OnabotulinumtoxinA is an FDA-approved treatment for adults with overactive bladder (OAB) who have an inadequate response to, or are intolerant of, oral pharmacotherapies including anticholinergics or beta-3 agonists. However, procedural practices of onabotulinumtoxinA intradetrusor injection vary among practitioners and can affect patient experience. To address this, a panel of six high-volume intravesical onabotulinumtoxinA providers with 100 years of combined experience convened to discuss the best office practices when treating patients with OAB. These key best practices include counseling patients on available OAB therapies, including onabotulinumtoxinA, at the initial consultation in accordance with established AUA and SUFU guidelines in a way that is easily understood. An office setting is preferred over a hospital or surgery center when performing the procedure. Staff involvement, from scheduling to post-procedure, is essential for establishing the relationships necessary to optimize patient experience and encourage compliance and retreatment. Experts generally recommend using a viscous lidocaine bladder instillation for an anesthetic 15 min prior to the reconstitution of onabotulinumtoxinA with 5 to 10 mL of normal saline. A range of one to 20 injection sites is acceptable, with a smaller number preferred. Starting in the lower bladder, experts recommend using a slower speed of injection to improve distribution and decrease patient discomfort. Subsequent treatments should be regularly scheduled at six-month intervals with the option of re-treating earlier if symptoms return, but no sooner than 12 weeks. For office intravesical onabotulinumtoxinA procedures, optimization of the patient experience by the physician and their staff, starting with the initial visit through the post-treatment follow-up, is key to long-term patient compliance.

INTRODUCTION:Onabotulinumtoxin A (BTX-A) is a minimally invasive therapy for idiopathic overactive bladder (iOAB). Incomplete bladder emptying is a known risk of the procedure, with an overall rate as high as 20% in male and female patients. Risk factors for incomplete bladder emptying after BTX-A have been reported in the literature, but are widely variable amongst studies and therefore patients at increased risk of this adverse effect cannot easily be identified by clinicians. The aim of this study was to evaluate whether pre-procedure urodynamics (UDS) findings are associated with incomplete bladder emptying after intradetrusor BTX-A injection for iOAB. METHODS:Data were analyzed from the SUFU Research Network (SURN) multi-institutional retrospective database. Men and women undergoing first-time injection of 100 units BTX-A for iOAB in 2016 were included. Subjects were excluded if they did not have record of pre-procedure and post-procedure (within 1 month) post-void residual volume (PVR). The primary outcome was incidence of urinary retention within 1 month after BTX-A, defined as PVR > 300 mL and/or initiation of self-catheterization or indwelling catheter. We assessed the association of pre-procedure UDS parameters with urinary retention using Wilcoxon rank tests, Fisher's exact test, and chi-squared tests. RESULTS:A total of 167 subjects (141 women, 26 men) were included. Ninety-nine subjects (59%) had urodynamic data. Thirty-seven subjects (22%) had urinary retention within 1 month of BTX-A. There were no significant differences in age, gender, race, or body mass index between the retention and non-retention groups. There was no statistically significant difference in median Qmax between those who did and did not have postprocedure retention (10.0 vs. 14.3 mL/s respectively, p = 0.06). Mean PVR at the start of UDS was not statistically significant when comparing the retention and non-retention groups (22.5 vs. 10.0 mL respectively, p = 0.70). Bladder outlet obstruction index (BOOI), bladder contractility index (BCI), and presence of detrusor overactivity (DO) were not found to be associated with posttreatment retention. CONCLUSION:This retrospective multi-institutional cohort study revealed that of patients who receive UDS before BTX-A, there are no significant UDS parameters or baseline demographic factors associated with incomplete bladder emptying after intradetrusor BTX-A injections for iOAB. Future studies that focus on better defining objective evidence-based predictors of incomplete emptying after BTX are needed to optimize patient perception of efficacy and satisfaction with this therapy.

