==inizio objective==

Overactive bladder syndrome (OAB) is a complex disease. It is associated with social embarrassment, depression and loss of work productivity. It is usually treated with antimuscarinics drugs, even if antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. Recentely Mirabegron has been investigated as a potential alternative to antimuscarinics (1),(2). Intravesical Botulinum injection is an effective treatment for overactive bladder in patients that are refractory to antimuscarinics. Botulinum toxin significantly improves OAB symptoms and urodynamic parameters in patients with OAB (3). The aim of this study is to evaluate our experience in the use of Botulinum toxin for OAB.

==fine objective==

==inizio methodsresults==

We conducted a retrospective analysis of patients treated with botulinum toxin for overactive bladder between June 2012 and January 2015 at our institution. A total of 70 patients were enrolled (45 women and 25 men). All patients enrolled in this study had failed a 8 months treatment with 2 different oral pharmacological therapies. All patients also suffered of urge incontinence. and used more than one pad/day. Patients with neurogenic detrusor overactivity and/or severe detrusor underactivity were excluded from the study. Prior to the BoNT-A injections all patients underwent an uroflussimetry and an urodynamic exam. We used onabotulinumtoxinA (BoNT-A). The injections were done cystoscopically by a single operator. Average dose of BoNT-A was 100 units. The BoNT-A (total volume 10 mL) was administered as intradetrusor injections across 20 sites on the lateral and posterior bladder walls (sparing the trigone), and 0.5 ml (5 U) was injected at each site. We used a rigid cystoscope. All patients took 1 injection. Clinical, urodynamic and QOL assessments were done at 1 and 12 months after BoNT-A treatment. All patients underwent to an uroflussimetry and an urodynamic exam at 1 and 12 months after the injection. Patient Global Impression of Improvement (PGI-I) score assessed patient quality of life pre- and postoperatively. PGI-I scores were obtained at 1 and at 12 months after injections. A PGI-I score < 2 at 12 months after BoNT-A was defined as a successful treatment. Statistical analyses were conducted using SAS version 9.3 software (SAS Institute, Inc., NC). Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05 (two-sides). ==fine methodsresults== ==inizio results== Mean age was of 44,2 years (range 24-56 years). The treatment with BoNT-A was successfully delivered in all 70 patients. There were no injection related complications and only 5 out of 70 patients (7,1%) had mild hematuria. Treatment was generally well tolerated. 5 out of 70 patients (7,1%) experienced postoperative uncomplicated UTI. 7 out of 70 (10%) patients (5 males and 2 females) had PVR urine volume >150 mL; 8 out of 70 (11,4%) patients (5 males and 3 females) had acute urinary retention after treatment. Overall after 1 month 59 out of 70 patients (84,3%) had a significant improvement of global urinary symptomatology and after 12 months 55 out of 70 patients (78,6%) had a significant improvement of global urinary symptomatology. Urgency disappeared in 62 out of 70 patients (88,6%) of the patients and incontinence resolved in 59 out 70 patients (84,3%) within 1 or 2 weeks after BoNT-A injections. We considered “dry” patients without any loss of urine (no pads/day) or those who used a safety pad/day. Mean maximal bladder capacity significantly increased from 248,06±47,1 to 310±58,5 milliliters (p=<0,05); mean volume at first desire to void significantly increased from 155,3±4,6 to 196,1±41,5 milliliters (p<0,05).PGI-I scores were available for 69out of 70 patients. Success rate was achieved in 51 out of 69 patients (73,9%). ==fine results== ==inizio discussions== Clinical experiences with BoNT-A application for OAB are still scarce and controversial, and it differs in dose, dilution, injection site, number of injections and rate. Most studies considered a low number of patients and there is a mixture of idiopathic and neurogenic detrusor overactivity. Our study showed that a dose of 100 U BoNT-A could achieve beneficial effects in a good percent of patients. We evaluated urodynamic (objective) and clinical (subjective) parameters. Urgency and incontinence significantly decreased after BoNT-A in the majority of patients. All of these objective improvement are followed by a significant impact on QOL, as based on PGI score. The side effect rate was low, and most common treatment-related complication was UTI. A limitation of this study is a short follow-up period. As a consequence we can not indicate the re-injection rate. ==fine discussions== ==inizio conclusion== In the most recent guidelines, it was stated that the best alterna¬tive among the minimally invasive treatment options in NDO is BoNT-A (recommendation level A). The effectiveness of BoNT-A was supported by several randomized, placebo-controlled studies, and there was no loss in effectiveness with repeated injections. In our experience intravesical BoNT-A is an effective treatment for OAB in patients refractory to antimuscarinics. We recommended a dose of 100 UI administered as intradetrusor injections across 20 sites using a rigid cystoscope. Treatment was generally well tolerated, and most common treatment-related complications were UTI and urinary retention. We believe that it can be offered to the patients before other invasive therapeutic options. ==fine conclusion== ==inizio references== 1-Sacco E, Bientinesi R, Bassi P, Currò D. Pharmacological methods for the preclinical assessment of therapeutics for OAB: an up-to-date review. Int Urogynecol J. 2016 Feb 17. [Epub ahead of print] 2- Wagg A, Nitti VW, Kelleher C, Castro-Diaz D, Siddiqui E, Berner T Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics. Curr Med Res Opin. 2016 Feb 17:1-18. [Epub ahead of print] 3- Karsenty G, Denys P, Amarenco G, De Seze M, Gamé X, Haab F, Kerdraon J, Perrouin-Verbe B, Ruffion A, Saussine C, Soler JM, Schurch B, Chartier-Kastler E.Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review. Eur Urol. 2008 Feb;53(2):275-87. Epub 2007 Oct 16. ==fine references==

