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Hemorrhagic cystitis is the endpoint of a variety of pathologies causing damage to, and diffuse bleeding from, the urothelial lining of the bladder. Etiologies include an array of infections, toxins, pelvic radiation, drugs, and occasionally systemic diseases. In simple as well as complex scenarios, the algorithm for treatment is the same. Underlying causes should be identified and treated, coagulopathies, if present, must be corrected, and supportive care aimed at arresting or controlling the hematuria is instituted. This chapter gives an approach to the various etiologies and management strategies for hemorrhagic cystitis. [ABSTRACT FROM AUTHOR]

The pharmacologic treatment of chronic pelvic pain requires knowledge about several classes of drugs. The standard approach is to use non-opioid drugs such as non-steroidal anti-inflammatory drugs or acetaminophen initially with or without non-opioid adjuvants (or adjuncts). Adjuvant therapy may include anticonvulsants, antidepressants, or a combination of both. Opioids are appropriate, safe, and effective in the treatment of non-cancer chronic pain. When initiating opioid therapy, patients should achieve a stable opioid dose with in a few months and thereafter be monitored regularly for pain relief, functionality, and side effects. Physicians who prescribe opioids should have an understanding of addiction, pseudoaddiction, tolerance, and dependence. [ABSTRACT FROM AUTHOR]

Conservative management of pelvic floor dysfunction (which includes pain with and without urinary symptoms, and incontinence problems) has a 30-70% success rate. Traditionally, the conservative management approach has addressed the pelvic floor from the point of weakness or excessive tone. A nuance of the pelvic floor that has not been previously addressed with pelvic floor therapy is the concept of a shortened pelvic floor. A shortened pelvic floor can appear weak and there may be excessive tone. But there is a point where the increased electrical activity abates and the pelvic floor is left in a shorted state. The primary goal of pelvic floor therapy is control and coordination of the pelvic floor musculature with strengthening being a secondary goal. To treat a short pelvic floor, the clinician must first recognize the condition and then appropriately treat it. Once the length of the pelvic floor is normalized, the primary goals of control and coordination can be achieved setting the foundation for strengthening. [ABSTRACT FROM AUTHOR]

Genitourinary (GU) pain is a complex subject with multiple possible causes and therapies. Chronic GU pain is often recalcitrant to standard treatment, and patients may be desperate to try anything in search of relief. Complementary and Alternative Medicine (CAM) has enjoyed increased popularity over the past decade, and many patients have sought pain relief from therapies such as herbs, acupuncture, and hypnotherapy. This chapter will review the topic of CAM and the state of the research in CAM therapies for GU pain. [ABSTRACT FROM AUTHOR]

Chronic pain after genitourinary prosthesis (penile, artificial urinary sphincters, and testicular) implantation is most often associated with infection or erosion. Management of infected or eroded devices requires device removal. Chronic pain in the absence of infection or erosion is rare. Most genitourinary prostheses are made with silicone or silicone elastomer. In the past, testicular prostheses usually contained silicone gel but today they do not. The controversy surrounding silicone breast implants and connective tissue disease is discussed. There is no significant evidence linking genitourinary prostheses and connective tissue disorders. [ABSTRACT FROM AUTHOR]

Although often a necessary intervention, urinary catheters are the leading cause of urinary tract infection (UTI) in hospitalized patients and are associated with significant morbidity, mortality, and cost. Avoidance of prolonged or any bladder catherization is recommended if possible. Pro-active care should be used to maintain optimal mechanical and antimicrobial operations. Numerous trials of oral antibiotics and urinary acidifying agents, antimicrobial bladder washes, antimicrobial drainage bag solutions, and topical disinfectants confirm that bacteriuria and UTI can be suppressed temporarily, but resistant flora eventually appear. Closed drainage systems remain the cornerstone for preventing catheter-associated UTI. [ABSTRACT FROM AUTHOR]

The use of sling procedures, including bone-anchored slings, is gaining popularity for the treatment of stress urinary incontinence secondary to anatomical disruption of the urinary sphincter following radical prostatectomy and occasionally transurethral prostatectomy. Although the incidence of osteomyelitis as a complication of pelvic surgery is low, careful preoperative and intra-operative use of antibiotics should be employed to achieve the best surgical and post-surgical outcomes and minimization of morbidity. This chapter discusses the signs and symptoms used to diagnose and the modalities used to treat infectious complications. [ABSTRACT FROM AUTHOR]

