- Email: [email protected]
Re: Neural Reconstruction Methods of Restoring Bladder Function
Urological Survey Voiding Function and Dysfunction, Bladder Physiology and Pharmacology, and Female Urology Re: Neural Reconstruction Methods of Restoring Bladder Function S. M. Gomez-Amaya, M. F. Barbe, W. C. de Groat, J. M. Brown, G. F. Tuite, J. Corcos, S. B. Fecho, A. S. Braverman and M. R. Ruggieri, Sr. Department of Anatomy and Cell Biology, Temple University School of Medicine, Philadelphia, and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, Division of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, Pediatric Neuroscience Centre, All Children’s Hospital, St. Petersburg, Florida, Department of Art, Barton College, Wilson, North Carolina, and Department of Surgery, Division of Urology, McGill University, Montreal, Quebec, Canada Nat Rev Urol 2015; 12: 100e118. doi: 10.1038/nrurol.2015.4.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25666987 Editorial Comment: Anyone interested in a compact, detailed review of this entire field with superbly crafted illustrations should read this article. Restoration of bladder control using surgical methods of reinnervation was first attempted more than 100 years ago in animal models. The various strategies for bladder reinnervation are described from a historical standpoint and in some detail, and include 1) sacral root repair, both homotopic and heterotopic; 2) transfer of peripheral nerves to sacral roots (primarily intercostal and spinal nerves as donors); 3) transfer of roots to sacral spinal nerves; 4) peripheral nerve transfer (peripheral nerves to pelvic nerves); 5) direct detrusor muscle reinnervation; 6) indirect detrusor muscle reinnervation; 7) artificial somatic to automatic reflex pathway (the so-called Xiao procedure), and 8) functional electrical stimulation, including the FinetechBrindley system. The overriding concept is that the bladder can be functionally reinnervated by nerve branches other than those that normally supply it. The authors caution evaluation of the results of such clinical studies, as they point out that “the patient and the patient’s family all desperately want the surgery to result in permanent improvement in bladder emptying and storage function. Because of this desire, the possibility is considerable that these patients and their families might report exaggerated improvements . [and] similarly, the clinician might overestimate the success.” Clearly sham surgery in humans is not possible, but the authors point out that it is also unethical to promote a surgical procedure that is not proved effective. They propose an ethical possibility, and that is to perform a randomized surgical bladder reinnervation trial in a group of patients who are undergoing current standard of care spinal surgery, such as patients with spina bifida who require a spinal cord untethering procedure. The patients could then be randomized to undergo either a reinnervation nerve transfer such as the Xiao procedure or a sham. Long-term followup evaluation of at least 2 to 3 years should be required. The article is well organized and well referenced, and it makes you wish that you had written it. Alan J. Wein, MD, PhD (hon)
0022-5347/16/1951-0131/0 THE JOURNAL OF UROLOGY® Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.10.073 Vol. 195, 131-140, January 2016 Printed in U.S.A.
www.jurology.com
j
131
132
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
Re: US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience K. M. Peters, H. Gilmer, K. Feber, B. J. Girdler, W. Nantau, G. Trock, K. A. Killinger and J. A. Boura Beaumont Health System, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, Michigan, and Urology Center of the Rockies, Fort Collins, Colorado Adv Urol 2014; 2014: 863209. doi: 10.1155/2014/863209.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24987412 Editorial Comment: The idea of a skinecentral nervous systemebladder reflux arc creation in patients with spina bifida was first reported in the American literature in 2005, after animal experimentation.1 Peters et al report their experience in creating such an arc with an intradural lumbar-to-sacral motor route microanastomosis to restore bladder/bowel function in these patients. Three-year data are presented, with 3 cases lost to followup being counted as failures. Of the 10 patients who returned 7 were labeled treatment responders and 9 had discontinued antimuscarinics, “most” of whom still leaked urine. Only 2 of 8 patients with baseline neurogenic detrusor overactivity (NDO) still had NDO. All 3 patients