Microhematuria in Women Presenting for Overactive Bladder.

PURPOSE OF REVIEW: Microscopic hematuria and overactive bladder are two common urologic conditions. The objective of this review is to provide an overview of current literature as well as highlight important guidelines that will aid physicians in the diagnostic workup of microscopic hematuria in patients experiencing symptoms of overactive bladder. RECENT FINDINGS: Updated microscopic hematuria guidelines provide a structured and appropriate workup for women based on risk factors, which stratifies patients to prevent unnecessary procedures and imaging. Women presenting with microscopic hematuria in the setting of overactive bladder should undergo microscopic hematuria workup according to their risk stratification while receiving appropriate treatment for their overactive bladder. The physician should consider the presence of irritative voiding symptoms during the investigation and management of microscopic hematuria in patients with overactive bladder and should not delay overactive bladder treatment due to the presence of microscopic hematuria.

Association between comorbidities and female sexual dysfunction: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

INTRODUCTION AND HYPOTHESIS: Although medical comorbidities are widely recognized to be associated with erectile dysfunction, less research has been done on their association with female sexual dysfunction (FSD). The purpose of this study was to assess whether FSD is associated with comorbidities; we hypothesized that there is an association. METHODS: This is a secondary analysis of the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a prospective stratified probability sample of individuals aged 16-74. We assessed for association between sexual function scores and heart attack, heart disease, hypertension, stroke, diabetes, chronic lung disease, depression, other mental health condition, other neurologic conditions, and incontinence, as well as menopause and smoking status. Correlation between comorbidities and specific domains of sexual function was also assessed. RESULTS: A total of 6777 women, with an average age of 35.4 (14.1), responded to the survey and reported sexual activity in the past year. There was an association between sexual function score and age, menopause, hysterectomy, heart disease, hypertension, diabetes, obesity, smoking, depression, other mental health condition, stroke, other neurological condition, and homosexual attraction (p < 0.05). On multivariate analysis, age, sexual attraction, smoking status, depression, and other mental health conditions remained significantly correlated with sexual function (p < 0.05). Comorbidities were found to be correlated with specific domains. CONCLUSIONS: Comorbidities were associated with FSD and specific comorbidities associated with dysfunction in specific domains. Urogynecologists and urologists must assess for comorbidities, as women presenting with sexual dysfunction may provide an opportunity for early diagnosis of life-threatening conditions.

Comparison of Correlated Comorbidities in Male and Female Sexual Dysfunction: Findings From the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: Many of the same mechanisms involved in the sexual arousal-response system in men exist in women and can be affected by underlying general medical conditions. AIM: To assess whether sexual function in men and women is correlated with similar comorbidities. METHODS: This study was a secondary analysis of the 3rd National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a prospective stratified probability sample of British individuals 16 to 74 years old interviewed from 2010 to 2012. We assessed for an association between sexual function and the following comorbidities: heart attack, heart disease, hypertension, stroke, diabetes, chronic lung disease, depression, other mental health conditions, other neurologic conditions, obesity, menopause, incontinence, smoking status, and age. OUTCOME: An association was found between multiple medical comorbidities and sexual dysfunction in women and in men. RESULTS: 6,711 women and 4,872 men responded to the survey, were in a relationship, and reported sexual activity in the past year. The average age of the women was 35.4 ± 14.1 and that of the men was 36.8 ± 15.6. There was an association between sexual function and all variables assessed except for chronic lung disease, heart attack, and incontinence in women compared with stroke, other neurologic conditions, incontinence, and smoking status in men. Comorbidities associated with erectile dysfunction included depression, diabetes, and other heart disease, whereas comorbidities associated with difficulty with lubrication included depression and other heart disease. Menopause was predictive of sexual dysfunction. Male sexual function appeared to decline after 45.5 years of age. CLINICAL IMPLICATIONS: Physicians should be aware of the correlation between medical comorbidities and sexual dysfunction in women and men and should ask patients about specific symptoms that might be associated with underlying medical conditions. STRENGTHS AND LIMITATIONS: Use of a stratified probability sample compared with a convenience sample results in capturing of associations representative of the population. Inclusion of multiple comorbidities in the multivariate analysis allows us to understand the effects of several variables on sexual function. Although this study shows only an association, further research could determine whether there is a causal relation between comorbidities and sexual dysfunction in women. CONCLUSION: Multiple medical comorbidities are associated with sexual dysfunction not only in men but also in women. Polland A, Davis M, Zeymo A, et al. Comparison of Correlated Comorbidities in Male and Female Sexual Dysfunction: Findings From the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). J Sex Med 2018;15:678-686.

