Nonneurogenic female bladder outlet obstruction: Conservative and medical management.

INTRODUCTION: In nonneurogenic female bladder outlet obstruction (BOO), management goals include reduction of outlet resistance to increase urinary outflow and improve bladder voiding to prevent or reduce lower and upper urinary tract (LUT and UUT) function deterioration, by correcting the underlying etiology. As significant progress has been achieved in the conservative and pharmacological management of nonneurogenic female BOO, the purpose of this article is to review and summarize the current literature. MATERIALS AND METHODS: For this narrative review, a PubMed® search was performed by cross-referencing the keywords "female bladder outlet obstruction," "female voiding dysfunction," "conservative management," "pharmacological management," and "treatment" with various terms related to the management of female BOO. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used. MANAGEMENT: This review discusses and summarizes the conservative and pharmacological management of nonneurogenic female BOO based on the most relevant data currently available in the literature. CONCLUSION: The recent advances in the understanding of underlying mechanisms involved in female BOO allow for more individualized management. Conservative and pharmacological options show interesting outcomes, particularly in the context of a functional cause of BOO. Overall, the level of evidence is still low regarding the use of conservative and pharmacological measures and more long-term data are required.

A cost-effectiveness analysis of bladder management strategies in neurogenic lower urinary tract dysfunction after spinal cord injury: A publicly funded health care perspective.

STUDY DESIGN: Economic evaluation study. OBJECTIVES: To investigate the long-term cost-effectiveness of clean intermittent catheterization (CIC) compared with suprapubic catheters (SPC) and indwelling urethral catheters (UC) among individuals with neurogenic lower urinary tract dysfunction (NLUTD) related to spinal cord injury (SCI) from a public healthcare perspective. SETTING: University affiliated hospital in Montreal, Canada. METHODS: A Markov model with Monte Carlo simulation was developed with a cycle length of 1 year and lifetime horizon to estimate the incremental cost per quality-adjusted life years (QALYs). Participants were assigned to treatment with either CIC or SPC or UC. Transition probabilities, efficacy data, and utility values were derived from literature and expert opinion. Costs were obtained from provincial health system and hospital data in Canadian Dollars. The primary outcome was cost per QALY. Probabilistic and one-way deterministic sensitivity analyses were performed. RESULTS: CIC had a lifetime mean total cost of $ 29,161 for 20.91 QALYs. The model predicted that a 40-year-old person with SCI would gain an additional 1.77 QALYs and 1.72 discounted life-years gained if CIC were utilized instead of SPC at an incremental cost savings of $330. CIC confer 1.96 QALYs and 3 discounted life-years gained compared to UC with an incremental cost savings of $2496. A limitation of our analysis is the lack of direct long-term comparisons between different catheter modalities. CONCLUSIONS: CIC appears to be a dominant and more economically attractive bladder management strategy for NLUTD compared with SPC and/or UC from the public payer perspective over a lifetime horizon.

The use of vaginal lasers in the treatment of urinary incontinence and overactive bladder, systematic review.

OBJECTIVES: To evaluate the available literature to assess the safety, efficacy, and outcomes of lasers in the treatment of female stress urinary incontinence (SUI) and overactive bladder (OAB). METHODS: Pubmed search was conducted up to May 2020, including observational and investigational human studies that documented the effects on laser treatment in SUI and OAB. RESULTS: A total of 27 studies, recording subjective or objective measures in SUI or OAB were included. Lasers used included Er:YAG and Fractional CO2 lasers. The overall quality of studies was poor, and 23/27 studies were case series (LOE:4). Er:YAG laser showed a modest reduction in mild SUI cases, with benefits lasting a maximum of 13-16 months. Er:YAG laser for OAB showed conflicting results, with a trend to improve OAB symptoms for up to 12 months. Fractional CO2 laser showed an improvement of mild SUI in few studies; however, no long-term data are available. For OAB symptoms, studies showed minimal improvement that was evaluated in short term studies. When reported, adverse events were insignificant, however, they were not reported systematically. Several limitations have been noticed in the current literature of vaginal lasers, including large variation in laser settings and protocols, short term follow up, lack of urodynamic evaluation, and appropriate objective measures. CONCLUSION: Based on the available literature, lasers cannot be recommended as a treatment option at this time. Future better-quality studies are needed to document the exact mechanism of action, longevity, safety and its eventual place into the current treatment algorithms of SUI and OAB.

