Variations of Nighttime and Daytime Bladder Capacity in Patients with Nocturia: Implication for Diagnosis and Treatment.

PURPOSE: We subtyped patients with nocturia according to daily variations in urine production and bladder capacity. MATERIALS AND METHODS: Patients with 1 or more nocturia episodes per day were prospectively enrolled in this study. Post-void residual urine was collected and a 3-day frequency-volume chart was created. Nocturnal polyuria and bladder capacity were calculated for each patient. Reduced bladder capacity was defined as mean 24-hour bladder capacity less than 200 ml. Patients were categorized into 4 subgroups by the presence or absence of nocturnal polyuria and reduced bladder capacity. RESULTS: Of the 84 patients enrolled in study 50 (59.5%) had nocturnal polyuria and 50 (59.5%) had decreased bladder capacity. Patients with reduced bladder capacity and nocturnal polyuria had significantly greater mean and maximum bladder capacity at night than during the day (p = 0.002) and the highest number of nocturia episodes (3, IQR 2-3). Patients with normal bladder capacity but with nocturnal polyuria had significantly larger mean and maximum bladder capacity at night (p = 0.033 and 0.016, respectively). In patients with reduced bladder capacity and no nocturnal polyuria we observed no significant variation in bladder capacity during the day vs the night. On multivariable analysis the body mass index (OR 1.28 per unit, 95% CI 1.04-1.58, p = 0.019) and severe nocturia (OR 6.26, 95% CI 1.71-22.92, p = 0.006) were risk factors for nocturnal polyuria while only severe nocturia was a predictive factor for reduced bladder capacity (OR 3.77, 95% CI 1.20-11.83, p = 0.023). CONCLUSIONS: Patients with nocturnal polyuria have a different bladder capacity in the day and the night. Severe nocturia (3 or more episodes per night) predicts the presence of nocturnal polyuria and reduced bladder capacity. Our data suggest that in patients with severe nocturia those 2 conditions should be considered and managed.

Sacral neuromodulation: an effective treatment for lower urinary tract symptoms in multiple sclerosis.

INTRODUCTION AND HYPOTHESIS: Most subjects with multiple sclerosis (MS) suffer from lower urinary tract symptoms (LUTS). Detrusor overactivity, detrusor hypocontractility and detrusor-sphincter dyssynergia are the most common bladder dysfunctions. Management is not straightforward due to the progressive course of the disease. Sacral neuromodulation (SNM) has received increasing attention among new effective treatments for bladder disorders associated with MS. The aim of this study was to review the published literature on the role of SNM in the treatment of LUTS in patients with MS. METHODS: A literature search was carried out up to December 2014, using relevant search terms in MEDLINE and EMBASE databases. The ClinicalTrials.gov and Controlled-trials.com online trial registries and the abstracts from international scientific meetings were searched for English-language studies containing relevant search terms. Relevant reviews and trials and prospective studies were analysed by two independent reviewers. RESULTS: Two prospective studies and four retrospective studies were included. Overall, MS patients represented small series (4 to 25 subjects). The longest follow-up was 7 years and the evaluation of the treatment outcomes was not homogeneous among the studies. The definition of objective cure was often unclear. The subjective cure rate was 45 %, patients' reported satisfaction was 85 % and all the results were stable over time. CONCLUSIONS: SNM seems to be a safe and effective treatment for LUTS in MS patients. Further and larger studies as well as randomized controlled trials are needed to confirm its clinical role in patients with MS.

The pelvic floor muscle hyperalgesia (PFMH) scoring system: a new classification tool to assess women with chronic pelvic pain: multicentre pilot study of validity and reliability.

OBJECTIVE: The contribution of pelvic floor muscle tenderness to chronic pelvic pain (CPP) is well established in the literature. However pelvic floor muscle hyperalgesia (PFMH) is often missed during vaginal examination of women with CPP. To our knowledge criteria for diagnosing PFMH has not been established or validated so far. The aim of this study is to assess the validity and reliability of the PFMH scoring system. STUDY DESIGN: Women with and without PFMH were recruited prospectively. Digital pelvic examination was performed to detect any pain. All women were asked to report of any discomfort or pain evoked by digital palpation of the PFMs and to rate the severity of pain/discomfort as none (grade 0), mild (grade I) moderate (grade II) or severe (grade III). All women were also asked to describe the severity of the pain/discomfort using a visual analogue scale (VAS). Following examination a PFMH score was given according to each patient's reactions. Intra-observer and inter-observer reliability was assessed. Construct and content validity was also determined. RESULTS: 111 (44 symptomatic and 67 controls) were recruited. Intraobserver reliability had ICCs between 0.426 and 0.804. Interobserver reliability had ICCs between 0.724 and 0.917. There was a good correlation between PFMH scores and VAS scores (rho 0.994, p<0.01). Total scores between symptomatic and controls were significantly different (p<0.01 Mann-Whitney U test). CONCLUSION: The PFMH scoring system is a simple, reliable, valid and easy screening tool for in the assessment of women with CPP.

