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Purpose: With the recent increase in the use of artificial intelligence in the medical field, this study aimed to evaluate the accuracy and adequacy of ChatGPT's responses to questions related to female urology. Methods: Intensive internet research was performed to prepare a frequently asked question (FAQs) list. Scientific questions were created in accordance with the European Urology Association (EAU) Non-neurogenic Female Lower Urinary Tract Symptoms Guidelines, EAU Chronic Pelvis Pain Guidelines, and EAU Neuro-Urology Guidelines. All answers by ChatGPT were analysed by two experienced urologists and each answer was scored between 1 and 4 by the physicians. A score of 1 was the highest and showed that the answer was completely true and sufficient. The reproducibility of ChatGPT answers was evaluated by asking each question twice using two different computers. Results: A total of 96 (97.0%) ChatGPT answers about female urology were accurate and sufficient, and categorized as grade 1. Additionally, two (2.0%) answers were scored as grade 2, and one answer (1.0%) was scored as grade 3. None of ChatGPT's responses about female urology were classified as grade 4. In total, 83 questions were prepared according to EAU guidelines recommendations, and ChatGPT gave complete accurate and satisfactory answers for 68 (82.9%) questions. The reproducibility rate was highest for ChatGPT answers for questions related to urinary incontinence, pelvic organ prolapses, and pelvic pain syndromes, and reproducibility rate was 100% for each subgroup. The reproducibility rate for ChatGPT answers was lowest for CPG questions (84.1%). Conclusion: For the first time our study revealed that ChatGPT had an excellent accuracy rate in answering questions related to female urology with 97% success rate. In addition, the outcomes of this study showed that ChatGPT accurately and satisfactorily answered 82.9% of questions about female urology based on EAU guidelines. [ABSTRACT FROM AUTHOR]

Objectives: Urethral bulking injections are thought to be a low risk minimally invasive but temporary treatment option for women with stress urinary incontinence (SUI) with increasing prominence especially in the current era of the mesh controversy. However, little is known about their long-term effects. This study aims to evaluate the efficacy and long-term outcomes of Deflux®, a non-animal stabilised hyaluronic acid/dextranomer (NASHATM/Dx) gel, when used as a urethral bulking agent in the treatment of SUI in women. Methods: All women with SUI treated with Deflux® from 2001 to 2007 were analysed. The success rates, duration of efficacy and short- and long-term complications of the treatment were recorded. Results: A total of 142 women with a follow-up of up to 13 years (mean 8.8 years) were included. Subjective treatment success was achieved in 92/142 (65%) patients. In those who achieved continence, the mean efficacy was 4.7 years. Side effects were uncommon with 12 (6%) of 209 experiencing transient urinary retention and 11 (5%) of 209 experiencing pseudocyst formation. All pseudocysts were treated successfully with an incision and drainage under either general or local anaesthetic. Sixty (42%) of 142 patients went on to have subsequent definitive incontinence surgery, and Deflux® treatment was found not to have negatively impacted the operation. Conclusion: Deflux® urethral bulking injections appear to be efficacious and safe when used as a treatment for SUI in women with a longer duration of efficacy than previously thought and a low side effect profile. This study provides a valuable timeline to help manage the expectations of patients considering urethral bulking treatment. Level of evidence: 4 [ABSTRACT FROM AUTHOR]

Introduction:: Single-incision slings were introduced for female stress urinary incontinence (SUI) treatment to decrease surgery time, postoperative pain, and the amount of mesh used. Objective:: This multicenter study aims to examine Altis® usage in real-world clinical practice, its effectiveness in treating SUI, patient satisfaction, quality of life, sexual function, and complication rates. Methods:: Between 2015 and 2022, a prospective single-arm observational cohort study was conducted across 33 European centers involving 564 patients, investigating the clinical effectiveness of the Altis® sling. Patients were monitored for 36 months. The primary endpoint (success) was a positive impression of improvement and absence of serious/severe/Clavien Dindo (CD) ≥ III-related adverse events at 12 months. Secondary endpoints included effectiveness at 36 months, impact on quality of life, and risk factors for failure. Results:: An Altis® was implanted in 564 women. At 12-months, 86.6% of patients achieved success, 97.2% endorsed the surgery, and 90.4% were satisfied with the outcomes. At 36 months, 83.0% reported significant improvement, 94.5% endorsed the surgery, and 89.9% were satisfied. Altis® demonstrated decreased daily pad usage and improved quality of life. Dyspareunia and sexual function largely remained unchanged. However, 11.3% reported pain, and there were instances of serious adverse events. Conclusion:: The Altis® implant demonstrated substantial improvements in symptoms and overall quality of life for a majority of women with SUI. Potential complications such as mesh exposure, reoperation, voiding dysfunction, and urinary retention emphasize the importance of preoperative counseling. The Altis® implant is a viable option within the available surgical treatments of SUI.

