterior vaginal prolapse. of either simple or complex cystometry, with active management of her prolapse, The supports of either uterus/ cervix or and flow studies with prolapse extended she should be counseled about non-sur- post hysterectomy vaginal cuff of the va- and reduced will reveal such conditions. gical and surgical treatment options. gina, that is the apex, are assessed with the Reduction will mimic bladder and ure- Treatment goals should be outlined and bivalve speculum. thral function once prolapse is repaired patient expectations understood. The International Continence Soci- or resupported. Instruments such as a ety developed a standard system for mea- single blade speculum, large cotton Q- Non-surgical treatment suring and staging prolapse known as the tips (scopettes), ring forceps, or pessary Non-surgical management is ideal Pelvic Organ Prolapse Quantification can be used to reduce the prolapse. for patients who wish to avoid surgery or (POPQ) system.6 This standardized sys- Imaging such as dynamic pelvic floor who present with medical conditions that tem allows for objective evaluation of pro- MRI and defecography are not routinely make them poor surgical candidates. lapse findings, accurate communication necessary in women with pelvic organ pro- Pessary use is the only specific non-surgi- between providers, and reliable pre and lapse, but can clarify etiologies of bowel, cal treatment available, but pelvic floor post-treatment comparison points. The bladder or sexual dysfunction; thus they muscle training and symptom directed POP-Q system measures nine locations on may be useful in formulating management therapy might reduce the progression of the vagina and vulva in relation to the hy- recommendations in a select group of prolapse symptoms.9 men. (Figure 1) All measurements, except women. Cystoscopy may be needed as well. for the measurement of total vaginal Symptom directed therapy length, are taken with the patient per- Symptom -directed therapy is aimed forming a maximal Valsalva maneuver Nulliparity does at altering specific symptoms that are with an empty bladder. Also, if the full not protect against bothersome to the patient and which may extent of prolapse is not appreciated with contribute to the progression of prolapse. the patient in the supine or lithotomy po- prolapse… Many practitioners utilize symptom- di- sition, the patient is examined in the stand- rected therapy as an adjunct to surgical ing position. The POP-Q measurements TREATMENT management in an effort to optimize sur- are then used to assign a stage of prolapse Indications for treatment gical outcome. (from 0-IV) for each patient according the Management of pelvic organ pro- Patients who complain of incomplete most advanced site. (Table 1) lapse is based upon symptom bother. If evacuation of stool, or the need to splint A bimanual examination should the presence of pelvic prolapse is not suf- during bowel movements, should undergo then be performed to assess the uterus ficiently bothersome to the patient to war- a complete gastrointestinal evaluation, diet (cervical length, uterine size and contour, rant active intervention, watchful waiting and bowel history. If no GI pathology is uterine mobility, and the quality of uter- is reasonable. Education and reassurance diagnosed, bowel habits should be regu- ine supports) and adnexa. The examiner regarding anatomy, symptom progression, lated to prevent straining and promote may also palpate the pelvic levator ani and possible treatment options is recom- regular evacuation. Increasing water and muscles. Muscle tenderness, baseline mended for these patients. Patients who fiber intake should be reinforced. Addi- muscle tone, as well as ability and strength choose to have no intervention for their tion of osmotic laxatives may be done as of voluntary contraction that is, the prolapse should be encouraged to follow necessary. “Kegel squeeze”, may be determined at symptom-directed therapy, pelvic floor Incomplete bladder emptying, or this time. It is important to note if a muscle training, and be monitored for symptoms of urinary frequency and ur- woman can locate and contract her pel- progression of prolapse. As described in gency may be controlled with such meth- vic muscles. If she cannot, a program of the Diagnostic section, a quantitative mea- ods as timed voids or fluid intake alter- pelvic muscle strength training by a surement of prolapse by the POP-Q stag- ation. A voiding diary is helpful for pa- physical therapist would be advised, as ing system allows for subsequent compari- tients to record their daily intake and an unsupervised course of Kegel exercises son of prolapse progression. voiding patterns. will likely not be beneficial. Rectal exami- When bladder or bowel evacuation In general, exercise and weight loss 6 MEDICINE & HEALTH/RHODE ISLAND are not proven to decrease prolapse symptom progression, but are encouraged for overall health.

Pelvic floor muscle training Commonly called Kegel exercises, pelvic floor muscle training is aimed at increasing the strength and endurance of the pelvic muscles. The pelvic muscles, specifically the levator ani muscles (pubococcygeous, ileococcygeous, puborectalis), act in concert with ligaments and connective tissue to support the pelvic organs. Strengthening these muscles therefore theoretically increases the support of these organs. There is no direct evidence that pelvic floor muscle exercises prevent or treat pelvic organ prolapse; however. they are effective for urinary and fecal incontinence and may be beneficial for prolapse.10 Pelvic floor muscle exercises, like Figure 2: Types Of Pessaries: A) Smith; (B) Hodge; (C) Hodge with support; (D) Gehrung; symptom directed therapy, can be used as (E) Risser; (F) Ring with diaphragm; (G) Ring; (H) Cube; (I) Shaatz; (J) Rigid Gellhorn; an adjunct to surgical management. There (K) Flexible Gellhorn; (L) Incontinence ring; (M) Inflatoball; (N) Donut. (Image from UptoDate) are virtually no adverse effects of pelvic floor muscle exercises; however, the patient must fitting is associated with short vaginal length and removal approximately every three be willing to invest the time. Few women and a wide introitus.11 Approximately 90% months. At the office visit, the provider effectively locate and contract their pelvic of women who are successfully fitted with inspects the vagina for erosion. Mainte- muscles when asked to during a vaginal ex- a pessary are satisfied at 2 months.12 nance with estrogen cream and/or Trimo- amination. Therefore, independent unsu- Patients can insert and remove some San ® (Milex Inc, Chicago, IL) is rec- pervised exercise of these muscles may not types of pessaries on their own, or they ommended to maintain vaginal health be as beneficial as supervised exercise with a may return to their provider for insertion during pessary use. physical therapist.

Pessary Use A vaginal pessary is a removable device placed in the vagina to support areas of pelvic organ prolapse. A variety of pessaries are available, made of rubber, plastic, or silicone- based materials. (Figure 2) Like all types of non-surgical management, pessary use is aimed at decreasing symptom frequency and severity. They are a choice of therapy in women who have medical contraindications to surgery or debilitated, and for any woman who desires to avoid surgery. Pessaries may also be used before implementing a surgical plan to assess symptom resolution or to document occult urinary incontinence with reduction of prolapse. Pessaries are available in a variety of shapes depending on the type of prolapse and vaginal configuration. Broadly, there are support and space-occupying pessaries, and a pessary is fitted to each individual patient. The pessary should be both stable and comfortable, and patients should be able to urinate and defecate without difficulty. Up to 75% of women can be successfully fitted with a pessary; unsuccessful Figure 3. Anterior vaginal colporrhaphy (Image from UpToDate) 7 VOLUME 92 NO. 1 JANUARY 2009 ture and function of the vagina. Recon- structive surgery may use the patient’s en- dogenous support structures, or may attempt to replace deficient support with a graft material. Approaches to pelvic reconstructive surgery for prolapse include vaginal, abdominal, and laparoscopic, or a combination of the above. Depending on the location of prolapse and prolapse symptoms, each compartment of the vagina (anterior, apical, posterior) may be addressed with a specific approach. In addition, concomitant surgery may be planned for the anal sphincter and/or bladder neck. As comparable data for prolapse operations are poor, surgical route is determined based on Figure 4. Sacrospinous Ligament Fixation the type and severity of prolapse, surgeon The main contraindication to pessary Obliterative procedures preference, and desired outcome. use is inability to follow up for treatment For patients who do not desire vaginal One of the most important compli- monitoring, which would result in pessary function, or who are at high risk for com- cations to remember when counseling a neglect and subsequent incarceration and plications during reconstructive proce- patient regarding reconstructive surgery fistula. Relative contraindications to pes- dures, an obliterative procedure, or colpo- is anatomic failure, or recurrence. All pa- sary use are severe vaginal atrophy, active cleisis, may be an appropriate treatment tients who undergo prolapse surgery must vaginitis, and persistent vaginal erosion choice. This is performed transvaginally, understand that each approach is associ- with pessary use, which may necessitate and can be done with or without a uterus ated with a recurrence rate, and though periodic discontinuation of the pessary. in place. Recurrence rates for colpocleisis lifestyle factors can be modifiable, inher- Vaginal neoplasm should be ruled out in are low; however, this may be due to self- ent connective tissue and muscle damage these cases of non-healing lesions. selection of a patient population that has a likely contributes to failure. limited life span and activity level. Surgical treatment Anterior vaginal repair The primary aim of prolapse surgery Reconstructive procedures Anterior vaginal prolapse has tradi- is to improve prolapse symptoms and Theoretically, prolapse is caused by a tionally been repaired transvaginally with bowel, bladder or sexual dysfunction as- disruption and dysfunction of one or both an anterior colporrhaphy. This entails ex- sociated with the prolapse. Surgery is of the natural anatomic supports: connec- posure and plication of the patient’s vesi- aimed at either reconstructing the vagina tive tissues and muscles. Reconstructive covaginal connective tissue in the mid- or obliterating the vagina to achieve surgery of the vagina repairs or replaces the line. (Figure 3) Graft material may be symptom relief. connective tissue supports, restoring struc- used in addition to or instead of the plication. The aim of graft material in this compartment is to effectively augment the vesicovaginal connective tissue, and therefore theoretically increase anatomic success and outcome. Paravaginal repair of the anterior vaginal wall may be approached either transvaginally, abdominally, or laparoscopically. This is aimed at reattaching the lateral vaginal sulcus to the arcus tendineous fascia pelvis. There are poor data comparing the above surgical approaches. Therefore a surgeon must consider patient presentation, surgeon preference, and concomitant sur- geries when choosing an approach to anterior vaginal wall repair.

Posterior vaginal repair Posterior vaginal prolapse has traditionally been repaired transvaginally with a Figure 5: Abdominal Sacrocolpopexy (Image from UpToDate) posterior colporrhaphy. Like an anterior 8 MEDICINE & HEALTH/RHODE ISLAND colporrhaphy, this entails exposure and pli- teral injury, and may be more challenging REFERENCES cation of the connective tissue supports of in post-hysterectomy vault prolapse. 1. Samuelsson EC, Victor FT, et al. Signs of genital the rectum, or rectovaginal connective tis- Abdominal and laparoscopic ap- prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J sue. This can be done with either a site- proaches to apical prolapse can be per- Obstet Gynecol.1999;180(2 Pt 1):299-305. specific or midline repair, and may be aug- formed with or without the uterus in place. 2. Olsen AL, Smith VJ, et al. Epidemiology of surgi- mented with graft use. Procedures that are Surgeons who perform abdominal sacral cally managed pelvic organ prolapse and urinary commonly combined with a posterior vagi- colpopexy use graft material attached to the incontinence. Obstet Gynecol 1997;89:501-6. 3. Subak LL, Waetjen LE, et al. Cost of pelvic organ nal repair include a levator muscle plica- anterior and posterior vaginal apex to sus- prolapse surgery in the US. Obstet Gynecol tion and/or a perineorrhaphy. Perineor- pend the apex to the anterior longitudinal 2001;98:646-51. rhaphy is usually carried out when there is ligament of the sacrum. (Figure 5) This can 4. Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol a separation of the perineal muscles, and is be done with the uterus in place, called a Clin North Am 1998; 25:723-46. often used to restore the natural posterior hysteropexy.. Uterosacral ligament suspen- 5. Hendrix SL, Clark A, et al. Pelvic organ prolapse in deflection of the vagina in the pelvis. sion can also be approached abdominally, the Women’s Health Initiative. Am J Obstet Gynecol Colorectal surgeons will often approach with or without the uterus in place. Suc- 2002;186:1160-6. 6. Bump RC, Mattiasson A, et al. The standardization posterior vaginal prolapse transanally. cess rates of the few trials available for com- of terminology of female pelvic organ prolapse and parison of vaginal and abdominal ap- pelvic floor dysfunction. Am J Obstet Gynecol Vaginal apical repair proaches to apical prolapse tend to favor 1996;175:10-7. Apical prolapse of the vagina includes abdominal sacral colpopexy, though com- 7. Rosenzweig BA, Poshkin s, et al. Prevalence of abnormal urodynamic test results in continent women uterine prolapse with or without small plications of abdominal entry and graft use with severe genitourinary prolapse. Obstet Gynecol bowel (enterocele) and vault prolapse need to be weighed when considering how 1981;79:539-42. (when the uterus is absent), which typi- to approach each patient. 8. FitzGerald MP, Kulkarni N, Fenner D. Postopera- cally includes small bowel. Hysterectomy tive resolution of urinary retention in patients with advanced pelvic organ prolapse. Am J Obstet Gynecol alone does not repair prolapse of the vagi- Addressing concomitant 200;183:1361-4. YEAR? nal apex. It is usually performed by pelvic symptoms 9. Hagen S, Stark D, et al. Conservative management of reconstructive surgeons to gain vaginal Symptoms of urinary, bowel, and pelvic organ prolapse in women. The Cochrane Data- access to structures from which to suspend sexual dysfunction must be discussed with base of Systematic Reviews 2006, Issue 4. CD003882. DOI: 10.1002/14651858.CD003882.pub3. the vagina. Thus, a vaginal vault suspen- patients before surgery, and resolution of 10. Thakar R, Stanton S. Management of genital pro- sion procedure must be performed with a such symptoms may or may not occur with lapse. BMJ 2004; 324:1258-62. hysterectomy for apical prolapse. surgical anatomic replacement of the pel- 11. Clemons JL, Aguilar VC, et al. Risk factors associated with an unsuccessful pessary fitting trial in There are several vaginal approaches vic organs. If a woman demonstrates stress women with pelvic organ prolapse. Am J Obstet to apical prolapse. Each re-suspends the incontinence with pessary support of the Gynecol 2004;190:345-50. vagina by using strong ligaments or fascia. pelvic organs preoperatively, she is at a 12. Clemons JL, Aguilar VC, et al. Patient satisfaction and A sacrospinous ligament fixation is tradi- higher risk of having post-operative stress changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ tionally performed after removal of the incontinence, and may benefit from an prolapse. Am J Obstet Gynecol 2004; 190:1025-9. 14 uterus, and entails attaching the vaginal anti-incontinence procedure. Fecal in- 13. Sze EH, Karram MM. Transvaginal repair of vault apex to the sacrospinous ligament. ( Figure continence may be addressed with an anal prolapse. Obstet Gynecol 1997;89:466-75. 4) Uterosacral ligament suspension is tradi- sphincteroplasty at the time of surgery. 14. Meschia M, Pifarotti P, et al. A randomized comparison of tension-free vaginal tape and endopelvic tionally performed after removal of the fascial plication in women with genital prolapse and uterus when done from a vaginal approach, SUMMARY occult stress urinary incontinence. Am J Obstet or may be performed abdominally or Pelvic organ prolapse can encompass Gynecol 2004; 190:609-13. laparoscopically with the uterus removed a range of disorders, from asymptomatic, or in place. The surgeon performs utero- altered anatomy to complete eversion of Brittany Star Hampton, MD, is As- sacral ligament suspension by attaching the the vagina and may present with associ- sistant Professor, Obstetrics and Gynecol- vaginal apex to the uterosacral ligament ated urinary, defecatory, and sexual dys- ogy Warren Alpert Medical School of remnants at the level of the ischial spines function. Patient symptoms are important Brown University. bilaterally. Though not the traditional ap- to elicit, because many patients with pro- proach, there are reports of sacrospinous lapse are asymptomatic. Ascertaining pa- Disclosure of Financial Interests ligament fixation and uterosacral suspen- tient treatment goals is necessary when The author has no financial inter- sion being approached vaginally with the discussing options for management, and ests to disclose. uterus in place. Vaginal approaches to api- patients can choose from conservative, cal prolapse are likely similar with respect noninvasive treatment and prevention to CORRESPONDENCE to anatomic outcome and recurrence rate.13 surgical reconstruction. As comparable Brittany Star Hampton, MD Sacrospinous ligament fixation is data for prolapse operations are poor, sur- Women and Infants Hospital of RI extraperitoneal, but may have increased risk gical route is determined based on the type 695 Eddy Street of vascular and nerve injury, while utero- and severity of prolapse, surgeon prefer- Providence, Rhode Island 02903 sacral suspension is intraperitoneal and ence, and desired outcome. Phone: (401) 453-7560 therefore may carry a risk of bowel or ure- e-mail:[email protected]

