Recurrent urinary tract infections (RUTI) are prevalent and pose significant clinical challenges. Although the term RUTI has long been vaguely defined, a consensus definition has emerged in recent years. The exact etiology behind RUTI remains under debate, with valid arguments for both ascending reinfections as well as persistent infection inside the bladder. These persistent infections exist in the form of quiescent intracellular reservoirs in the mouse model and may represent a novel concept to explain UTI recurrence in humans. Manageable risk factors such as behavioral patterns alongside nonmanageable risk factors including genetic susceptibility are growing fields of investigation. Acute UTI have been studied through two model bacterial strains: Escherichia coli UTI89 and CFT073. However, the clinical relevance to RUTI of these two strains has not been firmly established. Current treatment strategies for RUTI are limited and remain dominated by antibiotic usage despite variable efficacy. The majority of studies in humans have focused on younger groups of women with little information available about the postmenopausal population despite a heightened risk of RUTI in this age group.

Because there is reluctance to operate for pain, we evaluated midterm outcomes of vaginal mesh and synthetic suburethral tape removed for pain as the only indication. After receiving institutional review board approval we reviewed a prospective database of women without a neurogenic condition who underwent surgery for vaginal mesh or suburethral tape removal with a focus on pain as the single reason for removal and a minimum 6-month followup. The primary outcome was pain level assessed by a visual analog scale (range 0 to 10) at baseline and at each subsequent visit with the score at the last visit used for analysis. Parameters evaluated included demographics, mean time to presentation and type of mesh or tape inserted. From 2005 to 2013, 123 patients underwent surgical removal of mesh (69) and suburethral tape (54) with pain as the only indication. Mean followup was 35 months (range 6 to 59) in the tape group and 22 months (range 6 to 47) in the mesh group. The visual analog scale score decreased from a mean preoperative level of 7.9 to 0.9 postoperatively (p = 0.0014) in the mesh group and from 5.3 to 1.5 (p = 0.00074) in the tape group. Pain-free status, considered a score of 0, was achieved in 81% of tape and 67% of mesh cases, respectively. No statistically significant difference was found between the groups. When pain is the only indication for suburethral tape or vaginal mesh removal, a significant decrease in the pain score can be durably expected after removal in most patients at midterm followup.

OBJECTIVES: To compare elastin expression and elastic fibre width in the anterior vaginal wall of postmenopausal women with and with no bladder prolapse. PATIENTS AND METHODS: Full‐thickness specimens were obtained from the upper lateral anterior vaginal wall of women having a large cystocele repaired (stage III or IV; prolapse group, 33) and the same location in patients with no prolapse having radical cystectomy (control group, 10). The percentage of elastin‐positive tissue and elastic fibre width were measured by immunohistochemistry on 6 µm thick tissue sections from 10 random field readings per sample using image analysis software. The examiner was unaware of sample identity and the patients’ clinical history. RESULTS: The age was comparable between the control and prolapse groups (median 70.5 years), and the parity, vaginal deliveries, hormone replacement use, cigarette smokers and body mass index were no different between the groups. Immunohistochemical staining and morphometric analysis indicated that elastin expression in the prolapse group was 10.6%, vs 14.4% in the control group ( P = 0.049). The median width of elastic fibres was 0.9 µm in the prolapse and 1.8 µm in the control groups ( P < 0.001). Elastin expression and elastic fibre width appeared to be stable with increasing age in the prolapse group. CONCLUSIONS: In this case‐control study investigating elastin changes in postmenopausal women with prolapse, the elastin expression and fibre width were significantly lower in the vaginal wall of patients with a large cystocele than in controls of a similar age.

Study Type – Therapy (RCT) Level of Evidence 1b OBJECTIVES: To explore whether instruction in fluid management resulted in changes in fluid intake and incontinence over a 10‐week study period in women with urinary urge incontinence (UUI), as fluid management might be a critical strategy in treating this condition. PATIENTS AND METHODS: In the ‘Behaviour Enhances Drug Reduction of Incontinence’ trial, women with predominant UUI were randomized to daily treatment with tolterodine or tolterodine combined with behavioural therapies, among which were individualized instructions on fluid management. Patients in both groups received general fluid management instructions, while in the drug + behaviour arm, those with excessive urine output (>2.1 L/day) had additional individualized instruction during each of four study visits to learn behavioural strategies. Variables measured at baseline and at 10 weeks were type of incontinence, using the Medical, Epidemiological, and Social Aspects of Aging questionnaire, severity of incontinence by number of incontinence episodes based on a 7‐day diary, number of voids/24 h (F ₂₄ ), urgency rating, 24‐h fluid intake (I ₂₄ ) and 24‐h volume voided (V ₂₄ ), volume average (V _avg ), pad use, bothersomeness of UUI (Urogenital Distress Inventory and Overactive Bladder questionnaire), and quality of life (Incontinence Impact Questionnaire‐7 and Short‐Form‐12). RESULTS: Leakage episodes/24 h, V ₂₄ , I ₂₄ and average urgency ratings all significantly decreased from baseline to 10 weeks ( P < 0.001 for each). V _avg increased ( P < 0.001), as did voids/L intake ( P = 0.01). None of the changes in diary variable outcomes differed by treatment group after accounting for these changes between baseline and 10 weeks. In a multivariable model, treatment group was not associated with change in V ₂₄ from baseline to 10 weeks ( P = 0.81), but the difference in the number of accidents/diary day, F ₂₄ , I ₂₄ , and average voids/day each were positively related with the change in V ₂₄ ( P < 0.001 for each). Patients had a response to fluid management instructions; the decrease in the percentage of women with a V ₂₄ of >2.1 L between baseline and follow‐up was statistically significant ( P = 0.01 McNemar’s test). CONCLUSION: General fluid instructions can contribute to the reduction in UUI symptoms for women taking anticholinergic medications, but additional individualized instructions along with other behavioural therapies did little to further improve the outcome.

We report our experience with recurrence of pelvic organ prolapse after native tissue repair for stage 2 anterior prolapse. We reviewed a prospectively maintained, institutional review board approved database of women with symptomatic stage 2 anterior prolapse who underwent vaginal repair with anterior vaginal wall suspension between 1996 and 2014. Women with concurrent pelvic organ prolapse repair or hysterectomy or without 1 year followup were excluded from analysis. Failure was defined as stage 2 or greater prolapse recurrence on examination or reoperation for symptomatic pelvic organ prolapse. Outcome measures included validated questionnaires (Urogenital Distress Inventory-short form, quality of life), physical examination, standing voiding cystourethrogram at 6 months postoperatively, further surgery for pelvic organ prolapse in other compartments or for secondary stress urinary incontinence or fecal incontinence, and complications. A total of 121 women met the study inclusion criteria with a mean followup of 5.8 ± 3.7 years. Prolapse recurrence rates were isolated anterior 7.4%, isolated apical 10.7%, isolated posterior 8.3% and multiple compartments 19%. Surgery for recurrent prolapse included anterior compartment 3.3% at 1.4 ± 1.0 years, apical 9.9% at 2.8 ± 3.0 years, posterior compartment 5.8% at 2.0 ± 1.0 years and multiple compartments 17.4% at 3.2 ± 3.3 years. There was a 1.6% rate of intraoperative complications and a 5.7% rate of 30-day complications (all Clavien I). Anterior vaginal wall suspension for symptomatic stage 2 anterior prolapse offers a native tissue vaginal repair with minimal morbidity and a low anterior recurrence rate at intermediate to long-term followup. However, 33% of patients required secondary prolapse compartment procedures from 0.6 to 13 years later, highlighting the importance of long-term followup.