Fluid intake behavior in women with refractory overactive bladder undergoing third line therapy.

INTRODUCTION AND OBJECTIVES: Fluid intake has been shown to be related to urinary symptoms, but no studies to date have investigated the effect of fluid intake on urinary symptoms in women with refractory overactive bladder (OAB). As this group of women are considered to have a possible unique pathophysiologic mechanism of OAB, we investigated the relationship between fluid intake, fluid intake behavior, and urinary symptoms in women with refractory OAB. METHODS: A prospective cross-sectional study of women with refractory OAB was conducted by assessing the relationship between fluid intake and lower urinary tract symptoms (LUTS) in women undergoing third line OAB therapies. Fluid intake and behavior were measured by the questionnaire based voiding diary and urinary symptoms were measured by the International Consultation on Incontinence Questionnaire for Female Lower Urinary Tract Symptoms (ICIQ-FLUTS). The relationship between fluid intake and symptom severity was assessed using Spearman's rank correlation and χ2  tests. RESULTS: Of the 126 individuals undergoing third line therapy for OAB, 60 (48%) underwent intradetrusor onabotulinumtoxinA injection (BTX) injection, 42 (33%) peripheral tibial nerve stimulation, and 24 (19%) sacral neuromodulation. The mean total daily fluid intake was 2567.0 ± SD 1292.4 mL and did not differ significantly across treatment groups. Total fluid intake was weakly correlated with worse filling-type LUTS (r = 0.241, p = 0.007), and there was no relationship between LUTS and caffeinated fluid intake. Half (52%) of the subjects reported current fluid restricting behavior to control urinary symptoms, but this behavior was not correlated with LUTS severity (all p > 0.05). Patients that currently use tobacco have greater LUTS (current = 25.8 ± SD 9.5, former = 14.8 ± SD 6.1, never = 15.0 ± SD 6.1; p < 0.001). BMI was also positively correlated with worse incontinence symptoms (r = 0.351, p < 0.001). CONCLUSIONS: Fluid intake along with other lifestyle factors, including tobacco use and weight, are minimally related to the symptomatology seen in women with refractory OAB. Further studies are needed to assess if behaviors change during treatment with third line therapies, and if these behavioral changes may affect treatment response.

An analysis of factors that influence patient preference of third-line therapy for overactive bladder.

OBJECTIVE: Patients with overactive bladder (OAB) refractory to first- and second-line therapy may pursue third-line therapies, including intradetrusor onabotulinum toxin-A (BTX), peripheral tibial nerve stimulation (PTNS), and sacral neuromodulation (SNM). The factors that influence patient preference for each treatment modality have not yet been explored. This study sought to investigate the specific parameters that patients consider in choosing a third-line therapy for OAB. METHODS: Patients refractory to first- and second-line therapies for OAB were identified in our outpatient clinic and asked to watch an educational video providing information on the risks and benefits of each third-line treatment option. They were then given a questionnaire to rank their preference of therapy and select reasons for why they found each therapy favorable and unfavorable. Patients under age 18 years, non-English speakers, those with a developmental disability, and those with a diagnosis of neurogenic bladder were excluded. RESULTS: Of the 98 patients included in the study, 40 participants (40.8%) chose intradetrusor BTX injections, 34 (34.7%) chose PTNS, and 16 (16.3%) chose SNM as their first choice. Seven patients (7.1%) chose none of the offered therapies, and one patient (1.0%) chose all three therapies with equal preference. BTX was found most attractive for its long efficacy (47%); its least attractive feature was the potential need for self-catheterization due to urinary retention (54%). PTNS was found most attractive for being a nonsurgical option (32%) and having no reported significant complications (39%); its least attractive feature was need for frequent office visits (61%). SNM was found most attractive for its potential for long-term relief without frequent office visits (53%); its least attractive feature was need for an implanted device (33%). Patients opting for SNM had higher scores on Urinary Distress Inventory-6 and Incontinence Impact Questionnaire-7 questionnaires when compared to patients opting for BTX injections or PTNS (p < 0.05). 47.4% of patients eventually pursued a third-line therapy. Of those, there was a 67.6% concordance rate between the therapy patients ranked first and the therapy they eventually underwent. CONCLUSIONS: Patients with more severe OAB symptoms opt for more invasive and less time-consuming therapy with the potential for long-term relief, namely SNM. Despite thorough counseling, many patients do not progress to advanced OAB therapies. Understanding factors that influence patients' affinity toward a specific type of treatment can aid with individualized counseling on third-line OAB therapies.

