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Context Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series. Objective We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide. Evidence acquisition We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries. Evidence synthesis Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p =0.0176). Conclusions It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful. Patient summary Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

It is increasingly recognized that the bladder is the originator of storage lower urinary tract symptoms, including overactive bladder in men. As these symptoms are most bothersome for patients, there has been an increasing interest in the evaluation of drug treatment to better target the bladder. Consequently, several new drug classes have been introduced to the therapeutic armamentarium. Antimuscarinics, which were previously avoided due to the concern regarding urinary retention, are now used in routine practice; however, their use is still hampered by discontinuation due to side effects.

Serious complications can develop with the mesh implants used for stress urinary incontinence and pelvic organ prolapse surgery. We evaluated 2 materials currently in clinical use and 2 alternative materials using a rabbit abdominal model to assess host response and biomechanical properties of the materials before and after implantation.Poly-L-lactic acid and polyurethane meshes were electrospun to be compared to commercially available polypropylene and polyvinylidene fluoride meshes. A total of 40 immunocompetent full-thickness abdominal wall defect rabbit models were used, including 8 in each of the poly-L-lactic acid, polyurethane, polyvinylidene fluoride and polypropylene experimental groups, and sham controls. Two 20 mm defects were created per animal and primarily repaired. The experimental groups then underwent onlay of each repair material while sham controls did not. Four rabbits per group were sacrificed at days 30 and 90. Abdominal wall specimens containing the defect with or without repair material were explanted to be assessed by histology (hematoxylin and eosin staining, and immunohistochemistry) and biomechanical testing at 30 and 90 days.At 90 days of implantation tissues repaired with all 4 materials showed biomechanical properties without significant differences. However, polypropylene and polyvinylidene fluoride meshes demonstrated a sustained chronic inflammatory response profile by 90 days. In contrast, poly-L-lactic acid and polyurethane meshes integrated well into host tissues with a decreased inflammatory response, indicative of constructive remodeling.Poly-L-lactic acid and polyurethane alternative materials achieved better host integration in rabbit models than current synthetic repair materials.

Background Botulinum neurotoxin (BotN) is used to treat detrusor overactivity (DO) refractory to medical treatment. Catheterised patients with symptoms of bladder spasm and catheter bypass leakage are challenging to manage and the efficacy of BotN is not established. Objective To review our experience using intravesical BotN to treat refractory bladder pain and catheter bypass leakage in patients with long-term indwelling catheters. Design, setting, and participants We carried out a review of data prospectively collected for patients with indwelling urethral or suprapubic catheters receiving BotN for the treatment of bladder spasms and catheter bypass leakage in a UK tertiary centre. An unvalidated structured questionnaire was used to ascertain quality of life (QoL) outcomes. Outcome measurements and statistical analysis Qualitative data were collected for patient-reported symptoms and QoL. Paired Student t tests were applied for statistical analysis. Results and limitations Of the 54 catheterised patients who received BotN, 14 (26%) were male and 40 (74%) were female. The mean follow-up was 38 mo. Of the patients, 34 (63%) had a neurological aetiology and 94% had experienced failure of medical therapy before BotN administration. The BotN starting dose was 100 or 200 U and 17 patients (31%) required dose escalation. All 34 neurogenic and six non-neurogenic patients started on 200 U. After treatment, 63% of patients managed their catheter with intermittent drainage and 37% managed on free drainage; 51 patients (94%) reported that their symptoms were controlled and 38% reported being treated for a urinary tract infection following BotN. Patients reported a mean improvement in QoL of 7.7/10 following BotN, while 83% reported a significant reduction in urine leakage (p = 0.0001). Conclusions Outpatient intravesical BotN is safe and efficacious for patients with long-term catheters suffering from bladder pain and catheter bypass leakage. Patient summary Outpatient administration of intravesical botulinum toxin is a safe and effective treatment for patients with a long-term indwelling catheter with bothersome urine storage symptoms. Attention should be paid to urine microbiology results before treatment to ensure appropriate prophylactic antibiotic treatment to reduce the incidence of urinary tract infections.

We aimed to determine UK medical students' perceptions and attitudes and interest toward medical leadership and clinician managers.A cross-sectional study was conducted during the academic year 2015-2016. An online questionnaire was distributed to 2,349 final-year students from 10 UK medical schools. Participants were asked to complete a 5-point Likert scale on their current perceptions, attitudes, and interest toward medical leadership and clinician managers. They were also asked to self-rate their leadership competences set by the Medical Leadership Competency Framework and to rate the quality of management and leadership training they received from their medical school.In total, we received 114 complete responses. Only 7.9% of respondents were in agreement (strongly agree or agree) when asked whether they felt they were well informed about what a managerial position in medicine entails. When asked whether clinicians should influence managerial decisions within a clinical setting, 94.7% of respondents were in agreement with the statement. About 85% of respondents were in agreement that it is important for clinicians to have managerial or leadership responsibilities, with 63.2% of students in agreement that they would have liked more management or leadership training during medical school. Over half the respondents rated their management and leadership training they received during medical school as "very poor" or "poor" (54.4%).Our study suggests that UK medical students have an appetite for management and leadership training and appreciate its importance but feel that the training they are receiving is poor. This suggests that there is a gap between the demand for management and leadership training and the quality of training supplied by UK medical schools.

