key: cord-0009692-3dg917r0
authors: nan
title: ICS 2017 Abstracts
date: 2017-07-26
journal: Neurourol Urodyn
DOI: 10.1002/nau.23386
sha: e02044b01b81fd1747419fb2f1dfcffabdf1a076
doc_id: 9692
cord_uid: 3dg917r0

https://www.ics.org/2017/videos

Regarding subjective incontinence, currently there is no evidence of a difference in effectiveness between laparoscopic colposuspension and open colposuspension, nor between laparoscopic colposuspension and midurethral sling procedures. However, when laparoscopic colposuspension is performed, the use of two sutures appears to be more effective than one.

In the context of current safety concerns raised regarding the use of tapes in continence surgery, where in 2016 the FDA reclassified urogynecologic surgical mesh instrumentation from class I medical devices (low risk) into class II (intermediate risk) and the more recent legislative proposal in the European Parliament in 2017 proposing to reclassify the implantable device procedures from a class II device (medium risk) into class III device (high risk), it is particularly important that other surgical options such as laparoscopic colposuspension are thoroughly investigated using robust methods to ensure women and their health care providers can make informed decisions regarding treatment. The main outcome of interest was a composite of surgical site infection (superficial, deep incisional or organ/space), bleeding requiring blood transfusion, return to the operating room within 30 days, and surgical stay >48 hours. Secondary outcomes included urinary tract infection, peripheral neurologic injury, wound disruption, sepsis and total operating time. Log-binomial regression modelling was used to identify independent risk factors for the primary outcome and to generate adjusted effect measures for variables of interest.

Results 7,097 women met the inclusion criteria, of which 2,433 (34%) underwent a concomitant incontinence procedure. Patients undergoing a concomitant incontinence procedure were slightly older (59 ± 11 vs. 58 ± 12, p<0.0001) and had longer total operating time (225 [IQR 170-267] vs. 184 [IQR 120-232] minutes, p<0.0001). A greater proportion of concomitant incontinence procedures were performed by gynecologists compared to urologists (35% vs 28%, p=0.002). Overall rates of complications were low and the primary outcome occurred 227 patients (3%). Urinary tract infection was the most common overall complication occurring in 238 patients (3.34%). 5 ,070 patients were included in the multivariate analysis using log-binomial regression modelling. After adjusting for baseline patient characteristics and co-morbidities, no association was observed between concomitant incontinence procedure and the composite outcome (adjusted RR 0.99, 95% CI 0.71-1.38) but there was an increased risk of urinary tract infection (adjusted RR 2.28 95% CI 1.69-3.07). Bleeding disorder (aRR 3.83, 95%CI 2.09-7.02, p<0.0001), steroid use for a chronic condition (aRR 2.23, 95% CI1.23-4.04, p=0.01) were noted to be independent predictors of the primary outcome.

Despite being associated with a longer operative time, performing a concomitant incontinence procedure at the time of MISCP was not associated with an increased risk of clinically important surgical complications other than urinary tract infection in this large database study.

Concluding message Overall rate of 30 day perioperative complications at the time of MISCP are low. Addition of a prophylactic incontinence procedure at the time of MISCP is a reasonable strategy to offer patients. Although urinary tract infection is more common amongst patients having incontinence procedures with MISCP, overall surgical risk does not appear to be significantly increased.

Table. Comparison of operative times (average minutes ± standard deviation) for each step of robotic-assisted laparoscopic sacrocolpopexy (RASC) procedure by Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellow involvement and year of fellowship training.

Step of Procedure 

Tolterodine 4 mg (Tol) was associated with a greater risk of overall TEAEs rate than placebo (OR: 1.38; p<0.0001). Conversely, mirabegron 50 mg (Mir50) and mirabegron 100 mg (Mir100) were not associated with an increased risk of TEAEs when compared to placebo (OR: 0.94; p=0.32 and OR:0.97; p=0.31, respectively) In particular, Mir50 was not associated with an increased risk of hypertension (OR: 1.02; p=0.90), while with mirabegron 100 mg this risk was slightly increased (OR: 1.41; p=0.08) in comparison to placebo. Also the risk of cardiac arrhythmia was not significantly increased over placebo with Mir50 (OR: 1.0; p=1.00), but slightly with Mir100 (OR: 2.18; p=0.06). The risk of dry mouth was statistically greater for Tol (OR: 2.97; p<0.001) vs. placebo, but also vs. Mir50 and Mir100 (OR: 2.49; p<0.00001, and OR: 2.43; p<0.001, respectively). The discontinuation rate due to adverse events was not greater for Mir50 (OR: 0.97; p=0.80), Mir100 (OR: 0.89; p=0.63) or Tol (OR:1.42;p=0.12) vs placebo. (Figure 1 ). Interpretation of results Results showed a better TEAEs profile of β₃-adrenoceptor agonist compared to Tol, that can be explained by the different selectiveness of the drugs. β₃-adrenoceptor receptors are present in bladder and adipose tissue, while muscarinic receptors are well represented in many organs, leading to a higher rate of TEAEs in the Tol arm compared to mirabegron. Mirabegron's adverse effects, like hypertension can be explained to the intrinsic alfa-agonist activity of the drug that is concentration related, so higher dosages can bring higher rates of hypertension. Dry-mouth sensation can be also related to pharmacodynamics, but the adrenergic component is not as predominant as the muscarinic one on salivary glands, so that's why Tol results more bothersome. The discontinuation rate due to adverse effects shows that almost every drug is well-tolerated, independently to the TEAEs. The reason can be that the OAB/Storage LUTS are usually more bothersome than TEAEs, allowing a better compliance for the patients.

Concluding message Mir50 and Mir100 are associated with an acceptable safety profile. For Mir50 and Mir100, the risk of TEAEs and the discontinuation rate due to TEAEs is not superior to placebo. However, Mir100 is associated with a slight increase in hypertension and cardiac arrhythmia. Conversely, Tol was found associated with an increased risk of overall TEAEs vs placebo, but not with treatment discontinuation due to TEAEs. These findings should be considered when evaluating the risk-benefits of prescribing drugs for OAB/storage LUTS. Study design, materials and methods It was an observational study in one maternity hospital. We used data from medical records and a self-report questionnaire. Patients' approvals were obtained before participation to the study. Clinical characteristics for calculating jelovsek's probabilities of developing UI and FI and birth issues (instrumental extractions, perineal tears) were collected. For each participating woman, we calculated her UI and FI risks using antenatal data before delivery: maternal age, prepregancy BMI and predelivery BMI, ethnical origin, urinary incontinence symptoms before and during pregnancy, planned mode of delivery We studied the distribution of our participants' scores. For each score value, we calculated how many women had an equal or upper score. This represents the theoretical number of elective cesareans if Jelovsek's nomograms was used to determine the mode of delivery at this level of risk. We did likewise with all score's values and create a curve.Two curves were drawn: one for UI and one for FI. With these curves, we could estimate the number of elective prophylactic cesarean deliveries depending on perineal risk accepted by women. We also asked women if they would accept to randomize their mode of delivery. We performed a descriptive statistical analysis using R statistical software.

Between the 15th of March and the 15th of April, 125 nulliparous women gave birth in our hospital maternity, among them 99 agree to participate (79%). Mean maternal age was 28,8 years. Mean Body Mass index (BMI) was 23,6 kg/m² before pregnancy and 28 at the end of pregnancy. Before childbirth, 82 women reported no urinary incontinence symptom, 13 women had symptoms rarely and 3 sometimes. During the ninth month of pregnancy, 55 women reported no urinary incontinence symptoms, 28 women had symptoms rarely, 12 patients experienced sometimes and 3 often. One patient didn't answered these 2 questions.

Among these 99 women, 8 had an elective cesarean delivery and vaginal birth was planned for 91. The attempt of vaginal birth succeeded for 78: 55 spontaneous and 23 instrumental vaginal deliveries (20 vacuum extractions and 3 forceps); Among them, 18 women need an episiotomy and no anal sphincter injury was reported. 12 women need an emergency C-section. We calculated woman's individual probability of developing UI and FI for each 91 women who had planned a vaginal birth using only antenatal data available. Mean probability of developing UI was 27.4% (min= 9.2%, max= 84.2%) and mean probability of developing FI was 11% (min=1.6%, max=38.3%). Figure 1 estimated the theoretical number of elective prophylactic cesarean deliveries depending on Jelovsek's probability of developing UI and figure 2 of developing FI. Thirty-four women would accept to participate to a randomized trial, it represented 35% of our sample (3 didn't answered).

Jelovsek's prediction models are simple and none time-consuming tools. Data needed to calculate risk of incontinence are easy to collect. Prediction of a woman's individual probability of developing UI or FI after her first delivery can appear valuable. It might help women who want to choose their routes of delivery. Use of Jelovsek's prediction models for postpartum incontinence in common practice would probably lead to a significant increase of elective cesarean deliveries on demand in an obstetrical low risk population. For example, if women decide that a probability of 20% of FI is unacceptable, it would lead to increase the C-section rate by 10%. If women choose a threshold value for urinary incontinence as 40%, it would lead to increase the C-section rate by 19%. Prognostic value of Jelovsek's models has an area under the curve less than 0, 70. It appears for us insufficient for daily clinical practice (it gets wrong in 30% of case). There is a lack of external validation.

Concluding message Although prediction models might be an interested tool to assess UI or FI probabilities, their results might have a serious impact on cesarean deliveries rate. Considering that the preventive effect of cesarean on postpartum incontinence didn't show adequate clinical evidence, it should be used with caution. However, it may be a help to identify high-risk women that could be included in a randomized trial to investigate effectiveness of pelvic floor prevention interventions. 

Hypothesis / aims of study We performed the first large population-based study to evaluate lower urinary tract symptoms (LUTS) in Brazil. The study objective was to assess the prevalence and bother of LUTS in the population aged ≥40 years in five major cities in Brazil.

This study was conducted as a telephone survey between 1 September and 31 December 2015. Adults aged ≥40 years with residential phone lines (landlines) residing in the cities of Sao Paulo, Porto Alegre, Recife, Belem and Goiania were included. All participants provided informed consent. The survey included assessment of LUTS using a standardized protocol, which included the international prostate symptom score (IPSS) and, for overactive bladder (OAB), the OAB-V8 questionnaire. Participants were asked to rate how often they experienced individual LUTS during the past month ( [2] [3] [4] [5] , and definition 2 (Likert score [3] [4] [5] . The association between frequency of symptoms and bother intensity for each LUTS was evaluated using the Spearman's rank correlation coefficient. Chi-squared tests evaluated differences in LUTS prevalence between the sexes and age groups. Both analyses took sample plan into account.

Overall, there were 5,184 participants: 1,004 from Sao Paulo, 1,002 from Porto Alegre, 1,013 from Recife, 1,004 from Belem and 1,161 from Goiania. Among the total sample, 53% were women; 28% were aged 40-49 years, 34% were 50-59 years old, 21% were 60-69 years old, and 17% were aged ≥70 years. The most common marital status was "married or living with a partner" (60%), and the most common education level was "complete high school" (26%). Using definition 1, the prevalence of LUTS (at least one of voiding, storage or post-micturition symptoms) was 69% in men and 82% in women ( Figure 1) . The corresponding values using definition 2 were 40% and 59%. LUTS prevalence increased with age (definition 1: men, p=0.001; women, p<0.001). In men and women, definition 1 prevalence was 60% and 75%, respectively, among those aged 40-49 years, compared with 78% and 98% in those aged ≥70 years. According to the OAB-V8 questionnaire, the prevalence of OAB was similar in women and men (24% and 25%, respectively). In contrast, urinary incontinence (definition 1 prevalence 46% and 15%), urge urinary incontinence (15% and 9%) and stress urinary incontinence (20% and 3%) were all more common in women than men.

Results from the IPSS questionnaire showed that 83% of men and 84% of women had at least mild symptoms. Moderate-tosevere symptoms were present in 21% of men and 24% of women.

Among individuals with each specific symptom, the percentage rating the associated bother as at least "quite a bit" is shown in Figure 2 . The most bothersome symptoms among men were urgency with fear of leaking, urgency urinary incontinence and stress urinary incontinence. Over 70% of women reporting eight different symptoms (mostly storage symptoms) considered the associated bother to be at least "quite a bit". There was a statistically significant association between the frequency and bother intensity of each symptom (p<0.001). The correlation coefficients for these relationships ranged from 0.504 (nocturia in men) to 0.984 (leak during sexual activity in women). 

Hypothesis / aims of study Mirabegron is the first β3-adrenoceptor agonist for overactive bladder (OAB) patients in clinical practice, and 50 mg is the most common used daily dose. In contrast to other countries, the suggested initial dose is 25 mg daily in Taiwan. We conducted a randomized trial investigating the therapeutic adding effect of mirabegron 50 mg in OAB patients after initial treatment of mirabegron 25 mg.

Study design, materials and methods Male patients aged ≥20 years with symptoms of OAB (an average of ≥8 micturitions and an average of ≥1 episode of urgency or urgency incontinence per 24-hours) for at least 12 weeks were enrolled. Patients were randomized into 2 groups. Patients in the first group received mirabegron 25mg once-daily for 4 weeks, and continue the same dose for another 8 weeks. Patients in the second group received mirabegron 25mg once-daily for 4 weeks, and increase the dose to 50mg for another 8 weeks. The treatment results were assessed by using overactive bladder symptom score (OAB-SS), patient perception on intensity of urgency scale (PPIUS), international prostate symptom score (IPSS) storage subscore (IPSS-S), patient perception of bladder condition (PPBC), and quality of life index (QoL-I) at 4 and 12 weeks after treatment. All the adverse events (AEs) were also recorded. Primary end-point was comparison the treatment results between groups. Wilcoxon signed-rank tests were used to compare parameters before and after treatment.

Of the 266 enrolled patients (mean age, 69.0 years), 134 patients were randomized to 25 mg group while 132 patients were randomized to 50 mg group. The demographic and baseline parameters were similar between groups. Table 1 showed parameters before and after mirabegron treatment. The OAB-SS, PPIUS, IPSS-S, PPBC, and QoL-I improved significantly at 4 weeks and 12 weeks after mirabegron treatment in both groups. Further improvement of OAB-SS and IPSS-S from 4 weeks to 12 weeks could only be seen in patients receiving 50 mg mirbegron after initial 25 mg mirabegron. In void diary, the improvement of daily micturition episodes at daytime and urgency episode could be found at 12 weeks after treatment in both groups. There was no significant change of nocturia episodes after treatment. The improvement of daily UUI episode could only be found in patients receiving 50 mg mirabegron. Adding dose to 50 mg could result in further improvement of daily urgency and UUI episodes from 4 to 12 weeks after mirabegron treatment ( Figure 1 ). There were no significant changes of maximum flow rate (Qmax) and post-void residual (PVR) after treatment. Increased voided volume could be found at 4 and 12 weeks after mirabegron treatment in both groups. All the AEs were mild and tolerable. The rate of AEs was similar between groups.

Interpretation of resuls Our results showed that treatment with 25 mg mirabegron could result in improvement of OAB symptoms in Asian population. Adding dose of mirabegron to 50 mg could further improves daily urgency and UUI episode even patients were satisfied with 25 mg mirabegron. There was no significant difference of rate of AEs and PVR after treatment between groups.

Concluding message For patients receiving daily 25 mg of mirabegron for 4 weeks, adding dose to 50 mg could result in further improvement of daily urgency and UUI episodes. The safety and tolerability were similar between patients receiving 25 mg and 50 mg mirabegron. We suggested that although 25 mg mirabegron daily is safe and effective for Asian OAB population, 50 mg of mirabegron daily is a more optimal dose for those with severe urgency or UUI episodes. n=number of patients at baseline.

Anticholinergic add-on therapy was effective and well tolerated in all groups, with improvements from baseline to endpoint and no unexpected ADRs. Changes in QTcF interval were not clinically significant.

In OAB patients refractory to mirabegron monotherapy, anticholinergic add-on therapy is well tolerated and effective, and thereby a useful treatment option. 

Hypothesis / aims of study Many clinical studies indicate that pharmacologic treatment of overactive bladder (OAB) is considered effective and safe, but in real clinical practice a substantial proportion of patients discontinues the treatment. The reason for discontinuing the treatment most frequently reported is lack of efficacy and/or side effects. A further significant proportion of patients reports that they stopped the treatment because the symptoms disappeared or were resolved. This Beta-3 agonist seems to be crucial in providing comparable efficacy in the OAB treatment and better tolerance in comparison with anticholinergics.

Our aim was to investigate the durability of the Mirabegron effect in successfully treated OAB patients and to understand more fully what prompts patients to return to the medication. Is this merely a subjective decision, or is it based on objective worsening of the symptoms?

Study design, materials and methods This is a secondary analysis of longitudinal multicentre study of OAB Mirabegron treatment persistence. After continuing Mirabegron treatment for 29 months patients were assessed by bladder diary and specific questionnaires. Patients with a UB -VAS score (urgency bother visual analogue scale) of 50 or less were asked to stop the Mirabegron treatment and restart the treatment any time later if they felt the need. Patients recorded the date of return to medication; they kept a daily bladder diary and filled in the same questionnaires as at the time of medication discontinuation. We provide a comparison of symptoms at the time of Mirabegron discontinuation (V1) and at the time of Mirabegron medication restart (V2).

Results 206 patients entered the study. 176 females (85%) and 30 males (15%) with mean age 62.9±12.43, BMI ranging from 16.6 to 48.0 (mean 27.2±4.96).

After 18 months 126 patients were persisting with Mirabegron treatment. 89 patients had UB-VAS score <=50 (89 of 126 patients, i.e. 71%). Those patients were asked to stop the treatment. From the eligible group of 89 patients, 19 patients (21%) were unwilling to stop the treatment and were therefore excluded. There were no significant differences in bladder diary and QoL characteristics between patients who were unwilling to discontinue the treatment and patients who did stop taking the medication. The group who stopping treatment comprised 70 patients. At the time of last follow-up 22 patients (31%) had not restarted the medication, with mean follow-up of 122.6 days. Therapy was restarted by 48 patients (i.e. 69% of 70). The mean time without treatment was 48 days (±32.0 days), median 53 days. Table 1 presents a comparison of subjective and objective parameters when treatment was stopped and when it was restarted. Interpretation of results 69% of patients with OAB symptoms successfully treated with Mirabegron (UB-VAS <=50) are unable to discontinue taking the medication for more than 2 months. Subjective bother based on increase number of frequency, urgency, and nycturia causes patients with positive experience to return to Mirabegron treatment.

Concluding message:

The majority of patients with successfully-treated symptoms of OAB who discontinue treatment can only do so temporarily. A worsening of the symptoms occurs rather rapidly. Results 206 overactive bladder patients entered the study, 176 females (85%) and 30 males (15%). Patients were aged 23 -89 (mean age 62.9±12.43), males 30-78 (63.4±12.14) and females 23-89 (62.8±12.52). 178 patients (86%) switched from anticholinergics (108 due to lack of efficiency, 66 due to lack of tolerance, 4 for other reasons). Significant difference by age in the reason for therapy switch was found. Patients up to 60 years tend to switch due to lack of tolerance (52%). Patients over 60 years tend to switch for lack of efficacy of previous anticholinergic treatment (70%). 75 patients (36%) were up to 60 years, 9 males (12%) and 66 females (88%), and 131 patients (64%) were over 60 years, 21 males (16%) and 110 females (84%), at the beginning of the study. 126 patients (persistence in the study was 61.2%) finished the whole course of the study. 80 patients (39%) terminated the study prematurely -16 males (20%) and 64 females (80%), 27 patients (34%) were up to 60 years and 53 patients (66%) were over 60 years. 6 patients up to 60 years and 22 patients over 60 years terminated the study due to lack of efficacy. 12 patients up to 60 years and 7 over 60 years terminated the study due to the lack of tolerance. The remaining 43 patients dropped the study from other reasons (lost-follow-up, gravidity, disease, hospitalization, etc.). All the characteristics observed improved significantly within the 1.5 year's period of the study for all the patients who finished the study as planned. Slight worsening of observed quality of life patterns was observed between M12 and M18, but this was not accompanied by change in objective micturition diary patterns. Of the three age breakpoints the 60 year break point was found the best for evaluation of differences. There were no significant differences between patients up to 70 years and over 70 years. There were still some significant differences between patients up to 65 years and over 65 years, but the difference was statistically strongest between patients up to 60 years and over 60 years. It seems that the greatest effect in perception of quality of life lies between 60 and 65 years. Treatment development as measured by differences between D1 and M18 seems to be always slightly better for patients over 60 years either in objective characteristics from micturition diary or in quality of life characteristics TS-VAS, UB-VAS, PPBC and OAB. Differences in TS-VAS, urgencies gr.3 and urgencies gr.3+4 were found to be significant by age. TS-VAS improved by 5,4 from M3 to M18 for patients over 60 years and by 7,3 for patients up to 60 years. Number of urgencies gr. 3 decreased by 0,8 in patients up to 60 years and 2,0 in patients over 60 years. Number of urgencies gr. 3+4 decreased by 1,3 in patients up to 60 years and by 3,1 in patients over 60 years.

Interpretation of results Mirabegron treatment leads in all patients to the significant improvement of all objective and subjective parameters in the long term follow up of 18 months. It seems that the patients over 60 years react better to the mirabegron treatment and appreciate improvements in their quality of life more than patients up to 60 years. It seems that for patients over 60 years overactive bladder patterns are crucial for their perception of quality of life.

Concluding message Mirabegron treatment is effective in all patients for both micturition diary and quality of life patterns in the long term follow up. It seems that mirabegron treatment allows patients over 60 years to perceive their overactive bladder symptoms more bearable and probably to stay physically and socially more active for longer period of time. Study design, materials and methods This study was a 12-week, multicenter, randomized, double-blind, parallel, active control study. Patients≥20 years with OAB symptoms were recruited to a 2-week, single-blind, placebo run-in. Those with ≥8 micturitions and ≥2 urgency episodes per 24 hours and a total OABSS of 6 or more points were randomized 1:1 to tolterodine/pilocarpine (2/9mg) (n=193) or 2mg tolterodine (n=191) twice-daily for 12 weeks. Co-primary endpoints were the change from baseline in the mean number of daily micturitions and cumulative incidence of dry mouth at the end of the 12-week. Secondary endpoints included other OAB symptoms, xerostomia inventory total score and visual analogue scale (VAS) for dry mouth overall at the end of treatment period.

Baseline characteristics were similar across the treatment groups. In the per protocol set, tolterodine/pilocarpine (2/9mg) combination treatment was noninferior to tolterodine 2mg monotherapy. Change from baseline in the mean number of daily micturitions was -1.49 ± 2.20 of tolterodine/pilocarpine (2/9mg) combination group and -1.74 ± 1.99 of tolterodine 2mg group, for a difference of -0.26 ± 2.09 between two groups. The 95% confidence limits on the difference (-0.79 to 0.27) was above the prespecified noninferiority threshold of -1.0 (Figure1). In the safety analysis set, incidence of dry mouth was lower in tolterodine/pilocarpine (2/9mg) combination group than tolterodine monotherapy group, significantly (57 of 190 or 30.0% for combination group vs 82 of 191 or 42.93% for monotherapy group, p=0.009) (Figure1). All secondary and other efficacy outcomes related to OAB symptoms were improved in both groups while no statistically differences between two groups at the end of the 12- week. The change from baseline in the xerostomia inventory total score and VAS for dry mouth was significantly lower in tolterodine/pilocarpine (2/9mg) combination group than tolterodine 2mg group (Table1). The incidence of adverse events was similar between two groups. Interpretation of results This randomised, double-blind phase 3 study showed that tolterodine/pilocarpine (2/9mg) combination treatment effectively reduced the incidence of dry mouth compared with tolterodine monotherapy while maintaining antimuscarinic efficacy in OAB. The safety of combination drug was consistent with the known safety profiles of these agents when administered individually.

Concluding message A combination of tolterodine and pilocarpine effectively reduced incidence of dry mouth compared with tolterodine alone while preserving treatment efficacy in OAB and it was well tolerated. 

Hypothesis / aims of study hMaxi-K is currently the only gene therapy approach to treat benign urologic conditions with FDA approved IND's. hMaxi-K is a plasmid vector expressing the gene for Maxi-K, a potassium channel involved in regulation of smooth muscle tone which has been demonstrated to play a key role in normal bladder physiology in animal studies. This is the first study to evaluate the safety and effectiveness of direct bladder wall injections of this plasmid to treat the symptoms of overactive bladder and urinary incontinence in women.

Study design, materials and methods: Primary Objective: To evaluate occurrence of adverse events and their relationship to hMaxi-K treatment following multiple intramuscular (IM) injections into the bladder wall of two dose levels (16000 µg and 24000 µg) in women with moderate OAB/DO of ≥ six months duration.

Secondary Objective: To evaluate the following additional safety parameters (changes from baseline compared to placebo): Clinical laboratory tests, Electrocardiogram changes and Physical Examination. To evaluate efficacy parameters (change from baseline compared to placebo) that include: number of micturitions per day, volume per micturition, urgency episodes, incontinence episodes, pad weight, number of uninhibited contractions during cystometrogram (CMG) and other general and bladder-specific quality of life assessments. Methodology: This was a double blind, imbalanced placebo controlled sequential dose trial. Participants were healthy women of 18 years of age or older, of non-childbearing potential, with moderate OAB/DO of ≥ six months duration with at least one of the following: frequent micturition ≥ 8 times per day, symptoms of urinary urgency or nocturia (the complaint of waking at night two or more times to void), urge urinary incontinence (five or more incontinence episodes per week), and detrusor overactivity with ≥ 1 uncontrolled phasic contraction(s) of the detrusor of at least 5 cm/ H20 pressure documented on CMG. All of the participants had failed prior treatment with anticholinergics. Four had failed onabotulinumtoxinA therapy. Participants were randomly assigned to either hMaxi-K at one of two doses (16,000 mcg, or 24,000 mcg, or placebo. Treatment was administered as 20-30 IM injections into the bladder wall during cystoscopy. Participants were seen 8 times within a 24week period with a study follow-up of 18 months. All reported adverse events occurring after study drug dosing were recorded. Complex CMG's were done at screening visit 1A (week -1) and at week 4 (visit 5) and week 24 (visit 8) post-injection. Post void residual volume (PVR) was measured at every visit with a Bladderscan®. The data to assess efficacy were evaluated using summary descriptive statistics by treatment group (combined placebo vs 2 active treatment groups and combined placebo vs combined treatment groups). Linear mixed effect models were used to estimate difference of changes from baseline between placebo and active treatment and to test whether there was dose-response for different outcomes. Generalized estimating equation (GEE) models were to be used to estimate effects for the binary endpoints.

There were 6 participants who received 16000 mcg, 3 participants who received 24000 mcg and 4 participants who received placebo. In both active treatment groups, the majority of adverse events (AEs) were mild in severity and all were considered unrelated to study drug. Two women had mild unrelated UTIs post-treatment with hMaxi-K: one receiving 24000 mcg at month after dosing and the other receiving 16000 mcg at 6 months after dosing. There was one unrelated serious AE reported in the 16000 mcg group; exacerbation of pre-existing asthma due to the cold weather which required an ER visit and resolved after asthma treatment was given. No subject was discontinued due to an AE and all enrolled subjects completed the 6 month trial. In addition, during the18 month long-term post study safety follow-up, no issues were reported in the subjects followed to date (9 of 13 completed 18 month follow-ups; 13 of 13 completed the 12 month follow-ups). The average of diary data collected for 7 days prior to each visit revealed statistically significant (p<0.05) improvements vs placebo and baseline with durable reduction in mean number of voids per day and mean number of urgency episodes per day over the 6 months of the trial. The changes displayed in the two tables below are mean changes (+/-SE) from baseline compared to placebo Quality of life parameters (King Health Questionnaire) showed statistically significant sustained mean changes for the individual active treatments and for the combined active treatment groups (all doses) vs placebo and vs baseline in the domains of Impact on Life, Role Limitations, Physical Limitations, Social Limitations and Sleep Energy.

This phase IB clinical trial extends and substantiates prior pre-clinical reports that the instillation into the rat bladder of a plasmid containing the gene that expresses the human Maxi-K channel can safely reduce untoward effects of detrusor instability. (1) (2) (3) The measured significant reduction of the number of voiding and urgency episodes after a single administration of hMaxi-K lasted for the 6 month duration of the trial. Those results were observed in the absence of a change in PVR and treatment-related serious adverse events.

Concluding message The results of this novel clinical trial show for the first time that a single intradetrusor administration of human Maxi-K gene was safe. Though the number of participants was small, there was a durable, positive effect. These findings justify further study of this approach for treatment of OAB/DO. 

Hypothesis / aims of study Current treatments for lower urinary tract symptoms (LUTS) associated with bladder diseases have many setbacks, including limited efficacy and adverse side effects. Phosphodiesterase type 5 (PDE5) inhibitors like sildenafil (Viagra®), which are clinically used to treat erectile dysfunction, have been found to also alleviate LUTS. The ability of PDE5 inhibitors to directly relax smooth muscle has been described [1] , however, a complete understanding of its action on the bladder remains unclear. We are investigating the effects of sildenafil on several potential mechanisms involved in peripheral control of bladder function. In this study, the effects of sildenafil on nerve-mediated contractions of the isolated mouse bladder, and neuronal neurotransmitter release, were characterised. A comprehensive description of how sildenafil reduces detrusor contractile function should give insight into pathology of bladder diseases and suggest a potential therapeutic role of PDE5 inhibitors in their treatment.

Study design, materials and methods Bladders were removed from euthanised young (12 weeks) and aged (24 months) mice and detrusor strips tied to an isometric force transducer in a horizontal superfusion chamber. Contractures were generated by carbachol (CCh, 1 μM) added to the superfusate. Nerve-mediated contractions (tetrodotoxin-sensitive) were generated by electrical field stimulation (EFS: 0.1 ms pulses, 1-24 Hz, 3-s train every 90-s). Contraction amplitude was normalised for tissue preparation weight (mN.mg -1 ). Forcefrequency relationships were used to determine maximum tension (Tmax), the frequency to attain Tmax/2 (f1/2, Hz), and the ratio at low and near maximum frequencies (T2/20). The quantity of adenosine triphosphate (ATP) released (pmoles) into the superfusate during EFS was measured directly using a firefly luciferin-luciferase assay. A protocol of pelvic nerve stimulation using an arterially-perfused mouse model was used [2] to investigate nerve-mediated bladder pressure changes in situ. Data are means ± SD, n=number of experiments. Differences between data sets were subjected to ANOVA with post hoc Student's t-tests; the null hypothesis was rejected at p<0.05.

Sildenafil (1 -30 μM) significantly reduced peak CCh-induced contractions, from 0.47±0.05 to 0.18±0.03 mN.mg -1 at 30 μM sildenafil (p<0.001, n=8), with an IC50 value of 17.5±2.0 μM. Sildenafil (20 μM) also reduced EFS-stimulated contractions, but also significantly increased the f1/2 to the right, from 3.31±0.47 to 7.56±0.92 Hz in young mice (p<0.01, n=8), and from 1.92±0.67 to 7.65±0.42 Hz in aged mice (p<0.01, n=5) - Figure 1 . T2/20 values were also significantly decreased upon the addition of sildenafil, from 0.33±0.06 to 0.10±0.02 in young mice (p<0.01, n=8), and from 0.61±0.14 to 0.08±0.01 in aged mice (p<0.05, n=5). These results show that sildenafil reduced EFS-stimulated contractions more at low frequencies, compared to high frequencies. α,βme-ATP (10 μM), an ATP analogue, was used to desensitise purinergic receptors and leave only acetylcholine-mediated EFS contractions -sildenafil (20 μM) had no significant effects on Tmax, f1/2, or T2/20 (p>0.05, n=6). By contrast, in the presence of atropine (1 μM), to inhibit acetylcholine (ACh)-mediated EFS contractions, sildenafil (20 μM) significantly reduced Tmax from 0.79±0.11 to 0.64±0.12 mN.mg -1 , in comparison to the effects of atropine alone (p<0.05, n=6). Sildenafil also significantly reduced ATP release during EFS-stimulated contractions in young mice (n=8); from 70.1±12.3 pmoles to 38.5±8.5 pmoles at 2 Hz stimulation (p<0.001), and from 124.6±20.2 pmoles to 36.6±9.2 pmoles at 20 Hz stimulation (p<0.01) - Figure 2 . Pelvic nerve stimulation in the arterially-perfused mouse model generated a frequency-dependent increase in in situ bladder pressure recordings at 1-24Hz stimulation, and preliminary results demonstrate relaxation of nerve-mediated whole bladder pressure movements by sildenafil in situ, which is comparable to the effects in vitro. Interpretation of results Sildenafil reduced the magnitude of nerve-mediated contractions in detrusor from young and aged mice. Although it reduced agonist-induced contractions, the data on nerve-mediated contractions suggests an additional effect on neurotransmitter release or its down-stream effects. Nerve-mediated contractions are dominated by ATP release at low frequencies, and ACh release at higher frequencies [3] . The fact that sildenafil had no action on ACh-dependent contractions (in the presence of α,βme-ATP) suggests that the local ACh concentration is less than 10 μM, as it did suppress the CCh contracture. The predominant effect of sildenafil at low frequencies, the blockade of atropine-resistant contractions and its almost complete abolition of nerve-mediated ATP release all suggest that the agent has a specific effect on ATP neurotransmitter release or at least its persistence in the nerve-muscle junction. The particular pathways whereby this action is mediated are yet to be determined.

Concluding message Sildenafil has a significantly greater effect on the low-frequency, purinergic-mediated contractions, and significantly supressed neuronal ATP release. These results demonstrate a novel action of sildenafil to selectively inhibit ATP release from nerveterminals innervating detrusor smooth muscle, a neurotransmitter associated with overactive bladder conditions in humans. 

Hypothesis / aims of study Overactive bladder is a chronic syndrome characterized by urinary urgency, increased day or night-time voids, with or without urinary incontinence. Currently available treatment options, while providing benefit for many patients, have challenges that can affect adoption [1, 2, 3] . Some of these therapies act on the detrusor muscle (such as antimuscarinics or B3 agonist), others target peripheral nerves (SNS or PTNS), while others target synaptic transmission (OnabotulinumtoxinA). A novel treatment using RF energy aiming to fulgurate the nerve rich layers of the deep detrusor beneath the trigone including the adventitial space while sparing the bladder mucosa is currently being studied. Effacement of these nerves, including the C-Fiber (afferent) nerves, followed by collagen remodeling is intended to cause interruption of the signals causing the OAB symptoms.

Study design, materials and methods 34 female subjects with OAB were enrolled in the single arm, initial study cohort at 4 sites in Belgium and Canada. Primary inclusion criteria (via bladder diary) included >8 voids/day and >3 episodes of urgency with or without incontinence. Additionally, subjects had to have failed or were not candidates for drug therapy. Subjects received trigone RF ablation via a transurethrally placed proprietary device using cystoscopic guidance in a single procedure then were assessed for the primary endpoint at 12 weeks and followed out to 12 months. Assessments at baseline and follow-up included completion of a bladder diary, PVR and pad weight test along with subject completed questionnaires (OAB-q, PISQ-IR and King's Health Questionnaire). An independent clinical events committee (CEC) adjudicated applicable adverse events.

Overall, the mean subject baseline demographics and OAB characteristics include an age of 67.4 yrs range [38.7-81.5], a PVR of 29.7ml range [0-121], 12.9 voids/day, 7.3 urgency episodes/day and 2.8 urgency urinary incontinence (UUI) episode per day. 73.5% (25/34) reported at least 1 UUI/day while 4/34 (11.8%) reported no incontinence via the baseline bladder diary. The remaining 5/34 patients (14.7%) reported minimal incontinence at baseline but did not have at least 1 UUI/day. With regard to the procedure, 73.5% (25/34) of subjects were treated under IV sedation. The median number of ablations was 4 [range 3 -6] and subjects reported a mean post-op pain score of 1.9 out of 10 at 4 hours post-op. At 12 weeks, 59.4% of subjects reported improvement via the Treatment Benefit Scale (TBS) with a mean decrease of -1.7 voids/day, -2.3 urgency episodes/day and 0.6 UUI/day. Improvement continued to 12 months with subjects reporting a 65.5% improvement in the TBS and mean decrease of -2.4 voids/day, -4.2 urgency episodes/day and -1.3 UUI/day each with a significant p-value of <0.001 by paired t-test. The mean PVR of 29.7ml, range [0-121ml] had decreased by 47.1% at 12 weeks, 40.4% at 6mo and 36.0% at 12 months. The 25 subjects with urgency urinary incontinence (>1 UUI) at baseline also improved by similar margins in voids/day of -1.8 and urgency episodes/day of -3.0 at 12 weeks along with a decrease in UUI daily episodes of -0.9. Improvement via TBS of 52.2% was also reported and maintained out to 12 months at 59.1%. Four subjects (11.8%) developed a UTI within 12 weeks of procedure and one retention was reported (2.9%) that resolved within 2 days without sequela. Three subjects (8.8%) had an increase in LUTS and two (5.9%) reported dysuria all of which resolved within seven days of procedure. Two serious adverse events were reported, both were musculoskeletal in nature and unrelated to OAB or the urinary system.

Fulguration of the trigone via RF ablation shows significant improvement in OAB symptoms. In particular, the reductions of voids/day and urgency episodes/day appear consistent with outcomes of other OAB therapies and have maintenance of improvement through 12 months. This can be seen in both analysis groups; all subjects and urgency urinary incontinent subjects. Additionally, the treatment benefit scale data supports improvement of symptoms as well. While modest improvement in urgency urinary incontinence was seen, the magnitude of efficacy was less than anticipated as compared to other OAB therapies. While the rationale for this is not completely understood, it is theorized that the ablation size and/or depth was not substantial enough to fully efface the nerves necessary for disruption of incontinence signals. Safety events were as expected for this population and treatment modality considering the transurethral delivery.

Concluding message This early data documents minimal adverse effects and suggests safety of this innovative treatment. RF fulguration beneath the bladder mucosa, via ablation of the trigone, provides significant improvement in OAB symptoms. Additionally, the possibility of longer term durability of treatment effect, especially in patients with urgency urinary incontinence is encouraging. Additional studies are needed to confirm these early results. 

Hypothesis / aims of study A recent pilot RCT(1) comparing PTNS to SNS within the faecal incontinence cohort deduced that adequately powered RCT's examining these treatments are probably not feasible. Therefore a less robust design is used to explore similar themes within the female OAB cohort allowing easy accrual of large numbers. NICE (2) call for further research into comparative effectiveness of SNS and PTNS. This is the first comparative study within the female OAB cohort so a null hypothesis is utilised: H0 There is no difference in the effectiveness of SNS versus PTNS test phase in reducing OAB symptoms in adult females.

The aims of this study are:

1. Utilise local audit data to generate a pilot study evaluating which treatment test phase is most effective at reducing OAB symptoms for adult females. 2. Examine whether a multi site study woule be useful to validate the results from the pilot.

This is a quantitative non-randomised control group before and after trial involving two groups, PTNS and SNS. This retrospective audit of baseline and post bladder diary data for all patients who underwent PTNS or SNS test phase for symptoms of overactive bladder was undertaken at a single NHS site. The SNS service was commenced in August 2010, the PTNS service commenced in October 2011. All patients with completed pre and post test bladder diary data up until October 2016 were included. This led to a population of 24 participants within the PTNS treatment group and 50 within the SNS group (Power 80% 5% sig level). Baseline characteristics were compared utilising t test and Mann Whitney U to establish the groups were similar. Data was not normally distributed so non parametric tests were utilised for analysis. Overall response rates were calculated for both groups following the criteria that a responder ≥50% reduction in at least one troublesome symptom from the bladder diary. The number of responsive symptoms were then calculated for each treatment group. Symptoms were analysed assessing if there is a higher response rate to a particular mode of treatment utilising chi square. Percentage reduction of symptoms were analysed and assessed for significance utilising Mann Whitney U test and symptoms were ranked from most responsive to least responsive based on response rate and percentage reduction in symptom severity, looking for patterns within both treatment groups. Methods, definitions and units conform to the standards recommended by the International Continence Society and the International Urogynecological Association.

There were no significant differences between the groups regarding age or baseline symptom severity for incontinence, urgency, frequency or nocturia. The overall responder rate for PTNS was 54.2% (N=13) and SNS 86% (N=43). SNS had a significantly higher responder rate when analysed using chi square test (ᵡ 2 (1)=8.927 P=0.003). SNS had the most participants who responded (≥50% reduction) in more than one symptom indicating a larger overall response (see table 1 ). SNS treatment effect is significantly bigger than PTNS treatment in three out of four OAB symptoms. Frequency, ᵡ 2 (1)=6.983, P=0.08, Urgency , ᵡ 2 (1)= 16.331, P=<0.001, Incontinence , ᵡ 2 (1)=10.8, P=0.001. Nocturia was the only symptom where the difference was not significant (ᵡ 2 (1)= 0.922, P=0.337). Percentage reduction in symptom severity showed a significant difference between the efficacy of PTNS and SNS treatments for symptoms of frequency (P=0.02), urgency (P=0.002) and nocturia (P=0.031) Results for symptoms of incontinence were not statistically significant (P=0.261). Symptoms were ranked from most responsive to least responsive based on overall responders (table 2) and percentage reduction in symptoms (table 3) . This suggests that incontinence and urgency symptoms are most amenable to neuromodulation treatments.

Interpretation of results Within this study the hypothesis under test is refuted, there is a significant difference in the effectiveness of the two treatments. SNS test phase is statistically more effective at treating OAB symptoms in females than PTNS. This is identified by analysing the data in a number of ways. SNS has a significantly higher overall responder rate, it also has a higher responder rate within more OAB symptoms and has the greater percentage reduction of symptoms than PTNS. This study has generated new evidence within this cohort. However findings should be viewed with caution due to the studies retrospective design, lack of randomisation and small sample size. Findings from this pilot study may justify further evaluation as NICE (2) recommend further research into the effectiveness and long term effectiveness of third line management for OAB sufferers. A multi site study utilising a similar design would represent a way to collate large data sets that can be easily accessed and data is likely to be already available at sites that provide either treatment for their patients. Study limitations: This study does not take into account why patients are offered PTNS rather than SNS. These cohorts are likely to have different baseline characteristics, not examined within this study, which may introduce bias in favour of SNS treatment. If a future multi site study is undertaken additional baseline characteristic data including co morbidities, patient mobility status, and cognitive ability should be analysed as these factors are likely to influence clinician and patient treatment choice and treatment outcomes. The ability to compare these results to other studies examining effectiveness for either treatment is poor. This is due to a lack of standardisation regarding treatment protocols, procedures and outcome measures within both treatments.

Concluding message This study has generated new evidence about the effectiveness of SNS and PTNS treatments. Both treatments are effective however SNS is statistically more effective than PTNS at treating OAB in females. The study design and limited resources have restricted the validity of its findings. This pilot study has been useful and if recommendations are put into practice, a collaborative multi site study, accounting for differences in baseline characteristics, may yield more valid results. 

Hypothesis / aims of study Running is a popular sport and recreation activity with diverse benefits for the individual health. Yet many women reduce their participation in such sports activities because of the embarrassing condition of stress urinary incontinence (SUI) (1) . A high prevalence of 41% has been found in female elite athletes (2) with the highest prevalence in sports involving impact activities. Up to now the main focus of research on pelvic floor muscle (PFM) function has been on voluntary and concentric contractions. Nevertheless many activities of daily life that typically elicit SUI such as running require involuntary and fast reflexive PFM contractions. Data about reflex activity and contraction characteristics of the PFMs during impact loading are still inadequate. High PFM EMGactivation during running in young continent female subjects has been demonstrated in one study (3) . The aim of this study was to investigate and compare pelvic floor muscle activity in continent and incontinent women in a wider age band during running at three different speeds and thereby elucidate contraction characteristics of the pelvic floor during impact. Study design, materials and methods A cross-sectional, exploratory design was applied and a sample of 50 women between 18 and 60 years was recruited. Screening for inclusion was performed by an urogynaecologist and SUI was diagnosed according to the ICIQ-UIsf questionnaire. Surface electromyographic (EMG) activity from the PFMs during running on a treadmill was recorded with a vaginal probe, bandpass filtered (20-500 Hz) and computed by RMS-algorithm. EMG was measured during 10 seconds at the speeds 7, 11 and 15 km/h. Data from 30 ms before to 150 ms after heel-strike were RMS-parameterised to time intervals of 30 ms. The reference value set as 100% for EMG normalisation was calculated as the mean of the peak values of activity during two maximum voluntary contractions (MVC). The EMG activity onset threshold (ON) was considered as the mean plus two standard deviations of the filtered and rectified EMG during the 30 seconds rest.

Twenty-two incontinent (SUI, mean age 38.7±10.0) and twenty-eight continent (CON, mean age 45.3±9.5) women were included in this study. No statistically significant differences between continent and incontinent subjects could be found for the EMG values for all time intervals. Mean EMG pre-activity and reflex activity increased significantly with speed ( Figure 1 ). Values for running at 7 km/h ranged from 46.2 to 92.0 %MVC, from 55.7 to107.5 %MVC at 11 km/h and from 80.8 to151.8 %MVC at 15 km/h. ON values were calculated between 37.3 and 40.6 %MVC. Mean EMG activity of the 6 time intervals was significantly superior to PFM onset activation at all speeds. At the highest speed of 15 km/h values in women with SUI exceeded 100 %MVC for all time intervals.

Interpretation of results Running appears to trigger pre-activation before and reflex-activation after heel-strike with no statistical differences between the groups. The PFMs where always active during running related to the onset threshold. PFM activity increased with speed which may be explained by rising ground reaction forces and associated higher demand on muscles.

The health benefits of physical activity (which can also include running) are evident. Yet female athletes are inclined to reduce physical activity due to the embarrassing condition of SUI. Maybe women even with SUI should -besides PFM training -be encouraged to continue participation in recreational and regular fitness activities. Running-like stimuli (e.g. a few steps) should therefore not only be regarded with caution due to its contribution to the manifestation of SUI, but also more positively as a potential training stimulus, leading to reflex activity of the PFMs. Running training stimuli may serve as a beneficial complement to a PFM training rationale, leading to reflex activity of the PFMspelvic floor muscles, when used in sense of power training methodology.

Means and standard deviations of PFM activity during running at three different speeds for continent (CON) and incontinent (SUI) subjects. The horizontal black dashed line at 100% represents EMG activity during MVC in standing. The horizontal grey dashed lines represent EMG onset of activity (ON) for CON and SUI.

Hypothesis / aims of study There are no effective oral therapies available in the US for women with stress urinary incontinence (SUI). The pelvic floor and urinary sphincter are androgen receptor (AR) rich and can be modulated by androgenic agents. GTx−024 is a novel selective AR modulator (SARM) that has been shown to be well tolerated in clinical trials of more than 1,500 patients for other disease processes. The purpose of this pilot study is to assess the efficacy and safety of GTx−024 for the management of SUI.

Study design, materials and methods In this Phase 2 study, 3 mg of GTx−024 was given daily for 12 weeks to post−menopausal women. Inclusion criteria were predominant SUI, SUI symptoms for ≥ 6 months, 24 hour pad weights >3 grams, 3−15 SUI episodes per day averaged over three days, and a positive bladder stress test. The primary endpoint is the number of stress incontinence episodes per day on the 3day voiding diary. Secondary endpoints include: pad weights, bladder stress test, and quality of life instruments including the Female Sexual Function Index (FSFI) and Patient Global Impression of improvement (PGI-I).

This study is ongoing and the preliminary findings are presented on the first seven patients completing 12 weeks of treatment. Mean stress leaks decreased by 80.9% (Figure) and all patients saw at least a 65% reduction in leaking episodes. Stress leaks decreased from a mean number per day of 5.7 at baseline, to 1.1 at 12 weeks. Patients are being followed for durability of response post treatment and are demonstrating continued improvement up to 5 months. Patients pad weights decreased from a mean of 29.6 g at baseline, to 13.9 g at 12 weeks. FSFI scores increased from a mean of 16.8 at baseline, to 20.3 at 12 weeks, with 5/7 patients showing improvement. In all seven patients, PGI-I scores were improved at 12 weeks. Adverse events were minimal with none above a Grade I.

Both animal and human studies have demonstrated that a Selective Androgen Receptor Modulator can result in enhancement of muscle mass. The pelvic floor muscles are rich in androgen-receptors {1}. The role of the pelvic floor in maintaining the continence mechanism in women has been well established and is the basis of Kegel exercises and pelvic floor physical therapy. The integrity of the pelvic muscle support can be compromised by physical insults such as vaginal childbirth, atrophy associated with aging and changes in the hormone milleu. This is the first study to assess the role of a SARM in the management of SUI. The early results of this study showed an excellent safety profile with a profound effect on reducing incontinence episodes per day, improving quality of life and enhancing female sexual function. Interestingly, the improvements in symptom were sustained well beyond stopping the study drug. Although the results have been very impressive in this pilot study, the small sample size is a recognized limitation. A placebo-controlled trial is in development to further study the effect of GTx-024 in SUI.

Concluding message These early results suggest GTx−024 substantially improves stress incontinence in women with associated reductions in pad weight and improvements in quality of life measurements. The safety profile has been excellent. Additional patients will be studied as part of this ongoing study.

Hypothesis / aims of study Most treatment algorithms for lower urinary tract symptoms (LUTS) begin with an assessment of patient bother. If the patient is not bothered, only reassurance and follow-up are advised. The assumption behind this recommendation is that 1) if the symptoms are not bothersome, the underlying condition is not serious enough to warrant further investigation; 2) the worse the symptoms, the greater a patient will be bothered by those symptoms; and 3) the worse the symptoms, the greater the severity of the underlying condition. The aim of this study is to analyse the correlations between bother scores on LUTS questionnaires in order to determine the extent to which these hypotheses are true.

Study design, materials and methods This is an IRB approved retrospective multicenter study of women referred for LUTS who completed the LUTS score (LUTSS) on a mobile app or website. Contemporaneous uroflow (Q) & post-void residual (PVR) were obtained. Spearman's correlations were calculated between the LUTSS bother score and the LUTSS sub-scores, Q and PVR. Patients completed the LUTSS on a mobile app or website and the results appeared on the doctor portal (figure 1). Figure 1 : The total LUTSS and 5 sub-scores are color coded to represent normal (green), moderate (orange), and severe (red) symptoms.

Results 1189 patients completed the LUTSS; 436 females and 753 males aged 13 -99 years (mean 59 years, SD of 18). Of the 436 females, the correlation between the total LUTSS vs. bother score was strong (0.65), while the correlation between the total AUASS vs. bother was moderate (0.42). There was also a strong correlation between the storage and OAB sub-scores vs. bother (0.54, 0.53 respectively) and a moderate correlation between the voiding sub-score vs. bother (0.40). There was a weak correlation between the incontinence and nocturia sub-scores vs. bother (0.35, 0.33) . However, the box and whisker plot shows wide overlap between symptom severity and bother (plot 1). The correlation between Q, PVR vs. bother was very weak ( Table  1) .

Although there was a strong correlation between symptom severity as measured by the total LUTSS, storage and OAB subscores, there was considerable overlap; some patients with few symptoms had severe bother and some patients with severe symptoms had little or no bother. The correlation was weak or moderate between bother and voiding dysfunction, incontinence, and nocturia. These data suggest that patients are much more bothered by OAB than voiding symptoms, incontinence, or nocturia. Most importantly, though, there was no correlation at all between bother and either Q or PVR. In fact, 8% of patients with no bother at all had PVR > 200 mL and 25% had Q < 11mL. This is most disconcerting, insofar as, if one uses bother as a criteria for pursuing a workup or treatment for LUTS, serious conditions may be overlooked.

The correlation between patient bother, symptom severity, and severity of the underlying LUT condition is inexact. Some patients with severe bother have few symptoms; others with little bother have moderate symptoms. The poor correlation between bother, Q & PVR suggests that patients may have severe underlying conditions like urethral obstruction that might be misdiagnosed if one relies on bother to pursue a diagnostic evaluation. The hypothesis that bother should drive the diagnostic evaluation in patients with LUTS should be reconsidered.

Plot 1: Box plot of LUTSS total score by LUTSS bother sub-score. Boxes show interquartile range and median; whisker ranges by Tukey method. 1 (8%) 1 (5%) 1 (4%) 0 (0%) 0 (0%) 300-399 0 (0%) 3 (15%) 0 (0%) 0 (0%) 0 (0%) >400 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 

Hypothesis / aims of study The pubovisceral enthesis is classified as the connective tissue between levator ani tendon/ligament and the pubic bone (Kim J et al, 2011) .The imaging finding of hypoechogenicity of the pubovisceral attachment of the pelvic floor has been thought to be due to the literal detachment of the pubovisceral enthesis and has been termed an 'avulsion'. Some groups have suggested (Da Silva et al, 2016) that this imaging finding is not a true anatomical detachment of the pubovisceral muscle from the pelvic sidewall. This study aims to identify whether there is a histopathological difference in the tissue composition in cadavers with or without the levator ani detachment imaging finding.

Study design, materials and methods Female cadavers were imaged using 3D-translabial ultrasound using a GE Voluson I with a 5-9MHz electronic probe. The presence or absence of an hypoechogenicity of the pubovisceral attachment was identified in accordance with previous described methodology (Dietz et al, 2011) . A separate observer, blinded to the USS findings, meticulously dissected each cadaver to visualise the pubovisceral enthesis. The pubovisceral enthesis was excised for further histochemical processing. Samples were stained with Haematoxylin and Eosin and Masson's Trichrome according to standard procedures. Slides were randomly sectioned into three with each enthesis being considered independently and digitally scanned. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic pubovisceral enthesis hypoechogenicity by a blinded observer. The percentage of collagen and muscle was calculated for each sample. The results were analysed using SPSS v24, IBM, USA.

Fourteen cadavers were imaged, totalling twenty-eight pubovisceral samples. Incomplete data was available for three samples (one missing USS image, two lacking histology specimens). Sonographic pubovisceral enthesis hypoechogenicity was seen in four cadavers (30.1%); the defect was bilateral in 1/13 (7.7%) and unilateral in 3/13 (23.1%). No macroscopic anatomical detachment of the puboviseral muscle was seen in any cadaver. ImageJ quantification of Masson's Trichrome stain identified the proportion of muscle to collagen as 38. 8% Table 2 : Histological composition of the enthesis tissue using a Masson Trichrome stain in cadavers with ultrasound avulsion detected on 3D translabial ultrasound (n=5)

Interpretation of results In this study, there was no evidence of a microscopic tissue avulsion associated with an ultrasound avulsion. The tissue composition relating to the proportion of muscle versus collagen was not significantly different in specimens with or without sonographic pubovisceral enthesis hypoechogenicity (avulsion). The pathophysiology of the sonographic pubovisceral enthesis still remains unknown.

Hypothesis / aims of study: Most women, who suffer from POP, and desire treatment, can be successfully managed with non-invasive management. Currently, this involves using vaginal pessaries, mainly ring-shaped. Existing pessaries are reusable only devices which require medical assistance for insertion and removal, are used for long periods and are associated with discomfort, pain, bleeding, vaginal wall pressure trauma, discharge and smell. A new disposable vaginal device for the management of POP was developed. The device is inserted vaginally in very small dimensions within an applicator, by the user herself, at her home environment. Within the vagina the device opens to become a ring of up to 91 mm (various sizes). Following insertion, the applicator is removed and discarded and the device may remain within the vagina for up to seven days, when the user pulls a string and the device collapses and is comfortably removed from the vagina in small dimensions, for disposal. The user may insert the next device immediately or later, at her will. The aim of the study was to evaluate effectiveness (objective & subjective) and safety of the new disposable vaginal device, when used as intended by the user herself at her home environment.

The study was prospective, multi clinic, single arm, open label, hypothesis driven and statistically powered, home use performance study. Screening was conducted during visits 1&2. Following size fitting in visit 2, subjects were sent home with the device in situ for 40-80 hours to ascertain proper fit, and seen again during visit 3. Device usage period started following visit 3 and lasted 45 days, through visit 5. During that time subjects were allowed to use as many devices as they wished, for a period of 1-7 days each, to suit their needs and life style. Subjects were also examined during mid-study visit (4) , about 2 weeks following visit 3. They were examined vaginally within each of the visits, with the device in situ (visits 2-5), to assess prolapse reduction & integrity of vaginal walls. During the device usage period, subjects had to fill out a diary, denoting each device's usage length, functionality and adverse events. Findings and results from visits 1 and 5 were compared, including POP symptom scores & QoL questionnaires. Four almost identical device models were tested sequentially along 3 identical parts of the study (parts A, B, C), where part C was the pivotal study, using the final finished version of the device. Statistical analysis was done on results from both the pivotal study (part C only) and all parts (pooled analysis, parts A, B & C). The 1 st performance endpoint was the percentage of subjects with an improvement from baseline of at least 1 POP-Q stage.

Results 52 subjects completed the study in 3 clinics. 24 completed one part of the study, 14 completed 2 parts, and 14 used the device during 3 parts, altogether 94 usage cycles in which 1556 devices were used over 3530 usage days, an average of 36.1±5.70 days per subject (pooled analysis, parts A, B & C, 94 usage cycles). 41/52 subjects took part in the pivotal study (part C only, 41 usage cycles) where they used 591 devices over 1556 usage days, an average of 37±5.3 usage days per subject. Mean age was 60.4 , mean BMI was 25.8, and 81.1% of the subjects were postmenopausal.

In the pooled analysis population, 66 subjects (70.2%) had POP-Q stage 3 prolapse, while 28 (29.8%) had POP-Q stage 2 prolapse, at study start. At visit 5, 90 subjects (97.8%) had complete reduction of the prolapse (stage 0), while 2 subjects (2.2%) had POP-Q stage 1 prolapse. Objective assessment showed that 100% of subjects had 2 POP-Q stages reduction while using the device and 97% of subjects with stage 3 prolapse (64/66) had 3 stages reduction (p<0.0001). Subjective assessment of POP related symptoms (Figure 1 ) was carried out using an author compiled symptom scoring system which showed mean improvement from 29 (V1) to 2.7 (V5) (P<0.0001). Modified PFIQ-20 QoL questionnaire showed significant improvement in QoL, from score of 33.6 to 5.1 (p<0.0001), and modified PFIQ-7 showed improvement from 24.9 to 0.7 (p<0.0001).

Overall, within the pooled analysis group, there were 91 device related adverse events (AE's) which were recorded daily in a diary, and all recovered. There were no serious AE's, most AE's were mild (98.9%), of short duration and anticipated (87.9%), and included mainly spotting, discomfort and some pain. 62 AE's occurred during part A, 8 during part B and 21 during part C. Most adverse events occurred within 7 days from study start, and before using the first 5 devices (learning curve). There were no cases of vaginal infections, and there was only one case of urinary infection. Satisfaction rate by users was high and most users considered the device as easy to use. Figure 1 -Subjective assessment of POP related symptoms, before and while using the device (author compiled symptom scoring system, 3530 usage days, 1556 devices (P<0.0001)).

All study endpoints were met successfully. Reduction of at least 2 POP-Q stages was demonstrated in all 100% of subjects, but more importantly -alleviation of POP symptoms was significant (Fig 1) , with significant improve in QoL. Any vaginal device is expected to cause some discomfort, spotting or pain, during initial usage, mainly in postmenopausal women. Therefore, these AE's, specifically when daily recorded (as compared to questioning only at study-end) exhibit very low level of mild complaints.

Concluding message This new disposable vaginal device for the management of POP was found to be efficacious (with significant objective prolapse reduction and subjective relief of POP symptoms) and safe for use, with minimal mild and anticipated AE's. 

Hypothesis / aims of study The aetiology of Pelvic organ prolapse (POP) is shown to be multifactorial with heritage (1), increasing age and parity (2) to be the most consistent risk factors. Finding that parous women have a higher prevalence of POP compared to nulliparous women has led to the perception that POP is a long term effect of an injury acquired during vaginal childbirth. This hypothesis has been supported by the discovery of major injuries to the levator ani muscle (LAM) occurring in one third of women with anatomic POP (aPOP), and exclusively occurring after vaginal deliveries (3) . However, the fact that most women who deliver vaginally will not develop aPOP, that most women with aPOP does not have major LAM injuries, and that caesarean delivery is not fully protective for the development of POP indicate that we are still far from understanding the complex aetiology of POP and how childbearing interacts with the pelvic floor.

The aim of the present study was to identify risk factors for postpartum aPOP by comparing women with and without aPOP at six weeks postpartum with respect to pelvic floor measurements antepartum and obstetrical characteristics.

The present study is part of a prospective observational cohort study aiming at describing the pelvic floor from mid pregnancy until one year postpartum in a cohort of first time mothers. Data already presented from this cohort has shown that pelvic organ support changed both during pregnancy and following delivery, and that aPOP defined as pelvic organ prolapse quantification system (POP-Q) stage ≥ 2 had a peak prevalence of 9% at six weeks postpartum.

Nulliparous pregnant women with singleton pregnancies were followed from mid pregnancy to six weeks postpartum with repeat clinical examinations including POP-Q and transperineal three dimensional ultrasound. Background and obstetrical information was obtained from an electronic questionnaire and from the patient's electronic medical file respectively. Associations were estimated using logistic regression analyses where the dependent variable was aPOP defined as POP-Q stage ≥ 2 at six weeks postpartum, and the independent variables were mid pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at six weeks postpartum.

Of the 300 nulliparous pregnant women included in the cohort at mid pregnancy, 284 women had POP-Q data available for analyses at six weeks postpartum. These 284 women constitute our study sample. At the first visit the mean gestational age of pregnancy was 21.0 weeks (SD1.4), mean maternal age was 28.7 years (SD 4.3), and mean maternal body mass index (BMI) was 25.8 kg/m 2 (SD 3.9). At delivery mean gestational age was 40.1 weeks (SD1.5), and mean foetal birth weight was 3497 grams (SD 508). 196 women (69%) had normal vaginal delivery, 41 women (14%) had vacuum delivery and 4 women (1%) had forceps or combined vacuum and forceps delivery. 76 women (27%) had mediolateral episiotomy. 21 women (7%) had prelabour caesarean delivery, and 22 women (8%) had intralabour caesarean delivery (cervical dilatation≥3 cm) At the follow-up at 6.2 weeks postpartum (SD 1.1), 25 women (9%) had aPOP, all stage 2 prolapses, whereof 22 had anterior prolapse and 3 had posterior prolapse, and major LAM injuries were diagnosed in 46 women (16%).

Comparing women with and without aPOP at six weeks postpartum with independent sample T-test there was no statistically significant difference regarding age, BMI, height, gestational age at birth, foetal birth weight, maternal height/ foetal birth weightratio, or use of mediolateral episiotomy.

A larger LH area at Valsalva, a longer distance from the meatus urethra to anus (Gh+Pb), and a more caudal position of the anterior vaginal wall (Ba) at mid pregnancy, gave increased risk for aPOP at six weeks postpartum, while delivery route and presence of major LAM injuries did not. Adjusting for maternal age and body mass index (BMI) did not alter the results. 

Hypothesis / aims of study Single incision midurethral slings (SIS), such as Miniarc, were introduced to reduce postoperative pain, and improve recovery.

We set out to examine if Miniarc had at least equivalent objective cure rates against Monarc at 60m follow up, as well as comparing their subjective and functional outcomes Study design, materials and methods Women who had SUI or urodynamic stress incontinence (USI) were randomised, in a 1:1 ratio, to receive either Miniarc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, untreated detrusor overactivity or significant voiding dysfunctions were excluded. Assuming an objective cure rate of 85% for Monarc, this RCT was powered (80%) to detect a clinical difference of 15%, and allows for an attrition of 15% with a sample size of 220, using a one sided ₃₃of₃0.05. Computer generated random allocation was concealed and stratified to centre. Surgeons or patients were not blinded once allocation was revealed. Patients were seen at 6w, 6m, 12m, 24m, 36m, 48m and 60m with a clinical examination. Standardised proformas together with validated tools, including ICIQ UI SF, ICIQ OAB, PISQ12, IIQ7, PGII and 24 pad weigh (6m), were used to facilitate prospective collection of data to evaluate objective, subjective and functional outcomes following surgery. Objective cure was defined as negative urodynamic stress or cough stress test (CST) at follow up. Subjective cure was defined as absence of patient reported SUI at follow up. Surgeries were performed, according to manufacturer's instructions, by surgeons who had already performed at least 10 Miniarc, which was tensioned to snug. Urodynamic studies were performed pre operatively and 6m post operatively. Definitions, outcome measures and standardised reporting adhered to IUGA/ICS terminology, IUGA & CONSORT guidelines. Institution ethics approval was obtained and the trial was registered with the ANZCTR. Outcomes were compared with exact binomial tests (eg Fischer exact for dichotomous data) for categorical data and Student t test or exact versions of Wilcoxon test for numerical data as appropriate.

Results 282 women were assessed for eligibility, of which 42 declined participation, 2 indicated a preference to Miniarc (refused randomisation), and 14 were excluded post randomisation (3 did not meet criteria, 10 withdrawn from surgery, 1 unfit). 235 women aged 31-80 (51.6±9.71) received Miniarc (112) or Monarc (113). Median parity was 2 (0-7), mean BMI 27.5±5.6 (15 -47). Baseline characteristics were balanced, with no statistically significant difference between two treatment arms for known confounders, including age, parity, BMI, prior medical history, baseline symptom severity (excluding PGI-S), urodynamic diagnosis, vaginal topography and types of concomitant prolapse surgeries. Monarc patients reported more symptom severity on PGI-S at baseline.

Multivariate logistic regression for confirmed baseline PGI-S or surgeon type did not independently affect final outcome, confirming results of bivariate analysis. Table 1 demonstrated no statistically significant difference in the subjective (absence of SUI) or objective (absence of USI or CST) cure rates between Miniarc and Monarc at 6m, 12m, 24m, 36m, 48m or 60m. Within both Miniarc and Monarc groups, there was a statistically significant improvement from baseline to all 5 time points for ICIQ UI, ICIQ OAB, PISQ12, IIQ7, PGII scores and 24h pad weigh (6m). The ICIQ UI SF score was lower in the Monarc group at 36m, 48m and 60m but the difference was less than the minimally important difference of 5 and not statistically significant. At 12m the Miniarc arm has a lower proportion using antimuscarinics, which was not statistically different at subsequent time points. At 60m, 5 in Miniarc and 4 in Monarc group underwent repeat surgery for SUI (TVT). Two women had repeat surgery 6m after their Miniarc operation, two at 12m and one at 39m. In contrast, two women had repeat surgery 12m after their Monarc operation, one at 24m and one at 36m. There were no sling divisions or excision in both arms. There were two cases of mesh exposure on each arm, one (7mm, excised L Sulcus) in a patient who underwent concurrent anterior compartment mesh repair, another in a patient who underwent Monarc sling (L Sulcus). Interpretation of results There was a reduction in reported subjective cure rates, sustained improvement in patient reported outcomes, including incontinence impact and global impression of improvement across all time points with no statistically significant difference between two treatment arms.

Concluding message Although a reduction in subjective cure rate was observed between both arms across all time points to 60 months, mid to long term results suggest comparable cure rates and functional outcomes between Miniarc and Monarc. 

Hypothesis / aims of study To characterize outcomes following vaginal reconstructive surgery with synthetic mesh augmentation 5-30 years following initial operation Study design, materials and methods This study involved a retrospective chart review along with invitation to participate in a cross-sectional written survey and pelvic examination. Data were collected from medical records, written surveys, and pelvic exams of patients who underwent vaginal surgery for pelvic organ prolapse with synthetic mesh augmentation between 1985 and 2010 at a single academic institution in the United States. Details regarding relevant past medical and surgical history, index surgery performed, intra-and post-operative complications, and relevant subsequent operations were abstracted from electronic and paper medical records. Eligible patients were invited by mail to complete a brief written survey and a focused pelvic exam. The written survey included demographic information, the Pelvic Floor Distress Inventory Short Form (PFDI-20), the Patient Global Impression of Improvement (PGI-I), and questions related to satisfaction and sexual function following the index operation, as well as complications and subsequent surgeries. Those participants who presented for pelvic examination were reimbursed $20 for transportation costs. Descriptive analyses were performed to characterize the sample. The primary outcome of interest was re-operation for mesh-related complication, and logistic regression was used to identify associated factors. Factors associated with mesh-related re-operation on univariate analysis with p-value less than .2 were included in the backward linear regression model. Secondary outcomes of interest included rates of specific mesh-related complications, overall reoperation rate, and current reported satisfaction with the index procedure.

Among 804 potential patients identified, 161 patients were eligible for inclusion, with surgical dates ranging from May 1991 to October 2010. Of those 161 eligible patients, 43 (27%) have returned the written survey so far and 22 (14%) have completed a pelvic examination. Mean age at surgery was 60 years (SD11.6, range 31, 86) and mean BMI was 28.8 kg/m 2 (SD 5.6, range 19.4, 47.2). Seventy-nine percent (127/161) had undergone prior hysterectomy and 56% (90/161) previous prolapse repair. Table  1 describes the mesh placement for the 161 surgeries included in the chart review, of which 146 utilized macroporous, monofilamentous, non-absorbable mesh (type 1) and 9 (6%) involved a mesh kit. Overall, 33/161 (21%) women underwent mesh-related re-operation. Factors associated with re-operation for mesh-related complication are outlined in table 2. The most common indication for re-operation was vaginal mesh extrusion (n=25). The overall rate of mesh-related complication was 32% (52/161); 28% (45/161) had mesh extrusion into the vagina and 1% (2/161) had mesh erosion into the bladder (1) or rectum (1) . Vaginal extrusions were treated with local estrogen (n=11), office excision (n=8), or surgical excision (n=25). (11) .261 Wound complication 3 (9) 7 (6) .442 Perioperative Infection 9 (27) 39 (31) .720 Urinary tract injury 3 (9) 1 (1) .006 Removed

The rate of reoperation overall was 31% (45/161); 33% (15/45) underwent more than one subsequent operation. Common indications for reoperation included mesh-related complication (n=33), subsequent pelvic organ prolapse (n=15), and urinary symptoms (n=9).

Among the 43 questionnaires received thus far, according to the PGI-I, 74% (n=32) are better, 9% (n=4) are the same, and 16% (n=7) are worse. When asked about level of satisfaction with surgery, 42% (18/43) reported being very satisfied, 28% (12/43) somewhat satisfied, 14% (6/43) somewhat unsatisfied, and 16% (7/43) very unsatisfied. Sixty-five percent (28/42) would definitely or probably do it again and 47% (20/43) would recommend it to someone else.

In this sample of 161 women who underwent vaginal reconstructive surgery with synthetic mesh augmentation between 7 and 26 years ago, more than 20% underwent re-operation related to their mesh, mostly for vaginal mesh extrusion, and younger age was associated with higher risk of reoperation on multivariate regression. Overall, almost one third of women underwent subsequent pelvic operation, and one-third of these women underwent more than one subsequent operation. Despite relatively high rates of improvement on the PGI-I, and 65% of women reporting that they would definitely or probably undergo the operation again, fewer than half would recommend it to someone else.

Rates of re-operation following pelvic reconstructive surgery with vaginal mesh placement are high over a time horizon of 25 years, but the majority of women remain satisfied with the operation. The overall reoperation rate may be as high as 30%, with younger women being more likely to undergo subsequent operation. We hope these findings can be used to inform pre-operative counseling of patients considering these procedures about long-term outcomes and risks of complications. 

Hypothesis / aims of study Autologous Muscle Derived Cells for Urinary Sphincter Repair (AMDC-USR) are being investigated as a novel, durable therapy for treatment of stress urinary incontinence (SUI) in women. The technology is an intrasphincteric injection of muscle cells designed to augment sphincter function. Herein, we describe the challenges of progressing from early phase clinical studies to a randomized controlled trial (RCT) and discuss how initial RCT results have influenced the strategic design of current and future studies including 1) selection of clinically meaningful efficacy endpoints based on incontinence episode frequency (IEF) reduction, 2) improved understanding of the estimated placebo rate, and 3) refinement of patient selection criteria to match AMDC-USR's proposed mechanism of action.

Study design, materials and methods Women with predominant SUI who had diary-reported stress IEF of ≥3 leaks over 3 days, ≥3 g 24-hour pad test, and ≥3 g inoffice pad test were enrolled. Patients with recurrent or persistent SUI after incontinence surgery could be included in the study. After muscle biopsy to acquire tissue for AMDC-USR production, patients were randomized 2:1 to receive injection of 150 x 10 6 AMDC-USR or vehicle placebo. Patients were additionally randomized 1:1 to receive 1 or 2 treatments, with second treatment administered approximately 6 months after first treatment. SUI was assessed with 3-day diaries of stress IEF, 24-hour pad tests, in-office pad tests, and Incontinence Quality of Life (IQOL) questionnaires. The primary composite efficacy endpoint was the percentage of patients with ≥50% IEF reduction or ≥50% reduction in either pad test 12 months post-treatment. Patients were unblinded after completing 12-month visits, and placebo patients could opt to receive an open-label injection of AMDC-USR. Patients were followed for 2 years after initial treatment.

Overall . AMDC-USR and placebo groups had similar baseline characteristics and similar rates of adverse events. With the composite endpoint, responder rates for both AMDC-USR and placebo exceeded 80%; therefore, enrollment was halted at 61% (150/246) of the planned study size. To identify alternate, clinically meaningful endpoints, we examined the correlation of IEF reduction with improvement in IQOL scores ( Figure 1 ). Patients with ≥50% IEF reduction had greater IQOL score improvement than patients with <50% IEF reduction, and patients with ≥75% IEF reduction and ≤1 stress leak/3 days displayed even greater IQOL improvement.

With clinically meaningful IEF reduction endpoints, a potential treatment effect was detected at 3, 6, and 12 months for the entire patient cohort ( Figure 2A) and was enhanced for a subgroup of 17 patients (11 AMDC-USR, 6 placebo) with recurrent or persistent SUI after incontinence surgery ( Figure 2B ).

As outlined in the table below, results from our first cell therapy RCT for women with SUI have provided critical data to support the selection of clinically meaningful efficacy endpoints, to estimate placebo response rates, and to refine patient selection criteria for current and future studies.

Concluding message Lessons learned from our first RCT strengthen the design and scientific rigor of current and future AMDC-USR studies. Placebo effects are likely influenced by many variables (e.g., invasiveness of treatment, duration of follow-up, expectations of study population) and understanding their impact on outcome measures is critical to successful development of new treatments. Yet, knowledge of such effects is currently limited for SUI therapies. Likewise, SUI outcome measures must be viewed in terms of their sensitivity to placebo effects, clinical meaningfulness, and regulatory agency acceptance. From data collected in our first RCT, we correlated QOL improvement with diary-reported IEF reduction to identify clinically meaningful endpoints and estimated the placebo response rate for a cell therapy SUI trial with 12-month follow-up. Importantly, IEF reduction is viewed favorably by regulatory agencies as a primary outcome in SUI studies. Our data also suggest that patients with minimal urethral hypermobility (e.g., patients with recurrent or persistent SUI after incontinence surgery) may represent ideal candidates for sphincter augmentation, which aligns with the proposed mechanism of action for AMDC-USR. Future studies will focus on this patient population by excluding patients with notable urethral hypermobility at screening. 

Hypothesis / aims of study Sacral neuromodulation (SNM) is a minimally invasive and effective treatment in patients with overactive bladder syndrome (OAB) or non-obstructive urinary retention (NOR) when conservative treatment fails. A test stimulation (tined lead procedure, TLP) is performed to find out whether adequate symptom reduction is achieved. In centers worldwide the duration of this test stimulation vary considerably and it is not clear when the time of onset of the therapy effect can be expected. The experience in our clinic is that during the test stimulation period for responders it takes up to one week to achieve maximal effect, after the system is turned 'on'. However, no information concerning the so called onset and offset of effect of SNM is available in current literature. The objective of this prospective study is to evaluate the average time span within which "the onset of the effect" occurs in patients with LUTS. Knowledge about time of onset and off set, could have several practical clinical implications. Clinical experience renders clues that this time spans might be different for OAB and NOR patients. This study could lead to insight about the required length of the test stimulation period.

In this prospective study (ClinicalTrials.gov Identifier: NCT02040519) all OAB and NOR patients who were eligible for treatment with SNM were asked to participate. These patients filled out a voiding diary 7 days prior and after test stimulation. When no effect occurred after 7 days, another diary of 7 days was filled out. The transition point between no effect and time of onset is determined by assessing when certain complaints parameters are reduced by 50% compared to baseline per 24 hours. Onset of effect will be assessed in days. The Mann Whitney U test was used to compare the mean time to success between OAB and NOR patients.

In total 45 patients, 24 NOR and 21 OAB agreed and were included. After test stimulation 29 patients (64%) were successful and received an IPG. Seven patients did not fill out the diary completely and were excluded, leaving 22 patients (10 NOR and 12 OAB) to be analysed. Mean age was 46.3 (SD 14.6). In the NOR group, 5 patients were not able to void and were fully depended on self-catheterization. In patients with OAB mean frequency before test stimulation was 11,3 and mean voided volume per void was 135cc. Mean time to success for all patients was 3.3 days (range 1-9). There was no significant difference in mean time to success between OAB and NOR patients (p=0.73, Figure 1 ).

The effect of sacral neuromodulation in successful patients can be expected after a mean of 3.3 days of test stimulation. No differences were seen between OAB and NOR patients.

The results of this prospective study indicate that time of onset of sacral neuromodulation effect in both OAB and NOR patients can be expected in the first two weeks of test stimulation. This implicates that a TLP test stimulation of more than two weeks, is not necessary. Besides the patient's overall comfort and well-being, a shorter duration of the test period could reduce lead infections. 

Hypothesis / aims of study Bladder urothelium serves as the first line of host defense against uropathogens and drives subsequent innate immune response. We have previously reported: (1) Presence of large conductance voltage-gated calcium-activated potassium (BK) channel in bladder urothelial cells in vitro [1] ; (2) Significant increase in BK activity in vitro with exposure to lipopolysaccharide (LPS), surrogate for uropathogenic gram-negative bacteria [1] ; (3) Release of granulocyte-macrophage colony-stimulating factor (GM-CSF) in vitro in response to LPS [2] . Based on these findings, we hypothesize that LPS-induced increase in urothelial BK channel activity regulates downstream urinary cytokine release. In this study, we test this hypothesis in vivo using pretreatment of mice with intravesical iberiotoxin (IBTX), a BK-specific blocker, to determine (1) whether IBTX blocks LPS-induced urinary cytokine release and (2) whether induction and inhibition of urinary cytokine release occur at the level of urothelium.

Study design, materials and methods Using 12-week-old female C57BL/6 mice in our murine model, treatment (Figure 1 ) consisted of transurethral instillation of 150 µL of LPS (1 mg/mL in phosphate buffered saline, PBS) with or without IBTX (1 µM), following priming exposure to PBS or IBTX (1 µM in PBS). Instillation lasted 30 minutes under anesthesia, followed by activity ad lib in cage and urine collection within two hours. Prior to priming exposure and LPS treatment, mice underwent instillation with PBS or IBTX and urine collection within two hours to establish basal cytokine release for comparison with subsequent LPS treatment. Urine specimens were analyzed for levels of 32 cytokines using multiplex enzyme-linked immunosorbent assay (ELISA). Bladders were harvested from mice in each treatment group within two hours of LPS instillation, and urothelium was isolated from bladder mucosa using our unique dissection technique [3] , followed by extraction of urothelial ribonucleic acid (RNA), reverse transcription (RT), and quantitative polymerase chain reaction (qPCR) using primers for cytokines of interest.

Of the 32 cytokines surveyed, LPS significantly increased urinary concentrations of 19 cytokines in our murine model: Eotaxin, G-CSF, GM-CSF, IL-1α, IL-4, IL-5, IL-6, IL-15, IP-10, KC, LIF, MCP-1, M-CSF, MIG, MIP-1α, MIP-1β, MIP-2, RANTES, TNFα. Of these 19 cytokines, 15 showed significant reduction in urinary concentrations with pre-treatment with IBTX ( Figure 2 ).

Urothelial RNA expression of four select cytokines showed that LPS-induced increases in expression were significantly inhibited by pre-treatment with IBTX ( Figure 3 ).

Blockage of BK channel significantly inhibited LPS-induced increases in urinary concentrations of 15 of 19 cytokines surveyed. Transcript analyses of expression by dissected bladder urothelium for a sample of four cytokines demonstrated that urothelium was the source of these urinary cytokines induced by LPS and inhibited by IBTX.

Concluding message This is the first in vivo proof-of-concept demonstration that urothelial BK channel regulates urothelial innate immune response to uropathogens. Future treatment strategies for urinary tract infection may leverage this newly evidenced mechanism. , a BK-specific blocker, followed by urine collection within two hours. Treatment with LPS is preceded by priming (orange) exposure to phosphate buffered saline (PBS) or IBTX. Prior to priming exposure and LPS treatment, baseline (blue) is established using instillation with PBS or IBTX followed by urine collection with two hours.

Scatter plot with median cytokine concentration for urine specimens collected from mice (n = 5-9) in each treatment group. Each data point corresponds to an individual mouse. Asterisks indicate statistical significance (* for p < 0.05, ** for p < 0.01, and *** for p < 0.001) on one-tailed Mann-Whitney test.  Best in Category Prize -Geriatrics / Gerontology 30 Shaw 

Hypothesis / aims of study Urinary incontinence (UI) is increasingly common in later life. For many women UI is seen as a normal part of growing older. This attitude may serve to "normalise" the condition in older women and make the well-described delays in treatment seeking more likely. Severity of incontinence, younger age and a greater severity of disease experience are known to influence the likelihood of seeking help, but in a large community study, only 15.3% of people >60 years of age with incontinence expressed a "felt need" for healthcare [1, 2] . The aim of this study was to describe the distribution of UI, including type, frequency and impact on quality of life and likelihood of having sought help, in a large cohort of Canadian community dwelling older women. The relationship of the belief that UI is normal for aging with frequency of urine leakage, pad use, quality of life and help-seeking behaviour was examined and analysed Study design, materials and methods This was a secondary analysis of data collected as part of a large randomised controlled trial which evaluated whether continence promotion and self-management improved HRQoL in community dwelling older women. This study used baseline data from all women who signed consent for data collection and who were both eligible and ineligible for participation in the primary study. Collected data included validated assessments of overall health, physical activity, frequency of incontinence using the ICIQ-FLUTS scale, incontinence subtype (urgency, stress, mixed, other, help-seeking behaviour, and quality of life using the Incontinence Quality of Life (I-QOL) and Short Form 12 (SF-12) questionnaires. Data were analysed in STATA version 12.1 to describe the characteristics of the sample, the distribution of LUTS / UI, UI severity and quality of life. The relationship between symptom severity and QoL were examined using correlations and compared to women without LUTS / UI using unpaired t-tests. Multivariable logistic regression analyses described the relationships between diagnosis, severity and impact on HRQoL using the belief that UI is normal for ageing as the dependent variable.

The overall sample included 4446 women, with a mean (SD) age of 78.23 (8.99) and mean (SD) BMI of 26.55 (5.55). Women without incontinence numbered 2424 (54.52%). Of those 2022 (45.48%) with UI, 729 (16.4%) had a diagnosis of stress UI, 453 (10.19%) urgency UI, and 840 (18.89%) mixed incontinence symptoms. Women who contributed greater ≥19 responses to the I-QOL questionnaire, n=3579, were included in this analysis. The average (SD) IQOL score was 84.68 (19) /100. 2149 (68.56%) women believed that urinary incontinence is normal for ageing. Incontinence diagnosis (stress, urgency, or mixed UI) was significantly associated with BMI (adjusted relative risk ratios: stress 1.03, p <0.001; urgency 1.04, p <0.001; mixed 1.07, p <0.001), but not age (adjusted relative risk ratios: stress 0.98, p<0.001; urgency 1.00, p=0.501; mixed 1.00, p=0.635). Quality of life was statistically significantly decreased with increasing frequency of urine leakage (adjusted regression coefficients: once or less per week -3.51, p <0.001; 2-3 times per week -8.56, p <0.001; once per day -11.24, p <0.001; several times per day -22.67; p <0.001). All types of UI were associated with a decrease in IQOL score: stress incontinence (adjusted regression coefficients: -3.18, p <0.001), followed by urgency UI (-5.44 , p <0.001), and mixed UI (-14.46, p <0.001). Two or more urinations per night was statistically significantly associated with decreased quality of life (adjusted regression coefficients: 2 per night -3.23, p <0.001; 3 per night -7.86, p <0.001, 4 or more -15.94).

Adj OR (95% CI) p-value Table 1 . Multivariable logistic regression exploring the association between the belief that urinary incontinence is normal for aging with frequency of UI episodes and number of pads used.

There was no statistically significant association between the belief that incontinence is normal for ageing and incontinence sub type (χ 2 =1.35, df=5, p=0.50). However, women who believe that incontinence is normal for aging had a more impaired) QoL than those who did not (mean (SD) 83.9 (19.4) v 87.4 (18.6) (p<0.00001)).

For these older community dwelling women, urinary incontinence had a significant demonstrable impact on QoL, as expected. In this cohort, urgency incontinence did not demonstrate a more severe impact than the other subtypes. More than two-thirds of these women believed that incontinence is normal for ageing. This belief had no association with age, or perception of overall health, despite the expectation that older, sicker women may be more likely to hold this belief. Women who thought incontinence to be normal for aging were also more likely to have up to twice daily incontinence episodes and use up to two pads daily; more severe incontinence and greater quantities of pad use did not make women less likely to hold this belief. In contrast, women who held this belief were less likely to have either performed previous pelvic floor exercises or sought health care, although not statistically significantly so. There was no association between the belief that UI is normal for aging and UI subtype, it was anticipated that women may be more likely to suffer stress incontinence, as women may associate this with an expected consequence of childbirth. Compared to those women who think incontinence isn't normal for ageing, women who think incontinence is normal for aging experience a significantly worse impact of UI on QoL. Attitudes to UI in women are recognised as a barrier to healthcare seeking, this may be amenable to awareness raising amongst older community dwelling women.

Concluding message Despite being associated with a worse impact on quality of life, the belief that incontinence is normal for ageing is not affected by incontinence severity, pad use, or underlying diagnosis. 

Hypothesis / aims of study It is well recognized that serotonin (5HT) pathways in the central nervous system (CNS) play an important role in the control of bladder and urethral function (1) . In contrast, the role of 5HT at the periphery is less well characterized. However, cells expressing 5HT have been described in the urethral epithelium of several mammals, including humans (2) suggesting that locally released 5HT may also influence urethral and bladder function through a paracrine mechanism. However, this hypothetical role has never been extensively investigated, neither in normal nor in pathological conditions. Hypothesis: To describe the distribution of 5HT cells in the lower urinary tract of normal and inflamed rats as well as the functional effect of exogenous 5-HT administration during continuous cystometry.

Study design, materials and methods All experimental procedures were carried out according to the European Community Directives and ARRIVE guidelines. Female Wistar rats (n=24) were used and divided in two groups. The first group received an intravesical instillation of 0,5 ml of lipopolysaccharide (LPS; 2mg/ml) for one hour to induce lower urinary tract inflammation. The LPS solution was replaced 30 minutes after the beginning of instillation to avoid dilution with urine. The second group received intravesical instillation of saline and served as controls. Twenty-four hours after LPS or saline instillation 16 animals (8 saline; 8 LPS) were sacrificed, bladder and urethra were collected and processed for immunohistochemistry or 5-HT quantification by HPLC. For immunohistochemistry, antibodies against 5-HT, the pan-neuronal marker β3-Tubulin, calcitonin gene-related peptide (CGRP), vesicular acetylcholine transporter (VAChT), synaptic vesicle 2 (SV2) and tryptophan hydroxylase (TPH) were used. The number of cells expressing 5-HT was quantified and averaged in at least 5 sagital slices per animal. The total amount of 5-HT in the entire bladder and entire urethra was quantified by HPLC and expressed as pmol per mg of tissue. The remaining 8 animals (4 saline; 4 LPS) underwent cistometry under urethane anaesthesia for evaluation of bladder reflex activity. Bladder recordings were acquired during the continuous infusion of saline during 1 hour followed by the continuous infusion of 5-HT (100 uM) for another hour. Urodynamic parameters were analysed, quantified and averaged before and after 5-HT infusion. Statistical analysis was performed in the GraphPad prism software using an unpaired t-test.

Immunoreactivity for 5-HT was found in dispersed cells along the entire length of the urethra although more abundant in the proximal and middle parts, particularly at the level of the external urethral sphincter (EUS). No 5HT immunoreactivity was detected in the urinary bladder. Positive 5HT cells exhibited a round cell body commonly positioned in the basal layers of the epithelium and emitted slender processes reaching either the lumen or the lamina propria of the urethra. Positive 5HT cells also expressed β3-Tubulin (pan-neuronal marker), SV2 (synaptic vesicle marker) and TPH (tryptophan hydroxylase, rate-limiting enzyme for the production of 5HT). Below the urethral epithelium, a dense neuronal network was found, containing cholinergic (VAChT + ) and sensory (CGRP + ) fibers frequently showing appositions with the basal aspect of 5HT positive cells. In the urethra of control animals, the mean number of cells expressing 5HT was 181,3±7,80 cells/slice which significantly decreased to 117,1±10,35 cells/slice (p≤0.01) in animals with LPS inflammation. Tissue levels of 5HT measured by HPLC were below sensitivity (1.5 pmol/mg of tissue) in the bladder. In the urethra of control rats 5HT levels were 15,36±2,81 pmol/mg tissue. After inflammation, 5HT levels decreased to 7,45±0,42 pmol/mg tissue (p≤0.05). Regarding cistometry, the normal micturition pattern observed during the continuous infusion of saline in control animals was significantly altered by the continuous infusion of 5HT (100 uM). The urinary frequency was significantly decreased (0.6±0.093 to 0.28±0.037; p<0.05) and the maximal detrusor pressure and the amplitude of voiding contractions increased (44.71±1.458 to 53.49±1.176 and 34.95±0.804 to 46.24±1.011, respectively p≤0.001). In inflamed animals, a typical high frequency of voiding contractions was observed during saline infusion. This pattern was immediately altered by the infusion of 5-HT (100 uM), with a significant decrease of the frequency of voiding contractions to values similar to controls (1.4±0.10 to 0.53±0.025; p<0.05). Interestingly contractions appeared in bursts. Interpretation of results 5HT cells occurring in the urethral urothelium, in close proximity with sensory and cholinergic suburothelial nerve fibers exhibit neuronal-like characteristics (paraneurons) and may regulate the frequency and amplitude of bladder voiding contractions through the release of 5HT. Therefore we suggest that urethral 5HT cells may act as local sensors of external stimuli, similarly to what has been shown to occur with acetylcholine-containing cells in the same epithelium (3) . 5HT cells decrease during inflammation.

Concluding message 5HT produced and released by urethral paraneurons regulate the frequency and amplitude of bladder voiding contractions in normal and inflammatory conditions. 

Hypothesis / aims of study Fibrosis is implicated as central in many lower urinary tract pathologies, including chronic radiation cystitis, that exhibit decreased bladder compliance and contractile failure leading to urinary retention. Patients may need to use intermittent self-catheterisation or ultimately undergo a cystectomy, as there are no effective therapies to reverse fibrosis. Human relaxin-2 (hRLX2) is a pleiotropic insulin-like hormone, primarily detected in the blood-stream during pregnancy, to relax the uterus and allow the cervix and symphysis pubis to expand during delivery. It acts on G-protein coupled relaxin receptors 1 & 2, causing transient elevations of cAMP and cGMP and activation of transcription factors that lead to anti-inflammatory, vasodilatory and anti-oxidative properties, and reversal of fibrosis. We have established a mouse model of radiation cystitis that develops severe fibrosis within seven weeks and tested a hypothesis that hRLX2 can reverse fibrosis to re-establish normal bladder function.

Study design, materials and methods Adult female C57BL/6 mice were anesthetised (avertin, 300 mg/kg, IP), a lower midline incision made and the urinary bladder externalised for selective irradiation (10 Gray=1000 rad; X-RAD 320 KV, Fig. 1A ). Seven weeks later, subcutaneous osmotic pumps were implanted in the lower back to deliver saline or hRLX2 (400 µg/kg/day over 14 days; blood levels = 17.5 ng/ml at steady-state). Daily analysis of urine spots was performed to monitor changes in voiding function. After treatment, voiding function was evaluated by anesthesia-free decerebrate cystometry (CMG) and external urethral sphincter (EUS) electromyograms (EMG). In vitro, bladder active and passive contractile function was measured in superfused preparations; Cav1.2 (L-type Ca 2+ channel subunit) and relaxin receptor 1 & 2 expression by immunofluorescence; and bladder wall architecture (urothelial integrity, connective tissue and detrusor muscle content) by H&E staining. Data are means±SD with differences between sets tested using Student's t-test, the null hypothesis was rejected at p<0.05.

Urine spot analysis showed that non-irradiated mice were continent by voiding in one area of the cage; irradiated animals had leak incontinence by two weeks and retention 12 weeks after irradiation. hRLX2-treated irradiated mice had voiding patterns as in controls (not shown). Irradiated, untreated animals had overflow incontinence, associated with decreased compliance and pressure generation, with a prolonged EUS guarding reflex (Fig. 1B, C) . hRLX2-treated mice, exhibited more efficient voiding, longer intercontractile intervals (ICI), higher bladder compliance and EUS activity as in controls (Fig. 1D ). At nine weeks postinjury, bladder histology of irradiated mice showed urothelium loss, increased fibrosis and muscle layer disorganisation. hRLX2treated mice had an intact urothelium, normal smooth muscle architecture and a smaller connective tissue:smooth muscle ratio (Fig 2A) . Contractile responses to oxotremorine (10 µM), ABMA (10 µM) and high-K (120 mM KCl) were reduced significantly in muscle strips from irradiated bladders, but restored in hRLX2-treated mice (Fig 2B, n=5) . Passive length-tension curves (Fig 2C, left) showed increased tension in irradiated bladders, reversed in hRLX2-treated mice. By contrast, active force was decreased in irradiated mice and restored by hRLX2-treatment (Fig 2C, right) . Finally, Cav1.2 expression was greatly enhanced in irradiated bladders from hRLX2-treated mice ( Fig 2D) .

Responses to bladder radiation exposure include decreased bladder compliance and force generation and greater fibrosis. This is associated with inflammation from urothelial apoptosis, urine infiltration, and damage to the vascular endothelium. Treatment with hRLX2 reversed fibrosis by reducing collagen synthesis or enhancing its degradation. Contractile function also recovered, with responses to some agonists even augmented, associated with increased Cav1.2 expression that would enhance Ca 2+ influx into detrusor myocytes. hRLX2 was also anti-inflammatory, inhibiting damage to the urothelium and bladder wall.

Concluding message These studies are the first to demonstrate that treatment with hRLX2 reversed fibrosis and improved lower urinary tract function in chronic radiation cystitis. These improvements included cystometric and external sphincter functions, urothelial and muscle integrity, and detrusor contractility. The dose range used in these studies, is somewhat greater than those used in some clinical trials for other systemic conditions [1] and further studies will be needed to establish a working range to best manage lower urinary tract conditions. 

Hypothesis / aims of study The bladder urothelium has important pathophysiological role to manifest overactive bladder (OAB) symptoms. However, the mechanisms of pathogenesis of OAB at the molecular level remain poorly understood, mainly as a result of lack of modern molecular analysis. In this study we tried to identify novel urothelium proteins that are related to the development of detrusor overactivity (DO) using proteomic and bioinformatic methodologies. Study design, materials and methods The study was conducted using male Sprague-Dawley rats, subdivided into sham operated (n=40) and partial BOO groups (n=60). Partial BOO was induced for 2 weeks and DO was confirmed with measuring cystometry. The identification of protein was assessed with LC-MS/MS using LTQ-Velos mass spectrometry. Functional analysis of the data set was done using the Ingenuity GO (Gene Ontology) and Pathway Knowledge Base. Western blot and immunohistochemistry were performed for the expression validation.

In the OAB urothelium, pathways involved in inflammation, such as the complement system, acute phase response signaling, LXR/RXR activation, and p38 MAPK signaling, were notably up-regulated. By contrast, signaling pathways related to cytoskeletal organization, including ILK signaling, RhoA signaling, and remodeling of epithelial adherens junctions, were commonly downregulated. ER stress were down-regulated and proteins involved in death receptor signaling were up-regulated. 52 proteins involved in signaling molecules to communicate with closely located bladder nerves, detrusor muscles, and interstitial cells were identified. 7 ATP-related proteins were detected only in the OAB urothelium. Their expression pattern was validated by Western blot and immunohistochemistry experiments.

Signaling pathway analysis revealed that the differentially expressed proteins were mainly involved in the cytoskeletal organization, inflammatory response and apoptosis. These proteins may be associated with abnormal sensitivity and muscle contraction of the bladder.

Concluding message Our findings will provide new insights understanding the development and pathophysiology of OAB.

to contribute to DSD. Accordingly, our goal was to determine the benefits of the small molecule selective p75 NTR antagonist, LM11A-31, in ameliorating DSD.

Study design, materials and methods Female four to six week old C57Bl/6 mice had their spinal cords transected between the T8-T9 vertebrae. Following surgery, they were treated with an analgesic and prophylactic antibiotic and their bladders manually expressed twice a day. Expressed urine volumes were measured to estimate changes in bladder capacity. Seven days following SCI and daily thereafter, animals were gavaged with LM11A-31 (100 mg/kg in 100 μl of water). Fourteen days after transection, (seven days post treatment initiation), animals were decerebrated for anesthetic-free cystometrogram (CMG) and EUS electromyogram (EMG) recordings, after which their bladders were isolated for histology using hematoxylin and eosin (H&E) staining. All experiments were carried out using n ≥ 4 mice.

Control mouse CMG and EUS-EMG recordings demonstrate a guarding reflex that prevents leaking as bladder pressure approaches voiding threshold. This is followed by bursting with decreased tonic activity during which voiding occurs and bladder pressure returns to baseline (figure 1A). Two weeks post SCI, there is increased EUS tonic activity as the bladder contracts (DSD) resulting in non-voiding contractions (indicative of detrusor overactivity) and eventually overflow incontinence (figure 1B). In untreated SCI animals, bladder weights and urine volumes were dramatically increased: 78 ± 5 mg versus 24 ± 2 mg; and up to 500 μl of urine versus 90 ± 9 μl in non-transected controls, respectively. Treatment with LM11A-31 decreases bladder weights (to 41 ± 6 mg, p < 0.05) and urine volumes (to less than 100 μl) which contributed to much improved voiding function ( figure 1C) . Importantly, our results demonstrate that daily LM11A-31 treatment, starting seven days post injury, alleviated DSD and nonvoiding contractions permitting a return towards normal voiding function ( figure 1C ). Histological analysis of bladders from untreated SCI mice showed urothelial hyperplasia and detrusor hypertrophy (figure 2B) as a consequence of DSD and bladder overdistention. In animals treated with LM11A-31, the urothelial layer was preserved and the detrusor was not hypertrophied (figure 2C) as in controls (figure 2A).

Our results demonstrate that selective inhibition of p75 NTR and pro-neurotrophins interactions with small molecule LM11A-31 is remarkably effective in maintaining the structural integrity of the bladder wall and treating DSD permitting voiding. The mechanisms may include apoptosis inhibition of both neurons in spinal cord (preventing neuronal degeneration centrally) and urothelium in the bladder (reducing inflammation peripherally).

Concluding message LM11A-31 has been demonstrated to improve motor coordination in mice with spinal cord contusion [2] and is safe and translational as evidenced by the drug entering phase II clinical trials to treat Alzheimer's disease. Our results clearly demonstrate that it is therapeutic and reverses DSD to treat lower urinary tract dysfunction due to SCI. mouse with daily LM11A-31 treatment starting 1 week after injury and continued for seven days (C). A-1 shows bursting activity with decreased tonic activity during which voiding occurs and pressure returns to baseline. Following SCI and the development of DSD (B-1), when the bladder contracts, sphincter tonic activity increases, resulting in non-voiding contractions and eventually overflow incontinence. Gavage with LM11A-31 (100 mg/kg/day) caused a reduction in EUS tonic activity during bladder contractions facilitating urine outflow. 

Hypothesis / aims of study Prior preclinical OAB animal models (e.g. intraperitoneal cyclophosphamide, intravesical acetic acid or protamine, bladder outlet obstruction) have lacked translational relevance to the idiopathic female OAB seen in the clinics. Because human urothelial cells from female subjects with OAB urgency incontinence, had increased ornithine decarboxylase (ODC) expression and increased intracellular polyamines (the products of ODC enzymatic action) (1,2), the question is whether urothelial overexpression of ODC in an animal could recapitulate an OAB micturition phenotype. Therefore, we constructed a transgene vector containing a UPII promoter (urothelial restriction) linked to an truncated ODCt gene (ODCt is more stable than ODC) downstream. This transgene was inserted into the C57BL6 mouse (WT) genome to create a urothelial restricted ODC overexpressing transgenic mouse (ODC+). We present for the first time that the ODC+ female mice have an OAB phenotype.

Study design, materials and methods Three cohorts of 12-16 week old female mice, ODC+, ODC-(non-transgene carrying siblings in litter) and WT animals, were used. Whole bladders underwent H&E staining and q-RT-PCR for ODC specifically in the urothelium was performed. For voiding behaviour study, 18 mice (6 in each cohort) were used. Voiding behaviour was measured over 4 hours in the dark cycle and void spot assays (VSA) were performed per algorithm (3) . Urine specimens were collected in another set of animals (n=4 for each cohort) and analysed with 32-plex murine cytokine ELISA.

ODC+ animals were heavier (by 20%) and had shorter tails. There was more intraabdominal fat. H&E staining of bladder revealed intracellular inclusion bodies in umbrella cells. qPCR of the urothelium of the ODC+ animal showed 20x higher ODC mRNA expression compared to WT and ODC- (Fig. 1) . The ODC+ animal voided significantly more frequently ( Fig. 2A, 2D ) with significantly more spots in the center of the filter paper (Fig. 2B, 2E ). The voided volume was not different between the 3 cohorts of animals (Fig. 2C, 2F ). Urinary cytokine analyses revealed 6 of the 32 cytokines had a significant elevation in the ODC+ animals: G-CSF, IL-1α, IL-1β, KC (CXCL1), LIX (CXCL5) and VEGF (Fig. 3) .

The ODC+ female mice have an OAB voiding behaviour phenotype. This included more frequent voiding and more voids in areas that are not normally seen (centre part of filter paper). Because the voided volume was not different between the 3 cohorts, the increased voiding frequency in ODC+ animals was not due to polyuria. Six urinary cytokines in OAB+ animals were significantly elevated suggesting urothelial dysregulation of these cytokines.

We created a translationally relevant OAB transgenic animal model based on prior data from clinical OAB specimens. The ODC+ animal not only had an OAB voiding behaviour, it also had significant increases in several urinary cytokines. This transgenic animal is a valuable tool to study urothelial dysregulation contribution to OAB bladder behaviour phenotype and represents a beside to bench paradigm for studying OAB pathophysiology. 

From July 2014 to August 2016, 38 consecutive patients were included. Mean age was 66.36 ± 6.44 years. According to the IPSS score, 14 patients (37%) had mild symptoms, 18 (47%) moderate symptoms and 6 (16%) had severe symptoms. Men diagnosed with diabetes mellitus (DM2) were found to have higher collagen content in the bladder wall when compared to non-diabetic patients (17.71 ± 6.82% vs. 12.46 ± 5.2%, respectively; p = 0.024). Increased oxidative stress in the bladder wall was associated with clinical characteristics (LUTS severity and obesity), ultrasound findings (bladder wall thickness ≥ 3 mm, prostate volume ≥ 80 cm3) and urodynamic parameters (BOO severity, post-void residual volume ≥ 50 ml) (p<0.05). The intravesical protrusion of the medial prostate lobe (IPP ≥ 9 mm) was a predictive factor of BOO. Interpretation of results Collagen content into the bladder wall and oxidative stress markers have been previously described as surrogate endpoints for detrusor underactivity among patients with BOO (1, 2) . The findings of this pilot study suggest that clinical, ultrasound and urodynamic findings are associated with higher levels of oxidative stress in the bladder wall.

Concluding message Increased oxidative stress in the bladder wall was associated with severity of BOO. DM2 was associated with higher collagen content in the bladder wall of men with LUTS.

Hypothesis / aims of study Current treatments for stress urinary incontinence (SUI) do not repair the neuromuscular continence mechanism that can be damaged in childbirth. Stem cells, including mesenchymal stem cells (MSCs) and their secretions, including brain-derived neurotrophic factor (BDNF), facilitate recovery from neuromuscular injuries. We investigated if BDNF is a key factor in MSC secretions that repairs the neuromuscular continence mechanism and improves continence in a dual injury SUI rat model. Study design, materials and methods Bone marrow was harvested from Sprague-Dawley rats by flushing the femur and tibia with saline. The collected cells were sorted using intracellular adhesion molecule 1 (ICAM-1) to select for MSCs and were cultured in Dulbecco's Modified Eagle Medium (DMEM) media (containing 10% fetal bovine serum (FBS), and antibiotic). BDNF expression in MSCs was knocked down (KD) by transfecting anti-BDNF shRNA via a lentivirus. A scrambled sequence was transduced as a control. Antibiotic-and serum-free media that had been cultured with the MSCs for 24 hours and contained secretions from the MSCs was collected, spun and filtered to concentrate it to 50X, producing unmanipulated control concentrated conditioned media (CCM), BDNF KD CCM, and scrambled CCM. Concentrated control media (CM) was produced in the same manner but without being conditioned by cells. All CCM and CM were stored at -80°C until used. Total protein concentration in CCM was assessed by Bradford protein assay using BSA as a standard. The concentration of BDNF in CCM was analysed by ELISA.

For creation of SUI, rats were anesthetized with 2% isoflurane and underwent pudendal nerve crush (PNC) followed by vaginal distension (VD) as described previously [1] . In brief, the pudendal nerve was isolated bilaterally and crushed with a Castroviejo needle holder twice for 30 s. The vagina was then accommodated with increasing sizes of bouge a boule urethral dilators (24 -32Fr). A modified 10F Foley catheter was inserted into the vagina, and the balloon was inflated with 3 ml water for 4 h. Sham injury was created by making an incision in the dorsal skin, accommodating the vagina with the urethral dilators, and inserting a Foley catheter for 4 h without inflation. One hour and 1 week after the end of the sham injury (SI), rats received a 300 µl intraperitoneal injection of CM (n=17). One hour and 1 week after PNC+VD, rats received a 300 µl intraperitoneal injection of either CM (ST; n=16), BDNF KD CCM (n=12), scrambled CCM (n=11) or control CCM (n=10).

All rats underwent leak point pressure (LPP) and pudendal nerve sensory branch potential (PNSBP) recordings 3 weeks after injury, as we have described previously [1] . LPP, defined as peak bladder pressure at leakage minus baseline pressure, was used to assess urethral function. PNSBP was analysed in terms of the difference between firing rate and amplitude at peak activity during clitoral brushing and baseline activity, respectively. The urethra and pudendal nerve were harvested for anatomical assessment. ANOVA with a Student-Newman-Keuls posthoc test was used to compare quantitative outcomes with P<0.05 indicating a significant difference. Data is presented as mean ± standard error of the mean. Interpretation of results Control CCM-treated rats performed better than SI rats in urethral function as measured by LPP testing 3 wk after PNC+VD, suggesting that control CCM can restore continence effectively, consistent with our previous study [1] . PNC+VD rats treated with scrambled CCM showed no difference in LPP from SI rats, although BDNF was decreased compared to SI rats. However, control CCM-treated rats had significantly higher LPP than the other injury groups, including PNC+VD rats treated with scrambled CCM, suggesting that lentiviral transfection even with scrambled shRNA may alter other secretions important for promotion of recovery. In contrast, pudendal nerve recovery was facilitated by all 3 formulations of CCM tested, as indicated by improvements in PNSBP firing rate in all CCM treated groups compared to the CM treated group. However, histology findings showed better recovery in rats with BDNF KD CCM, scrambled CCM or normal CCM than ST rats, suggesting low amounts of BDNF may still be able to promote recovery of neuromuscular function but may take longer to recover to continence.

Concluding message BDNF is an important, but not the only recovery factor in CCM for this dual muscle-nerve injury SUI animal model. Other proteins in CCM also play an important role in injury repair and recovery from SUI. Unmanipulated CCM may provide a regenerative therapy to reduce postpartum incontinence and possibly prevent later development of SUI. 

Hypothesis / aims of study Denervation causes rapid loss of skeletal muscle mass and contractility. While skeletal muscle degeneration following nerve injury has been well investigated, comparably little is known about the effects of nerve root injury on smooth muscle. We studied changes in nerve and smooth muscle function of the bladder after sacral root transection to confirm the preservation of smooth muscle contractility despite the loss of presynaptic input.

Study design, materials and methods We designed a lower spinal cord injury model in which animals underwent surgical transection of all sacral roots, eliminating a majority of motor input to the bladder. Sham-operated controls received a lumbosacral laminectomy without root transection. Animals were housed for a year following the initial surgery. Three weeks prior to sacrifice, bladders were cystoscopically injected with a neuronal retrograde label at four positions around the ureterovesical junction for later pelvic plexus ganglia examination.

During terminal surgery at 1 year post sacral root transection, pelvic plexus nerves adjacent to the bladder were stimulated with either a monopolar or bipolar probe using a current of 3 -6 mAmp, a frequency of 20 Hz, and a duration of 0.2 msec. Contractions were recorded with external pressure transducers interfaced with the PowerLab® multichannel data acquisition system and LabChart® software (ADInstruments, Colorado Springs, CO). Following euthanasia, strips of smooth muscle were isolated from bladders and denuded of the mucosal layer. Electric field stimulation was delivered to the muscle strips, ex vivo, at 12 V, with a duration of 1 ms, at varying frequencies using a Grass S88 stimulator (Natus Neurology Inc., Warwich, RI) interfaced with a Stimu-Splitter II (Med-Lab Instruments, Loveland, CO) power amplifier and LabChart® software (ADInstruments, Colorado Springs, CO). Also following euthanasia, pelvic plexus and bladder tissues were collected, fixed in 4% buffered paraformaldehyde and cryosectioned. Bladder tissues were immunostained with anti-caspase 3 (diluted 1:20, Millipore, Billerica, MA). Sections were counterstained with a nuclear stain before cover slipping with 80% glycerol in PBS for visualization and quantification of caspase immunostaining. The external urethral sphincter was also harvested and immunostained for caspase 3 to confirm its denervation.

Interestingly, prior sacral root transection significantly altered the change in slope of the frequency response-curve in isolated smooth muscle strips ex vivo (p<0.05). The injury also caused an increase contraction in response to stimulation frequencies of 2 Hz (p<0.01), 5 Hz (p<0.05), and 12 Hz(p<0.05), compared to sham-operated controls.

No difference was seen in the number of pelvic plexus neurons labelled with retrograde dye between the sham-operated group (8.96 ± 2.97 cells/mm 2 , n=5) versus the sacral root transection group (14.57 ± 5.565 cells/mm 2 , n=3) in a previous cohort of dogs. Likewise, there was no difference in caspase 3 immunostaining in the smooth muscle of the bladder between groups. Thus, surgical transection of the sacral roots did not increase levels of apoptosis in detrusor muscle. In contrast, and as expected, striated muscle in the external urethral sphincter (EUS) of sacral root transected dogs (n=6) showed positive caspase 3 immunostaining, while no caspase 3 immunostaining was seen in EUS of sham-operated controls (n=5). Striated muscle fascicles of EUS in the injury model appeared atrophied and exhibited centronucleation, indicative of cell death, pathology not observed in sham animals.

The pelvic plexus maintained its ability to induce bladder contractions a year after spinal cord injury (Fig. 1) , tested in vivo, although sacral root transection significantly decreased maximal bladder contraction (p<0.01).

The decrease in pelvic plexus stimulation-induced bladder contractions in vivo suggest that long term loss of presynaptic input from the spinal cord directly effects the function of nerves in the pelvic plexus and bladder wall. Differences in results from electric field stimulation ex vivo indicate a change in phenotype of nerves found in the intramural wall of the bladder at one year post sacral root transection. It is possible that the root injury induced nerve sprouting. However, despite the decrease of neuronal input, no degeneration of bladder detrusor muscle was observed. This, combined with the preservation of smooth muscle contractility, may indicate that detrusor smooth muscle integrity does not depend on external neuronal input. Alternatively, other neuronal inputs (originating from sites other than the sacral cord) may be maintaining the detrusor smooth muscle.

Smooth muscle cells within the bladder maintain function after lower spinal cord injury. Although pelvic plexus-induced bladder contractions were less robust at one year after sacral root transection, the absence of atrophy and preservation of at least some nerve activity may allow for successful surgical reinnervation after long-term injury. 

Hypothesis / aims of study There is growing interest in chronic cystitis in the aetiology of overactive bladder (OAB). The tests used routinely to exclude urinary tract infection (UTI) have been discredited, catalysing a critical analysis of our assumptions. The methods used to test for infection are flawed and a negative result on culture and dipstick do not exclude infection or inflammation (1, 2) . The detection of microscopic pyuria remains the best surrogate marker of infection. There are other measures of immune activation in the urinary tract that are suitable as independent arbiters of the true pathology (3). Urothelial cells when infected with microbes signal their distress by expressing ATP and can be seen microscopically to be associated with microbes.

The aim of this study was to use a consilience approach to assess if patients with OAB show signs of infection and inflammation when compared with controls.

Study design, materials and methods A prospective observational study was conducted from April 2011 to October 2014. Patients presenting with OAB were recruited from incontinence clinics and clean-catch midstream urine samples obtained and compared to age and menopausal matched controls. Symptoms were measure using the ICIQ FLUTs questionnaire, Whittington Urgency and Pain score. Light microscopy was performed on fresh clean catch urine samples for leucocytes and urothelial cell counts by blinded investigators and cultured using the enhanced sediment culture. Urothelial cells were stained and assessed using fluorescent microscopy. Aliquots of spun urine were frozen at -80°C which were analysed for Lactoferrin and IL6 by high sensitivity ELISA and ATP using a luciferinluciferase assay.

There were 282 patient (mean age 63 sd=11) and 253 control visits (mean age 59 yrs sd=9). Linear mixed-effects models procedure was used to analyse the data with the group classification (Patient/Control) as an independent factor. Within the model the fixed effect was the group number and the dependant variables were selected in turn as LUTS score, urgency score, pain score, total bacterial growth on sediment culture, log pyuria and log epithelial cell shedding. Visit number was selected as the repeated effect. The analyses showed that group status (Patient/Control) was a significant predictor of total symptoms (Estimate of coefficient = -16.11, p<.0001); Pyuria (log pyuria) (Estimate of coefficient = -0.57, p<.0001); epithelial cell shedding (log epithelial cell count) (Estimate of coefficient = -0.30, p<.0001) and Log colony counts (Estimate of coefficient = -1.07, p<.0001).

In contrast to controls, patients demonstrated significantly greater bacterial growth characterised by culture of the centrifuged urinary sediment (Z=-5.981, p<.0001). The median log total colony counts in the patient group were 2.30 (interquartile range 1.54) and 1.50 (interquartile range 2.01) in the control group. The patient group also showed significantly higher levels of urinary leucocyte excretion and increased clue cell shedding (β=1.48, df=1, p<.0001). In the control group the mean clue cell proportion was 0.01, median 0.00 (sd=0.057, interquartile range=0.00) and in the patient group mean clue cell proportion was 0.19, median 0.17 (sd=0.16, interquartile range=0.17). 9.72% of the patients had a positive routine culture compared with 0.40% in the control group. 93.4% of patients had a positive spun sediment culture, significantly higher when compared to 70% of controls. The microbial diversity was distinctly different between patients and controls with recognised uropathogens predominating in the patient group. Urinary IL6 and Lactoferrin was also significantly higher in the patient group as compared with controls.

There is strong evidence to suggest that patient with OAB have signs of infection and inflammation which distinctly differs from matched controls. This provides an alternative hypothesis to the pathophysiology of overactive bladder.

Concluding message This study supports that in patients with symptoms of OAB, infection and inflammation provides an alternative hypothesis. Theoretically, the flow shape of DU is different from bladder outlet obstruction (BOO), but in practice PFS is the only gold standard for diagnosing DU. It is suggested that detrusor muscle contraction and abdominal squeezing act in total different frequencies, 0.1Hz and 1Hz respectively, which could be an indicator for differentiating DU and BOO [1] . However, this hypothesis has not been quantitatively validated. Therefore, continuing last year's research [2] , we have conducted a novel study on validating frequencies of abdominal and detrusor muscle activity as reflected in urine flow, and propose a potential indicator for diagnosing DU.

Study design, materials and methods Urine flow data of 114 adult male patients who had undergone PFS were analysed. Based on their PFS record, these patients were divided into three groups: 46 BOO, 44 DU, and 24 normal (DU and BOO disease free). A free urine flow rate was performed before each PFS, and the shape of those flows analysed. The starting and ending voiding point was selected by the threshold value of 0.5ml/s. Then a third order Butterworth filter was applied on the urine flow rate curve with different cut-off frequencies (1Hz, 0.8Hz, 0.6Hz, 0.5Hz, 0.3Hz and 0.1Hz), to count the peak numbers in each raw curve and filtered curve. The ratio of the number of peaks in the raw curve and the filtered curves was calculated for statistical analysis to find the best sensitivity/specificity for diagnosing DU. An example plot of raw curve and 1Hz filtered curve is presented in figure 1.

All statistical analysis was performed in SPSS version 23, Mann-Whitney U test and T-student test were performed as appropriate. A statistically significant difference was considered as P value<0.05. Figure 1 Raw urine flow rate curve and 1Hz filtered curve

We found the best statistically significant difference (P<0.002) on DU/BOO in ratio of peak numbers of 1Hz filtered curve against 0.1Hz filtered curve, followed by raw curve against 0.1Hz filtered curve with P value of 0.002 and 0.8Hz against 0.1Hz with P value of 0.002. Further receiver operating characteristic (ROC) analysis was performed on these three peak ratios in DU against with BOO and disease free group. The plot of ROC is presented as in figure 2.

Figure 2 ROC analysis on ratio of peak numbers in raw curve/0.1Hz filtered curve, 0.8Hz/0.1Hz filtered curve and 1Hz/0.1Hz filtered curve

The ratio of peak numbers in 1Hz filtered curve against 0.1Hz filtered curve has the largest area under the curve of 0.691. With cut-off value of 8.37, the best sensitivity and specificity for diagnosing DU are 73% and 61% respectively.

It is suggested in urine flow rate data, an averaging should be taken in a 2 second window for reducing drops and artefacts [3] , which equates to a 1Hz filter for a 10Hz sampling rate urodynamic equipment. In this research, we found the best diagnosing power for DU is the ratio of peak numbers in 1Hz filtered against 0.1Hz filtered curve. As DU patients have relativity lower detrusor contractility than BOO patients, they may have more abdominal straining for voiding out the urine. Therefore, we found the ratio of peak numbers in before and after filtering abdominal squeezing curve has significant statistical difference between DU group and BOO group. This result also verifies the hypothesis of frequencies for abdominal and detrusor squeezing are around 1Hz and 0.1Hz respectively. Concluding message This study shows promising non-invasive indicator for diagnosing DU in men by comparing the number of peaks in 1Hz filtered curve against the 0.1Hz filtered curve. It has also made suggestions on possible frequencies of abdominal squeezing and detrusor straining. Further research will follow on more frequency analytical methods, such as Fourier analysis and wavelet theory, to achieve a decent diagnosing power on non-invasively diagnosing DU and by combining multiple clinical parameters. 

Hypothesis / aims of study The anatomical and functional basis of urinary continence in female human remains confusing and controversial. The urethra is directly in charge of urinary continence and, it is such a complex and dynamic organ that conducts dramatically contrasting functions-to close tightly at most of time but to open widely at voiding. This means we need to understand the morphology and physiology at different states. Given the limitations of direct study of human beings, some lab mammals are alternatives. Female canine has unique advantages for this purpose: its urethra has clear tissue layers, long proximal urethral segment with pure smooth muscle and a distal segment with strong striated muscle. Importantly, canine urethra structure represents a preliminary status of the urethra evolution because canine locates at the lower level of the mammal branch on evolution tree. This study takes advantages of canine to elucidate urethral continence mechanism by urodynamic and morphometric analysis.

Study design, materials and methods Totally 12 adult female canines were used and urodynamic tests were conducted under pentobarbital anaesthesia. A midline abdominal incision were made with the pubis symphysis cartilage divided to get good expose of pelvic structures. A surgically installed bladder catheter was connected to the urodynamic equipment for leak point pressure (LPP) test which was conducted with manually press the bladder with the abdominal wall open. The possible movements of pelvic structures were observed directly and video-recorded and, the electromyography (EMG) of the striated urethral sphincter (SUS) and the levator ani (LA) were recorded. In 6 randomly chosen canines the urethral pressure profile (UPP) was recorded with a 7F urethral pressure catheter. Then we determined the segmental distribution of continence function along the whole urethra by the test of segmental invalidation of urethra (TSIU). This was achieved by inserting a 12F catheter into urethra lumen step by step at an interval of 1/16 of the whole urethral length (each interval is 4 to 5 mm, which was determined on basis of UPP of individual animal) and recording LPP at each step. The other 6 animals not having UPP and TSIU were used for morphological study. The whole urethra together with vagina was fixed and divided averagely into 16 segments and then embedded in paraffin. Each segment was averagely divided into 4 levels. For each level a slice of 5μm was stained by trichromatic staining，and serial three sections were immunolabeled for smooth muscle(Sm. M) and striated muscle (St. M, fast/slow) respectively. The digital images of all trichromatic stained slides were obtained on the Hamamatsu Nanozoomer Digital Pathology (NDP) System. Quantitative analysis of the different component of each 1/16 segment of urethra were performed using the Vectra imaging system according to manufacturer's protocols. Statistical analysis was performed with SPSS (version 20.0, IBM). The correlation between morphometric variables, which include submucosa, smooth muscle and striated muscle with urethral pressure at different segments of urethra was analyzed.

The UPP curves displayed low pressure zones in the proximal 56.25% urethral segments and high pressure zones in the 43.75% distal segments (Fig 1 b) . In TSIU, the distal 43.75% segments had a much higher LPPs indicating strong continence function, comparing to the proximal 56.25% segments that had lower LPPs indicating weak continence function. The LPPs changed sharply when the distal 2.5 to 3.0 cm of the urethra were invalidated (Fig 1 c&d) . At direct observation, we noted that the distal urethral part was much thicker than the proximal part ( Fig.2 a) . Also, only the distal urethra contraction (in a way like the heart beats) and only the SUS-EMG bursting occurred upon bladder pressure raised. There was no LA contraction and no LA-EMG bursting recorded.

The St. M might be further divided into two sections: one located at the most distal parts (1/16 to 3/16) with fibers distributed in a fan-like orientation and surrounded a large volume of spongy tissue with thin tubular sinusoids (TTS); another located close to the middle part (4/16 to 6/16) with fibers circularly orientated and surrounded some large cystic sinusoids (LCS) beneath the urethral mucosa. The bundles of dense connective tissue formed 3-dimentional framework in urethra to serve as foundation for other functional components. TTS mainly distributed in 1/16 to 3/16 but also appeared throughout the whole urethra, while the LCS only appeared in 3/16 to 6/16 segments, which corresponding to the peak pressure zone in UPP. These LCSs located close to urethral lumen and formed valve-like structures (Fig 2, b&c) . The distribution of urethral pressure failed showing any linear correlation with any particular tissue components in different urethral segments.

The female canine urethra can be divided into two segments in terms of the urodynamic features and the histological components. 

Hypothesis / aims of study There is substantive evidence supporting a role for chronic stress in the development, maintenance and even enhancement of functional bladder disorders such as painful bladder syndrome/interstitial cystitis (PBS/IC). More than half of patients with PBS/IC report daily or constant pain and urinary frequency, which are exacerbated by stressful circumstances. Stress can alter the sympathetic nervous system, whose activity is augmented in PBS/IC patients. While the etiology of functional disorders such as PBS/IC are not known, alterations in the bladder urothelium have been detected in both patients and animals diagnosed with PBS/IC. The urothelium not only forms a high-resistance barrier but also functions as an integral part of a 'sensory web' that can sense changes in their environment including those produced by chronic stress and via release of transmitters, can activate sensory nerves.

There is exciting new evidence that mitochondrial dysfunction and oxidative stress have been implicated in chronic pain as well as autonomic dysregulation. In fact, mitochondrial dysfunction may also be a final common pathway in the pathophysiology of many diseases and disorders that are impacted by chronic stress. Recent evidence shows that individuals with chronic conditions have impairment in mitochondrial pathways. Our novel concept is that abnormal processing of chronic stress involving autonomic and mitochondrial dysregulation can negatively impact urothelial signalling, leading to altered sensations and pain in patients with PBS/IC.

Study design, materials and methods This aim was investigated in an animal model consisting of a rat genetically predisposed to stress (Wistar Kyoto), exposed to psychological stress (chronic water avoidance or WAS).

• Female Wistar Kyoto rats (~200g; 3-4 month old) were exposed to WAS for 1h per day for 10 days and sacrificed on day 11 (versus handled groups as controls).

To assess the impact of sympathetic signalling some rats were treated with guanethidine which depletes catecholamines (50 mg/kg, i.p.; every other day starting 2 days prior to WAS and throughout the WAS protocol) or the adrenergic (α1/α2) antagonist, phenoxybenzamine (2 mg/kg i.p. every day starting the day WAS protocol was initiated and throughout the WAS protocol). • Bladders were collected from deeply anesthetized rats and utilized for cell culture and western blot per previously published methods.

Cultured urothelial cells (UTC) from control and WAS rats were loaded with various intracellular dyes to examine functional (intracellular calcium or mitochondrial) responses. These included: fura-2AM (to measure intracellular calcium concentration, [Ca 2+ ]i), Dihydrorhodamine 123 -DHR123 (to measure reactive oxygen species -ROS) and Tetramethylrhodamine methyl ester -TMRM (to measure mitochondria membrane potential, Ψm; Figure 1 ).

Our findings reveal that WAS UTC exhibit a more depolarized Ψm (~30%; decreased staining of the fluorescent indicator TMRM indicating a loss of viability; Figure 1 ) compared to control UTC. We also have evidence for higher baseline [Ca 2+ ]i and inability to buffer [Ca 2+ ]i after a stimulus (i.e., mitochondria uncoupler carbonyl cyanide-4-(trifluoromethoxy)phenylhydrazone or FCCP 5-10 µM). Both guanethidine and phenoxybenzamine treatment of WAS animals normalized these alterations, supporting sympathetic nervous system involvement. There was no difference in basal ROS production in between WAS or control UTC. In contrast, ROS generation in response to stressors (H2O2; 100 µM) was significantly higher in WAS UTC. ROS were also generated in both control and WAS UTC by stimulation of α-ARs with phenylephrine (10 µM) but not of β-ARs with isoproterenol (1 µM). We also find that chronic stress correlates with increased mucosal protein carbonylation as well as an increase in pAMPK often termed the metabolic gate keeper of the cell. In addition, we find an increase in mitofusin 2, which is thought to suppress cell proliferation and exert apoptotic effects. In all cases, we see a normalization in these targets in WAS animals treated with guanethidine or phenoxybenzamine. Interpretation of results While a number of factors are likely to contribute to chronic pain disorders, accumulating evidence suggests that altered cellular metabolism (i.e. mitochondrial functions) plays a key role. Mitochondrial uptake of calcium is important for cell survival and regulating release of mediators (such as ATP and ROS).The mitochondrial membrane potential Ψm is an important parameter to assess the functional state of these organelles. Disturbances in Ψm could result in alterations of cell metabolism, increased ROS production and altered calcium homeostasis; all of which were observed in WAS UTC.

Mitochondria are responsible for the majority of oxygen consumption and represent the major source of reactive oxygen species in all cells including urothelium. Chronic stress (with augmented levels of stress mediators such as norepinephrine) can lead to a prolonged change in mitochondrial properties. For example, the increase in ROS can result in protein carbonylation which is used as a biomarker for oxidative stress. In turn, WAS UTC may increase AMPK, which can activate anti-oxidant defenses.

Many of these changes are prevented by treatment with agents that either deplete catecholamines (guanethidine) or block alphaadrenergic receptors (phenoxybenzamine) supporting a role for the sympathetic nervous system. Taken together, chronic stress

Hypothesis / aims of study Lower urinary tract symptoms (LUTS) are commonly seen in males with benign prostatic hyperplasia (BPH), and their storage LUTS such as urinary frequency and urgency overlap with the symptoms of overactive bladder (OAB) syndrome. Although BPHinduced bladder outlet obstruction (BOO) has been studied as a mechanism inducing storage LUTS, there is also increasing clinical evidence showing that asymptomatic prostatic inflammation is involved in not only the development of histological BPH, but also the emergence of male LUTS suggesting that prostatic inflammation could be another potential mechanism inducing storage LTUS in BPH patients. Therefore, this study utilized a rat model of non-bacterial prostatic inflammation [1] to investigate the changes in bladder activity, and functional and molecular characteristics of bladder and prostatic afferent pathways following prostatic inflammation.

Study design, materials and methods Male SD rats were used, and prostatic inflammation was induced by formalin (5%; 50 µl per lobe) injection into bilateral ventral lobes of the prostate [1] . (1) Bladder function: Before and at 1 week after formalin injection, voiding behaviour was evaluated in metabolic cages. Thereafter, continuous cystometrograms (CMG) in a conscious condition were also recorded 1 week after formalin treatment to measure intercontraction intervals (ICI) of the micturition reflex. (2) Tissue inflammation: Ventral lobes of the prostate and the bladder were removed at 1 week post-prostatic inflammation, and myeloperoxidase (MPO) activity was also measured to evaluate neutrophil infiltration using ELISA. (3) Afferent neuron characterization: L6-S1 dorsal root ganglia (DRG) are removed at 1 week post-prostatic inflammation, whole-cell patch clamp recordings were performed on dissociated bladder and/or prostatic afferent neurons labelled by fluorescent dyes (Fast Blue [FB] and DiI) injected into the prostate and bladder wall, respectively, to examine the electrical properties of neurons Also, dye-labelled bladder and/or prostatic afferent neurons were collected from DRG sections using laser-capture microdissection (LCM) methods, and mRNA levels of TRP receptors (TRPV1, TRPA1) and an A-type K + channel (KA) subunit, Kv1.4 were measured by real-time RT-PCR.

(1) Bladder function: Compared to vehicle-injected rats, formalin-treated rats with prostatic inflammation exhibited a significant (p<0.05) decrease in voided volume per micturition (metabolic cage study) and a significant (P<0.05) reduction in ICI (CMG study) ( Fig. 1 ).

(2) Tissue inflammation: MPO activity in the formalin-injected prostate was increased 5-fold compared to vehicle injected controls, whereas there was no difference in MPO activity of the bladder between rats with intraprostatic vehicle or formalin injection. 3) Afferent neuron characterization: In DRG sections or dissociated DRG neurons, FB-labelled bladder afferent neurons, DiI-labelled prostatic afferent neurons and double-labelled (e.g., DiI and FB-positive) dichotomized afferent neurons innervating both prostate and bladder were identified. In patch clamp recordings, capsaicin-sensitive bladder and prostatic afferent neurons from prostatic inflammation rats had significantly (P<0.05) lower thresholds for spike activation (-28.3 ± 1.4mV and -28.7±1.4mV) compared to control rats (-19.5±1.1mV and -21.3±2.2mV, respectively) (Fig.2) . The number of action potentials of bladder or prostatic afferent neurons during an 800 msec depolarizing pulse was significantly greater after prostatic inflammation compared to control rats (Fig. 2 ). In the voltage clamp condition, the peak densities of KA currents during membrane depolarization to 0 mV were significantly (P<0.05) lower in neurons from prostatic inflammation rats than in those from control rats. In RT-PCR, mRNA levels of TRPV1 and TRPA1 were increased, and Kv 1.4 was decreased in FB, DiI and double-labelled neurons compared to nonlabelled neurons in prostatic inflammation rats.

These results indicate that: (1) formalin-induced inflammation after prostatic injection is confined in the prostate, without inducing inflammatory changes in the bladder, (2) prostatic inflammation induces bladder overactivity as evidenced by reduced voided volume per micturition and ICI, (3) prostatic inflammation induces hyperexcitability of capsaicin-sensitive C-fiber prostatic afferent neurons and also bladder afferent neurons, which is associated with reductions in KA current density and Kv1.4 α-subunit expression, and (4) prostatic inflammation induces upregulation of TRPV1 and TRPA1, which are expressed predominantly in Cfiber afferent neurons, not only in prostate afferent neurons, but also in dichotomize afferent neurons and bladder afferent neurons. Thus, it is assumed that prostatic inflammation that induces sensitization of C-fiber prostatic afferent pathways can also elicit functional and molecular changes in C-fiber bladder afferent pathways, possibly via afferent cross-sensitization from the prostate to the bladder through dichotomized afferents innervating both organs, thereby resulting in bladder overactivity.

Concluding message Chemically-induced inflammation localized in the prostate induces bladder overactivity evident as frequent micturition and enhances bladder afferent function shown by TRPV channel overexpression and increased excitability with reduced KA channel activity. Because there is clinical association between prostatic inflammation and BPH-induced LUTS, prostate-to-bladder afferent cross-sensitization through dichotomized afferents could contribute to storage LUTS in BPH patients with prostatic inflammation. 

Hypothesis / aims of study Birth trauma to the pelvic floor muscles (PFMs) is thought to result from mechanical demands that exceed muscle physiological limits. Previous work demonstrates that rat PFMs, including coccygeus (C), iliocaudalis (IC), and pubocaudalis (PC), undergo differential alterations in pregnancy [1, 2] . We sought to determine how pregnancy-induced adaptations modulate individual PFM response to strain produced by vaginal distention (simulating parturition) in a rat model. Study design, materials and methods Three-month-old Sprague-Dawley primigravid late pregnant (P) (N=13) and virgin nonpregnant (NP) rats (N=15) underwent vaginal distention (VD), replicating fetal crowning, with balloon volumes ranging from 1-5 millilitres (mL). Because differences in distensibility of other pelvic tissues in P and NP animals could impact strain effect on the PFMs, intrapelvic pressure (IP) generated during vaginal distention was measured with a pressure gauge contiguous with the balloon. To match a full spectrum of IPs observed in the NP group, an additional 11 P rats underwent VD with 6-10 mL volumes. Agematched P and NP rats (N=10/group) that did not undergo vaginal distention served as respective controls. Animals were anesthetized using isoflurane gas mixed with oxygen delivered via nose cone. P and NP rats were sacrificed and PFMs, which include coccygeus (C), iliocaudalis (IC), and pubocaudalis (PC), were fixed in situ to preserve in vivo architecture, harvested, and divided into 3 regions. Fiber bundles, consisting of 10-20 fibers, were dissected from each region of each muscle and fiber length (Lf) was measured. Bundles were microdissected into fibers for sarcomere length (Ls) determination by laser diffraction. Comparisons were performed by repeated measures and two-way analysis of variance (ANOVA) followed by multiple comparisons with Šidák or Dunnett's test, as appropriate. Significance level (α) was set to 5%. Results are presented as means ± standard error of the mean (SEM), except where noted.

Gross anatomic changes were observed in the PFMs following vaginal distention (VD). In particular, PC was extremely attenuated, with an almost translucent appearance of its enthesial region at distention volumes > 2 mL. Similar distortion was noted in C, while alterations in IC were less prominent. We believe these gross changes are due to myofiber stretch, as evidenced by significant increases in PFM fiber length (Lf) after VD compared to controls. As expected, PFM stretch ratios increased progressively with increase in strain volume. The largest stretch ratios were observed in C (1.7-2 in NP and 1.4-1.8 in P), compared to PC (1.4-1.8 in NP and 1.3-1.5 in P) and IC (1.3-1.4 in NP and 1.2-1.3 in P). Paralleling gross anatomic and macroscopic findings, VD resulted in progressive increase in Ls with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest Ls change observed in C, followed by PC, and a smaller rise in IC, observed only at higher distention volumes (Table) . We next compared PFM Ls of NP and P rats at each distention volume between 1-5 mL. Ls were significantly longer in NP compared to P animals at all volumes above 1 mL in both C (P<0.0001 for all except 5mL, P=0.009) and PC (P<0.0001 for all except 5mL, P=0.007). In contrast, in IC, there was no significant difference in Ls between NP and P rats at any volume besides 4 mL (P=0.01). The pattern of Ls changes in the individual PFMs in NP and P animals relative to respective controls and to each other was similar when the groups were matched either by strain volumes or intrapelvic pressures (IP).

To our knowledge, this is the first study to examine PFMs' response to strains associated with simulated parturition on a microscopic level. Our data demonstrate that in PFMs, mechanical strain results in acute sarcomere elongation, a wellestablished cause of mechanical injury in other skeletal muscles. Pregnancy-induced adaptations in PFMs appear to attenuate sarcomere hyperelongation in response to strain. The limitations of our study are inherent to use of animal models to represent human conditions. Given the ethical impossibility of directly probing PFMs in women during pregnancy and childbirth, animal models are essential to expand our understanding of the impact of pregnancy and vaginal delivery on the PFMs. The rat has been shown to have similar PFM architecture to humans, exhibits PFM adaptations in pregnancy, and is a useful model for the study of pregnancy and delivery-induced changes in the pelvic floor. In our protocol, since each animal must be euthanized in order to harvest PFMs, we were not able to follow the same animal longitudinally. Instead, we had to rely on cross-sectional examination of animals from each group and assumed homogeneity. Although this was a necessary constraint of our study design, Sprague-Dawley rats are widely used in biomedical research in general and, specifically, in studies of simulated birth injury. Furthermore, rats were obtained from a single vendor, were age-matched, were often from the same litter, and were housed together to minimize environmental variability and to assure concordant estrous cycle stage in NP animals.

Concluding message PFM sarcomere hyperelongation, caused by mechanical strain during simulated parturition with vaginal distention, is attenuated by pregnancy-induced adaptations. Remarkably, the extent of adaptation in the individual PFMs appears to be proportional to the degree of strain experienced by each muscle during simulated parturition.

Mechanical impact of pelvic floor muscle strain induced by vaginal distention with 1-5 mL balloon volumes, in nonpregnant and pregnant animals, represented as sarcomere length (Ls) in coccygeus, pubocaudalis, and iliocaudalis versus controls (0 mL). Measurements in micrometers (µm) are expressed as mean ± standard error of the mean (SEM 

Hypothesis / aims of study Bladder pain, frequent micturition, and urgency are symptoms commonly encountered in patients with painful bladder syndrome/interstitial cystitis, incontinence, and overactive bladder syndrome. A major underlying mechanism for these symptoms is abnormal sensory processing due to alterations in the pathways that detect, process, and transmit sensory stimuli from the periphery to the central nervous system (CNS). Sensory information from the urethra, including flow of fluid, distension, irritation, infection or pH, is critical for bladder function, triggering and/or amplifying bladder contractions and contributing to efficient emptying (1) (2) (3) . In pathologies, such as infections or incontinence, it is believed that increased excitatory input from the urethra contributes to bladder overactivity and symptoms of urgency, frequency and pain. However, how sensory information from the urethra is detected and transmitted to the CNS is not understood. We put forth the novel hypothesis that specialized cells within the urethral epithelium (called paraneurons) are part of a 'sensory web', which can detect, shape and transmit specific modalities of sensory information. The aim of this study is to characterize the morphology and putative function of a class of paraneurons, distinguished from other cells by their serotonergic (5-HT) content.

Study design, materials and methods Immunohistochemistry and confocal microscopy in whole mount urethrae from adult female C57Bl/6 mice (~25g, 6-8 weeks old) were used to investigate morphological features of 5-HT + cells (paraneurons) and their relationship with nerve fibers. Functional assessments were performed using fura-2AM calcium imaging in acutely dissociated primary afferent neurons labelled by retrograde axonal transport of the fluorescent dye FAST DiI injected into the urethral wall. Activation of nociceptive pathways was assessed using immunostaining for pERK (a marker for neuronal activation) in the lumbosacral spinal cord (L6-S1) and visceromotor reflexes (VMR; a surrogate method for assessing nociception in animals).

Immunohistochemical studies revealed 5-HT + cells of non-epithelial origin (negative for the epithelial markers cytokeratin 5 and 17) that were confined to the epithelium and were characterized by bipolar and multipolar dendritic-like processes ( Fig. 1A-C) . These cells were located in close proximity (< 3 µm) to sensory nerve fibers positive for calcitonin gene-related peptide (CGRP), substance P (SP) and TRPV1 ( Fig. 1A-C) . Synapsin I, a presynaptic marker, was present in 5-HT + cells as well as in afferent nerves. In contrast, there was no evidence for a close relationship with either efferent parasympathetic (positive for vesicular ACh transporter or nitric oxide synthesise) or sympathetic nerves (positive for tyrosine hydroxylase).

In vitro 5-HT (1 µM) stimulation of acutely dissociated urethral primary afferent neurons was used to mimic the effect of 5-HT released from paraneurons on afferent nerve activity. We found that this elicited an increase in intracellular calcium concentration ([Ca 2+ ]i) in ~80% of FAST DiI positive neurons (Fig. 1D ). These responses were blocked by antagonists of 5-HT2 and 5-HT3 receptors (ritanserin and Y-25130 hydrochloride, 1 µM). Approximately 50% of 5-HT responding neurons also responded to capsaicin (0.5 µM).

In vivo, urethral distension up to 40 cmH2O (pressures which are detected by the urethra during voiding when bladder pressure is equal to urethral pressure) had no effect on VMRs (Fig. 1E ). However, intra-urethral 5-HT (1 µM) application, as well as the positive control, acetic acid (1%), significantly increased VMRs triggered by similar urethral distension (Fig. 1E ). Intra-urethral 5-HT also activated pERK in the L6-S1 spinal cord neurons known to receive visceral afferent input (i.e., located in the superficial dorsal horn, sacral parasympathetic nucleus and dorsal commissure) (Fig. 1F ).

These key experiments identified 5-HT + paraneurons that are anatomically positioned to sense the urethral epithelial environment and transmit this information to underlying nerves. Our findings suggest a complex bidirectional communication network with underlying urethral nerves, which may also involve urethral epithelial cells (Fig. 1G ).

The results also suggest a crucial role of 5-HT + paraneurons in detection and transmission of noxious information. This is supported by: (1) close proximity of 5-HT + cells to TRPV1 + nerves, (2) evidence for expression of presynaptic machinery necessary to release 5-HT, (3) 5-HT induced changes in [Ca 2+ ]i in capsaicin sensitive urethral primary afferent neurons, and (4) activation of pERK in spinal cord neurons. Furthermore, visceral hyperalgesia developed in response to urethral distension after intra-urethral 5-HT perfusion. Additionally, 5-HT increased [Ca 2+ ]i in non-capsaicin sensitive primary afferent neurons, suggesting that 5-HT can alter the excitability of other non-nociceptive afferents. It is conceivable that changes in the properties of paraneurons resulting in increased availability of 5-HT could increase afferent input from the urethra. This can trigger or augment ongoing bladder contractions, contributing to urgency and overactivity, influencing lower urinary tract function and visceral sensations including pain. E. VMRs to urethral distension in the presence of intra-urethral saline (V), acetic acid (AA, 1%) and 5-HT (1 µM) (n=4 mice per group; * ANOVA p<0.05). F. pERK + cells in the L6-S1 spinal cord after intra-urethral perfusion of saline (V), AA and 5-HT (n=5-9 mice per group; * ANOVA p<0.05). G. Schematic of urethral 'sensory web' involving paraneurons and epithelial cells that detect mechanical and/or chemical stimuli (e.g., flow, distension, inflammation, pH), and transmit this information to the afferent nerves via release of transmitters (5-HT, others). Signals are then transmitted to the spinal cord and brain. Changes in peripheral 5-HT signalling can increase the excitability of afferent neurons, alter bladder/ urethral function and result in pain.

Concluding message These morphological and functional findings provide novel insights into a putative paraneuron-neural network within the urethra that utilizes 5-HT signalling to modulate primary sensory pathways carrying nociceptive and non-nociceptive information to the central nervous system. We further postulate that urethral paraneuron-neural interactions could lead to a 'urethral instability' that can influence storage and voiding reflexes and result in symptoms such as urgency and pain. Thus, increased understanding of the paraneuron-sensory web will provide insight into new targets and approaches to modulate signalling pathways for management of lower urinary tract disorders.

Li S 1 , Mei K 1 , Margot D 1 , Marc P 2 , Zutshi M 1

Hypothesis / aims of study Regenerating muscle at a time remote from injury requires re-expression of cytokines to attract stem cells to start and sustain the process of repair. We have demonstrated that a non-viral plasmid expressing stromal cell-derived factor 1 (SDF-1) increased muscle regeneration 4 weeks after treatment following a large chronic anal injury. Our aim was to evaluate the sustainability of this muscle regeneration and evaluate the muscle morphology and molecular mechanisms that lead to it.

Study design, materials and methods 56 female age/weight-matched Sprague-Dawley rats underwent an excision of 50% of the circumference of the anal sphincter complex. 3 weeks after injury, rats were randomly allocated to 1 of 4 groups(n=8) based on treatment: injury with no intervention (IA); 100μg plasmid encoding SDF-1 injected locally (P); both plasmid and 8x105 mesenchymal stem cells (MSC) injected locally (P+MSC) and plasmid injected locally with injection of a gelatin scaffold mixed with MSC (P+S&MSC). Rats underwent anal manometry pre-excision and pre and post-treatment. ImagePro Plus 7.0 was used for histological quantification by comparing muscle regenerated and fibrosis at the site of defect with intact muscle in the same section at 8 weeks. Immunohistochemistry used Desmin antibody for muscle identification. Protein expression of CXCR4 (receptor of SDF-1) and skeletal muscle proliferation/differentiation marker Myf5 was done by Western Blot at day 7 post treatment. One way ANOVA followed by Tukey test was used for data analysis (mean±SD), p<0.05 was regarded as significant.

Pre-treatment anal pressures were not significantly different among groups. 8 weeks post-treatment all 3 groups receiving the plasmid had significantly higher pressures (cmH2O) (P: 10 (Figure) . There were no significant differences in protein levels of CXCR4 or Myf5 between groups 7 days after treatment.

Representative pictures of transverse sections of rat anal canal stained by Desmin antibody. These sections are 3weeks post-excision of 50% of the circumference of the anal sphincter and treated with injury without treatment (IA)(right) and SDF-1plasmid local injection at the site of the defect (P) (left).There is regeneration of both smooth and skeletal muscle which is organized in the plasmid treated group. In the area of the defect (circled by blue oval), smooth muscle is indicated by red arrow and skeletal muscle is indicated by green arrow. Scale bar= 1mm.

Interpretation of results SDF-1 plasmid increased anal sphincter pressures 8 weeks post-treatment to near pre-excision levels. SDF-1plasmid alone also regenerated both smooth and skeletal muscle and decreased fibrosis at the site of defect. The injury alone group decreased in the pressures and had disorganized muscle regenerated. The other two groups using the SDf-1 plasmid also had a positive effect on both anal pressures and regeneration of smooth and skeletal muscle. The cytokines CXCR4 and Myf5 were not elevated indicating that the SDF-1 plasmid may not be effecting the regeneration through expression of these cytokines.

