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Background The etiology of interstitial cystitis (IC) is often idiopathic but can be due to Hunner’s ulcers. Hyperbaric oxygen (HBO) is used to treat ulcerative disease of the superficial skin. We hypothesized that HBO can treat ulcerative IC (UIC) but would be less efficacious for non-ulcerative IC (NIC). Methods Patients with NIC and UIC enrolled in this study. Following informed consent, demographic information was collected. A visual analog pain scale and validated questionnaires were collected; each patient underwent cystoscopy prior to treatment. Each subject met with a hyperbaric specialist and after clearance underwent 30 treatments over 6 weeks. Adverse events were monitored. Patients repeated questionnaires, visual analog pain scale and global response assessment (GRA) immediately, 2 weeks, 3, 6 and 12 months after treatment. Patients also underwent cystoscopy 6 months after treatment. Differences before and after treatment were compared. Results Nine patients were recruited to this study. One was unable to participate, leaving two subjects with NIC and six with UIC. All patients completed HBO without adverse events. Three patients completed HBO but pursued other therapies 7, 8.5 and 11 months after treatment. On GRA, 83% of patients with UIC were improved. This treatment effect persisted, as 66% of UIC patients remained better at 6 months. In contrast, only one patient in the NIC group improved. Questionnaire scores improved in both groups. Pain scores improved by 2 points in the UIC group but worsened by 1.5 points in the NIC group. Two patients with ulcers resolved at 6-month cystoscopy. Conclusion HBO appeared beneficial for both UIC and NIC. Data shows slightly better benefit in patients with UIC compared to NIC; both groups showed improvement. Given the small sample size, it is difficult to draw definitive conclusions from these data. Larger studies with randomization would be beneficial to show treatment effect.

The current ‘gold standard’ surgical repair for apical prolapse is the abdominal mesh sacrocolpopexy. Use of a robotic-assisted laparoscopic surgical approach has been demonstrated to be feasible as a minimally invasive approach and is gaining popularity amongst pelvic floor reconstructive surgeons. Although outcome data for robotic-assisted sacrocolpopexy (RASC) is only just emerging, several small series have demonstrated anatomic and functional outcomes, as well as complication rates, comparable to those reported for open surgery. The primary advantages thus far for RASC over open surgery include decreased blood loss and shorter hospital stay.

Neuromodulation has emerged as a second-line treatment option for patients with overactive bladder (OAB) refractory to initial treatment. In this Review, the authors summarize the diagnosis and first-line treatment options for OAB before providing an in-depth discussion of neuromodulation. Overactive bladder (OAB) affects millions of people worldwide yet first-line treatments are often poorly tolerated and compliance rates are low. Neuromodulation works via afferent nerve modulation and offers a minimally invasive and reversible alternative treatment option for patients with OAB who have failed first-line therapy. Neuromodulation has revolutionized the management of OAB and is now well established as a safe and effective treatment for those refractory to conservative treatments. Multiple neuroanatomical pathways have been described for sacral neuromodulation including the S3 nerve root, pudendal nerve and tibial nerve. The S3 nerve root is currently the main treatment target and has the most long-term data on safety and efficacy to support its use. However, studies on neuromodulation at the pudendal nerve or posterior tibial nerve have been positive and their role in treatment continues to evolve. Most urologists who are experienced in voiding dysfunction can become proficient in each technique. Patient selection, surgical techniques and postoperative management differ slightly between approaches and urologists should familiarize themselves with these differences. Treatment of OAB should progress from the least to most invasive modality, and neuromodulation provides an attractive option owing to its minimally invasive approach, tolerability, positive outcomes and reversibility. Key Points Overactive bladder (OAB) is defined by the International Continence Society (ICS) as a syndrome characterized by urgency, with or without urgency incontinence, usually with frequency and nocturia Initial treatment options for OAB include behavioural modification, pharmacotherapy and physical therapy, either as monotherapies or in combination Neuromodulation is hypothesized to relieve OAB symptoms by modifying somatic afferent sensory processing in the sacral spinal cord Sacral, tibial or pudendal nerves can be targeted by neuromodulation with specific indications and techniques for each Treatment of OAB should progress from the least to most invasive modality, and neuromodulation provides an attractive option owing to its minimally invasive approach, tolerability, positive outcomes and reversibility