The role of surgery in the management of bladder pain syndrome is unclear; particularly the optimum surgical approach. Treatment refractory patients should be managed in a multi-disciplinary setting including psychological support. Further prospective studies using validated assessments and clear diagnostic criteria would be useful to guide patient selection.

Background Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms. Objective The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention. Design, setting, and participants A retrospective review of data on patients undergoing AFS at a tertiary referral unit. Surgical procedure AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD. Measurements Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC). Results and limitations A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24–83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery. Conclusions A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate. Patient summary A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.

Genitourinary fistulae (GuF) are one of the oldest described causes of incontinence. They are associated with significant social and psychological debilitation. In developed countries, they most commonly occur after iatrogenic injury to the urinary tract during gynaecological surgery for benign conditions, whereas in developing countries the most common cause remains prolonged obstetric labour. The most frequent type of GuF occurs between the bladder and vagina. GuF require careful evaluation to confirm the diagnosis and assess the number, location, and anatomy of defects, as well as any associated injuries before operative management is undertaken. The surgical approach to each fistula is individualized and relies upon the use of healthy vascularized tissue to repair defects, preferably with interposition of a tissue flap to augment repairs.

Urinary incontinence (UI) is a highly prevalent and bothersome problem that affects men and women of all ages. The aetiological spectrum of UI is wide, encompassing dysfunctions of the lower urinary tract, its neural control, the pelvic floor as well as other factors such as the side effects of pharmacotherapy. Although not life-threatening, UI frequently impacts upon the quality of life, psychological and emotional well-being of affected individuals. Additionally, UI imposes a tremendous economic burden on both the individual and the wider society in costs of nursing care, treatments, and lost productivity. The purpose of this chapter is to provide a broad overview of the epidemiology, aetiopathophysiology of UI, and to discuss the approach to the assessment, investigation, and initial management of the patient presenting with UI.

Urethral diverticula (UD) are not uncommon, affecting up to 6% of the female population, but are in the majority of cases asymptomatic and of no clinical significance. They are thought to arise as a consequence of infection, obstruction, and subsequent rupture of a periurethral gland. UD often pose a significant diagnostic challenge, as symptoms are largely non-specific and easily confused with other conditions such as bladder pain syndrome and recurrent urinary tract infection. As such, both misdiagnosis and delayed diagnosis are common, to the frustration of both patients and surgeons. Traditional methods of diagnosis, such as voiding cystourethrogram, relied upon urethral catheterization and contrast instillation, and were associated with poor anatomical detail. Recent advances in imaging, particularly magnetic resonance imaging, have improved the diagnosis and staging of UD, and have allowed for more accurate preoperative planning.

Background Urethral strictures can be difficult to diagnose at an early stage because the urinary flow rate does not diminish until the urethral calibre is ≤3mm. In the past, posturethral surgery follow-up has relied upon flow rates and contrast imaging. Objective To evaluate the role of flexible urethroscopy in the follow-up of patients undergoing urethroplasty. Design, setting, and participants Prospective flexible urethroscopy follow-up of 144 male patients who underwent urethroplasty by a single surgeon over a 10-yr period at a tertiary referral centre. Intervention Flexible urethroscopy at 3, 6, and 12 mo postoperatively, and annually thereafter. Outcome measurements and statistical analysis Type of recurrence, based on urethroscopy findings, and further interventions were measured. Actuarial analysis was performed using Kaplan-Meier curves and a log-rank test. Results and limitations All 144 patients underwent flexible urethroscopy follow-up over a median postoperative follow-up of 22 mo (range: 1–96 mo). No further intervention was required for 117 patients (81.25%); 27 (18.75%) developed recurrences that required further treatment. Recurrences included diaphragms (13 patients) or significant restenosis (14 patients). Diaphragms were treated by urethrotomy, gentle dilatation, or a short course of intermittent self-dilatation. Restenosis required repeated simple procedures or surgical revision. Most recurrences (26 of 27, 96%) were detected within the first year. Urinary peak flow-rate data were available for 11 of 27 of these recurrences; 7 patients had flow rates >15ml/s. Anastomotic procedures had greater success than augmentation urethroplasty ( p =0.0136); there was no significant difference in outcomes between redo and non-redo surgery ( p =0.2093) Conclusions Endoscopic follow-up of patients after urethroplasty enables earlier identification and treatment of recurrences compared to the use of urinary flow rates alone. It also enables the identification of two different morphologic recurrence patterns that require different types of intervention. Patient summary Endoscopy detects most stricture recurrences within 1 yr after urethroplasty and is more sensitive than using urinary flow rates alone.

