Good afternoon. Welcome to our concurrent session number nine. I'm Dr. Rogel Gupta from Stanford and Dr. Dave from UC Irvine. We're going to begin with Dr. Richter, a short oral number 73, characteristics associated with a clinically important treatment response in women undergoing non-surgical therapy for fecal incontinence. And how do I move, just use this thing to move the slides up? Cool. Other things right here, okay. Good afternoon. I would like to acknowledge the support of the Pelvic Floor Disorders Network and my investigators in the network. These are our disclosures. We're going to continue with the theme of FI. As you all know, conservative treatment for fecal incontinence includes education, pharmacotherapy, and pelvic muscle exercises with or without biofeedback. To my mind, in order to optimize FI treatment outcomes, understanding demographic and clinical factors associated with FI treatment success is important. The objective of this planned secondary analysis was to identify clinical and demographic characteristics associated with a clinically important response to conservative fecal incontinence treatments. This was performed in women randomized in a factorial design to loperamide or placebo and anal-rectal exercises with biofeedback or just an educational pamphlet. Clinical and demographic data were obtained from women participating in the capable trial. Adjusting for clinical site, age stratum, and treatment, bivariate analyses were performed to identify baseline participant demographic and clinical variables associated with treatment response at six months using two separate definitions. Number one, a minimally clinically important difference in the St. Marks scores, which, as you know, is defined as a decrease in five points. Of note, this was the primary outcome for the capable trial. And two, a 50% reduction in FI episodes, as this is an outcome that we see quite a bit in the FI literature. So clinically relevant variables occurring in greater than 10% of participants with a P less than 0.2 in bivariate analyses were included in multivariable models. Logistic regression models were fit to estimate each outcome and adjusted odds ratios with 95% CIs were obtained. Interaction with treatment group was evaluated for one predictor at a time and models were run with and without controlling for adherence. So these are some select baseline criteria of all capable participants. Mean age was about 64. The majority of women were white. 30% of women were obese. Most of the women were postmenopausal. Importantly, the mean number of FI episodes per week was 11, so a fairly severe population. With regard to fecal incontinence type, about a third were urgency predominant, a third passive, and a third combined. The St. Marks score at baseline was 14 out of a high of 24. And if we look at exercise adherence at six months, 25% of subjects stated that they never missed doing their exercises. And with respect to drug adherence at six months, approximately 44% stated that they did not miss their medications. As you can see, a response rate of 52% met the St. Marks MID criteria and characteristics associated with achieving a St. Marks MID included BMI, vaginal estrogen therapy, randomized treatment, St. Marks baseline score, exercise adherence and drug adherence at 24 weeks. So multivariable logistic regression was performed, and those variables found to be independently associated with achieving a St. Marks MID were the St. Marks score at baseline, as well as although the BMI category in and of itself was not significant, the subscale of overweight versus normal was significant. When controlling for adherence, these two characteristics remained, and drug adherence at 24 weeks was seen to be associated with achieving a St. Marks MID. Similarly, we looked at characteristics associated with a 50% reduction in fecal incontinence episodes. As you can see here, there were 68% of the subjects were responders. Those characteristics included randomized treatment, prior rectal or anal surgery, mean number of FI leakage episodes per week, fecal incontinence subtype, St. Marks score at baseline, and MMHQ severity scores. On multivariable logistic regression, the characteristics independently associated with a 50% decrease in FI episodes were treatment randomization, St. Marks score and FI type. When controlling for adherence, these variables remained except for St. Marks score. In conclusion, six months after treatment initiation, factors associated with clinically important treatment response were increased severity of baseline FI symptoms, increased BMI, drug adherence, FI leakage type, and combined active treatment. This information may assist us in counseling patients regarding the efficacy and expectations of conservative treatment modalities for women with FI. Thank you for your attention. Good afternoon. We have no disclosures. Public floor disorders are common with almost one in ten women. In the United States, the prevalence of pelvic floor disorders increases with age and menopausal status, reaching 39 to 50% among women 60 years and older. Studies have demonstrated the presence of estrogen receptors in the bladder, pelvic floor, and anal sphincter. As such, estrogen has been explored as a potential mediator of pelvic floor disorders, but with mixed clinical results. Phytoestrogens are present in women who are biochemically similar to estradiol and are present in foods such as nuts, breads, and soy products. The current literature on phytoestrogens and pelvic floor disorders is very limited, with no prior studies examining the association between phytoestrogens and fecal incontinence. Therefore, the objective of this study was to investigate the association between urinary phytoestrogen levels in postmenopausal women and symptoms of fecal incontinence, or FI. This was a cross-sectional study utilizing the National Health and Nutrition Examination Survey, or NHANES data, from 2005 to 2010. We defined postmenopausal women as age greater than or equal to 40 years and either having both ovaries removed and or having no period in the past year due to hysterectomy or menopause. Urinary concentrations of 6 phytoestrogens were measured using high-performance liquid spectrometry. FI was defined as leakage of mucus, liquid, or solid stool occurring at least monthly on the Fecal Incontinence Severity Index, or FISI. Demographic information included age, race, body mass index, or BMI, obstetric history, and hysterectomy status. Prevalence estimates and 95% confidence intervals were calculated. The Pearson's Chi-squared test was used to assess the association between having FI and risk and protective factors. Multivariable logistic regression models were used to assess the association between FI symptoms and log-transformed urinary phytoestrogen levels. Prevalence odd ratios and 95% confidence intervals were reported from the multivariable models using the appropriate sampling weights, with the level of statistical significance set at P less than 0.05. Among the 1,341 postmenopausal women with phytoestrogen data, 91.1% reported FI symptoms. Postmenopausal women with and without FI symptoms had a mean age of 63.2 years, without differences by mean age or among racial groups. Compared to women without FI symptoms, women with FI symptoms were more likely to report diabetes, chronic lung disease, and depressive symptoms. Women with FI symptoms were also more likely to report using female hormones compared to women without FI symptoms. After adjusting for potential confounding covariates including age, race, BMI greater than or equal to 30, parity, hysterectomy status, smoking status, diabetes, chronic lung disease, depression, and hormone use, we found that increased level of urinary O-dismethylanglosin, or ODMA, was associated with decreased odds of FI symptoms. The strengths of this study include the population-based study design and large sample size. Validated questions were used to assess for FI symptoms. In addition, this is the first study to assess the association between phytoestrogens and FI symptoms in postmenopausal women. The limitations of this study include the cross-sectional nature of the NHANES dataset, and therefore the inability to prove causality between