Nathan Hoag

Underactive Bladder: Clinical Features, Urodynamic Parameters, and Treatment

Purpose: Underactive bladder is a complex clinical condition that remains poorly understood due to limited literature. This study aimed to determine its prevalence among patients with voiding dysfunction, presenting symptoms, risk factors, urodynamic findings, and ongoing treatment. Methods: A retrospective chart review of consecutive urodynamic studies performed on voiding dysfunction between 2012 and 2014 was conducted to identify patients with detrusor underactivity. Detrusor underactivity was defined by a bladder contractility index of less than 100. Charts and urodynamic tracings were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken. Descriptive statistics were utilized to analyze the data. Results: The prevalence of detrusor underactivity in this study was 23% (79 of 343). Average age of the patients was 59.2 years (range, 19–90 years). Women represented 68.4% (54 of 79) of the patients. The most common reported symptoms were urinary urgency (63.3%), weak stream (61.0%), straining (57.0%), nocturia (48.1%), and urinary frequency (46.8%). Prior pelvic surgery and prior back surgery were noted in 40.5% and 19.0% of the patients, respectively. The most common management was intermittent self-catheterization in 54.4%, followed by observation/conservative treatment in 25.3% and sacral neuromodulation in 12.7%. Conclusions: Although underactive bladder is a common condition, its precise diagnosis and treatment remain a challenge. Its symptoms significantly overlap with those of other bladder disorders, and hence, urodynamic evaluation is particularly useful in identifying patients with impaired detrusor contractility. This will help prevent mismanagement of patients with surgery or medical therapy, as that may worsen their condition. Much work needs to be done to better understand this condition and establish optimal management of patients.

Sacral neuromodulation for detrusor hyperactivity with impaired contractility

Detrusor hyperactivity with impaired contractility (DHIC) is a challenging condition to manage. Sacral neuromodulation (SNM) is a proven treatment modality for both the individual aspects of DHIC. To date, data reporting the outcome of SNM for DHIC are lacking.

The confusion surrounding prostate cancer screening faced by family physicians

Primary care physicians, in the forefront of prostate cancer screening, are challenged with confusing and often conflicting guidelines. The lack of uniformity on the optimal prostate cancer screening recommendations stems from conflicting interpretations of the results of recent screening studies. Unfortunately, two large trials, initially planned to define the usefulness of screening, were both significantly flawed and provided conflicting results and further fueled the debate.1,2 Not surprisingly, these results have led to a lack of consensus on the best screening practices among various medical associations and guideline committees. The limitations of prostate-specific antigen (PSA) itself as a screening tool have precluded standardized and widely adopted guidelines from being developed to date.3 Several guidelines have been established; the American Urological Association and Canadian Urological Association favour the inclusion of PSA testing as a tool for prostate cancer screening,4,5 while the Canadian Task Force on Preventative Health Care and the U.S Preventative Services Task Force (USPSTF) recommend against screening.6,7 These are in addition to provincial and advocacy organizations’ recommendations – it is no wonder physicians and patients are confused. Controversy surrounding optimal prostate cancer screening for primary care physicians was renewed with the recent publication of the USPSTF statement, which attracted considerable media attention. Their recommendations were against PSA-based screening for prostate cancer in all men. PSA screening was labelled a “Grade D” recommendation, which states that there is moderate or high certainty that PSA screening has no benefit, or that the harms outweigh any benefits.7 It is important to stress the results of the European Randomized Study of Screening for Prostate Cancer, considered the best PSA screening study to date. It was demonstrated that screening reduced the rate of prostate cancer death by 20%, with additional two-year follow-up consolidating these findings.2,8 Being the largest trial to date and suffering fewer methodological limitations than its U.S. counterpart, this European study represents “level one” evidence that screening does reduce prostate cancer-specific mortality. It was proposed that the modest benefit conveyed should support a “grade C” recommendation; this leaves the decision regarding PSA screening to the patient and primary care physician.9 The results of the survey in this issue of CUAJ provide evidence to suggest that Ontario family physicians use their own management strategies in deciding whether to offer prostate cancer screening to their patients.10 As well, there is apparent heterogeneity in the use of screening, as well as in the attitudes concerning its value. Interestingly, although almost 80% screen for prostate cancer, a considerably lower percentage of family physicians believe that the benefits of screening outweigh its risks, which suggests that other patient factors prompt the decision to screen. Obviously, a primary weakness of the paper is the poor response rate. The results do, however, provide a glimpse into the practice patterns of physicians directly involved in screening. It is likely that the results can be extrapolated to the rest of the country, as these findings have been corroborated by other papers addressing the same question in Newfoundland and British Columbia.11,12 Most importantly, the survey shows the need not only to provide clear and evidence-based guidelines, but also for better education on prostate cancer screening for family physicians. A significant onus of responsibility for this lies with our own association and members. It highlights the importance of relaying our own CUA guidelines to family physicians, and educating them regarding the evidence and considerations surrounding prostate cancer screening.