Preoperative symptoms predict continence after post-radiation transurethral resection of prostate.

INTRODUCTION: Lower urinary tract symptoms and retention are known complications of radiation for prostate cancer and traditionally transurethral resection of the prostate (TURP) has been avoided in these patients because of the risk of incontinence. The purpose of this study was to evaluate the incidence and predictors of post-TURP incontinence in previously radiated patients. MATERIALS AND METHODS: One-hundred and eleven patients who underwent brachytherapy or external beam radiotherapy for prostate cancer with subsequent TURP performed between 1992 and 2012 at a single institution were identified. We tested for associations between post-TURP continence status and pre-TURP predictors including age, preoperative urinary symptoms and type and timing of radiation therapy. RESULTS: New-onset incontinence developed in 27% (95% CI 17%, 39%) of patients after first post-radiation TURP and 32% (95% CI 23%, 42%) of patients after any TURP, including repeat TURPs. Forty-three percent of patients had resolution of incontinence with first TURP (95% CI 25%, 63%); only 25% (95% CI 7%, 52%) of patients had resolution following repeat TURPs. Age was significantly associated with incontinence (OR per 10 years 2.02, 95% CI 1.10, 3.74, p = 0.024). Post-TURP incontinence was more common in men with pre-TURP urgency. CONCLUSIONS: Rates of post-TURP incontinence were higher in men who were older or had pre-TURP urinary urgency. Assessment of preoperative symptoms would allow for better patient selection. Further research should determine whether this results in better outcomes, including decreased incidence of new onset incontinence and increase in resolution of incontinence.

Emerging treatments for urinary incontinence.

INTRODUCTION: Urinary incontinence (UI) is a common and distressing problem that can adversely affect a patient's quality of life. Medical treatment is integral in the management of UI, of which there are a number of novel therapeutic targets. AREAS COVERED: In this review, an overview of UI and its associated burden on patients and on the healthcare system is provided. While there are many options for therapy currently available, the focus of this review is emerging therapies that may contribute in the near future to the management of UI. EXPERT OPINION: Healthcare expenditures for diagnosis, evaluation and treatment are substantial and are increasing as the general population ages and as access to healthcare increases. Pharmacological therapy for stress UI is limited and autologous muscle-derived cell therapy holds great promise. Despite the myriad of antimuscarinics for urge UI, all those presently FDA approved have comparable efficacy and adverse events, despite advertisements that suggest otherwise. Antimuscarinics and ß agonists are likely to remain mainstays of treatment as agents that act on novel targets such as transient receptor potential vanilloid type 1 and neurokinin-1 require further study.

Prognostic value of postoperative urinary retention after male sling insertion.

INTRODUCTION: While urinary retention is a known complication of AdVance male sling (AMS) placement for post-prostatectomy incontinence (PPI), there is minimal data regarding ultimate continence outcomes for patients who experience this complication. The purpose of this study was to determine the rate of continence after AMS placement in patients who had postoperative urinary retention as compared with those patients who did not. MATERIALS AND METHODS: A retrospective review was conducted of patients who underwent AMS placement for PPI between 2008 and 2011 with postoperative void trial (TOV). Preoperative factors such as urodynamic findings, daily pad number (PPD) and weight were recorded. Follow up data included pad use, need for catheterization and complications. Statistical analysis compared patients with and without postoperative urinary retention. RESULTS: Thirty-five patients were included with a mean follow up of 11.8 months. Complete continence was 60%, while 83% of patients were improved. PPD improved from 2.9 pads to 0.8 pads after AMS placement. Sixteen patients (46%) had postoperative urinary retention requiring clean intermittent catheterization (CIC). Of the 16 patients in postoperative retention, 100% were completely continent (PPD = 0), compared to 5 of 19 patients (26%) who passed first TOV (p < 0.00001). All patients who required CIC were able to void within 7 days. CONCLUSIONS: Postoperative urinary retention after AMS placement for PPI occurs in about 50% of patients and is short-lived. Patients who experienced postoperative urinary retention had good continence outcomes.

