Bacteruria and Urinary Tract Infections in the Elderly.

Both urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) are common problems among elderly adults and represent a significant health care burden. Despite their frequency, differentiating between ASB and true UTI remains controversial among health care providers. Several challenges exist in the evaluation of urinary symptoms in the elderly patient. Symptoms of UTI are variable; problems are encountered in the collection, testing, and interpretation of urine specimens; and results of urinalysis are often misinterpreted and mishandled. Multiple studies have shown no morbidity or mortality benefit to antibiotic therapy in either community or long-term care facility residents with ASB.

Functional magnetic resonance imaging during urodynamic testing identifies brain structures initiating micturition.

PURPOSE: Normal voiding in neurologically intact patients is triggered by the release of tonic inhibition from suprapontine centers, allowing the pontine micturition center to trigger the voiding reflex. Supraspinal mechanisms of voluntary voiding in humans are just beginning to be described via functional neuroimaging. We further elucidated brain activity processes during voiding using functional magnetic resonance imaging in normal females to gain better understanding of normal voiding as well as changes that may occur in voiding dysfunction. MATERIALS AND METHODS: We screened 13 healthy premenopausal female volunteers using baseline clinic urodynamics to document normal voiding parameters. We then recorded brain activity via functional magnetic resonance imaging and simultaneous urodynamics, including the pressure flow voiding phase. After motion correction of functional magnetic resonance images we performed activation and connectivity analyses in 10 subjects. RESULTS: Group analysis revealed consistent activation areas, including regions for motor control (cerebellum, thalamus, caudate, lentiform nucleus, red nucleus, supplementary motor area and post-central gyrus), emotion (anterior/posterior cingulate gyrus and insula), executive function (left superior frontal gyrus) and a focal region in the pons. Connectivity analysis demonstrated strong interconnectivity of the pontine micturition center with many short-range and long-range cortical clusters. CONCLUSIONS: Our study is one of the first reports of brain activation centers associated with micturition initiation in normal healthy females. Results show activation of a brain network consisting of regions for motor control, executive function and emotion processing. Further studies are planned to create and validate a model of brain activity during normal voiding in women.

Objective Evaluation of Overactive Bladder: Which Surveys Should I Use?

Overactive bladder (OAB) is a common condition that affects many adults, and prevalence increases with age in both men and women. It is characterized by symptoms of urinary frequency and urgency with or without urge incontinence in the absence of another proven etiology. As a diagnosis based solely on urinary symptoms, proper evaluation of OAB often depends on the use of psychometrically validated questionnaires to assess symptom severity and degree of bother. General urinary assessment forms can evaluate many urinary symptoms while modular questionnaires can focus on the most bothersome complaints. Many questionnaires have been formulated and validated to achieve these goals. Currently, the ideal questionnaire does not exist. This review attempts to outline the range of questionnaires available to the clinician to assist in evaluating symptoms as well as degree of impact on quality of life.

Renal deterioration in multiple sclerosis patients with neurovesical dysfunction.

OBJECTIVES: Our aims were to determine the prevalence of renal ultrasound (RUS) abnormalities over time in multiple sclerosis (MS) patients with lower urinary tract symptoms (LUTS). METHODS: Data were examined retrospectively from MS patients with LUTS, from 2000-2009. Study inclusion requirements were both baseline urodynamics (UD) and RUS data, with followup RUS at ≥ 12 months. Age, time since diagnosis (TSD), MS subtype and the UD/RUS results were evaluated for associations. RESULTS: At presentation, 173 subjects underwent UD and RUS, but only 89 had a repeat RUS at ≥ 12 months. Median followup was 61 months. Initial RUS abnormalities were found in 10 (5.8%) subjects. At followup, upper urinary tract (UUT) abnormalities were seen in 11 (12.4%) subjects. Patients > 49 years old were more likely to have an abnormality (OR 0.181, 95% CI 0.037-0.892, p = 0.04). Patients with abnormal compliance were also more likely to have an abnormal followup RUS (OR 0.185, 95% CI 0.037-0.924, p = 0.04). No other demographic or UD factor was associated with RUS abnormalities. CONCLUSIONS: The development of structural UUT changes is low in MS patients. Urodynamic studies are useful for LUTS treatment strategies in complicated patients, but UD does not appear to have much impact with regard to upper tract changes.

Complex rectovaginal fistulas after pelvic organ prolapse repair with synthetic mesh: a multidisciplinary approach to evaluation and management.

