Maintenance Of Urinary Continence Research Articles

ANTENATALLY DIAGNOSED UPPER MOIETY HYDRONEPHROSIS IN A CHILD WITH ECTOPIC URETER: A CASE REPORT

An ectopic ureter is any ureter, single or duplex, that does not enter the trigonal area of the bladder. In a duplex system, the ectopic ureter is inevitably the upper pole ureter. In males, the ectopic ureter always enters the urogenital system above the external sphincter. The majority of ectopic ureters are detected through prenatal ultrasound imaging, even if the specific diagnosis is not made until after birth. Radionuclide renal imaging remains the gold standard for renal functional assessment, and this is usually best provided by dimercaptosuccinic acid imaging. The goals of therapy are the preservation of renal function; elimination of infection, obstruction, and reflux; and maintenance of urinary continence. We report a case of a 6-month-old male child presenting with urinary tract infection. The child was diagnosed to have had a cystic dilatation of the right upper moiety on antenatal ultrasonography imaging.

THE POTENTIAL ROLE OF DIETARY FACTORS ON URINARY INCONTINENCE IN THE ELDERLY

Maintenance of urinary continence is a complex physiological process. Multiple morbidities can alter this process including polypharmacy, and age-related loss of physiological function. An increasing body of evidence suggests the importance of dietary factors and ingested substances. Modification of nutrients and ingested substances might prove beneficial adjunctive therapies in the treatment of incontinence, but remain unproven. Extrapolation of the results of epidemiologic studies of the relationship of excess caloric intake to continence, from the general adult population, suggests trials of weight loss might help. Population studies of vitamin D supplementation and continence also suggest an association, but prospective experimental trials involving vitamin D supplementation have yet to be done. A potential but far more equivocally documented relationship exists for vitamin B12 and continence. Surprisingly little evidence exists for other potential risk factors for incontinence such alcohol and sweeteners, natural or artificial. Future research should involve prospective trials of weight loss and vitamin D, and exploration of the relationship between other dietary factors and continence.

Voiding Dysfunction in Multiple Sclerosis.

Voiding dysfunction is a common and debilitating consequence of multiple sclerosis (MS). The prevalence and severity of voiding dysfunction increases with the increasing severity of MS, but even the mildest forms of the disease are associated with urinary symptoms in 30% of patients. Every component of the central nervous system is involved in regulating voiding; as a result, MS can lead to a wide variety of urinary symptoms and urologic complications. The effect of MS on voiding can be classified according to the resulting function of the bladder and the urethral sphincter during storage and emptying of urine. Therapy is targeted to the specific bladder and sphincter abnormalities that occur. The primary goals of therapy are prevention of injury to the upper urinary tract (kidneys), reduction in urinary tract infections, and maintenance of urinary continence. These goals can be achieved by interventions ranging from behavioral modification to major reconstructive surgery.

Voiding Dysfunction in Multiple Sclerosis.

Voiding dysfunction is a common and debilitating consequence of multiple sclerosis (MS). The prevalence and severity of voiding dysfunction increases with the increasing severity of MS, but even the mildest forms of the disease are associated with urinary symptoms in 30% of patients. Every component of the central nervous system is involved in regulating voiding; as a result, MS can lead to a wide variety of urinary symptoms and urologic complications. The effect of MS on voiding can be classified according to the resulting function of the bladder and the urethral sphincter during storage and emptying of urine. Therapy is targeted to the specific bladder and sphincter abnormalities that occur. The primary goals of therapy are prevention of injury to the upper urinary tract (kidneys), reduction in urinary tract infections, and maintenance of urinary continence. These goals can be achieved by interventions ranging from behavioral modification to major reconstructive surgery.

