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AIMS Beyond single-institution case series, limited data are available to describe risks of performing a concurrent cystectomy at the time of urinary diversion for benign end-stage lower urinary tract dysfunction. Using a population-representative sample, this study aimed to analyze factors associated with perioperative complications in patients undergoing urinary diversion with or without cystectomy. METHODS A representative sample of patients undergoing urinary diversion for benign indications was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Perioperative complications of urinary diversion with and without concomitant cystectomy were identified and coded using the International Classification of Diseases, version 9. Multivariate logistic regression models identified hospital and patient-level characteristics associated with complications of concomitant cystectomy with urinary diversion. RESULTS There were 15,717 records for urinary diversion identified, of which 31.8% demonstrated perioperative complications: urinary diversion with concurrent cystectomy (35.0%) and urinary diversion without concomitant cystectomy (30.6%). Comparing the two groups, a concomitant cystectomy at the time of urinary diversion was significantly associated with a complication (OR = 1.23, 95%CI: 1.03-1.48). Comorbid conditions of obesity, pulmonary circulation disease, drug abuse, weight loss, and electrolyte disorders were positively associated with a complication, while private insurance and southern geographic region were negatively associated. CONCLUSIONS A concomitant cystectomy with urinary diversion for refractory lower urinary tract dysfunction elevates risk in this population-representative sample, particularly in those with certain comorbid conditions. This analysis provides critical information for preoperative patient counseling.

AimsTo review and assess the definitions of drug resistance and the evidence supporting treatment for drug resistant overactive bladder/detrusor overactivity (OAB/DO).MethodsEvidence review of the extant literature and consensus of opinion was used to derive the summary recommendations.ResultsDrug resistance or drug refractory status has been inconsistently defined and reported in current evident sources. Recent publications use some correlation of lack of efficacy and or experienced side effects to define drug resistance. Algorithms based upon these definitions largely relate to the appropriate use of neuromodulation or botulinum neurotoxin, based upon patient selection and patient choice. Current treatment pathways are hampered by inability to consistently profile patients to optimize management, particularly after failure of initial pragmatic treatment.ConclusionsFurther research is recommended to better identify patient phenotype for purposes of directing optimized therapy for OAB/DO. Current treatment algorithms are influenced by extensive data generated from recent neuromodulation and botulinum neurotoxin trials.

AIMS To identify the prevalence of and risk factors for urinary retention and catheterization among female Medicare beneficiaries. METHODS We identified women with a diagnosis of urinary retention in a 5% sample of Medicare claims in 2012. Women were categorized into three groups based on the occurrence and duration of urinary catheterization within a 1 year period: 1) no catheterization; 2) short-term catheterization (ie, one or more catheterizations in less than 30 days); and 3) chronic catheterization (catheterizations in multiple 30 day periods within 1 year). We then identified a group of age-matched controls without catheterization or a diagnosis of urinary retention in 2012. Clinical and demographic data were collected for each patient, and risk factors for retention and catheterization were compared across groups. We assessed factors associated with urinary retention using multivariable logistic regression. RESULTS We estimated the rate of retention to be 1532 per 100 000 U.S. female Medicare beneficiaries in 2012, with rates of short term and chronic catheterization estimated to be 160 and 108 per 100 000 women, respectively. Prior diagnoses of neurologic condition, urinary tract infection, and pelvic organ prolapse were positively associated with retention and catheterization in multivariable analyses. CONCLUSIONS We estimated the prevalence of urinary retention diagnoses among female Medicare beneficiaries to be 1532 per 100 000 women. Retention and catheterization were significantly associated with comorbid disease, with the strongest associations identified with a concomitant diagnosis of neurologic condition, UTI, and POP.

Underactive bladder (UAB) is a clinical symptom complex only recently gaining recognition as a clinical diagnosis. Lack of consensus agreement on a definition of UAB has limited its recognition and diagnosis in clinical practice. The purposes of this review are to: present existing definitions of UAB, review recent data regarding clinical and urodynamic diagnosis of the condition, and examine up-to-date hypotheses regarding its pathophysiology, with a focus on women.The process to develop a consensus definition for UAB as a clinical symptom complex is ongoing. Symptoms associated with UAB, such as weak stream, straining to void, and history of urinary retention are well correlated to detrusor underactivity on urodynamics, which frequently develops in elderly women. In addition to aging, UAB may be the end stage of a variety of contributing pathologic conditions such as diabetes and ischemic disease. In some women, UAB may result from a progression from overactive bladder to UAB.Existing evidence supports UAB in women as a symptom complex with a clinical and pathophysiologic profile distinguishable from other lower urinary tract-associated clinical conditions. Consensus definitions of clinical and urodynamic diagnostic parameters will be essential to more widespread recognition of UAB.

