Transcutaneous tibial nerve stimulation in patients with multiple sclerosis and overactive bladder: a real-life clinical and urodynamic assessment.

AIMS: The aims of the present study were to assess the effectiveness of transcutaneous tibial nerve stimulation (TTNS) on overactive bladder (OAB) symptoms and on urodynamic parameters in patients with multiple sclerosis (PwMS) and to seek predictive factors of satisfaction. METHODS: All PwMS who performed 12-24 weeks of TTNS and who underwent urodynamic assessment before and after treatment between June 2020 and October 2022 were included retrospectively. Data collected were bladder diaries, symptoms assessed with Urinary Symptoms Profile (USP), and urodynamic parameters (bladder sensations, detrusor overactivity, and voiding phase). Patients with improvement rated as very good or good on Patient Global Impression of Improvement (PGI-I) score were considered as responders. RESULTS: Eighty-two patients were included (mean age: 47.1 ± 11.5 years, 67 (82%) were women). The mean USP OAB sub-score decreased from 7.7 ± 3.5 to 6.0 ± 3.4 (p < 0.0001). On bladder diaries, voided volumes, void frequency, and the proportion of micturition done at urgent need to void significantly improved with TTNS (p < 0.05). No significant change was found in urodynamic parameters. According to the PGI-I, 34 (42.5%) patients were good responders. The only parameter associated with higher satisfaction was the percentage of micturition done at urgent need to void before the initiation of the treatment (39.8% ± 30.5 in the responder group vs 25.1% ± 25.6 in the low/no responder group; p = 0.04). CONCLUSION: TTNS improves OAB symptoms in PwMS, without significant changes on urodynamics. A high rate of strong or urgent need to void in daily life was associated with higher satisfaction.

De-obstruction of bladder outlet in humans reverses organ remodelling by normalizing the expression of key transcription factors.

BACKGROUND: Benign prostatic hyperplasia in elderly males often causes bladder outlet obstruction termed benign prostatic obstruction (BPO). BPO induces lower urinary tract symptoms and quantifiable urodynamic alterations in bladder function. When conservative medical treatments are exhausted, surgical interventions like transurethral resection of the prostate (TURP) are employed for bladder outlet de-obstruction. Elucidating the molecular changes in the human bladder resulting from BPO and their reversal post-de-obstruction is pivotal for defining the "point of no return", when the organ deterioration becomes irreversible. In this study we carried out a comprehensive molecular and urodynamic characterization of the bladders in men with BPO before TURP and 3 months after the relief of obstruction. METHODS: We report integrated transcriptome and proteome analysis of bladder samples from male patients with BPO before and 3 months after de-obstruction surgery (TURP). mRNA and protein profiles were correlated with urodynamic findings, specifically voiding detrusor pressure (PdetQmax) before TURP. We delineated the molecular classifiers of each group, pointing at the different pre-TURP bladder status. RESULTS: Age-matched patients with BPO without DO were divided into two groups based on the PdetQmax values recorded by UDI before de-obstruction: high and medium pressure (HP and MP) groups. Three months after de-obstruction surgery, the voiding parameters PdetQmax, Qmax and RV were significantly improved in both groups, without notable inter-group differences in the values after TURP. Patients with high PdetQmax showed less advanced remodeling and inflammatory changes than those with lower values. We detected significant dysregulation of gene expression, which was at least partially reversed by de-obstruction in both patients' groups. Transcription factor SOX21 and its target thrombospondin 4 (THBS4) demonstrated normalization post-TURP. CONCLUSIONS: Our findings reveal substantial yet incomplete reversal of cell signalling pathways three months after TURP, consistent with improved urodynamic parameters. We propose a set of biomarker genes, indicative of BPO, and possibly contributing to the bladder changes. This study unveils the stages of progressive obstruction-induced bladder decompensation and offers insights into selecting an optimal intervention point to mitigate loss of contractility.

