Kari A.O. Tikkinen

EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction

CONTEXTnLower urinary tract symptoms (LUTS) represent one of the most common clinical complaints in adult men and have multifactorial aetiology.nnnOBJECTIVEnTo develop European Association of Urology (EAU) guidelines on the assessment of men with non-neurogenic LUTS.nnnEVIDENCE ACQUISITIONnA structured literature search on the assessment of non-neurogenic male LUTS was conducted. Articles with the highest available level of evidence were selected. The Delphi technique consensus approach was used to develop the recommendations.nnnEVIDENCE SYNTHESISnAs a routine part of the initial assessment of male LUTS, a medical history must be taken, a validated symptom score questionnaire with quality-of-life question(s) should be completed, a physical examination including digital rectal examination should be performed, urinalysis must be ordered, post-void residual urine (PVR) should be measured, and uroflowmetry may be performed. Micturition frequency-volume charts or bladder diaries should be used to assess male LUTS with a prominent storage component or nocturia. Prostate-specific antigen (PSA) should be measured only if a diagnosis of prostate cancer will change the management or if PSA can assist in decision-making for patients at risk of symptom progression and complications. Renal function must be assessed if renal impairment is suspected from the history and clinical examination, if the patient has hydronephrosis, or when considering surgical treatment for male LUTS. Uroflowmetry should be performed before any treatment. Imaging of the upper urinary tract in men with LUTS should be performed in patients with large PVR, haematuria, or a history of urolithiasis. Imaging of the prostate should be performed if this assists in choosing the appropriate drug and when considering surgical treatment. Urethrocystoscopy should only be performed in men with LUTS to exclude suspected bladder or urethral pathology and/or before minimally invasive/surgical therapies if the findings may change treatment. Pressure-flow studies should be performed only in individual patients for specific indications before surgery or when evaluation of the pathophysiology underlying LUTS is warranted.nnnCONCLUSIONSnThese guidelines provide evidence-based practical guidance for assessment of non-neurogenic male LUTS. An extended version is available online (www.uroweb.org/guidelines).nnnPATIENT SUMMARYnThis article presents a short version of European Association of Urology guidelines for non-neurogenic male lower urinary tract symptoms (LUTS). The recommended tests should be able to distinguish between uncomplicated male LUTS and possible differential diagnoses and to evaluate baseline parameters for treatment. The guidelines also define the clinical profile of patients to provide the best evidence-based care. An algorithm was developed to guide physicians in using appropriate diagnostic tests.

The Prevalence of Clinically Meaningful Overactive Bladder: Bother and Quality of Life Results from the Population-Based FINNO Study

BACKGROUNDnWide variation exists in prevalence estimates of overactive bladder (OAB) syndrome.nnnOBJECTIVEnTo determine how the frequency of urinary urgency or urgency urinary incontinence (UUI)--the cornerstone symptoms of OAB--affects symptom-related bother, health-related quality of life (HRQL), and ultimately clinically meaningful prevalence.nnnDESIGN, SETTING, AND PARTICIPANTSnQuestionnaires were mailed to 6000 subjects (18-79 yr of age) randomly identified from the Finnish Population Register in 2003-2004.nnnMEASUREMENTSnThe frequency (scale: never, rarely, often, always) and bother (scale: none, small, moderate, major) of urgency and UUI were assessed using the Danish Prostatic Symptom Score (DAN-PSS). HRQL was measured with the generic 15D instrument. For HRQL analyses, respondents were classified according to six symptom categories by frequency of urgency and UUI.nnnRESULTS AND LIMITATIONSnOf those subjects queried, 62.4% responded to the survey (53.7% female). Any urgency was reported by more than half of all respondents (54.2% [95% confidence interval (CI), 51.6-56.7] of men; 56.9% [95% CI, 52.9-61.0] of women), whereas any UUI was reported by one in nine men (10.7% [95% CI, 8.9-12.4]) and one in four women (25.7% [95% CI, 22.8-28.7]). However, only one in seven of all respondents with urgency and less than one in three with UUI reported at least moderate bother. With increasing OAB severity, statistically significant decreases were found in the total 15D score and on all 15D dimensions (p<0.001 for all). Reporting often urgency without UUI or rare urgency with rare UUI is associated with a clinically important decrease in HRQL. Although the response proportion was high, approximately one-third of those contacted did not participate.nnnCONCLUSIONSnIncreased severity of urgency and UUI is associated with a statistically significant and clinically important decrease in HRQL. Assessing bother associated with OAB drastically modifies the measured OAB prevalence and accounts for variation among studies.