==inizio objective==

The short-medium term outcomes after TVT-O are quite known in the literature. Less known are the long-term results. With this retrospective study we wanted to examine the functional aspects, complications and the possible risk factors in the failure, after the TVT-O placement in a long time.

==fine objective==

==inizio methodsresults==

Hundred twenty-five patients who had undergone a period of twelve years of TVT-O positioning operation for stress urinary incontinence were evaluated retrospectively. One urogynecological team has performed all procedures. The patients had stress urinary incontinence (SUI) and had undergone Urodynamics (UDS). They excluded women with a history of previous surgery for incontinence or radical pelvic surgery and those with hyperactivity ‘detrusor overactivity (DO). They were considered objectively cured patients who had no urinary leakage during cough stress test (CST). Subjective outcomes were assessed using the Incontinence Questionnaire for Evaluating Female Lower Urinary Tract Symptoms (ICIQ-FLUTS). The quality of life was measured with the King’s Health Questionnaire (KHQ). To identify risk factors for the failures of the procedure have been used univariate and multivariate analyzes.

==fine methodsresults==

==inizio results==

The median follow-up was 102 months (range 72-144). 78.9% (98/125) of patients were objectively cured, while 80.4% (100/125) are subjectively cured. A significant improvement was observed in all domains of the KHQ. De novo urgency rate was 10% (12/125). The incidence of subjective and objective failures did not show statistically significant increases in relation to the length of follow-up. The patients who had undergone a vaginal hysterectomy or with apical prolapse had a higher and statistically significant risk of failure. The intraoperative complications were: perforation of the vaginal fornix in two patients, bleeding stopped with intravaginal compression in two patients, pain lasting more than seven days in the thighs 15%. Transient dyspareunia and less than one month in the 4%. No cases of vaginal erosion or bladder perforation.

