[Polypharmacy and medication review in the context of prehabilitation]. / Polypharmazie und Medikamentencheck im Kontext der Prähabilitation.

Against the background of typical geriatric multimorbidity and with the particular vulnerability of geriatric patients, polypharmacy deserves special attention. In accordance with the guidelines, medication should not only be reviewed regularly, but also on an ad hoc basis and with each hospital stay-and also in the context of prehabilitation. Thus, not only substances that interfere with the currently planned intervention, anesthesia, or risk of bleeding should be considered, but any medication that increases common risks for geriatric patients. These include drugs that cause or increase a tendency to fall, induce delirium, or alter the comedication through potential drug-drug interactions. Measures to minimize the risk include the following: exact documentation of medications, structured and complete transfer of information, patient and family training about any side effects that may occur, a recall system for possible laboratory checks, and compliance with the instructions for taking the medication.

[Short version of the S2k guideline on drug therapy of neurogenic lower urinary tract dysfunction (NLUTD)]. / Kurzfassung der S2k-Leitlinie medikamentöse Therapie der neurogenen Dysfunktion des unteren Harntraktes (NLUTD).

BACKGROUND: In Germany about one million patients suffer from neurogenic lower urinary tract dysfunction (NLUTD). If left untreated, various forms of NLUTD can lead to secondary damage of the lower and upper urinary tract. Thus, the guideline was developed for the drug therapy of patients with NLUTD, who frequently require lifelong care and aftercare. METHODS: The guideline was developed in a consensus process with several meetings and online reviews, and final recommendations were decided on in online consensus meetings. Ballots were sent to elected officials of the contributing professional societies. Level of consensus was given for each coordinated recommendation ( https://www.awmf.org/leitlinien/detail/ll/043-053.html ). RESULTS/MOST IMPORTANT RECOMMENDATIONS: (Video)urodynamic classification of the NLUTD should be conducted before the use of antimuscarinic drugs (84.2%). Approved oral antimuscarinics should be used as first choice. Contraindications must be respected (100%). If oral treatment is ineffective or in the case of adverse drug reaction (ADRs) alternatively instillation of oxybutynin solution intravesically (83%) or onabotulinumneurotoxine (OBoNT) injection should be offered (89.5%). In case of failure or ADRs of antimuscarinics, ß3 sympathomimetic mirabegron can be used to treat neurogenic detrusor overactivity (NDO) (off-label use) (100%). In case of paraplegia below C8 or multiple sclerosis with an expanded disability status scale (EDSS) of ≤ 6.5, OBoNT injection can be offered as an alternative (89.5%). Drug therapy for NDO should be started early in newborns/young children (84.2%). Conservative, nondrug therapy should be considered in frail elderly (94.7%). No parasympathomimetic therapy should be used to treat neurogenic detrusor underactivity (94.7%). CONCLUSION: Precise knowledge of the neurological underlying disease/sequence of trauma and the exact classification of the NLUTD are required for development of individualized therapy.

[Are there benefits for catheter valves for catheter-associated quality of life? : Results of an investigation in 427 catheter wearers with life-long indication]. / Hat eine Ventilversorgung Vorteile bei der katheterassoziierten Lebensqualität? : Ergebnisse einer Untersuchung an 427 Katheterträgern in lebenslanger Indikation.

BACKGROUND: In urology, a subset of patients with lifelong urine drainage are fitted with a catheter valve. Data on catheter-related quality of life (crqol) in this subset of patients are missing. AIM: Clarification of the whether there are advantages for valve-aided catheters in comparison with continuous urine drainage in catheter wearers with a lifelong indication. METHODS: In all, 357 patients with a catheter with lifelong indication of continuous urine drainage from a previous study were compared with 70 valve-aided patients. The crqol was evaluated by a validated assessment with 25 items and five domains. RESULTS: There were statistically more patients with a suprapubic catheter than with a transurethral indwelling catheter (73.4 vs. 54.4%, p = 0.005), significantly more patients with bladder voiding dysfunction (73.5 vs. 52.6%, p = 0.003) and significantly more patients with small catheter sizes (p = 0.001). Crqol was altogether slightly impaired with a median score of 4.2 (no impairment indicated by 5 points) in valve-aided patients, but crqol was more impaired in valve-aided patients compared to patients with continuous drainage (4.4 points, n. s.). Some items demonstrated more problems dealing with urinary urge in valve-aided patients, but catheter-related pain was more often worse in patients with continuous drainage. CONCLUSION: There is no clear evidence for an advantage of a catheter valve over a continuous urine drainage system. Thus, the decision regarding a catheter-valve system must be made individually according to the indication and the preferences of the patient.

