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Introduction:Neonatal circumcision remains controversial, with rates varying over the years. The Centers for Disease Control and Prevention and the American Academy of Pediatrics acknowledg...

Female Müllerian anomalies are the result of failure of formation, fusion or resorption of the Müllerian ducts and are relatively common, with a prevalence of 5.5-7.0% in the general population. While some of these anomalies are asymptomatic, those presenting with obstruction require accurate identification for optimal clinical management including potential surgical treatment. MRI is a useful adjunct to sonography in the evaluation of Müllerian anomalies, typically allowing a more complete characterization of the malformation. Technical aspects, embryologic concepts and controversies regarding classification systems are highlighted in this review. Several Müllerian anomalies are discussed and illustrated in more detail utilizing various cases with pelvic MRI studies.

Objective To evaluate the outcomes of neonatal circumcision performed by a PA in pediatric urology. Methods A retrospective review was performed of infants evaluated for neonatal circumcision by a single PA in pediatric urology over 30 months. Technique, age and weight at circumcision, presence or absence of genital anomalies, and complications were gathered. Results Of the 371 male infants evaluated for neonatal circumcision, 276 underwent the procedure. Complications included retained Plastibell (2.1%), penile adhesions (1.1%), swelling (1.8%), and cosmetic concerns (0.73%). Eighteen unanticipated postprocedure visits occurred-four in the ED and 14 in the outpatient clinic. No acute procedural complications occurred. One patient (0.3%) underwent lysis of penile adhesions at age 19 months. Conclusion Neonatal circumcisions are commonly performed by nonsurgeons with variable formal circumcision training. These data support that well-trained PAs can perform neonatal circumcisions with low complication rates.

Cystic dysplasia of the rete testis (CDT) is a rare, benign, cause of testicular mass in the pediatric population. The mass appears on sonography as multiple small cysts of varying size surrounded by normal or compressed testicular tissue. CDT is often associated with other genitourinary anomalies, commonly presenting with agenesis or dysplasia of the ipsilateral kidney. The pathophysiology and the management remains controversial. We report a case of a 3-year-old presenting with an enlarged testicular mass later presumed to be CDT associated with ipsilateral renal agenesis, review the literature, and propose an evaluation and management algorithm.

In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at Nemours Children's Hospital.We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥3 years seen at NCH for phimosis/circumcision from Sept. 2016-Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS.Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs.The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits, and returns to operating room. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.

Individuals with Neurofibromatosis I may develop plexiform neurofibromas throughout the body, however they are rarely seen in the pelvis. We present a 15-year-old patient with NF1 with a large unresectable neurofibroma located between the prostate and bladder discovered incidentally on renal/bladder ultrasound during the evaluation of bowel/bladder dysfunction. Despite the extensive nature of the mass, the patient presented with minimal symptoms and the lesion was thought to be stool or enlarged prostate on subsequent evaluations. Urologists should be aware of NF1 related pelvic masses in the evaluation of bowel bladder dysfunction and specify NF1 on radiologic requisitions.

The differential diagnosis of scrotal pain and swelling in adolescent males includes testicular and appendage torsion, epididymitis, epididymo-orchitis, trauma and incarcerated hernia. Physical examination, ultrasound and urinalysis often can identify the etiology of the scrotal pain and swelling. We present a case of left scrotal pain and swelling that was initially concerning for a paratesticular mass. Repeat examination and further imaging during pre-operative assessment was consistent with left-sided vasitis. The diagnosis of vasitis is difficult with ultrasound and commonly requires CT or MRI to differentiate from incarcerated inguinal hernia. Recognition of this uncommonly reported condition may prevent unnecessary surgeries.

Although perforated appendicitis in pediatric patients can result in a diverse array of complications, scrotal abscess is a rarely documented phenomenon. We present a case of acute scrotum after laparoscopic appendectomy. A retrospective review of prior literature on scrotal abscess secondary to perforated appendicitis was performed via PubMed to review the clinical presentation, etiology, type of treatment and outcome of pediatric patients. Patients without a patent processus vaginalis still require vigilant follow-up postoperatively to ensure timely intervention if scrotal pain develops during recovery.

