Neurourology and Urodynamics 34:206–212 (2015)

What Was Hot at the ICS Meeting 2014? Marianne Koch,1* Rufus Cartwright,2,3 Kari A.O. Tikkinen,4 Nazema Y. Siddiqui,5 Bruna M. Couri,6 William Gibson,7 Paula Igualada-Martinez,8 and Christopher R. Chapple9 1

Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria Department of Epidemiology & Biostatistics, Imperial College London, London, United Kingdom 3 Department of Urogynaecology, Imperial College London, London, United Kingdom 4 Department of Urology and Department of Public Health, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland 5 Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, North Carolina 6 Department of Obstetrics & Gynecology and Department of Biomedical Engineering, Cleveland Clinic, Cleveland Ohio 7 Division of Geriatric Medicine, University of Alberta, Edmonton, Canada 8 Physiotherapy Department and Pelvic Floor Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom 9 Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom 2

Key words: basic science; incontinence (female); incontinence (male); prolapse; International Continence Society; Annual Meeting

INTRODUCTION

The 44th annual meeting of the International Continence Society (ICS) was held in Rio de Janeiro, Brazil, and once again offered an extraordinarily diverse scientific and clinical program. Further to previous years, ICS 2014 held some innovations, such as the new format ‘‘Open Discussion Poster Sessions’’ in which expert poster pilots guided delegates around the display and moderated delegates’ questions to the authors. The three days of the scientific program were themed around a concept, which evolved from the ICS meeting 2013 Barcelona, and state of the art lectures were transformed into a new concept of roundtables and panels. Expert representatives from all ICS committees now serve as external abstract reviewers in addition to the N&U editorial board in order to guarantee broader scrutiny of abstracts. Also, a new permanent elected scientific chair was introduced, with the intention to support the local chair responsible for the ICS meeting. The number of scientific submissions to the ICS 2014 was slightly lower compared to the previous year with 960 submissions, of which 814 abstracts were accepted (Fig. 1), but contributions from the American region increased by 12.9% compared to 2013 (Table I). Overall, 48 abstracts were podium presentations, 253 podium posters with 10 podium videos, while 419 were open discussion posters or videos and 84 were read by title. With this report we have tried to summarize what we felt were the highlights and ‘‘hot topics’’ of this year’s ICS annual scientific meeting. Unfortunately we are not able to include more of the valuable contributions, but we hope to have provided a useful summary. If anyone wishes to add a comment or would like to highlight a matter not included in this article, please contact the journal via a letter to the editor. Imaging

The first scientific session opened with a presentation from €llner and colleagues,1 which was awarded the Basic Science Wo Abstract prize (Abstract 1). The authors used DTI fibre tracking to produce stunning images of the neuronal networks around #

2015 Wiley Periodicals, Inc.

the bladder and ureters. These pilot images demonstrated clear changes in patients with neurogenic bladder, and suggested future clinical applications in neuro-urology. Avulsion of the levator muscle remains a hugely promising imaging biomarker of prolapse, with clear associations with birth injury. The Best Clinical Abstract prize was awarded (jointly with Abstract 393) to a Dutch multicentre cohort, prospectively testing preoperative imaging of levator defects on risk of recurrence after prolapse surgery (Abstract 398).2 This presentation provoked robust debate, but the non-significant findings suggested that levator avulsion may be at most a modest risk factor for recurrence. Among several interesting presentations from the Dietz group,3 perhaps the most eagerly awaited were the results of 1 a randomized trial of the Epi-No Birth Trainer (Abstract 394). This balloon device has been claimed to shorten the second stage of labour and reduce the risk of pelvic floor trauma. In a large parallel group trial enrolling 660 women, no differences were found in the primary outcome of levator trauma, and no differences across a range of secondary obstetric outcomes, except that women 1 assigned to use of Epi-No were more likely to have ultrasound imaging consistent with residual external anal sphincter trauma. These results highlight the need for robust independent evalua1 tion of new obstetric devices such as Epi-No . Neurourology

