Validation of the Overactive Bladder Symptom Score

PURPOSE

We validated a new 7-item overactive bladder symptom score.

MATERIALS AND METHODS

Normal subjects and consecutive patients with lower urinary tract symptoms with or without overactive bladder were recruited and classified into 3 groups based on their response to the question on an intake questionnaire, "Do you ever experience a sudden urge to urinate that makes you want to stop what you are doing and rush to a bathroom?" Subjects completed the written questionnaire in privacy on 2 occasions.

RESULTS

There were 84 subjects, including 33 men and 51 women, with a median age of 62 years (range 18 to 88). Of the subjects 33 (39%) had overactive bladder, 30 (36%) had lower urinary tract symptoms without overactive bladder and 21 (25%) were normal. There was a high level of internal consistency at visits 1 and 2 (Cronbach's alpha = 0.83 and 0.80, respectively, p <0.001). For test-retest reliability Spearman's rank order correlation coefficients for the items were r = 0.72 to 0.79 (p <0.001). A strong correlation was also observed between the total 7-item scores at visits 1 and 2 for each diagnostic subgroup, and for all participants (r = 0.86, p <0.001). Discriminant validity was established by determining significant differences in responses among the 3 subgroups at each administration (p <0.01).

CONCLUSIONS

The overactive bladder symptom score is a valid instrument that assesses all aspects of overactive bladder. It may be used as a symptom score.

Do women with female ejaculation have detrusor overactivity?

INTRODUCTION

Questionnaire surveys suggest that 40-54% of women have experienced an expulsion of fluid at orgasm. Some of these women have coital incontinence, whereas others identify the fluid passed as female ejaculate.

AIM

To assess whether women who have experienced female ejaculation have detrusor overactivity or the bothersome lower urinary tract symptoms associated with coital incontinence.

METHODS

We recruited six women who self-identified as having experienced female ejaculation and six controls who had not. Each woman completed a 3-day bladder diary and two validated bladder questionnaires: the Urgency Perception Scale (UPS) and the Incontinence Impact Questionnaire (IIQ). Each woman underwent short provocative ambulatory urodynamics, a modified form of urodynamics, with a high sensitivity for detrusor overactivity.

MAIN OUTCOME MEASURES

Prevalence of detrusor overactivity, 24-hour urinary frequency, IIQ and UPS scores.

RESULTS

No woman in either group had detrusor overactivity. The bladder diaries and questionnaire results were within the normal range for all women.

CONCLUSION

Women who experience female ejaculation may have normal voiding patterns, no bothersome incontinence symptoms, and no demonstrable detrusor overactivity. Women who report female ejaculation, in the absence of other lower urinary tract symptoms, do not require further investigation, and may be reassured that it is an uncommon, but physiological, phenomenon.

A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse

OBJECTIVE

The objective of this study was to evaluate the impact of transvaginal prolapse surgery on overactive bladder symptoms in elderly women.

STUDY DESIGN

Women (> or = 65 years old) with stage III or IV prolapse who enrolled in a prospective study that compared vaginal reconstructive surgery (n = 39) to obliterative surgery (n = 26) and who underwent preoperative urodynamics are the subjects of this study. The women completed the Pelvic Floor Distress Inventory at baseline and again 6 months and 12 months after surgery. Postoperative changes in symptoms of urinary urgency, frequency, and urge urinary incontinence were assessed. The association between a baseline urodynamic diagnosis of detrusor overactivity and pre- and postoperative overactive bladder symptoms was also determined.

RESULTS

Data were analyzed from 65 subjects with a mean age of 75.3 years (range, 65.5-87.0 years). Detrusor overactivity was documented in 25% of subjects. There was no difference in the proportion of baseline urge incontinence (P = .38), urinary frequency (P = .53), or urgency (P = .76) in comparing women with and without detrusor overactivity. Surgery resulted in a significant reduction of urgency and frequency symptoms 6 months after surgery and a similar significant reduction in urgency and urge incontinence at 1 year after surgery. Overall, a clinically and statistically significant improvement in the irritative subscale of the Pelvic Floor Distress Inventory was noted at 6 months (18.3%; P < .0001) and 12 months (17.6%; P < .0001) after surgery. In our cohort, performance of a mid urethral sling, a bladder neck sling, or a Kelly plication was not associated with a reduction in postoperative symptoms of urgency, frequency, or urge incontinence (P = .48). Likewise, there was no difference in postoperative symptom reduction (urgency, frequency, or urge incontinence) between women who received reconstructive surgery vs women who had obliterative surgery (P = .84).

