A time-frame comparison study of surgical volume shifts on female primary stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the surgical volume shifts for primary female stress urinary incontinence (SUI) over a 20-year period (1999-2018) in Taiwan. METHODS: This was a retrospective cohort study based on Taiwan's National Health Insurance Research Database. We divided the time-frame into four periods: first period (1999-2003), second period (2004-2008), third period (2009-2013), and fourth period (2014-2018). The variables included major surgical types for SUI (retropubic urethropexy, pubovaginal sling, midurethral sling, etc.), surgeon gender, specialty, surgical volume (high ≥30, median 5-29, low <5), and hospital accreditation level. Reoperation rates within 1 year were analyzed as an outcome measurement. RESULTS: A total of 51,018 patients were identified. Major surgical types increased significantly during the first three periods and slightly decreased during the fourth period. The proportion of surgical volume shifted from high- to medium-, and low-volume, but it reversed during the fourth period. The proportion of SUI surgeries decreased in medical centers, whereas it increased in regional and local hospitals. The proportion of SUI surgeries by female surgeons increased. Similar phenomena occurred in MUS. As for surgeon specialty, major surgical types were performed by gynecologists and urologists equally, whereas MUS were performed more by gynecologists than by urologists. Unexpectedly, 1-year reoperation rates were higher in high-volume surgeons. CONCLUSIONS: The surgical trend of SUI surgeries shifted from high- to medium-, and low-volume surgeons, medical centers to regional and local hospitals during the study periods. This implied surgical skills and performance spreading, which may have a great influence on patient and healthcare provider choice of treatment.

Percutaneous Nephrolithotomy Combined Antegrade Flexible Ureteroscope for Complete Staghorn Stones: A Case Report of a New Concept of Stone Surgery.

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for staghorn stones. However, residual stones in calyces remain a challenge due to the limited angle which makes the approach difficult. The new operative technique of endoscopic combined intrarenal surgery (ECIRS), which integrates the advantages of PCNL and retrograde intrarenal surgery (RIRS), was developed to overcome this difficulty. However, two experienced urologists are required to perform ECIRS, and the patient has to be placed in the Galdakao-modified supine Valdivia position or modified prone split-leg position which cannot be achieved in the elderly or patients with ankylosing arthritis, as it may cause harm due to abnormal traction of the joints. In addition, it is difficult for surgeons to create an ideal access tract to perform PCNL in this position. We report the case of a 72-year-old female patient with left staghorn stone. We performed RIRS first and then placed the patient in the decubitus position for PCNL with antegrade flexible ureteroscopy. This method allows patients to be placed in an easier position, with the use of flexible ureteroscopy through a nephroscope to find previously unreachable stones. Moreover, in addition to the more comfortable position both for surgeons and patients, this procedure can also deal with large complex renal stones as with ECIRS. We also created a brand-new definition for stone clearance rate, namely, stone reduction efficiency (SRE). There was a high stone reduction efficiency of 12.64 (mm2/min) in our patient, and no complications occurred. We suggest that this procedure is an ideal alternative treatment for a huge staghorn stone instead of PCNL or ECIRS.

Review of underactive bladder.

In clinical practice, many patients cannot empty their bladders within an acceptable duration. Common complaints include weak urinary stream and incomplete emptying, which may affect quality of life. Bladder emptying requires sufficient detrusor contractile power, velocity, and durability. The urodynamic term for inadequate detrusor contraction is detrusor underactivity (DU). Although this definition was provided by the ICS, it may not be clinically practical. Analogous to the relationship between overactive bladder (OAB) and detrusor overactivity (DO), the symptom complex caused by DU is termed underactive bladder (UAB). Many conditions lead to UAB, such as advanced age, neurogenic bladder and BOO, but the definite pathophysiology directly leading to UAB is still being widely studied without a widely-accepted consensus. The preferred mainstream treatment for increased residual urine volume caused by UAB is intermittent catheterization, while pharmacotherapy is still disappointing after decades of development. There are no studies on surgical treatment for UAB with an acceptable level of evidence. We reviewed the recent literature on UAB and DU to provide a comprehensive discussion of the related presentation, etiology, diagnosis and management.

Spontaneous ureteral rupture and review of the literature.