Systematic Review and Meta-analysis of Candidate Gene Association Studies of Lower Urinary Tract Symptoms in Men

Context Although family studies have shown that male lower urinary tract symptoms (LUTS) are highly heritable, no systematic review exists of genetic polymorphisms tested for association with LUTS. Objective To systematically review and meta-analyze studies assessing candidate polymorphisms/genes tested for an association with LUTS, and to assess the strength, consistency, and potential for bias among pooled associations. Evidence acquisition A systematic search of the PubMed and HuGE databases as well as abstracts of major urologic meetings was performed through to January 2013. Case-control studies reporting genetic associations in men with LUTS were included. Reviewers independently and in duplicate screened titles, abstracts, and full texts to determine eligibility, abstracted data, and assessed the credibility of pooled associations according to the interim Venice criteria. Authors were contacted for clarifications if needed. Meta-analyses were performed for variants assessed in more than two studies. Evidence synthesis We identified 74 eligible studies containing data on 70 different genes. A total of 35 meta-analyses were performed with statistical significance in five (ACE, ELAC2, GSTM1, TERT, and VDR). The heterogeneity was high in three of these meta-analyses. The rs731236 variant of the vitamin D receptor had a protective effect for LUTS (odds ratio: 0.64; 95% confidence interval, 0.49–0.83) with moderate heterogeneity (I2 = 27.2%). No evidence for publication bias was identified. Limitations include wide-ranging phenotype definitions for LUTS and limited power in most meta-analyses to detect smaller effect sizes. Conclusions Few putative genetic risk variants have been reliably replicated across populations. We found consistent evidence of a reduced risk of LUTS associated with the common rs731236 variant of the vitamin D receptor gene in our meta-analyses. Patient summary Combining the results from all previous studies of genetic variants that may cause urinary symptoms in men, we found significant variants in five genes. Only one, a variant of the vitamin D receptor, was consistently protective across different populations.

What was hot at the ICS meeting 2013

Altaf Mangera,* Rufus Cartwright, Kari A.O. Tikkinen, An-sofie Goessaert, and Christopher R. Chapple Department of Urology, Royal Hallamshire Hospital, Sheffield, UK Department of Epidemiology & Biostatistics, Imperial College London, UK and Department of Urogynaecology, Imperial College London, UK Department of Urology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada Department of Urology, University Hospital Ghent, De Pintelaan, Ghent, Belgium

How to write an ICS/IUGA conference abstract.

IntroductionThis article aims to condense the lectures and discussions from workshops on good reporting at IUGA Como 2009 and ICS San Francisco 2009, providing practical advice for the novice researcher summarising their data for the first time.ConclusionsDrafting an abstract can be a time consuming process. Formal guidance, such as CONSORT and STROBE, exists for the kinds of information that should be included regarding almost all designs of clinical trials. Follow the abstract submission rules closely to avoid outright rejection. Plan to highlight the novelty, scientific merit and clinical impact of the work. Try not to overstate the importance of the findings. Do not forget to publish the work in a peer reviewed journal.

