Urgency-frequency Syndrome Research Articles

Frequency-Urgency Syndrome

Frequency-Urgency Syndrome

A novel sacral neuromodulation protocol is associated with reduction in removal for device infection.

Sacral neuromodulation (SNM) has been established as an effective third-line therapy for non-obstructive urinary retention and urinary urgency-frequency syndrome. Device infection, ranging from 2-10%, is a severe complication usually necessitating device explanation. This study sought to demonstrate an infection protocol founded upon established device implantation risk factors and novel approaches to reduce the incidence of device infection, while maintaining good antibiotic stewardship following best practice statements. A single-surgeon protocol was enacted from 2013 to 2022. Preoperatively, nasal swabs were cultured from each patient. If positive for methicillin-resistant Staphylococcus aureus or methicillin-sensitive Staphylococcus aureus, preoperative treatment with intranasal mupirocin was employed. Preoperative cefazolin was administered in patients with negative cultures or MSSA-positive. All protocol patients were given chlorhexidine wipes before surgery and prepped with a chlorhexidine scrub followed by alcohol/iodine paint. Post-procedural antibiotics were not given. Pre-protocol patients from 2011 to 2013 served as controls. Pre-protocol (n=87) patients had a significantly higher rate of device infection compared to protocol patients (n=444) in both the percentage of patients experiencing device infection (4.6% vs 0.9%, p=0.01) and percentage of procedures associated with device infection (2.9% vs 0.5%, p<0.05). A successful culture of the nares was achieved in 91.4% of protocol patients, with 11.6% MRSA-positive. Risk ratio for infection of pre-protocol/protocol patients was 0.19 (0.05-0.77) with odds ratio 5.1 (1.3-20.0). Utilization of a novel SNM infection protocol tailored to a patient's preoperative MRSA colonization is associated with a reduction in the overall incidence of explant for device infection while avoiding prolonged postoperative antibiotic regimens. The study was initiated prior to January 18, 2017 and does not meet the definition of an applicable clinical trial (ACT) as defined in section 402 (J) of the US PHS Act.

Discriminating Different Bladder and Bladder Outlet Dysfunctions by Urinary Biomarkers in Women with Frequency–Urgency Syndrome

To investigate the role of urinary biomarkers in discriminating different bladder and bladder outlet dysfunctions in women with frequency-urgency syndrome. Urine samples collected from 146 women with frequency-urgency syndrome and 34 controls were investigated. All patients were included in previous clinical trials of functional urology studies and underwent a videourodynamic study. Patients with frequency-urgency syndrome were subdivided into idiopathic detrusor overactivity (IDO), neurogenic detrusor overactivity (NDO), dysfunctional voiding (DV), and hypersensitive bladder (HSB) subgroups. Urine samples were collected before any treatment, and urinary inflammatory proteins (interleukin- (IL-) 1β, IL-2, IL-6, IL-8, tumor necrosis factor-α (TNF-α), and vascular endothelial growth factor (VEGF)), neurogenic proteins (nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and prostaglandin E2 (PGE2)), and oxidative stress biomarkers (8-isoprostane, total antioxidant capacity (TAC), and 8-hydroxydeoxyguanosine (8-OHdG)) were measured and compared between the different OAB subgroups and controls. Of the 146 patients, 31 had IDO, 41 had NDO, 45 had DV, and 29 had HSB. The control group included 34 women. The patients with HSB had lower urinary TAC and IL-2 levels than the controls. The patients with IDO, NDO, and DV had significantly higher urinary TNF-α levels than those with HSB. The patients with IDO and NDO showed an increase in the urinary 8-isoprostane levels, whereas the patients with IDO had higher urinary IL-2, NGF, and BDNF levels than those with NDO. The other urinary inflammatory biomarkers did not show enough significant differences to discriminate between the different bladder and bladder outlet dysfunctions. The urinary levels of inflammatory, neurogenic, and oxidative stress biomarkers varied widely among the patients with bladder and bladder outlet dysfunction. This study's results provide evidence that women with frequency-urgency syndrome and different urodynamic subtypes have varying bladder inflammation and oxidative stress conditions, which might have an impact on treatment outcomes.