Pelvic fracture urethral injuries comprise one of the most challenging reconstructive procedures in urology. The obliterated or stenosed urethra can usually be effectively repaired by an end-to-end anastomosis (bulbomembranous anastomosis). To achieve this, a progression of surgical steps can be used to make a tension-free anastomosis. Before undertaking surgery it is important to comprehensively assess the patient to define their anatomical defects, in particular the site of the stenosis, the length of the distraction injury and the integrity of the bladder neck, and thus guide preoperative decision-making. Contemporary reports suggest that most pelvic fracture urethral distraction defects (PFUDD) can be adequately managed by a perineal approach. Nevertheless it is essential that all surgeons treating these injuries are familiar with the whole spectrum of operative steps that are necessary to repair PFUDD.

Detrusor underactivity (DU) is an important contributor to lower urinary tract symptoms (LUTS). While DU has been defined in the literature in urodynamic terms, current definitions lack specific parameters. In addition, the clinical syndrome associated with and manifesting itself as DU, underactive bladder (UAB), has not been well defined in the literature. In the absence of a precise definition of UAB, it is difficult to appreciate the true nature and burden of this condition. We review the evidence regarding the epidemiology, pathogenesis, diagnosis, and treatment of DU and UAB and discuss the challenges in gathering data in the absence of precise definitions. DU may be idiopathic or caused by ageing, medications, or a number of causes of neurogenic, myogenic, or iatrogenic origin. Treatments are largely palliative due to a lack of curative options, and include watchful waiting, catheterization, medications, and surgical interventions. In light of the evidence available in the literature, we propose that a new symptom-based definition of UAB syndrome should be developed as a first step in furthering more standardized research. Further discussion on this proposed definition to reach expert consensus will enable researchers to gather more robust data, allowing greater insights into DU and UAB diagnosis and treatment.

Synthetic or biological materials can be used for the surgical repair of pelvic organ prolapse (POP) or stress urinary incontinence (SUI). While non-degradable synthetic mesh has a low failure rate, it is prone to complications such as infection and erosion, particularly in the urological/gynecological setting when subject to chronic influences of gravity and intermittent, repetitive strain. Biological materials have lower complication rates, although allografts and xenografts have a high risk of failure and the theoretical risk of infection. Autografts are used successfully for the treatment of SUI and are not associated with erosion; however, can lead to morbidity at the donor site. Tissue engineering has thus become the focus of interest in recent years as researchers seek an ideal tissue remodeling material for urogynecological repair. Herein, we review the directions of current and future research in this exciting field. Electrospun poly-L-lactic acid (PLA) and porcine small intestine submucosa (SIS) are two promising scaffold material candidates. Adipose-derived stem cells (ADSCs) appear to be a suitable cell type for scaffold seeding, and cells grown on scaffolds when subjected to repetitive biaxial strain show more appropriate biomechanical properties for clinical implantation. After implantation, an appropriate level of acute inflammation is important to precipitate moderate fibrosis and encourage tissue strength. New research directions include the use of bioactive materials containing compounds that may help facilitate integration of the new tissue. More research with longer follow-up is needed to ascertain the most successful and safe methods and materials for pelvic organ repair and SUI treatment.

The recent International Consultation on Urological Disease (ICUD) panel 2010 confirmed that a urethral stricture is defined as a narrowing of the urethra consequent upon ischaemic spongiofibrosis, as distinct from sphincter stenoses and a urethral disruption injury. Whenever possible, an anastomotic urethroplasty should be performed because of the higher success rate as compared to augmentation urethroplasty. There is some debate currently regarding the critical stricture length at which an anastomotic procedure can be used, but clearly the extent of the spongiofibrosis and individual anatomical factors (the length of the penis and urethra) are important, the limitation for this being extension of dissection beyond the peno-scrotal junction and the subsequent production of chordee. More recently, there has been interest in whether to excise and anastomose or to carry out a stricturotomy and reanastomosis using a Heineke-Miculicz technique. Augmentation urethroplasty has evolved towards the more extensive use of oral mucosa grafts as compared to penile skin flaps, as both flaps and grafts have similar efficacy and certainly the use of either dorsal or ventral positioning seems to provide comparable results. It is important that the reconstructive surgeon is well versed in the full range of available repair techniques, as no single method is suitable for all cases and will enable the management of any unexpected anatomical findings discovered intra-operatively.

Purpose Autologous buccal mucosa is commonly utilized in the surgical treatment of urethral strictures. Extensive strictures require a larger quantity of tissue, which may lead to donor site morbidity. This review assesses progress in producing tissue engineered buccal mucosa as an alternative graft material. Results Few clinical studies have introduced cells onto biological or synthetic scaffolds and implanted resulting constructs in patients. The available studies show that buccal mucosa cells on acellular human dermis or on collagen matrix lead to good acute stage tissue integration. Urothelial cells on a synthetic substrate also perform well. However while some patients do well many years post-grafting, others develop stricture recurrence. Acellular biomaterials used to treat long urethral defects in animals commonly lead to fibrosis. Conclusions Tissue engineered buccal mucosa shows promise as a substitute for native tissue. The fibrosis which occurs months post-implantation may reflect the underlying disease process recurring in these patients.

