The Brain and the Bladder: Forebrain Control of Urinary (In)Continence

Neural circuits extending from the cerebral cortex to the bladder maintain urinary continence and allow voiding when it is socially appropriate. Injuries to certain brain regions produce a specific disruption known as urge incontinence. This neurologic symptom is distinguished by bladder spasticity, with sudden urges to void and frequent inability to maintain continence. The precise localization of neural circuit disruptions responsible for urge incontinence remains poorly defined, partly because the brain regions, cell types, and circuit connections that normally maintain continence are unknown. Here, we review what is known about the micturition reflex circuit and about forebrain control of continence from experimental animal studies and human lesion data. Based on this information, we hypothesize that urge incontinence results from damage to a descending pathway that normally maintains urinary continence. This pathway begins with excitatory neurons in the prefrontal cortex and relays subcortically, through inhibitory neurons that may help suppress reflex micturition during sleep and until it is safe and socially appropriate to void. Identifying the specific cell types and circuit connections that constitute the continence-promoting pathway, from the forebrain to the brainstem, will help us better understand why some brain lesions and neurodegenerative diseases disrupt continence. This information is needed to pave the way toward better treatments for neurologic patients suffering from urge incontinence.

Standardization for reliable uroflowmetry testing in adults

OBJECTIVES

To assess if a standard hydration protocol will achieve voided volumes over 150 mL and more reliable uroflowmetry results.

METHODS

This is a single-blinded crossover study of 40 patients with benign prostatic obstruction and 34 healthy volunteers. Subjects were enrolled prospectively between January and March 2019. All subjects performed two randomly ordered uroflowmetry tests. One test was performed when subjects sensed their bladder was full and had the urge to void and another one after emptying the bladder and ingesting 1.5 L of water within 1 hour (prehydration). Uroflowmetry parameters were compared between the benign prostatic obstruction group and the healthy volunteers. Uroflowmetry results were categorized as reliable, residual, and suboptimal with respect to voided volumes. This study has been registered in the UMIN Clinical Trials Registry (UMIN000035446).

RESULTS

The benign prostatic obstruction group and the healthy volunteer group presented no difference in respect of uroflowmetry test reliability (P = .459). Uroflowmetry results were reliable in 58 (78.4%) subjects in the prehydrated group and was reliable in 30 (40.5%) subjects in the non-prehydrated group. The difference was statistically significant (P < .05). In the benign prostatic obstruction group and healthy volunteer group, the rate of reliable uroflowmetry tests was significantly higher with prehydration (P < .05). The comparative analysis of uroflowmetry parameters between tests performed with and without prehydration revealed higher values in the prehydrated group (voided volume, maximum flow rate, average flow rate, and postvoiding residual volume; P < .05).

CONCLUSION

Prehydration of patients with 1.5 L of water within 1 hour before uroflowmetry improves uroflowmetry outcomes. By this hydration protocol, the chance to obtain a voided volume over 150 mL is increased significantly.

Common feline problem behaviours: Unacceptable indoor elimination

PRACTICAL RELEVANCE

One of the reasons why cats enjoy such a high level of popularity as domestic pets is the fact that they are clean. When there is a breakdown in this fastidious behaviour and elimination occurs outside of the litter box or tray, the strain on the cat-owner bond and on human relationships within the household can be considerable.

EVIDENCE BASE

Indoor elimination behaviour is one of the most common reasons for cat owners to seek professional advice and there is a wide range of articles, book chapters and research papers that reference it. In many cases the topic of urination and defecation in unacceptable indoor locations is considered in combination with the deposition of urine or faeces as a marker, but this review focuses purely on problematic elimination. An accompanying article in this special issue discusses urine spraying.

CLINICAL CHALLENGES

Indoor elimination problems necessitate a clinical approach combining knowledge from the fields of physical and emotional health and an understanding of normal feline behaviour. They also require comprehensive history-taking skills as well as effective communication skills and a degree of empathy for owners who are often finding their pet's behaviour very distressing.

GLOBAL IMPORTANCE

Early diagnosis of physical health disorders that are associated with indoor elimination is extremely important in terms of safeguarding feline welfare. As we become more aware of the interplay between physical and emotional health, the significance of identifying suboptimal social and physical environments in terms of optimising the welfare of domestic cats is also being recognised. The potential for indoor elimination problems to cause considerable human distress highlights the importance of the concepts of One Health and One Welfare.

Optimal high-density lipoprotein cholesterol level for decreasing benign prostatic hyperplasia in men not taking statin medication: A historical cohort study

BACKGROUND

We evaluated the optimal high-density lipoprotein cholesterol level for benign prostatic hyperplasia (BPH) prevention in men not taking statin medication using a large historical cohort.

METHODS

We initially selected 130 454 men who underwent health checkups in 2009 from the National Health Information Database of the National Health Insurance Service. After excluding 36 854 men with BPH in 2009, and 45 061 men for statin use, 48 539 men were ultimately included in the analysis. A Kaplan-Meier analysis and multivariable Cox regression analysis was performed to assess the optimal high-density lipoprotein cholesterol level for preventing BPH.