Is Early Surgical Treatment for Benign Prostatic Hyperplasia Preferable to Prolonged Medical Therapy: Pros and Cons.

Background and objectives: Treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) has shifted over the last decades, with medical therapy becoming the primary treatment modality while surgery is being reserved mostly to patients who are not responding to medical treatment or presenting with complications from BPH. Here, we aim to explore the evidence supporting or not early surgical treatment of BPH as opposed to prolonged medical therapy course. Materials and Methods: The debate was presented with a "pro and con" structure. The "pro" side supported the early surgical management of BPH. The "con" side successively refuted the "pro" side arguments. Results: The "pro" side highlighted the superior efficacy and cost-effectiveness of surgery over medical treatment for BPH, as well as the possibility of worse postoperative outcomes for delayed surgical treatment. The "con" side considered that medical therapy is efficient in well selected patients and can avoid the serious risks inherent to surgical treatment of BPH including important sexual side effects. Conclusions: Randomized clinical trials comparing the outcomes for prolonged medical therapy versus early surgical treatment could determine which approach is more beneficial in the long-term in context of the aging population. Until then, both approaches have their advantages and patients should be involve in the treatment decision.

Does asymptomatic bacteriuria increase the risk of adverse events or modify the efficacy of intradetrusor onabotulinumtoxinA injections?

AIM: To assess the impact of asymptomatic bacteriuria (ASB) on the safety and efficacy of intradetrusor onabotulinumtoxinA injections in patients with overactive bladder and neurogenic detrusor overactivity. METHODS: We reviewed the medical records of patients who had received onabotulinumtoxinA between 2009 and 2014. Safety analysis was based on the appearance of urinary tract infections (UTIs), hematuria, and need for hospitalization because of related adverse event(s) in the month after injection. Patients who underwent urodynamic study before and 3 months after the first onabotulinumtoxinA treatment were included in efficacy analysis. Changes in maximal cystometric capacity (MCC), bladder compliance (BC), maximal detrusor pressure at maximal involuntary detrusor contraction (Pdetmax), and detrusor leak point pressure (DLPP) were assessed. RESULTS: Totally, 183 patients underwent 457 injection sessions. ASB was found in 38.8% (185) of urine cultures taken before injections. After treatment, 49 patients (with or without ASB) developed UTI. Urosepsis did not occur. The odds ratio of UTI in patients with ASB was 16.48. The efficacy cohort, consisting of 83 patients, showed that ASB had no significant effect on any of the efficacy parameters (MCC-risk ratio [RR]: 0.93, 95% confidence interval [CI]: 0.72-1.21; BC-RR: 0.88, 95% CI: 0.62-1.24; Pdetmax-RR: 0.9, 95% CI: 0.69-1.21; DLPP-RR: 1.69, 95% CI: 0.72-3.97). CONCLUSIONS: ASB is common among patients who are candidates for intradetrusor onabotulinumtoxinA treatment. ASB increases the risk of UTI, but does not heighten the risk of urosepsis, hospitalization, or therapy failure. This study should lead to the reconsideration of current recommendations.

Spontaneous vesicorectal fistula: a rare complication of neurogenic bladder.

BACKGROUND: We report a rare case of spontaneous vesicorectal fistula. CASE PRESENTATION: A 13-year-old female spina bifida patient who complained of fecal and urinary incontinence was eventually diagnosed with a spontaneous vesicorectal fistula. We hypothesized that infection, neurogenic bowel and neurogenic bladder caused her vesicorectal fistula. The patient refused the operation, and she is currently in a delicate balance. CONCLUSIONS: Early repair of the fistula is necessary. The treatment of neurogenic bladder after fistula repair is difficult and deserves further observation and follow-up.

Teaching and evaluation of basic urodynamic skills in urology residency programs: Randomized controlled study.

