AUA Annual Meeting 2011

WASHINGTON – Research has documented a strong association between the formation of kidney stones and the presence or development of cardiovascular disease, metabolic syndrome, and a number of components of the metabolic syndrome, said Dr. Dean G. Assimos.

"There is increasing evidence" of this link, he noted at the annual meeting of the American Urological Association. "We need to be cognizant of these associations."

Most recently, an analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study showed that individuals who developed kidney stones had a 1.6-fold increased risk of developing subclinical carotid artery atherosclerosis, even after adjustments for major cardiovascular risk factors were made, said Dr. Assimos, professor of urology at Wake Forest University, Winston-Salem, N.C.

The longitudinal cohort study followed 5,115 white and black men and women who were 18-30 years old at the time of recruitment in 1985-1986. Carotid artery intima-media thickness was measured with serial ultrasound periodically throughout the observation period. By 20 years, almost 4% had reported having kidney stones, and kidney stones were associated with a 60% increased risk of carotid atherosclerosis (J. Urol. 2011;185:920-5). Kidney stones were associated with myocardial infarction (MI) in another recent study aimed specifically at assessing "the risk of a kidney stone former developing an MI," Dr. Assimos said. Investigators of this case-controlled study matched almost 4,600 stone formers on age and sex with almost 11,000 control subjects among residents of Olmstead County, Minn.

During a mean follow-up of 9 years, "despite controlling for other medical comorbidities," investigators found that "stone formers had a 31% increased risk of sustaining an MI," he said.

Chronic kidney disease, which itself is a risk factor for MI, was one of the comorbidities adjusted for (J. Am. Soc. Nephrol. 2010;21:1641-4).

Numerous studies published since 2005 have demonstrated positive associations between kidney stone formation and specific components of the metabolic syndrome, as well as with the full constellation of disorders, Dr. Assimos said.

An analysis of National Health and Nutrition Examination Survey III data published in 2008, for instance, showed that individuals with four traits of the metabolic syndrome had two times the risk of having a history of kidney stones (Am. J. Kidney Dis. 2008;51:741-7). The prevalence of self-reported history of kidney stones, moreover, increased as the number of traits or component disorders of the metabolic syndrome increased, from 3% with no disorders to 7.5% with three disorders, and to almost 10% with five disorders. (An individual must have at least three of the five component disorders to qualify as having the metabolic syndrome.)

Similarly, in an Italian study of hospitalized adults, more than 10% of 725 patients with metabolic syndrome had evidence of nephrolithiasis on renal ultrasound (Nephrol. Dial. Transplant 2009;24:900-6). "This is 10 times higher than [rates reported from] renal ultrasound screening studies done in the general population," Dr. Assimos said.

Data from three large cohorts – the Nurses’ Health Study (NHS) I of older women, the NHS II of younger women, and the Health Professionals Follow-Up Study (HPFS) of men aged 40-75 years – have been crucial in elucidating the associations between kidney stones and specific components of the metabolic syndrome.

In one prospective study of the cohorts that looked at the incidence of symptomatic kidney stones, for instance, investigators documented that the relative risk of an obese individual (body mass index, 30 kg/m² or greater) for kidney stone formation, compared with individuals with a BMI of 21-23, was 1.9 in the NHS I cohort, 2.09 in the NHS II cohort, and 1.33 in the HPFS cohort (JAMA 2005;293:455-62).

"There was also a positive correlation in all these cohorts with waist circumference," Dr. Assimos said.

Other analyses of these cohorts have documented positive associations between type 2 diabetes or hypertension, and incident kidney stone formation, as well as associations between a history of kidney stone formation and the diagnosis of diabetes or development of hypertension.

The causative factors underlying the associations between stone formation and cardiovascular disease and the metabolic syndrome include low urinary pH levels. At lower urinary pH levels, "more [of the body’s] uric acid is in its undissociated form and is insoluble in urine," for instance, which increases the risk of uric acid stone formation, Dr. Assimos said.

Studies have demonstrated a negative correlation between BMI and urinary pH, he noted. The reasons are not fully known, but "it is hypothesized that individuals [with higher BMI] do not produce ammonium effectively in the proximal tubule," he said.

Individuals with obesity and low urinary pH also excrete greater amounts of calcium and oxalate, and this increases the risk of calcium oxalate stone formation, he said.