CONCLUSION

Vaginal surgery for stage III or IV pelvic organ prolapse significantly reduces overactive bladder symptoms in elderly women. In our cohort, symptom reduction was unrelated to the type of vaginal surgery (obliterative vs reconstructive) or the inclusion of a procedure to treat stress incontinence. Furthermore, preoperative urodynamic findings did not correlate with the presence or absence of overactive bladder symptoms.

Urethral Sphincter EMG as Event Detector for Neurogenic Detrusor Overactivity

The aim of this study was to investigate the feasibility of using external urethral sphincter electromyogram (EMG) (EUSEMG) to detect the onset of detrusor contractions in patients with both neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia (DSD). Detrusor pressure (Pdet) and EUSEMG was recorded in 23 neurogenic patients during slow artificial bladder filling. The time delay between the onset of a detrusor contraction and the onset of EUSEMG activity was calculated together with the detrusor pressure increase related to this delay. Of 23 patients enrolled, 12 patients showed both NDO and DSD. Of these 12 patients, 10 had a strong correlation between detrusor pressure and EUSEMG. One patient in this group was excluded due to a storage pressure above 30 cm H2O. Two detection methods were applied on the remaining 9 patients. Method 1 was a root mean square (RMS)-integrator with simple thresholding. This approach had a good sensitivity but also a poor specificity (many false-positive detections). Detection method 2 included a kurtosis-based scaling function, which was multiplied to a similar RMS-integrator as used in method 1. Onset detection occurred before Pdet exceeded 18 cm H2O with both methods. However, method 1 resulted in 14.1 +/- 12.8 false-positive detections during one bladder filling. Pdet at onset detection was on average 1.0 +/- 1.1 cmH2 0 higher with detection method 2 but the number of false-positives was reduced by 95.8%. This paper demonstrates the feasibility of using EUSEMG to estimate the onset of a detrusor contraction in selected patients.

[Diagnostic and treatment of overactive bladder]

The overactive bladder (OAB) is characterized by symptoms of frequency, urgency, nocturia, and urge incontinence, substantially affecting the quality of life of millions of people throughout the world. Diagnosis of OAB made on patient history, physical examination, and clinical tests can be used as the basis for treatment in most cases. In cases where there is uncertainty regarding the diagnosis, urodynamic assessment should be carried out. Treatment of OAB includes behavioral therapy, pharmacology and, in some cases, surgery. This article reviews current findings regarding diagnostics and treatment of the overactive bladder.

Bladder diary measurements in asymptomatic females: functional bladder capacity, frequency, and 24-hr volume

AIMS

To study the effects of age and 24-h volume (V(24)) on bladder diary measurements of voiding frequency (F(24)) and functional bladder capacity (FBC) from an asymptomatic female population. Also, to use these data to develop clinical reference values. (We use FBC as a generic term for bladder diary volume-per-void measurements.)

MATERIALS AND METHODS

Computer-processed 3-day bladder diaries were collected from 161 females (median age: 46.6 years; range = 19.6-81.8 years) claiming no urological symptoms, previous pelvic surgery and diseases and medications effecting urologic function. Regression analysis was used to investigate relationships among age, FBC and V(24).

RESULTS

Both FBC and F(24) increase as V(24) increases (P < 0.0005). With aging, F(24) increases (P = 0.026) and FBC may decrease slightly (P = 0.02-0.08). There is a concave downward, curvilinear relationship between age and V(24). We used multiple regression to generate tables of FBC and F(24) "normal limits" adjusted for these simultaneous influences of V(24) and age. Removing their relationships to age reduces the variability of FBC and F(24) reference values by 50% and 20%, respectively.

CONCLUSIONS

Our finding, supported by others, that, with increasing V(24), FBC increases more than F(24) suggests an adaptive mechanism that adjusts FBC to urine production to minimize changes in voiding frequency. We illustrate adjustment of reference values for age and V(24) by calculating traditional clinical "normal limits." However, the probable large overlap between "normal" and "abnormal" suggests that it may be more useful to report bladder diary measurements as reference population percentiles rather than to designate them "normal" or "abnormal".

