Uso y complicaciones del cateterismo urinario en salas de cuidados moderados de un hospital universitario

Introducción: El cateterismo urinario es un procedimiento frecuente y en ocasiones es utilizado por fuera de las indicaciones aceptadas para el mismo. Esto aumenta el riesgo de complicaciones vinculadas a su uso, por lo que pueden ser prevenibles. El objetivo del estudio es conocer las características del uso de cateterismo urinario en pacientes ingresados en salas de cuidados moderados de un hospital universitario del tercer nivel de atención, determinar la frecuencia, duración e indicaciones más frecuentes, así como evaluar la presencia de complicaciones asociadas al mismo Metodología: Estudio de corte transversal, realizado en salas de cuidados moderados de un hospital terciario y universitario de Montevideo, Uruguay, el 21 de diciembre de 2022. Se incluyeron pacientes hospitalizados que presentaban o presentaron catéter vesical en la presente internación y se completó la recolección de variables mediante la revisión de la historia clínica. Resultados: De 155 pacientes ingresados en salas de cuidados moderados, a 26 (16,7%) les fue colocado un catéter urinario. La mediana de edad fue 61 años, 80% eran de sexo masculino. La mediana de internación fue de 22 días. En todos los pacientes se utilizó sonda vesical y el 54% fue colocado en el Departamento de Emergencia. En el 46% de los pacientes no se encontró indicación escrita de colocación en la historia clínica. En 50% de los casos no está especificado el motivo de indicación de sonda vesical, mientras que las indicaciones identificadas más frecuentes fueron el control de diuresis (27%) y la desobstrucción de vía urinaria baja (23%). La duración de cateterismo fue de una mediana de 13,5 días, mientras que el 27% de los pacientes la usaron más de 30 días. 35% de los pacientes presentaron complicaciones vinculadas a la sonda vesical, en su mayoría no infecciosas (27%) y 15% presentaron infección urinaria. Estos pacientes tuvieron una duración de cateterismo mayor a los que no presentaron complicaciones (23 vs 10 días, p=0,411). Conclusiones: El catéter vesical fue utilizado en un porcentaje no despreciable de pacientes ingresados en salas de cuidados moderados, de forma prolongada y frecuentemente sin indicación precisa, lo cual expone a un riesgo aumentado de complicaciones vinculadas.

Introduction: Urinary catheterization is a frequent procedure and is sometimes used outside of its accepted indications. This increases the risk of complications related to its use, so they may be preventable. The objective of this study is to know the characteristics of the use of urinary catheterization in patients admitted to moderate care wards of a tertiary care university hospital, to determine the frequency, duration and most frequent indications, as well as to evaluate the presence of associated complications. Methodology: Cross-sectional study, carried out in moderate care wards of a tertiary care and university hospital in Montevideo, Uruguay, on December 21, 2022. Hospitalized patients who present or presented a bladder catheter during the present hospitalization were included, and the collection of variables was completed by reviewing the medical history. Results: Of 155 patients admitted to moderate care wards, 26 (16.7%) had a urinary catheter placed. The median age was 61 years, 80% were male. The median hospitalization was 22 days. In all patients a bladder catheter was used and 54% were placed in the Emergency Department. In 46% of the patients, no written indication for placement was found in the clinical history. In 50% of cases, the reason for indicating the bladder catheter is not specified, while the most frequent indications identified were diuresis control (27%) and lower urinary tract obstruction (23%). The duration of catheterization was a median of 13.5 days, while 27% of the patients used it for more than 30 days. 35% of the patients presented complications related to the bladder catheter, mostly non-infectious (27%) and 15% presented urinary tract infection. These patients had a longer duration of catheterization than those without complications (23 vs 10 days, p=0,411). Conclusions: The bladder catheter was used in a non-negligible percentage of patients admitted to moderate care wards, for a long time and often without a precise indication, which exposes them to an increased risk of related complications.

