Long-Term Outcomes of Laser Prostatectomy for Storage Symptoms: Comparison of Serial 5-Year Followup Data between High Performance System Photoselective Vaporization and Holmium Laser Enucleation of the Prostate.

PURPOSE: We compared long-term storage symptom outcomes between photoselective laser vaporization of the prostate with a 120 W high performance system and holmium laser enucleation of the prostate. We also determined factors influencing postoperative improvement of storage symptoms in the long term. MATERIALS AND METHODS: Included in our study were 266 men, including 165 treated with prostate photoselective laser vaporization using a 120 W high performance system and 101 treated with holmium laser enucleation of the prostate, on whom 60-month followup data were available. Outcomes were assessed serially 6, 12, 24, 36, 48 and 60 months postoperatively using the International Prostate Symptom Score, uroflowmetry and the serum prostate specific antigen level. Postoperative improvement in storage symptoms was defined as a 50% or greater reduction in the subtotal storage symptom score at each followup visit after surgery compared to baseline. RESULTS: Improvements in frequency, urgency, nocturia, subtotal storage symptom scores and the quality of life index were maintained up to 60 months after photoselective laser vaporization or holmium laser enucleation of the prostate. There was no difference in the degree of improvement in storage symptoms or the percent of patients with postoperative improvement in storage symptoms between the 2 groups throughout the long-term followup. However, the holmium laser group showed greater improvement in voiding symptoms and quality of life than the laser vaporization group. On logistic regression analysis a higher baseline subtotal storage symptom score and a higher BOOI (Bladder Outlet Obstruction Index) were the factors influencing the improvement in storage symptoms 5 years after prostate photoselective laser vaporization or holmium laser enucleation. CONCLUSIONS: Our serial followup data suggest that storage symptom improvement was maintained throughout the long-term postoperative period for prostate photoselective laser vaporization with a 120 W high performance system and holmium laser enucleation without any difference between the 2 surgeries. Also, more severe storage symptoms at baseline and a more severe BOOI predicted improved storage symptoms in the long term after each surgery.

Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment.

In Dysfunctional voiding, failure of the external sphincter-pelvic floor complex to relax during micturition results in bladder outflow obstruction with a spectrum of presentation from more benign lower urinary tract dysfunction including recurrent urinary tract infections, to significant upper tract pathology and end-stage renal failure. There is no underlying neurological or anatomical cause and the condition is postulated to be a largely learnt behavior. Diagnosis relies on non-invasive urodynamics and in particular uroflowmetry, plus or minus EMG, which is also used in biofeedback, the mainstay of treatment. The etiology, presentation, diagnosis, and treatment with particular emphasis on non-invasive urodynamics are covered.

Are Interferential Electrical Stimulation and Diaphragmatic Breathing Exercises Beneficial in Children With Bladder and Bowel Dysfunction?

OBJECTIVE: To evaluate the effects of interferential current (IC) stimulation and diaphragmatic breathing exercises (DBEs) in children with bladder and bowel dysfunction. PATIENTS AND METHODS: Seventy-nine children with dysfunctional voiding and chronic constipation who were failures of primary care interventions were included in the prospective clinical study. All the children were checked for their medical history regarding lower urinary tract symptoms and bowel habits. Physical examination, including abdominal and anorectal digital examination, was performed. Children kept a bladder and bowel diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys, and uroflowmetry with pelvic floor electromyography. Eligible children were divided into 3 groups (A, B, and C). All groups were assigned education and behavioral modifications. Additionally, group A underwent DBEs and IC stimulation, whereas group B received only DBEs. The treatment was conducted for 2 weeks in the clinic in all 3 groups,. The behavioral modifications and DBEs were continued at home for 1 month. Clinical manifestations, uroflowmetry parameters, and postvoided residual urine were analyzed before and after 6 weeks of therapy. RESULTS: After the treatment, significant improvement in defecation frequency and fecal incontinence was noticed only in group A (P < .001 and P < .05, respectively). These children demonstrated significant improvement in lower urinary tract symptoms and postvoided residual urine (P < .001 and P < .05, respectively). Bell-shaped uroflowmetry curve was observed in 73.3% of group A patients (P < .001). CONCLUSION: IC stimulation and DBEs are beneficial in chronically constipated dysfunctional voiders. Further trials are needed to define the long-term effects of this program.