The first plenary podium session was dedicated to novel insights into neural pathways including basic science contributions on the communication between the urinary tract and the nervous system, as well as clinical studies on spinal cord injuries. Periaqueductal gray (PAG) plays a key role in the physiologic

Potential conflicts of interest: Nothing to disclose.
Correspondence to: Marianne Koch, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria. E-mail: [email protected] Received 19 December 2014; Accepted 19 December 2014 Published online 14 February 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22734

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Fig. 1. Total abstracts submitted to ICS 2000– 2014

function of micturition and urine storage and altered perceptual responses in this pathway may explain bladder pathologies. Meriaux and colleagues4 aimed to determine, which structures of the PAG specifically respond to bladder electrical stimulation in rats. They found high neural activity especially in the medial area of the ventrolateral subdivision of the caudal part of the PAG during electrically induced bladder contractions (Abstract 2). Autoimmune events within the bladder are suggested to play a role in the pathophysiological mechanism of painful bladder syndrome/interstitial cystitis (PBS/IC) and neurogenic inflammation is thought to up-regulate sensory signaling connecting bladder and central nervous system. In addition, spinal cord glial cells might be key players in the development and maintenance of central sensitization. Bicer and colleagues5 used a validated mouse model of experimental autoimmune cystitis and noted evidence of microglial activation in sacral spinal cords, which might indicate the early onset of central sensitization and therefore of chronic pain (Abstract 5). New treatment methods are widely investigated to support patients with lower urinary tract dysfunctions due to spinal cord injury (SCI). Sievert and colleagues6 retrospectively reviewed data on nerve rerouting (NR) surgery to establish an alternative somatic- autonomic-reflex pathway. None of the eight included patients had improved urinary tract function following NR surgery during a mean follow up 5.9 years. Consequently, the effectiveness of this operating technique is in question and it should not be performed without further evidence (Abstract 3).

LUTS in Women

Smoking is strongly associated with both urinary frequency and urgency in women, but evidence of benefit from smoking cessation has been lacking. Wyman and colleagues10 presented a secondary analysis from a RCT (n ¼ 202) of nicotine patches, versus low nicotine cigarettes, for smoking cessation (Abstract 402). At 12 weeks, 22.8% of participants met criteria for abstinence, with a narrowly significant effect on frequency, but not on urgency or other LUTS. The temporal relationship between smoking and LUTS is poorly understood, and longer abstinence might be necessary for resolution of LUTS. Pelvic Organ Prolapse and Prolapse Surgery

TABLE I. Geographic Abstract Submissions to ICS 2014 YEAR

2014

%

Change

Asia Europe Americas Oceania Africa TOTAL

346 297 269 23 15 950

36.4% 31.3% 28.3% 2.4% 1.6%

2.0% 10.2% þ12.9% 0.6% 0.1%

Neurourology and Urodynamics DOI 10.1002/nau

Urodynamics

With new drugs for underactive bladder in the pipeline, there is renewed research interest in detrusor function. Two separate workshops tackled this topic, and the urodynamic scientific sessions were also dominated by presentations on diagnosis of underactive bladder and bladder outlet obstruction. A number of technical urodynamic innovations were presented including the use of a vibro-acoustic sensor placed on the dorsal side of the penis to non-invasively measure voiding parameters (Abstract 19)7 and the development of a cystoscopically placed intravesical capsule to perform long term ambulatory urodynamics (Abstract 611)8. Rademakers and colleagues,9 reported statistically significant, but modest correlations between selfreport of voiding lower urinary tract symptoms (LUTS) and formal measures of voiding function in women, suggesting perhaps that further innovation in measurement of voiding in women is still needed (Abstract 625).