9 VOLUME 92 NO. 1 JANUARY 2009 Physical Therapy for Pelvic Floor Dysfunction Wendy Baltzer Fox, PT, DPT GCS

Although the field of physical therapy to bowel and bladder incontinence, pel- ies, as well as the expectations or goals of began during the polio epidemic, the vic pain or pressure, and back pain. the patient, will guide the plan of care. sub-discipline of Women’s Health Physi- A review of all medications is necessary. cal Therapy1 is only approximately 30 EVALUATION OF PELVIC FLOOR For example, diuretic use by the patient years old. Until recently, specialized MUSCLE DISORDERS needs to be considered in the behavioral training in women’s health for physical When a patient is referred to physi- management of urinary incontinence, therapists was available only on a post- cal therapy, the typical management pro- particularly in timing activities and over- graduate level. The American Physical cess includes examination, evaluation, all outcome expectations. A review of all Association sanctioned Board certifica- diagnosis of impairments, and determi- laboratory and diagnostic testing (e.g. tion2 for the first time in 2009. Those nation of prognosis and interventional urodynamics, cystoscopy, defecogram, who pass the exam will be deemed to plan of care.4 Impairments may include MRI) are important as well as bowel, have professional expertise in the man- weakness, pain, decreased range of mo- bladder, nutrition and hydration diaries. agement of urinary incontinence, pelvic tion, and functional limitations. Inter- The patient’s medical history, as well as pain, pregnancy-related pain, lymphe- ventions may include therapeutic exer- current medical status, are required to dema that occurs following surgery for cises5 for strengthening, education of understand the connection of pre-exist- breast cancer, and pelvic pain.3 behavioral changes, orthotices, biofeed- ing conditions and outcome. An under- Pelvic floor muscle dysfunction or back and electrical stimulation. lying neurological condition may dictate chronic pelvic pain are not normal con- A physical therapist will complete a a course of management rather than a sequences of the aging process. For ex- thorough examination before designing resolution of the urinary concern. A ample, vaginismus may occur in the teen an interventional plan. Patient history patient’s perception of her general health; years when girls attempt to use tampons will include general demographics in- psychological issues including anxiety, and/or during their initial gynecological cluding primary language and race/ depression, impaired memory; and hab- examination. Pregnancy may be accom- ethnicity so that there is no language bar- its including smoking and exercise all are panied by bowel and/or bladder prob- rier that can impede treatment6 and all considered in forming a physical therapy lems as hormonal changes result in sup- verbal and written instruction will be plan of care. port dysfunction or muscle weakness. appropriate for the patient. An under- Following history and systems re- These changes may also occur along the standing of ethnic beliefs and traditions view, additional PT tests and measure- aging continuum as a consequence of may alter the treatment approach and ments are completed. These may in- decreased muscle use and decreased ac- dictate the education component. In clude assessment of the pelvic floor8 with tivity levels. This article will discuss the some cultures, discussion of female pel- external observation for anomalies, skin physical therapy management of women vic anatomy is limited, even taboo,. The integrity, palpation for tender points or who present with pelvic floor dysfunction patient’s occupation may indicate the trigger points, pain location, neurologi- or pelvic pain. need for behavioral modifications. For cal tests, strength grading by manual There are two main findings during example, jobs that require prolonged muscle test of superficial and deep a physical therapy examination for standing or sitting require postural muscles. Examination also includes the women with pelvic floor muscle disor- awareness, particularly with patients with evaluation of endurance, relaxation, and ders: supportive dysfunction and chronic pelvic pain. Functional status, contraction speed of the pelvic muscles. hypertonus dysfunction. Supportive dys- activity level, ability and willingness to Surface electromyography (EMG) is functions occur as a result of the loss of participate and to be compliant are im- used to assess the muscle tone. The nerve, muscle, ligament, or fascial integ- portant to note when setting patient patient’s breathing pattern at rest and rity of the pelvic floor muscles resulting goals. An elder’s living environment7 may during activity would be observed. in weakness and laxity. Weak supportive be a cause of incontinence if functional Breathing dysfunction is commonly seen dysfunctions could be caused by injury mobility or the need for an assistive de- with pelvic floor dysfunction; the in- incurred during childbearing or gyneco- vice such as a walker impedes toileting. creased intra-abdominal pressure and logic surgery, chronic constipation, Impaired mobility, combined with uri- straining contribute to the pelvic floor chronic coughing, obesity, or hormonal nary urgency and frequency, are safety dysfunction. More tests9 may include changes. A hypertonus dysfunction can concerns. A bedside commode at night musculoskeletal assessment of posture, cause symptoms of pain in the abdomi- can enhance safety and promote conti- spinal flexibility, abdominal and back nal area, back, or vulvar region. Patients nence. strength/stability, as well as assessment may report burning, itching, dyspareu- Determination of variables such as of lower extremity strength, range of nia, urinary urgency and leakage, or con- the onset of the current condition, what motion and length. A relatively new stipation. Interestingly, both supportive prompted the patient to seek medical technique, real time ultrasound, is used and hypertonus dysfunction contribute consultation, past interventions or surger- to observe muscle function during ac- 10 MEDICINE & HEALTH/RHODE ISLAND tivities, as well as a means to provide bio- SUMMARY 7. Functional Incontinence. Physiotherapy in Ob- feedback as a treatment.10 As examina- This article has summarized the as- stetrics and Gynecology eds. Mantle J. and Polden M. Butterworth-Heineman, 2004; 348. tion progresses, identification of addi- sessment of a woman with pelvic floor 8. Laycock J. Clinical evaluation of the pelvic floor. tional impairments would require refer- muscle dysfunction or pain complaints Pelvic Floor Re-education, Principles and Practice, ral to other medical practitioners. The and has briefly described the interven- ed. Stanton S. Springer- Verlang, Lon- physical therapy plan of care will outline tions used to treat women with these con- don;1994:42-8. 9. Prendagast SA, Weiss JM. Screening for muscu- a specific physical therapy diagnosis. cerns. The American Physical Therapy loskeletal causes of pelvic pain. Association explains: : “As a woman in Clin Obstet Gynecol 2003; 46:773-82. TREATMENT OF PELVIC FLOOR today’s world, you enjoy a life of many 10. Whitaker J. Ultrasound Images for Rehabilitation of the Lumbopelvic Region. Churchill- Livingston, MUSCLE DISORDERS choices. The choices we make will deter- London, 2007. Direct interventions prescribed by mine the way we use our body through 11. Kegel AH. Progressive resistance exercise in the physical therapists are evidence-based and the decades. A physical therapist will be functional restoration of the include the following elements: coordi- there for you as you progress through all perineal muscles. Am J Obstet Gynecol 1948; 56:238-49. nation of care, communication and docu- stages of your life.” 12. Burgio KL. Influence of behavior modification mentation, patient education and direct on overactive bladder. Urol 2002, 60; 72-7. intervention. The primary intervention ACKNOWLEDGEMENT: 13. Weis JM. Pelvic floor myofascial trigger points. J prescribed by physical therapists has al- I wish to thank Dr. Nancy Rich for Urol 2001;166: 2226-31. 11 14. Bok K, Talseth T, Holme I. Single blind, random- ways been therapeutic exercise. These her assistance in the preparation of this ar- ized controlled trial of pelvic floor exercises, elec- include core strengthening of abdomi- ticle, Nancy C. Rich, Ph.D.,PT, FACSM, trical stimulation, vaginal cones, and no treatment nal muscles, postural and pelvic floor Editor-in-Chief, Journal of Women’s Health in the management of genuine stress incontinence muscles. Breathing and relaxation exer- Physical Therapy, Bridgton (Maine) Hos- in women. Brit Med J 1999; 318: 487-93. cises are typical key components for ev- pital Physical Therapy, and Director of Wendy Baltzer Fox, PT, DPT GCS, ery patient. Relaxation involves the qui- Women’s Health, Bader Physical Therapy, is a Physical Therapist and Board-certi- eting of the autonomic nervous system Norway, Maine fied Geriatric Clinical Specialist, Women and includes visualization,12 soft tissue and Infants Hospital. mobilization, heat modalities and position- REFERENCES ing. Scar management (abdominal or 1. Section of Women’s Health, American Physical Disclosure of Financial Interests perineal) includes soft tissue mobiliza- Therapy Association; SOWH, APTA. www.SOWH.org The author has no financial inter- tion, application of heat or cold, and 2. American Board of Physical Therapy Specializa- ests to disclose. therapeutic ultrasound. Manual therapy tion, ABPTS; www.APTA.org. techniques include myofascial release, 3. Description of Specialty Practice, ABPTS, CORRESPONDENCE: trigger point release, soft tissue mobiliza- www.APTA.org. 4. American Physical Therapy Association. Guide to tion and massage.13 Active stretching and Wendy Baltzer Fox, PT, DPT GCS Physical Therapy Practice. Laycock J. Pelvic muscle Women and Infants Hospital specific tissue stretching may be com- exercises. Urol 1994;14:136-40. pleted with vaginal dilators. 6. Sangi-Haphpeykar H, Mozayeni P, et al. SUI, 101 Dudley Street counseling, and practice of pelvic floor exercises Providence, RI 02905 Methods of strengthening may in- in postpartum low-income Hispanic women. Int clude electrical stimulation, muscle re- Phone: 401-453-7560 Urogynecol J Pelvic Floor Dysfunct. 2008;19:361- e-mail:[email protected] education using biofeedback techniques, 5. Epub 2007 Aug 15. or instruction in the use of vaginal weights.14 Biofeedback involves the use of external or internal sensors that record levels of muscle activity that are displayed on a computer as the patient performs exercises. This visual technique can provide motivational support as it increases the awareness of correct muscle contractions in various positions. Electrical stimulation is used to correct incoordination. In the treatment of overactive bladder electrical stimulation is used to inhibit and decrease unstable detrusor contractions. Electrical stimulation is contraindicated for patients for whom there is urinary retention or post void residual volume > 200 cc. Electrical stimulation is also contraindicated for women during pregnancy and may not be effective with patients who are obese. 11 VOLUME 92 NO. 1 JANUARY 2009 Minimally Invasive Approaches To Pelvic Reconstructive Surgery Charles R. Rardin, MD The term “minimally invasive surgery” visualization of the laparoscope has im- sutures on each side (one at the generally represents the effort to reduce the proved identification and avoidance of the urethrovesical junction, the other at the impact of surgery on the patient, both in vascular structures that have complicated midurethra, at least 2 cm lateral to the ure- terms of incision size and location, as well retropubic procedures. Additionally, the thra itself), which are then suspended from patient discomfort and recovery of normal pneumoperitoneum used during Cooper’s ligament ipsilaterally ( Figure 1) health status. The recognition of the im- laparoscopy provided some measure of Suture placement in the paraurethral tissue portance of these characteristics has per- tamponade, again reducing the nuisance is facilitated by elevating the tissue with the vaded all aspects of surgery – generally of venous oozing during the retropubic surgeon’s finger in the vagina. Practitioners speaking, there is widespread acceptance dissections. Finally, patient satisfaction vary widely in their techniques of assessing of the role of minimization of incision size, with the laparoscopic approach to the right amount of bladder neck elevation; use of self-retaining retractors, and other urogynecologic procedures is favorable.4 however, the data have shown that correc- measures to improve the patients’ overall tion of hypermobility is a requirement for experience and recovery, and these might LAPAROSCOPIC TECHNIQUES successful outcome.10 Overcorrection, be considered efforts to reduce the inva- Laparoscopic Burch though, can lead to voiding dysfunction; siveness of surgery in general. For the pur- colposuspension procedure therefore, suture bridges are left to prevent poses of this article, two main categories of The retropubic colposuspension, along overcorrection. It is also advisable to close surgery will be considered: laparoscopic with suburethral slings, has become, to many, any peritoneal incision to prevent incarcera- (and robotic) surgery, and trocar-based sur- the gold standard for treatment of tion of bowel within these suture bridges. gical kits and techniques. urodynamic stress incontinence due to blad- With the popularity of minimally- The advent of laparoscopy for gyne- der neck hypermobility without intrinsic invasive slings, the popularity of the Burch cologic surgery was greeted with much en- sphincter deficiency.5 The Burch procedure, procedure has waned; the skillset required thusiasm; the potential advantages in de- or more accurately, the Tanagho modifica- and operative time tend to favor the creased postoperative pain1 , rapid recu- tion of the Burch procedure,6 was performed newer generations of slings, and success peration2 , decreased adhesion formation3 laparoscopically and described by Vancaillie rates of these slings are at least as high or and preferable cosmetic result led to a rapid in 19917 , with publication of a case series soon higher.11 Interest in the Burch proce- increase in the rate of tubal ligation. The afterwards.8,9 The laparoscopic advantages dure was regenerated, to some degree, utility of the laparoscope as a diagnostic tool of visualization, hemostasis, and quick recov- by the CARE trial, in which patients was quickly realized, and it enjoyed popu- ery for the generally healthy population undergoing open sacrocolpopexy for larity in the diagnosis and treatment of helped to make this a popular procedure for vaginal vault prolapse were randomized chronic pelvic pain and endometriosis, as adaptation to the laparoscopic approach. to receive, or not receive, a concomitant well as in surgical sterilization. Burch procedure, regardless of preopera- As the tool of the laparoscope has Technique: tive urodynamic findings.12 Patients who been applied to more advanced surgical Similar to the open technique, the underwent the Burch procedure were procedures, these advantages to the pa- laparoscopic Burch procedure involves ret- half as likely to report postoperative stress tient have remained significant, and other ropubic dissection, clearing of the paraure- incontinence as their counterparts. advantages were realized. The microscopic thral and paravesical fascia, placement of two Many practitioners who have developed

