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Urological complications are common in patients with chronic spinal cord injury (SCI). Inappropriate bladder management may result in high voiding pressure, low bladder compliance, large postvoid residual urine volume, and recurrent urinary tract infections. Thus, long-term surveillance of high-risk patients with SCI is required to avoid urological complications and improve the quality of life. Herein, the current evidence and expert opinions on patient-centered bladder management of neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic SCI in Taiwan are presented. Regular physical and urological examinations should be performed in patients with SCI depending on their risk of upper urinary tract deterioration. For patient with SCI who have received different bladder management and surgical intervention, education on proper bladder emptying and regular surveillance are mandatory. It is critical to identify high-risk patients to prevent renal functional deterioration in those with chronic SCI-induced NLUTD. Thus, annual active surveillance of bladder and renal function is required, particularly in high-risk patients with SCI. [ABSTRACT FROM AUTHOR]

Botulinum toxin A (BoNT-A) has been widely used in several urological functional disorders including neurogenic detrusor overactivity (NDO), overactive bladder (OAB), lower urinary tract dysfunction, and interstitial cystitis/bladder pain syndrome (IC/BPS). Chronic inflammation is found in a large proportion of patients with OAB and IC/BPS. The chronic inflammation activates sensory afferents which resulting in central sensitization and bladder storage symptoms. Because BoNT-A can inhibit the sensory peptides released from the vesicles in sensory nerve terminals, the inflammation can be reduced and symptom subsided. Previous studies have demonstrated that the quality of life improved after BoNT-A injections, both in neurogenic and non-NDO. Although the use of BoNT-A in treatment of IC/BPS has not been approved by FDA, intravesical BoNT-A injection has been included in the AUA guideline as the fourth line therapy. Generally, intravesical injections of BoNT-A are well tolerated, though transient hematuria and urinary tract infection can occur after the procedure. In order to prevent these adverse events, experimental trials have been conducted to test if BoNT-A can be delivered into the bladder wall without intravesical injection under anesthesia such as using liposomes encapsulated BoNT-A or application of low energy shock wave on the bladder to facilitate BoNT-A penetrating across the urothelium and treat OAB or IC/BPS. This article reviews current clinical and basic researches of BoNT-A on OAB and IC/BPS. [ABSTRACT FROM AUTHOR]

Objectives: To compare the therapeutic efficacy, adverse events (AEs), and patient preference in elderly patients with overactive bladder (OAB) receiving different combinations of mirabegron and solifenacin. Materials and Methods: Elderly OAB patients received mirabegron 25 mg (M25) daily for 1 month (1M) followed by randomization to receive M25 (Group 1), mirabegron 50 mg (M50, Group 2), solifenacin 5 mg (S5, group 3); or M25 plus S5 (Group 4) for further 2 months. Efficacy and AEs were evaluated. At the end of 3M, patients' preferred option for future treatment was investigated. Results: A total of 168 patients were enrolled, and 100 completed 3-month treatment. At 1M, all parameters improved significantly except postvoid residual (PVR), 23 (13.7%) patients had no symptom, 16 (9.5%) had no improvement, and 10 (6.0%) withdrew from the trial. Compared parameters at 3M with 1M revealed that quality of life, Patient's Perception of Bladder Condition scores, and voided volume improved significantly in group 1; the OAB Symptom Score (OABSS) increased in group 2; mean PVR and Global Response Assessment (GRA) deteriorated in group 3; and the OABSS and GRA improved in group 4. At 3M, the AEs prevalence increased significantly in group 3. Only 38.1% in group 4 preferred long-term usage of combination therapy. Conclusion: M25 daily is effective and safe in treating elderly OAB patients. Dose escalation to 50 mg or shifting to S5 does not increase the therapeutic efficacy. Combining M25 with S5 provides better treatment efficacy but is associated with lower patient compliance than M25 alone. [ABSTRACT FROM AUTHOR]

Objective: This study retrospectively investigated the influence of urodynamic parameters and patient characteristics on success rates among patients with overactive bladder (OAB) and urodynamic detrusor overactivity (DO). Materials and Methods: Consecutive patients with OAB and urodynamic DO initially received solifenacin, mirabegron, or combination of both for 1–3 months. If failed, patients were switched to another OAB medication subtype or provided additional OAB medication for a total of 6 months. A successful treatment was defined as an improvement in urgency severity and a global response assessment of ≥1. Success rates after initial or modulated OAB medication were analyzed based on patient and urodynamic characteristics. Results: A total of 453 patients were enrolled, among whom 144, 255, and 54 received solifenacin, mirabegron, and combined medications, respectively. Among the patients, 259 (57.2%) had OAB dry and 194 (42.8%) had OAB wet. Patients receiving mirabegron alone had a significantly higher initial medication success rate compared to that of others. Patients with a phasic DO (50.7%), bladder outlet obstruction (BOO, 52.5%), and no central nervous system (CNS) lesions (47.5%) exhibited higher success rates than those with a terminal DO (42.0%), no BOO (42.7%), and CNS lesions (31.6%), respectively. After switching or modulating the initial OAB medication following treatment failure, 115 (62.2%) of 185 patients still showed improvement in OAB symptoms, with an overall success rate of 70.2% after 6 months of treatment. Conclusion: Initial solifenacin or mirabegron treatment had a success rate of around 50%. In general, patients with a phasic DO, urodynamic BOO, and no CNS lesions have higher success rates than those with a terminal DO, no BOO, and CNS lesions, respectively. Success rates can further be improved by switching or modulating OAB medication. [ABSTRACT FROM AUTHOR]

Detrusor underactivity (DU), an important but under-researched issue, is thought to be complex and multifactorial in etiology, pathophysiology, and diagnosis. Bladder outlet obstruction (BOO) is one of the important known etiologies of DU, with significant morphologic and physiologic changes of the urothelium, suburothelium, and detrusor muscle in the urinary bladder. Chronic urinary bladder ischemia and repeated cycles of ischemia and reperfusion injury cause excessive oxidative stress, and it is thought to be responsible for the development of DU. DU might be the late phase or decompensated status of BOO, with the possible mechanisms of afferent nervous dysfunction, increased inflammation, denervation of the detrusor muscle, and myogenic failure. Prostaglandin E2 (PGE2) involves in the physiological detrusor contraction, and might provide the prognostic value for the recoverability of DU. Neurotrophins, including nerve growth factor and brain-derived neurotrophic factor, involve in the neuroplastic changes in many inflammatory bladder diseases, including BOO and DU. Oxidative stress biomarkers, including 8-hydroxy-2-deoxyguanosine, F2-isoprostane, and the involved pro-inflammatory cytokines, have been applied in BOO due to their involvements in chronic bladder ischemia. PGE2, neurotrophins, inflammatory cytokines, and oxidative stress biomarkers are the potential urine biomarkers in BOO-related DU. [ABSTRACT FROM AUTHOR]

Detrusor underactivity (DU) is a common urodynamic diagnosis in patients with lower urinary tract symptoms and large post-voiding residual volume. Animal and human studies showed the possible etiologies of DU include central or peripheral nerve injury, bladder outlet obstruction, chronic ischemia, aging, diabetes mellitus, and sympathetic inhibition of micturition reflex. Evidence from animal and human DU studies with various etiologies revealed highly similar gross and histological characteristics in the bladders, including increased bladder weight, bladder wall thickening, inflammation, collagen deposition, and fibrosis. In electron microscopy, smooth muscle destruction, swollen mitochondria, decreased nerve innervation, caveolae, and umbrella cell fusiform vesicles were noted in the DU bladders. Most animal DU models demonstrate detrusor contractility changes from compensatory to the decompensatory stage, and the change was compatible with human DU observation. The cystometry in the DU animal studies is characterized by impaired contractility, prolong intercontraction interval, and hyposensation, while in vitro bladder muscle strips experiment may exhibit normal detrusor contractility. Decreased bladder blood flow and increased oxidative stress in bladders had been proved in different animal DU models, suggesting they should be important in the DU pathogenesis pathway. Sensory receptors mRNA and protein expression changes in DU bladders had been observed in both animal and human studies, including muscarinic receptors M2, M3, adrenergic receptor β3, purinergic receptor P2X1, P2X3, and transient receptor potential vanilloid (TRPV) 1 and TRPV4. Although some of the sensory receptors changes remain controversial, it might be the target for further pharmacologic treatments. [ABSTRACT FROM AUTHOR]

