Persistent Lower Urinary Tract Symptoms Research Articles

Colpocleisis for Advanced Pelvic Organ Prolapse

To characterize our experience with colpocleisis in a urologic setting because it has not been documented broadly in the urologic literature. Retrospective review of demographics, urodynamics, presenting symptoms, complications, and outcomes for patients undergoing colpocleisis from 2001-2010 was performed. A questionnaire including the short forms of the Urinary Distress Inventory and Pelvic Organ Prolapse Distress Inventory (POPDI-6), and the Patient Global Impression of Improvement was sent to consenting patients. Fifty-three patients were identified. Examinations were all POP-Q stage 3 or greater or Baden Walker grade 3 or higher; 73.6% underwent total colpocleisis and 26.4% Le Fort; 60.4% underwent concomitant sling. Complications included 1 patient requiring transfusion, 1 with pulmonary embolus, 1 needing clot evacuation, and 1 requiring intraoperative cystotomy repair. There was no postoperative de novo urgency, no recurrence of prolapse, and no chronic urinary retention. In patients not undergoing urethral sling, stress urinary incontinence persisted in 4 patients and occurred de novo in 1. Mean follow-up was 9.3 months. Twenty-two surveys were returned: 90.9% described their condition as much or very much better on Patient Global Impression of Improvement. The average POPDI-6 score was 9.1. Frequency and urgency were the most common complaints leading to bother on the UDI-6 (33.3%). Most of these responders had a preoperative urge component. In a selected patient population, colpocleisis is safe and efficacious. Persistent lower urinary tract symptoms comprise the highest frequency of complaints after colpocleisis, and this must be included in patient counseling. In an aging patient population with expected increase in demand for pelvic floor reconstruction, colpocleisis is a useful approach for the urologist.

Can Staccato and Interrupted/Fractionated Uroflow Patterns Alone Correctly Identify the Underlying Lower Urinary Tract Condition?

Worldwide, uroflowmetry without simultaneous electromyography is often the only testing performed during the initial assessment of children with lower urinary tract symptoms. Various alterations in uroflow pattern are thought to indicate particular types of lower urinary tract conditions, specifically staccato uroflow indicating dysfunctional voiding and intermittent/fractionated uroflow indicating detrusor underactivity. We determined how reliable uroflow pattern alone is as a surrogate for simultaneously measured pelvic floor electromyography activity during voiding, and how well staccato and interrupted uroflow actually correlate with the diagnoses they are presumed to represent. We reviewed uroflow/electromyography studies performed during the initial evaluation of 388 consecutive neurologically and anatomically normal patients with persistent lower urinary tract symptoms. We identified those with staccato, interrupted/fractionated and mixed uroflow based on current International Children's Continence Society guidelines. A total of 69 girls (58.5%) and 49 boys (41.5%) met inclusion criteria. Staccato uroflow was noted in 60 patients, interrupted/fractionated uroflow in 28 and a combination in 30. An active electromyography during voiding confirmed the diagnosis of dysfunctional voiding in 33.3% of patients with staccato, 46.4% with interrupted/fractionated and 50% with mixed uroflow patterns. Diagnoses based on uroflow pattern appearance without simultaneous electromyography to support them can be misleading, and reliance on uroflow pattern alone can lead to overdiagnoses of dysfunctional voiding and detrusor underactivity. When assessing patients with uroflow, an accompanying simultaneous pelvic floor electromyography is of utmost importance for improving diagnostic accuracy and thereby allowing for the most appropriate therapy.

Missed Diagnosis of Complete Urethral Transection After Sling

Patients with complications of urethral sling placement for stress urinary incontinence are often treated for recurrent symptoms for years after initial reassuring evaluation. Translabial ultrasound is a noninvasive modality with minimal risks that can clearly diagnose urethral mesh complications. We present a 47-year-old premenopausal woman referred for treatment of urethral stricture and diverticulum 8 years after mesh sling placement. The diagnosis was made at an outside institution by voiding cystourethrogram and cystoscopy. However, translabial ultrasound confirmed the diagnosis of complete urethral transection, and the patient underwent a complex urethral reconstruction. Ultrasound should be used to evaluate patients with a history of urethral sling and persistent lower urinary tract symptoms. Referral to a center with advanced pelvic reconstruction services may be required.

