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By Z. Lisk. Oberlin College. 2019.

Fibroepithelial polyps may present as interlabial masses and may lead to bleeding or dysuria when located in the urethral meatus (Figure 114 cheap sarafem 10mg overnight delivery. However discount sarafem 20 mg visa, urologists and gynecologists must be familiar with the more common disorders of sexual differentiation whereby gender assignment and rearing is along female lines sarafem 20 mg visa. The most common etiology is congenital adrenal hyperplasia (21-hydroxylase deficiency in >90%) 10 mg sarafem visa. This autosomal-recessive disorder is among the most common heritable metabolic disorders [37]. The absence of 21-hydroxylase leads to the overproduction of androgens and results in a wide spectrum of genital abnormalities, ranging from mild masculinization of the clitoris (clitoromegaly) to complete masculinization. The labioscrotal folds are often rugated and hyperpigmented, giving the physical appearance of severe hypospadias with cryptorchidism. After the diagnosis is established, surgical treatment is individually tailored; feminizing genitoplasty entails reduction clitoroplasty, vaginoplasty, and urogenital mobilization [38,39]. These patients generally require lifelong glucocorticoid (hydrocortisone) and mineralocorticoid (9-alpha-fludrocortisone) supplementation [40]. This diagnosis should be suspected in all girls with inguinal hernias; the hernia sacs may contain testes. The diagnosis should also be considered in adolescent girls with normal development 1703 and primary amenorrhea [36]. The availability of estrogen-replacement therapy allows for the option of early gonad removal at the time of diagnosis that also takes care of the associated hernia, psychological problems with the presence of testes, and the malignancy risk. Estrogen must be replaced at puberty in girls who have undergone prepubertal orchiectomy, which is the standard of care due to risk of malignancy. Vaginal Agenesis and the Mayer–Rokitansky Syndrome Agenesis of the vagina in genetic females (Figure 114. Most patients present in adolescence with amenorrhea or pain, but this condition may also present in young girls with urinary tract infection or hydrocolpos. Genital defects range from vaginal agenesis alone to agenesis of the uterus and fallopian tubes. In some patients, stress urinary incontinence may result after having urethral intercourse. Treatment of the Mayer–Rokitansky syndrome (vaginal agenesis and solitary kidney) may include progressive vaginal dilation, vaginoplasty, or neovaginal reconstruction with bowel. Most simply, the patient can self-dilate with progressively larger vaginal dilators. Alternatively, an olive-shaped dilator or balloon can be (laparoscopically) placed into the vaginal dimple through the retropubic space. Upward traction is progressively applied via a pulley mechanism attached to the abdominal wall [42,43]. Alternatively, skin can be grafted into the vaginal space [44], or sigmoid colon can be used in vaginal replacement [45] (Figure 114. Longterm outcomes of patients undergoing creation of bowel neovagina indicate it is a durable and functionally desirable reconstructive option [46]. The current success in reconstruction of the lower urinary tract reflects improved understanding of the physiological principles involved in bladder and urethral function [47–52]. Spontaneous voiding can occasionally be achieved with an abnormal lower urinary tract, provided that the pressure gradient between the bladder and distal urethra is low. It follows, then, that even in cases where the bladder is replaced in part (intestinal cystoplasty) or entirely (neobladder), patients may still be able to empty their bladders satisfactorily. Since the advent of injectable urethral bulking agents, many patients with sphincteric incontinence owing to various causes have benefitted from antegrade and retrograde bladder neck bulking [55]. Continent reconstruction of the lower urinary tract is often desired in the face of congenital or acquired anomalies of both the outlet and bladder. The early work of Hendren, Mitrofanoff, and others has led to surgical approaches that produce both better reservoir function and a continent outlet [56]. Continent urinary diversion encompasses three interrelated but independently functioning components. These include a channel by which urine is conducted to the skin, a reservoir or pouch, and a mechanism by which continence is achieved [57]. The flap valve principle for continence dictates that a portion of the continence channel be fixed on the inner wall of the reservoir. This is the same principle by which ureteral tunneling in the bladder muscle prevents reflux during voiding. In general, a 5:1 length-to-diameter ratio of the continence structure is required. The Mitrofanoff principle of continent reconstruction describes a supple