High Bladder Pressure Research Articles

'Clam' ileocystoplasty.

'Clam' enterocystoplasty has been performed in 23 patients in the treatment of lower urinary tract dysfunction. Twenty patients had neurogenic disorder while three were neurologically normal. Patients were evaluated urodynamically pre- and postoperatively. A significant change from a high pressure bladder to a low pressure bladder was found. Most patients had detrusor instability/hyperreflexia but 7 were operated due to poor bladder compliance. Only 2 patients had postoperative detrusor instability. Three patients later had a urinary diversion. Nineteen patients became dry giving a total success rate of 87% although 14 had to do clean intermittent self catheterization.

Bladder pressure monitoring significantly enhances care of infants with abdominal wall defects: A prospective clinical study

Increased intraabdominal pressure (IAP) has been demonstrated to cause intestinal and renal ischemia in both animals and humans. Neonates undergoing closure of anterior abdominal wall defects are at risk for these complications from markedly increased IAP, which are putatively responsible for a 13% to 20% mortality. In an effort to decrease morbidity and mortality we performed a 4-year prospective clinical study to determine if monitoring IAP using bladder pressure (BdP) measurements would significantly improve perioperative care in infants with abdominal wall defects. Forty-two consecutive infants with gastroschisis (28) and omphalocele (14) were prospectively studied. Intraoperative and serial postoperative measurements of BdP were obtained from an indwelling bladder catheter using a standard pressure transducer. Methods of initial closure, as well as manipulations in sedation, paralysis, and silo reduction, were selected to keep BdP < 20 mm Hg. Bladder pressure monitoring significantly altered the management of 64% of our patients, particularly those with gastroschisis (74%). Thirteen patients with gastroschisis underwent staged closure; in 7 (54%) this decision was based on high BdP even though bowel reduction was mechanically possible. Elevated BdP influenced the closure method and timing of silo reductions in 5 of 14 (42%) infants with omphalocele. There were no episodes of renal failure or refractory oliguria. There were three patients in a single cluster who developed uncomplicated, nonsurgical necrotizing enterocolitis late in their respective courses. One patient whose bowel was placed in a silo had severe hypotension associated with group B streptococcal sepsis and subsequently developed necrotic bowel despite low BdP.(ABSTRACT TRUNCATED AT 250 WORDS)

The development of urologic complications in relationship to bladder pressure in spinal cord injured patients.

The medical records of 88 patients followed through our spinal cord injury clinic were reviewed to determine if elevated intravesical pressures result in more urologic complications than are seen with low pressure bladders. Fifty-two of the patients were noted to have a high bladder pressure (sustained detrusor pressure greater than 40 cm water) on cystogram while 36 had low pressures. All patients had routine urine cultures, urodynamics, ultrasonography, radioisotope renal scans, and excretory urograms. Bladder management was directed at maintaining a low bladder pressure and included one or more of the following: intermittent catheterization, anticholinergics, alpha blockers, transurethral sphincterotomy, or indwelling catheters. Average follow-up was 6 years. Mild degrees of hydronephrosis were noted in seven (14 percent) of the patients with a high pressure bladder and in one (3 percent) with a low pressure bladder. Pyelonephritis was noted in two (4 percent) with high bladder pressure and two (5 percent) with low bladder pressure. Preservation of renal function occurred as the result of patient compliance with bladder management and bladder pressure. Sustained high detrusor pressure, when not corrected, leads to upper tract deterioration which was reversed by aggressive lower tract management.

Relationship Between Dysfunctional Voiding and Reflux

Bladder instability and the nonneurogenic neurogenic bladder are 2 urodynamically different dysfunctional voiding patterns. However, they share a common urodynamic mechanism in that they both produce functional urinary obstruction, which by changing the anatomy and function of the bladder, and ureterovesical junction produces and perpetuates vesicoureteral reflux. Urodynamic studies show that bladder decompensation with high end filling pressures, rather than high voiding pressures, is the mechanism for reflux and help to explain the seemingly paradoxical relationship among obstruction, reflux and high bladder pressures, namely that reflux does not usually occur when bladder pressures are high. This urodynamic analysis and review of the literature strongly support the belief that functional urinary tract obstruction caused by dysfunctional voiding can initiate and perpetuate vesicoureteral reflux, and provide an understanding of the mechanisms involved.