Objective Deep Brain Stimulation (DBS) is an established adjunctive surgical intervention for treating Parkinson's disease (PD) motor symptoms. Both surgical targets, the globus pallidus interna (GPi) and subthalamic nucleus (STN), appear equally beneficial when treating motor symptoms but effects on nonmotor symptoms are not clear. Lower urinary tract symptoms (LUTS) are a common PD complaint. Given prior data in STN-DBS, we aimed to further explore potential benefits in LUTS in both targets. Methods We performed a prospective, nonblinded clinical trial evaluating LUTS in PD patients in both targets pre and post DBS using validated urologic surveys. Participants were already slated for DBS and target selection predetermined before study entry. LUTS was evaluated using: the American Urological Association (AUA-SI), Quality of Life score (QOL), Overactive Bladder 8 Questionnaire (OAB-q), and Sexual Health Inventory for Men (SHIM). Results Of 33 participants, 20 underwent STN DBS and 13 had GPi DBS. Patients demonstrated moderate baseline LUTS. The urologic QOL score significantly improved post DBS (3.24 ± 1.77vs. 2.52 ± 1.30; p = 0.03). Analyzed by target, only the STN showed significant change in QOL (3.20 ± 1.61 vs 2.25 ± 1.33; p = 0.04). There were no other significant differences in urologic scores post DBS noted in either target. Conclusion In PD patients with moderate LUTS, there were notable improvements in QOL for LUTS post DBS in the total sample and STN target. There may be differences in DBS effects on LUTS between targets but this will require further larger, blinded studies.

Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies.A retrospective review was performed at a single institution from 2011 to 2015 to identify patients with symptoms of UAB. Patients were excluded if they were male, had anti-incontinence, or pelvic organ prolapse (POP) surgery within 1 year, or the UDS did not demonstrate DU as defined within. Subjects were stratified by etiology into four cohorts: cardiovascular disease manifestations (CV), cardiac risk factors (CVR), neurologic (N), or idiopathic (I). Patient demographics, comorbidities, symptomatology, physical exam, and UDS parameters were compared.A total of 200 patients met inclusion criteria (CV: n = 53 [26.5%], CVR: n = 44 [22%] N: n = 81 [40.5%], I: n = 22 [11%]). Women in the CV cohort were significantly older and more likely to be post-menopausal (P 0.001). There were no differences between cohorts for BMI (P = 0.48), recurrent UTI (P = 0.63), history of urinary retention (AUR) (P = 0.65), POP (0.49), American Urological Association Symptom Score (AUA-SS) (P = 0.06), presenting symptomatology [urgency, frequency, urgency urinary incontinence, AUR, incomplete emptying, hesitancy, UTI (P = 0.97)], or UDS parameters (first sensation [P = 0.25], normal desire [P = 0.80], strong desire [P = 0.58], capacity [P = 0.11], QThough differences were observed between cohorts for age and menopausal status, clinical or urodynamic parameters did not demonstrate distinct differences across presumed categories of etiology, suggesting that the etiology of DU may be multifactorial. Neurourol. Urodynam. 36:1151-1154, 2017. © 2016 Wiley Periodicals, Inc.

Aims To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States. Methods Surgical volume for procedures performed primarily by FPMRS surgeons at eight academic institutions across the US was collected using Current Procedural Terminology (CPT) codes for stress urinary incontinence repair and revision surgeries from 2007 to 2013. SAS statistical software was used to assess for trends in the data. Results There was a decrease in the use of synthetic mesh sling for the treatment of SUI at academic tertiary care centers over the past 7 years; however, this was not statistically significant. While the total number of surgical interventions for SUI remained stable, there was an increase in the utilization of autologous fascia pubovaginal slings (AFPVS). The number of mesh sling revision surgeries, including urethrolysis and removal or revision of slings, increased almost three-fold at these centers. Conclusions These observed trends suggest a possible effect of the FDA Public Health Notifications regarding TVM on surgical practice for SUI in academic centers, even though they did not specifically warn against the use of synthetic mesh for this indication. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study. However, such data may provide alternative insights into reasons for the observed trends. Neurourol. Urodynam. 36:1155–1160, 2017. © 2016 Wiley Periodicals, Inc.

Botulinum neurotoxin (BoNT) is used to treat a variety of ailments, and its therapeutic application in lower urinary tract disorders (LUTDs) is well studied. Robust evidence supporting the efficacy and tolerability of BoNT in the treatment of neurogenic detrusor overactivity (NDO) and non-neurogenic overactive bladder (OAB) has led to regulatory approval for these conditions. Use of BoNT in the treatment of interstitial cystitis/bladder pain syndrome, chronic pelvic pain, and detrusor sphincter dyssynergia has demonstrated some promise, but is still evolving and off-label for these indications. Trials to date do not support the use of BoNT for benign prostatic hyperplasia. This comprehensive review outlines the mechanisms of BoNT in the treatment of LUTDs in adults and presents background and updated data examining the efficacy and adverse events associated with the use of BoNT in common urologic applications.