RESULTS

High-density lipoprotein cholesterol levels were less than 40 mg/dL in 7431 (15.3%) men, 40 to 49 in 15 861 (32.7%), 50 to 59 in 15 328 (27.5%), and greater than or equal to 60 in 11 919 (24.6%). The overall cumulative incidence of BPH was 4.4%, 8.7%, 13.0%, and 17.8% at the 1-, 2-, 3-, and 4-year follow-up periods, respectively. In multivariable analysis, high-density lipoprotein greater than or equal to 60 mg/dL were significantly associated with a decreased incidence of BPH, as were age, residence, income, body mass index, diabetes, hypertension, triglyceride, and increased annual clinic visits, especially in men in their 40s.

CONCLUSION

Elevated serum high-density lipoprotein cholesterol levels were negatively associated with BPH incidence. In addition, maintaining high-density lipoprotein greater than or equal to 60 mg/dL was associated with a decreased BPH incidence compared with high-density lipoprotein less than 40 mg/dL, especially in men in their 40s.

Sex of Walker Influences Scent-marking Behavior of Shelter Dogs

Simple Summary

In diverse settings, human presence and handling influence the behavior and physiology of other animals, often causing increased vigilance and stress, especially if the human is unfamiliar. Domestic dogs are unusual in that human interaction often reduces stress and behavioral signs of stress. Nevertheless, there is some evidence that the sex of an unfamiliar person can influence canine behavior. To determine whether sex of an unfamiliar walker might influence the behavior of dogs at an animal shelter, we observed 100 dogs during leash walks and recorded all occurrences of scent-marking behaviors. Male dogs urinated at higher rates when walked by unfamiliar women than when walked by unfamiliar men. Female dogs urinated at similar rates when walked by unfamiliar men and unfamiliar women. Sex of walker also influenced urinary posture in male dogs. Both male and female dogs were more likely to defecate when walked by unfamiliar women than when walked by unfamiliar men. Based on our findings, and those of others, we suggest that the sex of all observers and handlers be reported in behavioral studies of dogs and considered in behavioral evaluations at animal shelters, where results can impact whether or not a dog is made available for adoption.

Abstract

Interactions with humans influence the behavior and physiology of other animals, and the response can vary with sex and familiarity. Dogs in animal shelters face challenging conditions and although contact with humans typically reduces stress and behaviors associated with stress, evidence indicates that shelter dogs react differently to unfamiliar men and women. Given that some aspects of canine scent-marking behavior change under fearful conditions, we examined whether sex of an unfamiliar walker would influence scent-marking behavior of 100 shelter dogs during leash walks. Male dogs urinated at higher rates when walked by unfamiliar women than when walked by unfamiliar men; female dogs urinated at similar rates when walked by unfamiliar women and unfamiliar men. Sex of walker influenced urinary posture in male dogs, but not in female dogs. Both male and female dogs were more likely to defecate when walked by unfamiliar women than by unfamiliar men. Based on our findings that shelter dogs behave differently in the presence of unfamiliar men and women, we suggest that researchers conducting behavioral studies of dogs record, consider in analyses, and report the sex of observers and handlers as standard practice. We also recommend recording the sex of shelter staff present at behavioral evaluations because the results of these evaluations can impact dog welfare.

Disparities in Benign Prostatic Hyperplasia Progression: Predictors of Presentation to the Emergency Department in Urinary Retention

PURPOSE

This retrospective cohort study evaluates the characteristics of patients who presented to the emergency department with acute urinary retention.

MATERIALS AND METHODS

Using the Healthcare Cost and Utilization Project State Emergency Department Databases we conducted a retrospective cohort study of patients who presented to emergency departments in Florida between 2005 and 2015. Male patients age 45 years or older who presented with diagnosis codes for acute urinary retention and lower urinary tract symptoms/benign prostatic hyperplasia were considered. Information was collected on age, race/ethnicity, primary insurance and rural-urban commuting area codes.

RESULTS

The mean age for males presenting with acute urinary retention was 72.2 years, which was 10.6 years older than those presenting for nonurological complaints (p <0.001). Multivariable analysis adjusted for measured confounders found all covariates to be significant. The risk of presenting to the emergency department for acute urinary retention from lower urinary tract symptoms/benign prostatic hyperplasia increased with age, with the 75 to less than 85-year-old age group at the highest risk (OR 15.96, p <0.001). Other factors associated acute urinary retention included African American (OR 1.15, p <0.001) or Hispanic (OR 1.75, p <0.001) race, Medicare (OR 1.27, p <0.001) or private (OR 1.33, p <0.001) insurance, and urban rural-urban commuting area codes (OR 1.31, p <0.001).