Dr. Assimos’s own research team has identified a possible new pathway for the endogenous synthesis of oxalate. It involves the metabolism of glyoxal, which is stimulated by oxidative stress. The glyoxal metabolism "may explain the increased oxalate excretion in those with obesity as well as diabetes," he said.

The associations between kidney stone formation and cardiovascular risk have hit home for Dr. Assimos, he said at the end of his presentation. At age 39, he developed his first kidney stone. By 3 years later, he developed hypertension. "And 3 years ago. I started having symptoms of gastroesophageal reflux when exercising ... I had a stress test ... and here is my coronary arteriogram," he told the audience. The end result, he said, was successful coronary artery bypass grafting.

Dr. Assimos reported that he is an investigator for the National Institutes of Health and a partner at Piedmont Stone, a facility in Winston-Salem that provides lithotripsy procedures.

WASHINGTON – Research has documented a strong association between the formation of kidney stones and the presence or development of cardiovascular disease, metabolic syndrome, and a number of components of the metabolic syndrome, said Dr. Dean G. Assimos.

"There is increasing evidence" of this link, he noted at the annual meeting of the American Urological Association. "We need to be cognizant of these associations."

Most recently, an analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study showed that individuals who developed kidney stones had a 1.6-fold increased risk of developing subclinical carotid artery atherosclerosis, even after adjustments for major cardiovascular risk factors were made, said Dr. Assimos, professor of urology at Wake Forest University, Winston-Salem, N.C.

The longitudinal cohort study followed 5,115 white and black men and women who were 18-30 years old at the time of recruitment in 1985-1986. Carotid artery intima-media thickness was measured with serial ultrasound periodically throughout the observation period. By 20 years, almost 4% had reported having kidney stones, and kidney stones were associated with a 60% increased risk of carotid atherosclerosis (J. Urol. 2011;185:920-5). Kidney stones were associated with myocardial infarction (MI) in another recent study aimed specifically at assessing "the risk of a kidney stone former developing an MI," Dr. Assimos said. Investigators of this case-controlled study matched almost 4,600 stone formers on age and sex with almost 11,000 control subjects among residents of Olmstead County, Minn.

During a mean follow-up of 9 years, "despite controlling for other medical comorbidities," investigators found that "stone formers had a 31% increased risk of sustaining an MI," he said.

Chronic kidney disease, which itself is a risk factor for MI, was one of the comorbidities adjusted for (J. Am. Soc. Nephrol. 2010;21:1641-4).

Numerous studies published since 2005 have demonstrated positive associations between kidney stone formation and specific components of the metabolic syndrome, as well as with the full constellation of disorders, Dr. Assimos said.

An analysis of National Health and Nutrition Examination Survey III data published in 2008, for instance, showed that individuals with four traits of the metabolic syndrome had two times the risk of having a history of kidney stones (Am. J. Kidney Dis. 2008;51:741-7). The prevalence of self-reported history of kidney stones, moreover, increased as the number of traits or component disorders of the metabolic syndrome increased, from 3% with no disorders to 7.5% with three disorders, and to almost 10% with five disorders. (An individual must have at least three of the five component disorders to qualify as having the metabolic syndrome.)

Similarly, in an Italian study of hospitalized adults, more than 10% of 725 patients with metabolic syndrome had evidence of nephrolithiasis on renal ultrasound (Nephrol. Dial. Transplant 2009;24:900-6). "This is 10 times higher than [rates reported from] renal ultrasound screening studies done in the general population," Dr. Assimos said.

Data from three large cohorts – the Nurses’ Health Study (NHS) I of older women, the NHS II of younger women, and the Health Professionals Follow-Up Study (HPFS) of men aged 40-75 years – have been crucial in elucidating the associations between kidney stones and specific components of the metabolic syndrome.

In one prospective study of the cohorts that looked at the incidence of symptomatic kidney stones, for instance, investigators documented that the relative risk of an obese individual (body mass index, 30 kg/m² or greater) for kidney stone formation, compared with individuals with a BMI of 21-23, was 1.9 in the NHS I cohort, 2.09 in the NHS II cohort, and 1.33 in the HPFS cohort (JAMA 2005;293:455-62).

"There was also a positive correlation in all these cohorts with waist circumference," Dr. Assimos said.