with compliance less than 10 ml/cm H2O had normalized, 7 considered their bowels normal, 5 were continent of stool and 8 said they would undergo the procedure again. Treatment success was defined as voiding with at least 50% efficiency on uroflowmetry, using clean intermittent catheterization once per day, stable renal ultrasound and renal function studies, and no worsening of motor function from baseline. Secondary outcomes included evidence of a new neural pathway to elicit voiding, demonstrable by at least 2 detrusor contractions during the same urodynamic study of at least 10 cc water detrusor pressure while performing cutaneous stimulation of the operative dermatone. Other secondary outcomes were changes in bladder compliance, neurogenic detrusor overactivity, and overall changes in urinary and bowel function on questionnaires. The 3 patients who did not return for followup included 1 with permanent foot drop, and all were considered nonresponders because of a lack of positive response at their 2-year visit. Of the remaining 10 subjects only 4 were able to void at baseline and 8 were voiding at 3 years. Using the definition of treatment success, nerve rerouting was successful in only 7 of the original 13 patients since 1 was voiding with only 47% efficiency. Of the 8 patients who were voiding at 3 years only 4 reported that their stream was strong, and all but 1 used Valsalva to initiate voiding. One scratched the operative dermatone. Of the original cohort 2 of 8 patients with NDO still had this at 3 years. Eight patients from the original cohort had demonstrated reproducible sustained detrusor contractions with cutaneous stimulation at 12 months but only 2 still had reproducible contractions at 3 years. Only 1 patient at 3 years was dry and the remainder had persistent stress incontinence. Five of 10 patients reported at least some improvement on a global response assessment. At 3 years 7 of 10 patients considered their bowels normal (compared to 4 of 13 at baseline), 5 of 10 were continent of stool (compared to 2 of 13 at baseline). There was 1 patient with persistent foot drop. Two patients had suspected cerebrospinal fluid leaks requiring another surgical procedure at 25 and 37 days postoperatively, and 12 of 13 patients had transient lower extremity weakness that resolved by 12 months. Eight patients were able to void at 3 years (compared to 4 of 13 at baseline). It appears that 1 of the original 13 patients was dry at 3 years (the 3 who did not return for followup were nonresponders at their 2-year visit and were properly counted as failing treatment, and thus the persistent use of the number 10 as the denominator in some of the results is a bit confusing). Prior intrauterine closure became an exclusionary condition as the trial progressed, since the 1 patient with foot drop had undergone intrauterine closure and 2 others did not achieve treatment success, and it was felt by the surgeons that there was more scarring, making the surgery more difficult. The clinical significance of not being able to demonstrate a cutaneous-to-bladder reflux arc on urodynamic studies is difficult to understand. At 1 year 8 of 13 patients had a reproducible reflex. By 3 years this was demonstrated in only 2 patients, yet most could void efficiently using a degree of Valsalva. The authors themselves point out certain caveats regarding interpretation, including 1) there was no control series, but the authors pointed out that such controls would be susceptible to the negative
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
effects of growth spurts or tethered cord syndrome, and 2) it is possible, but the authors consider it unlikely, that the outcomes may be related to coincidental cord detethering during the procedure. Finally, the authors point out, and rightly so, that this is a very complex patient population, and absolute normalization of bowel and bladder function is not a realistic goal. They further point out that neurogenic dysfunction can be safely controlled with the use of pharmacological management and intermittent catheterization, along with augmentation and a bowel regimen. They further point out that in underdeveloped countries intermittent catheterization and antimuscarinics are not readily available. They conclude, “Even though more data are needed to fully understand the impact of this procedure, nerve rerouting has the potential to change how patients with neurogenic bladder are managed.” Alan J. Wein, MD, PhD (hon) 1. Xiao CG, Du MX, Li B et al: An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida. J Urol 2005; 173: 2112.
