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Newman DK, Burgio KL, Cain C, Hebert-Beirne J, Low LK, Palmer MH, Smith AL, Rickey L, Rudser K, Gahagan S, Harlow BL, James AS, Lacoursiere DY, Hardacker CT, Wyman JF. Toileting behaviors and lower urinary tract symptoms: A cross-sectional study of diverse women in the United States. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021; 3. [DOI: 10.1016/j.ijnsa.2021.100052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gilham D, Smith AL, Fu L, Moore DY, Muralidharan A, Reid SPM, Stotz SC, Johansson JO, Sweeney M, Wong NCW, El-Gamal D, Kulikowski E. Bromodomain and extraterminal (BET) protein inhibitor, apabetalone, reduces ACE2 expression and attenuates SARS-CoV-2 infection in vitro. Eur Heart J 2021. [PMCID: PMC8767620 DOI: 10.1093/eurheartj/ehab724.3267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background/Introduction SARS-CoV-2 causes life threatening COVID-19 complications including acute coronary syndrome, venous thromboembolism, hyperinflammation and damage in multiple tissues. The SARS-CoV-2 “spike protein” binds cell surface receptors including angiotensin-converting enzyme 2 (ACE2) for entry into host cells to initiate infection. Host cell dipeptidyl peptidase-4 (DPP4 / CD26) is implicated as a cofactor in uptake. Recent evidence indicates expression of factors involved in SARS-CoV-2 uptake into host cells is regulated by BET proteins, epigenetic readers modulating gene expression. Apabetalone, the most clinically advanced BET inhibitor (BETi), is in phase 3 trials for cardiovascular disease (CVD) (a,b). In cultured human cardiomyocytes, apabetalone suppressed infection with SARS-CoV-2 and prevented dysfunction of cardiac organoids induced by the cytokine-storm that arises in patients with severe symptoms (c). However, anti-viral properties of apabetalone in other cell types are not known. Purpose To examine effects of apabetalone on SARS-CoV-2 infection in cell culture via downregulated expression of cell surface receptors involved in viral entry. Cell systems used mimic initial sites of infection in the lung as well as cell types contributing to complications in late stages of infection. Methods Gene expression was measured by real-time PCR, protein levels by immunoblot or flow cytometry, and binding of recombinant SARS-CoV-2 spike protein by flow cytometry. Infection with SARS-CoV-2 was determined in a BSL3 facility. Infectivity was quantified by determining levels of viral spike protein amongst total cells via imaging on an Operetta CLS. Results In Calu-3, a human bronchial epithelial cell line, apabetalone dose-dependently downregulated ACE2 gene expression (up to 98%), reduced ACE2 protein levels (up to 84%) and diminished binding of SARS-CoV-2 spike protein (up to 77%, p<0.001 for all parameters). Further, apabetalone abolished infection of Calu-3 cells with live SARS-CoV-2, which was comparable to other antiviral agents. Apabetalone-driven ACE2 downregulation was also observed in extrapulmonary cell types including HepG2, Huh-7 or primary hepatocytes (up to 90%, p<0.001 for all cell types), and Vero E6, a monkey kidney epithelial cell line (up to 38%, p<0.05). DPP4/CD26, a potential cofactor for SARS-CoV-2 uptake, was also downregulated by apabetalone in Calu-3 cells (mRNA ∼65% and protein ∼40%, p<0.001), which may be synergistic with ACE2 reductions to impede SARS-CoV-2 infection. Conclusions Apabetalone, an investigational drug for CVD, reduced cell surface receptors (ACE2 and DPP4) involved in SARS-CoV-2 uptake into host cells and dramatically attenuated SARS-CoV-2 infection/propagation in vitro. Our results suggest apabetalone can mitigate SARS-CoV-2 replication in multiple organs, which together with an established safety profile supports clinical evaluation of apabetalone to treat Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): COVID-19 Rapid Response Grant from the College of Medicine at the University of Nebraska Medical Center (to DE and SPMR), and by University of Nebraska Medical Center start-up funds (to DE).
