Conventional Urodynamic Studies Research Articles

82 - A randomized controlled trial on the efficacy of binaural beats in reducing anxiety and pain levels in patients undergoing conventional urodynamic study. Preliminary data and perspectives

82 - A randomized controlled trial on the efficacy of binaural beats in reducing anxiety and pain levels in patients undergoing conventional urodynamic study. Preliminary data and perspectives

Comparison of Penile Cuff Test and Conventional Urodynamic Study Prior to Photoselective Vaporization of Prostate for Benign Prostate Hyperplasia Using a 120 W GreenLight High Performance System Laser.

Background: We compared the utility of the penile cuff test (PCT) and the conventional urodynamic study (UDS) for the preoperative assessment of patients undergoing scheduled photoselective vaporization of the prostate (PVP) for benign prostate hyperplasia (BPH). Methods: Fifty-nine patients with voiding lower urinary tract symptoms (LUTS) underwent a simultaneous PCT and conventional UDS before PVP. The modified International Continence Society (ICS) nomogram was used to confirm bladder outlet obstruction after measuring maximum urinary flow rate and highest pressure at flow interruption. The PCT and UDS results, in terms of modified ICS nomogram predictions, were compared. Their sensitivities, specificities, and positive and negative predictive values were calculated. Results: Thirty-six patients were diagnosed as obstructed and 23 as non-obstructed/equivocal using the modified ICS nomogram during the PCT. All 36 of the first group were confirmed as obstructed by UDS. Of the 23 diagnosed as non-obstructed/equivocal by the PCT, 14 were confirmed to be non-obstructed by UDS, with nine diagnosed as obstructed. The PCT showed a sensitivity of 80% and a specificity of 100%. The positive and negative predictive values were 100% and 60.9%, respectively. Conclusions: In conclusion, despite our small number of patients, the PCT’s high sensitivity and specificity suggest that it may provide diagnostic information about bladder outlet obstruction before PVP for patients with voiding LUTS. Evidently, the PCT has the potential to be used for some patients as a screening alternative to invasive UDS.

PD01-01 SIMILARITY ANALYSIS BETWEEN CATHETERLESS URODYNAMIC STUDY USING PENILE CUFF AND CONVENTIONAL URODYNAMIC STUDY FOR EVALUATION OF MALE LOWER URINARY TRACT SYMPTOM

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2016PD01-01 SIMILARITY ANALYSIS BETWEEN CATHETERLESS URODYNAMIC STUDY USING PENILE CUFF AND CONVENTIONAL URODYNAMIC STUDY FOR EVALUATION OF MALE LOWER URINARY TRACT SYMPTOM Sangrak Bae, Joonse Jung, Bonghee Park, Changhee Han, Sunghak Kang, and Yongseok Lee Sangrak BaeSangrak Bae More articles by this author , Joonse JungJoonse Jung More articles by this author , Bonghee ParkBonghee Park More articles by this author , Changhee HanChanghee Han More articles by this author , Sunghak KangSunghak Kang More articles by this author , and Yongseok LeeYongseok Lee More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2021AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Various examination tools are used for evaluation of lower urinary tract function just like uroflowmetry, urodynamic study (UDS), questionnaire, and etc. Conventional UDS has some disadvantage such as long time for the test, pain or discomfort due to catheter insertion. The objective of this study is to identify similarity between catheterless UDS using penile cuff and conventional UDS. METHODS From October 2013 to May 2015, 30 patients who was diagnosed benign prostate hyperplasia, neurogenic bladder, prostate cancer and agree to examination were included in the study. All patients was done penile cuff UDS(CT3000) and conventional urodynamic study. Also, uroflowmetry, transrectal ultrasonography, urine analysis was done. Comparison of urodynamic results and penile cuff test results, ICS nomogram and Newcastle nomogram. RESULTS Mean age was 69.1 years old, mean BMI was 25.63 kg/m2. Mean prostate volume was 72.85cc and PSA was 12.04ng/dL. 24 patients were BPH, 2 patients were neurogenic bladder, and 4 patients were prostate cancer in later examination. In conventional UDS, 19 obstructive pattern, 3 equivocal, 4 unobstructive pattern, and 4 patients was failed to void. On cuff test, 18 obstructive, 3 unobstructive, 6 low pressure low flow, and 3 high pressure high flow were identified. 15 patients were same result on UDS and cuff test, 5 patients were similar results. 4 pateints who was failed voiding on UDS was low pressure low flow in cuff test and maximal cuss pressure were lower than 100mmHg. 6 patients were represented opposite result between UDS and cuff test. In detailed analysis, Qmax in pressure flow study and maximal intravesical pressure was highly correlated with Qmax in cuff test and Qmax in uroflowmetry.(R=0.829, 0.398, 0.374/ P<0.001, 0.036,0.042) maximal cuff pressure was correlated with Qmax in pressure flow study (R=0.443, P=0.018) CONCLUSIONS Penile cuff UDS represented 80 % of concordance in prediction of lower urinary tract function compared to conventional UDS. Especially, the patients who had ‘low pressure low flow’ in cuff test was also failed in voiding on conventional UDS, so it might be possible to predict bladder function indirectly. This results might be helpful in prediction of postoperative result on voiding after TUR-P or HoLEP and replaced conventional UDS. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e45 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Sangrak Bae More articles by this author Joonse Jung More articles by this author Bonghee Park More articles by this author Changhee Han More articles by this author Sunghak Kang More articles by this author Yongseok Lee More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison Between Ambulatory and Conventional Urodynamics of the Modified Orthotopic Hautmann Neobladder.