Background:: Female urethral diverticula (UD) are rare and when one is present, it often receives a delayed diagnosis. Limited data is present on long-term and patient-related outcomes of a diverticulectomy. We aim to evaluate the clinical presentation of UD and to assess both objective and subjective effects of diverticulectomy in women. Methods: In this retrospective study, patient files of female patients with a UD from two tertiary hospitals were reviewed. Data collected from patient files included symptoms at presentation, surgery reports and complications. Patients were interviewed over the phone to evaluate the long-term impacts of surgery. The primary outcome was defined as subjective resolution of symptoms after diverticulectomy on short-term and long- term follow-up. Secondary outcomes included complications, time from the start of symptoms until diagnosis, recurrence risk and anatomical diverticulum characteristics relevant for success of surgery. Results:: 21 women were included. Urethral swelling was reported as a main symptom at presentation in 48%. Vaginal pain was the main symptom in 33% of the patients. Comparing the symptoms before diverticulectomy to the symptoms after surgery, at a mean follow-up of 36 months (range 6–78), there was a significant resolution of the sensation of a vaginal mass, dyspareunia, discharge and recurrent urinary tract infections (p < 0.05). A sensation of post-void residual, terminal dribbling and stress urinary incontinence (SUI) were reported more often after surgery than before (p < 0.05). De novo SUI was seen in 45% of the patients. Of the patients with a partially dorsally located diverticulum and those without involvement of the dorsal side of the urethra, respectively 50% and 43% experienced de novo SUI in the long-term (p = 0.57). 50% of the women were without any symptoms in the long-term and 35% reported fewer symptoms than before surgery. In four patients (20%) a recurrence was identified after surgery. Conclusion:: Urethral swelling and vaginal pain are the two main symptoms of a UD. In 50% of the patients diverticulectomy results in complete resolution of symptoms and in 35% of the patients it leads to fewer symptoms. Diverticulectomy entails a considerable risk (45%) of de novo SUI, of which patients should be informed pre-operatively.

Vaginal stones are rarely encountered in practice, often misdiagnosed as bladder stone on plain radiography. The clinical manifestation can be unspecific ranging from asymptomatic stones to acute onset of fever or abdominal discomfort, rendering the diagnosis challenging. They are classified into primary stones resulting from urine stasis, and more commonly secondary stones formed around a nidus.Cerebral palsy is frequently associated with urinary incontinence and leads to constant leakage of urine into the vagina. In addition, the prolonged recumbent position results in urinary stasis, thus promoting stone formation.

Purpose: To present the seven-year experience of a multi-component and interactive module on female, neurological and urodynamic urology (FNUU) training at the UK National Urology Simulation Bootcamp Course (USBC) and demonstrate trainee satisfaction and competency progression. Methods: During the week-long USBC, a four-hour module on FNUU was designed which consisted of short interactive presentations with an emphasis on practical stations in urodynamics, intravesical botulinum toxin injection, urethral bulking injection, female pelvic examination and, initially, mid-urethral tapes (subsequently replaced with percutaneous sacral nerve evaluation). The trainee's level of knowledge, operative experience and confidence were assessed pre- and post-course. The practical assessment consisted of preparation and intravesical administration of botulinum toxin, female pelvic examination, urodynamic trace interpretation or mid-urethral tape simulation. Trainee feedback was also collected. Results: Two-hundred sixty-one newly appointed urology trainees participated in the USBC during this period. A high level of satisfaction was constantly reported. The highest rated session was urethral bulking with 72% being very satisfied, followed by Botox and urodynamics. The final assessment showed 70% had achieved level 4 competency in cystoscopy and Botox. Qualitative feedback was also obtained. Conclusion: To our knowledge, this is the first module of its kind, and it shows that it is feasible to develop, implement and evaluate an introductory curriculum into FNUU that is reproducible over a 7-year period with very positive feedback. [ABSTRACT FROM AUTHOR]

Abstract Background Paraurethral leiomyoma are rare, benign, hormone-dependent growths. They originate from smooth muscle cells and occur in the paraurethral space of the urethra. They make up approximately 5% of urethral tumours. They usually appear in the reproductive age group of women with variable clinical presentation depending on the size and location of occurrence. They can either be asymptomatic or can present with local pressure symptoms, dyspareunia, and lower urinary tract symptoms. The usual treatment is surgical excision with confirmation of diagnosis on histology. Case presentation We report a case of a 58-year-old lady who initially presented to the gynaecology department with pelvic pain and lower urinary tract symptoms. After initial investigation with an ultrasound scan and MRI, a 5 × 5 × 4 cm mass was detected next to the bladder, with suspicions of it arising from the detrusor muscle. There was also a 3 cm Bartholin’s cyst detected in the left vaginal wall. Her care was referred to the urology team who after further investigation and a transperineal biopsy of the mass diagnosed a paraurethral leiomyoma on histology. Given the patient was symptomatic, she opted for treatment. Embolisation was explored but was deemed not feasible due to a complex blood supply. Therefore, the patient underwent an open excision of leiomyoma as a combined abdominal and vaginal procedure. Conclusion Paraurethral leiomyoma are rare benign lesions and therefore pose diagnostic challenges as they must be differentiated from malignant tumours. Radiological imaging aids with diagnosis but diagnosis is confirmed on histology. The mainstay of treatment is surgical excision. This case is unusual given the patient’s age and post-menopausal status as the average age of presentation in the literature is 41 years old. The authors would recommend initial USS imaging for all patients presenting with overactive bladder symptoms and pelvic pain/discomfort.