What was hot at the ICS meeting 2013?: Hot at the ICS Meeting 2013

submissions by geographic region. Hot at the ICS Meeting 2013 3 Neurourology and Urodynamics DOI 10.1002/nau bladder volume, and nociceptive behaviors. While both therapies may be some way off from routine practice, these data may open a route to early stage human trials. LUTS: INFECTION AND INFLAMMATION There is increasing recognition of inflammation and lowgrade infection as part of the pathophysiology of LUTS. Vijaya et al. (Abstract 123) demonstrated a significantly greater proportion of positive bacterial cultures in bladder biopsies from women with LUTS compared to asymptomatic women suggesting a link between bacterial infection and LUTS in women, however, therewas no significant association between women with recurrent UTI and positive biopsies. Similarly, Sorrentino et al. presented data demonstrating that in women without overt urinary tract infection, bacteriuria was associated with a range of LUTS (Abstract 126). Evidence of an inflammatory aetiology of OAB also was presented in a study by Gill et al. who demonstrated that women with OAB and pyuria of 1–9 cells/ml had significantly greater levels of two markers of urothelial inflammation (urinary lactoferrin and IL6) compared to controls (Abstract 124). This data suggests that contrary to the current literature, pyuria <10 cells/ml may be a pathological finding. The original diagnostic criteria for bladder pain syndrome/ interstitial cystitis (BPS/ICS), based on symptoms and presence of glomerulations after cystoscopic hydrodistention, resulted in a failure to detect about 60% of the clinically significant BPS/IC patients. Perceived as too restrictive, there has been a trend toward a symptom-based definition. Work by Kuo et al. (Abstract 54), raised further doubt with regards to the specificity of bladder glomerulations as a finding. They systematically recorded the finding of glomerulations at cystoscopy for a sample of 120 patients with a wide range of benign urological conditions and confirmed the non-specific nature of this finding. There remains huge heterogeneity in how patients with BPS/ICS are managed worldwide. One promising option is the use of intra-vesical onabotulinumtoxinA (Ono-BTX). Jhang et al. showed convincingly in a 2-year cohort study of 40 patients, that such treatment was more effective across a range of subjective and objective outcome measures for patients without bladder ulceration (Abstract 60). PELVIC FLOOR: PREGNANCY, DELIVERY AND BEYOND The first vaginal delivery is considered a critical window for intervention to prevent birth injury, and its long-term sequelae for the pelvic floor. Following recent successful pragmatic randomized trials showing benefits of a variety of regimes of pelvic floor muscle training (PFMT) during pregnancy, Fritel et al. tested the effect of supervised PFMT in a multi-center two arm RCT of 282 French nulliparous women (Abstract 5). In contrast to previous studies, they found no benefits either in late pregnancy, or through post-partum follow-up, even in a per protocol analysis. The French health services routinely provide impressive support for post-partum pelvic floor health, and contamination between armsmay have been present, with the control group women potentially having undertaken unsupervised PFMT. The role of obstetric practice in the development of urinary incontinence (UI) post-partum is well studied, but remains surprisingly controversial. Wesnes et al. used data from MoBa, the Norwegian Mother and Child Cohort Study, which is the world’s largest birth cohort, to assess the impact of delivery parameters on UI (Abstract 6). Among 5,219 primiparous women, delivering spontaneously vaginally, they found that both birth weight and head circumference were strong predictors of incident UI at 6-month follow-up. While birth weight, and particularly macrosomia remains difficult to accurately predict on ultrasound, these findings suggest that women with suspected large fetuses should be targeted for both primary (antenatal) and secondary (postnatal) prevention. The risk factors and impact on quality of life of persistent UI at 12 years after childbirth was examined in a longitudinal study conducted in theUK andNewZealand (Abstract 231). In total, 7,879 women were recruited three months after childbirth in three maternity units. Older maternal age, greater parity, and BMI were all associated with increased risk of persistent UI. Furthermore, birth by elective cesarean reduced risk ofUI (adjustedOR0.42 (95%CI 0.33–0.54). Unfortunately, UI was not reported by type and the case definition used in the analyses may be too inclusive (‘‘at present do you ever lose any urine’’). The epidemiology of fecal incontinence remains severely under-investigated relative to UI. Using data from the population based HUNT-3 survey, Rommen et al. tested associations between obstetric anal sphinctersphincter tears (OASIS) and fecal incontinence (Abstract 281). In a sample of 11,707 parous women aged 30–80 they observed huge age adjusted risks for significant fecal incontinence after OASIS (OR 5.54, 95%CI 3.5– 8.78). They also observed significant associations for forceps delivery and BMI, emphasizing these three factors as the major modifiable risks for fecal incontinence. Stedenfeldt et al. demonstrated how to reduce such risks of OASIS, presenting a before and after comparison of a training programme for obstetricians and midwives applied in five Norwegian hospitals, focusing on perineal support and appropriate use of episiotomy (Abstract 287). In analysis of 40,152 vaginal births they demonstrated an overall reduction in OASIS rates from 4.7% down to 2% before and after the intervention. Most impressively they demonstrated similar risk reductions for women across a range of low and medium risk categories, suggesting perhaps counter-intuitively thatmost improvement could be made for low risk ‘‘normal’’ births, and that such education efforts should prioritize routine midwifery care. PELVIC ORGAN PROLAPSE: TREATMENT Pelvic floor muscle training (PFMT) for pelvic organ prolapse has recently demonstrated excellent results, and Bo et al. evaluated this concept in an RCT of PFMT in the early postpartum period, reporting prolapse outcomes (Abstract 205). They randomized 175 primiparouswomen, stratified by levator avulsion status to a combination of supervised PFMT classes and home training, or usual care with a single instruction session in correct pelvic floor contraction. Overall rates of prolapse were low, and in this context they did not observe improvements in symptomatic or anatomic prolapse in either group. These results were surprising given other work from the same group demonstrating steady remission in prolapse during the first post-partum year (Abstract 207). These results when considered together suggest that post-partum PFMT should be used specifically to treat UI rather than prolapse, pending the results from further trials. Ultrasound evaluation of both sub-urethral tapes and mesh kits to treat prolapse has provided insight into their potential mechanism of action, and the causes of late failure. Wong et al. provided data on the optimal placement of sacrocolpopexy mesh that is of interest to all laparoscopic urogynecologists (Abstract 209). A 3-year mean follow-up of 114 patients after laparoscopic sacrocolpopexy, demonstrated that the majority of patients had anatomic prolapse recurrence in 4 Osman et al. Neurourology and Urodynamics DOI 10.1002/nau the anterior or posterior compartment (84%). There was a significant negative association between low mesh placement and cystocoele recurrence, emphasizing the importance of trying to extend and anchor the mesh around the bladder base. Wide practice variation is present for the surgical management of co-existing SUI and prolapse, with debate over the pros and cons of a combined procedure. In an important RCT, van der Ploeg et al. randomized 138women to vaginal prolapse repair with or without mid-urethral sling (Abstract 210). At 1 year follow-up, they observed a highly significantly increased risk of subjective SUI amongst women without a sling (RR 2.8 95%CI 1.7–4.7), however, they also noted no significant difference in patients’ global reports of incontinence severity, and a significant increase in surgical complications undergoing a combined procedure. With similar reoperation rates in both arms, the authors cautioned that the theremaybenoworthwhile benefits of a combined procedure in women with mild symptoms. Another areawithwide variations in the standard of care is in the use of post-operative urethral catheterization after prolapse surgery. Velusamy et al. presented a timely systematic review, including seven RCTs of early versus late removal of indwelling catheters (Abstract 247). The results very clearly demonstrate a balance of risks with short-term (<48hr) catheterization being associated with less risk of UTI (RR 0.24, 95%CI 0.17–0.35) but greater risk of retention (RR 3.67, 95%CI 2.35–5.72). Uterine conservation at prolapse surgery has gradually gained traction over recent years. Rahmanou et al. presented 1-year outcomes of an RCT comparing laparoscopic hysteropexy and vaginal hysterectomy (Abstract 249). With results available from 67 women they observed no difference in vaginal symptoms, but better apical support following hysteropexy. These results emphasize that uterine conservation should be considered as an option forwomenwho desire it, although long term outcomes are awaited before definitive conclusions can be drawn.

