Exploring lifelong overactive bladder: Transitions, evidence, and clinical implications; A modified Delphi process

INTRODUCTION

Overactive bladder (OAB) is a prevalent urological condition characterized by urinary urgency, with or without urgency urinary incontinence, accompanied by increased daytime frequency and nocturia. However, the current definition of OAB lacks a specified time frame, hindering our understanding of the temporal aspects and transitions that occur within the OAB spectrum.

METHODS

A modified Delphi study was conducted in three rounds, involving a panel of international experts in functional urology, urogynaecology, geriatrics, transitional medicine, and pediatric urology. The study took place between February 2023 and June 2023 and employed two sequential rounds of online surveys, followed by a final hybrid group discussion session in June 2023.

RESULTS

The Delphi process resulted in a consensus definition of lifelong OAB as a persistent and continuous condition that may manifest differently from birth and evolve over time, with varying levels of clinical perception. The course of its progression is influenced by transition periods and modifying factors, mainly anatomical, hormonal, and psychosocial/stressors. Three main transition periods were identified: achievement of daytime continence, adulthood to elderly, and transition to frail elderly. The panel also considered the therapeutic and diagnostic implications of lifelong OAB, as well as future research prospects in terms of importance and feasibility.

CONCLUSIONS

Future longitudinal research is needed to develop this concept and further identify transitions and temporal dynamics.

Can we use machine learning to improve the interpretation and application of urodynamic data?: ICI-RS 2023

INTRODUCTION

A "Think Tank" at the International Consultation on Incontinence-Research Society meeting held in Bristol, United Kingdom in June 2023 considered the progress and promise of machine learning (ML) applied to urodynamic data.

METHODS

Examples of the use of ML applied to data from uroflowmetry, pressure flow studies and imaging were presented. The advantages and limitations of ML were considered. Recommendations made during the subsequent debate for research studies were recorded.

RESULTS

ML analysis holds great promise for the kind of data generated in urodynamic studies. To date, ML techniques have not yet achieved sufficient accuracy for routine diagnostic application. Potential approaches that can improve the use of ML were agreed and research questions were proposed.

CONCLUSIONS

ML is well suited to the analysis of urodynamic data, but results to date have not achieved clinical utility. It is considered likely that further research can improve the analysis of the large, multifactorial data sets generated by urodynamic clinics, and improve to some extent data pattern recognition that is currently subject to observer error and artefactual noise.

Is detrusor underactivity associated with voiding dysfunction after single incision sling surgery?

BACKGROUND

Some women experience voiding dysfunction after stress urinary incontinence (SUI) surgery. We explore if detrusor underactivity (DU) found in urodynamic study (UDS) prior to SUI surgery using an adjustable single incision sling (SIS) may be related to voiding dysfunction after surgery.

METHODS

This is a prospective, diagnostic, transversal, single center study comparing voiding dysfunction after SUI surgery with a SIS (Altis®; Coloplast, Humlebæk, Denmark) between women with DU (cases) or normal detrusor (controls). Inclusion criterium was women ≥18 years with SUI/mixed UI (stress predominant) operated between June 2013 and December 2020. Exclusion criteria were: women without UDS prior to surgery or without voiding phase in the P/Q, previous incontinence surgery, POP stage ≥2, neurogenic conditions, other pelvic floor surgery. Urinary symptoms were assessed using structured questions evaluating storage/voiding symptoms. Patients were divided into two groups according to projected Isovolumetric Pressure Index (PIP1) with 30-75 cmH2O indicating normal contractility.

RESULTS

A total of 139 women were included, 29 (20.9%) in DU group and 110 (79.1%) in control group. Control and DU groups have shown similar objective (75.5% vs. 71.4% P=0.66) and subjective (85.4% vs. 96.1% P=0.22) success rates, respectively, without statistical differences. Voiding symptoms increased after surgery in both groups (+20.7% DU group vs. +8.1% normal group, P=0.29). More voiding symptoms (persistent/de novo) were found in DU group vs. normal group, but without statistically significant differences.

CONCLUSIONS

According to our results, the presence of DU previous to SUI surgery with a SIS (Altis®, Coloplast) has no impact on objective and subjective success rates. On the other hand, patients with preoperative DU showed higher proportion of voiding dysfunction but no statistical difference.

What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence Under the Auspices of the European Association of Urology, Female Non-neurogenic Lower Urinary Tract Symptoms Guidelines Panel

CONTEXT

Overactive bladder syndrome (OAB) is highly prevalent among women and has a negative impact on their quality of life. The current available treatments for OAB symptoms include conservative, pharmacological, or surgical modalities.

OBJECTIVE

To provide an updated contemporary evidence document regarding OAB treatment options and determine the short-term effectiveness, safety, and potential harms of the available treatment modalities for women with OAB syndrome.

EVIDENCE ACQUISITION

The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched for all relevant publications up to May 2022. The risk of bias assessment followed the recommended tool in the Cochrane Handbook for Systematic Reviews of Interventions, and quality of evidence was assessed using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A meta-analysis was performed where appropriate.

EVIDENCE SYNTHESIS

Antimuscarinics and beta-3 agonists were significantly more effective than placebo across most outcomes, with beta-3 agonists being more effective at reducing nocturia episodes and antimuscarinics causing significantly higher adverse events. Onabotulinumtoxin-A (Onabot-A) was more effective than placebo across most outcomes, but with significantly higher rates of acute urinary retention/clean intermittent self-catheterisation (six to eight times) and urinary tract infections (UTIs; two to three times). Onabot-A was also significantly better than antimuscarinics in the cure of urgency urinary incontinence (UUI) but not in the reduction of mean UUI episodes. Success rates of sacral nerve stimulation (SNS) were significantly higher than those of antimuscarinics (61% vs 42%, p = 0.02), with similar rates of adverse events. SNS and Onabot-A were not significantly different in efficacy outcomes. Satisfaction rates were higher with Onabot-A, but with a higher rate of recurrent UTIs (24% vs 10%). SNS was associated with 9% removal rate and 3% revision rate.

CONCLUSIONS

Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include Onabot-A bladder injections or SNS. The choice of therapies should be guided by individual patient factors.

PATIENT SUMMARY

Overactive bladder is a manageable condition. All patients should be informed and advised on conservative treatment measures in the first instance. The first-line treatment options for its management include antimuscarinics or beta-3 agonists medication, and posterior tibial nerve stimulation procedures. The second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation procedure. The therapy should be chosen based on individual patient factors.

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa)

Introduction

The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS.

Methods

The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement.

Results

98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or β 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance.

