Normal Detrusor Function Research Articles

May coexisting overactive-underactive bladder (COUB) be due to muscle fatigue? Data from a single-centre urodynamic database

The ICI–RS has proposed the definition of COUB (Coexistent Overactive-Underactive Bladder) as a syndrome characterized by voiding and filling LUTS in the same patient. The aim of this study is to explore whether the presence of DO can lead to DU, because of muscle asthenia and fatigue of the smooth muscle cells.Retrospectively, we included all consecutive male patients with LUTS who underwent an invasive UDS (January 2011–December 2022). Patients with neurologic diseases or with previous LUT surgery were excluded. They were divided into normal detrusor function, Group A and Detrusor Overactivity, Group B during the filling phase. BOOI, BCI, PVR and BVE were compared in the two groups. DO patients were divided according to the phasic or terminal DO contractions and mean BCI was calculated in these subgroups.We analysed 425 male patients with LUTS. During filling phase, 167 patients (39.3%, Group A) showed NDF and 258 patients (60.7% Group B) DO. 207 of them (80.2%) had phasic detrusor contractions and 51 (20.8%) had terminal DO. MCC was 409.8 mL and 308.7 mL (p<0.0001), respectively. During the voiding phase, 176 patients (41.4) were obstructed, 100 (23.5%) were equivocal and 149 (35.1%) were not obstructed. 179 patients had a BCI ≤100 and 246 (57.9%) >100. 207 (80.2%) patients of the group B showed phasic, while 51 (19.8%) terminal DO; in these subgroups, mean BCI was 118.8 and 112.0 respectively (p 0.806658).

The Stockholm Spinal Cord Uro Study: 3. Urodynamic characteristics in a regional prevalence group of persons with spinal cord injury and indications for improved follow-up

Aims Examine the outcome of urodynamic studies in a regional prevalence group of patients with traumatic spinal cord injury (SCI), explore relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions, assess the role of urodynamics in SCI follow-up. Methods In a cross-sectional study, 211 patients were included, who attended a yearly check-up and had urodynamics performed as part of the follow-up in addition to S-creatinine, S-cystatin-C, renal ultrasound, and a questionnaire regarding complications. Relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions were explored by descriptive and comparative statistics. Results Neurogenic detrusor overactivity (NDO) was found in 150, underactive/acontractile detrusor in 44, normal detrusor function in 17 patients. Maximum detrusor pressures during filling/voiding in NDO attained mean levels of >40 cm H2O in 68% of patients and >25 cm H2O in 83%. Reduced compliance of the bladder wall, cystometric bladder capacity <250 mL, and detrusor overactivity leakage during filling were associated with higher detrusor pressures. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications among patients with SCI duration 11–20 years. No significant relationships were found between other urodynamic parameters and renal/other SCI-related complications. Renal complications in underactive/acontractile and normal detrusor function co-varied with evidence of previous NDO and other co-morbidities which may negatively influence kidney function. Conclusions Maximum detrusor pressures during the filling/voiding phases attained high levels in a majority of patients. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications.

Repeat retropubic suburethral sling procedure is effective for recurrent female stress urinary incontinence.

The aim of the present study was to investigate the effectiveness of repeat retropubic suburethral sling for recurrent stress urinary incontinence (SUI) in women. A retrospective review was performed of 35 women with SUI who underwent repeat retropubic suburethral sling procedures between May 1994 and November 2014. Treatment outcome was assessed directly or by telephone interview. Sling position and urethral incompetence during straining and coughing after the procedure were evaluated. The overall continence rate after repeat suburethral sling procedures was 60% (21/35). Among the 35 women, 19 underwent a simple retropubic suburethra sling procedure and 16 underwent combined suburethral sling and other pelvic floor surgery; the success rate for these 2 groups was 84.2% (16/19) and 31.3% (5/16; P = .001), respectively. The success rate was 60% in patients with normal detrusor function (n = 18/30) and in those with detrusor underactivity (n = 3/5; P = 1.0). For patients with intrinsic sphincter deficiency and bladder base hypermobility, the success rate was 63.6% (n = 14/22) and 53.8% (n = 7/13), respectively (P = .36). Among the 25 patients with transrectal ultrasound follow-up data, the success rate following placement of the second sling at the bladder neck, proximal urethra, middle urethra, and distal urethra was 50% (2/4), 87.5% (7/8), 36.4% (4/11), and 0% (0/2), respectively (P = .122). Repeat suburethral sling procedures for recurrent SUI are safe and effective. The position of the second sling at the proximal urethra resulted in a relatively higher continence rate relative to other sites.