Sacral neuromodulation (SNM) is a guideline-recommended third-line treatment option for managing overactive bladder. Current SNM devices are not rechargeable, and require neurostimulator replacement every 3-6 years. Our study objective was to assess potential cost effects to payers of adopting a rechargeable SNM neurostimulator device.We constructed a cost-consequence model to estimate the costs of long-term SNM-treatment with a rechargeable versus non-rechargeable device. Costs were considered from the payer perspective at 2015 reimbursement levels. Adverse events, therapy discontinuation, and programming rates were based on the latest published data. Neurostimulator longevity was assumed to be 4.4 and 10.0 years for non-rechargeable and rechargeable devices, respectively. A 15-year horizon was modeled, with costs discounted at 3% per year. Total budget impact to the United States healthcare system was estimated based on the computed per-patient cost findings.Over the 15-year horizon, per-patient cost of treatment with a non-rechargeable device was $64,111 versus $36,990 with a rechargeable device, resulting in estimated payer cost savings of $27,121. These cost savings were found to be robust across a wide range of scenarios. Longer analysis horizon, younger patient age, and longer rechargeable neurostimulator lifetime were associated with increased cost savings. Over a 15-year horizon, adoption of a rechargeable device strategy was projected to save the United States healthcare system up to $12 billion.At current reimbursement rates, our analysis suggests that rechargeable neurostimulator SNM technology for managing overactive bladder syndrome may deliver significant cost savings to payers over the course of treatment. Neurourol. Urodynam. 36:727-733, 2017. © 2016 Wiley Periodicals, Inc.

Medical risk management in the United States remains a complicated process which involves not only an understanding of institutional experience but also regional as well as national expectations for outcomes and quality of care. Risk management requires integrated processes involving multiple aspects of institutional efforts including legal (general counsel) quality safety efforts, departmental and institutional leadership, as well as a formalized risk management group. Processes for identifying and analyzing present risk as well as potential future risk should be in place and formalized. These processes should be reproducible and be able to provide repetitive analyses that can be catalogued for purposes of tracking institutional experience and identifying environments within an institution that may be at risk for repetitive errors and/or risk-related activities

Aims Prompted by increased reports of complications with the use of mesh for pelvic organ prolapse (POP) surgery, the FDA issued an initial public health notification (PHN) in 2008. We proposed to determine if the numbers of POP cases augmented with surgical mesh performed in U.S. Medicare beneficiaries changed relative to this PHN. Methods Using administrative healthcare claims for beneficiaries enrolled in the U.S. Medicare program from 2008 to 2009, we identified women who underwent POP surgery with and without surgical mesh by procedural and diagnosis coding. In addition to comparing cases with and without mesh, we also calculated rates (number of cases per 100,000 female beneficiaries) and compared these relative to the timing of the PHN. Results We identified 104,185 POP procedures, of which 27,839 (26.7%) included mesh material and 76,346 (73.3%) did not. Between the last three quarters of 2008 and the first three of 2009, the rates of mesh cases increased (40.3–42.1, P

Urethral bulking therapy (UBT) is a minimally invasive procedure for stress urinary incontinence that is beneficial for properly selected patients. Many different materials are available for UBT, although none fulfill all the qualities of an ideal agent. In general, short-term clinical results are encouraging; however, over longer follow-up, results are disappointing and retreatment is often necessary. Proper patient selection and management of patient expectations are paramount to successful application of UBT.

The prevalence of posterior-compartment prolapse (rectocele) is not known. The authors have found that operative repair symptomatically improved a majority of patients with impaired defecation associated with a large rectocele, but this improvement was likely related at least in part to factors other than the size of the rectocele. Multiple surgical techniques are available for rectocele repair, and the literature is not clear regarding indications for each type of surgical intervention. This article reviews the literature regarding various types of posterior-compartment repair, and draws conclusions regarding their absolute efficacy and relative efficacy in comparison with one another.

Aims To estimate the prevalence of LUTS and OAB in a large, ethnically diverse US study. Methods This cross-sectional, population-representative survey was conducted via the Internet in the US among 10,000 men and women aged 18–70 (2,000 African-Americans [AA], 2,000 Hispanics, 6,000 whites). The LUTS tool assessed how often participants experienced LUTS during the past 4 weeks on a five-point Likert scale. OAB was defined by the presence of urinary urgency ≥ “sometimes” or ≥ “often,” and/or the presence of urgency urinary incontinence (UUI). Descriptive statistics were used to evaluate group differences. Logistic regression analyses were conducted to examine the impact of racial/ethnic group on OAB. Results Response rate, 56.7%. Prevalent LUTS included terminal dribble and nocturia across gender, post-micturition leaking (men), and stress incontinence (women). Prevalence of OAB ≥ “sometimes” and ≥ “often” were 17% and 8% in men and 30% and 20% in women—with significantly higher rates among AA men and women. A similar trend was found for UUI among men (AA, 10%; Hispanic and whites, 6%), while AA and white women had higher prevalence of UUI (19%) as compared to Hispanic women (16%). In logistic regression analyses, AA and Hispanic men and women were significantly more likely than whites to have OAB despite having lower prevalence of self-reported comorbid conditions and risk factors. Conclusions LUTS and OAB are highly prevalent in both men and women and increase with advancing age. Further, racial/ethnic group is a robust predictor of OAB in men and women. Neurourol. Urodynam. 32: 230–237, 2013. © 2012 Wiley Periodicals, Inc.