Introdução: O cateterismo urinário é um procedimento frequente e às vezes é usado fora de suas indicações aceitas. Isso aumenta o risco de complicações relacionadas ao seu uso, portanto, podem ser evitáveis. O objetivo deste estudo é conhecer as características do uso do cateterismo urinário em pacientes internados em enfermarias de cuidados moderados de um hospital universitário terciário, determinar a frequência, duração e indicações mais frequentes, bem como avaliar a presença de complicações associadas ao mesmo. Metodologia: Estudo transversal, realizado em quartos de cuidados moderados de um hospital terciário e universitário em Montevidéu, Uruguai, em 21 de dezembro de 2022. Foram incluídos pacientes que apresentaram ou apresentaram sonda vesical durante a internação atual e a coleta de variáveis ​​foi concluída .revisando o histórico médico. Resultados: Dos 155 pacientes admitidos em enfermarias de cuidados moderados, 26 (16,7%) tiveram um cateter urinário colocado. A idade média foi de 61 anos, 80% eram do sexo masculino. A mediana de internação foi de 22 dias. Em todos os doentes foi utilizada sonda vesical e 54% foram internados no Serviço de Urgência. Em 46% dos pacientes, nenhuma indicação escrita para colocação foi encontrada na história clínica. Em 50% dos casos não é especificado o motivo da indicação da sonda vesical, enquanto as indicações mais frequentes identificadas foram controle da diurese (27%) e desobstrução do trato urinário inferior (23%). A duração do cateterismo foi em média de 13,5 dias, enquanto 27% dos pacientes o utilizaram por mais de 30 dias. 35% dos pacientes apresentaram complicações relacionadas ao cateter vesical, em sua maioria não infecciosas (27%) e 15% apresentaram infecção urinária. Esses pacientes tiveram uma duração mais longa de cateterismo do que aqueles sem complicações (23 vs 10 dias, p=0,411). Conclusões: A sonda vesical foi utilizada em percentual não desprezível de pacientes internados em quartos de cuidados moderados, por tempo prolongado e muitas vezes sem indicação precisa, o que os expõe a um risco aumentado de complicações associadas.

Robotic surgery of the urothelial carcinoma of the upper urinary tract single surgeon initial experience, 66 consecutive cases.

PURPOSE: Robotic surgery is increasingly utilized in the treatment of urothelial carcinoma of the upper urinary tract (UTUC). This study investigates the advantages and burden of robot-assisted surgical treatment of the urothelial carcinoma of the upper urinary tract in a referral urological department, along with their functional and oncological results. METHODS: The study included 66 prospectively enrolled patients who were surgically treated by a single, robotically specialized surgeon between July 2019 and December 2023. Patients were divided into three groups. Group 1: 50 patients underwent robot-assisted radical Nephroureterectomy (RANU) with bladder cuff excision, Group 2: 11 patients underwent RANU simultaneously with robot-assisted radical cystectomy (RARC), and Group 3: 5 patients underwent robot-assisted segmental ureterectomy (RASU). Clinical and oncological parameters were compared. Perioperative morbidity according to Clavien-Dindo was the primary endpoint of our study. The secondary endpoint was oncologic outcomes. RESULTS: 37.8% of patients had locally advanced carcinomas. The average console time of RANU with bladder cuff excision was 69 min. The rate of positive surgical margins was n = 1/66 (2%). Lymphadenectomy (LAD) was performed on 30% of patients, with a mean of 13.7 lymph nodes removed. Of those who received LAD, 33% had lymph node metastasis. n = 6/66 (9%) patients received blood transfusion. The overall complication rate was 24%. The readmission rate was 7.5%. With a median follow-up of 26 months, the 2-year recurrence-free survival rate was 84.4%, and the 2-year overall survival rate was 94%. CONCLUSION: Robotic surgery is a feasible option for treating UTUC that can be adapted to meet the surgical needs of each patient. Prospective studies are warranted to confirm its benefits.

Effect of a Collaborative Medical-Nursing Catheter Removal Protocol on Incidence of Urinary Tract Infections in Urology Patients: A Retrospective Study.

OBJECTIVE: Urology patients are often placed with a catheter following surgery. Hence, a high-quality and appropriate management and removal programme can considerably reduce catheter-associated complications such as urinary tract infections and improve patient comfort. This retrospective study investigated the impact of a collaborative medical-nursing catheter removal protocol on reducing the incidence of urinary tract infections in urological surgery patients. METHODS: Patients who underwent partial nephrectomy at our hospital between January 2021 and December 2022 were enrolled and allocated to a control and an observation group based on the method of urinary catheter removal. A physician was solely responsible for monitoring, evaluating, and removing the catheter in the control group, whereas a physician and nurses performed these catheter management activities in the observation group. The two groups were compared in terms of urinary tract infections, urinary tract irritation and hematuria signs, pain levels, and catheter retention time. RESULTS: A total of 178 patients were included, among which 88 were divided into the control group and 90 into the observation group according to their corresponding urinary catheter removal method entered into the medical records system. The general characteristics of the two groups were similar (p > 0.05). However, the rates of urinary tract infections and urinary tract irritation and hematuria signs in the observation group were lower than those in the control group (1.11% vs. 9.09%, χ2 = 5.902, p = 0.037; 5.55% vs. 15.91%, χ2 = 4.159, p = 0.041, respectively). The observation group also exhibited lower levels of urinary pain within 1 h post-catheter removal and shorter total catheter retention time than the control group (t = 2.497, p = 0.013; t = 2.316, p = 0.022, respectively). CONCLUSIONS: Collaborative medical-nursing catheter removal protocols for patients undergoing partial nephrectomy may effectively alleviate urinary pain, decrease the incidence of urinary tract infections and irritation and hematuria signs, and shorten catheter retention time, underscoring the clinical significance of its implementation in this specific population.