Overactive bladder treatments in early phase clinical trials

'Overactive bladder' (OAB) is a syndrome that is characterised by symptoms of urgency, with or without urge urinary incontinence, usually with frequency and nocturia [1] . It is a highly prevalent condition affecting 17% of the general population, with a significant negative effect on quality of life, impairing several areas with physical, social, emotional and sexual limitations. The prevalence of OAB increases with age in both men and women [2,3] . The pathophysiology is multifactorial and not yet fully understood. Non-surgical treatment is the mainstay of therapy for OAB. The available options include biofeedback, electrical stimulation, bladder training, pharmacotherapy or a combination of these options. Nevertheless pharmacotherapy is still the treatment of choice for OAB symptoms [4] . The pharmacological treatment of OAB is generally directed towards the central or the peripheral neural control pathways or the detrusor muscle [5] . The antimuscarinic drugs are the most commonly used. In the US, approved antimuscarinics include oxybutynin, tolterodine, trospium chloride, solifenacin and darifenacin. Although this class of drugs has been shown to be more effective than placebo in specific meta-analyses [6] , it has been reported that < or = 80% of the patients discontinue the treatment within 6 months, mainly for the low drug compliance due to the high incidence of side effects [7] . Therefore, there is a strong need to identify drugs with novel mechanisms of action, which could provide equal or even better efficacy and overall greater acceptability than antimuscarinic drugs. At present, several other specific molecular targets identified within detrusor muscle and/or neural systems are under investigation for the development of more specific treatments of OAB. This article provides an up-to date review of drugs that are in investigational preclinical and early stage (Phase I and II) clinical trials for the treatment of OAB.

Age related pathogenesis of nocturia in patients with overactive bladder

PURPOSE

Nocturia is caused by increased nocturnal urine output (nocturnal polyuria) and/or diminished nocturnal bladder capacity. We retrospectively evaluated the causes of nocturia in patients with overactive bladder and nocturia.

MATERIALS AND METHODS

A total of 850 patients (18 years or older) with symptoms of overactive bladder (8 or more micturitions per 24 hours and urgency or urgency urinary incontinence) and nocturia (mean of 2.5 or more episodes per night) were enrolled in a 12-week study of tolterodine ER (4 mg QD) vs placebo. Of this total 845 patients (417 men and 428 women) completed 7-day bladder diaries. Patients were stratified post hoc by sex and age groups (less than 50, 50 to 70, more than 70 years). Indices of nocturnal urine production (nocturia index, nocturnal polyuria index and nocturnal bladder capacity index) were compared using ANOVA (alpha level 0.05). Higher nocturia index and nocturnal polyuria index values suggest that nocturia occurs because of nocturnal urine overproduction. Higher nocturnal bladder capacity index values suggest that nocturia occurs because of decreased nocturnal bladder capacity.

RESULTS

There were no statistically significant gender or age related differences in baseline nocturnal micturitions. Nocturia index increased significantly with age (p <0.0001), and values were significantly higher among men than women for all age groups (p = 0.0064). Nocturnal polyuria index increased significantly with age (p <0.0001) and there were no gender differences. For nocturnal bladder capacity index there was a significant decrease with advancing age among men (1.75 greater than 1.16 greater than 0.90) and women (1.53 greater than 1.42 greater than 1.08, P(interaction) = 0.0148).

CONCLUSIONS

In younger patients with overactive bladder, decreased nocturnal bladder capacity has a greater role in the pathogenesis of nocturia symptoms, whereas in older patients increased nocturnal urine output has a greater role.

[Overactive bladder--definition, epidemiology, pathogenesis]

The overactive bladder is characterized by the following symptoms: frequency, urgency, nocturia and urge incontinence, substantially affecting the quality of life of millions of people throughout the world, with recent findings estimating the prevalence in adults at about 16.4%. The symptoms are associated with significant social, psychological, occupational, domestic, physical, and sexual problems. This article reviews current findings regarding definition, epidemiology, and pathogenesis of the overactive bladder.

Male overactive bladder: The role of urodynamics and anticholinergics

Millions of men suffer from overactive bladder and lower urinary tract symptoms. The adverse effects on quality of life and costs associated with the condition have been well described. In men, the pathophysiology of lower urinary tract symptoms may be from a number of causes including bladder outlet obstruction, detrusor overactivity, or both. Increasing data and clinical experience support the efficacy and safety of anticholinergics in men; the rate of urinary retention has been equal to that of placebo in short-term studies. Urodynamics play a vital role in defining the bladder and/or outlet dysfunction and help direct one's therapy.