Postoperative Activity Restrictions After Slings: A Randomized Controlled Trial.

IMPORTANCE: Restricting activity after midurethral slings is an unproven practice. OBJECTIVE: The objective of this study was to evaluate the effect of postoperative activity restriction on satisfaction and outcomes after slings. STUDY DESIGN: This was a multicenter, 2-arm, noninferiority randomized controlled trial. Patients aged 18-85 years undergoing treatment with a midurethral sling were randomized 1:1 to postoperative activity restriction or liberal activity. Restrictions included avoidance of strenuous exercise and heavy lifting. The liberal group was allowed to resume activity at their discretion. Our primary outcome was satisfaction with postoperative instruction at 2 weeks. Secondary outcomes included surgical failure, mesh exposure rates, and other adverse events. RESULTS: In total, 158 patients were randomized with 80 to the liberal group and 78 to the restricted group. At 2 weeks, 54 (80.6%) of patients in the liberal group and 48 (73.9%) of patients in the restricted group were satisfied. We found statistical evidence supporting the hypothesis that postoperative liberal activity instruction is noninferior to activity restriction with regard to patient satisfaction (P = 0.0281). There was no significant difference in strenuous activity at 2 weeks (P = 0.0824). The liberal group reported significantly more moderate activity at 2 weeks (P = 0.0384) and more strenuous activity at 6 weeks and 6 months (P = 0.0171, P = 0.0118, respectively). The rate of recurrent or persistent stress incontinence for liberal versus restricted groups was 18.52% versus 23.53% (P = 0.635). There were no statistically significant differences in complication rates. CONCLUSIONS: Postoperative liberal activity was noninferior to activity restriction with regard to patients' satisfaction. There was no evidence supporting a statistically significant association between postoperative instruction and negative surgical outcomes.

Engaging and Empowering Female Urologists in Academic Publishing and Peer Review.

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STOMp: sexual function trial of overactive bladder medication.

Background: Female sexual function has been shown to improve with overactive bladder (OAB) treatment. Aim: The objective of this study was to evaluate the effects of anticholinergics (ACHs) or a beta-agonist (BAG) on female sexual function. Methods: This was a prospective multicenter cohort study. Sexually active women with OAB completed the Overactive Bladder questionnaire (OAB-q) and Female Sexual Function Index (FSFI) prior to and after 12 weeks of therapy. Sample sizes of 63 per group were calculated to detect a clinically relevant difference in the FSFI. Outcomes: The primary outcome was FSFI change from baseline at 12 weeks. Results: A total of 157 patients were recruited, and 91 completed follow-up (58/108, ACH; 31/49, BAG). There were within-group FSFI differences from pre- to posttreatment: a worsening of arousal in the ACH group (P = .046) and an improvement in overall FSFI (P = .04) and pain (P = .04) in the BAG group. After treatment, postmenopausal women in the BAG group had significantly better overall FSFI (P = .01), desire (P = .003), arousal (P = .009), and orgasm (P = .01). Clinical Implications: While further research is necessary, this study provides information about the comparative effects of OAB treatments on female sexual function, which may ultimately lead to better patient selection and outcomes. Strengths and Limitations: While there was no difference between the subjects who completed the study and those who did not, the study remained underpowered after the loss to follow-up. The multicenter cohort design allows for generalizability of results. Conclusion: Although this study was underpowered, an improvement in overall sexual function was seen with BAGs, while ACHs were associated with worsening aspects of sexual function.

Contemporary Clinical Research in the Management of Pelvic Organ Prolapse in the United States: A Systematic Review.