Purpose:The aim of the present study was to determine the diagnostic accuracy of conventional and ambulatory urodynamic studies (UDS) in estimating neobladder function.Methods:We evaluated 32 patients who underwent radical cystectomy and orthotopic Hautmann W neobladder with Abol-Enein-Ghoneim uretero-intestinal anastomosis for bladder cancer. The patients were initially examined by using both conventional and ambulatory UDS.Results:Conventional UDS detected a very high mean intravesical pressure at maximum capacity (53.7±17.5 cm H2O). By contrast, the mean intravesical pressure detected by using ambulatory UDS (which reflects the dominant pattern of pressure variation during filling) was significantly lower (34.4±5.2 cm H2O, P<0.001). The comparison between intravesical pressure at half of maximum capacity in conventional UDS and the mean value in ambulatory UDS did not show significant difference (P=0.152). The mean voided volume in conventional UDS was greater than both the mean voided volume (P<0.001) and the mean maximum voided volume in ambulatory UDS (P=0.001). However, this difference did not affect the postvoid residual urine volume measured in both studies (P=0.207). Moreover, incontinence episodes recorded in ambulatory UDS were more frequent but not statistically significantly different from those recorded in conventional UDS (P=0.332).Conclusions:The estimation of neobladder function by means of ambulatory UDS seems to provide interesting research data for the mode of lower urinary tract function in patients with orthotopic substitution after radical cystectomy. The great high value in ambulatory UDS, in cases in which conventional UDS had failed, is due to the exposure of daily and nocturnal incontinence episodes, confirming our patients’ complaints.

Differentiation of lower urinary tract dysfunctions: The role of ambulatory urodynamic monitoring.

To determine the value of ambulatory urodynamic monitoring in the assessment of patients with lower urinary tract symptoms. This was a cross-sectional study including patients who underwent both conventional urodynamic and ambulatory urodynamic assessment at our Center between December 2002 and February 2013. The ambulatory urodynamic studies were interpreted in a standardized way by a resident experienced with urodynamic measurements, and one staff member who specialized in incontinence and urodynamics. A total of 239 patients (71 male and 168 female) were included in the present study. The largest subgroup of patients, 79 (33%), underwent ambulatory urodynamic monitoring based on suspicion of an acontractile bladder. However, 66 of these patients (83.5%) still showed contractions on ambulatory urodynamics. Other groups that were analyzed were patients with suspected storage dysfunction (47 patients), inconclusive conventional urodynamic studies (68 patients) and incontinence of unclear origin (45 patients). Particularly in this last group, ambulatory urodynamics appeared to be useful for discrimination between different causes of incontinence. Ambulatory urodynamic monitoring is a valuable discriminating diagnostic tool in patients with lower urinary tract symptoms who have already undergone conventional urodynamics, particularly in the case of patients with suspected bladder acontractility and incontinence of unclear origin during ambulatory urodynamics. Further study is required to determine the clinical implications of the findings and their relationship with treatment outcome.