Conclusions

During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Benefits and Harms of Conservative, Pharmacological, and Surgical Management Options for Women with Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel

CONTEXT

While the management of bladder outlet obstruction (BOO) in men has been a topic of several systematic reviews and meta-analyses, no such evidence base exists for female BOO.

OBJECTIVE

The aim of this systematic review was to evaluate the benefits and harms of therapeutic interventions for the management of BOO in women.

EVIDENCE ACQUISITION

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The study protocol was registered with PROSPERO (CRD42020183839). A systematic literature search was performed and updated by a research librarian in May 2021. The study population consisted of adult female patients diagnosed with BOO, who underwent treatment.

EVIDENCE SYNTHESIS

Out of 6344 records, we identified 33 studies enrolling 1222 participants, of which only six randomized controlled trials (RCTs) were found. One placebo-controlled crossover randomized trial assessed the role of baclofen in 60 female patients with dysfunctional voiding. The trial met its primary endpoint with a significantly greater decrease in the number of voids per day in the baclofen group (-5.53 vs -2.70; p = 0.001). The adverse events were mild and comparable in both groups (25% vs 20%). One placebo-controlled crossover randomized trial assessed the role of sildenafil in 20 women with Fowler's syndrome. There were significant improvements from baseline in maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and postvoid residual (PVR), but with no statistically significant difference when compared with placebo. In a large RCT including 197 female patients with functional BOO, the alpha-blocker alfuzosin significantly improved IPSS, Qmax, and PVR compared with baseline, but the differences were not statistically significant compared with the placebo group. Several small single-arm prospective series reported improvement of BOO-related symptoms and voiding parameters with urethroplasty, sling revision, urethral dilation, vaginal pessary, and pelvic organ prolapse repair.

CONCLUSIONS

Evidence to support the use of conservative, pharmacological, and surgical treatments for BOO is scarce.

PATIENT SUMMARY

According to the present systematic review of the literature, evidence to support the use of conservative, pharmacological, and surgical treatments for either anatomical or functional bladder outlet obstruction is scarce.

European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia

CONTEXT

Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions.

OBJECTIVE

To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females.

EVIDENCE ACQUISITION

The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline.

EVIDENCE SYNTHESIS

The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

CONCLUSIONS

Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format.

PATIENT SUMMARY

This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to the treatment of underactive bladder, obstruction of the bladder outlet, and nighttime urination.

Development of a questionnaire set to evaluate adaptations to COVID era: The ICS TURNOVER project (Transition of fUnctional uRology to New COVID ERa)

OBJECTIVES

Coronavirus disease 2019 (COVID-19) pandemic has caused a massive cutdown in outpatient urological investigations, procedures, and interventions. Female and functional urology (FFU) has been probably the most affected subspecialty in urology. Several scientific societies have published guidelines to manage this new situation, providing general recommendations. The aim of this study was to devise a robust questionnaire covering every different aspect of FFU to obtain recommendations on COVID-19 adaptations.

METHODS

Delphi methodology was adapted to devise the survey questionnaires for male/female lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP), chronic pelvic pain (CPP), and neuro-urological disease. Content validity, face validity, and internal consistence were assessed to establish the final questionnaire. This study was ethically approved by the Local Research Ethics Committee.

RESULTS

A total 97, 59, 79, 85, and 84 items for female and male LUTS, POPs, CPP, and neuro-urology respectively were approved by the participants. Content validity over 0.70 was obtained which seemed reasonable content validity scores. Internal consistency obtains values of Cronbach's alpha was between 0.70 and 0.90 which was acceptable.

CONCLUSIONS

The collective wisdom obtained through a global survey using validated questionnaires covering every different aspect of FFU patient management is necessary. We have developed a robust and validated tool consisting of five questionnaires covering the most prevalent pathologies in FFU.

Diagnostic Tests for Female Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel

CONTEXT

Female bladder outlet obstruction (fBOO) is a relatively uncommon condition compared with its male counterpart. Several criteria have been proposed to define fBOO, but the comparative diagnostic accuracy of these remains uncertain.

OBJECTIVE

To identify and compare different tests to diagnose fBOO through a systematic review process.

EVIDENCE ACQUISITION

A systematic review of the literature was performed according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The EMBASE/MEDLINE/Cochrane databases were searched up to August 4, 2020. Studies on women ≥18 yr of age with suspected bladder outlet obstruction (BOO) involving diagnostic tests were included. Pressure-flow studies or fluoroscopy was used as the reference standard where possible. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

EVIDENCE SYNTHESIS

Overall, 28 nonrandomised studies involving 10 248 patients were included in the qualitative analysis. There was significant heterogeneity regarding the characteristics of women included in BOO cohorts (ie, mixed cohorts including both anatomical and functional BOO). Pressure-flow studies ± fluoroscopy was evaluated in 25 studies. Transperineal Doppler ultrasound was used to evaluate bladder neck dynamics in two studies. One study tested the efficacy of transvaginal ultrasound. The urodynamic definition of fBOO also varied amongst studies with different parameters and thresholds used, which precluded a meta-analysis. Three studies derived nomograms using the maximum flow rate (Q_max) and voiding detrusor pressure at Q_max. The sensitivity, specificity, and overall accuracy ranges were 54.6-92.5%, 64.6-93.9%, and 64.1-92.2%, respectively.

CONCLUSIONS

The available evidence on diagnostic tests for fBOO is limited and heterogeneous. Pressure-flow studies ± fluoroscopy remains the current standard for diagnosing fBOO.

PATIENT SUMMARY

Evidence on tests used to diagnose female bladder outlet obstruction was reviewed. The most common test used was pressure-flow studies ± fluoroscopy, which remains the current standard for diagnosing bladder outlet obstruction in women. TAKE  HOME MESSAGE: The available evidence on diagnostic tests for female bladder outlet obstruction is limited and heterogeneous. The most common test used was video-urodynamics, which remains the current standard for diagnosing bladder outlet obstruction in women.

[Cystoscopy in the assessment of patients with bladder pain syndrome: Results of a national multicenter observational study.]

OBJECTIVES

To study the use and results of cystoscopy and bladder hydrodistension in the objective assessment of patients with Bladder Pain Syndrome (BPS), in routine clinical practice.

MATERIAL AND METHODS

Observational, non-interventional, national, multicenter study carried out in Functional Urology and Urodynamic Units of Spain belonging to the IFU Group. 273 women with BPS who underwent cystoscopy at baseline as a diagnostic tool according to clinical criteria and following the routine clinical practice of each center, were studied. The pre and post hydrodistension findings and the scores of the symptom and Health-Related Quality of Life (HRQoL) questionnaires were described: BPIC-SS, PPBC, PGI-S and EQ-5D-5L.