Purpose: Female representation at scientific conferences is crucial for encouraging women pursuing an academic career. Nevertheless, gender inequity at urological conferences is common place and women are often stereotyped choosing functional urology. However, there is no evidence whether female representation is higher in functional urology. This investigations aims to analyze gender representation at functional urology sessions. Methods: National and international urological congresses between 2019 and 2021 with a focus on functional urology and female urology sessions were evaluated. Congresses were categorized as national or international. Session type, topic, gender of chairs and speakers of the identified sessions were recorded. In addition, affiliation and medical specialty were collected for chairs. Results: A total of 29 congresses were evaluated. Out of a total of 2893 chairs and speakers, 1034 (35.7%) were women and 1839 (63.6%) were men. This represents an overall gender gap of 27.9% for functional urology sessions. No significant differences in gender representation between national and international congresses could be identified (p = 0.076). When considering gender distribution of chairs, the gap was more pronounced by 35.5%. Furthermore, men were more likely to be invited to be a speaker in plenary and podiums sessions. Conclusions: Gender inequality is present in functional urology sessions. There is a need for greater efforts to achieve gender equality. An important step to remedy the situation is the inclusion of women in scientific program committees. Furthermore, support by the leadership of urological societies and academic departments is essential to herald a lasting change in gender inequality. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the use of percutaneous tibial nerve stimulation (PTNS) in an elderly population, as PTNS is a third-line treatment in the management of overactive bladder (OAB) and affects 10-26% of adult males and 8-42% of adult females, increasing in prevalence with age. Patients and methods: We performed a chart review of patients aged ≥ 65 years undergoing PTNS at a single institution over 6 years. We examined clinicopathological variables potentially associated with the outcomes of interest. Results: In total, 52 patients aged ≥ 65 years underwent an induction course of PTNS between 2011 and 2017, comprising 23 men and 29 women. The mean age of the patients was 75.75 years and the mean body mass index (BMI) was 26.33 kg/m2. In all, 36 patients used anticholinergic treatments prior to PTNS, five used a β3-adrenoceptor agonist, and three had Botox injections. After PTNS, 37 patients reported improvement of their symptoms, with 21 using combined therapy during PTNS. Only seven patients used an anticholinergic after PTNS, six used a β3-adrenoceptor agonist, five had Botox injections, and two had sacral neuromodulation. When looking at variables such as age, gender, race, BMI, and comorbidities, we found that an obese BMI was the only statistically significant variable predicting failure of response. A sub-analysis of only women did not demonstrate any predictors of failure. Conclusion: Our subjective response rate of 70% was within the success rates reported in literature. In all, 39% of patients used a concomitant treatment during PTNS and 13.2% required alternative treatment after PTNS. Abbreviations: BMI: body mass index; OAB: overactive bladder; PTNS: percutaneous tibial nerve stimulation; UI: urinary incontinence.

Objective: To evaluate the use of percutaneous tibial nerve stimulation (PTNS) in an elderly population, as PTNS is a third-line treatment in the management of overactive bladder (OAB) and affects 10-26% of adult males and 8-42% of adult females, increasing in prevalence with age. Patients and methods: We performed a chart review of patients aged ≥ 65 years undergoing PTNS at a single institution over 6 years. We examined clinicopathological variables potentially associated with the outcomes of interest. Results: In total, 52 patients aged ≥ 65 years underwent an induction course of PTNS between 2011 and 2017, comprising 23 men and 29 women. The mean age of the patients was 75.75 years and the mean body mass index (BMI) was 26.33 kg/m2. In all, 36 patients used anticholinergic treatments prior to PTNS, five used a β3-adrenoceptor agonist, and three had Botox injections. After PTNS, 37 patients reported improvement of their symptoms, with 21 using combined therapy during PTNS. Only seven patients used an anticholinergic after PTNS, six used a β3-adrenoceptor agonist, five had Botox injections, and two had sacral neuromodulation. When looking at variables such as age, gender, race, BMI, and comorbidities, we found that an obese BMI was the only statistically significant variable predicting failure of response. A sub-analysis of only women did not demonstrate any predictors of failure. Conclusion: Our subjective response rate of 70% was within the success rates reported in literature. In all, 39% of patients used a concomitant treatment during PTNS and 13.2% required alternative treatment after PTNS. Abbreviations: BMI: body mass index; OAB: overactive bladder; PTNS: percutaneous tibial nerve stimulation; UI: urinary incontinence.

Objective:To investigate the role, interest, and competence of the Turkish urologists for urologic surgeries which are also performed by the other surgeons.Materials and Methods:We conducted a 22-item online survey and invited urologists by e-mail. Questions were asked to evaluate the attitudes, performances, and capabilities of the urologists in surgeries which could be performed by the other surgeons.Results:A total of 305 responses were evaluated. The female incontinence surgery, pediatric urologic surgery, and adrenal surgery are mostly performed by the urologists in their hospitals. Turkish urologists mostly do not perform the following surgeries and interventions themselves and refer patients to the other surgeons for a percutaneous nephrostomy (47.2%), urinary diversions using the intestinal segments (44.9%), kidney transplantation (11.8%), and the transgender surgeries (7.2%). Almost half of the urologists do not perform adrenal surgeries (50.2%). Most urologists agree that they should be the main surgeons for all these surgeries.Conclusion:Urologists are no longer the main surgeons for some surgeries which are included on the urologic curriculum. Many urologists avoid performing the major urologic surgeries. Urology educators should familiarize the new urologists with all the urologic surgeries.

An ectopic ureter is a ureter that does not correctly connect to the trigone of the bladder and drains outside of the bladder. Here, we presented five cases of ectopic ureter opening into the vagina, whose clinical symptoms and malformations were rarely described in previous case reports. All five patients were hospitalized with complaints of gynecologic disease. Three of the five cases did not present the typical symptoms of urinary incontinence. Three of these cases showed congenital malformations of the female genital tract. Four cases were diagnosed in adulthood. All patients were analyzed using various imaging examinations. This study suggests that the ectopic ureter should be considered in the differential diagnosis of a pelvic mass in a patient with urinary and reproductive system abnormalities. It is essential to comprehensively evaluate complex malformations of the genitourinary system with multiple imaging tests. [ABSTRACT FROM AUTHOR]