As more women undergo repairs of pelvic organ prolapse (POP), an ever-increasing scrutiny has been placed on repairs utilizing vaginal mesh. We aim to review the current literature regarding mesh POP repairs and discuss the Food and Drug Administration controversy.Evidence-based literature indicates that the objective success of standard (plication-type) repairs in the anterior compartment may not be durable, and that augmentation with nonabsorbable, synthetic mesh may be superior. Augmentation in the posterior compartment may not present a clear advantage over standard repair. Transvaginal mesh used for POP repair may be associated with adverse sequelae, such as erosion, extrusion, and infection. Additionally, there is concern regarding potential long-term outcomes such as dyspareunia, chronic pelvic pain, and vaginal distortion, which may occur even in the absence of frank extrusion. Recent warnings by the Food and Drug Administration regarding adverse events after transvaginal mesh implantation have led to a call for an increase in the premarket testing and postmarket surveillance of these products.Although the use of transvaginal mesh may improve anatomical outcomes over standard repairs, the subjective improvement may be similar. Furthermore, the recent warnings regarding mesh placement may lead to a greater level of regulation of these products.

Objective To evaluate the impact of overactive bladder (OAB) on work productivity in a large, population-based study in the United States, with an overrepresentation of minorities. Methods This cross-sectional, Internet-based survey was conducted among men and women aged 18-70. The lower urinary tract symptoms (LUTS) tool was used to assess symptoms over past 4 weeks. OAB was defined by urinary urgency of at least “sometimes” and/or urgency urinary incontinence (UUI). Outcomes included work status, Work Productivity and Activity Impairment Questionnaire—General Health (WPAI-GH) and Specific Health (WPAI-SH), and questions about the impact of urinary symptoms on work. Descriptive statistics were used to evaluate group differences (no/minimal symptoms [NMS] vs OAB). Logistic regressions evaluated predictors of unemployment status controlling for comorbid conditions, risk factors, and demographic variables. Results The response rate was 57%. A total of 5795 men and women were included in the analysis (OAB, 2323; NMS, 3472). OAB cases were significantly more likely to be unemployed (men, 44%; women, 54%) compared to those with NMS (men, 24%; women, 41%). Mean work productivity and activity impairment (WPAI) percent impairment while working was as follows: 19% and 21% among men and women with OAB; NMS, 4% and 7%. Significant differences were found for all urinary-specific WPAI-SHP items and other condition-specific outcomes. Men with OAB were 1.5 times more likely to be unemployed as compared to those with NMS when covariates were controlled for, whereas the association between OAB and unemployment in multivariate analysis was nonsignificant among women. Conclusion Comparison with other outcomes suggests that OAB impairs work at levels comparable to other serious chronic conditions, including rheumatoid arthritis and asthma.

The use of biologic grafts in the surgical treatment of pelvic prolapse repair has been an intriguing prospect for several years. These tissues have been thought to potentially combine favorable attributes of both autologous and synthetic tissues. These tissues are harvested and undergo complex decellularization, dehydration, terminal sterilization, and possibly cross-linking. It is these steps that determine the graft’s eventual biocompatibility and potential for remodeling. A PubMed literature search has revealed a number of studies evaluating cadaveric allografts and bovine and porcine xenografts in repairs of the anterior, posterior, and apical compartments. While the study quality varies significantly, overall, there is little compelling evidence to unequivocally support the use of a biologic tissue in any compartment. Furthermore, an analysis of postoperative complications reveals a similarity in graft-related complication profiles between some biologic grafts and synthetic meshes.

Stress urinary incontinence (SUI) is quite common, such that about 50 % of women with urinary incontinence report SUI as their primary symptom. Once behavioral modifications and pelvic floor muscle training have failed, surgical management is the mainstay of treatment for SUI, and mid-urethral synthetic slings (MUSS) have been established as the surgical intervention of first choice. All commercially available MUSS are made from uncoated, knitted, macroporous, type 1 polypropylene mesh. With the evolution of mesh, the evolution of the surgical treatment of SUI has evolved in tandem. The popularity of MUSS has come under scrutiny with the US Food and Drug Administration (FDA’s) public health notification. While the FDA has not yet released its final recommendations on these devices, the American Urological Association has adopted position statements on the use of mesh for the surgical treatment of SUI.

Delivery of care for disorders of the female pelvic floor has changed significantly over the past two decades as the prevalence of the urinary incontinence and pelvic prolapse has increased and many new surgical techniques and devices have become available to the pelvic surgeon. The trend for surgical management of both stress incontinence and prolapse has been toward less invasive and morbid procedures that can be performed in outpatient settings. Unfortunately, early adoption of new technology can outpace clinical evidence for the efficacy and safety of certain devices. Recent actions by the US Food and Drug Administration regarding synthetic pelvic mesh reflect some of the controversy surrounding these newer technologies and highlight some of the major trends in patterns of care delivery.

