[POSITION STATEMENT ON OVERACTIVE BLADDER].

INTRODUCTION: Bothersome urinary symptoms during the storage phase are common among women and men. These symptoms described as urinary urgency, frequency and nocturia with or without urge urinary incontinence may be caused by various pathologies including bladder overactivity. Diagnosis of an overactive bladder is based on the patient's clinical presentation after exclusion of other disorders that may cause these symptoms. The minimal requirements for a urological evaluation include medical history, physical examination and urinalysis. Behavioral therapies and medical therapy are the mainstay of treatment for an overactive bladder. While the use of minimally invasive procedures are reserved for patients not interested in medications or for those patients in whom symptoms were not improved by other therapies. Treatment outcome is evaluated by documentation of changes in symptoms, signs and quality of life. This position statement paper represents the approach of the Israeli Urological Association regarding the evaluation and treatment of overactive bladder syndrome.

Low-dose oral desmopressin for treatment of nocturia and nocturnal enuresis in patients after radical cystectomy and orthotopic urinary diversion.

OBJECTIVES: To assess the effect of oral desmopressin on nocturia and nocturnal enuresis in patients after orthotopic neobladder reconstruction. PATIENTS AND METHODS: Of 55 patients who underwent radical cystectomy and orthotopic neobladder reconstruction at our medical centre in the period 2004-2011, 34 patients were deemed eligible for the present study. Inclusion criteria were estimated glomerular filtration rate >50 mL/min/1.73 m(2) , normal baseline sodium serum level, intact daytime urinary continence, and any degree of nocturia or nocturnal enuresis. Patients were treated daily with oral desmopressin 0.1 mg at bedtime for 30 days and completed the Nocturia, Nocturnal Enuresis and Sleep Interruption Questionnaire at trial enrollment and closure. Sodium serum levels were monitored throughout. RESULTS: Three patients withdrew from the trial because of headaches or anxiety. The mean (sd) number of nocturnal voids decreased from 2.5 (1.4)/night at baseline to 1.5 (1.3)/night at trial closure (P = 0.015). The number of patients with one or no episodes of nocturnal enuresis per week increased from six to 12 (19 to 39%; P = 0.065). Thirteen patients (42%) reported an increase of a minimum 1-2 h of sleep until the first nocturnal void; all of them asked to continue the drug. No significant adverse events or changes in sodium level were observed. CONCLUSIONS: Bedtime treatment with low-dose oral desmopressin appears to decrease episodes of nocturia and nocturnal enuresis effectively and safely in ∼50% of the patients with neobladder, allowing longer undisrupted sleep time and improved quality of life. Further investigation is warranted to determine if higher doses would result in a more meaningful clinical response.

PSA levels of 4.0 - 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy.

PURPOSE: The management of mildly elevated (4.0-10.0 ng/ml) prostate specific antigen (PSA) is uncertain. Immediate prostate biopsy, antibiotic treatment, or short term monitoring PSA level for 1-3 months is still in controversy. MATERIALS AND METHODS: We conducted a retrospective chart review of patients in a large community practice (2003 - 2007) who had PSA levels between 4.0-10 ng/mL without any further evidence of infection. Data was gathered regarding patient's age, whether standard antibiotic therapy (10-14 days of ofloxacin or ciprofloxacin) had been administered before the second PSA measurement, results of a second PSA test performed at 1- to 2-month intervals, whether a prostate biopsy was performed and its result. RESULTS: One-hundred and thirty-five men met the study inclusion criteria with 65 (48.1%) having received antibiotics (group 1); the PSA levels decreased in 39 (60%) of which, sixteen underwent a biopsy which demonstrated prostate cancer in 4 (25%). Twenty-six (40%) patients of group 1 exhibited no decrease in PSA levels; seventeen of them underwent a biopsy that demonstrated cancer in 2 (12%). The other 70 (51.9%) patients were not treated with antibiotics (group 2); the PSA levels decreased in 42 (60%) of which, thirteen underwent a biopsy which demonstrated prostate cancer in 4 (31%). In the other 28 (40%) patients of group 2 there was no demonstrated decrease in PSA, nineteen of these subjects underwent a biopsy that demonstrated cancer in 8 (42%). CONCLUSIONS: There appears to be no advantage for administration of antibacterial therapy with initial PSA levels between 4-10 ng/mL without overt evidence of inflammation.