CONCLUSIONS

Male patients who presented to the emergency department for acute urinary retention with benign prostatic hyperplasia were more likely to be older, of nonwhite race, have Medicare or private insurance, and live in more urban areas. These data suggest that African American and Hispanic patients may be untreated or under treated for benign prostatic hyperplasia in the outpatient setting, resulting in an increased risk of presentation to the emergency department with acute urinary retention.

Toileting Behaviors Related to Urination in Women: A Scoping Review

This scoping review explores the state of science regarding women’s toileting behaviors, gaps in knowledge, and areas for future research. Online databases were searched to identify papers published in English between January 2010 through July 2019; the search identified 25 articles. The Toileting Behaviors–Women’s Elimination Behaviors scale has been published in four validated language versions and used in 17 of the 25 studies. The most frequent behaviors include concern about public toilet cleanliness, delaying urination when busy or away from home, and using different toileting postures at and away from home. Determinants of toileting behaviors include environmental factors, chronic health conditions, and cognitive/psychological factors. Associations were found between toileting behaviors and lower urinary tract symptoms and between toileting postures and uroflowmetric parameters and post-void residual volume. Strategies that address modifiable determinants of toileting behaviors should be developed and tested in future research. Furthermore, little is known about the toileting behaviors and bladder health in older women and women from developing countries. Rigorous studies are needed to better understand the underlying mechanisms of toileting behaviors, the nature of associations between toileting behaviors and lower urinary tract symptoms, and effects of the environment on women’s toileting behaviors.

Simultaneous Measurement of Neuronal Activity in the Pontine Micturition Center and Cystometry in Freely Moving Mice

Understanding the complex neural mechanisms controlling urinary bladder activity is an extremely important topic in both neuroscience and urology. Simultaneously recording of the bladder activity and neural activity in related brain regions will largely advance this field. However, such recording approach has long been restricted to anesthetized animals, whose bladder function and urodynamic properties are largely affected by anesthetics. In our recent report, we found that it is feasible to record bladder pressure (cystometry) and the related cortical neuron activity simultaneously in freely moving mice. Here, we aimed to demonstrate the use of this combined method in freely moving mice for recording the activity of the pontine micturition center (PMC), a more difficultly approachable small region deeply located in the brainstem and a more popularly studied hub for controlling bladder function. Interestingly, we found that the duration of urination events linearly correlated to the time course of neuronal activity in the PMC. We observed that the activities of PMC neurons highly correlated with spike-like increases in bladder pressure, reflecting bladder contractions. We also found that anesthesia evoked prominent changes in the dynamics of the Ca²⁺ signals in the PMC during the bladder contraction and even induced the dripping overflow incontinence due to suppression of the neural activity in the PMC. In addition, we described in details both the system for cystometry in freely moving mice and the protocols for how to perform this combined method. Therefore, this work provides a powerful approach that enables the simultaneous measurement of neuronal activity of the PMC or any other brain sites and bladder function in freely behaving mice. This approach offers a promising possibility to examine the neural mechanisms underlying neurogenic bladder dysfunction.

Urinary and Sexual Function after Perineal Urethrostomy for Urethral Stricture Disease: An Analysis from the TURNS

PURPOSE

Perineal urethrostomy is a viable option for many complex urethral strictures. However, to our knowledge no comparison with anterior urethroplasty regarding patient reported outcome measures has been published. We compared these groups using a large multi-institution database.

MATERIALS AND METHODS

We performed a retrospective study of anterior urethroplasty in the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database. The anterior urethroplasty cohort was defined by long strictures greater than 6 cm. We compared demographic, clinical, urinary and sexual characteristics using validated patient reported outcome measures between patients treated with long stricture anterior urethroplasty and those who underwent perineal urethrostomy.

RESULTS

Of the 131 patients 92 treated with long stricture anterior urethroplasty and 39 treated with perineal urethrostomy met study inclusion criteria. The cumulative incidence of failure at 2 years was 30.2% (95% CI 18.3-47.3) for long stricture anterior urethroplasty and 14.5% (95% CI 4.8-39.1) for perineal urethrostomy (p = 0.09). Compared to baseline metrics, patients who underwent long stricture anterior urethroplasty and perineal urethrostomy had similar improvements in urinary function and stable sexual function after surgery.

CONCLUSIONS

Patients reported improvement in urinary function after perineal urethrostomy with no deleterious effect on sexual function. These patient reported outcome measures were comparable to those of long stricture anterior urethroplasty. Perineal urethrostomy failure rates were similar to those of long stricture anterior urethroplasty.

Ultrasound-guided placement of pigtail cystostomy tubes in dogs with urethral obstruction

BACKGROUND

Circumstances such as the inability to pass a retrograde urinary catheter or a lack of surgeon availability may prevent immediate relief of urethral obstruction in dogs. In such situations, a cystostomy tube may be placed with ultrasound guidance to allow urinary diversion until further treatment is possible.

