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In this review, the current literature regarding pharmacotherapy treatment strategies available for the management of interstitial cystitis/bladder pain syndrome in older adults is addressed. The focus is on those treatments described by the American Urologic Association guidelines, organized according to clinical phenotype. Symptoms at presentation can vary with age, with older adults being more likely to experience nocturia, urinary incontinence, and Hunner's lesions than their younger counterparts. As such, treatment of interstitial cystitis/bladder pain syndrome should follow an individualized multimodal plan based on the patient's unique phenotype(s), starting with the most conservative options and escalating as needed. The side-effect profile and medication interactions should be reviewed, especially when treating older adults, requesting the aid of pharmacists or the primary care physician as needed to safely provide treatment.

Background Posterior tibial nerve stimulation (PTNS) is a promising treatment for lower urinary tract symptoms (LUTS) in patients with MS. However, long term data focusing on PTNS impact on health-related quality of life (HRQOL), bowel and bladder symptoms are lacking. This paper describes a study protocol that examines the extended efficacy of PTNS on MS related bladder and bowel symptoms and resulting HRQOL. Methods/Design This is a single-centered, prospective, longitudinal, observational cohort study of patients with MS who suffer from LUTS and are refractory to two prior treatment modalities. Participants who have elected to pursue PTNS therapy for LUTS will be eligible. The primary outcome is the median number of urinary frequency and incontinence episodes on a 3-day voiding diary at 3, 12 and 24 months compared to baseline. Secondary outcome measures will include change in total AUA-SS, M-ISI, NBSS, SF-12, SSS and BCS scores from baseline The Expanded Disability Status Scale and magnetic resonance imaging will be evaluated at baseline and annually throughout the study. Discussion This research protocol aims to expand on the existing literature regarding outcomes of PTNS in MS. Specifically, it will provide long term follow-up data on bladder, bowel, sexual and HRQOL outcomes. The completion of this study will provide longitudinal efficacy data of the impact of PTNS in MS patients. Trial registration NCT04063852.

INTRODUCTION AND OBJECTIVE:Patients with multiple sclerosis (MS) commonly develop obstructive urinary symptoms and urinary retention, which affect quality of life. Although alpha-1 antagonists (A1A...

AIMS: We determined the prevalence, severity, and correlates of nocturia in a large clinical cohort of patients. METHODS: Patients presenting with lower urinary tract symptoms (LUTS) completed 3-day bladder diaries. Nocturia was quantified based on the mean number of nighttime voids documented over the 3 days. Nocturia subtypes (global polyuria, nocturnal polyuria [NP], reduced global bladder capacity, and reduced nocturnal bladder capacity) were assessed. Bother due to nocturia was measured by the LUTS Tool. Sleep quality was assessed with the Patient-Reported Outcomes Measurement Information System Sleep Scale. Multivariable multinomial regression was used to explore patient characteristics associated with nocturia. RESULTS: In 502 participants with analyzable diaries (285 men and 217 women), the mean number of nocturia episodes over 3 days was 0 in 103 (20.5%), >0 to 0 to

INTRODUCTION AND OBJECTIVE:We evaluated the effectiveness and safety of 3 surgical procedures (Artificial Urinary Sphincter, Suburethral Sling, Urethral Bulking agents) for treating stress urinary ...

INTRODUCTION AND OBJECTIVE:It is not well known if asymptomatic bacteriuria (ASB) at the time of botox injection increases the risk of post-procedure urinary tract infections (UTI) in catheter-depe...

Aims Bother attributed to lower urinary tract symptoms (LUTS) drives care-seeking and treatment aggressiveness. The longitudinal relationship of LUTS severity and bother in a care-seeking cohort, however, is not well understood. We aim to conduct a longitudinal evaluation of LUTS severity and bother and identify characteristics of patients with discordant LUTS bother relative to severity. Methods Men and women with LUTS seeking care at six US tertiary care centers enrolled in the symptoms of lower urinary tract dysfunction research network study. Patients reporting at least one urinary symptom based on the LUTS Tool were prospectively enrolled from June 2015 to January 2017. Correlations were used to assess the relationship between LUTS severity and bother. Discordance scores (ie, the difference between bother and severity) were used to classify patients with high and low bother. Patients were classified as having high or low bother phenotypes if scores were one standard deviation above or below zero, respectively. Repeated measures multinomial logistic regression evaluated characteristics associated with high and low bother phenotypes. Results LUTS severity and bother were at least moderately correlated for all symptom items and highly correlated for 13 out of 21 items. Correlations were highest for urgency, and lowest for daytime frequency and urinary incontinence. Odds of being in high bother phenotype were lowest at 3 and 12 months (3 months vs baseline odds ratio [OR] = 0.71, 95% confidence ninterval [CI] = 0.54-0.94; 12 months vs baseline OR = 0.66, 95% CI = 0.48-0.91), and highest for those who endorsed all urgency questions (OR = 3.65, 95% CI = 2.17-6.13). Odds of being in the low bother phenotype were lowest for patients who endorsed all urgency items (OR = 0.33, 95% CI = 0.26-0.42), and all frequency items (OR = 0.68, 95% CI = 0.53-0.88). Conclusions LUTS severity and bother correlate highly and measurement of both in clinical practice is likely redundant. There are patient factors associated with discordance which may justify additional evaluation.