Purpose: Urology has rapidly evolved during the last decades, incorporating new technologies faster than most specialties. The challenge to maintain a competent workforce that is prepared to deliver proper contemporary treatment has become increasingly difficult and newly graduated urologists throughout the world typically lack the skills to practice many urological subspecialties. We performed a survey to evaluate the practice patterns and educational aspirations in functional urology (FU) among Brazilian urologists. Methods: A web‐based survey was sent to board‐certified Brazilian urologists to collect data on clinical practice and training aspirations in four subareas of FU: female urology, urodynamics, postprostatectomy incontinence (PPI), and neurourology. We evaluated urologists' clinical and surgical workload in each subarea and investigated educational training aspirations to identify areas and training formats of interest. Results: A total of 366 urologists (mean age 47.7 + 10.7 years) completed the survey. Mean time since completion of residency was 17.9 + 11.9 years. Of the respondents, 176 (53%) perform urodynamics, 285 (83.1%) SUI surgeries, 159 (47.6%) PPI surgeries, 194 (58.1%) third line OAB procedures, 168 (48.9%) pelvic organ prolapse (POP), and 88 (26.3%) bladder augmentation. Mid‐urethral sling is the most performed SUI surgery and transobturator is the preferred route (64.0%). For those performing POP surgery, 40.5% use mesh in at least 50% of their cases, and the vaginal route is used in most cases (75.4%) for apical prolapse. For PPI, 64.6% use artificial sphincter in most surgeries and only 8.1% perform at least 5 surgeries/year. Being fellowship‐trained and working in an academic hospital are associated with a higher chance of being active in FU. Most urologists are interested in receiving training in PPI, female SUI, and POP and a hands‐on course is the preferred educational method (81%). Conclusions: Most urologists in Brazil are involved in the evaluation and treatment of FU patients, but few have a large volume of patient visits and surgical procedures. Completing a fellowship program and working in an academic practice are associated with a higher chance of being a FU practitioner. There is a high interest in training for PPI, female SUI, and POP. [ABSTRACT FROM AUTHOR]

Stress urinary incontinence (SUI) significantly affects the quality of life in women, causing social, psychological, and physical distress. While artificial urinary sphincter (AUS) implantation is a well-established treatment for male incontinence, it is less commonly used in female patients and is typically considered for cases where other treatments have failed. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of AUS implantation in treating SUI in female patients, focusing on continence rates, revision rates, explant rates, and perioperative complications. A comprehensive literature search was conducted across PubMed, Scopus, Google Scholar, and the Cochrane Library in September 2024. Studies published in English over the past 15 years were included if they reported outcomes such as continence, revision, explant, and complication rates in female patients who underwent AUS implantation. Data were analyzed using Review Manager 5.4, applying a fixed-effects model where appropriate, based on heterogeneity (I 2 > 50%). Publication bias was assessed using funnel plots and Egger's test. Eight studies, comprising a total of 300 female patients, were included in the analysis. AUS implantation significantly improved continence rates, achieving an overall continence rate of 72% (OR = 0.01, 95% CI: 0.00 to 0.02; p < 0.00001). Revision rates were 22.5%, explant rates were 17.6%, and overall postoperative complications were 26.3%. No significant bias was detected. AUS implantation is an effective and safe treatment option for a specific group of women with SUI, particularly in cases where other standard treatments have failed. It shows satisfactory continence rates with considerable revision and explant rates. However, further large-scale, long-term studies are needed to optimize outcomes and confirm these findings., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Estaphanous et al.)

Introduction:: The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients’ quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS. Methods:: The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0–10. Consensus achievement was defined as attaining ≥ 70% agreement. Results:: 98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or β3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities’ guidance. Conclusions:: During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Introduction: Leiomyoma of the bladder is a rare diagnosis and accounts for 0.43% of all bladder tumors. We herein present a case of a thirty-nine-year-old female diagnosed with bladder leiomyoma presenting with urinary retention. Workup of her urinary retention revealed a midline bladder neck mass. Transurethral resection of her tumor revealed pathology consistent with bladder leiomyoma. Surgical resection is generally the recommended management of this lesion to make a histopathological diagnosis despite low potential of malignant transformation. Although these tumors are benign, they can cause severe obstructive or irritative symptoms. Further research is needed to determine the pathophysiology of these tumors

" In the first place", the area of female urology was not well recognized within the field of urology. Women’s overactive bladder and urinary incontinence were considered "natural because they are old." In recent years, many drugs for overactive bladder and surgical treatments for urinary incontinence have been developed. Furthermore, the fields of female urology and urogynecology are finally being established. As women’s social advancement progresses, it seems that we are in an era where it is "true" to look at women’s QOL diseases. Diseases within the field of female urology include urinary tract infections such as cystitis and pyelonephritis, sexual infections, overactive bladder, interstitial cystitis, urinary incontinence, and pelvic organ prolapse. Further diseases which need to be addressed include sexual dysfunction and GSM (Genitourinary Syndrome of Menopause). Moreover female urology disease is closely associated with gynecological disease. Gynecological disorders are often the cause of urinary symptoms, and hence a gynecological approach is also required. In this paper, I consider the terms "in the first place" and "true" when used with regard to diseases that are often encountered in outpatient clinics. [ABSTRACT FROM AUTHOR]

Introduction:: The 3-Day Bladder Diary (3dBD) has good feasibility, reliability and validity for the assessment of Lower Urinary Tract Symptoms (LUTS) in women. This study aims to evaluate the reliability of the first day of the 3dBD (fdBD) in the assessment of the symptoms of women with LUTS. Materials and Methods:: An epidemiologic, descriptive and cross-sectional study was conducted. Fourteen Functional Urology and Urodynamic Units participated, and one hundred thirty-six women with a mean age (SD) of 55.2 (13.8) years with LUTS filled in the 3dBD. Investigators completed the evaluation sheet based on the interpretation of the three patient-completed sheets. The authors did a centralized reading of the diaries. A descriptive analysis of 3dBD was performed. The intraclass correlation coefficient (ICC) was used to assess the agreement between fdBD and 3dBD global results. ICC0.74 excellent agreement. Results:: One hundred ten women completed the 3dBD. Day-time micturition frequency, nocturia, urgency, urgency urinary incontinence (UUI) and pads showed an excellent concordance (ICC 0.932; 0.883; 0.947; 0.958; 0.961 respectively). Stress urinary incontinence (SUI), fluid intake and 24-hour urine production had a good/excellent concordance (ICC 0.859; 0,884; 0.869 respectively). However, voiding volumes exhibited a moderate level of agreement with wide confidence intervals (day-time 0.730 [0.415-0.886]; night-time 0.770 [0.462-0.889]), which implies a high variability in the fdBD data. Conclusions:: fdBD showed good reliability in the assessment of LUTS in women in all parameters except for the voided volume variables.

