Clinical Guideline for Female Lower Urinary Tract Symptoms

The “Japanese Clinical Guideline for Female Lower Urinary Tract Symptoms,” published in Japan in November 2013, contains two algorithms (a primary and a specialized treatment algorithm) that are novel worldwide as they cover female lower urinary tract symptoms other than urinary incontinence. For primary treatment, necessary types of evaluation include querying the patient regarding symptoms and medical history, examining physical findings, and performing urinalysis. The types of evaluations that should be performed for select cases include evaluation with symptom/quality of life (QOL) questionnaires, urination records, residual urine measurement, urine cytology, urine culture, serum creatinine measurement, and ultrasonography. If the main symptoms are voiding/post‐voiding, specialized treatment should be considered because multiple conditions may be involved. When storage difficulties are the main symptoms, the patient should be assessed using the primary algorithm. When conditions such as overactive bladder or stress incontinence are diagnosed and treatment is administered, but sufficient improvement is not achieved, the specialized algorithm should be considered. In case of specialized treatment, physiological re‐evaluation, urinary tract/pelvic imaging evaluation, and urodynamic testing are conducted for conditions such as refractory overactive bladder and stress incontinence. There are two causes of voiding/post‐voiding symptoms: lower urinary tract obstruction and detrusor underactivity. Lower urinary tract obstruction caused by pelvic organ prolapse may be improved by surgery.     

Surgical Options for Patients with Neurogenic Bladder

Neurogenic bladder encompasses many conditions that affect the bladder in patients with neurologic disease. Although there is no standard definition for neurogenic bladder, for the intent and purpose of this review, it is defined as any pathologic process affecting the central and/or peripheral nervous systems that results in urine storage or emptying dysfunction. It often presents clinically as varying degrees of urinary incontinence and/or retention but can present with urinary tract infections, urinary tract stones, or upper urinary tract deterioration. It is up to the clinician to identify wherein the problem lies—is it an outlet problem, bladder problem, or both? What is affected: storage, emptying, or both? These factors should be considered together to identify patients who may benefit from surgical intervention. This review focuses on patient evaluation and surgical interventions for adult patients with neurogenic bladder. Surgical interventions for problems with emptying due to detrusor external sphincter dyssynergia include surgical external sphincterotomy, chemical external sphincterotomy, urethral stent, and sphincter dilation. For detrusor underactivity, detrusor myoplasty and neuromodulation are discussed. For neurogenic detrusor overactivity and impaired compliance and capacity, botulinum toxin injection, sacral neuromodulation, and patch enterocystoplasty are discussed. For decreased compliance/capacity, detrusorotomy is also discussed. For combined problems, urinary diversions are also discussed.     

Promoting continence: simple strategies with major impact

Urinary incontinence is a common problem, especially among women, yet it remains underreported and undertreated. This is partly due to patients' beliefs that little can be done and partly due to healthcare professionals' perception that treatment is limited to surgery, advanced behavioral strategies requiring specialized equipment, or containment devices. Nurses are in a strategic position to reduce the incidence of incontinence by teaching bladder health strategies (ie, fluid management, appropriate voiding intervals, constipation prevention, weight control, smoking cessation, and pelvic muscle exercises), actively assessing patients for incontinence, and initiating appropriate referrals and primary interventions. Patients with significant neurologic deficits, structural abnormalities such as pelvic organ prolapse, or urinary retention should be referred for further workup. However, most patients can be treated with primary continence restoration strategies, which include identifying and correcting reversible factors such as urinary tract infection or atrophic urethritis; instruction in pelvic floor muscle exercises; and instruction regarding urge inhibition strategies. Implementing these simple strategies can significantly improve bladder function and continence in the majority of patients.     

Management of Bladder Diverticula in the Pediatric Population

Bladder diverticula represent protrusion of the urothelial mucosa through the bladder muscular layers and may be either congenital or acquired. Congenital bladder diverticula are usually located adjacent to the ureteral orifices and often are associated with vesicoureteral reflux. Acquired bladder diverticula are usually multiple in nature and are secondary to bladder outlet obstruction or neurogenic bladder. When bladder diverticula are small and do not cause symptoms, non-surgical observation is an acceptable management strategy. The absolute need for surgical intervention of bladder diverticula remains a controversial topic, where current surgical indications for bladder diverticula include diverticula larger than 3 cm, recurrent urinary tract infections, associated severe vesicoureteral reflux, voiding dysfunction, urinary retention, bladder stones, and lower urinary tract symptoms that are persistent after conservative treatment. Open surgical repair has traditionally been the primary treatment choice for bladder diverticula. However, recent advancements in laparoscopic and robotic technology have led to minimally invasive surgical treatment options as alternatives to open surgery with similar success rates, but with reduced morbidity, decreased hospital stay lengths, reduced pain medication requirements, and improved cosmesis.     