OBJECTIVES To evaluate the location and depth of placement of sacral sutures in a cadaveric sacrocolpopexy model. MATERIALS AND METHODS Following a 1-hour instructional session, trainees performed an open sacrocolpopexy on unembalmed cadavers under guidance by a Female Pelvic Medicine & Reconstructive Surgery board-certified surgeon. At completion of the session, the presacral tissues were dissected and the location and depth of each sacral suture was identified. RESULTS A total of 19 sutures were placed by 9 trainees into 8 cadavers. The majority of sutures (14/19, 74%) were placed between L5 and S1. Three sutures (16%) were placed at L5 and 2 (11%) were placed at the S1 vertebral body. The mean depth of the anterior longitudinal ligament (ALL) was 1.4 mm. When assessing depth of suture placement, 13 of 19 (68%) were placed into the ALL without penetrating the disc space. Two sutures (11%) were placed in the tissues superficial to the ALL and 4 (22%) were placed deep to the ALL into the periosteum or disc. CONCLUSION This study of cadaveric simulation of open sacrocolpopexy finds that location of sacral suture placement is most commonly at the level of the L5-S1 disc space and that placement of sutures into the underlying disc occurs about 1 in 5 times.

We examined how mental health measures, sleep and physical function are associated with the presence and type of urinary incontinence and severity in women seeking treatment for lower urinary tract symptoms.This baseline cross-sectional analysis was performed in treatment seeking women with lower urinary tract symptoms. All participants completed the LUTS (Lower Urinary Tract Symptoms) Tool (Pfizer, New York, New York), which was used to classify women based on urinary incontinence symptoms and measure severity. The PROMIS (Patient-Reported Outcomes Measurement Information System) questionnaire for depression, anxiety, sleep disturbance and physical function, the PSS (Perceived Stress Scale) and the IPAQ-SF (International Physical Activity Questionnaire Short Form) were administered. Multivariable regression modeling was done to assess associations with urinary symptom presence, type and severity.We studied 510 women with a mean ± SD age of 56 ± 14 years. Of the women 82% were Caucasian, 47% were obese and 14% reported diabetes. Urinary incontinence was reported by 420 women (82.4%), including stress urinary incontinence in 70, urgency urinary incontinence in 85, mixed urinary incontinence in 240 and other urinary incontinence in 25. On adjusted analyses there was no difference in any mental health, sleep or physical function measure based on the presence vs the absence of urinary incontinence. Among women with urinary incontinence PROMIS anxiety and sleep disturbance scores were higher in those with mixed urinary incontinence than stress urinary incontinence. Increasing urinary incontinence severity was associated with higher PROMIS depression and anxiety scores, and higher PSS scores. However, higher urinary incontinence severity was not associated with a difference in sleep or physical function.Among treatment seeking women with lower urinary tract symptoms, increasing urinary incontinence severity rather than the presence or type of urinary incontinence was associated with increased depression, anxiety and stress.

To review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function. A literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Crede; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT). Intermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Crede. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion. The Joint SIU-ICUD (Societe Internationale d’Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

The purpose of this review is to discuss the pathophysiology of neurogenic SUI in the female patient, examine the evidence supporting surgical and non-surgical treatment options, and outline our recommendations for the care of this population. AFPVS appears to be more efficacious than MUS for this group; however, almost all patients will require self-catheterization after surgery. MUS have a higher probability of maintaining spontaneous voiding but also care the risk mesh complications and higher failure rates. Bladder neck AUS placement may also be considered, but most studies show high reoperation rates and have only a few female subjects. In severe refractory cases of SUI or in the setting of urethral erosion, bladder neck closure has been shown to have good continence outcomes. SUI in the setting of neurogenic lower urinary tract dysfunction is often more severe and harder to address than non-neurogenic SUI, due in part to the high rates of ISD in this population. Patients should be screened for other causes of urinary incontinence with UDS prior to any invasive interventions. AFPVS is an appropriate first-line therapy for these patients, particularly in individuals who already perform self-catheterization. Finally, in the setting of moderate to severe urethral erosion, bladder neck closure or urinary diversion should be strongly considered.

