Demonstrated Detrusor Overactivity Research Articles

MP63-14 OVERNIGHT AMBULATORY URODYNAMICS FINDINGS IN PATIENTS WITH NOCTURIA AND/OR NOCTURNAL ENURESIS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2017MP63-14 OVERNIGHT AMBULATORY URODYNAMICS FINDINGS IN PATIENTS WITH NOCTURIA AND/OR NOCTURNAL ENURESIS Eskinder Solomon, Megan Duffy, Sachin Malde, Hazel Ecclestone, Mahreen Paksad, Rizwan Hamid, Tamsin Greenwell, and Jeremy Ockrim Eskinder SolomonEskinder Solomon More articles by this author , Megan DuffyMegan Duffy More articles by this author , Sachin MaldeSachin Malde More articles by this author , Hazel EcclestoneHazel Ecclestone More articles by this author , Mahreen PaksadMahreen Paksad More articles by this author , Rizwan HamidRizwan Hamid More articles by this author , Tamsin GreenwellTamsin Greenwell More articles by this author , and Jeremy OckrimJeremy Ockrim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1966AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nocturnal symptoms are very troublesome to patients, yet objective methods to assess night time bladder function are limited. We aimed to determine the prevalence of detrusor overactivity in patients with nocturia and nocturnal enuresis during overnight ambulatory urodynamics METHODS Twenty patients whose most bothersome symptoms were nocturia and/or nocturnal enuresis underwent overnight ambulatory urodynamic studies. All patients had undergone prior undiagnostic standard filling cystometry. Traces were reviewed and it was documented if detrusor overactivity (DO) +/-leakage was demonstrated, as well as the maximum voided volume and nocturnal urine output. RESULTS The mean ( SD) agewas 45.1 ± 19.9 years, comprising 14 female and 6 male patients All patients presented with nocturia with 17 patients additionally complaining of nocturnal enuresis. Only 5 patients reported bothersome day time symptoms. The mean duration for the overnight ambulatory urodynamic studies was 14.5 hours (range 12 to 16.6 hours). DO was demonstrated in 80% (n=16) of patients. 15 out of the 17 (88.3%) patients with nocturnal enuresis demonstrated DO. Small volume SUI was demonstrated in 4 out the 17 (23.5%) patients with nocturnal enuresis. The mean and median peak DO pressure was 68.3 (± 50.9) and 50 cmH2O. There appears to be no significant difference in the maximum voided volume and nocturnal urine output between the two DO groups (NB: small sample DO -ve patients). Incontinence was observed in 15 out of 16 (93%) patients with DO. CONCLUSIONS 80.0% of patients who present with nocturia and 88% with nocturnal enuresis demonstrate detrusor overactivity on overnight ambulatory urodynamics tests. The DO pressures demonstrated were large amplitude and resulted in incontinence by overcoming in most cases an otherwise competent outlet. Nocturnal ambulatory urodynamics are a useful clinical adjunct for assessing night time urinary symptoms. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e840-e841 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Eskinder Solomon More articles by this author Megan Duffy More articles by this author Sachin Malde More articles by this author Hazel Ecclestone More articles by this author Mahreen Paksad More articles by this author Rizwan Hamid More articles by this author Tamsin Greenwell More articles by this author Jeremy Ockrim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Low amplitude rhythmic contraction frequency in human detrusor strips correlates with phasic intravesical pressure waves.

Low amplitude rhythmic contractions (LARC) occur in detrusor smooth muscle and may play a role in storage disorders such as overactive bladder and detrusor overactivity. The purpose of this study was to determine whether LARC frequencies identified in vitro from strips of human urinary bladder tissue correlate with in vivo LARC frequencies, visualized as phasic intravesical pressure (p ves) waves during urodynamics (UD). After IRB approval, fresh strips of human urinary bladder were obtained from patients. LARC was recorded with tissue strips at low tension (<2g) and analyzed by fast Fourier transform (FFT) to identify LARC signal frequencies. Blinded UD tracings were retrospectively reviewed for signs of LARC on the p ves tracing during filling and were analyzed via FFT. Distinct LARC frequencies were identified in 100% of tissue strips (n=9) obtained with a mean frequency of 1.97±0.47cycles/min (33±8mHz). Out of 100 consecutive UD studies reviewed, 35 visually displayed phasic p ves waves. In 12/35 (34%), real p ves signals were present that were independent of abdominal activity. Average UD LARC frequency was 2.34±0.36cycles/min (39±6mHz) which was similar to tissue LARC frequencies (p=0.50). A majority (83%) of the UD cohort with LARC signals also demonstrated detrusor overactivity. During UD, a subset of patients displayed phasic p ves waves with a distinct rhythmic frequency similar to the in vitro LARC frequency quantified in human urinary bladder tissue strips. Further refinements of this technique may help identify subsets of individuals with LARC-mediated storage disorders.