Objectives To evaluate the long-term safety (primary objective) and efficacy/impact on quality of life (QoL, secondary objectives) of silodosin 8 mg once daily in men with LUTS/BPH. Patients and methods Men who completed the 12-week double-blind study with silodosin 8 mg, tamsulosin 0.4 mg, or placebo were offered to continue with the 9-month open-label study during which all patients received silodosin 8 mg once daily. Safety was assessed by analysing vital signs, electrocardiograms, laboratory tests, and adverse events. Efficacy was evaluated with the International Prostate Symptom Score (IPSS), IPSS voiding and storage sub-scores, IPSS-QoL, and maximum urinary flow rate (Q max). Results A total of 500 patients (mean age 66 years) entered the 9-month open-label study. Treatment-emergent adverse events (TEAE) were experienced by 33.4% patients. Ejaculation dysfunction was the most common TEAE (9.0%) but led to study discontinuations in only 1.6% of patients. Dizziness without orthostatic hypotension occurred in 0.8%. A marked reduction in total IPSS (-2.7 ± 3.8) was documented at the first visit of this extension phase in patients having de novo silodosin compared with lesser improvement in patients previously treated with silodosin (-0.82 ± 4.2) or tamsulosin (-0.83 ± 3.8). Improvements were maintained throughout the open-label phase. QoL also improved, with the greatest improvement in de novo silodosin patients. No relevant changes in Q max occurred. Conclusions Long-term treatment with silodosin was safe and efficacious. Abnormal ejaculation was the most common TEAE, but led to treatment discontinuation in only 1.6% of patients. Orthostatic hypotension was not seen, and only a few patients experienced dizziness.

Detrusor underactivity (DUA) is a poorly understood, yet common, bladder dysfunction, referred to as underactive bladder, which is observed in both men and women undergoing urodynamic studies. Despite its prevalence, no effective therapeutic approaches exist for DUA. Exactly how the contractile function of the detrusor muscle changes with ageing is unclear. Data from physiological studies in animal and human bladders are contradictory, as are the results of the limited number of clinical studies assessing changes in urodynamic parameters with ageing. The prevalence of DUA in different patient groups suggests that multiple aetiologies are involved in DUA pathogenesis. Traditional concepts focused on either efferent innervation or myogenic dysfunction. By contrast, contemporary views emphasize the importance of the neural control mechanisms, particularly the afferent system, which can fail to potentiate detrusor contraction, leading to premature termination of the voiding reflex. In conclusion, the contemporary understanding of the aetiology and pathophysiology of DUA is limited. Further elucidation of the underlying mechanisms is needed to enable the development of new and effective treatment approaches.

Background The prayer ritual is an essential component of Islam that requires entry into a state of physical purity (wudhu) through ablution, which is invalidated by voiding. An important dilemma for patients and surgeons may arise when a Muslim patient is counselled on cystectomy because of the belief by some that an incontinent urinary diversion will automatically invalidate their wudhu. Objective To determine if there are any religious barriers and implications for Muslim patients undergoing an incontinent urinary diversion. Design, setting, and participants A questionnaire was distributed to all UK mosques, addressed to the imam (n = 804). Results and limitations A total of 134 imams (response rate 16.7%) responded. There was general agreement among imams, with >90% answering that it is possible for a Muslim to perform ablution, pray, and enter a mosque with a urinary stoma. The majority of imams (86.6%) also stated that refusal of a urinary stoma was not justified by religious teachings. When asked if patients should choose the option of a neobladder despite this surgery having greater risk, 57.5% of respondents stated that they were either unsure or agreed with this alternative. Conclusions The majority of imams agreed that Muslims with a urinary stoma are able to maintain their ablution, allowing them to conduct their daily prayers, and that this form of surgery should not be refused on religious grounds. Our study suggests that the consensus view is that a urinary stoma is not contraindicated with regard to the practice of Islamic prayer rituals. Patient summary In this study we investigated if having a urinary stoma would be a religious barrier for Muslim patients in performing their obligatory prayer rituals. The overwhelming majority of imams stated that having a urinary stoma should not stop Muslim patients practising important aspects of their faith.

Synthetic non-degradable meshes used in pelvic floor surgery can cause serious complications such as tissue erosion. A repair material composed of an autologous oral fibroblast seeded degradable polylactic acid scaffold may be a viable alternative. The aims of this study were to investigate the effects of media supplementation with additives (ascorbic acid-2-phosphate, glycolic acid and 17-β-oestradiol) on the mechanical properties of these scaffolds. Oral fibroblasts were isolated from buccal mucosa. The effects of the three additives were initially compared in two-dimensional culture to select the most promising collagen stimulating additive. Sterile electrospun scaffolds were seeded with 500,000 oral fibroblasts and fixed in 6-well plates and subjected to ascorbic acid-2-phosphate (the best performing additive) and/or mechanical stimulation. Mechanical stimulation by fluid shear stress was induced by rocking scaffolds on a platform shaker for 1 h/day for 10 of 14 days of culture. In two-dimensional culture, ascorbic acid-2-phosphate (concentrations from 0.02 mM to 0.04 M) and glycolic acid (10 µM) led to significantly greater total collagen production, but ascorbic acid-2-phosphate at 0.03 mM produced the greatest stimulation (of the order of >100%). In three-dimensional culture, mechanical stimulation alone gave non-significant increases in stiffness and strength. Ascorbic acid-2-phosphate (0.03 mM) significantly increased collagen production in the order 280% in both static and mechanically stimulated scaffolds (p