EDITORIAL COMMENT

This manuscript describes the very short-term effects of electrical pudendal nerve stimulation (EPNS) versus pelvic floor muscle training (PFMT) plus transanal electrical stimulation (TES) in Chinese men with urinary incontinence after radical prostatectomy. EPNS has been suggested for use in the management of stress urinary incontinence, urge urinary incontinence, urgency-frequency syndrome, and neurogenic lower urinary tract symptoms. In this parallel designed randomized controlled trial at a research institute and a university hospital, Chinese men with post-prostatectomy urinary incontinence were assigned to EPNS (64 patients) or PFMT plus TES (32 patients) and treated 3 times a week for 8 weeks.

MP52-11 PATIENT-REPORTED ONSET OF SYMPTOM IMPROVEMENT FOLLOWING INITIAL INTRADETRUSOR ONABOTULINUMTOXINA INJECTIONS FOR OVERACTIVE BLADDER

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy II (MP52)1 Sep 2021MP52-11 PATIENT-REPORTED ONSET OF SYMPTOM IMPROVEMENT FOLLOWING INITIAL INTRADETRUSOR ONABOTULINUMTOXINA INJECTIONS FOR OVERACTIVE BLADDER Neil J. Kocher, Jacqueline Zillioux, Sarah Martin, Raymond R. Rackley, Sandip P. Vasavada, and Howard B. Goldman Neil J. KocherNeil J. Kocher More articles by this author , Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Sarah MartinSarah Martin More articles by this author , Raymond R. RackleyRaymond R. Rackley More articles by this author , Sandip P. VasavadaSandip P. Vasavada More articles by this author , and Howard B. GoldmanHoward B. Goldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002082.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intradetrusor onabotulinumtoxinA (BTX-A) is a common third-line therapy for treatment of refractory overactive bladder (OAB), however several gaps exist in pre- and post-procedural standard of care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. We performed a prospective study evaluating several factors involved in the BTX-A patient care pathway. The primary aim of this abstract was to determine patient-reported temporal improvement in symptoms following initial BTX-A therapy. METHODS: A prospective, non-randomized study of patients with non-neurogenic, refractory urgency-frequency syndrome and urgency urinary incontinence undergoing first-time BTX-A injection under local anesthesia was performed. Intradetrusor injection of 100 units BTX-A was performed by one of 3 FPMRS-trained providers using a standard 20-site template. Patients were required to discontinue their OAB medication(s) at the time of BTX-A injection for 3 weeks and complete a daily Patient Global Impression of Improvement (PGI-I) diary during this time. Data were collected at 1 month, including final satisfaction score and adverse outcomes. Descriptive analysis was performed in R programming. RESULTS: 25 patients were included (24 female, 1 male). Median age was 75 years and BMI was 34.3. Figure 1 shows a jitter plot with loess smoothed fit of patient-reported PGI-I over time following BTX-A injection. 24 patients (96%) reported symptom improvement (PGI <4) by 3 weeks, with 19 patients (76%) documenting at least “much better” (PGI >2). Median time to first improvement (PGI <4) was 1 day, at least “much better” was 4 days, and median time to maximum patient improvement was 6 days. Median final satisfaction score was PGI 2 (“much better”). Adverse outcomes included UTI in 2 patients (8%) and incomplete emptying requiring transient intermittent catheterization in 1 patient (4%). CONCLUSIONS: Patients with refractory OAB undergoing first-time 100 units BTX-A injection reported median time to first improvement (PGI <4) at 1 day, at least “much better” at 4 days, and median time to maximum patient improvement at 6 days. These data may help further counsel patient expectations following initial BTX-A therapy. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e934-e934 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Neil J. Kocher More articles by this author Jacqueline Zillioux More articles by this author Sarah Martin More articles by this author Raymond R. Rackley More articles by this author Sandip P. Vasavada More articles by this author Howard B. Goldman More articles by this author Expand All Advertisement Loading ...

