Micturition In Women Research Articles

The effects of intrathecal morphine on urinary bladder function and recovery in patients having a cesarean delivery – A randomized clinical trial

IntroductionSpinal anesthesia with intrathecal morphine (ITM) is a common anesthesia technique for cesarean delivery. The hypothesis was that the addition of ITM will delay micturition in women undergoing cesarean delivery. MethodsFifty-six ASA physical status I and II women scheduled to undergo elective cesarean delivery under spinal anesthesia were randomized to the PSM group (50 mg prilocaine + 2.5 mcg sufentanil + 100 mcg morphine; n = 30) or PS group (50 mg prilocaine + 2.5 mcg sufentanil; n = 24). The patients in the PS group received a bilateral transverse abdominal plane (TAP) block. The primary outcome was the effect of ITM on the time to micturition and the secondary outcome was the need for bladder re-catheterization. ResultsThe time to first urge to urinate (8 [6−10] hours in the PSM group versus 6 [4−6] hours in the PS group) and the time to first micturition (10 [8−12] hours in the PSM group versus 6 [6−8] hours in the PS group) were significantly (p < 0.001) prolonged in the PSM group. Two patients in the PSM group met the 800 mL criterium for urinary catheterization after 6 and 8 h respectively. ConclusionThis study is the first randomized trial to demonstrate that the addition of ITM to the standardized mixture of prilocaine and sufentanil significantly delayed micturition.

Central control of micturition in women: Brain-bladder pathways in continence and urgency urinary incontinence.

Urinary incontinence disproportionately affects women. Anatomical textbooks typically describe continence mechanisms in women in the context of the pelvic floor support of the urinary bladder and the urethral sphincters. However, the urinary bladder and urethral sphincters are under the central control of the brain through a complex network of neurons that allow storage of urine followed by voiding when socially appropriate. Recent studies suggest that the most common type of urinary incontinence in women, urgency urinary incontinence, involves significant dysfunction of the central control of micturition. In this paper, we review the anatomy and functional connectivity of the nervous system structures involved in the control of micturition. Clinical application of this anatomy in the context of urgency urinary incontinence is also discussed. Understanding the anatomy of the neural structures that control continence will allow clinicians to better understand the underlying pathology of urge incontinence and consider new ways of treating this distressing condition. Clin. Anat. 30:373-384, 2017. © 2017 Wiley Periodicals, Inc.

Detrusor pressures in urodynamic studies during voiding in women.

To investigate detrusor pressure during voiding in women using urodynamic studies (UDS). The study group comprised 57 women with non-neurogenic lower urinary tract symptoms. All patients underwent UDS between January 2010 and December 2014. UDS included filling cystometry, pressure flow study (PFS), uroflowmetry for the maximum flow rate (Qmax) and mean flow rate, and postvoid residuals. Existence of voluntary detrusor contraction was defined as a continuous and smooth increase in detrusor pressure (Pdet) after the instruction to micturate in the PFS. The bladder contractility index (BCI) was calculated as Pdet at Qmax + 5×Qmax. Statistical analyses were performed using the Mann-Whitney U test and p < 0.05 was considered statistically significant. The PFS showed that 23 patients had detrusor contraction (Pdet+ group) and 34 patients had no detrusor contraction (Pdet- group) during voiding. There were no significant differences in urodynamic parameters between the Pdet+ and Pdet- groups except in Pdet at Qmax and BCI. In the Pdet- group, 21 patients showed an increase in abdominal pressure during voiding (Pabd+ group), while the other 13 patients did not (Pabd- group). There were no differences in any of the urodynamic parameters between the Pabd+ and Pabd- groups. Based on UDS, an increase in detrusor or abdominal pressure may not be necessary in micturition in women. The present study suggests that relaxation of pelvic floor muscles including normal urethral function are important for micturition in women.

Association of urinary urgency and delay time of micturition in women with overactive bladder.

