Mahreen Pakzad

Urinary tract infections in multiple sclerosis

Background: Urinary tract infections (UTIs) are commonly reported by people with multiple sclerosis (PwMS) and significantly impact quality of life. Objective: To provide an overview of the problem of UTIs in PwMS and offer a practical approach for the diagnosis and management. Methods: A review of the literature through a Pubmed search up to October 2015 was performed using the following keywords: multiple sclerosis, neurogenic bladder, urinary tract infections, relapse, dipsticks, culture, recurrent and prevention. Results: Noteworthy topics include the definition of a confirmed symptomatic UTI as a positive urine culture defined by >105 colony-forming units (CFU)/mL or >104 CFU/mL if a urethral catheter urine sample is taken, or any count of bacteria in a suprapubic bladder puncture specimen, both in addition to symptoms including fever, pain, changes in lower urinary tract symptoms or neurological status. Urinalysis is useful to exclude a UTI; however, on its own is insufficient to confirm a UTI, for which urine culture is required. Experts advise asymptomatic UTIs should not be treated except in the context of an acute relapse. From international guidelines, there is no validated strategy to prevent recurrent UTIs in PwMS. Conclusion: This review provides an overview of the diagnosis, treatment and prevention of UTIs in the setting of multiple sclerosis (MS).

Treatment Options for Urogenital Dysfunction in Parkinson's Disease.

Opinion statementUrogenital dysfunction is commonly reported in Parkinson’s disease (PD), and history taking and a bladder diary form the cornerstone of evaluation. The assessment of lower urinary tract (LUT) symptoms include urinalysis, ultrasonography, and urodynamic studies and help to evaluate concomitant urological pathologies such as benign prostate enlargement. Antimuscarinic medications are the first line treatment for overactive bladder (OAB) symptoms and solifenacin has been specifically studied in PD. Antimuscarininc drugs may exacerbate PD-related constipation and xerostomia, and caution is advised when using these medications in individuals where cognitive impairment is suspected. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Intradetrusor injections of botulinum toxin have been shown to be effective for detrusor overactivity, however, are associated with the risk of urinary retention. Neuromodulation is a promising, minimally invasive treatment for PD-related OAB symptoms. Erectile dysfunction is commonly reported and first line treatments include phosphodiesterase-5 inhibitors. A patient-tailored approach is required for the optimal management of urogenital dysfunction in PD.

Radiotherapy is associated with reduced continence outcomes following implantation of the artificial urinary sphincter in men with post-radical prostatectomy incontinence

Objectives: The objective of this study is to present the outcomes of men undergoing implantation of artificial urinary sphincter, after treatment for prostate cancer and also to determine the effect of radiotherapy on continence outcomes after artificial urinary sphincter (AUS) implantation. Material and Methods: A prospectively acquired database of all 184 patients having AUS insertion between 2002 and 2012 was reviewed, and demographic data, mode of prostate cancer treatment(s) before implantation, and outcome in terms of complete continence (pad free, leak free) were assessed. Statistical analysis was performed by Chi-squared and Fishers exact tests. Results: A total of 58 (32%) men had bulbar AUS for urodynamically proven stress urinary incontinence consequent to treatment for prostate cancer in this period. Median follow-up post-AUS activation was 19 months (1–119). Forty-eight (83%) men had primary AUS insertion. Twenty-one (36%) men had radiotherapy as part of or as their sole treatment. Success rates were significantly higher in nonirradiated men having primary sphincter (89%) than in irradiated men (56%). Success rates were worse for men having revision AUS (40%), especially in irradiated men (33%). Conclusion: Radiotherapy as a treatment for prostate cancer was associated with significantly lower complete continence rates following AUS implantation.

Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence.

To assess the presenting features and medium‐term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition.

Does the appearance of the urethral pressure profile trace correlate with the sphincter EMG findings in women with voiding dysfunction

Women with functional voiding dysfunction often experience a “catching” sensation when catheterising and are in general investigated with both urethral pressure profilometry (UPP) and sphincter electromyography (EMG). It is unknown whether the pattern of the UPP trace correlates with this sensation of “catching” or with sphincter EMG findings.

Open label feasibility study evaluating D-mannose combined with home-based monitoring of suspected urinary tract infections in patients with multiple sclerosis

To assess the feasibility of using D‐mannose, a natural food supplement, in patients with multiple sclerosis (MS) reporting recurrent urinary tract infections (UTIs) as a preventative.

Female bladder outlet obstruction: Common symptoms masking an uncommon cause

Bladder outlet obstruction (BOO) in women remains an underdiagnosed condition. Although diagnosed rarely in general urologic practice, its incidence in specialist centers has been reported to be up to 29%. In the present study we evaluated the incidence of female BOO in adult women referred for evaluation of lower urinary tract symptoms or urinary incontinence, assessing its etiology and correlating this with its clinical presentation.