The Effect of Sacral Neuromodulation in Ambulatory Spina Bifida Patients with Neurogenic Bladder and Bowel Dysfunction

OBJECTIVETo assess the effect of sacral neuromodulation (SNM) in ambulatory spina bifida patients with neurogenic bladder and bowel dysfunction. MATERIALS AND METHODSWe retrospectively reviewed the records of 29 ambulatory spina bifida patients with neurogenic bladder and bowel dysfunction who underwent SNM testing from July 2012 to January 2020. Clinical data and video-urodynamic parameters were collected and compared using the t-test and the chi-square test. The potential risk factors were considered by logistic regression analysis. P < .05 was considered significant. RESULTSIn the test phase, 21 patients (72.4%) achieved successful improvement of at least 1 symptom. The success rate for chronic urinary retention (26.09%) was significantly lower (P <.05) than that for urgency–frequency syndrome (58.82%) and urinary incontinence (56.25%). The mean neurogenic bowel dysfunction score decreased from 13.3±6.29 to 6.9±5.09 (P <.0001). The urodynamic evaluation showed a significant improvement in the mean maximum cystometric capacity, compliance, and maximum detrusor pressure (P <.05). Implantation was performed in 16 cases (55.17%). The analysis of the risk factors showed that chronic urinary retention was a statistically significant variable (P <.05). No complications were reported in the test phase. The average follow-up time was 41.19±33.06 months. Two patients changed to intermittent catheterization, and 2 patients changed to augmentation cystoplasty. CONCLUSIONSNM is effective for neurogenic bladder and bowel dysfunction in patients with ambulatory spina bifida, especially in those without chronic urinary retention. And SNM can also significantly improve the urodynamic parameters of these patients during the storage period.

Evaluación de la eficacia, cambios en la calidad de vida y seguridad de la Neuromodulación sacra como tratamiento para pacientes con disfunción miccional en un Hospital de concentración de México

Antecedentes: La Neuromodulación Sacra es una técnica mínimamente invasiva para modular los reflejos espinales que tienen influencia sobre la vejiga, el intestino, el esfínter uretral externo y el piso pélvico, para mejorar y restaurar las funciones de micción y evacuación. Sus principales indicaciones terapéuticas son incontinencia urinaria de urgencia, síndrome urgencia-frecuencia, alteraciones en el vaciado no obstructivas, retención urinaria crónica, dolor pélvico crónico, incontinencia fecal y estreñimiento. En nuestro país se han realizado pocos estudios que evalúen la eficacia y seguridad de esta terapia.&#x0D; Objetivo del estudio: Evaluar la eficacia terapéutica, seguridad y calidad de vida de los pacientes con disfunción miccional crónica tratados con Neuromodulación sacra en el Hospital Central Militar.&#x0D; Material y métodos: Desde enero de 2010 hasta el 30 de junio del 2018, se realizó una revisión de los expedientes de pacientes tratados con terapia de Neuromodulación sacra por disfunción miccional crónica y que fueron refractarios a tratamiento médico, para hacer una evaluación de la calidad de vida mediante el empleo del instrumento SF-36 v2 (versión mexicana) e ICIQSF, eficacia con el empleo de los resultados de los diarios miccionales y parámetros urodinámicos, y se clasificaron las complicaciones del procedimiento según la escala de Clavien Dindo. Se utilizó el sistema estadístico IBM SPSS 22.0.&#x0D; Resultados: Se incluyeron 41 pacientes en el estudio con los siguientes diagnósticos: disinergia detrusor-esfínter, vejiga hiperactiva y esfínter urinario hipertónico, ubicados por género (16 masculinos y 25 femeninos). El 100% de los pacientes presentaron mejoría de los síntomas con la fase de prueba de la terapia y se les colocó neuroestimulador definitivo con los siguientes resultados: se obtuvo más del 65% de mejoría en la calidad de vida con parámetros cuantitativos y cualitativos, así como en las variables de capacidad vesical y volumen post miccional.&#x0D; Discusión y Conclusiones: Como se ha reportado en la literatura mundial, los resultados fueron similares en cuanto a la eficacia, mejoría en la calidad de vida y seguridad de la terapia de Neuromodulación sacra. Se han reportado porcentajes de éxito mayores al 50% en el cese total de los episodios de incontinencia. La Neuromodulación sacra es una terapia tanto mínimamente invasiva como duradera para el tratamiento de la disfunción miccional de etiología no obstructiva. En los casos en los que las pruebas de Neuromodulación no son efectivas, este tratamiento tiene la ventaja de ser reversible. Es necesario continuar con el desarrollo de estudios que puedan comprobar a mediano y largo plazo, mediante parámetros urodinámicos, la eficacia de este tratamiento.