phytoestrogens and FI symptoms. Given the definition of postmenopausal women, this study sample may not reflect an accurate representation of the general postmenopausal population. Although we control for potential confounding factors, there may be other confounding variables that influence the study outcome. In conclusion, increased urinary ODMA level was associated with decreased fecal incontinence symptoms in postmenopausal women. Further investigation is warranted to explore the relationships between phytoestrogen and the development of pelvic floor disorders in postmenopausal women. Thank you, and I welcome your questions. Thank you for the opportunity to present our work. We're grateful to our funders, and we have no relevant financial disclosures. Mind Over Matter, Healthy Bowels, Healthy Bladder, is a group-based intervention to improve both bladder and bowel continence. A small group of 8 to 12 older women who are led by a trained facilitator from the community who is not a healthcare professional. The workshop consists of three sessions over one month, during which participants build knowledge, skills, and self-efficacy for behavior changes to improve symptoms. This intervention was adapted with permission from Kera Tannenbaum's Dare to Age Well intervention. Our objective was to determine the impact of Mind Over Matter on urinary incontinence, bowel incontinence, and care-seeking at three months after the intervention. We conducted an individually randomized group treatment trial with weightless control. All participants were enrolled and randomized and completed surveys at the same three time points. Those allocated to the treatment group completed the mom workshop after the baseline survey, while those in the control group completed the mom workshop following the last data collection time point. Women over the age of 50 who had had any incontinence in the past three months were eligible for participation. They were recruited by community organizations and screened and consented by our study coordinators. Written questionnaires were obtained at three time points and included demographics, health behaviors, incontinence for care-seeking, as well as validated demographics for incontinence symptoms and quality of life and self-efficacy and depression. Our primary outcome of interest was the patient global impression of improvement of urinary incontinence at three months after completing the intervention. Appropriate statistical testing was utilized. We enrolled 122 women in six communities around Wisconsin. Of note, 95% returned our four-month questionnaire. There were no significant differences between treatment and control groups at baseline. Participants had a mean age of 75, were predominantly overweight, and non-Hispanic white. Approximately 50% had both UI and FI symptoms. The next two slides present color-coded survey results. These are color-coded responses to the PGII. The treatment group is on the top line and the control group at the bottom line. You can see a significant difference in the rate of improvement in UI symptoms between the treatment and control groups. It's also notable that only 5% in the treatment group reported worsening of symptoms versus 19% in our control group. You can see similar differences in bowel symptoms with more women in the treatment group having improved bowel symptoms and only 3% worsening versus 21% in the control group. Significantly more improvement was seen in the treatment group as compared to the control group for UI and FI, even when controlling for community, which is important when conducting a group-based intervention. This slide also demonstrates significant differences across multiple validated instruments assessing incontinent severity, quality of life impact, and self-efficacy. Depression scores were not statistically significant between the two groups. This slide just talks about how often patients are performing Kegel exercises, often or always. As you can see at baseline, not many people were performing them. However, at three months, 93% of our patients were performing Kegel exercises often or always, and 62% three months after the intervention were doing so. We did not see any differences in care-seeking between the treatment and the control group. Our study is limited by the short duration of follow-up, a homogenous sample, and lack of clinical assessment. Its strengths, however, include that it's an adequately powered randomized trial with a low attrition rate. In conclusion, bladder and bowel continence can be improved through an intervention implemented completely without healthcare professionals. There is high potential for sustainability given existing infrastructure for dissemination of other evidence-based chronic disease self-management programs. The long-term impact and impact in other populations remains to be seen. Thank you so much. I welcome your questions. We're now open for questions for any of the presented portals. Elliot Greenberg from Springfield, Massachusetts. Thank you for those talks. This is really interesting stuff, and anything we can do to improve people in continence non-surgically is certainly helpful. I have a couple of questions for the last speaker. Two questions. First of all, how difficult is it to recruit women for a group therapy that involves this type of therapy? And I'd also love to hear a little bit more about what actually the sessions are included, what goes on in the sessions, and how is it performed? Those are great questions. To answer your first question, the recruitment was different based on the different sites. So some sites had flyers that they put out in senior community centers. Some sent emails. Some it was also by word of mouth. So we had kind of varying modalities between the groups. And I think it was harder initially to recruit. However, we were able to get appropriate power. And to your second point, mainly these groups were led by a facilitator who had about two days of training to just kind of talk about things. And they recognized kind of their limitations of not being healthcare providers and were able to appropriately direct questions as well. They had a standard script though that was for each of the sessions. So was it primarily teaching Kegel or was it diet Kegel? I'm just curious about kind of like what the curriculum was. Each one had a separate component. So they did focus on diet as well as Kegel exercise and other lifestyle modifications. Thank you. Question for Dr. Cardenas. These phytoestrogens were in the diet. You measured them in the bladder. Have you ever thought about measuring them in the stool? That's a great question. So we used the NHANES data set. And so that's how they measured it is urinary excretion. So that would be a great way to in the future look for systemic phytoestrogen levels through the stool or serum. And a follow-up question. So phytoestrogen absorption requires good gut health. Were there any questions that you looked for when you were doing your multivariate analysis to sort of screen out patients that perhaps had malabsorption disorders that might impact your results? So we looked at several health conditions including diabetes, depression, hypertension. We did not specifically look at like any GI malabsorption disorders. We looked at thyroid disorders and things like that. But that's a good point. Okay. Well, thank you to our presenters. And we'll invite our next group of three presenters up. Randomized double-blind trial of short versus long-acting analgesia at the sacrospinous ligament. Thank you. Thank you, Dr. Cardenas. Thank you, Dr. Cardenas. Thank you for allowing us to present our work. This study was funded by a grant from the American Association of Gynecologic Laparoscopists. Enhanced recovery pathways reduce the length of hospital stay, help to provide adequate pain control with decreased narcotic need and lower costs. An essential component of any enhanced recovery pathway is effective dynamic pain relief using multimodal pain therapies. Use of intraoperatively injected local anesthesia can be an essential component of postoperative pain relief. Long-acting agents are available but they're not well studied in urogynecology. The primary objective in this project was to evaluate