Pelvic floor spasm as a cause of voiding dysfunction.

PURPOSE OF REVIEW: Pelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction. RECENT FINDINGS: To distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms. SUMMARY: Pelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patient's requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained physical therapist/nurse clinician is essential in the management of these patients.

[Chronic pollakiuria: cystectomy or psychotherapy]. / Chronische Pollakisurie : Zystektomie oder Psychotherapie.

BACKGROUND: Persistent unexplained urological complaints and diseases are a common problem in clinical practice. Psychological components can play an important role in urological complaints. Neglect of these facts can lead to an insufficient or incorrect treatment. Therefore, apart from the specific medical diagnostics, a complete examination of mental and psychological functions before an invasive intervention is also required. PSYCHOSOMATICS IN UROLOGY: Illustrated by the case of a young woman with a request for a cystectomy while suffering from a chronic pollakiuria, this paper explains the importance of good interdisciplinary collaboration for evidence-based, guideline-oriented medical treatment. The patient's suffering and urge for removing the bladder was contrasted by a lack of medical indication for surgery and the principle of proportionality. The essay gives insight into the discipline of psychosomatic medicine, somotoform disorders found in urology and, especially, the symptoms of pollakiuria and overactive bladder. CONCLUSION: The case illustrates the importance of timely and simultaneous medical and psychosocial diagnostics for the treatment outcome in patients with unspecific physical complaints. Treatment recommendations for patients with somatoform complaints in clinical practice are provided.

Voiding dysfunction due to detrusor underactivity: an overview.

Detrusor underactivity (DUA) is defined as a voiding contraction of reduced strength and/or duration, which prolongs urination and/or prevents complete emptying of the bladder within a 'normal' period of time. This issue is associated with voiding and postmicturition urinary symptoms, and can predispose to urinary infections and acute urinary retention. The aetiology of DUA is influenced by multiple factors, including ageing, bladder outlet obstruction, neurological disease, and autonomic denervation. The true prevalence of this condition remains unknown, as most data come from referral populations. Urodynamic testing is used to diagnose the condition, either by assessing the relationship between bladder pressures and urinary flow, or by interrupting voiding to measure detrusor pressure change under isovolumetric conditions. Current treatments for DUA have poor efficacy and tolerability, and often fail to improve quality of life; muscarinic receptor agonists, in particular, have limited efficacy and frequent adverse effects. Bladder emptying might be achieved through Valsalva straining, and intermittent or indwelling catheterization, although sacral nerve stimulation can reduce dependency on catheterization. Novel stem-cell-based therapies have been attempted; however, new drugs that increase contractility are currently largely conceptual, and the complex pathophysiology of DUA, difficulty achieving organ specificity of treatment, the limited availability of animal models, and the subjective nature of current outcome measures must be addressed to facilitate the development of such agents.

Changes in sexual functioning in women after neuromodulation for voiding dysfunction.