[Guidelines for consultations regarding incontinence care products]. / Leitlinie Hilfsmittelberatung bei Harninkontinenz.

An investigation of the German consumer organisation "Stiftung Warentest" in 2017 confirmed significant deficiencies in the information, advice and supply of incontinence care products received by urinary incontinence patients. The German Society of Urology (DGU) thereupon drafted and later published guidelines concerning the consultation of patients in the context of incontinence care. Important aspects of the consultation process include the determination of the type of incontinence as well as its severity, clinical examination, and advice regarding possible curative treatments. However, the advice appointment takes centre stage and should ideally be conducted by a qualified person in a separate room granting sufficient privacy and time. Furthermore, repeated supply of a selection of samples for differing degrees and types of incontinence, accommodating the patient's individual preferences and anatomical features, is crucial in order to ensure optimal incontinence care. In the case of commercial health care service providers, transparency relating to the financial implications of e.g. expensive products is key, which is what has been intended by German health insurance providers. The new guidelines concerning urinary incontinence care consultation constitute a step towards the improvement and structuring of processes in the consultation regarding, and the supply of, incontinence care products.

[Comparison of catheter-associated quality of life in external urinary diversion: nephrostomy vs. suprapubic catheter]. / Vergleich der katheterassoziierten Lebensqualität bei externen Harnableitungen: Nephrostomie vs. suprapubischer Katheter.

INTRODUCTION: A percutaneous nephrostomy (PCN) affects the integrity of the patient due to the requirement of an external drainage bag and regular changes. The catheter-associated quality of life (QOL) was evaluated using a validated assessment and compared to similar patients with suprapubic bladder drainage. METHODS: A validated assessment analyzing catheter-related QOL for 5 domains and 25 individual items (first published by Mary Wilde) was completed during a catheter change appointment by patients who had their unilateral or bilateral PCN for a minimum of 3 months in life-long indication. RESULTS: In 66 patients (unilateral PCN: 42 patients), a moderate impairment of their catheter-related QOL was shown. The overall QOL score was median 4.0 on a scale of 0-5. This was rated lower-indicating a stronger impairment of QOL-than in patients with a suprapubic bladder catheter, who had a median score of 4.3. Significant differences were found related to the catheter type in the items "feeling of humiliation due to the PCN", "conflicts with the medical or nursing staff", "fear of painful catheter changes", "feeling ill", "being handicapped in activities of daily living" and "concern of not being able to do what one wants to do" and "fear of catheter leakages". The indication for the PCN due to a malignant or benign underlying disease was not associated with the catheter-related QOL. CONCLUSION: For the first time, the catheter-related QOL was found to be moderately impaired in patients with a PCN using a validated assessment. Affected individuals report feeling "ill" and "limited/disabled" in activities of daily living; thus, the surgical indication should be strict. Fear of painful catheter changes and of catheter leakages indicates the need of technically correct catheter changes.

[Quality of life for wearers of a suprapubic or transurethral bladder catheter as lifelong permanent care]. / Lebensqualität bei Trägern eines suprapubischen oder transurethralen Harnblasenkatheters als lebenslange Dauerversorgung.

BACKGROUND: The insertion of a Foley catheter (FC) or a suprapubic catheter (SPC) in lifelong intent is an intervention with significant complications, comorbidities and impact on the further life that has not yet been analyzed. METHODOLOGY: The analysis was based on a validated assessment of catheter-related QoL with 25 items in 5 domains and applied to patients with a Foley or suprapubic catheter in lifelong indication and with the catheter in place for at least 3 months. Assessment data were enriched with information on the type and diameter of the catheter as well as demographic data. RESULTS: Questionnaires from 357 patients (260 male, 97 female, 193 with suprapubic catheter, 162 with Foley catheter, 2 no information) were included in the study. Patients with a Foley catheter were significantly older than patients with a suprapubic catheter (78.9 ± 11.1 years vs. 74.4. ± 12.6 years, p < 0.001). The average QoL score was 4.1 points on a scale from 1 (maximum impairment of QoL) to 5 (no impairment of QoL) indicating a moderately negative impact on QoL. Scores below the average were mainly driven and accompanied by a fear of urine leakage, urine odor, painful catheter changes and urinary infections increasing with age. Additionally, patients were worried about negative effects on their daily life activities due to the catheter. These worries seemed to be more pronounced in females with urinary incontinence, patients with a catheter size ≥ 18 Ch. and with an age of < 70 years. The type of catheter showed a greater impact on the QoL in females with suprapubic catheters when compared with males in contrast to patients with transurethral catheters. CONCLUSION: The results of the study provide further information for the medical clarification for patients and caregivers, having to decide between a lifelong catheter drainage or alternatives, such as provision of an aid or surgical recanalization.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]. / Einsatz von synthetischen Band- und Netzimplantaten bei der Behandlung von Belastungsinkontinenz und Descensus genitalis der Frau : Stellungnahme des Arbeitskreises Urologische Funktionsdiagnostik und Urologie der Frau der Akademie der Deutschen Gesellschaft für Urologie.