Medical treatment of overactive bladder (OAB) includes antimuscarinic agents, beta-3 adrenoceptor agonist (mirabegron), or combination with both drugs. Recently, a meta-analysis reported the integrated clinical trial data from 10 phase 2–4, double-blind, 12-week mirabegron monotherapy studies. The results confirmed that mirabegron is as effective as the previously used antimuscarinic agent to treat OAB. The treatment-emergent adverse events were similar across subgroups. This article comments on this largest integrated clinical trial data analysis, and reviews the recently published literature and tries to reveal how to choose the appropriate medication for OAB. For OAB patients, starting from antimuscarinic agent is feasible. However, if the patients have risk of cognitive dysfunction, a history of constipation, dry mouth, and urinary retention, starting with mirabegron 50 mg might be more safe and appropriate. In the elderly patients with low detrusor contractility, with central nervous system lesion, and men with benign prostatic hyperplasia, starting from 25 mg mirabegron is recommended. If the treatment result is not satisfactory to the 25 mg mirabegron, increase dose to 50 mg mirabegron is appropriate. In patients who have failed from the first OAB medication either with antimuscarinics or mirabegron 50 mg, the exchange of the OAB medication to each other should be tried first. If the treatment result is still not satisfactory, a combination of antimuscarinics and mirabegron is recommended. [ABSTRACT FROM AUTHOR]

Underactive bladder (UAB) is a symptom complex suggestive of detrusor underactivity (DU). Although it implies a primary dysfunction of the detrusor muscle, many other conditions such as advanced age, neurogenic factors, and bladder outlet obstruction also lead to UAB. The current understanding of the pathophysiology directly leading to UAB is limited. We believe that by identifying the morphological changes associated with UAB might shed light on this. Therefore, we searched literature with keywords of electron microscopy, ultrastructure, UAB, and DU to review current ultrastructural evidence concerning UAB. [ABSTRACT FROM AUTHOR]

Lower urinary tract symptoms (LUTSs) in women are common in urological practice but are usually uninformative for diagnosing the underlying lower urinary tract dysfunction. To obtain a precise diagnosis and devise a precise treatment strategy, a videourodynamic study (VUDS) is an essential tool for investigating the bladder and bladder outlet dysfunction, especially when LUTS cannot be relieved after initial medical treatment. An accurate VUDS diagnosis can guide effective treatment and prevent unnecessary or incorrect surgical intervention. This article reviews updated applications of VUDS in the diagnosis and treatment of LUTS in women. [ABSTRACT FROM AUTHOR]

Lower urinary tract symptoms (LUTS) are complicated and cannot be used alone to diagnose lower urinary tract dysfunctions (LUTDs) and guide treatment. Patients with bladder outlet obstruction (BOO), impaired detrusor contractility, and hypersensitive bladder might present with voiding predominant symptoms, whereas patients with detrusor overactivity (DO), dysfunctional voiding, or BOO might also present with storage symptoms. To clearly identify the pathophysiology of LUTD, a comprehensive urodynamic study (UDS) including pressure flow and image during the storage and emptying phases, naming videourodynamic study (VUDS), is necessary. This study is especially mandatory in the diagnosis of (1) male LUTS refractory to medical treatment for benign prostatic hyperplasia, (2) female voiding dysfunction and urinary retention, (3) diagnosis of overactive bladder syndrome refractory to first-line medication, (4) management of female stress urinary incontinence and postoperative LUTS, (5) diagnosis and management of neurogenic LUTD, (6) pediatric urinary incontinence and enuresis, (7) geriatric urinary incontinence, and (8) recurrent bacterial cystitis. Although VUDS should not be used as a screening test for any LUTS, it should be considered when the initial management cannot relieve LUTS, or when invasive surgical procedure is planning to undertake for patients with refractory LUTS. VUDS should be recommended as the second-line investigation when the initial diagnosis and treatment based on the symptoms alone or noninvasive tests fail to improve LUTS. [ABSTRACT FROM AUTHOR]

Male lower urinary tract symptoms (LUTSs) are highly prevalent in men and the incidence increases with aging. The pathophysiology of male LUTSs might be bladder outlet dysfunctions such as bladder neck (BN) dysfunction, benign prostatic obstruction, and poor relaxation of external sphincter and bladder dysfunctions such as detrusor overactivity (DO), detrusor underactivity, DO, and inadequate contractility. Male LUTSs include voiding and storage symptoms, and precision diagnosis should not be done based on the symptoms alone. Videourodynamic study provides a thorough look at the bladder and bladder outlet and can clearly demonstrate the underlying pathophysiology when the initial medication fails to relieve LUTS. Medical treatment should be given based on the underlying pathophysiology of LUTS, and surgical intervention to remove prostate should only be performed when a definite bladder outlet obstruction due to prostatic obstruction has been confirmed by invasive urodynamic study. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to evaluate the efficacy of mirabegron 25 mg daily in patients with nocturia-predominant hypersensitive bladder (HSB). Materials and Methods: This study prospectively investigated 219 consecutive patients with nocturia-predominant HSB and treated with mirabegron 25 mg daily from July 2015 to 2016. Patient with nocturia episode decreased by ≥1/night after treatment was considered successful. The subjective symptom score, such as International Prostate Symptom Score (IPSS), Quality of life index, Overactive Bladder Symptom Score (OABSS), Urgency Severity Scale, patient perception of bladder condition (PPBC), and nocturia episodes per night, was assessed before and 1 month after mirabegron treatment and between successful and failed groups. Results: A total of 219 patients, including 51 women and 168 men, were enrolled. The mean age of the population was 72.3 ± 11.0 years. Totally, 58 (26.5%) of the patients had improvement in nocturia at 1 month after treatment. Among them, 14 (27.5%) women and 44 (26.2%) men had improvement in nocturia episodes after treatment (P = 0.858). Compared the clinical data between successful and failed group, the baseline symptom scores were more severe in successful group, including IPSS-storage subscore (4.84 ± 2.09 vs. 4.11 ± 2.19, P = 0.031), OABSS (3.21 ± 0.67 vs. 2.91 ± 1.00, P = 0.037), and nocturia episodes (3.81 ± 0.95 vs. 3.095 ± 1.32, P = 0.000). Multivariate analysis revealed only a higher nocturia episodes (P = 0.046) predict a successful treatment result. Mirabegron 25 mg daily significantly improved PPBC score along the 3 months' follow-up (P < 0.05), and postvoid residual volume did not increase after mirabegron treatment in overall patients. Conclusions: Mirabegron 25 mg daily treatment showed a limited therapeutic effect on nocturia-predominant HSB patients. The patients with higher OAB symptoms predict a successful result. [ABSTRACT FROM AUTHOR]

Aims: To investigate the effects of transurethral incision of the bladder neck (TUI-BN) on long-term outcomes and quality of life (QoL) improvements in women with detrusor underactivity (DU) refractory to standard medical treatment. Materials and Methods: Data were retrieved for female patients with treatment-refractory DU who underwent TUI-BN between 2007 and 2018. Urodynamic parameters were measured at baseline and follow-up and were analyzed for surgical outcome. Patients who were capable of spontaneously voiding with a voiding efficiency (VE) of ≥50% with or without the aid of abdominal pressure were considered to have achieved satisfactory outcomes. Changes in self-reported QoL were measured based on the International Prostate Symptom Score QoL (IPSS-QoL), and treatment improvements were measured based on the global response assessment (GRA) index. Moreover, the voiding statuses of patients before and after TUI-BN were compared. Results: Overall, 82 women, with a mean age of 60.8 ± 17.9 years (range 12–102), were included. Most patients experienced chronic urinary retention or large postvoid residual (PVR) urine. Median follow-up period was 5 years (range 1–12). Following TUI-BN, 40 (48.8%) patients achieved satisfactory outcomes, with a mean GRA of 1.4 ± 0.93. Mean maximum flow rate, voided volume, PVR volume, VE, and IPSS-QoL were all significantly improved. Among all patients, 50 (61%) were subsequently able to spontaneously void with or without the aid of abdominal pressure without the need for catheterization. Indwelling catheters were required in 19 (23.2%) patients at baseline and in 5 (6.1%) following TUI-BN (P < 0.01). Moreover, 5 (6.1%) patients developed stress urinary incontinence and 2 (2.4%) experienced vesicovaginal fistulae following TUI-BN procedures, all of whom recovered satisfactorily after treatment. Conclusions: TUI-BN is an effective procedure for reducing the bladder outlet resistance and improving VE and QoL. Moreover, the procedure is durable with an acceptable incidence of complications. [ABSTRACT FROM AUTHOR]

