April 2013

UFE and the Urinary Tract
By Kathy Hardy
Radiology Today
Vol. 14 No. 4 P. 24

Researchers noticed that fibroid embolization improved urinary tract issues, so now they’re looking to better understand their observation.

As with many conditions, the symptoms that present most noticeably in women with uterine fibroids tend to attract the most attention in both treatment and research. Hidden among the heavy bleeding and fullness in the pelvic area are lower urinary tract symptoms (LUTS), such as frequent and urgent urination, as well as retention issues.

Research findings from a prospective study out of Georgetown University Hospital now redirect the focus on LUTS, reporting that uterine fibroid embolization (UFE) also can significantly improve women’s urinary problems related to uterine fibroids. According to the study, the noncancerous tumors that grow on the muscular lining of the uterus are the most common gynecological tumors, found in up to 70% of women of reproductive age.

This study was not designed to assess LUTS but still introduces the possibility that UFE could become a viable treatment for women who present only with classic urinary tract “bulk symptoms,” such as bladder pressure, frequent urination, or nighttime urination.

New Research Objective
“It’s an interesting point to consider that women who present with urinary incontinence or bladder symptoms could actually have fibroids and may benefit from UFE,” says David Shveiky, MD, head of female pelvic medicine and reconstructive surgery at Hadassah-Hebrew University Medical Center in Jerusalem. “However, we must be cautious about concluding that from our study, as it was not designed to test this hypothesis.”

Shveiky, an obstetrician/gynecologist and the lead author of the recent study, completed his subspecialty training with a three-year fellowship in female pelvic medicine and reconstructive surgery at the National Center for Advanced Pelvic Surgery of Washington Hospital Center and Georgetown University Hospital. In addition to his medical/surgical training and teaching, he conducted research studies, such as this one involving UFE and LUTS. He approaches his work with the goal of improving women’s quality of life, which is why he was interested in pursuing the topic of UFE for relieving all symptoms caused by uterine fibroids.

“I had clinical and research experience with treating women with uterine fibroids, and I wished to look at this condition from a different perspective,” Shveiky says. “Urinary symptoms are common among women with fibroids; however, only a small number of studies used the right tools to quantify these symptoms and their impact on quality of life.”

During his fellowship, Shveiky was introduced to James B. Spies, MD, MPH, FSIR, a professor and the chair of radiology at Georgetown University Medical Center. Spies and Shveiky share an interest in discovering more about the impact of UFE on women’s urinary symptoms and decided to join forces on this study.

“A growing portion of our patients are interested in preserving fertility or at least preserving their uterus and avoiding hysterectomy,” Shveiky says. “I thought the results of this study may be of interest, especially to these patients.”

An interventional radiology practitioner for the past 15 years, with special interests in UFE and gynecological intervention, Spies says that UFE continues to be an outstanding treatment choice for women suffering from typical uterine fibroids symptoms. Based on this study, he thinks this nonsurgical treatment also can improve related urinary tract problems.

Quality of Life
“Fibroids can cause a variety of unpleasant, life-disrupting urinary symptoms for women, such as bladder frequency, urgency, and the need to urinate during the night,” Spies says. “Informally, we knew that lower urinary tract symptoms were relieved by UFE, but the concept was never formally studied. This study shows that UFE can significantly improve these symptoms and the quality of life for women with uterine fibroids.”

As fibroids grow, they can press on the bladder or the outbound flow of a woman’s urinary tract, or they can create other types of obstructions to the flow of urine, according to the study authors. These bulk symptoms can increase over time and become more noticeable, along with large lumps or bulges, as fibroids increase in size. The heavy bleeding symptoms don’t always take center stage.

“You can have bulk symptoms with no bleeding,” says Scott Goodwin, MD, FSIR, a professor and the chair of radiology at the University of California at Irvine School of Medicine. Goodwin is known for his work in developing and validating uterine artery embolization.

The Georgetown study involved 57 women with an average age of 44 with symptomatic fibroids and LUTS who underwent UFE at the university’s hospital between March 2008 and May 2010. Originally, Spies says the study was to include a comparison of patients who underwent myomectomy (surgical removal of fibroids that keeps the uterus intact), but it became difficult to recruit patients who had undergone that procedure. However, he says the researchers decided to proceed with just the embolization portion of the study.