Comparison of Short-Term Therapeutic Effects between Amoxicillin-Clavulanic Acid and Ceftriaxone Sodium on Febrile Urinary Tract Infections in Children under Five Years Old.

BACKGROUND: Febrile urinary tract infections in children are typically treated with a standard 10-day course of antibiotics. However, prolonged antibiotic use can lead to increased bacterial resistance, underscoring the need to explore shorter treatment regimens. This study aimed to compare the short-term therapeutic effects of amoxicillin-clavulanic acid and ceftriaxone sodium in children under five years old with febrile urinary tract infections. METHODS: Clinical data from 109 children under five years old diagnosed with febrile urinary tract infections between August 2022 and December 2023 were retrospectively analyzed. Among them, 52 children received ceftriaxone sodium (group A), and 48 children received amoxicillin-clavulanic acid (group B). Clinical symptoms, laboratory indicators, clinical efficacy, and adverse reactions were compared between the two groups. RESULTS: Children from group B showed significantly shorter improvement times for fever, dysuria, and urinary frequency compared to those in group A (p < 0.05). Initially, there were no significant differences in the levels of white blood cell counts, squamous epithelial cells, bacteria, interleukin-6, interleukin-8, and neutrophil gelatinase-associated lipocalin between the two groups (p > 0.05). However, after treatment, group B exhibited significantly lower levels of white blood cell counts, squamous epithelial cells, bacteria, interleukin-6, interleukin-8, and neutrophil gelatinase-associated lipocalin compared to group A (p < 0.05). Moreover, the total effective rate was significantly higher in group B (95.83%) than in group A (80.77%) (p < 0.05). There was no significant difference in the incidence of adverse reactions between groups B (10.42%) and A (13.45%) (p > 0.05). CONCLUSIONS: Amoxicillin-clavulanic acid demonstrated superior short-term therapeutic efficacy for febrile urinary tract infections in children under five years old compared to ceftriaxone sodium. It effectively reduced cure times, mitigated inflammatory responses, and improved treatment outcomes, suggesting its potential for broader clinical application and adoption.

Asymmetrical primary vesicoureteral reflux: Which is the best surgical strategy?

INTRODUCTION: No report has been published regarding the recommended surgical treatment in patients presenting with symptomatic primary asymmetrical vesicoureteral reflux (VUR): high grade on one side and low grade on the contralateral side. The aim of this study was to evaluate the effectiveness and outcome of combined Lich-Gregoir extravesical reimplantation and subureteric Deflux® injection, of high grade and low grade VUR respectively. Non-inferiority to bilateral cross-trigonal reimplantation was investigated in terms of surgical complications, number of post-operative fUTIs and need for re-intervention. PATIENTS AND METHODS: A monocentric retrospective study was undertaken of all consecutive children with primary asymmetrical VUR on MCUG treated over an 18-year period (2004-2022). Surgery was indicated following an episode of febrile urinary tract infection despite appropriate non-operative management. Demographic and clinical such as length of hospital stay for pain management, use of urinary Foley catheter and complications were analyzed. RESULTS: A total of 80 children met the study criteria: 40 patients underwent bilateral cross-trigonal re-implantation (Group 1) and 40 patients the combined Lich-Gregoir extra vesical reimplantation and Deflux® sub ureteric injection (Group 2). Complication and success rates were comparable in the two groups. The median hospital stay was significantly shorter for Group 2, with 50 % of patients who were discharged on day 1. Moreover, the data showed a significant lesser need in number and length of bladder catheter and ureteral stents in Group 2. DISCUSSION: The technique proposed overcome the inconveniences of the other procedures that are commonly used in bilateral RVU: difficulty in retrograde catheterization or ureteroscopy after bilateral cross-trigonal reimplantation, the risk of transient bladder dysfunction after bilateral extravesical reimplantation and the low rate of success for high grade reflux of the sub ureteric Deflux® injection. The main limitation of the study lies in its retrospective nature and in the relatively short median follow-up. CONCLUSION: The combined Lich-Gregoir extra-vesical ureteral reimplantation and sub-ureteric Deflux® injection for the treatment of primary asymmetrical VUR is an effective alternative to the gold standard cross-trigonal ureteral reimplantation. Moreover, the position of the ureteric orifice is not modified in the eventuality of endourological procedures into adulthood.

Agreement between two uroflowmetry tests in children with lower urinary tract symptoms.