Other analyses of these cohorts have documented positive associations between type 2 diabetes or hypertension, and incident kidney stone formation, as well as associations between a history of kidney stone formation and the diagnosis of diabetes or development of hypertension.

The causative factors underlying the associations between stone formation and cardiovascular disease and the metabolic syndrome include low urinary pH levels. At lower urinary pH levels, "more [of the body’s] uric acid is in its undissociated form and is insoluble in urine," for instance, which increases the risk of uric acid stone formation, Dr. Assimos said.

Studies have demonstrated a negative correlation between BMI and urinary pH, he noted. The reasons are not fully known, but "it is hypothesized that individuals [with higher BMI] do not produce ammonium effectively in the proximal tubule," he said.

Individuals with obesity and low urinary pH also excrete greater amounts of calcium and oxalate, and this increases the risk of calcium oxalate stone formation, he said.

Dr. Assimos’s own research team has identified a possible new pathway for the endogenous synthesis of oxalate. It involves the metabolism of glyoxal, which is stimulated by oxidative stress. The glyoxal metabolism "may explain the increased oxalate excretion in those with obesity as well as diabetes," he said.

The associations between kidney stone formation and cardiovascular risk have hit home for Dr. Assimos, he said at the end of his presentation. At age 39, he developed his first kidney stone. By 3 years later, he developed hypertension. "And 3 years ago. I started having symptoms of gastroesophageal reflux when exercising ... I had a stress test ... and here is my coronary arteriogram," he told the audience. The end result, he said, was successful coronary artery bypass grafting.

Dr. Assimos reported that he is an investigator for the National Institutes of Health and a partner at Piedmont Stone, a facility in Winston-Salem that provides lithotripsy procedures.

WASHINGTON – Research has documented a strong association between the formation of kidney stones and the presence or development of cardiovascular disease, metabolic syndrome, and a number of components of the metabolic syndrome, said Dr. Dean G. Assimos.

"There is increasing evidence" of this link, he noted at the annual meeting of the American Urological Association. "We need to be cognizant of these associations."

Most recently, an analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study showed that individuals who developed kidney stones had a 1.6-fold increased risk of developing subclinical carotid artery atherosclerosis, even after adjustments for major cardiovascular risk factors were made, said Dr. Assimos, professor of urology at Wake Forest University, Winston-Salem, N.C.

The longitudinal cohort study followed 5,115 white and black men and women who were 18-30 years old at the time of recruitment in 1985-1986. Carotid artery intima-media thickness was measured with serial ultrasound periodically throughout the observation period. By 20 years, almost 4% had reported having kidney stones, and kidney stones were associated with a 60% increased risk of carotid atherosclerosis (J. Urol. 2011;185:920-5). Kidney stones were associated with myocardial infarction (MI) in another recent study aimed specifically at assessing "the risk of a kidney stone former developing an MI," Dr. Assimos said. Investigators of this case-controlled study matched almost 4,600 stone formers on age and sex with almost 11,000 control subjects among residents of Olmstead County, Minn.

During a mean follow-up of 9 years, "despite controlling for other medical comorbidities," investigators found that "stone formers had a 31% increased risk of sustaining an MI," he said.

Chronic kidney disease, which itself is a risk factor for MI, was one of the comorbidities adjusted for (J. Am. Soc. Nephrol. 2010;21:1641-4).

Numerous studies published since 2005 have demonstrated positive associations between kidney stone formation and specific components of the metabolic syndrome, as well as with the full constellation of disorders, Dr. Assimos said.

An analysis of National Health and Nutrition Examination Survey III data published in 2008, for instance, showed that individuals with four traits of the metabolic syndrome had two times the risk of having a history of kidney stones (Am. J. Kidney Dis. 2008;51:741-7). The prevalence of self-reported history of kidney stones, moreover, increased as the number of traits or component disorders of the metabolic syndrome increased, from 3% with no disorders to 7.5% with three disorders, and to almost 10% with five disorders. (An individual must have at least three of the five component disorders to qualify as having the metabolic syndrome.)

Similarly, in an Italian study of hospitalized adults, more than 10% of 725 patients with metabolic syndrome had evidence of nephrolithiasis on renal ultrasound (Nephrol. Dial. Transplant 2009;24:900-6). "This is 10 times higher than [rates reported from] renal ultrasound screening studies done in the general population," Dr. Assimos said.

