Faculty Bibliography

Introduction: The potential need for clean intermittent catheterization (CIC) is known to increase in overactive bladder (OAB) patients after onabotulinumtoxinA treatment. We determined the risk of CIC and assessed the efficacy and quality of life (QoL) outcomes after treatment with onabotulinumtoxinA in different age groups by performing a post-hoc analysis of a large cohort of OAB patients. Methods: Data from two onabotulinumtoxinA randomized, placebo-controlled, phase 3 trials and a post-marketing study were pooled for analysis (N=1177). Patients treated with onabotulinumtoxinA 100U in treatment 1 and placebo patients who received open-label onabotulinumtoxinA in treatment 2 were grouped by age: <40 (n=90), 40-49 (n=156), 50-59 (n=263), 60-69 (n=343), and >=70 (n=325) years. Assessments at week 12 after treatment were: incidence and duration of CIC, mean and percent change from baseline in urinary incontinence (UI) episodes/day, proportions of patients with >=50% UI reduction, a positive response (urinary symptoms 'improved'/'greatly improved') on the treatment benefit scale (TBS), and change from baseline in Kings Health Questionnaire (KHQ) domains of social limitations and role limitations. Adverse events (AEs) were assessed. Results: CIC rates after onabotulinumtoxinA treatment were lowest in the <40 group (1.1%) and increased slightly with age (3.2%, 5.3%, 5.3%, and 7.2% in the 40-49, 50-59, 60-69, and >=70 groups, respectively). Mean CIC duration was three and 44 days in the <40 and 40-49 groups, respectively, and ranged from 78-88 days in the other groups. Mean UI episodes/day at baseline were 3.9, 4.8, 5.2, 5.7, and 6.0 in the <40, 40-49, 50-59, 60-69, and >=70 groups, respectively. A robust treatment response was noted in all groups, including substantial reductions in UI episodes/day (-2.4, -2.6, -3.1, -3.6, and -2.9) and percent change in UI (-60.8%, -50.4%, -62.4%, -64.4%, and -46.8%). High proportions of patients in all groups achieved >=50% UI reduction (range 58.2-71.1%) and had a positive TBS response (range 66.2-73.8%). Improvements from baseline in KHQ domain scores were approximately 3-6 times the minimally important difference. Urinary tract infection was the most common AE in all groups. Conclusions: In this large cohort of onabotulinumtoxinA-treated OAB patients, CIC risk increased slightly with age, but was low in all age groups and accompanied by substantial reductions in UI episodes/day, improvements in QoL, and treatment benefit. The <40 group had the lowest rate of CIC (1.1%), with a duration of three days. OnabotulinumtoxinA was well-tolerated in all age groups

Gynecologic and urologic etiologies are the sources of pelvic pain for many individuals. This article aims to provide a comprehensive review of the various genitourinary sources of pelvic pain. It is important to recognize that although these disorders predominantly affect women, there are various conditions that affect both men and women, and these should be considered in the differential diagnosis of patients presenting with pelvic pain. Providers who encounter patients with pelvic pain should attempt to localize these symptoms and obtain a comprehensive history from the patient to help direct diagnostic evaluation.

Parkinson's disease (PD) and atypical Parkinsonism are the second most common neurodegenerative movement disorders. Lower urinary tract dysfunction is among the most common types of associated autonomic dysfunctions. Differentiating the subtypes of PD is important for symptom management and understanding prognosis, because Lower urinary tract symptoms (LUTS) can evolve differently depending on the primary disease. LUTS are caused by storage and/or voiding dysfunctions. Urodynamics is a key investigative tool. The complex pathophysiology of this bladder dysfunction is not responsive to levodopa, and add-on therapy is necessary. Newer interventions hold promise as therapy to improve bladder dysfunction.

AIM: The Actionable Bladder Symptom and Screening Tool (ABSST) is used to identify multiple sclerosis (MS) patients in possible need of evaluation for urinary symptoms. The primary objective of this study was to identify barriers experienced by MS patients in seeking evaluation for urinary symptoms. We also assessed the utility of ABSST tool in identifying patients that will follow up with urologic evaluation. METHODS: This was a prospective observational study where 100 patients with MS were enrolled from an MS center. Patients completed demographic information, questions to assess barriers to care, a short form of the ABSST, and incontinence questionnaires. An ABSST score >3 met criteria for referral and evaluation. One year after enrollment, follow up calls assessed whether patients had seen a urinary specialist. RESULTS: The most common barriers to seeking care included "Doctor never referred" (16%) and "Doctor never asked" (13%). Thirty-eight percent (n = 8/21) of men stated "Doctor never referred" compared to 10% (n = 8/79) of women (P = 0.002). Twenty-seven patients had an ABSST Score >/=3 and were more interested in seeing a specialist compared to those scoring <3 (88.9%, n = 24/27 vs. 26%, n = 19/73; P = <0.001). After 1 year, 70 patients were reached for follow up. A total of 57.9% (n = 11/19) patients who followed up for evaluation screened positive on the ABSST. CONCLUSIONS: The ABSST is a valuable tool to identify MS patients with urinary symptoms who will likely follow up for genitourinary evaluation. However, other barriers beyond awareness exist and prevent patients from being evaluated.

PURPOSE: There is controversy regarding performing concomitant anti-incontinence procedures at the time of pelvic organ prolapse (POP) repair. Data supports improvement in stress urinary incontinence (SUI) with concomitant sling, but increased adverse events. We assessed trends in preoperative SUI evaluation, concomitant anti-incontinence procedure at POP surgery, and post-operative anti-incontinence procedures at our institution before and after the 2011 FDA Public Health Notification pertaining to vaginal mesh. MATERIALS AND METHODS: A retrospective review was performed on patients who underwent POP surgery from 2009-2015. Preoperative workup included assessment of subjective SUI and/or evaluation for leakage with reduction of POP on physical exam, urodynamics or pessary trial. Percentage of concomitant and post-operative anti-incontinence procedures were compared before and after the 2011 FDA notification. RESULTS: 775 women underwent POP repair. The percentage of anti-incontinence procedures at POP repair decreased from 54.8% to 38.0% after the FDA notification (p = 0.002) while the incidence of pre-operative objective SUI on exam, urodynamics and pessary trials remained constant. The incidence of post-operative anti-incontinence procedures within one year of the index surgery remained low. CONCLUSIONS: We found a decrease in incidence of concomitant anti-incontinence procedures at the time of POP repair following the 2011 FDA notification despite no significant decline in subjective SUI or demonstrable SUI on preoperative evaluation. Further analysis is warranted to assess the impact of the FDA notification on management patterns of women with POP and SUI.

AIMS: Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient. METHODS: Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system. RESULTS: All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification. CONCLUSIONS: These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.