Circumcisions are among the most commonly performed procedures in the pediatric population, but the value of the preputial skin often goes unrecognized as a potential graft (Ehrlichman et al., 2018). We highlight three patients who underwent coordinated circumcision and use of the excised preputial skin as a graft for syndactyly repair. Syndactyly, a condition where fingers are fused together, is often repaired utilizing skin from the groin region, which can result in unwanted hair growth and subcutaneous fat growth. The utilization of the prepuce is a convenient alternative that may have fewer undesirable qualities.

Summary Introduction The natural history of asymptomatic nephrolithiasis (AN) in children is not well defined. Furthermore, there is no guidance on the utility of repeated renal ultrasound evaluations in this same population. Follow-up ultrasound studies are often obtained as frequently as every 6 months. The goal of this study is to assess the follow-up ultrasound interval in the management of these patients. Methods A retrospective IRB approved chart review was performed for patients seen for non-cysteine AN between 2012 and 2019. AN was defined as patients without obstructive uropathy abdominal, flank pain and/or gross hematuria. Asymptomatic stones were discovered incidentally or after an acute stone event. Patients with pre-existing renal anomalies and the timepoints with stone passage or stone procedure were excluded. Descriptive statistics were used for demographic information. Multiple linear regression was used to analyze risk factors. Statistical significance was set to p Results Twenty-nine patients had 90 ultrasounds. The average age at diagnosis was 10.8 ± 6.2 years. The average number of ultrasound studies per patient was 3.2 ± 1.7. The median time between follow-up ultrasounds was 5.2 months [IQR 2.8–10.0]. Median follow-up of patients was 10.6 months [IQR 4.9–21.9]. The change in total stone burden occurred at a rate of 0.11 mm/month (CI [-0.06–0.28], p = 0.20, r2 = 0.42) or 0.66 mm/6 months. Patients with more renal stones had almost a threefold increase in stone burden compared to patients with fewer renal stones (2.98 [CI 1.34–4.62], p=0.001, r2=0.33). Patients with a family history of stones had a twofold increase in the size of their largest stone when compared to patients without a family history (1.97 [CI 0.26–3.68], p=0.02, r2=0.60. Conclusion A complex interplay of multiple factors influence the progression of AN in children. Children with a greater number of stones have a higher increase in total stone burden and children with a family history of stones have a faster increase in largest stone size. These patients may require more frequent imaging studies. The small change in stone size over time favors a longer than 6-month interval for many children.

Inverted-Y ureteral duplication is one of the rarest anomalies of ureteral branching, which has been found to be more prevalent in females.2 Females commonly present with urinary incontinence often associated with distal limb ectopia to the bladder neck, uterus, or vagina.2 We present the case of a 7-year-old female with intermittent urinary incontinence who was found to have an inverted-Y ureteral duplication with perianal ectopia. We highlight the role of magnetic resonance urography in the evaluation of females with urinary incontinence and a normal renal/bladder ultrasound who are refractory to behavioral therapy.

Management of testicular rupture with a large tunical defect may not be feasible without excision of viable tissue. This study describes the use of a vascularized tunica vaginalis flap, without debridement of viable tissue, in four adolescents. Postoperative ultrasound showed good blood flow and 80% volume of the contralateral testis in two cases. Postoperative exam revealed normal exam and ultrasonographic appearance in three patients, the fourth was demonstrated to be small and undescended during evaluation of contralateral testicular torsion. This approach is recommended in cases of large tunical defects, as it avoids the debridement of viable testicular tissue.

Introduction: Non-neurogenic urinary incontinence in children is a common condition that affects the quality of life for both patients and parents. Symptoms may occur in the daytime, nighttime, or both and may be the result of structural and functional anomalies. Evaluation and management of associated co-morbidities, such as constipation is critical to management. Behavioral therapy is a fist line therapy in most cases of non-neurogenic urinary incontinence and pharmacologic therapy a second-line therapy.Areas covered: In this review, the authors cover the pharmacologic agents, FDA approved and commonly used non-FDA approved, available for the treatment of four non-structural etiologies of non-neurogenic urinary incontinence in children. These include nocturnal enuresis, overactive bladder, giggle incontinence, and dysfunctional voiding.Expert opinion: Non-neurogenic causes of urinary incontinence in children represent a complicated medical condition that requires both pharmacologic and non-pharmacologic management. Limited FDA-approved therapies as well as suboptimal results with approved therapies due to a lack in the understanding of the underlying pathophysiology and patient selection may lead to the use of alternative non-FDA approved therapies.

