Benjamin M. Brucker

Correlation of Patient Perception of Pad Use with Objective Degree of Incontinence Measured by Pad Test in Men with Post-Prostatectomy Incontinence: The SUFU Pad Test Study

PURPOSEnMany investigators have used the number of pads to determine the severity of post-prostatectomy incontinence and yet the accuracy of this tool remains unproven. We determined whether the patient perception of pad use and urine loss reflects actual urine loss. We also identified a quality of life measure that distinguishes patients by severity of incontinence.nnnMATERIALS AND METHODSnWe prospectively enrolled 235 men from a total of 18xa0sites 6 months or more after radical prostatectomy who had incontinence requiring protection. Patients completed a questionnaire on the perception of padxa0number, size and wetness, a quality of life question, several standardized incontinence questionnaires and a 24-hour pad test that assessed pad number, size and weight. SPSS® was used for statistical analysis.nnnRESULTSnPerception of the number of pads used closely agreed with the number ofxa0pads collected during a 24-hour pad test. Perceived and actual pad size had excellent concordance (76%, p <0.001). Patients with wet and soaked pads had statistically and clinically significantly different pad weights that were uniquely different from each other and from those of patients who were almost dry and slightly wet. Response to the quality of life question separated the men into 4xa0statistically significantly different groups based on mean 24-hour pad weight.nnnCONCLUSIONSnPatients accurately described the number, size and degree of wetness of pads collected during a 24-hour pad test. These values correlated well with actual urine loss. The single question, To what extent does urine loss affect your quality of life? separated men into distinct categories.

Treatment of Post-Prostatectomy Incontinence With Male Slings in Patients With Impaired Detrusor Contractility on Urodynamics and/or Who Perform Valsalva Voiding

PURPOSEnMale slings have emerged as a popular and efficacious treatment for men with post-prostatectomy stress urinary incontinence. Traditionally slings have been used with caution or avoided in men with impaired detrusor contractility or Valsalva voiding because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with post-prostatectomy urinary incontinence who have impaired contractility and/or void with abdominal straining for urodynamics can be safely treated with slings.nnnMATERIALS AND METHODSnA retrospective review of patients with post-prostatectomy urinary incontinence who underwent an initial sling procedure between January 2004 and January 2010 was conducted at a single institution. Preoperative urodynamic characteristics, and postoperative Patient Global Impression of Improvement, post-void residual and noninvasive uroflow data were examined. Patients were grouped by poor bladder contractility or Valsalva voiding status. Exclusion criteria were lack of preoperative urodynamics and/or postoperative post-void residual. A total of 92 patients were analyzed. The variables were compared using the Student t test and the chi-square test.nnnRESULTSnNo statistically significant difference was shown in postoperative post-void residual (mean 4 months postoperatively) or urinary retention when comparing by bladder contractility or Valsalva voiding. In the subset of patients with available postoperative uroflow data, there were no differences in postoperative maximum flow rate or voided volume.nnnCONCLUSIONSnMen with post-prostatectomy urinary incontinence with urodynamic findings suggesting impaired contractility or Valsalva voiding can be safely treated with sling surgery if they have normal preoperative emptying.

Urodynamic Differences Between Dysfunctional Voiding and Primary Bladder Neck Obstruction in Women

OBJECTIVEnTo determine the clinical and urodynamic differences in the presentation and the value of simultaneous fluoroscopy in dysfunctional voiding (DV) and primary bladder neck obstruction (PBNO); the 2 most common causes of non-neurogenic functional bladder outlet obstruction in women.nnnMETHODSnA review of our urodynamic study database (March 2003 to August 2009) was conducted. DV was diagnosed when increased external sphincter activity was found during voluntary voiding on electromyography (EMG) or fluoroscopy. PBNO was diagnosed when a failure of bladder neck opening was noted on fluoroscopy during voiding. The demographics, symptoms, and urodynamic study parameters were collected. Comparisons were done using chi-square and 2-tailed t-tests.nnnRESULTSnDV was diagnosed in 34 women and PBNO in 16. The patients with DV were younger than those with PBNO (40.9 vs 59.2 years, P < .001). Women with DV showed a clinical trend toward having more storage symptoms than those with PBNO and fewer voiding symptoms. Patients with DV had a greater mean maximal flow rate (12 vs 7 mL/s, P = .027) and lower mean postvoid residual urine volume (125 vs 400 mL, P = .012). No significant differences were found in maximal detrusor pressure, detrusor pressure at maximal flow rate, or detrusor overactivity. EMG showed increased activity during voiding in 79.4% of those with DV and 14.3% of those with PBNO (P < .001).nnnCONCLUSIONnClinically, women with DV and PBNO had similar presentations, although those with PBNO had poorer emptying. The flow rates and patterns seemed to differ between those with DV and PBNO, although the voiding pressures were similar. EMG alone would have given the wrong diagnosis in 20.6% of those with DV (false negative) and 14.3% of those with PBNO (false positive). When fluoroscopy is used to define these entities, the accuracy of EMG to differentiate them is questionable.

Guideline of guidelines: urinary incontinence

The objective of the article is to review key guidelines on the management of urinary incontinence (UI) to guide clinical management in a practical way. Guidelines produced by the European Association of Urology (updated in 2014), the Canadian Urological Association (updated in 2012), the International Consultation on Incontinence (updated in 2012), and the National Collaborating Centre for Womens and Childrens Health (updated in 2013) were examined and their recommendations compared. In addition, specialised guidelines produced by the collaboration between the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction on overactive bladder and the use of urodynamics were reviewed. The Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument was used to evaluate the quality of these guidelines. There is general agreement between the groups on the recommended initial evaluation and the use of conservative therapies for first‐line treatment, with a limited role for imaging or invasive testing in the uncomplicated patient. These groups have greater variability in their recommendations for invasive procedures; however, generally the mid‐urethral sling is recommended for uncomplicated stress UI, with different recommendations on the approach, as well as the comparability to other treatments, such as the autologous fascial sling. This ‘Guideline of Guidelines’ provides a summary of the salient similarities and differences between prominent groups on the management of UI.