OBJECTIVES: The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management. METHODS: Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution. RESULTS: Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain. CONCLUSIONS: This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

A modification to augmentation cystoplasty with catheterizable stoma for neurogenic patients: technique and long-term results.

OBJECTIVE: To evaluate the use of a modified Indiana continent urinary reservoir, the Indiana augmentation cystoplasty (IAC), for patients with neurogenic bladder (NGB). NGB with incontinence can be devastating for patients with neurologic illness. Augmentation cystoplasty with a continent catheterizable stoma creates a continent, low-pressure storage system, with catheterizable cutaneous stoma, leading to decreased urinary tract morbidity and increased quality of life. METHODS: Retrospective chart review of the IAC procedure in a single center from 1993 to 2010 was performed and included subjects with NGB and minimum 1-year follow up. Patients' demographics, NGB diagnosis, surgery details, urodynamic findings, concurrent operations, complications, and continence outcomes were recorded. RESULTS: Thirty-four patients met the inclusion criteria. Mean age at time of surgery was 39.8 years. Neurologic diagnoses included multiple sclerosis (n = 12), spina bifida (n = 9), and spinal cord injury (n = 14). Concurrent surgeries included: bladder neck closure (n = 3), pubovaginal sling (n = 4), hysterectomy (n = 3), artificial urinary sphincter (n = 1), and cystolithotomy (n = 1). Mean estimated blood loss was 461.8 mL. Short-term postoperative complications were prolonged ileus (n = 2), wound infection (n = 1), and transfusion (n = 1). Median follow-up was 31 months. Long-term complications occurred in 15 (44.1%) patients: recurrent urinary tract infections (n = 4), pyelonephritis (n = 1), pelvic abscess (n = 1), seroma (n = 1), bladder stones (n = 2), and stomal revision in (n = 4). All patients were continent at latest follow-up. CONCLUSION: This modification of the Indiana continent urinary reservoir is an excellent surgical option providing a low-pressure reservoir with a reliable continence mechanism and easily catheterizable stoma, with few complications or need for reoperation.

Demographic and urodynamic factors associated with persistent OAB after anterior compartment prolapse repair.

INTRODUCTION: Overactive bladder (OAB) symptoms often accompany pelvic organ prolapse. While there seems to be a relationship between symptom resolution and anatomic repair, a subset of patients will not experience improvement in OAB symptoms. Our aim was to identify preoperative demographic and urodynamic (UD) parameters related to persistence of OAB symptoms after anterior vaginal prolapse (AVP) repair. METHODS: This retrospective cohort study examined demographic and UD data from patients undergoing AVP surgery. Pre- and post-operative Urogenital Distress Inventory (UDI-6) scores for frequency, urge urinary incontinence (UUI), and difficulty voiding were analyzed, as were correlations between scores and pre-operative UD data. RESULTS: From 2002 to 2008, 88 patients underwent AVP repair and were included in the final analysis. Surgery resulted in a reduction of frequency (33%), UUI (49%), and difficulty voiding (74%) at median 21 months follow-up. Change in symptom scores was unrelated to age, parity, BMI, or AVP grade, although older women reported greater improvement in difficulty emptying after repair. Improvement in difficulty emptying was related to a larger pre-operative post-void residual (PVR) (129 ml vs. 31 ml, P = 0.0008). Persistent UUI after repair was significantly related to a higher preoperative P(det)Q(max) (OR 1.056, 95% CI 1.003-1.11, P = 0.04). Other pre-operative UDS variables were not significantly related to the persistence of OAB symptoms. CONCLUSIONS: AVP repair reduces lower urinary tract symptoms (LUTS); however, 67% and 51% of patients will report persistent frequency and UUI, respectively, post-operatively. In this cohort, persistent OAB symptoms were not related to age, parity, BMI, or prolapse grade, but rather to pre-operative P(det)Q(max).

Differential diagnosis of chronic pelvic pain in women: the urologist's approach.