Purpose: Evolving techniques and materials for pelvic reconstruction have resulted in corresponding increases in the risk of iatrogenic foreign bodies in the lower urinary tract and vagina. We review the presentation, management and outcomes of iatrogenic foreign bodies in the female lower urinary tract and vagina.Materials and Methods: We performed a retrospective review of the records of all women undergoing removal of lower urinary tract foreign bodies during a 9-year period. All patients underwent a structured evaluation including history, physical examination, ancillary testing as indicated and subjective symptom appraisal.Results: A total of 85 women were identified, of whom 48 had vaginal, 40 had lower urinary tract, and 3 had concomitant vaginal and lower urinary tract excision of foreign material. Of the lower urinary tract cases the foreign body was located in the urethra in 12, bladder neck in 10, bladder wall in 18 and trigone in 3, while the remainder of the cases was vaginal in location. Agg...

Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision.The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery.Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12).Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.

The following is a report of the proceedings of the Nocturia Think Tank sessions of the annual International Consultation on Incontinence-Research Society, which took place June 13–15, 2011 in Bristol, UK. The report is organized into sections pertaining to the main topics of discussions having occurred at that meeting, centering on the relationship of nocturnal polyuria (NP) and nocturia but also synthesizing more current evidence advancing our knowledge of the diagnosis and management of nocturia. This article is not meant to be a comprehensive review on the subject of nocturia, a number of which are available in the recent literature. All authors were physically present during, or in a preliminary session just prior to, the meeting in Bristol. Neurourol. Urodynam. 31:330–339, 2012. © 2012 Wiley Periodicals, Inc.

As overactive bladder (OAB) is highly prevalent and greatly impacts quality of life (QoL), effective therapeutic options are a welcome addition to the treatment algorithm. Recent evidence suggests that newer antimuscarinic agents are not only superior to placebo in the treatment of OAB, but may also have a role in treating OAB in the elderly and improve nocturia and sleep quality. While most adverse events (AEs) exceed those of placebo, cessation of therapy is infrequent.

Normal functioning of the urinary bladder and the distal gut is an essential part of daily physiological activity coordinated by the peripheral and central nervous systems. Pathological changes in one of these organs may induce the development of cross-organ sensitization in the pelvis and underlie clinical co-morbidity of genitourinary and GI dysfunctions. Experimental human and animal data suggest that the bladder and distal colon interact under both normal and pathological conditions, however, the directions of these interactions can change dramatically depending on the nature and duration of the applied stimuli. This review article aimed to summarize the clinical data on colon-bladder cross-reflexes in healthy individuals, as well as in patients with co-morbid disorders. It also discusses currently used animal models, experimental approaches, and suggested mechanisms of colon-bladder cross-talk. Additionally, it provides an overview of the potential pharmacological targets to develop treatment options for patients with co-morbid disorders. Presented work resulted from the discussion of colon/bladder interactions during “Think Tank 9” presentations at the International Consultation on Incontinence Research Society meeting held in Bristol, UK, 2011.

While it may serve functions as a permeability barrier, the glycosaminoglycan (GAG) layer is thought to function as an antibacterial coating for the bladder by retarding the adhesion of pathogens. Further research has confirmed that in patients with diseases involving bladder damage, such as interstitial cystitis and urinary tract infections, the GAG layer is damaged and in some cases may fail to differentiate properly. GAG replace- ment therapy with intravesical instillations of hyaluronic acid and proteoglycans such as chondroitin sulfate has been shown to be an effective therapeutic option for patients suffering from these conditions. Additionally, these intravesical therapies have been shown to be promising in combination therapy and as a prophylactic treatment option for patients a th igh risk of urinary tract infections.

Context Nocturia is a common urologic symptom that has been covered in a variety of reported studies in the literature but is not specifically covered in current guidelines. Objective To comprehensively review the literature pertaining to the definition, etiologies, and consequences of nocturia and assess the evidence supporting the use of conservative medical and interventional therapy. Evidence acquisition A literature search was conducted using the keyword nocturia , restricted to articles in the English language, after 2000 and before April 2012, in PubMed/Medline, Embase, Scopus, Web of Science, and Cochrane Library databases. Regarding treatment modalities, studies were included only if nocturia was a primary end point and if the studies were designed as randomized controlled trials without limit of date. When suitable, a meta-analysis was conducted. Papers covering treatment options for nocturia specifically related to nonurologic conditions were excluded. Evidence synthesis Nocturia is still defined as the symptom of wakening from sleep once or more often to void. The prevalence is high in both genders and increases with age. Frequency–volume charts, which are the pivotal tool of clinical assessment, detect 24-h polyuria, nocturnal polyuria (NP), or reduced nocturnal bladder capacity and help to target specific nonurologic etiologies. Nocturia is a morbid condition that significantly affects quality of life and increases mortality. Besides behavioral measures, validated treatment options include oral desmopressin, which is superior to placebo in treating NP. While the level of evidence for desmopressin is high, limited data support the use of α 1 -blockers and antimuscarinics; however, only rarely has nocturia been a primary end point when studying these drug classes, and studies have not consistently controlled for the effect of NP. Conclusions Our knowledge of nocturia, its etiology, and its management has substantially improved in recent years. The evidence available on the management of nocturia remains limited; contributory factors include (1) the complexity of associated conditions, (2) the underuse of objective evaluation tools, and (3) the lack of specific focus on nocturia in clinical trials.