Urodynamics for Clinically Suspected Obstruction After Anti- Incontinence Surgery in Women

PURPOSEnWe determined the usefulness of urodynamics in patients with obstruction secondary to anti-incontinence surgery.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of all procedures performed from January 2001 to June 2011 to relieve obstruction due to anti-incontinence surgery. Patients were excluded from study if they underwent prior procedures to relieve obstruction, followup data were missing or a neurological disorder was present. Patients were grouped into categories before intervention, including urodynamics diagnostic of obstruction vs nondiagnostic urodynamics vs no urodynamics testing. We also separated patients with predominantly storage symptoms and those with incomplete emptying.nnnRESULTSnA total of 71 women were included in analysis. Of 54 women who presented with increased post-void residual urine volume 33 (61%) were diagnosed with obstruction on urodynamics, urodynamics was not diagnostic in 4 (7.4%) and 17 (32%) did not undergo urodynamics preoperatively. All 18 patients with predominantly storage symptoms underwent urodynamics. In patients with incomplete emptying there was no difference between the groups in storage or voiding symptom improvement, overall cure or success according to whether diagnostic urodynamics were or were not done. Of patients with storage symptoms who underwent urodynamics those without evidence of detrusor overactivity had significantly greater storage symptom improvement than those with detrusor overactivity (85.7% vs 53.8%, p = 0.02).nnnCONCLUSIONSnWhen voiding symptoms or urinary retention is the primary indication for intervention after anti-incontinence surgery, urodynamic findings are not predictive of outcomes after intervention to relieve obstruction. If storage symptoms are the main indication for intervention, urodynamics may be valuable for patient counseling.

Artificial Urinary Sphincter Revision: The Role of Ultrasound

OBJECTIVEnTo assess the accuracy of office-based ultrasound (US) to identify the fluid status of the AMS 800 artificial urinary sphincter (AUS) pressure-regulating balloon (PRB).nnnMETHODSnPatients who underwent AUS revision surgery (removal/replacement) from January 4, 2007, to January 4, 2010, were identified. US were done preoperatively to assess the system fluid status. Intraoperative findings were recorded. Sensitivity and specificity were calculated comparing US results with intra-/postoperative findings. When the PRB was underfilled, the location of the device fluid leak was determined, and the device was removed/replaced. In cases of a full PRB, patients had a cuff downsizing or total removal/replacement.nnnRESULTSnA total of 27 patients were identified. Reasons for not obtaining US included: advanced device age (4), cuff erosion (2), volume determination by other modality (2), cuff site pain (1), isolated pump malfunctions (1), and other (3). Fourteen patients underwent an US before the removal/replacement. By US, PRB was full (21-23 mL) in 43% of the patients and empty/underfilled (0-6 mL) in 57%. US was 100% sensitive and specific determining fluid status. When PRB was full, management consisted of cuff downsizing (3), transcorporal cuff placement (1), and total removal/replacement (2). In all cases of device leak, an entire removal/replacement was performed. The cuff was identified as the site of leak in 50% of cases.nnnCONCLUSIONnUS is an effective and accurate way of determining the fluid status of the AMS 800 AUS. Given the accuracy of this modality, the system can be filled with saline solution without losing the ability to determine fluid status.

Comparative assessment of the efficacy of onabotulinumtoxinA and oral therapies (anticholinergics and mirabegron) for overactive bladder: a systematic review and network meta-analysis.

To compare the efficacy of onabotulinumtoxinA, mirabegron, and anticholinergics in adults with idiopathic overactive bladder (OAB) using network meta‐analysis (NMA).

Midurethral Slings for All Stress Incontinence: A Urology Perspective

The midurethral sling (MUS) is now the most commonly performed surgical treatment for stress urinary incontinence (SUI), and is considered the gold standard for patients with genuine SUI. This article examines the use of the MUS to treat all forms of SUI, with an emphasis on the nonindex patient (ie, intrinsic sphincter deficiency, lack of urethral hypermobility, mixed incontinence, failed MUS, concomitant prolapse, obesity, and elderly). The efficacy and safety of the MUS to treat SUI is assessed in these specific populations. Based on the available evidence, the discussion attempts to identify populations in whom MUS may not be appropriate.

Management of Neurogenic Lower Urinary Tract Dysfunction in Multiple Sclerosis Patients

Multiple sclerosis (MS) can be a debilitating neurological condition that attributes significant morbidity to bladder dysfunction. Although many effective treatment options exist, symptomatic patients are often underdiagnosed and undertreated. The purpose of this article is to give an overview of the current literature including new screening tools to identify symptomatic patients and updates on treatment options including medications, botulinum toxin, and neuromodulation.

Parkinson’s Disease and Its Effect on the Lower Urinary Tract: Evaluation of Complications and Treatment Strategies

Parkinsons disease (PD) and atypical Parkinsonism are the second most common neurodegenerative movement disorders. Lower urinary tract dysfunction is among the most common types of associated autonomic dysfunctions. Differentiating the subtypes of PD is important for symptom management and understanding prognosis, because Lower urinary tract symptoms (LUTS) can evolve differently depending on the primary disease. LUTS are caused by storage and/or voiding dysfunctions. Urodynamics is a key investigative tool. The complex pathophysiology of this bladder dysfunction is not responsive to levodopa, and add-on therapy is necessary. Newer interventions hold promise as therapy to improve bladder dysfunction.