INTRODUCTION: Sacral neuromodulation is a well-established treatment for urinary and bowel disorders with potential use for other disorders such as sexual dysfunction. AIM: To evaluate changes in sexual functioning in women undergoing neuromodulation for voiding symptoms. METHODS: Patients enrolled in our prospective, observational neuromodulation database study were evaluated. Data were collected from medical records, and patient-completed Female Sexual Function Index (FSFI) and Interstitial Cystitis Symptom-Problem Indices (ICSI-PI) at baseline, 3, 6, and 12 months post-implant. Patients rated overall change in sexual functioning on scaled global response assessments (GRA) at 3, 6, and 12 months post-implant. We grouped women by baseline FSFI scores: less (score<26) and more sexually functional (score≥26). Data were analyzed with Pearson's Chi-square or Fisher's Exact test and repeated measures. MAIN OUTCOMES MEASURES: Changes in FSFI and ICSI-PI scores in women grouped by baseline FSFI score<26 and ≥26. RESULTS: Of 167 women evaluated, FSFI scores improved overall from preimplant (mean 13.5±8.5) to 12 months (N=72; mean 15.9±8.9, P=0.004). At baseline and each follow-up point, ICSI-PI scores were similar between groups and improved through time. For patients in the FSFI<26 group there was improvement from baseline to 12-month scores (N=63; 11.9±6.9 to 14.8±8.7; P=0.0006). Improved FSFI domains included desire, orgasm, satisfaction, and pain. Furthermore, of the 74 subjects in this group not sexually active at baseline, 10 became sexually active during follow-up. In the FSFI≥26 group there was slight but statistically significant decline in mean scores between baseline and 12 months (N=9; 27.4±1.1 to 24.5±3.4; P=0.0302); however one had become sexually inactive. A significant decrease was seen in the satisfaction domain. CONCLUSIONS: Many factors affect sexual functioning in women; however sexual function may improve along with urinary symptoms after neuromodulation.

Observational study: daily treatment with a new compound "Tradamixina" plus serenoa repens for two months improved the lower urinary tract symptoms.

BACKGROUND: Lower urinary tract symptoms (LUTS) are associated with great emotional costs to individuals and substantial economic costs to society. This study seeks to evaluate the effect of a new natural compound "Tradamixina plus Serenoa Repens" in order to improve lower urinary tract symptoms. METHODS: 100 patients (≥ 45 years) who had had LUTS/BPH for >6 mo at screening and with IPSS -The international Prostate symptom scores- ≥ 13 and maximum urinary flow rate (Qmax) ≥ 4 to ≤ 15 ml/s. were recruited. The compound "Tradamixina plus Serenoa Repens" (80 mg of Alga Ecklonia Bicyclis, 100 mg of Tribulus Terrestris and 100 mg of D-Glucosamine and N-Acetyl-D-Glucosamine plus 320 mg of Serenoa Repens) was administered daily for 2 months. At visit and after 60 days of treatment patients were evaluated by means of detailed medical urological history, clinical examination, laboratory investigations (total PSA), and instrumental examination like urolfowmetry. Efficacy measures included IPSS-International Prostate Sympto, BPH Impact Index (BII), Quality-of-Life (QoL) Index. Measures were assessed at baseline and end point (12 wk or end of therapy) and also at screening, 1 and 4 wk for IPSS, and 4 wk for BII. Statistical significance was interpreted only if the results of the preceding analysis were significant at the 0.05 level. RESULTS: After 2 months of treatment the change from baseline to week 12 relative to "Tradamixina plus Seronea Repens" in total IPSS and Qol was statistically significant. Differences from baseline in BII were statistically significant for "Tradamixina plus Seronea Repens" above all differences in BII were also significant at 4 wk (LSmean ± SE: -0.8 ± 0.2). In the distribution of subjects over the PGI-I and CGI-I response categories were significant for"Tradamixina plus Seronea Repens" (PGI-I: p = 0.001; CGI-I). We also observed a decrease of total PSA. CONCLUSION: The daily treatment with a new compound "Tradamixina plus Serenoa Repens" for 2 months improved the male sexual function , it improved the bother symptoms which affect the patient's quality of life , improved uroflowmetric parameters, and we also observed a decrease of serum PSA level.

Photoselective vaporization of the prostate with GreenLight 120-W laser compared with monopolar transurethral resection of the prostate: a multicenter randomized controlled trial.

