Management Of Urinary Symptoms Research Articles

Management of Urinary Symptoms after Urethroplasty

Abstract Purpose of review The most definitive treatment for urethral stricture disease is urethroplasty, a procedure that has demonstrated great efficacy and durability in creating a patent urethral lumen. Criteria for success after urethroplasty have evolved over time, now with growing recognition of the importance of the patient experience. Recent Findings Despite good surgical outcomes, patient reported metrics demonstrate that some patients have persistent urinary symptoms that impact satisfaction rates. Achieving success in patient reported outcomes after urethroplasty may require repeat intervention or addressing alternative etiologies including benign prostatic hypertrophy, overactive bladder, and underactive bladder. Summary For patients who do not achieve symptom resolution after urethroplasty, evaluation should include addressing common complications, evaluating for recurrence, and consideration and treatment of additional causes of urinary bother.

The Role of Transurethral BPH Surgeries in Management of Urinary Symptoms in Prostate Cancer Patients, Narrative Review.

Prostate cancer and benign prostate hyperplasia (BPH) are two ubiquitous pathologies that may coexist. A significant percentage of patients with different stages of prostate cancer suffer lower urinary tract symptoms (LUTS) due to associated BPH. We aimed to review the literature regarding the role of transurethral surgeries in the management of prostate cancer patients and the different available management options. The evidence in literature for the use of BPH surgeries in prostate cancer patients is based mainly on low-quality retrospective studies. In patients on active surveillance, BPH surgeries are beneficial in relieving LUTS without oncological risk and can eliminate the contribution of adenoma to PSA level. In patients with advanced prostate cancer, palliative BPH surgery can relieve LUTS and urinary retention with unclear oncological impact; however some reports depict that the need for BPH surgery in advanced prostate cancer is associated with poorer prognosis. In patients receiving radiotherapy, various studies showed that transurethral resection of prostate (TURP) is associated with increased radiotoxicity despite some recent reports encouraging the use of Holmium Laser Enucleation of the Prostate (HoLEP) to improve urinary symptom scores before radiotherapy. The most commonly reported techniques utilized are TURP, photoselective vaporization of prostate (PVP) and HoLEP. The use of BPH surgery is justified for relieving LUTS in selected prostate cancer patients on active surveillance or in advanced stages, however the use in the pre-radiotherapy settings remains controversial. Future prospective and randomized controlled trials are required for validating the benefits and assessing potential hazards.

Real-world four-year functional and surgical outcomes of Rezum therapy in younger versus elderly men.

Management of urinary symptoms in elderly patients with benign prostatic hyperplasia (BPH) is complex given challenges with medications and invasive surgeries. Rezum, a minimally invasive water vapor therapy, is an emerging alternative. We compare real-world Rezum outcomes between young and elderly patients over 4 years. We retrospectively analyzed a multiethnic population treated with Rezum at a single center between 2017-2019. Patients were stratified into young (<65 years) or elderly (≥65 years) cohorts. International Prostate Symptom Score (IPSS), Quality of Life (QoL), maximum urinary flow rate (Qmax), decisional regret scores, and adverse events (AEs) were assessed at baseline, 1-, 3-, 6-, 12-, and/or 48-months. Descriptive statistics were compared using t-tests, Chi-squared, or Mann-Whitney U tests. Changes in outcomes were assessed using Wilcoxon signed-rank tests, stratified by age. 256 patients - 146 (57%) young and 110 (43%) elderly - were included. The majority were Asian (33.2%) or non-Hispanic Black (28.9%). Significant improvements were observed in the combined cohort at 4-years in IPSS, QoL, and Qmax when compared to baseline (all p < 0.05). Between the age cohorts, there were no significant differences in IPSS, QoL, or Qmax at any follow-up. Within both cohorts, significant improvements in IPSS and QoL were found from baseline to all follow-ups. In the young cohort, Qmax was significantly improved from baseline to all follow-ups while in the elderly cohort, this was observed only at the 3-month follow-up. No significant differences in AEs or regret was found between cohorts. There was no significant difference in 4-year surgical retreatment rates between cohorts (elderly 4.0% vs young 4.4%, p = 0.86). There were no significant differences in IPSS, QoL, or AEs between elderly and younger men over 4 years following Rezum, suggesting comparable benefits and risks. Future research is warranted to clarify the impact of Rezum on Qmax in elderly men.