Cystoscopic removal of an intravesical gossypiboma mimicking a bladder mass: a case report

BackgroundIntravesical retained surgical sponges are very rare and only a few cases have been removed by minimally invasive techniques.Case presentationWe report a case of an intravesical gossypiboma in a 71-year-old man from western Nepal, who presented with urinary retention and persistent lower urinary tract symptoms one year after open cystolithotomy. He was diagnosed with an intravesical mass using ultrasonography. The retained surgical sponge was found during cystoscopy and removed through endoscopy.ConclusionIntravesical gossypibomas are rare and can mimic a bladder mass. This is one of the few reported cases of cystoscopic removal.

Simplifying the Diagnosis of 4 Common Voiding Conditions Using Uroflow/Electromyography, Electromyography Lag Time and Voiding History

Noninvasive uroflowmetry with simultaneous electromyography is useful to triage cases of lower urinary tract symptoms into 4 urodynamically defined conditions, especially when incorporating short and long electromyography lag times in the analysis. We determined the prevalence of these 4 conditions at a single referral institution and the usefulness of uroflowmetry with simultaneous electromyography and electromyography lag time to confirm the diagnosis, guide treatment and monitor response. We retrospectively reviewed the records of 100 consecutive normal children who presented with persistent lower urinary tract symptoms, underwent uroflowmetry with electromyography as part of the initial evaluation and were diagnosed with 1 of 4 conditions based on certain uroflowmetry/electromyography features. The conditions included 1) dysfunctional voiding--active pelvic floor electromyography during voiding with or without staccato flow, 2a) idiopathic detrusor overactivity disorder-A--a quiet pelvic floor during voiding and shortened lag time (less than 2 seconds), 2b) idiopathic detrusor overactivity disorder-B--a quiet pelvic floor with a normal lag time, 3) detrusor underutilization disorder--volitionally deferred voiding with expanded bladder capacity but a quiet pelvic floor, and 4) primary bladder neck dysfunction--prolonged lag time (greater than 6 seconds) and a depressed, right shifted uroflowmetry curve with a quiet pelvic floor during voiding. Treatment was tailored to the underlying condition in each patient. The group consisted of 50 males and 50 females with a mean age of 8 years (range 3 to 18). Dysfunctional voiding was more common in females (p <0.05) while idiopathic detrusor overactivity disorder-B and primary bladder neck dysfunction were more common in males (p <0.01). With treatment uroflowmetry parameters normalized for all types. Electromyography lag time increased in idiopathic detrusor overactivity disorder-A cases and decreased in primary bladder neck dysfunction cases. Noninvasive uroflowmetry with simultaneous electromyography offers an excellent alternative to invasive urodynamics to diagnose 4 urodynamically defined conditions. It identifies the most appropriate therapy for the specific condition and objectively monitors the treatment response.

Pyospermia in an adult cohort with persistent lower urinary tract symptoms and a history of ablated posterior urethral valve

To assess for the presence of lower urinary tract symptoms and abnormal semen parameters in adults with a history of PUV. The study involved 29 male patients, aged 17-51 (mean 21.5 years), with a history of PUV. Ten had more severe symptoms of frequency, urgency and enuresis, and agreed to detailed study. Medical history, urine analysis, ultrasonography and voiding cystourethrogram were completed for all. Magnetic resonance imaging of the bladder, prostate, seminal vesicles and ejaculatory ducts, ultrasonography of the prostate, as well as semen analysis and culture, and measurement of serum levels of follicle-stimulating hormone, luteinizing hormone and testosterone were performed on the 10/29 patients with severe symptoms. Of the 8/10 patients who provided acceptable semen culture data, 88% (7/8) showed significant bacterial growth and pyospermia. On semen analysis, 3/8 patients had profound decreases in sperm count, 6/8<50% motility and 4/8≤30% normal forms. pH range for semen was 7.2-7.8 (mean 7.45). For all 10 patients, follicle-stimulating and luteinizing hormone values were within normal range. Elongation of the prostate was the only radiologic variant of the sex accessory structures. A significant finding of pyospermia and bacterial growth in semen culture is reported in a subpopulation of young men with a history of PUV and severe lower urinary tract symptoms. This may have an impact on fertility.