Etiologies of rectourethral fistula (RUF) include trauma, inflammatory processes, congenital defects, and prior pelvic surgery. Increasingly, RUF is being diagnosed in men who have received radiation therapy for prostate cancer. The most common presenting symptoms of RUF include passage of urine per rectum, irritative voiding symptoms, pneumaturia, and fecaluria. Spontaneous closure of RUF is uncommon and has not been reported in patients with RUF caused by radiation toxicity. Selection of an appropriate surgical approach is dictated by the clinical situation, life expectancy, pre-treatment urinary and bowel function, and local adjacent tissue damage. This chapter focuses on the diagnosis and surgical management of patients with iatrogenic and radiotherapy-induced RUF. [ABSTRACT FROM AUTHOR]

This chapter explores female genitourinary (GU) pain from a psychological perspective, including the question of whether it is a psychosomatic or somatoform disorder. Dyspareunia and vaginismus are explained in the context of the DSM-IV-TR classification as psychiatric sexual dysfunctions. A newer paradigm is explored, viewing female GU pain, or the vulvodynias, as chronic pain disorders as opposed to sexual dysfunctions. Subtypes of vulvodynia, both organic and non-organic (or idiopathic) in etiology, are presented. Psychosocial factors in the idiopathic female GU pain disorders, known as dysesthetic vulvodynia (DV) and vulvar vestibulitis syndrome (VVS), are explored. Psychosocial strategies recommended for use in the multidisciplinary treatment of female GU pain and suggestions for future research are reviewed. [ABSTRACT FROM AUTHOR]

Historically, urethral syndrome has been defined as symptoms suggestive of a lower urinary tract infection in the absence of significant bacteruria with a conventional pathogen. In the modern era, components of this term have been separated out into new disease entities such as overactive bladder, functional bladder outlet obstruction, and pelvic pain syndrome including dyspareunia and vulvodynia. Proper treatment is best initiated by correct usage of the terminology that describes the patient's symptoms and evaluation, followed by symptom-focused treatment. [ABSTRACT FROM AUTHOR]

Vulvodynia is a condition exclusive to women and involves mostly burning, rawness, and itching of the external genitourinary tract in the absence of obvious concomitant clinical pathology. Vulvodynia often results in painful intercourse. Symptoms impact daily activities and negatively affect quality of life, often with significant economic and psychosocial costs to patients. There are many potential etiologies of vulvodynia. Uncontrolled studies have examined the use of oral, topical, and injection medical therapy as well as physical therapy. Surgical outcome for vestibulitis is favorable, but this should only be considered after all other treatment options have been break exhausted. [ABSTRACT FROM AUTHOR]

Interstitial cystitis (IC) is a chronic pelvic pain syndrome. The key symptoms are urinary urgency, frequency, pelvic pain, bowel dysfunction, and vaginal pain in the abscence of other identifiable causes such as urinary tract infection, bladder cancer, or endometriosis. Treatment should be multifocal, not directed solely toward the bladder, and multimodal encompassing stress reduction, psychological support, dietary/behavioral therapy, pelvic floor and physical therapy, pharmacologic therapy and neuromodulation. [ABSTRACT FROM AUTHOR]

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Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common urological condition characterized by persistent pain in the perineum, pelvic area, and/or genitalia but exhibiting noted symptom variation in men across socioeconomic status, race, and age. Treatment using a biopsychosocial model must focus on providing the individual with specific techniques designed to help increase feelings of control over-persistent and problematic symptoms. The research reviewed emphasized wide variability in patients' responses to pain and biomedical treatment as a likely outcome predicated by the individual's prior history with pain, their cognitive appraisals and behavioral coping responses, the social milieu in which the pain occurs, and the course of the pain pathophysiology. CP/CPPS should not be viewed from a restrictive biomedical model because pain is not a purely physical phenomenon, but rather a complex physical, emotional, and interpersonal fusion, where the negative outcomes are suggested to advance over time if left unchecked. [ABSTRACT FROM AUTHOR]

Although the prevalence of post vasectomy pain syndrome is unknown, it is certain that the incidence of this uncommon complication will increase because of the continued popularity of vasectomy as a highly effective and economic means of contraception. This chapter covers the evaluation of and treatment options available for the sequelae of symptoms associated with post vasectomy pain syndrome and its complications. Therapeutic options are based on expert opinion and the compassionate creativity of specialists. Evidence-based treatments are not available, in part, because the exact cause of this debilitating disorder is, as yet, unconfirmed. [ABSTRACT FROM AUTHOR]