whether use of long-acting local anesthetic injected at the sacrospinous ligament would decrease postoperative pain as compared to short-acting local analgesia. Our primary outcome was buttock-specific pain. Secondary outcomes included global postoperative pain, opioid use, return to baseline pain status, trial avoid results and satisfaction with pain control. This was a randomized double-blind trial comparing use of lidocaine versus liposomal bupivacaine at the sacrospinous ligament. Patients were randomized one-to-one to these two arms. Those in the lidocaine arm received lidocaine with epinephrine injected at the sacrospinous ligament and those in the liposomal bupivacaine arm received the liposomal bupivacaine mixed with bupivacaine plain at the ligament. The authors determined that a minimally important difference clinically would be a 45% difference in pain and 26 subjects were required. Our study population did not differ in terms of their baseline demographics between the arms. The procedure characteristics also did not differ between study arms, including performance of concomitant procedures, duration of the surgical procedure, estimated blood loss, stirrups used for positioning or use of a vaginal pack. Moving on to our outcomes, our primary outcomes were postoperative pain, and our secondary outcome was buttock-specific pain, which was assessed using a visual analog scale at multiple postoperative time points. We compared this between groups and no differences were noted at any postoperative time point. Additionally, we compared the proportion of patients reporting no pain at all of these time points and there were no differences between the groups for buttock-specific pain. For our secondary outcomes, global pain was also assessed using a visual analog scale at multiple postoperative time points. And when this was compared, there was a difference between the groups only at the 36-hour time point with subjects in the lidocaine group reporting more pain than those in the liposomal bupivacaine group, with a mean pain score of 4 and 0, respectively. Proportion of patients reporting zero pain was also different only at the 36-hour time points, with three patients in the lidocaine group and nine patients in the bupivacaine group reporting zero pain. Opioid use was compared as milliequivalents of morphine, and this was measured at the time of hospitalization and at four and seven days post-discharge and no differences were noted between the groups. Proportion of patients using zero milliequivalents of morphine at these same time points was also assessed and no differences were noted. We also found no differences in return-to-baseline pain status or patient satisfaction with pain control. Based on the opioid results, we did find a difference in the groups, with those in the lidocaine arm passing the void trial at 88 percent and those in the liposomal bupivacaine arm passing the trials at 50 percent. To summarize our findings, there were no differences in buttock-specific pain when we compared short versus long-acting local analgesia at the sacrospinous ligament. Global postoperative pain differed only at the 36-hour time point, and there were more failed void trials in the liposomal bupivacaine arm. We believe that long-acting local analgesia at the sacrospinous ligament at the time of sacrospinous ligament fixation does not provide benefit over short-acting analgesia and may impair bladder function in the immediate postoperative period. I'd like to thank our study staff and my co-authors for making this possible. Thank you. Thank you for the opportunity to present our work. We have no disclosures. Myofascial pain is a chronic pain disorder characterized by the presence of tenderness to palpation, leading to both local and referred pain. In the pelvis, myofascial pain may be identified within the levator ani and obturator internus muscles. It is commonly found in patients with chronic pelvic pain, but has also been reported in patients with other pelvic floor disorder symptoms. Prevalence estimates vary widely, from 14% to as high as 78%, and are highest in studies where patients are universally screened. Unfortunately, physical examination methods to assess these muscles for the presence of trigger points or tenderness, which is characteristic of myofascial pain, are poorly defined. The objective of our study was to develop a simple and reproducible examination to screen for the presence of pelvic floor myofascial pain. During this examination protocol development, we conducted a systematic review on published strategies for assessment of the pelvic floor. Key examination components identified through this systematic review were incorporated into the examination protocol. The protocol was developed through collaboration between FPMRS surgeons and women's health physical therapists at our institution. Once developed, the protocol was tested in a simulated patient, revised based on simulated patient feedback, and repeated in the same simulated patient at a separate encounter, where consensus on the examination components was confirmed. We used a four-sensing resistor to standardize the amount of pressure applied to the muscles on internal examination. This small, thin device was applied to the index finger of the examiner and worn under the glove during the examination to record the pressure applied from the examining finger onto the muscles. Pressure was also standardized on all examinations by single-digit palpation of an area of the mid-thigh to provide a reference for the pressure of palpation the patient should expect internally and to demonstrate that palpation of a skeletal muscle is typically sensed as pressure and not pain. We recruited new patients presenting between November 2017 and March 2018. Examinations were performed on enrolled patients by paired, independent examiners who were blinded to the results of the prior examination. The presence of pain at external sites was reported as a binary yes or no response. Pain scores on palpation of the internal sites were reported on a verbal pain rating scale ranging from 0 to 10. Agreement between scores from each examiner was calculated using percent agreement at external sites and Spearman's rank correlation coefficient at internal sites. The final examination protocol begins with the patient seated on the examination table with both feet resting flat on the floor. The sacroiliac joints are identified and palpated bilaterally and the patient is asked whether this elicits pain. The patient is then asked to recline to dorsal ethotomy with her feet in the footrest. The point just medial to the anterior superior iliac spine, which corresponds to the insertion of the iliacus muscle, is then identified and palpated bilaterally. Additionally, the insertion points of the rectus pulmonum muscles at the superior aspect of the pubic symphysis are palpated. The patient is then oriented to the internal examination and the verbal pain rating scale. The index finger of the dominant hand is used to palpate the internal muscles once in the center of the muscle belly, then in a sweeping motion along the length of the muscle in the direction of the orientation of that muscle. The examination proceeds counterclockwise, beginning with the right obturator internus and concluding with the left obturator internus. After completion of the pelvic floor myofascial examination, the remainder of the pelvic examination, including urethral catheterization, are performed. Thirty-five patients were enrolled and underwent pelvic floor myofascial examinations by two providers according to the developed protocol. The majority of enrolled patients were Caucasian, post-menopausal and overweight. Force on internal examination, as measured using the force sensing resistor, was similar between the four examiners. Agreement was high at each external point and reported pain scores on internal sites spanned the entire range of possible scores. Correlation was also high between examiners at each internal point. In conclusion, we developed a simple and reliable screening examination for pelvic floor myofascial pain and demonstrated its reproducibility between examiners. We advocate for use of this examination by providers who routinely evaluate