Role of uroflowmetry with electromyography in the evaluation of children with lower urinary tract dysfunction

Introduction:A conventional urodynamic study (UDS) is considered invasive while uroflowmetry is considered inadequate in the evaluation of children with lower urinary tract dysfunction. The aims of this study were to identify the role of uroflowmetry with electromyography (UFEMG) in this group.Methods:A cohort of 121 children (age 5–12 years; M:F = 2:3) with symptoms of lower urinary tract dysfunction underwent a detailed voiding history and clinical assessment. Those with evidence of neurological abnormality, obstructive uropathy or active urinary tract infection were not included. They were prospectively studied using UFEMGfirst, followed by UDS on the same day.Results:A total of 76 (63%) children had abnormality on UFEMG while only 12 (10%) had abnormality on UDS. UFEMG was significantly superior in picking up abnormality (P = 0.03). Three types of UFEMG abnormalities were identified: (1) dysfunctional voiding (prolonged staccato trace with active pelvic floor and normal voided volume: n = 42), (2) idiopathic detrusor overactivity (shortened trace with quiet pelvic floor and reduced voided volume: n = 16) and (3) detrusor underutilization disorder (prolonged flat trace with quiet pelvic floor and large voided volume: n = 18).Conclusions:UFEMG is ideal non-invasive test in children with lower urinary tract dysfunction. It helps in identifying the different patterns and the appropriate treatment modality.

Ambulatory urodynamic studies (UDS) in children using a Bluetooth‐enabled device

• To report the early observations of using ambulatory urodynamic studies (UDS) using a Bluetooth-enabled device in children • To evaluate the incremental value of ambulatory over conventional UDS. • Ambulatory UDS were performed in selected children with voiding dysfunction between August 2009 and October 2010. • Conventional UDS were concurrently performed wherever possible. • The test results and treatment consequences of the two tests were compared. • In all, 12 ambulatory and seven conventional UDS were performed on 10 children (five boys, median [range] age 7 [4-16] years). • Six of the seven children had a normal conventional UDS. Ambulatory UDS detected phasic detrusor overactivity (DO) in five children and generalised DO in one. • Direct correlation of symptoms to DO was possible in two children during ambulatory UDS. Pressure rise during filling, seen in two children on conventional UDS, was not seen during ambulatory UDS. • Five children showed clinical improvement when therapy was guided by ambulatory UDS results. • Ambulatory UDS was generally well tolerated in eight children, with two complaining of discomfort. Inadequate information was obtained in two children who underwent ambulatory UDS due to technical problems in one and distress induced by the UDS in the other. • Ambulatory UDS provides useful additional information over conventional UDS and can be used to guide further therapy in selected children with voiding dysfunction. • It is safe and well tolerated in children. • There is a need for explicit guidance for the technical delivery and interpretation of ambulatory UDS in children.

Evidence for autonomic nervous system dysfunction in females with idiopathic overactive bladder syndrome