A mathematical model of penile vascular dysfunction and its application to a new diagnostic technique.

A noninvasive diagnostic device was developed to assess the vascular origin and severity of penile dysfunction. It was designed and studied using both a mathematical model of penile hemodynamics and preliminary experiments on healthy young volunteers. The device is based on the application of an external pressure (or vacuum) perturbation to the penis following the induction of erection. The rate of volume change while the penis returns to its natural condition is measured using a noninvasive system that includes a volume measurement mechanism that has very low friction, thereby not affecting the measured system. The rate of volume change (net flow) is obtained and analyzed. Simulations using a mathematical model show that the device is capable of differentiating between arterial insufficiency and venous leak and indicate the severity of each. In preliminary measurements on young healthy volunteers, the feasibility of the measurement has been demonstrated. More studies are required to confirm the diagnostic value of the measurements.

Continence and quality of life assessment after artificial urinary sphincter implantation.

BACKGROUND: Sphincter-related incontinence after radical prostatectomy, benign prostatectomy or due to neurogenic disease has a considerable negative impact on quality of life. Artificial urinary sphincter implantation is a mainstay therapeutic option for these patients. OBJECTIVES: To assess patient satisfaction, subjective long-term continence and complications after AMS 800 artificial urinary sphincter implantation. METHODS: The medical records of 34 patients who underwent artificial urinary sphincter implantation for radical prostatectomy (n = 23), simple prostatectomy (n = 9) or neurogenic disease (n = 2) between 1995 and 2003 were studied retrospectively. Median follow-up was 49 months (range 3-102 months). Records were analyzed for urinary sphincter survival and complications. Quality of life and continence assessment was done by mailing an impact questionnaire. RESULTS: In 4 of the 34 patients (11.7%) the device was removed due to infection. One of the four had surgical revision elsewhere, and the other three were not interested in re-implantation of the device. Two patients (5.9%) underwent revisions due to mechanical failure. One patient died and three patients were not located. Twenty-seven out of a possible 30 patients (88%) completed the questionnaire; 22 (85%) achieved social continence (0-2 pads daily), and one patient had subjective difficulty activating the device. Subjective improvement and patient satisfaction was rated as 4.22 and 4.11, respectively (scale 0 to 5). CONCLUSIONS: Artificial urinary sphincter implantation is an efficacious option for sphincter-related incontinence. This study documents the positive impact of artificial urinary sphincter implantation on quality of life with acceptable complications; these results are comparable to other published studies.

Erection mechanism of the penis: a model based analysis.

PURPOSE: We examined and elucidated the physical mechanism of penile erection in normal and pathological conditions of vascular origin. MATERIALS AND METHODS: A nonlinear lumped parameter mathematical model of penile hemodynamics was developed based on physical structure and physiological function. The model was applied to simulate the normal erectile mechanism and the pathological conditions of arterial insufficiency and venous leakage. RESULTS: The model showed physiological behavior and suggested explanations for the relationships of corporeal pressure and venous flow limitation during erection. Other results related the reduction in rigidity and tumescence to the type and severity of vascular impairment. CONCLUSIONS: This model can be used in future studies of the diagnosis of erectile dysfunction.

Urinary incontinence in women under 65: quality of life, stress related to incontinence and patterns of seeking health care.