Concluding message In a model of chronic injury, SDF-1 plasmid alone regenerated both smooth and skeletal muscle and decreased fibrosis at the site of defect. This resulted in elevating sphincter pressures to normal levels. This effect could not be attributed to a change in the expression of cytokines CXCR4 and Myf5

Hypothesis / aims of study The female pelvic floor is a support structure that includes fascia, ligaments and muscles (PFM) of the urogenital region. It extends from the symphysis pubis to the coccyx, and comprises the levator hiatus for the passage of the urethra, vagina and rectum. The PFM include the coccygeus, ileococcygeuos, pubococcygeus, and puborectalis muscles, the latter two frequently referred together as the pubovisceralis muscle (PVM) [1] . The impairment of the pelvic floor muscles (PFM) is a major ingredient to develop urinary incontinence (IU) and/or pelvic organ prolapse (POP) (Schwertner-Tiepelmann et al., 2012). These disorders may result from changes in the biomechanical properties of the supportive structures that occur from weakness or impairment of muscles or ligaments, or alterations in the stiffness of the pelvic fascia associated with the risk factors -age, hormonal changes, among others [2] . The related conditions have been studied through imaging techniques and experimental in vitro studies, evaluating biomechanical properties of the pelvic ligaments, vaginal tissue and levator ani (LA) muscle. To obtain these biomechanical properties, acquired tissue during surgery or from female cadaver has been tested using different techniques. However, these collected tissues are frequently afflicted in clinical environment, and consequently, the comparison to in vivo healthy tissues is difficult. Hence, these studies show the nonlinear mechanical behavior, but they do not reflect the natural conditions for in vivo muscle behavior in the pelvis. In this context, the computational analysis coupled with in vivo biomechanical properties may help to correctly reproduce the biomechanical behavior of the PFM.

In this work, the computational models coupled with an inverse finite element analysis technique (FEA) was used to understand the passive and active behavior of the pubovisceralis muscle (PVM) during Valsalva maneuver and voluntary muscle contraction, respectively. Individual computational models of women asymptomatic and with stress urinary incontinence (SUI) were built based on magnetic resonance images, including the PVM and surrounding structures ( Figure 1 ). To reproduce more accurately the nonlinear behavior of the PVM was used a quasi-incompressible transversely isotropic hyperelastic constitutive model [3] and posteriorly, the material parameters were estimated through inverse FEA. A set of women was asked to complete the International Consultation of Incontinence Questionnaire-Short Form (ICIQ-SF)which is validated for the Portuguese language -to evaluate the presence and symptoms of UI. Demographic characteristics (age, body mass index (BMI) and parity) were also collected. For this work, the exclusion criteria included pregnancy and previous pelvic surgery. A convenient sample of eight women who gave informed consent was recruited. Four incontinent women (with SUI) and other 4 asymptomatic women were recruited at a regular urogynecology consultation.

Demographic characteristics of the asymptomatic and incontinent women are presented in Table 1 . When comparing the two groups of women, no significant difference in age, BMI and parity were found. The estimation of the material parameters evidenced a significant difference between two groups (p<0.05), with the values of asymptomatic women showing higher values ( Table 2 ). The matrix parameters (c and b) and fiber parameters (A and α) were 84% and 28%, and 73% and 31% higher when compared with the ones of the incontinent women. The active material parameter ( 0 M T ) was approximately 75% higher than that of the incontinent women. AW -asymptomatic women; IW -incontinent women. * statistically significant.

The proposed methodology showed that the PVM of asymptomatic women are stiffer than that of women with incontinence. For these women, the lower passive parameters -as consequence of softer muscles -may be explained by a significant reduction of type III collagen, which is not due to a decreased production of collagen but due to increased degradation of new collagen. Additionally, previous studies also concluded that incontinent women have a decreased in active force and stiffness that can be associated with muscular weakness and also showed that these women have increased number of fibers but significantly narrower than that of the asymptomatic women.

In recent years, with the development of computer technologies, computer modelling tools have emerged, which deal with the application of mathematical models to analyse, understand and study the phenomenology of complex problems, and it has become an essential tool in the scientific environment due to its wide range of application fields -including medicine. The modelling of soft biological tissues has been facilitated due to substantial progresses in the fields of constitutive modelling and the finite element method (FEM). Hence, the computational models coupled with inverse FEA can represent mechanical phenomena such as the Valsalva maneuver and voluntary muscle contraction. In addition, they seem to be a promising possibility to determine the in vivo biomechanical properties of the PFM that characterize their mechanical behavior.

In conclusion, this methodology is completely non-invasive, using only MR images and it allows to compare asymptomatic women and incontinent women, which may contribute to the clinic. 

Hypothesis / aims of study Urodynamic measurement of patient sensation during the filling phase is currently constrained to the three ICS sensory thresholds (First Sensation, First Desire & Strong Desire) which are poorly characterized and can be contaminated by investigator prompting. Therefore, there is a pressing need to develop more accurate and reproducible methods to characterize real-time sensation during urodynamics. To address this deficiency, a patient-controlled, real-time sensation meter has been employed previously in noninvasive hydration studies to measure patient sensation during filling [1] . In the current study, we aim to evaluate real-time sensation during the filling phase of urodynamics in order to develop novel metrics to define sensation kinetics. These could ultimately be used to sub-categorize different forms of filling phase disorders.

Study design, materials and methods After IRB approval, individuals undergoing urodynamic testing (for any clinical indication) recorded real-time sensation changes during filling from 0% (feeling of complete emptiness) to 100% (complete fullness) using our previously characterized real-time sensation meter ( Figure 1 ) [1] . Urodynamics were performed according to ICS guidelines. Prior to testing, all patients completed the ICIQ−OAB questionnaire and were instructed on the use of the meter. Patients with incontinence during filling, non-continuous filling or not reaching 100% sensation were excluded from analysis. Sensation data was obtained at 10Hz and time linked to urodynamic data. Infused volumes were normalized as a percentage of cystometric capacity for statistical analysis. Sensation data obtained from our real-time sensation meter were sampled at every 5% cystometric capacity and sensation-capacity curves were generated for each patient. The sensation curves were then divided into equal quartiles (Q1-Q4) and sensation velocity (vi), defined as Δsensation/Δcapacity, was calculated for each quartile ( Figure 2) . A sensation index (SI) was calculated for each patient and defined as 4 th quartile sensation velocity/1 st quartile sensation velocity (v4/v1). Patients were grouped via ICIQ-OAB urgency scores (question 5a: 0 -4) and analysed for changes in sensation velocity between quartiles. Analysis was also performed across urgency groups for each filling quartile. Sensation indices were compared between urgency groups.

A total of 49 consecutive patients used the sensation meter during urodynamics with 28 meeting criteria for analysis. Patients were grouped by urgency scores as follows: n=5,9,9,5, corresponding to urgency scores of 0,1,2,3, respectively. No patients had urgency scores >3. There were no differences in cystometric capacity or First Sensation between the 4 groups. Within group comparison (Figure 3 ), demonstrated that patients with elevated urgency (urgency group 3) had an increase in sensation velocity through the 4 filling quartiles (β=0.39, p=0.0004) which was not seen for other urgency groups. Between group comparison ( Figure 4 ) demonstrated a decrease in 1 st (β=-0.25, p=0.005) and 2 nd (β=-0.12, p=0.03) quartile sensation velocities, but no change in sensation velocities for the other quartiles. Sensation index trended toward significance over urgency groups 0 to 3 (p=0.06).

The current study investigates the use of a previously characterized real-time sensation meter to augment the filling phase of urodynamic studies, thereby allowing for higher resolution data collection of patient sensation than methods in current clinical practice. Other groups have developed qualitative methods for assessing patient sensation during filling, however, our data collection allows for detailed quantitative analysis of sensation kinetics in patients which was not previously possible [2] . The sensation meter eliminates investigator contamination/prompting of standard sensory thresholds. With sensation data time-linked to urodynamic data, our method of determining sensation velocities and the derivative sensation index is easily reproducible.

Our findings show that patients with elevated chronic urgency (based on ICIQ scores) have accelerating sensation during filling (J-shaped sensation-capacity curve (example, Figure 2) ) which was not seen for patients with lower chronic urgency scores. In contrast, patients without chronic urgency had high sensation velocities in the first and second quartiles of filling and then remained steady (r-shaped sensation-capacity curve). These findings suggest that bladders of individuals without chronic urgency are able to recognize the sensation of filling but then have sensory accommodation to this filling. The sensation index that we describe in this study allows for an objective comparison of sensation velocity during the first and fourth quartiles of filling. These new metrics for sensation kinetics could represent a novel means to sub-characterize different types of storage disorders and could potentially allow for more targeted therapies.

Concluding message Addition of continuous real-time sensation data during urodynamics permits a detailed and quantitative analysis of patient sensation kinetics during filling. Patterns in sensation kinetics may be useful in distinguishing filling phase pathology, ultimately allowing for more targeted therapy. Hypothesis / aims of study Analysis of detrusor voiding contraction derives increasing attention. A recent publication introduces a derivate of pre-voiding isovolumic pressure increase as a proxy for detrusor (voiding contraction or) contractility. In a small series of urodynamic (pressure flow) tests was shown that 'velocity of initial pressure rise' (dP/dT before flow) had been an indicator for detrusor contractility independent from gender. There is however a paucity of data regarding (pre-voiding) opening detrusor pressure, flow acceleration (before Qmax) and contraction velocity during the voiding. We present clinical epidemiological data to unravel how these parameters relate to gender and to detrusor maximum work during voiding and to outflow conditions. Study design, materials and methods A database with 2180 pressure flow studies (all>45years; 620 women & 1560 men) performed in (men in) preferred position after cystometry until strong (but not extreme) desire to void, was analysed. All voiding volumes were >100mL. Detrusor pressure at the start of flow (P-Open -cmH2O) flow acceleration to Qmax (Accel -mL/s 2 ) and mean (total-) voiding detrusor shortening (contraction) velocity, based on mean flowrate, (Velocit mL/s) were tested for correlation, and also with Wmax (maximum contraction work during voiding) and URA (bladder outlet resistance). Results are given for men and women. Scatter-dot-graphs are presented to show associations between the parameters. 

(Here, PdetQmax is detrusor pressure at the point of maximum flow rate, Qmax is maximum flow rate, Pdet is detrusor pressure, vdet is velocity of shortening of detrusor circumference, Q is flow rate, V is bladder volume, and a, b and Vt are constants.)

We rearranged these equations in order to give Wmax as a function of BOOI and flow rate, allowing lines of constant flow to be plotted on the MH nomogram. This required a fixed estimation (we used 300 ml) for the bladder volume at which Wmax occurs, and the assumption that Wmax coincides with Qmax. In order to test this assumption, Wmax was compared to Watts factor at the point of Qmax in 38 male patients with lower urinary tract symptoms undergoing urodynamics as part of their standard care. Urodynamics was performed according to ICS guidelines.

In the case of equating flow rate to zero, Wmax is given by 3 /10πBOOI. Figure 1 , left, shows the patient data presented by Oelke et al and their MH nomogram centile lines. Our zero flow rate line is superimposed in red and is validated by the fact that the datapoints reach this line but all patients lie above it. Figure 1 , right, shows contours for a range of physiological flow rates (from zero to 20 ml/s in increments of 5 ml/s). We found that these lines closely resemble the centiles on the MH nomogram.

Of the 38 patients studied, data from five patients were excluded due to Wmax and/or Qmax being uninterpretable because of noise, leaving 33 cases for analysis. The mean (standard deviation) difference between Wmax and Watts factor at Qmax was 0.3 (0.4) W/m -2 . The values were within 1 W/m -2 in all but two cases, where detrusor overactivity immediately before voiding resulted in Wmax occurring at the start of the void, and Watts factor then fell towards Qmax a few seconds later. Figure 2 shows Wmax plotted against Watts factor at the point of Qmax for these 33 cases. 

The authors justify their suggested approach on the basis that bladder outlet obstruction brings about an increase in detrusor contractility and that its interpretation should therefore vary according obstruction level. However, owing to the interdependence of the nomogram's axes, it is in effect applying a threshold to flow rate in order to classify detrusor underactivity, and thus discarding the additional information that is provided by invasive urodynamics, namely detrusor pressure. Accordingly, as with flow rate, the nomogram does not distinguish between a low flow situation due to high pressure with high outlet resistance from one due to low pressure and low outlet resistance. This is the aim of urodynamics, in order to select appropriate management, or advise patients of the likelihood of success for treatment of obstruction.

The Maastrict-Hannover nomogram suffers from the same limitations as flow rate in diagnosing detrusor underactivity. Our preferred method to classify detrusor contractility remains the Schäfer nomogram.

Hypothesis / aims of study The penile cuff test allows an accurate non-invasive assessment of bladder contractility in men with lower urinary tract symptoms (1) . This previous work has recognised variability in the agreement between the pressure at which the penile cuff interrupts urine flow (pcuff.int) and simultaneously measured isovolumetric bladder pressure (pves.isv). The cause for the significant variability between the measurements remains unknown but we have previously reported a relationship between the error of non-invasively estimated isovolumetric bladder pressure with cuff size suggesting that larger diameter penile cuffs are more accurate. We aimed to investigate whether any other variables affected the error between pcuff.int and pves.isv, specifically; i) magnitude of pcuff.int ii) stage of contraction iii) time point within the void at which cuff test was performed

We also investigated whether the error was consistent within each patient (for those who had multiple inflations).

Data recorded during the previous study assessing bladder contractility using the penile cuff test were retrospectively analysed using MATLAB software to generate plots of flow rate against cuff pressure allowing further statistical analysis. An allowance was made for a 1 second delay in the flow rate recording as per the original protocol. A full description of the study protocol has been previously published (1) . To summarise; all patients were investigated with an automated penile cuff test, which inflates several times during a void to interrupt flow. A simultaneous pressure flow study was conducted via a double lumen cystometry catheter and rectal manometer line. All traces were evaluated for our current analysis by two separate authors to exclude those which did not meet previously defined quality control criteria.

The 117 previously described studies were analysed and a further seven studies were excluded due to erratic/uninterpretable traces. 110 studies comprising 318 inflations were included in the analysis.

We compared two measurements of intravesical pressure taken at different timepoints during flow cessation -firstly the intravesical pressure taken immediately at flow arrest (pves.int) and secondly the pressure at the end of the 2 second cuff inflation period (pves.endinf) immediately prior to cuff deflation and re-establishment of flow. In 225 inflations (71%) the intravesical pressure was higher after a 2 second period of flow arrest. Magnitude of cuff pressure A good correlation was observed between pcuff.int and error (difference between pcuff.int and pves.int): Spearman's rho = 0.6, p < 0.001, with no relation observed between invasively measured pves.isv and error.

There was no correlation found between whether the detrusor contraction was increasing or decreasing and error between pcuff.int and pves.isv (Spearman's rho =0.04 p=0.4).

The error between pcuff.int and pves.isv was consistent within some patients but not others. Of the 85 patients with more than one valid cuff inflation, for 34 patients (40%) the errors were within 10cmH2O, but in the rest the range was much greater, up to a maximum of 88 cmH2O.

There was a weak correlation between voided volume as a proportion of total voided volume at the point of cuff interruption and the difference between pcuff.int and pves.isv (Spearman's rho = -0.2, p = 0.002). This demonstrated that the closer towards the end of the void inflation occurred, the smaller the difference between pcuff.int and pves.isv .

These results and our previous work suggest that the cuff interruption pressure recorded during the penile cuff test is a valid estimate of the maximum isovolumetric bladder pressure. The difference between absolute values of pcuff.int and pves.isv is in part accounted for by the height difference between the reference point for the two measurements (upper border of pubic symphysis for invasively measured bladder pressures and mid-point of the penile urethra for cuff pressures). However significant variability still exists and this study has suggested possible reasons for this. Our analysis has shown that pcuff.int is closer aligned to the intravesical pressure at the end of the 2 second period of flow arrest rather than the intravesical pressure measured immediately after flow arrest. This is largely explained by the fact that the majority (71%) of men exhibited a rise in bladder pressure after isovolumetric conditions were imposed, which is supported by previous observations (2) . However this was not always the case and for nearly 1/3 of inflations a fall in intravesical pressure during isovolumetric conditions. For some, this was because detrusor contraction was already decreasing in magnitude before flow was interrupted. This may reflect a degree of voluntary inhibition or an inability to produce sustained contractions. The finding of a reduction in the error between pcuff.int and pves.isv during inflations occuriing later in the void suggests that voluntary inhibition during initial inflations may be occurring in some patients. We also observed correlation between the error with magnitude of pcuff.int which may suggest that the error is proportional rather than fixed.

This work suggests that one of the reasons for error between non-invasively derived cuff interruption pressure and isovolumetric bladder pressure may be a degree of voluntary inhibition during cuff inflation. This may be minimised by improved patient counselling and the use of interruption pressures in the latter part of the void. Further work is underway to examine whether this results in reduced variability and improved accuracy of cuff test parameters.

Hypothesis / aims of study There is currently little evidence of the importance of feeling incomplete emptying in our daily practice, not having enough literature which analyses this symptom included in questionnaires. The aim of this study is to assess the level of concordance and validity between this feeling and a high post void residual urine volume (PVR).

Study design, materials and methods A cross-sectional study between december 2016 to january 2017 was performed among patients who came to our hospital to undertake an urodynamic test. They gave us information about whether or not they had feeling of incomplete emptying by filling out a questionnaire based on the first question of the International Prostate Symptom Score (I-PSS). Prior to urodynamic study, all patients performed an uroflowmetry with posterior catheterization, as the gold standard to measure PVR. We considered high PVR over 50 cc of urine volume (1) .

The validity of the feeling of incomplete emptying to help diagnostic orientation was analyzed assessing the sensibility, specificity and the positive and negative predictive value.

In those patients who referred feeling of incomplete emptying, we carried out a descriptive analysis including sex, age, presence of recurrent urinary tract infections (UTIs), diabetes, urodynamic diagnoses, treatment with drugs related to lower urinary tract (alpha-blockers, antimuscarinics, β3-adrenoceptor agonists, 5-alpha-reductase inhibitors, antidepressants, benzodiazepines and botulinum toxin) and history of previous pelvic surgery.

We also compared the relationship between the variables above mentioned and the PVR urine volume obtained, dividing patients in two groups, those with PVR between 50-99 cc and those with more than 100 cc.

The exclusion criteria were: under 18 years of age, no intellectual capacity to read, understand and respond to the questionnaire as well as no previous diagnoses of neurogenic bladder.

Results 39 patients were included in the study, 12 (30,8%) were men and 27 (69,2%) women. The mean age was 50 years (SD 13,19). 85% of the patients presented feeling of incomplete emptying, and a high post void residual urine volume was quantified in 36% of the total cohort.

The specificity of this symptom was 24,0% (IC 11,5%-43,4%), sensitivity was 100% (IC 78,5%-100%), positive predictive value 42,4% (IC 27,2%-59,2%) and negative predictive value 100% (IC 61,0%-100%). The degree of concordance of the feeling of incomplete emptying with high PVR was 0,18 (IC -0,08-0,45). In those patients who referred feeling of incomplete emptying, 42% presented PVR. 35,7% referred previous pelvic surgery and 76,8% was in treatment with a drug from those described previously.

The 57,1% presented a PVR between 50-99 cc while 42,9% presented more than 100cc. According to urodynamic diagnosis, 33,3% of the patients who referred feeling of incomplete emptying was diagnosed as bladder outlet obstruction, 27,3% as detrusor overactivity, 9,1% as sensory dysfunction, 24,2% as detrusor hypocontractility and 6,1% as stress urinary incontinence.

When sub-stratifying patients according to PVR volume, there was no statistically significant association with age, diabetes, presence of recurrence UTIs, urodynamic diagnoses or treatment with drugs related to lower urinary tract.

Having feeling of incomplete emptying should not replace other complementary tests in order to achieve a correct urodynamic diagnose. According to our results, the sensitivity of this symptom is high although specificity is low. For this reason, most of the patients with a feeling of incomplete emptying do not have a high PVR. Therefore, the feeling of incomplete emptying is not predictive of high PVR. However, the lack of this feeling does seem to confirm the absence of a post void residual. . However, precise changes of detrusor contraction pattern remain to be completely elucidated. We reported that the parameter which represent when reach the maximum Watts factor (WF) (Wmax%) could provide the bladder contraction sustainability.

However, Wmax% could not represent the pattern of detrusor contraction completely throughout micturition. Because the WF curve was spiny appearance which could not be a smooth line (because of biological data) and Wmax% itself could not represent the duration of bladder contractility. Wmax% alone could not represent the patterns of bladder energy using throughout the voiding cycle. In the present study, we focused on the detrusor contraction pattern using pressure flow study parameters. A normal detrusor contractility pattern involves a marked increase in WF at the initiation of micturition followed by further gradual increases until the end of micturition (ref.

2). Intuitively, increasing WF values might indicate that the bladder muscles have sufficient physiological reserves. Conversely, decreasing WF values reflect poor contraction function, i.e., the inability to continue detrusor contraction.

Study design, materials and methods We calculated the percentage of when reach the peak of WF (Wmax%) and Area Under the Curve of throughout the voiding cycle (WF-AUC).

Thirty seven patients with clinically localized prostate cancer who were urodynamically evaluated pre and post RP. The urodynamic parameters included the maximum flow rate (Qmax), postvoid residual volume (PVR), Wmax, Wmax% and WF-AUC were examined. All data were represented as mean values ± standard deviation of the mean and all data were analysed using paired Student ttest. P<0.05 was regarded as statistically significant.

Representative examples of pre-and post-RP related parameters for the same patient. Qmax increased significantly, and PVR decreased significantly after RP (Table) . Although Wmax did not changed significantly, Wmax% and WF-AUC was increased significantly.

The contractility of the bladder was quantified using a parameter that approximates power per bladder wall area according to the Hill equation, which calculates detrusor pressure in relation to volume and flow rate. The WF was calculated throughout bladder emptying and plotted as a function of the volume of liquid in the bladder at each moment in time. Conceptually, WF represents the mechanical power generated per unit area of the bladder wall surface. Intuitively, increasing WF values might indicate that the bladder muscles have sufficient physiological reserves. Therefore, Wmax is a measure of detrusor contraction strength at a single point in time, but it is necessary to produce a WF curve throughout micturition to assess overall detrusor contractility. Neither Wmax nor WF provides any information about detrusor contraction sustainability, whereas combination of Wmax% and WF-AUC can be used to detect changes in detrusor contraction patterns. In the current patients setting, both Wmax% and WF-AUC are significantly increased after RP. This could represent the bladder muscles have recovered after RP as sufficient physiological reserves. To confirm our findings, a multicentre study will be critical, and further collection of data (various diseases or conditions) leads to enhancement of scientific reliability.

Sharaf A 1 , Bacon A 1 , Thomas L 1 , Chew C 1 , Hashim H 1

Hypothesis / aims of study Acute urinary retention (AUR) is one of the most common urological emergencies in men. The incidence increases with age and around 30% of men in their 80s will suffer from AUR (1). The commonest cause of AUR in men is benign prostatic obstruction (BPO) (2) . As standard practice, a trial without catheter (TWOC) is attempted usually after starting the patient on an Alpha-one receptor antagonist. If the TWOC fails, the patient may then be offered surgery to treat his BPO. This is commonly in the form of a transurethral resection of the prostate (TURP) (3). Sometimes urodynamics is requested to differentiate between men with bladder outflow obstruction (BOO) and men who have an underactive detrusor on voiding. However, this can be difficult if the patient is unable to void during the cystometry.

This study reviewed all the patients who attended for urodynamics with a long-term catheter after failing a TWOC and assessed the benefit of urodynamics in this group of men.

Study design, materials and methods This is a retrospective study of a urodynamics database from November 2012 until March 2017. All men who suffered from AUR, failed a TWOC and underwent a urodynamic study with a long-term catheter were reviewed. Data collected included age, diagnosis, urodynamic parameters and outcomes. The aim of the urodynamics is to see if there is any detrusor pressure generated to help guide whether TURP is indicated or not.

More than 1350 men were referred to urodynamics, but only 49 men met the inclusion criteria. The median age of these men was 73 (range from 46 -90). Of these 26 (53%) were unable to void during urodynamics and 23 (47%) voided.

The analysis showed that: 36 (73%) were found to either have an underactive (24) or acontractile detrusor (12) . 12 (24%) patients had findings suggestive of bladder outflow obstruction on the ICS nomogram and a normal bladder contractility index (BCI).One patient was found to have a normal urodynamics test and was sent home without a catheter. [ Figure 1 ] Within this sample, only 12 patients were found to have BOO with a median age of 69 (SD 7.8) ranging between 55-82. Of these 12 patients, 9 were listed for surgery (TURP) and 3 had conservative management (1 started on finasteride and 2 continued with a long term urethral catheter). Of the 9 undergoing surgery, 8 (89%) were under the age of 75.

36 patients had an underactive detrusor, the median age was 74 years (range 46-90 years). 31 ended up with a long-term catheter (7 suprapubic and 24 urethral), 4 started intermittent self-catheterisation and 1 had a successful TWOC.

Interpretation of results Our data shows, more than 70% of the patients would potentially fail to improve after a TURP. The majority of patients also failed to void and a result of this, the investigation was not completed. As current practice stands, most men who fail a TWOC after AUR will usually end up having a TURP. However, based on results from this study, urodynamics helped changed the management of patients and avoided them having a TURP.

If urodynamics was not available these men would have undergone unnecessary surgery and ended up with the same outcome prior to surgery i.e. in retention. A randomised control trial is needed to look at the outcome of patients in retention and the value of urodynamics in these patients. 

Hypothesis / aims of study Nowadays, clinical investigations to understand the functionality of the lower urinary tract (LUT) are based on invasive techniques (e.g. use of catheters) for measuring intra-bladder pressure and flowmetry through urethra. These techniques can lead to significant discomfort and possible complications to patients; moreover, they represent for the health agencies an economic burden in terms of costs associated with supplies, and above all they require a great deal of personnel's time; finally, current techniques are inadequate for urodynamic analysis in pediatric subjects. This project expands the work previously carried-out by the same research team on the analysis of the hydraulic behavior of bladder-urethra system. The research is based on a physical model specifically designed and assembled in our laboratory and experiments on water jets issuing from elastic tubes with similar behavior to the urethra and the development of mathematical models suitable to represent the complex phenomena that occur in the LUT in physiological and pathological conditions. Based on the previous results, a new instrumentation for non-invasive urodynamic diagnostic was developed. This instrumentation does not have any parts in contact with the human body, moreover it is characterized by the same diagnostic reliability of the current techniques in use. The basic concept arises from considering the LUT similar to a hydraulic system consisting of a pressure feed tank (bladder) and an outlet elastic duct (urethra) whose physical behavior is governed by the laws of fluid mechanics. Starting from the knowledge of the physical quantities of the urinary jet measurable outside of the urethra it is possible to model the LUT internal urodynamic characteristics.

In this report, we present the preliminary results of a clinical trial with healthy male volunteers designed to test and calibrate the diagnostic reliability of the new equipment.

The prototype (Figure 1 ), developed in the Laboratory of River And Lagoon Hydraulics And Bio-fluid-dynamics of the Department of Civil and Environmental Engineering of the University of our city, consists of a bearing structure of iron L-section bars which has the task of supporting a deflector and a funnel, as in a classic wall urinal; the funnel conveys the fluid in a vessel placed on a digital precision scale. A digital camera is placed on the right side; both instruments have been positioned on supports connected to the bearing structure. The prototype has overall external dimensions of 70x56x133 cm (WxDxH). The data acquisitions of the scale and the camera operate in a synchronous way at a frequency of 5.5 Hz. Both the acquisition and processing are carried out in a totally automatic way, without the need for any intervention by the medical staff, who only needs to input the patient's personal data before the beginning of the test. The patient has to urinate first positioning his feet on a ground mark and then starting the urinary flow horizontally. At the end of the flow a final report with the test's results is automatically printed. The flow rate (Q) was evaluated from the vessel weight variation over time, assuming an average value of 1020 kg/m 3 of the urine density.

The detrusorial pressure (Pdet) was estimated from a series of tests, carried out on our laboratory physical model of the LUT, which relates the output speed of the jet with the detrusorial pressure in healthy people. The jet velocity was calculated from the images of the trajectory taken with the digital camera.

In this first stage, as we have no information regarding the abdominal pressure, we assume Pdet equal to intravescical pressure.

The tests were carried out on 57 healthy male volunteers, aged between 25 and 30 years. Below, Table 1 shows a summary of the performed tests with the corresponding maximum and minimum recorded values, where Ttot is the total voiding time, Vtot the total voided volume, Qpeak the maximum flow, Pdet@Qpeak the bladder pressure recorded in the same time of maximum flow; moreover, well-known urodynamic index OCO (obstruction coefficient), BCI (bladder contraction index) and BOOI (bladder outlet obstruction index) have been evaluated. Note that only the trials with Vtot between 150 and 500 ml were analyzed.

The evaluation of the results was performed by plotting our data in the Schäfer's nomogram and then analyzing OCO, BCI and BOOI. Figure 2 shows the results of our tests on Schäfer's nomogram (currently used in Pressure/Flow Study), where each red cross represents the urinary maximum flow and the associated bladder pressure; it appears that the test results are all in the areas of the chart where the flow is considered not-obstructed (0 and I) and the estimated bladder contractility is considered good (N and ST). Note that the chart area was extended to show maximum flows higher than 25 ml/s. Also, urodynamic parameter analysis gives encouraging results: none of the volunteers shows a clear outlet obstruction (OCO less than 1 and BOOI less than 15) and the bladder contractility is for all normal or strong (BCI more than 100). 

Hypothesis / aims of study The accuracy of different measurement techniques in urodynamics is a topic of current debate [1] . The ICS has given guidance as to the desired accuracy for a urodynamic system, on the grounds that a system is only required to meet a clinical need and is not required to be more accurate than that need [2] . When comparing water-filled systems and air-filled systems, studies in women have shown that the values obtained are different by up to 10 cmH2O [3] , with a recent study even reporting 15 cmH2O. We determined to see what difference such disparity would have on diagnostics in men, where bladder outlet obstruction (BOO) is diagnosed on the basis of measured pressure and flow.

Study design, materials and methods A large database of urodynamic tests covering 32 years of clinical use with water-filled systems was analysed and the pressure flow studies of male patients were extracted. Tests on male patients aged 18 or over and with voided volumes of 150 ml or over only were included. Since BOO is diagnosed using the BOO Index (BOOI), the change in BOOI was calculated for varying levels of disparity in the pressure measurement. The range of 1 to 15 cmH2O disparity was chosen, this being the maximum range of difference found in recent studies between systems using water and air. The BOOI will change by the same amount as the change in pressure at maximum flow, since the Index is directly calculated from that pressure less twice the maximum flow rate. The analysis made is a worst case scenario, because not all of the differences in measurement between air and water systems will be at the limits quoted above. Those figures are the 95% limits of agreement, so many differences seen will be less than 10 cmH2O. Until the reasons for these differences are known, however, clinicians will not be sure which readings are more accurate and should plan according to the worst case examined here.

Another issue which has not been investigated fully is the effect on flow and pressure of the presence of the different catheters used to measure, particularly for the air-filled systems as they place a balloon in the urethra. Studies are apparently planned or are under way to examine this issue.

The choice of measurement system (air or water) in urodynamics will change the diagnosis and management in a proportion of male patients. Comparative urodynamic studies in men with air-filled catheters are imperative before they can be used with confidence in diagnosing obstruction. 

Hypothesis / aims of study Recognizing the growing role of urodynamics (UDS) in advanced urology, residency programs have rapidly incorporated it into their training curriculum. However, there is no consensus on the best methods of teaching UDS application. Therefore, we aimed to determine the most appropriate teaching method with objective evaluation to enhance urodynamic skills, in order to improve quality of teaching and patient care.

Study design, materials and methods Urology residents (n = 20) were randomized according to postgraduate year and training institution to either review a video training module (1) or a teaching document (2), on UDS, prior to an objective structured clinical examination (OSCE). Participants were given a basic questionnaire evaluating age, training level, adequacy of training, estimated UDS interpretation proficiency. The OSCE contained 12 UDS tracings with questions and assessing level of certainty. Two urologists independently established the correct answers. Two blinded, independent graders scored each UDS question to determine competency (0=incorrect, 1=partially correct, 2=correct). Certainty was scored on a scale of 0 to 4 (0 representing a guess and 4 representing 100% certainty).

The median self-reported proficiency was 5 out of 10, mean total score was 13.3 of 24, and overall certainty was 27 of 48. There was significant difference in overall competency between both groups (video: 15.1 ± 2.08, document: 11.4 ± 2.41, P<0.01). Also, the video training module group achieved a higher score on overall certainty (30.7 ± 4.99 versus 22.4 ± 10.3, P<0.05). When analyzing each diagnosis, we found that the mean score for correctly identifying proper calibration and bladder outlet obstruction was significantly higher in the video training module group, while approaching significance for detrusor sphincter dyssynergia (P<0.05) respectively. Overall competency was significantly correlated with self-reported proficiency (r = 0.502, P<0.05), total certainty (r = 0.531, P<0.05), and overall urodynamic experience (r = 0.503, P<0.05).

The overall competency score achieved by the video training group and document module in this study was low (median score =55.4%). In fact, this observation is apparently reflective of the UDS skills being dominated by other graduation requisites such as clinical skills and surgical performance. There is considerable variation within the use of UDS teaching materials and competency appraisal. Residents-in-training are taught using a mixture of tracings from faculty staff collections, various textbooks, and other resources. with didactic teaching sessions being the most frequent and Interactive video tutorials being the least common method

When reviewing residents' opinion for the most preferred urodynamic teaching method, 13 residents (65%) selected real patient practical sessions, and 8 (35%) preferred problem-based learning (case discussion). Most of the participants reported feeling they had received inadequate training allocated to UDS studies during their residency with a mean (SD) score of 4.9 (1.74) on a scale from 0 to 10. Participants recorded their satisfaction level based on a 5-point Likert scale that ranged from 0 to 4, overall mean (SD) satisfaction score was 2.1 (1.02),

In fact, this study does not assign a "magic number" of UDS traces that resident must read, but it does reveal that standard UDS training is insufficient. Moreover, there is a necessity of a standardized systematic exam to accurately assess interpretation.

As with all other practical skills, there is a learning curve, with the interpretation becoming easier with increasing experience. An intensified practical course of UDS consolidation has been suggested to enhance interpretation skills.

Concluding message A urodynamic video training module improved residents UDS knowledge and interpretation skills. These findings highlight the need to incorporate multimedia teaching for UDS interpretation into urology curriculum. Future research should focus on curriculum standardization and optimal learning methods to improve UDS competency. 

Hypothesis / aims of study Accurate estimates of the risks and benefits of different modes of delivery are needed to be able to correctly counsel pregnant women. Although operative delivery increases the risk of immediate pelvic floor trauma, a recent systematic review and meta-analysis found no evidence of increased risk of long-term stress urinary incontinence (SUI) among women with history of operative delivery (1). However, prior studies have neither directly compared forceps and vacuum for risk of urinary incontinence, nor assessed an impact of operative delivery on urgency urinary incontinence (UUI). We aimed to estimate and compare the effects of different kinds of vaginal deliveries on SUI and UUI, using a large prospective population based cohort study.

Study design, materials and methods Every citizen of one county in Norway aged 20 years or older, was invited to participate in two surveys, the first over the period 1995-97 and the second 2006-08, collecting identical information about SUI and UUI using validated items ("Do you leak urine when you cough, sneeze, laugh, or lift something heavy?" (yes/no) and "Do you have involuntary loss of urine in connection with sudden and strong urge to void?" (yes/no)), with severity defined using the Sandvik Index (slight, moderate, severe) (2) . Incontinence data were linked to the Medical Birth Registry of Norway. Women who had given birth at least once before 1967, were nulliparous, pregnant or in the first postpartum year at the time of the questionnaire, or who had any cesarean deliveries were excluded. We used logistic regression to adjust for potential confounders including age, parity, body mass index, and time since delivery. Furthermore, we performed secondary analyses stratified by age (aged less than 50 vs. 50 or more).

The (Figure 2 ). No significant differences were seen in the older age strata, or for UUI.

This is the largest available study of the impact of different types of operative delivery on urinary incontinence. Consistent with data from a recent systematic review showing increased protective benefit from cesarean section only for younger women (1), we observed harmful effects of forceps delivery only for younger women. Although these data suggest that obstetricians should choose vacuum over forceps, at least when considering long-term incontinence, no randomized study is available, and we cannot infer any causal effect from these observational data. Either larger or smaller true effects than we observed are possible, and may have been obscured by differential misclassification or residual confounding, particularly confounding by indication.

Concluding message Forceps delivery is associated with significant increased long term risk of stress incontinence, with a near significant increased risk of urgency incontinence, for women aged <50. In the absence of adequate randomized trials, this forms the best available evidence with which to counsel women. Hypothesis / aims of study Tearing of muscle fibres of the levator ani muscle (LAM) from the pubic bone occurring during delivery, so called major levator ani muscle (LAM) defects are associated with pelvic organ prolapse. The prevalences of major LAM defects diagnosed by ultrasonography range between 13 and 39.5 % in primiparous women within the first year postpartum with the highest prevalences reported shortly after delivery (1). Several studies have described maternal and obstetric risk factors for these LAM defects, however the time of defect diagnosis in those studies range between a few days and up to 6 months after delivery (1). Thereby the time from delivery to diagnosis might influence the postulated associations. Our aim was to assess the prevalence of persisting major LAM defects and maternal and obstetric factors associated with persisting muscle defects at 1 year postpartum in primiparous women.

Study design, materials and methods In this analysis 243 primiparous women with vaginal delivery were included. The overall design of the study was a combined observational cohort study and a randomized controlled trial (RCT) exploring the effect of organized pelvic floor muscle training between 6 weeks and 6 months postpartum. The study was conducted from December 2009 to December 2012 at a large university hospital.

At 6 weeks and 1 year postpartum all women underwent a 3D/4D transperineal ultrasound examination using the GE Voluson E8 (GE Medical Systems) with 4-8MHz curved array 3D/4D ultrasound transducer. The ultrasound images were stored offline by anonymous code numbers and analyzed using 4D View (v. 7.0 and 10.0; GE Healthcare). Major LAM defects were defined by using tomographic ultrasound imaging when an abnormal muscle insertion was present in three central slices; at the plane of minimal dimensions and 2.5 mm and 5 mm cranially to it using a methodology as suggested by Dietz et al. (2) . The evaluation of muscle defects were performed by two of the investigators. Good to excellent inter-and intra-rater agreement for detecting LAM defects found (kappa ≥0.79). We defined two groups according to sonographic findings: "no LAM defect group" with no LAM defect at both times or major LAM defect at 6 weeks, but no persistent LAM defect at 1 year postpartum. The second group, "persistent LAM defect group", included women with major LAM defects at both examinations. Demographic and obstetric data was retrieved from the hospital's electronic birth records. The assessors were blinded to previous ultrasound assessment, the women's demographic data and obstetric histories. Statistical analysis was performed using SPSS Statistics 23.0. Independent sample t-test and Chi-square test were used to assess differences between groups. Logistic regression analysis was performed. Power calculation was performed and the minimum number required in the study to detect a prevalence of 15% of pelvic floor muscle injuries with a 95% degree of confidence with a true population estimate between 10% and 20% was 49.

Mean maternal age of the 243 study participants was 29.7 years (SD 4.1), and the mean pre-pregnancy body mass index (BMI) was 23.7 kg/m 2 (SD 3.9). Mean gestational age at delivery was 281 days (SD 10.0). Mean follow up postpartum was 6.1 weeks (SD 1.0) and 51.6 weeks (SD 3.0 Interpretation of results In our study 50% of the major LAM defects diagnosed at 6 weeks postpartum were not detectable 1 year postpartum. Both overdiagnosing at 6 weeks and/or natural recovery are plausible explanations for this finding. No major LAM defects were diagnosed only at 1 year postpartum, suggesting that a negative diagnosis might safely be diagnosed early postpartum. Previously described obstetric risk factors for major LAM defects diagnosed within 6 months postpartum such as longer second stage of labour, high fetal birthweight and OASIS could be confirmed as factors associated with persisting major LAM defects. This may implicate that the time of major LAM defect diagnosis is less likely to have an impact when conducting and comparing studies on risk factors for major LAM defects.

Several studies have described forceps but not vacuum as an independent risk factor for major LAM defects. In our study population, the majority of women exposed to instrumental vaginal delivery underwent a vacuum-assisted delivery and we found that vacuum-assisted delivery significantly increased the risk of having a persistent muscle defects. This could indicate that it is not only the instrument used to facilitate the delivery that causes trauma to the pelvic floor but the fact that an urgent vaginal delivery by itself is a risk factor. Further, differences in obstetric management between hospitals could be an explanation.

The prevalence of major LAM defects decreases with time after delivery. Negative diagnosis of major LAM might safely be diagnosed early postpartum. Persisting LAM defects 1 year postpartum was found to be associated with known obstetric factors indicating difficult vaginal births. In contrary to other studies vacuum-assisted delivery was found to increase the risk of having persisting LAM defects 1 year postpartum. 

Hypothesis / aims of study During passage of the fetal head, at the time of delivery, the pelvic floor muscles are stretched and compressed against the pelvic sidewall, which could induce injuries. Little is known about normal recovery of the pelvic floor in the first weeks after vaginal delivery. Only one study (1) looked at the ultrasound images of the puborectalis muscle at 4 days and 3 months after first delivery. This study noticed the occurrence of hematomas and abruptions of the muscle from its attachment at the pubic bone. One other study (2) looked at the recovery of the levator hiatus 6 weeks, 6 months and 12 months after first delivery measuring the hiatal area and the rest to Valsalva hiatal area difference. This study showed that the levator ani muscle had the ability to recover, mostly during the first 6 months after delivery. Understanding the normal recovery of the pelvic floor after delivery is of importance when we consider early interventions to improve this recovery. Our aim is to use measurements of the levator hiatus after delivery compared to pregnancy state as a marker for recovery of the muscle.

This study is part of a prospective multicenter cohort study. Study population: Pregnant nulliparous women with a singleton pregnancy attending the prenatal clinic. Methods: Performing ultrasound assessment of the pelvic floor at 12 weeks gestation. Twenty out of a total of 306 women will have ultrasound follow-up after vaginal delivery (at 1 day, 1 , 2 , 3 , 4 , 6 ,12 , 18 and 24 weeks after delivery) to assess regeneration after delivery trauma. A perineal ultrasound is made at rest, on contraction and on Valsalva maneuver. We investigate the levator hiatus during recovery/regeneration. The analysis was performed offline. After storage on a hard disk, offline analysis was performed using 4D View 7.0 (GE Medical Systems Kretztechnik, Zipf, Austria). The correct plane of the puborectalis muscle in axial position is selected, levator hiatus was calculated and contractibility and distensibility were computed by subtracting hiatal area on contraction from hiatal area at rest and hiatal area at rest from hiatal area on Valsalva maneuver, respectively. Statistical analysis was performed with SPSS version 22.0 for Windows using median, range and the Wilcoxon Signed Rank Test with p < 0.05 considered significant.

Hiatal areas at 1 week postpartum during rest, contraction and Valsalva were significantly increased, compared to 12 weeks' gestation. Hiatal areas during contraction and Valsalva remained significantly increased at 6 weeks postpartum compared to 12 weeks' gestation. The hiatal areas at 12 weeks postpartum remained significantly increased compared to 12 weeks' gestation but only during Valsalva maneuver. There were no significant differences in hiatal area at 24 weeks postpartum compared to 12 weeks' gestation. The difference in hiatal area between rest and contraction (contractility) was significantly lower at 1 week and 6 weeks postpartum compared to 12 weeks' gestation. The difference in hiatal area between Valsalva and rest (distensibility) was significantly increased at 6, 12 and 24 weeks postpartum compared to 12 weeks' gestation. Interpretation of results After first vaginal delivery, levator hiatal area increased. But the levator ani muscle is able to recover within 24 weeks after delivery. Recovery occurs in resting state first (6 weeks after delivery), than women will be able to contract again (12 weeks after delivery) and the ability to do the Valsalva maneuver with a smaller hiatal area is the last stage of recovery (24 weeks after delivery).

Complete levator ani muscle recovery after fist delivery is seen at 24 weeks after delivery and not yet at 12 weeks after delivery. This knowledge is important to understand pelvic floor complaints postpartum and to decide if (future) therapy should be initiated.

Hypothesis / aims of study Pelvic floor muscle trauma occurring during vaginal delivery is an important risk factor for pelvic organ prolapse, urinary and faecal incontinence later in life (1, 2) . Previous studies have found increasing prevalence of incontinence and prolapse symptoms associated to increasing parity (3). Our aim was to investigate the association between vaginal parity and injury to the levator ani muscle (LAM) and the anal sphincters.

Study design, materials and methods We conducted a cross-sectional study in 2013-14 among women 847 who delivered their first child in 1990-97. Information about mode of delivery and parity was obtained from the National Birth Registry. The women underwent a pelvic floor ultrasound scan with a GE Voluson S6 device, using the RAB 4-8 RS abdominal threedimensional probe with an acquisition angle of 85 o . Four dimensional ultrasound volumes were acquired at rest, contraction and Valsalva maneuvre. Off-line analysis of the ultrasound volumes was performed using the 4D View Version 14 Ext.0 software 6-32 months later, blinded to all clinical and obstetrical data. Tomographic ultrasound imaging was used for evaluation of the LAM. A significant LAM injury was defined as a unilateral or bilateral abnormal insertion of the most medial fibers of the LAM to the pubic bone present in the plane of minimal levator hiatal dimensions and the planes 2.5 and 5 mm cranial to this. Levator hiatal area at Valsalva was measured in the plane of minimal hiatal dimensions in a rendered volume of 1-2 cm thickness. For the anal sphincters a set of eight slices was obtained on tomographic ultrasound imaging, where the entire external anal sphincter (EAS) was encompassed by placing the upper slice cranial to the EAS (at the level of the puborectalis muscle) and the lower caudal to the internal anal sphincter (IAS), at the level of the anal verge. The distance between each slice was adjusted depending on the length of the EAS, leaving six slices to delineate the entire muscle. The IAS was assessed with the first slice cranial to the IAS (at the level of the anorectal junction) and the most distal slice at the level of the subcutaneous portion of the EAS. Diagnosis of significant injury to the EAS or IAS was defined as ≥30° defect of the circumference in ≥4/6 planes on tomographic ultrasound imaging. Then the proportion of women with LAM injury and significant EAS and IAS defect on ultrasound according to vaginal parity was calculated. Mean (SD) hiatal area at Valsalva was calculated. One vaginal delivery was used as reference, and Chi-squared test and Fisher's Exact test was used to compute odds ratios (OR) for comparison of the proportion of women with trauma after 0, 2, 3 and ≥4 vaginal deliveries compared to the reference group. Independent samples t-test was used to compare mean difference (MD) in levator hiatal area at Valsalva between the groups. p<0.05 was counted as statistically significant.

A total of 608 women attended the clinical and transperineal ultrasound examination. Mean age was 48 years, mean total parity 2.2, mean BMI 25.8 kg/m 2 . Hundred and one women had only delivered by caesarean section (vaginal parity 0). Of vaginal parous women 156 had forceps and 131 vacuum at first delivery and 217 had normal vaginal delivery and no subsequent forceps/ vacuum. Table 1 shows the proportion of women with muscle injury according to vaginal parity. Table 2 is a comparison between groups of women with different vaginal parity. The tables demonstrate increased risk of pelvic floor muscle trauma after one vaginal delivery, and no further increase after subsequent vaginal deliveries.

Interpretation of results LAM injuries, EAS and IAS defects were not found among women delivered exclusively by caesarean section, with a marked step in prevalence from 0 to 1 vaginal delivery. A similar effect was found for levator hiatal area at Valsalva with increased hiatal area after 1 vaginal delivery. The only significant difference in prevalence of pelvic floor muscle trauma was found between women with vaginal parity 0 (caesarean section) and 1 vaginal delivery, with no significant effect of subsequent vaginal deliveries. This implicates that most muscle trauma of the pelvic floor occur during the first vaginal delivery. The effect of vaginal parity on symptomatic pelvic floor disorders was not part of this analysis and we cannot exclude an effect of increasing parity on prolapse and incontinence symptoms. Strengths of this study are the large number of women included and the long follow up after first delivery. The National Birth Registry provides high quality of data regarding mode of delivery and parity. Furthermore, standardised criteria for the definition of significant LAM injury, EAS and IAS defects and levator hiatal area were used. We analysed four different variables of pelvic floor anatomy in relation to vaginal parity, which to our knowledge has not been performed previously. A substantial part of the women in this study had forceps at first delivery. Forceps is an independent risk factor for pelvic floor muscle trauma. It is possible that the effect of subsequent deliveries could have been stronger in a population with lower proportion of operative vaginal deliveries at first childbirth.

Vaginal parity was strongly associated with pelvic floor muscle trauma. After the first vaginal delivery, no significant additional effect of subsequent deliveries was found. On a population level, there would probably be no benefit of performing a caesarean section for secondary prevention of pelvic floor muscle trauma for women who have had one vaginal delivery. This does not exclude that for some women, especially with sphincter defects and anal incontinence, a caesarean section in subsequent pregnancies could be beneficial in order to prevent worsening of incontinence symptoms. 

Hypothesis / aims of study Patient Reported Outcome (PRO) questionnaire are increasingly considered the keystone in Pelvic Floor Disorders assessment [1] . An innovative English language multidisciplinary electronic Personal Assessment Questionnaire (ePAQ-PF®) has been psychometrically validated in 2006 [2] . A certified Italian version of ePAQ® (I.ePAQ-PF®) has been made available by the Italian Society of Urodynamics (www.siud.it). To assess usefulness and validity of the urinary dimension of I.ePAQ-PF® we tested its psychometric properties.

Study design, materials and methods Patients presenting for Lower Urinary Tract Symptoms (LUTS) and undergoing Urodynamics (UDS) at our Unit were included. The study received IRB approval. After consent women filled-in the I.ePAQ-PF® via a dedicated touch-screen display (T0). The patients also completed an acceptability questionnaire to rate I.ePAQ-PF® for positive and negative features and some concurrent questionnaires: ICIq-SF, USS, UDI and PGI-I. To test reliability the questionnaire was completed again after one week (test-retest) in 47 cases and the Pearson's Coefficient was analyzed. The Spearman's correlation and the acceptability questionnaire were adopted for validity and face validity. Finally to assess responsiveness the questionnaire was administered again after treatment (T1) and results were analyzed with the Cohen's Effect-Size, the Standardized Response Mean, the Responsiveness Statistic (>30% = considerable change) [2] Interpretation of results I.ePAQ-PF® seems to be highly reproducible (>0,9 Pearson's coefficient) in all domains both at T0 and T1 with the single exception of QoL at T0. More than 95% of patients express a positive view and more than 70% disagree with negative features while judging the questionnaire, with the major concern as to the questionnaire being too long. Spearman's correlation test shows a good correlation (>0.6) between I.ePAQ-PF® domains and corresponding domains of conceptually competitors questionnaires. The questionnaire is also responsive to changes: answers in every domain are significantly different between T0 and T1 (tab 4) and this is further confirmed by Cohen's Effect-Size, the Standardized Response Mean and the Responsiveness Statistic, all above the 30%.

Concluding message: The Italian version of ePAQ-PF® (I.ePAQ-PF®), in its urinary section, fully meets the psychometric properties of validity, reliability and responsiveness. The questionnaire is now ready for clinical application in Italian language patients. 

Hypothesis / aims of study Tapes and meshes used for the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse can lead to complications that require additional surgical procedures. Our objective was to evaluate the indications and clinical outcomes of patient who suffered tape/mesh surgical revisions.

Study design, materials and methods After institutional review board approval, this original retrospective study was conducted in a tertiary referral center and included all consecutive women who underwent a synthetic tape/mesh surgical revision, from January 2008 to September 2016. For all eligible subjects, the following data were collected: demographics, past medical history, information on initial synthetic tape/mesh surgery if available, symptoms preceding revision surgery, surgical revision indication, postoperative complications and their management. Complications of the initial synthetic tape/mesh were classified according to the ICS/IUGA prosthesis complication classification.

Overall 140 women, with a mean age of 60. 5 Interpretation of results Surgical indications for tape/mesh surgical revisions are multiple and diverse ranging from vaginal erosion/extrusion to infections. Revision surgery indication and postoperative complication rates in this current study are comparable to what has been reported in the literature. The fact that revision surgeries can lead to the recurrence of patients' initial complaints and/or can fail to alleviate their symptoms emphasizes the complexity of such surgeries.

Complications related to tapes and meshes can require a surgical revision. Although most symptoms resolved after surgical revisions, patients must be informed that symptoms may persist. Recurrent or persistent SUI may require a subsequent surgical procedure. 

Hypothesis / aims of study The aims of this study were to evaluate the postoperative subjective outcome and satisfaction in female patients who underwent sacrospinous ligament fixation (SSLF) with and without concomitant hysterectomy for treating pelvic organ prolapse (POP).

Study design, materials and methods Female patients who underwent surgery for POP at A University Hospital from January 1994 to December 2007 were included in this study, consecutively. In this retrospective study, all patients underwent a unilateral vaginal SSLF (right side of patient) with or without vaginal hysterectomy and concomitant anterior-posterior vaginal wall repair. We reviewed the chart records for preoperative and postoperative history, pelvic examinations, urodynamic studies, early postoperative complications, or adverse effects related to this procedure. The subjective outcome of the operation was measured by patient self-reports as successful, improved, or failure of treatment, assessed by a nursing coordinator who interviewed patients by telephone in May 2008 and July 2016. Global improvement of POP was used to assess the outcome of treatment. Regarding the patient's overall impression of the procedure, two main questions were asked of these women. For the patient's perception of the operation's outcome: "Do you consider this operation to have been: successful, an improvement, or a failure? If you consider it a failure, when did it start to fail?" For present satisfaction: "Compare your present situation with that before the operation, do you feel satisfied with the outcome, and if not, when did your dissatisfaction begin and what are the symptoms that bother you?" Kaplan-Meier analysis was used to demonstrate the operative outcomes and self-reported satisfaction. Cox proportional hazard model was used to evaluate the correlation between various associated factors and the outcome of the operation in 2008 and 2016.

A total of 210 patients were included in this study. After a mean follow-up of 13.58years (range: 9-23 years), 171 (81.4%) patients responded to the telephone interview by July 31, 2016. The mean age was 59 years (range 27-88) at operation and median parity was 4 (range 0-11). A total of 107 (62.6%) patients had a history of hysterectomy or concomitant vaginal hysterectomy during the operation and 64 (37.4%) patients had sacrospinous hysteropexy with uterine preservation. Voiding difficulty (11.6%) is the most common post-operative complication. De novo frequency/urgency and buttock pain presented as 8.1% and 6.1 % respectively. The subjective patient-reported outcomes were: 41% (70/171) said that the operation was successful, 49.1% (84/170) had improved, and 9.9% (17/171) had failed.

One hundred and forty-nine (87.1%) women were satisfied with the outcome of the operation in 2016. The adjusted hazard ratio for uterine preservation in 2008 was significantly better than patients without uterine preservation. However, the adjusted hazard ratio for uterine preservation was 0.7 (95% CI 0.2-2) in 2016.

Our results imply that SSLF with uterine preservation has significantly better outcome at mid-term (< 10 years) follow-up than SSLF with concomitant hysterectomy for treating POP. However, there is no significantly statistical difference between long-term outcome of SSLF with and without hysterectomy. 

Hypothesis / aims of study: The internal pudendal artery (IPA) is one of the main arteries irrigating the pelvic floor muscles (PFM) and vulvo-vaginal tissues. Assessment of its blood flow with color Doppler ultrasound has been done before, proximally at the level of the ischial spine and more distally at the level of its terminal branch, the dorsal clitoral artery. Test-retest reliability of those two arteries' vascular parameters has been done recently in young women. However, reliability has not been assessed in women with genitourinary syndrome of menopause (GSM) yet. Assessing blood flow in this subpopulation (along the length of the IPA) may be important as menopause could affect vulvo-vaginal vascularity. Therefore, the purpose of this study was to assess the test-retest reliability of clitoral and IPA blood flow measurements at rest and after repeated PFM contractions in women using color Doppler ultrasonography.

Study design, materials and methods: Women aged 55 years old and older with GSM participated in this test-retest cohort study. Exclusion criteria were pathology or medication likely to interfere with blood flow measurements. Dosage of hormonal therapy or arterial hypertension medication had to be stable for six months to ensure perineal blood flow stability. One observer performed the two repeated measurement sessions of the clitoral and the IPA blood flow (T1 and T2) two weeks apart at the same time of the day (±2 hours). Caffeine and tobacco intake, sexual activity, physical activity as well as creams or other product applications in the vulvar and gluteal area were controlled for a period of 24 hours before the assessment as it has been shown to influence blood flow parameters.

Participants were asked to rest in the supine position for 15 minutes to ensure standardized conditions. Using a clinical ultrasound system (Voluson E8, GE healthcare) with a 4-13 MHz linear probe according to the procedure described by Khalifé et al [1] , three consecutive clitoral blood flow measurements were taken at rest and after a standardized PFM contraction protocol. Then, participants took the prone position and rested for an additional 15 minutes. With a 2-7 MHz curved-array probe on the participant's right gluteal area according to Kovac's procedure [2] , IPA blood flow measurements were again taken three times at rest and after the PFM contractions protocol. Each time, peak systolic velocity (PSV), time-averaged maximum velocity (TAMX) and pulsatility index (PI) were collected. Test-retest reliability of clitoral and IPA blood flow was assessed using the paired t-test, the intraclass correlation coefficient (ICC) and Bland-Altman plots.

Results: A total of 20 women aged between 57 and 82 years old (68.1 ± 7.1 years old) with a mean parity of 1.7 ± 1.1 delivery and a mean BMI of 26.7 ± 4.6 were recruited. Thirteen were sexually active, one was taking systemic hormonal therapy and four were taking local hormonal therapy. Among the data set, 18/20 measures were adequately visualized for the clitoral blood flow analysis and 16/20 for the IPA blood flow analysis.

Clitoral blood flow At rest, there was no significant difference between T1 and T2 for all parameters. Based on the ICC results, PSV and TAMX parameters showed excellent reliability while PI showed fair to good reliability (Table 1) . Bland-Altman plots demonstrated minimal bias with the mean difference close to zero for all parameters. The 95% limits agreement range was narrow only for PSV parameter, indicating a high consistency between both tests (Table 1) .

After PFM contractions, there was no significant difference between T1 and T2 for all parameters. Based on the ICC results, PSV showed excellent reliability while TAMX showed fair to good reliability (Table 1) . Poor reliability was found for PI parameter in this condition (Table 1) . Bland-Altman plots demonstrated minimal bias with the mean difference close to zero for all parameters and the 95% limits agreement range was narrow also for PSV parameters after PFM contractions (Table1).

IPA blood flow At rest, there was no significant difference between T1 and T2 for all parameters. Based on the ICC results, PSV parameters showed excellent reliability while TAMX and PI showed poor reliability ( Table 2) . Bland-Altman plots demonstrated minimal bias with the mean difference close to zero for PSV parameters with a narrow 95% limits agreement range ( Table 2) .

After PFM contractions, there was no significant difference between T1 and T2 for all parameters. Based on the ICC results, PSV showed excellent reliability while TAMX and PI showed fair to good reliability (Table 1) . However, Bland-Altman plots demonstrated minimal bias with the mean difference close to zero for all parameters, but the 95% limits agreement range was narrow for only PSV parameters after PFM contractions ( Table 2) . Interpretation of results: Results from this intra-observer test-retest reliability study indicates high correlation with no significant mean difference for PSV measurements of the clitoral and the IPA blood flow in the two conditions: at rest and after PFM contractions. Those results were confirmed by the Bland-Altman plots analysis, which showed narrow limits of agreements. Reliability of TAMX and PI parameters were poor at rest and after PFM contractions. Assessment of the IPA blood flow obtained lower reliability results compared to clitoral blood flow measurements because of a higher difficulty level in finding and measuring this artery.

Only two other studies in healthy younger women have evaluated clitoral blood flow measurement's reliability using color Doppler ultrasonography. Khalifé et al. assessed PSV and PI measurements test-retest reliability at rest, and found results similar to ours [1] . Mercier et al. reported excellent reliability at rest and after PFM contractions for the PSV and TAMX parameters for the clitoral blood flow and for the PSV parameter for the IPA blood flow, again with similar reliability coefficients [3] . Of note, reliability of TAMX and PI parameters were better in younger women then in post-menopausal women.

Concluding message: Our research findings are original as they suggest that PSV are reliable parameters of clitoral blood flow and IPA blood flow at rest and after PFM contractions in post-menopausal women. These parameters can form the basis of further research on the perineal vascular properties. 

Hypothesis / aims of study Currently, there is limited published data on the association between vaginal vault and introital defects before and after posterior repairs (PR). We hypothesize that there may be both: (i) a positive association between the size of vaginal vault (Level I) and introital (Level III) defects preoperatively; and (ii) a positive association between the reduction of these defects postoperatively if vault suspension (sacrospinous colpopexy -SSC) is used.

In a cross-sectional study of 300 consecutive PRs, the following were measured pre-and immediately postoperatively: 

Results are detailed in Table 1 . Mean (SD) pre-operative GH and PG were both larger in the SSC versus no SSC group: GH SSC was performed in 84% cases, not performed in 16% cases.

The mean (SD) post-operative reduction in GH (antero-posterior) was 29% (P =0.002), significantly greater 1.1 (0.69) cm (29.5%) in the SSC group and 0.77 (0.49) cm (22.9%) in the no SSC group. The decrease in PG (transverse) was greater by 11% (P=0.05) -2.91cm vs 2.61cm (11.5%) in the SSC vs no SSC group.

Level I and III defects are associated at PRs; preoperatively larger vaginal vault (PVVD over 5cm) and larger introital defects (GH and PG).

Postoperatively, the use of vault fixation resulted in significantly greater reduction in the antero-posterior (GH) and transverse (PG) measurements of the introital defects, than if vault fixation was not used.. To our knowledge, this latter finding has not previously been cited.

Concluding message There is a positive association between vaginal vault and introital defects before and after posterior repairs (PR). (1) Vaginal vault fixation (Level I) will significantly improve the vaginal introital (Level III) repair. (2) An effective and reproducible posterior prolapse repair should involve proper measurement of anatomical defects (including PG and PVVD from PR-Q 1,2 ). (3) Vaginal vault (Level I) fixation (SSC) is recommended if PVVD >5cm (around 84% cases). (4) Level III repair (100% cases) simply involves the excision of the perineal gap (PG) and repair, eliminating the PG and reducing the GH by around 30%. 

Hypothesis / aims of study We aim to demonstrate the reconstruction of anterior compartment defects with magnetic resonance (MR) visible vaginal mesh implants, and measure their postsurgical location and dimension relative to the bony pelvis and important anatomical structure.

Study design, materials and methods This is a proof of concept study from a prospective multi-center study with IRB approval evaluating women surgically treated with anterior vaginal mesh-repair using a MR-visible Fe3O4-polypropylene implant with six fixational arms (Seratom E PA MR, Serag Wiessner, Naila, Germany) for pelvic floor reconstruction. Written informed consent was obtained in all cases. High resolution sagittal T2-weighted sequences, transverse T1-weighted (T1w) FLASH 2D and transverse T1w FLASH 3D sequences were performed on a 1,5 T scanner in this trial to evaluate Fe3O4-polypropylene mesh MR-visibility and overall postsurgical pelvic anatomy three months and one year postsurgical. Full mesh course and important pelvic structures were reconstructed using the 3D Slicer® software program based on T1 and T2 MR-images ( Figure 1 ). Mesh dimensions to determine the functional postsurgical mesh length and effective size were evaluated. Furthermore, the implanted mesh location relative to the bony pelvis (e.g. distance to pubic symphysis, obturator foramen and ischial spine) and to important neurovascular structures (pudendal and obturator nerve/vessel bundles) was measured ( Figure 2 ). Regarding all performed measurements, the original mesh dimensions as constructed by the designers (e.g. mesh length of approximately 103 mm) were taken into consideration.

Six women with symptomatic POP-Q grade III cystoceles were successfully treated with a partially absorbable MR-visible anterior vaginal mesh with sacrospinale fixation showing no adverse event or recurrent cystocele in the 3 months and the 1 year follow-up examination. The course of the mesh and its arms in the pelvis was visible on T2 and T3 MR-images and reconstructable in five 3 months MRIs (patients A-E) and 2 one year MRIs (patients A & F) which had satisfactory image quality. Measurement results regarding mesh length and distances between pudendal vessel-nerve bundles are demonstrated in table 1. Distances between the locations of the posterior arms penetrating the sacrospinous ligaments and pudendal nerve/vessel bundles vary from 3 mm to 18 mm. 

The distances between implanted anterior arm and middle arm presented smaller than the designed distance ( Figure 2 , Panel a) and a double layering of the mesh was observable in the distal mesh part, possibly, due to the fact that in this used implant four arms (anterior and middle) are diverted outwards through the obturator foramen. Compared to the by the constructor given mesh length of 103mm, the postsurgical mesh length evaluated appears shorter with only 45-62 mm. There are variations in the implanted mesh location relative to the bony pelvis and obturator and pudendal nerve/vessel bundles. The penetration point of the sacrospinous ligaments by the posterior arms vary largely within the subjects evaluated.

The use of MR-visible Fe3O4-polypropylene meshes in combination with postsurgical 3D reconstruction of the mesh and important adjacent anatomic structures is feasible and reproducible within the same subject over time and between different patients. Inner pelvic measurements are also reproducible and suggest that this combined technique might be a useful tool to more precisely evaluate the postsurgical mesh location, possibly occurring complications and that it might be a valuable interactive feedback tool for surgeons and mesh design engineers for we could demonstrate variations of postsurgical mesh size, dimension and inner pelvic location of the identically constructed implant. 

Hypothesis / aims of study An in vivo study was conducted to evaluate the cellular and biomechanical properties of six long-term biodegradable polycaprolactone (PCL) meshes. The six meshes, comprising basic fibroblast growth factor (bFGF) and connective tissue growth factor (CTGF) including rat mesenchymal stem cells (rMSC), were tested in a full-thickness abdominal wall defect model in rats to mimic the weakened vaginal wall in women with pelvic organ prolapse (POP). The study was based on the hypothesis that bFGF-loaded PCL-meshes enhance collagen formation through direct stimulation of fibroblasts (1) . Furthermore, that CTGF will direct the differentiation of rMSC into fibroblasts thus improving the regenerative response in vivo (2) .

Study design, materials and methods Randomly, 84 rats were divided into three groups with two arms in each group. The groups were: (1) Hollow fiber PCL-meshes with bFGF; (2) Solid fiber PCL-meshes with bFGF; (3) Solid fiber PCL-meshes with CTGF and rMSC. bFGF in dosages of 4.8 ug and 48 ug, respectively, was loaded in the core of the hollow fiber meshes. Solid fiber meshes were embedded in either 10 ug bFGF or 9 ug CTGF; 2.5 x 10 6 rMSCs were cultured, expanded and seeded on the sterile CTGF-coated solid fiber mesh ( figure  1 ). The meshes consisted of biodegradable PCL fibers fabricated by electrospinning, where a mesh of hollow and solid fibrous nanostructure were spun, respectively.

A full-thickness part of the abdominal muscle-fascia layer was resected en bloc followed by implantation of a mesh covering the defect and 0.5 cm of the surrounding tissue. After eight and 24 weeks, seven rats from each arm were euthanized. The mesh area including one cm adjacent tissue was resected and divided into four sections for subsequent analysis. Evaluation at week eight and 24 included quantitative polymerase chain reaction (q-PCR) for mRNA-expression of collagen-I and -III, Western blot for protein assessment of collagen-I and -III and Hydroxyproline quantification for total collagen content.

Histologically, the sections were stained with Masson's trichrome, blinded and evaluated to quantify the presence of giant cells, mesh thickness and collagen amount, individually ranked between none (0) and abundant (4) . Biomechanical properties of the explanted mesh were tested by uniaxial mechanical testing.

After 24 weeks, the hollow fiber meshes were fully degraded both macroscopically and microscopically causing herniation of the mesh area. On the contrary, the solid fiber meshes were intact after 24 weeks providing biomechanical reinforcement to the weakened abdominal wall. The PCL-meshes were associated with multiple complications, such as localized abscess formation and hematoma, except from the solid fiber PCL-mesh with rMSC, where no complications were observed neither at eight nor at 24 weeks. Students t-test revealed a significantly higher protein amount and mRNA expression of collagen-I and -III after 24 weeks for the hollow fiber meshes with 4,8 ug bFGF compared to 48 ug bFGF (p< .05) (figure 2).

Analysis of variance (ANOVA) with Dunnett's test showed a significant difference between the solid fiber PCL-mesh with rMSC and muscle-fascia with respect to ultimate tensile strength after eight weeks (p< .05). Furthermore, the solid fiber PCL-mesh with rMSC showed a significantly higher stiffness compared to the solid fiber PCL-mesh without rMSC after 8 weeks (p< .01).

The hollow fiber meshes were fully degraded after 24 weeks resulting in herniation of the mesh area indicating an undesirable degradation rate of the hollow PCL-fibers compared to neo-tissue formation. The herniation tendency following implantation of hollow fiber PCL-meshes was also demonstrated by Glindtvad et al. (3) . The mechanical tests demonstrated lower ultimate tensile strength and stiffness for the hollow fiber meshes compared to solid fiber meshes. This suggests, that hollow fiber PCL-meshes do not meet the criteria for the optimal tissue-engineering strategy in the treatment of POP, because the degradation rate is too fast. Differently, SoCTGF+rMSC showed higher stiffness compared to the corresponding mesh without rMSC and muscle-fascia. Western blot and q-PCR analysis detected higher amounts of collagen-I and -III in HoLbFGF compared to HoHbFGF after 24 weeks thus demonstrating that collagen synthesis is not dependent on a high dosage of bFGF. Interestingly, none of the rats in SoCTGF+rMSC developed complications at eight or 24 weeks whereas the corresponding PCL-mesh, SoCTGF, was associated with severe abscess formation. This indicates a beneficial effect on the inflammatory response due to rMSCs thus reducing the risk of abscess formation through non-explored mechanisms of action. In the present study, a higher protein amount of collagen III was detected for SoCTGF+rMSC compared to SoCTGF after 8 weeks. At 24 weeks, the difference was reversed. This could imply an initial differential stimulus of the rMSCs and hence an increased collagen formation as described by Jangö et al. (2) .

Concluding message SoCTGF+rMSC is a potential alternative to conventional POP-repair because of the lack of complications and because of biomechanical reinforcement of the weakened abdominal wall, which is a preferable feature from a clinical safety point of view. Furthermore, we found no dose-response relationship between growth factor-dose and collagen neoformation. 

Hypothesis / aims of study There was not yet report on visualizing flow at voiding from baldder neck in vivo. We visualized urine flow from internal view of bladder neck using by wireless capsule endoscopes (WCEs) for cystoscopy at voiding in vivo.

Study design, materials and methods Methods: Experimental evaluation of capsule cystoscopy was performed in a 5-kg female rabbits(n=6). The capsule was inserted after incision of bladder. Images were continuously transmitted at a rate of four frames per second to a laptop computer and processed using proprietary software. Manipulation of the WCE within the bladder was performed using a set protocol. We measured the ability to deploy and manipulate the capsule within the bladder. Feasibility of capturing and retrieving images in real time was also assessed. We used air(injection by syringe) and dye(intravenous administration of indigo carmine) as urine flow tracer. Results: The WCE was efficiently deployed and manipulated within the bladder passively by manual. The entire bladder mucosa real-time image transmission and capture was visualized.

The Interpretation of results By this device, urine flow could be visualized a vortex at the bladder neck mucosa during voiding.

We had first report on vizualization of vortex of rabbit bladder neck. 

Hypothesis / aims of study Urinary incontinence (UI) and falls are clinically connected conditions in older adults. Despite evidence of UI as an independent risk factor for falls (1), there is a lack of acknowledgement and application of this association in both continence promotion and falls prevention clinical practice guidelines and primary and community health care practices. Given the strong research evidence, the relationship between these two conditions needs to be routinely addressed and treated in older adults presenting with falls or UI. The aims of this study were to: 1) Mobilize the research knowledge that supports the connection between falls and UI into action to address a current care provision gap; and 2) Develop a preliminary set of consensus-based practice principles related to falls prevention and UI for relevant stakeholders in community-based primary health care.

Study design, materials and methods This study was informed by the Knowledge to Action (K2A) framework for knowledge translation and followed Delphi consensus methodology (2) . The Delphi process commenced with a comprehensive literature review. Next, an expert panel (n=12) was purposively assembled from the disciplines of rehabilitation, nursing, research, policy and patient safety. All panelists participated in the four phases of the consensus process.

In phase one, an online survey was distributed to participants in order to gather their perspectives on the topic of falls and UI. Questions were posed regarding effective treatments and the barriers and facilitators of managing both UI and falls in older adults.

In phase two, an in-person meeting took place (May 11, 2016). At the meeting, presentations were delivered on falls, UI, and the relationship between UI and falls, each incorporating findings from the literature review and the phase one survey responses. After each presentation, participants discussed the evidence and determined potential practice indicators. A practice indicator was defined as an actionable item that a health care professional would enact, such as, include questions about UI in every falls assessment. In phase three, a follow-up online survey was sent to each panellist in which they were asked to rate the indicators on a 1-5 scale based on: 1. Potential for improvement in clinical practices; 2. Impact on patient outcomes; and 3. Feasibility of abstracting the data. In phase four, a follow-up teleconference took place (July 6 th , 2016). Final consensus of the items was determined at this concluding meeting.

In phase two, 37 potential practice indicators where generated. By phase four, 16 of the 37 indicators achieved consensus as practice principles.

The following parameters were used to establish consensus:

• Indicators with a score greater than one standard deviation (SD) above the mean were kept; • Indicators with a score greater than one SD below the mean were discarded; and •

Indicators that fell within one SD of the mean were discussed in phase four to determine if they should be included or removed.

The above process was iterative and further analysis included organization of the developed practice principles into three categories. Refer to Table 1 . 

Include questions about UI in every falls assessment. Ask client directly "Do you have any trouble getting to the bathroom dry?" Make UI screening a part of every community care assessment by every discipline, including: nursing, physiotherapy, occupational therapy, speech language pathology, registered dietician, and social work.

Common care plan developed and communicated to all care providers when a client is identified as having UI and at risk for falls.

Interdisciplinary team approach to falls prevention programs. Interdisciplinary team approach to UI prevention. Increased education to health care professionals on aging process and functional decline. Education re: safe and optimal use of gait aids. Education to patients/health consumers to reduce the amount of time spent in a seated position.

Patient/health consumer education to include bridges, lunges, repeated sit to stand and wall push-ups as standard health promotion exercises. Treatment plan is implemented for clients at risk. Inclusion of posture and diaphragmatic breathing exercises and education in treatment programs Pelvic floor muscle retraining is implemented for clients with UI.

To our knowledge, this is the first study to transfer the knowledge of the connection between falls and UI into action through the development of consensus-based practice principles. Findings from the online survey in phase one corroborated with the scientific literature on the topic of falls and UI, pointing to a clear practice gap that requires bridging. The sixteen indicators, derived by consensus, represent an important first step towards more comprehensive and robust practice principles related to falls and UI. Given that feasibility was one of the parameters in which the panellists rated the developed practice indicators, the final list of preliminary practice principles are not only evidence-informed, but were also deemed to be feasible and usable. Generally, the practice principles were supported because they: improved education for health care professionals, patients and health care consumers; are likely to improve outcomes; or promoted an interdisciplinary approach to practice. These findings need to be disseminated, enacted and built upon.

The knowledge related to the connection between falls and UI requires mobilization into action. We have established the first set of preliminary practice principles that could support improved care provision related to falls and UI in community and primary health care settings. It is essential that all relevant stakeholders, including health care professionals and the older adults they serve, understand the association between UI and falls and the connected actions that can be taken to health promote, prevent and manage these two conditions successfully.

Hödl M 1 , Lohrmann C 1

Background:

Maintaining continence in old age may increase well-being and may reduce morbidity and healthcare costs [1] . However incontinence is still considered a taboo subject [2] and there still exist a societal misconception that incontinence is a normal consequence of aging [3] . It is known from the international literature that studies about preventive interventions for older continent hospital patients are missing.

Hypothesis / aims of study:

The aim of this study is to investigate preventive interventions for older continent hospital patients.

Study design, materials and methods: The Austrian version of the "International Prevalence Measurement of Care Problems" is an annual multicentre, cross-sectional study including a tested and standardised questionnaire for data collection, including nursing problems like incontinence, malnutrition etc.. In 2016, data from 26 health institutions were obtained and included data from 1560 hospital patients. Beside questions focusing on (in)continence demographic variables like age and gender were measured. In this study older patients are considered to be those aged 60 years or older (UN 2013). Continent patients are defined in this study as "not losing urine and/or faecal material".

In this study a response rate from 78.7% (1560 patients) was achieved. When excluding patients younger than 60 (N=541) and patients with a catheter (N=130) data from 889 patients could be included in this analysis. The majority of the patients was continent (80.9%). Continent patients were statistically younger and less often female than incontinent patients. Beside that continent patients were statistically significant more often completely or to a great extend care independent (90.6%) than incontinent patients (85%) (See table 1). A statistical significant decrease was found in the prevalence of continence with increasing age. More than three quarter of the continent patients receive no intervention (74.4%) in order to promote continence and prevent incontinence. If continent patients receive interventions, these were most likely the adoption of the environment and clothes (28.5% vs. 20.4%). Evaluation of medication (0.1%) or medication itself (0.3%) were seldom used as preventive interventions in older continent hospital patients. Beside that conservative interventions like bladder training (0.3%) or pelvic floor muscle training (0.6%) were also rarely used for promotion of continence (See figure 1).

Interpretation of results: The findings reveal that promotion of continence in the hospital setting for older patients is not common. However our findings are in line with results from the nursing home setting, where only 12% of the continent residents receive interventions at admission for promoting continence and preventing incontinence [1] .

Concluding message: More than three quarter of older hospital patients are continent and stay a mean of 10 days in hospital. This leads to the recommendation, to screen every older patient for incontinence and start conservative preventive interventions as early as possible. For future research studies that investigate the effectiveness of interventions to promote continence are warranted. 

Hypothesis / aims of study People suffering from persistent urinary incontinence (UI) not suitable for active treatments can only be managed with properly applied incontinence aids to achieve a 'social continence'. The selection of a well-fitted absorbent product is of utmost importance in order to empower independent and dignified living to incontinent subjects [1] . A thorough patient assessment is an important part of the product selection process in continence care services, and the appraisal of the UI severity is a key aspect of this assessment [2] . The "Determining the Individual Appropriateness in Pads Provision and Enhancing its Realization" (DIAPPER) study has been the largest reported study of its kind aimed to objectively assess and improve the appropriateness of continence products prescription in a very large population of Italian incontinent subjects. Preliminary results in terms of inappropriateness rates before and after pad test-based correction of the products provision have been previously reported [3] . Herein the results of the analyses of meaningful risk factors affecting products appropriateness are reported in order to provide continence professionals with a better insight empowering them to prevent inappropriate pad provision.

Study design, materials and methods Five Italian continence care services were involved in the study. Overall, 15,385 patients suffering from UI and provided with absorbent products from 01/2012 to 03/2016 were included. All patients/carers have been invited to perform a 48-hour homebased pad test and to fill in a diary with detailed information on their pad usage, as standard of care. Patients had to perform usual daily activity and use their usual pads. The diaries were analysed by continence professionals. The pad usage was defined as appropriate if the maximum absorbent capacity of the product was from 30% to 50% higher than the mean real urine load. A limit of ±50 ml has been considered in order to define borderline products. To investigate risk factors influencing prescription appropriateness, univariate and multivariate logistic regression analyses were performed using Logit model. Several demographic, antropometric and clinical patients' characteristics have been included in the model. Statistically significant factors at univariate analysis have been included in the multivariate model. Statistical significance has been set at P < 0.05.

Overall, 14,493 patients (94.2%) (mean age 78 years, range 5-104; 26% males, 74% females) adequately performed the pad test, using during the study days 98,362 pads. Overall, 59,017 products (60%) were found to be not appropriate: in particular 51,148 (52%) were found to be inappropriate and 7,869 (8%) borderline. In most of cases (75%), products were inappropriate because too large. Sixty-two percent of the patients were found to use not appropriate products. Statistically significant higher rates of not appropriate usage were observed for products indicated for moderate (82%), severe (83%) and very severe UI (71%). At multivariate analysis the patients characteristics positively and independently associated to the propensity to inappropriate pad use were younger age (in the range 0-79 years) and age higher than 79 years, male gender, lower body weight, lower waist circumference (≤ 179 cm) and waist circumference higher than 179 cm, lower level of activity, need for assistance (versus autonomy), lower mobility, lower mean pad wearing time (in the range 2.1-14 hours) and mean wearing time higher than 14 hours, lower mean urine load (especially < 500 ml), unhealthier skin status, absence of catheterization and belonging to a northernmost located health district ( Figure 1 ).

The results suggest that younger and male incontinent patients give to the absorbency a higher priority compared to older and female patients and consequently they tend to use bigger products than strictly necessary. Patients with restricted mobility and needing assistance may be provided with too large products in order to reduce the changing frequency and ease the caregivers' work. The association of inappropriateness with lower urine load is justified by the frequent utilisation of a limited proportion of the product's absorbent capacity particularly among patients with light-moderate UI. Patients with very long wearing time had very light UI but were provided with excessively large products. The differences between health districts can be multifactorial: clients' cultural differences, regional health services disparities in resources and methods of products provision, different products costs.

Concluding message Younger age and lower mean pad weight gain, followed by male gender, need for assistance and restricted mobility and very long mean wearing time are the most significant characteristics associated to inappropriate absorbent product use in incontinent subjects managed with containment strategies. A careful patients assessment, including the pad test with a diary, can enhance continence professionals to provide a well-fitted product avoiding prescription inappropriateness. Figure 1 . Results of the logistic regression multivariate analysis (dependent variable: continence product prescription appropriateness). Solid rectangles indicate statistically significant odds ratio (OR) reported with confidence interval (OR>1 indicating higher appropriateness and OR<1 indicating lower appropriateness than reference, set at 1).

Hypothesis / aims of study Urinary incontinence (UI) and faecal incontinence (FI) are common and distressing conditions that increase in prevalence with age and can lead to severe psychosocial morbidity in some individuals. Incontinence is associated with an increased risk of developing pressure ulcers (4.1% in continent patients vs. 16.3% in incontinent patients) [1] . Timely changing of incontinence products is important since patients are at risk of developing incontinence-associated dermatitis (IAD). In frail and acutely unwell hospitalized patients, containment with incontinence products such as pads is often an immediate management strategy [2] . Nurses and other healthcare providers must understand the impact of incontinence on elderly inpatients in order to maintain dignity and provide person-centred care, but there are very little quantitative data on what patients and providers view as an acceptable time to remain in a soiled pad. Without knowing how closely aligned patient and provider perspectives are in terms of "waiting times" with urinary and faecal soiling, it is difficult to deliver best possible continence care and minimize distress to patients. The primary objective of this study was to examine patient and direct care provider (DCP) views on the acceptable and actual lengths of time spent in a soiled pad during the day and the night. A secondary objective was to investigate patient-or DCP-related factors that might contribute to variation in acceptance of longer times spent with either urinary or faecal soiling.

Study design, materials and methods This was a cross-sectional survey of inpatients using incontinence products and their DCP in a single acute care hospital. Standardized, quantitative data collection forms asked patients and DCP for their views on acceptable wait times and estimated actual wait times (minutes) in the following circumstances: 1) soiled with urine during the day, 2) soiled with urine at night 3) soiled with faeces during the day, and 4) soiled with faeces at night. Data on previous continence status, pad use, use of mobility aids and place of residence (community, institution) were collected. Inclusion criteria were patients aged 65 years and older. Patients who were unable to provide consent due to underlying cognitive impairment and/or acute medical illness were excluded. DCP (registered nurses, licensed practical nurses, and nursing assistants) had a minimum of three months' inpatient care experience. Those who spent less than 25% of their working time providing direct patient care were excluded. A sample size of 50 patients and 50 DCP was planned to give a robust estimate of acceptability. Wait times were categorized into 0-30 (score 1), 31-60 (score 2), 61-90 (score 3), 91-120 (score 4), 121-150 (score 5), 151-180 (score 6), and >181 (score 7) for urine and 0-15 (score 1), 16-30 (score 2), 31-45 (score 3), and 46-60 (score 4) for faeces to examine the distributions. This allowed calculation of a composite "tolerance score" of patient and provider attitudes toward wait times by summing the categorical scores (range 4-22) to categorize each patient or provider as "low" tolerance (generally intolerant of incontinence; score ≤8) or "high" tolerance (generally tolerant of incontinence; score >8). Tolerance score cutoffs were defined by median score. Differences between groups were assessed using Student's t-test, correlations with Spearman's rank correlation coefficient. Patient-or DCP-related factors associated with tolerance to incontinence were analysed by univariate and multivariate binomial logistic regression. A p-value <0.05 was deemed statistically significant.

The mean (SD) age of the patient sample was 79.1 (±9.2) years and the majority was female (84%). Over half of patients (60%) were regular users of continence pads (either using them at night or on a 24-hour basis). Eighty per cent of patients lived at home, and 58% of patients used some form of walking aid (such as a cane or walker). The majority of patients (90%) felt that a wait time of up to 60 minutes in the case of daytime urinary incontinence was acceptable (66% less than 30 minutes). This was significantly shorter than DCPs (38.0 vs. 85.9 min for patients and DCPs, respectively; p<0.0001), nearly half of whom (44%) deemed daytime urinary incontinence wait times of an hour or more to be acceptable, 14% even considering wait times of two and half to three hours to be acceptable. At night, for urinary incontinence, 56% deemed wait times of over 60 minutes acceptable, although the distribution was more variable; 28% reported wait times of two and a half hours or more to be acceptable. Interpretation of results There was considerable patient-provider mismatch for daytime UI, with patients mostly intolerant of urinary soiling of over an hour but DCPs reporting that they felt that longer wait times were acceptable. Both patients and DCPs reported that pads soiled by FI required changing within 15 mins during both day and night. The vast majority of both patients and providers reported that long wait times (over fifteen minutes) with FI were unacceptable, most likely reflecting cultural and societal differences in attitudes towards urine and faeces (the latter being regarded as "worse" than the former) [3] . These assumptions need revisiting both from the patient perspective (i.e., that they do not have to accept soiling due to UI) and the provider perspective (i.e., that patients only find FI distressing). Although patient-and DCP-reported "actual" wait times were consistently longer than those deemed acceptable, there were significant differences in the value reported between patients and DCPs. The reporting of actual times by the majority of DCPs at two or three hours may reflect predefined care round schedules and a lack of detailed knowledge (or direct questioning) about exactly how long patients had been soiled.

Concluding message This study has reported significant gaps in patient-provider perspectives with respect to acceptable wait times in soiled incontinence products, especially for daytime UI. Patient factors, particularly markers of institutionalisation and healthcare exposure, influence tolerance to soiling. Patient perspectives are important to establish person-centred care.

Hypothesis / aims of study Despite the many treatment options available and guidelines suggesting containment products as a last resort, up to 77% of women manage incontinence with containment products on a daily basis [1] . It may be that they accept incontinence as a normal part of ageing, or see it only as a minor problem and therefore they do not seek professional help. Previous research suggests consumers' desire more information on the cost, design, quality and comfort of different products [2] , but may not know where to find this information. To date there has been little published work examining user's knowledge of continence products and from where they obtain their information. The objectives of this study were to determine from what sources women sought and received information about continence products and to evaluate their perception of the utility of this information.

Study design, materials and methods This was a descriptive mixed methods study with quantitative and qualitative phases. For the quantitative phase an online survey was created and advertised to target community dwelling women who use some sort of containment products to manage their urinary incontinence. The survey was advertised at the host university, local health organizations, incontinence, urogynaecology and other health clinics, medical supply stores and local newspaper. To maximize recruitment from beyond the local community, non-for-profit health websites and social media were also used to advertise the survey. At the local urogynaecology and continence clinic a researcher conducted oral surveys with patients who were not comfortable doing an online survey. Data was collected on SurveyMonkey. Descriptive statistics, including means and frequency distributions, were completed using Microsoft Excel 2010 ® . Even though the survey was targeted towards women, a question specifying gender was included after the survey went live to ensure respondents met the inclusion criteria.

Using results of the initial local quantitative phase, a draft semi-structured interview guide was refined with the intention of gaining further insight into survey results. Local survey participants were invited to participate by calling a telephone number provided at the end of the survey or at clinic survey completion. Written consent was obtained from all interview participants. Interviews focused on participant use, knowledge of and information sources about containment products and participant's opinions about the utility of the information they received. Interviews were digitally recorded and transcribed verbatim. All identifying data were removed at the transcription stage. Using a constant comparative approach, the two researchers developed a coding framework from the first transcript to which new codes were added. The codes were then collapsed into categories and finally themes.

Results 396 participants met the inclusion criteria for the quantitative phase; 62% were between the ages of 41-70 with a median age range of 51-60 years old. 247 (75%) were from Canada, 45 (14%) from the USA, 17 (5%) from the UK, 13 (4%) from New Zealand, and 6 (2%) from other countries (n=328). 59% reported leaking urine once or less per week and only 9% had leaked several times a day. Most women leaked drops or a tablespoon of urine each time (34% and 40%, respectively), while 26% of women leak significant amounts each time (half or a full cup or more). 66% of women used bladder products for their incontinence, 24% used feminine hygiene products and 9% used both (n=390). Of the women who used bladder products, only 2 out of 288 (0.69%) used reusable/washable products. Data concerning preferences of different bladder products (n=285) revealed women with light and medium incontinence preferred small disposable pads during the day and night. Those with heavy incontinence preferred large disposable pads during the day and night. Those with severe heavy incontinence preferred large disposable pads during the day and all-in ones at night.

The most common sources of information (n=364) were stores (45%) and television/radio (43%), followed by health care professionals (24%), online information (23%) and magazines or newspapers (22%). For utility of sources (n=358) the greatest percentage of "useful" or "very useful" responses were for friends/acquaintances (83%) and healthcare professionals (82%). Leaflets available in primary care offices and health or social care advertisements were identified as infrequent sources, but rated as useful. (Figure 1 ). When asked who participants would they like to receive information about continence products from (n=249) 53% identified health care professionals as best placed to give information about continence products. Figure 1 : Utility of Sources 9 women completed interviews (mean age 70 years). Five themes were identified: existing knowledge, seeking knowledge, reasons for choosing, how incontinence affects life, and perceptions of health care professionals' roles. When seeking information they were looking for an informative and trustworthy source. This is why women turned to healthcare professionals, but the helpfulness of their experiences with healthcare professionals varied. Product choice was made through a trial and error approach as they drew information from a variety of sources included product labels. Cost was an influential factor in product selection. Women wanted a product that allowed them to feel safe and secure.

There was a contrast between how participants received information about continence products and what they believed to be the most useful sources of information. Popular sources such as pharmacies/other stores and television and radio were accessible, but they lacked the ability to give specific information based on the individual needs. Friends/acquaintances and healthcare professionals were highly ranked, but experiences with these sources varied because of the varying knowledge and willingness Not at all useful (1) n=358 to discuss incontinence. Women are not receiving information about continence products in a manner that suits their needs reinforcing a trial and error approach to product selection.

Concluding message Women seek information on continence products from a variety of sources. Health care professionals are a desirable source, but may not have the knowledge to provide when approached. Health care professionals need to incorporate assessment of incontinence in patient encounters, and provide information on options, including products. Providing samples of products may aid women in finding the proper fitting product. Study design, materials and methods Twenty-eight patients (17 female, mean age 52 range 24-73) with neurogenic bowel disorder (NBD) were recruited from two specialist centres (19 with spinal cord injury, 2 spina bifida, 4 Multiple Sclerosis and 1 each following spinal surgery, tumour and cauda equina syndrome). All participants were experienced with TAI, used at a frequency of at least 2 times/week. Patients were trained to use Navina™ Smart, a system of irrigation controlled by an automated balloon inflation and water pump, and followed up for 4 weeks to monitor patient satisfaction, perception and compliance using a Patient Reported Outcome questionnaire. There were two telephone contacts at week 1 and 2. Safety of the Navina™ Smart system was also assessed by questioning and selfreport.

Results 19 patients (68%) completed the 4 weeks of TAI per protocol (PP), whilst 9 discontinued prematurely (3 for lack of efficacy, 2 for leakage of irrigation fluid, 1 trip abroad and 3 missing). Of those 19, 14 (74%) reported a desire to continue with TAI using Navina™ Smart, representing 50% of the intention to treat (ITT) population; 12/19 (63% of PP and 14/28 of ITT) reported complete or adequate satisfaction with therapy. At baseline 10/19 were neutral or not satisfied with existing TAI, 8 of these 10 would consider continuing with Navina™ Smart. A majority (81 %, 22 of 27 available patients) found the preparation and handling of the system, and the components, to be easy or very easy.

Three-quarter of patients who completed the study with Navina wanted to continue use of the product. This was especially true in a group who were dissatisfied with their existing TAI, a challenging group to manage given the invasive alternatives. This indicates that Navina Smart is a viable option in TAI treatment. A similar majority found the Navina system easy to handle, which is an indication that an electronic device may be an advantage from a patient's perspective. The heterogeneity and small patient number mean limited conclusions can be drawn about response to Navina in different patient subtypes.

Concluding message From this first clinical study of Navina™ Smart System we conclude that handling was easy for 81% of patients and, that there were no safety concerns. The device was well accepted and effective in 74% of patients that continued for 4 weeks. This is especially relevant in a patient group, such as included here, who were unhappy with their existing TAI treatment. 

Hypothesis / aims of study A patient-completed bladder diary is one of most recommended tools to assess bladder habits. An epidemiological study demonstrated patients with pelvic floor disorders reported voiding dysfunction, constipation (59.5%, 12.6%, respectively) 1) . The diary is required to focus on both bladder and bowel problems and collect precise data in daily life as an excretion management tool. With the recent advancements of Internet of Things (IoT), the web-based portable devices into the medical field are expected to improve patients QOL, including health management, education and assessment. However, although web-based assessment has become technically possible, to our knowledge, there are no studies about the assessment system evaluated via cloud service for the patients with bladder and bowel dysfunction. The objective of this pilot study was development of a patient-centred excretion management for early detection of health and monitoring their daily excretion.

Study design, materials and methods This study was prospectively designed. Since we organized the research system, recruited specialists from many different fields for developing HIGH-TECH bladder and bowel diary (HIGH-TECH B&B diary). Two urologists and a physiotherapist were involved for selecting clinical outcome measures for excretion. An IoT specialist from Laboratory of information media environment was responsible for the development of a tablet device and cloud-based system. A Research Coordinator from university research administrator worked for operational management. We regularly held meeting for the service conceptualization.

The realization of entire systematic composition in this study: 1. Selecting outcome measures for excretion in daily life 2. Developing cloud-based system in a highly secure fashion 3. Installing sound recorder and human detecting sensor 4. After the alpha version of tablet device completed, two healthy adult volunteers were involved in providing feedback in preliminary evaluation in the pilot study.

The basic cloud-based system and the prototype of a tablet device have lunched asalpha version that was introduced in the media in 2016 (Figure1). Bristol scale can be recorded by selecting stool-form icon on tablet screen. It was confirmed that the cloudbased system could store collected data from the individual tablet device, and transfer to the server in the medical institution with Blockchain technology. The system can automatically detect frequency of urination and defecation per day and toilet use time and duration by human detecting sensor. The feasibility and accessibility of tablet device were evaluated through recruited volunteers' feedback. We clarified the 3 problems including the feasibility for elderly users (appropriate graphic-design, features and ease of use), the simplification of connecting to a power source and the modification of human detecting sensor, based on the preliminary evaluation.

This study was the first attempt to establish cloud-based monitoring system of bladder and bowel dairy in urological field. The development of a prototype tablet and cloud-based system has been successful in the beginning phase. The mobile device-based system was previously reported in a spine outpatient clinic 2) . The response rate of mobile system was higher than that of paper system despite of the same contents of the questionnaire. Also the review focusing on demonstrated that portable device can offer considerable benefits for patient care 3) . The health care professionals can follow patient's precise updated data through cloud-based storage and file-sharing. In this study the tablet device was composed of Bristol scale and distinction between defecating and urinating as patient-reported outcomes. The displayed each icon was selected on the touch screen. Toilet use duration was measured automatically with human detecting sensor. Although the development of utilizing hardware is needed, basic features were installed into individual device. Also we adopted Blockchain that provides assurance for safety of internet connection between patient's home and medical institution to prevent information leak. The additional data can be recorded at anytime in highly secure environment, and electronic medical record systems will be adopted with Blockchain in near future. This preliminary study was the starting point of improvement projects, which resulted in basic operating features of HIGH-TECH B&B diary in daily life. It will be needed to improve usability of system quality toward application of HIGH-TECH B&B diary to local healthcare centers (Figure2).

Concluding message This is the first study to pilot the development of cloud-based evaluation system that is technologically advanced to observe bladder and bowel habits. The usability will be improved in future research for the trial introduction of the system into local area. 

Hypothesis / aims of study Voiding diary (VD) is a key diagnostic tool for voiding dysfunction. However, this is a great burden for both the patient and the doctor, because the patient should record all micturitions several days and the doctor must analyze the many records in the outpatient clinic as soon as possible.

We developed a new device, which allowed the patient to carry a small, portable device and conveniently record the micturition by touching the screen (Fig. 1A ). In addition, when the patient brings the device to the doctor and connects to the computer, they can automatically see the analyzed data related to micturition immediately.

In this study, we performed a prospective study to estimate and compare the subjective burden felt by patients when they were asked to complete electronic and paper frequency volume charts. We also observed what advantages of using this device doctors have over paper VD.

Study design, materials and methods A total of 205 men and women (mean 59.7 years old, 17-84), with lower urinary tract symptoms suggestive benign prostatic hyperplasia or overactive bladder, were enrolled from two hospitals in South Korea between October 2016 and February 2017. They were randomly assigned to complete an electronic VD (Lee Diary, Mcube Technology, Seoul, Korea) (n=77) or paper VD (n=85) for consecutive 3 days. At first visit, patients were instructed how to put the time and volume of fluid intake or micturition into the device or paper. At second visit, the device or paper was received back. The device was connected to computer via USB cable and various results analysed from the above data were displayed on the computer screen ( Fig. 1B, 2) . The data on the paper VD was put into the excel datasheet by medical practitioner and analysed it and produced the results sheet. The time taken to analyse the device or paper data was measured. And all the participants were asked answer the questionnaires with 7 questions about burden. The chi-square test was used to compare the burden between electronic and paper VD.

Twelve patients were excluded during the study due to lost follow-up, and 30 patients were excluded from the analysis as incomplete record, a total of 163 results were used in the study analysis.

Burden on the patients. Paper VD group experienced higher levels of burden than electronic VD group (p<0.002), and higher burden during daytime (p<0.002) and night time (p<0.01) than electronic group. The portability of electronic VD was better than those of paper VD (p<0.0001). The strange thing is that the electronic VD group felt that they have missed to record more data than the paper VD group (p<0.0001), although there was no difference in real data (p>0.05). This is probably because the data on the paper can be seen again, but electronic VD group cannot see the data recorded on the touch screen again.

Burden on the medical practitioner. It took about 10-15 minutes for a medical practitioner to insert and analyse data from a paper VD into a computer, but in the case of an electronic VD, we could immediately see the results of various types of analysis as soon as the computer was connected. This is not statistical comparative data, but it is considered a considerable advantage.

The use of this electronic VD reduces the burden of not only the patient but also the medical practitioner, comparing to that of the paper VD.

Until recently, research on VD has been tailored largely to the accuracy or burden of patient's writing a VD, or the accuracy of data interpretation by medical practitioner without considering the interpretation speed. Due to the uncertainty of micturition patterns, statistical observation is needed, especially as the observation period becomes longer. It is almost impossible to observe the characteristics of micturition from a statistical point of view, for a short period of time when clinicians meet patients at the outpatient clinic. From this new perspective, we believe that our electronic VD machine will have advantages over other VD machines.

Grzybowska M 1 , Wydra D 1

Hypothesis / aims of study The aims of the study were as follows: (i) to compare the quality of life (QoL) in women with urinary incontinence (UI) using continence pads only during the day versus all day and night; (ii) to identify the time-frame for the onset of deteriorated QoL in female UI.

Study design, materials and methods A cross-sectional study was conducted in a group of 331 consecutive women referred to an urogynecology ambulatory clinic due to lower urinary tract symptoms. Medical history was taken, urogynecological and urodynamic examinations were performed according to the standards of the International Continence Society. The degree of prolapse was assessed using the Pelvic Organ Prolapse Quantification (POP-Q). The subjects were asked to complete a disease-specific QoL questionnaire -the King's Health Questionnaire (KHQ). Detailed questions were asked about symptom severity, as well as day and night use of continence pads. A total of 307 women with UI were enrolled for further analysis and categorized according to the use of absorbent materials. Group I included women using continence pads only during the day i.e. in and outside the home, only outside the home, occasionally or changing underwear, but not at night. Group II consisted of patients using continence pads during day and night (24 hours). Patients not using continence pads or only for hygiene reasons were excluded. Medical history, urogynecological examination and questionnaire scores were compared. Altman's nomogram was used to determine the sample size for approximately 60 subjects in each group to give 80% power to detect a difference of 15 units in KHQ scores based on SD=30.0 at a significance level of 5%.

Out of 307 women with UI, only 28 (9.1%) did not use any protection during the day, and 168 (54.7%) during the night. Based on the KHQ evaluation, QoL was significantly deteriorated in Group II as compared to Group I in the following domains: Incontinence Impact, Role-, Physical-, and Social Limitations, Emotions, Sleep/Energy and Severity Measures (p<0.01). Additionally, the scores in General Health Perception and Personal Relationships domains indicated lower QoL, but did not reach statistical significance ( Table 2 ). The correlation analysis and hierarchical linear regression revealed no significant impact of BMI on the KHQ scores.

Interpretation of results Out of the UI women consulted in an urogynecological ambulatory clinic, approximately one-third used continence pads over the period of 24 hours/day, which resulted in significantly deteriorated QoL as compared to patients using continence pads only during the day.

Concluding message Continence pad use is an important aspect of the QoL assessment in women with UI. The questions about continence pad use should become an obligatory part of the medical interview as it might pinpoint the exact moment when more active management of patients with UI is necessary. 

Hypothesis / aims of study The aim of this study was to exam the accuracy of a new portable handheld ultrasound bladder scanner for measuring bladder volume.

Study design, materials and methods A portable handheld ultrasound bladder scanner, Lilium® α-200 (Lilium Otsuka Co., Ltd., Kanagawa, Japan. Weight: 150g (excluding batteries). Size: H 120mm x W 68mm x D 27mm), has been introduced to measure bladder volume ( Figure 1 ).

Consecutive inpatients with voiding problems after removal of indwelling urethral catheter and needing clean intermittent catheterization (CIC) were included in this prospective study. Recruitment was conducted in convalescent rehabilitation or longterm care wards at a single hospital between April 2016 and March 2017. Patients' bladder volumes were measured by generalist ward nurses (not urology specialist nurses) using the Lilium® α-200 scanner, before CIC. Evaluations were made with patients in the supine position. Pearson's correlation was used to compare bladder volume measured by Lilium® α-200 with by volume measured at CIC.

We collected data from 34 inpatients (10 males and 24 females. Mean age was 81.7 years), with in total 123 separate examinations of bladder volume (1-20 examinations / patient). A correlation coefficient of r = 0.74 was found between Lilium® α-200 and CIC ( Figure 2 ). The mean differences between the two was -10.5mL, with the corresponding 95% confidence interval (-174.9, 153.8) (Figure 3 ).

This was a first clinical study to evaluate the accuracy of a new portable handheld ultrasound bladder scanner, Lilium® α-200, for measuring bladder volume.

Concluding message A new portable handheld bladder scanner, Lilium® α-200, is applicable with good accuracy. 

Hypothesis / aims of study Penile compression devices (PCDs) or clamps are applied to the shaft of the penis to compress the urethra thereby preventing urinary incontinence (UI) in men. PCDs are significantly more secure and less likely to leak than pads or other devices allowing men to participate in short vigorous activities, such as swimming or dancing (1). However, they can be uncomfortable, can affect penile blood flow (2) and are not currently recommended by the National Institute for Health and Care Excellence (NICE). Of the 16 clamps available on the open market, designs vary widely and further investigation is needed to assess their comparative efficacy, strengths and limitations of each as well as the effect on penile circulation and skin integrity.

The objective of the present study was to evaluate existing clamps for physiological impact and user acceptability.

Study design, materials and methods 12 men with post prostatectomy UI were recruited to review 16 existing clamps; 5 were selected for further investigation in a home-based usability study: Cunningham, Weisner, Dribblestop, Cook & Uriclak (Fig. 1) . Measures of superficial circulatory impedance (Doppler flow), applied interface pressure and inflammatory response were made in the clinic/hospital. MRI scanning was used to measure physiological impact of the Dribblestop and Weisner. Informed consent was obtained from all participants.

User Acceptability: No single clamp design proved ideal for all users with varying opinion amongst participants as to their preferences (Fig. 4) . The Weisner was acceptable to most and most effective at preventing leakage. It was also the only clamp associated with haematuria (x1 episode) and elicited the highest pain score. Physiological Impact: Varying interface pressures were noted between clamps for each individual participant to the order of 156.5mmHg and across all participants (mean 137.4mmHg, SD 69.7; range 20-310mmHg). Pressures >300mmHg were recorded with the Cunningham clamp and associated with a substantial decrease in superficial penile blood perfusion distal to the clamp. On clamp removal perfusion levels were restored. Other than the Uriclak, pressures generally decreased with wear time. In practice, this required adjustment of the clamp by the participants to maintain continence. MRI scanning of the penis identified substantial deformation compared to the unloaded morphology ( Fig. 2a/b ) under clamping pressure from the Dribblestop (Fig. 3a) and Weisner (Fig. 3b) . The corpus cavernosum and corpus spongiosum were flattened in cross-sectional images. Tissues external to Buck's fascia, incorporating blood vessels and skin, were displaced laterally to areas outside of the clamp pads. Urine was contained within the urethra proximal to the clamp site.

The four effective PCDs affected superficial blood flow and caused pain to an unsuitable user. Most participants however found a device that prevented incontinence with little discomfort for wear times up to 2 hours. Raised perfusion flux upon some clamps' removal, implies prior occlusion to the superficial blood vessels. Based on the current findings, future work will develop a new PCD with acceptable and appropriate features.

Concluding message PCDs are favoured by some men but modifications in design are necessary before being more widely acceptable. A computational penile model (FEBio), with morphological features and dimensions provided from the MRI images will aid in designing an acceptable PCD.

Weisner Dribblestop Cook Uriclak Fig. 1 

Hypothesis / aims of study Urinary incontinence is a social and hygienic problem of involuntary urination and is a common health problem for women. It has been reported that in Japan, 50% of people aged over 60 have urinary incontinence. It is said that urinary incontinence significantly decreases QOL (Quality of life) as it leads to urinary tract infections, physical dysfunction in seniors, bed-ridden elderly and causes dementia in the elderly. Additionally, a study compared the frequency of the use of diapers in facilities for the elderly with incontinence in Japan and European countries and reported that use in Japan is extremely high. This is because elderly residents of facilities who are able to go to the bathroom during the day are given diapers for urinating at night due to manpower shortages and strategies to prevent falling. In Japan in 1984, polymer absorbent adult diapers began to be used. The improved water absorption capacity of diapers gave birth to all-night use of diapers for elderly with urinary incontinence. On the other hand, the quality of night sleep (Quality of Sleep: less QOS) in elderly decreases as they age. Elderly women in particular, often have residual urine due to the effects of chronic cystitis or anti diuretic hormones with 72% of 80 year old women experiencing frequent urination at night which can contribute to sleep disorders. Additionally, as changing diapers or assisting elderly to urinate during the night causes them to wake-up they are often left in wet diapers until scheduled assisted urination times.

However, some reports have warned that improper use of diapers causes patients to lose awareness of their urge to urinate, increases the amount of urine incontinence, increases sleep disturbance and decreases cognitive function. In other studies a connection was found between residual urine volume, urinary incontinence and the amount of daytime activities and it became obvious that these affect sleep and daytime activeness. However, few studies have revealed effects on sleep and activity of individual nursing care for the elderly with dementia who are using diapers. Are seniors who are left to use diapers with incontinence at night really able to sleep soundly? We believe it is of great significance to uncover whether nurses changing diapers and taking patients to the bathroom in line with individual patients' urination patterns inhibits sleep at night or daytime activities. This study is to examine the urinary condition of elderly women with dementia who require nursing care and are institutionalized. After that, proper care was provided for women with urinary incontinence that require nursing care and the impact on sleep and daytime activities of the use of diapers was examined.

Study design, materials and methods The subjects were 30 residents of nursing homes who met the selection criteria. Among these 2 did not give consent as they complained of stiff shoulders due to metal allergies or use of watches. Of those who consented, 3 left the facility during the study Cook Overall opinion score and 4 others were rejected for either taking off the actigraphs for measuring cognitive function due to dementia related mood changes resulting in a significant loss of measured data analysis. The data of the remaining 21 people was analysed. All subjects underwent urinary tract management using diapers. A random check of the number of times diapers were changed at night in three day periods was conducted (herein the control period) and 3 nights of care appropriate for individual subjects urination was conducted (herein intervention period). In the meantime an actigraphy (United States AMI Inc.) survey of sleep and daytime activities was carried out. The intervention entailed making sure of the elderly subjects' urge to urinate, taking them to the bathroom and using diaper sensors then changing diapers immediately after urinary incontinence.

The average age of the 23 subjects in the facility's target was 88.1 (± 7.3) years all of who underwent urinary tract management using diapers. Six subjects showed signs of a mild decrease in cognitive functioning (MMSE = 20 points or more) with an average of 24.8 (± 2.28); three subjects showed a moderate decrease in cognitive function (MMSE = 10-19 points) with an average of 10.67 (± 4.04); and fourteen subjects showed an advanced decrease in cognitive function (MMSE = 0-9 points) with an average of 0.29 (± 0.61). Physical dysfunction (FIM) in those with a mild decrease in cognitive function was 73.0 (± 11.6) while it was 54.7 (± 20.2) for those with a moderate decrease in cognitive function and 17.4 (± 7.1) for those with an advanced decrease in cognitive function. QOL (QLDJ) was 41.20 (± 6.5) for those with a mild decrease in cognitive function, 54.7 (± 20.2) for those with a moderate decrease in cognitive function and 17.4 (± 7.1) was for those with an advanced decrease in cognitive function. The number of times per night that urination care was conducted during the control period was 1.35 (± 1.40) and 4.47 (± 1.39) times during the intervention period showing a significant increase in the amount of care during the intervention period. The quantity of urine incontinence during the control period was 271.78 (±393.50) ml while during the intervention period it was 242.22 (±211.46) ml showing subjects were less prone to urine incontinence during the intervention period.

The total sleep time at night for the 6 subjects with a mild decrease in cognitive function was 381.17 (± 97.49) minutes during the control period, but during the intervention period it was 407.22 (± 67.85). Sleep efficiency during the control period was 69.00 (± 30.29) per cent while during the intervention period it was 79.45 (±12.59) per cent showing that intervening leads to longer sleep time at night and an increase in sleep efficiency. A tendency for a decrease in the frequency partial waking up and fully waking overnight was also noticed. 

The results of this study into the nursing care of elderly women with urinary incontinence, the quality of their sleep and daytime activeness indicated that while changing diapers or taking them to the bathroom did temporarily increase wakefulness and there was an improvement of the quality of sleep following. It was also found that for subjects with milder cognitive impairment, the maximum sleep time is longer and there is a tendency to increase the amount of daytime activities. It has been pointed out that it is hard for subjects with dementia to fall back asleep after waking up. By changing diapers immediately after urination, taking subjects to the bathroom according to their individual needs the quantity of urine incontinence decreased and subjects were more comfortable. This resulted in a deeper and longer sleep than if they had been left in wet diapers. This in turn lease to an increase in daytime activities and improved cognitive function.

Concluding message It is suggested that instead of changing diapers at set times, decreasing the number of times patients are woken to change diapers and leaving patients to sleep in wet diapers, changing diapers when incontinence occurs leads to a more comfortable, higher quality of sleep which may result in an increase in daytime activities and better cognitive function. 

Hypothesis / aims of study Physical exercises form part of the conservative treatment of female urinary incontinence (UI), in particular training of the pelvic floor muscles (PFM), which improves the pressure, strength, resistance, and relaxation of this musculature. Our hypothesis was that supervised PFM training would be more effective than unsupervised training and no training. The aim of this study was to conduct a systematic review of the literature to evaluate the efficacy of supervised training of PFM in the treatment of UI in women.

Study design, materials and methods This is a systematic review of randomized controlled trials. We performed this review according to the Cochrane Handbook for Systematic Reviews of Interventions. General and adaptive search strategies were created for the electronic databases in the health area; Embase (1989-2014), Pubmed (1968-2014), LILACS and Central COCHRANE (Central Register of Controlled Trials of the Cochrane Collaboration -CENTRAL) . There were no restrictions on language or year of entry. For the construction of the strategy, the following descriptors and their respective synonyms were used: Urinary Incontinence, Lifestyle Change, Exercise, and Randomized Clinical Study. We included randomized trials in which women with UI were assigned to participate in supervised training of the PFM (intervention group) or not to perform any physical activity, or to perform the same exercises but without supervision (control group). The primary outcomes were cure of UI, frequency and amount of involuntary loss of urine, PFM strength, and quality of life. The homogeneous endpoints with the same unit of measure in at least two studies were plotted in a meta-analysis using Review Manager 5.3 software. The statistical methods used were the inverse variance method to weight the estimates of effect of the continuous variables and the Mantel-Haenszel method for the dichotomous variables. The inconsistency between the results of the included studies was ascertained through visual inspection of the forest plot (absence of overlapping CI around the effect estimates of the individual studies) and by the Higgins or I2 inconsistency test in which I2> 50% indicates a moderate probability of heterogeneity. The quality of evidence was generated in accordance with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

In total, 3,221 references were identified and two reviewers independently read the titles and abstracts of the articles. Of the 33 potentially eligible studies, 18 were included and 15 were excluded as they did not meet the eligibility criteria. A total of 1,079 women were randomized to the intervention or control groups. Eleven studies which evaluated UI remission were plotted in the meta-analysis, in five studies the cure criterion was according to the negativity of the absorbent test, and in six remission was reported by the patient. In each subgroup as well as in the final analysis there was a significant difference favoring the intervention group (RR: 5.49 [2.74; 11] , I² = 0%, RR: 4.22 [1.87; 9 .53], I² =64%, RR: 4.63[2.65; 8.09], I²=47%, respectively). We also separately plotted the results of UI cures in the four studies in which the control group received the same training of the PFM, but to be performed at home without supervision; the result was also significant in favor of the intervention (RR: 4.48 [2.06, 9 .73], p=0.0002, I²=0%. The meta-analysis also showed a significant difference in favor of the intervention group in the one-hour absorbent test, the three-and seven-day voiding diary, the strength of the PFMs through the Oxford scale, and four domains of the quality of life questionnaire King's Health Questionnaire -KHQ (RR: -3.11 [-5.55 [-18 .98, -2.50], I²=0%, respectively). The evaluation of the quality of evidence of the intervention estimates in the primary outcomes according to the GRADE was moderate for remission of UI and urinary loss assessed using the 3-day voiding diary. The quality of evidence was low for the outcomes urinary loss, PFM strength, and in the quality of life domains impact of UI, physical limitations, emotions, sleep/energy, and severity measures (assessed by the KHQ). The quality of evidence for muscle strength outcomes and the quality of life domains, general health, limitations of daily activities, social limitations, and personal relationships (also assessed by the KHQ) were very low.

Interpretation of results Data from 16 studies were able to be plotted in the meta-analysis. This was significant in favor of the intervention group in the outcomes remission of UI, urinary loss, PFM muscle strength, and in some quality of life domains. Regarding the quality of the evidence of the findings of this systematic review, for the majority of outcomes it was necessary to reduce the risk of bias one level, as in some included studies the randomization process was undetermined or high risk. The same was true for the allocation concealment, blinded analysis of outcomes, and losses. It was also necessary to reduce the quality of evidence due to the presence of inconsistencies in the results generated by the meta-analysis in the outcomes PFM muscular strength, evaluated by the perineometer, and the KHQ domains general health, limitation of daily activity, social limitations, and personal relationships. Despite heterogeneity (I²> 50%) in some outcomes, the level was not lowered, since the results were in the same direction in favor of the intervention (urinary loss evaluated by the 7-day diary, muscle strength assessed by the Oxford scale and perineometer, the impact of UI domains, limitations of daily activities, and personal relationships assessed by the KHQ). With the exception of the cure outcome, for the other results it was necessary to reduce the evidence one level for imprecision, since the number of patients studied by outcome was small (<400).

In women with UI, supervised training of PFMs is effective in curing UI, reducing involuntary loss of urine, and improving some domains of quality of life. 

Hypothesis / aims of study Anal incontinence (AI) can have distressing physical, emotional and psychosocial consequences. Fear and shame of involuntary loss of solid stool often cause self-imposed isolation, thus limiting the patients' life. In patients with AI, knowledge about developing and implementation a patient education program is scant. The present study aims to examine the outcomes of a group-based patient education program for women with AI. We hypothesise that one-third of the patients do not need further treatment. Further we expect a reduction in severity of incontinence and an increase in quality of life.

The present study is a survey based cohort study of female patients participating in the group based patient education. 75 patients were invited. In the period from October 2016 to January 2017, 36 (48 %) patients completed the group-based patient education. Previous to participating, all patients were scored with the St. Marks Score (1). Follow up was gathered one month after the patients have finished the patient education. During the follow up, each patient was screened for the need of further treatment. Self-rated quality of life was measured through the Fecal Quality of Life scale (FIQL) (2) . Baseline was reported before entering the group-based education program and with follow up three months after finishing the education.

Data are presented as median with range or mean with standard deviation. Statistical analysis was performed using the Wilcoxon signed rank test or Wilcoxon rank sum test. The significance level was p<0.05.

At present, one-month follow up was carried through in 32 patients. 17 (53 %) patients were discharged after finishing the groupbased patient education. Figure 1 presents the results of the St. Marks Incontinence score. St. Marks incontinence score (0= best and 24 = worst) was 12.5 (range 5-19) at baseline and 10 (range 0-18) at one month follow up. This reduction in severity was statistic significant (p <0.001). Differences were found in baseline St. Marks score stratified by treatment status after completing the patient education. Baseline St. Marks Score was 11 (range 5-19) in patients discharged and 15 (range 9-17) in patients with further need for treatment (p=0.04). The preliminary results of the self-scored quality of life are shown in table 1. Statistic significant improvement was found in the dimensions: "depression", "embarrassment" and for the total score. Interpretation of results Patients have reduced their severity of anal incontinence after participating in the patient education. In addition, we performed an analysis on the baseline score, to determine if severity before entering the patient education is influencing the effect. Both the highest and the lowest baseline score was found in patients discharged after participated the patient education. Thus, indicating that severity is not a limit for entering the patient education as we were able to treat any different severities and symptoms in the patient education. With regard of a moderate correlation between severity and each FIQL dimensions (3), we further suggest an increase in FIQL after participating in the patient education.

The study finds that the group based patient education is effective as the first line treatment of female patients with anal incontinence.

Hypothesis / aims of study Premature ejaculation is the most common male sexual disorder. The aim of the study was to evaluate the possible therapeutic role of pelvic floor muscle rehabilitation in patients affected by lifelong premature ejaculation.

Study design, materials and methods 40 male patients were enrolled in this study after undergoing assessment and providing informed consent. PE was diagnosed by applying the ISSM definition of PE. All of the subjects had lifelong PE with a baseline IELT ≤60 seconds (mean: 31.7 s, range: 16.6-57.4 s). For inclusion in the study, each patient had to be in a stable relationship with a partner for at least 6 months and to engage in sexual intercourse once a week or more often. At the first visit, the patients and their partners were interviewed individually and each was requested to give an independent estimation of IELT. The patients were all treated with PFM rehabilitation. To evaluate the effectiveness of PFM rehabilitation, we compared the mean IELT values of the patients after 12 weeks of treatment. The rehabilitation treatment group comprised 40 patients aged 19-46 years (mean age: 30 years) with a mean baseline IELT of 31.7 ± 14.8 s (range: 16.6-57.4 s). The PFM rehabilitation protocol consisted of (1) physiokinesitherapy to achieve a muscle contraction that allows the patient to be aware of motor activity; (2) electro-stimulation of the perineal floor to directly stimulate the pudendal nerve, resulting in stimulation of the pubo-rectalis muscle, which causes the urethral sphincter to contract; and (3) biofeedback, in which the patient learns to control the muscle contractions of the perineal floor and the genitourinary sphincter. The patients had three 60-min therapy sessions each week, during which the 3 techniques were applied for 20 min each. The results were measured after the first 20 sessions (6 weeks) and then again at the end of therapy (12 weeks). Physiokinesitherapy and biofeedback were used to train patients to recognise the muscular structures involved in pelvic floor contraction. The patients executed personalised physical exercises, during which they conducted isometric and isotonic contractions of the PFMs. During each session, after execution of the physical exercises, the patients underwent electrostimulation to help strengthen the PFMs. A cylindrical anal probe was positioned in the anal canal. Contact between electrodes in the anal probe and the anterior portion of the sphincter system stimulated the pubovisceral muscles (puborectal and pubourethral); mild, painless electrical pulses were then sent to these muscles via the electrodes.

In the PFM rehabilitation group, at the end of 12 weeks of treatment, 33 (82.5%) of the 40 patients gained control of their ejaculation reflex, optimising the latency time to ejaculation from the start of intravaginal intercourse (IELT before therapy: ≤60 seconds). Five patients were non-responsive to the treatment, whereas 2 improved their ejaculation after the first 20 sessions and opted to drop out of the study. For the 33 patients who responded favourably to the PFM rehabilitation, the results were maintained throughout the follow-up time (until 6 months after the 12-week treatment). None of the patients reported adverse effects that could have led to discontinuation of the treatment. At the first evaluation after 6 weeks of rehabilitation, the patients achieved a mean IELT of 124.6 ± 18.4 seconds (range: 122.7-143.1 seconds). At the end of week 12 of the PFM rehabilitation, the mean IELT was 146.2 ± 38.3 seconds (range: 129.6-184.5 seconds). 13 / 33 (39%) patients reached 6 months follow-up and the mean reported IELT was 112.6± 16.4 seconds (range: 108.7-121.1 seconds; Figure 2 ), which resulted significant when compared to their initial IELT (mean 39.8 sec; range:24-6 -56.3 sec).

Interpretation of results All our enrolled patients had lifelong PE and did not report any significant improvements after previously undergoing other various therapeutic treatments such as local anaesthetic creams, behavioural therapy (including the squeeze and stop-and-start techniques), and psychological treatment of various types. In the present study, the pelvic floor exercises led to an improvement in body and, especially, pelvic floor awareness in all of the enrolled subjects, which helped them improve their self-confidence and sense of control of their ejaculatory reflex. In addition, we demonstrated that active perineal muscle control inhibits the ejaculation reflex through intentional relaxation of the bulbocavernous and ischiocavernous muscles, which are active during arousal and should be intentionally relaxed during this phase of sexual intercourse. This is an easily learned technique that can be mastered by using pelvic floor biofeedback.

In conclusion, the results we obtained with PFM rehabilitation are promising. Furthermore, this treatment option could represents an important cost reduction as compared with other commonly used treatments (SSRIs, local anaesthetic creams, and PDE-5 inhibitors). Thus, we propose PFM rehabilitation as a new type of physical treatment that may be a viable treatment option for PE.

Hypothesis / aims of study Elvie is a commercially available intravaginal pelvic floor exercise device (see Figure 1 ). It contains a force-sensitive resistor and accelerometer, to simultaneously measure pelvic floor contraction and motion. The device connects to a smartphone via Bluetooth and an associated application provides users with biofeedback and guidance on pelvic floor muscle training (PFMT) exercises. Users can set notifications to encourage PFMT frequency. The device has potential as an adjunct or alternative to supervised PFMT . Figure 1 : the Elvie device

We conducted a web survey of current users of the device in the United States (US) and United Kingdom (UK) aiming to better understand the demographics of users of PFMT devices, gauge user attitudes towards the Elvie, and determine if users perform PFMT more often with Elvie. We further investigated the odds of self-reported improvement in stress urinary incontinence (SUI) symptoms from the use of Elvie, dependent on duration and frequency of use.

The questionnaire was sent to US-and UK-based user email addresses, attached to Elvie accounts from which user consent had been given to receive communications from the company. We incentivised user participation through the opportunity to enter a prize draw for a 150GBP/200USD retail voucher on questionnaire completion. Prior to taking the questionnaire, users were informed on how their data would be used and that their responses would remain anonymous. It was not compulsory to answer any questions relevant to symptoms to complete the survey and no identifying data were collected. Items asked included demographics (age, parity, age of youngest child, if currently pregnant), motivations (frequency of PFMT before and after using Elvie device, main motivation to purchase) and invited general feedback. Users who answered "Improve bladder control" or "Prevent bladder problems in the future" to the question regarding main motivation to purchase were invited to answer questions from the ICIQ-UI short form questionnaire on urinary incontinence symptoms and experience, and a Global Perception of Improvement (GPI) [1] question on improvement of condition with Elvie. All respondents were invited to answer the Net Promoter Score (NPS) question on satisfaction: 'How likely is it that you would recommend Elvie to a friend or colleague?' (responses '0' (not at all likely) through '10' (extremely likely)). Frequency of performance of pelvic floor exercise was assessed by two questions: "How frequently did you do pelvic floor exercise before using Elvie?" and "How frequently do you do pelvic floor exercise now that you have an Elvie?", both of which had options: "Never", "Rarely", "At least once a month", "At least once a week", "At least three times a week", and "At least once a day". Statistical significance of the difference in resulting proportions was assessed via a chi-square contingency test.

Respondents who filled out the ICIQ-UI questionnaire were assessed for symptoms of SUI via the frequency and amount of leakage, and the conditions under which urine leaked. For these respondents, duration of use was segmented into intervals ([0, 2) months, [2, 4) months, and [4, 6] months), and frequency into bins ("Rarely" or "At least once a month", "At least once a week", and "At least three times a week" or "At least once a day") to improve sample sizes. Multiple logistic regression was used to determine relationships between these variables and the odds of respondents reporting improvement in the GPI question.

Data analysed are from the first 417 users to complete the survey. The median age of survey respondents was 39 years (interquartile range 33-49 years). 33.5% of respondents were nulliparous, 25.0% were primiparous, and 41.5% multiparous. Median parity was 1 (interquartile range 0-2). Of the respondents who had children, 46% had not given birth for at least 10 years. 9.5% had had a child within the previous 6 months. 6 .5% of respondents answered that they were currently pregnant. All 417 participants answered the questions regarding how frequently they performed PFMT. Prior to purchasing Elvie, the modal answer was "Rarely" and 25.9% of respondents reported exercising at least once per week. After purchasing Elvie, the modal response was "At least three times a week" and 77.0% of participants reported exercising more than once per week. The proportions of responses were found to be significantly different (p<0.001) between the two questions. The modal pairwise difference in the rank of responses was found to be +1 rank. The modal combination of answers was "Rarely" before receiving Elvie and "At least three times a week" after receiving Elvie (14.6%), followed by "Rarely" before receiving Elvie and "At least once a week" after receiving Elvie (11.8%).

Results of the number of respondents and proportions of reported improvement in SUI symptoms are shown in Figure 2 after segmentation by time duration and frequency of use. After filtering, 156 respondents remained. Among these, the percentage of respondents who reported an improvement in symptoms (gauged by selecting either "A little better" or "Very much better") was 62.8%, while the proportion who answered "Very much better" was 10.3%. Multiple logistic regression revealed a statistically significant relationship between odds of improvement and duration of use (p=0.001), with an odds ratio of 2.24 per duration segment (95% CI: 1.4-3.7). A statistically significant relationship was found between odds of improvement and frequency of use (p=0.002), with an odds ratio of 2.17 (95% CI: 1.34-3.51) per frequency segment. Across all respondents, 67.8% of respondents indicated a high degree of satisfaction with the device (NPS score of 8 or more).

Respondents report more frequent performance of PFMT after purchasing an Elvie compared to prior to purchase, suggesting that Elvie motivates users to exercise more frequently. However, this result is based on self-reported data and is likely to be subject to bias. Statistically significant relationships in the odds of improvement were found with both duration and frequency of use, indicating that Elvie users are more likely to see improvements given more time or an increase in frequency.

Concluding message Using questionnaire results from 417 users of a commercially available PFMT device, we assessed the impact of the device on frequency of PFMT and its benefits. Our findings resonate with literature on the effectiveness of biofeedback as an adjunct to PFMT [2] . Future work is needed on the impact of baseline incontinence severity on improvement rate, and to compare training with an Elvie with conventional supervised PFMT. 

Hypothesis / aims of study We aimed to systematically characterise the association between Vitamin D and pelvic floor disorders including incontinence.

This review was conducted in adherence with Preferred Reporting Items for Systematic Reviews. Citations were retrieved using a comprehensive database search [inception to June 2016: CINAHL, Cochrane, EMBASE, Medline and SIGEL and grey literature]. Search strategies consisted of MeSH subheadings for the concepts of Vitamin D and its relation to pelvic floor disorders and incontinence Information regarding study characteristics and primary outcomes was collated.

Results 45 citations were identified, 15 studies fulfilled the inclusion criteria of which 8 (4 longitudinal prospective observational studies, 1 randomised controlled study, 1 case -control study, 1 case series, 1 retrospective study) were included in the systematic review. A multicentre, double blind randomised placebo controlled trial included women (n=308) with overactive bladder symptoms to receive either placebo or elocalcitol(1). The study found elocalcitol to be effective and well tolerated drug for management of overactive bladder symptoms. A cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) reported significantly decreased risk of pelvic floor disorders with increasing Vitamin D levels in women aged 20years or older (OR 0.94 95% CI 0.88-0.99) and in women aged 50 years and older (OR 0.92 95% CI 0.85-0.99) (2).

From the NHANES 2005-2006 survey, it was noted that vitamin D level was inversely proportional to the risk of pelvic floor disorders in all women (p=0.043) including those aged 50 and older (p=0.022) (2). Dallosso et al, in their longitudinal study found that a higher dietary vitamin D intake was associated with lower risk of overactive bladder symptoms (p<0.01) (3). Vitamin D has a pleitropic effect. Clinicians should consider correction of Vitamin D deficiency as an adjunct to the routine conservative therapies offered to patients with pelvic floor disorders and incontinence.

Concluding message There is plausibility that Vitamin D supplementation may have complementary effect to the conservative therapies in decreasing the risk of pelvic floor disorder and incontinence. We need robustly designed RCTs to prove this beyond doubt. 

Hypothesis / aims of study The efficacy of preoperative pelvic floor muscle training (PFMT) for urinary incontinence after robot-assisted radical prostatectomy (RARP) is still unclear (1). A previous study evaluating the somatic and autonomic innervation of the pelvic floor and external urethral sphincter using neurophysiological tests demonstrated that autonomic afferent denervation of the membranous urethral mucosa was seen in most patients after nerve-sparing radical prostatectomy, and this denervation was proposed to attribute to post-prostatectomy incontinence (2) . A recent study in postpartum women received an intensive 3-month PFMT program augmented with biofeedback using ultrasound (US)-images (US-guided PFMT) from 3 to 6 months postpartum showed that motor learning of correct pelvic floor muscle (PFM) contractions was associated with early recovery of urinary continence (3). We hypothesized that if similar US-guided PFMT introduced before RARP facilitates motor learning of correct PFM contraction and ameliorates urethral sphincter dysfunction related to the membranous urethral afferent denervation after RARP, US-guided PFMT would be applicable also for achieving early recovery of urinary continence after RARP. To test this hypothesis, we examined whether this US-guided PFMT promotes early recovery of urinary continence after RARP.

This prospective observational study included 116 patients who underwent RARP from March to November 2016. These patients were divided into two groups; the US-guided PFMT group consisted of 36 patients who voluntarily visited the pelvic floor rehabilitation clinic to have US-guided PFMT before RARP, and the verbal-PFMT group consisted of the other 80 patients who received verbal instruction of PFMT after RARP. In the US-guided PFMT, a team composed of a physiotherapist and a nurse taught a patient about pelvic floor anatomy and continence mechanism using a standardized leaflet, provided individually PFMT augmented with US-guided biofeedback, and finally instructed the patient about home PFM exercises at 2-3 weeks before RARP.

The biofeedback was carried out by using transperineal US images visualizing whether a patient was able to contract PFM correctly or not. The correct contraction of PFM was judged by shortening the membranous urethral diameter and closing of the bladder neck on the US images. Thereby, patients could recognize the strength and sensation of PFM contractions before RARP and relearn them after RARP. In the verbal-PFMT group, patients received verbal instruction of PFMT by a nurse using a standardized leaflet after the removal of a transurethral catheter in the ward. Urinary continence status was defined as pad-use less than one per day by self-report postoperatively. Statistical analyses were carried out by Student's t test, Fisher's exact test, or the Cox proportional-hazards model.

There were no differences in demographic or operative parameters between the US-guided PFMT group and verbal-PFMT group except the operative time, which was significantly longer in the US-guided PFMT group than the verbal-PFMT group (229.2 ± 47.6 vs. 207.7 ± 51.9, p = 0.033) [ Table 1 ]. The continence status was achieved within 90 days after RARP in 88.9 % (32/36 patients) of the US-guided PFMT group, which tended to be higher (p = 0.09, by Fisher's exact test) than that of the verbal-PFMT group (73.8 %; 59/80 patients). After adjusted by the demographic and operative parameters, the US-guided PFMT was solely associated with better postoperative continence status (Hazard ratio (95% Confidence interval): 0.55 (0.31-0.99), p = 0.050) [ Table 2 ].

The present US-guided PFMT introduced preoperatively seems beneficial to achieve early recovery of urinary continence after RARP. It is considered that the preoperative US-guided biofeedback would be helpful for patients to percept the correct contraction of PFM before surgery, when they have normal function and sensation of urethral closure, and that this motor learning may promote relearning of PFM contraction after RARP. Randomized control studies are needed to confirm the efficacy of the preoperative US-guided PFMT.

Our results suggest that the preoperative US-guided PFMT is helpful for patients to achieve urinary continence recovery earlier after RARP. 

Goode P 1 , Markland A 1 , Barnacastle S 2 , Wright M K 2 , Redden D 2 , Echt K 3 , Colli J 4 , Burgio K 1

Hypothesis / aims of study Incontinence can be extremely burdensome and is common after prostate cancer surgery. Although incontinence improves or resolves over the first several months following prostatectomy, even transient incontinence can deter the return to employment and resumption of beneficial activity, since activity worsens stress incontinence. Also, studies show that a significant number of men have long-term post-prostatectomy incontinence sufficient to warrant wearing a pad [1] . At least six adequately powered, randomized controlled trials have shown that perioperative outpatient pelvic floor muscle training can hasten postoperative recovery of bladder control and reduce the severity of incontinence following radical prostatectomy [2, 3] . However, most men undergoing prostatectomy do not receive this training. One reason is a lack of providers trained in male pelvic floor muscle rehabilitation. Also, men may have difficulty getting time off from work or not want to travel long distances to attend this training if it is available. To provide more men with perioperative pelvic floor rehabilitation, we developed a home telehealth program, based on an evidence-based in-clinic protocol that reduced post-prostatectomy incontinence. The program was then pilot tested to demonstrate feasibility and patient acceptance.

The aims of the innovative study were to convert a successful, clinic-based, perioperative rehabilitation program, including pelvic floor muscle training, progressive exercises, and bladder control techniques, to a home telehealth format and to do feasibility and pilot testing. The hypothesis was that men would use the program and find it beneficial.

This innovative study used a panel of experts including a urologist, geriatricians, and health educators with input from patients to develop a story-based series of lessons to assist the patients to master the evidence-based content which is shown in the Table.  Table -Content Each daily session is 5-10 minutes in length, written on a 6 th grade reading level, and accessed on a telehealth device. There were 2-4 weeks of daily sessions pre-operatively depending on how close to surgery the patient was enrolled. There were 60 sessions post-operatively, started as soon as their urinary catheter was removed. Adherence was monitored remotely via the telehealth device and patients were telephoned if they missed more than 3 daily sessions in a row. Inclusion criteria: 1) men with prostate cancer scheduled to undergo a radical prostatectomy and 2) ability to read English (later versions in other languages are planned). Exclusion Criterion: self-reported incontinence prior to prostatectomy. Evaluation of the home telehealth program was done with mixed quantitative and qualitative methods. The primary outcome was feasibility defined a priori as enrollment of at least 75% of men undergoing radical prostatectomy who met the inclusion criteria and then at least 75% of those men enrolled completing 90% or more telehealth sessions. Qualitative evaluation of the program included a semi-structured telephone interview after completion of the program. Interviews were taped for determination of themes by 2 coder analysts.

Of 31 men scheduled to undergo radical prostatectomy and meeting inclusion/exclusion criteria, 30 (97%) were enrolled. Age ranged 53-70 years with a mean age of 62 years; 58% African American, 42% Caucasian. Of the 30 enrollees, 4 did not have surgery due to change in treatment plan to radiation therapy, leaving 26 who were eligible and participated in the home telehealth program. Of the 26 participants, only 1 declined to continue doing the sessions and dropped out of the study; 1 died of postoperative complications. Thus, 92% of participants completed the program. Three of the men needed telephone reminders to start using the device. All 24 completers did 100% of the sessions.

The qualitative data were very informative with themes of ease of use, usefulness of knowledge provided, helpfulness of the story format, and appreciation of the home setting for acquiring the information. Quotes highlighting the themes follow. Asked "What did you think about the information you received in the telehealth program?" -"Once I started [the program] I couldn't believe that all the questions I should have asked the doctor were right there in the program and with answers. I didn't know what to ask so I just made the doctor think I had enough information. He [the urologist] asked me several times if I had any questions, but really, I would never have thought of those questions." "Doing the program made it a lot easier and quicker to get back to normal." Asked about the exercises: "At first, it was quite difficult, because I didn't realize or understand what they meant by it. But once I kept doing and doing it, and I figured out how to really do it, it was a piece of cake." Asked about the stories: "They make you want to use the machine more. It made you look forward to using it." "I learned about different people having prostate cancer and they survived it and they are doing well." Asked about the overall program: "I liked the how the program was set up, the way they told me to do it. Nobody disturbs you, nobody watches you, it is private."

This evidence-based, home telehealth program including pelvic floor muscle training, progressive exercises, and bladder control techniques, met our benchmarks for feasibility during this pilot study: 97% of men scheduled for radical prostatectomy enrolled and 92% completed the program. Qualitative findings supported benefits of the program before and after prostatectomy.

Concluding message Home telehealth is a feasible venue to teach pelvic floor muscle exercises and behavioral strategies to control urine leakage to men undergoing radical prostatectomy. A randomized, controlled trial of this home telehealth program is in progress. 

Hypothesis / aims of study The overactive bladder syndrome (OAB) is defined as urinary urgency (the primary symptom of OAB), usually accompanied by frequency and nocturia, with or without urgency urinary incontinence (UUI) by the International Continence Society (ICS) (1). Within conservative management, behavioural treatment in combination with biofeedback-assisted pelvic floor muscle training (BAPFMT) is a first-line treatment option (2) . Literature on comparative effectiveness indicates that behavioural treatments are either equivalent to or more effective than medications for reducing incontinence and overactive bladder (OAB) symptoms, without exposing patients to the typical side effects of medications. However, pelvic floor physiotherapy has a lack of evidence regarding long-term outcomes and comparison with other treatments. The aims of this study were to determine the long-term effect of Biofeedback Assisted Pelvic Floor Muscle Therapy (BAPFMT) in female patients with OAB on symptoms, health-related Quality of Life (QoL) and the effect on the EMG signals of the individual pelvic floor muscles after one year follow-up.

Study design, materials and methods All women who had participated in a prospective randomized controlled trial were included (3) . At the start of the study patients were randomly assigned to an intervention group, which received 9 weeks of BAPFMT with the MAPLe, or into a control group which received toilet behaviour and lifestyle instructions and had a postponed treatment starting nine weeks after inclusion. An examination of the pelvic floor was performed, consisting of administering the Pelvic Floor Inventories (PeLFIs), a vaginal visual inspection and digital palpation, as well as EMG registration and all patients were asked to fill out the King's Health Questionnaire (KHQ), a 24-hr bladder diary and to perform a 24-hr pad test. At each examination, EMG signals of the pelvic floor were registered during one minute rest, 10 maximum voluntary contractions (MVCs) and endurance. At 9 weeks, 6 months, and 1 year after treatment in both groups, the examination of the pelvic floor was repeated. Location of electrodes was checked in MRI.

Descriptive statistics were calculated for all clinical variables for each time period. Comparison between groups for continuous variables was made by repeated measure analysis of variance using a mixed model after transformation of the data to enhance normality, with treatment, time (categorical) and their interaction as fixed effects and with random patient effects Results Fifty-eight patients were included in this study. Before treatment and after one year follow up the groups were comparable on all key parameters such as severity measures and loss of urine. There were no significant changes between the two groups after one year follow up. Thirteen patients were lost to follow-up at one year. Of 45 women the results at the start of the study were compared to the results after one year follow up. During the one year follow up patients received no other intervention. After one year, the PeLFIs showed significant improvement in complaints of OAB in the domains micturition pattern, urinary incontinence, obstructive micturition and pain (p< 0.05). For the KHQ the domains, social limitations, and severity measures improved significantly. The 24-hr voiding diary and 24-hr pad test showed significant reduction at one year follow up compared to the start of the study. Figure 1 shows the average loss in grams for the two groups. An average reduction of more than 50% is achieved after BAPFMT with the MAPLe after treatment. Furthermore it shows that the effect of the treatment is sustained after one year follow-up in both groups. Besides QoL measures, average EMG signals per electrode for rest, MVC, and endurance were calculated and compared for every patient. At one year follow-up, for the combined groups tone at rest was significantly lower for electrodes at the urogenital diaphragm, nearest to the bladder and urethra on the anterior side and nearest to the iliococcygeus muscle on the left side and in the deepest region on the posterior side and significantly higher on the left side nearest to the bulbospongiosus and ischiocavernosus. Mean EMG for MVC and Endurance were significantly higher after one year follow-up for the superficial parts of the PFM (the Bulbospongiosus and Ischiocavernosus muscles on both sides, at posterior side and the superficial part of the urogenital diaphragm) and significantly lower for most of the deeper parts of the PFM. For the right side of the pubo coccygeus muscle the average EMG was significantly higher and for the iliococcygeus significantly lower. For endurance, average EMG for the puborectal muscle overall was significantly higher and significantly lower for one deeper region of the urogenital diaphragm ( Figure 2 ). The most outer ring are located at the most caudal or superficial parts of the PFM, the most inner ring (nearest to the center) is located at the most cranial or deeper parts of the PFM. Colour indicates a significant difference, + is higher -is lower.

Results show that BAPFMT is effective in women with complaints of OAB after one year follow-up. Validated questionnaires showed a significant reduction in symptoms and complaints of OAB and an increase Quality of Life for patients. Significant changes were still seen in EMG activity after one year follow up, nearest to specific muscle layers and sides for tone at rest, MVC and endurance. This indicates that in the diagnosis and treatment of OAB should focus more on the individual muscle sides and layers of the pelvic floor, instead of the conventional average EMG of all muscles sides and layers combined. The increase in EMG activity in superficial parts and decrease in deeper parts of the PFM could also indicate a restoration of the Guarding reflex Concluding message This is the first study that shows that EMG biofeedback assisted pelvic floor muscle therapy with the MAPLe is effective in the OAB syndrome after one year follow up. It significantly reduces symptoms and complaints of OAB and increases Quality of Life for patients. 

McClurg D 1 , Alex P 1 , Campbell P 1 , Elders A 1 , Hazleton C 1 , Hagen S 1 , Hill D 1

Hypothesis / aims of study At least one in four women will experience urinary incontinence (UI), negatively impacting on their quality of life (QoL) (1) . Multiple overlapping reviews about conservative management have been published and it is challenging for clinicians and policy makers to keep up to date with the evidence. Cochrane Overviews aim to provide a succinct overview of reviews relevant to a specific clinical question. We completed an Overview to bring together Cochrane systematic reviews of evidence relating to conservative interventions for the treatment of female urinary incontinence.

Study design, materials and methods A stakeholder group (n=14) including clinicians, service users, and commissioners contributed to the Overview protocol development. The group met on two occasions and, using consensus methodologies, helped us outline the scope of the review by defining the population and conservative interventions, and by identifying key areas of clinical priority. Our overview analysis and selection criteria were specified in advance and documented in a protocol (2) . We comprehensively searched the Cochrane Database of Systematic Reviews (from inception to September 2016) for systematic reviews of trials involving women with UI which investigated the effectiveness of conservative management. Our primary outcomes of interest were cure or improvement (CorI) as reported by the women and condition-specific QoL questionnaires. Secondary outcomes included adverse effects, general quality of life, and pelvic floor muscle strength. Two independent reviewers applied selection criteria and assessed the methodological quality of the reviews using the Risk of Bias in Systematic reviews (ROBIS) tool. We documented the quality of evidence synthesised within the reviews using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Data relating to the effects of conservative management on female stress, urgency or mixed urinary incontinence (SUI, UUI, MUI), and comparisons of conservative management versus control, versus other conservative management, or versus non-conservative management, were extracted and summarised within tables. The data extracted included the number of trials, number of participants, participant characteristics, intervention, comparison, outcomes (primary and secondary), timing of outcomes, our GRADE decisions, evidence of effect and notes on direction of effect. Meta-analysis on the trial data was undertaken producing network maps illustrating intervention comparisons for which research evidence exists. Treatment effect size was summarised within forest plots. Interventions supported by high or moderate GRADE evidence were highlighted.

A total of 1896 titles were screened, 186 full texts were considered, and 27 reviews and 8 protocols were included. Thirteen reviews focussed on conservative interventions, including a total of 200 trials (mean per review 15.4, SD 13.3) and 20411 participants (mean per review 1570, SD 1580). Ten reviews focussed on non-conservative interventions but included comparisons with conservative interventions, including a total of 167 trials (mean per review 16.7, SD 9.88) and 35060 participants (mean per review 3506, SD 5827). Four reviews focussed on a specific aetiology or condition, with results described narratively. Of the reviews that were included, there is a tendency for high risk of bias around the synthesis and findings (ROBIS Domain 4). The 23 reviews included 460 meta-analyses (Table 1) . 124/460 (27%) were meta-analyses for CorI, 50/460 (11%) for QoL and 286/460 (62%) were for other secondary outcomes. From our modified GRADE approach we judged the quality of evidence to be high in 33/460; moderate in 215/460; low in 179/460 and the rest very low or inestimable. Within our primary outcome of CorI (Table 2) there is high level evidence that pelvic floor muscle training (PFMT) is more beneficial than control for all types of UI, and also has high level of evidence for QoL for SUI and MUI. There is also high/moderate level of evidence for CorI that PFMT is more effective when more intense, combined with biofeedback/feedback or behavioural change techniques. Electrical stimulation is of benefit (CoI) when compared to control for women with MUI or UUI. Only 13 women from 4 trials reported minor side effects due to conservative intervention. 380/460 outcomes were reported at immediate follow-up, 51 at 3-6 months, and 29 later or unclear. Socio-economic analysis was reported in 4 trials. 

The majority of SUI and UUI meta-analyses produced moderate or high GRADE quality evidence. There is a large and growing body of systematic review evidence relating to conservative management of UI. There is good quality evidence that PFMT with or without adjuncts is effective in most types of UI. There is a lack of evidence on many educational/lifestyle interventions. There is a need for improvements in the quality of future reviews (in terms of meta-analysis) and primary studies (in terms of presenting adequate data and using consistent outcome measures).