Multiple presentations highlighted the impacts of postpartum levator trauma or levator defects on the development of prolapse (Abstracts 425, 430, 434).11–13 Ultrasound measures of the levator hiatus, when used clinically among women with prolapse, were not useful in predicting recurrence of anterior wall prolapse after reconstructive surgery (Abstract 429).14 In a study of knockout mice with defective collagen and elastin, investigators showed parity-dependent changes in the regulation of bone morphogenic protein 1, which may play a

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role in the pathophysiology of prolapse (Abstract 433)15 Transvaginal mesh (TVM) continues to be a much-debated technique for prolapse repair. One group16 presented their findings of electron microscopy of mesh explants, challenging the notion that mesh is ‘‘inert’’ after surgical implantation (Abstract 366). Investigators also presented their outcomes after using meshes coated with either collagen or autologous plasma (Abstracts 371, 432).17,18 These studies lead us to wonder if there may come a day when biologic coatings might improve surgical mesh for prolapse repair. Concerning current surgical techniques, investigators attempted to answer the ever-present question of whether vaginal native-tissue repair or mesh sacrocolpopexy is the preferred approach for prolapse repair. A prospective cohort study comparing sacrospinous ligament fixation to laparoscopic mesh sacrocolpopexy showed similar 3-month outcomes (Abstract 364).19 However a retrospective study evaluating over 1,200 women undergoing vaginal repairs, laparoscopic, and robotic sacrocolpopexies showed higher 6 year recurrence risks than may be expected, with these risks varying dramatically based on the definitions that are used (Abstract 367).20 When looking specifically at robotic and laparoscopic sacrocolpopexy, it appears that outcomes may be similar in obese women (Abstract 369).21 Female Pelvic Floor

This year’s female pelvic floor session had multiple prizewinning presentations. In the PREVPROL randomized trial, Hagen and colleagues22 compared pelvic floor muscle training (PFMT) to a lifestyle advice leaflet for women without significant prolapse symptoms; after two years there were fewer prolapse symptoms in the PFMT group, though there were no differences in other subjective or objective outcomes (Abstract 393). An interesting basic science presentation by Couri et al.23 suggested that a non-invasive cell-based therapy could be used to prevent or delay onset of pelvic floor disorders in high-risk women (Abstract 395). Other presentations in the session proposed standards for external anal sphincter imaging and showed that levator avulsion after vaginal delivery is strongly associated with the clinical factors of 3rd or 4th degree EAS laceration or vaginal sidewall laceration (Abstract 397).24 Stress Urinary Incontinence

Clinicians and researchers often struggle with predicting who may be prone to stress urinary incontinence (SUI), and whether genetic predispositions exist. At this meeting results were presented from a genome wide association study of almost 9,000 women from the UK and Finland. They identified five separate genomic loci with variants associated with urinary incontinence. Four of these loci were associated with urgency incontinence (UUI) symptoms, while one locus was associated with both UUI and SUI. These findings require replication, but also suggest new targets for investigation into the pathology of urinary incontinence (Abstract 690).25 Mathematical modeling has also been proposed as a method to predict who may be at risk for SUI after pelvic organ prolapse (POP) surgery. In a study of Turkish women undergoing POP surgery, a previously published mathematical prediction model did not improve predictive accuracy over preoperative urodynamic studies. In addition, the model may over-predict the number of anti-incontinence surgeries needed (Abstract 634).26 The UResta intravaginal device, a self-positioning home pessary, was examined in a randomized trial. When compared Neurourology and Urodynamics DOI 10.1002/nau