Initial experience using the Axonics sacral neuromodulation system in patients with multiple sclerosis.

INTRODUCTION: Sacral neuromodulation (SNM) is third-line therapy approved for urge urinary incontinence (UUI) and urgency, and nonobstructive urinary retention. Multiple sclerosis (MS) patients often suffer from neurogenic lower urinary tract dysfunction (NLUTD). The utility of SNM in the MS population is limited by magnetic resonance imaging (MRI) incompatibility as routine MRIs to evaluate for disease progression are required. The Axonics System is the first Food and Drug Administration-approved SNM device that is 1.5/3 T full-body MRI-conditionally safe. This study seeks to investigate the symptomatic improvement in MS patients after implantation of the Axonics System. METHODS: All MS patients who elected for Axonics SNM from December 2019 to January 2021 were included. Demographics and scores were queried for urogenital distress inventory (UDI-6), incontinence impact questionnaire (IIQ-7), and global response assessment (GRA). RESULTS: Fifteen MS patients with UUI were included. The time to follow-up averaged 121 days. On UDI-6, 12 patients reported improvement, 1 worsening, and 2 no change. Average UDI-6 scores before and after implantation were 56.6 and 25.2 (p < 0.0001). Improvements were significant for all questions under stress urinary incontinence, UUI, and voiding difficulty subcategories. On IIQ-7, 14 patients reported improvement and 1 reported worsening. Average IIQ-7 scores before and after implantation were 59.0 and 22.2 (p < 0.001). Improvements were significant for travel, social, and emotional subcategories, but not for physical activity. The average GRA score was 6 ("moderately improved"). CONCLUSION: The majority of MS patients reported significant initial improvement in UUI and associated quality of life measures on validated questionnaires after implantation of the Axonics System. Future studies are needed to determine the long-term outcomes and durability of this MRI full-body conditionally-safe system.

The Future is Female: The Influence of Female Faculty and Resident Representation on Female Applicant Match Rate Amongst Urology Residency Programs Over 3 Years.

OBJECTIVE: To investigate whether there is a correlation between the proportion of female faculty and residents at urology residency programs and the proportion of females matched to those programs. MATERIALS AND METHODS: We utilized official results from 3 consecutive AUA match cycles from 2018 - 2020 to obtain the number of females matched to each program. The number of female residents and faculty members in each program was acquired through querying program websites and contact with residency program coordinators. The correlation between the proportion of females in the newly matched class of residents and the proportion of current female faculty members and residents in that program was calculated for each match cycle. RESULTS: There was a positive correlation between the proportion of matched female applicants and the proportion of female residents in each program for the 2018, 2019, and 2020 match cycles (R = 0.23, P = .01; R = 0.21, P = .02, R = 0.11, p <.001, respectively). There was a positive correlation between the proportion of matched female applicants and the proportion of female faculty at their matched program in the 2018 and 2020 match cycles (R = 0.22, P = .02; R = 0.06, P < .01, respectively). There was no significant predilection of females matching to programs with a female program director or chairperson, and geographic location of program (based on AUA section) did not appear to influence female applicant match rates. CONCLUSION: There has been a consistent trend in the proportion of matched female applicants to urology programs correlating positively with the proportion of female residents at those programs over the past three years. This is indicative of the increased potential for female mentorship and leadership opportunities. Further research is needed to investigate the factors that draw female applicants to urology programs with increased female representation.

Access to Academic Female Pelvic Medicine and Reconstructive Surgery Providers for New Patient Visits: How Long Are Wait Times?