Assessing and treating pelvic organ prolapse

At least half of all women who have given birth experience pelvic organ prolapse, a condition where pelvic organs protrude through the vagina. Because of the presentation of the different aspects of prolapse, treatment had become compartmentalized in line with pelvic involvement, with urologists, gynecologists, colorectal surgeons, and gastroenterologists each addressing their field of expertise. In addition, urinary or fecal incontinence, urinary retention, and urinary tract infections often are associated with pelvic organ prolapse. Both pelvic organ prolapse and incontinence have a significant impact on the quality of life. New training programs in urogynecology and reconstructive pelvic surgery are producing clinicians who are better equipped to treat pelvic organ prolapse, as well as related urinary and fecal incontinence. This article provides an overview of the various aspects of pelvic organ prolapse for all clinicians involved in assessment, treatment, and potential prevention of this condition.     

Management of neurogenic voiding dysfunction in the male patient

Management of neurogenic bladder in the male patient centers on identifying the optimal way to manage the lower urinary tract for the individual patient. Factors in this decision include intravesical detrusor storage pressures (and protection of the upper urinary tracts), upper extremity function and ability to perform intermittent catheterization, and patient preference when choosing between options such as intermittent catheterization versus condom catheter use. The medical community has come a long way from the days when the primary mode of management of neurogenic bladder included indwelling catheters or diapers. Patients today have several options for bladder management that when used appropriately can lead to significant improvements in urinary continence, quality of life, and patient independence. This paper reviews the various options available today as well as several potential therapies that may become available in the future.     

Update on detrusor hyperactivity with impaired contractility

Detrusor hyperactivity with impaired contractile function (DHIC) is a complex voiding dysfunction that is often misdiagnosed as incontinence resulting from benign prostatic hyperplasia with outlet obstruction, underactive detrusor with chronic retention, and stress urinary incontinence due to sphincter incompetence, particularly in women. Urodynamic assessments have shown that these subjects exhibit low pressure and almost unrecognizable involuntary detrusor contractions associated with reflex urethral relaxation accompanied with inefficient bladder emptying. These patients therefore tend to develop high residual volumes with a tendency towards chronic urinary retention. DHIC is a major cause of urinary incontinence in institutionalized elderly women. Accurate diagnosis requires awareness of this condition, careful video-urodynamic evaluation, and elimination of other disorders such as outlet obstruction and neurogenic bladder that confound DHIC. The exact causes are unclear, although some studies indicate that this entity may be a coincidental association of two separate etiologies, with each one independently contributing to the two different components of DHIC. Alternately, impaired detrusor function could emerge as a long-term sequelae of detrusor overactivity. Recent ultrastructural studies of the bladder in those with DHIC show distinct morphological patterns characteristic of both detrusor overactivity and impaired contractility. Management of this condition requires knowing that the condition potentially causes incontinence in women and lower urinary tract symptoms in men. Failure to diagnose DHIC in symptomatic patients may lead to inappropriate therapies including morbidity-prone surgical misadventures.     

Stress Urinary Incontinence in Women with Neurogenic Voiding Dysfunction

Female neurogenic sphincteric incontinence is a complex and debilitating condition. Stress urinary incontinence in this population is complicated by mixed urinary incontinence caused by functional and structural anomalies, which impacts upon management options. Patients require a full incontinence work-up, including a comprehensive history and physical examination, renal imaging, and videourodynamics. Understanding personal and physical limitations in addition to patient goals of treatment is tantamount in choosing the appropriate course of care. Options range from conservative therapy (behavioral modification) and clean intermittent catheterization with pharmacotherapy to invasive surgical options (bladder neck closure and urinary diversion). Before increasing sphincteric resistance, it is imperative to confirm that the bladder reservoir is well-balanced and filling under safe pressures. The risk of chronic urinary retention following treatment of the sphincter is high in this population. Much of the literature on this topic is anecdotal. Prospective studies comparing treatment options for neurogenic sphincteric incontinence within this population are needed.     

Evaluation,Treatment and Management of Urinary Incontinence in Patients with Orthotopic Neobladder

Patients who undergo radical cystectomy for bladder cancer require reconstruction of the lower urinary tract. Orthotopic neobladder in carefully selected patients offers a more physiologic way of voiding. However, daytime and nighttime incontinence are commonly seen in male and female patients following surgery. Evaluation of incontinence requires careful history and physical exam to differentiate stress urinary incontinence from neobladder-vaginal fistula or poorly compliant neobladder with hypercontinence. Treatment of incontinence in patients with ONB may include: placement of retropubic sling, artificial urinary sphincter, or repair of fistula when present.     