Objectives: To review the use of non-hormonal pharmacotherapies in the treatment of lower urinary tract symptoms (LUTS) due to presumed benign prostatic hyperplasia (BPH). Materials and Methods: A search of the PUBMED database was conducted for the terms BPH, LUTS, bladder outlet obstruction, alpha-adrenoceptor blockers, anti-muscarinics, and phosphodiesterase-5-inhibitors. Results: Medical therapy has long been established as the accepted standard of care in the treatment of male LUTS. The aim of treatment is improvement in symptoms and quality of life whilst minimizing adverse effects. The agents most widely used as 1 st line therapy are alpha-blockers (AB), as a standalone or in combination with 2 other classes of drug; 5-α reductase inhibitors and anti-muscarinics. AB have rapid efficacy, improving symptoms and flow rate in a matter of days, these effects are then maintained over time. AB do not impact on prostate size and do not prevent acute urinary retention or the need for surgery. Anti-mucarinics, alone or in combination with an AB are safe and efficacious in the treatment of bothersome storage symptoms associated with LUTS/BPH. Phosphodiesterase-5 inhibitors are an emerging treatment option that improve LUTS without improving flow rates. Conclusions: AB are the most well-established pharmacotherapy in the management of men with LUTS/BPH. The emergence of different classes of agent offers the opportunity to target underlying pathophysiologies driving symptoms and better individualize treatment.

The absence of any effective drug therapy for underactive bladder makes the use of regenerative medicine approaches an attractive option. Tissue engineering of whole bladders has been investigated for over a decade and resulted in a small clinical study with some success, however such bladders can only fulfill a storage function due to the difficulty of recreating the complex neural innervation to enable volitional emptying. Stem cell injection therapy would be appear to be a more workable and practical approach in the patients with underactive bladder, however only pre-clinical studies are available. It is likely that any future stem cell injection approach should be tailored to the particular likely underlying pathophysiology, such as targeting the bladder wall in patients with myogenic failure.

The patient with detrusor underactivity can fit into two broad clinical entities; those with a significant post voiding residual or those who demonstrate reasonable bladder emptying but present with symptoms. These are not necessarily two separate processes and there can be considerable overlap between the two, however it is important to decide whether treatment strategies are directed at improving bladder emptying, controlling symptoms or both. Intuitively, intermittent catheterisation is the preferred treatment option, however outlet surgery is a potential alternative for those with large post-voiding residuals who are motivated to be catheter-free. However, the outcomes of surgery in this context are clearly inferior to those with bladder outlet obstruction and several authors have suggested parameters, which can help to predict success following surgery.

The last two decades in urology has seen major refinements in thought with regards to the categorization of lower urinary tracts symptoms (LUTS) and the understanding of the underlying pathophysiological basis of these symptoms. For the most part there has been an overwhelming focus on detrusor overactivity (DO) and bladder outlet obstruction (BOO) as the causes storage and voiding LUTS respectively. This focus has been beneficial in that it has generated a large body of basic and clinical research that has furthered our understanding and led to the development of numerous beneficial medical and surgical therapies. By contrast the problem of detrusor underactivity (DU), although recognized, has been largely neglected and it is salutary to note that last major advance in management was the introduction of clean intermittent catheterization by Jack Lapides over 40 years ago.

Detrusor underactivity (DU) is a urodynamic diagnosis which is associated with groups of symptoms, which have been termed underactive bladder (UAB). The symptoms and signs of DU have some crossover with those associated with Bladder outlet obstruction (BOO). This poses a considerable challenge to the acquisition of useful epidemiological data as it is impractical to perform urodynamic studies on large groups of people who may be entirely asymptomatic. In this chapter we discuss our current knowledge of the epidemiology of DU based on available clinical studies, it associations and natural history.

Currently, underactive bladder, the symptom-based correlate of the urodynamic diagnosis of detrusor underactivity, has no effective drug treatments. Use of sympathomimetics, targeting cholinergic receptors, is not supported by current evidence. Several potential targets are the subject of ongoing investigation.