Concluding message This overview has brought together all Cochrane systematic review evidence for the conservative management of women with urinary incontinence and provides a summary of existing evidence to support clinical decision making and improve patient care. Implications for clinical practice: Pelvic floor muscle training is of benefit in all types of UI. Electrical Stimulation is of benefit for MUI and UUI. Evidence is currently insufficient to give certainty over the relative effectiveness of other conservative interventions. Implications for research: Future research for conservative management should use standardised outcome measures, detailed descriptions of the intervention and control arms, adequately powered with long-term follow-up and socio-economic analysis. 

Hypothesis / aims of study Pregnancy, vaginal delivery and various other conditions associated with intraabdominal pressure increases or neurological changes can lead to reduced muscle thickness and increased urogenital hiatus and abnormal bladder neck mobility. This may contribute to urinary and fecal incontinence and pelvic organ prolapse (POP). 1 The aim of this study was to evaluate the effect of Pelvic Physiotherapy (PP) on morphological changes and objective improvement of urine incontinence (UI) and fecal incontinence (FI) and POP.² ). In addition reference lists were scanned. Studies with operative or pharmaceutical therapy only, studies without information about interventions, morphological or positional changes, or studies that included women pre-and one year postnatal were excluded. The language was restricted to English and German. Eight studies remained for analysis. (Figure 1 ). Data extraction Two investigators screened all titles, abstracts and full texts independently for eligibility. In case of disagreement, a discussion took place until consensus was achieved. The quality of the included studies and the risk of bias were analyzed with "The Cochrane Collaboration´s tool for assessing risk of bias". The following data were extracted: Characteristics of the subjects, characteristics of the intervention and the control group (if present), duration of intervention, outcomes including morphological changes and organ position changes, as well as changes in symptomatic and quality of life (if present).

Studies investigated effects of PP on female patients with incontinence and POP and on male patients before prostatectomy. No studies were found dealing with the effect of PP on healthy people as a preventive measure. We found five clinical trials and three RCT´s.

Length of treatment ranged between 30 days and six month, with varying decrease of supervision by health care providers. In all studies assessment of correct pelvic floor contraction was performed. Finding after PP included several markers of morphological changes (Table 1) . Morphological changes Urethral sphincter increased thickness and cross sectional area PFM increased thickness and stiffness hiatal area decreased hiatal area at rest, shortened muscle length bladder neck reduced mobility during coughing, elevated position during rest and contraction Rectum Narrowing of anorectal angle Table 1 All studies showed significant changes in pelvic floor morphology and / or organ position after PP. There was also a reduction of the symptomatic.

Interpretation of results Supervised PP of approximately 12 weeks duration with assessment of correct pelvic floor contraction leads to morphological changes and reduction of symptoms in patients with UI, FI and POP. There is a risk considerable of bias because of the small number of patients in the included studies and the poor reportings of therapie in most of the studies. Since success of PP appears to depend on cooperation, compliance and diligence of the patient and the ability of the therapist for motivational support, a standardized approach of reduce would be helpful.

In our systematic review PP showed effects on muscular structures and lead to measurable changes of position of pelvic organs (bladder neck and rectum). These results should be interpreted with caution, because of small patient number and risk of bias. 

Hypothesis / aims of study Pelvic floor muscle training (PFMT) is recommended as a first-line treatment for stress urinary incontinence (SUI) (Grade A evidence) (1). It has been reported that PFMT can be performed with special vaginal/rectal devices in the form of resistance training (2, 3). Bø suggested a different way of resistance training with a vaginal cone, by which the cone is placed into the vagina and the patient was asked to contract around the cone while a physiotherapist or the patient simultaneously try to pull it out (3). This new training results in the elimination of the weight of the cone during the process of pulling it out of the vagina. So, we preferred to use inexpensive, hygienic, and single-use vaginal tampons in this training method. To the best of our knowledge, there is no randomized controlled trial (RCT) investigating the additional effect of resistance training with vaginal tampons in SUI. Therefore, the aim of this RCT was to assess vaginal tampon training (VTT) combined with PFMT results in better outcomes than PFMT alone for the treatment of SUI.

The present study was designed as a randomized, controlled, and single-center study comprising of two parallel arms (PFMT+VTT and PFMT). Inclusion criteria were being 35-60 years of age, having symptoms of SUI according to MESA urinary incontinence questionnaire, being able to contract the pelvic floor muscles, and had sufficient literacy. Women excluded from the present study who: had undergone surgery for incontinence; were taking medications for UI; had neurological disorders; had recent/recurrent urinary tract infections; had Pelvic Organ Prolapse (POP) score ≥ Stage 3 according to POP Quantification System; were pregnant or in a postnatal period of under 6 months. After a comprehensive clinical evaluation and a screening for the inclusion criteria, a computer-based block randomization procedure was used to assign blocks of four participants to each study arm (PFMT+VTT or PFMT). A standardized 12 weeks of training protocol was performed for both study groups. In PFMT protocol, fast and sustained contractions were taught to all participants. In VTT, the tampon was inserted into the vagina by a physiotherapist (in clinic) or by database searching and snowball-system (n=157) the patient (at home) and while the patient was instructed to contract her pelvic floor muscles around the tampon, the physiotherapist or patient tried to pull it out of the vagina (a total of five days per week; two days by physiotherapist, three days by themselves). In PFMT alone group, biweekly visits were performed to check the progression of training and to increase the adherence of the treatment. The primary outcome measure was a self-reported improvement by 4-item Likert-type scale (worse, same, better, cured). Secondary outcome measures included the severity of urinary incontinence by Incontinence Severity Index (ISI), symptom distress and quality of life score by King's Health Questionnaire (KHQ), number of UI episodes and micturition frequency by urinary diaries, pelvic floor muscle strength (PFMS) and pelvic floor muscle endurance (PFME) by vaginal perineometer. Treatment adherence was also evaluated with 100 mm Visual Analog Scale (VAS). All outcome measures except the self-reported improvement were assessed at baseline, 4 th week, 8 th week and 12 th week. Values were analyzed with Friedmann test (nonnormally distributed data) and Chi-Square tests (for categorical variables). Mann-Whitney U and Wilcoxon tests were used to compare values (non-normally data) between and within groups, respectively. Alpha was set at 0.05.

A total of 34 women who had symptom of SUI (mean age: 48.26 SD: 6.49 year, BMI: 27.98 SD:3.26 kg/m 2 ) had completed this study [PFMT+ VTT (n=16), PFMT(n=18)]. There were no statistically significant differences between two groups in terms of the physical/demographic characteristics and baseline outcome measures (p>0.05). Adherences to PFMT were also similar between groups at 4 th , 8 th and 12 th weeks (p>0.05).

No statistically significant difference was found in self-reported improvement between groups at 4 th week, 8 th week and 12 th week (p>0.05). However, both groups had high subjective total cure and improvement rates (total cure+improvement rate: % 75 and % 72.2 at 4 th week, % 87.5 and % 88.9 at 8 th week, % 93.8 and % 94.4 at 12 th week for PFMT+VTT and PFMT groups, respectively).

Within-group analysis showed that both treatment groups experienced statistically significant improvements in terms of the ISI score, symptom distress score, PFMS, PFME, UI episodes, micturation frequency, and all domains of KHQ except personal relationships over the time (p<0.05). However, between-group analysis showed that there were no statistically significant differences in terms of the incontinence severity, symptom distress score, PFMS, PFME, UI episodes, micturation frequency and in all domains of KHQ scores except social limitations at all time points (p>0.05). According to pairwise analysis, the PFMT+VTT group experienced a statistically significant improvement in PFMS and PMFE starting from the 8 th week until the end of the treatment. On the other hand, there was a significant improvement in PFMS and PFME only at 12 th week in the PFMT group. In addition, the increase in PFMS and PFME between baseline and 12 th week in the PFMT+VTT group was significantly greater than the PFMT group (p=0.37, p=0.32). Interpretation of results This is the first RCT investigating the additional effect of the different type of resistance training with vaginal tampons to PFMT in the treatment of SUI. The findings from the present study showed that pelvic floor exercises with and without vaginal tampon exercises had similar effectiveness on the symptoms and severity of SUI, quality of life, and subjective cure+improvement rates. Although between group analysis showed no statistically difference in PFMS and PFME at all time points, it appears that the combination therapy may also lead to an earlier and greater increase in PFMS and PFME. While the significant improvements in PFMS and PFME were shown in PFMT+VTT group at the end of the 8 th week, in PFMT group the improvement was only seen at the end of the 12 th week. Concluding message Although there was an earlier and greater improvement in PFMS and PFME in the PFMT+VTT group, combination therapy did not promote greater gains in the subjective cure/improvement rates, severity of urinary incontinence, incontinent episodes, quality of life compared with PFMT alone. We think that resistance training with vaginal tampons may be added to an early phase of training due to the additional effect on PFMS and PFME. Further long-term follow-up RCTs with VTT as an only home-based programme or comparing PFMT with VTT alone are needed. 

Hypothesis / aims of study The aim of this study was to determine if a physiotherapy led gynaecology physiotherapy screening clinic (GPSC) can improve access to care and health outcomes in women with incontinence and / or pelvic organ prolapse (POP) referred for gynaecology / urogynaecology outpatient services and wait listed as category 3. Many healthcare systems are currently facing multiple challenges with increasing costs of providing healthcare, ageing populations as well as an increase in chronic diseases. Urinary incontinence and pelvic organ prolapse affect many women across all ages and have a significant impact on women's quality of life. Treatment involves conservative and / or surgical management. With increasing waiting lists for gynaecology review a different model of care was a priority for both the patient and the health service.

It was hypothesized that implementation of a GPSC:

• Reduces the waiting time to initiation of care for women on gynaecology / urogynaecology department outpatient waiting lists -these women can access the GPSC much earlier than waiting for an initial gynaecology / urogynaecology consultation • Reduces the number of category 3 patients requiring gynaecology / urogynaecology appointments -women who experience a resolution of their symptoms with GPSC management can be removed from the Gynaecology Outpatient Department (GOPD) waiting list • Reduces the number of specialist appointments (gynaecology / urogynaecology) required or provides a more efficient pathway to surgical management, for women who remain on the GOPD waiting list after discharge from the GPSC. These women can receive intensive physiotherapy treatment prior to their specialist consultation. It was also hypothesized that the majority of women who complete a course of treatment and are discharged from GPSC will have a reduction in the severity of their incontinence and / or prolapse symptoms, have an improvement in their overall quality of life and will have a high level of satisfaction with the GPSC service.

The study involved a service evaluation comparing patient outcomes before and after the introduction of the GPSC service at two hospital sites.

GPSC admission and discharge data were collated on women completing a course of treatment for incontinence and / or pelvic organ prolapse from January 2015-March 2016. Following initial assessment, management options available included conservative management comprising a course of physiotherapy +/-continence nurse advisor review, gynaecology / urogynaecology review, or if clinically indicated referral expediated for specialist review. For patients appropriate for conservative management discharge options included discharge from GPSC with no gynaecology / urogynaecology review indicated or continued on for specialist review in GOPD -again this may have been upgraded for earlier review if clinically indicated. Percentage of women with clinical improvement on clinical outcome measures (Australian pelvic Floor Questionnaire (APFQ) and the AQOL-6D), between initial and discharge were reviewed. Global rating of change scale which was completed on discharge from GPSC was also reviewed. Data were retrieved from a historical comparator group of women attending an initial gynaecology or urogynaecology appointment between 1 st July 2013 -31 st December 2013. Medical records were searched to ensure primary diagnosis at initial consultation, follow up appointments or surgery performed was for incontinence and / or POP. For both groups wait time to initiation of care (days), number of specialist appointments required before discharge or surgery were recorded. The data collected was quantitative, non-identifiable and grouped for analysis and reporting.

A total of 380 patients were discharged from GPSC across the two sites from January 2015 to March 2016, with 202 female patients (average age 52 years -range 16-84) conservatively managed. Women completing a course of treatment demonstrated significant clinical symptom reduction as measured on the APFQ across all domains following treatment (p <0.001). 80% of patients reported positive improvement on the GRC scale (n=167). There was no difference in the total AQOL-6D between pre and post treatment however there was a statistically significant reduction in the dimensions for coping and pain (p=0.31 and 0.23 respectively) however numbers were low (n=44). Of the 178 patients who did not complete treatment in GPSC 43% were failed to attend, 30% requested discharge, 13% declined the offer of an appointment and 14% did not respond to the initial offer of an appointment.

Wait time to initiation of care was significantly reduced from a mean 133 days (SD 120) to mean 87 (SD 75) post commencement of the GPSC. Of those that completed a course of treatment 33% of women no longer required a gynaecology / urogynaecology appointment and were removed from the GOPD waiting list. Patients who needed specialist review (66%), both surgical and non surgical, required an average of 1 (SD 1.1 and 0.96 respectively) less gynaecology / urogynaecology appointments per patient. For those 178 patients who didn't complete a course of treatment 14% were able to be removed from the GOPD waiting list. Earlier specialist review was facilitated in 5% of the patient cohort. Satisfaction surveys were completed by 121 discharged patients. All participants expressed satisfaction with the service and would recommend it to others. Over 73% were very satisfied that their main problem was identified and treated by a physiotherapist as well as with the outcome of their management through GPSC.

Interpretation of results Early intervention in a GPSC can provide patient benefits by providing earlier access to care and significantly reducing patient symptoms. Additionally the GPSC had a positive effect on the health service by reducing the number of patients requiring gynaecology / urogynaecology review, resulting in increased availability of specialist appointments reducing specialist waiting list time.

Irrespective of whether patients were discharged from GPSC with no specialist follow up required or continued on for gynaecology / urogynaecology review there were still significant improvements in their clinical symptoms following treatment in the GPSC. The GPSC service has improved the patient flow with the patient completing a course of physiotherapy treatment prior to seeing the gynaecologist / urogynaecologist which is in line with current international guidelines (1). It has also allowed for the facilitation of earlier review for patients with severe symptoms.

Early physiotherapy intervention in a GPSC prior to gynaecology appointment for women with incontinence and or POP can significantly decrease waiting times for initial care, reduce the number of gynaecology appointments required, improve patient outcomes as well as improve patient flow to the gynaecologist. 

Hypothesis / aims of study Sacral neuromodulation (SNM) is used for refractory overactive bladder (OAB). Its mechanism of action is unknown, but likely involves spinal reflexes and afferent signaling to the brain. This study assessed SNM effects on brain activity in OAB, as measured by functional magnetic resonance imaging (fMRI).

Following IRB approval, women with non−neurogenic refractory OAB who responded to SNM via InterStim II device, had a stable program for 3 or more months, and received no adjuvant OAB treatment were recruited. Enrolled patients completed pre−fMRI validated symptom and quality of life instruments [UDI−6, IIQ−7, PGI−S, Perceived Urgency Intensity (PUI)]. Stimulus settings were recorded, devices switched off for a 5−day washout, and instruments repeated.

Three fMRI scans below, at, and above stimulus sensory threshold were done after washout. Images were 2−dimensional gradient echo−planar imaging blood−oxygenation level dependent contrast (EPI−BOLD) acquired over 5 stimulator−off and 4 on cycles of 42 seconds each. Output images use single voxel p−value 0.05 with false positive error of 0.05 (cluster−analysis determined).

A total 13 patients enrolled (3 did not undergo fMRI, 4 were excluded for poor OAB symptom control or low image quality) and 6 completed fMRI with analyzable data. The sample median age was 52[36−64] years. Urinary bother and symptoms worsened with the 'washout' period and voiding diary data supported this.

An overall pattern of brain activation generally increased with stronger stimulation ( Figure 1 ). Activation of the right inferior frontal gyrus remained stable with stimulus intensity, while deactivation of the pons and periacqueductal gray matter was only noted with sub−sensory stimulation. Sensory stimulation activated the insula but deactivated the medial and superior parietal lobes. Suprasensory stimulation activated multiple structures and the expected S3 sensory region. After fMRI, all devices had normal impedances and neither PUI (p0.36) nor PGI−S (p0.36) changed from baseline.

Varying SNM stimulus influenced fMRI signal intensity, suggesting SNM alters brain activity in a dose-related fashion in OAB. These results support the theory that SNM has a centrally−mediated mechanism of action in OAB treatment. The findings also raise the question of what role stimulus parameters play in the therapy.

Concluding message SNM for OAB appears to have a dose-related centrally-mediated mechanism of action. 

Hypothesis / aims of study We evaluated functional connectivity of brain regions involved in bladder control post hoc and compared differences between continent and urgency incontinent women, and explored changes caused by positive response to pelvic floor muscle therapy.

Study design, materials and methods 54 women over age 60 years with urgency urinary incontinence (UUI), and 10 continent women, had fMRI scans during fullbladder urinary urgency provocation, before and after (in UUI) therapy. Therapy 'responders' had >50% reduction in leaks on 3day bladder diary. A priori selected regions of interest (ROIs) were: right insula, medial prefrontal cortex (mPFC), and dorsal anterior cingulate cortex/supplementary motor area (dACC/SMA). Generalized psycho-physiological interaction (gPPI) was used to calculate 'effective connectivity' between ROIs during urgency at low and high bladder volume conducted using our urge provocation task using small bolus infusion and withdrawal of fluid [1] . We conducted a one-way ANOVA pre-treatment on groups (continent vs responders vs non-responders) and a two-way mixed ANOVA (responders vs non-responders and pre-vs posttherapy) using false discovery rate (FDR) correction. Principal component analysis was used to assess origins of connections within our chosen 18mm radius spherical ROIs. Exploratory voxel-wise connectivity analyses were conducted between each ROI and the rest of the brain to assess other brain regions which interact in the continence mechanism, beyond those chosen from the working model.

ROI-ROI connectivity yielded no significant results with multiple comparisons correction, but trends (grey charts in fig 1) showed connectivity differences between dACC-Insula and mPFC-dACC based on group (responders vs non-responders) and between dACC-Insula at baseline (controls vs UUI). Principal component analysis showed that the chosen ROI fully encompassed the densest cluster of origin of connections (spherical ROIs in fig 1) . Baseline exploratory voxel-wise analyses showed connections to the primary visual, motor/sensory and midcingulate. In responders, connectivity values changed towards that of the controls after therapy, whereas in non-responders, consistent changes were not seen (white violin plots, fig 1) .

Principal component analysis: The examination of spatial distribution of connections within the original ROIs suggests that these were appropriately selected, if slightly off centre, prioritizing the dACC, anterior insula, and anterior mPFC. In future analysis, we will adjust our ROI centre to encompass these connectivity clusters. gPPI analysis: No ROI comparisons survived correction for multiple comparisons. However, we do comment on trends: In the low volume task, insula-mPFC connectivity changes differently in responders to therapy (away from 'normal') compared to nonresponders (towards 'normal'). Such differences may suggest a compensatory reaction in responders. At high volume, changes are slightly larger and tend more towards 'normal' in responders rather than non-responders ( fig 2) . Exploratory voxel-wise analysis: the occipital areas play a significant part, particularly the lingual area (visualization and analysis of the logical order of events). These areas form connections with the insula and dACC and may be part of the coping mechanism for urgency, since responders tend to 'normalize' these connections post-therapy. Non-responders stay in the 'normal' range which may suggest why these strategies are not useful -their connections are not 'abnormal' initially. The connection between the dACC and visual cortex is present even at low volumes, though it diminishes after therapy, possibly indicating a change in perception of the test (pre-urgency), if indeed this represents a visualization mechanism. The mPFC exhibits differential connections with the precuneus, cingulum and post-central gyrus, as expected from our working model. Our previous work showed these areas, but this analysis shows direct connectivity between the areas, dependent on continence status, suggesting that this connection might be involved in the therapeutic mechanism. The insula exhibits differential connections to the motor/sensory cortex, which may support our original hypothesis concerning the SMA-Insula connectivity, but might suggest a revision of (or addition to) our ROI coordinates. The caudate (motor processing, process learning, inhibitory control of actions), putamen (movement regulation) and thalamus (motor/sensory relay, sleep regulation, consciousness), have differential connections to the dACC at rest, suggesting motor processing mechanisms which may be differently dependent on continence status and altered through. Concluding message This builds upon work identifying brain areas involved in UUI by showing how regions interact, how interaction differ between disease states and how interaction changes with therapy. Overarching themes can be observed. Principal component analysis has shown that our selected ROIs are appropriate but suggest a slight positional shift. Figure 1 serves to show that identified connections in responders, tend towards the 'normal' level after therapy (though they may overshoot). In contrast, non-responders have connections which more often move away from normal, or do not change. This theme provides some supportive evidence that our decision to stratify by response may show two subsets of UUI: (1) predominantly caused by a breakdown in brain control of the continence mechanism and which is represented in those who respond to a behavioural therapy which targets cerebral control, and hence 'normalizes' connectivity; and (2) may have another, yet unknown, cause, represented by those who do not respond well to therapy and do not show consistent 'normalization' of connectivity. This suggestion, (initially demonstrated by baseline differences in brain activation of responders and non-responders [2] ) has also been supported by our structural studies (in press). If confirmed by future study, identification of UUI subsets could help therapy trials and targeting of specific UUI types, as well as advance understanding of the brain bladder mechanism. 

Hypothesis / aims of study It has been claimed that atherosclerosis and vascular dysfunction might be important factors as possible mechanisms of OAB and bladder dysfunction (1). We aimed to evaluate the relationship between Overactive bladder (OAB) and systemic atherosclerosis in a cohort of women.

Study design, materials and methods Women aged >18 with OAB (cases), and women without OAB (controls) were eligible for recruitment (2) . Women with OAB were recruited from the urogynecology unit and they were classified as OAB-wet or OAB-dry, based on a voiding diary record of having urgency urinary incontinence or not, respectively. Control subjects were recruited from the gynecology outpatient clinic that had an Overactive Bladder Awareness Tool (OAB-V8) score of <8 and had no urgency or urinary tract infection. In this case control study, we assessed atherosclerosis indicators such as Framingham Risk scores, carotid and femoral artery intima media thicknesses (CIMT and FIMT) and evaluated possible bladder wall responses to atherosclerosis using endovaginal color Doppler ultrasound and urinary cytokines such as Nerve growth factor (NGF), monocyte chemotactic protein-1 (MCP-1) in women with OAB and controls. CIMT and FIMT measurements were performed using a 9L4 linear high frequency probe in both sides of the neck and the inguinal regions (Acuson S 1000 diagnostic ultrasound device, Siemens Medical Solutions, USA). Endovaginal ultrasound was performed on all participants with the use of a biplane, high frequency (12 MHz) transducer (type 8848, B-K Medical, Herlev, Denmark). To provide quantitative assessment of blood perfusion of bladder neck, commercially available PixelFlux software (Chameleon Software, Germany: www.chameleon-software.de) was used. Each parameter was calculated including data from all imaged vessels in Color Doppler mode coded as red and blue reflecting the direction and velocity of the blood particles movement. Results represent the sum of ''red'' and ''blue'' values named as the ''mix'' value for each parameter (Vmix, Imix, Amix, PImix, and RImix.). These parameters were explained previously (3). Figure 1 shows carotid and femoral arteries intima media thickness measurements and evaluation of bladder neck vascular perfusion with endovaginal ultrasound. In analysis, independent samples t-test was used to evaluate the relationship between OAB and atherosclerotic findings when parametric conditions were met and Mann Whitney U test when parametric conditions were not met. Since OAB-V8 is a Likert style index, Kendall's Tau was used to assess the correlation between the severity of OAB and atherosclerotic variables. P < 0.05 was considered significant.

In the final cohort, 147 women were included. Of these, 73 were controls, and 74 were overactive bladder (OAB) cases (wet type n=45; dry type n=29). Mean age of the OAB cases was significantly higher than of the controls (55.78 ± 13.12 vs. 44.07 ± 14.43, p < 0.001). Compared to controls OAB cases had significantly more gravidity (3.60 ± 2.02 vs. 2.11 ± 2.00, p < 0.001), and parity (2.45 ± 1.53 vs. 1.42 ± 1.41, p < 0.001). Among participants, most of them never smoked (n=129, 88.4%) and among the smokers, there were significant differences between the groups when means of package year was evaluated (p = 0.844). One fourth of participants stated that they have hypertension, whereas 23% were receiving anti-hypertensive therapy. Characteristics associated with OAB included pre-existing hypertension (HT) (p < 0.001), higher means of fasting blood glucose (FBG) (p = 0.03), higher total cholesterol (TC) (p = 0.04); higher systolic (p = 0.01) and diastolic blood pressure (BP) (p = 0.004), and higher BMI (p < 0.001). On further analysis, when compared to control group, wet type OAB patients had higher means of FBG (p = 0.03), diastolic BP (p = 0.009), and BMI (p < 0.001), while dry type OAB patients had higher means of FBG (p = 0.03), LDL-C (p = 0.01), TC (p = 0.01) and both systolic (p = 0.004), and diastolic BP (p = 0.04). Indicators of atherosclerosis such as Framingham scores, CIMT and FIMT, the level of urinary biomarkers such as NGF and MCP-1, and the calculated color pixel ratio in region of interest of bladder neck were evaluated. OAB cases had significantly higher means of 10-year CVD and CHD risks (both p < 0.05), and higher right and left carotids intima media thickness (p < 0.05), and femoral artery thickness (p < 0.05). Compared to controls wet type OAB patients had higher means of 10-year CVD, and CHD risks (both p < 0.05), and higher right and left carotid intima thickness (p < 0.05) and femoral artery thickness (p < 0.05). However, 10-year CVD risk was the only variable associated with dry type OAB when compared controls (p < 0.001). Mean MCP concentration was significantly higher in the control group compared to OAB cases (p < 0.001) and wet type OAB patients (p < 0.001) but not significantly different after adjusting for urine creatinine. Cytokine concentrations were not significantly different between the groups after urinary creatinine adjustments. In contrast, mean NGF concentrations in dry type OAB patients were higher than the control group (p = 0.001) but similar after adjusting with urine creatinine. Women with OAB have decreased bladder neck perfusion as found by color Doppler ultrasound. In women with OAB, calculated color pixel ratio in the ROI measured by the software system was found to be significantly lower in sagittal section of bladder neck. When correlation analysis was performed between OABV8 scores, and Framingham scores, and bladder vascular indexes, there was a significant positive correlation between developing atherosclerosis risk. There was a significant negative correlation between the severity of OAB and the calculated color pixel ratios.

An impaired vascular circulation result from systemic atherosclerosis might be associated with overactive bladder and its severity. Concluding message In conclusion, OAB is known as creating significant impact on the health-related quality of life and a considerable economic burden. However these findings show that OAB might be the microvasculature disease a component of the systemic atherosclerosis, which is life threatening comorbidity.

Wrobel A 1 , Rechberger E 2 , Skorupska K 1 , Miotla P 1 , Wojtas M 1 , Zietek A 1 , Rechberger T 1

Hypothesis / aims of study A large body of evidence has pointed to the co-occurrence of overactive bladder (OAB) and depression [1] . Antimuscarinic drugs are currently the first-line therapy for OAB. However, there is no gold standard for the treatment of OAB co-existing with depression. The corticotropin-releasing factor system participates in the pathophysiology of both disorders. Inhibition of CRF1 was found to produce antidepressant-like effect and to improve cystometric parameters in a model of detrusor overactivity (DO). We compared the effects of an antimuscarinic drug, solifenacin; a ß-3 adrenoreceptor agonist, mirabegron, which is the second-line treatment for OAB; a tricyclic antidepressant, imipramine, which is approved for enuresis treatment and SN003, a reversible CRF1 receptor antagonist, in a model induced by 13-cis-retinoic acid (13-cis-RA) administration in rats, which causes detrusor overactivity (DO) symptoms and depressive-like behavior [2] .

We tested the effects of acute treatment with a reversible CRF receptor type-1 (CRF1) antagonist, SN003 (1 mg/kg, i.v.), representatives of first (solifenacin, SOL, 0.03 mg/kg, i.v.) and second (mirabegron, MIR, 1 mg/kg, i.v.) line treatments for OAB as well as an antidepressant imipramine (IMI, 30 mg/kg, i.p.) on changes in behavior and detrusor overactivity (DO) symptoms induced by a 6-week administration of 13-cis-retinoic acid (13-cis-RA, 1 mg/kg/day, i.p.), using in vivo cystometric investigations, forced swim test (FST) and spontaneous locomotor activity test in female Wistar rats. 60 min after drug injection cystometric investigations were performed in conscious unrestrained rats. The following cystometric parameters were recorded: basal pressure (BP, cm H2O), threshold pressure (TP, cm H2O), micturition voiding pressure (MVP, cm H2O), voided volume (VV, ml), post-void residual (PVR, ml), volume threshold (VT, ml), voiding efficiency (VE, %), intercontraction interval (ICI, s), bladder contraction duration (BCD, s), relaxation time (RT, s), bladder compliance (BC, ml/cm H2O), detrusor overactivity index (DOI, cm H2O/ml), nonvoiding contractions amplitude (ANVC, cm H2O), nonvoiding contractions frequency (FNVC, times/filling phase), and volume threshold to elicit NVC (VTNVC, %). The locomotor activity of rats was measured 24 h after cystometric studies. The locomotor activity was assessed with the aid of a Digiscan apparatus: an Optical Animal 2` ``SActivity Monitoring System. Horizontal activity was assessed. This was defined as the total number of beam interruptions that occurred in the horizontal sensors during 1 hour of measurement. The forced swim test (FST) was also performed. Following cystometric and behavioral studies, tissue was harvested and CRF level was assessed in the hypothalamus, amygdala and plasma of rats. CRF concentration was assessed using Mouse/Rat CRF-HS ELISA Kit (Alpco, Salem, NH, U.S.A.) in plasma, hypothalamus and amygdala, according to the manufacturer's protocol. Each sample was measured in duplicate.

Results 13-cis-RA-induced depressive-like behavior and DO symptoms were associated with increased CRF level in the hypothalamus, amygdala and plasma. SOL and MIR attenuated DO symptoms induced by 13-cis-RA, did not display antidepressant-like activity and did not influence CRF levels in brain tissues or plasma. IMI and SN003 displayed antidepressant-like activity and lowered increased levels of CRF in brain tissue and plasma. IMI attenuated changes in some of the cystometric parameters, which are associated with OAB dry (without urge incontinence), whereas SN003 attenuated changes in almost all cystometric parameters that were induced by 13-cis-RA.

The present study shows that 13-cis-RA-induced depressive and DO symptoms were associated with increased CRF levels in the hypothalamus, amygdala and plasma. A large body of preclinical and clinical evidence has linked disturbances of the CRF system to depression. A decrease in the CRF concentration in either brain regions or plasma was observed after administration of drugs which exerted antidepressant-like activity, namely SN003 and imipramine, but not after treatment with drugs that did not exhibit this action, namely mirabegron and solifenacin. These observation supports inhibitory effect of antidepressants on hyperactivity of the CRF system. In parallel to antidepressant-like action, SN003 and imipramine (partially) attenuated DO symptoms in 13-cis-RA-administered rats. The current study demonstrates that co-occurrence of depressive and DO symptoms is associated with higher concentration of CRF in brain regions (hypothalamus, amygdala) and plasma. Although the data on the role of CRF receptors in the urinary bladder are scarce, it is plausible that conditions which are present with DO symptoms are associated with alterations in CRF receptors expression in the urinary bladder, which may have a consequence for voiding function. It is also possible that CRF receptor antagonists exert positive effects on cystometric parameters via modifying CRF receptors expression and/or function in the urinary bladder. Moreover, the transcript levels of CRF1 were significantly increased in the hypothalamus of rats after chronic all-trans retinoic acid administration, which produces depressive-like behavior in the FST. Therefore, both OAB and depression may cause peripheral and central alterations of CRF and its receptors while treatment with CRF antagonists may be beneficial in depression co-existing with OAB via normalization of these changes.

Concluding message Based on the observation that first (solifenacin) and second (mirabergon) line treatments for OAB did not improve depressive-like symptoms, whereas imipramine and a reversible CRF1 receptor antagonist, SN003 improved both DO and depressive-symptoms induced by 13-cis-RA, the two latter compounds could be beneficial in case of co-occurrence of depression and OAB. Importantly, while imipramine attenuated only changes in the following cystometric parameters: DOI, ANVC, FNVC and VTNVC, SN003 attenuated changes in almost all cystometric parameters that were induced by 13-cis-RA. These findings suggest that imipramine could be useful in case of OAB dry, while SN003 in case of both, OAB dry and wet. Our data point to CRF1 inhibition as a potential therapeutic strategy for co-existing depression and OAB. The possible mechanism may be related to the effects on central/peripheral level of CRF and/or its receptors. 

Hypothesis / aims of study Animal studies have consistently shown that uropathogens such as Escherichia coli (E. coli) are capable of intracellular growth. This intracellular growth may enable the bacteria to escape detection by the immune system and thus provide a reservoir for recurrent urinary tract infections. The aim of this study was to determine whether other uropathogens (Enterococcus Faecalis (E. Faecalis) and Group B streptococcus (GBS)) are also capable of intracellular colonisation of urothelial cells.

Study design, materials and methods Mid-Stream Urine (MSU) specimens (n=121) were collected from women (n=94) attending a regional urogynaecology clinic. Half the sample underwent routine microbiology to identify uropathogens, the rest was used for evaluating bacterial colonisation in exfoliated urothelial cells. Exfoliated urothelial cells were concentrated onto a microscope slide and then stained using Wright staining and approximately 100 cells from each sample were counted by light microscopy and categorized according to the presence of bacteria, the location (attached to the outside of the urothelial cell or appears intracellular) and the bacterial density (low density (LD) or high density (HD)) The mean percentage (± SEM) of each category in relation to the total number of cells was calculated. Based on the Wright staining results cells from samples that appeared to contain intracellular bacteria were stained by immunofluorescence, using specific antibodies to E. coli and E. Faecalis. The urothelial cell membrane was stained with Wheatgerm agglutinin (WGA) and the nucleus visualised with DAPI. These stained cells were imaged on confocal microscopy, to confirm intracellular localisation of the bacteria. Z-stack analysis included the top and bottom of the imaged urothelial cells. A single line was drawn through the urothelial cell on the X/Y axis, ensuring that the urothelial cell membranes and bacterial cells were included and the fluorescence intensity of each channel was measured.

Uropathogens E. coli (n=19), E. Faecalis (n=10), and GBS (n=14) were detected in 35.5% (43/121) of MSU samples. Of these, cells from patients with GBS and E. Faecalis were more likely to have exfoliated urothelial cells that were clear of bacteria (p<0.0001, Table 1 , no Bacteria). As expected low density intracellular growth was seen in a large proportion of urothelial cells from patients with E.coli (Table 1) . However, GBS and E. Faecalis were also seen to localise intracellularly, although to a lesser extent (Table 1 , p<0.0001). Confocal microscopy confirmed the intracellular localisation of E. coli within exfoliated urothelial cells ( Figure 1A and B). Similarly, confocal microscopy was able to demonstrate intracellular localisation of E. Faecalis within the urothelial cells ( Figure 1C and D). 

Previously only E.coli has been shown to grow intracellularly in exfoliated urothelial cells isolated from patient urine samples. The results of the current study demonstrate that both E. Faecalis and GBS are also capable of intracellular growth, although to a lesser extent that E. coli. This suggests that intracellular growth might be a common characteristic of uropathogens and may provide a mechanism for these pathogens to evade the bladders defence mechanisms, leading to an increased likelihood of urinary tract infections.

Concluding message Intracellular growth may be a common strategy used by uropathogens to enhance their ability to cause urinary tract infections. 

Hypothesis / aims of study Bacterial cystitis is known to occur in 40% of patients with refractory detrusor overactivity (DO). The bladder response to infection is determined by a balance between the pro-inflammatory and anti-inflammatory cytokines. In this study we have compared urinary levels of the pro-cytokine interleukin-1α (IL-1α) and the anti-inflammatory cytokine interleukin-10 (IL-10) in women with urodynamically diagnosed refractory DO, women with newly diagnosed DO, and controls who exhibited no urgency.

Study design, materials and methods Midstream urine samples were collected, with careful labial toilet, by patients from a regional urogynaecology clinic. Any current UTI and history of previous UTI was noted. The presence of leukocytes in the urine specimen was determined by dipstick. Patients were divided into three groups: control (n=51, no current UTI and no history of UTI), newly diagnosed DO (n=39) and refractory Detrusor Overactivity (DO) (n=56). Patients were excluded if they had voiding dysfunction or a history of neurological dysfunction. Urinary levels of the cytokines, IL-1α and IL-10, were quantitated by enzyme-linked immunosorbent assays following the manufacturer's instructions. Cytokine concentrations were compared based on the urological diagnosis, the presence of a current diagnosis of a urinary tract infection or a history of a urinary tract infection. Data are presented as median cytokine concentration (pg/mL) with interquartile range.

As expected based on the current literature history of urinary tract infection was significantly more common in patients with refractory DO than in patients newly diagnosed with DO (P<0.001, Chi-square, Table 1 ). Similarly a current UTI was significantly more common in patients with refractory DO (P 0.005, Chi-square, Table 1 ). In patients with DO the presence of a UTI significantly increased secretion of both IL-1α (P 0.04) and IL-10 (P 0.005). IL-10 (anti-inflammatory) 4.6 (1.9-7.5) n=49

8.1 (6.3-13.9)*** n=37 8.1 (6.8-9.9)*** n=56 *statistically different to control, P<0.05, *** statistically different to control, P<0.001 NOTE: a current UTI or a history of UTI was an exclusion criteria in control patients. We also examined whether leukocytes were more commonly detected in patients with refractory DO compared to controls and patients newly diagnosed with DO (Table 1 ). Similar to the results seen with UTI, leukocytes were more common in patients with refractory DO (p<0.0001, Chi-square, Table 1 ). The presence of leukocytes had no influence on the secretion of IL1a but was associated with significantly increased expression on IL-10 (P 0.045). IL1α was undetectable in approximately15% of urine specimens, 12% of controls, 13% of newly diagnosed DO and 15% of refractory DO patients. The median concentration of IL-1α was significantly elevated in women with newly-diagnosed DO compared to controls (P 0.015). The median concentration of IL-10 was elevated in both newly diagnosed DO and refractory DO compared to controls (P<0.001). The ratio of IL1α to IL10 was significantly decreased in patients with refractory DO compared to the ratio in controls (P 0.03, Figure 1 ).

Patients with refractory DO were more likely than patients newly diagnosed with DO to have both a history of UTI and a current UTI. In addition these patients were more likely to have leukocytes detected in their urine suggesting the presence of an inflammatory response. Both pro-Inflammatory and anti-inflammatory cytokines (IL-1α and IL-10 respectively) were seen to be elevated in patients with DO compared to controls. The ratio of Pro (IL-1α): anti (IL10) inflammatory cytokines was lower in patients with refractory DO, suggesting a suppression of the immune response in these patients relative to that seen in patients with newly diagnosed DO or control patients. This suppression of the immune response in patients with refractory DO may result in an increased prevalence of UTI in these patients.

It is well known that there is an increased prevalence of UTI in patients with refractory DO. The results of this study suggest that this may be the result of a suppression of the immune response whereby the anti-inflammatory response is relatively greater than the pro-inflammatory response in these patients. This alteration in the balance between pro and anti-inflammatory cytokines may play a role in the pathogenesis of DO and may predispose a patient to the refractory state. 

Hypothesis / aims of study The impact of polyuria on bladder function has been studied in diabetic models, but has not been investigated in a context without hyperglycemia. We have previously demonstrated that the Dahl salt-sensitive (Dahl/SS) rat, a model with hypertension, shows signs of bladder overactivity compared to control rats. Our aim was to determine the effect of a high salt intake in this model on bladder function, and the associated polyuria.

Study design, materials and methods Dahl/SS rats received either a 4% NaCl (high-salt) diet (n=5), or a normal diet (n=4) for 6 weeks. Water intake and micturition patterns over a 24-hour period were recorded in metabolic chambers. Blood pressure measurements were also recorded. After 6 weeks of the diet, these measurements were repeated. Conscious cystometry was then carried out. Bladders were collected for measurements of contractile force using organ bath experiments, collagen quantification using the Masson's trichrome stain and H&E staining for qualitative comparisons. Paired t-tests were used to compare changes between week 0 and week 6 within each group. Unpaired t-tests were used for comparisons between normal and 4% NaCl diet for cystometry, organ bath and collagen quantification. p<0.05 was considered significant.

Systolic blood pressure significantly increased after 6 weeks with the high-salt diet but not in the rats fed a normal diet (Table 1) . Similar water 24-hour intake, as well as micturition patterns were observed initially in all animals. After 6 weeks, the control rats had unchanged measurements from the start of the study. However, rats on the high-salt diet had significantly increased water intake, increased total urine, and higher volume of urine per micturition. 

Cystometry showed significantly higher intercontraction intervals, bladder capacity, micturition volumes and bladder compliance in rats on high-salt diet compared control ( Table 2) . No difference in detrusor contractility in organ bath studies was observed between the two groups ( Fig. 1) . H&E staining showed an impaired integrity in bladder of animals fed a 4% NaCl diet compared to those fed a normal diet. The animals in the high-salt diet group also had thinner urothelium and detrusor layers ( Fig. 2 A-B) . Collagen content was significantly increased in the lamina propria of rats fed a high-salt diet, compared to those fed a normal diet (p<0.05) ( 

The high-salt diet led to higher blood pressures in an animal model of hypertension. As a result of increased salt intake, the animals developed polydipsia and polyuria. This disrupted the morphology of the bladder and led to an increase in bladder capacity. In addition, there was an increase in collagen content in the lamina propria due to overstretching of the bladder. While this is an immediate response of the bladder to constant stretch, it may take longer for the detrusor to be affected by changes in collagen content, explaining our organ bath findings.

The polydipsia and polyuria observed in the high-salt diet group led to an increase in bladder capacity in this group. Polyuria in a context of hypertension may lead to changes in bladder morphology and function. These findings may clarify the clinical impact of polyuria on voiding function, specifically in patients of metabolic syndrome. 

Hypothesis / aims of study Metabolic syndrome (MetS) has been implicated in the aetiology of lower urinary symptoms and a few previous epidemiological studies have suggested a relationship between MetS and overactive bladder (OAB) in women [1] . We thus aimed to evaluate the relationship between OAB and MetS or components of MetS among Japanese men and women.

Study design, materials and methods We collected data on 12,478 individuals (5,313 males and 7,165 females) who participated in a multiphasic health screening in 2015, in Fukui, Japan. As part of a multiphasic health screening, waist circumference, blood pressure, fasting blood sugar, triglycerides and HDL-cholesterol were measured. All participants were asked to answer a standardized self-reported questionnaire for OAB screening (SQOAB, Screening Questionnaire for Overactive Bladder. [2] ).

We analyzed the relationships between OAB and other variables including age, gender, waist circumference, high blood pressure, impaired glucose tolerance, and dyslipidemia. The relationships between OAB and MetS were also analyzed. MetS in the Japanese criteria was diagnosed in individuals who had a high waist circumference (≥ 85 cm in men and ≥ 90 cm in women) plus any 2 of the following: (a) high blood pressure (systolic blood pressure ≥ 130/85 mmHg and/or current use of antihypertensive medicine); (b) impaired glucose tolerance (fasting glucose concentration ≥ 110 mg/dL and/or current use of antidiabetic medication); and (c) dyslipidemia (triglyceride concentration ≥ 150 mg/dL and/or HDL-cholesterol level < 40 mg/dL) [3] . The chisquare test and logistic regression modeling were used for statistical analyses. Values of P<0.05 were considered statistically significant.

The median age of participants was 69 (18-95) years. The overall prevalence of OAB and MetS were 13.5% (11.2% for men and 15.2% for women) and 15.2% (24.5% for men and 8.2% for women), respectively. The prevalence was higher in older age groups ( Figure) .

In the multivariate analysis, a significant association was found between OAB and the following: age (Odds ratio = 1.04) and high waist circumference (1.42) for men, and, age (1.04), high waist circumference (1.42) and hyperglycemia (1.17) for women (Table) .

A significant association was found between OAB and MetS. The age-adjusted odds ratio (95%CI) were 1.22 (1.06-1.39) for men and 1.49 (1.21-1.83) for women, respectively.

The results from our epidemiological study indicate that OAB can be a marker of MetS.

Our study confirmed the relationship between OAB and MetS in both men and women. This findings suggest that OAB is a facet of the MetS. 

Hypothesis / aims of study Overactive bladder (OAB) is a common condition with a prevalence that increases with age. However, OAB is rarely identified as a primary diagnosis, particularly with men. Rather, it is a diagnosis that is often arrived at after ruling-out other, potentially more severe, diagnoses. For example in men, clinicians may first consider prostate-related symptoms such as benign prostate enlargement or prostate cancer. Consequently, these patients are more likely to be given a prostate-specific patient-reported outcome (PRO) instrument rather than one for OAB. If, after further testing and evaluation, the patient is found to have OAB, the scores generated from the prostate-specific PRO are usually irrelevant, rendering the data and its collection effort, wasted. Given the prevalence of both OAB and prostate-related diseases, we suspect that the administration of irrelevant PROs happens quite frequently.

Thus, the aim of this study was to develop a statistical model for mapping the responses of a commonly used prostate-specific PRO to OAB-specific PRO.

This study was a secondary analysis of data that was collected prospectively from men with lower urinary tract symptoms. Participants completed both the IPSS and the OAB-V8 while waiting for their appointment with a urologist. Ordinary least squares was used for three models that estimated the OAB-V8 global score as a function of the responses to IPSS items: Model 1 used just the IPSS global score, Model 2 used the response values to IPSS' individual items, and Model 3 used the IPSS's individual items and the patients' demographic characteristics.

A total of 441 participants completed both the IPSS and the OAB-V8. As expected, there was a strong positive relationship between the IPSS and OAB-V8 global scores. Adjusted R-squared for the three models ranged from 0.42 -0.50, and root mean squared errors between 6.37 and 6.96. A non-parametric bootstrap analysis demonstrated robustness of the findings.

This study successfully developed a mapping model to associate responses to the IPSS with OAB-V8 global scores. The results from this study are within the range of other mapping studies. Comparatively, Model 2 performed the best and is recommended over the other two. This model could be used by clinicians to estimate the severity of OAB-related symptoms based on the responses to the IPSS.

Concluding message Prior to a formal diagnosis, it can be difficult to ascertain which PRO instrument should be administered. Mapping models, like the one developed in this study, can be used retrospectively to compare PRO values for clinical and evaluative purposes. 

Hypothesis / aims of study The main purpose of the study was to gather requirements for the development of a mobile phone application from all stakeholders (medical and healthcare staff and end-users). Furthermore, the study focused on collecting feedback on how successful current treatment approaches are in the UK from the patients' perspective and the ongoing and longer term issues with current Overactive Bladder (OAB) treatment.

The requirements gathering phase was divided into two studies, as follows:

The first stage consisted of four semi-structured, in-depth design interviews with healthcare practitioners with OAB expertise. The purpose of these interviews was to collect feedback on how successful current treatment approaches are in the UK and the ongoing and longer term issues with OAB treatment. A secondary aim was to gather design ideas for the mobile phone application that could support bladder training.

The healthcare practitioners taking part in the interviews were two medical consultants (one urologist and one urogyneacologist) and two urinary continence specialist nurses.

2. Recruitment: Medical staff were recruited by an OAB expert through personal contacts. 3. Procedure: An in-depth interview, lasting approximately one hour, consisted of three topics. The first part investigated how patients manage the condition and what problems they face in the UK when seeking medical care. The second part of the interview focused on the treatment and diagnostic and the third part focused on a discussion about the mobile phone application features.

The second part of the requirements gathering phase consisted of eight single and one paired end-user interviews. The purpose of these interviews was to identify current issues in the treatment process of the OAB condition from the end-users' perspective and to gather design ideas for the mobile phone application.

In total two males, seven females and one family member of a person with OAB symptoms were interviewed. Age range was between 23 and 80 years old, mean age 48. Most participants (8/10) answered with agree or strongly agree when asked if they are confident with using a smartphone.

2. Recruitment: Information was provided to patients attending group sessions in Glasgow, UK with the purpose of recruiting participants for the user interviews. Invitations via email were sent to Glasgow Caledonian University, UK staff and via newsletter to Heriot Watt University, UK staff.

3. Procedure: Each interview lasted for approximately two hours and was divided into three main parts. The first part consisted of a discussion about the participants' experiences to gain a deep understanding about the treatment. The current state of the treatment and how people cope with the condition were the main focuses of the discussion. In the second part participants were presented with screenshots of potential mobile phone app functionalities and scenarios and asked to comment on them. In the third part participants were asked to design their own version of functionalities or to propose new ones. A demographic questionnaire was also completed prior to the interview to collect demographic information about the participants and their smartphone familiarity and usage.

The following features, based upon literature review and discussions with clinicians, were presented to the end-users: 1. A map indicating the closest toilet from the user's current location. 2. Methods of tracking progress and providing feedback. 3. Methods of providing pelvic floor muscle exercise reminders. 4. Different distraction techniques. 5. Ways of providing quick access and disguising the application. 6 . Bladder Diary layout. The back-end of the application will apply a Machine Learning engine to help in the decision-making process and provide a high level of personalization. The user's daily routine and location will be the input to the Machine Learning and the algorithm will then determine what distraction technique to send and for how long, will show progress and decide when is appropriate to send reminders.

Based upon the interviews and the subsequent proposed features, the following outcomes were recognized: With respect to the mapping functionality, both medical consultants and end-users agreed with this feature. However, the nurses did not settle upon it arguing that, since the purpose of bladder training is to avoid going to the bathroom, such a map would only ease toilet access. Regarding the progress feature, users would like to set up a personal goal regarding the daily number of voids and leakages and to have feedback provided regarding their progress. As a distraction technique, both stakeholder categories agreed that games would help in diverting attention from the urge sensation. As this application targets an embarrassing condition, users would like to disguise the icon of the app and the alerts they receive from it. An extra new functionality arose from one of the end-users, who suggested a feature that would help the user to gain quick access to toilets in unknown locations. Additionally, the feedback collected from the staff interviews highlighted that treatment descriptions should be an important feature for this mobile health application.

Interpretation of results Both end-users and healthcare staff agreed with the proposed functionalities which confirms literature findings from people with OAB. However, slight contradictions were noticed between what healthcare practitioners would suggest and what end-users desire. Moreover, new functionalities were proposed during the interviews that are not covered in the literature.

During the requirements gathering phase of mobile phone app design it is important to include stakeholder views and opinions. Design features should take account of real-world challenges and reflect expressed views of all users; patients as well as healthcare staff. 

Hypothesis / aims of study Overactive bladder (OAB) is a clinical diagnosis based on lower urinary tract symptoms (LUTS). Once remediable pathology has been excluded, most treatment algorithms recommend empiric treatment based on a monolithic, one-size-fits-all approach. The purpose of this study is to refine the OAB diagnosis further by developing phenotypes that can be used to promote more individualized treatment and to offer clues to search for underlying causes.

Study design, materials and methods This is a retrospective multicenter observational study of patients evaluated for LUTS who completed a 24 hour bladder diary (24HBD) and lower urinary tract symptoms score (LUTSS) on a mobile app, website and/or paper. The results appeared on the doctor portal (figure 1). Those with an overactive bladder symptom sub-score (OABSS) ≥ 8, which has been validated to correspond to a clinical diagnosis of OAB, were included. When multiple diaries or scores were completed, the earliest was used. Maximum voided volume (MVV), 24 hour voided volume (24HV) and, when available, contemporaneous uroflow (Q) and post-void residual (PVR) were recorded. Patients with incomplete LUTSS or 24HBD were excluded. Subjects were first divided into three major phenotypes according to the 24HV as follows: Phenotype 1 = polyuria (P) [24HV > 2. normal (Q>12 mL/s and PVR ≤100 mL) or abnormal (Q ≤12 mL/s and/or PVR >100 mL), resulting in a total of 18 minor phenotypes.

Results 1189 patients completed the LUTSS. 331 patients, 197 men and 134 women, completed the LUTSS and a contemporaneous 24HBD. OAB, as defined by OABSS ≥ 8, was present in 235 (71%) of these patients (128 male and 107 female). Of these, 115 (31 male and 84 female) had contemporaneous Q and PVR data inputted. Prevalence data for the 18 phenotypes is seen in table 1. 

In subtype "_._.1," Q and PVR are normal (Q > 12 mL/s, PVR ≤ 100 mL) In subtype "_._.2," Q and/or PVR are abnormal (Q ≤ 12 mL/s and/or PVR>100 mL) *In some of the phenotypes, such as this one, there were no patients who fulfilled the criteria, but it is expected that there will be patients with these phenotypes in larger studies.

We have identified three major phenotypes based on a 24HBD that are further subdivided according to MVV, Q & PVR for a total of 18 subtypes. In the next phase of investigation we will focus on developing and testing individualized diagnostic and treatment algorithms based on the phenotypes. For example, we hypothesize that OAB patients with polyuria, large capacity bladder and normal Q & PVR are optimally treated with behaviour modification; whereas those with oliguria, small capacity bladder and high PVR require advanced diagnostic evaluation and treatment. Further, by combining the phenotypic data with other parameters such as urgency and incontinence episodes, we hope to tailor our electronic and clinical data gathering into a user friendly, efficient and cost-effective means of caring for patients with OAB. By combining both subjective and objective data gathering into a central electronic repository, we will be able to more proactively identify patients that will benefit from specific treatments and, more importantly, develop new and more effective treatments.

The stratification of OAB variants into 18 phenotypes provides the substrate for further research into the etiology of OAB, new treatments and more precise treatment algorithms. 

Hypothesis / aims of study Overactive bladder (OAB) has a multi-dimensional impact on quality of life (QOL). However, the standard symptom score questionnaire for OAB, such as OABSS [1] , is aiming to question the severity of four OAB-specific symptoms (Q1; frequency, Q2; nocturia, Q3; urgency, and Q4; incontinence) but not to assess the QOL (or bother) specific to each of these 4 OAB-symptoms. We have reported the clinical significance of our developed novel assessment tool to evaluate the QOL (or bother) specific to each of the 4 OABSS-questions with visual analogue scale (VAS) of a 100-mm line, which was integrated into the OABSS and called OABSS-VAS ( Figure 1) [2]. Aim of this study was to identify each threshold of the 4 OABSS-questions to impact significantly on patient's QOL (or bother) suggested by the OABSS-VAS.

We analysed total of consecutive 500 female patients who visited our clinic from 2012 to 2016 and answered both OABSS (Q1; 0 to 2, Q2; 0 to 3, Q3; 0 to 5, Q4; 0 to 5) and OABSS-VAS (0 to 100 in each 100-mm line specific to Q1-4) questionnaire at the same time. The median age of the patients was 69 (22-94) y.o. In order to identify the significant impact on QOL, we defined greater than 60-mm as the threshold for the VAS-measure.

The outcome of the relationship between OABSS-VAS and each OABSS were demonstrated in Figure 2 . As for daytime frequency (OABSS-Q1), the value of OABSS-VAS for OABSS-Q1 score of 0 (less than 7times), 1 (8-14 times), and 2 (more than15 times) were 38.2±26.5 (n=131), 61.4±26.4 (n=316), and 76.9±20.0 (n=53), respectively. As a result, the score of 1 (8-14 times) was identified as the significant severity for daytime frequency. As for nocturia (OABSS-Q2), the value of OABSS-VAS for OABSS-Q2 of 0, 1, 2, and 3 were 13.0±19.1 (n=81), 38.4±25.4 (n=131), 61.0±24.2 (n=136), and 80.0±17.7 (n=152), respectively. As a result, the score of 2 (2 times) was identified as the significant severity for nocturia. As for urgency (OABSS-Q3), the value of OABSS-VAS for OABSS-Q3 of 0 (none), 1 (less than once a week), 2 (more than once a week), 3 (once a day), 4 (2-4times a day), and 5 (more than 5 times a day) were 24.7±25.4 (n=91), 46.2±25.4 (n=86), 69.7±20.4 (n=66), 70.5±17.8 (n=94), 80.1±19.9 (n=114), and 90.0±11.9 (n=49), respectively. As a result, the score of 3 (once a day) was identified as the significant severity for urgency. As for urinary urge incontinence, UUI (OABSS-Q4), the value of OABSS-VAS for OABSS-Q4 of 0 (none), 1 (less than once a week), 2 (more than once a week), 3 (once a day), 4 (2-4times a day), and 5 (more than 5 times a day) were 26.5±27.5 (n=163), 64.9±27.5 (n=83), 74.9±20.2 (n=63), 80.4±20.6 (n=75), 88.0±12.8 (n=90), and 91.3±11.4 (n=26), respectively. As a result, the score of 1 (not zero) was identified as the significant severity for UUI.

Our study clearly demonstrated the each concrete threshold of the 4 OAB-symptom severity to impact significantly on patient's QOL (or bother). It is demonstrated that the OAB-patients' QOL could be significantly disturbed when urge incontinence exists that is "if not zero", and also when urgency occurs "even once a day", and also that the threshold of daytime frequency to impact significantly on patients' QOL was identified 8-14 times and that of nocturia was 2 times. These data would contribute to appropriate selection of the therapeutic target-symptom with significant severity to impact on patients' specific QOL or bother. Our results supports that concomitant use of both OABSS and OABSS-VAS. Concomitant use of both symptom-severity-score (OABSS) and symptom-specific-QOL-measure (OABSS-VAS) would contribute to identify the patient's specific significant symptom which each patient wants to be treated most or which has most significant impact on their QOL or bother.

Concluding message Concomitant use of both OABSS and OABSS-VAS identified each concrete threshold of the 4 OAB-symptom severity to impact significantly on patient's QOL (or bother). Concomitant use of both OABSS and OABSS-VAS would contribute to identify the patient's specific significant symptom which has most significant impact on their QOL or bother. 

Putonti C 1 , Malki K 1 , Garretto A 1 , Shapiro J 1 , Wolfe A 1 , Brubaker L 1

Hypothesis / aims of study Prior research identified many bacterial components of the bladder microbiota. The viral fraction, however, is largely unknown. Viruses in the human microbiome far outnumber bacteria; the most abundant viruses are those that infect bacteria (bacteriophages). Bacteriophages (phages) play key roles shaping bacterial metabolism and community structure. Thus, previously observed links between urinary bacteria, clinical symptoms and outcomes may be due, in part, to phage activities. The study's aim was to isolate and characterize phages from the urinary microbiome of females with and without symptoms of urgency urinary incontinence (UUI).

We sequenced genomes from bacteria isolated previously from urines obtained from women enrolled in IRB-approved female urinary microbiome studies focused on UUI. By analyzing these sequenced bacterial genomes, we identified numerous phage species that had integrated their genomes into their host ("latent" phage). Latent phage genome sequences were identified using the tools VirSorter [1] and Phaster [2] and results were manually curated. These phage sequences were next compared to publicly available phage genome sequences in NCBI's GenBank through BLAST queries.

Bacterial isolates harboring such latent phage genomes were cultured under conditions that induced latent phages to reproduce and release mature virions into the culture medium ("active" phage). To assess the active phage's host-range, each isolated phage was plated onto diverse bacterial strains, including lab strains and clinical isolates. Phage growth characteristics were evaluated in culture with each of their identified hosts. Morphology of the isolated phages were assessed using transmission electron microscopy (TEM).

From >100 urinary bacterial genomes isolated from unique women with and without UUI symptoms, we detected upwards of 5 latent phage sequences per genome. There is a rich diversity of novel active phage species in the bladder microbiota; latent phage genome sequences identified within the bacterial urinary isolates exhibit little to no similarity to sequenced phage species in extant databases. From urinary bacteria, 9 active phages able to infect Escherichia coli were isolated. These isolated phages were tailed phages, as determined by TEM (Fig. 1) . Although morphologically similar, they differ with respect to their genome sequences and genome size ( [3] and unpublished results). Furthermore, while these phages could infect standard laboratory strains of E. coli, their ability to infect urinary E. coli isolates varied ( Table 1) Table 1 . Host-range of 4 of the E. coli-infecting phages isolated from the urinary microbiome.

Interpretation of results Latent and active phages are abundant in the female urinary microbiome. Active phages can be collected from bacterial cultures for subsequent analyses. These phages are unique to the urinary microbiome; nevertheless, it is worth noting that phage species within the human microbiome are largely uncharacterized to date.

Concluding message Discovery of phage species able to selectively infect urinary bacteria and shape bacterial communities in the bladder could inform treatment, as phage could be used as an alternative to antibiotics and/or to augment efficacy of current treatment regimes for urinary disorders.

Price T 1 , Brubaker L 2 , Mueller E 1 , Brincat C 1 , Wolfe A 1

Hypothesis / aims of study To determine if Female Urinary Microbiota (FUM) differs between women with lower urinary tract disorders and non-symptomatic controls.

Study design, materials and methods With IRB approval, transurethral catheterized urine samples were collected from 384 adult women, categorized into 4 groups: 75 with self-reported Urinary Tract Infection (UTI), 109 with Urgency Urinary Incontinence (UUI), 50 with Stress Urinary Incontinence (SUI), 150 without Lower Urinary Tract Symptoms (non-LUTS). Women with UUI and SUI were characterized by response to the Pelvic Floor Distress Inventory. Bacterial growth was assessed with Enhanced Quantitative Urine Culture (EQUC) protocol, which uses 100X more urine plated onto more types of media and cultured 2X longer under more environmental conditions relative to Standard Urine Culture (SUC). All bacteria detected by EQUC were identified using Matrix Assisted Laser Desorption/Ionization -Time of Flight Mass Spectrometry. Microbiota composition and diversity were compared in terms of relative proportion of genera amongst all cohorts and by dominant genera (i>50% relative abundance) within each cohort.

All cohorts were predominantly White/Caucasian. The Non-LUTS cohort was significantly younger (p<0.05). The distribution of dominant genera differed amongst cohorts (Fig. 1A) . Not surprisingly, genera containing typical pathogens (e.g., Proteus, Pseudomonas, Klebsiella, Staphylococcus, Escherichia) were enriched in the UTI cohort. Other genera were enriched in other cohorts (non-LUTS -Micrococcus, Bacillus; SUI -unclassified & Alloscardovia; UUI -Actinobaculum, Bifidobacterium). Some genera are common in all non-UTI cohorts (Lactobacillus, Streptococcus), while others were enriched in the incontinent (UUI, SUI) cohorts (Gardnerella) or in both UTI and UUI cohorts (Aerococcus). Most culture-negative samples appeared in non-LUTS, while most Mixed cultures (i.e. a single genus is not present at >50%) appeared in SUI and UUI. Amongst different patient cohorts, distinct microbial differences were detected (Fig. 1B) . The non-LUTS cohort tended to be culture-negative or dominated by Lactobacillus, while Escherichia dominated the UTI cohort. The UUI and SUI cohorts appeared very similar and differed from the non-LUTS cohort primarily by the percentage of mixed cultures, suggesting lower diversity in the non-LUTS cohort; this is supported by Shannon Diversity Indices that are greater in UUI and SUI.

Interpretation of results Compared to women without LUTS, the FUM differs in the presence of any of the studied LUTS. Moreover, the primary LUTS disorders appear related to FUM composition, with differences between women with UTI and common forms of UI. Although this analysis detected differences between women with SUI and UUI, they are relatively subtle. Enrichment of Aerococcus in the UTI and UUI cohorts supports the contention that this Gram-positive bacterium is an emerging uropathogen. 

Hypothesis / aims of study In urogynecologic patients who report they have a UTI, we compared the proportion of patients with at least one uropathogen detected using 4 different diagnostic thresholds. We also assessed the symptoms resolution after clinically directed treatment.

Study design, materials and methods We prospectively enrolled 75 urogynecologic patients who reported they had a UTI (yes response to "Do you feel you have a UTI?"). Catheterized urine samples were assessed with standard urine culture (SC) thresholds and an enhanced quantitative urine culture (EQUC) protocol that uses a larger urine volume than SC incubated under diverse combinations of media and environmental conditions. Four diagnostic thresholds for uropathogen detection were compared: ≥10 5 , ≥10 4 and ≥10 3 CFU/ml by SC and the presence of any uropathogen detected by EQUC. Clinical treatment was directed by the patient's physician using SC results with the >10 5 CFU/ml threshold. Post-treatment, patients were asked to self-complete the validated UTI Symptom Assessment (UTISA) questionnaire. Symptom resolution was determined by the answer to the question, "Since you last completed this questionnaire, have there been any changes in your urinary tract infection symptoms?"

The majority of the patients were Caucasian (62/75, 83%) and overweight (mean body mass index [BMI] = 29.9 kg/m 2 ). EQUC detected 23 known and emerging uropathogens present in nearly all patients 92% (69/75). The proportion of patients with at least one uropathogen detected declined as the diagnostic threshold increased (≥10 3 = 81%, ≥10 4 = 71% and ≥10 5 = 61%) (Fig. 1) . The effect of the diagnostic threshold was related to the characteristics of the uropathogens present. At ≥10 5 CFU/mL, most (85%) patients with detected uropathogens had Gram-negative bacteria. In contrast, when the "any" detection threshold was used, only 38% had Gram-negative uropathogens; the other 62% had polymicrobial or Gram-positive uropathogens. Many (23/37, 62%) treated patients reported symptom resolution within one week. Conversely, many (60%) untreated patients with at least one uropathogen present below the ≥10 5 CFU/mL reported that their UTI symptoms persisted ('same' or 'worse') one week later.

In urogynecologic patients who self-report UTI, uropathogens are commonly present. These data support a diagnostic threshold less that the commonly used ≥10 5 CFU/mL. Patients with polymicrobial or Gram-positive infections are less likely to be diagnosed with UTI and less likely to be treated for these uropathogens.

The current diagnostic methods used for UTI are ineffective in a urogynecologic population. 

Hypothesis / aims of study: Overt postpartum urinary retention (PUR) is the inability to void spontaneously after delivery and affects up to 7% of patients postpartum. [1] While urinary retention can result in bladder overdistention and potentially long-term problems like reduced detrusor contractility, urinary tract infections and hydronephrosis, early recognition and catheterization is necessary. [2] Clean intermittent (CIC) and transurethral indwelling catheterization (TIC) are both standard treatment options but have not been compared yet. [3] Clinical guidelines on postpartum bladder management are missing. The aim of the study was to compare micturition symptoms three months after delivery between the two groups and duration of catheterization.

Study design, materials and methods This randomized clinical trial (RCT) included 86 patients after vaginal delivery with symptomatic PUR (no spontaneous voiding within 6 hours after giving birth) who were allocated to CIC and TIC in five teaching hospitals in the Netherlands. In total data of 68 patients (n=34 in both groups) were used for the final analysis. In the TIC group, patients received an indwelling catheter for 24 hours. In case adequate voiding was not possible, a second indwelling catheter was inserted for another 48 hours. Patients allocated for CIC were intermittently catheterized or taught to self-catheterize until adequate voiding with post void residual volume (PVRV) < 150 mL was achieved. The primairy outcome was the presence of bothersome micturition symptoms as measured by the Dutch validated UDI-6 (Urogenital Distress Inventory) questionnaire three months after delivery. Secondary outcomes included duration of catheterization and patient experience.

No statistical significant differences in micturition symptoms after 3 months were found between the two groups ( Table 1 ). The median PVRV was 800 mL in CIC group compared to 625 mL in TIC group. 24% of the total group of patients had PVRV ≥ 1000 mL. In patients with CIC, 65% of patients regained adequate bladder emptying within 24 hours: in 35%, only one single catheterization was necessary to regain adequate bladder emptying. After 4 times of CIC (mean duration 24 hours) this was 78%.In patients with TIC, 84% of patients were able to void adequately after 24 hours. (Table 2 ) Duration of treatment was not related to the initial PVRV. Both treatments were well accepted by the included patients.

Concluding message PUR is a condition with a mild character as it mostly resolves spontaneously. However, if catheterization is indicated, our trial results show that clean intermittent catheterization is preferred, as it results in faster normalization of bladder emptying as compared to an indwelling catheter for 24 hours. Voiding symptoms at 3 months after PUR are not affected by the catheterization regime. (2), reviewing the literature, no data is available regarding long term urine flow parameters of women who had RMUS in the past.

Objective and subjective outcomes related to urine flow of patients who had a retropubic sling for more than five years will give us a better understanding of the impact of retropubic slings and we will be able to advice better regarding operation's long term implications.

Study design, materials and methods Patients who had a retropubic sling inserted before August 2011 were eligible to participate in the study. Women with chronic voiding dysfunction, neurological disease, failed retropubic sling after August 2011 but before follow up appointment and those who had non-retropubic sling were excluded.

Those who fit the inclusion criteria were contacted and asked to participate in the study. They were invited to attend for a follow up consultation. All patients would be asked to fill in Patient Reported Outcome tools including: ICIQ UI SF, ICIQ OAB, PGIS, and W-IPSS voiding questionnaire. Those who did not want or could not attend were sent the questionnaires by mail. At the consultation they were offered a vaginal examination to assess pelvic organ prolapse (POPQ) and to check for mesh exposure. A cough stress test would also be performed with a comfortable full bladder. A uroflowmetry test to assess their urine flow followed and then a bladder US scan to measure post void residual. All Data was collected on a standardized proforma including patient characteristics.

Outcomes were compared with Pearson  2 test for categorical data and Student t test or Wilcoxon rank-sum for continuous data as appropriate. ICIQ UI SF, ICIQ OAB ,PGI-I and W-IPSS voiding questionnaire were analysed using repeated measures analysis of variance ANOVA or Friedman test as appropriate.

Results 240 patients were eligible to participate. We were able to contact 84 who accepted to participate in the study. Mean age was 70 +/-10 years old. Mean age at the time of surgery of 64 +/-11 years old. The mean follow up was 86.6 +/-17.6 months. Mean parity was 2+/-1. 22 had had an hysterectomy and 10 had had previous POP surgery, 3 of them had mesh used. 10 patients had had previous incontinence surgery, 6 had a midurethral sling and 4 had a Burch colposuspension. Median POP-Q prior to surgery was Ba -2 (-2 -0), C -5 (-7 -0) and Bp -2 (-2 -0). Only 10 patients had concomitant surgery at the time.

Preoperative urodynamics confirmed SUI in all patients. Median maximal urethral closure pressure (MUCP) was 20 (14 -27) and Median abdominal leak point pressure (ALPP) was 60 (40 -76). Detrusor overactivity (DO) was a urodynamic finding in 10 patients. 75 (90%) of the retropubic slings were TVT exact, 9 (10%) were Advantage fit. There were 5 bladder perforations that were corrected intraoperatively, 2 slings required loosening in the first two weeks and 1 patient developed a retropubic haematoma that was managed conservatively. 

Hypothesis / aims of study 10 to 40% women have recurrent or persistent SUI after surgery [1] . Clinicians base their treatment choice on clinical experience and personal preference as little evidence exists to guide them on which secondary treatment is "best". Relevant systematic reviews presented limited evidence [2, 3] . No randomised controlled trials (RCT) solely recruited recurrent cases. Subgroup analysis of RCT data was inconclusive for comparisons between retropubic and transobturator MUT, or between MUT and colposuspension. Data from non-randomised studies suggest cure rates of 73% and that retropubic MUT is more effective than transoburator [12] . We examined the British Society of Urogynaecology (BSUG) database records for treatment given for recurrent stress incontinence and to compare outcomes. . Patient Global Impression of Improvement (PGI-I) data were available for 1,616 (60.5%) women; 1,319 (81.6%) were "much better" or "very much better". "Change in stress incontinence" data were available for 1,499 (56.2%) women. Of these, 993 (66.2%) were "cured" and 344 (22.9%) "improved". Both PGI-I scores (p<0.001) and "change in stress incontinence" (p<0.001) differed by surgery type, with midurethral tapes, colposuspension and fascial sling more likely to achieve cure or major improvement than bladder neck injection.

Interpretation of results MUT and bladder neck injections were the most common procedures for repeat SUI but treatment patterns have changed in the last 8 years. Follow up data in the BSUG database are incomplete but suggest MUT, colposuspension and fascial sling are superior procedures.

Concluding message Recurrent SUI remains a therapeutic challenge. These data suggest that repeat MUT, colposuspension or autologous fascial sling are the best options. However, low completion rates for outcomes mean these conclusions must be tentative, and robust prospective data are needed to provide evidence to guide treatment decisions.

Hypothesis / aims of study Although obesity is considered to be one of the risk factors for pelvic organ prolapse (POP), relationship between BMI and the condition has not yet been established 1 . Cases of POP in underweight women are also not clinically uncommon. Association between pelvic inclination and pelvic organ prolapse was retrospectively examined with consideration of a possibility that the spine becomes out of alignment and the vector of abdominal pressure changes, increasing chances of POP to occur.

Study design, materials and methods Subjects of the study were eleven patients who had preoperative chain cystourethrography and underwent transvaginal mesh surgery for treatment of stage2 POP or above in our hospital between May 2016 and March 2017. Sacral slope (SS) defined as the angle between the sacral plate and the horizontal plane was measured using standing lateral images taken in chain cystourethrography, and the correlation with age, the number of vaginal delivery, BMI, presence or absence of spinal disease, POP-Q scores was examined. Statistical analysis was conducted using Pearson's correlation coefficient.

The average age of eleven patients was 71.0±4.6 years, mean BMI was 25.2±3.0, and mean POP-Q scores were Aa1.45±1.12, Ba1.54±1.12, C-2.45±3.72, pb1.90±0.30, tvl7±1.10, Ap-1.91±2.43, Bp-1.9±2.43, D-4.09 ± 4.78, respectively. With regards to physiological curvature, a normal value of SS is considered to be between 25° and 45°. In this study, the average of measured SS was 26.9±9.99°. Correlation between SS and each parameter was not found. Also, when considering cases presented SS between 25° to 45° to be normal, less than 25° to be posterior pelvic tilt, and over 45° to be anterior pelvic tilt, there were seven cases in the normal group, three in the posterior pelvic tilt group, and one in the anterior pelvic tilt group. No difference was found among three groups in terms of BMI and POP-Q scores.

Although obesity is one of the risk factors of POP, there are clinical cases of severe POP in underweight women, and thus, it was considered that posterior pelvic tilt could be a risk factor of POP. Cine MRI and transperineal ultrasound are used in image diagnosis of POP, although all examinations are carried out in the recumbent position and not in the standing position. Therefore, the study attempted to evaluate pelvic inclination in the standing position with sacral slope measured using standing lateral images taken in chain cystourethrography. Since the sample size is small, it would be necessary to examine a larger number of cases as well as carry out comparison with non-POP cases in the future.

The study investigated pelvic inclination of patients with POP. 

Hypothesis / aims of study To compare the clinical outcome between midurethtral sling procedure for stress urinary incontinence with and without concomitant repair of asymptomatic grade II pelvic organ prolapse (cystocele) repair.

Study design, materials and methods Seventy two female patients with stress urinary incontinence (SUI) and asymptomatic grade II cystocele were included in a randomized study between June 2014 and June 2015. They were divided equally into two groups. Group (A) treated only with trans-obturator tape (TOT) without treatment of the cystocele while in group (B) TOT was associated with cystocele repair by a tailored proline mesh. Postoperative follow up was performed after 3, 6 and 12 months. The two groups were compared regarding clinical outcome of SUI (cure, improvement or failure) and development of any denovo events.

For clinical outcomes based on patients' subjective symptoms, the cure rate of group (A) was 77.8%.66.7% and 66.7% meanwhile for group (B) was 85%,90% and 90% at 3,6 and 12 months, respectively (p<0.05). Cystocele was cured in all patients in group (B). Six patients (17%) with asymptomatic cystocele grade II in group (A) became symptomatic or with a higher grade at 6 months duration that required surgical repair. Denovo urgency with or without UUI was 12.5% in group (A) increasing up to 50% at 6 months follow up which was treated with anticholenergic medications, but was 5% in group (B) with highly stastistically significant difference (p<0.05).

Concluding message Concomitant asymptomatic cystocele repair with midurethral sling improve the cure rate of stress urinary insentience, reduce the incidence of denovo urgency incontinence and worsening of existing cystocele. Hypothesis / aims of study Sacropexy is considered to be the golden standard in the treatment of pelvic organ prolapse (POP) in women, offering superior anatomical results compared to vaginal approaches (1). The switch from the abdominal (open) sacropexy to a minimally invasive, laparoscopic approach over the last 20 years, reduced morbidity and offered faster patient recovery while retaining the benefits of the open surgery (2) . According to the current literature, the complications' rate vary from 1-11% and the relevant existing data suffer from the unavoidable effect of the learning curve, inconsistent documentation, variable and dissimilar techniques and eventually the bias from fragmented data collection from various centres who participate to the analyses (3). Aim of this study is to present data regarding the perioperative complications of sacrocolpopexy in a large cohort of patients who were treated in a single centre from one surgeon with the same, unchanged, nerve-preserving sacropexy technique.

Study design, materials and methods This is a single center, retrospective analysis of all patients who underwent sacropexy for POP in our institution between January 2007 and December 2016. All procedures were performed by the same experienced surgeon beyond learning curve, using the same surgical technique. Collected data included age at the time of surgery, body mass index (BMI), comorbidities, smoking, previous abdominal surgery and previous surgical procedures for the treatment of POP as well as concomitant procedures performed at the time of sacropexy. All complications that occurred during and up to 3 weeks after surgery were documented. Statistical calculations included: cross-tabs and non-parametric correlations analysis. Logistic regression was used to provide a model of identifying risk factors for the occurrence of complications. SPSS (v. 24) was used for the analysis.

During the ten-year period between January 2007 and December 2016, 769 women underwent sacropexy: 580 per laparoscopy, 168 per laparotomy and 21 were converted from laparoscopy to laparotomy. Mean age and mean BMI of all patients were 59.9 years (min. 30.0, max. 82.1, SD 10.6) and 25.0 kg/m2 (min. 16.0, max. 44.1, SD 3.5). 27 complications occurred in 27 patients (3.5%) including 5 injuries (one respectively of the bladder, the mesocolon, the rectum -during concomitant colporrhaphy -and two of the iliac vessels) , 7 hematomas/bleedings, 2 cases of postoperative ileus, 4 wound infections and 2 cases of small intestine herniation in the trocar insertion point (Table1). The presence of at least one concomitant disease at the time of surgery was positive correlated with the occurrence of complications (p<0.001) and could be identified as a risk factor for adverse event (logistic regression, OR 2.97, p=0.01) (Table2).

The rate of complications in this large patient cohort was low and the majority of them were minor and easy to resolve, although surgical intervention was often required. Age and BMI, which were correlated with higher rate of complications in other reports, could not be identified as risk factors in this study. Also the number of previous surgical procedures and concomitant procedures like hysterectomy, vaginal cystocele and rectocele repair as well as colposuspension and lateral repair did not increase the complications rate.

Concluding message Sacrocolpopexy can be considered as a safe procedure at every age and also in patients with high BMI and multiple previous procedures. Patients for sacropexy, especially those with multiple comorbidities should be selected carefully. 

Hypothesis / aims of study Pelvic floor disorders affect up to 75% of women considering bariatric surgery. There is a considerable, growing body of evidence regarding the beneficial effect of significant weight loss on pelvic floor disorders. However, most studies are either small, short, or focused solely on urinary incontinence (UI), ignoring other aspects of female pelvic floor disorders as well as sexual function.

Moreover, it remains unclear whether these beneficial effects are long lasting. The aim of this prospective, nonrandomized study was to compare the short and medium term effect of surgically induced weight reduction on lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP), colorectal-anal (CRA) complaints and sexual dysfunction among obese women undergoing bariatric surgery.

Study design, materials and methods 160 consecutive obese women, who underwent bariatric surgery in a single university-affiliated medical center, were prospectively enrolled. The study protocol was approved by the local hospital Helsinki Committee. Four validated questionnaires on UI (ICIQ-UI), LUTS (BFLUTS-SF), pelvic floor disorders (PFDI-20), and condition-related sexual dysfunction (PISQ-12) were used to evaluate patient's pelvic floor symptoms before, and 3-6 months after surgery. 150 participants completed pre-and postoperative questionnaires at 3-6 months (short term). All participants were then contacted at 12-24 months postoperatively, and invited to complete an additional set of the same four questionnaires during a follow-up office visit, or by mail. Of the 150 eligible patients, 101 (67%) completed the requested follow up questionnaires at 12-24 months (medium-term). Comparing the 101 responders versus the 49 non-responders, there were no statistically significant differences in terms of their mean age, parity, BMI, or presenting pelvic floor symptoms. A positive answer to the question "How often do you leak urine?" on the ICIQ questionnaire was used to define the presence or absence of UI. Similarly, any participant whose score was higher than 0 for either POP or CRA domains in the PFDI-20 questionnaire was classified as symptomatic for that particular domain. .9 kg/m 2 ) had UI with a mean preoperative ICIQ score of 9.2±4.0. Of the 50 incontinent women, 32 (64%) had stress incontinence (SUI), 12 (24%) had mixed incontinence (MUI), 4 (8%) had urgency incontinence (UUI), and 2 (4%) women did not fall into any category and were therefore regarded as 'other UI'. By 3-6 months following surgery, 27 (54%) women were completely free of symptoms, and the mean ICIQ score decreased to 2.9±3.6 (p<0.001 compared to baseline). By 12-24 months following surgery, 30 (60%) women were completely symptoms free, and the mean ICIQ score was 2.8±3.9 (p<0.001 compared to baseline). Improvement was mainly documented in the SUI and MUI subtypes, with complete cure rates of 56% and 75%, respectively. Pelvic organ prolapse symptoms: Before surgery, 31 (29.7%) women (mean age 42.8±12.0 years; mean BMI 41.4±5.1 kg/m 2 ) had POP symptoms with a mean PFDI POP score of 17.1±11.6. By 3-6 months following surgery, 11 (35%) women were completely free of symptoms, and the mean POP score decreased to 9.7±11.2 (p=0.005 compared to baseline). By 12-24 months following surgery, 16 (52%) women were completely free of symptoms, and the mean POP score was 9.4±14.7 (p=0.009 compared to baseline). Colorectal-anal symptoms: Before surgery, 48 (47.5%) women (mean age 44.5±11.8 years; mean BMI 40.7±4.0 kg/m 2 ) had CRA symptoms with a mean preoperative PFDI CRA score of 20.9±15.7. By 3-6 months following surgery, 16 (33.3%) women were completely free of symptoms, and the mean CRA score decreased to 13.5±15.0 (p=0.008 compared to baseline). By 12-24 months following surgery, 11 (22.9%) women were completely free of symptoms, and the mean CRA score was 16.0±14.7 (p=0.092 compared to baseline). Sexual dysfunction: Postoperatively, there was no significant increase in the number of sexually active women (75 and 79 at 3-6 and 12-24 months respectively, compared to 75 at baseline). According to the BFLUTS questionnaire, a statistically significant improvement (i.e. lower scores) was achieved and remained significant at both 3-6 and 12-24 months postoperatively (0.3±0.9 at baseline; 0.2±0.6, p=0.021 at 3-6 months; and 0.1±0.5, p=0.026 at 12-24 months). According to the PISQ-12 questionnaire, a significant improvement (i.e. a higher score) was achieved at 3-6 months following surgery (38.9±5.2 vs 36.7±6.0; p=0.004), however, at 12-24 months after surgery this improvement was no longer statistically significant (38.1±5.0 vs 36.7±6.0; p=0.155).

Interpretation of results Significant-rapid weight loss resulted in a striking improvement in LUTS, including resolution of UI in half of incontinent patients. Statistically significant improvements were also noted in POP and CRA symptoms. These beneficial early postoperative effects were sustained through 12-24 months after surgery. The short and medium term outcome results regarding sexual dysfunction remain inconclusive and further studies are required to investigate this important aspect. We believe that the benefit of bariatric surgery in terms of pelvic floor disorders should be taken into account when discussing the option of bariatric surgery with relevant patients.

Concluding message Rapid and significant improvement of female pelvic floor symptoms is expected following bariatric surgery. This beneficial effect is sustained through 12-24 months after surgery. Further studies are required to investigate the long-term impacts of bariatric surgery on the various aspects of pelvic floor function as well as female sexual dysfunction. 

Hypothesis / aims of study In spite of intensive study, the association between lower urinary tract symptoms (LUTS) and obesity is still controversial. Moreover, these studies mainly focused on elderly adults, and information in women around age at onset of LUTS is limited. In this study, we evaluated the relationship between obesity and urgency, the most bothersome symptoms in LUTS in young and middle-aged adults.

This study included 1,296 healthy women ≥20 years; 294 in 20's, 473 in 30's, 368 in 40's, and 133 in 50's and over. LUTS was assessed using I-PSS questionnaire and urgency was evaluated using overactive bladder Symptom score questionnaire with higher score indicating more severe symptoms. LUTS was diagnosed as I-PSSS ≥8. Severity of LUTS was defined by I-PSS-QOL as follows; 0-1 as mild, 2-3 as moderate, and 4-6 as severe. Obesity was evaluated by body weight, BMI, circumference and visceral fat. Interpretation of results Association of obesity and the risk of urgency was found in young and middle-aged women.

Our findings indicated that weight loss for obese subjects may delay the onset of urgency. 

Hypothesis / aims of study Pathogenesis of ulcer type interstitial cystitis/bladder pain syndrome (IC/BPS) might be different from the non-ulcer IC/BPS. Previous study revealed subepithelial lymphoplasmacytic infiltration with focal lymphocyte aggregation in the bladder of ulcer IC/BPS. However, the etiology is still unknown. The aim of current study is to investigate the role of EB virus in the pathogenesis of IC/BPS, including ulcer and non-ulcer type.

Study design, materials and methods A total of 33 patients with IC/BPS were enrolled. Thirteen of these patients were severe IC/BPS and were admitted to our ward for partial cystectomy with augmentation enterocystoplasty (10 ulcer type and 3 non-ulcer IC/BPS). The others 20 patients were mild IC/BPS and were admitted for cystoscopic hydrodistention with cold-cup bladder biopsy. The bladder specimens were obtained during the operation and sent to our pathology department for immunochemical staining for EB virus. Immunochemical staining cell markers CD3 for T lymphocyte and CD20 for B lymphocyte were also performed in the ulcer IC/BPS bladder. Blood samples for EB virus serological markers were obtained in the patients with positive immunochemical finding, including EB-VCA IgG, IgM, EBEA IgG and EBNA IgG. Twelve female patients who were admitted for anti-incontinence surgery were also enrolled and were considered as normal controls. Bladder mucosa biopsies were taken during the procedure, and the specimens were also sent to the pathology department for immunochemical staining for EB virus.

Among the severe 13 IC/BPS bladder specimens from partial cystectomy, immunochemical staining revealed EB virus positive in 7 patients (7/13=53.8%) ( Figure 1 ). Five of the 7 patients were ulcer type IC/BPS, and the others 2 patients were non-ulcer IC/BPS. The EB virus positive rate was 5/10=50% in the ulcer IC/BPS bladder specimens, and was 2/3=66% in the non-ulcer IC/BPS bladder. None of the mild 20 IC/BPS or 12 normal control bladder specimen was positive for EB virus. The immunochemical staining also showed CD3 positive in the EB virus positive cells. The serological tests for EV virus revealed EB-VCA IgG and EBNA positive in all patients. The serum EBNA IgG was positive in only one patient, and EB-VCA IgM was all negative. The clinical symptoms severity was not significantly different between IC/BPS patients with or without EB virus positive.

Current study revealed about 50% EB virus positive in patients with severe IC/BPS who underwent enterocystoplasty. EB virus infected T cells were also found in the immunochemical staining. The serological markers also revealed a chronic infection in these patients. IC/BPS is a heterogeneous syndrome, and EB virus infection may involve the pathogenesis in some IC/BPS patients with severe clinical symptoms. In the patients with mild IC/BPS, immunochemical staining showed EB virus negative in all bladder biopsies. It suggested the pathogenesis between mild and severe IC/BPS might be different. 

Hypothesis / aims of study Interstitial cystitis (IC) is considered to manifest Hunner's lesion or glomerulation in the bladder based on NIDDK criteria, but the pathology remains elusive. While Hunner's lesion displays an inflammatory gene signature, intrinsic abnormalities of the urothelium per se are largely unknown. Tissue specific master transcription factors (TFs) play pivotal roles in human development and disease, and we sought to characterize IC pathology based on the expression profile of urothelial master TFs.

Study design, materials and methods To identify candidate urothelial master TFs, we used bladder carcinoma cell lines which are derived from the urothelial stem cells but display two contrasting characteristics: epithelial or mesenchymal. Gene expression was measured with quantitative RT-PCR. From the initial screening of 170 TFs (human homologs of Drosophila segmentation genes and known master TFs from a database), 28 TFs were selected. Subsequently we purified mRNA from bladder biopsies of IC patients and measured gene expression levels of known urothelial marker genes and candidate master TFs. Multivariate expression data were analyzed with SPSS software.

Results mRNA expression of the 28 candidate TFs as well as known urothelial marker genes were measured in IC specimens sampled endoscopically. IC biopsies included various clinical status, including ulcerative type biopsies (Hunner's lesion or 'apparently normal' urothelium counterpart from the same patient) and non-ulcerative type biopsies (urothelium with or without glomerulation during hydrodistension). Initially, we noted that E-cadherin expression (encoded by CDH1 gene) had a huge variation among different IC specimens ( Figure 1A , Log2 expression range: from 5.29 to 14.96, 815-fold expression difference). Endoscopic handling could have resulted in significant variation of epithelial/stromal ratio and we presumed that the contaminated stroma (i.e. submucosal tissue and inflammatory cells) significantly affected data interpretation. Therefore, we changed the internal control of RT-PCR from 18s ribosomal RNA to CDH1, thereby exclusively focusing on urothelial status. UPK1A expression (uroplakin 1A, a known marker of urothelial cells) was lower in IC biopsies from Hunner's lesion (ulcer positive) compared to urothelium from both ulcerative and non-ulcerative patients (collectively defined as ulcer negative) ( Figure 1) . Moreover, expression of other urothelial marker genes, TP63, SHH or FOXA1 was lower in Hunner's lesion. Conversely, retinoic acid receptor RARA expression was higher in ulcer positive compared to ulcer negative urothelium ( Figure 2 ). Among 28 candidate TFs, expression of EVX1, OVOL1, EHF, ELF3 or GRHL2 was lower in Hunner's lesion. Conversely, expression of vitamin D receptor VDR, ELF4, IRF1 ( Figure 3 ), ETS2, NR4A2 or ZBTB7B was higher in ulcer positive compared to ulcer negative urothelium. We noted that several factors are associated with each other and the multivariate expression data could be decomposed to fewer number of dimensions. Factor analysis reduced the expression complexity of known urothelial markers and the candidate TFs and we chose four axes for convenience of classification ( Figure 4 ). From the known markers, retinoic acid receptors RARA and RXRA were classified into the first axis ( Figure 4A , Principal Axis: PA1), and the second axis (PA2) was related to the urothelial basal cell marker, KRT5 ( Figure 4A ). Other known markers, KRT7, UPK1B, and UPK3A were classified into PA2 but these three were inversely correlated with KRT5 ( Figure 4B ). The third axis (PA3) included four markers, TP63, KRT20, UPK1A, and UPK3B ( Figure 4A ), which are closely associated with each other ( Figure 4B ). The fourth axis (PA4) included SHH and FOXA2 ( Figure 4A ). Most candidate TFs were classified according to these criteria but some were under-detected (KLF3, KLF15, NR5A2 and FOS) in IC biopsies, and EHF and CEBPG were not classified into the four PAs, due to poor correlation with other factors ( Figure 4A ). Finally, we sought to characterize IC biopsies according to these multivariate expression profiles ( Figure 5 ). Principal component (PC) analysis produced a similar multivariate classification as that obtained in factor analysis. We drew a scatter plot as shown in Figure 5 according to these four principal components. Although there was no remarkable segregation between ulcer statuses (black circles: Hunner's lesion, white circles: 'apparently normal' urothelium counterparts from ulcerative type patients and urothelium from non-ulcerative type patients), biopsies from Hunner's lesion (black) tended to be located in particular PC areas ( Figure 5 ).

IC might be characterized based on the urothelial master TF.

We developed a method to characterize IC biopsies based on the urothelial master TF signature and Hunner's lesion might be defined as 'decreased progenitors and higher regeneration'. 

Hypothesis / aims of study Both metabolic syndrome (MS) and type II diabetes mellitus (IIDM) are known risk factors for lower urinary tract symptoms and detrusor overactivity, being the latter a well-known cause of urgency urinary incontinence in obese individuals. A recent study has suggested that a lower expression and diminished function of neuronal cannabinoid CB1 and CB2 receptors, as well as a lower nerve fiber density is involved in the impaired excitatory neurotransmission of the urinary bladder in the insulin-resistant obese Zucker rat (OZR), a MS experimental model similar to that produced in man (1) . Antioxidants are agents that protect cells from the damage caused by unstable molecules known as free radicals or reactive oxygen species (ROS). Since increased oxidative stress can cause bladder nerve dysfunction, nerve fiber and mitochondrial injury and detrusor muscle cell damage (2), we investigate whether this pathophysiological mechanism is involved in the bladder motor dysfunction in OZR.

Bladder samples from OZR and their respective controls lean Zucker rat (LZR) were processed for western blot, spectrophotometry and/or fluorimetry for oxidative stress and antioxidant enzymatic activity measurement. Detrusor strips from OZR and LZR were also mounted in myographs for isometric force recordings induced by electrical field stimulation (EFS) on basal tension.

EFS-elicited contraction was considerably lower in OZR bladder compared with that exhibited in LZR. In OZR bladder homogenates, an increased amount of ROS and of the thiobarbituric acid reactive substances (TBARS) and protein carbonyls levels were detected. In addition, superoxide dismutase (SOD), catalase (CAT), glutathione reductase (GR) and glutathione peroxidase (GPx) activities were found to be significantly lower (p=0.0001) in OZR in comparison with LZR controls. The glutathione/oxidized glutathione ratio (GSH/GSSG) decreased significantly, causing a more oxidized GSH redox status.

These results suggest that the decline in the antioxidant enzyme system reflects a reduction in the cellular defense to ROS and an increased susceptibility of the bladder tissue to oxidative damage in OZR, leading to impaired excitatory neurotransmission of detrusor muscle in these rats.

Concluding message An increased oxidative stress and reduced antioxidant enzyme activity could contribute to the bladder motor dysfunction in OZR through an impaired ROS-related pathway. 

Hypothesis / aims of study The intrapelvic portions of the lumbosacral nerves have been well described for decades. However, capable laparoscopic surgeons in the fields of gynecology, urology and colorectal surgery are not accustomed to diagnosing and treating peripheral nerve entrapments, while specialists who are (neurosurgeons, spine, hip and hand surgeons), rarely have the skills required to navigate the pelvis laparoscopically, which is the best route to approach these nerves (1) . For this reason, intrapelvic nerve entrapment remains a significant, neglected cause of perineal and sciatic pain, as well as refractory pelvic floor dysfunction (2) . Our objective is to report the outcomes of the first 50 patients undergoing laparoscopic nerve root decompression for refractory pudendal nerve pain and pelvic floor dysfunction at our center.

Study design, materials and methods A retrospective cohort study of 50 consecutive patients undergoing laparoscopic nerve root decompression from December 2009 to December 2017 was conducted at our center. A diagnosis of nerve entrapment was made based on symptomatology, clinical and neurological examinations. The onset of symptoms was recorded at the initial consultation. The number of previous surgeries documented included only those aimed at treating lumbosacral nerve entrapment. Visual analogue scale (VAS) scores were used to assess pain severity at each patient visit. A paired t-test was used to compare preoperative VAS-scores to VAS-scores at the last post-operative visit. A 50% reduction on VAS score and/or a significant reduction in the use of analgesics was considered a successful outcome.

A total of 50 patients underwent laparoscopic nerve root decompression during the study period. Etiologies of the intrapelvic nerve entrapments, the nerves involved, and the clinical and surgical data are displayed in tables 1 & 2. Success rate -at least a 50% improvement in pain scores -was 86%. These results are in keeping with those reported in the literature [3] using the same technique. The average interval between symptom onset and correct diagnosis was 4.5 years, with patients undergoing an average 1.2 previous ineffective surgery for treatment of their symptoms. Following nerve decompression, 52.9% of patients experienced neuropathic pain, lasting on average 4.1 months. 19.6% of patients experienced a post-decompression motor deficit, lasting on average 2.6 months. Perioperative complications included one pudendal nerve transection, one obturator nerve tear, one ureteral injury, 2 cases of genitofemoral neuropathy, 2 cases of urinary retention, one incisional hernia, one rectovaginal fistula and one case of pyriformis muscle adhesions requiring a transgluteal endoscopic procedure.

Laparoscopic detrapment of intrapelvic portions of the lumbosacral plexus yields satisfactory and reproducible results.

Concluding message The diagnosis and treatment of intrapelvic nerve entrapment is poorly understood by physicians. Awareness must be raised in order to provide patients with a more timely diagnosis and treatment, and to avoid unnecessary or ineffective surgical procedures. 

Hypothesis / aims of study Previous studies revealed nerve hyperplasia and fibrosis in the bladder of ketamine related cystitis (KC). However, the pathogenesis of these pathologic changes was still unclear. The aim of current study is to investigate the neurotrophin expression and the fibrogenesis pathway in the KC urothelium.

The patients with KC who were admitted to our hospital for partial cystectomy with augmentation enterocystoplasty were enrolled into this study. The diagnosis of KC was based on previously recreational use of ketamine for at least 6 months and lower urinary tract symptoms. All patients underwent a comprehensive history review and urodynamic study. The bladder specimens was obtained from the surgery and sent to our laboratory for western blotting and immunochemical staining. Western blotting with quantification was used to investigate the expression of neurotrophin growth associated protein 43 (GAP-43), nerve growth factor (NGF) and its receptor tropomyosin receptor kinase A (TrkA) in these bladder specimens. The fibrogenic cystokine transforming growth factor beta (TGF-β) was also investigated. Immunochemical staining with 3,3' Diaminobenzidine (DAB) was also performed to verify the location of Trk-A and GAP-43 expression in the KC bladder. Bladder specimens from patients with bladder cancer and underwent radical cystectomy were also obtained for western blotting and were considered as normal control.

Pearson's correlation coefficients were calculated to determine the correlations between the quantification results of western blotting and clinical symptoms scores, including Visual Analogue Scale for pain (VAS), bladder capacity and compliance in the urodynamic study.

A total of 13 KC patients and 3 normal controls were enrolled. The mean age in KC patients and controls is 29.0 ± 5.4 and 54.7 ± 10.5 years old, respectively. The western blotting quantification revealed significantly higher expression of neurotrophin GAP-43 and Trk-A in the KC bladder than that in the controls (table 1 and figure 1 ). The fibrogenic cytokine TGF-β also significantly increased in the KC bladder. The expression of GAP-43 in KC bladders was significantly correlated with TGF-β (r=0.714, p=0.001). The GAP-43 also was significantly correlated poor bladder compliance in urodynamic study (r=-0.548, p=0.022). The DAB immunochemical staining also revealed GAP-43 and Trk-A expression in the KC bladder urothelial cells and suburothelial tissue ( Figure 2 ). 

Current study used western blotting and revealed increased neurotrophin GAP-43 in the KC bladder. The expression of NGF was not increased, but its receptor Trk-A was upregulated in the KC bladders. It suggests increased neurotrophin activity might involve the pathogenesis of KC, but the detail mechanism is still unclear. The upregulation of TGF-β suggested it play an important role in the fibrogenesis mechanism of KC bladder. The expression of GAP-43 and TGF-β was significantly correlated, and GAP-43 also negative correlated with bladder compliance. The increased neurotrophin in bladder also might be associated with fbrogenesis in KC.

Neurotrophin and fibrogenesis cytokines TGF-β might play an important role in the pathogenesis of KC. Increased neurotrophin expression was correlated with the upregulation of TGF-β, and may be associated with fbrogenesis in KC. 

Hypothesis / aims of study Pelvic organ neural cross-sensitization has been reported to be involved in overlapped pain symptoms in chronic pelvic pain syndrome (CPPS) including bladder pain syndrome/interstitial cystitis (BPS/IC) and irritable bowel syndrome (IBS). It has been reported that rats with experimental colitis exhibit enhanced bladder pain sensitivity [1, 2] . Previous studies reported that transient receptor potential vanilloid-1 (TRPV1) receptors greatly contribute to the colon-to-bladder cross sensitization following colitis [1, 2, 3] . It has also previously shown that herpes simplex virus (HSV) vector-mediated gene delivery of poreless TRPV1, in which the segment in C terminus of TRPV1 receptor is deleted to suppress TRPV1 activation, or protein phosphate 1α (PP1α), which negatively modulates TRPV1 activation, had a therapeutic effect on TRPV1-mediated bladder overactivity and pain behavior in chronic cystitis rats. In the present study, we investigated the effect of gene therapy with HSV vectors encoding poreless TRPV1 or PP1α using a rat model of experimental colitis.

Replication-deficient HSV vectors encoding green fluorescent protein (GFP), poreless TRPV1 or PP1α were injected into the bladder wall of adult female Sprague-Dawley (SD) rats. One week later, following 24-hour-fasting, 2,4,6-Trinitrobenzenesulfonic acid (TNBS) (50mg/ml in 50% ethanol) or 50 % ethanol (vehicle) were administered into the distal colon through the anus (total volume 0.4ml each). Two weeks after viral injection, awake cystometry (CMG) was performed, nociceptive behavior such as licking (urethral pain) and freezing (bladder pain) induced by intravesical instillation of resiniferatoxin (RTX; 3µM for 1 min) was observed.

GFP expression was seen in L6/S1 DRG and in the bladder after HSV-GFP vector injection into the bladder wall. In CMG, the GFP + TNBS (GFP/TNBS) group showed a significant decrease in intercontraction intervals (ICIs) compared to the GFP + ethanol (GFP/EtOH) group (p<0.01). Then, the reduced ICIs in the GFP/TNBS group were significantly prolonged by 43.6% and 49.0% in poreless TRPV1 + TNBS (PL/TNBS) and PP1α + TNBS (PP1α/TNBS) groups (p<0.01), respectively ( Figure 1 ). The number of freezing behavior was significantly higher in GFP/TNBS group compared to GFP/EtOH group (p<0.01). It was then significantly reduced in both PL/TNBS and PP1α/TNBS groups by 87.3% and 87.2%, respectively, compared to the GFP/TNBS group ( Figure  2 ). In contrast, the number of licking behavior was not significantly different among these four groups.

Rats with TNBS-induced colitis exhibited bladder overactivity shown by reduced ICIs, which was ameliorated in colitis rats treated with HSV-poreless TRV1 or PP1α vectors. Freezing behavior representing bladder pain was significantly increased in TNBS colitis rats, which was significantly reduced by both poreless TRPV1 and PP1α vector treatments. These results indicate that experimental colitis induced by TNBS demonstrated both bladder overactivity and bladder pain symptoms, and those symptoms were significantly reduced by HSV vectors-mediated gene delivery of poreless TRPV1 or PP1α. The results of the present study also suggest that the activation of TRPV1 receptors in the bladder could be an underlying mechanism of bladder overactivity and enhanced bladder pain sensitivity, which are induced by colon-to-bladder cross organ sensitization in CPPS.

Concluding message HSV-mediated TRPV1-targeting gene therapy could be a novel and effective modality for the treatment of bladder pain and urinary frequency symptoms in CPPS patients who have overlapped symptoms of IC/BPS and IBS. 

Miyata Y 1 , Matsuo T 1 , Araki K 1 , Nakamura Y 1 , Yasuda T 1 , Ohba K 1 , Sakai H 1

Hypothesis / aims of study In the diagnosis of interstitial cystitis (IC), both the gross findings on cystoscopy and the histopathological findings on bladder biopsy play very important roles. In particular, the differentiation of non-Hunner type (N-type) and Hunner type (H-type) lesions is critical because the result sometimes affects patient prognosis. If the H-type, which is thought to be a more severe IC, is treated appropriately with electrical ablation, the treatment outcome with bladder hydrodistension alone would be insufficient. Although gross diagnosis has obvious limitations the use of simple and useful preoperative biomarkers to differentiate these different lesions has not been fully investigated.

Recently, reports have indicated the usefulness of inflammatory markers associated with disease severity and patient prognosis in the management of chronic inflammation diseases and malignant tumors. Thus, we investigated C-reactive protein (CRP) as an inflammatory marker for differentiation of N-type and H-type in IC patients.

This study included patients who were diagnosed with IC at our hospital between April 2007 and September 2016. They were divided into an N-type group and an H-type group according to the gross findings on intraoperative cystoscopy. Serum CRP levels were measured preoperatively were used to compare the 2 groups. In addition, the relationships between the presence of Hunner lesions and the Interstitial Cystitis Symptoms Index (ICSI), the Interstitial Cystitis Problem Index (ICPI), and serum CRP were evaluated.

Of 42 patients (13 men), with a mean age of 62.7 ± 10.7 years, the N group and H group comprised 15 (5 men) and 27 (8 men), respectively. The CRP levels were 0.04 ± 0.03 mg/dL in the N group and 0.16 ± 0.12 mg/dL in the H group; the difference was significant (P < 0.001). The ICSI-total score was 14.1 ± 3.8 in the H group, which was significantly higher than the 8.3 ± 3.6 in the N group (P < 0.001). The ICPI-total score was 12.4 ± 3.3 in the H group, which was also significantly higher than the 6.7 ± 3.1 in the N group (P < 0.001). Additionally, both the ICSI-total score and ICPI-total score were positively correlated with the CRP levels (ICSI-total score, r = 0.455, P = 0.003; ICPI-total score, r = 0.492, P < 0.001). Evaluation of the presence of Hunner lesions and the CRP levels with a receiver operating characteristic curve (ROC) showed an area under the curve (AUC) of 0.936. When the cut-off value for CRP was defined as 0.07mg/dL, the sensitivity and specificity were 92.6% and 86.7%, respectively, for the diagnosis of Hunner lesions.

Given the high level in IC patients with Hunner lesions, CRP may be a useful preoperative marker for their presence. In addition, CRP may also be associated with disease severity, and thus can be used to determine the therapeutic effect.

The preoperative serum CRP level, when combined with gross findings on intraoperative cystoscopy, may be a simple and useful predictive marker of Hunner lesions in patients with suspected IC. 

Hypothesis / aims of study Low energy shock wave therapy (LESWT) has been suggested to attenuate inflammatory condition and reduce somatic pain [1] .

Recently, several studies demonstrate that LESWT significantly improve pain, QoL, and voiding conditions in patients with nonbacterial prostatitis /CPPS comparison to the placebo treated group [2] . However, the mechanisms and molecular changes of LESWT on nonbacterial prostatitis /CPPS are still unclear. We hypothesize that LESWT can suppress inflammatory moleculars, and reduce the inflammatory condition and prostatic pain in the nonbacterial prostatitis. To our knowledgement, this is the first animal study to elucidate the effects and mechanisms of LESWT in a capsaicin induced nonbacterial prostatitis in rats.

Adult male S.D. rats were injected with vehicle or capsaicin (10 mM, 0.1 cc) into the prostate. Right after injection, various numbers of shock wave (0, 100, 200 or 300 shocks; 0.12 mJ/mm 2 ) were applied into the prostate. The nociceptive effects of capsaicin were evaluated for 90 min by using a behaviour approach. Behavioral changes following shockwave therapy were then scored every 30 minutes for 3 times 2 hours after recovery from anesthesia. We used a scoring scale of 1 to 5 as previous reported [3] . Blinded observers performed all experiments and each experimenter scored 2 rats in parallel.Three or seven days after LESWT, the prostate were removed for histology, COX-2, and TNF-ɑ expression by using immunohistochemical staining.

Capsaicin injection into prostate induced marked behaviour changes: including closing of the eyes and hypolocomotion, which were significantly decreased by LESWT (Fig. 1) . The eye open score increased in capsaicin group (3.25±0.34 vs vehicle 1.37 ± 0.08, p=0.0001) and significantly decreased after 100, 200 and 300 shockwave treatment (1.92±0.37; 1.46±0.14; 1.37±0.12, respevtively, p< 0.05 n=8 each group). Locomotion socres in all groups were lower after LESWT compared with capsaicin group but not significant in 100 shock wave group (3.46±0.39; 3.00±0.13; 2.13±0.18; 1.75±0.20, p<0.05, n=8 each group). Capsaicin induced inflammatory cells accumulation in prostate and significant higher COX-2, TNF-alpha positive stain cells compared with vehicle injection (Fig.2) . The capsaicin-induced prostate inflammation was dose dependently ameliorated by LESWT. On day 3 LESWT decreased COX-2(+) cell accumulation in 100, 200 and 300 shockwave groups (4.5%, 63.5%, and 54.9% reductions, repectively) (Fig. 2b) . The decrement was significant in 200, 300 shock wave group but not in 100 shock wave group ( p=0.002, 0.0046 and 0.757). The same result was observed at day 7 (Fig 2e) . The TNF-alpha cell(+) count increased with time (6.08±1.00 for day 3 and 26.78±8.36 for day 7 , Fig 2c, 2f) . L-ESWT also decreased the TNF-alpha(+) cells but was only significant at day 7 in both 200 and 300 shock wave group (p=0.028).

Interpretation of results LESWT decreased pain behaviour and reduce inflammatory conditions in capsaicin induced prostatitis. The effect of LESWT was dose and time dependent, which showed no significant effect at the dose of100 shock waves, but the inflammatory conditions and pain behaviour were significantly reduced at the dose of 200 and 300 shock waves.

Intraprostatic capsaicin injection activates COX2 and TNF-ɑ expression in the prostate and induces prostatic pain. LESWT could inhibit the capsaicin induced COX-2 and TNF-ɑ expression and inhibit prostatic pain and inflammation in a dose dependent fashion. This finding suggests a potential clinical benefit of LESWT at the optimal dose for the treatment of nonbacterial prostatitis. 

Lin C 1 , Lin A 1 , Yang A 1

Hypothesis / aims of study ketamine-induced cystitis (KC) are chronic inflammation with eroded urothelium, eosinophil infiltration, and neovascularization in the urinary bladder with resultant fibrotic change. Nevertheless, the exact pathogenic signaling pathway remains obscure and controversial. Recently, the microvascular injury in urinary bladder was reported in the patients with ketamine abuse. 1 This study is to investigate the pathogenic role of the mammalian target of the rapamycin (mTOR) activation in the ketamine induced microvascular injury.

Study design, materials and methods In human study, there were 23 patients with ketamine-induced cystitis (KC) and 16 control volunteers were recruited between September 2010 and August 2011. Bladder tissues were obtained from both groups by cystoscopic biopsies. Phospho-S6 ribosomal protein (p-S6RP), an end product of the mTOR pathway, was stained in the urinary bladder from both groups. Endothelial cells of the urinary bladder (HBdMECs) were examined by western blotting analysis of phospho-mTOR, phosphor-Akt, phospho-S6 ribosomal protein, and phospho-p70 S6 kinase to investigate the in vitro activation of the mTOR pathway. With reference to the clinical application and abuse dose of patients, concentrations of ketamine of 1, 10, 100, and 1000 μM (equivalent to 0.01, 0.1, 1, and 10 times the clinical plasma concentration) were selected as the administered dosages for endothelial cells in this study. 2 Double immunofluorescence stain were used for the co-expression of the endothelial marker [cluster of differentiation 31 (CD31)] and the mesenchymal marker [fibroblast-specific protein 1 (FSP-1)]. Rapamycin (100ng/ml), mTOR inhibitor, was applied with ketamine treatment for blocking the activation of mTOR pathway. Differences in immunohistochemistry staining between the KC and control groups were analyzed by means of the Mann-Whitney U test, with comparisons of HBdMECs between groups analyzed using a one-way analysis of variance (ANOVA) followed by post hoc comparisons using the Bonferroni method.

Expression of p-S6RP increased significantly after ketamine exposure more in the vesical microvessels of KC patients (2.26 ± 0.14) than in control volunteer (0.50 ± 0.18). (Table 1 ) In HBdMECs treated with 100 μM Ketamine, time-dependent activation of the mTOR pathway occurred, with significantly increased levels of the phosphorylated forms of mTOR at 30 min and of S6RP and p70S6 kinase (p70S6K) at 6 h. The increased level of p-S6RP returned to baseline within 2 days after ketamine exposure. (Figure 1 ) The co-expression of CD31 and FSP-1 implied that EndMT was present in HBdMECs at 7 days after ketamine treatment. Furthermore, when the mTOR inhibitor rapamycin was administered with ketamine to the HBdMECs, the expression of FSP-1 decreased significantly.

The expression of phosphorylated S6RP was presented more significantly in KC patients. Cultured HBdMECs embedded with ketamine showed activation of mTOR pathway. The co-localization of CD31 and FSP1 in the endothelial cell of urinary bladder showed positive finding of EndMT.

Ketamine induces activation of the mTOR pathway and subsequent mesenchymal phenotypic expression (FSP1) in HBdMECs 

Hypothesis / aims of study Urinary bladder fibrosis is a consequence of various chronic inflammatory conditions (e.g. ketamine, radiation and interstitial cystitis) as well as aging. Increased fibrosis is an underappreciated factor in the aetiology of underactive bladder (UAB) as it will decrease contractile performance and voiding efficiency, as well as decrease bladder compliance and bladder capacity. Concurrently, the increased passive bladder wall tension during filling, due to reduced compliance, may potentiate stretch-evoked ATP release which can increase sensory nerve outflow. The combination of these effects could explain why patients with UAB also experience symptoms associated with bladder overactivity (OAB). Our aim was to utilise a mouse model of chronic radiation cystitis as a surrogate for fibrosis-induced UAB and determine its effects on bladder wall compliance and stretch-evoked ATP release.

Study design, materials and methods Selective bladder irradiation: Adult female C57Bl/6 mice (six weeks of age) were used for this study and subjected to selective bladder irradiation. Briefly, mice were anesthetised with avertin (2,2,2-tribromoethanol, 300 mg/kg, IP) and a small incision was cut into their lower abdominal wall to expose the bladder. A suture was tied to the urachus after which the mice were placed sideways on a Lexan platform, allowing the organ to be held outside the abdominal cavity by the suture during irradiation. The mice on the platform were placed in an X-RAD 320 biological irradiator (Precision X-Ray) and the collimator and table height adjusted to focus the irradiation beam on the exposed organ. An irradiation dose of 10 Gray (1 Gy = 100 rads) was delivered, the organ returned to the abdominal cavity and the incision was sutured closed. Mice were used for experiments 12 weeks following irradiation. Age-matched non-irradiated animals were used as controls.

Isolated bladder sheet tension recordings and ATP measurements: Mice were humanely sacrificed and the bladders isolated. Bladders were cut along the ventral midline to form sheets approximately 8 mm long and 3 mm wide. Preparations were mounted in a temperature controlled recording chamber and connected to a tension transducer in line with a computer controlled stepper motor to implement stretch protocols. Bladders were superfused with a modified Tyrode's solution gassed with O2/CO2 (95%/5%) and maintained at 36 ± 0.5°C. Tissues were stretched by 500 to 1500 µm at a rate of 10-100 µm/s and the stretch was held for five minutes before returning to baseline. During maintained stretch, 100 µl superfusate samples were taken from the proximity of the mucosal surface and ATP concentrations were measured in a luminometer (Promega) using a luciferin-luciferase based assay. The biomechanical properties of the mouse bladder were determined as magnitudes of steady-state tension (E1), transient tension (E2) and τ (tau), the time constant for the relaxation phase of E2 ( Figure 1A) ; tau was measured from an exponential fit to the transient section of the tension recording after stretch. These parameters were determined for each stretch protocol. Data are mean±SD, n=number of mice. Differences between data sets were tested by Student's t-test, the null hypothesis was rejected at p<0.05.

Chronic radiation cystitis resulted in stiffer bladders as shown by the increase of steady-state passive tension (E1) on stretch ( Figure 1B ). The magnitude of the transient component (E2), equivalent to stress-relaxation, was unchanged in the irradiated bladders. However, the rate of decline of stress-relaxation was significantly slowed, as shown by a greater value of the relaxation time-constant, tau ( Figure 1C ). Overall, radiation cystitis generated a less compliant bladder wall that also relaxed more slowly after a stretch. The change of biomechanical properties with bladder irradiation was mirrored by a greater release of ATP during the stretch protocol ( figure 1D ).

Chronic radiation cystitis results in decreased bladder compliance and poor contractile function [1] with excessive deposition of extracellular matrix. These changes are reflected in the altered biomechanical properties of greater stiffness and slowed stress relaxation. Furthermore, the changes to passive stiffness were accompanied by greater stretch-induced ATP release. Such ATP release is postulated to underlie activation of afferent nerves in the bladder wall [2] and such enhanced release would result in greater sensations of urge, and even urgency on filling.

Concluding message Chronic inflammation within the lower urinary tract can result in tissue fibrosis which adversely affects bladder storage and voiding functions. Furthermore, increased bladder wall tension enhances stretch-evoked ATP release and potentially sensory nerve activity. Bladder fibrosis and the consequent increase in basal ATP release may be a contributing factor to the OAB-like symptoms in UAB.

A 

Hypothesis/aims of study Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a multifactorial chronic inflammatory disease characterized by suprapubic pain, discomfort, urgency and excessive urinary frequency, which profoundly impairs patient's quality of life. Despite efforts to understand the etiology of IC/BPS, this condition remains poorly understood, and therefore no fully effective treatment has been developed to date [1] . Changes in innate immune function contribute to the onset and progression of numerous chronic inflammatory diseases, and toll-type receptors (particularly TLR4) are fundamental in this process [2] . However, there are still no studies in the literature addressing the contribution of TLR4 receptors in IC/BPS. The aim of the present study was to investigate the contribution of TLR4 signaling pathway in the development of cyclophosphamide (CYP)-induced cystitis.

Study design, materials and methods Ten to twelve-week old C57BL/6 (wild-type, WT) and/or TLR4 knockout (TLR4 -/-) male mice (20-25 g) were treated with a single intraperitoneal injection of CYP (300 mg/kg) or saline (5 mL/kg, control), and studies were performed at 24 h after injection 3 .

Measurements of TLR4, TRIF and MyD88 mRNA expression were determined by RT-PCR. For micturition pattern analysis, mice were placed in cages individually and urine output was collected for 3 h ours on filter paper covering the cage bottom, photographed under UV light and analyzed to identify the surface area of individual spots and volume, and calculated based on a calibration curve. Cystometry was performed in urethane-anesthetized mice. Briefly, bladders were filled at a constant rate (0.6 mL/h) and intravesical pressure was recorded for 45 min. Results are expressed as mean ± SEM of a number of experiments (n). Comparisons among the groups were evaluated using Student's t test and one-way ANOVA followed by Bonferroni's post hoc analysis (for multiple comparisons).

As seen in figure 1 , in isolated bladders of WT mice RT-PCR analysis for genes activated by TLR4 pathway revealed in CYP injected mice a significantly increase (P<0.05) of TLR4 itself and its downstream adaptor proteins MyD88 and TRIF (P < 0.05). In WT mice, micturition pattern analysis showed a marked increase in the number of spots and a reduction of micturition volume in CYP-injected mice (9 ± 1.7 spots and 328 ± 38 µL) in comparison to saline group (2.4 ± 0.5 spots and 779 ± 56 µL). TLR4 deletion significantly reduced the number of spots (3.5 ± 0.9 spots, P<0.05 in relation to CYP-injected WT mice) but had no effect in volume (262 ± 90 µL). Cystometric studies showed significant changes in several micturition patterns in CYP-injected WT mice compared to saline, including bladder capacity, micturition interval, voiding frequency and NVCs frequency, all of which were prevented by TLR4 deletion (Table 1 ). Interpretation of results Administration of CYP caused pronounced urinary bladder inflammation and overactivity, which was accompanied by an upregulation of TLR4 signaling pathway. TLR4 deletion prevents significantly these alterations and ameliorates bladder dysfunction.

Concluding message TLR4 signaling pathway activation mediates inflammation and bladder dysfunction in CYP-induced cystitis and may provide a potential therapeutic target for IC/BPS. 

There is not enough evidence to conclude the efficacy of BTX-A for the treatment of interstitial cystitis to improve quality of life.

Hypothesis / aims of study One in two women experience urinary tract infection (UTI) at least once in their lifetime, and after menopause one in four women with UTI develop recurrence. Treatment for UTI primarily centers on antibiotics which target uropathogens. Of the approaches that leverage host defense factors, topical estrogen administered transvaginally has been shown to reduce UTI in randomized controlled trials. To hone in on estrogen's effect on the bladder urothelium [1] in vivo, we created a mouse model with overexpression (OE) of estrogen receptor β (ERβ) restricted to the urothelium (uERβ-OE + ). We hypothesize that uERβ overexpression facilitates recovery form UTI, and we aim to ascertain whether female uERβ-OE + mice demonstrate faster bacterial clearance when challenged with uropathogenic E. coli (UPEC).

Study design, materials and methods A transgenic uERβ-OE + mouse line was created by linking the urothelium-specific uroplakin II (UPII) promoter to the ERβ gene ( Figure 1 ) utilizing a C57BL/6 genetic background. Female 4-6 month-old uERβ-OE + mice were compared to female age-matched wildtype (WT) and negative, non-transgene carrying (uERβ-OE neg ) littermates in this study. Urinary tract infection was simulated using transurethral inoculation of UPEC (clinical isolate UTI89) at a dose of 1 x 10 8 colony forming units (CFU) in 50 µL of phosphate buffered saline (PBS) administered intravesically under anesthesia using established protocol [2] . Urine specimens were collected 1, 2, 3, and 4 days post UPEC inoculation and plated on agar in serial dilution to determine bacterial load. After the last urine collection on Day 4, mice were euthanized, and their bladders and kidneys were harvested, homogenized, and plated for bacterial count. 

Bladder urothelium was isolated from bladder mucosa using our unique dissection technique [3] , and urothelial expression of ERβ ( Figure 2A ) was shown to be significantly increased in uERβ-OE + mice on reverse transcription of urothelial ribonucleic acid (RNA) and quantitative polymerase chain reaction (qPCR) analysis. In addition, overexpression of ERβ was shown to be specific to the urothelium, given the absence of differential ERβ expression in other bladder tissues or other organs ( Figure 2B ) from uERβ-OE + mice as compared to those from wildtype. Histologic examination showed no significant differences in bladder urothelium or stroma among the three cohorts. 

Increased urothelial ERβ expression confers significant protection against UPEC.

The uERβ-OE + murine model serves as a valuable new tool to identify pathways to be harnessed for future UTI treatment paradigm, without the direct use of antibiotics or estrogen. 

Hypothesis / aims of study Multiple sclerosis (MS) is the commonest disabling neurological disease affecting younger adults. Neurogenic bowel dysfunction (NBD) occurs in 50-80% of these patients and is the term used to describe constipation and faecal incontinence which often coexist. A pragmatic randomised controlled trial aimed to determine the effectiveness of abdominal massage in the management of NBD. This qualitative process evaluation nested within the trial aimed to capture the experiences of those participating in the intervention.

The main study was a parallel group multicentre randomised controlled trial. People with MS who had reported constipation symptoms as being bothersome and had no confounding 'red flags' e.g. rectal bleeding, were invited to take part. Following randomisation, a purposive sample of 20 participants from the intervention group were recruited to reflect a variety of characteristics; different types of multiple sclerosis and various stages of disease progression; a range of age groups, with different lifestyles (e.g. some employed, others retired or unemployed due to ill health); drawn from half of the twelve sites involved in the trial (see table 1 ). Table 1 Serial semistructured telephone interviews were conducted at four weeks post-enrolment in the trial and again at the end of the trial (at twenty-four weeks). Interviews explored: expectations about the treatment; motivations for taking part in the trial; experiences of taking part in the trial, whether they felt the treatment worked for them and their post-trial intentions. Each interview was transcribed and thereafter analysed in QSR NVivo (v10) informed by the framework approach. Reliability and credibility was ensured by frequent discussion of emerging themes/coding between two of the authors (SD & FH) as well as further expertise being contributed by the wider AMBER team.

Participants spoke of the impact that bowel dysfunction has on the quality of their lives. For those with more severe problems, it could lead to social isolation because potential faecal incontinence made them reluctant to leave home. For others, persistent constipation led to fatigue, bloating and in extreme cases required hospitalisation. Coping strategies included reducing food intake or limiting meals to only certain times of day in order to try to control symptoms and for many participants bowel problems were a constant source of anxiety. The most common motivator for taking part in the AMBER trial was thus the need to eradicate or reduce current bowel problems and to gain personal control over their lives.

Part of the appeal of the massage was that it did not involve additional medication and many participants were hopeful that abdominal massage might offer an alternative to the use of laxatives which could lead to unpredictable bowel movements and 'accidents'. However, there was also a degree of scepticism about the likely benefits of undertaking the abdominal massage and for these participants, the motivation to take part was altruistic, wanting to give something back to the NHS.

Three-quarters of the patients interviewed felt the treatment had some positive impact on their bowel problem and expressed intent to continue with it at the end of the trial. The main improvements reported by these patients were around visiting the toilet more frequently and with more ease and/or being able to stop other forms of treatment such as laxatives. On the other hand, four patients perceived a lack of impact with the treatment. In both of these groups there was a mixture of those who expected improvement at the outset and of those who were sceptical. Several who stopped doing the massage for personal reasons noticed a reversal in any improvements.

A number of the patients who had a reduction in constipation symptoms also reported additional benefits such as reduced anxiety, feeling less fatigued, and improved eating and sleep patterns. Another unanticipated benefit was shared intimacy where a partner assisted with the massage. Although four patients did not perceive any direct benefit from the massage, nevertheless they remained in the trial and reported feeling some benefit from the additional support provided by the regular supportive telephone calls from the research nurses. No one reported disappointment in taking part in the study and those who experienced symptom improvement reported an intention to continue with the massage in future.

Bowel dysfunction can have a detrimental effect on the quality of life of people with MS, to the extent that it may be a constant source of anxiety and may lead to social isolation. Self massage is one way that patients can gain back some control over their lives, whether this leads to active reduction of symptoms or not. This self-management strategy may offer a means to take personal control that does not involve medications that may have adverse side effects. While it may not benefit all participants, it does not cause harm. 

Hypothesis / aims of study Multiple sclerosis (MS) is the commonest disabling neurological disease affecting younger adults. Neurogenic bowel dysfunction (NBD) occurs in 50-80% of these patients and is the term used to describe constipation and faecal incontinence (FI) which often coexist with MS. A pilot study of 30 people with MS found benefits with an intensively supported programme of abdominal massage (weekly home visits by a nurse)(1). We undertook a pragmatic randomised controlled trial (RCT) to determine clinical and cost-effectiveness of abdominal massage in the management of NBD with fewer supervised sessions which may be deliverable within existing United Kingdom national health services.

This was a parallel group multicentre RCT. People with MS who had reported constipation symptoms as being bothersome, and had no confounding 'red flags' e.g. rectal bleeding, were invited to take part. Participants (and a carer if assisting with massage) in the intervention group were randomised to a one-to-one session of instruction on abdominal massage. They were provided with training materials demonstrating the technique including a video and written/diagrammatic information, and were given a lifestyle advice leaflet for the alleviation of symptoms of constipation. Participants in the control group were also seen once when the advice leaflet alone was provided. During the six weeks of intervention, all participants were telephoned weekly and offered support regarding abdominal massage (intervention group) and discussion of lifestyle changes (both groups).

Randomisation was by computer allocation using a remote randomisation service. Minimisation variables were: centre, disability level of the participant (walking unaided, aided, wheelchair). A daily bowel diary was completed a week prior to randomisation, during the whole six weeks of treatment and during week 23. A diary recording the massage undertaken was also completed by the intervention group participants. Questionnaires were administered at baseline, 6 and 24 weeks post-randomisation. The primary outcome was the Neurogenic Bowel Dysfunction (NBD) Score (2), a clinician-administered questionnaire validated in spinal cord injured patients, at 24 weeks. The NBD score is a 10 item questionnaire covering: frequency of bowel movements; headache, perspiration or discomfort during defaecation; medication for constipation; time spent on defaecation; frequency of digital stimulation or evacuation; frequency of FI; medication for FI; flatus; and perianal skin problems. The NBD score ranges from 0 to 47; scores over 14 are considered severe. Secondary outcomes included a bowel diary, constipation scoring system (3), adherence to the intervention, bladder function and quality of life (EQ-5D-5L) (4). A process evaluation was undertaken alongside the trial. Analysis was by intention-to-treat. NBD scores were compared between trial groups using repeated measures mixed models with adjustment for gender, minimisation variables and (if applicable) baseline measurements. A sample size calculation (using a 5% level of significance (two-sided), 90% power and allowing for 20% dropout. indicated a trial of 150 was necessary to detect a difference in the primary outcome measure of 4.2. The funders recommended this was increased to 200 to allow for higher attrition. We report here results of the analysis of the primary outcome measure.

In total 191 participants were randomised, of which 189 provided data (2 participants withdrew immediately post-randomisation).

The trial group characteristics were well-balanced at baseline. Mean age was 52 years (SD 10.83 years). Most participants were able to walk unaided (n=79, 41.8%) or with a walking aid (n=89, 47.1%), the remainder using a wheelchair (n=21, 11.1%). The majority were female (n= 154, 81.5%). Massage was self-administered in 84% (n=73). At 24 weeks 71% (n=51) were continuing with the massage, all except one of whom were undertaking self-massage, with 80% (n=44) reporting that they felt a benefit. The response rate for the NBD score at 24 weeks was 81% (n=153).

There was no significant difference between the intervention and control groups in the NBD score at 24 weeks ( 

p-value 0.0558 *Adjusted for centre, sex, level of disability and baseline. Centre was used as a random coefficient

There were 10 serious adverse events requiring hospitalisation but none were related to the abdominal massage (3 MS relapses, one myocardial infarction 1 myocardial infarction, 3 infections, 3 falls).

There is weak evidence of a small effect (<2 units on NBD scale) at week 24 and many participants continued to self-massage. However, the 95% confidence interval of -3.3 units rules out the minimally important clinically difference of 4.2 that we originally estimated.

Concluding message From the preliminary analysis of the data a home programme of abdominal massage may offer a small reduction in some of the symptoms of neurogenic bowel dysfunction in patients with multiple sclerosis. Analysis of the other outcomes is underway and may offer further insights. 

Hypothesis / aims of study Fecal incontinence (FI) occurs in 3% to 46% of residents in nursing homes and hospitals (1); in the overall population, the prevalence of FI is probably 7.2 to 10.% (2). FI is common in patients with acquired brain injury (ABI): few studies have been carried out, but prevalence has been reported as 68% acutely and 5% at one year. While there is evidence that FI affects global outcome, to date, no data are available from clinical studies that were specificallydesigned to evaluate FI as a predictor of discharge settings after inpatient rehabilitation.

Retrospective evaluation was made on 546 patients, admitted consecutively to a Neurorehabilitation Unit following ABI, between January 2000 and December 2013, of whom 382 were male and 164 female, with an average age of 46.8±19.3 years. Patients who presented associated spinal cord injury (11 patients) were excluded, as were those with previous faecal or anal incontinence (4 patients). Data were collected from electronic medical records and supplemented with chart review. The rehabilitation programme for these patients includes the provision of optimal nutrition, control of infections, management of bladder, bowel and autonomic disorders, provision of specialist seating and control of posture and tone problems. Patients underwent one hour of physical therapy treatment and one hour of speech therapy every day, to prevent tertiary injury. Rehabilitative treatment involved passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table.

All the patients were evaluated upon entry as to their bladder and bowel voiding, combining clinical observations with items specific to related activities contained within the Functional Independence Measure (FIM). The discharge setting from neurorehabilitation was verified, seeking any correlatable factors such as the pathogenesis of the ABI, Level of Cognitive Functioning Scale score (LCF) (3) at admission and at discarge, site of the encephalic lesion, occurrence of paroxysmal sympathetic hyperactivity, presence of pelvic girdle fractures, duration of tube feeding, fecal incontinence at admission, incidence since the acute event of healthcare-related infections, in particular Clostridium Difficile infections.

Fecal incontinence was present in 448 patients (84.4%) on admission. This can be correlated particularly with the presence of frontal lobes lesions (n=210, 39.7%), the occurrence of paroxysmal sympathetic hyperactivity in the acute phase (n=103, 19.4%), and pelvic girdle fractures (n=57, 10.7%). On discharge, anal or fecal incontinence was present in 274 patients (52%) and its persistence as a function of the variables analysed in the logical model can be correlated to the presence of frontal lobes lesions caused by high kinetic impact (p<.0001, OR 33.83), the persistence of paroxysmal sympathetic hyperactivity in the rehabilitative phase (p<.0001, OR 2.08), and to the LCF score < 5 upon discharge (p<.0001).

On discharge, the incidence of anal or faecal incontinence is lower than the overall average (103, 34% vs. 52%) in patients discharged to their homes (n=302); for those discharged into long-term care (n=109), the incidence of faecal incontinence is above average (95, 87% vs. 52%); the pattern is similar for transfers to Vegetative State Unit (n=31, 94% vs 52%). All of the above findings are statistically significant (p<.05).

New-onset faecal incontinence is a frequent outcome of serious ABI, particularly concomitantly with the presence of frontal lobes lesions and with long-term persistence of paroxysmal sympathetic hyperactivity; there is apparently no significant correlation with the duration of enteral feeding, the presence of healthcare-related infections, or the presence of faecal incontinence on admission. Therefore, it seems to correlate predominantly with the severity of the brain damage and its presence determines the type of setting after discharge.

These data confirm the importance of introducing the management of neurogenic bowel dysfunction into rehabilitative treatment during the intensive rehabilitation phase following brain injury. 

Hypothesis / aims of study Volitional control of defecation is complex and information on central mechanisms controlling defecation in humans is sparse. Functional connectivity (FC) based on coherent fluctuation of blood oxygenation level (BOLD), allows identification of functional networks in the brain and has been used to examine state-dependent activity. We have recently identified and reported brain regions that are activated or deactivated with defecation, using tasked-based fMRI with simulated defecation. Here, we Hypothesis that there is a consistent pattern of functional connectivity (FC), in the brain between these areas, when performing simulated defecation. We aimed 1) to investigate functional connectivity in the human brain when performing this task, 2) to quantify connections between regions of interest and 3) to express their importance of facilitating flow of information.

We performed fMRI with concurrent rectal pressure monitoring, through a 30 ml water-filled rectal balloon, in 11 healthy women. A block-design was used (20 seconds simulated evacuation (bear-down manoeuvre) interspersed by 20 seconds rest, 5 repetitions performed twice). FC was calculated with the CONN connectivity Matlab toolbox (version 15h) for brain regions identified in the SPM atlas. Areas with highest betweenness centrality, a measure of information flow, were identified (p<0.05). An explorative hierarchical cluster analysis yielded six brain sub-networks working together to accomplish the defecation process.

The following areas: left frontal pole, left post-central gyrus, left posterior supra-marginal gyrus, right hippocampus, sub-callosal cortex, left posterior parahippocampal gyrus, right putamen, vermis, precuneus and regions in the brain stem showed the highest betweenness centrality ( figure 1A ). Besides the cerebellum (n=157), other areas in brain that showed the largest number of connections ( figure 1B) 

Areas with highest information flow, i.e. hubs for FC, were recruited from cortical brain regions indicated in procession memory, executive function, self-expression and the motor system. Subcortical areas included a defecation centre located in the brain stem. Regions with largest number of connections reflected their importance as centres of information flow. Identified subnetworks included parts of the frontal-parietal attention network (1), the thalamo-insular network (4) and other connections between the motor network and regions with high anatomical connectivity (5, 6).

Concluding message This is the first study to show that defecation activated neural networks maintain a consistent pattern of functional connectivity. We confirmed that combined fMRI and rectal pressure monitoring can study mechanisms of regulation of simulated defecation in humans. This could further be used to provide unique information on the pathophysiology of defecatory disorders. No association were found between fourth-degree perineal tears and the use of forceps (10% in forceps and 11.1% in normal vaginal deliveries). We also found no association between the use of midline episiotomy and fourth-degree perineal tears (midline episiotomies were performed in 15% of third-degree perineal tears and in 13% of fourth-degree perineal tears). Episiotomy was not performed in 38% of OASI, both in third and fourth-degree perineal tears. Anal continence was referred in 98.7% of patients at 6 months. Levator ani muscle avulsion in patients with OASI was less than 18%.

Although forceps delivery and midline episiotomy have described as risk factors for OASI we did not find any associations between fourth-degree perineal tears with forceps delivery and the use of midline episiotomy.

The increase in the diagnosis of less severe perineal tears (IIIa and IIIb) and, in turn, the high percentage of asymptomatic patients, could be associated with increased training of professionals on anal sphincter tears. On the other hand, the rate of avulsions in our population is lower in comparison to available literature. 

Hypothesis/aims of study Obstetric anal sphincter injury (OASIS) is the most common cause of anorectal symptoms in women. Despite immediate recognition and primary surgical repair with adequate protocols, there are known long-term sequelae. Little is known from prospective studies on the effect of a second vaginal delivery on the injured sphincter. The aim of our study was to evaluate the effect of a subsequent delivery in women with OASIS on pelvic floor and anorectal symptoms and on 3D transperineal ultrasound findings.

Study design, materials and methods This is an update from a prospective longitudinal follow-up study of women who sustained OASIS. The enrollment and follow up visits included an interview, standardized pelvic floor questionnaire, Cleveland Clinics Incontinence Score questionnaire (CCIS), and 2D/3D transperineal pelvic floor ultrasound (GE Kretz Voluson 730, E8, E6, E10). The ultrasound evaluation included pelvic organ mobility, levator assessment, and sphincter measurements and characteristics. Women were counseled for a repeat mode of delivery based on reported symptoms and objective clinical and ultrasound findings during the third trimester. Questionnaires and ultrasound datasets were analyzed offline (4DView) and compared over time. Statistical analysis was performed with SPSS. A p-value<0.05 was considered statistically significant.

Out of a prospective cohort of 671 women who sustained OASIS, 274 women have been seen repeatedly. Among them there were 106 women who had a repeat delivery and a repeat visit during the follow-up period, consisting of a median overall followup time of 77 months (21-145) from the delivery with OASIS. Median time to first exam, second exam and in between exams was 3, 29, and 21 months respectively. The original OASIS classification included 24 -3A tears, 6 -3B, 5 -3C, 9 -4 th degree tears, and 62 grade 3 tears in the era before tear sub-classification. The mean age was 28.1±4.4, BMI 23.4±4.1, 80% were primiparous. 28 women had a repeat normal vaginal delivery (NVD group) and 78 women had an elective cesarean section (ECS group). Two women had more than one repeat NVD, 3 women were scheduled for an ECS but arrived with precipitous labor and were delivered vaginally. Of the women who had an NVD there were previously 3A -11, 3B -2, 3C -1, 4 -1, 13 unclassified. 1 woman after a previous 3C tear sustained a repeat 3C tear. Demographic data, symptoms, and sonographic findings of the women are described in Table 1 . There were no significant differences between the groups in demographics and pelvic floor symptoms. Women in the ECS group had more severe anorectal symptoms and worse findings on sphincter analysis, all of which were considered in the original pre-labor counseling. Levator area was smaller in women who underwent ECS but this did not reach significance. For the 28 women who had NVD we compared findings from first and last follow-up visits, and these are described in Table 2 : Following a repeat NVD there was a trend towards thinning of the residual sphincter width with an increase in the defect angle but this was not associated with worsening of symptoms. Interpretation of results: This ongoing prospective study shows the evolution of symptoms and sonographic signs in women who sustained OASIS and had a repeat delivery. We did not observe more severe symptoms in women who were preselected for NVD. Women who underwent ECS had more severe symptoms, which we took into account during pre-labor counseling. Our findings highlight the need for adequate counseling before repeat delivery in women with OASIS preferably in a dedicated perineal clinic.

Women who sustained OASIS should be prospectively followed and counseled before each subsequent delivery. The preferred delivery mode should be tailored based on symptoms, clinical status, ultrasound findings, and patient needs. (1). Despite the increasing prevalence of OASIS, there is still a lack of robust evidence for the optimal mode of delivery in future pregnancies. A number of algorithms based on bowel symptoms, endoanal ultrasound and anal manometry have been proposed to guide future mode of delivery (2, 3) .

The objectives of this study were to assess the clinical value of the proposed diagnostic tools and the performance of different algorithms in counselling women about future mode of delivery after sustaining an OASIS.

Study design, materials and methods Prospective data were collected from a teaching hospital's perineal clinic over a 5-year period. Women undergoing endoanal ultrasound scan and anorectal manometry investigations were included in this study, which based on the current hospital protocol were all symptomatic 3a or any 3b, 3c or 4 th degree OASIS. Bowel symptoms were assessed using the validated Pescatori anal incontinence questionnaire. Endoanal ultrasound evaluated external anal sphincter (EAS) and internal anal sphincter (IAS) defects. Sonographic sphincter defects of more than 30 degrees were considered significant. Manometry studies recorded maximum anal sphincter pressures at rest and during squeeze. A difference of less than 20mmHg between these two values was considered an abnormal result. We theoretically applied a number of different published management algorithms to our cohort, to determine their impact on recommended future mode of delivery.

Out of 1002 patients who were reviewed in the perineal clinic, 233 went on to have further investigations and were therefore included in this study. Out of the 233 women, 51 were symptomatic for anal incontinence, while 182 were asymptomatic. The results of the investigations in our cohort are summarised in figure 1.

One asymptomatic and five symptomatic patients were found to have isolated IAS defects without concomitant EAS defects. There were no patients who had a low resting pressure (<40mmHg) with a normal increment on squeeze (>20mmHg).

If symptoms alone were used to determine future mode of delivery, 51 out of 233 (21.9%) would be recommended caesarean section (CS). Interpretation of results The presence of isolated IAS defects affected only 2.5% of patients and would have an impact in the management of only 2% of women. A low resting pressure had no impact on the management plans as all of those women also had low increase on squeeze and therefore would have already been identified as having abnormal manometry.

Different management algorithms resulted in very different recommended caesarean section (CS) rates. By applying proposed algorithms to our cohort we can see that the presence of symptoms has little impact on the recommended mode of delivery when abnormal endoanal ultrasound scan or manometry studies lead to recommendation for CS, changing the management plan in only 4% of the cases (85% vs 81%) (81% recommended caesarean in the asymptomatic group, vs 85% in the symptomatic group).

The number of patients recommended to have CS after OASIS varies from 22% to 85% depending on the used management algorithm. The additional value of isolated IAS defect and low resting pressure is minimal. Prospective studies validating proposed algorithms are urgently required. 

Hypothesis / aims of study: To evaluate a new service experience & the rate of Obstetric Anal Sphincter Injuries (OASIS) with the use of Episcissors at instrumental deliveries.

A total of 179 instrumental deliveries were performed between December 2016 & February 2017. Episcissors was used in 67 cases, standard episiotomy pack scissors were used in 98 and in 14 cases no episiotomy was performed. Of the cases where episcissors were used, the following is a breakdown of the type of deliveries; 13 Ventouse/Kiwi deliveries, 49 Neville Barnes Forceps (NBF) deliveries, and 4 double instrument deliveries. Cases were collected from the delivery registrar. An audit proforma was completed to evaluate the rate of OASIS, which included information on grade of operator, type of instrumental delivery, location (room/theatre) & degree of perineal trauma sustained.

With the use of episcissors, no 4th degree tears sustained over the three month period. One 3b tear was sustained with the use of episcissors for a NBF delivery. This is compared to 4 women who sustained OASIS in the same time period, all delivering by NBF. Two of these women had no episiotomy performed and sustained a 3b and 3c degree tear. In the remaining two cases, episiotomy was performed; episcissors were not used. Both of the patients sustained a 3b tear to the perineum. The overall impression of operators was that the scissors definitely helped with keeping the angle of episiotomy fixed in the safe 40-60 degree range and were easy to use.

There was one incident of OASIS with the use of episcissors in the three months studied. This compares with two incidents of OASIS with the use of standard episiotomy pack scissors. The data appears supportive for the use of episiotomy in instrumental deliveries, confirming that it reduces the number of tears sustained, however the time period chosen was short and hence a small number of patients were audited with the use of episcissors.

This highlights the need for training and education of medical and midwifery staff in the use of episcissors to further evaluate its effect on OASIS. We aim to introduce & evaluate the use of episcissors for all deliveries, instrumental and non-instrumental, in reducing the rate of OASIS. Additionally this data supports the advantage of a safe 60 degree angle of episiotomy from the midline in decreasing OASIS. A larger prospective trial is needed to substantiate these initial results. 

Hypothesis / aims of study The postpartum period is known to be a at risk for urinary (around 20%) or fecal incontinence (around 5%). More and more pregnant women ask for a personalized information about their own postpartum risk and what can be done to prevent it (including caesarean section). Two predictive models have been developed by Jelovsek to predict urinary and fecal postpartum incontinence in nulliparous women [1] , but they are not validated in another population. Our aim was to compare the prediction of incontinence computed by these models [1] and the prevalence observed in a sample of pregnant nulliparous women included in a longitudinal study [2] . We also performed an analysis to identify the antenatal factors of postnatal urinary incontinence in our longitudinal data.

The two prenatal models developed by Jelovsek use information about maternal age, race, urinary incontinence before pregnancy, urinary incontinence during pregnancy, prepregnancy BMI, predelivery BMI, and planned mode of delivery to calculate postnatal urinary and fecal incontinence risks [1] . Our sample was from a randomized trial on prenatal pelvic floor muscle training [2] ; 282 nulliparous women were included before 29 weeks of gestation and followed at 12 months postpartum (192 women). All data needed to compute models, except race, were available. Additionally, we had collected at inclusion information about pelvic organ prolapse (Aa, gh, and pb measures according to POP-Q), pelvic floor strength, and ultrasound bladder neck descent during Valsalva [3] . We calculated the postnatal incontinence risks for each woman included assuming a racial value carrying the highest risk (Asian). Calculated risks were divided into 4 increasing categories (5-29% / 30-59% / 60-89% / 90-99%) and compared to the prevalence observed at 12 month postpartum. ICIQ-UI SF score was used to define urinary incontinence severity (no incontinence if score = 0; slight if 1-5; moderate if 6-12; and severe if 13-21) and Australian Pelvic Floor Questionnaire to define fecal incontinence. We performed a multivariate logistic regression to identify antenatal factors associated with urinary incontinence at 12 months postpartum.

At 12-month postpartum, among the 15 women with an anticipate risk of fecal incontinence of 60% or higher, none reported fecal incontinence; Among the 146 women with an anticipate risk of faecal incontinence <60%, 5 (3.4%) reported some degree of fecal incontinence (Table) . Table: Comparison between calculated risk and incontinence reported at 12-month postpartum Multivariate logistic analysis identified only 3 factors significantly related to 12-month urinary incontinence: predelivery BMI, point Aa position at inclusion, and urinary incontinence during pregnancy. The logistic model had c-index (area under the receiver operating characteristic curve) of 0.79.

Misclassification observed between prevalence reported and calculated may be explained by the role of delivery in incontinence occurrence. However, antenatal models and models including labor and delivery characteristics developed by Jelovsek to predict postnatal incontinence, had a similar accuracy with a c-index of 0.69 versus 0.68 for urinary incontinence and 0.67 versus 0.68 for fecal incontinence [1] . It seems that considering some antenatal pelvic floor measure, as point Aa, may increase prediction accuracy [3] .

Using a prognostic model to predict postnatal incontinence leads to a substantial risk of misclassification, clinical implementation cannot be recommended. New efforts should be done to find new biomarkers to improve model's accuracy. 

Hypothesis / aims of study Sacral nerve stimulation (SNS) is an effective treatment for patients with severe faecal incontinence refractory to conservative treatments. To date, SNS has utilized a non-rechargeable device which requires replacement every 4-5 years. A new rechargeable SNS system, 60% smaller in size and with an estimated battery longevity of over 15 years is now available. This device, the Axonics r-SNM System TM , has regulatory approval for use in Europe and Canada. The aim of this case series was to evaluate the handling and short-term benefits of a rechargeable SNS device in a small group of patients prior to introduction into general clinical practice. This was performed at a University hospital with extensive experience in the use of SNS for bowel control.