The past 5 years have seen exponential growth in etiologic research and evidence-based therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The focus of this chapter is on symptomatic men without urinary tract infection (UTI), those classified as CPPS or NIH category III. The authors cover etiologies, diagnosis, evaluation, and treatments, including antimicrobials, anti-inflammatory agents, alpha blockers, hormonal manipulations, prostate massage and ejaculation, surgery and minimally invasive therapy, and alternative medicine. [ABSTRACT FROM AUTHOR]

Bacterial prostatitis includes: acute bacterial prostatitis (ABP) and chronic bacterial prostatitis (CBP). Most infections involve only a single bacterial organism. ABP generally presents as a severe febrile illness. CBP is characterized by recurrent urinary tract infection (UTI) due to the same organism, which persists in the prostatic fluid. This chapter outlines the etiologies, diagnosis, evaluation, and treatment of both acute and CBP. [ABSTRACT FROM AUTHOR]

Testicular pain is an assiduous visitor in the urological consultation. When it appears as an acute onset, it constitutes a medical emergency that needs proper evaluation and an immediate solution, sometimes by means of surgery. When it appears as chronic problem, it is a riddle that requires great knowledge to know the wide inventory of differential diagnosis, upon which the mechanisms of testicular pain are based on. Limited knowledge of options of differential diagnosis frequently implies mistaken diagnosis assignation to clinic onset that shares identical signs and symptoms but were originated in different diseases or physiopathology. [ABSTRACT FROM AUTHOR]

Anorectal pain is distressing for the patient and challenging for the physician. The vague and inconsistent use of terms such as proctalgia fugax, levator ani syndrome, spastic pelvic floor, coccygodynia, chronic idiopathic anorectal pain, and pelvic floor dyssynergia make it difficult to identify a cause and an effective therapy. Many conditions, some of which may be potentially fatal, must be excluded before the diagnosis of chronic idiopathic anorectal pain, including conditions of proctalgia fugax and levator spasm, can be made. Therapy for anorectal pain targets muscle spasm though no one therapy has proven ideal. An organized algorithm and a tactful patient approach are required for the management of anorectal pain. [ABSTRACT FROM AUTHOR]

Musculoskeletal and rheumatic complaints account for over 15% of patients' visits in a primary care setting. Although systemic rheumatic disease, in general, is uncommonly associated with lower genitourinary diseases and bladder dysfunction, the myriad of musculoskeletal and rheumatic complaints may co-exist in a patient, and it is important to be aware of more frequent associations. When performing a thorough history and physical examination, it is important to consider genitourinary manifestations of rheumatic diseases such as arthritis of lower spine, pelvis, or hips, spondyloarthropathies, Sjogren's syndrome, and fibromyalgia. Treatment is dependent on the specific disease process involved. [ABSTRACT FROM AUTHOR]

Chronic abdominal pain accounts for 10% of gynecological consultations and over 30% of diagnostic laparoscopies. There are numerous causes of chronic pelvic pain, and it is important to consider non-gynecologic causes such as gastroenterological, urological, and neurological causes. The most common gastroenterological cause of chronic abdominal and pelvic pain is irritable bowel syndrome (IBS), but other gastrointestinal conditions such as diverticular disease of the colon, inflammatory bowel disease, endometriosis, colorectal cancer, hernias, proctalgia fugax, levator ani syndrome, and chronic appendicitis must be considered in the differential diagnosis. When evaluating a patient with IBS and chronic pelvic pain, it is extremely important to establish a relation of trust and respect with the patient, to include a social history, explore the possibility of emotional, physical, or sexual abuse because these are factors that are often ignored by health care providers and have a significant impact in the disease process, symptoms, and clinical outcome. The gastrointestinal system performs complex functions that require the proper function of the intrinsic nervous system (enteric nervous system), central nervous system, neuroendocrine and immune systems. The neuroendocrine system plays an important role in the regulation of intestinal motility, secretions, and visceral sensation. Between 90 and 95% of the serotonin in the human body is found within the gastrointestinal system, particularly within the epithelial layer. There are numerous abnormalities that have been described in IBS including abnormal enterochromaffin cell numbers, serotonin content, tryptophan hydroxylase levels, 5-hydroxyindoleacedic acid levels, serum serotonin levels, and expression of the serotonin-selective reuptake transporter. Therefore, serotonin agonists and antagonist alter sensory input and have a significant effect in gut function including secretion and motility (1,2). The concept of "visceral hyperalgesia" was proposed by Ritchie in 1973 (3), this concept has helped us better understand the pathophysiology and symptoms of IBS, and conceptually, it serves as the basis for some pharmacological treatments; however, this knowledge has not translated into better diagnostic modalities. [ABSTRACT FROM AUTHOR]