The bladder urothelium plays an important role of barrier function to prevent influx of urinary toxic substance and bacteria. When there is insult to the urinary bladder, the urothelium will start to regenerate on injury. However, several factors might affect the regenerative function of bladder urothelium, including aging, chronic inflammation, and system diseases such as diabetes and chronic kidney diseases (CKDs). Impairment of bladder mucosal regenerative function might result in defective urothelial cell differentiation as well as barrier function, which might be the underlying pathophysiology of interstitial cystitis/bladder pain syndrome (IC/BPS) and recurrent bacterial cystitis. Our previous immunohistochemistry (IHC) study and electron microscopic study revealed that the loss of normal umbrella cells and defective junction proteins in IC/BPS and recurrent cystitis. Platelet-rich plasma (PRP) has been previously used in many medical aspects as regenerative medicine therapy. PRP is rich in many growth factors and cytokines which modulate the process of inflammation and regeneration in the wound healing process. Recent pilot studies have shown that intravesical PRP injections improve IC symptoms and yield a success rate of 70% at 3 months after treatment. The results highly suggest that PRP injection could improve urothelial regenerative function and reduce chronic inflammation in IC patients. This article reviews recently published researches on the urothelial dysfunction biomarkers, urothelial cell differentiation, and urinary regenerative and inflammatory proteins in patients with IC/BPS or recurrent bacterial cystitis. The pathophysiology of the insufficient urothelial regeneration and differentiation; and chronic inflammation may induce urothelial dysfunction and further affect the regenerative ability of the diseased bladder urothelium in IC/BPS and recurrent bacterial cystitis are discussed. [ABSTRACT FROM AUTHOR]

Overactive bladder (OAB) syndrome is highly prevalent in both men and women and might have negative impact on quality of life. Clinical trials of OAB usually highly select participants that may not reflect the real-world practice of OAB patients. The spectrum of OAB includes patients with idiopathic, neuropathic, with bladder outlet obstruction, and patients in elderly and medical comorbidities. Patients might have poor response to OAB medication or have adverse events after treatment. Therefore, treatment of OAB should be individualized to obtain therapeutic efficacy and avoid unacceptable adverse events. This article reviews the recently published literature and provides a guide for physicians to choose the appropriate treatment for different OAB patients. [ABSTRACT FROM AUTHOR]

Botulinum toxin A (BoNT-A) has been widely used in the treatment of overactive bladder and neurogenic detrusor overactivity. Recently, prostatic injection of BoNT-A had been tried to reduce the prostate volume and relieve lower urinary tract symptoms (LUTS) in patients with benign prostatic enlargement (BPE) due to benign prostatic hyperplasia (BPH). However, the efficacy of BoNT-A on BPE is still controversial. Traditionally, male LUTS have been considered as synonym of BPE because most male LUTS developed in aging men. Recent investigations have revealed that bladder dysfunction and bladder outlet dysfunction other than BPE contribute equally in male LUTS. Injecting BoNT-A into the prostatic urethra and bladder neck yielded improvement of LUTS, but not reduction of the prostatic volume, especially in men with small prostatic volume. The therapeutic effects of BoNT-A on LUTS might not be due to prostatic volume reduction, but through inhibiting the adrenergic hyperactivity in men with LUTS/BPH. This article discusses the current consensus and controversy of BoNT-A treatment on LUTS/BPH. [ABSTRACT FROM AUTHOR]

Objective This study investigated the urinary incontinence status and urodynamic changes of localized prostate cancer patients after laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RaRP). Materials and methods We enrolled 36 and 30 patients who underwent LRP and RaRP, respectively. The urinary incontinence status and videourodynamic studies (VUDS) of the LRP and RaRP groups during the first year after the surgery were compared. Results The RaRP group was younger and had a smaller prostate volume, shorter operation time, less blood loss, and higher proportion of patients who received postoperative radiotherapy than the LRP group. Twenty RaRP and 26 LRP patients completed VUDS during the 1-year follow-up. Overall, reduced detrusor voiding pressure (Pdet), increased maximal urinary flow rate (Qmax), and reduced bladder outlet obstruction index (BOOI) were detected at 3, 6, and 12 months postoperatively. At 12 months, both the LRP and RaRP groups had similar significant reductions of Pdet. However, only the RaRP group had a significant increase of Qmax and significant reduction of BOOI. Overall, 56.5% of patients (26 of 46) had detrusor overactivity (DO) before the surgery. The de novo DO rate and DO remission rate were 15.2% and 19.6%, respectively, without significant difference between the LRP and RaRP groups. At 6 months, the RaRP group had a significantly lower rate of stress urinary incontinence (SUI) than the LRP group (4.5% versus 47.2%, p = 0.003). In the RaRP group, the greater degree of recovery of both stress and urgency urinary continence developed during the first 6 months postoperatively. Conclusion The changes of VUDS at 12 months postoperatively for radical prostatectomy included reduced Pdet and BOOI, and increased Qmax. At 6 months, the RaRP group had a lower SUI rate then the LRP group. The key phase of urinary continence recovery was the first 6 months after the surgery. [ABSTRACT FROM AUTHOR]

Objective To investigate the underlying pathophysiology in the urothelium of different lower urinary tract diseases (LUTDs) and in patients with overactive bladder (OAB) or hypersensitive bladder (HSB), including chronic inflammation, barrier proteins, and sensory functional receptors. Materials and Methods A total of 156 patients, including 14 with idiopathic OAB, 11 with detrusor overactivity and inadequate contractility (DHIC), 19 with end-stage renal disease (ESRD) and HSB, 26 with spinal cord injury (SCI) and detrusor overactivity (DO), 23 with bladder outlet obstruction (BOO) and DO, 19 with diabetes mellitus (DM) and OAB, 20 with interstitial cystitis (IC), and 24 with ketamine cystitis (KC) were investigated for urothelial dysfunction and sensory protein expressions. Twenty control patients without LUTD were invited and separated into two groups for comparative studies. All participants had urodynamically proven DO or increased bladder sensation on video urodynamic studies. Urothelial dysfunction and functional receptor expressions were investigated and compared between patients with LUTD and controls. Results All patient subgroups had significant increases in mast cell activation and apoptotic cell counts and a decrease in E-cadherin expression. P2X3 expression was significantly decreased in DHIC but was increased in BOO/DO. Urothelial M3 expression was significantly increased in patients with OAB, BOO/DO, DM/OAB, and KC. M2 expression was significantly decreased in DHIC but increased in patients with BOO/DO. β3-AR expression was significantly decreased in patients with OAB and increased in patients with DHIC, ESRD/HSB, DM/OAB, and KC. Patients with OAB and BOO/DO had significantly increased M2/β3-AR. Lower M2/β3-AR was associated with lower voiding efficiency and large postvoid residual (PVR) in DHIC, ESRD/HSB, and SCI/neurogenic detrusor overactivity (NDO). Conclusion Patients with OAB or HSB showed increased urothelial inflammation and lower barrier protein expression. Increased M3/β3-AR or M2/β3-AR in the urothelium was associated with OAB, whereas decreased M3/β3-AR or M2/β3-AR was associated with poor voiding efficiency and large PVR in LUTD. [ABSTRACT FROM AUTHOR]

Objective Patients with interstitial cystitis (IC) and ketamine cystitis (KC) usually have similar symptoms, such as frequency, urgency, and bladder pain. In patients with IC, ulcer type and nonulcer type may have different cystoscopic features. This study investigated the clinical characteristics and bladder wall thickness (BWT) measured using computed tomography (CT) in patients with nonulcer IC, ulcer IC, and KC. Materials and methods The detailed history and bladder condition of patients with a clinical diagnosis of IC and KC were retrospectively analyzed. An abdominal to pelvis CT scan with/without contrast was performed in every patient. Ulcer type IC was noted in nine patients, nonulcer IC in seven patients, and KC in 13 patients. The bladder mass volume and BWT were measured. Bladder CT images of 10 patients with nonmetastatic renal cancer served as controls. Results The bladder wall was significantly thicker in all patients with ulcer type IC (8.91 ± 2.67 mm) and KC (10.7 ± 3.44 mm) than in those with nonulcer IC (2.89 ± 0.73 mm) or controls (2.65 ± 0.97 mm). Among KC patients, eight patients received augmentation enterocystoplasty. Moreover, the bladder wall was significantly thicker in patients who underwent augmentation enterocystoplasty (11.50 ± 3.21 mm) than those who did not (9.50 ± 3.81 mm). The bladder mass volume was increased in patients with KC who received augmentation enterocystoplasty (35.67 ± 11.19 mL) compared with those who did not (21.24 ± 7.25 mL). BWT significantly correlated with visual analogue scores for pain ( R 2 = 0.484, p < 0.001), functional bladder capacity ( R 2 = 0.31, p = 0.002), and maximum bladder capacity ( R 2 = 0.469, p < 0.001) in overall patients. Conclusion There are obvious differences in bladder CT scans of patients with symptoms of bladder pain due to different etiology. Increased BWT was associated with increased pain scores and decreased bladder capacity in patients with KC and IC. BWT on a CT scan might be considered a marker for the severity of bladder inflammation. [ABSTRACT FROM AUTHOR]