BACKGROUND: Uroflowmetry is a non-invasive examination considered as a first-line assessment for children with lower urinary tract symptoms (LUTS). Currently, the performance of two uroflowmetry tests is recommended by ICCS for all patients with LUTS. This study aims to evaluate the differences between two uroflowmetry tests in children with lower urinary tract symptoms and their impact on the patient's diagnostic workup and clinical outcome. METHODS: Forty patients with LUTS, aged 4-17 years, were evaluated prospectively with two consecutive uroflowmetry tests and ultrasonography. They were classified based on the ICCS criteria for curve pattern and divided into two groups based on the SPU classification of fractionated (staccato and intermittent) and smooth (bell, tower and plateau). They were also separated into three groups based on estimated bladder capacity (voided volume + post-void residual on ultrasound): high (>115%), low (<60%) or normal capacity. RESULTS: The mean age was 8 (IQR 6.0-10.0) years and 25 (62.5%) patients were female. There was an increase in nonbell-shaped curves from the first (32.5%) to the second test (52.5%). The curve shape between the uroflowmetries based on ICCS classification showed a Kappa value of 0.349 (fair). Classifying curves as fractionated or smooth yielded a Kappa value of 0.714 (substantial) (table). The Bland-Altman test showed disagreement in the parameter of time to Qmax. There was a significant difference in categorizing bladder capacity as high, low, or normal: it was concordant in 63.6% for high, 68.4% for normal and 50% for low capacity (p = 0.001). DISCUSSION: Despite the disagreement found classifying the curves based on the ICCS pattern, also demonstrated in other studies, there was a substantial agreement using the SPU criteria. It reinforces the greater reliability of the SPU system and it may be the key to reduce the subjectivity of uroflowmetry. Even though this classification being associated with a higher agreement in interpretation of the curves, repeating uroflowmetry does not present a clinically significant divergence that changes the patient's diagnostic workup. Our study is limited by the lack of EMG and larger sample. CONCLUSION: Considering the flow curve pattern, the agreement between two uroflowmetries was substantial according to the SPU and only reasonable by the ICCS classification. Regardless of some differences found between the flows, a second uroflowmetry test might not have clinical relevance that justifies its recommendation for all patients.

Underactive bladder as defined by the International Continence Society in the 2023 Japan Community Health Survey.

OBJECTIVE: To investigate the characteristics of underactive bladder (UAB) in participants of the 2023 Japan Community Health Survey (JaCS 2023). METHODS: The JaCS 2023 was conducted among individuals aged 20-99 years old who had anonymously registered with a Japanese online research company. We divided the 6210 participants of JACS 2023 into UAB and non-UAB groups as defined by the International Continence Society Working Group (ICS-WG) and evaluated the prevalence of UAB as well as concomitant lower urinary tract symptoms. In addition, an association between UAB and vulnerability-related factors, namely participants' characteristics including frailty and comorbidities, was explored by univariable and multivariable analyses. RESULTS: The prevalence of UAB in Japanese community-dwelling men and women aged 20 years or older was 9.3% and 4.0% overall (p < 0.0001), respectively, and when excluding benign prostatic hyperplasia or pelvic organ prolapse, 7.0% and 3.7%, respectively, (p < 0.0001). A significant increase in the prevalence of UAB with age was observed (p < 0.0001). In addition, storage symptoms including overactive bladder were more frequent in the UAB group than the non-UAB group (p < 0.0001). Frailty and several comorbidities were independently associated with UAB. CONCLUSIONS: According to the definition proposed by the ICS-WG, the JaCS 2023 demonstrated that UAB was more prevalent in men than in women and increased in prevalence with age. Storage symptoms including overactive bladder sometimes coexisted with UAB. Vulnerability-related factors were associated with UAB.

From Awareness to Action: Pioneering Solutions for Women's UTI Challenges in the Era of Precision Medicine.

This article aims to bring clinicians' awareness to the widespread impact of urinary tract infection (UTI) on the lives of women and to the advances that offer hope for future improvements in the diagnosis and management of UTI. Thanks to physiological, anatomical, and lifestyle factor differences, women face heightened vulnerability to UTIs compared to men. In fact, women are four times more likely than men to develop a UTI and around half of these women encounter UTI recurrence, which is a significant source of both physical and psychosocial burdens. Despite the current shortcomings in diagnosis and management, emerging diagnostic technologies promise to identify UTIs more accurately and rapidly, offering women hope for a revolution in UTI management. Meanwhile, clinicians have the opportunity to reduce the psychosocial burden by recognizing the value of patients' lived experiences and ensuring their care plan is in alignment with their patients' goals and expectations for medical care.

Determination of the Frequency of BCL-2 Polymorphisms (c.-717C>A and c.*2364G>A) and LIF Polymorphism (c.*1414T>G) in Patients with Congenital Anomalies of the Kidney and Urinary Tract.

