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Finazzi Agrò E, Rosato E, Wagg A, Sinha S, Fede Spicchiale C, Serati M, Mancini V, de Rijk M, Tarcan T, Wein A, Abrams P, Bou Kheir G. How do we make progress in phenotyping patients with LUT such as OAB and underactive detrusor, including using urine markers and microbiome data, in order to personalize therapy? ICI-RS 2023: Part 1. Neurourol Urodyn 2024; 43:1261-1271. [PMID: 38178627 DOI: 10.1002/nau.25377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Overactive bladder (OAB) and Underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction. OBJECTIVES The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment. METHODS A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU investigating metabolic, neurogical, psychological and gastrointestinal aspects with the aim to personalize the treatment. RESULTS AND CONCLUSIONS The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract symptoms, such as OAB and UAB. The intricate interplay between the lower urinary tract and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.
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Affiliation(s)
- Enrico Finazzi Agrò
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Eleonora Rosato
- School of specialization in Urology, Policlinico Tor Vergata University Hospital, University of Rome Tor Vergata and Urology Unit, Rome, Italy
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | | | - Maurizio Serati
- Department Obstetrics and Gynecology, Urogynecology Unit, University of Insubria, Varese, Italy
| | - Vito Mancini
- Urology and renal transplantation Unit, Urinary incontinence center, Policlinico di Foggia Hospital and University of Foggia, Foggia, Italy
| | - Mathijs de Rijk
- Department of Urology, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Tufan Tarcan
- Marmara University School of Medicine, Istanbul, Turkey and Koç University School of Medicine, Istanbul, Turkey
| | - Alan Wein
- University of Miami Miller School of Medicine, Desai Sethi Institute of Urology, Miami, Florida, USA
| | - Paul Abrams
- Department of Urology, University of Bristol, Bristol, UK
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Jo JK, Kim H, Bang WJ, Oh CY, Cho JS, Shim M. Effect of Diabetes Mellitus on Symptomatic Improvement After Surgery for Benign Prostatic Hyperplasia in Patients With Lower Urinary Tract Symptom and its Relations With Prostatic Urethral Angulation. Int Neurourol J 2023; 27:116-123. [PMID: 37401022 DOI: 10.5213/inj.2346008.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/08/2023] [Indexed: 07/05/2023] Open
Abstract
PURPOSE To compare improvement of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia in diabetic versus nondiabetic patients after transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP). METHODS The medical records of 437 patients who underwent TURP or HoLEP at a tertiary referral center from January 2006 to January 2022 were retrospectively analyzed. Among them, 71 patients had type 2 diabetes. Patients in the diabetic mellitus (DM) and non-DM groups were matched 1:1 according to age, baseline International Prostate Symptom Score (IPSS), and ultrasound measured prostate volume. Changes in LUTS were assessed at 3 months after surgery using IPSS and evaluated by categorizing patients according to prostatic urethral angulation (PUA; <50° vs. ≥50°). Medication-free survival after surgery was also investigated. RESULTS No significant differences were noted between the DM and non-DM groups in baseline characteristics except for comorbidities (i.e., hypertension, cerebrovascular disease, and ischemic heart disease, P=0.021, P=0.002, and P=0.017, respectively) and postvoid residual urine volume (115±98 mL vs. 76±105 mL, P=0.028). Non-DM patients showed significant symptomatic improvement regardless of PUA, while DM patients demonstrated improvement in obstructive symptoms only in those with large PUA (≥51°). Among patients with small PUA, DM patients had worse medication-free survival after surgery compared to controls (P=0.044) and DM was an independent predictor of medication reuse (hazard ratio, 1.422; 95% confidence interval, 1.285-2.373; P=0.038). CONCLUSION DM patients experienced symptomatic improvement after surgery only in those with large PUA. Among patients with small PUA, DM patients were more likely to reuse medication after surgery.