OBJECTIVES: To determine the wait times to see an academic Female Pelvic Medicine and Reconstructive Surgery (FPMRS) urologist or gynecologist and to identify factors that may impact these wait times. METHODS: We reviewed all Accreditation Council for Graduate Medical Education accredited urology and gynecology residency programs. Offices of FPMRS providers were called to ascertain the earliest available new patient visit for a fictional female patient with "urine leakage." Programs without FPMRS faculty (18.7%) were excluded. FPMRS providers that did not accept Medicaid (15.6%) were also excluded. Negative binomial regression was performed using SPSS v24. RESULTS: Final analysis included 362 FPMRS providers. Median wait time for a patient with Medicaid was 30 days (interquartile range [IQR] 15-51) and 26 days (IQR 14-42) for Medicare. The median wait time to see an FPMRS-trained gynecologist was 28 days (IQR 15-50) while FPMRS-trained urologists had a median wait time of 25 days (IQR 13.8-43.3). Female providers had longer median wait times when compared to male providers (30 vs 25 days). On regression analysis, only female gender of the provider was significant (P < .01). CONCLUSION: Our study found that nearly 1 in 5 academic departments did not have an FPMRS-trained provider. We found that new patients with urinary incontinence encountered substantial wait times to see FPMRS providers at academic institutions. As we project increased demand for the FPMRS workforce, our findings reflect a challenging landscape where training additional FPMRS providers may be needed to meet demand.

Trends of Mesh Utilization for Stress Urinary Incontinence Before and After the 2011 Food and Drug Administration Notification Between FPMRS-Certified and Non-FPMRS-Certified Physicians: A Statewide All-Payer Database Analysis.

OBJECTIVES: To investigate the utilization of mesh slings for stress urinary incontinence (SUI) across time - before and after the 2011 US Food and Drug Administration (FDA) public health notification regarding an increase in adverse events related to transvaginal mesh (TVM) for pelvic organ prolapse (POP) repair - and among FPMRS-certified urologists and gynecologists and non-FPMRS counterparts using a statewide database. METHODS: The New York Statewide Planning and Research Cooperative System all-payer database was utilized to extract outpatient Current Procedural Terminology procedure codes for SUI mesh sling utilization and revision or removal performed between 2007 and 2015. RESULTS: After the 2011 FDA warning on POP with TVM, sling placement decreased by 43% from 5214 cases in 2011 to 2958 in 2015. However, over the study period, the rate of sling revision remained stable relative to total sling placement. The rise and fall in mesh sling usage for SUI was primarily driven by non-FPMRS providers. FPMRS providers performed a higher proportion of sling procedures. The number of FPMRS physicians also increased from 2011 to 2015, and each individual physician had a higher median case volume for sling placements and revisions. CONCLUSION: In New York state, utilization of mesh slings for SUI has significantly decreased since the 2011 FDA public health notification, without any specific warning for the utilization of mesh in this setting. This trend was mainly driven by a decrease in mesh usage among non-FPMRS physicians, although the specific causality is likely complex.

Gynecologic Considerations for the Urologic Surgeon.

While gynecologic malignancy is uncommon in women with conditions such as pelvic organ prolapse and bladder cancer, urologists should be acquainted with the relevant gynecologic literature as it pertains to their surgical care of female patients. While taking the patient history, urologists should be aware of prior cervical cancer screening and ask about vaginal bleeding, which can be a sign of uterine cancer. Urologic surgeons should also discuss the role of concomitant prophylactic oophorectomy and/or salpingectomy for ovarian cancer risk reduction at the time of pelvic surgery. An understanding of basic tests, such as a transvaginal sonogram, can help urologists provide comprehensive care.

Fluid Intake and Urinary Symptoms in Patients with Multiple Sclerosis.