catheterizable structure (ureter, appendix, etc. The most popular form of flap valve construction for urinary continence is the use of appendix implanted into the bladder or reservoir (appendicovesicostomy). Assurance of complete bladder emptying is essential, as this type of continence channel is very effective in its ability to withstand elevated intraluminal pressures. In the noncompliant patient, pouch rupture, or upper tract injury may result from failure to empty the reservoir regularly. Urinary Tract Reconstruction and Pregnancy Future pregnancy must be kept in mind when reconstructing the genitourinary tract. Pregnancy may be complicated and requires care by both the obstetrician and urologist. Neobladder reconstruction has a good outcome, but chronic bacteriuria is frequent and occasionally requires an indwelling catheter in the third trimester [59]. Similarly, when suprapubic catheterizable continent stomas have been constructed, indwelling catheterization through the stoma during the third trimester may be required to avoid recurrent urinary tract infections from status [60]. Successful pregnancies and deliveries have been reported after both continent and loop urinary diversions [61–64]. The mode of delivery should be guided by obstetric indications, although vaginal delivery has been successful in the majority of cases. Alternatively, if the bladder neck has been reconstructed, it is usually advisable for delivery to be by cesarean section to avoid damage to the bladder neck reconstruction. The urologist should be available to the obstetric team for consultation if cesarean section is deemed necessary, especially if a bladder augmentation with bowel has been carried out, in order to avoid injury to the vascular pedicle to the bowel segment. The proximal appendix may be brought out to the umbilicus for clean intermittent catheterization (b). Same patient 2 years after appendicovesicostomy performing self-catheterization (c). Combination of the enuresis alarm and desmopressin: Second line treatment for nocturnal enuresis. Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. The standardization of terminology of lower urinary tract function in children and adolescents: Report from the Standardisation Committee of the International Children’s Continence Society. The use of botulinum toxin A injection for the management of external sphincter dyssynergia in neurologically normal children. The modern staged repair of bladder exstrophy in the female: A contemporary series.

Maceration can be used to corroborate intrauterine fetal death and estimate an interval between demise and delivery discount sarafem 10mg otc. This child was mildly to moderately decomposed with bloating and separation of tissue planes generic sarafem 20 mg with visa. The brain material was squeezed from the cranium through the neck following compression of the head by the compactor 10 mg sarafem with visa. When the initial Y-shaped autopsy incision was made to the skin of the trunk sarafem 10 mg generic, brain material leaked from the chest region (arrow). Children born via vaginal delivery often have scalp hemorrhages, and it was not possible to characterize the skull fractures as antemortem. Tis is in contrast to a sharp force injury, and scraping your knee, or very long, like being dragged which cuts and separates the tissue as it penetrates. It is ofen possible to determine the direction Te extent of injury resulting from trauma is a bal- of impact. Layers of skin are scraped away and bead up at ance between the amounts of force applied, the surface the margin where the contact to the wound last occurred. Antemortem abra- smaller the area, and shorter the duration, the greater sions, those that occur during life, are typically red the injury will be. Taking into account that force = to brown and will eventually form a scab with dried mass × acceleration and acceleration = velocity ÷ time, blood. Postmortem abrasions are yellow in non-lividity- if time decreases and velocity remains constant, accel- dependent areas. If acceleration increases and the with blood pressure to produce hemorrhage and a red to mass remains constant, force increases. A postmortem scrape in a lividity- time means increased force and increased damage. Te dependent region will appear red and may be difcult to sharper or smaller the surface area, the less force is diferentiate from an antemortem injury. Blunt objects have a relatively large surface area diferences regarding timing of the injury can lead to in contrast to sharp objects, where the cutting edge has diferent conclusions. It takes much less force that an injury occurred during resuscitative eforts in to penetrate the skin with an ice pick than with the end the hospital, or the body was dropped from the stretcher of a baseball bat. Some other arguments may include: he shoes, pipes, bricks, bats, hammers, roadways, side- was dead already