Data from three large cohorts – the Nurses’ Health Study (NHS) I of older women, the NHS II of younger women, and the Health Professionals Follow-Up Study (HPFS) of men aged 40-75 years – have been crucial in elucidating the associations between kidney stones and specific components of the metabolic syndrome.

In one prospective study of the cohorts that looked at the incidence of symptomatic kidney stones, for instance, investigators documented that the relative risk of an obese individual (body mass index, 30 kg/m² or greater) for kidney stone formation, compared with individuals with a BMI of 21-23, was 1.9 in the NHS I cohort, 2.09 in the NHS II cohort, and 1.33 in the HPFS cohort (JAMA 2005;293:455-62).

"There was also a positive correlation in all these cohorts with waist circumference," Dr. Assimos said.

Other analyses of these cohorts have documented positive associations between type 2 diabetes or hypertension, and incident kidney stone formation, as well as associations between a history of kidney stone formation and the diagnosis of diabetes or development of hypertension.

The causative factors underlying the associations between stone formation and cardiovascular disease and the metabolic syndrome include low urinary pH levels. At lower urinary pH levels, "more [of the body’s] uric acid is in its undissociated form and is insoluble in urine," for instance, which increases the risk of uric acid stone formation, Dr. Assimos said.

Studies have demonstrated a negative correlation between BMI and urinary pH, he noted. The reasons are not fully known, but "it is hypothesized that individuals [with higher BMI] do not produce ammonium effectively in the proximal tubule," he said.

Individuals with obesity and low urinary pH also excrete greater amounts of calcium and oxalate, and this increases the risk of calcium oxalate stone formation, he said.

Dr. Assimos’s own research team has identified a possible new pathway for the endogenous synthesis of oxalate. It involves the metabolism of glyoxal, which is stimulated by oxidative stress. The glyoxal metabolism "may explain the increased oxalate excretion in those with obesity as well as diabetes," he said.

The associations between kidney stone formation and cardiovascular risk have hit home for Dr. Assimos, he said at the end of his presentation. At age 39, he developed his first kidney stone. By 3 years later, he developed hypertension. "And 3 years ago. I started having symptoms of gastroesophageal reflux when exercising ... I had a stress test ... and here is my coronary arteriogram," he told the audience. The end result, he said, was successful coronary artery bypass grafting.

Dr. Assimos reported that he is an investigator for the National Institutes of Health and a partner at Piedmont Stone, a facility in Winston-Salem that provides lithotripsy procedures.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with "neurogenic bladder" and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the annual meeting of the American Urological Association.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

"Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive," said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but "they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity," Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is "always a point of contention," several studies have "clearly" shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators "saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) ... and most importantly, they did not see any change in the number of multidrug-resistant infections," he said.

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach "has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months ... presumably because the neurogenic bladder management is that much better," he said.

The term "neurogenic bladder," Dr. Kraus noted, is one that’s "not very precise." For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with "neurogenic bladder" and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the annual meeting of the American Urological Association.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

"Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive," said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but "they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity," Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is "always a point of contention," several studies have "clearly" shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators "saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) ... and most importantly, they did not see any change in the number of multidrug-resistant infections," he said.

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach "has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months ... presumably because the neurogenic bladder management is that much better," he said.

The term "neurogenic bladder," Dr. Kraus noted, is one that’s "not very precise." For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with "neurogenic bladder" and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the annual meeting of the American Urological Association.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

"Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive," said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but "they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity," Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is "always a point of contention," several studies have "clearly" shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators "saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) ... and most importantly, they did not see any change in the number of multidrug-resistant infections," he said.

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach "has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months ... presumably because the neurogenic bladder management is that much better," he said.

The term "neurogenic bladder," Dr. Kraus noted, is one that’s "not very precise." For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with "neurogenic bladder" and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the annual meeting of the American Urological Association.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

"Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive," said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but "they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity," Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is "always a point of contention," several studies have "clearly" shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators "saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) ... and most importantly, they did not see any change in the number of multidrug-resistant infections," he said.

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach "has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months ... presumably because the neurogenic bladder management is that much better," he said.