Incontinencia urinaria de esfuerzo. Fisiopatología de la micción

En resumen, deseamos dejar establecido algunos conceptos básicos de este largo capítulo de la fisiopatología de la I.O.E. en los siguientes términos: Para que la continencia urinaria pueda realizarse en condiciones normales es preciso una normalidad de las estructuras que componen el conjunto anatómico vésico-uretral, y de todo el grupo de músculos, ligamentos y fascias de la región pelvi-perineal. Es fundamental que el sistema nervioso central y el sistema neuro-vegetativo con su normalidad aseguren el normal funcionamiento esfinteriano y del detrusor. Es importante señalar que en el deterioro de la continencia urinaria interviene el traumatismo obstétrico favoreciendo la dislocación de la uretra, su alejamiento del pubis, y la aparición del prolapso víscero-pélvico en sus distintos grados. Que el factor trófico vinculado a la edad de la paciente e influido por insuficiencias hormonales puede ser una causa favorecedora en la aparición del trastorno. Que debe concedérsele importancia como factor predisponente a las alteraciones del ángulo sub-pubiano. Que es muy importante la existencia de una presión intrauretral mayor que la intravesical, y un largo adecuado de la uretra. Que debe destacarse la importancia del descenso anormal del sector proximal de la uretra que debe ser normalmente intraabdominal y su embudización fuera del esfuerzo. Que a los efectos de la salida anormal de la orina reviste importancia que el orificio uretral esté situado por delante del punto de máxima presión hidrostática.

Effects of intravesical electrical stimulation therapy on urodynamic patterns for children with spina bifida: A 10-year experience

ObjectiveIntravesical electrical stimulation (IVES) has been performed for various purposes in children with a neurogenic bladder. We evaluated the results of IVES on urodynamic study parameters in children with spina bifida. MethodsWe retrospectively analyzed the cases of 88 children who received IVES between August 1999 and May 2010 and whose comparative urodynamic data were available before and after treatment. According to the pre-IVES urodynamic study, children were divided into 3 groups: detrusor overactivity, detrusor underactivity and acontractile detrusor. We investigated the changes in detrusor function, bladder capacity and detrusor-sphincter dyssynergia. ResultsIn the group showing detrusor overactivity, the bladder had a synergic pattern in 41.7%, and normal detrusor function was observed in 16.7% of them. Bladder capacity increased after IVES therapy, especially in those who started therapy before 18 months of age (p = 0.019). Detrusor-sphincter dyssynergia was resolved in 55.6%. In the acontractile detrusor group, detrusor contraction ability increased in 48%, but bladder capacity did not. ConclusionsAppropriate candidates for this treatment need to be carefully selected.

Sensory Dysfunction of Bladder Mucosa and Bladder Oversensitivity in a Rat Model of Metabolic Syndrome

PurposeTo study the role of sensory dysfunction of bladder mucosa in bladder oversensitivity of rats with metabolic syndrome.Materials and MethodsFemale Wistar rats were fed a fructose-rich diet (60%) or a normal diet for 3 months. Based on cystometry, the fructose-fed rats (FFRs) were divided into a group with normal detrusor function or detrusor overactivity (DO). Acidic adenosine triphosphate (ATP) solution (5mM, pH 3.3) was used to elicit reflex micturition. Cystometric parameters were evaluated before and after drug administration. Functional proteins of the bladder mucosa were assessed by western blotting.ResultsCompared to the controls, intravesical acidic ATP solution instillation induced a significant increase in provoked phasic contractions in both FFR groups and a significant decrease in the mean functional bladder capacity of group DO. Pretreatment with capsaicin for C-fiber desentization, intravesical liposome for mucosal protection, or intravenous pyridoxal 5-phosphate 6-azophenyl-2′,4′-disulfonic acid for antagonized purinergic receptors can interfere with the urodynamic effects of intravesical ATP in FFRs and controls. Over-expression of TRPV1, P2X3, and iNOS proteins, and down-regulation of eNOS proteins were observed in the bladder mucosa of both fructose-fed groups.ConclusionsAlterations of sensory receptors and enzymes in the bladder mucosa, including over-expression of TRPV1, P2X3, and iNOS proteins, can precipitate the emergence of bladder phasic contractions and oversensitivity through the activation of C-afferents during acidic ATP solution stimulation in FFRs. The down-regulation of eNOS protein in the bladder mucosa of FFRs may lead to a failure to suppress bladder oversensitivity and phasic contractions. Sensory dysfunction of bladder mucosa and DO causing by metabolic syndrome are easier to elicit bladder oversensitivity to certain urothelium stimuli.