INTRODUCTION AND OBJECTIVES:Neonatal circumcision rates in the United States vary and are as high as 71%. A recent survey of Society of Pediatric Urology members identified that 79.6% of responding...

Hypogonadism, defined as a low serum testosterone in the presence of signs and symptoms, is common, particularly in aging men. Testosterone supplementation therapy (TST) is the standard treatment for male hypogonadism. It has been demonstrated to have a significant impact on the signs and symptoms of hypogonadism, but there are concerns about the increase in TST and its potential adverse effects, particularly cardiovascular effects.This review presents health care providers with current information regarding the prevalence and impact of hypogonadism, as well as the diagnosis, evaluation, and treatment of hypogonadism. The beneficial and potential adverse effects are reviewed with a discussion on the current cardiovascular controversy.We reviewed current and "landmark" articles in the English-language literature pertaining to hypogonadism, its prevalence, etiologies, presentation, evaluation, and treatment.Authorities in the field have offered guidelines and recommendations regarding the diagnosis, evaluation, and management of hypogonadism. Although there is a consensus as to the definition of hypogonadism as the presence of a low serum testosterone with signs and symptoms of hypogonadism, there is variability in the definition of "low testosterone." Various testosterone formulations exist, differing in route and frequency of administration as well as in side-effect profiles. Testosterone supplementation therapy should be continued in individuals demonstrating an improvement in signs and symptoms, which may take 3 months to a year for maximum response. Individuals treated with TST require monitoring for adverse effects. Further studies are needed to determine the impact of TST on cardiovascular health.Hypogonadism is common, particularly in aging men. Symptomatic individuals who have no contraindications to TST should be offered treatment. A careful assessment of treatment response after adequate titration and duration of therapy as well as monitoring for adverse effects is essential in treating patients for hypogonadism. Although hypogonadism is associated with increased all-cause and cardiovascular-related mortality, controversy exists regarding the impact of TST on cardiovascular risk, highlighting the need for further studies.

submissions by geographic region. Hot at the ICS Meeting 2013 3 Neurourology and Urodynamics DOI 10.1002/nau bladder volume, and nociceptive behaviors. While both therapies may be some way off from routine practice, these data may open a route to early stage human trials. LUTS: INFECTION AND INFLAMMATION There is increasing recognition of inflammation and lowgrade infection as part of the pathophysiology of LUTS. Vijaya et al. (Abstract 123) demonstrated a significantly greater proportion of positive bacterial cultures in bladder biopsies from women with LUTS compared to asymptomatic women suggesting a link between bacterial infection and LUTS in women, however, therewas no significant association between women with recurrent UTI and positive biopsies. Similarly, Sorrentino et al. presented data demonstrating that in women without overt urinary tract infection, bacteriuria was associated with a range of LUTS (Abstract 126). Evidence of an inflammatory aetiology of OAB also was presented in a study by Gill et al. who demonstrated that women with OAB and pyuria of 1–9 cells/ml had significantly greater levels of two markers of urothelial inflammation (urinary lactoferrin and IL6) compared to controls (Abstract 124). This data suggests that contrary to the current literature, pyuria

Overactive bladder is a highly prevalent disorder with a significant impact on quality of life. Antimuscarinic agents are commonly used, but persistence is limited due to unsatisfactory efficacy and/or tolerability. Mirabegron is the first beta-3 adrenoceptor agonist approved for the treatment of overactive bladder syndrome. This paper reviews the pharmacology, mechanism of action, efficacy, and safety of mirabegron. A PubMed search of all English articles pertaining to mirabegron was performed. An alternative to antimuscarinics, mirabegron has a unique mechanism, improves overactive bladder symptoms and quality of life, and has limited adverse effects and few contraindications.