BACKGROUND: Evidence supporting the widespread use of GreenLight High Performance System (HPS) 120-W photoselective vaporization of the prostate (PVP) is lacking. OBJECTIVE: To assess the noninferiority of PVP compared with transurethral resection of the prostate (TURP) on urinary symptoms and the superiority of PVP over TURP on length of hospital stay. DESIGN, SETTING, AND PARTICIPANTS: A multicenter randomized controlled trial was conducted. INTERVENTION: Patients underwent monopolar TURP or PVP with the GreenLight HPS 120-W laser. MEASUREMENTS: International Prostate Symptom Score (IPSS), Euro-QOL questionnaire, uroflowmetry, Danish Prostate Symptom Score Sexual Function Questionnaire, sexual satisfaction, and adverse events were collected at 1, 3, 6, and 12 mo. The two groups were compared using the 95% confidence interval (CI) of median difference for testing noninferiority of the IPSS at 12 mo and the student t test for testing the difference in length of hospital stay. RESULTS AND LIMITATIONS: A total of 139 patients (70 vs 69 men in each group) were randomized. Median IPSS scores at 12-mo follow-up were 5 (interquartile range [IQR]: 3-8) for TURP versus 6 (IQR: 3-9) for PVP, and the 95% CI of the difference of the median was equal to -2 to 3. Because the upper limit of the 95% CI was >2 (the noninferiority margin), the hypothesis of noninferiority could not be considered demonstrated. Median length of stay was significantly shorter in the PVP group than in the TURP group, with a median of 1 (IQR: 1-2) versus 2.5 (IQR: 2-3.5), respectively (p<0.0001). Uroflowmetry parameters and complications were comparable in both groups. Sexual outcomes were slightly better in the PVP group without reaching statistical significance. CONCLUSIONS: The present study failed to demonstrate the noninferiority of 120-W GreenLight PVP versus TURP on prostate symptoms at 1 yr but showed that PVP was associated with a shorter length of stay in the hospital. TRIAL REGISTRATION: NCT01043588.

Satisfaction and patient experience with sacral neuromodulation: results of a single center sample survey.

PURPOSE: We systematically assessed long-term satisfaction and patient experience with sacral nerve modulation therapy. MATERIALS AND METHODS: All patients who received sacral neuromodulation between 1990 and 2007 at our center and who still had the implant were included in the survey. All received a postal questionnaire regarding satisfaction and experiences with the system, such as side effects, complications, burden, impact on sexuality and defecation changes. RESULTS: Of the 275 questionnaires sent 207 were returned for a 75% response rate. The population was 83% female. Overall treatment was done for overactive bladder syndrome, nonobstructive urinary retention, combined overactive bladder and retention, and pelvic pain in 55%, 24%, 20% and 1% of patients, respectively. Overall satisfaction with sacral neuromodulation was high at 90%. No correlations were found between the satisfaction rate, and pretreatment age, gender, complaint type, sexual dysfunction or therapy duration. However, 56% of patients reported side effects, such as pain at the internal nerve stimulator site and due to stimulation. However, 89% of these patients did not seek further therapy. Of patients with additional defecation problems 47% experienced relief of complaints. CONCLUSIONS: This study shows a high satisfaction rate in patients with sacral neuromodulation. There was no relation between patient age, complaint type, therapy duration or side effects and the satisfaction rate. The number of side effects was limited but further analysis in prospective cohorts should identify patients who are likely to have side effects or stop sacral neuromodulation treatment.

A prospective, randomised trial comparing plasmakinetic enucleation to standard transurethral resection of the prostate for symptomatic benign prostatic hyperplasia: three-year follow-up results.