To evaluate the association of clinical factors on outcomes in patients with spinal cord injury (SCI) undergoing ureteroscopy. Immobility, recurrent urinary tract infection, and lower urinary tract dysfunction contribute to renal stone formation in patients with SCI. Ureteroscopy is a commonly utilized treatment modality; however, surgical complication rates and outcomes have been poorly defined. Evidence guiding safe and effective treatment of stones in this cohort remains scarce.Records were retrospectively reviewed for patients with SCI who underwent ureteroscopy for kidney stones from 1996 to 2014 at a single institution. Multivariate relationships were evaluated using a general estimating equation model.Forty-six patients with SCI underwent a total of 95 ureteroscopic procedures. After treatment, stone-free rate was 17% and 20% with2-mm fragments. The complication rate was 21%. On multivariate analysis, SCI in cervical (C) levels was associated with higher risk of complications (C3: odds ratio [OR] 3.83, 95% confidence interval [CI] 2.17-6.98; C6: OR 3.83, 95% CI 1.08-13.53). American Spinal Injury Association Scale A classification was associated with a lower probability of stone-free status (OR 0.16, 95% CI 0.03-0.82). Patients averaged 2.2 procedures yet more procedures were associated with lower stone-free status (OR 0.83, 95% CI 0.03-0.32). Chronic obstructive pulmonary disease and bladder management modality were not associated with stone-free status or complications.In patients with SCI, higher injury level and complete SCI were associated with worse stone clearance and more complications. Stone-free rate was 17%. Overall, flexible ureteroscopy is a relatively safe procedure in this population. Alternative strategies should be considered after failed ureteroscopy.

AIMS Bowel symptoms, pelvic organ prolapse, and sexual dysfunction are common, but their frequency among women with lower urinary tract symptoms (LUTS) has not been well described. Our aims were to describe pelvic floor symptoms among women with and without urinary incontinence (UI) and among subtypes of UI. METHODS Women with LUTS seeking care at six U.S. tertiary care centers enrolled in prospective cohort study were studied. At baseline, participants completed the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ-IR), and PROMIS GI Diarrhea, Constipation, and Fecal Incontinence Scales. RESULTS Mean age among the 510 women was 56.4 ± 14.4 years. Women who reported UI (n = 420) had more diarrhea and constipation symptoms (mean scores 49.5 vs 46.2 [P = 0.01] and 51.9 vs 48.4 [P

We described and compared the frequency and type of lower urinary tract symptoms reported by men and women at the time that they were recruited from urology and urogynecology clinics into the Symptoms of Lower Urinary Tract Dysfunction Research Network multicenter, prospective, observational cohort study.At 6 research sites treatment seeking men and women were enrolled who reported any lower urinary tract symptoms at a frequency more than rarely during the last month on the LUTS (Lower Urinary Tract Symptoms) Tool. At baseline the study participants underwent a standardized clinical evaluation and completed validated questionnaires. Urological tests were performed, including pelvic/rectal examination, post-void residual urine measurement and urinalysis.A total of 545 women and 519 men were enrolled in the study. Mean ± SD age was 58.8 ± 14.1 years. At baseline nocturia, frequency and a sensation of incomplete emptying were similar in men and women but men experienced more voiding symptoms (90% vs 85%, p = 0.007) and women reported more urgency (85% vs 66%, p0.001). Women also reported more of any type of urinary incontinence than men (82% vs 51% p0.001), which was mixed incontinence in 57%. Only 1% of men reported stress incontinence but they had other urinary incontinence, including post-void dribbling in 44% and urgency incontinence in 46%. Older participants had higher odds of reporting symptoms of nocturia and urgency.In this large, treatment seeking cohort of men and women lower urinary tract symptoms varied widely by gender and age. Men reported more voiding symptoms and nonstress or urgency urinary incontinence while women reported more incontinence overall and urgency. Older participants had greater odds of urgency and nocturia.

Aims The use of cystoscopy and hydrodistention in the management of interstitial cystitis/bladder pain syndrome (IC/BPS) varies widely between providers. Current evidence regarding the risks and benefits of hydrodistention, as well as the long term effects of repeated hydrodistention are not well established. We sought to characterize the effects of hydrodistention on IC/BPS symptoms as well as bladder capacity. Methods We retrospectively queried our institutional records for patients with non-ulcerative IC/BPS who underwent hydrodistention over an 11-year period to obtain demographic and clinical factors at the time of diagnosis and treatment. Symptom relief and bladder capacity changes were assessed, and multivariable models were used to predict response to treatment. Results There were 328 patients who underwent hydrodistention during the study period, of whom 36% received the procedure multiple times, and overall median follow-up was 38.6 months. Patients with repeated hydrodistentions were more likely to be female, have more comorbid pain disorders, and have trialed anticholinergic medications and intravesical instillations. No decrease in mean bladder capacity was observed over time (P = 0.40). Significant decreases in symptom scores were observed following the procedure on multiple questionnaires. Conclusions Hydrodistention does not decrease bladder capacity even with multiple procedures, and measurably improves symptoms in some patients with IC/BPS. Continuing efforts to better identify those patients most likely to benefit from this procedure are justified.