121 UROTHELIAL DYSFUNCTION AND BLADDER OVERSENSITIVITY IN A RAT MODEL OF METABOLIC SYNDROME

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Basic Research II1 Apr 2012121 UROTHELIAL DYSFUNCTION AND BLADDER OVERSENSITIVITY IN A RAT MODEL OF METABOLIC SYNDROME Wei-Chia Lee and Yao-Chi Chuang Wei-Chia LeeWei-Chia Lee Kaohsiung, Taiwan More articles by this author and Yao-Chi ChuangYao-Chi Chuang Kaohsiung, Taiwan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.169AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We studied the role of urothelial dysfunction on bladder oversensitivity in rats with metabolic syndrome. METHODS Female Wistar rats were fed a fructose-rich diet (60%) or a normal diet for 3 months. Based on cystometry, the fructose-fed rats (FFRs) were divided into a group with normal detrusor function or detrusor overactivity (DO). Acidic adenosine triphosphate (ATP) solution (5mM, pH 3.3) was used to elicit reflex micturition. Cystometric parameters were evaluated before and after drug administration. Functional proteins of the urothelium were assessed by western blotting. RESULTS Compared to the controls, intravesical acidic ATP solution instillation induced a significant increase in provoked phasic contractions in both FFR groups and a significant decrease in the mean bladder capacity of group DO. Pretreatment with capsaicin for C-fiber desentization, intravesical liposome for mucosal protection, or intravenous pyridoxal 5-phosphate 6-azophenyl-2ꜟ,4ꜟ-disulfonic acid for antagonized purinergic receptors can interfere with the urodynamic effects of intravesical ATP in FFRs and controls. Over-expression of TRPV1, P2X3, and iNOS proteins, and down-regulation of eNOS proteins were observed in the urothelium of both fructose-fed groups. CONCLUSIONS Urothelial dysfunction, including over-expression of TRPV1, P2X3, and iNOS proteins, can precipitate the emergence of bladder phasic contractions and oversensitivity through the activation of C-afferents during acidic ATP solution stimulation in FFRs. The down-regulation of eNOS protein in the urothelium of FFRs may lead to a failure to suppress bladder oversensitivity and phasic contractions. Urothelial dysfunction and DO causing by metabolic syndrome are easier to elicit bladder oversensitivity to certain urothelium stimuli. Table 1. Comparisons of general characteristics, biochemistry variables, and cystometric parameters among controls and FFRs. Controls FFRs with NDF FFRs with DO (n=12) (n=12) (n=12) General characteristics Body weight (g) 276.4±6.6 295.6±13.3 290.1±8.9 Bladder weight (mg) 111.6±3.8 105.2±5.2 114.8±3.9 Waist circumference (cm) 16.9±0.22 17.4±0.27 18.2±0.27⁎ Systolic pressure (mmHg) 123.6±4.1 150.1±4.6⁎ 153.1±6.3⁎ Water intake 31.3±2.49 34.9±2.35 32.9±1.79 Urine output (ml/ 24hrs) 26.6±2.2 31.2±2.1 29±2.6 Biochemistry parameters (fasting values) Triglycerides (mg/dl) 34.3±2.5 86.1±4.8⁎ 81.3±6.9⁎ Cholesterol (mg/dl) 45.7±2.3 66.6±3.4⁎ 64.8±3.5⁎ Glucose (mM) 6.6±0.19 7.3±0.39 7.0±0.28 Insulin (mU/l) 13.9±0.69 24.2±1.94⁎ 22.2±1.71⁎ †HOMA-IR 4.1±0.27 7.7±0.65⁎ 6.9±0.53⁎ Cystometry parameters Before treatment Voiding pressure (mmHg) 21.5±0.9 21.8±1.2 25.0±1.1 Bladder capacity (ml) 1.19±0.04 1.17±0.03 0.95±0.06⁎ After 5mM ATP instillation Voiding pressure (mmHg) 22.3±1.1 23.1±1.2 27.7±1.4⁎ Voiding pressure increase (mmHg) 0.78±0.49 1.27±0.54 2.74±0.46⁎ Bladder capacity (ml) 0.89±0.08 0.79±0.04 0.52±0.04⁎ Lessened bladder capacity (%) 26.0±4.6 32.9±2 46.2±2.1⁎ No. provoked phasic contraction (> 15 cmH2O) per void 0.9±0.21 3.3±0.4⁎ 2.1±0.27⁎ Immunofluorescence stain of the bladder Nerve fiber density of suburothelium (Number per cross-section of bladder base) 537.7±36.2 489.5±40.4 578.5±31.4 Data presented as mean ± SEM and tested among groups using one-way ANOVA with Dunnett's test. ⁎ The Dunnett's test showed a significant difference between the control group and other groups. † Homeostasis model assessment of insulin resistance (HOMA-IR) =fasting plasma insulin (μU/ml) × fasting plasma glucose (mmol/l)/22.5. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e49-e50 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wei-Chia Lee Kaohsiung, Taiwan More articles by this author Yao-Chi Chuang Kaohsiung, Taiwan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pathophysiological Studies of Overactive Bladder and Bladder Motor Dysfunction in a Rat Model of Metabolic Syndrome