BACKGROUND: Plasmakinetic enucleation of the prostate (PKEP) has recently been proved a safe and technically feasible procedure for benign prostatic hyperplasia (BPH). However, its long-term safety, efficacy, and durability in comparison with the gold-standard transurethral resection of the prostate (TURP) have not yet been reported. OBJECTIVE: To report the 3-yr follow-up results of a prospective, randomised clinical trial comparing PKEP with standard TURP for symptomatic BPH. DESIGN, SETTING, AND PARTICIPANTS: A total of 204 patients with bladder outflow obstruction (BOO) secondary to BPH were prospectively randomised 1:1 into either the PKEP group or the TURP group. INTERVENTION: The patients in each group underwent the procedure accordingly. MEASUREMENTS: All patients were assessed perioperatively and followed at 1, 3, 6, 12, 18, 24, and 36 mo postoperatively. The preoperative and postoperative parameters included International Prostate Symptom Score (IPSS), quality of life (QoL) scores, the International Index of Erectile Function (IIEF) questionnaire, maximum urinary flow rates (Q(max)), transrectal ultrasound (TRUS)-assessed prostate volume, postvoid residual urine (PVRU) volume, and serum prostate-specific antigen (PSA) level. Patient baseline characteristics, perioperative data, and postoperative outcomes were compared. All complications were recorded. RESULTS AND LIMITATIONS: PKEP was significantly superior to TURP in terms of the drop in haemoglobin (0.74±0.33 g/dl vs 1.88±1.06 g/dl; p<0.001), intraoperative irrigation volume (11.7±4.5 l vs 15.4±6.2 l; p<0.001), postoperative irrigation volume and time (18.5±7.6 l vs. 30.0±11.4 l and 16.6±5.2 h vs 25.3±8.5 h; all p<0.001), recovery room stay (67.3±11.1 min vs 82.0±16.4 min; p<0.001), catheterisation time (51.7±26.3 h vs 80.5±31.6 h; p<0.001), hospital stay (98.4±20.4 h vs 134.2±31.5 h; p<0.001), and resected tissue (56.4±12.8 g vs 43.8±15.5 g; p<0.001). There were no statistical differences in operation time and sexual function between the two groups. At 36 mo postoperatively, the PKEP group had a maintained and statistically significant improvement in IPSS (2.4±2.2 vs 4.3±2.9; p<0.001), QoL (0.6±0.5 vs 1.6±1.4; p<0.001), Q(max) (28.8±10.1 ml/s vs 25.1±8.0 ml/s; p=0.017), and TRUS volume (21.0±7.3 ml vs 26.4±6.8 ml; p<0.001), with urodynamically proven deobstruction (Schäfer grade 0.2±0.02 vs 0.8±0.1; p<0.001). More extensive clinical trials are required to validate these results. CONCLUSIONS: PKEP is a safe and highly effective technique for relieving BOO. At 3-yr follow-up, the clinical efficacy of PKEP is durable and compares favourably with TURP.

The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study.

OBJECTIVES: To evaluate the efficacy of a training program with uroflowmetry biofeedback and pelvic floor relaxation biofeedback on urodynamic and voiding parameters in women with dysfunctional voiding. METHODS: Eighty-six women with recurrent urinary tract infections (UTIs) and dysfunctional voiding were randomly assigned to receive a treatment schedule as follows: uroflowmetry biofeedback (group 1), biofeedback training of the pelvic floor muscles (group 2), uroflowmetry biofeedback combined to biofeedback training of the pelvic floor muscles (group 3), no treatment (group 4). Patients were regularly evaluated by American Urological Association Symptom Index and urodynamics during the study period. All the patients were followed up for 1 year with monthly urine cultures. A further evaluation was done at month 24 by American Urological Association Symptom Index and free uroflowmetry with measurement of residual urine. RESULTS: The prevalence of storage and emptying symptoms decreased significantly at 3, 6, and 12 months in the groups 1, 2, and 3, and remained stable during the study period. Mean flow rate, flow time, voiding volume increased significantly, whereas postvoid residual urine decreased. The prevalence of UTI decreased significantly in groups 1, 2, and 3. At month 24, storage and emptying symptoms and voiding patterns were similar to the baseline values in all the patients. The incidence of UTIs was similar to baseline values in groups 1, 2, and 3. CONCLUSIONS: Training the voluntary control of the pelvic floor seems essential in obtaining control over the bladder function. These results reinforce the importance of pelvic floor therapy in the resolution of UTIs.

Management of abnormal postvoid residual urine in children with dysfunctional voiding.