Chronic pelvic pain in women can be caused by a host of gynecological, gastrointestinal, musculoskeletal, neurologic, as well as urologic disorders. An initial broad differential diagnosis is essential. At times, overlapping symptoms and vague physical findings necessitate a multidisciplinary diagnostic approach. A thorough history, which is careful to characterize all aspects of the patient's symptoms, can usually direct the differential toward the bladder when this organ is the source of the pain. Interstitial cystitis/painful bladder syndrome (IC/PBS) should be included in the differential diagnosis, but it should not be used as an expeditious diagnosis when pain coexists with frequency and urgency. Multiple other urologic conditions such as overactive bladder, urinary tract infection, urethral diverticulum, periurethral masses (Skene gland cyst or abscess), and even urethral stricture disease, have overlapping symptom complexes with IC/PBS, and they must not be overlooked as they are much more easily diagnosed and treated. By using a stepwise approach and an evidence-based thought process, the obscurity of chronic bladder and urethral pain can evolve into a progressively narrowing differential.

Sexual dysfunction in patients with multiple sclerosis: a multidisciplinary approach to evaluation and management.

Multiple sclerosis (MS) is the most common cause of progressive neurological disability in young adults. In addition to spasticity, tremors, weakness, sensory disturbances, depression, cognitive problems, and bladder or bowel dysfunction, sexual dysfunction (SD) is also a prevalent and destructive manifestation of the disease that severely affects quality of life. Evaluation of this disorder requires insight into the primary (changes that directly affect libido, sexual response and orgasm due to direct damage to the nervous system), secondary (complaints which are related to the physical disability of MS, such as fatigue, muscle rigidity, weakness and spasms), and tertiary (emotional, social and cultural aspects of MS) components of MS-associated SD. Given the complexity and multifactorial nature of SD, a multidisciplinary approach is necessary when treating patients with MS. The aim of this Review is to provide a holistic approach to the evaluation and management of SD in patients with MS, incorporating the latest data from the fields of urology, neurology, nursing, social work, and psychology. What is currently known regarding the evaluation and management of SD in patients with MS will be presented from the perspective of these specialties.

Clarifying the role of urodynamics in the preoperative evaluation of stress urinary incontinence.

It has not yet been definitively demonstrated that preoperative evaluation of women with stress urinary incontinence (SUI) with urodynamic testing (UDS) enhances surgical outcomes. Nonetheless, UDS is frequently utilized in the assessment of women with SUI in the hopes that results will shed light on preoperative risk factors for failure or postoperative voiding dysfunction. Poorer outcomes for stress incontinence surgery are primarily attributed to intrinsic sphincter deficiency (ISD), detrusor overactivity (DO), and voiding dysfunction. The ability of UDS to identify and characterize those parameters reliably remains under investigation. Furthermore, debate continues regarding the association of each of those factors with postoperative success for various SUI procedures. Since UDS is invasive, costly, and not always available, it is imperative that its benefit be carefully explored. In this review, we discuss the value of UDS in identifying risk factors for poor outcome and how those risk factors are associated with surgical failure.

Benign masses of the female periurethral tissues and anterior vaginal wall.

Due to their rarity, benign masses of the periurethral tissues and anterior vaginal wall are poorly understood. Arriving at the proper evaluation and treatment is challenging because many of these masses have similar presenting signs and symptoms, as well as overlapping differential diagnoses. The literature regarding these lesions mainly consists of level III evidence, mostly involving case reports and series. Clinical management has traditionally been based on established surgical principles and expert opinion. This review presents the pertinent embryologic and anatomic background for these benign masses, as well as other pertinent etiological processes. Furthermore, the most current evidence is reviewed regarding the differential diagnosis, evaluation, and treatment for each mass.

Regression of inflammatory pseudotumor of the bladder in a child with medical management.

Inflammatory pseudotumor of the bladder is a benign proliferative lesion of the submucosal stroma that cannot be distinguished from malignant tumors of the bladder either endoscopically or radiographically. Although benign, the proliferative nature of the inflammatory pseudotumor histopathology has led others to recommend open surgical removal or complete transurethral resection for definitive treatment. A limited number of case reports have described inflammatory pseudotumor of the bladder in either adults or children. This is a case of biopsy-proven inflammatory pseudotumor in the bladder of a child that regressed after medical management alone.

Case-matched comparison of contemporary radiation therapy to surgery in patients with locally advanced prostate cancer.