AIMS: Considering the growing role of urodynamic studies (UDS) in urology, we aimed to determine the most effective teaching method with objective evaluation for urodynamic skills, to improve training and patient care. METHODS: Urology residents (n = 20) post-graduate years 3-5 were randomized to receive either a UDS video training module or a standard UDS teaching document one week prior to an objective structured clinical examination (OSCE). The OSCE was a validated visual recognition exam with interpretation of 12 UDS tracing scenarios. Participants rated their proficiency to interpret UDS tracings before doing the OSCE. Total interpretation score was determined by the accuracy of their response to each question ranging from 0 to 2. RESULTS: The mean total interpretation score was 13.3 of 24 (55%). The video group achieved significantly higher interpretation scores (15.1 ± 2.08 vs 11.4 ± 2.41, P = 0.0017), and cumulative certainty scores (P = 0.0341). Overall interpretation scores significantly correlated with self-reported proficiency scores prior to the exam (r = 0.502, P < 0.05), and total certainty scores (r = 0.531, P < 0.05). CONCLUSIONS: Reviewing a UDS video training module resulted in significantly better scores on objective assessment of urology residents' UDS interpretation skills when compared with a standard teaching document. These findings must be interpreted with caution in light of sample size and short knowledge retention required for the assessment within a week. Therefore, using a UDS video training module could be more effective review tool for urology residents. These findings highlight the need to incorporate multimedia teaching into urology training curriculum.

Lumbar to sacral root rerouting to restore bladder function in a feline spinal cord injury model: Urodynamic and retrograde nerve tracing results from a pilot study.

AIMS: Lumbar to sacral rerouting surgery can potentially allow voiding via a skin-central nervous system-bladder reflex pathway. Here, we assessed if this surgery was effective in treating neurogenic bladder dysfunction/sphincter in felines. METHODS: Eight cats underwent spinal cord transection (SCT) at thoracic level 10/11. Unilateral L7 to S1 ventral root anastomosis was performed 1 month later in six cats. Two cats served as transection-only controls. Electrical and manual stimulation of L6-S1 dermatomes, and urodynamics were performed at 3, 5, 7, and 9/10 months post transection. At 9/10 months, cats were also evaluated by direct electrophysiological testing of anastomosed roots with urodynamics, then tissue collection and examination of the root anastomosis site and lumbosacral cord ventral horns for cells retrogradely labeled from tracer dye injected 2 weeks earlier into the bladder wall. RESULTS: At 9/10 months, four of six rerouted cats exhibited increased detrusor pressure provoked by cutaneous stimulation, one cat bilaterally. Two cats presented with a voiding stream after ipsilateral cutaneous stimulation at 7 and 9 months. All six rerouted animals showed regrowth of axons from the L7 ventral horn to the bladder, although some aberrant axonal regrowth was also observed. CONCLUSION: L7 to S1 ventral root rerouting below the level of SCT showed successful axonal regrowth to the bladder from the L7 spinal cord segment in all rerouted animals, and induced increased detrusor pressure response to cutaneous stimulation in a subset. This feasibility study paves the way for future animal studies for bladder reinnervation.

Impact of surgery on quality of life of women with obstetrical fistula: a qualitative study in Burkina Faso.

INTRODUCTION AND HYPOTHESIS: Obstetric fistula, caused by traumatic delivery and patient lack of access to obstetric care, is an important public health concern in developing countries, particularly in Sub-Saharan Africa. This research focuses on the experience of women living with obstetric fistula in Burkina Faso as well as their reintegration into community after surgery. METHODS: This project was funded by the Mères du Monde en Santé (MMS) Foundation and conducted in collaboration with the Boromo Hospital. A qualitative approach based on grounded theory and using the principles of participative action research (PAR) was used with semidirected interviews prior to surgery and follow-up interviews 1-2 years after surgery directly in the women's village of origin. Thirty-nine participants were recruited between 2012 and 2015. RESULTS: The results point to circumstances leading to obstetric fistula development: poverty, gender inequality in terms of decision making, healthcare-system deficiencies, and lack of services for referral and treatment of this condition. Our results reinforce the knowledge about the social and psychological repercussions of fistula by exploring the concepts of gossips, shame and self-exclusion as powerful mechanisms of exclusion, but they also show that social support was conserved for several women through their journey with this disease. There was complete social rehabilitation within the community after surgery; however, persistent barriers in term of anxiety regarding obstetric future and economic insecurity were present. CONCLUSIONS: Early recruitment for surgery and prevention are the main objectives when attempting to reduce the impact of obstetric fistula and facilitate patient reintegration. Improvements in local and governmental public health policies are required.

Is multichannel urodynamic assessment necessary before considering a surgical treatment of BPH? Pros and cons.

