Evidence-based review of nonantibiotic urinary tract infection prevention strategies for women: a patient-centered approach.

PURPOSE OF REVIEW: There is a growing interest in nonantibiotic prevention strategies for recurrent urinary tract infections (rUTIs). Our objective is to provide a focused, pragmatic review of the latest evidence. RECENT FINDINGS: Vaginal estrogen is well tolerated and effective for preventing rUTI in postmenopausal women. Cranberry supplements at sufficient doses are effective in preventing uncomplicated rUTI. Methenamine, d -mannose, and increased hydration all have evidence to support their use, although the evidence is of somewhat variable quality. SUMMARY: There is sufficient evidence to recommend vaginal estrogen and cranberry as first-line rUTI prevention strategies, particularly in postmenopausal women. Prevention strategies can be used in series or in tandem, based on patient preference and tolerance for side effects, to create effective nonantibiotic rUTI prevention strategies.

Female pelvic medicine and reconstructive surgery fellows' case logs remained stable during the COVID-19 pandemic.

INTRODUCTION: During the COVID-19 pandemic and subsequent staffing shortages there was concern about the case volume, and thus competency, of graduating trainees due to reduced surgical volumes. Elective procedures were particularly affected, which includes Female Pelvic Medicine and Reconstructive Surgery (FPMRS) cases. To understand whether FPMRS fellows were affected, we assessed their case logs for changes during the pandemic. METHODS: The nationally aggregated case logs of graduating FPMRS fellows, both urology and obstetrics and gynecology (OBGYN), were obtained from the Accreditation Council for Graduate Medical Education. The available academic years (AYs) included 2018-2019, 2019-2020, and 2020-2021. Standard deviation for each index category was derived from the average and 90th percentile data. One-way analysis of variance was used to compare differences in case volumes for tracked index categories between AYs. RESULTS: Graduating fellows logged an average of 517.4 (standard deviation [SD] 28.6) and 818.0 (SD 37.9) cases, for urology and OBGYN respectively, over their fellowship training during the examined period. No significant differences in total surgical procedures were found for either specialty between pre-COVID AY 2018-2019 and COVID-affected AYs 2019-2020 and 2020-2021. For urology fellows, gastrointestinal (GI) procedures was the only index case category with a significant difference, and it was a decrease between the two COVID-affected AYs: 2020-2021 compared to 2019-2020 (8.9 vs. 4.2, p = 0.04). For both urology and OBGYN fellows, there was a statistically significant decrease in graft/mesh augmentation procedures from COVID-affected AY 2019-2020 to AY 2020-2021. This may be attributed to the reclassification of mesh removal cases from graft/mesh augmentation procedures to genital procedures in 2020-2021. There was not a significant decrease in these procedures from pre-COVID AY 2018-2019 to the COVID-affected AYs. There were no other statistically significant differences between AYs for OBGYN fellows. CONCLUSIONS: Surgical case volumes for FPMRS urology and OBGYN fellows who trained during the COVID-19 pandemic were comparable to those of their pre-pandemic peers. No significant differences between pre-COVID and COVID-affected years were found for either total surgical procedures or index case categories. Despite disruptions in health care nationwide, FPMRS trainee case volumes were largely unaffected.

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.

Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline.

PURPOSE: In 2019 the American Urological Association (AUA) released the evidence-based guideline "Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline." Information supporting the guideline came from a 2019 systematic evidence review prepared for the AUA by the Pacific Northwest Evidence-based Practice Center (EPC). The AUA used evidence found for 11 Key Questions (Appendix C) in the EPC's report to derive 16 Guideline Statements. In 2021 the EPC conducted an Update Literature Review (ULR) assessing abstracts from new studies published since the 2019 systematic review. The AUA asked the EPC to further assess a subset of studies included in the ULR report, to support potential changes to the 2019 guideline. MATERIALS/METHODS: A systematic-review utilized research from the Oregon Health & Science University. Pacific Northwest EPC was used to update the 2019 AUA Guideline on rUTI in women with new evidence published through 2021. RESULTS: Updates were made to reflect changes in literature since 2019. Updates include recent publications on antibiotic prophylaxis, non-antibiotic prophylaxis, and estrogen therapy. CONCLUSION: The presence of rUTI is crucial to the health of patients and its effects must be considered for the welfare of society. This document will undergo updating as the knowledge regarding current treatments and future treatment options continues to expand. .

Incomplete bladder emptying and urinary tract infections after botulinum toxin injection for overactive bladder: Multi-institutional collaboration from the SUFU research network.