Introduction: Congenital anomalies of the kidney and urinary tract (CAKUT) are characterized by several malformations. Its prevalence is 0.3-0.6% in live births. The B-cell lymphoma (BCL-2) gene regulates apoptosis, and the Leukemia Inhibitory Factor (LIF) gene plays a role in many biological processes, such as blastocyst growth and uterine preparation for implantation. In this study, two single nucleotide polymorphisms (SNPs) of the BCL-2 gene (rs2279115 and rs4987856) and one SNP of the LIF gene (rs929271) were investigated in CAKUT patients for the first time. Methods: Hundred and twenty-nine CAKUT patients and 105 controls were enrolled in this study. We used polymerase chain reaction-restriction fragment length polymorphism for rs2279115 and rs929271 and SNaPshot for rs4987856. The χ2 test was used to compare discrete variables, and the independent sample t test was used to compare continuous variables. Results: The allele frequencies for the rs2279115 and rs4987856 polymorphisms of BCL-2 and the rs929271 polymorphism of LIF were not significantly different between the patient and control groups (p = 0.162, p = 0.053, p = 0.635, respectively). However, the co-segregation analysis revealed a significant difference in the distribution of allele frequencies between the patient and control groups for two genetic variations: LIF rs929271 SNP and BCL-2 rs4987856 SNP (p = 0.034). The relative odds ratio was 2.444 (95% Confidence Interval (CI) 1.054-5.671). Conclusion: This study, which is the first time in the literature, showed that changes in BCL-2 and LIF genes are associated with CAKUT disease.

Female sexual dysfunctions in multiple sclerosis patients with lower urinary tract symptoms: an Italian case-control study.

Background: Multiple sclerosis (MS) is a recurrent, autoimmune, and inflammatory demyelinating chronic disease that typically manifests in young adulthood and exerts adverse effects on sexual functions. Aim: The study evaluated the prevalence of sexual dysfunctions (SDs) and the relationship with neurological disability, depression, and lower urinary tract symptoms (LUTS) in a cohort of MS female patients, comparing these results with those of healthy women. Methods: From January 2023 to January 2024, consecutive premenopausal female patients with MS, were recruited and the examination included urinalysis, ultrasonography and a urodynamic test according to the International Continence Society standard. Outcomes: Descriptive statistics were reported as mean and standard deviation for continuous variables (analyzed by independent samples Mann-Whitney U test and independent samples Kruskal-Wallis test) while categorical variables were reported as frequency and percentage (analyzed by chi-square test with Fisher's exact test). Results: Female Sexual Function Index (FSFI) total score and all FSFI subscales scores were significantly lower in patients with MS vs healthy control subjects (P < .001); FSFI total scores and all FSFI subscale scores were statistically significantly lower in patients with MS with an International Prostate Symptom Score ≥20 (P < .001) and considering a cutoff for Beck Depression Inventory-II score ≥17, depression was present in 61% (n = 47 of 77) of patients with MS and completely absent in the control group. Clinical Translation: The knowledge that SDs are a common problem in MS and in other chronic illnesses can alleviate the feeling of stigma and talking openly of sexual problems can be helpful for the patients and so the doctor-patient relationship can be reinforced. Strengths and Limitations: The sample was drawn from a single center, and larger multicenter studies that include both genders are needed to obtain strong results. Conclusion: Our findings confirm the idea of a polygenic and multifactorial etiology of female SDs in MS. Therefore, women with MS should be evaluated in terms of SDs during follow-ups.

Clinical features and sequelae of detrusor underactivity: a study of possible cause and effect.

PURPOSE: To describe the clinical presentation and urodynamic findings in detrusor underactivity (DU) patients and investigate the association between DU and straining related complications such as pelvic organ prolapse (POP), inguinal hernia, and hemorrhoids. METHODS: We retrospectively reviewed all consecutive patients who underwent urodynamic studies (UDS) from 2012 to 2023, divided into two groups: those with evidence of DU (n = 573), and control subjects with normal voiding parameters (n = 522). Exclusion criteria were patients who lacked sufficient data, those with obstructive voiding parameters, and those who had received intravesical botulinum toxin injections within the previous nine months. Demographic information, clinical presentation, straining related complications, and UDS findings were compared between the two groups using univariate statistical analysis. RESULTS: The male DU group had a statistically significant higher prevalence of spinal disease and previous cerebrovascular accidents, while the female DU group had a statistically significant higher prevalence of spinal disease, multiple sclerosis, diabetes, previous colorectal surgery, previous transabdominal gynecological surgery, POP surgery, and recurrent UTIs. Female DU patients had a higher prevalence of pronounced vaginal bulging symptoms, recurrent POP, inguinal hernia, and hemorrhoids. The predominant LUTS were voiding symptoms (81.2% in males and 77.9% in females), followed closely by storage symptoms (66.2% in males and 74.7% in females). The median Qmax, PdetQmax, and PVR were 6 ml/sec, 18 cmH2O, 190 ml for male DU patients, and 8 ml/sec, 11 cmH2O, and 200 ml for female DU patients, respectively. CONCLUSION: Risk factors for DU that were identified include age, neurological diseases (spinal disease, CVA in men, MS in women), diabetes and transabdominal surgery (colorectal, gynecological) that can cause pelvic denervation in women. DU patients commonly present with both voiding and storage symptoms. There is approximately twice the risk of having POP surgery and inguinal hernia, an eight-fold risk of hemorrhoids, and a three-fold risk of recurrent UTIs for females. This is thought to be secondary to increased intra-abdominal pressure during urinary straining.