To systematically evaluate and synthesize the existing literature on treatment outcomes for primary bladder neck obstruction (PBNO) in women, given the absence of prior systematic reviews focused on this population. Current treatment options for PBNO in women include nonsurgical alpha-adrenergic receptor blockers (AB), surgical bladder neck incision (BNI), and investigational use of onabotulinumtoxinA injections (BTX-BN). Success rates for AB and BNI are approximately 50

The purpose of this review is to better understand the etiology and prevalence of primary bladder neck obstruction (PBNO) in women. In addition, we hope to provide an update on current diagnostic tools and treatment modalities for this condition. New studies show that magnetic resonance imaging may be beneficial for the diagnosis of PBNO. In addition, studies have shown improvement in symptoms and urodynamic parameters for onabotulinumtoxinA (onaBoNTA) injection at the bladder neck. Lastly, surgical technique has been modified to minimize the risk of stress urinary incontinence and vesicovaginal fistula traditionally associated with transurethral incision of the bladder neck (TUIBN). PBNO is a functional obstruction of the bladder when the bladder neck fails to adequately open during voiding. The exact etiology and prevalence are unknown. Patients usually present with obstructive voiding symptoms, and uroflow and post-void residual volumes can be used as an adjunct for screening for this condition. While urodynamic parameters defining outlet obstruction may be beneficial, videourodynamics is the mainstay of diagnosis, as fluoroscopic imaging of the open bladder neck during voiding is critical. Treatment options include expectant management, pharmacotherapy with α-adrenergic receptor blockers, onaBoNTA injection at the bladder neck and/or surgery, where the gold standard for treatment is TUIBN.

Overactive bladder (OAB) is a prevalent and potentially debilitating syndrome that significantly impairs quality of life. Mirabegron and vibegron are β3-adrenoceptor (β3AR) agonists that provide a different mechanism of action to antimuscarinic medications. Vibegron has high β3AR selectivity and enhances detrusor relaxation without compromising voiding function. This review summarises the clinical and real-world evidence supporting the efficacy, safety and patient-reported benefits of vibegron in OAB. A comprehensive search of the PubMed database was conducted in December 2024 using the keyword "vibegron". This search yielded 123 entries, which were subsequently screened by title for relevance to the objectives of this narrative review. All relevant articles identified through this process were included. Pivotal phase III trials have demonstrated significant reductions in urgency, urinary frequency and urgency urinary incontinence with vibegron, with rapid onset of action and a more favourable tolerability profile than antimuscarinics. The benefits of vibegron were consistent across diverse patient populations, including older adults and those with concomitant benign prostatic hyperplasia. Real-world data further suggest that vibegron is associated with improved adherence and persistence compared with other OAB therapies. Additionally, cardiovascular safety studies confirm that vibegron has no clinically significant effects on blood pressure or heart rate. While comparative trials with mirabegron indicate similar efficacy, vibegron’s higher β3AR selectivity and lack of cytochrome P450 interactions offer advantages in specific patient groups. Ongoing research, including real-world phase IV studies, aims to further define the long-term effectiveness and safety of vibegron in clinical practice. Vibegron represents an important advance in the pharmacologic management of OAB, providing a well-tolerated and effective alternative to existing therapies.

OnabotulinumtoxinA (onabotA) is approved for the treatment of various therapeutic indications, which require retreatment. In clinical practice, many patients receive onabotA for multiple therapeutic indications concomitantly over extended time periods; however, there is limited long-term utilization and safety data for treating comorbid indications. SYNCHRONIZE, a 2-year, multicenter, retrospective observational chart review study in 10 US clinics, describes onabotA real-world utilization and safety in adults treated for ≥2 therapeutic indications within repeating 3-month periods for up to 7 treatments. This analysis assessed the long-term onabotA safety profile for multiple therapeutic indications by analyzing the incidence of treatment-emergent adverse events (TEAEs). Of 279 patients treated for ≥2 different therapeutic indications across all treatment combination groups in Period1, there was a gradual decrease to 80 patients at the last treatment period. The overall mean onabotA treatments over the study period was 9.3 (range: 2-48). Across treatment periods, most patients had a treatment interval between different indications of ≤24 h (range: 62-98 %) and received ≥200-<400U of cumulative 3-month dosages for multiple indications (range: 43 %-50 %) with a mean 3-month dose from 231.8 to 287.0 U. In total, 28.7 % of patients reported ≥1 TEAE after Period1; this proportion remained broadly constant across treatments (range: 28.3-31.8 %). Overall, the most common TEAEs across treatments were UTIs (range: 0.7-5.7 %), neck pain (range: 3.7-9.1 %), headache (range: 2.9-6.5 %), and migraine (range: 2.5-6.4 %). There was no apparent trend between TEAE incidence and treatment intervals nor cumulative 3-month dose categories for multiple indications. No patients were determined to have lack of effect based on clinical objective measurement. OnabotA showed a safety profile with no new signals in patients treated concomitantly for ≥2 therapeutic indications over repeat treatments up to 2 years. TEAEs across treatment periods were commonly related to the site of injection and were consistent with those previously reported for individual indications.

