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Purpose of Review To summarize the current understanding on the epidemiology, pathophysiology, and management strategies of urinary incontinence (UI) in female athletes, highlighting findings specific to nulliparous elite athletes. Recent Findings UI occurs in about 20 – 50% of female athletes of all ages and parity status, around 40% for younger nulliparous athletes, and is more prevalent in high-impact sports. Possible contributing factors to UI in female elite athletes include pelvic floor laxity and bladder neck descent, pelvic floor muscle fatigue, low energy availability, and hypermobility syndrome. In female elite athletes, urinary symptoms negatively affect quality of life, although the effects of symptoms on exercise participation are not well understood. Current management strategies are primarily conservative and centered on behavioral modifications and pelvic floor muscle physiotherapy. Summary UI in female elite athletes appears to be multifactorial. Clarifying how individual factors influence UI in this population will inform athlete counseling, prevention, and treatment strategies.

Purpose of Review Microscopic hematuria and overactive bladder are two common urologic conditions. The objective of this review is to provide an overview of current literature as well as highlight important guidelines that will aid physicians in the diagnostic workup of microscopic hematuria in patients experiencing symptoms of overactive bladder. Recent Findings Updated microscopic hematuria guidelines provide a structured and appropriate workup for women based on risk factors, which stratifies patients to prevent unnecessary procedures and imaging. Women presenting with microscopic hematuria in the setting of overactive bladder should undergo microscopic hematuria workup according to their risk stratification while receiving appropriate treatment for their overactive bladder. Summary The physician should consider the presence of irritative voiding symptoms during the investigation and management of microscopic hematuria in patients with overactive bladder and should not delay overactive bladder treatment due to the presence of microscopic hematuria.

Purpose of Review This review discusses the role and benefits of telemedicine as an integral component of the post-pandemic care paradigm in urological practice and, in particular, as part of the care of patients with overactive bladder (OAB). Recent Findings The COVID-19 pandemic accelerated the implementation of telemedicine across almost every medical specialty and (at least temporarily) swept away barriers including those regarding reimbursement and licensure. Telemedicine benefits patients and providers alike including savings on transportation costs, access to specialists or tertiary care from geographically remote locations, and minimized exposure to a contagious illness. Integration of telemedicine into clinical practice can reduce costs for office/exam space and staffing overhead, as well as facilitate greater scheduling efficiency. Many, if not most, aspects of care for the uncomplicated OAB patient can be as effectively managed remotely as with in-person encounters, across the treatment algorithm. Summary Telemedicine will almost certainly remain a key component in the care of OAB, general urology, and throughout all medical specialties.

Purpose of Review To examine the latest published findings on the pathophysiological mechanisms involved in the development of overactive bladder (OAB) and detrusor overactivity (DO), and to identify common pathways linked to the risk factors associated with these conditions. Recent Findings Evidence is accumulating, both clinical and experimental, that many of the factors linked to the development of OAB/DO, including ageing, bladder outlet obstruction, psychological stress, and obesity are associated with reduced bladder blood flow. This induces local tissue inflammation with cytokine release and enhanced oxidative stress, ultimately resulting in altered detrusor sensitivity, detrusor hypertrophy and fibrosis, together with afferent hypersensitivity. These mechanisms would explain the symptoms of urgency and frequency observed in OAB patients. Although not a characteristic of OAB, undetected low level bacterial infections of the bladder have been proposed to explain the OAB symptoms in patients resistant to standard treatments. In this condition, inflammatory responses without reductions in perfusion activate the inflammatory pathways. Summary Evidence is mounting that poor bladder perfusion and local inflammatory responses are central mechanisms involved in the development of OAB/DO. As our understanding of these pathophysiological mechanisms advances, new avenues for drug development will be identified and ultimately treatment may become more individualized depending on the particular pathway involved and the drugs available.

Purpose of Review Urinary incontinence (UI) is a common global condition that has been noted to disproportionately affect women. In this review, the authors present discussion of factors contributing to cost of care and various modalities of cost-effective care for UI for female patients. Recent Findings We found insurance and out-of-pocket (OOP) costs strongly impact of costs for patients. Further, in evaluation of UI, diagnosis can be a costly multi-step process for effective treatment. Treatment can be multimodal, including non-surgical (e.g., pessary, vaginal insert, pelvic floor muscle training, or PFMT), of which PFMT is a cost-effective, effective, and accessible treatment. Pharmacologic management is generally second-line for overactive bladder, but anti-muscarinic drugs and beta-3 agonists are cost-effective depending on willingness-to-pay and the health system in which they are acquired, respectively. Surgical management is considered the most cost-effective treatment as willingness-to-pay increased, with minimally invasive slings being the mainstay. Other relatively novel treatments are also discussed (e.g., EMSELLA) but require further research. Additionally, we discuss systematic barriers in decisions to seek care for urinary incontinence. Summary Urologists are key agents in treating UI for their female patients, and seeking cost-effective options for treatment remains pivotal for quality care.

