Predictors for adverse events following intravesical botulinum toxin injections in men.

INTRODUCTION: Intravesical botulinum toxin A (BTX-A) has been long established as treatment for overactive bladder and neurogenic bladder dysfunction. However, most published data are reported among a female cohort. Adverse events such as intermittent self-catheterization (ISC) and urinary tract infections (UTIs) play a large role in discontinuation of therapy. There is currently limited information regarding predictive factors to appropriately counsel male patients. MATERIALS AND METHODS: We retrospectively collected data on male patients undergoing their first intravesical BTX-A therapy from January 2016 to July 2021 in two high-volume centers. Data included demographics, past medical and surgical history, and urodynamic parameters. Patients were excluded if they had a long-term catheter or ISC before initiation of therapy. RESULTS: A total of 69 men were included in the study with a median age of 66 years. There were 18 patients with neurogenic bladder dysfunction. Thirty men had urge incontinence secondary to radical prostatectomy or bladder outflow surgery. Overall rates of ISC were 43.5%. Predictors for ISC included a baseline postvoid residual (PVR) ≥ 50 mL (odds ratio [OR]: 4.2, 95% confidence interval [CI]: 1.36-13.03, p = 0.01), BTX-A dose >100 units (OR: 4.2, 95% CI: 1.36-13.0, p = 0.01). Stress urinary incontinence was protective against ISC (OR: 0.20, 95% CI: 0.04-1.00, p = 0.049) as well as history of prostatectomy/bladder outflow obstruction (BOO) surgery (OR: 0.16, 95% CI: 0.05-0.47, p < 0.001). A multivariable logistic regression model with these factors yielded a c-statistic of 0.80 (optimism-adjusted = 0.75). An enlarged prostate was the only predictor for UTI among our male cohort (OR: 8.0, 95% CI: 2.03-31.5, p = 0.003). CONCLUSIONS: This is the first study assessing risk factors of adverse events among men following BTX-A injection. High PVR and BTX-A dose of >100U were predictors of requiring ISC after BTX-A. Stress incontinence, previous radical prostatectomy, and BOO surgery were all protective against needing ISC post-BTX-A. An enlarged prostate was associated with development of UTI. These factors can be used to assist in counseling male patients regarding their risk of ISC and UTI.

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.

Clinical characteristics of phenotypes of fecal incontinence.

PURPOSE: Fecal incontinence (FI) is common, but its etiology is complex with large knowledge gaps. Several phenotypes of FI are known, but the phenotype is often not decisive in the chosen therapy. In this study we aimed to assess the association of the clinical characteristics of patients with FI and the various phenotypes, in order to establish a targeted clinical treatment decision tree. METHODS: We retrospectively studied the charts of patients with FI, who visited our institute from January 2018 until December 2020. Patients were divided into the following groups: passive fecal loss, urge incontinence, combined fecal incontinence with predominantly passive fecal loss, and combined fecal incontinence with predominantly urge incontinence. We compared the characteristics between the passive and urge incontinence groups, the passive  and combined mainly passive groups, and the urge and combined mainly urge groups. RESULTS: Patients with passive incintinence were older, more often had a flaccid anus with presence of a mucosal prolapse, and had a lower resting pressure on anorectal manometry. Patients with urge incontinence were younger and more often had a history of birth trauma. The combined groups showed characteristics of both of the main types of FI. CONCLUSION: Differentiating into phenotypes of FI can be clinically meaningful. The patient history and clinical judgement of the consulting specialist, rather than the physical characteristics, seem to be decisive in the categorization. Additional diagnostic testing can be helpful in complicated cases, but should not be used routinely.

[Male Incontinence - An Overview and its Relationship to Benign Prostatic Enlargement]. / Die männliche Inkontinenz.

Male Incontinence - An Overview and its Relationship to Benign Prostatic Enlargement Abstract: Male urinary incontinence is a common disease in elderly men and can lead to a significantly reduced quality of life. Reported prevalence of urinary incontinence increases up to 32% in men over 85 years. Risk factors for urinary incontinence are prostate surgery, advanced age, immobility, urinary tract infections, diabetes mellitus, cognitive disorders, and neurological disease. Urinary incontinence is divided into three subtypes: stress urinary incontinence, urge urinary incontinence, and mixed urinary incontinence. Benign prostatic obstruction can lead to a detrusor overactivity and a further urge incontinence. However, iatrogenic injury or a preexisting weakness of the external urinary sphincter are more common and can lead to stress urinary incontinence in men following prostate surgery. A correct treatment can significantly improve symptoms in men suffering from urinary incontinence. Though, every treatment plan must be tailored to the individual patient.