PURPOSE: The relationship between fluid intake and lower urinary tract symptoms in individuals with neurogenic bladder is unknown. We investigated the association between fluid intake and urinary symptoms in patients with multiple sclerosis. MATERIALS AND METHODS: A prospective cross-sectional study of patients with multiple sclerosis presenting to the neurology office was conducted. Fluid intake and lower urinary tract symptoms were assessed by the questionnaire based voiding diary and the American Urological Association Symptom Score, respectively. The relationship between fluid intake and lower urinary tract symptoms was assessed using univariate and multivariate analyses. RESULTS: Among 200 individuals with multiple sclerosis the mean total daily fluid intake was 2,489 ml (SD 1,883) and did not differ according to severity (ie mild, moderate, severe) of lower urinary tract symptoms (F=0.30, p=0.74). Fluid restricting behavior to control urinary symptoms was reported by 47% of subjects. Subjects who reported fluid restricting were more likely to have worse urinary symptoms (OR 1.95, 95% CI 1.53-2.47, p <0.01). After accounting for fluid restricting behavior on multivariate analysis, there was a minimal relationship between caffeinated fluid intake and lower urinary tract symptom severity (OR 1.00, 95% CI 1.00-1.01, p=0.01), and there was no relationship between total fluid intake and lower urinary tract symptom severity (OR 1.00, 95% CI 1.00-1.00, p=0.07). CONCLUSIONS: Caffeinated fluid intake has a minimal effect on lower urinary tract symptoms in patients with multiple sclerosis. On average, patients with multiple sclerosis do not hydrate excessively and a considerable proportion restrict fluid intake to control urinary symptoms. Fluid intake may not contribute considerably to lower urinary tract symptoms in patients with multiple sclerosis.

What's in a name? Choosing a title for a female pelvic medicine and reconstructive surgery clinic: A prospective questionnaire.

AIMS: A new multidisciplinary clinic specializing in female pelvic medicine and reconstructive surgery (FPMRS) opened at our institution. We sought to assess patient preference in naming this new center, and how readability and word choice informs these preferences. METHODS: We prospectively surveyed patient preference in naming this new center, as well as patient knowledge and societal perception of pelvic floor disorders. This survey was distributed to female patients presenting to general urology and gynecology clinics. RESULTS: There were 300 respondents out of 1000 distributed surveys. Patients preferred titles with accessible readability scores and societally neutral vocabulary. Preferred titles for the clinic were at a 6th-grade readability level. Patients preferred neutral titles that included the word "health" and disliked titles that contained the words "pelvic floor" and "dysfunction." In general, survey participants believed that "incontinence" was associated with negative connotations. CONCLUSION: Readable and neutral vocabulary in the title of the clinic are key components of patient-preferred titles for an FPMRS clinic and affect patient comfort levels in scheduling an appointment.

Association between urinary symptom severity and white matter plaque distribution in women with multiple sclerosis.

AIMS: Multiple sclerosis (MS) is characterized by demyelinated white matter plaque throughout the central nervous system. Plaque involvement in regions that regulate micturition may be associated with urinary symptom severity in patients with MS. The aim of this prospective study is to investigate the relationship between cerebral plaque volume (PV), location, and urinary symptoms in women with MS. METHODS: We conducted a case-control pilot study of women with MS undergoing routine yearly brain MRI. Women were administered the American Urologic Association-Symptom Index (AUA-SI) and divided into two groups: severe urinary symptoms (AUA-SI ≥20) and mild symptoms (AUA-SI ≤7). PV and location in the brain were determined using a validated automated white matter lesion segmentation algorithm. RESULTS: This study of 36 women found that the median total PV did not differ between groups. Women with severe urinary symptoms had larger median PV in the left frontal lobe (LFL) and right limbic lobe (RLL) compared with women with mild urinary symptoms. Within the RLL, women with severe symptoms had a larger median PV in the right cingulate gyrus (RCG). There was a moderate correlation between LFL lesion volume and RLL lesion volume with the AUA emptying subscore; however, these regions did not correlate with the storage subscore. CONCLUSIONS: This preliminary study found urinary symptom severity in women with MS is associated with PV in the RCG and LFL, and not total cerebral PV. These findings may explain why disease burden alone is not a predictor of severity or type of voiding dysfunction in patients with MS.

