Alpha-1 Adrenergic Receptor Blockers for the Treatment of Lower Urinary Tract Symptoms in Women: A Systematic Review and Meta-Analysis

Investigating the impact of age and sex on cataract surgery complications and outcomes

Cataract surgery, a common procedure for vision restoration, exhibits variable outcomes based on patient demographics. This study aimed to elucidate the effects of age and sex on risk factors, intraoperative complications, and postoperative outcomes of cataract surgery. A single-center retrospective cohort study analyzed 691 eyes from 589 individuals who underwent surgery at a tertiary referral center, using electronic medical records to assess preoperative risk factors, intraoperative complications, and best corrected visual acuity (BCVA) pre- and post-operatively, alongside demographic data. The study found that males aged 65-75 years had significantly higher rates of functional postoperative BCVA (91% for males vs. 79% for females, p = 0.007), a disparity not attributable to differences in surgical complications or risk factor prevalence. Age-specific thresholds were identified where BCVA improvements significantly declined beyond 65 years for females and 75 years for males. The likelihood of worsened BCVA post-surgery increased with age for both sexes, with a notable decline in BCVA improvement between the 55-65 years and 65-75 years age groups. These findings underscore the critical influence of sex and age on cataract surgery outcomes, advocating for the integration of these factors into preoperative evaluations to better tailor the timing and planning of cataract surgery and optimize clinical outcomes.

Nonneurogenic female bladder outlet obstruction: Conservative and medical management

INTRODUCTION

In nonneurogenic female bladder outlet obstruction (BOO), management goals include reduction of outlet resistance to increase urinary outflow and improve bladder voiding to prevent or reduce lower and upper urinary tract (LUT and UUT) function deterioration, by correcting the underlying etiology. As significant progress has been achieved in the conservative and pharmacological management of nonneurogenic female BOO, the purpose of this article is to review and summarize the current literature.

MATERIALS AND METHODS

For this narrative review, a PubMed® search was performed by cross-referencing the keywords "female bladder outlet obstruction," "female voiding dysfunction," "conservative management," "pharmacological management," and "treatment" with various terms related to the management of female BOO. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used.

MANAGEMENT

This review discusses and summarizes the conservative and pharmacological management of nonneurogenic female BOO based on the most relevant data currently available in the literature.

CONCLUSION

The recent advances in the understanding of underlying mechanisms involved in female BOO allow for more individualized management. Conservative and pharmacological options show interesting outcomes, particularly in the context of a functional cause of BOO. Overall, the level of evidence is still low regarding the use of conservative and pharmacological measures and more long-term data are required.

Therapeutic Approaches for Urologic Chronic Pelvic Pain Syndrome; Management: Research Advances, Experimental Targets, and Future Directions

Urologic chronic pelvic pain syndrome (UCPPS) is a painful chronic condition with persistent pain originating from the pelvis that often leads to detrimental lifestyle changes in the affected patients. The syndrome develops in both sexes, with an estimated prevalence of 5.7% to 26.6% worldwide. This narrative review summarizes currently recommended therapies for UCPPS, followed by the latest animal model findings and clinical research advances in the field. The diagnosis of UCPPS by clinicians has room for improvement despite the changes in the past decade aiming to decrease the time to treatment. Therapeutic approaches targeting growth factors (i.e., nerve growth factor, vascular endothelial growth factor), amniotic bladder therapy, and stem cell treatments gain more attention as experimental treatment options for UCPPS. The development of novel diagnostic tests based on the latest advances in urinary biomarkers would be beneficial to assist with the clinical diagnosis of UCPPS. Future research directions should address the role of chronic psychologic stress and the mechanisms of pain refractory to conventional management strategies in UCPPS etiology. Testing the applicability of cognitive behavioral therapy in this cohort of UCPPS patients might be promising to increase their quality of life. The search for novel lead compounds and innovative drug delivery systems requires clinically relevant translational animal models. The role of autoimmune responses triggered by environmental factors is another promising research direction to clarify the impact of the immune system in UCPPS pathophysiology. SIGNIFICANCE STATEMENT: This minireview provides an up-to-date summary of the therapeutic approaches for UCPPS with a focus on recent advancements in the clinical diagnosis and treatments of the disease, pathophysiological mechanisms of UCPPS, signaling pathways, and molecular targets involved in pelvic nociception.