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Roberson D, Newman DK, Ziemba JB, Wein A, Stambakio H, Hamilton RG, Callender L, Holderbaum L, King T, Jackson A, Tran T, Lin G, Smith AL. Results of the patient report of intermittent catheterization experience (PRICE) study. Neurourol Urodyn 2021; 40:2008-2019. [PMID: 34516673 DOI: 10.1002/nau.24786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
AIMS Patient satisfaction is paramount to health-related quality of life (HR-QoL) outcomes. High quality, quantitative data from the US describing patients' actual experiences, difficulties, and HR-QoL while on an intermittent self-catheterization (ISC) regimen is very scarce. Our objective was to better understand patient practices with and attitudes towards ISC. METHODS This is a cross-sectional, multi-centered, clinical study of adult men and women performing ISC in the United States. Data collected included demographics, medical history, catheter characteristics, specific self-catheterization habits and two validated HR-QoL questionnaires: The Intermittent Self-Catheterization Questionnaire (ISC-Q) and the Intermittent Catheterization Difficulty Questionnaire (ICDQ). RESULTS Two hundred participants were recruited from six sites; 70.0% were male, 73.5% were Caucasian with a median age was 51.0 years (range 19-90 years). The ISC-Q showed that the vast majority of participants reported ease with ISC (82.0% satisfaction score) had confidence in their ability to perform ISC (91.9% satisfaction score); yet, many felt self-conscious about doing so (58.3% satisfaction score) and had concerns about long-term adverse effects (58.1% satisfaction score). The ICDQ indicated little to no difficulty for most participants with all routine ISC practices. A small minority of participants reported some difficulty with a "blocking sensation" during initiation of catheterization, leg spasticity, and painful catheterization. Multivariate linear regression results are also reported. DISCUSSION/CONCLUSION Participants are confident with ISC and have little overall difficulty, which may be a product of successful education and/or catheter design. urinary tract infections (UTIs) were common (yet variable) and may contribute to the noted long-term ISC concerns. Limitations exist including various selection biases leading to concerns of external validity. Future educational interventions in this population may further improve HR-QoL, optimize UTIs prevention, and diminish concerns with long-term ISC.
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Rogers RG, Meyer I, Smith AL, Ackenbom M, Barden L, Korbly N, Mazloomdoost D, Thomas S, Nager C. Improved body image after uterovaginal prolapse surgery with or without hysterectomy. Int Urogynecol J 2021; 33:115-122. [PMID: 34432089 DOI: 10.1007/s00192-021-04954-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/15/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to compare body image and sexual activity and function changes up to 3 years after sacrospinous ligament fixation with graft hysteropexy or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy). METHODS This was a planned secondary analysis of a multi-center randomized trial of women undergoing prolapse repair with mesh hysteropexy versus hysterectomy. Women were masked to intervention. The modified Body Image Scale (BIS), sexual activity status, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) scores were reported at baseline and 1.5, 6, 12, 18, 24, and 36 months after surgery. We compared mean BIS and PISQ-IR scores, the proportion of women whose BIS scores met a distribution-based estimate of the minimally important difference (MID), and sexual activity status. Comparisons were analyzed with linear and logistic repeated measures models adjusted for site, intervention, visit, and intervention by visit interaction. RESULTS Eighty-eight women underwent mesh hysteropexy; 87 underwent hysterectomy. Women were similar with regard to baseline characteristics, mean age 65.9 ± 7.3 years, and most had stage III or IV prolapse (81%). Baseline mean BIS scores were not significantly different, improved in both groups by 1.5 months, and were sustained through 36 months with no differences between groups (all p > 0.05). The estimated BIS MID was 3; and by 36 months, more women in the mesh hysteropexy group achieved the MID than in the hysterectomy group (62% vs 44%, p = 0.04). The makeup of the sexually active cohort changed throughout the study, making function comparisons difficult. CONCLUSIONS Body image improves following prolapse surgery whether or not hysterectomy is performed or transvaginal mesh is used at the time of repair; sexual activity status changes over time following prolapse surgery.