to a placebo silastic ring, there were significant improvements in SUI with UResta, though it remains to be seen how this compares with other existing office-prescribed pessaries (Abstract 632).27 In a very small pilot study, a group of investigators from Japan presented some promising outcomes after periurethral injection of autologous adipose-derived regenerative cells (ADRCs). In a single procedure, the investigators harvested adipose tissue using liposuction, processed the tissue without requiring cell culture, harvested ARDCs, and performed peri-urethral injections of ADRCs. Though they presented very early preliminary data, 2/3 subjects showed persistent and significant improvement in SUI 12 months after injection (Abstract 636).28 As one would expect, there were numerous presentations regarding midurethral slings. Since 2006, we have known that stress incontinent women undergoing sacrocolpopexy benefit from prophylactic Burch urethropexy at the time of prolapse surgery. However, in those who have SUI, it has been unclear whether Burch or midurethral sling (MUS) is the preferred approach at the time of POP surgery. In a trial of 113 women in the US randomized to either Burch or MUS at the time of sacrocolpopexy, MUS resulted in higher stress-specific continence rates, higher patient satisfaction and perception of improvement, and similar complication rates as Burch (Abstract 689).29 Finally, as many surgeons can attest, postoperative urinary retention after MUS can be a vexing situation. In a large series of over 19,000 Norwegian women receiving MUS, 746 (3.8%) experienced post-operative urinary retention, for which the investigators suggested that early adjustments of the sling may result in more favorable outcomes (Abstract 691).30 Anatomy and Biomechanics

The anatomical changes and biomechanics of pelvic floor disorders are topics of constant interest and still instigate great debate, as do the various treatment options. Peng et al.31 presented an interesting 3D pelvic floor model, developed by utilizing MRI images and intra-abdominal pressures, to simulate and assess pelvic floor dynamics (Abstract 73). The mapping of 29 anatomical points and their dynamics could be helpful in understanding pelvic floor disorders, choosing a surgical technique, and possibly, predicting possible surgical complications. Using this model, the same group showed that of the levator ani muscles, the puborectalis is the most important contributor to urethral support (Abstract 640).32 The use of implants for vaginal surgery and which materials should be used are in continuous debate. Li et al.,33 in an ex-vivo study, compared the biomechanical characteristics of a synthetic mesh (Prolene) and biological grafts (Permacol and Biodesign), in a novel surgical technique, using a puborectalis sling to repair the levator hiatus. The results showed that Biodesign had the greatest stretch properties and a low failure force, making it the most compliant one, which may cause it to fail in providing support. The Permacol graft had the stiffest response with the highest failure force and lowest failure stretch, suggesting that this material could provide a strong mechanical support. This study was done exclusively ex-vivo and native tissue response was not incorporated into the analysis (Abstract 72). In a randomized control trial with 47 women, Jacomo et al.,34 demonstrated that there is a lack of knowledge of pelvic anatomy among the general female population. They showed that pelvic anatomy education by healthcare providers resulted in a greater awareness of pelvic floor muscles among the treated population. This education could influence physical therapy and biofeedback training and outcomes (Abstract 209).

Hot at ICS meeting 2014 Geriatrics 35

The conservative management award went to Murphy et al. for their study of the decision making process behind placing a catheter in acute medical care (Abstract 317). They used thinkaloud and semi-structured interviews to examine the reasons why physicians and nurses use urinary catheters in the acute setting, and found inconsistent and often fallacious reasons, including avoiding missing acute retention due to low staffing levels, or junior doctors feeling that they were more likely to be reprimanded for not catheterizing a patient than for doing so. A similar study by Ma et al.36 used both case note review and staff interviews to judge the appropriateness of catheter insertion in older adults attending the emergency room (Abstract 318). They found that the majority (58.7%) of catheters were inappropriate based on published guidelines, although the nurses caring for the patients deemed 58.8% of them to be appropriate. A quarter of the inappropriate catheterizations were to manage incontinence, and 19% because of immobility. These two studies suggest the need to improve guidance and education of staff across acute care to reduce the harm associated with inappropriate catheterizations. For patients who cannot avoid a long-term catheter, a catheter valve can often be a better solution than a bag. However, the standard FlipFloTM valve requires considerable manual dexterity, and is often unsuitable for older patients. Marcus Drake’s group37 in Bristol demonstrated a proof-ofprinciple project of a non-manual catheter valve which is opened by voluntary straining. Their small study suggested the valve design was feasible for use and well tolerated by patients (Abstract 320). Continence-related care forms a significant portion of the time and monetary cost of long-term care for older people. Ostaszkiewicz and colleagues38 used a grounded theory study to explore how care staff determined, delivered and communicated their residents’ needs with respect to continence care. They found multiple constraints to quality care, across four main areas; a regulated work environment, ethical challenges, highly dependent residents, and a lowstatus, devalued role. They identified staff coping strategies they termed ‘‘weathering constraints,’’ which included concealing, acquiescing, ‘‘blanking out’’ and using distancing language. They conclude that staff training and education is insufficient to improve care, and that comprehensive, multifaceted organisational interventions are required (Abstract 313). Finally, apart from excellent presentations and abstracts, the highlight for geriatrics for the ICS this year was the election of a geriatrician, Professor Adrian Wagg, as the society’s first non-surgical general secretary, which will hopefully inspire more geriatricians and other professionals interested in continence care for older adults to become involved. Anorectal Dysfunction