Micturition and continence are largely under the control of the autonomic nervous system (ANS). In this study, we analyzed ANS function using autonomic cardiovascular (CV) testing in females with idiopathic overactive bladder syndrome (iOAB) versus control females. Our hypothesis was that ANS dysfunction could comprise part of the pathophysiology of iOAB. Twenty-three females with iOAB and 29 controls were enrolled into this prospective study. Patients performed CV autonomic testing, including two sympathetic tests (hand grip exercise and cold pressor test), two parasympathetic tests (deep breathing and 30:15 ratio), and two mixed tests (Valsalva manoeuvre and blood pressure [BP] response to standing). Patients with iOAB also underwent conventional urodynamic studies in order to define iOAB as either with or without demonstrable detrusor overactivity (DO). Both groups were similar with respect to age and menopausal status. Females with iOAB had significantly more positive tests than controls (P < 0.0001), particularly for sympathetic tests (P < 0.0001). Among the iOAB group, the sympathetic tests (P = 0.03) were significantly more often positive in patients without DO (based on cystometry) compared to patients with DO, with the results being particularly significant for the cold pressor test (P = 0.02). No differences were found among iOAB sufferers with respect to a past history of enuresis. These results suggest ANS dysfunction, predominantly a sympathetic ANS dysfunction, is associated with iOAB, specifically in patients with iOAB without DO.

Concomitant repeated intravesical injections of botulinum toxin‐type A and laparoscopic antegrade continence enema; a new solution for an old problem

To report our experience of treating bladder and bowel dysfunction in children with myelomeningocele, with simultaneous laparoscopic antegrade continence enema (LACE) and repeated intravesical injection of botulinum toxin-type A (BTX-A). Six girls and 14 boys (mean age, 8.7 years) with myelomeningocele were included in this study. All patients had received one or two intravesical injection(s) of BTX-A, but had persistent fecal incontinence or constipation despite improved urinary symptoms. We performed a two-port laparoscopic appendicostomy, immediately after repeated intravesical injection of BTX-A, through a V-shaped skin flap at McBurney's point. The stoma was finally covered by a quadrilateral skin flap, using the 'VQ' technique. The degree of urinary incontinence and bowel dysfunction were determined in each patient, and conventional urodynamic studies were performed 4 months after each injection. All patients were followed-up for a mean (range) of 19.1 (14-33) months. Urinary continence improved significantly after the first injection, and remained constant after repeat injections. The maximum detrusor pressure, bladder compliance and capacity improved significantly (P < 0.001) compared with baseline. Interestingly, the simultaneous intravesical BTX-A injection/LACE procedure significantly improved all urodynamic variables compared with the values obtained after the last BTX-A injection alone. The laparoscopic procedure was well tolerated, and 19 (95%) children were nappy-free at the final follow-up. Only two patients had stoma stenosis, and one patient had minor stoma leakage. Concomitant repeat intravesical injection of BTX-A and LACE can effectively manage bladder and bowel dysfunction in children with myelomeningocele. The procedure may further contribute to improve bladder urodynamic function, as effective evacuation of the bowel provides more room for bladder distension.

Pre‐operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre‐operative mixed urinary incontinence

To determine if specific pre-operative urodynamic parameters could predict detrusor overactivity following TVT in patients with urodynamic mixed incontinence. Notes of women with detrusor overactivity (DO) and urodynamic stress incontinence (USI) before undergoing tension-free vaginal tape (TVT) surgery were retrospectively reviewed. Patients underwent clinical evaluation pre-operatively including history, examination, and conventional urodynamic studies and were treated with pelvic floor exercises and anti-cholinergic medication. Those with persistent stress urinary incontinence (SUI) underwent TVT. Patients were re-assessed after at least 6 months post-operatively. Pre- and post-operative opening and closing detrusor pressure, and detrusor pressure at maximum flow were recorded retrospectively from pre-operative urodynamics traces by two clinicians independently and compared to the patients' post-operative symptoms and urodynamic diagnosis. Fifty-one women were reviewed. Forty-six of the 51 attended follow-up and 35/51 agreed to conventional urodynamic studies. Seventeen of the 35 reported OAB symptoms, and 18/35 were asymptomatic. Nineteen of the 35 women had DO and 16/35 had normal urodynamic studies (NUDS). The median pre-operative opening detrusor pressure was higher in women with overactive bladder symptoms post-operatively. The median pre-operative opening detrusor pressure in women with DO post-operatively was 33.0 cmH(2)O and the median pre-operative opening detrusor pressure in those with NUDS post-operatively was 16 cmH(2)O (15.0-23.0 cmH(2)O) (P < 0.05 Mann-Whitney U-test). Higher numbers of patients are required to demonstrate the value of opening detrusor pressure in predicting post-operative overactive bladder symptoms. Opening detrusor pressure is predictive of post-operative DO after TVT.

