Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023).

PURPOSE: The purpose of this guideline is to provide a clinical structure with which to approach the diagnosis, counseling, and treatment of female patients with stress urinary incontinence (SUI). MATERIALS/METHODS: The primary source of evidence for the 2017 version of the SUI guideline was the systematic literature review conducted by the ECRI Institute. The initial search spanned literature from January 2005 to December 2015, with an additional updated abstract search through September 2016. The current amendment represents the first update to the 2017 iteration and includes updated literature published through February 2022. RESULTS: This guideline has been amended to reflect changes in and additions to the literature since 2017. The Panel maintained that the differentiation between index and non-index patients remained important. The index patient is a healthy female with minimal or no prolapse who desires surgical therapy for treatment of pure SUI or stress-predominant mixed urinary incontinence. Non-index patients have factors that may affect their treatment options and outcomes, such as high grade prolapse (grade 3 or 4), urgency-predominant mixed incontinence, neurogenic lower urinary tract dysfunction, incomplete bladder emptying, dysfunctional voiding, SUI following anti-incontinence treatment, mesh complications, high body mass index, or advanced age. CONCLUSION: While gains have been made in the field to support new methods for the diagnosis, treatment, and follow-up of patients with SUI, the field continues to expand. As such, future reviews of this guideline will take place to stay in keeping with the highest levels of patient care.

The Evolving Story of Mesh Mid Urethral Slings: The Surgeon's Perspective.

PURPOSE: The objective of this study was to obtain the perspectives of surgeons who treat female stress urinary incontinence (SUI) and better understand their range of experiences with mesh mid urethral sling (MUS) surgery. MATERIALS AND METHODS: This qualitative study recruited gynecologic and urological surgeons who treat SUI. Surgeons were interviewed by phone and in person using a standardized interview guide. Interviews were transcribed, de-identified, and analyzed by 2 independent researchers. The transcripts were coded and summarized using the principles of thematic analysis. The research team came to consensus that a saturation of ideas representing a diverse demographic of surgeons had been achieved. RESULTS: Twenty-four interviews of surgeons from diverse geographic locations and practice types were performed. Many surgeons described MUS surgery as rewarding and favorably impactful for women with SUI, while others grappled with the serious risks associated with MUS surgery. Those who had treated women with life-altering pain after MUS recounted impactful patient stories. Many stated that recognition, acknowledgement, and appropriate referral of complications were fundamental to responsible and ethical care. Some surgeons expressed frustration and concern about the raised level of controversy and anxiety regarding the MUS landscape. All participants expressed that there was substantial room for improvement in multiple domains. Participants also shared their optimal strategies relevant to MUS surgery. CONCLUSIONS: Despite diverse views regarding the role of the MUS, there was agreement among surgeons that the surgeon-patient relationship, thorough informed consent and patient counseling, and accountability are essential when implanting MUSs.

Prevalence of Urinary Incontinence among a Nationally Representative Sample of Women, 2005-2016: Findings from the Urologic Diseases in America Project.

PURPOSE: Urinary incontinence is frequently underreported and underdiagnosed in the clinical setting. We analyzed 12 years of data from a large, nationally representative sample of women in the United States to assess the prevalence, severity, and daily impact of urinary incontinence and its subtypes at the population level. MATERIALS AND METHODS: We analyzed data from 15,003 women aged ≥20 years who participated in the 2005-2016 National Health and Nutrition Examination Survey. We estimated the prevalence of urinary incontinence in the prior year, overall and by subtype (stress, urgency or mixed). Among women with urinary incontinence, we additionally assessed symptom severity using the validated 4-level Incontinence Severity Index, as well as impact on daily activities. RESULTS: The 2005-2016 prevalence of any urinary incontinence was 53%; 16% of women had mixed urinary incontinence, 26% had stress only and 10% had urgency only. While urgency urinary incontinence and mixed urinary incontinence were highest among women aged ≥60 years, stress urinary incontinence was highest among women aged 40-59 years. NonHispanic Black women had higher prevalence of urgency urinary incontinence and lower prevalence of stress urinary incontinence compared to other racial/ethnic groups. Of women with urinary incontinence, 30% reported moderate or severe symptoms, which were more common among older than younger women. In addition, 24% of women with urinary incontinence reported that the condition affected their daily activities. CONCLUSIONS: Our study demonstrates a high prevalence of urinary incontinence among a nationally representative population of women in the United States, with many reporting that urinary incontinence affected their daily activities. Age and racial/ethnic trends varied by urinary incontinence subtype.