OBJECTIVE To determine how a patient's demographics, including insurance type, race/ethnicity, gender, and age, may impact the choice of medication prescribed for overactive bladder (OAB). METHODS We queried the AUA Quality Registry for adults between 2014 and 2020 with a diagnosis of OAB for > 1 year, excluding neurogenic causes. Variables included age, race/ethnicity, gender, insurance type, medication first prescribed, year of prescription, provider metropolitan status, and provider practice type. Primary outcome was which factors were associated with increased odds of beta-3 prescription as first medication choice. RESULTS We found 1,453,566 patients with OAB, 641,122 (44.1%) with complete data. Of these, 112,021 (17.5%) were prescribed medication. On multivariate analysis, patients with Medicaid, Medicare, and other/self-pay insurance were less likely to receive a beta-3 vs an anticholinergic compared to private or military insurance. Compared to white patients, Asian, Black, and other races were less likely to receive a beta-3, as were patients outside of metropolitan areas. Age > 50, prescriptions after 2014, and nonacademic settings were associated with increased odds of beta-3 prescription. There was no difference between genders. CONCLUSION Many nonclinical factors, including insurance type and race, may affect which medication is first prescribed for OAB. This is useful for practicing urologists and may help lower barriers to beta-3 prescription through policy change and advocacy. UROLOGY 184: 51-57, 2024. (c) 2023 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Overactive Bladder II (PD54)1 May 2024PD54-06 PREOPERATIVE URODYNAMIC FINDINGS ARE NOT ASSOCIATED WITH URINARY RETENTION AFTER BLADDER ONABOTULINUMTOXINA INJECTION Anjali Kapur, Katherine Shapiro, Meredith Wasserman, Shavy Nagpal, Giulia Ippolito, Ariana Smith, Una Lee, Anne Suskind, Jennifer Anger, Doreen Chung, W. Stuart Reynolds, Anne Cameron, Christopher Tenggardjaja, Priya Padmanabhan, Benjamin Brucker, and SUFU Research Network* Anjali KapurAnjali Kapur , Katherine ShapiroKatherine Shapiro , Meredith WassermanMeredith Wasserman , Shavy NagpalShavy Nagpal , Giulia IppolitoGiulia Ippolito , Ariana SmithAriana Smith , Una LeeUna Lee , Anne SuskindAnne Suskind , Jennifer AngerJennifer Anger , Doreen ChungDoreen Chung , W. Stuart ReynoldsW. Stuart Reynolds , Anne CameronAnne Cameron , Christopher TenggardjajaChristopher Tenggardjaja , Priya PadmanabhanPriya Padmanabhan , Benjamin BruckerBenjamin Brucker , and SUFU Research Network* View All Author Informationhttps://doi.org/10.1097/01.JU.0001008724.35538.9c.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Onabotulinumtoxin A (BTX-A) is a third-line therapy for idiopathic overactive bladder (iOAB). Transient urinary retention is a known risk of the procedure occurring in 5% of patients; however, risk factors for retention are unknown. The aim of this study was to evaluate whether pre-procedure urodynamics (UDS) findings are associated with for retention after BTX-A injection for iOAB. METHODS: Men and women undergoing first-time 100 unit BTX-A injection for iOAB in 2016, within the SUFU Research Network (SURN) multi-institutional retrospective database, were included. Patients were excluded if they did not have pre-procedure and post-procedure (within 1 month) post-void residual volume (PVR). The primary outcome was incidence of urinary retention within 1 month after BTX-A, defined as PVR >300mL and/or initiation of self-catheterization or indwelling catheter. We assessed the association of UDS parameters with retention using Wilcoxon rank tests and chi-square tests. RESULTS: A total of 193 subjects (159 women, 34 men) were included in the final analysis. 42 patients (22%) had retention within 1 month of BTX-A. There were no significant differences in age, gender, race, or medical history (e.g. diabetes, stroke) between the retention and non-retention groups. There was no statistically significant difference in median Qmax between those who did and did not have post-procedure retention (11 vs 14 ml/s respectively, p=0.13). Mean PVR at the start of UDS did not reach statistical significance when comparing the retention and non-retention groups (22.5 vs. 10mL respectively, p=0.9). Bladder outlet obstruction index (BOOI), bladder contractility index (BCI), and presence of detrusor overactivity (DO) were not found to be associated with post-procedure retention (Table 1). CONCLUSIONS: This retrospective multi-institutional cohort study did not reveal any significant baseline demographic factors or urodynamic parameters predictive of urinary retention after intradetrusor BTX-A injections for iOAB. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e1145 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Anjali Kapur More articles by this author Katherine Shapiro More articles by this author Meredith Wasserman More articles by this author Shavy Nagpal More articles by this author Giulia Ippolito More articles by this author Ariana Smith More articles by this author Una Lee More articles by this author Anne Suskind More articles by this author Jennifer Anger More articles by this author Doreen Chung More articles by this author W. Stuart Reynolds More articles by this author Anne Cameron More articles by this author Christopher Tenggardjaja More articles by this author Priya Padmanabhan More articles by this author Benjamin Brucker More articles by this author SUFU Research Network* More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION:Bladder outlet obstruction (BOO) in women includes functional and anatomic etiologies. Primary bladder neck obstruction (PBNO), Fowler's syndrome (FS), and dysfunctional voiding (DV) are some examples of functional obstructions, whereas pelvic organ prolapse (POP), periurethral masses, and intragenic causes are some of the anatomic causes. METHODS:This literature review describes the etiologies of female BOO, unique aspects of the workup and diagnosis, and the data for the standard surgical treatments and newer surgical techniques to treat women. Urethral stenosis and sling-related obstruction are treated in the other articles of this series. Where possible the focus is the efficacy and outcomes. RESULTS:Treatment of PBNO using a transurethral incision of the bladder neck and injection of botulinum toxin in the bladder neck decreases the BOO. After the failure of conservative approaches, sacral neuromodulation (SNM) is effective for FS, while DV may benefit from SNM or botulinum toxin injections. Concerning POP, most surgeries have been reported to significantly improve a pre-existent BOO but the level of evidence is low. Benign urethral and periurethral masses may provoke BOO, and surgical excision usually resolves this condition. CONCLUSION:Although most surgical treatments of BOO for functional and benign anatomical etiologies in women seem to be effective, data are scarce even for more common conditions like POP. Further studies are required to give better advice on the choice of surgical technique for these patients.