The management of overactive bladder: percutaneous tibial nerve stimulation, sacral nerve stimulation, or botulinum toxin?

PURPOSE OF REVIEW: We have reviewed the evidence published on botulinum toxin A (BoNT/A), percutaneous tibial nerve stimulation (PTNS), and sacral nerve stimulation (SNS) in the management of overactive bladder (OAB). RECENT FINDINGS: BoNT/A is effective irrespectively of the number of previous anticholinergic treatments and of the reason for failure. Doses up to 360U 3-monthly are well tolerated. BoNT/A is well tolerated and effective also in the pediatric population. Bladder instillation of liposome encapsulated BoNT/A is a new approach, deserving further research. When using PTNS, motor response from the electrical stimulus is not required, a sensory response suffices. PTNS has a lasting effect compared to oxybutynin alone. SNS is superior to standard medical treatment but the combination of SNS and anticholinergics is more effective than anticholinergic alone. SUMMARY: The evidence published in the last 18 months has increased the level of evidence on safety and effectiveness of BoNT/A, PTNS, and SNS in the management of OAB. BoNT/A is now recommended as standard third-line treatment for OAB (in the USA) and urgency incontinence (in the USA and in Europe) in selected patients refractory to pharmacological therapy. All available third-line treatment options for OAB/urgency urinary incontinence should be offered before surgery is contemplated. VIDEO ABSTRACT: http://links.lww.com/COU/A7.

The FIGO assessment scoring system (FASS): a new holistic classification tool to assess women with pelvic floor dysfunction: validity and reliability.

INTRODUCTION AND HYPOTHESIS: The aim of our study was to assess the interobserver and intraobserver reliability as well as the content and construct validity of the FIGO prolapse assessment scoring system (FASS). METHODS: Women with and without (controls) symptoms of pelvic organ prolapse (POP) attending gynaecology outpatient clinics in four different countries were recruited prospectively. Each woman was assessed using the FASS which included: (1) physical examination findings designated with the letter P; (2) presence of symptoms of prolapse, urinary and bowel symptoms designated with the letter S; and (3) assessment of degree of bother designated with the letter B. A scoring system was also developed. For interobserver reliability women were examined by two separate examiners using the FASS. For intraobserver reliability the FASS was repeated by the same examiner within 2 weeks. The interclass correlation coefficient (ICC) was also calculated to assess limits of agreements. Validity was assessed by comparing the FASS scores between symptomatic and asymptomatic women using the Mann-Whitney U test (p value <0.001). RESULTS: A total of 177 women (98 symptomatic and 79 controls) were recruited. Intraobserver reliability had ICCs between 0.716 and 1. Interobserver reliability had ICCs between 0.795 and 0.909. Domain and total scores were significantly different between symptomatic and asymptomatic women (p < 0.001, Mann-Whitney U test). There was a good correlation between FASS P scores and POP-Q scores (rho 0.763, p < 0.001). CONCLUSIONS: The FIGO prolapse assessment scoring system has good intraobserver and interobserver agreement and has demonstrated both content and construct validity.

[5ARI and PSA: open questions.] / 5ARI e PSA: questioni aperte.

No consensus has ever been reached on the predictive value of serum prostate specific antigen(PSA) for the diagnosis of prostate cancer. Limitations of PSA testing in clinical practice have beenoften discussed in the peer-reviewed literature following data derived from clinical trials such as theProstate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events(REDUCE) study that showed a linear rise in the risk of prostate cancer with increasing PSA levels.Benign prostatic hyperplasia is a known confounding factor for the use of PSA as a marker of prostatecancer. Increased prostate volume observed with ageing, urinary retention, acute and chronicinflammatory conditions of the prostate, sexual activity and digital rectal examination may all cause anincrease of PSA values. Both finasteride and dutasteride, 5-alpha reductase inhibitors (5ARI) used inthe treatment of BPH, are known to induce a significant decrease of serum PSA levels close to 50%.The observed change in PSA values following 5ARI treatment has raised questions about the accuracyof PSA testing for the early diagnosis of prostate cancer in patients on finasteride/dutasteride treatment.Careful analysis of data from various clinical trials on pharmacological treatment of LUTS due toBPH suggested that the accuracy of PSA testing is not just maintained but rather increased following5ARI use. Then, the question of PSA accuracy during 5ARI treatment can be considered closed.