Relationship between voided volume and the urge to void among patients with lower urinary tract symptoms

Abstract Objective.The aim of this study was to explore the relationship between voided volume (VV) and urge to void among patients with lower urinary tract symptoms. Material and methods. Consecutive adult patients (aged 23–90 years) were enrolled, and completed a 24 h bladder diary and the Urgency Perception Scale (UPS). Patients were categorized as urgency or non-urgency based on the Overactive Bladder Symptom Score. The relationship between UPS and VV (based on the bladder diary) was analyzed by Spearman’s rho and proportional odds model. Results. In total, 1265 micturitions were evaluated in 117 individuals (41 men, 76 women; 56 individuals in the urgency and 61 in the non-urgency group). The mean (± SD) VV and UPS were 192 ± 127 ml and 2.4 ± 1.2 ml in the urgency group and 173 ± 124 ml and 1.7 ± 1.1 ml in the non-urgency group, respectively. Spearman’s rho (between UPS and VV) was 0.21 [95% confidence interval (CI) 0.13–029, p < 0.001] for the urgency group, 0.32 (95% CI 0.25–0.39, p < 0.001) for the non-urgency group, and 0.28 (95% CI 0.23–0.33, p < 0.001) for the total cohort. Urgency patients had higher UPS [odds ratio (OR) 3.1, 95% CI 2.5–3.8]. Overall, each additional 50 ml VV increased the odds of having a higher UPS with OR 1.2 (95% CI 1.2–1.3). The relationship between VV and UPS score was similar in both groups (p = 0.548 for interaction). Conclusion. Although urgency patients void with a higher UPS score, among both urgency and non-urgency patients there is only a weak correlation between VV and the urge to void. This suggests that there are factors other than VV that cause the urge to void.

What was hot at the joint ICS and IUGA meeting Toronto, Canada, 23–27 August 2010†

For the first time in 5 years, 2010 saw the jointmeeting of the International Continence Society (ICS) and the International Urogynecological Association (IUGA), held in Toronto Canada fromthe23rd to the27thofAugust. Themeetingsetnewrecords for both societies, attracting more delegates, and more abstract submissions than ever before (Table I). As inpreviousyears, in thisarticlewehave tried to summarize what we believe to be the highlights of the scientific sessions. Again we must apologize in advance for inevitable subjective bias in these personal selections. Eachpresentedabstract isreferencedtotheconferencesupplement of Neurourology and Urodynamics, but the interested reader may also refer to the ICS website (www.icsoffice.org) for non-presented abstracts, and webcasts including slides and audio for many sessions are also available online (www.webcasts.prous.com/ICSIUGA2010). The proportion of accepted, presented, and non-presented abstracts by category is shown in Figure 1.

Prostate cancer and deprivation

Less radical treatment corresponds with higher deprivation, but the effect on survival differences is unclear