We studied bladder motor dysfunction and searched for markers of neurogenic and myogenic alterations among fructose fed rats with or without abnormal voiding behavior. Female Wistar rats were fed with a fructose rich diet (60%) or a normal diet for 6 months. Based on cystometry and voiding behavior the fructose fed rats were divided into 3 groups, including a group with normal detrusor function with normal micturition frequency, a group with detrusor overactivity with increased micturition frequency and a group with acontractile detrusor with increased micturition frequency. Denuded bladder tissues were obtained to assess in vitro detrusor contractility, postsynaptic receptors, smoothelin, nitrosative products and the intrinsic pathway of apoptosis. Fructose fed rats with abnormal voiding behavior had obvious neurogenic and myogenic alterations, including increased expression of postsynaptic receptors, dysregulation of smoothelin and decreased expression of Bcl-2 with a subsequent increase in apoptotic cells in the bladder stroma, causing decreased carbachol induced contractility. Rats with detrusor overactivity were also insulted by nitrosative stress associated with nitrotyrosine up-regulation in the bladder tissue. Up-regulation of M(2) and M(3)-muscarinic receptors, and P2X(1) receptors appeared to be generalized alterations of fructose fed rats and not exclusive to those with detrusor overactivity. Up-regulation of postsynaptic receptors and dysregulation of smoothelin contribute to overactive bladder symptoms in rats with metabolic syndrome. Nitrosative stress and decreased Bcl-2 expression lead to bladder muscle cell loss via the intrinsic pathway of apoptosis, which may further deteriorate bladder function.

Idiopathic Parkinson's disease patients at the urologic clinic

To quantitatively evaluate the urinary symptoms at different stages of idiopathic Parkinson's disease (IPD) severity and its relation to urodynamic parameters. This study was conducted on 49 patients with probable IPD to quantitatively evaluate their urinary symptoms using International Prostate Symptom Score and urodynamic tests. Four, 10, 29, 5, and 1 cases were classified as stages 1-5, respectively, according to Hoehn and Yahr staging of IPD severity. The most prevailing urinary symptom in IPD was nocturia (77.5%) followed by urgency (36.7%) and frequency (32.6%). Urodynamic tests revealed neurogenic detrusor overactivity in 33 patients (67.3%), detrusor underactivity in 6 patients (12.2%), and 10 (20.4%) patients with normal detrusor function. Irritative symptom index score correlated significantly with disease severity as well as the volume at initial desire to void and maximum bladder capacity meanwhile obstructive symptom index score had no significant correlation with any of the urodynamic parameters or disease severity. Total IPSS symptoms score significantly correlated with quality of life score. The mean of urodynamic parameters did not differ in IPD patients who did or did not receive anticholinergic or dopaminergic drugs. The irritative urinary symptoms manifested urodynamically as neurogenic detrusor overactivity are more common in IPD patients than obstructive symptoms. These irritative symptoms deteriorate progressively with the disease severity and significantly affect the quality of life of these patients. The International Prostate Symptom Score is a valuable tool in evaluating the urinary dysfunction in such patients.