Current and Emerging Pharmacological Targets and Treatments of Urinary Incontinence and Related Disorders

Overactive bladder syndrome with and without urinary incontinence and related conditions, signs, and disorders such as detrusor overactivity, neurogenic lower urinary tract dysfunction, underactive bladder, stress urinary incontinence, and nocturia are common in the general population and have a major impact on the quality of life of the affected patients and their partners. Based on the deliberations of the subcommittee on pharmacological treatments of the 7th International Consultation on Incontinence, we present a comprehensive review of established drug targets in the treatment of overactive bladder syndrome and the aforementioned related conditions and the approved drugs used in its treatment. Investigational drug targets and compounds are also reviewed. We conclude that, despite a range of available medical treatment options, a considerable medical need continues to exist. This is largely because the existing treatments are symptomatic and have limited efficacy and/or tolerability, which leads to poor long-term adherence. SIGNIFICANCE STATEMENT: Urinary incontinence and related disorders are prevalent in the general population. While many treatments have been approved, few patients stay on long-term treatment despite none of them being curative. This paper provides a comprehensive discussion of existing and emerging treatment options for various types of incontinence and related disorders.

Predictive factors for the success of trial catheter removal for women with urinary retention

OBJECTIVE

To investigate the outcome, determine the predictors for the success of, and evaluate the efficacy of pharmacokinetic therapy on trial catheter removal for women with urinary retention.

METHODS

Inclusion criteria were female patients with acute urinary retention defined as painful, palpable, or percussive bladder, when the patient is unable to pass any urine, accompanied by postvoid residual (PVR) > 250 ml, and who underwent trial catheter removal between July 2009 and July 2019. Before trial catheter removal, alpha-blockers alone or alpha-blockers and parasympathomimetics (bethanechol or distigmine bromide) were used to facilitate spontaneous voiding in some cases.

RESULTS

Fifty-nine of 104 (56.7%) women with urinary retention were catheter-free post trial. There was no significant difference between successful and non-successful trials in average age (p = .392), median ECOG (Eastern Cooperative Oncology Group) performance status (p = .374), diabetes mellitus (p = .842), dementia (p = .801), previous history of cerebrovascular events (p = .592), or intrapelvic surgery (p = .800). Oral medications were administered for 39/59 (66.1%) in the success group and 30/45 (66.7%) patients in the non-success groups (p = .598). Serum albumin (3.2 ± 0.7 g/dl and 2.8 ± 0.8 g/dl, p = .039) and total protein values (6.5 ± 0.8 g/dl and 6.0 ± 1.0 g/dl, p = .038) at diagnosis of urinary retention were higher in the success group than the non-success group, respectively. Multivariate logistic regression found that a serum albumin >3 g/dl was an independent predictor of successful trial catheter removal for women with urinary retention (p = .030, odds ratio [OR] 3.3, 95% confidence interval [CI] of OR 1.1-9.9). Age < 70 years old was a likely predictor of successful trial catheter removal (p = .066, OR 4.8, 95% CI of OR 0.9-25.0).

CONCLUSIONS

This is the first retrospective study to investigate the predictive factors for successful trial catheter removal in women with urinary retention. A serum albumin value >3 mg/dl at diagnosis of urinary retention was a significant independent predictor of catheter-free status after trial catheter removal, and age < 70 years-old was a possible contributor. There was no evidence that oral medication contributed to catheter-free status.

Risk of intraoperative floppy iris syndrome among selective alpha-1 blockers—A consistency model of 6,488 cases