Introduction and hypothesis To examine changes in sexual function after abdominal and transvaginal pelvic organ prolapse repair. Methods Women enrolled in our prospective, longitudinal prolapse database with abdominal sacrocolpopexy (ASC) or transvaginal (TVR) pelvic organ prolapse (POP) repair with or without mesh, between 19 December 2008 through 4 June 2014. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory (PFDI -20) were mailed preoperatively, and at 6 and 12 months postoperatively. Patients completed Global Response Assessments to rate their overall satisfaction. Results Two hundred and four of the 300 women met the inclusion criteria: 74 out of 204 (36 %) had ASC and 130 out of 204 (64 %) had TVR. Seventy-two out of seventy-four ASCs were performed robotically and 2 were open. Baseline demographics were similar except that the ASC patients were significantly younger (60 vs 63, P  = 0.019) and had a higher rate of apical repair (77 % vs 55 %). Thirty-six out of seventy-four ASC (48.7 %) and 63 out of 128 TVR patients (49.2 %) were sexually active at baseline ( P  = 0.94). Sixteen out of thirty-eight ASC (42.1 %) and 18 out 63 TVR patients (28.6 %; P  = 0.16) reported dyspareunia at baseline. Seventy-two out of seventy-four ASC (97 %) and 86 out of 130 TVR patients (66 %) had mesh-augmented repairs. There was no difference in sexual activity or dyspareunia between the groups at the 6- or 12-month follow-up. PISQ and PFDI scores improved significantly in both the ASC and TVR groups over time compared with the baseline ( p  < 0.0001). Most women in the ASC (77.5 %) and TVR (64.8 %) groups were satisfied with the results of prolapse surgery at 12 months. Conclusions Sexual function and pelvic floor symptoms improved in a similar manner in patients after abdominal and transvaginal POP surgery.

We report on the first regulatory approved clinical trial of a prospective open-label physician-initiated study assessing the safety and efficacy of intradetrusor injected Autologous Muscle Derived Cells (AMDC) treatment for underactive bladder (UAB). 20 non-neurogenic UAB patients were treated. Approximately 50–250 mg of quadriceps femoris muscle was collected using a spirotome 8-gauge needle. The muscle biopsy samples were sent to Cook MyoSite (Pittsburgh, PA) for processing, isolation, and propagation of cells. Research patients received approximately 30 intradetrusor injections of 0.5 mL delivered to the bladder, for a total of 15 mL and 125 million AMDC, performed utilizing a flexible cystoscope under direct vision using topical local anesthesia. Follow-up assessments included adverse events and efficacy via voiding diary and urodynamic testing at 1, 3, 6 and 12 months post-injection. An optional second injection was offered at the end of the 6 months visit. 20 patients received the first injection and all 20 patients requested and received a second injection. Median patient age was 65 years old (range 41–82 years). There were 16 male (80%) and 4 female (20%) patients. Etiology included 7 men (35%) with persistent urinary retention after transurethral resection of the prostate for benign prostatic hyperplasia and 13 patients (65%) with idiopathic chronic urinary retention. At the primary outcome time point of 12 months, 11/19 patients (58%) reported a global response assessment (GRA) ≥ 5, showing slight to marked improvement in their UAB symptoms, compared to 6/20 (30%) patients at 3 months post-injection. No serious procedure or treatment-related adverse events occurred. Noted improvements included: decreased post void residual urine volume, increased voiding efficiency, and decreased catheter use. Intradetrusor-injected AMDC as a treatment for UAB was successfully completed in a 20-patient trial without serious adverse event and with signal of efficacy. Cellular therapy may be a promising novel treatment for catheter-dependent chronic urinary retention. A multicenter controlled trial is needed to further assess the promise of regenerative medicine in the treatment of lower urinary tract dysfunction.