Voiding dysfunction due to detrusor underactivity or urethral sphincter dysfunction is a treatment challenge for urologists. Recently, urologists have used botulinum toxin A (BoNT-A) injection into the urethral sphincter to treat voiding dysfunction. This treatment has been found to decrease urethral pressure and postvoid residual volume, and increase voiding efficiency in patients with neurogenic detrusor sphincter dyssynergia, nonneurogenic dysfunctional voiding, and detrusor underactivity. Although not all patients can achieve excellent therapeutic outcomes, patients with idiopathic detrusor underactivity might have recovery of detrusor contractility after urethral sphincter BoNT-A injection. However, urinary incontinence might be a de novo adverse event after treatment. Repeat urethral injection is necessary to maintain therapeutic efficacy. Patients should be fully informed of the limited therapeutic efficacy and possible adverse events prior to treatment. This article reviews recent studies of urethral sphincter BoNT-A treatment for voiding dysfunction. [ABSTRACT FROM AUTHOR]

Objectives Lower urinary tract symptoms (LUTS) are highly prevalent in aging men. In this study we examined the relationship between age, total prostate volume (TPV), and videourodynamic study findings. Methods We retrospectively analyzed a total of 971 men ≥ 40 years of age referred to us for investigation of LUTS. We analyzed the distribution of the different videourodynamic study diagnoses in male LUTS by correlating their age and prostate size. Results The most common diagnosis in the bladder outlet obstruction (BOO) group differed significantly by age and poor relaxation of the external sphincter (PRES) in those aged < 50 years; bladder neck dysfunction in those aged 50–69 years, and benign prostatic obstruction in those ≥ 60 years. Detrusor overactivity was the most common diagnosis in all ages in the bladder dysfunction group, and the cases of hyperactivity with impaired contractility (DHIC) increased with age. In patients < 50 years of age, PRES was the most common diagnosis in the BOO group in both those with small prostates (total prostate volume ≤ 40 mL) and large prostates (total prostate volume > 40 mL). In patients aged 50–69 years, the most common diagnosis in those with BOO and a small prostate was bladder neck dysfunction, and that in those with BOO and a large prostate was benign prostatic obstruction. Similar results were observed in patients aged ≥ 70 years. In all age groups, the majority of patients with detrusor overactivity, hypersensitive bladder, detrusor underactivity, and DHIC had a small prostate. Conclusion In male LUTS, the diagnoses in the BOO group differed by age and prostate volume. In young patients with BOO, the leading diagnosis was PRES, and the contribution of prostate volume to BOO increased with age. As age increased, the bladder function became more complex with an increased percentage of patients with DHIC. Both bladder outlet and bladder functions were affected by age. [ABSTRACT FROM AUTHOR]

The prevalence of overactive bladder (OAB) increases with age. Degeneration of the central nervous system in the elderly has been proposed as one of the pathogenic factors of OAB. Antimuscarinic therapy is effective in the treatment of OAB; however, intolerable systemic adverse events and cognitive dysfunction during treatment with nonselective antimuscarinic agents is of growing concern in elderly patients. The newly developed beta-3 adrenoceptor agonist mirabegron does not adversely affect flow rate and detrusor pressure, and its therapeutic efficacy and tolerability are similar in patients aged > 65 years and > 75 years, suggesting it might be the therapeutic choice in older patients with OAB. Nocturia can cause sleep deprivation at night and increase daytime sleepiness and loss of energy in the elderly. Desmopressin add-on therapy is effective in improving nocturia and storage symptoms. However, elderly patients with a baseline serum sodium level below the normal range are at high risk of developing significant hyponatremia. [ABSTRACT FROM AUTHOR]

Interstitial cystitis or bladder pain syndrome (IC/BPS) is a disease of unknown etiology manifested with bladder pain and frequency urgency symptoms. Although several pathophysiologic mechanisms have been proposed, the underlying mechanism of IC/BPS is still unclear. Accumulated evidence supports that IC/BPS is actually a spectrum of clinical phenomena that involves several different genes and environmental factors. Heterogeneous syndromes are seen in patients with IC/PBS, which suggests that the disease should be classified into different subtypes. Abnormal expressions of several bladder epithelial markers, including mast cells, epithelial differentiation proteins, cell membrane proteins, neurotransmitters, and cytokines, are present in IC/BPS. This review discusses the possible biomarkers that may play crucial roles in IC/BPS, and especially focuses on those that have the potential to be used as biomarkers for prognosis and for the determination of the best treatment for patients. [ABSTRACT FROM AUTHOR]

Ketamine, an n -methyl- d -aspartic acid receptor complex antagonist, has been used as an anesthetic and/or analgesic. However, in the past decade, ketamine has been illegally available as a recreational drug in Asian countries and Taiwan. Due to the characteristic of being short-acting, youngsters widely assume that ketamine is not as harmful as other drugs, such as heroin. Consequently, many young patients used this drug for a longer duration before they presented with severe urinary frequency and urgency symptoms. Subsequently, other cases have been reported in Taiwan, Hong Kong, Singapore, Malaysia, and Europe. Ketamine abuse is increasing, with rates of 0.30% in 2006 to 0.40% in 2007 among those in the 16–59 year age group. In general, affected patients tend to be young with a peak age range of 16–35 years. The incidence of lower urinary tract symptoms in ketamine abuse patients is around 30%. The actual underlying pathomechanism of ketamine cystitis (KC) and associated pelvic pain remains unclear. It is speculated that chronic contact and stimulation to the bladder or ureteral mucosa due to metabolites of ketamine will result in submucosal edema, vascular ectasia, fibrosis, detrusor muscle inflammation, and fibrosis. Presentations of KC include remarkable dysuria, urinary frequency/urgency, urge incontinence, and bladder pain. Urine culture usually fails to yield any microbiology in KC with bladder pain alone. The majority of patients can enjoy clinical improvement after cessation of ketamine and urological treatment similar to interstitial cystitis/bladder pain syndrome (IC/BPS). However, patients who are still abusing ketamine and/or who have a longer duration of ketamine abuse might suffer from severe bladder pain, which does not respond to empirical oral or intravesical treatments such as hyaluronic acid. Among these patients, most have a remarkably impaired quality of life and are at risk of developing upper urinary tract damage, including hydronephrosis and kidney injury. To reduce bladder pain, improve quality of life, and avoid further deterioration of renal function, surgical intervention might be indicated. [ABSTRACT FROM AUTHOR]

Objective The actual pathophysiology of interstitial cystitis (IC)/bladder pain syndrome (BPS) is still uncertain. Immune or hypersensitivity mechanisms may play an important role in the pathogenesis of IC/BPS. This study was designed to investigate and analyze serum immunoglobulin E (IgE) levels in patients with IC/BPS. Materials and methods Patients with IC/BPS who were admitted for cystoscopic hydrodistention were enrolled in this study. Blood samples were obtained to investigate their serum IgE levels. A serum IgE level more than 200 IU/mL was considered abnormal. The patients' symptoms, visual analog scale (VAS) scores, O'Leary–Sant symptom (OSS) scores, cystometric bladder capacity (CBC), maximal bladder capacity (MBC), and grading of bladder glomerulation hemorrhage during cystoscopic hydrodistention were recorded. Serum IgE levels were also investigated in women with stress urinary incontinence, who served as the control group. Results Two hundred patients with IC/BPS and 35 controls were investigated. In total, 22 IC/BPS patients (11%) had abnormal serum IgE levels. No abnormal serum IgE levels were detected in the controls. The mean serum IgE level in IC/BPS patients and controls were 102.37 IU/mL ± 250.68 IU/mL and 74.21 IU/mL ± 88.62 IU/mL, respectively ( p = 0.204). The VAS, OSS, CBC, MBC, and grading of glomerulations were not significantly correlated with serum IgE levels ( p = 0.317, 0.587, 0.774, 0.559, and 0.309, respectively). The serum IgE levels were slightly higher in men than in women, although the difference was not significant (152.98 IU/mL ± 201.73 IU/mL vs. 94.87 IU/mL ± 262.54 IU/mL, p = 0.183). Conclusion In this study, 11% of patients with IC/BPS had IgE level more than 200 IU/mL, but the mean serum IgE level was not higher than the controls. Aggravating factors such as food or environmental substance should be carefully investigated in IC/BPS patients with elevated serum IgE levels. [ABSTRACT FROM AUTHOR]

