Antibiotic prophylaxis in invasive urodynamics, a Delphi consensus of the Italian Society of Urodynamics (SIUD).

INTRODUCTION: Although antibiotic prophylaxis (AB) demonstrated a statistically significant reduction in bacteriuria after invasive urodynamics (UDS), no significant decrease in the incidence of urinary tract infections (UTI) has been confirmed. No absolute recommendations on the use of AB in case of relevant potential risk of UTI have been reported, though some categories of patients at increased infective probability after UDS have been recognized. The aim of this study is to report the experts' consensus on the best practice for the use of AB before UDS in the main categories of patients at potential risk of developing UTI. MATERIALS AND METHODS: A systematic literature review was performed on AB before UDS in males and females. A panel of experts from the Italian Society of Urodynamics, Continence, Neuro-Urology, and Pelvic Floor (SIUD) assessed the review data and decided by a modified Delphi method on 16 statements proposed and discussed by the panel. The cut-off percentage for the consensus was a ≥70% of positive responses to the survey. The study was a Delphi consensus with experts' opinions, not a clinical trial involving directly patients. RESULTS: The panel group was composed of 57 experts in functional urology and UDS, mainly urologists, likewise gynaecologists, physiatrists, infectivologists, pediatric urologists, and nurses. A positive consensus was achieved on 9/16 (56.25%) of the statements, especially on the need for performing AB before UD in patients with neurogenic bladder and immunosuppression. Urine analysis and urine culture before UDS are mandatory, and in the event of their positivity, UDS should be postponed. A consensus was reached on avoiding AB in menopausal status, diabetes, age, gender, bladder outlet obstruction, high postvoid residual, chronic catheterization, previous urological surgery, lack of urological abnormalities, pelvic organ prolapse, and negative urine analysis. CONCLUSIONS: Antibiotic prophylaxis is not recommended for patients without notable risk factors and with a negative urine test due to the potential morbidities that may result from antibiotic administration. However, AB can be used for risk categories such as neurogenic bladder and immunosuppression. The evaluation of urine analysis and urine culture and postponing UDS in cases of positive tests were considered good practices, as well as performing AB in the neurogenic bladder and immunosuppression.

Swine Pudendal Nerve as a Model for Neuromodulation Studies to Restore Lower Urinary Tract Dysfunction.

Lower urinary tract dysfunction, such as incontinence or urinary retention, is one of the leading consequences of neurological diseases. This significantly impacts the quality of life for those affected, with implications extending not only to humans but also to clinical veterinary care. Having motor and sensory fibers, the pudendal nerve is an optimal candidate for neuromodulation therapies using bidirectional intraneural prostheses, paving the way towards the restoration of a more physiological urination cycle: bladder state can be detected from recorded neural signals, then an electrical current can be injected to the nerve based on the real-time need of the bladder. To develop such prostheses and investigate this novel approach, animal studies are still required since the morphology of the target nerve is fundamental to optimizing the prosthesis design. This study aims to describe the porcine pudendal nerve as a model for neuromodulation studies aiming at restoring lower urinary tract dysfunction. Five male farm pigs were involved in the study. First, a surgical procedure to access the porcine pudendal nerve without muscle resection was developed. Then, an intraneural interface was implanted to confirm the presence of fibers innervating the external urethral sphincter by measuring its electromyographic activity. Finally, the morphophysiology of the porcine pudendal nerve at the level of surgical exposure was described by using histological and immunohistochemical characterization. This analysis confirmed the fasciculate nature of the nerve and the presence of mixed fibers with a spatial and functional organization. These achievements pave the way for further pudendal neuromodulation studies by using a clinically relevant animal model with the potential for translating the findings into clinical applications.

bTUNED: transcutaneous tibial nerve stimulation for neurogenic lower urinary tract dysfunction.

OBJECTIVE: To present the protocol for a randomized controlled trial (RCT) evaluating the efficacy and safety of transcutaneous tibial nerve stimulation (TTNS) for refractory neurogenic lower urinary tract dysfunction (NLUTD). STUDY DESIGN AND RESULTS: bTUNED (bladder and TranscUtaneous tibial Nerve stimulation for nEurogenic lower urinary tract Dysfunction) is an international multicentre, sham-controlled, double-blind RCT investigating the efficacy and safety of TTNS. The primary outcome is success of TTNS, defined as improvements in key bladder diary variables at study end compared to baseline values. The focus of the treatment is defined by the Self-Assessment Goal Achievement (SAGA) questionnaire. Secondary outcomes are the effect of TTNS on urodynamic, neurophysiological, and bowel function outcome measures, as well as the safety of TTNS. CONCLUSIONS: A total of 240 patients with refractory NLUTD will be included and randomized 1:1 into the verum or sham TTNS group from March 2020 until August 2026. TTNS will be performed twice a week for 30 min during 6 weeks. The patients will attend baseline assessments, 12 treatment visits and follow-up assessments at the study end.