Response of Bladder, Urethral and Intracavernous Pressure to Ventral Lumbosacral Root Stimulation in Sprague-Dawley and Wistar Rats

Six Sprague-Dawley and six Wistar rats were used for electrostimulation of the L5 to S2 ventral roots. Landmarks for identification of the roots were developed; bladder, urethral and intracavernous pressures were recorded; and tail and leg movements were checked. Urethral sphincter contraction was elicited by stimulation of the L5–L6 ventral roots, while bladder contraction and penile erection were mediated by the L6–S1 ventral roots. The best sphincteric response and intracavernous pressure rise were obtained by stimulation of the L6 ventral root, and the highest bladder pressures by stimulation of the S1 ventral root. Stimulation of the S1-S2 ventral roots provoked ipsilateral tail movement; of L6, tail movement, hindleg muscle twitch, and slight toe spread; and of L5, hindleg stretch and plantar flexion. No significant differences were found between the two strains of rats, although a higher bladder pressure was recorded during stimulation of the L6 ventral root in Sprague-Dawley rats, which might be explained by a small caudal shift of the sacral parasympathetic nucleus in the Wistar strain.

The prophylactic value of clean intermittent catheterization and anticholinergic medication in newborns and infants with myelodysplasia at risk of developing urinary tract deterioration.

To determine if prophylactic use of clean intermittent catheterization and oxybutynin chloride is effective in preventing urinary tract deterioration in myelodysplastic children with high bladder pressure and detrusor-sphincter dyssynergia. Sequential, nonrandomized trial. Referral-based urodynamics facility and myelodysplasia program at a major city pediatric hospital. Twenty-six of 71 consecutive newborns with myelodysplasia who exhibited these urodynamic findings were treated prophylactically over 5 years, whereas 56 of 105 consecutive newborns with the same findings treated during the previous 7 years were treated expectantly. Clean intermittent catheterization and oxybutynin therapy were begun when these specific urodynamic findings were detected. Follow-up urodynamic studies and roentgenographic assessment of the urinary tract were performed periodically over 5 years. Oxybutynin eliminated uninhibited contractions in two of 14 newborns and lowered peak contractile pressure in the remaining 12. Oxybutynin also lowered bladder-filling pressure at capacity in all 12 additional neonates with only hypertonicity. Twenty-four (92%) of 26 children had normal kidney function and drainage during the observation period, two (8%) developed hydroureteronephrosis, and one of these two had vesicoureteral reflux. In a prior study of children similarly at risk who were treated expectantly, the roentgenographic appearance of the upper urinary tract had changed in 48%. Minimal side effects were noted with oxybutynin, and no adverse effects of clean intermittent catheterization were detected. Oxybutynin effectively reduces uninhibited contractions and lowers detrusor filling pressure, while clean intermittent catheterization allows bladder emptying at low pressures with no measurable side effects in these neonates. The overall effect maintains the integrity of the upper urinary tract in almost all myelodysplastic children at risk of urinary tract deterioration. Expectant therapy can no longer be advocated when these "at risk" children are identified because prophylactic treatment is so effective.

Post‐prostatectomy incontinence: Part I. The urodynamic findings in 107 Men

AbstractA retrospective review of 107 men referred for evaluation of post‐prostatectomy incontinence (71 post radical retropubic prostatectomy, 26 post transurethral resection of the prostate, and 10 post open prostatectomy) was conducted.After in‐depth urodynamic studies, only 40 men (37%) were found to have sphincteric insufficiency alone, 36 men (34%) had sphincteric insufficiency combined with high pressure bladder dysfunction (detrusor instability and/or decreased compliance), and 21 men (20%) had bladder dysfunction alone as the sole cause of post‐prostatectomy incontinence. Ten patients (9%) had normal urodynamic studies.The role of bladder dysfunction as a causative factor in post‐prostatectomy incontinence is strongly emphasized. © 1992 Wiley‐Liss, Inc.

