The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder.

PURPOSE: The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process that will maximize symptom control and quality of life, while minimizing adverse events and burden of disease. METHODS: An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements. RESULTS: This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including non-invasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB. CONCLUSION: Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

A Pilot Study of the Effect of Transcutaneous Spinal Cord Stimulation on Micturition-Related Brain Activity and Lower Urinary Tract Symptoms After Stroke.

PURPOSE: Transcutaneous spinal cord stimulation (TSCS) is a novel neuromodulation modality developed to promote functional restoration in patients with neurological injury or disease. Previous pilot data suggest that lower urinary tract dysfunction (LUTD) due to stroke may be partially alleviated by TSCS. In this study, we examine the mechanism of this effect by evaluating bladder-related brain activity in patients before and after TSCS therapy and comparing it to healthy volunteers. MATERIALS AND METHODS: Patients who developed storage LUTD after a stroke and healthy volunteers without LUTD were recruited. Patients and healthy volunteers underwent simultaneous urodynamics and functional MRI. Patients then completed 24 biweekly sessions of TSCS and underwent another simultaneous urodynamics-functional MRI study. Clinical outcomes were assessed using validated questionnaires and voiding diary. RESULTS: Fifteen patients and 16 healthy volunteers completed the study. Following TSCS, patients exhibited increased blood-oxygen-level-dependent activity in areas including periaqueductal grey, the insula, the lateral prefrontal cortex, and motor cortex. Prior to TSCS therapy, healthy controls exhibited higher blood-oxygen-level-dependent activity in 17 regions, including multiple regions in the prefrontal cortex and basal ganglia. These differences were attenuated after TSCS with no frontal brain differences remaining between healthy volunteers and stroke participants who completed therapy. Neuroimaging changes were complemented by clinically significant improvements in questionnaire scores and voiding diary parameters. CONCLUSIONS: TSCS therapy modulated bladder-related brain activity, reducing differences between healthy volunteers and stroke patients with LUTD. These changes, alongside improved clinical outcomes, suggest TSCS as a promising approach for LUTD management.

Health Care Economic Burden of Treatment and Rehabilitation for Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review.

PURPOSE: The clinical, social, and economic impacts of neurogenic lower urinary tract dysfunction (NLUTD) on individuals and health care systems are thought to be immense, yet the true costs of care are unknown. The aims of this study are to illuminate the global costs related to the current state of care for NLUTD. MATERIALS AND METHODS: A systematic review of the literature was performed using MEDLINE, the National Health Service Economic Evaluation Database, and the Cochrane Specialized Urology and Incontinence Registers. Studies reporting the health care costs of NLUTD were identified. All steps of the review were performed by 2 independent reviewers. Costs were converted to 2022 U.S. dollars and reported for different categories of services. RESULTS: A total of 13 studies were included in the final review (12 from high-income economy, and 1 from an upper-middle-income economy). Routine maintenance care varied notably across studies in terms of included services. Annual supportive costs ranged from $2,039.69 to $12,219.07 with 1 study estimating lifetime costs of $112,774 when complications were considered. There were limited data on the costs of care from the patient's perspective. However, catheters and absorbent aids were estimated to be among the costliest categories of expenditure during routine care. More invasive and reconstructive treatments were associated with significant costs, ranging between $18,057 and $55,873. CONCLUSIONS: NLUTD incurs a variety of health care expenditures ranging from incontinence supplies to hospitalizations for management of complications and leads to a significant burden for health care systems over the patient's lifetime. Approaches to NLUTD that focus on functional rehabilitation and restoration, rather than on management of complications, may prove to be a less costly and more effective alternative.

The Association of Physical Activity and Urinary Incontinence in US Women: Results from a Multi-Year National Survey.