Patients with faecal incontinence that met UK NICE guidance for SNS were offered the choice of a non-rechargeable or rechargeable SNS device. Potential advantages and disadvantages of each system were explained to the patient as part of the consent process. Perceived advantages of the rechargeable device related to its smaller size (a potential reduced risk of infection and device related site pain) and longer battery life (reduced need for replacement surgery) with the caveat that battery charging was required for up to one-hour per week. Advantages of the non-rechargeable system related to its established therapeutic benefits and safety profile compared to the rechargeable system in which these factors are yet to be verified.

Symptom severity at baseline and at three months post implantation was recorded by bowel diary and St Mark's continence score. Evaluation of patient preference for device type was recorded. All patients underwent percutaneous nerve evaluation under general anaesthesia. In those that exhibited a good neurophysiological response (anal bellows +/-toe flexion at <3mA) a quadripolar tined lead and pulse generator were implanted. Follow-up at one and three months was performed. Effectiveness data in addition to morbidity and side-effects from the therapy were recorded. Treatment success was defined by a >75% reduction in episodes of faecal incontinence.

Five of six consecutive patients being considered for SNS chose the rechargeable SNS system. Patient preference to have the rechargeable device related to its smaller size and potential for fewer future surgical interventions. All five patients demonstrated a good physiological response to percutaneous evaluation and were implanted with the rechargeable device. On programming, the sensory threshold to stimulation was <2mA in all patients. There were no short-term complications associated with device implantation.

All patients reported a good response to therapy at one month post-implantation. The St Mark's continence score was reduced from a mean (±SD) of 18 (±1.6) at baseline to 5 (±2.5) at one-month. At three months, four patients continued to benefit from therapy. One patient reported reduced efficacy having suffered two major incontinent episodes. This patient was found to be utilizing a very low stimulation amplitude and was encouraged to stimulate at higher level. Data regarding this patient's outcome is awaited. Recharging was performed at a median (range) of 7 (7-10) days with no patient requiring greater than 60 minutes per charging session. No patient reported any problems with recharging the device, in some cases charging was achieved whilst the patient was mobile and there were no therapy related side-effects.

Interpretation of results SNS using a rechargeable device appears to have satisfactory efficacy. The numbers of patients in this case series however are small and therefore comparison with published data of non-rechargeable device clinical outcomes is not possible. There were no short-term complications associated with surgery or device operation. Recharging does not appear to be a burden to patients undergoing the therapy.

Concluding message SNS using a rechargeable device has a potential clinical and cost benefit due to the reduction in need for future surgical procedures. Whilst battery change is not the sole reason for revision surgery, the smaller size of the Axonics r-SNM System may result in less risk of device related site pain and associated surgical intervention. Post-marketing monitoring to ensure reliability, safety and efficacy of the new device is imperative.

Disclosures Funding: No grant or specific. Devices supplied and implanted as part of NHS neuromodulation clinical service. Clinical Trial: No Subjects: HUMAN Ethics not Req'd: New device meets regulatory requirements for use in humans (CE mark) and is available commercially. Case study reports on first use in humans for faecal incontinence as part of a service review. Device was discussed at new procedures advisory group and as device is seen as a replacement for an existing product applying the same therapy (electrical stimulation) ethical approval was not required. Helsinki: Yes Informed Consent: Yes 

Hypothesis / aims of study Surgical repair of the anal sphincter is the main treatment approach for treating fecal incontinence caused by anatomical defects. Currently, the most exciting and promising incontinence research is focused on regenerative repair of damaged rhabdosphincter with stem cell therapy. Mesenchymal Stem Cells (MSC) injection may represent a new attractive treatment option for anal sphincter lesions [1] The aim of this study is to investigate the potential therapeutic effects of local MSC injection in children presenting with fecal incontinence (FI) after posterior sagittal anorectoplasty (PSARP) operation for high imperforate anus.

Study design, materials and methods Study Design: preliminary, non-randomized single group assignment, open Label, interventional study. Children with FI following PSARP surgery for repair of high imperforate anus were included. Children having associated rectal prolapse, rectocele, or any neurological abnormalities or sacral deformities were excluded. After taking history and confirming fecal incontinence based on the Wexner Continence Grading Score [2] , all subjects underwent electromyography (EMG) and MRI pelvic floor muscle testing.

Ten ml bone marrow sample was extracted from the patient's iliac crest, using a heparinized syringe, under general anesthesia and in a suitable clean operation room. The method of isolation of MSC from bone marrow was carried out using the Ficoll-Paque technique for the isolation of mononucleated cells followed by the separation of MSC. Finally, the cells were re-suspended and counted using a hemocytometer. Mononucleated cells were cultured and incubated at 37°C in an atmosphere of 95% relative humidity and 5% CO2. A single dose of 1.2 ml MSC was divided into 12 parts of 0.1ml of MSC, then injected into the anal sphincter all around in 12 injection sites according to the clock meridian under general anesthesia and direct ultrasound guide (Figure 1 & 2) Anal sphincter EMG (for external anal sphincter, puborectalis and levator ani muscles), was performed using disposable concentric needle electrode. Activity was recorded during muscle relaxation and contraction. The external anal sphincter muscle was tested in the four quadrants of the anal opening (sites 3, 6, 9 and 12 o'clock). All patients were followed up clinically using Wexner score for one year. Post injection anal EMG and MRI pelvic floor muscle were performed at 1, 3 and 6 months post-injection. Data were compared with pre injection ones.

Twelve boys were consecutively enrolled in the study. Their mean age was 7.3 years (range 4-11 years). All of them had EMG and MRI evidence of a muscular defect of the external anal sphincter of different degrees. They had also history of failed conservative treatment. Injection was very well tolerated by all patients with no evidence of immediate or delayed side effects. The average injection time was 11 minutes for each patient. There was a highly significant reduction in incontinence scores with improved symptoms over the first six months study period (Wexner score decreased by a mean of 15.52 units, P < 0.05). Unfortunately, scores deteriorated with time and had nearly returned to baseline by the end of one year ( figure 3 & 4) . EMG activity of pelvic floor muscles was measured as the mean amplitude/turn and mean number of turns/second during maximum squeezing. No significant change in EMG activity could be detected between pre-and 1, 3 or 6 months post injections. MRI pelvic floor muscles showed also no significant change in the thickness of any anal sphincter component over the course of the study.

In our study, the overall results of our approach are not satisfactory. The markedly but un-sustained improvement in clinical scores couldn't be explained. We were unable also to demonstrate any sustained physiological change detected by EMG or anatomical changes detected by MRI, to account for the improvements we observed clinically. We hypothesized that the injected MSCs couldn't integrate into the damaged external sphincter and were unable to improve its functional integrity but it is still able to improve the clinical symptoms for short period may be due to its effect as bulking agent. Sarveazad et al [3] conducted a randomized double-blind clinical trial on patients with sphincter defects to investigate the therapeutic effect of injecting stem cells derived from human adipose tissue (hADSCs) into each end of the muscle defect during the repair surgery. Two months later, they followed up patients and concluded that injection of hADSCs during repair surgery may cause replacement of fibrous tissue, which acts as a mechanical support to muscle tissue with contractile function. Although in their study only short term follow up was performed, it may give us another clue for the success of stem cell injection. Early timing of injection or even during the surgery itself would give better results. Our study does have limitations: The lack of randomized control group (using sham injection, of saline for example) which would exclude any placebo effect and also help to investigate the effect of needling and injection alone on the anal tissues. The number of enrolled patients is relatively small. There is a need for larger sample of patients, with different degrees of sphincter muscle defects, in order to reach significance.

Concluding message Many questions are still in need to be answered before stem cell therapy can be introduced into routine surgical practice for fecal incontinence. 

Hypothesis / aims of study High resolution anorectal manometry (HRAM) is an established method for the collection and interpretation of data relevant to sphincteric and rectal function in adults. We present a protocol for the use of this contemporary investigation in children. This protocol has been developed and used for awake HRAM in children with chronic constipation (CC) and faecal incontinence (FI) in our Children's Anorectal Physiology Services (CAPS).

Study design, materials and methods HRAM was performed using a water perfused state catheter (8 channels) using a commercially available manometric system (Solar GI HRM; Medical Measurement Systems [MMS], Enschede, The Netherlands). Our protocol was adopted (with amendments) from the adult gastrointestinal physiology unit at our centre, which performs between 1500 -2000 studies/year. Prospective analysis of all patients was performed from the start of the service.

The protocol has been performed on 58 patients (September 2016 -January 2017). Each subject was instructed to defaecate, if required, prior to investigation. No bowel preparation was given, however children were asked to ensure they kept up with their usual bowel routine a week before the procedure, to maximise the chance of presenting with an empty rectum. Patients were studied in the left-lateral position with knees and hips flexed. Prior to catheter insertion, a digital rectal examination was performed to assess anal tone and the ability of the patient to understand the commands of 'squeeze' and 'push' when confirmed. All test manoeuvres were performed in accordance with published guidelines. The catheter was inserted into the anorectum, and anal canal was located. The protocol we followed is illustrated in Figure 1 . Data was analysed by the software.

This study provides an HRAM protocol which can be easily performed in awake children providing information about sphincteric function and rectal sensation of the anorectum. 

Hypothesis / aims of study Alpha-blockers are the first choice of drug treatment for male LUTS. The Dutch guideline for general practitioners (GPs) "Male LUTS" recommends to discontinue α-blockers in case of symptom relief after 12-26 weeks [1] . No evidence is given to support this advice. In contrast, the Dutch guideline for urologists does not support this recommendation, whereas in the EAU guideline the discontinuation of α-blockers is only considered in combination-therapy [2] . Before conducting a randomised controlled trial (RCT) to study the impact of continued versus discontinued use, it is important to study the attitude towards deprescribing of α-blockers among men using this drug. Deprescribing has been defined as the process of discontinuation of an inappropriate drug, supervised by a healthcare professional [3] . We hypothesised that men with less symptoms were more often willing to consider deprescribing. Next, we analysed the proportion of participants who were willing to participate in a RCT on discontinuation and we expected that men who had positive attitudes towards deprescribing more often would be willing to participate.

We conducted a survey among α-blocker users. Men were selected from the IADB.nl prescription database. This database contains all dispensed prescriptions of 60 Dutch community pharmacies in the Netherlands, for a period of 20 years. We applied the following inclusion criteria: men ≥ 30 years of age with a first α-blocker prescription in 2015 or 2016 by a GP or specialist/urologist from 10 participating pharmacies. We defined a first prescription to occur if such prescriptions were absent in the 2 preceding years, and only included men who were current α-blocker user on the day of invitation. Invitations were sent through the local pharmacies, using a patient identification number. In case of non-response a reminder was sent after two weeks. Questionnaires could be completed on paper or online at the convenience of the participant. The questionnaire included the IPSS, and the linguistically validated Dutch version of the revised Patients Attitudes Towards Deprescribing (rPATD) questionnaire. In addition to the rPATD -which originally was developed to collect on attitudes towards deprescribing in general -10 questions were added on attitudes towards deprescribing of α-blockers: the specific rPATD (s-rPATD). Participant with less than 3 drugs were excluded of the general rPATD. We investigated six to eight factors (the overall burden, appropriateness, concerns about stopping and involvement factor, and the appropriateness of α-blocker and concerns about stopping of α-blocker factor). Each factor was scored between 1 and 5 and the questions of the appropriateness factors were scored reversely. Additionally, rPATD included questions about the overall satisfaction of drug use and if participants would be willing to discontinue a drug if their doctor said it was possible. Information on a future RCT was administered, both on paper as well as in a video message. In the future RCT, continued αblocker use will be compared to placebo treatment in men who are still using an α-blocker after three months. Men were consequently asked for their willingness to participate in such a study when invited. We categorised IPSS score as mild (1-7 points), moderate (8-19), and severe (20-35). Using Spearman's rho, we analysed the correlations between the attitudes towards deprescribing (the rPATD and s-rPATD factors) and patient characteristics and severity of LUTS. In addition we analysed the correlation between those with the willingness to participate in the RCT. We also used multivariable logistic regression to identify predictors of willingness to participate.

In the IADB database, we identified 592 patients, of whom 188 were still using α-blockers on the day of invitation. Eighty-nine men (47.3%) completed the questionnaire. Due to incomplete responses or exclusions (prescription by another specialist than urologist or GP or with another indication such as kidney stones and urinary catheter), 78 men constitute the basis for this analyse. Interpretation of results Lower LUTS-related QoL and higher number of drugs were associated with increased burden of treatment. Further, lower QoL coincided with less global satisfaction about current drugs, and lower scores on α-blocker specific appropriateness scores ( Table  2) .

Willingness to participate in a RCT on discontinuation was reported by 60% of participant and did not depend on age, number of drugs used, LUTS severity or QoL. Willingness was higher for participants who thought their α-blockers may be inappropriate (e.g. thinking of giving side effects, may not be working or would like to stop it) ( Table 3) .

This preliminary study is the first on patient attitudes towards deprescribing in men who use α-blockers. Men with worse LUTS-QoL scores less often considered the use of α-blockers as appropriate.

About two-thirds of α-blocker users would participate in a RCT on discontinuation and this willingness is higher when the patient thinks the α-blocker is inappropriate. There was no significant relationship between LUTS severity and the attitudes towards deprescribing or the willingness to participate. 

Hypothesis / aims of study The CombAT study proved that the significant improvement of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia(BPH) continued for about 18 months after administration of either dutasteride or combination therapy [1] . After this period, the patients' symptoms remained stable, but further significant improvements were not observed. Dutasteride is a type of drug which reduces prostate volume (PV) and relieves symptoms. If treated with dutasteride for a mid to long term period, the PV reduction rate is gradually reduced. For this reason, we assume that dutasteride withdrawal might be possible, if temporary. Symptoms following withdrawal of dutasteride have not been well clarified in BPH patients. We have evaluated (2015 ICS abstract No. 595) the withdrawal of dutasteride at the 3 month interval for the short term of six months. The result was no observed deterioration of LUTS. Few studies have focused on the change of PV and symptoms after withdrawal of dutasteride. Jeong YB et al reported the withdrawal of dutasteride for a one year interval [2] . However, there are almost no studies which investigate the relationship between LUTS and testosterone level following withdrawal of dutasteride. Therefore, we further evaluated the outcome for a year with an increased number of patients compared to our data two years ago.

Study design, materials and methods A total of 47 BPH patients who have been treated with dutasteride for over two years and are stable were entered in the study. Forty-three patients had been treated with combination therapy of dutasteride and α-blocker, and four patients had been treated with monotherapy of dutasteride. We examined the total International Prostate Symptom Score ( . Eight patients withdrew from this study. Two patients suffered from acute urinary retention (AUR) at the 6 and 9 month study periods. One and 2 patients complained of severe voiding and storage symptoms, respectively. Three patients did not respond to follow up.

The withdrawal of dutasteride could be accomplished with no significant symptom deterioration in the majority of patients during the one year study period. IPSS-S might be influenced by a decrease of testosterone following the withdrawal of dutasteride based on the findings of the TT decrease in Group B. IPSS-V in Group A was considered to be affected only by PV and not by TT. In contrast, a previous study reported significant improvements in overactive bladder symptom score (OABSS) in the TTelevated group, whereas no significant change was noted in the non-elevated group [2] . Another study reported that among patients with overactive bladder (OAB), dutasteride significantly improved urgency and urgency incontinence, especially in those who had lower OABSS, urgency incontinence scores and TT at the baseline [3] . Based on this evidence, TT is likely to contribute to improvement of storage symptoms. To date there are few studies regarding the deterioration of storage symptoms accompanied by a decrease of TT after withdrawal of dutasteride. However, this study has limitations because of its small sample size and necessitates further detailed discussion. Future studies including more patients are needed to confirm our findings.

To our knowledge, this is the first prospective study addressing withdrawal of dutasteride in Japanese patients. This study suggested that deterioration of storage symptoms was affected by the decrease of TT after the withdrawal of dutasteride. These findings provide further insights into the management of BPH/LUTS patients who have been treated with dutasteride. Almost all patients could safely undergo withdrawal of the dutasteride treatment; however, medical professionals should carefully monitor patients for events such as AUR.

Mean changes from baseline of TT were analyzed using the Wilcoxon signed-rank test.

P<0.05 was considered as statistical significance.

GroupA ( 

Little is known about β3-adrenoceptor (AR) expression and function in human prostate. We examined the expression and distribution of β-AR subtypes in normal prostate and benign prostatic hyperplasia (BPH) tissues, and investigated which selective β-AR subtype agonist was most involved in the relaxation of isolated human prostate strips.

Study design, materials and methods Prostate tissue specimens were obtained from patients undergoing either radical cystectomy for bladder carcinoma or transurethral/open prostatectomy for BPH. Specimens collected from radical cystectomy patients with no evidence of either lower urinary tract symptoms (LUTS) or benign prostatic enlargement were defined as normal prostate tissues. Specimens collected from transurethral or open prostatectomy for LUTS/BPH were defined as BPH tissues. The expression of messenger RNA (mRNA) for β1-, β2-, and β3-AR was investigated using reverse transcriptase-polymerase chain reactions (RT-PCR) in 35 patients (19 normal prostate and 16 BPH specimens, mean age: 68.5 ± 8.5 years, age range: 55-88). Quantitative analysis of mRNA expression of β-AR subtypes between normal prostate and BPH tissues was performed using quantitative RT-PCR. Distributions were examined by immunohistochemistry (IHC). Paraffin sections of surgical resection specimens of human prostate were obtained from 15 patients (nine normal prostate and six BPH specimens; mean age, 69.1 ± 9.4 years; age range: 52-88). Human prostate strips obtained from 36 patients (25 normal prostate and 11 BPH specimens, mean age: 67.8 ± 9.6 years, age range: 44-88) were suspended in organ baths and exposed to isoproterenol (a non-selective β-AR agonist), dobutamine (a selective β1-AR agonist), procaterol (a selective β2-AR agonist), and TRK-380 (a selective β3-AR agonist) to investigate their relaxant effects on KCl-induced contractions, and their inhibitory effects on electrical field stimulation (EFS)-induced contractions.

We confirmed the presence of mRNA for β1-, β2-, and β3-ARs both in normal prostate and in BPH tissues. For β3-AR, mRNA expression in BPH tissues was significantly higher than in normal prostate tissues, but there was no significant difference in β1and β2-AR expression between normal and BPH tissues. IHC revealed differences in staining intensity between smooth muscle cells and glandular cells, with different proportions for different β-AR subtypes. Staining of β3-AR was particularly intense in smooth muscle cells as opposed to glandular cells. Isoproterenol and TRK-380 significantly decreased the tone of KCl-induced contractions of the normal prostate strips (Fig. 1a) . The rank order of relaxant effects was isoproterenol > TRK-380 > procaterol > dobutamine. All selective β-AR agonists significantly decreased the amplitude of EFS-induced contractions of the normal prostate strips (Fig. 2a) . The rank order of inhibitory effects was isoproterenol > dobutamine >TRK-380 > procaterol. In BPH strips, all selective β-AR agonists showed no significant relaxant or inhibitory effects on KCl-or EFS-induced contractions (Figs.1b and 2b).

Present study demonstrates that all β-AR subtypes are expressed in both normal prostate and BPH. The expression of β3-AR is predominant in prostate smooth muscle cells. Relaxation of human prostate is mainly mediated via β1-and β3-ARs. Previous study demonstrated that the β3-AR agonist mirabegron produced concentration-dependent relaxation against phenylephrineinduced contraction in human and rabbit prostate [1] . Present study is the first report confirming the function of β3-AR compared to other β-AR subtypes, β3-AR agonists may have the potential to relax normal human prostate in clinical settings. Our results support the idea that β3-AR agonists may have clinical application in non-BPH patients with voiding symptoms such as weak stream, intermittency, and straining, and in neurogenic bladder patients with similar symptoms.

Concluding message β3-AR is abundant in human prostate smooth muscle, whose relaxation is mediated by β1-and β3-AR stimulation. β3-AR agonists may have clinical use in the treatment of male non-BPH patients or neurogenic bladder patients with voiding dysfunction. 

Hypothesis / aims of study Mirabegron, a β3-adrenoreceptor antagonist, may effectively mitigate overactive bladder (OAB) symptoms in males without adverse events. Thus, the present study aims to evaluate the efficacy and safety of mirabegron in males with OAB symptoms.

Study design, materials and methods A phase IV, randomized, double-blind, placebo-controlled, parallel comparison clinical trial was conducted at 14 institutes in South Korea. The study included males aged ≥ 18 years with OAB symptoms for at least 12 weeks. The sample size of patients in the two groups provided 80% power to detect a significant difference of 0.77 in mean numbers of micturitions per 24 hours (based on the median value of treatment differences from previous studies [1, 2] ) between placebo and mirabegron group, based on a twosided t-test with α = 0.05 and a standard deviation of 2.52. Assuming post-randomization dropout rates of 10%, 464 patients were to be randomized 1:2 to placebo vs mirabegron 50 mg group (154 vs 308). Change from baseline to 12 weeks of treatment in mean numbers of micturitions per 24 hours was compared between the two groups as the primary end point. Change of overactive bladder symptom score (OABSS) and international prostate symptom score (IPSS) from baseline to 12 weeks of treatment was compared between the two groups as the secondary endpoint; total score, urgency score (question 3), and urgency incontinence score (question 4) from OABSS and storage subscore (sum of question 2, 4, and 7), urgency score (question 4), and quality of life (QoL) score from IPSS were assessed. Safety assessments included treatment-emergent adverse events (TEAEs), blood pressure, pulse rate, postvoid residual (PVR) volume, and maximum urinary flow rate (Qmax). The comparison of continuous variables between the two groups and between baseline and 12 weeks of treatment within each group was performed by using independent t-test and paired t-test, respectively. The categorical variables between the two groups were compared by using chisquare test.

The numbers of micturitions per 24 hours and the scores of the questionnaires assessed in this study were significantly reduced from baseline to 12 weeks of treatment in both groups (p <0.001 in all). The mean reduced numbers of micturitions per 24 hours from baseline to 12 weeks of treatment in placebo and mirabegron group were 1.45 ± 2.54 and 1.61 ± 2.20, respectively, and were not significantly different between the two groups (p = 0.06). A significant difference between the two groups was observed regarding the reduced amount of scores from baseline to 12 weeks of treatment in OABSS total score (p = 0.01), OABSS urgency score (p = 0.01), OABSS urgency incontinence score (p = 0.01), IPSS storage subscore (p = 0.01), and IPSS urgency score (p = 0.02). However, the reduced amount of IPSS QoL from baseline to 12 weeks of treatment was not significantly different between the groups (p = 0.34). The detailed mean reduced values of each scores are presented in Table 1 . TEAEs, blood pressure, pulse rate, PVR, and Qmax of treatment were not significantly different between the two groups at 12 weeks (p > 0.05 in all, Table 2 ).

Although the 12 weeks of treatment with mirabegron 50mg did not significantly reduced the numbers of micturitions per 24 hours compared to the placebo, the reduced amount of OAB symptoms in mirabegron group were significantly larger than those in the placebo group. Such result implies that daily dose of mirabegron 50 mg for at least 12 weeks can be an effective treatment method that significantly improves urgency and storage symptoms in male OAB patients. Also, the treatment using mirabegron was well tolerated, without additional important safety findings compared with placebo.

Concluding message Daily dose of mirabegron 50mg for 12 weeks symptomatically improved male OAB patients without significant adverse events compared to the placebo group. 

Hypothesis / aims of study The combination of an antimuscarinic with an α-blocker is the recommended treatment option for male storage lower urinary tract symptoms (LUTS). Previous studies indicate that the therapeutic effect of α-blockers occurs independent of prostatic relaxation and perhaps involving a direct effect on blood vessels. There is strong evidence that improves prostate perfusion and decrease oxidative stress markers. In contrast, it is unclear if anticholinergics affect prostatic perfusion. Here in, we tried to assess prostate vascularity before and after Tamsulosin monotherapy and combination with anticholinergic treatment.

In a prospective, randomized study we recruited treatment naïve patients with prostate volume ≥30mls and predominantly storage LUTS, who had maximum urine flow rate (Qmax) ≥10ml/s, post-void residual (PVR) <100ml, scored ≥ 3 in the International Prostate Symptoms Score urgency question. The recruited patients had at least 3 urgency episodes per 24h, daytime frequency ≥8 and at least 2 nocturia episodes as documented in a 3-day bladder diary. Patients with neurogenic bladder, PSA > 4ng/ml, recurrent urinary tract infections or a history of urinary tract malignancy were excluded. The study was designed and powered to identify changes in the detected vascular surface from baseline to week 26, as well as in prostate and adenoma volumes. The primary end point was the mean percentage changes in the detected vascular surface as measured by the colour pixel Doppler (CPD). All patients were submitted to transrectal ultrasonography at baseline and at the end of the study. The CPD was assessed by a sequence of Doppler images from prostatic apex to base using a 5mm step using a stepper. The image processing software (Image J) used to manually delineate the visible vessels and calculate the pixels contained within the selected area. The total number of prostate pixels was extracted from a 3D prostate model, which was created for volumetric measurements. We calculated the CPD as a percentage of vascular surface to the total prostate volume ((Total Vessels Pixels / Total Prostate Pixels)*100). Paired t-test was used for intragroup variability and Mann-Whitney test for intergroup variability. The local ethics committee approved this study and all recruited patients gave their written informed consent.

A total of 80 men were enrolled in the study. At baseline, both groups were comparable for bladder diary, questionnaire scores, prostate parameters and demographics. Sixty-three men completed the study (Group I: n=31, Group II n=32). At baseline both groups were comparable for CPD (1.3±1.1% in Group I and 1.7±0.9% in Group II), prostate size (48.93±13.6 ml vs. 52.63±31 ml) and adenoma volume (24.45±10.2 ml vs. 28.37±21.4 ml). At the end of the treatment there was a marked increase (149.3%) in the CPD in the monotherapy group that corresponds to 1.9±1.0% of total prostate vascular surface, as opposed to a reduction (-19.8%) in the combination group, corresponding to 1.0±0.6% of total prostate vascular surface. After treatment an increase was noted in total prostate volume (9.2%) in the monotherapy group as opposed to a decrease (-9.5%) in the combination group (comparative p<0.001). Similar changes were found in adenoma volume (+17.4% vs. -12.5%, p<0.001).

To our knowledge, this is the first analysis of a randomized population focusing on the effect of the combination of Solifenacin and Tamsulosin on the detected vascular surface of prostates in patients with benign prostatic enlargement who present with predominately storage LUTS. The results of this study confirm that Tamsulosin monotherapy positively affects the perfusion of prostate gland. In contrast, the combination therapy and Solifenacin seems to reduce the detected vascular surface. These changes are proportional to volumetric changes of prostate and adenoma in both groups. Whether antimuscarinics and, in this case Solifenacin, may cause prostatic ischemia leading to reduction of the prostate and adenoma volume remains to be further investigated, as well as possible associations of these morphometric changes of the prostate with symptomatic improvement. As both muscarinic and adrenergic receptors exist in the prostate, the role of prostate muscarinic receptors needs to be examined, also in association with the acknowledged function of adrenergic receptors.

Concluding message The results of this pilot study suggest that both Tamsulosin and Solifenacin affect prostatic perfusion. It is unclear if muscarinic receptor blockage predominates over the adrenergic receptors at the level of prostatic arterioles or whether our findings reflect actions via an indirect alternative pathway. 

Tadalafil is the only PDE5-inhibitor approved for patients with lower urinary tract symptoms (LUTS) suggestive of BPH (LUTS/BPH). Smooth muscle relaxation in the bladder, urethra, and prostate due to increased nitric oxide/cGMP pathway activity via inhibition of PDE5 isoenzymes and the increase blood perfusion to the pelvic area was reported to be the mechanism of LUTS improvement with tadalafil. However, some papers reported that tadalafil did not reveal a significant improvement in urinary flow rate as compared with placebo 1, 2 . Although tadalafil has been shown to improve LUTS significantly, little is known about its effect on lower urinary tract dysfunction. Some issues remain to be investigated, including the discrepancy between the improvement in subjective symptoms and objective findings with tadalafil. The principal aim of this study was to determine whether tadalafil has an objective effect on storage function and bladder outlet obstruction (BOO) in patients with LUTS/BPH, based on urodynamic study (UDS).

This was an open-labeled, single-center, prospective study. Eighty untreated outpatients with LUTS/BPH received tadalafil 5 mg/day for 12 weeks. The International Prostate Symptom Score (IPSS), IPSS-QOL, Overactive Bladder Symptom Scores (OABSS), and BPH impact index (BII) were measured before and after drug administration to evaluate subjective symptom severity and QOL. Patients also underwent UDS, including uroflowmetry, cystometrogram, and pressure flow study (PFS), to evaluate their lower urinary tract function before and 12 weeks after administration. First desire to void (FDV), maximum cystometric capacity (MCC), and detrusor overactivity (DO) were assessed as parameters of storage function. Maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), detrusor pressure at Qmax (PdetQmax), and bladder outlet obstruction index (BOOI) were evaluated as parameters of voiding function.

Of 80 patients who met the entry criteria, 4 (5.0%) discontinued treatment owing to adverse reactions, including headache (n = 2), problem on erection (n = 1), and dizziness (n = 1). One patient developed urinary retention during the study period. UDS was not performed after treatment in 4 patients. As a result, the analysis included 71 patients with a mean age of 70.2 years (range, 51-85 years) and a mean prostate volume of 45.6 mL (range, 25.2-87.1 mL). 

Hypothesis / aims of study The operative procedure of radical prostatectomy, even in robot-assisted radical prostatectomy (RARP), impairs the anatomical and functional structure of the bladder and consequently induces lower urinary tract dysfunction (LUTD). The prognostic factors for postoperative LUTD are unknown. On the other hand, dyslipidemia appears to contribute to lower urinary tract symptoms 1) . It is possible that dyslipidemia affects bladder function after radical prostatectomy. Recently, attention has focused on the low density lipoprotein cholesterol (LDL-C) / high-density lipoprotein cholesterol (HDL-C) ratio as a predictor of cardiovascular disease (CVD). It has been demonstrated that the LDL-C/HDL-C ratio more accurately predicts CVD risk than LDL-C or HDL-C levels 2) . The aim of this study was to determine whether preoperative dyslipidemia contributes to LUTD after RARP and can be used to predict LUTD after RARP by evaluating the association between the preoperative triglyceride (TG), LDL-C, and HDL-C levels and the LDL-C/HDL-C ratio and the changes in urodynamic parameters before and one month after undergoing RARP.

Study design, materials and methods Patients with localized prostate cancer who underwent RARP in our hospital between February 2013 and April 2014 were included in this study. LDL-C and HDL-C levels were measured before RARP. Urodynamic studies were performed before and one month after RARP. The associations between the preoperative LDL-C and HDL-C levels and the LDL-C/HDL-C ratio and the changes in urodynamic parameters before and one month after RARP were prospectively analyzed. The Schäfer nomogram contraction was used to evaluate the changes in bladder contraction before and one month after RARP. All values are expressed as mean ± standard deviation. P-values of <0.05 were considered significant.

A total of 44 patients (age 65.5 ± 4.7 years) entered the study. The preoperative IPSS (8.0 ± 6.5) and QOL index (2.8 ± 1.3) were moderate. The prostate volume was 35.3 ± 15.1 mL. Before RARP, the TG was 151.5 ± 74.8 mg/dL, the LDL-C was 104.7 ± 30.8 mg/dL, the HDL-C was 56.3 ± 20.5 mg/dL, and the LDL-C/HDL-C ratio was 2.0 ± 0.8. The preoperative postvoid residual urine volume was 36.6 ± 77.4 mL ( Table 1 ). The LDL-C/HDL-C ratio was significantly higher in patients whose volume at first desire to void was decreased than in the other patients (2.3 ± 0.8 vs 1.7 ± 0.5, P=0.026). Receiver-operating characteristic (ROC) analysis showed a cut-off value of 2.1 for the LDL-C/HDL-C ratio (sensitivity, 62.5%; specificity, 58.8%; area under the curve (AUC), 0.692). The LDL-C/HDL-C ratio was significantly higher, and the HDL-C was significantly lower in patients whose bladder contraction was reduced (LDL-C/HDL-C ratio: 2.3 ± 0.8 vs 1.6 ± 0.8, P=0.019; HDL-C: 50.8 ± 8.5 vs 66.9 ± 31.3, P=0.029). ROC analysis showed cut-off values of 1.7 for the LDL-C/HDL-C ratio (sensitivity, 80.0%; specificity, 66.7%; AUC, 0.723) and 48.5 for HDL-C (sensitivity, 78.6%; specificity, 54.2%; AUC, 0.714). The LDL-C/HDL-C ratio tended to be higher in patients whose volume at strong desire to void was decreased as compared with the other patients (2.3 ± 0.8 vs 1.8 ± 0.5, P=0.085) (Figure 1 ).

An elevated LDL-C/HDL-C ratio before RARP decreased volume at first desire to void after RARP, and preoperative low HDL-C and elevated LDL-C/HDL-C ratio reduced postoperative bladder contraction. This result suggested that dyslipidemia may decrease bladder capacity and impair bladder smooth muscle contraction after RARP. This result might indicate that the LDL-C/HDL-C ratio more accurately predicts LUTD after RARP than TG, LDL-C, or HDL-C levels.

Concluding message Dyslipidemia may be one cause of LUTD after RARP. The preoperative LDL-C/HDL-C ratio appears to be a useful predictor of LUTD after RARP. 

Hypothesis / aims of study Radical perineal prostatectomy (RPP) is an alternative to minimally invasive procedures such as robotic-assisted laparoscopic prostatectomy (RALP) that has been shown to be associated with lower mean health care expenditure and similar oncologic outcomes. The purpose of the study is to compare functional voiding outcomes and interventions after RPP vs RALP.

Study design, materials and methods Following IRB approval, we performed a review of patients who underwent RALP or RPP from 2009-2015 at a single institution. One surgeon performed all RPPs and 4 surgeons performed all RALPs. We compared baseline demographics, perioperative data, and post-operative outcomes including International Prostate Symptom Score (IPSS), quantitative pad use, continence rates defined as no pad use on follow-up visit, and voiding dysfunction interventions at 3, 6, 9, 12, 24 and 60 months.

Results 256 men underwent RALP and 157 RPP. Mean follow-up was 26 months for RALP and 27 months for RPP with follow up as follows: 86% at 3 months, 75% at 6, 65% at 9, 72% at 12, 49% at 24, and 14% at 60 months. Interpretation of results Patients who underwent RPP had similar oncologic outcomes to those who underwent RALP, with less associated direct costs, with a more rapid and complete recovery of continence following prostatectomy.

Concluding message Patients who underwent RPP had a more complete and rapid recovery of continence in the first two years compared to RALP; however, overall rates of interventions for voiding dysfunction were similar for RPP and RALP, and no differences in continence persisted at 5 years. 

Hypothesis / aims of study It is well known that many men undergoing surgery and radiotherapy for localised prostate cancer experience adverse effects on urinary function. Those undergoing active monitoring or surveillance may also experience some adverse effects related to ageing or the receipt of radical treatments after changing management. However, the precise levels Study design, materials and methods Details of the recruitment methods of the ProtecT trial and the baseline data have been published previously. In brief, after population-based PSA testing, 1643 men with clinically localised prostate cancer underwent randomisation: 545 to active monitoring, 553 radical prostatectomy, and 545 radiotherapy. Patient-reported outcomes were pre-specified secondary outcomes. Urinary incontinence (UI) and its impact on quality of life (QoL) were assessed by the International Consultation on Incontinence Questionnaire (ICIQ) score and QoL item;(1) Expanded Prostate Cancer Index Composite (EPIC) 50-item UI subscore and item on pad-use; (2) and International Continence Society Male Short-Form (ICSmaleSF) questionnaire UI score. (3) Lower urinary tract symptoms (LUTS) and their impact on QoL were assessed by the ICSmaleSF questionnaire voiding score and frequency, nocturia and QoL items, and the EPIC urinary summary, bother and obstruction/irritation sub-scores. Study questionnaires were completed at baseline before the diagnosis was known, at six and 12 months after randomisation, and annually thereafter. PROMs were scored and analysed as recommended by their authors. Analyses were performed according to the intention-to-treat principle, and summary statistics and 95% confidence intervals were reported according to randomisation group. Two-level random-effects models were used to accommodate the correlation between the repeated assessments. Twolevel linear models were used for continuous measures and logistic models for binary measures. No meaningful differences across groups were observed at baseline. As UI and LUTS were not assessed directly through pad measurement or urodynamics, PROMs were compared with each other.

Response rates were higher than 85% and did not decline over time. All measures of UI (ICIQ, ICSmaleSF UI and EPIC UI scores and EPIC item on pad-use) showed that surgery had the greatest negative effect at 6 months, and that UI remained worse in the surgery group compared with radiotherapy and active-monitoring at all time points over six years (P<0.001 for each measure). There was little difference in UI between radiotherapy and active monitoring over six years. Only the ICIQ measure had a specific item assessing the QoL impact of UI. This showed that men in the surgery group experienced most impact at six and 12 months after randomization; after 24 months, the QoL impact of UI recovered and became similar to the other groups, although the profiles were different (p<0.001). The ICSmaleSF voiding score showed differences between the groups (p<0.001), with worse voiding symptoms in the radiotherapy group at six months, returning to be similar to the other groups from 12 months onwards. The EPIC obstruction/irritative sub-score did not detect these differences (p=0.77). The ICSmaleSF illustrated differences between the groups for nocturia (p<0.001) with radiotherapy worse at six months, but no differences in daytime frequency (p=0.47). The distinct effect of voiding difficulties on QoL was unclear, however, as the question in both measures -EPIC urinary bother and ICSmaleSF QoL score -referred to the impact of all urinary symptoms including UI. The profiles from these scores as well as the EPIC urinary summary score, were very similar to the profiles related to UI. The EPIC urinary bother sub-score was not clearly different between the groups (0.095).

The EPIC, ICIQ and ICSmaleSF measures produced very similar profiles for the effects of treatments on UI. While the magnitude of differences was a little different between the measures, they were equally effective at measuring the effects of treatments on levels of UI. The only measure that assessed the impact of UI on QoL was the ICIQ questionnaire. The ICSmaleSF and EPIC measures did not concur over the assessment of LUTS. The main EPIC scores (urinary summary and bother) included items on UI, and so their profiles conflated UI with other LUTS. EPIC also did not have a specific voiding score, as its sub-score assessed obstructive and irritative symptoms combined (dysuria, haematuria, weak stream and frequency). ICSmaleSF had separate voiding and incontinence scores, as well as specific items for nocturia and frequency, which it recommends reporting separately. ICSmaleSF did not include items on dysuria or haematuria in its assessment. EPIC and ICSmaleSF both conflated UI and LUTS in their QoL impact item/scores.

There are clear similarities between measures in their assessment of UI, and so any of these validated PROMs could be used: ICIQ, EPIC or ICSmaleSF. However, the assessment of QoL related to UI is only assessed by the ICIQ. For the assessment of LUTS, the measures have differences that need to be taken into account when interpreting the results. The EPIC and ICSmaleSF questionnaires include different LUTS in their assessments of voiding, UI and obstruction/irritation. It is essential to use validated and standardized PROMs in research and clinical practice to include the assessment of patient-reported symptoms, but care needs to be taken when using scores as different measures include different items within similar-sounding scores. Particular issues arise for the assessment of voiding or storage symptoms, and the assessment of the impact of all LUTS, including UI, on QoL. 

Hypothesis / aims of study It is known that long term partial bladder obstruction induced detrusor contractile dysfunction. Actually, persistent voiding dysfunction following the holmium laser enucleation of the prostate (HoLEP) is not uncommon. The aim of this study is to predict the proper timing of the HoLEP through variable parameters.

Study design, materials and methods A total of 210 patients who underwent HoLEP between January 2012 and October 2016 were retrospectively reviewed. According to treatment results, the patients were divided into 2 groups (Group I -improvement in International Prostate Symptom Score (IPSS) + Qmax value > 12ml/s and PVR > 100ml; Group II -no improvement in IPSS + Qmax value ≤ 12 ml/s or PVR ≥ 100ml). The improvement of IPSS was defined as the shift between grades (severe to moderate, moderate to mild). We evaluated the predicting risk factors of voiding dysfunction following HoLEP.

Mean (±SD) age of patients with group I an II was 68.8 (±6.4) and 70.6 (±4.7) years, respectively. In the analysis of subjective symptom score (IPSS subscores and total score), there were significant differences between two groups (P<0.001). Also, in the analysis of urodynamic parameters, maximum detrusor pressure, detrusor pressure at peak flow rate, compliance, bladder contractility index, bladder outlet obstruction index also showed significant differences (P<0.05). In the rogistic regression analysis, bladder contractility index and IPSS storage subscore were risk factors for voiding dysfunction following HoLEP.

Reduced detrusor contractility was associated with poor treatment results.

Concluding message Urodynamic parameters, indicating detrusor contractility could be a good diagnostic tool for predicting voiding dysfunction after HoLEP. In addition, the relatively high symptom score could suggest better treatment results. 

Hypothesis / aims of study Holmium laser enucleation of the prostate (HoLEP) is an effective and safe surgical method for managing benign prostatic hyperplasia causing severe bladder outlet obstruction (BOO). The present study aims to evaluate the safety and the postoperative outcomes of HoLEP as a palliative management in severe BOO patients with advanced prostate cancer.

Study design, materials and methods Data of 32 patients with advanced prostate cancer (≥ cT3) who underwent palliative HoLEP between October 2012 and March 2015 to manage severe BOO was retrospectively reviewed. Preoperative and postoperative (3 and 12 months) International prostate symptom score (IPSS) and quality of life (QoL) score, peak urinary flow rate (Qmax), postvoid residual urinary volume (PVR), and number of pads per day was compared by using repeated-measures analysis of variance to evaluate the effectiveness of palliative HoLEP. Postoperative complications were also investigated to evaluate the safety of the management.

Median age and follow-up of the patients was 70 years (58-84) and 18 months (5-28). At the time of palliative HoLEP, 87.50% (28/32) of patients were managing with androgen deprivation therapy. None of the patients received radiation therapy for prostate cancer before and after the palliative HoLEP. Preoperatively, 71.88% of patients (23/32) have experienced acute urinary retention (AUR) and the urethral catheterization was performed in 46.88% of the patients (15/32). Collapse of surgical plane within the prostate and bladder invasion was found in 46.88% (15/32) and 65.63% (21/32) of the patients, respectively. Other demographic and perioperative data of the patients are described in Table 1 . IPSS, QoL, Qmax, and PVR measured at 3 and 12 postoperative months was improved significantly compared to those measured preoperatively ( Table 2 ). Complications were low and no patient received postoperative blood transfusion. Catheter and pad free rate was 100% (32/32) and 84.38% (27/32) at last follow-up, respectively.

Interpretation of results Significant improvement was noted in Qmax, PVR, IPSS, and QoL at 3 and 12 months of postoperative follow-up compared to the baseline.

HoLEP can be a safe and effective palliative treatment in severe BOO patients with advanced prostate cancer despite the destructed surgical plane within the prostate. 

Hypothesis / aims of study Intravesical prostatic protrusion (IPP) is useful factor for predicting clinical progression of benign prostatic hyperplasia (BPH). We attempted to analyze whether IPP affects the postoperative outcomes of holmium laser enucleation of the prostate (HoLEP).

Study design, materials and methods From January 2012 to December 2015, 94 patients with a possible measurement of IPP and follow-up period of at least 6 months were enrolled. IPP was measured by transrectal ultrasonography (TRUS). We divided the patients into two groups on the basis of the degree of IPP: the insignificant IPP group (group A, IPP ＜ 10 mm) and the significant IPP group (group B, IPP ≥ 10 mm). Surgical outcomes were analyzed at 3 months and late complications were analyzed at 6 months after HoLEP. Patient's characteristics and surgical outcomes were retrospectively compared between the two groups.

Results 39 patients presented with significant IPP (41.5%). Patient's characteristics were not significantly different between the two groups except for preoperative International Prostate Symptom Score (IPSS)-storage and Quality of life score (QoL). Preoperative IPSSstorage and QoL was significantly higher in the group B (p = 0.023, 0.029, respectively). Postoperative improvement in IPSSstorage, IPSS-voiding, and QoL were higher in the group B (p=0.001, 0.011, 0.002, respectively).

Interpretation of results IPP is an independent factor for predicting postoperative outcomes in BPH patients who undergo HoLEP.

We can expect better post-HoLEP outcomes in patients with significant IPP (IPP ≥ 10 mm). 

Hypothesis / aims of study Since the 1990's, when the tension-free vaginal tapes (TVT) or midurethral slings (MUS) were first introduced, the use of synthetic materials to surgically treat female stress urinary incontinence (SUI) has dramatically increased and overtaken the former Burch colposuspension. However, in the past 5-10 years, the possible, sometimes irreversible, complications of tapes (e.g. obstruction, pain, dyspareunia, erosion) have received more and more attention. The patient is then asked to contact the department with their procedure preference. They are also offered to be seen in clinic to discuss options further if they wished. The surgical options would have also been discussed with them at the urodynamics session. The type of treatment offered is therefore purely patient-decided, based on standardised information and their own research. Statistical analysis was performed using SPSS 24 (IBM, NY, USA). Data were analysed using Pearson's Chi square tests and statistical significance was set at p < 0.05.

Over a period of 5 years, 599 female SUI surgical interventions were performed. Data is presented in Table 1 . Statistical analysis showed a significant difference between the different years (p < 0.001). The post-hoc analysis is presented in Table 1 , and the decrease in synthetic MUS procedures and increase in Colposuspension were found to be statistically significant factors in the Bonferroni post-hoc analysis (p < 0.0025). Percentage distribution is presented in Figure 1 .

This retrospective study on female SUI surgery shows a significant change in preference of procedure by the patients when offered different SUI surgical options. There is a re-emergence of Colposuspension as a treatment of choice for female SUI.

Bulking agents are also gaining in popularity as a minimal-invasive alternative. Autologous Fascial Sling remains a stable alternative. Synthetic MUS still remains the most performed procedure but its dominance has significantly declined over the past 2 years.

Concluding message A retrospective study on surgery for female SUI in a centre that offers all surgical options as per the NICE guidelines showed a significant decline in synthetic MUS procedures and a re-emergence of Colposuspension when patients were allowed to choose their preferred surgical procedure based on informed consent using national information leaflets and their own research. Social awareness of synthetic tape-related complications possibly has a role in this and may further influence daily female urology and urogynaecology practice in the future when dealing with female SUI.

Tables and Figures  Table 1 : Overview of procedures for female stress urinary incontinence by year, performed in a single centre. 

Hypothesis / aims of study Pelvic organ prolapse (POP) is a global health problem for which the pathophysiological mechanism remains to be elucidated. The loss of extracellular matrix proteins is considered to be important in the molecular basis of this pathology. Heparanase is a heparin sulfate degrading endoglycosidase that has important roles in various biological processes, including proteoglycan degradation, and is a key component of the extracellular matrix. The aim of this study was to compare expression of Heparanase in connective tissue of uterosacral ligaments in women with or without uterine prolapse. Study design, materials and methods Thirty-nine women who underwent hysterectomy for benign reasons enrolled in this study. Twenty-three women underwent vaginal hysterectomy (VH) for uterine prolapse (stage ≥3) and sixteen women underwent total abdominal hysterectomy (TAH) for fibroid uterus without uterine prolapse (stage <2). Uterosacral ligaments biopsies were obtained from all uterine specimens near its origin. All tissue samples were analyzed by immunohistochemistry with regard to presence of heparanase using antiheparanse antibody 733.

Women characteristics were presented in table 1. Heparanse positive staining was more common in the connective tissue of uterosacral ligaments in women with uterine prolapse. Positive staining was seen in 17/23 (73.9%) women with uterine prolapse compared to 4/16 (25.0%) without uterine prolapse (p = 0.007). On multivariate logistic regression analysis, positive staining was independently associated with VH, after controlling for women's age. In women with uterine heparanase immunostaining was noted as brown gargle (arrow) in the cytoplasmatic portion of the fibroblasts in the uterosacral ligaments prolapse (Figure 1 A,B) .

In women without prolapse absence of such delicate sign was more common (Figure 1 C,D) .

Heparanase expression is more common in the connective tissue of uterosacral ligaments in women with uterine prolapse compared to normal

Concluding message These results may suggest its role in the pathological processes of compromising pelvic floor function and the development of uterine prolapse 

Hypothesis / aims of study The relation between pelvic floor muscles and abdominal muscles allows the protection of urinary continence under increased urethral pressure (1) . It was seen that abdominal muscle co-activation contributed to pelvic floor muscle contraction (2, 3). Sapsford et al. reported that pelvic floor muscles became activated during abdominal muscle contraction and the opposite was true, in other words, abdominal muscles became activated during pelvic floor muscle contraction (3). Two contractions have been defined in the literature for abdominal muscle training namely the hollowing and bracing maneuvers. The hollowing maneuver is used for Pilates exercise training and the bracing maneuver is used during stabilization exercises. It was mentioned that pelvic floor muscles contracted in both of these exercise types. Pelvic floor muscle contraction and anal contraction methods are used during pelvic floor muscle training. This study was aimed to determine which of the four different contraction methods enabled pelvic floor muscle function the most and to determine the exercises that should be prioritized while creating an exercise program.

Study design, materials and methods 120 asymptomatic, volunteer women with no pelvic floor dysfunction symptoms participated in the study. The number of the participants was set as to include 30 women in each subgroup and the total number of asymptomatic women was set as 120 to ensure 80% power with an alpha level 0.05. Volunteer women, who had no mental problem to hinder their cooperation and comprehension, were literate and over the age of 18 and got 0 point from the global pelvic floor bother questionnaire, participated in the study. The women, who had urinary incontinence, pelvic organ prolapse and fecal incontinence symptoms, a neurologic illness and musculoskeletal problem and were pregnant or at the postpartum term and used neuromuscular blocking agents for any reason, were excluded. The women's physical features, education duration, menstrual and constipation status, profession, obstetric anamnesis and presence of chronic illness were recorded. Global pelvic floor bother questionnaire was applied for deciding whether the women were asymptomatic or not. Gynecologist and physiotherapist evaluated the pelvic floor muscle contraction of the women by transabdominal ultrasonography. A physiotherapist provided 1 hour training to the women prior to the transabdominal ultrasonography evaluation. During this training, four contraction methods (pelvic floor muscle contraction, hollowing maneuver, bracing maneuver and anal contraction) were taught visually and practically. The measurements were repeated 3 times for each contraction and the average of the 3 measurements was analyzed. The sequence of the contractions was set by using the random method for the assessment of the four contractions. The descriptive statistics of the acquired data were estimated as the mean, standard deviation, numbers and percentile frequencies. The simple repeated measurement analysis of variance and Sidak post-hoc test were used for the comparison of pelvic floor muscle function measured for the four contraction types. The statistical significance level was accepted as p<0.05 and SPSS (ver. 18) program was used for the estimations.

The women's physical and socio-demographic features are shown in Table 1 . By comparing the contraction types in terms of pelvic floor muscle function, it was found that the average of pelvic floor muscle function ranked from the highest to the lowest respectively as the bracing maneuver, hollowing maneuver, pelvic floor muscle contraction and anal contraction (p=0.0001).

The women's pelvic floor muscle function was at the highest level during the bracing maneuver and it was at the lowest level during the anal contraction.

We think that teaching the women exercises including the bracing maneuver during the pelvic floor muscle training will be more effective for improving pelvic floor muscle function. 

Hypothesis / aims of study There is controversy in the role of cystodistension treatment of painful bladder syndrome/interstitial cystitis. Amercian guidance suggests a role for cystodistension in the treatment for painful bladder syndrome/interstitial cystitis as third line in the event of failed response to medical therapies and cognitive behavioural therapies. European guidance is much more guarded and highlights a lack of reliable evidence whilst recognising its widespread use. The authors evaluate the available evidence base for the use of cystodistension for painful bladder syndrome with particular reference to patient related outcomes. (1, 2) Study design, materials and methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement, a prospective search and evaluation protocol was prepared and registered with PROSPERO database (ID CRD42017053710). A review of the literature was performed using search terms cystodistension and hydrodistension of the bladder using the Pubmed database on 6 October 2016.

Fifty-four papers and abstracts were identified from 1975-2016, but only seventeen studies contained original outcome data (Table  1 ). Ten studies (533 patients) evaluated the outcome of cystodistension in a single arm design or used cystodistension as the control for evaluating other treatments. Seven studies (302 patients) evaluated cystodistension in combination with other agents or therapies. The best symptomatic responses reported a subjective improvement in 56% of men with moderate to severe prostatitis and 57% in patients with interstitial cystitis respectively. A single study reported a 100% improvement in O'Leary Sant questionnaires at 6 months in patients treated with cystodistension and DMSO. There were no studies that employed a validated outcome measure, either questionnaire or analogue scale, to assess the effect of cystodistension alone.

Cystodistension remains popular in spite of a weak evidence base. The quality of available evidence falls below the level that would be expected of a new intervention prior to widespread usage.

Concluding message This review highlights the need for cystodistension to be further investigated with randomised control trials and to standardise national/international protocols. 

Hypothesis / aims of study This is the first study on the management of postpartum urinary retention (PUR), based on evidence and consensus of experts. PUR is defined as the absence of spontaneous urination six hours after vaginal delivery or after removal of the bladder catheter. It can be 'overt' or 'covert'. It is persistent, when it extends for more than three days after giving birth(1). Therefore, the objective of this study was to establish consensus among specialists about clinical recommendations, based on evidence, to prevent and treat PUR.

Study design, materials and methods A descriptive-exploratory study developed through the Delphi Technique for the purpose of forming consensus among experts on recommendations, based on evidence. Prior to the consensus-building phase, publications on PUR management from two search strategies were selected and analyzed, these publications having been authored by two independent researchers, and the selection of these publications was finished in January 2016. The first search was carried out in six databases: EMBASE, MEDLINE (PubMed), Scopus, Cinahl, LILACS, SciELO and DARE. The second search was carried out through Google Scholar. Data collection for consensus formation occurred from November 2016 to January 2017. Four instruments were used to collect data, one of them for characterization of the sample. For the consensus formation three rounds of the Delphi panel were performed. In the first round, the pre-intervention instrument, composed of structured questions, based on the recommendations, was sent. In the second round, intervention instrument 1 was sent, composed of the issues structured and reviewed by the experts in the first round, plus the links to the evidence that provided the basis for the recommendations. In the third round, the intervention instrument 2, composed of the questions structured and reviewed by the experts in the previous round, the percentage of agreement of each recommendation and the opinions of the specialists, was sent. A Likert scale with scores from 1 (fully disagree) to 5 (I fully agree) was used to check agreement with each recommendation.

There was an open question at the end of each recommendation where the experts could suggest changes. The instruments were made available on the Google Drive® platform. The selection of the participating experts was conducted according to the criteria of the Delphi technique, which consists of the valuation of the knowledge and practical experience of the specialist, referring to the object of study. We included in the sample doctors and nurses with experience in the care and/or research, with at least the qualification of specialist in one or more of the following areas: obstetrics, urology or urogynecology. We also carried out descriptive statistical assessment of the data (mean, median and standard deviation). The scores of the questions were submitted to the analysis to verify the level of agreement of the respondents for each question. The consensus considered for the inclusion of the recommendation was ≥80% (2) . The answers to the open questions were evaluated and grouped according to similarity, relevance and pertinence. The suggestions for change were compiled after each round and added to the instruments of the subsequent rounds.

After the analysis of the collected material, 23 articles of the first search and four international guidelines of the second search were selected, which subsidized the elaboration of 48 clinical recommendations for PUR prevention and treatment. In order to compose the recommendations to identify and prevent PUR, we considered the evidences that portrayed the risk factors for PUR, as well as the measures to avoid their occurrence and possible complications. Evidence was also used on the ways of treating overt and covert PUR and re-education of the bladder in cases of persistent PUR. The 48 clinical recommendations were distributed in three domains: 18 (37.5%) recommendations to prevent overt and covert PUR, 14 (29.2%) recommendations to treat overt and covert PUR, and 16 (33, 3%) recommendations for re-educating the bladder in persistent PUR. After the first round, ten recommendations were modified and after the second round, two recommendations were modified based on the opinions issued by the experts. The number of specialists per round participating in the study is shown in Table 1 . There was a gradual increase in the consensus of inclusion of the recommendations among the specialists, as the rounds progressed. In the first round, the specialists had access to the 48 recommendations without knowing the evidence that substantiated them. In the second round, the experts had access to the evidence of recommendations categorized according to the level and grade of recommendation and the 48 recommendations changed after the first round. In the third round, the experts had access to the level of agreement obtained in the previous round, to the opinion of their peers and to the 48 recommendations changed after the second round. At the end of the study, it was possible to obtain inclusion consensus for 39 recommendations, 12 (30.8%) to prevent overt and covert PUR, 12 (30.8%) to treat overt and covert PUR, and 15 (38.4 %) To re-educate the bladder in persistent PUR. Table 2 shows the distribution of recommendations with inclusion consensus ≥80%. Interpretation of results Risk factors and evidence found in the literature provided support for the development of clinical recommendations. In addition, the Delphi panel composed of experienced experts was essential in the process of validation and improvement of the recommendations, given the critical capacity and the involvement of each one of the members. The experts made several suggestions for the recommendations, some of which were aimed at semantics and clarity, others to patient safety. It can be inferred that the opinions were contextualized from the previous knowledge and practical experience of each specialist, judging, mainly, by their commitment to the safety and well-being of the postpartum patient. The Delphi panel ends when an acceptable degree of consensus is reached and, generally, three rounds are sufficient to achieve consensus, with most adjustments occurring between the first and second (3) . Even after the three rounds of the Delphi panel, nine recommendations did not reach inclusion consensus. The opinions expressed by the experts on the recommendations with a consensus of inclusion and exclusion provided important inputs that can be considered in the decision-making process. Regarding the relevance of this consensus, as the first to be carried out in this area, it is believed that it is necessary to periodically review and update these recommendations, due to the rapid evolution of knowledge in the health area.

Concluding message Through a rigorous methodology, it was possible to obtain inclusion consensus for 39 recommendations to prevent and treat overt and covert PUR and re-educate the bladder in persistent PUR. 

Hypothesis / aims of study Pelvic organ prolapse (POP) is a prevalent condition that is known to affect the quality of life. It is common among older women, although other risk factors including high parity-vaginal deliveries, instrumental deliveries and high body mass index (BMI), have been suggested as predisposing factors. Reconstructive surgery is a common treatment for 3 rd degree prolapse. The Pelvic Organ Prolapse Quantification System (POP-Q) is a staging system in which eight sites are measured and according to the measurements one can determine the severity of the prolapse and the leading site of the prolapse. As opposed to 2 nd and 4 th degree, the 3 rd degree is composed of a wide range of prolapse of the leading part. Our medical center serves an orthodox Jewish population with a high average parity per women. As a result, there is a high percentage of women with symptomatic prolapse including 3 rd and 4 th degree prolapses Untill now there is no reference in the literature to the severity of the prolapse and it's impact on the surgical outcome.

Our objective is to answer that question by comparing different degrees of anterior wall prolapse within the 3 rd degree (according to POP-Q) and their surgical outcome.

Study design, materials and methods A retrospective cohort study. One hundred thirteen women who underwent reconstructive surgery using vaginal polypropylene mesh. Data from medical files was retrieved, including demographics, pre and post operation POP-Q measurements, surgical outcome from the follow-up visits.

The participants were divided according to their pre-operation POP-Q -Ba measurement and post operation outcome was reviewed and compared in relation to the pre-operation data.

Post operative measurement values of -3 or -2 were considered success.

There were 89 women with 3 rd degree anterior wall prolapse. The women were divided into 2 major groups according to their pre-operation Ba measurement; one group comprised of Ba measured +2,+3 , the second group was comprised of Ba measured +4 and above. Post operative Ba measurements were compared in relation to the pre-op measurements.

The success rate of reconstructive surgery for pelvic floor prolapse was statistically higher (94.4%) in the group comprised of +2,+3 Ba measurements (according to Fisher's exact test).

Other possible confounders were analyzed using logistic regression test and non was found to affect the main outcome.

Concluding message According to our research the success rate of reconstructive surgery in mild 3 rd degree prolapse is significantly better compared to advanced 3 rd degree prolapse This is the first report that addresses the issue of stratifying the 3 rd degree anterior wall prolapse in correlation to surgical outcome and can be used as a prognostic factor to assess success rate of reconstructive surgery. We believe that this information can improve the decision making process of electing the best treatment for patients with 3 rd degree prolapse. 

Hypothesis / aims of study: Coital incontinence has been standardized for the first time in 2010 by IUGA/ICS. It is a frequent but underreported problem and has a strong effect on female sexuality. Our aim is to analyze the effect of conservative and surgical treatment methods on coital incontinence and quality of life.

Study design, materials and methods: Women applying with urinary incontinence and suffering from coital incontinence and treated with pelvic floor rehabilitation or surgery were included. Urogynecologic evaluation, urodynamics, posttreatment results, and quality of life were analyzed. There was no significant difference in the quality of life between conservative treatment group and the surgery group. (Table 1) Interpretation of results Some authors advocate that coital incontinence-both at penetration and at orgasm is almost invariably a symptom of urodynamic stress incontinence and treatment with midurethral slings resulted in 87% cure rate in some series. [1, 2] However, as seen in our group of patients, coital incontinence may accompany detrusor overactivity as well as urodynamic stress incontinence. In our study, similar success rate was observed between the group that underwent pelvic floor rehabilitation and the group that underwent surgery. Pelvic floor rehabilitation is the first line treatment for urinary incontinence and it is also effective in the presence of coital incontinence.

Concluding message Conservative treatment and surgery are both effective in the treatment of coital incontinence symptoms with improvement in quality of life. However, larger studies,especially studying the timing of incontinence during coitusa and its correlation with treatment and the evaluation of the effect on sexual functions after treatment are needed. 

Hypothesis / aims of study The objective of this study is to determine the effectiveness of pelvic floor muscle (PFM) training in the management of female urinary incontinence (UI). The following hypothesis was tested: that PFM training is better than no treatment, placebo, sham, or any other form of inactive control treatment. Because new trials are eligible for inclusion in the Cochrane systematic review (last updated 2014) [1] , an update of current best evidence is needed.

We searched (17 March 2017) the Cochrane Incontinence Group Specialised Register, which contain: trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process; hand searched journals and conference proceedings; and the reference lists of relevant articles. We included randomised or quasi-randomised trials in women with stress (SUI), urge (UUI) or mixed urinary incontinence (MUI), based on symptoms, signs, or urodynamics. One arm of the trial included PFM training. The comparator arm was no treatment, placebo, sham, or other inactive control treatment. Trials were sub-grouped by UI types. Outcomes of interest were patient reported measures, clinician reported measures, quality of life (QOL) and side effects. Two reviewers (LC and CD) independently assessed eligibility and methodological quality of trials. Any disagreement was resolved by discussion or arbitration with a third party (JHS). Two reviewers independently extracted data for the pre-defined outcomes (LC and CD). Meta-analysis was conducted when appropriate, in subgroups (by UI type), due to the heterogeneity of samples. For categorical outcomes we used risk ratio (RR) and for continuous outcomes we determined a mean difference, both with 95% confidence intervals (CI). A fixed effect model was used except if there was statistically significant heterogeneity in which case a random-effects model was considered. Risk of bias assessment was carried out as described in the Cochrane Handbook [2] .

Nine new trials were added in the update. In total, thirty trials involving 1788 women (918 PFM training, 870 controls) were included in the review; 26 trials (1526 women) contributed data to the meta-analysis. The trials were generally of small or moderate size and many were at moderate risk of bias, based on the trial reports. Risk of bias assessment showed that across all studies approximately 55% of trials had adequate random sequence generation and 30% had adequate allocation concealment. In 40% of trials there was low risk for attrition bias, and outcome assessors were adequately blinded. 75% of trials presented adequate baseline comparability (Figure 1 ). Figure 1 . Risk of bias graph.

Fourteen countries contributed studies to this review (USA, Brazil, UK, Japan, Turkey, Canada, Norway, Austria, China, Iran, Korea, Portugal, The Netherland, and Sweden). There was considerable variation in: interventions used (e.g., programs lasting from 1 to 24 weeks, with 8 to 500 PFM voluntary contractions per day); study populations (e.g., pre-and post-menopausal women, women with osteoporosis and also young volleyball athletes); and outcome measures (e.g., patient reported cure or improvement of symptoms, satisfaction, quantification of symptoms, specific and non specific QOL questionnaires, adverse effects, measures of PFM function and of adherence, among others). For the first time there were trials that reported on women with mixed UI only (n=1) and urge UI only (n=1), and trials that presented an intervention provided exclusively by a smartphone app (n=1).

In women with stress UI, cure was more likely with PFM training in comparison with inactive control (4 trials, RR 8.4, 95% CI 3.7 to 19.1, p<0.00001), and cure or improvement was more likely with PFM training in comparison with inactive control (3 trials, RR 6.3, 95% CI 3.9 to 10.3, p<0.0001). For women with mixed UI, one trial reported that PFM training is associated with better quality of life (ICIQ-UI-SF) in comparison with inactive control (MD -3.97, 95% CI -7.85 to -0.09, p<0.0001). For women with urgepredominant mixed UI one trial reported a greater reduction in the number of leakage episodes with PFM training in comparison with inactive control (MD -1.8m, 95% CI -2.7 to -1.0, p<0.0001). Finally, in trials with women with any type of UI, there was also moderate quality evidence that PFM training is associated with cure (3 trials, RR 5.5, 95% CI 2.9 to 10.5), or cure and improvement (2 trials, RR 2.4, 95% CI 1.6 to 3.5), in comparison with inactive control.

We found evidence that PFM training is better than no treatment, placebo, sham, or other inactive control treatment for women with stress UI, urge UI, mixed UI or UI of any type. The addition of nine new trials did not change the essential findings of the prior review. The wider range of populations, countries and secondary outcomes within these new trials emphasized the strength of recommendation for women with UI. Of note, in almost all new included trials, the PFM training protocols were described in more detail, with progressive training based on exercise physiology. Moreover, there were more use of patient reported symptoms and QOL outcomes, in line with recent recommendations [3] .

Notwithstanding that long-term effectiveness of PFM training needs to be further researched, the updated review provides support for the widespread recommendation that PFM training be included as first-line conservative management programs for women with stress UI, mixed UI, urge UI and UI of any type.

Palleschi G 1 , Pastore A L 1 , Al Salhi Y 1 , Leto A 1 , Fuschi A 1 , Capone L 1 , Velotti G 1 , Pajoncini C 1 , Carbone A 1

Hypothesis / aims of study Women affected by urethral syndrome (US) experience irritative disturbances, the urgency-frequency syndrome and/or pain associated. Usually, in these patients, cystocopy reveals typical lesions of the bladder mucosa characterized by the evidence of metaplastic tissue in the trigonal-bladder neck region (trigonitis). We prospectively evaluated efficacy of Hyaluril, a combination of ialuronic acid and chondroitin sulphate, on urinary and sexual symptoms in a cohort of females with US comparing treatmentnaive patients (group 1) with those who previously discontinued other ineffective therapies (group 2). Study design, materials and methods All consecutive women who had been diagnosed with US were enrolled in the study. Exclusion criteria were: significant voiding dysfunction, stress urinary incontinence, neurologic status, pelvic organ prolapse >II stage, recurrent tract urinary infections. Three days-voiding diary, Overactive Bladder Questionnaire Short Form (OABq-SF), Indevus urgency severity scale (USS), the Patient Global Impression of Improvement (PGI-I) and Female Sexual Function Index were administered at baseline and after this treatment: intra-vesical administration of Hyaluril [sodium Hyaluronate 800mg/50ml (1.6% w/v) and sodium Chondroitin Sulfate 1g/50ml (2% w/v)] in prefilled syringes adopting the following scheme: 1 dose / week in the first 4 weeks, 1 dose every 2 S272 ICS 2017 weeks in the following 2 weeks and 1 dose / month for 2 months. Kolmogorov-Smirnov test, chi-squared test, Mann-Whitney Rank Sum, and Wilcoxon test were adopted to evaluate outcomes.

Results 66 women (30 in the group 1, 36 in the group 2) met the inclusion criteria, were treated and re-assessed after 4 months from baseline. The voiding diary showed a significant improvement in both groups; however this finding was significantly more relevant in the group of naive patients. The subjective success based on USS reduction and PGI-I was the 71.5% in group 1 and 39.4% in group 2 (p<0.0001). The FSFI data showed an improvement without any significant difference between the two groups. No systemic side effects were reported by patients; 8% of subjects described mild bother during catheterism. However, no symptoms or other disturbances were related after the administration of Hyaluril in the bladder and this procedure was well tolerated by all the cohort.

The US may be the consequence of a primary defective urothelium lining or from damaged glycosaminoglycans (GAGs) layer of the bladder. This condition may lead to chronic bladder epithelial damage and neurogenic inflammation. The main aim of new therapies is to restore the GAG layer and some favourable experiences have been already published in Literature regarding the administration of GAGs. In our experience treatment with Hyaluril improved urinary and sexual symptoms in women suffering from US. Naive patients achieved better results when compared to those patients who were previously submitted to other treatments. This results should clinicians to consider the chance to early administrate this type of treatment in subjects with this pathological condition. 

Hypothesis / aims of study Ureteric fistulas are secondary nicks, cuts, or ties in the distal ureter where it is near the cervix(1). Ureteric injury is a serious complication. It causes significant morbidity to the patients.Ureteric injuries have become increasingly common in Obstetrics and Gynaecology (2). This study was conducted to find out prevalence of ureteric fistula and associated risk factors in low resourced setting in Africa.

Study design, materials and methods Descriptive cross sectional study was conducted in Comprehensive Community Based Rehabilitation Centre in Tanzania . Ureteric Injuries in females presenting to biggest fistula treatment centre in Africa between 2011-2015 ( 5years) were evaluated. Causes of fistula , duration of incontinence and treatment mode were recorded and analysed .

There were total 2750 patients with genitourinary fistula in 5 years in CCBRT. 108 patients were diagnosed as ureteric fistulas. 

In low resourced setting , Obstetric cause are still the most common cause of incontinence secondary to ureteric injuries Concluding message Better health care delivery system and good maternity services would go a long way preventing these problems.

Hypothesis / aims of study Autologous muscle derived cells (AMDC) have the potential to restore muscle function, thus reconstructing the weakened urinary sphincter that causes stress urinary incontinence (SUI). A systematic review has suggested that AMDC injection in the urethral sphincter is promising due to its safety and potential effectiveness as a treatment modality for SUI (1) (2) . Autologous muscle cell therapy, which involves isolation of cells from skeletal muscle biopsies, ex vivo expansion, and subsequent injection into the urethral sphincter, may serve as a potential durable therapy. In animal studies, muscle derived cells have successfully integrated within tissue to improve sphincter function (3).

Despite promising results on continence in women, no predictive factors have been identified in order to more accurately select patients who could benefit from this therapy. Therefore, the objective of this study was to explore predictive factors for the efficacy of AMDC injections, defined as a reduction of incontinence episode frequency (IEF) at 12-months compared to baseline.

Study design, materials and methods This prospective study was conducted at a tertiary care center between February 2012 and January 2015. This is a secondary analysis from a larger randomized controlled trial (RCT) in which participants received either a placebo or a 150 x10 6 AMDC injection. Participants in the treatment group received either one or two injections (second treatment was approximately 6 months after the initial). Patients who received the placebo treatment were not included in this analysis. After obtaining informed consent and approval by the ethics committee, thirty-seven women with SUI received transurethral injections of AMDC that were derived and manufactured from a quadriceps muscle biopsy as part of the larger RCT. All subjects were evaluated at baseline and 12 months post-injection. A transperineal 3D ultrasound was performed at baseline and each of the follow-up visits. A total of 14 (37.8%) women were considered responders as they showed a reduction of 75% or more of IEF at 12 months. Univariate logistic regression revealed that the following variables were non-significantly associated with treatment success (p>0.05): age, body mass index, length of urethra, volume of rhabdosphincter, VLPP and clinical urethral hypermobility. However, as shown in Table 1 , lower ultrasound bladder neck hypermobility at valsalva, defined as caudal displacement (p=0.05), and dorso-caudal displacement (p=0.04) were associated with greater success. Univariate logistic regression for bladder neck dorsal displacement showed a tendency towards statistical significance (p=0.07) (see Figure 1 for example of bladder neck position measurement at rest). It should be noted that the strong correlations between these variables (multicollinearity) prevented computing multivariate logistic regression. When defining responders as a reduction of 50% or more of IEF at 12 months, similar results were obtained from univariate logistic regression showing a tendency towards statistical significance for the following: bladder neck caudal (p=0.06) and dorso-caudal displacement (p=0.06).

To our knowledge, this is the first study that explores predictive factors for the efficacy of AMDC injections in women with SUI.

Results suggest that patients with limited bladder neck hypermobility at valsava on ultrasound respond better to this treatment modality. These results corroborate with the principle that AMDC injections improve SUI by reducing intrinsic sphincter deficiency rather than reducing bladder neck hypermobility. These data may allow physicians to preoperatively identify women that may benefit from such treatment.

Concluding message Ultrasound bladder neck hypermobility was shown to be a predictive factor for the efficacy of AMDC injections in women with SUI. More precisely, this suggests that patients with limited bladder neck hypermobility at ultrasound respond better to this treatment. Studies focusing on the identification of predictive factors on a larger scale are much needed. 

Hypothesis / aims of study The research aims at developing an original model for the identification, measurement and analysis, in a societal perspective, of the costs that arise from the complex Diagnosis and Treatment Paths (DTPs) of female UI, making distinction between the costs that are borne by the national healthcare system (NHS) and private expenditures. The need for a model derives from three main motivations: i) UI is a very diverse disease: its various types largely differ for their aetiology and subsequent treatments; ii) in many countries (Italy included), it is not possible to obtain complete and detailed information on actual costs, given the absence of precise treatment protocols, a significant diversity among the different regions of the country and the lack of specifically designed cost accounting systems; iii) through a model, it is possible to assess also the costs privately borne by individuals (and their families, employers, etc.).

The research has been carried on by an interdisciplinary team, with specialists in the study and treatment of UI and -with a particular focus on the identification, measurement and assessment of the economic dimensions of the DTPs -experts in business economics and accounting. The application of the model has been limited to 18-85 years old women, not living in residential care homes and not affected by disabling or extremely severe diseases. The model is based on a two-dimensional classification of UI (i.e. by type and by age: four main types, anatomic SUI and ISD SUI, UUI and -as a combination of the other types -MUI, and four significant ages, 30, 45, 60 and 75 yrs), defining modules that have been studied and analysed through the Event tree analysis (ETA) method. The event trees start with the first visit with the GP and, after a sequence of events linked by conditional probabilities, lead to a list of possible outcomes, characterised by different probabilities and costs. The combination of events and probabilities of each module depends mainly on the capability of the healthcare system to effectively attract patients and address them towards proper treatments (supply side) and on the awareness and determination of incontinent women, together with their overall trust in the healthcare system (demand side). The direct costs of DTPs have been classified into six broad categories: GP visits, specialist visits, surgical treatments, pharmacological therapy, physical therapy, absorbent and skin protection products. For the definition of the structure of the trees, the probabilities of the events, the identification and estimates of the cost components and their attribution to either NHS or private expenditure, the study has formulated hypotheses in coherence with the existing research (on Italy and other comparable contexts). When it was not possible to rely unambiguously on adequate publications and secondary data, the overall plausibility of the hypotheses has been validated with a wider panel of selected experts.

The table below shows the event tree for the most common type of UI for a woman aged 60. Outcomes that are labelled "A.x" (e.g. A.1) correspond to a recovery, while those labelled "B.x" may correspond to a partial recovery (e.g. B.

3) or to no improvement (e.g. B.7, B.8, B.9). In the "DTPs costs" column, the costs of absorbent products are not included, in order to highlight just the costs of diagnosis and therapy attempts. Interpretation of results The event tree of each module offers a quick overview of the main possible outcomes of the DTP and provides measures of how an outcome probability may be affected if the probability of a certain event along the path would change. In other words, the observation of the event-tree may suggest which actions could be taken by decision makers to favour more desirable outcomes.

For example, Table 1 shows that in Italy, a sixty years old woman affected by anatomic SUI currently has a 70% probability to quit the DTP without even starting any therapy (outcomes B.7+B.8+B.9). The event tree indicates that this is mainly due to what happens after the GP visit, suggesting the opportunity of initiatives that could increase the number of women that visit a specialist instead of accepting their condition (for example, specific awareness raising projects or the introduction of limitations to the possibility of GPs to prescribe absorbent products). Another possible use of the probabilities of each possible outcome, e.g. in combination with data on incidence, is to predict the demand of specific treatments, allowing the NHS (or private investors) to better focus their investments. Focusing on costs: -the event trees of all the modules showed a very wide range for the cost estimates of the possible outcomes (e.g., in Table 1 , DTPs costs range from € 40 -outcome B.9 -to € 7.253 -A.5-B.4). As an important contribution for the studies on cost-of-illness, the event tree analysis allows the calculation of the "probabilities weighted average cost" of each module, providing measures that could be useful to assess the total costs for a certain population. The use of different averages could take to unfounded estimates; -comparisons between the costs of different DTP outcomes cannot be performed without extending the cost observation to the subsequent years and without taking into account also the costs of absorbent products, the indirect costs and, when possible, also the intangible costs.

In the case described in Table 1 , we have demonstrated that it takes less than two years for the total direct and indirect costs of outcome B.9 to exceed the DTP expense of the outcome A.1. In other, words, the shifting towards a DTP with an apparent higher expenditure, eventually leads to a saving, without even taking into account the positive effects of the recovery on intangible costs and quality of life.

Concluding message Event-tree based models may be a powerful tool for a better understanding of the key drivers of UI direct costs and, consequently, of the aspects that should be primarily addressed by public policies makers, scientific community, specialists, GPs and their representative associations. Also, the method of event-tree analysis favours the interdisciplinary dialogue that is fundamental for well-grounded and in-depth cost-of-illness studies. 

Hypothesis / aims of study The American College of Obstetricians and Gynecologists supports vaginal hysterectomy as the safest and most cost effective route. While the cost-benefit ratio is favorable, there are still opportunities to optimize efficiency and contain cost. Numerous studies have highlighted the low instrument utilization within surgical trays, which results in excess processing costs and surgical case set-up time. Other risks related to excess surgical instruments include a reduction in instrument longevity from excess wearand-tear, increased risk for tray assembly errors, and unnecessary strain placed on operating suite staff from instrument tray weight. Notably, in gynecologic surgery, one study reported as few as 13% of instruments on a surgical tray were used in vaginal cases.

We aimed to evaluate the instrument usage within our vaginal hysterectomy trays to reduce unnecessary instruments without compromising high quality, safe patient care. Using an estimated cost of processing of $0.51/instrument, we calculated cost savings from the development of a "minor gynecology" tray that could replace the vaginal hysterectomy tray previously used for benign outpatient vaginal cases.

The Female Pelvic Medicine and Reconstructive Surgeons (FPRMS) and operating room staff first eliminated extraneous instruments based on clinical experience. Following that initial reduction, the Surgical Quality Committee initiated a formal audit of surgical instrument usage. The vaginal hysterectomy tray was used for major benign gynecology cases including vaginal hysterectomy with and without pelvic reconstruction, urogenital and rectovaginal fistulas approached vaginally, and vaginal mesh removal. Minor gynecology cases included isolated anterior or posterior repairs, Bartholin cyst/labial lesions, urethral diverticulum, midurethral sling, and revision of midurethral sling. Cost of sterile processing and packaging was estimated to be $0.51/instrument based on published data 1 .

The standard vaginal hysterectomy tray contains 67 instruments. This was reduced to 48 instruments in the Minor GYN pan (Figure 1) . 

Cost savings are likely underestimated in this study due to the surgeon-and operating room staff-driven initiative to reduce the number of instruments in each tray prior to the formal audit. Healthcare costs related to set-up, processing and packaging of unused surgical instruments can be reduced when surgeons and operating suite staff work together to identify opportunities to reduce inefficiencies.

The development of a minor gynecology pan resulted in a modest cost savings within this department, but advantages regarding time to set-up and process instruments as well as longevity cannot be understated. Study design, materials and methods This is a prospective cohort study design in the "Plan-Do-Study-Act" quality improvement format. A lecture series to 58 out of a total of 65 internal medicine residents was given by a urogynecology fellow that included guidance on UI screening, treatments that can be started in a primary care setting, and when and how to refer to a specialist. A validated urinary incontinence screen was given to residents in an electronic health record "dot phrase" to be added to their new female patient history and physical documentation. Inclusion criteria included, new, female patients to the internal medicine clinic over the age of 40. Metrics collected were patients' race, preferred language, age, number of comorbidities documented in electronic health records, number of female patients screened, treated, referred to specialist for UI. A chart review of 200 charts prior to the intervention and 92 charts after the intervention were reviewed. Statistical analysis was carried out with SPSS version 23. This study was

In the pre-intervention group, 13% of patients were screened for UI and of those screened, 46% were positive, which is consistent with previously documented incontinence rates. Twelve percent of those patients who screened positive were offered treatment, including pelvic floor exercises and anticholinergics. No specialist referrals were made.

In the post-intervention group 15% of patients were screened, 35.7% were positive for UI and of that group, 40% were offered treatment. There was no statistical difference between pre-and post-intervention groups for screening, positive screen, or treatments offered. Interpretation of results Providing a lecture series, a very common format for educating a Urogynecology referral base, was not effective. Screening rates for UI did not improve with the intervention, and therefore there was no improvement in diagnosis or treatment.

The next step of this study will be to add a validated questionnaire to the nursing intake in primary care clinics that is automatically added in the electronic health record, a more automatic screen for this very common medical condition. We also are surveying the internal medicine residents to pinpoint issues that may hinder UI screening in clinic so that we can create a more effective intervention. 

Hypothesis / aims of study The James Lind Alliance (JLA) was established in the UK in 2004 to ensure that the voices of patients, carers and clinicians are heard when establishing research priorities [1] . Initially, the emphasis was on determining 'treatment uncertainties' for particular health conditions by setting up disease-specific Priority Setting Partnerships (PSPs). However, increasingly PSPs have widened this remit by including questions that lead to evidence uncertainties such as day to day life or care for patients with a particular condition. Since 2013, the infrastructure of the JLA has been funded by the National Institute for Health Research (NIHR), the research arm of the National Health Service (NHS) in the UK.

A number of research PSPs have been carried out recently that considered research priorities for people who have physical or cognitive limitations and/or long-term or terminal health conditions, most led by charitable research funding organisations such as Parkinson's UK, Marie Curie and the Alzheimer's Society. In a number of these PSPs, incontinence was raised as an important topic. In consequence, a joint workshop was carried out by a number of participating charities for their research communities as well as patients and carers, to encourage more research, more collaboration and more multi-disciplinary approaches, for both urinary and bowel incontinence.

Study design, materials and methods JLA PSPs follow a standard methodology [1, 2, 3] consisting of an initial survey to patients, carers and clinicians to identify questions. Questions are then refined and combined, checked against systematic reviews to ensure they are not already answered and prioritised in a second survey. The final step is for patients, carers and clinicians to agree, at a face-to-face workshop, the most important questions for future research to answer.

A number of research questions / evidence priorities that relate to continence problems have been highlighted by patients, carers and clinicians in the following PSPs.

What treatments are helpful in reducing urinary problems (urgency, irritable bladder, incontinence) in people with Parkinson's? This question was prioritised as the 10 th most important question for Parkinson's research [2] . What treatments are helpful in reducing bowel problems (constipation, incontinence) in people with Parkinson's?

How is incontinence best managed in people who are approaching the end of life (including those with Parkinson's disease)?

What are the best ways to manage incontinence in people with dementia?

What bladder management strategy is most effective in reducing the number of urinary tract infections and secondary complications? This question was prioritised as the 4 th most important question for Spinal Cord Injury research [3] .

What are the effects of ageing after spinal cord injury on the development of complications, including spasticity and bladder and bowel incontinence, and need for home-based support? This question was prioritised as the 9 th most important question for Spinal Cord Injury research [3] .

What is the best treatment for controlling diarrhoea and/or incontinence symptoms in people with IBD, including novel pharmacological and non-pharmacological options? Is high-dose Loperamide safe and effective in the treatment of diarrhoea in IBD? This question was prioritised as the 6 th most important question for Inflammatory Bowel Disease research.

Alongside these recent PSPs, an older PSP on Urinary Incontinence was conducted in 2006 which generated a full list of questions relating to the treatment and management of urinary incontinence (http://www.jla.nihr.ac.uk/priority-setting-partnerships/urinaryincontinence/top-10-priorities/). The workshop held jointly by a number of charities in December 2016 highlighted the inadequacy of current interventions to manage faecal and urinary incontinence -either through self-management and management by carers. A lack of training for health care professionals in continence care and a lack of information for patients and carers on treatment and self-management options were highlighted by participants. The workshop was an important next step in addressing this important priority across a range of conditions and highlighted that new strategies to manage and treat incontinence are urgently needed.

Incontinence is a major issue impacting severely on the quality of life of people who have physical or cognitive limitations and/or long-term or terminal health conditions and for older people who may face limitations from a range of co-morbidities. More research is needed in a number of important areas, from the fundamental understanding of the mechanisms of incontinence to more non-drug and non-surgical interventions to improve self-management of patients.

There is an urgent need for more patient-centred research for people who have physical or cognitive limitations and/or long-term or terminal health conditions and for older people who may face limitations from a range of co-morbidities. Interventions to improve training for health care professionals and information provision for patients and carers are needed as well as non-drug and nonsurgical interventions that promote self-management. 

Aims of study Pelvic floor muscle exercises (PFME) are effective for prevention of urinary incontinence (UI) related to pregnancy and childbirth [1] . Guidelines for managing UI recommend offering PFME to women during pregnancy as a preventative strategy [2] . Successful implementation of interventions must be underpinned by an understanding of the complex individual, professional, and organisational context in which care takes place. This study aimed to understand the perspectives of women and healthcare professionals regarding opportunities, challenges and concerns that may be essential for implementing PFME and maximising its impact during childbearing years, through synthesis of existing literature using a critical interpretive synthesis (CIS) approach. CIS provides an innovative method for synthesising literature as the basis for an implementation project, drawing on qualitative research methods to synthesise a broad range of empirical and non-empirical evidence using an interpretive analysis.

Study design, materials and methods CIS was used to analyse a range of sources reporting women's and healthcare professionals' perspectives of UI and PFME during childbearing years. Fifteen electronic databases were searched from date of inception to July 2016 for terms relating to pregnant women and mothers and PFME. Reports were included if they presented either contemporary or retrospective views of women or healthcare professionals relating to PFME education, assessment or training during pregnancy or after birth. Data analysis and synthesis similar to that of primary qualitative research identified study characteristics and key themes.

Thirty-two papers were included. Twenty-seven reported primary research data from 23 studies (surveys (n=16), qualitative interviews (n=3), qualitative focus group (n=1), Q-methodology (n=1), mixed methods (n=1), pre-/post-intervention cohort (n=1)), one presented a review of qualitative studies, and four were commentaries/opinion pieces. Of the 27 reports of primary research 14 documented perspectives of postnatal women, four studies concerned the experiences of women during pregnancy, and seven studies presented the perspectives of healthcare professionals. Healthcare professional data specifically relating to antenatal PFME largely represented the beliefs and practices of midwives. The views of obstetricians, obstetric physiotherapists and nonmidwifery childbirth educators were poorly represented. No qualitative studies of healthcare professionals' perspectives were found, and the majority of material focussed on individual attitudes and behaviours with little or no evidence relating to organisational influences. Four themes were inductively derived: service provision; knowledge and understanding; motivation; taboo.

Service provision A lack of information was provided to women about UI and/or PFME by healthcare professionals during pregnancy. Challenges and concerns included low prioritisation of PFME and cultural opposition to PFME assessment by midwives, appropriate timing of information delivery during pregnancy, lack of clear guidelines and recommendations, and unclear professional responsibility for PFME during or following pregnancy. Opportunities for improvement included routine antenatal continence screening and counselling regarding risk of UI by midwives, individualised advice and instruction in PFME early in pregnancy, development of protocols with clear guidelines and standards for UI/PFME in antenatal care, and transparent referral pathways for specialist services for women at high risk of UI.

Women had limited understanding of the importance and benefits of PFME and were unclear of their role in prevention and treatment of UI. They were unsure how to perform PFME and expressed feelings of lack of control and low self-efficacy for performing and maintaining correct, regular PFME. UI was normalised by healthcare professionals, friends and relatives, reinforcing women's beliefs that UI should be accepted and would resolve spontaneously. Midwives and other healthcare professionals felt ill-informed about UI, were unaware of guidelines and recommendations for PFME, and lacked confidence in knowledge and skills for teaching PFME to women. Implementation of PFME in antenatal care requires training for healthcare professionals to ensure women receive accurate, evidence-based information, care and support. This includes developing communication skills and behaviour change techniques to support uptake of PFME.

Women lacked motivation to carry out regular PFME. Low expectation of benefit or efficacy of PFME, and lack of interest in or low perceived threat of UI made it difficult to integrate PFME in daily life. Prioritising PFME alongside other roles and responsibilities was challenging and women often forgot to exercise. Some women who experienced UI symptoms or witnessed UI in close friends or relatives were motivated to exercise, others who lacked belief in effectiveness of PFME were not. Opportunities were identified for improved communication from healthcare professionals to help identify and problem-solve challenges, and persuade and enable women to see positive value in PFME in order to integrate this into daily life.

Women viewed UI as taboo, and linked symptoms to older age and lack of personal control. Normalisation of UI meant women feared they were time wasting and that their symptoms were too trivial to bother their healthcare professional with. Feelings of shame, embarrassment and humiliation prevented women from seeking help for UI. Women feared judgement or censure from healthcare professionals for not doing their exercises and blamed themselves for lack of success with PFME. Women would like to be asked direct questions about UI to provide an opportunity to discuss this embarrassing topic and to access appropriate support.

Interpretation of results Previous research has focused on women's perspectives of treatment and management of postnatal UI with limited evidence exploring views and experiences of women during the antenatal period or healthcare professionals regarding PFME during childbearing years. Despite evidence for the effectiveness of PFME for preventing UI, these findings suggest that PFME is not implemented effectively during pregnancy.

There is a need to engage and support women, healthcare professionals and organisations in overcoming the taboo of UI and identifying opportunities for improving implementation of PFME during childbearing years. Further research is underway to develop an understanding of current service provision and to explore the views and experiences of midwives and other healthcare professionals involved in delivery of antenatal care. Findings from this review combined with ongoing research will inform the development of training resources for midwives to support effective implementation of antenatal PFME. 

Wagg A 1 , Sheri N 1 , Gibson W 1 , Hunter K 1

Hypothesis / aims of study Urinary incontinence in older people has a significant impact on not only quality of life, but also can lead to adverse outcomes such as depression, urinary tract infection, falls, and an increased rate of institutionalization. Older people often delay health care seeking for their incontinence [1] . Awareness of the many treatment options available to help cope with the issue appears to be low. In terms of treatment and cure, the dictionary definition does not adequately consider the feelings of the observer, whether patient or clinician. As patient reported outcomes from medical treatments become increasingly important in assessing quality of care and service provision, it is important to understand to what degree patients' expectations are met as part of assessments of the overall patient experience. Likewise, an understanding of those interventions which patients might find unacceptable would allow clinicians to counsel patients regarding realistic expectations, or cater to their preferences. There are no data, which examine expectations and acceptability of treatments in older patients. The aims of this study were therefore to determine what degree of improvement in UI was desirable for older persons with UI, what treatments older patients found acceptable and what symptoms they would be willing to tolerate following treatment.

Study design, materials and methods Consecutive older outpatients over 65 years of age referred to a secondary care multi-professional incontinence clinic were assessed using a validated three-part questionnaire, which included the Leicester Urinary Symptom Questionnaire [2] , an attitude questionnaire used in studies of younger patients, and the King's Health Questionnaire [3] . The Leicester Urinary Symptom Questionnaire (LUSQ) is a validated ten-item questionnaire, reliable in establishing a diagnosis based on symptoms of bladder problems in both men and women. The attitudes questionnaire consisted of 28 questions divided into five different categories, including: acceptance of current problems, willingness to modify lifestyle, willingness to undergo various treatments, frequency of hospital visits, and acceptability of side effects. A glossary of terms defining terms used in the questionnaire was provided to patients. The King's Health Questionnaire (KHQ) is a well validated and reported condition specific health related quality of life questionnaire. The questionnaires and definitions were handed to patients following explanation of the study along with a replypaid return envelope. As a descriptive, observational study, no a priori sample size could be calculated, a group of 150 individuals was hypothesised to provide robust data on the primary outcomes of interest, degree of desired improvement in symptoms. In addition to descriptive and summary statistics, relationships between quality of life, diagnosis, and acceptability items were analysed using Pearson's correlation coefficients. Differences in proportions between groups were analysed using the chi-squared test. Length of time with bladder problems was categorized into three groups: less than one year, between one to five years and over 5 years.

Of 150 questionnaires distributed, 121 patients, 91 women and 28 men, returned surveys. The mean (SD) age of the participants was 77.5 (7.9) years (65-95 years, N= 117) and the mean (SD) length of time with bladder problems was 8. Table 5 ). The majority of respondents (n= 56, 85.5%) identified short-term medication as being the most acceptable treatment to them, followed by a clinical procedure with no long-term risk (n= 47, 72.5%). The least popular option was long term catheterisation, which only 6.2% (n= 113) of participants were willing to accept, followed by undergoing a major surgical operation (n= 112,12.6%). In terms of residual symptoms, patients were less prepared to tolerate frequent nocturia, persistent stress incontinence, and frequent pad use. Infrequent nocturia, and using pads only when necessary were more acceptable as residual "problems" (Table 4 ). Least desirable outcomes were having an occasional large leak on coughing or sneezing and frequent small leaks on coughing or sneezing, 10.3% and 21.4% acceptability, respectively. Overall 75.4% of participants were prepared to accept one nocturia episode per night. Women were much more accepting of small leaks on sneezing or coughing and on strenuous exercise post treatment (Χ 2 =.001, p< 0.01, Χ 2 =.003, p< 0.01, respectively) and having to wear pads (Χ 2 =.0004, p< 0.01) than men. Men reported that leaking during sexual intercourse after having treatment (Χ 2 =.002, p< 0.01) was less acceptable to them than women. Men reported a clinical procedure with risk of catheterization more acceptable to them than women (Χ 2 =.0005, p< 0.01). Patients with a longer duration of symptoms were statistically significantly more likely to report lower expectations of treatment compared to those with shorter durations of symptoms (Χ 2 =.008, p< 0.01). There was no statistically significant association between reported quality of life and acceptability of different treatment types, acceptability of outcomes, or expectations of cure. Nurses knowledge By utilizing brainstorming sessions with nurses from the main intervention ward, specific local target areas for CAUTI prevention strategies were identified. This method aimed at involving local clinicians with their active input throughout the project and complemented the literature review findings with organisation-specific factors. Key tools to change practice were tested and refined prior to the development of a more comprehensive CPG. These consisted of:

• Catheter checklist • Discharge form with CAUTI diagnosis checkbox • Patient pamphlet A CPG draft was completed and trialled across the hospital wards

The results indicated improvements in all of the measured criteria over the 8 month project phase:

• The total catheter count across in-patient wards decreased by 42%.

The CAUTI rate decreased from 14 CAUTI/ 1000 Catheter Days to 1.6 CAUTI/ 1000 Catheter Days.

The nursing knowledge assessed by a questionaire increased from 54% pre -CPG exposure to 76% post -CPG exposure. Interpretation of results This clinical practice improvement (CPI) project delivered significant improvements to bladder and urinary management in a regional hospital. The combination of a literature search to review current evidenced based practice with the CPI methodology led to the development of new clinical tools to optimize clinical management. The integration of best practice standards with the innovative clinical tools resulted in a clinical practice guideline based on a 'bundle of care' approach.

The substantial reduction of the CAUTI rate and total catheter days over the study period are seen as a direct effect of the project interventions and promise wider applicability in other centres. Beyond the clinical impact of CAUTI reduction, significant financial benefits were calculated. 

Hypothesis / aims of study Most of SCI patients fail to regularly follow for urological care for the reasons such as lack of awareness, poor guidance, economic issues and distances to travel. Failure to follow predisposes them to greater risk of complications and adversely affects quality of life. We reviewed the role of WhatsApp as a tool to enhance the distance care and follow-up in SCI patients.

We reviewed the use of Instant messaging service such as WhatsApp, an encrypted freeware communication tool, in improving the urological care of SCI patients. Team of 4 urology nurses accessed patients on WhatsApp and requested for their participation. They were encouraged to fill in a questionnaire and share their queries and concerns for prompt resolution by qualified nurse counselors. They were also asked leading questions about their urological health. At the end of one year, they filled in a survey form sharing their experience.

We approached 840 patients through WhatsApp, of whom 720 patients agreed to participate. 600 patients stayed in active contact till the end of study while 120 patients dropped out. WhatsApp was used to schedule appointments and send reminders. 40% of patients followed in-person. Remaining 60% of patients filled in the given proforma and actively shared their relevant concerns. We received about 20 queries daily. About 70% queries were received during work-hours, while 30% during off-hours and on holidays. During the year, 6754 routine and 546 emergent concerns were received. Common queries were failure to catheterize, hematuria, fever, autonomic dysreflexia, catheter blockage and urine leaks. Mainly text messages were used; however pictures and direct talk were often helpful. We could directly resolve 72 % of queries successfully. At final survey, 85% patients found the service valuable and expressed their wish to continue using it.

Instant messaging technology such as WhatsApp is a useful tool to provide distance-care and follow-up of SCI patients. Its main advantages are familiarity and ease of use, free access and round the clock availability.

Concluding message Technology can fill in the gaps of our routine healthcare system in a cost-effective and patient-friendly manner. 

Hypothesis / aims of study Urinary incontinence (UI) is considered a public health problem due to its prevalence and impact in all dimensions of health. It is consensual the positive effect of clinical Pilates on the abdominal core of healthy women, however in this type of condition there is no evidence. Objectives: To evaluate the impact of Clinical Pilates on the functionality of pelvic floor muscles and Quality of Life in women with urinary incontinence.

Study design, materials and methods Quasi-experimental study was conducted in a consecutive sample of 60 women aged ≥50 years and diagnosis of stress or mixed UI and grade ≥ 3 on the modified Oxford scale. The sample was divided into two groups: experimental group (EG; n = 30) and control group (CG; n = 30), this study has 80.0% power to detect an effect size of E = S * E/S = 0.736. The EG performed Clinical Pilates sessions for 60-minutes,twice a week during ten weeks. The impact of the Pilates method on the functionality of the pelvic floor, through the Broome Self-Efficacy Scale, and the Quality of Life by means of the Ditrovie Scale was evaluated. We used descriptive and inferential statistics (Parametric T-Student and Wilcoxon and Mann-Whitney non-parametric tests, with α = 0.05). 

Hypothesis / aims of study Female Pelvic floor dysfunction (PFD) is an important health care issue, because of its high prevalence, its invalidating effect on quality of life and its impact on the health care system. Multiparity, menopause, pregnancy and childbirth are some of the most important risk factors for PFD. Although pelvic floor muscle training is recommended as first-line treatment and prevention strategy for PFD in women, the prevalence rates of PFD remain very high in women during the reproductive age and beyond. Feelings of embarrassment and shame, combined with insufficient knowledge and misperceptions about PFD are the largest barriers to seeking care [1, 2] . PFD remains a taboo topic and is underreported. The prevalence of PFD in healthy female adolescents (4 to 6% occasionally urinary incontinence) is low [3] , but nevertheless, their exposure to the most common risk factors (such as pregnancy and delivery) is approaching while they are growing up to sexual active young females. Therefore primary prevention should ideally start in adolescence. To the best of our knowledge, no previous research ever studied the knowledge of PFD in female adolescents. Asking young females questions about the intimate pelvic floor seem to form an ethical dilemma and may therefore be avoided. The objective of this research was to investigate whether adolescent girls ever received information about the pelvic floor muscles (PFM) and PFD; whether they are interested to receive more information about these topics; and through which canals they would prefer to get informed. In a small sample of this group of adolescent girls, the knowledge of the PFM function was also investigated. Study design, materials and methods Cross-sectional survey design. A reliable and valid questionnaire was distributed to female adolescents (12-18 years old) in High Schools, technical education and vocational schools. All participants and their parents were informed about the research goals and were asked to sign an informed consent form. A small sample received four supplementary questions about the function of the PFM. Descriptive statistics were generated for all variables, Chi-square tests were used.

A total of 399 questionnaires were distributed, the responses of 381 female adolescents (mean age= 15.0, SD= 1.78) were included (response rate 95.5%). All girls and their parents signed the informed consent form. Sixteen percent (n= 61) of the 381 adolescents ever received information about PFM, mostly during comprehensive sex education on School. A total of 166 (44%) girls wants to receive further information on this topic; 136 (36%) is not interested and 65 (17%) is undecided. 140 (36%) girls answered that they already searched for information on their own, through friends or family; while more than half of all girls (n= 221, 58%) would prefer to be informed through school, in group. A sample of 100 girls were asked if they knew the function of the PFM: 76 (76%) declined, only 25 (25%) knew the closure function; 21 (21%) the support function and 22 (22%) the sexual function of the PFM.

The test results reveal that most adolescent girls have a lack of knowledge about the PFM function. Most adolescent females were never informed about the PFM and PFD. Although general anatomy courses and sex education are included in every high school educational programme. One could assume that the topic PFM and possible PFD is considered not important for young female adolescents; another explanation might be that the topic is avoided because PFD is considered as a taboo or to intimate to teach about. Although the results reveal that the majority of the adolescents clearly prefers to get better informed about these topics, ideally through school, in group. We therefore argue that information about the PFM and possible PFD should be included and discussed during their general education in High School. Because PFD are highly prevalent during the lifetime of women (and men) and should not be a taboo to talk about.

The present research is the first to reveal that young female adolescents have a lack of knowledge about the pelvic floor and its (dys)function; and are interested to get better informed. If these topics would be discussed in their general education, through school, the taboo about pelvic floor dysfunction later in life could be diminished.

Hypothesis / aims of study The aims of this study were to examine the effects of applying standardized clinical pathway (CP) on postoperative outcomes, as well as the medical expenses for patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP).

Study design, materials and methods A prospective study was conducted at a single institution. A total of 104 patients participated in this study, and half of them received nursing care based on CP (CP group) while others received traditional care (non-CP group). Patients with bladder cancer, emergency surgery, and preoperative stage 4 of prostate cancer were excluded from this study. Patients who had other operations, together with RALP, were also excluded. Data was collected from November 1, 2016 to February 28, 2017. To compare operative and postoperative outcomes and medical expenses between CP and non-CP groups, Chi-square test and ttest were performed using SPSS (version 24.0).

Participants' demographics, such as age and body mass index (BMI), were not significantly different between CP and non-CP groups. No significant differences were observed in disease-related characteristics such as preoperative prostate volume, Gleason score, TNM state, console time, operation time, estimated blood loss, and lymph node dissection between the two groups. In contrast, tumor volume was significantly greater in CP group compared to non-CP group (3.90 ± 6.52, 2.63±3.10, respectively, p= .037). Regarding the comparison of postoperative outcomes and medical expenses between the two groups, CP group had significantly lower length of postoperative hospital stay (p < .001), pain score at discharge (p= .007), and medical expenses (p= .004) compared to non-CP group. Similarly, CP group had earlier date of gas passing compared with non-CP group (p < .001); however, the number of patients visiting emergency department within 30 days after discharge was not significantly different between the two groups.

Shorter hospital stay shown in CP group can be an important outcome for both patients and hospitals, as it could mean rapid recovery from surgery for patients and increase in profit from fast bed turnover rate for hospitals. In addition, the lack of difference in the number of patients visiting emergency department within 30 days after discharge between these two groups indicates that the recovery rates for one month were similar in CP and non-CP groups.

The CP application after RALP could help improve postoperative outcomes of patients, while also reducing medical expenses. To validate our results, more studies including large samples are needed. 

Hypothesis / aims of study Transcutaneous tibial nerve stimulation (TTNS) is a newly recognised treatment for overactive bladder (OAB) and can be safely used in adults with this condition. The establishment of two demonstration TTNS clinics in a community continence service in 2015 had previously shown clinical and cost-effectiveness for adults referred with wet or dry overactive bladder (OAB) or mixed urinary incontinence (1). This study aimed to determine if similar success could be achieved by rolling the TTNS out across the whole community continence service, implementing it into the routine practice of the specialist continence nurses. This was the first such service of its kind.

Study design, materials and methods Consecutive patients referred with OAB symptoms, or mixed UI received first-line lifestyle and behavioural interventions in accordance with current guidance (2) . Where further intervention was necessary the experienced continence nurses assessed motivation, capability and desire to use TTNS to establish suitability for the self-management treatment approach. The first stimulation session was applied by the specialist nurse, who then taught the patient how to self-administer the TTNS. Following the individualised education, each patient who consented to self-manage their TTNS treatment was provided with written instructions, a programmed, locked stimulation unit, sufficient electrodes for a 12 session treatment programme, contact details of the specialist nurse and a follow-up appointment. A clinical audit of TTNS outcomes was undertaken in February 2017, 10 months following the service commencement. Clinical effectiveness was evaluated using paired t-tests to compare any differences from pre-TTNS to post-TTNS in urinary symptoms (IPSS), urinary leakage (ICIQ-UI SF) and quality of life (IPSS single question).

A total of 69 patients (60 female, 9 male) completed the TTNS programme during the 10 month data collection period. Mean age 63.1 years (SD 15.2). Eleven (16%) had a neurological condition, 5 (7%) had mild dementia. Eleven (16%) were taking antimuscarinic medication concurrently with the TTNS programme. All reported symptoms of OAB. Improvements in urinary symptoms were reported by 50 (73%) patients, and improvements in urinary leakage were reported by 45 (65%) patients (Table1 Urinary symptoms improved significantly, as indicated by a reduction in IPSS by a mean of 4.8 points (t=7.061, df 68, p<.0001, 95% CI 3.45, 6.17) [ Figure 1 ]. This was a large effect size of d= 0.8. Urinary leakage improved significantly, indicated by a reduction in ICIQ-UI SF by a mean of 3.3 points (t=5.161, df 68, p<.0001, 95% CI 2.01, 4.54) [ Figure 2 ] , a medium effect size of d=0.6 and quality of life improved significantly as indicated by a reduction in IPSS QoL score by a mean of 1.62 (t=7.898, df68, p<.0001, 95% CI 1.21, 2.03) [ Figure 3 ], a large effect size of d=1.05. Interpretation of results Adults with OAB symptoms attending a specialist community continence service were taught to self-administer TTNS and on completion reported significant improvements in urinary symptoms, urinary leakage and quality of life.

Concluding message Self-managed transcutaneous tibial nerve stimulation may be successfully implemented into the routine practice of specialist community continence services with no loss of clinical or cost-effectiveness. 

Hypothesis / aims of study Levator avulsion is a risk factor for pelvic floor organ prolapse and for prolapse recurrence after surgical repair. Avulsion diagnosis on transperineal ultrasound can be performed using tomographic ultrasound imaging (TUI) on volumes acquired on pelvic floor muscle contraction (PFMC) (1). The levator-urethra gap (LUG) is the distance between the urethral lumen centre and levator insertion on the inferior pubic rami. It has been previously suggested that a LUG≥2.5 mm is another valid method to diagnose avulsion defects (2) . However there appear to be ethnic variations (3) which question the validity of this cut-off for widespread use. Our aim was to determine a cut-off for LUG measurements in our patient population.

Study design, materials and methods Women followed prospectively in our tertiary referral centre after sustaining labour trauma (OASIS) underwent an interview, standardized pelvic floor questionnaires and 2D/3D/4D transperineal ultrasound examination (GE Kretz Voluson 730, E6 or E8). Levator avulsion was diagnosed on PFMC using tomographic ultrasound imaging (TUI) and abnormal insertion was determined in the three central slices. Ultrasound datasets were analyzed offline (4DView) at a later time blinded to the clinical data and previous ultrasound measurements. LUG was measured on each side of the three central slices, yielding 6 measurements and an average for each side was obtained. Statistical analysis was performed using SPSS and a two-sided P-value of < 0.05 was considered statistically significant. Both methods were correlated and agreement between methods was determined. Different cut-off were evaluated using ROC curve analysis.

Results 507 complete datasets were available for analysis. The mean age was 28.9±4.9 years, the mean BMI 23.9±4.1 kg/m 2 , median parity 1, 73.4% were primiparous, instrumental deliveries -25.6% of which forceps -4.2%. None of them had previously undergone pelvic floor surgery. Mean LUG distances were: right LUG 2.15±0.56 mm, left LUG 2.12±0.53 mm. Data was analysed for groups based on the presence of avulsion. The relevant demographic data and levator measurements are described in Table  1 . 

The measurement of LUG is indeed helpful in evaluating and in standardizing imaging diagnosis of avulsion defects. However, there seems to be a significant ethnic variation, and it appears that the suggested cut-off of 2.5 mm is not always appropriate. It is reasonable to know the cut-off in a specific population, which in our study was 2.1 mm.

Concluding message LUG distance measurement is useful but should be tapered based on the population studied. 

Belebecha V 1 , Casagrande R 1 , Urbano M 1 , Alves S 1 , Mathiel D 1 , Martinez R 1 , Valle D 1 , Almeida S H 1

Hypothesis / aims of study The use of meshes in surgeries is a very common practice. The polypropylene mesh is the most used type of mesh, which causes adhesions with the intestine when in contact with it. Adhesion occurs when there is peritoneum surface injury, with intense peritoneal inflammatory response, fibrinous exudate development, pro-inflammatory cytokine activation, and reduced fibrinolysis. Fibrinolysis reduction results in the formation of fibrous bands between organs and the abdominal wall, called adhesions. This study proposes the use of platelet rich plasma (PRP) as a protective material since there have been a few studies on the effect of PRP on meshes, but these studies have demonstrated an improvement in the mesh incorporation, greater neovascularization, and decrease in recurrence and adhesions.

Study design, materials and methods An experimental study was carried out with 30 New Zealand white rabbits (6 months old). After induction of anesthesia (ketamine 40mg/kg and xylazine 3mg/kg), 5 mL of blood was collected from the animals by cardiac puncture to obtain the PRP. After plasma collection, a midline abdominal incision was made and in each animal, two meshes were implanted: the polypropylene mesh without plasma on the left side and the same mesh coated with PRP on the right side. A defect in the abdominal wall was created, such that the mesh could be placed in the interface between the peritoneum and bowel loops.Then, a layered closure was carried out. Ten rabbits served as controls and underwent median laparotomy and layered closure alone, without mesh insertion (euthanized at 60 days). From the 20 remaining rabbits, 10 rabbits had the mesh for 30 days and 10 rabbits had the mesh for 60 days. The adhesion tenacity observations were graduated as 0-no adhesions, 1easy release of adhesions from tissues, 2 -traction required to release adhesions, 3-blunt dissection required to release adhesions, and 4-fine dissection required to release adhesions. The modified Diamond scale (mDs), which divides the adhesions according to their extent, was used. Then, the meshes were removed for analysis. The inflammatory parameters were evaluated by measuring the myeloperoxidase (MPO) activity (indirectly measures neutrophil activity) and the N-acetylglucosaminidase (NAG) activity (indirectly measures macrophages).The oxidative stress parameters included evaluation of ferric reducing antioxidant power (FRAP), 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid) (ABTS) radical reducing ability, reduced glutathione (GSH) endogenous antioxidant levels, specific endogenous antioxidants, and the determination of superoxide anion production. The results of the inflammatory and oxidative stress parameters were analyzed by analysis of variance (ANOVA), followed by Tukey's multiple comparison test .The results were considered significant at p <0.05. The Mann-Whitney-Wilcoxon Test for paired data was used to evaluate the tenacity and extent of adhesions. The comparison analysis of the control group was conducted using the Kruskal-Wallis test.

Evaluation of the tenacity and extent of adhesions, after 30 and 60 days, showed no statistical difference between the two groups (with and without PRP) and of these groups for the control group. There were no differences between the groups, in the inflammatory and oxidative stress parameters. There was an increase in neutrophils (measured indirectly by MPO) in over 60 days in the group without PRP compared to the control group (p <0.05), and a significant reduction of these cells in the group with PRP. The NAG activity (which indirectly evaluates macrophage activity) increased for all time points in the group without PRP, compared to the control. However, it decreased in the group with PRP compared to that in the group without PRP at 60 days. Regarding the effects of oxidative stress, the analysis showed a significant increase in antioxidant levels in the group with PRP at 60 days. This increase was measured by evaluating the FRAP and ABTS radical reducing ability (both tests evaluate nonspecific antioxidants. There was a decrease in FRAP in the group without PRP in 60 days compared to that in the control group, and the group with PRP displayed increased FRAP. There was a decrease in GSh in the group without PRP in 60 days compared to that in the control group, and the group with PRP.Superoxide anion production was also evaluated by nitroblue tetrazolium (NBT) reduction assay. The assay results indicated that the group without PRP had increased superoxide anion levels at all time points and that PRP causes a decrease in these levels at 60 days.

There has been no other study on the effect of PRP on the oxidative stress generated by polypropylene mesh implantation. Although the group with PRP did not present differences in adhesions, the evaluation of inflammatory activity and oxidative stress indicated the use of PRP as beneficial. This result is significant since complications such as erosion, extrusion, and adhesions are closely related to inflammatory reactions to the implant. There are a few studies on the use of PRP on meshes for hernia repairs. An in vitro study with seven types of meshes with PRP achieved adhesion reduction and improved biocompatibility with its use after 6 weeks {1}. In this study, the possible benefit of the use of PRP occurred at a later stage. This agrees with the findings of Gerullis et al., who studied the in vivo and in vitro biocompatibility of mesh coated with autologous plasma and observed no effect of the mesh on early inflammatory events of inflammatory infiltration and macrophage invasion {1,2}. The hypoxia generated by surgical trauma is a determining factor for the formation of adhesions, this oxygen deficit generates oxidative stress, which is highly damaging for cellular functions {3}. Immediately after implantation and with the onset of the inflammatory response, neutrophils begin to produce oxidants. Production of reactive oxygen species, proteases, and growth factors, mediated by neutrophils and macrophages, results in tissue destruction, fibroblast proliferation inhibition, aberrant collagen accumulation, and fibrosis {3}. In addition, polypropylene oxidation produces free radicals with subsequent depolymerization, oxidative degradation, leaching, and hydrolysis. These changes result in the loss of mesh structure with changes in molecular weight and mechanical integrity.In this study, the use of PRP reduced the oxidative stress by significantly increasing the FRAP and ABTS radical reducing ability. This reduction is important for the maintenance of implant integrity. There was also an increase in reduced glutathione (GSH), an important biological antioxidant with a protective role in adhesion formation {3}. A decrease in superoxide anion levels, which increases with surgical trauma, was detected. Fibroblasts, when exposed to superoxide anions, increase the TGF-beta and collagen I levels, both involved in the pathogenesis of the adhesions {3}. The PRP usage results are very interesting because they indicate a decrease in the occurrence of adhesion triggering events.A decreased inflammatory response was observed with decreasing levels of NAG in the lysosome of activated macrophages. This is a significant observation since the concentration of macrophages at the site is high for a few hours after implantation and the real invasion takes place after 7 days. The inflammatory reaction continues for several months, depending on the material implanted and the site of implantation. This process becomes chronic over time, with the formation of small granulomas, and the result ranges from fibrosis to functionally normal tissue. The extensive presence of macrophages on site suggests a determinant role of macrophages in tissue remodeling after mesh implantation `{2}. In addition, the levels of MPO, an important inflammatory marker and an enzyme present in neutrophils, decreased with PRP. MPO is a heme-protein, which uses hydrogen peroxide and chloride ions to generate cytotoxic acids and diffusible radical species {3}. Studies have revealed an important role of this enzyme in the development of fibrous tissue, indicating that MPO inhibition could be a target for therapeutics to reduce post-operative adhesions. Thus, the combination of lower inflammatory response (indicated by decrease in MPO activity) and lower NAG levels (associated with decreased oxidative stress), potentially reduces the risk of fibrosis and other integration complications and maintains the physical integrity of polypropylene.

The use of PRP in polypropylene meshes showed no significant difference in the presence and severity of the adhesions. However, there was a reduction in the inflammatory response and oxidative stress with PRP use.

Linde M 1 , Nijman R 1 , Trzpis M 1 , Broens P 1

Hypothesis / aims of study The aim of this study was to determine the prevalence of urinary incontinence (UI) and associated risk factors in adults and children living in the Netherlands.

This study was designed as a cross-sectional, population-based study. A company that specializes in performing surveys, created a sample by using a database of respondents living in the Netherlands. Adult participants (aged 18 years or older) in this database received a digital link that enabled them to fill out the the validated Groningen Defecation and Fecal Continence (DeFeC) Checklist. Out of the 3031 respondents who started filling out the checklist, 1642 (54.2%) actually filled it out completely. A selection of the completed checklists was made in order to obtain a representative cohort. The included respondents were distributed equally across gender, region of the Netherlands, educational level, and age, in accordance with the Dutch population pyramid, as reported by Statistics Netherlands(1). Out of these 1642 checklists, 1259 (76.7%) were selected for analysis. During further examination of the checklists, two respondents were excluded due to illogical answers. Finally, 1257 checklists filled out by adults were analyzed. For the analysis the adult respondents were divided into subgroups based on gender and age. Three age groups were formed: 18-39-year-olds, 40-59-year-olds, and 60-85-year-olds. Based on their body mass index (BMI) respondents were grouped either as underweight (BMI < 18.5 kg/m2), normal (BMI between 18.5 to 25 kg/m2), overweight (BMI between 25 to 30 kg/m2), or obese (BMI > 30 kg/m2) in accordance with the WHO guidelines. Children (aged 8-17 years old) received the Groningen Pediatric Defecation and Fecal Continence (P-DeFeC), which is the equivalent of the adult version of the DeFeC checklist. The checklists consists of the same questions. The P-DeFeC however is worded in a way that is understandable to a eight year old child. In total 241 children filled out the checklist completely, one was excluded due to illogical answers. Two age groups were formed out of the child respondents: 8-12-year-olds and 13-17-year-olds. Based on their body mass index (BMI), children were grouped either as underweight, normal weight or overweight.

UI was defined as any involuntary leakage of urine in the past six months. Respondents were further classified as having stress UI, urge UI, mixed UI or any other form, such as: 'while asleep', 'for no clear reason', 'continuously, or 'while getting dressed after urinating'. Definitions according to the International Continence Society were used for this study.

The prevalence of UI in the adult group was 36.8%. Women experienced UI significantly more often than men (49.0% versus 22.6%, respectively, P<0.001). We found that in both men and women the prevalence of UI increased with age (P=0.003 and P<0.001, respectively). However, multivariate analysis showed that age did not significantly influence the presence of UI in men. The most reported form of UI in women was stress UI, followed by mixed UI (26.3% and 10.0%, respectively). The most common type of UI among men was the aforementioned 'any other type of UI'. This amounted to 11.7%, while urge UI was the second most common type. In men younger than 40 years of age, we found that stress UI was more frequent than urge UI (4.7% versus 2.3%, respectively).

In children the total prevalence was 21.7%, where stress UI was the most frequent form of UI (8.8%). Similarly to the adults, girls experienced UI significantly more often than boys (30.1% vs. 14.2% respectively, P=0.003). However, the prevalence of UI did not change with age. The prevalence between the younger (8 -12 years old) and older (13 -17 years old) group was similar, 21.5% and 21.8% respectively, P=0.962. Enuresis nocturna without daytime UI was reported by 4 children (1.7%). Combined day and night UI was seen in 3 children (1.2%).

In adults we established that diabetes mellitus, fecal incontinence, constipation and experiencing other lower urinary tract symptoms were risk factors for UI. In women, obesity, vaginal hysterectomies, and vaginal parturition were also risk factors for UI, as was prostate surgery in men. In the group of children univariate analysis showed that the presence of straining, intermittency, nocturia or fecal incontinence was significantly associated with urinary incontinence.

Urinary incontinence is a common condition in the Netherlands with a prevalence of 36.8% in adults and 21.7% in children. Women and girls especially, are affected by this problem (49% and 30.1% respectively). Importantly, UI in men should not be underestimated, because 22.6% of men living in the Netherlands experiences UI as well. Our findings therefore negate the current prejudice that UI is a female ailment. Using multivariate analysis, we found that age was a significant risk factor in women only. It seems that age, as a single factor, influences UI in both men and women, but in combination with other age-associated diseases, it only correlated with UI in women. The reasons for these finding are unclear, but because men and women often experience different types of UI, and different types of UI possibly have different causative factors, this could explain why age influences UI differently in men and women. It is remarkable that in children there is no difference between the prevalence of UI in the two age groups. This means that there is no such thing as 'outgrowing UI'. On the basis of the findings of this study, we are able to confirm that in adult men and women in the Netherlands, lower urinary tract symptoms are correlated with UI -according to both univariate and multivariate analyses. We also showed that obesity is a risk factor for UI in women, not in men. We found a significant correlation between a BMI of > 30 and UI, even after correcting for age and diabetes. Finally, we found that vaginal parturition as well as the number of vaginal parturitions were risk factors for UI, while cesarean sections were not. Our finding indicates that not pregnancies, but the type of delivery and the number of parturitions are risk factors for UI. Vaginal hysterectomies increased the risk of being incontinent for urine, while abdominal hysterectomies did not. It is plausible that vaginal hysterectomies are more often performed in women with pre-existing UI. Additionally a surgeon may choose the vaginal approach more frequently in parous women, because this is easier to perform in parous than in nulliparous women. In children the presence of lower urinary tract symptoms, especially straining, intermittency and nocturia were risk factors for experiencing UI.

The prevalence of urinary incontinence in the Netherlands is high. The risk factors associated with UI are different for men and women, and also for children and adults. It is important for medical practitioners to not underestimate the magnitude of this problem and to be aware of the associated risk factors.

Kim M K 1 , Kim Y G 1 , Shin Y S 1 , You J H 1

Hypothesis / aims of study The distinction between anatomic urethral length and functional length is important. But there is no study that has investigated the relationship of female urethral length with urodynamic parameters. We evaluate the association between anatomic urethral length and urodynamic parameters as well as effect of anti-incontinence surgery in women with stress urinary incontinence (SUI).

Study design, materials and methods 391 women who had transobturator sling operation for SUI between April 2009 and March 2016 were prospectively enrolled in this study. The patients underwent a physical examination and urodynamic study (UDS). Uroflowmetry and post-void residual urine volume (PVR), cystometry, Valsalva leak point pressure (VLPP), cough leak point pressure (CLPP), maximal urethral closure pressure (MUCP) and functional urethral length (FUL) were evaluated by UDS. The anatomic urethral length (AUL) was measured using Foley catheter. In order to determine a "actual urethral ratio", we calculated FUL/AUL ratio for this study.

A total of 299 patients were included in our study. The mean patient age was 57.73 ± 10.18 years. The mean AUL and FUL were 26.89 ± 4.50 mm and 32.20 ± 16.09 mm, respectively. In Pearson correlation coefficients, FUL/AUL ratio correlated with PVR (-0.064, p= 0.270), VLPP (0.193, p=0.001), CLPP (0.119, p=0.040) and MUCP (0.249. p=<0.001). Multivariate analysis revealed that FUL/AUL ratio (HR 2.452, p=0.001) and MUCP (HR 1.131, p=0.012) were significantly associated with success of surgery.

The female anatomic urethral length measured by simple method can be used as predictor of urodynamic parameters such as ALPP and MUCP and results of anti-incontinence surgery in women with stress urinary incontinence Concluding message Our results showed that female urethral length was associated with urodynamic parameters of SUI. Also it can be used as a significant predictive factor for a successful surgery. 

Hypothesis / aims of study Prevalence rates of bladder outlet obstruction (BOO) and detrusor underactivity (DU) and their related clinical and urodynamic findings in women with ≥ pelvic organ prolapse quantification stage II cystocele are important for clinical consultation. Thus, the aim of this study was to elucidate the above findings and between-group associations.

Study design, materials and methods Between November 2011 and January 2017, medical records of all women with ≥stage II cystocele who underwent 20 min pad testing and urodynamic studies in a medical center were reviewed. Only those with complete data of maximum flow rate (Qmax) and detrusor pressure at maximum flow rate (PdetQmax) were enrolled. ANOVA test and post-hoc testing with bonferroni's correction were used for statistical analysis. Woman were defined as having DU when Qmax was <12 mL/s and PdetQmax was <10 cmH2O [1, 2] , and were defined as having BOO when Qmax was <12 mL/s and PdetQmax was ≥25 cmH2O with sustained detrusor contraction during voiding cystometry [2, 3] .

Among 455 women with ≥stage II cystocele, thirty-five (7.7%) women were found to have BOO, and 12 (2.6 %) women were found to have DU (Table 1) . Women with cystocele and coexistent BOO or DU had significantly smaller voided volume and the volume at strong desire to void and longer voiding time (Table 1 ). In addition, women with BOO had significantly higher urgency episodes than those without BOO/DU. Women with DU had higher nocturia episodes than those without BOO/DU (Table 1) . Urgency episodes of 72 hours = 11 was the most strongly predictive cutoff value for predicting BOO with receiver operating characteristic curve (ROC) area of 0.57 (95% CI = 0.45 to 0.70, sensitivity = 37.0%, specificity = 82.4%, Fig 1a) . Nocturia episodes of 72 hours = 6 was the most strongly predictive cutoff value for predicting DU with ROC area of 0.79 (95% CI = 0.66 to 0.92, sensitivity = 83.3%, specificity = 72.7%, Fig 1b) .The scores of lower urinary symptoms and scores of King's Health Questionnaires did not differ between the groups ( Table 2) .

Interpretation of results Both BOO and DU had a decrease in the bladder capacity and prolonged voiding time. Urgency was associated with BOO, and nocturia was associated with DU.

Concluding message Both BOO and DU are not infrequently in women with ≥ stage II cystocele, and are associated with small bladder capacity, prolonged voiding time, and some lower urinary tract symptoms. The above findings may provide useful information for preoperative consultation and management. 

Hypothesis / aims of study Opioids are the most common drug of choice for analgesia after hysterectomy, but are associated with significant side effects. A third generation anti-epileptic, gabapentin can be used as an adjunct to decrease opioid requirements. While studies have demonstrated the benefit of a single pre-emptive dose of gabapentin given 1-2 hours before abdominal and vaginal hysterectomies (1, 2), this has not been studied in urogynecologic surgery where vaginal hysterectomy is combined with pelvic floor repair and anti-incontinence procedures. Our objective is to determine the effect of a single pre-emptive dose of gabapentin in women undergoing vaginal hysterectomy with pelvic reconstructive surgeries with or without tension-free vaginal tape (TVT) on postoperative pain control. We hypothesized that pre-emptive gabapentin will significantly reduce the use of postoperative opioid medications.

After research ethics board approval, a randomized double-blinded placebo controlled trial was commenced in January 2017. All women aged 18 and older presenting to a tertiary referral hospital with prolapse symptoms requiring hysterectomy with pelvic reconstructive surgeries (e.g. anterior/posterior colporrhaphy, uterosacral ligament suspension), with or without TVT, were included. Patients were excluded if they were already on gabapentin, had a proven allergy, sensitivity, or contraindication to gabapentin, or were unable to understand spoken English. Informed consent was obtained from all patients enrolled. As per our institution's anesthesia department, the single dose of pre-emptive gabapentin was 600 mg for those under age 65, and 300 mg for those age 65 and older. Computer-based randomization was used.

In a previous randomized controlled trial examining the effect of gabapentin on postoperative pain medications (in this case, fentanyl bolus of 50 mcg) in patients undergoing vaginal hysterectomy (without pelvic reconstructive surgeries) (2), the total dose was reduced from 23 boluses to 14 boluses. Using an estimated standard deviation of 400 mcg (i.e. 8 boluses), power of 90%, two-tailed alpha of 5%, and Student-t test, the sample size was 17 subjects per group. Given that sedation is a side effect of gabapentin, we also ensured that our study was adequately powered to detect any difference in prolonged stay in the recovery room. With a typical recovery room stay up to 120 minutes, we believed that a 30-minute prolongation would be clinically significant. Using a standard deviation of 30 minutes, power of 90%, two-tailed alpha of 5%, and Student-t test, the final sample size was increased to 22 subjects per group.

The Student t-test was used to compare the difference in opioid consumption in the first 24 hours after surgery, as well as time from the end of surgery to leaving the recovery room, and length of recovery room stay between the groups. Visual analogue scale (VAS) scores for anxiety, drowsiness/sedation, pain, and nausea were compared using the Mann-Whitney U test.

After half the patients were recruited, an interim blinded analysis of 22 patients was performed. There were 10 women in Group A and 12 in Group B. There was no significant difference in age, menopausal status, parity, previous surgeries, allergies, or body mass index. Furthermore, there was no significant difference in general or spinal anesthetic or American Society of Anesthesiologists physical status classification. There was no difference in total opioid use (converted to oral morphine equivalents) in the first 24 hours after surgery between Groups A and B (27.8 ± 29.0 mg vs. 27.2 ± 19.6 mg, P = 0.952). Further, there was no difference in time from the end of surgery to leaving the operating room (11.3 ± 2.00 min vs. 16.3 ± 10.5 min, P = 0.157), or total time in recovery room (248 ± 136 min vs. 175 ± 70.6 min, P = 0.117). There was also no significant difference in VAS measures of anxiety and drowsiness/sedation upon arrival in the operating room; drowsiness/sedation, pain, and nausea two hours after surgery; and nausea on postoperative day 1 between the two groups.

Based on this interim analysis, there does not seem to be a significant difference in post-operative opioid use in women undergoing vaginal hysterectomy with additional pelvic floor repair and/or anti-incontinence procedures who received pre-emptive gabapentin compared to those given a placebo.

Concluding message As per our institution's dosing policy, a single dose of pre-emptive gabapentin of 300 mg (if age 65 and older) or 600 mg (if younger than age 65) is not significantly different from a placebo in affecting post-operative pain in women undergoing urogynecologic surgery. These data are based on an interim analysis performed after half of the subjects have been recruited.

París Zamora I 1 , Pérez Mallada N 1 , Coronado Martín P J 2

Hypothesis / aims of study The hypothesis of this project is that Transversus Abdominis (TrA) muscle contraction increases pelvic floor muscle (PFM) electric activity more than Hypopressive Abdominal Exercises (HAE) and HAE decrease abdominal pressure (AP) both compared with a basal state.

The aim of this study is to assess TrA muscle contraction and HAE on pelvic floor muscle electric activity and AP compared with a basal state.

Study design, materials and methods Twenty-two urinary-continent women participated in this study. Sample size and power have been calculated with GRANMO software (Version 7.12 April 2012). Alpha and Beta risks were set as 0.01 and 0.10 respectively. Standard deviations were taken from a pilot study and minimum expected differences were taken from different RCTs(1,2). Only patients who were able to perform correct HAE were included in the study. Participants were placed in the orthostatic position of HAE. They performed randomized repeated HAE and contractions of TrA. PFM and TrA electromyography (EMG) signals and associated AP data were recorded simultaneously. AP data were recorded from a rectal pressure balloon. The ANOVAs repeated measures with LSD Post-Hoc test were used for statistical analysis.

Results are shown in Table 1 . TrA contraction increases the activity of PFM more than a HAE or basal state (p<0,001). However, HAE increases the activity of PFM more than basal state (p=0.048). A HAE decreases AP on both the basal state and TrA contraction (p=0.002 and p=0.047 respectively). With regard to TrA muscles, they have more EMG activity during a voluntary contraction of themselves (p<0.001), although they increase EMG activity during a HAE but not significantly (p=0.057 in right TrA and p=0.089 in left TrA). 

In accordance with Sapford and Hodges group, TrA contraction is the one which has increased more PFM EMG (2) . PFM activation during an HAE was greater than the basal state; nevertheless, it was significantly less than during TrA contraction.

There is evidence that a HAE decreases the AP (1) during its realization. This result is in line with this study. TrA increases electrical activity during a voluntary TrA contraction but not during a HAE performance in a significant way. This fact should be investigated in further studies. According to these results, HAE would not be the first therapeutical option to be used for increase PFM activity. In this case, TrA contractions and PFM are more appropriate techniques. On the other side, if the problem is related to a bad management of AP, the technique of choice is HAE.

Concluding message HAE decrease AP on both TrA contractions and basal state and increase PFM activity but to a lesser extent than TrA contraction. If treatment objective is to strengthen PFM the choice technique must be related to a TrA contraction, but if the objective is to improve pressure dynamics is better to choose HAE. The technique to be used should depend on the treatment objectives. Hypothesis / aims of study Randomised, placebo-controlled, multicentre trials with onabotulinumtoxinA 100U have demonstrated significant improvements in urinary incontinence (UI) and quality of life in idiopathic overactive bladder (OAB) patients who were inadequately managed by ≥1 anticholinergic. Incomplete bladder emptying resulting in the need for clean intermittent catheterisation (CIC) is known to occur in OAB patients who have been treated with onabotulinumtoxinA. However, there is little information on the incidence of CIC in OAB patients according to age following treatment with onabotulinumtoxinA. Thus, this post hoc analysis of the pooled placebocontrolled trials was undertaken to assess the incidence of CIC, and efficacy and quality of life outcomes, in various age groups of OAB patients treated with onabotulinumtoxinA. Quality of life outcomes were also evaluated by patients' urinary tract infection (UTI) status.

Study design, materials and methods Two phase 3 trials and a post-marketing study enrolled patients with OAB who had experienced ≥3 urgency UI episodes over a 3-day period and ≥8 micturitions per day. All patients were inadequately managed by ≥1 anticholinergic. Patients with a predominance of stress UI were excluded. Pooled data from patients (N=1177) randomised to onabotulinumtoxinA 100U in treatment 1 and patients initially randomised to the placebo group who received open-label onabotulinumtoxinA 100U in treatment 2 were grouped by age: <40, 40-49, 50-59, 60-69, and ≥70 years. CIC was initiated during the studies if post-void residual (PVR) urine volume was ≥350 mL regardless of symptoms, or was ≥200 mL to <350 mL with symptoms of difficult micturition. Assessments at week 12 included incidence and duration of CIC, mean change from baseline in PVR urine volume, mean and percentage change in UI episodes/day, proportions of patients with ≥50% and 100% reduction in UI episodes/day, and with a positive response ("improvement" or "great improvement" in their urinary condition) on the Treatment Benefit Scale. The mean change from baseline in King's Health Questionnaire (KHQ) Role Limitations and Social Limitations domain scores and proportions of patients who achieved/exceeded the minimally important difference (-5 points) on the KHQ domains were also evaluated. The KHQ results were also examined in the various age groups by patients' UTI status. Scores on the KHQ range from 0-100 with lower scores (and negative change over time) indicating better quality of life. Adverse events (AEs) were recorded. The incidence of AEs, including use and duration of CIC, was analysed in the safety population (all patients who received treatment), and efficacy and quality of life outcomes were analysed in the intent-to-treat population (all randomised patients).

Results CIC rates were low in all age groups in the first 12 weeks following treatment with onabotulinumtoxinA. Rates were lowest in the <40 group (1.1%) and increased with age (3.2%, 5.3%, 5.3% and 7.2% in the 40−49, 50−59, 60−69, and ≥70 groups, respectively). The mean (median) duration of CIC in the <40 and 40−49 groups was 3 (3) and 44 (26) days and ranged from 78 (68) to 88 (74) days in the other groups. The mean change from baseline in PVR urine volume at week 12 after onabotulinumtoxinA treatment was low overall and showed small increases with age (7.7, 14.1, 20.5, 29.7, and 36.5 mL in the 40−49, 50−59, 60−69, and ≥70 groups, respectively). At baseline, the mean numbers of UI episodes/day were 3.9, 4.8, 5.2, 5.7, and 6.0 in the <40, 40−49, 50−59, 60−69 and ≥70 y groups, respectively. Substantial reductions in UI episodes/day (−2.4, −2.6, −3.1, −3.6, and −2.9) and percentage change in UI (−60.8%, −50.4%, −62.4%, −64.4%, and −46.8%) were observed. Nearly half (45.6%) of the patients in the <40 group achieved 100% reduction in UI episodes/day, which was the highest among all age groups (28.8%, 34.2%, 31.5%, and 20.3% in the 40-49, 50-59, 60-69, and ≥70 groups, respectively). High proportions of patients across all age groups achieved ≥50% reduction in daily UI episodes (64.4%, 64.7%, 71.1%, 70.6%, and 58.2%). Likewise, high proportions of patients reported treatment benefit as reflected by a positive response on the TBS (67.8%, 69.9%, 73.8%, 70.9%, and 66.2%) and achieved improvements ≥MID in the KHQ Role Limitations (66.7%, 64.7%, 72.2%, 62.7%, and 58.2%) and Social Limitations domains (54.4%, 57.7%, 63.1%, 55.1%, and 51.7%). Improvements from baseline in the KHQ Role Limitations and Social Limitations domain scores were similar across all age groups and were approximately 5−6 and 3−4 times the MID, respectively. In addition, improvements in the KHQ domain scores were generally similar across all age groups regardless of UTI status, with mean decreases from baseline in patients of all ages either with or without UTI approximately 5 times the MID for Role Limitations and approximately 3 times the MID for Social Limitations. Overall AEs were similar across all age groups. UTI was the most common AE in all groups and showed a trend for increased incidence with age; younger groups reported the lowest rates (10.0% and 8.3% in the <40 and 40-49 groups, respectively) compared with the other groups (range: 11.8-16.8%).

In this large cohort of patients with OAB who were inadequately managed by ≥1 anticholinergic, the incidence of CIC following treatment with onabotulinumtoxinA was low in all age groups and increased somewhat with age with an acceptable benefit/risk profile. The <40 group had the lowest rate of CIC (1.1%), with a mean duration of 3 days, and the ≥70 group had a rate of 7.2%, with a mean duration of 86 days. The low incidence of CIC was accompanied by a robust treatment response across all age groups including substantial reductions in UI, clinically meaningful improvements in quality of life, and high proportions of patients reporting treatment benefit. Similar improvements in quality of life were seen following onabotulinumtoxinA treatment regardless of UTI status. OnabotulinumtoxinA treatment results in no unexpected safety signals.

The risk of CIC was low in all age groups, was especially low in the youngest patients, and showed small increases with age. All age groups showed substantial improvements in UI, treatment benefit, and quality of life in this large cohort of OAB patients treated with onabotulinumtoxinA. UTI status did not have an effect on quality of life. OnabotulinumtoxinA was well tolerated in all age groups. 

Hypothesis / aims of study Clinical trials have established the efficacy and safety profile of mirabegron [1, 2] , a first-in-class β3-adrenoreceptor agonist that is an alternative therapeutic option for overactive bladder (OAB). This is the first large European, prospective, observational study on the impact of mirabegron on quality of life (QoL), patient satisfaction, healthcare resource utilization, adverse events (AEs) and treatment persistence in a non-interventional clinical setting. The primary objective was to evaluate change from Baseline (BL) in QoL based on OAB questionnaire (OAB-q) subscales. Here we focus on the evaluation of persistence with mirabegron treatment over a 12-month period.

Patients aged ≥18 years with OAB symptoms ≥3 months, whose physician had made the decision to prescribe mirabegron as part of routine clinical practice and who were about to start treatment were enrolled. Follow-up was done for a period of 12 months and included visit windows of 2-4 months and 10-12 months. A total of 862 patients were enrolled from 9 European countries. Overall, 848 (98.4%) were included in the Safety Analysis Set (all patients who received ≥1 dose of mirabegron during the study), 796 (92.3%) in the Full Analysis Set (all enrolled patients who completed the OAB-q at BL and at ≥1 follow-up visit, regardless of whether they remained on mirabegron therapy or not) and 452 (52.4%) in the Per Protocol Set (all enrolled patients who remained on mirabegron therapy and who completed the OAB-q at BL and at 10-12 months).

In the full analysis group, at BL 42.2% of patients were 'new' or treatment naïve, 10.1% were lapsed, 41.3% had switched from other OAB treatments to mirabegron, and 6.4% were on combination treatment. Overall, there was a clinically meaningful improvement in QoL as measured by the OAB-q subscales. At all the assessment windows, the majority of patients were using mirabegron as a single agent. In the full analysis group, at 10-12 months, 53.8% of patients were receiving mirabegron either as a single agent or as a combination agent; 6.0% patients switched from mirabegron to other OAB treatment; and 13.1% patients discontinued treatment completely (Table) . Additionally, treatment-naïve patients or those without treatment for OAB ≥2 years tended to stay on mirabegron as a single treatment. Similar observations were made in the per protocol group. In terms of incontinence status, 34.9% of patients from the full analysis group had an OAB dry episode at BL, which increased to 36.4% at 2-4 months and 43.7% at 10-12 months. The mean (SE) change from BL for the number of incontinence pads used in the last 7 days was -2.9 (0.47) at 2-4 months and -2.0 (0.49) at 10-12 months. Similarly, improvements in incontinence status were noted in the per protocol group. A large percentage of patients who were OAB wet at BL shifted to OAB dry after treatment. Most patients who were OAB dry at BL remained OAB dry after treatment (Table) . Finally, overall incidence of adverse events (AEs) was consistent with other studies (42.8% of SAF patients reported ≥1 AE, 7.5% had ≥1 serious AE, 21.0% had ≥1 mirabegron-related AE and 1.8% of patients reported ≥1 mirabegron-related serious AE) and mirabegron was found to be well tolerated.

Interpretation of results A notable improvement in patient reported QoL outcomes, along with incontinence status and incidence of AEs may contribute to the high persistence rate observed in this study, with 53.8% of patients remaining on mirabegron after approximately 12 months for the full analysis group.

In this prospective, observational study, patients receiving mirabegron reported meaningful improvements in QoL and showed high persistence with treatment over a period of 12 months. Hypothesis / aims of study There is a need for different pharmacological compounds to treat overactive bladder (OAB)/storage LUTS in order to improve the ratio efficacy/side-effect and the compliance when compared to the standard of care, i.e. the antimuscarinics: mirabegron, a β₃adrenoceptor agonist, has been recently approved in this indication. Aim of our systematic review and meta-analysis is to assess the efficacy and safety of different dosage of mirabegron, in the treatment of OAB/storage LUTS. Study design, materials and methods A MEDLINE, EMBASE, Cochrane Library, and Science Citation Index Expanded Medline search was performed to identify all published randomized placebo-controled trials (RCTs) evaluating mirabegron for the treatment of OAB/storage LUTS. We evaluated the mean difference (MD) to assess the efficacy profile in terms of incontinence episodes/24h, number of micturitions/24h, voided volume per micturition. We also evaluated the different rate of treatment-emergent adverse events (TEAEs).

Out of 491 retrieved articles, 8 RCTs were included in the present meta-analysis, evaluating a total of 10,239 participants. Mirabegron 50 mg (Mir50), mirabegron 100 mg (Mir100) and tolterodine 4 mg (Tol) were significantly associated with improvement of voiding outcomes when compared to placebo. Regarding the number of incontinence episodes/24h, Mir100 did not provide greater efficacy than Mir50 (weighted mean difference [WMD]: 0.15; p=0.08) or Tol (WMD: -0.07; p=0.48). Moreover, Mir50 was statistically similar to Tol (WMD: -0.09; p=0.49). Likewise, we did not find any difference in the decrease in the number of micturitions/24h when comparing Mir100 vs. Mir50 or Tol (WMD: 0.03; p=0.70 and WMD: -0.08; p=0.39 respectively), or Mir50 vs. Tol (WMD: -0.11; p=0.12). The increasing of mean voided volume per micturition was similar among the 3 treatments. Both Mir50 (OR: 0.94; p=0.32) and Mir100 (OR: 0.97; p=0.75) did not provide increased TEAEs vs placebo. Conversely, Tol was associated with a higher occurrence of TEAEs (OR: 1.38; p<0.0001).

According to our meta-analysis Mirabegron can significantly improve the voiding outcomes at the investigated dosages. However, there were no statistically significant improvement when Mir50 was compared to Mir100. These results can be explained to pharmacokinetics effects, to the reaching of the drug's maximum effects, but β₃-adrenoceptor are sensible to downregulation in chronic therapy, so an higher dosage of the drug can be necessary on long term treatment. Tolterodine proved to be as effective as Mir50 and Mir100, but at the cost of an higher rate of TEAEs, because of the drug' mechanism of action and the receptors distribution. Muscarinic receptor are widely present in different organs and the drug pharmacokinetic does not provide a focused action on bladder, and that can explain the higher TEAEs rate. On the other hand, β₃-adrenoceptor are located only in bladder and adipose tissue, allowing a higher selectiveness and reduced TEAEs compared to Tol.

Our meta-analysis showed that Mir100, Mir50 and Tol share the same efficacy profile. Mir100 and Mir50 share the same rate of TEAEs without any difference when compared with placebo. Conversely Tol was associated with an increase in TEAEs, potentially leading to treatment discontinuation. 

Hypothesis / aims of study TRPM8 is a non-selective cation channel having multiple modes of activation such as cold, and has been widely expressed in urothelial cells and sensory nerve fibres of the bladder and in L6 dorsal root ganglia (DRG) of the rat, and also in the urothelial cells of the human bladder [1] . A previous study by measuring ex vivo bladder afferent activities revealed that TRPM8 channels may have a role in activation of mechanosensitive afferent pathways of the normal rat bladder, which was mediated at least partly via C-fibres [2] . RQ-00434739 (RQ) was newly developed as a potent antagonist selective for TRPM8, and it displayed analgesic efficacy in an oxaliplatin-induced cold allodynia model in the rat and cynomolgus monkey [3] . In this study, to disclose the functional role of TRPM8 channel in the bladder, we examined effects of intravesical instillation of L-menthol (a TRPM8 agonist), and counter-effects of RQ on bladder function, especially on the in vivo primary bladder single-unit afferent activities (SAAs) in rats.

Forty-two female Sprague-Dawley rats were used. In conscious cystometry (CMG), after baseline recording with saline-instillation at a rate of 6 mL/hour, further recording was performed with an intravesical instillation of L-menthol (6 mM) after intravenous (i.v.) pretreatment with RQ (1 mg/kg) or vehicle. CMG parameters were analysed before and after drug-administrations for 1 hour in each. In the SAAs measurements by using separate animals, rats were anesthetized with urethane (1.2 g/kg, intraperitoneally) and SAAs recorded from the left L6 dorsal root were classified by conduction velocity as Aδ-or C-fibers by electrical stimulation of the left pelvic nerve and by bladder distention. Thereafter, SAAs were recorded as baseline with saline-instillation (6 mL/hour), and further recordings were performed during intravesical instillation of L-menthol (6 mM) after i.v. administration of RQ (1 mg/kg) or vehicle.

In the CMG measurements, intravesical L-menthol after pretreatment with vehicle showed decreases in threshold pressure and mean voided volume, whereas such decreased responses were not observed with RQ-pretreatment (Table 1 ). In the SAAs measurements, 32 single afferent fibers (n = 16 in each fiber) were isolated from 30 rats. In the presence of vehicle, after Lmenthol-instillations SAAs of C-fibers significantly increased, whereas those of Aδ-fibers tended to increase, but not significantly. In the presence of RQ, L-menthol-instillation did not significantly affect SAAs of either Aδ-or C-fibers (Figures 1 and 2) .

Interpretation of results CMG and SAAs measurements showed that intravesical L-menthol-instillation provoked bladder hyperactivity, which was mediated mainly via facilitation of mechanosensitive C-fiber activities in rats. The L-menthol-induced bladder hyperactivity was attenuated by pretreatment with RQ-administration, suggesting that TRPM8 channel in the rat bladder has a functional role in the activation of bladder mechanosensitive C-fibers whereas its role in bladder mechanosensitive Aδ-fiber activation may be limited. These results are in line with those of a previous study by measuring ex vivo afferent activities [2] .

