Phenotyping women with detrusor underactivity by presumed etiology: Is it plausible?

AIMS: Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies. METHODS: A retrospective review was performed at a single institution from 2011 to 2015 to identify patients with symptoms of UAB. Patients were excluded if they were male, had anti-incontinence, or pelvic organ prolapse (POP) surgery within 1 year, or the UDS did not demonstrate DU as defined within. Subjects were stratified by etiology into four cohorts: cardiovascular disease manifestations (CV), cardiac risk factors (CVR), neurologic (N), or idiopathic (I). Patient demographics, comorbidities, symptomatology, physical exam, and UDS parameters were compared. RESULTS: A total of 200 patients met inclusion criteria (CV: n = 53 [26.5%], CVR: n = 44 [22%] N: n = 81 [40.5%], I: n = 22 [11%]). Women in the CV cohort were significantly older and more likely to be post-menopausal (P < 0.001). There were no differences between cohorts for BMI (P = 0.48), recurrent UTI (P = 0.63), history of urinary retention (AUR) (P = 0.65), POP (0.49), American Urological Association Symptom Score (AUA-SS) (P = 0.06), presenting symptomatology [urgency, frequency, urgency urinary incontinence, AUR, incomplete emptying, hesitancy, UTI (P = 0.97)], or UDS parameters (first sensation [P = 0.25], normal desire [P = 0.80], strong desire [P = 0.58], capacity [P = 0.11], Qmax [P = 0.50], Pdet at Qmax [P = 0.22], post-void residual [P = 0.82]). CONCLUSIONS: Though differences were observed between cohorts for age and menopausal status, clinical or urodynamic parameters did not demonstrate distinct differences across presumed categories of etiology, suggesting that the etiology of DU may be multifactorial. Neurourol. Urodynam. 36:1151-1154, 2017. © 2016 Wiley Periodicals, Inc.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications.

AIMS: To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States. METHODS: Surgical volume for procedures performed primarily by FPMRS surgeons at eight academic institutions across the US was collected using Current Procedural Terminology (CPT) codes for stress urinary incontinence repair and revision surgeries from 2007 to 2013. SAS statistical software was used to assess for trends in the data. RESULTS: There was a decrease in the use of synthetic mesh sling for the treatment of SUI at academic tertiary care centers over the past 7 years; however, this was not statistically significant. While the total number of surgical interventions for SUI remained stable, there was an increase in the utilization of autologous fascia pubovaginal slings (AFPVS). The number of mesh sling revision surgeries, including urethrolysis and removal or revision of slings, increased almost three-fold at these centers. CONCLUSIONS: These observed trends suggest a possible effect of the FDA Public Health Notifications regarding TVM on surgical practice for SUI in academic centers, even though they did not specifically warn against the use of synthetic mesh for this indication. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study. However, such data may provide alternative insights into reasons for the observed trends. Neurourol. Urodynam. 36:1155-1160, 2017. © 2016 Wiley Periodicals, Inc.

Underactive bladder in women: is there any evidence?

PURPOSE OF REVIEW: Underactive bladder (UAB) is a clinical symptom complex only recently gaining recognition as a clinical diagnosis. Lack of consensus agreement on a definition of UAB has limited its recognition and diagnosis in clinical practice. The purposes of this review are to: present existing definitions of UAB, review recent data regarding clinical and urodynamic diagnosis of the condition, and examine up-to-date hypotheses regarding its pathophysiology, with a focus on women. RECENT FINDINGS: The process to develop a consensus definition for UAB as a clinical symptom complex is ongoing. Symptoms associated with UAB, such as weak stream, straining to void, and history of urinary retention are well correlated to detrusor underactivity on urodynamics, which frequently develops in elderly women. In addition to aging, UAB may be the end stage of a variety of contributing pathologic conditions such as diabetes and ischemic disease. In some women, UAB may result from a progression from overactive bladder to UAB. SUMMARY: Existing evidence supports UAB in women as a symptom complex with a clinical and pathophysiologic profile distinguishable from other lower urinary tract-associated clinical conditions. Consensus definitions of clinical and urodynamic diagnostic parameters will be essential to more widespread recognition of UAB.