when the second car hit him, the other walks, cars, trains, airplanes, walls, etc. Classifcations perpetrator shot the body afer he was dead, the child of blunt-force injuries to skin include abrasions, contu- had no injuries before entering the hospital, etc. Tese may occur separately but Abrasions may also change character with increas- are ofen present at the same time. For example, initial examination of a body injury may be described as an abraded contusion with retrieved from water may reveal no or much less obvious central laceration. Fractures are breaks in the bone as a injuries due to the moisture from the water at the skin’s result of blunt force. As the body is stored in the morgue overnight sue or sof tissue planes with or without a laceration as and allowed to dry, the abrasions will darken and may a result of shearing forces. Clinicians may sometimes miss these subtle contusions that may become very obvious Contusions are bruises. Clinicians should realize bruising with minimal impact and greater crushing this and create a medical record that is as accurate as force. A postmortem impact may accu- to regions of the body, yet they are found on autopsy, mulate blood due to lividity in a gravity-dependent area. Accurate, concise, truthful, objective docu- One must exercise great care when dating contu- mentation is always best. Te autopsy remains the most sions at the time of autopsy with gross fndings alone. One must account for skin color, whether the contusion is deep or superfcial, the presence of hematoma, etc. Bruises go through various color changes with advanc- Lacerations ing time as the body reacts to repair the injury. Tis depends on the size of the injury, the physiologic state of Lacerations are tears of sof tissues including skin, the individual, including immune response and coagu- internal organs, or vessels as a result of an impact, lation system function, the vascular efciency adjacent overstretching, or crushing-type forces. Color changes range from are characterized by irregular margins, ofen with an light blue-red to dark purple then green to yellow-brown abrasion and underlying sof tissue bridging caused by as time progresses. If the laceration contusions based only upon a visual gross examination is large and gaping, tissue bridging may not be present of skin color changes may create problems in court. Skin lacerations one sees a variability with color ranges demonstrating tend to occur more ofen over hard surfaces, such as the some bruises as red-purple and others as yellow-brown, scalp, knees, elbows, etc. Te direction of the impact can it is reasonable to say that some injuries are older than be determined by the presence of sof tissue undermin- others. With respect to standard anatomic hemosiderin-laden macrophages, and eventual heal- planes, a downward impact will produce undermining ing with fbrosis. Te frst sev- should be described in the autopsy report with reference eral hours reveal hemorrhage-with no infammation. Estimation of injury dating should be given in time ranges due the variable nature of all of these parameters. Bruises can also change appearance as the post- Motor Vehicle Injuries mortem time interval increases. A contusion will become more obvious as blood settles away from the Motor vehicles include any motorized means of car- skin surrounding the contusion. Tese include trucks, sue will become paler and the contusion will be more buses, cars, motorcycles, mopeds, snow mobiles, etc. It prominent, as in a supine body with anterior contu- is always important to be as accurate as possible, includ- sions in full livor mortis. Bleeding associated with a ing the type of vehicle on the death certifcation for vital contusion does not settle away from the impact site records. Te type of vehicle is obviously important when as lividity forms because it is spread throughout the evaluating injuries. It is important to recognize various patterns that Another example is that during vigorous emergency might help diferentiate drivers from passengers. In high- room resuscitation, the head and upper trunk may speed collisions with unrestrained occupants, people become congested. As lividity settles to the charges are fled, the living driver may indicate that the back of the head, contusions to the face may become dead passenger was driving, regardless of the truth. Blunt-Force Injuries 255 One should look for steering wheel impact marks site better, which is also associated with formation of a to the chest, seatbelt-related abraded contusions, and pocket of crushed tissue. It is good practice to include pattern injuries associated with impacts to the wind- the measuring ruler in the picture. Front and back wind- into whether the vehicle was braking before the impact shields are ofen made of laminated glass and fracture occurred because as this happens the front end of a car with elongated curves or splinters.