OBJECTIVES: To evaluate the relationships between physical activity, both work and recreational, and urinary incontinence among women. METHODS: We assessed women aged 20 years and older in 2008-2018 NHANES (National Health and Nutrition Examination Survey) cycles who answered self-reported urinary incontinence and physical activity questions. Weighted, multivariate logistic regression model was used to determine the association between incontinence and physical activity levels after adjusting for age, body mass index, diabetes, race, parity, menopause and smoking. RESULTS: A total of 30,213 women were included in analysis, of whom 23.15% had stress incontinence, 23.16% had urge incontinence, and 8.42% had mixed incontinence (answered "yes" to both stress and urge incontinence). Women who engaged in moderate recreational activity were less likely to report stress and urge incontinence (OR 0.79, 95% CI 0.62-0.99 and OR 0.66, 95% CI 0.48-0.90, respectively). Similarly, women who engaged in moderate activity work were less likely to report stress, urge and mixed incontinence (OR 0.84, 95% CI 0.70-0.99; OR 0.84, 95% CI 0.72-0.99; and OR 0.66 95% CI 0.45-0.97, respectively). CONCLUSIONS: Moderate physical activity and greater time spent participating in moderate physical activity are associated with a decreased likelihood of stress, urge and mixed incontinence in women. This relationship holds for both recreational and work-related activity. We hypothesize that the mechanism of this relationship is multifactorial, with moderate physical activity improving pelvic floor strength and modifying neurophysiological mediators (such as stress) involved in the pathogenesis of incontinence.

The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up.

PURPOSE: The clinician treating patients with neurogenic lower urinary tract dysfunction (NLUTD) needs to balance a variety of factors when making treatment decisions. In addition to the patient's urologic symptoms and urodynamic findings, other issues that may influence management options of the lower urinary tract include cognition, hand function, type of neurologic disease, mobility, bowel function/management, and social and caregiver support. This Guideline allows the clinician to understand the options available to treat patients, understand the findings that can be seen in NLUTD, and appreciate which options are best for each individual patient. This allows for decisions to be made with the patient, in a shared decision-making manner, such that the patient's quality of life can be optimized with respect to their bladder management. MATERIALS AND METHODS: A comprehensive search for studies assessing patients undergoing evaluation, surveillance, management, or follow-up for NLUTD was conducted from January 2001 through October 2017 and was rerun in February 2021 to capture newer literature. The primary search returned 20,496 unique citations. Following a title and abstract screen, full texts were obtained for 3,036 studies. During full-text review, studies were primarily excluded for not meeting the PICO criteria. One hundred eight-four primary literature studies met the inclusion criteria and were included in the evidence base. RESULTS: This guideline was developed to inform clinicians on the proper evaluation, diagnosis, and risk stratification of adult patients with NLUTD and the non-surgical and surgical treatment options available. Additional statements on urinary tract infection and autonomic dysreflexia were developed to guide the clinician. CONCLUSIONS: NLUTD patients may undergo non-surgical and surgical treatment options depending on their level of risk, symptoms, and urodynamic findings. Appropriate follow-up, primarily based on their risk stratification, must be maintained after treatment.

The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation.

PURPOSE: The clinician treating patients with neurogenic lower urinary tract dysfunction (NLUTD) needs to balance a variety of factors when making treatment decisions. In addition to the patient's urologic symptoms and urodynamic findings, other issues that may influence management options of the lower urinary tract include cognition, hand function, type of neurologic disease, mobility, bowel function/management, and social and caregiver support. This Guideline allows the clinician to understand the options available to treat patients, understand the findings that can be seen in NLUTD, and appreciate which options are best for each individual patient. This allows for decisions to be made with the patient, in a shared decision-making manner, such that the patient's quality of life can be optimized with respect to their bladder management. MATERIALS AND METHODS: A comprehensive search for studies assessing patients undergoing evaluation, surveillance, management, or follow-up for NLUTD was conducted from January 2001 through October 2017 and was rerun in February 2021 to capture newer literature. The primary search returned 20,496 unique citations. Following a title and abstract screen, full texts were obtained for 3,036 studies. During full-text review, studies were primarily excluded for not meeting the PICO criteria. One hundred eight-four primary literature studies met the inclusion criteria and were included in the evidence base. RESULTS: This guideline was developed to inform clinicians on the proper evaluation, diagnosis, and risk stratification of patients with NLUTD and the non-surgical and surgical treatment options available. Additional statements on urinary tract infection and autonomic dysreflexia were developed to guide the clinician. This Guideline is for adult patients with NLUTD and pediatric NLUTD will not be discussed. CONCLUSIONS: NLUTD patients should be risk-stratified as either low-, moderate-, high-, or unknown-risk. After diagnosis and stratification, patients should be monitored according to their level of risk at regular intervals. Patients who experience new or worsening signs and symptoms should be reevaluated and risk stratification should be repeated.