OnabotulinumtoxinA (onabotA) is approved in the US for 12 therapeutic indications. Real-world data on onabotA multi-indication use are limited, often leading to delayed or reduced treatment. This study provides real-world evidence on the safety of onabotA when treating multiple indications concomitantly. SYNCHRONIZE was a multicenter, retrospective, chart-review study evaluating onabotA’s safety for adults treated for ≥2 therapeutic indications within a 3-month period. The primary outcome was treatment-emergent adverse events (TEAEs) within 6 months post-treatment. A total of 279 patients were included. The most common concomitant indications treated were cervical dystonia and chronic migraine (43.4%). The average 3-month cumulative dose for multiple indications was 282.2 U. The treatment interval for multiple indications was ≤24 h for most patients (62.4%). Overall, 28.7% of patients reported ≥1 TEAE with no apparent trends in TEAEs and dose interval or cumulative dose. Reported TEAEs included UTI (5.7%), neck pain (5.0%), and headache (4.3%). No patient had a lack of effect according to clinical objective measurements. SYNCHRONIZE described the real-world safety of onabotA for patients treated concomitantly for ≥2 indications within a 3-month period. TEAEs were generally consistent with the known safety profiles of individual indications. No new safety signals were identified).

Importance Urinary incontinence (UI) is a common and treatable medical condition among women, but only approximately one third of women seek care. Objective The objective of this study was to determine factors associated with care-seeking behavior in women with UI. Study Design This was a cross-sectional study using patient-reported survey data collected by the National Association for Continence from November 2018 to January 2019. This survey included 60 questions and was conducted using SurveyMonkey. Descriptive statistics were used for baseline characteristics, the χ2 test was used for categorical variables, and multivariate logistic regression was used to determine predictors of care-seeking behavior. Results Four hundred eighty-five women completed the survey, 30.7% were not care seeking, and 69.3% were care seeking for UI. Most women were 55 years or older and had UI for more than 4 years. Care-seeking women had more overactive bladder symptoms. Women who sought care were more likely to report feelings of anger, depression, hopelessness, isolation, and report greater social effects from UI than non–care-seeking women. Less than 10% of women who sought care were asked about their UI by a medical professional. In the multivariate logistic regression expenditure of $5 or more on monthly incontinence maintenance, daily UI and older age were associated with seeking care. Conclusions Most women in our study population sought care for UI. Factors associated with seeking care were expenditure greater than $5 per month on incontinence, daily UI, and age. This information demonstrates the need for effective implementation of screening interventions to increase treatment access.