==fine results==

==inizio discussions==

Several studies have confirmed the safety and short-term efficacy of the TVT-O. The procedure is technically simple, is associated with a short learning curve, a short operating time and low morbidity. French registry data on 984 TVT-O procedures showed a perioperative morbidity rate of 2.2% and a postoperative complication rate of 5.2%.4 The most common complication was residual pain (2.7%). The other complications of paravesical hematoma, urinary retention, vaginal erosion, and reintervention had an incidence of < 1%. These studies, along with several randomized trials, confirm that short-term and mediumterm outcome results of the TVT-O are favorable and similar to the results of the retropubic TVT. Long-term outcome results of the TVT-O procedure are scarce. Several recent studies have demonstrated that the incidence of perioperative and short-term postoperative complications associated with the TVT-O procedure is low. In our study, no patient presented symptoms/signs suggestive of vagina, bladder, or urethral erosion; neurologic complication; or persistent pain with 144 months follow-up. ==fine discussions== ==inizio conclusion== An 21% rate of surgical failure was observed with median 102 months follow-up without significant increase over the duration of follow-up. There are no recorded cases of women with symptoms/signs suggestive of vagina, bladder, or urethral erosion; neurologic complication; or persistent pain with 144 months follow-up. De novo urgency rate was 10%. The positioning of TVT-O is characterized by a high long-term effectiveness, determines a significant improvement on the quality of life of patients and the relative technique has a high degree of safety. The vaginal hysterectomy and apical prolapse are significantly associated with an increased risk of subjective and objective failures. ==fine conclusion== ==inizio references== Collinet P, Ciofu C, Costa P, et al. The safety of the insideouttransobturator approach for transvaginal tape (TVT-O) treatment in stress urinary incontinence: French registry data on 984 women. Int Urogynecol J 2008;19:711–715. Waltregny D, Gaspar Y, Reul O, et al. TVT-O for the treatment of female stress urinary incontinence: Results of a prospective study after a 3-year minimum follow-up. Eur Urol 2008;53:401–408 Liapis A, Bakas P, Creatsas G. Efficacy of inside-out transobturator vaginal tape (TVT-O) at 4 years follow-up. Eur J Obstet Gynecol Reprod Biol 2010;148199–201. ==fine references==

==inizio objective==

The number of surgeries as a treatment for female SUI has increased, and an alternative approach using a transobturator passage of the tape has been developed; the midurethral slings (MUS) procedures has become increasingly popular. In literature Few studies compared these two widespread techniques used for the management of SUI, and none, at the best of our knowledge, evaluated before the sexual function after these procedures.
Single-incision slings (SIS) have been developed to reduce procedure-related discomfort without negatively affecting the benefit. Similar to the transobturator slings, the SIS perforates the obturator internus muscle and the foramen obturatum but does not perforate the adductor muscles, resulting in less postoperative pain.
Thus, the aim of the study was to prospectively evaluate the effect of TVT-O vs. SIS procedures on the sexual function and QoL in female patients with SUI by using the Female Sexual Function Index (FSFI) and International Consultation on Incontinence Modular Questionnaire-Short Form (ICIQ-SF).

==fine objective==

==inizio methodsresults==

In total, 48 patients were included in the study and were divided into groups for treatment of SUI: 24 patients underwent insertion of tension-free transobturator suburethral tape (TVT-O group) and 24 underwent insertion of transobturator single-incision mini-sling (SIS group). Patients were divided by a simple randomization (after a stratified randomization to control all the baseline covariates between the two study arms) in the two treatment groups. Using a computer table generation of random numbers: group 1 (n = 24 women) was treated with TVT-O to correct SUI, and group 2 (n = 24 women) was treated with the SIS. Both groups were evaluated with the same questionnaires after 6 and 12 months of treatment to assess the impact of continence on quality of life and the sexual function. The preoperative urodynamic assessment of the patients was performed in accordance with the International Continence Society guidelines.
Only sexual-active patients were enrolled in the study; the participants who have had at least one sexual activity within three months prior to surgery were considered as being sexual active. Before the surgery and at six months of follow-up (when the participants attended the Urogynecology outpatient clinic), the participants were asked to complete the Italian versions of the FSFI questionnaires for the assessment of sexual function and the ICIQ-SF questionnaires.

==fine methodsresults==

==inizio results==

Mean operative time was 23.5 mins (range: 13-26) in TVT-O group, and 22.5 mins (range: 12.8-25) in SIS group. No intra and postoperative complications occurred. One patient of TVT-O group experienced a vaginal wall erosion (21 days after surgery) and one of the SIS group reported a denovo outlet obstruction. No patients reported a denovo urgency incontinence and/or overactive bladder.
All women who had an active sexual life preoperatively reported sexual activity after procedures. The mean time of postoperative sexual activity resumption was 36 days (range : 32-44 days).
The 6 months postoperative results indicated that the total FSFI scores increased from 23.96 ± 5.56 to 28.09 ± 3.34 for the TVT-O group and from 23.51 ± 3.78 to 27.42 ± 3.62 for the SIS group. Additionally, significant improvements were also found in all the domains considered (sexual desire, sexual arousal, lubrication, orgasm, satisfaction and pain). No statistically significant differences were observed between the two treatment groups. Furthermore, the mean postoperative ICIQ-SF scores were significantly lower than the mean preoperative ICIQ-SF scores (an indicator of improvement of QoL).
At the initial follow-up of 6 months 18/21 (85.7%) and 17/21 (80.9%) patients after SIS and TVT-O groups respectively experienced a complete recovery of urinary continence. At 12 months follow-up after surgery, 19 (90.4%) patients who successfully underwent the SIS procedure reported a complete resolution of urinary incontinence while 2 (9.5%) reported an improvement in urinary incontinence. In the TVT-O group, total recovery of urinary incontinence was observed in 18/21 (85.7%) of patients, and an improvement in the incontinence was observed in 1/21 (4.1%) of patients who had showed negative results during the physical examination. In addition, one vaginal wall erosion complication was observed in the TVT-O group, and one patient reported acute retention of urine in the SIS group.