Purpose of Review To summarize recent experience with robotic vesicovaginal fistula repair and describe the contemporary technique. Recent Findings Robotic vesicovaginal repair has been tested at multiple centers, with similar outcomes to open surgery. It has benefits including decreased hospital stay, less blood loss, and similar long-term outcomes. As long as the surgeon is experienced in robotic surgery, this technique appears to be promising. Summary Robotic vesicovaginal repair results in similar outcomes to open surgery with decreased morbidity.

Purpose of Review Transgender and non-binary patients (TGNB) undergoing gender affirming genital surgery may experience perioperative voiding dysfunction. This review aims to outline and analyze literature about gender affirming pelvic surgery urinary complications, evaluation, and treatment. Recent Findings If a patient is seeking bottom surgery, then urinary goals and pre-operative symptoms should be discussed with respect to variable post-operative outcomes. Urologists should also be aware of the effect that gender affirming hormone therapy has on urinary symptoms. Urethral strictures and urethrocutaneous fistulae occur after feminizing and masculinizing procedures and may manifest as LUTS. Although there is no standardized approach for managing post-operative voiding issues, we present available options. Summary The evaluation of TGNB patients is ideally affirming and tailored to the patient. Long-term urinary and voiding outcomes measurements after vaginoplasty and phalloplasty are also needed, as current validated questionnaires do not capture these symptoms well in TGNB patients.

Purpose of Review The purpose of this review is to evaluate the evidence regarding the efficacy and safety of implantable sacral neuromodulation (SNM) in pediatric patients with voiding dysfunction. The aim is to address the lack of substantial supporting data for SNM use in pediatric populations and provide insights into its potential as a treatment option. Recent Findings Recent research indicates that SNM can be an effective treatment for pediatric voiding dysfunction when conventional therapies fail. A systematic review of eight studies published between 2008 and 2021, involving 427 pediatric patients, revealed promising outcomes. These included a 68% improvement rate in urinary symptoms, with 39% experiencing complete resolution. Urodynamic improvements were also noted, with reductions in detrusor pressure, uninhibited detrusor contractions, and postvoid residual volume. However, complications such as lead issues, device migration or erosion, pain, and IPG replacement were observed in a notable percentage of cases, necessitating reoperation in some instances. Summary In conclusion, implantable SNM emerges as a potentially effective treatment for pediatric voiding dysfunction, improving urinary symptoms and quality of life. However, the presence of complications underscores the importance of careful risk-benefit assessment for individual patients. Further research is warranted to address varying success rates and complications, emphasizing the need for improved trial quality in this field. The findings of this review highlight the potential impact of SNM in pediatric populations and underscore the need for continued investigation and refinement of this therapeutic approach.

Purpose of Review Up to half of postmenopausal women experience genitourinary symptoms secondary to hormone deficiency, and there is little consensus on the use of vaginal hormone therapy (VHT) for lower urinary tract symptoms (LUTS) in these patients. This is a review of the scientific literature in the last decade evaluating the use of VHT for disorders of the lower urinary tract including overactive bladder (OAB), stress urinary incontinence (SUI), recurrent urinary tract infections (UTI), and interstitial cystitis/bladder pain syndrome (ICS/BPS). Recent Findings Vaginal estrogen therapy improves OAB symptoms in postmenopausal women, but results are mixed when VHT is used in combination with other treatments. There is inconclusive or limited data for the use of VHT to treat SUI and IC/BPS. Vaginal estrogen and prasterone (DHEA) therapies have demonstrated efficacy as treatment modalities for patients who experience recurrent UTIs. Summary VHT preparations show efficacy for the treatment of certain LUTS and can be considered in carefully selected patients when clinically indicated.

Purpose of Review The goal of this review was to critically appraise the current literature on diagnosing and managing bladder outlet obstruction (BOO) with detrusor underactivity (DU) in males. This review evaluated the diagnostic criteria for these conditions employing both clinical and urodynamic parameters. Current treatment options were also assessed. Recent Findings In recent years, research has concentrated on obtaining secure diagnostic criteria for DU and to distinguish it from BOO. Many recent retrospective papers have reported predictive clinical factors; however, clinical findings are still insufficient. Urodynamics are required. However, the parameters remain not uniformly standardised and include Bladder Contractility Index, Schäfer pressure-flow nomogram and Watts Factor, amongst others. Conversely BOO is almost universally diagnosed with a standardised index. Treatment options for DU and BOO include conservative management with clean intermittent self-catheterisation or catheterisation. Pharmaceutical options remain limited. Botulinum toxin urethral sphincter injection and sacral neuromodulation show promise. Surgical options include BOO surgery with significant improvement in physiological parameters and clinical recovery of spontaneous voiding. Newer laser techniques may be superior to traditional surgical options. Summary Recent studies of DU and BOO remain predominantly retrospective, unrandomised and small. Hence, the clinical significance of any findings is quite uncertain. The lack of standardisation in the diagnostic criteria and urodynamic parameters for DU also remains a concern. Meaningful comparison of available treatment options is compromised. Larger prospective randomised studies with diagnostic standardisation are urgently required to allow confidence in evidence-based treatment decisions.