Voiding dysfunction in older women with overactive bladder symptoms: A comparison of urodynamic parameters between women with normal and elevated post-void residual urine.

AIMS: To compare urodynamic parameters in two groups of older women who have overactive bladder (OAB) symptoms: those with normal and those with elevated post-void residual (PVR). METHODS: Secondary data analyses were conducted on medical record data from 203 women who were 65 years or older and who completed urodynamic testing. Of these, 151 (74%) medical records met the study criteria. A PVR of 100 ml or greater during the pressure-flow study was considered elevated for this study. Maximal flow rate (Qmax ) and detrusor pressure at Qmax , bladder capacity, voiding volume, and voiding pattern were compared between these two groups. RESULTS: The mean Qmax and detrusor pressure at Qmax were 19.63 ml/sec (SD = 8.74) and 16.15 cmH2 O (SD = 11.19) for the overall sample, respectively. The elevated PVR group (n = 54) had significantly higher detrusor pressure at Qmax and bladder capacity than the normal PVR group (n = 97) (P < 0.05, P < 0.01, respectively). An interrupted voiding pattern accounted for 47.4% of the normal PVR group and 77.4% of the elevated PVR group, respectively (P < 0.01). CONCLUSIONS: Older women with an elevated PVR required on average a higher detrusor pressure at Qmax and greater bladder capacity than women with a normal PVR. Although an interrupted voiding pattern was more prevalent in the elevated PVR group, many women in the normal PVR group also had an interrupted voiding pattern. These findings indicate that many women may habitually strain to void as well as strain due to inadequate detrusor function.

Incontinence related to management of benign prostatic hypertrophy.

BACKGROUND: The prevalence of incontinence ranges from 11% to 34% among community-dwelling men aged > or =65 years. OBJECTIVE: The objective of this analysis was to determine the nature of incontinence diagnosed in men with benign prostatic hypertrophy (BPH), focusing on its incidence, prevalence, diagnostic workup, and management. METHODS: A cohort of patients with BPH was identified in the Integrated Healthcare Information Services National Managed Care Benchmark Database (1997-2003). Age and duration in the database after the first diagnosis of BPH were used as matching strata. Therapeutic subgroups consisted of watchful waiting, alpha-blockers, 5-alpha-reductase inhibitors (5ARIs), and BPH-related surgery. RESULTS: A total of 411,658 males with BPH were identified from 12,298,027 males (3.3%). Of the BPH cohort, 2.7% (n = 11,172) were identified as having incontinence; of these, 57.8% of patients were > or =65 years of age. Alter applying inclusion/exclusion criteria, the final matched case-control sample included 6346 men as case subjects and 229,154 men as control subjects. The overall incidence of incontinence in this BPH sample was 1835/100,000/year, and the prevalence was 2713/100,000 men. In 48.5% of the incontinent men, the type of incontinence was not specified. Diagnostic testing was performed in 2.9% of men with incontinence. Conditional logistic regression analyses found that BPH-related surgery and alpha-blocker use increased the adjusted odds ratio for the risk of incontinence 3.1-fold, and 1.1- to 1.7-fold, respectively. The odds ratio of the risk of incontinence was not significantly increased with long-term 5ARI use. CONCLUSIONS: Use of alpha-blockers, 5ARIs for the short term (<1 year), and BPH-related surgery were independently, significantly associated with BPH-related incontinence; 5ARI use for >1 year and watchful waiting were not. BPH-related incontinence may be related to progression of BPH or as a postsurgical complication. Patients with BPH should be asked specifically about incontinence, especially after BPH-related surgery, and undergo a full diagnostic workup for the diagnosis of urinary incontinence.

An evaluation of the economic costs and patient-related consequences of treatments for benign prostatic hyperplasia.

