Friday, May 30, 2014

أفضل 10 جامعات عربية لعام 2013

http://www.ibda3world.com/أفضل-10-جامعات-عربية-لعام-2013/

Tuesday, May 27, 2014

priapism

http://www.slideshare.net/atefms/priapism-12491868

Sunday, May 25, 2014

Methods of castration (part 5 final)


5- Orchiectomy
Orchiectomy (also named orchidectomy, and sometimes shortened as orchi) is a surgical procedure to remove one or both testicles (testes). The removal of both testicles specifically can be referred to as a bilateral orchiectomy.

There are three main types of orchiectomy: simple, subcapsular, and inguinal. The first two types are usually done under local or epidural anesthesia, and take about 30 minutes to perform. An inguinal orchiectomy is sometimes done under general anesthesia, and takes between 30 minutes and an hour to complete.
Simple orchiectomy
A simple orchiectomy is commonly performed as part of sex reassignment surgery (SRS) for transgender women, or as palliative treatment for advanced cases of prostate cancer. The patient lies flat on an operating table with the penis taped against the abdomen. After anesthetic has been administered, the surgeon makes an incision in the midpoint of the scrotum and cuts through the underlying tissue. The surgeon removes the testicles and parts of the spermatic cord through the incision. The incision is closed with two layers of sutures and covered with a surgical dressing. If the patient desires, a prosthetic testicle can be inserted before the incision is closed to present an outward appearance of a pre-surgical scrotum.

Subcapsular orchiectomy
A subcapsular orchiectomy is also commonly performed for treatment of prostate cancer. The operation is similar to that of a simple orchiectomy, with the exception that the glandular tissue that surrounds each testicle is removed rather than the entire gland itself. This type of orchiectomy is done primarily to keep the appearance of an ordinary scrotum.

Inguinal orchiectomy
Inguinal orchiectomy (named from the Latin inguin for "groin," and also called radical orchiectomy), is performed when an onset of testicular cancer is suspected, in order to prevent a possible spread of cancer from the spermatic cord into the lymph nodes near the kidneys.
An inguinal orchiectomy can be either unilateral or bilateral. The surgeon makes an incision in the patient's groin area (in contrast to an incision in the scrotum, as is done in both simple and subcapsular orchiectomies). The entire spermatic cord is removed, as well as the testicle(s). A long, non-absorbable suture may be left in the stump of the spermatic cord in case later surgery is deemed necessary.

After the cord and testicle have been removed, the surgeon washes the area with saline solution and closes the various layers of tissues and skin with various types of sutures. The wound is then covered with sterile gauze and bandaged.

The Prostate Health Index: A New Test for the Detection of Prostate Cancer Stacy Loeb, MD, MSc, William J. Catalona, MDDisclosures Ther Adv Urol. 2014;6(2):74-77.


A major focus in urologic research is the identification of new biomarkers with improved specificity for clinically-significant prostate cancer. A promising new test based on prostate-specific antigen (PSA) is called the Prostate Health Index (PHI), which has recently been approved in the United States, Europe and Australia.

PHI is a mathematical formula that combines total PSA, free PSA and [-2] proPSA. PHI is calculated using the following formula: ([-2]proPSA/free PSA) × √PSA. Intuitively حدسي, this formula makes sense, in that men with a higher total PSA and p2PSA with a lower free PSA are more likely to have clinically significant prostate cancer.

PHI also predicts the likelihood of progression during active surveillance, providing another noninvasive modality to potentially select and monitor this patient population. This article reviews the evidence on this new blood test with significant promise for both prostate cancer screening and treatment decision-making.



