The Effect of Symptomatic Stress Urinary Incontinence on Catheterization Rates After Intradetrusor OnabotulinumtoxinA Injections
OBJECTIVES/OBJECTIVE:To determine whether catheterization rates after intradetrusor onabotulinumtoxinA injection for nonneurogenic overactive bladder and urgency incontinence differ between women with urgency urinary incontinence only and women with urgency-predominant mixed urinary incontinence. METHODS:This was a retrospective cohort study of patients that underwent intradetrusor onabotulinumtoxinA injection of 100 U for nonneurogenic urgency urinary incontinence. The primary outcome was the difference in catheterization rates between women with urgency urinary incontinence alone compared with women with urgency-predominant mixed urinary incontinence. Descriptive statistics and multivariate logistic regression analysis were performed. RESULTS:Of the 177 women included in the final analysis, 105 had urgency urinary incontinence and 72 had urgency-predominant mixed urinary incontinence. The overall catheterization rate after onabotulinumtoxinA injection was 11.3%, with significantly fewer women with mixed urinary incontinence requiring catheterization when compared with women with urgency urinary incontinence alone (4.2% vs 16.2%; P = 0.03), despite an older population (P = 0.02). Patient-reported improvement (P = 0.37) and decision to continue onabotulinumtoxinA treatments (P = 0.89) were similar between groups. Multivariate logistic regression analysis revealed that women with mixed urinary incontinence had significantly lower odds of requiring catheterization after onabotulinumtoxinA injections than women with urgency urinary incontinence alone (odds ratio, 0.16; 95% confidence interval, 0.04-0.67; P = 0.01). CONCLUSIONS:Findings suggest that the presence of symptomatic stress urinary incontinence is associated with lower rates of catheterization after intradetrusor onabotulinumtoxinA, but does not compromise efficacy of treatment for urgency-predominant mixed urinary incontinence.
Estimation of urinary frequency: does question phrasing matter?
PURPOSE/OBJECTIVE:To evaluate if question phrasing and patient numeracy impact estimation of urinary frequency. MATERIALS AND METHODS/METHODS:We conducted a prospective study looking at reliability of a patient interview in assessing urinary frequency. Prior to completing a voiding diary, patients estimated daytime and nighttime frequency in 3 ways: 1) how many times they urinated 2) how many hours they waited in between urinations 3) how many times they urinated over the course of 4 hours. Numeracy was assessed using the Lipkus Numeracy Scale. RESULTS:Seventy-one patients completed the study. Correlation of estimates from questions 1, 2 and 3 to the diary were not statistically different. Prediction of nighttime frequency was better than daytime for all questions (correlation coefficients 0.751, 0.754 and 0.670 vs 0.596, 0.575, and 0.460). When compared to the diary, Question 1 underestimated (8.5 vs 9.7, p=0.014) while Question 2 overestimated (11.8 vs 9.7, p=0.027) recorded voids on a diary. All questions overpredicted nighttime frequency with 2.6, 2.9 and 3.9 predicted vs 1.6 recorded voids (p <0.001). Although not statistically significant, for each question, the predicted frequency of numerate patients was more correlated to the diary than those of innumerate patients. CONCLUSIONS:When compared to a voiding diary for daytime urinary frequency, asking patients how many times they urinated underestimated, and asking patients how many hours they waited between urinations overestimated the number recorded voids. Regardless of phrasing, patients overestimated nighttime urination. Patients in our functional urology population have limited numeracy, which may impact accuracy of urinary frequency estimation.
Vaginal Estrogen-What a Urologist Should Know
The implications of estrogen depletion on the lower urinary tract and vagina are relevant to the urologist treating women with genitourinary symptoms. The main symptoms of vaginal estrogen depletion that affect women are dyspareunia and vaginal dryness, recurrent UTIs and lower urinary tract symptoms. Vaginal estrogen can be used to effectively treat these conditions. Vaginal estrogen is available in a variety of formulations. Each formulation has different considerations regarding its use and patients should be actively involved in choosing the right product for them. Contrary to concerns over the risks of oral estrogen, vaginal estrogen has a low risk profile. In terms of contra-indications for use, there are relatively few absolute contraindications for vaginal estrogen. A thorough understanding of vaginal estrogen's safety, efficacy and correct use is essential to the urologist treating the post-menopausal female.