Context Different types of behavioural, dietary, interventional, pharmacologic, and surgical therapies have been used to treat painful bladder syndrome/interstitial cystitis (PBS/IC). Because of the paucity of randomised placebo-controlled studies on different treatments, an evidence-based management approach has not yet been developed. Objective To critically review and synthesize data from a wide range of current therapeutic approaches to PBS/IC, to quantify the effect size from randomised controlled trials (RCTs), and to reach clinical agreement on the efficacy of treatments for PBS/IC. Evidence acquisition We performed a systematic review of the literature to identify articles published between 1990 and September 2010 on the management of PBS/IC. We included articles restricted to the English language published since 1990 to date that reported on oral and intravesical treatment, multimodal or combined treatment, and surgical treatment. For all RCTs, standardised mean differences (SMDs) were extracted and combined in a meta-analysis applying a random-effect model that incorporated the heterogeneity of effects. The four outcomes assessed in all studies were a change in the Interstitial Cystitis Symptom Index (ICSI), pain, urgency, and frequency. Non-RCTs (nRCTs) were analysed with a narrative synthesis of the evidence from all research designs. Evidence synthesis We included 7709 adult patients from 29 RCTs and 57 nRCTs. Meta-analysis of RCTs showed that only cyclosporine A provided a simultaneous great effect size of SMD on ICSI, pain, and frequency. Amitriptyline at different dosages showed a great effect size of SMD on pain and urgency or on ICSI and frequency. The remaining RCTs showed sporadic significant changes in only one of the four considered parameters. The attributed levels of evidence for treatments reported in RCTs were 1b; grades of recommendations ranged from A to C. According to the Jadad score, 11 RCTs were high-quality studies. Meta-analysis of RCTs showed a great heterogeneity in the applied methodologies, clinical outcomes assessed, and the obtained results in different studies. The results from the nRCTs showed that the most frequently adopted treatment is oral pentosan polysulfate and that the use of botulinum A toxin intradetrusorial injections in PBS/IC is increasing. A high heterogeneity in drugs and treatment modalities, clinical outcomes, and obtained results was also found for nRCTs. Conclusions Limited evidence exists for the few treatments for PBS/IC. The lack of definitive conclusions is due to the great heterogeneity in methodology, symptoms assessment, duration of treatment, and follow-up in both RCTs and nRCTs.

Study Type – Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Short-term (12-week) trials have demonstrated that subjects with OAB who receive treatment with fesoterodine 4- and 8-mg, either in fixed-dose or flexible-dose regimens, show significant improvements in measures of HRQL and other patient-reported outcomes. The results of this long-term, open-label study show that treatment with fesoterodine for up to 24 months resulted in sustained improvement in measures of HRQL and severity of bladder-related problems in subjects with OAB symptoms. Throughout the study, a high percentage of subjects reported satisfaction with fesoterodine treatment. The results were similar in men and women and across age groups (

PURPOSE OF REVIEW Deciding on an optimal therapy for mixed urinary incontinence (MUI) is challenging, as a single-treatment modality may be inadequate for alleviating both the urge and stress component. A MEDLINE search was conducted regarding English-language literature pertaining to the treatment for MUI focusing on literature within the last 18 months. RECENT FINDINGS Behavioral therapy and lifestyle modification, such as moderate weight loss and caffeine reduction, should be considered first-line options for all women with MUI. The addition of pelvic floor muscle therapy may have an additional salutary effect. Treatment of the urge component with antimuscarinics is effective; however, the stress component is likely to persist after therapy. Treatment with vaginal estrogen cream may help in the short-term, but long-term benefits are unknown. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI; however, it appears that women with MUI may have lower cure rates compared to women with pure stress urinary incontinence. SUMMARY The optimum treatment of MUI may often require multiple treatment modalities. Although surgery may often have a positive impact on both components, its routine implementation should be approached with caution and patients should be carefully selected and counseled.

Purpose of review As overactive bladder (OAB) is a prevalent and chronic medical condition that greatly impacts an individual's quality of life, novel therapeutic options are always welcome. Recent findings Recent evidence suggests that newer antimuscarinic agents are not only superior to placebo, but may also have a role in treating OAB symptoms in children and men with lower urinary tract symptom. Dose escalation for trospium and fesoterodine has shown to be both efficacious and safe. Adverse events typically exceed those of placebo but infrequently lead to cessation of therapy. Long-term outcomes of sacral nerve stimulation for refractory OAB have been recently reported. Although the overall satisfaction with this therapy is high, more than 50% may experience chronic pain; however, this adverse event also does not frequently lead to device removal. Percutaneous tibial nerve stimulation continues to display superiority to sham treatment and benefits similar to antimuscarinic therapy may be observed. This therapy is well tolerated and durable outcomes have been seen at 12 months of follow-up. Recent evidence suggests that a dose of 100 U per botulinum neurotoxin type A injection may optimally balance symptom improvement and incidence of voiding difficulty. Summary Treatment modalities for OAB continue to evolve and the abundance of options can only benefit the individuals with this condition.