Leiomyomas are benign tumors of smooth muscle origin occurring throughout the genitourinary system. Sometimes paraurethral leiomyoma can cause a bulking effect on the bladder without gross involvement of the urethra. In our work we describe the case of a woman with a vulvar mass found after self-examination. She was investigated pelvic Magnetic Resonance Imaging (MRI) which showed a well encapsulated solid mass, about 24mm (maximum diameter) located at paraurethral level, on right anterolateral side, It showed uptake of contrast, with a compressive-dislocative effect on the urethra, without involvement of the sphincters. Surgery was performed with excission “en-block” of the mass. The procedure was well tolerated under spinal anesthesia and the patient was discharged 24h later, after removing the bladder catheter. No signs of haematuria nor symptoms of incontinence were reported in the following weeks. Pathology of the excised specimen revealed complete resection of a benign, submucus leiomyoma. Although leiomyomas are very common in organs such as the uterus, the presentation of a urethral leiomyoma, as found in the present case, is very rare. The description of these lesions is however important to create a scientific path that can clarify the cause and the evolution. It can also represent an evolution for imaging through MRI, improving its framework and distinguishing it from malignant tumors that require another surgical strategy.

Background: Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement.Objective: This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM.Methods/material: Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the "opening up" of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen.Results: The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation.Conclusion: The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices. [ABSTRACT FROM AUTHOR]

Objective: To investigate the role, interest, and competence of the Turkish urologists for urologic surgeries which are also performed by the other surgeons. Materials and Methods: We conducted a 22-item online survey and invited urologists by e-mail. Questions were asked to evaluate the attitudes, performances, and capabilities of the urologists in surgeries which could be performed by the other surgeons. Results: A total of 305 responses were evaluated. The female incontinence surgery, pediatric urologic surgery, and adrenal surgery are mostly performed by the urologists in their hospitals. Turkish urologists mostly do not perform the following surgeries and interventions themselves and refer patients to the other surgeons for a percutaneous nephrostomy (47.2%), urinary diversions using the intestinal segments (44.9%), kidney transplantation (11.8%), and the transgender surgeries (7.2%). Almost half of the urologists do not perform adrenal surgeries (50.2%). Most urologists agree that they should be the main surgeons for all these surgeries. Conclusion: Urologists are no longer the main surgeons for some surgeries which are included on the urologic curriculum. Many urologists avoid performing the major urologic surgeries. Urology educators should familiarize the new urologists with all the urologic surgeries. [ABSTRACT FROM AUTHOR]

Introduction: Stress urinary incontinence (SUI) affects countless women worldwide. Given ChatGPT's rising ubiquity, patients may turn to the platform for SUI advice. Our objective was to evaluate the quality of clinical information about SUI from the ChatGPT platform., Methods: The most-asked patient questions regarding SUI were derived from patient materials from societal websites and forums, and queried using ChatGPT 3.5. The responses from ChatGPT were compiled into a survey and disseminated to 3 AUA guideline committee members who developed the Surgical Management of Female SUI guidelines. They were asked to grade responses on reliability, understandability, quality, and actionability using DISCERN and Patient Education Materials Assessment Tool standardized questionnaires. Accuracy was assessed with a 4-point Likert scale and readability using Flesch Reading Ease score., Results: The overall material was rated as moderate to moderately high quality (DISCERN = 3.73/5) with potentially important but no serious shortcomings. Reliability and quality were reported to be 63% and 75%. Understandability was 89%, actionability 18%, and accuracy 88%. All question domains were rated at moderate or better. Actionability was poor in all domains. Every response was "hard to read" translating to a college graduate reading level., Conclusions: The urologic community should critically evaluate this platform's output if patients are to use it for adjunctive medical guidance. AUA committee members, who are experts in the field, rate ChatGPT-produced responses on SUI as moderate to moderately high quality, moderate reliability, excellent understandability, and poor actionability utilizing standardized questionnaires. The reading level of the material was advanced, which is an area of potential improvement to make generated responses more comprehensible.

Objective: To objectively determine the percentage of female trainees and consultants who are interested in their career being focussed on female urology (FU) in order to facilitate the improved planning for the future of this sub‐specialty. Subjects and methods: This was an international cross‐sectional study spanning 1 year, from December 2018 to December 2019. An anonymous, voluntary survey was generated using the online survey generator Survey monkey®. The survey was sent to urology consultants and trainees who were female from Australia, New Zealand, and Canada. Results: The total response rate to the survey was 61%. Up to 50% of female consultants and trainees selected a career in FU due to their gender, but up to 75% of respondents were also interested in FU of their own accord. Common concerns held by a majority of respondents included both the medical community's and the public's lack of awareness of FU as a component of urological expertise. Despite these concerns, most of the trainees were not concerned regarding their future work opportunities in FU, and many had intentions to pursue a fellowship in FU. Conclusion: Female urology is an increasingly popular sub‐specialisation of urology, given the steady increase in the intake of female trainees. Similar trends were identified internationally. Urology training in this area will need to continue to increase the community's and the primary health care referrer's awareness in order to ensure the continued success and growth of the sub‐specialty. [ABSTRACT FROM AUTHOR]

