Pelvic Floor Electromyography Research Articles

The effects of multidisciplinary rehabilitation: RePCa—a randomised study among primary prostate cancer patients

Background:The objective of this study is the effectiveness of multidisciplinary rehabilitation on treatment-related adverse effects after completed radiotherapy in patients with prostate cancer (PCa).Methods:In a single-centre oncology unit in Odense, Denmark, 161 PCa patients treated with radiotherapy and androgen deprivation therapy were randomly assigned to either a programme of two nursing counselling sessions and two instructive sessions with a physical therapist (n=79) or to usual care (n=82). Primary outcome was Expanded Prostate Cancer Index Composite (EPIC-26) urinary irritative sum-score.Before radiotherapy, pre-intervention 4 weeks after radiotherapy, and after a 20-week intervention, measurements included self-reported disease-specific quality of life (QoL; EPIC-26, including urinary, bowel, sexual, and hormonal symptoms), general QoL (Short-form-12, SF-12), pelvic floor muscle strength (Modified Oxford Scale), and pelvic floor electromyography. Intension-to-treat analyses were made with adjusted linear regression.Results:The intervention improved, as compared with controls, urinary irritative sum-score 5.8 point (Cohen's d=0.40; P=0.011), urinary sum-score (d=0.34; P=0.023), hormonal sum-score (d=0.19; P=0.018), and the SF-12 Physical Component Summary, d=0.35; P=0.002. Patients with more severe impairment gained most. Pelvic floor muscle strength measured by electromyography declined in both groups, P=0.0001.Conclusion:Multidisciplinary rehabilitation in irradiated PCa patients improved urinary and hormonal symptoms, and SF-12 physical QoL.

Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial

Intra-vaginal diazepam suppositories are commonly prescribed as a treatment option for high-tone pelvic floor myalgia. This triple-blinded placebo-controlled randomized trial sought to determine if 10 mg diazepam suppositories improve resting pelvic floor electromyography (EMG) compared with placebo. Women ≥18 years of age with hypertonic pelvic floor muscles on examination, confirmed by resting EMG ≥2.0 microvolts (μv), administered vaginal suppositories containing either diazepam or placebo for 28 consecutive nights. Outcomes included vaginal surface EMG (four measurements), the Female Sexual Function Index (FSFI), the Short Form Health Survey 12 (SF-12), four visual analog scales (VAS), the Patient Global Impression of Severity (PGI-S), and the Patient Global Impression of Improvement (PGI-I). A priori sample size calculation indicated that 7 subjects in each group could detect a 2-μv difference in resting EMG tone with 90% power. Twenty-one subjects were enrolled. The mean age was 36.1 (SD 13.9) years, mean body mass index was 28.56 (SD 9.4), and the majority (85.7%) was Caucasian. When evaluating response to therapy, no difference was seen in any of the resting vaginal EMG assessments at any time point within subjects or between groups, nor was an interaction found. Additionally, no differences were noted in any of the validated questionnaires. When used nightly over 4 weeks, 10 mg of vaginal diazepam was not associated with improvement in resting EMG parameters or subjective outcomes compared with placebo. This suggests such that therapy alone may be insufficient in treating high-tone pelvic floor dysfunction.

Pelvic floor muscle training program increases muscular contractility during first pregnancy and postpartum: Electromyographic study

The aim of this study was to evaluate the effect of a training program over both pelvic floor muscles contractility and urinary symptoms in primigravid pregnant and postpartum primiparous women. A clinical, prospective and blinded trial was conducted with 33 women divided into three groups: (G1) 13 primigravid pregnant women; (G2) 10 postpartum primiparous women (49.3 ± 5.84 days), after vaginal delivery with right mediolateral episiotomy; (G3) 10 postpartum primiparous women (46.3 ± 3.6 days), after cesarean section delivery. The evaluation was carried out using digital palpation (Modified Oxford Grading Scale), pelvic floor electromyography and, for the investigation of urinary symptoms, validated questionnaires (International Consultation on Incontinence Questionnaire-short form-ICIQ-UI SF and International Consultation on Incontinence Questionnaire Overactive Bladder-ICIQ-OAB). The protocol consisted of 10 individual sessions carried out by the physiotherapist through home visits, three times a week, with 60 min duration each. The statistical analysis was performed using ANOVA and Spearman's correlation coefficient. The pelvic floor muscle contractility increased after the training program (P = 0.0001) for all groups. Decreases in the scores of both ICIQ-UI SF (P = 0.009) and ICIQ-OAB (P = 0.0003) were also observed after training. Pelvic floor muscle training is an effective means for the increase in its own contractility in both primigravid pregnant and primiparous postpartum women, accompanied with a concomitant decrease in urinary symptoms.

External Urethral Sphincter Pressure Measurement: An Accurate Method for the Diagnosis of Detrusor External Sphincter Dyssynergia?