Lower urinary tract dysfunction in patients with dysautonomia.

With the goal of better defining the types of bladder dysfunction observed in this population, we present the chief urologic complaints, results of urodynamic studies, and treatments of patients with dysautonomia-related urinary symptoms. All patients with dysautonomia referred to our neurourology clinic between 2005 and 2015 for management of lower urinary tract dysfunction were retrospectively reviewed. Each patient's chief urologic complaint was recorded and used to initially characterize the bladder storage or voiding symptoms. Patient evaluation included history and physical examination, urinalysis, post void bladder ultrasound, and urodynamic studies. Successful treatment modalities that subjectively or objectively improved symptoms were recorded. Of 815 patients with the diagnosis of dysautonomia, 82 (10 %) were referred for evaluation of lower urinary tract dysfunction. Mean age was 47 years (range 12-83) and 84 % were female. The chief complaint was urinary urgency ± incontinence in 61 % and hesitancy in 23 % of patients. Urodynamic findings demonstrated detrusor overactivity ± incontinence in 50 % of patients, although chief complaint did not reliably predict objective findings. Successful objective and subjective treatments were multimodal and typically non-operative. Lower urinary tract dysfunction may develop in at least 10 % of patients with dysautonomia, predominantly females. Bladder storage or voiding complaints do not reliably predict urodynamic findings. Urodynamically, most patients exhibited detrusor overactivity. The majority of patients were successfully managed with medical or physical therapy.

Role of Urodynamic Study in Nocturnal Enuresis: Urodynamic Findings and Treatment Outcome Correlation in Children with Pharmacotherapy-resistant Monosymptomatic Nocturnal Enuresis or Severe Non-monosymptomatic Nocturnal Enuresis.

This study aimed to determine whether or not a urodynamic study (UDS) is beneficial for management of pediatric nocturnal enuresis (NE), especially in pharmacoresistant monosymptomatic nocturnal enuresis (PRMNE) or severe non-monosymptomatic nocturnal enuresis (NMNE) patients. Children with PRMNE or severe NMNE who underwent a UDS for the process of NE treatment were retrospectively reviewed. The UDS findings of patients and treatment outcomes of subsequent tailored therapies according to the UDS findings were analyzed. A total of 80 children (50 boys and 30 girls, mean age 8.4 ± 2.2 years), 19 of which were diagnosed with PRMNE and 61 of which were diagnosed with NMNE, were included in the final analysis. Of the 19 PRMNE children, 12 (63.2%) demonstrated abnormal UDS findings. Ten demonstrated detrusor overactivity (DO) with or without decreased cystometric bladder capacity (CBC); the treatment outcomes markedly improved in all of the children after anticholinergics were added to the initial desmopressin therapy. Biofeedback was found to be helpful for two children with detrusor-sphincter dyssynergia. All of the total 61 children with NMNE demonstrated abnormal urodynamic findings of DO with or without decreased CBC, and 42 (68.9%) achieved more than partial response (> 50% decrease in the number of wet nights) when given a combination therapy of anticholinergics and desmopressin. The urodynamic findings were helpful for guiding children with PRMNE in the proper choice of further treatment strategies. A routine UDS should not be recommended prior to a first-line combination treatment in children with NMNE.

0842 Episodic loss of consciousness in the toilet

A 21-year-old student presented with events of loss of consciousness whilst passing urine since the age of nine. After voiding a small quantity of urine, she would lose awareness and...