Objective: To review the rates of persistent and de novo stress urinary incontinence (SUI) following urethral diverticulum (UD) repairs performed without concomitant SUI surgical procedures.Methods: Following IRB approval, charts of women who underwent UD excision by three FPMRS surgeons were reviewed. Data collected from the electronic medical record included demographic information, preoperative symptoms and evaluation (validated questionnaires [UDI-6, QoL]), imaging studies, operative details, post-operative symptoms, and subsequent surgical interventions. Excluded were women with <6 months follow-up or concomitant pubovaginal sling placement. SUI was diagnosed by patient report, and UD was confirmed by preoperative magnetic resonance imaging or voiding cystourethrogram. The primary outcome was defined as the rate of SUI following UD repair. Secondary outcomes included resolution of pre-operative SUI, rate of self-reported secondary SUI, and SUI surgical intervention post-UD repair.Results: From 2003-2018, 61 of 67 women met study criteria. SUI pre-UD repair was reported in 31 of 61 (51%). During UD repair, 3 patients underwent Martius flap interposition. Post-UD repair, 18/61 (30%) reported SUI. Persistent SUI was present in 14 of 31 (45%), and de novo SUI occurred in 4 of 30 (13%). Postoperative responses revealed statistically significant improvements in QoL and most questions of UDI-6 at median 18 months. SUI was surgically managed in 3 patients using bulking agent injections (2) and autologous fascial sling placement (1). Overall, 3 of 61 (5%) underwent SUI intervention post-UD repair.Conclusion: Without prophylactic SUI corrective procedures performed during UD repair, we observed a low rate of de novo SUI, and only 5% with bothersome SUI opting for surgical intervention. [ABSTRACT FROM AUTHOR]

Female urethral strictures are rare with limited literature to guide management. We present a case of a 27 year old female diagnosed with a urethral stricture secondary to chronic graft-versus-host disease. This diagnosis should be considered in females presenting with obstructive voiding symptoms and have risk factors for stricture development.

Chronic urinary retention (CUR) in women is not well studied, and its prevalence is not well established. This article estimates CUR prevalence in the female population of the United States based on a literature survey of neurologic conditions known to result in or be associated with CUR in women. [ABSTRACT FROM AUTHOR]

Purpose of Review: This article provides an overview of MRI as a dynamic imaging modality as well as recent updates on the role of MRI in the evaluation of female pelvic floor disorders, including pelvic organ prolapse (POP), rectal prolapse, and defecatory dysfunction. Recent Findings: Pelvic floor disorders in women are common, and demand for treatment is high. Recently, multidisciplinary guidelines for dynamic MRI have been published to reflect this need. Despite criticisms that MRI is an expensive modality, cost-analysis studies are demonstrating utility for MRI in surgical decision-making trees for patients at risk for treatment failure after POP repairs. Novel measures such as anterior pelvic area and levator volumes are being used to predict and study patients with and at risk for POP. Summary: Recent standardized radiographic guidelines as reviewed in this paper will likely lead to improved reproducibility of dynamic MRI techniques across institutions, making complex pelvic floor assessment increasingly accessible to patients while creating opportunities for novel and collaborative research. [ABSTRACT FROM AUTHOR]

The final clinical session of the British Association of Urological Surgeons (BAUS) annual meeting is the Updates and Highlights session, where the most important advances in the main urological sub-specialities are summarised and presented by sub-specialist experts representing each BAUS section. The aim of the session is to disseminate knowledge on the latest research, new guidelines and changes to general and specialist clinical practice. This paper covers contemporary urological advances as presented at the Liverpool BAUS meeting in June 2018. [ABSTRACT FROM AUTHOR]

Purpose of Review: Lower urinary tract dysfunction (LUTD), including stress urinary incontinence (SUI), is increasingly recognized as a public health issue due to the prevalence, individual burden, and societal impact. Women are disproportionately affected by UI and are exposed to unique events that affect LUT function including higher rates of LUT infection, childbirth, pelvic floor anatomic changes, and hormonal milieu. The majority of LUTD research and clinical practice has focused on treatment of the most affected subset of women, but there are millions of women living with urinary incontinence that do not seek advice or treatment, and the evidence base for prevention or detection of early symptoms is lacking. Recent Findings: Individual factors such as sociodemographic elements, medical history, physical exam, and comorbidities have been well studied; however, the contribution of family and environmental factors is less well understood. Emerging data suggests that some types of high-impact physical activity in adolescence can confer increased UI risk later in life. Prenatal and postpartum pelvic floor muscle training appears to be beneficial in preventing SUI in some women. Summary: While certain individual risk factors for SUI have been identified, sociocontextual factors also affect health outcomes and can mediate an individual's risk of disease. The social ecological model considers factors within the family/peer, community, and societal levels that can affect an individual's health behaviors. Prevention research that investigates these multiple levels of influence on individual biology and behavior is a fundamental step to better understand the complex factors that impact bladder health and inform LUTS prevention agendas. In addition, strategies to educate girls and women and engage communities in bladder health promotion are essential in order to effectively disseminate scientific findings and implement intervention programs. [ABSTRACT FROM AUTHOR]

