Base bibliographique

Objective

To study the intrinsic diagnostic value of the exams performed to explore bladder outlet obstruction in women.

Methods

Review of literature (PubMed, Embase, Cochrane Database) using following keywords: female, bladder outlet obstruction, post-void residual, uroflowmetry, flow pattern, cystoscopy, MRI, retrograde cystography, bladder wall thickness, bladder trabeculation, urinary retention, voiding cystometry, pressure flow studies, electromyography. Among 2660 articles (animal and anatomical studies have been excluded), 40 have been selected because they focused on the evaluation of the intrinsic value of exams.

Results

The concomitant recording of bladder and abdominal pressure during voiding (pressure flow study) is useful to diagnose an hypocontractile detrusor, abdominal pressure efforts during voiding and obstruction (low voiding flow associated with a high bladder pressure). The reproducibility of pressure flow studies seems to be very good in the literature. Nomograms have been described to assess a possible obstruction, but some studies show no correlation between the severity of symptoms of bladder outlet obstruction and results on the main nomogram (nomogram of Blaivas). The measurement of the thickness of the bladder wall appears correctly correlated to the diagnosis of obstruction but measures vary significantly depending on the abdominal or vaginal ultrasonographic approach.

Conclusion

In literature, only methods of measurement of maximum urinary flow rate and post-void residual volume have been extendedly studied.

Aim

Some changes were of a physical nature whereas other changes were of a psychological nature (feeling less attractive, having less self-confidence, difficulties to meet a partner). It would be risky to attempt a clear analysis of female sexuality outside its neurohormonal determinants and ability to relate to a wide anatomical area. The SCI women reported that the injury caused many changes in their sex life and affected many aspects of their sexuality negatively.

Methods

Review of the literature using the following keywords: spinal cord injury; sexuality; sexual life; woman; sexual arousal; libido; orgasm; psychology; psychogenic, sexual dysfunction.

Results

Women presenting with spinal cord injury face numerous challenges (denial of motor deficit, phantom limbs and the collapse of libido to which amenorrhea is added). After a period of rehabilitation (short or long), the automatic spinal reflexes and rehabilitation exercises (in order to recover ordinary life) force the women to challenge their own difficulties before recovering autonomy. The sensitivo-motor dissociation she discovers, forces her to confront the psychic divisions of desire and physical desire as she tries to find his sexuality. Hence, she attempts to get out of her emotional loneliness and be confronted with the risk of marital breakdown, problems sphincter and its dreams of pregnancy.

Conclusion

Successful SCI rehabilitation requires a holistic approach, taking into account the patient’s physical and psychological circumstances. Despite the presence of handicaps occurring following spinal cord injuries, a long way toward recovering self-esteem may enable her to find a different sexuality but flourished.

Objectives

To provide a critical review of the currently available guidelines on female urinary incontinence diagnosis and treatment.

Methods

Through a review of Medline, we identified the guidelines produced by five associations: French Urological Association (AFU), French National College of Gynaecologists and Obstetricians (CNGOF), American Urological Association (AUA), European Association of Urology (EAU) and International Urogynecological Association (IUGA). These guidelines were evaluated by the instrument provided by the Appraisal of Guidelines, Research and Evaluation. Then, the diagnosis and treatment recommendations were compared.

Results

The quality of guidelines were variable. Three of them (CNGOF, AFU, EAU) yielded to a score of more than 70. The rigor of development was not always optimal with a dilemma between evidence based medicine and the practice of experts. The best guidelines based on excellent meta-analysis failed to consider the recent modifications of management.

Conclusions

We found many differences in the quality of available guidelines.

Purpose

The aim of this review was to examine the relationship between menopause and urinary incontinence (UI).

Material

Our work is based on a review of the literature on the epidemiology of UI in women and the effects of hormone therapy on symptoms of urinary leakage. A search of the Medline database between January 2000 and April 2012 was performed by crossing the keywords “urinary incontinence, stress urinary incontinence (SUI), urge incontinence, over active bladder, menopause, estrogen therapy”.