Urinary retention in women is an uncommon and poorly understood condition. In 1986, Fowler and colleagues described a syndrome in young women with unexplained urinary retention associated with polycystic ovary syndrome. The underlying abnormality was a poorly relaxing external urethral sphincter that when studied using concentric needle electromyography showed a distinct abnormal pattern suggesting direct spread of impulses between muscle fibres. These findings were subsequently reproduced by other researchers and in larger patient cohorts, but remain the subject of much debate. A poorly relaxing sphincter is thought to cause increased urethral afferent activity, which inhibits bladder afferent signalling leading to poor bladder sensation and detrusor underactivity. Most studies of Fowler's syndrome are limited due to small cohorts with no control group and a lack of videourodynamic data. Whether Fowler's syndrome represents a distinct cause of urinary retention or results from a maladaptive behaviour and is similar to dysfunctional voiding is unclear. Application of sacral neuromodulation in patients diagnosed with Fowler's syndrome can restore normal voiding, in the absence of any effective pharmacotherapy or surgical treatment.

submissions by geographic region. Hot at the ICS Meeting 2013 3 Neurourology and Urodynamics DOI 10.1002/nau bladder volume, and nociceptive behaviors. While both therapies may be some way off from routine practice, these data may open a route to early stage human trials. LUTS: INFECTION AND INFLAMMATION There is increasing recognition of inflammation and lowgrade infection as part of the pathophysiology of LUTS. Vijaya et al. (Abstract 123) demonstrated a significantly greater proportion of positive bacterial cultures in bladder biopsies from women with LUTS compared to asymptomatic women suggesting a link between bacterial infection and LUTS in women, however, therewas no significant association between women with recurrent UTI and positive biopsies. Similarly, Sorrentino et al. presented data demonstrating that in women without overt urinary tract infection, bacteriuria was associated with a range of LUTS (Abstract 126). Evidence of an inflammatory aetiology of OAB also was presented in a study by Gill et al. who demonstrated that women with OAB and pyuria of 1–9 cells/ml had significantly greater levels of two markers of urothelial inflammation (urinary lactoferrin and IL6) compared to controls (Abstract 124). This data suggests that contrary to the current literature, pyuria

Female urethral stricture (FUS) is a rare and challenging clinical entity. Several new surgical techniques have been described for the treatment of FUS, although with the limited number of reports, there is no consensus on best management.We evaluated the evidence for surgical interventions reported for treating FUS.We performed a systematic review of the PubMed and Scopus databases, classifying the results by surgical technique and type of graft in the case of graft augmentation urethroplasty.A total of 221 patients have been reported on with outcome measures after intervention for FUS. The mean age of women was 51.8 yr of age (range: 22-91). All studies were retrospective case series. There was no consistent definition of FUS nor unified diagnostic criteria. Most studies used a combination of diagnostic tests. Where aetiology was defined, idiopathic and iatrogenic stricture were the two most common causes. Ninety-eight patients underwent prior intervention for FUS, mostly urethral dilatation or urethrotomy. Success was defined as the lack of need for further intervention. Urethral dilatation, assessed in 107 patients, had a mean success rate of 47% at a mean follow-up of 43 mo. Fifty-eight patients had vaginal or labial flap augmentation, with a mean success rate of 91% at 32.1 mo of mean follow-up. Vaginal or labial graft augmentation had a mean success rate of 80% in 25 patients at a mean follow-up of 22 mo. Oral mucosal augmentation, performed in 32 patients, had a mean success rate of 94% at 15 mo of mean follow-up. No instances of de novo stress incontinence were reported.The techniques of urethroplasty all have a higher mean success rate (80-94%) than urethral dilatation (50%), although with shorter mean follow-up. Urethroplasty in experienced hands appears to be a feasible option in women who have failed urethral dilatation, although there is a lack of high-level evidence to recommend one technique over another.

Detrusor underactivity (DU) is an increasingly recognised cause of lower urinary tract symptoms in both men and women. There has been a lack of research into all aspects of this dysfunction, and as yet, no effective treatments exist. DU can be diagnosed at present only on the basis of an invasive urodynamic study. An international consensus group met at the International Consultation on Incontinence–Research Society and International Continence Society annual meetings in 2014 to consider the feasibility of developing a working definition of a symptom complex associated with DU. Drawing an analogy to detrusor overactivity (urodynamic diagnosis) and overactive bladder (symptom complex), the aim of this process is to help identify affected patients and facilitate further clinical and epidemiological research. Patient summary Bladder underactivity is an underresearched but important cause of urinary symptoms in men and women. In this paper, an international expert group presents a working definition for the symptoms that characterise bladder underactivity, with the aim of facilitating further research in this area.

KEYWORDSOveractive bladder;Antimuscarinics;Botulinum toxin;MirabegronABBREVIATIONSOAB, overactive blad-der syndrome;DO, detrusor overac-tivity;AM, antimuscarinicagent;ER, extended-release;BTX,botulinumtoxinA;PTNS, posterior tibialnerve stimulation;Abstract Objectives: The overactive bladder syndrome (OAB) is a highly prevalentand bothersome symptom complex. We review contemporary reports to provide anupdate of the key aspects of its pathogenesis and the therapeutic approaches.Methods: The PUBMED database was searched for relevant publications in theperiod from 1 January 1985 to 1 May 2013, using the keywords ‘overactive bladder’,‘anti-muscarinics’, ‘b-3 agonists’, ‘intravesical botulinum toxin’, ‘tibial nerve stimu-lation and ‘sacral neuromodulation’.Results: In all, 33 articles were selected for this review. OAB is very common,affecting 10–20% of the population. It is often bothersome and frequently affectsthe quality of life. The current definition of OAB remains a source of controversy.Anti-muscarinic agents remain the mainstay of pharmacotherapy. The new b-3 ago-nists have some efficacy whilst avoiding anti-cholinergic effects, and so might benefitpatients who are unable to tolerate anti-muscarinic agents. Intravesical botulinumtoxin is recommended for patients in whom oral pharmacotherapy fails, althoughthe optimal parameters in terms of dosing, number of injections and injection siteare yet to be fully established. Sacral neuromodulation is another option that hasa good response in about half of patients.