Summary Introduction Metachronous undescended testis (mcUDT), an acquired UDT after contralateral orchiopexy, can occur in some boys. If one were able to predict its occurrence, one might consider a proactive approach or at least one would be able to counsel the parents accordingly. Our hypothesis was there may be characteristics evident at the time of initial orchiopexy which could predict the development of contralateral mcUDT. Objective The aim was to Identify factors present at initial orchiopexy that predict development of subsequent mcUDT. Study design Subjects were identified using the Current Procedural Terminology code for inguinal orchiopexy (54640). We included patients from January 1997 to October 2015. We included patients who underwent orchiopexy for unilateral UDT (uUDT). The study population consisted of patients who had undergone metachronous orchiopexies; controls were patients who were 17 years at time of data collection with a single orchiopexy. Cox proportional hazard regression was used to model the relationship between possible predictors of subsequent UDT using PROC PHREG with SAS Software 9.4. Results From 1035 eligible patients we identified 38 with mcUDT and 207 controls (uUDT). Median age at the first orchiopexy of mcUDT patients was 2.5 years (min/max, 0.50/10.4 years) and 8.2 years (min/max 0.70/12.8 years) for uUDT, p Discussion Contralateral retractile UDT was a significant predictor of mcUDT. We believe patients with a contralateral retractile testis at time of orchiopexy should be counseled on bilateral orchiopexy. The risks of complications with orchiopexy should be weighed against risks of a subsequent surgery and anesthesia event. Conclusion A discussion of risks and benefits regarding bilateral orchiopexies should be undertaken with the parents prior to surgery in the setting of an UDT with contralateral retractile testis. Table . Patient characteristics and predictors of mcUDT. Contralateral UDT (38) Unilateral UDT (204) p Age at initial orchiopexy, years 2.5 8.2 Congenital, % 65 52 0.10 Contralateral examination in office (% retractile) 52 18 Contralateral examination under anesthesia (% retractile) 22 2 Ipsilateral PV open, % 48 59 0.14 PV = processus vaginalis.

Overactive bladder (OAB) is a common syndrome that affects both men and women. First-line therapies for the management of OAB symptoms consist of antimuscarinic agents and behavioral therapy, ideally used in combination. Although effective in improving OAB symptoms, the use of antimuscarinic therapy may be limited by side effects, contraindications, and insufficient response. Current second-line therapies include sacral nerve stimulation and percutaneous tibial nerve stimulation. These therapies have been shown to be useful in treating OAB symptoms, but are more invasive and time-consuming than medical therapy. Onabotulinum toxin A is currently under investigation for idiopathic OAB, as well as the β-3-adreno-renoreceptor agonists mirabegron and solabegron. The role of these agents, with different mechanisms of action, in the pharmacologic management of OAB remains to be determined, although they appear to be promising alternatives and possible adjuncts to current pharmacologic and behavioral therapy. This article discusses second-line and current and future therapies for the management of OAB symptoms.

Aims Once-daily extended release (XR) trospium chloride, which provides therapeutic trospium plasma concentrations over 24 hours, has demonstrated efficacy in treating overactive bladder (OAB) symptoms as evaluated over a 24-hr period. This analysis examined the effects of trospium XR on diurnal and nocturnal OAB symptoms. Methods Pooled data were analyzed from two identically designed Phase III trials in which patients with OAB were randomized to receive trospium XR 60 mg or placebo once daily in the morning for 12 weeks. Efficacy was assessed using 3-day urinary diaries. Diurnal events were those occurring from arising from bed in the morning until retiring in the evening; nocturnal events were those occurring from retiring until arising. Results In total, 1,165 patients received trospium XR (N = 578) or placebo (N = 587). At Week 12 comparison of trospium XR versus placebo, a significantly greater mean reduction from baseline in nocturnal voids (−0.8 vs. −0.6; P = 0.006) and diurnal voids (−1.9 vs. −1.4; P

This study used pooled data from 2 large, phase III, double-blind, randomized, placebo-controlled studies for a subgroup analysis of the safety and efficacy of trospium chloride extended-release (XR) in men with overactive bladder (OAB).A subgroup analysis was performed on data from the 176 male patients (trospium XR, 94; placebo, 82) who participated in 1 of the 2 studies. Patients received either trospium XR 60 mg or placebo once daily for 12 weeks.The mean age was 66.2 years for trospium XR and 63.1 years for placebo. A history of benign prostatic hyperplasia was recorded for 29 trospium XR recipients (30.9%) and 23 placebo recipients (28.0%). A total of 19 patients (20.2%) receiving trospium XR and 15 (18.3%) receiving placebo experienced ≥1 treatment-emergent adverse event considered at least possibly related to the study medication. Two trospium XR patients (2.1%) developed urinary retention; both were aged ≥75 years, and 1 had a history of prostate enlargement. Treatment with trospium XR compared with placebo resulted in significantly greater decreases from baseline in the mean number of daily toilet voids (-2.5 vs -1.5; P.05) and urgency urinary incontinence episodes (-2.3 vs -1.4; P.05) in men at week 12 (the coprimary efficacy variables).Trospium XR is safe and effective in men with OAB. The risk of urinary retention is low and may be further decreased by careful patient selection.