IMPORTANCE: Pelvic organ prolapse (POP) can cause bothersome symptoms that negatively affect quality of life. Management strategies include observation, conservative management, and surgery. OBJECTIVE: The purpose of this study was to evaluate the current focus of research in POP. STUDY DESIGN: We queried clinicaltrials.gov, a registry of clinical research studies maintained by the U.S. National Library of Medicine, for active, recruiting, and enrolling studies involving POP. RESULTS: A total of 104 unique clinical trials were included for analysis. Investigators most commonly specialized in obstetrics and gynecology (obstetrician-gynecologists [ob-gyns]; n = 66, 57.9%); urologists numbered 5 (4.4%). The most common subspecialty was urogynecology (n = 46, 40.4%). Seventy-six percent of clinical research involved surgical intervention. The second most common field of research was diagnostic evaluation of POP (8.4%). Only 12.1% of clinical research focused on conservative measures, and 2.8% investigated medications. Objective outcome measures were used more often than subjective or mixed measures (42.3%, 22.3%, and 32.7%, respectively). The most common outcome measure was Pelvic Organ Prolapse Quantification (14.5%), followed by the mixed measure, "composite success" (8.7%). CONCLUSIONS: Urologists are less involved in POP research than ob-gyns. Urogynecologists from either background are most involved. Most clinical research involves surgical management of POP, despite the fact that less than 20% of women pursue surgical correction. Despite dubious concordance with quality of life, objective outcome measures are used more often than subjective or mixed measures to assess severity of POP. Clinical research in POP should be directed to better align with the needs and preferences of patients.

Availability of Lactation Accommodation Information for Urology Residency Programs.

OBJECTIVE: To assess whether urology residency programs publish information about lactation accommodations online. Although residencies are required to provide lactation accommodations, there is limited data on whether programs disclose this information. MATERIALS AND METHODS: Webpages of U.S. urology residency programs were assessed for presence of information about lactation accommodations. Program characteristics were noted, as were mentions of resident wellness and diversity. Associations between program characteristics and published lactation accommodations were determined by univariate analysis and development of a multivariate logistic regression model. RESULTS: Of 145 urology residency programs, 72.4% included information about lactation accommodations anywhere on the institution's website There was great variability in ease of accessing information and of quality of information available. Information was most commonly on graduate medical education websites (28.3%) followed by human resources (24.1%), press releases (7.6%), or other sections (11.0%), and least likely to be found on urology residency websites (1.4%). Programs with lactation accommodations anywhere on the institution website were more likely to be larger (P < 0.001), university-based (P < 0.01), and to publish information about resident wellness (P < 0.001), or diversity and inclusion (P < 0.01). On multivariate analysis, only university-based setting and presence of wellness information were predictors of availability of lactation accommodation information. CONCLUSION: Lactation accommodation information is usually not available on urology residency websites and most online information is found elsewhere. Predictors of publishing lactation accommodation information were university-based setting and information about resident wellness. Efforts to recruit and retain female urologists should include making this information more easily accessible.

Role of preoperative platelet level in clinical and pathological outcomes after surgery for renal cortical malignancies.