Does the onset or bother of mixed urinary incontinence symptoms help in the urodynamic diagnosis?

OBJECTIVE: To determine whether evaluation of the first occurring symptom and bother of mixed urinary incontinence (MUI) might help in the clinical assessment of incontinent women. STUDY DESIGN: Prospective observational study carried out in a tertiary referral urogynaecology unit in London. Women who underwent urodynamic investigations for MUI were asked whether stress or urgency incontinence was the first occurring symptom and which was the most bothersome one. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the first occurring symptom and most bothersome component of their mixed urinary incontinence symptoms in relation to the urodynamic diagnosis were calculated. RESULTS: One hundred and eighty women with MUI were studied. Initial or most bothersome urgency urinary incontinence (UUI) had a good specificity and PPV for diagnosing detrusor overactivity (DO). When UUI was the initial and most bothersome symptom the specificity and NPV increased up to 93% and 73%. Stress urinary incontinence (SUI) as first occurring or most bothersome had a moderate specificity, PPV and NPV for diagnosing urodynamic stress incontinence (USI). When SUI was the initial and most bothersome symptom the specificity, PPV and NPV increased up to 91%, 70% and 78%. Initial or most bothersome UUI with antecedent or most bothersome SUI had a high specificity and good NPV for a mixed urodynamic diagnosis of DO and USI. CONCLUSIONS: Determination of the first occurring and most bothersome symptom in women with MUI relates closely to the urodynamic diagnosis. Therefore, our symptom-guided approach may in some cases provide useful information directing the clinician towards a more appropriate therapy when urodynamics are inconclusive or cannot be performed.

The importance of cystoscopy and bladder biopsy in women with refractory overactive bladder: the urogynaecologist's point of view?

OBJECTIVES: To assess the sensitivity, specificity, positive and negative predictive value of cystoscopy and the clinical value of bladder biopsy in women with refractory overactive bladder (OAB) symptoms. STUDY DESIGN: Prospective observational study carried out in a tertiary referral urogynaecology unit in London. Consecutive women with OAB resistant to pharmacotherapy who underwent cystoscopy, hydrodistention and bladder biopsy were studied. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cystoscopy as well as histological findings for chronic cystitis were evaluated. RESULTS: 106 women aged 22-91 years were studied. Histopathology showed chronic cystitis in 94 women, follicular cystitis 3, acute and chronic cystitis in 2, transitional cell carcinoma in 6 and no abnormality in 1 woman. Trabeculations and increased vascularity were the most common cystoscopic findings, seen in 71% and 72% of women respectively. Haemorrhages on first filling and haemorrhages on refilling had specificities of 86.6% and 80% respectively for chronic cystitis. Their sensitivities were 9.8% and 13.1% respectively. Trabeculations and increased vascularity had sensitivities of 68.1% and 68.1% and their specificities were 11.6% and 4.5% respectively. Trabeculations, increased vascularity, haemorrhages on first filling and haemorrhages on refilling all had a PPV over 80% for chronic cystitis. CONCLUSIONS: More than 90% of women with refractory OAB symptoms have chronic cystitis on histopathology. Cystoscopy alone is useful, but not always adequate to diagnose chronic cystitis. Antibiotic therapy in those women might be beneficial before starting anticholinergics. Larger randomised controlled trials are mandatory to confirm our hypothesis.

Botulinum neurotoxin type A injection of the pelvic floor muscle in pain due to spasticity: a review of the current literature.

The role of muscle spasm is not a new concept in the genesis of pain. Botulinum neurotoxin type A (BoNTA) has been successfully employed in a variety of muscular and inflammatory conditions. The aim of our study was to review the published literature on the role of BoNTA injection of the pelvic floor muscle in the management of women with chronic pelvic pain (CPP). A systematic search of the literature published up to June 2012 on the use of BoNTA in the treatment of female pelvic floor muscle spasm was carried out using relevant search terms in MEDLINE and EMBASE databases. The results were limited to full-text English language articles. Relevant trials as well as relevant reviews were selected and analyzed by two independent reviewers. Five studies (2 case reports, 1 prospective pilot study, 1 retrospective study and 1 randomised double-blind placebo controlled study) were included in this systematic review. Overall, BoNTA has shown to be beneficial in relieving CPP related to pelvic floor spasm. The role of BoNTA as a treatment of CPP has been recognized for more than 10 years. Although data are still scarce preliminary results are encouraging. BoNTA is an attractive option for refractory CPP related to pelvic floor muscle spasm, but further studies using validated and reproducible outcome measures are needed, to establish its effectiveness, safeness, technique, optimal dosage, and duration of symptom relief.