patients presenting with chronic pelvic pain in order to screen for an underlying myofascial component. Given emergent evidence for a role of pelvic floor myofascial pain and other pelvic floor disorders, incorporation of this myofascial pain screening examination should be considered as part of the evaluation for all patients with new pelvic floor complaints. Thank you. Thank you for the opportunity to present my research. Our disclosures are as listed. Stress is emerging as an important factor in the development of chronic pain syndromes such as vulvodynia, interstitial cystitis, fibromyalgia and irritable bowel syndrome. It has been reported that patients with chronic pelvic pain have difficulty coping with stressful situations, suffer from depression and or anxiety, and report that stress initiates or exacerbates existing symptoms. These syndromes are often comorbid and suggest that there is a common etiology affecting the development of visceral pain. Of the chronic pain syndromes, vulvodynia has been reported to have the highest prevalence of comorbidity with other chronic pain disorders. Amongst those with vulvodynia, the reported prevalence of interstitial cystitis, fibromyalgia and irritable bowel syndrome are 6, 10 and 10% respectively. In addition, vulvodynia has been reported to have the highest prevalence of chronic pain syndromes. Chronic stress via water-avoidant stress is a validated interstitial cystitis model. It has been shown to have a disruption of the epithelial layer of the bladder, increased number of mast cells, urinary frequency and sustained bladder hyperalgesia greater than one month after stress exposure. Stress during early development and general chronic physiologic stress has been associated with permanently enhanced nociceptive signaling and increased sensitivity within the gastrointestinal and urinary systems of the rodent. Animal models of stress have also shown functional changes in the smooth muscle of the affected organ. Given the frequent comorbid presentation of pain syndromes and the relationship of stress and chronic pelvic pain and smooth muscle function, we sought to determine if chronic environmental stress also induces vaginal pain and alters vaginal contractility in an anxiety-prone rodent model. In this study, 16 female Western Kyoto rats predisposed to anxiety were separated into two groups. Group 1 were exposed to 10 days of water-avoidant stress. Group 2 were handled controls. This remote response was obtained by electromyographic activity of the external oblique muscle, which was recorded while the vagina was descended at increasing volumes of 0, 0.5, 1, 1.5 and 2 cc's. In addition, vaginal tissue was then harvested, separated into proximal and distal vaginal segments, placed in an organ bath of oxygenated Kreb solution and isometric tension transducers were used to measure vaginal contractility. Statistical analysis was performed using a student's T-test and further analysis of vaginal contractility was performed using multilinear regression modeling. Overall, the results in this study showed that the WASP group had higher visceral motor responses during vaginal descension compared to controls. The WASP group also had lower vaginal contractility responses to carbacol compared to controls. In this initial figure, this is showing the visceral motor response in response to a vaginal descension of the varying volumes of 0.5, 1 cc, 1.5 cc's and 2 cc's. For this particular study, we found a statistically significant difference as the vagina is being descended at 1 mL between the control and the WASP group. This finding is similar to other studies that have reported neonatal maternal stress and its impact on vaginal descension and increased visceral motor responses. This second graph is looking at the dose response curve of carbacol for the proximal and distal vaginal tissue. And as you can see in this study, the control group is the top curve and the WASP group is the bottom curve. In the control group, they were found to have a higher contractility in response to carbacol compared to the WASP group. This is also similar to studies that have looked at bladder function in response to carbacol in an interstitial cystitis model. Currently, there aren't any studies looking at the effect of stress on vaginal contractility in response to carbacol, but our study was similar to studies looking at the response of stress on bladder tissue in response to carbacol. A strength of this study is that it's one of the few evaluating the impact of stress on vaginal tissue contractility and sensitivity. One of the limitations is that in our particular study, we did not account for the time of the estrous cycle, which could be a potential confounder as hormones may play a role in vaginal contractility and sensitivity. However, when doing a review of the literature, other studies looking at neonatal maternal stress and its impact on vaginal sensitivity found that stress was able to override the impact of the estrous cycle. And there's also a question as to whether doing vaginal smears to assess the stage of the estrous cycle, how that may also impact vaginal sensitivity. In conclusion, we found that chronic stress induced increased visceral motor response during vaginal distension and altered vaginal contractility. This suggests that this water-avoiding stress model may also be a potential animal model for the study of vaginal hyperalgesia, in addition to it already being used as a validated model for interstitial cystitis. Thank you. We're now open for questions for the previous three presenters. Hi there. Laura Fraser, Pelvic Floral Physical Therapist from Northern California. Dr. Meister, really great job. Question about the way in which the patients were examined. Was it just one patient, or was it two patients, or was it three patients? And to that point, did you notice a sidedness with myofascial pain? Did patients present with pain in one side of the pelvic floor more than another? Thank you. To answer your first question, it was just one hand. So all of the examiners that were part of the study were right-handed and used their index finger of their right hand for the entirety of the exam. Interestingly, sort of anecdotally, it does seem that there is a sidedness. We tend to see a little bit more or higher scores on the right side for most of our patients, but it's sort of anecdotal from this data. Thank you. To answer a follow-up question, I'm Colleen Fitzgerald from Loyola in Chicago. The flexiforce is really interesting, and I'm wondering if you're suggesting that that become part of the standardized exam, or you just used it for research purposes? Thank you. We used it for research purposes. It was actually nice and very slim and could easily fit under the glove, but sort of the entire setup and everything as part of the exam was a little... Cumbersome. Much. And that's why we incorporated the palpation of the patient's thigh, and we were able to show that the sort of maximum force that we used to palpate using the force sensing resistor corresponded pretty nicely to the depth of palpation on the thigh, and we thought that that was a little bit more readily usable in the clinic. It might be a nice tool to use for training, too, like for the residents. Yes. Thank you. Great suggestion. I'm Rhonda Cotterino, Chicago, and this is for Dr. Meister. You said you palpated the levator ani, and did you vary your stroke based upon the fiber orientation of the three different muscle fibers that you used? So we attempted to palpate in the center of the muscle belly, and then along the length of the various muscle bodies as we could. That being said, I think sort of being sure that we're identifying each specific muscle component of the levator ani is a little challenging during an examination, so we didn't necessarily ensure that we were palpating each muscle belly specifically. So you didn't really use the idea that is proposed elsewhere, that you palpate perpendicular to the fiber orientation first to find the top band, and then to palpate within the top bands to look for the most tender spot? You did not do that? We did for the most part. I just meant to say that we didn't necessarily isolate each individual muscle belly of the