1357. Urinary Symptom Management in Children with Neuropathic Bladder Presenting to the Emergency Department

BackgroundChildren with neuropathic bladders are at high risk for developing urinary tract infections (UTIs). The accurate diagnosis of UTI is complicated by altered sensation and the ubiquity of bacterial colonization. As a result, overdiagnosis and overtreatment for presumed UTIs is common. The objective of this study is to estimate potential overdiagnosis and unnecessary antibiotic treatment in children with neuropathic bladder presenting to the Emergency Department (ED) with urinary symptoms.MethodsRetrospective cohort study of patients with neuropathic bladder presenting to the Children’s National Hospital ED between October 2008 and December 2019. Chart review was used to determine presenting symptoms, urinary evaluation, and antibiotic treatment. We used the validated urinary symptoms questionnaire (USQNB-IC) to categorize ED visits as ‘evaluation warranted’ if the patient presented with at least one of the actionable symptoms on the USQNB-IC. We used the Spina Bifida Association’s (SBA) published definitions for UTI to determine which patients warranted presumptive antibiotic treatment.ResultsThere were 211 visits by 82 patients (43% female), with a mean of 4.6 visits per patient (IQR 6). Mean age at ED visit was 5.2 years (SD 4.2 years). The most common presenting symptoms were fever (57%), emesis (32%), abdominal pain (24%), foul-smelling urine (11%), and cloudy urine (8%). Of the total visits, 122 (58%) had a urinary evaluation and 31% were treated with antibiotics. Sixteen ED visits (8%) resulted in a urinary evaluation that was not warranted. Of the 122 ED visits with urinary evaluation, 32 patients (26%) did not meet SBA criteria for UTI but were treated empirically with antibiotics.Table 1: Urinary evaluation in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019. Table 2: UTI treatment in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019. ConclusionMost children with neuropathic bladder presenting to the ED were appropriately evaluated and treated for presumed UTI. One-quarter of evaluated children received empiric antibiotics despite not meeting SBA criteria for UTI, indicating this may be a target for educational initiatives to promote antibiotic stewardship. Further research is needed to generate and validate clinical guidelines for emergency department providers to limit unnecessary testing and antibiotic therapy in this population.Disclosures All Authors: No reported disclosures

Holmium laser enucleation of the prostate in Jehovah's Witness patients.

To evaluate if HoLEP is a viable option for male patients with medication-refractory urinary symptoms due to an enlarged prostate who are surgical candidates, but do not accept blood product transfusion. Between August 2008 and March 2019, nine Jehovah's Witness patients were undergoing HoLEP for relief of lower urinary tract symptoms and urinary retention. We described change in hemoglobin, change in PSA, enucleated prostate weight, enucleation and morcellation times, length of stay, and postoperative retention rate. The average age was 71.4years (range 53-87). Urinary retention requiring catheterization was present in seven patients (78%). Two patients had a known diagnosis of prostate cancer preoperatively. The mean preoperative PSA on average was 21.6ng/dL. Patients had a wide range of gland sizes, with a mean enucleated weight of 141g (range 18-344g). Mean reduction in hemoglobin was 16.9% following HoLEP. All patients managed to void postoperatively. All but one patient went home on postoperative day 1, and this patient went home on postoperative day 2. No patients required blood product transfusion or return to the operating room for clot irrigation postoperatively. HoLEP is a reasonable option for Jehovah's Witness and other patients with contraindications to blood product transfusion requiring surgical management of urinary symptoms due to enlarged prostate.

Management of Urinary Symptoms Associated with Fibroids

Uterine fibroids are the most common benign tumours in women of reproductive age. Fibroids are linked with a variety of lower urinary tract symptoms (LUTS). Direct pressure on the bladder, but also vascular, neurogenic and hormonal changes have been proposed as underlying pathophysiological mechanisms. There is conflicting evidence in the literature regarding the association between LUTS and fibroid volume and position. Conservative management with bladder retraining, supervised pelvic floor muscle training with or without drug therapy might be used as first line. In the presence of persistent symptoms, conventional urodynamics or ideally videourodynamics might be considered before more invasive treatment. Counselling of patients prior to uterine artery embolisation, myomectomy or hysterectomy could be challenging, as it is difficult to estimate the effect of fibroid reduction or removal on LUTS.