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Yeguez AC, Yeguez CE, Smith AL. Lost in Translation: Misconceptions and Miscommunications Among Spanish-Speaking Latinas with Pelvic Floor Disorders. Urology 2021; 163:34-43. [PMID: 34015394 DOI: 10.1016/j.urology.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/19/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
This review sought to identify impediments to disease understanding among Spanish-speaking Latinas with pelvic floor disorders (PFDs). Five databases were queried and reference lists were searched for relevant articles, 14 were included. Thematic analysis identified 10 themes composed of 52 findings. Three synthesized findings were established: patient-related, provider-related, and system-related barriers to care. We identified that Spanish-speaking Latinas with PFDs face multiple, interacting healthcare barriers related to language and culture at the level of the patient, provider, and healthcare system. Emerging themes identified in this review provide insights for clinical practice as well as hypotheses and directions for future research.
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Ocádiz-Flores JA, Gheribi AE, Vlieland J, de Haas D, Dardenne K, Rothe J, Konings RJM, Smith AL. Examination of the short-range structure of molten salts: ThF 4, UF 4, and related alkali actinide fluoride systems. Phys Chem Chem Phys 2021; 23:11091-11103. [PMID: 33949518 DOI: 10.1039/d1cp00566a] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The short-range structures of LiF-ThF4, NaF-AnF4, KF-AnF4, and Cs-AnF4 (An = Th, U), were probed using in situ high temperature Extended X-ray Absorption Fine Structure (EXAFS) spectroscopy. Signally, the EXAFS spectra of pure molten ThF4 and UF4 were measured for the first time. The data were interpreted with the aid of Molecular Dynamics (MD) and standard fitting of the EXAFS equation. As in related studies, a speciation distribution dominated by [AnFx]4-x (x = 7, 8, 9) coordination complexes was observed. The average coordination number was found to decrease with the increasing size of the alkali cation, and increase with AnF4 content. An average coordination number close to 6, which had not been detected before in melts of alkali actinide fluorides, was seen when CsF was used as solvent.
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Shoham DA, Wang Z, Lindberg S, Chu H, Brubaker L, Brady SS, Coyne-Beasley T, Fitzgerald CM, Gahagan S, Harlow BL, Joinson C, Low LK, Markland AD, Newman DK, Smith AL, Stapleton A, Sutcliffe S, Berry A. School Toileting Environment, Bullying, and Lower Urinary Tract Symptoms in a Population of Adolescent and Young Adult Girls: Preventing Lower Urinary Tract Symptoms Consortium Analysis of Avon Longitudinal Study of Parents and Children. Urology 2021; 151:86-93. [PMID: 32679271 PMCID: PMC8074340 DOI: 10.1016/j.urology.2020.06.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To examine whether the school toilet environment at age 13, including bullying at toilets, is associated with female lower urinary tract symptoms (LUTS) at ages 13 and 19, as little is known about the association among school toilet environment, voiding behaviors, and LUTS in adolescent girls. METHODS The sample comprised 3962 female participants from the Avon Longitudinal Study of Parents and Children. At age 13, participants reported on 7 school toilet environment characteristics and a range of LUTS items. At age 19, participants completed the Bristol Female Lower Urinary Tract Symptoms questionnaire. RESULTS All toilet environmental factors were associated with at least 1 LUTS outcome at age 13. Holding behavior was associated with all school toilet environmental factors, with odds ratios ranging from 1.36 (95% confidence interval [CI]: 1.05, 1.76) for dirty toilets to 2.38 (95% CI: 1.60, 3.52) for feeling bullied at toilets. Bullying was associated with all daytime LUTS symptoms and nocturia; odds ratios ranged from 1.60 (95% CI: 1.04, 2.07) for nocturia to 2.90 (95% CI: 1.77, 4.75) for urgency. Associations between age 13 school toilets and age 19 LUTS were in the same direction as age 13 LUTS. CONCLUSION This is the first examination of associations between school toilets and LUTS. Toileting environments were cross-sectionally associated with LUTS in adolescent girls. While further work is needed to determine whether these associations are causal, school toilet environments are modifiable and thus a promising target for LUTS prevention.