Pelvic floor dysfunctions in women with fibromyalgia: A cross-sectional study.

BACKGROUND: Fibromyalgia (FM) is a rheumatic syndrome that causes musculoskeletal disorders and is associated with several problems that affect quality of life. As the musculoskeletal system is affected, it can have an impact on the pelvic floor muscles, leading to pelvic floor dysfunction (PFD). OBJECTIVE: Investigate the occurrence of PFD, such as urinary incontinence (UI) and anal incontinence (AI), sexual problems, and pelvic organ prolapse (POP), in women with FM compared to a control group composed of women without FM; and investigate the association between FM and PFD. STUDY DESIGN: This was an online cross-sectional survey. Demographic and anthropometric data, the description of PFD (UI, nocturia, AI, genital-pelvic pain/penetration disorder, and POP), and previous obstetric history were collected through a web-based questionnaire. The groups were compared using the independent t-test for quantitative variables and the chi-square test for categorical variables. The association between FM and PFD was tested using logistic regression analysis. RESULTS: A total of 175 women answered the questionnaire (97 with FM and 78 healthy controls). The women with FM reported significantly more UI, mixed urinary incontinence, AI, POP, and vaginismus than the healthy controls (p ≤ 0.05). FM was associated with mixed urinary incontinence (OR: 2.6; 95 % CI: 1.1-6.4; p = 0.04), anal incontinence (OR: 2.9; 95 % CI: 1.3-6.1; p = 0.01), and flatus incontinence (OR: 2.6; 95 % CI: 1.2-5.4; p = 0.01). CONCLUSION: The prevalence of PFD was significantly higher in women with FM compared to healthy women. Indeed, the women with FM were 2.6-fold to 2.9-fold more likely to report mixed urinary incontinence, anal and flatus incontinence than those in the control group. The present findings show possible impairment of the pelvic floor musculature in women with FM.

Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery - Non-inferiority study.

OBJECTIVE: Urinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery. STUDY DESIGN: A sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection. RESULTS: Women suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007. CONCLUSION: Femistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Change in Postoperative Storage Symptoms and De Novo Urge Incontinence After Thulium:YAG Laser Enucleation of the Prostate: Results from a Prospective Multicenter Study.

Objectives: To assess the change of storage symptoms (SS) and their impact on quality of life in men undergoing thulium:YAG laser enucleation of the prostate (ThuLEP) for benign prostatic hyperplasia (BPH). Materials and Methods: BPH patients requiring surgery were prospectively evaluated (April 2019-October 2020). Inclusion criteria: International Prostate Symptom Score (IPSS) ≥8, maximum urinary flow rate ≤15 mL/s, and urinary retention. Exclusion criteria: previous urethral/prostatic surgery, pelvic irradiation, bladder/prostate cancer, neurogenic bladder, concomitant transurethral surgery, and active urinary tract infection. IPSS, International Continence Society-Overactive Bladder (ICIQ-OAB) and International Continence Society-Overactive Bladder Quality of Life (ICIQ-OABq) scores were gathered before surgery and 1, 3, 6, and 12 months after surgery. Results: In total, 117 men were included. Mean age was 68.0 ± 7.7 years. Mean prostate volume was 86.6 ± 34 cc. Mean IPSS subscore was 8.7 ± 3.1 and 11.7 ± 4.7 for storage and voiding symptoms, respectively. Mean ICIQ-OAB was 29.1 ± 16.8. Mean ICIQ-OABq was 80.3 ± 30.6. Voiding IPSS decreased 72.8% at 1 month, whereas the reduction of storage IPSS was 38.0%. ICIQ-OAB decreased 49.6% at 1 month. ICIQ-OABq showed a 30.0% reduction. One year after surgery, the reduction of voiding IPSS was 94.8%, ICIQ-OAB 85.5%, storage IPSS 76.7%, and ICIQ-OABq 60.5%. Urge incontinence was present in 26.5% of men at 1 month, 15.4% at 3 months, and 4.3% at 6 months. Four (3.4%) patients complained of urge incontinence 12 months after surgery. Conclusion: Both storage and voiding lower urinary tract symptoms significantly decreased after ThuLEP, but storage symptoms showed less reduction with a significant impact on patients' quality of life, particularly during the first 3 months.