Cerebral control of bladder storage in patients with detrusor overactivity

To identify the brain areas that control bladder storage by technetium-99m hexamethylpropyleneamine oxime single-photon emission computed tomography (SPECT) with the Neurological Statistical Image Analysis software (NEUROSTAT) in patients with detrusor overactivity (DO). SPECT scans were performed on 19 patients with DO. Eight patients with normal detrusor function, who had some storage symptoms of the lower urinary tract as the patients with DO, also had a SPECT scan, as controls. All the patients were male and right handed, and were scanned twice under two conditions: resting state and urine withholding state. NEUROSTAT was adopted to analyze the difference in brain--blood perfusion between groups and states. The results were displayed on Z score images at a significance threshold of P value of less than 0.05 with correction for multiple comparisons. No region reached the significant threshold in comparison with patients with DO and normal detrusor function in resting state. Significant increases in tracer activity in the right inferior frontal gyrus and the right middle temporal gyrus during urine withholding state as compared with resting state in patients with normal detrusor function were observed. Among the regions, the right inferior frontal gyrus was distinctly prominent at both Z score and the extent. The regions that were significantly activated in patients with normal detrusor function did not reach a significant threshold during urine withholding in patients with DO. The study indicated that the right inferior frontal gyrus and the right middle temporal gyrus, especially the right inferior frontal gyrus, played a role in the cerebral control of bladder storage, inhibiting the contraction of detrusor in urine storage.

Investigation of Urodynamic Characteristics and Bladder Sensory Function in the Early Stages of Diabetic Bladder Dysfunction in Women With Type 2 Diabetes

We studied urodynamic characteristics and bladder sensory function in the early stages of diabetic bladder dysfunction in diabetic women. A total of 86 consecutive type 2 diabetic women with minimal confounders of voiding dysfunction followed at a diabetes clinic were prospectively enrolled and subjected to urodynamic studies. The sensory response of Adelta and C fibers of the bladder was measured by intravesical current perception threshold testing at frequencies of 250 and 5 Hz, respectively. Of these 86 women 30 (34.9%) were classified as having detrusor underactivity, 12 (14.0%) presented signs of detrusor overactivity, 11 (12.8%) were referred to as having bladder outlet obstruction and 33 (38.4%) showed normal detrusor function on urodynamics. The normal detrusor function group was the reference group. The detrusor underactivity group showed impaired emptying function and decreased sensation on cystometry and intravesical current perception threshold testing. The detrusor overactivity group showed impaired storage and emptying function but had no significant changes in intravesical current perception threshold values. When the normal detrusor function group and detrusor underactivity group were pooled to perform multivariate analysis, an increase in current perception threshold values was associated with a decrease in bladder voiding efficiency on 5 and 250 Hz current perception threshold testing. Our data provide the electrophysiological evidence that indicates an association between impaired Adelta as well as C fiber bladder afferent pathways and poor emptying function in diabetic women with detrusor underactivity. Diabetes can affect the bladder presumably via peripheral pathogenetic mechanisms to induce detrusor overactivity with impaired contractility.

Urodynamic analysis of the chronic impairment of cauda equina caused by lumbar disk herniation

To evaluate the urodynamic characteristics of the chronic impairment of cauda equina caused by lumbar disk herniation. Clinical data and urodynamic parameters of 67 male patients with lumbar disk herniation were retrospectively analyzed. Lower urinary obstruction was excluded from the cohort using the Lin-PURR analysis. Patients were divided into group A (normal detrusor function), group B (detrusor underactivity) and group C (detrusor areflexia) according to the detrusor contraction function analyzed in Lin-PURR. Clinical data and urodynamic parameters were analyzed statistically between these groups. The category of the detrusor contraction function had a significant effect on the urodynamic parameters. There were significant differences in the maximum flow rate (Q(max)), maximum pressure (P(max)), pressure at the maximum flow (P(det Qmax)) and post-voiding residual urine (PVR) among group A, B and C. There were significant differences in the first sensation volume of the bladder and the maximum cystometric capacity between group A and C, B and C, but no significance was found between group A and B. There was no significant difference in age, disease duration, and compliance of the bladder among 3 groups. Urodynamic study is important in exploring the severity of the chronic impairment of cauda equina caused by lumbar disk herniation. Detrusor areflexia and loss of bladder sensory indicate more severe degree of impairment of the cauda equine. Q(max) and PVR are helpful in early diagnosis of the chronic impairment of cauda equina.