INTRODUCTION: Onabotulinumtoxin A (BTX-A) is an effective therapy for overactive bladder (OAB), however, adverse events may prevent patients from initiating therapy. The study objective was to report real-world rates of incomplete emptying and urinary tract infection (UTI) in men and women undergoing BTX-A for OAB. METHODS: Eleven clinical sites performed a retrospective study of adults undergoing first-time BTX-A injection (100 units) for idiopathic OAB in 2016. Exclusions included: postvoid residual (PVR) > 150 ml, prior BTX-A, pelvic radiation, or need for preprocedure catheterization. Primary outcomes at 6 months were incomplete emptying (clean intermittent catheterization [CIC] or PVR ≥ 300 ml without the need for CIC); and UTI (symptoms with either positive culture or urinalysis or empiric treatment). We compared rates of incomplete emptying and UTI within and between sexes, using univariate and multivariable models. RESULTS: 278 patients (48 men and 230 women) met inclusion criteria. Mean age was 65.5 years (range: 24-95). 35% of men and 17% of women had incomplete emptying. Men had 2.4 (95% CI: 1.04-5.49) higher odds of incomplete emptying than women. 17% of men and 23.5% of women had ≥1 UTI, the majority of which occurred within the first month following injection. The strongest predictor of UTI was a history of prior UTI (OR: 4.2 [95% CI: 1.7-10.3]). CONCLUSIONS: In this multicenter retrospective study, rates of incomplete emptying and UTI were higher than many previously published studies. Men were at particular risk for incomplete emptying. Prior UTI was the primary risk factor for postprocedure UTI.

The Impact of Frailty on Outcomes of Sling Surgery with and without Prolapse Repair.

PURPOSE: Frailty has emerged as a significant predictor of morbidity in urological surgery, but its impact on outcomes of sling surgery for stress incontinence remains unclear. The purpose of this study is to describe the prevalence of frailty among women undergoing sling surgery and determine the association of frailty with 30-day postoperative outcomes. MATERIALS AND METHODS: We analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP®) in 2013-2016 to identify patients undergoing sling placement using Current Procedural Terminology, 10th edition, code 57288. Patients were categorized into 2 groups based on whether they underwent isolated sling placement or had a sling with concomitant prolapse surgery. Frailty was assessed using the 5-factor Modified Frailty Index (mFI-5) developed for use with the NSQIP data set. Patients were considered frail if 2 or more factors from the mFI-5 were present. Outcomes and complications within 30 days were captured from the NSQIP data and logistic regression models used to adjust for age, race/ethnicity, body mass index and frailty. RESULTS: We identified 25,887 women who underwent sling placement, 15,087 of whom underwent isolated sling placement (Group 1) and 10,800 of whom underwent sling with concomitant prolapse repair surgery (Group 2). Frailty was present in 9.3% of patients in Group 1 and 10.2% of patients in Group 2 (p=0.0122). Among those who underwent isolated sling placement, frailty was associated with increased length of hospital stay (OR 1.2, 95% CI 1.1-1.4, p=0.0008) and 30-day hospital readmission (OR 1.7, 95% CI 1.1-2.5, p=0.0093). Older patients undergoing isolated sling placement were more likely to have longer operation time (OR 1.2, 95% CI 1.1-1.3, p <0.0001) and hospital length of stay (OR 1.3, 95% CI 1.2-1.4, p <0.0001). Frailty was also associated with increased 30-day hospital readmission in patients who underwent sling with concomitant prolapse repair (OR 1.8, 95% CI 1.3-2.6, p=0.0003), while age was not (OR 0.9, 95% CI 0.7-1.1, p=0.29). CONCLUSIONS: We found that frailty was present in relatively few patients undergoing sling surgery. Adverse postoperative outcomes and complications were low overall. Increased age and frailty were both associated with longer length of stay. Frailty, but not age, was significantly associated with increased likelihood of hospital readmission within 30 days following surgery. Our findings provide insight into the preoperative characteristics of women undergoing sling surgery in a large national sample, suggesting the need for preoperative identification of the frail patient.

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.

The extracellular matrix molecules versican and hyaluronan in urethral and vaginal tissues in stress urinary incontinence.