==fine results==

==inizio discussions==

To the best of our knowledge this is the first study to compare sexual function in patients affected by SUI submitted to SIS versus TVT-O. Minimally invasive mid-urethral slings have become the standard surgical procedure for treatment of stress urinary incontinence in women. The TVT-O procedure is an inside-out transobturator sling technique that is a modified version of the TVT procedure. It has gained worldwide use because of its safety, simplicity, and effectiveness in treating SUI. However, limited investigation exists on the effect of transobturator sling procedures, including TVT-O, on sexual function.
For avoiding the complications due to the blind needle passage through the retropubic space (TVT sling) or transobturator foramen (TOT sling), the new SIS systems were introduced. These slings aim to obtain the same suburethral support with less invasivity by anchoring the two arms in the obturator fascia while avoiding the passage through the adductor muscles.
In this study no evidence of a significant difference in terms of continence rates between SIS (90.4%) and TVT-O (89.8%) groups was observed. However, this lack of significant differences has to be carefully interpreted because of the study main limitations: short term follow-up, and the small number of enrolled patients.
Sentilhes et al. have found no significant differences after surgery regarding the frequency and appreciation of sexual intercourse, extent of sexuality, and frequency of leakage during intercourse.
A review by Abdel-Fattah et al. reflected the primary suboptimal results of SIS with inferior patient-reported and objective cure rates on the short-term follow-up and higher reoperation rates for SUI when compared with standard midurethral tapes.
In a multicentre prospective randomised trial in six UK centers, Mostafa and colleagues compared the postoperative pain profile, peri-operative details, and short-term patient reported and objective success rates of single-incision mini-slings (SIS) versus standard mid-urethral slings (TVT-O) in 137 women suffering from pure SUI. The adjustable single-incision sling was associated with a significantly improved postoperative pain profile and earlier return to work when compared to standard mid-urethral slings, with encouraging results in patient-reported and objective success rates at short-term follow-up.
In our study, both the sling systems provided high continence rates without major complications: 90.4% in SIS group and 89.8% in TVT-O group with total continence or improvement support equality of data. A median follow-up period of 12 months is short for the comparison of objective outcome measures to reveal the benefits of different sling systems.
Thus, the limitations of the study include the differences between pre- and postoperative results that were minimal, probably because of the small number of sample size. Furthermore, sexual function is affected by multiple factors such as anatomy, traditional culture, education, and psychological factors, and the FSFI questionnaire hardly reflects all the possible problems related to sexual function. It would have been useful to have had a longer follow-up period to see whether sexual function changed over time.

==fine discussions==

==inizio conclusion==

The current evidence of pelvic floor surgery on sexual function is contradictory. Many studies dealing with the changes of sexual function after incontinence surgery show varying results.
SIS and the TVT-O procedures seem to be effective and safe in the operative treatment of female SUI. Twelve-months of follow-up data showed comparable continence rates for SIS and TVT-O without any severe side-effects or complications. The results also showed improved QoL after the surgery. In addition, significant improvements in sexual function were also observed for both the TVT-O and SIS procedures. In our study, both the sling systems are equally effective in improving continence and sexual function of female patients with SUI.