INTRODUCTION: Spontaneous ureteral rupture is defined as non-traumatic urinary leakage from the ureter. This is a diagnosis that, although uncommon, is important for emergency physicians to know about. The literature is relatively sparse. MATERIALS AND METHODS: This was a retrospective review of patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed by radiography (computed tomography or intravenous urogram) with spontaneous ureteral rupture. These cases all showed extravasation of the contrast outside the excretory system. We evaluated underlying causes, diagnostic and therapeutic procedures, and outcomes. RESULTS: There were 9 men and 9 women with a median age of 59 years (range, 22-82 years). In 56% of patients, a ureteral stone was the cause; in 17% of, a ureteral stricture; in 1 patient, a ureteral tumor; and in the remaining 22%, no cause was identified. In 13 patients (72.2%), primary ureteroscopy to place D-J stents was performed. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). The other 5 patients (27.8%) were managed conservatively with antibiotic treatment and the outcome was good. CONCLUSIONS: Ureteral stones most commonly cause spontaneous ureteral rupture. In our experience, most patients received ureteroscopy and Double-J stenting. Conservative management with antibiotics also had good outcomes. Most patients had sudden onset of abdominal or flank pain. Spontaneous ureteral rupture should be kept in the differential diagnosis of patients with acute abdominal or flank pain in the emergency department.

The translation and validation of Chinese overactive bladder symptom score for assessing overactive bladder syndrome and response to solifenacin treatment.

BACKGROUND/PURPOSE: Overactive bladder symptom score (OABSS) was developed by a Japanese urologist and is widely used in Asian countries. The aim of this study was to develop and validate a Chinese OABSS for assessing overactive bladder (OAB) and treatment outcome after solifenacin. METHODS: The Chinese OABSS was developed by linguistic validation of the original version. Its reliability and validity, and correlations with a three-day bladder diary were tested. Patients answered the Chinese OABSS at enrollment and repeated the questionnaire after a non-treatment period of 2 weeks, and at 4 and 12 weeks after solifenacin (5mg/day). Patients also completed a three-day bladder diary and forms including patient perception of bladder condition, International Prostatic Symptom Score and quality of life index at each study visit (for a total of four visits). An analysis was conducted to evaluate the reliability and validity of the Chinese OABSS and the correlations with a three-day bladder diary and a patient perception of bladder condition, respectively. RESULTS: A total of 60 patients with OAB, including 31 OAB wet and 29 OAB dry, were enrolled. The test-retest reliability of Chinese OABSS was moderate to good with weighted kappa coefficients of 0.515-0.721 for each symptom score and 0.610 for total symptom score. Forty-eight (80%) patients completed the responsiveness study and were followed-up at all time points. Patients' OAB symptoms improved significantly from baseline to 3 months after solifenacin treatment. The changes in OABSS decreased gradually with time within the three months of solifenacin treatment. CONCLUSION: The Chinese OABSS has been validated as a reliable instrument for assessing OAB. Solifenacin 5mg once daily improved urgency and other symptoms of OAB including frequency, urge incontinence, OABSS and International Prostatic Symptom Score. The adverse effects were acceptable and became less significant with time in the three months of treatment.

Treatment Patterns with Mirabegron and Antimuscarinics for Overactive Bladder: A Prospective, Registry Study in Taiwan and South Korea (FAITH).

