Emma Hitt, PhD

June 01, 2012

June 1, 2012 (Atlanta, Georgia) — At the 2012 Annual Scientific Meeting, the American Urological Association (AUA) issued new guidelines on overactive bladder (OAB), microscopic hematuria, vasectomy, and urodynamics.

Overactive Bladder

The OAB guidelines recommend behavioral approaches as a first-line treatment, including bladder training, pelvic floor muscle training, and fluid management. Second-line treatment recommendations include medications (ie, darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium), which can also be combined with behavioral approaches as first-line treatment.

In more severe cases that are refractory to second-line treatment, or in patients who cannot tolerate antimuscarinics, clinicians should offer sacral neuromodulation or percutaneous tibial nerve stimulation for carefully selected patients.

The guidelines also recommend as third-line, the non-FDA approved approach of intradetrusor onabotulinumtoxinA in the "carefully-selected and thoroughly-counseled patient who has been refractory to first- and second-line OAB treatments."

The OAB panel, led by E. Ann Gormley, MD, urology program director at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, based their recommendations on a report from the Agency for Healthcare Research and Quality (AHRQ) that extracted data from 151 studies on OAB published in English between January 1966 and October 2008. The panel also evaluated relevant articles not included in the AHRQ report and published between October 2008 and December 2011. Most of the treatment recommendations had an evidence strength of B (moderate) or C (low).

A treatment algorithm was published along with the guidelines.

Asymptomatic Microhematuria

Asymptomatic microhematuria guidelines were also updated this year, based on 192 articles retrieved using a search data of January 1980 to November 2011.

Asymptomatic microhematuria is defined in the guideline as "three or more red blood cells per high-powered field on a properly collected urinary specimen in the absence of an obvious benign cause" (eg, infection, trauma, or renal disease) and may indicate more serious conditions.

The new guideline suggests that a single positive urinalysis with microscopy for asymptomatic microhematuria is enough to warrant a complete urologic examination. This guidance updates previous recommendations, issued in 2001, which stated that a full exam be completed only after 2 of 3 properly collected samples test positive for microhematuria on microscopy.

A urologic malignancy will be diagnosed in only a small subset of patients with microhematuria, the AUA states in a written release; however, benign conditions that can cause microhematuria, such as stricture and stone disease, can benefit from active clinical management or follow up.

"Urinary tract conditions that cause bleeding are often 'silent' and present with few symptoms until the disease is advanced or causes more serious symptoms," said panel chair Rodney Davis, MD, from the Vanderbilt University Medical Center in Nashville, Tennessee. "For most patients, microhematuria may be the earliest warning to health care providers of urinary tract disease, so it is important that we evaluate these patients to prevent serious problems later."

Vasectomy

The vasectomy guideline update was led by Ira D. Sharlip, MD, clinical professor at the University of California, San Francisco, and was based on a systematic review of the literature using the MEDLINE and POPLINE databases (search dates January 1949 to August 2011), which identified 275 articles. The full guideline is available online.

Topics addressed included "pre-operative evaluation and consultation of prospective vasectomy patients; techniques for local anesthesia, isolation of the vas deferens and occlusion of the vas deferens during vasectomy; post-operative follow-up; post-vasectomy semen analysis and potential complications and consequences of vasectomy."

Urodynamics

To develop the urodynamics guidelines, a panel led by J. Christian Winters, MD, chairman and professor, Department of Urology, Louisiana State University School of Medicine, New Orleans, reviewed the literature regarding the use of urodynamic testing in common lower urinary tract symptoms (LUTS) conditions.

The panel reviewed 393 studies identified during a literature search of articles published between January 1, 1990, and March 10, 2011.

Several new recommendations were made regarding urodynamic studies in the areas of stress urinary incontinence/prolapse, OAB and incontinence, neurogenic bladder, and lower urinary tract symptoms.

American Urological Association (AUA) 2012 Annual Scientific Meeting. Presented May 21, 2012.

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