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

[Palliative long-term urinary bladder drainage: the uro-geriatric point of view]. / Palliative Harnblasenlangzeitdrainage: eine urogeriatrische Disputation.

A serious voiding disorder or urinary incontinence represent indications for long-term catheterization of the urinary bladder. Treatment by a transurethral or suprapubic bladder catheter for life-long bladder drainage is accompanied by technical short-term complications and long-term sequelae. The mortality risk associated with inserting a suprapubic catheter is approximately 2% due to an incorrect bladder puncture. Long-term consequences of life-long bladder drainage are hematuria, infection, spasms, stone formation, obstruction, catheter loss, risk of falls and automanipulation especially in cognitively impaired persons. These constitute frequent reasons for emergency treatment or hospitalization. Further problem areas are dependency on caregivers to perform the catheter change and dermal problems in the area of the fistula stoma. To what extent this limits the quality of life of those affected remains unclear up to now. The acute complications and the long-term consequences of life-long bladder drainage make careful decision-making necessary after other therapeutic options have failed, are not appropriate or not desired.

Does lack of deeper understanding of shared decision making explains the suboptimal performance on crucial parts of it? An example from breast cancer care.

PURPOSE: Although most of the clinicians in breast cancer care seem to approve of shared decision making (SDM), actual implementation is limited. The aim of this study was to explore the experiences, issues and concerns of early-adopter professionals with regards to shared decision making. METHODS: This qualitative descriptive study was part of a pilot study aimed at implementing SDM in breast cancer teams. We interviewed 27 clinicians; 9 breast cancer surgeons, 11 nurse practitioners and 7 nurses. The teams were exposed to a multifaceted implementation programme, among others: a patient decision aid (PtDA), a procedure to disseminate the PtDA and advice on redesigning the clinical pathway. RESULTS: Participants considered SDM, including the delivery of the PtDA, to be a team effort, in which every professional should take responsibility. Most clinicians primarily focused on the first steps of SDM ignoring preference and decision talk. The remaining steps, like the uptake of the PtDA in the clinical pathway, were regarded as challenging, with surgeons, intentionally or unconsciously, delegating this responsibility to nurses. One barrier to successfully implementing SDM seems to lie in the fact that clinicians were unaware of their lack of competency regarding SDM. CONCLUSIONS: A deeper understanding is needed among clinicians of what SDM actually is and how a PtDA contributes to this process. Nurses play an important role in the delivery of the PtDA, but their role is not clearly defined. Teams should consider a clear realignment of tasks between surgeons and nurses, which implies redesign of the pathway.

Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status.

PURPOSE: To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. METHODS: 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. RESULTS: Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). CONCLUSIONS: Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

[Lower urinary tract dysfunction in Guillain-Barre syndrome]. / Harntraktfunktionsstörungen bei Guillain-Barré-Syndrom.