Patients with Sacral Neuromodulation: What Are the Factors Affecting Their Therapy Satisfaction?

Introduction and Objectives: Technology has brought about changes to the sacral neuromodulation (SNM) therapy and has rendered it as a minimally invasive procedure. The presence of tined lead, smaller implantable pulse generator, and the different available patient programmers are the factors new modifications this procedure; however, no enough data are available about patient satisfaction comparing these different parameters. We therefore conducted our study among SNM-implanted patients, assessing factors affecting long-term satisfaction. Patients and Methods: We conducted a cross-sectional study with a survey questionnaire for all SNM-implanted patients from December 2011 to May 2012. The survey questionnaire included information on patient demographics, level of satisfaction, and the need for combined medical therapy for symptom control, type of programmer used by patient, and their ability to use it efficiently. Results: A total of 117 patients visited the clinic in that duration, and 71 patients filled up the survey questionnaire, with a response rate of 60.7%, diagnosis OAB 41 (57.7%), chronic non-obstructive retention 15 (21.1%) and frequency-urgency syndrome 15 (21.1%). Forty-nine (69%) of patients were on SNM therapy alone, while 31% patients needed other forms of therapy for symptoms control. The types of patient programmers used were old programmers in 10 (14.1%), new programmers in 44 (62%), and twin programmers in 4 patients. Patient SNM therapy satisfaction level was 95.8%, while 3 patients (4.2%) were not satisfied. SNM therapy satisfaction showed that it was correlated with the need for combined therapy for symptoms control (correlation coefficient 0.341, p value = 0.004), but there was no correlation with age, duration of therapy, complication, or programmer type. Conclusion: SNM satisfaction in patients is mainly correlated with the need for additional medications for symptom control.

Re: The Efficacy of Botulinum Toxin A and Sacral Neuromodulation in the Management of Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS), What do we Know? ICI-RS 2017 Think Tank, Bristol.

No AccessJournal of UrologyUrological Survey1 Jul 2019Re: The Efficacy of Botulinum Toxin A and Sacral Neuromodulation in the Management of Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS), What do we Know? ICI-RS 2017 Think Tank, Bristol Alan J. WeinMD, PhD (hon) Alan J. WeinAlan J. Wein More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557762.34778.a0AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: The Efficacy of Botulinum Toxin A and Sacral Neuromodulation in the Management of Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS), What do we Know? ICI-RS 2017 Think Tank, Bristol." The Journal of Urology, 202(1), pp. 40–41 Reference 1. : Bladder pain syndrome. In: Incontinence, 6th ed. Edited by . Bristol, United Kingdom: International Continence Society 2017; pp 2203-2301. Google Scholar Suggested Reading : Botulinum A toxin intravesical injection in patients with painful bladder syndrome: 1-year followup. J Urol 2008; 179: 1031. Link, Google Scholar : Long-term outcomes of urgency-frequency syndrome due to painful bladder syndrome treated with sacral neuromodulation and analysis of failures. J Urol 2010; 183: 173. Link, Google Scholar : Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol 2003; 169: 1369. Link, Google Scholar © 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 202Issue 1July 2019Page: 40-41 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alan J. Wein More articles by this author Expand All Advertisement Loading ...

Comparison of efficacy and safety between electroacupuncture at ‘four sacral points’ and conventional electroacupuncture for the treatment of urinary incontinence after stroke: study protocol for a randomised controlled trial

IntroductionElectroacupuncture at ‘four sacral points’, also known as electrical pudendal nerve stimulation therapy, combines the advantages of pudendal nerve neuromodulation and the technique of deep insertion of long acupuncture needles....