OBJECTIVES: To evaluate the effect of biofeedback therapy on the residual urine volume in children with dysfunctional voiding. METHODS: This prospective study was conducted in children with dysfunctional voiding associated with abnormal postvoid residual urine (PVR) from June 2002 to 2007. The children were divided randomly into 2 groups. Group 1 was treated with standard urotherapy combined with biofeedback therapy and group 2 was treated with only standard urotherapy. The outcomes of uroflow-electromyography pattern, urinary tract infection (UTI), and PVR were recorded before and at the end of sixth month of treatment. RESULTS: A total of 94 patients were enrolled in this study. Groups 1 and 2 consisted of 62 and 32 patients, respectively. The voiding pattern became normal in 80.6% (50/62) and 56.2% (18/32) of patients in groups 1 and 2, respectively. The PVR resolved in 40 of 62 (64.5%) patients in group 1 and in 11 of 32 (34.4%) children in group 2. Before the treatment, UTI was noted in 22.5% of patients (14/62) in group 1 and 21.8% of patients (7/32) in group 2. After the treatment, UTI was observed in 3.2% of patients (2/62) and in 9.3% (3/32) of patients in groups 1 and 2, respectively. Although both treatment modalities changed the voiding pattern, rate of febrile UTI, and PVR positively, these outcomes were better in a combination group. CONCLUSIONS: The combination of standard urotherapy with the biofeedback therapy improved the results significantly.

Hydrodistension under local anesthesia for patients with suspected painful bladder syndrome/interstitial cystitis: safety, diagnostic potential and therapeutic efficacy.

OBJECTIVES: To evaluate the safety, diagnostic potential and therapeutic efficacy of cystoscopy with hydrodistension under local anesthesia in patients with suspected painful bladder syndrome/interstitial cystitis (PBS/IC). METHODS: Thirty-six patients with frequency, urgency or bladder pain for > or = 6 months and an average voided volume of <200 mL were enrolled in the study. Hydrodistension was carried out 10 min after instillation of 10 mL of 4% lidocaine. The instilled saline volume for hydrodistension was determined based on each patient's level of tolerance of urinary sensation and symptoms. RESULTS: Overall, 30 patients (median age 54 years, range 25-76) were evaluated. The median instilled saline volume was 450 mL (250 to 580 mL). No patients were admitted to hospital due to adverse events associated with hydrodistension. Glomerulation was found in 23 patients and two had Hunner's ulcers. Therapeutic efficacy at one month after hydrodistension was shown in 21/30 patients (71%). A median efficacy period of 20 + or = 3.7 weeks was determined by Kaplan-Meier analysis. Factors with an independent influence on therapeutic efficacy of hydrodistension were not identified, but patients with an instilled volume greater than the median volume had significantly longer efficacy periods (P < 0.022). CONCLUSIONS: Cystoscopy with hydrodistension under local anesthesia provides a simple and safe method for differential diagnosis and has some therapeutic efficacy in patients with suspected PBS/IC.

[From end-organ disease to a classifiable bladder pain syndrome: paradigm shift in the understanding of urological pain syndromes exemplified by the condition currently called interstitial cystitis]. / Von der Endorganerkrankung zum klassifizierbaren Blasenschmerzsyndrom: Paradigmenwechsel im Verständnis urologischer Schmerzsyndrome am Beispiel der interstitiellen Zystitis.

Growing clinical and scientific data imply that the condition currently called interstitial cystitis is not just a mere bladder end-organ disease but that the symptoms perceived to be related to the bladder are rather one aspect of a complex pelvic pain syndrome. The term bladder pain syndrome/interstitial cystitis (BPS/IC) suggested by the European Society for the Study of IC/PBS (ESSIC) for this condition is currently the only one strictly consistent with the taxonomy guidelines of the European Association of Urology and the International Association for the Study of Pain. BPS would be diagnosed on the basis of chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder, accompanied by at least one other urinary symptom such as persistent urge to void or urinary frequency. Confusable diseases as the cause of the symptoms must be excluded. Classification of BPS types might be performed according to findings at cystoscopy with hydrodistention and morphologic findings in bladder biopsies. The end-organ condition interstitial cystitis has thus become a chronic pain syndrome with a predominantly neurovisceral pathophysiology. In daily practice, therapeutic approaches aiming at both the peripheral bladder urothelium and central nervous targets should be combined. A multimodal treatment strategy, such as the combination of tricyclic antidepressants with instillation therapy, still appears reasonable and justified.