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Smith AL. AUTHOR REPLY. Urology 2021; 150:124. [PMID: 33812536 DOI: 10.1016/j.urology.2020.05.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Smith AL. AUTHOR REPLY. Urology 2021; 150:187. [PMID: 33812543 DOI: 10.1016/j.urology.2020.03.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lane GI, Gracely A, Uberoi P, Lee U, Smith AL, Anger JT, Theva D, DeLong J, Kowalik C, Padmanabhan P, Powell CR, Carmel ME, Clemens JQ, Cameron AP, Gupta P. Changes in patient reported outcome measures after treatment for female urethral stricture. Neurourol Urodyn 2021; 40:986-993. [PMID: 33719145 DOI: 10.1002/nau.24653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. METHODS American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. RESULTS Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). CONCLUSION Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.
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Hendrickson WK, Amundsen CL, Rahn DD, Meyer I, Bradley MS, Smith AL, Myers DL, Jelovsek JE, Lukacz ES. Comparison of 100 U With 200 U of Intradetrusor OnabotulinumToxinA for Nonneurogenic Urgency Incontinence. Female Pelvic Med Reconstr Surg 2021; 27:140-146. [PMID: 33620895 PMCID: PMC8117667 DOI: 10.1097/spv.0000000000001020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to compare efficacy and adverse events between 100 U and 200 U of onabotulinumtoxinA for 6 months in women with nonneurogenic urgency incontinence. METHODS This is a secondary analysis of 2 multicenter randomized controlled trials assessing efficacy of onabotulinumtoxinA in women with nonneurogenic urgency incontinence; one compared 100 U to anticholinergics and the other 200 U to sacral neuromodulation. Of 307 women who received onabotulinumtoxinA injections, 118 received 100 U, and 189 received 200 U. The primary outcome was mean adjusted change in daily urgency incontinence episodes from baseline over 6 months, measured on monthly bladder diaries. Secondary outcomes included perceived improvement, quality of life, and adverse events. The primary outcome was assessed via a multivariate linear mixed model. RESULTS Women receiving 200 U had a lower mean reduction in urgency incontinence episodes by 6 months compared with 100 U (-3.65 vs -4.28 episodes per day; mean difference, 0.63 episodes per day [95% confidence interval (CI), 0.05-1.20]). Women receiving 200 U had lower perceptions of improvement (adjusted odds ratio, 0.32 [95% CI, 0.14-0.75]) and smaller improvement in severity score (adjusted mean difference, 12.0 [95% CI, 5.63-18.37]). Upon subanalysis of only women who were treated with prior anticholinergic medications, these differences between onabotulinumtoxinA doses were no longer statistically significant. There was no statistically significant difference in adverse events in women receiving 200 U (catheterization, 32% vs 23%; adjusted odds ratio, 1.4 [95% CI, 0.8-2.4]; urinary tract infection, 37% vs 27%; adjusted odds ratio, 1.5 [95% CI, 0.9-2.6]). CONCLUSIONS A higher dose of onabotulinumtoxinA may not directly result in improved outcomes, but rather baseline disease severity may be a more important prediction of outcomes.