Urinary tract infection is one of the most common health problems affecting patients of all ages. It is the most common nosocomial bacterial infection in the elderly. Women are especially prone to urinary tract infections (UTIs). Although prostatitis syndrome accounts for 25% of male office visits for genitourinary tract infections, only 5% are attributed to a bacterial cause. Acute cystitis or pyelonephritis in adult patients should be considered uncomplicated if there are no known functional or anatomic abnormalities of the genitourinary tact. Most of these infections are caused by Escherichia coli. Acute uncomplicated cystitis can be effectively treated with a 3-day course of trimethoprim/sulfametho oxazole (TMZ/SMZ). For acute uncomplicated pyelonephritis, a 10- to 14-day regimen is recommended. Sexually transmitted diseases including those caused by Chlamydia, Mycoplasma hominis, and Ureaplasma urealyticum should be considered potential culprits in sexually active patients. [ABSTRACT FROM AUTHOR]

Screening for sexually transmitted diseases is an essential form of secondary prevention. Physicians should construct a differential diagnosis for genital ulcers, urethritis, vaginitis, and other inflammatory disorders of the genitourinary tract with a higher index of suspicion for sexually transmitted diseases. The authors outline various sexually transmitted infections (STIs) and diseases and current recommended treatment options. [ABSTRACT FROM AUTHOR]

Pudendal neuralgia is a peripheral neuropathy of the pudendal nerve, generally due to compression between the sacrotuberous and sacrospinous ligaments. It is a tunnel syndrome. We have treated persons of both genders between 14 and 87 years of age. The characteristic symptoms are pelvic pains that are aggravated by sitting and driving and reduced by sitting on a toilet seat. Bowel, bladder, and sexual dysfunctions are common. The diagnosis is confirmed at physical examination of the pudendal sensory nerves. Objective neurophysiological tests include quantitative sensory testing of warm detection threshold and the pudendal nerve terminal motor latency test. Pudendal neuralgia is caused by repetitive flexion of the hip as in exercise and athletics, childbirth, sitting, and cycling. Treatment of pudendal neuralgia is analogous to treatment of the carpal tunnel syndrome. Nerve damage is prevented by a self-care protection program. When necessary, pudendal nerve perineural injection (PNPI) of local anesthesia and corticosteroids is necessary. Thirty percent or more patients require decompression surgery of the pudendal nerves. Each of these sequential treatments can provide prolonged relief of more than 5 years. [ABSTRACT FROM AUTHOR]

Skin diseases of the male genitalia represent a diverse spectrum of maladies. Most cases fall into the differential diagnosis: fixed drug eruption, allergic/irritant contact dermatitis, infection, neoplasia/tumor, papulosquamous/systemic, and balanitides. A thorough history and physical examination defining the primary lesion, secondary changes, and distribution will establish most cutaneous diagnoses. [ABSTRACT FROM AUTHOR]

Flank pain has multiple etiologies including but not exclusive to the genitourinary system. Treatment begins with a thorough history and physical examination. Before executing surgical treatment, the urologist would do best to evaluate a complete patient history, associated findings, and laboratory and radiologic tests to determine the cause of flank pain. A structured approach is recommended for diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Chronic pelvic pain is a response of the nervous system to somatic and visceral pathology. Involving multiple pain pathways, it is unlikely to be confined to one organ system or to one mechanism. An understanding of the complex neuroanatomy and pathophysiologic mechanisms is essential to the treatment of patients presenting with this disorder. [ABSTRACT FROM AUTHOR]

A 55-yr-old woman presents with significant apical and anterior vaginal wall prolapse. She had a hysterectomy 5 yr earlier and a cystocele and rectocele repair and uterosacral vault suspension 2 yr ago. Currently, she is bothered by the prolapse, has difficulty voiding, and has a postvoid residual (PVR) of 200 cc. She does not note any incontinence. She is not interested in a pessary. [ABSTRACT FROM AUTHOR]