The Role of Health Insurance in Patient Reported Satisfaction with Bladder Management in Neurogenic Lower Urinary Tract Dysfunction Due to Spinal Cord Injury.

PURPOSE: Neurogenic lower urinary tract dysfunction is a significant source of morbidity for individuals with spinal cord injury and is managed with a range of treatment options that differ in efficacy, tolerability and cost. The effect of insurance coverage on bladder management, symptoms and quality of life is not known. We hypothesized that private insurance is associated with fewer bladder symptoms and better quality of life. MATERIALS AND METHODS: This is a cross-sectional, retrospective analysis of 1,226 surveys collected as part of the prospective Neurogenic Bladder Research Group SCI Registry. We included patients with complete insurance information, which was classified as private or public insurance. The relationship between insurance and bladder management, bladder symptoms and quality of life was modeled using multinomial logistic regression analysis. Spinal cord injury quality of life was measured by the Neurogenic Bladder Symptom Score. RESULTS: We identified 654 privately insured and 572 publicly insured individuals. The demographics of these groups differed by race, education, prevalence of chronic pain and bladder management. Publicly insured patients were more likely to be treated with indwelling catheters or spontaneous voiding and less likely to take bladder medication compared to those with private insurance. On multivariate analysis insurance type was not associated with differences in bladder symptoms (total Neurogenic Bladder Symptom Score) or in urinary quality of life. CONCLUSIONS: There is an association between insurance coverage and the type of bladder management used following spinal cord injury, as publicly insured patients are more likely to be treated with indwelling catheters. However, insurance status, controlling for bladder management, did not impact bladder symptoms or quality of life.

The effect of stroke on micturition associated brain activity: A pilot fMRI study.

OBJECTIVE: Cerebral stroke is a unique model for studying the role of the brain in lower urinary tract (LUT) control. By its nature, stroke must change the activity of the brain to cause LUT dysfunction. The objective of this study was to describe changes in micturition-related brain activity in patients who develop LUT symptoms (LUTS) after a cerebral stroke. MATERIALS AND METHODS: Healthy controls (HC, n = 10) and patients who developed storage LUTS after a cerebral stroke (n = 7) were recruited. Functional magnetic resonance imaging was used to assess brain activity in each subject. In the task-based block design, blood-oxygen-level-dependent (BOLD) signal was detected during rest, active bladder filling, and bladder voiding. BOLD signal intensity was compared between HCs and stroke subjects during bladder filling, voiding, and voiding initiation. RESULTS: Stroke subjects exhibited higher activity in the periaqueductal gray and cerebellum during bladder filling and bladder voiding. HCs exhibited more intense activity in higher centers, such as the cingulate cortex, motor cortex, and the dorsolateral prefrontal cortex in each of the phases examined. CONCLUSIONS: Subjects with stroke-related LUTS exhibit a specific pattern of brain activity during bladder filling and voiding. There appears to be a greater reliance on primitive centers (cerebellum, midbrain) than in healthy controls during both phases of the micturition cycle. We hypothesize that these findings may reflect loss of connectivity with higher brain centers after a stroke.

Predictors of Device-related Complications After Exchange of the Pressure-regulating Balloon in Men With an Artificial Urinary Sphincter.

OBJECTIVE: To identify patient and component specific factors that predispose patients to device-related complications when undergoing pressure-regulating balloon (PRB) exchange in men with an artificial urinary sphincter (AUS). METHOD: From 2009 to 2018, 55 patients underwent AUS revision with placement of a higher pressure 71-80 cm H2O PRB to treat recurrent stress incontinence. Patient demographics, perioperative data, and postoperative outcomes were examined and multivariable logistic regression analyses performed to identify predictors of erosion and mechanical failure. RESULT: After a median follow-up of 26.4 months (range: 6-103.7 months), 21 of 55 (38.1%) patients developed a device-related complication that required operative repair or removal of the AUS. Four (7.3%) patients developed erosion after the PRB pressure increase and 5 patients showed evidence of impending erosion on follow-up and underwent successful revision surgery. Twelve patients developed mechanical failure (cuff leak, n = 7; pump malfunction, n =4; unidentified fluid loss, n = 1). Multivariable logistic regression analysis found that increasing body mass index was a predictor of mechanical failure. Hypertension and lower body mass index were found to increase the risk of cuff erosion whereas radiotherapy was not. CONCLUSION: In the carefully selected patient, PRB exchange can be performed to treat recurrent incontinence in patients with an AUS, including those treated with pelvic radiotherapy. Our data suggest that this technique is susceptible to a high rate of revision surgery. As such, when revising a functional AUS system, meticulous preoperative screening, comprehensive informed consent, and follow-up protocols are essential in minimizing adverse events.