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Williams BR, Vargo K, Newman DK, Yvette Lacoursiere D, Mueller ER, Connett J, Low LK, James AS, Smith AL, Schmitz KH, Burgio KL. It's About Time: The Temporal Burden of Lower Urinary Tract Symptoms Among Women. UROLOGIC NURSING 2020; 40:10.7257/1053-816x.2020.40.6.277. [PMID: 33642840 PMCID: PMC7906293 DOI: 10.7257/1053-816x.2020.40.6.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This secondary analysis studied 50 transcripts of women who shared day-to-day experiences of lower urinary tract symptoms (LUTS) and characterized temporal (time-associated) features of living with LUTS. Findings revealed two overarching time-associated themes: The Complexity of LUTS and The Quest for Empowerment over LUTS. Findings suggest that the temporal burden of LUTS is the accumulated impact of symptoms and symptom management on women's daily lives within multiple contexts across the life course. Increasing nurses' knowledge of the temporal context of LUTS may heighten awareness and improve symptom detection and management.
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Lane GI, Smith AL, Stambakio H, Lin G, Al Hussein Alawamlh O, Anger JT, Brandes ER, Carmel ME, Chung DE, Cox L, DeLong J, Elliott CS, Eltahawy E, Aparecido França W, Gousse A, Gupta P, Hagedorn JC, High RA, Khan A, Kowalik C, Lee RK, Lee UJ, Lucioni A, MacDonald S, Malaeb B, McKay S, Padmanabhan P, Powell CR, Sajadi KP, Sutherland SE, Theva D, Vollstedt A, Welk B, Zheng Y, Cameron AP. Treatment of urethral stricture disease in women: A multi‐institutional collaborative project from the SUFU research network. Neurourol Urodyn 2020; 39:2433-2441. [PMID: 32926460 DOI: 10.1002/nau.24507] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/11/2020] [Accepted: 08/27/2020] [Indexed: 01/18/2023]
Abstract
AIM Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. METHODS This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. RESULTS Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. CONCLUSION This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.
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Sutcliffe S, Cain C, Bavendam T, Epperson CN, Fitzgerald CM, Gahagan S, Markland AD, Shoham DA, Smith AL, Rudser K. Revisiting the Spectrum of Bladder Health: Relationships Between Lower Urinary Tract Symptoms and Multiple Measures of Well-Being. J Womens Health (Larchmt) 2020; 29:1077-1090. [PMID: 32831001 DOI: 10.1089/jwh.2019.8167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Little research to date has investigated the spectrum of bladder health in women, including both bladder function and well-being. Therefore, we expanded our previous baseline analysis of bladder health in the Boston Area Community Health (BACH) Survey to incorporate several additional measures of bladder-related well-being collected at the 5-year follow-up interview, including one developed specifically for women. Methods: At follow-up, participants reported their frequency of 15 lower urinary tract symptoms (LUTS), degree of life impact from and thought related to urinary symptoms or pelvic/bladder pain/discomfort, and perception of their bladder condition. Prevalence ratios were calculated by generalized linear models with robust variance estimation, adjusting for LUTS risk factors and individual LUTS. The BACH Survey was approved by the New England Research Institutes Institutional Review Board and all participants provided written informed consent. Results: Generally similar findings were observed in the 5-year cross-sectional analysis as at baseline, irrespective of how we categorized LUTS or measured bladder-related well-being. Approximately one in five women (16.2%-18.0% of 2527 eligible women) reported no LUTS and no diminished bladder-related well-being, the majority (55.8%-65.7%) reported some LUTS and/or diminished well-being, and a further one in five (16.9%-26.6%) reported the maximum frequency, number, or degree of LUTS and/or diminished well-being. Measures of storage function (urinating again after <2 hours, perceived frequency, nocturia, incontinence, and urgency) and pain were independently associated with bladder-related well-being. Conclusions: Our similar distribution of bladder health and consistent associations between LUTS and bladder-related well-being across multiple measures of well-being, including a female-specific measure, lend confidence to the concept of a bladder health spectrum and reinforce the bothersome nature of storage dysfunction and pain.