BACKGROUND: Guillain-Barré syndrome (GBS) as acute inflammatory demyelinating polyradiculoneuropathy frequently leads to lower urinary tract dysfunction. The available knowledge in the medical literature is limited and good recommendations for diagnosis and therapy are rare. MATERIALS AND METHODS: In this study, 189 patients with GBS were screened for lower urinary tract dysfunction. In symptomatic patients, a urodynamic study was performed. Detrusor contractility, post-void residual, and changes of the symptoms over time were studied. Overall Barthel index and urinary control Barthel index as well as the relationship of time after onset of the disease and post-void residual were studied as possible screening criteria for urodynamic assessment. RESULTS: According to the urinary control Barthel index (BI), 115 of 189 patients (61%) presented lower urinary tract symptoms sometime during the course of disease. In 28 patients, these symptoms were temporary during the acute phase. At the time of urological assessment, 87 patients had lower urinary tract symptoms. At the end of rehabilitation, 37 had no symptoms anymore (BI 10), 20 were able to control micturition to a certain extent (BI 5), and 30 had no lower urinary tract control (BI 0). There was a significant negative correlation between post-void residual volume and overall BI (ρ -0.5823, p < 0.0001) and BI for urinary tract control (ρ -0.6430, p < 0.0001). CONCLUSIONS: Overall BI and BI for urinary tract control are suitable screening criteria for urodynamic assessment.

[Not Available]. / Therapie der weiblichen OAB.

The syndrome of overactive bladder (OAB) with the symptoms of frequency, urgency and nocturia is often seen. After the diagnosis has been made by careful exclusion of other conditions, there are different symptomatic treatment strategies available. These include drug treatment as well as minimally invasive local surgical treatments and treatments which intervene with the control of the bladder by modulating central nervous areas. Alternative methods such as acupuncture may help in individual cases; the placebo effect is high and there is a lack of controlled studies.

[Urethral Syndrome and Urethral Pain: Do we Treat People or Diagnoses?]. / Das Urethralsyndrom und urethrale Schmerzen - behandeln wir den Menschen oder die Diagnose?

The urethral syndrome with urethral pain and bladder voiding disorders is a diagnosis of exclusion. Possible aetiologies are diverse and include organic, functional and inflammatory pathologies of the urethra. Infections, inflammation of the paraurethral glands, spasms of the sphincter muscle and/or of the pelvic floor muscles, oestrogen deficiency, trauma, neuropathies, hypersensitivity and psychosomatic issues have been investigated as possible causes.Patients with urethral syndrome must be viewed, evaluated and treated holistically. They need a lot of time and attention during their evaluation and treatment. It is now well known that psychosocial aspects are involved in the development of many somatic conditions and may have a crucial impact on the course of a disease. This needs to be taken into consideration during the treatment process.

[Physiotherapy in Women with Overactive Bladder]. / Physiotherapie bei Frauen mit überaktiver Blase.

As regards treatment for overactive bladder, physiotherapeutic interventions can be seen as an alternative to drug treatment. Targeted pelvic floor and bladder training is used to decrease the number of voids and the incontinence episodes or to increase the average voided volume in women with overactive bladder (3 systematic reviews with evidence level 1/1a).An additional option to treat women with overactive bladder is to use functional electrical stimulation and magnetic stimulation.2 systematic reviews 1 2 and 2 RCTs 3 4 reveal a low level of evidence (2 studies with level 2/2b) for the use of electrical stimulation (transcutaneous, vaginal or transanal) to reduce incontinence episodes and the number of voids and to increase the average voided volume. The trial from Yamanishi et al. (2014) shows that magnetic stimulation has a positive effect 5. Further studies are needed to evaluate the benefit of conservative treatment procedures for overactive bladder.

[How Does Lower Urinary Tract Dysfunction Affekt Female Sexuality?]. / Welchen Einfluss haben Symptome des unteren Harntraktes auf die weibliche Sexualität?

With increasing age many women suffer from lower urinary tract dysfunction (LUTD) and female sexual dysfunction. An increasing body of evidence supports an association between the 2 conditions. Especially women with urodynamically proved detrusor hyperactivity suffer from sexual dysfunction and there is some evidence that in patients with stress incontinence sexual health improves after successful surgery.

[Characteristic Features of Urinary Incontinence--Diagnostic Investigation in Geriatric Patients]. / Besonderheiten der Harninkontinenz--Diagnostik beim geriatrischen Patienten.

Urinary incontinence is a common medical and social problem in elderly people. It leads to a massive reduction in the quality of life of affected persons and their dependants and causes an enormous socio-economic burden, which will increase significantly within the next years and decades as the age structure of the German population changes. Successful treatment of urinary incontinence in the elderly requires a good pathophysiological understanding of the underlying problem as well as individually tailored diagnostic procedures, which must be oriented at the patient's wishes, the social environment and the resulting therapeutic consequences. This especially applies to persons with symptoms of dementia. Comorbidities such as diabetes mellitus, reduced mobility and a medication-induced decrease in cognitive function play a major role in the severity of urgency and urinary incontinence in the elderly. Also the frequently described concomitant diagnosis of urinary tract infection must be exactly evaluated. Before antibiotic treatment is given, it should be clarified if the patient suffers from "harmless" bacteriuria or a urinary tract infection requiring treatment. Patients with an age-associated decrease in brain power must be diagnosed quite carefully, because these patients may potentially be harmed by pharmacological treatment for overactive bladder syndrome.