Testicular torsion and the acute scrotum: current emergency management

The acute scrotum is a challenging condition for the treating emergency physician requiring consideration of a number of possible diagnoses including testicular torsion. Prompt recognition of torsion and exclusion of other causes may lead to organ salvage, avoiding the devastating functional and psychological issues of testicular loss and minimizing unnecessary exploratory surgeries. This review aims to familiarize the reader with the latest management strategies for the acute scrotum, discusses key points in diagnosis and management and evaluates the strengths and drawbacks of history and clinical examination from an emergency perspective. It outlines the types and mechanisms of testicular torsion, and examines the current and possible future roles of labwork and radiological imaging in diagnosis. Emergency departments should be wary of younger males presenting with the acute scrotum.

Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment

Sacral neuromodulation (SNM) is a well‐established treatment modality for refractory overactive bladder (OAB). There is a paucity of evidence examining the use of SNM in patients who have received prior intravesical onabotulinumtoxinA (BTXA) treatment. We aim to review those patients who underwent SNM for refractory OAB following treatment with BTXA.

Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence—a review

Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (RP). It can be the sole cause of post prostatectomy incontinence (PPI) or may be found in association with stress urinary incontinence (SUI). The aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post RP bladder dysfunction. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, PPI, detrusor overactivity (DO), detrusor underactivity (DU), impaired compliance, anticholinergic, onabotulinumtoxinA (Botox®) and sacral neuromodulation (SNM). Definitions, general overview and management options were extracted from the relevant medical literature. DO, DU and impaired compliance are common and may occur alone or in combination with SUI. In some patients the conditions exist pre RP, in others they arise due to denervation and surgical changes. DO can be treated with anticholinergics, Botox® and SNM. DO may need to be treated before SUI surgery. DU may be a contraindication to male sling surgery as some patients may go into urinary retention. Severely impaired bladder compliance may be a contraindication to SUI surgery as the upper tracts may be at risk. Each individual dysfunction may affect the outcome of PPI treatments and clinicians should be alert to managing bladder dysfunction in PPI patients.

Intravesical OnabotulinumtoxinA Injection for Overactive Orthotopic Ileal Neobladder: Feasibility and Efficacy

The efficacy of intravesical onabotulinumtoxinA (BTXA) in the treatment of overactive bladder (OAB) has been well documented. The use of BTXA injection in orthotopic neobladders is yet to be studied. We present 4 cases of patients injected with intravesical BTXA for overactive orthotopic ileal neobladder. We recorded patient demographics, presenting and follow-up symptoms, urodynamic profiles, and Patient Global Impression of Improvement (PGI-I) scores. The 4 patients reported varying degrees of subjective improvements in the symptoms, including urgency, urge incontinence, and pad usage. Mean follow-up duration was 8.3 months (range, 5–14 months). Average PGI-I score was 3 (“a little better”) (range, 2–4). To our knowledge, the current study is the first case series examining BTXA injection for orthotopic neobladder overactivity. BTXA injection yielded varying degrees of objective and subjective improvements, without significant complications. Intravesical BTXA injection is feasible and may be considered as a potential treatment alternative for OAB in orthotopic neobladders, although further study is warranted.

Clinical fellows: valuable or not? Opinions of Australian and New Zealand urology trainees and consultants.