RESULTS

The mean age (SD) was 59 (14) years with a high presence of bladder symptoms: increased voiding frequency (81.7%), nocturia (74%) and urgency (60.4%). 40.7% of cystoscopies were performed under anesthesia and 73.7% uses a standard rigid cystoscope. Hunner lesions were observed in 9.9% of the patients, hypervascularizations (46.2%), glomerulations (23.4%), mild bleeding (6.6%) and scars (2.2%). After hydrodistension, a greater number of grade 1 and 2 lesions were observed. In 51.6% of the patients there were no changes, but in 27.5% slight changes were observed and in 11.4% moderate or severe changes. Symptom and HRQoL questionnaire scores showed no association with cystoscopy findings before and after hydrodistension.

CONCLUSIONS

The value of the cystoscopic findings in the SDV has yet to be defined, although it plays a fundamental role in the differential diagnosis. In this observational study, we did not find a correlation of the cystoscopic findings with the symptoms of the patients, measured by validated questionnaires, nor with the HRQoL.

Longer is better than shorter: The added value of the seven-day pad test in the post-radical prostatectomy urinary incontinence

AIMS

To investigate the feasibility and reliability of the seven-day pad test (7DPT), the correlation between 7DPT and 24-hour pad test (24HPT), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire, and the different categorization by the severity of each pad test. Pad weighting tests have been recommended in the evaluation of post-radical prostatectomy urinary incontinence severity, being considered the 24HPT gold standard. Some authors consider that the longer the testing, the better assessment. We propose a self-filled pad weight, the 7DPT.

METHODS

A prospective study of incontinent male patients after radical prostatectomy. We carried out the study in two phases. All patients underwent urodynamic study. The first phase evaluated the feasibility and reliability of 7DPT. The second evaluated the correlation between 7DPT, 24HPT, and ICIQ-SF questionnaire in a larger sample.

RESULTS

First phase: 32 patients were recruited. Test-retest reliability was excellent, with good agreement between mean 7DPT and 24HPT. The number of pads and mean 7DPT showed a good correlation. Second phase: 72 patients were screened, 51 (71%) met inclusion criteria. Mean 7DPT and 24HPT showed a strong association. Mean 7DPT and 24HPT correlated moderately with ICIQ-SF score. 7DPT and 24HPT agreement with ICIQ-SF groups was slight. As 7DPT captures better days with maximum urinary leakage, up to 12 patients would have been misclassified according to 24HPT (number need to treat for 7DPT was seven).

CONCLUSIONS

7DPT is a feasible and reliable tool to evaluate post-radical prostatectomy urinary incontinence, with a strong correlation with the 24HPT and moderate with the ICIQ-SF.

Can radiation-induced lower urinary tract disease be ameliorated in patients treated for pelvic organ cancer: ICI-RS 2019?

Aims

This article reviews the clinical outcomes and basic science related to negative effects of radiotherapy (RT) on the lower urinary tract (LUT) when used to treat pelvic malignancies.

Methods

The topic was discussed at the 2019 meeting of the International Consultation on Incontinence―Research Society during a “think tank” session and is summarized in the present article.

Results

RT is associated with adverse effects on the LUT, which may occur during treatment or which can develop over decades posttreatment. Here, we summarize the incidence and extent of clinical symptoms associated with several modes of delivery of RT. RT impact on normal tissues including urethra, bladder, and ureters is discussed, and the underlying biology is examined. We discuss innovative in vivo methodologies to mimic RT in the laboratory and their potential use in the elucidation of mechanisms underlying radiation‐associated pathophysiology. Finally, emerging questions that need to be addressed through further research are proposed.

Conclusions

We conclude that RT‐induced negative effects on the LUT represent a significant clinical problem. Although this has been reduced with improved methods of delivery to spare normal tissue, we need to (a) discover better approaches to protect normal tissue and (b) develop effective treatments to reverse radiation damage.

ANalogical UroFlowmetry (ANUF): Correspondence Between This New Visual Pictogram and Uroflowmetry in Men With Lower Urinary Tract Symptoms: A new approach for the study of male micturition dynamics

OBJECTIVE

To study the correlation between a new visual tool (ANalogical UroFlowmetry (ANUF)) and uroflowmetry (UF) parameters when performed to assess male lower urinary tract symptoms (MLUTS).

METHODS

We configured an original pictogram composed of 4 different urine streams. In the setting of a University Hospital based prospective study where 545 men were enrolled between September 2018 and January 2019. Variables collected were age, UF pattern, Qmax, average flow rate (Qave), voided volume, postvoid residual, and selected image. The Spearman's rank test, ANOVA, and Tukey test, as well as the lineal regression model were used.

RESULTS

A total of 358 patients fulfilled the inclusion criteria. Mean age was 64.6 ± 12 years. Mean value and standard deviationfor the Qmax were 20.4 ± 10.5 mL/s for Image1; 15.5 ± 6.4 mL/s for Image2; 13.5 ± 6.0 mL/s for Image3 and 10.4 ± 5.4 mL/s for Image4. Statistically significant negative correlations were found between ANUF and Qmax (r = -0.317; P<.0001), and ANUF and Qave (r = -0.305; P<.0001). Qmax mean values among images were statistically different when compared in pairs, except Image1 and Image2 (P= .153). The confidence intervals calculated through the lineal regression model for the Qmax and each image were Image1) 17.8, confidence interval [CI] 95%: [14.9-21.5] mL/s; Image2) 14.3, CI 95%: [13.0-15.7] mL/s; Image3) 12.3, CI 95%: [11.5-13.1] mL/s and Image4) 9.1, CI 95%: [8.1-10.3] mL/s.

CONCLUSION

According to our results, ANUF is a useful and inexpensive tool presenting a correlation with the Qmax as well a correspondence of each image with a range of Qmax and its mean value.

Should we routinely assess psychological morbidities in idiopathic lower urinary tract dysfunction: ICI-RS 2019?

AIMS

Psychological morbidities play a major role in idiopathic lower urinary tract dysfunction (iLUTD). The aim of the Think Tank (TT) was to discuss the relevance of psychological morbidities in idiopathic LUTD over the life span, including overactive bladder (OAB) or dysfunctional voiding (DV) and methods of assessment.

METHODS

The paper is based on a selective review of the literature and in-depth discussions, leading to research recommendations regarding the assessment of psychological morbidities in iLUTD on children and adults held during the TT of the International Consultation on Incontinence Research Society in 2019.