==fine conclusion==

==inizio references==

1. Abdel-Fattah M, Agur W, Abdel-All M et al (2012) Prospective multi-centre study of adjustable single-incision mini-sling (Ajust°) in the management of stress urinary incontinence in women: 1-year follow-up study. BJU Int 109(6):880–886.
2. Pickens RB, Klein FA, Mobley JD 3rd, White WM (2011) Single-incision mid-urethral sling for treatment of female stress urinary incontinence. Urology 77(2):321–324.
3. Elzevier HW, Putter H, Delaere KPJ, Venema PL, Lycklama à Nijeholt AAB, Pelger RCM. Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs. tension-free vaginal tape obturator. J Sex Med 2008;5(2):400–6.
4. Sentilhes L, Berthier A, Caremel R, Loisel C, Marpeau L, Grise P (2008) Sexual function after transobturator tape procedure for stress urinary incontinence. Urology 71:1074–1079
5. Mostafa A, Agur W, Abdel-All M, Guerrero K, Lim C, Allam M, Yousef M, N’Dow J, Abdel-fattah M. A multicentre prospective randomised study of single-incision mini-sling (Ajust®) versus tension free vaginal tape-obturator (TVT-O™) in the management of female stress urinary incontinence: pain profile and short-term outcomes. Eur J Obstet Gynecol Reprod Biol. 2012;165(1):115-2.

==fine references==

==inizio objective==

Urinary incontinence following radical prostatectomy has yet a significant incidence, varying from 4% to 8% in modern series, and impairs deeply quality of life [1]. The number of radical prostatectomies performed in 2010 in US was about 138000 (source Center for Disease Control and Prevention, http://www.cdc.gov/nchs/fastats/prostate.htm) and therefore the number of patients involved is significant as well and can be estimated in 5500 to 11.000 de novo incontinent cases per year. Incontinence is mainly a consequence of external sphincter weakness. However a concomitant urge component can be present in at least a fifth of incontinent cases [2,3] and best assessed only after an appropriate “restitutio ad integrum” of the sphincter function. Hence, the partial effect achieved after surgery for post prostatectomy incontinence could be due to a failure and/or to the presence of minor or latent functional bladder dysfunction, which becomes dominant after the surgical correction of the sphincter defect. After urodynamic evaluation assessing the presence of the bladder dysfunction, sacral neuromodulation may be offered in order to improve continence and quality of life. Our report is intended to assess feasibility of sacral neuromodulation for the treatment of the urge component of incontinence in this specific clinical scenario.