Successful treatment with botulinum toxin A after failed augmentation ileocystoplasty

BACKGROUND

A 49-year old man initially underwent clam ileocystoplasty 14 years ago. A revision of this original procedure was required 11 years ago for intractable detrusor overactivity secondary to transverse myelitis; he experienced only temporary symptomatic improvement that lasted 6 months after each procedure. Despite the use of oral anticholinergic drugs, the patient subsequently needed to perform clean intermittent self-catheterization approximately 10 times every 24 h, and when he presented to our department, he still suffered from occasional episodes of urgency incontinence that required the regular use of a penile sheath.

INVESTIGATIONS

Symptom severity was assessed using a 4-day bladder diary.

DIAGNOSIS

Cystometry confirmed the presence of terminal detrusor overactivity.

MANAGEMENT

After the patient provided his informed consent, he was treated as an outpatient with intradetrusor injections of botulinum toxin A, delivered under local anesthesia by a minimally invasive technique that used a flexible cystoscope. A significant improvement was noted in the patient's lower urinary tract symptoms, urodynamic parameters and quality of life, measured at 4 and 16 weeks after treatment. The patient was completely dry at both follow-up visits and was able to discontinue the use of anticholinergic drugs and the penile sheath for a total of 11 months.

Overactive bladder: recognition requires vigilance for symptoms

Overactive bladder (OAB) is a prevalent condition in both men and women that imposes significant burdens on the patient and his or her quality of life. Nevertheless, only a small percentage of patients with OAB receive diagnosis and treatment. The identification of OAB is well within the scope of the primary care provider, as it is symptom-based and does not generally require specialized testing. The treatment of OAB relies on behavioral modification and/or pharmacologic options, primarily antimuscarinic therapy. Better identification of OAB symptoms in the primary care setting should reduce the number of patients suffering from untreated OAB.

The value of cystoscopy and bladder biopsy taken at the time of tension-free vaginal tape insertion

The primary aim of this study was to determine if a cystoscopy performed at the time of a tension-free vaginal tape (TVT) insertion is useful in finding unexpected pathology. A secondary outcome measure was to assess whether a bladder biopsy and cystoscopy performed during the TVT operation provide useful information about the outcome of surgery. The findings in 100 consecutive women were reviewed. A total of 42 women demonstrated mixed detrusor overactivity (DO) and urodynamic stress incontinence (USI); 32 women had abnormal biopsies. Women with DO were no more likely to have abnormal bladder biopsies than women without DO (p > 0.05). An abnormal bladder biopsy or cystoscopy failed to predict postoperative irritable symptoms (p > 0.05). The presence of preoperative DO correctly predicted postoperative irritable symptoms (p < 0.01). Cystoscopic abnormalities were noted in 14 women including one carcinoma, and one case of dysplasia was discovered on biopsy. In five women, the cystoscopy showed a bladder perforation. Cystoscopy should be performed in all women undergoing continence procedures.

[Validation of the Spanish version of the "Bladder control Self-Assessment Questionnarie" (B-SAQ). A new screening instrument for lower urinary tract dysfunction]

BACKGROUND

Taking into account the high prevalence in our country of Overactive Bladder Syndrome (OAB) ("urgency", with or without incontinence, sometimes associated to an increase in frequency and/or nocturia) and the difficulty to identify it, it would be interesting to have a short patient self assessment screening questionnarie for the evaluation of lower urinary tract symptoms. The objective of the study is to evaluate the psychometric properties of the Spanish version of the Bladder control Self-Assessment Questionnaire (B-SAQ).

PATIENTS AND METHODS

133 women consulting due to lower urinary tract symptoms in a health care centre specialised on uroginecology. The subjects filled the B-SAQ (scales "symptoms" and "discomfort") and the ICIQ-UI SF, and underwent the usual protocol: uroginecologic history, pelvic examination and urodynamic study. Feasibility, validity, and reliability of the B-SAQ were assessed, as well as the ROC curve for the scores of both BCSEQ scales regarding the urodynamic diagnosis of Detrusor Overactivity (DO).

RESULTS

Feasibility: Average administration time, 3.5 (1.5) minutes: 2 women did not answer any of the questionnaires.