Is it Possible to Regenerate the Underactive Detrusor? Part 2 Electrical Stimulation Therapies, Treatment of Bladder Outlet Obstruction, Constipation, and Pelvic Floor Disorders ICI-RS 2024.

INTRODUCTION: Detrusor muscle weakness is commonly noted on urodynamics in patients with refractory voiding difficulty. No clinical therapy has been proven to augment the strength of a detrusor contraction. METHODS: This subject was discussed at a think-tank at the International Consultation on Incontinence-Research Society (ICI-RS) held in Bristol, June 2024. The discussions of the think-tank are being published in two parts. This second part discusses the role of electrical stimulation therapies, treatment of bladder outlet obstruction, constipation, and pelvic floor disorders, in the enhancement of strength of a detrusor contraction. RESULTS: Electrical stimulation therapies, specifically sacral neuromodulation, have long been used in the salvage of patients with refractory nonobstructive voiding dysfunction. Clinical improvements can be noted in men following bladder outlet resistance reduction surgery especially, though not limited to those with demonstrable obstruction. Some patients may also show improvement with pelvic floor relaxation therapies and constipation care. However, there is a lack of high-quality urodynamic data to demonstrate an improvement in the strength of a detrusor contraction with these therapies. The think-tank recommends standards for future clinical studies examining treatments aimed at improving an underactive detrusor. CONCLUSIONS: Studies need to examine whether clinical improvement following treatment of patients with an underactive detrusor is associated with improvement in strength of the detrusor contraction. New therapeutic options should apply specified standards for assessing and reporting the impact on detrusor contraction.

Phenotyping Men With Lower Urinary Tract Symptoms: Results From the Symptoms of Lower Urinary Tract Dysfunction Research Network.

AIMS: Men with lower urinary tract symptoms (LUTS) represent a heterogeneous group, and treatment decisions are often based on severity of symptoms and physical examination findings. Identification of clinically meaningful subtypes could allow for more personalized care. This study advances phenotyping efforts from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) by adding data domains to previous phenotyping using urologic symptoms alone. METHODS: Two-hundred-seventeen LUTS, demographics, medical history, and physical examination datapoints from the LURN Observational Cohort study were assessed among 519 men with at least one bothersome LUTS, using weighted Tanimoto indices, semi-supervised learning, and resampling-based consensus clustering to identify distinct clusters of participants. Differentially abundant serum proteins of 220 men were compared across identified clusters. RESULTS: Five refined male clusters (RM1-RM5) were identified. Two clusters reported mild LUTS (RM1: n = 66; RM2: n = 84). RM1 was older than RM2 (70.3 vs. 56.1 years), had more comorbidities (functional comorbidity index 2.4 vs. 1.5) and erectile dysfunction. Two benign prostatic hyperplasia-like symptom clusters were identified (RM3: n = 64; RM4: n = 188). RM3 has the largest postvoid residual volume (275 mL); RM4 reported more urinary frequency, urgency, urinary incontinence, pain, and psychosocial symptoms. RM5 (n = 119) was characterized by urgency urinary incontinence, frequency, and significant comorbidities and psychosocial symptoms. Fifteen (RM2) to 87 (RM1) differentially abundant proteins were identified within each cluster. Minimal overlap was observed between affected proteins and pathways across clusters. CONCLUSIONS: Protein signatures across newly discovered subgroups suggest identified subtypes are biochemically distinct. Findings should be validated, but may represent populations with separate pathophysiology and therapeutic needs. CLINICAL TRIAL REGISTRATION: The LURN ClinicalTrials.gov Identifier is NCT02485808.

Investigating urinary characteristics and optimal urine white blood cell threshold in paediatric urinary tract infection: A prospective observational study.