Re: Does Cystocele Repair Improve Overactive Bladder Symptoms? C. S. Fok Department of Urology, University of Minnesota, Minneapolis, Minnesota Curr Bladder Dysfunct Rep 2015; 10: 1e5. doi: 10.1007/s11884-014-0284-1
Abstract available at http://link.springer.com/article/10.1007%2Fs11884-014-0284-1 Editorial Comment: This is a review article regarding the apparent connection between the 2 topics in the title. Although there is no mechanism that is agreed on consistently, there are data to show that overactive bladder symptomatology may be related to anatomical changes in any vaginal compartment. There are no data that correlate prolapse symptoms, degree of prolapse, or any urodynamic test parameters to predict the occurrence or resolution of overactive bladder symptomatology. The author summarizes that anywhere from 50% to 90% of patients with concomitant overactive bladder symptoms and pelvic organ prolapse will show improvement in their overactive bladder symptomatology after prolapse repair. There is no evidence that types of prolapse repair, suture vs mesh use or any other factor regarding the repair is related to the degree of improvement. It is also noted that there have been very few long-term studies to show, in those who do experience improvement, the duration of the improvement and whether the overactive bladder symptoms occur. Alan J. Wein, MD, PhD (hon)
Re: Vaginal Estrogen Use in Postmenopausal Women with Pelvic Floor Disorders: Systematic Review and Practice Guidelines D. D. Rahn, R. M. Ward, T. V. Sanses, C. Carberry, M. M. Mamik, K. V. Meriwether, C. K. Olivera, H. Abed, E. M. Balk and M. Murphy; Society of Gynecologic Surgeons Systematic Review Group Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas Int Urogynecol J 2015; 26: 3e13. doi: 10.1007/s00192-014-2554-z.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25392183 Editorial Comment: This is a report by the Society of Gynecologic Surgeons Systematic Review Group assessing the literature on vaginal estrogen and the management of pelvic floor disorders in postmenopausal women. Of 1,805 abstracts they identify 12 eligible papers. They labeled evidence as generally poor to moderate quality. Their conclusions included 1) vaginal estrogen before pelvic organ prolapse surgery improved the maturation index and increased vaginal epithelial thickness;
133
GERIATRICS
134
2) postoperative vaginal estrogen after a mid urethral sling resulted in decreased frequency and urgency; 3) vaginal estrogen and immediate release oxybutynin were similar in improvement of urinary urgency, frequency and urgency urinary incontinence but oxybutynin had higher rates of adverse events and 4) the addition of vaginal estrogen to immediate or extended release tolterodine did not improve urinary symptoms any more than tolterodine alone. The clinical practice guidelines that the group formulated, presuming no contraindications to vaginal estrogen in postmenopausal women, used a grading system of only 1 (strong) or 2 (weak) and, for the quality of evidence, used a scale of A (high) to D (very low). For women undergoing pelvic reconstructive surgery with a mid urethral sling the group suggests postoperative application of vaginal estrogen to prevent or treat urinary urgency and frequency (grade 2C). For those presenting with symptoms of overactive bladder considering an immediate release oral anticholinergic they suggest either immediate release oral anticholinergics or application of vaginal estrogen (the agent studied being a vaginal estradiol ring; grade 2C). For those presenting with symptoms of stress urinary incontinence without intrinsic sphincter deficiency they suggest application of vaginal estrogen (conjugated estrogens and estradiol creams were studied; grade 2D). They added that for those undergoing pelvic reconstructive surgery with a mid urethral sling vaginal estrogen use postoperatively did not demonstrate an improvement in nocturia (moderate quality evidence), urgency urinary incontinence or urinary tract infection frequency (very low quality evidence). This hopefully will suggest another review by the Cochrane Collaboration group. Alan J. Wein, MD, PhD (hon)
Geriatrics Re: Effect of Medications with Anti-Cholinergic Properties on Cognitive Function, Delirium, Physical Function and Mortality: A Systematic Review C. Fox, T. Smith, I. Maidment, W. Y. Chan, N. Bua, P. K. Myint, M. Boustani, C. S. Kwok, M. Glover, I. Koopmans and N. Campbell School of Medicine and School of Rehabilitation Sciences, University of East Anglia, and Norfolk and Norwich University Hospital, Norwich, Norfolk, Pharmacy, School of Life and Health Sciences, Medicines and Devices in Ageing, Aston Research Centre for Healthy Ageing, Aston University, Birmingham, and School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, United Kingdom, and Indiana University School of Medicine, Indianapolis and Purdue University, West Lafayette, Indiana Age Ageing 2014; 43: 604e615. doi: 10.1093/ageing/afu096.