The present results demonstrated that TRPM8 channel in the rat bladder has a role in activation of mechanosensitive C-fibers. Functional inhibition of TRPM8 channel should be further explored as a novel tool for the treatment of bladder hypersensitive disorders. 

Hypothesis / Aims of study Recent studies (1-2), have suggested that the preoperative administration of phenazopyridine reduces short-term postoperative voiding dysfunction (VD) in patients undergoing a retropubic midurethral sling (RMUS). None of these studies were specifically designed to prospectively assess phenazopyridine for voiding function, but all demonstrated a significant reduction in the rate of postoperative VD. We performed a prospective randomized clinical trial assessing the effect of phenazopyridine on postoperative VD in women undergoing RMUS.

Study design, materials and methods A single-institution randomized controlled trial was performed comparing 200 mg oral preoperative phenazopyridine to no phenazopyridine in patients undergoing a RMUS. Sample size calculations indicated that 41 subjects per arm would provide a 20% difference with an α-error rate of 0.05 and a power (1-β) of 0.80. Assuming a 10% dropout rate, we recruited 46 subjects per arm. Patients with stress urinary incontinence or stress-predominant mixed urinary incontinence undergoing a RMUS under general anesthesia with no concomitant procedures were offered the opportunity to participate. Subjects in the intervention group received 200 mg of oral phenazopyridine. Because phenazopyridine stains urine orange, we could not blind surgeons, patients or staff to this effect and no placebo was used. Randomisation was blinded by computer allocation and carried out using sequential, sealed opaque envelopes. Subjects underwent a RMUS by either top-down (suprapubic) vs bottom-up (transvaginal) approach, per surgeon preference. Preoperative demographics, intraoperative medications, blood loss and complications were recorded. A standardized postoperative voiding trial was performed prior to discharge. A successful voiding trial was defined as a post void residual volume of less than one-half of the voided volume. Subjects failing the voiding trial had a Foley catheter re-inserted and returned to our clinic 1 to 4 days later to repeat the voiding trial. Pain scores were obtained through a validated visual analogue score (VAS) administered 2-3 hours after the surgery. Patient characteristics and surgical data were compared between groups using Chi Square, Fisher's exact test, or Wilcoxon rank sum test.

We enrolled 92 subjects. Three subjects cancelled their surgery and one subject did not have an immediate postoperative voiding trial secondary to intraoperative urethral injury. Eighty-eight subjects were included in the final analysis, 44 per arm. Patient demographics did not show any differences between the two groups, as shown in Table 1 . Notably, the approach for RMUS was also balanced, with 47 suprapubic and 41 transvaginal routes (p=.205). Intent-to-treat analysis showed no difference in the distribution of failed void trials between the randomized groups. Twenty-seven percent of the subjects who received preoperative phenazopyridine and 21% of the control group failed the void trial (p=0.453).

An adjusted logistic regression model controlling for potential confounders including sling approach (suprapubic vs transvaginal), perforation, and intraoperative fentanyl dose, showed no significant effect on void trial results. As-treated analysis showed similar results. While preoperative pain VAS between both groups was similar (p=0.606), postoperative pain VAS was significantly higher in those that did not receive phenazopyridine, with a mean of 1.76 vs. 1.21 (p=0.046). However, the change between pre-and postoperative pain VAS between the groups did not show a significant difference, p=0.087.

Our study suggests that preoperative phenazopyridine has no effect on short-term postoperative bladder emptying in women undergoing RMUS. This result is in marked contrast to prior retrospective studies. There may be a decrease in postoperative pain in those who receive preoperative phenazopyridine, although the clinical significance of the small difference seen in our study is minimal. Previous research suggests that neither postoperative VAS nor pain medicine usage is affected by phenazopyridine (3).

Although previous retrospective studies showed a reduction in VD, our prospective trial showed no such decrease in VD with phenazopyridine. Short-term postoperative VD appears to be multifactorial and further research identifying risk factors and interventions are needed. 

Hypothesis / aims of study Cyclophosphamide (CYP), an anticancer drug, causes hemorrhagic cystitis as a serious adverse effect. Mesna is used for prevention of cystitis induced by CYP but can not prevent all cases. Moreover, the pathological mechanisms of cystitis have not been revealed completely. Tryptophan is metabolized to kynurenine with indoleamine-2,3-dioxygenase (IDO), and this pathway is called the kynurenine pathway. The two important metabolites in the kynurenine pathway are kynurenic acid (KYNA) and quinolinic acid (QUIN). KYNA is made from kynurenine by kynurenine aminotransferase (KAT), which has neuroprotective activity. On the other hand, QUIN has a neurotoxic property and is made with 3-hydroxyanthranilic acid oxygenase (HAAO). The amount of IDO in the cerebrospinal fluid is increased by inflammation [1] . However, the relationship between the kynurenine pathway and cystitis has not been reported. Thus, we examined the role of the kynurenine pathway in bladder function by using a rat model of cystitis induced by CYP.

We used 10-to 11-week-old female Wistar/ST rats. Cystitis was induced by intraperitoneal injection of CYP (150 mg/kg body weight). Control rats were administered the same volume of saline. At 24 hours after injection, we performed conscious cystometry (80 µL/min). Then, we used other rats for tissue evaluation. We injected CYP or saline at the aforementioned dose and removed the bladders 24 hours after injection. We evaluated bladder hypertrophy based on bladder weight-to-body weight ratio. We measured the mRNA expression levels of IDO1, KAT1, and HAAO in the bladders by using real-time polymerase chain reaction analysis and the tryptophan and kynurenine contents of the bladders by using ultraperformance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Statistical analysis was performed by using the Student t test.

Intercontraction intervals were significantly decreased in the cystitis rat model in comparison with those of the control rats (p < 0.05). The bladder weight-to-body weight ratio of the cystitis models was significantly higher than that of the control rats (p < 0.01). In the cystitis models, the mRNA expression level of IDO1 in the bladder was approximately 23 times as much as the levels in the control rats (p < 0.01, Figure 1 left), and that of HAAO was increased to twofold that of the control rats (p < 0.01, Figure 1 middle). On the other hand, the expression level of KAT1 did not significantly change between the two groups (Figure 1 right) . The kynurenine and tryptophan levels in the urinary tissues from the cystitis rats were upregulated about 18 times ( Figure 2 ) and twice more, respectively, than those in the urinary tissues from the control rats. Interpretation of results Shortening of intercontraction intervals and hypertrophy of the bladder are known symptoms of cystitis. In this study, these symptoms were observed as in existing reports. In the bladder of the cystitis models, the mRNA expression level of IDO significantly increased and the kynurenine content also increased in comparison with those in the control rats. These data suggest that the tryptophan metabolism in the kynurenine pathway in the bladder was promoted by cystitis induced by CYP. Moreover, our results suggest that the production of QUIN increased on the basis that the mRNA expression level of HAAO, the producing enzyme of QUIN, increased. QUIN is known to act as a neurotoxin, so we speculated that QUIN acted on the sensory nerves of the bladder and that the increase in QUIN was a factor that shortened the micturition intervals in the cystitis rats.

To our knowledge, this study is the first that focused on the relationship between the kynurenine pathway in the bladder and hemorrhagic cystitis. In this study, we found that CYP induced hemorrhagic cystitis with enhancement of the kynurenine pathway in the bladder, suggesting that the kynurenine pathway might be a new target for treatment and prevention of cystitis. Therefore, we are currently performing further study that involves, for example, measurement of KYNA and QUIN levels in the bladder by using UPLC-MS/MS to determine the detailed mechanisms.

Meister M 1 , Wang C 1 , Lowder J 1 , Mysorekar I 1

Hypothesis / aims of study This original work was designed to explore the relationship between the postmenopausal bladder state, vaginal estrogen therapy, and urinary tract infections (UTIs). Urinary tract infections are common and can result in significant healthcare morbidity, especially in the aging population. Postmenopausal women are at increased risk for recurrent UTIs, which may be related to the relative estrogen deficiency leading to inflammation and increased susceptibility to infection in the genitourinary tract [1, 2] . Topical vaginal estrogen therapy has been shown to decrease the risk of recurrent UTIs in postmenopausal patients, but the mechanism of action is still unclear [3] . The objective of our work is to characterize the postmenopausal inflammatory profile to assess whether this contributes to increased susceptibility to UTIs and whether vaginal estrogen therapy modulates this risk.

We prospectively enrolled post-menopausal patients (>65 years) into one of three cohorts: 1) postmenopausal without a history of UTIs who are currently using vaginal estrogen therapy; 2) postmenopausal women with a history of UTIs who are currently using vaginal estrogen therapy; and 3) postmenopausal women with a history of recurrent UTIs who are not receiving vaginal estrogen therapy but are willing to start. We followed patients over a 6-month course and collected urine and serum samples from each patient at study enrollment, 3 months, and 6 months. Comprehensive cytopathologic analysis was performed using Pap and Hema-staining, urine inflammatory scoring was performed, and urothelial cell shedding was closely monitored.

We have recruited a total of 41 patients into the pre-defined cohorts: 1) no UTI on vaginal estrogen (n=20); 2) patients with UTIs on vaginal estrogen (n=15); 3) patients with recurrent UTIs not on estrogen but willing to start (n=6). At this time, 23 (56%) have returned for one follow-up visit, and 13 (32%) have completed the full 6 months of follow-up. On cytologic analysis, urine from post-menopausal patients without a history of recurrent UTIs shows scant urothelial cell shedding, while patients with history of recurrent UTIs demonstrate increased inflammatory cells, debris, and exfoliated urothelial cells (Figure) . Urine inflammation scores are significantly higher in post-menopausal women with recurrent UTIs compared to women without UTIs (1.25 and 1.67 vs 0.12, p<0.05) (Figure) .

Postmenopausal women with recurrent UTIs demonstrate increased urine inflammation scores and urothelial cell shedding.

Vaginal estrogen therapy appears to modulate this effect with reduced urine inflammation and decreased cell shedding in women with recurrent UTIs already on an established vaginal estrogen regimen. Further studies using urine and serum inflammatory markers will be performed to further analyze the effect of vaginal estrogen therapy on the post-menopausal inflammatory profile.

This novel work should help further delineate the role of the postmenopausal inflammatory state in UTIs and the role vaginal estrogen plays in reversing these effects and reducing UTI risk. 

Hypothesis / aims of study The aim of the present study was to assess the prevalence of urinary incontinence (UI) and its association with disordered eating (DE), among female elite athletes and non-athletes. Association between UI and DE (global score of the EDE-Q) was estimated using adjusted odds ratio (adj OR) with respective 95% confidence intervals (CI) through binary logistic regression models. Estimates were adjusted for age and type of sports (leanness vs. non-leanness).

Background variables for the two study groups are listed in Table 1 . Twenty-eight sports disciplines were included. More athletes were grouped in the non-leanness sports group (73.1%) compared to leanness sports. There was no difference in prevalence of DE between athletes and non-athletes. Athletes presented higher prevalence of UI of any type than non-athletes (Table 1) . Among the athletes, the prevalence of DE was 26.1% in the leanness sports group vs 16.2% in the non-leanness sports group (p=0.086). In non-athletes there was no statistically significant difference in prevalence of any UI between those with or without DE. In athletes, the prevalence of UI of any type was higher among those with DE (Table 2) .

In athletes, after adjustment for age and type of sports (leanness vs. non-leanness), athletes with DE were about 3 times more likely to present UI of any type (adj OR=3.07; 95% Cl 1.73-5.45), in comparison to those without DE. Athletes with DE also presented an increased odds of stress urinary incontinence (SUI) and urgency urinary incontinence (UUI), 3.24 (95% Cl 1.81-5.81) and 2.84 (95% Cl 1.27-6.34), respectively. 

The present study included young women with no comorbidities. Athletes with DE had significantly higher odds of UI than those without DE. As far as we have ascertained there are sparse knowledge on this phenomenen. Although the development of UI is multifactorial, the results are in line with a former study [3] .

More basic studies are needed to investigate the relationship between these two conditions.

Strengths of the present study are the large sample size and the use of validated instruments to assessed both DE and UI. The use of self-reported data is a limitation of the study. In addition, the lower number of participants in the leanness groups may have influenced the results.

Concluding message Female elite athletes with DE have higher risk of UI than other athletes. Both UI and DE can have a negative impact on the athletes' well-being, quality of life and sport performance. Female elite athletes should be screened for both DE and UI and prevention and treatment strategies for both conditions should be evaluated in future high quality RCTs.

Hypothesis / aims of study The symptoms of overactive bladder (OAB), particularly urinary incontinence (UI), have a substantial negative effect on patients' quality of life. Management of these symptoms with conservative interventions such as long-term use of incontinence pads presents a considerable cost burden to patients and healthcare systems. OnabotulinumtoxinA has been shown to significantly reduce UI and improve patients' quality of life and their perception of treatment benefit in two large, randomized, placebocontrolled, phase 3 trials. There are few published reports on the real-world use of onabotulinumtoxinA in everyday clinical practice. This prospective real-world study examined the efficacy of onabotulinumtoxinA and the practical impact of urinary symptom improvements on OAB patients' daily lives, including the use of incontinence products and the frequency of the need to urinate.

Study design, materials and methods This multicentre, prospective, observational, non-interventional, study enrolled idiopathic OAB patients ≥18 years of age in the UK, Germany, Sweden, and Spain. All patients were inadequately managed by ≥1 anticholinergic and had to be willing to initiate clean intermittent catheterisation if necessary. Patients who had ever received botulinum toxin treatment for OAB or had received treatment with any type A botulinum toxin in the preceding 18 months were excluded. Patients were treated with onabotulinumtoxinA, and treatment details, retreatment, or discontinuation of therapy were decided by the physician. Assessments at week 12 post-treatment included mean number of incontinence products used, concomitant use of anticholinergic/other OAB therapies, mean (co-primary endpoint) and percentage change in UI episodes/day, proportions of patients with a positive response ("improvement" or "great improvement" in their urinary condition) on the Treatment Benefit Scale (TBS; co-primary endpoint), mean and percentage change in urgency UI (UUI) episodes/day, and proportions of patients with ≥50% and 100% reduction in UI and UUI episodes/day. An evaluation in which patients ranked each urination during the 3 days prior to a study visit by the need to urinate from 0-3 on a 4-point scale was also included. Adverse events were recorded. The safety population (n=485) was comprised of all patients who received ≥1 onabotulinumtoxinA treatment. Treatment outcomes were assessed for patients with data available at the evaluated timepoint (UI and UUI episodes, n=159; TBS response, n=144).

The patients' mean age was 63.7 years and 85.6% were female. Mean onabotulinumtoxinA dose/patient at treatment 1 was 100.3U. At the time of this analysis, 485 patients had received at least 1 dose and 3 patients had received 2 doses. The mean number of injection sites was 17.6 ± 5.1. Patients reported a 2-to 3-fold decrease in the use of incontinence products at week 12 after onabotulinumtoxinA treatment; patients used an average of 71.9 pads/liners and 12.7 diapers per month at baseline compared with 31.8 and 4.3 after treatment, respectively. Use of concomitant anticholinergic/other OAB medications was low at week 12 (2.1%). Treatment with onabotulinumtoxinA resulted in improvements in OAB symptoms, including significant mean decreases in UI episodes/day (-7.7; P<0.001) and percentage reductions from baseline in UI episodes (-63.7%; P<.001). Similarly, significant decreases were seen in the mean UUI episodes/day (-5.1; P<.001) and percentage change from baseline in UUI episodes/day (-61.1; P<0.001). A high proportion of patients (70.6%) achieved ≥50% reduction in UI episodes/day and 23.9% became "dry" (100% UI reduction). A majority of patients (87.5%) reported an improvement in their urinary symptoms on the TBS. Patients responded "I could delay urination as long as necessary without worrying to wet myself" with greater frequency at week 12 postinjection than at baseline (mean score: 7.6 vs 2.0), and "I could not delay urination, had to rush to the toilet" with lesser frequency at week 12 postinjection than at baseline (mean score: 5.1 vs 18.6). OnabotulinumtoxinA was well tolerated; the rate of adverse drug reactions was 2.9%.

In this interim analysis of a real-world study, treatment with onabotulinumtoxinA resulted in significant reductions in UI and UUI episodes in patients who were inadequately managed by ≥1 anticholinergic. High proportions of patients achieved ≥50% reduction in UI episodes and and reported treatment benefit; 23.9% of the patients became 'dry". Improvements were similar to those in prior phase 3, randomised, controlled clinical trials. In addition, onabotulinumtoxinA-treated patients reported decreases in the use of incontinence products and in the frequency of the need to urinate.

OnabotulinumtoxinA significantly improved the urinary symptoms and provided treatment benefit in OAB patients in everyday clinical practice. The reductions in incontinence had clinically meaningful effects on the practical aspects of patients' daily lives including decreases in the use of incontinence products and the frequency of the need to urinate. OnabotulinumtoxinA was well tolerated. 

Hypothesis / aims of study This study describes a novel approach to the study of the prevention of lower urinary tract symptoms (LUTS). The goal was to develop a conceptual framework to guide a LUTS prevention research program among girls and women across the life course. Prevention science is the application of scientific methodology to prevent or moderate major human dysfunction before it occurs. It involves the systematic study of potential risk and protective factors for illness and health, as well as the development of prevention interventions that attempt to change selected risk and protective factors. The prevention science paradigm progresses through phases of translational research, spanning from basic research to effectiveness trials of prevention interventions in real world settings. A key strategy in developing a prevention research program is to devise a conceptual framework that can direct the study and analysis of potential risk and protective factors across different levels of biology and the social ecology within which the individual interacts through the life course. Conceptual frameworks can also aid in identifying potential opportunities for prevention intervention. Our aim was to adopt a conceptual framework to assist in the development of a prevention science agenda for LUTS and promotion of bladder health.

Study design, materials and methods A transdisciplinary research consortium was formed from U.S. experts across a broad range of disciplines including adolescent medicine, pediatrics, geriatrics, female pelvic medicine and reconstructive surgery, preventive medicine, community health science, psychology, nursing, medical sociology, behavioral science, epidemiology, and biostatistics. The consortium developed a conceptual framework of bladder health that was informed by traditional social ecological models of public health, biopsychosocial models of health, Glass and McAtee's Society-Behavior-Biology Nexus, life course perspectives and the World Health Organization's Conceptual Framework for Action on Social Determinants of Health. Methods of conceptual framework development included (1) defining levels of social ecology and biology that are relevant to the preservation of bladder health/prevention of LUTS, (2) generating potential risk and protective factors within different levels of social ecology and biology, (3) prioritizing risk and protective factors for study by the consortium, and (4) developing research themes based on categorized risk and protective factors. In addition, the consortium delineated life course periods that are relevant to the prevention of LUTS in females. Table 1 shows a sample of potential risk and protective factors for LUTS and bladder health that were identified by the consortium. Factors are organized by levels of social ecology and biology. Over 600 potential risk and protective factors were generated by the consortium; these were condensed into 44 broad categories of factors, from which eight research themes emerged and were prioritized: (1) Toileting environment/access/habits/techniques; (2) Pregnancy and childbirth; (3) Personal physical health/medical conditions; (4) Musculoskeletal function/ pelvic floor health/muscle awareness; (5) Lifestyle behaviors (e.g., fluid intake, hydration management, dietary factors, smoking, sexual behaviors); (6) Stress and mental health; (7) Infections and microbiome; and (8) Hormonal status across the lifespan. Risk and protective factors that may be particularly salient and influential during different periods of the life course were identified. In identifying life course phases, risk factors were noted when they typically begin to be observed within a developmental period. Chronological age was deemed not as relevant as developmental status and events relevant to bladder health. Interpretation of results A conceptual framework was developed based on potential risk factors for LUTS and protective factors for bladder health at different developmental periods of the life course in women. This framework incorporated the interaction between social ecology and biologically-based predispositions towards health or disease and the embodiment of societally constructed risk and protective factors.

The consortium's conceptual framework is the foundation for a research agenda to develop and test evidence-based approaches to promote bladder health and prevention of LUTS in girls and women. The consortium's work has potential to promote the health equity and overall well-being of girls and women in diverse communities, as well as population health more broadly. 

Hypothesis / aims of study Stress urinary incontinence is a worldwide health problem concerning over 30% of adult women. Mid-urethral slings are the gold standard of treatment with relatively high efficacy and safety rates. Nevertheless, approximately 10-30% of patients undergoing the procedure still suffer form persistent or recurrent incontinence. It has been suggested that the problem is connected with suboptimal sling location proximal to the bladder neck. The aim of the study was to determine whether suboptimal sling location is connected with its migration or is a result of incorrect surgery technique or another epidemiologic risk factor such as age or obesity.

Study design, materials and methods A prospective cohort study was performed in a group of 238 patients who underwent retropubic sling implantation (TVT). Sling location was determined with the use of pelvic floor ultrasound examination and calculated relative to the individual patient's urethral length, measured before the procedure (Fig. 1) .

Sling location was visualized 1 day and 1 and 6 months after the surgery.

Mean urethral length in the studied cohort (n= 242) was 28,76 +/-3,67mm. The distribution of the urethral length was normal (min 19,5; max 39 mm). Mean tape position (distance from the bladder neck to the middle part of the tape) 1 day after the surgery was 21,13 +/-3,83 mm (66,18 +/-8,43% of the urethral length) and did not change as it was visualized one and six months after the surgery: 19,92 +/-3,57 (65,80 +/-7,23% of urethral length) and 19,18 +/-3,53 mm (65,5 +/-7,62% of urethral length) (Fig. 2 ) Figure 2 . Sling location (% of urethral length) -1 day, 1 month and 6 months post TVT implantation

The tape location shifts did not differ significantly between the analyzed groups.

As proximal sling position seems to be suboptimal for best clinical results of sub-urethral slings, there is ongoing discussion whether proximal location of the sling is connected with tape "migration" or with incorrect implantation during the surgery. The question is extremely important from the clinical point of view. Assuming that the tape location remains stable after the surgery it becomes evident that proximal positioning of the sling should be diagnosed immediately after the procedure and is connected with inappropriate surgery technique. Our study for the first time shows stable sling location in middle term observation after the TVT procedure. We also demonstrated that the sling does not change its position, regardless of the patient's age or weight.

The sling location does not change after implantation in middle term observation. Therefore it appears that suboptimal sling location is a result of incorrect surgical technique and should be diagnosed and treated early after the primary surgery. 

Hypothesis / aims of study The validation of integrated total pelvic floor ultrasound in defecatory dysfunction by comparison with defaecation proctography as the gold standard.

Study design, materials and methods A prospective study 224 consecutive women (mean age 51 years (range 19 -87)) presenting to a tertiary pelvic floor unit with defaecatory dysfunction (incomplete evacuation with or without concomitant faecal incontinence).

Each patient underwent integrated total pelvic floor ultrasound and defaecation proctography. Integrated total pelvic floor ultrasound was performed in accordance to previously published methods (1). Defaecation proctography was performed with rectal paste and small bowel oral contrast. Each scan was performed and interpreted by a pelvic floor clinical fellow, clinical scientist or clinical nurse specialist blinded to symptoms and corresponding imaging. Each report was verified by a blinded surgical consultant with a specialist interest in pelvic floor dysfunction.

The presence and size/grade of rectocoele, enterocoele, intussusception, dyssynergy and poor propulsion was recorded for both modalities. Uterine descent was noted for integrated total pelvic floor ultrasound. Incomplete evacuation, a trapping rectocoele and seepage of paste at rest was noted for defaecation proctography.

Mean time between integrated total pelvic floor ultrasound and defaecation proctography was 10 days (median 6, range 0 -104, inter quartile range 0 -14.5).

Integrated total pelvic floor ultrasound showed; 130 rectocoeles, 72 enterocoeles, 47 with intussusception, 118 cystocoeles,13 uterine descent, 46 with dyssynergy and 101 with poor propulsion. Defaecation proctography showed: 110 rectocoeles (63 caused trapping barium paste), 72 enterocoeles, 155 with intussusception, 14 with dyssynergy, 139 with poor propulsion, 61 with incomplete evacuation and 77 with seepage of paste. Ultrasound when compared to proctography had a sensitivity and specificity for; rectocoele -75% and 58%, enterocoele -54% and 75%, intussusception -30% and 83%, dyssynergy -29% and 80% and poor propulsion -55% and 72%.

Rectocoele: There was a moderate positive correlation between rectocoele measurements (correlation R coefficient 0.54 (p<0.0001)). Agreement for measurement of rectocoele depth with the two modalities was fair (intraclass correlation coefficient 0.47, 95% limits of agreement -2.63 to 1.66, 95% confidence interval -0.63 to -0.34). Agreement for classification of rectocoele (small (<2cm), moderate (2 -4cm), large (>4cm)) was moderate (Cohen's kappa 0.44). Rectocoeles causing barium trapping on proctography were larger (unpaired T tests -proctography p = 0.02; ultrasound p = 0.003) and more likely to be seen on both transvaginal and transperineal ultrasound than only one view (Fishers exact p=0.007). Those with seepage of barium paste during defaecation proctography were significantly likely to have a rectocoele which was larger on transperineal ultrasound than defaecation proctography (p=0.03).

Enterocoele: There was a positive correlation for grading of enterocoele (Spearman's Rho 0.33, 2-sided p<0.0001). Agreement for grading enterocoele on transperineal ultrasound compared to defaecation proctography was fair (weighted Cohen's Kappa 0.26).

Intussusception: There was a positive correlation between grading on ultrasound and proctography (Spearman's Rho 0.28, 2sided p<0.0001). Agreement grading was fair (weighted Cohen's Kappa 0.24). Specificity increased with increasing grade.

Patients with incomplete evacuation on proctography were more likely to display a higher grade of intussusception on ultrasound than defaecation proctography (p=0.01). Those patients with poor propulsion on posterior transvaginal ultrasound were significantly more likely to display a higher grade of intussusception on defaecation proctography than ultrasound (p= 0.02).

Functional Aspects: Those with dyssynergy or poor propulsion ultrasound were more likely to display incomplete evacuation on defaecation proctography (dyssynergy p=0.03, poor propulsion p=0.001). When possessing any dyssynergy and/ or poor propulsion on integrated total pelvic floor ultrasound, the positive predictive value of displaying dyssynergy, anismus and/ or incomplete evacuation on defaecation proctography was 82% (negative predictive value 47%, sensitivity 56%, specificity 76%).

Multiple pathologies: There were 123 women with multiple pathologies on integrated total pelvic floor ultrasound (i.e. 2 or more of; rectocoele, enterocoele, intussusception, cystocoele or uterine descent) and 69 women with multiple pathologies on defaecation proctography (i.e. 2 or more of; rectocoele, enterocoele or intussusception).

If an enterocoele, intussusception, dyssynergy or poor propulsion are on ultrasound they are likely present on proctography. If there is no rectocoele on ultrasound it is unlikely to be present on proctography.

This study assumes proctography is 100% accurate, not necessarily the case; studies comparing ultrasound with clinical findings are required.

Though there was positive correlation for rectocoele measurement between the two modalities there was a bias toward rectocoele appearing larger on proctography and 95% of the differences lay between -2.63 and 1.66 which means the difference for an individual could be from -2.63 to 1.66cm. Ultrasound cannot be relied upon to measure exact rectocoele size. In those with incontinence (i.e. seepage of paste during proctography) ultrasound may confer an advantage as it allows soft tissue visualisation without the need to retain contrast. If a rectocoele is seen on transvaginal and transperineal ultrasound it is more likely to cause barium trapping on proctography; this may indicate the rectocoele is more clinically relevant than if only seen on one view.

The presence of any dyssynergy or poor propulsion on ultrasound has a high positive predictive value for a functional abnormality on proctography. Integrated total pelvic floor ultrasound facilitates the diagnosis of multiple pathologies more readily than defaecation proctography. This may be advantageous as women presenting with defaecatory dysfunction often possess concomitant anterior and middle compartmental pathology (2).

Concluding message Integrated total pelvic floor ultrasound is a reliable alternative for proctography though due to our lack of confidence and experience we may use it as a screening tool. The presence of pathology during ultrasound examination means that defaecation proctography is also likely to demonstrate pathology. We have previously shown the clinical utility of PFUS is as reliable as proctography and as we increase our numbers and confidence PFUS may be proved to be a reliable alternative to proctography.

Hypothesis / aims of study Hypertension is known as one of the risk factors for nocturia and/or urinary frequency. Urinary storage dysfunction has been also identified in animal models of salt-sensitive hypertension, such as Dahl salt-sensitive (DS) rats [1] . However, the mechanisms underlying storage dysfunction induced by high salt loading are unknown. In this study, we focused on the epithelial sodium channel (ENaC), which acts as a mechanosensor in the bladder epithelium [2] . ENaC is expressed in the kidneys and upregulated by high salt loading [3] . Thus, we investigated whether high salt intake alters the expression of ENaC in the bladder and affects bladder function.

Six-week-old male Dahl salt-resistant (DR) and DS rats were fed a high-salt diet (8% NaCl, w/w) for one week. Then, heart rate, blood pressure, and body weight were measured, and cystometry was performed under intrabladder infusion of saline (80 μl/min), followed by infusion of amiloride, an ENaC inhibitor, in saline at the same speed. Localization and expression levels of ENaC-α protein in the bladder were evaluated by immunohistochemistry and western blot analysis. The two-sided Student's t-test was used to evaluate differences between the DS and DR rats, while the paired t-test was used to compare pre-and post-intervention differences.

There was no difference in bladder-to-body weight ratio between DR and DS rats. Systolic and diastolic blood pressures were significantly higher in DS rats than in DR rats after treatment. The intercontraction intervals (ICI) were significantly shorter in the DS group than in DR group during saline infusion ( Figure 1A,B) . Subsequent infusion of amiloride significantly prolonged ICI in DS group, while no intragroup difference in ICI was observed in the DR group ( Figure 1A,B) . No intra-or intergroup differences in maximum intravesical pressure were observed ( Figure 1A,C) . Protein expression levels of ENaC-α in the bladder were significantly higher in the DS group than in the DR group. ENaC-α protein was localized at the bladder epithelium in both groups similarly.

High salt intake induced storage dysfunction with the upregulation of ENaC-α in the bladder epithelium in DS rats. This storage dysfunction was inhibited by infusion of amiloride, an ENaC-α inhibitor, suggesting that high salt induced storage dysfunction via ENaC-α. Amiloride did not change the intercontraction intervals and the expression of ENaC-α in DR rats treated with high salt. The data also suggested that overexpression of ENaC-α is involved in storage dysfunction in salt-sensitive rats.

High salt intake is considered to cause urinary storage dysfunction via the upregulation of ENaC-α in the bladder epithelium in rats with salt-sensitive hypertension, suggesting that ENaC-α might be a candidate therapeutic target for this pathological condition. 

Hypothesis / aims of study Clean intermittent catheterization (CIC) has been contributing to the improvement of life expectancy in patients with spina bifida (SB). However, prevention of febrile urinary tract infection (fUTI) during a patient's lifetime, and bladder instability by secondary tethered cord syndrome (sTCS), is an important element of urological management. Previously, the author reported the importance of urodynamic study (UDS) examination for early detection of sTCS (ICS 2015). The author consider UDS a central point of examinations, although UDS needs human resources, time and comes at a cost, and it is more of a burden on patients in comparison to ultrasonography or urinalysis. In long-term follow-up, the author experienced that good-adherence SB patients suffered fUTI for the first time upon commencement of work. In this study, we determined those patients who have displayed risk factors of deterioration of renal function and require UDS examination post-adolescence among SB patients tracked at our institute from infancy.

Study design, materials and methods A total of 199 SB patients who were admitted to our department from 2000 to 2013 were retrospectively reviewed. Medical records of the patients, urological symptoms, results of examinations and treatment for urological symptoms, including medicine and surgery, were investigated. In the cohort, 56 patients have been continuously tracked from infancy, 22 of those were over 18 years old. Twenty-two of the 56 patients over 18 years were divided into two groups, according to whether they had still UDS examination regularly or not (UDS: non-UDS=7:15, respectively).

The cohort includes 29 male patients and 27 females from the age of 12 to 29 years (median 17 years) with underlying diseases of myelomeningocele (38 patients) and spinal lipoma (18 patients). Fifty-two of the 56 patients used CIC for bladder management. Twenty-tree of the 56 patients were prescribed anticholinergic agents regularly and 11 patients had vesicoureteral reflex (VUR). Twenty-five patients had asymptomatic pyuria and 9 of those 25 patients have been receiving fUTI treatments in the last 3 years. The significant risk factors for UDS examination for those over 18 years old were fUTI (p=0.006) and VUR (p<0.001), but not pyuria (p=0.083) ( Table 1) .

Adult SB patient with VUR or a fUTI episode have received regular UDS examination even after they stopped growing, while adolescent patients who don't have these factors avoided UDS examination. Asymptomatic pyuria wasn't a crucial factor in continuous UDS evaluation. This implies that adult SB patient with VUR or a fUTI episode still have a risk of deterioration of renal function, even though they have visited the hospital regularly and been treated with CIC and anticholinergic agent. The author assumes that the regular school routine allows patients to manage urination strictly and prevent fUTI in spite of having VUR or pyuria.

When Adult SB patients have VUR or a treatment episode of fUTI, health providers should focus especially on management of urination and prevention of deteriorating renal function. In order to evaluate bladder function particularly, UDS should be a central point among examinations. On the other hand, a regular UDS examination can be avoided when SB patients stop growing and get used to managing their urination without VUR or a fUTI episode. Moreover, we should not hesitate to perform invasive treatments including bladder augmentation for the patient suffering repeated-fUTI and/or VUR. 

Wang X Z 1 , Wen J G 1 , Wen Y B 1 , Han Z J 1 , Li Y L 1 , Li S L 2 , Li X 3 , He Y L 1 , Wang Y H 1 , Li J Y 4 , Shang X P 5

Hypothesis / aims of study The using diapers might impact the developing of voiding control in infant and children. The purpose of present study is to assess the impact of using diapers on children's enuresis incidence.

Study design, materials and methods A cross-sectional study of using diapers was performed by distributing 6522 self-administered questionnaires to parents of 5 to 7-year-old children in 51 schools of Zhengzhou City, Henan province China. The questionnaire was filled by parents including information of age, gender, inhabitation (living in rural or urban areas), arousal dysfunction, using diapers data, enuresis data, physical or psychological disorders, daily behaviour to the toilet, and so on.

The response rate of investigation was 86% (5609/6522) in which 5302 (81.3%) were qualified to enter the final statistical analysis. A total of 4822(90.95%) children used diapers after born and their enuresis incidence is 20.71% ; 436 (9.05%) children never use diaper and their enuresis is 9.05% , enuresis is significantly more in those who used diapers after born(P<0. 

This is the first investigation aim to find the association between diaper and enuresis, the investigation is still underway and the primary results show a significant impact of using diapers on the enuresis incidence. The reason of this might be related the decrease of voiding training chance to children who used diapers. At 12 years ago we had made an epidemiological study of PNE in Chinese children and find that PNE incidence in 5 to 8 years old children is about 10%, which is significant less than that in western country(more than 15% -20% of children by the age of 5, which decreases to 1%-2% by the age of 17). However, 19.56% incidence of enuresis is found in present study, significant increase comparing to those of 12 years ago. We strive to seek the reason, once again made epidemiological investigation again in the same city and found main reasons might be due to using diaper. Therefore, we collect the information of duration, frequency, usage of using diapers , age, gander, inhabitation (living in rural or urban areas), arousal dysfunction, associated daytime symptoms and family history as well as inquiry about how the infants and children were raised including whether using toilet training, and any urination and defecation function disturbance. The result indicated that more diapers that used the higher of the enuresis in children. Chi-square and rank analysis are used to analysis the above information, the differences are statistically significant. In recent 2 decades, a rapid growth in usage of diapers in mainland of China, and the diaper using do decrease the labour of parents to take care of the infants. From 1998 to 2016, the usage of diaper number increased from 0 to 24 billion. Considering the number of children included in this study is not enough to make detail analysis, more investigation is needed in the future, to find the relationship between the using of diapers and incidence of urinary incontinence in children.

Increasing using diapers might contribute to the increasing incidence of enuresis in children in China.

Reis J 1 , Saiovici S 1 , Mello L F 1 , Vidolin E 1 , Trigo Rocha F 2

Hypothesis / aims of study Electromyography (EMG) biofeedback is an effective treatment for children with lower urinary tract dysfunction (LUTD) especially those with bladder-sphincter dysfunctional voiding (1, 2) . Similarly parasacral transcutaneous electrical nerve stimulation (PTENS) is a well established treatment option for overactive bladder in children (3) . However there is a lack of controlled studies comparing these treatments for different voiding dysfunction in children.

Study design, materials and methods A prospective and randomized study to evaluate the efficacy of EMG biofeedback and PTENS for the treatment of children with non-neurogenic dysfunction voiding. The study involved 64 children, 43 girls and 21 boys, average age of 9.39 years. Initial evaluation consisted in history, physical examination, urine analyses, voiding diary, uroflowmetry and ultrasound. It also included incontinence and quality of life questionnaires. The children were divided into two treatment groups independent of the predominant type of dysfunction voiding (dysfunctional or overactive bladder): biofeedback group and PTENS group. The criteria for assessing the effectiveness of techniques were resolution of daytime and nighttime symptoms including urinary leakage, improvements in voiding diary and changes in uroflowmetry. The assessment also included pre and post treatment questionnaires (DVSS -Dysfunction voiding symptom score), quality of life (QOL). We also analyzed the presence of constipation and number of episodes of urinary tract infection (UTI) before and after treatment.

The study based only in non-invasive tests we observed a prevalence of overactive bladder (OAB) in 64.1% , dysfunctional voiding in 21.9% and 14% in combination. Regarding daytime symptoms 54.9% of children treated by EMG biofeedback had a complete response and 60.6% in the PTENS group. The results were similar between the two groups (p = 0.483). The same have been observed in the night time incontinence with complete resolutions in 29.6% and 25% respectively (p = 0.461) (table 1) . Analyzing the voiding diary, uroflowmetry and DVSS questionnaires both groups had significant improvement (p = 0.001) after treatment. However the QOL questionnaire did not show differences in both groups before and after treatment (p = 0.959 and p = 0.065) (table 2). In the evaluation of constipation, after treatment we observed a decrease from 61.3% to 19.4% (p = 0.002) in EMG biofeedback group and from 33.3% to 6.2% (p = 0.013) group in PTENS group. The number of sessions to obtian such results was lower in the biofeedback group if compared to PTENS group (p< 0,05)

Interpretation of results In our study there was a prevalence of overactive bladder, and the PTENS group had a complete response when compared to the biofeedback group but no significant difference between groups. Physical therapy has been the first line of choice for children with LUTD, with great scientific support to the effectiveness of the main techniques available Biofeedback requires participation and collaboration of children to the appropriate relearning and PTENS does not require participation in its application. Both techniques show great results on the treatment of the symptoms of LUTD. PTENS can also be applied in some non collaborative children with attention deficit Concluding message Both techniques EMG biofeedback and the PTENS are effective for treating LUTD. EMG biofeedback seems to require a lower number of sessions in order to obtain similar results of the PTENS. Study design, materials and methods 48 children aged 6-14 years with OAB diagnosed by urodynamics failing standard management were treated with TMS. TMS was added to treatment as usual. Patients were kept on the same regimen (medication and dosage) as they were before study initiation. TMS was administered with magnetic coil placed in the sacral, perineal and suprapubic region over the bladder twice daily for 20 minutes per site for four weeks. Patients were monitored for four weeks before and after TMS therapy. Baseline measurements prior to the commencement of the treatment included: urinary control assessment form, PedsQL questionnaires and weekly urinary diaries.

Compared to baseline, there was a significant decrease in the number of urinary urgency and incontinence during TMS therapy (p< 0.05). Similarly, there were significant improvements in urinary control and both the parental and children quality of life scores after TMS treatment. Instead, most patients reported a non-significant improvement in abdominal pain.

Compared to the traditional TMS with only directed across the sacral region, we used alternative method with magnetic coil application to the sacral, perineal and suprapubic region over the bladder. By the new TMS, we were able to achieve statistically significant results increasing urinary control in children with OAB. The trend for improvement in quality of life was also demonstrated. This new method of TMS warrants further assessment in a randomised control trial comparing new coil placement versus traditional sacral placement.

Concluding message TMS in the sacral, perineal and suprapubic region is a safe and optional method in children with OAB. It warrants further evaluation in a randomised, controlled trial. 

Hypothesis / aims of study Duration of response following the intravesical injection of onabotulinum toxinA among the SCI patients with neurogenic detrusor overactivity (NDO) is quite variable. Variations in the magnitude of maximum detrusor pressure of NDO represent differing severity of NDO. Time to request for retreatment is an important indicator of the longevity of clinical response in a given patient. We reviewed the relevance of the severity of pre-treatment NDO on the duration of response to the standard dose of onabotulinum toxinA treatment.

Records of 180 SCI patients receiving onabotulinum toxinA (200Units) for the control of their NDO were reviewed. Timing of their request for repeat onabotulinum toxinA injection treatment was noted. The pre-treatment UDS findings were correlated to the duration of effective clinical response.

After the standard dose of onabotulinum toxinA (200 units), 50 patients with pre-treatment maximum detrusor pressure of NDO (of more than 80 cm. of water) tended to request for re-treatment significantly earlier at 148 days (range 120-174 days) compared to a mean of 240 days (range 210-282 days) for the 70 patients with the pre-treatment maximum NDO detrusor pressure between 40-80 cm. Sixty patients with maximum NDO detrusor pressure of less than 40 cm. had the longest duration of effective response with the time to retreatment request at 322 days( range 280-362 days).

Standard dose (200 units) of onabotulinum toxinA tends to remain effective for significantly much shorter duration in patients with higher pressures NDO with maximum detrusor pressure more than 80cm. of water as compared to those with lower pressure NDO.

Concluding message Time to request for retreatment appears to be inversely proportional to the initial severity of neurogenic detrusor overactivity, as manifested by its maximum detrusor pressure. This may encourage reconsideration of differential dosing schedule among patients with varying severity of NDO, indicating possibly the need to use higher doses for more severe NDO. 

Hypothesis / aims of study Typical histopathological finding of Hunner type interstitial cystitis (HIC) is infiltration of inflammatory cells and it cause acute nociceptive pain. However, it is often seen that the pain become chronic and refractory to NSAIDs and opioids, and those medicines for neuropathic pain such as pregabalin and amytriptyline show better effect on pain relief, instead. Lysophosphatidilcholine (LPC) is a demyelinating and signaling molecule involved in neuropathic pain, hyperalgia and allodynia.

Our aim was to investigate the relationship between LPC and its related mediators and pain plasticity in patients with interstitial cystitis.

Study design, materials and methods A total of 13 HIC patients and 22 non-IC controls who underwent spinal anaesthesia were enrolled to this study. Diagnosis of IC and differential diagnosis of HIC and NHIC were made according to the clinical guidelines for interstitial cystitis and hypersensitive bladder syndrome and controls were patients without chronic pain and hospitalized for other reason than IC (e.g. URS for urolithiasis, TUR of tiny bladder cancer). Self-assessment questionnaire for IC, OAB and pain (O'Leary and Sants' symptom index and problem index (OSSI, OSPI) and VAS scores were measured before hospitalization. Spinal fluid samples were collected when these patients underwent spinal anaesthesia and then investigated for the amount of LPC by using mass spectrometry. Results Table 1 shows the patient demography. The background of the control cases as follows; 8 URS cases, 12 TUR-BT, 1 TUR-P, 1 TVM. All the patients in control group did not have any history of pelvic pain nor discomfort. The symptom scores OSSI, OSPI, OABSS and VAS scores showed symptomatic severity was significantly higher in HIC group, compared to control. All the LPC species, except 14:0 LPC showed significant elevation in HIC group, compared to the control group. (Figure 1 )

We demonstrate LPC was significantly increased in the spinal fluid of HIC. LPC is known to cause demyelination of sensory nerves which leads to neurogenic pain, hyperalgia, allodynia.

Recently, Foster et. al. demonstrated primary afferent neurons associated with the bladder exhibit increased chemokine receptor signalling following sciatic nerve injury with LPC in rodent model, suggesting the somatic nerve injury may induce neurogenic inflammation.

Although the major pathophysiology of pain in HIC is nociceptive, prolonged HIC pain may have induced neural cross talk, causing neural plasticity.

Concluding message Neurogenic pain related LPC was increased in the spinal fluid of HIC. This finding suggests that cross talk of nociceptive neurons may have occurred in HIC and is attributed to chronification of bladder pain. In the univariate analyses, gender, VAS score, numbers of hydrodistention, and bladder capacity at the first hydrodistention were significantly related to onset of contracted bladder, while age, OSSI, and OSPI were not significant. (Table 2) In the multivariate logistic model showed that the bladder capacity at the 3 rd time hydrodistention was the risk factors for onset of contracted bladder of HIC (Odds ratio;26.2). ( Interpretation of results We demonstrate the risk factor of the contracted bladder in HIC is the reduced bladder capacity at the third time hydrodistention. Intrafascicular fibrosis of the bladder is one of the well-known histopathological finding of IC and it can be presumed that chronic inflammation may have caused bladder fibrosis and thus bladder contracture.

This study revealed that the reduced bladder capacity at the 3 rd time hydrodistention may be a possible predictor of contracted bladder in Hunner type IC. Patient with reduced bladder capacity should be carefully observed and informed for the future risk of contracted bladder. 

Hypothesis / aims of study Transient Receptor Potential Melastatin 8 (TRPM8) channels are widely expressed in urothelial cell and sensory nerve fibres of the bladder and in L6 dorsal root ganglia (DRG) of the rat, and also in the urothelial cells of the human bladder [1] . A previous study suggested that TRPM8 channels have a role in activation of bladder sensory pathways at least partly through mechanosensitive C-fibres during bladder filling in rats [2] . In addition, another study demonstrated a significantly increased number of TRPM8-immunoreactive nerve fibres in the bladder suburothelium taken from patients with overactive bladder and painful bladder syndromes, and its correlation with clinical symptoms of pain and urinary frequency [3] . These findings suggest that TRPM8 channels may play a pathophysiological role in the development of bladder hypersensitive disorders via activation of mechanosensitive bladder afferents. However, there have been no studies directly investigating pathophysiological roles of TRPM8 channels in a model of hypersensitive bladder. In this study, we examined the effect of KPR-2579 (KPR), a novel selective TRPM8 antagonist, on deep body temperature and acetic acid (AA)-induced bladder hyperactivity by cystometry (CMG) and measuring primary bladder single-unit afferent activities (SAAs) in rats.

Study design, materials and methods Ninety-one female Sprague-Dawley rats were used and anesthetized with urethane (1.2 g/kg intraperitoneally). The effect of KPR on deep body temperature (intrarectal temperature) was evaluated with cumulative intravenous (i.v.) administrations of KPR (0.03 -1 mg/kg) or its vehicle (20% N,N-dimethylacetamide in saline). In the CMG measurement, after baseline recordings with salineinstillation at a rate of 6 mL/hour, 0.1% AA was continuously instilled into the bladder, and 1 hour later, KPR (0.03 or 0.3 mg/kg) or vehicle was administered (i.v.), then further recordings were performed. CMG parameters were evaluated for 15 minutes in each time point. SAAs measurements were made in separate animals and Aδ-and C-fibres were identified by electrical stimulation of the pelvic nerve and by bladder distention. After baseline recordings with saline-instillation (6 mL/hour), recordings were continuously performed during intravesical AA (0.1%)-instillation after i.v.-administration of KPR (0.03 or 0.3 mg/kg) or vehicle.

KPR even at the highest dose used (1 mg/kg) did not significantly affect deep body temperature. In the CMG measurements, AAinstillation significantly shortened intercontraction interval, and a high dose (0.3 mg/kg) of KPR-administration significantly attenuated the effect of AA-instillation compared to vehicle-administration (Table 1 ). In the SAAs measurements, 48 single afferent fibers (n = 24 in each fiber) were isolated from 41 rats. In the presence of vehicle, AA-instillations significantly increased the SAAs of C-fibers, but not those of Aδ-fibers. Pretreatment with a high dose (0.3 mg/kg) of KPR significantly inhibited the AA-induced activation of C-fiber SAAs (Figures 1 and 2) .

Interpretation of results CMG and SAAs measurements demonstrate that AA can induce bladder hyperactivity accompanied with facilitation of mechanosensitive C-fiber activities. In addition, AA-induced bladder hyperactivity was attenuated by KPR-administration at the doses which did not influence body temperature. These results suggested that KPR, a novel TRPM8 antagonist, can ameliorate AA-induced bladder hyperactivity without hypothermic effects.

The present results suggest that KPR, a novel TRPM8 antagonist, can inhibit frequent voiding and exaggerated activity of bladder mechanosensitive C-fibers induced by AA-instillation without affecting body temperature. TRPM8 channel may be a promising target for the treatment of bladder hypersensitive disorders. 

Hypothesis / aims of study A recent randomized control study in women with overactive bladder (OAB) demonstrated significant improvement of OAB symptoms with a low dose of tadalafil, a PDE type 5 inhibitor, as compared with placebo [1] . During the storage phase, enhanced localized microcontractile activity has been suggested to contribute to the development of urinary urgency in patients with OAB [2] . An animal study showed that tadalafil has an inhibitory effect on the increased mechanosensitive bladder afferent activities induced by intravesical instillation of acrolein in rats [3] . These findings lead the hypothesis that tadalafil ameliorates OAB symptoms by inhibiting localized bladder microcontractions and their related abnormally increased bladder mechanosensive afferent activities. In this study, we evaluated the effects of chronic administration of tadalafil on the bladder mechanosensitive single-unit afferent activities (SAAs) and their relation with microcontractions in a male rat model of BOO.

Study design, materials and methods Twenty-six male Wistar rats were used. To create partial BOO, the proximal urethra was ligated with a steel rod (1.2 mm in diameter) and then the rod was removed. At 4 days after surgery, daily oral administration of tadalafil (0.1 or 1 mg/kg) or its vehicle (0.5% methyl cellulose) was started, and at 10 days after surgery, the rats were anesthetized with urethane after administration. Through a laminectomy, fine filaments were dissected from the left L6 dorsal roots and placed across a bipolar electrode for monitoring SAAs. Nerve fibers primarily originating from the bladder were identified by electrical stimulation of the left pelvic nerve and by bladder distension. Nerves with conduction velocities (CVs) more than 2.5 m/second were designated as Aδ-fibers and those with CV less than 2.5 m/second as C-fibers. The intravesical pressure and SAAs were recorded and analysed during constant filling at a rate of 10 mL/hour with saline until the intravesical pressure reached 30 cmH2O. A microcontraction was defined as the contraction of which amplitude was more than 2 cmH2O, and pressure was ascending at 0.25 cmH2O/second or more and then descending at 0.15 cmH2O/second or more. The microcontraction was divided into two phases as "ascending" and "descending" phases. The portion between the two microcontractions was termed as the "resting" phase.

There were no significant differences in CVs, bladder weight, bladder compliance, and amplitude and number of microcontractions between groups (Table 1) . During bladder filling, SAAs of C-fibers, but not of Aδ-fibers, in the high dose (1 mg/kg) of tadalafiltreated group was significantly lower than those in vehicle-and the low dose (0.1 mg/kg) of tadalafil-treated groups (Figure 1 ). In the vehicle-treated group, the SAAs of both Aδ-and C-fibers during the ascending phase of microcontraction were significantly higher than those at the other two phases. In contrast, such intermittent increases in SAAs of C-fibers associated with the ascending phase of microcontractions were not observed in both doses of tadalafil-treated groups, while those of Aδ-fibers were preserved ( Figure 2 ).

Tadalafil-administrations, even at a high dose (1 mg/kg), did not inhibit microcontractions themselves, but inhibited the intermittently enhanced SAAs of C-fiber during the ascending phase of microcontractions. Furthermore, when treated at the high dose, this inhibitory action of tadalafil became conspicuous by supressing whole SAAs of C-fibers no matter which phases. These results suggest that PDE type 5 in the BOO rat bladder are involved in the activation of the bladder mechanosensitive afferent Cfibres during bladder filling, especially in their facilitation related to microcontractions.

Concluding message Tadalafil inhibited bladder mechanosensitive C-fiber activities especially in a way to supress their intermittent enhancement associated with bladder microcontractions in male BOO rats. Such pharmacological action of tadalafil may contribute to improve bladder abnormal sensation associated with OAB/BOO. 

Hypothesis / aims of study Dipeptidyl-peptidase 4 inhibitors (DPP-4Is) are widely used for diabetes. DPP-4Is inhibit the degradation of incretins such as glucagon-like peptide-1 (GLP-1) or glucose-dependent insulinotropic polypeptide and enhance insulin secretion. In addition, DPP-4I has been recently reported to have neuroprotective and angiogenic effects. Bladder ischemia is considered a cause of overactive and underactive bladder. In this study, we investigated whether chronic treatment with anagliptin, a DPP-4I, improved bladder function of rats with acute bladder ischemia and elucidated the mechanisms of the improvement by focusing on bladder blood flow.

Study design, materials and methods First, 8-week-old female Wistar-ST rats were divided into four groups: (1) control (n = 9), (2) ligation (n = 6), (3) ligation plus anagliptin (n = 7), and (4) ligation plus liraglutide, an agonist of the GLP-1 receptor (n = 6). The rats in groups 2-4 underwent ligature of bilateral internal iliac arteries. The rats in group 1 were subjected to sham surgery. Anagliptin was administered to the rats in the form of CE-2 mixed with anagliptin (final concentration, 0.3% anagliptin). Liraglutide (300 μg/kg) was injected subcutaneously. After 4 weeks, blood glucose levels, DPP-4 activity, and GLP-1 levels were measured, and cystometry (80 μL/min) was performed for all the rats.

Next, under anesthesia induced by isoflurane, the bladder blood flow was measured with the bladder empty by using laser-Doppler flowmetry in the other rats in the control, ligation, and ligation plus anagliptin groups that did not undergo cystometry (n = 8 in each group). The dose and administration period of anagliptin were the same as those in the functional study. In addition, we examined the bladder blood flow before and after injection of anagliptin (1 mg/kg, intravenously) by using intact rats (n = 5) to examine the effect of the acute administration of anagliptin on bladder blood flow. Statistical analysis was performed by using analysis of variance (ANOVA) and Bonferroni's multiple t test.

At 4 weeks after the observation period, blood glucose levels did not change in all the groups. As expected, the DPP-4 activity in the ligation plus anagliptin group was significantly inhibited in comparison with those in the control, ligation, and ligation plus liraglutide groups (P < 0.01). The GLP-1 activity in the ligation plus anagliptin group was significantly higher than that in the control and ligation groups (P < 0.01), and that in the ligation plus liraglutide group was significantly higher than that in the other three groups (P < 0.01). The intercontraction intervals (ICIs) in the ligation group were significantly longer than those in the control group (P < 0.05, Figure  1 ). The ICIs in the ligation plus anagliptin group were significantly shorter than those in the ligation group (P < 0.05, Figure 1 ), whereas those in the ligation plus liraglutide group were unaltered in comparison with the values in the ligation group. No significant differences were found among groups in terms of baseline pressure, maximum voiding pressure, and threshold pressure.

The bladder blood flow in the ligation group was significantly lower than that in the control group (P < 0.01, Figure 2 ), whereas that in the ligation plus anagliptin group was significantly higher than that in the ligation group (P < 0.01, Figure 2 ). In the study that used intact rats, acute intravenous injection of anagliptin did not change bladder blood flow.

We found that bilateral ligation of the internal iliac arteries caused bladder ischemia and impaired sensory nerve function. The treatment with anagliptin normalized the ICIs, suggesting that treatment preserved sensory nerve function. Liraglutide did not affect the ICIs, suggesting that the effects of anagliptin were not attributable to GLP-1. However, whether anagliptin improved these effects directly or indirectly remains unknown. Thus, we examined the effects of anagliptin on bladder blood flow. Hence, chronic anagliptin treatment improved bladder blood flow in the rats with an ischemic bladder, although acute injection of anagliptin did not change blood flow in the intact rats. These results suggest that chronic treatment with anagliptin improved bladder blood flow indirectly, which led to the improvement of bladder function.

Anagliptin improved the prolongation of micturition intervals with the improvement of bladder hemodynamics in acute ischemic conditions, and the underlying mechanism was not considered to involve GLP-1. 

Hypothesis / aims of study Mirabegron, a β3-adrenoceptor agonist, has been used for the treatment of overactive bladder (OAB) because of its major action inducing bladder smooth muscle relaxation. However, the role of β3-adrenoceptors or action of mirabegron in the control of urethral continence function is not well elucidated although the existence of β3-adrenoceptors in the human external urethral sphincter has been shown previously [1] . Also, a recent study demonstrated that mirabegron induce smooth muscle relaxation of rat urethral strips by blocking α1-adrenoceptors, rather than an agonistic action on β3-adrenoceptors [2] . Therefore, this study tried to investigate the effect of mirabegron and selective β-adrenoceptor antagonists on the urethral contractile function using female rats.

Study design, materials and methods Twenty female Sprague-Dawley rats were used and divided into 3 groups. In group A, 2 mg/kg mirabegron was administered intravenously (IV) in 5 rats and 10 mg/kg mirabegron in other 5 rats. In group B, 50 μg/kg L-748,337, a selective β3-adrenoceptor antagonist, was injected IV prior to 10mg/kg mirabegron in 5 rats. In group C, 3 mg/kg propranolol, a non-selective β-adrenoceptor antagonist, and 50 μg/kg L-748,337 was injected IV to inhibit all 3 β-adrenoceptor subtypes; and then 10 mg/kg mirabegron was injected in 5 rats. Before drug administration, the T8-9 spinal cord was transected to block the spino-bulbo-spinal voiding reflex under isoflurane anesthesia. Thereafter, a PE60 catheter and a microtransducer-tipped catheter were inserted into the bladder through the dome and into the mid urethra from the external urethral orifice, respectively. Then, LPP (leak point pressure), UBP (urethral baseline pressure), and dUP (differential values of urethral pressure during intravesical pressure elevation) were measured before and after drug administration under urethane anesthesia. LPP was defined as the intravesical pressure at which the fluid leakage occurred by increasing the intravesical pressure gradually using a water reservoir connected to the bladder. UBP was measured as the urethral pressure maintained stable at 0 cmH2O intravesical pressure for more than 2 minutes. dUP was measured in the mid urethra at 10-14 mm from the urethral meatus and defined as the greatest urethral pressure differential value just prior to the fluid leakage when the intravesical pressure was gradually elevated (Fig. 1) . For statistical analysis, Wilcoxon's signed rank test was used to compare the changes in parameters within the same group, and Mann-Whitney U test among the different groups.

In group A, LPP, UBP, and dUP were not changed after 2 mg/kg mirabegron, but showed significant decreases in these 3 parameters from 45.0 ± 2.1 to 29.5 ± 2.3 cmH2O, from 23.9 ± 1.1 to 14.0 ± 1.8 cmH2O and from 21.2 ± 0.9 to 10.3 ± 0.7 cmH2O, respectively, after 10 mg/kg mirabegron (Fig. 2) . In group B, after administration of L-748,337 (β3 antagonist), there were no changes in LPP or dUP whereas UBP was slightly, but significantly, increased from 20.3 ± 2.1 to 23.0 ± 1.7 cmH2O. 10 mg mirabegron following L-748,337 still significantly reduced LPP from 41.5 ± 2.9 to 26.5 ± 1.3 cmH2O, UBP from 23.0 ± 1.7 to 12.9 ± 1.6 cmH2O, and dUP from 19.9 ± 0.8 to 10.9 ± 0.7 cmH2O compared to L-748,337 alone (Fig. 3) . In group C, any of 3 parameters were not changed by the combined administration of propranolol and L-748,337. However 10 mg/kg mirabegron following propranolol and L-748,337 still reduced LPP from 43.5 ± 1.3 to 29.0 ± 1.3 cmH2O, UBP from 24.8 ± 1.6 to 16.3 ± 1.2 cmH2O, and dUP from 21.2 ± 1.4 to 11.0 ± 1.2 cmH2O (Fig. 4) .

Mirabegron did not affect urethral pressure within the clinically approved dose (2mg/kg) in rats, but, at a higher dose, it reduced the baseline urethral activity and reflex urethral contractions during passive bladder pressure elevation. Because this action of high-dose mirabegron was not interrupted by selective β3-adrenoceptor antagonist or non-selective β-receptor antagonist, suggesting that mirabegron can exert its action via other receptors than β-adrenoceptors, possibly including blockade of α1adrenoceptors [2] . In addition, the selective β3 adrenoceptor antagonist showed a slight, but significant increase in urethral baseline tone, suggesting that β3-receptor activation is tonically active to reduce baseline urethral activity although this mechanism does not seem to be involved in mirabegron-induced effects on urethral function.

Concluding message β3-adrenoceptors play a minor role in the control of urethral baseline tone and reflex contractions of the urethral sphincter muscles. Mirabegron can induce urethral sphincter relaxation through β3-receptor-independent mechanisms at a high dose, possibly through interactions with other receptor types such as α1-adrenoceptors. 

Hypothesis / aims of study Radiation therapy is used in the clinical management of more than 50% of all cancers. In patients with pelvic malignancies, lower urinary tract symptoms (LUTS) are a common and unavoidable consequence of radiation therapy (1) and this condition is known as radiation-induced bladder toxicity (RIBT). RIBT occurs from direct irradiation of cells within the radiation field and also indirectly, where non-irradiated bystander cells respond to signals released by irradiated cells (2) . Bystander signalling may therefore be a significant contributor to the development of RIBT and is the focus of the present study. Radiation causes pathological damage to cells of the bladder wall including the urothelium (3) comprising cell swelling and degeneration with some cells undergoing apoptosis.

We hypothesised that 'radiation bystander effects evoke apoptosis in bladder cells modulated by purinergic P2X7 receptors' and tested this by addressing the following specific aims:

(1) to investigate radiation bystander effects on urothelial cell survival and apoptosis;

(2) to determine whether ATP mimics the bystander effect and if this is mediated through P2X7 receptor signalling;

(3) to elucidate the molecular mechanisms underpinning radiation bystander pro-apoptotic signalling in 2D and 3D models.

Study design, materials and methods Immortalized human urothelial cells (SV-HUC) and primary human bladder fibroblasts (HBF) were cultured in 2D to subconfluence before being irradiated (2Gy) to generate conditioned medium (CM). Non-irradiated SV-HUC were exposed to CM for 1 hour as a model of radiation bystander signalling. Cells were then studied with: flow cytometry to elucidate the percentage of apoptotic cells; RT-PCR and Western blotting to measure relative mRNA and protein expression respectively; and cell survival assays. SV-HUC were studied with patch-clamp electrophysiology to assess ATP-evoked currents. 3D-organotypic rafts of SV-HUC and HBF were developed in the absence and presence of ATP. Cells and rafts processed for immunofluorescence labelling were imaged with confocal microscopy. Data were generated from 3-5 independent experiments, analysed with Student's t-tests and one-way analysis of variance (ANOVA), and presented as mean±S.E.M with P<0.05 considered as significant. Interpretation of results Irradiated urothelial cells release ATP into the medium, greater than basal levels which sensitises non-irradiated (bystander) neighbouring cells by eliciting P2X7 receptor-mediated Ca 2+ -transients, caspase-3 overactivity, cytoskeletal remodelling and directing the cells towards apoptosis.

Concluding message Urothelial cells respond to factors released from irradiated cells with induction of pro-apoptotic processes. Targeting ATP/P2X7R signalling may therefore present a promising therapeutic strategy protecting urothelial damage and minimising the symptoms of RIBT.

Cristofaro V 1 , Carew J A 1 , Dasari S P 1 , Goyal R K 1 , Sullivan M P 1

Hypothesis / aims of study Bladder dysfunction is a common urologic complication in patients affected by diabetes. Diabetic bladder dysfunction is characterized by an early compensatory phase in which bladder smooth muscle (BSM) is hyperactive, followed by a late stage in which the bladder contracts less efficiently. While it appears that a loss in neuromuscular transmission might be responsible for the late decompensated stage of diabetic bladder, the mechanism leading to BSM hyperactivity in the early phase remains unclear. Our previous findings in an animal model of type 2 diabetes showed that the increased BSM contractility in the early stage of diabetes was correlated with upregulation of Rho signaling and increased myosin light chain (MLC) phosphorylation. In other smooth muscle systems, Rho-associated signaling is regulated by caveolae [1] , specific membrane microdomains enriched in cholesterol that play a pivotal role in regulating tissue contractility. The purpose of this study was to investigate whether caveolae are involved in Rho-dependent changes in contractility induced by hyperglycemia.

Longitudinal BSM strips from male C57 (10-12 weeks old) mice were mounted in organ bath at 37°C and stretched under 0.5 grams for isometric tension studies. Hyperglycemia was induced by exposing BSM tissue to a high glucose (23mM) Kreb's solution. Separate tissue was exposed to normal Kreb's (11.5mM glucose) supplemented with 11.5mM mannitol to control for the hyperosmotic conditions of Krebs with high glucose. Bladder contractions were induced by administration of carbachol (CCh, 1µM) under euglycemic conditions, and repeated at intervals of 1, 2, 4 and 8 hours under either hyperglycemic or control conditions. The effect of hyperglycemia on the contractile response to CCh stimulation was investigated in the presence of a Rho kinase inhibitor (Y27632), using a dose that does not affect the response to CCh under normal glucose conditions (1µM). The response to CCh under hyperglycemic conditions was also determined after depletion of caveolae, achieved by incubation with methyl-β-cyclodextrin (mβCD, 10mM, 1 hour). For molecular studies, hyperglycemia-induced changes in myosin light chain phosphorylation (pMLC) were analyzed by western blot. The molecular interaction between Rho associated protein kinase 2 (ROCK-2) and caveolin proteins in mouse BSM tissue were investigated by immunoprecipitation experiments. High glucoseinduced changes in caveolin protein expression in BSM tissues from db/db mice, an animal model of diabetes, was compared with non-hyperglycemic control mice.

The contractile response to CCh after 2, 4 and 8 hours of hyperglycemia was significantly higher than CCh responses recorded under euglycemic conditions at the same time points. The amplitude of CCh responses in tissue exposed to Kreb's supplemented with mannitol were not increased over the same time period, indicating that the augmented CCh responses under hyperglycemic conditions were not due to osmotic changes. In contrast, the high glucose-induced increase in CCh responses was prevented by the ROCK inhibitor Y27632, as well as by caveolae depletion using mβCD. Phosphorylation of MLC in response to CCh stimulation was significantly higher in BSM tissue exposed to high glucose compared to pMLC levels detected under euglycemic conditions. Cav-3, but not Cav-1 expression was upregulated in BSM tissue from hyperglycemic, db/db mice compared to non-diabetic bladders. ROCK-2 co-precipitated with Cav-3 in mouse bladder tissue.

The augmented responses to CCh stimulation in the presence of high glucose indicates that hyperglycemia contributes to the hypercontractile phenotype characteristic of the early stage of diabetic bladders. The increased MLC phosphorylation induced by hyperglycemia, together with the prevention of hyperglycemia-induced hypercontractility by a ROCK inhibitor, suggest that hyperglycemia alters Rho/ROCK signaling. The molecular interaction between ROCK-2 and Cav-3 along with the inhibitory effect of caveolae depletion on high glucose-induced BSM hyperreactivity suggest that caveolae facilitate the activation of Rho-ROCK signaling in the bladder during hyperglycemia.

The upregulation of Cav-3 in bladder tissue from hyperglycemic/diabetic mice may enhance Rho-ROCK signaling and potentially contribute to the development of bladder hyperreactivity in these animals. Our findings suggest a potential link between hyperglycemia-induced BSM hyperreactivity and the caveolae-mediated facilitation of Rho-ROCK signaling. 

Hypothesis / aims of study The Hyperpolarization activated Cyclic Nucleotide gated (HCN) ion channel is the molecular analog of an inward, depolarizing current, Ih. This current is known in several tissues including neural, cardiac, and gut, and has recently been identified in human and rat bladders. It serves variously as the feedback current in neural oscillators, membrane potential stabilization, and regulator of susceptibility to excitatory potentials. It is activated by hyperpolarization, and its dynamics enhanced by intracellular cyclic nucleotides. Mouse cystometric evidence suggests enhanced sympathetic-mediated detrusor muscle relaxation with advancing age. This could underpin the loss of bladder volume sensitivity in older humans, associated with an increased risk of urinary dysfunction. We hypothesized that changes in HCN expression would be associated with changes in detrusor relaxation to adrenergic stimulation, in the mouse model.

Expression of HCN mRNA and the impact of aging was tested with qRT-PCR using bladder tissue from WT 2-3month (Young, YWT)) and 21-22 month old (Old, OWT) C57Bl/6 female mice. HCN1 protein was confirmed by Western Blot from Young WT female mice. The dependence of adrenergic detrusor relaxation on HCN was tested in bladder strips from YWT and OWT mice and young HCN1 KO mice (YKO). In these studies, 1 mm mucosa-intact strips taken transversely from the mid-bladder were stabilized at 8-10 mN tension in a Ca++-contained buffer, and loss of tension measured in response to adrenergic stimulation using 1 microM isoproterenol. After re-tensioning the strip with carbachol, the degree of isoproterenol-induced relaxation was again measured in the presence of an HCN blocker, either CsCl or ZD7288. Strip integrity was confirmed at experiment end with carbachol-induced contraction. Tension and spectral power (0.01-0.05 Hz) were compared with 2-way ANOVA across groups and conditions.

YWT mouse bladders express HCN1>HCN2. OWT bladders express significantly less HCN1 but HCN2 levels are similar to YWT. The presence of HCN1 protein was confirmed. Strip tension studies demonstrated isoproterenol-induced relaxation in YWT and YKO strips, significantly inhibited by HCN blockade only in YWT. OWT bladders conversely showed minimal relaxation to isoproterenol in the absence of HCN blockade but significant relaxation in the presence of HCN blockade. Paralleling these findings, maximum spectral power was increased by isoproterenol in YWT in the absence of HCN blockade, and in OWT in the presence of HCN blockade.

Aging and/or maturation is associated with a change in HCN expression, away from HCN1 dominance. HCN1 partially mediates adrenergic detrusor muscle relaxation in young mouse bladders, however altered isoform distribution in old bladders may inhibit adrenergic relaxation. Enhanced isoproterenol-induced relaxation is marked by increased spectral power suggesting myocycte coordination and is age-and HCN-status dependent. HCN is an age-sensitive determinant of bladder responses to sympathetic stimulation with advancing age.

We conclude that altered bladder HCN function with advancing age could contribute to loss of range of response to sympathetic input, diminished volume sensitivity, and impaired detrusor preparation for voiding contraction. As symptom complexes of overactive/underactive bladder and associated incontinence can be considered disorders of bladder volume sensitivity, these changes contribute to an increased prevalence of disorders of urine storage and voiding in later life. 

Hypothesis / aims of study In nociceptive pathway, T-type calcium channel promotes pain signal at pain receptor of peripheral nerve and spinal cord. To date, three molecular subtypes are known for the α1 subunit of low voltage-activated T-type Ca 2+ channel, namely alpha1G (Cav3.1), alpha1H (Cav3.2) and alpha1I (Cav3.3) . Blockage of calcium channels in vascular smooth muscle results in relaxation (1). Detrusor myocytes from overactive human bladder have a higher T-type Ca 2+ channel current density (2) . Mibefradil is an antagonist to T-type Ca 2+ channel (alpha1G). We investigated that to determine whether mibefradil has an effect or not on cyclophosphamide-induced cystitis in mouse.

To evaluate the role of T-type calcium channel for voiding, capsaicin was injected intravesically to alpha1H T-type calcium channel (Cav3.2) lacking mice and Cav3.2 null mutation mice. Cystometry (CMG) was performed. Inter-contraction interval (ICI), pressure threshold (PT) and maximum voiding pressure (MVP) were measured. On the other hands, to evaluate the effect mibefradil, cyclophosphamide-induced cystitis mice were generated. After then, dose-response curves were constructed by administering increasing dose of mibefradil (0.1, 0.5, and 1mg/kg intraperitoneally). Interpretation of results In Cav3.2 lacking mice, capsaicin had no effect on voiding. It was considered that pain signal from dorsal root ganglion was blocked in Cav3.2 lacking mice. Mibefradil (0.5mg/kg and 1mg/kg) has significantly induced increase of the ICI on cyclophosphamide-induced cystitis in mouse.

These results suggest that T-type calcium channel blocker might become a possible drug as treatment agent of overactive bladder.

Hypothesis/aims of study Spinal cord injury (SCI) rostral to the lumbosacral level eliminates voluntary and supraspinal controls of voiding, leading initially to areflexic bladder, urinary retention and bladder hypertrophy, resulting in increased levels of growth factors including nerve growth factor (NGF) in the bladder wall [1] . NGF is taken up by afferent nerves and transported to the dorsal root ganglion (DRG) cells where NGF changes the phenotypes of C-fiber bladder afferent neurons, thereby inducing bladder afferent hyperexcitability, which contributes to the emergence of neurogenic detrusor overactivity (NDO) following SCI [1] . In this study, we examined the effects of NGF neutralization using anti-NGF antibody on the SCI-induced changes in electrophysiological properties of capsaicinsensitive bladder afferent neurons in the mouse model, focusing on action potentials (APs) and voltage-gated K + (Kv) currents, which are major determinants of neuronal excitability.

In female C57BL/6 mice (9-10 weeks old), the spinal cord was transected at the Th8/9 level. In some SCI mice, 2 weeks after SCI, an osmotic pump was placed subcutaneously in order to administer anti-NGF antibody at 10 µg/kg/h for 2 weeks. The dosage of the antibody was determined according to previous studies [1, 2] and our preliminary experiments. Bladder afferent neurons were labelled by axonal transport of Fast Blue (FB), a fluorescent retrograde tracer, injected into the bladder wall at 3 weeks after SCI. Four weeks after SCI, freshly dissociated L6-S1 DRG neurons were prepared. Whole cell patch clamp recordings were performed in FB positive neurons (=bladder afferent neurons). After recording APs or Kv currents, capsaicin sensitivity was identified by a transient inward current evoked by capsaicin application. Two major types of Kv currents expressed in small-sized DRG neurons, namely slow decaying A-type K + (slow KA) and sustained delayed rectifier-type K + (sustained KDR) currents were evaluated [3] . In these neurons, slow KA currents are activated by depolarizing voltage steps from hyperpolarized membrane potentials and inactivated when the membrane potential is maintained at a depolarized level more than -40 mV [3] , therefore, slow KA currents are estimated by the difference in these currents activated by depolarizing voltage pulses from a holding potential (HP) of -40 mV and from a HP of -120 mV (see Fig. 2 ).

In capsaicin sensitive bladder afferent neurons, the resting membrane potentials and the peak and duration of APs did not change by SCI (Table) . On the other hand, the threshold for eliciting APs was significantly reduced in SCI compared to spinal intact (SI) mice ( Fig. 1 and Table) . Also, SCI increased the number of APs during 800 ms membrane depolarization (Table) . In addition, the cell diameter and input capacitance of capsaicin sensitive bladder afferent neurons from SCI mice were significantly greater than those of SI mouse neurons (Table) . Densities of slow KA and sustained KDR currents evoked by depolarization to 0 mV in capsaicin sensitive bladder afferent neurons from SCI mice were significantly lower than those measured in SI mouse neurons ( Fig. 2 and Table) . NGF neutralization significantly reversed SCI-induced changes to the threshold, the number of APs and the density of slow KA current, while other SCI-induced changes were not affected by NGF neutralization (Figs. 1 and 2 , and Table) .

Our results indicate that; (1) capsaicin sensitive bladder afferent neurons from SCI mice show hyperexcitability as evidenced by lower spike activation thresholds and tonic firing pattern, and (2) Kv current densities, both slow KA and sustained KDR, are reduced in these neurons from SCI mice. Therefore, functional changes in Kv channels could be responsible for the hyperexcitability of bladder afferent neurons in SCI mice. NGF neutralization in SCI mice ameliorates the hyperexcitability by reversing the KA current reduction. In addition, SCI induces somal hypertrophy of these neurons in mice as evidenced by greater cell diameter and input capacitance, which is proportional to membrane surface area; however, these morphological changes are not affected by NGF neutralization in SCI mice. Taken together, NGF plays an important role in SCI-induced functional, but not morphological, changes in capsaicin sensitive C-fiber bladder afferent neurons, thereby enhancing synaptic transmission in the spinal cord and leading to NDO in SCI mice.

Concluding message NGF plays an important role in hyperexcitability of capsaicin sensitive C-fiber bladder afferent neurons due to KA current reduction in SCI mice. Thus, NGF-targeting therapies could be effective for the treatment of C-fiber afferent hyperexcitability and NDO in SCI.

Solomon E 1 , Yasmin H 2 , Duffy M 2 , Malde S 1 , Ockrim J 2 , Greenwell T 2

Hypothesis / aims of study Unlike the diagnosis of bladder outlet obstruction (BOO) in men, BOO in women has neither a standard definition nor wellaccepted defining diagnostic criteria. The aim of this study is to assess the level of agreement between seven diagnostic criteria for female BOO based on voiding pressure and/or flowrates with radiographic evidence of BOO.

We reviewed the video-urodynamics and clinical data of 535 women. We categorised the women as obstructed or unobstructed based on seven previously published urodynamic definition of obstruction (see Table 1 ). We also assessed if there was radiological evidence of BOO in the presence of a sustained voiding pressure as described by (1). We then assessed the level of agreement between urodynamics and radiographic data using Cohen's kappa coefficient. 

Hypothesis / aims of study Detrusor underactivity (DU) is a common cause of lower urinary tract symptoms (LUTS) in both men and women, yet is poorly understood. DU is present in 9 -48% of men and 12-45% of elder women undergoing urodynamic evaluation for non-neurogenic LUTS (1) . A diagnosis of detrusor underactivity is possible neither by LUTS nor by uroflowmetry, but only by pressure flow study. Detrusor contractility is one aspect in detrusor underactivity, can be evaluated by projective isovolumetric pressure (PIP) (2) and Watt factor (3). Especially PIP1 can be used to evaluate detrusor contractility in elderly women. PIP1 is defined by the formula, that is, Pdet@Qmax + Qmax, which is obtained by pressure flow studies. The aim of this study was to investigate the characteristics of weak detrusor contractility in elderly women at our hospital.

Study design, materials and methods Our accumulated urodynamic date between 2012 and 2016 was retrospectively examined for this study. Totally 108 patients were found in women (more than 50 year-old) to evaluate the detrusor contractility of women who were refered to our hospital for evaluation of LUTS. We mainly used projected isovolumetric pressure 1 (PIP1) to evaluate detrusor contractility for women. Normal contractility is defined as PIP1 =30-75, therefore, weak detrusor contractility wad defined as PIP1 less than 30. Thirty two women out of 87 women met the criteria of weak detrusor contractility, that is PIP1 less than 30. The age of 32 women with weak detrusor contractility was 72.8 ± 4.6 year old. The comparison of urodynamic parameters between women with weak detrusor contractility and without weak detrusor contractility was shown in table 1. PIP1 seemed to be associated with WF max. The disease category of women with weak detrusor contractility was shown in table 2.

The frequency of women with weak detrusor contractility was 30 % in urodynamic data base of our hospital. The frequency of weak detrusor contractility in each disease and condition was between 0% and 42%. Even though these results are very limited because this study is a retrospective analysis.

The frequency of elderly women with weak detrusor contractility was 30% in our hospital using PIP1. 

Hypothesis / aims of study The prevalence of pure stress urinary incontinence (P-SUI) and the role of urodynamic (UD) test prior surgery for stress urinary incontinence (SUI) have been under debate in the last years (1). Since is not clear the exact prevalence of P-SUI, its clinical and economical impact is not well defined. The aim of this study was to evaluate the prevalence of P-SUI in a population of women underwent UD for urinary incontinence (UI). We also assessed the correspondence between clinical diagnosis of P-SUI and urodynamics findings. The other objective of the study was the analysis of the amount of cost of the urodynamic tests in this cohort, the number of avoided surgical procedures due to the UD results and the related costs saved.

Study design, materials and methods An electronic database was used to identify women who had UD for UI between January 2012 and July 2016. Urodynamic tests were performed according to The Good Urodynamic Practice (2). P-SUI was defined by International Continence Society (ICS) criteria (Table 1) . A very experienced urologist prior to the UD took history and physical examination of patients and evaluated the correspondence between clinical and urodynamic P-SUI. We evaluated the number of women in whom the clinical diagnosis of P-SUI was changed after the execution of UD. Moreover, we estimated the number of unnecessary intervention after UD. We estimated the exact cost of a single urodynamic investigation including human resources (one medical doctor, one nurse) and all the materials used in a UD test. An additional economical evaluation was performed considering the National Health System refund. Moreover, it has been calculated the total amount of expense saved avoiding unnecessary surgical procedures due to UD results. Considering the National Health System refund the cost of each UD was 296,5 euros and the total amount was 17.493,5 euros. In 10.2% of the cases (6/59) the scheduled middle urethral sling (MUS) was avoided because of UD results. In 3/6 cases detrusor overactivity and urge incontinence were prevalent, in 2/6 cases SUI was treated with a conservative management, in 1/6 cases there was an important voiding dysfunction. So far, the total amount saved due to UD findings was 10800 euros and considering the refund provided by the National Health System.

In our study the prevalence of P-SUI is in the range reported in literature (5.2-36%). The high rate of P-SUI has been attributed to the lack of expertise on the part of clinicians (3). The potential mistake linked to the less experience in taking a complete urological history was avoided by the expertise of selected urologist. This choice can explain our lower rate of PSUI if compared to other higher literature data. The published data on correspondence between clinical and urodynamics P-SUI has been very controversial, ranging from 99% to 60%. Our data are show a high correspondence. We avoided a relevant number of unnecessary surgical procedures due to the urodynamic findings (10%) Moreover, although the total expense for the UD in P-SUI patients exceed the cost saved due to unnecessary surgical procedures, the clinical relevance of UD prior SUI surgery seems to be still very crucial.

Our results showed that the prevalence of P-SUI is relevant, involving about 20% of the women with clinical SUI. The correspondence between clinical and urodynamic diagnosis was high, but we demonstrated that in a considerable number of patients an inappropriate treatment was avoided on the basis of urodynamic results. Also even if the execution of a UD involves an economic burden, it should be emphasized the very important clinical role of UD. Therefore, we consider UD prior SUI surgery still useful to achieve a correct counseling of patients and to avoid unnecessary surgical procedures. Therefore, we consider UD a crucial step for all the patients candidates to SUI surgery. In particular it is useful for both a correct counseling that for avoid unnecessary surgical procedures.

Hypothesis / aims of study Valuable and reliable information is obtained from uroflowmetry studies only if curve and data quality can be ensured. ICS reports on Good Urodynamic Practice (GUP) have been published to improve excellence in measurement, quality control and documentation of urodynamic investigations, including uroflowmetry [1] . Despite ICS recommendations, it is very common to find traces with artifacts, inadequate micturition volumes and incomplete information that makes difficult to obtain a good interpretation. Using a checklist may improve quality of different procedures. The aim of this study was to evaluate the ability to improve uroflowmetry quality implementing a checklist from GUP based on ICS recommendations.

Study design, materials and methods Diagnostic, transversal, interventional study, designed to evaluate uroflowmetry quality performed in 5 urodynamic departments in Valencia (Spain), before and after implementing a checklist. We developed the Uroflowmetry Quality Score (UQS) tool in order to evaluate uroflowmetry trace and inform quality [2] , including 14 items scoring from 0 to 1 (except item #2, exclusion of artifacts, scoring from 0 to 3). UQS ranges from 0 to 16 (Table 1) . First group of uroflowmetries were done following usual daily practice, and the second group after implementing the checklist based on GUP recommendations of ICS. UQS and percentage of items correctly fulfilled were compared before and after checklist intervention, using T-Test for independent samples. Comparison among urodynamic centers were done using ANOVA (post-hoc comparison with Tukey test). P-value < 0.05 was considered significant. Table 3 shows percentage of items fulfilled before and after checklist intervention. Interpretation of results Some items described in ICS GUP on uroflowmetry are well fulfilled in daily clinical practice (>80%), like uroflowmetry indication (#1), trace without artifacts (#2), patients gender (#3), scale adapted to gender (#4), correct volume (#5), postvoid residual measurement (#6). The use of a checklist easily improves uroflowmetry quality (trace and report), especially in some items not usually included in daily practice, like reporting the time from micturition to PVR measurement (#7), labeling of a usual micturition (#8) or smoothing traces (#9), s or using a nomogram. However, some others, like rounding value or Qmaxraw, were not accepted in spite of ICS recommendations (#11 and # 12) and are very difficult to fulfill even using a checklist. Not all the items have the same clinical significance for uroflowmetry quality and preferences of the researcher should be considered. Item #4 (Scale adapted to patient´s gender) didn't convince some operators who refused to change; other #13 (Results shown as ICS standard), was partially implemented. Probably because some hospitals had their own more complete-preferred standard format; item #14 (Presence of a validated nomogram) depended on the machine; and items #1 (Uroflowmetry indication included in application form), #4 (Scale adapted to patient's gender) and #5 (Volume voided is acceptable) didn't change too much. They were well accomplished before intervention and/or did not depend on the operator. It should be interesting to define an ideal checklist for daily practice. 

Hypothesis / aims of study To evaluate the effect of listening to music on pain, anxiety or stress during a urodynamic study (UDS).

Study design, materials and methods A total of 74 female and 74 male patients who underwent UDS between March 2013 and October 2013 were prospectively randomized. The patients were divided into 2 groups according to gender (female, n=74 vs male, n=74) and into 2 sub-groups according to whether they listened to music or not. Music group subjects played their preferred music during UDS. Before and after UDS, all subjects completed the State-Trait Anxiety Inventory (STAI) form and their degree of pain, anxiety, and satisfaction during examination were assessed by the visual analog scale (VAS, 0-10). Basic vital signs were also checked before and after the procedure.

In the analysis of anxiety, pain and stress score, the mean shame, discomfort and satisfaction scores (VAS) were significantly higher in females, whereas the mean score of willingness to retry the procedure was higher in males whether listening to music or not (p<0.001). In the analysis of differences of STAI total, state anxiety and trait anxiety, there were no statistical significances between the music group and the no music group in either gender.

In both gender, there were no significant differences in anxiety scores even though listening music.

Concluding message In our study music during UDS did not reduce anxiety, pain and stress in either gender. In the analysis focusing on gender difference, females showed statistically higher levels of pain, anxiety and stress score than males whether listening to music or not. 

Hypothesis / aims of study Reactivation of C fiber afferents is considered one cause of detrusor overactivity (DO) in older men with bladder outlet obstruction1). Intravesical instillation of lidocaine is thought to exert its effect by blocking C fibers2). Although a lidocaine pressure flow study (LPFS) in older male subjects with LUTS and without other neurological disorders is predicted to show changes to PFS factors associated with C fibers, few reports have provided such evaluations. We examined response to a LPFS in older subjects with LUTS and without neurological disorders and assessed the results with reference to PFS findings.

Study design, materials and methods Participants comprised 58 men (13 controls, 45 men who underwent a LPFS) >60 years old, with International Prostate Symptom Scores >8 and with Quality of Life Index >2. Individuals with neurological disorder, prostate cancer, urethral stricture, or active urinary tract infection, as well as those taking medications that could influence urination, were excluded. The method for PFS in the control and LPFS groups is shown in Figure 1 . We assessed differences in urinary sensation (first desire to void (FDV), normal desire to void (NDV), maximum desire to void (MDV)) and factors associated with DO (volume at DO, maximum pressure at DO, presence of DO) between 2 PFS (control = conventional vs. conventional; LPFS = conventional vs. LPFS).

No differences in subject characteristics were evident between the control and LPFS groups ( Table 1 ). The control group showed no difference in urinary sensation and factors associated with DO between the two conventional PFS. On the other hand, the LPFS group showed that each urinary sensation in LPFS was greater than those in the conventional PFS. As for factors associated with DO, 14 of the 27 subjects (52%) with DO in the initial conventional PFS showed no DO in the LPFS, and BOO (bladder outlet obstruction) index ≥40. In subjects for whom DO persisted, significant differences were seen in Volume at DO and Maximum pressure at DO between the conventional PFS and LPFS ( Table 2) .

This study revealed that reactivation of C fibers in the bladder influenced storage symptoms even in subjects without neurological disorder.

Concluding message If C fiber activation is reversible and relief of BOO restrains C fiber activation, LPFS offers potential for showing storage status postoperatively. In the near future, we intend to study whether the results of LPFS show any relationship with those of postoperative PFS. The conventional pressure flow study (cPFS) was performed as follows: after placing a 10-F catheter in the rectum to monitor abdominal pressure, an 8-F two-way catheter was inserted through the urethra into the urinary bladder, and physiological saline at room temperature was delivered at a rate of 50 mL/min. In controls, cPFS was performed twice consecutively. In LPFS, cPFS was performed the first time, then the second PFS was performed 10 min after intravesical instillation of 20 mL of 4% lidocaine. 

Our study confirms the clinical evidence of micturition changes induced by prostate Radiotherapy, both in emptying and storage phase: changes are particularly relevant, expecially in the period immediately following the treatment. Regarding the emptying phase, data collected from the 56 patients at 2 months after EBRT show a decrease in the Qmax (-12,24%) and in the Qmean (-16,2%), that are correlated with a increase in BOOI (+20,6%) and consequently in PVR (+43,2%%), without cases of complete urinary retention. The micturition charts show an increase in the frequency (+50,0%), due to obstruction as well as to bladder overactivity. In fact, 5 pts developed a urgency-frequency syndrome, including 2 pts with mild UUI. Regarding the filling phase, cystometry shows a reduction of bladder capacity (-24,2%) and 5 pts with 'de-novo' low bladder compliance. All these findings show evidence for an interference of EBRT on detrusor function and on urethral resistance, influencing the frequency of urination (+50%) and limiting the emptying phase (PVR +43,2%). In few cases (8,9%) we found DO at the urodynamic tests and only 2 patients developed 'de novo' UUI. The results of the IPSS questionnaire summarize all these observations with an increase of symptoms from score 7 to 11 (+57,1% change). This study shows also the significative impact of ERBT on micturition cycle in the filling phase as well as in the emptying one. The relevant findings recorded in the second month after EBRT, characterized by a worsening of the IPSS score of + 57% related to the decrease in maximum cistometric capacity (-26,8%) and to an increase in the BOOI value (+18%), show an improvement at the 18 th month after ERBT with a IPSS score of 10 (+42%) and an increment in the maximum cistometric capacity of 350 mL. In the following evaluations at 4 and 5 years from ERBT, we can observe a mild global clinical worsening characterized by an increased frequency (+ 35%) and by an outlet obstruction (+27%).

Concluding message A urodynamic study conducted after the definitive conformal prostate EBRT, allows us to understand and quantify the patients symptoms in the immediate post-treatment period and in the following years. Changes emerged from the Urodynamic evaluation, from IPSS-questionnaire and from Voiding diary are more pronounced than the clinical symptoms, probably because these patients are usually treated with symptomatic drugs. Even if the clinical significance of the findings presented here should not be overemphasized, results obtained can be useful in counseling patients about EBRT side-effects.

Daimon H 1 , Minagawa T 2 , Matsutaka J 2 , Ogawa N 2 , Saito T 2 , Suzuki T 2 , Domen N 2 , Ishikawa M 2 , Hiragata S 2 , Nagai T 2 , Ogawa T 2 , Ishizuka O 2

Hypothesis/aims of study Many studies have demonstrated favorable long-term biochemical outcomes of low-dose rate brachytherapy (LDRB) and have reported biochemical freedom from disease recurrence for stage T1 -T2 prostate cancer following LDRB. LDRB is generally reported to be well tolerated. However, lower urinary tract symptoms (LUTS) often occur following LDRB seed implantation. LUTS are common problems that affect quality of life (QOL) after LDRB for prostate cancer. As the natural course after LDRB, the LUTS peak at 1 -3 months, begin to fall by 6 months, and return to baseline by 12 months after implantation (1). The presumed causes of LUTS after LDRB are the traumatic effect of needle insertion, seed implantation, and inflammatory changes in the urethra and prostate following radiation exposure (2) . However, the mechanisms and processes of LUTS after LDRB have not been confirmed. Aoki et al. reported that prostate volume increased to 173% due to edema of the prostate on the first day after implantation, and decreased by 30% in 2 weeks (3). Although LUTS after LDRB usually reach a peak at 1 -3 months, edema of the prostate peaks within 2 weeks. Therefore, edematous changes just after implantation of LDRB cannot explain the mechanisms of LUTS after LDRB. We hypothesized that the main cause of LUTS after LDRB may not be edema or inflammation of the prostate but atrophic changes induced by radiological damage to the prostate tissue. This retrospective study was performed to investigate changes in prostate volume and the processes underlying LUTS and inflammation of the LUT after LDRB, and to clarify the causes of LUTS induced by LDRB.

Study design, materials, and methods Patients undergoing LDRB from 2013 to 2016 were retrospectively enrolled in this study. International Prostate Symptom Score (IPSS), IPSS-QOL, Overactive Bladder Symptom Score (OABSS), uroflowmetry including voided volume (VV), maximum flow rate (Qmax), residual urine volume (RUV), and prostate volume (PV) were evaluated at the preimplantation stage and at 1, 3, 6, 9, and 12 months after implantation of LDRB. PV was measured by transabdominal ultrasound by a single ultrasonographer. Blood and urine tests were performed to evaluate the inflammatory effects of LDRB.

Seventy-six patients with prostate cancer were enrolled in this study. The basic clinical characteristics of the patients are shown in Table 1 . After implantation of the LDRB seed, alpha-blocker and/or phosphodiesterase type 5 inhibitor were routinely prescribed in all patients to reduce LUTS. The clinical courses of LUTS and PV after implantation are shown in Table 2 . IPSS, IPSS-QOL, OABSS, and RUV deteriorated from 1 to 3 months after LDRB, and improved to the preoperative levels within 1 year. In contrast, PV decreased by 1 month, and reached the lowest level at 3 months, returning to the preoperative level 12 months after implantation. The courses of IPSS and PV are shown in Figure 1 . Until 3 months after LDRB, IPSS became worse and PV decreased. Little positive relationship was observed between changes in IPSS and PV 3 months after implantation (r = 0.27) as shown in Figure 2 . After LDRB, only five patients showed microscopic hematopyuria (WBC > 10/HPF or RBC > 10/HPF) and only two patients showed marked inflammatory reactions (CRP > 0.50 mg/dl or WBC > 9000/µl) on urine and blood tests.

Interpretation of results LUTS reached a peak at 3 months after LDRB, synchronizing with the decrease in PV. From 3 months to 1 year after LDRB, LUTS improved as PV recovered. These results indicated that the severity of LUTS after LDRB is not associated with prostate enlargement induced by edema, hematoma, or inflammation after LDRB. Atrophic changes in the prostate induced by radiation may influence LUTS. Factors resulting in prostatic volume reduction, such as disorder of prostatic microcirculation, should be considered as the main cause of LTUS after LDRB. However, no strong correlation was observed between prostatic volume reduction and IPSS change in this study. Therefore, factors that are not associated with prostatic volume change should also be considered as causes of LUTS after LDRB. Theoretically, strong levels of radioactivity remain for almost 3 months after LDRB. Therefore, direct nerve damage by radiation may be associated with LUTS after LDRB.

The severity of LUTS after LDRB is synchronized with the decrease in PV. Edematous and inflammatory changes in the prostate may be excluded as a mechanism of LUTS after LDRB.

Hypothesis / aims of study Urinary incontinence (UI) is not a life threatening condition but it does have a negative impact on many aspects of a woman's quality of life such as social, physical, psychological and sexual aspects. Current evidence has shown that stress urinary incontinence (SUI) does not occur exclusively in the postnatal period or in elderly women but also in young athletes. Several studies indicate a high prevalence in high-impact sports such as trampolining, tumbling and gymnastics [1] . ICS guidelines recommend pelvic floor training as the first-line treatment of SUI. Previous research has revealed that young nulliparous women lack knowledge about the pelvic floor and possible pelvic floor dysfunction [2] . Despite its high prevalence, SUI still remains a taboo to talk about. It can even cause refrainment or limitation of sports participation; certainly in a population of ambitious and competitive young females [3] . To the best of our knowledge the effectiveness of integrating pelvic floor education and exercises in the training of young adult athletes has not yet been studied. Thus, the objectives of this pilot study are to estimate the prevalence of UI in young adult female athletes; to introduce basic education about the pelvic floor and pelvic floor exercises in their training program; and to evaluate how this study is perceived by the participants and its influence on UI.

This pilot study applied a pre-post test design. Twenty-eight subjects between 14 and 25 years old (mean age 16.9, SD 2.5) were recruited in local sports clubs; inclusion criteria were nulliparous women, performing (at least 3h/week) high risk sports, being able to perform an analytic pelvic floor muscle contraction (PFMC). All participants signed an informed consent form and minors required permission from their parents. Subjects received an explanation on the anatomy and functions of the pelvic floor, the prevalence and mechanics of SUI and the procedure for the intervention. The pre-assessment consisted of a PAD-test, an individual evaluation by external palpation of the PFMC and multiple reliable and valid questionnaires (PRAFAB, ICIQUI, IIQ). The trainers were instructed how to include PFME in their training program and were encouraged to repeat this during eight weeks. The given exercises focused on training strength and endurance of the pelvic flor muscles and also included the knack. After eight weeks, the post-assessment was performed. All participants completed a qualitative questionnaire to evaluate the benefit and the importance of this study. To analyse the results descriptive statistics, Wilcoxon signed rank test, Kruskal-Wallis test, Monte Carlo Chi-Squared and Spearman correlation were used.

Only 18 of the initially 28 participants also enrolled in the post assessment and finished their participation as intended. Subjective report of urinary leakage was established in 67.8% (n=19) of the participants. According to the ICS guideline (>1.4g) UI was observed in 7.1 % (n=2). Only 10.7% (n=3) of the participants ever talked about urinary leakage with a peer, their parents or a health professional. 89.3% (n=25) declared to be interested to learn the pelvic floor exercises. There was no significant difference in objective urinary leakage after the pelvic floor exercise intervention (p= 0.5). When comparing the objective UI to the questionnaires (PRAFAB, ICIQ-UI) no significant differences were found (p=0,392 and p=0,719 respectively). Only one participant perceived the individual control as being unpleasant, no other participants experienced this as a problem. All participants (100%) were convinced of the importance of this research and emphasized the benefit of the education. Five (29%) declared that this topic was difficult to talk about in group, while the remaining 71% were eager to discuss this theme in group and break all taboos about it.

Contradictory to the hypothesis that UI is highly prevalent in nulliparous female athletes; the objective test results reveal a prevalence of UI of 7.1%; but 42.9% (n=12) of the participants declared to experience urinary leakage on a regular basis. This raises the question whether 1.4g as the cut-off for UI in young adult athletes may be overestimated and unrealistic. The statistical tests indicate at most a weak correlation between the objective and subjective measurement of urinary leakage (r=0.417). When questioned, only a few participants declared to have talked about the problem with peers, their parents or a health professional indicating that there is a taboo around the subject. Despite this lack of communication about the issue, 89.3% of the girls showed a keen interest in the pelvic floor exercises and the majority of them wanted to discuss this topic in group. There was no significant difference concerning pre and post measurements of the PAD-test. This may be due to a lack of participants or the fact that only a few subjects suffered from UI. Additionally, there were several subjects who did not participate in all trainings due to the exam period. Also, there was no control on how well the pelvic floor exercises were performed and whether they were performed during every training.

This pilot study is the first study to try and gauge the efficacy of pelvic floor exercises integrated in the training of young female athletes in high risk sports. No significant results were found in this trial however the education about pelvic floor function and dysfunction is clearly appreciated and could break the taboo of incontinence in female athletes. Further studies might want to focus on implementing the exercises more thoroughly and over a longer period.

Valdevenito J P 1 , Mercado A 1 , Hernandez-Matas R M 1 , Alvarez D 2 , Kobus C 2 , Bull L 2

Hypothesis / aims of study: Most of our knowledge of voiding function in women has been extrapolated from studies of patients with lower urinary tract dysfunction. Few studies have described the voiding patterns of "healthy, continent and/or asymptomatic" women. All women included in these reports voided with a measurable detrusor contraction and variable participation of abdominal muscles, which might be considered the normal voiding pattern. Definitions of what is considered detrusor contraction and abdominal contraction during voiding vary between these studies. It has been declared that only patients with low urethral closure pressure void with negligible or no detrusor contraction, which leads to question if these types of voiding are indeed normal. The aim of this study was to describe the voiding pattern in women without voiding symptoms and compare clinical and urodynamic characteristics between women who urinate using detrusor contraction (with or without participation of abdominal muscles) and women who do not use detrusor contraction. To our knowledge this is the first study to investigate this.

In a three year period, 580 consecutive women underwent conventional cystometry following "good urodynamic practices". At the time of examination and in a standardized manner, symptoms were obtained by a directed anamnesis as being either present or absent without any stratification for severity. We included patients without voiding symptoms (slow stream, straining to void and intermittent stream) and excluded those with: a) previous lower urinary tract surgery, b) pelvic organ prolapse > stage II, c) pelvic radiotherapy, d) medications active on the lower urinary tract, e) bladder pain syndrome/interstitial cystitis, f) insulin-dependent diabetes mellitus and g) neurological diseases. In the pressure-flow study, detrusor contraction (Det-cont) was defined as an increase of detrusor pressure at maximum flow rate ≥ 10 cm H2O over baseline and abdominal contraction (Abd-cont) as an increase of abdominal pressure at maximum flow rate ≥ 10 cm H2O over baseline. Four voiding patterns were determined: a) voiding using Det-cont, b) voiding using Det-cont and Abd-cont, c) voiding using Abd-cont and d) voiding without Det-cont or Abdcont. Patients were classified according to their: a) age (≤ 50 or > 50 years old), b) history of hysterectomy, c) symptoms of stress, urgency or mixed urinary incontinence, d) presence of detrusor overactivity and e) degree of sphincteric deficiency (abdominal leak point pressure < 100 or ≥ 100 cm H2O). We compared these variables between women who voided using Det-cont (with or without Abd-cont) and those who do not (women that voided using Abd-cont and women that voided without Det-cont or Abdcont). Either Student's t test or Wilcoxon rank-sum test was used to compare the numerical variables. Either the chi-square test or Fisher's exact test was used to compare the categorical variables. The odds ratios were calculated. The multivariate analysis was performed with the logistical regression method. The information was processed with the Stata 12.1 program (StataCorp, 2012), and statistical significance was defined as P < 0.05.

One hundred eighty six women age 58 ± 10.7 (range 24 -83) years formed the study group. Table 1 shows some of their clinical and urodynamic characteristics. The vast majority of women voided using Det-cont with or without Abd-cont (77.4%). Women that voided using Det-cont with or without Abd-cont were significantly younger than the others (56.8 ± 10.8 versus 62.2 ± 9.6 years, p=0.004), had similar maximum flow rates (26 ± 8.8 versus 28 ± 11,5 mL/s, p=0.513) and had not significantly different post void residual volumes (9 ± 33 versus 17 ± 58 mL, p=0.667) than the others. Table 2 shows the univariate and multivariate analysis of the variables associated with voiding using Det-cont with or without Abd-cont.

The classic description of voiding patterns in women did not provide information on symptoms of the women studied. This study included only women without voiding symptoms and excluded many factors that can alter lower urinary tract function. Although they are not completely healthy individuals (due to detrusor overactivity and urodynamic stress urinary incontinence during the filling phase), we think that these results give a good approximation to the voiding phase of normal women. Statistically significant association between age and degree of sphincteric deficiency with voiding using Det-cont (with or without Abd-cont) suggest that voiding pattern may vary with ageing and changes in the sphincteric deficiency status. These factors should be taken into consideration when analyzing the voiding phase in women. Further studies are required to define normal and abnormal voiding patterns in women.

Concluding message: The vast majority of women without voiding symptoms voided using Det-cont with or without Abd-cont. Voiding pattern may vary with ageing and changes in the degree of sphincteric deficiency. Interpretation of results • The physical characteristics of the electrode component (shape, flexibility, hydrogel adhesiveness) are suitable to accommodate a broad range of body types. • PFM access through the perineal tissues requires a different stimulation waveform than conventional intravaginal therapies.

Candidate waveforms familiar to orthopaedic applications (e.g. Modulated, BMAC) comfortably delivered stimulation energy across the skin-electrode interface and deep within the underlying musculature. • The relatively low pain patient sensitivity to applied current (i.e. the current delta from initial perception of stimulation to discomfort) is desirable in that it reduces the risk profile of the device in patient-administered use scenarios. • Measured impedance across the perineal tissue is within the 500-1000Ω range commonly cited for general use (i.e. orthopaedic) EMS applications [3] . This supports ongoing utilization of those devices as relevant baselines for development and testing. • A homogeneous response across a diverse patient population supports pursuit of a simple treatment approach that does not rely on various compensatory factors that could overly complicate the system intent for home-use.

The findings validate device efficacy in comfortably contracting the PFM. Further, the device achieves this through a means that requires minimal patient instruction and which a woman can conveniently adopt as part of an at-home routine. Future work will move from single-session assessments to multi-week trials designed to show clinical efficacy in reducing incontinence systems. Based on pelvic floor therapy literature, successful treatment regimens are likely to comprise daily 20 minutes treatment sessions, with measureable improvement after 6-8 weeks. This promising technology, which aims to deliver an efficacious alternative to intravaginal SUI devices, will potentially lead to greater adoption and compliance rates among the 1 in 3 women affected by urinary incontinence. 

Hypothesis / aims of study The need for conventional clinic setting post-operative follow-up after routine middle urethral sling (MUS) for Stress Urinary Incontinence (SUI) has been recently questioned as unnecessary and some instead advocate a concept of "self-directed care" (1). We investigated whether a telephone follow-up, in a cohort of women treated for SUI with MUS, was comparable to a follow-up in the outpatient clinic.

Study design, materials and methods Our database was searched for all cases of primary retro-pubic and trans-obturator MUS performed between January 2000 and December 2016. All patients were called and evaluated by a telephone interview. The presence of Lower Urinary Tract Symptoms (LUTS), SUI, Urge Urinary Incontinence (UUI), dyspareunia, vaginal discharge were investigated. It was also asked to women if they had the tactile perception of abnormal vaginal mucosa. Patient Global Impression of Improvement (PGI-I) and Patient Perception of Bladder Condition (PPBC) questionnaires were administered at the phone call, and at the clinic setting. At the end of the phone call all patient were scheduled for a conventional outpatient clinic setting for the next week. In clinic setting all women have been investigated with the same questions and questionnaires by a different urologist masked to the phone outcome. It was also evaluated the objective outcome and stress test by a vaginal inspection. MUS success rate was considered when patient had no episode of SUI. Correspondence between telephone and office follow-up was obtained with statistical evaluation by Cohen test. No ethical approval was required for this investigation as it was a simple observational study.

Of 263 consecutive patients treated with MUS, 137 were followed-up via telephone and in a conventional outpatient clinic setting (52.1%). Patients' characteristics are reported in table 1. Mean follow-up was 62.83 months (51.06 SD). In table 2 are reported the different outcome between phone and office follow-up. Cohen test showed a "substantial agreement" (K=0.765) between the two methods of follow-up. In our study 11/35 women (31.4%) were mistakenly considered SUI recurrence by the only phone interview. Of these 11 patients with different outcome between the phone and the office evaluation, all had UUI: in 9 cases there was a de novo UUI, and in 2 cases UUI was still present before the MUS. No vaginal discharge has been reported neither the phone nor in the clinic. Most of the women were sexually not active; of the sexually active women the only one extrusion was reported during the telephone follow-up as partner dyspareunia. 

In women treated with MUS, by using telemedicine 90% of the patients who would previously have been seen in clinic were followed up remotely saving clinic time and costs (2) . In our data only in 73.7% of the cases telemedicine was able to assess accurately the urinary condition regarding continence and the type of incontinence. Indeed, our results show no significant difference in assessing patients without urinary incontinence (UI) between phone and clinical setting. The lower success rate of MUS obtained by phone was due to a wet overactive bladder mistakenly interpreted as a recurrence of SUI. At the Cohen statistical test we gained the "substantial agreement" class, instead of the "perfect agreement", because of the misunderstanding between UUI and SUI. Vaginal extrusion was easily assessed by office evaluation. However, the poor assessment of tape extrusion during the phone evaluation was due to the lack of sexual activity and vaginal discharge.

Concluding message A criticism of telephone follow-up compared to conventional clinic outpatient setting is the inability to obtain objective outcomes. In particular, telemedical assessment of patients treated with MUS does not offer the accurate capability to evidence the type of IU, the real recurrence rate and extrusion of the tape.

Hypothesis / aims of study Urinary incontinence (UI) and other urinary symptoms are common and impact on daily life. Different studies have shown contradictory results on the association between physical activity behaviour and lower urinary tract symptoms (LUTS). There however seems to be a trend in some studies towards less severe urinary symptoms being associated with walking and moderate physical activity. Other studies have shown no association between physical activity and urinary symptoms. Therefore the relationship between activity behaviour and bladder dysfunction needs to be further determined.

Our aim was to investigate relationships between objectively measured physical activity/inactivity behaviour in older adults with different forms of bladder dysfunction. These included UI, urgency urinary incontinence (UUI), stress urinary incontinence (SUI) and the lower urinary tract symptom of nocturia.

Study design, materials and methods The study analysed cross-sectional data from the American National Health And Nutrition Examination Survey (NHANES) database cycle 2005-2006. We included male and female participants aged 60 and above. Urinary symptoms were assessed using self-reported questionnaires. Physical activity and inactivity behaviour were measured objectively with a physical activity monitor (PAM) which participants were asked to wear on the hip during waking hours for seven days. Those who wore it for 5 days or more were included.Since the PAM was not waterproof, swimming and other watersport activities were not measured. In this first phase of data analysis the activity behaviour was divided into three categories: sedentary behaviour (physical inactivity), low intensity physical activity (LIPA) and moderate and vigorous physical activity (MVPA). Independent t-tests were performed to investigate the relationship between objectively measured physical activity/inactivity behaviour and self-reported UI, UUI and SUI and also nocturia. Analyses were completed using IBM SPSS, version 23. 

Earlier studies have suggested physical activity is correlated with reduced prevalence of urinary incontinence. No studies have been reported where physical activity and physical inactivity have been objectively measured by a PAM and previous studies have relied on self-reported physical activity behaviour, known to be an inaccurate source of data. Our results confirm that among older adults a higher percentage of the waking day spent in moderate and vigorous physical activity is associated with less reported urgency urinary incontinence and stress urinary incontinence overall.

Concluding message Evidence from a large dataset of older adults with bladder dysfunction suggests increased moderate to vigorous physical activity is associated with reduced urgency urinary incontinence and stress urinary incontinence. 

Hypothesis / aims of study Previous studies have shown that some patients with overactive bladder (OAB) may discontinue antimuscarinic agent after a period of adequate treatment. Older age and severe urgency urinary incontinence are predictors of re-treatment with antimuscarinic agent. However, limited data show how long a patient should take beta-3 adrenoceptor agonist for OAB and whether OAB will relapse or get worse after discontinuing medication. Thus, we hypothesized that selected OAB patients may discontinue mirabegron and OAB severity plays an important role to decide whether medication can be stopped or not. This study investigated the incidence and predictive factors of symptom recurrence after discontinuation of successful mirabegron therapy in patients with OAB.

Study design, materials and methods Three hundred seventy-four OAB patients who reported improvement in subjective symptoms after at least 3-month mirabegron treatment were enrolled in this study. One hundred and nine (29.1%) patients who wished to continue medication were excluded from this study. The remaining 265 patients discontinued mirabegron and their recurrence of OAB symptoms was evaluated at baseline, 1, 3, 6, 9, and 12 months. They were requested to record International Prostate Symptom Score (IPSS) questionnaires, Quality of Life index (QoL-I), Overactive Bladder Symptom Score (OABSS), Urgency Severity Scale (USS), Patient's Perception of Bladder Condition (PPBC), Global Response Assessment (GRA), uroflowmetry, and post-void residual (PVR) volume at each visit. When patients' symptoms were recurrent and they wanted to resume medication, administration of mirabegron was refilled.

The study protocol was approved by the Institutional Review Board of the hospital and written informed consent was received from all patients.

After discontinuation of mirabegron, 62 (23.4%) patients were excluded due to lost to follow-up. Finally, a total of 203 patients (172 male and 31 female) completed follow-up. Their mean age was 75.3 ± 10.1 (range 45 to 97) years. The mean duration of drug persistence before active discontinuation was 9.2 ± 3.4 (range 3 to 12) months. Ninety-two (45.3%) of 203 patients reported worsening of symptoms after the discontinuation of treatment and they asked to resume treatment. The mean duration from discontinuing to resuming medication was 2.25 ± 1.17 (range 1 to 12) months. Compared with the patients without resuming mirabegron after discontinuation, patients resuming medication had higher USS at baseline. The other parameters were comparable in both groups at baseline (Table 1 and Table 2 ). Patients resuming mirabegron had significantly worse IPSS, QoL-I, OABSS, USS, PPBC and nocturia episodes at the time point of resuming mirabegron than those at baseline. However, these parameters were similar before and after stopping medication in patients without resuming mirabegron. In addition, the uroflowmetry and PVR were comparable before and after discontinuing mirabegron in both groups. Univariable analysis showed baseline USS was a predictor to resume mirabegron treatment (OR: 1.315, 95% CI: 1.051 -1.646, p=0.02). The most common reason to resume medication was urge urinary incontinence (50.5%), followed by symptoms of urgency (21.5%) and nocturia (19.4%).

Interpretation of results. Many patients who are satisfied with the improvement of OAB treatment might wonder how long they should maintain the medication. The study indicates that approximately half of OAB patients may discontinue mirabegron after adequate symptoms control. Although OAB symptoms could only be controlled but not cured, considering the minimal effects of discontinuation of mirabegron, this study suggests that after a priming period, beta-3 agonist might be discontinued in some patients without OAB symptoms relapsed. The clinical information can result in substantial reduction in healthcare expenditure and potential side effects for the patients. On the other hand, patients with higher USS and/or OAB wet should have long-term maintenance of mirabegron treatment to achieve better therapeutic outcomes and quality of life.

Concluding message About half patients may consider discontinue mirabegron treatment after adequate symptoms control. Higher urgency severity scale may predict re-treatment after discontinuation of mirabegron in OAB patients. 

Hypothesis / aims of study Mirabegron (Myrbetriq/Betmiga; Astellas Pharma) is a β3 adrenergic receptor agonist with demonstrated efficacy and safety at managing the symptoms of OAB. 1 In clinical practice, mirabegron is typically given as second-line pharmacotherapy, after failure or dissatisfaction with antimuscarinics. 2 To date, the efficacy of mirabegron has been assessed in a number of randomized controlled trials, but limited safety information is available based on analysis of large sample sizes in a real-world observational setting. Integrated claims and electronic health records (EHR) datasets can be powerful research tools due to availability of detailed clinical data and ability to corroborate findings across datasets. However, comparisons of endpoints between groups may be affected by residual bias due to unmeasured confounding. This is particularly relevant when comparing medications typically administered sequentially for the same indication, as inherent patient differences can lead to identification of spurious associations. Falsification analysis, in which endpoints with no known association to treatment are identified and compared, is a recently proposed technique for assessing residual bias. 3 If unassociated outcomes appear to be associated with treatments under study, further analysis should be stopped to avoid biased findings.

The objective of this study was to assess presence of residual bias via a falsification endpoint analysis of OAB patients treated with mirabegron or antimuscarinics.

Claims and EHR data of OAB patients were examined. Index date was defined as the first date of treatment using antimuscarinics or mirabegron between October 2012 and December 2014. Unadjusted patient characteristics, including CV risk factors, were compared across groups at index and propensity-matching was used to reduce bias associated with observed confounders. A 3:1 propensity matching scheme was employed to improve efficiency given a relatively small number of mirabegron patients available in the dataset relative to antimuscarinic patients. Falsification analysis was used on the propensity-matched cohort to assess the associations between OAB treatment and outcomes with no known relationship to OAB treatment. Falsification analysis is characterized by odds ratios and corresponding 95% confidence intervals (CI) between treatment groups. The chosen falsification endpoints were hepatitis C, shingles, and community-acquired pneumonia, and a combined endpoint of hepatitis C and shingles, all of which have no known or plausible relationship with the exposure or outcome of interest.

10,311 antimuscarinic patients and 408 mirabegron patients were identified. Compared to AM patients, mirabegron patients were older (mean age 70 vs. 67 years), more likely to be male, to have had a recent CV event, and/or to have other comorbidities. After 3:1 propensity-matching, the sample included 1,188 antimuscarinic patients and 396 mirabegron patients; no statistically significant baseline differences were observed between treatment groups in the matched sample. Point estimates and 95% CIs for falsification endpoint odds ratios for mirabegron relative to antimuscarinics were 0.7 (CI: 0.3-1.7) for shingles, 1.5 (CI: 0.3-8.2) for hepatitis C, 0.8 (CI: 0.4-1.8) and 0.9 (CI: 0.6-1.4) for pneumonia (Figure) . While 95% CIs spanned 1.0, all were wide due to small sample sizes; and hence definitive conclusions could not be drawn and the presence of residual bias could not be excluded.

Hep-C=Hepatitis C Interpretation of results While 95% CIs spanned 1.0, all were wide due to small sample sizes; and hence definitive conclusions could not be drawn and the presence of residual bias could not be excluded.

In a real world analysis, baseline risk for CV events differs between OAB patients receiving mirabegron versus antimuscarinics. While propensity matching was successful at balancing known covariates, a small sample size and resultant wide CIs for falsification analysis was concerning, as such the potential for residual bias could not be ruled out.

Ng D B 1 , Espinosa R 2 , Johnson S 2 , Walker D 1 , Gooch K 1

Hypothesis / aims of study Patients who persist on mirabegron as a pharmacological treatment for overactive bladder (OAB) may see a reduction in allcause, OAB-related, and adverse event costs. The objective of this study was to compare healthcare costs and resource utilization for OAB patients who persisted on mirabegron with those who switched to onabotulinumtoxinA (onabotA).

Study design, materials and methods A retrospective study was conducted using the OptumHealth administrative claims data from April 2012 to September 2015 comparing patients who persisted on mirabegron with those who switched to onabotA. The study included OAB patients ≥18 years with ≥1 claim for an OAB diagnosis and ≥1 claim for mirabegron. It excluded subjects with pregnancy, benign prostatic hyperplasia, stress incontinence, or urinary tract infection. All-cause and OAB-related healthcare costs and number of medical visits in patients who switched to onabotA after mirabegron therapy and those who persisted on mirabegron for at least 180 days were compared. Index dates were defined as the first onabotA injection for onabotA switchers and randomly assigned to the mirabegron persisters based on the distribution of time to switch for the onabotA group. Healthcare costs and resource utilization were measured in the 6 months before and 12 months after the index date, and included initial onabotA treatment. Propensity score weighting was used to account for differences in patient baseline characteristics. Costs were analyzed with generalized linear models, and healthcare visits were analyzed with negative binomial regressions.

Results 449 patients were included in this study: 54 OAB patients in the onabotA group and 396 patients in the mirabegron persistence group. After propensity score weighting, both patient groups were similar in demographics and baseline healthcare Table 1) .

The study showed that, 12 months after index date, OAB patients who continued mirabegron treatment for at least 180 days had lower total OAB-related medical visits and costs compared to those who switched to onabotA.

OAB patients who persisted on mirabegron treatment for at least 180 days had lower healthcare costs and resource utilization compared to OAB patients who switched to onabotA. 

Hypothesis / aims of study Outcomes following prosthetic urethral lift implants (UroLift) (PUL) have been reported in a number of clinical trials. This investigation is unique because it follows the mid-term results in patients of five German centers who were treated in a normal clinical setting outside of clinical trial limitations. Previously reported studies rigorously selected subjects with mild to moderate obstruction. We report the prospective outcomes of patients treated by PUL in lieu of TURP after education concerning the less invasive therapy. The only exclusion criteria were a obstructive median lobe or high entrance into the bladder. 

Of the 212 candidates submitted for TURP, 85 (patient age was 38-85y) chose PUL. A total of 2-7 (3.9±1.4) implants were delivered over 42-90m (57.0±12.0) under general or local anesthesia. 37% of our more severely obstructed patients would have been denied PUL utilizing previously reported study criteria. 96% reported immediate symptom relief; mean Qmax, PVR, IPSS, and QoL significantly improved (p<0.001) within the first month that were maintained or further improved within the time of followup. Sexual function including ejaculation was unchanged or even improved of those who reported sexual activity prior to surgery. Eleven patients (12.94%) without severe obstruction but related to their high PVR underwent retreatment: two had successful additional PUL and 9 (with PVR values of 90-280ml) underwent TURP, four of which did not significantly improve further and one remained with a suprapubic catheter.

Interpretation of results Independent to the prospective study inclusion criteria, patients with BPO can be effectively treated by PUL. The outcome is similar to the data of other published two year follow-up with specific in-and exclusion criteria.

Concluding message PUL is a new and promising surgical technique which may alleviate symptomatic BPH, even in severely obstructed patients. It is an easy surgical technique and has been efficacious in candidates who would have undergone, until now, TURP or another equivalent therapy, thereby demonstrating higher levels of obstruction or previous urinary retention. Within the follow-up, these patients demonstrated a similar outcome to those in published studies. 

Hypothesis / aims of study Orgasm/sexual activity induced urinary incontinence (climacturia) is not uncommon after radical prostatectomy. Men with climacturia uniformly list this as a significant detractor to quality of life contributing to shame and avoidance of sexual intimacy. Current literature suggests climacturia may be present in 20-40% of men who have undergone radical prostatectomy. Unfortunately, post-prostatectomy patients are rarely queried as to the presence of climacturia. We report the largest series to date of men with climacturia after radical prostatectomy who were treated with a transobturator male sling.

Study design, materials and methods Review of registry data for men treated with the AdVance transobturator male sling following robotically assisted radical prostatectomy from January, 2010 through April, 2016 identified 44 men who had climacturia concurrent with clinically significant stress urinary incontinence (SUI) and 2 as a stand alone complaint. At the time of this abstract all had resumed sexual activity following sling placement and had reported on their incontinence, sexual function and specifically climacturia.

All 46 patients (100%) report complete resolution of orgasm/sexual activity induced incontinence. Of the men with SUI, 37/44 (84%) report complete resolution of SUI.

Interpretation of results As we report in this series, we have successfully treated men with climacturia either in conjunction with day-to-day SUI or as a stand alone complaint. The AdVance transobturator sling has proven to be an effective treatment for climacturia with resolution in 100% of our patients. Given these results, we now routinely query our patients with post-prostatectomy SUI about climacturia and, if present, counsel them that an AdVance sling will effectively treat this complaint. Also, we readily offer sling treatment to men who only complain of climacturia.

Concluding message Climacturia may be present following radical prostatectomy and impacts cancer survivorship. Climacturia can be effectively treated with a transobturator male sling, whether it exists in conjunction with SUI or independently. 

Hypothesis / aims of study To date, urethral pressure profilometry (UPP) is still being performed as a routine urodynamic investigation in many institutions. We aimed to compare UPP and clinical parameters in elderly men with LUTS and determine whether it helps to diagnose bladder outlet obstruction BOO inpatients with lower urinary tract symptom (LUTS)/ benign prostatic hyperplasia (BPH).

Study design, materials and methods Urodynamic database of a consecutive 1,134 patients with LUTS/BPH older than 45 between May 2011 and May 2014 was included for analysis. Patients with a history of previous genitourinary surgery, pelvic radiation therapy, urinary tract infection, urethral stricture, interstitial cystitis, and neuropathy suggesting neurogenic bladder or incomplete evaluations were excluded. All UDS were performed using a multichannel video system (UD-2000 or Solar, Medical Measurement System) according to International Continence Society recommendations. UPP parameters include maximum urethral pressure (MUP), maximum urethral closure pressure (MUCP) and functional urethral length (FUL). The BOO index (BOOI) was used to determine BOO. Patients with BOOI <20, 20-40, and ≥40 were considered as unobstructed, equivocally obstructed, and obstructed, respectively. Pearson's and Spearman's correlations were performed for continuous and rank data, respectively. ROC curve was used to study the practical value of UPP parameters in diagnosing BOO. All comparisons were two-tailed, and p-values<0.05 were considered significant. Statistical analysis was performed by using IBM SPSS ver. 21.0 (SPSS Inc., Chicago, IL, USA).

The mean age of patients was 67.6 (±7.5, SD) years. The TPV and PSA were 57.1 (±34.0) ml and 3.1 (±3.9) ng/ml, respectively. The International Prostatic Symptom Score (IPSS)-total, IPSS-storage, IPSS-emptying, and IPSS-QoL were 17.9 (±8.1), 7.2 (±3.6), 10.7 (±5.6), and 4.0 (±1.2), respectively. The Mean BOOI was 40.1 (±26.8), and 468 patients (42.8%) were classified as having BOO. The mean total prostate volume (TPV), transition zone of prostate volume (TZV), serum PSA level, free uroflowmetry (FF)-postvoid residual (PVR), BOOI, bladder contractility index (BCI), PdetQmax, and involuntary detrusor contraction (IDC) were significantly higher in the patients of the obstructed group than those of the other two groups (P<0.05). The storage IPSS score was significantly higher in the obstructed group than the equivocally obstructed group (P<0.05). Pearson's correlation analysis showed that each UPP parameters correlated significantly with age, PSA, and PdetQmax, but not to total IPSS or Qmax. Moreover, FUL was significantly correlated with TZV, PVR, or BOOI (P<0.01, P=0.001, and P<0.01, respectively) ( Table 1) . As for the ROC curves of UPP parameters in diagnosing BOO, only FUL was found to correlate with the diagnosis of BOO in men with BPH (P<0.01). However, the sensitivity was only 53.2% and the specificity was 63.2% when FUL ≥74.5 mm was set as BOO standard (Fig. 1) .

Compared with patients with unobstructed pattern, our results showed that, the obstructed patients had significantly higher age, larger TPV and TZV, and higher serum PSA levels, confirming that prostate volume and serum PSA concentration were significantly and positively correlated with advanced age, as previously reported [1] . Our results showed that the FUL of obstructed group was significantly longer than that of the unobstructed group. There was no significant correlation between UPP parameters and total IPSS. FUL was significantly correlated with TZV, PSA, PVR, and BOO index (P < 0.01). It is thus obvious that the prolongation of the prostatic urethral tract is another reason for increase in urethral resistance. ROC curve was used to compare the sensitivity and specificity of all UPP parameters in diagnosing BOO, PFS result was set as standard. When FUL ≥67.5 mm was set as BOO standard, the sensitivity was 76.4%, but the specificity was only 38.9%, while when FUL ≥74.5 mm was set as BOO standard, the sensitivity was 53.2% and the specificity was 63.2%, indicating that FUL≥74.5 mm is a standard to evaluate BOO due to BPH. However, the diagnosis value was low.

Concluding message FUL on UPP was useful in assessing the BOO due to BPH, but the diagnosis value was low. Our results showed that poor correlation between UPP and the diagnosis of BOO. 

Hypothesis / aims of study Post radical prostatectomy urinary incontinence (PPI) is the most feared consequence of radical prostatectomy and it's occurrence has a major negative impact on quality of life. Around 5% of the patients undergoing radical prostatectomy will have surgical treatment for PPI. The urinary artificial sphincter is the gold standard, but the slings indications have increased due to lower cost, practicality, reproducibility, shorter learning curve and similar results, in mild to moderate incontience, in short and medium term follow-up. Unlike female slings, failure rates vary, and each male sling should be individually analyzed as a single device. The failure rates can be reduced by sling adjustability, but which are the predictive factors of adjustment? Who is the patient who will benefit from sling adjustment?

This study aims to identify clinical and urodynamic predictive factors for male sling adjustment.

Study design, materials and methods Seventy two consecutive patients with mild to severe incontinence underwent surgery for PPI, transobturator adjustable sling (Argus-T, Promedon, Cordoba, Argentina), from 2009 to 2016. Open abdominal radical prostatectomy was the procedure in all the patients. Prior to implantation and during follow up, patients were accessed through clinical evaluation, 24 hours pad test, International Index of Erectile Function (IIEF-5), International Consultation on Incontinence-Short Form questionnaire (ICIQ-SF), Global Impression of improvement (GII) and Visual Analogue Scale (VAS) for treatment satisfaction. Urodynamics and terminology followed ICS standardisation (1, 2) . All the patients were operated by the same surgeon, through a perineal incision and two crural incisions (4cm lateral to the genitofemural fold). They received 2g of Ceftriaxone 1 hour before the procedure and remained with Cefuroxime for 7 days. Follow up visits occurred n 14 days, 1,3 and 6 months and annually thereafter. The sling tensioning was based on urethral retrograde perfusion pressure, reaching between 35 and 40 cmH2O. Adjustments were done only after one months. Only tightening was required, and the tension was readjusted between 35 and 40cmH2O. Clinical and urodynamic variables were correlated with outcomes: subjective success (VAS ≥ 8 and GII 1 or 2) and objective success (Dry or improvement > 50% on number of pads/day), and the need of adjustments, adjusted to the uni and multivariate logistic regression model.

Median time between prostatectomy and the sling was 48 months (8 -204 

The success rates of the male sling should be analyzed according to each device specifically, and not generically as in the female sling. The success rates in this study are similar to those previously published for this device, however, the complications and adverse events are lower, especially regarding infection rates and sling removal. Probably due to some surgical details to prevent infection, such as distancing the crural incisions of the genitofemural fold, and the medial and anterior path of the subcutaneous hidden excess silicone arms, preventing their passage under this fold. As far as we know, this is the first study to determine the risk factors for sling adjustment. Of the irradiated patients, 76% and 69% achieved subjective and objective success respectively, however, 62% were submitted to sling adjustment. Thus, there was no correlation between radiotherapy and success rates solely because of the adjustability of the sling. The same can be said about detrusor hypocontractility, number of pads, and urethral stenosis. Thus, patients with pad test ≤ 475g are more likely to be satisfied with this sling. However, irradiated patients, and those with detrusor hypocontratility will require adjustment more frequently, which will allow the maintenance of success rates similar to those without these characteristics.

Sling adjustment benefits more than 20 % of the patients who were treated for PPI and more than a half of those with previous radiotherapy or detrusor hypocontratibility.

te Dorsthorst M J 1 , Martens F M J 1 , Farag F 1 , Heesakkers J 1 1. RadboudUMC

Hypothesis / aims of study The aim of the study was to determine the functional survival of the artificial urinary sphincter (AMS800) in different patient populations. We hypothesized that patients with known risk factors for failure who underwent placement of an AMS800, nowadays have a better survival of their prosthesis, because of increasing experience and dexterity of the operating team. Approximately 25% of the patients in G1 had had additional therapy for prostate cancer and 14% had had previous surgery for incontinence. In G2 51% and 55% underwent additional therapy for prostate cancer and previous surgery for incontinence respectively. In G3 we found an almost stable number of patients who had had additional therapy for prostate cancer, 45% and previous urethral surgery, 45% respectively. The revision-free estimated survival of the artificial urinary sphincter was higher if correction for risk factors was performed. (Figure  1 .) This could only be done for G1 and G2 because of the smaller sample size of G3 and the shorter period of follow up. Concluding message Despite the changing patient population, the survival of the artificial urinary sphincter is not decreasing. In some patient categories (previous radiotherapy or a male sling) the AMS800 function survival is even still improving over the past few years. 

Hypothesis / aims of study Male stress urinary incontinence (SUI) represents a possible complication after radical prostatectomy or BPO surgery. The artificial urinary sphincter (AUS) is considered the standard treatment for this condition but interest on other minimally invasive devices, as adjustable balloons or bulbourethral slings, has increased in the last few years. Unfortunately, evidence on efficacy of the adjustable balloons (ProACT™, Uromedica, Plymouth, MN, USA) is sparse and further data are needed to understand the real role of this therapy in male SUI. Aim of this national multicentric retrospective study is to evaluate the efficacy and safety of ProACT system in the short term follow up.

In this multicentric retrospective study, we report data from the databases of seven centers in Italy. Patients with SUI who underwent a ProACT device implantation for SUI after radical prostatectomy or BPO surgery between 2001 and 2016 were included. Efficacy was evaluated at the end of the balloons volume adjustment (6 months after the implant) and was assessed considering 24-h pad test. Patients were considered: "Dry" if presenting a urine leak count lower than 8g at 24-h pad test; "Improved" if presenting a reduction of urine leak higher than 50% compared to the pre-operatory assessment (but higher than 8g/24h); "Failure" if presenting a reduction in urine leak lower than 50% compared to the pre-operatory assessment. 24/h pad test and number of pads pre-op and at 6-month follow-up were collected. Evaluation included record of perioperative complications, pre-operative VLPP, medical history of radiotherapy, volume of balloons at the end of adjustment period, type of guidance and their impact on outcomes. T test was used to compare continuous and Chi square test to compare discrete variables. P value <0.05 was considered statistically significant. All statistical analyses were performed with STATA 14.2 program.

A total of 515 consecutive patients were treated with ProACT implantation. The balloons adjustment period was 3-6 months. Data on outcomes were not available in 29 patients who were excluded from the analysis. Of the remaining 486 patients, 192 (39,5%), 181 (37,2%) and 113 (23,3%) were considered respectively dry, improved or failure, according to the previously reported definitions (Tab. 1). No correlation was found between age and treatment success (tab 1). The mean number of daily pads per patient (1.52 vs 3.39 at baseline; p<0.001; data available in 478 patients) and the mean 24h pad test (113.9 vs 350 at the baseline; p<0.001; data available in 399 patients) significantly improved after ProACT implantation (tab. 2). Among the patients with a pre-operatory pad test <400ml, 262 patients were dry or improved (80%) whereas 67 patients were failed (20%); among the patients with a pre-operatory pad test >400ml, 76 patients were dry or improved (67%) whereas 37 patients were failed (33%) with a significant higher improvement in the first group (p <0.001). The pre-operative 24h pad-test was significantly lower in patients dry or improved (345ml vs 391ml p=0.001). No differences in outcomes were observed (p=0.464) as regards the pre-operatory VLPP (data available in 211 patients). Worse outcomes have been observed among the 77 patients who underwent previous radiotherapy: in this cluster 17 patients were dry (22%), 27 patients improved (35%) and 33 patients failed treatment (43%) (p<0.001). 301 patients underwent implantation under fluoroscopic guidance and 184 under TRUS guidance; no differences were found considering only Dry patients (40% vs 39%), but there is a slight evidence in favour of TRUS guidance considering patients Dry and Improved (73% of patients dry or improved under fluoroscopic guidance vs 83% under TRUS guidance, p=0.02). Mean volume of balloons at the end of adjustment was significantly lower in dry patients (4.83ml vs. 6.8ml in failure group, p<0.001). Perioperative complications were found in 42 patients (8.6%) and included bladder perforation (5.1%), urethral perforation (2.2%) and bleeding (1.2%). All complications were classified as grade I (8,3%) or II (0,2%) according to the Clavien-Dindo Classification of Surgical Complications (1) (Tab. 3).

To our knowledge, our database represents the larger series of patients treated by means of ProACT balloons. Despite the short follow up time, this treatment seem to represent a good option to treat patients with SUI after prostate surgery with a percentage of cured or significantly improved subjects of 76,7%. Patients with a lower pre-operative 24h pad test leakage (<400ml) seem to be better responder than those with more severe incontinence; on the other hand, radiation therapy seems to be a negative prognostic factor. Functional results were not affected by preoperatory VLPP and age but we found a slight better result in patient who underwent a TRUS guided procedure. Rate and severity of complications seem low.

ProACT implantation represents a safe and efficacious treatment option for male SUI after prostatic surgery. Studies with longer follow up are needed to evaluate results in the long-term. 

Hypothesis / aims of study Male stress urinary incontinence (SUI) represents a possible complication after radical prostatectomy or BPO surgery. The artificial urinary sphincter (AUS) is considered the standard treatment for this condition but interest on other minimally invasive devices, as adjustable balloons or bulbourethral slings, has increased in the last few years. Unfortunately, evidence on efficacy of the adjustable balloons (ProACT™, Uromedica, Plymouth, MN, USA) is sparse and further data are needed to understand the real role of this therapy in male SUI. Aim of this multicentric national retrospective study is to evaluate the efficacy and safety of ProACT system in the medium term follow up.

In this multicentric retrospective study, we report data from the databases of nine centers in Italy. Patients with SUI who underwent a ProACT device implantation for SUI after radical prostatectomy or BPO surgery between 2001 and 2015 and had a minimum follow-up of 24 months were included. Efficacy was evaluated at the maximum available follow-up and was assessed considering 24-h pad test. Patients were considered: "Dry" if presenting a urine leak count lower than 8g at 24-h pad test; "Improved" if presenting a reduction of urine leak higher than 50% compared to the pre-operatory assessment (but higher than 8g/24h); "Failure" if presenting a reduction in urine leak lower than 50% compared to the pre-operatory assessment. Evaluation included record of complications. T test was used to compare continuous and Chi square test to compare discrete variables. P value <0.05 was considered statistically significant. All statistical analyses were performed with STATA 14.2 program.

On a total of 515 consecutive patients treated with ProACT implantation, 247 had a follow-up time ≥24 months. The mean 24h pad test significantly improved after ProACT implantation (125,52 (0-900) ml vs 364,77 (40-1000) ml); p<0.001; data available in 227 patients). Seventeen patients had incomplete data and were excluded from the study; on the remaining 230 patients, 89 (38,7%), 91 (39,6%) and 50 (21,8%) were considered respectively dry, improved or failure, according to the previously reported definitions. Mean follow-up was 77,5 (SD 37, range 24-174) ) months. Forty-six complications were recorded in 44 patients (19%) and included: ProACT device ropture (22, 9,5%) ; recurrent urinary tract infection (1, 0,4%); acute urinary retention (2, 0,8%); ProACT infection (7, 2,8%); ProACT migration (9, 3,6%); urethral erosion (5, 2%). Thirty-one complications (67,4%) were considered grade I, 3 complications (1,2%) grade II and 12 grade IIIa according to the Clavien-Dindo Classification of Surgical Complications (1). No grade 4 or higher complications were found. Fifteen patients (6%) underwent monolateral (12, 4,8%) or bilateral (3, 1,2%) reimplant of ProACT balloons. Three (1,2%), 9 (3,6%) and 3 (1,2%) of these patients were respectively dry, improved or failure at maximum follow-up.

Interpretation of results To our knowledge, our database represents the larger series of patients treated by means of ProACT balloons with a follow-up time ≥24 months. At a mean follow-up of 77,5 months, this treatment seem to represent a good option to treat patients with SUI after prostate surgery with a percentage of cured or significantly improved subjects of 78,3%, even if only 38,7% of patients were cured. Rate complications is 19% at this follow-up time; on the other hand, severity of complications seem low with the majority being grade I or II according to the Clavien-Dindo Classification of Surgical Complications. Grade IIIa complications are managed usually in an office setting, not requiring major surgical procedures. Patients after a ProACT reimplantation may be dry (20%) or improved (60%) in the majority of cases. The limitations of this study are: retrospective design, incomplete evaluation of patients with no patient reported outcome data, no cross-sectional evaluation at different follow-up times. Strengths of this study are: multicentric nationwide database; mean follow-up of 77,5 months.

ProACT implantation represents a safe and efficacious treatment option for male SUI after prostatic surgery at a mean follow-up of more than 6 years. Cured or improved patients are 78,3%. Complications rate is 19% but the majority of complications is low grade, with no life threatening complications.

Gotoh M 1 , Yamamoto T 1 , Funahashi Y 1 , Matsukawa Y 1

Hypothesis / aims of study We created a novel treatment strategy to regenerate the urethral sphincter function, using autologous adipose-derived regenerative cells (ADRCs) without the need of cell culture (Fig.1) . We published the short-term results of 11 male patients with stress urinary incontinence [1] . Although favourable efficacy and safety were confirmed at one year after treatment, durability of efficacy and safety should be confirmed in a long-term period. In the present study, we assessed the long-term durability of efficacy and safety in 14 male patients with stress urinary incontinence caused by urethral sphincter deficiency, who underwent periurethral injection of ADRCs and were followed longer than 4 years.

Study design, materials and methods Fourteen male patients with persistent stress urinary incontinence after prostate surgery (radical prostatectomy, 12 patients; holmium laser enucleation of the prostate, 2 patients) underwent the periurethral injection of ADRCs and were followed longer than 4 year. After liposuction of 250 mL of adipose tissue from the abdomen, we isolated ADRCs from this tissue by using the CelutionTM system (Cytori Therapeutics Inc., San Diego, USA). Subsequently, these ADRCs and a mixture of stem cells and adipose tissue were transurethrally injected into the rhabdosphincter and submucosal space of the urethra, respectively. Unlike other cell therapies, this treatment is entirely autologous, does not require cell culture, and is performed as a single surgical procedure within 3 hours. Outcomes were mean daily leakage volume for 4 days assessed by a 24-hour pad test, maximum urethral closing pressure and functional profile length on urethral pressure profile, blood flow at the injected area evaluated by contrast-enhanced transrectal ultrasonography, and morphological changes of injected adipose tissue assessed by magnetic resonance imaging. Measurement of urethral pressure, blood flow at the injected site and morphological change of injected adipose tissue were made until 12 months after treatment as previously reported [1] . Daily leakage volume was measured in a long-term follow-up at 1, 3, 6, 9, 12, 18, 24, 30, 36 and 48 months after the treatment.

Mean follow-up period was 57.8 months (49 to 72 months). After injection, mean leakage volume/24-hours changed from 249.5 to 151.9g (mean of all patients). Urinary incontinence progressively improved up to 12 months after treatment in 11 of the 14 patients, and one patient with moderate incontinence achieved total continence at 14 weeks after injection. In the 11 patients who showed improvement, the mean daily leakage volume improved from 265.4 to 124.5 g at 4 years. In other 3 patients, mean daily leakage volume increased from 191.1 to 223.3 g. In the patients with improvement in leakage volume, the improvement was maintained in the long-term follow-up to 4 years after the treatment (Fig 2) . In 5 of 14 patients achieved improvement of leakage volume of more than 50% (Fig.3) , with mean leakage volume decreasing from 302.0 g to 84.5 g (72% reduction rate).

In the urethral pressure profile, the maximum urethral closing pressure and functional profile length in all patients significantly increased from 35.9 to 45.0 cmH2O and from 16.9 to 24.0 mm (mean), respectively at 6 months after the treatment. Magnetic resonance imaging showed sustained presence of the injected adipose tissue in all patients at 12 months after the treatment. Enhanced ultrasonography showed a progressive increase in blood flow to the injected area up to 12 months after the injection in 13 patients. No significant adverse events were observed peri-or post-operatively.

The periurethral injection of ADRCs gradually improved SUI over time in 11 patients. The results of the present clinical trial and a previous experimental study [2] suggest the mechanisms involved in the improvement of the sphincteric function to be bulking effect, regeneration of the smooth muscle, and increased blood flow caused by ADRCs injection. The efficacy of the treatment in improved patients will be durable during a long-term period.

The present study showed that periurethral injection of autologous ADRCs is a safe and feasible treatment modality with durable efficacy for patients with stress urinary incontinence caused by urethral sphincter deficiency. Based on the outcomes of the clinical study, we started a multicentre, investigator initiated clinical trial (ADRESU trial), approved by Japanese PMDA (Pharmaceuticals and Medical Devices Agency) from September 2016 (UMIN-CTR : UMIN 000017901, Clinical Trials. gov : NCT02529865). Randomized controlled trials and meta-analyses have revealed post-operative groin and lower extremity pain to be adverse events of transobturator slings in 6-15% of women. Although many will have resolution of pain once postoperative healing occurs, this effect does not resolve in all patients and some are left with persistent debilitating pain. In our experience, when this pain persists despite conservative measures, removal of the vaginal portion of the sling alone is often inadequate to treat the symptoms. A variety of techniques to identify and remove mesh from the thigh and obturator region have been described including mobilization and elevation of the adductor muscles from their bony origins. This case report video demonstrates a surgical technique to minimize muscular trauma by sparing the detachment of the adductor muscles from their origins during trasobturator mesh removal.

This patient presented with a seven year history of dyspareunia, pelvic pain, and lower extremity radiating pain with abduction of the upper legs following a transobturator sling. The vaginal portion was removed during two previous removals prior to referral without resolution of her symptoms. She was consented for muscle-sparing transobturator sling arm removal. The technical steps Watch video www.ics.org/tv?play=3300 of the procedure include: 1. Exposure of the adductor muscles over the obturator foramen 2. Separation of the muscle fibers and retraction by a nasal speculum to identify the mesh and 3. Dissection of the mesh to the inferior pubic rami permits vaginal identification. Paramount to this technique is traction on the sling arm and direct instrument application on the sling arm during dissection to minimize inadvertent vascular injury as well as to reduce tissue loss.

We utilized this minimally invasive technique for transobturator sling arm excision in a patient with intractable lower extremity and pelvic pain despite previous removal of the vaginal sling portion. Postoperatively, she was discharged home after an overnight stay without any complications. Her post-operative convalescence was without readmission, infection, blood transfusion, or other events. Her lower extremity pain was completely resolved at 6 weeks and her pelvic pain was markedly improved. Paramount to this technique is traction on the mesh arm and direct instrument application on the sling arm during dissection to minimize inadvertent vascular injury and reduces tissue loss.

In patients with intractable pain after removal of the vaginal portion of the transobturator sling, removal of residual transobturator mesh arms from the adductor musculature can be performed with minimal disruption of the muscles. When patients have intractable pain that is suspected to be secondary to the trajectory of a sling arms through the obturatory muscle groups, counseling patients on this technique for removal may be considered. Further studies examining patient outcomes are needed.

Erosion or insertion of the tape mesh to adjacent organs is one of the serious possible complications of tension-free vaginal tapes. These complications are mostly related to retropubic trajectory of insertions and are rare after the use of transobturator tape. Management of such complications is difficult, and there is no common surgical approach about resolving them. The aim of this video is to provide a step-by-step description of our approach to laparoscopical removal of transobturator tape after previous failure of repeated cystoscopic tape resection.

Design A 68-year-old woman (G3/P2) was referred to our department with tape erosion to the urinary bladder after repeated cystoscopic tape resection, recurrent stone formation in the urinary bladder, and repeated lithotripsy, with recurrent urinary tract infections, OAB with urgency incontinence. All those symptoms followed the insertion of transoturator tape in 5/2005. The patient also described severe hematuria following the procedure, which was treated with indwelling catheter for 9 days. Cystoscopy revealed the presence of stone on the bladder wall above the left ureteral orifice.

Surgical procedure Cystoscopy was performed and ureteral stents were bilaterally inserted. Laparoscopy was performed, using a 10 mm port inserted in the inferior edge of the umbilicus to accommodate the laparoscope and three other ports (one 10 mm and two 5 mm). After filling the urinary bladder with 150 ml of sterile saline, the peritoneum was opened and the Retzius space was reached. Tape was identified in the left obturator muscle, cut near the obturator muscle and dissected up to the bladder wall. Afterward a vertical 2 cm incision was made in the bladder wall, the stone was removed and the rest of the tape was dissected from the bladder wall. A two-layer suture of the bladder wall was performed using 2-0 Vicryl running suture, and the bladder suture line integrity was tested with retrograded filling of the urinary bladder to 300 ml with "Patent blue" diluted in sterile saline. Postoperative course The postoperative course was uneventful. An indwelling Foley catheter was left for ten days. The patient was discharged from hospital on the third day after surgery. In follow-up visits 3 and 6 months after surgery the patient was continent; with no symptoms of OAB, and a cystoscopy check established adequate healing of the bladder wall.