AimsTo evaluate whether baseline symptoms and outcomes are influenced by gender in a matched cohort undergoing neuromodulation.MethodsPatients in our prospective neuromodulation database that had a tined lead placed were reviewed. Those that had implantable pulse generator (IPG) placed were matched on age and urologic diagnosis. History, voiding diaries, satisfaction, Interstitial Cystitis Symptom/Problem Index (ICSIPI), and overactive bladder symptom severity (OABq ss)/health-related quality of life (HRQOL) preimplant and over 3 years were evaluated using descriptive statistics, repeated measures, and matched pair GEE or mixed analyses.ResultsOf 590 patients in the database, more women than men received an IPG (450/488; 92.2 vs. 84/102; 82.4%; p = 0.0011). Eighty matched pairs (n = 160; 81% ≥ 50 years old; 56.25% had urgency/frequency with urge incontinence—UI) were identified and evaluated. On voiding diaries, volume/void was greater in women only at baseline (p = 0.040); both groups improved over time (p < 0.0001). Urinary frequency improved in both women and men (p = 0.0010; p = 0.0025). Over 3 years, UI episodes/day improved only in men (p = 0.017) and UI severity improved only in women (p < 0.0001). ICSIPI, OABq ss, and HRQOL scores improved similarly in both groups (p < 0.0001 for all measures in both groups), and although more women were satisfied at 3 months (p = 0.027), groups did not differ at other time points.ConclusionsMore women undergo neuromodulation and have initial success and subsequent IPG implantation. UI episodes improved only in men, and UI severity improved only in women. Both women and men experienced similar levels of symptom improvement on other measures.

A 46-year-old white female underwent a left hemipelvectomy for chondrosarcoma. She presented with total incontinence and a bulging vaginal mass. Exam confirmed complete transurethral bladder eversion that was addressed with transvaginal multilayer bladder neck closure and suprapubic tube placement. Eventually she underwent abdominal hysterectomy, mesh sacral colpopexy, and catheterizable stoma creation. Patient is continent of urine 3 months postoperatively. We present the first reported case of bladder eversion after hemipelvectomy and propose possible pathophysiologic mechanisms.

Purpose To investigate associations of bullying and abuse with pelvic floor symptoms, urogenital pain, and sexual health characteristics of women presenting to a multidisciplinary women’s urology center. Methods Retrospective review of a prospective database. Patients completed questions about bullying, abuse, sexual health and validated questionnaires including the Pelvic Floor Dysfunction Inventory (PFDI-20), Overactive Bladder Questionnaire (OAB-q), and visual analog scale (VAS 0–10) for genitourinary pain. Statistical analyses included Chi-squared and t tests, which compared victims of bullying and/or abuse to non-victims. Results Three hundred and eighty patients were reviewed. Three hundred and thirty-eight had data on bullying and abuse history. Out of 380, 94 (24.7 %) reported that they were victims of bullying. Out of 380, 104 (27.4 %) reported that they were victims of abuse. Women with a history of bullying and abuse had increased overall pain scores compared to those without a history of either. Women with a history of abuse and bullying had increased PFDI-20, POPDI, and UDI-6 scores compared to women who were not bullied or abused. There was no difference in being sexually active or in sexual satisfaction between the groups. Patients with a history of abuse and bullying had the greatest percentage of dyspareunia ( p  = 0.009). Conclusions Women with a history of bullying, abuse, or both predict increased pelvic floor distress, urological symptoms, increased urogenital pain, and increased dyspareunia. Clinicians should screen for exposure to bullying or abuse in order to provide comprehensive resources to address these psychosocial issues.

ObjectivesDiscuss the incidence and definition of stress urinary incontinence (SUI).Review and provide tips for the assessment of SUI.Discuss management of SUI.

Interstitial cystitis (IC) is a chronic, functional pain syndrome characterized by urinary frequency, urgency, nocturia, and, most importantly, pain or discomfort associated with bladder filling. The pathophysiology of the condition is still poorly understood, but recent research has shed a great deal of light on the epidemiology of IC, its clinical course, and associated comorbid functional somatic disorders. The classic finding of “bladder ulcers” is seen in the minority of IC patients, with differing management for those with and without ulcers. IC remains a diagnosis of exclusion, but recently released guidelines by the American Urological Association provide a clinical algorithm for the evaluation and management of IC. The current trend is towards less-invasive diagnostic studies and limiting the number of different agents used to manage IC symptoms, while discontinuing the use of any treatment that is not deemed successful. Furthermore, the guidelines, which are reviewed in this chapter, promote a multimodal approach towards therapy, including noninvasive treatments such as stress management, more focused pharmacotherapy, and pelvic floor physical therapy.