Management of the Bladder in Spinal Cord Injury Patients

Management of the lower urinary tract in spinal cord injury patients can be very challenging The decision-making process should be based on the individual patient symptoms, which could vary even between patients with a similar level of injury, and an appropriate evaluation. Important factors in the evaluation of patients with neurogenic bladder secondary to spinal cord injury include intravesical detrusor storage pressures, integrity of the outlet, upper extremity function, and the ability to perform clean intermittent catheterization, as well as patient preference when choosing between the various conservative and surgical treatment options available. When used appropriately, treatment of neurogenic bladder can lead to significant improvements in urinary continence, protection of the upper urinary tracts, improved quality of life, and patient independence. This paper reviews the various options available today as well as several potential therapies that may become available in the future.     

Voiding Dysfunction Associated with Pudendal Nerve Entrapment

Pudendal nerve entrapment?(Alcock canal syndrome)?is an uncommon?source of?chronic pelvic pain, in which the?pudendal nerve?is entrapped or compressed.?Pain is located in the perineal, genital and perianal areas and is worsened by sitting. By simple entrapment of the PN without neurogenic damages, pain is usually isolated. In neurogenic damages to the PN, genito-anal numbness, fecal and/or urinary incontinence can occurred. PNE can be caused by?obstetric traumas, scarring due to genitoanal surgeries (prolaps procedures!), accidents and surgical mishaps. Diagnosis is based on anamnesis, clinical examination including vaginal or rectal palpation of the pelvic nerves with selective nerve blockade. Pudendal pain non systematic mean PNE since other neuropathies may induce pudendal pain. So sacral radiculopathies (sacral nerves roots S#2-4) are underestimated etiologies frequently responsible for pudendal pain with irradiation in sacral dermatomes, bladder hypersensitivity or in neurogenic lesions, bladder retention.     

Neuroanatomy of the pelvis

PURPOSE: Urinary dysfunction remains a common complication of radical pelvic surgery, particularly after abdominoperineal resection. In treating rectal carcinoma, the extent of primary resection and lymphadenectomy are major determinants in the degree of postoperative urologic morbidity. METHODS: Twelve male and eight female hemipelves from fresh cadavers were dissected with reference to the neuroanatomy of the lower genitourinary tract. These cadavers were dissected within twelve hours of thaw from frozen state. The cadavers were hemisected at the level of the sacral promontory for better exposure of neural trunks and vascular structures leading into the pelvis. These structures were followed down sequentially into the true pelvis, using magnified dissection under operating microscope or loupe dissection or both. RESULTS: Coordinated lower urinary tract function relies on both autonomic and somatic nerve activity. Emanating from the inferior hypogastric plexus, the pelvic nerve supplies sympathetic and parasympathetic innervation to the pelvic viscera. The course of the pelvic nerve is as follows: 1) from the inferior hypogastric plexus, it has multiple branches forming a web-like complex within the endopelvic fascial sleeve, some of which innervate the bladder detrusor; 2) a main branch traveling inferolateral to the rectum remains deep to the fascia of the levator ani muscle and courses to the external urinary sphincter; 3) at the level of the prostatic apex (or bladder neck in females), this pelvic nerve branch sends direct branches to the urinary sphincter. The pudendal nerve traverses the pelvis in the pudendal canal, and before leaving the pelvis to enter the perineum, it gives an intrapelvic branch that courses alongside the ischium to enter the external urinary sphincter. In the ischiorectal fossa, terminal branches of the pudendal nerve (i. e., perineal nerve) can be seen inserting into the urinary sphincter. CONCLUSIONS: Urinary retention and urinary incontinence represent two distinct urologic complications after abdominoperineal resection. Injury to detrusor branches of the pelvic nerve can cause detrusor denervation and urinary retention. In addition, injury to intrapelvic branches of the pelvic and pudendal nerves to the urinary sphincter can result in intrinsic sphincter deficiency and urinary incontinence. A better understanding of the neuroanatomy of the lower genitourinary tract can give a physiologic basis for clinical findings of postoperative voiding dysfunction and may help the surgeon refine surgical technique by more precisely determining resection limits to minimize urologic complications.     