The outcome of intravesical onabotulinum toxin injections for salvage therapy of refractory detrusor overactivity following augmentation enterocystoplasty

Objective: The objective of this article is to assess the effect of intravesical onabotulinum toxin A (OBTX-A) injections in patients with persistent/refractory symptomatic detrusor overactivity (DO) and urge urinary incontinence (UUI) following previous augmentation enterocystoplasty. Patients and methods: We conducted a retrospective review of all patients with previous augmentation enterocystoplasty having intravesical OBTX-A for persistent/refractory DO and UUI. Information on demographics, original diagnosis, date and technique of enterocystoplasty, dose of OBTX-A and symptomatic outcomes was recorded. Results: Fifteen patients (three men) with mean age 42 years were studied. Eight out of 15 (53%) reported complete continence or significant improvement, while the remaining seven (47%) noticed no difference in their symptoms. Urodynamics were repeated in these seven patients and persistent DO was confirmed. Four out of five (80%) NDO patients who received 300 U of OBTX-A reported a favourable outcome, whereas a favourable response was noted in only four out of 10 IDO (40%) when smaller amounts of OBTX-A (100 U or 200 U) were used. Conclusions: Intravesical OBTX-A injections completely resolved or significantly improved persistent/recurrent symptoms of DO in 53% of patients with a previous augmentation enterocystoplasty. The success rate was higher for those receiving the higher dose of 300 U and/or those with NDO.

SINGLE CENTRE RANDOMISED PILOT STUDY OF TWO REGIMENS (30 MINS DAILY OR 30 MINS WEEKLY FOR 12 WEEKS) OF TRANSCUTANEOUS TIBIAL NERVE STIMULATION USING A NOVEL DEVICE FOR TREATING MULTIPLE SCLEROSIS-RELATED OVERACTIVE BLADDER SYMPTOMS

Introduction Percutaneous tibial nerve stimulation (PTNS) is effective for managing multiple sclerosis (MS)-related overactive bladder (OAB) symptoms. However the need for weekly clinic visits restricts its use. The purpose of this study was to evaluate safety and efficacy of a novel, self-applying device for managing OAB symptoms. Study design, materials and methods 48 patients reporting OAB (MS n=24, idiopathic n=24), were randomized (1:1) to either daily or weekly treatments for 12 weeks with geko™, a novel device stimulating the tibial nerve transcutaneously. Efficacy was assessed using validated questionnaires (ICIQ-OAB, ICIQLUTS-QoL) and bladder diaries filled at weeks 4, 8, and 12. Urinary neurotrophins (Nerve growth factor (NGF) and Brain derived neurotrophic factor) were measured. Results 34 patients (MS n=19) completed the study. 18 patients responded to treatment (53%); 72% of responders belonged to the MS cohort. Multilevel regression analysis suggested significant improvements in questionnaire scores (ICIQ-OAB –10.2 (–13.5 to –6.9; p=0.001), ICIQLUTS-QOL –40.8 (–57.4 to –24.3; p=0.000)), without differences between weekly and daily-treated arms. No significant adverse effects were reported and patients rated the treatment as easy to use and comfortable. NGF levels at baseline were significantly greater in non-responders (p=0.05). Concluding message In this pilot study, a patch device suitable for self-application at home appears to be an effective, safe and convenient alternative for managing MS-related OAB symptoms.

PERCUTANEOUS TIBIAL NERVE STIMULATION FOR OVERACTIVE BLADDER

Background Percutaneous Tibial Nerve Stimulation (PTNS) is a minimally invasive neuromodulation technique for treatment of overactive bladder (OAB). The aim of this study was to assess safety and efficacy in neurological patients. Methods In this prospective evaluation over 18 months at a tertiary centre, patients finding first-line treatments for OAB ineffective or intolerable underwent standard 12-week course of PTNS (Urgent PC, Uroplasty). Symptoms were evaluated using standardised questionnaires (ICIQ-OAB and ICIQLUTS-QoL) and bladder diaries. Results Of 74 consecutive patients (52 males; mean age 57; 25(33.8%) idiopathic OAB, 19 (25.7%) multiple sclerosis (MS), 30 (40.5%) other neurological conditions), 64(86%) completed treatment. Significant improvements (p<0.05) were noted in OAB scores, quality of life, 24-hour bladder frequency, number/severity of incontinent episodes. Patients found treatment comfortable and no adverse effects were reported. Thirty-two(61.5%) opted to continue; mean top-up interval 44.4 days (7–155 days). Patients reporting improvements in OAB symptoms, leakage severity and quality of life at week 12, as well as patients with MS and other neurological disorders, more often returned for top-up sessions(p<0.05). Conclusions PTNS is a safe and effective treatment in patients with neurological disorders, associated with significant improvements in overactive bladder symptoms and quality of life.