As subspecialized urology fellowship training becomes more commonplace in Australia and New Zealand (ANZ), there exists an imperative to study the impact of fellows in greater depth. Little is known about the beliefs and opinions of local trainees surrounding the integration of clinical fellows into urology departments, and how it relates to their own education. Previously stated benefits of fellows to their respective departments include academic productivity, clinical service, teaching of more junior trainees and increasing their reputation and expertise on a national and international scale. A literature review by Plerhoples et al. attempted to assess the impact of fellowships on surgical residents in several subspecialties. Of the 23 articles reviewed, one was found to have positive impact on resident education, while nine had negative impact. Of the other 13 studies, mixed results were noted in six, with minimal to no impact in seven. It was noted by the authors that any conclusions were limited by the quality of the data in their analysis. A survey exploring the opinions of the American orthopaedic surgery faculty and trainees noted that a majority of trainees expressed the role of the fellow in the operating theatre as a major source of conflict, while 86% agreed that fellowship training is an important educational issue for residency programmes. A minority of these residents (29%) believed that their educational experience had been compromised. Our aim is to survey ANZ urology trainees and consultants in order to gauge their beliefs on the issue of clinical urology fellows. We also aim to compare these opinions with previously published opinions of urology trainees in Canada. With permission from the Urological Society of Australia and New Zealand (USANZ), hard-copy questionnaires were given to ANZ urology trainees in attendance at a mandatory meeting for those in training years 3–5. Questionnaires were modified based upon a previously published survey, with permission (Appendix S1). Electronic surveys were emailed inviting consultant members of USANZ to participate, with a reminder sent 2 months after the first email. Responses were recorded using the 5-point Likert scale (1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree). A two-group unpaired t-test with equal variances was performed to evaluate the differences between ANZ trainees and consultants. The one-sample mean comparison t-test was used to compare ANZ trainees to Canadian urology trainees from a single institution (University of Toronto). The previously published mean values were used as the comparator figure. All tests were two sided with significance set at 0.05. Analysis was performed using Stata v. 12.0 SE (Statacorp LP, College Station, TX, USA). Overall response rate from registrars and consultants was 47% (52/111) and 11% (48/420), respectively. Responses to survey questions posed to ANZ urology trainees and consultants are summarized in Table 1 and the associated P-values comparing responses between ANZ trainees/consultants and ANZ trainees/ Canadian trainees for each question are also shown. The most commonly mentioned ‘characteristics of a good clinical fellow’ were being a ‘team player’ (58.6%), ‘teaching’ (43.7%) and being ‘collegial/supportive’ (34.4%). As the specialty of urology trends towards an increasing emphasis on subspecialization, the presence of clinical fellows will likely continue to increase. Department heads, urology educational programme directors, fellows and trainees will need to work in concert to strike an appropriate balance sharing learning opportunities to maximize educational value for all parties. As was seen in our survey, ANZ trainees felt less strongly than their previously questioned Canadian counterparts that fellows ‘steal’ operative cases, although there was agreement that fellows add to the overall education of urology trainees in both countries. It does highlight the potential challenges in striking a balance in providing optimal educational opportunities for both trainees and fellows. Open communication, setting of roles/objectives for trainees and fellows and good working relationships would likely be of great benefit in fostering an agreeable working environment and ensuring fair distribution of learning opportunities. The top two most frequently cited desirable characteristics of a good clinical fellow were being a team player and teaching. It underscores the importance of selecting for these attributes when advertising and interviewing for potential fellows. The introduction of additional fellows should be carried out cautiously, so as to maintain the balance of educating local trainees while raising the profile of individual departments on the worldwide stage and attracting the best possible international fellows. It may also be of benefit for local urology units to clearly define the roles of trainees and fellows to promote a more harmonious relationship between the two entities. Several limitations exist for this study. The study was administered only to those in attendance at trainee session where the survey was conducted. The relatively low response rate by consultants represents another important limitation. As urology fellowship opportunities continue to proliferate in ANZ, it remains of upmost importance to strive to maintain an optimal balance respecting the training needs of all parties. Maintaining communication between local urology departments and training coordinators is essential to ensure that the personnel are optimally assigned. When appropriate integration of trainees and fellows is achieved, the educational benefits towards enhancing trainee learning may be significant.

Sacral Neuromodulation in Non-Obstructive Urinary Retention and Painful Bladder Syndrome: an Update

Sacral neuromodulation (SNM) is an established treatment option for several urologic conditions, and its use continues to grow. Indications and applications for SNM are expanding as our understanding of its mechanism of action improves, and our experience develops. Current urologic applications include overactive bladder (OAB), non-obstructive urinary retention, and pelvic pain disorders. SNM has become an established therapeutic modality for non-obstructive urinary retention, while SNM for pelvic pain disorders has found a place in accepted treatment guidelines. This review provides an update on SNM and focuses on developments in SNM relating to the less-studied applications of non-obstructive urinary retention and painful bladder syndrome.

Genitourinary tuberculosis masquerading as a ureteral calculus.

The genitourinary tract is a common extrapulmonary site of tuberculosis infection, yet remains a rare clinical entity in North America. We report the case of a 37-year-old man who presented for extracorporeal shock wave lithotripsy for a suspected ureteral stone on imaging. Further workup confirmed a diagnosis of genitourinary tuberculosis. Medical management was undertaken and, ultimately, nephrectomy performed. This case highlights the importance of maintaining a high index of clinical suspicion for genitourinary tuberculosis.