SUMMARY Overactive bladder syndrome is a common and highly bothersome problem in the general adult population and a major source of health expenditure in industrialized nations. Much research has been undertaken to advance the understanding of the symptom syndrome and develop optimal management strategies. Although, currently, treatment options are increasing, it is often the case that treatment is inefficacious, impractical or associated with intolerable side effects. The latest European Association of Urology guidelines provides evidence-based recommendations for the diagnosis and management of overactive bladder syndrome within the guidelines for urinary incontinence in women and men as well as non-neurogenic male lower urinary tract symptoms. Their aim is to improve the standard of care of patients with lower urinary tract symptoms. In this article we review the latest guidance and discuss the evidence behind the recommendations, and the practical aspects of their application, as well as their limitat...

Nocturia is one of the most bothersome lower urinary tract symptoms and most common causes of disturbed sleep in the elderly. By fragmenting the sleep cycle, it leads to a negative impact on the quality of sleep and consequently is associated with daytime tiredness. Nocturia is also associated with falls and fall-related morbidity, as well as an incidence of mortality. Traditionally, nocturia has often been viewed as simply due to lower urinary tract dysfunctions, such as bladder outlet obstruction due to benign prostatic hyperplasia or overactive bladder syndrome, which has led to a failure to properly evaluate the condition in clinical practice and research. The contribution of nocturnal polyuria to the etiology of nocturia in elderly persons has led to new treatment approaches that focus on reducing night time urine production. This review discusses the current evidence on the etiology, epidemiology, pathogenesis and management of nocturia in the elderly.

Aims: Synthetic non-absorbable meshes are widely used to augment surgical repair of stress urinary incontinence (SUI) and pelvic organ prolapse (POP); however, there is growing concern such meshes are associated with serious complications. This study compares the potential of two autologous cell sources for attachment and extra-cellular matrix (ECM) production on a biodegradable scaffold to develop tissue engineered repair material (TERM). Methods: Human oral fibroblasts (OF) and human adipose-derived stem cells (ADSC) were isolated and cultured on thermo-annealed polyL-lactic acid (PLA) scaffolds for two weeks under either unrestrained conditions or restrained (either with or without intermittent stress) conditions. Samples were tested for cell metabolic activity (AlamarBlue 1 assay), contraction (serial photographs analyzed with image J software), total collagen production (Sirius red assay), and production of ECM components (immunostaining for collagen I, III, and elastin; and scanning electron microscopy) and biomechanical properties (BOSE tensiometer). Differences were statistically tested using two sample t-test. Results: Both cells showed good attachment and proliferation on scaffolds. Unrestrained scaffolds with ADSC produced more total collagen and a denser homogenous ECM than OF under same conditions. Restrained conditions (both with and without intermittent stress) gave similar total collagen production, but improved elastin production for both cells, particularly OF. The addition of any cell onto scaffolds led to an increase in biomechanical properties of scaffolds compared to unseeded scaffolds. Conclusions: OF and ADSC both appear to be suitable cell types to combine with biodegradablescaffolds,in thedevelopmentofa TERMfor thetreatmentofSUI andPOP.Neurourol.Urodynam. 33:531– 537, 2014. # 2013 Wiley Periodicals, Inc.

Urological disease is highly prevalent and affects both males and females in all age groups. The disorders affecting the urinary tract are diverse encompassing neoplastic, inflammatory, neurogenic, infective as well functional disease. Urological emergencies represent a significant proportion of surgical admissions, therefore the ability to properly assess patients is essential. History-taking and clinical examination form the basis of the urological assessment, which is further aided by bedside tests such as urinalysis as well as basic laboratory investigations including urine microscopy/culture and blood tests. Thereafter imaging with radiography, ultrasound or computed tomography scanning is often undertaken in the acute situation to confirm the cause of haematuria or loin pain. MRI scanning is mainly used to image the pelvic organs and stage bladder or prostatic malignancy. Nuclear medicine is useful in detecting metastases from urological malignancy as well estimating the split renal function and assessing renal obstruction. Direct inspection of the urinary tract is possible through endoscopic techniques, essential for determining the cause of haematuria. Urodynamic studies are undertaken to assess the underlying pathophysiological abnormality causing urinary symptoms and to plan subsequent treatment. We review the basis of history-taking and examination in urology as well as describing the common investigations undertaken.