In recent years anorectal dysfunction has sparked increased interest in a society that predominantly focuses on urinary dysfunction with more abstracts and workshops being presented about the pathology from the posterior pelvic floor compartment. It is known that anorectal dysfunction does not arise in isolation and more often will be the culmination of longstanding LUTS and vice versa.39 However the primary risk factor for young women to develop anorectal dysfunction continues to be pregnancy and delivery, in particular obstetric anal sphincter injury (OASIS).40 Ros and colleagues41 also found that at three months postpartum women with OASIS delivered by instrumental Neurourology and Urodynamics DOI 10.1002/nau

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delivery had worse pelvic floor muscle and function outcomes than those with a spontaneous vaginal delivery (Abstract 420). Johannessen et al.42 explored changes in anal incontinence (AI) among primiparous women during pregnancy and the first year after delivery (Abstract 417). They reported that one in three women of a cohort of 862 women suffered from AI in late pregnancy and a third of those continued to have problems a year later after delivery, suggesting that hormonal and mechanical changes may affect postpartum AI more than vaginal delivery. In this particular study occipito-posterior fetal position and young age were identified as predictors for postpartum AI. Worldwide health care systems strive to combine both patient satisfaction and economically viable ways of evaluating and managing their patients. Another innovative presentation came from Matthews and colleagues,43 who reported on the preliminary findings of using the vaginal bowel control (VBC) system for the management of fecal incontinence (FI) (Abstract 411). Their results showed a decrease in both liquid and solid stool incontinence episodes after using the VBC, but further research is required to establish this new device as a new strategy for the non-surgical management of FI. Conservative Treatment, Rehabilitation and Biomechanics.

The ever-growing question of finding the ‘‘gold standard’’ pelvic floor exercise regime, the most innovative treatment device or the best combination of conservative treatment measures that will speed up rehabilitation and improve quality of life as well as pelvic floor symptoms is in continuous development. Kafri and colleagues44 found that the combination of pelvic floor muscle training (PFMT), bladder training and behavioral guidance was more effective for the treatment of urgency urinary incontinence than drug treatment, PFMT or bladder training in isolation and should be offered as a first line management for this condition (Abstract 404). Interestingly the group receiving drug therapy had the highest dropout and contrary to previous belief it was due to group allocation rather than side effects from the medication. In the study by Frawley and colleagues, 45 an attempt was made to engage midwives as well as obstetricians in a public hospital setting in continence screening and pelvic floor muscle exercise instruction during pregnancy (Abstract 666). By the end of the study only midwives in the midwifery-led units had engaged fully in the research study and felt competent with both assessment and instruction. Barriers to engage in a change in practice were identified raising the question of the challenges of implementing new interventions within the multidisciplinary setting. Cruz and colleagues46 found that supervised pelvic floor muscle training by a health professional might reduce UI and improve pelvic floor muscle strength during pregnancy (Abstract 403). Obesity has been identified as a risk factor for UI, however, Perez et al.47 did not find this association when comparing pelvic floor muscle strength as well as the presence or not of urinary symptoms among obese women (Abstract 669). The authors’ concluding message was that the relationship between obesity and UI is multifactorial rather than solely due to weakness of the pelvic floor muscles. Prieto and colleagues48 conducted a systematic review comparing the technique, design and user acceptability of intermittent catheterization and its impact on the development of urinary tract infection. They did not find any correlation between all variables and there is no evidence as