Although no single marker in isolation has perfect performance characteristics, PHI (Prostate Health Index) is a simple and inexpensive blood test that should be used as part of a multivariable approach to screening. In multiple prospective international trials, this composite measurement has been shown to outperform conventional PSA and free PSA measurements. Unlike PCA3 and TMPRSS2:ERG, PHI is also consistently associated with Gleason score and upgrading during active surveillance. PHI should be considered as part of the standard urologic armamentarium for biopsy decisions, risk stratification and treatment selection.

http://www.medscape.com/viewarticle/822544?nlid=57463_1004

Thursday, May 22, 2014

Methods of castration (part 4)


4- Leuprorelin
Leuprorelin (INN) or leuprolide acetate (USAN) is a GnRH analog. Proper Sequence: Pyr-His-Trp-Ser-Tyr-D-Leu-Leu-Arg-Pro-NHEt (Pyr = L-Pyroglutamyl)
Mode of action
Leuprolide acts as an agonist at pituitary GnRH receptors. By interrupting the normal pulsatile stimulation of, and thus desensitizing, the GnRH receptors, it indirectly downregulates the secretion of gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH), leading to hypogonadism and thus a dramatic reduction in estradiol and testosterone levels in both sexes.

Clinical use
An LH-RH (GnRH) analog, leuprolide may be used in the treatment of hormone-responsive cancers such as prostate cancer or breast cancer, estrogen-dependent conditions (such as endometriosis or uterine fibroids), to treat precocious puberty, and to control ovarian stimulation in In Vitro Fertilization (IVF). It is considered a possible treatment for paraphilias.

Leuprolide has been tested as a treatment for reducing sexual urges in pedophiles and other cases of paraphilia. High doses are sometimes used to chemically castrate sex offenders.

Leuprolide is also under investigation for possible use in the treatment of mild to moderate Alzheimer's disease.

Leuprolide is also used to treat chronic adrenal disease in ferrets.[citation needed] It also used for treatment of steroid abuse.[citation needed]

Leuprolide, along with triptorelin and goserelin, are often used to delay puberty in transgender youth until they are old enough to begin hormone replacement therapy. They are also sometimes used as superior alternatives to anti-androgens like spironolactone and cyproterone acetate for suppressing testosterone production in trans women.

Lupron protocol
A 2005 paper suggested leuprolide as a possible treatment for autism,[9] the hypothetical method of action being the now defunct hypothesis that autism is caused by mercury, with the additional unfounded assumption that mercury binds irreversibly to testosterone and therefore leuprolide can help cure autism by lowering the testosterone levels and thereby mercury levels. However, used on children or adolescents it could cause disastrous and irreversible damage to sexual functioning, and there is no scientifically valid or reliable research to show its effectiveness in treating autism. This use has been termed the "Lupron protocol" and Mark Geier, the proponent of the hypothesis, has frequently been barred from testifying in vaccine-autism related cases on the grounds of not being sufficiently expert in that particular issue and has had his medical license revoked. Medical experts have referred to Geier's claims as "junk science".

Approvals
Lupron Injection (5 mg/ml for daily subcutaneous injection) was first approved by the FDA for treatment of advanced prostate cancer on April 9, 1985.
Lupron Depot (7.5 mg/vial for monthly intramuscular depot injection) was first approved by the FDA for palliative treatment of advanced prostate cancer on January 26, 1989, and subsequently in 22.5 mg/vial and 30 mg/vial for intramuscular depot injection every 3 and 4 months, respectively. 3.75 mg/vial and 11.25 mg/vial dosage forms were subsequently approved for subcutaneous depot injection every month and every 3 months, respectively for treatment of endometriosis or fibroids. 7.5 mg/vial, 11.25 mg/vial, and 15 mg/vial dosage forms were subsequently approved for subcutaneous depot injection for treatment of children with central precocious puberty.
Viadur (72 mg yearly subcutaneous implant) was first approved by the FDA for palliative treatment of advanced prostate cancer on March 6, 2000. Bayer will fulfill orders until current supplies are depleted, expected by the end of April 2008
Eligard (7.5 mg for monthly subcutaneous depot injection) was first approved by the FDA for palliative treatment of advanced prostate cancer on January 24, 2002, and subsequently in 22.5 mg, 30 mg, and 45 mg doses for subcutaneous depot injection every 3, 4, and 6 months, respectively.
Leupromer® 7.5 ( 7.5 mg, One month depot for subcutaneous injection) is the second In-situ forming injectable drug in the world. It is used for palliative treatment of advanced prostate cancer, endometriosis and fibroids. It was approved by The Ministry of Health and Medical Education Of Iran.