RESULTS

Psychological comorbidities affect the health behaviors and treatment outcomes in patients with iLUTD. Both clinically relevant comorbid mental disorders, as well as subclinical psychological symptoms have a major impact and negatively influence incontinence treatment. Research is needed to elucidate mechanisms underlying iLUTD and psychological comorbidities. Clinical studies are needed to determine how perception generation and cognition impacts on the relationship of urinary perceptions, symptoms, and objective urodynamic function. Due to high psychological comorbidity rates, screening with validated, generic questionnaires for emotional and behavioral disorders in children with nocturnal enuresis, daytime urinary incontinence, and fecal incontinence is recommended. Brief screening is recommended for all adults with iLUTD, especially with OAB and DV, who are refractory to treatment.

CONCLUSIONS

Due to the high rate and relevance in clinical practice, screening for psychological comorbidities is recommended for all age groups. The research recommendations of this TT may be followed to improve the assessment of psychological morbidities in iLUTD.

Management of Female and Functional Urology Patients During the COVID Pandemic

Context

Coronavirus disease 19 (COVID-19) has changed standard urology practice around the world. The situation is affecting not only uro-oncological patients but also patients with benign and disabling conditions who are suffering delays in medical attention that impact their quality of life.

Objective

To propose, based on expert advice and current evidence where available, a strategy to reorganize female and functional urological (FFU) activity (diagnosis and treatment).

Evidence acquisition

The present document is based on a narrative review of the limited data available in the urological literature on SARS-Cov-2 and the experience of FFU experts from several countries around the world.

Evidence synthesis

In all the treatment schemes proposed in the literature on the COVID-19 pandemic, FFU surgery is not adequately covered and usually grouped into the category that is not urgent or can be delayed, but in a sustained pandemic scenario there are cases that cannot be delayed that should be considered for surgery as a priority. The aim of this document is to provide a detailed management plan for noninvasive and invasive FFU consultations, investigations, and operations. A classification of FFU surgical activity by indication and urgency is proposed, as well as recommendations adopted from the literature for good surgical practice and by surgical approach in FFU in the COVID-19 era.

Conclusions

Functional, benign, and pelvic floor conditions have often been considered suitable for delay in challenging times. The long-term implications of this reduction in functional urology clinical activity are currently unknown. This document will help functional urology departments to reorganize their activity to best serve their patients.

Patient summary

Many patients will suffer delays in urology treatment because of COVID-19, with consequent impairment of their physical and psychological health and deterioration of their quality of life. Efforts should be made to minimize the burden for this patient group, without endangering patients and health care workers.

[Functional urology during COVID-19: Recommendations during de-escalation.]

Due to the COVID-19 Pandemic, all surgical activity that was not life threatening was cancelled , as well as most face-to-face consultations. Currently the beginning of the de-escalation phases that will led us to a new normal, forces us to establish some degree of priority in the interventions as well as in the medical consultations. Our objective is to establish some recommendation on Functional Urology office visits and surgical interventions that serve as a tool to facilitate decision-making. MATERIAL AND METHODS: Experts in Functional Urology from different autonomous communities of Spain were contacted to design a strategy to reorganize the activity of both, diagnosis and treatment. A modified nominal group technique has been used due to the extraordinary restrictions of assembly and mobility during the COVID pandemic. The first signer (EMC) made the first draft with the measures adopted and the strategy to be followed during the evolution of the COVID-19 pandemic. The proposal was sent to the rest of the authors, in order to unify criteria and experiences to reach a quick consensus on the relative priority of the different activities, problems and solutions. A final version was approved by all authors May 27, 2020. RESULTS: Tables of recommendation have been prepared for outpatient consultation, surgical and technical interventions, according to de-escalation phases proposed by the Spanish Associations of Surgeons. CONCLUSIONS: The change that COVID-19 Pandemich as involved in our clinical practice force us to seek alternative methods to treat our patients, some of which may already be established. Mean while, a consensusin decision making is necessary. Documents such as the current one, are intended to guide the management of patients with urological functional pathology in exceptional situations. Logically, it should be adapted to material and human availability, and to the idiosyncrasy of each Urology service.

Nocturia and Nocturnal Polyuria in Neurological Patients: From Epidemiology to Treatment. A Systematic Review of the Literature

CONTEXT

Nocturia is among the most common and bothersome lower urinary tract symptoms (LUTS), but there is no clear consensus on how to identify and manage this symptom in the neurological population.

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

Studies were identified by electronic search of Cochrane and Medline databases. The studies were included if their participants had acquired neurological pathology among multiple sclerosis (MS), Parkinson's disease (PD), stroke, spinal cord injury (SCI), and reported data on the epidemiology, aetiology, diagnosis, or treatment of nocturia. An independent extraction of the articles was performed by two authors using predetermined datasets, including quality-of-study indicators.

EVIDENCE SYNTHESIS

A total of 132 studies were included; 46 evaluated the epidemiology of nocturia, 28 the possible aetiologies, 10 the diagnostic tools, and 60 the treatments. Nocturia prevalence ranged from 15% to 96% depending on the pathology and definition used. It was one of the most frequently reported LUTS in PD and stroke patients. Several validated questionnaires were found to screen for nocturia in this population. Causalities were numerous: LUT, renal, sleep, cardiovascular dysfunctions, etc. Treatments targeted these mechanisms, with an overall risk of bias assessed as high or serious. The highest level of evidence was seen in MS patients: pelvic floor muscle training, cannabinoids, and desmopressin were effective, but not melatonin. In stroke patients, transcutaneous sacral and transcutaneous tibial nerve stimulation (TTNS) improved nocturia; in PD patients, TTNS, solifenacin, and rotigotine did not.

CONCLUSIONS

Nocturia is highly prevalent in patients with neurological disorders. Causalities and treatments are not different from the general population, but are poorly studied in neurological patients.

PATIENT SUMMARY

In this report, we looked at the published studies about nocturia-the fact of waking to void during the hours of sleep-in patients with neurological diseases. We found that nocturia is very frequent in this population, that the causes are the same as in the general population but may be combined, and that treatments are also the same but have an overall weak level of evidence. We conclude that more research is needed on this topic.

What developments are needed to achieve less-invasive urodynamics? ICI-RS 2019

AIMS

To assess the state of technologies for urodynamics that are less invasive than standard cystometry and pressure-flow studies and to suggest areas needing research to improve this.

METHODS

A summary of a Think Tank debate held at the 2019 meeting of the International Consultation on Incontinence Research Society is provided, with subsequent analysis by the authors. Less-invasive techniques were summarized, classified by method, and possible developments considered. Discussions and recommendations were summarized by the co-chairs and edited into the form of this paper by all authors.