[Uroflowmetry: A follow-up tool for neurogenic bladder patients treated by transcutaneous tibial posterior stimulation?] / Débitmétrie : outil de suivi chez les patients avec vessie neurologique traités par neurostimulation tibiale postérieure ?

OBJECTIVE: Neurogenic bladders can suffer from overactivity, underactivity or dyssynergia depending on the level of the initial lesion. These symptoms can lead to severe alterations of the upper urinary tract. One of the first-line treatments is the transcutaneous tibial posterior stimulation (TTNS), which was demonstrated to be efficient on urodynamics. But it is an invasive, expensive and sometimes not patient-accepted examination, contrary to the uroflowmetry. The aim of this study is to assess the feasibility of a follow-up with a uroflowmetry when treated by TTNS and show that the maximum flow rate increased after treatment, displaying a better detrusor contraction. METHODS: In total, 38 patients with neurogenic bladder undergoing a 12-weeks TTNS treatment and with 2 uroflowmetries interpretable before and after treatment were included. The maximum flow rate (Qmax), the urinated volume and the post-void residual (PVR) were retrieved from the uroflowmetry, and the USP-score and the urinary discomfort were asked at each appointment. RESULTS: Qmax is increased from 17,53ml/s to 18,26ml/s, as well as the PVR (from 76,97ml to 79,16ml). Urinated volume is decreased from 241,4ml to 193,66ml. Patients feel enhanced after TTNS according to the decrease in the USP-score and the urinary discomfort scale. CONCLUSION: The increase of the cystomanometric capacity and the delay of the detrusor overactivity due to TTNS explains the reduction of the urinated volume and the increase of PVR. Increased Qmax might show a better voluntary bladder contraction, with a restraint due to the lack of abdominal pressure measurement during voiding.

Correlation of urodynamic studies and somatosensory evoked potential and their prognostic value in children with closed spinal dysraphism.

INTRODUCTION: Somatosensory evoked potential (SSEP) and urodynamic studies (UD) are valuable tools for assessing patients with closed spinal dysraphism (CSD) before neurosurgical intervention. No studies have correlated their findings in this cohort and our aim is to study their correlation and prognostic value in pediatric patients with closed spinal dysraphism. METHODS: Retrospective review of all patients referred to a multidisciplinary clinic in a tertiary pediatric surgical center over a 17 years period between April 2004 to September 2021 was performed. Inclusion criteria were <18 years old, diagnosed with CSD, with SSEP and UD done within 1 year of each other. Demographics data collected include age at presentation/at referral/at neurosurgical operation, gender, symptoms at presentation and intra-operative diagnoses. Pre-operative SSEP and UD findings were documented. Primary outcome was UD results in the group with normal and abnormal SSEP. Secondary outcome was urological and bowel function outcome in 4 groups of patients (Group A-both normal SSEP and UD, Group B- abnormal SSEP only, Group C - abnormal UD only and Group D-both abnormal SSEP and UD). RESULTS: A total of 45 patients were included for analysis. Mean follow up time was 118.9 months (24-216 months, SD 55.8 months). SSEP was normal in 20 patients and abnormal in 25 patients. Baseline demographics, preoperative symptoms and imaging were similar between 2 groups. Primary outcome Patients with abnormal SSEP were more likely to have abnormal UD results with a statistically significant difference (84% vs 40%, p < 0.05). They have a significantly higher end-fill detrusor pressure (12% vs 0%, p < 0.05), abnormal bladder compliance (20% vs 0%, p < 0.05), abnormal cystometric capacity (48% vs 10%, p < 0.05), poor emptying efficiency (24% vs 5%, p < 0.05) and sphincter incompetence (8% vs 0%, p < 0.05). Secondary outcome When compared to Groups A to C, patients in group D were more likely to be on anti-cholinergic (33.3% vs 4.3%, p < 0.05), required clean intermittent catheterization (42.9% vs 4.3%, p < 0.05) and had intravesical botulinum injection (19% vs 0%, p < 0.05). All the patients who had augmentation cystoplasty were in this group as well. Bowel function in terms of regular enema use was also statistically significantly higher in this group (33.4% p < 0.05). CONCLUSION: Pre-operative SSEP and UD results correlate well in patients with closed spinal dysraphism. Patients with abnormal SSEP and UD preoperatively have higher risk of urological deterioration over time. Close monitoring in this group is warranted.