MP9-10 ASSESSMENT OF FEMALE URETHRAL STRICTURE RECONSTRUCTION: BUCCAL MUCOSA GRAFT AND VAGINAL FLAP

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery III1 Apr 2014MP9-10 ASSESSMENT OF FEMALE URETHRAL STRICTURE RECONSTRUCTION: BUCCAL MUCOSA GRAFT AND VAGINAL FLAP Casey Kowalik, John Stoffel, Leonard Zinman, Alex Vanni, and Jill C. Buckley Casey KowalikCasey Kowalik More articles by this author , John StoffelJohn Stoffel More articles by this author , Leonard ZinmanLeonard Zinman More articles by this author , Alex VanniAlex Vanni More articles by this author , and Jill C. BuckleyJill C. Buckley More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.498AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The management of female urethral strictures is challenging given the variable presenting symptoms and extremely low incidence. Our objective was to evaluate the safety, operative technique and outcomes of women following urethral reconstruction with either a vaginal flap urethroplasty (VFU) or dorsal buccal mucosa graft (BMG). METHODS We retrospectively identified 10 women undergoing urethral reconstruction between February 2007 and October 2012. All patients had active urinary symptoms and/or urodynamic study indicating bladder outlet obstruction, confirmed by cystoscopy. Recurrent stricture was defined by a urethral diameter less than 17fr. Follow-up included urethral calibration (>16fr), symptom assessment, voiding cystourethrogram, and cystoscopy when there was difficulty voiding or symptoms recurred. RESULTS Mean age was 49 years (range 32-74). For urethral reconstruction, 6 patients had a VFU and 4 had a dorsal BMG. Location was mid in 6 and distal in 4 women. The indication for urethral reconstruction was urethral stricture in 9 patients. One woman had a traumatic 2 cm ventral urethral laceration associated with a pelvic fracture. Average stricture length was 1.25 cm (range 0.2-2). All patients with urethral stricture had previously undergone multiple urethral dilations. There were no major post-operative complications. Patients with available data (BMG patients) demonstrated improvement with a median pre-operative maximum flow of 4.5 mL/sec to a median post-operative maximum flow of 10.5 mL/sec. The median post-void residual was 163 mL prior to reconstruction and 25mL at follow-up. Two patients undergoing VFU underwent dilation at an average of 27 months following reconstruction for recurrent stricture with an average follow-up of 41 months. No patients undergoing dorsal BMG had a recurrent stricture or experienced urinary incontinence at an average follow-up of 24 months. CONCLUSIONS Female urethral reconstruction, either VFU or dorsal BMG, is a safe procedure with high success and significant improvements in quality of life. Outcomes of dorsal BMG are promising, demonstrating improved clinical and physiological parameters with maintenance of urinary continence. Women should be offered urethral reconstruction as a definitive management option rather than repeated urethral dilations. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e125 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Casey Kowalik More articles by this author John Stoffel More articles by this author Leonard Zinman More articles by this author Alex Vanni More articles by this author Jill C. Buckley More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Continence and micturition: An anatomical basis

Urinary incontinence remains an important clinical problem worldwide, having a significant socio-economic, psychological, and medical burden. Maintaining urinary continence and coordinating micturition are complex processes relying on interaction between somatic and visceral elements, moderated by learned behavior. Urinary viscera and pelvic floor must interact with higher centers to ensure a functionally competent system. This article aims to describe the relevant anatomy and neuronal pathways involved in the maintenance of urinary continence and micturition. Review of relevant literature focusing on pelvic floor and urinary sphincters anatomy, and neuroanatomy of urinary continence and micturition. Data obtained from both live and cadaveric human studies are included. The stretch during bladder filling is believed to cause release of urothelial chemical mediators, which in turn activates afferent nerves and myofibroblasts in the muscosal and submucosal layers respectively, thereby relaying sensation of bladder fullness. The internal urethral sphincter is continuous with detrusor muscle, but its arrangement is variable. The external urethral sphincter blends with fibers of levator ani muscle. Executive decisions about micturition in humans rely on a complex mechanism involving communication between several cerebral centers and primitive sacral spinal reflexes. The pudendal nerve is most commonly damaged in females at the level of sacrospinous ligament. We describe the pelvic anatomy and relevant neuroanatomy involved in maintaining urinary continence and during micturition, subsequently highlighting the anatomical basis of urinary incontinence. Comprehensive anatomical understanding is vital for appropriate medical and surgical management of affected patients, and helps guide development of future therapies.