Media coverage of the 2019 United States Food and Drug Administration ordered withdrawal of vaginal mesh products for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: On April 16, 2019, the United States Food and Drug Administration announced a withdrawal on sales and distribution of transvaginal mesh products for pelvic organ prolapse. The aim of this study was to asses online user behavior on pelvic-mesh related articles after the withdrawal and to evaluate article accuracy. MATERIALS AND METHODS: We used Google Trends© to identify the terms related to pelvic mesh that experienced increased activity after the FDA announcement. The terms were analyzed for worldwide social media engagement (Facebook, Twitter, Pinterest, and Reddit) between April 16-19, 2019. The top ten lay press articles shared for each term were evaluated. We also examined the top ten Google search results for each term on June 6, 2019, in the US to evaluate what information was available after peak interest subsided. RESULTS: During peak activity in April, 30 unique articles were identified after the FDA announcement. Two (6.7%) did not mention the April 2019 FDA announcement. Seven (23%) discussed mesh for stress urinary incontinence. After peak interest on June 6, 2019, Google identified 26 unique articles for the four terms. Seven (27%) did not mention the FDA announcement, and 3 (12%) mentioned mesh for incontinence. CONCLUSIONS: Internet search patterns and social media behavior following the April 2019 ordered withdrawal on transvaginal mesh for pelvic organ prolapse reveal that some of the most disseminated information did not accurately or thoroughly distinguish the type of mesh discussed. This could lead to negative consequences for other mesh indications in female pelvic medicine and reconstructive surgery.

National Trends in the Surgical Management of Urinary Incontinence among Insured Women, 2004 to 2013: The Urologic Diseases in America Project.

PURPOSE: The objective of this study was to examine national trends in the surgical management of urinary incontinence in women in the United States from 2004 to 2013. MATERIALS AND METHODS: We analyzed the CDM (Optum® de-identified Clinformatics® Data Mart) for women 18 to 64 years old and the CMS (Centers for Medicare and Medicaid Services) Medicare 5% Sample for women 65 years old or older. We created annual cross-sectional cohorts and assessed trends in the annual prevalence of urinary incontinence related surgical procedures overall and by age, race/ethnicity and geographic region. RESULTS: We observed a decline in the percent of women with urinary incontinence who underwent surgical treatment according to the CMS (from 4.7% in 2004 to 2.7% in 2013) and the CDM (from 12.5% in 2004 to 9.1% in 2013). This trend persisted independently of age, race/ethnicity and geographic region. Slings were the most common procedure but started to decline in 2011, ultimately decreasing by about 50% during the study period. Compared to other groups the prevalence of urinary incontinence related surgical procedures, including slings, was highest among women 35 to 54 years old and White women, and lowest among women residing in the Northeast. These sociodemographic patterns persisted with time. During the study period injection procedures remained stable, sacral neuromodulation increased slightly but remained uncommon and suspension decreased to nearly 0% of all anti-incontinence procedures. CONCLUSIONS: Surgical management of female urinary incontinence experienced several shifts from 2004 to 2013, including a decline in sling procedures. Age, racial/ethnic and regional differences in treatment persisted with time. Improved understanding of the drivers of these trends may help direct future development of treatments of pelvic floor disorders.

Single Institutional Experience with Single Stage Sacral Neuromodulation: Cost Savings and Outcomes in a Contemporary Case Series.

PURPOSE: Sacral neuromodulation is traditionally performed in 2 stages. Studies have projected that 1-stage sacral neuromodulation is cost-effective if the conversion rate is 61.3% or greater. To our knowledge we present the first case series in the literature to evaluate the cost of 1-stage sacral neuromodulation. The objective of our study was to evaluate outcomes and analyze cost using our institutional experience with 1-stage sacral neuromodulation. MATERIALS AND METHODS: A total of 15 consecutive 1-stage sacral neuromodulation procedures were performed at a self-insured, integrated health care institution. Cost data were determined using 2019 Medicare reimbursement rates for CPT codes 64581, 64585, 64590 and 64595. Median operative time was derived from actual institutional data. RESULTS: One-stage sacral neuromodulation implantation was performed in 15 patients. Median followup was 14.6 months (IQR 6.9-22.5). Of the 15 cases 14 (93.3%) were successful, defined as a 50% or greater improvement from baseline. Total reimbursement for the 15 patients who underwent 1-stage implantation was $329,430. If these patients had undergone traditional 2-stage implantation with equivalent outcomes, the overall reimbursement was determined to be $414,796. Single-stage sacral neuromodulation implantation provided a calculated total cost savings of $85,366 (p <0.01). Moreover, a projected 233 minutes in operative time was saved by performing 1-stage sacral neuromodulation (p <0.01). CONCLUSIONS: This study demonstrates the potential health care savings of a 1-stage sacral neuromodulation procedure. Moreover, 1-stage sacral neuromodulation may have other added benefits, such as reduced infection rates, patient satisfaction and other indirect cost savings, including reduced time off from work.