Effect of detrusor function on the therapeutic outcome of a suburethral sling procedure using a polypropylene sling for stress urinary incontinence in women

To assess the effect of detrusor function on the therapeutic outcome of a suburethral sling procedure in women with stress urinary incontinence (SUI). A total of 192 women with SUI who had undergone a suburethral sling procedure were enrolled. According to the baseline urodynamic results, patients' bladder functions were classified as follows: (i) normal detrusor function; (ii) detrusor overactivity; and (iii) detrusor underactivity or acontractile detrusor. Surgical results, urodynamic parameters and patient satisfaction were compared among these three groups. Overall, 106 patients had normal detrusor function, 36 had detrusor overactivity and 50 had detrusor underactivity or an acontractile detrusor. A continent outcome was achieved in 135 women (70.3%), urge incontinence in 23 (12%), minimal SUI in 32 (16.7%) and moderate SUI in two (1%). Persistent urge incontinence was noted in 13 women (36%) with detrusor overactivity, and recurrent SUI occurred in 18 women (36%) with detrusor underactivity or an acontractile detrusor. No significant change in urodynamic parameters between baseline and after treatment was found in any of the patient groups. The satisfaction rate was 98.1% in patients with normal detrusor function, 82% in patients with detrusor underactivity or an acontractile detrusor and 75% in patients with detrusor overactivity (p<0.05). Compared to women with normal detrusor function, those with preoperative detrusor overactivity and those with detrusor underactivity or an acontractile detrusor experienced an unfavorable therapeutic outcome of the suburethral sling procedure in terms of urge incontinence and recurrent SUI after surgery.

Recovery of Detrusor Function After Urethral Botulinum A Toxin Injection in Patients with Idiopathic Low Detrusor Contractility and Voiding Dysfunction

To investigate the effect of urethral botulinum A toxin (BoNT-A) injection on idiopathic low detrusor contractility and the correlation of this effect with baseline urodynamic parameters. Twenty-seven patients with idiopathic low detrusor contractility received urethral injection of BoNT-A. Videourodynamic studies were performed at baseline and after treatment. Recovery of detrusor contractility was defined as an increase in detrusor pressure and maximal flow rate and reduced postvoid residual urine volume. The therapeutic results and changes in urodynamic parameters were compared between patients with and without recovery of detrusor contractility. The recovery of detrusor contractility after urethral BoNT-A injection occurred in 13 patients (48%). Patients with recovery of detrusor contractility had baseline data characterized by normal bladder sensation during bladder filling combined with a poor relaxation or hyperactive urethral sphincter activity. In contrast, patients without recovery of detrusor contractility had poor bladder sensation and a nonrelaxing urethral sphincter. Patients with baseline characteristics of low detrusor contractility combined with poorly relaxed or hyperactive urethral sphincter activity had better results than those with true detrusor underactivity. Of the 13 patients with recovery of detrusor contractility, 5 had a long-term therapeutic effect without the need of repeat urethral injection of BoNT-A for more than 1 year of follow-up. Patients with detrusor underactivity with normal bladder sensation combined with a poor relaxation or hyperactive urethral sphincter were significantly more likely to recover normal detrusor function. Neuromodulation of the hyperactive urethral sphincter by urethral BoNT-A is the likely mechanism for this therapeutic effect.