The Impact of Pallidal and Subthalamic Deep Brain Stimulation on Urologic Function in Parkinson's Disease.

OBJECTIVE: Deep Brain Stimulation (DBS) is an established adjunctive surgical intervention for treating Parkinson's disease (PD) motor symptoms. Both surgical targets, the globus pallidus interna (GPi) and subthalamic nucleus (STN), appear equally beneficial when treating motor symptoms but effects on nonmotor symptoms are not clear. Lower urinary tract symptoms (LUTS) are a common PD complaint. Given prior data in STN-DBS, we aimed to further explore potential benefits in LUTS in both targets. METHODS: We performed a prospective, nonblinded clinical trial evaluating LUTS in PD patients in both targets pre and post DBS using validated urologic surveys. Participants were already slated for DBS and target selection predetermined before study entry. LUTS was evaluated using: the American Urological Association (AUA-SI), Quality of Life score (QOL), Overactive Bladder 8 Questionnaire (OAB-q), and Sexual Health Inventory for Men (SHIM). RESULTS: Of 33 participants, 20 underwent STN DBS and 13 had GPi DBS. Patients demonstrated moderate baseline LUTS. The urologic QOL score significantly improved post DBS (3.24 ± 1.77vs. 2.52 ± 1.30; p = 0.03). Analyzed by target, only the STN showed significant change in QOL (3.20 ± 1.61 vs 2.25 ± 1.33; p = 0.04). There were no other significant differences in urologic scores post DBS noted in either target. CONCLUSION: In PD patients with moderate LUTS, there were notable improvements in QOL for LUTS post DBS in the total sample and STN target. There may be differences in DBS effects on LUTS between targets but this will require further larger, blinded studies.

The Impact of Urethral Risk Factors on Transcorporeal Artificial Urinary Sphincter Erosion Rates and Device Survival.

PURPOSE: We report the impact of urethral risk factors on erosion rates and device survival outcomes after transcorporeal artificial urinary sphincter placement. MATERIALS AND METHODS: We performed a retrospective analysis of all transcorporeal artificial urinary sphincters placed at a single institution between January 2000 and May 2014. We assessed patient demographic, comorbid diseases and surgical characteristics for risk factors considered poor for device survival. Risk factors were compared to postoperative complications requiring explantation, including cuff erosion, infection and device revision. RESULTS: A total of 37 transcorporeal artificial urinary sphincters were placed in 35 men. Placement was performed as a primary procedure in 21 of 37 cases (56.8%) and as salvage in the remainder. In this transcorporeal population there were 7 explantations (18.9%) due to erosion in 4 cases, cuff downsizing in 2 and infection in 1. Median followup from implantation to last followup was 8.5 months (range 0.9 to 63). Median time from artificial urinary sphincter placement to explantation was 17.3 months (range 0.9 to 63) and time specifically to transcorporeal erosion was 7.4 months (range 0.9 to 26). On univariate analysis no parameters were associated with sphincter cuff erosion but a history of an inflatable penile prosthesis was associated with a higher device explantation rate (60% vs 12.5%, p=0.04). No associations were revealed on multivariate logistic analysis. All 4 cuff erosion cases demonstrated greater than 2 urethral risk factors, including prior radiation therapy in all. The probability of cuff erosion in patients with 2 or more urethral risk factors was 1.65 times the probability of erosion in those with 0 or 1 urethral risk factor (95% CI 1.3, 2.2). The proportion of patients free of erosion at 35 months was 100% in those with 0 or 1 urethral risk factor and 64% in those with 2 or more risk factors (log rank test p=0.00). Similarly the proportion of patients free of explantation at 35 months was 100% in those with 0 or 1 urethral risk factor and 52% in those with 2 or more (log rank test p=0.02). CONCLUSIONS: Transcorporeal artificial urinary sphincter implantation is generally reserved for complex and high risk cases but favorable functional results were demonstrated. However, patients with multiple urethral risk factors face a higher risk of erosion and device loss.