Spinal cord stimulation ameliorates detrusor over-activity and visceromotor pain responses in rats with cystitis.

AIM: Interstitial cystitis/painful bladder syndrome/(IC/PBS) results in recurring pain in the bladder and surrounding pelvic region caused by abnormal excitability of micturition reflexes. Spinal cord stimulation (SCS) is currently clinically used for the attenuation of neuropathic and visceral pain. The present study examined whether SCS at upper lumbar segments modulates detrusor overactivity and visceral hyperalgesia associated with cystitis in a rat model of cyclophosphamide (CYP)-induced cystitis. METHODS: Cystitis was induced by intraperitoneal injection of CYP (200 mg/kg) in six adult female Sprague Dawley rats 48 h prior to urodynamic recordings. Another six rats served as-controls with saline injection. Cystometry and the external urethral sphincter (EUS) electromyography during bladder infusion were evaluated under urethane anesthesia. The visceromotor reflexes (VMR) obtained from the external abdominal oblique muscle were quantified during bladder infusion and isotonic bladder distension (IBD), respectively. After baseline recordings were taken, SCS was applied on the dorsal surface of L3 for 25 min. Urodynamic recordings and VMR during bladder infusion and IBD were repeated 2 h after SCS. RESULTS: CYP resulted in detrusor overactivity, stronger EUS tonic contractions, and increased VMR. SCS significantly reduced non-voiding contractions, prolonged EUS relaxation, and delayed VMR appearance during bladder infusion as well as significantly decreased VMR during IBD in cystitis rats. CONCLUSION: SCS improved bladder function and EUS relaxation during bladder infusion and significantly attenuated visceral nociceptive-related VMR during IBD in cystitis rats. SCS may have therapeutic potential for patients with hyperalgesia and IC/PBS.

Mechanical failure rates of artificial urinary sphincter components: Is the 3.5-cm urethral cuff at higher risk?

AIM: We report the rates of artificial urinary sphincter (AUS) mechanical failure in a contemporary cohort of patients stratified by component type and size to determine if the 3.5-cm cuff is at higher risk of failure. METHODS: From 2005-2016, a total of 486 male patients with stress incontinence underwent implantation or revision of an AUS. 993 individual cases were retrospectively reviewed (465 primary placements and 528 revisions). Components were separately tallied and cases of mechanical failure were identified. Multiple variables including duration until failure and follow-up interval were collected and analyzed for each malfunction. RESULTS: After median follow-up of 31.5 months, there were 48 distinct cases of mechanical failure. The urethral cuff was the most common component to fail (n = 27, 56.3%), followed by the pressure regulating balloon (PRB) (n = 6, 12.5%), tubing (n = 6, 12.5%), and the control pump, (n = 5, 10.4%). Four (8.3%) cases did not have the source of malfunction identifiable in available records though fluid loss was evident at the time of device interrogation. Sub-analyses of cuff failure events showed that the 3.5-cm cuff had a statistically significant higher risk of failure (HR: 7.313, (P < .0001) compared to larger cuff sizes. CONCLUSIONS: While each component is prone to malfunction, our study suggests that the 3.5-cm urethral cuff is more susceptible to failure and failure events occur earlier after placement than larger cuff sizes.

Surveillance and management of urologic complications after spinal cord injury.