Introduction: Nephrogenic adenoma (NA) was first described by Davis in 1949 as a “hamartoma” of the bladder. There are many proposed predisposing factors for NA including chronic inflammation, renal transplantation, and bladder cancer. We examined our experience with NA to determine predisposing factors and determine if there was any increased risk for development of subsequent malignancy. Materials and Methods: All patients with a pathologic diagnosis of bladder NA from 2001-2013 were included. Patient history, clinical factors including possible predisposing factors for NA, and follow-up were reviewed. Results: Among 60 patients, 68% were males with an average age of 61, an average BMI of 28.7, and 60% had a smoking history. In evaluating pro-inflammatory factors, 26.7% underwent either Bacillus Calmette-Guerin or mitomycin C, 30% had recurrent urinary tract infections, and 25% had a history of catheterization. Recurrence of NA after initial resection occurred only in 14.7% of patients who underwent follow-up cystoscopy. A history of concurrent bladder cancer was seen in 41.7% of patients, but there were no cases of de novo bladder cancer diagnosed after NA. Conclusion: To the best of our knowledge, this is the largest series of patients with NA of the bladder. NA occurs in a heterogeneous population of patients, but most often with underlying inflammation. NA occurred concurrent with bladder cancer; however there were no cases of de novo bladder cancer after NA, reassuring that NA is likely a benign reactive condition.

Introduction: This study aimed to determine if gentamicin bladder instillations reduce the rate of symptomatic urinary tract infection (UTI) in neurogenic bladder (NGB) patients on intermittent self-catheterization (ISC) who have recurrent UTIs. Secondary aims were to examine the effects of intravesical gentamicin on the organism resistance patterns.Methods: We retrospectively reviewed our prospective NGB database. Inclusion criteria were NGB patients performing ISC exclusively for bladder drainage with clinical data available for six months before and six months after initiating prophylactic intravesical gentamicin instillations. Symptomatic UTIs were defined as symptoms consistent with UTI plus the need for antibiotic treatment.Results: Twenty-two patients met inclusion criteria; etiology of NGB was 63.6% spinal cord injury, 13.6% multiple sclerosis. Median time since injury/diagnosis was 14 years and 6/22 (27.3%) hadundergone urological reconstruction. Patients had fewer symptomatic UTI’s (median 4 vs. 1 episodes; p

More than 12,000 spinal cord injuries occur annually in the United States; more than 80% of these individuals will experience urinary tract dysfunction. Despite the clinical demand, there is a paucity of guidelines for the care of these patients. Although most urologists are familiar with dangerous urodynamic parameters and the benefits of clean intermittent catheterization, these patients face a myriad of risks that may go unrecognized. In this article, the authors discuss the impact of specific neurologic diseases on the urinary tract, examine the risks inherent to each, and determine strategies for screening, prevention, and treatment of these complications.

Aim Here, we present the clinical presentation and surgical outcomes of women with symptomatic urethral prolapse presenting to our institution over 20 years, and seek to provide treatment recommendations for management of symptomatic urethral prolapse and caruncle. Methods A retrospective review of medical records from female patients who underwent surgery for symptomatic urethral prolapse from June 1995 to August 2015 was performed. Surgical technique consisted of a four-quadrant excisional approach for repair of urethral prolapse. Results A total of 26 patients were identified with a mean age of 38.8 years (range 3-81). The most common presentations were vaginal bleeding, hematuria, pain, and dysuria. All patients underwent surgical excision of urethral prolapse via a standard approach. Follow-up data was available in 24 patients. Six patients experienced temporary postoperative bleeding, and one patient required placement of a Foley catheter for tamponade. One patient experienced temporary postoperative urinary retention requiring Foley catheter placement. Three patients had visible recurrence of urethral prolapse, for which one later underwent re-excision. Conclusion Surgical excision of urethral prolapse is a reasonable treatment option in patients who have tried conservative management without relief, as well as in those who present with severe symptoms. Possible complications following excision include postoperative bleeding and recurrence, and patients must be counseled accordingly. In this work, we propose a treatment algorithm for symptomatic urethral prolapse.

Parkinson’s disease (PD) and multiple system atrophy (MSA) are degenerative neurological diseases that have significant urological manifestations. Both diseases can be accompanied by erectile dysfunction, nocturia, urgency, urgency incontinence, and urinary frequency. These diseases are quite different in their presentation with urological symptoms occurring after motor symptoms in PD and before in MSA. MSA is also much more likely to have obstructive or retention symptoms. It is important that urologists are aware of these diseases since some patients may present to them before their neurological disease is identified and the management of their lower urinary tract symptoms is also different. This chapter describes the neuropathology and presentation of these diseases and the urological treatment both conservative and surgical.

