Faculty Bibliography

Stress urinary incontinence (SUI) is said to effect up to 80 % of all women who complain of some type of urinary leakage. As education about the diagnosis and treatment of SUI becomes more widespread, there is a need for understanding the efficacy and potential complications of the therapies used to treat this condition. It is widely accepted that the gold standard for treatment of SUI is mid-urethral sling (MUS). One significant complication of the MUS procedure is subsequent bladder outlet obstruction (BOO). We review the incidence and etiology of BOO following MUS and hope this document can be used as a guide for identifying patients who may be affected by postsurgical BOO. Additionally, we discuss modalities for achieving a timely and accurate diagnosis and highlight recent evidence regarding the various applications of urodynamic studies, when concerned for BOO. Lastly, various managements of this complication are discussed. This chapter serves as a comprehensive overview of BOO after incontinence procedures, highlighting the recent research contributions, which have enhanced our understanding of this potential complication when treating SUI

OBJECTIVE: to review key guidelines on the management of urinary incontinence in order to guide clinical management in a practical way. MATERIALS AND METHODS: guidelines produced by the European Association of Urology (updated in 2014), the Canadian Urological Association (updated in 2012), the International Consultation on Incontinence (updated in 2012), and the National Collaborating Centre for Women's and Children's Health (updated in 2013) were examined and their recommendations compared. In addition, specialized guidelines produced by the collaboration between the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction on overactive bladder and the use of urodynamics were reviewed. The Appraisal of Guidelines for Research & Evaluation II (AGREE) Instrument was used to evaluate the quality of these guidelines. RESULTS: there is general agreement between the groups on the recommended initial workup and the use of conservative therapies for first line treatment, with limited role for imaging or invasive testing in the uncomplicated patient. These groups have greater variability in their recommendations for invasive procedures, however generally the mid-urethral sling is recommended for uncomplicated stress urinary incontinence, with different recommendations on the approach as well as the comparability to other treatments, such as the autologous fascial sling. CONCLUSION: this Guideline of Guidelines provides a summary of the salient similarities and differences between prominent groups on the management of urinary incontinence

CASE: Xanthogranulomatous inflammation of the prostate is a rare condition that can cause lower urinary tract symptoms and may be mistaken for adenocarcinoma. It is often seen on prostate biopsy, but can usually be treated conservatively with temporary catheterization, alpha blockade, and allowing time for improvement. We present a case of a 78-year-old man found to have a 318 g prostate secondary to xanthogranulomatous inflammation. OUTCOME: After a negative MRI-guided biopsy to rule out malignancy, the patient was treated successfully with open suprapubic prostatectomy with significant improvement in voiding symptoms. CONCLUSION: This case highlights the ability of this clinical and pathologic entity to cause significant prostatic enlargement, how it is diagnosed, and the possible role of surgical therapy in its treatment.

Pelvic organ prolapse is a common condition for which age is a significant risk factor, making pelvic organ prolapse particularly prevalent in the elderly population. While not a life-threatening condition, pelvic organ prolapse can affect quality of life and impact daily activity with bothersome vaginal, urinary, bowel, and sexual symptoms. This review article addresses the management of symptomatic pelvic organ prolapse in the elderly population including evaluation, conservative and surgical approaches. Conservative management encompasses pelvic floor muscle training therapy and use of vaginal pessaries in addition to lifestyle modifications. Patients who have failed conservative management or desire definitive repair may be amenable to surgical intervention, comprising traditional and minimally invasive abdominal sacrocolpopexy, transvaginal repairs and obliterative procedures. Important pre-operative, intra-operative, and post-operative considerations unique to the elderly population are addressed as well

Multiple sclerosis (MS) can be a debilitating neurological condition that attributes significant morbidity to bladder dysfunction. Although many effective treatment options exist, symptomatic patients are often underdiagnosed and undertreated. The purpose of this article is to give an overview of the current literature including new screening tools to identify symptomatic patients and updates on treatment options including medications, botulinum toxin, and neuromodulation.

Mixed urinary incontinence is estimated to affect 30% of all women who have urinary incontinence, and it has been shown to be more bothersome to women than pure stress incontinence. Given the degree of bother, many women will undergo surgical correction for incontinence. Patients have high expectations about the success of these interventions. Understanding mixed incontinence and the effects of our interventions can help guide therapeutic choices and manage patients' expectations.