VALIDITY

the scores for "symptoms" and "discomfort" were higher in those women with a DO diagnosis: "symptoms" = 7.8 (2.6) vs 6.2 (2.3) (p=0.0002); "discomfort" = 9.1 (3) vs 7.8 (3.6) (p=0.03); the Spearman's correlation coefficient between "discomfort" scale and item 3 of the ICIQ-UI SF (affection) was 0.65 (p<0.001). Feasibility: Cronbach's alpha for "symptoms" was 0.722 and 0,889 for "discomfort". According to the COR curve for both scales, a score greater than or equal to 6 showed adequate sensibility and specificity for the DO diagnosis.

CONCLUSIONS

The B-SAQ is an easy-use instrument which shows adequate feasibility, validity and reliability for its use in clinical practice as screening instrument for OAB.

Lower urinary tract symptoms and bladder control in advanced Parkinson's disease: effects of deep brain stimulation in the subthalamic nucleus

Deep brain stimulation in the subthalamic nucleus (STN) leads to significant improvement in motor function in patients with advanced Parkinson's disease (PD). In this prospective study including 16 patients with PD, we investigated (1) lower urinary tract symptoms (LUTS) by questionnaires International Prostate Symptom Score (IPSS, symptoms only) and Danish Prostate Symptom Score (DanPSS, symptoms and bother of symptoms) and (2) bladder control (assessed by urodynamics) before and after implantation of electrodes in the STN. PD symptoms (Unified Parkinson's Disease Rating Scale score) improved significantly (P < 0.0001), and symptoms of overactive bladder (IPSS) decreased along with the troublesome symptoms of overactive bladder (DanPSS; P < 0.01 for both). Urodynamic parameters before and after implantation of electrodes in the STN, evaluated with and without the stimulation on, did not change significantly.

“Urgency Tip”: A Portable Patient-Activated Device for Objective Measurement of Urinary Urgency

For clinical practice and research of overactive bladder syndrome, it is essential to evaluate urgency symptoms in daily life. We have developed a portable patient-activated device to record bladder sensations. This electronic device is pocket-size and light, with five grading buttons and another button for cancellation.

Diagnóstico y manejo de pacientes con síndrome de vejiga hiperactiva en las consultas de urología y atención primaria en España

OBJECTIVES

Despite its high prevalence and its important impact on patient's life, overactive bladder is a disorder poorly known and not usually tackled in daily clinical practice. The aim of this study is to know the main procedures and techniques used by both urologists and general practitioners to diagnose overactive bladder in usual clinical practice in Spain.

METHODS

A standardized questionnaire was administered to 748 physicians specialized in urology and to 696 primary core physicians or general practitioners. The questionnaire collected information about the management of patients who attended surgery with urinary symptoms suggesting overactive bladder.

RESULTS

A total of 64.8% of urologists argued they followed a standardized protocol in order to diagnose patients suffering from overactive bladder. Concerning primary care physicians, 58.4% of them admitted not referring patients with urinary symptoms suggesting overactive bladder to specialist. Up to 77.8% of urologists confirmed that referred patients from primary care had no previous exam or diagnosis. Health history, physical examination and urinalysis were the usual diagnosis procedures in clinical practice conditions for both specialities. Other instruments such as the micturition diary or the questionnaires to assess symptoms or patients' quality of life are still little used for the diagnosis and management of overactive bladder.

CONCLUSIONS

Although overactive bladder is a condition that causes a high impairment in the quality of life (QoL) and daily activities of those patients suffering from it, it still remains poorly tackled by doctors. Therefore, it is important to define strategies to detect its symptoms in the clinical practice.

Urgency assessment in the evaluation of overactive bladder (OAB)

Overactive bladder (OAB) is a highly prevalent urinary condition with a profound affect on quality of life. Urinary urgency is the cornerstone symptom that defines OAB and drives all subsequent OAB symptoms. The clinical assessment and measurement of urgency has been limited by its definition, limited understanding of well-defined pathophysiology, and psychometric measurement properties. This review outlines the important issues relevant to the clinical assessment and measurement scales commonly used to evaluate and measure urinary urgency. This will have important implications toward further understanding and advancing the field of overactive bladder.