levator. Okay. Thank you. You know, as far as measuring the pressure, I can't really tell you against the thigh punch suggestion. If you're a barista, when you're putting the pressure on an espresso, you're taught to press on a scale because you're supposed to put 30 pounds of pressure on the coffee to get the perfect shot. You could actually do that. You could very easily figure out what the equivalent pressure is just putting your finger on a scale and use that as resident teaching protocol for a much simpler, easier way to figure out the pressure. And that would be from Blair. Thank you. Thank you for your presentation. We'll call up the next set of speakers. Our first speaker will be Dr. Lovejoy, who will be presenting vaginal delivery and lactation-induced estrogen depression. Is there an association between breastfeeding and pelvic floor disorders? Yes, there is. There's a lot of people with pelvic floor disorders. So we all know pelvic floor disorders are common. Breastfeeding is also very common. And we know, however, that despite the known maternal and newborn benefits of breastfeeding, there is a hypoestrogenic state that's associated with lactation. The potential of this hypoestrogenic state is intriguing. There's a growing volume of literature that suggests that breastfeeding is a very common form of breastfeeding. And we know, however, that despite the known maternal and newborn benefits of breastfeeding, there is a hypoestrogenic state that's associated with lactation. The potential of this hypoestrogenic state is intriguing. There's a growing volume of literature that suggests that estrogen plays an essential role in muscle regeneration or repair. Orthopedic literature suggests that delays in regeneration can result in atrophy and scar tissue that can inhibit the return to baseline muscle function. Some of our prior or some prior studies describe prolonged breastfeeding as a risk factor for persistent postpartum urinary incontinence, both at 12 months and at 24 months. So the aim of our study was to examine the association between breastfeeding and pelvic floor disorders up to two decades after the first vaginal delivery. This is a secondary data analysis of the mother's outcomes after delivery study, a longitudinal cohort study that examined pelvic floor disorders after childbirth in which women were recruited five to ten years after delivery. PFD outcomes were measured at study enrollment and then annually thereafter using annual EPIC validated questionnaires as well as annual examination with a POPQ. Our analysis only included women with at least one vaginal delivery. All the women in our study completed a self-administered questionnaire with specific breastfeeding questions adopted from the 2008 National Immunization Survey for those women that reported breastfeeding. They were then prompted to describe the total duration of breastfeeding as well as the earliest moment that they fed their child something other than breast milk. From that information we created three exposure categories. Prolonged exclusive breastfeeding was defined as exclusive or unsupplemented breastfeeding greater than 12 weeks or equal to. Limited exclusive breastfeeding was unsupplemented or exclusive breastfeeding greater than one week but less than 12. And then unexposed, which was our reference group, women who did not breastfeed at all or were unsuccessful at breastfeeding, breastfeeding less than one week. Our outcomes of interest were stress urinary incontinence, anal incontinence and pelvic organ prolapse. SUI and AI were both defined using EPIC validated questionnaires. And POPQ was defined as the leading edge of descent beyond the hymen per POPQ examination. Demographic and clinical characteristics were compared using Chi-squared and Fisher's exact test. Generalized estimating equations were utilized to account for the multiple measures captured during annual follow-up. The following is a flow diagram showing patient selection. The initial mode study incorporated about 1,529 women, of which 750 had at least one vaginal delivery. And of those, 705 women in regards to the breastfeeding questionnaire definitively answered both duration and exclusivity of their breastfeeding status. That contributed to 371 women in the prolonged exclusive breastfeeding category, 145 in the limited exclusive breastfeeding category, and 189 in our reference group. I included this table simply to demonstrate the impact of the longitudinal data collection of multiple measures up to nine years after study enrollment. The two take-home messages here are, number one, that irregardless of breastfeeding category, a minimum of the median follow-up was at least four years, and then secondly, of the 705 women, they contributed to 3,079 person-years of follow-up. Our analysis, the incidence of SUI was 27%, of POP was 20%, and AI, 25%. Our results, we calculated both adjusted and unadjusted odds ratios, and for stress urinary incontinence. As you can see, the proportion of women with SUI was not different, irregardless of breastfeeding status for POP. Similarly, irregardless of breastfeeding status, the proportion of women with POP was not statistically significant, and finally, for anal incontinence, the proportion of women with AI was not statistically significant, irregardless of breastfeeding status. There was no observed relationship between breastfeeding and development of PFDs. So the strengths of our study, a large population, it was prospective data collection, and pelvic floor disorders were defined with validated questionnaire on POPQ examination. The limitations, we were unable to ever confirm actual delivery to the pelvic floor. There were no measures of postpartum estrogen levels, and we were unable to capture whether or not women received postpartum hormonal contraception. Also, there was a potential for breastfeeding response bias. In conclusion, our findings should provide reassurance for physicians counseling patients regarding the long-term effects of breastfeeding. Thank you. Acticumption of the Female Interstitial Cystitis Painful Bladder Syndrome, a Randomized Controlled Trial. Thank you for allowing us to present our work. We would like to thank Interstitial Cystitis Association for funding this study. We have no relevant financial disclosures. As we all know, Interstitial Cystitis Painful Bladder Syndrome is a frustrating disorder, and treatments have limited success and problematic side effects. Over 80% of these patients seek complementary alternative medicine. Acupuncture has been proven effective for other chronic pain disorders, and there is preliminary evidence showing that it's helpful in men with chronic prostatitis, chronic pelvic pain, kind of male equivalent of the Interstitial Cystitis, female pelvic pain disorders. We have two aims. One was to determine is acupuncture safe, is it tolerable, and to determine if electroacupuncture was effective in reducing pain as compared to minimal acupuncture. As mentioned before, it's a prospective, randomized, controlled, single-blinded study comparing minimal acupuncture to electroacupuncture. What the heck is minimal acupuncture, you wonder? Well, these are very small needles placed superficially about one millimeter in non-meridian points. The electrodes were connected, however, the electricity was not turned on. The electroacupuncture is a large protocol of 14 needles with, actually, electricity connected to them. So it was blinded to the patient, it was not blinded to the provider, because the doctor had to know where to place the needles. Pain criteria were women 21 through 65. I see symptoms over six months. I see, as defined by International Continence Society and AUA, in pain scores three over ten or more. We used brief pain inventory, worse pain scores, primary outcomes, and other outcomes for average pain, pain severity, pain interference score, and physical exam. This is a simple flow diagram of the study. Twenty-one patients were randomized. Once patients were randomized, they received a baseline exam and questionnaires. Then they followed the small treatment of about four or five needles to see, can these patients tolerate needle placement? Because we don't want to torture them with 14 needles if they can't tolerate