Figure1. Burch Colposuspension Figure 2. Paravaginal Defect Repair 12 MEDICINE & HEALTH/RHODE ISLAND skills in laparoscopic sacrocolpopexy are inferior edge of the pubic ramus can be ral ligaments have as much tensile strength adding laparoscopic colpopsuspension in located by palpation under laparoscopic as vaginally-placed sutures.18 With the light of these findings. observation. The surgeon will appreci- proximal uterosacral ligament thus cap- ate the fact that, in this approach, the tis- tured, the sutures are then brought ipsi- Laparoscopic repair of a sues being sutured together are adjacent; laterally through the full thickness of the cystocele paravaginal defect in the vaginal paravaginal repair, the vagi- posterior and anterior vaginal walls (ex- Although the traditional repair of cys- nal sutures must be placed with the tis- cluding epithelium) at the cuff. ( Figure tocele (colporrhaphy) has involved the cen- sue everted, and thus distant from the 3) The attenuated enterocele sac that may tral plication of the pubocervical fascia, the targeted area of reattachment. lie at the apex, between anterior and pos- idea that anterior compartment defects can terior vaginal wall fasciae, can often be be lateral (paravaginal), as well as central, was Laparoscopic repair of vault visualized with the use of the vaginal first published nearly a century ago.13 (Fig- prolapse – Uterosacral ligament probe. Some surgeons advocate the ex- ure 2) As the surgical reattachment of suspension cision of this attenuated tissue sac; pubocervical fascia to the arcus tendineus of While uterosacral ligament vault sus- whether or not it is removed, the sup- the fasciae pelvis (or “white line” of the pel- pension has been well described vagi- porting sutures should be placed beyond vic sidewall) is more challenging than simple nally;16 the abdominal or laparoscopic it, on the intact fasciae. Advocates of this colporrhaphy, this idea lay dormant until the approaches are also feasible. However procedure point out that it is restorative 1970s, when Richardson postulated that the approached, the technique involves iden- of the original anatomic support and vagi- majority of cystoceles are a result of this lat- tifying the intact remnants of the utero- nal axis. eral disruption.14 More recent anatomic sacral ligaments, at or above the level of studies have confirmed that lateral defects the ischial spines, which are then sutured Sacrocolpopexy are usually present in cases of anterior com- to the ipsilateral aspects of the posterior The uterosacral vault suspension partment prolapse and bladder neck and anterior fascia of the vaginal vault. procedure described relies on the pres- hypermobility.15 Needless to say, a central It should be noted that, in the case of fas- ence and identification of useful utero- repair for a lateral defect may reasonably be cial attenuation, an enterocele sac is likely sacral remnants; it also depends on vagi- expected to yield suboptimal success rates. to be found between these intact ante- nal sutures at the vault apex for long-term rior and posterior fasciae. The vaginal success. In addition, for the reasons out- Technique: approach can be made difficult by the lined above, the vaginal apex, in the pres- The laparoscopic paravaginal repair, challenge of identifying the proximal liga- ence of an enterocele, may represent the as with the Burch procedure, starts with ment remnants. In addition, the suture, most attenuated segment of the entire retrograde filling of the bladder, if permanent (as many advise), must be vagina. Vaginal techniques of vault sus- supravesical peritoneal incision, and dissec- tied extraluminally, which can be diffi- pension, including the vaginal version of tion of the retropubic space. As the goal is cult; alternatively, an absorbable suture the uterosacral vault suspension, as well the reattachment along the full length of can be tied within the vaginal lumen. The as the sacrospinous ligament fixation, may arcus tendineus along the pelvic sidewall, possibility of ureteral compromise, re- be susceptible to the same vulnerability. the dissection must be carried out more lat- ported to be as high as 11% with the For these reasons, many surgeons prefer erally than is required for the Burch. For vaginal approach,17 necessitates the use the sacrocolpopexy using permanent this reason, the peritoneal incision is usu- of intraoperative cystoscopy. The visual- materials. Although not anatomic in the ally taken beyond the medial umbilical ization of the ureters throughout their strictest sense, it has been shown to yield folds; care must be taken to avoid injury to pelvic course that laparoscopy can pro- a vaginal axis that is closer to normal than the inferior epigastric vessels. Similarly, vide may be an additional benefit. that found after vaginal sacrospinous liga- identification and protection of the obturator neurovascular bundles is crucial. Technique: After the paravesical fascia is cleared Laparoscopic uterosacral with gentle dissection, a series of perma- vault suspension can be per- nent sutures is used to reattach the fascia formed at the time of hysterec- to the obturator internus muscle on each tomy, or remotely from hyster- side. The appearance of the arcus ectomy, in the case of vaginal tendineus along the sidewall may be vari- vault prolapse. After the ure- able; one study showed that the conden- ters and the rectum are identi- sation of fibers known as the “white line” fied, the uterosacral ligaments are often avulsed and thus attached to are identified at the level of the the paravaginal fascia, rather than intact ischial spines. Permanent su- along the pelvic sidewall..15 Thus the sur- ture is then brought through geon may not always have the clear vi- the ligaments at this level; tensi- sual cue along the sidewall. Whether or ometry studies have demon- not the arcus is readily visible, its original strated that laparoscopically- location between the ischial spine and the placed sutures in the uterosac- Figure 3. Uterosacral Ligament Suspension. 13 VOLUME 92 NO. 1 JANUARY 2009 ment fixation.19 It also permits the place- a series of permanent sutures. (Figure 4) future pregnancy and delivery may have ment of multiple suture points along the Care should be taken to avoid the middle deleterious effects on the repair, cervical sur- anterior and posterior vaginal walls, dis- sacral vessels, and tools to control for pre- veillance remains necessary, and hysterec- tributing tension over a wider area and sacral bleeding should always be avail- tomy may be needed in the future. This op- decreasing the likelihood of suture pull- able. The proximal ends of the graft are tion continues to be valued by some women out. In its abdominal version, it has been then affixed to the sacrum, with care and some practitioners. Both the uterosac- demonstrated to have a remarkably low taken to avoid tension. After excess graft ral ligament suspension, and the recurrence rate over the long term.20 is trimmed, the peritoneum is closed over sacrocolpopexy using mesh, can be per- the graft to reduce the likelihood of bowel formed for the treatment of uterine prolapse Technique: incarceration or adhesion. among women who desire uterine conser- A peritoneal incision over the sacral Although long-term or prospective vation; the techniques are very similar to promontory is made and the underlying data regarding the effectiveness of the those described for vault prolapse above. anterior longitudinal ligament of the laparoscopic approach is limited, several sacrum is visualized. Laparoscopically, reports support the benefits of minimally Robotics in Pelvic the pneumoperitoneum facilitates dissec- invasive techniques in the execution of Reconstructive Surgery tion of the retroperitoneal areolar tissue, this form of vaginal support. As has been The da Vinci robotic surgical platform and the microscopic visualization allows demonstrated in many other arenas, (Intuitive Surgical, Inc., Sunnyvale, CA) easier identification of the sacral vessels laparoscopic sacrocolpopexy in the hands represents a significant technical advance- which, if injured, retract into the sacrum of trained surgeons yields similar efficacy ment in the instrumentation for and results in catastrophic bleeding. It while enhancing hemostasis and reduc- laparoscopic surgery. Sitting at a console, should be noted, however, that the left ing postoperative pain and hospitaliza- the surgeon uses controls to operate a set of common iliac vein, which lies just below tion.21 22 23 Here, as before, the prin- robotic arms fitted with specialized instru- and inferior to its arterial counterpart, can ciple that laparoscopy is a means of ac- ments. The main advantages include mo- be compressed by the pneumoperito- cess, and that the steps of the procedures tion scaling (converting large movements neum, and therefore inadvertently in- should be identical to that of the open of the surgeon to very fine movements of jured. For this reason, the dissection over technique, are of utmost importance. the instruments), instruments with an ad- the sacral promontory should be kept ditional degree of motion (known as an slightly to the right of the midline. This OTHER RECONSTRUCTIVE endo-wrist), and the enhancement of dex- incision is carried down into the pelvis, PROCEDURES terity and psychomotor performance remaining slightly to the right of midline Rectocele (through tremor-stabilizing algorithms). (to avoid mesenteric vasculature) but well Variations on the above procedures The da Vinci system also uses binocular, 3- medial to the right ureter. This incision have been performed and described for dimensional video, enhancing depth per- allows for the retroperitonealization of the treatment of similar conditions. ception. The performance of these sys- the mesh after the suspension. Laparoscopic rectocele repair has been de- tems in the training of residents is in the After the vaginal vault is prepared scribed, in a procedure which involves the early stages. One study demonstrated a by dissecting peritoneum off of the ante- extended dissection of the rectovaginal sep- steeper (that is, more rapid) learning curve, rior and posterior aspects (and the devel- tum all the way to the perineal body, and among both experienced and inexperi- opment of the vesicovaginal and either plicating the levator musculature,24 enced surgeons, in the performance of drills rectovaginal spaces, respectively), a Y- or suturing mesh material in place.25 In using a robotic system.29 Another study shaped graft is affixed to both sides of the principle, this approach to mesh-based demonstrated that laparoscopic drills were vaginal vault. At that point, the main arm repair of the posterior wall may enhance completed more quickly with the robotic of the Y is affixed directly to the anterior outcomes by eliminating vaginal incisions, system compared to traditional laparoscopy, longitudinal ligament of the sacrum, with which are thought to be contributory in and that novice surgeons on the robot per- the development of problem- formed as quickly, and in some cases more atic mesh erosion. quickly, than expert surgeons with traditional laparoscopy.30 The continued re- Uterine Preservation finement of these systems may redress some In addition, several studies of the deficiencies in laparoscopic training have called into question the by improving skill acquisition. The robotic practice of routine extirpation platform will likely increase the number of of prolapsed uteri.26 ,27 Patients surgeons with minimally-invasive skills to interested in uterine preserva- treat pelvic floor defects. tion value the availability of this Most of the literature regarding the choice, and the elimination of usefulness of the robotic platform addresses the hysterectomy decreases its use in Urology, where its application to blood loss, hospitalization, and minimally invasive radical prostatectomy has other complications28 . Clearly, generated significant interest. In terms of Figure 4. Abdominal Sacrocolpopexy patients must understand that Gynecologic Oncology, the introduction of 14 MEDICINE & HEALTH/RHODE ISLAND robotics resulted in significantly lower blood Apogee/Perigee™ (American Medical 9. Liu CY, Paek W. J Am Assoc Gynecol Laparosc loss and postoperative hospitalization, while Systems, Minnetonka, MN), and the 1993;1:31-5. 31 10. Zivkovic F, Tamussino K. Int Urogynecol J 2001 lymph node yield remained similar. Early Avaulta™ ( Bard, Covington, GA) and 12:199-202. literature supporting the use of robotics in Prolift™ ( Ethicon, Cinncinatti, OH) are 11. Paraiso MF, Walters MD, et al. Obstet Gynecol pelvic reconstructive surgery shows prom- such systems. These devices, although 2004; 104: 1249-58. ising results in applications such as with some differences, share the funda- 12. Brubaker L, Cundiff GW, et al. NEJM 2006; 354: 1557-66 32 sacrocolpopexy mental principles of self-retaining, ten- 13. White GR.. Am J Obstet Dis Woman Child sion-free mesh, introduced vaginally and 56:286-290, 1912 TROCAR-BASED MESH REPAIRS affixed to a variety of pelvic anatomic 14. Richardson AC, Lyon JB, Williams NL. Am J The trocar - basedTension-free Vagi- Obstet Gynecol 1976;126:568 landmarks, to support the appropriate 15. Delancey JO. Am J Obstet Gynecol 2002;187:93- nal Tape suburethral sling procedure her- compartments of the vagina. These tech- 8. alded the arrival of a new paradigm of re- niques are discussed in greater detail else- 16. Shull BL, Bachofen C, et al. Am J Obstet Gynecol constructive surgery, and the principles where in this issue. 2000;183:1365-73. 17. Barber MD, Visco AG, et al. Am J Obstet Gynecol underlying its effectiveness continue to be 2000;183:1402-10. applied to new pelvic reconstructive tech- DISCUSSION 18. Culligan PJ, Miklos JR, et al.. Obstet Gynecol niques. There are three important ways in At its best, laparoscopic pelvic floor de- 2003;101:500-3. which the TVT ® ( Gynecare Ethicon, fect repair represents an alternative ap- 19. Sze EH, Meranus J, et al.. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:375-9. Sommerville, NJ) differs from the slings that proach to performing established proce- 20. Lefranc JP, Atallah D, et al. J Am Coll Surg preceded it: midurethal placement (rather dures; laparoscopy can offer benefits to the 2002;195:352-8. than at the bladder neck), trocar-based surgeon (improved visualization, access for 21. Hsiao KC, Latchamsetty K, et al. J Endourol 2007; delivery, performed blindly and with mini- multiple procedures) and patient (de- 21: 926-30. 22. Agarwala N, Hasiak N, Shade M. J Minim Inva- mal dissection, and self-retaining mesh that creased pain, scar formation, recuperation, sive Gynecol 2007; 14: 577-83 required no anchoring or fixation. A vari- and improved cosmesis). Many practitio- 23. Elliott DS, Krambeck AE, Chow GK. J Urol ety of tensioning techniques exist, with the ners prefer the term “minimal access sur- 2006; 176: 655-9 key provision that, at rest, the tape should gery” to the more prevalent “minimally-in- 24. Ross JW. J Am Assoc Gynecol Laparosc 1997;4:173- 83. exert no tension on the underside of the vasive surgery,” as, ideally, only the route of 25. Lyons TL, Winer WK. J Am Assoc Gynecol Laparosc urethra. The blind passage of trocars access, not the procedure itself, is changed. 1997;4:381-4. through the retropubic space requires ad- At its worst, laparoscopy invites surgeons to 26. Hefni M, El-Toukhy T, et al. Am J Obstet Gynecol vanced anatomic understanding and con- 2003;188:645-50. take these established procedures and to 27. Barranger E, Fritel X, Pigne A. Am J Obstet Gynecol fidence on the part of the surgeon, and is modify them, to eliminate steps and cut 2003;189:1245-50. beset with a certain incidence of bladder corners, to the point where it bears only a 28. Diwan A, Rardin CR, et al. Int Urogynecol J Pelvic perforation and, much less commonly, tenuous relationship to the original. As Floor Dysfunct. 2006; 17: 79-83. 29. Prasad SM, Maniar HS, et al. Am J Surg bowel and vascular injury. such, some experts have challenged 2002;183:702-7. Taking several principles of the TVT, laparoscopists that their patients should be 30. Sarle R, Tewari A, et al. J Endourol 2004;18:63-6. de Leval introduced the transobturator sling consented for “experimental” surgery.34 31. Veljovich DS; Paley PJ; et al. Am J Obstet Gynecol in 2003. It is similar to the TVT in its tro- Similarly, dialogue and debate about the 2008; 198: 679.e1-9 32. Daneshgari F, Kefer JC, et al. BJU Int 2007; 100: car-based, midurethral placement, and self- merits and concerns of trocar-based mesh 875-9. retaining mesh materials. However, this prolapsed repair kits continue. While Gy- 33. Sung VW, Schleinitz MD, et al. Am J Obstet technique passes the trocar through the necology will benefit from further investi- Gynecol, 2007; 197:3-11. obturator membrane avoiding entry into gations of outcomes of minimally invasive 34. Weber AM. Clin Obstet Gynecol 2003;46:44-60. the true pelvis. This lateral approach seeks pelvic reconstruction, there is evidence al- Charles R. Rardin, MD, is Assistant to reduce the likelihood of injury to pelvic ready that these techniques are feasible and Professor, Obstetrics and Gynecology, The organs or vasculature. Indeed, a meta- offer options in the treatment of patients Warren Alpert Medical School of Brown analysis of randomized trials between the with pelvic floor disorders. University. techniques found similar success rates, with an apparent reduction in complications REFERENCES Disclosure of Financial Interests with the obturator approach.33 The suc- 1. Brumsted J, Kessler C, et al.. Obstet Gynecol The author has no financial inter- cess of the obturator approach in cases of 1988;71:889-92. 2. Azziz R, Steinkampf MP, Murphy A. Fertil Steril ests to disclose. intrinsic sphincter deficiency has yet to be 1989;51:1061-1064 fully described, but several authors have 3. Filmar S, Gomel V, McComb PF. Fertil Steril CORRESPONDENCE reported lower success rates of this tech- 1987;48:486-489. 4. Myers DL, Peipert JF, et al. J Reprod Med Charles R. Rardin, MD nique among these patients. 2000;45:939-43. Women and Infants Hospital of RI Finally, the concept of self-retaining 5. Leach GE, Dmochowski RR, et al. J Urol 1997; 695 Eddy Street mesh prostheses implanted with trocars 158: 875-80. Providence, Rhode Island 02903 performed for incontinence was brought 6. Tanagho EA, J Urol. 1976;116:751. 7. Vancaillie TG, Schuessler W. J Laparoendosc Surg Phone : (401) 453-7560 to repair of prolapse. The introduction 1991;1:169-73. e-mail:[email protected] of trocar-based mesh kits- the intravagi- 8. Albala DM, Schuessler WW, Vancaillie TG. Semin nal slingplasty (IVS ™ Tyco Corp.), the Urol 1992;10:222-26 15 VOLUME 92 NO. 1 JANUARY 2009 Urinary Incontinence Vivian W. Sung, MD, MPH Urinary incontinence (UI) affects over alone may be significant enough to cause toms reported UI 5 years later.19 Pelvic floor 13 million people in the United States.1, UI or increase the risk of developing UI injury following childbirth is not always as- 2 Most women suffer in silence and do when other inciting or promoting factors sociated with UI, UI usually does not occur not seek help. Affected women may feel are present. Inciting factors may cause UI immediately after vaginal delivery, and too embarrassed to discuss this issue with due to injury to the continence mecha- women who have not experienced childbirth their healthcare provider or may be un- nism. Promoting factors contribute to the or have delivered by cesarean delivery may informed about treatment options. development of UI by continuously pro- also develop UI—these facts all strongly longed deterioration of the continence point to additional causes. EPIDEMIOLOGY AND IMPACT OF mechanism. These increase a woman’s risk UI can also be caused by several tran- URINARY INCONTINENCE of experiencing UI. Decompensating fac- sient or reversible conditions. A useful Prevalence estimates of UI in women tors are not sufficient to cause incontinence mnemonic is “DIAPPERS”20 : 1) Delirium range from 11%-72%.3-5 Potential expla- but may “tip” a woman with other risk fac- or acute confusion; 2) Infection (symptom- nations for these variations include varying tors towards experiencing UI. These fac- atic urinary tract infection); 3) Atrophic definitions of UI (i.e. frequency of UI epi- tors may be temporary or permanent. The urethritis; 4) Pharmaceutical agents; 5) Psy- sodes, degree of bother, symptom severity), most well studied ones include age, obe- chological disorder (depression, behavioral differing study methods to determine UI sity and parity. (Table 1) disturbance); 6) Excess urine output (ex- (i.e. random survey, self-reporting, personal Vaginal delivery is generally considered cess fluid intake, diuretics); 7) Restricted interview, clinical exam), the dynamic na- a major cause for the development of UI. mobility; and 8) Stool impaction. Identi- ture of incontinence symptoms, and the However, the exact relationship between UI fying a woman’s modifiable factors may be study population.6 In addition, because and vaginal delivery is not well understood the greatest opportunity for preventing UI. many women feel embarrassed, it is likely and studies in the literature are inconsistent.8, that UI is overall underreported. A recent 17 Borello- France et al reported that in primi- EVALUATION OF URINARY literature review estimated that 1 out of parous women, cesarean delivery before la- INCONTINENCE every 4 women have UI.7 bor was not entirely protective against pelvic The goals of an evaluation for a woman The prevalence increases with age, floor disorders, including UI.18 Further- presenting with UI are to 1) provide a clini- ranging from 20-30% in young adult more, in one study, half of women who re- cal diagnosis of type of UI; 2) determine fac- women, 30-40% in middle-aged women, ported UI had no symptoms at 1 year post- tors that may contribute to symptoms or that and 40-50% in older women.8 It is up to partum, but 19% of women without symp- may require further evaluation; 3) assess for 6 times higher in younger women compared to men; older women are twice as likely to experience UI compared to older men.1, 8 Despite these differences, women are less likely to seek help compared to men.2 It is estimated that only 25% of women will seek care.9 UI leads to embarrassment, humili- ation, a loss of self-esteem, social isolation and depression.10, 11 Direct costs are estimated to be over $16 billion (1995 dollars) per year in the US12, 13 and over $26 billion if other costs of care are included, such as protective garments and treatment of related complications.14 It is estimated that women with UI pay $750-$900 annually in out- of-pocket for supplies, laundry and dry cleaning. 15, 16