Objective Hyaluronic acid (HA) is currently used in Taiwan as intravesical instillation for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS). This study investigated the therapeutic effects of HA on IC/BPS in the Taiwanese population. Materials and methods Men and women aged ≥18 years with documented IC/BPS were initially treated with four weekly intravesical HA instillations (treatment time, 1 month) and then with five monthly instillations (total treatment time, 6 months). Clinical assessments included the evaluation of the Visual Analog Scale (VAS) score of bladder pain, O'Leary–Sant Symptom (OSS) score, IC Symptom Index (ICSI), IC Problem Index (ICPI), functional bladder capacity (FBC), uroflowmetry parameters, and global response assessment (GRA). Therapeutic effects were compared between responders (GRA increased ≥ 2 scales) and nonresponders (GRA increased < 2). Multivariate linear analysis was used to determine predictive factor for successful treatment. Results A total of 64 patients (3 men and 61 women) with mean age of 49.4 years (range, 20–79) completed the study. Compared with the baseline data, VAS, ICSI, ICPI, OSS score, daytime frequency, nocturia, and FBC all improved at 1 month or 6 months after starting HA treatment. Significantly more improvements in ICSI, ICPI, OSS score, VAS, and FBC were noted in the responders than in the nonresponders at 6 months of treatment. A low-grade glomerulation was the only predictor for successful treatment response to intravesical HA treatment. Conclusion Intravesical HA administrations improved IC symptoms, decreased bladder pain, and decreased frequency after four instillations, and decreased nocturia and increased bladder capacity after completion of all nine instillations. Low-grade glomerulation predicts successful outcome. [ABSTRACT FROM AUTHOR]

Objective Mirabegron, a β 3 -adrenoceptor agonist, has been shown to be effective and safe in the treatment of overactive bladder (OAB). The aim of this study was to assess the efficacy and safety of mirabegron (50 mg) versus placebo in Taiwanese patients with OAB. Materials and patients This was a multicenter, randomized, double-blind, parallel-group, placebo- and active-controlled trial conducted at 12 sites in Taiwan. Patients were randomized in a 1:1:1 ratio to receive placebo, mirabegron (50 mg), or tolterodine extended release (4 mg) orally once daily for 12 weeks. The primary efficacy end point was the change in the mean number of micturitions per 24 hours from baseline to the final visit. Secondary end points were volume voided, and the number of urgency, urinary incontinence, urge incontinence, and nocturia episodes per 24 hours; in addition, the King's Health Questionnaire (KHQ) was administered to assess effects on quality of life. Results A total of 218 patients were included in the full analysis set (68 in the placebo group; 76 in the mirabegron group; and 74 in the tolterodine group). The adjusted mean difference between the mirabegron and placebo groups for the change in mean number of micturitions per 24 hours was −1.42 ( p = 0.004). The adjusted mean difference between the mirabegron and placebo groups with regard to the change in volume voided per micturition was 16.7 mL ( p = 0.013). However, the mirabegron group did not show statistically significant superiority to the placebo group in the other efficacy variables. There was also no statistically significant difference between mirabegron and placebo in any KHQ domain score. The incidence of treatment-emergent adverse events in the mirabegron group was low and similar to that in the placebo group. Conclusion Mirabegron at a dose of 50 mg once daily for 12 weeks is superior to placebo in reducing the frequency of micturitions in Taiwanese patients with symptoms of OAB. No clinically relevant, serious adverse events were identified. [ABSTRACT FROM AUTHOR]

The purpose of this guideline is to direct urologists and patients regarding how to identify overactive bladder (OAB) in male patients with lower urinary tract symptoms (LUTS) and to make an accurate diagnosis and establish treatment goals to improve the patients' quality of life (QoL). LUTS are commonly divided into storage, voiding, and postmicturition symptoms, and are highly prevalent in elderly men. LUTS can result from a complex interplay of pathophysiologic features that can include bladder dysfunction and bladder outlet dysfunction such as benign prostatic obstruction (BPO) or poor relaxation of the urethral sphincter. Diagnosis of OAB in male LUTS leads to accurate diagnosis of pure OAB and bladder outlet-related OAB, and appropriate treatment in men with residual storage symptoms after treatment for LUTS. [ABSTRACT FROM AUTHOR]

Purpose To search for risk factors for delayed urinary continence after laparoscopic radical prostatectomy (LRP). Materials and methods Patients who received LRP for localized prostate cancer between January 2011 and December 2013 were enrolled. All patients were evaluated with a detailed history, physical examination, and videourodynamic study (VUDS) prior to the operation. After surgery, they were followed up in the outpatient department at 1 month, 3 months, 6 months, and 12 months. The clinical patient data and VUDS parameters were compared between subgroups of patients with and without stress urinary incontinence (SUI), urgency, or urgency urinary incontinence (UUI) according to their clinical symptoms 6 months after surgery. Results A total of 48 patients with a mean age of 72.1 ± 5.68 years were enrolled. Patients with SUI had a larger mean baseline total prostate volume (TPV) (61.42 ± 30.4 mL vs. 45.64 ± 19.98 mL, p = 0.04), higher cancer stage (47.6% vs. 18.5%, p = 0.031), and longer operation time (269.95 ± 52.17 minutes vs. 230.15 ± 48.77 minutes, p = 0.011) than those without SUI. Most baseline VUDS parameters were not significantly different between SUI and non-SUI subgroups except for full sensation (FS; p = 0.037) and the presence of bladder outlet obstruction (BOO; 52.4% vs. 22.2%, p = 0.038). Patients with urgency had a higher maximal flow rate ( p = 0.046) than those without. Patients with postoperative UUI had a larger first sensation of filling (FSF; p = 0.035) than those without. Interestingly, baseline urodynamic detrusor overactivity (DO) and BOO did not have an impact on postoperative urgency or UUI. Multivariate analysis showed no parameters which predicted SUI, urgency, or UUI after radical prostatectomy. Conclusion Preoperative small bladder capacity at FS, large prostate, and BOO are predicting factors of SUI at 6 months after LRP. Baseline DO and BOO did not have an impact on postoperative urgency or UUI. [ABSTRACT FROM AUTHOR]

Detrusor underactivity (DU) is frequently encountered in elderly patients with chronic medical or neurological diseases. DU causes chronic urinary retention or large postvoid residual urine that is usually difficult to manage. The pathophysiology of DU may involve neurogenic, myogenic, and bladder outlet pathologies. Recent studies also reveal that urothelial dysfunction of the urinary bladder may be associated with impaired bladder sensation as well as impaired detrusor contractility. This article reviews recent research on the prevalence, pathophysiology, and clinical management of DU. Comprehensive clinical investigations and basic research may provide a better understanding and effective treatment for this common but difficult bladder disorder. [ABSTRACT FROM AUTHOR]

Chronic pelvic pain syndrome in men is characterized by lower urinary tract symptoms consisting of pelvic pain, variable urinary symptoms, and sexual dysfunction. Chronic pelvic pain syndrome is different from chronic prostatitis, in which an identifiable bacterial infection or a positive bacterial culture can be obtained. Chronic pelvic pain syndrome affects approximately 7% of men and causes significant morbidity, disability, and cost. The assessment of men with chronic prostatitis/chronic pelvic pain syndrome involves a cascade of diagnostic steps, including an evaluation of the clinical presentation, physical examination, evaluation of urine and expressed prostatic secretions, special examination of the seminal plasma, and a search for common bacteria and uncommon pathogens. Cystoscopy, urodynamics, and medical imaging studies may provide valuable information for patients with predominantly urinary symptoms. Histopathological examination of prostatic biopsy samples may also be beneficial. [ABSTRACT FROM AUTHOR]