four, right? Then they received six consecutive treatments. And at the end of treatment, we once again repeated questionnaires and exam. And at 12, we pull up the repeated exam and questionnaires. Our demographics were very similar in both groups and reflective of Loyola Chronic Pelvic Pain Clinic population. On this table, interesting fact is that majority of these patients in both groups failed secondary and above-line treatment modalities for IC pelvic pain, and as expected, had a number of painful comorbidities. We had no adverse events to report in either groups, and needles were well-tolerated. This table is kind of the meat of the study. I'm going to call your attention to the second blue box. As you see here, the pain interference score was effective, more effective in electro-acupuncture group. Otherwise, both groups experienced improvement in pain. The divergence happens at 12 weeks at the follow-up, where electro-acupuncture group sustained all of their improvements. The minimal acupuncture group only sustained improvement in the worst pain. This is graphic representation of what we just showed in the table. Once again, the pain interference score here, the red line, is electro-acupuncture. It dips down more and sustains result, and otherwise, worst pain was sustained for both groups. This is kind of interesting finding that we did pelvic exam. Thank you to Wash U for trying to develop wonderful standardized way to examine these women. While women that received electro-acupuncture had actual pelvic floor physical exam changes that were also sustained at the follow-up. In conclusion, yes, this is a small study. That's the downside of it. But in our study, acupuncture was safe and well-tolerated. So far, less side effects than many other treatments described for painful bladder syndrome. Although both minimal and electro-acupuncture had improvements in pain, only electro-acupuncture showed sustained improvements at 12 weeks, as well as pain interference score. Also, this is the first study that showed improvements in pelvic floor physical exam. Thank you for your attention. Obviously, we need larger studies to confirm it. We'd like to thank our collaborators that worked very hard on this over four years. All of them are in the audience. Dr. Mark Hu will include cystoscopic findings after hydrodystension in a urogynecological population, as well as the prevalence of glomerulations in a prospective cohort of asymptomatic women. Thank you for the opportunity to present our data. We have no relevant financial disclosures. The definition of interstitial cystitis, painful bladder syndrome, is evolving, and our understanding of IC is evolving as well. Society definitions for IC do not require cystoscopy with hydrodystension for diagnosis. This is partly due to the fact that glomerulations have been described in patients without a pre-diagnosis of IC, and also in patients who are asymptomatic and limited prospective data. Therefore, we set out to further characterize cystoscopic findings in asymptomatic women. Our hypothesis was that asymptomatic women will have fewer glomerulations on cystoscopy with hydrodystension than women with clinical IC, and our main objectives were to assess the difference in cystoscopic findings, namely glomerulations, between these two groups. Participants in this study were part of a larger prospective cohort examining objective findings in patients undergoing cystoscopy with hydrodystension. All participants were initially scheduled to undergo benign gynecologic or urogynecologic procedures, some including cystoscopy with hydrodystension. All participants were consented to undergo cystoscopy with hydrodystension as part of this study. Cystoscopic images were reviewed by three blinded urogynecologists. So we analyzed cystoscopic findings in asymptomatic subjects, who we defined as subjects who are nonsmokers, who were not scheduled for cystoscopy with hydrodystension, and who had either zero or one in each category of the O'Leary Symptom Index. We then compared these subjects with clinical IC, we defined also as nonsmokers, but patients of a urogynecology practice with an active diagnosis of IC who were also scheduled to undergo cystoscopy with hydrodystension at the time of the study. We used the following data analysis as shown on the slide. When comparing demographics of these two groups, we can see that both groups were in their mid to late 40s, that about half were menopausal, that BMI was around 28, and that they did not differ in autoimmune disorders or endometriosis. We can also see that patients with clinical IC were more likely to be white, more likely to have GERD and IBS, and more likely to report recurrent urinary tract infections. They were also more likely to have fewer pregnancies. In terms of incontinence and prolapse surgery, as well as abdominal, vaginal, and laparoscopic hysterectomy, the two groups did not differ. Here we see our cystoscopic findings. On the left, you see the two groups, asymptomatic women and women of clinical IC. Across the top, you see the predetermined glomerulation categories. More than 10 glomerulations in 3 to 4 quadrants, more than 10 glomerulations in 1 to 2 quadrants, glomerulations occurring at any lower rate, and no glomerulations. The difference between glomerulations was significant. There were more glomerulations in IC patients than in asymptomatic patients. I specifically want to draw your attention to the two extremes. Asymptomatic women had only a rate of 2.8% of having greater than 10 glomerulations in 3 to 4 quadrants. Patients with clinical IC had a rate of 28.7%. Asymptomatic women had a 75% rate of having no glomerulations. Patients with clinical IC had a 48.3% rate. We then performed a logistic regression model. Interstitial cystitis was associated with having extensive glomerulations in 3 to 4 quadrants, even when accounting for age, GERD, and recurrent UTI. In conclusion, we found extensive glomerulations were 10 times more likely in patients with IC compared to asymptomatic women, with an incidence of 2.78% in asymptomatic women and an incidence of 28.7% in women with IC. These findings are in contrast with limited perspective data that showed similar incidence and degree of glomerulations in asymptomatic patients and patients with IC. This study highlights the importance of further evaluations of asymptomatic women and their rate of glomerulations. Thank you. We'll open the floor up now to questions. My question is actually for Dr. Russell, I think of Loyola. I'm just curious how a single blind, if one had electrical stimulation and one did not, how did patients not know? Thank you for this question. Great question. So the electrodes were connected to needles in both groups. Four hertz is such a minimal buzzing, you can't feel it too well, and this was explained to patients that it was a low frequency stimulation, therefore you may or may not feel it. In fact, many patients that didn't get it thought they did get electrical stimulation. Thank you for clarifying. Hi, Emily Meyer from Minnesota. I have a question for our last presenter. Did you notice a difference in the response to cystoscopy with hydrodystension in patients with IC and the glomerulations? Although this was not part of this particular study, that data is collected and we will be looking at that as part of our final manuscript. But overall, anecdotally, yes. Is that another question for Dr. Westbay? As you know, choosing the proper protocol for acupuncture studies is always quite problematic, so I was curious as to how you came up with which protocol you selected and how you came up with the parameters for that protocol. Well, actually, it's Dr. Bressler, the PI in the study. Dr. Westbay is over there. But you can ask her if you want. All right. So the PI in the study, myself, is a board certified doctor of acupuncture medicine. When the protocol for painful bladder was selected, I reviewed studies from the last 50 years, including descriptive studies. And since this is such a diverse diagnosis, the easiest way to identify the treatment was to direct the study towards pelvic health. Not meaning that we are going to direct this acupuncture study for bladder mucosa, but more to fix pelvic appearance. This