Repeated Endoscopic Excision of an Eroding Calcified Mesh Sling—Continued Follow-Up Is Required

The tension-free vaginal tape (TVT) procedure is the most popular worldwide for treating stress urinary incontinence. Intravesical mesh erosion related to the use of the TVT sling is rare. We report a rare case of mesh erosion over the bladder dome, with stone formation developing 11 years after TVT surgery. The diagnosis was made by cystoscopic examination after a 5-month history of lower urinary tract symptoms. Cystoscopic cystolithotomy was performed. No obvious mesh material was seen except for a small filament that was excised cystoscopically. Repeat cystoscopic follow-up was performed a year later. A recurrent stone formation resulted from a nonvisible mesh filament. Repeat cystoscopic cystolithotomy was performed, and the patient refused further surgical intervention. In women with a history of undergoing the TVT procedure and who have persistent lower urinary tract symptoms, a cystoscopic examination is mandatory to avoid delay in diagnosis and underreporting of sling-related complications. Despite satisfactory cystoscopic management, long-term regular follow-up is still required.

Robotic-assisted laparoscopic simple prostatectomy: an alternative minimal invasive approach for prostate adenoma.

To substantiate robotic-assisted laparoscopic simple prostatectomy (RLSP) as an alternative minimal invasive approach for the treatment of prostatic adenoma. Retrospective chart review performed with institutional review board (IRB) approval. Demographic and clinical data were collected on 15 men between May 2007 and October 2009 who underwent RLSP for urinary retention secondary to benign prostate hypertrophy (BPH) and complicated by significant median lobe hypertrophy, bladder diverticula and/or stones. International Prostate Symptoms Score (IPSS), postvoid residual (PVR), prostate-specific antigen (PSA) and cystoscopy, urodynamics evaluation, and operative reports were reviewed and analyzed. Average age, PSA, IPSS, and PVR in the series were 65.8years, 5.17ng/ml, 23.85, and 265.79ml, respectively. Eleven men (73%) had urinary retention at presentation, 93.3% had significant intravesical lobe hypertrophy, 13.3% had bladder diverticula with/without stones, and mean prostate volume was 70.85ml. All the men complained principally of persistent lower urinary tract symptoms (LUTS) despite maximal medical treatment. Mean operative time, estimated blood loss, and adenoma weight were 128.8min, 139.3ml, and 46.4g, respectively. Mean hospital stay was 2.5days with average postoperative Foley catheter time of 4.6days. The only significant complication in the series was a postoperative incarcerated hernia in a patient with intraoperative repair of inguinal hernia. Postoperatively, symptom score improved significantly to an average of 8.13 (P=0.0002), and urine residual also improved to an average of 44.19ml (P≤0.0001). Significant improvement from the sequelae of BPH can be successfully achieved with RLSP.

Cystoscope- and Robot-Assisted Bladder Diverticulectomy

Background and Purpose: Minimally invasive approaches to manage bladder diverticula have become increasingly popular; however, intracorporeal identification of bladder diverticula may be challenging. We report a novel technique for diverticular illumination using flexible cystoscopy. Patients and Methods: After management of bladder neck obstruction, two patients with bladder diverticula and persistent lower urinary tract symptoms underwent robot-assisted bladder diverticulectomy. Cystoscopic illumination was used in both cases to aid diverticular identification and dissection. This video illustrates the steps of this approach in a patient with a 7 cm posterior and a 3 cm left lateral diverticulum. The steps include (1) externalized ureteral stent placement; (2) placement of laparoscopic ports in a configuration similar to that required for robotic cystectomy; (3) incision of peritoneum overlying posterior bladder; (4) exposure of diverticulum; (5) transurethral insertion of a flexible cystoscope into the diverticulum for transillumination and identification of the diverticular wall; (6) diverticular dissection down to its ostium; (7) transection of diverticulum at its ostium; (8) bladder closure in two layers; (9) confirmation of water-tight closure with bladder distension; and (10) insertion of Foley catheter and perivesical drain. Results: The perivesical drain was removed on postoperative day 1 and the patient was discharged on postoperative day 2. A cystogram on day 6 revealed no evidence of residual diverticula or leak, and the Foley catheter was removed. Conclusions: Our technique was simple to perform and facilitated identification and dissection of bladder diverticula. Cystoscope-assisted illumination provides a straightforward method of identifying bladder diverticula during robot-assisted laparoscopic diverticulectomy. Runtime of video: 3 min 55 sec