PurposeAccurately measuring urinary urgency is important for diagnosing overactive bladder (OAB) and quantifying improvements in treatment outcome. Various methods have been recommended for evaluating urinary urgency, but these methods assess individual perceptions and preferences. To overcome the subjectivity in measuring urinary urgency, we evaluated the relationship between uroflowmetric parameters and urinary urgency in women with OAB.MethodsConsecutive female patients with lower urinary tract symptoms (n=110) were prospectively enrolled in this study between April 2011 and September 2012. Individuals with a history of using medications that are known to affect bladder function were excluded. All enrolled patients completed uroflowmetry with a delayed time to voiding (T2V). After urination was completed, patients were asked whether they experienced any urinary hesitancy or urgency at that time.ResultsThe mean patient age was 56.1 years; 70 out of 110 patients reported some degree of urinary urgency. T2V decreased with increased urgency. Several uroflowmetric parameters were observed to have a significant correlation with urinary urgency. T2V had a meaningful correlation coefficient for individuals with urgency, regardless of the voided volume. There was no significant correlation between the presence of urinary hesitancy and T2V.ConclusionsWe believe that T2V would be a complementary tool for diagnosing and determining the degree of urinary urgency in women with OAB.

Functional effect of transient transurethral catheterization on micturition in women: comment

Dear Editor, We would like to congratulate Suskind and Smith on their article on “Evidence of a Functional Effect of Transient Transurethral Catheterization on Micturition in Women,” and we agree with their conclusion, from the only analysis of urodynamic parameters of free uroflow, of the functional effect of transient transurethral catheterization on micturition in women [1]. Our main concern is that results are only based on change in uroflow curve pattern and of Qave value. If the geometric obstructive effect of an in situ catheter is not arguable because of a reduced cross section of the flow, the persistent residual obstructive effect on a free flow, after the catheter has been removed, has been little studied. We think that we can offer some arguments. In a preliminary study [2], we analyzed the effect of a urethral catheter during intubated flow that followed a free uroflow, and we proposed the occurrence of a compression-like effect of the urethra; this would explain a greater decrease in Qmax than expected by the geometric effect of the catheter. More recently [3], using the value–belief–norm (VBN) model for a careful analysis of tracings, we concluded that the cause of this additional effect (observed in 62 % of our population-positive group) was a residual excitation of the sphincter. In addition, the phenomenon (observed during intubated flow) could remain the same (condition observed in 31 % of the positive group) during free uroflow after catheter removal. Thus, as the authors concluded, the transient catheterization has a more complex impact than expected.

Functional effect of transient transurethral catheterization on micturition in women: reply

Dear Editor, We greatly appreciate Drs. Valentini and Nelson’s comments [1] on our article, “Evidence of a Functional Effect of Transient Transurethral Catheterization on Micturition in Women” [2]. Their added insights pertaining to the complex effects of transient catheterizaiton on voiding parameters with regards to their Valentini‐Besson‐Nelson (VBN) model are much respected and appreciated. We agree that our finding that alterations in Qave and not in Qmax are somewhat unexpected. However, this finding reinforces previous observations in animals and humans and further emphasizes that urethral intubation has a more complex impact on micturition than previously shown in clinical models. We feel that this is an interesting finding, with real clinical implications, warranting further clinical investigation.

Evidence of a functional effect of transient transurethral catheterization on micturition in women

The objective of this study is to evaluate the effect of transient catheterization on uroflow parameters. Consenting women (ages 18-90) provided an uninstrumented uroflow pre- and post-indicated in urodynamic procedures. Voided volume, Qmax, and Qave were recorded for both uninstrumented uroflows. Uroflow curves were classified as "normal" or "abnormal." Pre- and post-urodynamic uroflow data were compared. Thirty-five patients were included in the study. There was a statistically significant decrease in Qave from the pre- to the post-urodynamic uroflows from 14.71 to 10.55 ml/s (p = 0.012). Additionally, 28.6% of uroflow tracing patterns changed from "normal" to "abnormal," whereas only one (2.9%) changed from "abnormal" to "normal" (p = 0.031). This study showed a degradative effect of transient catheterization on uroflow parameters, suggesting that catheterization may cause more than simply a passive obstructive effect. Urethral stimulation due to catheterization may perturb detrusor urethral function, altering voiding and possibly filling performance.