A 45-yr-old woman with pure stress urinary incontinence (SUI) undergoes a sling procedure. Preoperatively, she had no irritative voiding symptoms and no voiding complaints. After the sling is done, she notes some mild increase in her urinary frequency. At her 6-wk follow-up visit, she complains of onset of urge incontinence requiring two pads per day. She has no SUI. She notes her stream has slowed a bit since the surgery. [ABSTRACT FROM AUTHOR]

The first clinical description of a female urethral diverticulum is credited to Dr. John Hey in 1805. In his essay "Of Collections of Pus in the Vagina," Dr. Hey described the diagnosis and treatment of this entity, which included a transvaginal incision, and packing of the diverticular sac with lint (1). Over the next 150 yr, the medical literature offers scant references pertaining to the topic of female urethral diverticula. However, in 1956, with the advent of a new diagnostic tool in the form of positive pressure urethrography (PPU), the detection and diagnosis of female urethral diverticula demonstrated a predictable dramatic increase (2). [ABSTRACT FROM AUTHOR]

A vesicovaginal fistula (VVF) is an abnormal communication between the bladder and vagina, resulting in continuous leakage of urine through the vagina. It is one of the most significant and devastating conditions in female urology and urogynecology. VVFs have been recognized and described since ancient times, but successful repair was not reported until James Marion Sims': first paper in 1852 (1). His transvaginal repair included the use of silver wire sutures. Many principles he originally described are still applicable. Subsequent advances included the first "layered„ repair by Mackenrodt (2) and the interposed labial fat graft of Martius (3) in the late 1920s. [ABSTRACT FROM AUTHOR]

A 79-yr-old active woman complains of symptoms of mixed incontinence requiring four thick pads per day. Exam reveals no prolapse, a postvoid residual (PVR) of 170 cc and a Q-tip test of 0-30°. Urodynamics demonstrates a Valsalva leak-point pressure of 52 cm H2O, detrusor overactivity, and poor detrusor contraction during voiding. [ABSTRACT FROM AUTHOR]

A 64-yr-old man is 2 yr postradical retropubic prostatectomy for prostate cancer. He currently leaks and uses two to three thick pads per day. He does not leak at night while in bed and can sleep through the night without needing to urinate. Prostate-specific antigen is undetectable. [ABSTRACT FROM AUTHOR]

A 41-yr-old woman complains of urinary frequency and pelvic pain. Three years earlier, she began to have "recurrent urinary tract infections." Cultures were always negative. Since then, she has developed significant urinary frequency and pelvic pain that seems to intensify when she needs to void. She also has significant dyspareunia and says this is ruining her life. She has had a normal office cystoscopy, normal pelvic magnetic resonance imaging (MRI), and urodynamic studies that show early sensation of need to void but no detrusor overactivity or emptying problems. She has been on Elmiron, Atarax, multiple anticholinergics, amitriptylene, and occasionally narcotics for the pain—all without any significant improvement. On exam, she has no prolapse but does have diffuse tenderness throughout the vagina and appears to have a tense pelvic floor by palpation. [ABSTRACT FROM AUTHOR]

A 72-yr-old active woman presents for evaluation of incontinence. She leaks with any sort of activity and wears 11 pads per day. She rarely goes to the bathroom as the bladder rarely fills—it all leaks out. The only time the bladder fills and she has the urge to void is at night in bed, and as soon as she gets the urge, the bladder completely empties before she even stands up. She has had an autologous fascial sling at the bladder neck and four treatments with a bulking agent, all with minimal improvement. On exam, she has no prolapse or urethral hypermobility. Urodynamics show no detrusor overactivity, a capacity of 245 cc, and a Valsalva leak-point pressure of 41 cm H2O. [ABSTRACT FROM AUTHOR]

A 23-yr-old woman presents with slow onset over the course of 2 yrs of worsening hesitancy and slowing of urinary stream and recent onset of urgency and frequency. Her physical exam is normal. Postvoid residual (PVR) is 100 cc. Urodynamics reveal a detrusor pressure at maximum flow of 28 cc H2O and a peak flow of 4 cc/s. Electromyography (EMG) of the external sphincter is normal (not shown on urodynamic studies tracing). Magnetic resonance imaging (MRI) of the pelvis is normal. [ABSTRACT FROM AUTHOR]