RISK FACTORS FOR URINARY INCONTINENCE The cause of UI is likely comprised of a variety of risk factors including predisposing, inciting, promoting and decompensating factors. Predisposing factors 16 MEDICINE & HEALTH/RHODE ISLAND coexisting pelvic floor disorders such as pel- confirm a diagnosis of stress incontinence. lower urinary tract. Often, urodynamic vic organ prolapse or fecal incontinence; 4) To rule out urinary retention, a post-void studies incorporate a variety of measures establish baseline severity to aid in counsel- residual can be assessed using either di- that assess the functional parameters of the ing, recommendations, and treatment ef- rect catheterization or by ultrasonography. bladder, including bladder pressure, capac- fects; and 5) determine the impact of UI on This should be performed within 10 min- ity, sensation during bladder filling and quality of life.21 The initial evaluation should utes of voiding to prevent a false positive emptying. They can be helpful in distin- include a history and general assessment, a finding. Although based on limited evi- guishing between different types of UI. symptom assessment, a physical examination dence, the consensus is that a postvoid re- Briefly, complex urodynamic testing and baseline tests. sidual volume less than 50 mL is consid- begins with asking the patient to void in a ered normal and a volume greater than specialized commode that plots the volume HISTORY 100-200 mL is considered abnormal. of urine passed over time. This provides Incontinence symptoms: The nature information on flow time, peak flow rate and duration of UI should be detailed, in- BASELINE TESTS and time to peak flow increase with the cluding leakage, frequency, severity and vol- A clean catch urinalysis is recom- volume voided. Next, the bladder is filled ume of urine loss, activity at the time of urine mended to exclude urinary tract infections. to capacity, usually with fluid at room tem- loss, sensations of urge, and how bothersome A negative dipstick urinalysis has a specific- perature, and the bladder and urethral these symptoms are to the patient. A woman ity of 97%-99%. In women where there is pressures are recorded during this filling who leaks large volumes daily may have a a clinical suspicion, urine should be sent for phase. During the filling phase, the detru- greater problem that requires a more com- culture and sensitivity. It is suggested that sor should not contract, and the pressure plete evaluation compared to a woman who for women with a long-standing history of within the bladder should stay relatively low leaks only rarely when she is doing high im- UI who have a positive dipstick urinalysis, in a normally compliant bladder. If a de- pact sports. Women are also asked about a urine culture should also be sent before trusor contraction is noted during the fill- other pelvic floor symptoms including sen- assuming that their UI is solely due to a uri- ing phase, this is highly suggestive of detru- sation of vaginal bulging or pressure, noc- nary tract infection. sor overactivity, which causes urge urinary turia, hematuria, recurrent urinary tract in- A voiding diary can provide further incontinence (See next section). At various fections, voiding problems, anal inconti- information that can aid in the diagnosis times during the filling phase, the patient nence, and defecatory dysfunction. of UI. Patients record information about is asked to cough to evaluate for stress in- Medical history: including prior voiding or UI episode time, volume, fre- continence. A large capacity bladder with treatments for UI and pelvic floor disor- quency, fluid intake, and activity at the decreased sensation would indicate a hy- ders, medical problems, medications, and time of any UI episode. Three-day dia- potonic bladder. Tests of urethral function mobility issues that may exacerbate UI as ries are as predictive as 7-day diaries in are also performed to evaluate urethral pres- well as acute and reversible causes of UI. detecting abnormal voiding patterns. The sures during filling and emptying phases. Patient functioning: including voiding diary can be particularly helpful Finally, testing usually concludes with the sexual and bowel function. for patients who have difficulty describ- patient voiding while the bladder, abdomi- Patient goals and expectations of ing their voiding or UI patterns. nal and urethral pressures are measured. treatment should be assessed at the ini- The pad test is another test less com- There have been limited large scale tri- tial visit. This will help to guide further monly used that can help document the se- als assessing the utility of urodynamic test- evaluation. verity of UI. Patients are instructed to wear ing. Recently, a multicenter randomized perineal pads for 24 hours, changing them surgical trial for stress incontinence completed EXAMINATION when necessary. Wet pads are placed in a by The Urinary Incontinence Treatment The physical examination includes a zip-lock bag and returned to the office within Network (UITN), a National Institutes of complete evaluation of the abdomen and 72 hours to be measured. These weights Health-sponsored network, suggested that pelvis. Abdominal examination is per- are compared to the weight of a dry, control incontinence detection may be highly vari- formed to rule out any masses. Detailed pad. An increase greater than 8 grams within able depending on technique.22 Further pelvic examination is performed to assess 24 hours is considered abnormal. research is needed to evaluate if specific popu- for pelvic organ prolapse, pelvic floor muscle lations will benefit from urodynamic testing function, estrogen status, and to rule out URODYNAMIC TESTING to improve treatment outcomes. pelvic masses. External genitalia are exam- Urodynamic testing is warranted if the ined to evaluate for irritative or inflamma- diagnosis is still uncertain such as: if there TYPES OF URINARY INCONTINENCE, tory skin conditions. Rectal examination are discrepencies between the patient’s his- PATHOPHYSIOLOGY AND TREATMENTS to assess anal tone and pelvic floor function tory, voiding diary and examination, sur- The International Continence Society is performed. A neurological examination gery is considered, the patient has an el- (ICS) defines UI is defined as “the complaints includes assessment of sensory and motor evated postvoid residual, the patient has a of any involuntary leakage of urine”.23 This function of S2-4, which innervate to the neurologic condition that may complicate definition may include symptoms (subjec- pelvic organs. This also includes testing of treatment, significant pelvic organ prolapse, tive, qualitative patient report), signs (physi- lower extremity movement and strength. or multiple prior surgical attempts at cor- cian observations of urine loss), or A cough stress test to evaluate for rection. A urodynamic study is defined as urodynamic study observations. The 3 most leakage at the time of cough is helpful to any test that evaluates the function of the common types of UI are stress urinary in- 17 VOLUME 92 NO. 1 JANUARY 2009 domized 655 women to undergo either a fascial sling or Burch for SUI and reported that fascial slings were associated with higher cure rates of SUI at 24 months (66% vs 49% P<.001), but were associated with more urinary tract infections, voiding difficulty and postoperative UUI .30 The advent of minimally invasive midurethral tension free slings introduced first as the “tension-free vaginal tape” or TVT™ (Gynecare, Sommerville, NJ) in 1996 marked a major shift in the surgical treatment of SUI. It is proposed that the midurethral sling stabilizes the vagina and ure- continence (SUI), urge urinary inconti- of UI symptoms (SUI, UUI, MUI).27 To thra during times of increased intra-abdomi- nence (UUI), and mixed incontinence maximize the effectiveness of pelvic floor nal pressure, reinforcing the “vaginal ham- (MUI) a combination of SUI and UUI. muscle exercises, women should be coun- mock”. In a randomized trial comparing (Table 2) Although there are many extant seled on how to do them correctly, regularly the TVT to Burch, similar objective cure theories for incontinence, most are based on and for an adequate duration. Women may rates were reported at 2 years between the expert opinion or observational evidence need referral to a physical therapist for evalu- two procedures: 63% and 51%, respectively, which have not necessarily been proved or ation and supervised training sessions. assuming women who were lost to follow up disproved by rigorous scientific method. Vaginal devices (pessaries) and ure- as failures; or 78% and 68% respectively, thral inserts are also non-surgical options carrying the last observed result forward at STRESS URINARY INCONTINENCE for SUI. Specialized pessaries called “con- 2 years.31 The procedure includes placing 2 SUI, the most common type, is the tinence dishes” provide support for the an- needles vaginally through 2 paraurethral complaint of involuntary leakage with ef- terior vaginal wall and urethra to minimize tunnels, then into the retropubic space, and fort or exertion. It often occurs during SUI symptoms. Women need to undergo exiting the retropubic space through 2 small sneezing, laughing, lifting and walking. a pessary fitting to find the correct fit and suprapubic skin incisions. No fixation su- These activities result in an increase in in- most women (89%) can be fitted tures are required and the sling is ultimately tra-abdominal pressure, causing the blad- succesfully.28 These may be a good option held in place by fibrosis. (Figure 1) Mini- der pressure to exceed the maximum ure- for women who want to avoid surgery, need mal dissection is required, and the procedure thral pressure ultimately resulting in the to defer surgery, or complete childbearing. can be done under local anesthesia as an loss of urine. This occurs in the absence Medications for SUI include alpha- outpatient with minimal patient morbidity of a detrusor contraction. agonists, which increase urethral tone have and recovery time. Other approaches to the There are multiple theories for how been shown to have a modest effect in small mid-urethral sling have been developed, but SUI may develop. Two more recent trials.29 Serotonin and norepinephrine there is limited randomized trial data com- complementary theories include the “inte- reuptake inhibitors are being investigated paring various approaches. These include gral theory”24 and the “hammock theory”.25 for their role for SUI. The “integral theory”24 describes 3 oppos- When behavioral and pharma- ing vaginal muscle forces stretching the vagi- cologic interventions do not improve nal membrane and endopelvic fascia, which symptoms, surgery may be offered. helps to secure urethral closure during in- The decision to undergo surgery creased intra-abdominal pressure. The should be a shared decision between “hammock theory”25 theorizes that the an- the patient and her healthcare pro- terior vaginal wall provides a hammock-like vider, as only the individual patient support for the urethra that is critical to can weigh potential risks and ben- maintain urethral closure. Injury to con- efits of surgical treatment. Although nective tissue supports may cause dysfunc- many surgical procedures have been tion of the continence mechanism. described to treat SUI, few random- Any treatment for UI should start with ized trials inform treatment. We will counseling regarding non-surgical interven- review the most common proce- tions. Lifestyle interventions that may de- dures. crease SUI include weight loss in overweight The Burch colposuspension and obese women26 and decreasing caffeine and suburethral fascial sling are two intake. Well designed randomized clinical well established procedures and for trials have shown that supervised pelvic floor many years, they were considered muscle training (“Kegel exercises”) is effec- to be equally effective. A recent Figure1. Mid- urethral sling TVT ™ tive in treating or at least improving any type trial conducted by the UITN ran- (Gynecare, Ethicon Inc, Sommerville, NJ) 18 MEDICINE & HEALTH/RHODE ISLAND the transobturator approach, “needle-less as possible when a feeling of urgency occurs REFERENCES slings”, and adjustable slings. by using a variety of distraction techniques 1. Herzog AR, Fultz NH. J Am Geriatr Soc 1990;38:273-81. 2. Roberts RO, Jacobsen SJ, et al. J Am Geriatr Soc Another surgical option is injection of or quickly contracting the pelvic muscles to 1998;46:467-72. a urethral bulking agent, such as GAX inhibit voluntary bladder contraction and 3. Sampselle CM, Harlow SD, et al. Obstet Gynecol 2002;100:1230-8. ™collagen (Bard Inc., Covington, GA) at reinforce detrusor inhibition. As discussed, 4. Burgio KL, Zyczynski H, et al. Obstet Gynecol the bladder neck. Complications are rare pelvic floor muscle training has been shown 2003;102:1291-8. 5. Moller LA, Lose G, Jorgensen T. Acta Obstet Gynecol and cure rates range from 20%-30%, but to improve symptoms for all types of UI. Scand 2000;79:298-305. 50%-60% report marked improvement. Acetylcholine is the primary neu- 6. Minassian VA, Stewart WF, Wood GC. Obstet Gynecol 2008;111:324-31. Although improvement is reported to last rotransmitter involved in a detrusor con- 7. Minassian VA, Drutz HP, Al-Badr A. Int J Gynaecol Obstet from 3 months to years, most patients retraction, therefore, anti-cholinergic medi- 2003;82:327-38. 8. Bump RC, Norton PA. Obstet Gynecol Clin North Am port relief ranging from 3-12 months and cations help to reduce detrusor overactivity. 1998;25:723-46. will require more than one injection.32 There are many brands on the market. The 9. Hannestad YS, Rortveit G, Hunskaar S. Scand J Prim Health Care 2002;20:102-7. efficacy of anti-cholinergic treatment alone 10. Weber AM, Abrams P, et al. Int Urogynecol J Pelvic Floor URGE URINARY INCONTINENCE ranges from 9%-56%. Because they all Dysfunct 2001;12:178-86. 11. Melville JL, Delaney K, et al. Obstet Gynecol Micturition involves the interaction of have the same mechanism of action, effi- 2005;106:585-92. muscular, neurologic, and psychologic sys- cacy is comparable among the different 12. Thom D. J Am Geriatr Soc 1998;46:473-80. 13. Wilson L, Brown JS, et al. Obstet Gynecol tems. During bladder filling, the normal types of anti-cholinergics. Many pharma- 2001;98:398-406. detrusor relaxes to allow filling without re- ceutical companies focus on minimizing side 14. Hu TW, Wagner TH, et al. Urol 2004;63:461-5. 15. Subak LL, Brown JS, et al. Obstet Gynecol sistance. As a person becomes aware of blad- effects by increasing selectivity for the blad- 2006;107:908-16. der distention, urination is voluntarily de- der. The most common side effects include 16. Subak LL, Brubaker L, et al. Obstet Gynecol 2008;111:899-907. layed through cortical centers in the frontal dry mouth, constipation and central ner- 17. Buchsbaum GM, Chin M, et al. Obstet Gynecol lobe until one can reach the restroom. The vous system effects. 2002;100:226-9. 18. Borello-France D, Burgio KL, et al. Obstet Gynecol detrusor muscle then contracts in coordina- Surgical treatment for refractory UUI 2006;108:863-72. tion with urethral relaxation in response to includes sacral neuromodulation. In the past, 19. Viktrup L, Lose G, et al. Obstet Gynecol 1992;79:945-9. 20. Resnick NM. Hosp Pract (Off Ed) 1986;21:80C-80L, cholinergic signals from the pelvic nerves. patients with refractory UUI were limited 80Q passim. This results in bladder emptying. to radical procedures such as urinary diver- 21. Nygaard IE, Heit M. Obstet Gynecol 2004;104:607-20. 22. Visco AG, Brubaker L, et al. Int Urogynecol J Pelvic Floor sion or cystectomy. Sacral neuromodulation Dysfunct 2008;19:607-14. DISRUPTION OF THESE COMPLEX offers a less invasive alternative. The tech- 23. Abrams P, Cardozo L, et al.. Am J Obstet Gynecol 2002;187:116-26. INTERACTIONS RESULTS IN UUI. nique stimulates the sacral nerves to modu- 24. Petros PE, Woodman PJ. Int Urogynecol J Pelvic Floor Inappropriate contraction of the blad- late the neural reflexes influencing bladder Dysfunct 2008;19:35-40. 25. DeLancey JO. Am J Obstet Gynecol 1994;170:1713-20; der causes UUI, often referred to as detru- and pelvic floor function. It is being applied discussion 1720-3. sor overactivity or “overactive bladder”. This in the treatment of UUI, urinary urgency 26. Subak LL, Whitcomb E, et al. J Urol 2005;174:190-5. 27. Hay-Smith EJ, Dumoulin C. Cochrane Database Syst Rev may be caused by changes at the tissue and and frequency, and urinary retention. This 2006:CD005654. cellular levels, injury to the spinal cord, stretch implantable system is comprised of a lead 28. Donnelly MJ, Powell-Morgan S, et al. Int Urogynecol J Pelvic Floor Dysfunct 2004;15:302-7. injury to the pudendal nerve during labor, with 4 electrodes, an extension cable, and a 29. Nygaard IE, Kreder KJ. Clin Obstet Gynecol or neurologic problems. Many women may programmable impulse generator. The lead 2004;47:83-92. 30. Albo ME, Richter HE, et al. NEJM 2007;356:2143-55. experience bothersome urgency and fre- is usually implanted into the S3 sacral nerve 31. Ward KL, Hilton P. Am J Obstet Gynecol quency without actually experiencing UUI. root, and the impulse generator is placed in 2004;190:324-31. 32. Bent AE, McLennan MT. Obstet Gynecol Clin North Am The treatment includes behavioral the upper buttock region. The procedure 1998;25:883-906. therapy, bladder training, pelvic floor is usually done in 2 stages. After implanta- 33. van Kerrebroeck PE, van Voskuilen AC, et al. J Urol muscle therapy, and anti-cholinergic tion of the lead, if the patient’s symptoms 2007;178:2029-34. therapy. Behavioral techniques include improve (defined as > 50% improvement Vivian W. Sung, MD, MPH, is Assis- lifestyle changes, including fluid and dietary in one bladder parameter), the generator is tant Professor, Obstetrics and Gynecology, modification, scheduled voiding, and pel- placed approximately one week later. Both The Warren Alpert Medical School of vic floor reeducation. The overall goal is to stages are done on an outpatient basis. In Brown University. train the bladder to store larger volumes of one prospective, multi-center study, 68% of urine and control urgency by using pelvic patients with refractory UUI and 56% of Disclosure of Financial Interests muscles to inhibit detrusor activity. Fluid patients with urgency/frequency reported The author has no financial inter- management may involve restriction if in- successful outcomes at 5 years.33 ests to disclose. take is high. Patients are also asked to re- strict intake of known bladder irritants, in- CONCLUSION CORRESPONDENCE cluding caffeinated foods and beverages. UI will affect 30% of all women at some Vivian W. Sung, MD, MPH The goal of bladder training and/or point in their lives. It is associated with dis- Women and Infants Hospital of RI scheduled voiding is to increase the bladder’s tressing psychosocial stigma and substantial 695 Eddy Street capacity. Patients are asked to schedule void- medical costs to both the individual and so- Providence, Rhode Island 02903 ing if they have problems with frequency. ciety. Psychological and social effects of UI Phone: (401) 453-7560 The patient can also delay voiding for as long may prevent women from seeking attention. e-mail:vsung @wihri.org 19 VOLUME 92 NO. 1 JANUARY 2009

(Actual headlines in support of AMA’s efforts)

Senators flip Medicare vote

Congress overrides Medicare veto

With the support of the Rhode Island Medical Society (RIMS), the American Medical Association (AMA) made news with its stunning victory in Congress that secured $40 million (or $10,000 per physician) in reimbursements to Rhode Island physicians, preserved access to care for Rhode Island’s seniors, military families and people with disabilities, and set the stage for groundbreaking health care system reform in 2009.

As a member of RIMS, you already understand the importance of participating in organized medicine. The AMA is the only organization that unifies and speaks for doctors from every state and specialty. Together the AMA and RIMS work on your behalf to make medicine better for doctors and patients. Join the AMA or renew your membership today through RIMS by calling (401) 331-3207.

Interstitial Cystitis Deborah L. Myers, MD Interstitial cystitis (IC)(IC) is a chronic teria, the estimated prevalence of IC in ber density including sympathetic nerves condition of urinary urgency, frequency, the United States is approximately 1.5 in bladders of patients with IC. IC could and suprapubic pain in the absence of million to 25 to 30 million women. Prac- be a type of reflex sympathetic dystrophy bacteruria. It is part of the painful blad- titioners involved in women’s health with abnormal spinal sympathetic activ- der syndrome whose known causes are should know about this condition.2 ity.4 tuberculosis, stones, malignancy, previous The pathophysiology of IC remains The cause of the “leaky epithelium” chemotherapy of the bladder, and pelvic unknown, but two integrated theories, the still remains unknown. Work by Keay et radiation. Interstitial cystitis is a diagno- (1) “leaky epithelium” and (2) “neurogenic al has identified proteins in the urine sis of exclusion when no known cause of up-regulation” are proposed. The bladder which affect the ability of the painful bladder can be identified. It has uroepithelium has a protective mucous uroepithelium to regenerate and repair. classically been diagnosed by the presence coat layer, the glycosaminoglycan (GAG) Patients with IC have increased levels of of “Hunner’s ulcers”, a lesion noted on layer, which, when injured, becomes defi- Anti-proliferative factor (APF). APF in- cystoscopy in 1915.1 The word “ulcer” cient, or “leaky”, thus allowing potassium hibits the growth of the bladder lining. has proven to be a misnomer; the lesion and toxins in the urine to penetrate into IC patients have lower levels of other pro- is actually a coalescence of vessels. IC is a the underlying bladder and causing in- teins HB-EGF (heparin binding epider- chronic illness for which we do not have flammation and pain.3 In response to this mal growth factor-like), required for epi- a full understanding in terms of etiology bladder insult, detrusor mast cells release thelial growth.5 In summary, the dam- or management. substance P, histamines and prostaglandins aged epithelium leads to a complex cas- IC occurs predominantly in women which cause vasodilatation and pain. The cade of interactions involving urinary between 40-60 years, and in a ratio of sensory C afferent nerve fibers of the blad- cations, activated mast cells, sensory 9:1 of women to men. With newer diag- der can become “up-regulated.” (Figure nerves, detrusor muscle overactivity, and nostic techniques and less stringent cri- 1) Studies have shown increased nerve fi- spinal cord sensitization.

Figure 1. The Integrated Theories of Interstitial Cystitis.

Figure 2. Hunner’s Ulcer 22 MEDICINE & HEALTH/RHODE ISLAND IC can be associated with irritable bowel syndrome, migraines, endometriosis, vestibulitis, vulvodynia, and collagen vascular diseases such as systemic lupus erythematosis. Depression and anxiety are often seen in these women; however, this is likely secondary to the chronic pain of IC. Women with IC score poorly on quality of life questionnaires, but IC should not be considered a psychosomatic disorder.6

SYMPTOMS Patients with IC will complain of urgency, frequency (> 8 voids per day), and bladder pain. Nocturia (>2xs/night) is almost always present. Episodes of incontinence are rare. These women often complain of difficulty voiding or postvoid fullness. These patients do not tol- erate large volumes of urine in their bladder, thus often sensing fullness. Many patients have been on chronic antibiotic therapy for supposed chronic urinary tract infections. Symptoms of IC overlap with overactive bladder, i.e., urgency and frequency, and thus some patients may have received anti-cholinergic therapy without relief. Patients with IC can complain of either cyclic or constant pelvic pain. They Table 1. NIH-NIDDK Diagnostic Criteria of Interstitial Cystitis7 may also complain of vaginal burning Category A: At least one of the following findings on cystoscopy: and/ or painful intercourse. Bladder -Diffuse glomerulations (at least 10 per quadrant) in at least three quadrants symptoms are often increased with inter- -A classic Hunner’s ulcer course and near the menses. Symptoms of IC can mimic some gynecologic disor- Category B: At least one of the following symptoms: ders, particularly endometriosis. -pain associated with the bladder -urinary urgency DIAGNOSIS Exclusion criteria: Traditionally the diagnosis has been -age < 18 years made by cystoscopy with other criteria as -urinary frequency while awake <8/ per day described by the National Institute of -nocturia <2/night Diabetes and Digestive and Kidney Dis- -maximal bladder capacity >350ml while patient awake eases (NIDDK) in 1988. Table 17 Inclu- -absence of an intense urge to void with bladder filled to 150ml during sion criteria require that the patient com- cystometry plain of urgency/ frequency or pain in -involuntary bladder contractions on cystometry -duration of symptoms < 9 months the bladder, and have the presence of ei- -symptoms relieved by antimicrobial agents, anticholinergics, or ther glomerulations or Hunner’s ulcers antispasmodics (Figure 2) in the bladder at cystoscopy. -urinary tract or prostatic infection in the past 3 months The exclusion criteria have been shown -active genital herpes to be too strict for general clinical use, -vaginitis because approximately 60% of patients -uterine, cervical, vaginal, or urethral cancer within the past 5 years judged to have IC by experienced clini- -bladder or ureteral calculi -urethral diverticulum cians fail to meet the NIDDK criteria. -hx of cyclophosphamide or chemical cystitis or tuberculous or radiation Clinically, the diagnosis of IC can often cystitis be made by history, physical, screening -benign or malignant bladder tumors questionnaires, laboratory studies, and office testing.8 23 VOLUME 92 NO. 1 JANUARY 2009 UROLOG A 24-48 hour voiding diary (urolog) records the amount and type of fluid intake, the time of each void and the volume voided at each micturition. Patients with IC will usually have frequent voids (>12/ day) and small voided volumes (av- erage of 75-100cc). Nocturia will usually be present. The urolog also allows the clinician to determine if the fluids con- sumed are potential bladder irritants. (Figure 5)

ASSESS POST VOID RESIDUAL Patients with IC often complain of incomplete emptying and/ or post void fullness, therefore an assessment of postvoid residual urine volume is needed, either by bladder ultrasound or by catheterization.

TREATMENT IN THE PRIMARY CARE SETTING Treatment can be initiated based after careful assessment and exclusion of other causes. Treatment ultimately is multi- modality, but may need to be introduced one at a time, to determine which options will be long term.