RESULTS

There is a full spectrum of technologies available for less-invasive assessment, ranging from simple uroflowmetry through imaging techniques to emerging complex technologies. Less-invasive diagnostics will not necessarily need to replace diagnosis by, or even provide the same level of diagnostic accuracy as, invasive urodynamics. Rather than aiming for a technique that is merely less invasive, the priority is to develop methods that are either as accurate as current invasive methods, or spare patients from the necessity of invasive methods by improving early triaging.

CONCLUSIONS

Technologies offering less-invasive urodynamic measurement of specific elements of function can be potentially beneficial. Less-invasive techniques may sometimes be useful as an adjunct to invasive urodynamics. The potential for current less-invasive tests to completely replace invasive urodynamic testing is considered, however, to be low. Less-invasive techniques must, therefore, be tested as screening/triaging tools, with the aim to spare some patients from invasive urodynamics early in the treatment pathway.

Consensus document on the multidisciplinary management of neurogenic lower urinary tract dysfunction in patients with multiple sclerosis

AIM

Neurogenic lower urinary tract dysfunction (NLUTD) is very common in multiple sclerosis (MS) patients. Early diagnosis and treatment are crucial to avoid irreversible damage and improve quality of life. Our aim was to develop recommendations to improve NLUTD identification in MS patients, along with their referral and management.

METHODS

A multidisciplinary group of 14 experts in the management of patients with MS and NLUTD (nine urologists, three neurologists, and two rehabilitators) was selected. A comprehensive review of the literature was undertaken and a set of recommendations was generated and submitted to a Delphi panel of 114 experts. Recommendations were presented according to the grade of agreement (GA).

RESULTS

Early diagnosis in asymptomatic patients with risk factors for complications is recommended (GA 94%). Postvoid residual volume should be measured if changes in urinary symptoms (GA 87%), preferably ultrasound-guided (GA 86%). Early referral to urologist is recommended if urinary incontinence (GA 91%), significant post-void residual volume (94%), quality of life impairment (GA 98%) and recurrent urinary infections (GA 97%). The initial evaluation should include physical examination (GA 99%) and urodynamics including cystometry (GA 89%), pressure-flow study (90%) and electromyography (GA 70%). The panel recommends multidisciplinary collaboration (GA 100%) with a rehabilitation specialist and trained nurses in the management of NLUTD (GA 99%).

CONCLUSIONS

Multidisciplinary management for patients with NLUTD due to MS is advised, including urologists, neurologists, rehabilitation, and nurses. Panel recommends early diagnosis with post-void residual volume in symptomatic patients before referring to urologist and urodynamics when referred.

Do the definitions of the underactive bladder and detrusor underactivity help in managing patients: International Consultation on Incontinence Research Society (ICI-RS) Think Tank 2017?

AIMS

The Think Tank aimed to discuss the pitfalls and advantages of current definitions in terms of research and management of underactive bladder (UAB). UAB broadly defines a symptom complex of bladder emptying problems and does not indicate a specific pathology. Detrusor underactivity (DU) is a urodynamic diagnosis from pressure-flow studies. The correlation of UAB with DU remains to be precisely determined.

METHODS

The presentations and subsequent discussion, leading to research recommendations during the Think Tank of the International Consultation on Incontinence Research Society in Bristol, 2017, are summarized.

RESULTS

To develop more specific individualized management strategies, the Think Tank panel proposed (i) that, since defining a single type of index patient to represent all UAB will not fulfill all clinical research needs, several index patients should be defined by phenotyping of patients with UAB, including, children, young men and women, elderly male and female patients with co-existing DU and detrusor overactivity, and neurological patients with UAB; (ii) prospective longitudinal studies to assess the natural history of UAB, in the different target populations, based on different UAB phenotypes, should be initiated; (iii) DU should be precisely defined by urodynamic parameters; and (iv) work to develop validated specific questionnaires combined with non-invasive tests for screening, diagnosis and follow up, needs to be continued.

CONCLUSIONS

The precise relationship of UAB to DU remains to be defined. Phenotyping patients with UAB/DU, performing prospective trials of natural history, and developing symptom questionnaires and diagnostic investigations will improve our ability to identify and treat UAB/DU.

Adaptation to Spanish of the ICS Good Urodynamic Practices

The standardisation working group of the International Continence Society has updated the Good Urodynamic Practice directives. This evidence-based ICS-GUP2016 has defined the terminology and standards of Urodynamic practice, for the laboratory and for individual practice, in quality control during cystometry and pressure-flow analysis. In addition, the working group included recommendations prior to the test and information about how to prepare the patient, as well as recommendations for the reporting of urodynamics. Based on earlier International Continence Society standardisations and current evidence, the practice of uroflowmetry, cystometry and pressure-flow study have been detailed with a view to ensuring that this Good Urodynamic Practice update contributes towards improving clinical and research quality in urodynamics.

Validation of the Spanish version of the Bladder Pain/Interstitial Cystitis-Symptom Score (BPIC-SS) questionnaire. A useful tool for the diagnosis of bladder pain syndrome

OBJECTIVES

Validation of the Spanish version of the Bladder Pain/Interstitial Cystitis-Symptom Score (BPIC-SS) questionnaire to evaluate its utility for the diagnosis of Bladder Pain Syndrome (BPS) patients in the Female and Urodynamics Urology Functional Units in Spain.

MATERIAL AND METHODS

The Spanish adaptation of the BPIC-SS questionnaire was evaluated in 243 BPS patients. EQ-5D-5L, Patient Perception of Bladder Condition (PPBC) and global impression questionnaire (CGI-S) were collected. Consistency, test-retest reliability in patients without clinical changes at 15 days, criterion validity and sensitivity to change were assessed in BPS patients with clinical changes at 6 months. The cut-off point for discriminating BPS patients from other similar pathologies (Hyperactive Bladder or other urinary pathologies) was analysed using ROC curve.

RESULTS

Mean (SD) BPIC-SS score (0-38) was 16.2 (12.0) points. Cronbach's alpha was 0.92 and intraclass coefficient correlation (ICC) was 0.82, ranging from 0.5-0.9 per item. Convergent validity determined a Spearman correlation of 0.63 with PPBC and -0.40 with EQ-5D-5L Visual Analogue Scale (VAS) and the effect size obtained in patients who improved their clinical status was 1.9. A score greater than or equal to 12 points in the BPIC-SS has been established as the best cut-off point for the diagnosis of BPS (87.5% sensitivity and 91.9% specificity).

CONCLUSIONS

The Spanish version of the BPIC-SS is a valid and reliable instrument for the diagnosis and follow-up of patients with BPS in Spain.

Oral quality of life after buccal mucosal graft harvest for substitution urethroplasty. More than a bite?