Solifenacin objectively decreases urinary sensation in women with overactive bladder syndrome

To evaluate the test-retest reliability of a device that measures urinary sensation during cystometry, and to use that device to determine whether treatment of overactive bladder syndrome (OAB) with solifenacin is associated with a change in urinary sensation. Overall 15 women were recruited for this study, ten women with OAB and urodynamically demonstrated detrusor overactivity and five controls without OAB underwent filling cystometry twice with contemporaneous, continuous recording of urinary sensation. Women with OAB received solifenacin 10 mg daily during the weeks between testing. We compared the areas under the initial and repeat sensation-volume curves. While taking solifenacin, the maximum cystometric capacity increased from 329 ± 168 ml to 464 ± 123 ml (P < 0.002), and the area under the bladder volume-sensation curve decreased (P < 0.0001). Untreated controls did not exhibit these changes. We present psychometric data demonstrating improved bladder sensation during the treatment of OAB with solifenacin. If clinical correlations are confirmed by future study, such urinary sensation measures may prove useful as assessment, treatment predictor, or outcome measures in OAB research and/or clinical care.

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.

What is the predictive value of urodynamics to reproduce clinical findings of urinary frequency, urge urinary incontinence, and/or stress urinary incontinence?

The aim of this study was to determine the predictive value of urodynamics to reproduce clinical findings of urinary frequency (UF), urge urinary incontinence (UUI), and/or stress urinary incontinence (SUI). We retrospectively reviewed the data of patients diagnosed with UF, UUI, and/or SUI and subsequently underwent urodynamics. Urodynamic findings were correlated with clinical findings to determine the predictive value of urodynamics. A total of 537 patients (366 females and 171 males) met study criteria. Two hundred seventy-eight patients had symptoms of UUI; 59% demonstrated detrusor overactivity on urodynamics. Three hundred eight patients had SUI on history and physical examination; 45% had urodynamic stress incontinence. A low maximum cystometric capacity (<200 ml) was not significantly associated with urinary frequency (p = 0.4). Urodynamics has a low predictive value to reproduce clinical findings of UF, UUI, and/or SUI. Many patients with evidence of UF, UUI, and/or SUI on history and/or physical examination do not demonstrate supporting urodynamic evidence.

Observations relating to urinary sensation during detrusor overactivity

To describe the temporal relationship between increases in lower urinary tract (LUT) sensation and changes in detrusor and/or urethral pressures measured in real time. We reviewed 33 multichannel urodynamic tracings that included a continuous recording of LUT sensation and that demonstrated detrusor overactivity incontinence (DOI) or detrusor overactivity (DO). Four physicians reviewed each urodynamic tracing and reached agreement about the temporal relationship between LUT sensation and detrusor contraction. Median age was 60 (36-82) years. Fourteen (42%) had urodynamic diagnoses of mixed incontinence, 18 (55%) had DOI, and 1 (3%) had DO without DOI. We reviewed 119 episodes of detrusor overactivity from the 33 recordings. We found no difference in change in sensation level when comparing DO episodes with DOI episodes or between different urodynamic diagnoses (P > 0.5). There was no dominant temporal pattern seen for the whole group (P = 0.84), that is, there was no evidence that the change in sensation level was more likely to occur before, during, or after DO/DOI episodes. When evaluating the changes in the urethral pressure, the most common pattern seen was an increase in sensation level after a fall in urethral pressure, but no dominant pattern was seen. Our findings suggest that increased LUT sensation during DO/DOI is not reliably caused by measurable alterations in bladder or urethral pressure.

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Do Women with Female Ejaculation Have Detrusor Overactivity?

ABSTRACT Introduction Questionnaire surveys suggest that 40–54% of women have experienced an expulsion of fluid at orgasm. Some of these women have coital incontinence, whereas others identify the fluid passed as female ejaculate. Aim To assess whether women who have experienced female ejaculation have detrusor overactivity or the bothersome lower urinary tract symptoms associated with coital incontinence. Methods We recruited six women who self-identified as having experienced female ejaculation and six controls who had not. Each woman completed a 3-day bladder diary and two validated bladder questionnaires: the Urgency Perception Scale (UPS) and the Incontinence Impact Questionnaire (IIQ). Each woman underwent short provocative ambulatory urodynamics, a modified form of urodynamics, with a high sensitivity for detrusor overactivity. Main Outcome Measures Prevalence of detrusor overactivity, 24-hour urinary frequency, IIQ and UPS scores. Results No woman in either group had detrusor overactivity. The bladder diaries and questionnaire results were within the normal range for all women. Conclusion Women who experience female ejaculation may have normal voiding patterns, no bothersome incontinence symptoms, and no demonstrable detrusor overactivity. Women who report female ejaculation, in the absence of other lower urinary tract symptoms, do not require further investigation, and may be reassured that it is an uncommon, but physiological, phenomenon.

Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation

The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.

Voiding patterns in uroplakin II knockout mice

Uroplakins are integral components of urothelial plaques crucial to normal genitourinary function. We examined the effect of uroplakin II (UPII) gene deletion on mouse voiding function and sought to develop a simple surrogate measurement of bladder function in mice using ultraviolet visualization of urinary voiding patterns. Wild type (WT; n=6) and UPII knockout (KO; n=6) mice were evaluated by cystometric analysis and voiding pattern markings. The voiding pattern markings were graded by independent observers on a 1–5 scale according to the degree of dispersion of the voided urine. These grades were then correlated to the cystometric results. The UPII KO mice demonstrated detrusor overactivity (DO) and increased urinary frequency. Furthermore, the voiding pattern markings were markedly more dispersed with increased severity of DO. Consistent with these findings, the Pearson correlation coefficients for the observed voiding patterns were highly correlated with bladder weight, basal pressure, threshold pressure, and intermicturition pressure measurements obtained during cystometry (p value < 0.05). In conclusion, UP II KO mice demonstrated DO and urinary frequency. The ultraviolet visualization of urinary voiding patterns of mice correlated well with certain measures of standard cystometric evaluations, and may provide a simple, possibly automated, noninvasive method of evaluating mouse DO.

Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?

We sought to determine if there are differences in clinical and urodynamic parameters between women with urge predominant and those with stress predominant mixed urinary incontinence (MUI). Charts of 99 female patients with complaints of MUI were reviewed. Patients were divided into two groups based on the subjective predominance of either stress incontinence (MSUI) or urge incontinence (MUUI). All patients completed a subjective evaluation including an AUA Symptom Index, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Objective non-invasive measures included physical exam, 48-hr voiding diary, and a 24-hr pad test. Videourodynamics studies (VUDS), performed in all patients, were reviewed and the presence and characteristics of detrusor overactivity (DO) and stress incontinence were noted. There were no significant differences between groups with respect to symptom scores. MUUI patients had significantly higher pad usage, and lower maximum and average voided volumes than MSUI patients. They were also more likely to have lower urodynamic bladder capacities and demonstrable DO (70% vs. 26%) on VUDS with contractions occurring at lower bladder volumes and with higher amplitude. MSUI patients were more likely to have demonstrable SUI on physical examination (63% vs. 16%) and on VUDS (100% vs. 61%). There do appear to be differences in clinical and urodynamic parameters between patients with stress predominant and urge predominant MUI. These may help to determine which component of the mixed incontinence is more problematic.

Efficacy of botulinum-A toxin in the treatment of detrusor overactivity incontinence: A prospective nonrandomized study

This study was undertaken to investigate the efficacy and safety of botulinum-A toxin (BTX-A) treatment for non-neurogenic detrusor overactivity incontinence. This prospective nonrandomized ongoing study was performed in a tertiary referral urogynecology department. In 26 women with urge incontinence and urodynamically demonstrated detrusor overactivity incontinence resistant to conventional treatment 100 units of BTX-A were injected into the detrusor muscle at 30 sites. Clinical and urodynamic evaluations and a quality of life assessment were performed at baseline and 4, 12, and 36 weeks after BTX-A treatment. Of 26 women, 14 were dry after 4 weeks, 13 of 20 women after 12 weeks, and 3 of 5 women after 36 weeks. Two women failed to respond. Two women were on self-catheterization temporarily. There were no other complications besides 9 urinary tract infections within the 51 follow-up visits. BTX-A treatment seems to be a safe and efficacious new treatment option for patients with detrusor overactivity incontinence.