OBJECTIVE •To investigate preoperative platelet level (PLT) as a prognostic factor for pathologic and clinical outcomes following surgery for renal cortical malignancy. PATIENTS AND METHODS • 1422 patients underwent radical or partial nephrectomy at our institution from 1988-2009 for renal cortical lesions. • The cohort with available PLT values was divided into group 1 (PLT ≤ 400 × 109) and (PLT > 400 × 109) based on institutional laboratory upper threshold (400 × 109 cells/liter). RESULTS • 961 patients were divided into groups 1 (n = 870) and 2 (n = 91), with mean age at surgery of 61 and 60 years, 70.6% and 50.6% males (P ≤ 0.0001), 56% undergoing radical nephrectomy in each group, 39.1% vs. 22% undergoing partial nephrectomy (P = 0.001) respectively. • Groups differed significantly inmedian tumour size (5.06 vs. 7.28 cm) (P ≤ 0.001), pathologic T stage (P = 0.002), and metastases (P ≤ 0.0001). No significant difference existed regarding histologic findings at surgery. • With median follow-up of 24 months, PLT > 400 × 109 cells/liter was associated with decreased overall (OS) and disease-specific survival (DSS) using log rank test (P ≤ 0.0001). • On multivariate analysis, controlling for TNM stage, histology, and tumour diameter, PLT > 400 × 109 cells/liter independently predicted decreased OS (HR 1.67, P = 0.007) and DSS (HR 2.39, P = 0.001). As a continuous variable, PLT predicted OS (HR 1.002, P = 0.005) and DSS (HR 1.003, P = 0.004). • With metastatic patients excluded, PLT was significantly associated with OS and DSS, but was not an independent predictor. CONCLUSION • PLT is a clinically significant independent predictor of OS and DSS in continuous and categorical analyses in patients undergoing renal cortical malignancy surgery. PLT may be clinically useful for risk stratifying patients undergoing surgery for renal cancer, especially for prognosis assessment of patients with renal cortical malignancy and micrometastatic disease at surgery.

Who is at the Podium? Women Urologist Speakers at Recent AUA Meetings.

OBJECTIVE: To quantify the representation of women urologists as invited speakers at the AUA Annual Meeting. METHODS: Programs for the AUA Annual Meeting were reviewed from 2017 to 2019. Topics of sessions and genders of moderators and panelists were collected. Percentages of women urologists as well as topics of sessions were compared between years. RESULTS: Women urologists comprised 60 of 467 moderators (12.8%) and 63 of 614 panelists (10.3%). Sessions about infection had the most women urologist moderators while oncology had the least. Sessions about FPMRS has the most women urologists as panelists. Male urologists were more likely to be full professors compared to women urologists. While the percentage of female panelists fluctuated, the percentage of female moderators decreased each year. CONCLUSION: Although the proportion of women to men in urology is increasing, the number and proportion of woman urologist panelists and moderators at the annual AUA meeting does not reflect this trend. It is important to recognize and correct this discrepancy, as well as to increase visibility of women and others underrepresented in the field.

Description of Vaginal Laxity and Prolapse and Correlation With Sexual Function (DeVeLoPS).

INTRODUCTION: Vaginal laxity (VL) is a sensation of vaginal looseness which may develop after pregnancy and vaginal delivery and may be affected by prior pelvic surgery, menopause and aging. Pelvic organ prolapse (POP) is a disorder in which pelvic organs descend from the normal position. VL has attracted recent attention due to the advent of energy-based treatments for this symptom. AIM: To determine the correlation between VL symptoms and physical exam findings of POP, specifically the introital measurement of genital hiatus. METHODS: This was a multi-center cross-sectional study of sexually active women over 18 years of age with a parity of one or greater. Subjects completed the Vaginal Laxity Questionnaire (VLQ), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index (FSFI), and were asked if a sexual partner had commented on laxity. Subjects underwent pelvic exam, including the pelvic organ prolapse quantification (POP-Q). MAIN OUTCOMES MEASURES: Correlation between VL symptoms as measured by the VLQ and POP as measured by elements of the POP-Q. RESULTS: A total of 95 subjects with an average age was 54.3 ± 13.18 years were included. Sixty-three percent of patients were postmenopausal. The average VLQ score was 4.2 ± 1.35 and the average FSFI score was 23.42 out of 36. There was no significant correlation between VLQ score and POP or mid-vaginal caliber. Sensation of vaginal tightness was significantly associated with age (P=0.03) and menopausal status (P=0.04). Only 28% of partners commented on laxity and the majority commented on the vagina being tight (21%) rather than loose (7%). CONCLUSION: VL was not correlated with physical exam findings quantifying POP or sexual function. This study emphasizes the need to develop a more standardized definition of VL and a better assessment tool for VL symptoms. Polland A, Duong V, Furuya R, et al. Description of Vaginal Laxity and Prolapse and Correlation With Sexual Function (DeVeLoPS). Sex Med 2021;9:100443.

Incidence of Significant Findings of Microhematuria Workup in Women-What Guidelines Work Best?