The bladder, stomach, intestines, heart, and lungs all move dynamically to achieve their purpose. A long-term implantable device that can attach onto an organ, sense its movement, and deliver current to modify the organ function would be useful in many therapeutic applications. The bladder, for example, can suffer from incomplete contractions that result in urinary retention with patients requiring catheterization. Those affected may benefit from a combination of a strain sensor and electrical stimulator to better control bladder emptying. The materials and design of such a device made from thin layer carbon nanotube (CNT) and Ecoflex 00-50 are described and demonstrate its function with in vivo feline bladders. During bench-top characterization, the resistive and capacitive sensors exhibit stability throughout 5000 stretching cycles under physiology conditions. In vivo measurements with piezoresistive devices show a high correlation between sensor resistance and volume. Stimulation driven from platinum-silicone composite electrodes successfully induce bladder contraction. A method for reliable connection and packaging of medical grade wire to the CNT device is also presented. This work is an important step toward the translation of low-durometer elastomers, stretchable CNT percolation, and platinum-silicone composite, which are ideal for large-strain bioelectric applications to sense or modulate dynamic organ states.

There are more questions than answers in the explanation for failure of onabotulinumtoxinA injection. We need to define what criteria should be used to diagnose it, what local bladder, neurological, or possibly immune phenomena are responsible for it, and the best and safest way to proceed in these vulnerable patients. We propose a management algorithm that may be worth testing at each step in clinical trials.

Some patients continue to have bothersome lower urinary tract symptoms despite treatment. We examined characteristics associated with bother from lower urinary tract symptoms in a prospective cohort.In this 1-year prospective, observational cohort study we obtained data on patients with lower urinary tract symptoms who were seeking care at a total of 6 tertiary care centers in the United States. Participants answered the AUA-SI (American Urological Association Symptom Index) global urinary bother question at study entry and 12 months later. Multilevel logistic and linear regression was used to identify factors associated with worsening bother and bother at 12 months, respectively.Of the 756 participants 121 (16%) had worsened lower urinary tract symptom bother during the study period. When adjusted for other variables, worsened lower urinary tract symptom bother was more likely among men who were nonwhite (OR 1.79, 95% CI 0.94-3.40) or who had diabetes (OR 1.68, 95% CI 0.86-3.27) and among women with diabetes (OR 1.77, 95% CI 0.85-3.67), prior treatment of lower urinary tract symptoms (OR 2.58, 95% CI 1.22-5.46) or a higher depression level (OR 1.29, 95% CI 1.10-1.52). Baseline factors associated with more severe bother at 12 months in men included more severe bother at baseline, nonwhite race, worse urinary frequency and incontinence, and higher levels of stress (p0.05). Among women more severe bother at baseline, urinary urgency and frequency, and worse physical function were associated with more severe bother at 12 months.Urinary symptom severity at baseline, race, depression and psychological stress were associated with the bother of lower urinary tract symptoms in a prospective cohort of men and women treated at tertiary care facilities. These findings may inform the clinical care of patients with bothersome lower urinary tract symptoms and direct providers to better prognosticate for patients with challenging lower urinary tract symptoms cases.

The purpose of our study was to describe the symptom profile of patients who presented to a tertiary care hospital for sling revision, define the efficacy of sling removal/revision in alleviating symptoms and identify what factors, if any, contribute to favorable surgical outcomes.We retrospectively reviewed the records of patients who underwent revision of a synthetic mid urethral sling at our institution between 2004 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from analysis. The outcomes assessed were the AUASI (American Urological Association Symptom Index) score, the M-ISI (Michigan Incontinence Symptom Index) score, pad use, post-void residual urine volume, examination findings and subjective improvement.A total of 430 patients met study inclusion criteria, of whom 182, 172 and 40 received a transobturator tape, a retropubic mid urethral sling and a mini-sling, respectively. Patients presented with 4 primary complaints, including mesh exposure or erosion, pain or dyspareunia, incontinence and/or bladder outlet obstruction. Of the patients 77% presented with at least 2 categories of symptoms. Average followup was 15 months. Postoperatively the AUASI score decreased from 19.0 to 14.7 (p0.001) and the bother score decreased from 5.0 to 3.4 (p0.001). The M-ISI also improved from total and bother scores of 15.7 and 4.4 to a postoperative average of 13.2 and 3.1 (p = 0.002 and0.001, respectively). During this time approximately 40% of patients who presented with pain had persistent postoperative discomfort, in 20% with obstruction that condition failed to resolve and recurrent mesh complaints developed in 5% with mesh exposure or erosion. On multivariate analysis preoperative narcotic use was a significant risk factor for persistent postoperative pain (OR 6.9).Despite complex patient presentations subjective and objective urological symptom measures significantly improve following mid urethral sling revision.

INTRODUCTION AND OBJECTIVES:The degree of bother caused by LUTS often guides treatment decisions. However, the relationship of LUTS severity and bother at the individual level and for individual sy...

INTRODUCTION AND OBJECTIVES:In 2011 the FDA approved onabotulinum toxin A (BTX-A) in patients with NGB. This allowed for patients refractory to medical therapy an alternative to proceeding directly...