Current Concepts in Female Neurogenic Voiding Dysfunction

Neurogenic lower urinary tract dysfunction (NLUTD) encompasses a wide spectrum of abnormal voiding patterns ranging from detrusor overactivity and urgency to detrusor–external sphincter dyssynergia and urinary retention. NLUTD results from injury to the central or peripheral nervous system or some primary neurological disease that disrupts the normal neurological regulation of the lower urinary tract. Female patients with neurogenic voiding dysfunction deal with special challenges that make management of incontinence and lower urinary tract storage more problematic than in their male counterparts. Over the past 30 years, technological advancements have improved the care of these patients and reduced the morbidity and mortality associated with NLUTD. More recent developments, including intravesical botulinum toxin injection and neuromodulation (not US Food and Drug Administration approved for this indication), have provided further treatment options, resulting in improved quality of life. Still, management of the neurogenic bladder patient can be exceptionally complex, and attentive, specialized care is critical.     

Functional Outcomes for Incontinence and Prolapse Surgery

The majority of women with pelvic organ prolapse and stress urinary incontinence report more than one symptom that affects urinary, bowel, or sexual function. Most research studies on outcomes following surgery for pelvic organ prolapse and stress incontinence focus on anatomic outcomes and relief of symptoms specific to prolapse and/or stress incontinence. Pelvic symptoms related to voiding function such as de novo urgency or incontinence, bowel function, and sexual function are clinically important outcomes but are infrequently reported. Deterioration of pelvic symptoms postoperatively is associated with decreased patient satisfaction, which underscores the importance of effectively assessing functional and anatomic treatment outcomes. Future studies of reconstructive pelvic surgery should routinely include multiple domain functional outcomes specifically addressing voiding, defecatory, and sexual function.     

Electrocardiographic artifact induced by an electrical stimulator implanted for management of neurogenic bladder

Serial electrocardiograms (ECGs) obtained in a 79-year-old woman revealed consistently sharp regular high-voltage spikes, which were superimposed on her ECG curve, and which were caused by an implanted pelvic electrical stimulator used for the management of a neurogenic bladder, with symptoms of urinary urgency and incontinence.     

Lower urinary tract and bowel dysfunction after incontinence and prolapse interventions

The incidence of anti-incontinence procedures and surgery for prolapse repairs has increased significantly over the past decade. As more clinicians have embarked on performing these surgeries using new techniques and variations on traditional repairs, complications are starting to be recognized. We review the literature, focusing on postoperative lower urinary tract and bowel dysfunction following surgery for incontinence and pelvic prolapse. We performed a comprehensive review of the literature on interventions for urinary incontinence and pelvic prolapse using MEDLINE and resources cited in those peer-reviewed papers. Postoperative voiding dysfunction including symptomatic bladder outlet obstruction, de novo urgency and urge incontinence, and recurrent stress urinary incontinence appear to be the most common voiding issues after anti-incontinence surgery, with rates varying based on the type of sling used. Bowel dysfunction following prolapse surgery can occur after rectocele repair and sacrocolpopexy or other apical repair and may vary based on the surgical technique and graft reinforcement used. Success rates for incontinence and prolapse repairs remain stable. With the introduction of new techniques, it is important to consider potential postoperative bladder and bowel effects so that clinicians may counsel their patients appropriately prior to intervention.     

Management of the neurogenic bladder in the female patient

Management of the female patient with neurogenic bladder requires special considerations that are not seen with many male neurogenic bladder patients. Because of the unique challenges that certain women present, a disproportionate number of women end up with an indwelling catheter or continuously leak urine into a diaper. Other options for bladder management include intermittent catheterization and reconstruction, which, when used appropriately, can lead to significant improvements in urinary continence, quality of life, and patient independence. This article reviews the various options available today as well as several potential therapies that may be available in the future.     

Urodynamic evaluation of the bladder and pelvic floor

Pelvic floor disorders including lower urinary tract dysfunction are common, and may be evaluated by urodynamic tests, such as cystometry, uroflowmetry, pressure flow studies, electromyography, and video-urodynamics. These urodynamic tests provide objective information regarding the normal and abnormal function of the urinary tract and pelvic floor, and provide a better understanding of the pathophysiologic processes that cause lower urinary tract symptoms. This article describes typical urodynamic studies and their roles in the evaluation of common pelvic floor disorders, including stress urinary incontinence, overactive bladder, and pelvic organ prolapse.     

Managing prostate disorders in middle age and beyond

Diseases of the prostate may be benign or malignant. It is important for the clinician to realize that a complete urinalysis and digital rectal exam are the cornerstones of management in the diagnosis of prostate disease. Surgery for benign disease is indicated if the patient has compromised renal function, hydronephrosis, recurrent urinary tract infections, urinary retention, or bladder calculi. Surgery is also indicated if the obstructive urinary symptoms interfere with the patient's quality of life. Prostate cancer is a common malignancy in elderly men and treatment options must be guided by the stage of the disease and the general medical status of the patient.