The significance of natural bladder filling by the production of urine during cystometry

Natural bladder filling by the production of urine could potentially influence the outcome of urodynamic investigations. In this prospective study, we determined the natural bladder filling rate during cystometry. Between October 2005 and March 2006, we performed conventional urodynamic studies in 101 consecutive patients. We measured the exact volume infused during artificial filling, the volume voided and post-void residual urine (PVR) after a pressure flow study to examine the difference between the measured bladder volume (voided volume plus PVR) and the infused volume. We also measured the exact time required for the urodynamic investigation. Finally, we analyzed the natural filling rates in 34 patients after excluding inadequate cases. The mean volume of artificial filling was 304.4 ml (SD +/- 100.5 ml) and the mean measured volume consisting of the voided volume plus PVR was 337.2 ml (SD +/- 106.5 ml). The mean total time was 24.2 min (range: 15.0-41.5 min) and the mean time for artificial filling was 7.2 min. The mean volume of natural filling and the mean rate of natural bladder filling were 32.8 ml (12.1% of artificial filling) and 1.4 ml/min, respectively. Natural filling by the production of urine can affect the results of cystometry considerably, and should be considered when performing urodynamic investigations and interpreting the results. Because the effects can increase with the time required to conduct the investigation, effort should be made to decrease the total duration of urodynamic investigations.

New Method for Minimally Invasive Urodynamic Assessment in Men with Lower Urinary Tract Symptoms

Urodynamic studies are considered the reference standard to diagnose bladder outlet obstruction. However, the procedure is invasive, expensive, and time-consuming. The purpose of this study was to evaluate a new minimally invasive urodynamic assessment model and compare the results with those of conventional urodynamic evaluation. The study included 50 male patients who presented with lower urinary tract symptoms. Their mean age was 62 years (range 34 to 82). After undergoing a conventional urodynamic study, they underwent the minimally invasive evaluation. The urethral device is a conical apparatus that adapts to the urethral meatus and fossa navicularis. The isometric bladder pressure and interrupted flow were recorded. The results of the conventional assessment were classified according to the Abrams-Griffiths number and a logistic regression fit was applied to the minimally invasive method. Only two variables demonstrated the predictive capacity: the isometric pressure and interrupted flow. In addition to selecting the relevant variables, logistic regression analysis is a more adequate model that provides a binary result of obstructed and unobstructed, used to predict the normal and equivocal categories of the Abrams-Griffiths classification, and taken as the reference standard. The sensitivity and specificity of the new method was 67% and 79%, respectively. The urethral device proved to be simple and easy to use. The minimally invasive method was able to detect most patients with bladder outlet obstruction; thus, the conventional urodynamic assessment could be avoided. We consider this method to have a place as a first-line noninvasive examination.

Real‐time flow resistance compensation for urodynamic examinations of the upper urinary tract through single lumen catheters

We developed a special calculation method for the compensation of resistance in urodynamic studies of the upper urinary tract that allows us to use existing single lumen nephrostomy catheters. We integrated a new calibration routine into the setup of our urodynamic equipment. Following the initial calibration procedure using the same size catheter as the previously inserted nephrostomy catheter, our software calculates actual resistance based on actual flowrate and the known linear resistance-flow correlation. Actual resistance and calculated intrapelvic pressure curves are presented in real-time. Using single lumen nephrostomy catheters for pressure-flow studies allows us to consider intrapelvic pressure during the measurement, to adjust filling pressure accordingly. It makes time consuming and sophisticated postprocessing resistance calculation unnecessary and also provides a challenging new method for conventional urodynamic studies of the lower urinary tract.