The term "neurogenic bladder," Dr. Kraus noted, is one that’s "not very precise." For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with "neurogenic bladder" and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the annual meeting of the American Urological Association.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

"Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive," said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but "they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity," Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is "always a point of contention," several studies have "clearly" shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators "saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) ... and most importantly, they did not see any change in the number of multidrug-resistant infections," he said.

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach "has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months ... presumably because the neurogenic bladder management is that much better," he said.

The term "neurogenic bladder," Dr. Kraus noted, is one that’s "not very precise." For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with "neurogenic bladder" and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the annual meeting of the American Urological Association.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

"Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive," said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but "they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity," Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is "always a point of contention," several studies have "clearly" shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators "saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) ... and most importantly, they did not see any change in the number of multidrug-resistant infections," he said.

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach "has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months ... presumably because the neurogenic bladder management is that much better," he said.

The term "neurogenic bladder," Dr. Kraus noted, is one that’s "not very precise." For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

"It’s unfortunate, but many women currently manage their incontinence with pads," said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the annual meeting of the American Urological Association.

The mainstay of SUI management is still active pelvic floor muscle training that is taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.

Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. "Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy," she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. "This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports," said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of "highly effective" incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts "can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success," she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609-17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715-21).

"Women will decide early on if this is the right option for them," Dr. Lightner said. "And if it’s not, they can move on to other therapies."

Clinical experience over the past 2 decades with urethral inserts has been "somewhat challenging," she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but "mainly with indwelling inserts, and not with episodic use," she said.

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this "excellent" continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, Dr. Lightner emphasized. "It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam ... find out, what can she do with her pelvic floor?"

Dr. Lightner reported that she had no disclosures.

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

"It’s unfortunate, but many women currently manage their incontinence with pads," said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the annual meeting of the American Urological Association.

The mainstay of SUI management is still active pelvic floor muscle training that is taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.

Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. "Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy," she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. "This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports," said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of "highly effective" incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts "can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success," she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609-17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715-21).

"Women will decide early on if this is the right option for them," Dr. Lightner said. "And if it’s not, they can move on to other therapies."

Clinical experience over the past 2 decades with urethral inserts has been "somewhat challenging," she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but "mainly with indwelling inserts, and not with episodic use," she said.

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this "excellent" continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, Dr. Lightner emphasized. "It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam ... find out, what can she do with her pelvic floor?"

Dr. Lightner reported that she had no disclosures.

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

"It’s unfortunate, but many women currently manage their incontinence with pads," said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the annual meeting of the American Urological Association.

The mainstay of SUI management is still active pelvic floor muscle training that is taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.

Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. "Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy," she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. "This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports," said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of "highly effective" incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts "can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success," she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609-17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715-21).

"Women will decide early on if this is the right option for them," Dr. Lightner said. "And if it’s not, they can move on to other therapies."

Clinical experience over the past 2 decades with urethral inserts has been "somewhat challenging," she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but "mainly with indwelling inserts, and not with episodic use," she said.

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this "excellent" continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, Dr. Lightner emphasized. "It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam ... find out, what can she do with her pelvic floor?"

Dr. Lightner reported that she had no disclosures.

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

"It’s unfortunate, but many women currently manage their incontinence with pads," said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the annual meeting of the American Urological Association.

The mainstay of SUI management is still active pelvic floor muscle training that is taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.

Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. "Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy," she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. "This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports," said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of "highly effective" incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts "can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success," she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609-17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715-21).

"Women will decide early on if this is the right option for them," Dr. Lightner said. "And if it’s not, they can move on to other therapies."

Clinical experience over the past 2 decades with urethral inserts has been "somewhat challenging," she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but "mainly with indwelling inserts, and not with episodic use," she said.

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this "excellent" continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, Dr. Lightner emphasized. "It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam ... find out, what can she do with her pelvic floor?"

Dr. Lightner reported that she had no disclosures.

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

"It’s unfortunate, but many women currently manage their incontinence with pads," said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the annual meeting of the American Urological Association.

The mainstay of SUI management is still active pelvic floor muscle training that is taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.

Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. "Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy," she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. "This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports," said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of "highly effective" incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts "can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success," she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609-17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715-21).

"Women will decide early on if this is the right option for them," Dr. Lightner said. "And if it’s not, they can move on to other therapies."