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Affiliation(s)
- Jung Ki Jo
- Department of Urology, College of Medicine, Hanyang University, Seoul, Korea
| | - Hwanik Kim
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Woo Jin Bang
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Cheol Young Oh
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jin Seon Cho
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Myungsun Shim
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Bai J, Tian Y, Wang Y, Zhang X, Wang P. Physical and Rehabilitation Therapy for Overactive Bladder in Women: A Systematic Review and Meta-Analysis. Int J Clin Pract 2023; 2023:6758454. [PMID: 36704247 PMCID: PMC9833926 DOI: 10.1155/2023/6758454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To compare the effects of different physical and rehabilitation therapies on women with overactive bladder (OAB). DESIGN Network meta-analysis. Data source: The Embase, Scopus, and PubMed databases were systematically searched from their inception to June 22, 2022. We included only RCTs, with no language restrictions. Articles in the reference lists and related studies were thoroughly reviewed. Review Methods. This network meta-analysis included related studies on different physical and rehabilitation therapies for OAB. Data were extracted independently from the included randomized controlled trials by two authors, and they used the Cochrane Collaboration's tool to evaluate the risk of bias. We used RevMan to assess the risk assessment of research bias. This network meta-analysis was performed using the Stata software. We completed the review in accordance with the PRISMA items for systematic reviews and meta-analyses statement. RESULTS Twelve randomized controlled trials involving 637 patients were included in this meta-analysis. All physical and rehabilitation therapies improved daytime micturition frequency and nocturia frequency in OAB patients. Percutaneous tibial nerve stimulation (PTNS), BT + ES, and BT + BF + ES are better interventions for OAB treatment. There were no significant differences in PTNS, BT + ES, and BT + BF + ES. CONCLUSION All physical and rehabilitation therapies can improve daytime micturition and nocturia frequency in OAB. PTNS, BT + ES, and BT + BF + ES were the priority therapies.
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Affiliation(s)
- Jingwen Bai
- Department of Obstetrics and Gynecology, The West China Second University Hospital, Sichuan University, No. 20 Section Three, South Renmin Road, Chengdu 610041, Sichuan Province, China
- Department of Obstetrics and Gynecology, Affiliated Hospital of Chengdu University, Chengdu 610081, Sichuan Province, China
| | - Yilan Tian
- Department of Obstetrics and Gynecology, The West China Second University Hospital, Sichuan University, No. 20 Section Three, South Renmin Road, Chengdu 610041, Sichuan Province, China
| | - Yiran Wang
- Department of Obstetrics and Gynecology, The West China Second University Hospital, Sichuan University, No. 20 Section Three, South Renmin Road, Chengdu 610041, Sichuan Province, China
| | - Xiaofang Zhang
- Department of Obstetrics and Gynecology, The West China Second University Hospital, Sichuan University, No. 20 Section Three, South Renmin Road, Chengdu 610041, Sichuan Province, China
| | - Ping Wang
- Department of Obstetrics and Gynecology, The West China Second University Hospital, Sichuan University, No. 20 Section Three, South Renmin Road, Chengdu 610041, Sichuan Province, China
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Erdogan BR, Liu G, Arioglu-Inan E, Michel MC. Established and emerging treatments for diabetes-associated lower urinary tract dysfunction. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2022; 395:887-906. [PMID: 35545721 PMCID: PMC9276575 DOI: 10.1007/s00210-022-02249-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/28/2022] [Indexed: 12/16/2022]
Abstract
Dysfunction of the lower urinary tract (LUT) including urinary bladder and urethra (and prostate in men) is one of the most frequent complications of diabetes and can manifest as overactive bladder, underactive bladder, urinary incontinence, and as aggravated symptoms of benign prostate hyperplasia. We have performed a selective literature search to review existing evidence on efficacy of classic medications for the treatment of LUT dysfunction in diabetic patients and animals, i.e., α1-adrenoceptor and muscarinic receptor antagonists, β3-adrenoceptor agonists, and phosphodiesterase type 5 inhibitors. Generally, these agents appear to have comparable efficacy in patients and/or animals with and without