SELF HELP AND PATIENT EDUCATION The chronic nature of the disease, including the possibility of relapses, should be explained to the patient. Sev- eral self-help books are available and agencies from which to get additional History taking should query for uri- urinary causes (bladder stones or malig- information on the condition.13 Both the nary tract infections, pelvic surgery, nancy, urethral diverticulum) and urinary NKUDIC (3 Information Way known causes of painful bladder syn- tract infection should be considered. In Bethesda, MD 20892–3580 Phone: 1– drome, IC symptoms and the associated lieu of findings, pelvic exam may only show 800–891–5390) and the Interstitial conditions described above. O’Leary et tenderness of the anterior vaginal wall, Cystitis Association (110 North Wash- al, in 1997, developed two validated self- bladder and urethra. Spasticity, tender- ington Street, Suite 340, Rockville, MD, administered questionnaires to monitor ness, and localized ‘trigger points’ of the 20850 301-610-5300, 1-800-helpica) symptoms.9 (Figure 3) Clemons et al in levator ani muscles of the pelvic floor may have accurate information. The Inter- 2002 found that a score of = 5 on the be elicited. Women with chronic pelvic stitial Cystitis Association (ICA) pro- symptom index was 94% sensitive in di- pain can develop levator spasm which in vides support group information, con- agnosing interstitial cystitis.10 Parsons CL turn can continue to cause symptoms of ferences and medical information. Pa- et al developed the PUF (pelvic pain and pain, urinary urgency, and frequency.12 tients can be referred to the various urgency/ frequency) questionnaire as websites; e.g., www.ichelp.org and another tool to detect IC.11 (Figure 4) LABORATORY www.ic-network.com. Stress reduction Physical and pelvic exam will most Urinalysis and urine culture are re- techniques (self-visualization, yoga, likely have few findings, but is necessary quired laboratory studies. Urine cytology baths, deep breathing, meditation) can to rule out other causes of pelvic pain and would be obtained in patients who have create a sense of well being. Develop- urgency/ frequency symptoms. Gas- risk factors for bladder cancer. An abnor- ment of coping mechanisms, problem trointestinal conditions such as irritable mal urine cytology or microscopic hema- solving, and also sex therapy with the bowel syndrome, neurological conditions turia, will require radiologic studies such help of a psychologist may also be of the sacral nerves, musculoskeletal dis- as CT nephrogram and referral for cys- needed. orders, gynecologic conditions and other toscopic evaluation. 24 MEDICINE & HEALTH/RHODE ISLAND as-needed basis for symptom flares. The URODYNAMIC TESTING Table 2. Dietary irritants to anti-cholinergic medications used to treat In general full urodynamic studies 14 avoid overactive bladder may improve urinary (cystometrogram, assessment of sphinc- frequency and urge incontinence if present. ter function, pressure flow studies, All alcoholic beverages Apples However, if used alone, the anti-cholinergics uroflowmetry) are not necessary. How- Apple juice are unlikely to be effective based upon our ever, if after initial screening post void Cantaloupes current understanding of the pathophysi- residual volumes are found to be >100cc Carbonated drinks ology of IC, since they do not affect the or if the patient complains primarily of Chili, cascade pathway. urgency and frequency, then Spicy foods urodynamic testing would be indicated. Citrus fruits (lemons, limes, SPECIALIZED DIAGNOSIS AND oranges, etc.) Coffee MANAGEMENT MANAGEMENT Cranberries If initial diagnostic maneuvers are Pharmacologic therapy Grapes not conclusive and/ or initial treatments Pentosan polysulfate Guava have not proven to be effective, then fur- Pentosan polysulfate (Elmiron®, Lemon juice ther testing or referral to indicated spe- Ortho-McNeil, Raritan, NJ) is the only Peaches cialists: urogynecology, urology, physical FDA-approved oral medication for the Pineapple therapy, psychology, psychiatry or pain treatment of IC. Its chemical structure is Plums Strawberries clinics for further diagnostic steps and/ similar to the GAG layer and it works to Tea or treatment is indicated. The primary rebuild “leaky epithelium”. Elmiron has Tomatoes care physician should have a working 1/15th of heparin’s anticoagulant effects Vinegar knowledge of the methods used to man- and should be used with caution in women age more advanced cases of IC. with a bleeding diasthesis. Possible side Dietary recommendations effects include gastrointestinal distress, Avoidance of (1) carbonated, citrus POTASSIUM TESTING headache and reversible hair loss. Only 60 and caffeinated beverages, (2) foods high In 1996, Parsons introduced the % of patients will experience relief of symp- in potassium content such as citrus fruits potassium sensitivity test as an office test toms and relief may not be seen until 4- 6 and tomatoes or (3) foods with a high that can detect IC.15 The KCL test involves months of use.17 Therefore, continued use, acid content, and (4) spicy foods and instilling two different solutions in to the despite no change of symptoms at 3 foods rich in tyrosine and tryptophan can bladder (sterile H2O vs. a KCl solution) months, is recommended. Other treat- help relieve symptoms in some patients.14 and comparing symptoms. Instilling a ment options may be needed during this (Table 2) Increasing water intake is an- solution of potassium chloride into the waiting period as described. other important dietary recommenda- bladder of a patient with IC with a “leaky tion. Patients with IC tend to decrease epithelium” should cause symptoms of Tricyclic Anti-depressants their fluid intake to limit the frequency urinary urgency, frequency and pain, but Tricyclic anti-depressants such as of voids; however this concentrates the not into the bladder of a normal patient. amitriptyline and nortriptyline are fre- urine, leading to increased irritation. Although the potassium test may only quently prescribed “off- label” for IC. Tri- detect 66% of women with IC, it is still a cyclic anti-depressants (1) reduce blad- Over the counter (OTC) useful simple office diagnostic test.16 der urgency by their anticholinergic prop- Supplements and alternatives erties, (2) raise the pain threshold, (3) im- Glucosamine/ chondroitin sulfate CYTOSCOPY prove sleep by sedation, and (4) elevate taken 1000mg daily and the amino acid Cystoscopy with hydrodistension, mood. Tricyclics can give prompt relief of supplement L-arginine taken 500 mg PO the traditional method in the diagnosis symptoms in most patients. They should TID for 6 months can provide relief of of IC, is done under either general or be used with caution in the elderly be- symptoms. Other alternatives Algonot regional anesthesia. During cystoscopy cause they can cause confusion and elec-

Plus® and CystoProtek ®,(Alaven Phar- the bladder is filled to 70- 80 cm H20 trocardiogram changes. Van Ophoven et maceutical, Marietta GA) and Cysta-Q™ pressure and held at this capacity for 2-5 al, recently demonstrated in a prospective (Farr Laboratories, Westwood, CA) are minutes. Cystoscopic findings of IC are randomized placebo controlled double found at various websites on the Internet. glomerulations and Hunner’s “ulcers” are blind study that amitriptyline can improve Calcium glycerophosphate (Prelief ®) sought. (Figure 2). Suspicious areas for symptoms in IC patients.18 from AKPharma Inc., Pleasantville, NJ, a carcinoma are biopsied. Traditionally, tasteless deacidifier, taken before meals can biopsies were routinely taken to look for Central Nervous System Drugs reduce food acidity. a high number of mast cells in the blad- Medications for neuropathic pain der muscularis. However, as more re- are used off label to manage the pain com- ANALGESICS AND ANTI-SPASMODICS search has been done, no characteristic ponent of IC. Gabapentin, pregabalin, Phenazopyridine (Pyridium® Warner pathologic change has been described for carbamazepine and duloxetine are used. Chilcott, Rockaway, NJ) is a bladder anal- the tissue diagnosis of IC. Prescribing neuroleptics is done as for gesic that can relieve symptoms and on an other pain conditions with escalating 25 VOLUME 92 NO. 1 JANUARY 2009 doses until desired effect or until side ef- was FDA-approved for treatment of IC ized diagnostics and therapies. The pri- fects become intolerable. Black box warn- in 1978. Heparin, hyaluronic acid (avail- mary care provider should stay involved ings should remain mindful. able only in Canada), BCG (Bacillus in the management of these patients as Calmette Guerin), Elmiron, anesthetic part of a multi-disciplinary team to pro- Anti-histamines agents, and “cocktails” of combinations vide the best overall care for the patient. Hydroxyzine is used off- label in the of xylocaine, corticosteroid, heparin, an- management of IC. Possible mechanisms tibiotics, and sodium bicarbonate have REFERENCES of action include stabilization of mast cells, all been used. Frequency of installations 1. Hunner GL. Boston Med Soc J 1915;172:660. anti-cholinergic properties, and a sedative will vary. 2. Parsons CL, Dell J, et al. Urol 2002;60:573-8. 3. Parsons CL, Greenberger M, et al. J Urol effect. Theoharides and Sant in a 1997 1998;159:1862-7. clinical trial demonstrated that hydrox- Surgical treatments 4. Hohenfellner M, Nunes L, et al. J Urol yzine provided an overall 40% reduction Cystoscopy with hydrodistention 1992;147:587-91. of symptoms; in patients with a history of causes epithelial damage by mechanical 5. Keay SK, Zhang CO, et al. Urol 2001;57(6 Suppl 1):9-14. allergies, they found a 55% reduction of trauma with regeneration of new epithe- 6. Rothrock NE, Lutgendorf SK, et al. J Urol symptoms.19 Hydroxyzine has a sedating lium and improvement of symptoms. 2002;167:1763-7. effect, thus it can also improve sleep. The Sympathetic fiber density has been found 7. Gillenwater JY, Wein AJ. J Urol 1988;140: 203-6. allergy/ asthma medication montelukast a to be decreased after bladder distension, 8. Hanno PM, Landis JR, et al. J Urol 1999;161:553-7. 9. O’Leary MP, Sant GR, et al. Urol 1997;49:58-63. leukotriene inhibitor, may prove to be ef- thus explaining the relief of symptoms 10. Clemons JL, Arya LA, Myers DL. Obstet Gynecol fective as leukotrienes are released from after the procedure.4 Remission generally 2002;100:337-41. mast cells and thought to play a role in lasts for 6 months, with a gradual recur- 11. Parsons CL, Dell J, et al. Urol 2002;60:573-8. 12. Sinaki M, Merritt JL, Stillwell GK. Mayo Clin inflammation rence of symptoms in most patients. More Proc 1977;52:717-22. radical surgical procedures such as 13. Moldwin R. The Interstitial Cystitis Survival Physical therapy and bladder enterocystoplasty, cystolysis, urinary diver- Guide. Oakland, CA: New Harbinger Publica- retraining sion alone, and urinary diversion into a tions, Inc., 2002. 14. Gillespie L. You don’t have to live with cystitis! Referral to a physical therapist who continent pouch combined with cystec- New York, Avon Books, 1986: 244. specializes in treatment of pelvic floor tomy, have been used to treat intractable 15. Parsons CL. Tech Urol.1996;2:171-3. dysfunction can help patients re-educate cases of IC. However, these radical end 16. Chambers GK, Fenster HN, et al. J Urol the levator ani muscles. Women with IC stage procedures have not shown to be 1999;162(3 Pt 1):699-701. 17. Hanno PM. Urol 1997;49:93-9. often have levator ani muscle spasm. beneficial: patients continue to suffer 18. van Ophoven A, Pokupic S, et al. J Urol Bladder retraining can be introduced if from sensory urgency/ pain.20 2004;172:533-6. symptoms are mild or after symptoms are 19. Theoharides TC, Sant GR. Urol 1997;49(5A controlled. Monthly provider visits assist Sacral neuromodulation Suppl):108-10. 20. Nielsen KK, Kromann-Andersen B, et al. J Urol with maintaining compliance, providing Sacral neuromodulation (Interstim® 1990;144:255-8. motivation, and monitoring progress. Medtronic Corp., Minneapolis, MN) is 21. Comiter CV. J Urol 2003;169:1369-73. FDA-approved for patients with urge in- Intravesical therapy continence, urinary retention and urinary Deborah L. Myers, MD, is Associate Intravesical therapy may be needed urgency/ frequency, but not yet for IC. It Professor, Obstetrics and Gynecology, The if initial oral medications cannot control offers a less radical and reversible option Warren Alpert Medical School of Brown symptoms or if patients on oral therapy than an extirpative procedure and should University. have a flare in symptoms. Intravesical be considered before an end stage proce- treatments are done by instilling medi- dure. There are preliminary reports of its Disclosure of Financial Interests cations into the bladder through a cath- use in patients with IC, but the long term The author has no financial inter- eter. Dimethylsulfoxidole (Rimso-50 ® success of the sacral stimulation and its ests to disclose. Bioniche Pharma USA, Lake Forest,IL) management of pain in these patients is still preliminary.21 Of-Label Usage of Medications All medications for IC except Primary Care Provider’s Role DMSO and Elniunrion are off-label. The primary care provider can diagnose IC and initiate several treatment CORRESPONDENCE protocols. Simple treatments can be in- Deborah L. Myers, MD stituted based on symptoms, physical ex- Women and Infants Hospital of RI amination, and screening labs. If suffi- 695 Eddy Street cient relief is not obtained, the provider Providence, Rhode Island 02903 can initiate further testing or refer to the Phone: (401) 453-7560 appropriate specialist for more special- e-mail: dmyers @wihri.org

26 MEDICINE & HEALTH/RHODE ISLAND ADVANCES IN PHARMACOLOGY

Effect of Zoledronic Acid on Bone Pain Secondary To Metastatic Bone Disease Porpon Rotjanapan, MD You are in your office. Mr.X, a 64 year-old patient well known BISPHOSPHONATES to you for over 10 years, comes for persistent severe bone pain Metastatic bone disease is associated with a marked increase despite palliative radiotherapy and recent opioid treatment. in bone resorption and formation rates, which can be evalu- Six years ago, he was diagnosed with stage IV prostate cancer ated by the measurement of biochemical markers of bone me- with metastasis in the right pubic bone. He was treated with tabolism in the serum or urine. surgery and pelvic irradiation including the right pubis. One Bisphosphonates inhibit osteoclastic bone resorption and year prior to presentation he had an orchiectomy with prompt control bone metabolism via several mechanisms that differ from relief of pain and a decrease in his prostate specific antigen those of other antiresorptive agents. They contain 2 phosphate (PSA). He is taking morphine and dexamethasone was added groups linked to 1 carbon atom, forming a stable structure (phos- recently with minimal effect. The pain has affected his sleep, phorus-carbon-phosphorus) resistant to the action of osteoclas- appetite, and ability to enjoy life. He does not like the opiates’ tic hydrolytic enzymes. This backbone and the presence of R1 effect on his ability to make high level decisions. and R2 chains allow bisphosphonates to bind calcium phos- The patient comes into the office noting that he just saw a phate and inhibit bone resorption by osteoclasts.14 commercial about a new medication, zoledronic acid, for treat- Bisphosphonates inhibit osteoclast maturation and func- ment of cancer bone pain. He wants to know if this can help him. tion and ultimately cause osteoclast apoptosis. Initially bisphosphonates were developed to treat predominately os- What are the current treatment options for teolytic bone metastases. However histomorphometric and bio- metastatic bone disease? chemical evidence show that osteoblastic lesions also lead to increased osteolysis and bone turnover and that bone resorp- Bone metastases are frequent in patients with advanced cancer. The most common cancer which metastasize to bone tion markers are significantly raised in patients with advanced prostate cancer.14 are breast, lung, prostate, multiple myeloma, and renal. Skull, spinal column, rib cage, pelvis and femur are the most fre- There are 3 different classes of bisphosphonates; the first is characterized by the absence of nitrogen atoms; the second quent sites of bone metastases. Pain from cancer is a major problem. Thirty percent of contains only 1 nitrogen atom, and the third has 2 nitrogen atoms.20 Zoledronic acid (ZA) is one of the most active nitro- patients with cancer have pain at the time of diagnosis; 65 to 85% have pain when their disease is advanced. The impact of gen-containing bisphosphonates, the third generation intrave- nous bisphosphonate that is at least 100 fold more potent than cancer pain is magnified by its interaction with other common 7 cancer symptoms: fatigue, weakness, dyspnea, nausea, consti- pamidronate. It inhibits the enzyme farnesyl diphosphonate synthase and has been approved for treatment of bone me- pation, and impaired cognition.18 With an integrated program of systemic, pharmacologic, and anticancer therapy, cancer pain tastases. Recent studies suggest that ZA also has direct antitu- mor activity.16 can be effectively treated in 85-95% of patients. Many of the We reviewed the literature, using Pubmed (January 1966- remaining patients can be helped by the use of invasive proce- 2007) and the keywords zoledronic and pain. The initial search dures. In the final days of life, pain not controlled by therapies yielded 162 articles. After selecting those clinical studies pub- aimed at both comfort and function can be relieved by inten- lished in English, 25 articles met our review criteria. Thirteen tional sedation. No patient with cancer needs to live or die with articles were applicable to the current case. The majority of unrelieved pain. Pain caused by bone metastases lowers the studies were conducted in the United States and Italy (n= 7 quality of life and performance status of patients, and causes and 5 respectively). Others were from Canada, UK, and one disability occurring at rest or typically during movement.14 study from South Korea. The time frame ranged from 2000- Treatment of bone metastases is aimed at reducing the risk 2007. Study populations were Caucasians, and the minority of of pathological fractures and other skeletal related events study populations were black and Asians. Mean age ranged (SREs), as well as reducing pain to maximize patients’ quality from 57-72 years old. Proportion of male to female was close to of life. The options include surgery, radiation therapy, 1: 1 overall. radiometabolic therapy, chemotherapy, hormone therapy, and Table 1 shows the types of study and demographic of pa- other palliative treatment. Bisphosphonate therapy is now well tients in each study. Table 2 summarizes the methods and re- established as a way of reducing morbidity from the lytic skel- sults of each study focusing on pain assessment and analgesic etal metastases.19 use in some clinical trials. A majority of patients received ZA 4

27 VOLUME 92 NO. 1 JANUARY 2009 ment, the bone metabolism biomarkers, C-telopeptide and bone alkaline phosphatase also decreased which confirmed the biochemical mechanism of action of zoledronic acid both on markers of bone formation and resorption.7 ZA is the only bisphosphonate confirmed to be effective in reducing skeletal complications associated with bone metastases from advanced prostate cancer.13 The findings from these studies suggest that patients receiving ZA experienced a higher likelihood of clinically meaningful reductions in pain. Thus, ZA may help to avert the pain experienced by patients with progressing metastatic disease secondary to prostate cancer. The benefit from ZA therapy in terms of pain control and analgesic use from these 7 studies could potentially apply to Mr. X who has been through several modalities of treatment for his bone pain.

WHAT ARE THE RISKS? ZA was well tolerated. Reported adverse events ranged from 2-60% of patients. These events were generally mild to moderate in severity and were consistent with known safety profile of i.v. bisphosphonates. From our review, we found that common adverse reactions were pyrexia (22-44%), fatigue (39%), skeletal pain (10-60%), nausea and vomiting (3%), headache (2-19%), hypocalcemia (9-33%), and confusion (7-13%).1-13 All these events were mild in severity. Renal adverse events were noted, with an increase in serum creatinine levels from screening to final visit of < 0.5 mg/dL in 94.7% of patients from study #4 but all returned to within the normal range mg, the standard dose intravenously every 3-4 weeks for a total during follow-up. of 3 months to 2 years depending on studies except study # 10 Overall, ZA is the most broadly active i.v. bisphosphonate, that used ZA dose ranged from 0.1-8 mg. pain assessment was and is the only one approved for preventing skeletal complica- evaluated before, while receiving treatment, and at the end of tions of malignancy in patients with bone metastases from all each study. solid tumor types.15 ZA is well tolerated with long-term use. It has an overall safety profile similar to other i.v. bisphosphonates WHAT IS THE BENEFIT FOR THIS PATIENT? and the renal safety profile is comparable with pamidronate Of the 13 published studies, 7 focused on patients with when administered in accordance with treatment guidelines.17 metastatic, hormone refractory prostate cancer. Six out of the ZA is associated with a minimal risk of increased serum creati- 7 studies demonstrated significant reduction in pain scores ex- nine in patients with advanced prostate cancer and not influ- cept that Ripamonti et al4 showed that pain scores showed no enced substantially by prior bisphosphonate exposure.13 statistically significant difference before and after treatment. DISCUSSION This could be explained by the very small sample (N= 19) en- ZA has demonstrated statistically significant long-term ef- rolled in this study. ficacy and has the broadest clinical utility for pain palliation in Unlike bone metastases from other types of cancer, most a variety of tumor types of ZA therapy for bone pain second- bone lesions in prostate cancer are osteoblastic. However, re- ary to bone metastases. The number needed to treat for bone cent studies showed that osteoblastic lesions not only have pain calculated from available data from our review was 1.92 upregulated bone growth, but also concomitant increased os- (indicating that 2 patients need to be treated with ZA to ob- teolysis. The new bone created by tumor-stimulated osteoblasts tain improvement in 1), which strongly confirmed the supe- is weak and poorly mineralized, and the osteopenia secondary rior benefit of this new drug treatment. ZA was extremely well to the increased osteolysis results in a bone matrix with severely tolerated in most clinical trials. Renal toxicity was the only seri- compromised integrity. The risk of developing a skeletal com- ous safety finding after ZA treatment. Renal toxicity was re- plication is thus increased.13 Fulfaro et al investigated the use lated to dose (more with 8 mg than 4 mg), infusion duration of ZA in patients with bone metastases from prostate cancer (more with infusion over 5 minutes than 15 minutes), and to- and the effect on analgesic response and bone metabolism tal number of infusions. But no long- term complications were biomarkers. Besides the impressive pain control from ZA treat- observed from the clinical trials. 28 MEDICINE & HEALTH/RHODE ISLAND Hypocalcemia is a side effect common to all bisphosphonates, These clinical trials have confirmed the favorable benefits regardless of administration method. However, it can be controlled of ZA for bone pain secondary to multiple types of malignancy. with calcium and vitamin D supplements. Other adverse reac- Moreover, ZA was likely to be associated with clinical reductions were generally mild to moderate. Some patients reported tions in pain not only at rest but also on movement. This sup- only a single episode following the first infusion of ZA. ports the consideration of ZA for bone pain reduction in metastatic bone disease due to prostate cancer. Taken altogether, the results of the contemporary randomized controlled trials indicate that ZA decreases the risk of skeletal complications and pain palliation in men with androgen-independent prostate cancer and bone metastases while other bisphosphonates: pamidronate, ibandronate, and clodronate, although tested, seem to be in- effective in this setting.21,22

WHAT IS THIS PATIENT’S DECISION FOR HIS NEXT STEP OF TREATMENT? The patient was treated with ZA, with improvement of his pain and reduction in his opiate dose.