OBJECTIVE: To compare the costs and effectiveness of treatments for benign prostatic hyperplasia (BPH), including watchful waiting, pharmaceuticals (alpha-blockers, 5-alpha-reductase inhibitors, combined therapy), transurethral microwave thermotherapy (TUMT), and transurethral resection of the prostate (TURP). PATIENTS AND METHODS: This study used a Markov model over a 20-year period and the societal perspective to evaluate the costs of treatment alternatives for BPH. Markov states include urinary symptom improvement, symptom improvement with adverse effects, or no urinary symptom improvement. For the analysis, patients could remain on their initial treatment, change to a different treatment, have treatment failure that required TURP, or die (all-cause mortality). We used published data for outcomes, including systematic reviews when possible. Costs were estimated using a managed-care claims database and Medicare fee schedules. Costs and effectiveness outcomes were discounted at 3%/year where appropriate. Men (aged > or = 45 years) with moderate-to-severe lower urinary tract symptoms and uncomplicated BPH were included in the analysis, and results were stratified by age. Outcomes include costs, disease progression, surgery, hospitalization, and catheterization time. RESULTS: What is the 'best' treatment depends on the value that an individual and society place on costs and consequences. alpha-Blockers are less expensive than the alternatives, and are effective at relieving patient-reported symptoms. Unfortunately, they have little effect on clinical outcomes and have the highest BPH progression rate. Other treatments have lower disease progression and better clinical outcomes, but are more expensive and entail more invasive treatments, and/or more uncertainty. CONCLUSIONS: Treatment decisions are made using a variety of information, including the cost and consequences of treatment. The best treatment depends on the patient's preference and the outcome considered most important. alpha-Blockers are very effective at treating urinary symptoms but do not improve clinical outcomes, including disease progression, relative to other treatments. TURP remains the 'gold standard' for surgical procedures. The desire to avoid TURP or the 2 weeks of catheterization associated with TUMT might affect a patient's treatment decision when symptoms are severe. Therefore, more information about patient preferences and risk aversion is needed to inform treatment decision-making for BPH.

The long-term cost effectiveness of treatments for benign prostatic hyperplasia.

INTRODUCTION: Excellent treatment outcomes with long-term durability and few adverse effects are expectations of treatments for chronic conditions. The long-term cost effectiveness of newer treatments for benign prostatic hyperplasia (BPH), including high-energy transurethral microwave thermotherapy (TUMT) and combination pharmaceutical therapy, has not been sufficiently studied against existing alternatives. The objective of this study was to estimate the incremental cost effectiveness of BPH treatment alternatives. METHODS: We employed a Markov model over a 20-year time horizon and the payer's perspective to evaluate the cost effectiveness of watchful waiting (WW), pharmaceuticals (alpha-adrenoceptor antagonists [alpha-blockers], 5-alpha-reductase inhibitors [5-ARIs], combination therapy), TUMT and transurethral resection of the prostate (TURP) in treating BPH. Markov states included improvement in symptoms, no improvement in symptoms, adverse effects and death. We used data from the published literature for outcomes, including systematic reviews whenever possible. Costs were estimated using a managed-care claims database and Medicare fee schedules, and were reported in Dollars US, 2004 values. Costs and effectiveness outcomes were discounted at a rate of 3% per year. Men (aged > or =45 years) with moderate to severe lower urinary tract symptoms and uncomplicated BPH were included in the analysis, and results were stratified by age and BPH symptom levels. Outcomes included costs, QALYs, incremental cost-utility ratios and cost-effectiveness acceptability curves. Sensitivity analysis was performed on important parameters, with an emphasis on probabilistic sensitivity analysis. RESULTS: alpha-Blockers and TUMT were cost effective for treating moderate symptoms using the threshold of Dollars US 50,000 per QALY. For example, at 65 years of age, the cost per QALY was Dollars US 16,018 for alpha-blockers compared with WW and Dollars US 30,204 for TUMT versus alpha-blockers. TURP was the most cost-effective treatment for severe symptoms (Dollars US 5824 per QALY ) versus WW. Model results were robust to changes in costs and sensitive to the assumed probabilities, utility weights, extent of improvement and life expectancy. Nevertheless, acceptability curves consistently demonstrated the same alternatives as most likely to be cost effective. CONCLUSIONS: Our model suggests that alpha-blockers and TURP appear to be the most cost-effective alternatives, from a US payer perspective, for BPH patients with moderate and severe symptoms, respectively. TUMT was promising for patients with moderate symptoms and the oldest patients with severe symptoms, but otherwise was dominated. Value of information analysis could be used to determine the net benefit of additional research.

Management of incontinence for family practice physicians.

Family practice physicians are likely to encounter urinary incontinence and overactive bladder (OAB) in their patients. An informed family practice physician can generally accurately diagnose the cause and type of incontinence in patients with a properly focused physical examination and, if necessary, auxiliary testing. Accurate diagnosis can lead to effective treatment when physicians are familiar with available treatment options, including pharmacologic, surgical, behavioral therapies, and catheterization.

Rare cause of ureteral obstruction.