Is sacral neuromodulation effective in patients with Parkinson's disease? A retrospective review.

INTRODUCTION AND OBJECTIVE: Parkinson's disease (PD) is the second-most common degenerative neurologic disease worldwide. Overactive bladder (OAB) is prevalent in this population but can be challenging to treat. Sacral neuromodulation (SNM) is an attractive option but remains understudied. We have utilized SNM in PD patients and herein describe our outcomes. METHODS: We performed a retrospective chart review of PD patients who underwent peripheral nerve evaluation (PNE) or Stage 1 SNM from 2000 to 2020. The primary outcome was progression to a permanent implant. The impact of PD stage and preprocedural urodynamic (UDS) parameters on test-phase outcome were investigated. Long-term efficacy was assessed using Wilcoxon matched-pairs test looking at a change in urinary symptoms (frequency, nocturia, incontinence episodes, and pad use) documented at follow-up visits and further need for treatment. RESULTS: Thirty-four patients underwent test phase SNM (7 PNE and 27 Stage 1). Median follow-up was 11 (interquartile range 5.8-29.8) months. Indications included refractory OAB (30/34) and nonobstructive urinary retention (4/34). Overall, 82% (28/34) of patients proceeded to a permanent implant. 71% (5/7) of PNEs were successful. Test-phase success did not differ based on PD disease severity or UDS parameters. In patients with OAB/urgency incontinence who progressed to the permanent implant, there was a statistically significant improvement in their urinary symptoms from baseline. Most (68%) patients were able to discontinue OAB medications post-implant. The overall lead revision rate was 14% (4/28) and 3 devices required removal. CONCLUSIONS: SNM is an efficacious treatment option for PD patients with a high percentage of patients having improvement in their urinary symptoms.

Sacral nerve stimulation for refractory OAB and idiopathic urinary retention: Can phenotyping improve the outcome for patients: ICI-RS 2019?

AIMS: Sacral nerve stimulation (SNS) is widely used to treat refractory idiopathic overactive bladder (OAB) and idiopathic urinary retention. However, clinical outcomes are variable and understanding predictive factors for success or side-effects would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society meeting 2019, a Think Tank was convened to discuss how advances in the basic science study of SNS may be translatable into clinical practice to improve outcomes of patients undergoing SNS treatment. METHODS: We conducted a literature review and expert consensus meeting focusing on current methods of phenotyping patients and specifically, how advances in basic science research of the mechanism of action of SNS can be translated into clinical practice to improve patient selection for therapy. RESULTS: The terms "Idiopathic OAB" and "idiopathic urinary retention" encompass several underlying pathophysiological phenotypes. Commonly, phenotyping is based on clinical and urodynamic factors. Animal studies have demonstrated that high-frequency stimulation can produce rapid onset, reversible conduction block in peripheral nerves. Altering stimulation parameters may potentially enable personalization of therapy depending upon the clinical indication in the future. Similarly, advances in conditional and closed-loop stimulation may offer greater efficacy for certain patients. Phenotyping based on psychological comorbidity requires further study to potentially optimize patient selection for therapy. CONCLUSIONS: Idiopathic OAB and idiopathic urinary retention are heterogenous conditions with multiple potential underlying phenotypes. Tailoring stimulation parameters to the needs of each individual according to phenotype could optimize outcomes. Assessing psychological comorbidity may improve patient selection. Areas for further research are proposed.

Outcomes of transurethral resection of the prostate in unobstructed patients with concomitant detrusor underactivity.