Leuprolide acetate is marketed by Bayer AG under the brand name Viadur, by Sanofi-Aventis under the brand name Eligard, and by TAP Pharmaceuticals (1985–2008), by Varian Darou Pajooh under the brand name Leupromer and Abbott Laboratories (2008-current) under the brand name Lupron. It is available as a slow-release implant or subcutaneous/intramuscular injection.

In the UK and Ireland, leuprorelin is marketed by Takeda UK as Prostap SR (one-month injection) and Prostap 3 (three-month injection).

Methods of castration (part 3)


3- Goserelin
Goserelin acetate (Zoladex, AstraZeneca) is an injectable gonadotropin releasing hormone superagonist (GnRH agonist), also known as a luteinizing hormone releasing hormone (LHRH) agonist. Structurally, it is a decapeptide. Goserelin acetate is used to suppress production of the sex hormones (testosterone and estrogen), particularly in the treatment of breast and prostate cancer.

Goserelin acetate stimulates the production of the sex hormones testosterone and estrogen in a non-pulsatile (non-physiological) manner. This causes the disruption of the endogenous hormonal feedback systems, resulting in the down-regulation of testosterone and estrogen production.

Zoladex was approved by the U.S. Food and Drug Administration in 1989 for treatment of prostate cancer.

Pharmacokinetics
Goserelin is a synthetic analogue of a naturally occurring luteinising-hormone releasing hormone (LHRH). Bioavailability is almost complete. Goserelin is poorly protein bound and has a serum elimination half-life of two to four hours in patients with normal renal function. The half-life increases with patients with impaired renal function. There is no significant change in pharmacokinetics in subjects with hepatic failure. After administration, peak serum concentrations are reached in about two hours. It rapidly binds to the LHRH receptor cells in the pituitary gland thus leading to an initial increase in production of luteinizing hormone and thus leading to an initial increase in the production of corresponding sex hormones. This initial flare may be treated by co-prescribing/co-administering Casodex (Bicalutamide) or similar medication. Eventually, after a period of about 14–21 days, production of LH is greatly reduced due to receptor downregulation, and sex hormones are generally reduced to castrate levels.

Indications
Goserelin Acetate is used to treat hormone-sensitive cancers of the breast (in pre- and peri- menopausal women) and prostate, and some benign gynaecological disorders (endometriosis, uterine fibroids and endometrial thinning). In addition, goserelin is used in assisted reproduction and in the treatment of precocious puberty. It may also be used in the treatment of male-to-female transsexuals and is favoured above other anti-androgens in some countries, such as the UK. It is available as a 1-month depot and a long-acting 3-month depot.

Side effects
Goserelin Acetate may cause a temporary increase in bone pain and symptoms of prostatic cancer during the first few weeks of treatment. This is known as the tumour flare effect, and is the result of an initial increase in luteinizing hormone production, before the receptors are desensitised and hormonal production is inhibited. The symptoms will disappear, with hormonal inhibition. It is therefore advisable to co-treat with an antiandrogen during the first 2–3 weeks of Gosrelin treatment, particularly in patients with pre-existing bone symptoms. Goserelin may cause bone pain, hot flushes, headache, stomach upset, depression, difficulty urinating (isolated cases), weight gain, swelling and tenderness of breasts (infrequent), decreased erections and reduced sexual desire. Bone pain can be managed symptomatically, and erectile dysfunction can be treated by Levitra (Vardenafil) or other similar oral therapies.





Methods of castration (part 2)


2- Buserelin

Buserelin is a Gonadotropin-releasing hormone agonist (GnRH agonist). The drug's effects are dependent on the frequency and time course of administration. GnRH is released in a pulsatile fashion in the postpubertal adult. Initial interaction of any GnRH agonist, such as buserelin, with the GnRH receptor induces release of FSH and LH by gonadotrophes. Long-term exposure to constant levels of buserelin, rather than endogenous pulses, leads to downregulation of the GnRH receptors and subsequent suppression of the pituitary release of LH and FSH.

Like other GnRH agonists, buserelin may be used in the treatment of hormone-responsive cancers such as prostate cancer or breast cancer, estrogen-dependent conditions (such as endometriosis or uterine fibroids), and in assisted reproduction.