This article reports the current evidence and expert opinions on the diagnosis and management of neurogenic lower urinary tract dysfunction (NLUTD) in Taiwan. The main problems of NLUTD are failure to store, failure to empty, and a combination of these two. Priorities in the management of NLUTD, in order of importance, should be the following: (1) preservation of renal function; (2) freedom from urinary tract infection; (3) efficient bladder emptying; (4) freedom from indwelling catheters; (5) patient agreement with the management modality; and (6) avoidance of medication after proper management. Management of the urinary tract in patients with spinal cord injuries or multiple sclerosis must be based on urodynamic findings rather than on inferences from the neurological evaluation. Identification of high-risk patients is important to prevent renal functional impairment in those with chronic NLUTD. The lower urinary tract function of patients with NLUTD should be regularly followed up by urodynamic study, and any urological complication should be treated adequately. Avoiding a chronic indwelling catheter can reduce the incidence of developing a low compliant bladder. Intravesical instillation of vanilloids and injecting botulinum toxin-A are alternative treatments for refractory detrusor overactivity or a low compliant bladder, and can replace the need for bladder augmentation. When surgical intervention is necessary, less invasive types of surgery and reversible procedures should be considered first, and any unnecessary surgery in the lower urinary tract should be avoided. Keeping the bladder and urethra in good condition without the interference of neuromuscular continuity provides patients with NLUTD the opportunity to use new technologies in the future. Improving the quality of life in patients with neurogenic voiding dysfunction is the most important aspect of treatment. [ABSTRACT FROM AUTHOR]

Abstract: This article reports the current evidence and expert opinions on diagnosis and management of neurogenic lower urinary tract dysfunction (NLUTD) in Taiwan. The main problems of NLUTD are failure to store, failure to empty, and combined failure to store and empty. The priority of management of NLUTD should follow the order of: (1) preservation of renal function; (2) freedom from urinary tract infection (UTI); (3) efficient bladder emptying; and (4) freedom from indwelling catheter, and patients' expectation of management should be respected. Management of the urinary tract in patients with spinal cord injury (SCI) or multiple sclerosis (MS) must be based on urodynamic findings, rather than inferences from the neurologic evaluation. Selecting high risk patients is important to prevent renal function impairment in patients with chronic NLUTD. Patients with NLUTD should be regularly followed up for their lower urinary tract dysfunction by urodynamic study and any urological complication should be adequately treated. Avoiding a chronic indwelling catheter can reduce the incidence of developing a low compliant bladder. Antimuscarinic agents with clean intermittent catheterization (CIC) may reduce urological complications and improve quality of life (QoL) in patients with NLUTD. Intravesical injection of botulinum toxin A provides an alternative treatment for refractory detrusor overactivity (DO) or low compliant bladder and can replace the need for bladder augmentation. When surgical intervention is necessary, we should consider the least invasive type of surgery and reversible procedure first and avoid any unnecessary surgery of the lower urinary tract. Keeping the bladder and urethra in a good condition without interference of the neuromuscular continuity provides patients with NLUTD a chance for future new technologies. It is most important to never give up on improving the QoL in patients with NLUTD. [Copyright &y& Elsevier]

Abstract: Objectives: Neurogenic voiding dysfunction (NVD) results in lower urinary tract symptoms and upper urinary tract complications. Management of urinary tract dysfunction in patients with spinal cord injury (SCI) must be based on patient needs and urological complications. This study surveyed the bladder management and urological complications in patients with SCI in Taiwan. Materials and methods: A total of 894 patients with SCI were surveyed throughout Taiwan over a period of 5 years (2007–2011). All patients received neurological and urological examinations, renal sonography, bladder sonography, and urinalysis. They were further requested to report urinary tract infections (UTI), voiding conditions, and bladder management in the past 3 years. The bladder management and urological complications were analyzed based on different SCI levels and duration of disease. Results: Among all patients, 39.7% voided spontaneously or by reflex, 23.8% used percussion to void, 20.9% voided by abdominal pressure, 18.1% used clean intermittent catheterization (CIC), and 22.9% had indwelling catheters or cystostomy. Detrusor sphincter dyssynergia (DSD) was noted in 39.7% of patients and autonomic dysreflexia (AD) in 19.9%. UTI was noted in 483 (54%) patients, hydronephrosis in 110 (12.3%) patients, and severe urinary incontinence in 257 (28.7%) patients. UTI occurred significantly more often in patients without, than with normal voiding. CIC was more frequently used in patients with duration of SCI < 1 year, but the rate of CIC significantly decreased as the duration of SCI increased. Conclusion: The rates of urological complications in patients with chronic SCI remained high in this survey in Taiwan. Patients with a duration of SCI > 5 years chose indwelling catheters or a cystostomy more often than CIC. [Copyright &y& Elsevier]

Abstract: Detrusor sphincter dyssynergia (DSD) and neurogenic detrusor overactivity (NDO) are common conditions in patients with spinal cord injury, multiple sclerosis, and transverse myelitis. With advancements in the clinical application of botulinum toxin A (onabotulinumtoxinA, BoNT-A) injections in the treatment of chronic lower urinary tract dysfunction, there has been much improvement in the management of DSD and NDO. Therefore, we reviewed the current literature with focus on subjective outcomes and patient satisfaction scores after BoNT-A treatment. We searched PubMed for articles on the management of neurogenic bladder using the following keywords: DSD, NDO, BoNT-A, satisfaction, dissatisfaction, quality of life, urodynamics, and lower urinary tract dysfunction. Patients receiving BoNT-A urethral injections for DSD have improvements in voiding volume, decreased postvoid residual (PVR) urine, and maximal urethral pressure. Most patients are satisfied and benefit from less difficult urination. However, some patients are dissatisfied with increased urinary incontinence. The BoNT-A detrusor injections for NDO can significantly increase reflex volume and maximal bladder capacity as well as decrease uninhibited bladder contractions. Most patients are satisfied with reduced urinary incontinence. However, some patients are dissatisfied with increased volumes of PVR urine and more difficult urination. Although published clinical studies usually include only a small number of patients and lack randomization and placebo-controlled groups, they provide important evidence of subjective improvement in the management of patients with DSD and NDO using BoNT-A injections. Urologists should inform patients about the main therapeutic effects and possible disadvantages of BoNT-A injections. [Copyright &y& Elsevier]

Abstract: The current paradigm of diagnosing interstitial cystitis/painful bladder syndrome (IC/PBS) focuses largely on the exclusion of other pathology and symptoms of urinary frequency, urgency, and pain, pressure, or discomfort with bladder filling, and places less emphasis on diagnostic tests. Consequently, many experts have suggested that urodynamic study (UDS) is not recommended for routine clinical use to establish IC/PBS diagnosis. However, recent studies have demonstrated the correlations of UDS variables with clinical symptoms, the results of a potassium sensitivity test, severity of glomerulations, and maximal bladder capacity during cystoscopic hydrodistention. Moreover, a combination of UDS and potassium sensitivity test has been shown to aid in differentiating IC/PBS in women with increased bladder sensation. All of these facts suggest that there might be a role for UDS in the diagnosis of IC/PBS. [Copyright &y& Elsevier]

Abstract: Objective: This study was conducted to investigate patients with bladder pain syndrome (BPS) and cystoscopic findings of Hunner's lesion. The treatment and pathological findings related to Hunner's ulcers are unclear. The purpose of this study is to clarify the characteristics and to develop a new method for the diagnosis and treatment of Hunner's lesions in patient with BPS. Methods: From 2005 to 2011, 12 women with BPS were found to have bladder ulcers by cystoscopy without anesthesia. Previous therapy results for these patients had been limited. All patients received a bladder ulcer biopsy and cystoscopic electrocauterization in our hospital as treatment for the bladder ulcers. Patient demographics, patient clinical history, the characteristics of the cystoscopic findings, and treatment outcomes were recorded. Results: The cystoscopy characteristics of the bladder ulcers were central hyperemic patches with peripheral scarring and increased vascularity. Several subtypes of cystoscopic finding were also identified. The pathology findings of these patients included chronic cystitis with ulceration or eosinophilic cystitis. Mast cells and macrophages were also found in the bladder mucosa by immunohistochemical staining for c-kit and CD68. Nine of the 12 patients were immediately pain-free after electrocauterization, and the other three also showed a marked improvement. The patients' mean Visual Analogue Score before the operation was 9.64 ± 0.81, and their mean Visual Analogue Score after electrocauterization showed significant improvement (2.95 ± 1.85, p < 0.001). Bladder pain relapse occurred at 2–4 months after the procedure in six patients. Conclusion: Patients with BPS who show a poor response to conventional intravesical treatments should receive cystoscopy to identify ulcer type BPS. Treatment of patients by transurethral electrocauterization when they have ulcer type BPS is able to provide pain relief. [Copyright &y& Elsevier]