INTRODUCTION AND OBJECTIVES:Despite its utility in the non-neurogenic population, limited objective data exists regarding the efficacy of autologous pubovaginal sling (PVS) placement for management...

The bladder, stomach, intestines, heart, and lungs all move dynamically to achieve their purpose. A long-term implantable device that can attach onto an organ, sense its movement, and deliver current to modify the organ function would be useful in many therapeutic applications. The bladder, for example, is a smooth muscle organ that can suffer from incomplete contractions that result in urinary retention with patients requiring using catheterization. Those affected may benefit from a combination of strain sensor and electrical stimulator to better control bladder emptying. We describe the materials and design of such a device made from thin layer carbon nanotube (CNT) and Ecoflex 00-50 and demonstrate its function with in vivo feline bladders. During bench-top characterization, the resistive and capacitive sensors exhibited reliable output throughout 5,000 stretching cycles under physiology condition. In vivo measurement with piezoresistive device showed a high correlation between sensor resistance and volume. Stimulation driven from Pt-PDMS composite electrodes successfully induced bladder contraction. We present method for reliable connection and packaging of medical grade wire to the CNT device. This work is an important step toward the translation of low-durometer elastomers, stretchable CNT percolation and Pt-PDMS composite, which are ideal for large strain bioelectric applications to sense or modulate dynamic organ states.

Severe debilitating lower urinary and bowel dysfunction is unfortunately common in patients with neurological conditions such as spinal cord injury (SCI), multiple sclerosis (MS), spina bifida and transverse myelitis on top of their physical disabilities. Despite the extraordinarily high prevalence of neurogenic bladder (87–95%) [1, 2] and neurogenic bowel (62–95%) [3, 4] in these populations, only the bladder has received the attention of medical providers with neurogenic bowel physiology is less understood and characterized compared to neurogenic bladder [5]. Neurogenic bowel has a significant impact on these patients and is characterized by combination of symptoms including lower gastrointestinal symptoms of constipation, diarrhea and or fecal incontinence. It could also have upper gastrointestinal impairment which can lead to bloating, nausea earlier satiety, reflux symptoms and gaseousness [6–10].

IntroductionProstate cancer is the most common cancer in men. Prostatectomy is the most common treatment. Morbidity from prostatectomy is high—80% of men experience urinary incontinence which negatively impacts the quality of life. Postsurgical pelvic floor muscle training is commonly prescribed but recent systematic reviews found no evidence of efficacy. We propose a new treatment that commences preoperatively and targets functional training of specific pelvic floor muscles that contribute to urinary continence. Assessment and biofeedback using transperineal ultrasound imaging assists in training. This will be compared against conventional training (maximal pelvic floor muscle contraction assessed by digital rectal examination) and no training. Embedded physiological studies will allow the investigation of moderation and mediation of the treatment effect on the outcomes.Methods and analysisThis randomised clinical trial will include 363 men scheduled to undergo radical prostatectomy for prostate cancer. Participants will be randomised into urethral training, conventional training and no training groups. Clinical data will be collected at baseline (1–2 weeks presurgery) and postsurgery after catheter removal, weekly to 3 months (primary endpoint) and monthly to 12 months. Outcomes include 24-hour pad weight test (primary), incontinence, quality of life and cost-effectiveness data. Neuromuscular control measures of pelvic floor muscles will be measured at baseline, postsurgery, 6 weeks, 3 and 12 months. Study assessors and statisticians will be blinded to the group allocation.Ethics and disseminationThis study is registered with the Australian New Zealand Clinical Trials Registry and has ethical approval from the university and host hospital ethics committees. Trial outcomes will be shared via national/international conference presentations and peer-reviewed journal publications.Trial registration numberACTRN12617000788370; Pre-results.

Objectives To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling. Design Cross-sectional observational study. Setting A Spinal Cord Injury Model System, with additional participants recruited from other sites. Participants Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview. Interventions Not applicable. Main Outcome Measures Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling. Results Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake. Conclusions These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

OBJECTIVE In this study, we analyzed claims data from the Ingenix data base to analyze outcomes of sacral neuromodulation with respect to both provider and patient factors. MATERIALS AND METHODS We used the Ingenix (I3) data base to determine demographic, diagnosis, and procedure success information for years 2002-2007 for privately insured patients. Demographic information was obtained, as were the diagnoses given and procedures performed, based on ICD-9 diagnosis codes and Current Procedural Terminology procedure codes. Multivariate analysis was performed to identify specific predictors of success, as measured by progression to implantation of a pulse generator. RESULTS Overall success, as defined by battery placement, was 49.1%. Fifty-one percent of staged procedures were followed by battery placement compared with 24.1% of percutaneous cases (p