Prevalence of nocturia after brain injury: a cross-sectional study in a single rehabilitation center.

Aim: to analyze the prevalence of nocturia and its possible neuro-urological correlations in patients with a history of acquired brain injury (ABI).Methods: a single-centre population-based prospective study involving outpatients who were previously admitted to our Rehabilitation Hospital for acute ABI ≥ 18 months and ≤2 years prior. Impact of nocturia on QoL was evaluated by the standardized International Consultation on Incotinence Nocturia Quality of Life (ICIQ N-QoL). All participants were given a three-day frequency chart. Probability value <0.05 was statistically significant.Results: 48/138 subjects (35%) showed nocturia at 2-year follow-up visit. No, significant differences in age, gender, duration of coma, state of consciousness, disability, cognitive impairment and stroke severity were found in patients with or without nocturia. Subarachnoid haemorrhage (ESA) was the main reason for ABI in subjects showing nocturia (p = .037). The overall ICIQ N-QOL score ranged from 12 to 50 (mean 30.12 ± 8.87). Of them, 75% showed a total score >26. Increased diurnal frequency and small bladder capacity was statistically significantly associated with nocturia (p < .05).Conclusions: the rate of nocturia 2 years following ABI was lower compared to other neurological populations, although it was significantly associated with other storage urinary symptoms.

Adolescence transitional care in neurogenic detrusor overactivity and the use of OnabotulinumtoxinA: A clinical algorithm from an Italian consensus statement.

AIMS: OnabotulinumtoxinA (onaBNTa) for treating neurogenic detrusor overactivity (NDO) is widely used after its regulatory approval in adults. Although the administration of onaBNTa is still considered off-label in children, data have already been reported on its efficacy and safety. Nowadays, there is a lack of standardized protocols for treatment of NDO with onaBNTa in adolescent patients in their transition from the childhood to the adult age. With the aim to address this issue a consensus panel was obtained. METHODS: A panel of leading urologists and urogynaecologists skilled in functional urology, neuro-urology, urogynaecology, and pediatric urology participated in a consensus-forming project using a Delphi method to reach national consensus on NDO-onaBNTa treatment in adolescence transitional care. RESULTS: In total, 11 experts participated. All panelists participated in the four phases of the consensus process. Consensus was reached if ≥70% of the experts agreed on recommendations. To facilitate a common understanding among all experts, a face-to-face consensus meeting was held in Rome in march 2015 and then with a follow-up teleconference in march 2017. By the end of the Delphi process, formal consensus was achieved for 100% of the items and an algorithm was then developed. CONCLUSIONS: This manuscript represents the first report on the onaBNTa in adolescents. Young adults should be treated as a distinct sub-population in policy, planning, programming, and research, as strongly sustained by national public health care. This consensus and the algorithm could support multidisciplinary communication, reduce the extent of variations in clinical practice and optimize clinical decision making.

Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: A systematic review.

AIMS: To describe all outcome parameters and definitions of cure used to report on outcome of surgical interventions for stress urinary incontinence (SUI) in neuro-urological (NU) patients. METHODS: This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol was registered and published (CRD42016033303; http://www.crd.york.ac.uk/PROSPERO). Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov were systematically searched for relevant publications until February 2017. RESULTS: A total of 3168 abstracts were screened. Seventeen studies reporting on SUI surgeries in NU patients were included. Sixteen different outcome parameters and nine definitions of cure were used. Six studies reported on objective outcome parameters mainly derived from urodynamic investigations. All studies reported on one or more subjective outcome parameters. Patient-reported pad use (reported during interview) was the most commonly used outcome parameter. Only three of 17 studies used standardized questionnaires (two on impact of incontinence and one on quality of life). Overall, a high risk of bias was found. CONCLUSIONS: We found a considerable heterogeneity in outcome parameters and definitions of cure used to report on outcome of surgical interventions for SUI in NU patients. The results of this systematic review may begin the dialogue to a future consensus on this topic. Standardization of outcome parameters and definitions of cure would enable researchers and clinicians to consistently compare outcomes of different studies and therapies.

Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: A systematic review.

AIM: The main goals of neurogenic lower urinary tract dysfunction (NLUTD) management are preventing upper urinary tract damage (UUTD), improving continence, and quality of life. Here, we aimed to systematically assess all available evidence on urodynamics predicting UUTD in patients with NLUTD. METHODS: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in March 2017. Only neuro-urological patients assessed by urodynamics were included. Any outcome of upper urinary tract function were evaluated. RESULTS: Forty-nine studies (1 randomized controlled trial, 9 prospective, and 39 retrospective case series) reported urodynamic data on 4930 neuro-urological patients. Of those, 2828 (98%) were spina bifida (SB) children. The total number of adults was 2044, mainly having spinal cord injury (SCI) (60%). A low bladder compliance was found in 568 (46.3%) and 341 (29.3%) of the paediatric and adult population, respectively. Hydronephrosis (HDN) was detected in 557 children (27.8%) in 19/28 studies and 178 adults (14.6%), mainly SCI, in 14/21 studies. Nine out of 30 multiple sclerosis (MS) patients affected by HDN (16.8%) showed low compliance in 4/14 studies. CONCLUSIONS: Patients with SB and SCI have a higher risk of developing UUTD (mainly reported as HDN) compared to those with MS. Reduced compliance and high DLPP were major risk factors for UUTD. Although our findings clarify the mandatory role of urodynamics in the management of NLUTD, standardization and better implementation of assessments in daily practice may further improve outcomes of neuro-urological patients based on objective measurements, that is, urodynamics.

Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review.

AIMS: To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients. METHODS: The search strategy and studies selection were performed on Medline, Embase, and Cochrane using the PICOS method according to the PRISMA statement (CRD42015019212; http://www.crd.york.ac.uk/PROSPERO). RESULTS: After screening 3,634 abstracts, 11 studies (all retrospective, enrolling 213 patients) were included in a narrative synthesis. Mean follow-up ranged from 21.6 months to 8.7 years (median: 36 months, IQR 28.5-44). At last follow-up, the ability to catheterize rate was ≥84% (except in one study: 58.3%) and the continence rate at stoma was >75%. Data comparing health-related quality-of-life before and after surgery were not available in any study. Overall, 85/213 postoperative events required reoperation: 7 events (7 patients) occurring ≤3 months postoperatively, 22 events (16 patients) >3 months, and 56 events (55 patients) for which the time after surgery was not specified. Sixty additional complications (60 patients) were reported but did not require surgical treatment. Tube stenosis occurred in 4-32% of the cases (median: 14%, IQR 9-24). Complications related to concomitant procedures (augmentation cystoplasty, pouch) included neovesicocutaneous fistulae, bladder stones, and bladder perforations. Risk of bias and confounding was high in all studies. CONCLUSIONS: CCS/T appears to be an effective treatment option in adult neuro-urological patients unable to perform intermittent self-catheterization through the urethra. However, the complication rate is meaningful and the quality of evidence is low, especially in terms of long-term outcomes including the impact on the quality-of-life.

Long-term effectiveness and complication rates of bladder augmentation in patients with neurogenic bladder dysfunction: A systematic review.

AIMS: To systematically evaluate effectiveness and safety of bladder augmentation for adult neuro-urological patients. METHODS: The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement was followed for review of publications. The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched until January 2015. No limitations were placed on date or language. Non-original articles, conference abstracts, and publications involving children and animals were excluded. Risk-of-bias and confounder assessment was performed. RESULTS: A total of 20 studies including 511 patients were eligible for inclusion. The level of evidence for the included studies was low, most level 4 studies with only one level 3 study. The data were narratively synthesized. Across all studies high risk-of bias and confounding was found. Primary outcomes were assessed in 16 of the 20 studies and showed improved quality of life and anatomical changes as well as stable renal function. The secondary outcomes were reported in 17 of the 20 studies and urodynamic parameters and continence all demonstrated improvement after bladder reconstruction. Long-term complications continued up to 10 years post-operatively, including bowel dysfunction in 15% of the patients, stone formation in 10%, five bladder perforations and one bladder cancer. CONCLUSIONS: Available studies are not plentiful and of relatively poor quality, appropriately designed prospective studies are urgently needed. Despite this, bladder augmentation appears to be a highly effective procedure at protecting the upper urinary tract and improving quality of life. However, it is associated with relatively high morbidity in both the short and long term.

