Characterizing the cortical pathways underlying visual trigger induced urinary urgency incontinence by functional MRI.

Abstract

Visual triggers have long been recognized clinically to stimulate urgency urinary incontinence (UUI). Current pathophysiology recognizes the importance of cortical control over micturition but there is no standardized methodology for clinicians to study the impact of visual triggers. Our aim was to develop an imaging protocol able to characterize the brain's response to personalized visual triggers, providing a methodology for evaluation on connectivity within the brain in patients with visually triggered urinary urgency. A magnetic resonance imaging (MRI) methodology specific for urologic use was developed. A 3T-Elition Scanner was first used to acquire static structural images. These images were then used to define approximately 200 brain regions of interest (ROI) using a validated brain atlas. Then, real-time functional MRI (fMRI) scans were conducted during natural bladder filling, where study subjects were shown randomized block sequences of visual stimuli comprised of both subject-specific trigger images and neutral images. The fMRI scan data were merged to identify key ROI underlying UUI. Dynamic fMRI scans were conducted in 10 subjects, 4 with trigger-induced UUI, 2 with trigger-induced urgency, and 4 with no urgency or leakage to visual triggers. No subjects with UUI history lost continence during imaging, but all four subjects reported sensations of urgency in response to their own subject-specific trigger images. The ROI identified were the periaqueductal gray, anterior cingulate gyrus, pons, and prefrontal cortex. We found increased activity in the prefrontal cortex and limbic system ROI in response to subject-specific visual triggers of UUI. This information provides proof of principle for further exploration of subject-specific trigger image evaluation using fMRI to explore causation in patients with UUI.