Introduction: Transvaginal mesh surgery (TVM) is an effective treatment measure for pelvic organ prolapse (POP). However, the ORIHIME mesh (Kono Seisakusho, Japan, Tokyo), which has the disadvantage of poor adherence to tissues, is currently the only product available for this procedure. Our research team has previously developed a modified ORIHIME mesh with wider arms with the aim of minimizing the risk of POP recurrence. Additionally, the length of the mesh behind the anterior vaginal wall has been adjusted to prevent urinary incontinence. The current study aims to examine the efficacy of this modified mesh in minimizing postoperative complications in patients undergoing uphold-type TVM., Methods: The data of 84 patients who underwent TVM using ORIHIME at our hospital since July 2019 were retrospectively analyzed. The patients were divided into three groups as follows: (a) normal arms (NA; arm width < 6 cm; n = 29 cases); (b) wide arms without length adjustment (WA and LA (-); arm width > 6 cm; n = 27 cases); and (c) wide arms with length adjustment (WA and LA (+); n = 28 cases). Data were collected using various questionnaires, and the residual urine volume was measured before and after surgery. Additionally, the 60-minute pad test was performed where possible, and the recurrence and complication rates were recorded., Results: The incidence of mesh exposure and urinary incontinence in daily life tended to be lower in the WA and LA (+) groups, although this difference was not statistically significant. The one-year postoperative POP recurrence rate, residual urine volume, International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score were significantly lower in the WA and LA (+) groups compared to the other groups., Conclusion: Uphold-type TVM using the modified ORIHIME mesh with wider arms and adjusted length was associated with better postoperative treatment outcomes compared to TVM using the traditional ORIHIME mesh., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Kuroda et al.)

Introduction Transvaginal mesh surgery (TVM) is an effective treatment option for pelvic organ prolapse (POP). Although ORIHIME®, the only available mesh product, is thin, soft, and easy to handle, it has the disadvantages of sliding off or mildly adhering to the surrounding tissues. The current study compared the efficacy of using wide-arm ORIHIME (Kono Seisakusho, Japan, Tokyo), non-wide arm ORIHIME, Gynemesh PS (Johnson and Johnson, Japan, Tokyo), and Polyform (Boston Scientific Japan, Japan, Tokyo) meshes for TVM. Methods The study included 116 patients who underwent TVM (Prolift with Gynemesh PS (n = 14); Elevate with Polyform (n = 43); Uphold with non-wide-arm ORIHIME   (n = 24); Uphold with wide-arm ORIHIME   (n = 35)) at our hospital. Pre- and post-surgical changes in symptoms were measured using questionnaires and 60-minute pad weight testing and compared by mesh type and surgical methods used. Results The residual urine volume, 60-minute pad weight testing, international prostate symptom score (IPSS), overactive bladder symptom score (OABSS), and international consultation on incontinence questionnaire-short form score (ICIQ-SF) significantly improved one year postoperatively in the TVM with the wide-arm ORIHIME group. Comparison of pre and one-year postoperative findings by mesh type and surgical methods used showed no significant differences in the 60-minute pad test, IPSS, Quality of Life (QOL), OABSS, and urinary incontinence in daily life scores, and improvement in residual urine volume, ICIQ-SF, and mesh exposure and POP recurrence rates in the TVM with the wide-arm ORIHIME group. Conclusion TVM with wide-arm ORIHIME had better postoperative outcomes compared to TVM with other mesh products., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Kuroda et al.)

The management of female stress urinary incontinence (SUI) has come under scrutiny in recent years following growing reports of mesh-related complications. Patients require thorough evaluation and management as part of a multidisciplinary team, and extensive counselling about the surgical treatment options is imperative. There is no clear consensus on the optimal management of the complex group of patients with mesh-related complications or recurrent SUI. We present two cases of female SUI to highlight the key factors to be considered when managing these patients. Level of evidence: Level 5. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the long‐term efficacy of electrofulguration in women with recurrent urinary tract infections. Methods: After institutional review board approval, a retrospective study of women who underwent electrofulguration alone was carried out. All patients had recurrent urinary tract infections defined as three or more urinary tract infections/year, and a preoperative office cystoscopy showing inflammatory lesions, categorized by location: urethra, bladder neck, trigone and beyond the trigone. All lesions were cauterized during outpatient electrofulguration under anesthesia. On 6‐month postoperative office cystoscopy, endoscopic success was defined as resolution of all lesions previously seen and no new lesions. The primary outcome was urinary tract infections/year, with urinary tract infection defined as antibiotic treatment for urinary tract infection‐like symptoms and/or for positive urine culture. Clinical cure was defined as no further urinary tract infections, clinical improvement as less than three urinary tract infections/year, and clinical failure as three or more urinary tract infections/year. Results: Of 95 women who met the study criteria between 2004 and 2016, 62 (65%) were endoscopically successful, and 33 (35%) were endoscopic failures based on postoperative cystoscopy. Among all patients, over a median follow‐up period of 4.9 years, the median number of urinary tract infections/year was 0.8. Endoscopically successful patients had fewer urinary tract infections/year compared with endoscopic failures (0.6 vs 0.9, P = 0.03). Clinically, 14 (15%) patients were cured, 69 (73%) were improved and 12 (13%) failed. Compared with clinically improved patients, clinical failures were more likely to have infections with multiple organisms (92% vs 35%, P < 0.001) and highly resistant organisms (92% vs 23%, P < 0.001). Conclusions: In our experience, nearly two‐thirds of women with recurrent urinary tract infection can be successfully treated with electrofulguration, and >80% experience long‐term clinical cure or improvement in urinary tract infections. [ABSTRACT FROM AUTHOR]

Purpose of Review: Fossa navicularis strictures represent a surgically challenging disease process that requires detailed preoperative planning and an understanding of each patient's goals in order to achieve a satisfactory long-term outcome. This review summarizes the various approaches used in the management of fossa navicularis strictures over the past several decades. Recent Findings: In addition to existing evidence to support open flap- and graft-based reconstruction, recent studies suggest a potential role for limited open repair via a transurethral approach. Summary: Open repair of fossa navicularis strictures has become the standard of care with high success rates using local skin flaps or tissue grafts. There remains a very limited role for minimally invasive techniques in definitive management of this disease. [ABSTRACT FROM AUTHOR]