Pelvic Fracture: The Last 50 Years

The past 50 years have been a time of rapid progress in the control of mortality and morbidity of pelvic fracture. Early understanding of the anatomic features of the fracture and the potential for major, life-threatening arterial hemorrhage in a small proportion of patients led to multidisciplinary approaches designed to control hemorrhage and temporarily stabilize the fracture. Progress in the diagnosis and management of lower urinary tract injuries has resulted in maintenance of urinary continence and sexual function in a large proportion of patients with pelvic fracture-associated urinary tract injury. Finally, definitive open reduction and fixation of the fracture has led to permanent pelvic stability and pain-free walking in most patients. With successful combination of these approaches, survival and return to a satisfactory level of function is now the rule rather than the exception for patients with severe pelvic fracture.

Neural control of the female urethral and anal rhabdosphincters and pelvic floor muscles.

The urethral rhabdosphincter and pelvic floor muscles are important in maintenance of urinary continence and in preventing descent of pelvic organs [i.e., pelvic organ prolapse (POP)]. Despite its clinical importance and complexity, a comprehensive review of neural control of the rhabdosphincter and pelvic floor muscles is lacking. The present review places historical and recent basic science findings on neural control into the context of functional anatomy of the pelvic muscles and their coordination with visceral function and correlates basic science findings with clinical findings when possible. This review briefly describes the striated muscles of the pelvis and then provides details on the peripheral innervation and, in particular, the contributions of the pudendal and levator ani nerves to the function of the various pelvic muscles. The locations and unique phenotypic characteristics of rhabdosphincter motor neurons located in Onuf's nucleus, and levator ani motor neurons located diffusely in the sacral ventral horn, are provided along with the locations and phenotypes of primary afferent neurons that convey sensory information from these muscles. Spinal and supraspinal pathways mediating excitatory and inhibitory inputs to the motor neurons are described; the relative contributions of the nerves to urethral function and their involvement in POP and incontinence are discussed. Finally, a detailed summary of the neurochemical anatomy of Onuf's nucleus and the pharmacological control of the rhabdosphincter are provided.

Early Development of the Urethral Sphincter Muscle : Relationship of the Striated Muscle Fibres with the Prostate in Human Fetuses

Purpose The urethral sphincter muscle has a major hole in the maintenance of urinary continence; its quick voluntary contraction especially during an abrupt interruption of micturition. Our purpose is to describe the arrangement of the striated muscle fibres of the urethral sphincter during gestation and to correlate these finds with those described in grown up prostates. Material and methods We analyzed 17 prostates of 17 human fetuses that died of causes unrelated to the urogenital tract. The fetuses were well preserved and none had any kind of detectable congenital malformations. Gestational age ranged between 10 and 31 weeks post conception (WPC) and was estimated according to foot length criteria. Transverse sections of the prostate were made and stained with Gomori's trichrome and immunolabeled with anti alpha-actin antibodies. Results We observed that the urethral sphincter muscle is located on the periphery of the smooth muscle and there wasn't a mixture between these two types of muscle fibres at any period. In the prostatic apex, the striated sphincter shows a circular arrangement and completely covers the urethra externally; adjacent to the verumontanum, it seems like a “horseshoe” and covers the anterior and lateral sides of the urethra, but not the posterior side. Near the neck of the bladder, we've found striated muscle fibres only at the anterior side of prostate, although they could be found at the lateral side of the prostate of the fetus from 20 WPC older. Conclusions The urethral sphincter muscle was present in all fetuses covering the anterior and lateral sides of the urethra. This muscular arrangement is very important in understanding the normal anatomy of the pelvic floor musculature and the alterations of this musculature in congenital anomalies of the genital tract.