Trends in Toilet Training and Voiding Habits among Children with Down Syndrome.

PURPOSE: Children with Down syndrome are at risk for lower urinary tract dysfunction and delayed toilet training. Comparative studies regarding voiding function in the Down syndrome population are lacking. We assessed urinary continence and voiding function in patients with Down syndrome and a control group. MATERIALS AND METHODS: A questionnaire designed to assess toilet training, continence status, symptoms of lower urinary tract dysfunction and prior evaluation of urological complaints was sent to parents of 326 children with Down syndrome who had been seen at our institution previously. The same survey was administered to parents of patients without Down syndrome. Data were compiled, and descriptive and comparative statistical analyses were performed. RESULTS: A total of 77 patients comprised the Down syndrome group and 78 patients without Down syndrome comprised the control group. Average age of reported toilet training completion was 5.5 years in children with Down syndrome and 2.2 years in controls. Of children 5 years or older 79% with Down syndrome were toilet trained, compared to 100% of those without Down syndrome. Incontinence was reported in 46% of previously toilet trained children with Down syndrome and 24.5% of controls. These findings were statistically significant. No significant difference was observed in the rate of urinary tract infection, symptoms of lower urinary tract dysfunction or evaluation for urological complaints. CONCLUSIONS: Children with Down syndrome can experience marked delay in toilet training and are more likely to suffer incontinence afterward. This study was ineffective in determining whether symptoms of lower urinary tract dysfunction could be related to decreased continence rates.

New evidence in the treatment of overactive bladder.

PURPOSE OF REVIEW: Overactive bladder (OAB) in women is highly prevalent. It can be very bothersome and affect quality of life. Treatment differs significantly depending on the clinical presentation, and includes behavioural modification, medicinal therapies and surgical procedures. New treatment options have become available in recent years, and can offer great benefit to patients with persistent, bothersome OAB. RECENT FINDINGS: First-line management for OAB consists of lifestyle and behavioural therapy, followed by antimuscarinic therapy or oral beta-3 agonists. Sacral neuromodulation, onabotulinumtoxinA and posterior tibial nerve stimulation are additional well tolerated and efficacious treatment options that should be considered in carefully selected, refractory OAB patients. These recent advances in OAB therapy are discussed in this review. SUMMARY: The treatment of OAB is often complex, and can require trials of multiple different treatment modalities. Although the treatment advances discussed in this review have augmented treatment of OAB, the condition continues to negatively impact quality of life for our ageing female population. Clinical trials and development of novel therapies continue to be paramount.

Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents.

OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

Longitudinal Changes in the Operative Experience for Junior Urology Residents.

OBJECTIVE: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.

Bowel evisceration through the bladder neck in a paraplegic female secondary to urethral coitus.

INTRODUCTION: Urethral coitus is rarely reported in the literature. The majority of reported cases have been secondary to vaginal agenesis or hymenal anomalies. AIM: We report a case of urethral coitus in a paraplegic patient with a patulous urethra resulting from chronic indwelling catheter use, with the unfortunate presentation of bladder rupture and evisceration per urethra. To our knowledge, this is the only report of urethral coitus due to sequelae from an indwelling catheter, as well as the only report of the subsequent complication of bowel evisceration per urethra. RESULTS: After initial temporization at an outside facility, we were able to perform primary cystorrhaphy. There was no need for bowel resection. The patient has chosen to defer her decision on permanent reconstruction. CONCLUSIONS: Urethral coitus is rare and the subsequent ramifications can be devastating, particularly in neurologically impaired patients. This unusual case speaks to the importance of properly caring for the neurogenic bladder.