REFERENCES 1. Carteni G. The Oncologist 2006; 11: 841-8. 2. Facchini G. J Exp Clin Cancer Res 2007; 26: 307-12. 3. Sung JJ.. Yonsei Med J 2007;48: 1001-8. 4. Ripamonti C. Support Care Cancer 2007; 15:1177-84. 5. K.P.Weinfurt. Annals Oncol 2006; 17: 986-9. 6. Storto G.. Bone 2006;39:35-41. 7. Fulfaro F. J Chemotherapy 2005;17: 555-9. 8. Wardley A.. Brit J Cancer 2005;92:1869 -76. 9. Berenson JR. Clin Cancer Res 2001;7: 478-85. 10. Berenson JR. Cancer 2001;91 :1191-200. 11. Clemons MJ. J Clinical Oncol 2006; 24:4895-900. 12. Vogel CL. The Oncologist 2004; 9: 687-95. 13. Saad F. BIU International 2005: 964-9. 14. Gralow J. J Pain Symptom Manag 2007; 33:462-72. 15. Body JJ. Support Care Cancer 2006; 14: 408-18. 16. Saad F. Cancer Treat Reviews 2008:183-92. Epub27007Dec3. 17. Body JJ. European J Cancer 2007; 43:852-8. 18. Cameron D. Seminars Oncol 2004;31: 79-82. 19. Verl A. Internat J Biological Markers 2007;22:. 24-33. 20. Reid IR. Current Opinion Rheumatol 2003: 458-63. 21. Body JJ. Europ J Cancer 2007; 43: 852-8. 22. Michaelson MD. J Clinical Oncol 2005; 23:8219-24.

Porpon Rotjanapan, MD, is a Geriatric Medicine Fellow, Rhode Island Hospital.

Disclosure of Financial Interests The author has no financial interests to disclose.

CORRESPONDENCE: Porpon Rotjanapan, MD Rhode Island Hospital 593 Eddy Street APC 424 Providence, RI 02903 Phone: (401) 444-5248 e-mail:[email protected]

29 VOLUME 92 NO. 1 JANUARY 2009 THE WARREN ALPERT MEDICAL SCHOOL OF B ROWN UNIVERSITY GERIATRICS FOR THE Division of Geriatrics PRACTICING PHYSICIAN Quality Partners of RI Department of Medicine EDITED BY ANA TUYA FULTON, MD The Practicing Physicians’ Guide To Pressure Ulcers in 2008 Rachel Roach, MSN, ANP, GNP, WCC, and Clarisse Dexter, MSN, FNP, GNP, WCC MS is a 79-year-old woman admitted to the nursing home plish tones in darker skin. This area may be painful, pruritic, following a lengthy hospitalization for pneumonia and COPD. and warmer than the surrounding tissue. Her hospital course was complicated by Clostridium difficile Stage II is a partial thickness skin loss involving the epi- colitis and respiratory failure requiring mechanical ventilation. dermis and/or the epidermis. This ulcer appears as an abra- During her stay, she developed a sacral pressure ulcer. While sion, blister or a shallow crater. performing your admission examination, you note that the pres- Stage III is a full thickness loss of the subcutaneous tissue sure ulcer is 3 cm x 4 cm wide and 1.2 cm deep, with thick, extending to, but not through the underlying fascia. This adherent, yellow slough covering the entire wound bed. The wound is a deep crater. walls of the wound are gray, fibrous tissue; there is undermin- Stage IV is also a full-thickness tissue loss, with destruction ing from 10 to 2 o’clock. There is minimal wound exudate. extending into the muscle, supporting structures or to the bone. The peri-wound tissue is macerated. The presence of eschar covering a wound prevents stag- Pressure ulcers are, in most cases, preventable injuries.1 ing. These wounds are documented as “unstageable” until the This article will guide the clinician in formulating a reason- eschar is removed and the wound bed can be inspected. able, evidence-based plan to heal pressure ulcers. Deep tissue injury is the most recent classification of pressure ulcer added by the NPUAP. This type of ulcer often has ASSESSMENT the appearance of a deep bruise under intact skin and may A comprehensive assessment of the overall health status of rapidly progress to a full thickness ulcer.3 the patient and the characteristics of the ulcer are essential, and form the basis for treatment. Aspects to be assessed and TREATMENT documented include: The selection of a treatment for a wound should be based Location and size of the ulcer, documented by anatomi- on the needs of the patient, the wound, the caregiver and the cal part, and measured as length x width x depth in clinical setting. The dressing should provide moisture balance centimeters. in the wound bed, manage exudate, prevent infection, not Describe the wound from the bottom up: cause pain to the patient and protect the periphery of the • A description of the tissue or necrotic debris in the wound from damage. The goals of care of the patient and the wound bed, noted as slough or eschar, and reporting cost to the payor should also be considered. the percentage of debris versus granulation tissue. The clinician should become familiar with the different • Record the characteristics of any exudate present, categories of dressings and their composition. Knowledge of documenting odor, color and consistency. the facility or institution’s protocol and inventory, along with • Note the presence of tunneling, tracts and under- communication with the wound care team will assist in formu- mining, using a clock and head-to-toe direction for lating a comprehensive treatment plan. documentation reference points. Table 1 will assist in selection of an appropriate treatment • Note and remark on the condition of the surround- modality. ing skin. Table 1: CLASSIFICATION OF PRESSURE Wound Care Matrix Intact Skin Stage I Stage II Stage III Stage IV ULCERS The National Pressure Ulcer Exudate None None Light Dry to Heavy Advisory Panel (NPUAP) has devel- Moderate oped a specific, standardized rating Product Category Skin Barrier Hydrocolloid Hydrogels Foams 2 system to “stage” pressure ulcers. Care Creams Dressings to add Specialty Stage I is an observable pres- or moisture Absorptive sure-related alteration of intact skin, Transparent or Dressings, as compared with the adjacent skin Film Alginates or or opposite area on the body. The to absorb Negative ulcer appears as a defined area of Pressure Wound persistent redness in lightly pig- Therapy mented skin, and red, blue or pur- 30 MEDICINE & HEALTH/RHODE ISLAND The third consider- Table 2. Assessment of and Intention to Treat Infection in Chronic Wounds6 ation is providing an environment to the wound Bacterial Burden Contaminated Colonized Critically Local Systemic bed that provides moisture Colonized Infection Infection to promote healing and Wound Clinical Wound +/- early No/subtle Local Constitutional controls exudate. Lastly, Symptoms and progressing, signs of s/s of s/s of ss/ of Signs Host stable local infection infection infection optimize the repair process infection by providing the patient with nutritional support, Bacterial culture No +/- C&S C&S C&S C&S wound vitamin supplementation, and sensitivity wound wound wound and blood adequate hydration and by culture avoiding exposure to cold Topical antibiotic No +/- Yes Yes Yes (vasoconstriction reduces blood flow to the wound). Systemic antibiotic No No +/- +/- Yes It is also important to provide an appropriate support surface, such as a low WOUND BED PREPARATION air loss or air fluidized mattress for pressure relief. Adjunct thera- Wound bed preparation provides a conceptual approach pies should also be considered. This may include negative pres- to treatment decisions. Wound bed preparation is defined as sure wound therapy, physical therapy, growth factor modalities “the global management of the wound to accelerate endog- and referral to plastic surgery when indicated. enous healing or to facilitate the effectiveness of other therapeutic measures.”4 The first step is removal of dead tissue and contaminants in a timely manner.5 This cleaning of the wound SUMMARY bed can be accomplished by bedside sharp debridement, au- Let us now revisit the patient MS. The clinician performed tolysis (synthetic dressings cover a wound and allow devitalized sharp debridement of the devitalized tissue with a scalpel. The tissue to self-digest from enzymes normally present in wound remaining slough was removed using enzyme therapy - Santyl fluid), mechanical (wet to dry dressings), chemical removal (col- Collagenase, for example. The debridement revealed a stage lagenase enzymatic debridement), and whirlpool irrigation of III ulcer. The wound was irrigated daily with normal saline the wound. Wounds should be cleansed with low toxicity solu- and lightly packed with a hydrogel-impregnated dressing (to tions, preferably normal saline. Topical antiseptics (such as provide moisture). The macerated skin surrounding the wound Dakin’s solution, Domeboro’s solution, Betadine and Acetic was protected from excessive moisture using a topical material, Acid solutions) should be reserved for wounds that are not ex- Skin Prep, for example. A nutritionist was consulted, who ad- pected to heal or those in which the local bacterial burden is of vised a multivitamin and a protein supplement. Wound clo- greater concern than the stimulation of healing. sure was achieved in a timely fashion. The second consideration is to control the bacteria in the wound. It is important to differentiate between contamination REFERENCES and the colonization of bacteria in a wound. On the continuum 1. Niezgoda, JA, Mendez-Eastman S. The effective management of pressure ulcers. Advances Skin Wound Care 2006; 19(1) Supplement 1: 3-15. of bacterial burden, contamination is the presence of bacteria 2. http://www.npuap.org on the wound surface. Colonization reflects the presence of rep- 3. http://www.npuap.org/DOCS/DTI.doc licating bacteria that is not yet causing injury to the host. Critical 4. Falanga V. Wound bed preparation and the role of enzymes. Wounds 2002; 14:47-57. 5. Ayello EA, Cuddigan JE. Conquer chronic wounds with wound bed prepara- colonization occurs when the presence of bacteria (or bio-bur- tion. The Nurse Practitioner 2004; 29: 8-25. den) delays or stops healing, but without signs or symptoms of 6. Sibbald RG, Williamson D, et al., Preparing the wound bed-debridement, bac- infection. When pain, erythema, warmth, purulent discharge, terial balance, and moisture balance. Ostomy Wound Manag 2000; 46: 25. odor or new breakdown is present, local infection must be sus- pected. Systemic infection is marked by symptoms which extend Disclosure of Financial Interests beyond the borders of the wound. Symptoms may include The authors have no financial interests to disclose. erythema, induration, fever, and leukocytosis. These symptoms indicate the need for treatment with a systemic antibiotic. 9SOW-RI-GERIATRICS-12009 The swab cultures of contaminated or colonized wounds THE ANALYSES UPON WHICH THIS PUBLICATION IS BASED were per- are of limited diagnostic value. If a wound culture is indicated, formed under Contract Number 500-02-RI02, funded by the Cen- a tissue biopsy is preferred. ters for Medicare & Medicaid Services, an agency of the U.S. De- partment of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the De- partment of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented.

31 VOLUME 92 NO. 1 JANUARY 2009 RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH EDITED BY SAMARA VINER-B ROWN, MS

Rhode Island HEALTH Web Data Query System: Death Certificate Module Annie Gjelsvik, PhD, and Karine Monteiro, MPH

The Rhode Island HEALTH Web Data Query System (not contributing causes). The results found here may not il- (RI HEALTH WDQS) allows health professionals, commu- lustrate the full picture of the burden due to deaths of some nity agenccies, Rhode Island Health Department personnel, diseases. For instance an underlying cause of death and con- and the general public to access Behavioral Risk Factor Sur- tributing cause of death identified 2.5 times more diabetes veillance System (BRFSS), Youth Risk Behavior Survey deaths.3 Missing, unknown, not stated and not classifiable data (YRBS) and Death Certificate Data online. This resource are not tabulated in the output tables; however, they are in- can provide health professionals and community organiza- cluded in the totals. Therefore the individual categories may tions with valuable information with which to improve the not sum to the total. health of Rhode Islanders through data-driven programs and policies. DEVELOPMENT PROCESS The RI HEALTH WDQS is publicly accessible and re- The Centers for Disease Control and Prevention’s (CDC) quires no sign-in or registration. It contains ten years (1998- Assessment Initiative Cooperative Agreement supported the 2007) of RI BRFSS data on over twenty topics, four years development of this system. Core programming used for the (2001, 2003, 2005 and 2007) of RI YRBS data on over eleven RI HEALTH WDQS Death Module was adapted from the topics and two years (2004 and 2005) of Death Certificate Arkansas Department of Health Center for Health Statistics data on fifty two underlying causes of death. (Table 1). The Query System.4 The Rhode Island Assessment Initiative will BRFSS module has been described elsewhere1 and the YRBS use a similar process to create a Birth Data module, scheduled module has very similar design and functionality. Here we de- to go on-line by June 2009. scribe the new addition of Death Certificate Data. HOW TO ACCESS THE SYSTEM DESIGN AND FUNCTIONALITY You can access each of the modules from the RI HEALTH The RI HEALTH WDQS Death Module allows users to WDQS homepage (http://www.health.ri.gov/data/ obtain crude and age-adjusted or age-specific rates, select all webquery.php) or navigate there from the individual database cause or specific underlying cause of death (with up to four web pages. sub categories) and limit tables by demographics. In addition users can combine years in order to obtain stable estimates, FUTURE PLANS define the report content and output. Output can be viewed The project will incrementally expand access to other da- in a browser window or downloaded to an Excel file. To ensure tabases in phases, beginning with Birth Certificate data and confidentiality, the RI HEALTH WDQS Death Query mod- Middle School Youth Risk Behavior. Other databases consid- ule adheres to the same rules as consistent with the Vital Records ered for inclusion in the system within the next five years in- determination and masks information for causes of death for clude Pregnancy Risk Assessment Monitoring System which there are 5 or fewer deaths. 2 (PRAMS), Hospital Inpatient and Hospital Outpatient data- The RI HEALTH WDQS Death Module includes only bases and Cancer Registry Data. data on Rhode Island residents. The deaths of RI residents oc- The Rhode Island Assessment Initiative will be holding curring in other states are included in the data while deaths of workshops on how to access Rhode Island vital statistics data non-RI residents occurring in RI are not included. This en- and how to interpret and present results. This workshop will ables crude, age-adjusted and age-specific rates to be deter- be modeled on the Web Access to Rhode Island Public Health mined using US Census data for Rhode Island as the denomi- Data workshops developed to provide the Rhode Island pub- nator. Data posted on the RI HEALTH WDQS Death Mod- lic health work force with training in how to access data and ule are posted initially as provisional data and are updated once interpret and present results of BRFSS and YRBS data. to final when the Vital Statistics Annual Report2 is issued for that year. Provisional data are close to final but subject to ACKNOWLEDGEMENTS changes as additional records are added to the dataset or up- Development of the RI HEALTH Web Query System was dated information is obtained. Therefore, before the data are supported by the Centers for Disease Control and Prevention’s final, deaths of RI residents occurring in other states may not Assessment Initiative Cooperative Agreement 82/ have yet been included. CCU122380-05. Ongoing trainings and maintenance are The Death Module reports on underlying cause of death supported by the Centers for Disease Control and Prevention’s

32 MEDICINE & HEALTH/RHODE ISLAND Assessment Initiative Cooperative Agree- Table 1: Causes of Death Currently Available on Rhode Island’s ment 5U38HK000051-02. HEALTH Web Data Query System – Death Certificate Module We gratefully acknowledge the Ar- Salmonella infections (A01-A02) kansas Department of Health for all Shigellosis and amebiasis (A03, A06) the support provided in the develop- Certain other intestinal infections (A04, A07-A09) ment of the RI HEALTH WDQS *Tuberculosis (A16-A19) Death Module. Whooping cough (A37) Scarlet fever and erysipelas (A38, A46) REFERENCES Meningococcal infection (A39) 1. Gjelsvik A. Rhode Island HEALTH Web Query Septicemia (A40-A41) System. Med & Health/RI 2005; 88:407-8. Syphilis (A50-A53) 2. Rhode Island Department of Health. Division Acute poliomyelitis (A80) of Vital Records. Vital Statistics Annual Report Arthropod-borne viral encephalitis (A83-A84, A85.2) (2000). http://www.health.ri.gov/chic/vital/ Measles (B05) annual2000.pdf 3. Wier L, Gjelsvik A. Diabetes mortality in Rhode Viral hepatitis (B15-B19) Island. Med & Health/RI 2008; 91: 86-7. Human immunodeficiency virus (HIV) disease (B20-B24) 4. http://www.healthyarkansas.com/data/data.html Malaria (B50-B54) Other and unspecified infectious and parasitic diseases and their sequelae Annie Gjelsvik, PhD, is Assistant Pro- (A00, A05, A20-A36, A42-A44, A48-A49, A54-A79, A81-A82, A85.0- A85.1, A85.8, A86-B04, B06-B09, B25-B49, B55-B99) fessor (Research), Warren Alpert Medical *Malignant neoplasms (C00-C97) School of Brown University and Project Co- In situ neoplasms, benign neoplasms and neoplasms of uncertain or unknown ordinator of the Rhode Island Department behavior (D00-D48) of Health’s Assessment Initiative. Anemias (D50-D64) Karine Monteiro MPH, is Data Diabetes mellitus (E10-E14) Manager of the Rhode Island Department *Nutritional deficiencies (E40-E64) of Health’s Assessment Initiative. Meningitis (G00, G03) Parkinson’s disease (G20-G21) Disclosure of Financial Interests Alzheimer’s disease (G30) The authors have no financial inter- *Major cardiovascular disease (I00-I78) ests to disclose. Other diseases of circulatory system (I80-I99) *Influenza and pneumonia (J10-J18) *Other acute lower respiratory diseases (J20-J22) *Chronic lower respiratory diseases (J40-J47) Pneumonitis due to solids and liquids (J69) Other diseases of respiratory system (J00-J06, J30-J39, J67, J70-J98) Peptic ulcer (K25-K28) Diseases of appendix (K35-K38) Hernia (K40-K46) *Chronic liver disease and cirrhosis (K70, K73-K74) Cholelithiasis and other disorders of gallbladder (K80-K82) *Nephritis, nephrotic syndrome and nephrosis (N00-N07, N17-N19, N25-N27) Infections of kidney (N10-N12, N13.6, N15.1) Hyperplasia of prostate (N40) Inflammatory disease of female pelvic organs (N70-N76) *Pregnancy, childbirth and the puerperium (O00 –O99) Certain conditions originating in the perinatal period (P00-P96) Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99) Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) All other disorders (Residual) *Accidentals (unintentional injuries) (V01-X59, Y85-Y86) *Intentional self-harm (suicide) (X60-X84, Y87.0) Assault (homicide) (X85-Y09, Y87.1) Legal intervention (Y35, Y89.0) *Events of undetermined intent (Y10-Y34, Y87.2, Y89.9) Operations of war and their sequelae (Y36, Y89.1) Complications of medical and surgical care (Y40-Y84, Y88)

*Indicates diagnosis category contains subcategories ICD 10 codes are in parentheses 33 VOLUME 92 NO. 1 JANUARY 2009 DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH RHODE ISLAND DEPARTMENT OF HEALTH EDITED BY JOHN P. FULTON, PHD