PURPOSE: Few studies critically compare current radiotherapy techniques to surgery for patients with locally advanced prostate cancer, despite an urgent need to determine which approach offers superior cancer control. Our objective was to compare rates of biochemical relapse-free survival (BFS) and surrogates of disease specific survival among men with high risk adenocarcinoma of the prostate as a function of treatment modality. METHODS AND MATERIALS: Retrospective data from 409 men with prostate-specific antigen (PSA) > or =10 or Gleason 7-10 or Stage > or =T2b cancer treated uniformly at one university between March 1988 and December 2000 were analyzed. Patients had undergone radical prostatectomy (RP), brachytherapy implant alone (BTM), or external beam radiotherapy with brachytherapy boost with short-term neoadjuvant and adjuvant androgen deprivation therapy (BTC). From the total study population a 1:1 matched-cohort analysis (208 patients matched via prostate-specific antigen, Gleason score) comparing RP with BTC was performed as well. RESULTS: Estimated 4-year BFS rates were superior for patients treated with BTC (BTC 72%, BTM 25%, RP 53%; p < 0.001). Matched analysis of BTC vs. RP confirmed these results (BTC 73%, BTM 55%; p = 0.010). Relative risk (RR) of biochemical relapse for BTM and BTC compared with RP were 2.92 (1.95-4.36) and 0.56 (0.36-0.87), (p < 0.001, p = 0.010). RR for BTC from the matched cohort analysis was 0.44 (0.26-0.74; p = 0.002). CONCLUSIONS: High-risk prostate cancer patients receiving multimodality radiation therapy (BTC) display apparently superior BFS compared with those receiving surgery (RP) or brachytherapy alone (BTM).

An improved approach to followup care for the urological patient: drop-in group medical appointments.

PURPOSE: To increase prompt access to routine office visits the concept of the group appointment was developed in the primary care setting. Drop-in group medical appointments have been piloted at our department. We hypothesized that 1) efficiency could be improved by seeing 6 to 14 patients at 1 appointment, 2) access to appointment times would increase and 3) patient satisfaction would be enhanced with 60 minutes of didactic contact and discussion with the urologist. MATERIALS AND METHODS: Patients were invited to participate in a drop-in group medical appointment. Appointments were made based on sex and not on diagnosis. A 60-minute group teaching session was followed by a private 2 to 5-minute physical examination or further testing, as indicated. Confidential satisfaction surveys were administered to drop-in group medical appointment participants and patients seen at traditional individual (solo) appointments. Results were compared. RESULTS: From September 22, 2003 to August 30, 2004, 279 patients attended a drop-in group medical appointment. Mean patient age was 63 years and 142 patients were 65 years or older. Most diagnoses were prostate cancer, erectile dysfunction, benign prostatic hyperplasia, incontinence, neurogenic bladder and chronic discomfort syndromes. Of the patients 287 were surveyed, including 177 at drop-in group medical appointments and 110 at solo appointments. Patient satisfaction with the drop-in group medical appointment format was as high as that of solo patients with 87% of drop-in group medical appointment patients rating their experience as excellent or very good vs 88% by solo patients. CONCLUSIONS: Drop-in group medical appointments can be implemented successfully in a urological practice with high patient satisfaction despite the sensitive nature of topics discussed. Ideal patients are those with chronic or complex conditions and those requiring repetitive discussions, such as elderly individuals.

Surgery or radiation: what is the optimal management for locally advanced prostate cancer?

INTRODUCTION: To date, randomized trials comparing radiotherapy to surgery for adenocarcinoma of the prostate are few. Lacking, are randomized comparisons between treatment modalities for the patient with high-risk locally advanced disease. Hence, there is a need to determine which approach offers superior results in these patients who comprise a significant proportion of those dying of prostate cancer. In this short review we highlight key studies that may provide interim answers while awaiting definitive results from randomized studies. MATERIAL AND METHODS: A MEDLINE literature review was performed of studies evaluating current treatment modalities for high-risk (TNM stage >T2b, PSA>10, Gleason > or =8) prostate cancer. Publications from 1975 to present were searched using the keywords: prostate cancer, locally advanced prostate cancer, high-risk prostate cancer, prostatectomy, external beam radiation, brachytherapy, and PSA-doubling time. RESULTS: Comparisons of different treatment modalities are difficult due to many factors, from uncertainties in clinical staging to the questionable equivalence of PSA failure. However, the general consensus is that low dose rate brachytherapy monotherapy is not ideal for high-risk patients. There are several options for combination therapy which show moderately good survival results. Because of the lack of prospective randomized trials comparing these approaches, matched analyses with uniform patient treatment and pathological review may provide an interim answer. CONCLUSION: The optimal management for patients with locally advanced prostate cancer is unclear. While randomized clinical trials will eventually shed light on this question, interim solutions may provide some answers in the short term.