PURPOSE: Neurogenic bladder due to spinal cord injury has significant consequences for patients' health and quality of life. Regular surveillance is required to assess the status of the upper and lower urinary lower urinary tracts and prevent their deterioration. In this review, we examine surveillance techniques in neurogenic bladder, describe common complications of this disease, and address strategies for their management. METHODS: This work represents the efforts of SIU-ICUD joint consultation on Urologic Management of the Spinal Cord injury. For this specific topic, a workgroup was formed and comprehensive literature search of English language manuscripts regarding neurogenic bladder management was performed using key words of neurogenic bladder. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for Levels of Evidence (LOEs) and Grades of Recommendation (GORs). RESULTS: At a minimum, patients should undergo an annual history and physical examination, renal functional testing (e.g., serum creatinine), and upper tract imaging (e.g., renal ultrasonography). The existing evidence does not support the use of other modalities, such as cystoscopy or urodynamics, for routine surveillance. Urologic complications in neurogenic bladder patients are common and often more complex than in the general population. CONCLUSIONS: There is a shortage of high-quality evidence to support any particular neurogenic bladder surveillance protocol. However, there is consensus regarding certain aspects of regular genitourinary system evaluation in these patients. Proper surveillance allows the clinician to avoid or address common urological complications, and to guide, alter, or maintain appropriate therapeutic regimens for individual patients.

Neobladder-Vaginal fistula: The University of Southern California experience.

AIMS: The use of orthotropic neobladder (ONB) construction in women has increased in popularity. With increasing numbers so have complications distinct to this procedure. Neobladder vaginal fistula (NVF) is a rare but challenging complication. We present our experience correcting this problem. METHODS: An IRB approved database of female patients with an ONB was retrospectively reviewed. Patients with a history of NVF were identified and charts reviewed. Our standard technique of radical cystectomy and orthotopic diversion in female patients includes interposition of omentum between the neobladder and anterior vaginal wall and sacrocolpopexy. RESULTS: Two hundred and forty-nine female patients underwent cystectomy and ONB construction between 1995 and 2015. Fourteen patients were diagnosed with a NVF (5.6% incidence). The average age and follow-up was 67 years and 33.7 months, respectively. Surgery for fistula closure was attempted in 13 patients. One repair was combined abdominal and transvaginal; the remaining 12 were performed transvaginally. Location of NVF was categorized as at the urethra-neobladder anastomosis (UNA, nine patients) and anterior vaginal wall (AVW, four patients). Eight patients had a successful fistula repair (61.5%) but only five patients ultimately retained their ONB (39%). CONCLUSIONS: Patients with a NVF pose a surgical challenge. Successful fistula repair does not necessarily result in adequate continence due to an incompetent outlet. NVF location at the UNA is the more common location and is more challenging in regard to successful resolution of the NVF as well as possible urinary incontinence post-NVF repair.

Comparative assessment of the efficacy of onabotulinumtoxinA and oral therapies (anticholinergics and mirabegron) for overactive bladder: a systematic review and network meta-analysis.

OBJECTIVES: To compare the efficacy of onabotulinumtoxinA, mirabegron, and anticholinergics in adults with idiopathic overactive bladder (OAB) using network meta-analysis (NMA). PATIENTS AND METHODS: Information sources were searched for blinded randomised controlled trials (RCTs), of ≥2 weeks duration, comparing any dose of onabotulinumtoxinA, eligible oral/transdermal anticholinergics, or mirabegron, with each other or placebo, in adults with OAB. Bayesian random-effects models were used to synthesise the results at week 12: NMA for responder analyses and network meta-regression (NMR) for change from baseline analyses. The NMR was used to adjust for differences in baseline severity between studies. Sensitivity analysis, excluding studies considered to be at a high risk of methodological bias, was conducted. RESULTS: In all, 56 RCTs were included in the networks. For each outcome, results are reported for all licensed treatment doses. For each NMR, results are based on patients with an average number of episodes of the outcome at baseline. After 12 weeks, all treatments were more efficacious than placebo. Patients who received onabotulinumtoxinA (100 U) had, on average, the greatest reductions in urinary incontinence episodes (UIE), urgency episodes, and micturition frequency, and the highest odds of achieving decreases of 100% and ≥50% from baseline in UIE/day. When comparing onabotulinumtoxinA with other pharmacotherapies, mean differences favoured onabotulinumtoxinA 100 U over all comparators for UIE and urgency episodes (credible intervals excluded zero) and all but two of the comparators for micturition frequency. OnabotulinumtoxinA 100 U was also associated with higher odds of achieving a 100% and ≥50% decrease in UIE/day than most other licensed treatments in the network. The exclusion of studies with a high risk of bias had little impact on the conclusions. CONCLUSION: The results indicate that, after 12 weeks, onabotulinumtoxinA 100 U provides greater relief of OAB symptoms compared with most other licensed doses of other pharmacotherapies in the network.