was, if you're wondering, Chunmo Yang Ming. This is the pairing of curious meridian responsible for the pelvis and usual principal meridian. Some of the points completely make sense on the extremities as far as neuromodulative effect covering posterior tibial nerve, et cetera. Some points actually were over the lower abdomen where the uracus, vestigial appearance is. And some points, who the heck knows from upper extremities. But they come from 2,600 years of traditional Chinese medicine. Was it different than the protocol they used in the recent endometriosis trial? I'm sorry. I'm not familiar with that trial. I'm a urologist. What was the protocol they used? Oh, now you're putting me on the spot now. Okay. So I... I was thinking on your note. I don't think so because the majority of acupuncture trials, the treatment is provided by medical acupuncturists who don't use electricity and don't place more than about 10 needles. I will look into it, but I don't think so. There are only two urologists in the country that provide acupuncture treatments and only one that's board certified. So I'll look into it for you. Thank you. Yeah. Yeah. Because they came up with... That study was... Had a negative response to acupuncture. So I was curious. Is there a difference? Well, this was positive response, I would say. No. But the endometriosis was another large NIH-funded trial that was negative. So that's why I'm... Question for Dr. Lovejoy. Over the five to 10 years that you followed these women, how did you account for women who had multiple deliveries and had variations in their breastfeeding strategies from one delivery to another? So we considered a couple of things and we did look at parity initially. But as we followed with each delivery, the women were instructed to fill out the same questionnaire. So we had the data based on what the duration and exclusivity was for each delivery. What we found was traditionally if you breastfed successfully during the first delivery, you continue to have successful breastfeeding throughout and vice versa. If you were unsuccessful, you didn't tend to retry a lot of times going forward. With that said, we looked primarily at the first or the index vaginal delivery for all of our information. And that's based on data that shows that the majority of the trauma that occurs to the pelvic floor occurs at that first vaginal delivery. Thank you very much. We'll call up our next set of speakers. Thank you for the opportunity to present our work. We have no relevant disclosures. Major depression and depressive symptoms are prevalent and they're disproportionately affect women. Anxiety symptoms are often coexisting with depressive symptoms. And depressive symptoms have been found to be highly prevalent in women with urinary incontinence as well as more common in women with prolapse than women without. We know very little about the relationship of depressive and anxiety symptoms and postoperative pelvic floor symptoms. Our aim was to determine the prevalence of postoperative depressive and anxiety symptoms in women undergoing surgery for pelvic organ prolapse at three and six months following surgery and to describe the subjects with persistent depressive and anxiety symptoms. We hypothesized that women with postoperative depressive or anxiety symptoms would have higher or worse pelvic floor quality of life scores. This was a prospective cohort study of women with symptomatic prolapse undergoing surgery enrolled between 2008 and 2013. Our primary outcomes included the PHQ-9 and the BEX anxiety inventory with depressive symptoms defined as a PHQ-9 score of greater than or equal to 10 and anxiety symptoms as a BEX score of 16 or more. Our secondary outcomes included pelvic floor quality of life measures and assessments were performed at baseline three months and six months. A total of 275 women who had surgery for prolapse were enrolled. Of these, 167 had depression and anxiety data for all three time points and are included in this analysis. Subjects had a mean age of 62 years, were predominantly white with a median leading edge of prolapse of three centimeters. Forty percent had had prior prolapse and incontinence surgeries. Nearly a quarter reported a history of depression or anxiety and subjects had a median of eight comorbidities and reported having prolapse symptoms for a median of two years. So this figure shows depressive symptoms in the dark red line and anxiety in the pink and comorbid anxiety and depression in the gray. Depressive symptoms were significantly lower at three and six months postoperatively compared to baseline going from a prevalence of 16 percent preoperatively to seven percent at six months. The prevalence of anxiety and comorbid depression and anxiety demonstrated a downward trend postoperatively. Twelve of the 167 subjects had significant depressive symptoms postoperatively. This table lists differences in their baseline variables between subjects with and without postoperative depressive symptoms with those no depressive symptoms on the left and with depressive symptoms on the right. The variables that are highlighted in pink were significantly different. So subjects with depressive symptoms postoperatively were younger, had more comorbidities, were more likely to smoke, were more likely to have baseline anxiety or depression and had significantly higher baseline PFDI and PFIQ scores compared to those without depressive symptoms postoperatively. This table lists the six-month PFDI and PFIQ scores in women with and without postoperative depressive symptoms. And women with postoperative depressive symptoms have higher UIQ scores as well as higher postoperative PFDI scores. This presentation represents our preliminary analysis, but we plan to further analyze the data to assess for other factors that may impact depressive and anxiety symptoms and postoperative outcomes. So in conclusion, the prevalence of depressive and anxiety symptoms decreases following surgery for prolapse, with depressive symptoms decreasing by 55%. In studies looking at the natural history of depression, remission rates are estimated as 23 to 43%, suggesting that the changes we saw are likely not due to natural history alone. Postoperative depressive symptoms are associated with higher UIQ and PFDI scores postoperatively, suggesting that there is likely a relationship between these mood symptoms and pelvic floor symptom bother that continues in the postoperative period. Many questions still remain regarding the relationship between mood and pelvic floor symptoms. Thank you. Fertility and anxiety prone rat, a potential rodent model for studying vaginal, hybralgesia, and vulvodynia. Thank you for the opportunity to present my research. Our disclosures are as listed. Stress is emerging as an important factor in the development of chronic pain syndromes such as vulvodynia, interstitial cystitis, fibromyalgia, and irritable bowel syndrome. It has been reported that patients with chronic pelvic pain have difficulty coping with stressful situations, suffer from depression and or anxiety, and report that stress initiates or exacerbates existing symptoms. These syndromes are often comorbid and suggest that there is a common ideology affecting the development of visceral pain. Of the chronic pain syndromes, vulvodynia has been reported to have the highest prevalence of comorbidity with other chronic pain disorders. Amongst those with vulvodynia, the reported prevalence of interstitial cystitis, fibromyalgia, and irritable bowel syndrome are 6, 10, and 10% respectively. Chronic stress via water-avoidant stress is a validated interstitial cystitis rodent model. It has been shown to have a disruption of the epithelial layer of the bladder, increased number of mast cells, urinary frequency, and sustained bladder hyperalgesia greater than one month after stress exposure. Stress during early development and general chronic physiologic stress has been associated with permanently enhanced nociceptive signaling and increased sensitivity within the gastrointestinal and urinary systems of the rodent. Animal models of stress have also shown functional changes in the smooth muscle of the affected organ. Given the frequent comorbid presentation of pain syndromes