Selective α1-blockers are commonly administered to patients with lower urinary tract syndrome and benign prostatic hyperplasia, but may increase the risk of intraoperative floppy iris syndrome (IFIS). The purpose of this study aimed to clarify the risk of IFIS among various selective α1-blockers. Four databases were searched for prospective studies comparing alpha-1-antagonists. Data were pooled using the consistency model, and used risk ratio (RR) and mean difference (MD) for IFIS and pupil diameter, respectively. This study finally included 25 prospective comparative studies. Based on 51 direct comparisons with 6488 cases, risks of IFIS in patients who received tamsulosin [RR, 13.85; 95% confidence interval (CI): 7.34 to 26.11], terazosin (RR, 8.94; 95% CI 2.88 to 27.74), alfuzosin (RR, 7.73; 95% CI: 3.05 to 19.62), and doxazosin (RR, 3.88; 95% CI: 1.13 to 13.28) were significantly higher than those did not receive α1-antagonists. Based on 11 direct comparisons with 564 cases, as compared to no α1-antagonists, patients who received tamsulosin (MD, −0.36; 95% CI: −0.71 to −0.01) and alfuzosin (MD, −0.34; 95% CI: −0.62 to −0.07) showed smaller pupil diameter under mesopic light levels, while those received silodosin did not show significantly smaller mesopic pupil diameter than people without α1-antagonists. IFIS seems to be inevitable with the usage of α1-antagonists, and tamsulosin needs to be cautious due to the significantly higher risk of severe IFIS. With regard to silodosin, there is no strong evidence to support the uses of italthough it does not significantly decrease mesopic pupil diameter.

Bladder Dysfunction in Older Adults: The Botulinum Toxin Option

Bladder dysfunction, which involves inadequacies of urine storage or emptying, increases with age. Conventional medications may have insufficient efficacy for patients with refractory lower urinary tract symptoms, and their concomitant adverse events (AEs) may be intolerable for the older adult population. For decades, the botulinum toxin type A (BoNT-A) injection has been an option for managing urine frequency, urge incontinence, and voiding dysfunction in the general population refractory to conventional management. This review focuses on studies of BoNT-A application in the management of bladder dysfunction in older adult patients aged ≥ 65 years. In this target population, intravesical BoNT-A injections provide similar efficacy in idiopathic overactive bladder to that in younger adults. Good clinical response has also been demonstrated in older adult patients presenting with storage dysfunction and with various concomitant underlying neurological diseases. However, caution must be taken for the AEs that occur after intravesical BoNT-A injection, including increased post-void residual urine, acute urine retention, and urinary tract infection. Most evidence shows that age is not a major determinant of AEs after adjusting for other factors. In contrast to its application in storage dysfunction, evidence for voiding dysfunction in older adults is scarce. In general, BoNT-A may be a reasonable option for older adult patients with refractory storage dysfunction because of its promising clinical response without significant systemic AEs. Overall, clinicians should be aware of the balance between the therapeutic efficacy of BoNT-A and local AEs in vulnerable members of this population.

Best nonsurgical managements of acute urinary retention: what's new?

PURPOSE OF REVIEW

To provide a comprehensive review of the nonsurgical management of acute urinary retention (AUR).

RECENT FINDINGS

A recent meta-analysis confirmed that α-blockers are associated with higher rates of successful trial without catheter (TWOC) compared with placebo, while combination therapies do not significantly reduce the rate of recatheterization. Compared with standard TWOC, bladder perfusion with physiological serum prior to catheter removal is a simple and cost-effective method to increase TWOC success rates (odds ratio 2.41, 95% confidence interval 1.53-3.8), and to reduce time-to-discharge (-89.68 min, 95% confidence interval -160.55, -18.88). Clean intermittent catheterization (CIC) is increasingly used for urinary retention in patients with benign prostatic hyperplasia as existing data suggest that it may decrease the risk of urinary tract infections, accelerate spontaneous voiding recovery and might be more cost-effective compared with indwelling urethral catheterization. Ongoing trials are examining whether office-placed prostate stent may be a promising solution in patients with AUR.

SUMMARY

The recent development of alternative approaches to traditional TWOC may lead to new therapies for treating patients with AUR. Further studies are needed as the level of evidence from published studies remains low.

Diagnostic Value of the Maximum Urethral Closing Pressure in Women With Overactive Bladder Symptoms and Functional Bladder Outlet Obstruction

Purpose

Overactive bladder (OAB) is observed in women with functional bladder outlet obstruction (FBOO), as are lower urinary tract symptoms (LUTS). Therefore, we evaluated the urodynamic characteristics of women with storage LUTS and FBOO diagnosed by urodynamic studies (UDS).

Methods

Women (n=108) with storage LUTS and FBOO diagnosed by UDS were included in this study. The urodynamic characteristics of women with FBOO were compared with those of women with OAB (n=34) and stress urinary incontinence (SUI, n=78). FBOO was defined as a maximum flow rate (Qmax) < 15 mL/sec, combined with detrusor pressure at a Qmax (PdetQmax) > 20 cm H₂O in a pressure-flow study. The UDS included uroflowmetry, postvoid residual volume determination, a cystometrogram, and a pressure-flow study.