Long-term response of different Botulinum toxins in refractory neurogenic detrusor overactivity due to spinal cord injury.

PURPOSE: To assess the response in spinal cord injured patients alternatively treated with different types and dosages of Botulinum neurotoxin type A (BoNT/A) over 15 years. MATERIAL AND METHODS: Patients who underwent first BoNT/A from 1999-2001 and practiced intermittent catheterization were included. Baseline 3-day bladder diary (BD) and urodynamics were collected. BoNT/A failure was defined when patients asked for re-injection ≤ 3 months post-treatment. Criteria for re-injection was at least one daily episode of urinary incontinence at BD. Before re-injection, patients were asked if they had reached 6 months of dryness without antimuscarinics (YES response). RESULTS: Overall, 32/60 (53.4%) "No failure" (NF) group; 16 (26.6%) "occasional failure" (OF) and 12 (20%) "consecutive failure" (CF) were included. A total of 822 BoNT/A infiltrations were performed. The mean interval from previous injection to treatment re-scheduling was 8 months. No significant differences between treatments were found within the three groups (p>0.05). The percentage of YES responses increased from 19% (AboBoNT/A 500IU) to 29 % (OnaBoNT/A 300IU) in NF, and from 18% (AboBoNT/A 500IU) to 25% (OnaBoNT/A 300IU) for OF. Five NF cases (15.6%) maintained 6 months of dryness after each injection. Among the baseline variables, only low compliance (< 20mL/cmH2O) was found as predictor for failure (p=0.006). CONCLUSIONS: Long term BoNT/A for NDO did not increase failures, independent of the types of treatments and switching. Definition of failure and other criteria for continuing repetitive BoNT/A treatment is mandatory. CF was predictable for no response in earlier follow-up.

Percutaneous Tibial Nerve Stimulation Improves Female Sexual Function in Women With Overactive Bladder Syndrome.

INTRODUCTION: Percutaneous tibial nerve stimulation (PTNS) is an established treatment for overactive bladder (OAB), especially in women with other concomitant pelvic disorders, such as sexual impairment. AIM: To evaluate the impact of PTNS on female sexual dysfunction (FSD) in women undergoing PTNS for OAB and analyze the results. METHODS: An observational prospective study was conducted in two Italian centers. Consecutive women undergoing PTNS for dry OAB were enrolled from May 2013 to June 2014. All patients were asked to complete the Female Sexual Function Index (FSFI), the OAB short-form questionnaire, and a 24-hour bladder diary at baseline and 3 months later, at the end of the PTNS course. Patients with an FSFI total score no higher than 26.55 at inclusion were considered as presenting with FSD. Patients with an FSFI total score higher than 26.55 after treatment (if the increase in FSFI score was ≥20%) were considered FSD objective responders. MAIN OUTCOME MEASURES: Sexuality was assessed using the FSFI. The 24-hour bladder diary and completed OAB short-form questionnaire were assessed before and after PTNS to evaluate OAB symptoms. RESULTS: Forty-one women were evaluable. Twenty-one of 41 women (51%; mean age = 51 ± 10.67 years) were considered affected by FSD at inclusion. All FSFI domains showed statistically significant improvement in women with FSD (P < .05). In particular, 9 of 21 patients with FSD (43%) objectively responded (before treatment: mean FSFI total score = 18.11, range 10.8-26.3; after treatment: mean FSFI total score = 31.04, range 27.6-35). Also, women without FSD at baseline reported statistically significant improvement in their sexual function based on FSFI scores (P < .05). No significant correlations were seen between data questionnaires. CONCLUSION: PTNS improves sexual function in women with dry OAB. This amelioration is independent of urinary symptoms. Further studies are needed to confirm a possible role of PTNS in treating FSD.

Management of sexual dysfunction due to central nervous system disorders: a systematic review.

OBJECTIVE: To systematically review the management of sexual dysfunction due to central nervous system (CNS) disorders. PATIENTS AND METHODS: The review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified independently by two reviewers using electronic searches of MEDLINE and OVID (from January 2004 to August 2014) and hand searches of reference lists and review articles. RESULTS: In patients with CNS disorders, neuro-urological assessment is recommended for both genders before starting any treatment for sexual dysfunction. For men, blood sexual hormones evaluation is the main investigation performed before phosphodiesterase type 5 inhibitors (PDE5Is) treatment, whereas there is no consensus on routine laboratory tests for women. PDE5Is are the first-line medical treatment for men, with the most robust data derived from patients with spinal cord injury assessed by validated questionnaires, mainly the International Index of Erectile Function-15. There is no effective medical treatment for sexual dysfunction in women. Sacral neuromodulation for lower urinary tract dysfunction may improve sexual dysfunction in both genders. CONCLUSIONS: Although sexual dysfunction is a major burden for patients with CNS disorders, high-evidence level studies are rare and only available for PDE5Is treating erectile dysfunction. Well-designed prospective studies are urgently needed for both genders.