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Despite this delay purchase sarafem 10mg with mastercard, retrograde conduction over the bypass tract is still not possible cheap sarafem 10 mg on line. D: Despite similar coupling intervals discount 20 mg sarafem mastercard, a slightly shorter H1-H interval results 10mg sarafem visa, which leads to an increase in the H2-V2 interval. Only after the H2-V22 interval reaches a critical value of 135 msec is retrograde conduction over the bypass tract is possible and tachycardia is initiated. Value of programmed stimulation of the heart in patients with the Wolff-Parkinson-White syndrome. Therefore, at comparable coupling intervals of atrial extrastimuli, the bypass tract will always be able to recover more easily when stimulation is initiated from the site of the bypass tract (see text for discussion). Antegrade conduction cannot proceed to the ventricles, because they have just been depolarized and are refractory. Initiation of orthodromic circus movement tachycardia by ventricular stimulation is possible in 80% of patients. Modes of initiation and incidence of initiation are identical to tachycardia induction by ventricular stimulation in patients with concealed bypass tracts (see Chapter 8). This occurs because it is easier to engage the right bundle branch and conduct retrogradely through the A-V node than it is to reach a distant left-sided bypass tract. The atrial activation pattern depends on the relative refractoriness and conduction times over both pathways and usually exhibits a variable degree of atrial fusion. If the retrograde refractory period and/or conduction time of any of the components of the A-V conducting system exceeds that P. The most common mode of initiation with ventricular extrastimuli is 66 pattern 1, in which block in the His–Purkinje system occurs. Ventricular stimulation during sinus rhythm or at long paced cycle lengths almost invariably results in block in the His–Purkinje system with retrograde conduction over the bypass tract. Conduction to the ventricle over the A-V conducting system then will depend on antegrade conduction time over the A-V conducting system and ventricular refractoriness. Because block in the His–Purkinje system occurs in response to the ventricular extrastimulus, the atrial response will return to the ventricle over the normal A-V conducting system with a short A-H interval. In this situation the H-V must be long enough to allow for recovery of ventricular refractoriness for the ventricle to be reexcited. While the H-V prolongation in Figure 10-20 provides enough time to allow the ventricles to P. This blocks in the His–Purkinje system and conducts retrogradely solely over the anteroseptal bypass tract. The left bundle branch block pattern of the first complex does not provide additional delay for this anteroseptal bypass tract to recover. The impulse then returns antegradely over the normal A-V conducting system to initiate the tachycardia. At shorter paced cycle lengths, with or without ventricular extrastimuli, penetration into the A-V node usually occurs, producing some retrograde A-V nodal concealment. In such cases, when the impulse goes over the bypass tract to the atrium and then reexcites the ventricle over the normal A-V conducting system, A-V nodal delay will occur, and the first A-H interval of the tachycardia will be longer than subsequent A-H intervals. This uncommonly occurs with ventricular extrastimuli delivered at paced drive cycle lengths ≥500 msec. During rapid ventricular pacing, one can see retrograde block in the normal conducting system either in the His–Purkinje system or the A-V node. When block occurs at the initiation of pacing, it is frequently in the His–Purkinje system, because the first or second paced complex usually acts as a long short interval producing V-H delay and/or block. Pacing is initiated at a cycle length of 400 msec, but the first paced complex occurs 800 msec following the last sinus complex. The second paced complex is associated with a long V-H interval owing to block in the right bundle branch retrogradely with conduction over the left bundle branch system (see Chapter 2). Simultaneously, the ventricular stimulus conducts solely over a left-sided bypass tract to the atrium. Following the third paced complex, complete block in the His–Purkinje system occurs, and an antegrade His bundle deflection follows atrial activation, which resulted from conduction over the bypass tract. Following the first spontaneous complex, ventricular pacing at a cycle length of 400 msec is initiated. During the first paced complex, A-V dissociation is present, but the His bundle is retrogradely captured by the ventricular paced complex. The second paced complex is associated with marked retrograde His–Purkinje delay and