Creation of a Feline Model of Obstructive Uropathy

The aim of this project was to create a reproducible, quantifiable feline model of obstructive uropathy. Seventy-three adult female cats of comparable age were evaluated to obtain the normal control urodynamic data base. Twenty-four cats had a silastic cuff installed around the urethra to induce bladder outlet obstruction, and eight underwent a sham operation. Repeated urodynamic evaluations were performed at predetermined postoperative intervals. The obstructed and normal cats inhibited detrusor contractility by reflex striated urethral sphincter activity. Measurements of voiding pressure to verify the presence, and to assess the degree of induced outlet obstruction, required paralysis of the sphincter by curare. Following cuff implantation, voiding pressure increased from a mean normal of 17.2cm./H2O to 31.6 to 42.5cm./H2O in animals designated as moderately obstructed, and to 101.7-125.0cm./H2O in animals designated as severely obstructed. 84.6% of the high pressure bladders developed vesicoureteral reflux. Analysis of resting, low bladder volume, urethral pressure profile (UPP) data and voiding pressures indicate a compensatory sphincteric response to filling in non-curarized animals, and a lack of that response in curarized animals.It appears that implantation of a silastic cuff to prevent full opening of the urethra during voiding, without actually compressing it, is a reasonable model of obstructive uropathy. The observation that the relationship between striated urethral sphincter activity and inhibition of detrusor contractility is influenced by administration of curare was unexpected, and may have clinical implications.

A pressure management system for the neurogenic bladder after spinal cord injury

AbstractOne hundred eighteen patients consecutively admitted to a University Rehabilitation Program entered a protocol study of urologic management. Bladder pressures were kept below 30 cms/H2O by urologic treatment. Serial urodynamic, radiographic, bacteriologic, and endoscopic studies were performed at regular intervals. Eighteen patients have been lost to follow‐up; 100 patients were followed for a mean 25.4 months with a range of 6 months to 56 months. There were 105 patients with lesions superior to the sacral segments and 13 patients with low lesions. At discharge 11 patients were voiding normally, 105 were continent on an intermittent catheterization (IC) protocol, and 2 patients used condom catheter drainage following sphincterotomy. Bacterial cultures and urinalysis data showed little or no relationship to clinical outcome, and treatment for 387 weeks by antimicrobial agents was not associated with discernible benefit as opposed to no treatment. Five patients developed bladder calculi, and five developed unilateral epididymitis. Bladder pressure was relatively easy to control following spinal cord injury, a result which suggests that high bladder pressure is not a direct result of the neural injury, but rather an evolutionary change as a result of bladder and urethral interactive dysfunction.

Assessing the effects of positive buoyancy on rainbow trout (Oncorhynchus mykiss) held in gas supersaturated water

We examined the effects of swim bladder overinflation associated with dissolved gas supersaturation on rainbow trout (Oncorhynchus mykiss). The change in swim bladder volume with increased swim bladder pressure was measured in fish subjected to a decrease in ambient pressure. An expansion of swim bladder volume occurs that is related to the excess swim bladder pressure. The volume change results in a decrease in density and positive buoyancy in the fish. Small fish are adversely affected when exposed to gas supersaturated water because of the high swim bladder pressure required to force gas out the pneumatic duct. Changes in behaviour and depth distribution of fish held in gas supersaturated water were measured in a 2 m deep observation column. A large change in density caused small fish to increase depth and compensate for the swim bladder expansion. Although swim bladder inflation occurs for all sizes of trout held in gas supersaturated water, the impact is greatest for small fish and they must compensate by seeking depth. However, adequate depth to compensate for positive buoyancy may not always exist. In such a case, fish must swim continuously in a head down position to overcome excess buoyancy. The power necessary for a fish to swim with an overinflated swim bladder is greatest for small fish that show the largest change in density.

New development and progression of renal scarring in children with primary VUR.

To study the development of new scars and progression of previous scarring, we analysed 711 children with primary VUR. New scar or progression of previous scarring was observed in 7.3% of the kidneys with reflux. Factors which promote the formation of new scars are high-grade VUR, recurrent UTIs and high-pressure bladder which results in high-pressure reflux. The average age of new scarring was from 7 to 9 years. We emphasize the importance of the follow-up study until the age of 15 years, even after reflux has stopped following surgery.