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25038833 Editorial Comment: Careful prescribing practice should be a hallmark of geriatric clinical care. Many drugs can have serious side effects that are often more pronounced in elderly patients compared to younger people. Anticholinergic medications are one such class of medications that tend to have more issues among geriatric patients. Numerous medications commonly prescribed by urologists have anticholinergic properties, including the antimuscarinics used for treatment of overactive bladder and urgency incontinence. The authors describe a structured literature review of the relationship between increased anticholinergic load and changes in cognitive function and other functional parameters in 46 published studies representing 60,944 treated subjects. Increased anticholinergic burden was linked to impairments in cognitive function in 75% of the studies reviewed (p <0.05). Impaired physical function was reported in 5 of 8 studies that examined this parameter (p <0.05). There was a trend toward increased mortality with increased anticholinergic use but no clear relationship with delirium, although the number of studies examining these 2 outcomes was limited. These medications can be beneficial for treatment of urinary symptoms but prescribers should strongly consider possible risks. Overall this study supports the concept that anticholinergic
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25666987 Editorial Comment: Anyone interested in a compact, detailed review of this entire field with superbly crafted illustrations should read this article. Restoration of bladder control using surgical methods of reinnervation was first attempted more than 100 years ago in animal models. The various strategies for bladder reinnervation are described from a historical standpoint and in some detail, and include 1) sacral root repair, both homotopic and heterotopic; 2) transfer of peripheral nerves to sacral roots (primarily intercostal and spinal nerves as donors); 3) transfer of roots to sacral spinal nerves; 4) peripheral nerve transfer (peripheral nerves to pelvic nerves); 5) direct detrusor muscle reinnervation; 6) indirect detrusor muscle reinnervation; 7) artificial somatic to automatic reflex pathway (the so-called Xiao procedure), and 8) functional electrical stimulation, including the FinetechBrindley system. The overriding concept is that the bladder can be functionally reinnervated by nerve branches other than those that normally supply it. The authors caution evaluation of the results of such clinical studies, as they point out that “the patient and the patient’s family all desperately want the surgery to result in permanent improvement in bladder emptying and storage function. Because of this desire, the possibility is considerable that these patients and their families might report exaggerated improvements . [and] similarly, the clinician might overestimate the success.” Clearly sham surgery in humans is not possible, but the authors point out that it is also unethical to promote a surgical procedure that is not proved effective. They propose an ethical possibility, and that is to perform a randomized surgical bladder reinnervation trial in a group of patients who are undergoing current standard of care spinal surgery, such as patients with spina bifida who require a spinal cord untethering procedure. The patients could then be randomized to undergo either a reinnervation nerve transfer such as the Xiao procedure or a sham. Long-term followup evaluation of at least 2 to 3 years should be required. The article is well organized and well referenced, and it makes you wish that you had written it. Alan J. Wein, MD, PhD (hon)
0022-5347/16/1951-0131/0 THE JOURNAL OF UROLOGY® Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.10.073 Vol. 195, 131-140, January 2016 Printed in U.S.A.
www.jurology.com
j
131
132
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
Re: US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience K. M. Peters, H. Gilmer, K. Feber, B. J. Girdler, W. Nantau, G. Trock, K. A. Killinger and J. A. Boura Beaumont Health System, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, Michigan, and Urology Center of the Rockies, Fort Collins, Colorado Adv Urol 2014; 2014: 863209. doi: 10.1155/2014/863209.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24987412 Editorial Comment: The idea of a skinecentral nervous systemebladder reflux arc creation in patients with spina bifida was first reported in the American literature in 2005, after animal experimentation.1 Peters et al report their experience in creating such an arc with an intradural lumbar-to-sacral motor route microanastomosis to restore bladder/bowel function in these patients. Three-year data are presented, with 3 cases lost to followup being counted as failures. Of the 10 patients who returned 7 were labeled treatment responders and 9 had discontinued antimuscarinics, “most” of whom still leaked urine. Only 2 of 8 patients with baseline neurogenic detrusor overactivity (NDO) still had NDO. All 3 patients with compliance less than 10 ml/cm H2O had normalized, 7 considered their bowels normal, 5 were continent of stool and 8 said they would undergo the procedure again. Treatment success was defined as voiding with at least 50% efficiency on uroflowmetry, using clean intermittent catheterization once per day, stable renal ultrasound and renal function studies, and no worsening of motor function from baseline. Secondary outcomes included evidence of a new