INTRODUCTION

The aim of our study was to analyze the oral quality of life (QoL) in patients with urethral stricture treated with BMG by using a validated questionnaire (OIDP).

MATERIALS AND METHODS

A prospective, single-arm, observational single-centre study of a cohort of patients scheduled for BMG Urethroplasty was conducted. OIDP assesses the impact of oral conditions on daily activities including an oral QoL question (0-10). The questionnaire was self-administered before, 3 months postoperatively and at the end of the study. Means, pre- and postoperatively, were compared. Multivariate analysis was performed to analyze the risk factors for a low quality of life (<8) after surgery.

RESULTS

We included 41 patients (2013-2017). The mean preoperative oral QoL was 9.33 points (SD1.16). Preoperative mean OIDP dimensional score and global score were 0,5 (SD:0.02) and 0,8%. The most frequently preoperative altered aspect was hygiene. Mean oral QoL, 3 months after surgery, was 8,56 (SD1.89) and OIDP dimensional score and global score were 0,67 (SD0.21) and 1,1%. Mean oral QoL at the end of the study (mean 3,12 years) was 8,50 (SD1.13). OIDP dimensional score and global score were 0,7 (SD 0.16) and 1,1%.The most frequently altered aspect at the end of the study was eating. No statistical (p = 0.07) decrease in oral QoL was found. The increase in OIDP dimensional and global score was also not statistically significant. Neither age nor smoking, diabetes mellitus, cardiovascular morbidity, previous OIDP score, width, length of the graft, or surgery success could explain a low oral QoL alter graft harvesting.

CONCLUSIONS

BMG harvesting is not free of problems at the donor site. Eating seems to be the most affected aspect after surgery. Nevertheless, those sequelae do not induce a reduction in oral QoL.

Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence

CONTEXT

Surgical nonautologous meshes have been used for several decades to repair abdominal wall herniae. Implantable materials have been adopted for the treatment of female and male stress urinary incontinence (SUI) and female pelvic organ prolapse (POP).

OBJECTIVE

A consensus review of existing data based on published meta-analyses and reviews.

EVIDENCE ACQUISITION

This document summarises the deliberations of a consensus group meeting convened by the European Association of Urology (EAU) and the European Urogynecological Association, to explore the current evidence relating to the use of polypropylene (PP) materials used for the treatment of SUI and POP, with reference to the 2016 EAU guidelines (European Association of Urology 2016), the European Commission's SCENIHR report on the use of surgical meshes (SCENIHR 2015), other available high-quality evidence, guidelines, and national recommendations.

EVIDENCE SYNTHESIS

Current data suggest that the use of nonautologous durable materials in surgery has well-established benefits but significant risks, which are specific to the condition and location they are used for. Various graft-related complications have been described-such as infection, chronic pain including dyspareunia, exposure in the vagina, shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and meshes (used in POP)-which differ from the complications seen with abdominal herniae.

CONCLUSIONS

When considering surgery for SUI, it is essential to evaluate the available options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for surgical treatment of SUI in both male and female patients has good efficacy and acceptable morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent prolapse in the same compartment and restricted to those surgeons with appropriate training who are working in multidisciplinary referral centres.

PATIENT SUMMARY

Synthetic slings can be safely used in the surgical treatment of stress incontinence in both male and female patients. Patients need to be aware of the alternative therapy and potential risks and complications of this therapy. Synthetic mesh for treating prolapse should be used only in complex cases with recurrent prolapse in specialist referral centres.

When should video be added to conventional urodynamics in adults and is it justified by the evidence? ICI-RS 2014

AIMS

To debate and evaluate the evidence base regarding the added value of video to urodynamics in adults and to define research questions.

METHODS

In the ICI-RS Meeting 2014 a Think Tank analyzed the current guidelines recommending video urodynamics (VUD) and performed a literature search to determine the level of evidence for the additional value of the imaging with urodynamic assessment of both neurogenic and non-neurogenic lower urinary tract dysfunction.

RESULTS

Current guidelines do not specify the added value of imaging to urodynamics. Recommendations are based on single center series and expert opinion. Standard imaging protocols are not available and evidence regarding the balance between number and timing of pictures, patient positioning, and exposure time on the one hand and diagnosis on the other hand is lacking. On the basis of expert consensus VUD is relevant in the follow-up of patients with spinal dysraphism. Evidence for the value of VUD in non-neurogenic lower urinary tract dysfunction is sparse. There is some evidence that VUD is not necessary in uncomplicated female SUI, but expert opinion suggests it might improve the evaluation of patients with recurrent SUI.

CONCLUSIONS

There is only low level evidence for the addition of video to urodynamics. The ICI-RS Think Tank encourages better reporting of results of imaging and systematic reporting of X-ray doses. Specific research hypotheses regarding the added value of imaging are recommended. The panel suggests the development of standards for technically optimal VUD that is practically achievable with machines that are on the market.

Hydrodistension plus Onabotulinumtoxin A in bladder pain syndrome refractory to conservative treatments

INTRODUCTION

For bladder pain syndrome (BPS) refractory to conservative treatment, the European guidelines consider bladder hydrodistention (HD) under anaesthesia and the injection of Onabotulinumtoxin A (OnabotA) jointly. The objective of this study was to assess our experience in implementing this technique.

MATERIAL AND METHODS

A prospective study of 25 patients with BPS who underwent HD plus a submucosal injection of 100 U of OnabotA in trigone. The Hunner lesions were treated endoscopically using resection or electrocoagulation. Thirty-eight procedures were performed (25 first interventions and 13 reoperations). To study the clinical change, we evaluated the subjective improvement (Treatment Benefit Scale [TBS] and Patient Global Impression of Change [PGIC] scales), the visual analogue scale (VAS) for pain, the Bladder Pain/Interstitial Cystitis Symptom Score (BPIC-SS) questionnaire and the voiding diary for 3 days. For the data analysis, we employed the Wilcoxon, Kruskal-Wallis, Kaplan-Meier and log-rank tests.

RESULTS

We observed subjective improvement in 21 patients (84%), which was significant in 47% of these patients, moderate in 41.2% and slight in 11.8%. Four patients did not improve. A post-treatment reduction in the pain VAS (from 7.1 to 1.8 points; P=.001), in daytime (from 11.8 to 7.5; P=.012) and night-time (from 5.9 to 3.6; P=.003) voiding frequency and in the BPIC-SS (from 27.9 to 11.2 points; P=.042). The degree of improvement was not related to age, the presence of bladder lesions or the treatment of relapses. The median duration of improvement was 7 months (95% CI 5.69-8.31), although this duration was somewhat longer for the patients younger than 65 years. Mild complications occurred in 23.7% of the cases.