It is normally delivered via a nasal spray, but is also available as an injection.

Buserelin acetate is marketed by Sanofi-Aventis under the brand name Suprefact and a generic form of Buserelin is now produced by CinnaGen under the brand name CinnaFact.

Buserelin is also marketed under the brand name Metrelef. Metrelef is approved to treat patients with endometriosis by suppression of ovarian hormone production. In ovulation induction Metrelef is used as a pituitary blockade as an adjunct to gonadotrophin administration.

Methods of castration (part 1)


1- Triptorelin
Triptorelin, a decapeptide (pGlu-His-Trp-Ser-Tyr-D-Trp-Leu-Arg-Pro-Gly-NH2), is a gonadotropin-releasing hormone agonist (GnRH agonist) used as the acetate or pamoate salts. By causing constant stimulation of the pituitary, it decreases pituitary secretion of gonadotropins luteinizing hormone (LH) and follicle stimulating hormone (FSH). Like other GnRH agonists, triptorelin may be used in the treatment of hormone-responsive cancers such as prostate cancer or breast cancer, precocious puberty, estrogen-dependent conditions (such as endometriosis or uterine fibroids), and in assisted reproduction.
Triptorelin is marketed under the brand names Decapeptyl (Ipsen) and Diphereline and Gonapeptyl (Ferring Pharmaceuticals).
In the United States, it is sold by Watson as Trelstar.
In Iran Triptorelin is marketed under the brand name Variopeptyl (Varian Darou Pajooh).

During the treatment of prostate cancer it does cause a surge of testosterone (an initial uplevel of testosterone levels), known as a flare effect. In men a reduction of serum testosterone levels into the range normally seen after surgical castration occurs approximately two to four weeks after initiation of therapy. In contrast, gonadotropin-releasing hormone antagonists do not cause a surge, but a sudden reduction of testosterone levels.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 13)


References
http://journals.lww.com/greenjournal/Fulltext/2014/06000/Committee_Opinion_No__603___Evaluation_of.52.aspx#P22

1. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al.. Prevalence of symptomatic pelvic floor disorders in US women. Pelvic Floor Disorders Network. JAMA 2008;300:1311–6.
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2. Fultz NH, Burgio K, Diokno AC, Kinchen KS, Obenchain R, Bump RC. Burden of stress urinary incontinence for community-dwelling women. Am J Obstet Gynecol 2003;189:1275–82.
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3. Urinary incontinence in women. ACOG Practice Bulletin No. 63. American College of Obstetricians and Gynecolo-gists; Obstet Gynecol 2005;105:1533–45.
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4. Food and Drug Administration. Urogynecologic surgical mesh: update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse. Silver Spring (MD): FDA; 2011. Available at: http://www.fda.gov/downloads/medicaldevices/safety/alertsandnotices/UCM262760.pdf. Retrieved January 14, 2013.
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5. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al.. An International Urogynecological Associa-tion (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International Urogynecological Association. International Continence Society. Neurourol Urodyn 2010;29:4–20.
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6. Toozs-Hobson P, Freeman R, Barber M, Maher C, Haylen B, Athanasiou S, et al.. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse. Int Uro-gynecol J 2012;23:527–35.
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7. Pelvic organ prolapse. ACOG Practice Bulletin No. 85. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:717–29.
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8. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al.. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.
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9. Visco AG, Brubaker L, Nygaard I, Richter HE, Cundiff G, Fine P, et al.. The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: the Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial. Pelvic Floor Disorders Network. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:607–14.
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10. Farrell SA, Epp A, Flood C, Lajoie F, MacMillan B, Mainprize T, et al.. The evaluation of stress incontinence prior to primary surgery. Urogynaecology Committee, Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can 2003;25:313–24.
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11. Nager CW, Brubaker L, Litman HJ, Zyczynski HM, Varner RE, Amundsen C, et al.. A randomized trial of urodynamic testing before stress-incontinence surgery. Urinary Incontinence Treatment Network. N Engl J Med 2012;366:1987–97.
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12. Nager CW. The urethra is a reliable witness: simplifying the diagnosis of stress urinary incontinence. Int Urogynecol J 2012;23:1649–51.
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13. Richter HE, Litman HJ, Lukacz ES, Sirls LT, Rickey L, Norton P, et al.. Demographic and clinical predictors of treatment failure one year after midurethral sling surgery. Urinary Incontinence Treatment Network. Obstet Gynecol 2011;117:913–21.
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14. Crystle CD, Charme LS, Copeland WE. Q-tip test in stress urinary incontinence. Obstet Gynecol 1971;38:313–5.
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15. Mattison ME, Simsiman AJ, Menefee SA. Can urethral mobility be assessed using the pelvic organ prolapse quantification system? An analysis of the correlation between point Aa and Q-tip angle in varying stages of prolapse. Urology 2006;68:1005–8.
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16. Dalpiaz O, Curti P. Role of perineal ultrasound in the evaluation of urinary stress incontinence and pelvic organ prolapse: a systematic review. Neurourol Urodyn 2006;25:301–6; discussion 307.
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17. Dietz HP, Wilson PD. The ‘iris effect’: how two-dimensional and three-dimensional ultrasound can help us understand anti-incontinence procedures. Ultrasound Obstet Gynecol 2004;23:267–71.
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© 2014 by The American College of Obstetricians and Gynecologists.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 12)