A Rapid Method to Preoperatively Assess Frailty for Older Patients with Pelvic Floor Conditions.

PURPOSE: Assessment of frailty can help surgeons predict perioperative risk and guide preoperative counseling. However, current methods are often cumbersome in the clinical setting. We prospectively compared the effectiveness of a rapid picture based Clinical Frailty Scale (CFS-9) assessed by patient and surgeon against reference standard Fried Frailty Index in older patients with pelvic floor conditions. MATERIALS AND METHODS: We enrolled 71 patients between March 2018 and June 2019. Frailty assessment using CFS-9 (scale ranging from very fit to terminally ill) was performed followed by the Fried Frailty Index, a validated tool of 5 measures (shrinking, physical energy, activity, grip strength, walking speed). Correlations and agreement between Fried Frailty Index and CFS-9 scores from the treating surgeon, a second surgeon (surgeon 2) and patient were analyzed using sensitivity, specificity, area under the curve and Cohen's Kappa. RESULTS: The patient cohort was mostly female (97.2%), with a mean age (±SD) of 73.0 (±5.9) years and 23.9% were frail using the Fried Frailty Index. Compared to the Fried Frailty Index, CFS-9 scores of the treating surgeon, surgeon 2 and patient had AUC values (95% CI) of 0.86 (0.77-0.86), 0.91 (0.84-0.91) and 0.88 (0.79-0.88), respectively. As assessed by Cohen's Kappa the CFS-9 scores all had substantial (surgeon 2, Kappa 0.66, 95% CI 0.46-0.85 or moderate (all other CFS-9 measures, Kappa 0.44 to 0.58) agreement with the Fried Frailty Index scores. CONCLUSIONS: Rapid and effective validated tools to screen for frailty are needed in the clinical setting. CFS-9 is an excellent predictor of frailty compared to the Fried Frailty Index for patients with pelvic floor conditions.

Microhematuria: AUA/SUFU Guideline.

PURPOSE: Patients presenting with microhematuria represent a heterogeneous population with a broad spectrum of risk for genitourinary malignancy. Recognizing that patient-specific characteristics modify the risk of underlying malignant etiologies, this guideline sought to provide a personalized diagnostic testing strategy. MATERIALS AND METHODS: The systematic review incorporated evidence published from January 2010 through February 2019, with an updated literature search to include studies published up to December 2019. Evidence-based statements were developed by the expert Panel, with statement type linked to evidence strength, level of certainty, and the Panel's judgment regarding the balance between benefits and risks/burdens. RESULTS: Microhematuria should be defined as ≥ 3 red blood cells per high power field on microscopic evaluation of a single specimen. In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. The Panel created a risk classification system for patients with microhematuria, stratified as low-, intermediate-, or high-risk for genitourinary malignancy. Risk groups were based on factors including age, sex, smoking and other urothelial cancer risk factors, degree and persistence of microhematuria, as well as prior gross hematuria. Diagnostic evaluation with cystoscopy and upper tract imaging was recommended according to patient risk and involving shared decision-making. Statements also inform follow-up after a negative microhematuria evaluation. CONCLUSIONS: Patients with microhematuria should be classified based on their risk of genitourinary malignancy and evaluated with a risk-based strategy. Future high-quality studies are required to improve the care of these patients.