The emperor has no clothes: OAB can be cured surgically.

The paper by Karjalainen et al., who reviewed 2,933 pelvic organ prolapse surgeries, showed 75% cure for "bothersome" urge urinary incontinence (UUI), is more than an "Aha" moment; it is an "Emperor has no clothes" moment. Since 1976, a convention of "no surgery" for women with UUI (now overactive bladder, OAB) has become almost an article of faith. Yet, surgical cure of OAB has been known since 1997, when this journal published the first urodynamically controlled study with 20-month data: 86% cure for UUI, 85% for frequency, 80% for nocturia following pubourethral ligament (PUL) and uterosacral ligament (USL) sling repair in 85 women. This study was followed by many other publications over the years recording OAB cure. It is not that even a small fraction of the 600 million women on the planet will now undergo surgery, or that damaged ligaments are the only cause of OAB. However, knowing OAB can be cured opens the door for young creative minds to bring hope and relief to these women non-surgically, as well as surgically.

Prevalence of Overactive Bladder Symptoms Among Women With Interstitial Cystitis/Bladder Pain Syndrome.

IMPORTANCE: Symptoms of urinary frequency, urgency, and urinary leakage are characteristic of overactive bladder (OAB) syndrome. However, frequency and urgency symptoms are also present in most patients with interstitial cystitis/bladder pain syndrome (IC/BPS). OBJECTIVE: Our objective was to describe the urge incontinence among women with IC/BPS, which may indicate true overlap of OAB and IC/BPS. STUDY DESIGN: This is a prospective study of women with IC/BPS diagnosed clinically in the Veterans Affairs Health Care system. Patients completed the OAB and Female Genitourinary Pain Index (F-GUPI) questionnaires. Questions from the OAB questionnaire were used to analyze symptoms of urinary urgency and urge incontinence. Pain symptoms, urinary symptoms, and impact on quality of life were assessed based on the F-GUPI. Patient demographics, comorbidities, and symptoms were reviewed. RESULTS: Within the cohort of 144 women with IC/BPS, 100 (69%) had urinary leakage associated with the strong desire to void and were more likely to have incontinence compared with healthy controls (P < 0.001). The IC/BPS group also had higher total and pain scores on the F-GUPI (P < 0.001), but pain scores were not affected by the presence of incontinence (P = 0.478). CONCLUSIONS: The prevalence of OAB symptoms of urinary leakage is high among women with IC/BPS. This may explain the efficacy of OAB medication and third-line therapies in this population.

Postoperative Urinary Incontinence in Diabetic Patients Undergoing Pelvic Reconstructive Surgery.

IMPORTANCE: Diabetes is an independent risk factor for urinary incontinence, and its impact on rates of postoperative incontinence after pelvic reconstructive surgery remains unexplored. OBJECTIVE: The aim of the study was to compare the incidence of postoperative stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence in patients with diabetes mellitus undergoing surgery for pelvic organ prolapse (POP) with or without SUI surgery. STUDY DESIGN: This is a secondary analysis of a multicenter retrospective cohort study involving 10 diverse medical centers that identified a cohort of women with diabetes who had prolapse and/or anti-incontinence surgery. We compared rates of postoperative urinary incontinence among patients who had surgery for prolapse and incontinence versus surgery for prolapse only. RESULTS: Three hundred five patients had surgery for prolapse and incontinence, 330 had surgery for prolapse only, and 189 had anti-incontinence surgery only. De novo UUI was higher among those who underwent surgery for POP and SUI compared with surgery for POP alone (26.4% vs 14.1%, P < 0.01). Rates of persistent SUI (21% vs 4.9%, P < 0.01) and mixed urinary incontinence (15.9% vs 2.7%, P < 0.01) were higher for those who underwent prolapse surgery alone versus prolapse and an incontinence procedure. No differences were seen in hemoglobin A1C levels between those who did and did not report postoperative UI. CONCLUSIONS: We found that postoperative de novo UUI rates were high among patients with diabetes after pelvic reconstructive surgery, with the incidence being significantly higher for those who had surgery for prolapse and incontinence compared with surgery for prolapse only.