Conclusions and Recommendations
Stress urinary incontinence is common in women, and obstetrician–gynecologists play an important role in its diagnosis and treatment. The College and the American Urogynecologic Society recommend performance of the following basic six-step evaluation of a patient with symptoms of uncomplicated SUI before primary surgical repair with a midurethral sling: 1. History 2. Urinalysis 3. Physical examination with an assessment for POP 4. Cough stress test 5. Assessment of urethral mobility 6. Measurement of postvoid residual urine volumeFor women with uncomplicated SUI in whom conservative treatment has failed and who desire midurethral sling surgery, evidence indicates that the performance of preoperative multichannel urodynamic testing versus a basic evaluation does not affect treatment outcomes (11). However, women with complicated SUI may benefit from additional diagnostic evaluation with multichannel urodynamic testing, particularly before surgical treatment. In these women, the results of the basic six-step evaluation and clinical judgment should guide the decision to perform preoperative multichannel urodynamictesting.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 11)


6- Postvoid Residual Urine Volume
In the Value of Urodynamic Evaluation trial, only women with a postvoid residual urine volume of less than 150 mL were included in the study as meeting the a priori definition of uncomplicated SUI (11). The presence of an elevated postvoid residual urine volume can indicate a bladder-emptying abnormality or incontinence associated with chronic urinary retention (previously referred to as overflow incontinence). An elevated postvoid residual urine volume in the absence of POP is uncommon and should trigger an evaluation of the bladder-emptying mechanism, usually with a pressure-flow urodynamic study.

Multichannel Urodynamic Testing
Preoperative multichannel urodynamic testing is not necessary before planning primary anti-incontinence surgery in women with uncomplicated SUI, as indicated by observed urinary leakage from the urethra by provocative stress measures, a normal urinalysis result (without urinary tract infection), no POP beyond the hymen, and a normal postvoid residual urine volume. Randomized controlled trial results have demonstrated that in women with uncomplicated SUI, outcomes 1 year after midurethral sling surgery were the same for those who had a basic office assessment performed by trained pelvic floor health care providers compared with those who had a preoperative evaluation that included urodynamic test-ing (11). However, women who have complicated SUI (Table 1) may benefit from multichannel urodynamic testing and other diagnostic tests before initiation of treatment, especially surgery. Determination of the need for additional diagnostic testing before surgery should be based on clinical judgment after completion of the basic UI evaluation outlined in this document. Clinical judgment should guide the health care provider’s decision to perform preoperative multichannel urodynamic testing or to refer the patient to a specialist with appropriate training and experience in female pelvic medicine and reconstructive surgery.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 10)