CONCLUSIONS

The joint implementation of HD plus OnabotA is a valid therapeutic option in refractory BPS, which provides good clinical results and maintains its effectiveness in retreatments.

Recommendations for the Diagnosis and Management of Bladder Pain Syndrome. Spanish Urological Association Consensus Document

INTRODUCTION

Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) and other bladder pathologies share common manifestations, such as the presence of mictional symptoms and a negative impact on the patient's quality of life. To be properly diagnosed and clinically managed, it is important to distinguish between its clinical modalities and diagnostic criteria for adequate exclusion.

OBJECTIVE

The purpose of this study was to standardize criteria for making decisions in BPS management, for its diagnosis, initial treatment and follow-up.

MATERIAL AND METHOD

A nominal group methodology was employed, using scientific evidence on BPS taken from a systematic (non-exhaustive) literature review for developing recommendations along with specialist expert opinions.

RESULTS

The diagnosis of BPS should be made based on the patient's clinical history, with emphasis on pain and mictional symptoms as well as excluding other pathologies with similar symptomatology. BPS treatment should be directed towards restoring normal bladder function, preventing symptom relapse and improving patients' quality of life. It is therefore advisable to start with conservative treatment and to adopt less conservative treatments as the level of clinical severity increases. It is also recommended to abandon ineffective treatments and reconsider other therapeutic options.

CONCLUSIONS

Quickly identifying the pathology is important when trying to positively influence morbidity and care quality for these patients.

Expert consensus on scientific evidence available on the use of botulinum toxin in overactive bladder

OBJECTIVES

Overactive bladder (OAB) is a pathology impairing patients' quality of life and with a high percentage of patients who are refractory to medication. In this paper, technical opinion of an «expert panel» is assessed in order to gain the most reliable professional consensus on scientific evidence available on the criteria of use of Onabotulinumtoxin A (OnabotA) in OAB.

MATERIAL AND METHODS

according to DELPHI method, 42 panelists answered a survey of 93 items divided into four strategic areas including clinical criteria and recommendations in order to improve, at different levels, the current approach to patients with OAB. The recent advances in the field, areas of controversy and their real application possibilities in the different areas of our health care system were taken into consideration.

RESULTS

Two rounds of the questionnaire were completed by all experts. In the first round, a criteria consensus was reached for 64 of 93 (68.8%) questions analyzed; in the second round the consensus reached was for 83 items evaluated (89.25%). An agreement among panelist was reached for: 1) definition, classification, detection and differential diagnosis; 2) medical treatment; 3) surgical treatment; 4) role of OnabotA in the treatment of OAB.

CONCLUSIONS

the consensus is broadly in line with the latest scientific evidence on OAB. The panelists believe that it is necessary to propose a change in the current definition of OAB and that it seems necessary to improve the screening tools too. Medical treatment of OAB must be tailored to each patient, staged and progressive. The use of OnabotA (Botox(®)) could imply therapeutic advantages with respect to other treatments, and positions itself as a safe and effective alternative to treat drug refractory OAB.

Profile of lower urinary tract symptoms in the male and their impact on quality of life

OBJECTIVES

Following current European Guidelines, Lower Urinary Tract Symptoms (LUTS) are produced by several causes and, thus, thorough clinical assessment should be undertaken for a correct therapeutic management. This study was conducted in order to assess the symptoms profile and their impact on Health-Related Quality of Life (HRQL) of male patients attending urology outpatient clinics.

MATERIAL AND METHODS

Epidemiological, cross-sectional study including adult male patients (n=826) presenting with at least one de novo previously untreated LUTS. Socio-demographic and clinical variables were collected. Patients completed IPSS, Bladder Control Self-Assessment Questionnaire (B-SAQ) and SF-12 questionnaires.

RESULTS

Mean age (SD) was 65 (10) years. A combination of storage, voiding and post-micturition symptoms were present in 69% of subjects and 30% showed >2 urgency episodes and >6 micturitions daily (storage symptoms -SS- sub-population). Storage symptoms were the reason for consultation in 86%. Mean peak urinary flow (Q(max)) was 11.4 mL/s, in 44% of patients,prostate volume was 20-40 mL and 91% showed moderate or severe symptoms on IPSS with an overall mean (SD) score of 17 (7). SS sub-population had higher B-SAQ scores (6,9 vs 4,8 for symptoms; 7,8 vs 5,1 for bother), and worse HRQL (IPSS item 8).

CONCLUSIONS

These findings support the importance of addressing treatment adequately according to patient profile, bothersomeness and impact on HRQL.

Quality of life in patients with overactive bladder: validation and psychometric properties of the Spanish Overactive Bladder Questionnaire-short Form

BACKGROUND

Overactive bladder (OAB) is characterized by the symptoms of urinary urgency or urge incontinence, which appear without a local pathological or metabolic explanation. OAB is defined by symptoms and the evaluation of treatment effectiveness should be based upon patient perceptions. The Overactive Bladder Questionnaire-Short Form (OAB-q SF) is a brief, self-administered patient-reported outcomes tool with two scales assessing symptom bother and health-related quality of life (HR-QOL) in patients with OAB.

OBJECTIVE

This study aimed to adapt the OAB-q SF into Spanish and to estimate its psychometric properties in patients with symptomatic overactive bladder.

METHODS

The Spanish version of the OAB-q SF was administered on two occasions, 3 months apart, to a set of patients of both sexes, over 18 years of age, diagnosed with OAB, scoring ≥8 on the OAB-V8 scale (a self-reported 8-item OAB screening and awareness tool), and able to understand patient-reported-outcome instruments written in Spanish. Patients were recruited consecutively at urology clinics. Feasibility, internal consistency (Cronbach's alpha), test-retest reliability, structure of instrument, criteria and construct validity and responsiveness were examined using classic test theory statistics.

RESULTS

Data from 246 OAB patients (mean age 57.7 years, 76% women, 99% Caucasian, 37% workers and 36% with a primary education) were evaluated. Floor and ceiling effects ranged between 0.8% and 33%, and missing items were below 2%. Cronbach's alphas attained 0.811 and 0.922 for symptom-bother and HR-QOL domains, respectively. These two subscales matched the original structure and explained variances above 50%, which correlated moderately with EQ-5D (EuroQol) [r = -0.28 and r = +0.31, respectively (p < 0.001 in both cases)]. A significant change in OAB-q SF mean domain scores (-23.8; 95% CI -26.3, -21.3; and +17.7; 95% CI 15.4, 20.6; p < 0.001 in both cases; [effect sizes: 1.32 and 0.98]) was observed after 3 months of medical treatment.

