Altaf Mangera’s research while affiliated with Sheffield Teaching Hospitals NHS Foundation Trust and other places

Any pathology of the nervous system leading to any changes on the complex interplay between the autonomic and somatic innervation of the lower urinary tract leads to a “neuropathic bladder”. Always, one must remember that the urinary sphincters may also be affected by any pathology and, in these cases, it is not just the bladder which is neuropathic. This chapter covers, the functions of the bladder which switches from involuntary urine storage to voluntary emptying. We discuss the interaction of the autonomic and somatic nervous systems in allowing this and how pathology has a role in affecting this relationship. Due to the vast complexity of the nervous control of the lower urinary tract a large number of pathologies may be implicated. Therefore we apply an approach whereby lower urinary tract behaviour can be classified according to the type of injury and level of injury. Lesions can thus be classified as suprapontine, suprasacral with a distal autonomous cord (complete or incomplete), subsacral (complete or incomplete), peripheral neuropathies and polyneuropathies. Each “type” of injury may be managed according to the dysfunction which is best assessed with a video urodynamic study.

Purpose: Nocturia (waking from sleep at night to void) is a common cause of sleep disruption and associated with increased comorbidity and impaired quality of life. However, its impact on mortality remains unclear. We performed a systematic review and meta-analysis to evaluate the association of nocturia with mortality, both as a prognostic and causal risk factor. Materials and methods: We searched PubMed, Scopus, CINAHL and major conference abstracts up to December 31, 2018. Random effects meta-analyses addressed adjusted relative risks (RR) of mortality for people with nocturia and a meta-regression explored potential determinants of heterogeneity, including risk of bias. We applied the GRADE framework to rate the quality of evidence for nocturia as a prognostic risk factor for mortality and, separately, as a cause of mortality. Results: Of 5230 identified reports, 11 observational studies proved eligible. For the assessment of nocturia, ten studies used symptom questionnaires and one frequency-volume charts. Nocturia was defined as ≥2 episodes/night in six (55%), and as ≥3 episodes/night in five (45%) studies. Pooled estimates demonstrated a risk ratio of 1.27 (95% confidence interval 1.16-1.40; I2=48%; absolute 5-year mortality difference 1.6% and 4.0% in people aged 60 and 75 years, respectively). The pooled estimates of relative risk did not differ significantly across varying age, gender, follow-up time, nocturia case definition, risk of bias, or study region. We rated the quality of evidence for nocturia as a prognostic factor as moderate and as a cause of mortality as very low. Conclusions: Nocturia is probably associated with an approximately 1.3-fold increased risk of death.

Purpose: Although nocturia is associated with various comorbidities, its impact on falls and fractures remains unclear. We performed a systematic review and meta-analysis to evaluate the association between nocturia with falls and fractures, both as a prognostic and causal risk factor. Materials and methods: We searched PubMed, Scopus and CINAHL and abstracts of major urologic meetings up to December 31, 2018. We conducted random effects meta-analyses of adjusted relative risks (RR) of falls and fractures. We applied the GRADE approach to rate the quality of evidence for nocturia as a prognostic and causal factor of falls and fractures. Results: Of 5230 potential reports, nine observational longitudinal studies provided data on the association between nocturia and falls or fractures (1 for both, 4 for falls, 4 for fractures). Pooled estimates demonstrated a risk ratio of 1.20 (95% confidence interval 1.05-1.37; I2=51.7%; annual risk difference 7.5% among the elderly) for association between nocturia and falls and 1.32 (95% confidence interval 0.99-1.76; I2=57.5%; annual risk difference 1.2%) for association between nocturia and fractures. Subgroup analyses showed no significant effect modification by age, gender, follow-up time, nocturia case definition or risk of bias. We rated the quality of evidence for nocturia as a prognostic factor as moderate for falls and low for fractures, and as very low as a cause of falls/fractures. Conclusions: Nocturia is probably associated with an approximately 1.2-fold increased risk of falls and possibly with an approximately 1.3-fold increased risk of fractures.