Association Between Ejaculatory Dysfunction and Post-Void Dribbling After Urethroplasty.

OBJECTIVE: To determine whether ejaculatory dysfunction (EjD) and post-void dribbling (PVD) after urethroplasty are associated, providing evidence for a common etiology. METHODS: We reviewed a prospectively maintained database for first-time, anterior urethroplasties. One item from the Male Sexual Health Questionnaire (MSHQ) assessed EjD: "How would you rate the strength or force of your ejaculation". One item from the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) assessed PVD: "How often have you had slight wetting of your pants after you had finished urinating?". The frequency of symptoms was compared after penile vs. bulbar repairs, and anastomotic versus augmentation bulbar repairs. Associations were assessed with chi-square. RESULTS: A total of 728 men were included. Overall, postoperative EjD and PVD were common; 67% and 66%, respectively. There was a significant association between EjD and PVD for the whole cohort (p<0.0001); this association remained significant after penile repairs (p=0.01), bulbar repairs (p<0.0007), and bulbar anastomotic repairs (p=0.002), but not after bulbar augmentation repairs (p=0.052). EjD and PVD occurred at similar rates after penile and bulbar urethroplasty. The rate of EjD was similar after bulbar augmentation and bulbar anastomotic urethroplasties, but PVD was more common after bulbar augmentation (70% vs. 52%) (p = 0.0001). CONCLUSION: EjD and PVD after anterior urethroplasty are significantly associated with one another, supporting the theory of a common etiology. High rates after penile repairs argue against a bulbospongiosus muscle damage etiology, and high rates after anastomotic repairs argue against graft sacculation. More work is needed to better understand and prevent symptoms.

Evaluation of Urine Choline Levels in Women With and Without Overactive Bladder Syndrome.

OBJECTIVE: The objective of this study was to determine whether levels of choline (Ch) differ in women with and without overactive bladder (OAB) symptoms. METHODS: New patients were evaluated using the overactive bladder symptom score; Medical, Epidemiologic, and Social Aspects of Aging (MESA) urgency incontinence questionnaire; and Impact Questionnaire 7 and provided a urine sample. Patients were stratified into asymptomatic controls, scoring 0 on overactive bladder symptom score and the MESA questionnaire, and patients with OAB and urgency incontinence (OAB-wet). Patients with conditions predisposing to OAB or had a history of OAB treatment were excluded. Choline detection was accomplished using a commercially available kit. Wilcoxon rank sum test and Fisher exact test were used to express differences between groups. Spearman ρ correlation was used to determine the relationship between Ch and questionnaire scores. Logistic regression was used to identify significant variables associated with OAB. RESULTS: Sixty-three women were included in the final analysis. Patients with OAB-wet were older (P = 0.001), more likely to be obese (P = 0.04), had greater apical descent (P = 0.02), were more likely to be postmenopausal (P = 0.01), and were more likely to have stress incontinence (P = 0.005). Choline was 34.8% lower in OAB compared with the controls (P = 0.014). Lower Ch levels were associated with higher MESA (Spearman ρ = -0.311, P = 0.03). After logistic regression, lower Ch (adjusted odds ratio [aOR], 0.97; 95% confidence interval [CI], 0.96-0.98), age (aOR, 1.12; 95% CI, 1.08-1.18), and body mass index (aOR, 1.09; 95% CI, 1.01-1.18) were significantly associated with OAB-wet. CONCLUSIONS: Choline levels are significantly decreased in women complaining of OAB with urgency incontinence, and lower levels are associated with higher MESA scores.

Comparison between erbium-doped yttrium aluminum garnet laser therapy and sling procedures in the treatment of stress and mixed urinary incontinence.