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yet as to what is most cost-effective and least invasive form of intermittent catheterization (Abstract 399). Epidemiology

One European registry-based study examined symptom persistence among 2175 male benign prostatic hyperplasia (BPH)/LUTS patients (Abstract 35).49 As many as 62% of pharmacologically treated and 59% of untreated men remained symptomatic (defined as IPSS  8) at 2 years. A US healthcare claims database study explored the safety of different antimuscarinics among new users (Abstract 36).50 No differences were found in rates of diagnosis of cognitive decline. Differences in constipation rates were found between different medications, however, whether these associations were due to selective prescribing patterns or causality remains unclear. European physicians, urologists, and gynecologists were surveyed regarding diagnostics and treatments of almost 9,000 LUTS patients (Abstract 37)51 If overactive bladder (OAB) (n ¼ 4425, 47%) was diagnosed, 71% received a prescription for an antimuscarinic drug. If BPH (n ¼ 4,492, 47%) was diagnosed, 65% received a prescription for an alpha-blocker and 21% for a 5-alpha reductase inhibitor. When neither of those were diagnosed, but primarily nocturnal polyuria (NP) was the case (n ¼ 569, 6%), there were substantial variation in treatment decisions: 46% antimuscarinics, 14% alpha-blocker, 3% 5-alpha reductase inhibitor, 21% no drug and 25% other drug. Of those with ‘‘other drug’’, approximately two thirds got desmopressin. Koehler et al.52 analyzed 27 incontinence questionnaires recommended by the ICS to develop a validated short and simple instrument to quantify the impact of UI and FI. Using the International Classification of Functioning, Disability and Health (ICF) instrument, it was found that available questionnaires only cover a small spectrum of the burden of UI and FI (Abstract 33). The authors are creating a more comprehensive tool, and it will be interesting to see how to create an instrument, which is both comprehensive and feasible in daily practice. Sexual Function

Female pelvic floor disorders may affect the partner and can result in shared sexual dysfunction. Cunkelman and colleagues53 aimed to objectify sexual dysfunction among patients suffering from stress urinary incontinence (SUI) and/ or pelvic organ prolapse (POP) and their male partners via independently completed questionnaires. They showed that overall dysfunction was reported in 43% of male participants and 31% of female participants, in particular in terms of infrequency and non- communication. A significant correlation was demonstrated between a diagnosis of SUI alone or SUI and POP and sexual dysfunction, whereas POP alone did not seem to correlate with sexual dysfunction. Focusing on the sexual function of women with OAB- dry and its potential improvement through the application of percutaneous tibial nerve stimulation (PTNS), Musco et al.54 assessed patients’ sexuality via the female sexual function index (FSFI) before and after PTNS treatment. Among patients with previously reported sexual disturbances, complete remission of sexual dysfunction could be observed in 5/14 patients after PTNS, whilst general improvement was shown in almost all patients. Urinary function improvements were statistically significant in patients with and without reported sexual dysfunction. However, improvement in urinary function did not seem to correlate with sexual function improvement, which led the authors to the conclusion that sexual function improvement might be directly related to PTNS effects Neurourology and Urodynamics DOI 10.1002/nau