Urodynamic Analysis of Old-aged Men with Persistent Lower Urinary Tract Symptoms after Medical Treatments

Urodynamic Analysis of Old-aged Men with Persistent Lower Urinary Tract Symptoms after Medical Treatments

Should an antimuscarinic agent be used for persistent LUTS after treatment with an α1-blocker?

This Practice Point discusses the study by MacDiarmid and colleagues, which is the latest to support a beneficial effect of adding antimuscarinic agents to alpha(1)-blockers in men with persistent lower urinary tract symptoms. Such studies have also alleviated concerns about the adverse effects of antimuscarinic agents, particularly the risk of developing urinary retention. In practice, however, some issues regarding the use of antimuscarinic agents in this patient population remain. First, persistent storage symptoms are suggestive of other pathologies, and this possibility must be carefully evaluated before combined treatment is initiated. Second, postvoid residual urine volume should be repeatedly monitored during antimuscarinic therapy to avoid sequelae of residual urine or urinary retention. Third, the effect of adding an antimuscarinic agent is statistically significant, but might not be clinically significant for the majority of men. Better evaluation of storage symptoms might facilitate the more-appropriate use of combined treatment in this setting.

Cystoscope- and Robot-Assisted Bladder Diverticulectomy

Minimally invasive approaches to manage bladder diverticula have become increasingly popular; however, intracorporeal identification of bladder diverticula may be challenging. We report a novel technique for diverticular illumination using flexible cystoscopy. After management of bladder neck obstruction, two patients with bladder diverticula and persistent lower urinary tract symptoms underwent robot-assisted bladder diverticulectomy. Cystoscopic illumination was used in both cases to aid diverticular identification and dissection. Our technique was simple to perform and facilitated identification and dissection of bladder diverticula. Postoperative cystography revealed no evidence of residual diverticula. Cystoscope-assisted illumination provides a straightforward method of identifying bladder diverticula during robot-assisted laparoscopic diverticulectomy.

Anticholinergics in men: Does the evidence support combination therapy?

Benign prostatic hyperplasia (BPH) is common in men older than age 50, and the symptoms occurring from bladder outlet obstruction (BOO) commonly overlap with lower urinary tract symptoms (LUTS) experienced in overactive bladder (OAB). Anticholinergics are often withheld from men with BOO. This article reviews seven randomized controlled trials (RCTs) and a meta-analysis study examining anticholinergic use in men with LUTS associated with OAB and BPH. There is growing evidence that anticholinergics are a suitable, safe treatment in men with persistent LUTS associated with BOO, refractory to α-blockers. Only four of 750 men treated with anticholinergics in the seven RCTs reviewed had acute urinary retention. Further well-designed, placebo-controlled RCTs are required to assess the efficacy and long-term safety outcomes of combination therapy. However, it appears feasible to effectively use adjunctive anticholinergic therapy in men with LUTS/BPH and no significant increase in postvoid residual volume.

Endoscopic excision of an eroding calcified mesh sling, 10 years after primary surgery

Management of urethral erosion typically entails two options: sling incision (in the early postoperative period) or excision of the suburethral part of the sling (urethrolysis). This paper describes a different endoscopic technique. A forty-year-old woman with a synthetic sling implanted 10 years prior presented with persistent lower urinary tract symptoms. A kidney ureter bladder X-ray showed a stone at the level of the bladder neck. Disintegration of the stone revealed eroding mesh embedded in the urethral wall. Complete resection of the mesh using an electrocautery knife was performed. Two months since the procedure, the patient has had an uneventful course. Both vaginal and urethral walls are intact, and she is capable of normal voiding with some stress incontinence. Although it is unusual, a sling eroding the urethra is a diagnosis that needs to be considered even 10 years after surgery. Endoscopic management is feasible and can be successful.