conduction up both the normal conducting system and a left lateral bypass tract. The third paced complex is associated with retrograde block in the His–Purkinje system and retrograde conduction proceeding solely over the left lateral bypass tract. Antegrade conduction over the normal conducting system can be seen by the antegrade H (arrow). In this instance, retrograde block usually occurs in the bypass tract and conduction proceeds over the normal A-V conducting system to induce a bundle branch reentrant complex. This depends on the paced cycle lengths used, the sites of atrial and/or ventricular stimulation, and the conduction velocity and refractoriness of 38 68 the bypass tract and normal A-V conducting systems at the time of the study. In this instance, the His bundle extrasystole blocks retrogradely in the A-V node and conducts antegradely to the ventricles to retrogradely conduct over the bypass tract, reexcite the atrium, and return to the ventricles over the normal A-V conducting system. In this case, owing to retrograde concealment, the first A-H interval of the tachycardia will usually be slightly longer than that of subsequent complexes (Fig. Preexcited Tachycardias Preexcited circus movement tachycardias are much less frequent, perhaps occurring spontaneously in 5% to 10% of P. Moreover, many of these wide-complex tachycardias are not studied in the electrophysiology laboratory, and even when those patients with wide-complex tachycardias are evaluated, proof that the mechanism is circus movement antidromic tachycardia is not always available. Initiation of preexcited tachycardias in the laboratory is at least twice as frequent as their spontaneous occurrence. Antidromic tachycardia is the most common mechanism of preexcited tachycardias in which the accessory pathway participates in the reentrant circuit. This tachycardia uses the accessory pathway anterogradely and the normal A-V conducting system retrogradely. At a paced cycle length of 600 msec, a ventricular extrastimulus delivered at an S1-S2 of 250 msec results in retrograde block in a left lateral bypass tract and initiation of a bundle branch reentrant complex (see Chapter 2). Value of programmed stimulation of the heart in patients with the Wolff-Parkinson-White syndrome. The right ventricular extrastimulus had to be delivered at A-V intervals of ≥200 msec for the A-V node to recover to allow retrograde conduction to the atrium (Fig. Perhaps ventricular stimulation at a site farther from the His–Purkinje system would have been associated with a longer V-H interval, and retrograde conduction would have occurred. This may in fact be the case during antegrade preexcitation because ventricular excitation begins at the ventricular insertion site at the mitral or tricuspid annuli, which are farther from the conduction system than when stimulation is performed at the right ventricular apex. This may provide an additional 50 msec delay to allow the A-V node to recover for retrograde conduction, but this may not be enough time unless the A-V node has a short retrograde refractory period and/or rapid conduction. The basic drive consists of A- V pacing (A1-V1) at a cycle length of 600 msec, with an A-V interval of 120 msec. Progressively earlier atrial extrastimuli (A2) are delivered until A2 blocks in the node. V2 must be delayed so that the A2-V2 interval must exceed 200 msec for A-V nodal refractoriness to recover and for retrograde conduction to occur.

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Oestrogen-induced changes in muscarinic receptor density and contractile responses in the female rabbit urinary bladder 20 mg sarafem otc. Rapid effects of estriol and progesterone on tone and spontaneous rhythmic contractions of the rabbit bladder cheap sarafem 20mg. Vaginal oestradiol for the treatment of lower urinary tract symptoms in postmenopausal women—A double-blind placebo-controlled study buy 20mg sarafem amex. Low-dose 17 beta-estradiol vaginal tablets in the treatment of atrophic vaginitis: A double- blind placebo controlled study trusted sarafem 10 mg. A systematic review of the effects of estrogens for symptoms suggestive of overactive bladder. Tachykinins as modulators of the micturition reflex in the central and peripheral nervous system. Role of supraspinal tachykinins for micturition in conscious rats with and without bladder outlet obstruction. Efficacy and safety of a neurokinin-1 receptor antagonist in postmenopausal women 749 with overactive bladder with urge urinary incontinence. American Society of Clinical Oncology guideline for antiemetics in oncology: Update 2006. Tramadol inhibits rat detrusor overactivity caused by dopamine receptor stimulation. Safety and efficacy of tramadol in the treatment of idiopathic detrusor overactivity: A