==fine objective==

==inizio methodsresults==

Our report is prospective case series without a control group or randomization.Internal review board approved our data analysis. The study was conducted according to the Helsinki Declaration.
From January 2010 to December 2011, 77 patients referred to our center for post radical prostatectomy incontinence. Cases characterized by partial intrinsic sphincter deficiency (defined as functional length less than 2 cm, retrograde leak point pressure test < 40 cm H2O, maximal urethral closure pressure < 45 cm H2O) and mild incontinence (24h pad test lower and upper limits respectively 20 and 500 mL, computed as 3 days mean) underwent transobturatoy tensive perineal tape placement [4]. Twenty seven patients declared a partial or no improvement and were submitted again to urodynamic evaluation. Twenty-five cases with a reduced bladder compliance (<10 mL/cm H2O) or reporting a partial improvement after a trial with anticholinergic drugs were candidates to sacral neuromodulation. Twenty-two were implanted with sacral neuromodulator (InterStim – Medtronic) [5]. Before implantation patients signed a detailed informed consent. Patients were followed up with interview, physical examination, ICIQ-SF questionnaires and pad test before and post implantation, at 3 months and then yearly. The interview included a detailed continence assessment: number of pads used, number of incontinence episodes, number of days affected by incontinence. Complete responders were dry cases, not necessitating anymore of pads. Partial responders were defined as cases that more than halved the number of pads used or reported a reduction of at least of 50% of incontinence episodes or days affected by incontinence. ICIQ-SF and pad test findings pre and post implant were subjected to a Student’s T –test for paired samples for analysis of statistical significance.The object of the analysis were the 2-year findings.. The test was two tailed for ICIQ-SF assessment and one tailed for the pad test. Significance level was 0.05. ==fine methodsresults== ==inizio results== Two patients died within 2 years after the implant, one for disease and one for unrelated causes whereas 18 had at least 2 year follow up and were object of the report. Indications to implantation were bladder compliance < 10 cm H2O and improvement of continence during the anticholinergic drugs trial in 4 cases (group 1), bladder compliance < 10 cm H2O without improvement with drugs in 8 cases (group 2), bladder compliance >10 cm H2O and improvement with drugs in 6 cases (group 3). Median age at prostatectomy was 72 (range 44 – 78), median number of years from prostatectomy to implant was 2 years (range 2 – 14). Two years after the implant, 4(22%) patients were completely continent (no pad), 4(22%) quasi-continent (1 pad), 5(28%) improved of at least 50% (halved the number of pads) and five improved of at less than 50% or did not at all respect to pre implant assessment. Concerning the number of incontinence episodes, 11 (61%) had a reduction greater than 50% whereas the number of days affected by incontinence reduced more than 50% in 10 (56%) cases. Overall 13/18 patients (72%) had a complete or partial response to the treatment and, most important, 10/18 (55%) declared to be satisfied and happy to have decided to be treated. The pads’ number was reduced significantly from 4.4 ± 2.2 to 1.9 ± 1.6 (p<0.001). The ICIQ-SF score decreased significantly from 16.3 ± 3 a 10.9 ± 4.5 (p<0.001). Data are summarized in table 1. Stratifying according to indication of implantation, group 1 patients were more likely to respond than group 2 and 3 patients, with a rate of respectively 4/4, 5/8, 3/6. Interestingly all the complete responders belonged to group 1. ==fine results== ==inizio discussions== Patients submitted to radical prostatectomy, irrespective of the technical approach, open, laparoscopic, robotic, may develop permanent urinary incontinence [1] with similar rates [6], ranging from 4% to 8%. Considering the number of prostatectomy performed every year, the number of patients affected by incontinence is significant. Data suggest that most are mainly stress incontinence cases and only a minority, about 4%, is linked solely to overactive bladder [1]. However concomitant impaired compliance and detrusor hypocontractility in stress incontinent cases have a significant incidence and are reported in up to 40% and 60% of patients respectively [1, 7, 8, 9]. Particularly urodynamic studies performed after radical prostatectomy in incontinent patients, show that detrusor overactivity can be found in at least one fifth cases [2, 3, 10] and coexist with sphincter weakness. The gold standard for the treatment of stress post prostatectomy incontinence is the artificial urinary sphincter which is successful in about 80% of cases [11], however, in selected cases with mild incontinence, slings have comparable results [12] and less complications [13,14]. Our cohort consisted of properly selected cases. Anastomotic stricture was excluded by office cystoscopy, degree of incontinence was mild and urodynamic findings identified intrinsic