A 42-yr-old woman with a 10-yr history of multiple sclerosis presents with worsening voiding complaints. For the past 3 yr, she has had increasing frequency, which was treated successfully with anticholinergics. Recently, she has noticed worsening urgency and has also begun to have hesitancy and straining to void. Physical exam is normal. Postvoid residual (PVR) is 240 cc. Urodynamics demonstrates detrusor overactivity and detrusor-sphincter dyssynergia (DSD). She voids with a detrusor pressure of 37.7 cm H2O with a maximum flow of 5.4 cc/s. [ABSTRACT FROM AUTHOR]

A 57-yr-old woman presents with significant mixed incontinence requiring six heavy pads per day. She says both aspects of the incontinence (stress urinary incontinence [SUI] and urge incontinence [UI]) are equally bothersome. She has failed pelvic floor exercises and multiple anticholinergics. Physical exam reveals no prolapse, but she does have some urethral hypermobility. No other testing has been done. [ABSTRACT FROM AUTHOR]

A 65-yr-old woman presents with a history of chronic urinary tract infections (UTIs) for the past 8 mo. As soon as appropriate antibiotics are stopped, she gets another UTI. Antibiotic prophylaxis has not helped. She also notes recent onset of some urge incontinence and straining to void. On exam, she has significant atrophic vaginitis and a cystocele to the introitus with strain. There is a question of some apical prolapse as well. Postvoid residual (PVR) is 180 cc. [ABSTRACT FROM AUTHOR]

It is estimated that one in nine women in the United States will undergo a hysterectomy during their lifetime, and up to 10% of these women will need surgical repair for treatment of a symptomatic vaginal vault prolapse (1). The search for the repair that offers the best combination of the most effective, safest, and most durable for the treatment of apical prolapse is an ongoing process, as evidenced by the multiple surgical approaches available to treat this problem. Clearly, no one surgical approach is ideal for every patient. However, as the known risk factors for prolapse, such as age, obesity, and hysterectomy, continue to increase in the United States, so does the need for continuing the search for better means to repair vaginal vault prolapse (2-4). [ABSTRACT FROM AUTHOR]

A rectocele occurs secondary to a defect in the supporting fascia of the rectum, which results in herniation of the anterior rectal and posterior vaginal wall into the lumen of the vagina. The true incidence of rectocele is clearly not well identified, as exemplified by prior literature, which places the prevalence at a range from 18 to 80% of the general population (1,2). Wells et al. reported a 12% incidence of rectoceles on physical examination when evaluating patients complaining of urinary incontinence (3). However, Raz et al. noted the need for rectocele repair in 65% of patients who underwent repair of a grade IV cystocele (4). [ABSTRACT FROM AUTHOR]

Prolapse of the anterior vaginal wall is the most common presentation of pelvic organ prolapse. Studies suggested that, of the various segments of the vagina that may be involved in prolapse (anterior, posterior, or apical), the anterior vaginal wall is the segment most likely to demonstrate recurrent prolapse after reconstructive surgery. In addition, normal anterior vaginal support plays an important role in supporting the urethra, and loss of this support can contribute to the development of stress urinary incontinence. It is therefore important that the pelvic reconstructive surgeon understand the normal support mechanisms of the anterior vaginal wall and the full spectrum of techniques for correction of anterior vaginal prolapse and cystoceles. [ABSTRACT FROM AUTHOR]

Normal bladder function is characterized by storage of adequate volumes of urine at low pressures without leakage and without unwanted bladder sensations (urgency) interspersed with short time periods of efficient unimpeded expulsion of urine. Tightly regulated neural control of the bladder and outlet (urethral complex, i.e., internal and external urethral sphincters) is required for the proper integration of urinary storage and expulsion. The bladder and internal urethral sphincter are comprised of smooth muscle fibers, whereas the external urethral sphincter is composed of skeletal striated muscle fibers. Although we have learned much of bladder neurophysiology from studying animal models, the actual pathological defects in bladder dysfunction frequently encountered clinically, such as urinary incontinence (both stress and urge), nonneurogenic detrusor overactivity, hypersensitive bladder syndromes (e.g., overactive bladder [OAB] and interstitial cystitis [IC]), and nonobstructive urinary retention, remain elusive. Animal models have helped test etiological theories and define treatment modalities for disorders of micturition and urinary continence. This review focuses on data obtained from experiments performed with human tissues if available. [ABSTRACT FROM AUTHOR]