double-blind, placebo-controlled, randomized study. The incidence of a positive ice water test in bladder outlet obstructed patients: Evidence for bladder neural plasticity. The effect of intravesical resiniferatoxin in patients with idiopathic detrusor instability suggests that involuntary detrusor contractions are triggered by C-fiber input. Botulinum-A toxin injections into the detrusor muscle decrease nerve growth factor bladder tissue levels in patients with neurogenic detrusor overactivity. Cystometric evidence that capsaicin-sensitive nerves modulate the afferent branch of micturition reflex in humans. Intravesical capsaicin as a treatment for refractory detrusor hyperreflexia: A dual center study with long-term followup. Intravesical capsaicin in patients with detrusor hyper-reflexia—A placebo- controlled cross-over study. Capsaicin and neurogenic detrusor hyperreflexia: A double-blind placebo- controlled study in 20 patients with spinal cord lesions. Intravesical capsaicin versus resiniferatoxin for the treatment of detrusor hyperreflexia in spinal cord injured patients: A double-blind, randomized, controlled study. Urodynamic effect of intravesical resiniferatoxin in patients with neurogenic detrusor overactivity of spinal origin: Results of a double-blind randomized placebo-controlled trial. Intravesical resiniferatoxin versus botulinum-A toxin injections for neurogenic detrusor overactivity: A prospective randomized study. Therapeutic effect of multiple resiniferatoxin intravesical instillations in patients with refractory detrusor overactivity: A randomized, double-blind, placebo controlled study. Intravesical resiniferatoxin for the treatment of women with idiopathic detrusor overactivity and urgency incontinence: A single dose, 4 weeks, double-blind, randomized, placebo controlled trial. Clinical and urodynamic effects of norfenefrine in women with stress incontinence. Role of alpha2-adrenoceptors and glutamate mechanisms in the external urethral 750 sphincter continence reflex in rats. Functional and metabolic effects of terbutaline and propranolol in fast and slow contracting skeletal muscle in vitro. Effect of clenbuterol on contractile response in periurethral striated muscle of rabbits. Beta(2)-adrenergic agonists and pelvic floor exercises for female stress incontinence. Clenbuterol ingestion causing prolonged tachycardia, hypokalemia, and hypophosphatemia with confirmation by quantitative levels. Effects of duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, on central neural control of lower urinary tract function in the chloralose-anesthetized female cat. Neural control of the urethra and development of pharmacotherapy for stress urinary incontinence. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. Urethral sphincteric insufficiency in postmenopausal females: Treatment with phenylpropanolamine and estriol separately and in combination. Cholinergic and adrenergic contributions and interactions of sympathetic and parasympathetic systems in bladder function. Further observations on the cystometric and uroflowmetric effects of bethanechol chloride on the human bladder. Intermittent catheterization and bladder rehabilitation in spinal cord injury patients. Effects of bethanechol chloride on the external urethral sphincter in spinal cord injury patients. Duration of postoperative catheterization: A randomized double blind trial comparing two catheter management protocols and the effect of bethanechol chloride. Clinical and experimental studies on the action of prostaglandins and their synthesis inhibitors on detrusor muscle in vitro and in vivo. The value of intravesical prostaglandin E2 and F2 alpha in women with abnormalities of bladder emptying. Study of intravesical instillation of 15(S)-15 methyl prostaglandin F2-alpha in patients with neurogenic bladder dysfunction. Prostaglandin F2 alpha for prevention of urinary retention after vaginal hysterectomy. Prostaglandins for enhancing detrusor function after surgery for stress incontinence in women. Clinical and urodynamic assessment of alpha-adrenolytic therapy in patients with neurogenic bladder function. Influence of the sympathetic nervous system on the lower urinary tract and its clinical implications. The sympathetic innervation and adrenoreceptor function of the human lower urinary tract in the normal state and after parasympathetic denervation. Further observation on the denervation supersensitivity of the urethra in patients with chronic neurogenic bladders. Urethral denervation supersensitivity to noradrenaline after radical hysterectomy. Effect of alpha adrenergic blockage and anticholinergic agents on the decentralized primate bladder. Experimental evidence for a central nervous system site of action in the effect of alpha-adrenergic blockers on the external urinary sphincter.