KEY FINDINGS

A case of a 5-year-old male neutered Swiss Mountain dog with an obstructive urolith at the level of the os penis is used to describe the technique. Multiple attempts to pass a urinary catheter under sedation were unsuccessful. A pigtail cystostomy tube was placed with ultrasound guidance to allow urinary diversion. The dog was discharged from the hospital within 2 days after scrotal urethrostomy and the dog made a full recovery. Ultrasound-guided placement of a pigtail cystostomy tube was straightforward and without complications.

SIGNIFICANCE

Ultrasound-guided placement of a pigtail cystostomy tube may be beneficial as it is not technically challenging, can be performed rapidly, and may avoid the need for general anesthesia. Additionally, ultrasound is readily available and an inexperienced ultrasonographer can easily locate the urinary bladder. This report serves to provide a detailed technique of ultrasound-guided placement of a pigtail cystostomy tube in dogs for emergency urinary diversion.

Lrig2 and Hpse2, mutated in urofacial syndrome, pattern nerves in the urinary bladder

Mutations in leucine-rich-repeats and immunoglobulin-like-domains 2 (LRIG2) or in heparanase 2 (HPSE2) cause urofacial syndrome, a devastating autosomal recessive disease of functional bladder outlet obstruction. It has been speculated that urofacial syndrome has a neural basis, but it is unknown whether defects in urinary bladder innervation are present. We hypothesized that urofacial syndrome features a peripheral neuropathy of the bladder. Mice with homozygous targeted Lrig2 mutations had urinary defects resembling those found in urofacial syndrome. There was no anatomical blockage of the outflow tract, consistent with a functional bladder outlet obstruction. Transcriptome analysis revealed differential expression of 12 known transcripts in addition to Lrig2, including 8 with established roles in neurobiology. Mice with homozygous mutations in either Lrig2 or Hpse2 had increased nerve density within the body of the urinary bladder and decreased nerve density around the urinary outflow tract. In a sample of 155 children with chronic kidney disease and urinary symptoms, we discovered novel homozygous missense LRIG2 variants that were predicted to be pathogenic in 2 individuals with non-syndromic bladder outlet obstruction. These observations provide evidence that a peripheral neuropathy is central to the pathobiology of functional bladder outlet obstruction in urofacial syndrome, and emphasize the importance of LRIG2 and heparanase 2 for nerve patterning in the urinary tract.

Toileting Behaviors of Women-What is Healthy?

PURPOSE

The objective of this study was to assess toileting behaviors in community dwelling women.

MATERIALS AND METHODS

Women 18 years old or older were recruited through a national registry of research volunteers. They were asked to complete validated questionnaires assessing urinary symptoms and toileting behaviors, specifically place preference for voiding, convenience voiding, delayed voiding, straining during voiding and position preference for voiding. The PPBC (patient perception of bladder condition) was administered to assess the participant impression of bladder health. Analyses were done to determine the prevalence of each toileting behavior reported to occur sometimes or more often as well as differences in toileting behaviors in women with vs without self-perceived bladder problems based on the PPBC response.

RESULTS

The 6,695 women who completed the questionnaires were 18 to 89 years old (mean ± SD age 41.4 ± 15). Of the women 79.9% identified as white and 71.0% were college educated. Of the women 6,613 (98.8%) reported a place preference for voiding. The 3,552 women (53.1%) who reported a bladder problem were more likely to report convenience voiding, delayed voiding and strained voiding behaviors. While 6,657 women (99.4%) reported sitting to void at home only 5,108 (76.2%) reported sitting when using public toilets.

CONCLUSIONS

Certain toileting behaviors, of which some may be considered unhealthy, were common in this sample of women and most were associated with a perception of bladder problems. Voiding positions other than sitting were frequently used when away from home. These data have important implications for defining bladder health and implementing behavior based interventions for women with lower urinary tract symptoms.

Brain activation during the voiding phase of micturition in healthy adults: A meta-analysis of neuroimaging studies

Several studies have used a variety of neuroimaging techniques to measure brain activity during the voiding phase of micturition. However, there is a lack of consensus on which regions of the brain are activated during voiding. The aim of this meta-analysis is to identify the brain regions that are consistently activated during voiding in healthy adults across different studies. We searched the literature for neuroimaging studies that reported brain co-ordinates that were activated during voiding. We excluded studies that reported co-ordinates only for bladder filling, during pelvic floor contraction only, and studies that focused on abnormal bladder states such as the neurogenic bladder. We used the activation-likelihood estimation (ALE) approach to create a statistical map of the brain and identify the brain co-ordinates that were activated across different studies. We identified nine studies that reported brain activation during the task of voiding in 91 healthy subjects. Together, these studies reported 117 foci for ALE analysis. Our ALE map yielded six clusters of activation in the pons, cerebellum, insula, anterior cingulate cortex (ACC), thalamus, and the inferior frontal gyrus. Regions of the brain involved in executive control (frontal cortex), interoception (ACC, insula), motor control (cerebellum, thalamus), and brainstem (pons) are involved in micturition. This analysis provides insight into the supraspinal control of voiding in healthy adults and provides a framework to understand dysfunctional voiding. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

Urological symptoms among 23,240 men in the general danish population - concerns about symptoms, their persistence and influence on primary care contacts

OBJECTIVE

To analyse possible associations between men's likelihood of contacting a general practitioner (GP) for urological symptoms and the persistence of the symptoms, the influence on daily activities and the level of concern about the symptoms.