Introduction Unnoticed bladder injury during tension-free vaginal tape (TVT) is a rare condition occurring in 4% of the procedures. This complication implies persistent irritative symptoms, haematuria, calcification of the mesh segment and recurrente urinary tract intections (UTI's). The treatment of this condition is surgical removal of the exposed mesh segment transvaginally, endoscopic or laparoscopic, but there is no consensus of which is the best approach.

We present a case report of a 40-year-old patient with history of TVT mesh placement six months before she presented to our service. The symptom of presentation was recurrent UTI's with Escherichia coli BLEE positive after mesh placement, there was no obstructive symptoms, no significant postvoid residual. The pelvic physical exam was normal, no palpable transvaginal mesh. A cystoscopy was performed observing an erosion in the left lateral wall of the bladder. As the mesh couldn't be palpated transvaginally we decided a laparoscopic approach for the removal.

An transperitoneal laparocopic approach was used, three trocars were placed, the intraperitoneal segments were removed, the peritoneal wall of the bladder wall incised, the intravesical segment of the mesh was removed and the points of entry of the mesh were repaired with continuous 3-0 vicryl suture. The operative time was 63 minutes and the intraoperative bleeding was minimal.

Laparoscopy approach could allow the total removal of bladder exposed and intraperitoneal segments of mesh as well.

Funding: self-sustaining Clinical Trial: No Subjects: NONE Introduction Sacral colpopexy was the first technique used to treat pelvic organ prolapse (POP) with robotic assistance. However, dissection at the level of the promontory may be associated with rare but potentially serious complications, in particular life-threatening vascular injuries. To avoid this risk, lateral suspension with mesh may be an interesting alternative.

Our video presents the case of a 73 years old menopause patient gravida 5 para 4, with history of asymptomatic myomatous uterus, breast cancer 5 years earlier, and vaginal POP repair one year ago with posterior colporraphy. She was referred to our clinic for POP stage 3, complaining of pelvic discomfort. On clinical examination, there was a stage 3 apical and anterior compartment defect (Aa +2, Ba +2, C +1) without significant posterior compartment defect. Preoperative ultrasonography showed a 3 cm anterior myoma and an atrophic endometrium. We decided to perform a robotic-assisted laparoscopic repair of anterior vaginal wall and uterine prolapse by lateral suspension with mesh in association with a bilateral adnexectomy.

Watch video www.ics.org/tv?play=3302

Watch video www.ics.org/tv?play=3303

We used the Da Vinci Xi robot with an 8 mm umbilical port for a 0° optique, and two 8 mm ports placed laterally, 4 cm over the anterior superior iliac spine on each side. We used a 10 mm right paraumbilical assistant port to introduce sutures and mesh. We performed dissection of the vesico-vaginal space followed by placement of a polypropylene mesh (TiLOOP® "Prof Dubuisson" ® 9X 41.5 cm, 65g/m 2 ) consisting of an anterior part of 6 cm length and 5 cm width with two lateral arms of 3 cm width. The mesh was fixed to the vagina by 6 to 8 sutures of 2-0 polyglactin 910 (Vicryl® suture 2-0, V3170H, JB needle by Ethicon). It was also fixed to the isthmus of the uterus by 2 sutures of 0 polyester (Ethibond® suture 0 V7 needle by Ethicon).Once the mesh was sutured, the two lateral arms were pulled retroperitoneally by the assistant through a peritoneal incision situated about 4 cm over the anterior superior iliac spine, just at the end of the lateral ports. One of the lateral arms of the robot was undocked to perform this manoeuvre. Thereafter, the peritoneum of the vesicouterine fold was closed over the mesh with uninterrupted suture of polyglactin 910 (Vicryl® suture 0 CT-2 needle, V330). During the closure, we performed a plication of the round ligaments and included the mesh in the suture thus increasing the binding of the mesh to the uterus and to the round ligaments. After checking the result of the procedure and avoiding excessive tension and in order to avoid sliding during the healing, the arms of the mesh were fixed to the peritoneum of the abdominal wall by the field assistant with absorbable tacks (Absorba Tack® fixation device by Covidien).

Our video demonstrates that in case of anterior vaginal wall and uterine prolapse, hysteropexy with lateral suspension may be an alternative to the classical sacral hysteropexy, with reduced risk of complications. Robotic assistance is not mandatory but offers a better 3 dimension vision and allows us to avoid the transparietal passage of the mesh of the traditional laparoscopic technique, thus limiting the risks of ilioinguinal and ilio-hypogastric nerves injury. 

Sacrocolpopexy has become a gold standard procedure for the treatment of vaginal vault prolapse. Initially described as a laparotomic approach, the minimaly invasive alternative has gained popularity due to rapid recovery and decrease in morbidity. Various complications con occur intraoperatively and postoperatively. In perioperative complications there are those inherent to the technique of laparoscopy (not discussed here), and those specifically associated to the different steps of sacrocolpopexy.

Design : In our institution, a single surgeon performed over 1200 laparoscopic sacrocolpopexies. The majority of interventions was recorded, which made it possible to document numerous complications of all varieties. All postoperative complications were managed and/or reoperated by the same surgeon.

Out of 1200 sacrocolpopexies, we recorded 14 severe complications : -1 wound of the left iliac vein -2 bladder wound -1 uereteral wound -0 rectal wound -1 vaginal wound -1 spondylodicitis -1 mesh infection -4 intestinal occlusion -2 breakdown of the promontory suture line -1 intra rectal erosions

We presented a video gallery of various complications occuring during laparoscopic sacrocolpopexy. Certain complications are specific to the technique and the use of prothetic meshes. Some complications can be avoided by respecting the different steps described for the procedure. In any case it is crucial to know how to manage them. We believe that surgeons must know, when to give up when confronted with difficulties and consider alternative approaches such as vaginal surgery.

We present a case of a 67 years old lady who had constant daytime urinary incontinence for 40 years. Her personal history included an emergency hysterectomy for a miscarriage, which had severe complications and held her hospitalized for one entire year at the time. After that she developed a stress urinary incontinence, that progressively evolved to the complete day-time incontinence she presented in our clinic. She had been submitted to several procedures, including colpocleisis 20 years ago and a TOT sling 3 years ago, with no improvement to in-continence. Another complaint that the patient had had before widowing, was dyspareunia after surgical management (patient did not know about the colpocleisis), which indicates that patient probably had "coitus per uretram". At examination, she had a megameatus, but as we were not able to extract more information from physical examination, she underwent a com-puted tomography and a bladder stone was identified, close to the bladder neck. After diagnosing these two findings, we submitted the patient to a vaginal approach in order to correct both defects at the same time.

First we evaluated her urethra and bladder with a urethrocistoscopy, that showed a megaurethra and a stone attached to the eroded sling within the urethra. After examination of the rest of the bladder, which was normal, we approached the megaurethra through a suprameatal access. After dissection of the retropubic space and liberation of the urethra and bladder from pubic bone, opening of the urethra allowed to identify and excise the sling and stone. Excess of urethral tissue was excised and tailoring of the urethra on a 16Fr Foley catheter was carried with a 5-0 polydioxanone run suture, in two layers. A Martius flap was obtained and placed between pubic bone and urethra to avoid fixed urethra and in case the patient needs another procedure to achieve continence.

Patient was left with Foley catheter for 10 days and 30 days after procedure, she has referred improvement in urinary continence pattern, still having leakage during stress, but with increase in quality of life scores.

Challenging cases in Female Urology are to be presented in order to share experience among peers and provide options in complicated surgeries. 

Hypothesis / aims of study The Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) are both well-known. In obstetric fistula (OF) repair outcome is usually assessed by the surgical team. The patient perspective is often neglected. Therefore we translated both questionnaires in Lingala and Kikongo, official languages in DR Congo. Secondly used the questionnaires in an OF population to assess the real life continence status and the impact of fistula repair surgery.

Watch video www.ics.org/tv?play=3303

Study design, materials and methods UDI-6 and IIQ-7 were translated and underwent content validity checks using focus groups. The final versions were tested in a normal population and in an OF population (33 for Kikongo, 35 for Lingala) for internal consistency and test-retest reliability. The responsiveness was tested in an OF population and effect sizes were calculated.

The content validity as measured in a normal student population, both in Lingala and Kikongo Interpretation of results Both questionnaires showed good internal consistency and reliability. The Cronbach's α for UDI-6 in both languages was 0.47 for the IIQ-7, 0.96 for Lingala and 0.94 for Kikongo in an OF population. The test-retest reliability was high in all cohorts. Both questionnaire scores improved significantly after fistula repair. The effect size for UDI-6 was -1, 09 and -1, 6 for IIQ-7. 

Hypothesis / aims of study A recent randomized trial and many cohort studies have concluded that overall quality of life, in terms of physical, social or emotional wellbeing, is not affected by surgery, radiotherapy or active monitoring for localized prostate cancer. However, each treatment is associated with a particular set of side-effects which can affect specific aspects of quality of life. For example, erectile dysfunction is a relatively common side-effect of radical treatment (surgery or radiotherapy), and raised levels of bother are found when comparing randomized or treated groups. Urinary incontinence is a less common side-effect of surgery, but this is also associated with raised levels of specific bother.

The aim of this study was to investigate this seeming contradiction by examining levels of general quality of life (physical and mental health, anxiety and depression) amongst men reporting urinary incontinence or erectile dysfunction following treatment for localized prostate cancer, compared with those not reporting these symptoms.

In the randomized trial in which the study is based, 1643 men with clinically localised prostate cancer underwent randomisation: 545 to active monitoring, 553 radical prostatectomy, and 545 radiotherapy. Urinary incontinence (UI) was assessed by patientreported outcome measures (PROMs) -specifically the Expanded Prostate Cancer Index Composite (EPIC) items on absorbent pad-us and the firmness of erections for intercourse.(1) Physical and mental health were assessed by two domains of the generic health measure, the SF-12.

(2) Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). (3) Study questionnaires were completed at baseline before the diagnosis was known, at six and 12 months after randomisation, and annually thereafter. PROMs were scored and analysed as recommended by their authors. Means and standard deviations were calculated for the HADS and SF-12, with p values testing the null hypothesis of equal population means across groups without the symptom or with the symptom at six months, or with the symptom at six, 12 and 24 months -assessed over the duration of the study (six years).

Response rates were higher than 85% for all measures and did not decline over time.

There were 133 (13%) men with urinary incontinence (UI) who needed to use pads at six months and 62 men (6%) who needed to use pads at six, 12 and 24 months, compared with 845 (81%) who did not use pads for UI. Men who needed to use pads for UI had higher depression scores compared with those who did not need to use pads at all time points, with scores highest of all for those who needed to use pads for longer. There was strong evidence that depression scores were worse in those using pads at six months and 12 months (p<0.001). The pattern for anxiety scores was somewhat similar. The highest anxiety scores were evident among men needing to use pads for longer, with those using pads only at six months having scores more similar to those without needing pads. There was some evidence that anxiety scores were particularly worse for those using pads at six and 12 months (p=0.02 at six months and p=0.03 at 12 months). SF-12 scores for physical health were different only at six months, when there was slightly worse physical health in those who needed pads compared with those who did not (p<0.001). After this, physical health was similar between the groups. Reflecting the HADS scores above, SF-12 scores for mental health were worse among those needing pads at six months (p=0.005), with some weaker evidence of worse mental health at 12 months among those needing pads longer-term (p=0.07). There were 278 (27%) men who had erectile dysfunction (ED) at six months, 454 (44%) who had ED at six, 12 and 24 months, compared with 289 (28%) who did not report ED. HADS depression and anxiety scores were much higher in men reporting longer-term ED than those with ED only at six months, or no ED. For depression, this evidence was very strong (p<0.001 at each time point); it was slightly less strong for anxiety at p=0.001 to 0.07). Depression and anxiety levels did not decline over time among those with long-term ED, but there was some evidence that those who recovered function after six months experienced less anxiety and depression. These patterns mirrored in the SF-12 mental health scores. Perhaps more surprisingly, the experience of ED at six months or longer term was associated with a small reduction in physical functioning, and this was maintained for six years (p<0.001).

High levels of erectile dysfunction are experienced by men who undergo treatment for localized prostate cancer and it affects physical and mental health, including anxiety and depression. ED continues to have a small but measureable impact on these aspects of general quality of life for the duration of the time it is experienced. Urinary incontinence affects a smaller number of men, but has a clear impact on anxiety, depression, physical and mental health at six months. This impact on physical and overall mental health reduces after six months, but urinary incontinence continues to be associated with slightly higher levels of depression and anxiety over time.

Concluding message While it is commonly found that treatments for localized prostate cancer do not affect overall quality of life on average across the treatment groups, men who experience side-effects of erectile dysfunction or urinary incontinence have higher levels of impact on physical and mental health, particularly anxiety and depression, than men without these side effects. Men undergoing treatment need to be aware of these symptoms and their potential impact, and may need additional support when they experience them.

Hypothesis / aims of study Physical and mental health, urinary symptoms and erectile function of men with a newly diagnosed prostate cancer (PCa) are determinant for the clinical outcomes after radical treatment. Aim of present study is to evaluate in a large cohort of consecutive patients the general health and the cancer-specific QoL at the time of the diagnosis of PCa.

The quality of life (QoL) of the enrolled patients was assessed by SF-12 (PCS=Physical Component Summary and MCS=Mental Component Summary) and UCLA-PCI (UF,UB=Urinary Function/Bother; SF,SB=Sexual Function/Bother; BF,BB=Bowel Function/Bother). The differences between subjects enrolled in urologic centers [URO] and radiatherapic and oncology centers [RO] were evaluated through the Generalized Linear Model procedure on the ranked data, adjusting for age at diagnosis. Spearman's rho non-parametric correlation coefficients between symptoms and bother were also calculated. We reported a strong or moderate correlation between UF-UB (a) and BF-BB (b) in both URO and RO populations (0.5≤rho≤0.63), while we found remarkable differences between SF-SB (c) in the subgroup of RO men (rho=0.38, indicating a weak correlation, see figure) .

Concluding message Pros-IT CNR is a multicenter, observational, prospective cohort study on PCa in Italy. The preliminary data, regarding the QoL at time of diagnosis underline the remarkable differences between men enrolled in URO vs. RO centers, in particular, regarding mental health and sexual activity. 

Hypothesis / aims of study Urinary incontinence is a common, complex problem that affects women of all ages and affects the quality of life of women. The quality of life can be defined as the perception of the state of life in terms of the system of cultural values in which the individual lives and their own expectations (1). It was reported that mixed urinary incontinence type affected quality of life of women the most (2). This study was planned to investigate the effect of urine leakage amount on the perceived dryness sensation and quality of life in women with mixed urinary incontinence.

Study design, materials and methods 268 women with mixed urinary incontinence symptom participated in the study. The women with mixed urinary incontinence who were older than 18 years of age and able to speak Turkish participated in the study. The women, who did not have cooperation and did not have an assessment form and had a mental problem, neurologic disorder and psychological illness and were pregnant, were excluded. The physical and socio-demographic features of the women were recorded. Women were classified as mild (1-10 gr), moderate (11-50 gr), and severe (50 gr and more) after the urinary leakage amount was determined by 1-hour pad test (3) . The perceived dryness sensation of the women was assessed by a 10-cm visual analogue scale (VAS), their incontinence severity was assessed by incontinence severity index (ISI) and their quality of life was assessed by quality of life specific to urinary incontinence (I-QOL). In the VAS assessment, women were asked to mark the severity of the perceived dryness sensation on a line. The left side of the line means I feel dry, while the right side of the line means that the severity has increased and at the far right I have been feeling constantly wet. Whether the numerical properties in each group showed normal distribution was assessed by Kolmogorov Smirnov test. Kruskal-Wallis test and post hoc Dunn test were used for comparisons. The statistical significance level was accepted as p≤0.05 and SPSS version 20-demo program was used for estimations.

It was found that the difference between the average age of the women classified according to the pad test and that this difference was caused by women with mild to moderate urinary incontinence (p=0.02). The comparison of the incontinence severity showed that there was a difference between the mild and moderate and the mild and severe incontinence (p≤0.05). Considering the perceived dryness sensation and quality of life of the women, it was found that there was a difference according to classification and that this difference was between mild to severe and moderate to severe (p<0.001) ( Table 1) . Interpretation of results Although women with mild to moderate urinary incontinence had a significant difference in severity of incontinence, the perceived dryness sensation and quality of life were similar.

Concluding message There may be many social and cultural reasons underlying women's mild urinary incontinence being affected as much as women with moderate urinary incontinence. It was seen that the majority of the women who participated in the study attempted to stay dry in order to fulfill their religious obligations based on our clinic experiences despite their results could not be shown objectively.

There is a requirement that an ablution must be performed in order to pray in Muslim societies. Since urinary incontinence is one of the conditions spoiling ablution, we think that the obligation to stay dry for worshiping affected the quality of life and perceived dryness sensation of the women negatively.

Hypothesis / aims of study Up to 55% of women living in the community experience urinary incontinence (UI). Of these, 20 to 25% have severe symptoms (>10 episodes/week). UI is a serious medical condition with significant negative impacts on overall quality of life. While most older women want to maintain social contact with family and friends, UI can compromise physical activity and functional independence, restrict social functioning and induce elevated levels of anxiety and stress. One factor that can influence the experience of UI is the stigma associated with diagnosis and symptoms. Individuals are stigmatized when they possess, or are thought to possess, an attribute or characteristic that conveys a social identity that is devalued in a particular social context. Some individuals direct prejudicial attitudes inward, a phenomenon known as selfstigmatization. In Western societies, the elimination of bodily waste is a private matter that is done in a tidy way. Failure to do so risks being perceived as 'different'. The onset of UI is often accompanied by embarrassment, elevated stress, and shame. It is common for individuals with UI to withdraw from social activities due to self-stigmatization [1] . A recent meta-analysis demonstrated that social disconnectedness in seniors is as detrimental to health and predictive of mortality risk as obesity and lack of physical activity [2] . Some have suggested that the incorporation of support from peers with similar health issues might be a way to better address the rehabilitation needs of clients and to diminish the self-stigma associated with age-related health conditions. Some of the key functions of peer support are: (a) assistance in daily management of health conditions, (b) social and emotional support, and (c) providing continued support over time as the condition changes. The purpose of this study was to assess how peer support for older women with UI might influence the self-stigma associated with UI and self-management of the condition. This could inform how current interventions might be adapted in order to prevent social disconnection among seniors with UI.

To understand the stigma associated with UI in older women and the influences of peer support, we conducted 8 semi-structured qualitative interviews, with a subset of women who participated in a 12-week group Pelvic Floor Muscle Training (PFMT) program for UI. The PFMT program was delivered to groups of eight participants in a weekly 60-min exercise class by an experienced physiotherapist. All participants in the study were aware that their peers shared the same condition. Each session included a tenminute education period, a 30-minute session of PFMT in different static positions such as lying, sitting, four-point kneeling and standing feet apart and a 20-minute dynamic PFMT (dance). Participants were also given a PFMT to do at home, 5 days per week. To be included in the present study, women had to: be aged 60 or older; present symptoms of stress or mixed UI; have completed the 12-week group PFMT and have consented to an individual interview. Women were excluded from the project if they had a cognitive or communication condition that made it impossible to participate in interviews. A trained interviewer with knowledge of UI and stigma conducted the interviews. All sessions were audio recorded and transcripts of the sessions were analyzed using content analysis [3] .

The women interviewed were aged 60 to 77 years old (68 ± 5.26 years) they had been living with mixed UI for the last 2 to 36 years (11.13 ± 13.04 years). Before the PFMT, the average number of urine loss episodes on a 7-day urinary diary was 20.50 ± 28,47 episodes per week and the self-diagnosed severity through the ICIQ-UI SF questionnaire ranged from 7 to 16 (11.75 ± 3.99). Participants described UI as a social problem. They stated that others see UI as a taboo subject, endorsing stereotypes that describe UI as dirty, abnormal, a female issue and an aging issue. Participants reported that the stigma surrounding UI is hard to break and they thought that UI is a subject that should be openly discussed. Overall, the 12-week PFMT provided the participants with 1) indirect peer-support, 2) direct peer-support that helped in daily management of UI and 3) the opportunity to disclose UI (within the group and outside of it). 1) Indirect peer-support: Knowing the other participants had UI removed the need to explain/discuss UI and may have reduced efforts to conceal the condition. Whether they use the support or not, knowing that peer support is available is comforting. Simply being in the class with peers provided women with the opportunity for social and emotional support. Participants indicated that they no longer felt alone with this condition, and felt a sense of belonging with other group members. Additionally, within the group the stereotypes associated with UI (e.g.people with UI are dirty) were demystified and not perpetuated. Rather, group members described one another as "pretty, dynamic and intelligent women".

2) Direct peer-support: The group provided the opportunity to talk about UI and gave the occasion to learn from common experiences. Participants appreciated sharing self-management strategies, tips and tricks that might not have been addressed if they were not in a group of their peers. In some cases, comparing oneself to others (i.e., condition severity) fostered empathy for others which could lead to compassion for self. For certain individuals, these comparisons made them realize that UI has varying levels of severity and that their problem may not be the worst, leading to diminished self-stigma and improved self-image.

3) Opportunity to disclose: Directly addressing UI in a group setting facilitated disclosing information about diagnosis and symptoms within the group and outside of the group. Disclosing within the group was described as less threatening since all the participants were in attendance for the same reason. Likewise, group members referred to being empowered by other participants and be more prepared to share and discuss UI outside of the group.

We are cautiously encouraged by these findings. Our data analyses support the notion that peer interactions may provide social and emotional support to older women with UI, which may diminish self-stigmatization and help improve self-management strategies. It may be reasonable to think that these types of psychosocial benefits could serve to prevent social disconnection among community dwelling women. Nevertheless, it is prudent to state that these are preliminary findings and this study is ongoing.

Our study suggests that direct and indirect peer support from group training can influence the decision to disclose UI, and may aid in reducing self-stigma and in improving self-management. Peer interactions may help diminish self-stigma by giving opportunities for social and emotional support, providing assistance in daily management of UI and support during group rehabilitation. Support outside the group may carry forward over time.

Navas J 1 , Amaya S 2 , Yazdany T 1

Hypothesis / aims of study To determine the effect of a decisional aid on patients' decisional conflict, self-efficacy, satisfaction and regret when choosing between treatment options for stress urinary incontinence (SUI) in an underserved, diverse hospital setting.

Study design, materials and methods Our IRB-approved, randomized-controlled trial included women presenting with SUI to a urogynecology clinic from July 2016 to November 2016. Patients who agreed to participate after receiving informed consent, were randomized to standard consultation (SC) or standard consultation with decision aid (DA) for SUI. The decision aid is based on the International Patient Decision Aid Standards Collaboration, which is available at https://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOCHWID=aa137467. Participants completed the decisional conflict scale (DCS-16), decision self-efficacy scale (DSES), and satisfaction with decision scale for pelvic floor disorders (SDS-PFD) upon completion of the initial visit. During the follow-up visit, participants completed the decision regret scale for pelvic floor disorders (DRS-PFD). The primary outcome evaluated was decisional conflict with treatment decisionmaking. With a sample size of 40 per group, we anticipated that we will achieve about 80% statistical power to detect the effect size 0.6 as found in Causarano et al [1] in decisional conflict score using a two-sample t-test with a level of significance of 0.05. Considering a 25% dropout rate, the projected final sample size was 30 per group (total of 60) in the beginning of the study. Statistical analysis was conducted with SPSS v.22.

Of the 120 women who presented with lower urinary tract symptoms, 78 women presented with SUI. Of these 78 women, 69 met eligibility, agreed to participate and were enrolled and randomized to either standard consultation (SC, n=35) or standard consultation with decision aid (DA, n=34). The majority of participants were Spanish speaking (74%) with a mean age of 51.3 years (+/-8.6), a mean BMI of 31.8 (+/-6), a mean of 8 years (+/-4.7) of education, and a mean monthly income of $1614 (+/-1361). Of the 69 women, 38 (54%) chose behavioral therapy, 9 (12.9%) chose pessary, and 22 (31.4%) chose surgery. The use of a decision aid did not significantly improve decisional conflict, self-confidence in decision making, or decision satisfaction (p=.957, p=.405, p=.838, respectively), with both groups having low decisional conflict (SC 13.88, DA 13.73), high self-confidence in decision making (SC 87.40, DA 90.77), and high decision satisfaction (SC 4.59, DA 4.56). The use of a decision aid also did not improve decisional regret (p=.502) or impact treatment decision for Kegel's, pessary or surgery (p=.825, p=.825, p=.575, respectively).

The inclusion of a decision aid into a standard consultation for women with stress urinary incontinence did not significantly improve decisional conflict, self-confidence in decision-making, decisional satisfaction or decisional regret. It also did not impact treatment decision for stress urinary incontinence. Of note, our study population was predominantly underserved with low-income and minimal educational background. These socioeconomic factors may play a role when counseling women with SUI unaffected by a decision aid. Hence, standard consultation suffices when counseling women with SUI, even in diverse, underserved populations with varying health literacy.

The addition of a decision aid did not significantly impact decision making, including shared decision making, or the treatment of choice for women with SUI in our diverse, underserved population. 

Hypothesis / aims of study Anxiety and depression are associated factors to urinary incontinence (UI) in women, with strongest association for urgency component of UI and for severe UI. (1, 2) There is also some evidence for co-occurance between some psychotropic drugs and UI (2) , but this has not been investigated in large epidemiological studies. The aims of this study were: 1) to investigate the mentioned associations in a large population-based servey and compare the strength of these associations with the well-known UI-risk factors parity and BMI, and 2) to investigate the association between use of psychotropic medication and urinary incontinence for the possible confounder of anxiety and depression.

The HUNT2-study is a large population-based servey performed in the county of Nord-Trøndelag in Norway in the period 1995-97. All women aged 20 years or more who could come to a screening station could participate. EPINCONT is a questionnairebased substudy of the HUNT2-study, including those 27992 women who answered the UI-questions. A multivariate logistic regression model was used to predict the adjusted odds of having high levels of anxiety and depression, using psychotropic medicines, having high BMI and having given birth among women with UI compared with women without UI. UI was defined as any leakage of urine. Anxiety and depression was defined with a score of 8 or more on the Hospital Anxiety and Depression Scale (HADS). Using medicine was defined as answering yes on the question if the person had used the specific psychotropic drug during the last 12 months.

The response rate for the EPINCONT-part of the HUNT2-study was 80%.The mean age was 49 years. 25% met the criteria for UI. Of these, almost half had stress UI, about 11% had urgency UI, 25% had severe UI and a third moderate UI. About 10% had ≥8 on the depression-score and 17% had ≥8 on the anxiety-score. 4% used anti-depressive medication. Anxiety and depression was associated with UI with adjusted ORs of 1.42 (95% CI 1.31-1.54) and 1.45 (95% CI 1.32-1.60), respectively, BMI ≥30 with OR 2.11 (95% CI 1.95-2.29) and having given birth to more than two children with OR 1.87 (95% CI 1.67-2.09). Use of antidepressants was associated with UI with adjusted OR 1.37 (95% CI1.20-1.57). Unspecified use of analgesics was associated with UI with OR 1.36 (95% CI 1.24-1.49). We did not find any association between use of sedatives and sleep medicine and having UI (data not shown).

In this large epidemiologic study, anxiety and depression was significantly associated with UI, but weaker than the established risk factors BMI ≥30 and parity. Use of antidepressants is associated with UI, also after adjusting for depression and anxiety as possible confounders.

Concluding message Use of antidepressants seems to be associated with UI. The association is of great interest and importance for clinical practice, and needs to be investigated with more reliable medication data. 

Hypothesis / aims of study Overactive Bladder (OAB) and Urinary Incontinence (UI) occur about twice as frequently in women as in men and become more prevalent with advancing age. Stress incontinence is more common in younger women, whereas mixed and urge incontinence is more common in older females. The constant provision of care in elderly incontinent females is an extremely exhausting process. For the caregiver, it often leads to increased psychiatric morbidity (depression), a loss of "self", social isolation and limitations in their personal relationships. The high levels of burden observed among caregivers make them ineffective in their work, expediting the transfer of their patients to long-term care institutions [1] . This is one of the few studies, evaluating the impact of mirabegron's treatment on the degree of burden experienced by the caregivers of elderly patients with incontinence.

Study design, materials and methods Two hundred and thirty caregivers of elderly females with incontinence were included in the study and were divided into three groups. Group A included 95 caregivers of elderly patients with various conditions (strokes, Parkinson's disease, post-operative recovery after major surgery, dementia, etc.) who did not present urinary incontinence. Group B consisted of 73 caregivers of elderly patients who presented urinary incontinence, in addition to the forementioned conditions. In this group, elderly females were treated with mirabegron 50 mg/daily. Group C, consisted of 62 caregivers of incontinent elderly patients. The patients did not wish to receive any treatment. All caregivers were evaluated with the Zarit Burden Scale (ZBS), both at the beginning and end of the study three months later. ZBS is a brief, valid and reliable method for assessing the burden experienced by those caring for a family member suffering from chronic diseases [2] . Higher scores are indicative of a greater burden on the caregiver, with a maximum of 88. Ethical approval was obtained by the Institutional Ethical Committee. Informed consent was taken by all patients and their caregivers. A probability P<0.05 was considered to be statistically significant.

Results Table 1 shows the distribution of the individual scales and of the overall caregiver burden scale in all groups, at the beginning of study. Table 2 represents the overall caregiver burden scale after 3 months observation. At the end of the study, a significant percentage of caregivers who experienced a "severe burden" (corresponding to a score of 61-88 on the Zarit scale) were noted in Group C. Thus, while the rates are 25% in Group A and 28% in Group B, in Group C this reached 37%. In practice, it means that 1 out of 3 caregivers of elderly incontinent patients experience a severe burden. Table 2 : Distribution of the scales and of the overall ZBS at the end of the observation

At the end of the study, Group B demonstrated slightly higher rates on the Zarit scale in relation to the caregivers in Group A and a statistically significant decrease in total score (p<0,05). Mirabegron treatment in Group B resulted in a reduction of incontinence episodes and number of pads needed. In Group C, the increased total score depends on the presence of incontinence. The elderly with incontinence require constant cleaning and this makes it necessary for caregiver to be with the patient all day long. The high rate of caregivers with a "severe burden" in Group C indicates the synergistic effect of incontinence with other factors creating a burden for caregivers.

Results of the study demonstrate that caring for a patient with incontinence is associated with an increased burden for caregivers. It also shows that incontinence is one of the factors that could predict burden, which means that incontinence treatment with a daily dose of mirabegron 50 mg represents a way to alleviate the burden of the caregivers of incontinent female patients.

Hypothesis / aims of study This innovative clinical trial enrolled adult women, > 55 years from diverse backgrounds who reported stress, urgency, or mixed urinary incontinence (UI) and who had never been treated for UI. The study aim was to compare the effectiveness of a novel group-administered behavioral treatment class, the Group Behavioral Treatment (GBT), to no treatment.

Study design, materials and methods A multi-site, prospective randomized, controlled trial to assess the efficacy of a face-to-face 2-hour GBT compared to a no care control. A reactive mass mailing recruitment was used, with enriched sampling for representation to achieve oversampling in urban and African American communities through zip code indicators for each study site. Mailings were sent to communitydwelling adult women 55 years and older. Responders were screened centrally for incontinence frequency and severity and to insure that potential participants were naïve to UI treatment. Potentially eligible women were referred to their local clinical sites for screening and random assigned to one of two treatment arms: 1) Group Behavioral Treatment or 2) No treatment. Inclusion/exclusion criteria included women 55 years and older, International Consultation on Incontinence Questionnaire (ICIQ UI-SF), score of at least 3 (1 for frequency, 2 for severity), report of UI for at least 3-months duration, no prior UI treatment, no symptomatic prolapse, and no previous bladder surgery or pelvic cancer. Primary outcome: ICIQ UI-SF. Secondary outcomes: 3day voiding diary, paper towel test, 24-hr pad weight, Brink test, Incontinence Quality of Life Questionnaire (I-QOL) and Patient Global Impression of Improvement (PGI-I). GBT group received a one-time 2-hour bladder health class whereas the control group received no treatment. Both received a behavioral education brochure, were monitored every 3 months for 12-months with clinic visits at 3 & 12 months and mailed questionnaires at 6 & 9 months.

This study was able to recruit 463 women with a mean age of 64+/-7.3 years, age range 55 to 91 years, mean BMI >30 in 52%, 46% African American; 1% Hispanic; 13% high school education or less, 30% employed full time. 232 subjects were randomized to GBT and 231 to no treatment control; 34 withdrew (GBT=22 & Control =12). Demographics were not significantly different between groups. Outcomes at 3, 6, 9 & 12 months showed significant differences in favor of GBT over control including ICIQ-UI SF (p<0.0001) ( 

This novel group learning intervention safely and effectively reduced incontinence frequency, severity, and bother, while improving incontinence-related quality of life as measured by multiple validated instruments. Improvement was maintained for 12 months after the 2-hour, one time intervention. Behavioral interventions are recommended in most treatment guidelines as first line therapy for UI. The study recruitment methodology of mailed letters with a toll-free response telephone number was able to yield a group of treatment-naïve older adult women who were very accepting of a group behavioral intervention. The potential of using a group learning intervention as an initial treatment strategy for adult women with urinary incontinence may be less-costly for this very burdensome condition that affects 1 in 3 older women.

Concluding message This bladder health education program delivered in a group setting was safe and effective in reducing UI frequency, severity and bother and improving quality of life for community-dwelling older adult women with UI. This easily scaled intervention increases opportunity to reach larger populations beyond medical practices and into community settings. 

Hypothesis / aims of study Continence problems affect one in two women over 65 but only a minority either seek care or implement evidence-based conservative, pharmaceutical or surgical treatments [1] . Many believe that incontinence is a normal part of ageing and fail to realize that simple treatments and self-help improve urinary symptoms.

The CACTUS-D trial aimed to test the effectiveness of an integrated, evidence-based continence promotion intervention on urinary symptom improvement, quality of life, and care seeking among community-dwelling women aged 65 years and older suffering from incontinence in France, the UK, and Canada [2] . We hypothesized that women exposed to a community-based continence promotion intervention would experience improvements in urinary symptoms and incontinence-related quality of life, more frequently compared to women who were exposed to a general health information workshop. We planned to monitor the demand for care (GP visit and hospitalization).

Study design, materials and methods CACTUS-D was an open-label cluster randomised controlled trial conducted across Canada, the UK, and France. Communitydwelling women were recruited via community groups (lunch clubs, older people's groups, women's institutes, church groups, etc.) or health insurance databases. Women were eligible if they were aged 65 years or older, reported urinary leakage of at least 2 times a week and were not treated for urinary incontinence in the previous year. The experimental intervention was an integrated evidence-based continence promotion workshop that used constructivist learning and behaviour change techniques to encourage women with incontinence to initiate evidence-based self-management. The control was a general health information workshop that mentioned the prevalence of incontinence, but did not direct participants towards self-management options. Each community group (cluster) was randomized 1:1 with blinded group allocation to receive either the control or experimental intervention. The workshop (intervention or control) was delivered to groups of 6-30 women as a single 45-minute interactive session. Women were asked to fill in a questionnaire covering risk factors and continence status prior to the workshop. Participants in the intervention group received a self-management booklet. Within one week of the workshop participants were phoned by a research assistant, blinded to the intervention, for a more detailed follow-up. Participants were contacted at three and six months after the workshop. Self-reported improvements in incontinence were measured with the Global Impression of Improvement questionnaire. Urinary symptoms were measured with the ICIQ-FLUTS questionnaire (F-score for OAB symptoms and I-score for urinary incontinence symptoms). Urinary specific quality of life at all time points was measured with the I-QOL. Healthcare resource use (hospitalisation, treatment consultation) as well as falls were measured by self-report. 

The self-management tools delivered during the promotion workshop may explain that more women in the intervention group reported an impression of improvement despite no significant difference on symptoms.

Concluding message A single continence promotion intervention delivered to groups of older women significantly induced an impression of improvement. There was no difference between the continence promotion and general health workshop's effect on urinary incontinence severity.

Hypothesis / aims of study Pelvic floor disorders can significantly affect a woman's quality of life, yet many women feel uncomfortable openly discussing these topics. Treatments include lifestyle modification, pelvic floor exercises/physiotherapy, medications, and/or surgery. "Decisional conflict" arises when patients have difficulty choosing between several viable treatment options (1) . Factors contributing to decisional conflict include biased information, poor peer support, and unaddressed fears. Effective counselling may help address these factors.

The primary objective of this pilot study was to assess the impact of a small-group workshop about pelvic floor disorders (urinary incontinence (UI), or pelvic organ prolapse (POP)) on decisional conflict regarding treatment options. The primary outcome was change in decisional conflict between baseline and follow up. The secondary outcome was to assess patient satisfaction with the quality of information shared during the workshop, comfort with discussing pelvic health in a group setting, and the perceived benefits of a nurse continence advisor and psychologist.

We hypothesized that women attending an educational and motivational interviewing workshop on pelvic floor disorders would have a greater improvement in decisional conflict than those who received the usual counselling with their gynecologist.

Study design, materials and methods This pilot study was a non-blinded, randomized control trial, conducted between April 2016 and May 2017 at a Canadian tertiary care hospital. Eighty women aged 18 years and over with urinary incontinence or pelvic organ prolapse were randomized at the time of their first urogynecology consultation to "usual care" or a 90-minute workshop on either UI or POP, as chosen by the patient. Each workshop had 5-13 participants, and was led by a nurse continence advisor and a psychologist. The first 15 minutes of the workshop comprised a nurse-led information session, while the last 75 minutes was a guided discussion by the psychologist. Usual care consisted of follow up with the gynaecologist three months after first consultation. Randomization was done using a computer-generated sequence in blocks of 1 or 2 using opaque, sequentially numbered envelopes, with group allocation revealed only at the time of randomization. Decisional conflict was measured using the validated Decisional Conflict Scale (DCS) questionnaire (1), administered at baseline and at a follow-up time-point, between 2 and 6 months later. Women in the workshop group completed their follow-up surveys at a separate time-point following the workshop. The DCS ranges from 0 to 100 (0=no decisional conflict; 100=high decisional conflict). The DCS contains sub-scores from 0 to 100, reflecting factors contributing to ineffective decision making: feeling uncertain, uninformed, unclear about values, and unsupported in decision-making. Analysis was done using an intention to treat model. Paired t-tests were used to compare mean DCS between baseline and follow up, two-sample t-tests were used to compare the mean change in DCS between baseline and follow up in each group. Chi-square tests were used to compare categorical data.

Women in the workshop group were asked to complete a survey following the workshop This survey consisted of 15 questions on a Likert scale assessing their satisfaction with the information session, the group discussion, and the overall workshop. They were also invited to submit written comments.

Women meeting eligibility criteria (n=80) were randomized to attend the workshop (n=38) or to usual care (n=40). Two women in the workshop group were later found to meet exclusion criteria. Nine women randomized to the workshop group did not attend. An interim intention-to-treat analysis was performed (n=28 workshop, n=24 usual care). At the time of submission, follow up surveys are outstanding for 10 women in the workshop group and 16 women in the control group. Workshop surveys demonstrated that 90% of women agreed or strongly agreed that the workshop was beneficial and 97% agreed or strongly agreed that they felt comfortable discussing the topics in a group setting. Thirty-one percent agreed or strongly agreed that they would prefer to discuss these issues "alone with my doctor", while 76% felt the discussion brought out "feelings [they] may not have discussed with their doctor".

These interim data suggest that, in this population of predominantly Caucasian, married, post-secondarily-educated women aged 35-83 years, decisional conflict surrounding treatment options for pelvic floor disorders is reduced after participation in a 90minute group workshop. comprising a brief educational session on pelvic floor disorders followed by a psychologist-led group discussion. The workshop was perceived by most participants to be beneficial, and most felt comfortable with group discussion. The workshop was a forum for participants to discuss feelings and ideas that they may not have been comfortable discussing with their physician.

Concluding message Among women with pelvic floor disorders, decisional conflict is reduced after attending a workshop led by a nurse continence advisor and psychologist. This workshop format, which provides information and addresses factors influencing treatment decisions, is acceptable to patients and provides a non-threatening forum for women to discuss concerns regarding pelvic floor disorders and available treatment options. To our knowledge this is the first study to show the impact of an interdisciplinary, patient-centred workshop, on reducing decisional conflict in women with pelvic floor disorders.

Dufour S 1 , Bernard S 2 , Murray-Davis B 1 , Graham N 1

Hypothesis / aims of study: Pregnancy-related diastasis rectus abdominis (DRA) is a highly prevalent condition in women during the perinatal period. It is estimated that 32 % to 53 % of women present with a persistent DRA at 1-year post-delivery (1). To date, knowledge remains limited on risk factors or long-term sequelae of a widened linea alba (LA) in postpartum women, but many suggest implications for trunk control and pelvic floor support function (2, 3) . Current evidence is conflicting regarding the conservative management of DRA, which presently creates much debate amongst health care providers and women seeking care. Practitioners working with pregnant women would benefit from greater understanding of how to prevent and care conservatively for this condition. Given that what presently constitutes the best approaches to this condition needs further research to support them, we sought to bring together key stakeholders regarding this condition to develop a set of consensus-based practice principles for the conservative management of pregnancy-related DRA. The main objective of this 3-Phases study is to establish a set of practice principles to support a cohesive evidence-informed approach to DRA that can be used across disciplines. The specific aim of Phase 1 was to develop a preliminary set of consensus-based statements regarding the conservative management of pregnancy-related DRA.

Study design, materials and methods This study followed Delphi consensus methodology and was informed by the Knowledge to Action (K2A) framework for knowledge translation. The Delphi process commenced with a comprehensive literature review. Following Ethics approval, an expert panel (n=28) was purposively assembled and invited to participate in this study. Experts were identified nationally as credentialed clinical specialists from different backgrounds and with varied experience in women's health, or determined as qualified experts from their academic and research accomplishments, to ensure the requisite diversity and expertise of the panel. All participants provided informed consent before enrollment in the study. For this initial phase, participants were invited to answer an online survey where their perspectives on various topics related to DRA were collected. A total of 82 questions related to prevention, management and assessment of DRA through the different phases of the perinatal period composed the survey. Participants had to answer each question using a 5-point scale to indicate their agreement with the statement (1=Strongly disagree to 5=Strongly agree). For the analyses, it was considered that a participant agreed with a statement if a ''4'' (agree) or a ''5'' (strongly agree) was answered. Simple proportion analysis was calculated for each statement, and consensus was established when there was at least 75% of agreement between respondents. For the upcoming Phase 2 and 3 of this study, a practice principle will be derived from the statements reaching consensus, and will be defined as an actionable item that a health care professional could enact. If less than 55 % of agreement was found between the experts, disagreement was considered for these statements and will not be included in the subsequent Phases (2 and 3) of the study.

For Phase 1, 21 out of the 28 invited experts participated and completed the survey (participation rate = 75 %). Preliminary analysis show that the answers from the participants generated 38 consensus-statements, 20 of which a high percentage of agreement was achieved and presented in Table 1 . Preliminary results also highlight lack of agreement (less than 55% agreement) between experts on 4 statements from the survey, most of which corroborate perspectives of statements which achieved consensus (see Table 1 ). The remaining statements of the survey have yet to generate agreement or disagreement from the participants, and will be explored further during Phase 2 of the consensus process.

To our knowledge, this is the first study to establish consensus across key stakeholders to bridge the gap in both evidence and clinical practice approaches regarding pregnancy-related DRA. Findings from Phase 1 determined 38 practice statements that achieved consensus between experts, with 20 statements achieving high percentage of agreement. Further, answers to Phase 1 of this study show that there is agreement amongst experts that the tissue of the LA is intrinsic to the thoraco-pelvic abdominal manometric system. As such, they agree that compromised integrity of the LA after pregnancy needs to be considered within the context of this system when assessing and intervening for this condition. These statements will be further developed and prioritized in the next two Phases of this study to form a final list of practice principles will be both evidence-informed, and deemed to be feasible and usable. As some of these principles will corroborate with the scientific literature, and some will not, our findings will help point out important practice gaps that will require further study. The 40 statements that required further exploration in Phase 2 are also of interest, as they highlight the need for further exploration to increase understanding of these phenomenon.

As nationally recognized experts in women's health, the participants in Phase 1 of this study agree that the impairments and dysfunctions related to DRA are multi-dimensional and multifactorial. The consensus-statements established during Phase 1 of this study emphasize the need for a global care approach when addressing DRA. From Phase 1 and its subsequent phases, it is hoped that the results of this study will facilitate the development of further research and to enhance care regarding pregnancyrelated DRA. 

Avoid exercises that concentrically engage the superficial abdominal muscles. 83.2 Facilitate optimal co-activation of the inner unit muscles during exercises.

Promote effective tension-free diaphragmatic breathing.

82.2 Emphasize postures that reduce excessive sustained intra-abdominal pressure. 90.6 Encourage optimal elimination habits to reduce straining.

Avoid exercises that concentrically engage the superficial abdominal muscles. 83.2 Avoid front loaded exercises (planks, push-ups).

76.8 Avoid exercises in which continence mechanism is not maintained.

94.8 Avoid high impact exercise.

86.4 Facilitate optimal co-activation of the inner unit muscles during exercises.

87.4

Avoid exercises that cause doming or invagination of the LA. 93.6 Introduce front loaded exercises if tension through the LA is maintained.

90.0 Avoid exercises in which continence mechanism is not maintained.

87.8 Progress core training if appropriate tension through the LA is achieved.

90.0 Address contributing pelvic girdle and thoracic movement impairments.

Statements related to the assessment of DRA Palpate for depth and quality of tissue integrity (LA) at rest. 76.6 Assess development of tension through the LA with voluntary pelvic floor and transverse abdominis co-contraction.

Ensure optimal pelvic floor contraction through a digital exam.

Assess for doming or invagination of LA during exercises.

A non-functional DRA is determined when tension of LA cannot be developed voluntarily.

Statements with a lack of agreement (less than 55%)

DRA does not appear to be related to the pelvic floor 38.4 The severity of DRA does not impact my approach 33.6 Emphasize "closing of the gap" via "Noble Technique" (head lift) 38.8 DRA is a cosmetic issue, not a functional issue 24.0

Study design, materials and methods This study was informed by a reference group of women who reported symptoms of urinary incontinence, but who had not sought help. This study is perhaps the first of its kind to collaborate with women experiencing undiagnosed urinary incontinence prior to the research design being finalised. Members of the reference group provided meaningful insight into living with urinary incontinence, and their use of pads. They assisted with development of the research design; piloted data collection tools; and provided feedback to the researcher.

The research comprised of two phases; a qualitative interview study and a Q study. Participants of the main study were selfselecting and a process of informed consent was undertaken prior to data collection. Potential participants responded to advertising, or as a result of 'snowballing' as knowledge of the study became more widespread. Based on data provided by the reference group, incontinence-related terminology was removed from participant documentation. Instead, socially acceptable terms were used; 'urine leakage' was used to describe urinary incontinence. Sampling criteria were purposefully broad, to ensure that women who identified as experiencing 'urine leakage' could participate (irrespective of clinically relevant measures which may ordinarily be used during sampling).

Eleven semi-structured interviews were conducted; the data from these informed the Q study. Q Methodology objectively measures subjective attitudes [1] . Q Methodology lends itself well to incontinence research as it does not require participants to explain their experience, overcoming potential barriers to engagement. Instead, predefined statements (the Q set) are provided to participants during data collection, which is known as the Q sort.

Participants were given a condition of instruction; they then ranked forty-three statements based on their own experience. Each statement card was placed on a quasi-normal distribution curve, by level of agreement. Secondary data was collected in a booklet. Twenty women participated in the Q study after pilot testing.

Rotated factor analysis was conducted using PQ Method software [2] . Interpretation of results was inductive, using the secondary data collected. Results were verified by a second researcher. Where there was uncertainty about interpretation, discussions were had until agreement could be reached.

The results use terms provided by the reference group, rather than ICS standardised terminology, to remain consistent with the data collected.

No participant was familiar with Q Methodology prior to participating in the study. All participants were able to undertake Q sorting after briefing. Nineteen participants chose to provide secondary data, one chose not to. All completed Q sorting successfully. Duration of data collection meetings was dependant on whether participants chose to verbalise information during Q sorting.

Characterised attitudes obtained through Q Methodology are known as factors. After analysis, five factors were identified. Factor 1 was typified by uncertainty about the leakage experienced and a lack of knowledge about how to cope with it effectively. The perceived attitudes of others (including healthcare professionals) affected behaviour and choices.

Factor 2 was typified by an ability to continue with life in spite of leakage. These women accepted the leakage they experienced and had little desire to change the situation, as the negative impact on their lives was minimal. Absorbent products were the key coping strategy in maintaining routine.

Factor 3 was typified by the need to strategize planning for leakage by taking a pragmatic approach. These participants were aware of help available but had confidence in their own ability to manage symptoms. They had busy lives and whilst leakage was a concern, other things took priority. They were conscious of others' potentially negative attitudes. Admitting leakage would not only have challenged their social identity but also their self-identity.

Factor 4 was typified by using absorbent products as a first-line defence strategy for a problem perceived to be the sole responsibility of the individual. Maintaining secrecy was paramount because of the embarrassment that surrounded the issue.

Factor 5 was typified by pads not meeting the needs of these women, who believed leakage was an expected part of ageing. They wanted product innovation and were prepared to pay for it. They had good social and emotional support to deal with leakage. They would have liked products to improve their daily experience, as they had uncertainty about the value of accessing healthcare for leakage-specific intervention.

Interpretation of results Five attitudes were characterised through the Q study. Factor 1 -Hidden Uncertainty; 2 -Carry on Regardless; and 3 -Pragmatic Confidence prioritised the individual.

Factor 4 -First-line Defence and 5 -Limited by Products prioritised pads as a coping strategy. Both factors 4 and 5 assumed that UI was a normal ageing process.

Women's attitudes towards urinary incontinence and pad use can be successfully characterised. This small study suggests that women who consider urinary incontinence to be a normal part of ageing may be more likely to prioritise pad use, than those who do not.

The results also suggest that there are opportunities for development of interventions which support women with differing attitudes. As attitudes to healthcare varied, there may be particular benefit in developing self-management interventions, which could be accessed outside of traditional healthcare settings. There is also opportunity to develop new products which would meet the lifestyle needs of these women.

Working with women to design UI research increased engagement with the study, by removing barriers which may have affected participation.

The attitudes of women experiencing urinary incontinence are varied, and may affect help-seeking behaviours. There may be opportunity for new interventions and products to be designed which take attitude type into account, recognising the nuances in women's experience and coping strategies.

Q Methodology is a suitable method to use to elicit attitudes about urinary incontinence because the method of data collection enables participants to maintain a level of secrecy. This is particularly useful when working with those who have not sought help.

Hypothesis / aims of study Many authors have compared the incidence of urinary incontinence (UI) and other pelvic floor dysfunctions in sportswomen and non-sportswomen. To date, however, there is a lack of studies investigating the impact of UI as a risk factor for various aspects of quality of life (QoL) among sportswomen in relation to high-intensity physical activity. The aim of this study was to compare the intensity of physical activity in sportswomen and non-sportswomen using the IPAQ questionnaire, measured in metabolic equivalent of task (MET)-min/wk, and to determine the prevalence of symptoms of stress urinary incontinence (SUI) according to the calculated load, as well as to investigate the impact of UI on QoL.

The research population comprised a convenience sample of sportswomen and non-sportswomen (n = 537), paired by age and body mass index (BMI). The sportswomen were randomly selected from the National Register of Sports Clubs. Non-sportswomen were randomly selected from three universities. We determined the prevalence of SUI according to the following estimation: n = Z 2 P(1−P)/d 2 , where Z = 1.96 (95% level of confidence), P = 0.2 for expected UI prevalence of 20% and d = 0.05 (10% confidence interval [CI] width). Based on this calculation, the minimum number was set at n = 246 probands in each group. We used the International Consultation on Incontinence Questionnaire -Short Form (ICIQ-SF), the Overactive Bladder Questionnaire (OAB-q), the Incontinence Quality of Life (I-QOL) scale and the International Physical Activity Questionnaire (IPAQ, short version). The inclusion criteria were as follows: nulliparous women aged 18-35 years; in sportswomen, high-intensity physical activity confirmed by IPAQ (over 3000 MET-min/wk) in the last three months, performing sports at least three days a week for more than two years; in non-sportswomen, low-intensity physical activity confirmed by IPAQ (under 600 MET-min/wk) in the last three months.

The exclusion criteria were: sportswomen with handicaps, combinations of multiple sports, irregularity of sport performance, performing sport for less than two years, childbirth, surgical treatment of gynaecological and urological illnesses, infection of urinary tract, respiratory disease, incomplete questionnaires, refusal to participate in the study, BMI above 30 (BMI = m/h 2 , where m = body weight in kg, h = body height in m), urgent urine incontinence (UUI) according to the OAB-q.

The sample consisted of 270 sportswomen and 287 controls. The IPAQ results confirmed the high intensity of physical activity among sportswomen (over 3000 MET-min/wk) and low intensity in the control group (up to 600 MET-min/wk). The ICIQ-SF results confirmed mild difficulties with urine leakage in 33 (6.14%) sportswomen and in 11 controls (2.04%).The I-QOL recorded significantly worse parameters (total score and scores of 3 subscales: avoidance and limiting behaviour score, psychosocial impact score and social embarrassment score) in the group of sportswomen (p < .000). Odds ratio [OR] = 3.49 (p < .000), 95% CI (1.727-7.064). The results are summarized in Table 1 . Interpretation of results We evaluated the intensity of physical activity through the IPAQ in MET-min/wk. We found that in the high-intensity physical activity group, the risk of urine leakage was 2.49 times higher than in the low-intensity control group. Other authors have evaluated the intensity of physical activity in terms of its duration in years and the number of hours per week [1] . We used the IPAQ, which evaluates the cumulative metabolic equivalent of task (MET-min/wk). Concluding message Sportswomen (nulliparous) engaging in high-intensity physical activity according to the IPAQ (MET-min/wk) have a 2.49 times higher chance of developing SUI compared to non-sportswomen and this has a negative impact on QoL.

Walter M 1 , Ruiz-Romero I 1 , Krassioukov A 1

Hypothesis / aims of study Management of neurogenic lower urinary tract dysfunction (NLUTD) is among the highest of priorities for individuals with spinal cord injury (SCI). Among the various options presently available to facilitate bladder emptying in individuals who are unable to void spontaneously, clean intermittent catheterization (CIC) is considered to be the preferred management for preserving bladder function and reducing the risk of developing upper urinary tract damage and renal failure. Despite CIC's widespread acceptance in clinical practice, urinary tract infections (UTI) and hematuria still occur. Moreover, whether certain methods and types of catheters are more likely to cause urethral damage is unknown. This is a critical question as urethral damage resulting from catheterization can commonly lead to the development of urethral strictures and urinary tract infections, which furthermore can result in potentially life-threatening episodes of severe spikes in blood pressure known as autonomic dysreflexia. Despite this, there is little information available on the incidence, severity, and mechanism of urethral injuries related to catheter usage in adults. Furthermore, there is a paucity of data available on factors (e.g. type of catheter, behavioural, etc.) that predispose individuals who utilize CIC to urinary tract infections.

The main question of the study is to establish the incidence of urethral injuries and related complications in individuals with SCI using CIC.

Study design, materials and methods In this retrospective cross-sectional study, we utilized a questionnaire to collect desired information. This 30-item questionnaire, comprising multiple segments (three for females, four for males), provides information on a) demographics including the character of the SCI, b) questions from the assessment form 'lower urinary tract' of the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI), c) catheterization and complications, and d) history of urinary tract inflammation. Overall, 117 individuals with chronic SCI were enrolled in this study.

Data from 116 (including 13 females) participants, who completed the questionnaire, was analysed. Baseline characteristics are shown in table 1. While 84% (97, i.e. 10 females, 87 males, out of 116) of all participants performed CIC as their preferred method of bladder emptying, the remaining 16% (19/116) either were able to void spontaneously, used a condom or indwelling catheter, performed the Crede maneuver or a combination of different methods.

In individuals performing CIC, the overall incidence of urethral injuries was 28% (27/97, i.e. all males) -either during selfcatheterization (78%, 21/27) or CIC performed by others (22%, 6/27). Participants with urethral injuries were using either hydrophilic (37%, 10/27) a non-hydrophilic (33%, 9/27) or other catheter (30%, 8/27). As a result of an urethral injury, 5 participants (19%) had to convert from urethral CIC to other permanent methods of bladder emptying, i.e. suprapubic (n=2) or urethral Foley catheter (n=3). The incidence of UTI during the last 12 months was more than 60% (59/97, i.e. 6 females, 53 males) in this subpopulation. Of the affected participants, 24 (41%) were using a hydrophilic catheter, 20 (35%) a non-hydrophilic catheter, and 12 (24%) could not specify their catheter. The frequency of UTI during the last 12 months was as follows: once (41%), twice (32%), thrice (9%), 4 to 10 times (15%) or more (3%). Antibiotic treatment was applied in 80% (47/59) of all UTIs. Furthermore, 28% (24/87) of males using CIC reported about the history of inflammations from other lower urinary tract organs, i.e. testicles 23% (20/87), epididymis in 9% (8/87) and prostate 2% (2/87). Interpretation of results Our findings reveal a high incidence of urethral injuries and associated complications in individuals performing CIC following SCI.

This retrospective study provides evidence that urethral injuries and associated complications, i.e. UTI, and the need for conversion to other methods of bladder emptying, in individuals performing CIC following SCI are underrepresented in the current literature.

Potentially, prospective studies might determine whether continuous education of individuals living with SCI performing CIC can reduce urethral injuries and associated complications in the future. Hypothesis / aims of study The anatomy and function of the female pelvic floor provide optimal support for urinary bladder, urethra, uterus, rectum and intestines. It is well known that many different factors such as pregnancy, childbirth, age, body mass may affect the pelvic floor via a number of mechanisms. The intra-abdominal pressure increasing with BMI, tearing of the pubovaginal or rectovaginal fascia, damage of arcus tendineus fasciae pelvis or rectovaginal fascia connected with gravid uterus, engagement of the fetal head, and age may result in higher incidence of urinary incontinence connected with urethra hypermobility as well as with pelvic organ prolapse. Ultrasonography of the anterior perineal compartment seems to be a useful diagnostic tool in the assessment of urethrovesical junction and its mobility. The aim of the study was quantitative evaluation of bladder neck mobility in women and its connection to various demographic features.

It has been shown that hypermobility of the bladder neck is strongly associated with SUI and morphological changes in the bladder and bladder neck occurring during pregnancy have been visualised with different imaging techniques. Numbers of different parameters have been used to evaluate urethrovesical junction (UVJ) position and mobility, including the retrovesical angle (RVA) and the anterior angle between the UVJ and the pubic bone. The aim of the study was to assess ultrasonographic changes in the UVJ position in relation to lower edge of pubic symphysis in pelvic floor ultrasound examination and its correlations with different demographic features. Results Mean bladder neck position at relaxation, tension and at Valsalva maneuver are shown in Table 1 .

There was a statistically significant negative correlation between age, number of vaginal deliveries and bladder neck position during relaxation, tension and at Valsalva maneuver (Fig. 2, Fig. 3 ).

Mean urethral mobility (measured as the difference between the distance above lower edge of symphysis pubic at rest and the above distance during Valsalva maneuver) values are shown in Table 2 . Higher urethral mobility is positively associated with the number of vaginal deliveries, and among nulliparas it is significantly lower (p<0.001) (Fig. 4) . Age does not affect urethral mobility. 11.2 ± 7.0 Table 1 Bladder neck position during relaxation,tension of pelvic floor muscles and at Valsalva maneuver. 

Hypothesis / aims of study Nocturia is a bothersome symptom in lower urinary tract symptom. It is reported that lifestyle-related diseases, such as hypertension, diabetes mellitus, could influence nocturia in recent days. Japanese people in their lives consume more salt than most other countries people. We therefore examined the relationships between salt intake and nocturia or other factors.

Study design, materials and methods We recruited 167 patients at our hospital who complained of nocturia. We measured sodium and creatinine levels in spot urine specimens and calculated daily estimated salt intake (g/day) according to age, height, and body weight [1] . Frequency-volume chart (FVC) and International Prostatic Symptom Score (IPSS) were collected, and patients' sleep quality was evaluated using Pittsburgh Sleep Quality Index (PSQI). Past histories of hypertension, diabetes, hyperlipidemia, and other lifestyle-related diseases were noted. Blood pressure and heart rate were recorded, and blood samples were collected for evaluation of estimated glomerular filtration rate (eGFR,ml/min/1.73m 2 ).

Night-time frequency was not associated with salt intake (correlation coefficient (r)=−0.005, P=0.951) (Graph 1, Table 1 ). We also showed the associations between salt intake and FVC parameters including bladder capacity, nocturnal polyuria index, 24-hour voided volume, and PSQI global score (Table 1) . Salt intake was negatively associated with nocturnal polyuria (P<0.05), but its r value was relatively low (r=−0.184). None of the indivisual IPSS results were associated with salt intake. According to multiple regression analysis, night-time frequency was also not associated with salt intake ( Table 2) . Age was independently associated with night-time frequency. However, in stratified analysis, night-time frequency was positively associated with salt intake in case of heart rate≥80 beats per minute (r=0.314, P=0.032) (Graph 2). There was also a tendency towards a correlation in female aged≥75 years (r=0.325, P=0.140) (Graph 3).

Nocturia is considered to have multiple etiology and to be especially associated with lifestyle diseases, including so-called metabolic syndrome. We therefore hypothesized daily salt intake was associated with nocturia. However, our result was that unexpectedly night-time frequency was not associated with salt intake according to either simple or multiple regression.

In contrast, among the patients with a higher than average heart rate, we found a positive association between salt intake and night-time frequency. This result suggests that salt intake may activate the sympathetic nervous system, leading to an increased heart rate and possibly causing nocturia. In female aged over 75 years, there was also a tendency towards a positive association between salt intake and night-time frequency. Although exact mechanisms of these observations are unclear, there may be the association between salt intake and nocturia in specific groups of patients. Further studies are needed to seek out such patients who may benefit from interventions.

There were several limitations in our study. First, the number of patients was relatively small. Secondly, salt intake was only evaluated once, and the accuracy may have been improved if salt intake had been assessed on two or three occasions. Third, nocturia was the chief complaint in all the patients, and the inclusion of patients with other symptoms may have allowed an association between salt intake and nocturia to be detected.

Our results indicate that nocturia is not associated with salt intake among nocturia patients overall. However, there might be a relationship in specific groups of patients, such as those with a higher heart rate or elderly female. 

Hypothesis / aims of study Cancer in female urethral diverticulum is extremely rare. We have reviewed all patients having excision of urethral diverticulum to determine the incidence of urethral diverticulum cancer, mode of diagnosis, management and outcome.

Study design, materials and methods Pathological reports on all women having excision of urethral diverticulum between 2005-2016 were reviewed. All women had preoperative T2 pelvic MRI. Those patients with clinical (N=2) or MRI (N=3) suspicion of cancer had urgent TUR biopsies and/or transvaginal biopsies. All patients proceeded to excision of urethral diverticulum +/-Martius fat pad interposition. Further surgery for women with urethral diverticulum cancer was as determined by the urological cancer MDT and the patient.

Results 100 women of mean age 44 years (17-77) had excision of urethral diverticulum, 3 of whom (mean age 42 years (38-55) had cancer in their diverticulum. The commonest preoperative symptoms were urethral pain (3/3) and UTI (2/3). 2/3 were noted to be 'hard' on palpation and MRI was reported as suspicious but not diagnostic of cancer in 2/3. Transurethral and transvaginal biopsy was negative for cancer in all cases. Results for MRI, biopsy and definitive histology are detailed in table 1.

One patient had anterior exenteration and radiotherapy and is alive with metastases at 72 months, one patient declined further treatment and died at 23 months and one patient had radical urethrectomy and is alive at 6 months.

Urethral diverticulum often present with non specific symptoms. Urethral diverticulum cancer occurred in 3% of diverticulum and was adenocarcinoma in all cases.

Pre-operative biopsy is unhelpful in determining malignancy and MRI suspiscion does not appear to be diagnostic of cancer.

Concluding message All suspicious cases of urethral diverticulum should proceed to urgent diverticulum excision for definitive diagnosis. 

Hypothesis / aims of study Urethral stricture in females (FUS) has traditionally been managed with endoscopic treatment, with or without intermittent selfcatheterisation. Studies suggests this is effective in < 50% of cases. Furthermore, urethral pain can limit the ability of women to self-catheterise. Relatively high success rates at medium-term follow up has led to substitution urethroplasty becoming reasonably established as the gold-standard treatment. It is particularly indicated in women who have recurrent urethral stricture, refractory to endoscopic management and those who cannot self-catheterise. Various substitution urethroplasty procedures have been described in the literature and there is currently no consensus on the optimal technique.

To our knowledge, this is the first case series describing the medium-term outcomes of ventral-onlay buccal mucosa graft substitution urethroplasty (VOBMGSU) in treating FUS.

We reviewed a prospectively collated database of urethroplasties performed at our tertiary institution for women with urethral stricture. Data was collected on all woment who underwent VOBMGSU by a single surgeon since June 2012, and who had a minimum follow up of 6 months (median 21.5, range 6-51). Stricture was diagnosed on voiding video urodynamics as a Pdet.Qmax > 2.2Qmax + 5 as per the Solomon-Greenwell nomogram associated with evidence of urethral ballooning proximal to a portion of narrowed urethra. Women who couldn't void with pressure lines in-situ underwent cystourethroscopy. All stricture lengths were accepted.

22 women (median age 50 years; range 34-72) were identified. All women who underwent VOBMGSU had a BMI < 35 at the time of surgery and adequate fitness for general anaesthesia. All stricture lengths were accepted.

Data were analysed for stricture recurrence, change in median peak free flow rate (Qmax), median post-void residual volumes (PVR) and complications including SUI. Statistical analysis was performed with the Wilcoxon signed rank test, Students T-Test and Mann-Whitney U Test.

Cure was achieved in 21/22 (95%) women. Median Qmax significantly improved from 7 ml/s (range 3.5-11.2) to 18 ml/s (range 5-37) (p < 0.05). Median PVR significantly reduced from 100mls (range 0-300) to 15 mls (range 0-150) (p < 0.05). Short and longer-term complication rates were low. Other than the treatment failure there were no Clavien-Dindo complications > grade 1.

One patient developed mild de novo stress urinary incontinence, which settled with conservative measures by 6 months. Interpretation of results Staistically significant improvement in post-operative Qmax, with associated significant decrease in PVRs, at almost 2 years follow-up indicates, that in the medium-term at least, VOBMGSU is an effective treatment for urethral stricture. The one case of restricture involved a woman who had previously undergone simultaneous excision of a circumferential urethral diverticulum and 2 paraurethral cysts. We believe our low rate of de novo SUI, which was mild and self-limiting is due to our ventral stricturotomy technique preserving the urethral sphincter mechanism by incising only through the ventral deficiency.

Limitations of this study include small numbers and the medium length follow-up period. There is also a lack of patient reported outcomes.

Medium term results indicate that in appropriately skilled hands, VOBMGSU is an effective treatment for recurrent female urethral stricture refractory to endoscopic intervention, with a low complication rate and high rates of maintenance of continence, and can avoid the need for repeat procedures commonly necessary after traditional endoscopic management. Further evaluation with patient reported outcomes and longer term follow-up is planned. 

Between January 2015 and January 2017 ten patients who underwent one stage buccal mucosa graft urethroplasty for panurethral strictures were included in this study. All of patients were performed one stage double buccal mucosal graft urethroplasty with one side dissection of the urethra which was described by Kulkarni. Urethral catheter was removed 3 weeks after surgery. Patients' age, etiology of stricture, comorbidity, previous treatments, concomitant meatal stenosis, postoperative maximal flow rate (Q max), pre and post operative International Index of Erectile Function (IIEF-5) scores, per and postoperative complications and QOL questionnaire scores were noted.

The results were presented in Table- 1.

Panurethral stricture involves the full length of the urethra from meatus until the most proximal bulb. The incidence of panurethral strictures is increasing. The etiology of panurethral strictures may vary in industrialized and developing countries (1) . In developed countries, most urethral strictures in general have iatrogenic or idiopathic origin (2) . Iatrogenic causes include urethral catheterization, cystourethroscopy, transurethral resection, and previous urethral surgeries. Other causes include idiopathic, trauma, infection/inflammation, and lichen sclerosus. In the developing countries, the most common cause of panurethral stricture is genital lichen sclerosus (3). In our study the etiology of strictures were transurethral resection in 4 (%40) patients, urethral catheterization in 4 (%40) patients and idiopathic in 2 (%20) patients. The mean age was 50 (31-75). In the Kulkarni technique, the whole anterior urethra is repaired by a single perineal incision, single technique, and single substitute material. In a retrospective study including 117 patients with panurethral stricture disease treated mean stricture length was 14 cm and the overall success rate was 83.7% (3) . In our study we found mean stricture length 13.6 cm and %90 success rate. Most recurrent strictures occurred at the proximal anastomotic site and none of these was a full-length recurrence (3) . In our study recurrent stricture occurred in one (%10) patient and stricture site was on the proximal anastomotic site. Recurrent stricture was managed successful with direct visual urethrotomy. The major advantage of this technique is that it is minimally invasive and performed in one stage. It also avoids the psychological trauma of 2 (or more) operations and the need of living for 6 months with bifid scrotum after staged procedures (3) . In our study patients had high satisfaction rate and all of the complications were minor complications. In our study erectile function deterioration occurred in 2 (%20) patients, chordee occurred in 2 (%20) patients, oral numbness occurred in 1 (%10) patient and incontinence occurred in 1 (%10) patient. Major complications were not observed. Although this procedure has some minor complications, patient satisfaction is high.

Hypothesis / aims of study Voiding dysfunction due to neurogenic or non-neurogenic urethral sphincter hyperactivity is a treatment challenge for urologists. Voiding dysfunction can result from detrusor underactivity, bladder outlet obstruction, urethral sphincter hyperactivity, or inadequate relaxation of the urethral sphincter during micturition. Urethral sphincter dysfunction may be neurogenic or non-neurogenic in origin, with large post-void residual (PVR) volume and upper urinary tract deterioration. In recent decades, urologists have used onabotulinumtoxinA injection into the urethral sphincter to treat such voiding dysfunction. Although onabotulinumtoxinA seems effective in treating voiding dysfunction, not all patients have successful treatment results. Normal voiding requires adequate detrusor contractility and coordinated bladder neck and urethral sphincter relaxation. In patients with non-neurogenic dysfunctional voiding or neurogenic DSD, a decrease in the urethral resistance during voiding is needed for efficient voiding. Injecting onabotulinumtoxinA into the urethral sphincter reduces urethral sphincter resistance, but the treatment is not effective in all such patients. Therefore, we retrospectively analyzed recently treated patients to identify the video-urodynamic predictive factors for the success of onabotulinumtoxinA treatment in patients with voiding dysfunction due to urethral sphincter hyperactivity.

In this retrospective study, the medical records from 2011 to 2016 were examined for consecutive patients with voiding dysfunction due to urethral sphincter hyperactivity refractory to medical treatment who were treated with 100 U of onabotulinumtoxinA (Allergan, Irvine, CA, USA) injected into the urethral sphincter. Patients underwent video-urodynamic study and cystoscopy before the injections to verify they had no urethral stricture or anatomical bladder outlet obstruction. The patients underwent urethral sphincter onabotulinumtoxinA injections in the operating room under light intravenous general anesthesia. Each 100 U vial of onabotulinumtoxinA was reconstituted to 4 mL with normal saline, making the concentration equivalent to 25 U/mL. The dose of onabotulinumtoxinA was 100 U for patients with DSD, dysfunctional voiding, or a non-relaxing urethral sphincter. The video-urodynamic parameters including bladder neck status during voiding cystourethrography, first bladder sensation of filling, cystometric bladder capacity, detrusor pressure, maximum flow rate (Qmax), PVR, and abdominal pressure to void were recorded and analyzed. Treatment outcomes were assessed 1 month after urethral onabotulinumtoxinA injection. The video-urodynamic variables were compared between patients with good and poor treatment outcomes. The changes of assessment parameters from baseline to posttreatment were also compared between patients with neurogenic and non-neurogenic urethral sphincter hyperactivity.

Of the 95 patients who underwent urethral sphincter onabotulinumtoxinA injection for urethral sphincter hyperactivity, 53 had non-neurogenic and 42 had neurogenic etiologies. Table 1 shows the baseline video-urodynamic characteristics. Treatment outcomes were not related to age, gender, or voiding dysfunction subtype. When we compared the baseline video-urodynamic characteristics between patients with good and poor outcomes. Patients with good outcomes had a significantly smaller volume at the first sensation of filling (122.0 ± 53.2 vs 147.2 ± 67.0 mL, p=0.046), greater detrusor pressure (36.1 ± 27.9 vs 24.2 ± 19.3 cmH2O, p=0.027), higher Qmax (7.64 ± 5.03 vs 5.16 ± 4.46 mL/s, p=0.017), and smaller PVR (169 ± 130 vs 251 ± 149 mL, p=0.006) than patients with poor outcomes. An open bladder neck during voiding was noted in 87.5% patients with good outcomes but only in 12.5% of patients with poor outcomes (p <0.001). Multivariate analysis revealed that an open bladder neck was the only predictor of a successful therapeutic outcome. There was no significant difference in the improvement of symptom score, Qmax, voided volume or PVR volume between patients with neurogenic and non-neurogenic voiding dysfunction. However, patients with non-neurogenic voiding dysfunction had a significantly longer lasting therapeutic duration than did patients with neurogenic voiding dysfunction (9.55 ± 4.18 vs 7.44 ± 2.91 months, p=0.033). After urethral onabotulinumtoxinA injection, increased urinary incontinence was reported in 18 patients, including 6 with stress urinary incontinence and 12 with urgency urinary incontinence. Patients with neurogenic voiding dysfunction had significantly higher rates of developing de novo urinary incontinence. De novo urinary tract infection was also observed in 12 (22.2%) patients overall ( Table 2 ). 

The findings revealed that urethral sphincter onabotulinumtoxinA injection relieved voiding dysfunction in 61.1% of patients regardless of neurogenic or non-neurogenic etiology. Preoperative video-urodynamic studies provide a valuable prognostic indication of treatment success. Patients who had an open bladder neck on voiding cystourethrography had predictably successful therapeutic results. In addition, patients with early bladder sensation of filling, higher detrusor pressure, higher Qmax, and a smaller PVR volume appeared to benefit more from urethral sphincter onabotulinumtoxinA injection than those with lower bladder contractility.

OnabotulinumtoxinA urethral sphincter injection is effective in 61.1% of patients with voiding dysfunction due to neurogenic or non-neurogenic voiding dysfunction refractory to conventional medical treatment. Careful evaluation of the bladder neck opening at baseline provides predictive value for a successful treatment outcome. However, urinary incontinence might be a de novo adverse event after the urethral sphincter onabotulinumtoxinA injections. 

Hypothesis / aims of study In pediatric urology, an excess excretion of urinary calcium (Ca) has been demonstrated to result in nocturia or decreased functional bladder capacity, and may be a cause of enuresis [1] . Additionally, adults with hypertension, which is a typical lifestylerelated disease and can be the cause of nocturia, are also known to have increased urinary Ca excretion. It has been reported that excess urinary Ca excretion causes a decrease in nocturnal antidiuretic hormone secretion as well as aquaporin-2 production in the renal collecting tubule, and thereby affects its urine concentrating ability [2] . Thus, excess urinary Ca excretion may have an effect on urinary symptoms including nocturia; however, no clinical studies have investigated the relationship between the amount of urinary Ca excretion and urinary symptoms, particularly in adults. We therefore conducted a study to clarify the relationship between various urinary symptoms including nocturia and the amount of urinary Ca excretion.

We included patients aged 18 years or older who received treatment for the chief complaint of urinary symptoms, in a crosssectional study to investigate the relationship between the amount of urinary Ca excretion and urinary symptoms. The spot urine samples were collected, and the patients were divided into a group with normal urinary Ca excretion (normal group: N group) and a group with high urinary Ca excretion (hypercalciuria group: H group). The amount of urinary Ca excretion was corrected for urinary creatinine (Crea), and urinary Ca/Crea of 0.21 or more was defined as hypercalciuria. The urinary symptoms were assessed with a frequency volume chart and the Core Lower Urinary Tract Symptom Score (CLSS), and the two groups were compared.

Data were analyzed for 317 patients (109 men), with a mean age of 65.4 ± 13.8 years. The N group and H group comprised 208 (82 men) and 109 (27 men), respectively. The H group showed a significantly higher daytime frequency (7.2 ± 2.3 in the N group and 8.0 ± 2.5 in the H group; P = 0.006) and nighttime frequency (1.4 ± 1.2 in the N group and 2.6 ± 1.4 in the H group; P < 0.001) than the N group did. The mean single voided volume was lower in the H group that in the N group (304.8 ± 65.4 mL in the N group and 218.7 ± 62.5 mL in the H group; P < 0.001). The H group had a significantly greater nocturnal urine volume (412.8 ± 206.2 mL in the N group and 640 ± 242.1 mL in the H group; P<0.001) and higher nocturnal polyuria index (19.7 ± 7.0% in the N group and 27.6 ± 7.7% in the H group; P < 0.001) than the N group did. The H group had higher CLSS scores than the N group did for parameters such as Q1 (daytime frequency), Q2 (nocturia), and Q3 (urgency) (Q1, P = 0.003; Q2, P < 0.001; Q3, P = 0.045), with a worse quality of life (QOL) (P < 0.001). In addition, the urinary Ca/Crea was positively correlated with both nighttime frequency (r = 0.407, P < 0.001) and the nocturnal polyuria index (r = 0.488, P < 0.001). Furthermore, the results of both univariate and multivariate analysis revealed that hypercalciuria was an independent risk factor for urination two or more times per night (odds ratio, 3.303; 95% confidence interval, 1.81-6.17; P < 0.001).

Our study had limitations. The subjects were only those with urinary symptoms and the study was cross-sectional. However, even though the study population already had urinary symptoms, the amount of urinary Ca excretion was found to be associated with nocturia, nocturnal urine volume, and the nocturnal polyuria index. In addition, hypercalciuria itself was an independent risk factor for frequent nocturnal urination. These results seem to suggest that the control of hypercalciuria itself, through drug therapy or lifestyle modification, could lead to improvement in urinary symptoms.

The study results suggest that hypercalciuria could affect the QOL. 

Hypothesis / aims of study According to several reports, high salt intake causes excessive water consumption and edema, which may lead to lower urinary tract symptoms (LUTS), such as polyuria or nocturia. [1] Furthermore, chronic excessive salt intake is considered as one of the risk factors of lifestyle-related diseases, such as hypertension and renal dysfunction. These lifestyle-related diseases are also causative diseases of LUTS, such as nocturia. However, there is no prospective study on the influence and effect of dietary salt intake restriction on LUTS. This study aims to determine the effects of restricted salt intake on patients with LUTS associated with excessive salt intake, especially nocturia.

The subjects were patients who woke up at least one time during the night and were diagnosed with excessive salt intake (8 g/day or more for men; 7 g/day for women). For restricted salt intake, the subjects were instructed using a brochure via interview once every four weeks. Urination conditions (e.g. voided volume and urinary frequency) at the initiation of restricted salt intake and at 12 weeks after the initiation were prospectively evaluated using a frequency volume chart. In addition, changes of urinary symptoms before the initiation of the study and at 12 weeks after initiation were compared using the core lower urinary tract symptom score (CLSS). Patients who had organic abnormalities as potential causes of dysuria, such as neurogenic bladder, were excluded from the study. During the study period, switch of therapeutic drug for dysuria was never conducted. For estimated salt intake, urine sodium and creatinine were measured using spot urine samples with a conversion formula with adjustment for height, weight, and age. Statistical significance was established at P < 0.05.

A total of 321 subjects (including 102 men) were analyzed and the mean age was 64.3 ± 13.6 years. Of these subjects, 223 patients (69.5%) achieved salt intake restriction during the observation period (success [S] group) while 98 patients (30.5%) did not (failure [F] group). In the S group, the mean estimated salt intake decreased from 10.7 ± 2.3 g to 8.0 ± 2.1 g (P < 0.001); the number of nocturia was improved from 2.3 ± 0.9 times to 1.4 ± 1.0 times (P < 0.001); water intake volume decreased from 2287.5 ± 577.1 ml to 1982.4 ± 524.3 ml (P < 0.001); Nocturnal Polyuria index (NPi) was also significantly improved from 30.2 ± 7.5% to 27.7 ± 7.3% (P < 0.001). In the F group, the mean estimated salt intake increased from 9.6 ± 1.3 g to 11.0 ± 1.8 g (P < 0.001); the number of nocturia worsened from 2.3 ± 1.1 times to 2.7 ± 1.1 times (P < 0.001); water intake volume increased from 2262.2 ± 589.2 ml to 2540.3 ± 604.9 ml (P < 0.001); the NPi showed no change (from 30.8 ± 8.3% to 30.5 ± 7.9 %; P < 0.583). In the S group, the CLSS indicated not only that Q1 (diurnal frequency) was improved from 0.8 ± 0.9 to 0.4 ± 0.7 (P < 0.001) and Q2 (nocturia) was improved from 1.9 ± 0.6 to 1.3 ± 0.8 (P < 0.001), but also that Q3 (urgency) was significantly improved from 1.0 ± 1.0 to 0.9 ± 1.0 (P = 0.001) and the score of the quality of life (QOL) was significantly improved from 3.6 ± 1.2 to 2.7 ± 1.3 (P < 0.001). In addition, the improvement of nocturia and the salt reduction rate with a receiver operating characteristic curve (ROC) showed an area under the curve (AUC) of 0.757. When the cut-off value for salt reduction rate was defined as 4.83%, the sensitivity and specificity were 92.8% and 53.1%, respectively, for the predicting improvement of nocturia.

In this clinical study performed in patients with nocturia who were diagnosed with excessive salt intake, the S group showed a significant decrease of nighttime frequency, nocturnal urine volume, NPi and urinary urgency as well as improved QOL. The main cause of improvement of nocturia and nocturnal urine volume was thought to be decreased water consumption due to salt intake restriction. However, it is very interesting that urinary urgency was also improved. In this regard, further examination is required.

Concluding message For patients with excessive salt intake who had urinary symptoms, especially nocturia, salt intake restriction can be considered as a treatment option and as a part of lifestyle guidance. Even for patients who have not responded to current drugs for nocturia, salt intake restriction can be considered when they are diagnosed with excessive salt intake.

Denys M 1 , Goessaert A 1 , Decalf V 1 , Kumps C 1 , Vande Walle J 1 , Everaert K 1

Hypothesis / aims of study Aging is accompanied by a higher prevalence of nocturnal polyuria (NP), which is explained by the interplay between physiological and pathological changes in hormonal mechanisms involved in water and sodium handling.

The aim of this study was to compare circadian variations of diuresis rate, free water clearance and sodium clearance between subjects with and without NP across different ages.

This was a post-hoc analysis of two prospective observational studies. A urine sample was collected every 3 hours during 24h and a blood sample was provided in order to calculate diuresis rate, free water clearance and sodium clearance. Assignment to subgroups was based on age: <40y (n=28), 41-50y (n=13), 51-60y (n=30), 61-70y (n=72), 71-80y (n=67) and >80y (n=20). In each subgroup, patients with (cases) and without (controls) NP (nocturnal urine output >90ml/h) were compared.

We included 230 subjects (64% female) with a median age of 67 (56-74) years. Controls ≤60y had a lower nighttime diuresis rate and sodium clearance compared to daytime, while cases of the same age showed no circadian rhythms. In participants >60y, controls had no circadian rhythm in diuresis rate and sodium clearance, while cases showed an inversed rhythm with a higher nighttime diuresis rate and sodium clearance compared to daytime. Compared to daytime, higher nighttime values of free water clearance were found in cases >60y (figure 1).

We documented that in a population of adults without NP, there is an age-related loss of the circadian rhythm of diuresis, water diuresis and sodium diuresis. We also found that all subjects with NP, regardless of age, had a significantly higher nocturnal diuresis rate compared to the control population, but they also had an age-dependent change in circadian rhythm of diuresis, with a turning point around 60 years. Until 60 years, subjects without NP had a decrease in nighttime diuresis rate compared to daytime, while no circadian variation was observed in the subjects with NP. In participants older than 60 years, the opposite was observed: subjects with NP developed a circadian rhythm with a higher nighttime diuresis rate compared to daytime, while participants without NP lost their circadian rhythm. The timing of the change in circadian rhythm of diuresis rate coincided with the timing of changes in circadian rhythms of water and sodium diuresis.

We found a turning point in the circadian pattern of diuresis rate, free water clearance and sodium clearance around 60 years. 

Hypothesis /Aims of Study: It is commonly assumed that the number of times an individual reports waking at night needing to pass urine is the appropriate marker of treatment efficacy for nocturia. However, not all patients with nocturia report the same frequency night to night or level of bother. Given the multifactorial causal pathway, the high prevalence of clinically relevant comorbidities and the potential floor effect of nocturia frequency, this may be an insufficient measure.

The primary aim of this study was to investigate predictors of nocturia bother and episode frequency in order to identify variables that can be individualized as additional outcome measures of treatment efficacy. A secondary aim was to identify variables that either amplify or modify the bother associated with nocturia. Variables predictive of nocturia ≥2 per night were: moderate to extreme bother (OR 7.34); daily urgency (OR 5.29); short time to first waking to void or FUST (OR 0.26); low sleep efficiency (OR 2.37); sleep disturbed by uncomfortable breathing (OR 5.94) and bad sleep quality (OR 2.37). Independent predictors that explained 44-61% of the variance of high frequency nocturia were FUST, bother and daily urgency. This model correctly classified 89% of affected patients.

Predictors of moderate to severe nocturia-related bother were: fair to very bad sleep quality (OR 4.13), short FUST (OR 0.60), daily urgency (OR 2.78), high nocturia frequency (OR 1.70) and weekly use of sleep medication (OR 2.24). This model explained 21-29% of the variance in nocturia bother and correctly classified 84% of individuals.

High bother related to a single episode of nocturia was associated with impaired sleep (quality and total hours of sleep), use of sleep medication and daytime fatigue. Older age, male gender and urgency were protective against high bother in patients with multiple episodes of nocturia.

Interpretation of Results: Data was used to develop a suite of individualised outcome measures for nocturia that address domains of importance to individual patients (Figure 1 ). Items were drawn from validated and reliable metrics.

Concluding Message: This is the first study to translate individual multifactorial aetiological data into a clinically useful framework that allows patients to prioritise aspects of nocturia impact. Treatment efficacy can then be evaluated based on change in patient-selected variables of importance. These measures sit alongside self-report of nocturia frequency. 

Hypothesis / aims of study Multiple Sclerosis (MS) is a chronic neurological disorder caused by eventual neurodegeneration within the central nervous system resulting in impaired physical, cognitive and psychological functioning. It is often progressive and can result in many unpredictable symptoms, all of which can have a detrimental effect on quality of life (1) . Commonly, people with MS will report a number of lower urinary tract symptoms (LUTS) including nocturia (1). This is defined by the International Continence Society (ICS) as the need to 'wake at night one or more times to void' (2) . Previously, clinical trials have sought to understand the causes of nocturia and have found an association between melatonin secretion and nocturia (3) . However, to date, no qualitative studies have been conducted which explore the experience of taking melatonin for the treatment of nocturia within the context of a clinical trial. This study specifically aimed to explore perceptions of this intervention on nocturia and associated quality of life impact from the patients' perspective.

Study design, materials and methods This qualitative exploration was embedded within a double blind, placebo controlled, randomised trial which explored the effectiveness of melatonin for the treatment of nocturia in MS. During the trial, participants were invited to take part in five study visits to monitor progress and were interviewed by a qualitative researcher following their final study visit. Semi-structured, face to face interviews were conducted among 17 consenting participants with progressive MS and were facilitated by a semistructured topic guide. The sample consisted of ten female participants and seven males with an age range of 39 to 67 (mean 58 year). Interviews took between 20 and 40 minutes to complete and where possible, the partners of participants were also involved within these discussions. Data was audio recorded and transcribed verbatim. Transcripts were then coded using NVivo 10 and analysed using a thematic analysis.

Data revealed a number of significant themes that were grouped and divided into two key categories 'perceived improvements' and 'adverse effects' which captured participants' experiences of taking melatonin and a placebo for the treatment of nocturia. All themes were believed to have a significant effect on various aspects of their quality of life.

-'It's having more energy the following day and having a better life really… I think that's what it is really just giving me a better standard of life' -'To go from getting up twice every night to only getting once in the last week is significant progress' -'My sleep was a lot better… so it's the quality of sleep is a lot better and because the quality of sleep's a lot better I feel a lot better I've got more energy I just felt great'

-'I could have been on the placebo both times really yeah I didn't notice enough to go wow that's made a difference' -'You were getting up with a very thick head and quite grumpy and it would take you a long time to come round' -'An hour or so after I'd fallen asleep I would have a dream. They weren't unpleasant, they weren't nightmares they were just a bit whacky'

Interpretation of results This qualitative exploration revealed that some participants perceived the intervention to be beneficial as they described positive changes to their nocturia, sleep quality, and energy levels. This was found to have a substantial effect on their quality of life as individuals noted that their psychological and cognitive functioning had improved, as did their ability to fully engage with their daily lives. However, for other participants, some negative experiences were reported including a range of side effects such as headaches and vivid dreams. Furthermore, some noted that this intervention was largely ineffective as they reported a distinct lack of change to their condition. Finally, the presence of excessive drowsiness and tiredness during the day meant that participants were reluctant to view the trial as a success even when occurrence of nocturia had reduced.

Concluding message Some participants taking melatonin for the treatment of nocturia reported a perceived reduction in nocturnal voiding, resulting in better sleep which improved their daily quality of life. However, for others, drowsiness resulted in enhanced feelings of MS-related fatigue, making their daily lives much more challenging. These qualitative findings will ultimately support the quantifiable trial data and enable more accurate counselling for future recipients of this treatment for nocturia.

Hypothesis / aims of study To elucidate the differences in clinical efficacy of anticholinergics to manage the diabetes mellitus (DM) related overactive bladder bladder (OAB) versus idiopathic OAB in Korean women Study design, materials and methods We conducted multicenter, prospective, parallel-group, open-label, 12 week study. Patients (20 ~ 65 years old women) suffered OAB symptom for over than 3 months were classified into DM OAB group and idiopathic OAB group. Changes in OABSS score, urgency, urge incontinence, frequency night, frequency on voiding diary, uroflowmetry, and PVR at the first visit (V1), week 4 (V2), and week 12 (V3) were compared.

No significant difference was found between the baseline patient characteristics of DM OAB group and idiopathic OAB group. Treatment with solifenacin demonstrated improvement in urgency, urge incontinence, frequency night, frequency on voiding diary OABSS Total scores in both of between V1 and V2 and that between V1 and V3. And improvement in urgency, urge incontinence were significant between V2 and V3 in DM OAB group However, no significant changes were found in any other parameters. There were no significant differences between DM OAB group and idiopathic OAB group except urgency, urge incontinence in V2 (3.71versus 2.28 and 0.47 versus 0.32). 

Hypothesis / aims of study: Litoxetine (LTX) is a highly selective serotonin (5-HT) reuptake inhibitor and a Multifunctional Serotonin Agonist Antagonist (1, 2) . LTX is currently in phase 2 development in an international multicenter clinical trial for the treatment of Mixed Urinary Incontinence (MUI) in women. 5-HT plays an important role in centrally and peripherally modulating the reflexes of continence/micturition; 5-HT potentiates the guarding reflex which allows continence by increasing urethral pressure and inhibiting micturition reflex.

The aims of this preclinical study were to determine the effects of LTX in two in vivo experimental models of MUI. In rats, the effects of LTX were evaluated on bladder and urethral functions. In rabbits, LTX was evaluated in comparison to duloxetine (DLX) on striated anal sphincter functions in a model of detrusor overactivity. The external anal sphincter serves as a proxy of urethral sphincter activity.

Rat experiments: In anesthetized female rats, the urethra or the bladder were catheterized. Saline was infused into the urethra 

Rat experiments: UP measurement (Fig.1A) . Basal UP was not statistically different between groups. Following administration of vehicle small variations of UP were observed. In contrast, LTX induced a dose-dependent increase of UP. In comparison to vehicle, LTX effects were significant starting from the dose of 0.3 mg/kg. Cystometry (Fig.1B) . In animals with intravesical AA infusion, ThP and BC were markedly and significantly decreased in comparison to saline infused animals (data not shown). No significant difference was observed for all other cystometric parameters. In rats infused with AA, LTX (2 mg/kg, i.v.) significantly increased BC during the 60 min observation period (Fig. 1B) . At this dose, LTX was devoid of significant effect on MP, BP and ThP.

Rabbit experiments: Intravesical infusion of AA induced reproducible micturition patterns. Vehicle administration did not affect BC ( Fig. 2A) . On SAS-EMG activity (Fig. 2B) , the first administration of vehicle was without effect whereas a decrease occurred after the second administration. At 1 mg/kg, LTX did not modify either BC or SAS-EMG activity. In contrast, at 3 mg/kg, LTX significantly increased BC and SAS-EMG activity. At 1 and 3 mg/kg, DLX dose-dependently and significantly increased BC and SAS-EMG activity. DLX also significantly increased MV at 3 mg/kg (data not shown). LTX and DLX were devoid of significant effects on the other cystometric parameters analyzed (data not shown). 

We showed that LTX increased UP, BC and striated sphincter activity. Considering the pharmacological profile of LTX, it could be proposed that these effects could be related to a 5-HT-mediated mechanism involving spinal or supraspinal structures, as reported for duloxetine (3) . However, a direct effect on bladder and/or urethral smooth muscles cannot be ruled out.

These data support the therapeutic potential of litoxetine as a new treatment of mixed urinary incontinence.

Hypothesis / aims of study To explore the safety and effectiveness of the 3-D printing poly-lactactic acid patch in rabbit augmentation cystoplasty through observing the degradation and biocompatibility of the patch as well as the ingradation and regeneration of the tissue. days postoperatively). Urinary tract from pelvis to bladder were anatomized to justify the degree of adhension and upper urinary tract dilation and the formation of bladder stone. Regenerated bladder strips and the original normal bladder strips from the same bladder were obtained and then underwent histologic and immunocytochemical analyses to find out the degradation of the patch and the degree of inflammation as well as the regeneration of the the bladder mucosa, the muscle layer and the vessels.

The degree of adhension in group C and D were greater than that in group A and B. The total incidence of lithiasis was 50%, and encustration (Figure1 (a)(d)) was 58.3%. Dilation of upper urinary tract were not seen in all of the rabbits. After 30 days of the operations, the sites of the patch were covered by regenerated mucosa (Figure1 (a)(b) ). The number of epithelium layer in group A was much lower than that in normal bladder (0.3±0.5 vs 4.0±1.3), while in group B, the two resembled each other (1.8±1.3 vs 2.8±0.4). The inflammatory responses of the regenerated tissue in both group A and B were obvious and some of the mucosas were contracted radically. The new tiny vessels were observed and the regenerated smooth muscle cells were not well organized. After 90 days of the operations, the regenerated mucosas were smooth (Figure1 (c)(d) ). The number of epithelium layer in group A and group B were similar to that in corresponding normal bladder (4.0±0.8 vs 3.0±0.8, 4.0±0.6 vs 3.8±0.8). The inflammatory responses were much alleviated. The new vessels grew thicker and the smooth muscle cells were well organized and oriented, resembling those in the normal bladder. The regenerations of epithelium, the muscle layers and the vessels of patch one group were similar to those of patch two.

There were no dilations of the upper urinary tract or severe complication such as bladder ruptures seen in the study. The epithelium regeneration of patch one group is lower than that of patch two (P<0.05) after 30 days of the operations while 90 days later, patch one and two group resembled each other. The inflammatory responses were alleviated as time went by and the biocompatibility was satisfied. The regeneration of the epithelium, the smooth muscle cells and the vessels were getting normal, reaching a satisfactory histologic outcome.

The 3-D printing poly-lactactic acid patch was successfully applied in the augmentation cystoplaty in rabbits histogically. It can be used in rabbit augmentation cystoplaty while further researches need to been done to find out the functional outcomes. Study design, materials and methods Patients completing 12 weeks of randomized, double-blind treatment with either tolterodine/pilocarpine (2/9mg) or 2mg tolterodine twice daily were continued in the 12 weeks, open-label, uncontrolled extension study. Double-blind study medication was discontinued, and patients were started, open-label, on tolterodine/pilocarpine (2/9mg) twice daily. Efficacy analysis consisted of a comparison of the change from baseline in the mean number of daily micturitions, incontinence episodes, and urgency episodes at the end of the 24-week. The incidence of dry mouths and other adverse events were monitored and were evaluated for severity, duration, outcome, and relationship to the study drug. Overactive bladder symptom score(OABSS), xerostomia inventory total score, visual analogue scale (VAS) of dry mouth symptoms were also administered at each of the study visits.

Of completers of randomized control study, 256 patients continued the extension study; 124 from tolterodine/pilocarpine (2/9mg) combination treatment (extended group) and 132 from the 2mg tolterodine monotherapy group (changed group). In the full analysis set, change from baseline in the mean number of daily micturitions was -1.78 ± 2.39 (p<0.0001) of extended group and -1.61 ± 2.32 (p<0.0001) of changed group. Other efficacy outcomes including the change from mean number of daily incontinence episodes and urgency episodes were improved in both groups while no statistically differences between two groups at the end of the 24-week (Table1). During the 12 weeks of randomized study period, incidence of dry mouth was lower in tolterodine/pilocarpine (2/9mg) combination group than tolterodine monotherapy group, significantly (33.06% vs 45.45%, p=0.0427). By the end of the 12-week period of the extension study, the incidence rate of dry mouths was 4.03% (95% confidence interval; 1.32-9.16) of extended group and 0.00% (confidence interval; 0.00-2.76) of changed group. The other adverse events were not significantly different between two groups.

The long-term administration of tolterodine/pilocarpine (2/9mg) combination for 24 weeks resulted in an additional increase in efficacy and it was tolerable for safety results. It has been confirmed that the efficacy is maintained and there was no occurrence of dry mouths during the extension period when tolterodine 2mg monotherapy is replaced with the tolterodine/pilocarpine (2/9mg) combination treatment. Changes in the subjective symptoms of dry mouth also improved to baseline levels after 24-week longterm treatment. Especially in changed group, VAS for dry mouth and xerostomia inventory total score was decreased dramatically after conversion to combination treatment during extension period.

In this 12-week, open-label extension study, a combination of tolterodine and pilocarpine demonstrated a favourable safety and tolerability profile. The efficacy and safety remained excellent even though 2mg tolterodine monotherapy was changed to tolterodine/pilocarpine (2/9mg) combination treatment. Patients demonstrated sustained improvement in OAB symptoms for up to 24 weeks of combination treatment. 

Hypothesis / aims of study Overactive bladder (OAB) is a prevalent disease that affects 15-21% of the population. Initial management consists of bladder training, weight loss and fluid management. If these fail, second line therapy consists of medication, like antimuscarinics or beta-3 agonists. Reports have shown that many patients taking drugs for OAB are nonadherent and nearly 75% of them discontinue treatment within one year, mainly due to the drug-related side effects, inadequate drug efficacy and poor patient education [1] .

One new treatment option being investigated is fulguration of the trigonal nerves via radiofrequency ablation (RFA). RFA uses heat generated from alternating current. Three-dimensional mapping of human bladder innervation demonstrate that sensory neurons and parasympathetic fibers traverse the adventitia and penetrate the detrusor near the bladder neck at the 3 and 9 o'clock positions, around the ureteral orifices and interureteric ridge [2] . Therefore, RFA could be used specifically to treat these areas without affecting surrounding tissue.

The objectives of this institutional study were to compare clinical outcomes following RFA in female patients suffering from OAB with or without uninhibited bladder contraction (UBC) as determined by baseline urodynamic study (UDS) using a sub-set of patients from a larger multicenter study.

Study design, materials and methods From a prospectively maintained database, we retrospectively reviewed cases of trigonal RFA at our institution. The device used for treatment is only available as part of a clinical trial. Under direct visualization of the trigone during the procedure, RF cannulae were inserted through the device followed by stabilization of the trigonal mucosa with a suction paddle. This allowed targeting of the nerves below the trigone while preserving the mucosa. RF was administrated across the trigone sparing ureteral orifices. Between 3 to 6 ablations were done depending on the size of the trigone.

Patients (exclusively female) were categorized into two groups: i) presence of UBC on pre-treatment UDS (UBC+) and ii) absence of UBC (UBC-). Clinical data were available for all patients and three main post-procedural outcomes were compared between the groups at three months, namely: subjective improvement rates (SIR), 24h Pad-weight test (PWT) and number of urgency urinary incontinence/72h (UUI/72h). Baseline characteristics, voiding diaries and UDS findings between both groups were compared using Wilcoxon rank-sum tests for continuous variables and using either chi-square or Fisher exact tests for categorical variables.

A total of 22 patients were enrolled. Of these, 10 were found to be UBC-. When the baseline characteristics, voiding diaries and UDS findings of patients with or without UBC were compared, no statistical differences were observed between both groups. Patients in the UBC-group reported a significantly greater 3-months SIR (70% vs 40%; p=0.03) than their counterparts. At 3 months, although not statistically significant, we observe a trend towards better results in the UBC-group versus UBC+ for UUI/72h (2 vs 3, p=0,4) and #urgency/72h (5 vs 16, p=0,1). PVR was not statistically different between groups after treatment (26ml vs 18ml, p=0,3). When stratifying groups by age, the SIR reported at 3 months was similar, but not statistically significant, for patients under 70 years old and over 70 years old (40% vs 50% respectively, p=0,4). 

Our results have demonstrated that female patients who are UBC-on pre-treatment UDS have a significantly better SIR at 3 months than UBC+ patients. Voiding diary characteristics at 3-months show a trend towards better results in the UBC-group though none were statistically significant. This novel technique did not seem to put patients at risk for increased PVR at 3 months. Our data raised thoughts on patient suitability for RFA based on the presence or absence of UBC. Though both groups benefited from the treatment, one interpretation of our findings suggest UBC-patients would be better candidates for RFA of the trigonal nerves. This could relate to the underlying pathophysiology behind OAB. Patients that are UBC+ might correspond to the ''myogenic theory'', whereas UBC-patients may fall in the ''increase sensory afferent theory'' [3] . Knowing that the sensory nerves innervating the bladder are mainly derived from the bladder neck area, RFA of trigonal nerves can benefit UBC-patients since their symptoms might be generated by sensory impulses originating from trigonal nerves. However, the mixed results and small sample size limits the interpretation of our results. Further studies with larger samples might better identify elements that would support patient selection.

Concluding message While subjects in both groups appeared to benefit from treatment with RFA, OAB patients with UBC-on pre-treatment UDS had statistically significant improvement via SIR at 3 months following RFA treatment. This observation suggests trigonal nerve ablation may provide a greater benefit for this subset of patients with OAB refractory to medical therapy. However, as the other clinical outcomes were not significant, this is not definitive. The sample size limited the interpretation of some of the analysis. Further studies are required to validate these results. 

Mean follow-up was 90.6 + 45.6 months. SUI recurrence rate was higher in group 1 (24.4% vs 14.3%) with no statistical significant difference (p 0.52). There was no statistical difference in objective results between TVT (46% 35/76) and TVTO (54% 41/76), p 0.25. Complications included urinary retention, granuloma, pelvic pain, extrusion of the tape. Only one case of tape extrusion was documented in a TVT of group 1, this woman had a concomitant diagnosis of Papilloma Virus in the site of extrusion. No biomesh or mesh extrusion was documented in women underwent anterior POP repair. In group 1 we had just one patient, treated with TVTO, with voiding dysfunction with early spontaneus resolution. Voiding dysfunctions in group 2 were documented in 4 patients. In two cases (TVTO) we had an early spontaneous resolution, while in other two cases (TVT) a tape incision was performed. Follow-up results are reported in table 1. Considering patients who had MUS plus cystocele repair (group 2) we documented a better SUI success rate in the group where a biomesh or mesh was used (100% 17/17) respect to the AC group (72.2% 13/18) with a statistical significant difference (p 0.045), as reporte in table 2.

Our results show no significant influence of cystocele repair in patients treated for SUI. However, we documented a recurrence rate 10.1% higher in patients treated with the only MUS. It is possible that in a larger cohort this could became statistical significant. Another interesting finding was the difference (p<0.045) of recurrence in the sub-group of patients treated by mesh/biomesh versus the fascial repair. This result could have a twofold explanation: the greater support created by a mesh/biomesh at level 2 of DeLancey, and the superior fibrosis effect that could create a pull consequence on paraurethral tissues. The association between MUS and cystocele surgery did not increase the rate of complications.

Concluding message MUS objective results are not influenced by anterior wall repair. In case of cystocele repair the use of a bio/mesh showed better results on SUI. Patients with concomitant POP repair obtained higher subjective satisfaction. 

Hypothesis / aims of study A coordinated and simultaneous activity between pelvic floor muscles (PFM) and transverse abdominal muscle (TrA) seems to favor the maintenance of urinary continence. According to the International Continence Society and International Urogynecological Association, the contraction of two or more muscles at the same time is denominated as 'co-contraction' and can result in an augmentation of motor activity when occur in a synergistic way (1) . The presence of co-contraction between PFM and TrA in young asymptomatic women has been reported in some studies. However, there is still no consensus in the literature about the presence of a synchronious muscle activity in women with stress urinary incontinence (SUI) (2) . The authors also suggest that the presence of urinary symptoms is related to an uncoordinated action between these muscles, characterized by a lower PFM response compared to TrA response.

Thereby, the aim of this study was to analyze and compare the pelvic floor muscles' percentage of co-contraction from TrA contraction in continent and incontinent women.

Study design, materials and methods A transversal clinical study was carried out after Research Ethics Committee approval and conduct in accordance with the Helsinki declaration. Initially, 127 women were recruited and it was investigated if they fulfilled the study eligibility criteria. Eight of these women did not fulfill the inclusion criteria due to PFM strength grade 0 or 1 (n=3), presence of predominant urgency urinary incontinence (n=1), previous surgery for SUI (n=2) and pelvic organ prolapse grade III or greater (n=2). Thus, 119 women participated in the study. The participants' urinary symptoms were evaluated using the International Consultation on Incontinence Questionnaire Urinary Incontinence -Short Form (ICIQ UI-SF) and they were divided into two groups: (1) continent women (n=88) (Mean age: 30.2±10 years old, mean BMI: 23.25±3.23 kg/m 2 , mean number of pregnancies: 1.2±1.7, ICIQ UI-SF score: 0) and (2) incontinent women -women with predominant SUI (n=31) (Mean age: 51.6±8.3 years old; mean BMI: 24.1±5.1 kg/m 2 ; mean number of pregnancies: 2.6±1.4; ICIQ UI -SF score: 15±3.8). Afterward, they were submitted to PFM surface electromyography exam, being requested three PFM maximal voluntary contractions (obtaining the PFM electromyographic activity when it was requested) and more three TrA maximal voluntary contractions (obtaining the PFM electromyographic activity when it was co-contracted). The mean Root Mean Square (RMS) was calculated from three contractions and was used for data analysis. The PFM percentage of co-contraction was calculated through this formula:

The sample homogeneity and the comparison between PFM percentage of co-contraction in continent and incontinent women were analyzed using the Kolmogorov-Smirnov and Mann-Whitney tests, adopting a significance level of 5%.

The groups were homogeneous only in terms of body mass index (p=0.6). There was significant difference between PFM electromyographic activity when it was requested and co-contracted, both in continent (p<0.0001) and incontinent (p<0.0001) women, demonstrating a greater PFM activation when it was requested. Table 1 presents the PFM percentage of co-contraction between groups. Interpretation of results Several authors discuss the relationship between PFM and TrA. There are indications that TrA thickness correlates directly with PFM electromyography activity (3). However, the preliminary results of our study demonstrated that PFM co-contraction from TrA contraction is significantly lower when compared to direct PFM contraction in both continent and incontinent women, corroborating with other studies.

In addition, we had verified that PFM percentage of co-contraction in continent women was 70.2% while in incontinent women was 57.8%. However, no statistically significant difference was found between groups, being necessary to continue the study to elucidate this question, since these findings will contribute to the conservative management of pelvic floor dysfunctions, allowing a clinical practice based on evidence.

In conclusion, the PFM electromyographic activity is statiscally greater when this muscle is required than when it is co-contracted, in both continent and incontinent women. Besides, PFM co-contraction occurs more frequently in continent women, although no significant statistical difference was found between groups.

Chang 

Hypothesis / aims of study Interstitial cystitis/bladder pain syndrome (IC/BPS) is a clinical syndrome of the bladder that is characterized by pelvic pain and urinary urgency and frequency in the absence of identifiable causes. Clinicians have noted that large proportions of patients with IC/BPS had a history of pelvic surgery. Delivery itself is a trauma to pelvic area that was one of the hypothetic causes of IC/BPS. We tried to investigate the causal effect of cesarean section on IC/BPS after controlling confounding factors in a large nationwide cohort study.

From the Longitudinal Health Insurance Database 2010 (LHID2010) which including 1 million insured patients, women received caesarean section or vaginal delivery between 2002 and 2013 were included. Women younger than 18 years or those with both methods of delivering were excluded. IC/BPS diagnosed before delivery or occurred within 1year after delivery were also excluded. All included women were followed until the end of 2013 to detect the event of IC/BPS. The risk of IC/BPS during the study period in the caesarean section cohort was compared with the vaginal delivery cohort after controlling the confounding factors.

The caesarean section rate in our database was 35.7%. Mean age of women was 30.60±4.86 years, and 28.88±4.67 years, in caesarean section cohort (n=20391) and the vaginal delivery cohort (n=36748), respectively. The comorbidities of pelvic inflammation disease, leiomyomata, adhesion fibromyalgia, depression, anxiety and systemic lupus erythematosus in the cesarean section cohort were significantly higher than in the vaginal delivery cohort (p<0.05).However, comorbidities of pelvic organ prolapse and stress incontinence in the vaginal delivery cohort were significantly higher than in the cesarean section cohort (p<0.05). After controlling age and the comorbidities, the risk of IC/BPS revealed no different between these two cohorts (HR 1.464, 95%CI 0.956-2.241). The interval between delivery and diagnosis of IC/BPS was also not significantly different between two cohorts (5.281 ± 3.022 vs. 5.124 ± 2.600 years, p=0.789). The incidence densities of IC/BPS were similar among two cohorts and the general population.

The Caesarean rate in our data was higher than the developed countries. The mean age of caesarean delivery was higher than vaginal delivery statistically. Caesarean section most likely related to pathological or functional disorders (such as inflammation, neoplasm or systemic diseases). In contrast, vaginal delivery most likely related to mechanical pelvic disorders (such as prolapse or incontinence). However, after controlling the comorbidities, the risk of IC/BPS revealed no different between these two cohorts. The developed interval time of IC/BPS after delivery was not different between caesarean and vaginal delivery cohorts. There is no causal effect of IC/BPS by delivery due to the similar incidence densities with the general population in our database. Limitation: The effect of delivery frequency could not be accurately analyzed in LHID 2010.

The risk of IC/BPS was not affected by different birth delivery methods (caesarean section or vaginal delivery). Similar incidence densities with the general population revealed no causal effect by delivery. The developed interval time of IC/BPS after delivery also showed no different between caesarean and vaginal delivery cohorts. Other pelvic surgery should be further evaluated in the future.

Hypothesis / aims of study This is the first known study to examine the relationship between restricted toileting or limited fluid intake behaviours and work productivity for female nurses and midwives with storage lower urinary tract symptoms (LUTS) while at work.

Study design, materials and methods A cross sectional observational study, with a pragmatic multi-modal data collection strategy was used. A survey (electronic and 600 paper based) was distributed to female nurses and midwives at three urban hospitals, between June and November 2016. An estimated 2,750 nurses and midwives worked in the three hospitals in 2016. A sample size of at least 600 was required to achieve a 95% confidence (5% error) on an estimated 56% response rate [1] . The presence of storage LUTS (urinary frequency, urinary urgency, urinary incontinence and nocturia) in the last month was determined by responses to questions from the Female International Consultation on Incontinence LUTS questionnaire. The presence of storage LUTS "at work" was determined by the question "In the last month, did you experience urinary symptoms at work? By urinary symptoms we mean feeling the need to pass urine more frequently than usual; feeling discomfort because of the need to delay passing urine; needing to rush or hurry to pass urine when you get the urge; or leaking urine with work activities or with the need to hurry to pass urine?" [2] . Descriptive statistics were used to provide information about the characteristics of the nurses and midwives, and Chi Square tests to identify any significant differences in the health variables for those with or without limited fluid intake or toileting restrictions at work. Logistic modelling was used to estimate the predictive association between limited fluid intake and restricted toileting behaviours of nurses with LUTS at work, and work impairment measured by items from the Work Limitations Questionnaire (WLQ) [3] . The productivity domains examined were time management, mental concentration and physical demands. Scores for the WLQ were calculated as percentage of work impairment, for example, a score of 25% indicated that a respondent was limited in the particular domain during 25% of the reporting period (the previous 2 weeks). Survey questions included sociodemographic, health and female gender data known to influence the occurrence of LUTS. Respondents reporting a current pregnancy were excluded from analyses. P values are significant to <0.05 (two tailed).

The mean age of the included response sample (n=353) . Storage LUTS at work was significantly associated with delayed voiding (X 2 =20.53; P ≤ 0.001) and restricted access to toilets (X 2 =5.39; P = 0.020).

Limitation of fluids at work was significantly associated with urinary urgency (X 2 =6.25; P = 0.012) and nocturia (X 2 =5.18; P = 0.023). The proportions of nurses and midwives with urinary specific work impairments are shown in Figure 1 . Nurses and midwives with storage LUTS at work who limited fluids were more likely to a have time management work impairment than those who didn't (OR: 3.68; 95% CI: 1.58-8.61). Those who delayed voiding at work were more likely to have a concentration impairment than those who didn't (OR: 8.80; 95% CI: 1.07-72.16), with models adjusted for age, body mass index, back pain, anxiety, depression, storage LUTS at any time (not just at work) and other pelvic floor dysfunction (constipation, pelvic organ prolapse and urinary tract infection).

In this study almost one in two female nurses or midwives reported storage LUTS at work. Symptoms were associated with delayed voiding and lack of access to toilets. Limited fluid intake and restricted toileting behaviours are modifiable, hence storage LUTS and accompanying productivity loss preventable. Further investigations are required of workforce groups with workplace restrictions on the accessibility of these fundamental human needs. Workplace barriers to regular voiding and fluid intake need to be identified and solutions to improving healthy behaviours investigated. Sample characteristics are comparable to related demographic workforce data, which is a strength of this study. Limitations include the cross sectional design which precludes examination of causality and the potential for uncontrolled confounding. Sampling and response effects may have biased findings; practical workplace barriers precluded randomisation as a sampling strategy, and it was not possible to determine the number of nurses who had access to the electronic version of the survey.

Concluding message These findings have implications for workforce policy considering the preventable and treatable nature of LUTS at work. This health issue is a priority in occupational health with an ageing workforce, to allay future costs for employers and health care systems. The ability to drink fluids and access toilets at work is a public health concern, an occupational health issue and a fundamental human right. 

Hypothesis / aims of study This original work was designed to demonstrate a novel approach to the study of prevention for lower urinary tract symptoms (LUTS) in women and girls. While prevalence and risk factors for LUTS have been extensively studied, there has been little work in the area of LUTS prevention or "bladder health" promotion. This, in part, is due to the lack of a commonly accepted definition of optimal "bladder health." The general misconception that a response of "no" to LUTS questions implies "bladder health" has hindered our ability to appropriately identify modifiable risk factors. Epidemiologic studies classically use this methodology to define referent groups when calculating risk factors for LUTS. But, this does not ensure that those in the referent group are without other unassessed LUTS. Yet, strategies to mitigate risk factors have been suggested based on these false assumptions, particularly during pregnancy or in older women; and there has been little to no focus on primordial or primary prevention in girls, adolescents or younger women. Thus, to accurately identify and promote "bladder health," a systematic approach to defining "bladder health" across the life course is needed. This abstract describes the process by which a working definition of "bladder health" was developed to establish a foundation for developing instruments, and assessing outcomes of LUTS prevention and bladder health promotion in scientific research, clinical practice, and public health initiatives.

Study design, materials and methods A transdisciplinary research consortium comprised of U.S. experts in adolescent medicine, pediatrics, geriatrics, female pelvic medicine & reconstructive surgery, preventive medicine, community health science, psychology, nursing, medical sociology, behavioral science, epidemiology, and biostatistics was assembled to identify "bladder health" as a state to preserve and protect. We explored lessons from other health promotion research (e.g. cardiovascular health) and determined that there was insufficient evidence in "bladder health" to apply similar models. Thus, we proceeded in defining it using an iterative process starting with expert opinion (consortium members) to develop a framework for focus group exploration and population-based testing. Consistent with the World Health Organization (WHO) definition of "health," we propose that the absence of particular LUTS is insufficient to define "bladder health," and emphasize the ability of the bladder to adapt to short term physical, social, and psychological challenges [2, 3] . Further, in addition to the commonly defined phases of bladder function: 1) bladder storage and 2) bladder emptying, we identified 3) protection of the individual from infection, neoplasia, and other biologic threats as a third function. [3] This third bioregulatory function was added to reflect the increasing knowledge surrounding relationships between urothelial function, urinary markers, proteins and biomes associated with LUTS. After defining overall "bladder health", we used currently accepted LUTS definitions to capture various dysfunctions of the bladder and developed "healthy" counterparts to a variety of bladder functions. This iterative process began with a subgroup of investigators and then was validated by the larger consortium, and continues to be refined. Definitions were created recognizing that definitions of "bladder health" may vary across the life course; with development of continence in children reliant on bladder maturation and appropriate neurodevelopmental function, while storage capacity and emptying efficiency may change with advanced age.

The working definition of "bladder health" developed by the consortium is: "A complete state of physical, mental, and social wellbeing related to bladder function, and not merely the absence of LUTS. Healthy bladder function permits daily activities, adapts to short term physical or environmental stressors, and allows optimal well-being (e.g. travel, exercise, social, occupational or other activities)." A comprehensive table was developed to categorize dysfunction and health for each of the three bladder phases (Storage, Emptying and Bioregulatory). The table below is an excerpt of the working version of our tool to identify gaps in knowledge and areas for future "bladder health" research. Additional domains under each phase are described as "functions" Subjective and objective measures to assess health in each of these domains are proposed.

The bioregulatory category -the most novel element of the table -is organized in terms of three main bioregulatory functions: host defense/biosis barrier, chemical/physical barrier, and cancer barrier. We recognize that the bladder functions in a bidirectional manner to communicate with the environment, prevent systemic and/or local infection, transmit appropriate physiologic signals, and regulate cellular function. Possible biomarkers for LUTS prevention research were also compiled as targets of study as we move forward in our novel approach to understanding the healthy bladder.

Interpretation of results This is the first report of a definition of "bladder health" that has been systematically developed for purposes of studying LUTS prevention and bladder health promotion. Future efforts of this consortium include refining definitions, and developing and validating measures of bladder health for use in scientific research, clinical practice, and public health initiatives. We plan to describe the healthy bladder experience using community engagement and focus group methods, and intend to collect normative objective data for the three bladder functions. With this foundational work, we hope to lay the groundwork for development of survey instruments and other assessment tools to explore risk and protective factors for bladder health.

Concluding message This work provides a bladder health framework for research, clinical practice, and public health promotion.

Hypothesis / aims of study The abdominal sacrocolpopexy is considered to be a gold standard in surgical treatment of apical vaginal prolapse. Minimally invasive approaches specifically reduce morbidity associated with open sacrocolpopexy. Laparoscopic sacrocolpopexy has similar outcomes to abdominal sacrocolpopexy (1) . When compared to open techniques, robotic abdominal sacrocolpopexy is associated with less blood loss, shorter lengths of stay, and longer operative times. The present randomized study compares laparoscopic sacropexy (LSC) and robotic assisted sacropexy (RASC) in women with advanced pelvic organ prolapse (POP) to demonstrate the equivalence between the two techniques Study design, materials and methods Consecutive patients referred to our tertiary Department of Urology for symptomatic stage >II POP according to the POP-Q classification were prospectively randomized to test the clinical equivalence of RASC and LS, using a predetermined computergenerated randomization code. The local ethics committee approved the study . All patients signed an informed consent. Preoperative evaluation included detailed medical and urogynaecological surgery history, evaluation of storage symptoms, voiding symptoms, urinary incontinence (ICS standardization) and sexual activity, clinical examination, urodynamic study. Patients completed self-administered Urinary Distress Inventory Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), Female Sexual Function Index questionnaire (FSFI). All procedures were performed by 2 senior surgeons, with standardized technique. Surgical technique in laparoscopic and robotic-assisted is the same. Patients were followed up at 1, 3, 6, and 12 months after surgery, and then annually. At each visit, patients underwent clinical examination, evaluation of urinary and sexual symptoms, uroflowmetry with PVR measurement and Patient Global Impression of Improvement (PGI) questionnaire. Furthermore patients completed self-administered UDI-6 and IIQ-7 questionnaires annually and FSFI at 1 and 2 years. All the data present in our database were collected and recorded along the follow up period.The following outcomes were recorded: a) anatomic outcomes, b) functional outcomes c) complications d) global patient perceptions. Then we evaluated the difference between the two groups in terms of hospital stay length, blood loss, operating time. Statistical analysis was performed by using the non parametric Mann-Whitney U test was used for analysis of continuous variables and the categorical data were analyzed by using X2 test. . The subjective success rate was very high, 100% of patients of both groups reported to be "much satisfied" and "very much satisfied" at the PGI-I questionnaire.

Anatomic success rate was high in both groups, with more improvement in RASC group probably for the best technical characteristics of robotic procedures. Functional outcomes were comparable. These results were confirmed by PGI-I. Our work showed a relatively small increase in operative time in the robotic group, but it was not statistically significant, probably because the operating time in robotic procedure included docking and undocking time. Intraoperative blood loss was low in both groups mostly for RASC, however the statistical difference was not clinically significant. Mean hospital stay was about 4 days in both groups, this result is included in benefits of minimally invasive surgery.

Concluding message RASC aims at providing a similar excellent outcome as LSC in terms of anatomical results, satisfaction rate, complications, sexual function and voiding and storage symptoms relief. 

Hypothesis / aims of study Although a high success rate has been achieved in the early follow-up after suburethral sling for female stress urinary incontinence (SUI), there are limited data about long-term effects. The objective of this study is to survey the long-term durability of suburethral sling for female SUI and to identify urodynamic changes that are correlated with successful outcomes.

Study design, materials and methods Totally 434 women who underwent suburethral slings for SUI between October 1989 and November 2014 were enrolled in this survey. Patients received standardized urodynamic testing preoperatively as the baseline and postoperatively within 6 months. Successful outcome of suburethral slings was defined as negative cough and Valsalva stress test, no self-reported SUI symptoms, and no re-treatment for SUI. Surgical results, demographic characteristics, pre-operative and post-operative urodynamic parameters, and postoperative clinical manifestation were retrospectively analyzed. Changes in urodynamic parameters were correlated to a successful outcome.

The median follow-up period was 87 months. The overall subjective cure rate was 82.5%. Vaginal delivery and previous SUI surgery had negative influence on cure rate (P= 0.029 and 0.038, respectively). Concomitant pelvic organ prolapse (POP) surgery was beneficial for cure rate (P=0.03) ( Table 1) Table 2) .

Interpretation of results In this study, a trend suggests a correlation between greater increases in bladder outlet resistance and long-term successful surgical outcome. These findings suggest that, for sling operations, increased outlet resistance as measured by increased Pdet.Qmax, increased BOOI, decreased Qmax, decreased VE, and increased PVR are associated with better SUI-specific outcomes.

Concluding message Suburethral sling has a durable long-term effect in our study. The results indicate that decreased Qmax, decreased corrected Qmax and decreased VE are associated with surgical success, while increased Pdet.Qmax, increased BOOI, and increased PVR are also associated with success. Slight bladder outlet obstruction after sling operation provides long-term efficacy and success. The increased bladder outlet resistance seems essential for achieving dryness. 

Hypothesis / aims of study Lower urinary tract symptoms (LUTS) are highly prevalent in middle-aged and elderly men and are negatively associated with their quality of life (QOL), contributing to significant public health burden. Despite extensive research efforts, the etiology and mechanism of LUTS has not been fully elucidated. Prolonged sitting time can produce changes of musculoskeletal and vascular milieu in the pelvis and lower extremity and these changes may cause LUTS. We hypothesized that prolonged sitting time would affect adversely LUTS. No studies have investigated the association between sitting time and the incidence of LUTS independent of physical activity. We, therefore, evaluated the association of sitting time and physical activity level with the development of LUTS in a large cohort of men free of LUTS at baseline who participated in a health screening examination program.

Study design, materials and methods Data on demographic characteristics, education level, medical history, medication, smoking status and alcohol consumption, were also collected by self-administered, standardized questionnaires. The study population consisted of the subset of male Kangbuk Samsung Health Study participants who completed a physical activity questionnaire and underwent a comprehensive health examination from March, 2011 to December, 2014, and who had at least one follow-up visit prior to December, 2015 (n = 107,099). We excluded participants who had any of the following conditions at baseline: missing data for IPSS, the serum prostate-specific antigen (PSA) level ≥3 ng/dL, pyuria, hematuria, history of malignancy, history of cardiovascular disease, liver cirrhosis on ultrasound, history of kidney, bladder disease, renal failure or benign prostate hyperplasia, use of antipsychotic or antidepressant medication, use of medication for benign prostate hyperplasia, or use of medication for alopecia. Finally, we excluded participants with IPSS ≥8 at baseline. As some individuals met more than one criterion for exclusion, the total number of subjects included in the study was 69,795. Physical activity level and sitting time were assessed using the validated Korean version of the international Physical Activity Questionnaire Short Form. Physical activity levels were classified into three categories: inactive, minimally active, and healthenhancing physically active (HEPA), as previously described. sitting time was categorized into the following groups using cutpoints commonly used in previous studies: <5, 5-9, and ≥10 hours/day. Usual dietary consumption was assessed using a 106-item self-administered FFQ designed and validated for use in Korea. BMI and blood pressure was measured. Serum levels of fasting blood glucose, haemoglobin A1c, insulin, total cholesterol, HDL-C, LDL-C, triglycerides, total PSA are recorded. LUTS was assessed using the International Prostate Symptom Score (IPSS) and clinically significant LUTS was defined when IPSS score was 8 or higher. Cox proportional-hazards models were used to estimate the adjusted hazard ratios with 95% confidence intervals (CIs) for incident LUTS. Insulin resistance was assessed with the homeostatic model assessment -insulin resistance (HOMA-IR). Hypertension and diabetes was assessed.

Of the 175,810.4 person-years, 9,217 developed significant LUTS (incidence rate, 39.0 per 1000 person-years). In a multivariableadjusted model, both decreased physical activity level and prolonged sitting time were independently associated with the incidence of LUTS. The hazard ratios (95% CIs) for incident LUTS comparing minimally active and health-enhancing physically active (HEPA) groups to the inactive group were 0.94 (0.89-0.99) and 0.93 (0.87-0.99), respectively (P for trend <0.001). The hazard ratios (95% CIs) for LUTS comparing 5-9 and ≥10 h/day sitting time to <5 h/day were 1.08 (1.00-1.24) and 1.15 (1.06-1.24), respectively (P for trend <0.001).

Prolonged sitting time and decreased physical activity were positively associated with the development of LUTS in a large sample of middle-aged Korean men. This result supports the importance of both reducing sitting time and promoting physical activity for preventing LUTS. Concluding message We look at the impact on voiding symptoms of sitting time length and physical activity level. We conclude that prolonged sitting time and decreased physical activity may deteriorate voiding symptoms. 

Hypothesis / aims of study Central obesity is known to be an important risk factor of benign prostatic hyperplasia (BPH). Altough chronic Intraprostatic inflammation and alteration in androgen to estrogen conversion process associated with increased fat tissue are assumed as the factors which contribute to the development of BPH in obesity (1), the underlyning pathophysiological mechanism is unclear. Therefore, to findout the effect of obesity on the prostate, we investigated alternations in the histopathology and expression of inflammatory related cytokines and estrogen receptors (ERs) in the prostate using a high-fat diet-induced obesity rat model.

Male wistar rats (190-210g, n=8) were randomly assigned to either a normal diet (ND, n = 4) or a high fat diet (HFD, n = 4). The ND formula consisted of standard rodent chow containing 5 % fat. In contrast, HFD consisted of rodent chow containing 32 % fat. After the animals were maintained on these diets for 16 weeks, visceral fat and the lateral prostate were excized for analysis of weigt gain, histopathology and protein level of IL1α, IL1β, IL6, IL10, and monocyte chemotactic protein-1 (MCP-1) by multiple beads suspension array system as well as mRNA level of ERα and G protein-coupled estrogen receptor (GPER) by RT-qPCR. Statistical analysis was performed using Mann-Whitney U test. P values less than 0.05 were considered statistically significant Results After 16 weeks, HFD showed increased weight of body, visceral fat and lateral prostate compared to ND(P < 0.05). In hematoxyline eosin stain, lymphcyte and macrophage infiltration into glandular and stromal area were shown in the lateral prostatic tissue section from HFD while ND did not demostate inflammatory cell infiltration. Additionally, masson's trichrome stain demonstrated increased collagen fiber in the stroma of the lateral prostate of HFD compared to ND. Protein levels of IL1α, IL1β, IL6 and MCP-1 were significantly increased compared to ND (P < 0.05). In contrast, protein levels of IL10 was significantly decreased in HFD compared to ND (P < 0.05) (Figure1) . Furthermore, RT-qPCR revealed significantly increased mRNA level of ERα and GPER in HFD compared to ND (Figure2).

In this study, HFD-induced obesity rats demonstrated lateral prostatic inflammation in association with alterd immunobalance evidenced by increased protein level of IL1α, IL1β, IL6 and MCP-1 and decreased level of IL10, an anti-inflammatory cytokine which is known to be decreased in metabolic syndrome (2) , correlated with central obesity in rats evidenced by increased weight body and visceral fat. Furthermore, lateral prostatic enlargement was shown in HFD associated with upregulation of ERα and GPER which are reported to play an important role in prostatic abberant proliferation and inflammation leading to prostatic hyperplasia (3) . These results suggest that high fat diet intake might caused prostatic inflammation and enlargement via metabolic inflammation and hormonal change followed by ERs activation.

We demonstrated that high fat diet intake induces prostatic enlargement and inflammation in association with alterd immunobalance and expression of estrogen receptors. Therefore, anti -inflammatory agents or estrogen receptor modulater could be therapeutic alternatives for the treatment of BPH in patients with obesity.

Hypothesis / aims of study The ICIQ-UAB is the first patient reported outcome (PRO) measure for the assessment of the symptoms and impact associated with underactive bladder (UAB), developed in-line with the Food and Drug Administration (FDA) PRO guidance (2009, 2014) . UAB is the proposed symptom complex associated with urodynamically diagnosed detrusor underactivity (DU). This study describes the pilot testing of the psychometric properties of the draft ICIQ-UAB in patients with known DU. Based on the initial qualitative interview phase, a draft of the ICIQ-UAB was developed consisting of the following domains:

•

Symptoms, signs and related bother (20 items) • Impact and related bother (8 items) To assess the measurement properties, the reliability (test-retest reliability, internal consistency), validity (known group validity, convergent and divergent validity) and item distribution of the draft ICIQ-UAB were investigated. For symptom and sign items, different versions with a 24 hour and 1 week recall period were tested.

Study design, materials and methods Patients recruited for the study met eligibility criteria based on pressure flow study (PFS) parameters for DU. Patients completed paper versions of the ICIQ-UAB and seven validated concurrent PRO measures relating to general health, urinary symptoms, and severity, over a period of 10 days. ICIQ-UAB (1 week) was completed on days 1 and 8, and ICIQ-UAB (24 hr) on days 1, 2, 3 and days 8, 9, 10.

A total of 54 patients with a primary diagnosis of DU on PFS were recruited from 8 sites in the United Kingdom, Netherlands and Germany. The mean age was 61.2 years, 80% were male (n=43) and all patients were Caucasian. Overall, the level of missing data on items was less than 7%. Items were considered to have a floor effect if >20% of the patients answered the lowest response option (1st of 5). A total of 9 of 20 of the symptom and sign items and all of the impact items in the ICIQ-UAB (1 week), and 12 of 20 symptom and sign items in the ICIQ-UAB (24 hr) had floor effects. Following sub-group analysis using subjects with moderate to severe symptoms as determined by the Patient Global Impression of Severity (PGI-S), the floor effects found were reduced to 4 symptom and sign items in the ICIQ-UAB (1 week) and 3 symptom and sign items in the ICIQ-UAB (24 hr). Internal consistency for the ICIQ-UAB (1 week) was high (Cronbach's α = 0.85), and similar for the ICIQ-UAB (24 hr) (α = 0.86). Table 1 shows the intra-class correlation coefficient (ICC) for the ICIQ-UAB (1 week) and ICIQ-UAB (24 hr) when calculated between consecutive administrations in 'stable' patients (n=42) as determined by the Patient Global Impression of Change (PGI-C). Evidence for scale construct validity for both versions based on correlations with concurrent PRO measures was acceptable. The symptom subscales of both versions were able to differentiate between groups of known severity: participants with moderate to severe symptoms (based on the PGI-S) had higher scores (analysis of covariance p<0.005).

Overall, the ICIQ-UAB, both 1 week and 24 hour versions, showed acceptable reliability and validity. The internal consistency and test-retest reliability were above the standard threshold of 0.7 to indicate acceptable reliability in both versions. Convergent and discriminant validity was demonstrated by the correlations with concurrent PRO measures. The analysis of groups of known severity supports the validity of the symptom subscales. The high floor effects found on some items may indicate further revisions (revised response options, deletion of items, or removal of items from the scoring) are required.

These results provide initial evidence to support the reliability and validity of both versions of the draft ICIQ-UAB in a pilot setting. Following minor revisions, further assessment of the measurement properties will be conducted in larger studies, to confirm the suitability of the ICIQ-UAB for use as a research and clinical outcome measure. 

Hypothesis / aims of study Most treatment algorithms for lower urinary tract symptoms (LUTS) begin with an assessment of patient bother. If the patient is not bothered, only reassurance and follow-up are advised. The assumption behind this recommendation is that 1) if the symptoms are not bothersome, the underlying condition is not serious enough to warrant further investigation; 2) the worse the symptoms, the greater a patient will be bothered by those symptoms; and 3) the worse the symptoms, the greater the severity of the underlying condition. The aim of this study is to analyse the correlations between bother scores on LUTS questionnaires in order to determine the extent to which these hypotheses are true.

Study design, materials and methods This is an IRB approved retrospective multicenter study of men referred for LUTS who completed the LUTS score (LUTSS) on a mobile app or website, and the results appeared on the doctor portal (figure 1). Contemporaneous uroflow (Q) & post-void residual (PVR) were obtained. Spearman's correlations were calculated between the LUTSS bother score and the LUTSS sub-scores, Q and PVR. Results 1189 patients completed the LUTSS; 436 females and 753 males aged 13 -99 years (mean 59 years, SD 18). Of the 753 males, the correlation between the total LUTSS vs. bother was strong (0.76), while the correlation between the total AUASS vs. bother was moderate (0.48). There was also a strong correlation between the storage and OAB sub-scores vs. bother (0.62, 0.61 respectively). The correlation between the voiding sub-score vs. bother (0.56) was moderate and there was a weak correlation between the incontinence and nocturia sub-scores vs. bother (0.35, 0.37). The box and whisker plot shows wide overlap between symptom severity and bother (Plot 1). The correlation between Q, PVR vs. bother was very weak ( Table 1) .

Although there was a strong correlation between symptom severity as measured by the total LUTSS, storage and OAB subscores, there was considerable overlap; some patients with few symptoms had severe bother and some patients with severe symptoms had little or no bother. The correlation was weak or moderate between bother and voiding dysfunction, incontinence, and nocturia. These data suggest that patients are much more bothered by OAB than voiding symptoms, incontinence, or nocturia. Most importantly, though, there was no correlation at all between bother and either Q or PVR. In fact, 26% of men with no bother at all had PVR > 200 mL and 65% had Q < 11mL. This is most disconcerting insofar as, if one uses bother as a criteria for pursuing a workup or treatment for LUTS, serious conditions may be overlooked.

The correlation between patient bother, symptom severity, and the severity of the underlying LUT condition is inexact. Some patients with severe bother have few symptoms, while some with little bother have moderate symptoms. The poor correlation 

Hypothesis / aims of study Lower Urinary Tract Symptoms (LUTS) in males are a condition with which the urologist has to deal daily. Two simple, useful, and popular diagnostic tools are voiding diaries (VD) and uroflowmetry (UFM). Voiding diaries are a semi-objective method of quantifying LUTS, and have the great avail to register more physiological voided volumes (VV). Uroflowmetry is a widely used non-invasive urodynamic test whose diagnostic accuracy is substantially influenced by threshold values of voided volume (1). Aim of the study was to assess the correspondence between the more physiological voided volumes at VD and the voided volumes at the UFM.

Study design, materials and methods This is a observational prospective multicenter study. We analyzed a cohort of 345 male patients with LUTS. Each patient scheduled for a UFM had a VD to fill at home. The return of VD could have been by mail, email, social network, or during office evaluation. Statistical analysis was performed using T student and Mann-Whitney test.

Currently, only 103 male patients (29.8%) returned the filled VD. Average age was 68.74 (DS 10.36 years). We found a statistical difference between the average voided volumes at UFM and at VD (p <0.001). A statistical difference was assessed also between the median of voided volumes at UFM and VD (p 0.0018). Data are reported in Table 1 . Data regarding differences in voided volumes between VD and UFM are listed in Table 2 . Interpretation of results Since the most physiological micturition is obtained at own home, we considered the voided volumes recorded in diaries as the most physiological. We found a poor correspondence between the voided volumes reported in voiding diaries and those obtained during UFM. This difference in voided volumes was present in the half of patients when 100 ml was the "threshold difference", and 69% of the patients when the "threshold difference" was 50 ml. This means that e relevant number of the patients had a nonphysiological micturition. Moreover, in 25% of patients the difference of voided volumes was >150 ml, meaning that in this group UFM was not a real picture of physiological micturition.

Concluding message Average and median voided volumes between VD and UFM have a poor correspondence. Only a half of the patients had similar voided volumes at VD and UFM. This data could explain how sometimes UFM results do not correspond to the reported voiding condition. Furthermore, the difference between voided volumes at VD and UFM could explain some unexpected outcomes after therapeutic treatments. 

Hypothesis / aims of study Pressure-flow studies (PFS) are the most accurate invasive urodynamic technique to investigate functional mechanism of male lower urinary tract symptoms (LUTS) (1) . PFS allow diagnosing bladder outlet obstruction (BOO) or detrusor underactivity (DU). As post void residual (PVR) urine is still a parameter under investigation in men with LUTS, in order to asses a more accurate PVR, we consider the ratio of PVR to bladder volume (BV) called PVR ratio (R-PVR). Aim of the study was to evaluate the role of R-PVR in men with LUTS and R-PVR association with the urodynamic diagnosis.

Study design, materials and methods We analyzed from our urodynamic database all male patients with LUTS that performed PFS from January 2012 to December 2016. All urodynamic tests were performed according to The Good Urodynamic Practices (2) . Using Schäfer nomograms we subdivided males according to detrusor contractility, considering detrusor underactivity as "very weak" and "weak" classes. BOO was defined as class of obstruction II-VI according to Schäfer nomograms. Figure 1 shows how the cohort was subdivided and analyzed. BV was calculated as VV (voided volume) + PVR. R-PVR was calculated as the ratio of PVR to BV. We investigated R-PVR and PVR in all the described classes. BOO was also assessed using the International Continence Society (ICS) nomograms, considering only the classes "unobstructed" and "obstructed". Statistical analysis was obtained by Mann-Whitney test. Figure 1 . Division of the patients groups according to Schäfer nomograms.

We analyzed 308 consecutive male pressure-flow studies. Patients mean age was 61.6 years (+/-14.6). Table 1 reports median R-PVR and PVR of obstructed and unobstructed patients stratified for detrusor contractility, according to Schäfer nomograms. In Table 2 median R-PVR and PVR of underactive and non-underactive patients have been stratified according to Schäfer's obstruction nomograms. Our data showed that both R-PVR and PVR were different in all compared groups (p < 0.001). According to ICS nomograms, median R-PVR and PVR have been compared between obstructed and unobstructed patients, and a statistically significant difference was found (Table 3) . Interpretation of results Our analysis showed that both R-PVR and PVR were higher when detrusor underactivity and obstruction were associated. Currently, we have not been able to state a R-PVR threshold to define a specific clinical condition. However, our data showed that in patients with both underactivity and obstruction the median R-PVR was 50%. Instead, in patients with obstruction and normal detrusor contractility the R-PVR was only 24%. In patients without pathological condition of BOO and DU, both median R-PVR and PVR were "0" because of their complete bladder emptying. According to ICS nomograms, considering only the classes of clear obstruction or non-obstruction, both median R-PVR and PVR were different in the two groups (p < 0.001).

Concluding message Post-void residual urine is one of the parameters used in the evaluation of male LUTS and correlate with R-PVR. Even if a threshold of R-PVR associated to specific clinic conditions was not yet found, our data showed a significant increase of R-PVR when a condition of detrusor underactivity was associated to BOO. Therefore, in males with LUTS and suspected BOO, R-PVR is useful to suggest an underlying condition of detrusor underactivity that may request a better evaluation with PFS.

Hypothesis / aims of study In the treatment of male lower urinary tract symptoms (LUTS) patients with overactive bladder (OAB), urgency is the main symptom of OAB and the satisfaction of the treatment of LUTS can be affected by the severity of urgency. We examined how urgency severity affects efficacy or satisfaction in LUTS treatment of the male patients with benign prostatic hyperplasia and OAB.

Study design, materials and methods From 2012 January to 2013 June, 78 male LUTS patients were prospectively enrolled. Inclusion criteria were age over 40 years, international prostate symptoms score (IPSS) over 8, overactive bladder symptoms score (OABSS) over 3 with question 3 score over 2. In all patients, bladder diary of 3 days with incorporation of 5 stratified urgency scaling at each voiding or urgency episode, patient-perceived bladder condition (PPBC), prostatic ultrasonography, prostate-specific antigen (PSA) and uroflowmetry with residual urine check were examined. All patients received tamsulosin 0.2mg and solifenacin 5mg daily. 12 weeks later, IPSS, OABSS, PPBC, patient-received treatment benefit (PPTB), bladder diary and uroflowmetry were examined again. According to baseline urgency severity, patients were divided as 2 or more urgency per day (group I) and urgency less than 2 times per day (group II). Comparisons between the 2 groups about the various parameters was made using independent T-test. P-value less than 0.05 was regarded as significant. Interpretation of results Patients with more severe urgency have the worse baseline subjective bladder condtition but this difference attenuates after treatment. This means that patients with severe urgency appear to experience more treatment benefit with anticholinergics and alpha blocker than those with less severe urgency.

In the alpha blockers and anticholinergics treatment of male LUTS patients with OAB, the treatment efficacy and satisfaction of the patients is higher in the more severe urgency patients. 

Hypothesis / aims of study This study aimed to compare real−time bladder sensation generated through the use of a novel sensation meter in overactive bladder (OAB) patients undergoing an accelerated hydration protocol with a different group of OAB patients undergoing urodynamic studies (UDS). The purpose of the comparison was to potentially identify sensation patterns that might be useful to non-invasively sub-type different forms of OAB.

Study design, materials and methods Two different groups of OAB patients were enrolled in separate IRB approved studies involving the use of our novel sensation meter during accelerated hydration [1] or during UDS. The ICIq-OAB survey question 5a ("Do you have to rush to the toilet to urinate?") was used to categorize participants: those who answered 3 ("most of the time") or 4 ("always") were considered to have OAB. In the accelerated hydration study, OAB participants drank 2L of Gatorade-G2® as rapidly as possible and then completed two fill/void cycles while recording real-time sensation. In the UDS study, participants underwent cystometric filling at a rate of 10% expected capacity per minute based on the maximum voided volume recorded on a three day bladder diary. All participants recorded real−time sensation (0-100% scale) using a touch-screen sensation meter [1] . A two-tailed power study with significance level of 0.05 and power of 80% was performed in R using previously published data [2] comparing bladder volumes in OAB patients at different sensations resulted in a sample size of 7 (6.22) people in each group would be required, but this study aimed to recruit 14 in each group to account for participants who may fail to complete the protocol or to have non-evaluable data. The UDS fill volume (550.4 ml) was less than the total volume of the hydration fills, but this was only significant compared to fill 1 (p = 0.033 compared to fill 1, p = 0.064 compared to fill 2). During accelerated hydration there was a left-shift in the sensationcapacity curve from fill1 to fill2 at 15-20%, 35-40%, and 85% sensation levels (Fig. 1A) . During UDS, the sensation-capacity curve was significantly lower than hydration fill 1 at 75-95% sensation (Fig1B). Percent capacity was also significantly lower for UDS when compared to hydration fill 2 at lower sensation levels (45-55% and 65% sensation) (Fig. 1C) .

The left shift seen in the OAB group from fill 1 (slow fill) to fill 2 (faster fill) was a surprising result as increased tension (and thus increased afferent nerve activity) would be expected at a faster deformation rate in a soft tissue. This suggests that the roles of desensitization and training may play more important roles than bladder muscle biomechanics in individuals with OAB. Interestingly, our previously published study showed the opposite result (right-shift) during hydration for asymptomatic volunteers (1) . The UD curve (fastest fill) initially lay between the curves for hydration fill 1 and fill 2 and was generally closer to fill 1 despite utilizing a much faster fill rate. This, again, may indicate that the identified left shift is an effect of desensitization and/or training as opposed to a biomechanical viscoelastic change. A study in rats showed a large increase in fill rate in a second cystometric bladder fill rate sometimes decreased afferent nerve response, demonstrating desensitization [3] . These results may indicate that desensitization is common in humans with OAB and may provide rationale for more behaviour-based rather than pharmacologic treatments in this population.

This study demonstrates the value of non−invasive hydration as a means to characterize real-time bladder sensation in participants with OAB. Accelerated hydration data in OAB patients were largely consistent with UDS. Differences between fill 1 and fill 2 reveal dynamic characteristics of the bladder that cannot be identified by a single UDS fill and suggest that bladders in subjects with OAB may undergo acute changes in bladder compliance, tone, training, sensitization, and other factors. This type of real-time sensation metrics could ultimately be used to identify sub-groups of OAB patients that would respond better to behavioural interventions (right-shifted sensation-capacity curve in fill 2 vs. 1) and those that might have purely biomechanical defects (left-shifted sensation-capacity curve in fill 2 vs. 1).

Hypothesis / aims of study To evaluate in vivo accuracy of intravesical pressure measurement using a prototype of a wireless intraluminal vesical pressure measurement device in awake animals Study design, materials and methods Design of the bladder pill has been previously reported, which consists of a circuit board containing a pressure sensor microchip combined with a 3 dimensional coil (1). Paired with a belt carrying the transmitting coil, circuitry and battery, which allows free ranging of the animal. The pill measures 5x15 mm, and a polyurethane pigtail 6 Fr in size is affixed to the device to prevent loss. We report results of a pilot study by transurethral insertion in a 50 kg female Göttingen minipig. Simultaneous pressure measurement is performed by insertion of double channel air charged urodynamic catheter and filling cystometry is performed. Animals are housed in accordance to national guidelines and institutional animal ethical approval for experiments were obtained. Investigations are performed in accordance with the ICS Good Urodynamic Practice guidelines.