Patient experiences of bladder problems following stroke

To elicit the experiences of patients with bladder problems following stroke in one dedicated stroke unit and to share these findings with the multidisciplinary stroke team. A structured questionnaire was completed by 40 inpatients who had an identified bladder problem, had had a stroke more than two weeks previously and were able to give informed consent. Following analysis of the results, a focus group discussion was held with the multidisciplinary stroke team. The urinary symptom most frequently reported by patients two weeks following stroke was urgency (65%, n = 26), followed by leakage of urine (57%, n = 23), frequency (37%, n = 15) and nocturia (37%, n = 15). Depression and feelings of embarrassment were common. Patients were least satisfied with the use of bedpans for toileting purposes and a urethral catheter as a method of containment. The need for more proactive patient-focused continence management was identified by the multidisciplinary stroke team during the focus group discussion. Patient-focused management of urinary symptoms is important to alleviate concern, distress and discomfort, and reduce the potential effect that these symptoms may have on the patient's ability to participate in therapeutic activities that promote recovery.

Bladder dysfunction in peripheral neuropathies

Normal bladder function depends on the complex interaction of sensory and motor pathways. Bladder dysfunction can develop as a result of several neurological conditions. It can happen in a number of ways, including diabetic cystopathy, detrusor overactivity, bladder outlet obstruction, and urge and stress urinary incontinence. Diabetic neuropathy is the most common cause of peripheral neuropathy-associated bladder dysfunction. Guillain-Barré syndrome (GBS), human immunodeficiency virus (HIV)-associated neuropathy, chronic inflammatory demyelinating polyneuropathy (CIDP), and amyloid neuropathy are other major causes. The diagnosis of bladder dysfunction should be established by the history of neurological symptoms, neurological examination, and urological evaluation. Functional evaluation of the lower urinary tract includes cystometry, sphincter electromyography, uroflowmetry, and urethral pressure profilometry. Management of urinary symptoms in patients with bladder dysfunction is usually supportive. In some cases, alpha-blocker and/or anti-muscarinic agents are needed to help improve urinary dysfunction. Intermittent self-catheterization is needed occasionally for patients with slow and/or poor recovery.

Interactive workshops increase chlamydia testing in primary care--a controlled study

Primary care clinicians suggest that staff education is needed to increase chlamydia testing appropriately. To determine if interactive workshops and modified laboratory request forms could increase testing and case detection. Prospective cluster randomized controlled study, using modified Zelen's design, examining the effect of workshops and modified request forms on primary care clinicians' chlamydia specimen submission and case positivity rate. 82 general practices in six geographical clusters within five primary care trusts (PCTs) in Gloucestershire and County Durham and Darlington. Practices within geographical clusters were randomly assigned to workshops on chlamydia or a control consisting of comparable workshops on the management of urinary symptoms, held in PCT-protected learning time. Half the practices were randomized to receive modified laboratory request forms. Staff were unaware that they were part of a study. Interactive workshops increased chlamydia testing in 16- to 24-year-old women by 33% in intervention practices compared to controls with effect persisting at 10 months (P = 0.003). No associated rise in the number of chlamydia infections was detected (P = 0.91), suggesting that increased testing may have occurred in a lower risk population. Modified forms did not change test submission (P = 0.75). Interactive workshops for general practices can be used to successfully increase chlamydia-testing rates. Chlamydia detection rates will need to be monitored as this type of educational programme may not increase absolute numbers of chlamydia infections detected, if patients at lower risk of infection are inappropriately tested. Other interventions may need to be combined with the workshops, to reach sufficiently high chlamydia screening rates to significantly reduce prevalence of chlamydial infection.

Preconceptual care for women with spina bifida

Results Common themes emerged during the six consultations. These related to the need for preconceptual folic acid supplementation (6/6), discussion of recurrence risks (6/6), screening for neural tube defects (6/6), management of urinary symptoms and urinary infection (5/6), potential problems with backpain, mobility and the ability to continue to work during pregnancy (6/6), analgesia in labour (6/6), anaesthesia (3/6), mode of delivery (6/6). Management options for the above were discussed. All women reported that they had found the consultation to contain useful information and that the actual risks were not as high as they perceived. They were also reassured by the suggested management plans. Two of the women have become pregnant.