Study Type – Therapy (data synthesis from RCTs) Level of Evidence 1c What’s known on the subject? and What does the study add? Treatment of overactive bladder syndrome (OAB) in elderly individuals presents several potential clinical challenges, which include alterations in sleep and cognition, multiple co-morbidities, polypharmacy, and frailty syndrome. A broad consensus of clinical opinion exists that the addition of an overactive bladder medication may amplify these clinical challenges via the antimuscarinic effects on cognition and the potential for drug-drug interactions. The quaternary amine structure of trospium chloride provides protection against penetration of the blood-brain barrier, and minimizes the potential for metabolic drug-drug interactions. This study globally supports the efficacy and safety of Sanctura XR (extended release trospium chloride) in a population of elderly patients (75 years or older) with overactive bladder syndrome and multiple co-morbidities at risk for drug-drug interactions, impaired cognition and frailty syndrome. OBJECTIVE • To evaluate the safety and efficacy of once-daily trospium chloride extended release (ER) in overactive bladder syndrome (OAB) in subjects aged ≥75 years. SUBJECTS AND METHODS • The analysis included subjects ≥75 years of age with OAB. • A subgroup analysis of pooled data was performed for subjects aged ≥75 years from two randomized, double-blind, multicenter studies of subjects with OAB receiving once-daily trospium 60 mg extended release (ER) or placebo for 12 weeks, followed by 9-month open-label extension periods during which all subjects received trospium ER. A total of 143 of the 1165 subjects from two phase III registration trials who were aged ≥75 years (85 trospium ER, 58 placebo; mean age 79 years and ranging up to 90 years; 73% female) were evaluated. • Dual primary efficacy variables were the changes from baseline in the average number of toilet voids per day and urge urinary incontinence episodes per day. RESULTS • At week 12 of the double-blind period, trospium ER produced greater improvements from baseline than placebo in voiding diary parameters, OAB Patient Global Assessment, and quality of life. • Efficacy and tolerability persisted among subjects receiving open-label trospium ER for up to 1 year. CONCLUSIONS • Once-daily trospium chloride 60 mg ER demonstrated efficacy vs placebo and was tolerated in subjects aged ≥75 years with OAB. • For subjects who continued into the open-label treatment period, efficacy and tolerability were observed for up to 1 year.

Overactive bladder is a highly prevalent condition that affects both males and females. The risk of developing overactive bladder increases with aging. There appear to be multiple etiologies for overactive bladder. Antimuscarinic agents have been the main-stay for pharmacologic treatment of overactive bladder. Their role is thought to be via antagonism with acetylcholine at the M3 receptor in the detrusor. More recently, the urothelium and suburothelium have been demonstrated to have muscarinic receptors and thus anti-muscarinic agents may affect the afferent pathway component of overactive bladder symptoms. Historically, although effective, the use of antimuscarinic agents has been limited by poor tolerability. The development of once daily formulations and alternative methods of delivery, multiple dose agents and agents with variable muscarinic receptor affinity profiles has resulted in improved tolerability profiles while maintaining efficacy. Although effective, antimuscarinic agents typically improve OAB symptoms and are less likely to lead to complete resolution of symptoms. The success rates of antimuscarinic therapy are improved when used in combination with behavioral therapy. Fesoterodine is one of the most recent OAB agents to be approved by the FDA. It acts as a prodrug and is rapidly and extensively metabolized to 5-hydroxymethyltolterodine, which is also the active metabolite of tolterodine. Fesoterodine is available in two formulations and clinical studies have demonstrated a dose-related response in efficacy with fesoterodine. Fesoterodine is well tolerated, the most common side effects being those of dry mouth and constipation. There were very few discontinuations in the clinical trials due to either dry mouth or constipation. Fesoterodine’s long-term efficacy and tolerability has been demonstrated in the 3-year open label extension trial with fesoterodine. A thorough QT study confirmed the absence of an effect on the QT interval with standard dosing of fesoterodine, 4 mg or a high dose, 28 mg of fesoterodine. Due to multiple metabolic pathways, via the CYP P450 system and excretion by the kidneys, there are limited dosing restrictions with fesoterodine. Fesoterodine is the only antimuscarinic therapy available that comes with the YOURWAY plan, a multidimensional program that brings together pharmacotherapy with education and skills training.