Results

Women with FBOO who had storage symptoms showed a higher PdetQmax and maximum urethral closing pressure (MUCP) than women with OAB and SUI. Interstitial cystitis/bladder pain syndrome (IC/BPS) was observed in 17.6% of women with FBOO. MUCP was significantly higher in women with BOO than in women with BOO and IC/BPS (115.6±27.4 and 96.6±14.1 cm H₂O, P=0.00). The receiver operating characteristic curve analysis showed that the cutoff values of MUCP in women with FBOO compared to women with OAB and SUI were 87 cm H₂O (sensitivity=81.5%, specificity=73.5%) and 36 cm H₂O (sensitivity=92.6%, specificity=84.4%), respectively. The cutoff value of MUCP in women with FBOO compared to women with FBOO and IC/BPS was 92 cm H₂O (sensitivity=85.4%, specificity=78.9%).

Conclusions

MUCP could have predictive value for identifying FBOO in women with complex LUTS.

Effect of the symptom-based alpha-blocker treatment on lower urinary tract symptoms in women: systematic review and meta-analysis

Aims

The aim of this study was to evaluate the effects of alpha blockers in women with lower urinary tract symptoms.

Methods

We conducted systematic review and meta-analysis on published a priori protocols. We searched multiple data sources for published and unpublished randomized controlled trials in any language. Primary outcomes included urologic symptom scores, quality of life, and overall adverse events. We performed meta-analysis using RevMan 5.3 and rated the certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation.

Results

Alpha blockers likely reduced urological symptom score (mean difference: -1.50, 95% confidence interval: -2.91 to -0.09; moderate certainty of evidence). Alpha blockers may improve quality of life (standardized mean difference: -0.35, 95% confidence interval: -0.85 to 0.15; low certainty of evidence) and have little to no difference in overall adverse events (risk ratio: 1.09, 95% confidence interval: 0.55 to 2.15; low certainty of evidence). Based on five studies comparing combination therapy with alpha blockers and anticholinergics to anticholinergic monotherapy, combination therapy likely results in little to no difference in urological symptom score (mean difference: -0.35, 95% confidence interval: -1.98 to 1.27; moderate certainty of evidence) and quality of life (mean difference: -0.11, 95% confidence interval: -0.48 to 0.27; moderate certainty of evidence). We are very uncertain about the effect of combination therapy on overall adverse events (risk ratio: 1.07, 95% confidence interval: 0.40 to 2.84; very low certainty of evidence).

Conclusion

Alpha blocker monotherapy for the women with lower urinary tract symptoms regardless of the underlying cause likely has satisfactory efficacy compared with placebo. However, combination therapy with anticholinergics likely has no additional effect on urologic symptom score and quality of life compared with anticholinergic monotherapy.

Metformin and Sildenafil Attenuate Inflammation and Suppress Apoptosis After Ischemia/Reperfusion Injury in Rat Urinary Bladder

Purpose

Although metformin and sildenafil can protect various organs against ischemia/reperfusion (I/R) injury, their effects and mechanisms of action in bladder I/R injury remain unknown. This study investigated the effects and mechanisms of action of metformin and sildenafil against bladder I/R insult in rats.

Methods

One hundred male Sprague-Dawley rats were randomly divided into five groups each of twenty rats: a sham-operated group, a bladder I/R group, and bladder I/R groups treated with metformin, sildenafil, or both agents. Ischemia was induced by clamping the bilateral common iliac arteries with atraumatic vascular clamps for 2 hours, followed by reperfusion for 7 days. During this period, rats were injected once daily with 4 mg/kg metformin and/or 1 mg/kg sildenafil.

Results

The increased malondialdehyde (MDA) levels and myeloperoxidase (MPO) activities and the decreased superoxide dismutase (SOD) activities induced by I/R injury were reduced by treatment with metformin and/or sildenafil. The I/R group had significantly higher JNK, p38 MAPK, Bax, caspase-3, and NF-κB levels, and lower ERK and Bcl-2 levels in the bladder than the sham-operated group; these changes were significantly ameliorated by metformin and/or sildenafil treatment. No differences in the levels of these markers were observed between rats co-administered metformin and sildenafil and those treated with either agent alone.