The impact of concomitant mid-urethral sling surgery on patients undergoing vaginal prolapse repair
INTRODUCTION AND HYPOTHESIS/OBJECTIVE:The aim of this study was to assess whether mid-urethral sling (MUS) placement at the time of vaginal prolapse repair compared to vaginal prolapse repair alone is associated with an increase in 30-day postoperative complications. METHODS:Using the American College of Surgeons National Surgical Quality Improvement Database, Current Procedural Terminology codes were used to identify cases of vaginal prolapse repair with and without concomitant MUS from 2012 to 2017. Student's t-test and chi-square test were used to compare differences between the groups. RESULTS:A total of 1469 cases of vaginal prolapse repair with sling were compared to 4566 cases without sling. There was no difference between prolapse repair with sling compared to without sling in mean hospital length of stay (LOS) (1.42 versus 1.32Â days, pÂ =â€‰0.65), postoperative urinary tract infection (UTI) (6.1% versus 5.8%, pÂ =â€‰0.670), perioperative blood transfusion (1.1% versus 1.2%, pÂ =â€‰0.673), readmission (2.7% versus 2.6%, pÂ =â€‰0.884) and postoperative wound infection (0.5% versus 0.7%, pÂ =â€‰0.51). There was a higher rate of reoperation (2.2% versus 1.5%, pÂ =â€‰0.049) and venous thromboembolism (VTE) (0.4% versus 0.1%, pÂ =â€‰0.030) in patients undergoing concomitant MUS compared to those undergoing prolapse repair alone. CONCLUSIONS:Compared to prolapse repair alone, the addition of a sling did not increase hospital LOS, UTI, perioperative blood transfusions, readmission or postoperative wound infections. However, concomitant sling was found to be associated with a higher risk of reoperation and VTE.
Persistence in percutaneous tibial nerve stimulation treatment for overactive bladder syndrome is best predicted by patient global impression of improvement rather than symptom-specific improvement
OBJECTIVES/OBJECTIVE:To evaluate whether progression to maintenance percutaneous tibial nerve stimulation (PTNS) was related to perceived global impression of improvement (PGII) rather than symptom-specific improvement in patient with overactive bladder (OAB). We hypothesize that PGII will predict continuation of PTNS long-term. METHODS:This prospective observational study included 90 patients with OAB that initiated PTNS. The PGII and overactive bladder short-form questionnaires (OABq-SF) were used to assess bladder symptom severity and improvement. Those that completed the 12-week induction phase were offered to continue PTNS monthly maintenance or pursue other options. The primary outcome was difference in PGII score between those pursuing maintenance therapy versus other options. Descriptive statistics and mixed effect modeling analysis were employed. RESULTS:Seventy patients (78%) completed 12 weeks of PTNS. The majority of completers pursued monthly maintenance (p<0.01) and had significantly lower median PGII scores compared with those who sought alternatives (p<0.01), while OABq-SF scores did not differ significantly (p=0.65). Patients that pursued monthly PTNS maintenance had lower body mass index than those who chose alternative therapies (p<0.01). Only 19% continued PTNS therapy for at least 1 year. CONCLUSIONS:More patients pursued PTNS monthly maintenance over any other therapy, and this was significantly associated with lower PGII scores. Global improvement, and not symptom-specific response, predicts long-term PTNS maintenance. No symptom-specific predictors were identified in those who pursued maintenance over other options. One-year continuation rates are low.
Impact of urodymamics on diagnosis and treatment plans for the overactive bladder patient [Meeting Abstract]
Introduction: Urodynamics (UDS) is the study of urine transport, storage, and evacuation and is the gold standard in assessment of bladder function. Per AUA guidelines, UDS are not to be used in the initial workup of the uncomplicated patient with OAB, however their role in more complex patients remains uncertain. The primary aim of this study is to assess the impact of UDS on diagnosis and treatment plans of complex patients with OAB.
Method(s): Patients undergoing workup for OAB between 2016 and 2018 were prospectively enrolled and completed a voiding diary and UDS. Physicians first provided a diagnosis and treatment plan based on patient history, clinical data and voiding diary alone. The patients then underwent UDS and the physician provided a diagnosis and treatment plan after reviewing the additional testing. The impact of UDS on diagnosis and treatment plan were analyzed.
Result(s): 26 patients underwent evaluation with voiding diary and UDS with prospective documentation of diagnosis and treatment plan. All patients had previously trialed oral OAB medications10 (38.4%), complained of mixed incontinence 11 (42.3%), or were considering third line therapy 14 (53.8%). After UDS were performed, 13 (50%) had a modification in diagnosis and 11 (42.3%) had a change in treatment plan. The most common change in diagnosis was observation of voiding phase dysfunction in 4 (15.4%). Treatment plans changed for 6 patients with mixed incontinence primarily by elucidating severity of stress vs urgency incontinence when it was difficult to determine from patient report and available clinical data. Plans also changed for 1 patient found to have underactive bladder and 2 with bladder outlet obstruction. 9 (34.6%) patients went on to third line therapy.
Conclusion(s): UDS done for patients with complex OAB symptoms led to modification in patient diagnosis in 50% of patients and change in treatment plan in 42.3%. Change to diagnosis and management plan may reflect the utility of UDS especially in complicated patients (ie mixed incontinence) or who have failed second line therapies
Barriers to completion of voiding diary in patient with overactive bladder [Meeting Abstract]
Introduction: Overactive bladder (OAB) affects 10-19% of adults, strongly influencing quality of life. Voiding diaries may provide valuable information on the OAB patient, identifying modifiable behavior factors and the timing and severity of symptoms that can help guide treatment. The primary aim of this prospective cohort study is to report the percent of patients completing a diary, and secondary aim is to assess what factors may predict completion.