5- Assessment of Urethral Mobility
Anti-incontinence surgery is more successful in women with urethral mobility, defined as a 30 degree or greater displacement from the horizontal when the patient is in a supine lithotomy position and straining. The presence of urethral mobility indicates uncomplicated SUI. Lack of ureth-ral mobility is associated with a 1.9-fold increase in the failure rate of midurethral sling treatment of SUI (13). The cotton swab test has been the traditional assessment of urethral mobility (14), but other methods of evaluating urethral mobility include measurement of point Aa of the POP Quantification system, visualization, palpation, and ultrasonography (15–17). Patients who lack urethral mobility may be better candidates for urethral bulking agents rather than sling or retropubic anti-incontinence procedures.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 9)


4- Demonstration of Stress Incontinence: Cough Stress Test
Stress urinary incontinence should be objectively demonstrated before any anti-incontinence surgery is performed (10–12). Visualization of fluid loss from the urethra simultaneous with a cough is diagnostic of SUI. Delayed fluid loss is considered a negative cough stress test result and suggests cough-induced detrusor overactivity. The cough stress test can be performed with the patient in the supine position during the physical examination. However, if urine leakage is not observed, the cough stress test needs to be repeated with the patient standing and with a full bladder (or a minimum bladder volume of 300 mL) to maximize test sensitivity. Health care providers often ask patients to come to the office with a full bladder during an initial evaluation so that the cough stress test can be performed before bladder emptying (12).To perform the cough stress test in the standing position, the patient stands near the examination table with one foot on the table step. The health care provider then bends and separates the labia to visualize the urethral meatus. The patient is then asked to cough while the health care provider directly visualizes the urethra. If no leakage is observed despite patient symptoms of SUI, the health care provider needs to ensure that the patient had a full bladder by measurement of voided urine volume and postvoid residual urine volume by catheterization or bladder ultrasonography. The health care provider may need to retrograde fill the bladder until the patient feels bladder fullness or is holding at least 300 mL of fluid and then repeat the cough stress test. If the standing cough stress test result remains negative despite patient symptoms of SUI, then multichannel urodynamic testing is recommended.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 8)


3- Physical Examination
The primary purpose of the physical examination is to exclude confounding or contributing factors to the incontinence or its management.
A urethral diverticulum (an out-pouching of the urethral lumen) can produce incontinence or postvoid dribbling. Occasionally, vaginal discharge can be confused with urinary incontinence. Extraurethral incontinence, caused by a fistula or ectopic ureter, is rare but can be seen on examination. A lack of such physical findings indicates the patient may have uncomplicated SUI. Evidence of pelvic organ prolapse (POP) beyond the hymen is consistent with complicated SUI because the prolapse can produce a relative obstruction of the urethra that can impair bladder emptying. Therefore, it is recommended that all pelvic support compartments (anterior, posterior, and apical) be assessed (7, 8). Pelvic organ prolapse can mask or reduce the severity of SUI symptoms; this is referred to as occult, potential, masked, or hidden SUI. When POP is reduced with a nonobstructing pessary or large cotton swabs, SUI may become apparent or worsen (9). If no POP is found beyond the hymen, then the patient’s SUI remains uncomplicated.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 7)


2- Urinalysis
Urinary tract infections should be identified using urinalysis and treated before initiating further investigation or therapeutic intervention for UI. If the urinalysis result is negative, the patient’s condition is still consistent with uncomplicated SUI.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 6)


1- History
The purpose of history taking is to determine the type of urinary incontinence (UI) that is bothersome to the patient.
Urinary incontinence is commonly classified as stress, urge, postural, continuous (or total), insensible (spontaneous), coital, or incontinence associated with chronic urinary retention (previously referred to as overflow incontinence); nocturnal enuresis; or some combination thereof (5, 6).
The history should include questions about the type of incontinence (eg, stress, urge, mixed), precipitating events, and frequency of occurrence, severity, pad use, and effect of symptoms on activities of daily living.
Questions should be asked to assess symptoms related to bladder storage and emptying functions. Storage symptoms include frequency, nocturia, urgency, and incontinence. Emptying or voiding symptoms include hesitancy, slow stream, intermittency, straining to void, spraying of urinary stream, feeling of incomplete emptying, need to immediately revoid, post micturition leakage, position-dependent micturition, and dysuria. Health care providers can use validated questionnaires to evaluate bother, severity, and the relative contribution of urge UI and SUI symptoms (Box 1). Patients with uncomplicated SUI will have classic symptoms of leakage on effort or physical exertion. In contrast, inability to reach the toilet that is associated with urgency indicates the presence of urge UI.