Results

Twenty-nine articles over the 482 articles were initialy selected. The UI was a common symptom during menopause, with a prevalence of 15 to 30% and an annual incidence of 5 to 10%. The association between UI and menopause was controversial. Indeed, although underpinned by pathophysiological mechanisms such as the sensitivity of tissues of the urogenital sinus to estrogen, the epidemiological data available were contradictory and should be interpreted, if possible, depending on the type of UI. Thus, it remained difficult to distinguish the effect of menopause of the aging. The effects of estrogen on IU differed depending on the route of administration and of the type of UI. Randomized trials showed that oral administration of estrogen after menopause increased the occurrence of UI or SUI. However a vaginal administration of estrogen improved urge urinary incontinence (UUI) and overactive bladder.

Conclusion

The data of this review were consistent with the French and European guidelines.

Aim

The aim of our study was to assess the link between pelvic organ prolapse (POP) characteristics and sexual well-being using validated tools.

Material

A prospective analysis was carried out in 148 women with a POP. The degree of prolapse was measured by using the Pelvic Organ Prolapse Quantification (POPQ). Pelvic Floor Distress Inventory (PFDI-20) questionnaire score was used to estimate the severity of symptoms. Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores determined sexual function level.

Results

No correlation was found concerning the global sexual function score and the POP stage (P =0.24). Pelvic and urinary symptoms were associated with a decrease in sexual function score (P =0.04 and P =0.002). Defecation symptoms were correlated with decreased sexual satisfaction (P ≤0.05) and were associated with premature ejaculation (P ≤0.05). Urinary symptoms were associated with dyspareunia (P ≤0.01), avoidance of sexual activities (P ≤0.05), negative emotions during intercourse (P ≤0.01) and decreased sexual excitement (P ≤0.05). Pelvic symptoms were significantly tied to avoidance of sexual activities (P ≤0.01), dyspareunia (P ≤0.05) and a poorer orgasm quality (P ≤0.05).

Conclusion

The degree of pelvic organ prolapse was not statistically associated with sexual function. However, urinary, pelvic and defecatory (ano-rectal) symptoms were associated with a decrease in the couple’s sexual well-being.

Objectives

To assess the clinical outcome following artificial urinary sphincter (AUS) implantation after failure of Advance™ sub-urethral male sling for post-prostatectomy incontinence (PPI).

Methods

A prospective evaluation was conducted about consecutive patients who received an AUS after failure of Advance™ therapy in one tertiary reference center. Evaluation included medical history, pad use and operative data (duration, cuff size, technical difficulties). Follow-up was scheduled at 1, 6, 12months and yearly thereafter. Clinical outcome was evaluated by pad use, patient global impression of improvement (PGI-I) scale and assessment of side effects. Cure was defined as no pad usage.

Results

Twelve patients were included in this evaluation. Median follow-up was 20months (12–43). No patient was lost to follow-up. Four patients had a history of radiation therapy and all patients had mild or moderate PPI with previous failed Advance™ surgery. Median (range) operative time was 47minutes (40–60). No technical problem occurred during AUS implantation. Hospital stay duration and catheterization duration were respectively 2days and 24hours in all but one case. At last follow-up, 10/12 patients (83%) were cured and fully satisfied. Two were improved, wearing only one pad per day. Postoperative complications were noted in two cases (17%) (one case of cutaneous erosion and one case of superficial iliac wound infection).

Conclusions

AUS implantation is feasible in patients who have undergone Advance™ male sling implantation. Mid-term results of this procedure are comparable to those obtained after first line AUS implantation.

Objective

To determine whether the presence of a previously implanted suburethral sling for post-prostatic surgery incontinence influences the outcomes of subsequent AUS implantation.