Editorial Comment on: Is Botulinum Neurotoxin Type A (BoNT-A) a Novel Therapy for Lower Urinary Tract Symptoms Due to Benign Prostatic Enlargement? A Review of the Literature

mechanism of botulinum toxin type A as a treatment modality of benign prostatic hyperplasia. Yons Med J 2006;47:706–14. [28] Larson TR, Scottsdalle AZ, Huidobro C, et al. Intraprostatic injection of botulinum toxin in the treatment of symptomatic LUTS, including sequential MRIs for accurate changes in size of the prostate. J Urol 2005;173(suppl):376. [29] Guercini F, Giannantoni A, Bard RL, et al. Intraprostatic botulin toxin injection in patients with severe benign prostatic hyperplasia: a multicenter feasibility study. J Urol 2005;173(suppl):376–7. [30] Silva J, Silva C, Saraiva L, et al. Intraprostatic botulinum toxin type A injection in patients unfit for surgery presenting with refractory urinary retention and benign prostatic enlargement. Effect on prostate volume and micturition resumption. Eur Urol 2008;53:153–9. [31] Maria G, Brisinda G, Civello IM, Bentivoglio AR, Sganga G, Albanese A. Relief by botulinum toxin of voiding dysfunction due to benign prostatic hyperplasia: Results of a randomized, placebo-controlled study. Urology 2003;62:259–64. [32] Kuo HC. Therapeutic effects of botulinum toxin A on large benign prostatic hyperplasia with persistent lower urinary tract symptoms and suboptimal treatment outcome of combination medical therapy—clinical and histological investigation of effects. J Urol 2007;177(suppl): 609–10. [33] Plante MK, Folsom JB, Zvara P. Prostatic tissue ablation by injection: a literature review. J Urol 2004;172:20–6.

Urinary complications of migrated intrauterine contraceptive device

The study aimed to present diagnosis and management of urinary complications resulting from migration of intrauterine contraceptive device (IUD). Between May 2002 and January 2007, eight women were treated for urinary complications because of migrated IUD. Persistent lower urinary tract symptoms were the main complaint in five cases, while one patient presented with urinary incontinence and two had suffered from right loin pain. Diagnosis was established after performing noncontrast computed tomography (NCCT) in all cases. Intravenous urogram (IVU) was carried out for evaluation of hydronephrosis in two cases. Cystoscopy was performed before surgical intervention in six cases. The interval between insertion of IUD and onset of symptoms ranged from 1 week up to 2 years. NCCT revealed complete intravesical position of the IUD with calculus formation on top in four cases and partial bladder wall penetration in the fifth. Cystoscopy confirmed the site of the IUD as detected by NCCT. In the last two cases, retroperitoneal migration of IUD had led to fibrosis around the right pelvic ureter. Intravesical IUDs and stones were successfully retrieved using transurethral endoscopy while suprapubic retrieval of the device was followed by repair of vesicouterine fistula in the fifth case and ureteroneocystostomy in the last two cases. Persistent lower urinary tract symptoms in women with IUD should raise the suspicion of intravesical migration. Noncontrast CT permitted excellent depiction of the site of migrated IUD for selection of proper management. Endoscopic retrieval is feasible and safe in cases with intravesical migrated IUD.

1836: Therapeutic Effect of Botulinum Toxin a on Large Benign Prostatic Hyperplasia with Persistent Lower Urinary Tract Symptoms and Suboptimal Treatment Outcome of Combination Medical Therapy-Clinical and Histological Investigation of Effects

1836: Therapeutic Effect of Botulinum Toxin a on Large Benign Prostatic Hyperplasia with Persistent Lower Urinary Tract Symptoms and Suboptimal Treatment Outcome of Combination Medical Therapy-Clinical and Histological Investigation of Effects