The Effect of Asymptomatic Urethral Caruncle on Micturition in Women with Urinary Incontinence

PurposeThe aim of this study was to evaluate the effect of asymptomatic urethral caruncle (UC) on micturition in women suffering from urinary incontinence.Materials and MethodsA total of 232 patients participated in the study. UC was diagnosed in 50 of 232 patients with urinary incontinence during a physical examination in our clinic. All cases were divided into 2 groups: UC combined with urinary incontinence (group 1) and urinary incontinence only (group 2). Urodynamic evaluations were performed according to the International Continence Society standards.ResultsBoth groups were similar in terms of voiding diary, pad test and residual urine volume. Urodynamic studies revealed no significant difference between group 1 and 2 (infravesical obstruction: 6% vs. 4.4%; overactive detrusor: 44% vs. 42.9% respectively). The rates of severe IPSS (37.8% vs. 20.9%) and severe cystocele (20.9% vs. 13.8%) were numerically higher in group 1 with no statistically significant difference.ConclusionsOur results suggest that there is no effect of asymptomatic UC on lower urinary tract symptoms in women with urinary incontinence. Therefore, treating asymptomatic UC is unnecessary in these patients. However, during incontinence surgery, it is the surgeon's decision whether to treat asymptomatic UC.

CORTICAL REPRESENTATION OF THE URGE TO VOID: A FUNCTIONAL MAGNETIC RESONANCE IMAGING STUDY

The urge to void generally increases with bladder distention but the relationship between the 2 factors is complex. When the bladder is moderately filled, the desire to void can be called forth deliberately but it can also be suppressed. To elucidate human brain mechanisms that are active during such intentional modulations of the desire to void we performed functional magnetic resonance imaging in healthy volunteers. Brain activity was studied in 22 young women. At moderate bladder filling (about 350 ml) they periodically suppressed or enhanced the urge to void without allowing urine to pass. A manual task with a dynamometer, in which the current urge to void was expressed as grip force, demonstrated that the intensity of sensations could be influenced voluntarily. We also examined brain activity during repetitive (1 Hz) contractions of pelvic floor muscles after the bladder was emptied. Significant brain activity associated with an increased urge to void was found in the insular cortex, frontal opercula, supplementary motor area (SMA), cingulate motor area (CMA), right posterior parietal cortex, left prefrontal cortex and cerebellum. Trends toward activation were detected in the thalamus, peri-aquaeductal gray matter and ventral pons. Suppression of the urge to void significantly activated the left superior frontal lobe. The SMA and CMA were active during voluntary rhythmical contractions of pelvic floor muscles. Sensation intensity of the desire to void can be influenced intentionally. Frontoparietal cortical areas and the SMA/CMA seem to be involved in this process.

Brain activation during micturition in women.

Experiments in the cat have led to a concept of how the CNS controls micturition. In a previous study this concept was tested in a PET study in male volunteers. It was demonstrated that specific brainstem and forebrain areas are activated during micturition. It was unfortunate that this study did not involve women, because such results are important for understanding urge incontinence, which occurs more frequently in women than in men. Therefore, a similar study was done in 18 right-handed women, who were scanned during the following four conditions: (i) 15 min prior to micturition (urine withholding); (ii) during micturition; (iii) 15 min after micturition; and (iv) 30 min after micturition. Of the 18 volunteers, 10 were able to micturate during scanning and eight were not, despite trying vigorously. Micturition appeared to be associated with significantly increased blood flow in the right dorsal pontine tegmentum and the right inferior frontal gyrus. Decreased blood flow was found in the right anterior cingulate gyrus during urine withholding. The eight volunteers who were not able to micturate during scanning did not show significantly increased regional cerebral blood flow in the right dorsal, but did so in the right ventral pontine tegmentum. In the cat this region controls the motor neurons of the pelvic floor. In the same unsuccessful micturition group, increased blood flow was also found in the right inferior frontal gyrus. In all 18 volunteers, decreased blood flow in the right anterior cingulate gyrus was found during the period when they had to withhold their urine prior to the micturition condition. The results suggest that in women and in men the same specific nuclei exist in the pontine tegmentum responsible for the control of micturition. The results also indicate that the cortical and pontine micturition sites are more active on the right than on the left side.