What's known on the subject? and What does the study add? Nocturia is currently defined by the International Continence Society (ICS) as the complaint that an individual has to wake at night one or more times to void. It is, however, an underreported, understudied, and infrequently recognized problem in adults. Many factors may contribute to nocturia which are treatable, yet patients do not seek care or the condition may not be identified by providers. This paper aims to help healthcare providers better serve patients who are experiencing nocturia by summarizing current research, clinical approaches, and treatment options. The results of the conference provide a balanced evaluation of the full treatment armamentarium capable of meeting the needs of patients with the manifold causes of nocturia such as nocturnal polyuria, overactive bladder, or benign prostatic hyperplasia.

Neurogenic lower urinary tract dysfunction (NLUTD) encompasses a wide spectrum of abnormal voiding patterns ranging from detrusor overactivity and urgency to detrusor–external sphincter dyssynergia and urinary retention. NLUTD results from injury to the central or peripheral nervous system or some primary neurological disease that disrupts the normal neurological regulation of the lower urinary tract. Female patients with neurogenic voiding dysfunction deal with special challenges that make management of incontinence and lower urinary tract storage more problematic than in their male counterparts. Over the past 30 years, technological advancements have improved the care of these patients and reduced the morbidity and mortality associated with NLUTD. More recent developments, including intravesical botulinum toxin injection and neuromodulation (not US Food and Drug Administration approved for this indication), have provided further treatment options, resulting in improved quality of life. Still, management of the neurogenic bladder patient can be exceptionally complex, and attentive, specialized care is critical.

Neuromodulation has become an integral part of our treatment algorithm for overactive bladder symptoms refractory to conservative therapy and for nonobstructive urinary retention. Long-term outcomes are available for sacral neuromodulation and reflect high satisfaction rates and acceptable rates of revision and reoperation. Recent studies suggest that there also may be beneficial outcomes in patients with symptoms related to the bowels or with pelvic pain. Likewise, pediatric patients may also derive benefit from this type of therapy. Although other forms of neuromodulation have only recently emerged, there is already evidence to suggest that stimulation of the dorsal tibial, pudendal, and dorsal genital nerves may provide benefits in the aforementioned conditions. Although long-term outcomes and placebo-controlled studies are generally lacking, there are few adverse events, and therapy may be performed with minimal anesthetic requirements. Further cost-effectiveness analyses also will be helpful if these procedures are to be adopted into routine use.

Summary Overactive bladder syndrome (OAB) is a chronic condition that has an impact on patients’ daily activities and health-related quality of life (HRQL). Anticholinergic therapy is often prescribed following insufficient results with behaviour modification alone; however, rates of treatment discontinuation are consistently high. This study systematically reviewed persistence and adherence data in patients with OAB treated with anticholinergic therapy. A search focused on the intersection of OAB, persistence/adherence, and anticholinergic therapy was conducted in MEDLINE and EMBASE. Articles published after 1998 were reviewed and selected for inclusion based on prespecified criteria. A total of 147 articles and two abstracts were included in the review. Results from 12-week clinical trials showed high rates of discontinuation, ranging from 4% to 31% and 5% to 20% in treatment and placebo groups, respectively. Unsurprisingly, rates of discontinuation found in medical claims studies were substantially higher, with 43% to 83% of patients discontinuing medication within the first 30 days and rates continuing to rise over time. Findings from medical claims studies also suggest that over half of patients never refill their initial prescription and that adherence levels tend to be low, with mean/median medication possession ratio (MPR) values ranging from 0.30 to 0.83. The low levels of persistence and adherence documented in this review reveal cause for concern about the balance between the efficacy and tolerability of anticholinergic agents. Strategies should be identified to increase persistence and adherence. New agents and non-pharmacologic alternatives with good efficacy and minimal side effects should be explored.

Urethral bulking agents are a commonly employed modality utilized for treatment of female stress urinary incontinence. These primarily collagen-based agents are placed in the proximal urethra to facilitate mucosal coaptation during increases of intra-abdominal stress. Several known complications of these agents exist, including urethral prolapse, retention, and urinary infection. Herein, we report two cases diagnosed as urethral diverticuli which were ultimately determined anatomic aberration secondary to prior bulking agent therapy. Recognition of this potential sequela of bulking agent placement is important for the female pelvic surgeon to recognize to avoid the morbidity of potential invasive interventions.

Not only does the prevalence of incontinence increase with age, but the incidence does as well, in no small part due to the greater recognition of its signs and symptoms and the significant negative impact on quality of life. Elderly women differ from their younger counterparts by the presence of several physiologic changes in the urinary tract, as well as the presence of concomitant morbidity and polypharmacy. While the elderly have the same treatment options as younger women, they may experience a greater incidence of adverse events due to urologic and nonurologic factors. The objective of this article is to elucidate the unique changes in the elderly population and summarize the treatment options.