This report presents bilateral ureteral obstruction due to possible ureteritis in a bone marrow transplant patient with resurgence of BK virus after hemorrhagic cystitis. This is believed to be the first description of this type of ureteral obstruction. The presented case includes the management plan.

Plasma cell (Zoon's) balanitis with concomitant HIV infection.

We report a case of the development of Zoon's balanitis in an African-American man with human immunodeficiency virus. Photographs of the clinical and pathological lesion are presented. To our knowledge, this has not been recently reported in urologic studies. The clinicopathologic correlation is discussed.

Intravesical protamine sulfate and potassium chloride as a model for bladder hyperactivity.

OBJECTIVES: An acute animal model for hyperactive bladder in rats was developed using intravesical infusion of protamine sulfate (PS), an agent thought to break down urothelial barrier function, and physiologic concentrations of potassium chloride (KCl). METHODS: Continuous cystometrograms (CMGs) were performed in urethane-anesthetized female rats by filling the bladder (0.04 mL/min) with normal saline followed by intravesical infusion of a test solution consisting of either KCl (100 or 500 mM) or PS (10 or 30 mg/mL) for 60 minutes. Subsequently, the 10 mg/mL PS-treated animals were infused intravesically with 100, 300, or 500 mM KCl. Some animals were pretreated with capsaicin (125 mg/kg subcutaneously) 4 days before the experiments. RESULTS: Unlike KCl (100 or 500 mM) or a low concentration of PS (10 mg/mL) alone, the intravesical administration of a high concentration of PS (30 mg/mL) produced irritative effects with a decreased intercontraction interval (by 80.6%). After infusion of a low concentration of PS, infusion of 300 or 500 mM KCl produced irritative effects (intercontraction interval decreased by 76.9% or 82.9%, respectively). The onset of irritation occurred more rapidly after 500 mM KCl (10 to 15 minutes) than after 300 mM KCl (20 to 30 minutes). Capsaicin pretreatment delayed the onset (approximately 60 minutes) and reduced the magnitude (intercontraction interval decreased by 35.5%) of irritative effects. CONCLUSIONS: Intravesical administration of KCl after PS treatment activates capsaicin-sensitive afferents and detrusor muscle and presumably capsaicin-resistant afferents. Modest, noncytotoxic affronts to urothelial barrier function can result in dramatic irritative responses. This model may be useful in the study of bladder irritation and hyperactivity.

Manganese superoxide dismutase gene therapy protects against irradiation-induced cystitis.

Urinary bladder cystitis occurs in patients receiving radiation therapy for pelvic tumors. Radiation-induced formation of superoxide radicals is believed to damage the urothelium, exposing the underlying bladder smooth muscle to urine, culminating in nerve irritation and muscle dysfunction. We tested whether overexpression of MnSOD could decrease superoxide levels and protect the bladder from radiation damage. Pelvic irradiation led to sloughing of urothelial umbrella cells, with decreased transepithelial resistance, increased water and urea permeabilities, and increased expression of inducible nitric oxide synthase. Six months after irradiation, cystometrograms showed elevated intravesical pressures and prolonged voiding patterns. However, urothelia transfected with the MnSOD transgene recovered from radiation injury more rapidly, and detrusor function was much closer to that of control bladders than irradiated bladders without the transgene. We conclude that MnSOD gene therapy is protective, which could lead to its use in mitigating radiation cystitis and preventing dysfunction of the urinary bladder.

The future of bladder control-intravesical drug delivery, a pinch of pepper, and gene therapy.

The incidence of urinary incontinence and overactive bladder problems will continue to grow as the population ages. Future treatments are likely to include an implantable drug delivery system, gene therapy, and the intravesical use of the vallinoids capsaicin and resiniferatoxin (RTX). An understanding of the urothelium is essential for effective design of these therapies. Intravesical anticholinergic drug treatment is currently not widely used, but intravesical pumps are under development to provide less cumbersome treatment methods and will provide nonsurgical options for patients who cannot tolerate oral anticholinergic agents. Research on the use of capsaicin as an intravesicular drug has had limited success, but trials have confirmed the efficacy of intravesical capsaicin for detrusor hyperreflexia. RTX is as effective as capsaicin but without side effects, such as pain and inflammatory neuropeptide release. RTX treatment may eliminate the need for surgical and other drug treatments of lower urinary tract dysfunction in patients with spinal cord injuries. Gene therapy will change the practice of urology by addressing the deficiencies that cause symptoms rather than attacking the symptoms themselves.