INTRODUCTION: This study aimed to assess overactive bladder (OAB) treatment patterns and factors associated with effectiveness and persistence. METHODS: A prospective, longitudinal, observational registry study of adults starting OAB therapy with mirabegron or antimuscarinics was undertaken. Primary endpoints were time from treatment initiation to discontinuation/switching; proportion who discontinued/switched; and reasons for discontinuation/switching. Secondary endpoints included OAB Symptom Score (OABSS), OAB Questionnaire: Short Form, and OAB Bladder Assessment Tool scores; factors associated with effectiveness and persistence; and safety. RESULTS: In total, 556 patients initiating mirabegron and 250 initiating antimuscarinics were enrolled. There was no treatment switch, change, or discontinuation in 68.5% of the mirabegron initiator group and median time to treatment change was not reached. Mean initial treatment duration was 130.8 days. In multivariable models, baseline OABSS was the only variable significantly associated with change from baseline in OABSS, and patients with mild and moderate OAB had significantly better persistence with mirabegron than those with severe OAB. Urinary tract infection was the most common adverse event with mirabegron. There was no treatment switch, change, or discontinuation in 60.4% of the antimuscarinics initiator group and median time to treatment change was not reached. Solifenacin was the most frequent initial treatment (66.0%). Mean treatment duration was 122.2 days. In multivariable models, baseline OABSS was the only variable significantly associated with change from baseline in OABSS, while patients with OAB medication in the 12 months before enrollment had significantly better persistence with antimuscarinics than those with no previous OAB medication. Dry mouth was the most common adverse event with antimuscarinics. CONCLUSIONS: Mirabegron and solifenacin were commonly prescribed as first-line OAB medications. There was no treatment switch, change, or discontinuation in more than 60% of the mirabegron initiator and antimuscarinics initiator groups. Mean initial treatment duration was 130.8 days and 122.2 days for mirabegron and antimuscarinics, respectively. Graphical Abstract available for this article. TRIAL REGISTRATION: ClinicalTrials.gov NCT03572231.

Remote monitoring of videourodynamics using smart phone and free instant messaging software.

AIMS: To evaluate the feasibility of using smart phones plus free instant messaging software for remote monitoring of videourodynamics. METHODS: From November 2011 to October 2012, 85 females with voiding disorders were enrolled for videourodynamic tests. The patients were assigned to videourodynamics remotely monitored by the attending physician by using iPhone/iPad and Skype (group 1) and videourodynamics with the attending physician present (group 2). The procedural time and videourodynamic qualities, assessed by the frequency of adherence to the modified Sullivan criteria, in each group were recorded and compared. RESULTS: There were 44 and 41 patients in group 1 and group 2, respectively. The mean procedural time was comparable between group 1 and group 2 (56.3 vs. 54.4 min, P = 0.25). The frequencies of adherence to the modified Sullivan criteria were similar in each group. CONCLUSIONS: The qualities of videourodynamics under the attending physician's remote or direct monitoring were both appropriate. Based on the convenience of Internet, the popularity of smart phones and the intention to make the urologists use their time more efficiently, our study provides remote monitoring as an alternative way for performing videourodynamics.

Correction: Tsai et al. The Efficacy of Transvaginal Ultrasound-Guided BoNT-A External Sphincter Injection in Female Patients with Underactive Bladder. Toxins 2023, 15, 199.

In the original publication [...].

The Efficacy of Transvaginal Ultrasound-Guided BoNT-A External Sphincter Injection in Female Patients with Underactive Bladder.

Owing to the diverse treatment outcomes after a botulinum toxin A (BoNT-A) injection to the external sphincter, this study aimed to develop a new technique: an ultrasound-guided BoNT-A external sphincter injection. This single-center prospective cohort study was conducted at a tertiary medical center in Taichung, Taiwan. From December 2020 to September 2022, 12 women were enrolled. The patients were evaluated for lower urinary tract syndrome using patient perception of bladder condition (PPBC), international prostate symptom score (IPSS), uroflowmetry, post-void residual volume (PVR), cystometry, and external sphincter electromyography. We evaluated the patients the day before surgery and 1 week after the BoNT-A injection. For the patients requiring self-catheterization, we recorded the number of times they required clean intermittent catheterization (CIC) per day before the procedure and 1 month after the procedure. The IPSS, PPBC, and PVR were significantly better after the transvaginal ultrasound-guided BoNT-A external sphincter injection. The number of times the patients required daily CIC was also reduced after the injection. Only one patient developed de novo urge urinary incontinence. Our results demonstrated that a transvaginal ultrasound-guided BoNT-A injection was efficacious and safe in the treatment of underactive bladder.

Mirabegron is better tolerated than solifenacin in Sjogren's syndrome patients with overactive bladder symptoms-A randomized controlled trial.