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Other evidence-based guidance has specifically recommended against cystometry for uncomplicated stress incontinence [51] generic sarafem 10 mg without a prescription. The decision to reaffirm the role of cystometry effectively means the diagnosis can only be made in secondary care settings generic sarafem 10mg mastercard, which might limit patient access to appropriate community-based care cheap sarafem 20 mg line. The 2002 report revised detrusor overactivity from a diagnosis to a urodynamic observation on the basis that no available evidence supported the additional benefit of cystometry over noninvasive symptom assessment [52] sarafem 20 mg. It is a retrograde step to have divided patients with urgency and frequency symptoms into “detrusor overactivity” and the new “bladder oversensitivity” on the basis of “involuntary detrusor muscle contractions during filling cystometry. Further threats to the validity of detrusor overactivity as a measure of urgency have come from studies demonstrating unacceptably poor interrater reliability [59,60] and no significant association between individual contractions and reporting of increased sensation [61,62]. The consensus process for drafting the 2009 report would therefore seem to have reiterated the conventional wisdom regarding cystometry, in the face of the best evidence. In some quarters, “voiding dysfunction” has become a catchall term for lower urinary tract symptoms. This report specifies however that the term refers only to “abnormally slow and/or incomplete micturition. The new report suggests a 30 mL residual as the upper limit of normal and a 200 mL residual as representing chronic retention [64]. Although usage of the Liverpool nomogram for average flow rate is recommended, the report recognizes that this is an area requiring further validation studies, with poorly defined relationships between symptoms and pathology [65,66]. The report specifies that the diagnosis requires both subjective symptoms and objective findings. It is not entirely clear which term is intended to represent objective voiding dysfunction but without symptoms. For the first time, it provides unifying coverage of urogynecology and female urology. It should be an invaluable reference both for researchers planning and reporting studies and for clinicians who need to map the research evidence base onto the myriad of individual complaints and symptoms reported by patients. This commentary, however, identifies some sections that would benefit from greater depth and other areas where recommendations substantially diverge from recent evidence. Future reports should consider incorporating systematic reviews of current evidence, such as those provided by the International Consultation on Incontinence [44], and use of a formal Delphi method to achieve better balance of coverage. Second report on the standardisation of terminology of lower urinary tract function. International Continence Society Committee on standardisation of Terminology, Copenhagen. Third report on the standardisation of terminology of lower urinary tract function. Fourth report on the standardisation of terminology of lower urinary tract function. Sixth report on the standardisation of terminology of lower urinary tract function. Procedures related to neurophysiological investigations: Electromyography, nerve conduction studies, reflex latencies, evoked potentials and sensory testing. The International Continence Society Committee on Standardisation of Terminology, New York. Seventh report on the standardisation of terminology of lower urinary tract function: Lower urinary tract rehabilitation techniques. Standardization of terminology of lower urinary tract function: Pressure- flow studies of voiding, urethra resistance, and urethral obstruction. International Continence Society Subcommittee on Standardization of Terminology of pressure flow studies. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Subcommittee of the International Continence Society. The standardization of terminology of lower urinary tract function in children and adolescents: Report from the Standardisation Committee of the International Children’s Continence Society. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. The standardization of terminology for researchers in female pelvic floor disorders. Standardization of terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor clinical assessment group of the International Continence Society. Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Standardisation of ambulatory urodynamic monitoring: Report of the Standardisation Sub-committee of the International Continence Society for Ambulatory Urodynamic Studies. Standardisation of urethral pressure measurement: Report from the Standardisation Sub-committee of the International Continence Society. Clinical efficacy, safety, and tolerability of once-daily fesoterodine in subjects with overactive bladder. Author’s reply to editorial comment regarding “Overactive bladder and the definition of urgency. Cystometrical sensory data from a normal population: Comparison of two groups of young healthy volunteers examined with 5 years interval. Is catheter cause of subjectivity in sensations perceived during filling 1814 cystometry? Can a faked cystometry deceive patients in their perception of filling sensations? A study on the reliability of spontaneously reported cystometric filling sensations in patients with non- neurogenic lower urinary tract dysfunction. Prioritizing research: Patients, carers, and clinicians working together to identify and prioritize important clinical uncertainties in urinary incontinence. Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: A literature review. A systematic review of the reliability of frequency-volume charts in urological research and its implications for the optimum chart duration. The incidence and prevalence of nocturia (increased nocturnal voiding frequency): Results from a community based cohort study in older men. A longitudinal population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in women. A randomized trial of urodynamic testing before stress-incontinence surgery N Engl J Med 2012; 366(21):1987–1997. Value of urodynamics before stress urinary incontinence surgery: A randomized controlled trial. Preoperative clinical, demographic, and urodynamic measures associated with failure to demonstrate urodynamic stress incontinence in women enrolled in two randomized clinical trials of surgery for stress urinary incontinence. Predictive value of urodynamics on outcome after midurethral sling surgery for female stress urinary incontinence. Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response. Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation. Reliability testing of urodynamics, pressure flow studies and cough leak point pressure in women with urodynamic stress incontinence with and without detrusor overactivity.

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