Partially Obstructed Longitudinal Vaginal Septum Presenting in Adulthood With Complaint of Urinary Incontinence.

A longitudinal vaginal septum can be obstructive or nonobstructive. We report on an adult woman who presented with involuntary fluid loss per vagina and had a partially obstructive longitudinal vaginal septum. A 36-year-old nulliparous female presented with malodorous, clear, leakage per vagina that she described as "urinary incontinence." Examination revealed a fluid-filled fluctuant anterior vaginal wall with a draining sinus. Imaging revealed a solitary right kidney with duplicated ectopic fluid-filled ureters inserting into a partially obstructed left hemivagina with a longitudinal vaginal septum. A longitudinal vaginal septum may present in adulthood with the complaint of urinary incontinence.

Brain activation during the voiding phase of micturition in healthy adults: A meta-analysis of neuroimaging studies.

Several studies have used a variety of neuroimaging techniques to measure brain activity during the voiding phase of micturition. However, there is a lack of consensus on which regions of the brain are activated during voiding. The aim of this meta-analysis is to identify the brain regions that are consistently activated during voiding in healthy adults across different studies. We searched the literature for neuroimaging studies that reported brain co-ordinates that were activated during voiding. We excluded studies that reported co-ordinates only for bladder filling, during pelvic floor contraction only, and studies that focused on abnormal bladder states such as the neurogenic bladder. We used the activation-likelihood estimation (ALE) approach to create a statistical map of the brain and identify the brain co-ordinates that were activated across different studies. We identified nine studies that reported brain activation during the task of voiding in 91 healthy subjects. Together, these studies reported 117 foci for ALE analysis. Our ALE map yielded six clusters of activation in the pons, cerebellum, insula, anterior cingulate cortex (ACC), thalamus, and the inferior frontal gyrus. Regions of the brain involved in executive control (frontal cortex), interoception (ACC, insula), motor control (cerebellum, thalamus), and brainstem (pons) are involved in micturition. This analysis provides insight into the supraspinal control of voiding in healthy adults and provides a framework to understand dysfunctional voiding. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

Clinical Considerations for Intravesical Prostatic Protrusion in the Evaluation and Management of Bladder Outlet Obstruction Secondary to Benign Prostatic Hyperplasia.

BACKGROUND: Intravesical prostatic protrusion (IPP) is a manifestation of benign prostatic hyperplasia marked by overgrowth of the prostatic median lobe into the bladder, producing bladder outlet obstruction and related storage and voiding symptoms. METHODS: A MEDLINE® database search of the current literature was guided using combination of "prostate" with the following terms: intravesical prostatic protrusion, bladder trabeculation, bladder outlet obstruction, lower urinary tract symptoms, alpha blockers, transrectal ultrasonography, and prostatectomy. RESULTS: Although IPP can be identified via a variety of imaging modalities, it is easily detected via transrectal ultrasonography (TRUS). Failing to detect IPP promptly by TRUS may result in refractory symptoms of benign prostatic hyperplasia, as the condition may not respond to typical α1-adrenoceptor antagonist therapy. In addition, depending on grade, IPP can influence outcomes and complications of prostatectomies. CONCLUSION: Upon report of lower urinary tract symptoms, initial performance of TRUS along with digital rectal examination prevents delay in the appropriate evaluation and management of prostatic diseases.

Specific Changes in Brain Activity during Urgency in Women with Overactive Bladder after Successful Sacral Neuromodulation: A Functional Magnetic Resonance Imaging Study.