The determination of sensation-dependent bladder emptying time in patients with complete spinal cord injury above T11

Retrospective investigation using urodynamic studies and medical records. To evaluate the safety of sensation-dependent bladder emptying in complete spinal cord injury (SCI) patients, based on the preservation of the desire to void. Spinal Cord Injury Unit, Yonsei Rehabilitation Hospital, Seoul, Korea. This study was performed retrospectively on 79 complete SCI patients with lesions above T11, who had preserved the desire to void during conventional urodynamic studies. Patients were classified according to detrusor compliance and maximal bladder capacity. The clinical and urodynamic characteristics of each group were analyzed. Forty-five (57.0%) patients were classified as group A and 34 (43.0%) patients were classified as group B. There were no significant differences in clinical features, such as voiding methods and the presence of autonomic dysreflexia between the two groups. Compared with group B, there were significantly more areflexic neurogenic bladder cases in group A (P<0.05). There were significantly higher maximal detrusor pressures in group B (P<0.05). There were significantly more cases with the preservation of the strong desire to void in group B (P<0.05). Not all patients with discomplete SCIs accepted the use of sensation-dependent bladder emptying. The safe use of sensation-dependent bladder emptying will be determined based on the results of urodynamic studies.

Intravesical injection of botulinum toxin type A: Management of neuropathic bladder and bowel dysfunction in children with myelomeningocele

Objectives To evaluate the efficacy of botulinum toxin A in the treatment of children with detrusor hyperreflexia caused by myelomeningocele and the effects of this treatment on neuropathic bladder and bowel dysfunction. Methods In a prospective study, 26 children with myelomeningocele (20 boys and 6 girls, mean age 6.9 years) were included. All patients had been nonresponders to medical treatment and required clean intermittent catheterization. Under cystoscopic guidance, 10 IU/kg of botulinum toxin A was injected into the detrusor muscle, sparing the trigone and ureteral orifices. In each patient, urinary incontinence grade and improvement in parameters of interest in the evaluation of bowel dysfunction were assessed before and 4 months after injection. Conventional urodynamic studies to determine maximal bladder capacity and maximal detrusor pressure and voiding cystoureterography were also performed. Results Four months after procedure, 19 patients (73%) had become completely dry between clean intermittent catheterizations, and the total improvement in urine incontinence was 88%. The mean maximal detrusor pressure was decreased to 83.2 ± 4.6 cm H 2O from the baseline of 139.3 ± 11.2 ( P <0.01). The average maximal bladder capacity increased from 102.8 ± 6.3 mL to 270.2 ± 9.5 mL ( P <0.01). Of the 15 patients who had varying degrees of vesicoureteral reflux before the procedure, 11 (73%) had decrease in the vesicoureteral reflux grade. Also, bowel dysfunction improved in 10 (66%) of the 15 patients. Conclusions Botulinum toxin A appears to be a safe, minimally invasive procedure for the management of neuropathic bladder and bowel dysfunction in children with myelomeningocele.

Ureterocystoplasty: Videourodynamic Assessment

We evaluated bladder function outcome in children who underwent ureterocystoplasty based on preoperative and postoperative videourodynamic studies. Between 1977 and 2003, 8 patients with a median age of 6 years who had severe bladder dysfunction underwent ureterocystoplasty as a single surgical procedure. Augmentation was performed in 1 refluxing ureter in 7 patients and with a nonrefluxing megaureter in 1. All patients were evaluated urodynamically before and after augmentation using videourodynamic studies. Preoperative bladder capacity was estimated subtracting the volume trapped inside the refluxing ureter from the total amount of contrast fluid infused into the bladder. Controls included 8 patients matched in age (median 7.8 years) and diagnosis who had undergone ileocystoplasty and were studied with the same urodynamic methodology. Median age in patients with ureterocystoplasty and controls at postoperative urodynamic testing was 7.3 and 11.2 years, respectively. Median cystometric bladder capacity for age before and after ureterocystoplasty was 75% (range 10% to 92%) and 94% (range 49% to 100%), respectively. In the ileocystoplasty group cystometric bladder capacity increased significantly after augmentation (median 44% vs 118, p <0.0005). Comparison of postoperative cystometric bladder capacity between the 2 treatment groups showed significantly higher bladder volumes in the ileocystoplasty group (median 217 vs 290 ml, p <0.02). When we analyzed compliance before and after ureterocystoplasty, no statistically significant difference was found (4.09 vs 10.5 ml/cm water). The same parameter in the ileocystoplasty group was statistically significant (1.6 vs 22.5 ml/cm water, p <0.016). Our retrospective study suggests that, although ureterocystoplasty is a useful method for improving bladder storage abnormalities in properly selected patients, enterocystoplasty is associated with a better storage function outcome.