Method(s): 93 patients undergoing workup for OAB between 2016 and 2020 were enrolled and asked to complete a three-day voiding diary. They were provided standard written and oral instructions, in addition to urine collection device and a printed diary template. Completed voiding diary, OAB-q questionnaire, and demographic factors were collected and analyzed.
Result(s): Of the 93 patients enrolled, 61 (65.6%) completed at least one day of a voiding diary. Two of these patients (3.3%) returned diaries that could not be interpreted. There was no difference in OAB-q score for those completing diary and those who did not (76.7 vs 79, p=0.86). In addition, no significant differences were seen in age, BMI, ethnicity, gender or prior surgeries between those who did and did not complete the diary.
Conclusion(s): Voiding diaries are used in the workup of OAB to quantify symptoms and determine their cause. We found a completion rate of 65.6% among patients with bothersome OAB. No demographic differences were observed between those who did and did not complete a diary. Further study of barriers to completion could aid in higher capture rates and improved diagnostic evaluation of the OAB patient
The effect of stress urinary incontinence on catheterization rates following intradetrusor onabotulinumtoxina for urgency urinary incontinence
Introduction: The objective of this study was to determine whether patient-reported stress urinary incontinence (SUI) at the time of intradetrusor onabotulinumtoxinA injection (ONA) for urgency urinary incontinence (UUI) had an effect on catheterization rates.
Method(s): This was a retrospective chart review conducted between 1/2010 and 12/2019. Female subjects with either UUI or urgency-predominant mixed urinary incontinence (MUI) were identified for intradetrusor injection of ONA 100 Units. Charts were reviewed for demographic information, past medical and surgical history, the presence of SUI symptoms, post void residual (PVR) before and after ONA injection, need for catheterization (CIC), and subjective response to ONA. Subjects with a diagnosis of neurogenic bladder or baseline catheterization requirement were excluded. CIC was at the discretion of the clinician and was typically recommended if PVR>350mL or <350mL with symptoms of incomplete emptying. Primary outcome was difference in CIC rates between those with MUI and those with UUI at time of ONA. Demographics and outcomes were analyzed using descriptive statistics after assessing for normality. Two-tailed p-values <0.05 were considered to be statistically significant.
Result(s): A total of 177 females were included, of which 72 reported MUI symptoms at the time of ONA and 105 did not (UUI only). Women with MUI were significantly older (74.5 years [67,80] vs 69 years [61.5,78.5], p=0.02) and demonstrated lower pre-ONA PVRs (12.5ml [0,33.75] vs 24ml [0,55], p=0.04) compared to women with UUI only. There was no difference in other demographic characteristics, including proportion of women with prior anti-incontinence procedures (p=0.2) between groups. Following ONA, overall CIC rates were 11.3%. Women with MUI had significantly lower rates of CIC (4.2% vs 16.2%, p=0.015) and lower post-ONA PVRs (49 ml [16.25,129.5] vs 107ml [48.5,199.5], p=0.002) than women with UUI only. Combined subjective improvement or cure rates of UUI symptoms between groups was not different (U
Venous thromboembolism prophylaxis in vaginal surgery for pelvic organ prolapse: Predictors of high risk in a low-risk population
AIM/OBJECTIVE:Venous thromboembolism (VTE) rates in vaginal pelvic organ prolapse (POP) repair are low. Our aim is to evaluate specific risk factors for VTE in patients undergoing vaginal POP repair. METHODS:Â tests for categorical variables. Multivariate logistic regression was performed to identify factors independently associated with VTE. RESULTS:Of 44â€‰207 women who underwent vaginal POP repair, there were 69 cases of VTE (0.16%). VTE rates for obliterative (0.15%) and functional (0.16%) vaginal POP repair, as well as for repairs with hysterectomy (0.17%) and without hysterectomy (0.12%) were not significantly different (pâ€‰=â€‰.616 andÂ .216, respectively). Multivariate analysis demonstrated predictors for postoperative VTE to be ASA physical status classificationâ€‰â‰¥â€‰3 (aOR, 1.99; pâ€‰=â€‰.014), length of stay >75th percentile (aOR, 2.01; pâ€‰=â€‰.007), operative time >3â€‰hÂ (aOR, 2.24; pâ€‰=â€‰.007), and dyspnea (aOR, 3.26, pâ€‰=â€‰.004). CONCLUSION/CONCLUSIONS:Despite the low incidence of VTE after vaginal POP repair, patients with ASA physical status classificationâ€‰â‰¥â€‰3, length of stayÂ >75th percentile, operative timeÂ >3â€‰h, and dyspnea were at higher risk for VTE. Vaginal POP repair may have independent VTE risk factors not captured in standard risk assessment tools.
Gel-Infused Translabial Ultrasound in the Evaluation of Female Urethral Stricture
OBJECTIVES/OBJECTIVE:The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques. METHODS:Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison. RESULTS:Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis. CONCLUSIONS:Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.