The primary treatment of lower urinary tract symptoms thought to be associated with histological benign prostatic hyperplasia causing bladder outflow obstruction (LUTS/BPH) has evolved from an emphasis on surgical through to medical therapies. More recently there has been an increasing trend toward developing combination pharmacotherapy utilizing agents with differing mechanism of action aimed at the various pathophysiolgies potentially underpinning voiding and storage symptoms. The focus has been on clinical benefit such as reducing disease progression, acute urinary retention and need for BPH surgery in the case of alpha-blockers (AB) and 5-alpha-reductase inhibitor combination. This effect appears to be appropriate in the subset of men with larger prostates. Anti-muscarinics with AB is safe and effective treatment in those with bothersome storage symptoms and LUTS/BPH, although only confirmed as not associated with retention based on the existing literature for men with low PVR’s

Nocturia is a prevalent highly bothersome urinary symptom that may significantly detriment the health and well-being of sufferers. It is characterized by waking at night to void, each void preceded and followed by sleep, hence leading to fragmentation of sleep and day-time tiredness. This may result in reduced productivity in the workplace, which contributes to the significant burden to the wider society that nocturia incurs. Nocturia was traditionally viewed as one of the many urinary tract symptoms that occur due to lower urinary tract dysfunction. However, recently it has been recognized that due to its multi-factorial aetio-pathogenesis, nocturia should be viewed as distinct clinical condition in its own right. Careful assessment of the nocturic patient is essential so that treatment strategies are guided by the likely causes. Much research is currently being undertaken into the underlying causes and the optimal management approaches. This review will explore the contemporary status of research on nocturia with a focus on the current and newly available pharmacotherapies.

It is increasingly recognized that the bladder is the originator of storage lower urinary tract symptoms, including overactive bladder in men. As these symptoms are most bothersome for patients, there has been an increasing interest in the evaluation of drug treatment to better target the bladder. Consequently, several new drug classes have been introduced to the therapeutic armamentarium. Antimuscarinics, which were previously avoided due to the concern regarding urinary retention, are now used in routine practice; however, their use is still hampered by discontinuation due to side effects.

Urethral stricture disease affects many men worldwide. Traditionally, the investigation of choice has been urethrography and the management of choice has been urethrotomy/dilatation. In this review, we discuss the evidence behind the use of ultrasonography in stricture assessment. We also discuss the factors a surgeon should consider when deciding the management options with each individual patient. Not all strictures are identical and surgeons should appreciate the poor long-term results of urethrotomy/dilatation for strictures longer than 2 cm, strictures in the penile urethra, recurrent strictures, and strictures secondary to lichen sclerosus. These patients may benefit from primary urethroplasty if they have many adverse features or secondary urethroplasty after the first recurrence.

The inability to generate a voiding contraction sufficient to allow efficient bladder emptying within a reasonable time frame is a common problem seen in urological practice. Typically, the symptoms that arise are voiding symptoms, such as weak and slow urinary flow. These symptoms can cause considerable bother to patients and impact upon quality of life. The urodynamic finding of inadequate detrusor contraction has been termed detrusor underactivity (DUA). Although a definition is available for this entity, there are no widely accepted diagnostic criteria. Drawing parallels to detrusor overactivity and the overactive bladder, the symptoms arising from DUA have been referred to as the “underactive bladder” (UAB), while attempts to crystallize the definition of UAB are now ongoing. In this article, we review the contemporary literature pertaining to the epidemiology and etiopathogenesis of DUA as well as discuss the definitional aspects that are currently under consideration.

Context Stress urinary incontinence (SUI) is a common and bothersome problem that frequently requires operative management. Over the past two decades, novel techniques have been introduced into clinical practice. With the greater variety of surgical options now available, there is an increasing focus on selecting the appropriate procedure for the individual patient based on the likely underlying pathophysiologic mechanism. Objective To review the methods used in the evaluation of SUI and the proposed classification systems. Evidence acquisition A search of the PubMed database for the relevant search terms was conducted, and selected articles were retrieved and reviewed. Evidence synthesis Standardised terminology for the description of SUI has been produced by the International Continence Society describing the problem in terms of symptoms, clinical signs, and urodynamic observations. The two major pathophysiologic theories that have emerged over the past 50 yr, urethral hypermobility and intrinsic sphincteric deficiency, have influenced the development and adoption of surgical techniques. It is now recognised that these two entities are not dichotomous but often coexist. The primary aim of the evaluation of the patient presenting with SUI is to confirm the diagnosis and assess symptom severity before instituting conservative treatments. Secondary evaluation consists of more sophisticated techniques that assess anatomy of the bladder neck and urethra under rest and stress (eg, videourodynamics, ultrasound) or direct or indirect physiologic measures of the integrity of the sphincter mechanism. Conclusions Classification of patients with SUI into distinct groups based on probable pathophysiologic mechanism could help guide the choice of surgical procedure, but current systems are likely too simplistic, and methods of assessment lack standardisation in techniques and sensitivity. Patient summary Urinary leakage on exertion, termed stress incontinence , is a common problem that affects many women. There is a need to develop better ways of categorising the underlying causes of leakage to ensure that patients receive the optimal treatments.