Detrusor Underactivity: Clinical Features and Pathogenesis of an Underdiagnosed Geriatric Condition

Urinary incontinence and other lower urinary tract symptoms exert a major influence on the health and independence of frail older people. Detrusor underactivity (DU) is defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. DU may influence the clinical presentation and impede the therapy of disorders as common and as disparate as detrusor overactivity, urinary retention, and benign prostatic hyperplasia. Urodynamically, nearly two-thirds of incontinent nursing home residents exhibit DU. The clinical diagnosis of DU when present alone or in association with other bladder conditions such as detrusor overactivity (detrusor hyperactivity with impaired contractility (DHIC)) is challenging, because symptoms lack adequate precision. A catheterized and increasingly noninvasive ultrasound-based postvoid residual assessment allows a bedside diagnosis of retention and may suggest the presence of DU in individuals (mostly women) with a low likelihood of bladder outlet obstruction (BOO). Nevertheless, it cannot differentiate primary DU from retention secondary to BOO. The management of individuals with DHIC remains unsatisfactory, because antispasmodic anticholinergic medications may worsen retention, whereas bethanechol does not improve bladder emptying. Human detrusor biopsies reveal axonal degeneration, muscle loss, and fibrosis in DU. Animal studies suggest that multiple risk factors, including retention itself, lack of estrogen, infection, inflammation, and aging, may contribute to DU. Priority areas for future research include efforts to facilitate clinical nonurodynamic diagnosis of probable DU plus translational research designed to address the pathogenesis of this complex multifactorial geriatric syndrome.

[Lower urinary tract symptoms in women and impact on quality of life. Results of the application of the King's Health Questionnaire]

BACKGROUND

The self-assessment of quality of life (QoL) of women with urinary symptoms may help in selecting the best treatment in each case.

METHOD

Epidemiologic, observational, cross-sectional and multicentric study of 674 women who underwent to a gynecology unit with symptoms suggesting Overactive Bladder, with or without urinary incontinence (UI). All women fill out the King's Health Questionnaire. Sociodemographic data and a complete register of urinary symptoms and the degree of afectation which caused, were also collected.

RESULTS

Most frequent symptoms were "frequency" (612 women-90.8%), followed by "urgency" (562-83.4%), "nocturia" (543-80.6%) and "stres UI" (535-79.4%). Symptoms of "frecuency", "nocturia", "urgency" and "urgency UI" were more frequent in women aged 65 or under 65 years and that of "stress UI", in women over 65 years (79.8% vs 77.9%). 210 women did not fill out all the KHQ dimensions, mainly "Personal Limitations", "Personal Relationship", "Social limitations" and "Incontinence Impact". Global KHQ score was38.3 (SD=19.2). Higher scores (worse QoL) corresponded to "Incontinence Impact", "Severity Measures", "Personal Limitations" and "Role Limitations". Variables associated to global KHQ score were (multiple linear regression): age, BMI, urgency UI, UI in sexual intercourse, frequent urinary infections.

CONCLUSIONS

QoL impact in women with urinary symptoms is important. The symptoms with higher association with QoL are: UI in sexual intercourse, urgency UI and frequent urinary infections.

Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: a literature review

Urodynamic investigations have been advocated to be incorporated in the standard diagnostic workup of patients undergoing surgical correction of genital prolapse. Stress incontinence is reported by 40% of patients with genital prolapse. Urodynamic stress incontinence (USI) is diagnosed in 70-75% of these patients. Occult urodynamic stress incontinence (OUSI) is diagnosed in about 50% of the patients with genital prolapse not reporting stress incontinence before surgery. Performing urodynamic investigation in patients undergoing prolapse surgery may be valuable if diagnosing USI or OUSI results in the selection of the optimal treatment strategy. This treatment strategy is either a combination of prolapse and stress incontinence surgery or prolapse surgery at the beginning and re-evaluation of possible stress incontinence afterwards. The combination of prolapse and stress incontinence surgery has the advantage of attempting to solve two problems at the same moment, but carries an increased risk on unwanted side-effects, of which, voiding dysfunction and detrusor overactivity are the most important. This review presents a literature overview of what has been proven about the diagnostic and therapeutic value of urodynamic investigations in patients undergoing prolapse surgery.

Evaluation and management of refractory overactive bladder

The refractory overactive bladder patient is a complex new entity for the urologic community. We present the most current review of this difficult subject matter with an emphasis on evaluation and new treatment options such as sacral neuromodulation and botulinum toxin injection. It is hoped that in this new era of medical innovation, extirpation and reconstruction of the bladder will become historic in nature and refractory therapy can be transitioned to the office and outpatient operation rooms.