Jennifer H. Yang

Mixed Urinary Incontinence: Greater Impact on Quality of Life

PURPOSE We compared the impact of mixed, stress and urge urinary incontinence on quality of life in middle-aged or older women. MATERIALS AND METHODS We analyzed cross-sectional data from a population based cohort of 2,109 ethnically diverse middle-aged or older women. Among participants reporting weekly incontinence, clinical type of incontinence was assessed by self-reported questionnaires and disease specific quality of life impact was evaluated using the Incontinence Impact Questionnaire. Multivariable logistic regression was used to compare the odds of greater quality of life impact from incontinence, defined as an Incontinence Impact Questionnaire score in the 75th percentile or greater in women with stress, urge and mixed incontinence. RESULTS More than 28% (598) of women reported weekly incontinence, including 37% with stress, 31% with urge and 21% with mixed incontinence. Unadjusted Incontinence Impact Questionnaire scores were higher for women with mixed vs urge or stress incontinence (median score 29 vs 17 and 13, respectively, p <0.01). Adjusting for age, race/ethnicity, health status and clinical incontinence severity, women with mixed incontinence were more likely to report a greater overall quality of life impact compared to those with stress incontinence (OR 2.5, 95% CI 1.4-4.3), as well as a greater specific impact on travel (OR 2.2, 95% CI 1.3-3.7) and emotional (OR 1.8, 95% CI 1.0-3.4) Incontinence Impact Questionnaire domains. The overall impact of urge incontinence did not differ significantly from that of stress (urge vs stress OR 1.6, 95% CI 0.9-2.7) or mixed incontinence (mixed vs urge OR 1.6, 95% CI 0.9-2.8) in adjusted models. CONCLUSIONS In middle-aged or older women mixed incontinence is associated with a greater quality of life impact than stress incontinence independent of age, race, health or incontinence severity. Identification of women with mixed incontinence symptoms may be helpful in discovering which women are most likely to experience functional limitations and decreased well-being from incontinence.

Morphology of Mouse External Genitalia: Implications for a Role of Estrogen in Sexual Dimorphism of the Mouse Genital Tubercle

PURPOSE We examined the role of androgens and estrogens in mammalian sexual differentiation by morphological characterization of adult wt and mutant mouse external genitalia. We tested the hypothesis that external genitalia development depends on androgen and estrogen action. MATERIALS AND METHODS We studied serial sections of the external genitalia of the CD-1 and C57BL6 wt strains of adult mice (Charles River Laboratories, Wilmington, Massachusetts). We recorded linear measurements of key structures in each specimen, including the urethra, erectile tissue, bone and cartilage. We used similar methodology to analyze mice mutant for estrogen receptor α (αERKO) and androgen receptor (X(Tfm)/Y) (Jackson Laboratory, Bar Harbor, Maine). RESULTS Morphology in X(Tfm)/Y adult murine external genitalia was remarkably similar to that in wt females. Bone and clitoral length was similar in wt females and X(Tfm)/Y mice. Conversely the αERKO clitoris was 59% longer and bone length in αERKO females was many-fold longer than that in female wt mice or X(Tfm)/Y mutants. The αERKO clitoris contained cartilage, which is typical of the wt penis but never observed in the wt clitoris. Serum testosterone was not increased in female αERKO mice 10 days postnatally when sex differentiation occurs, suggesting that masculinization of the αERKO clitoris is not a function of androgen. CONCLUSIONS Masculinization of the αERKO clitoris suggests a role for estrogen in the development of female external genitalia. We propose that normal external genital development requires androgen and estrogen action.

New Insights on the Morphology of Adult Mouse Penis

ABSTRACT The adult mouse penis represents the end point of masculine sex differentiation of the embryonic genital tubercle and contains bone, cartilage, the urethra, erectile bodies, several types of epithelium, and many individual cell types arrayed into specific anatomical structures. Using contemporary high-resolution imaging techniques, we sought to provide new insights to the current description of adult mouse penile morphology to enable understanding of penile abnormalities, including hypospadias. Examination of serial transverse and longitudinal sections, scanning electron microscopy, and three-dimensional (3D) reconstruction provided a new appreciation of the individual structures in the adult mouse penis and their 3D interrelationships. In so doing, we discovered novel paired erectile bodies, the male urogenital mating protuberance (MUMP), and more accurately described the urethral meatus. These morphological observations were quantified by morphometric analysis and now provide accurate morphological end points of sex differentiation of mouse penis that will be the foundation of future studies to identify normal and abnormal penile development.

Gender Identity in Disorders of Sex Development: Review Article

OBJECTIVES Many concerns have been raised regarding the treatment and long-term outcome of infants born with complex genital anomalies. Debate among clinicians, psychologists, ethicists, and patient advocate groups regarding the optimal management of these individuals is ongoing. Although determining the most appropriate gender is a difficult task, this review will help clarify some of the issues at hand. METHODS A literature review which addresses the challenges of advising families about gender identity in infants and children with disorders of sex development. RESULTS The evidence for endocrine effects on neurobiological development with regard to sexual behavior is compelling, although the existing outcome studies are largely anecdotal and somewhat contradictory. CONCLUSIONS Gender assignment in infants born with a disorder of sex development remains only one of the many difficult decisions faced by both the treatment team and the family. Improved long-term follow-up of these patients will provide much needed feedback on previous and contemporary management.