OBJECTIVE:The aim of this study was to compare the efficacy of a non-hormone alternative, vaginal hyaluronic acid (HLA), to a standard-of-care therapy, vaginal estrogen, for the treatment of genitourinary syndrome of menopause (GSM). METHODS:This was a randomized, parallel arm pilot trial. Women with GSM were randomized to an HLA vaginal suppository or vaginal estrogen cream for 12 wk to compare the primary outcome, the vulvovaginal symptom questionnaire (VSQ) score. Secondary outcomes included the following: the female sexual function index (FSFI), the vaginal symptom index (VSI), visual analog scale (VAS) for dyspareunia, vaginal itching, and vaginal dryness, patient global impression of improvement (PGI-I) at follow-up, vaginal maturation index, and vaginal pH. Differences between treatment groups were estimated using the two-sided, two-sample t -test and 95% confidence intervals. RESULTS:Forty-nine women were randomized and 45 participants (vaginal estrogen = 23, vaginal HLA = 22) provided data at week 12. Baseline characteristics were similar in both groups. On the VSQ, there was no observed difference in overall scores between the HLA and vaginal estrogen groups at 12 wk ( P = 0.81). Improvement was seen within both treatment groups on the VSQ after 12 wk. The VAS score, total VSI score, total FSFI score, and vaginal pH improved over time; however, improvement did not differ between study arms. Over 90% participants noted improvement on the PGI-I in both groups ( P = 0.61). No treatment-related serious adverse events occurred. CONCLUSIONS:There were no clinically meaningful differences between vaginal HLA and vaginal estrogen for the treatment of GSM after 12 wk. Vaginal HLA may be a promising non-hormone therapy for GSM.

OBJECTIVE To report out-of-pocket costs associated with overactive bladder (OAB) medications among Medicare beneficiaries and the uninsured. METHODS We performed a cross-sectional analysis of the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary Data (Q1-2022). FDA -approved medications for OAB were identified. We calculated out-of-pocket costs for Medicare beneficiaries in each Part D prescription benefit phase, average retail price, total yearly costs and discounted prices through cash -pay discount coupons (GoodRx) or online pharmacies like Mark Cuban Cost Plus Drug Company (MCCPDC). We also report plan utilization management requirements. RESULTS We analyzed 5721 plan formularies for 18 medications. Mirabegron was the only beta -3 agonist (B3). Only Vesicare oral solution (14.3% of plans) and Mirabegron (0.1%) required prior authorization. Many plans required step therapy for selective generic anticholinergics (ACH) (12.4%-43.3%), while the B3 rarely required step therapy (0.6%). Monthly costs varied by coverage phase and averaged $59 for ACHs in the initial coverage phase ($14 in catastrophic; $72 in coverage gap). The monthly cost for the B3 averaged $47 in the initial coverage phase ($26 in catastrophic; $129 in coverage gap). The total yearly cost for generic ACHs ranged from $494 (oxybutynin IR) to $1452 (darifenacin) and the yearly cost for brand -name ACHs ranged from $1175 (Toviaz ER) to $2198 (Oxytrol). The total yearly cost for the B3 was $1283. CONCLUSION We evaluated coverage, out-of-pocket costs, total yearly costs, and utilization management for OAB medications to make pricing more transparent. While selective medications may be "covered," coverage does not translate into affordable drug prices. UROLOGY 183: 57-62, 2024. (c) 2023 Elsevier Inc. All rights reserved.