CONCLUSION

The Spanish version of the OAB-q SF demonstrated sufficiently strong psychometric properties of reliability, validity and responsiveness to be used in the measurement of OAB symptom severity and HR-QOL.

Usefulness of bladder-prostate ultrasound in the diagnosis of obstruction/hyperactivity in males with BPH

OBJECTIVE

To determine the utility of prostate ultrasound in the diagnosis of infravesical obstruction (IVO) and detrusor hyperactivity(DH).

METHODS

Prospective study with 39 patients consulting for LUTS. Clinical history was compiled, IPSS was determined, a digital rectal exam was performed, abdominal ultrasound was used to calculate detrusor thickness/weight, prostate volume, and middle lobe length (MLL). Urodynamic study (UD) was performed with determination of the Abrams-Griffiths number and ICS nomogram. Mean values were compared with Mann-Whitney U-test, and ROC curves were plotted determining the cutoff points for optimum sensitivity/specificity.

RESULTS

Mean age was 63.1 years (SD: 7.8), with a mean IPSS score of 14 (SD: 6). 53.8% of the patients presented IVO at UD evaluation, and 43.6% DH. The differences between free flowmetry Qmax(p=0.015) and MLL (p=0.003) between patients with and without IVO proved significant. The ROC curves yielded an AUC for middle lobe length of 0.772, with a maximum sensitivity and specificity cutoff point at 10.5 mm (sensitivity 90%, specificity 73%, PPV 76%, NPV 85%). There were no significant differences in any parameter between patients with and without DH.

CONCLUSION

Ultrasound MLL measurement in patients with LUTS offers high sensitivity/specificity in diagnosing IVO, with a cutoff point of 10.5 mm. In our study it wasn't effective in the noninvasive diagnosis of DH.

[Causes, characteristics and mid-term course of acute urinary retention in women referred to a urodynamics unit]

OBJECTIVES

Acute urinary retention (AUR) is uncommon in women and can be related to different conditions. Only some patients are referred to the urodynamics units for a more extensive study. We intend to describe the charcteristics and causes of AUR in women referred to our unit and to analyze their middle term evolution.

MATERIAL AND METHODS

We performed a descriptive retrospective study (January 1982-December 2006), including the women referred to our Uro-Neurology and Urodynamics Unit after suffering an AUR. Medical charts were reviewed with special emphasis on medical history, physical examination, and also complete urodynamics study during the AUR event and after its resolution.

RESULTS

A total of 202 women were included, median age of 57 years (12-87 years). Prior to the AUR, 59 women (28.7%) reported voiding symptoms. The urodynamics findings were: 65 (32.2%) detrusor hypocontractility; 64 (31.7%) normal study; 37 (18.3%) detrusor acontractility; 21 (10.4%) bladder outlet obstruction; 15 (7.4%) poor pelvic floor relaxation. The causes of the AUR were: 53 neurological (26.2%); 46 unknown (22.8%); 19 gynecological (9.4%); 22 diabetes mellitus (10.9%); 16 urological (7.9%). Renal insufficiency was observed in 14 patients (6.9%). After the AUR 106 women (52.4%) needed some kind of prolonged treatment.

CONCLUSIONS

In our experience, AUR in the female is mainly related to underlying neurologic/urogynecologic disease, even though the etiology could not be known in a significant percentage of patients. Half of the patients recovered completely and did not require any treatment.

[Computer-aided analysis of transrectal ultrasound images of the prostate]

INTRODUCTION

Prostate cancer is usually diagnosed by transrectal ultrasound (TRUS) biopsy. Nevertheless, suspicious images are frequently not found. Imaging analysis studies aim to identify ultrasound patterns characteristic of apparently hidden conditions.

MATERIAL AND METHODS

We digitally recorded 288 TRUS ultrasound guided transrectal biopsies and extracted 3 static images from the puncture-biopsy area. The extraction of the texture characteristics were obtained by "simple mapping" on a gray scale and spatial gray level dependence matrices (SGLDM), also known as Haralick's co-occurrence matrices, which study the relationship of each pixel and its neighbors. A pattern recognition software system was developed with two different classification methods: nearest neighbor (k-NN) and Markov's hidden models. Finally, a virtual experiment was carried out in which four urologists compared their diagnostic accuracy for prostate cancer with our system in 408 TRUS images, not in real time.

RESULTS

The diagnostic capacity (R.O.C. curve) with the simple gray map study was 59.7% with nearest-neighbor classification and 61.6% with Markov's hidden models classification. The co-occurrence matrices showed an area under R.O.C. curve of 60.1% and 60.0% with k-NN and Markov's hidden models classification, respectively. The virtual experiment was conducted with a simple gray map study and k-NN classification. The images processed by our system showed the following diagnostic accuracy: 63.3, 67, 64.3 and 63.7% compared to 61.7, 60.5, 66.2 and 60.7% with the original image.

CONCLUSIONS

Our pattern recognition system for prostate cancer TRUS images has a limited, yet stable, accuracy.

Cost-effectiveness of sacral neuromodulation compared to botulinum neurotoxin a or continued medical management in refractory overactive bladder

OBJECTIVES

This study assessed the cost-effectiveness and health-care budget impact of sacral neuromodulation (SNM) in refractory idiopathic OAB-wet patients in Spain.

METHODS

A 10-year Markov analytic model was developed to estimate quality-adjusted life-years (QALYs) gained and incontinence episode avoided associated with SNM therapy compared with botulinum neurotoxin A (BoNT-A) or continued optimized medical treatment (OMT).

RESULTS

At 10 years, the cumulative costs of SNM, BoNT-A, and OMT were €29,166, €29,458, and €29,370, respectively, whereas the QALYs for SNM, BoNT-A, and OMT are 6.89, 6.38, and 5.12, respectively. Consequently, incremental cost-effectiveness ratios (ICERs) for SNM demonstrate that although the initial costs for SNM are higher than those for the other treatments, decreasing follow-up costs coupled with consistently greater effectiveness in the long term make SNM the economically dominant option at 10 years. Sensitivity analyses suggest that 99.7% and 99.9% (for SNM vs. BoNT-A and OMT, respectively) of the 1000 Monte Carlo iterations fall within the €30,000 cost-effectiveness threshold, considered to be acceptable in Spain. The 10-year incremental cost per incontinence episode avoided for SNM also makes this therapy the dominant option compared to BoNT-A or OMT. Additionally, the estimated budget impact of the gradually increased referral for SNM for the management of OAB patients in Spain is small.

CONCLUSIONS

As a treatment option for refractory idiopathic OAB, at 10 years, SNM provides a considerable possibility of symptom and quality-of-life improvement and is cost-effective compared to BoNT-A or continued OMT.