Conclusions

Metformin and sildenafil protected rat bladder against I/R injury. This effect may be due to the inhibition of ROS production through MAPKs, Bax, and Bcl-2 activation, and the restoration of inflammation through NF-κB inhibition. However, the combination of metformin and sildenafil was no more effective than either agent alone.

An Exploratory Analysis of Tamsulosin for Overactive Bladder (OAB) in Men With Varying Voiding Symptom Burden

OBJECTIVE

To evaluate tamsulosin (α-blocker therapy) for male overactive bladder (OAB) and to examine if indicators of concomitant benign prostatic hyperplasia are associated with OAB symptom improvement.

MATERIALS AND METHODS

This was a planned, exploratory analysis of a 4-week, α-blocker (tamsulosin 0.4 mg) run-in phase of the Male Overactive Bladder Trial in Veterans (MOTIVE). Participants with urinary urgency and urinary frequency (> 8 voids/24 hours) completed bladder diaries, answered symptom questionnaires (AUA-7 SI), and had post-void residual and noninvasive uroflowmetry measurement.

RESULTS

A total of 116 male Veterans aged 42-88 years with OAB participated. There were statistically significant reductions in voiding frequency (11.3 > 10.0 voids/24 hours, P < .0001), urgency scores (mean 2.5-2.2 points, P < .0001), and nightly nocturia (2.1 > 1.8, P < .001). Only baseline AUA-7 SI total and voiding subscale categories (mild, moderate, severe) were associated with significant reduction in AUA-7 SI total score. For continuous variables, only AUA-7 SI baseline total score was associated with AUA-7 SI storage symptom changes. No other baseline measures were associated with changes in urgency, frequency, or nocturia.

CONCLUSION

Initiation of short course tamsulosin therapy in men was associated with statistical reduction in OAB symptoms. Baseline post-void residual, uroflow rate, and the voiding symptom subscore of the AUA-7 SI were not predictive of OAB symptom improvement with tamsulosin. These findings merits further exploration.

The Neuromodulator-Encoding sadA Gene Is Widely Distributed in the Human Skin Microbiome

Trace amines (TA) are endogenously produced in mammals, have a low concentration in the central nervous system (CNS), but trigger a variety of neurological effects and intervene in host cell communication. It emerged that neurotransmitters and TA are produced also by the microbiota. As it has been shown that TA contribute to wound healing, we examined the skin microbiome of probands using shotgun metagenomics. The phyla Actinobacteria, Proteobacteria, Firmicutes, and Bacteroidetes were predominant. Since SadA is a highly promiscuous TA-producing decarboxylase in Firmicutes, the skin microbiome was specifically examined for the presence of sadA-homologous genes. By mapping the reads of certain genes, we found that, although there were less reads mapping to sadA than to ubiquitous housekeeping genes (arcC and mutS), normalized reads counts were still >1000 times higher than those of rare control genes (icaA, icaB, and epiA). At protein sequence level SadA homologs were found in at least 7 phyla: Firmicutes, Actinobacteria, Proteobacteria, Bacteroidetes, Acidobacteria, Chloroflexi, and Cyanobacteria, and in 23 genera of the phylum Firmicutes. A high proportion of the genera that have a SadA homolog belong to the classical skin and intestinal microbiota. The distribution of sadA in so many different phyla illustrates the importance of horizontal gene transfer (HGT). We show that the sadA gene is widely distributed in the human skin microbiome. When comparing the sadA read counts in the probands, there was no correlation between age and gender, but an enormous difference in the sadA read counts in the microbiome of the individuals. Since sadA is involved in TA synthesis, it is likely that the TA content of the skin is correlated with the amount of TA producing bacteria in the microbiome. In this way, the microbiome-generated TA could influence signal transmission in the epithelial and nervous system.

Efficacy and Safety of Naftopidil in Patients With Neurogenic Lower Urinary Tract Dysfunction: An 8-Week, Active-Controlled, Stratified-Randomized, Double-Blind, Double-Dummy, Parallel Group, Noninferiority, Multicenter Design

Purpose

The aim of this study was to evaluate the efficacy and safety of naftopidil compared with tamsulosin in patients with neurogenic lower urinary tract dysfunction (LUTD).