Prospective Blinded Laboratory Assessment of Prophylactic Antibiotic Compliance in a Pediatric Outpatient Setting

PURPOSE Prophylactic antibiotics are commonly used to prevent urinary tract infections in children with conditions such as vesicoureteral reflux. Patient compliance with antibiotics is salient, given the effects that noncompliance can have on development of antibiotic resistance and outcomes of clinical trials. Prior series have shown variable compliance (17% to 70%). However, no study has used objective methods. We hypothesized that direct measurement of urine antibiotic levels can reveal poor compliance. MATERIALS AND METHODS During a pediatric urology clinic visit patients 0 to 18 years old taking trimethoprim prophylaxis for any urological diagnosis were invited to participate in the study. They were unaware of any potential urine testing before the visit. Urine was sent for chromatography to quantify trimethoprim levels. Parents also completed a compliance self-assessment. RESULTS Of patients invited to participate 97% consented (54 patients). Of the patients 91% were compliant based on urine levels. Factors not associated with compliance included age, gender, self-report of compliance, duration of time on antibiotics, insurance status and history of breakthrough infection, surgery, pyelonephritis or hospitalization. CONCLUSIONS This study demonstrates the highest compliance reported for children taking prophylactic antibiotics to prevent urinary tract infection. We attribute this unexpected result to the discussion by specialists of 1 problem for the duration of an office visit. All education in this study was part of clinical care. Thus, our results should be generalizable to nonstudy environments. Future studies should confirm whether this high level of compliance can be achieved by nephrologists and pediatricians. If such compliance cannot be achieved at nonsurgical clinics, then early referral to a pediatric urologist may be warranted.

Saw palmetto and finasteride in the treatment of category-III prostatitis/chronic pelvic pain syndrome.

Chronic nonbacterial prostatitis/chronic pelvic pain syndrome is a common entity for which a standardized management has not been established. Patients often have a significant symptom complex and impact on quality of life, but very little is known about the efficacy of second- and third-line treatments, such as the use of herbal supplements. Many treatments studied in recent literature include antibiotics, á-blockade, anti-inflammatory agents, and cognitive behavioral interventions such as biofeedback and psychotherapy.

Granular cell tumor of the glans penis in a 9-year-old boy.

Granular cell tumor of the penis is a rare lesion, especially in the pediatric population. We present a case of a 9-year-old white boy with a granular cell tumor of the glans penis, as well as a review of literature. We also discuss clinical management and subsequent implications pertinent to lesion location.

VesEcho Training System: Suprapubic Catheterization under Ultrasound Guidance

Introduction: Suprapubic catheterization is a fundamental skill for urology residents and trainees. Ultrasound guidance for this procedure is effective for minimizing complications and the British Association of Urological Surgeons guideline recommends use of ultrasound for suprapubic catheterization whenever possible. We developed a novel, cost‐effective and sonographically accurate training model for suprapubic catheterization and incorporated it into our resident training curriculum. Methods: The model consists of the 4 components of the bladder (water balloon), a pelvic bone replica and rectus fascia (nonrebreather masks), all housed within an ultrasound compatible gelatin mold. The model was tested during a resident training course to facilitate instruction of suprapubic catheterization. Surveys were administered before and after training to 13 participating urology residents, assessing the models anatomical and sonographic realism as well as the utility of the curriculum in their education. Results: The simulator model received a mean score of 4.2 out of 5 (SD 0.6, range 3 to 5) for anatomical realism and 4.4 out of 5 for sonographic realism (SD 0.5, range 4 to 5). The value of the simulator as a training tool was rated 4.7 and the overall value of the training course was rated 5 of 5. Regarding change in overall comfort with the procedure, mean total scores (out of 25) significantly increased for all residents after the training course (14.6 to 19.7, 5.1‐point increase, p <0.001). Conclusions: Our novel simulation model and didactic curriculum received positive evaluations from urology residents and increased their comfort with ultrasound guided suprapubic catheterization. It is a sustainable teaching tool and can easily be incorporated into any urology training curriculum.

Gender Identity in Disorders of Sex Development

Disorders of sex development (DSD) are rare conditions that often create challenging circumstances for patients, their families, and health care providers. Our understanding of the management of DSD has significantly evolved over the last century as new studies have shed light on the topics of psychosexual development and gender identity. The new knowledge has further changed our approaches toward the care of patients with DSD. The aim of this chapter is to review the history of DSD, our current understanding of psychosexual development, and the management of gender identity, gender assignment, and surgical interventions in patients with DSD as well as other congenital anomalies that commonly present with ambiguous genitalia. Through a review of the literature and discussion of more common forms of DSD, including congenital adrenal hyperplasia and androgen insensitivity syndrome, we intend to further explore the controversies behind gender identity in this unique population.

Combined Method of Bladder Neck Closure and Concomitant Augmentation Cystoplasty in the Setting of Refractory Urinary Incontinence

OBJECTIVE To describe the technique of concomitant bladder neck closure and augmentation cystoplasty in a 22-year-old woman with a history of bladder exstrophy and refractory urinary incontinence. This patient had prior augmentation cystoplasty and circumferential fascial urethral sling placement with continued incontinence. During closure of the bladder neck, the bladder neck was incorporated into the augmentation cystoplasty to help prevent failure of bladder neck closure. MATERIAL AND METHODS The patient had previously undergone augmentation cystoplasty, circumferential fascial urethral sling placement, and antegrade collagen injection of the bladder neck. Despite these interventions, she continued to have refractory urinary incontinence. Her bladder neck was closed by incorporating the bladder neck into the cystotomy and using the bladder neck as an edge of anastomosis during augmentation cystoplasty. RESULTS The patient tolerated the procedure well. She catheterizes easily through her appendicovesicostomy and has remained continent. She has no leakage from her closed bladder neck 30 months after closure. CONCLUSION Incorporating the bladder neck into the cystotomy during a planned augmentation cystoplasty and bladder neck closure should be considered as an alternative to separate bladder neck closure, which can fail and can result in continued urinary incontinence.