Female pelvic anatomy can be a conceptual challenge. To understand the function of the pelvis, one must understand the basic anatomy and then the dynamic nature of the structures that allow for urinary and bowel continence in a variety of circumstances. An understanding of normal anatomy and function provides the clinician with a framework for understanding the pathophysiology of pelvic organ prolapse and female urinary incontinence. The evaluation of female urinary incontinence often involves the recognition and treatment of concurrent pelvic abnormalities, such as cystocele, uterine prolapse, enterocele, rectocele, or perineal laxity. The factors responsible for pelvic floor relaxation rarely affect isolated anatomic areas. This chapter provides a detailed description of normal female pelvic anatomy, and an emphasis is placed on key surgical landmarks for reestablishing normal anatomy. [ABSTRACT FROM AUTHOR]

Many disease processes can result in an "end-stage„ bladder that has a small capacity, poor compliance, and high storage pressures. When surgical intervention is contemplated, the ultimate goals are the preservation of renal function and the restoration or preservation of continence. In carefully selected patients, augmentation cystoplasty can be used to achieve those goals. [ABSTRACT FROM AUTHOR]

Urinary frequency/urgency and urinary urge incontinence, collectively referred to as overactive bladder, represent common problems in the urologist's practice. Although pharmaceutical management and pelvic floor rehabilitation combined with behavioral modification helps many patients with overactive bladder symptoms, a substantial minority of patients are refractory to these interventions. In such refractory cases, sacral neuromodulation, a minimally invasive and reversible treatment, provides an attractive alternative prior to consideration of more invasive and irreversible treatment modalities. This chapter reviews the current state of sacral neuromodulation for the treatment of refractory voiding dysfunction, with emphasis on the techniques, efficacy, risks, and benefits of this procedure. [ABSTRACT FROM AUTHOR]

Neuromodulation is becoming a mainstay as a treatment modality for idiopathic voiding dysfunction. Neuromodulation and neurostimulation have been applied to the sacral nerves and their more distal branches at the level of the anus, vagina, and penis. Sacral nerve stimulation has been approved by the Food and Drug Administration (FDA) since 1997 for the treatment of urinary urge incontinence, urgency, frequency, and refractory retention. Neuromodulation utilizing more distal branches of the sacral nerve roots may have added outcome-related benefits and can be less invasive. [ABSTRACT FROM AUTHOR]

Botulinum toxin is a neurotoxin produced by the Gram-positive, rod-shaped anaerobic bacterium Clostridium botulinum (1). First discovered in 1897 by Professor Pierre Emile van Ermengem of Ellezelles, Belgium botulinum toxin is the most poisonous naturally occurring toxin known to man (2). Seven immunologically distinct antigenic subtypes of botulinum toxin have been isolated: A, B, C1, D, E, F, and G (1). Only types A and B are available for use clinically. Botulinum type A toxin (BTX-A), known as Botox® in the United States and Dysport® in the United Kingdom, is more potent and has a longer duration of action than type B (1,2). Type B is commercially available in the United States as MyoBloc® and in Europe as NeuroBloc® (2). [ABSTRACT FROM AUTHOR]

Overactive bladder (OAB) is a recently defined symptom complex that includes urinary urgency with or without urge incontinence, urinary frequency (voiding eight or more times in a 24-h period), and nocturia (awakening two or more times at night to void) (1-3). The overall prevalence of OAB in Western Europe and the United States is 16-17% (4,5). The symptoms of OAB can affect quality of life and are associated with social, occupational, and psychological disruption. [ABSTRACT FROM AUTHOR]

Multiple classes of drugs, drug therapies, and other pharmacological agents are potentially useful to decrease bladder contractility or decrease sensation and thereby treat overactive bladder (OAB) (see Table 1), but few have been utilized clinically (1). Antimuscarinic agents are the only oral class of drugs that have demonstrated proof of concept in managing this disorder and remain the most commonly prescribed treatment. Since Diokno and Lapides described the properties and application of oxybutynin chloride in the therapy of urinary dysfunction, antimuscarinic therapy has remained the mainstay of therapy for detrusor overactivity and, more recently, the symptom complex known as OAB (2,3). According to the International Continence Society (ICS), OAB is classified as a symptom syndrome and is characterized by urgency, with or without incontinence and sometimes with frequency and nocturia (4). These symptoms are suggestive of detrusor overactivity (that is, urodynamically demonstrable IVCs) but can be attributed to other forms of voiding or urinary dysfunction as well. [ABSTRACT FROM AUTHOR]