OBJECTIVE: To apply the American Urogynecological Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) recommendations of foregoing workup in patients under 50 years of age with less than 25 red cells per high-powered field, to a cohort of asymptomatic microscopic hematuria (AMH) patients, and assess diagnostic accuracy, sensitivity, specificity, positive, and negative predictive value compared to the American Urologic Association (AUA) guidelines. METHODS: Retrospective review of female patients who underwent AMH evaluation from 2012 to 2015. The number of patients who would have avoided workup following the AUGS/ACOG recommendations was determined. Sensitivity, specificity, positive- and negative-predictive value and accuracy of the AUGS/ACOG recommendations compared to AUA guidelines were determined. RESULTS: Six hundred twenty women underwent AMH workup with 265 women undergoing full workup as per the AUA guidelines. Applying the AUGS/ACOG recommendations to this cohort would not have resulted in missed malignant diagnoses. Two tumors were found, both in patients who had undergone complete workup, and for whom AUGS/ACOG recommends workup. Following the AUGS/ACOG recommendations would have avoided workup in 126/620 of all women and 44/265 women who underwent the full AUA workup. In looking at findings of malignancy, the AUGS/ACOG workup had a sensitivity of 100% and a negative predictive value of 100% as compared to the AUA guidelines. CONCLUSION: AUA guidelines may over screen female low risk AMH patients. Extensive workup in a low risk group of female patients does not result in increased cancer diagnoses. Perhaps a more nuanced approach could result in fewer workups without compromising cancer detection.

Hydronephrosis Associated With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVES: The aim of this study was to report the prevalence of hydronephrosis associated with pelvic organ prolapse (POP). METHODS: We conducted a MEDLINE and PubMed search from 1996 to October 2016 using PRISMA guidelines. Eight studies met criteria for inclusion, including 3 prospective and 5 retrospective studies. RESULTS: The prevalence of hydronephrosis ranged from 3.5% to 30.6% in studies that included multiple stages of prolapse. Hydronephrosis correlated with prolapse severity in multiple studies, but serum creatinine did not consistently predict hydronephrosis. Two studies reported a significantly higher prevalence of hydronephrosis in patients with uterovaginal prolapse compared with vaginal vault prolapse. Complete resolution of hydronephrosis was described in 56% to 83% of patients after undergoing surgical treatment for advanced prolapse. CONCLUSIONS: Hydronephrosis among patients with POP is not rare, and we suggest consideration of upper tract evaluation in patients presenting with POP, particularly in those with advanced uterovaginal prolapse electing to proceed with expectant or conservative management.

Development of Female Pelvic Medicine and Reconstructive Surgery Fellowship Programs following the Deadline for Senior Accreditation.

INTRODUCTION: Female pelvic medicine and reconstructive surgery recently became a board-certified subspecialty. Certification, available to urologists and gynecologists, requires completion of an accredited fellowship for residents graduating after 2010. We describe shifts in available training programs and applicants since this time. METHODS: The National Resident Matching Program database was queried for "pelvic medicine and reconstructive surgery" from 2010 to 2016. Residency match data from the National Resident Matching Program and the American Urological Association matches during the same period were examined as a proxy for potential applicants. Linear regression was used to predict changes in number of programs and applicants through time. RESULTS: Since 2010, there have been consistently more applicants than positions. The increase in obstetrics and gynecology programs has been greater than that in urology and combined programs. Despite this fact, there are far more obstetrics/gynecology than urology residency graduates each year, resulting in approximately 3 times the number of obstetrics/gynecology graduates per available fellowship position. Since 2010, only 1 obstetrics/gynecology position has gone unfilled, compared to 3 urology positions. CONCLUSIONS: While the female pelvic medicine and reconstructive surgery fellowship accreditation is designed for graduates of urology and gynecology, there are more programs designated as obstetrics/gynecology than as urology or combined, and obstetrics/gynecology programs are less likely to go unfilled. If urologists are to continue their role as an important part of the female pelvic medicine and reconstructive surgery workforce, we must encourage residents to pursue this career choice.