In the end, participants indicated an improvement in most urinary symptoms three months after undergoing UFE. According to the study, bladder diaries kept prior to UFE and continued to the three-month point showed significant reduction in the number of total voids throughout the day and night. However, researchers found no difference in incontinence episodes, stress incontinence, or urge incontinence scores before and after the procedure. The size of the woman’s uterus or the dominant fibroid did not affect study outcomes.

“This study confirms what many have suspected,” Spies says. “A substantial number of patients present with lower urinary tract symptoms.”

Follow-Up Research
Shveiky says vascular steal phenomenon is another interesting aspect of how uterine fibroids can adversely affect the lower urinary tract. This theory hypothesizes that some of the blood flow to the bladder is being directed to the fibroid uterus, which requires a lot of blood flow. “It may be interesting to examine the effect of UFE on changing flow patterns to the area and its effect on urinary symptoms,” Shveiky says.

In the future, researchers plan to compare the results of this study with the results of another study evaluating the effect of myomectomy on LUTS, according to Shveiky. Spies says additional studies will look at the long-term outcomes for UFE.

Goodwin, who is beginning his first year as president of the Society of Interventional Radiology, says it’s been known since the 1990s how UFE can benefit LUTS, but data related to this always have been imbedded in results about outcomes. He hopes that studies like this one will help increase awareness of the benefits of this nonsurgical option. “The Georgetown group is taking these observations about the effects of UFE on urinary tract issues and conducting some really good scientific studies,” he says. “I hope this will help increase physicians’ awareness of patients with urinary tract symptoms related to fibroids.”

As doctors become more aware of the benefits of interventional radiology procedures such as UFE, Goodwin says they will begin informing patients about all of their options when it comes to dealing with uterine fibroids. “There is a shifting paradigm, where doctors are making up their own minds and then fully informing patients of all their options,” Goodwin says.

The interventional radiology community has seen forward progress within the gynecology community toward more acceptance of UFE as an alternative to hysterectomy in the treatment of uterine fibroids. Goodwin says that previous studies not related to the work at Georgetown show the effectiveness of UFE as a safe alternative to hysterectomy, with less risk and pain, and shorter recovery time compared with surgery. “The evidence is overwhelming that UFE is better for women than the surgical alternative,” he says.

Educating Women
While Shveiky accepts UFE as a viable procedure for his patients, he knows other gynecologists may be reluctant to refer their patients to interventional radiologists rather than performing surgical hysterectomies or myomectomies. He recommends collaboration between the two disciplines to come up with a solution that best fits the patient’s needs. “I, and many other OB/GYNs and pelvic surgeons I know, believe in putting the patient first and making decisions after presenting all the relevant alternatives,” he says. “The treatment should be tailored and individualized for each woman.”

Patient awareness also may play a role in bringing UFE to the forefront of women’s health. “These days, with everything that’s out there in the media and on the Internet, more women are better prepared to discuss all their options with their doctors,” Shveiky says. “Women deserve to know every option on the table but will need the assistance of their physicians to help them in choosing the right alternative for them.”

Spies says uterine fibroids are the most frequent indication for hysterectomy in premenopausal women. In the United States, more than 300,000 women each year undergo this surgical procedure to treat symptomatic uterine fibroids and with that statistic, he believes it is important for physicians to educate themselves and their patients on the best options available.

“This research shows that minimally invasive uterine fibroid embolization effectively reduces fibroid-related urinary symptoms in women and should therefore be offered as a treatment choice,” Spies says. “Women need to know their options and make treatment choices that are right for them, knowing confidently that uterine fibroid embolization is an option besides hysterectomy and myomectomy. Women who have uterine fibroids need to have a frank discussion about their treatment options with their gynecologists, urogynecologists, primary care providers, and interventional radiologists to determine their best treatment option, especially if their urinary symptoms are put in the background and not addressed initially.”

Shveiky points out that as the population grows older, medical professionals see more women with urinary symptoms, as their incidence increases with age. Women who present with urinary tract issues also can have an enlarged uterus, Spies says. Even after menopause, women can still suffer from fibroids. “While the bleeding symptoms can go away, so can the pressure and discomfort,” Spies says. “However, if the bladder is still being compromised, the urinary tract symptoms will persist.”

Shveiky and Spies say these quality-of-life issues now are receiving greater focus, so there is more public conversation about the problem. “Social barriers, such as shame, are now less of an issue,” Shveiky says. “Women are willing today to discuss lower urinary tract symptoms with their physicians. We need to encourage healthcare providers to raise these issues, as many of them are treatable and curable.”

— Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania. She frequently reports on women’s imaging topics for Radiology Today.