sphincter deficiency. However only an half recovered from incontinence. Our study focuses on cases not responding, totally or partially, to sling placement. Given the significant incidence of bladder impaired compliance concomitant to stress incontinence, every patient was resubmitted to urodinamic study. Sacral neuromodulation was offered to cases with a bladder compliance <10 mL/cm H2O or clinical improvement of continence after a trial with anticholinergic drugs. Sacral neuromodulation was preferred to tibial nerve stimulation simply because it does not imply repeated weekly office visits. Patients were prospectively followed up. In all, 18 patients had a follow up lasting at least 2 years and were object of our study. Sacral neuromodulation may improve continence by a wide range of mechanisms, related to the stimulation of sensitive and motor neural fibers of the ventral ramus localized at the S3 level, as eloquently described in a paper from Chancellor and Chartier-Kastler [15]. Return to continence in about half of patients shows effectiveness of sacral neuromodulation as treatment of urge incontinence also in this clinical setting. Moreover, satisfaction rate, expressed by a direct and precise question to the patient was significantly high considering the general dissatisfaction underlying post prostatectomy continence and a “failed” sling implant. The impression obtained by interviewing the patients is substantiated by an objective and statistically significant improvement in ICIQ-SF score and number of pads used. We reported ours results over a period of 2 years thus suggesting the achievements are likely to remain definitive. Interestingly, even if not statistically significant, the patients who benefit most from the implant were those with a bladder compliance < 10 cmH2O and who experienced a continence improvement after a trial with anticholinergic drugs. Indeed failures should have probably an additional incontinence component beyond impaired bladder compliance linked to the prostatectomy technique like a too short urethral stump or urethral fibrosis [16]. ==fine discussions== ==inizio conclusion== In this series of selected patients, the residual urinary incontinence was treated effectively with sacral neuromodulation when the urodynamic evaluation, performed after the implant of the sling perineal bulb, showed a reduction in bladder compliance. The 2-year follow up is not yet enough to consider definitively stable the results achieved even if it will likely remain unchanged. Most important the procedure is safe, mini invasive and performed in local anesthesia. The procedure is feasible but further studies are needed to validate the technique and its results. By the way our report should encourage centers specialized in male incontinence treatment to perform dedicated clinical trials focusing on the population who is most likely to respond, namely cases with a bladder compliance < 10 cmH2O and reporting an incontinence improvement after a trial with anticholinergic drugs. ==fine conclusion== ==inizio references== 1) Hoyland K, et al. Post-radical prostatectomy incontinence. Rev Urol 2014;16:181-8. 2) Chung DE, et al. Detrusor underactivity is prevalent after radical prostatectomy. Can Urol Assoc J 2012;24:1-5. 3) Dubbelman Y, et al. Quantification of changes in detrusor function and pressure-flow parameters after radical prostatectomy. Neurourol Urodyn 2012;31:637-41. 4) Ceresoli A, et al. New perineal tensive transobturator tape (T-TOT) for postprostatectomy urinary incontinence. Arch Ital Urol Androl 2010;82:154-8. 5) Spinelli M, et al. New sacral neuromodulation lead for percutaneous implantation using local anesthesia. J Urol 2003;170:1905-7. 6) Gagnon LO, et al. Comparison of open and robotic-assisted prostatectomy. Can Urol Assoc J 2014;8:92-7. 7) Gomha MA, Boone TB. Voiding patterns in patients with post-prostatectomy incontinence. J Urol 2003;169:1766-1769 8) Porena M, et al. Voiding dysfunction after radical retropubic prostatectomy: more than external urethral sphincter deficiency. Eur Urol 2007;52:38-45. 9) Giannantoni A, et al. Assessment of bladder and urethral sphincter function before and after radical prostatectomy. J Urol 2004;171:1563-1566. 10) Chao R, Mayo ME. Incontinence after radical prostatectomy. J Urol 1995;154:16-8. 11) James MH, McCammon KA. Artificial urinary sphincter for post-prostatectomy incontinence: a review. Int J Urol 2014;21:536-43. 12) Chung E,et al. Adjustable versus non-adjustable male sling for post-prostatectomy urinary incontinence. Neurourol Urodyn 2015 Feb 14 13) Van Bruwaene S, et al. The use of sling versus sphincter in post-prostatectomy urinary incontinence. BJU Int 2015;116:330-42 14) Hoy NY, Rourke KF. A retrospective comparison of transobturator male slings and the artificial urinary sphincter. Can Urol Assoc J 2014;8:273-7 15) Chancellor MB, Chartier-Kastler EJ. Principles of sacral nerve stimulation (SNS) for the treatment of bladder and urethral sphincter dysfunctions. Neuromodulation 2000;3:15–26 16) Paparel P, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis. Eur Uro 2009;55:629-37 ==fine references==

