What’s known on the subject? and What does the study add? Waking at night to pass urine, nocturia, is widely regarded as urological, but many medical conditions can be responsible. Overproduction of urine overnight on the frequency volume chart, “nocturnal polyuria”, is a key feature signifying possible contribution of systemic disease; renal, endocrine, neurological, or cardiovascular malfunction may be responsible. Failure to evaluate the potential medical basis risks poor treatment outcomes for a bothersome symptom. Inappropriately instigating surgical treatment, such as TURP, can lead to harm in a patient whose nocturia is caused by nocturnal polyuria. Global and nocturnal polyuria should be fully investigated, in case a potentially serious illness is responsible. Nocturia is commonly referred to urologists, but the mechanisms underlying the problem, together with the appropriate clinical assessment and management, may lie outside the ordinary scope of the specialty. Some serious conditions may manifest nocturia as an early feature, often as a consequence of nocturnal polyuria (NP). Voiding frequency is influenced by rate of urine output, reservoir capacity of the bladder, lower urinary tract (LUT) sensation and psychological response. Polyuria can result from polydipsia or endocrine dysfunction. NP can result from endogenous fluid and solute shifts, cardiovascular and autonomic disease, obstructive sleep apnoea, and chronic kidney disease. Nocturia without polyuria occurs in the presence of LUT pathology, pelvic masses and sleep disturbance. Drug intake can contribute to, or counteract, each of these problems. In assessing nocturia, clinicians need to consider an undiagnosed serious condition that may manifest nocturia as an early feature, or suboptimal management of a known condition. The frequency‐volume chart is a key tool in categorizing the basis of nocturia, identifying those patients with global polyuria or NP, for whom involvement of other specialties is often necessary for assessment and management. Treatment should be directed at the cause of the problem, with a view to improving long‐term health and health‐related quality of life. Simple steps should be undertaken by all patients, including improvement of the sleep environment and behaviour modification. Evaluation of treatment response requires objective data to corroborate subjective impressions. Some mechanisms of nocturia do not reliably improve with treatment, leading to refractory symptoms.

Many people are affected by urinary urgency, which can be highly bothersome. Urgency is the cornerstone symptom of overactive bladder (OAB), commonly occurring in conjunction with urinary frequency and nocturia. Once other medical causes of similar symptoms have been excluded, first-line OAB management comprises fluid intake advice and bladder training, supplemented by antimuscarinic drugs if necessary. Urodynamic confirmation of the diagnosis is required for OAB patients whose symptoms are refractory to first-line interventions. If patients are severely bothered by OAB despite optimization of medical treatment, they may proceed to invasive treatments, including neuromodulation, enterocystoplasty, detrusor myectomy, or urinary diversion. Our burgeoning understanding of the complex cellular, neural and integrative physiology of the bladder offers new insights into the causative mechanisms of OAB, and reasons why patients sometimes fail to respond to treatment. Study of sensory information pathways in the lower urinary tract has led to identification of the urothelium, afferent nerves and interstitial cells as key cellular elements in OAB. In-depth knowledge of the hierarchy of central nervous system control is lacking, but functional imaging is beginning to elucidate the challenges that lie ahead. New treatments under investigation include botulinum neurotoxin-A injection, oral β(3)-adrenergic agonists, and novel modalities for nerve stimulation. The subjective nature of urinary urgency, the lack of animal models and the multifactorial pathophysiology of OAB present significant challenges to effective clinical management.

printing of pelvic fracture urethral injuries-fusion of technology and urethroplasty.

The first uretero-arterial fistula (UAF) was reported in 1908 by Moschcowitz. In 2009, a systematic review identified 139 cases. Since then a further 23 cases were described with 19 cases originating from a single center. It has been recognized as a very rare condition in the past. However, more recently, the increasing incidence of UAF has led us to believe that this condition is more frequent than previously described. Aging population, improved cancer survival and extensive multimodal pelvic cancer treatments have been recognized as culprits for the increased incidence of UAFs. We have reviewed literature on UAFs, identified risk factors, patho-physiology and treatment options. Also, we present a case of fistulous communication between the internal iliac artery and ureter in a patient with a potential risk factor previously not described in the literature.

OBJECTIVE To assess the conservative management of pelvi‐ureteric junction obstruction (PUJO), according to severity, accepted in paediatric urology but rarely reported in adults. PATIENTS AND METHODS A series of 23 patients (median age 58 years, 17 men and six women) with asymptomatic or minimally symptomatic PUJO were managed conservatively. The patients’ age, preference and comorbidities were considered. The diagnosis of PUJO was based on intravenous urography and isotopic renography. After stringently reviewing the renograms based on relative renal function (RRF) and output efficiency (OE), 15 patients had an OE consistent with definitive PUJO. One patient had no further imaging due to associated comorbidities. Ten patients had right PUJO, three left and one with bilateral PUJO, with unilateral conservative management. The follow‐up included annual renography and clinical consultation. Laparoscopic pyeloplasty was considered for patients with a >10% loss of RRF and/or <40% RRF during the follow‐up. RESULTS Overall, 14 of 15 patients had renograms during the follow‐up. The mean RRF of the affected kidney at diagnosis was 48.6% which marginally decreased to 46.7% after a median (range) follow‐up of 44 (23–75) months. The RRF of 11 patients remained stable and in three decreased significantly (median 11% RRF), requiring pyeloplasty. None of the patients became symptomatic throughout the follow‐up. CONCLUSION In asymptomatic adults the conservative management of PUJO appears to be safe during a short‐ to medium‐term follow‐up. We recommend that patients are regularly followed with renography and seen promptly should they become symptomatic. A longer follow‐up is needed in a larger group to confirm these findings.