Safety and Efficacy of Intermittent versus Continuous Anticholinergic Medication in Management of Overactive Bladder in Adult

Background: overactive bladder (OAB) also referred to as the urgency-frequency syndrome, with or without urge urinary incontinence can considerably impair the patient's quality of life. It is widely accepted that diet and life style modifications, behavioral therapy and medication belong to the standard conservative therapeutic options and considered as the first-line measures. The International Consultation on Incontinence (ICI) guidelines reported that when the first line approach is not fully satisfactory or fails after 8-12 weeks, alternative therapies should be sought out. It is worthwhile and justified to proceed to second-line therapy if patients are refractory to antimuscarinic therapy or if the treatment is contraindicated. Second-line of therapies include less-invasive measures such as percutaneous posterior tibial neve stimulation, sacral neuromodulation, detrusor injections with botulinum toxin (BTX) and whereas more-invasive measures constitute surgical techniques e.g. bladder augmentation or substitution. Pelvic neuromodulation has been proven effective and is today an established treatment option for patients refractory to or intolerant of conservative treatments. Objective: this study aimed to compare between the efficacy of continuous anticholinergic therapy and intermitted anticholinergic therapy for treatment of the overactive bladder. Patients and Methods: our study included 60 patients categorized into two groups: continuous anticholinergic therapy group and intermitted anticholinergic therapy. By using 12 weekly intermitted anticholinergic therapies, remarkable clinical results were obtained. Percent of the patients who complained OAB in the intermitted anticholinergic group reported a statistically significant subjective success. These patients chose to continue treatment to maintain the response. Results: patients in the intermitted anticholinergic therapy group showed significant improvement of frequency (31%) urgency (50%) urge incontinence (50%) and nocturia (53%) compared to propiverine group frequency (50%) urgency (60%) urge incontinence (67%) and nocturia (67%). No serious side effects were reported, in group A 8 patients had horm of dry mouth in 5 cases (16.7%), constipation in 2 cases (67%) 8 blurred vision in one case (33%). In group B, there were 5 patients (16.7%) in the horm of dry mouth in 3 cases (10% constipation in one case (3.3) and blurred vision in one case (3.3%). Conclusion: our study concluded that intermittent anticholinergic therapy induced improvement of bladder over activity symptoms and less side effects than continuous anticholinergic group.

Vulvodynia Treated by Sacral Nerve Stimulation: Case Report

Sacral nerve stimulation is an FDA approved therapy for refractory overactive bladder, frequency urgency syndrome and nonobstructive urinary retention. It has been applied to other off label uses such as interstitial cystitis and chronic prostatitis for subjective patient symptomatic improvement. We report a 54 year old female who presented with vulvodynia and had been treated successfully with sacral neuromodulation.

Percutaneous Nerve Evaluation Test Versus Staged Test Trials for Sacral Neuromodulation: Sensitivity, Specificity, and Predictive Values of Each Technique.

PurposeInterStim device is an U.S. Food and Drug Administration approved minimal invasive therapy for sacral neuromodulation for lower urinary tract dysfunction. Before InterStim implantation, a trial with the appropriate screening tests is required to determine patient therapy eligibility. There are two different techniques for patient screening: percutaneous nerve evaluation (PNE) test and staged test. Few studies have reported success and failure rates for each technique. However, test sensitivity and predictive values of either test have not been studied. The aim of our study was to determine the sensitivity and specificity of each test and to establish a decision algorithm for the most appropriate testing method to be used as a screening test.MethodsThis cross-sectional study was conducted from August 2009 to February 2012 and included patients with lower urinary tract dysfunction who participated in the stimulation test trial. Patients underwent PNE as the first stimulation test, while those who encountered technical difficulty during PNE or electrode migration underwent staged testing.ResultsA total of 213 patients, including 172 female and 41 male subjects, underwent PNE. The patients’ diagnoses included refractory overactive bladder (47.9%), nonobstructive urinary retention (29.6%), and frequency urgency syndrome (22.1%). A total of 202 patients were screened with PNE and 10 patients with staged testing. Overall sensitivity of PNE was 87.3%, and it was 90% for staged test. PNE specificity was 98.5% as compared to 92.9% for staged test. Positive and negative predictive values for PNE were 99% and 82.1% and for staged test were 90% and 92.9%, respectively.ConclusionsPNE test has high specificity and positive predictive value. We recommend PNE, a simple office-based, less expensive procedure as the first option for screening.