diabetes. We also review effects of antidiabetic medications on LUT function. Such studies have largely been performed in animal models. In the streptozotocin-induced models of type 1 diabetes, insulin can prevent and reverse alterations of morphology, function, and gene expression patterns in bladder and prostate. Typical medications for the treatment of type 2 diabetes have been studied less often, and the reported findings are not yet sufficient to derive robust conclusions. Thereafter, we review animal studies with emerging medications perhaps targeting diabetes-associated LUT dysfunction. Data with myoinositol, daidzein, and with compounds that target oxidative stress, inflammation, Rac1, nerve growth factor, angiotensin II receptor, serotonin receptor, adenosine receptor, and soluble guanylyl cyclase are not conclusive yet, but some hold promise as potential treatments. Finally, we review nonpharmacological interventions in diabetic bladder dysfunction. These approaches are relatively new and give promising results in preclinical studies. In conclusion, the insulin data in rodent models of type 1 diabetes suggest that diabetes-associated LUT function can be mostly or partially reversed. However, we propose that considerable additional experimental and clinical studies are needed to target diabetes itself or pathophysiological changes induced by chronic hyperglycemia for the treatment of diabetic uropathy.
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Affiliation(s)
- Betül R Erdogan
- Department of Pharmacology, Faculty of Pharmacy, Izmir Katip Celebi University, Izmir, Turkey
| | - Guiming Liu
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ebru Arioglu-Inan
- Department of Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Martin C Michel
- Department of Pharmacology, University Medical Center, Johannes Gutenberg University, Mainz, Germany.
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Dawson S, Duncan L, Ahmed A, Gimson A, Henderson EJ, Rees J, Strong E, Drake MJ, Cotterill N, Huntley AL, Andrews RC. Assessment and Treatment of Nocturia in Endocrine Disease in a Primary Care Setting: Systematic Review and Nominal Group Technique Consensus. Eur Urol Focus 2022; 8:52-59. [PMID: 34996740 DOI: 10.1016/j.euf.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022]
Abstract
CONTEXT Salt and water homeostasis is regulated hormonally, so polyuria can result from endocrine disease directly or via secondary effects. These mechanisms are not consistently considered in primary care management of nocturia. OBJECTIVE To conduct a systematic review (SR) of nocturia in endocrine disease and reach expert consensus for primary care management. EVIDENCE ACQUISITION Four databases were searched from January 2000 to April 2020. A total of 4382 titles and abstracts were screened, 36 studies underwent full-text screening, and 14 studies were included in the analysis. Expert and public consensus was achieved using the nominal group technique (NGT). EVIDENCE SYNTHESIS Twelve studies focused on mechanisms of nocturia, while two evaluated treatment options; none of the studies took place in a primary care setting. NGT consensus identified key clinical evaluation themes, including the presence of thirst, a medical background of diabetes mellitus or insipidus, thyroid disease, oestrogen status, medications (fluid loss or xerostomia), and general examination including body mass index. Proposed investigations include a bladder diary, renal and thyroid function, calcium, and glycated haemoglobin. Morning urine osmolarity should be examined in the context of polyuria of >2.5 l/24 h persisting despite fluid advice, with urine concentration >600 mOsm/l after fluid restriction excluding diabetes insipidus. Treatment should involve education, including adjustment of lifestyle and medication where possible. Any underlying endocrine disorder should be managed according to local guidance. Referral to endocrinology is needed if there is hyperthyroidism, hyperparathyroidism, or morning urine osmolarity <600 mOsm/l after overnight fluid avoidance. CONCLUSIONS Endocrine disease can result in nocturia via varied salt and water regulation pathways. The aim of management is to identify and treat causative factors, but secondary effects can restrict improvements in nocturia. PATIENT SUMMARY People with altered hormone function can suffer from severe sleep disturbance because of a need to pass urine caused by problems in controlling water and salt levels. An expert panel recommended the best ways to assess and treat these problems on the basis of the rather small amount of up-to-date published research available.