PURPOSE: The mechanism of sacral neuromodulation is poorly understood. We compared brain activity during urgency before and after sacral neuromodulation in women with overactive bladder and according to the response to treatment. MATERIALS AND METHODS: Women with refractory overactive bladder who elected sacral neuromodulation were invited to undergo functional magnetic resonance imaging before and after treatment. During imaging the bladder was filled until urgency was experienced. Regions of interest were identified a priori and brain activity in these regions of interest was compared before and after treatment as well as according to the treatment response. Whole brain exploratory analysis with an uncorrected voxel level threshold of p <0.001 was also performed to identify additional brain regions which changed after sacral neuromodulation. RESULTS: Of the 12 women who underwent a pretreatment functional magnetic resonance imaging examination 7 were successfully treated with sacral neuromodulation and underwent a posttreatment examination. After sacral neuromodulation brain activity decreased in the left anterior cingulate cortex, the bilateral insula, the left dorsolateral prefrontal cortex and the bilateral orbitofrontal cortex (each p <0.05). No new brain regions showed increased activity after sacral neuromodulation. Pretreatment brain activity levels in the bilateral anterior cingulate cortex, the right insula, the bilateral dorsolateral prefrontal cortex, the right orbitofrontal cortex, the right supplementary motor area and the right sensorimotor cortex were higher in women who underwent successful treatment (each p <0.05). CONCLUSIONS: Brain activity during urgency changes after successful sacral neuromodulation. Sacral neuromodulation may be more effective in women with higher levels of pretreatment brain activity during urgency.

Female Pelvic Medicine and Reconstructive Surgery-What Does Certification Mean?

PURPOSE OF REVIEW: There are advantages and disadvantages of subspecialty certification for physicians, trainees, patients, and society at large. As female pelvic medicine and reconstructive surgery (FPMRS) became the second subspecialty of urology to offer subspecialty certification, understanding the effects of FPMRS subspecialty certification on the healthcare system is important. RECENT FINDINGS: While subspecialty certification may improve training, identify experts, and ultimately lead to improved patient outcomes, certification might also be unnecessary for some physicians, weaken residency training, and limit the number of physicians who are deemed qualified to offer certain treatments. As pelvic floor disorders can considerably affect quality of life, and their prevalence is expected to increase with the aging population, high-quality FPMRS care is needed. In this article, we describe the history of FPMRS subspecialty certification as well as its potential advantages and disadvantages as suggested by literature. There are advantages and disadvantages of FPMRS subspecialty certification. Further research is needed to assess the effect of FPMRS subspecialty certification on patient outcomes.

The history of the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction.

AIMS: To review the history of the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU). METHODS: We reviewed Society meeting minutes, contacted all living former Society presidents, searched the William P. Didusch Center for Urology History records, and asked Society members to share their important Society experiences in order to gather important historical information about the Society. RESULTS: The Society initially formed as the Urodynamics Society in 1969 in the backdrop of a growing passion for scientific research in the country after World War II ended. Since then, Society meetings have provided a pivotal forum for the advancement of science in lower urinary tract dysfunction. Meetings occurred annually until 2004, when the meeting schedule increased to biannual. The journal, Neurourology and Urodynamics, became the official journal of the Society in 2005. SUFU has authored important guidelines on urodynamics (2012), non-neurogenic overactive bladder (2012), and stress urinary incontinence (2017) and has shared important collaborations with other societies, including the American Urological Association (AUA), the International Continence Society (ICS), and the International Society of Pelvic Neuromodulation (ISPiN). SUFU has also been instrumental in trainee education and helped to establish formal fellowship training in the field in addition to holding a yearly educational meeting for urology residents. The Society has been led by 21 presidents throughout its history. CONCLUSION: Throughout the Society's near half-century long existence, the Society has fostered research, published guidelines, and educated trainees in order to improve the care of individuals suffering from lower urinary tract dysfunction.

Neuromodulation for Chronic Pelvic Pain.

PURPOSE OF REVIEW: Chronic pelvic pain is a heterogeneous condition that often requires multiple physician visits and various treatments prior to achieving an acceptable management strategy. Neuromodulation has been used to treat chronic pelvic pain that has failed other therapies. RECENT FINDINGS: Numerous modalities of neuromodulation have been used to alleviate chronic pelvic pain with promising results. Numerous modalities of neuromodulation have demonstrated efficacy in the management of pelvic pain. Further investigation is needed to elucidate the most effective treatment modality and to identify the patients who would benefit most from this therapy.