Ca2+ signalling in urethral interstitial cells of Cajal.

Interstitial cells of Cajal (ICC) in the urethra have been proposed as specialized pacemakers that are involved in the generation of urethral tone and therefore the maintenance of urinary continence. Recent studies on freshly dispersed ICC from the urethra of rabbits have demonstrated that pacemaker activity in urethra ICC is characterized by spontaneous transient depolarizations (STDs) under current clamp and spontaneous transient inward currents (STICs) under voltage clamp. When these events were simultaneously recorded with changes in intracellular Ca(2+) (using a Nipkow spinning disk confocal microscope) they were found to be associated with global Ca(2+) oscillations. In this short review we will consider some of these recent findings regarding the contribution of intracellular Ca(2+) stores and Ca(2+) influx to the generation of pacemaker activity in urethral ICC with particular emphasis on the contribution of reverse Na(+)/Ca(2+) exchange (NCX).

Supra-ampullar Cystectomy and Ileal Neobladder

ObjectiveThis article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC). MethodsBoth open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained step by step. ResultsBetween May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5–260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation. ConclusionSAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.

Duloxetine for management of stress urinaryincontinence

Objective: The aim of this article was to review data regarding the efficacy and tolerability of duloxetine, a selective serotonin (S-HT)-norepinephrine (NE) reuptake inhibitor that has received US Food and Drug Administration marketing approval for the treatment of major depressive disorder and painful diabetic neuropathy, and that has been investigated as a treatment for stress urinary incontinence. Methods: A MEDLINE/PubMed search was conducted to identify English-language study reports. In addition, proceedings of meetings of the International Continence Society, European Association of Urology, American Urological Association, and American College of Obstetrics and Gynecology were reviewed for relevant abstracts (search terms included duloxetine, thiophenes, serotonin uptake inhibitors, adrenergic uptake inhibitors, and stress urinary incontinence). Additional references were obtained from the bibliographies of these sources. Data for the period from 1986 through January 2005 were reviewed. Results: All in vitro and in vivo studies of duloxetine were included. Because both S-HT and NE are involved in the maintenance of urinary continence, duloxetine may have a role in the treatment of urinary incontinence. Duloxetine is primarily eliminated via metabolism, with <1% of the parent compound excreted via urine. Duloxetine QD or BID has been found to be significantly superior to placebo in reducing incontinence episode frequency ( P < 0.001 to P < 0.05), increasing the interval between micturitions ( P < 0.001 to P = 0.004), and improving the condition as measured by patient self- report ( P < 0.001 to P = 0.028) and incontinence quality-of-life scores ( P = 0.002 to P = 0.03). The most problematic adverse events are nausea, dry mouth, constipation, dizziness, and insomnia. Conclusions: Although statistically superior to placebo in efficacy trials, the clinical effects of duloxetine therapy on incontinence are small, suggesting that any benefits to the patient would be modest and must be weighed against the drug's adverse event profile. No comparative efficacy/tolerability data with alpha-receptor agonists (eg, pseudoephedrine) are available. On the basis of available data, duloxetine is a modest, but welcome, advance in the pharmacotherapeutic management of stress urinary incontinence.

Changes of collagen type III in female patients with genuine stress incontinence and pelvic floor prolapse

Purpose: Objective of this study was to determine possible changes in the quantity of type III collagen in women with genuine stress incontinence (GSI) and with pelvic relaxation or not. Material and methods: Ninety-four women participated in the study and they were divided in to three groups as follow: 34 patients with GSI and pelvic relaxation (group 1), 32 patients with pelvic relaxation but without GSI (group 2) and 28 patients with neither pelvic relaxation nor GSI (group 3). All the women underwent a complete pre-operative urodynamic evaluation. The presence of collagen type III was determined by immunohistochemical technique. The X-test was used for statistical analysis. A P<0.05 was considered statistically significant. Results: Collagen type III was significantly reduced ( p<0.05) in patients with GSI and pelvic relaxation in both sites of biopsy (group 1), compared to patients in groups 2 and 3.Specimens from women without GSI (group 2 and group 3) had a similar density of collagen type III in both sites of biopsy. Conclusion: In this study, we found that women with GSI had less collagen type III around the urethra regardless of the degree of pelvic relaxation. It appears that collagen has a significant role in the maintenance of urinary continence but the mechanism by which collagen metabolism is altered remains unknown.