Detrusor after-contraction: a new insight.

ABSTRACTAims:Detrusor after-contractions (DAC) are non-common in adults. Both definition (nothing in ICS reports) and significance (artefact, link with detrusor overactivity (DO) or bladder outlet obstruction (BOO)) remain discussed. Our purpose was to carry out an analysis of the urodynamic parameters during voidings with DAC and, using the VBN model, to simulate pathophysiological conditions able to explain both voiding phase and DAC.Materials and Methods:From large urodynamic database of patients referred for evaluation of lower urinary tract dysfunction, DAC were observed in 60 patients (5.7%). Criteria for DAC were post-void residual <30mL and increase of detrusor pressure >10cmH2O. VBN model was used for analysis of both pressure and flow curves, and simulations of pathophysiological conditions.Results:Onset of DAC (ODAC) occurred when Q=7.3±5.7mL/s and bladder volume=17.9±15.4mL. Urgency-frequency syndrome and urodynamic diagnosis of DO were the more frequent scenarios associated with DAC. ODAC was associated to an inversion of the slope of detrusor pressure curve without any perturbation in flow curve. Among tested pathophysiological hypothesis (great, abnormal, detrusor force, sphincter contraction), none allowed restoring all recorded curves (flow rate, voiding pressure and DAC).Conclusion:No urodynamic characteristic of the first part of voiding is an index of occurrence of DAC. ODAC is a significant phenomenon linked with the bladder collapse. DAC is not associated with BOO but more probably with DO and appears as the result of local conditions in an almost empty bladder (concentration of stresses around a transducer); thus DAC seems of weak clinical significance.

Effect of sacral neuromodulation on female sexual function and quality of life: Are they correlated?

Sacral neuromodulation (SNM) has become an established therapy for voiding dysfunction. Additional benefits, such as improved bowel functions and bladder pain, have been reported. Improvement in female sexual function after SNM treatment has been suggested; however, reports examining the effects of SNM on female sexual functions are scarce. We evaluate the effects of SNM on female sexual function and its impact on quality of life and analyze any correlation. Data were collected from January 2010 to May 2012 for all female patients who underwent SNM InterStim (Medtronic, Minneapolis, MN) therapy at a single centre in Canada. They were treated for voiding dysfunction, including refractory over-active bladder, frequency-urgency syndrome and non-obstructive urinary retention. Patients were screened by percutaneous nerve evaluation (PNE) to assess their response to therapy using a 4-day voiding diary. Patients who experienced 50% or more improvement in their voiding parameters were permanently implanted. All patients completed the Female Sexual Function Index (FSFI), Short-Form Health Survey (SF-36), and incontinence questionnaires (Urinary Distress Inventory [UDI]-6) preoperatively and 4 months postoperatively. A total of 33 female patients had SNM therapy; 10 were excluded from the study because they were not sexually active. The indications were: refractory overactive bladder in 19, frequency-urgency syndrome in 2, and non-obstructive urinary retention in another 2 patients. SNM therapy significantly improved the total FSFI score (p = 0.011); the components of desire and orgasm showed significant improvement (p = 0.014 and p = 0.035, respectively). Age, body mass index, diagnosis, and urinary symptoms did not show significant correlation with FSFI score improvement. Quality of life showed significant improvement after SNM treatment in 5 categories. There was no correlation between improvement in quality of life and FSFI. SNM may improve female sexual function and quality of life, yet there is no correlation between the improvement in FSFI and quality of life.