(Abstract 44). Whereas pelvic floor muscle training (PFMT) is a common therapy option for women with pelvic floor disorders, it was yet unclear whether PFMT would improve erectile dysfunction or orgasm- associated incontinence (climacturia) in men after nerve- sparing radical prostatectomy (RP). Geraerts and colleagues55 randomized 33 patients to either PFMT (12 weeks) directly after surgery (case group) or 3 months later (control group). The treatment group showed a significantly better erectile function at 3 months post- operation and climacturia significantly decreased in both groups after 3 months of overall PFMT (Abstract 50). Pain and Cystitis

This year’s sessions on pain and cystitis hosted many basic science abstracts, including studies on human proteomics/ metabolomics and the evaluation of different animal models. Interstitial cystitis or painful bladder syndrome (IC/PBS) covers a wider spectrum of clinical presentations, which complicates an accurate diagnosis. Moreover, underlying pathophysiologic mechanisms are yet insufficiently defined. Moitinho and colleagues56 presented preliminary results of a case-control study investigating differences in the urinary proteomic profile of female patients with IC/PBS and healthy controls. IC/PBS patients showed decreased levels of proteins related to cell proliferation, glycosaminoglycan biosynthesis and cell adhesion, whereas on the other hand they presented with increased levels of proteins involved in acute phase reaction and apoptosis. These findings could help to identify biomarkers to facilitate IC/PBS diagnosis in the future (Abstract 18). In a different approach to illuminate potential IC/PBS biomarker candidates, Bray et al.57 applied high field proton nuclear magnetic resonance (H-NMR) spectroscopy in order to measure urinary metabolites in female IC/ PBS patients and healthy controls. Analysis of spectral data revealed consistently reduced levels of urinary hippuric acid in IC/PBS patients, which could confirm the previously established theory of an inflammatory pathogenesis (Abstract 348). Bladder mucosal biopsy samples were investigated in the context of bladder dysfunction following bladder outlet obstruction (BOO), as well as for the examination of estrogen receptor- a (ERa) expression in IC/PBS. Wang and colleagues58 could demonstrate a greater mast cell activity in bladder biopsy samples of patients with BOO and detrusor overactivity (DO) compared to patients with BOO and hypersensitive bladder (HSB), and a significantly lower E- cadherin distribution in BOO patients with DO and detrusor underactivity compared to BOO with HSB. These findings suggest that impairment of junctional proteins of the urothelial cells, as well as apoptosis and chronic inflammation are associated with different bladder tissue stages after BOO (Abstract 349). Animal models in rats and mice for simulation of chronic urothelial injury and bladder pain hypersensitivity/ hyperactivity were presented. Okada and colleagues59 reported increased levels of prostaglandin E2 (PGE2) and COX-2 in the dorsal root ganglia (L6-S1), the spinal dorsal horn (L6-S1), the pons and the bladder of rats after 28 days of induced hypersensitivity using intermittent infusion of protamine sulphate. EP1 receptor activation by PGE2 may contribute to peripheral and central sensitization leading to increased bladder pain (Abstract 351). Male Urinary Incontinence and Benign Prostatic Obstruction

A Norwegian study by Holm et al.60 examined 844 men treated with radical prostatectomy and found substantial differences according to the definition used (Abstract 302). At 12 months post operatively, when defined as ‘‘any pad use,’’ prevalence of incontinence was 40%, while defined as ‘‘any

Hot at ICS meeting 2014 leakage’’ it was 74%. Severe postprostatectomy incontinence (PPI) was reported by 3%, but according to the Ellison et al.61 questionnaire criteria, 25% actually had severe PPI. In a pooled analysis of three industry-initiated Asian studies,62 the efficacy of tadalafil 5 mg once daily for 12 weeks was compared with placebo in improving the total International Prostate Symptom Score (IPSS). Of a total of 1,199 patients, 601 and 598 patients were randomly assigned to the tadalafil group and placebo group, respectively. The least squares (LS) mean change in total IPSS from baseline to week 12 was -5.3 for tadalafil 5 mg and -3.8 for placebo—representing a statistically significant, but clinically modest improvement (Abstract 660). Nocturia