The correlation between urodynamics and morphology in men with benign prostatic hyperplasia

We have the impression that the degree of obstruction was stronger in the patients with a middle lobe of hyperplastic nodule than in those without such a lobe in patients with benign prostatic hyperplasia. In the present study, we compared the data from a pressure-flow study (PFS) and a presence of a middle lobe. A transurethral resection for benign prostatic hyperplasia was performed in 2,439 patients, 798 underwent PFS. The PFS findings and the presence of a middle lobe were compared with the following parameters, namely, the bladder detrusor function, the degree of obstruction, the post-voided residual volume, the maximum flow rate, the prostate volume and the resected volume. In the pressure-flow study, the rate of the normal bladder detrusor function was higher in the patients with a middle lobe than in those without such a lobe (71.9 versus 53.3%). The degree of obstruction was also stronger in the patients with a middle lobe than in those without in the patients with a normal bladder detrusor function (89.0 versus 79.4%). Then in the patients with a middle lobe, the quantity of the post-voided residual volume was greater, however, the maximum flow rate was lower. Most patients with a middle lobe demonstrate an improved voiding ability after underwent a transurethral resection.

Day-care ultrasound avoids urodynamics.

Post-voiding residual urine is a common problem underlying urinary symptoms in many children often associated with infection. Tertiary referral is often made to exclude a neurological aetiology. This review reports the experience of clinician-performed ultrasound examinations in the Day-Care Unit on 50 children during a 9-month period, with various aetiologies of urinary incontinence avoiding urodynamic studies in 34. From March 1999 tertiary referral patients with urinary incontinence with or without infection and secondary referrals not responding to 'standard' management regimes, underwent clinician-performed bladder ultrasound scans in the day-care ward. A standard renal tract ultrasound examination had been reported as normal in 19 patients. In general referral had been made to exclude a neuropathic aetiology. In addition 5 patients were studied who were known to have a neurogenic bladder, 3 with an anorectal anomaly, 3 were post cystoplasty and 2 had undergone surgery for ureteric reflux. In 34 patients it was considered that a urodynamic study had been avoided, while in one results from a urodynamic study were refuted. By means of directly visualising the bladder on real time scanning, 12 children and families achieved a significantly better understanding of the relevance of residual urine in relation to symptoms, or were shown to have normal detrusor function (7), excluding a neuropathic aetiology. The three who had undergone cystoplasty were shown to have adequate bladder volumes in spite of persisting wetness. Real-time ultrasound examination of the bladder performed by a clinician in a patient-friendly environment (day-care ward) can provide significant information regarding detrusor function, often avoiding urodynamic studies. The test does not replace formal scanning for anomalies but may provide information that is masked by the more rigid environment of a radiology department, sometimes correcting results from standard urodynamic studies.

NORMAL URODYNAMICS IN PATIENTS WITH BLADDER EXSTROPHY: ARE THEY ACHIEVABLE?

Purpose Urodynamic study was performed in patients with exstrophy to determine the effect of bladder neck reconstruction and the ability to achieve normal urodynamics following surgery. Materials and Methods A total of 30 exstrophy cases at different stages of reconstruction were retrospectively reviewed in terms of bladder capacity, compliance, stability and presence of detrusor contractions following urodynamic study. Results Bladder capacity increased from a third predicted volume for age to half after reconstruction. Approximately 80% of patients had compliant and stable bladders before bladder neck reconstruction. Following bladder neck reconstruction approximately half of the patients maintained normal compliance with a smaller number maintaining normal stability. A quarter of patients maintained normal filling dynamics following bladder neck reconstruction, and 19% maintained normal filling and voiding dynamics after reconstruction. Conclusions The majority of closed exstrophy bladder have normal filling dynamics before bladder neck reconstruction. Compliance and stability are impaired following bladder neck reconstruction. Approximately 25% of patients with exstrophy may maintain normal detrusor function following reconstruction. However, less invasive alternatives to the Young-Dees-Leadbetter bladder neck reconstruction should be sought.

Early predictors of bladder recovery and urodynamics after spinal cord injury.

Our purpose was to determine if intact perianal (S4-5) pin sensation (PPS) and bulbocavernosus (S2-4) reflex (BCR) shortly after spinal cord injury (SCI) are predictive of bladder function recovery. Twenty-eight SCI patients (aged 18-68 years, Frankel Classification A-D, spinal injury level C4-T12), admitted within 72 hours of injury, underwent evaluation of initial PPS and BCR. The presence of intact PPS and BCR were correlated with the patient's voiding function and urodynamic evaluation results 1 year postinjury. Of the 28 patients within 72 hours of SCI, PPS was intact in 17 (60%) and absent in 11(40%), while 15 patients (54%) demonstrated a positive BCR and 13 (46%) did not. One year after SCI, no patient with absent PPS voided unassisted, while of the 17 patients with preserved PPS, 11 (65%) were voiding spontaneously. Of these 11 patients, urodynamic evaluation revealed detrusor areflexia in 1 (9%), normal detrusor function in 2 (18%), and detrusor hyperreflexia in 8 (73%), with 3 of these 8 patients (38%) also demonstrating detrusor-sphincter dyssynergia. At 1 year postinjury, only 2 of 13 patients (15%) with an absent BCR voided spontaneously, while 9 of 15 patients (60%) with an intact BCR were able to void. Although PPS and BCR are moderately sensitive in predicting the return of spontaneous voiding, they cannot predict detrusor hyperreflexia and sphincter dyssynergia. Therefore, urodynamic study remains an essential component of initial urologic evaluation after SCI.