DESIGN

Web-based nationwide cross-sectional questionnaire study.

SETTING

The general population in Denmark.

SUBJECTS

48,910 randomly selected men aged 20+ years.

MAIN OUTCOME MEASURES

Urological symptom prevalence and odds ratios for GP contact with urological symptoms in regard to concern for the symptom, influence on daily activities and the persistence of the symptom.

RESULTS

Some 23,240 men responded to the questionnaire, yielding a response rate of 49.8%. The prevalence of at least one urological symptom was 59.9%. Among men experiencing at least one urological symptom almost one-fourth reported contact to general practice regarding the symptom. Approximately half of the symptoms reported to be extremely concerning were discussed with a GP.

CONCLUSION

Increased symptom concern, influence on daily activities and long-term persistence increased the likelihood of contacting a GP with urological symptoms. This research points out that guidelines for PSA testing might be challenged by the high prevalence of urological symptoms. Key points  The decision process of whether to contact the general practitioner (GP) is influenced by different factors, but contradictory results has been found in triggers and barriers for help-seeking with urological symptoms.   • Increased symptom concern, influence on daily activities and long-term persistence consistently increased the likelihood of contacting a general practitioner with urological symptoms in men.   • Only 50% of the symptoms reported to be extremely concerning were however discussed with the GP.   • Guidelines for PSA testing might be challenged by the high prevalence of urological symptoms.

Lower Urinary Tract Dysfunction and Associated Pons Volume in Patients with Wolfram Syndrome

PURPOSE

Wolfram syndrome is a neurodegenerative disorder characterized by childhood onset diabetes mellitus, optic nerve atrophy, diabetes insipidus, hearing impairment, and commonly bladder and bowel dysfunction. We hypothesized that there is an association between a smaller pons, which contains the pontine micturition center, and abnormal lower urinary tract function.

MATERIALS AND METHODS

Patients with genetically confirmed Wolfram syndrome attended an annual multidisciplinary research clinic. Subjects underwent noninvasive urodynamic testing and brain magnetic resonance imaging, and completed validated patient reported outcome measures. Bowel and bladder diaries were completed before visits. Age and gender corrected linear and logistic mixed effects models were used to correlate pons volume, corrected for whole brain size, to urodynamic and patient reported outcomes.

RESULTS

A total of 36 patients attended 142 visits between 2010 and 2016. Mean age was 16.9 years (range 7 to 30) and 64% of patients were female. Functional bladder capacity was decreased in 31% of the patients, normal in 54% and increased in 14%. Of the patients 44% and 54% had abnormal uroflowmetry and post-void residual, respectively, on at least 1 occasion. There was no increase through time in incidence of lower urinary tract dysfunction. Decreased pons volume was associated with increased post-void residual (p = 0.048) and higher PinQ (Pediatric Incontinence Questionnaire) score (p = 0.011), indicating lower quality of life and higher levels of dysfunction.

CONCLUSIONS

A significant number of children, adolescents and young adults with Wolfram syndrome have objective evidence of lower urinary tract dysfunction. Decreased pons volume is associated with more abnormal urinary function and lower quality of life in patients with Wolfram syndrome.

Risk factors for postpartum urinary retention after vaginal delivery at term without epidural anesthesia

Objective: We performed a retrospective case-control study of vaginal delivery at term without epidural anesthesia to identify clinical predictions of postpartum urinary retention (PUR). Methods: We reviewed the obstetric records of all singleton vaginal deliveries at Japanese Red Cross, Katsushika Maternity Hospital form January 2016 through December 2017. Results: There were 58 women (2.4%) complicated by PUR and 2391 women without PUR. A multivariate analysis revealed nulliparity, instrumental delivery, and episiotomy as independent risk factors for PUR (nulliparity: adjusted OR 2.39, 95%CI 1.2-4.8, p = 0.01; instrumental delivery: 3.53, 95%CI 1.9-6.7, p < .01, episiotomy: adjusted OR 1.96, 95%CI 1.0-3.8, p = .04). While, urination (or urethral catheterization) within 1 hour before delivery revealed as independent prevention factor for PUR (adjusted OR 0.54, 95%CI 0.30-0.99, p = .048). Conclusions: The risk factors identified in our institute seemed to approximately similar to those observed in the institutes capable of performing epidural anesthesia. In addition, urination just before delivery seemed to be an independent prevention factor for PUR.