I leaked, then I Reddit: experiences and insight shared on urinary incontinence by Reddit users.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is a highly prevalent condition, but is often not discussed owing to social stigma. Reddit is an internet platform for anonymous information sharing, expression, and discussion. We sought to qualitatively analyze people's behavioral, psychological, and illness experiences with UI expressed on Reddit to improve our understanding of patients' perceptions and ultimately the care we provide. METHODS: We used the Subreddit group "Incontinence" over 5 years and "BeyondtheBump" (postpartum forum) over 1 year as transcripts for qualitative analysis. Two independent researchers read and coded relevant threads (>100 posts and >400 comments). Charmaz's principles of grounded theory were applied. This included line-by-line coding of transcripts utilizing key phrases followed by grouping similarly coded phrases into preliminary themes. Emergent concepts were derived from these themes. RESULTS: A group of Reddit users with diverse UI etiologies were sampled. Qualitative analysis resulted in six preliminary themes. Users with UI were initially self-aware of their incontinence. They were interested in optimal product use. Users struggled with major life adjustments and relating to others. Nonetheless, they learned gradually to cope with their symptoms. Last, postpartum women specifically wanted additional immediate help for managing UI, often in the form of pelvic physiotherapy. Three emergent concepts were formed: the sense of isolation, acceptance over time, and self-drive to manage their UI. CONCLUSIONS: Internet forums such as Reddit may serve as a health resource for people with UI. Physicians can strive to better understand the patient perspective and their needs in order to provide optimal care.

Do Patients Discontinue Overactive Bladder Medications after Sacral Neuromodulation?

PURPOSE: Overactive bladder medications often have poor tolerability or lack of efficacy with many patients progressing to third line therapy such as sacral neuromodulation. Those treated with sacral neuromodulation may avoid the potential side effects of overactive bladder medications while achieving symptom improvement. We evaluated the postoperative rate of discontinuing overactive bladder medications in patients who underwent sacral neuromodulation of refractory overactive bladder. MATERIALS AND METHODS: We queried a prospectively collected, institutional review board approved database for patients who underwent sacral neuromodulation. Patients were excluded from analysis if the surgical indication was urinary retention or a sacral neuromodulation device was removed 1 year or less postoperatively. We assessed clinical characteristics, urodynamic parameters and filled overactive bladder medications using an external prescription database. Patient perceived postoperative outcomes were examined. Groups were compared by the Student t-test and the chi-square test. RESULTS: Of the 78 patients who met inclusion criteria 82.1% stopped and never restarted overactive bladder medications (the sacral neuromodulation only group). Of the patients 14.1% consecutively continued filling overactive bladder medications 1 year or more following surgery (the concurrent group). There was no difference between the groups in body mass index, gender, sacral neuromodulation revision, urodynamic parameters, the PGI-I (Patient Global Impression of Improvement) or patient perceived percent improvement. However, concurrent patients were significantly older than those who received sacral neuromodulation only (p = 0.002). CONCLUSIONS: More than 80% of patients who progressed to sacral neuromodulation discontinued overactive bladder medications and received sacral neuromodulation as the sole treatment. A small portion of patients concurrently used overactive bladder medications following sacral neuromodulation for 1 year or more. However, outcomes were similar in the 2 groups. Sacral neuromodulation is a strategy to provide a successful outcome in refractory cases and yet avoid the potentially detrimental side effects related to overactive bladder medications.

Outcomes in a contemporary cohort undergoing sacral neuromodulation using optimized lead placement technique.

AIMS: To evaluate factors associated with progression to stage 2 sacral neuromodulation (SNM) for refractory overactive bladder, urinary retention, or fecal incontinence using optimal lead placement techniques with curved stylet. METHODS: This is a retrospective analysis of a prospectively collected database of all consecutive stage 1 SNM lead placements at our institution between August 2014 and May 2017 using optimal lead placement technique with curved stylet. Patients with refractory overactive bladder, urinary retention, or fecal incontinence were enrolled. Patients with 50% or more symptom improvement on voiding diaries were offered stage 2 implant. Demographics, clinical, and surgical characteristics were compared for patients who underwent successful stage 2 implants versus those who underwent lead removal at the end of the stage 1 trial period. RESULTS: 127 patients underwent SNM during the study period. Motor thresholds of ≤2 mA in all four electrodes were achieved in 74% of patients (94/127). A total of 89.0% (113/127) of patients received stage 2 implants. The main indication for implant, specifically urgency urinary incontinence, was positively associated with progression to stage 2 implant. Male gender, history of pelvic pain and previous SNM were negatively associated with progression to stage 2 implant. CONCLUSIONS: Our findings demonstrate that the contemporary optimized lead placement technique resulted in low motor thresholds and successful progression to stage 2 SNM implant in the majority of our cohort. Predictive factors associated with success or failure may potentially guide decision making for therapeutic interventions and counseling patient expectations.