Pediatric voiding dysfunction: current evaluation and management.

Voiding dysfunction and urinary incontinence in children is common. Both are associated with significant effects on quality of life and comorbidities, including urinary tract infections (UTIs) and constipation. A thorough history, physical examination, and non-invasive evaluation are essential in determining the etiology. Interventions, such as behavioral therapy/biofeedback and pharmacologic therapies, are primary treatments. Prevalence rates, current evaluation, and management techniques are discussed in this article.

How to engage the Latino or African American patient with benign prostatic hyperplasia: crossing socioeconomic and cultural barriers.

Disparities based on race and ethnicity still exist in the US healthcare system. Such disparities are reflected in the diagnosis and treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) among African Americans and Latinos. The prevalence of risk factors for BPH and LUTS and symptom progression are higher in these populations, but treatment is less common. African American men and Latinos frequently have other serious comorbidities, such as cardiovascular disease, diabetes mellitus, and metabolic syndrome. Health plan constraints and variabilities, race/ethnicity, socioeconomic status, language, healthcare-seeking behaviors, and cultural beliefs and practices influence the treatment of BPH and LUTS, oftentimes resulting in unequal access to care or inferior quality of care. The provision of nondiscriminatory treatment poses a challenge to clinicians that can partially be addressed by improving the cultural competence of practitioners in minority communities. An awareness of the customs and healing traditions of African Americans and Latinos may also facilitate culturally appropriate care and improve outcomes, and the participation of clinicians in continuing education/professional development programs to increase knowledge about minority health issues is recommended. Conversely, improving the health literacy of African American and Latino patients with BPH and LUTS can help avoid ineffective nontraditional methods of treatment.

Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms.

INTRODUCTION: Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement. Diabetes mellitus is also more prevalent in this group. LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both. OBJECTIVES: The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate. A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients. PATIENTS AND METHODS: 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS), ultrasonography and urodynamics. BOO diagnosis was based on pressure/flow measurements according to the International Continence Society's standards. RESULTS: Of the 50 patients in the study, 23 (46%) had BOO. There was no correlation between the IPSS, uroflowmetry, post-voiding residual urine or prostate volume and the presence of BOO (p > 0.05). CONCLUSIONS: There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS. Non-invasive tests did not allow the identification of these subjects. Only urodynamic evaluation is able to determine symptom etiology.

Current and future techniques of neuromodulation for bladder dysfunction.

Recent increase in the use of neuromodulation for the treatment of urinary urgency and frequency, urge incontinence, and nonobstructive urinary retention has coincided with improved knowledge of micturition physiology and concurrent technologic advances in nerve stimulation. Currently, the most common technology for bladder neuromodulation involves stimulation through the S3 foramen, or sacral neuromodulation, although other techniques of neuromodulation continue to be explored. Despite many advances in neuromodulation, the exact mechanism of action remains uncertain. Additionally, which patients will respond to neuromodulation remains unclear, and although there is a standard method for testing, this procedure is invasive and expensive. As we continue to improve patient selection criteria and better understand the mechanism of action, the efficacy and patient satisfaction should continue to increase. Currently, most patients considered for implantation with a neuromodulator are those unresponsive to other conservative treatments for bladder dysfunction.

Neuromodulation techniques: a comparison of available and new therapies.

Neuromodulation has become ever more common in the fields of urology and voiding dysfunction. Many therapeutic alternatives have emerged to increase effectiveness of these therapies and reduce morbidity and invasiveness. Each new modality needs to prove its efficacy in common indications for voiding dysfunction such as refractory urgency-frequency, urge incontinence, and perhaps urinary retention, as well as in select patient populations and subgroups. We need more information to broaden the applicability of neuromodulation to larger numbers of patients and conditions.