Few studies have explored nocturia longitudinally. One Japanese study examined the prognosis of nocturia, including 8,265 individuals (Abstract 337).63 Overall prevalences of nocturia each year between 2003 and 2007 were 11.6%, 11.3%, 13.3%, 15.1%, and 13.6%, respectively. Although the prevalence of nocturia increased with age, the annual remission rates ranged between 37% and 46%, highlighting the dynamic nature of nocturia. A meta-analysis using data from 9 studies enrolling 28,366 participants found evidence of increased mortality for men or women with nocturia, equivalent to 28% excess risk per year, suggesting that nocturia may be an important marker of ill health (Abstract 338).64 Yoshimura and colleagues65 conducted a randomized trial studying the add-on efficacy of ramelteon (MT1/2-receptor agonist / mild hypnotic drug) with lifestyle measures in the improvement of nocturia and nocturia-related sleep disturbance. The addition of ramelteon did not show any benefit compared with lifestyle measures alone (Abstract 344). CONCLUSIONS

Once again, the scientific content of the programme represented an ambitious interdisciplinary approach to lower urinary tract and pelvic floor dysfunction, as well as continence care. The success of organizational innovations led to a stimulating meeting, and no doubt great excitement for the next annual scientific meeting in Montreal, Canada. We hope that our report provides you with a useful overview of the new scientific content presented at the ICS 2014. ACKNOWLEDGMENT

The authors would like to thank Dominic A. Turner for his editorial help in accessing the abstract submission statistics for ICS 2014. REFERENCES 1. Wollner J, Zweers P, Krebs J, et al. In-vivo imaging of the neuronal network of the lower urinary tract using DTI-fibre tracking—a pilot study. Neurourol Urodynam 2014;33:649–50. 2. Notten K, Weemhoff M, Kluivers K, et al. Do levator ani muscle defects predict recurrent pop after anterior colporraphy? Neurourol Urodynam 2014;33:860– 1. 3. Dietz HP, Langer S, Atan IK, et al. Does the Epi-no prevent pelvic floor trauma? A multicentre randomised controlled trial. Neurourol Urodynam 2014;33: 853–5. 4. Meriaux C, Jahanshahi A, Hohnen R, et al. Communication between the lower urinary tract and the central nervous system: Functional mapping of the periaqueductal gray matter. Neurourol Urodynam 2014;33:650–2. 5. Bicer F, Huang W, Daneshgari F, et al. Investigation of an acute role for nonneuronal cells in pelvic pain and bladder dysfunction in a novel mouse model of experimental autoimmune cystitis (Eac). Neurourol Urodynam 2014; 33:653–5.

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6. Sievert K, Amend B, Roser F, et al. Investigation to restore innervation of the lower urinary tract of spinal cord injured patients: A European single-center retrospective study with long-term follow-up. Neurourol Urodynam 2014; 33:652–3. 7. Blaivas J, Rozenberg Y, Ravid L, et al. The dynamic urine vibration halter: A new outpatient ambulatory flowmeter. Neurourol Urodyn 2014;33:671–2. 8. Wille S, Schumacher P, Paas J, et al. Catheterless long-term ambulatory urodynamic measurement using a novel three-device system. Neurourol Urodynam 2014;33. 9. Rademakers K, Oelke M, van Koeveringe G. Detrusor underactivity in females: Significant correlation between standardised medical history assessment and urodynamic findings. Neurourol Urodynam 2014;33:922–922. 10. Wyman J, Allen A, Hertsgaard L, et al. Effect of smoking cessation on overactive bladder symptoms in adults: A pilot study. Neurourolo Urodynamics 2014;33:866–7. 11. Atan IK, Furtado G, Caudwell-Hall J, et al. 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