PURPOSE: Abnormal extracellular matrix (ECM) changes are correlated with stress urinary incontinence (SUI). The ECM components versican (Vcan) and hyaluronan (HA) play key roles in regulating tissue inflammation and maintaining connective tissue homeostasis. We analyzed the localization and expression of these ECM components in urethral and vaginal tissues from a rat model of urinary incontinence and from human clinical specimens. METHODS: Nulliparous rats underwent vaginal distension (VD), a rodent model of SUI, or a sham procedure. Tissues were harvested from six rats per group at days 1, 4, and 21 for immunohistochemistry and RNA expression analysis of ECM components. Periurethral vaginal samples from female patients with SUI were also examined. RESULTS: High-intensity staining for Vcan was observed 1 day after procedure in both control and VD animals. This level of abundance persisted at day 4 in VD compared to control, with concurrent reduced messenger RNA (mRNA) expression of the Vcan-degrading enzymes ADAMTS5 and ADAMTS9 and reduced staining for the Vcan cleavage epitope DPEAAE. Abundance of HA was not different between VD and control, however mRNA expression of the HA synthase Has2 was significantly reduced in VD tissues at day 4. Abundant Vcan staining was observed in 60% of SUI patient samples, which was strongest in regions of disrupted elastin. CONCLUSION: Reduction of Vcan-degrading enzymes and HA synthases at day 4 postsurgery indicates a potential delay in ECM turnover associated with SUI. Abundant Vcan is associated with inflammation and elastin fiber network disruption, warranting further investigation to determine its role in SUI pathogenesis.

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.

Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network.

AIM: Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. METHODS: This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. RESULTS: Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. CONCLUSION: This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

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.

Obesity and pelvic organ prolapse.

PURPOSE OF REVIEW: The purpose of this review is to review the data on the relationship of obesity and pelvic organ prolapse (POP). This review is timely and relevant as the prevalence of obesity is increasing worldwide, and it is an important risk factor to consider in counseling women on management of prolapse symptoms and outcomes for surgical treatment. RECENT FINDINGS: The main findings in the literature include: Obesity is increasing worldwide and impacts health, social life, work and healthcare costs. Elevated BMI is an important lifestyle factor affecting pelvic prolapse. The most probable mechanism of POP development among obese women is the increase in intra-abdominal pressure that causes weakening of pelvic floor muscles and fascia. Obesity is associated with significant pelvic floor symptoms and impairment of quality of life (QOL). Weight loss is likely not associated with anatomic improvement, but may be associated with prolapse symptom improvement. Weight loss should be considered a primary option in obese women for its beneficial effects on multiple organ systems and reducing pelvic floor disorder (PFD) symptoms. Although the operation time in obese women is significantly longer than in healthy weight women, the complication rate of surgery has not been shown to be increased compared to nonobese patients, regardless of route of surgery. There are data to support the vaginal approach in obese women. Some studies have shown that women with high body weight are associated with an increase in the risk for both anatomical and functional recurrence, and other studies have shown no difference. SUMMARY: Obesity is a prevalent modifiable condition that impacts PFDs including pelvic prolapse. Patients should be counseled using clinical judgment, knowledge of the literature and with the goal of improving QOL.

The Glt1 glutamate receptor mediates the establishment and perpetuation of chronic visceral pain in an animal model of stress-induced bladder hyperalgesia.

Psychological stress exacerbates interstitial cystitis/bladder pain syndrome (IC/BPS), a lower urinary tract pain disorder characterized by increased urinary frequency and bladder pain. Glutamate (Glu) is the primary excitatory neurotransmitter modulating nociceptive networks. Glt1, an astrocytic transporter responsible for Glu clearance, is critical in pain signaling termination. We sought to examine the role of Glt1 in stress-induced bladder hyperalgesia and urinary frequency. In a model of stress-induced bladder hyperalgesia with high construct validity to human IC/BPS, female Wistar-Kyoto (WKY) rats were subjected to 10-day water avoidance stress (WAS). Referred hyperalgesia and tactile allodynia were assessed after WAS with von Frey filaments. After behavioral testing, we assessed Glt1 expression in the spinal cord by immunoblotting. We also examined the influence of dihydrokainate (DHK) and ceftriaxone (CTX), which downregulate and upregulate Glt1, respectively, on pain development. Rats exposed to WAS demonstrated increased voiding frequency, increased colonic motility, anxiety-like behaviors, and enhanced visceral hyperalgesia and tactile allodynia. This behavioral phenotype correlated with decreases in spinal Glt1 expression. Exogenous Glt1 downregulation by DHK resulted in hyperalgesia similar to that following WAS. Exogenous Glt1 upregulation via intraperitoneal CTX injection inhibited the development of and reversed preexisting pain and voiding dysfunction induced by WAS. Repeated psychological stress results in voiding dysfunction and hyperalgesia that correlate with altered central nervous system glutamate processing. Manipulation of Glu handling altered the allodynia developing after psychological stress, implicating Glu neurotransmission in the pathophysiology of bladder hyperalgesia in the WAS model of IC/BPS.