OBJECTIVE: We sought to describe quality of life, psychological stress and patterns of seeking health care (PSHC) among young and middle-aged women experiencing urinary stress incontinence (USI). Reasons and variables associated with delay in seeking care were also investigated. METHODS: A sample of 131 patients, aged 22-65, filled out a questionnaire consisted of: SF-36, stress related to incontinence, patterns of seeking health care questionnaires and a 10 cm visual analogue scale (VAS) measuring perceived suffering from USI (0 indicating absence of suffering while 10 indicating most severe suffering). RESULTS: Scores on eight domains of SF-36 were lower, compared to 405 Israeli healthy women (p < 0.001). Forty-one percent reported impairment in performing work and other activities. Mean scores on the VAS was 5.04 (SD: 2.59), 30% marked 7 cm and higher and 12.6% reported most severe suffering due to USI (scored 10 cm). Psychological stress related to incontinence was higher among the younger women and those with severe impairment to sexual activity. The majority of the sample (74%) delayed seeking help for at least a year, 46% delayed it for 3 years. Common reasons for delay were lack of time (36.3%), shame (15.7%) and fear of surgery (14.7%). Age, psychological stress, perceived suffering and social functioning (SF) were associated with patterns of seeking care. CONCLUSIONS: USI causes suffering and impaired quality of life among young women. Reluctance to seek help highlights the need to promote women's knowledge of treatment options and cure prospects.

PSA levels of 4.0 - 10 ng/ml and negative digital rectal examination: antibiotic therapy versus immediate prostate biopsy

Purpose: The management of mildly elevated (4.0-10.0 ng/ml) prostate specific antigen (PSA) is uncertain. Immediate prostate biopsy, antibiotic treatment, or short term monitoring PSA level for 1-3 months is still in controversy. Material and Methods: We conducted a retrospective chart review of patients in a large community practice (2003 - 2007) who had PSA levels between 4.0-10 ng/mL without any further evidence of infection. Data was gathered regarding patient's age, whether standard antibiotic therapy (10-14 days of ofloxacin or ciprofloxacin) had been administered before the second PSA measurement, results of a second PSA test performed at 1- to 2-month intervals, whether a prostate biopsy was performed and its result. Results: One-hundred and thirty-five men met the study inclusion criteria with 65 (48.1 percent) having received antibiotics (group 1); the PSA levels decreased in 39 (60 percent) of which, sixteen underwent a biopsy which demonstrated prostate cancer in 4 (25 percent). Twenty-six (40 percent) patients of group 1 exhibited no decrease in PSA levels; seventeen of them underwent a biopsy that demonstrated cancer in 2 (12 percent). The other 70 (51.9 percent) patients were not treated with antibiotics (group 2); the PSA levels decreased in 42 (60 percent) of which, thirteen underwent a biopsy which demonstrated prostate cancer in 4 (31 percent). In the other 28 (40 percent) patients of group 2 there was no demonstrated decrease in PSA, nineteen of these subjects underwent a biopsy that demonstrated cancer in 8 (42 percent). Conclusions: There appears to be no advantage for administration of antibacterial therapy with initial PSA levels between 4-10 ng/mL without overt evidence of inflammation.

Medical treatment for urinary retention in rehabilitating elderly women: is it necessary?

BACKGROUND AND AIMS: It is unclear whether medical treatment of elderly women with acute urinary retention in geriatric rehabilitation centers affects the recovery rate. The aims of the present study were to assess the rate of spontaneous recovery from urinary retention in elderly women in rehabilitation centers and to determine whether medical treatment with a adrenergic receptor blockers (a blockers) is effective in resumption of urination in this population. METHODS: We surveyed 84 elderly women with urinary retention, admitted to a geriatric rehabilitation center between September 1998 and March 2000. Most had undergone orthopedic surgeries. Post-voiding urine residual (PVR) was measured 3 days after an acute episode of urinary retention. PVR of 250 mL and below was the desirable outcome. Patients with PVR over 250 mL were randomly assigned to two groups, placebo vs Doxazosin. Medication doses in both groups were increased every 3 days and catheterization was used until a desirable outcome was achieved. RESULTS: Seventy-eight out of the 84 patients entered the study, of whom 48 (62%) recovered spontaneously prior to initiation of medical treatment. Of the remaining 30, 7 patients dropped out and 23 began medical treatment. Twelve women recovered (a similar rate occurred in the placebo and Doxazosin groups), and 11 did not. The study was terminated due to the high rate of spontaneous recovery and because it became clear from the initial results that Doxazosin had no beneficial effect over placebo in the treatment of urinary retention. Diabetes and poor functional status were found to be prognostic factors for recovery failure. CONCLUSIONS: Most elderly women with urinary retention in geriatric rehabilitation centers will probably recover spontaneously. Alpha blockers appear to have no beneficial effect in this population.