PURPOSE: Stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) lead to poor quality of life. In Japan, urinary incontinence is treated with tension-free vaginal tape (TVT) or transobturator tape (TOT) sling procedures, which involves inserting a synthetic material; however, problems arise with artificial mesh in some instances, requiring new treatment methods. Hence, laser therapy, whereby an erbium-doped yttrium aluminum garnet laser is directed into the vagina and urethra, may be useful. The study aimed to compare the effects of these three treatments. METHODS: Subjects included patients who received TVT, TOT, or laser therapy (n = 50 each). The 1-h pad test, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and overactive bladder symptom score were used to assess the patients before and 12 months after treatment. For laser therapy, a probe was inserted into the vagina after applying a local anesthetic to the vaginal wall, and irradiation was performed for 20 min at a wavelength of 2940 nm. This treatment was performed three times every alternate month. RESULTS: As per the 1-h pad test and ICIQ-SF, the TVT, TOT, and laser therapy groups showed comparable improvements in SUI. For patients with MUI, some in the TVT and TOT groups showed exacerbation; however, all patients in the laser therapy group tended to improve. CONCLUSIONS: The efficacy of laser therapy for urinary incontinence was confirmed. This is the first study to report on the effect of laser therapy on urinary incontinence in Japanese women.

Usefulness of Ospemifene in the treatment of urgency in menopausal patients affected by mixed urinary incontinence underwent mid-urethral slings surgery.

The aim of this study was to assess the effectiveness and safety of Ospemifene in the improvement of urgency component in women affected by mixed urinary incontinence (MUI) who underwent surgery with mid-urethral sling (MUS). Eighty-one patients with MUI underwent surgical intervention with MUS were enrolled. After surgical intervention 38 patients received Ospemifene 60 mg one tablet daily per os for 12 weeks. Physical examination, 3-day voiding diary, urodynamic testing were performed at the start and the follow-up after 12 weeks in the Trans-Obturator-Tape (TOT)-Alone group and TOT-Ospemifene. Patients completed the Overactive Bladder Symptom and Health-Related Quality of Life Short-Form (OAB-Q SF), International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), and King' s Health Questionnaire (KHQ). A significant difference between the two groups was observed in peak flow (ml/s), in first voiding desire (ml), in maximum cystometric capacity (ml), and in detrusor pressure at peak flow (cmH2O) at urodynamic evaluation. A significative difference between the two groups at voiding diary was observed in the mean number of voids, urgent micturition episodes/24 h, urge urinary incontinence, and in nocturia events. The OAB-Q symptoms and OAB-Q (HRQL) scores after 12 weeks showed a significative difference between the two groups. Ospemifene is an effective potential therapy after MUSs in women with MUI improving urgency symptoms and quality of life.

[Comparison of the symptoms of overactive bladder in women with mixed urinary incontinence and idiopathic urge urinary incontinence.] / Comparación de los síntomas de vejiga hiperactiva en mujeres con incontinencia urinaria mixta e incontinencia urinaria de urgencia pura.

INTRODUCTION: Various authors argued that the voiding urgency component in mixed urinary incontinence (MUI) is different than urge urinary incontinence (UUI). In this last case they suggest that incontinence in MUI could be overdiagnosed in patients with SUI, misunderstanding the leak as UUI. OBJETIVES: To evaluate clinical and urodynamic characteristics of patients with MUI and pure UUI. METHODS: A retrospective study of our urodynamics database was performed evaluating 450 women with MUI and UUI. Patients with neurogenic bladder, fistulae, urethral diverticula, previous urogynecologic surgery, known infravesical obstruction, previous pelvic radiotherapy, urinary tract infection or psychiatric drugs intake. A full clinical history, physical exam, uroflowmetry, filling cystometry and pressure flow study were performed. RESULTS: There is no difference relative to age, menopause and number of births. The presence of nocturia was bigger in the UUI group (66.4% vs. 46.1%, p 0.0004) the same as increased voiding frequency (53.6% vs. 34.6%, p 0.0006). The presence of urethral hypermobility and SUI in the physical exam was greater than MUI, meanwhile the presence of reduced vaginal trophism was bigger in the UUI group. Differences in sensibility or specificity were not found. The presence of overactive detrusor was 56.4% in pure UUI vs. 33.2% in MUI (p<0.0001). No differences in pressure flow study were found. CONCLUSIONS: There is a significant difference in the clinical and urodynamic parameters between patients with MUI and pure UUI. The urgency in patients with pure UUI could be related to overactive detrusor. It is probable that many patients with MUI just have pure SUI which could lead to positive effects in the outcomes of anti-incontinence surgery.