AIMS: The aim of the study was to evaluate the transurethral resection of the prostate (TURP) outcomes of unobstructed patients with detrusor underactivity (DUA), comparing the surgical results between obstructed and unobstructed males with concomitant DUA, at midterm follow-up. METHODS: This was an observational, prospective, comparative, nonrandomized study. Candidates to TURP underwent preoperative urodynamics (UD), with a diagnosis of DUA, were divided in two cohorts: Group A unobstructed men, group B males with bladder outlet obstruction (BOO). Males were evaluated yearly with uroflowmetry (UF), post-void residual (PVR), and bladder voiding efficiency (BVE), International Prostate Symptom Score (IPSS) questionnaire, visual analogic scale (VAS) for subjective assessment of the quality of life. The degree of the variation of maximum flow rate (Qmax), PVR, BVE, IPSS, VAS between baseline and follow-up (Δ) was evaluated. RESULTS: Patients in group A were 28 and in group B 23. Overall patient's mean ± SD age was 63.37 ± 12.41 years. Preoperative urodynamics characteristics: mean bladder contractility index (BCI) of 61.15 and 76.25 in group A and B, respectively; mean bladder outlet obstruction index (BOOI) of 17.25 and 50.15 in group A and group B, respectively. After surgery, overall patient group, group A, and group B showed a statistical improvement in IPSS score (P < .0001), Qmax (P < .0001), PVR (P < .0008), BVE (P < .03) and VAS (P < .0001). CONCLUSIONS: BOO had an important impact on the degree of improvement of Qmax and PVR/BVE, while had a poor influence on lower urinary tract symptoms amelioration. The most relevant outcomes were found when BOO was associated with DUA, which was not a contraindication to surgery.

[Course of neurogenic bladder dysfunction in patients with spinal cord injury under homeopathic treatment]. / Verlauf der neurogenen Blasenfunktionsstörung bei Patienten mit Rückenmarkschädigung unter klassisch homöopathischer Therapie.

BACKGROUND: Nearly all patients with spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD). Untreated NLUTD is a risk factor for renal damage and can significantly affect quality of life (QoL). Patients with SCI frequently use complementary medicine to alleviate symptoms, namely for urologic problems. OBJECTIVES: We evaluated whether homeopathic treatment influences objective urodynamic parameters. MATERIALS AND METHODS: In a retrospective study, urodynamic data of patients with NLUTD due to SCI who received constitutional homeopathic treatment by the consultants of our hospital were evaluated before initiation of homeopathic treatment and at the most recent follow-up. Modifications in urologic treatment were taken into account. RESULTS: Urodynamic results from 35 patients who underwent homeopathic treatment (14 women, 21 men, median age 46 years, tetraplegia: n = 14; paraplegia: n = 21) were available at both time points and could therefore be evaluated. In all, 20 patients used intermittent catheterization, 6 persons had an indwelling catheter, and 9 persons emptied their bladders without a catheter. There were no significant differences in the urodynamic parameters before and during treatment. Changes in urologic therapy correlated with significant improvement in urodynamic findings. CONCLUSIONS: As all patients were under urologic surveillance, and immediate urologic treatment was established if necessary, a retrospective study design proved not to be suitable to detect possible influences of homeopathic treatment on urodynamic parameters in patients with SCI. Thus, a prospective randomized study is essential.

Urinary Tract Infection in Outpatient Children and Adolescents: Risk Analysis of Antimicrobial Resistance.