Long‐term follow‐up of sacral neuromodulation for lower urinary tract dysfunction

To report our long-term experience of sacral neuromodulation (SNM) for various lower urinary tract dysfunctions but with a focus on efficacy, safety, re-interventions and degree of success. This is a single tertiary referral centre study that included 217 patients (86% female) who received an implantable pulse generator (IPG) (Interstim™, Medtronic, Minneapolis, USA) between 1996 and 2010. Success was considered if the initial ≥50% improvement in any of primary voiding diary variables persisted compared with baseline, but was further stratified. The mean duration of follow-up was 46.88 months. Success and cure rates were ≈70% and 20% for urgency incontinence, 68% and 33% for urgency frequency syndrome and 73% and 58% for idiopathic retention. In those patients with an unsuccessful therapy outcome, the mean time to failure was 24.6 months after implantation. There were 88 (41%) patients who had at least one device or treatment related surgical re-intervention. The re-intervention rate was 1.7 per patient with most of them (47%) occurring ≤2 years of follow-up. SNM appears effective in the long-term with a success rate after definitive IPG implant of ≈70% and complete cure rates ranging between 20% and 58% depending on indication. Patients with idiopathic retention appear to do best. The re-intervention rate is high with most occurring ≤2 years of implantation. It is likely that with the newer techniques used, efficacy and re-intervention rates will improve.

Potential urine and serum biomarkers for patients with bladder pain syndrome/interstitial cystitis.

There is a lack of consensus on the pathophysiology of bladder pain syndrome/interstitial cystitis. The chronic pain symptoms of bladder pain syndrome/interstitial cystitis refractory to local treatment could be a result of central nervous system sensitization and persisting abnormalities in the bladder wall, which activate the afferent sensory system. Evidence also shows that bladder pain syndrome/interstitial cystitis is a heterogeneous syndrome and that the two subtypes, the ulcerative (classic) and non-ulcerative types, represent different disease entities. There is a need for non-invasive markers for the differential diagnoses of the subtypes of bladder pain syndrome/interstitial cystitis, and between bladder pain syndrome/interstitial cystitis and bladder sensory disorders, such as hypersensitive bladder syndrome or overactive bladder. Bladder pain syndrome/interstitial cystitis, but not overactive bladder, involves an aberrant differentiation program in the bladder urothelium that leads to altered synthesis of several proteoglycans, cell adhesion and tight junction proteins, and bacterial defense molecules. These findings have led to the rationale for identifying urinary biomarkers to detect bladder pain syndrome/interstitial cystitis in patients with frequency urgency syndrome. Recently, the markers that have been the focus of the most research are antiproliferative factor, epidermal growth factor, heparin-binding epidermal growth factor, glycosaminoglycans and bladder nitric oxide. In addition, inflammatory proteins in the urine and serum play important roles in the pathogenesis of bladder pain syndrome/interstitial cystitis. The urinary proteome is an easily accessible source of biomarkers for differentiation between inflammatory bladder disorders. Analysis of multiple urinary proteins and serum cytokines could provide a diagnostic basis for bladder pain syndrome/interstitial cystitis, and could be a tool for the differential diagnosis of bladder pain syndrome/interstitial cystitis and other sensory bladder disorders.

Long-term efficacy of electrical pudendal nerve stimulation for urgency–frequency syndrome in women

Electrical pudendal nerve stimulation (EPNS) was developed by combining the advantages of pudendal neuromodulation (PNM) and percutaneous tibial nerve stimulation (PTNS) and incorporating the technique of deep insertion of long acupuncture needles. The purpose of this study is to show the long-term efficacy of EPNS in treating urgency-frequency syndrome (UFS) in women. One hundred and six consecutive female UFS patients were enrolled and treated with EPNS. Long acupuncture needles were deeply inserted into four sacral points and electrified to stimulate the pudendal nerves. Evaluation of therapeutic effects was based on a questionnaire (including questions on storage, voiding, and postmicturition symptoms). Patients with ≥50% posttreatment symptom improvement were followed up for at least 60months. Complete resolution and ≥50% improvement rate were 42.5% and 85.8%, respectively, in the 106 patients after a mean of 21.2 sessions of EPNS treatment. Of the 91 patients with ≥50% posttreatment improvement, 62 (29 with complete resolution, 15 with marked improvement, and 18 with moderate improvement) were available for follow-up at 60-126 (mean 99.5; median 98) months after the end of EPNS treatment. Of these 62 patients, 35 maintained the posttreatment effect, 18 changed from better to complete resolution, and seven changed back to <50% improvement; only four of whom changed to <25% improvement. EPNS combines the advantages of PNM (better effect) and PTNS (minimally invasive, easily applicable, and well tolerated) in treating UFS. It has a good long-term therapeutic effect on UFS in women.