Sleep Quality and Daytime Sleepiness Among Women With Urgency Predominant Urinary Incontinence.

OBJECTIVE: The objective of this study was to examine the strength and direction of the association between urinary symptoms and both poor quality sleep and daytime sleepiness among women with urgency urinary incontinence. METHODS: A planned secondary analysis of baseline characteristics of participants in a multicenter, double-blinded, 12-week randomized controlled trial of pharmacologic therapy for urgency-predominant urinary incontinence in ambulatory women self-diagnosed by the 3 Incontinence Questions was performed. Urinary symptoms were assessed by 3-day voiding diaries. Quality of sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness using the Epworth Sleepiness Scale. RESULTS: Of the 640 participants, mean (SD) age was 56 (±14) years and 68% were white. Participants reported an average of 3.9 (±3.0) urgency incontinence episodes per day and 1.3 (±1.3) episodes of nocturia per night. At baseline, 57% had poor sleep quality (PSQI score, >5) and 17% reported daytime sleepiness (Epworth Sleepiness Scale score, >10). Most women (69%) did not use sleeping medication during the prior month, whereas 13% reported use of sleeping medication 3 or more times per week. An increase in total daily incontinence episodes, total daily urgency incontinence episodes, total daily micturitions, and moderate to severe urge sensations were all associated with higher self-report of poor sleep quality according to the PSQI (all P ≤ 0.01). Higher scores on the Bother Scale and the Health-Related Quality of Life for overactive bladder on the Overactive Bladder Questionnaire were similarly associated with higher rates of poor sleep quality (both P ≤ 0.01). In subgroup analysis of those who took sleeping medications less than twice a week, there was still a significant relationship between incontinence measures and quality of sleep as measured by the PSQI. In multivariable analyses, greater frequency of nighttime urgency incontinence was associated with poor sleep quality (P = 0.03). CONCLUSIONS: Among ambulatory women with urgency urinary incontinence, poor sleep quality is common and greater frequency of incontinence is associated with a greater degree of sleep dysfunction. Women seeking urgency urinary incontinence treatment should be queried about their sleeping habits so that they can be offered appropriate interventions.

Mixed urinary incontinence: A prospective study on the effect of trans-obturator mid-urethral sling.

OBJECTIVES: It is hypothesized that urethral dysfunction is central in mixed urinary incontinence (MUI) in women, since urine entering the proximal urethra under increased intra-abdominal pressure provokes a urethro-detrusorial reflex and involuntary detrusor contraction. Mid-urethral slings have been proposed as a solution. Our primary objective was to evaluate the long-term subjective and objective outcomes on continence and other urinary symptoms of a trans-obturator mid-urethral sling (TOT) procedure. Our secondary objectives were to determine its impact on quality of life (QoL), and to investigate which factors influence outcomes. STUDY DESIGN: This is a single-centre prospective study on a consecutive series of 86 women who underwent TOT for MUI as defined by ICS/IUGA. Since the definition of MUI that we used is symptom-based, we included patients both with and without associated detrusor overactivity. All patients underwent placement of Monarc® Subfascial Hammocks. STATISTICAL ANALYSIS: We used the McNemar chi-square test, the paired t-test and Fisher's exact test. A logistic regression model and odds ratios were used to assess age, parity, body mass index, menopausal status, preoperative detrusor over-activity, and detrusor pressure at maximum flow as possible factors for treatment failure. Only those that were statistically significant in the univariate analysis were included in the multivariate analysis. RESULTS: With a mean follow-up of 59 months, SUI was cured objectively in 83.7% of patients and subjectively in 87.2%. Three patients underwent further anti-incontinence surgery. The continence rates were 74.4% for urgency urinary incontinence (UUI) and 66.3% for SUI-UUI. The patient-reported success rate was 87.2% ('much better' or 'very much better' on Patient Global Impression of Improvement scale). There were statistically significant improvements in all domains except general health. The univariate analysis found no significant risk factor for persistence of SUI. Median age >60 years and menopause were predictive for persistence of UUI. Median and mean age >60 years were predictive of persistence of overall incontinence. In the multivariate model, all variables lost their statistical significance. CONCLUSION: Our study demonstrates TOT surgery can be performed for patients with MUI following unsuccessful conservative therapy. We also demonstrate that menopause and age >60 are risk factors for failure. This should be considered when counselling preoperatively.