Urinary tract fistulas represent a complex group of pathologies that present significant management challenges. While most such fistulas ultimately require definitive surgical management, compromised local tissue quality or other factors often render straightforward simple one layered closure challenging with a substantial risk of failure. Interpositional tissue flaps have become a mainstay of treatment in these circumstances, enabling the delivery of healthy tissue from other locations to the site of pathology. Herein, we present an overview of the assessment and management of complex urinary tract fistulas involving the reproductive and gastrointestinal organs, and the decision to utilize flaps. We review the underlying principles of tissue flaps and classify different types of flaps. We conclude with a discussion of the indications, advantages, disadvantages, and harvesting techniques for the most commonly utilized flaps in urinary tract fistula repair. [ABSTRACT FROM AUTHOR]

Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used. Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: 'female urology', 'lower urinary tract symptoms', 'urodynamic', 'incontinence', 'overactive bladder', 'bladder outlet obstruction'. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society. Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS. Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity. Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; PdetQmax: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Qmax: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence [ABSTRACT FROM AUTHOR]

Background: Abdominal sacrocolpopexy is the gold standard for treatment of apical prolapse.1 Minimally invasive surgery offers many advantages over the open approach, including incision size, blood loss, postoperative pain while maintaining similar long-term outcomes.2,3 OBJECTIVE: To assess the safety and feasibility of performing a magnetic-assisted single-port robotic sacrocolpopexy (MARS).Materials: Prior to surgery, a magnetic controller was secured to the surgical bed. The Hassan technique was used to place a 25 mm SP port through a single 2.5 cm supra-umbilical incision. A 12 mm assistant port was placed 10 cm lateral to the SP port on the right side, this additional trocar placement may be obviated by using a gel-point for both ports. The SP robot was docked on the right side of the bed. The magnet was clipped onto the sigmoid mesentery and the outer magnet was repositioned to retract the sigmoid laterally. The sacral promontory was exposed, and the peritoneal incision was carried down to the vagina. The magnet was repositioned, and the bladder was reflected off the anterior vagina. The posterior dissection was carried out to reveal the posterior vagina. "Y" mesh was placed, appropriately tensioned, secured to the sacral promontory and retroperitonealized. Cystoscopy was performed. The magnet was removed from the sigmoid colon, and all incisions were closed.Results: A 66-year-old G2P2 female, BMI 25, status-post prior abdominal hysterectomy presented with symptomatic stage IV prolapse. Surgery was uneventful with an operative time of 247 minutes and an estimated blood loss of 10cc. The patient was discharged the following day. At 3 months postoperatively, she had anatomic and symptomatic resolution of her prolapse.Conclusion: Using magnetic assistance, MARS can be offered to women who want a durable option for prolapse repair with improved cosmesis compared to conventional methods and may offer cosmetic benefits when paired with a concurrent hysterectomy. [ABSTRACT FROM AUTHOR]

Introduction: The existing literature shows that mesh reinforcement improves the anatomical success rate of cystocele repair. We report the long-term results of a custom bell-shaped mesh with simultaneous urethral support for the repair of cystocele. Materials and Methods: The present study was a single-center, single-surgeon case series of 36 patients. Only patients with Pelvic Organ Prolapse Quantification system (POP-Q) stage 2 and above were included in the study. Patients having rectocele or uterine/vault prolapse were excluded. Body of the mesh was used for reinforcement of the cystocele repair and two limbs were left tension free in the retropubic space. Patients were followed 3 monthly for the first year and yearly thereafter. Recurrence was defined as cystocele ≥stage 2 (Aa or Ba 0) any time after the first follow-up. Results: Mean patient age was 58.5 ± 6.2 years. The mean parity was 3.2 ± 1.6. Of 36 patients, 11 (30.5%) of the patients were POPQ stage 2, 15 (41.7%) were stage 3 and 10 (27.7%) were stage 4 cystocele. The mean follow-up period was 53.4 months, with 32 patients reporting for follow-up till date (88.9%). There was no bladder injury, no mesh erosion or infection. No patient required CIC (clean intermittent catheterization) or had stress urinary incontinence post-operatively at 5 years of follow-up. Conclusion: The bell-shaped mesh is a simple, effective and safe procedure in the surgical management of cystocele with excellent long-term outcome.

Background and Objectives: The pathophysiology of female stress urinary incontinence (SUI) is far from unraveled. Capturing all aspects of this bothersome condition in one theory remains challenging. The well‐known Hammock and Integral theories, both from the early 90's, were successful in explaining a large proportion of the observations made in clinical practice. Nevertheless, some (pre)clinical observations cannot be explained by the current understanding. One of the issues concerns the pressure transmission. Is this process really a passive mechanical action, or is an additional active mechanism responsible for urethral closure? The finding that an increase in urethral pressure sometimes precedes and exceeds the increase in intravesical pressure suggests the latter. This concept has never been incorporated in one of the existing theories describing SUI. This is remarkable as a lot of evidence has been generated in recent years that proves involvement of active components. This review aims to provide an additional theory in which an active reflex closure mechanism of the urethra is incorporated. Methods: Recent as well as older publications from clinical and animal studies are included to support the hypothesis. Results: The smooth muscles of the urethra, the vascular bed, and the estrogen‐influenced urethral mucosa, combined with striated muscle tone, contribute to the intra‐urethral pressure. A passive transmission of force to the urethra exists only in the abdominal proximal third of the urethra. In the distal two thirds of the urethra an active closure mechanism is present, dependent on sufficient urethral support in the proper anatomical position. This active closure mechanism is generated by reflex contraction of striated muscles of the urethra and the pelvic floor. Conclusion: Continence is a result of passive as well as active urethral closure mechanisms. The most important factor in female continence seems to be the proper functioning of an active reflex urethral closing mechanism. [ABSTRACT FROM AUTHOR]