Traumatic complete urethral disruption: the West Virginia experience.

Type III complete urethral disruption is an uncommon injury that occurs primarily in male patients with pelvic trauma. Herein we present our results from management of this condition. Management should initially be conservative with a catheter placement in all cases. Full return of urinary function was noted in all patients managed endoscopically, and in 1 of 3 of patients managed with open urethroplasty. Erectile function was preserved in 2 of 3 of patients managed with endoscopic repair, and in none of the patients managed with open urethroplasty. The most common surgical urologic complication was traumatic urethral stricture.

Penile prosthesis pump tubing erosion into urethra appearing as inability to catheterize: a case report.

INTRODUCTION: Erosion of penile prosthesis tubing represents a late complication of penile prosthesis surgery. To our knowledge, this is the first report of isolated erosion of penile implant pump tubing into the urethra in an otherwise asymptomatic patient. The patient had no signs of infection or erosion and no voiding complaints. His only problem was that his urinary catheter was not able to be placed during his vascular surgery procedure. METHODS: Patient with a 5-year history of erectile dysfunction refractory to therapy with PDE5 inhibitors, injection therapy, and vacuum erection device therapy underwent placement of an Alpha-1 Mentor inflatable penile prosthesis. The patient underwent femoral-popliteal bypass at month 21, and during the procedure, the vascular service was unable to place a urinary catheter. Erosion of the tubing from his penile prosthesis was then noted at approximately the junction between the membranous and bulbar urethra. RESULTS: Patient was without signs of infection and had no voiding complaints. These findings were discovered because of the inability to place a urinary catheter for his femoral-popliteal bypass. Diagnosis was made by flexible cystoscopy. CONCLUSIONS: No evidence of infection was noted on examination, and the patient was otherwise asymptomatic. Diagnosis can be made by flexible cystoscopy. Subsequent removal of the penile implant was curative.

Chromophobe renal cell carcinoma presenting as hemorrhagic shock: case report.

The majority of patients with chromophobe renal cell carcinoma (CRCC) are determined to be asymptomatic, with a small minority of patients having the classic triad of flank pain, hematuria, and abdominal mass. This case report describes a 56-year-old man first seen with hemorrhagic shock from retroperitoneal bleeding attributable to a large renal mass. An emergent exploratory laparotomy and radical nephrectomy were performed and the patient has since remained disease free at 3 year follow-up.

Sexual dysfunction in patients with painful bladder syndrome.

PURPOSE: The degree of sexual dysfunction in patients with Painful Bladder Syndrome (PBS) has not been documented previously. The Female Sexual Function Index (FSFI) was used to measure the degree of female sexual dysfunction (FSD) in these patients. MATERIALS AND METHODS: The FSFI was administered on-line to female patients with self-reported PBS. This 19-item questionnaire evaluated FSD in six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. RESULTS: The data was analyzed on an item-for-item basis and by the six domains of sexual dysfunction for 100 patients and compared to a control group of 131 healthy volunteers and a second group consisting of 128 patients with Female Sexual Arousal Disorder (FSAD). When compared with the controls, PBS patients self-report sexual dysfunction in all domains evaluated by the FSFI. CONCLUSIONS: The degree of FSD in PBS patients is significantly higher in all domains when compared to the control group.

Pharmacologic management of non-neurogenic functional obstruction in women.