Urodynamic Changes after Endoscopic Correction of Vesicoureteral Reflux

Massive bilateral vesicoureteral reflux (VUR) in a 7-year-old girl with spinal scoliosis was successfully treated by endoscopic correction. She was admitted due to a febrile urinary tract infection and urinary incontinence. A cystometrogram demonstrated normal detrusor function during storage. The endoscopic subureteric injection of polytetrafluoroethylene (Teflon) was performed, resulting in the disappearance of the VUR. A postoperative cystometrogram demonstrated overactive detrusor function during storage, necessitating anticholinergic medication. She has been free of febrile urinary tract infections and incontinence for 2 years postoperatively, although self-catheterization is necessary. In a case of neurogenic vesical dysfunction with massive reflux, endoscopic subureteric injection is not only a therapeutic tool, but also a useful diagnostic option for detecting occult detrusor overactivity during storage prior to open surgery.

URODYNAMIC EFFECTS OF INTRAVESICAL RESINIFERATOXIN IN HUMANS: PRELIMINARY RESULTS IN STABLE AND UNSTABLE DETRUSOR

Purpose Resiniferatoxin, a substance isolated from some species of euphorbia, a cactus-like plant, presents pharmacological effects similar to those of capsaicin. We studied the urodynamic effects of intravesical resiniferatoxin * * RBI Research Biochemicals International, Natick, Massachusetts. in normal subjects and patients with unstable detrusor contraction to provide insight into the action mechanism of the molecule on sensory neurons and possible future pharmacological and clinical use. Materials and Methods A total of 15 subjects with normal (8 patients) or unstable detrusor muscle (1 with detrusor instability and 6 with detrusor hyperreflexia) underwent urodynamic assessment during and after intravesical instillation of resiniferatoxin. Volume required to elicit the first desire to void, maximum bladder capacity and maximum bladder pressure were recorded during instillation of resiniferatoxin at a flow rate of 20 ml. per minute (normal subjects) or 15 minutes after instillation of 30 cc of a saline solution containing 10 sup −8 M. of resiniferatoxin and kept for 30 minutes in patients with unstable detrusor. The experiment was examined by the analysis of variance for repeated measures and post hoc comparisons were performed by Tukey-Kramer procedure. A p value <0.05 was accepted as significant. Results Resiniferatoxin did not decrease the volume required to elicit the first desire to void and did not produce warm or burning sensations at the suprapubic/urethral level during infusion in subjects with normal detrusor function. In patients with bladder hyperactivity mean bladder capacity increased from 175.28 ml. plus or minus standard deviation 36.05 to 280.85 ml. plus or minus standard deviation 93.33 (p <0.01) immediately after treatment, and no significant modification of bladder pressure was recorded. Four weeks after treatment, bladder capacity remained increased in 2 patients but mean capacity did not increase significantly from 175.28 ml. plus or minus standard deviation 36.053 to 216.71 plus or minus standard deviation 86.91. The 2 patients with stable increase of bladder capacity reported significant clinical improvement of frequency, nocturia and incontinence 4 weeks later. Conclusions Our results suggest that in humans there may be substantial differences in urodynamic effects between resiniferatoxin and capsaicin when the drugs are instilled into the bladder. Further studies, in vitro and in vivo, are necessary to define the pharmacological and clinical effects of resiniferatoxin. Because resiniferatoxin did not produce warm or burning sensations at the suprapubic/urethral level during infusion and seems to have rapid desensitization, it could be an interesting alternative to intravesical capsaicin in the treatment of select cases of bladder hyperactivity.