Acquired Rectourethral Fistula: Methods of Repair

Rectourethral fistulas are a rare but devastating complication of urinary or rectal surgery, trauma or inflammation. Historically repair has posed a challenge because of technical difficulties and the high incidence of recurrent fistulas. We report 7 cases of acquired rectourethral fistulas of varying etiology (3 after prostatectomy, 3 after trauma and 1 after recurrent perineal abscess), which were managed by various means. Our data and those in the literature suggest that the first attempt at repair is the best and subsequent repairs become increasingly difficult; the York Mason approach allows easy accessibility with minimal risk of complications and the best chance for a functionally successful outcome when a vascularized flap is not required, and some cases may have such a low probability of successful resolution of the fistula as well as maintenance of urinary continence that cystectomy and supravesical diversion are appropriate considerations.

Experimental investigation of an infolded bowel segment as an anti-incontinence mechanism without interposing the ileo-cecal valve.

A technique for using bowel segment as an anti-incontinence mechanism was developed in an animal model and evaluated urodynamically. Variously modified bowel segments were investigated alone and later attached to a colonic reservoir to establish their value in preventing urinary incontinence while allowing easy catheterization. Using careful surgical technique, intussuscepted, tapered and plicated bowel segments were constructed. The maximum segmental closure pressure and functional length were evaluated in all preparations. The three bowel segments remained continent during slow filling and up to reservoir capacity. The recordings demonstrated both highest maximal closure pressure and longest functional length in the plicated system when evaluated both alone and following reservoir attachment. These recording differences occurred both with the reservoir full and empty. These results demonstrate the value of a plicated bowel segment in the maintenance of urinary continence when attached to a compliant urinary reservoir without using the ileo-cecal valve in this model.

Reflex activation of sympathetic pathways to vesical smooth muscle and parasympathetic ganglia by electrical stimulation of vesical afferents.

1. Activation of the sympathetic input to the urinary bladder by electrical stimulation of afferent fibres in the pelvic nerve evoked three responses: (1) an initial transient rise in intravesical pressure, (2) an inhibition of neurally evoked bladder contractions and (3) an inhibition of transmission in vesical parasympathetic ganglia. Similar responses were elicited by stimulation of the hypogastric nerve. 2. The reflex responses were observed in acute spinal preparations (T10-T12) and in cats with intact spinal cords, but were abolished by bilateral transection of the hypogastric nerves. 3. The inhibition of bladder contractions was antagonized by the administration of propranolol (200-400 mug, I.A.), a beta-adrenergic blocking agent. The inhibition of ganglionic transmission was antagonized by dihydroergotamine (30-75 mug, I.A.), an alpha-adrenergic blocking agent. The initial rise in intravesical pressure was not antagonized by either agent. 4. Electrical stimulation of other afferents (carotid sinus nerve and sciatic nerve) did not consistently elicit responses in the urinary bladder. However, stimulation of these afferents as well as pelvic nerve afferents evoked reflex firing in nerve filaments on the surface of the urinary bladder. The firing was abolished by transection of the ipsilateral hypogastric nerve. 5. It is concluded that stimulation of vesical afferents activates a spinal sympathetic reflex which results in closing of the internal urethral sphincter and a depression of bladder activity. The latter occurs by a direct depression of detrusor smooth muscle as well as a block of the neural input to the bladder. This vesico-sympathetic reflex represents a negative feed-back mechanism which may have an important role in the maintenance of urinary continence.