Data from 4 filling and voiding cycles were obtained. Measured pressure showed strong correlation both in non voiding events (r=0.8008) as well as voiding pressures (r=0.8938). The Bladder Pill is retained in the bladder during filling and voiding cycles. No expulsion was observed up to 48 hours until transurethral extraction by cystoscopy.

Interpretation of results We previously reported feasibility of wireless and catheterless pressure measurements in vivo. (2) In this report, we demonstrate recording of pressure during both filling and voiding phase of bladder function in awake animals. Pressure data from the bladder pill shows good correlation with catheter based measurements.

Concluding message This modification of the Bladder Pill reports results of longer recordings of a pill type device which can be retained within the bladder for consecutive voiding cycles. These results are promising for test and development of the device, with device and animal dimensions compatible for human use.

aspect of fluid dynamics. Although urine flow velocity was assessed by ultrasonography (US) (1), especially power Doppler US, fluid dynamical assessment including direction and vorticity of urine flow in urinary bladder and urethra has nat investigated yet. (1) (2) (3) In patients with voiding dysfunction induced by benign prostatic hyperplasia (BPH), vorticity may be interrupted by compression or deformity of urethra by prostatic adenoma. Indeed, a flatten-shape duct is not ideal to pass fluid making vorticity whereas a round-shape duct can keep enough space to make vorticity. Althoug fluid dynamics may be important to understand pathology of BPH patients, there are no clinical method to assess fluid dynamics including vorticity passing urethra. Therefore, to establish methodology is one of the most important problems to assess LUT in the aspect of fluid dynamic. On the other hand, color Doppere ultrasonography (CDUS) is common clinical modality to evaluate fluid dynamics in blood circulation. Herein, we attempted to observe fluid dynamical characteristics of urine flow in male urethra using CDUS. As the first step of fluid dynamical assessment of LUT, urine flow was observed using CDUS in the prostatic urethra with enough space for flow direction observation, just after transurethral surgery for BPH. The aim of this study is development of method to evaluate urine flow in the aspect of fluid dynamics, especially flow direction and vorticity.

Study design, materials and methods A patient who was diagnosed as BPH was enroled in this study. Under general anesthesia, Holmium Laser Enucleation of the prostate (HoLEP) was parformed. Digital ulgrasoographic diagnostic system (HIVISION Preirus, HITACH, Tokyo, Japan) was used in this study. Fine Flow mode (high flame rate and high resolution of color imaging mode) was set up to detect direction of fluid flow as CDUS. Just after HoLEP, prostatic bleeding was coagulated using bipolar resect scope. Micro bubbles are fulled in urinary bladder for a while. (Fig. 1A, B, C) The top of external cylinder was placed on urethral sphincter to make the urinary bladder empty, and transabdominal ultrasonogaphy was done to observe direction of fuid flow saggitally. (Fig. 1D) The results were recorded in the hard-disc-drive in the US system as movie, and were analysed dynamically. All of the above procedures was done under general anesthesia in lithotomy position.

After transurethral coagulation, micro bublles diffused in urinary bladder. (Fig. 2A, B) After removal of internal cylinder placing urethral sphyincter, micro bubbles started to make flow from all direction to bladder neck. (Fig. 2C ) And, Doppler signals were revealed in prostatic urethra under ultrasonography with CDUS. Moreover, the Doppler signals in the prostatic urethra, red and blue signals made clear contrast alternately. (Fig. 2D ) During the voiding, the contrast of blue and red signals remained at the end of voiding. (Fig. 2E, F) Interpretation of results Using transabdominal CDUS, the directions of urine flow in the prostatic urethra were successfully observed in this method. The red and blue Doppler signals showed clear contrast in prostatic urethra alternately. These findings indicted that urine flow in the prostatic urethra is vorticity to reduce the flow resistance. (Fig. 2G, H) This phenomenon is rational in the aspect of fluid dynamics. Micro bubbles generated by transurethral coagulation assisted to see urine flow in the urinary bladder outside of CDUS windows. This method is helpful to conduct fluid dynamical assessment in LUT widely. This is the first report to assess urine flow in the aspect of fluid dynamics using CDUS, and to observe vorticity in prostatic urethra just after HoLEP. Indeed, there are many limitations, such as general anesthesia, position, and condition just after surgery. However, possibility of fluid dynamical assessment was shown in these results. In the aspect of fluid dynamics, vorticity can be a new parameter to understand normal and abnormal urine flow.

The results of this study indicates that CDUS can be a method to observe direction and vorticity of urine flow in urethra. 

Hypothesis / aims of study Benign prostatic enlargement (BPE) and its consequences, bladder outlet obstruction (BOO) and acute urinary retention (AUR) are a common condition in the aging man. Abrams-Griffiths number (A-G) is considered as the gold standard to evaluate BOO. Unfortunately it needs invasive investigation. The D index derived from free uroflow (FF) has been developed to assist in the management of BPE patients [1] . D is an index of voiding dysfunction. Our purpose was to build a tool based on D (non invasive) to evaluate BOO in men, which is usable by a general practitioner. [3] ) the (no recorded) detrusor pressure during FF (without reflex) and so to obtain an amended value of AG (cor-AG) [3] : cor-AG = pdetQmax.FF -2*Qmax.FF which has the same cut-off values as A-G. 

Hypothesis / aims of study Sacral neuromodulation (SNM) is an effective treatment for overactive bladder syndrome (OAB) when conservative treatment fails. If patients show a successful response to test stimulation, a permanent device is implanted. Success is defined as more than 50% improvement in voiding diary parameters. Currently, the frequency, voided volume per void and number of leakages are the parameters used for evaluation of treatment effect. However, bladder sensations such as urgency and bladder fullness can also be documented by the use of sensation-related bladder diaries (SR-BDs). It has been previously shown that bladder sensations differ between OAB patients and healthy volunteers. Furthermore, SR-BDs could be used to evaluate treatment effect. The aim of this study is to evaluate the influence of SNM on bladder sensations in patients with OAB.

In a prospective longitudinal cohort we included patients, diagnosed with OAB using the ICS criteria. All patients had failed conservative treatment including physical therapy and anticholinergic drugs. Test stimulation was conducted using the tined lead procedure. All procedures were performed under local anaesthesia. Patients filled in a SR-BD for 3 consecutive days, one at baseline and the second during test stimulation. The sensation-related bladder diaries include, besides the conventional parameters, a 4-points urgency scale (0=no bladder sensation, 1=voiding can be delayed for more than 30 minutes, 2=voiding can be delayed for at least 10 minutes, 3=voiding cannot be Delayed), and a bladder fullness Visual Analogue Scale ranging from 0 to 10. Sample size calculation showed that 29 patients are needed at a 95% confidence interval. After testing for normality using a Shapiro-Wilk test, histogram and boxplot, either a paired samples test or a Wilcoxon signed rank test was used to examine differences in parameters before and during test stimulation.

We included 31 patients with OAB who were eligible to undergo SNM test stimulation. The results of the SR-BD showed that patients void less frequently (12.5 vs. 9.1 /24h; p<0.001) with a higher mean voided volume (160 vs. 188 ml/micturition; p=0.003). The mean degree of urge was significantly lower with SNM (2.4 vs. 1.9 /micturition; p=0.002). In addition, the mean voided volumes were higher for each degree of urge during SNM (figure 1). The mean perception of bladder fullness was similar ( figure  2 ). When looking at the distribution of daily voids per degree of urge, SNM reduced the number of voids with higher degree of urge (figure 3). Interpretation of results Besides frequency and voided volume, SNM reduces the degree of urge experienced by OAB patients. Perception of bladder fullness shows no change during SNM.

Concluding message SNM has a direct influence on bladder sensations. SR-BDs can provide additional information compared to the standard voiding diaries, which may be useful in clinical practice. Hypothesis / aims of study Urgency urinary incontinence (UUI) is prevalent, and the utilization of third line therapy is increasing. We compared urgency urinary incontinence episodes (UUIE) over a 24-month period in women treated with either sacral neuromodulation (SNM) or intradetrusor onabotulinumtoxinA (BTX).

Study design, materials and methods 381 eligible women were randomized to either SNM or 200 U BTX. Based on PGSC scores, reprogramming and revisions were evaluated in the SNM group, and two additional injections were allowed in the BTX group after 6 months. The primary outcome was change from baseline in mean daily UUIE over a 24-month period as measured by bladder diary. Secondary outcomes included no UUIE and >75% UUI reduction, quality of life, satisfaction, and adverse events.

Results 293 had primary outcome data at 24 months. There was no difference in mean decrease in UUIE between the two groups over 24 months (Fig 1) . The BTX group was significantly more likely to experience complete resolution of UUI and >75% reduction within the first year, but this difference was not seen at 24 months (Fig 2) . No difference in overactive bladder symptom bother improvement was seen after 6 months; however, higher satisfaction (mean difference = -9.3, 95% CI= -15.2, -3.4) and treatment endorsement (mean difference = -10.49, 95% CI= -16.7, -4.1) were sustained to 24 months in the BTX group. There were no differences in other QOL measures. In the BTX group, 70% requested a 2nd injection (mean interval was 385 days SD + 172) and 35% requested a 3rd (mean interval between 2nd and 3rd was 290 days SD + 96). 1.8% chose to dose reduce. SNM revision and removals occurred in 3% and 9%, respectively. 30% of subjects in each group opted for additional medication or alternative study therapy. Recurrent urinary tract infections at 24 months were 27% in the BTX group and 10% in the SNM group, p = <0.0001. Interpretation of results SNM and BTX resulted in similar reductions in mean daily UUIE at 24 months. BTX was more likely to provide complete resolution of UUIE in the first year compared to SNM. Higher satisfaction and treatment endorsement throughout 24 months was seen with BTX compared to SNM. Use of additional therapy was similar between the two groups, but UTI rates were higher following BTX.

At 24 months, SNM and BTX resulted in similar reductions in mean daily UUIE. BTX was more likely to provide complete resolution of UUIE in the first year and higher satisfaction and treatment endorsement throughout 24 months. Use of additional therapy was similar, but UTI rates were higher following BTX. 

Hypothesis / aims of study Overactive bladder without detrusor overactivity (OAB without DO) is an "extraordinary" form of OAB. The exact pathogenesis of this condition is unknown. Antimuscarinics, β3-adrenoagonists, intradetrusor botulinum toxin injections are standard treatment for patients with OAB without DO 1 . However, antimuscarinics are associated with high incidence of side effects, including dry-mouth, constipation and blurred vision 2 , and often are not effective enough to reduce OAB symptoms.

The aim of study was to investigate the efficacy of percutaneous tibial nerve stimulation (PTNS) and transcutaneous tibial nerve stimulation (TTNS) in patients with OAB without DO who didn't respond to antimuscarinics. Study design, materials and methods 35 (24 female and 11 male) patients with OAB without DO were included in our study. All of them had OAB symptoms: urgency, urge incontinence and frequency. The urodinamic study was performed to all patients -there were no signes of DO. According to their medical history, they were refractory to different antimuscarinic drugs (solifenacine, oxibutinine, trospium chloride, tolterodine) within the mean perod 26,8±8,7 (12 -44) weeks. All participants received a treatment course of PTNS (weekly administration during 12 weeks). The patients, who had good results (≥ 50% improvement) after PTNS, were prescribed TTNS at home (with the same schedule).

Results 24 (70%) from 35 patients had the improvement of results ≥ 50% after the course of PTNS (12 weeks). (Table 1) . Table 1 parameters

Urge incontinence episodes Urgency episodes Frequency Quality of life (EQ-5D) score Before treatment 4,6 ± 0,2 6,4 ± 0,3 15,3 ± 0,5 43,0 ± 1,3 In 12 weeks of PTNS (n=35) 1,9 ± 0,2 * 2,8 ± 0,3 * 9,8 ± 0,3 * 73,8 ± 3,3 * * -statistical significance ≤ 0,05

After completing the 12-week period of PTNS, 24 patients with good results were enrolled in the second stage of the study with TTNS at home. (Table 2 ). Table 2 parameters

Urge incontinence episodes Urgency episodes Frequency Quality of life (EQ-5D) score Before treatment 4,2 ± 0,3 6,2 ± 0,4 16,6 ± 0,5 42,3 ± 1,1 In 12 weeks of PTNS (n=24) 1,1 ± 0,2 * 1,7 ± 0,2 * 9,1 ± 0,3 * 85,1 ± 2,1 * In 12 weeks of TTNS (n=24) 2,2 ± 0,3 * 3,5 ± 0,2 * 10,7 ± 0,4 * 67,9 ± 1,9 * * -statistical significance ≤ 0,05 There were not any adverse events in both groups.

Our results demonstrate statisticaly significant improvement of urgency, urge urinary incontence, frequency and quality of life in patients with OAB without DO after administration of both methods (PTNS and TTNS). However better results were observed in group with PTNS, as in whole coghort of patients, as in 24 patients with more than 50%-improvement after the first stage of study.

Concluding message PTNS and TTNS are effective and safety methods of treatment in patients with OAB without DO, refracted to anticholinergic drugs. Regarding our results, PTNS shows better outcomes in compare with TTNS, and could be a treatment method of secondline in the management of OAB without DO. Hovewer, TTNS could be also prescribed in this kind of patients, especcialy as supportive treatment, because of its convenience and easy to use by patients at home, pretty good efficacy and safety.

Hypothesis / aims of study Sacral neuromodulation is a well-accepted treatment for overactive bladder, non-obstructive urinary retention and faecal incontinence. A lead is placed through the 3 rd or 4 rd sacral foramen to stimulation the sacral nerve roots, and position is determined based upon clinical observation of an inward movement of the bellows (e.g. pelvic floor contraction). However for urological when the needle was in the cranial position compared to the caudal. Furthermore, for clinical practice voltage at or below 2V are advised for lead placement to spare battery life during sacral neuromodulation treatment. Looking at the EMG responses upon low voltage stimulation showed significantly more PF activity when the cranially placed needles were stimulated compared to the caudally placed ones.

Concluding message Position of the needle inside the foramen determines the pelvic floor muscle activation. A cranial position inside the foramen gives the strongest contraction of the pelvic floor. This should be the position aimed for to release the tined lead for sacral neuromodulation. Study design, materials and methods A systematic literature search for full length original articles meeting the following inclusion criteria was conducted: a) patients with pelvic pain syndromes, such as Interstitial Cystitis (IC), Bladder Pain Syndrome (BPS), as well as patients with non-specific pelvic pain syndromes such as genital pain or urethral pain, not initiated by surgery, oncology or other underlying pathology; b) treatment with one of the following neurmodulation technqiues: Percutaneous nerve stimulation (PTNS), Sacral neuromodulation (SNM) and Pudendal neuromodulation; c) reporting pain-specific outcomes; d) published in English in a peer-reviewed journal. Reviews, case reports, expert opinions, abstracts and comments were excluded. Two authors independently examined titles, abstracts and full text articles. There was no age restriction on the articles and the last search was dated March 1 st 2017. PRISMA guidelines were used and risk of bias assessment was performed according to the Cochrane Collaboration guidelines. Two authors performed data extraction and quality assessment independently, using a standard data extraction form.

In the PubMed search 258 records were identified and the abstracts screened for eligibility. Eventually 114 full text articles were assessed for eligibility, 78 articles were excluded resulting in a final set of 36 articles out of 35 studies. There were several reasons for exclusion, malignancy, trauma, no pelvic pain, bowel disorders, no pain scores or a technique focus trial without clinical result mentioned. PTNS was used in 8 trials, treating 204 patients with CPPS. The clinical results strongly varied between the trials. In one study, which compared PTNS with a sham procedure, 40 % of the patients had objective success on the VAS scores with a follow up of 12 weeks. The other studies showed improvement of 25-50% on the VAS scores with a short follow up. In addition, 3 trials showed no significant results on the VAS pain scores. SNM was described in 23 trials: 11 retrospective and 12 prospective studies. In total, 523 patients, mostly females, were treated with SNM. PNE test was used in 14 trials. The follow-up ranged from 6 till 61 months. Nearly all studies reported a positive result, with success rates ranging between 25 to 73%, only one study reported no significant improvement. In general the level of evidence was low and the risk of bias high. Pudendal stimulation for BPS was evaluated in one trial, which randomised between SNM and pudendal stimulation. No difference was found between the outcomes of the two treatments

The currently available studies suggest that neuromodulation may be a valuable treatment option in patients with refractory chronic pelvic pain. However, the reported studies are mostly retrospective and with relatively small groups of patients. Most trials have high risks of bias and the results are variable. Symptoms were assessed via OSSI/OSPI, NRS and frequency volume chart prior to therapy and at four weeks after the last instillation. Four weeks after the therapeutic period, all the enrolled patients selected one of seven grades of global response assessment (GRA; markedly improved, improved, slightly improved, no change, slightly worsened, worsened, and markedly worsened), and patients graded better than "slightly improved" defined as responder. Adverse events were monitored by interviewing patients every time before instillation. The primary endpoint was GRA at four weeks after the last instillation. Other outcome measures were compared between the baseline and end values by signed Wilcoxon's rank sum test for paired samples and changes in clinical parameters were compared with t-test. P<0.05 was considered significant. SPSS Version18.0 (SPSS, Chicago, IL., USA) was used for statisitics.

Ten patients each were enrolled for both groups (Table 1 ). There was no significant difference in baseline values. All the patients of Group A completed six instillations, while three patients in Group B withdrew because of symptom worsening (P=0.21). The respondse rate according to GRA was 70% in Group A and 40% in Group B, respectively (p=0.178, Table 2 ). Excluding three withdrawers in Group B, the changes of OSPI, NRS, and voiding frequencies showed virtually no change by instillation (Table 3) , and no significant difference between the groups ( Table 4 ).The OSSI showed significant decrease in Group B alone, and the decrease was signifncaltly larger in Group B than Group A (Tables 3 and 4 ). During the therapy, there were no adverse events except three cases of symptom worsening in Group B.

Weekly intravesical instillation with heparin alone or heparin plus lidocaine was comparably effective for refractory IC. Heparin plus lidocaine may cause symptom worsening early but improve symptoms, if completed for 6 weeks. Lack of placebo arm, a small sample size, and unknown long-term outcomes are limitation. Assessment (GRA), urinary frequency, O'Leary-Sant score and Problem Index (ICSI, ICPI, OSS), quality of life index (QoL-I), and urodynamic study at the 8 th week after the injection.

Twenty patients (bladder body, N=10; trigone, N=10) with refractory IC/BPS was included in this study. Patients in both group had significant improvement in VAS, ICSI, ICPI, OSS and FBC (functional bladder capacity) after the injection. The changes of ICSI (9.5±4.7 vs 5.7±4.3, p= 0.043) and OSS (18.6±8.6 vs 11.3±5.9, p= 0.047) at 8 th week after the injection had significant difference between two groups, which trigonal injection had more improvement. There was no significant difference in the changed of urinary frequency (day/night), voiding volume, post-void residual volume (PVR) and cystometric bladder capacity (CBC) from baseline to second month after BoNT-A injection at either bladder body or trigone (Table 1) . Seventy percent (N=7) patients in bladder body group and 50% (N=5) patients in trigone group had decrease of VAS more than 2 points after the injection. Twenty percent (N=2) patients who received bladder body injection and 40% (N=4) patients who received trigonal injection had excellent improvement of the symptoms (GRA≥2) ( Table 2 ). The adverse effects showed no significant difference between two groups (Table 3) . However, there was more patients experience dysuria after the treatment in the bladder body group.

Compared the primary and secondary endpoints between two group, most of the urodynamic parameters showed no significant difference.

Concluding message Bladder body and trigonal BoNT-A injection had similar therapeutic effect and adverse effects on relieving IC/BPS symptoms. 

Hypothesis / aims of study Interstitial cystitis/painful bladder syndrome (IC/PBS) is a debilitating chronic disease of unknown etiology characterized by urgency frequency and suprapubic pain at full bladder. Current treatments are usually unsuccessful in completely eradicating bladder pain and increasing bladder capacity. Autologous platelet-rich plasma (PRP) is growing in popularity as a therapy to augment wound healing, speed the recovery from muscle and joint injuries, and enhance recovery after surgical repair. PRP is extremely rich in growth factors and cytokines, which regulate tissue reconstruction and has been studied extensively among trauma patients and trauma experimental models. Tissue regeneration can be improved by local application of autologous bone marrow derived progenitor cells and PRP.

Study design, materials and methods This pilot study attempts to use autologous PRP in treatment of interstitial cystitis refractory to currently available medical treatment or intravesical therapy. The results of this study might provide clinical evidence for a novel therapeutic regimen in the treatment of IC/PBS. A total of 17 patients with IC/PBS who have failed conventional treatments for at least 6 months was enrolled in this study. All patients had IC symptoms and proven to have diffused glomerulations after cystoscopic hydrodistention (HD) within recent 1 year without Hunner's lesion. The patients received intravesical injection of 10-12 mL PRP (extracted from 50ml of patient's own whole blood) followed by cystoscopic hydrodistention under intravenous general anesthesia in the operation room. The procedure was repeated every one month for a total of four treatments. Urine samples (30 mL) were also collected before intravesical PRP injection and at 4 weeks after each PRP injection. Primary end-point was the change of the O'Leary-Sant symptom score (OSS, including ICSI and ICPI) from baseline to 1 month after the last injection. Secondary endpoints include VAS, daily frequency, nocturia and functional bladder capacity (FBC) as record in 3-day voiding diary, Qmax, vided volume, postvoid residual (PVR) and global response assessment (GRA). Urine samples were collected for urinary vascular endothelial growth factor (VEGF) and cytokines tests.

Among the patients, 13 women completed the study. The mean age was 52.9±12.1 years (38-76). Table 1 shows the changes of symptom scores and urodynamic parameters. A significant improvement was noted in OSS after two PRP injections, in VAS after one and three PRP injections, in FBC after two and three PRP injections, and in GRA after each PRP injection. However, the improvement of the measures was not stable. At 1 month after four injections, the symptoms relapsed and bladder capacity decreased. Urinary interleukin (IL)-2 and IL-8 showed significant increase after the first PRP injection. In patients with VAS reduction ≥1, urinary IL-8 and VEGF increased, in patients without VAS reduction IL6 increased after PRP injection. Significant change of IL and VEGF was observed only in patients with a baseline OSS ≥18 but not in those with a baseline OSS <18. The PVR did not change after repeat PRP injections. All patients were free of urinary tract infection or difficult urination.

Intravesical PRP injection provides a therapeutic potential to change the interior environment of the bladder wall in patients with IC/BPS refractory to conventional therapy. The treatment is safe, but this preliminary study revealed that the therapeutic efficacy was limited. Several critical points might result in the limited successful results, including unstable platelet count, injection technique, and the volume injected. Nevertheless, the changes of urinary cytokines and VEGF in patients with VAS reduction deserve further investigation. Intravesical PRP might improve inflammation and facilitate tissue regeneration in IC/BPS.

The results of this study demonstrates that intravesical injections of PRP is safe and effective to increase bladder capacity and provide greater pain relief in patients with IC/PBS. The clinical effect of PRP on IC/PBS is further reflected by the changes of the urinary VEGF and cytokines levels. 

As shown below, both groups were similar at baseline with regards to age, years from diagnosis, ESSIC score, and cystoscopic capacity. Almost one-third of study drug recipients had tried other bladder instillations previously, predominantly DMSO, and all women had trialled multiple other therapies. Participants were evenly distributed across participating sites and similar in baseline characteristics (see table 1 ). The most common ESSIC score for IAluRil participants was 3c or 3x (n = 16) and 3x for DMSO (n = 4). Mean maximum cystoscopic capacity was not significantly different.

When comparing baseline to 3 months post treatment, iAluRil® showed statistically significant improvements in pain when measured with the VAS (mean drop 2 points), symptoms (BPIC-SS mean drop 8.07 points, ICSI 4.76 points, ICPI 4.53 points) and QOL (ED5Q 1.93 points). The global health score did not significantly decrease. Of note, 45% of iAluRil® recipients had a more than 50% reduction in pain score as represented by the VAS. While both instillations demonstrated significant improvements in ICSI and ICPI, iAluRil® appears to be equivalent to DMSO when comparing measures of pain, with 32% (11/34) having a 50% or more reduction in ICSI compared with 27.8% (5/18) for DMSO (p=1). Additionally, there were no reports of significant adverse effects documented by the instilling nursing staff with iAluRil®, opposed to commonly recognised difficulties with DMSO. 

Hypothesis / aims of study We report an original work about prolonged first stage Sacral Neuromodulation (SNM) and the use of programming sets tailored to the underlying diagnosis. As stated by the International Neuromodulation Society (INS, Sakas et al., 2007) , "for a therapy to be considered Neuromodulation the therapy must be a dynamic, ongoing intervention and not a short and non recurring procedure and the clinical effect is continuously controllable by varying one or more stimulation parameters to satisfy a patient's need" (1) . Neuromodulation of central circuits through the sacral nerve (Sacral Neuromodulation, SNM) implies a trial of therapy with a tined quadripolar lead to select patients for permanent implant (staged Interstim® therapy). Suggested duration of first stage evaluation is three weeks. In our Center with 21 years experience with SNM and patients reprogramming, a retrospective review was performed of 94 consecutive patients implanted with a first stage SNM from January 2014 through December 2016. All of the patients had adequate follow-up and were considered eligible for the study. Length of follow-up of first stage SNM implant was up to 12 weeks (6-12 weeks) and weekly follow-up controls were performed. Based on clinical experience of our "sacral neuromodulation goup", programming and reprogramming was correlated with the underlying diagnosis. Aim of the analysis was to evaluate the safety of prolonged follow-up with external cable, and the effectiveness of tailoring reprogramming to the underlying diagnosis.

Study design, materials and methods A retrospective review of 94 consecutive patients implanted with a first stage SNM from January 2014 through December 2016 was performed. All of the patients had adequate follow-up and were considered eligible for the study. The mean age was 54.1 (22-76 years), 30 males and 64 women. Main underlying diagnosis was urinary retention in 46 patients, painful bladder syndrome in 5, chronic pelvic pain in 5, urge urinary incontinence in 11, urgency frequency in 24, constipation in 1 and fecal incontinence in 2. Fourteen patients were tested on each side in two distinct surgical procedures with a total of 108 first stage procedures performed. Length of follow-up was 6 weeks in 16 patients, 8 weeks in 51 and 12 weeks in 27. Each patient received standard in-office training about management of external cable. Since the introduction of staged procedure in 2002 we've been tunneling the extension cable through the flank to the abdominal wall. Anterior tunneling facilitates management of the external cable to be connected to external power source. It's easier for the patient to handle and dress a cable exiting the abdominal wall than the back. Follow-up controls were performed weekly as standard in-office procedure in 71 patients, as weekly telephone consultation for the first three weeks followed by an in-office procedure at the first month in 23 patients. As regards stimulation programming, Pulse Width (PW) was maintained in a range between 180 and 270 microseconds. Frequency (Pulse Rate, PR) was tailored to the underlying diagnosis: 5 pps in urinary retention due to detrusor underactivity, 40 pps in urinary retention due to dysfunctional voiding, 10 to 21 pps in urge urinary incontinence and urgency/frequency. In pelvic pain and painful bladder syndrome we used 70 to 85 pps. Electrode polarity was chosen based on the lowest stimulation threshold. In all of the patients with weekly in-office follow-up visits PR was changed at each control. The remnant 23 patients started with PR tailored to the underlying diagnosis and it was eventually changed at the first in-office control.

Neither infection nor breaking of external cable was experienced by any patient. Stimulus amplitude varied from 0.3 to 3.3 Volts (mean 0.59-1.59). Frequency tailored for the underlying diagnosis was reprogrammed at the end of follow-up in 82 patients (87.2%) due to better clinical outcome. Follow-up of the 94 patients closed with a second stage with permanent device implant in 65 patient and with the explant of electrode and external cable in 43.

The purpose of this study was to evaluate the consequences of prolonged follow-up of first stage SNM procedure and the value of programming sets tailored to the underlying diagnosis. Prolonged follow-up demonstrated to be a safe choice in informed and trained patients. The absence of complications was observed either in the "weekly controlled" patients or in the "telephone contacted" with monthly in-office controls. A careful selection of stimulation parameters is crucially important to obtain clinical improvement, since the perception of paresthesia is critical to ameliorate clinical outcome (2) . In time we developed and used certain programming sets tailored to the underlying diagnosis. Patients were informed about the necessity of reprogramming to optimize therapy and in 87.2% of cases they defined as optimal the "optimized for the underlying diagnosis" set.

In SMN programming and reprogramming is of crucial importance to optimize clinical outcome. We defined different parameters set to be tailored to different underlying diagnosis. Length of first stage follow-up can be safely prolonged up to 12 weeks. None of the patients were prescribed new medications; instead, recommendations were for surgical evaluation (6, 38%), physical therapy/rehabilitation (1, 6%), an outpatient procedure (1, 6%), and a headache diary (1, 6%). Only 2 (10%) of explanted patients underwent device replacement, while 7 patients (33%) pursued oral medications, 3 (14%) utilized intermittent self-catheterization or an indwelling catheter, 2 (10%) patients pursued Botulinum toxin, 1 (5%) sought care with a local urologist, and 1 (5%) underwent cystectomy and ileal conduit urinary diversion. Of the remainder, 1 (5%) is deceased and 4 (19%) were lost to followup.

The current study investigated the situations in which devices were removed to allow for MRI, and the subsequent course of clinical management. Orthopedic and neurologic concerns were the major drivers of device removal. Not all of the patients who underwent device removal ultimately had MRIs, and of those that did have the planned imaging study, management for the condition that warranted imaging and device removal changed in only slightly more than half of the cases (56%, 9/16 patients).

In the current study, only 10% of explanted patients ultimately underwent replacement of their SNS systems.

In patients receiving SNS therapy, device removal for MRI is most commonly due to orthopedic and neurologic pathologies. Study design, materials and methods Inclusion criteria were singular tumor outside of the trigonal area as well as cT2-tumors. Patients with suspected cT3-tumors after CT-scan as well as suspected lymph nodes got excluded. Furthermore we performed a routine biopsy of the prostatic urethra as well as prostate biopsy in patients with elevated PSA >2 ng/ml. Follow up was performed 6 and 12 months postoperatively, a videourodynamic assessment as well as the questionnaire IIEF5 plus 2 questions from the IIEF15 questionnaire (Q8 + Q9) was performed.

We could offer and perform this technique in 31 patients. Mean age was 51 years (29-65), all patients had strong persistent wish for family planning and/or preserving of ejaculation.

After catherter removal all patients were continent during daytime, 6 patients presented a passageric enuresis. After follow up after 6 and 12 months all patients were still continent and presented no post void residual urine. Micturition frequency was time dependent after 3-4 hours. Erection ability was preserved in 28/31 patients. Mean time to recovering erection ability was 6.3 months (0-14 months). 19 patients agreed to a videourodynamical assessment. Mean maximal cystometric capacity was 440 ml (300-650 ml).

The preserving of erection and ejaculation by preserving the important areas surrounding the verumontanum including the M. ejaculatorius is possible. By preserving the prostate functional outcome with respect to urodynamical parameters were excellent. For young patients with muscle invasive bladder cancer, this technique offers a real alternative with excellent functional outcome, an important factor for life quality.

Concluding message Ejaculations-preserving transprostatic cystectomy is feasible and results in excellent functional outcome for continence and sexuality. 

Hypothesis / aims of study Successful nerve-sparing radical prostatectomy is supposed to preserve continence and erectile functions, which require a high knowledge of anatomic and qualitative periprostatic nerve distribution. Our objective was to anatomically characterize the distributions of cholinergic, adrenergic, and sensory periprostatic nerves and verify those histological findings by diffusion tensor imaging (DTI).

For the microscopic study, radical prostatectomy specimens from 19 patients were examined. Additionally, in five volunteers nerve concordance was investigated by DTI as a new MRI based technique to investigate neural structure. Serial whole-mounted sections were stained with PGP9.5 to estimate total nerve content, neuronal nitric oxide synthase (nNOS) as a marker for cholinergic nerves, tyrosine hydroxylase (TH) as a marker for adrenergic fibers, and calcitonin gene related peptide (CGRP) as a marker for sensory nerves. Extracapsular stained nerves were counted by prostate surface sector and classified by diameter. Relative density was calculated and distribution patterns were evaluated for each stain. MRI imaging using DTI technique was conducted and analyzed on a 3 Tesla MRI system with DTI tracking software.

In the histological investigation at the prostatic base, cholinergic nerves were distributed across anterolateral, posterolateral, and posterior sectors. Their course continued posterolaterally in the midsection and both posterolaterally and posteriorly toward the apex of the prostate. Adrenergic nerves were distributed across the anterolateral, posterolateral, and posterior sectors at the prostate base, with the course narrowing to the posterolateral and posterior sectors at the mid and apical levels. Sensory fibers were found posterolaterally and posteriorly at the base, continuing posterolaterally over the mid and apical levels. Although it was not possible to determine the different nerve qualities it was possible to verify with DTI the concordance of the nerves from the base to the apex, confirming the histological findings.

Interpretation of results Hostolgical findings were confirmed by DTI. This opens the option not only to use DTI to preoperatively correlate the nerve concourse and the tumor(s) but with the incrising possibilities to project the findings into the OR-field to visualize the nerve structures and protect or to sacrifice them where possible or needed to have the best possible outcome.

Concluding message Cholinergic, adrenergic, and sensory periprostatic nerve fibers show differences in their distribution and concordance over the surface of the prostate. When linked to possible functional aspects of the different nerve types, this morphologic evidence may be of importance when using nerve-sparing techniques in a radical prostatectomy to improve postoperative functions. DTI confirmed the histological findings and showed that DTI might be a tool to correlate the nerves to the tumor for better pre-operative planning and performance of the treatment. The histological concordance of the different nerve qualities can be confirmed by DTI.

To ensure a good nerve sparing prostatectomy outcome, the concordance of the nerves need to be simultaneously respected on different levels from base to apex taking into account that the sector (anterior to posterior) might be different. 

Hypothesis / aims of study Patients with incidentally found prostatic F-18 fluorodeoxy glucose (FDG) uptakes in positron emission tomography /computed tomography (PET/CT) were referred to urologists to characterize the significance. While malignancy and infection are two commonly suggested etiologies for increased FDG uptake, only few patients of incidental prostate FDG uptake (IPU) revealed prostate cancer and the study for chronic infections through a strict localization test is not reported yet [1] [2] [3] . Therefore, we evaluated the association between prostate infections and the IPU in non-malignant prostate tissues.

Study design, materials and methods Only 51 men from 7,493 men who underwent FDG PET/CT scanning for six years agreed to physical prostate examination and expressed prostatic secretion (EPS) test within two weeks after FDG PET/CT scans. We examined the prostate infection by using a modified a two-glass test (pre-massage urine and 100 µL of EPS). We routinely performed prostate biopsy if presence of prostate nodule and high serum prostate-specific antigen level (≥ 4ng/mL) in both of initial and follow-up. Five men were pathologically diagnosed with prostate cancer, and excluded from this study. We reviewed FDG PET/CT scan in en-rolled patients, calculated the maximum standardized uptake value (SUVmax) in prostate and evaluated the relationship between FDG PET/CT and clinical and laboratory features for prostate diseases.

Clinical features and the results of FDG PET/CT were described in 

A bacterial presence in prostate tends to increase the risk of incidental non-malignant prostatic FDG uptake on FDG PET/CT.

Concluding message Therefore, men with incidental prostate FDG uptake should be considered the possibility of their prostate infection besides concomitant malignancy. Table 1 . Clinical characteristics of study subjects and influence of patient characteristics on 18 F-FDG on positron emission tomography-computed tomography scan positivity several patterns. We named the defect of contrast medium at membranous urethra as stop sign, and categorized patients into 3 grades according to the degree of defect. That is to say, no defect was grade 0, complete defect was grade 2, and grade 1 was between grade 0 and grade 2. Furthermore, we also named the difference in brightness of contrast medium between in bladder neck and in body bladder as contrast sign, and categorized patients into 3 grades. No difference was grade 0, obvious deference was grade 2, and grade 1 was between grade 0 and grade 2. Urinary incontinence was evaluated using the questionnaires about urinary incontinence.

The median age of patients was 67 years old (range 51-76). The median PSA, BMI, prostate volume and the length of membranous urethra was 7.4 ng/ml (range 4.1-35.5), 22.8 kg/m 2 (range 20.8-28.1), 30.0 cm 3 (range 14-67.2) and 12.3 mm (range 4.9-24.6), respectively. 62 patients were diagnosed as pathological T2 and 9 patients were T3. The median period of observation was 12 months (range 6-24). In total, 24 patients (35%) recovered urinary incontinence and 35 patients (49%) used only one pad a day 6 months after RARP. A statistical analysis of the relationship between these parameters and urinary continence 6 months after RARP was performed. The median age of continent group (n=24) and incontinent group (n=47) was 69 and 67, respectively (p=0.68). While BMI, PSA and prostate volume were not significantly different between groups (p=0.20, 0.51 and 0.17, respectively), but significant differences in the length of membranous urethra (p=0.0015), stop sign (p<0.001) and contrast sigh (p=0.047) were observed. Moreover, we analysed in details about membranous urethra, stop sign and contrast sign. As a result, the longer the membranous urethra was, the better urinary incontinence was recovered (p-trend=0.0006) at 6 months after RARP. What is more, the higher grade of stop sign or contrast sign was, the earlier urinary incontinence was recovered. To reveal the meaning of stop sign and contrast sign, we analysed correlation between these parameters. The membranous urethra had a correlation with stop sign (p-trend=0.001), but not with contrast sign (p-trend=0.913).

The length of membranous urethra, stop sign and contrast sign may be a promising predictor for early recovery of urinary incontinence after RARP. From our analysis, we assume that the length of membranous urethra reflects the physical length of sphincter muscle of urethra, and stop sign reflects the function of sphincter muscle of urethra. We also assume that contrast sign reflects the function of bladder neck. In that case, preoperative early intervention of pelvic floor training may be able to make a higher grade stop sign, and careful bladder neck sparing in operation may be able to make a higher grade contrast sign. To improve the QOL of patients after RARP, we should perform RARP with the understanding of the risk of urinary incontinence preoperatively. That allows us to understand the necessity of preoperative early intervention of pelvic floor training and the necessity of careful bladder neck sparing in operation. 

Hypothesis / aims of study To compare safety and efficacy of bipolar resection (BPR) vs holmium laser enucleation (HOLEP) for large prostate.

Study design, materials and methods One hundred and forty one patients with BPH (≥75gm) indicated for surgical intervention were included in this cohort study between January 2013 and November 2015. Group A (71 cases) was treated by HOLEP (Versa pulse 100W; Lumenis; Germany) using 550micron laser fibers (2J-50Hz for enucleation and 1.5J-30Hz for hemostasis). Enucleation was followed by use of morcellator (Versa cut). Group B (70 cases) was treated by BPR using bipolar resectoscope (Karl Storz) and its generator (AUTOCON® II 400 ESU). Power output was set at 5 for resection and 6 for coagulation. Preoperative criteria, operative and postoperative findings were compared between both groups using Mann-Whitney, Chi-Square, Student-t or Fisher-Exact tests as appropriate. Preoperative vs postoperative findings were compared in each group using Wilcoxon-signed rank test. Interpretation of results Perioperative and follow-up findings are presented in Table 1 . Adenoma size and patients on anticoagulants were significantly higher in HOLEP group. Hospital stay, catheterization time and hemoglobin loss were significantly better in HOLEP group. Follow up was done for 6months in all patients. There was significant postoperative improvement in IPSS score and Qmax in each group. Qmax improvement was significantly better in Group A. There was no significant difference in postoperative complications between both groups but blood transfusion was clinically higher in group B (and near significance, p=0.058).

Concluding message HOLEP and bipolar resection are safe for treatment of large prostate. Although significantly more patients on anticoagulants and larger adenoma size were present in HOLEP group, it provided a better voiding pattern, Hb loss, hospital stay and catheterization time. 

Hypothesis / aims of study Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical treatment for bothersome moderate to severe lower urinary tract symptoms (LUTS) secondary to benign prostate obstruction. The aim of the study is to compare monopolar vs. bipolar TURP focusing on operative and functional outcomes, and evaluating complications with a long term followup.

Study design, materials and methods From January 2007 to July 2014 a total of 497 patients were randomized and prospectively scheduled to undergo bipolar (251) or monopolar (246) TURP. International prostate symptom score (IPSS), IPSS-Quality of life (QoL), post-void residual and maximum flow rate were assessed preoperatively and postoperatively at 3, 12, 24 and 36 months. Operative time, length of catheterization and hospitalization were all recorded. Complications were classified and reported.

All patients completed the 36 months follow-up visit. Perioperative results showed no statistical significance between the two groups in terms of catheterization days, post-void residual, IPSS, IPSS-QoL score. The hospitalization length was found statistically significant in favor of the bipolar group. The 3, 12, 24 and 36 months follow up showed significant and equal improvements in LUTS related to BPO in the 2 treatment groups. Regarding TURP complications, significant differences were observed in relation to urethral strictures, blood transfusion and TUR syndrome in favor of the bipolar group.

Interpretation of results Several technical modifications have been developed in an effort to improve the safety profile and surpass the monopolar TURP, including the use of bipolar energy technology. The principal advantage of bipolar technology is avoiding dilution hyponatremia with the use of isotonic irrigation, therefore reducing the risk of TUR syndrome. Results from randomized clinical trials (RCT)-based meta-analysis concluded that B-TURP is preferable due to a more favourable safety profile defined by less bleeding (lower blood transfusion and lower clot retention rates), no instance of TUR syndrome, shorter catheterization with a significant lower hospitalization length. B-TURP can coagulate small venous bleeding providing a clearer image during prostate resection in comparison to M-TURP, therefore leading to a decrease in operation time. The results of our study showed a statistical difference between the 2 groups in favor of the bipolar group in terms of blood transfusion rates, and/or hematuria requiring intervention as well as in days of catheterization (even though these last two data were not significant). The drop in haemoglobin level was significantly lower in B-TURP when compared with M-TURP group. Accordingly, this study did demonstrate a valuable benefit from B-TURP with regard to bleeding complications.

Concluding message Monopolar and bipolar TURP are both safe and effective procedures for surgical treatment of BPH. We found significant differences in terms of mean serum sodium, haemoglobin drop, and length of hospitalization days that were all in favor of the bipolar group. Regarding TURP complications, significant differences were observed in relation to urethral strictures, blood transfusions, and TUR syndrome in favor of the bipolar group. It has to be highlighted that the risk of TUR syndrome is totally prevented by the use of bipolar energy device. Bipolar TURP in our prospective study reported the same functional efficacy of M-TURP, with a significant reduction of related morbidities (TUR syndrome, blood transfusions rate, and urethral strictures).

showed that AUS becomes cost-effective when compared to AdVance sling starting the 4th year in the treatment period. The incremental cost savings of AUS over 10-year period was $8376 with an added effectiveness of 0.55 QALYs. Consequently, the AUS implementation is the dominant strategy over the AdVance sling over a 5-and 10-year time-horizon.

We modeled a hypothetical population of men with presumed uncomplicated symptomatic severe PPSUI (defined as using more than 4 pads per day). All patients have equal access to both therapeutic options. Based on literature evidence, we choose a success rate of 90% for AUS treatment strategy, while our base-case success rate for AdVance sling was 67%. Additionally, patients with recurrent SUI after sling release were offered an AUS placement rather than repeat sling procedure.

Similarly, reported AUS 5-years durability rate as high as 80% in comparison to 62.5% for sling strategy at 2-years. Based on our model, it is likely that AUS would become even more cost effective for the management of PPSUI as time goes on. Moreover, AdVance sling is mainly applied for management of mild to moderate PPSUI with insufficient evidence to support its long-term efficacy for severe SUI.

Concluding message Although the initial cost of sling is attractive, superior long-term outcomes are demonstrated with durable high success rate of AUS in men with severe PPSUI. Hence, the AUS implementation strategy over a 10-year period time is estimated to be more economical to our health care system. More studies are needed to define utility values for health states experienced by males with PPSUI. This will enhance our ability to develop more accurate cost-utility models. 

Hypothesis / aims of study Chronic prostatic inflammation has been implicated in the pathogenesis of benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS). In previous studies, the degree of chronic prostatic inflammation has been evaluated by using histological scores. We previously demonstrated that the number of high endothelial venule (HEV)-like vessels was correlated with the magnitude of chronic inflammation in various chronic inflammatory gastrointestinal diseases [1] . The aim of this study is to evaluate the degree of BPH-associated chronic prostatic inflammation from the standpoint of appearance of HEV-like vessels, and to determine whether the magnitude of chronic prostatic inflammation is correlated with the severity of LUTS, particularly those evaluated by urodynamic study.

Study design, materials and methods 86 BPH tissue specimens with preoperative urodynamic study were immunostained for CD34 and MECA-79 to determine the number of HEV-like vessels. We scanned tissue sections immunostained with MECA-79 at x40 magnification and identified three tissue fragments with highest density of MECA-79+ vessels (a so-called "hot spot"). MECA-79+ vessels in these three fragments were then counted at x 200 magnification. In serial sections immunostained for CD34, the number of CD34+ vessels in the three tissue fragments was also determined, and the MECA-79+/CD34+ vessel ratio was calculated in each case. To demonstrate the validity of assessment of chronic prostatic inflammation by using the number of HEV-like vessels, we evaluated the extent of chronic inflammatory cell infiltrates in each of the three tissue fragments above was categorized into four grades: none (score 0), mild (score 1), moderate (score 2), and marked (score 3), and average score of the three tissue fragments was calculated in each case based on the criteria described by Nickel et al [2] . This histological grading is illustrated in Figure 1 . Triple immunohistochemistry for either CD3 and CD20 or CD4 and CD8, together with MECA-79, was conducted to determine which lymphocyte subset is more closely associated with HEV-like vessels. Correlation analyses were carried out to determine whether the magnitude of chronic prostatic inflammation, as assessed by the number of HEV-like vessels, was correlated with the degree of LUTS.

HEV-like vessels were induced in lymphoid aggregates formed frequently in BPH (Fig.1) . The number of HEV-like vessels, that is, the MECA-79+/CD34+ vessel ratio, was positively correlated well with chronic inflammation score (correlation co-efficient=0.6458; P<0.0001. see Fig.2 ). The magnitude of chronic prostatic inflammation, as assessed by the number of HEV-like vessels, was correlated with the degree of LUTS, particularly those associated with voiding functions, which was measured objectively by pressure flow study (Fig.3) . On the other hand, the number of HEV-like vessels was not correlated with the prostatic volume. 

The strong correlation between the number of HEV-like vessels and the extent of chronic prostatic inflammation indicates that the number of HEV-like vessels could be a surrogate for identifying the degree of chronic prostatic inflammation. Despite no correlation between the prostatic volume and the number of HEV-like vessels, voiding dysfunction was correlated with the number of HEV-like vessels. This result indicated that chronic prostatic inflammation could influence on the functional obstruction of lower urinary tract.

Hypothesis / aims of study It was previously published that statins significantly reduced prostate volume, improved lower urinary tract symptoms, and slowed the clinical progression of BPH. Consequently in the research, we apply the national database to investigate whether the statins reduces the risk of acute urinary retention (AUR) and receiving transurethral resection of prostate (TURP) in the outpatients of genitourinary clinic. In the group of statins users, the percentage (10.47%) of receiving TURP in patients with medication of α-blockers and/or 5α reductase inhibitors is significantly lower than that (11.84%) of patients without α-blockers and/or 5α reductase inhibitors (p < 0.001). Inconsistently in statins users with occurrence of AUR, the percentage of AUR showed no significant difference between patients with and without BPH medication. Conversely in the group of non-statins users, the percentage (5.14%) of receiving TURP in patients with medication of α-blockers and/or 5α reductase inhibitors is significantly higher than that (3.08%) of patients without α-blockers and/or 5α reductase inhibitors (p < 0.001). In the patients with BPH medication, the odds ratio of occurrence of AUR and receiving TURP of statins users (non-statins users as the reference value) is 0.57 and 0.48, respectively(p < 0.01)

In the both groups of non-BPH or BPH medication users, the risk of occurrence of AUR and receiving TURP in patients with medication of statins is significantly lower than that of patients without statins (p < 0.001).

Concluding message In this research, the patients with statins use have lower risk to have AUR and receive TURP, even in the occasion without any BPH medication. 

Hypothesis / aims of study It is well recognized that endothelial dysfunction is strongly related to lower urogenital problems such as erectile dysfunction, which shortly precedes clinical coronary arterial occlusion. The study aims to investigate the potential correlation of systemic vascular endothelial dysfunction and coronary artery disease (CAD) with bladder outlet obstruction (BOO).

Study design, materials and methods Thirty men age 50 years and older (mean=62.7 years ±14.6) with moderate to severe LUTS were enrolled and gave written consent. All patients underwent pressure flow study and simultaneous non-invasive recording of detrusor tissue oxygenation and haemodynamics with Near Infrared Spectroscopy (NIRS). Systemic endothelial integrity was assessed by measurement of inflammatory and endothelial-prothrombotic markers such as Endothelin-1 (ET-1), Interleukin-6 (IL-6), Assymetric Dimethylarginine (ADMA) and N-terminal C-type natriuretic peptide (NT-pro CNP). CAD, defined as occlusion of coronary arteries, was also recorded. IBM-SPSS ver. 22 was used for the statistical analysis.

Logistic regression model was applied to examine whether BOO -as diagnosed properly with the standard Pressure Flow study and also by estimation of detrusor muscle oxygenation with the NIRS technique -correlates with vascular lesions. Elevated values of ΕΤ-1, IL-6 and NT-proCNP were found, but they were not statistically significant. NIRS showed a specificity of 88% and a sensitivity of 79% in diagnosing BOO. Also, a sevenfold increase was found in the likelihood of BOO in patients with CAD.

Elevated biochemical markers of endothelial dysfunction such as ΕΤ-1, IL-6 and NT-proCNP, as well as by the sevenfold increase in the likelihood of BOO in coronary patients suggest that there may be a correlation between lower urinary tract dysfunction and vascular occlusion. With the limitation of the small sample size, a common pathophysiological background may exist such as impaired blood perfusion of the bladder and/or prostate. This is also supported by the use of NIRS that assesses obstruction through detrusor oxygenation impairment.

Concluding message Bladder outlet obstruction may be related to endothelial dysfunction and coronary artery disease. Also, NIRS may be a good alternative for non-invasive urodynamic studies in the assessment of bladder outlet obstruction. Unilateral nerve resection S3 and below was uniformly associated with immediate post-op retention (p<0.001). CIC dependence conformed to a similar pattern. No nerve resection levels were directly associated with hydronephrosis, but S3 showed a trend with 36% vs. 19% of patients with vs. without S3 involvement developing hydronephrosis (p=0.08). As expected, any S3 nerve involvement was characterized by increased in immediate post-op retention (p=0.01). Bilateral S3 nerve resection was characterized by retention and CIC dependence in 82% and 90% of patients, respectively, which was significantly increased over unilateral compromise.

Pelvic radiation was associated with lower post-op retention (31% vs. 50%; p=0.03) and increased hydronephrosis (35% vs. 12%; p=0.01). Since pelvic radiation was surprisingly associated with lower post-op retention, we explored differences in patient characteristics and treatment characteristics by radiation status, with a full table included in a supplemental table (Table S1) * P-value is computed only for patients with non-missing information. However, missing retention information appears to be more highly associated with hydronephrosis.

Based on the presence of S3 involvement alone, almost half of our patient cohort would be predicted to have prolonged voiding dysfunction requiring evaluation and long-term monitoring. Initiation of appropriate intermittent catheterization along did not prevent the development of hydronephrosis indicating the need for neurourologic monitoring and management. Currently, postsacrectomy post-operative follow-up does not integrate urologic consultation in all patients with expected urinary retention.

Our data has one of the largest series to date evaluating urologic outcomes of patients undergoing sacrectomy of any type with a respectable median follow-up of 27 months. However, the deficiencies are the retrospective nature of the study resulting in missing data points. We also found that a urologic specialist was consulted in only 36 patients (22.7%) despite many more showing evidence of long-term bladder dysfunction.. Overall, while the incomplete data is disconcerting, it highlights the opportunity for collaboration with the goal of improving the management of this patient population.

Hypothesis / aims of study Patients with Parkinson's disease (PD) have not only motor impairment but also lower urinary tract dysfunction (LUTD) as a one of non-motor impairment. Nocturia (= nocturnal frequency) is a common LUTD in patients with PD, and which not only impairs quality of life but also disturbs sleep and results in falling and fracture. Nocturia is reported to be a risk factor of cognitive dysfunction, mental dysfunction and increased mortality. In general, decrease in bladder volume and nocturnal polyuria are considered to be common causes of nocturia. However, nocturia caused by nocturnal polyuria is a little known in neurological disease except some neurological diseases such as cerebrovascular disease, multiple sclerosis, multiple system atrophy, Alzheimer disease and spinal cord injury. The mechanism of nocturnal polyuria in these neurological disease is also little known except decreased ADH secretion during sleeping at night. We previously reported that not only decreased bladder capacity but also nocturnal polyuria may have a greater role in the causes of nocturia in patients with PD, and the pathophysiology of nocturnal polyuria in PD may be associated with abnormal circadian rhythm of AVP. However, the other pathophysiology of nocturnal polyuria in PD has not been known. Recently, the association between melatonin secretion and nocturia in elderly individuals is reported. And it is also reported that melatonin agonist may improve nocturia. Then, We evaluate the association between circadian rhythm of melatonin secretion and nocturnal polyuria, and try to estimate the another pathophysiology of nocturnal polyuria in PD.

Study design, materials and methods Eighteen patients with PD with motor fluctuations were recruited; those with other conditions that might have influenced lower urinary tract function were excluded. All studied subjects were evaluated using a lower urinary tract symptom questionnaire and bladder diary (voiding frequency diary), and blood serum of them were collected every 4 hours for 24 hours to evaluate the circadian rhythm of melatonin secretion.

Fourteen patients with PD (77.8%) had nocturnal polyuria. Ten patients with PD (55.6%) had decreased amplitude/night-todaytime ratio of melatonin secretion, eight (44.4%) had a phase advance of the nocturnal melatonin secretion, and seventeen (44.4%) had decreased duration/disruption of melatonin secretion. All patients with PD and without nocturnal polyuria had almost normal melatonin secretion, but all patients with PD and nocturnal polyuria had one and more of abnormal melatonin secretion which described above.

Most of patients with PD and motor fluctuation had nocturnal polyuria. And all patients with PD and nocturnal polyuria had one and more of the pattern of abnormal circadian rhythm of melatonin secretion.

In patients with PD, nocturnal polyuria and abnormal circadian rhythm of melatonin secretion were coexisted with high probability. Thus, the pathophysiology of nocturnal polyuria in patients with PD may be associated with abnormal circadian rhythm of melatonin secretion. Yes of the brain). Single or continuous cystometry was performed to calculate the voiding parameters before Ang II administration and from 0 to 60 min after the Ang II administration. When performing single cystometry, saline was infused into the bladder until the peak of a voiding bladder contraction, then the infusion was stopped and voided saline and residual urine from the bladder were collected and measured. Then, voided volume (VV), postovoiding residual urine volume (RV) were measured, and bladder capacity (BC), and voiding efficacy (VE) were calculated. In the continuous cystometory, muscimol (Mus, GABAA receptor agonist, 100 or 300 pmol/3 µl/rat, icv) or vehicle (PBS) was administered 30 min before central Ang II (30 pmol/3 µl/rat) administration. Also, Ang II (100 or 300 pmol/300 µl/rat) was intravenously administered into the femoral vein. In the continuous cystometry, the intercontraction interval (ICI) and maximum voiding pressure (MVP) were evaluated 20 min before and after the Ang II administration.

In the single cystometry, centrally administered vehicle failed to affect VV, RV, BC or VE compared to the pre-treatment (-20~0 min). While, centrally administered Ang II significantly reduced VV and BC without affecting RV or VE compared to the vehicle treated group for 0~60 min after the administration (Table 1 ). In the continuous cystometry, centrally administered Ang II significantly reduced ICI without affecting MVP compared to the vehicle-treated group for 0~60 min after the administration ( Table  2) . Centrally administered Mus alone failed to affect ICI or MVP compared to the vehicle treated group for 0~60 min. However, pre-treatment with high dose but not low dose of Mus significantly suppressed the Ang II induced reduction in ICI compared to the vehicle for 0~40 min after the administration (Table 3) . On the other hand, intravenously administered Ang II failed to affect ICI or MVP for 0~60 min after the injection compared to the pre-treatment (-20~0 min).

Interpretation of results Current data demonstrated that pre-treatment with Mus suppressed Ang II-induced micturition reflex. GABA is an important inhibitory neurotransmitter in the nervous system. And, GABAA receptor agonist is known to inhibit the micturition reflex in the brain [3] . There are several findings shows about a relationship between Ang II and GABAergic nervous system in the brain [2] . AT1 receptors and GABAA receptors have been shown to appear within the periaqueductal gray (PAG), a site coordinating activity of the pontine micturition center. Previous report showed Ang II-induced stimulation of AT1 receptors inhibits GABA release in the PAG [2] . These data suggest that brain Ang II increases frequent urination via inhibition of GABAergic nervous system in the brain.

Concluding message The brain Ang II nervous system is involved in the facilitation of the rat micturition through the inhibition of the GABAergic nervous system, specifically involved in GABAA receptors.

Hypothesis / aims of study TRPA1 channel is expressed in the urothelial cells and bladder sensory nerve fibers, and acts as bladder mechanosensor and nociceptor (1) . A recent study revealed that mRNA expression of TRPA1 was up-regulated in human bladder tissue with Hunner type interstitial cystitis, suggesting that TRPA1 may play a role in the pathophysiology of inflammatory bladder hypersensitivity (2) . In this study, to disclose roles of TRPA1 in bladder inflammatory hypersensitivity, we investigated in vitro and in vivo inflammatory responses to intravesical LPS-instillation in TRPA1-knock out (KO) mice in comparison with those in wild type (WT) mice.

Study design, materials and methods Female WT and TRPA1-KO mice (10-12 weeks-old, N = 24 and 17, respectively) were used. Mice were received intravesical instillation of LPS (2.0 mg/ml) or saline (vehicle) for 1 hour, and all experiments were examined at 24 hours after instillation. For in vivo investigation, decerebrate unanaesthetized cystometry (CMG) was performed. For in vitro investigations, histological evaluation of the bladder, count of the infiltrating inflammatory cells in the suburothelial layer, and mRNA expression of several TRP channels known to be expressed in the bladder and L6 dorsal root ganglion (DRG) were determined.

In the CMG measurements, after LPS instillation, TRPA1-KO mice showed significantly longer intercontraction interval and larger voided volume than WT mice ( Figure 1 ). Histologically, urothelial denudation, inflammatory cell infiltration and edema in the suburothelial layer were similarly observed in the bladder of both WT and TRPA1-KO mice with LPS-instillation, whereas neither of these findings was observed in the bladder of saline-instilled WT mice (Figure 2 A-F). Compared to saline-instilled WT mice, the number of infiltrating inflammatory cells was significantly higher in both LPS-instilled WT and TRPA1-KO mice, but there was no significant difference between WT and TRPA1-KO mice with LPS-instillation (Figure 2 G) . None of the other TRP channel expressions in the bladder or L6 DRG was significantly different between WT and TRPA1-KO mice. TRPM2 mRNA expression of the bladder significantly increased with LPS-instillation in both WT and TRPA1-KO mice when compared with those with salineinstillation, while LPS-instillation did not change significantly any of the other TRP channels in the bladder or L6 DRG of either group of mice ( Figure 3 ). 

The results of CMG measurements suggest that TRPA1 channel is involved in the LPS-induced bladder hyperactivity in mice. On the other hand, LPS induced similar degree of inflammatory cell infiltration in the bladders of both WT and TRPA1-KO mice, suggesting a limited role of TRPA1 in inflammatory responses themselves. Our results also revealed that no compensatory gene expression changes of other TRP channels were observed in the bladder or L6 DRG of TRPA1-KO mice. In addition, LPSinstillation did not change mRNA expression of TRPA1 in either the bladder or L6 DRG. This finding seems discrepant from the present results of CMG measurements. More detailed investigation such as evaluation of the single-cell RT-PCR of the neuronal cells in L6 DRG innervating the bladder are needed. Interestingly, mRNA expression of TRPM2 channel, which is known to contribute to inflammatory and neuropathic pain (3), was up-regulated in the bladders of both WT and TRPA1-KO mice with LPS-instillation, suggesting that TRPM2 channel would be further explored as a target for bladder inflammatory pain disorders.

Concluding message TRPA1-KO mice showed attenuated bladder hyperactivity induced by LPS-instillation, but similar inflammatory changes in the bladder as WT mice. These results suggest that TRPA1 is involved in bladder hyperalgesia induced by bladder inflammation, but not in inflammation itself. 

Hypothesis / aims of study In 1993 in their 'Integral Theory' , Petros and Ulmsten assumed that the lax uterosacral ligaments (USLs) may contribute for causing urgency urinary incontinence (UUI) in females due to a lax vagina unable to support the bladder stretch receptors. Many surgical interventions were done for treating female LUTs by repairing the USLs depending on this theory and reporting a high overall cure rate .We tried to to find a correlation between the laxity (length) of the USLs and the UUI in females using the MRI pelvic floor.

Study design, materials and methods A prospective controlled study was conducted on 68 females (30 cases complaining of UUI diagnosed by history with or without positive urodynamics and 38 normal controls). They were evaluated and included in this study from May 2014 to september 2015.

The goal of this study was to use cystometry in fully conscious sheep and determine if SNM "targeted" to early or latter stages of the bladder fill cycle could elicit the same increase in capacity as continuous SNM.

Study design, materials and methods Adult, female, Polypay sheep (n=8) were used in two separate sets of studies using an implanted research stimulator connected to bilateral leads (Model 3889) placed at S3 or S4 foramen to deliver SNM [3] . Acute cystometry, infused at 15 or 30 ml/minute, was performed in the fully conscious sheep comparing bladder capacity in baseline trials to those with SNM. The timing of SNM (parameters: bilateral, 10 Hz, 0.21 ms pulses, at maximum tolerable amplitude) was based on the total duration of three baseline SNM trials and was then targeted at different times of the bladder filling cycle (e.g. first 50%, second 50%, last 25% or last 10%). In some cases, multiple SNM trials occurred with two baseline trials given between SNM trials. Groups were compared with ttest or ANOVA with p<0.05 considered significant.

Initial data from 12 cystometry sessions in four sheep showed that SNM during the second 50%, but not first 50%, of bladder filling cycle significantly increased bladder capacity (p<0.05). The increase in bladder capacity with SNM applied during last 50% of filling (2 nd half stim) and the lack of effect with SNM during first 50% of filling (1 st half stim) was independent of order of presentation ( Figure 1) . Moreover, the increase in bladder capacity was not different from SNM applied continuously, consistent with previous rodent data [2] . Follow-up experiments in four sheep examined the effect of timing in more detail, comparing SNM during second 50%, last 25% and last 10% compared to first 50% and continuous delivery. Figure 1 . Bladder capacity is increased with SNM delivered to the latter phase g, but not early phase of bladder filling. Cystometric trial number is on the x-axis and bladder capacity is on the y-axis. The graph at left shows all trials where last 50% was presented before 1 st 50% SNM, while the graph at right shows all trials where the 1 st 50% was applied before 2 nd 50%. Interestingly, 2 nd 50% SNM showed an equivalent increase in bladder capacity to continuous SNM (Full stim).

These cystometry data in the fully conscious sheep show that intermittent SNM applied at certain phases of the bladder filling cycle can significantly increase bladder capacity in a similar manner to continuously applied SNM. SNM applied early in the filling cycle did not have an effect, while SNM applied later in the filling cycle increased bladder capacity. This is consistent with the idea that the therapeutic mechanism of SNM is a sensory, neural modulation and that there must be a robust bladder afferent signal present for SNM to modulate. These data support clinical data showing effectiveness of cycling SNM and also may help to optimize temporal delivery.

Hypothesis / aims of study Deterioration of the neural control at any level usually leads to the development of neurogenic dysfunction of the lower urinary tract. Neurogenic detrusor overactivity (NDO) is defined as a urodynamic observation characterised by involuntary contraction of the detrusor during the filling phase, where there is a evidence of a neurological disorder. [1] NDO is a typical urodynamic observation in patients suffering from suprasacral spinal cord injury (SCI). NDO is most frequently reported urodynamic observation in patients with multiple sclerosis (MS). Anticholinergics are considered standard way to treat NDO, however especially side effects represent a significant limitation for long term treatment. [2, 3] Mirabegron is approved for treatment of idiopathic overactive bladder, however the data about use of mirabegron in neuropathic patients are missing. The aim of the study was to assess efficacy and safety of mirabegron in the treatment of NDO in patients with SCI or multiple sclerosis MS.

In total, 78 patients were enrolled into this prospective, multi-centre, randomised, double blind, placebo controlled study conducted in three tertiary centers. The study protocol was approved by the Institutional Review Board. Three visits were scheduled during the study. After signing of informed consent, patients were advised to stop their anticholinergic medication and were administered with placebo for single blind run-in period (2 weeks). Subjects with proven NDO during filling cystometry at the end of the washout period were considered suitable for randomisation. Eligible subjects were randomised in 1:1 ratio using a central computerised randomisation scheme to active treatment arm (mirabegron 50 mg) (Group A) or placebo arm (Group B) for 4 weeks of double blind treatment period. Urodynamic parameters, 24hours pad weight test (24PWT) and patient -reported outcome variables were assessed at randomisation (baseline) and the end of study visit (Week 4). Safety assessments included the monitoring of the incidence and severity of adverse events (AE). Changes in time and differences between groups were assessed using non-parametric Kruskal-Wallis one-way ANOVA test. p values ≤ 0.05 were considered statistically significant. Total seven AEs in seven patients were observed during the study (8.97%). The incidence of AEs in placebo arm during double blind treatment period was 2.94%. The incidence of AEs in mirabegron arm was 6.25%, however incidence of study drug related AEs was 3.13% (1 of 32 patients). In addition, there were no statistically significant changes from baseline to end of treatment found neither in blood pressure nor in pulse rate.

Mirabegron 50 mg improves both urodynamic and patient -reported outcome variables in patients with NDO. The treatment with mirabegron was well tolerated with low incidence of AEs.

Concluding message These data strongly support the hypothesis that mirabegron can be safely used in the treatment of NDO. Further research in order to identify appropriate dosage of mirabegron in this specific population is highly required.

in the light did not show any difference through measurement in control mice. However, VF in the light increased significantly higher after RS compared to baseline (Fig. 1) . Uvol/v in mice has the circadian rhythm, which was higher in the light than in the dark. This rhythm was observed only in baseline and disappeared after RS in RS mice. Moreover, a decrease of Uvol/v was not observed in the dark in RS mice. However, Uvol/v in the light was significantly lower at Day1 and Day 3 compared to baseline in RS (Fig. 2) . Per2 expression showed circadian rhythm in control mice. RS mice also showed rhythmic expression in Per2. However, the oscillation cycle was shorter in RS mice than control mice (Fig. 3) .

The physical stress in the sleep phase could alter the circadian rhythm of clock genes in the bladder. This result indicated that RS induce nocturia through the changes of circadian bladder function.

Concluding message Abnormalities of circadian rhythm in the urinary bladder caused by physical stress are one of important factors in changes of urination pattern, particularly nocturia.

Hypothesis / aims of study During the filling phase, sensory information about bladder filling, is continuously available to the brain. However, only after reaching a certain threshold, this information reaches the conscious level. We conducted a pilot study using a 7T Siemens Magnetom MRI scanner, with a 64-channel head coil in order to study the relevant brain areas and their inter-connectivity during bladder filling.

Study design, materials and methods High resolution functional T2*-weighted images (1.25mm 3 , 99 slices, TR=2000ms, 270 volumes) were obtained. The data were corrected for motion artefacts, after which linear trends and low frequency temporal drifts were removed. In addition, one high resolution T1-weighted anatomical scan was obtained for each participant (320 slices, resolution 0.65mm 3 ), and transformed to Talairach space. The diuresis was stimulated by drinking 1 litre of water before entering the scanner. At the beginning of the measurement, the bladder of the subjects was empty, but at the end, participants reported a maximal urinary urge sensation.

In two right handed female healthy volunteers, a dynamic functional connectivity analysis was conducted. The time series were split in 4 time windows of 67 volumes each. For each time window, functional connectivity was measured between five anatomically defined seed regions in each subject's brain: periaqueductal gray (PAG), pons, parahippocampal complex (PHC), dorsal anterior cingulate gyrus (dACG) and right insula (rINS).

The resulting connectivity maps were thresholded using a false-discovery rate correction (q = 0.05), after which the surviving voxels that showed a systematic increase or decrease in functional connectivity over these 4 time windows were mapped. Only the voxels appearing in both subjects are depicted in the figure.

With bladder filling the connectivity between the right insula and PAG increased. Furthermore, a decrease in connectivity between parahippocampal complex and the frontal lobe of the brain was seen.

Concluding message These preliminary data show that it is feasible to study functional connectivity between relevant brain areas involved in bladder filling sensation using 7 Telsa fMRI of the brain. Further studies with larger group of subjects are needed to identify the location and magnitude of brain area involvement in bladder sensation. 

Hypothesis / aims of study Detrusor underactivity (DU) is frequently encountered in elderly patients with chronic medical disease or neurological diseases. The pathophysiology of DU may involve neurogenic, myogenic and bladder outlet pathologies. Part of patients with DU might have bladder function recovery after treament. This study investigated the urinary proteins in these patients in comparison with patients with detrusor overactivity (DO), detrusor hyperactivity and inadequate contractility (DHIC), and patients with normal urodynamic tracing.

Study design, materials and methods A total of 374 men with mild to moderate LUTS were initially treated with alpha-blocker A total of 37 patients with chronic urinary retention and urodynamically proven DU were enrolled. After medical or surgical treatment, 24 DU patients had bladder function recovery whereas 13 had not, after one-year follow-up. Urine collection at baseline was performed and the urinary protein including nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) and prostaglandin E2 (PGE2) were measured by ELISA. Twenty urodynamically normal, 34 DO and 15 DHIC patients served as comparative groups. 

In this study we found urinary NGF levels were significantly increased in patients with DU, DHIC and marginal elevated in DO. However, no significant difference of urinary NGF was noted between DU patients with and without bladder function recovery. Although NGF is associated with nerve regeneration, this protein might not act as a biomarker to predict bladder function recovery in DU bladders. Interestingly, we found urinary BDNF level was significantly elevated in patients with DU but not in DHIC and DO. The urinary BDNF level in DU patients with bladder function recovery was significantly higher than that in the control group and patients without recovery. These results suggest that urinary BDNF might be a better biomarker to predict bladder function recovery in patients with DU. Increase of urinary NGF and BDNF levels not only reflect the increase of protein secretion under pathological conditions, but also is seen in part of DU patients with bladder function recovery, suggesting a process of nerve regeneration is undergoing. The results of this study revealed that urinary PGE2 was significantly elevated in patients with DU, DHIC and marginal elevated in DO. Patients with DU and bladder function recovery had significantly higher urinary PGE2 level than patients without recovery and DO, suggesting the factors contributing to detrusor contractility are not completely lost in these bladders. The highly secreted PGE2 in DU bladders might reflect a compensatory response to certain bladder pathological conditions causing temporary low detrusor contractility. Through increase of PGE2 secretion from the urothelium or detrusor patients with DU may regain detrusor contractility gradually. Measurement of baseline urinary PGE2 level might predict the recovery of bladder function in patients with DU.

Patients with DU had significantly elevated urinary NGF, BDNF and PGE2 levels. DU patients with bladder function recovery had significantly higher urinary PGE2 and BDNF levels. Among the three urinary proteins, PGE2 provides the most prognostic value for bladder function recovery in patients with DU. Urinary protein levels provide prognostic value of bladder function and dysfunction. 

Hypothesis / aims of study The role of increased neurotrophin levels in neurogenic bladder dysfunction has been extensively investigated, however, the role of proneurotrophins has received less attention. Proneurotrophins are released initially from cells that are then proteolytically cleaved to form the mature protein (e.g., nerve growth factor). Mature neurotrophins can then bind to the p75 neurotrophin receptor (p75 NTR )-TrkA/B complex to promote cell growth and differentiation. Interestingly, proneurotrophins can also bind to p75 NTR when it is dimerized with sortilin to initiate apoptotic pathways [1] . Therefore, proneurotrophins may elicit different effects to the mature proteins following nerve injury. Our aim was to determine the expression of the p75 NTR and its selective ligand, pronerve growth factor (proNGF) in control and spinal cord transected (SCT) mouse bladders.

Study design, materials and methods SCT surgery: Female C57Bl/6 mice were anesthetized using 1.5-2% isoflurane, a laminectomy performed and the spinal cord completely transected between the T8-T9 vertebrae, packed with haemostatic sponge and the muscle and skin sutured. After surgery, the animals had their bladders expressed twice a day by gentle abdominal compression and given daily prophylactic antibiotics and analgesics. Mice were humanely sacrificed at one, three or seven days after surgery and bladders isolated (N=3 mice per time point).

Immunohistochemistry and image analysis: Freshly isolated bladders from control, one and seven day post-SCT mice were embedded for cryosectioning. Tissues were examined for immunoreactivity to p75 NTR (Neuromics, extracellular domain), the sensory nerve marker calcitonin gene related peptide (CGRP, Sigma), sympathetic nerve marker tyrosine hydroxylase (TH, Abcam), and nuclei were stained with DAPI. Images from labelled tissue sections were obtained using an Olympus FV3000 confocal microscope system.

Western blot: Bladder tissues from control, one and three day post-SCT mice were homogenized in a lysis buffer and run on AnyKD miniProtean gels (Bio-Rad). Expression of p75 NTR and proNGF was detected by conventional Western analyses using anti-p75 NTR (Abcam, intracellular domain) and anti-proNGF (Thermofisher) antibodies. 

Immunohistochemical labelling of control mouse bladder sections demonstrated the expression of p75 NTR on nerve-like structures throughout the bladder wall that co-localised with TH and CGRP-positive structures ( Figure 1A and B). In bladders from SCT mice (seven days post-injury) there was decreased TH-immunoreactivity (1C) and no apparent co-localisation with p75 NTR . At this time-point, CGRP-immunoreactivity was increased specifically in the lamina propria (1D) which again did not co-localise with p75 NTR .

Western blot analysis of control mouse bladders demonstrated that proNGF, the ligand for the p75 NTR -sortilin complex, was not expressed under normal conditions ( Figure 2) . However, at one day post-SCT there was a dramatic rise in proNGF levels which was markedly decreased by three days post-SCT. Analysis of p75 NTR levels showed that the spike in proNGF at one day post-SCT correlated with the loss of the full-length p75 NTR , indicating that there was proteolytic cleavage of the extracellular domain initiated by proNGF binding.

These data demonstrate that p75 NTR is robustly expressed on sensory and sympathetic nerves innervating the mouse urinary bladder. Following spinal cord injury, there is a surge in proNGF levels that can activate the pro-apoptotic p75 NTR -sortilin complex and this may account for the loss of p75 NTR /TH and p75 NTR /CGRP positive nerves seen at seven days post-SCT. However, the increased CGRP labelling following SCT suggests that there is a subset of sensory nerves that are resistant to the apoptotic effects of proNGF, i.e., p75 NTR -sortilin negative. Therefore, the transient rise in proNGF during the acute stages of spinal cord injury may be the initiator for degeneration of bladder sympathetic nerves.

Concluding message There are differential roles of pro and mature neurotrophins in neurogenic bladder dysfunction. Selective inhibition of proneurotrophin signalling (e.g., LM11A-31, selective modulator of p75 NTR currently in clinical trial for Alzheimer's disease) may be a potential therapy to reduce bladder neural degeneration following spinal cord injury.

Hypothesis / aims of study To characterize the relationship between the female urinary microbiota and bladder urinary oxygen tension (BUOT).

Study design, materials and methods Ambulatory female urogynecology patients willing to undergo transurethral catheterization were eligible for enrollment. Consented participants underwent BUOT determination with a non-invasive flow-through oxygen sensor with a compact fiber optic oxygen transmitter (Precision Sensing Regensburg, Germany) attached to the urethral catheter. Given the need to account for oxygen contamination within the sensor system, BUOT was defined as the lowest value obtained from the sensor if it reached a nadir within 2% of the previous value. Lowest oxygen values that did not meet this criterion were not considered to accurately represent the BUOT and thus excluded. Urine volume >50cc was often required for oxygen values to reach such a nadir. Outliers 1.5 IQR above the third quartile (n=2) were excluded from analysis.

Patients with measurable BUOT values were sorted into 3 groups: middle (mean BUOT +/-1 SD), low (< mean BUOT -1 SD) and high (> mean BUOT + 1 SD). Bacterial presence in urine was assessed with the Enhanced Quantitative Urinary Culture protocol; each distinct colony type was identified with Matrix-Assisted Laser Desorption/Ionization Time-of Flight mass spectroscopy. Fisher's Exact test was used for comparisons of demographic data. Results BUOT was measurable in 65% of participants (n=70). Most of these women were Caucasian (81.4%) and post-menopausal (78.6%); the mean age was 65 years (32-88). Mean BUOT was 24.84 mmHg (0.47-53.7; SD 13.6); BUOT range for the 3 groups were: "middle" (11.50-38.40 mmHg), "low" (<11.50 mmHg), and "high" (>38.40 mmHg). Between BUOT groups, we detected no difference in age, BMI, ethnicity, menopausal status, or smoking status.

Interpretation of results Using number of genera per patient, we detected a trend for less microbial diversity in the "low" BUOT group compared to the other 2 BUOT groups (Figure 1 ). Escherichia and Staphylococcus dominated the urinary microbiota in the "low" BUOT group (Figures 1 & 2) .

Concluding message This is the first study to demonstrate a wide range of BUOT values can be obtained in many urogynecology patients through a non-invasive oxygen sensor system. There appears to be an association between BUOT and the female urinary microbiota with low BUOT having increased representation of known uropathogens. 

Hypothesis / aims of study Integrated total pelvic floor ultrasound (transvaginal, transperineal) has emerged as a new imaging modality to assess the pelvic floor dysfunction as an alternative to defaecatory imaging. However, 'normal' appearances must be understood before it can be useful for the assessment of pathology.

The aim of this study was to assess the pelvic floor anatomy in individuals with no pelvic floor symptoms.

Study design, materials and methods A prospective observational case series of 20 asymptomatic female volunteers.

All women were screened with symptom questionnaires ((ICIQ-BS and ICIQ-VS (International Consultation on Incontinence Modular Questionnaire -Bowel and Vaginal Symptoms), B-SAQ (Bladder self-assessment questionnaire), ODS score (obstructed defaecation symptom), St Marks' faecal incontinence grade) to ensure they were asymptomatic prior to recruitment.

Each subject underwent assessment with; -Integrated total pelvic floor ultrasound (transperineal, transvaginal, endovaginal, endoanal) performed as per previously published methods (1). -Defaecation MRI performed in a closed configuration magnet to record the expulsion of rectal sonographic gel. The presence and size or grade of rectocoele, enterocoele, intussusception, cystocoele, dyssynergy and poor propulsion was recorded for both imaging modalities. Bladder neck descent, anal sphincter integrity and levator plate integrity were assessed during integrated total pelvic floor ultrasound. Pattern of evacuation and incomplete evacuation was noted during defaecation MRI.

There were 7 parous and 13 nulliparous women. Mean age was 37 years (range 22 -53).

Anatomical deficits: On integrated total pelvic floor ultrasound; there were 3 subjects who displayed a rectocoele (2cm, 2.5cm, 2.5cm), 3 with enterocoele (2 grade II, 1 grade III with relation to the vagina), 1 with intussusception (grade III), 8 with cystocoele (4 grade I, 4 grade II in relation to the vagina) and 5 with bladder neck descent 2cm or greater. The internal and external sphincter was intact for all subjects. Mean internal anal sphincter thickness was 1.9 (range 1 -3.9). There were three subjects with mild levator plate damage.

On defaecation MRI; there were 3 with a rectocoele (2cm, 2cm, 2.6cm), 2 with enterocoele (grade II), 8 with cystocoele (7 grade I, 1 grade II). There were no cases of intussusception.

Overall, there were 8 cases with no anatomical defects on either imaging modality and 6 cases without any posterior pathology on either imaging modality but a cystocoele on either one or both scan. There were 6 cases with posterior pathology (one with enterocoele on both modalities, one with enterocoele and cystocoele on both, one with a rectocoele on ultrasound only, one with a rectocoele on MRI only and a cystocoele on both, one with a rectocoele on both and an enterocoele on ultrasound only and one with a rectocoele and cystocoele on both) (figure 1). There were 2 with a rectocoele on both imaging modalities but the 2cm rectocoele visualised on ultrasound was not seen during MRI and the 2.6cm rectocoele seen on MRI was not visualised during ultrasound. The two grade II enterocoeles visualised during ultrasound were also seen during MRI (both also grade II on MRI) but the grade III enterocoele seen on ultrasound did not develop during MRI. There was one cystocoele which was seen on ultrasound (grade I) but not MRI and one seen on MRI (grade I) but not ultrasound. Grade of cystocoele was underestimated by MRI compared to ultrasound in four cases (grade II on ultrasound and grade I on MRI). Interpretation of results Comparing defaecation MRI with integrated total pelvic floor ultrasound has allowed us to refine our anatomical knowledge of ultrasound. There was agreement between the two imaging modalities for the presence or absence of anatomical abnormalities. However, severity of pathology did not always correspond. This may be related to the positioning of patients or the differences in the presence or absence of rectal contrast. Ultrasound tended to overestimate cystocoele compared to MRI (which may represent underestimation on MRI). Defaecatory MRI in a closed configuration system may overestimate functional abnormalities due to difficulty in expulsion of rectal gel in the supine position.

In this group of normal subjects with no bowel symptoms a significant number of anatomical abnormalities where identified on both investigation modalities. Clearly not all anatomical abnormalities cause symptoms. Due to difficulties with recruitment the cohort of women recruited was not a true representation of the population as most were nulliparous and pre-menopausal. Concluding message Not all anatomical abnormalities cause symptoms. The spectrum of 'normal' findings on imaging may be wider than previously appreciated and decision making for management based on imaging alone is unreliable and should be avoided. Possibly further work to identify why anatomical abnormalities cause symptoms in some people and not others is needed.

Hypothesis / aims of study The 2002 ICS Standardisation Report and the 2009 ICS-IUGA Standardisation Report imply that urinary urgency is the 'cardinal' symptom of the OAB syndrome. However, as identified by the report from the ICS Standardisation Steering Committee (1), the Standardisation Reports are exclusively based on expert opinion and not on any existing literature. Furthermore, there is very limited qualitative understanding of the most bothersome symptom(s) of OAB, as perceived by patients, the life impact of OAB symptoms and the extensive coping mechanisms that are employed by patients. This influences how patient reported outcome measures (PROMs) for OAB are evaluated, which, in turn, impacts end points used in OAB clinical research. Therefore, the aims of the study are to: (i) evaluate urinary urgency as the 'cardinal' symptom of the OAB syndrome (ii) gain an understanding of patient-reported most bothersome OAB symptom(s) and any other symptoms that can be addressed to improve patient outcomes (iii) explore the life impact of OAB symptoms and the coping mechanisms employed by patients.

This is an original prospective qualitative focus group study. Prior to this study, women with refractory OAB were recruited from a separate randomised control trial (RCT), and preliminary data were obtained. For this study, women with symptoms of OAB, from a primary (primary community continence clinics) and secondary (Urogynaecology Clinics, University Hospitals) setting were given a participant information pack. Interested patients returned a completed reply slip to the research team and were contacted to determine appropriate dates and times for focus groups. The focus groups aimed to include 6 -8 participants, lasting for 90 -120 minutes. Before starting the focus groups, participants individually completed a Symptom Bother Chart and a Visual Analogue Scale (VAS) Sheet. The focus group was conducted using a focus group schedule, and was audio recorded and transcribed verbatim. Transcribed data was imported into Nvivo. The transcripts were read multiple times to initially generate 'open codes', which were then organised into themes, using the constant comparative method (2) .

Work is on-going. Four focus groups have been completed so far, two with patients with refractory OAB recruited from the RCT (n= 12), one with patients with refractory OAB from urogynaecology clinics (n = 2) and one with patients with mixed symptom severity from urogynaecology clinics (n = 7). Data from the Symptom Bother Chart and the VAS Sheet formed part of the descriptive statistics. Some of the themes identified have been included. Interpretation of results Urgency seemed to be the most bothersome symptom with the greatest impact, based on the Symptom Bother Chart and VAS data (Table 1 & 3) . However, UUI also had significant impact. Patients with moderate symptom severity regarded nocturia to be bothersome with impact. Extensive self-management strategies were employed and the life impact of the symptoms was profound. For some, the consequences of the symptoms were equally, if not more, significant than the physical manifestation of the symptoms. A key concept was the role of the 'support system' in patients' management of their symptoms, especially the specialist continence nurses.

Multi-thematic analysis indicates that it is imperative for both healthcare professionals as well as pharmacological companies to understand how symptoms are viewed by OAB patients, and data from this study can supplement other subsequent quantitative studies in the field.

Hypothesis / aims of study Overlapping symptoms of interstitial cystitis (IC) and overactive bladder (OAB) often complicate the diagnosis and suitable treatments. In addition, the chronic inflammatory condition seems to be a shared characteristic in patients with IC and OAB. Thus, we measured forty inflammatory urine markers in IC patients with or without Hunner lesions (HIC and NHIC, respectively) and OAB patients.

Study design, materials and methods Urine was collected from 30 HIC consecutive patients, 30 NHIC patients and 28 age and gender-matched OAB patients with no history of IC, recurrent urinary tract infection or bladder cancer. The diagnosis of IC was based on the Asian IC guideline criteria. Representative forty inflammatory growth factors, cytokines and chemokines in urine were measured by a MILLIPLEX immunoassay kit. Statistical differences in these markers among the groups were determined by non-parametric ANOVA followed by multiple comparison test. The diagnostic efficiency of these markers was measured using receiver operating characteristic analysis.

Vascular endothelial growth factor (VEGF), interleukin-1α (IL-1α), IL-6 and chemokines including CCL2, CCL5, CXCL1/2/3, CXCL8 and CXCL10 were significantly increased in HIC and NHIC patients compared with OAB patients. The significant increases in CXCL8 and CXCL10 were also found in HIC patients compared with NHIC patients (Fig. 1) . However, there were no significant differences in the other urine markers among the groups. Area under the curves (AUCs) for VEGF, CXCL10, CXCL8, IL-1α, CCL5, CCL2, IL-6 and CXCL1/2/3 to detect IC in these patients were 0.87, 0.86, 0.81, 0.80, 0.80, 0.71, 0.66 and 0.50, respectively (Table 1) . Table 1 Receiver operating characteristic analysis for inflammatory urine markers.

Interpretation of results VEGF plays a key stimulatory role in angiogenesis whereas CXCL10 is a potent inhibitor of angiogenesis (Ref. 1). CXCL10 can induce not only anti-angiogenesis effects, but also pro-inflammatory response by activating T lymphocytes. CCL2 or CCL5 causes chemotactic migration of monocytes, eosinophils, basophils, lymphocytes or mast cells but not does not act on neutrophils (Ref.

2) whereas CXCL1/2/3 and CXCL8 are mainly chemotactic for neutrophils (Ref. 3 ). In addition, both IL-1, including IL-1α and IL-1β, and IL-6 have many pro-inflammatory effects.

Concluding message IC patients seems to have more severe chronic bladder inflammation evidenced by the significant increases in IL-1α, IL-6, CCL2, CCL5, CXCL1/2/3, CXCL8 and CXCL10 compared with OAB patients. In addition, the increases in angiogenesis-associated proteins such as VEGF and CXCL10 may pathophysiologically be important for the development of IC.

Hypothesis / aims of study Severe anterior and apical POP are considered a risk factor for pelvic organ prolapse (POP) recurrence [1] . The aim of the study was to compare laparoscopic sacral cervico/colpopexy (LSC-CS) with anterior vaginal mesh (AVM) for the correction of anterior vaginal wall associated with apical POP (uterine or vault) in women with advanced POP stage.

Study design, materials and methods A prospective randomised controlled trial (RCT) was designed in a tertiary university hospital from January 2011 to March 2016. The inclusion criteria were: women requiring POP surgery with primary or recurrent symptomatic POP (stage 3 or greater anterior POP with a stage 2 or greater apical POP). Given a 77% anatomic success rate for LSC-CS [2] , the sample size necessary to detect a difference of 25% in anatomic success rates, having a β error of 0.2 and an α error of 0.05, was 52 patients per arm.

Considering a drop-out rate of 15%, 120 patients were included in the study (60 per group). Surgical success (primary composite outcome) was defined as: 1) vaginal apex descent no more than one-third into 

Surgical success was achieved in 79% with LSC-CS and 76% with AVM (NS) ( Table 1) . No statistically significant differences were found among POP-Q anterior vaginal wall points between groups, whereas better results were obtained with LSC-CS in posterior vaginal wall points and total vaginal length. Intraoperative outcomes were similar in the two groups, except for the operating time (78.1 ± 35.0 minuts for LSC-CS and 44.3 ± 18.4 minuts for AVM group; p <0.001). Anatomical correction was also analyzed, as well as subjective and objective intraoperative and postoperative outcomes incontinence and dyspareunia. Worse results were found in the CRAD-8 in the LPSC-CS group, due to constipation symptoms. Three patients (7%) explained dyspareunia de novo (% of sexually active at baseline) in the LSC-CS group, while 7 women (19%) in the AVM group (NS). Late postoperative complications and reinterventions were similar in both groups. Two reinterventions (3%) were performed in the LSC-CS group for complications of the mesh, whereas 3 (5%) in the AVM. Reintervention for POP recurrence 1 (2%) 3 (5%) * Two patients of each group were missing due to lack of follow-up.

Interpretation of results

Anterior and apical POP correction with LSC-CS or AVM shows similar results based on questionnaires or the POP-Q system. The apical compartment can be successfully corrected vaginally, although TVL and point C are higher in the LCS-CS.

De novo dyspareunia was more frequent in the AVM group (NS), whereas constipation was significantly more prevalent in the LCS-CS group.

3)

The number of complications and reinterventions in both groups were similar.

Hypothesis / aims of study Reported outcomes of hydrodistention for interstitial cystitis/painful bladder syndrome (IC/PBS) patients have varying response rates making it difficult to standardize its clinical utility. We aim to better delineate patient characteristics involved in the symptomatic response to bladder hydrodistention and in subsequent therapy modalities. We hypothesize that patients that move on to third line therapy according to the American Urological Association's (AUA) guidelines give us valuable information as to which 4 th line therapy they would ultimately benefit from in the long term, if necessary.

This was an IRB exempt retrospective review based on our practice pattern of allowing hydrodistention data to dictate subsequent care in IC/PBS patients. Between March 2008 and March 2016, 77 patients underwent bladder hydrodistention at our institution as third line therapy according to the AUA guidelines, as indicated. If present, Hunner's ulcers were fulgurated accordingly, and injected with triamcinolone in selected cases. A retrospective chart review was performed. All procedures were done in the operating room under anesthesia with bladder filling pressure of 60-80 cm H2O. Patients were assessed at routine follow up visits.

Median follow up was 190 days (range, 0-2717). Of the 64 patients for which we had follow up, 41 (64%) had improvement in symptoms and 23 (36%) did not. Ulceration was present on cystoscopy in 20 (26%). Of responders, 16 (39%) had ulcers and 25 did not. Of non-responders, two (9%) had ulcers and 21 did not (p<0.01). Responders had lower mean anesthetic bladder capacity (496.0ml±235.4) versus non-responders (747.4ml±276.05) (p=0.<0.001). There was no difference in responders and nonresponders in bladder capacity (p=0.41) or involuntary detrusor contractions (p=0.80) on urodynamics. Twenty-five patients proceeded to fourth (19 intradetrusor botulinum toxin A (BTX-A), nine neuromodulation) and sixth-line (three cystectomies) therapies, In the BTX-A group, 11 (69%) had improvement of symptoms with BTX-A. Ulceration was present in 63.6% of those who improved compared to 20% of those who did not (p=0.28). Average anesthetic capacity was 387mL for those who improved compared to 540mL for those who did not (p=0.24). All 9 patients who had neuromodulation had improvement of symptoms but this was not sustained in everyone. The average anesthetic capacity for this group was 703mL, and none had ulceration on cystoscopy.

Interpretation of results Patients with lower anesthetic bladder capacity as well as patients who have ulceration on cystoscopy may be more likely to have relief of symptoms with hydrodistention alone. When considering moving on to 4 th line therapy, we have identified that patients with smaller bladder capacity and ulcerations are naturally likely to benefit from BTX-A, as this appears to be more of a bladder focused disease process in this group. Those with larger anesthetic capacity and no ulcerations are more likely to benefit from neuromodulation as their bladders are essentially morphologically normal, therefore no additional treatment to the bladder proper is likely to deliver any additional benefit. The net result is that by this selective approach of determining the next step on bladder capacity an appearance, we were able to achieve a high success rate overall in this difficult to treat population.

Concluding message In our practice, hydrodistention is used as both a therapeutic treatment and diagnostic provocation in IC/PBS patients to assist in deciding appropriate further treatment options with great success in the series presented in this very difficult patient population. 

Hypothesis / aims of study Studies investigating genitourinary syndrome of menopause (GSM) are lacking uniformity in symptoms evaluation [1] . For this reason, the US Food and Drug Administration (FDA) recommended the use of the Most Bothersome Symptom (MBS) questionnaire in 2003 which investigates the symptoms' severity and identifies the most important symptom for women with GSM [2] . Another interesting questionnaire, the Atrophy symptom questionnaire, assesses the impact of GSM symptoms on quality of life (i.e. activities of daily living and sexuality) [3] . However, the repeatability of these questionnaires has never been assessed. Moreover, the relationship between GSM symptoms and their impact on post-menopausal quality of life has never been studied, nor the relationship between the MBS questionnaire and the Atrophy symptom questionnaire. Therefore, the aims of this prospective study were 1) to assess the test-retest repeatability of the MBS questionnaire and the Atrophy symptom questionnaire and 2) to explore the relationship between the MBS questionnaire and the Atrophy symptom questionnaire.

Study design, materials and methods Community-dwelling women aged 55 years and older with GSM were recruited for this prospective test-retest cohort study from a mother study on older women with urinary incontinence. To be included in this study, participants had to present at least two of the following signs: petechiae, absent rugae, decreased elasticity and friability of the vaginal wall. Subjects with dermatological diseases of the vulva, important prolapses (POPQ>2), radiation for gynecological cancer or vaginal or urinary infection within the previous 3 months and who were taking antiestrogenic medication were excluded. Dosage of systemic and local hormonal therapy medication had to be stable for six months to ensure symptoms stability.

One evaluator administered the questionnaires twice (at T1 and T2) two weeks apart. The MBS questionnaire is composed of four common GSM's symptoms (vaginal dryness, vaginal itching/irritation, dysuria and dyspareunia) and participants have to rate each of these symptoms on a 4-point scale (0=not present, 1=mild, 2=moderate or 3=severe). Then, women have to select a single symptom as the MBS. According to the FDA, the evolution of this specific symptom is the one to consider after treatment or intervention [2] . The Atrophy symptom questionnaire has four items assessing the impact of GSM's symptoms on activities of daily living and one item on sexual activity. In sexually active women, this item assesses the impact of dyspareunia on intercourse and sexual satisfaction. Each of the five items is rated on a 4-point scale (0=none, 1=mild, 2=moderate and 3=severe). For the total score, the individual items' scores are summated and divided by five in sexually active women or by four in non-sexually active women.

Agreement between test and retest responses to items of the MBS questionnaire was observed by graphical analysis of paired differences and the weighted Kappa (ĸ) statistic. Test-retest repeatability of the Atrophy symptom questionnaire was assessed using paired t-test and intraclass correlation coefficient (ICC). Finally, Pearson correlation coefficient was computed to assess the correlation between MBS item's severity and the Atrophy symptom questionnaire total score.

A total of 20 women aged between 57 and 82 years old (68.1 ± 7.1 years old) were recruited with a mean parity of 1.7 ± 1.1 delivery and a mean BMI of 26.7 ± 4.6. Thirteen were sexually active, one was taking systemic hormonal therapy, four were taking local hormonal therapy and two used a non-hormonal vaginal moisturizer.

MBS questionnaire: Observed agreement between T1 and T2 for the MBS questionnaire symptoms' severity ranged from 60% to 80%, and Kappa's strength of agreement was fair to substantial (Table 1) . For the severity of the selected MBS symptom item, observed agreement of 85% was obtained with a substantial Kappa's strength of agreement (0.751 ± 0.132; p < 0.001)( Table 1) . Atrophy symptom questionnaire: There was no significant difference between T1 and T2 for the Atrophy symptom questionnaire total (T1 mean=0.76 ± 0.30, T2 mean=0.83 ±0.37; p=0.203). Based on the ICC results, excellent repeatability was obtained (0.81 (95% CI 0.54-0.92); p <0.001).

Correlation between questionnaires: There was a strong, positive correlation between the selected MBS item's severity and the Atrophy symptom questionnaire total score for the two measurements sessions (T1: r=0.572; p=0.008, T2: r=0.620; p=0,004).

Interpretation of results MBS questionnaire: Results from this test-retest study indicates a substantial agreement of the MBS item's severity in the MBS questionnaire between measurements sessions. Being able to reproduce the MBS item's severity from the questionnaire is of major importance as FDA recommended its use to evaluate change following an intervention, in women with GSM. Looking at each specific item of the MBS questionnaire, agreement obtained was fair for the vaginal dryness, the vaginal itching/irritation, and the dysuria symptoms and was substantial for the dyspareunia symptom. The non-concordant answers seem to be related to a higher rating of GSM's symptoms' severity at T2, mostly for the vaginal dryness and the vaginal itching/irritation symptom items. Those results may be related to women's misunderstanding the meaning of vaginal dryness and vaginal itching/irritation compared to the meaning of dyspareunia.

Atrophy symptom questionnaire: For the Atrophy symptom questionnaire, results obtained in this study indicates excellent repeatability according to the ICC values.

To our knowledge, this is the first study assessing the test-retest repeatability of the MBS questionnaire and the Atrophy symptom questionnaire.

Correlation between questionnaires: A strong positive correlation was found between the MBS item's severity and the Atrophy symptom questionnaire total score. These results appear to support the relationship between higher severity of GSM's symptoms and higher impact on activities of daily living and sexuality (intercourse and sexual satisfaction). Of note, no other study was found in the literature that investigated the relationship between these questionnaires or other questionnaires looking at the same content. Only correlations between GSM's symptoms' severity and physical findings were assessed previously (observed signs, pH and maturation value), with various results.

Among UDS parameters, PVR > 150 ml during free-flow study strongly indicated a diagnosis of MSA rather than PD (OR 8.723, 95% CI 2.612-29.130, p < 0.001). PVR during PFS > 150 ml also indicated a diagnosis of MSA (OR 6.030, 95% CI 2.122-17.137). 'Weak detrusor' also suggested MSA, but the relation was not statistically significant (OR 10.598, 95% CI 0.359-312.473, p = 0.172). The presence of DO and neurogenic change in EAS-EMG (mean duration of MUPs > 10 ms) did not significantly contribute to the differentiation of MSA from PD (Table) . Interpretation of results We have previously reported that urinary voiding dysfunction is more prevalent and severe in MSA compared to PD and measuring PVR might be useful for the differentiation of MSA [1] . However, second consensus criteria of MSA emphasize the presence of urinary incontinence rather than incomplete bladder emptying for the clinical diagnosis of MSA. Many neurologists might be confused with the examination of LUTD in diagnosing MSA or PD because urgent urinary incontinence is also common in PD with advanced stage. It should be pointed out that PVR > 150 ml during free-flowmetry had a large odds ratio with statistical significance. Although PVR > 150 ml during PFS and impaired bladder contractility also had large odds ratios, PFS is necessary for their examination. PFS is an invasive examination and is not appropriate for routine use. Based on clinical reliability and invasiveness, PVR > 150 ml during free-flowmetry is appropriate for the diagnosis of MSA with regard to urological dysfunction. The present study might confirm that urinary voiding dysfunction as evaluated by measuring PVR is more useful than the presence of storage dysfunction in differentiating MSA from PD. The present result also indicated that the prevalence of DO is not different between PD and MSA, which was consistent with our previous study [3] . Although we have also previously reported that neurogenic change in EAS-EMG suggest the diagnosis of MSA rather than PD [2] , the present study indicated that PVR is more useful than EAS-EMG in differentiating MSA from PD.

The present study indicated that PVR larger than 150 ml might be more useful than other UDS parameters in differentiating MSA from PD.

Hypothesis / aims of study The lower urinary tract control is a result of complex interaction between peripheral and central nervous system. Impairment of one of this system may change this balance bringing to neurogenic bladder bowel dysfunction (NBBD) with a negative impact in continence and patients quality of life [1] . SNM is a minimally invasive treatment widely used to treat patients with BBD. The beneficial effect of sacral neuromodulation has been demonstrated in patients with BBD but the effectiveness of this treatment in patients with neurogenic BBD still unclear [2, 3] . This probably is related with the type and the side of the lesion. Moreover results od SNM in neurogenic patients is controversial and there is no study in literature regarding the effect of SNM in patients with NBBD related to spina Bifida and still unclear the selective criterion to treat neurogenic patients with SNM [1, 3] . The aim of this study is to evaluate and demonstrate the effectiveness of SNM in patients with Spina Bifida comparing to other congenital neurogenic BBD.

Study design, materials and methodsù From 2008 onwards 45 pediatric patients have been treated with SNM in our department. All patients were treated according to our protocol approved by our Institute, and when anticholinergic or onabotulinum toxin A were not effective. All patients were operated with a 2 stages surgical procedure.

We have selected and include in the study all pediatric patients with congenital neurogenic bowel bladder dysfunction and divided in two groups: patients with spina bifida and patients with other NBBD. Clinical and urodynamic parameters after and before treatment where analyzed and compared. All patients were treated according to our protocol approved by our Institute, and when anticholinergics or onabotulinum toxin A were not effective. All patients were operated with a 2 stages surgical procedure. All patients were followed up for at least 24 months and the outcomes were evaluated basing on clinical and urodynamic parameters such as bladder diary, the need of CIC, and PVR.

Seventeen patients with a mean age of 14.4 ± 3.0 years old underwent a two-stage SNM implantation. Five patients (29.4%) suffering from spina bifida and 70.6 % n=12 neurogenic bladder not related with spina bifida, The implant was unsuccessful with remotion in 25% (n=3/12) patients with congenital NBBD not related with spina bifida. No rimotion was observed in spina bifida patients. Moreover in this group 1/5 patient underwent the test phase with a scant response and the definitive procedure was not done. The global success rate was observed in 80% (n=4/5) of patients with Spina bifida compared with 75% patients with other NBBD. PVR improvement and the need of CIC were comparable in the two groups with non-statistical significance.

The role of SNM in neurogenic patients still controversial. The effectiveness of SNM in spina bifida patients compared with other NBBD has not been previously reported. Improvement in clinical and urodynamic parameters was reported in patients with spina bifida. Despite a better global response in spina bifida the clinical and urodynamic response were comparable in the two group. Moreover is important to see that in Spina Bifida group no removed was observed. This result is related to an improvement of clinical outcomes with an improvement of patients quality of live, suggesting that the implant od SNM in patients with neurogenic BBD is effective with a good clinical and urodynamic response. The role of patient selection should be important to a better management of bladder emptying. 

Hypothesis / aims of study In recent decades, treatment of neurogenic detrusor overactivity (NDO) with onabotulinumtoxinA has emerged as an alternative method for the management of urological complications due to spinal cord injury (SCI) or multiple sclerosis. Injection of 200-300 U of onabotulinumtoxinA into the detrusor muscle can reduce contractility, improve bladder compliance, and restore urinary continence in patients with NDO. Currently, a 200 U single injection of onabotulinumtoxinA into the detrusor has been recommended as standard treatment for NDO. However, the therapeutic duration of this dosage on NDO was shorter than that of a 300 U injection. Most studies of onabotulinumtoxinA on NDO come from animal models, and only a few human studies have been noted. The current study investigated changes in urothelial dysfunction and sensory protein expression in the bladder urothelium with time after a single onabotulinumtoxin injection in SCI patients.

Study design, materials and methods Twenty-six patients with chronic SCI causing neurogenic detrusor overactivity and urinary incontinence were treated with a single injection of 200 U onabotulinumtoxinA. Video urodynamic studies were performed at baseline, 3 months, and 6 months after treatment. Bladder mucosal biopsy was performed at the same time-point. Treatment outcomes were considered successful if patients had a 50% increase in cystometric bladder capacity and improvement of incontinence. Twenty patients with stress-related urinary incontinence served as controls. Bladder tissues were investigated for E-cadherin, zonula occludens-1 (ZO-1) expression, mast cell activity, and urothelial cell apoptosis. Western blotting was completed to assess expression of sensory proteins [purinergic receptor P2X3, endothelial and inducible nitric oxide synthases (NOS), β3-adrenoceptor, and muscarinic receptors M2 and M3] between controls and SCI patients, as well as successful and failed treatment groups. 

The mean age was 42.7 ± 13.1 years in SCI patients and 52.4 ± 10.5 years in controls. After onabotulinumtoxionA injection, successful treatment outcome was noted in 17 (65.4%) patients at 3 months but only 13 (50%) patients at 6 months; 12 patients had a successful outcome lasting up to 6 months. Table 1 shows the urodynamic parameters at baseline and 3 and 6 months after onabotulinumtoxinA injection. As expected, Pdet decreased, while CBC and PVR volume increased at 3 months after treatment. However, these urodynamic changes faded at 6 months. Comparison of urodynamic parameters at baseline to those as 3 and 6 months revealed only the successful treatment group showed these therapeutic effects (Table 1) . Compared to controls, urothelial expression of E-cadherin was significantly lower, while mast cell activity and apoptotic cell count were significantly higher in SCI bladders ( Table 2) . Increased E-cadherin levels were noted 3 months after injection but were reduced at 6 months. Mast and apoptotic cell counts showed no change at 3 or 6 months after treatment. ZO-1 expression was significantly increased at 3 months but returned to baseline levels at 6 months. Among the urothelial sensory proteins, only baseline M3 and eNOS levels were significantly lower in SCI bladders versus controls. Interestingly, there were no significant changes in any of the sensory proteins examined from baseline to 3 or 6 months in SCI patients after onabotulinumtoxinA injection (Table 2) . However, M3 receptor density was significantly decreased in SCI patients with successful treatment outcome at 6 months (0.44 ± 0.29 versus 0.35 ± 0.26, P = 0.01).

The results of the current study revealed that after detrusor injection of 200 U onabotulinumtoxinA, the urothelial levels of Ecadherin and ZO-1 improved after 3 months, but the effect declined 6 months after treatment. Urothelial sensory protein levels were not significantly changed after onabotulinumtoxinA treatment. Improvement of bladder sensation and CBC were noted in 65.4% of SCI patients who had successful outcomes but not in patients who experienced treatment failure. These results imply that the therapeutic effect of 200 U onabotulinumtoxinA might not be adequate for NDO.

Concluding message A single injection of 200 U onabotulinumtoxinA in SCI patients improved urothelial expression of E-cadherin and ZO-1 at 3 months, but the effect declined 6 months after treatment. Urothelial sensory protein levels did not significantly change after onabotulinumtoxinA treatment. Observed protein changes were in accordance with bladder function improvements in 65.4% of SCI patients with successful outcomes. These results imply that the therapeutic effect of 200 U onabotulinumtoxinA might not be adequate for NDO. 

Hypothesis / aims of study Iatrogenic urethral obstruction is a potential complication of anti-incontinence surgery. Symptoms can be either urinary retention (partial or complete), or less specific voiding or storage symptoms.The incidence of iatrogenic urethral obstruction is poorly defined and probably underestimated. Permanent voiding dysfunction has an incidence of 5%(1) and, in particular, urinary retention has been reported with an incidence of 3-7% after retropubic colposuspension, 4-8% with needle-suspension procedures and 6-11% with sling procedures, and urinary retention following TVT occurs in 1.4-9.0% of cases (2, 3) . The primary objective of this study was to evaluate the effect of trans-vaginal urethrolysis on storage and voiding symptoms and its impact on quality of life (QoL). As a secondary outcome, we evaluated possible predictive factors for treatment failure.

Study design, materials and methods This is prospective study. All women with storage symptoms or voiding symptoms (incomplete emptying with postvoid residual of more than 200ml thus requiring intermittent catheterisation) or both, after anti-incontinence surgery, were included. In all patients urodynamics showed a pdetQmax > 25 cmH2O and a Qmax < 10 ml/sec (Defreitas) were included. They underwent trans vaginal urethrolysis (Nitti and Raz's technique). Exclusion criteria were: the presence of POP, the recurrence of SUI. Preoperative evaluation included: history, structured questionnaire for storage and voiding symptoms,3-day voiding diary, pelvic examination, evaluation of degree of urinary incontinence according to Ingelmann-Sundberg classification, cystourethroscopy, urodynamic studies. After urethrolysis they completed a 3-day voiding diary, a conventional urodynamic study and the following validated selfadministered questionnaires for the assessment of QoL:SF-36,PGI-S scale, OAB-q. We defined the resolution of storage symptoms as the absence of urgency and urge incontinence with a daytime frequency less than 8 times a day. Criteria to define improvement were a reduction in frequency of at least 30% and also a reduction in urgency and urge incontinence of at least 50%.Resolution of voiding symptoms was defined as absence of voiding symptoms, or postvoid residual of less than 50cc thus allowing interruption of clean intermittent catheterization (CIC). We defined improvement as a decrease in postvoid residual of at least 50%.Statistical analysis was carried out using McNemar's Chi-square test for categoric variables, the paired t-test for parametric variables and the Mann-Whitney test for non-parametric variables. We considered p<0.05 to be statistically significant.

Between 2011 and 2015 we enrolled 30 women who came to our clinic for iatrogenic outlet obstruction. All were aged 46-76 yrs (mean 59.7 yrs±8.7), median parity was 2 (range 0-4), 27 patients (90%) were post-menopausal. Pre-operative data are summarized in Table 1 . Trans vaginal urethrolysis was performed mean 19.4 months after the anti incontinence surgery. In eight cases, a suprameatal urethrolysis was associated. In cases of previously failed urethrolysis, a Martius flap was performed, in order to improve tissue repair and prevent new adhesions from forming. Only four patients had recurrent stress urinary incontinence in addition to outlet obstruction; these were given an anti-incontinence procedure in association to urethrolysis. Mean follow-up was 13.2 ±14.2 months. Following urethrolysis, we observed complete resolution of voiding symptoms in 16/27 patients (59.3%) and significant improvement in 7 other patients (25.9%). As regards storage symptoms, post-operative resolution was observed in only 4 patients (16.6%), and clinical improvement in 3 patients (12.5%). These patients ha an improvement of QoL. To investigate why storage symptoms persisted in some cases and not in others, and if any predictive factors exist, we divided the patients into those whose symptoms persisted (group 1) and those whose symptoms resolved (group 2). Table 2 showed no differences in pre-operative voiding symptoms, significant post-void residue, anticholinergic treatment, or need for CIC. Table 3 showed no significant difference between the groups in any preoperative urodynamic parameters, except for detrusor overactivity (p=0.002). Group 1 had a time-lag between SUI surgery and urethrolysis of 12-38 months, compared to 6-11 months for group 2 (p=0.01). 

This study showed a significant improvement in voiding symptoms, but not in storage symptoms. The literature presents conflicting data on this point.In our sample women with persistent storage symptoms had a time -lag between anti incontinence surgery and urethrolysis.It could explain its. Infact a prolonged obstruction could determine urotelium morphological alterations, which determine clinically storage symptoms.

Concluding message This study confirms that trans-vaginal urethrolysis is an effective treatment for voiding symptoms caused by anti-incontinence surgery but gives poor results in correction of storage symptoms. syndrome wet. The analysis of PIP index showed that preoperatively 8 women had detrusor underactivity of which 6 solved the dysfunction after surgery, however in the total sample the mean change postoperative PIP index was not statistically significant (p=0.224). Before LSC 15 patients had BOO, of which 11 (73%) solved the obstruction with surgery (p=0.022). The results confirm LSC is an efficacy procedure for the treatment of POP also for functional results. Voiding symptoms significantly improved, result confirmed by the improvement of Qmax and BOO, and decrease of Pdet max. Storage symptoms improved probably for the disappearance of the obstructive effect of POP but the persistence of them in more patients compared voiding symptoms maybe was linked to other causes such as the aging. Women with NIC decreased after surgery, as effect of the disappearance of the obstruction, however they persisted in 1 patients with OAB symptoms, demonstrating different physiopathological causes .In according to PIP detrusor underactivity improved in 6 women after LSC probably for low degree of underactivity .

Concluding message This study confirms the good functional outcomes of LSC in the treatment of POP in the medium follow-up.

METHODS: Female subjects who were assessed and referred for stress urinary incontinence surgery were eligible to participate in this study. Women with intrinsic sphincter deficiency (maximum urethral closure pressure (MUCP) of 20 cmH2O or less and/or abdominal leak point of 60 cm H2O or less), previous failed midurethral or fascial sling, untreated detrusor overactivity or significant voiding dysfunction (maximum flow rate < 15 mL/s or < 10% Liverpool nomogram and/or postvoid residual > 100 mL) were excluded.

Patients had equal probability of allocation to TVT Abbrevo or MiniArc sling; randomisation was performed with computergenerated blocks of 4-8, with concealed allocation. Surgeons or patients were not blinded once allocation was revealed. Assuming an objective cure rate of 90% for TVT Abbrevo TM with a power of 80%, a sample size of 79 in each arm was required to detect a clinical difference of 15%, using a one sided  of 0.05.

The target recruitment number was 220 allowing for an attrition rate of 15%. Institution ethics approval (11261B) was obtained and the trial was registered with the national clinical trial registry.

Routine preoperative assessment (symptom evaluation, clinical examination, urodynamics and perineal ultrasound, urinary diary) was conducted for objective data, whilst patient reported outcome tools (PRO) were utilised for subjective outcomes. These include ICIQ UI SF, ICIQ OAB, IIQ7, EQ5D, PISQ12, PGIs & PGII.

TVT Abbrevo TM or Miniarc TM were performed in a standardized fashion, together with any concomitant prolapse surgery, followed by routine post operative care including voiding trial and assessment of post operative pain. Review was conducted at 6 weeks and at 6 and 12 months at which time, uroflowmetry, a clinical cough stress test and examination were performed in addition to symptom and quality of life questionnaires.

Objective cure was defined as a negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with physical exertion. All Data was collected on a standardized proforma including patient characteristics. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t test or exact versions of Wilcoxon tests for numerical data as appropriate. Table 1 .

At the current time-point, 178 women were assessed. There were significant differences in subjective cure at 12 months though no differences were seen in objective cure rates and patient reported outcomes, as shown in Table 2 . Five MiniArc patients had failed surgery in the first 12 months requiring a second sling at 3, 12, 13, 14 and 14 months. Two of these were in Miniarc pro (newly introduced tensioning device).

Hypothesis / aims of study This original work was designed to explore the prevalence of pelvic floor and obturator internus (OI) myofascial pain in women presenting for evaluation of pelvic floor disorders (PFD). Pelvic floor and obturator internus myofascial pain refers to pain arising from pelvic and internal hip muscles [levator ani (LA) and OI] and connective tissue 1 . The result can be chronic pelvic pain that significantly and adversely affects quality of life for many patients 2 . Female pelvic medicine and reconstructive surgery (FPMRS) providers at our institution routinely examine the internal hip and pelvic floor muscles on all new patient examinations and have anecdotally identified an increased prevalence of pelvic floor and OI myofascial pain in this population. We aimed to formally estimate this prevalence.

We performed a retrospective cross sectional study of all new patients presenting to our FPMRS practice for new patient evaluation from 1/2014-4/2016. A pelvic floor and OI myofascial examination was performed on all new patients by transvaginal palpation of the OI and LA muscles bilaterally proceeding counter clockwise starting with right OI and ending with left OI. Pain was recorded on an 11-point verbal pain rating scale. Myofascial pain scores were categorized as none (0), mild (1-3/10), moderate (4-6/10), or severe (7-10/10) based on the numeric rating.

A total of 912 new patients were evaluated during the study period with chief complaints including urinary symptoms (n=91.8%), prolapse (n=30.4%), and pain (n=58.3%); some patients reported more than 1 chief complaint. The average age in this cohort was 55±14.9 years. Most women were obese (mean BMI 30.2±7.48), white (70%), parous (median parity 2, IQR 1-3), and postmenopausal (68%). Some degree of pelvic floor and OI myofascial pain was identified on examination in most patients (93%). Most rated their pain as severe (68.9%); mild (2.35%) and moderate (22.2%) pain scores were less common. When stratified by the chief complaint of pain, women presenting for evaluation of pelvic floor disorders without a chief complaint of pain were found to have median myofascial pain scores of 6/10 in the LA and 6-7/10 in the OI. In those patients presenting with chief complaint of pain, median pain scores were significantly higher at all locations examined (p<0.0001) than median pain scores in patients who did not endorse pain at time of presentation (Figure) .

Pelvic floor and OI myofascial pain is common in patients presenting with pelvic floor symptoms, even when pain is not a presenting complaint. These results from our population, which was universally examined, suggest pelvic floor and OI myofascial pain may be under-assessed and under-diagnosed in these patients.

This work provides a novel finding of the presence of obturator internus myofascial pain in women with PFD and an association with levator ani myofascial pain/dysfunction. The presence of pelvic floor and OI myofascial pain was present in women with PFD Part 2-survey of HCPs working with MS patients: 98 HCPs (90 female, 8 male) participated in the questionnaire. The commonest barriers reported were presence of family or friends in the consultation room (n=34, 34.7%), lack of knowledge about sexual dysfunction (n=30, 30.6%), inadequate time during the consultation (n=27, 27.6%), perception that patient not ready to discuss the problem (n=27, 27.6%), perception that a discussion may increase patient's anxiety and discomfort (n=23, 23.4%) (figure 1). Fear of offending, fear of inappropriateness, and age gap between patient and HCP (p<0.05) were reported significantly more by HCPs than patients as being barriers (Figure 1 .) Both patients and HCPs indicated that addressing sexual problems was a priority.

Due to the wide range of neurological symptoms that dominates MS, a discussion on SD may not always be prioritized, and therefore time should be set aside during one of the initial clinic visits to specifically enquire about SD. Bladder dysfunction was identified to interfere with intimacy and sexual activity. The presence of family or friends during clinic visits was identified as an important barrier, and a part of the clinic consultation should therefore remain private to facilitate a discussion on SD. Patients report not being asked about sexual problems as being a barrier (33.8%), suggesting that there is an expectation that HCPs should be initiating the discussion on SD. However HCPs were concerned that discussing SD may result in patient anxiety and discomfort; however a mismatch in perceptions exists and patients are prepared to discuss the problem. A lack of knowledge was identified as a barrier by HCPs. Interpretation of results Our study demonstrates that adult patients with CGUA generally lacked knowledge about sexuality and fertility despite their interest in these topics. Regardless of gender, over half of participants had never heard of ART, and only 1 had received prior fertility counselling. 1/3 of participants wanted to learn more about sexuality and/or fertility. 24.6% (n=14) of participants were not currently sexually active but wanted to become sexually active. A possible explanation for the discrepancy between participants' knowledge of and desire to learn about sexuality and fertility could be their hesitancy to ask healthcare professionals about such topics. In addition, a considerable challenge of this study was getting participants to complete questionnaires pertaining to their sexuality and fertility status. Despite assistance with filling out questionnaires, many participants still left them unanswered. Only 40% of male participants completed the SHIM questionnaire, a standard diagnostic aid for ED screening. This poor response rate could reflect participants' discomfort addressing sexuality and fertility in a healthcare setting. Many adults with CGUA do not receive sexual education in school, and only a small fraction report receiving sexual education specific to their diagnoses either from home, clinic, or school. [1, 2] Discussion of sexuality and fertility should occur early in adolescence in order to promote patient comfort with such topics. [3] Furthermore, these questionnaires may be too difficult and detailed for this patient population. Improvement of standard sexuality questionnaires may be indicated.

Adults with CGUA desire more sexuality and fertility education but are hesitant to address these sensitive topics in our current healthcare environment. This study revealed a need for medical providers to discuss sexual and reproductive health with adult CGUA patients earlier and in more detail. Additionally, current sexuality questionnaires are difficult for this patient population to complete despite assistance. Modification or updates may need to be considered.

In one of the largest cohorts of patients with FRDA, a high prevalence of LUT symptoms was reported. Using validated questionanires, LUT storage symptoms predominated, and this is likely due to detrusor overactivity (2) . Voiding symptoms, likely to be due to detrusor sphincter dyssynergia from spinal cord involvement, was reported less often (2) . LUT symptoms correlated with increasing neurological disability, duration of disease, and is more prominent in late-onset ataxia. Surprisingly, there was not correlation with the length of the GAA trinucleotide repeat. Additionally, LUT symptoms correlated with bowel and sexual symptoms. Despite the significant impact on quality of life, only 24% of patients had received treatment at any point.

LUT symptoms are common in FRDA and commonly co-exist with bowel and sexual complaints. Symptoms are underrecognised, and therefore greater awareness is required amongst health care professionals to address these disabling complaints.

The majority of pregnant women demonstrate clitoral hyposensitivity, but vaginal sensation is normal in 90% of cases. Peripheral sensation is also impaired in 40% of women. One possible explanation is the additional extravascular fluid of pregnancy causes nerve compression, although the vaginal sparing suggests this occurs as the clitoral nerve traverses the inferior pubic rami rather than in Alcock's canal. An alternative explanation is the centrally mediated neuromodulatory effects of circulating progestogens. The absence of an association with gestation suggests nerve compression from head engagement is not a factor. 

Hypothesis / aims of study Normal voiding is triggered by release of tonic inhibition from suprapontine centres, allowing the pontine micturition centre to trigger the voiding reflex. In this study, we seek to compare brain activity processes at the time of initiation of voiding in Multiple Sclerosis (MS) patients who are voiders versus patients with voiding dysfunction. We hypothesize that female MS Patients with voiding dysfunction have a distinct Blood Oxygen Level Dependant (BOLD) pattern activation in specific a priori regions of interest (ROIs) at the time of initiation of voiding when compared to female MS patients who void spontaneously.

Study design, materials and methods Twenty seven ambulatory (with or without assistance) female patients with MS and lower urinary tract dysfunction were recruited for this IRB approved study. Patients were divided to two groups. Group 1; voiders (n=15) and group 2; voiding dysfunction (n=12) which included patients with postvoid residual of ≥ 40% of their maximum cystometric capacity or the ones who performed selfcatheterization. We recorded brain activity via fMRI with simultaneous UDS. After motion correction, the Generalized Linear Model created individual fMRI activation maps at initiation of voiding. A high-resolution structural scan of the brain transformed the individual fMRI activation maps into Talairach space. From these transformed datasets, average fMRI activation maps (student ttest) for both groups were created separately, from which areas of significant activation were identified (p<0.05). A priori ROIs identified by a meta-analysis to be involved in the micturition cycle were identified in the pontine micturition centre (PMC), periaqueductal grey (PAG), reticular formation, cingulate, midbrain, thalamus, and prefrontal cortex. Average BOLD activation was determined and compared between groups.

Group-averaged BOLD activation maps indicated distinct differences in activation patterns between groups (figure 1a). ROI analysis yielded consistent areas of increased BOLD signal activation in all ROIs group 1 compared to group 2 except in the left cerebellum (figure 1b, p-value < 1.5e-4). A reversed (negative) BOLD effect was noted in the PMC, PAG, left cingulate, left thalamus and the reticular formation.

Lower urinary tract has two functions: storage and voiding. Voiding symptoms (hesitancy, incomplete bladder emptying, and urinary retention) are common in MS, occurring in 34% to 79% of patients. [1] The switch between storage of urine to initiation of voiding and the control over this switch in located in the brain. Despite extensive research in the pelvic floor and the bladder, supraspinal centers and their role in initiating or modulating voiding in patients with neurogenic or nonneurogenic voiding dysfunction have not been studied. To our knowledge this is the first study to investigate the differences and similarities of brain regions involved in initiation of voiding in ambulatory MS patients.

Investigation in the higher neural control of micturition using functional neuroimaging thus far shows that the initial afferent stimulus comes from the sensation in the bladder as "strong desire to void". Afterwards, the forebrain determines a person's social circumstance and whether to proceed with voiding. Once it is socially acceptable to void, canters in the brain and spinal cord coordinate to produce bladder contraction and urethral sphincter relaxation. [2] In order for the pontine micturition centre (PMC) to begin micturition, visceral sensations from passive filling in the bladder are transmitted to the periaqueductal gray (PAG) of the brainstem and higher centres including thalamus, insula, and anterior cingulate gyrus. Other neural structures associated with the voiding reflex are the motor prefrontal cortex, supplementary motor cortex, and parahippocampus. Earlier positron emission topography studies have identified right dorsomedial pontine tegmentum and the right inferior frontal gyrus to be associated with significantly increased blood flow in healthy women at the time of voiding. [3] Our fMRI BOLD signal analysis results are consistent with these preliminary data in the literature where PMC, PAG, left cingulate, left thalamus and the reticular formation seem to have different pattern of activation between female MS voiders and the ones with voiding dysfunction. All of these structures may be involved during PAG activation to transmit input to the PMC to initiate micturition.

Our preliminary group and network analyses demonstrate that distinct patterns of activation and deactivation exists between MS patients who are voiders and who have voiding dysfunction. Exploring brain areas in patients with Multiple Sclerosis with voiding dysfunction is important to discern any altered control over the micturition cycle.

Hypothesis / aims of study This is the first study to investigate changes in cerebral perfusion using arterial spin labeling in subjects with overactive bladder (OAB). Arterial spin labeling (ASL) is a fMRI technique that uses inverted proton spins of magnetically labeled water in the blood as a tracer to quantitatively and non-invasively measure cerebral perfusion. Our aim is to determine whether CNS processing of sensory information differs between women with OAB and healthy controls. Our hypothesis is that OAB is associated with quantitative increase in cerebral perfusion in select regions of interest in women with OAB as compared to controls.

Study design, materials and methods Cerebral perfusion was measured in 12 women with OAB and 10 healthy female controls using arterial spin labeling (ASL) fMRI. All women underwent two imaging studies using a pseudocontinuous ASL sequence: 1) on an empty bladder and 2) on a full bladder when experiencing urinary urgency using an oral fill protocol. We selected ROIs in the brain a priori based on the existing literature of OAB and interstitial cystitis ( Ref.1-3 ). Absolute regional cerebral blood flow (rCBF) for each ROI for each subject was calculated. We compared 1) rCBF at baseline (empty bladder state) between OAB and control groups 2) rCBF in the empty bladder state to rCBF in full bladder state within each group (OAB and controls) and 3) change in rCBF (from empty to full bladder) in the OAB group to change in rCBF in the control group. We also performed secondary non-hypothesis driven whole-brain analysis using SPM to evaluate for rCBF pattern changes between empty and full bladder states.

There was no significant difference in the median age of the OAB (52.5±16) and control (45.1±11.5) groups. The median anxiety and depression scores were low for both groups.

At baseline, in the empty bladder state, women with OAB had significantly greater absolute rCBF than controls in the right thalamus, left thalamus, pons/midbrain area, and right and left supplemental motor area (SMA) ( Table 1 ). Figure 1 shows the group activation map of regions that showed greater perfusion at baseline in women with OAB than controls.

In the OAB group, rCBF (ml/100g/min) in the full bladder state was significantly higher in the full bladder state as compared to empty bladder state in right ACC (49.52±1.49 vs. 44.56±0.59, P < .05), left ACC (54.02±1.46 vs. 49.29±0.85, P <.05) and left insula (54.99±1.09 vs. 50.46±1.72, P <.05) (Fig. 2 & Table 2 ). There were no significant differences in rCBF between the full and empty bladder states in the control group (Fig. 2 & Table 2 ).

The change in absolute rCBF from empty to full bladder state in the right ACC, right DL PFC and left thalamus was significantly greater in the OAB group than the control group ( Interpretation of results At baseline, even in the empty bladder state, women with OAB show greater cerebral perfusion (increased neural activity) in the thalamus, pons/midbrain area and SMA than controls. Activation of the thalamus and the pons/midbrain area in the empty bladder state suggests presence of increased afferent signalling in women with OAB as compared to controls. Greater activity of the SMA in OAB group may represent pelvic floor muscle activity to protect against incontinence until a socially acceptable place to void is reached.

In women with OAB, urinary urgency is associated with 10-14% increase in cerebral perfusion in key regions of the brain that process anxiety i.e. the dorsal ACC and the insula.

Our finding that changes in rCBF in response to bladder filling can be quantitatively measured suggests that cerebral perfusion could potentially be used as an objective biomarker for OAB.

The brains of women with OAB show evidence of increased afferent signalling at baseline. In women with OAB, urgency is associated with further quantitative increase in cerebral perfusion in regions known to process anxiety (limbic system). Cerebral perfusion changes quantitatively in response to bladder filling and is a potential objective biomarker for OAB. stimulated and changes in pressure were continuously recorded with external pressure transducers interfaced with the PowerLab® multichannel data acquisition system and LabChart® software (ADInstruments, Colorado Springs, CO). Strength of nerve-evoked bladder contractions after spinal cord or ventral root stimulation were derived from the difference between pressure at resting baseline and peak pressure obtained from continuous stimulation. In a different cohort of sham-operated (n=6) and sacral root transected (n=5) dogs, bladders were cystoscopically injected with Fluoro-gold, a neuronal retrograde label, at four sites around the ureterovesical junction bilaterally three weeks prior to euthanasia. Following euthanasia, the spinal cord was collected, fixed in 4% buffered paraformaldehyde, cryosectioned, and examined for retrogradely labelled neurons in the ventral horns of spinal cord segments T10 through S3.

At one year after sacral root transection, there was a significant decrease in maximum bladder contraction after stimulation of S1-S3 spinal cord/roots, confirming complete transection. Interestingly, sacral root transection also caused an increase, just shy of statistical significance, in maximum bladder contraction following stimulation of T12-L3 spinal cord segments and roots compared to control animals (16.0±3.8 and 8.0±3.3 cmH2O respectively; p=0.1714). An increase in sample size is needed to better study this effect.

Also at one year after sacral root transection, we observed a significant decrease in the number of retrogradely labelled cells in the S1-S3 ventral horns, confirming completely transected spinal roots caudal to L7 in the sacral root transected animals. However, in both groups, similar numbers of retrogradely labelled neuronal cell bodies were observed in the ventral horns of T10 through L2 spinal cord segments following injection of a retrograde dye into the bladder wall, indicative of direct axonal projections from these segments to the bladder. These neurons were located in lamina VIII and IX of the ventral horns, strongly suggestive of motor function.

Little is known about the motor axons originating from the upper lumbar or lower thoracic spinal cord that innervate the bladder. The presence of retrogradely labelled neuronal cell bodies in ventral horn regions of T10-L2 cord segments is the first evidence of direct motor projections from these segments to the bladder. Only low numbers of labelled cells were observed, indicating this is likely not the main innervation of the bladder. This result, combined with the increase in upper lumbar/lower thoracic stimulationinduced bladder contractility (although just short of statistical significance) after long-term sacral root transection, is suggestive of increased sensitivity to stimulation rather than an injury-induced increase in neuronal cell numbers. Beyond mediating bladder contractility, sacral nerves may stimulate interneurons that inactivate tracts originating from the upper lumbar region. Without sacral input, latent tracts may become uninhibited and partially compensate for the contractile deficit.

Future acute experiments will include stimulation of all spinal roots caudal to T9 prior to sacral root transection and immediately after transection to better determine whether intact sacral roots inhibit upper lumbar/lower thoracic input on the bladder. A clearer picture of normal and adaptive bladder innervation will inform our future surgical bladder reinnervation studies. 

Hypothesis / aims of study Phosphodiesterases type 5 inhibitors (PDE5-Is) increase levels of cyclic guanosine monophosphate (cGMP) and can amplify nitric oxide (NO) signaling to cause smooth muscle relaxation peripherally. They are increasingly used to treat lower urinary tract symptoms (LUTS). The proposed mechanisms improving LUTS include increased peripheral oxygenation, the relaxation of the bladder and prostate, and decreased afferent activity [1] . However, other potential, central mechanisms remain to be investigated. Previously, we have reported a decerebrate, arterially perfused rat (DAPR) preparation which allows consistent filling and voiding responses [2] . The present study aimed to develop a decerebrate arterially perfused mouse (DAPM) preparation and investigate the effects of PDE5-Is on bladder and urethral function of mice.

Study design, materials and methods CD1 male mice (2 -3 months, 34-36 g), were terminally anaesthetized with isoflurane. The mice were rapidly cooled and then decerebrated at the pre-collicular level. The preparation was arterially perfused through the left ventricle with carbogenated, Ringer's solution at 31°C. A glass suction electrode was used to record from the left phrenic nerve, this activity gave a continuous index of preparation viability. To record external urethral sphincter (EUS) -electromyography (EMG), a glass suction electrode was placed on the proximal sphincter under direct visual control. A 27G needle was inserted into the bladder dome for pressure monitoring and infusion of 0.9 % saline at the rate of 25µl/min ( Figure 1A ). Once the preparation was cardiovascularly 'tuned', a robust eupnoeic pattern of phrenic activity was stably observed for periods up to 3 hours. Functional micturition cycles were observed in in response to infusion of 0.9% saline ( Figure 1B) . During the void, the bladder showed strong contractions and bursting activity of the EUS was observed.

To investigate the effect of sildenafil, (a PDE5-I), on the bladder and urethral function of mice, after obtaining baseline recordings of >5 voiding cycles, sildenafil was applied to the perfusate on an incrementing dose schedule every 4 voiding cycles (10 pM and 30 pM).

To investigate the peripheral effects of sildenafil directly on the bladder (excluding any drug effects on CNS), we established the DAPM and then removed the brain stem and pithed the spinal cord with a blunt wire. The micturition cycle was lost and the bladder became incontinent therefore to allow measures of bladder compliance when the urethra was clamped and saline was instilled into the bladder (25ul/min, to a maximal intra-vesical pressure of 15 mmHg). After control recording, sildenafil was applied into the perfusate and the recordings were repeated.

In the DAPM, systemic application of sildenafil decreased the threshold pressure (at both 10 and 30pM, P<0.01, n=6) and increased the bladder compliance (30µM, 32%, P<0.05) compared with vehicle ( Figure 2 ). Sildenafil significantly increased the number of spikes during bursting activity of the EUS (Figure 2 ). In the pithed DAPM (without the control of CNS), Sildenafil significantly increase the bladder capacity at the dose of 30 pM (P=0.038, compared with baseline (n=7), Figure 3 )

No study has previously assessed the effects of PDE5-Is on the activity of the EUS in voiding. This is first report to show that sildenafil increased EUS-EMG activity during voiding in mice. A previous immunofluorescence assessment identified that PDE5 was abundantly expressed in the striated muscle of the urethra and the levator ani muscle of rats, and this indicated that striated muscles are possibly regulated by PDE5. Sildenafil has a relaxing effect on the urethral muscle of mice and rats in organ bath studies. However, previous clinical evidence showed that PDE5-Is had few effects of increased urine flow rate, which indicated that this relaxant effect does probably not explain why sildenafil is useful in LUTS -our new finding may help to account for the beneficial effects on EUS activity and possibly central nervous system, especially sympathetic neural activity, which might improve LUTS symptoms. In terms of bladder parameters, sildenafil decreased the threshold pressure and increased bladder compliance. The possible mechanism is decreased afferent firing of pelvic nerve. Some papers indicated that PDE5-Is and NO reduces mechanosensitive afferent activities of both A δ -and C-fibres elicited by bladder distension in the rat although investigation of afferent activity in mice is yet to be undertaken. The other possible mechanism is direct relaxation of the bladder which we were able to demonstrate in the pithed DAPM. This finding is consistent with previous reports and sildenafil has been reported to have relaxant effect on the human bladder and mouse detrusor showed relaxant response to soluble guanylyl cyclase stimulators [3] .

sphincter dyssynergia, DSD), suggesting that at least mGluR1 plays an inhibitory role in modulation of EUS activity to obtain efficient voiding [2] . The aims of the present study using mGluR1-knockout (KO) mice were: (1) to determine the contribution of mGluR1 in voiding function of wild-type (WT) phenotypes after chronic spinal cord transection (SCT), and (2) to further examine, by using a mGluR5 antagonist, the possible involvement of mGluR5 in voiding of the spinal cord-transected mice.

Study design, materials and methods Twenty-four female C57BL/6 mice were used for this study. All surgical procedures were conducted under sevoflurane anesthesia. Spinal cord transection (SCT) was performed in 12 mice at 9 week-old by sectioning at the T9-10 level, and experiments on the spinalized mice were performed 4 weeks post-spinalization. Simultaneous recordings of continuous infusion CMG (30 μl/min) and EUS EMG were conducted in 13 week-old mice under decerebrate, unanesthetized conditions. A mGluR5 antagonist, 2-methyl-6-(2-phenylethynyl)pyridine (MPEP) (30 mg/kg) or the vehicle (diluted HCl) was administered i.p., and changes in patterns of voiding and EUS EMG activity after the drug were evaluated. Evacuation of intravesical fluid occurred during a descent phase of sudden decrease of bladder contraction pressure presented as a notch on cystometrogram chart (Fig. 1 , from a SCT-WT mouse). The number of notches (# Notches) and sum of evacuation duration (SED) per each bladder contraction were evaluated. All values are expressed as means ± SEM. Unpaired t-test and repeated measures two-way ANOVA followed by Sidak's multiple comparisons test were used for statistical analysis, if applicable. For all analyses, P values of <0.05 were considered significant.

SCT mice exhibited DSD and periodical detrusor-sphincter 'synergistic' (DSS) pattern during each bladder contraction (Fig. 1) .

Fluid was evacuated at the DSS, which is presented as a notch on cystometrogram chart. Before MPEP injection, there were marked differences between SCT-WT and SCT-KO mice in the number of notches and the SED (P<0.0001 for each). MPEP produced greater decrease in the number of notches in both SCT groups (Fig. 2) . Meanwhile, MPEP markedly decreased SED in SCT-WT mice, whereas it had no effect on SED in SCT-KO mice (Fig. 2) .

The results showed that mGluR1 and mGluR5 are involved in urethral relaxation during a bladder contraction, indicating that mGluR1 and mGluR5 participate in an inhibitory control of external urethral sphincter activity during bladder contraction in SCT mice. Study design, materials and methods Female C57BL/6N (8-9 week-old) mice weighing 18-20 g were used, and SCI was induced by complete transection of the Th8/9 spinal cord under isoflurane anesthesia. SCI mice were divided into 2 groups; (1) SCI mice treated with SB203580 (1 mg/ml), a p38 MAP kinase inhibitor (p38 MAPK i) (n=4), (2) SCI mice with artificial cerebrospinal fluid (CSF) (n=4). Two weeks after SCI, an intrathecal catheter connected to an osmotic pump was implanted into the intrathecal space of L6-S1 spinal cord for continuous intrathecal instillation at infusion rate of 0.51 μl/hr for 2 weeks. Osmotic pumps filled with p38 MAPK i or CSF were placed in the subcutaneous space between shoulder blades. After spinal cord transection, their bladders were manually squeezed to eliminate the urine once daily for 4 weeks until cystometric evaluation. SCI mice were evaluated using single-filling cystometry (CMG) and external urethral sphincter (EUS)-electromyogram (EMG) under an awake condition. In single CMG recordings, the number of non-voiding contractions (NVCs), micturition pressure (MP), post-void residual volume (PVR) and voiding efficiency (VE) were evaluated in each SCI mouse (Figure 1 ). In simultaneous CMG and EUS-EMG recordings, voiding contraction time, reduced EMG activity duration and the ratio of reduced EMG activity time to voiding contraction time were measured during the voiding phase to evaluate DSD in each SCI mouse. In real-time PCR analyses, L6 dorsal root ganglia (DRG) were removed from CSFtreated SCI mice (n=8) and p38 MAPK i-treated SCI mice (n=5) as well as CSF-treated normal (spinal intact) mice (n=6) and the levels of TRPV1, TNFα and iNOS transcripts were evaluated.

Compared to CSF-treated SCI mice, NVCs during bladder filling were significantly reduced (Figure 1 ), and voiding efficiency was significantly improved with increased voided volume and micturition pressure in p38 MAPK i-treated SCI mice ( Figure 2 ). In CMG and EUS-EMG recordings, the duration of reduced EMG activity or the ratio of reduced EMG activity time to voiding contraction time during the voiding phase was not significantly different between p38 MAPK i -treated and CSF-treated SCI mice. The expression of TRPV1, TNFα and iNOS mRNA was increased in SCI mice compared to spinal intact mice, and significantly decreased after p38 MAPK i treatment in SCI mice (Figure 3) .

The treatment with a p38 MAPK inhibitor improved DO evident as a decrease in NVCs in association with the reduction of the expression of TRPV1 in L6 DRG, which is predominantly expressed in C-fiber afferent pathways, and also voiding dysfunction as shown by increased voiding efficiency due to increased voided volume and micturition pressure without affecting DSD in SCI mice. Also, the p38 MAPK inhibitor treatment reduced the iNOS and TNFα expression in L6 DRG, suggesting that the p38 MAPK signaling pathway is involved in the inflammatory changes in bladder afferent pathways. Overall, the results of this study demonstrated that activation of the p38 MAPK signaling pathway significantly contributes to lower urinary tract dysfunction as well as inflammatory changes in bladder afferent pathways after SCI and that inhibition of the p38 MAPK pathway can improve SCIinduced voiding and storage dysfunction.

The p38 MAPK signalling pathway could be an effective target for the treatment of storage and voiding problems such as DO and inefficient voiding, respectively, after SCI.

The incidence of fistulas between an orthotopic reservoir and the intestinal tract is about 1.5-2%. The most common symptom is fecaluria or pneumaturia. The etiology is multifactorial, being preoperative radiotherapy the main risk factor. Other causes include diabetes, poor reservoir irrigation, presence of tension in anastomosis, nutritional deficiency, or reservoir distention due to obstruction of an urethral catheter.

We report a case of neobladder-rectal fistula that developed as an early postoperative complication of radical cystoprostatectomy and orthotopic VIP (Padovana) neobladder construction procedures.

A 59 year-old man underwent a radical cystectomy and orthotopic neobladder construction using VIP (Padovana) technique for locally invasive bladder cancer (cT2N0M0). The patient started on postoperative day 8 with pneumaturia and brown discharge in one urethral catheter. A CT scan with double contrast was performed and the patient was diagnosed with a neobladder-rectal fistula.

At postoperative day 20, VCC showed solution of continuity of 2cm in medium rectum. Then an OTSC (Over the Scope Clip) clip was inserted.

A proof with methylene blue by the foley urethral catheter was made and no leaks were evidenced. Three months later, the patient refered an episode of pneumaturia and fecaluria. A new VCC was performed and showed the persistance of a small orifice of 3mm. A new OTSC clip was inserted after removal of dead tissue with argon plasma. There were no leaks in the blue methylene proof. In the 6 month follow-up, patient remains asymptomatic.

The OTSC system consists of a clip of nitinol that can trap a large amount of tissue and compress the lesion, thus stimulating healing. Information from animal studies and initial clinical use, support the efficacy of OTSC in the treatment of digestive hemorrhage and postoperative colorectal fistulas. The endoscopic treatment with OTSC clips is a minimally invasive option in the treatment of neovesico-rectal fistulas, achieving good results with low morbidity Introduction Bowel care is a complex issue and may often be a difficult and sensitive subject to address in rehabilitation. As individuals we all learn differently by a combination of visual, auditory or kinaesthetic methods. It is difficult to source a dynamic visual explanation tool for the teaching of the practical aspects of bowel evacuation in a condensed and user-friendly manner. Challenges arise when an individual with a spinal cord injury (SCI) requires appropriate bowel care support outside a specialist SCI facility. As bowel care is multifaceted there is often ambiguity about the procedures and training required (1, 2) . The acquisition of appropriate theoretical and clinical skills and knowledge is a key element that underpins neurogenic bowel management education. This training should be provided in an appropriate manner in order to foster a culture of learning to support bowel care issues.

Animation is a visual step by step approach, which assists in structuralising the education required for individuals with a neurogenic bowel dysfunction, their family, carers or health care workers (HCW). Animation can offer a standardized way for learning and performing clinical skills. To meet these needs the spinal cord system of care nursing programme designed and developed a short animation training video for the following procedures: insertion of a suppository, digital rectal stimulation (DRS) and digital removal of faeces (DRF) (1, 2) . The video is produced in a manner that supports the culture and diversity of individuals regardless of age or gender. The animation video is a suitable aid as it is an explicit and nonintrusive method for educating individuals on the practical aspects such as DRE, DRF. By using this video it integrates basic and clinical sciences to give a more enhanced working knowledge on how to perform bowel care safely and effectively. Retention of information is enhanced when it is communicated using both visual and verbal communication. It supports training effectiveness for both skills and knowledge using evidence based practice.

During the animation process regular audit activity helped to create a culture of quality improvement throughout the process and ensured that the video was user friendly. All stakeholders i.e. anyone who attended bowel training during an 8 month period were included in the audit. A questionnaire was distributed using the Likert scale. This reinforced the concept of animation and determined how well the training video was received, and ensured an accepted standard. The audit proved valuable and offered opportunities for improvement throughout the process before completion of the project. An audit was conducted with 103 individuals and 92% stated that it was an excellent tool for HCW, 90% stated that it was excellent tool for patients families or carers and 89% felt it would be a useful tool for training in the practical aspects of bowel care. 'The uses of videos seems to be a promising, relevant, and increasingly used instructional strategy that could enhance the quality of clinical skills education' (3). As an overall recommendation from the audit groups a voice -over for the video phase two is in progress.

Videos are becoming a standard part of clinical teaching resources as they can be beneficial in the explanation of clinical concepts. Overall the animation video has shown to be an excellent quality improvement initiative in teaching such a sensitive clinical procedure. By using this animation DVD to share knowledge it will augment the learning experience by integrating technology and modernising our training for an enriched learning experience. The animation DVD promotes an innovative, comprehensive and flexible educational programme, for all health care workers involved in the management of the neurogenic bowel for the SCI population.

The main drawback of the artificial urinary sphincter (AUS) in women is the technical complexity of its implantation. Over the past two years, several french teams have reported their preliminary experience of robot assisted AUS implantation in female patients. The aim of this video was to describe a standardized technique of robotic AUS implantation in women.

In an academic department of urology, over 12 consecutive cases, a standardized technique of robotic AUS implantation in women has been developed in order to facilitate its reproducibility. This technique is described with emphasis on the tips and tricks that can be use to facilitate the shorten the learning curve.

We present the case of a 74-year-old female patient with a history of laparoscopic sacrospinofixation and cauda equina syndrome secondary to L3 fracture and who presented with urinary incontinence due to neurogenic intrinsic sphincter deficiency loss of urethral mobility, a negative Marshall/Bonney test, an urethral closure of 17 cm H2O.

The procedure is performed by two surgeon: a robotic surgeon and another surgeon to provide assistance. The patient is placed in a 23 ° Tredelenburg position. The implantation is performed using a transperitoneal approach. The four-arm Da Vinci robot is placed in a right sidedocking position. The Retzius space is dissected until the bladder neck and the endopelvic fascia is opened on both sides of the urethra. The bladder neck is then dissected from the vagina below the periurethral fascia just below the level of the catheter balloon. The assistant surgeon introduce two fingers of his left hand into the vagina to help the dissection. The plane is initiated with cold scissors and then developped using the prograsp forceps, under the digital control of the assistant surgeon who ensure vaginal wall is not entered. At the end of the dissection the bladder is filled with saline stained with methylene blue to verify the integrity of the bladder neck. The bladder dome is not routinely open during the dissectionto verify that the bladder neck is not entered. The bladder neck circumference is measured using a measuring tape which is introduced through the 12mm port. The cuff is then introduced through the 12 mm port and positioned around the bladder neck. The balloon is implanted in the prevesical space via a 3 cm suprapubic incision. The pump is implanted in one of the labia majora using the short suprapubic incision with a subcutaneous passage.