Palliative Care – Evolution of a Vision Anna Wheat

Dame Cicely Saunders, MD, OM, DBE, established the first A service that provides all the essentials of care modern hospice, St Christopher’s, in 1967 in London. Prior to needed by those who face a terminal illness; allow- that time, terminally ill hospitalized patients did not “fit” the ing palliative and curative treatment, care for the mission of hospitals – to cure. Physicians equated terminal ill- family, and services at home and in inpatient set- ness with failure; thus terminally ill patients were often tings. The combined skills of an interdisciplinary “placed… at the end of the hall.”1 Dame Cicely took it upon team must bring care to the patient and family in herself to help these patients, usually suffering from advanced the context of their life and values.4 cancer, with the goal of facilitating dignity and comfort as death approached. She founded St. Christopher’s Hospice, believ- In addition to “the care needed by those who face a termi- ing that dying people have the right to an improved quality of nal illness,” the IWG’s vision squarely addresses “care for the life, using pain control and social and emotional support to family.” Family members of terminally ill patients frequently achieve psychological and spiritual contentment. Dame Cicely’s become caregivers, encountering a gamut of problems—dis- vision for end of life care soon spread to the United States where rupted schedules, fatigue, loss of wages, fear of impending loss, it became known as “palliative care.” and anxieties related to patient care.5 Absent financial assis- Dame Cicely’s apprentice at St. Christopher’s, Florence tance and psychological counseling, the caregiver’s role can be Wald, MN, brought the new vision for end of life care to the quite overwhelming.6 United States, establishing the Connecticut Hospice in 1974. Furthermore, the IWG promotes a team approach to the Known thereafter as “the mother of the American hospice planning and delivery of services. Individual needs – and movement,” Ms. Wald not only established an inpatient hos- wants – of terminally ill patients and caregivers are quite di- pice similar to St. Christopher’s, but also developed the first verse, and change over the course of a terminal illness. There- home care program for terminally ill patients in the United fore, teams designed to support patients and caregivers must States.2 From these small beginnings the American hospice incorporate a diverse—and flexible—set of skills. Medicine, movement grew rapidly. By the year 2000, hospice organiza- nursing, social work, and spiritual counseling are commonly tions in the US were serving an estimated 105,500 patients in the mix. annually — 18,500 inpatients, and 87,000 home care clients.3 By 1990, Dame Cicely’s concept had spread to many Since its articulation at St. Christopher’s four decades ago, nations. In recognition of this fait accompli, the World Health the basic, comprehensive approach to palliative care has not Organization (WHO) released its own definition of pallia- changed, but the definition of palliative care has evolved – it tive care. has broadened significantly – as have unresolved issues of palliative care. The active total care of patients whose disease is not responsive to curative treatment. Control of pain, AN EVOLVING CONCEPT other symptoms, and of psychological, social, and In the 4th century, hospices were initially places for travelers spiritual problems is paramount. The goal of pal- to rest. Then in the 19th century, churches in England and Ire- liative care is achievement of the best possible qual- land began to establish places for dying persons called “hospices.” ity of life for patients and their families. Many as- When St. Christopher’s hospice was established, it differed from pects of palliative care are also applicable earlier in existing hospices in the United Kingdom primarily because Dame the course of the illness, in conjunction with anti- Saunders’ vision of end of life care was broader than the estab- cancer treatment.7 lished vision. Dame Cicely’s hospice was more than a place to gather up dying people; its goal was to improve the quality of re- The WHO defines the goal of palliative care as “the best maining life (including spiritual and psychological wellbeing) by possible quality of life for patients and their families,” expand- providing strategic supports, such as effective pain control. ing the reach of palliative care to “earlier in the course of the In 1974, seven years after the founding of St. Christopher’s illness, and thus, to patients with potentially terminal illnesses. hospice, and shortly after the establishment of the first hospice The WHO definition recognizes that patients undergoing in the United States, The International Work Group on Death, curative treatments may benefit significantly from palliative Dying and Bereavement (IWG) was founded. IWG is an or- care. ganization that seeks to advance and nurture the development Since 1990, the WHO has been an essential partner in of the field of palliative care through thanatology, the study of the palliative care movement. In 2002 they revised their offi- human death. In 1979, IWG officially adopted a definition cial definition of palliative care. of palliative care.

34 MEDICINE & HEALTH/RHODE ISLAND An approach that improves the quality of life of pa- PALLIATIVE CARE VS. HOSPICE CARE tients and their families facing the problems associ- In 1967, Dame Cicely Saunders redefined hospice care ated with life-threatening illness, through the pre- by incorporating an expansive, patient-centered approach to vention and relief of suffering by means of early iden- the care of terminally ill patients, focusing on dignity and tification and impeccable assessment and treatment comfort. In essence, St. Christopher’s Hospice defined pal- of pain and other problems, physical, psychosocial liative care with clear vision, specific goals, distinct methods, and spiritual.8 and of course, a successful, functioning model. Since that time, hospice care has become a distinct subset of palliative Two important revisions are incorporated in the WHO’s care, as the latter concept has expanded. Palliative care is new definition. First, “terminal illness” is replaced by “life- now broadly valued, not only for terminal illness, but also threatening illness.” Superficially, this modification may ap- throughout the trajectory of all serious illness. Hospice care pear to be slight, but its implication is nothing short of revolu- incorporates all of what palliative care (now) is, but contin- tionary, broadening the reach of palliative care to all people ues to focus on the special needs of patients and caregivers as suffering from chronic illnesses. By so doing, the WHO’s defi- end of life approaches. nition has been brought into line with recent medical advances. Diseases formerly considered to be “death sentences,” such as ISSUES OF PALLIATIVE CARE TODAY cancer, cardiac disease, and infection with HIV, are now man- The foremost issues of palliative care today are accessibility ageable. Second, “relief of suffering by means of early identifi- and utilization. In Rhode Island, as elsewhere in the United cation” has been added. Thus, palliative care is envisioned as States, palliative care is largely inaccessible and greatly preemptive, as well as responsive. In one bold stroke, the WHO underutilized.11 Cancer patients, for example, are often un- affirms that end of life problems have significantly earlier ori- aware of palliative care options, and those who are not consid- gins, and that treating them early enhances management ered to be terminally ill do not have access to a palliative care throughout the course of illness.9 team; minority groups may be distinctly disadvantaged in this Building on the WHO’s definitions of palliative care, the regard.12 The Rhode Island Comprehensive Cancer Control National Consensus Project for Quality Palliative Care (NCP) Plan, developed by the Partnership to reduce Cancer in Rhode developed consensual clinical palliative care guidelines in 2004. Island and released in 2007, aims to increase access to pallia- The project was launched by 5 organizations committed to tive care by the year 2012. end-of-life issues: the American Academy of Hospice and Pal- As well, issues have always swirled around the use of palliative Medicine, the Center to Advance Palliative Care at the liative sedation—the use of sedatives to relieve extreme suf- Mount Sinai School of Medicine, the Hospice and Palliative fering by inducing unconsciousness (deep sleep) while the Nurses Association, the Last Acts Partnership, and the National disease takes its course, eventually leading to death.13 Advo- Hospice and Palliative Care Organization. The essence of all cates of palliative sedation believe it should be used to avoid previous definitions is incorporated in the NCP’s vision of pal- unnecessary suffering, even if sedation hastens death (by sup- liative care. pressing respiratory function).14 Opponents argue that palliative sedation is a euphemism for euthanasia.15 This issue is The goal of palliative care is to prevent and relieve certainly not new. It is discussed more openly now, however. suffering and to support the best possible quality Let us hope that this new willingness to confront the issue of life for patients and their families, regardless of will benefit the patient, as Dame Cicely, who strongly op- the stage of the disease or the need for other thera- posed euthanasia,16 would have insisted. In this regard, per- pies. Palliative care is both a philosophy of care haps it is fitting to quote the following from Dame Cicely’s and an organized, highly structured system for obituary: delivering care. Palliative care expands traditional disease-model medical treatments to include the Many years ago, in response to a question at a sym- goals of enhancing quality of life for patient and posium about the prospect of death, Saunders de- family, optimizing function, helping with decision- clared that she would hope for a sudden demise making and providing opportunities for personal but would prefer to die—as she has—with a cancer growth. As such, it can be delivered concurrently that gave due notice and allowed the time to reflect with life-prolonging care or as the main focus of on life and to put one’s practical and spiritual af- care.10 fairs in order.17

This is by far the most comprehensive definition to date. Dame Cicely died peacefully as a patient of St. Dame Cicely’s original vision of care for the dying is now rec- Christopher’s Hospice in 2005. ognized as nothing less than a philosophy of care, operationalized through effective management of pain and other distressing REFERENCES symptoms, while incorporating psychosocial and spiritual care 1. Krisman-Scott MA. The Room at the End of the Hall: Care of the Dying, 1944- according to the needs, values, beliefs, and cultures of patients 1976. Unpublished doctoral dissertation in Nursing, University of Pennsyl- vania, 2001. and their families. 2. Hevesi D. Florence Wald opened first U.S. hospice. New York Times, 16 No- vember 2008. 35 VOLUME 92 NO. 1 JANUARY 2009 3. National Center for Health Statistics. National Home and Hospice Care Data. 12. The Partnership to Reduce Cancer in Rhode Island. Rhode Island Comprehen- (Data from the National Home and Hospice Care Survey, 2000) Current sive Cancer Control Plan 2007. Providence, RI: Rhode Island Department of Hospice care Patients, Tables 1-13. Bethesda, Maryland: National Center for Health, p. 36. Health Statistics, February, 2004. http://www.cdc.gov/nchs/data/nhhcsd/ 13. Brender E, Burke A, Glass RM. Palliative sedation. JAMA 2005; 294; 1850. curhospicecare00.pdf 14. Carr MF, Mohr GJ. Palliative Sedation as part of a continuum of palliative care. 4. International Work Group on Death and Dying. Assumptions and Principles J Palliative Med 2008; 11: 76-80. Underlying Standards for Terminal Care. Appendix I. Amer J Nurs 1979; 79: 15. Rousseau PC. Palliative sedation and the fear of legal ramifications. J Palliative 296-7. Med 2006; 9: 246-8. 5. Lynn J. Serving patients who may die soon and their families. JAMA 16. Richmond C. Dame Cicely Saunders. (Obituary) British Med J 2005; 331 2001;285:925-32. (7509). http://www.bmj.com/cgi/content/full/331/7509/DC1 6 . Roy DJ. Need I believe? J Palliative Care 1997; 13:3-4. 17. Dame Cicely Saunders: Visionary founder of the modern hospice movement 7. World Health Organization: Cancer Pain Relief and Palliative Care. Technical who set the highest standards in care for the dying. Obituary. The Times of Report Series 804. Geneva, Switzerland: WHO, 1990; p.11. London July 15, 2005. http://www.timesonline.co.uk/tol/comment/obituar- 8. World Health Organization. National Cancer Control Programs: Policies and ies/article544059.ece Managerial Guidelines, 2nd ed. Geneva, Switzerland: World Health Organiza- tion, 2002. Anna Wheat is a Master of Public Health candidate at 9. Sepulveda C, Marlin A, et al. Palliative care. J Pain Symptom Manag 2002; 24: 91-6. Brown University. She works as an intern for the Rhode Island 10. National Consensus Project for Quality Palliative Care. Clinical practice guide- Comprehensive Cancer Control Program, based at the Rhode Is- lines for quality palliative care. Pittsburgh: National Consensus Project for land Department of Health. Quality Palliative Care, 2004. 11. The Partnership to Reduce Cancer in Rhode Island. Rhode Island Comprehen- sive Cancer Control Plan 2007. Providence, RI: Rhode Island Department of Disclosure of Financial Interests Health, p. 36. The author has no financial interests to disclose.

36 MEDICINE & HEALTH/RHODE ISLAND Physician’s Lexicon Medical Words in Extremis

The English language is said to embrace a those idle, antiquarian medical words for which Thymergasia: An abnormal psychiatric bit over one million words; but since an av- even historians can find no use. state, usually mania. erage citizen can get along readily in urban In truth, medical dictionaries are suf- Paralyssa: an acute form of rabies associ- life with an active knowledge of but 20,000 fused with words that only a lexicographer ated with bat-bites. Lyssa, incidentally, words, what are the purposes and reasons might understand or cherish. Many [particu- is the Greek goddess of rabies, mad for survival of the remaining 980,000 terms larly psychiatric terms] have long since been dogs and human rage. - beyond burdening the pages of hernia-pro- supplanted by newer, more accurate terms. Nosophilia: A morbid urge to be ill. ducing dictionaries? Consider, for example, an arbitrarily gath- Amaxophobia: A pathologic fear of riding Lexicographers claim that each learned ered battery of ancient words culled from a in automobiles. profession adds its own contrived vocabulary standard medical dictionary: Anerythroblepsia: Obsolete term for an- to the general pool of words; in the case of erythropsia which, in turn, is an an- medicine this amounts to an arcane collection Innidiation: an archaic term for neoplastic cient term for protanopia which de- of about 85,000 technical words. We are of- metastasis. fines blindness to the color red. ten asked by the lay public: Are all of these Allotriogeustia: an ancient term for abnor- polysyllabic words really necessary? With all mal taste preferences; this word is These words, if not dead, are certainly of your professional commitments to linked to allotriophagy, the eating of moribund. I doubt that any member of the economy and brevity of expression, why do bizarre foods [such as the earth-eaters Rhode Island Medical Society, no matter you not have a Committee on Retiring Medi- of South Carolina]. how erudite, could give accurate meaning cal Lexicography, its purpose to prune and dis- Athymia: An old psychiatric diagnosis of an to these verbal dinosaurs without retreating card your older terms which have been replaced individual displaying an absence of affect; to ancient reference books. by newer and more accurate words? To be pre- one showing extreme indifference [the cise, the Committee should ruthlessly discard word is unrelated to the thymus gland]. – STANLEY M. ARONSON, MD

RHODE ISLAND DEPARTMENT OF HEALTH VITAL STATISTICS DAVID GIFFORD, MD, MPH DIRECTOR OF HEALTH EDITED BY C OLLEEN FONTANA, STATE REGISTRAR

Underlying Reporting Period Rhode Island Monthly January Cause of Death 12 Months Ending with January 2008 Vital Statistics Report 2008 Number (a) Number (a) Rates (b) YPLL (c) Provisional Occurrence Diseases of the Heart 225 2,679 250.4 3,407.0 Malignant Neoplasms 188 2,277 212.9 5,960.0 Data from the Cerebrovascular Diseases 33 384 35.9 592.5 Division of Vital Records Injuries (Accidents/Suicide/Homicde) 46 523 48.9 8,365.5 COPD 61 444 41.5 342.5

Reporting Period (a) Cause of death statistics were derived from the underlying cause of death reported by Vital Events July 12 Months Ending with physicians on death certificates. 2008 July 2008 (b) Rates per 100,000 estimated population of Number Number Rates 1,067,610 Live Births 1,121 12,775 12.0* Deaths 737 9,929 9.3* (c) Years of Potential Life Lost (YPLL) Infant Deaths (4) (77) 6.0# Neonatal Deaths (4) (58) 4.5# Note: Totals represent vital events which occurred in Rhode Marriages 710 6,109 5.7* Island for the reporting periods listed above. Monthly pro- Divorces 223 2,839 2.7* visional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation. Induced Terminations 350 4,897 383.4# Spontaneous Fetal Deaths 68 829 64.9# * Rates per 1,000 estimated population Under 20 weeks gestation (62) (757) 59.3# # Rates per 1,000 live births 20+ weeks gestation (6) (72) 5.6# 37 VOLUME 92 NO. 1 JANUARY 2009

The Official Organ of the Rhode Island Medical Society

Issued Monthly under the direction of the Publications Committee

VOLUME 1 PER YEAR $2.00

NUMBER 1PROVIDENCE, R.I., JANUARY, 1917 SINGLE COPY, 25 CENTS

NINETY YEARS AGO, JANUARY 1919 TWENTY-FIVE YEARS, JANUARY 1984 Because key staff at the Rhode Island Medical Society were Wendy J. Smith, the managing editor, contributed an serving in World War I, the Society suspended publication of Editorial, “A New Look at the Fiscal Impact of the Malpractice its journal throughout 1919. Premium.” The total bill for premiums of physicians, employ- ees and hospitals came to an estimated $3.5 billion in 1983; Fifty Years Ago, January 1959 $1.655 to 1.75 billion of that went for physicians’ coverage. Leo M. Davidoff, MD, Professor and Chair, Department Those estimates did not include an estimated $15.1 billion spent of Surgery, Albert Einstein College of Medicine, delivered the yearly for “defensive medicine.” In Rhode Island, malpractice 11th Dr. Isaac Gerber Oration: “Some Influences of the In- claims were pending against one-third of the physicians. tracranial Controls on the Roentgen Appearance of the Skull.” On the President’s Page, Charles P. Shoemaker, Jr, MD, The Journal reprinted the oration. noted in “Physician Manpower in Rhode Island” that the Shields Warren, MD, Professor of Pathology, Harvard Brown University Program in Medicine had decided to create Medical School, gave an address at the ceremony marking the 40 new full-time positions. “The decision….sent shock waves cornerstone of the George Memorial Building [named for through the entire medical community,” especially new physi- David E. George] at Rhode Island Hospital. The building was cians, “already struggling to survive in the face of the ‘doctor to focus on the treatment of cancer. glut.’” Third-party insurers feared an estimated cost for each An Editorial, “Hospital Sepsis and the Staphylococcus,” new position of $300,000 annually. Dr. Shoemaker urged fur- urged hospitals to adopt changes to the laundry, housekeep- ther study, to document evidence of the hypothesized glut. ing, and engineering departments (for instance, “well-main- Henry M. Lichtman, MD, and Stanley D. Simon, MD, tained air conditioning systems”). The Editorial urged frequent in “The Doctor John E. Conley Rehabilitation Center: A Com- hand-washing, use of masks during surgery, and “gentle han- munity Resource,” urged Rhode Island physicians to “utilize dling of tissues.” the facilities for the benefit of their patients.” The General As- sembly had established the center in 1943, expressly to care for injured workers covered by Workers Compensation Insur- ance – “the first state-operated rehabilitation facility in the country.” Kemi Nakabayashi, Sarah C. Aronson, Michael Siegel, William Q. Sturner, MD, and Stanley M. Aronson, MD, in “Traffic Fatalities in RI: Part I – Descriptive Epidemiology,” recounted the basic statistics: traffic fatalities were responsible for 17.6% of all years of life lost before age 65, and 1.4% of all deaths in Rhode Island. John L. Margolis, MD, Anthony V. Migliaccio, MD, FACS, and Anthony J. Migliaccio, MD, FACS, in “Gastric Gullet Obstruction produced by gallstones in the Duodenal Wall,” discussed the case of a 77 year –old man. The authors noted that the condition was generally managed by cholecys- tectomy and gastrectomy.