Summary Introduction Nocturnal enuresis is a common pediatric condition with limited treatment options. In older children, pharmacologic therapy is often the preferred treatment. Pharmacologic therapies including desmopressin (DDAVP) or imipramine are effective in 40–50% of children. However, imipramine has serious safety concerns. Desmopressin in combination with a fixed dose anticholinergic has been shown to be useful in individuals who fail desmopressin monotherapy, but still fails to achieve success rates greater than 60%. Objective The goal was to explore the efficacy and safety of using combination therapy desmopressin plus oxybutynin with increasing dose of oxybutynin in patients refractory to standard combination therapy. Study design This was a single institution, IRB-approved, retrospective chart review of 61 patients (ages 7–18 years) including those with monosymptomatic primary nocturnal enuresis and non-monosymptomatic enuresis with controlled daytime voiding symptoms (CDVS) treated initially with desmopressin. All patients who failed initial therapy with desmopressin were started on combination therapy desmopressin (0.6 mg) plus standard dose (5 mg) oxybutynin. In patients who failed standard combination therapy, the dose of oxybutynin was titrated upwards until a response or the maximum dose of 10 mg was achieved. Demographic and medical history data were evaluated to determine predictive factors associated with response/failure to different therapy groups. Results The use of escalating doses of oxybutynin in combination with desmopressin achieved an overall response rate of 96.7% defined as a 2-week period without any enuretic events following initiation of treatment. Low-dose combination therapy (LDCT) (0.6 mg of desmopressin + 5 mg of oxybutynin) had a response rate of 68% (Table). Advanced dose combination therapy (ADCT) (0.6 mg of desmopressin + 7.5–10 mg of oxybutynin) had a response rate of 75.0%. A statistically significant relationship was found correlating both attention deficit disorder/attention-deficit hyperactivity disorder(ADD/ADHD) and CDVS with failure on monotherapy. No patients in the study reported any adverse events or side effects from the medications. Discussion The overall success rate of 96.7% with titrated doses of oxybutynin in combination with desmopressin is considerably higher than the response rates on fixed dose combination therapy quoted in the literature and supports the need for further evaluation in larger studies. Additionally, we found a statistically significant association between monotherapy failure and children with either ADD/ADHD or controlled daytime voiding symptoms. Our study is limited by small numbers and larger studies are needed to confirm these results. Conclusion Our results suggest that ADCT is a safe and effective treatment option for primary nocturnal enuresis refractory to standard and low-dose combination therapy. Desmopressin monotherapy LDCT ADCT Total Patients treated 61 25 8 61 Responders 36 17 6 59 Response rate 59.0% 68.0% 75.0% 96.7%

Peyronie's disease is a chronic condition affecting approximately 3% to 9% of adult males and is associated with significant negative effects on physical and psychosocial well-being and quality of life. Historically, treatment has been limited by a lack of understanding of the pathophysiology. Recent advances have led to the first FDA-approved therapy for the treatment of Peyronie's disease. Evaluation, treatment, and management of patients with this condition, including use of an algorithm and pre-/post-treatment questionnaire, will be discussed.

Hydronephrosis is the most common genitourinary tract anomaly identified on prenatal ultrasound studies. Ureteropelvic junction obstruction accounts for approximately 50% of the cases of prenatally detected hydronephrosis. Postnatal evaluation allows for the identification of the cause and further management. Rarely, in utero intervention may be performed for severe oligohydramnios associated with hydronephrosis. Prenatal consultation with a pediatric urologist is useful in decreasing parental anxiety and facilitating postnatal management.