The robot-assisted approach could decrease the morbidity of AUS implantation in female patients and could contribute to balance the presumed volume-outcome relationship associated to this procedure. Standardization of the surgical technique could help its widespread.

Ureteral catheters were placed bilaterally. We Utilized the Davinci™ Xi Robotic platform. Multiple dense adhesions throughout the pelvis were noted and dissected down. The bladder was opened and the fistula was identified. The vagina was dissected free to a distance about 3 cm distal to the vesicovaginal fistula site. The bladder was then further mobilized in order to ensure good distance away from the vaginal opening as well. The vagina was then closed. The bladder was closed watertight in two layers. Attention was turned to the rectus flap harvesting. The robot was undocked and the robot boom was rotated so that we were operating towards the patient's right side. The fourth arm port became the camera port. Two additional robot ports were placed, one in the left lower quadrant and another one in the left upper quadrant as our working arms for dissection of the rectus flap. Rectus flap dissection was carried out under the guidance of a plastic surgeon (AR) using an intraperitoneal anterior sheath sparing technique. The right rectus muscle was mobilized to its lateral border in order to obtain maximum mobility, making sure to leave the inferior blood supply intact. It was transected superiorly near the right costal margin. The flap reached the pelvis easily and under no tension. The robot was undocked, rotated again and docked back into the pelvic configuration. The Flap was then interposed between the closed vagina and bladder, securing in with interrupted absorbable sutures. A 15 Fr Blake drain was left in place and a 20 Fr Foley catheter was left in place for 2 weeks

Robotic harvest and interposition of a rectus abdominus flap is a technically feasible and effective technique with minimal morbidity, and could prove quite useful for a variety of needs in pelvic reconstructive surgery. In the case described here, the patient had a successful outcome done in a minimally invasive approach. Pudendal Nerve Entrapment (PNE) is an uncommon source of chronic pain, in which the nerve is entrapped or compressed as it leaves or enters the pelvis in various tunnels created by adjacent muscles, tendons or bony and ligamentous tissues. The symptoms of PNE syndrome occurs from changes in nerve function and structural changes in the nerve that arise from the mechanical effects of compression. This syndrome presents with pain, hypo or hyperesthesia, anal incontinence, urinary incontinence and impotence. The diagnosis of pudendal neuralgia is essentially clinical, and Nantes criteria were described in 2008 to help physicians recognize pudendal neuralgia. Surgical treatment of PNE can be performed with different approaches, but Laparoscopy is the only method which enables us to confirm diagnosis and to treat the patient at the same time. We describe our experience with laparoscopic management of PNE.

We present the case of a 68-year-old woman who was referred to our service with chronic pain in the right anogenital side, allodynia, vaginal foreign body sensation and high urinary frequency without urgency. The physical examination shown right hypoalgesia without other pathologies. MRI was normal and neurophysiology tests (pudendal nerve motor latency test and electromyography) shown right abnormalities. Because of a lack of response to medication, pudendal nerve block and local radiofrequency, surgical option was offered. The functional integrity of all exposed nerves is assessed using intraoperative laparoscopic electrostimulation. Before surgery, electrodes are placed at both legs, feet, major labia and external anal sphincter. For laparoscopic approach we used 5 trocars similar to other uro-oncologic pelvic surgeries.

The external iliac vein was identified and the peritoneum was incised between the ureter and external iliac vein. Careful blunt dissection techniques were used to create a peritoneal window medial to the obturator nerve after obturator lymphadenectomy. Blunt dissection downwards allows exposure of the sacrospinous ligament (SSL). Dense and thickening SSL is identified and bluntly dissected from sacral roots. The SSL is then divided with a cut and seal instrument. Full exposure of the pudendal nerve begins with exposure of its endopelvic segment, followed by the transection of the SSL, which permits further dissection of the nerve downward to Alcock's canal. From the proximal side of the canal, the upper wall is opened with incision of the aponeurosis. Finally, the pudendal nerve can be completely decompressed at the entrance of the canal. The patient was discharged at the third day of the surgery without complications. She referred pain improvement out of a 70% on a Visual Analog Scale instantly after the surgery, with improvement of the urinary frequency and foreign body sensation after 6 months.

Laparoscopic has become feasible and allows the surgeon a global vision of small nerves and provides a minimally invasive and safe exposure of all pelvic nerves but, obliges the surgeon to have better knowledge of pelvic anatomy. In combination, electrostimulation permits an intraoperative functional mapping of the pelvic nerves. In men with urinary incontinence due to neurogenic intrinsic sphincter insufficiency, it is recommended to place artificial urinary sphincter (AUS) cuff around the bladder neck to spare antegrade ejaculation, to avoid the risk of pressure ulcers at the perineal incision site and to limit the risk of cuff erosion due to clean-intermittent-self-catheterization (CISC). The objective of this study was to describe a surgical technique of periprostatic AUS implantation in neurogenic male patients.

The technique of periprostatic AUS implantation in men is described in this video. We present the case of a 50 year-old male with a past medical history of cauda equina syndrome and stress urinary incontinence due to neurogenic intrinsic sphincter deficiency. The patient performed 5 to 6 CISC per day due to underactive bladder. The urethral closure pressure was 33 cm H2O on urodynamics and the amount of urine leakage was 350 g/24 hour according to the pad test.

The procedure is performed under general anesthesia. The patient is placed in a 23° Trendelenburg position. A laparoscopic transperitoneal approach is performed and five ports are placed in total, including three ports for the robotic arms and one 12 mm-port for the assistant surgeon to allow the insertion of the AUS cuff. First, the peritoneum is opened just above the seminal vesicles. The space between the posterior part of the prostate and the seminal vesicles is dissected. The bladder is then released down and the Retzius space is dissected. The lateral sides of the prostate are dissected and the endopelvic fascia is opened on both sides. A Prograsp forceps is used to open the angle between seminal vesicles and bladder on both sides from inside to outside. A measurement tape is then passed around the bladder neck and the AUS cuff is inserted through the 12-mm port. The balloon is implanted in the Retzius space through a 3 cm suprapubic incision and the pump is placed in the scrotum by a subcutaneous passage made from the suprapubic incision

This video report the feasibility of robot-assisted periprostatic AUS implantation in male patient with neurogenic stress urinary incontinence. The benefits of positionning the AUS cuff around the bladder neck (vs. bulbar urethra) and of the robot-assisted approach to perform this periprostatic implantation (vs. open or laparoscopic approaches) remain to be proven by clinical research studies. 

Hypothesis / aims of study In continent women, we observed that a mental distraction task (DT) altered reaction time (RT) between an order to contract pelvic floor muscle (PFM) and the onset of PFM contraction activation in sitting position (1). In the same way, during a mental DT, the RT between the initiation of cough effort (activation of the external intercostal (EIC) muscles) and the onset of the PFM contraction is delayed in sitting position (2) . The aim of the current study was to evaluate whether changing body position (sitting vs standing position) had an effect on voluntary and reflex PFM contraction during a mental DT.

The study group consisted in 19 healthy volunteer women. As the volunteers were expected to not suffer from uro-gynecological diseases, inclusion criteria were as follows: nulliparous, no diabetes, no heart rhythm disorder, no neurological disease, no pregnancy, no urinary symptoms (UDI-6 questionnaire score equal 0), no bowel symptom (Wexner questionnaire score equal 0), no problems in understanding the language used during the trials, no cognitive depletion or dementia (Mini Mental Status questionnaire (MMS) score equal 30). Volunteers were initially evaluated with the same protocol process as we previously published (1) (2) . EMG recordings evaluation consisted on recording external anal sphincter (EAS) electromyographic (EMG) activity during voluntary and involuntary PFM contraction with and without a distraction task (Paced Auditory Serial Addition Task (PASAT) in a sitting and a standing position. Voluntary PFM contraction were recorded in eleven volonteers women. During voluntary PFM contraction, we mainly recorded latency between the order of PFM contraction and the onset of the EAS EMG activation (RT1 There was no significant difference between standing position RT3 and sitting position RT3. Without and with DT, RT1' seemed to be shorter in a standing position than in a sitting position (without DT, standing RT1': 585 ms vs. sitting RT1: 715 ms, R=0.82, p=0.007) With DT, standing RT1': 572 ms vs. sitting RT1: 664 ms, R=0.86, p=0.032). Without DT, RT2 seems to be shorter in a standing position than in a sitting position (621 ms vs. 742 ms, R=0.84, p=0.009). As we previously showed in a sitting position, in a standing position, there was also a significant difference between RT3 without and with DT: -96 ms (-114 ;-62) vs. -36 ms (-76 ;-3), respectively (R=0.38, p<0.001). Vertical column bar graph, (mean with ± SEM) representing total collagen (%), elastin (%) and smooth muscle and myofibroblasts content and thickness (mm). Significant differences between groups are displayed above the bars.

The same results were obtained for rectum tissues. Young's moduli of comfort and stress zones were higher in pregnant sheep (61.9%, p<0.05; 44.1%, p<0.05).

Rectum become less extensible than of virgin (23.8%, p<0.05). In agreement with the mechanical properties, pregnant sheep rectum contained more total collagen (p<0.05), less elastin fibres (p<0.05) and smooth muscle cells (p<0.05) than virgin. For the external anal sphincter (surrounds the margin of the anus and helps to control and delay defecation through contraction), there were significant differences in Young´s modulus at comfort zone, between virgin and pregnant sheep (p<0.05). The urethra and the rectum are mechanically closed by the levator ani muscle; it relaxes at the beginning of urination and defecation. During the pregnancy, the muscle becomes more compliant (p<0.05).

Table1. Mechanical characteristics of ovine pelvic floor organs. Data is presented as mean (± SEM), significant differences among the groups were set to p <0.05 (×) Interpretation of results In this study, it was conducted a biomechanical/histological combined analysis of the sheep pelvic floor soft tissues. The impact of subsequent pregnancies on pelvic floor soft tissues was considered. Due to pregnancy, pelvic floor soft tissue undergoes profound histological and mechanical changes. Vaginal wall tissue become very extensible and compliant. This is associated

Hypothesis / aims of study This original work was designed to explore the relationship between pelvic floor and obturator internus (OI) myofascial pain and lower urinary tract (LUTS) symptoms [1] . Lower urinary tract symptoms are common, costly, and negatively impact quality of life for many patients. The prevalence of LUTS increases with advancing age, and by 2018 there is projected to be an 18.4% increase in the number of patients affected by at least one LUTS [2, 3] . Myofascial pain has been identified and studied in various regions throughout the body, and is known to affect the pelvis in both men and women. In our patient population, we have found that LUTS frequently co-exist with pelvic floor and obturator internus myofascial pain. We have observed anecdotally that a substantial number of these patients demonstrate improvement in both their myofascial pain scores on physical exam as well as their LUTS after pelvic floor physical therapy (PFPT) directed at their myofascial pain. We hypothesized that presence and severity of pelvic floor and OI myofascial pain is correlated with degree of LUTS severity as measured on the urinary distress inventory short form (UDI-6).

We performed a retrospective cross sectional study of all new patients presenting for new patient evaluation between 1/2014 and 4/2016. A pelvic floor and OI myofascial examination was performed on all new patients by transvaginal palpation of the bilateral OI and LA muscles; starting with the right OI, proceeding counter clockwise and finishing with the left OI. Pain was recorded on an 11-point (0-10) verbal pain rating scale. Pelvic floor and OI myofascial examination pain scores and UDI-6 scores were compared and correlation between these measures was investigated using Spearman's correlation.

A total of 912 new patients were evaluated during the study period. The majority of patients endorsed any urinary symptoms (92%) and 554 had complete UDI-6 scores available for analysis. Some degree of pelvic floor and OI myofascial pain was present in 93.4% with 68.8% reporting severe pain (rated 7/10 or higher). Cumulative myofascial pain score and average scores for the levator ani (LA), OI, right, and left sites were significantly correlated with total UDI-6 score (Table) . Urinary urgency, represented by question 2, do you usually experience urine leakage associated with a feeling of urgency, was significantly correlated with right and left OI myofascial pain. Significant correlation was also identified between pelvic floor and OI myofascial pain and UDI-6 questions addressing incomplete emptying and lower abdominal/pelvic pain (do you usually experience difficulty emptying your bladder, and do you usually experience pain or discomfort in the lower abdomen).

We have demonstrated a high prevalence of pelvic floor and OI myofascial pain in women presenting to our clinic with bothersome LUTS. Degree of symptom severity, as measured using the UDI-6, was significantly correlated with pelvic floor and OI myofascial examination pain scores. Interestingly, OI myofascial pain tended to have a stronger correlation with LUTS than LA muscle groups.

This work provides additional support of the association between pelvic floor myofascial pain on palpation and LUTS. We present a novel finding of the association between OI myofascial pain with palpation and LUTS that had a stronger correlation with LUTS than pelvic floor myofascial pain. These findings should be investigated further for their potential to inform possible new treatment modalities for LUTS such as myofascial pain-directed therapy. Table. Correlation between pelvic floor and OI myofascial pain and UDI-6 scores. Spearman correlation coefficients presented. Total cumulative score represents the summation of the scores for right LA, left LA, right OI, and left OI. LA, levator ani; OI, obturator internus; Avg, average; cum, cumulative; UDI, urinary distress inventory. *p<0.05; **p<0.01; ***p<0.0001 scores ranging from 1 to 5. PFM morphometry was evaluated using TPUS imaging (Voluson E8 Expert BT10; GE Healthcare) with a 3-/4-dimensional transperineal probe (RM6C next-generation matrix). Images were recorded at rest, during maximum PFM contraction and during cough. Each maneuver was performed twice and the ultrasound volume with the most effective contraction (i.e., most reduced levator hiatus antero-posterior diameter) and cough (i.e., most caudal displacement of the bladder neck (BN)) were considered for analysis. TPUS data was analyzed offline (4D View, Version 10.2; GE Healthcare) by an observer blinded to the digital assessment. Morphometry was assessed by measuring the following parameters in the midsagittal and axial planes (at the level of minimal hiatal dimensions) planes: (1) anorectal height, distance from the apex of the anorectal angle to a horizontal reference line passing by the inferior-posterior margin of the symphysis pubis, BN (2) x-axis and (3) y-axis related to the inferiorposterior margin of the symphysis pubis, (4) levator hiatus area, (5) levator hiatal antero-posterior and (6) transverse diameters. The shift between rest condition and both tasks (cough and contraction) were calculated (rest -task), as well as the percentage of change for each variable ((rest -task)/rest %). BN cranioventral displacement was also calculated for contraction and cough as the hypotenuse of a right-angled triangle (square root: ΔBN-x 2 +ΔBN-y 2 ). The relationships between digital and TPUS assessments of PFM function were investigated using Pearson correlation coefficient and hierarchical stepwise regression by assessment condition (rest, contraction/couch). This method was used to explore how well digital assessment variances are explained by morphometric parameters of the pelvic floor TPUS evaluation.

Results 204 incontinent women were evaluated. Participants were aged between 60 and 84 (68 ± 5.6) years, mean BMI was 27.1 ± 4.6 Kg/m 2 , parity ranged from 0 to 8 (median 2, interquartile range from 1 to 3) and the mean ICIQ-UI SF score was 12.3 ± 3.3. For the digital assessment, flexibility score ranged from 0.75 to 4 (median 2, interquartile range from 2 to 2.5) and MOS ranged from 0 to 5 (median 3, interquartile range from 3 to 4). Ultrasound morphometric parameters are shown in Table 1 .

Associations between flexibility and morphometric parameters of the PFM during rest and cough are shown in Table 2 . Using hierarchical regression by assessment condition (rest, cough) levator hiatus area at rest explained 10.9% of the variance in flexibility (Beta coefficient in the final model is β= 0.327; p<0.01). When adding variables in the cough condition to the model, BN cranio-ventral shift (β = 0.028; p = 0.700) explained additionally 0.1% of the variance, for a total explained variance of 11%.

Bladder neck cranio-ventral shift [mm]: contraction 6.7 ± 4.6 and cough 9.2 ± 6.0. Table 2 Pearson correlation coefficients and p values (flexibility versus morphometry) BN cranio-ventral shift (r= 267, p<0.01); Statistically significant results are highlighted, p<0.05 Associations between strength (MOS) and morphometric parameters of the PFM during rest and contraction are shown in Table  3 . Using hierarchical regression by assessment condition (rest, contraction), the anorectal height at rest explained 1.6% of the variance in strength (Beta coefficient in the final model is β= 0.135; p=0.052). When adding variables in the contraction condition to the model, anorectal height percentages of change (β = -0.324; p<0.001), levator hiatus anteroposterior shift (β = -0.726; p = 0.002) and percentages of change (β = 1.198; p<0.001) explained additionally 33.8% of the variance (p<0.001) for a total explained variance of 35.4%. Interpretation of results Higher PFM flexibility (passive vaginal opening) was associated with larger levator hiatus at rest. For the cough task, higher flexibility was related to more dorsally positioned BN and larger displacements of BN and levator hiatus. Levator hiatus area at rest contributed more to predicting PFM flexibility than any other morphometric parameter assessed during rest or cough, although with poor agreement. PFM strength was associated with smaller hiatus area and anteroposterior dimension, with more cranial and ventrally positioned BN and with higher shifts and percentages of change of almost all measured variables during contraction. Anorectal height, levator hiatus dimension shift and percentages of change during contraction were the variables that better contributed to the prediction of PFM strength, with fair agreement.

In older women with UI, increased flexibility was poorly associated with PFM morphometry during rest and cough. Higher PFM strength was fairly associated with increased constriction of the PFM and inward movement of the PFM structure during contraction. Interpretation of results These findings suggest that both PFM and TrA contractions increase the IRD. These results challenge the belief that the PFM and TrA muscles play an important role in reducing the IRD (1). Hence, clinicians ought to be cautious when prescribing isolated PFM and TrA exercises if the aim is to reduce the IRD in postpartum women presenting with a DRA. Further studies are needed to investigate how to reduce the IRD in postpartum women presenting with DRA, and explore the importance of reducing the IRD.

This study suggests that both a PFM and a TrA contraction increase the IRD.

women. Studies used wide range of PFMs EMG measurement methods, including vaginal probes, surface, needle, and wire EMG. They also contained a wide array of EMG calculations and comparisons for several reflex tasks, like coughing, running, rapid arm movements, load-catching tasks, and horseback riding, in different test positions. Continent women contracted their PFMs before other trunk and arm muscles. Incontinent women performed the PFMs activity later than continent women during impact loads. This was observed during coughing and rapid arm movements. Time interval in relation to the onset of other trunk muscles seemed to be important, and so did time interval from the onset of PFMs activity in comparison to the onset of intraabdominal-, urethral-and posterior vaginal wall pressure rise. Coughing significantly increased PFMs EMG activity, which correlated with the intensity of coughing. Gradual adaptation of PFMs activity was also evident for running speeds and pace of horseback riding. As for other muscles, PFMs activity during impact loads is greater than activity during maximal voluntary contraction (MVC). While running, the maximal PFMs activity varied from 98.6 to 238.7 %EMG (MVC-normalised); pre-activity (activation before heel strike; -30 to 0 ms) varied from 72.1 to 136.9 %EMG (1, 2). Posture did not influence timing, but in a neutral pelvis position PFMs activity was higher than in hypo-or hyperlordosis posture, suggesting that posture should be considered in rehabilitation. Parous SUI women showed asymmetrical and uncoordinated levator ani muscle activation patterns, and revealed behavioural abnormalities.

The initial phase of intravaginal pressure increase seen during abdominal contraction was caused by PFMs contraction. Our findings support the "subvesicular hammock" theory of Delancey et al. (3) . They suggest that compression of the urethra closes the lumen through its lateral attachment to the arcus tendineus fascia pelvis and levator ani muscle. This endopelvic fascia tissue stiffens under the influence of a reflex contraction of PFMs because intra-abdominal pressure increases. Therefore the stiffness of fascia is of consideration. This finding supports the thesis that the time interval between the onset of PFMs activity and the onset of intra-abdominal pressure rise are important for continence. Our review confirmed the significance of timing during impact activities; specifically SUI women had delayed PFMs activation. PFMs reflex activity during coughing is not a univocal response but a modulated reflex; it gradually adapts to the impact tasks. An alteration of the modulation of cough anal reflex showed a no graded PFMs response during impact activities in SUI women. This alteration may contribute to the pathophysiology of SUI. During impact loads incontinent women had more PFMs activity than continent women, this supports the idea that incontinence might not be caused by morphological changes of PFMs, but by altered muscle activation patterns. PFMs may maintain basal tonus with slow twitch muscle fibres, while fast twitch muscle fibres are recruited for rapid contractions. We found behavioural abnormalities in muscle activation patterns for SUI women. These findings should be integrated into a PFMs rehabilitation program for SUI women that include training control and coordinating abdominal muscle activity, and integrating impact loads to exercise and activate fast twitch muscle fibres and, first of all, their involuntary function.

We summarise current knowledge of PFMs activity during impact loads. Time interval between the onsets of PFMs activity in relation to the onset of trunk muscles and relation to the onset of abdominal and bladder pressure rise, which is a result of abdominal strain, seems to be crucial for the maintenance of continence. Our results suggest that impact activities should be included in rehabilitation programs, because of their intensive involuntary PFMs activation, although we still do not clearly understand the pathomechanism of PFMs activity during impact loads. Future research should focus on dynamic PFMs activities during impact loads and could integrate the influence of stiffness from the endopelvic fascia tissue and PFMs tone into research question.

Study design, materials and methods This is a cross-sectional study. Included were women aged between 18 and 59 years with urinary incontinence confirmed by a 1hour pad test and woman without urinary incontinence [confirmed by a score of zero, using the International Consultation on Incontinence Questionnaire -(ICIQ)]. Excluded were women with neurological diseases, rheumatic diseases, congenital skeletal muscle disorders, use of prostheses or orthoses, pregnant women, obese women and / or woman submitted to orthopedic surgery. The 1 hour pad test was performed. Then, the participant was instructed to wear tight underwear that helps to mark the anatomical points: anterior superior iliac spine, posterolateral iliac spine, with white polystyrene balls fixed with double-sided tape. The pictures were taken in a room with white background. The digital camera was located three meters away from the participant, placed parallel to the floor, on a camera tripod level at half of the height of the participant. The images were sent to the computer and analyzed using the SAPO Postural Assessment Software version 0.68 by a blind examiner familiar with the program. The evaluation of the Pelvic Floor Muscle (PFM) function was performed by bidigital vaginal palpation, following the recommendations of the International Continence Society, using the letters P, E, R and F of the PERFECT scheme. Then, electromyography (EMG) (New Miotool Uro™, Miotec) was performed. Both evaluations were performed in dorsal decubitus and in orthostasis. Two surface electrodes were attached in the perianal region (position of 3 and 9 o'clock), two on the right internal oblique muscle and one on the right anterior superior iliac spine. The EMG signal was recorded by the Miotec Suite software version 1.0. A 20Hz high-pass filter, 500Hz low-pass filter and 60Hz notch filter were used. Measured were the value of the maximum voluntary contraction (MVC), the mean of the basal electric activity for one minute, the peak of the highest phasic contraction and the mean of the best tonic contraction.

The sample consisted of 40 women, 20 with UI, the incontinence group (IG) and 20 without UI in the continence group (CG). The groups were matched for age. The mean age of the CG was 43.5 ± 8.4 years, while in the IG it was 47.1 ± 7.8 years (p = 0.16). There was no difference in the sociodemographic variables, only the variable 'childbirth' presented a difference between the groups, in which vaginal delivery was more frequent in IG (p = 0.01). Among incontinent women, 14 (70.0%) presented Stress Urinary Incontinence (SUI) and six (30.0%) Mixed Urinary Incontinence (MUI), and presented a median of 06 (3.0 -13.0) grams of urinary loss. When assessing muscle function, only P (power), in dorsal decubitus, presented a difference between the groups (p = 0.04). The median CG was 4.0 (3.0 -4.0) while the IG was 3.0 (3.0 -3.0). A greater electrical activity was observed in the CG women, with a significant difference between the groups in the measurements of the basal electric activity and tonic contraction in dorsal decubitus and orthostasis (p = 0.01). Analysed was the correlation between the degree of left and right pelvic anterior inclination with the muscular strength and the electrical activity of the PFM in the IG and CG. There was a moderate correlation between the anterior pelvic inclination (LS) and the repetition (p = 0.05). The electrical activity of the basal pelvis in orthostasis and the angles of anterior pelvic inclination in the views were: RS r = 0.51 (p = 0, 02) and LS r = 0.46 (p = 0.04). No correlation was found in the CG.

It was evidenced that IG has a greater left anterior pelvic inclination. A greater electrical activity was observed in women of CG, with a significant difference between the groups, in the measurements of basal electrical activity and tonic contraction in dorsal decubitus and orthostasis. CG also had a higher strength than IG. A moderate correlation was found in the IG, indicating that the higher the degree of anterior slope (in both views), the greater the electrical activity of the PFMs during orthostatic rest. And, the greater the anterior slope in the right side, the lower the dorsal decubitus repetition.

Concluding message It appears that incontinent women have a greater anterior slope of the pelvis. The greater the degree of anterior slope, the greater the electrical activity of the PFMs during rest in orthostasis. And the greater the anterior slope in the right side the less contraction repetition in the dorsal decubitus one makes.

peripheral ligamentous laxity and pelvic floor muscles (levator ani) has been reported during pregnancy. (3) . We hypothesize that this peripheral ligamentous laxity at term could be an indicator for the risk of OASIS. Our main endpoint was to assess whether peripheral ligamentous laxity at term is associated with OASIS occurrence. Study design, materials and methods This prospective study included women above 36 weeks of gestational age. Exclusion criteria were indication for prophylactic cesarean section and conjunctive tissue's diseases. We collected maternal, delivery and neonatal parameters. We assessed ligamentous laxity between the 36 th week of pregnancy and the admission in the delivery room by measuring the passive extension of the non-dominant index finger after applying 0.26N.m to the second metacarpo-phalangeal joint (MCP laxity) with a specific extensometer ( Figure 1) (3). Perineal body length was assessed at the same time. Perineal tears were reported using the classification of the Royal College of Obstetricians and Gynaecologists (RCOG) and OASIS was defined by a stage 3 or more. After excluding patients who had undergone cesarean section, we reported perineal tears prevalence and the characteristics of our population. We investigated the association between MCP laxity and OASI using a one-way ANOVA test then a Mann-Kendall test. An ethical committee approved the study.

Among the 300 included women, 272 of them had vaginal delivery and were then considered for the analysis. Mean age was 29±5 years old; mean body mass index was 25±5 kg.m -2 ; 109 (37.3%) were nulliparous and the mean perineal body length was 3.5±0.7cm. Mean term at delivery was 40±1 weeks; there were 3 twin pregnancies and 6 breech presentations. 216 women (74%) benefited from epidural analgesia; 51 (17.5%) had an instrumental delivery; 14 (4.8%) had an episiotomy; the second stage of labor mean length was 60±67 minutes and the mean birthweight was 3320±469g. Twelve (4.4%) women suffered from OASIS. Mean MCP laxity significantly increased with the RCOG stage of perineal tears ( Table 1) . A MCP laxity greater than 64° was associated with OASIS with a 75% sensibility and 56% specificity. Interpretation of results Increased MCP laxity seems to be associated with a higher risk of OASIS. These results suggest that tissues with a greater elasticity could be less resistant to the perineal trauma during childbirth. This could be related to significant changes in conjunctive tissue's metabolism during pregnancy, in particular changes in collagen metabolism (2, 3) . Taking into account biomechanical characteristics of pregnant women in our risk prediction for OASIS occurrence could lead to an individualized risk assessment including the intrinsic women's characteristics This would allow allowed personalized information of pregnant women about their risk of OASIS. A deeper exploration of this research thematic may improve both our predictive and preventive strategies for OASIS occurrence during vaginal delivery. Results 12 women were included. Their mean age was 31±2.6 years, mean body mass index was 28±7.4kg.m -2 . They were all parous women with a mean delay since the last delivery of 14±1.6 months. All examinations were successfully completed for assessments at rest. We reported 2 failures for Valsalva assessments with a lost of visibility of levator ani muscle during the maneuver. These two failures occurred in women with the highest mean body mass index (37.7 and 42.2 kg.m -2 ). Mean shear modulus for each sequence and comparison between rest and Valsalva were reported in Table 1 .

The present study is the first that demonstrates the feasibility to measure in vivo the elastic properties of women's levator ani muscle using the shear wave elastography. We reported an increase of muscle stiffness during the transition from rest to Valsalva maneuver. To investigate the role of pelvic floor elastic properties in pelvic floor disorders genesis, these data needs to be confirmed on larger populations of women with and without pelvic floor disorders.

Bø K 1 , Ellström Engh M 2 , Hilde G 2

Hypothesis / aims of study Today, all healthy pregnant women are encouraged to be physically active throughout pregnancy, with recommendations of at least 30 min of aerobic activity on most days of the week, in addition to strength training of the major muscle groups 2-3 days per week (1). There is an ongoing debate whether general physical activity enhances or declines pelvic floor muscle (PFM) function. However, there is sparse knowledge on this relationship in the general female population and we have not been able to find any such studies in pregnant women. The aim of the present study was to compare vaginal resting pressure (VRP), PFM strength and endurance at mid-pregnancy in regular exercisers vs non-regular exercisers.

Study design, materials and methods This study used cross-sectional data of 300 first time mothers, mean age 28.7 (SD 4.3) and pre-pregnancy body mass index (BMI) 23.9 (SD 3.9), giving birth at a public hospital. Background data, including information about physical activity level, was collected through an electronic questionnaire. For the purpose of the present study, regular exercisers were defined as women participating in exercise training ≥ 30 min ≥ 3 times per week. Women reporting exercising ≤ 30 min ≤ 3 times per week were defined as non-regular exercisers. Two trained physical therapists assessed PFM function. Ability to contract the PFM was assessed by visual observation and vaginal palpation. Manometry, with a high precision pressure transducer connected to a vaginal balloon, was used to assess VRP (cm H2O), PFM strength (mean of three attempts of maximal voluntary contraction; cm H2O) and muscular endurance (measurement of area under the curve for one attempt of a 10 second holding period; H2Osec). To ensure validity of the manometry measurements, only contractions with simultaneous inward movement of the perineum/catheter were accepted as correct contractions (2) . Measurements were conducted at mean gestational week 20.8 (SD 1.4). Data are presented as means with standard deviations (SD) and differences as means with 95% confidence intervals (CI). Differences between groups are analysed using Independent Sample T-test. Linear regression analysis was used to adjust for pre-pregnancy BMI, age, smoking during pregnancy and regular PFM training during pregnancy. P-value was set to ≤ 0.05

The results are presented in Table 1 . Pregnant women exercising regularly had stronger PFM and better PFM endurance than non-regular exercisers. At the time of assessment, 16 women (17.3%) of the exercisers versus 30 (14.5%) of the non-exercisers reported to do PFMT ≥ 3 times per week (p=0.67). Adjusted analyses showed that the difference in PFM strength was still statistically significant in favor of women exercising regularly (adjusted B=5.0 (95% CI 0.5-9.6, p=0.03) whereas the adjusted analyses for VRP and PFM endurance were not (p=0.42 and 0.1, respectively) Table 1 . Vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength, PFM endurance (area under the curve holding for 10 seconds) at mean gestational week 21.8 in exercisers (exercising ≥ 30 min x ≥ 3 times per week) and non-exercisers. Means with standard deviation (SD) and mean differences with 95% CI.

Non-regular exercisers n=207

Difference between exercisers and non-exercisers p-value for differences VRP (cmH2O) 44.0 (9.8) 42.6 (9.9) 1. 

As far as we have ascertained this is the first study investigating the association between physical activity and PFM variables during pregnancy and our results showed that women exercising ≥ 30 minutes ≥ 3 times per week had stronger PFM adjusted for possible covariates. Among possible covariates, one would expect PFM training to be the most important. Our results are in contrast to one study in non-pregnant elite athletes showing that volleyball-and basketball players had weaker PFM than a nonexercising control group (3). However, the participants in the present study were pregnant and not elite athletes and the study on elite athletes did not control for confounding factors. The strengths of the present study are the large number of participants, use of reliable and valid assessment methods and use of adjusted analyses to control for possible covariates. A limitation may be lower numbers of exercising women compared to non-regular exercisers. Given the limited scientific evidence in this area, more studies are needed to elaborate on the relationship between general physical activity, including strenuous exercise, and PFM function.

Concluding message Pregnant women who were physically active ≥ 30 minutes ≥ 3 times per week had stronger PFM than their sedentary counterparts.

Medina Lucena H 1 , Tincello D 1

Hypothesis / aims of study A forced diuresis protocol has been developed to evaluate bladder sensation during filling. The original protocol required consumption of 250-300 ml water every 15 minutes to achieve a steady diuresis rate (1). In recent work, the reliability of this protocol to produce a stable and predictable diuresis was proven (2) . Variability is reduced with a water load of 300ml/15 minutes instead of 250ml, and any test where the variation in diuresis rate between the two test cycles exceeds 4.5 ml/min should be rejected (2). This study was designed to calculate diuresis rates, confirm test-retest reliability and to compare graphically bladder sensation curves.

This study was the second of four stages of an observational and experimental study. Twenty-four volunteers were asked to undergo a previously designed diuresis and bladder sensation protocol (1) . The protocol allowed the visual recording of bladder sensation by the patient marking sensations on a 10 point visual analogue scale every 5 minutes while drinking an excess of water continually for the duration of the test. Following ethical approval, informed consent was obtained from participants before obtaining serum to measure glomerular filtration rate to exclude undiagnosed kidney disease. A biomedical impedance test was performed prior to the diuresis test to determine the participant's fluid status. The volume drunk during the test was 300 ml/15 minutes.

Participants were asked to drink 250 ml of water every 15 minutes 1 hour before the test. No verbal cues were given other than to concentrate on the sensation in their bladder and to mark on the data-logging sheet the intensity of this sensation. When they reached the strongest sensation they could bear they were asked to hold on for up to 5 minutes and to remember this as their maximum sensation, marking it as a 10 on their sheet. They were then asked to void and this volume measured (V1). Immediately post void they recorded this as the minimal sensation. Participants continued to drink and recorded bladder sensation for another entire filling cycle, where the voided volume was measured (V2) and for at least 30 minutes of the next cycle (voided volume V3). The first cycle allowed participants to fix the maximum and minimum sensations in their minds; cycle two was the core part of the experiment where analyses were done, and cycle three was used to confirm a steady diuresis rate has been achieved during cycles two and three (i.e. V2/t2 = V3/t3). This test was performed twice within 14 days apart. Data were presented as median (range) and compared by Wilcoxon signed rank test or Mann Whitney U test for paired and unpaired data. 

Hypothesis / aims of study Lower urinary tract symptoms (LUTS) are a common complaint in aged males and usually have a major impact on their quality of life (QoL). Looking at pathogenesis of LUTS, although multiple factors, including benign prostatic hyperplasia are associated with symptoms, detailed etiologies of LUTS remain unknown yet. On the other hand, metabolomics analysis enables the detection and semi-quantitative measurement of hundreds of unique metabolites from broad range of metabolic pathways, and these approaches can detect metabolites associated with pathophysiological states. Possible biomarkers in interstitial cystitis were actually detected using metabolomics analysis.(1)(2) In the present study, we identified metabolites from metabolomics approach and investigated association between these metabolites and LUTS.

Study design, materials and methods A total of 58 male participants without apparent neurological diseases at our outpatient clinic were enrolled in the present study; Age: 71.5+/-4.3 years old, body mass index (BMI): 23.0 +/-2.7. A 24hrs-bladder diary was carried out to assess behavior of 

Disclosures Funding: No funding was received Clinical Trial: No Subjects: NONE

Surgical management of pelvic organ prolapse in women

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Longer operative time during benign laparoscopic and robotic hysterectomy is associated with increased 30-day periperative complications

Determining the importance of change in the overactive bladder questionnaire

Cost profiles and budget impact of rechargeable versus nonrechargeable sacral neuromodulation devices in the treatment of overactive bladder syndrome

Disclosures Funding: Axonics Modulation Technologies, Inc Clinical Trial: Yes Registration Number: ClinicalTrials.gov Identifier: NCT02620410 RCT: No Subjects: HUMAN Ethics Committee: University College London Hospital & National Hospital for Neurology & Neurosurgery Ethical Committee; approval was obtained subsequently from the ethical committees in all participating hospitals Helsinki: Yes Informed Consent: Yes

BJOG : an international journal of obstetrics and gynaecology

UR-CHOICE: can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? International urogynecology journal

Prediction models for postpartum urinary and fecal incontinence in primiparous women. Female pelvic medicine & reconstructive surgery

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics not Req'd: they fulfilled only a self-report questionnaire and participants' approvoal were obtained before particicpation to the study

Signalling pathways involved in sildenafil-induced relaxation of human bladder dome smooth muscle

Muro-Neuro-Urodynamics; a Review of the Functional Assessment of Mouse Lower Urinary Tract Function

Contractile effects and receptor analysis of adenosine-receptors in human detrusor muscle from stable and neuropathic bladders

Persistence & Adherence in Treatment of OAB with Anticholinergic Therapy: Systematic Review of Lit

Anticholinergic Therapy vs. Onabotunlinum Toxin A for Urgency Urinary Incontinence. NEJM

Adverse events of intravesical botulinum toxin a injections for idiopathic detrusor overactivity: risk factors and influence on treatment outcome

Estrogen, progesterone, and androgen receptor expression in levator ani muscle and fascia

On the Anatomy and Histology of the Pubovisceral Muscle Enthesis in Women

Pelvic organ prolapse in nulliparous women and their parous sisters

Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study

Association between pelvic floor muscle trauma and pelvic organ prolapse 20 years after delivery

No Subjects: HUMAN Ethics Committee: The Regional Ethics Committee (REK Southeast D 2009/170) and the Akershus University Hospital Privacy Ombudsman (2799026) approved the study Helsinki: Yes Informed Consent: Yes References

The role of duloxetine in stress urinary incontinence: a systematic review and meta-analysis

Reductions in stress urinary incontinence episodes: what is clinically important for women?

Evidence for bladder urothelial pathophysiology in functional bladder disorders

Urothelial Dysfunction and Chronic Inflammation in Diabetic Patients with Overactive Bladder

Overexpression of NGF in mouse urothelium leads to neuronal hyperinnervation, pelvic sensitivity, and changes in urinary bladder function

Correlation between detrusor collagen content and urinary symptoms in patients with prostatic obstruction

Human bladder smooth muscle cell damage in disturbed oxygen tension

International Continence Society Urodynamic Equipment Working Group, International Continence Society guidelines on urodynamic equipment performance

Mathematical modelling analysis of male urine flow traces

Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies

Pregnancy-induced adaptations in the intrinsic structure of rat pelvic floor muscles

Pregnancy and delivery-induced biomechanical changes in rat vagina persist postpartum

Disclosures Funding: K12 HD001259 Clinical Trial: No Subjects: ANIMAL Species: Rat Ethics Committee

Effect of urethral dilation on vesical motor activity: identification of the urethrovesical reflex and its role in voiding

Role of positive urethrovesical feedback in vesical evacuation. The concept of a second micturition reflex: the urethrovesical reflex

Chemosensory epithelial cells in the urethra: sentinels of the urinary tract

Disclosures Funding: Winters foundation to FAK

Clinical Trial: No Subjects: ANIMAL Species: mouse Ethics Committee: Institutional Animal Care and Use Committee at the University of Pittsburgh, which adheres to NIH Guidelines for the Care and

Regenerating the Anal Sphincter: Cytokines, Stem Cells, or Both?

Functional outcome after anal sphincter injury and treatment with mesenchymal stem cells

Mesenchymal stem cells can improve anal pressures after anal sphincter injury

Disclosures Funding: Armed Forces Institute of Regenerative Medicine (AFIRM-2) W81XWH-13-AFIRMIIRP Clinical Trial: No Subjects: ANIMAL Species: Sprague Dawley Rats Ethics Committee: Cleveland Clinic Institutional Animal Care and Use Committee

Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs

Tissue mechanics, animal models, and pelvic organ prolapse: a review

A numerical model of passive and active behavior of skeletal muscles

Disclosures Funding: The authors gratefully acknowledge the funding by Ministério da Ciência Tecnologia, e Ensino Superior, FCT, Portugal, under grants SFRH/BD/89519

Non-invasive characterization of real-time bladder sensation using accelerated hydration and a novel sensation meter: An initial experience

Do patients with OAB experience bladder sensations in the same way as healthy volunteers? A focus group investigation

Bladder Afferent Signaling: Recent Findings. The Journal of urology

Virginia Urology IRB (#2016-73) Helsinki: Yes Informed Consent: Yes References

Estimation of bladder contractility from intravesical pressurevolume measurements

Analysis of maximum detrusor contraction power in relation to bladder emptying in patients with lower urinary tract symptoms and benign prostatic enlargement

Comparison of passive urethral resistance relation and urethral resistance factor in analysis of bladder outlet obstruction in patients with benign prostatic enlargement

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Newcastle and North Tyneside 1 Helsinki: Yes Informed Consent: Yes References

Noninvasive assessment of bladder contractility in men

Noninvasive measurement of bladder pressure. Does mechanical interruption of the urinary stream inhibit detrusor contraction?

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Initial stufy approved by: Joint Ethics Committee Newcastle and North Tyneside Health Authority Ref 99/155 Helsinki: Yes Informed Consent

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee: Scientific Ethics Committee of Hokkaido University (#016-0098) Helsinki: Yes Informed Consent: Yes

An evidence-based approach to emergency department management of acute urinary retention

Natural history of prostatism: risk factors for acute urinary retention

Lower urinary tract symptoms: The management of lower urinary tract symptoms in men; NICE clinical guideline 97. National Institute for Health and Clinical Excellence site

Comparison of Water and Air-Charged Transducer Catheters in the Evaluation of Cystometrogram Pressures. Posters 270 and 272

Comparison of air-charged and water-filled urodynamic pressure measurement catheters

Simultaneous in vivo comparison of water-filled and air-filled pressure measurement catheters: Implications for good urodynamic practice

Air filled, including "air-charged," catheters in urodynamic studies: does the evidence justify their use

International continence society guidelines on urodynamic equipment performance

Simultaneous in vivo comparison of water-filled and air-filled pressure measurement catheters: Implications for good urodynamic practice

Webinar: How to interpret urodynamic study Video file

Good urodynamic practices: uroflowmetry, filling cystometry, and pressure-flow studies

Disclosures Funding: No Clinical Trial: No Subjects: HUMAN Ethics Committee: Mcgill university Institutional Review Board Helsinki: Yes Informed Consent: Yes References

Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis

A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests

Disclosures Funding: Academy of Finland, Jane and Aatos Erkko Foundation, and Sigrid Juselius Foundation. Clinical Trial: No Subjects: HUMAN Ethics Committee: Regional Ethics Board (REK nord)

Obstetric levator ani muscle injuries: current status

Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound

Disclosures Funding: South-Eastern Norway Regional Health Authority Clinical Trial: No Subjects: HUMAN Ethics Committee: The Regional Ethics Committee (Cohort: REK South-East D 2009/170 and RCT: REK South-East D 2009/289a) and the Norwegian Social Science Data Service (Cohort: 2799026 and RCT: 2799004) approved the study Helsinki: Yes Informed Consent: Yes References

Levator hematoma at the attachment zone as an early marker for levator ani muscle avulsion

Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy

Disclosures Funding: No disclosures Clinical Trial: Yes Registration Number: Nederlands Trialregister RCT: No Subjects: HUMAN Ethics Committee: METC UMC Utrecht Helsinki: Yes Informed Consent: Yes References

Long-term anal continence and quality of life following postpartum anal sphincter injury

Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study

The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment

Disclosures Funding: Norwegian Women's Public Health Association/the Norwegian Extra Foundation for Health and Rehabilitation through EXTRA funds Clinical Trial: Yes Registration Number: clinicaltrials.gov NCT01766193 RCT: No Subjects: HUMAN Ethics Committee: the Regional Committee for Medical and Health Research Ethics

Buzzi Children's Hospital

Buzzi Children's Hospital

Prevalence of Pelvic Floor Disorders in the Female Population and the Impact of Age, Mode of Delivery, and Parity

Computer interviewing in urogynaecology?: concept , development and psychometric testing of an electronic pelvic floor assessment questionnaire in primary and secondary care

Academic Hospital, Department of Urology

Evaluation of clitoral blood flow by color Doppler ultrasonography

New, simple, ultrasound-guided infiltration of the pudendal nerve

Test-retest reliability of clitoral blood flow measurements at rest and after pelvic floor muscle contractions in healthy adult women using color Doppler ultrasonography. ICS

Disclosures Funding: nil Clinical Trial: No Subjects: HUMAN Ethics Committee: St Vincent's Hospital. Sydney. LNR/13/SVH/408 Helsinki: Yes Informed Consent: Yes References

Electrospun PCL/PEO coaxial fibers for basic fibroblast growth factor delivery

Examinations of a new long-term degradable electrospun polycaprolactone scaffold in three rat abdominal wall models

Electrospun biodegradable microfibers induce new collagen formation in a rat abdominal wall defect model: A possible treatment for pelvic floor repair?

Urinary incontinence is associated with an increase in falls: a systematic review

What does it mean to transform knowledge into action in falls prevention research? Perspectives form the Canadian Institutes of Health Research

Management Using Continence Products

Disclosures Funding: Capital Health Chair in Healthy Ageing Clinical Trial: No Subjects: HUMAN Ethics Committee: University of Alberta HREB Helsinki: Yes Informed Consent: Yes

Rajabali S 1 , Milsom I 2 , Hunter K 1 , Wagg A 1 1

Prevalence and triage of first-contact complaints on pelvic floor dysfunctions in female patients at a Pelvic Care Centre

The usefulness of a mobile device-based system for patient-reported outcomes in a spine outpatient clinic

Mobile devices and apps for health care professionals: uses and benefits

Disclosures Funding: No relevant funding or grant to disclose

Prospective comparison of faecal incontinence grading systems

Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence

Quality of Life Differences in Female and Male Patients with Fecal Incontinence

Disclosures Funding: The study is funded by the Health Foundation and Medtronic. Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: The study is approved under the terms of the arrangement between the capital Region of Denmark and the Danish Data Protection Agency

Leto A 1 , Fuschi A 1 , Capone L 1 , Velotti G 1 , Carbone A 1 1. Sapienza University of Rome, Faculty of Pharmacy and Medicine Department of

A prospective randomized study to compare pelvic floor rehabilitation and dapoxetine for treatment of lifelong premature ejaculation

Pirozzi Farina F: Pelvic floor and sexual male dysfunction

Single-and multiple-dose pharmacokinetics of dapoxetine hydrochloride, a novel agent for the treatment of premature ejaculation

Phase IIb, multicenter, double-blind, randomized, placebocontrolled, parallel-group study to determine effects of elocalcitol in women with overactive bladder and idiopathic detrusor overactivity

Vitamin D and pelvic floor disorders in women: results from the National Health and Nutrition Examination Survey

Nutrient composition of the diet and the development of overactive bladder: a longitudinal study in women

Disclosures Funding: None Clinical Trial: No Subjects: NONE

Five-year Urinary and Sexual Outcomes after Radical Prostatectomy: Results from the Prostate Cancer Outcomes Study

Editorial Comment: Efficacy of an Assisted Low-Intensity Programme of Perioperative Pelvic Floor Muscle Training in Improving the Recovery of Continence after Radical Prostatectomy: A Randomized Controlled Trial

Preoperative Biofeedback Assisted Behavioral Training to Decrease Post-Prostatectomy Incontinence: A Randomized, Controlled Trial

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training

Voorham-van der Zalm PJ. The effect of EMG biofeedback assisted pelvic floor muscle therapy on symptoms of the overactive bladder syndrome in women: A randomized controlled trial

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a short version Cochrane systematic review with meta-analysis

A pilot randomised controlled trial of the pelvic tooner device in female urinary incontinence

The 5th International Consultation on Incontinence

Test-retest repeatability of patterns of brain activation provoked by bladder filling

Brain Mechanisms Underlying Urge Incontinence and its Response to Pelvic Floor Muscle Training

Disclosures Funding: R01 AG20629 Clinical Trial: No Subjects: HUMAN Ethics Committee: University of Pittsburgh Institutional Review Board Helsinki: Yes Informed Consent: Yes

Chronic bladder ischemia and oxidative stress: new pharmacotherapeutic targets for lower urinary tract symptoms

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

Quantitative assessment of urethral vascularity in nulliparous females using high-frequency endovaginal ultrasonography

Disclosures Funding: None Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: Clinical Research Ethics Committee of Faculty of Medicine Ege University Helsinki: Yes Informed Consent: Yes References

Disclosures Funding: JSPS KAKENHI Grant Number 16K11041 Clinical Trial: No Subjects: HUMAN Ethics Committee: The Ethical Committee of The University of Fukui Helsinki: Yes Informed Consent: Yes References

VirSorter: mining viral signal from microbial genomic data

PHASTER: a better, faster version of the PHAST phage search tool

Disclosures Funding: Loyola University Chicago's Multidisciplinary Grant Clinical Trial: No Subjects: NONE

Urinary retention in the post-partum period. The relationship between obstetric factors and the post-partum post-void residual bladder volume

National survey for intrapartum and postpartum bladder care: assessing the need for guidelines

Effects of acute urinary bladder overdistension on bladder response during sacral neurostimulation

RCT: Yes Subjects: HUMAN Ethics Committee: The study was approved by the medical ethical committee of the Academic Medical Centre in Amsterdam, the Netherlands (MEC AMC 10/187). Local approval was obtained in all participating centres

An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence

Seventeen years' follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence

Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence

Effectiveness of midurethral slings in recurrent stress urinary incontinence: a systematic review and meta-analysis

Surgical treatment of recurrent stress urinary incontinence in women: a systematic review and meta-analysis of randomised controlled trials

Disclosures Funding: No funding for this work. Data provided by the British Society of Urogynaecology Clinical Trial: No Subjects: HUMAN Ethics not Req'd: Retrospective analysis of routine outcome data (patient consent for database storage obtained) Helsinki: Yes Informed Consent

Pelvic organ prolapse

Surgical management of pelvic organ prolapse in women (Review) The Cochrane database of systematic review

The current status of laparoscopic sacrocolpopexy: a review

A Comparison of 30-Day Surgical Outcomes for Minimally Invasive and Open Sacrocolpopexy

Clinical guidelines for interstitial cystitis and hypersensitive bladder syndrome

Master transcription factors and mediator establish super-enhancers at key cell identity genes

Disclosures Funding: DOD W81XWH-12-1-0565

No Subjects: ANIMAL Species: Rat Ethics Committee: University of Pittsburgh Institutional Animal Care and Use Committee

An overview of shock wave therapy in musculoskeletal disorders

Extracorporeal shock wave therapy (ESWT) in urology: a systematic review of outcome in Peyronie's disease, erectile dysfunction and chronic pelvic pain

Effects of low energy shock wave therapy on inflammatory moleculars, bladder pain, and bladder function in a rat cystitis model

A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society

Inflammation and inflammatory control in Interstitial Cystitis/Bladder Pain Syndrome: Associations with painful syndromes

Activation of soluble guanylyl cyclase by BAY 58-2667 improves bladder function in cyclophosphamide-induced cystitis in mice

Intravesical Botulinum Toxin-A Injections Reduce Bladder Pain of Interstitial Cystitis/bladder Pain Syndrome Refractory to Conventional Treatment -A Prospective, Multicenter, Randomized, Double-Blind

A randomized controlled trial of bacillus calmetteguerin and botulinum toxin-A for the treatment of refractory interstitial cystitis

A multicentre, prospective, randomised, double-blind study to measure the treatmenteffectiveness of abobotulinum A (AboBTXA) among women with refractory interstitial cystitis/bladder pain syndrome

Estrogen supports urothelial defense mechanisms

A murine model of urinary tract infection

A method to study bladder urothelial cellular function in situ

5 , Coggrave M 5 , Manoukian S 1 1. Nursing, Midwifery and Allied Health Professions Research Unit

Abdominal Massage for the Relief of Constipation in People with Multiple Sclerosis

Neurogenic Bowel Dysfunction Score

A constipation scoring system to simplify evaluation and management of constipated patients

Prediction models for postpartum urinary and fecal incontinence in primiparous women

Preventing urinary incontinence with supervised prenatal pelvic floor exercises: A randomized controlled trial

Is prenatal urethral descent a risk factor for urinary incontinence during pregnancy and the postpartum period?

Stem cells in gynecology

Etiology and management of fecal incontinence

A new method for treating fecal incontinence by implanting stem cells derived from human adipose tissue: preliminary findings of a randomized double-blind clinical trial

Summary of the NHG practice guideline 'Lower urinary tract symptoms in men

EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction

A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice

Helsinki: Yes Informed Consent: Yes References

The aging male

Disclosures Funding: no funding or grant Clinical Trial: No Subjects: HUMAN Ethics Committee: Kindai University Faculty of Medicine Helsinki: Yes Informed Consent: Yes

Disclosures Funding: Astellas Pharma Korea, Inc Clinical Trial: Yes Public Registry: No RCT: Yes Subjects: HUMAN Ethics Committee: PNUH-IRB Helsinki: Yes Informed Consent: Yes References

Disclosures Funding: This study was supported by funding from Nippon Shinyaku Co

ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence

Development and validation of the expanded prostate cancer index composite (EPIC)

Scoring the short form ICSmaleSF questionnaire. International Continence Society

Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery

The content of a college-level outdoor leadership course

Rheumatoid arthritis antirheumatic drug trials, III: setting the Delta for clinical trials of antirheumatic drugs-results of a consensus development (Delphi) exercise

Disclosures Funding: Self funded Clinical Trial: No Subjects: HUMAN Ethics Committee: Comite de Ética da Faculdade Estadual de Campinas -UNICAMP -Campinas

Coital incontinence: relation to detrusor overactivity and stress incontinence

Impact of tension-free vaginal tape on sexual function: results of a prospective study

Disclosures Funding: No funding Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics not Req'd: It is a retrospective study Helsinki: Yes Informed Consent: Yes

Dunedin School of Medicine, Department of Women's and Children's Health

Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0

Disclosures Funding: None Clinical Trial: No Subjects: NONE

Enigma of urethral pain syndrome: why are there so many ascribed etiologies and therapeutic approaches?

Treatment of female urethral syndrome refractory to antibiotics

Urethral pain syndrome and its management

Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries

Urinary tract injury: medical negligence or unavoidable complication?

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

1-year follow-up of autologous muscle-derived stem cell injection pilot study to treat stress urinary incontinence. International urogynecology journal and pelvic floor dysfunction

Improvement of urethral sphincter deficiency in female rats following autologous skeletal muscle myoblasts grafting

Disclosures Funding: Cook MyoSite Clinical Trial: Yes Registration Number: ClinicalTrials.gov Autologous Muscle-derived Cells Female Stress Urinary Incontinence Clinical Study CT01382602 RCT: Yes Subjects: HUMAN Ethics Committee: Comité d'éthique de la recherche du Centre intégré universitaire de santé et de services sociaux de l'Estrie -Centre hospitalier universitaire de Sherbrooke Helsinki: Yes Informed Consent: Yes

The James Lind Alliance -Tackling treatment uncertainties together

Priority setting partnership to identify the top 10 research priorities for the management of Parkinson's disease

Top ten research priorities for spinal cord injury

Disclosures Funding: Capital Health Research Chair in Healthy Ageing Clinical Trial: No Subjects: HUMAN Ethics Committee: HREB University of Alberta Helsinki: Yes Informed Consent: Yes

Women's reluctance to seek help for stress incontinence during pregnancy and following childbirth

Prevalence of stress urinary incontinence in both sexes at or after age 15 years: a cross-sectional study

Knowledge of the pelvic floor in nulliparous women

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee: Antwerp University Hostpital Helsinki: Yes Informed Consent: Yes References

Coating with autologous plasma improves biocompatibility of mesh grafts in vitro: development stage of a surgical innovation

Ideal in meshes for prolapse, urinary incontinence, and hernia repair

The biology of adhesions formation in the peritoneal cavity

Obesity: preventing and managing the global epidemic

Disclosures Funding: Nothing do disclose Clinical Trial: No Subjects: HUMAN Ethics not Req'd: the participant of this study weren't subject to any procedures or required to follow rules of behaviour

Clinical assessment of urethral sphincter function

Why do women have stress urinary incontinence?

Recovery of urinary function after radical prostatectomy: Predictors of urinary function on preoperative prostate magnetic resonance imaging

Pathophysiology and subjective symptoms in women with impaired bladder emptying

Prevalence and clinical features of detrusor underactivity among elderly with lower urinary tract symptoms: a comparison between men and women

Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee

Preemptive use of gabapentin in abdominal hysterectomy: A systematic review and meta-analysis

Gabapentin for the prevention of postoperative pain after vaginal hysterectomy

Disclosures Funding: None Clinical Trial: Yes Registration Number: ClinicalTrials.gov, NCT02999724 RCT: Yes Subjects: HUMAN Ethics Committee: Mount Sinai Hospital Research Ethics Board Helsinki: Yes Informed Consent: Yes References

Comparación de las variaciones de presión abdominal en medio acuático y aéreo durante la realización de cuatro ejercicios abdominales hipopresivos

Co-activation of the abdominal and pelvic floor muscles during voluntary exercises

Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography

Disclosures Funding: This study has been funded by The Nursing and Physiotherapy School of Pontificial Comillas University. Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: San Carlos Clinical Hospital Clinical Research Ethics Committee Helsinki: Yes Informed Consent: Yes

Disclosures Funding: This study was funded by Astellas Pharma Europe BV Clinical Trial: Yes Registration Number: NCT02320773 RCT: No Subjects: HUMAN Ethics Committee: Central Ethics Committee Helsinki: Yes Informed Consent: Yes References

The Effect of Preoperative Phenazopyridine on Urinary Retention Following Midurethral Sling

Voiding Function After Midurethral Slings With and Without Local Anesthetic: Randomized Controlled Trial

Phenazopyridine does not improve catheter discomfort following gynecologic surgery

Disclosures Funding: The study was investigator initiated with no funding received. Clinical trial: yes. Registration number. ClinicalTrials.gov (Id: NCT02806713). Ethics Committee: University of Massachusetts Medical School H00008816. Informed consent: yes Clinical Trial: Yes Registration Number: ClinicalTrials.gov Id: NCT02806713 RCT: Yes Subjects: HUMAN Ethics Committee: University of Massachusetts Medical School H00008816. Helsinki: Yes Informed Consent: Yes References

Disclosures Funding: none Clinical Trial: No Subjects: ANIMAL Species: Rat Ethics Committee: The Institutional Animal Care and Use Committee at Nagoya City University

Assessment of eating disorders: interview or self-report questionnaire?

Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls

Prevalence of stress and urge urinary incontinence in elite athletes and controls

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Ethics Committee of the Faculty of Sports of the University of Porto Helsinki: Yes Informed Consent: Yes

Henrichs T 3 , Aboushwareb T 4 , Farrelly E 5

Total pelvic floor ultrasound for pelvic floor defaecatory dysfunction: A pictorial review

A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram

Disclosures Funding: nil Clinical Trial: No Subjects: HUMAN Ethics Committee: South East London Helsinki: Yes Informed Consent: Yes

Yasui T 3 , Kimura K 5 1. Department of Hospital Pharmacy

An epidemiological study of primary nocturnal enuresis in Chinese children and adolescents. 2. Nocturnal enuresis: an international evidence based management strategy

cn Disclosures Funding: supported by Natural Science Foundation of China (NSFC), No. 81370689 Clinical Trial: No Subjects: HUMAN Ethics Committee: Ethics committee of the First Affiliated Hospital Of Zhengzhou University Helsinki: Yes Informed Consent: Yes References

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study

Comparison of biofeedback therapy in children with treatment-refractory dysfunctional voiding and overactive bladder

Transcutaneous electrical nerve stimulation in children with overactive bladder: a randomized clinical trial

The work was approved by the ethics committee of the institution in which it was performed and their legal guardians signed a consent form approved by the Ethics Committee of hospital

Long-term results of reconstructive surgery in patients with bladder pain syndrome/interstitial cystitis:subtyping is imperative

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee: The University of Tokyo Hospital Ethical Committee Helsinki: Yes Informed Consent: Yes

Cool (TRPM8) and hot (TRPV1) receptors in the bladder and male genital tract

Functional role of the transient receptor potential melastatin 8 (TRPM8) ion channel in the urinary bladder assessed by conscious cystometry and ex vivo measurements of single-unit mechanosensitive bladder afferent activities in the rat

Cool and menthol receptor TRPM8 in human urinary bladder disorders and clinical correlations

Clinical Trial: No Subjects: ANIMAL Species: Rat Ethics Committee: Animal Ethics Committee

Efficacy of Daily Low-dose Tadalafil for Treating Overactive Bladder: Results of a Randomized, Double-blind, Placebo-controlled Trial

Localized contractions in the normal human bladder and in urinary urgency

Inhibitory effects of phosphodiesterase 5 inhibitor, tadalafil, on mechanosensitive bladder afferent nerve activities of the rat, and on acrolein-induced hyperactivity of these nerves

Disclosures Funding: None Clinical Trial: No Subjects: ANIMAL Species: Rat Ethics Committee: Animal Ethics Committee

Disclosures Funding: NIH R01DK107450 Clinical Trial: No Subjects: ANIMAL Species: Rat Ethics Committee

Functional outcomes and complications following radiation therapy for prostate cancer: a critical analysis of the literature

Radiation-induced bystander signalling in cancer therapy

Intravesical Liposomal Tacrolimus Protects against Radiation Cystitis Induced by 3-Beam Targeted Bladder Radiation

Calcium Channel Blockade in Vascular Smooth Muscle Cells: Major hypotensive mechanism of S-Petasin

The association between T-type Ca2+ current and outward current in isolated human detrusor cells from stable and overactive bladders

Disclosures Funding: None Clinical Trial: No Subjects: ANIMAL Species: Mouse Ethics Committee: Kyung Hee Medical Center IACUC 465

Changes in afferent activity after spinal cord injury

Suppression of detrusor-sphincter dyssynergia by immunoneutralization of nerve growth factor in lumbosacral spinal cord in spinal cord injured rats

Increased excitability of afferent neurons innervating rat urinary bladder after chronic bladder inflammation

Disclosures Funding: NIH Grant (P01DK093424) Clinical Trial: No Subjects: ANIMAL Species: Mice Ethics Committee: The Institutional

Disclosures Funding: NONE Clinical Trial: No Subjects: HUMAN Ethics Committee: Saitama Medical University Hospital IRB Helsinki: Yes Informed Consent: No References

A randomized trial of urodynamic testing before stress-incontinence surgery

Good urodynamic practices: uroflowmetry, filling cystometry, and pressure-flow studies

Urodynamics useless before surgery for female stress urinary incontinence: Are you sure? Results from a multicenter single nation database

Disclosures Funding: None source of funding or grant Clinical Trial: No Subjects: HUMAN Ethics not Req'd: Our ethics committee did not required approval for this study Helsinki: Yes Informed Consent

Hospital Universitario y Politécnico La Fe (Valencia. Spain), 4. Hospital Universitario Dr

The incidence of a positive ice water test in bladder outlet obstructed patients: evidence for bladder neural plasticity

Diagnostic value of intravesical lidocaine for overactive bladder

Outcomes of external-beam radiation therapy for prostate cancer: a study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas

Health-related quality-of-life effects of radical prostatectomy and primary radiotherapy for screen-detected or clinically diagnosed localized prostate cancer

Quality-of-life impact of primary treatments for localized prostate cancer in patients without hormonal treatment

Factors influencing risk of acute urinary retention after TRUS-guided permanent prostate seed implantation

Urinary morbidity after 125I brachytherapy of the prostate

Changes of edema associated with I-125 prostate brachytherapy. Nihon Igaku Hoshasen Gakkai Zasshi

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics not Req'd: this study was analyzed based on data of daily practice retrospectively. Helsinki: Yes Informed Consent: Yes

Aerenhouts D 2 , Vermandel A 1 1

Urinary incontinence in elite nulliparous athletes

Knowledge of the pelvic floor in nulliparous women

The impact of urinary stress incontinence in young and middle-age women practising recreational sports activity: an epidemiological study

International Continence Society Annual Meeting

Disclosures Funding: National Science Foundation (award #1630203) Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: Western IRB (#20162650) Helsinki: Yes Informed Consent: Yes References

Is there a need for postoperative follow-up after routine Urogynecological procedures? Patients will selfpresent if they have problems

Disclosures Funding: None source of founding or grant Clinical Trial: No Subjects: HUMAN Ethics not Req'd: No ethical approval was required for this investigation as it was a simple observational study

Mirabegron -a selective beta3-adrenoreceptor agonist for the treatment of overactive bladder

Retrospective Study Of Utilization Patterns Of Overactive Bladder Therapy In Men In A Commercially Insured Population: The Early Us Mirabegron Experience

Comparison of transradial versus transfemoral percutaneous coronary intervention in routine practice: evidence for the importance of "falsification hypotheses" in observational studies of comparative effectiveness

Disclosures Funding: This work was funded by Astellas Americas Clinical Trial: No Subjects: NONE

Disclosures Funding: None. Clinical Trial: No Subjects: HUMAN Ethics Committee: Comitê de Ética em Pesquisa (CEP) em seres humanos da

Urologia Azienda USL 8, Arezzo, Italia, 4. Struttura Complessa di Neuro-Urologia

Disclosures Funding: None. Study conducted on behalf of "Italian Society of Urodynamics (SIUD) working group on adjustable balloons evaluation". Clinical Trial: No Subjects: HUMAN Ethics Committee: Tor Vergata University Hospital Ethics Committee Helsinki: Yes Informed

Canepa G 10 , Gregori A 11 , Paoletti G 3 , Ammirati E 4 , Varca V 12 , Saracino A 8 , Pinto A 13 , Carone R 4 , Volpe A 14 1. Department of Experimental Medicine and Surgery

Disclosures Funding: None. Study conducted on behalf of "Italian Society of Urodynamics (SIUD) working group on adjustable balloons evaluation

Abverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

Mid-urethral sling operations for stress urinary incontinence in women

Two routes of transobturator tape procedures in stress urinary incontinence: a metaanalysis with direct and indirect comparison of randomized trials

Laparoscopic promonto-fixation for urogenital prolapsus

Spondylodiscitis following sacral colpopexy procedure: is it an infection or graft rejection? Api M

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics not Req'd: this wasn't a study Helsinki: Yes Informed Consent: Yes References

Development and validation of the Expanded Prostate Cancer Index Composite (EPIC) for comprehensiveassessment of health-related quality of life in men with prostate cancer

Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment

Disclosures Funding: UK National Institute for Health Research (NIHR) Health Technology Assessment Programme

Mirone V 12 , Montironi R 13 , Muto G 14

Section of Pathological Anatomy, Polytechnic University of the Marche Region (Italy), 14. Department of Urology

Fizyoterapi ve Rehabilitasyon. Ankara: Hipokrat Kitabevi

Severity of urinary incontinence and effect on quality of life in women, by incontinence type

The Pad Test for urinary incontinence in women

Fréchette-Chaîné É 4 , Morin M 5

Faculte des sciences humaines, département de psychologie, UQAM, 3. Faculty of Health Sciences

Stigmatizing a "normal" condition: urinary incontinence in late life

Social Relationships and Mortality Risk: A Meta-analytic Review

The qualitative content analysis process

Pre-consultation educational group intervention to improve shared decision-making for postmastectomy breast reconstruction: a pilot randomized controlled trial

Major depression and urinary incontinence in women: Temporal associations in an epidemiologic sample

Anxiety and depression associated with urinary incontinence. A 10-year follow-up study from the Norwegian HUNT study (EPINCONT)

Are commonly used psychoactive medications associated with lower urinary tract symptoms?

Disclosures Funding: Ph.d. scholarship from University of Bergen Clinical Trial: No Subjects: HUMAN Ethics Committee: Regional and National ethics review Board and the Norwegian Data inspectorate. Helsinki: Yes Informed Consent: Yes 503

Urology Department, Elpis Hospital

A qualitative study of the im¬pact of caring for a person with urinary incontinence

Results Preliminary results on 810 women at the six-month endpoint are included. There were 406 women in the intervention group and 404 in the control group. There was no significant difference between the 2 groups at baseline; the mean age and ranges of the women in each group were 77.3 and 78.7 respectively; severity of incontinence was comparable with 36% and 40% of women leaking urine once per day or more in the intervention group and control group, respectively. At 6-month follow-up, compared to the control group, more women exposed to the intervention reported an impression of improvement of their continence

] respectively, and for I-score -1.7 [-2.0/.1.5] and -1.6 [-1.8/-1.3] respectively. The difference between groups was not significant for changes in OAB symptoms (difference in F-score: -0.07 point, 95% CI: -0.4 to +0.3, p= 0.80), and for changes in incontinence symptoms

The individual determinants of care-seeking among middle-aged women reporting urinary incontinence: Analysis of a 2273-woman cohort

Continence Across Continents To Upend Stigma and Dependency (CACTUS-D): study protocol for a cluster randomized controlled trial

Clinical Trial: Yes Registration Number: ClinicalTrials.gov: NCT01858493, registered 13 May 2013 RCT: Yes Subjects: HUMAN Ethics Committee

An Evidence-Based approach to managing women's decisional conflict

Disclosures Funding: Unrestricted Educational Grant

Diastasis recti abdominis during pregnancy and 12 months after birth: prevalence, risk factors and report of lumbopelvic pain

Behaviour of the linea alba in a curl up task in diastasis rectus abdominis: an observational study

Prevalence of diastasis recti abdominis in a urogynecological patient population

Doing Q Methodological research. Theory, Method and Interpretation

PQ Method

Institute of Physical Education and Sport

Prevalence study of stress urinary incontinence in women who perform high-impact exercises

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics not Req'd: we performed observational study as an ordinary medical care, and there was no harm to patients

Management of Panurethral Stricture

Management of Long-Segment and Panurethral Stricture Disease

Management of panurethral stricture disease in India

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee: pamukkale university ethics commitee Helsinki: Yes Informed Consent: Yes 516

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Nagasaki University Hospital Helsinki: Yes Informed Consent: Yes References

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Nagasaki University Hospital Helsinki: Yes Informed Consent: Yes References

Protocol for a randomized, double blind, placebo controlled, crossover trial of Melatonin for treatment of Nocturia in adults with Multiple Sclerosis (MeNiMS)

the International Continence Society (ICS) report on the standardisation of terminology in nocturia on the quality of reports on nocturia and nocturnal polyuria: a systematic review: Impact of the ICS-2002 report on standardisation of terminology in nocturia

Melatonin Pharmacotherapy for Nocturia in Men With Benign Prostatic Enlargement

Disclosures Funding: Multiple Sclerosis Society, AMRC Charity, UK. Neurim/Flynn provided medications (unrestricted donations) Clinical Trial: Yes Registration Number: ISRCTN Registry: ISRCTN38687869 RCT: Yes Subjects: HUMAN Ethics Committee: National South West Research Ethics Comittee Helsinki: Yes Informed Consent: Yes References

Disclosures Funding: None Clinical Trial: No Subjects: ANIMAL Species: rats and rabbits Ethics Committee: Experiments were performed

Evaluating Outcomes in Patients with Overactive Bladder within an Integrated Healthcare Delivery System Using a Treatment Patterns Analyzer

A three dimensional nerve map of human bladder trigone

Handbook of experimental pharmacology 202

Disclosures Funding: None Clinical Trial: Yes Registration Number: Cystoscopic Ablation Via RF Energy Clinical Trial NCT02398578 RCT: No Subjects: HUMAN Ethics Committee: Comité d'éthique de la recherche du CIUSSS de l'Estrie-CHUS Helsinki: Yes Informed Consent: Yes References

Disclosures Funding: no source of founding or grant Clinical Trial: No Subjects: HUMAN Ethics not Req'd: Our ethics committee did not required approval because of the observational type of study Helsinki

An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction

The response of the abdominal muscles to pelvic floor muscle contraction in women with and without stress urinary incontinence using ultrasound imaging

Effects of co-contraction of both transverse abdominal muscle and pelvic floor muscle exercises for stress urinary Incontinence: a randomized controlled trial

Response rates in postal surveys of healthcare professionals between 1996 and 2005: An observational study

Developing and validating a Chinese instrument to measure lower urinary tract symptoms among employed women in Taiwan

Disclosures Funding: Australian Bladder Foundation; Australian Government Research Training Program Scholarship; Australian Research Council Linkage Scheme Grant no: LP130100694; NSW Nurses & Midwives Association (NSWNMA) Clinical Trial: No Subjects: HUMAN Ethics Committee: University of Technology Sydney Human Research and Ethics Committee: HREC 2015000478 and South Eastern Sydney Local Health District HREC: Reference No

The Children's Hospital of Philadelphia, 3. University of Minnesota, 4. UC San Diego Health System, 5

Constitution of the World Health Organization -Basic Documents, Forty-fifth edition

Stress, adaptation, and disease: Allostasis and allostatic load

Bladder Dysfunction in the Adult: The Basis for Clinical Management, Current 19 Clinical Urology

Disclosures Funding: Support by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Orcidi D 1 , Carbone A 3 , Di Tonno P 2 , Illiano E 1 1. Department of Surgical and Biomedical Sciences

Abdominal, laparoscopic, and robotic surgery for pelvic organ prolapse

Disclosures Funding: NONE Clinical Trial: Yes Registration Number: ClinicalTrials.gov Identifier: NCT02852512 RCT: Yes Subjects: HUMAN Ethics Committee: CEAS UMBRIA Helsinki: Yes Informed Consent: Yes References

The impact of obesity towards prostate diseases

Adipose Natural Regulatory B Cells Negatively Control Adipose Tissue Inflammation

Aromatase up-regulation, insulin and raised intracellular oestrogens in men, induce adiposity, metabolic syndrome and prostate disease, via aberrant ER-alpha and GPER signalling

Azienda Ospedaliera Universitaria

Pre-and post-operative ICIQ-SF and EORTC QLQ-C30 questionnaires were available for every patient. Minimal clinical important difference (MCID) values between pre and post-operative scores (defined as the smallest difference in score in the domain of interest which patients perceive as successful) were used to define a successful outcome after surgery. Paired T-test analyses were used to compare pre and post-operative results. Patients where then subdivided, according to the MSID, in two groups: patients with successful outcome and without successful outcome. Chi-squared test was used to investigate the relationship between ICIQ-SF and EORTC QLQ-C30 results. Results Mean follow up was 13.5 months (median11, range 1-43). Before surgery, 81% of patients reported a ICIQ-SF score of 0. Using MCID= 4,11 points, this proportion decreased to 60% (N=227), p=0.26. At baseline 45% of patients had Global health scores of 100 (45%)

Interpretation of results and Concluding message According to our knowledge, this is the first prospective, single center study comparing ICIQ-SF results and the real-life outcomes addressed with EORTC QLQ-C30, of a big cohort of patients submitted to RARP. We showed that quality of life is not only determined by objective continence outcomes and should be associated with more true-life questionnaires, in order to improve the knowledge and the treatment of this group of patients

Morristown Memorial Hospital, 4. Institute for Bladder and Prostate Research between bother, Q & PVR suggests that patients may have severe underlying conditions like urethral obstruction that might be misdiagnosed if one relies on bother to pursue a diagnostic evaluation

Validation of the Lower Urinary Tract Symptom Score

Disclosures Funding: None source of funding or grant Clinical Trial: No Subjects: HUMAN Ethics not Req'd: Our ethics committe did not required approval because it is an observational study Helsinki: Yes Informed Consent: Yes References 1

Good Urodynamic Practices: uroflowmetry, filling cystometry, and pressure-flow studies

Disclosures Funding: No source of funding or grant were obtained Clinical Trial: No Subjects: HUMAN Ethics not Req'd: It is a retrospective evaluation and for this reason our commettee didnt required approval evaluation Helsinki: Yes Informed Consent

Non-invasive characterization of real-time bladder sensation using accelerated hydration and a novel sensation meter: An initial experience

Can a faked cystometry deceive patients in their perception of filling sensations? A study on the reliability of spontaneously reported cystometric filling sensations in patients with non-neurogenic lower urinary tract dysfunction

Does the cystometric filling rate affect the afferent bladder response pattern? A study on single fibre pelvic nerve afferents in the rat urinary bladder

A Wireless Powering and Communication System for Implantable Devices Based on a Royer Oscillator with Radio and Near-field Communication Links

A wearable biosensor for the bladder: Study of awake bladder urodynamics in large animal model

Disclosures Funding: The research leading to these results has received funding from the European Research Council under the European Union's Seventh Framework Program (FP7/2007-2013) / ERC grant agreement n° 340931 Clinical Trial: No Subjects: ANIMAL Species: Minipig Ethics Committee: Ethical Committee for

Development of non-invasive velocity flow video urodynamics using Doppler sonography. Part I:Experimental urethra

Development of non-invasive velocity flow video urodynamics using Doppler sonography. Part II:Clinical application in bladder outlet obstruction

Noninvasive urodynamic evaluation of bladder outlet obstruction using Doppler ultrasonography

Disclosures Funding: None Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics not Req'd: This is a retrospective observational study. Helsinki: Yes Informed Consent: No References

Challenging the maximum flow rate: a new index of voiding dysfunction in men with benign prostatic enlargement

Clinically relevant modelling of urodynamics function: The VBN model

Are nomograms based on free uroflows helpful to evaluate urethral obstruction in men?

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics not Req'd: It involved retrospective analysis of urodynamic studies from a database. Helsinki: Yes Informed Consent: Yes 546

Vasavada S 4

RTI International, 4. Dept of Urology -Cleveland Clinic Foundation, 5. Dept of Obstetrics and Gynecology -Southern California Kaiser Permanente, 6

Objective differences between overactive bladder patients with and without urodynamically proven detrusor overactivity

Disclosures Funding: Russian national research medical university Clinical Trial: Yes Registration Number: the Committee of Russian national research medical university

Voorham -van der Zalm P 1 , Putter H 2 , Pelger R 1 , Vagenee D 3 , Lycklama à Nijeholt G 1

On-and post-treatment symptom relief by repeated instillations of heparin and alkalized lidocaine in interstitial cystitis

Clinical guidelines for interstitial cystitis and hypersensitive bladder updated in 2015

Combined intravesical sodium hyaluronate/chondroitin sulfate therapy for interstitial cystitis/bladder pain syndrome: a prospective study

Disclosures Funding: iALuril supplied free Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: HREC Helsinki: Yes Informed Consent: Yes

An introduction to operative neuromodulation and functional neuroprosthetics, the new frontiers of clinical neuroscience and biotechnology

Sacral neuromodulation reprogramming: is it an office burden?

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics not Req'd: Approved procedures in clinical practice Helsinki: Yes Informed Consent: Yes References

Policies, guidelines, and recommendations for MR imaging safety and patient management. SMRI safety committee

Safety of MRI at 1.5Tesla in patients with implanted sacral nerve neurostimulator

Disclosures Funding: Dr Goldman has the following disclosures: Medtronic -consultant and study support Axonics -consultant Nuvectraconsultant Allergan -consultant The remaining co-authors have nothing to disclose

Is further evaluation needed for incidental focal uptake in the prostate in 18-fluoro-2-deoxyglucose positron emission tomography-computed tomography images?

Incidental focal 18F-FDG uptake in the prostate: clinical significance and differential diagnostic criteria. Nuclear medicine and molecular imaging

Re: Is further evaluation needed for incidental focal uptake in the prostate in18-fluoro-2-deoxyglucose positron emission tomography-computed tomography images?

Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy

Bladder neck sling suspension during robot-assisted radical prostatectomy to improve early return of urinary continence: a comparative analysis

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Osaka University Graduate School of Medicine Institutional Review Board Helsinki: Yes Informed Consent: Yes References

Bipolar transurethral resection of the prostate: The "golden standard" reclaims its leading position

Examining the 'gold standard': a comparative critical analysis of three consecutive decades of monopolar transurethral resection of prostate(TURP) outcomes

Transurethral resection of the prostate for benign prostatic obstruction: will it remain the gold standard?

McGill University References 1. d'assurance maladie du Québec R. Manuel des médecins spécialistes

Ministère de la Santé et des Services sociaux. Performance hospitalière Available: wwwinformamsssgouvqcca

Preferential induction of peripheral lymph node addressin on high endothelial venule-like vessels in the active phase of ulcerative colitis

The relationship between prostate inflammation and lower urinary tract symptoms: Examination of baseline data from the REDUCE trial

Disclosures Funding: NONE Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: the Ethics Committee of the Faculty of Medical Sciences

Taipei Veterans General Hospital

Association Between Erectile Function and Biomarkers of Subclinical Atherosclerosis: A Study Based on Middle-Aged Healthy Men from the General Population

Chronic bladder ischemia and oxidative stress: new pharmacotherapeutic targets for lower urinary tract symptoms

Diagnosis of bladder outlet obstruction in men using a near-infrared spectroscopy instrument as the noninvasive monitor for bladder function

Disclosures Funding: The study was funded partialy by a research grant of the Urological Association of Norhtern Greece Clinical Trial: No Subjects: HUMAN Ethics Committee: Bioethics Committee of the Medical School of the Aristotle University of

Orthopedic and neurosurgical literature report bladder dysfunction up to 100% depending on the extent and level of resection. We sought to evaluate the treatment characteristics of the sacrectomy patients at our institution and the indicators of the need for long-term neuro-urologic monitoring

Sacral and presacral tumors: problems in diagnosis and management

Maintenance of bowel, bladder, and motor functions after sacrectomy

Bowel and bladder continence, wound healing, and functional outcomes in patients who underwent sacrectomy

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: MDACC Institutional Review Board 4 Helsinki: Yes Informed Consent

BRAIN GABAA RECEPTOR FOR ANGIOTENSIN II-INDUCED FREQUENT URINATION IN THE RAT

Hypothesis/aims of study Psychological stress can lead to the exacerbation of urinary bladder dysfunction including overactive bladder and bladder pain syndrome. Recently, we showed that angiotensin II (Ang II), which is a stress-related neuropeptide, centrally increases urinary frequency by acting on brain Ang

Previous study showed brain Ang II can inhibit activity of the γ-aminobutyric acidergic (GABA)ergic nervous system [2], which has been also shown to regulate micturition reflex [3]. In the current study, we investigated central roles of GABAA receptor in the Ang II-induced frequent urination in the rat. Study design, materials and methods In urethane anesthetized (1.0 g/kg, ip) male Wistar rats (320-390 g), a catheter was inserted into the bladder dome in order to perform cystometry (12 ml/h saline infusion). Three hours after the surgery, Ang II (30 pmol/3 µl/rat, icv) or the vehicle (PBS) was centrally administered

Angiotensin II centrally induces frequent detrusor contractility of the bladder by acting on brain angiotensin II type 1 receptors in rats

Angiotensin II inhibits GABAergic synaptic transmission in dorsolateral periaqueductal gray neurons

Melatonin increases bladder capacity via GABAergic system and decreases urine volume in rats

Disclosures Funding: JSPS KAKENHI Grant (#26861271 and #16K09243) Clinical Trial: No Subjects: ANIMAL Species: Rat Ethics Committee: Institutional Animal Care and Use Committee of Kochi University

Kaneko S 4 , Homma Y 5 , Igawa Y 2 1. Department of Urlogy and Continence Medicine

Distribution and function of the hydrogen sulfide-sensitive TRPA1 ion channel in rat urinary bladder

Increased mRNA expression of genes involved in pronociceptive inflammatory reactions in bladder tissue of interstitial cystitis

TRPM2 contributes to inflammatory and neuropathic pain through the aggravation of pronociceptive inflammatory responses in mice

The University of Tokyo Graduate School of Medicine Both groups were of similar demographics (age) and clinical history (parity and previous surgical interventions)

Comparing the MRI findings , there is significant statistical difference (P <0.01) between the USL length in both groups being longer in the cases. In the cases group: mean length of right USL is 35.11 ± 11 mms (range 18 to 49.5mms) while the left USL is 34.03 ± 11 mms (range 18 to 57mms)

We divided the UUI cases group into 2 subgroups: (with uterine descent [n=11] and without uterine descent [n=19]). We did not find a significant difference between the USL length of the 2 subgroups

We divided the UUI cases group into 2 subgroups (with POP[n=21] and without POP

No relation was found between the length (laxity) of the ligament and the symptoms(duration or severity)

This may suggest " the lax vagina" as an explanation of the UUI in females . Our study suggests that the long (lax) USLs may indeed be associated with the UUI itself , and that the USLs may be further longer in patients with pelvic organ prolapse in conjunction with the UUI . This is supported by many researchers who found (using the Source MRI ) that patients with POP have longer USLs than normal

PHYSIOLOGICAL TARGETING OF SACRAL NEUROMODULATION Hypothesis / aims of study InterStim® Therapy for overactive bladder (OAB) and fecal incontinence is most often delivered in a continuous mode. Recent clinical evidence [1] and the emergence of intermittent percutaneous tibial neuromodulation for treatment of OAB suggest equal therapeutic efficacy can be achieved with non-continuous sacral neuromodulation (SNM). If true, it would give insight into therapeutic mechanism of SNM and could potentially translate to an increase in battery savings

Prospective randomized feasibility study assessing the effect of cyclic sacral neuromodulation of urinary urge incontinence

Late intermittent sacral neurostimulation significantly increases bladder capacity

A Chronic, Conscious Large Animal Platform to Quantify Therapeutic Effects of Sacral Neuromodulation on Bladder Function

Bilkova K 3 , Sykora R 4 , Mika D 4

Spinal Cord Rehabilitation Unit

International Urogynecological Association; International Continence Society. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

Summary of European Association of Urology (EAU) Guidelines on neuro-urology

Anticholinergic drugs for adult neurogenic detrusor overactivity: a systematic review and meta-analysis

Disclosures Funding: Study was supported by research grant by Astellas Pharma Clinical Trial: Yes Registration Number: EudraCT 2014 -002592-29 RCT: Yes Subjects: HUMAN Ethics Committee: Institutional Review Board of the University Hospital, Ostrava (265/2014) Helsinki: Yes Informed Consent: Yes 575

Sawada N 1 , Yoshiyama M 1 , Koizumi S 3 , Nakao A 2 , Takeda M 1 1. Depatment of Urology

Clock Genes Regulate the Circadian Expression of Piezo1, TRPV4, Connexin26, and VNUT in an Ex Vivo Mouse Bladder Mucosa

Entrainment of the mouse circadian clock by sub-acute physical and psychological stress

Lower urinary tract symptoms, nocturia and overactive bladder in patients with depression and anxiety

Disclosures Funding: I do not have any affiliations to disclose

Rahnama'i S 1 , van den Hurk J 2

Brookes S 1 , Spencer N 1 1. Flinders University IDENTIFICATION OF DIFFERENT TYPES OF PELVIC AFFERENT ENDINGS IN THE MOUSE BLADDER USING ANTEROGRADE TRACING FROM DORSAL ROOT GANGLIA IN VIVO Hypothesis / aims of study Sensory stimuli within the bladder are detected by spinal afferent neurons

In functional electrophysiological studies four major classes of sensory neurons were identified in the mouse bladder: (i) low threshold stretch-sensitive muscular and (ii) muscular-mucosal; (iii) stretch-insensitive mucosal and (iv) so-called serosal afferents [1]. In the urinary bladder, the terminal endings of spinal afferents that detect noxious and innocuous stimuli have never been identified in any species. The main objective of the study was to identify the different morphological types of spinal afferent nerve endings within the mouse urinary bladder wall. Study design, materials and methods In C57BL/6 (n=15) mice, left L6 -S2 dorsal root ganglia were exposed in vivo and injected with 1 ul dextran biotin (Molecular Probes)

Results From 15 mice studied in vivo, 160 discrete spinal afferent nerve endings were identified in the bladder wall. These endings were classified into four distinct classes, based on their morphology and location in the bladder wall. The endings were identified as simple endings in the sub-urothelium

One quarter (25%) of all anterogradely labelled nerve endings were identified as simpletype endings, that were located in the detrusor muscle, 78% of which were CGRP positive. These endings always ran along the smooth muscle fibres, with little or no branching. Complex-type endings in the detrusor muscle were the most common ending located in the mouse bladder, accounting for 44% of all endings located, 75% of which were CGRP immunoreactive. Complextype endings consisted of a single axon branching into many fibres with no obvious directionality to one another. Branching-type endings in the detrusor accounted for 12% of all endings identified in the mouse bladder, 89% of which were CGRP positive. These endings consisted of a single axon that branched into many varicose fibres which lay parallel to one another and to the smooth muscle fibres. In electrophysiological recordings from urothelium-free bladder preparations, based on sensitivity to stretch, two major group of afferents were distinquished: (i) low threshold stretch-sensitive afferents (threshold 1-3 g) with mean firing rate of 6.52 ± 1.45 Hz (n=7) at 30 g load and high threshold afferents

Hz (n=6)

Interpretation of results The data demonstrate the morphological complexity of the sacral-pelvic innervation of the bladder with at least three distinct types of endings: simple-type endings in both the sub-urothelium and muscle layers and complex and branching-types endings in the detrusor. In electrophysiological experiments in detrusor preparations, where the urothelium and most of the sub-urothelium were sharp dissected away, two distinct types of afferents: low and high threshold stretch-sensitive mechanoreceptors were recorded. It is tempting to speculate that two distinct morphological types of endings identified in the muscle layers (branching-and complextype), correspond to low and high threshold stretch-sensitive afferents determined by functional electrophysiological studies

Characterization of mouse lumbar splanchnic and pelvic nerve urinary bladder mechanosensory afferents

Properties of major classes of bladder mechanoreceptors of the guinea pig in vitro

Disclosures Funding: National Health and Medical Research Council of Australia grant #1046881 Clinical Trial: No Subjects: ANIMAL Species: mouse Ethics Committee: Animal Welfare Committee of Flinders University References

Disclosures Funding: P01 DK093424 Clinical Trial: No Subjects: ANIMAL Species: Mouse Ethics Committee

Total pelvic floor ultrasound for pelvic floor defaecatory dysfunction: A pictorial review

Disclosures Funding: Guy's and St Thomas' Charity Clinical Trial: No Subjects: HUMAN Ethics Committee: South East London Helsinki: Yes Informed Consent: Yes 708

Developing evidence-based standards for diagnosis and management of lower urinary tract or pelvic floor dysfunction

No Subjects: HUMAN Ethics Committee: Ethical committee approval granted by HRA East Midlands -Leicester South Research Ethics Committee (REC Reference: 16/EM/0403) Helsinki: Yes Informed Consent: Yes 709

Tokyo Metropolitan Rehabilitation Hospital, 3. Nagoya University Graduate

Disclosures Funding: JSPS KAKENHI Grant Number JP15K10633 Clinical Trial: No Subjects: HUMAN Ethics Committee: Jikei University Institutional Review Board Helsinki: Yes Informed Consent: Yes Ros-Cerro C 1 , Bataller E 1 , Anglès S 1 , Elias N 1 , Gallego M 1 , Espuña-Pons M 1

Risk factors for pelvic organ prolapse and its recurrence: a systematic review

Disclosures Funding: Dr. Eduardo Bataller was a consultant for AMS (Astora, women's health). The Elevate® Anterior kits were donated by AMS as a grant for the study without any other support or supervision

Department of Obstetrics and Gynecology, Maisonneuve-Rosemont Hospital, Montreal, Canada, 4. Department of Obstetrics and Gynecology

Assessment of vaginal atrophy: a review

Guidance for Industry Estrogen and Estrogen/Progestin Drug Products to Treat Vasomotor Symptoms and Vulvar and Vaginal Atrophy Symptoms -Recommendations for Clinical Evaluation, The Division of Drug Information (HFD-240) Center for Drug Evaluation and Research

Are women with urogenital atrophy symptomatic?

Fond de recherche du Québec en santé fellowship

POSTVOID RESIDUAL IS A STRONG PREDICTOR OF THE DIAGNOSIS OF MULTIPLE SYSTEM ATROPHY IN PATIENTS WITH PARKINSONIAN SYNDROME Hypothesis / aims of study Multiple system atrophy (MSA) is clinically characterized by combination of autonomic dysfunction, cerebellar dysfunction and extrapyramidal dysfunction. Lower urinary dysfunction (LUTD) is usually severe and many patients eventually need urethral catheterization in advanced stage. MSA is also clinically classified into two phenotypes: parkinsonism predominant (MSA-P) and cerebellar ataxia predominant (MSA-C). It is difficult to differentiate MSA-P from Parkinson's disease (PD) at least in the early stage

We aimed to clarify which UDS parameter is useful for differentiating MSA from PD. Study design, materials and methods We retrospectively reviewed 230 case records; both UDS and external anal sphincter electromyography (EAS-EMG) were performed in patients with MSA (n = 146, mean age 64.1 ± 0.53 years, mean duration 3.2 years) and PD (n = 84, mean age 66.2 ± 0.46 years, mean duration 3.2 years). We performed multivariate step-wise logistic regression analysis to determine the useful UDS parameters among post-void residuals (PVR) during free-flow study, the presence or absence of detrusor overactivity (DO), the degree of bladder contraction evaluated by Schafer's nomogram and

Since urodynamic parameters include both quantitative (PVR and mean duration of MUP) and qualitative (presence of DO and bladder contractility evaluated by Schäfer's nomogram) variables, we categorised quantitative parameters into several groups. PVR was categorised into four groups: 0-50, 50-100, 100-150 and > 150 ml. We categorised mean duration of MUP into < 10 ms and > 10 ms. Results Urodynamic parameters PVR during free-flow study was significantly larger

1 ± 12.6 ml) than in patients with PD (71.7 ± 6.6 ml). The mean duration of MUPs was significantly longer in patients with MSA (9.3 ± 0.1 ms) than in patients with PD (7.7 ± 0.1 ms).The prevalence of DO did not significantly differ between patients with PD and patients with MSA. The severity and prevalence of detrusor contractility were significantly larger

Pelvic organ dysfunction is more prevalent and severe in MSA-P compared to Parkinson's disease

Receiver operating characteristic analysis of sphincter electromyography for parkinsonian syndrome

Urinary Dysfunction in Progressive Supranuclear Palsy Compared with Other Parkinsonian Disorders

De Gennaro M 3 , Mosiello G 1 1. Paediatric Hospital Bambino Gesù, Neuro-Urology unit , Dept. of Robotic Surgery and Urodynamic, Paediatric Hospital Bambino Gesù

Sacral neuromodulation for neurogenic bladder dysfunction in children. Guys JM

Sacrl Neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis

Current state of the nerve stimulation technique for lower urinary tract dysfunction in children

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: Comitato Etico dell'Ospedale Pediatrico Bambino Gesù

Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. The American Urological Association

A nationwide analysis of complications associated with the tension-free vaginal tape (TVT) procedure

United States experience with tension-free vaginal tape procedure for urinary stress incontinence: assessment of safety and tolerability

Disclosures Funding: NONE Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: CEAS Helsinki: Yes Informed Consent: Yes

Diagnosis of urinary symptoms was made my means of clinical history according to the joint IUGA/ICS terminology report definitions. To assess the detrusor contraction strength we used the contractility index PIP [detrusor pressure at maximum flow rate (PdetQmax) + Qmax] (normal detrusor contractility 30-75cmH2O). To assess the bladder outlet obstruction (BOO) we used the Blaivas and Groutz nomogram using (BOO = Qmax < 12 mL/sec combined with a Pdet Qmax of > 20 cm H2O in pressure-flow study). All surgical procedures were performed by two senior surgeons with standardized technique. Patients were followed up at 1, 3, 6, and 12 months after surgery, and then annually

Resolution of motor urge incontinence after surgical repair of pelvic organ prolapse

Bladder outlet obstruction in women: definition and characteristics

Uroflowmetry in women with urinary incontinence and pelvic organ prolapse

MINIARC VS TVT ABBREVO MIDURETHRAL SLING IN WOMEN WITH STRESS URINARY INCONTINENCE -AN RCT -6 AND 12MONTH FOLLOW UP

The FDA has requested ongoing studies to determine the efficacy of single incision slings. The TVT Abbrevo is a modification of the TVT-O with a reduced length and less immediate postoperative pain 1 . The Miniarc SIS has been shown to be equivalent to outside-in transobturator sling, Monarc at 12 month follow-up 2 . OBJECTIVE: To evaluate objective and subjective outcomes of MiniArc SIS and TVT

Decreasing transobturator sling groin pain without decreasing efficacy using TVT-Abbrevo

Randomizes trial of a single incision versus an outside-in obturator midurethral sling in women with stress urinary incontinence: 12 months results

RCT: Yes Subjects: HUMAN Ethics Committee: Human Research Ethics Committee Research Support Services I Monash Health Level 2, I Block

Myofascial pelvic pain

Pelvic pain in urogynaecology. Part I: evaluation, definitions, and diagnoses

Disclosures Funding: National Institutes of Health Reproductive Epidemiology Training Grant, T32HD055172-08 Clinical Trial: No Subjects: HUMAN Ethics Committee: Washington University in St Louis Institutional Review Board Helsinki: Yes Informed Consent

Despite having an immense impact on quality of life, sexual dysfunction is often under-reported. Previous studies in non-neurological patients have suggested that the clinic setting poses several challenges to discussing SD (1), however these have never been systematically evaluated in neurological disease. The aim of this study was to identify barriers faced by MS patients and their health care professionals (HCPs) in discussing SD during clinic. Study design, materials and methods This was a two-part prospective study carried out at a tertiary care teaching out-patient clinic

Sexual dysfunction was assessed using Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ) and Arizona Sexual Experience Scale (ASEX) and depression screened using Patient Health Questionnaire-2 (PHQ -2). The questionnaire was reviewed by five patients attending outpatient clinics for content validity and modified according to the feedback received. Subsequently, consecutive MS patients, between the age 16 and 65, attending a specialist out-patient clinic over six months were invited to complete the anonymized questionnaire. Questionnaires were returned to the study investigators either by hand or post. Part 2-survey of HCPs working with MS patients: a bespoke 23-item questionnaire was designed. The questionnaire was reviewed by 5 HCPs for content validity and finalized after receiving feedback. An online version of the questionnaire was designed and uploaded onto an online survey portal (SurveyMonkey.com) and was sent through email

Less intense or pleasurable orgasms or climaxes (24.4%), Worries about sexually satisfying the partner (23%). 32.59% (n=17.6) women report inadequate vaginal wetness or lubrication, while 94.5% (n=18.9) men reported difficulty in getting or keeping a satisfactory erection. The commonest barriers reported by patients were: prominent neurological symptoms dominating the consultation (n=30, 40.5%), presence of family or friends during the consultation (n=28, 37.8%), not being asked about sexual problems (n=25, 33.8%)

GP (n=38), MS organisation or trust (n=28), another person with MS (n=20), physiotherapist (n=18), junior doctor (n=11), Internet (n=10) and friend or relative (n=10), were most suited for discussing management of sexual dysfunction

Sexual difficulties for persons with multiple sclerosis in New South Wales

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics not Req'd: Service Evaluation registered with the Quality and Clinical Governance Department

ADULTS WITH CONGENITAL GENITOURINARY ABNORMALITIES Hypothesis / aims of study In this study, we investigated the sexual function and fertility status of adult patients with congenital genitourinary abnormalities (CGUA) in a tertiary transitional urology care setting. Study design, materials and methods This cross-sectional study included adult patients with congenital spinal dysraphism and other forms of CGUA who were referred to a single tertiary transitional care clinic. Of the 164 total referred patients, 72 patients consented and filled out questionnaires between 2013-2017. Patients were offered and received assistance in completing questionnaires by research coordinators. The questionnaires included questions about education level, functional status, bowel and bladder continence, partnership, sexual function, and fertility status

9%) responded to questions pertaining to their sexuality and fertility status. 4 patients were excluded from analysis because of poor cognitive ability and/or functional status, which was defined as an education level of pre-elementary and cumulative self-care score of ≤ 12 respectively

16 men had myelomeningocele (MMC), 1 lumbar meningocele, 1 sacral agenesis, 1 cloacal exstrophy, and 4 had other CGUA. 10 men (43.5%) reported a history of sexual activity, with 6 (26.1%) being currently sexually active. 16 (69.6%) expressed a desire to become or continue being sexually active, and 12 (52.2%) wanted to learn more about sexuality and/or fertility

At the time of investigation, 14 men (82.4%) were unmarried, 2 (11.8%) were married, and 1 (5.9%) was widowed. None of the men had fathered biological children. 5 (29.4%) reported using a form of contraception, of which all specified condoms. None of the men had ever received fertility counselling

5 (50%) had mild, 3 (30%) had mild/moderate, 1 (10%) had moderate, and none had severe ED. 5 men (20%) partially completed the SHIM questionnaire, so a composite score could not be calculated. The remaining male participants (40%) left the questionnaire blank despite being offered assistance in filling it. Females: 34 of the 35 female participants (97.1%) responded to the sexual function questionnaire. 20 women had MMC, 2 tethered cord, 2 bladder exstrophy, 2 cloacal exstrophy, and 8 had other CGUA. 9 women (26.5%) reported a history of sexual activity, with 5 (14.7%) being currently sexually active. 9 (26.5%) expressed desire to become or continue being sexually active, and 7 (20.6%) wanted to learn more about sexuality and/or fertility. The most commonly unanswered questions by female participants were those regarding further sexuality

14 (51.9%) had previously seen an obstetrics/genecology specialist, and 11 (40.7%) reported using a form of birth control, with the majority (n=7, 63.6%) taking oral contraceptives. At the time of investigation, 25 (92.6%) were unmarried, and 1 (3.7%) was married. The married woman was the only participant who had been pregnant and given birth to children

9%) currently had a sexual partner, with 4 (14.8%) reporting sexual activity in the past month. 11 women (40.7%) answered questions pertaining to sexual orientation. A mixture of both heterosexual and homosexual desires and experiences were reported. The remaining BISF-W questions are divided into 7 dimensions: D1 (thoughts/desire), D2 (arousal), D3 (frequency of sexual activity), D4 (receptivity/initiation), D5 (pleasure/orgasm), D6 (relationship satisfaction), and D7 (problems affecting sexual function)

Family and peer issues among adolescents with spina bifida and cerebral palsy

Characteristics of psychosexual functioning in adults with cerebral palsy

Sexuality of children and adolescents with developmental disabilities

Disclosures Funding: RK is a scholar supported in part by the National Institutes of Health (NIH) grant K12 K0083014, the Multidisciplinary K12 Urologic Research (KURe) Career Development Program to Dolores J Lamb (DJL) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Academic Unit of Neurology

Lower urinary tract (LUT) dysfunction has been described in this condition, however is poorly characterised (1,2), and its' relation to the underlying neurological condition is uncertain. The aim of this study was to prospectively evaluate LUT symptoms in a large cohort of patients with FRDA using validated questionnaires, and explore their relation with bowel and sexual dysfunction, and duration and severity of neurological disease. Study design, materials and methods Patients with a classical phenotype and confirmed diagnosis of FRDA by genetic analysis being seen at a tertiary centre were prospectively evaluated. Demographic information was obtained, and ataxia severity assessed using Scale for the Assessment and Rating of Ataxia

No gender differences were noted in bladder scores. The mean post-void residual volume was 30 mls (n=2). 64% (n=37) reported bowel symptoms (reduced bowel frequency (86%) and faecal incontinence (16%)), whereas 25% (n=9, 5 females) reported sexual dysfunction. 75% of patients (n=44) who reported LUT storage symptoms also reported bowel dysfunction, and were also more likely to report sexual dysfunction (p=0.0003). Patients with bowel symptoms were also more likely to report sexual dysfunction (p=0.024). Late-onset of ataxia (onset on or after 25 years of age) was significantly associated with higher LUT storage scores

Clinical features of Friedreich's ataxia: classical and atypical phenotypes

Urinary symptoms and urodynamics findings in patients with Friedreich's ataxia

No Subjects: HUMAN Ethics Committee: REC No. 10/H0716/51 Helsinki: Yes Informed Consent: Yes 723

Manchester Academic Health Science Centre, 2. The Warrell Unit, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre; Institute of Biological Sciences, Faculty of Medical and Human Sciences

Genital sensation in women with pelvic organ prolapse

Pelvic floor damage and childbirth: a neurophysiological study

Normative values for female genital sensation

UK Clinical Trial: No Subjects: HUMAN Ethics Committee: UK National Research Ethics Service: Committee Northwest -Greater Manchester West (14/NW/1316) Helsinki: Yes Informed Consent: Yes References

Urodynamics in the evaluation of the patient with multiple sclerosis: when are they helpful and how do we use them? The Urologic clinics of

Control of bladder sensations: an fMRI study of brain activity and effective connectivity

Brain activation during micturition in women

Disclosures Funding: RK is a scholar supported in part by the National Institutes of Health (NIH) grant K12 DK0083014, the Multidisciplinary K12 Urologic Research (KURe) Career Development Program to Dolores J Lamb (DJL) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Brain activation in response to bladder filling in healthy adults: An activation likelihood estimation meta-analysis of neuroimaging studies

Central control of micturition in women: Brain-bladder pathways in continence and urgency urinary incontinence

Quantitative changes in regional cerebral blood flow induced by cold, heat and ischemic pain: a continuous arterial spin labeling study

Roberts A 1 , Mazzei M 1 , Frara N 1 , Braverman A 1 , Barbe M 1 , Ruggieri M 1

Latest Evidence on the Use of Phosphodiesterase Type 5 Inhibitors for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

An exploration of the control of micturition using a novel in situ arterially perfused rat preparation

Evaluation of the relaxant effect of the nitric oxideindependent soluble guanylyl cyclase stimulator BAY 41-2272 in isolated detrusor smooth muscle

Disclosures Funding: Funding is through United States National Institutes of Health grant NIH R01 DK098361 (MJD, CHF, AEP) Clinical Trial: No Subjects: ANIMAL Species: Mice Ethics Committee: All experiments conformed to the UK Home office guidelines regarding the ethical use of animals and were approved by ethical review committee of

Nedumaran B 1 , Hypolite J 1 , Meacham R 1 , Malykhina A 1 1. University of Colorado Denver DIFFERENTIAL PHENOTYPES OF NEUROGENIC VOIDING DYSFUNCTION IN A VIRAL MURINE MODEL OF MULTIPLE SCLEROSIS

Hypothesis/aims of study Neurogenic voiding dysfunction often develops in patients with neurodegenerative disorders such as multiple sclerosis (MS)

Animals in both REC and RELAP groups showed the most significant body weight loss at 1wk after inoculation with the virus (22.3±0.28g at baseline vs 16.5±0.3g in REC group, and 9.2±0.86g in RELAP group, p<0.05). Muscarinic responses evaluated by contractility studies in vitro of bladder strips isolated from REC mice were similar to the control group. However, the bladders from RELAP group showed significantly decreased responses to stimulation of M3 muscarinic receptors. Micturition patterns evaluated by filter paper assay in vivo, also confirmed an increased micturition frequency in mice from RELAP group. Interpretation of results Long-term follow up of CIE mice revealed two differential phenotypes of neurologic impairment mimicking two forms of MS in humans: relapsing-remitting MS and chronic type of MS. Mice in the RELAP group expressed overactive voiding patterns, and also had decreased M3 responses suggesting that anti-muscarinic drugs may have limited effects on neurogenic bladder dysfunction in patients with relapsing-remitting type of MS. Concluding message Our study confirmed that initial neurological damage in murine viral model of multiple sclerosis can cause long-lasting alterations

A2A RECEPTOR ANTAGONIST ISTRADEFYLLINE IMPROVES LOWER URINARY TRACT SYMPTOMS IN PATIENTS WITH PARKINSON'S DISEASE IN A LONG-TERM PERIOD

Istradefylline improves wearing-off phenomena and is tolerated well by PD patients treated with levodopa. We previously reported that Istradefylline improved not only motor symptoms, but also lower urinary tract symptoms (LUTS) in patients with PD in a short-term period (ref. 1). However, the long-term effects of istradefylline for LUTS has not yet been clarified. The aim of this study was to determine the effects of 1 year istradefylline treatment on LUTS in PD patients. Study design, materials and methods We enrolled male 12 male PD patients

King's Health Questionnaire (KHQ) score, 3-day voiding diary, and urinary flow rate and post-voiding residual urine volume before and after its administration. Results Motor symptoms significantly improved after 1 year evaluating movement disorder rating scale (P<0.01)

Central LUTS in patients with PD are OAB symptoms, characterized by urinary urgency and increases in daytime and night time urinary frequency [ref. 2]. LUTS are more likely to occur at more advanced stages of PD

ICS Meeting (2006) Abstract No. 210. Disclosures Funding: JSPS KAKENHI for Scientific Research (No. 25462507 & No. 16K11042) (to M. Yoshiyama) Clinical Trial: No Subjects: ANIMAL Species: Mouse Ethics Committee: The Institutional Animal Care and Use Committee of the University of Yamanashi

ROLE OF P38 MAP KINASE SIGNALLING PATHWAYS IN STORAGE AND VOIDING DYSFUNCTION IN MICE WITH SPINAL CORD INJURY Hypothesis / aims of study Chronic spinal cord injury (SCI) rostral to the lumbosacral level induces detrusor overactivity (DO) during the storage phase, which is mediated by spinal reflexes triggered by hyperexcitable C-fiber afferent pathways. During the voiding phase, inefficient voiding is commonly observed due to detrusor-sphincter dyssynergia or DSD after SCI. It has also been shown that neurotrophic factors such as nerve growth factor (NGF) released within the urinary bladder or the spinal cord are an important mediator inducing DO after SCI [1]. It is also known that the second messenger signalling pathways activated by NGF involve activation of p38 MAP kinase (MAPK

However, it remains to be elucidated whether the p38 MAPK pathway is also involved in lower urinary tract dysfunction induced by SCI. Therefore, we investigated the effects of a p38 MAPK inhibitor treatment using SCI mice to clarify the role of the p38 MAPK pathway in SCI-induced storage and voiding dysfunction

Disclosures Funding: NIH P01DK093424 Clinical Trial: No Subjects: ANIMAL Species: Mouse Ethics Committee: University of Pittsburgh Institutional Animal Care and Use Committee

neovejiga ileal: a propósito de dos casos

Treatment of Lower-GI Post-Surgical Fistulas With the Over-the-Scope Clip

An Over-the-Scope Clip (OTSC) System for Closure of Iatrogenic Colon Perforations: Results of an Experimental Survival Study in Pigs

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics not Req'd: it was a treatment of a surgery complication Helsinki: Yes Informed Consent: Yes References 1. MASCIP 2012 (Multidisciplinary Association of Spinal Cord Injury Professionals) 'Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions

Neurogenic bowel management after spinal cord injury: a systematic review of the evidence

Use of Videos to support teaching and learning of clinical skills in nursing education: A review

Disclosures Funding: NRH Foundation (National Rehabilitation Hospital Foundation ) Clinical Trial: No Subjects: NONE Watch video www

WOMEN: STANDARDIZATION OF THE SURGICAL TECHNIQUE

They observed that in a normal standing position EMG activation of the PFM was higher than in a lying or standing position with hypo or hyperlordosis. However, Capson et al. (3) used an intravaginal probe (Periform™) whereas we used surface electrode. As previously reported by Capson et al. (3), during cough, we didn't find any influence of body position on the timing of PFM contraction. However, RT to voluntary contract PFM was shorter in a standing position, meaning that continent women were more able to contract faster their PFM in a standing than in a sitting position

Influence of a distraction task on pelvic floor muscle contraction

Influence of a distraction task on the involuntary reflex contraction of the pelvic floor muscles following cough

The role of lumbopelvic posture in pelvic floor muscle activation in continent women

Disclosures Funding: None Clinical Trial: No Subjects: HUMAN Ethics Committee: CPP ile de france 3 Helsinki: Yes Informed Consent: Yes

Rynkevic R 1 , Martins P 1 , Fernandes A 1

Portugal with significantly low total collagen and high elastin content. External anal sphincter and levator ani muscle also showed compliant behaviour. In contrast, bladder and rectum had the highest total collagen, which was associated with a high ultimate stress. Elastic fibres and smooth muscle tissue in the walls of the urinary bladder and rectum contribute to its distensibility and elasticity. Results showed, that bladder and rectal walls become thinner. In addition, rectum and bladder elastin fibres and smooth muscle cell content significantly decrease. This consequently reduces their flexibility. As a result, this could be related with frequent urination or urinary incontinence, constipation and haemorrhoids or POP. Concluding message It was observed that pelvic floor soft tissue undergoes profound histologic and mechanical changes, particularly during pregnancy and do not recover to its original status one year after. There was a connection observed between mechanical properties of the soft tissues and histological analysis

Disclosures Funding: The authors gratefully acknowledge funding from: FCT, Portugal, under grants SFRH/BD/96548/2013, SFRH/BPD/111846/2015; UROSPHINX -Project 16842, COMPETE2020, through FEDER and FCT

The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Neurol Urodyn

The overlap of storage, voiding and postmicturition symptoms and implications for treatment seeking in the USA

Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study

Disclosures Funding: National Institutes of Health Reproductive Epidemiology Training Grant, T32HD055172-08 Clinical Trial: No Subjects: HUMAN Ethics Committee: Washington University in St Louis Institutional Review Board Helsinki: Yes Informed Consent

Sao Paulo, Brazil, 2. School of Rehabilitation, Faculty of Medicine and Health Sciences

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee: Ethics committe of the Centre de recherche de l

Stability, continence and breathing: The role of fascia following pregnancy and delivery

Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study

Disclosures Funding: NONE Clinical Trial: No Subjects: HUMAN Ethics Committee: The Regional Medical Ethics Committee

Bern University of Applied Sciences, Murtenstrasse and Graduate School for Health Sciences

Evaluation of pelvic floor muscle activity during running in continent and

Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study

Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis

Disclosures Funding: non Clinical Trial: No Subjects: HUMAN Ethics not Req'd: it is an systematic review Helsinki not Req'd: it is a systematic review

The role of lumbopelvic posture in pelvic floor muscle activation in continent women

Postural assessment software (PAS/SAPO): Validation and reliabiliy

Disclosures Funding: Foundation for Research Support of the State of Bahia -Governmental Clinical Trial: No Subjects: HUMAN Ethics Committee: Ethics Review Board from Bahiana School of Medicine and Public Health

Gachon B 1 , Desgranges M 1 , Fradet L 2

Futuroscope, France IS LIGAMENTOUS LAXITY PREDICTIVE OF OBSTETRICAL ANAL SPHINCTER INJURY IN TERM PREGNANT WOMEN? Hypothesis / aims of study Obstetric anal sphincter injuries (OASIS) strongly affect women's health due to its association with urinary/fecal incontinence. Some risk factors are well known but both predictive and preventive strategies remain disappointing (1). An increase in ligamentous laxity and in pelvic organ

Disclosures Funding: non Clinical Trial: No Subjects: HUMAN Ethics Committee: Comité de Protection des personnes

Agence Nationale de Sécurité du Médicament et des produits de santé Helsinki: Yes Informed Consent: Yes 746

Department of Obstetrics and Gynecology, La Miletrie University Hospital, Poitiers France, 4. Department of Obstetrics and Gynecology, La Miletrie University Hospital, Poitiers France /INSERM, Center for Research in Epidemiology and Population Health (CESP), U1018, Gender, Sexuality and Health Team

Disclosures Funding: none Clinical Trial: No Subjects: HUMAN Ethics Committee: Comite de protection des personnes POITIERS Ouest III Helsinki: Yes Informed Consent: Yes

Committee Opinion No. 650 Summary: physical activity and exercise during pregnancy and the postpartum period

Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength. The necessity of supplementary methods for control of correct contraction

Assessment of pelvic floor muscle pressure in female athletes

The Regional Ethics Committee (REK Sør-Øst D 2009/170) and the Norwegian Social Science Data Service (2799026) approved the study, and all women gave informed written consent to participate Helsinki: Yes Informed Consent: Yes Results Twenty-five healthy volunteers were recruited. 24 underwent the forced diuresis protocol once and 21 twice

Median age was 28 years (19-47years), median BMI 26.3 Kg/m 2 (19.0-39.0 kg/m 2 ). 21 were female participant and four male. All participants had a glomerular filtration rate >60ml/min and a normal sodium level

Participants with a difference diuresis rate >4.5ml/min were excluded leaving 16 participants for analysis

Similarly, there was no significant difference in the median diuresis rate between V2 12.33ml/min (8.43-17.38ml/min) and V3

/min) (p=0.255). The median difference in diuresis rate between cycle 2 and cycle 3 was 0

During the second test, there was no difference in the median voids within cycles. The median for V1 is 820ml (474-1538ml) and for V2 is 796ml (502-1489ml) (p=0.756). Equally, the median diuresis rate did not differ between V2 14.40 ml/min (9.55-18.75ml/min) and V3 13

By excluding patients with a large difference in the diuresis rate, we are reducing the variability between tests and within cycles

Test-retest and reliability analysis of a water load protocol as a tool to achieve a fixed diuresis rate for investigation into bladder sensation

Saccharin increases perception of bladder filling in a forced diuresis experiment

University of Yamanashi micturition, and we used the International Prostate Symptom Score (IPSS) and QOL score to analyze LUTS and QOL. LUTS was defined as a total score of IPSS was 8 and more (LUTS-group), and patients with 7 and less was belong to Control-group. To investigate etiologies of LUTS in males and novel molecular insights into disease pathogenesis, we conducted a comprehensive study of plasma metabolites using capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS). Metabolites were compared between LUTS-and Control-groups using Mann-Whitney U test, and biomarkers of male LUTS from metabolites in CE-TOFMS were analysed using a multivariable

Although there was a trend of lower maximum voided volume and higher nocturnal polyuria index, 24hrs-urine volume was not different between groups. (Table 1) Metabolomics analysis with CE-TOFMS identified 110 metabolites from plasma of participants. In a total of 10 metabolites, there was significant difference or a trend of difference between LUTS-and Control-groups. (Table 2) Regarding these 10 metabolites, a multivariate analysis showed that an increase of Glu and a decrease of Arg and IMP were identified as etiologies of LUTS in males. A decrease of ADP, Asn, Citrulline and Gln was also a possible etiologies of male LUTS. (Table 3) Interpretation of results From the present study, some metabolic pathways could be involved in incidence of male LUTS. Particularly, we speculate that central carbon metabolism

Interstitial cystitis-associated urinary metabolites identified by mass-spectrometry based metabolomics analysis

Urinary metabolite profiling combined with computational analysis predicts interstitial cystitis-associated candidate biomarkers

Disclosures Funding: None Clinical Trial: Yes Public Registry: No RCT: No Subjects: HUMAN Ethics Committee: Ethics Committee

Further research is required to investigate this imaging finding, until there is a better understanding of the pathology of this lesion surgical attempts at repair should be avoided.

Our study confirmed that RP change the detrusor contractility pattern of prostate cancer patients. The measurement of Wmax% and WF-AUC provides new approach to the bladder contraction sustainability.Concluding message Older patients with UI express preferences for less invasive treatments for their UI and have reasonable expectations for cure and improvement in their symptoms.Concluding message Instillation of heparin or heparin plus lidocaine is a reasonable therapeutic option for refractory IC, although heparin plus lidocaine may be associated with early symptom worsening.Concluding message Preoperative MRI and postoperative urethrocystography are useful as a predictor for early recovery of urinary incontinence after RARP. This is the first report about the importance of stop sign and contrast sign in urethrocystography.

Chronic prostatic inflammation could be one of the factors that determine the association between BPH and voiding function. To the best of our knowledge, this is the first report demonstrating a correlation between chronic prostatic inflammation assessed by the HEV-like vessel count and the severity of voiding function evaluated objectively by urodynamic study. The number of HEVlike vessels could be a surrogate for the degree of chronic prostatic inflammation.Concluding message Non-continuous sacral neuromodulation can significantly increase bladder capacity, but only when applied to the latter phases of the bladder filling cycle. These data are consistent with a therapeutic effect of SNM being sensory afferent modulation.Concluding message This is the first identification of spinal afferent nerve endings in the urinary bladder wall. The data shows the complexity of the sensory innervation of the urinary bladder, with three distinctly different morphological endings in two different layers of the bladder. Ongoing studies will reveal which specific morphological types of endings relate to the known functional classes of bladder mechanoreceptors. This would be greatly beneficial for understanding mechanisms of both normal and pathological sensation from the bladder.

The MBS and the Atrophy symptom questionnaires have repeatable outcomes and correlated between each other in women with GSM. Therefore they appear to be good outcome measures to assess GSM symptoms and QOL in this population.There were 4 failures, in the Abbrevo group, one of them had to be removed due to pain. One had to be loosened. No sling had to be divided. There were 2 mesh exposures in the Abbrevo group, one required excision at 6 month causing recurrence of SUI and the need for a repeat sling. OAB symptoms at 12m were reported in 16 TVT abbrevo (4 requiring treatment), 11 Miniarc (6 requiring treatment). Sixty patients (44 Abbrevo vs 16 MiniArc) complained of transient groin pain varying between 1 to 6 weeks; all self resolved.CONCLUSION: There were no significant differences in objective cure rates at 6 and 12months between MiniArc and TVT Abbrevo. Subjective cure rate was significantly higher for TVT Abbrevo compared with MiniArc at 12months but not at 6 months.

who did not present with a chief complaint of pelvic pain. Further investigation into this relationship and on the role of pelvic floor and OI myofascial pain in pelvic floor disorder symptoms (irritative voiding symptoms, pressure, etc.) and bother is warranted.

The clinic consultation should be structured to allow a private discussion on SD between the patient with MS and their HCP. Training should be provided to HCPs on how to enquire about sexual dysfunction and to discuss its management.Concluding message Further research is needed to evaluate the causes for altered sensation in pregnancy and influences on return to normal postpartum.Concluding message Body position only influence RT of voluntary PFM contraction. Influence of DT on the voluntary and reflex PFM, was the same wathever the body position.Concluding message Ligamentous laxity could be a significant marker to investigate the risk of OASI during the delivery. It could be useful to offer personalized information to pregnant women about their own risk including the impact of their intrinsic characteristics.Concluding message This technique could be very relevant to describe changes that occur in pelvic floor elasticity during pregnancy and the impact of these changes on the mode of delivery and the risk of pelvic floor disorders.

Concluding message Retropubic midurethral slings may alter patients voiding parameters in the long term.

Kolb E 1 , Kolb G 1 1. Elidah, Inc.

Hypothesis / aims of study Electrical muscle stimulation (EMS) of the pelvic floor muscles (PFM) through use of intravaginal electrodes has been demonstrated as an effective tool in treating women with stress urinary incontinence (SUI). Unfortunately, many women opt-out of this invasive treatment, allowing incontinence symptoms to gradually worsen. This suggests the need for a means of delivering PFM stimulation in a manner that will be more readily adopted. Application of EMS proximate the perineal tissue has shown therapeutic promise when administered in a clinical setting [1] [2] , and recently our team had engineered this non-invasive treatment into a form factor suitable for patient-administered home use. In this study we assessed the usability of a novel, patient-applied surface electrode designed to deliver EMS through the perineal region. Specific elements of the assessment included: 1. Validation of intuitive self-application, anatomic fit and comfortable removal of a one-size-fits-all device. 2. Identification of preferred candidate waveforms capable of comfortably stimulating the pelvic floor muscles. 3 . Characterization of patient-to-patient variability of key EMS electrical parameters including impedance and stimulation current. 4. Formative human factors observations to inform optimization of user interface features.

The device comprises a disposable surface (i.e. transcutaneous) electrode and an electrical muscle stimulator, both custom build for this application. The electrode has an hourglass shape with four conductive regions and a central egress. The stimulator, provided in a compact wearable form factor, contains a microcontroller that allows programming of various candidate stimulation waveforms.Left: Novel SUI electrode and stimulator use in study, Right: Pictoral representation of hwo device is worn. Eight subjects self-applied the device per textual and pictorial instructions. With the subjects fully dressed and seated in a chair, the voltage controlled treatment intensity was incremented while the subjects commented on the strength and comfort of the PFM stimulation. This was repeated with various waveforms and subjects provided comparative assessments. An adaptive approach eliminated the least effective waveforms from further consideration and allowed additional evaluation of derivatives of the more effective waveforms. At the end of the study the subjects completed a questionnaire. Throughout the study an oscilloscope and multimeter allowed direct measurement of treatment parameters including applied voltage (Vpp) and current (Irms). All waveforms were delivered at a stimulation frequency of 50 Hz and provided alternating 6 second periods of contraction and relaxation with 1 second of ramping. In total, 7 waveforms were tested, each broadly classified as one of three types: • Traditional Intravaginal -Single pulse bi-phasic square wave • Burst Mode Alternating Current (BMAC) -Repeating bi-phasic square wave profile with 30-50% duty cycle • Modulated -Repeating bi-phasic square wave with sinusoidal amplitude modulation Results • All subjects were able to apply, wear (~1 hour) and remove the device without difficulty or discomfort, even in the presence of pubic hair. • Subjects identified a modulated waveform at 2000Hz modulation frequency as delivering the most comfortable muscle contractions. BMAC at 2000 Hz and 50% duty cycle was also favourably evaluated. • Subjects reported initial perception of stimulation at 5.6±1.4 mA, comfortable PFM muscle contraction at 10.1±2.3 mA and an initial level of discomfort at 15.6±2.7 mA. This later level corresponded to peak voltage of 40-60V. • System impedance (i.e. electrode + tissue) was calculated as 840±310Ω.• Patient demographics varied widely (age: 25-70, BMI: 16-27, prior births: 0-3, incontinence symptoms: none-moderate) but no correlation with electrical performance measured was identified. 

Hypothesis / aims of study The aim of the study was to elicit views of women outside of a clinical context to understand their attitudes towards urinary incontinence and management using absorbent pads.Plot 1: Box plot of LUTSS total score by LUTSS bother sub-score (0) (1) (2) (3) (4) . Boxes show interquartile range and median; whisker ranges by Tukey method. 

Hypothesis / aims of study In fluid with high Reynolds number, Newton's law of resistance is important to define resistance of fluid passing in a duct. To reduce flow resistance of fluid with high verocity, vorticity can be created, such as narrow duct. Then, vorticity is key physical phenomenon for fluid dynamics when fluid passes a narrow duct like urethra. Although pressure flow study is main observative method to assess voiding mechanism in lower urinary tract, there are few studies to understand lower urinary tract (LUT) in the indications, intention to treat results varies between 50 and 60% (1). One of the reasons may be inadequate lead location, e.g. not close to the target nerve. The aims of the study are to determine the pelvic floor (PF) EMG responses upon electro-stimulation at different locations within the same foramen (e.g. S3 or S4); hypothesizing that different locations inside the foramen will lead to different EMG responses.Study design, materials and methods After ethical approval, 6 patients considered eligible for sacral neuro modulation were tested during the lead placement procedure. Patients under general anaesthesia without muscle relaxants were positioned prone. Standard PNE needles were used. In 4 patients 4 needles were introduced in the same foramen (S3 in 2 patients; S4 in 2 patients, parallel to the midline, with the needles also parallel to each other. In the other 2 patients, 3 parallel needles were placed (S3 in 2 patients; S4 in 1). X-ray was used to ensure that the needle tip was inside the foramen superposing the bone table. This would be the ideal position to finally release the tined lead. Electrostimulation was delivered on the PNE needle (square wave pulses 210 msec , 5 Hz) at increasing amplitudes (1-2-3-5-7-10V). PF-EMG activity was measured using the Multiple Array Probe (MAPLe) placed intravaginally. The MAPLe is a probe with a matrix of 24 electrodes enabling EMG measurement from different sides and layers of the PF (2) . For this study the maximal EMG response was taken from the anterior, posterior, ipsilateral (EMG response at same side as where the foramen needle was) and contralateral side, irrespective of the depth layer of the PF.

In total 147 measurements were made. There was a clear amplitude difference in EMG response at the four measuring sites (repeated measures ANOVA p<0.001)( Table I) .

Mean SD  Ipsilateral  1227  314  345  Posterior  674  149  193  Contralateral  466  121  136  Anterior  420  98  102 When stimulation caused an inward movement of the bellows, different EMG activity patterns were measured. Cranially placed needles had higher PF EMG activity than the caudally placed needles, although statistical significance was only reached between cranial lateral and caudal lateral position (Table II) . The PF EMG activity within an individual also depended on the position of the needle inside foramen( Figure 1 ). Stimulation amplitude (V) -data are mean EMG (µV)  1  2  3  5  7  10  Cranial Medial  81  208  212  346  396  554  Cranial Lateral  109  411  627  597  702  695  Caudal Medial  146  211  347  389  391  493  Caudal Lateral  16  102  187  291  306  315 Figure I: PF EMG activity within an individual also depended on the position of the needle inside the foramen.Remarkably, in 4 stimulations inward contraction posteriorly from the anus was observed without any measurable EMG activity on any of the 24 electrodes. From a clinical point of view, the response at low amplitude (1V and 2V stimulation) is the most important to find the best position for lead placement. With these low voltage stimulation on cranial positioned needles 22% of the stimulations delivered more than 25% of the individual patient's maximal EMG response, compared to 9% in the caudal positions (Chi-square; P=0.01).

In the majority of cases, clinical observation of bellows contraction coincided with measurable PF EMG. Only in 4 stimulations, the bellows contraction was visible posterior from the anus without any PF EMG. Stimulation on the PNE needle leads to an amplitude dependent PF EMG response. In the majority of positions, highest responses are measured at the ipsilateral side, followed by the posterior, contralateral en anterior side. In some positions this order was different. Highest PF EMG was measured

The role of SNM in the treatment of CPP seems promising but larger prospective trials with long-term evaluation are required. 

Hypothesis / aims of study Interstitial cystitis (IC) is a chronic bladder disease associated with hypersensitive bladder symptoms such as bladder pain, discomfort, urgency, and urinary frequency. The etiology is largely unknown, but the deficiency in glycosaminoglycan layer is regarded as a possible cause. On this assumption intravesical therapy with heparin, which is expected to restore the glycosaminoglycan layer deficiency, has been used to relieve the symptoms [1] . To date, however, there is no study comparing the efficacy of instillation therapy of heparin versus heparin plus lidocaine. In this study, we compared therapeutic outcomes and safety of instillation of these two solutions in a randomized double-blind trial.Study design, materials and methods The diagnosis of IC was based on the clinical guidelines for IC and hypersensitive bladder [2] . Patients with refractory IC were enrolled to the study after submitting written informed consent. Refractory IC was defined as persisting symptom of O'Leary and Sant's Interstitial Cystitis symptom index / problem index (OSSI/OSPI) score more than six points, respectively, and numerical rating scale for pain (NRS) more than three out of ten points despite of multiple conventional therapies such as life-style modification, hydrodistension, and oral medication. The patients were randomized to 6-week weekly intravesical instillation of heparin (Group A) or heparin plus lidocaine (Group B). The solution of heparin contained 20,000unit heparin (Yoshindo, Toyama, Japan) in 30 ml physiological saline. The cocktail of heparin plus lidocaine consisted of 20,000 unit heparin and 5ml 4%lidocaine in phosphate-buffered saline adjusted at pH 7.5. At each instillation, patients were instructed to refrain from voiding for at least 30 minutes. The solution was prepared every time immediately before instillation in a sterilized condition. 

Hypothesis / aims of study Robot-assisted radical prostatectomy (RARP) can achieve better functional recovery than conventional surgery, such as retropubic or laparoscopic radical prostatectomy (1). However, early urinary incontinence remains one of the most bothersome postoperative complications, even in RARP (2) . The objective of this study is to predict early recovery of urinary incontinence after RARP using preoperative MRI and postoperative urethrocystography which are performed in all patients noninvasively. 

Hypothesis / aims of study The pathophysiologies of nocturia are multifactorial and complex. Their etiologies remain unclear in a large number of patients. Previously, we reported that urination behavior in mice showed circadian rhythm which is regulated by clock genes and the abnormalities of clock genes might cause nocturia because of the loss of circadian bladder function (1). On the other hand, it has been reported that anxiety or post-traumatic-stress-disorder could increase nocturnal voiding (2) . Furthermore, some types of continuous acute stress such as restraint stress (RS) caused disruption of the circadian rhythm only in peripheral organs, without any effect on central nervous system in mice (3) . In the present study, to reveal effect of restraint stress on alternation of circadian bladder function, we investigated urination behaviour and expression rhythm of clock genes in the mice bladder after restraint stress.Study design, materials and methods Male C57BL/6 mice aged 8 -12 weeks were bred under 12 h light/dark conditions for 2 week. The light period started from 6 am [Zeitgeber time (ZT) 0)]. Mice were individually placed into the metabolic cages, and were subjected to RS for 2 hrs from ZT4 to ZT6 by enfolding using metal mesh sized 12cm×12cm after the aesthesia of sevoflurane. RS was applied for 5 days (from RS1 to RS5) and the urination behavior for 24 hrs was continuously recorded from baseline to RS5. In control, urination behavior was recorded without any RS in metabolic cages for 6 days (baseline and from Day1 to Day5). The following parameters were measured both in control and RS mice, respectively: water intake volume (WIV), voiding frequency (VF), urine volume (UV) and urine volume/void (Uvol/v). Urination during the light period was counted as a nocturnal voiding.In the measurement of gene expression rhythm in clock genes, Period2 luciferase knock-in mice (Per2::luc) were used. Per2 is one of the clock genes, which act as a negative transcriptional factor for clock-controlled-genes. The bladder was removed from Per2::luc mice at ZT10, which is the peak time of Per2 expression. Then the bladder was placed into the dish type lumino-meter immediately. The bioluminescence of luciferin-luciferase reaction from removed bladder was measured for 3 days and Per2 expression rhythm was compared between control and RS mice. 15μM Forskolin was used in order to confirm the viability of bladder tissue at the end of measurement. Data were analysed using Mann-Whitney's U-test, and a one-way ANOVA with Bonferroni test.

The body weight (BW), WIV and UV for 24 hrs showed no difference between control and RS mice. VF in the dark on Day 5 was significantly higher than baseline in control mice. However, RS mice did not show any difference in VF in the dark. In contrast, VF

The surgical success rate of both LSC-CS and AVM was similar in the treatment of POP in patients with advanced stage apical and anterior compartment prolapse. A longer follow-up is compulsory in this type of study.

Hypothesis / aims of study Pelvic floor dysfunction is associated with motor and sensory nerve impairment. (1) Motor nerves are injured during childbirth and this is likely to be true for sensory nerves. (2) However before the effect of childbirth can be investigated, it is important to understand how pregnancy alone affects pelvic sensation. This original study aimed to investigate sensation in pregnancy compared to previously published normative data in non-pregnant women. (3) Study design, materials and methods Women in their first pregnancy were recruited from the antenatal clinic at a tertiary hospital. Exclusion criteria included genital mutilation and pre-existing neurological impairment. Women underwent neurophysiological assessment using quantitative sensory testing (QST) at the index finger, lower third of the vagina and clitoris for vibration sensation in the third trimester. QST uses a strict protocol to examine the minimum stimulus, or sensation threshold, needed for a subject to perceive a sensation, with vibration assessing large myelinated Aβ nerve function.

150 women aged between 20 and 49 years (31.82 ±5.61) were tested and results compared to normative data in non-pregnant women. Hyposensitivity was detected in 40.6% of women at the finger, 8.0% at the vagina and 83.3% at the clitoris. All women with vaginal hyposensitivity also demonstrated clitoral hyposensitivity. There were no cases of hypersensitivity. There was no correlation between gestation at testing (median 32 weeks, range 28-40) and sensation threshold at the finger, vagina or clitoris (p-value =0.720, 0.943 and 0.806 respectively).

Hypothesis / aims of study It is well established that the bladder receives parasympathetic fibers that directly project motor axons from the sacral spinal cord, as well sympathetic fibers from the lower thoracic and upper lumbar spinal cord. Additionally, we have preliminary evidence of a small number of motor neurons originating in lower thoracic and upper lumbar ventral horns that also directly project to the detrusor. We further explored this innervation pattern and hypothesize that these direct fibers originating outside of the sacral region increase their input to the bladder after sacral root transection.Study design, materials and methods This study consisted of two different experiments, an in vivo electrophysiological study and a retrograde dye tracing study. For the in vivo experiment, female mixed-breed hounds were assigned to either a sham-operated group (n=4) or a sacral root transection group (n=6), which included bilateral transection of all roots caudal to spinal level L7. At terminal surgery 8-12 months following the initial procedure, animals received a laminectomy from spinal level T10 to S4. Roots originating from each level were

The present study demonstrates the utility of a novel voiding mice preparation, DAPM, which allows the complete micturition cycle of mice to be investigated without the confound of anaesthesia. Using the DAPM we have shown a novel effect of sildenafil on the EUS which may be of relevance to its use in the treatment of LUTS.disease duration. Furthermore, LUTS become "unmasked" in patients with advanced PD. Prior to the treatment of motor symptoms, patients may be preoccupied with coping with motor symptoms and, thus, be less aware of bladder symptoms. When the severity of motor symptoms decreases with treatments, patients become more aware of LUTS. Istradefylline effectively improved not only motor symptoms, but also LUTS in patients with PD in a long-term period. Istradefylline does not have direct effects on dopaminergic mechanisms, which may provide anti-PD effects on motor and lower urinary tract. Not only IPSS and OABSS, but also KHQ significantly improved after 1year treatment. The mechanism responsible for this improvement has not yet been elucidated, but may be related to the mechanism underlying the indirect impact of adenosine A2A receptor antagonists.Concluding message Istradefylline effectively improved not only motor symptoms, but also LUTS in patients with PD in a long-term period. 

Hypothesis / aims of study In rats, group I metabotropic glutamate receptors (mGluRs) (i.e., mGluR1 and mGluR5) are found in Onuf's nucleus [1] . Previous study demonstrated that spinal cord intact mice lacking mGluR1 exhibit facilitated external urethral sphincter (EUS) electromyogram (EMG) activity with a prominent tonic component superimposed on bursting activity during voiding (i.e., detrusor-Concluding message Both mGluR1 and mGluR5 are important in relaxation of external urethral sphincter of SCT mice. The present results suggest the possibility that dysfunction of these metabotropic glutamatergic transmission in the spinal cord underlies a mechanism exacerbating DSD subsequent to spinal cord injury. 

Hypothesis / aims of study The vaginal wall and pelvic floor organs must adapt to pregnancy. This requires pelvic floor tissues to change their biomechanical properties. Nevertheless, epidemiologic studies show that many women fail to recover completely from these events. The aim of this study was to investigate the effect of consecutive pregnancies on pelvic floor soft tissues, conducting biomechanical and histological analyses. In addition, the links between biomechanical and histological parameters were investigated.Study design, materials and methods Three groups of Swifter ewes were considered: young post-menarchal (virgins) (n=5; avg. age = 9 months), near term (n=5; term = 145 days; avg. age= 3 years) and after two prior vaginal deliveries (pregnant). For this investigation, vaginal wall (distal part), rectum (distal part), bladder, levator ani muscle and external anal sphincter were collected. Biomechanical and histological analyses were conducted on samples from the excised tissues. The biomechanical properties were estimated through uniaxial tests. The biomechanical properties of the tissues (Young's moduli at comfort and stress zones, inflection point and Strain at Ultimate stress) were obtained from the stress-strain curve. For histological analysis, samples were stained with Miller's Elastica to allow identification and quantification of collagen, elastin, and smooth muscle content distributions. The fraction area of each constituent was measured using ImageJ software [1] . Statistical analysis was performed to study possible variations (on mechanical properties and content distributions) of pelvic floor organs between groups. Using GPower software, the statistical power analysis (to compute required sample size) showed that at least 16 samples for mechanical and 6 for structural analysis were needed to achieve 90% power when alpha error was set to 0.05. Kolmogorov-Smirnov tests showed the data follows a normal distribution, unpaired Student`s t-test was used for intergroup comparisons. The level of significance was set to p<0.05.

Vaginal tissue of pregnant sheep was more compliant, than of virgin (39.8%; p<0.05) ( Table 1 ). The morphological analysis showed that, vaginal wall becomes thinner than virgin (p<0.05) during pregnancy (Figure 1b) . The total collagen content in vaginal wall was higher in virgin sheep than in pregnant (p<0.05). The opposite was observed for the elastin content. Pregnant sheep had a higher amount of elastin fibres (p<0.05). During the pregnancy, smooth muscle cell content increased, compared to virgin sheep (p<0.05). There was a significant difference in the mechanical behaviour of the bladder during the pregnancy. Pregnant sheep bladder became more rigid. Young's moduli in comfort and stress zones were higher compared to virgin (74.6%; p<0.05).The bladder became less extensible (21.2%; p<0.05) and thinner during the pregnancy (p<0.05). It contained more total collagen (p<0.05), less elastin fibres (p<0.05) and less smooth muscle cells (p<0.05).

Hypothesis / aims of study Pelvic floor muscles (PFM) should have an adequate resting tone, symmetry and the ability to voluntarily and involuntarily contract with constriction and inward (ventro-cephalad) movement of the pelvic openings [1] . Decreases in muscle tone and strength are associated with either reduced contractile activity and/or passive stiffness, which are components of the mechanism related to pelvic organs descent and urinary incontinence (UI). PFM function is commonly assessed by digital palpation scales, with the disadvantage of being a subjective method with limited reproducibility. Transperineal ultrasound (TPUS) has been increasingly used as an objective and non-invasive method to assess both the constriction of the PFM muscle and the inward movement of the pelvic floor structure, however its relation to digital assessments of PFM function in UI women is still unclear. The aim of this study is to explore the relation between PFM digital assessment (flexibility and strength) and morphometric parameters measured by TPUS in women with UI.

This is a cohort study with 60 years or older women suffering from UI symptoms. Participants were recruited through communitybased advertising. UI was defined as at least one weekly episode of involuntary urine loss during the preceding 3 months. The participants were asked to empty their bladders, and were positioned in supine. Digital and TPUS assessments of the PFM were conducted by an experienced physiotherapist. The flexibility of the vaginal opening (passive vaginal opening) was measured with the index and, if possible, the middle finger inserted into the distal vagina to the proximal interphalangeal joints and abducted in the 3 and 9 o'clock plane. It was scored from 0 (less than one finger insertion) to 4 (two finger insertion with fingers abducted horizontally ≥2cm) [2] . PFM strength was assessed intra-vaginally with one finger, using the Modified Oxford Scale (MOS) with

Theodorsen N 1 , Strand L I 1 , Bø K 2

Hypothesis / aims of study It has been postulated that the pelvic floor muscle (PFM) may play an important role in reducing the Diastasis Recti Abdominis (DRA) (1), and postpartum women are commonly prescribed isolated PFM and Transversus abdominis (TrA) contractions to reduce the DRA. There is scant research and knowledge on how to prevent and reduce DRA in postpartum women, and recent studies have emphasised urgent need for more studies on the relationship between the PFM and DRA (2) . The aim of the present study was to investigate how the PFM contraction influence inter-rectus distance (IRD) in postpartum women presenting with a DRA.Study design, materials and methods This is a cross sectional experimental study aiming to identify the acute influence of a PFM and a TrA contraction on the IRD. Parous women, 0-6 months postpartum (n=38), presenting with a DRA of two fingerwidths or more were included. A power calculation was performed based on a significance level of 0,05 and power of 0,80 resulting in a sample size of 38 parous women.The participants completed a short questionnaire on background information, symptoms of urinary incontinence (International Consultation on Incontinence Urinary Incontinence Short Form questionnaire), and symptoms of back pain (Modified Oswestry Disability Index) and pelvic girdle pain (Pelvic girdle pain questionnaire) in the postpartum period. All measurements were done in supine position with knees bent, feet resting on the plinth, and arms resting alongside the body. The IRD was measured at two different locations; 2 cm above and 2 cm below the umbilicus, using two-dimensional ultrasound imaging. The images of the IRD were collected at rest, during a pelvic floor contraction, during a transversus abdominis contraction, and during a combined contraction of the pelvic floor and transversus muscle. A correct performance of PFM and TrA contraction was confirmed by palpation and ultrasonography prior to the actual data collection. The IRD was measured using the ultrasonography's integrated measurement tool, and presented in mm.Background variables are shown as means with standard deviations (SD) and range, or numbers and percentages. The IRD data were found with normal distribution using Kolmogorov-Smirnov test, and inspecting Q-Q plots. A paired t-test with a 95% CI was used to examine the hypothesis of no difference between IRD at rest and during each contraction, and during PFM and TrA contractions combined (table 2) . The significance level, p ≤ 0,05.

38 postpartum women were included, presenting with an average age of 34,6 years (range 28-42 years), an average BMI of 24,4 (range 20, 9) , and with an average parity of 2,2 (range 1-3). There were 4 multiple births (10,5%) registered, and 73,7 % of the participants had participated in an organized postpartum exercise programme.The results are presented in Table 1 . There was a statistical significant difference (p< 0,01) in the IRD at rest compared to IRD at PFM and TrA contractions both 2 cm above the umbilicus; 25,7mm (rest) vs. 26,9mm (PFM), 28,4mm (TrA), 29,6mm (PFM+TrA), and 2 cm below the umbilicus; 21mm (rest) vs. 22mm (PFM), 23,3mm (TrA), 24,3mm (PFM+TrA). The IRD significantly increased with PFM and TrA contractions and was largest with combined PFM and a TrA contraction (above umbilicus 3,9mm and below 3,3mm). 

Twenty-eight studies fulfilled inclusion criteria; 26 were cross-sectional studies. Ten studies compared continent to incontinent

Hypothesis / aims of study An appropriate posture of the lumbar-pelvic segment can influence the activation of pelvic floor muscles, being a contributing factor to urinary continence. (1) The aim of this study is to compare the angular pelvic parameters of woman with and without urinary incontinence and correlate them with the pelvic floor muscles´ electrical activity and function.

Hypothesis / aims of study The pathophysiology of pelvic floor disorders remains poorly understood, in particular the impact of intrinsic women's characteristics and the role of pregnancy. Elastic properties of pelvic floor muscles may be related with the risk of pelvic floor disorders but there was no non invasive technique described in the literature to measure these properties in vivo (1, 2) . The aim of the study was to evaluate the feasibility of in vivo assessment of elastic properties of levator ani muscle using shear wave elastography in women in various conditions. Study design, materials and methods Non-pregnant women were evaluated in lithotomy position using shear wave elastography technology with an Aixplorer device ® (Supersonic Imagine). The proximal part of levator ani muscle (pubic insertion) was identified in 2D classical ultrasound mode using a translabial linear 8MHz probe (3) . A region of interest containing the levator ani muscle was identified, corresponding to the region in which shear wave elastography analysis were performed. In this region of interest, the contours of the levator ani muscle were drawn in order to perform an exclusive assessment of levator ani muscle and not the adjacent tissues ( Figure 1 ).Measurements of the shear modulus were performed at rest and Valsalva maneuver for both right and left sides. We obtained a Young's modulus measure (representing the relationship between stress and strain in a material) in kPa, which was to be divided by 3 to calculate the shear modulus (in kPa), more appropriate for anisotropic tissues such as muscles. Greater is the shear modulus, stiffer is the tissue. We recorded dynamic continuous acquisition from rest to maximal Valsalva. The highest shear modulus value during the acquisition was considered for the analysis.We reported the number of complete successful assessments, mean shear modulus values and a comparison of shear modulus during each times of the acquisition (Wilcoxon test). An ethical committee approved the study protocol.

The water load protocol achieves a constant high diuresis with rapid, non-invasive bladder filling. The data provide further evidence of reproducibility and provide proof of concept that area under the curve is a valid analysis. Table 3 The odds ratio associated with a one-unit increase of substances