Correlation between penile cuff test and pressure-flow study in patients candidates for trans-urethral resection of prostate.

BACKGROUND: Aim of this study was to make a comparison between penile cuff test (PCT) and standard pressure-flow study (PFS) in the preoperative evaluation of patients candidates for trans-urethral resection of prostate (TURP) for benign prostatic obstruction (BPO). METHODS: We enrolled male patients with lower urinary tract symptoms candidates for TURP. Each of them underwent a PCT and a subsequent PFS. A statistical analysis was performed: sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), likelihood ratio and ratio of corrected classified were calculated. Fisher exact test was used to evaluate relationships between PCT and maximal urine flow (Qmax): a p-value < 0.05 was considered statistically significant. RESULTS: We enrolled 48 consecutive patients. Overall, at PCT 31 patients were diagnosed as obstructed and 17 patients as unobstructed. At the subsequent PFS, 21 out of 31 patients diagnosed as obstructed at PCT were confirmed to be obstructed; one was diagnosed as unobstructed; the remaining 9 patients appeared as equivocal. Concerning the 17 patients unobstructed at PCT, all of them were confirmed not to be obstructed at PFS, with 10 equivocal and 7 unobstructed. The rate of correctly classified patients at PCT was 79% (95%-CI 65%-90%). About detecting obstructed patients, PCT showed a SE of 100% and a SP of 63%. The PPV was 68%, while the NPV was 100%. CONCLUSIONS: PCT can be an efficient tool in evaluating patients candidates for TURP. In particular, it showed good reliability in ruling out BPO because of its high NPV, with a high rate of correctly classified patients overall. Further studies on a huger number of patients are needed, including post-operative follow-up as well.

Prevalence of lower urinary tract symptoms in taxi drivers: a cross-sectional web-based survey.

PURPOSE: Aim of the study was to evaluate the prevalence of LUTS in taxi drivers. METHODS: Between February 24th 2021 and March 26th 2021 a web based survey was administered to Taxi drivers in the city of Florence. Taxi drivers were evaluated with baseline characteristics such as: age, BMI, smoking, career length, comorbidities, and treatment. LUTS were evaluated using the international prostate symptom score (IPSS) and the overactive bladder (OAB) score. As well sexual function was evaluated using the international index erectile function (IIEF) and female sexual function index (FSFI) questionnaires. Risk factors for LUTS were evaluated using regression analysis. RESULTS: The overall response rate was 64.6% (537/830 taxi drivers filled the questionnaires). Among them, 449 (83.6%) were men and 88 (16.4%) females. Overall, median IPSS was 5 (2/9) and median OAB score was 10 (7/14). On multivariate binary regression analysis age > 50 (OR:1.60; p < 0,05), Smoking (OR:1.57; p < 0,05), chronic treatment (OR:1.57; p < 0,05), recurrent cystitis (OR: 2.66; p < 0,05) and chronic pelvic pain (OR:4.94; p < 0,05) were independent risk factors for moderate/severe LUTS. On multivariate binary logistic regression analysis, risk factors for erectile dysfunction were age older than 50 years (OR = 3.64; p < 0.05) and urinary incontinence (OR = 5.53; p = 0.005). CONCLUSIONS: According to our web-based survey, Taxi drivers in the metropolitan city of Florence had non-negligible symptomatic LUTS and even sexual dysfunction. Our data suggest as LUTS are particular influenced by several life-style and behavioural factors as type and duration of work.

Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology.

BACKGROUND AND OBJECTIVE: Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology. METHODS: A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data. KEY FINDINGS AND LIMITATIONS: Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients. CONCLUSIONS AND CLINICAL IMPLICATIONS: The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients. PATIENT SUMMARY: Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Update on Italian-validated questionnaires for pelvic floor disorders.