Abstract: Objective: To investigate the safety and efficacy of first-line antimuscarinic monotherapy for men with predominant storage symptoms in the lower urinary tract based on the International Prostate Symptom Score (IPSS) voiding-to-storage subscore ratio (IPSS-V/S). Materials and Methods: We conducted a prospective open-label study of first-line tolterodine (4 mg daily) monotherapy in 132 men (age 41–90 years) with a total IPSS (IPSS-T) ≥ 8 and IPSS-V/S ≤ 1. The IPSS storage subscore (IPSS-S), voiding subscore, IPSS-T, quality of life (QoL), maximal flow rate, voided volume, and post-void residual urine (PVR) were evaluated after treatment for 1 month and 3 months. Results: The treatment results were satisfactory (global response assessment ≥ 1) in 103 men (78.0%). Mean IPSS-T, IPSS-S, nocturnal frequency, and QoL improved significantly. No patient developed acute urinary retention. However, mean PVR increased significantly (from 51.8 to 63.9 mL), especially among patients older than 70 years. The treatment results did not differ significantly between patients with a total prostate volume (TPV) ≥ 30 mL and those with TPV < 30 mL. Conclusion: First-line antimuscarinic monotherapy is safe and effective for men with IPSS ≥ 8 and IPSS-V/S ≤ 1. The treatment results were similar in men with TPV larger or smaller than 30 mL. However, we recommend that first-line antimuscarinic monotherapy in men older than 70 years should be administered with caution. [Copyright &y& Elsevier]

Abstract: There is a lack of consensus on the pathophysiology of overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). The chronic pain symptoms in IC/BPS and OAB refractory to antimuscarinic agents may be due to central nervous system sensitization and persisting abnormalities in the bladder wall that activate the afferent sensory system. Evidence also indicates that IC/BPS is a heterogeneous syndrome and that the two subtypes, the ulcer type (classic) and nonulcer disease, represent different disease entities. There is a need for noninvasive markers for the differential diagnosis of the subtypes of IC/BPS and OAB. Increased levels of nerve growth factor (NGF) have been reported in the bladder tissue and urine of patients with OAB and IC/PBS. Recent studies have also revealed that serum NGF and C-reactive protein (CRP) are elevated in these two diseases. IC/BPS, but not OAB, involves an aberrant differentiation program in the bladder urothelium that leads to altered synthesis of several proteoglycans, cell adhesion and tight junction proteins, and bacterial defense molecules. These findings have led to the rationale for identifying urinary biomarkers to detect IC/BPS in patients with frequency urgency syndrome such as OAB-dry and OAB-wet. Recently, the markers that have been the focus of the most research are antiproliferative factor, epidermal growth factor, heparin-binding epidermal growth factor, glycosaminoglycans, and bladder nitric oxide. In addition to these urothelial defense molecules, inflammatory proteins in the urine and serum have been found to possess important roles in the pathogenesis of IC/BPS and OAB. The urinary proteome is a potential easily accessible source of biomarkers for differentiation between inflammatory bladder disorders. Analysis of multiple urinary proteins and serum cytokines is a convenient approach to monitoring the activation of inflammatory cells in the bladder tissue. Differences in urinary proteins and serum cytokines might provide a diagnostic basis for IC/BPS and could be a tool for the differential diagnosis between IC/BPS and OAB. [Copyright &y& Elsevier]

Abstract: Objective: Protein arrays are rapidly becoming a powerful means to detect proteins, monitor their expression levels, and investigate protein interactions and functions. We used this technology and demonstrated its application in identifying potential biomarkers for the diagnosis and treatment of interstitial cystitis/painful bladder syndrome (IC/PBS). Materials and Methods: To compare the expression profiles of 40 proteins related to inflammation, 30 proteins related to apoptosis, and 20 proteins related to angiogenesis, we performed a protein array assay using bladder tissues of three normal and six IC/PBS patients and urine samples at the baseline and after three repeated intravesical onabotulinumtoxinA injections. Different protein expression levels were determined using the Image J process. After the onabotulinumtoxinA injections, urine samples of IC/PBS the patient were analyzed using angiogenesis proteins, and results were compared with the untreated baseline data. Results: Of all inflammatory antigens, 15 were slightly promoted in the IC/PBS patients'' bladder tissues. Moreover, 80% of proapoptotic proteins and 10% of antiapoptotic proteins on the protein array increased. We also found that several angiogenesis cytokines decreased in the urine of the IC/PBS patients after the onabotulinumtoxinA injections. Conclusion: Our results indicate that several signal transduction pathways are involved in the pathophysiology of IC/PBS and provide valuable information on the signal networks of different pathways in IC/PBS, including inflammation, apoptosis, and angiogenesis. This is a powerful database to further investigate molecular mechanisms of IC/PBS. [Copyright &y& Elsevier]

Abstract: Objectives: To investigate the therapeutic effects of repeated detrusor onabotulinumtoxinA (BoNT-A) injections on autonomic dysreflexia (AD) in patients with chronic spinal cord injuries (SCI). Materials and Methods: A total of 49 patients with SCI were enrolled to receive two sets of 200 U BoNT-A injections into the detrusor at baseline and 6 months later. The primary end points were improvement in the severity of AD and net change in the grade of incontinence. Secondary end points included net changes in the scores of the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire, and quality of life index as well as urodynamic parameters. Results: A total of 31 men and 18 women with cervical (n = 27) or thoracic (n = 22) SCI were enrolled. They had a mean age of 41.6 years and duration of injury of 8 years. Fifteen patients did not have AD at baseline or after treatment. AD was completely resolved in three patients, and improved in 18; treatment made no difference in three patients and AD was exacerbated in 10. There were no significant differences in any urodynamic variables between patients with and without AD. A significantly greater improvement in the UDI-6 was noted in patients without AD and those in whom AD improved than in those with AD. The occurrence of AD was also not significantly associated with persistent urinary incontinence after the BoNT-A injections. There was no significant difference in the quality of life index between patients with and without AD at the end point. Conclusion: Detrusor BoNT-A injections improved AD in 62% of SCI patients with AD at baseline. [Copyright &y& Elsevier]

Abstract: Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic bladder condition characterized by bladder pain, frequency and nocturia. There is no definite treatment providing a long-term cure for IC/PBS. Recent studies have demonstrated that intravesical botulinum toxin A (BoNT-A) has promising effects on IC/PBS. Repeated BoNT-A injections might provide long-term symptom relief and decrease glomerulations after cystoscopic hydrodistention. Our previous studies demonstrated bladder tissue nerve growth factor is elevated in IC/PBS bladders and decreased in responders to BoNT-A injection associated with decreased visual analog pain scores. Another study revealed that increased urothelial cell apoptosis, decreased cell proliferation, increased mast cell activation, and impaired expression of junction protein E-cadherin were significant in IC/PBS bladders. Further study of apoptotic markers and inflammatory protein expression also revealed that apoptotic signaling molecules, including Bad, Bax, and caspase 3, were increased in the bladder tissues of patients with IC/PBS. The apoptosis and growth arrest of bladder tissues of IC/PBS patients could be due to upregulation of inflammatory signals, including p38 mitogen-activated protein kinase and tumor necrosis factor alpha. We reviewed the possible pathologic mechanisms of the therapeutic effects of intravesical BoNT-A injection and presented the results of our pilot studies of BoNT-A injections for IC/PBS. [Copyright &y& Elsevier]

Abstract: Objectives: Intravesical injection of onabotulinumtoxinA (BoNT-A) provides effective treatment for idiopathic detrusor overactivity (IDO). However, not all patients have successful long-term therapeutic effects. This study investigated the effects of baseline urodynamic parameters on the therapeutic outcome, after injecting 100 U BoNT-A in patients with IDO. Materials and Methods: A total of 174 patients who received a first single intravesical BoNT-A 100 U injection for refractory IDO were included. A successful outcome was defined as an improvement of at least two points on a patient perception of bladder condition scale, which was scored from 0 to 6. The short-term (3 months) and long-term (up to 24 months) success rates were analyzed according to baseline urodynamic parameters, including cystometric bladder capacity, maximum flow rate, postvoid residual, voiding efficiency, and detrusor overactivity (DO) subtypes. BoNT-A- related adverse events were also reported. Results: A successful outcome was reported by 138 (79.3%) patients at 3 months. The baseline urodynamic parameters did not affect the success rates, except that patients with phasic DO had a significantly higher success rate at 3 months than patients with terminal DO. Patients with a baseline postvoid residual (PVR) > 100mL, had higher rates of acute urinary retention and need to strain to void. However, long-term success rates up to 24 months showed no significant differences between patients with different urodynamic parameters. Conclusions: Except for patients with phasic DO, the baseline urodynamic parameters did not affect the treatment outcome of intravesical injection of 100 U BoNT-A for IDO. However, acute urinary retention and difficult urination occurred more often in patients with a baseline PVR of > 100mL. [Copyright &y& Elsevier]