Are women's needs being met by specialist health services managing urinary incontinence in the remote Top End NT?

BACKGROUND: Urinary incontinence (UI) is likely to be high in Aboriginal women in rural Australia due to risk factors including high body mass index, parity and diabetes. However, UI appears to be under-reported with limited information on whether women access appropriate care. AIMS: To assess whether women who access specialist gynaecological services in rural and remote Top End Northern Territory (NT) through the specialist outreach program (SONT) are receiving care for UI aligned with best practice. METHODS: Review of all 1426 SONT referrals in 2012, with audit of management for those women referred for UI or prolapse. RESULTS: Of 1426 SONT referrals, there were 43/1426 (3%) women referred for UI, with 34/43 (79%) attending. Of those referred, 31/43 (72%) were Aboriginal. Of twenty-six women diagnosed with probable stress UI, less than a fifth, 5/26 (19%), were referred to physiotherapy, with 2/5 (40%) attending appointments. Referral occurred for 14/23 (61%) of those suitable for urodynamics but only 6/14 (43%) attended. Just under half of women 7/16 (14%) with stress UI were referred for surgery, with 6/7 (86%) attending. CONCLUSION: In rural and remote Top End NT, specialist health service management of female UI could be improved by increased provision of current best-practice and an integrated multi-disciplinary team approach with allied health. Under-reporting and under-referral for female UI could be addressed by increasing awareness among community and primary healthcare providers of the problem of female UI and the conservative, medical and surgical treatments available.

Effect of pelvic organ prolapse repair on detrusor overactivity in women following incontinence surgery: A multivariate analysis.

AIMS: To determine the effect of pelvic organ prolapse (POP) repair on post-operative detrusor overactivity (DO) in women who have underwent incontinence surgery, using multivariate analysis. METHODS: A retrospective study was carried out on a cohort of 105 women who underwent incontinence surgery. In 39 of the patients this surgery was associated with pelvic organ prolapse repair. Clinical and urodynamic data were collected pre- and 3 months post-operatively. A multivariate statistical analysis was performed to detect confounding factors which could influence on the risk factors associated with post-operative detrusor overactivity. RESULTS: On univariate analysis, the following pre-operative factors were associated with post-operative detrusor overactivity: symptomatic mixed urinary incontinence, rectocele, detrusor overactivity, voided volume on free uroflowmetry, maximum cystomanometric capacity, and performing concomitant pelvic organ prolapse repair. Multivariate analysis, by means of confounding factors elimination, revealed that only pre-operative rectocele and detrusor overactivity were independent risk factors. CONCLUSIONS: The pelvic organ prolapse repair acts as a confounding factor. Women with a pre-operative rectocele and detrusor overactivity are on a greater risk to develop post-operative detrusor overactivity and, therefore, they should be informed.

The long term predictive value of preoperative pressure flow studies in the resolution of overactive bladder after insertion of a retropubic midurethral sling.

AIMS: To identify if the short term association of pressure flow rates with resolution of overactive bladder (OAB) is maintained in the long term in patients with mixed urodynamic incontinence treated with a retropubic midurethral sling. To assess if other demographic factors are associated with the long term resolution of OAB. METHODS: This was follow up study of a consecutive case series of 100 patients treated with a MUS at a single center followed up with questionnaires. Preoperative pressure flow studies were compared to the resolution of urgency and urgency incontinence after surgery. RESULTS: A total of 6.25 years after surgery, resolution of urgency and urgency incontinence was associated with a higher preoperative flow rate (26.7 mL/s vs 19.1 mL/s P = 0.02) and a higher flow rate centile (33.1 vs 14.0 P = 0.01). No other demographic parameters were associated with resolution of OAB. CONCLUSIONS: The long term outcome and resolution of urgency and urgency incontinence can be predicted by preoperative pressure flow studies over 6 years after surgery.