OBJECTIVES: This study investigates the efficacy and adverse events of beta-3 agonists and antimuscarinic agents for managing overactive bladder syndrome in Sjogren syndrome. METHODS: Sjogren's syndrome patients with an Overactive Bladder Symptom Score (OABSS) >5 were enrolled and were randomly assigned to mirabegron 50 mg/day or solifenacin 5 mg/day. Patients were evaluated on the recruitment day and reassessed at Week 1, 2, 4, and 12. The study's primary endpoint was to have a significant change in OABSS at Week 12. The secondary endpoint was the adverse event and crossover rate. RESULTS: A total of 41 patients were included in the final analysis, with 24 in the mirabegron group and 17 in the solifenacin group. The study's primary outcome was a change of the OABSS at Week 12. We found that both mirabegron and solifenacin significantly reduce patients' OABSS after 12 weeks of treatment. The evolution of the OABSS was -3.08 for mirabegron and -3.71 for solifenacin (p = .56). Six out of 17 patients from the solifenacin group crossed over to the mirabegron arm due to severe dry mouth or constipation, while none from the mirabegron arm crossed over to the solifenacin group. Sjogren's syndrome-related pain was also improved in the mirabegron group (4.96-1.67, p = .008) compared to the solifenacin group (4.39-3.4, p = .49). CONCLUSIONS: Our study showed that mirabegron is equally effective as solifenacin in treating Sjogren's syndrome patients with overactive bladder. Mirabegron is superior to solifenacin in terms of treatment-related adverse events.

Endoscopic management of upper tract urothelial cancer in a highly endemic area: A Taiwan nationwide collaborative study.

BACKGROUND: Endoscopic management of upper tract urothelial cancer (UTUC) is an important treatment option for low risk UTUC. Although Taiwan is an endemic area for UTUC, endoscopic treatment outcomes in Taiwan are frequently under- reported. METHODS: This study retrospectively reviewed the treatment outcomes of endoscopic management for clinically localized UTUC. Patients with biopsy or washing cytology confirmed UTUC who underwent endoscopic or percutaneous management with a curative intent were retrospectively reviewed for eligibility of analysis. Those cases without pre-intervention confirmed UTUC, and metastatic or nodal disease at diagnosis were excluded. RESULTS: In total, 307 patients who underwent endoscopic management were reviewed and 279 cases were eligible for final analysis. With a median follow-up of 44.3 months (inter-quartile range (IQR): 23.4-76.4 months), 117 cases (46.4%) were endoscopic cured after median one session (range:1-8; IQR:1-2) of endoscopic treatment. Those endoscopic cured UTUC was associated with more small-sized tumor, more low-grade biopsied-histology, less concomitant bladder UC and less pre-operative hydronephrosis. In addition, 201(79.7%) cases among 252 cases with confirmed oncological outcome were free of UTUC at the end of follow-up and only 43 (17%) patients had a UTUC related mortality. Salvage RNU offered a better tumor free survival rate (92% vs. 77.5%) than those without salvage RNU in those UTUC refractory to endoscopic management. In multivariable analyses, pre-operative hydronephrosis was the independent risk factor for OS. Multiplicity and concomitant bladder UC were independent risk factors for DFS. CONCLUSIONS: We confirmed the consistent safety and efficacy of endoscopic management of clinical localized UTUC in a highly UTUC endemic area like Taiwan. Early salvage RNU is mandatory in those UTUC refractory to endoscopic management in prevention of UTUC related death.

Urinating in the standing position: a feasible alternative for elderly women with knee osteoarthritis.

PURPOSE: Urinating while standing is a possible alternative for elderly women with knee osteoarthritis when a sitting toilet is unavailable. We evaluated uroflowmetric characteristics and post-void residual urine volume in elderly women with knee osteoarthritis who urinated while standing. MATERIALS AND METHODS: We recruited 21 women with a mean±SD age of 65.0±4.6 years who had a knee osteoarthritis Lequesne index score of at least 6 points and were unable to maintain or found it difficult to stand up from a squat or crouch. Participants used a homemade auxiliary appliance to collect urine and drain it forward while stand voiding. Uroflowmetric data, including voided volume, and maximal and average flow rates, were recorded. Post-void residual urine volume was detected using an ultrasound bladder scanner. Participants completed a questionnaire to evaluate their attitude toward stand voiding and using the auxiliary device. RESULTS: Maximal and average flow rates, and voided and post-void residual urine volumes were not statistically different while sitting and standing. No learning curve was noted for stand voiding. Uroflowmetry patterns while standing were smooth. Of the 21 participants 17 (81%) experienced no difficulty while stand voiding. All expressed willingness to urinate while standing position if they did not have access to a satisfactorily clean toilet seat. CONCLUSIONS: Urinating while standing is a feasible option for elderly women with knee osteoarthritis who have difficulty crouching or squatting to void in public restrooms.