Box 1 Examples of Validated Urinary Incontinence Questionnaires
* Urogenital Distress Inventory (UDI)*
* Incontinence Impact Questionnaire (IIQ)*
* Questionnaire for Urinary Incontinence Diagnosis (QUID)†
* Incontinence-Quality of Life Questionnaire (I-QoL)‡
* Incontinence Severity Index (ISI)§
* International Consultation on Incontinence Questionnaire (ICIQ)‖
*Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3:291–306 and Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995;14:131–9.
†Bradley CS, Rahn DD, Nygaard IE, Barber MD, Nager CW, Kenton KS, et al. The questionnaire for urinary incontinence diagnosis (QUID): validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence. Neurourol Urodyn 2010;29:727–34.
‡Brown JS, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet Gynecol 1999;94:66–70.
§Sandvik H, Seim A, Vanvik A, Hunskaar S. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Urodyn 2000; 19:137–45.‖
Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23:322–30.

Negative responses to queries regarding symptoms of predominant urgency, incomplete emptying, incontinence associated with chronic urinary retention (previously referred to as overflow incontinence), functional impairment, continuous leakage, and incomplete emptying are consistent with uncomplicated SUI (Table 1). Absence of cognitive impairment typically rules out a functional component to the incontinence, and a lack of continuous leakage in women with recent pelvic surgery or radiation exposure points away from the presence of a fistula.

After the urologic history, thorough medical and neurologic histories should be obtained. Certain conditions, such as diabetes and neurologic disorders, can cause UI. In addition, a complete list of the patient’s medications (including nonprescription medications) should be obtained to determine whether individual drugs may be influencing the function of the bladder or urethra, which leads to UI or voiding difficulties (3). Agents that can affect lower urinary tract function include diuretics, caffeine, alcohol, narcotic analgesics, anticholinergic drugs, antihistamines, psychotropic drugs, alpha-adrenergicblockers, alpha-adrenergic agonists, and calcium-channel blockers. Surgical, gynecologic, and obstetric histories also should be elicited. Findings on history taking that are consistent with a diagnosis of uncomplicated SUI are listed in Table 1. Physical examination and office tests are needed to confirm the uncomplicated SUI diagnosis (see following sections).




Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 5)


Basic Evaluation of Stress Urinary Incontinence
When women are evaluated for SUI, counseling about treatment should begin with conservative options. The minimum evaluation before primary mid-urethral sling surgery in women with symptoms of SUI includes the following six steps: 1) history, 2) urinalysis, 3) physical examination, 4) demonstration of stress incontinence, 5) assessment of urethral mobility, and 6) measurement of postvoid residual urine volume.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 4)


Treatment options for SUI range from conservative to surgical. Conservative options include pelvic muscle exercises (with or without physical therapy), behavioral modification, continence-support pessaries, and urethral inserts (3). In 2010, approximately 260,000 women in the United States underwent surgical treatment of SUI (4).
Surgical treatment options include anti-incontinence procedures, such as retropubic urethropexies, autologous fascial slings, urethral bulking agents, and synthetic midurethral slings. An evaluation of symptoms of SUI needs to be completed before performing surgery. In this joint document, the American College of Obstetricians and Gynecologists (the College) and the American Urogynecologic Society provide recommendations for the basic evaluation of a patient with symptoms of uncomplicated SUI (Table 1) before primary surgical repair with a midurethral sling.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 3)


Stress urinary incontinence (SUI) is a condition of involuntary loss of urine on effort, physical exertion, sneezing, or coughing that is often bothersome to the patient and frequently affects quality of life. It is estimated to affect 15.7% of adult women (1). Among women with SUI, 77.5% report their symptoms to be bothersome, and of this group 28.8% report their symptoms to be moderately to extremely bothersome; the degree of bother is associated with the severity of SUI (2).