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Smith AL, Weissbart SJ. Gynecologic Considerations for the Urologic Surgeon. Urology 2020; 150:116-124. [PMID: 32739307 DOI: 10.1016/j.urology.2020.05.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/17/2020] [Accepted: 05/25/2020] [Indexed: 11/17/2022]
Abstract
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.
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Cruz AP, Chelluri R, Ramchandani P, Guzzo TJ, Smith AL. Post-cystectomy Enterocele: A Case Series and Review of the Literature. Urology 2020; 150:180-187. [PMID: 32512108 DOI: 10.1016/j.urology.2020.03.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/08/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication and discuss opportunities for prevention. Women with muscle invasive bladder cancer undergo RC with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for POP. METHODS We present 4 cases of high-grade POP in women who underwent RC for bladder cancer. We reviewed the literature by conducting a Boolean search in PubMed with the terms "("radical cystectomy") AND ("enterocele" OR "pelvic organ prolapse" OR "rectocele" OR "vaginal vault prolapse")." RESULTS All 4 women reported a bulge sensation in the vagina and physical exam confirmed POP. Three had radiographic findings consistent with high-grade enterocele at rest. Three experienced prolonged intra-abdominal pressure rise post-RC that may have further weakened pelvic floor support, while the fourth had a history of surgery for high-grade POP. Nine articles on POP following RC were identified. Four focused on treatment and 3 focused on prevention. CONCLUSION Administration of a single validated question would have identified all 4 cases of postoperative enterocele and is sensitive to detect most women who are experiencing POP. Attention to the pelvic floor on cross-sectional imaging with identification of features that indicate POP, such as herniation of intestinal contents below the pubo-coccygeal line, will identify and/or confirm high-grade enterocele. Familiarity with risk factors for POP and identification of weakened vaginal wall support opens up the opportunity for prevention.
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Brady SS, Berry A, Camenga DR, Fitzgerald CM, Gahagan S, Hardacker CT, Harlow BL, Hebert-Beirne J, LaCoursiere DY, Lewis JB, Low LK, Lowder JL, Markland AD, McGwin G, Newman DK, Palmer MH, Shoham DA, Smith AL, Stapleton A, Williams BR, Sutcliffe S. Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women. Neurourol Urodyn 2020; 39:1185-1202. [PMID: 32119156 PMCID: PMC7659467 DOI: 10.1002/nau.24325] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/23/2020] [Indexed: 01/18/2023]
Abstract
AIMS Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts. METHODS Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span. RESULTS Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research. CONCLUSIONS This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.
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Smith AL, Rickey LM, Brady SS, Fok CS, Lowder JL, Markland AD, Mueller ER, Sutcliffe S, Bavendam TG, Brubaker L. Laying the Foundation for Bladder Health Promotion in Women and Girls. Urology 2020; 150:227-233. [PMID: 32197984 DOI: 10.1016/j.urology.2020.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 02/27/2020] [Accepted: 03/05/2020] [Indexed: 01/03/2023]
Abstract
Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement. Important foundational work of PLUS includes development of clear definitions of both BH and disease, as well as a BH measurement instrument that will be validated for use in the general population, adolescents, and Latinx and Spanish-speaking women.1 The BH measurement instrument will be used in an upcoming nationally-representative cohort study that will measure BH and investigate risk and protective factors. PLUS investigators also developed a conceptual framework to guide their research agenda; this framework organizes a broad array of candidate risk and protective factors that can be studied across the life course of girls and women.1 As PLUS begins to fill existing knowledge gaps with new information, its efforts will undoubtedly be complemented by outside investigators to further advance the science of LUTS prevention and BH across additional populations. Once the BH community has broadened its understanding of modifiable risk and protective factors, intervention studies will be necessary to test LUTS prevention strategies and support public health efforts. LUTS providers may be able to translate this evolving evidence for individual patients under their care and act as BH advocates in their local communities.