Background: The management of neurogenic bowel and bladder by individuals with spinal cord injury (SCI) often requires a complicated set of behaviors to optimize functioning and reduce complications. However, limited research is available to support the many recommendations that are made. Objective: To describe the occurrence of behaviors associated with the management of neurogenic bowel and bladder among individuals with chronic SCI and to explore whether relationships exist between the performance of those behaviors and outcomes related to health and quality of life. Methods: A survey was developed based on clinical guidelines to collect self-report information about the performance of specific behaviors associated with the management of neurogenic bowel and bladder by individuals with SCI. It was administered to 246 individuals with chronic SCI living in the community as part of a larger ongoing study. Results: Results suggest that the methods that those with SCI use to manage neurogenic bowel and bladder are multifaceted. Many methods are performed with significant consistency, but significant variations exist for some and are often associated with neurological status, methods of evacuation, and quality of life. Conclusion: Many people with SCI of long duration are not sure of the sources of recommendations for some of the management activities that they or their personal care assistants conduct. It is prudent for clinicians working with these people to review their recommendations periodically to ensure that they are current and understood.

In the management of neurogenic bladder (NGB), the goals are first and foremost to protect the upper tract from damage. The second treatment goal is to maintain urinary continence, but all the while maintaining the patient’s quality of life. These goals are achieved by treating most patients with NGB in a targeted fashion based on urodynamic findings. Medical therapy optimization and appropriate bladder drainage are the cornerstones of NGB management. Detrusor overactivity, poor bladder compliance, and incontinence related to these are best initially managed with antimuscarinic agents,; however, there is an increasing role for the new beta3 agonists. In the event these therapies fail, botulinum toxin is often the next choice; however, is an expensive treatment, and some patients may be treated with combination drug therapy. Nocturnal polyuria is also extremely common in this group of patients and is quite bothersome. After other risk factors have been excluded, medical treatment with desmopressin may be a suitable alternative. This review contains 3 highly rendered figures, 2 tables, and 85 references Key words: adrenergic alpha blockers, antimuscarinics, botulinum toxin, desmopressin, imipramine, mirabegron, multiple sclerosis, neurogenic bladder, spinal cord injury

Patients with neurological conditions often experience severe debilitating lower urinary and bowel dysfunction in addition to the physical disabilities. However, only the bladder has received the attention of medical providers with neurogenic bowel being poorly understood and characterized.This is a cross-sectional analysis of a prospective institutional neurogenic bladder database from 2010 to 2013.Of the 175 patients 60.6% had traumatic spinal cord injury and 18.3% had multiple sclerosis. Median ± SD FISI (Fecal Incontinence Severity Index) scores were 18.0 ± 1.39 (moderate). The median neurogenic bowel dysfunction score was 11.0 ± 0.63 (moderate). Those scores were worse in those patients with spinal cord injury and spina bifida compared to those with other diseases and in younger patients (each p = 0.020), and those in the spinal cord injury group with higher levels of injury (p = 0.0046). Based on the Bristol stool scale 65% of patients had abnormal stool consistency, mostly constipation. None of the FISI, Bristol or neurogenic bowel dysfunction scores correlated significantly with SF-12® quality of life measures. However, bladder symptom scores on M-ISI (Michigan Incontinence Symptom Index) (p = 0.05) and AUA-SI (American Urological Association symptom index) (p = 0.03) correlated with FISI severity while the neurogenic bowel dysfunction score correlated with M-ISI (ρ = 0.29, p = 0.02). Patients with abnormal stool consistency on the Bristol scale reported more urgency and stress incontinence on M-ISI.Bowel dysfunction is common among patients with neurogenic bladder. Those with worse bladder symptoms also experience worse bowel dysfunction. This highlights the importance of addressing both bowel and bladder dysfunction in this often poorly understood population.

Augmentation cystoplasty (AC) is a surgical enlargement of the bladder, typically performed by suturing detubularized colon or ileum to the superior aspect of the bladder to achieve an increase in volume. Augmentation is a surgical procedure most commonly performed in patients with neurogenic bladder (NGB) who have failed other therapies. Surgical treatment has an advantage over medical therapy by permanently increasing the bladder capacity and decreasing bladder overactivity, which in turn reduces incontinence episodes and improves bladder compliance. In the long term, however, it is uncertain what risk of malignancy exists for these patients given that this augmentation is often performed when the patient is a child or young adult. This review will explore the current and past literature on the risk for malignancy in this population and the available data on the best way to follow these patients for bladder cancer. Based on the available literature, bladder cancer in the NBG patient is rare, but often presents at higher stage and has a greater risk of mortality than bladder cancer in the general population. Surveillance, in the form of yearly cystoscopy (±random biopsies) and urine cytology, has not been successful at detecting bladder cancer at low stage and has not proven a cost-effective strategy. Symptomatic patients should always undergo prompt evaluation with a high index of suspicion, but yearly screening in the asymptomatic patient is not currently recommended.