Clinical experience over the past 2 decades with urethral inserts has been "somewhat challenging," she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but "mainly with indwelling inserts, and not with episodic use," she said.

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this "excellent" continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, Dr. Lightner emphasized. "It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam ... find out, what can she do with her pelvic floor?"

Dr. Lightner reported that she had no disclosures.

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

"It’s unfortunate, but many women currently manage their incontinence with pads," said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the annual meeting of the American Urological Association.

The mainstay of SUI management is still active pelvic floor muscle training that is taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.

Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. "Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy," she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. "This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports," said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of "highly effective" incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts "can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success," she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609-17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715-21).

"Women will decide early on if this is the right option for them," Dr. Lightner said. "And if it’s not, they can move on to other therapies."

Clinical experience over the past 2 decades with urethral inserts has been "somewhat challenging," she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but "mainly with indwelling inserts, and not with episodic use," she said.

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this "excellent" continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, Dr. Lightner emphasized. "It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam ... find out, what can she do with her pelvic floor?"

Dr. Lightner reported that she had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.

WASHINGTON – Rapid molecular diagnosis of urinary tract infection will soon enable individualized, evidence-based selection of antibiotics "right at the point of care," according to Dr. Joseph C. Liao.

"Currently we rely on urine culture, which takes 2-3 days at a central microbiology laboratory," he said. "What if in the future [you] could obtain molecular diagnosis in less than 1 hour right there in your office? And what if we could tailor the choice of antibiotics for the patient sitting in your office [rather than start broad-spectrum antibiotics empirically]?"

Personalized, evidence-based selection of antibiotics has become an increasingly important goal – for both individual and public health – as the problem of antibiotic resistance has intensified, said Dr. Liao and other speakers at the annual meeting of the American Urological Association.

Over the past several years, Dr. Liao and his colleagues in the urology department at Stanford (Calif.) University have used biosensor technology to develop an assay for rapid pathogen identification, as well as a biosensor-based antimicrobial susceptibility test for urinary tract infection (UTI).

"We’ve been able to achieve pathogen identification within an hour, and antimicrobial susceptibility testing within 3 hours," Dr. Liao reported.

The biosensor (a molecular sensing device that generates a measurable signal in the presence of a target analyte) is already part of everyday clinical practice, he noted. The glucose sensor and the i-STAT portable clinical analyzer, for example, are commonly used biosensor-based devices.

The biosensor being utilized in the "next generation" of UTI diagnostic tools is comprised of a chip about the size of a microscope slide with 16 individual sensors. "Like computer technology, it can be mass produced at a relatively low cost," said Dr. Liao, who is also chief urologist at the Veterans Affairs Palo Alto (Calif.) Health Care System.

The overall strategy for pathogen identification involves lysis of the bacteria present in a urine sample, followed by a hybridization process that enables the sensor to detect bacterial 16S rRNA, a kind of "bacterial molecular fingerprint." This results in a signal output.

"Essentially, we’re converting a molecular hybridization event into an electrical signal," Dr. Liao explained. "And the higher the bacterial concentration, the higher the signal."

Bacterial 16S rRNA is also a marker of bacterial growth, a property that Dr. Liao’s research group has exploited to develop a biosensor-based antimicrobial susceptibility test (AST). By incubating a urine sample in the presence or absence of commonly used antibiotics, and quantifying the 16S rRNA level, "we can follow the differential growth and derive the AST," he said.

Dr. Liao and his colleagues recently completed a clinical validation study in which they compared results from their biosensor platform with results from standard microbiological analysis in more than 200 urine samples collected from patients at the Spinal Cord Injury Service at the Veterans Affairs Palo Alto system.

Pathogen detection sensitivity and specificity were 92% and 97%, respectively, and "in corresponding AST, we found an overall agreement of 94%," said Dr. Liao, whose study was published early this year (J. Urol. 2011;185:148-53).

In the future, Dr. Liao hopes to use biosensor technology to also detect biomarkers that are shown to be indicative of infection in the presence of pathogens, he said. Such an integrated assay would detect both biomarkers and pathogens, and thus address the host immunity response as well as identify the pathogen. This could further improve the now-challenging task of differentiating colonization, simple UTI, and early complicated UTI, "and [could] help us better differentiate and stratify the severity of infection," he said.

Dr. Liao reported that he had no disclosures.