BACKGROUND: Urinary tract infection (UTI) is a common bacterial infection in children. ​​​​​​​Early treatment may prevent renal damage in pyelonephritis. The choice of empiric antibiotic treatment is based on knowledge of the local susceptibility of urinary bacteria to antibiotics. In Israel the recommended empiric oral antibiotic treatment are First or second generation cephalosporin, trimethoprim-sulfamethoxazole or amoxicillin-clavulanic acid. OBJECTIVES: To describe resistance rates of urine bacteria isolated from children with UTI in the community settings. Identify risk factors for resistance. METHODS: A retrospective cross-sectional study of UTI in children aged 3 months to 18 years diagnosed with UTI and treated as outpatients in a large community clinic between 7/2015 and 7/2017 with a diagnosis of UTI. RESULTS: A total of 989 urinary samples were isolated, 232 were included in the study. Resistance rates to cephalexin, cefuroxime, ampicillin/clavulanate and Trimethoprim-Sulfamethoxazole were 9.9%, 9.1%, 20.7%, and 16.5%, respectively. Urinary tract abnormalities and recurrent UTI were associated with an increase in antibiotic resistance rates. Other factors such as age, fever, and previous antibiotic treatment were not associated with resistance differences. CONCLUSIONS: Resistance rates to common oral antibiotics were low compared to previous studies performed in Israel in hospital settings. First generation cephalosporins are the preferred empiric antibiotics for febrile UTI for outpatient children. Amoxicillin/clavulanate is not favorable due to resistance of over 20% and the broad spectrum of this antibiotic. Care should be taken in children with renal abnormalities as there is a worrying degree of resistance rates to the oral first line antibiotic therapy.

Brain activation patterns of female multiple sclerosis patients with voiding dysfunction.

AIMS: We compared brain activation patterns between female multiple sclerosis (MS) patients with voiding dysfunction (VD) and those without. We aim to expand current knowledge of supraspinal correlates of voiding initiation within a cohort of female MS patients with and without VD. MATERIALS AND METHODS: Twenty-eight ambulatory female MS patients with stable disease and lower urinary tract dysfunction were recruited for this study. Subjects were divided into group 1, without VD (n = 14), and group 2, with VD (n = 14), defined as postvoid residual urine of ≥40% of maximum cystometric capacity or need for self-catheterization. We recorded brain activity via functional magnetic resonance imaging (fMRI) with simultaneous urodynamic testing. Average fMRI activation maps (the Student t test) were created for both groups, and areas of significant activation were identified (P < .05). A priori regions of interest (ROIs), identified by prior meta-analysis to be involved in voiding, were selected. RESULTS: Group-averaged blood-oxygen level-dependent (BOLD) activation maps demonstrated significant differences between groups 1 and 2 during initiation of voiding with group 2 showing significantly lower levels of activation in all ROIs except for the left cerebellum and right cingulate gyrus. Interestingly, group 2 displayed negative BOLD signals, while group 1 displayed positive signals in the right and left pontine micturition center, right periaqueductal gray, left thalamus, and left cingulate gyrus. The activation map of group 1 was similar to healthy controls. CONCLUSIONS: Our results support the hypothesis that distinct supraspinal activation patterns exist between female MS patients with VD and those without.

The mechanical stop test and isovolumetric detrusor contractile reserve are associated with immediate spontaneous voiding after transurethral resection of prostate.

PURPOSE: To identify urodynamic factors associated with the mechanical stop test and immediate spontaneous voiding following transurethral resection of prostate (TURP). METHODS: We identified 90 men who underwent TURP over a 12-month period. Forty-three (mean age 68 years) underwent urodynamic evaluation prior to TURP. Isovolumetric detrusor contractile pressure (Piso) was obtained using the mechanical stop test during the voiding phase, and used to calculate detrusor contractile reserve (Pres = Piso - Pdet@Qmax). Primary outcome was spontaneous voiding after TURP. RESULTS: Preoperative catheter-free spontaneous voiding was present in 63% of men (27/43) with a urodynamic (mean ± SD): Qmax 6.2 ± 2.7 mL/s, Pdet@Qmax 102 ± 47 cmH2O, Piso 124 ± 49 cmH2O, Pres 22 ± 16 cmH2O, bladder outlet obstruction index (BOOI) 90 ± 49, and bladder contractility index (BCI) 132 ± 44. The remaining 16 catheter-dependent men demonstrated a urodynamic (mean ± SD): Qmax 3.6 ± 3.3 mL/s, Pdet@Qmax 87 ± 38 cmH2O, Piso 99 ± 51 cmH2O, Pres 10 ± 18 cmH2O, BOOI 82 ± 36, and BCI 106 ± 48. Following TURP, 67% of men voided spontaneously with their first void trial, and in receiver operator analysis of urodynamic measures (Pdet@Qmax, Piso, Pres, BOOI and BCI), only Pres was significantly associated with immediate spontaneous voiding after TURP (threshold Pres ≥ 9 cmH2O, AUC = 0.681, p = 0.035). CONCLUSIONS: In men who underwent TURP, a Pres ≥ 9 cmH2O was associated with immediate spontaneous voiding and may be easily incorporated into the postoperative pathway.