Use of Third Line Therapy for Overactive Bladder in a Practice with Multiple Subspecialty Providers-Are We Doing Enough?

PURPOSE: Overactive bladder impacts more than 15% of the adult population. Compliance with medical treatment is low due to inadequate symptom control or intolerable side effects. Although third line therapies have improved the treatment of overactive bladder, many patients do not receive optimal treatment. We hypothesized that third line treatment use is higher among female pelvic medicine and reconstructive surgery urologists, and we examined its use at our tertiary referral center. MATERIALS AND METHODS: The electronic medical record was queried for patients with overactive bladder seen in 1 year. The number of visits associated with an overactive bladder prescription and the number of patients who received third line therapy were determined and subcategorized by department. Female pelvic medicine and reconstructive surgery providers were considered separately. RESULTS: A total of 5,445 patients (8,994 visits) were seen for overactive bladder. Of all patients seen for overactive bladder 3.5% received third line therapy compared with 10.0% and 14.1% of those seen by urology providers and female pelvic medicine and reconstructive surgery providers, respectively. CONCLUSIONS: The use of third line therapy was reported to be less than 5%. This rate is higher at our institution, which is likely due to multiple female pelvic medicine and reconstructive surgery providers. We also apply an algorithm that facilitates patient education on available options should first and second line treatments fail. Given the limited compliance with medical treatment for overactive bladder, we are likely missing a segment of the patient population who would benefit from third line treatment. Our data demonstrate an opportunity for urologists to improve the quality of overactive bladder treatment and subsequently improve patient quality of life.

Inconsistency in the Definition of Urinary Tract Infection after Intravesical Botulinum Toxin A Injection: A Systematic Review.

PURPOSE: To more accurately examine the rate of urinary tract infection following onabotulinumtoxinA injection of the bladder we systematically reviewed the literature for definitions of urinary tract infection in studies of onabotulinumtoxinA injections. We assessed the studies for consistency with guideline statements defining urinary tract infections. MATERIALS AND METHODS: We systematically reviewed the literature by querying MEDLINE® and Embase®. We included original studies on adult patients with idiopathic overactive bladder and/or neurogenic detrusor overactivity who underwent cystoscopy with onabotulinumtoxinA injection and in whom urinary tract infection was a reported outcome. RESULTS: We identified 299 publications, of which 50 met study inclusion criteria. In 27 studies (54%) urinary tract infection diagnostic criteria were defined with a total of 10 definitions among these studies. None of the overactive bladder studies used a definition which met the EAU (European Association of Urology) criteria for urinary tract infection. Only 2 of the 10 studies on patients with neurogenic bladder used a urinary tract infection definition consistent with the NIDRR (National Institute on Disability and Rehabilitation Research) standards. CONCLUSIONS: Definitions of urinary tract infection are heterogeneous and frequently absent in the literature on onabotulinumtoxinA to treat overactive bladder and/or neurogenic bladder. Given the potential for post-procedure urinary symptoms in this setting, explicit criteria are imperative to establish the true urinary tract infection rate following treatment with onabotulinumtoxinA.

The history of the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction.

AIMS: To review the history of the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU). METHODS: We reviewed Society meeting minutes, contacted all living former Society presidents, searched the William P. Didusch Center for Urology History records, and asked Society members to share their important Society experiences in order to gather important historical information about the Society. RESULTS: The Society initially formed as the Urodynamics Society in 1969 in the backdrop of a growing passion for scientific research in the country after World War II ended. Since then, Society meetings have provided a pivotal forum for the advancement of science in lower urinary tract dysfunction. Meetings occurred annually until 2004, when the meeting schedule increased to biannual. The journal, Neurourology and Urodynamics, became the official journal of the Society in 2005. SUFU has authored important guidelines on urodynamics (2012), non-neurogenic overactive bladder (2012), and stress urinary incontinence (2017) and has shared important collaborations with other societies, including the American Urological Association (AUA), the International Continence Society (ICS), and the International Society of Pelvic Neuromodulation (ISPiN). SUFU has also been instrumental in trainee education and helped to establish formal fellowship training in the field in addition to holding a yearly educational meeting for urology residents. The Society has been led by 21 presidents throughout its history. CONCLUSION: Throughout the Society's near half-century long existence, the Society has fostered research, published guidelines, and educated trainees in order to improve the care of individuals suffering from lower urinary tract dysfunction.