INTRODUCTION: Impaired bladder emptying in women without neurologic disease may be related to urethral obstruction and/or impaired bladder contractility. Mechanical obstruction generally requires surgical management and options are limited for impaired bladder contractility. However, functional obstruction from voiding dysfunction or primary bladder neck obstruction may present an opportunity for pharmacologic intervention. AREAS COVERED: In this review, the authors extensively reviewed available literature regarding the use of off-label medications for functional bladder outlet obstruction in women. In addition, side effect profiles and pharmacology of these medications determined from on-label indications are reviewed. Specific medications reviewed include vaginal diazepam, baclofen, urethral botulinum toxin injection, and alpha-adrenergic blockers. EXPERT OPINION: Alpha-blockers in particular have demonstrated promise in women with demonstrable or suspected bladder outlet obstruction with side effect profiles similar to those observed in men. However, lack of quality data hinders informed decision making with alpha-blockers or any of the other agents studied in women with non-neurogenic functional outlet obstruction. In the absence of well-designed, placebo-controlled multi-institutional trials, those prescribing these medications must be aware of special considerations and side effects associated with relatively unfamiliar treatments in the context of uncertain benefit.

An update on the use of transdermal oxybutynin in the management of overactive bladder disorder.

Antimuscarinic medications are used to treat nonneurogenic overactive bladder refractory to nonpharmacologic therapy. Side effects such as dry mouth, constipation, blurred vision, dizziness, and impaired cognition limit the tolerability of therapy and are largely responsible for high discontinuation rates. Oxybutynin is a potent muscarinic receptor antagonist whose primary metabolite after first-pass hepatic metabolism is considered largely responsible for its associated anticholinergic side effects. Transdermal administration of medications bypasses hepatic processing. Specifically with oxybutynin, whose low molecular weight permits transdermal administration, bioavailability of the parent drug with oral administration is less than 10%, whereas with transdermal delivery is a minimum of 80%. The result has been an improved side effect profile in multiple clinical trials with maintained efficacy relative to placebo; however, the drug may still be discontinued by patients due to anticholinergic side effects and application site reactions. Transdermal oxybutynin is available as a patch that is changed every 3-4 days, a gel available in individual sachets, or via a metered-dose pump that is applied daily. The transdermal patch was briefly available as an over-the-counter medication for adult women, although at this time all transdermal formulations are available by prescription only.

Pelvic Organ Prolapse Surgery in Academic Female Pelvic Medicine and Reconstructive Surgery Urology Practice in the Setting of the Food and Drug Administration Public Health Notifications.

OBJECTIVE: To understand the effect of the Food and Drug Administration (FDA) public health notifications regarding transvaginal placement of surgical mesh for pelvic organ prolapsed (POP) on surgeon practice patterns in tertiary care academic medical centers. MATERIALS AND METHODS: Surgical volume for procedures performed primarily by fellowship trained Female Pelvic Medicine and Reconstructive Surgery at a sampling of 8 academic institutions across the US were collected using current procedural technology codes for POP repair and revision surgeries from 2007 to 2013. SAS statistical software was used to analyze data for trends and to assess differences in number of procedures across years by performing Spearman correlation analysis and Pearson's chi-squared test. Significance of trend was defined as P <.05 for both analysis methods. RESULTS: There has been a substantial reduction in transvaginal mesh-augmented repair of POP since the FDA warning statements of 2008 and 2011. Mesh revision surgery has increased over this same period. However, the total number of interventions for POP has remained stable over the study period. Abdominal sacrocolpopexy has increased as a whole but represents only a small percentage of total cases. CONCLUSION: Surgical correction of POP comprises a large portion of Female Pelvic Medicine and Reconstructive Surgery practice that continues to evolve in the aftermath of the FDA public health notifications. The utilization of transvaginal placement of surgical mesh augmented POP repair has decreased among practicing urologists at a sampling of academic institutions across the United States. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study; however, such data may provide alternative insights into the reasons for the observed trends.

An uncommonly encountered perirenal mass: Robotic resection of renal vein leiomyosarcoma.

Primary leiomyosarcoma (LMS) of the renal vein is a rare tumour and poorly described in the literature. Surgical resection, using open and laparoscopic approaches, is the mainstay of treatment. In this report, we describe a patient with left renal vein LMS, report the first robotic laparoscopic resection for this tumor, and review the typical presentation, imaging, pathology and treatment for this rare clinical entity.