The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium: A Transdisciplinary Approach Toward Promoting Bladder Health and Preventing Lower Urinary Tract Symptoms in Women Across the Life Course

Lower urinary tract symptoms (LUTS) are highly prevalent in women, and are expected to impose a growing burden to individuals and society as the population ages. The predominance of research related to LUTS has focused on underlying pathology, disease mechanisms, or the efficacy of treatments for women with LUTS. Although this research has been vital for helping to reduce or ameliorate LUTS conditions, it has done little to prevent the onset of LUTS. Health promotion and prevention require an expansion of scientific inquiry beyond the traditional paradigm of studying disease mechanisms and treatment to the creation of an evidence base to support recommendations for bladder health promotion and, in turn, prevention of LUTS. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) introduced the concept of prevention as an important priority for women's urologic research as a prelude to supporting the formation of the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium. In this article, we introduce the PLUS research consortium to the scientific community; share the innovative paradigms by which the consortium operates; and describe its unique research mission: to identify factors that promote bladder health across the life course and prevent the onset of LUTS in girls and women.

Assessing Women's Negative Sanitation Experiences and Concerns: The Development of a Novel Sanitation Insecurity Measure

Lack of access to acceptable sanitation facilities can expose individuals, particularly women, to physical, social, and mental health risks. While some of the challenges have been documented, standard metrics are needed to determine the extent to which women have urination- and defecation-related concerns and negative experiences. Such metrics also are needed to assess the effectiveness of interventions to mitigate them. We developed a sanitation insecurity measure to capture the range and frequency of women's sanitation-related concerns and negative experiences. Research was conducted in rural Odisha, India with women across various life course stages to reflect a range of perspectives. This paper documents the mixed data collection methods and the exploratory and confirmatory factor analyses we employed to arrive at a final measure. The final sanitation insecurity measure includes 50 items across seven factors that reflect the physical environment, the social environment, and individual-level constraints. Most factor scores were significantly higher for unmarried women and for women who lacked access to functional latrines, indicating social and environmental influence on experiences. This measure will enable researchers to evaluate how sanitation insecurity affects health and to determine if and how sanitation interventions ameliorate women's concerns and negative experiences associated with sanitation.

Self-reported toileting behaviors in employed women: Are they associated with lower urinary tract symptoms?

AIMS

To describe toileting behaviors working women habitually use and investigate behaviors associated with lower urinary tract symptoms (LUTS), especially urinary urgency with or without leakage.

METHODS

Non-pregnant female employees of a large academic medical center 18 years and over were eligible to complete an online survey about bladder health and toileting behaviors.

RESULTS

One hundred eighty-two women participated in the survey. The majority were white (83.52%), married (52.49%), had ≥1 pregnancy (54.40%), and in excellent health (93.41%). The average age and body mass index were 47.28 ± 13.56 years and 27.92 ± 6.78, respectively. The sample was further sub-divided into two groups: urinary urgency (N = 119) or no urinary urgency symptoms (N = 51). Habitual toileting behaviors for these groups (N = 170) included: sitting to urinate at home (98.24%), emptying the bladder completely (88.82%), emptying the bladder before leaving home (80.00%), and sitting to urinate when away from home (68.82%). Logistic regression analysis showed age increased the odds of urinary urgency (aOR 1.06, 95%CI 1.02-1.09). Women who waited too long to urinate at work (aOR 7.85, 95%CI 1.57-39.24) and wore panty liners for urinary leakage (aOR 2.86, 95%CI 1.25-6.56) had greater odds of urinary urgency than women who did neither.

CONCLUSIONS

Most habitual toileting behaviors were not associated with urinary urgency except waiting too long to urinate when at work. Logistic regression revealed significant relationships among health-related factors, personal characteristics, behaviors, and urinary urgency. LUTS in women is both a women's health and occupational health issue.

Functional Effects of Bulbospongiosus Muscle Sparing on Ejaculatory Function and Post-Void Dribbling after Bulbar Urethroplasty

PURPOSE

Bulbar urethroplasty outcomes studies have shown low but significant rates of post-void dribbling and ejaculatory dysfunction. The bulbospongiosus muscle is involved with the expulsion of seminal fluid and urine from the bulbar urethra and, thus, we hypothesized that performing urethroplasty using a technique that does not split the muscle may result in better postoperative patient reported ejaculatory function and less post-void dribbling.

MATERIALS AND METHODS

We performed a multi-institutional matched, case-control analysis comparing men treated with a bulbospongiosus sparing technique to men treated with the traditional nonbulbospongiosus sparing technique. Preoperative and postoperative (3 to 12 months) ejaculatory function was assessed using the 4 ejaculatory questions of the Male Sexual Health Questionnaire short form as well as a patient perception questionnaire. Post-void dribbling was assessed using a validated urethroplasty questionnaire.