Surgical Treatment of Female Stress Urinary Incontinence: AUA/SUFU Guideline.

PURPOSE: Stress urinary incontinence is a common problem experienced by many women that can have a significant negative impact on the quality of life of those who suffer from the condition and potentially those friends and family members whose lives and activities may also be limited. MATERIALS AND METHODS: A comprehensive search of the literature was performed by ECRI Institute. This search included articles published between January 2005 and December 2015 with an updated abstract search conducted through September 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. RESULTS: The AUA (American Urological Association) and SUFU (Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction) have formulated an evidence-based guideline focused on the surgical treatment of female stress urinary incontinence in both index and non-index patients. CONCLUSIONS: The surgical options for the treatment of stress urinary incontinence continue to evolve; as such, this guideline and the associated algorithm aim to outline the currently available treatment techniques as well as the data associated with each treatment. Indeed, the Panel recognizes that this guideline will require continued literature review and updating as further knowledge regarding current and future options continues to grow.

Urologic Dermatology: a Review.

PURPOSE OF REVIEW: Genital dermatology represents a challenge to many providers. Though dermatologic lesions involving the genitalia may present to any of a number of practices, ranging from primary care to urology, gynecology, and dermatology, few training programs provide significant training regarding the diagnosis and management of genital dermatologic lesions. The purpose of this review is to provide urologists with an overview of common genital dermatological lesions that may be encountered in a clinic. The review also provides a guide to how to approach these conditions. RECENT FINDINGS: This manuscript summarizes the most common categories of genital dermatologic lesions, starting with normal variants and progressing to a review of contagious conditions, premalignant lesions, and malignant lesions. In cases in which a lesion does not definitively belong to one of these categories, an algorithmic approach to making a diagnosis may be helpful to narrow the differential diagnosis. The most common benign genital growths include cysts, syringomas, seborrheic keratosis, pearly papules, and Fordyce spots. Contagious lesions, such as herpes, syphilis, scabies, or molluscum contagiosum, should be treated immediately before complications or transmission can occur. Inflammatory genital lesions are very diverse in etiology and presentation but are the most common genital lesions in urological clinical practice. This category of lesions can be approached by dividing them into non-erythematous and erythematous (scaling and non-scaling) lesions. Given the potential evolution of the challenging category of premalignant genital lesions, proper recognition and early biopsy play an important role. Premalignant lesions can be broadly classified into two categories: those not related to HPV infection and those that are related to HPV, including erythroplasia of Queyrat (EQ), Bowen's disease, Bowenoid papulosis, vulvar intraepithelial neoplasia (VIN), and giant condyloma. Herein, contemporary nomenclature and proper evaluation and management of premalignant lesions are reviewed which provide safe and efficacious outcomes for patients. Finally, malignant genital lesions, though rare, must be recognized early and addressed correctly. Squamous cell carcinoma represents 95% of penile and approximately 90% of vulvar and vaginal malignancies, and diagnosis and management can be challenging and require proper referral to an oncologist. Genital dermatology is a challenging field marked by diagnostic difficulty and management challenges. This manuscript provides an overview of genitourinary dermatologic lesions in an effort to provide clinicians with a framework with which to approach the evaluation of these various conditions that will facilitate proper consideration of the differential diagnoses and help the urologist distinguish between normal, benign, premalignant, and malignant lesions.

Mixed incontinence: what takes precedence in its management?

Mixed urinary incontinence is a commonly encountered condition for urologists, urogynecologists, and primary care providers. In this review, we discuss the approach to the evaluation and management of patients with simultaneous stress and urgency urinary incontinence. The available evidence for treatment modalities in the setting of mixed urinary incontinence is presented, and we discuss our treatment algorithm for this common but challenging clinical scenario. An accurate assessment of stress and urge symptoms and their relative impact on quality of life help guide the management plan, appropriate counseling, and appropriate appraisal of patient expectations for treatment.

Practical use of the new American Urological Association adult urodynamics guidelines.

In 2012, the American Urological Association published guidelines on adult urodynamics. On the basis of a review of the available evidence, they established guideline recommendations for urodynamics in adults with stress urinary incontinence/pelvic organ prolapse, overactive bladder/urinary urgency incontinence/mixed urinary incontinence, neurogenic bladder, and lower urinary tract symptoms. This article reviews the practical use of these guidelines in a clinical practice.