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Meyer I, Whitworth RE, Lukacz ES, Smith AL, Sung VW, Visco AG, Ackenbom MF, Wai CY, Mazloomdoost D, Gantz MG, Richter HE. Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence. Int Urogynecol J 2020; 31:2155-2164. [PMID: 32146521 DOI: 10.1007/s00192-020-04271-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/18/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence. METHODS This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse. RESULTS Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II. CONCLUSIONS Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.
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Williams BR, Nodora J, Newman DK, Kane Low L, James AS, Camenga DR, Hebert-Beirne J, Brady SS, Hardacker CT, Smith AL, Cunningham SD, Burgio KL, Prevention Of Lower Urinary Tract Symptoms Plus Research Consortium. I never knew anyone who peed on themselves on purpose: Exploring adolescent and adult women's lay language and discourse about bladder health and function. Neurourol Urodyn 2020; 39:225-236. [PMID: 31578778 PMCID: PMC8126963 DOI: 10.1002/nau.24174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/09/2019] [Indexed: 11/06/2022]
Abstract
AIMS This analysis explored and characterized adolescent and adult women's lay language and discourse related to bladder health/function. METHODS Forty-four focus groups were conducted across seven United States research centers with 360 adolescents and adult women, organized by six age categories. Multilevel content analyses classified emergent themes. A transdisciplinary lens and inductive approach guided data interpretation. Interpretive insights were validated by a community engagement panel. RESULTS A repertoire of bladder function terms emerged, including explicit functional terms, formal and polite euphemistic terms, and informal familiar terms, as well as cultural and regional metaphors and idioms. Terminology usage was historically grounded, developmental, and cumulative across the life course. Lay discourse was contextual and affectively valent, suggesting unspoken, commonly understood, situation-based "rules" for talking about bladder function. Discourse appeared to be siloed within family and friendship circles. Adolescents and adult women often described, rather than named, bladder sensations or problems. Terminology for bladder issues tended to minimize severity and frequency, with medical language only relevant to extreme examples and not applicable to mild episodes. CONCLUSIONS A definitional discordance between medical and lay views of bladder problems was identified, signifying a need to clarify the meaning of medical terms for lay persons. Adolescents and adult women do not have or use standardized precise terminology for bladder health and function, relying instead on social convention and interpersonal context. Findings can be used to foster shared understandings between lay persons and health professionals, informing development of clinical, research, and public health initiatives to promote bladder health.
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Smith AL, Weissbart SJ, Hartigan SM, Bilello M, Newman DK, Wein AJ, Malykhina AP, Erus G, Fan Y. Association between urinary symptom severity and white matter plaque distribution in women with multiple sclerosis. Neurourol Urodyn 2019; 39:339-346. [PMID: 31691357 DOI: 10.1002/nau.24206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
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.
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Sung VW, Borello-France D, Newman DK, Richter HE, Lukacz ES, Moalli P, Weidner AC, Smith AL, Dunivan G, Ridgeway B, Nguyen JN, Mazloomdoost D, Carper B, Gantz MG. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial. JAMA 2019; 322:1066-1076. [PMID: 31529007 PMCID: PMC6749544 DOI: 10.1001/jama.2019.12467] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking. OBJECTIVE To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017. INTERVENTIONS Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207). MAIN OUTCOMES AND MEASURES The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms. RESULTS Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only). CONCLUSIONS AND RELEVANCE Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01959347.