neural pathway to elicit voiding, demonstrable by at least 2 detrusor contractions during the same urodynamic study of at least 10 cc water detrusor pressure while performing cutaneous stimulation of the operative dermatone. Other secondary outcomes were changes in bladder compliance, neurogenic detrusor overactivity, and overall changes in urinary and bowel function on questionnaires. The 3 patients who did not return for followup included 1 with permanent foot drop, and all were considered nonresponders because of a lack of positive response at their 2-year visit. Of the remaining 10 subjects only 4 were able to void at baseline and 8 were voiding at 3 years. Using the definition of treatment success, nerve rerouting was successful in only 7 of the original 13 patients since 1 was voiding with only 47% efficiency. Of the 8 patients who were voiding at 3 years only 4 reported that their stream was strong, and all but 1 used Valsalva to initiate voiding. One scratched the operative dermatone. Of the original cohort 2 of 8 patients with NDO still had this at 3 years. Eight patients from the original cohort had demonstrated reproducible sustained detrusor contractions with cutaneous stimulation at 12 months but only 2 still had reproducible contractions at 3 years. Only 1 patient at 3 years was dry and the remainder had persistent stress incontinence. Five of 10 patients reported at least some improvement on a global response assessment. At 3 years 7 of 10 patients considered their bowels normal (compared to 4 of 13 at baseline), 5 of 10 were continent of stool (compared to 2 of 13 at baseline). There was 1 patient with persistent foot drop. Two patients had suspected cerebrospinal fluid leaks requiring another surgical procedure at 25 and 37 days postoperatively, and 12 of 13 patients had transient lower extremity weakness that resolved by 12 months. Eight patients were able to void at 3 years (compared to 4 of 13 at baseline). It appears that 1 of the original 13 patients was dry at 3 years (the 3 who did not return for followup were nonresponders at their 2-year visit and were properly counted as failing treatment, and thus the persistent use of the number 10 as the denominator in some of the results is a bit confusing). Prior intrauterine closure became an exclusionary condition as the trial progressed, since the 1 patient with foot drop had undergone intrauterine closure and 2 others did not achieve treatment success, and it was felt by the surgeons that there was more scarring, making the surgery more difficult. The clinical significance of not being able to demonstrate a cutaneous-to-bladder reflux arc on urodynamic studies is difficult to understand. At 1 year 8 of 13 patients had a reproducible reflex. By 3 years this was demonstrated in only 2 patients, yet most could void efficiently using a degree of Valsalva. The authors themselves point out certain caveats regarding interpretation, including 1) there was no control series, but the authors pointed out that such controls would be susceptible to the negative
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
effects of growth spurts or tethered cord syndrome, and 2) it is possible, but the authors consider it unlikely, that the outcomes may be related to coincidental cord detethering during the procedure. Finally, the authors point out, and rightly so, that this is a very complex patient population, and absolute normalization of bowel and bladder function is not a realistic goal. They further point out that neurogenic dysfunction can be safely controlled with the use of pharmacological management and intermittent catheterization, along with augmentation and a bowel regimen. They further point out that in underdeveloped countries intermittent catheterization and antimuscarinics are not readily available. They conclude, “Even though more data are needed to fully understand the impact of this procedure, nerve rerouting has the potential to change how patients with neurogenic bladder are managed.” Alan J. Wein, MD, PhD (hon) 1. Xiao CG, Du MX, Li B et al: An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida. J Urol 2005; 173: 2112.
Re: Does Cystocele Repair Improve Overactive Bladder Symptoms? C. S. Fok Department of Urology, University of Minnesota, Minneapolis, Minnesota Curr Bladder Dysfunct Rep 2015; 10: 1e5. doi: 10.1007/s11884-014-0284-1
Abstract available at http://link.springer.com/article/10.1007%2Fs11884-014-0284-1 Editorial Comment: This is a review article regarding the apparent connection between the 2 topics in the title. Although there is no mechanism that is agreed on consistently, there are data to show that overactive bladder symptomatology may be related to anatomical changes in any vaginal compartment. There are no data that correlate prolapse symptoms, degree of prolapse, or any urodynamic test parameters to predict the occurrence or resolution of overactive bladder symptomatology. The author summarizes that anywhere from 50% to 90% of patients with concomitant overactive bladder symptoms and pelvic organ prolapse will show improvement in their overactive bladder symptomatology after prolapse repair. There is no evidence that types of prolapse repair, suture vs mesh use or any other factor regarding the repair is related to the degree of improvement. It is also noted that there have been very few long-term studies to show, in those who do experience improvement, the duration of the improvement and whether the overactive bladder symptoms occur. Alan J. Wein, MD, PhD (hon)