A Bladder Pressure Management System for Myelodysplasia—Clinical Outcome

A program for the management of neurogenic bladder in patients with myelodysplasia was instituted in July 1983. Of the 114 patients entered into the program who have been followed for a minimum of 18 months 42 per cent required treatment for high intravesical pressures. None of this group or the larger group with low bladder pressures showed progressive upper urinary tract deterioration. In 8 children (17 per cent of those with high pressure bladder dysfunction) high intravesical pressure persisted despite anticholinergic medication and intermittent catheterization, and they required an operation to achieve a low pressure bladder. These results confirm the findings in other studies that about 40 per cent of myelodysplastic children are at high risk for the development of upper tract changes, and that approximately 6 to 8 per cent will not respond sufficiently to anticholinergic agents and intermittent catheterization.

The Effect of Intravesical Pressure on Glomerular Filtration Rate in Patients with Myelomeningocele

Numerous investigators have demonstrated the development of hydronephrosis and renal deterioration in patients with myelomeningocele who have high pressure bladders. By drawing blood at sequential intervals during 99mtechnetium-diethylenetriaminepentaacetic acid renal scanning we are able to generate nuclide clearance curves that correlate well with glomerular filtration rate. Renal scanning is done most frequently with the bladder catheterized and left to gravity drainage. By filling the bladder under manometric control to a pressure of 35 to 40cm. water we have followed routine scanning with continued blood sampling to generate nuclide clearance at low and high bladder pressures. In 5 myelomeningocele patients so studied we found consistent and significant decreases in glomerular filtration rate at high bladder pressures.

Clinical significance of ureteric diameter on intravenous urography after spinal cord injury.

The ureteric diameter on IVU was compared with the MCU findings of reflux or lower urinary tract dysfunction in a group of patients followed up after spinal cord injury. A wide ureter was associated with reflux in 20%, but 8 normal sized ureters on IVU also refluxed--5 of them to a significant degree. In the non-refluxing group, wide ureters were noted more often in patients whose bladder pressures were high and wildly fluctuating than in those with normal bladder pressures. Similarly, the incidence of reflux was higher in patients with high bladder pressures and wild fluctuations of bladder pressure than in those with normal pressures. While a wide ureter on IVU should arouse suspicion that reflux or lower urinary tract dysfunction might be present, these conditions are not necessarily excluded by the finding of a ureter of normal size.

Surgical Treatment of the Incontinent Female Patient with Myelomeningocele

Surgical therapy was required for 42 incontinent female patients with myelomeningocele who had urodynamically documented high pressure bladders. Conservative treatment consisting of cholinolytic and alpha-adrenergic agents, and intermittent self-catheterization had failed. The surgical approach consisted of perivesical denervation (for hyperreflexia), Burch bladder neck suspension, enlargement cystoplasty and ureteral reimplantation when required. Among 33 patients (79 per cent) there was no incontinence on intermittent self-catheterization and 6 (14 per cent) had improvement with rare urgency or stress incontinence. In 3 patients (7 per cent) sphincteric incompetence required a transvaginal sling procedure.

DOES VESIOCURETERAL REFLUX (VUR) CORRELATE WITH INTRAVESICAL PRESSURE (IVP)?

With this purpose 14 patients with known VUR were studied with urodynamic methodology and simultaneous radiology. Evaluating IVP simultaneously with time of appearance of VUR: 1) while bladder filling (in the first or second half), 2) with the presence of uninhibited contractions (UC), 3) during voiding, 4) in the postmicturition (PM). It also was quoated if the VUR was intermitent or permanent. None of the patients evaluated had neurogenic bladder or urinary tract obstruction. All had urinary tract infection being this the reason for the urodynamic study. All the patients were females between 2 and 15 years of age. 14 patients, 28 renal units, VUR was detected in 19 units: 6 in the first half of bladder filling, 7 in the second half, 0 during UC, 1 while voiding, and 5 in the PM. 7 were permanent and 12 intermitent. Of the 12 intermitent: 6 while filling, 1 during micturition, and 5 in the PM. Of the 7 permanent: 5 in the first half of bladder filling and 2 in the second half. From the data presented it is clear that VUR does not correlate with high bladder pressure during micturition or UC, showing that VUR can appear at any moment of the vesical cycle. VUR is a radiologic sign of the incompetence of the vesicoureteral junction, and this incompetence may be is more related to the migration of the wall of the detrusor muscle of the bladder during compliance or micturition. From an hydraulic point of view, areteral filling during VUR should depend on 3 interdependent factors: 1) the competence of the vesicoureteral junction, 2) the ureteral compliance, 3) ureteral peristaltic activity. With this criteria if appears inconvenient to clasify VUR according to the ureteral filling because this is nothing more than the radiologic evidence of the interrelation of these 3 factors unknown by this methodology.