Diagnostic Potential of Low Serum Platelet, Albumin and Prolong PT-INR for Overactive Bladder and Nocturia in Chronic Hepatitis-Related Liver Cirrhosis.

Overactive bladder (OAB) is defined as urgency, usually with frequency, nocturia, and incontinence. Patients with liver cirrhosis often present with urinary complaints. The possible reason for this is fluid redistribution, which may induce OAB resulting from portal hypertension and ascites. We conducted this study to investigate predictors of OAB in cirrhotic patients. A total of 164 patients with chronic viral hepatitis-related liver cirrhosis were enrolled and 158 (96.3%) completed the Overactive Bladder Symptoms Score (OABSS) questionnaire. Age, severity of liver cirrhosis, comorbidities, serum sodium level, use of diuretics, body mass index and renal function were also recorded. In the study cohort, the prevalence of OAB was 31.01% and the prevalence of urge incontinence (OAB wet) was 18.3%. Patients with an urgency score ≥2 in OABSS had a significantly lower platelet level (p = 0.025) regardless of the use of diuretics. In addition, 98 patients (62%) with nocturia and 29 patients (18%) with urge incontinence had significantly lower levels of serum albumin (p = 0.028 and 0.044, respectively). In conclusion, patients with liver cirrhosis have a high prevalence of overactive bladder. A low platelet and low serum albumin level in these patients may be predictors for overactive bladder. And longer PT-INR is also a possible biomarker for nocturia.

Effectiveness and Safety of Intradetrusor OnabotulinumtoxinA Injection for Neurogenic Detrusor Overactivity and Overactive Bladder Patients in Taiwan-A Phase IV Prospective, Interventional, Multiple-Center Study (Restore Study).

We conducted a phase IV, pre/post multi-center study to evaluate the efficacy and safety of intradetrusor onabotulinumtoxinA injection in patients with neurogenic detrusor overactivity (NDO, n = 119) or overactive bladder (OAB, n = 215). Patients received either 200U (i.e., NDO) and 100U (i.e., OAB) of onabotulinumtoxinA injection into the bladder, respectively. The primary endpoint for all patients was the change in the PPBC questionnaire score at week 4 and week 12 post-treatment compared with baseline. The secondary endpoints were the changes in subjective measures (i.e., questionnaires: NBSS for patients with NDO and OABSS for those with OAB) at week 4 and week 12 post-treatment compared with baseline. Adverse events included symptomatic UTI, de novo AUR, gross hematuria and PVR > 350mL were recorded. The results showed that compared with baseline, PPBC (3.4 versus 2.4 and 2.1, p < 0.001) and NBSS (35.4 versus 20.4 and 18.1, p < 0.001) were significantly improved at 4 weeks and 12 weeks in NDO patients. In addition, compared with baseline, PPBC (3.5 versus 2.3 and 2.0, p < 0.001) and OABSS (9.1 versus 6.2 and 5.7, p < 0.001) were significantly improved at 4 weeks and 12 weeks in OAB patients. Eight (6.7%) had symptomatic UTI and 5 (4.2%) had de novo AUR in NDO patients. Twenty (9.3%) had symptomatic UTI but no de novo AUR in OAB patients. In conclusion, we found that intradetrusor onabotulinumtoxinA injections were safe and improved subjective measures related to NDO or OAB in our cohort.

Voiding dysfunctions in children with mental retardation.

