This Month in Adult Urology

Article Outline

• Increased Startle Responses and Interstitial Cystitis
• Cost-Effectiveness of Botulinum Toxin A for Idiopathic Urge Incontinence
• The Adjustable Continence Therapy System for Recurrent Female Stress Urinary Incontinence
• Sexual Function of Overweight and Obese Women With Incontinence
• Renal Sinus Fat Invasion in pT3a Clear Cell Renal Cell Carcinoma
• Metabolic Complications of Androgen Deprivation Therapy for Prostate Cancer
• Copyright

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Increased Startle Responses and Interstitial Cystitis 

Previous work in feline cystitis has suggested increased autonomic activity and enhancement of the central stress network culminating as an increased “startle response” in this animal model of interstitial cystitis. Furthermore, studies suggest overactivity of the hypothalamic and pituitary system in patients with interstitial cystitis. Twiss et al (page 2127) from Los Angeles, California, using a similar paradigm to one that has been used for irritable bowel syndrome and fibromyalgia, demonstrated increased acoustic startle response in 13 female patients with interstitial cystitis compared to healthy controls. The threat was muscle stimulation via electrodes to the area over the lower abdomen. These findings are consistent with those from patients with anxiety disorders, and suggest heightened stress responses. It would be interesting to test a separate group of patients who may respond to threats directed at the body irrespective of type of stress.

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Cost-Effectiveness of Botulinum Toxin A for Idiopathic Urge Incontinence 

Increasing evidence suggests that botulinum toxin A (BoTn-A) may be useful for idiopathic overactive bladder caused by urge urinary incontinence although the data appear more robust for neurogenic detrusor overactivity. Patients appear to respond to this therapy after antimuscarinic medications fail. Although BoTn-A is more expensive, it may be more effective overall with reduced side effects. Thus, when balancing efficacy, side effects and cost between BoTn-A and antimuscarinics, it is unclear which therapy is better. Wu et al (page 2181) from Durham, North Carolina used a Markov decision analysis model to evaluate effectiveness of BoTn-A vs antimuscarinics by quality adjusted life years, assuming a 2-year time frame and 3-month cycles of injections. The authors estimated efficacy and persistence with therapies based on estimates from the literature. They considered a treatment strategy to be cost-effective when the incremental cost-effectiveness ratio was less than $50,000 per quality adjusted life years. Using these assumptions, botulinum toxin was cost-effective despite the increased expense because it was more effective for the treatment of refractory urge incontinence.

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The Adjustable Continence Therapy System for Recurrent Female Stress Urinary Incontinence 

Results from trials outside North America suggest that the adjustable continence therapy system may be useful for the treatment of female stress urinary incontinence. The device compresses the proximal urethra via 2 small balloons percutaneously placed at the ureterovesical junction under fluoroscopy. Injection ports are placed subcutaneously in the labia and gradually filled over several weeks to increase outlet resistance. In this nonrandomized prospective study of the adjustable continence therapy device Aboseif et al (page 2187) analyze 1-year data on 140 cases. Efficacy was measured using a Stamey score improvement of greater than 1, quality of life questionnaires and the Urogenital Distress Inventory. Mean provocative pad weight decreased from 49.6 to 11.2 gm, 52% of patients were dry (less than 2 gm) on pad testing and 80% of patients experienced greater than 50% reduction in pad weight. However, complications occurred in 24.4% of patients, and the device was explanted in 18%. Nonetheless, the authors conclude that the device is simple and relatively safe, and represents a future option for the treatment of stress urinary continence due to severe intrinsic sphincter deficiency.

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Sexual Function of Overweight and Obese Women With Incontinence 

Recent results of the PRIDE (Program to Reduce Incontinence by Diet and Exercise) National Institutes of Health trial revealed that an intensive program to promote weight loss is able to reduce stress urinary incontinence. Huang et al (page 2235) from San Francisco, California evaluated sexual function in 330 overweight or obese women with at least 10 incontinence episodes per week undergoing behavioral therapy (226) or merely attending a structured education program (112). Of these women 223 were sexually active at baseline, more than half reported low sexual desire and a quarter were sexually dissatisfied. More than 50% of the sexually active participants had problems with arousal, orgasm or incontinence during sex. Compared to controls, participants in the behavioral intervention group demonstrated increased sexual activity frequency 6 months after therapy (OR 1.34, 95% CI 0.99 to 1.81, p = 0.06) but no difference in satisfaction, desire or problems. The clinical incontinence severity index was independently associated with baseline change in function. The authors conclude that sexual dysfunction is common in overweight and obese women with incontinence but the severity of this dysfunction is not directly related to the severity of incontinence or obesity. Unfortunately, weight reduction did not improve sexual function relative to controls.

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Renal Sinus Fat Invasion in pT3a Clear Cell Renal Cell Carcinoma 

The recent American Joint Committee on Cancer TNM classification modified the pT3a renal cell carcinoma (RCC) primary tumor category to include sinus fat invasion as an adverse prognostic indicator. Because of controversy regarding the outcome in patients with renal sinus fat invasion, Bertini et al (page 2027) from Milan, Italy retrospectively analyzed the records of 115 patients who underwent partial or radical nephrectomy for clear cell RCC from 1989 to 2006. Ten patients had direct ipsilateral adrenal invasion and were excluded from analysis. Of the remaining patients renal sinus fat invasion affected cancer specific survival in those without nodal or distant metastases. However, renal sinus fat invasion in RCC was not an independent predictor of cancer specific survival of patients with more serious metastatic disease.

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Metabolic Complications of Androgen Deprivation Therapy for Prostate Cancer 

Saylor and Smith (page 1998) from Boston, Massachusetts provide an excellent overview of the adverse events associated with androgen deprivation therapy (ADT). While many urologists are aware of the commonly associated adverse events such as vasomotor flushing and muscle fatigue, other complications such as obesity, diabetes and cardiovascular disease should be the focus of attention. These authors provide a timely review documenting the cumulative effects of treatment with gonadotropin releasing hormone (GnRH) agonists, particularly the increase in obesity associated with sarcopenia and muscle wasting. GnRH agonist therapy also causes significant changes in serum lipids, primarily total cholesterol, triglycerides and high density lipoprotein. The cluster of cardiovascular risk factors called the metabolic syndrome includes a combination of low high density lipoprotein, increased waist circumference, elevated triglycerides, increased fasting glucose and hypertension. Studies indicate that ADT increases cardiovascular risk and decreases insulin sensitivity. Men receiving GnRH agonists are more likely to meet the criteria for metabolic syndrome. Up to a third receiving GnRH therapy have a higher hazard ratio for diabetes. Interestingly, men who receive GnRH agonists are at higher risk for coronary heart disease, myocardial infarction and ventricular arrhythmias. Of particular interest, the risk of coronary heart disease, myocardial infarction and ventricular arrhythmias is not increased for men treated with bilateral orchiectomy, which implies factors beyond mere reduction in serum testosterone as a potential confounder. This article should be read by anyone interested in ADT and by those informing patients of possible adverse effects.