580 - Pharmacologic Suppression of the High Pressure Bladder: A Reasonable Alternative for the Spinal Cord Injured Patient

No AccessJournal of Urology1 Jun 1987Pharmacologic Suppression of the High Pressure Bladder: A Reasonable Alternative for the Spinal Cord Injured Patient David F. Green, and Claire Puklin David F. GreenDavid F. Green More articles by this author , and Claire PuklinClaire Puklin More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)75730-8AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Pharmacologic Suppression of the High Pressure Bladder: A Reasonable Alternative for the Spinal Cord Injured Patient." The Journal of Urology, 137(6), p. 248A © 1987 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 137Issue 6June 1987Page: 248A Advertisement Copyright & Permissions© 1987 by The American Urological Association Education and Research, Inc.MetricsAuthor Information David F. Green More articles by this author Claire Puklin More articles by this author Expand All Advertisement PDF DownloadLoading ...

Identification of the Poor Risk Patient with “Prostatism” and Detrusor Failure

Twenty-five patients with "prostatism" and chronic retention of urine have been followed up for 4 years to determine the natural history of the disorder and results of elective treatment. Twenty-one patients with low pressure during bladder filling maintained normal upper tracts and renal function; they were subdivided by micturition pressure into two groups which differed significantly in terms of both total bladder capacity and variance of capacity. Patients with good voiding pressures had a very satisfactory outcome following surgery, with almost complete relief of symptoms, but patients with poor voiding pressures obtained a poor symptomatic and urodynamic result from repeated surgical procedures. Four patients declined operation and the subsequent course of the disorder is described. Four patients had painless retention associated with high pressure bladder filling, hydronephrosis and uraemia. Operation was successful in reversing these potentially terminal complications. None of the 25 patients developed acute retention. Men with "prostatism" do not constitute a homogeneous population. Identification of specific patient groups enables an accurate prediction of the consequences of both conservative and operative management.

Pathogenetic factors in vesicoureteral reflux

AbstractThe pathogenesis of vesicoureteral reflux and reflux nephropathy is multifactorial, but certain known interconnections between different factors have been established. There exists an age‐dependent anatomy and function of the ureterovesical junction, and this is of absolute importance for the presence of vesicoureteral reflux. Also, bladder urethral dysfunction with formation of high bladder pressures, urinary tract infections, and ureteric peristaltic properties seem to be of major importance for the development and maintenance of reflux. Vesicoureteral reflux combined with normal bladder‐urethral function induces no change in the dynamic function of the upper urinary tract. In cases of bladder‐urethral dysfunction that lead to high‐pressure reflux, dilatation of the upper urinary tract is produced with irreversible damage of the peristaltic rhythm, frequency, and propagation. Such changes are aggravated by simultaneous infection. Reflux nephropathy most often occurs in cases of pyelorenal backflow with infected urine but can be aggravated by bladder‐urethral dysfunction producing high pelvic pressures. Bacteria ascend from the bladder to the kidney, and maximal bladder pressures and the peristaltic conditions in the ureter have an impact on this. The maximal bladder pressure and the compiled pressure load transmitted without hindrance from the bladder to the kidney are presumably mandatory for the formation of nephropathy in cases of sterile reflux.

The Development of Neurogenic Vesical Dysfunction after Experimental Spinal Cord Injury or Sacral Rhizotomy in Non-Human Primates

Vesical and urethral function were studied urodynamically before and after spinal cord or sacral root injury in non-human primates. Detrusor sphincter discoordination developed in animals with complete suprasacral spinal cord injury. Animals subjected to complete intradural sacral rhizotomy developed hypertonic areflexic vesical dysfunction while those subjected to dorsal root ganglionectomy developed a high compliance low pressure bladder.