[Imaging for urinary incontinence]. / Bildgebung bei Harninkontinenz.

BACKGROUND: Ultrasonography and functional cine magnetic resonance imaging (MRI) are noninvasive and x-ray free tools, which are currently widely used in clinical diagnostics and scientific research of male and female urinary incontinence. The increasing use and improving techniques of modern imaging tools are closely linked to rapid development of minimally invasive surgery in patients with urinary incontinence and insights gained in continence mechanisms. METHODS: Whereas ultrasonography is a cost-efficient and readily available diagnostic tool for a routine use, the more expensive functional MRI, as a tool with more precise visualization of functional interactions and spatial representation of anatomical structures of the pelvic floor, is suitable for complex diagnostic purposes and scientific research. Both tools are already well established for evaluations of the female pelvic floor. For evaluation of the male pelvic floor, and in particular postprostatectomy incontinence, perineal ultrasonography and functional cine MRI are becoming increasingly evident. CONCLUSION: Further development of both imaging tools will contribute to new insights into the continence mechanism and improve the techniques of radical prostatectomy and minimally invasive surgery of male and female urinary incontinence in the future.

[Urinary incontinence in men]. / Harninkontinenz des Mannes.

Stress urinary incontinence in men is predominantly iatrogenic whereby radical prostatectomy is the most common cause with persistent stress urinary incontinence rates varying between 10 % and 25 %. The first line therapy for postoperative male stress urinary incontinence is physiotherapy, especially pelvic floor muscle rehabilitation. If conservative treatment fails to show sufficient improvement, surgical therapy is recommended. Several treatment options are currently available for the surgical treatment of male stress urinary incontinence including artificial sphincters, adjustable and functional sling systems, bulking agents and implantable balloon systems.

[Characteristics of urinary incontinence in the elderly]. / Besonderheiten der Harninkontinenz im Alter.

Geriatric patients are defined as being over 70 years of age and are vulnerable due to multimedication and multimorbidity. The typical incontinence type in geriatric patients is the overactive bladder syndrome as a result of anatomical alterations and the influence of conditions which typically occur in the elderly, e.g. diabetes mellitus, vaginal atrophy, constipation, neurological affections and dementia. This multimorbidity leads to multimedication but many pharmaceutical compounds aimed at indications of diseases distant from the urinary tract can also influence the continence situation. This has been proven for cardiac medications, such as alpha-blockers and diuretics, neurological drug therapy and analgesics. Diagnostic investigations in geriatric patients are usually non-invasive and include geriatric assessment to quantify incontinence symptoms but invasive diagnostic tools are required if the primary therapy fails or an operative intervention is planned. Pharmacotherapy considers the special requirements of the very old patient with cognitive impairment and vulnerability due to falls or delirium. In the group of anticholinergic drugs, trospium chloride seems to be the favorite substance to treat this group of patients because this hydrophilic compound is considered to be unable to cross the blood-brain barrier and therefore minimizes the risk of side effects in the central nervous system (CNS).

[Conservative treatment in male urinary incontinence]. / Konservative Therapie der Harninkontinenz beim Mann.

Prevalence, pathophysiology, diagnostic and therapeutic approaches of urinary incontinence are well studied in women; however, studies on male urinary incontinence focus on incontinence following surgery of the bladder or prostate, predominantly incontinence after radical prostatectomy. Aging men suffer from incontinence, most frequently urge incontinence (overactive bladder, OAB), nearly as often as women do.The domain of conservative therapy of urinary stress incontinence in men is pelvic floor training. It remains unclear whether biofeedback procedures, electrostimulation therapy, or magnetic stimulation therapy can enhance pelvic floor training. There are data suggesting that an off-label therapy with Duloxetin®, a selective serotonin-noradrenaline reuptake inhibitor (SSNRI), improves urinary incontinence following radical prostatectomy. Antimuscarinic agents in combination with bladder training have been proven as safe and effective treatment in men with OAB. Data, however, suggest that men with OAB are far less frequently treated than women.