RESULTS

A total of 25 patients who underwent bulbospongiosus sparing urethroplasty and 25 who underwent nonbulbospongiosus sparing urethroplasty were matched by total preoperative Male Sexual Health Questionnaire score, age, and performance of excision and primary anastomosis. The bulbospongiosus sparing and nonbulbospongiosus sparing groups had similar postoperative total Male Sexual Health Questionnaire scores (15.24 vs 15.40, respectively, p=0.90) and there were no significant postoperative questionnaire score changes in either group (bulbospongiosus sparing 14.56 to 15.24, p=0.4; nonbulbospongiosus sparing 14.64 vs 15.40, p=0.44). Individual responses to the Male Sexual Health Questionnaire were analyzed and no statistically significant difference was found between the groups. Rates of postoperative post-void dribbling and perception of ejaculatory function were similar between the groups.

CONCLUSIONS

Sparing the bulbospongiosus muscle during urethroplasty does not seem to have a significant impact on patient reported ejaculatory function or post-void dribbling compared with nonbulbospongiosus sparing urethroplasty at early followup.

Impact of Living at the Japanese Antarctic Research Expedition Base on Urinary Status

OBJECTIVES

Urinary disorders are generally well understood, but there are few reports on the urinary status of people living in unusual climates such as the polar regions. We studied the impact of living conditions on the urinary status of members of the Japanese Antarctic Research Expedition.

METHODS

This prospective study enrolled 12 consenting members of the wintering party stationed at the Syowa Station in Antarctica between November 2012 and March 2014. The subjects completed questionnaires (the International Prostate Symptom Score [IPSS], Overactive Bladder Syndrome Score [OABSS] and Pittsburgh Sleep Quality Index [PSQI]) and kept daily voiding dairies for 3 days consecutively every 2 months.

RESULTS

Compared with baseline values, the mean scores on all the questionnaires decreased during the stay in Antarctica, from 3.42 to 2.31 for the IPSS, 1.25 to 0.986 for the OABSS, and 4.58 to 3.78 on the PSQI. A significant difference was noted in the scores of seven subjects with a 3 point or more decrease in IPSS score and five members with a decrease less than 3 points (-2.22 vs 0.448, P = 0.0416).

CONCLUSION

This is the first survey of the urinary status of people living in a polar environment. The findings obtained by questionnaires and voiding dairies indicated that urination and sleep status did not worsen during the stay in Antarctica.

High Rates of Inadequate Urine Volume Cause Failure of Clinic Based Uroflowmetry in Men with Lower Urinary Tract Symptoms

INTRODUCTION

Clinic based uroflowmetry is commonly used in the diagnosis and management of lower urinary tract symptoms. AUA (American Urological Association) guidelines recommend 2 separate uroflowmetry tests with a voided volume greater than 150 ml for accurate interpretation. We characterized the interpretability of a series of uroflowmetry tests done at our institution and hypothesized that a significant number were noninterpretable because of inadequate urine volume.

METHODS

Uroflowmetry results were collected from male patients at the UH (University of Utah Hospital) and VAMC (George Wahlen Veterans Affairs Medical Center) urology clinics between August 31, 2014 and September 30, 2014. Average time to perform uroflowmetry was determined. Tests with a volume of 150 ml or less were classified as noninterpretable. Data were characterized using descriptive statistics.

RESULTS

During the study period 169 tests were collected, including 104 at UH and 65 at VAMC, of which 107 (63%) were noninterpretable. An estimated total of 1,452 tests were performed at UH and VAMC within a 12-month period. Average time to perform uroflowmetry by health care workers was 2 minutes 18 seconds. The estimated time loss per year for medical personnel due to noninterpretable uroflow studies was 35 hours.

CONCLUSIONS

More than 50% of clinic based uroflowmetry tests at our institution had a voided volume of 150 ml or less and were deemed noninterpretable per AUA guidelines. Current clinic based uroflowmetry testing strategies are inefficient and wasteful. Reliable, accurate alternatives to clinic based uroflowmetry for the diagnosis and management of lower urinary tract symptoms should be explored.

Normalized Urinary Flow at Puberty after Tubularized Incised Plate Urethroplasty for Hypospadias in Childhood

PURPOSE

An obstructive urinary flow pattern is frequently seen after tubularized incised plate urethroplasty for hypospadias. However, the significance of this finding has not been determined and long-term results are few. We describe postoperative long-term uroflowmetry results after puberty in males who underwent tubularized incised plate urethroplasty in childhood.

MATERIALS AND METHODS

A total of 126 boys underwent tubularized incised plate urethroplasty for distal penile to mid shaft hypospadias at Queen Silvia Children's Hospital in Gothenburg between 1999 and 2003. Of the patients 48 were toilet trained at surgery. We report on 40 patients who had data available at 2 and 12 months postoperatively, 7 years postoperatively and at puberty (median age 15.0 years, range 13.7 to 17.1). Of the patients 31 had distal and 9 had mid penile hypospadias. Clinical examination, urinary medical history, uroflowmetry and ultrasound measuring residual urine were performed. Maximum urinary flow was correlated to age and voided volume, using Miskolc nomograms for comparison of percentiles.