PURPOSE: Lower urinary tract symptoms (LUTS) are common in middle-aged men and could be consequences of multiple etiologies responsible for bladder outlet obstruction (BOO), detrusor underactivity (DUA) and/or overactive bladder. When LUTS are suggestive of BOO secondary to benign prostatic hyperplasia, a surgical treatment can sometimes be consider. Even if multichannel urodynamic study (UDS) is currently the gold standard to properly assess LUTS, its use in non-neurogenic men is still a matter of controversy. Here, we aim to explore the evidence supporting or not the use of systematic multichannel UDS before considering an invasive treatment in men LUTS. METHODS: The debate was presented with a "pro and con" structure. The "pro" side supported the systematic use of a multichannel UDS before considering a surgical treatment in men LUTS. The "con" side successively refuted the "pro" side arguments. RESULTS: The "pro" side mainly based their argumentation on the poor correlation of LUTS and office-based tests with BOO or DUA. Furthermore, since a multichannel UDS could allow selecting men that will most benefit of a surgical procedure, they hypothesized that such an approach could reduce the overall morbidity rate and cost associated with. The "con" side considered that, in most cases, medical history and symptoms were reliable enough to consider surgery. Finally, they underlined the UDS limitations and the frequent lack of alternative to surgery in this context. CONCLUSIONS: Randomized clinical trials are being conducted to compare these two approaches. Their results would help the urological community to override this debate.

Multiple sclerosis (MS) for the urologist: What should urologists know about MS?

UNLABELLED: Multiple sclerosis (MS) is a unique central nervous system (CNS) inflammatory disease with a broad spectrum of clinical presentations, which are time- and disease progression-related. It usually affects young adults, with a female predominance of 3:1. Men are more likely to develop symptoms at a slightly older age with a more progressive disease course. Diagnosis relies on a combination of clinical, radiological, and laboratory investigations, with a central role of magnetic resonance imaging (MRI). Although the exact etiology is still obscure, the leading hypothesis behind MS relapses is acute inflammatory attacks on CNS myelin and axons. This complex process involves B and T cells together with macrophages and microglia. Genetic and environmental factors are thought to be major contributors to the disease's evolution. MS therapies consist of long-term (immunomodulatory) management, focusing on disease modification, and short-term symptomatic control. Symptomatic treatment includes pharmacological and non-pharmacological methods to protect function and restore quality of life (QoL). The introduction and development of disease-modifying medications provide opportunities to change the face of this disease, enhancing QoL over the long-term. Interferon (INF) and Glatiramer acetate (GLAT) represent first line medications with limited effect and relatively fair safety profile. Newer medications with improved efficacy along with a more hazardous side effect profile are now considered second line therapy. CONCLUSIONS: The present review summarizes current knowledge of this frequent disease. Urologists must acquire a deeper understanding for better integration of practice recommendations.

Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women: An MRI study.

AIMS: To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. METHODS: This 2008-2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal-Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. RESULTS: Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. CONCLUSIONS: Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women. PATIENT SUMMARY: Older women with UI demonstrate different problems with their pelvic organ support structures depending on the type of UI. These new findings should be taken into consideration for future research into developing new treatment strategies for UI in older women. Neurourol. Urodynam. 35:515-521, 2016. © 2015 Wiley Periodicals, Inc.

Risk factors of nocturia (two or more voids per night) in Chinese people older than 40 years.

AIMS: To explore the risk factors of nocturia in Chinese inhabitants aged ≥40 years. METHODS: A randomized, community-based, cross-sectional study was performed on 10,160 inhabitants ≥40 years old in mainland China, via a stratified sampling approach. A questionnaire, including socio-demographics, lifestyle factors and medical history, was completed. Nocturia was defined as a threshold of two or more voids per night. Differences in prevalence between age and gender groups were ascertained by the chi-squared test. Gender-related factors were evaluated by multivariate logistic regression analysis. P < 0.05 was considered to be statistically significant. RESULTS: Data on 9,637 (94.9%) people aged 59.6 ± 9.7 years qualified for final statistical analysis. The overall prevalence of nocturia was 31.7% (3,053/9,637), and this increased with age (P < 0.001). Nocturia was significantly associated with cardiovascular disease and overactive bladder symptom score (OABSS) (P < 0.05), while sporting activities were protective (P < 0.001). Diabetes mellitus (DM) was significantly correlated with nocturia in men (P < 0.05), whereas hypertension was correlated with nocturia in women (P < 0.05). No correlation was found between nocturia and education level, occupation, civil status, tea consumption, body mass index (BMI), female birth history, and International Prostate Symptom Score. CONCLUSIONS: In Chinese people aged ≥40 years, nocturia is associated with aging, OABSS, cardiovascular disease, hypertension, and DM. Sporting activities are negatively associated with nocturia.