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Sutcliffe S, Bavendam T, Cain C, Epperson CN, Fitzgerald CM, Gahagan S, Markland AD, Shoham DA, Smith AL, Townsend MK, Rudser K. The Spectrum of Bladder Health: The Relationship Between Lower Urinary Tract Symptoms and Interference with Activities. J Womens Health (Larchmt) 2019; 28:827-841. [PMID: 31058573 PMCID: PMC6590721 DOI: 10.1089/jwh.2018.7364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Little research to date has focused on lower urinary tract symptom (LUTS) prevention and bladder health promotion in women. To address this gap, the Prevention of LUTS Research Consortium developed the following working bladder health definition: "A complete state of physical, mental, and social well-being related to bladder function [that] permits daily activities [and] allows optimal well-being." To begin to inform and quantify this definition, we used data from the Boston Area Community Health Survey, drawing upon its rare collection of information on LUTS and LUTS-specific interference with activities. Methods: At baseline, participants reported their frequency of 15 LUTS and interference with 7 activities. Prevalence ratios (PRs) were calculated by generalized linear models with robust variance estimation, adjusting for LUTS risk factors and individual LUTS. Results: Of the 3169 eligible participants, 17.5% reported no LUTS or interference, whereas the remaining 82.5% reported some frequency of LUTS/interference: 15.1% rarely; 21.7% a few times; 22.6% fairly often/usually; and 22.9% almost always. LUTS independently associated with interference were urgency incontinence, any incontinence, urgency, nocturia, perceived frequency, and urinating again after <2 hours (PRs = 1.2-1.5, all p < 0.05). Conclusions: Our findings suggest that bladder health exists on a continuum, with approximately one in five women considered to have optimal bladder health (no LUTS/interference), the majority to have intermediate health (LUTS/interference rarely to usually), and a further one in five to have worse or poor health (LUTS/interference almost always). These findings underscore the need for LUTS prevention and bladder health promotion.
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Abstract
PURPOSE OF REVIEW The purpose of this paper is to review (1) the epidemiology and pathophysiology of pelvic organ prolapse (POP) and occult stress urinary incontinence (SUI), (2) examine the data on combined operative management of POP and occult SUI, (3) discuss the approaches to clinical decision making, and (4) present future therapies. RECENT FINDINGS Prospective data on many approaches to concomitant treatment of prolapse and occult stress urinary incontinence, such as minimally invasive sacrocolpopexy and midurethral sling, or older approaches that have regained favor among patients and clinicians wishing to avoid synthetic mesh, such as native tissue prolapse repair and pubovaginal sling, are limited. Safe durable treatments with absorbable graft materials that promote a beneficial host response are intriguing but may be far from clinical implementation. Stem cell therapy for the treatment of stress urinary incontinence has demonstrated benefit in phase I/II trials but has not been studied in the setting of concomitant treatment of occult SUI with POP surgery and remains in the preclinical phase for the treatment of POP. A personalized approach to concomitant SUI surgery that incorporates individual risk assessment as well as informed patient preferences likely optimizes the risk/benefit ratio and patient satisfaction. Novel therapies, including graft materials and cellular therapies that stimulate a regenerative response, may improve or maintain continence outcomes while mitigating risk and alter the approach to both POP and SUI surgery.
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Abstract
Understanding the pathophysiologic mechanisms responsible for overactive bladder (OAB) and urgency urinary incontinence (UUI) is critical to advancing the treatment options available to men and women with this prevalent and bothersome condition. Development of novel technologies and advanced functional neuroimaging modalities has provided us with new information to support and refine existing mechanistic theories. Emerging research on central pathophysiologic mechanisms of OAB from functional magnetic resonance imaging may provide new targets for therapeutic interventions and opens the door for novel treatment strategies. Several regions of interest—specifically the anterior cingulate gyrus, insula, and frontal cortices—have been implicated as areas of activation in women with OAB, suggesting a neural correlate of the experience of urgency. The cerebellum and parietal lobe have demonstrated increased activation during inhibition of voiding, and increased connectivity between the cerebellum and parietal lobe and the right insula and anterior cingulate gyrus has been demonstrated in women with UUI compared with controls. Evolving literature is beginning to shed light on the prerequisite effective connections between regions of interest in the healthy bladder and negative connectivity in OAB and UUI. Precision medicine with individualized care pathways may better select available treatment modalities for rightful recipients, thus improving efficacy with prescribed treatment approaches and adherence to therapy.
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