RESULTS

At 1 year postoperatively 15 boys (37.5%) had normal urinary flow (above 25th percentile), compared to 16 (40%) at 7 years and 38 (95%) at puberty (p <0.0001). Improvement was significant in patients with distal (p <0.0001) and mid penile hypospadias (p = 0.008), as well as in patients who did (p = 0.0078) and did not undergo intervention (p <0.0001). During followup 5 patients underwent meatotomy due to obstructive symptoms and 4 underwent dilation. Three of these 9 patients had lichen sclerosus.

CONCLUSIONS

There is great potential for normalization of urinary flow at puberty for boys with hypospadias treated with tubularized incised plate urethroplasty. Unless symptoms occur, a conservative approach seems preferable.

Invasive urodynamic studies for the management of lower urinary tract symptoms (LUTS) in men with voiding dysfunction

BACKGROUND

Invasive urodynamic tests are used to investigate men with lower urinary tract symptoms (LUTS) and voiding dysfunction to determine a definitive objective diagnosis. The aim is to help clinicians select the treatment that is most likely to be successful. These investigations are invasive and time-consuming.

OBJECTIVES

To determine whether performing invasive urodynamic investigation, as opposed to other methods of diagnosis such as non-invasive urodynamics or clinical history and examination alone, reduces the number of men with continuing symptoms of voiding dysfunction. This goal will be achieved by critically appraising and summarising current evidence from randomised controlled trials related to clinical outcomes and cost-effectiveness. This review is not intended to consider whether urodynamic tests are reliable for making clinical diagnoses, nor whether one type of urodynamic test is better than another for this purpose.The following comparisons were made.• Urodynamics versus clinical management.• One type of urodynamics versus another.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, issue 10), MEDLINE (1 January 1946 to Week 4 October 2014), MEDLINE In-Process and other non-indexed citations (covering 27 November 2014; all searched on 28 November 2014), EMBASE Classic and EMBASE (1 January 2010 to Week 47 2014, searched on 28 November 2014), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (searched on 1 December 2014 and 3 December 2014, respectively), as well as the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in men who were and were not investigated with the use of invasive urodynamics, or comparing one type of urodynamics against another, were included. Trials were excluded if they did not report clinical outcomes.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included two trials, but data were available for only 339 men in one trial, of whom 188 underwent invasive urodynamic studies. We found evidence of risk of bias, such as lack of outcome information for 24 men in one arm of the trial.Statistically significant evidence suggests that the tests did change clinical decision making. Men in the invasive urodynamics arm were more likely to have their management changed than men in the control arm (proportion with change in management 24/188 (13%) vs 0/151 (0%), risk ratio (RR) 39.41, 95% confidence interval (CI) 2.42 to 642.74). However, the quality of the evidence was low.Low-quality evidence indicates that men in the invasive urodynamics group were less likely to undergo surgery as treatment for voiding LUTS (164/188 (87%) vs 151/151 (100%), RR 0.87, 95% CI 0.83 to 0.92).Investigators observed no difference in urine flow rates before and after surgery for LUTS (mean percentage increase in urine flow rate, 140% in invasive urodynamic group vs 149% in immediate surgery group, P value = 0.13). Similarly, they found no differences between groups with regards to International Prostate Symptom Score (IPSS) (mean percentage decrease in IPSS score, 58% in invasive urodynamics group vs 59% in immediate surgery group, P value = 0.22).No evidence was available to demonstrate whether differences in management equated to improved health outcomes, such as relief of symptoms of voiding dysfunction or improved quality of life.No evidence from randomised trials revealed the adverse effects associated with invasive urodynamic studies.

AUTHORS' CONCLUSIONS

Although invasive urodynamic testing did change clinical decision making, we found no evidence to demonstrate whether this led to reduced symptoms of voiding dysfunction after treatment. Larger definitive trials of better quality are needed, in which men are randomly allocated to management based on invasive urodynamic findings or to management based on findings obtained by other diagnostic means. This research will show whether performance of invasive urodynamics results in reduced symptoms of voiding dysfunction after treatment.

The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society

AIM

The impact of the original International Children's Continence Society (ICCS) terminology document on lower urinary tract (LUT) function resulted in the global establishment of uniformity and clarity in the characterization of LUT function and dysfunction in children across multiple healthcare disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric LUT function.

METHODS

A variety of worldwide experts from multiple disciplines within the ICCS leadership who care for children with LUT dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. Additionally, contributions and feedback from the multidisciplinary ICCS membership were solicited.

RESULTS

Following a review of the literature over the last 7 years, the ICCS experts assembled a new terminology document reflecting current understanding of bladder function and LUT dysfunction in children using the resources from the literature review, expert opinion and ICCS member feedback.

CONCLUSIONS

The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of LUT function in children. Neurourol. Urodynam. 35:471-481, 2016. © 2015 Wiley Periodicals, Inc.