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 2)


Abstract
ABSTRACT: Stress urinary incontinence (SUI) is a condition of involuntary loss of urine on effort, physical exertion, sneezing, or coughing that is often bothersome to the patient and frequently affects quality of life. When women are evaluated for SUI, counseling about treatment should begin with conservative options. The minimum evaluation before primary midurethral sling surgery in women with symptoms of SUI includes the following six steps: 1) history, 2) urinalysis, 3) physical examination, 4) demonstration of stress incontinence, 5) assessment of urethral mobility, and 6) measurement of postvoid residual urine volume. For women with uncomplicated SUI in whom conservative treatment has failed and who desire midurethral sling surgery, evidence indicates that the performance of preoperative multichannel urodynamic testing versus a basic evaluation does not affect treatment outcomes. However, women who have complicated SUI may benefit from multichannel urodynamic testing and other diagnostic tests before initiation of treatment, especially surgery. Clinical judgment should guide the health care provider’s decision to perform preoperative multichannel urodynamic testing or to refer to a specialist with appropriate training and experience in female pelvic medicine and reconstructive surgery.

Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment (part 1)


This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Published concurrently in the June 2014 issue of Female Pelvic Medicine & Reconstructive Surgery
Copyright June 2014 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.
Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. Committee Opinion No. 603. The American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1403–7.

Stress Urinary Incontinence: ‏New ACOG Guidelines Laurie Barclay, MD May 21, 2014


The American College of Obstetricians and Gynecologists has issued first-time guidelines regarding the evaluation of uncomplicated stress urinary incontinence (SUI) before surgical treatment in women.

"[SUI] is a condition of involuntary loss of urine on effort, physical exertion, sneezing, or coughing that is often bothersome to the patient and frequently affects quality of life," the committee writes in an opinion published in the June issue of Obstetrics & Gynecology. "It is estimated to affect 15.7% of adult women. Among women with SUI, 77.5% report their symptoms to be bothersome, and of this group 28.8% report their symptoms to be moderately to extremely bothersome; the degree of bother is associated with the severity of SUI."

Conservative treatment options for SUI include pelvic muscle exercises prescribed alone or with physical therapy, behavioral modification, continence-support pessaries, and urethral inserts. Surgical options to treat incontinence include retropubic urethropexies, autologous fascial slings, urethral bulking agents, and synthetic midurethral slings.

Counseling regarding treatment should first highlight conservative options, the authors emphasize. Before performing primary midurethral sling surgery in women with symptoms of SUI, clinicians should evaluate patients with a minimum of 6 steps:

Obtain history, including urologic history, thorough medical and neurologic histories, and medications, including nonprescription medications.

Perform urinalysis to exclude urinary tract infection.

Perform a physical examination to exclude confounding or contributing factors. These may include urethral diverticulum, vaginal discharge, or extraurethral incontinence. Pelvic organ prolapse is a form of complicated SUI because the prolapse can cause a relative obstruction of the urethra, thereby hindering bladder emptying.

Demonstrate stress incontinence using the cough test.

Evaluate urethral mobility using the cotton swab test, pelvic organ prolapse quantification system, visualization, palpation, or ultrasonography. Antiincontinence surgery is more successful in women with urethral mobility, which indicates uncomplicated SUI and is defined as at least a 30 degree displacement from the horizontal when the patient is in a supine lithotomy position and straining.

Measure postvoid residual urine volume. In women with uncomplicated SUI, this is less than 150 mL. Elevated postvoid residual urine volume may indicate a bladder-emptying abnormality or incontinence associated with chronic urinary retention.

Adding preoperative multichannel urodynamic testing to this basic evaluation does not affect treatment outcomes for women with uncomplicated SUI who have not responded to conservative treatment and who wish to undergo midurethral sling surgery, according to available evidence. However, multichannel urodynamic testing and other diagnostic tests before surgery or initiation of other treatment may benefit women with complicated SUI.

"Clinical judgment should guide the health care provider's decision to perform preoperative multichannel urodynamic testing or to refer to a specialist with appropriate training and experience in female pelvic medicine and reconstructive surgery," the committee writes.

Obstet Gynecol. 2014;123:1403-1407.

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