Objective: To identify barriers multiple sclerosis (MS) patients experience in seeking evaluation for urinary symptoms and its relationship to the Actionable Bladder Symptom and Screening Tool (ABSST). Background: The ABSST is used to identify urinary symptoms in patients with MS and may identify patients in need of referral and evaluation for neurogenic overactive bladder symptoms (NDO). Although up to 80% of MS patients may experience urinary symptoms, evaluation by a specialist and treatment are under-utilized in this population. Methods: This was a prospective observational study. 100 patients with MS, but currently not seeing a genitourinary specialist were enrolled from an MS comprehensive center with a Female Pelvic Medicine and Reconstructive Surgery (FPMRS) physician on staff. Patients completed demographic information, a short form of the ABSST and questions to assess barriers to seeking a specialist for bladder problems. An ABSST score >3 met criteria for referral and evaluation. In addition they were asked a single item question about their desire to be evaluated by a specialist for bladder problems. Two-month after enrollment, follow up calls assessed whether patients had seen a specialist to assess their urinary complaints. X² tests were used to compare categorical variables. Results: Of the 100 patients, there were 79 women and 21 men, mean age was 44.5 years and average time since diagnosis of MS was 10.4 years. Ethnicities included 45% Caucasian, 21% African American, 21% Hispanic, 2% Asian, and 11% Other/Multiracial. Overall, 40% of patients indicated that they would want to see a specialist to evaluate their bladder symptoms and 33% of patients had already seen one in the past. Most frequent reasons for seeking prior care were incontinence (46%) and recurrent UTIs (24%). Overall, the most common barriers to seeking care included "Doctor never referred" (18%), "Doctor never asked" (15%), "Had enough problems to deal with" (15%), "Thought there were no treatments available" (12.5%) and "Felt embarrassed" (10%). 40% of men stated "Doctor had never referred or asked" compared to 10% of women (p=0.002). 27 patients had an ABSST Score>3 and were more interested in seeing a specialist compared to those scoring <3 (91% vs. 40%; p= .000). When compared to patients with an ABSST<3, those with an ABSST>3 had a significant difference in level of education (p<0.05), type of mobility used (p<0.05), and employment status (p=0.005). Patients with an ABSST >3 cited limitations associated with insurance, cost, transportation, or inaccessibility more often than those with an ABSST <3 (9% vs. 3%, p=0.009). After 2 months, 49 patients were reached for follow up. Despite persistent or worsening urinary symptoms in some patients, only 1 participant had followed up. Conclusions: The ABSST is a valuable tool to identify MS patients with urinary symptoms and willingness to seek evaluation. Identification of this need alone unfortunately did not result in a significant increase in evaluation, despite ongoing symptoms. This underscores that other barriers, beyond awareness such as communication, costs and logistics, play a tremendous role preventing patients getting the evaluation that is needed. Further work is required to elucidate these factors

Objective: s To characterize a sample of patients with multiple sclerosis (MS) that would be recommended for evaluation by an expert in bladder dysfunction based on the Actionable Bladder Symptom and Screening Tool (ABSST), and to correlate the ABSST with several commonly used questionnaires including the Overactive Bladder Questionnaire (OABq), Patient Global Impression of Severity (PGI-S), International Consultation on Incontinence Questionnaire (ICIQ), and Medical Epidemiology and Social Aspects of Aging (MESA). Background: Although up to 80% of patients diagnosed with multiple sclerosis (MS) experience lower urinary tract symptoms, evaluation and treatments are significantly under accessed. The (ABSST) is a newly validated tool that can be used in patients with MS to screen for neurogenic overactive bladder symptoms (NDO). It is a simple 8-item questionnaire that aids in identifying patients that need a referral for evaluation. Methods: This was a prospective observational study. 100 patients diagnosed with MS, not currently seeing a bladder dysfunction specialist, were enrolled from an MS center. After obtaining consent, patients were asked to fill out a validated short form of the ABSST, the OABq short form, the PGI-S, the ICIQ and the MESA. An ABSST score >3 is considered a positive screening test and met criteria for referral to a specialist. OAB subscale scores grouped responses related to symptom bother and Quality of life (HRQL), which was further subdivided into HRQL-Coping, HRQL-Sleep, or HRQL-Emotions. A high score for the symptoms subscale indicated worse symptoms and a low score of the quality of life subscales indicated worse quality of life. The MESA scores grouped responses that characterized either urgency or stress incontinence. There were no subscales for PGIS or ICIQ. Mean questionnaire scores were compared between patients who screened positive or negative for the ABSST using one-way ANOVA and X2 tests. Results: Patient's mean age was 44.5 years and average time since diagnosis was 10.4 years. There were 79 women and 21 men. Ethnicities included 45% Caucasian, 21% African American, 21% Hispanic, 2% Asian, and 11% Other/Multiracial. 27 patients had an ABSST Score >3. When compared to patients with an ABSST<3, those with an ABSST>3 had a significant difference in level of education (p<0.05), level of mobility (p<0.05), and employment status (p=0.005). See figure 1. Patients with an ABSST>3 were more likely to have seen a doctor in the past for bladder problems (52% vs. 27%; p=0.019), more frequently for urinary incontinence (19%) and urinary tract infections (13%). They were also more likely to be using medications for bladder symptoms (23% vs. 4%; p=0.004) or to have used them in the past (42% vs. 15%; p=0.004). Patients with a positive ABSST had a significant difference in the mean scores of the following subscales: OABq Symptoms (57.4 vs. 15.0; p=0.000); OAB-Total HRQL (50.4 vs. 89.9;p=0.000); OABHRQL Cope (43.4 vs. 89.4;p=0.000); OAB-HRQL Sleep (42.5 vs. 84.2; p=0.000); OAB-HRQL Emotion (62.1 vs. 93.7; p=0.000); MESA-Urgency Incontinence (40.4 vs. 12.3; p=0.000); MESA-Stress Incontinence (33.8 vs.15.0; p=0.000); and ICIQ-SF (8.2 vs. 2.3; p=0.000). There was a significant correlation between PGIS Score and a positive ABSST (p=0.000). Conclusions: The differences observed in MS patients who score positive on the ABSST may represent the progressive nature of some cases of MS and its association with NDO. A positive screening response correlates and captures the severity of symptoms, impact on quality of life and classifications of both urinary incontinence across several overactive bladder and urinary incontinence questionnaires. These findings highlight the importance of continued screening in MS patients for NDO, even when patients have been evaluated or treated in the past. This need makes the ABSST a valuable simple tool for providers to efficiently identify and refer MS patients for further evaluation and treatment. (Figure presented)