Patients and methods

A retrospective study comparing 15 patients who underwent AUS placement after suburethral sling failure between November 2004 and December 2009 to 15 patients who underwent AUS placement as first-line treatment during the same period. Demographic characteristics, preoperative assessment of urinary incontinence and technique of implantation of the AUS were similar in the both arms. A USP^® continence questionnaire was sent to patients by mail. Success was defined as a subjective improvement of the incontinence in patients using less than one pad per day.

Results

No perioperative incidents were noted in either arm. Mean operative time, the size of implanted cuffs, duration of catheterisation, length of hospital stay and postoperative complication rate, as well as the rate of surgical revision, were similar in both arms. The follow-up was slightly lower in the first arm (21 vs. 28.8 months, P =0.83). Stress incontinence and bladder overactivity scores of the USP^® questionnaire, as well as success rates (73.3 vs. 80%, P =0.67), were equivalent in both arms.

Conclusion

The results associated with the AUS procedure were not significantly different between men who had a suburethral male sling implanted before and those who had the AUS implanted as a first-line treatment.

Purpose

To assess the diagnostic performances and the acceptability of the penile cuff test (PCT) which is a non invasive method for the evaluation of bladder outlet obstruction (BOO), in comparison with the pressure flow study (PFS), the actual gold-standard.

Material

Monocentric prospective study comparing the following subsets: “obstructed”, “not obstructed” or “equivocal”, deduced from PFS vs PCT, in 30 consecutive patients presenting with lower urinary tract symptoms. For the PCT, a cuff placed around the penis inflated automatically during the micturition, until flow rate interruption. The interruption cuff pressure revealed the isovolumetric bladder pressure (Pcuff-int). The data collected – Pcuff-int and maximum flow rate – were automatically reported on ICS modified nomogram.

Results

With the PFS, 11 patients (39%) were classified “obstructed”, six patients (22%) “non-obstructed” and 11 patients (39%) “equivocal”. In 61% cases, the patient was classified in the same category by both techniques. The “obstructed positive predictive value” of the PCT was 82% and the “non-obstructed-equivocal negative predictive value” was 88%. The median acceptability visual analogic scale score was 1/10 (0–3) for the PCT whereas it was 5/10 (2–10) for the PFS. This difference was statistically significant (p =0.004).

Conclusion

The PCT was a reliable non-invasive tool for the diagnosis of BOO in male, in comparison with PFS. The predictive values of the PCT were relevant and its tolerance was better than PFS.

Managing an elderly subject with prostate cancer brings into play the notion of likelihood of survival before any diagnostic or therapeutic decision can be made. The diagnostic strategy must be specifi ed for each patient in accordance with the clinical presentation so as to determine whether prostate biopsies are indicated in this elderly population. To estimate the likelihood of survival, one must make use of geriatric assessment techniques comprising medical strategies ranging from screening for frailty to detailed geriatric evaluation for the most complex patients. The many tools available for estimating the likelihood of survival requires a critical review of their advantages and disadvantages in daily clinical practice.

Androgen suppression clearly increases the occurrence of cardiovascular risk factors : increased body fat, dyslipidemia and type II diabetes. Thus, several studies (but not all), showed an increase in coronary artery disease but also of sudden death and ventricular arrhythmias in relation to androgen deprivation, even for a short duration. This risk is particularly important in patients with existing cardiovascular risk factors or a history of heart disease. Cardiovascular risk should be balanced with the benefit of androgen deprivation on overall survival, especially when it is proposed in adjuvant setting, combined with radiotherapy in locally advanced prostate tumors.

In practice, it is recommended that patients be referred to their physician for an evaluation before starting treatment, then 3 to 6 months after starting treatment, then once a year. The initial assessment should include: a clinical examination (with measurement of blood pressure and body index) and laboratory test with full lipid profile (total cholesterol, HDL and LDL cholesterol, triglycerides) and glucose. It is also important that patients with heart disease, receive lifestyle advice and low- dose aspirin (80mg/day).