Associate Editor Michael G. Wyllie Editorial Board Ian Eardley, UK Jean Fourcroy, USA Sidney Glina, Brazil Julia Heiman, USA Chris McMahon, Australia Bob Millar, UK Alvaro Morales, Canada Michael Perelman, USA Marcel Waldinger, Netherlands OBJECTIVE To determine whether patients with erectile dysfunction (ED) and treated with tadalafil use the 36-h duration of effect of the drug, and to discern if the timing of intercourse attempts is influenced by patient age, baseline severity of ED, or previous experience with sildenafil citrate. PATIENTS AND METHODS In 11 multicentre, double-blind, placebo-controlled studies, 2102 patients with ED were randomized to a maximum of one dose per day of tadalafil 10 or 20 mg (1464 men), or placebo (638 men) with no time restrictions before attempting sexual activity after the dose. A post hoc analysis was used to determine the proportion of men with ED who attempted sexual intercourse during various intervals (>0 to ≤ 1, >1 to ≤ 4, and >4 to ≤ 36, including >12 to ≤ 36 h) after dosing with tadalafil or placebo over a 12-week period. Patients were stratified by age, baseline severity of ED, and previous history of sildenafil use. RESULTS Of patients in different age groups and various ED severity, ≥ 79% and ≥ 53% chose to attempt sexual intercourse at least once during the 12-week treatment period at 4–36 and 12–36 h, respectively, after taking tadalafil. Regardless of previous experience with sildenafil, about a third of patients using tadalafil attempted intercourse a mean of at least once per week at 4–36 h after the dose over 12 weeks. Furthermore, 58% of patients attempted intercourse at least once during two intervals (>1 to ≤ 4 h and >12 to ≤ 36 h) after separate doses of tadalafil. CONCLUSION Regardless of age, ED severity, or previous experience with sildenafil, most patients attempted sexual intercourse at least once at 12–36 h after one dose of tadalafil over a 12-week treatment period. Furthermore, by engaging in sexual intercourse at both earlier and later intervals after separate doses, most patients on treatment did not adhere to a fixed schedule of intimacy and thus took advantage of the 36-h duration.

Objective: Urethrocutaneous fistula is a well-known complication of hypospadias surgery and is reported in 5–10% of repairs. Using a previously described juvenile pig model, we present a histological analysis of the healing of the ventral aspect of the urethral repair and describe the histological mechanism of fistula formation. Materials and Methods: Twelve juvenile pigs underwent ventral, longitudinal urethral incision and closure over a 5-French feeding tube. The ventral aspect was closed in running fashion using two closure techniques and three suture types in each animal. Three animals were sacrificed on postoperative day 3, three on day 5, three on day 12, one on day 14, and two on day 21. Closure was one-layered incorporating urethral mucosa in the animals sacrificed on days 3, 5, and 21. An extra-mucosal suture technique was used in the group sacrificed on day 12. Sections of the penis were cut, paraffin embedded, and treated with Hematoxylin and Eosin staining. Results: Fistulae were seen in 12 specimens and in association with each suture type. Fewer sections of the extra-mucosal technique showed fistulization. Fistulae lined with immature epithelium were seen by day 5. Mature fistulae were observed by day 12. Skin epithelium and urethral mucosa migrated along suture tracts. By days 12 and 21, in addition to mature fistulae, several sections showed well-healed ventral repairs with clearly extramucosal suture tracts. Conclusions: Fistula formation begins early in the healing process after ventral urethral repair. Incorporation of urethral mucosa in the ventral repair is a substrate for fistula formation with rapid migration of urethral mucosa and skin epithelium into suture tracts. The importance of a multi-layered repair and extra-mucosal suture technique are thus emphasized with respect to urethral repair. Whether the mucosal or dermal migration along suture tracts can be attenuated or prevented by changing the biochemical environment awaits further investigation.

Introduction: Overactive bladder (OAB) affects many women and men worldwide and has a significant adverse effect on a person’s quality of life. Historically, behavioral therapy and anti-muscarinic agents have been the primary therapies used in the management of OAB. However, persistence with anti-muscarinic therapy has been limited. The role of β-3 agonists is established in the management of OAB with the first β-3 agonist recently approved by the FDA. Solabegron is one such selective β-3 agonist currently under investigation.Areas covered: In this review, the authors discuss animal studies, in vitro human bladder strip and Phase II studies, which suggest a role for solabegron in the management of OAB. The authors also discuss its potential role in combination therapy.Expert opinion: Phase II studies with solabegron support its potential future role in the management of OAB. However, further studies are needed to establish its efficacy and safety as well as to allow its clinical comparison with current th...