Introduction: While the definitive diagnosis of urinary tract infection (UTI) requires a positive urine culture, the likelihood of UTI can be determined by urinalysis that includes white blood cell (WBC) count. We aimed to determine the optimal urine WBC threshold in urinalysis to predict UTIs in children presenting at the emergency department (ED). Method: We performed a prospective observational study in the ED at KK Women's and Children's Hospital for children below 18 years old who underwent both urine microscopy and urine cultures, between 10 January and 7 November 2022. We assessed the various urine WBC thresholds associated with culture-proven UTIs using sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and area under receiver operating characteristic curve. Results: We found a culture-proven UTI rate of 460/1188 (38.7%) among all patients analysed, and 278/998 (27.9%) among those with nitrite-negative urine samples. Among all patients, a urinalysis WBC threshold of 100/µL had a sensitivity of 82.2% (95% confidence interval [CI] 78.4-85.5) and negative predictive value of 86.2% (95% CI 83.6-88.4). Among those who were nitrite-negative, a WBC threshold of ≥100/µL resulted in a potential missed rate of 48/278 (17.3%). By lowering the WBC threshold to ≥10/µL, the potential missed cases reduced to 6/278 (2.2%), with an estimated increase in 419 urine cultures annually. Conclusion: A urine microscopy WBC threshold of ≥100/µL results in a clinically significant number of missed UTIs. Implementation of various thresholds should consider both the potential missed UTI rate and the required resource utilisation.

Bidirectional relationships between depression, anxiety and urinary symptoms in women: A prospective cohort study.

OBJECTIVES: To examine (i) if depression and anxiety are prospectively associated with subsequent lower urinary tract symptoms (LUTS) and (ii) if LUTS are prospectively associated with subsequent depression. PARTICIPANTS AND METHODS: The study is based on data from parous middle-aged women from the Avon Longitudinal Study of Parents and Children. LUTS were assessed using the Bristol Female LUTS Questionnaire and the International Consultation on Incontinence Questionnaire on Female LUTS. Depression was assessed using the Edinburgh Postnatal Depression Scale and anxiety was assessed using the Crown Crisp Experiential Index. We used multivariable logistic regression to examine (i) associations between depression and anxiety at baseline in 2002-04 and subsequent LUTS at follow-up in 2011-2012 (n = 5291) and (ii) associations between LUTS at baseline in 2002-04 and subsequent depression at follow-up in 2010-11 (n = 6147). Analyses were adjusted for age, socioeconomic factors, stressful life events, social support, smoking, weekly alcohol consumption, BMI, physical activity, obstetric/reproductive factors, and menopausal status. RESULTS: We found evidence of prospective associations between depression and subsequent mixed urinary incontinence [odds ratio = 1.97, 95 % confidence interval = 1.16, 3.33], any urinary incontinence [1.68 (1.21, 2.31)], and urgency [1.90 (1.28, 2.83)]. Anxiety was only associated with subsequent nocturia [1.84 (1.04, 3.26)]. Only stress urinary incontinence was associated with subsequent depression [1.37 (1.03, 1.83)]. CONCLUSIONS: We find evidence that mental health problems could be contributing factors, as well as consequences, of LUTS. Research is needed to determine if these observed associations are causal and to identify underlying mechanisms.

Bladder irrigation with tap water to reduce antibiotic use for urinary tract infections in catheter users.

OBJECTIVE: To evaluate the safety and effectiveness of bladder irrigation (BI) with tap water to reduce antibiotic use for the treatment of urinary tract infections (UTIs) in patients with recurrent UTI symptoms and to assess the treatment satisfaction of BI. PATIENTS AND METHODS: This prospective, observational study included patients with an indwelling catheter or performing clean intermittent catheterisation (CIC) who had recurrent UTI symptoms between July 2022 and March 2024. BI with tap water was used for the treatment of UTIs without systemic symptoms (e.g., fever, flank pain or delirium). Patients started daily irrigation at the onset of UTI symptoms and used a tapering schedule. The number of antibiotic treatments for UTIs, UTI incidence rate ratio (IRR), UTI-related hospitalisations, treatment satisfaction and quality of life (QoL) were compared between a 3-month period before and after BI with tap water. RESULTS: A total of 60 patients were included with a median (interquartile range) age of 64.5 (50.4-72.6) years, 66.7% were male, and 83.3% were performing CIC. Antibiotic use was decreased on average by 38.1% (IRR = 0.62; P = 0.016) and catheter-associated UTIs by 37.9% (IRR = 0.62; P = 0.005). No increase was observed in the incidence of UTIs with systemic symptoms or UTI-related hospitalisations. In addition, no differences were observed in the health-related QoL. The majority of patients were positive about the subjective effectiveness (81%), ease of use (86%) and overall satisfaction (85%) of BI with tap water. CONCLUSION: These findings emphasise the potential of BI with tap water as a promising and patient-friendly alternative for the treatment of UTIs in patients with urinary catheters. BI with tap water significantly reduces antibiotic use and UTI incidence in patients with recurrent UTIs and is a safe and patient-friendly alternative that can be easily implemented in the management of UTIs.

Macroscopic hematuria-associated severe acute kidney injury triggered by kidney stone formation in a patient with thin basement membrane and no history of microscopic hematuria.