Nocturnal micturition, sleep and well-being in women of ages 40-64 years.

To study the relationship between sleep and nocturnal micturition in women 40-64 years old. A questionnaire study was carried out in 3669 (6000 invited) randomly selected women in the County of Jämtland in Sweden. Questions were asked about the general state of health, nocturnal micturition, sleep, menstruation and menopausal symptoms, and also about visits to doctors and the use of sleeping pills and hormone preparations. The subjective evaluation of the general state of health and of a feeling of contentedness and of confidence in the future worsened with increasing numbers of nocturnal voiding episodes. Sleep was more strongly correlated to the number of nocturnal voiding episodes (R2 = 0.099; P < 0.0001) than to age (R2 = 0.021; P < 0.0001) or the menopause (R2 = 0.017; P < 0.0001). Daytime sleepiness was three times more common among women with three or more nocturnal voiding episodes than among those with no nocturnal micturition. Women who voided three or more times in the night consulted a doctor twice as frequently as those without nocturnal micturition and were treated with drugs 2.5 times as often. The corresponding figures for sick-listing were 75 and 15 days per year, respectively. Frequent nocturnal micturition is common in 40-64-year-old women and impair sleep with subsequent decrease in daytime performance and general well-being.

Original Articles

We describe a surgical technique to conserve urinary continence in 7 women who underwent radical cystectomy with construction of an orthotopic ileal neobladder for infiltrating bladder carcinoma. The selection of the patients and the surgical procedure to preserve the anatomical and functional integrity of the female urethra are described. Followup ranged from 7 to 28 months. There were no postoperative deaths or serious clinical complications. The urinary continence rate was 100% during the day and 71% at night with micturition at regular 3-hour intervals. The vesical capacity varied from 250 to 400 cc and pressure at maximum capacity from 10 to 25 cm. water. Urinary flow was satisfactory and the urethral pressure profile showed a normal sphincteric mechanism at rest. Two patients died of metastases at 14 and 8 months postoperatively, and 5 are alive and disease-free. We believe that these results confirm the possibility of obtaining micturition in women via the urethra following radical cystectomy.

Original Articles: Bladder Cancer: Orthotopic Ileal Neobladder in Female Patients After Radical Cystectomy: 2-Year Experience

ABSTRACTWe describe a surgical technique to conserve urinary continence in 7 women who underwent radical cystectomy with construction of an orthotopic ileal neobladder for infiltrating bladder carcinoma. The selection of the patients and the surgical procedure to preserve the anatomical and functional integrity of the female urethra are described.Followup ranged from 7 to 28 months. There were no postoperative deaths or serious clinical complications. The urinary continence rate was 100% during the day and 71% at night with micturition at regular 3-hour intervals. The vesical capacity varied from 250 to 400 cc and pressure at maximum capacity from 10 to 25 cm. water. Urinary flow was satisfactory and the urethral pressure profile showed a normal sphincteric mechanism at rest. Two patients died of metastases at 14 and 8 months postoperatively, and 5 are alive and disease-free. We believe that these results confirm the possibility of obtaining micturition in women via the urethra following radical cystectomy.

The vesicocavernosus reflex: Role in the act of micturition

The paper studies the action and clinical significance of a reflex termed ‘vesicocavernosus’ in 24 healthy volunteers (mean age 44.6 years, 15 men and 9 women). A balloon-tipped catheter was introduced into the urinary bladder and inflated with air in increments of 50 ml up to 300 ml. The response of the two cavernosus muscles to rapid vesical inflation and deflation, as well as to interruption and termination of micturition, was displayed on an EMG apparatus. The muscles contracted upon rapid vesical inflation or deflation, and upon the interruption or termination of micturition. These results were reproducible. In the male, bulbocavernosus muscle contraction seems to compress and expel the urine into the bulbous urethra. Ischiocavernosus muscle contraction helps to elevate the penile shaft. The role of the cavernosus muscles at micturition in women is unknown. The vesicocavernosus reflex could be of diagnostic significance in neurologic conditions.

Discussion on Frequency of Micturition in Women

Discussion on Frequency of Micturition in Women