Overactive bladder syndrome affects up to 17% of the American population and adversely impacts quality of life. Antimuscarinic agents have been the primary treatment of neurogenic detrusor overactivity and overactive bladder, but they are often ineffective or poorly tolerated. Onabotulinum toxin A for refractory cases provides an important therapeutic alternative. Indications, use, efficacy and safety data for intradetrusor injection of onabotulinum toxin A will be reviewed.

Transitional cell carcinoma (TCC) is a rare cause of hematuria in children. This type of urothelial bladder tumor is typically low grade and carries a good prognosis. In this article, a case report is presented along with a review of the literature on TCC in children.

Bowel-related injuries are known complications of suprapubic tube (SPT) catheterization placement. A literature review was conducted to determine identifiable risk factors for bowel injury. Results on the analysis of 25 cases are presented along with a proposed algorithm to aid in choosing between open, percutaneous, and image-guided methods of placement.

Children presenting with nonpalpable undescended testes are evaluated with diagnostic laparoscopy. The laparoscopic findings of blind-ending vessels and vas deferens are felt to be diagnostic for 'vanished' testes. We present a case of an overweight male in whom the testis was not palpable in the office or under anesthesia and in whom blind-ending vessels were identified on laparoscopy. Inguinal exploration revealed a normal appearing inguinal testis. Although not advocated as a tool in the evaluation of the child presenting with an undescended testis, inguinal ultrasound may have a role in overweight children in whom the examination may be difficult. Furthermore, we would advocate inguinal exploration in overweight children, given the limitations of laparoscopy in this overweight child.

Obesity, defined as a body mass index ≥ 30 kg/m² in adults by the National Institutes of Health, is associated with an increased risk for a number of health conditions, including hypertension, unfavorable lipid level, and diabetes mellitus. During the past 2 decades of the twentieth century, the prevalence of obesity has increased in the United States. In 2009 to 2010, 36% of adults were obese, including 41 million women and > 37 million men. In addition, the prevalence of metabolic syndrome (MetS), which is a constellation of interrelated cardiac risk factors including visceral obesity, impaired insulin action (ie, insulin resistance), atherogenic dyslipidemia, endothelial dysfunction, and systemic inflammation, has been increasing in the United States. More recently, there has been greater interest in the effects of obesity and MetS on a variety of benign and malignant urologic conditions. Obesity/MetS has been shown to have an effect on urolithiasis; benign prostatic hyperplasia and lower urinary tract symptoms; female incontinence and pelvic prolapse; male hypogonadism; and male sexual function and infertility. These urologic diseases have a considerable impact on patients' quality of life. From a urologic cancer standpoint, obesity/MetS has been demonstrated to play a role in prostate cancer and in renal cell cancer; its role in bladder cancer remains ill defined. Furthermore, dietary or lifestyle modifications may improve outcomes in many of these urologic disease processes. Thus, it is imperative for physicians to understand these relationships in order to better screen obese patients and be aware of the potential impact of weight loss on affected benign and malignant urologic conditions.

Neurogenic detrusor overactivity (NDO) affects a variety of patients with storage and voiding dysfunction including those with multiple sclerosis, spinal cord injuries, Parkinson's disease, cerebral palsy, and myelomeningocele, and includes symptoms of urinary frequency, urgency, and incontinence. Primary treatment goals are 1) preventing renal injury, and 2) improving quality of life. First-line therapies include behavioral and anticholinergic agents, with onabotulinum toxin-A as the only FDA- approved second-line therapy, and non-FDA approved second-line therapies including neuromodulation, and intravesical vanilloids. Surgical intervention is reserved for those at risk for upper-tract deterioration and with persistent incontinence. In select individuals an indwelling catheter may be necessary.

Conditions affecting male fertility may be detected in childhood. Affected children and adolescents and their parents are often anxious and concerned when infertility is discussed. Urology nurses and midlevel providers play a key role in the education and counseling of the patient and family An awareness of the more common conditions, including presentation, evaluation, and management, is critical.

Infertility, the inability to conceive after one year of regular, unprotected intercourse, is secondary to male-only factors in 20% and a combination of male and female factors in 30% to 40% of cases. Advances in the identification and management of male factor infertility have provided new and often successful options for paternity.