A prospective study to evaluate the safety, tolerability, efficacy and durability of response of intravesical injection of botulinum toxin type A into detrusor muscle in patients with refractory idiopathic detrusor overactivity

To assess, in a prospective study, whether botulinum toxin A (BTXA) injected into the detrusor muscle is safe and well tolerated, produces significant changes in urodynamic variables, if the effect is durable, as measured by the Bristol Female Lower Urinary Tract Symptom Questionnaire (BFLUTS), and to assess changes in quality of life, as measured by the Kings Health Questionnaire (KHQ), when it is used to manage idiopathic detrusor overactivity. This was a single-centre, prospective unrandomized study of 15 women to assess the efficacy of a single dose of 300 units of BTXA injected intravesically into the detrusor muscle, under cystoscopic control. Patient evaluation included a full history and examination, frequency/volume charts, BFLUTS and KHQ scores, and a conventional urodynamic study at baseline and at 6 weeks after treatment. Symptomatic improvement was assessed at 6 weeks and every 4 weeks thereafter until baseline values were reached. All 15 patients completed the study; 14 noted an improvement in urgency and frequency immediately after treatment. There were no major adverse effects reported to date. The volume at first desire to void increased in 13 patients (P < 0.006), the maximum cystometric capacity increased in 10 (P < 0.011) and six of the 15 had no evidence of detrusor overactivity; in the remaining eight the volume at first overactive contraction increased in six (P < 0.0023) and the volume at first overactivity incontinence increased in 11 (P < 0.005). The median modified projected isovolumetric pressure decreased significantly (P = 0.01), from 69 to 45. The improvement in frequency appeared to last up to 24 weeks, and that in urinary incontinence up to 20 weeks. The overall improvement in quality of life was maintained up to 24 weeks. BTXA appears to be a safe treatment with good clinical efficacy in refractory idiopathic detrusor overactivity; the effects seem to last 20-24 weeks.

EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients

The aim of the study was to determine the short- and long-term efficacy of an intensive and EMG-biofeedback-assisted pelvic floor muscle training (PFMT) program as a therapy of female stress or mixed urinary incontinence. All women with stress or mixed urinary incontinence treated in the pelvic floor reeducation program at our clinic between September 1996 and March 2003 were included. EMG-biofeedback assisted PFMT was performed by specially trained therapists (one registered nurse and one midwife). Electric stimulation preceded PFMT if the pelvic floor muscle contractions were considered too weak for active training (Oxford < 2). Examinations included among others: conventional urodynamic studies prior to therapy, a stress provocation test (cough test), and determination of maximal pelvic floor muscle strength (Oxford-grading and electric EMG-potential). A retrospective chart review was performed. A questionnaire was administered for long-term follow-up. Four hundred and thirty four women attended our PFR-program in this 7-year period. All 390 women with stress (80%) or mixed (20%) urinary incontinence were evaluated. Mean age: 52 years. Mean duration of incontinence: 6.7 years. Two hundred and sixty three women completed the training (group 1, average number of training sessions: 8.7), 127 patients ended therapy prematurely (group 2, average number of training sessions: 4.1). Short-term results at the end of the PFR-program are available for group 1. There was a statistically significant improvement of the stress provocation test (cough test). The data before the therapy was 141x SUI degrees III (60%); 50x SUI degrees II (21%), 24x SUI degrees I (10%), 20x SUI degrees 0 (9%) as opposed to after the therapy 9x SUI degrees III (5%), 34x SUI degrees II (19%), 48x SUI degrees I (26%), 91x SUI degrees 0 (50%). There was a significant increase in the Oxford-score by 1.2 points (2.9-4.1; P<0.001). Self-reported improvement of incontinence symptoms was 95%. The electric EMG-potentials almost doubled (11.3-20.5 muV; P<0.001). Long-term results (questionnaire) for all patients: the average follow-up time was 2.8 years (range: 3 months to 7 years). Three hundred and twelve (80%) of the questionnaires returned. Seventy-one percent of them self-reported a persisting improvement of their incontinence symptoms. Thirteen percent of all women underwent incontinence surgery following the completion of conservative therapy (9.2% group 1, 25% group 1; P<0.001). An intensive and EMG-biofeedback assisted PFMT is very effective. Often, avoidance of surgery is possible.