AIMS: This study aims to evaluate the voiding disorder and lower urinary tract symptoms in mentally retarded children. METHODS: Fifty-one mentally retarded children (age 7.7 years) was assessed. A volunteer sample comprised of 36 typically developing children (age 6.4 years) served as the comparative group. All participants underwent uroflometric investigation, and residual urine was detected by sonography. Urological history including history of urinary tract infection, incontinence, frequency, and dysurea was collected. In addition, the mentally retarded group was classified according to IQ: severe mentally retarded group (IQ below 40) (n = 11), moderate mentally retarded group (IQ: 41 to 55) (n = 19), mild mentally retarded group (IQ: 56 to 70) (n = 21). Group comparisons were analyzed using Chi-square and Student's t-test. RESULTS: Of the 51 mentally retarded children, 18(35.2%) were found to have voiding dysfunction, which is significantly higher than the control group (8.3%). The incidence of urine incontinence and frequency is also significantly higher in the mentally retarded group. The comparison of the three mentally retarded subgroups showed that the severe mentally retarded group had the highest incidence of voiding dysfunction and urinary incontinence. Overall, the mentally retarded group had higher percentage of small bladder capacity. CONCLUSIONS: We concluded that mentally retarded children have a higher incidence of voiding dysfunction and incontinence than the control group. Early detection of voiding dysfunction in an objective, non-invasive manner is important in mentally retarded children, particularly those with severe cognitive impairment.

Women urinate in the standing position do not increase post-void residual urine volumes.

AIMS: The effects of standing while voiding have seldom been investigated in women. We evaluate urodynamic parameters of voiding while standing in healthy women using uroflowmetry and post-void residual urine volume assessment. Results are compared with crouching and sitting. METHODS: Between July and October, 2008, a total of 30 healthy, nulliparous female volunteers were enrolled. Ages were 22-37 (mean: 28±4). Urodynamic studies were performed for all in sitting, crouching and standing positions; 3, 3 and 5 times in each position, respectively. Volunteers used homemade auxiliary appliances for collecting urine from the urethra and draining it forward when standing. Volume, maximum flow rate, mean flow rate and post-void residual urine volume were compared. RESULTS: Maximum and average flow rates in the sitting and standing positions were significantly different, but not between sitting and crouching or between crouching and standing. There were no differences in voided volume and post-void residual urine volume. There's no apparent learning curve for women in the standing position. CONCLUSIONS: Though flow rates are decreased while standing, post-void residual volume is not significantly different. Women have another choice for voiding in public restrooms.

Female voiding postures and their effects on micturition.

INTRODUCTION AND HYPOTHESIS: This study investigated the effect of sitting and non-sitting postures on uroflowmetric parameters and postvoid residual urine (PVR) and women's preferred voiding posture. METHODS: Female university students (N = 45) voided on a modified sitting-type toilet in three postures: sitting, semi-squatting, and crouching over. Data on uroflowmetric measures were collected using a weight transducer urodynamic device and PVR was estimated by transabdominal ultrasound. RESULTS: Voiding in the three postures did not differ in terms of PVR and five of six uroflowmetric outcomes. However, "delay time to void" was significantly longer while semi-squatting than while sitting and crouching over. Furthermore, 51.1% of women had bell-shaped urinary flow curves while sitting, whereas only 22.2% and 17.8% did while semi-squatting and crouching over, respectively. Most women (88.9%) preferred a non-sitting posture when using a public sitting-type toilet. CONCLUSIONS: Women's preferred non-sitting void posture on public sitting-type toilet should be a concern.

Incomplete bladder emptying in patients with stroke: is detrusor external sphincter dyssynergia a potential cause?

OBJECTIVES: To delineate the frequency, clinical risk factors, and urodynamic mechanisms of incomplete bladder emptying (IBE) among patients with recent stroke. DESIGN: Retrospective study. SETTING: Inpatient setting in the rehabilitation ward of a university hospital. PARTICIPANTS: All patients with acute stroke admitted for rehabilitation between January and December 2005, excluding those with a history of lower-urinary tract symptoms and urologic diseases. Eighty-two patients (42 women and 40 men; mean age, 65.5 y) were included. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We measured postvoid residual (PVRs) by catheterization or by using an ultrasonic bladder scanner. Twenty-five patients (30.5%) had IBE with PVRs greater than 100 mL on 2 consecutive days. Patients with IBE were evaluated by a urologist and subsequently underwent urodynamic studies. RESULTS: The presence of IBE was significantly associated with urinary tract infection (P<.001) and aphasia (P=.046). The presence of IBE was not related to sex, stroke location, nature of stroke (hemorrhagic or ischemic), history of diabetes mellitus, or previous stroke. Urodynamic studies done on 22 patients with IBE revealed acontractile detrusor in 8 patients (36%) and detrusor underactivity in 3 (14%). Eleven patients (50%) had detrusor-external sphincter dyssynergia (DESD) combined with normative detrusor function (5 patients) or detrusor hyperactivity (6 patients); all but 1 of these patients had a supratentorial lesion. The presence of DESD was associated with a longer onset-to-evaluation interval (P=.018) [corrected] and spasticity of the stroke-affected lower limb (P=.02). [corrected] Diabetes mellitus was associated with the presence of acontractile detrusor or detrusor underactivity (P=.03). CONCLUSIONS: IBE is common among patients with stroke and is caused by decreased detrusor contractility or DESD. Spasticity of the external urethral sphincter is a possible pathophysiologic mechanism of DESD.