INTRODUCTION: Pelvic floor disorders (PFDs), which include urinary incontinence, pelvic organ prolapse, sexual dysfunction and gastrointestinal disorders, affect over 20% of the adult population. Prevalence may also be underestimated, since a certain portion of patients may be reluctant to talk to physicians about PFDs due to embarrassment. Consequently, there is a need for self-assessed diagnostic tools with the capability to screen population and collect clinical information. Symptom and quality of life (QoL) questionnaires - also identified as patient-reported outcomes (PROs) - have been developed with this purpose. Despite the large number of questionnaires available for the assessment of PFDs and QoL-related issues in the English language, few of them have been validated for the Italian language. The objective of this article is to update the list of Italian-validated PROs for PFDs along with practical information concerning literature references and suggestions on how to obtain every single questionnaire. EVIDENCE ACQUISITION: PubMed/MEDLINE databases and websites were used to update the list of available Italian-validated questionnaires about PFDs. Once identified, the possibility to get a copy of the questionnaire was verified and steps to obtain it are reported in the tables. EVIDENCE SYNTHESIS: Eight additional questionnaires validated into the Italian language, for diagnosis and overall management of common urinary, vaginal, sexual and bowel conditions, were retrieved. The complete list of PFDs PROS is reported in a modular format for consultation. CONCLUSIONS: This format is intended to serve as a tool to promote appropriateness in PROs adoption while investigating PFDs in Italian patients.

Neuro-Urology: Call for Universal, Resource-Independent Guidance.

Neurogenic lower urinary tract dysfunction (NLUTD), the abnormal function of the lower urinary tract in the context of neurological pathology, has been the subject of multiple efforts worldwide for the development of clinical practice guidelines. These guidelines are based on the same body of evidence, and are therefore subject to the same gaps. For example, sexual and bowel dysfunction in the context of NLUTD, optimal renal function assessment in those who are non-ambulatory or with low muscle mass, optimal upper tract surveillance timing, and modification of diagnostic and treatment modalities for low-resource nations and communities are inadequately addressed. In addition, many aspects of the conclusions and final recommendations of the guidelines are similar. This duplicative work represents a large expenditure of time and effort, which we believe could be focused instead on evidence gaps. Here, we call for a global unified approach to create a single, resource-independent, comprehensive guidance on NLUTD, neurogenic sexual, and neurogenic bowel dysfunction. Targeted research addressing the evidence gaps should be called for and pursued. This will allow for focus to shift to filling the gaps in the evidence for future guidelines.

Approach and management to patients with neurological disorders reporting sexual dysfunction.

Sexual difficulties are common in patients with neurological disorders, and different domains of sexual function-desire, arousal, orgasm, and ejaculation-can be affected. Advances in the past 7 years in structural and functional neuroimaging have contributed to a greater understanding of the neural pathways involved in the regulation of sexual functions in health and disease, and this increased knowledge might help with development of future therapeutic strategies. A comprehensive assessment of patients includes history taking-covering the different domains of dysfunction, and primary, secondary, and tertiary contributory factors-as well as clinical examination in select patients (ie, patients for whom an associated non-neurological cause for sexual dysfunction is suspected). Investigations, such as assessment of associated cardiovascular risk factors, might also be indicated in specific situations. PDE5A inhibitors and intracavernosal injections of the prostaglandin alprostadil are effective for treating erectile dysfunction; however, options for managing other domains of sexual dysfunction in men and women remain poor. Research into different domains of sexual dysfunction is likely to lead to additional therapeutic strategies in the future.

How to Prevent Catheter-Associated Urinary Tract Infections: A Reappraisal of Vico's Theory-Is History Repeating Itself?

New, contextualized modern solutions must be found to solve the dilemma of catheter-associated urinary infection (CAUTI) in long-term care settings. In this paper, we describe the etiology, risk factors, and complications of CAUTI, explore different preventive strategies proposed in literature from the past to the present, and offer new insights on therapeutic opportunities. A care bundle to prevent CAUTI mainly consists of multiple interventions to improve clinical indications, identifying a timeline for catheter removal, or whether any alternatives may be offered in elderly and frail patients suffering from chronic urinary retention and/or untreatable urinary incontinence. Among the various approaches used to prevent CAUTI, specific urinary catheter coatings according to their antifouling and/or biocidal properties have been widely investigated. Nonetheless, an ideal catheter offering holistic antimicrobial effectiveness is still far from being available. After pioneering research in favor of bladder irrigations or endovesical instillations was initially published more than 50 years ago, only recently has it been made clear that evidence supporting their use to treat symptomatic CAUTI and prevent complications is needed.