ENTEROCOCCAL ENDOCARDITIS PRESENTING WITH SUDDEN RIGHT ARM WEAKNESS IN A 73‐YEAR‐OLD MAN

ENTEROCOCCAL ENDOCARDITIS PRESENTING WITH SUDDEN RIGHT ARM WEAKNESS IN A 73‐YEAR‐OLD MAN

HOLMIUM LASER BLADDER NECK INCISION VERSUS HOLMIUM ENUCLEATION OF THE PROSTATE AS OUTPATIENT PROCEDURES FOR PROSTATES LESS THAN 40 GRAMS: A RANDOMIZED TRIAL

Bladder neck incision (BNI) is a common, minimally invasive treatment option for bladder outflow obstruction in men with a small prostate. We compared BNI using the holmium:YAG laser to holmium enucleation of the prostate (HoLEP) in a prospective, randomized, urodynamically based trial. A total of 40 patients with urodynamic obstruction (Schafer grade 2 or greater) and a prostate of 40 gm or greater on transrectal ultrasound (TRUS) were randomized equally to holmium laser BNI (HoBNI) or HoLEP as an outpatient procedure. The outcomes assessed were operative time, catheter time and hospital time. American Urological Association and quality of life scores, and maximal urinary flow rates were measured at baseline, and 1, 3, 6 and 12 months postoperatively, while pressure flow studies and TRUS volume measurement were performed at baseline and 6 months. The 2 groups were well matched for all variables at baseline. HoBNI was significantly more rapid to perform than HoLEP (p <0.001). Two patients (10%) in the HoBNI group required recatheterization compared with none in the HoLEP group. There was no significant difference in catheter time (22.9 vs 23.2 hours) or hospital time (12.3 vs 13.7 hours) between the groups. Five patients remained obstructed urodynamically at 6 months. All were in the HoBNI group and 4 of the 5 men had a prostate that was greater than 30 gm. Four of these patients required HoLEP for persistent lower urinary tract symptoms. In the remaining unoperated patients there were no significant differences in American Urological Association and quality of life scores or in the maximal urinary flow rate at each assessment. At 6 months detrusor pressure at maximal urinary flow was significantly lower (p <0.05) and TRUS volume was significantly smaller (p <0.001) in the HoLEP group There was significantly more early stress incontinence postoperatively in the HoLEP group but no bladder neck contractures were detected. Relief of obstruction was better after HoLEP and fewer patients required recatheterization or reoperation, although more reported early postoperative stress incontinence. Catheter time, hospital time and perioperative morbidity were similar. HoBNI and HoLEP are safe and feasible as outpatient procedures in patients with a small prostate but HoBNI is more rapid to perform.

Analysis of the Pathophysiology of Lower Urinary Tract Symptoms in Patients after Prostatectomy

Objectives: To analyze the pathophysiology of persistent lower urinary tract symptoms (LUTS) in patients after transurethral prostatectomy (TURP). Methods: A total of 185 patients who had persistent LUTS after TURP were enrolled into this study. All of these patients underwent multichannel videourodynamic studies and were classified into 6 groups according to the urodynamic results. Preoperative prostate volume, resected adenoma weight, and preoperative Q_max were determined in each of the groups and the symptomatology and urodynamic findings were compared. Results: A normal videourodynamic tracing was found in 17 patients (9.1%), pure detrusor instability in 18 (9.6%), low detrusor contractility in 35 (18.7%), detrusor instability and inadequate detrusor contractility (DHIC) in 27 (14.4%), poor relaxation of the urethral sphincter in 36 (19.3%), and bladder outlet obstruction (BOO) in 52 (27.8%). Incontinence was noted in 74 patients (40%), and 18 of them had BOO (24.3%). In urodynamic findings, Q_max and residual urine showed no significant difference among patients with low contractility, poor relaxation of sphincter, DHIC and BOO. Concerning the preoperative prostatic volume, patients with low contractility, poor relaxation of urethral sphincter, and DHIC had a nonsignificantly smaller prostate volume and resected prostate weight than other groups. Preoperative Q_max showed no significant difference among all groups. Conclusions: Symptoms alone are unreliable in predicting urodynamic findings with respect to obstruction and detrusor instability after TURP. Over half of the patients with persistent LUTS had a small prostate volume and small resected adenoma weight, indicating that some of these patients may not have had BOO. Videourodynamic study is helpful in making an accurate diagnosis for refractory LUTS after TURP.