INTRODUCTION:With increased access to gender affirming care, the rate of vaginoplasties in the US has risen rapidly. Although some retrospective studies report high rates of lower urinary tract symptoms (LUTS) after gender affirming vaginoplasty, the type and severity of symptoms has not been well-described. The purpose of this study was to prospectively characterize postoperative changes in lower urinary tract function after robotic peritoneal flap vaginoplasty as measured by the American Urological Association Symptom Index questionnaire (AUASI), Urogenital Distress Inventory 6 (UDI6), and additional measures. METHODS:This was a prospective observational study of patients undergoing gender affirming robotic peritoneal flap vaginoplasty enrolled between August 2020 to September 2021. LUTS were evaluated pre- and postoperatively (1, 3, 6, and 12-month) via the AUASI, UDI6, uroflowmetry, and post void residual (PVR) measurements. Averages and 95% confidence intervals over time were estimated and compared through univariate mixed-effect linear regression models. RESULTS:A total of 43 patients were enrolled. The average patient age was 31.1 ± 9.1 years. Overall AUASI Score declined over time (p = 0.002; -0.42,-0.09), though the decrease was less than the clinically minimum importance difference (MID) of 3 points. Preoperative AUASI was 8.1 ± 5.2, 1 month: 8.1 (95% CI: -1.9,1.8); 3 months: 5.2 (-5.0,-1.2); 6 months: 5.7 (-4.6,-0.62); 12 months: 5.2 (-4.9,-0.81). Similarly, UDI6 score declined over time (p = 0.002; -1.12,-0.26), though the decrease was less than MID of 16.7 points. UDI6 score preoperatively was 16.3 ± 1.8; 1 month post op: 16.5 (-5.2,5.0); 3 months: 16.2 (-5.6,5.1); 6 months: 11.6 (-10,1.0), and at 12 months: 8.1 (-13,-2.3). Overall uroflowmetric outcomes measured at postoperative visits including post void residual volume, maximum flow velocity, and average flow velocity did not show any difference at any postoperative time point when compared with preoperative measurements. CONCLUSIONS:In this study both the AUASI and UDI6 declined over time from initial preoperative evaluation to the 12 month follow up period, although the changes in AUASI and UDI6 score did not reach MID. Additionally, urodynamic measurements remained unchanged postoperatively. This data suggests that robotic peritoneal flap vaginoplasty has no effect on lower urinary tract function.

Introduction: Overactive bladder (OAB) patients who do not achieve satisfactory results with second-line OAB medications should be offered third-line therapies (percutaneous tibial nerve stimulation, sacral neuromodulation, onabotulinumtoxinA bladder injection [BTX-A]). We aimed to determine which clinical factors affect progression from second- to third-line OAB therapy. Methods: Between 2014 and 2020, the AUA Quality Registry was queried for adult patients with idiopathic OAB. For the primary outcome, patient and provider factors associated with increased odds of progression from second- to third-line therapy were assessed. Secondary outcomes included median time for progression to third-line therapy and third-line therapy utilization across subgroups. Results: A total of 641,122 patients met inclusion criteria and were included in analysis. Of these, only 7487 (1.2%) received third-line therapy after receiving second-line therapy. On multivariate analysis, patients aged 65 to 79, women, White race, history of dual anticholinergic and beta 3 agonist therapy, metropolitan area, government insurance, and single specialty practice had the greatest odds of progressing to third-line therapy. Black and Asian race, male gender, and rural setting had lower odds of progressing to third-line therapy. BTX-A was the most common therapy overall (40% BTX-A, 32% sacral neuromodulation, 28% percutaneous tibial nerve stimulation). The median time of progression from second- to third-line therapy was 15.4 months (IQR 5.9, 32.4). Patients < 50 years old and women progressed fastest to third-line therapy. Conclusions: Very few patients received third-line therapies, and the time to progression from second- to third-line therapies is > 1 year. The study findings highlight a potential need to improve third-line therapy implementation.

Ehlers-Danlos syndrome (EDS) is a hereditary tissue and collagen synthesis disorder that can predispose patients to gynecologic and obstetric complications. Female patients often suffer from bothersome pelvic floor disorders, but due to the medical complexity of EDS, special considerations are needed for the treatment of pelvic organ prolapse and associated incontinence. In this paper, we present three unique cases of pelvic organ prolapse (POP) in EDS patients and delve deeper into the multidisciplinary approach involving urogynecology, rheumatology, physiatry, gastroenterology, and anesthesiology required to appropriately manage this condition.

Urogenital fistulae are defined as abnormal connections between genitourinary organs. Worldwide, the majority of fistulae occur in the developing world and are secondary to sequalae of obstructed labor and lack of access to medical care. In the developed world, the majority of fistulous connections occur following pelvic surgery, particularly in the setting of unrecognized injury to the urinary tract during hysterectomy. Fistulae can have a negative impact on quality of life, not to mention a significant psychosocial and financial burden to the individual and healthcare system, respectively. It is essential that clinicians maintain a high level of suspicion and perform a thorough evaluation to diagnose and appropriately manage urogenital fistulae in a prompt and efficient manner. This chapter explores the etiology, presentation, evaluation, and diagnosis of urogenital fistulae. Particular attention is paid to the presentation, appropriate investigation, and expected findings of the most common urogenital fistulae, including vesicovaginal, ureterovaginal, and urethrovaginal fistulae.