Background: Botulinum neurotoxin (BotN) is used to treat detrusor overactivity (DO) refractory to medical treatment. Catheterised patients with symptoms of bladder spasm and catheter bypass leakage are challenging to manage and the efficacy of BotN is not established. Objective: To review our experience using intravesical BotN to treat refractory bladder pain and catheter bypass leakage in patients with long-term indwelling catheters. Design, setting, and participants: We carried out a review of data prospectively collected for patients with indwelling urethral or suprapubic catheters receiving BotN for the treatment of bladder spasms and catheter bypass leakage in a UK tertiary centre. An unvalidated structured questionnaire was used to ascertain quality of life (QoL) outcomes. Outcome measurements and statistical analysis: Qualitative data were collected for patient-reported symptoms and QoL. Paired Student t tests were applied for statistical analysis. Results and limitations: Of the 54 catheterised patients who received BotN, 14 (26%) were male and 40 (74%) were female. The mean follow-up was 38mo. Of the patients, 34 (63%) had a neurological aetiology and 94% had experienced failure of medical therapy before BotN administration. The BotN starting dose was 100 or 200U and 17 patients (31%) required dose escalation. All 34 neurogenic and six non-neurogenic patients started on 200U. After treatment, 63% of patients managed their catheter with intermittent drainage and 37% managed on free drainage; 51 patients (94%) reported that their symptoms were controlled and 38% reported being treated for a urinary tract infection following BotN. Patients reported a mean improvement in QoL of 7.7/10 following BotN, while 83% reported a significant reduction in urine leakage (p=0.0001). Conclusions: Outpatient intravesical BotN is safe and efficacious for patients with long-term catheters suffering from bladder pain and catheter bypass leakage. Patient summary: Outpatient administration of intravesical botulinum toxin is a safe and effective treatment for patients with a long-term indwelling catheter with bothersome urine storage symptoms. Attention should be paid to urine microbiology results before treatment to ensure appropriate prophylactic antibiotic treatment to reduce the incidence of urinary tract infections.

Purpose: Neurogenic bladder due to spinal cord injury has significant consequences for patients' health and quality of life. Regular surveillance is required to assess the status of the upper and lower urinary lower urinary tracts and prevent their deterioration. In this review, we examine surveillance techniques in neurogenic bladder, describe common complications of this disease, and address strategies for their management. Methods: This work represents the efforts of SIU-ICUD joint consultation on Urologic Management of the Spinal Cord injury. For this specific topic, a workgroup was formed and comprehensive literature search of English language manuscripts regarding neurogenic bladder management was performed using key words of neurogenic bladder. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for Levels of Evidence (LOEs) and Grades of Recommendation (GORs). Results: At a minimum, patients should undergo an annual history and physical examination, renal functional testing (e.g., serum creatinine), and upper tract imaging (e.g., renal ultrasonography). The existing evidence does not support the use of other modalities, such as cystoscopy or urodynamics, for routine surveillance. Urologic complications in neurogenic bladder patients are common and often more complex than in the general population. Conclusions: There is a shortage of high-quality evidence to support any particular neurogenic bladder surveillance protocol. However, there is consensus regarding certain aspects of regular genitourinary system evaluation in these patients. Proper surveillance allows the clinician to avoid or address common urological complications, and to guide, alter, or maintain appropriate therapeutic regimens for individual patients.

Overactive bladder syndrome (OAB) is a common and highly bothersome chronic symptom complex that has a negative impact upon quality of life. Several investigators have sought to assess objectively the relationship between the symptom complex of OAB and the urodynamic diagnosis of “detrusor overactivity” (DO). This chapter addresses a series of focused clinical questions that are addressed in a systematic fashion, including a comprehensive literature search, a rating of the quality of evidence, and an assessment of ratio of benefit and harm of a given treatment option. The clinical questions are: What is the evidence for the definition of overactive bladder? How does overactive bladder relate to detrusor overactivity? What is the evidence base relating to the use of placebo treatments in overactive bladder? and What is the evidence base relating to the use of botulinum toxin in overactive bladder?

Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. Patient summary: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common.

Background: Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms. Objective: The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention. Design, setting, and participants: A retrospective review of data on patients undergoing AFS at a tertiary referral unit. Surgical procedure: AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD. Measurements: Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC). Results and limitations: A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24-83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery. Conclusions: A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate. Patient summary: A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.