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Affiliation(s)
- Shoba Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lorna Duncan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ahmed Ahmed
- Endocrinology and Diabetes Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Amy Gimson
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Emily J Henderson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Older Person's Unit, Royal United Hospital NHS Foundation Trust Bath, Combe Park, Bath, UK
| | - Jonathan Rees
- Tyntesfield Medical Group, Backwell Medical Centre, Bristol, UK
| | - Ed Strong
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Nikki Cotterill
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK; School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Alyson L Huntley
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robert C Andrews
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
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Park GH, Kim SJ, Cho YS. Development of a voiding diary using urination recognition technology in mobile environment. J Exerc Rehabil 2021; 16:529-533. [PMID: 33457390 PMCID: PMC7788254 DOI: 10.12965/jer.2040790.395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/05/2020] [Indexed: 11/30/2022] Open
Abstract
We invented a wearable device that can measure voiding time and frequency by checking a habitual series of characteristic motions among men. This study collected and analyzed urination time data collected smart bands worn by patients to resolve the clinical issues posed by using voiding charts. By developing a smart band-based algorithm for assessing urination time in patients, this study aimed to explore the feasibility of urination management systems. This study aimed to assess urination time based on a patient’s posture and changes in posture. Motion data were obtained from a smart band on the arm. An algorithm that identifies the three stages of urination (forward movement, urination, backward movement) was developed based on data collected from a 3-axis accelerometer and tilt angle data. Therefore, we analyze hidden Markov model (HMM)-based sequential data to determine urination time. Real-time data were acquired from the smart band. For data corresponding to a specific duration, the value of the signals was calculated and then compared with the set analysis model to calculate the time of urination. The final accuracy of the algorithm was calculated based on clinical guidelines for urologists. The experiment showed a high average accuracy of 92.5%, proving the robustness of the proposed algorithm. The proposed urination time recognition technology draws on acceleration data and tilt angle data collected via a smart band; these data were then analyzed using a classifier after applying the HMM method.
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Affiliation(s)
- Gun Hyun Park
- Department of Urology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Su Jin Kim
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Sam Cho
- Department of Urology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Catheter-Related Bladder Discomfort: How Can We Manage It? Int Neurourol J 2020; 24:324-331. [PMID: 33401353 PMCID: PMC7788325 DOI: 10.5213/inj.2040108.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/10/2020] [Indexed: 12/12/2022] Open
Abstract
The urethral catheter is used in various clinical situations such as diagnosing urologic disease, urine drainage in patients after surgery, and for patients who cannot urinate voluntarily. However, catheters can cause numerous adverse effects, such as catheter-associated infection, obstruction, bladder stones, urethral injury, and catheter-related bladder discomfort (CRBD). CRBD symptoms vary among patients from burning sensation and pain in the suprapubic and penile areas to urinary urgency. CRBD significantly reduces patient quality of life and can lead to several complications. CRBD is caused by catheter-induced bladder irritation due to muscarinic receptor-mediated involuntary contractions of bladder smooth muscle and also can be caused by mechanical stimulus of the urethral catheter. Various pharmacologic studies for managing CRBD, including antimuscarinic and antiepileptic agents and botulinum toxin injections have been reported. If urologists can reduce patients’ CRBD, their quality of life and recovery can improve.