Labial adhesion in a postmenopausal female: A case report.

RATIONALE: Voiding difficulty is more common in males, although it is not uncommon in females. Female voiding difficulty can be caused by iatrogenic, anatomic, and neurogenic factors, and specifically urethra stricture, impaired detrusor contractility, primary bladder neck obstruction, and detrusor-external sphincter dyssynergia. Labial adhesion is a rare cause of female voiding difficulty.The incidence of labial fusion has been reported to be 0.6% to 1.4% in children; however, the incidence in the elderly has yet to be fully elucidated. PATIENT CONCERNS: We present the case of a postmenopausal and sexually inactive 76-year-old female patient who had nearly total vaginal and urethral occlusion due to labial adhesion. She had no underlying diseases and came to our clinic with a 10-month history of voiding difficulty, postmicturition dribbling, and involuntary urinary leakage when getting up. DIAGNOSIS: A genital examination revealed nearly total fusion of the labia minor with only a 3-mm pinhole opening at the posterior end. INTERVENTIONS: Treatment included surgical separation, the local application of estrogen cream, and self-dilatation. She also received an antimuscarinic agent to treat overactive bladder secondary to bladder outlet obstruction which was caused by labial adhesion. OUTCOMES: No surgical complications occurred. Moreover, no labial adhesion or voiding dysfunction was found immediately after the surgery or after 6 months of follow-up. LESSONS SUBSECTIONS: Genital examinations are a basic but very important noninvasive skill for physicians. This case report highlights that genital examinations should be a priority for patients with gynecological or urological symptoms.

Polysomnography and Nocturia Evaluations after Uvulopalatopharyngoplasty for Obstructive Sleep Apnea Syndrome.

A higher incidence rate of nocturia in patients with obstructive sleep apnea (OSA) has been observed. We investigated the differences in clinical examinations between OSA patients with and without nocturia, and further compared those with successful and unsuccessful uvulopalatopharyngoplasty (UPPP). This retrospective study enrolled 103 patients with OSA undergoing UPPP. Patients were diagnosed with OSA by following the 2018 American Academy of Sleep Medicine (AASM) Scoring Manual Version 2.5. Patients were divided into two groups depending on if they urinated more than twice per night. The medical data of body mass index (BMI), nocturia frequency per night, apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), International Prostatic Symptom Score (IPSS), and Overactive Bladder Symptom Score (OABSS) were analyzed before and after uvulopalatopharyngoplasty (UPPP) surgery. All of the measurements were compared between successful and unsuccessful surgery in the non-nocturia or nocturia groups, respectively. Fifty patients (41 males and nine females) without nocturia were assigned to group 1, and 53 patients (43 males and 10 females) with nocturia were assigned to group 2. Nocturia frequency and post-surgery AHI in group 2 were significantly higher than those in group 1 (p < 0.05). Significant decreases in IPSS and OABSS were observed in the successful surgery subgroup of group 2 (p < 0.05). A significant decrease in post-surgery AHI was observed between unsuccessful and successful surgery in patients with nocturia (p < 0.05), but not in the non-nocturia group (p > 0.05). Although AHI had a significant correlation to nocturia frequency in all OSA patients before UPPP, no significant correlation between AHI reduction and nocturia frequency was found. UPPP appeared to be an effective treatment for nocturia associated with OSA. OSA should be taken into consideration for patients who complain of nocturia syndrome. The relationship of AHI reduction and nocturia improvement after OSA treatment with UPPP is still unclear. In addition, it is necessary to establish the existence of nocturia in patients with OSA, as a result of its high prevalence in OSA patients. UPPP could reduce the symptoms of OSA and could also contribute to a reduction of nocturia even in the unsuccessful surgery group.