Phosphodiesterase type 5 (PDE5) inhibitors are arguably the gold standard for treatment of erectile dysfunction in men. While all three PDE5 inhibitors approved for use in the U.S. are effective in treating ED, they possess different characteristics. Tadalafil differs from both sildenafil and vardenafil in its long half-life, which makes it ideal for daily dosing. This regimen has been shown to be effective over placebo, and studies suggest that it may be preferable by both partners over on-demand dosing. Side effects are typically mild in nature and infrequently lead to discontinuation of the drug. Once-daily dosing has also shown to be effective in ‘difficult-to-treat’ groups, such as diabetics and non-responders to on-demand therapy. The implementation of once-daily therapy represents a significant advancement in the understanding of male erectile dysfunction.

Treatment options for antimuscarinic refractory neurogenic detrusor overactivity (NDO) are botulinum toxin type A injections (BTX-A) and augmentation cystoplasty (AC). We estimated initial and cumulative 5-year costs of these treatments.Base case is an individual with antimuscarinic refractory NDO and decreased bladder compliance. Primary analysis is from the health care payor perspective. Model probabilities and ranges were derived from literature and chart review. Reimbursements were derived from the average of insurance carriers. Complication cost calculations were based on standard practice. Decision-analysis model was made with TreeAge Pro Healthcare 2009 Software, Inc. and rolled back for cost calculation. One-way sensitivity analysis was performed on all variables, and two-way sensitivity analyses were based on these results.Average reimbursement for one BTX-A injection and AC was $2,946.83 and $25,041.53, respectively. BTX-A treatment was less expensive over 5 years, costing $28,065. The model was only sensitive within a reasonable clinical range for Botox durability. BTX-A was more cost-effective over 5 years if the effect lasted for5.1 months. The model was based on an AC complication rate of 40%. If the PAC complication rate14%, AC was cheaper over 5 years. The model was sensitive to surgeons costs of BTX-A ($3,027) and facility costs of BTX-A ($1,004) and AC ($17,100).This is the first cost analysis of BTX-A and AC. BTX-A is cheaper at durations5.1 months and AC was cheaper when the cost of BTX-A increases or the AC complication rate dropped below 14%.

Aims To characterize the patient profile, medication utilization, and healthcare encounters of patients with neurogenic bladder dysfunction related to incontinence. Methods Medical and pharmacy claims were retrospectively analyzed from April 1, 2002 to March 31, 2007 to characterize neurogenic bladder patients. There were 46,271 patients in the Neurogenic bladder cohort, and 9,315 and 4,168 patients in Multiple Sclerosis (MS) and Spinal Cord Injury (SCI) subcohorts, respectively. Demographic data, concomitant diseases, use of overactive bladder (OAB) oral drug, and healthcare encounters were summarized using descriptive statistics. Results The mean age of neurogenic bladder patients was 62.5 (standard deviation 19.6) years. A high frequency of lower urinary tract infections (UTIs; 29%–36%), obstructive uropathies (6%–11%), and urinary retention (9%–14%), was observed. Overall, 33,100 (71.5%) patients were taking an OAB oral drug; 10,110 (30.5%) patients discontinued and did not restart. During the one-year follow-up period, 39.0% (8,034) of neurogenic bladder patients had a urology visit, 31.7% (14,679) had a neurology visit, 33.3% (15,415) were hospitalized, and 14.4% (6,646) were in a nursing home (highest rates observed in SCI subcohort). UTI diagnoses comprised over 20% of all hospitalizations one-year post-index. Annually, neurogenic bladder patients averaged 16 office and 0.5 emergency room visits. Conclusions This is the largest observational study conducted to address the epidemiology of the neurogenic bladder population, including healthcare utilization. These data suggest that patients with neurogenic bladder may have suboptimal management, indicated by high incidences of urinary tract complications and hospitalizations. Neurourol. Urodynam. 30:395–401, 2011. © 2010 Wiley-Liss, Inc.

Female neurogenic sphincteric incontinence is a complex and debilitating condition. Stress urinary incontinence in this population is complicated by mixed urinary incontinence caused by functional and structural anomalies, which impacts upon management options. Patients require a full incontinence work-up, including a comprehensive history and physical examination, renal imaging, and videourodynamics. Understanding personal and physical limitations in addition to patient goals of treatment is tantamount in choosing the appropriate course of care. Options range from conservative therapy (behavioral modification) and clean intermittent catheterization with pharmacotherapy to invasive surgical options (bladder neck closure and urinary diversion). Before increasing sphincteric resistance, it is imperative to confirm that the bladder reservoir is well-balanced and filling under safe pressures. The risk of chronic urinary retention following treatment of the sphincter is high in this population. Much of the literature on this topic is anecdotal. Prospective studies comparing treatment options for neurogenic sphincteric incontinence within this population are needed.