Because of the low mortality rates associated with prostate cancer, treatments long-term adverse effects constitute an important parameter in the management of patients. In particular, androgen deprivation has been shown to be linked to several metabolic disorders which are already frequent in men after age 60, such as weight and fat gain, insulin resistance likely to evolve into diabetes, and dyslipidemia. So far no consensus guidelines have been published regarding the screening and treatment of metabolic disorders in men with prostate cancer. It is essential to detect and manage these metabolic disorders, all the more so as they seem to be associated with an increased aggressiveness of prostate cancer. Here we report the development of a new questionnaire, which might contribute to the systematic management, and potentially the screening and treatment or the prevention of these metabolic disorders in patients with prostate cancer. In accordance with recent reviews and on the basis of experience, our French board of experts also recommends systematic screening and selective treatment for diabetes, regular follow-up of fasting glucose rates, lipid profile and blood pressure in all patients under long-term androgen deprivation treatment, as well as lifestyle changes (practice of exercise, nutritional habits).

All treatments of prostate cancer have a negative effect on both sexuality and male fertility. There is a specific profile of changes in the fields of quality of life, sexual, urinary, bowel and vitality according to the treatment modalities chosen.

Maintain a satisfying sex is the main concern of a majority of men facing prostate cancer and its treatment. It is essential to assess the couple’s sexuality before diagnosis of prostate cancer in order to deliver complete information and to consider early and appropriate treatment options at the request of the couple.

Forms of sexuality sexual preference settings stored (orgasm) may, when the erection is not yet recovered, be an alternative to the couple to maintain intimacy and complicity.

In all cases, a specific management and networking will in many cases to find a satisfactory sexuality.

Consequences of the treatment on male fertility should be part of the information of patients with prostate cancer and their partners. The choice of treatment must take into account the desire of paternity of the couple. A semen analysis with sperm cryopreservation before any therapy should be routinely offered in men with prostate cancer, particularly among men under 55, with a partner under 43 years old or without children. If the desire for parenthood among couples, sperm cryopreservation before treatment and medical assisted reproduction are recommended.

Androgen deprivation therapy represents an important part of the management of prostate cancer. However, epidemiological data have shown that it is a well-established cause of osteoporosis and increased risk of fracture. So far no consensus guidelines have been published regarding the screening and treatment of osteoporosis in men with prostate cancer. Here we report the design of a new questionnaire, derived from the FRAX^® (“Fracture Risk Assessment Tool”) algorithm, to evaluate the risk of fracture in those patients. In accordance with recent reviews and on the basis of their experience, our French board of experts recommends systematic screening for osteoporosis with dual energy x- ray absorptiometry scans, practice of exercise and calcium and vitamin D supplementation, and selective treatment with bisphosphonates in men at greatest osteoporotic risk.

Prostate cancer has become a chronic disease. In this context, it is important to take into account the quality of life of patients and their family in the therapeutic approach. Recent studies have demonstrated the importance of depression and the risk of suicide in patients with prostate cancer as well as the repercussions of the disease on the spouse and their relationship. The implication of hormonal treatment in the increase in risk of depression is difficult to affirm. Few studies have investigated this subject and they present methodological biases. Some authors report an increased risk of cognitive decline in patients on androgen deprivation. However, even if certain physiopathological hypotheses have been put forward, the imputability of the treatment on the alteration of cognitive functions has not been clearly established.

Urologists are at the forefront of diagnosis and treatment of prostate cancer occurring most often in elderly subjects. Therefore, given the prevalence of depression syndromes and/or the alteration of cognitive functions in this population, the urologist must be aware of these different factors, which are potentially aggravated by the introduction of androgen deprivation.

Based on a review of the recent literature, the authors suggest using a simple depression screening tool: confirmation of the diagnosis and management is within the competence of the general practitioner. As for the risk of cognitive decline, it seems difficult to imagine, and not necessarily relevant, to systematically propose a battery of neuropsychometric screening tests. On the other hand, giving the patient the G8 screening test can allow the urologist to assess whether the patient needs a geriatric consultation or not.