Chronic pudendal nerve neuromodulation in women with idiopathic refractory detrusor overactivity incontinence: Results of a pilot study with a novel minimally invasive implantable mini‐stimulator

To assess the results of chronic pudendal nerve neuromodulation with a novel technique in a pilot study on women with idiopathic refractory detrusor overactivity incontinence. A percutaneous screening test (PST) was performed in patients with urodynamically demonstrated detrusor overactivity incontinence. Such a test includes the performance of a cystometrogram without and with percutaneous pudendal nerve stimulation and is considered positive if stimulation results in a more than 50% increase in the bladder volume at the first involuntary detrusor contraction or the maximum cystometric capacity. Patients with a positive PST qualified for the implantation of a mini-neurostimulator with an integrated electrode, a so-called bion(R), adjacent to the pudendal nerve at Alcock's Canal. Five-day voiding-incontinence diaries were the main tool for the evaluation of therapy. A PST was performed in 14 women. Six patients responded positively and received a bion. The degree of incontinence decreased significantly in this group, which also included patients in whom sacral neuromodulation had failed. There were no severe adverse events. Chronic pudendal nerve stimulation may reduce the degree of detrusor overactivity incontinence, even in patients in whom sacral neuromodulation fails. Bion therapy is relatively simple and minimally invasive and is well tolerated by the patient.

Does posture affect cystometric parameters and diagnoses?

The objective of this study was to investigate the effect of lying and sitting positions on urodynamic parameters and diagnoses. This prospective study was carried out on 96 women with urinary incontinence who underwent urodynamic assessment. Cystometry was performed both in the lying and sitting positions. For filling cystometry, we infused normal saline at a rate of 50 ml/min. All the results were entered on the urodynamic database and were analysed using Minitab software release 13.30. Mean age was 49 (20-84) years. Sixty-four (67%) women complained of mixed incontinence, 16 (17%) of urgency alone, eight (8%) of stress incontinence and eight (8%) of urgency and urge incontinence. Two (2%) showed stress incontinence by lying cystometry, and 53 (55%) by sitting cystometry. During lying nine (9%) demonstrated detrusor overactivity, while 53 (55%) demonstrated detrusor overactivity in sitting position. No case of mixed incontinence was diagnosed by lying cystometry but 17 (18%) cases were detected by sitting cystometry. This study explains the higher detection rate of stress incontinence, detrusor overactivity and mixed incontinence by cystometry in sitting position. Therefore, we recommend that sitting posture is preferred over lying position for performing cystometry.

Stamey's abdominovaginal needle colposuspension for the correction of female genuine stress urinary incontinence--long-term results.

To evaluate the long-term continence rate, subjective satisfaction and treatment-associated morbidity in a carefully selected group of patients undergoing Stamey bladder neck suspension. We studied 24 women with objectively validated genuine stress urinary incontinence (GSI) who were treated using the Stamey needle colposuspension method. Follow-up was performed by means of a questionnaire, a urodynamic assessment and a new standardized quantification test. Time to follow-up ranged from 28 to 100 months (mean 63 months). Of the 24 patients, 20 (83%) reported an improvement in clinical symptoms for a mean of 37 (range 12-84) months at the evaluation and 10 (42%) were completely continent after the Stamey procedure. Four patients (17%) reported a poor outcome of the operation, but in only one case could this be related to recurrent GSI. Treatment-associated morbidity was low but the frequency of postoperative urgency symptoms was higher than that reported in other studies (21%). In a selected population of pure GSI patients with no demonstrable detrusor overactivity, the Stamey bladder neck suspension procedure appears a feasible therapeutic option with few complications.

Reproducibility of Cystometry in Overactive Detrusor

Objective: To examine the reproducibility of cystometry in the overactive detrusor.Methods: The study sample involved 30 patients of the placebo arm in double–blind clinical trials for an overactive detrusor. They had demonstrated detrusor overactivity and underwent the second cystometry after 2–4 weeks. Nonparametric tests for paired data were used to examine the reproducibility of four variables: volume at first desire to void, volume at first involuntary contraction, cystometric capacity, and the maximum pressure of involuntary contraction. Percent change and within–subject standard deviation were calculated to assess intraindividual variability.Results: The second test results showed a significant and systematic change for the better. Volume variables increased by 10–13% (p<0.01), involuntary contraction was not elicited in 3 cases (10%), and the maximum contraction pressure decreased by 18% in the remaining cases. Intraindividual variability was not small. Seventeen patients (57%) demonstrated ≧25% change in one or more variables, and the 95% confidence interval of cystometric capacity, for example, was calculated as (x –57, x +57), where x is a test result. No specific patients’ demographics were found related to variability.Conclusion: Repeat cystometry in the overactive detrusor is not highly reproducible and may be subject to a systematic effect for the ‘better’. Whether this is due to the placebo effect or the learning effect could not be determined.