Can we improve our management of dysfunctional voiding in children and adults: International Consultation on Incontinence Research Society; ICI-RS2018?

AIMS: Dysfunctional voiding (DV) remains a poorly understood and a poorly managed problem, both in children and adults. The Think Tank (TT) discussed how to improve the management of DV in these two different age groups and in transitional care. METHODS: During the 2018 International Consultation on Incontinence Research Society held in Bristol, a multidisciplinary TT on DV was created. The presentations and subsequent discussion, leading to research recommendations intended to improve the management of DV in children and adults are summarized. RESULTS: To improve the management of DV in children and adults, the TT panel proposed: (1) to conduct reliable prevalence studies of DV; (2) to perform longitudinal studies to prospectively test the sequence hypothesis by answering the following questions: (a) Which, if any children show a progression from overactive bladder or voiding postponement to DV?; (b) Which children develop each disorder without precursors?; and (c) Is there a continuation of DV from childhood to adulthood, or are adult cases new-onset presentations?; (3) to obtain detailed information regarding psychopathology to understand which comorbid psychological disorders prevail and at which rate, in those suffering DV; (4) to develop and validate diagnostic tools specifically for DV; (5) to better establish urodynamic correlates of DV specific for different age groups; and (6) to generate prospective long-term data regarding the efficacy of different treatment options and management strategies. CONCLUSIONS: The future research recommendations of this TT may improve our management of DV in children and adults.

How can we better manage drug-resistant OAB/DO? ICI-RS 2018.

AIMS: Botulinum toxin A (BTX-A), sacral nerve stimulation (SNM), and posterior tibial nerve stimulation (PTNS) are established treatments for idiopathic overactive bladder (OAB) refractory to oral drug therapy. At the ICI-RS meeting in Bristol in 2018 a think tank was convened to address the question of how to better manage drug-resistant OAB/DO (detrusor overactivity). METHODS: The think tank conducted a literature review and an expert consensus meeting focusing on the evidence for predicting response and adverse events (AEs) with the current therapies for drug-resistant idiopathic OAB. RESULTS: Several factors have been associated with poor outcomes using BTX-A including increasing age, body mass index, male sex, and frailty. Voiding dysfunction with BTX-A also appears to be more prevalent in those with increasing age, male sex, higher baseline postvoid residual and with poorer contractility as assessed by urodynamic parameters. SNM full implantation appears to be higher with the first stage tined lead placement procedure compared to percutaneous nerve evaluation. Urodynamics do not appear to predict outcomes with SNM. Patients with psychiatric comorbidity are more likely to experience AEs with SNM. Outcomes related to lead positioning and the number of active electrodes are mixed in predicting long term success. Patients with increased daytime frequency and lower first sensation of bladder filling were independent factors associated with success with PTNS. CONCLUSIONS: Further research is required to optimize these procedures and to better understand which patients will benefit from the various options available in managing refractory OAB.

Persistent storage symptoms after TURP can be predicted with a nomogram derived from the ice water test.