Re: Vaginal Estrogen Use in Postmenopausal Women with Pelvic Floor Disorders: Systematic Review and Practice Guidelines D. D. Rahn, R. M. Ward, T. V. Sanses, C. Carberry, M. M. Mamik, K. V. Meriwether, C. K. Olivera, H. Abed, E. M. Balk and M. Murphy; Society of Gynecologic Surgeons Systematic Review Group Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas Int Urogynecol J 2015; 26: 3e13. doi: 10.1007/s00192-014-2554-z.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25392183 Editorial Comment: This is a report by the Society of Gynecologic Surgeons Systematic Review Group assessing the literature on vaginal estrogen and the management of pelvic floor disorders in postmenopausal women. Of 1,805 abstracts they identify 12 eligible papers. They labeled evidence as generally poor to moderate quality. Their conclusions included 1) vaginal estrogen before pelvic organ prolapse surgery improved the maturation index and increased vaginal epithelial thickness;
133
GERIATRICS
134
2) postoperative vaginal estrogen after a mid urethral sling resulted in decreased frequency and urgency; 3) vaginal estrogen and immediate release oxybutynin were similar in improvement of urinary urgency, frequency and urgency urinary incontinence but oxybutynin had higher rates of adverse events and 4) the addition of vaginal estrogen to immediate or extended release tolterodine did not improve urinary symptoms any more than tolterodine alone. The clinical practice guidelines that the group formulated, presuming no contraindications to vaginal estrogen in postmenopausal women, used a grading system of only 1 (strong) or 2 (weak) and, for the quality of evidence, used a scale of A (high) to D (very low). For women undergoing pelvic reconstructive surgery with a mid urethral sling the group suggests postoperative application of vaginal estrogen to prevent or treat urinary urgency and frequency (grade 2C). For those presenting with symptoms of overactive bladder considering an immediate release oral anticholinergic they suggest either immediate release oral anticholinergics or application of vaginal estrogen (the agent studied being a vaginal estradiol ring; grade 2C). For those presenting with symptoms of stress urinary incontinence without intrinsic sphincter deficiency they suggest application of vaginal estrogen (conjugated estrogens and estradiol creams were studied; grade 2D). They added that for those undergoing pelvic reconstructive surgery with a mid urethral sling vaginal estrogen use postoperatively did not demonstrate an improvement in nocturia (moderate quality evidence), urgency urinary incontinence or urinary tract infection frequency (very low quality evidence). This hopefully will suggest another review by the Cochrane Collaboration group. Alan J. Wein, MD, PhD (hon)
Geriatrics Re: Effect of Medications with Anti-Cholinergic Properties on Cognitive Function, Delirium, Physical Function and Mortality: A Systematic Review C. Fox, T. Smith, I. Maidment, W. Y. Chan, N. Bua, P. K. Myint, M. Boustani, C. S. Kwok, M. Glover, I. Koopmans and N. Campbell School of Medicine and School of Rehabilitation Sciences, University of East Anglia, and Norfolk and Norwich University Hospital, Norwich, Norfolk, Pharmacy, School of Life and Health Sciences, Medicines and Devices in Ageing, Aston Research Centre for Healthy Ageing, Aston University, Birmingham, and School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, United Kingdom, and Indiana University School of Medicine, Indianapolis and Purdue University, West Lafayette, Indiana Age Ageing 2014; 43: 604e615. doi: 10.1093/ageing/afu096.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25038833 Editorial Comment: Careful prescribing practice should be a hallmark of geriatric clinical care. Many drugs can have serious side effects that are often more pronounced in elderly patients compared to younger people. Anticholinergic medications are one such class of medications that tend to have more issues among geriatric patients. Numerous medications commonly prescribed by urologists have anticholinergic properties, including the antimuscarinics used for treatment of overactive bladder and urgency incontinence. The authors describe a structured literature review of the relationship between increased anticholinergic load and changes in cognitive function and other functional parameters in 46 published studies representing 60,944 treated subjects. Increased anticholinergic burden was linked to impairments in cognitive function in 75% of the studies reviewed (p <0.05). Impaired physical function was reported in 5 of 8 studies that examined this parameter (p <0.05). There was a trend toward increased mortality with increased anticholinergic use but no clear relationship with delirium, although the number of studies examining these 2 outcomes was limited. These medications can be beneficial for treatment of urinary symptoms but prescribers should strongly consider possible risks. Overall this study supports the concept that anticholinergic