Methods

This study was conducted as an 8-week, active-controlled, stratified-randomized, double-blind, double-dummy, parallel group, noninferiority, and multicenter clinical trial. After 2 weeks of screening, eligible subjects were randomly assigned to receive naftopidil (25 mg for 1 week followed by 75 mg for 7 weeks) or tamsulosin (0.2 mg for 8 weeks). Primary endpoint was a change of International Prostatic Symptom Score (IPSS) total score after 8 weeks of treatment.

Results

One hundred ninety-four subjects with neurogenic LUTD were included into this trial. There were no differences between the 2 groups in baseline characteristics, including urodynamic study results, subtype of LUTD, pretreatment and concomitant medication, and causes of neurogenic bladder. The medication compliance rate was 94.0% (naftopidil, 93.6%; tamsulosin, 94.4%). There was a statistically significant decrease of IPSS total score at 8 weeks versus baseline in both the naftopidil (-5.64±0.66) and tamsulosin (-6.53±0.65) groups (P<0.0001 each). The mean difference between both groups was 0.89 (upper limit of 95% confidential interval, 2.72), which was lower than the noninferiority limit of 3 points. A subgroup analysis of neurologic lesions and sex found no mean difference of IPSS total score in each group. There was also no difference in safety profiles, including treatment emergent adverse events.

Conclusions

Naftopidil was not inferior to tamsulosin as a therapeutic drug for patients with neurogenic LUTD and had a similar safety profile.

Obstructive patterns in videourodynamic studies predict responses of female dysfunctional voiding treated with or without urethral botulinum toxin injection: a long-term follow-up study

INTRODUCTION AND HYPOTHESIS

We report long-term changes in VUDS profiles of women with dysfunctional voiding and investigate potential predictors for treatment response.

METHODS

Women with dysfunctional voiding and available VUDS data between November 1997 and June 2018 were enrolled for retrospective analysis. The patients were all treated with medication first. In refractory patients, urethral botulinum toxin was provided as an additional option. The primary outcome was the change of VUDS parameters between baseline and follow-up studies. The secondary outcomes were baseline parameters and clinical factors that were associated with the BOOI response (> 10 points of BOOI reduction).

RESULTS

A total of 195 women with DV were included in this study. The mean age was 54.5 years old. Sixty patients received urethral botulinum toxin injection. For all patients, Pdet decreased from 47.2 to 36.8 cm H₂O (p < 0.0001), and BOOI decreased from 26.4 to 17.7 (p = 0.0001). Patients with urethral injection had significantly smaller Qmax, voided volume, and voiding efficiency (VE) and significantly larger PVR and BOOI at baseline, indicating a severer obstruction in this group. The overall BOOI response rate was 44% (85/195). A higher baseline BOOI was associated with the BOOI response in multivariate analysis.

CONCLUSIONS

In this long-term study of women with dysfunctional voiding, medical treatment with or without urethral botulinum toxin injection both resulted in reduction of Pdet and BOOI. A more prominent obstructive profile at baseline VUDS study was associated with a higher rate of BOOI response at follow-up study.

Detrusor underactivity in women: A current understanding

AIMS

To examine the current understanding and management of detrusor underactivity (DUA) and underactive bladder (UAB) in women.

METHODS

A review of the current literature was performed with a specific focus on new management strategies and treatment options for women with DUA and UAB.

RESULTS

DUA has become an area of increased interest in recent years. Affecting up to 45% of older women undergoing urodynamic evaluation for non-neurogenic lower urinary tract symptoms, DUA is common. There are a variety of possible etiologies including neurogenic or myogenic dysfunction. As there is currently no cure for DUA and no way to restore the ability of the detrusor muscle to contract, management of DUA in women is mostly focused on effective bladder drainage by urinary catheterization. Clean intermittent catheterization is the gold standard for bladder drainage however for a variety of reasons, women with DUA often are managed with indwelling urethral catheter or suprapubic tube. Medications, sacral neuromodulation, and the inFlow urinary prosthesis are also treatment alternatives or additions to catheterization. Novel therapies using stem cells and gene therapy are also under investigation for the treatment of DUA and UAB.

CONCLUSIONS

DUA is likely more prevalent than recognized and undertreated in women. It is vital that further research in treatment options beyond catheterization be developed for these patients to offer patients a variety of treatment options.