38 MEDICINE & HEALTH/RHODE ISLAND 2008 Index

AUTHORS Fulton, Ana Tuya 197,224 Nazareth, Samantha 63 Young, Beverly R. 252 Adashi, Eli Y. 240 Fulton, John P. 229,290 Nolan, Patricia 255 Zaidi, Najam 283 Ahmed, Hanna N. 5[abs] Gaines, Alan 171 Nothnagle, Melissa 283 Zayas, Vlad 258 Ain, David L. 23 Ganim, Marie 109 Obell, John W. 315 Ali, Akhtar 4[abs] Garneau, Deborah 323 O’Connor, Bonnie B. 365 TITLES Alvarez, Antonio 294 Gardner, Rebekah L. 285 Ott, Brian R. 146 A Place to be Healthy: Blueprint Amick, Melissa M. 146 Gass, Jennifer 5[abs] Palenchar, Eileen 242 for a new Free Clinic for the Aronson, Stanley M. 3,34,43,67, Gentilesco, Bethany 342[abs] Partridge, Robert 20 Medically Uninsured of RI 105 71,94,99,123,126, Gerber, Rebecca 105 Patel, Paras 346[abs] A Planetary Vocabulary [PL] 203 155,159,203,207,235, Giannotti, Tierney E. 27 Patrozou, Eleni 23 A Primer on Hospice for the 239,263,267, 295,299, Gifford, David R. 64 Patten, Richard 4[abs] Internist {GPP] 121 327,331,355, 359,391 Giguere, Louise 285 Pawasaukas, Jayne 268,273 A Purgatory of Ambiguous Arrighi, James A. 27 Gillani, Fizza S. 344[abs] Pearlman, Deborah N. 199 Words [PL] 391 Arsenault, Fred 113 Gilson, Thomas 288 Perlman, Elliot M. 44,45,48 A Slothful Afternoon on an Atalay, Michael K. 320 Gjelsvik, Annie 86 Perry, Donald K. 349 Alabama Farm 70 Baier, Rosa R. 64 Glicksman, Arvin S. 103 Poppas, Athena 6[abs] Abstracts: RI Chapter, American College Baird, Janette 100,339 Gold, Richard 258 Proano, Lawrence 20 of Physicians 2008 Bandy, Uptala Goldman, Roberta E. 361 Quilliam, Daniela N. 88,384 annual meeting 342 290 Gong, Rujun 6[abs] Rakatansky, Herbert 352 Advances in Therapeutic Immuno- Barbosa, Anna A. 345[abs] Gordon, Paul 315 Ranney, Megan L. 100 modulation of IgE-mediated Becker, Bruce M. 15 Gosciminski, Michael 290 Rastellini, Cristiana 345[abs] Respiratory Disease 187 Bernal, Oscar 7[abs] Goulette, Christine 290 Ratnapradipa, Dhitinut 88 AIDS-Related Lymphoma: The Rhode Besdine, Richard W. 129,247 Gruppuso, Philip A. 242 Regnante, Richard A. 5[abs],315 Island Experience 332 Beste, Lauren A. 116 Gupta, Rakesh 346[abs] Retsinas, Joan 35,68,96,124, Aging of the Human Nervous Bitar, Imad 213 Gupta, Ravi 344[abs] 156,204,236,264, System: What Do We Block, Stanley Hoyt 164 Gutman, Ned H. 320 296,328,356,392 Know? [QP] 129 Blum, Andrew S. 138 Gutmann, Matthew 369 Ricci, Anthony R. 184 American College of Physicians, Borkan, Jeffrey 360,361 Hansen, Caitlin 332 Rich, Josiah 271 RI Chapter –2007 Podium Bowman, Sarah 271 Hesser, Jana 25,119,259 Ritter, Dale A. 252 presentation abstracts An Braman, Sidney S. 166 Hopkins, Richard 6[abs] Rizvi, Syed 216 Alien Legend with a Bite 159 Brown, Melissa 345[abs] Howard, Margaret 255 Roach, Rachel 382 Anterogade Amnesia and Fornix Browning, Carol 290 Jagminas, Liudvikas 339 Rochefort, David A. 109 Infarction [IM] 258 Bryan, Richard G. 51 Jeha, Jeannine 326,354 Romain, Carmelle V. 252 Anthropological Perspectives on Buechner, Jay S. 60,64,199 Jiang, Yongwen 25,119,259,349 Rosen, Rochelle K. 374 Medicine: Introduction 360 Burgess, Frederick W. 11,268, Jones, Christopher A. 121,347 Rothstein, Marcos 346[abs] Apocalyptic Prefix [PL] 355 273,276 Julian, Linda 232 Rougas, Steven C. 252 Asthma and Allergy – Burgess, Thomas A. 11 Kantor, Rami 344[abs] Rusley, Jack C. 252 Introduction 160 Burtt, Douglas 309 Kazim, Ali 339 Sachs, George M. 142 Awkward Birth Pangs of Bolero 207 Campbell, Susan 378 Kelly, Erin T. 15 Sadiq, Immad 301,305 Biomonitoring in RI [PHB] 88 Carino, Gerardo 344abs] Kempananjappa, Thejaswini 6[abs] Saint-Hilaire, Marie-Helen 136 Business, Gifts and Boundaries Carpenter, Charles C. 344[abs] Kim, Hyun 323 Salerno, Mary E. 232 in the Physician Patient Casoy, Flavio 4[abs] King, Ewa 88 Settipane, Russell A. 160,187 Relationship [PHB] 354 Castillo, Jorge 332 Klein, Robert B. 161 Shah, Samir A. 63 CATS: A New Answer to an Old Chan, Philip A. 344[abs] Kohn, Robert 335 Shield, Renee R. 247,360,378 Problem 98 Charpentier, Margaret 105 Kolankiewicz, Luiz M. 346[abs] Shih, Grace 88 Can Privacy Survive in the Brave Chen, James Y. 258 Kopel, Sheryl J. 161 Siclari, Michael 339 New World? 43 Chodosh, Adam 309 Korr, Kenneth S. 300,305,309 Simoli, Michael 202 Case of a Surger with Sudden Cicalese, Luca 345[abs] Lally, Edward V. 213 Simon, Peter R. 384 Hemiplegia [abs] 7 Colvin, Gerald A. 226 Lambrese, Jason V. 252 Singh, Arun 6[abs] Case Presentation: Mr. J, an 88 Cooper, George 6[abs] Landau, Carol 81 Starr, Rebecca 197 year-old man found on the floor, Corl, Keith 339 Larkin, Jerome 208,209,212 Stein, Michael 116 complaining of generalized Cossor, Furha 5[abs] Linsky, Russell A. 5[abs],305 Steinkeler, Jill A. 196 weakness [GPP] 197 Crausman, Robert 202,232, Liu, Sze 199 Stoukides, John 154 Characteristics and Outcomes of 262,326,354 Magee, Susanna R. 88 Strawbridge, Elizabeth M. 255 Patients in the RI Takotsube Cryan, Bruce 151 Margolius, David 219 Summerhill, Eleanor 4[abs] Cardiomyopathy Registry Cu-Uvin, Susan 344[abs] Maslow, Andrew 276 Surti, G. Mustafa 335 [abs] 5 Culhane-Pera, Kathleen A. 361 Massi, Molli 105 Sutton, Nancy 199 Chest Pain as the Presenting D’Ordine, Helen M. 124 Matheson, Jean K. 144 Tannenbaum, Jerome S. 346[abs] Features of High Output Dalia, Samir 226 Mayer, Kenneth H. 15 Taner, Anil T. 320 Heart Disease due to Congenital Damle, NS 342 McAteer, Kristina 20 Tashima, Karen 332 Arteriovenous Malformation De Groot, Anne S. 105 McCormack, Elise 7[abs] Tecun, Stephanie 105 [IM] 320 De la Monte, Suzanne 23 McDonnell, Janice 27 Tellioglu, Tabir 279 Childhood Asthma and DePue, Judith 374 McDonough, Kim 5[abs] Teno, Joan 31 Obesity 161 Diaz, Judy 105 McGarry, Kelly A. 72,77,81 Theodoropoulos, Nicole 342[abs] Circumstances of Suicide Deaths Dhillon, Jaspreet 4[abs] McGarvey, Stephen T. 374 Tong, Iris L. 73 in RI, 2004-6 [HBN] 288 Diamond, Amanda M. 138,216 McIntyre, Bruce 232,262 Tsiaras, Sarah 6[abs] Clinical Update on Optic Neuritis Dixon, Lauren 232 McKenzie, Michelle 271 Tung, Glenn 294 and Multiple Sclerosis 57 Dizon, Don S. 5[abs] McNicoll, Lynn 321 Tuya, Ana 31,65 Dollase, Richard 252 McNulty, Brendan 226 Verhoek-Oftedahl, Wendy 288 Donnelly, Edward F. 60,288 Mega, Anthony 332 Viggs, Arul 166 COLUMN KEY Donnelly, Kevin P. 109 Mellion, Michelle L. 8 Viner-Brown, Samara 323 Dworkin, Lance 6[abs] Mello, Michael J. 100,339 Viticonte, Janice 242 AP: Advances in Pharmacology Duffy, Christine 77 Merchant, Roland C. 15 Wachtel, Tom J. 91 Duffy, Susan J. 15 Mermel. Leonard A. 345[abs] Wakeman, Sarah Elizabeth CC: Creative Clinician Elias, Georg 345[abs] Mernoff, Stephen T. 148 351[poem] GPP: Geriatrics for the Practicing Farrell, Timothy W. 65,378 Metz, Yasmin 63 Wang, Feng 4[abs] Physicina Feller, Edward 23,63,255 Mileno, Maria 23 Waters, William J. 33 Fenton, Miriam 288 Mitty, Jennifer 208,219 Weinberg, Marc S. 346[abs] HBN: Health by Numbers Fontes, Janice 199 Modesto, Maria Mae 4[abs] Weinsier, Steven B. 5[abs],301 IM: Image in Medicine Foody, JoAnne M. 27 Monroe, Alicia D. 252 Wetle, Terrie Fox 247,378 Freye, Henry B. 174 Morton, John 88 Wheat, Anna 387 PHB: Public Health Briefing Friedman, Joseph H. 2,42,70,98, Munusamy, Venkataraman 283 Wier, Lauren M. 86 PL: Physicians Lexicon 126,134,158,206, Murphy, Marjorie A. 57 Woodfield, Courtney A. 196 238,266,298,330, Najarian, Shaun 153 Wu, Chuang-Kuo 132 POV: Point of View 358 Nanda, Aman 378 Wu, Difu 129 39 VOLUME 92 NO. 1 JANUARY 2009 Colorectal Cancer in RI 103 Health Risks among Rhode Island High Negotiating Clinically Workable Redesign of Chronic Care for Contemporary Management of Peripheral School Students 1997-2007 [HBN] 349 Solutions across Cultures: Hepatitis C in a RI Homeless Arterial Disease – Helmet Use among 510 Injured Lessons Learned 365 Population based on Provider A Review 305 Motorcyclists in a State with Neurological Complications of Compliance with Hepatitis C Covered by Still at Risk: How Limited Helmet Laws 100 Lyme Disease 216 Guidelines 116 can Policymakers Address Heritage 35,68,96,124,156, Neuropathic Pain 8 Renal Artery Stenosis: Clinical and Increased Cost Sharing in 204,236,264,296, Neuroprotective Trials: No Longer Therapeutic Implications 315 Private Health Insurance? 109 328,356,392 a Cautious Optimism 158 Rhode Island Board of Medical Creative and Sensory Therapies Hospital Payment Monitoring New Strategies for Common Licensure and Discipline, Enhance the Lies of People Program: The RI Experience Eye Diseases 44 2007 Summary [PHB] 232 with Alzheimers [PV] 154 [QP] 27 Nutrition in the Older Adult Rhode Island Survey of Physician Creative Clinician 23,226,283 Hospitalizations and Associated Costs [GPP] 65 EMR Adoption [PHB] 64 Cultural Bias and ‘No-Scalpel for Principal versus Additional One Man’s Poison…[is another’s Rituximab in Treating Refractory Vasectomies’: Lessons Learned Diagnosis of Asthma: Implica- unfurrowed brow] 359 Thrombotic Thrombocytopenic by a Brown Anthropologist tions for Monitoring Children’s Opioid Therapy and Prescription Purpura [CC] 226 in Mexico 369 Health [HBN] 199 Drug Diversion 268 Role of Pollens in Allergy 174 Decline and Fall of the Red House Calls and Home Care [GPP] 91 Osler and the Art of Sexual Dysfunction after Tomato 267 Hypokalemic Thyrotoxic Periodic Paralysis Procrastination 299 Menopause: Assessment and Dementia Screening: Should We Screen in a Young African Overdose Prevention: Naloxone Treatment 77 Asymptomatic Older American Male [abs] 344 with Long Acting Opioids 271 Shape of Medical Terms [PL] 91 Adults? [GPP] 224 Images in Medicine 63,196, Overweight and Diabetes in Sleep Disorders in the Elderly 144 Department of Health Promotes 258,294,320 American Samoa: The Cultural Smoking and Tooth Loss in e-Licensing for Physicians Incarcerated Inguinal Hernia Translation of Research into RI, 2004 [HBN] 119 [PHB] 202 as the Presenting Feature of Health Care Practice 374 Smoking in Theatrical Depression and Associated Health Carcinoma of Unknown Pain Management in the Elderly Productions [PV] 352 Risks and Conditions Among Primary Site [IM] 63 Surgical Patient 11 Some Thoughts on Ethical RI Adults in 2006 HBN] 25 Increasing Post-partum Depression Parkinson’s Disease in the Guidelines for the Neurology- Development of a Student-Based Detection in RI: Targeting Elderly 136 Impaired Elderly 126 Teaching Academy 252 Pediatric Providers 255 Patterns of Health-Related Status of Drug-Eluting Diabetes Mortality in RI: Comparing Index 2007 36 Quality of Life and Associated Coronary Stents 309 Underlying Cause of Death Infection of Malignancy by Health Risks among RI Adults Still [poem] 351 versus Any Listed Cause PET/CT: A Cautionary Case in 2004 [HBN] 259 Successful Interventions for of Death [HBN] 86 Report [abs] 5 Peripheral Neurology: Speech Avoiding Readmission in the Dilemma of Multiple Meanings [PL]263 Inhibition of Glycogen Synthase Concerns in the Elderly 142 Elderly [GPP] 285 Do Quality of Life Measures Kinase (GSK) – 3 beta Physician’s Lexicon [PL] 34,67,94, Successful Mitral Valve Repair Measure Anything we Want Attenuates Progressive Renal 123,155,203,235, is Associated with Preoperative to Measure? 298 Inflammation in Rats with 263,295,327,355,391 Left Ventricular Function Dr. Keefe and his Surgery 113 Unilateral Ureteral Obstruction Point of View [PV] 33,154,352 and Immediate Post Repair Driving Safety among Older [abs] Inner City Asthma 164 Political Economics of Public Anterior Leaflet Mobility Adults 146 Internet Prescribing and the Health Neglect [PV] 33 [abs] 6 Effects of Erythropoletin Adjust Physician Patient Relationship Post operative Pain Management Tenacity of Tuberculosis 331 Automated Protocols on [PHB] 326 for the Opioid-Tolerant These are the Times that Try Hemoglobin Levels in ESRD Intracerebral Aspergillosis [CC] 2 Patient 276 Men’s Soles 239 Patients [abs] 346 Introduction: ACP Abstracts 342 Practicing Physicians’ Guide Ticks and Tick-Related Illness 209 Eight Little Wrist Bones {PL] 235 Introduction: Lyme Disease 208 to Pressure Ulcers in Towards Cultural Humility in Electronic Medical Records 266 Introduction: Medical Education 240 2008 [GPP] 382 Healthcare for Culturally Endothelial Keratoplasty 45 Introduction: Menopause 72 Predicting HIV Viral Load by Diverse Rhode Island 361 Enigmatic Words of the Introduction to Geriatric Immunological Trends: Treatment of Menopausal Hot Urinary System [PL] 295 Neurology Issue 126 Implications for Identification Flashes 73 Epilepsy in the Elderly 138 Issues of Sexuality in the Elderly of Treatment Failure in Trends of Visits to RI Emergency Estimating the Incidence of [GPP] 321 Resource-poor Settings Departments for Pediatric New Onset Lyme Disease Kidney: A Precious Gift or a [abs] 344 Sexual Exposures, in RI [HBN] 229 Stolen Organ? 99 Prefixes of the Past [PL] 155 1995-2001 15 Estrogen Inhibits Cardiomyocyte Latex Allergy 184 Preparing for the Silver Tsunami: Trichiasis [poem] 124 Hypertrophy by Modulating Lyme Disease in Children and The Integration of Geriatrics Tuberculosis Outbreak in a RI Calcineurin Signaling Pregnant Women 212 into the new Medical High School [PHB] 290 Pathway [abs] 4 MR Imaging of Acute Appendicitis Curriculum at the Alpert Update on Stinging Insect Evaluating Geriatrics in the Medical in Pregnancy [IM] 196 Medical School 247 Allergy 171 School Curriculum: Using Management of Behavioral Presbyopic Intraocular Lenses 48 Update on the Management of Student Journals 378 Problems in Dementia 335 Prescribing for Self and Others Atherosclerotic Carotid Evaluation of Case Management Services Medical History 42 [PHB] 262 Artery Disease 301 for Lead Poisoned Medical Intervention for Displaced Prognostication: Medicine’s Updates and Controversy in the Children in RI [HBN] 384 Hurricane Katrina Victims Lost Art [GPP] 347 Treatment of Lyme Eye Injuries Treated in RI Airlifted to RI 20 Public Health Briefing [PHB] 64, Disease 219 Hospitals [HBN] 60 Medical Notes 358 88,153,202,232,262, Use of Urine Drug Testing to Feeding Tubes for Nursing Menopause and Mood 8 290,326,354,387 Monitor Patients Receiving Home Residents with Mental Health among Children Pulmonary Embolism in a Patient Chronic Opioid Therapy Advanced Dementia: How with Special Health Care with Pernicious Anemia and for Persistent Pain to Approach Feeding Tube Needs in RI [HBN] 3231 Hyperhomocysteinemia Conditions 279 Decisions [GPP] 31 Methadone Analgesia for Persistent [abs] 4 Value Equation: Costs and Fever of Unknown Origin [abs] 342 Pain: Safety and Toxicity Pyogenic Ventriculitis [IM] 294 Quality of RI’s Health Forty Days in Limbo PL] 67 Considerations 273 Quadrivalent Human Plans [HBN] 151 From Telepathy to Telekinesis [PL] 327 Methicillin-resistant Papillomavirus Vaccine Variations in Laboratory Testing Gait in the Elderly 134 Staphylococcus Aureus [PHB] 387 During Medical Clearance of Genetic and Functional Adaptation Colonization of Surgical Quality of Sleep in Hospitalized Patients Psychiatric Patients in the of Pancreatic Beta Islets To and Medical Residents [abs] 346 Emergency Department 339 Pregnancy: Potential for [abs] 345 Quality Partners of RI 27,131 Vascular Disease: Medical Therapy, Gene Therapy in Diabetic Mild Cognitive Impairment, Quantitative Prefixes of Medical Surgery and Interventional Patients [abs] 345 Healthy Aging and Vocabulary [PL] 123 Technologies 300 Geriatric Rehabilitation in the Alzheimer’s Disease 132 Quest to Conquer Age-Related Vital Statistics 44,67,94,123, New Millenium 148 Mission Statements 238 Macular Degeneration 51 155,203,235,263, Geriatrics for the Practicing Musculoskeletal Manifestations Questionable Art of Detachment 3 295,327,355,391 Physician [GPP] 31,65,91,121, of Lyme Disease 213 Rapids [poem] 287 Vocabulary of Medical Science 197,224,285, My Ties to Big Pharma 70 Rat Doctors 330 [PL] 34 321,347,382 National Asthma and Education Rating Instruments 2 Warren Alpert Medical School of Health by Numbers 25,60,86, and Prevention Program Recurring Meningitis: Recurrence Brown University: Class of 119,151,199,229, (NAEPP) Guidelines: Will after Suppressive Therapy – 2008 242 259, 288,323,349, They Improve the Quality of Can We Call for Life-long When is a Somatic Disorder 382 Care in America? 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