and the relationship of stress and chronic pelvic pain and smooth muscle function, we sought to determine if chronic environmental stress also induces vaginal pain and alters vaginal contractility in an anxiety-prone rodent model. In this study, 16 female Western Kyoto rats predisposed to anxiety were separated into two groups. Group 1 were exposed to 10 days of water-avoidant stress. Group 2 were handled with controls. This remotal response was obtained by electromyographic activity of the external oblique muscle, which was recorded while the vagina was descended at increasing volumes of 0, 0.5, 1, 1.5, and 2 cc. In addition, vaginal tissue was then harvested, separated into proximal and distal vaginal segments, placed in an organ bath of oxygenated Krebs solution, and isometric tension transducers were used to measure vaginal contractility. Statistical analysis was performed using a student's T-test, and further analysis of vaginal contractility was performed using multilinear regression modeling. Overall, the results in this study showed that the WASP group had higher visceral-motor responses during vaginal descension compared to controls. The WASP group also had lower vaginal contractility responses to carbacol compared to controls. In this initial figure, this is showing the visceral-motor response in response to a vaginal descension at the varying volumes of 0.5, 1 cc, 1.5 cc, and 2 cc. For this particular study, we found a statistically significant difference as the vagina is being descended at 1 mL between the control and the WASP group. This finding is similar to other studies that have reported neonatal maternal stress and its impact on vaginal descension and increased visceral-motor responses. This second graph is looking at the dose-response curve of carbacol for the proximal and distal vaginal tissue, and as you can see in this study, the control group is the top curve and the WASP group is the bottom curve. In the control group, they were found to have a higher contractility in response to carbacol compared to the WASP group. This is also similar to studies that have looked at bladder function in response to carbacol in an interstitial cystitis model. Currently, there aren't any studies looking at the effect of stress on vaginal contractility in response to carbacol, but our study was similar to studies looking at the response of stress on bladder tissue in response to carbacol. A strength of this study is that it's one of the few evaluating the impact of stress on vaginal tissue contractility and sensitivity. One of the limitations is that in our particular study, we did not account for the time of the estrous cycle, which could be a potential confounder as hormones may play a role in vaginal contractility and sensitivity. However, when doing a review of the literature, other studies looking at neonatal maternal stress and its impact on vaginal sensitivity found that stress was able to override the impact of the estrous cycle. And there's also a question as to whether doing vaginal smears to assess the stage of the estrous cycle, how that may also impact vaginal sensitivity. In conclusion, we found that chronic stress-induced increased visceral motor response during vaginal distension and altered vaginal contractility. This suggests that this water-avoiding stress model may also be a potential animal model for the study of vaginal hyperalgesia, in addition to it already being used as a validated model for interstitial cystitis. Thank you. We're now open for questions with the previous three presenters. Hi there. Laura Fraser, Pelvic Fluorophysical Therapist from Northern California. Dr. Meister, really great job. Question about the way in which the patients were examined. Was it just one hand of the examiner, or was right hand for the right side of the pelvic floor, left hand? And to that point, did you notice a sidedness with myofascial pain? Did patients present with pain in one side of the pelvic floor more than another? Thank you. To answer your first question, it was just one hand. So all of the examiners that were part of the study were right-handed and used their index finger of their right hand for the entirety of the exam. Interestingly, sort of anecdotally, it does seem that there is a sidedness. We tend to see a little bit more or higher scores on the right side for most of our patients, but it's sort of anecdotal from this data. Thank you. I have a follow-up question. I'm Colleen Fitzgerald from Loyola in Chicago. The flexiforce is really interesting, and I'm wondering if you're suggesting that that become part of the standardized exam, or you just used it for research purposes? Thank you. We used it for research purposes. It was actually nice and very slim and could easily fit under the glove, but sort of the entire setup and everything as part of the exam was a little... Cumbersome. Much. And that's why we incorporated the palpation of the patient's thigh, and we were able to show that the sort of maximum force that we used to palpate using the force-sensing resistor corresponded pretty nicely to the depth of palpation on the thigh, and we thought that that was a little bit more readily usable in the clinic. It might be a nice tool to use for training, too, like for the residents. Yes. Thank you. Great suggestion. Rhonda Cotterino, Chicago, and this is for Dr. Meister. You said you palpated the levator ani, and did you vary your stroke based upon the fiber orientation of the three different muscle fiber orientations in the levator? So we attempted to palpate in the center of the muscle belly and then along the length of the various muscle bodies as we could. That being said, I think sort of being sure that we're identifying each specific muscle component of the levator ani is a little challenging during an examination, so we didn't necessarily ensure that we were palpating each muscle belly specifically. So you didn't really use the idea that is proposed elsewhere that you palpate perpendicular to the fiber orientation first to find the top band and then to palpate within the top bands to look for the most tender spot? You did not do that? We did for the most part. I just meant to say that we didn't necessarily isolate each individual muscle belly of the levator. Okay. Thank you. As far as measuring the pressure against the thigh, one suggestion, if you're a barista, when you're putting the pressure on an espresso, you're taught to press on a scale because you're supposed to put 30 pounds of pressure on the coffee to get a perfect shot. You could actually do that. You could very easily figure out what the equivalent pressure is just putting your finger on a scale and use that as resident teaching protocol for a much simpler, easier way to figure out the pressure. And that would be from Blair. Thank you. Thank you for your presentation. We'll call up the next set of speakers. Naturophysiologic activity of the urinary bladder. I want to thank Augs for allowing us to present our research. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. I think it's a really good presentation. 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So in conclusion, multi-electrode basket catheters may result in a greater ability to detect spontaneous bladder activity, and our preliminary data show that the use of multi-electrode catheters to measure human bladder electrophysiology is feasible, but future studies aimed at recording paced electrical activity in the bladder of OAB patients, sort of in a more focused manner, and comparing these to normal controls eventually. Thank you. You're welcome. Questions? Heidi Brown, UW-Madison. This question is for Dr. Getty. Dr. Getty, have you observed similar, are you aware of other studies where patients who undergo elective surgery have improved depression scores post-operatively? I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative. I'm wondering if it's like a chicken-and-egg thing, where if you're a depression-induced patient, you're going to have to do a post-operative.

breastfeeding

pelvic floor disorders

electroacupuncture

interstitial cystitis

pain relief

cystoscopic findings

bladder wall hemorrhages

glomerulations

pelvic organ prolapse

chronic stress

vaginal pain

bladder function