==inizio objective==

Chronic pelvic pain syndrome (CPPS) is used to designate unexplained chronic pelvic pain in men. The management of patients with chronic pelvic and perineal pain requires preliminary clinical analysis designed to identify correlated urological and abdominal dysfunction. Physical evaluation is required to identify trigger points responsible for myofascial pain, pelvic floor muscle tension, and lumbar-pelvic-hip instability. Physiotherapy is one of the first step therapy suggested in and must be initiated early in the course of the disease by therapists trained in these techniques. These techniques can be supported by use of several drugs. Palmitoylethanolamide (PEA) is an endogenous fatty acid amide, belonging to the class of nuclear factor agonists. PEA has been demonstrated to bind to a receptor in the cell-nucleus (a nuclear receptor) and exerts a great variety of biological functions related to chronic pain and inflammation. Aim of this study is to describe muscle examination in patients with chronic pelvic and perineal pain and to determine the results that can be expected from physiotherapy and use of palmitoylethanolamide.

==fine objective==

==inizio methodsresults==

In the study from January 2014 to April 2015 22 men (average age 37,8 – range 26-62) with Chronic Pelvic Pain Syndrome (CP/CPPS) were selected and enrolled in this study. The pain was associated to irritative voiding symptoms in 12. Preliminary clinical and instrumental evaluation was performed to exclude other pathologies. Physical evaluation was performed to identify trigger points responsible for myofascial pain, pelvic floor muscle tension, and lumbar-pelvic-hip instability. In all patients we administered palmitoylethanolamide, 1200 mg for 15 days and 600 mg for 75 days. Pelvic floor rehabilitation was performed after 15 days of therapy and comprised repeated muscle contractions of the pelvic floor and biofeedback, twice a week for 6 weeks.

==fine methodsresults==

==inizio results==

All patients were evaluated with Vas pain score and SF 12 score for quality of life before and after therapy. Vas and SF 12 were administrated at three and six months after therapy. We observed a significant decrease of Vas score and increase of SF 12 in 18 of 22 patients ( 81,8%). In 8 of the 12 patients with irritative voiding symptoms we observed significant improvements (66% ). These evaluations were confirmed by the dates at three and six months after therapy ( 16 and 14 of 22 patients). No adverse reactions were recognized during administration of the drug.

==fine results==

==inizio discussions==

Pelvic pain is pain in the area of the pelvis. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both women and men. Chronic pelvic pain in men is often referred to as Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP/CPPS). This pain is associated with irritative voiding symptoms and/or pain located in the groin, genitalia, or perineum in the absence of pyuria and bacteriuria. The use of the term prostatodynia is not encouraged in current practice. This term carries the negative historical connotation of being a “wastebasket” designation for a melange of psychosomatic symptoms and suggests that the source of the patient’s symptoms invariably lies within the prostate gland itself. Current research has provided evidence of numerous extraprostatic considerations, including neuropathic and other systemic pathologies.
There are no standard diagnostic tests; diagnosis is by exclusion of other disease entities. Multimodal therapy is the most successful treatment option, and includes blockers, phytotherapy, and protocols aimed at quieting the pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control. Recently some protocols have used Palmitoylethanolamide (PEA). It is an endogenous fatty acid amide, belonging to the class of nuclear factor agonists. PEA, as an N-acylethanolamine, has physico-chemical properties comparable to anandamide, and while it is not strictly an endocannabinoid, it is often studied in conjunction with anandamide because of their overlapping synthetic and metabolic pathways. The signaling lipid PEA is known to activate intracellular, nuclear and membrane-associated receptors and regulate many physiological functions related to the inflammatory cascade and chronic pain states. PEA’s mechanism of action sometimes is described as Autacoid Local Injury Antagonism (acronym ALIA),and PEA under this nomenclature is an ALIAmide. Since 1993, many papers have been published on the various effects of PEA on the mast cell. Mast cells are often found in proximity to sensory nerve endings and their degranulation can enhance the nociceptive signal, the reason why peripheral mast cells are considered to be pro-inflammatory and pro-nociceptive and in this work has been used successfully in association with pelvic rehabilitation, in order to emphasize the role of the drug with the use of relaxing exercises understood through biofeedback.

==fine discussions==

==inizio conclusion==

PEA’s activity is currently seen as a new inroad in the treatment of neuropathic pain and related disorders. PEA has been explored in various clinical trials in a variety of pain states, for inflammatory and pain syndrome. From a clinical perspective the most important and promising indications for PEA are linked to neuropathic and chronic pain states, such as diabetic neuropathic pain, sciatic pain, CRPS, pelvic pain and entrapment neuropathic pain states.
Although the limited number of treated patients in this work Palmitoylethanolamide, in association with pelvic floor rehabilitation, seems to be a useful alternative in the first step of treatment of chronic pelvic pain in men with or without voiding symptoms.

==fine conclusion==

==inizio references==

Treatment of the musculoskeletal component of chronic pelvic and perineal pain
M Guerineau, J-J Labat, L Sibert, D Delavierre, J Rigaud
Nov 2010 • Progrès en Urologie

Pelvic Floor Muscle Examination in Female Chronic Pelvic Pain
Colleen M Fitzgerald, Cynthia E Neville, Trudy Mallinson, Suzanne A Badillo, Christina K Hynes, Frank F Tu . Jun 2011 • The Journal of reproductive medicine

Efficacy of Kegel exercises on lower back pain control in patients of Cystocele
T. Naqaish, F. Rizvi, S. Ambreen
Jan 2013 • Rawal Medical Journal

==fine references==