Macroscopic hematuria (MH)-associated acute kidney injury (AKI) is a rare condition that causes acute tubular damage due to severe glomerular bleeding with MH. A 66-year-old Japanese woman with no significant past medical history was referred for severe kidney injury with oliguric MH. Her prior medical checkup results showed no occult blood in her urine. Seven days earlier, she had experienced transient severe acute right lumbar back pain. On admission, her serum urea nitrogen was 147 mg/dL, serum creatinine (sCr) 18.3 mg/dL, urinary red blood cells (RBCs) > 100/hpf, urinary protein 28.8 g/gCr, with no hydronephrosis in either kidney, but two stones were found in the right kidney and right ureteropelvic junction. At the start of her hemodialysis, the patient was treated with high-dose steroids because of suspected rapidly progressive glomerulonephritis. A renal biopsy of the left kidney showed acute tubular injury with massive RBC casts filling the tubular lumen. Glomerulitis was not detected, but electron microscopy revealed diffuse glomerular thin basement membrane (TBM). Despite immediate steroid discontinuation, the patient's renal function and MH improved, and she was weaned from hemodialysis. The stones resolved 2 months after onset, but microscopic hematuria persisted for 7 months post-onset. The sCr level was fixed at 1.1 mg/dL 20 months post-onset. This is the first report of MH-AKI in a TBM without the risk of MH-AKI development, such as bleeding tendency or iron overload. In this TBM, a colic attack of the renal urinary tract induced glomerular bleeding, and intolerance to hematuria may have caused severe tubular damage.

Anterior deflected urinary stream in female children: description of a unique clinical entity and surgical management.

Objectives: To investigate the clinical presentation and outcomes for a series of female pediatric patients with severe anterior deflection of the urinary stream (ADUS) who were managed via urethromeatoplasty. Methods: This single institution retrospective cohort study used the institutional billing database to identify female patients ≤18 years who received a urethromeatoplasty (CPT 53450) from 2007 to 2022. Patients were included if a substantial anterior deflection of their urinary stream was the primary indication for surgery. Patients were excluded if they were >18 years of age, had a history of prior genital trauma, or underwent surgery for an indication other than a deflected urinary stream. Results: Twenty female patients underwent urethromeatoplasty between 2007 and 2022, with a median age of 3 years old. All patients presented with difficulty aiming the urinary stream during toilet training and demonstrated a web of tissue along the posterior aspect of the urethral orifice. 19/20 patients noted immediate response (i.e., normal, non-deflected urinary stream) after the urethromeatoplasty with no further urinary complaints. There were no post-operative complications within a 90-day period. Conclusions: ADUS is a clinical entity characterized by a web of deflecting tissue at the female posterior urethral meatus that causes severe urinary deflection without other urologic symptoms. This is not well-described in the literature. Surgical correction via urethromeatoplasty is safe and effective.

Acute kidney injury induced lithium toxicity with concomitant neuroleptic malignant syndrome.

Lithium, despite being an indispensable agent in the treatment of psychiatric disorders, has a narrow therapeutic index and needs to be carefully administered. Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication due to central dopaminergic blockade. This case report illustrates the challenges in lithium therapy particularly related to the development of NMS when further risk factors such as polypharmacy and dehydration are present. We report a case of a 50-year-old man with underlying bipolar affective disorder who was previously able to tolerate olanzapine and lithium well, however developed chronic lithium toxicity due to diminished lithium elimination in acute kidney injury following a two-week history of viral acute gastroenteritis. He also developed NMS which could either be triggered independently by olanzapine; lithium toxicity; or attributed by a synergistic combination from lithium and olanzapine which led to an enhanced neurotoxicity in an already unstable dopaminergic pathway. Fluid therapy and supportive care allowed the patient to recover, and he was discharged well with a lower potency neuroleptic with slow dose titration.

Overcoming challenges in the management of recurrent urinary tract infections.

INTRODUCTION: Urinary tract infection (UTI) is a major global health concern. While acute UTIs can usually be effectively treated, recurrent UTIs (rUTIs) impact patients for years, causing significant morbidity and can become refractory to front-line antibiotics. AREAS COVERED: This review discusses the risk factors associated with rUTI, current rUTI treatment paradigms, prophylactic strategies, and challenges in rUTI diagnostics. We specifically discuss common risk factors for rUTI, including biological sex, age, menopause status, and diabetes mellitus. We also review recently available evidence for commonly used treatments, from oral antibiotic therapy to intravesical antimicrobials, electrofulguration of chronic cystitis, and the last-resort treatment, cystectomy. We discuss the most current literature evaluating prophylactic strategies for rUTI including long-term antibiotic prophylaxis, estrogen hormone therapy, and dietary supplements. Finally, we address the important role of UTI diagnostics in effective rUTI management and review the strengths and limitations of both current and emerging UTI diagnostic platforms as well as their ability to operate at point-of-care. EXPERT OPINION: We discuss the current challenges faced by clinicians in managing rUTI in women and the steps that should be taken so that clinicians, scientists, and patients can work together to better understand the disease and develop better strategies for its management.