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Moussa M, Papatsoris A, Chakra MA, Fares Y, Dellis A. Lower urinary tract dysfunction in common neurological diseases. Turk J Urol 2020; 46:S70-S78. [PMID: 32384046 DOI: 10.5152/tud.2020.20092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
Abstract
The lower urinary tract has the main function of urine storage and voiding. The integrity of the lower urinary tract nerve supply is necessary for its proper function. Neurological disorders can lead to lower urinary tract dysfunction (LUTD) and cause lower urinary tract symptoms (LUTS). Common causes of neurogenic LUTS or LUTD include spinal cord injury, multiple sclerosis, Parkinson's disease, cerebrovascular accidents, cauda equina syndrome, diabetes mellitus, and multiple system atrophy. The pathophysiology is categorized according to the nature of the onset of neurological disease. Assessment requires clinical evaluation, laboratory tests, imaging, and urodynamic studies. Impaired voiding is most often managed by clean intermittent self-catheterization if the postvoid residual urine exceeds 100 ml, whereas storage symptoms are most often managed by antimuscarinic medications. Intradetrusor injection of botulinum toxin type A is emerging as an effective treatment for managing refractory neurogenic detrusor overactivity. This review provides an overview of the clinical characteristics, diagnosis, and management of LUTD in patients with central and peripheral common neurological diseases.
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Affiliation(s)
- Mohamad Moussa
- Department of Urology, Al Zahraa University Medical Center, Beirut, Lebanon
| | | | | | - Yousef Fares
- Department of Neurosurgery, Al Zahraa University Medical Center, Beirut, Lebanon
| | - Athanasios Dellis
- Department of Urology/General Surgery, Areteion Hospital, Athens, Greece
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Sheyn D, Mahajan ST, Hijaz A, Slopnick E, Chapman G, El-Nashar S, Mangel JM. Cerebral White Matter Disease and Response to Anti-Cholinergic Medication for Overactive Bladder in an Age-Matched Cohort. Int Urogynecol J 2019; 30:1755-1761. [PMID: 31152187 DOI: 10.1007/s00192-019-03988-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/14/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine if the presence of cerebral white matter disease (WMD) affects the response to anti-cholinergic medications. MATERIALS AND METHODS This was a retrospective cohort of age-matched patients treated for OAB with anti-cholinergic medications between January 2010 and December 2017. Inclusion criteria were a chief complaint of OAB, never evaluated by a urogynecologist for OAB, treated with a maximum dose for a minimum of 4 weeks, and underwent head computed tomography (CT) within 12 months of starting therapy. Patients with WMD were matched 1:1 by age and number of prior failed antimuscarinics to controls with normal head CTs. Exclusion criteria included incomplete documentation of therapeutic response, non-WMD CT abnormalities, and non-idiopathic OAB. The primary outcome was anti-cholinergic treatment failure. Pairwise analysis between groups was performed using Wilcoxon rank-sum and Fisher's exact test where appropriate. Univariate logistic regression was performed, and any variable that was associated with treatment failure and a p value ≤ 0.2 was included in the multivariable regression analysis. RESULTS Sixty-eight cases were matched with 68 controls. Patients with WMD were more likely to have undergone hysterectomy (57.4% vs. 41.2%, p = 0.04) and to use diuretics (31.1% vs. 19.1%, p = 0.04). Patients with WMD were more likely to fail treatment compared with controls (60.7% vs. 29.4%, p = 0.004). After adjusting for confounders, WMD was strongly associated with an increased probability of failure (aOR = 7.31, 95% CI: 1.49-12.20). Additional significant risk factors for treatment failure were the previous number of failed medications (aOR = 3.65 per medication, 95% CI: 1.48-9.01) and a rising HbA1c (aOR: 1.39 per 1.0% increase, 95% CI: 1.0-1.91). CONCLUSION WMD is independently associated with anti-muscarinic treatment failure in women with overactive bladder symptoms.
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Affiliation(s)
- David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Urology, University Hospitals Cleveland Medical Center, 11000 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Sangeeta T Mahajan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adonis Hijaz
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Urology, University Hospitals Cleveland Medical Center, 11000 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Emily Slopnick
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Urology, University Hospitals Cleveland Medical Center, 11000 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Graham Chapman
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Urology, University Hospitals Cleveland Medical Center, 11000 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sherif El-Nashar
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Mangel
- Division of Female Pelvic Medicine and Reconstructive Surgery, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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