PURPOSE: To predict the persistence of storage symptoms after transurethral resection of the prostate (TURP) using a nomogram derived from the ice water test (IWT). METHODS: The IWTs of 73 men with lower urinary tract symptoms and prostatic bladder outlet obstruction were retrospectively analyzed. The strength of the detrusor contraction was approximated by using the detrusor gradient of Δpdet /Δt at maximum detrusor pressure and the area under the curve. The parameters were utilized in a nomogram, which facilitated a severity categorization from 1 to 10. Patients with a positive IWT in the categories 1 to 2 were assigned to group A, categories 3 to 4 to group B and categories 5 and higher to group C. After TURP, patients with persisting storage symptoms were offered a botulinum toxin injection. RESULTS: There were 32 patients (44%) with negative and 41 patients (56%) with positive IWTs. Patients with negative IWTs were classified in category 1. Regarding patients with positive IWTs, 14 (34%) were correlated to group A, 14 (34%) to group B, and 13 (32%) to group C. The necessity of a subsequent botulinum toxin injection correlated significantly with a higher nomogram category (P < .001) as well as higher severity categorization (P < .001). In multivariate analysis, the nomogram category was an independent predictor for botulinum toxin injection (P = .002, OR, 6.9, CI, 2.0-23.9). CONCLUSION: The quantification of the detrusor contraction during the IWT allowed stratification of patients in risk categories for persistent storage symptoms after TURP and the potential need for later botulinum toxin injections.

Role of poor urethral sphincter relaxation in men with voiding dysfunction refractory to α-blocker therapy: Clinical characteristics and predictive factors.

OBJECTIVES: This study evaluates the diagnostic value of poorly relaxed external sphincter (PRES) in men with voiding dysfunction. We analyzed clinical and video-urodynamic characteristics to identify predictive factors of PRES in patients with lower urinary tract symptoms (LUTS) refractory to α-1 adrenoceptor blocker (α-blocker) therapy. METHODS: This retrospective study included 3379 men with LUTS in whom the initial 1-month α-blocker therapy failed. Clinical parameters and video-urodynamic results were analyzed. Patients with bladder outlet disorders including bladder neck obstruction (BNO), benign prostatic obstruction (BPO), urethral stricture (US), or PRES were categorized according to video-urodynamic findings. Predictive factors for PRES were analyzed. RESULTS: A total of 3379 men were included in this study. Among the patients with voiding dysfunction, 905 (43.6%) had BPO, 624 (30.0%) had BNO, 487 (23.4%) had PRES, and 62 (3.0%) had US. Patients with PRES were younger and had a higher maximum flow rate, larger bladder capacity, smaller total prostate volume (TPV) and transition zone index, and a lower rate of LUTS of urgency or urge urinary incontinence (UUI) than other groups. On multivariate analysis, only small TPV and lower urgency/UUI rate were predictive factors of PRES. A scale composed of voided volume, TPV, and urgency/UUI predicted PRES with high specificity. CONCLUSIONS: PRES was the etiology of voiding dysfunction in 23.4% of the men with LUTS refractory to α-blocker therapy. A simple scale composed of voiding volume, TPV, and urgency/UUI was useful in predicting the presence of PRES before video-urodynamic studies.

Effects of magnetic stimulation on urodynamic stress incontinence refractory to pelvic floor muscle training in a randomized sham-controlled study.