OBJECTIVE To evaluate the national patterns of urologic follow up after spinal cord injury (SCI) and the occurrence and predictors of urological complications.MATERIALS AND METHODS This retrospective cohort study used a 5% sample of Medicare data 2007-2010. The minimum adequate urologic surveillance was defined as a urologist visit, serum creatinine evaluation, and upper urinary tract imaging study within the 2-year period. Patients were classified to their most severe complication in a multivariate linear regression model.RESULTS Among the 7162 patients with SCI, the majority were functionally paraplegic (82.4%) and Caucasian (80.9%). Among them, 4.9% received no screening studies over the 2-year period; 70.5% received some, but not all screening; and 24.6% received all three screening tests. Patients traveled a mean of 21.3 +/- 27.5 miles to receive care. A total of 35.7% of patients saw a urologist during the 2-year period; 48.6% had some form of upper tract evaluation, with the majority being computed tomography scans; and 90.7% had serum creatinine evaluation. Of all patients, 35.8% had a minor complication during their 2-year follow up, 17.1% had a moderate complication, and 8.0% had a severe complication. In our prediction model, patient factors that correlated with increased complications included male gender, African American race, paraplegia, and receiving some or all of the neurogenic bladder recommended screening. Patients' distance of travel to their treating physician (urologist or physiatrist) did not affect the rate of complications.CONCLUSION Urological complications are common in patients with SCI who receive Medicare. Most of these patients with SCI are not receiving even the minimum recommended surveillance for these urological complications. (C) 2015 Elsevier Inc.

Purpose: There is no consensus on the management of persistent or recurrent stress incontinence after a failed synthetic mid urethral sling. After a mesh complication or sling failure many women and surgeons prefer to avoid a repeat mesh procedure and choose an autologous pubovaginal sling. However, little empirical work has been performed to assess the efficacy.Materials and Methods: We performed a retrospective review of 66 women who underwent autologous pubovaginal sling with rectus fascia after 1 or more failed synthetic mid urethral sling from 2007 to 2012.Results: Mesh removal was performed before autologous pubovaginal sling in 21 patients (31.8%) while 6 (9.1%) had mesh removed simultaneously with autologous pubovaginal sling. Indications for the autologous pubovaginal sling were pure stress urinary incontinence in 16 patients (24.2%) and mixed incontinence in 50 (75.8%), 8 of whom were deemed complex with a prior urethral diverticulum or urethrovaginal fistula/urethral mesh erosion. At a mean of ...

Objective To determine predictors of physical and emotional discomfort associated with urodynamic testing in men and women both with and without neurologic conditions. Methods An anonymous questionnaire-based study was completed by patients immediately after undergoing fluoroscopic urodynamic testing. Participants were asked questions pertaining to their perceptions of physical and emotional discomfort related to the study, their urologic and general health history, and demographics. Logistic regression was performed to determine predictors of physical and emotional discomfort. Results A total of 314 patients completed the questionnaire representing a response rate of 60%. Half of the respondents (50.7%) felt that the examination was neither physically nor emotionally uncomfortable, whereas 29.0% and 12.4% of respondents felt that the physical and emotional components of the examination were most uncomfortable, respectively. Placement of the urethral catheter was the most commonly reported component of physical discomfort (42.9%), whereas anxiety (27.7%) was the most commonly reported component of emotional discomfort. Presence of a neurologic problem (odds ratio, 0.273; 95% confidence interval, 0.121-0.617) and older age (odds ratio, 0.585; 95% confidence interval, 0.405-0.847) were factors associated with less physical discomfort. There were no significant predictors of emotional discomfort based on our model. Conclusion Urodynamic studies were well tolerated regardless of gender. Presence of a neurologic condition and older age were predictors of less physical discomfort. These findings are useful in counseling patients regarding what to expect when having urodynamic procedures.

Introduction The S-CAHPS survey assesses patient experience and satisfaction with 1 episode of surgical care. We describe the initial implementation, results and experience using S-CAHPS in urology. Methods This was a prospective, institutional review board approved, observational study at a tertiary care academic medical center. Adult patients who underwent elective outpatient or 23-hour observation surgery during a 33-month period were mailed the survey. Survey content was separated into composites 1 to 6 and percent top box scoring (percent of most positive responses) was performed. Summary scores for each composite were correlated with the mean of a global surgeon rating question. Results A total of 430 surveys were returned for a 33.8% response rate. Respondents were statistically older than nonrespondents and more likely to reside in Michigan (p Conclusions Survey results suggest that patient satisfaction with the surgeon is more influenced by postoperative communication and information than by preoperative counseling and decision making processes. This underscores the importance of attention to continued postoperative care and interactions. The role of S-CAHPS in urology requires further exploration in this era of quality improvement.

The Lower Urinary Tract Symptoms (LUTS) Tool was developed to assess the prevalence and bother of individual LUTS in the general population,1 however, no validated subscales of the questionnaire currently exist. The objective of this study was to create a summary score for the LUTS Tool urinary incontinence (UI) questions and assess its behavior relative to summation scores.