FUNCTIONAL MAGNETIC STIMULATION FOR MIXED URINARY INCONTINENCE

In this study we determined the efficacy of functional magnetic stimulation (FMS) compared to placebo for treating women with mixed urinary incontinence (MUI). A total of 39 women with MUI were randomly assigned to the FMS group (23 patients) or to the placebo group (16 patients). FMS was applied continuously at 18.5 Hz day and night for 2 months. Conventional urodynamic studies were performed before and after stimulation. Outcome measures assessed were clinical (daytime frequency, nocturia, pad use, pad weight) and urodynamic variables (first sensation of bladder filling, maximum cystometric capacity, maximum urethral closure pressure), and patient subjective assessment (visual analogue scale). After 2 months of FMS significant decreases in voiding frequency (from 9.0 to 6.7, p = 0.0002), nocturia (from 2.6 to 1.4, p = 0.0007) and pad use (from 3.9 to 2.2, p = 0.007) were observed only in the FMS group. First sensation of bladder filling and maximum cystometric capacity increased significantly after stimulation compared with prestimulation levels only in the FMS group, p = 0.003 (from 118 to 174 ml) and p = 0.00004 (from 267 to 396 ml), respectively. A total of 18 women (78.3%) reported an improvement in symptoms after FMS with an average success rate of 41.9%. The success rate was significantly lower in the placebo group (p = 0.021) at 22.9%. Functional magnetic stimulation was useful and safe for treating women with MUI.

Localized contractions in the normal human bladder and in urinary urgency

To describe an observational study to establish whether localized activity arises in the normal human bladder, and whether there is any correspondence between changes in such activity and reported sensation. The generation of sensory information by the bladder depends on afferent stimulation by increased tension within the bladder wall. Autonomous bladder activity is apparent in several species, which is often localized and multifocal, giving rise to localized areas of stretch. Thus afferent activity may partly result from localized distortions of the bladder wall. Fourteen women patients presenting with increased bladder sensation during filling-phase cystometry were compared with six asymptomatic women volunteers. Localized bladder activity was assessed by the micromotion detection (MMD) method, using eight electrodes mounted on a Silastic balloon; local displacements of the electrodes were recorded as changes in electrical resistance, which were used to compute changes in the distance between each pair of electrodes. In two of the six volunteers, micromotions were seen in the extraperitoneal (ventral) portion of the bladder. Women with increased sensation on filling cystometry had a significantly higher prevalence of localized activity than the control group during MMD recording. The localized activity was more sustained and at a higher frequency than in asymptomatic women. All nine women reporting urinary urgency during MMD recording had localized contractile activity, while only four had phasic increases in detrusor pressure during the episodes of urgency. By measuring localized contractions within the bladder wall, we established a significant difference in the prevalence of localized activity between the groups studied, but there was no objective difference with conventional urodynamic studies. There was also a difference in the character of the localized contractions, with the exaggerated activity in the symptomatic group corresponding with the reported sensations. These findings suggest that localized distortion of the bladder wall stimulates afferent activity, and that the human detrusor may be functionally modular.