OBJECTIVE: The aim of the present study was to evaluate the effect of magnetic stimulation on urodynamic stress incontinence refractory to pelvic floor muscle training in a randomized sham-controlled study. METHODS: Female patients with urodynamic stress incontinence who had not been cured by pelvic floor muscle training were randomly assigned at a ratio of 2 : 1 to either active treatment or sham treatment for 10 weeks. The randomization was made using magnetic cards for individuals indicating active or sham stimulation. The primary endpoint was changes in the number of incontinence episodes/week, with secondary endpoints of the degree of incontinence (in g/day; determined using the pad test), the total score on the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), the ICIQ quality of life (QOL) score, and the abdominal leak point pressure (ALPP) on urodynamic study. RESULTS: Although 39 patients were enrolled in the study, 9 dropped out, leaving a total patients for analysis (18 in the active treatment group, 12 in the sham treatment group). The number of incontinence episodes/week, the degree of incontinence, total ICIQ-SF score, ICIQ-QOL score, and ALPP were significantly improved after active treatment compared with baseline (all P < .05), but did not change significantly after sham treatment. There was a significant intergroup difference with regard to changes from baseline in the ICIQ-SF and ALPP in favor of the active treatment group (P < .05). There were no significant differences in any other parameters between the 2 groups. Treatment-related adverse events were not found in both groups. CONCLUSION: Magnetic stimulation was effective in treating urodynamic stress incontinence.

Fibrosis and the bladder, implications for function ICI-RS 2017.

AIMS: Most benign bladder pathologies are associated with an increase of extracellular matrix (ECM-fibrosis) and may progress from formation of stiffer matrix to a more compliant structure. The aims were to summarize current knowledge of the origins of bladder fibrosis and consequences in bladder function. METHODS: A meeting at the International Consultation on Incontinence Research Society 2017 congress discussed the above aims and considered paradigms to reduce the extent of fibrosis. Discussants based their arguments on the basis of their own expertise, supplemented by review of the literature through PubMed. Proposals for future work were derived from the discussion. RESULTS: Altered urodynamic compliance when ECM deposition is increased is mirrored by changes in the elastic modulus of isolated tissue, whether compliance is decreased or increased. No changes to compliance or fibrosis have been reported after botulinum toxin injections. Several paracrine and autocrine agents increase ECM deposition, the role of TGF-ß was particularly emphasized. None of these agents has a net long-term effect on detrusor contractility and the reduction of contractile performance with increased ECM is due solely to a loss of detrusor mass. Several strategies to reduce fibrosis were described, ranging from potential therapeutic roles for vitamin-D or endostatin, manipulation of intracellular pathways that mediate myofibroblast differentiation and the potential role of the anti-fibrotic hormone relaxin. An understanding of epigenetic regulation of ECM deposition was also considered. CONCLUSIONS: The conclusion that reduced bladder contractile function with increased fibrosis is due largely to the replacement of detrusor with ECM offers a way forward for future research to consider approaches that will restore bladder function by reducing ECM deposition.

What is the exact working mechanism of botulinum toxin A and sacral nerve stimulation in the treatment of overactive bladder/detrusor overactivity? ICI-RS 2017.

AIMS: Botulinum toxin A (BTX-A) and sacral nerve stimulation (SNS) are established treatments for overactive bladder (OAB) and are standard of care in refractory cases in international guidelines. Despite long term use over decades their "exact" working mechanisms are not entirely clear. At the ICI-RS meeting in Bristol in 2017 a think tank was convened to address the question. METHODS: The think tank conducted a literature review and an expert consensus meeting focusing on current mechanisms and what could be learned from clinical experience and objective urodynamic data. RESULTS: BTX-A results suggests effects on both filling and voiding parts of the micturition cycle. The salient data in this regard is presented as well as additional studies related to the urothelium and evidence for central effects. Urodynamics have consistently shown increases in bladder capacity, compliance, and reductions in detrusor pressures during filling, however post void residuals also increase in a dose-dependent fashion. During SNS activation of somatic afferents inhibits bladder sensory pathways and reflex bladder hyperactivity. Evidence in cats suggest the inhibition of bladder activity occurs primarily in the CNS by inhibition of the ascending or descending pathways of the spinobulbospinal micturition reflex. Urodynamics have suggested improvement in bladder capacity and reduction in detrusor pressures during filling with little observed effects on voiding parameters. CONCLUSIONS: The working mechanism of BTX-A and SNS is complex. The exact mechanisms are still unknown, although considerable progress has been made in our understanding. Further research proposals are suggested to help further elucidate these mechanisms.