Sacral neuromodulation therapy of the lower urinary tract: A review of the literature and unanswered questions

Objective: To review the evidence surrounding Sacral Neuromodulation therapy and delineate areas that will need more research. Methods: An extensive search was performed on the available literature on SNM for lower urinary tract dysfunction. Based on the results of the search, the mechanisms of action, indications, technique, and patient characteristics of therapy failures and success are presented and discussed. Results: SNM is accepted by the FDA since 1997 for the treatment of lower urinary tract dysfunction. As it is a relatively new procedure, there are variations in the technique of lead placement, generator choice, testing interval, patient selection, time to explantation, and definitions of therapy failures and successes. Conclusions: SNM is a safe and therapeutic option for the treatment of urgencyfrequency syndrome, urge incontinence, and idiopathic urinary retention. However, there are multiple unanswered questions that require extensive research.

Sacral nerve stimulation: 50 years in the making

While it is true that sacral neuromodulation has only been approved for use in North America since 1997, the concept of sacral stimulation for “curing” voiding dysfunction first took shape almost 50 years ago. After the success of cardiac pacemakers in the 1960s, hopes were high that a number of body functions could be helped with electrical stimulation.1 In the early 1970s, the National Institutes of Health began a comprehensive program involving numerous research centres and research disciplines. The goal was to achieve synergic voiding. Although that did not happen, intermittent voiding was achieved and the dawn of sacral nerve stimulation was upon us.1,2 In 1981, the University of California, San Francisco initiated the first clinical program on sacral neuromodulation (SNM) followed quickly by a large multi-centred trial from 1985 to 1992. In 1997, the Food and Drug Administration (FDA) granted Medtronic approval of the Interstim system for the treatment of urge incontinence in the United States and in 1999 the FDA approved Interstim for the treatment of symptoms of urgency-frequency syndrome and urinary retention. Over the next 13 years, SNM has undergone a tremendous therapeutic evolution. There have been advances in treatment, including a tined lead, the use of fluoroscopic imaging and the smaller implantable pulse generators.3 The indications for SNM have also grown to include interstitial cystitis, chronic pelvic pain, fecal incontinence, constipation and neurogenic bladder.4–8 With these therapeutic changes researchers have searched for less invasive modalities to stimulate these sacral nerves. Posterior tibial nerve stimulation (PTNS) was first described in a small study in 1983 and was shown to inhibit bladder contractions for 2 to 3 days.9 This technology laid dormant until it was revived in the late 2000s when a large randomized double-blind controlled trial demonstrated it to be a safe, effective and viable treatment option for overactive bladder.10 Data for this non-invasive technology continue to accumulate with a multitude of excellent studies published over the last several years.11,12 Elkelini and colleagues describe a rodent model that incorporates a novel transdermal amplitude-modulated signal (TAMS) as a non-invasive alternative to an implantable SNM to treat neurogenic detrusor overactivity.13 The results appear to demonstrate that the amplitude-modulated waveform is sufficient to overcome skin and tissue impedance and stimulate the sacral nerves. The authors demonstrate a decrease in the calcitonin gene-related protein (CGRP) concentration with neurostimulation and significant lowering of the cystometrogram threshold pressure (p = 0.02). Earlier studies using spinal cord injured rodents and SNM revealed a similar finding – lowered CGRP and elimination of bladder hyper-reflexia.14 Unfortunately for the authors, abolishment of uninhibited bladder contractions in their rodent model were not demonstrated. The results are still nonetheless, encouraging. Perhaps, these non-invasive modalities, such as TAMS and PTNS, are the way of the future for treating voiding dysfunction. Many are skeptical that peripheral stimulation of nerves with retrograde migration of signal can actually affect various voiding patterns, despite the accumulation of robust evidence that supports this technology. Of course, these same skeptics likely didn’t believe that we would be removing a prostate with the use of a robot or using lasers to obliterate stones and evaporate prostates. Whether these non-invasive technologies revolutionize the way urologists treat voiding dysfunction remains to be seen. Until then, to quote Charles Kettering: “Our imagination is the only limit to what we can hope to have in the future.”