What do we know and not know about mirabegron, a novel ß3 agonist, in the treatment of overactive bladder?

INTRODUCTION AND HYPOTHESIS: Mirabegron is a novel ß3-adrenoceptor agonist recently approved by Japanese, American, and European authorities for overactive bladder (OAB) therapy. Here we review existing knowledge on this new class of medication, analyze existing literature on the topic, and make recommendations regarding its administration and necessary future studies. METHODS: We reviewed the current literature and analyzed mirabegron efficacy, safety, and suitability for treating OAB symptoms. We performed a systematic search of Medline/PubMed, and Embase. Studies exploring mechanisms involved in the effects of mirabegron were included. Searches were limited to the English language. RESULTS: Two phase II and two large-scale phase III multinational randomized controlled trials have supported mirabegron efficacy and tolerability with up to 12 weeks of therapy in OAB patients. The reported frequency and severity of treatment-emergent and serious adverse events were similar to antimuscarinics but with more than threefold lower incidence of dry mouth than with tolterodine. However, effects on the cardiovascular system, cognitive functions, pharmacokinetic interactions with other drugs, and long-term adverse events have not yet been fully investigated. CONCLUSION: Anticholinergic drugs should remain the first-line pharmacologic treatment for OAB until head-to-head comparative study eventually shows that mirabegron has equivalent or superior efficacy. However, it seems logical to use mirabegron as second-line treatment of OAB in patients who are poor responders or intolerant to anticholinergics.

The Utility of Urodynamic Studies in Neuro-Urological Patients.

INTRODUCTION: The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review. METHODS: For this narrative review, a PubMed® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used. ANALYSIS: Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities. CONCLUSION: Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

Effect of the anticonvulsant medications pregabalin and lamotrigine on urodynamic parameters in an animal model of neurogenic detrusor overactivity.

AIMS: To assess the effects of different doses and treatment durations of pregabalin and lamotrigine on the urodynamic parameters of an animal model of neurogenic detrusor overactivity (NDO). MATERIALS AND METHODS: Ninety rats were used; six as normal controls and the remaining 84 were divided as follows: Six "paraplegic controls," 6 "paraplegic-vehicle controls," and the remaining 72 divided into two equal groups. Group 1 was divided into six subgroups; pregabalin was given in doses of 10 mg/kg, 20 mg/kg, or 30 mg/kg for 1 or 2 weeks. Group 2 was similarly subdivided; lamotrigine was given in doses of 1.5 mg/kg, 3 mg/kg, or 6 mg/kg for 1 or 2 weeks. RESULTS: All paraplegic controls developed NDO within 3 weeks from spinalization. Their baseline bladder pressure (BBP) 19 ± 4.4 cmH(2) O, detrusor pressure at maximum capacity (DPMaxC) 47.6 ± 4.3 cmH(2) O, bladder capacity (BC) 0.45 ± 0.1 ml, and frequency of detrusor overactivity (FDO) 3.7 ± 0.9/min. Both pregabalin and lamotrigine produced significant improvement. Urodynamic values in those treated with 20 mg pregabalin for 1 or 2 weeks were: BBP 11.7 ± 1.3 and 9 ± 0.2 cmH(2) O, BC 0.6 ± 0.1 and 0.7 ± 0.01 ml, DPMaxC 17.3 ± 4.0 and 23 ± 2.6 cmH(2) O, FDO 2.1 ± 0.2/min and 1.7 ± 0.1/min. Urodynamic values in those treated with 3 mg/kg lamotrigine for 1 or 2 weeks were: BBP 9.7 ± 2.2 and 8.6 ± 1.9 cmH(2) O, DPMaxC 17.2 ± 1.8 and 29 ± 1.2 cmH(2) O, BC 0.7 ± 0.1 and 0.8 ± 0.1 ml, FDO 1.9 ± 0.2/min and 1.9 ± 0.2/min (P < 0.001). CONCLUSIONS: Pregabalin and lamotrigine may represent novel alternative treatments of NDO. Clinical trials remain to be performed.