Summary: Background: Dysfunctional voiding is an abnormality of bladder emptying in neurologically normal individuals where the external sphincter activity increases during voiding, and it is difficult to diagnose by symptoms alone. Videourodynamic study could provide great help in differentiating dysfunctional voiding and other voiding disorder. In this retrospective study, we analyze the videourodynamic parameters of the patients with dysfunctional voiding. Purpose: To investigate the clinical presentations and videourodynamic characteristics of adult women with dysfunctional voiding (DV). Methods: A total of 1605 women with lower urinary tract symptoms (LUTS) were investigated with videourodynamic (VUD) studies from 1997 to 2010. The clinical urinary symptoms and VUD characteristics of DV were compared with a group of urodynamically normal controls. Antimuscarinic or alpha-blocker treatment, with or without a skeletal muscle relaxant according to the chief complaint was given. Results: There were 168 women diagnosed with DV. Detrusor overactivity (DO) occurred in 69% of women with DV. Patients with DV had significantly lower cystometric bladder capacity, higher detrusor pressure, lower maximum flow rate, and larger post-void residual volume than the controls. A total of 114 (67.9%) patients had storage symptoms and 54 (32.1%) had voiding symptoms as their chief complaints among those with DV. Among them, urinary frequency (n = 69, 41.1%) was the most common chief complaint, followed by dysuria (n = 54, 32.1%), and urgency incontinence (n = 26, 15.5%). The incidence of urgency incontinence and dysuria were significantly greater than that in the control group, however, the incidence of frequency, urgency, or nocturia showed no significant difference between DV and control groups. Recurrent UTI was a common adverse event, and happened in 20 patients (12%) with DV. The medication, alpha-blocker or antimuscarinic agent, was prescribed to the patients with DV according to their symptoms. The success rates were 41.2% (n = 47) for antimuscarinic therapy and 51.9% (n = 28) for alpha-blocker therapy in patients with storage and voiding LUTS, respectively (p = 0.366). Conclusion: DO and storage LUTS commonly occurred in women with DV, suggesting DO could be one of the etiology in the pathophysiology of DV. VUD studies yielded a high diagnostic rate for DV in women with LUTS. [Copyright &y& Elsevier]

Abstract: Renal cell carcinoma (RCC) metastatic to the pancreas is relatively uncommon, and RCC metastatic to the duodenum is extremely rare, with only a small number of case reports in the literature. We describe a 76-year-old woman with a history of RCC who had been treated by radical left nephrectomy 6 years earlier. The patient presented with anemia, hematochezia, and a bulging mass in the pancreaticoduodenal area, and was treated by pancreaticoduodenectomy. Histopathology confirmed metastatic RCC of the duodenum, the pancreas, and one of the dissected regional lymph nodes. The patient remains healthy to date without recurrence more than 24 months after pancreaticoduodenectomy. Our case report and review of the literature supports the curative surgical treatment in this rare group of patients. [Copyright &y& Elsevier]

Abstract: Objective: Detrusor overactivity (DO) is a urodynamic term for uninhibited detrusor contractions, which occur in the bladder-filling phase. Women with urodynamic DO might have different clinical presentations and pathophysiology involving the bladder, urethra, and pelvic floor. This retrospective study used videourodynamic study (VUDS) to analyze the correlation between clinical symptoms and DO subtypes in women. Materials and Methods: The records of 526 consecutive women with urodynamic DO who underwent VUDS for lower urinary tract symptoms (LUTS) from 1996 to 2009 were included. LUTS were classified as storage, emptying, pain, and postmicturition symptoms. A final diagnosis was made based on VUDS findings. Patients were stratified into the categories idiopathic DO only, DO with inadequate contractility (DHIC), and DO with bladder outlet obstruction (BOO). The main symptoms and associated symptoms were used to analyze the correlation with DO subgroups. A group of 272 women with LUTS who were urodynamically normal served as the symptomatic controls. Results: Among women with DO, 308 (58.6%) had idiopathic DO only, 69 (13.1%) had DHIC, and 149 (28.3%) had BOO. All of the women in the DO subgroups had storage symptoms as the main or associated symptoms. A combination of storage and emptying symptoms were more common in patients with DHIC [49 (71%)] and BOO [77 (51.7%)]. According to the reported storage symptoms in all women, urodynamic DO was detected in 504 (65.5%) of 770 with frequency symptoms, 467 (73.3%) of 637 with urgency symptoms, and 293 (87.5%) of 335 with urgency urinary incontinence. Conclusion: Storage and emptying symptoms are common in women with different DO subtypes. Differential diagnosis of the DO subtype in women should not be based on LUTS alone. [Copyright &y& Elsevier]

Abstract: Clinical diagnosis of lower urinary tract dysfunction (LUTD), such as bladder outlet obstruction (BOO) or overactive bladder (OAB), is usually based on presenting symptoms. A biomarker for objective diagnosis of these LUTDs is mandatory. Detrusor wall thickness (DWT) has been noted to be increased in men with BOO and children with bladder-induced enuresis. Patients with OAB are also found to have thicker DWT compared with controls. Although clinical studies using transabdominal or transvaginal ultrasound examination have reported a thicker DWT in patients with BOO or OAB, the reported data are not consistent and lack standardization. We believe that DWT is a promising biomarker for objective diagnosis of LUTD, but the examination technique, including sonoprobe frequency, route of scanning, magnification, and landmarks of bladder wall measurement, need standardization before DWT can be widely applied for clinical diagnosis of LUTD. [Copyright &y& Elsevier]

Objective: In this study, we tested the validity of the 2009 Chinese version of the King''s Health Questionnaire (KHQ) in patients with an overactive bladder (OAB). Materials and Methods: In 2009, the Taiwan Continence Society commenced linguistic validation and other elements of production required for a Chinese version of the KHQ. Data for the psychometric assessment came from a multicenter clinical trial. Patients who visited urology clinics with OAB and symptoms of urgency frequency with or without urge incontinence were asked to fill out the KHQ at the initial visit and again 1 week later. The internal consistency was measured by Cronbach''s alpha statistics. The test-retest method was used to compare the reliability of responses of the two completed questionnaires using Spearman''s rank correlation coefficient. An alpha value > 0.70 was considered acceptable. Results: In total, 55 patients were enrolled, including 37 women and 18 men. Forty-seven (85.5%) patients correctly completed both questionnaires. The alpha values exceeded the minimum requirement for reliability in all domains of the questionnaire, except for the severity measure item (0.60). The internal consistency was also consistently high between tests 1 and 2 in all domains. Test-retest reliability also showed significant correlations between the two tests in all domains. Conclusion: This study demonstrates that the 2009 Chinese version of the KHQ is a reliable instrument for assessing health-related quality of life in patients with OAB. [Copyright &y& Elsevier]

Abstract: Objective: Urinary nerve growth factor (NGF) has gained great interest in detecting detrusor overactivity (DO) in patients with overactive bladder syndrome. However, the source of urinary NGF has not been fully elucidated. We investigated the relationship of urinary NGF levels and NGF expression in the urothelium and suburothelium of patients with idiopathic DO. Materials and Methods: Bladder tissues not involving the muscle layer were obtained from 18 patients with urodynamic DO with or without bladder outlet obstruction. Urine samples at full bladder were also collected for urinary NGF measurement. Fourteen bladder and urine samples obtained from patients with stress urinary incontinence but no lower urinary tract symptoms served as controls. Urinary NGF levels were measured by ELISA. Expression of NGF in the urothelium was measured by immunohistochemical staining using anti-human antibody, and stained sections were captured by a digital image system. Correlation analysis between the urothelial NGF levels in the bladder tissue and urinary NGF/creatinine (Cr) were performed. Results: Urinary NGF/Cr levels were significantly higher in DO patients (0.78 ± 1.26) compared with the control group (0.01 ± 0.02; p= 0.02). However, NGF expression in the DO urothelium (125.87 ± 21.79) were not significantly higher than the controls (135.60 ± 13.50; p = 0.142). Correlation between urinary and urothelial NGF levels were not significant in both controls and patients with DO (Spearman''s r = −0.32, p = 0.26 and Spearman''s r = 0.28, p = 0.22, respectively). Conclusion: DO patients have higher urinary NGF/Cr levels than controls. However, urothelial NGF expression was no different between the two groups. The results suggest elevated urinary NGF levels in DO patients might not be due to urothelial NGF overproduction. [Copyright &y& Elsevier]