BackgroundCombined pelvic floor electromyography (EMG) and videocystourethrography (VCUG) during urodynamic investigation are the most acceptable and widely agreed methods for diagnosing detrusor external sphincter dyssynergia (DESD). Theoretically, external urethral sphincter pressure (EUSP) measurement would provide enough information for the diagnosis of DESD and could simplify the urodynamic investigation replacing combined pelvic floor EMG and VCUG. Thus, we evaluated the diagnostic accuracy of EUSP measurement for DESD.Patients & MethodsA consecutive series of 72 patients (36 women, 36 men) with neurogenic lower urinary tract dysfunction able to void spontaneously was prospectively evaluated at a single university spinal cord injury center. Diagnosis of DESD using EUSP measurement (index test) versus combined pelvic floor EMG and VCUG (reference standard) was assessed according to the recommendations of the Standards for Reporting of Diagnostic Accuracy Initiative.ResultsUsing EUSP measurement (index test) and combined pelvic floor EMG and VCUR (reference standard), DESD was diagnosed in 10 (14%) and in 41 (57%) patients, respectively. More than half of the patients presented discordant diagnosis between the index test and the reference standard. Among 41 patients with DESD diagnosed by combined pelvic floor EMG and VCUR, EUSP measurement identified only 6 patients. EUSP measurement had a sensitivity of 15% (95% CI 5%–25%), specificity of 87% (95% CI 76%–98%), positive predictive value of 60% (95% CI 30%–90%), and negative predictive value of 56% (95% CI 44%–68%) for the diagnosis of DESD.ConclusionsFor diagnosis of DESD, EUSP measurement is inaccurate and cannot replace combined pelvic floor EMG and VCUR.

Can Staccato and Interrupted/Fractionated Uroflow Patterns Alone Correctly Identify the Underlying Lower Urinary Tract Condition?

Worldwide, uroflowmetry without simultaneous electromyography is often the only testing performed during the initial assessment of children with lower urinary tract symptoms. Various alterations in uroflow pattern are thought to indicate particular types of lower urinary tract conditions, specifically staccato uroflow indicating dysfunctional voiding and intermittent/fractionated uroflow indicating detrusor underactivity. We determined how reliable uroflow pattern alone is as a surrogate for simultaneously measured pelvic floor electromyography activity during voiding, and how well staccato and interrupted uroflow actually correlate with the diagnoses they are presumed to represent. We reviewed uroflow/electromyography studies performed during the initial evaluation of 388 consecutive neurologically and anatomically normal patients with persistent lower urinary tract symptoms. We identified those with staccato, interrupted/fractionated and mixed uroflow based on current International Children's Continence Society guidelines. A total of 69 girls (58.5%) and 49 boys (41.5%) met inclusion criteria. Staccato uroflow was noted in 60 patients, interrupted/fractionated uroflow in 28 and a combination in 30. An active electromyography during voiding confirmed the diagnosis of dysfunctional voiding in 33.3% of patients with staccato, 46.4% with interrupted/fractionated and 50% with mixed uroflow patterns. Diagnoses based on uroflow pattern appearance without simultaneous electromyography to support them can be misleading, and reliance on uroflow pattern alone can lead to overdiagnoses of dysfunctional voiding and detrusor underactivity. When assessing patients with uroflow, an accompanying simultaneous pelvic floor electromyography is of utmost importance for improving diagnostic accuracy and thereby allowing for the most appropriate therapy.

Simplifying the Diagnosis of 4 Common Voiding Conditions Using Uroflow/Electromyography, Electromyography Lag Time and Voiding History

Noninvasive uroflowmetry with simultaneous electromyography is useful to triage cases of lower urinary tract symptoms into 4 urodynamically defined conditions, especially when incorporating short and long electromyography lag times in the analysis. We determined the prevalence of these 4 conditions at a single referral institution and the usefulness of uroflowmetry with simultaneous electromyography and electromyography lag time to confirm the diagnosis, guide treatment and monitor response. We retrospectively reviewed the records of 100 consecutive normal children who presented with persistent lower urinary tract symptoms, underwent uroflowmetry with electromyography as part of the initial evaluation and were diagnosed with 1 of 4 conditions based on certain uroflowmetry/electromyography features. The conditions included 1) dysfunctional voiding--active pelvic floor electromyography during voiding with or without staccato flow, 2a) idiopathic detrusor overactivity disorder-A--a quiet pelvic floor during voiding and shortened lag time (less than 2 seconds), 2b) idiopathic detrusor overactivity disorder-B--a quiet pelvic floor with a normal lag time, 3) detrusor underutilization disorder--volitionally deferred voiding with expanded bladder capacity but a quiet pelvic floor, and 4) primary bladder neck dysfunction--prolonged lag time (greater than 6 seconds) and a depressed, right shifted uroflowmetry curve with a quiet pelvic floor during voiding. Treatment was tailored to the underlying condition in each patient. The group consisted of 50 males and 50 females with a mean age of 8 years (range 3 to 18). Dysfunctional voiding was more common in females (p <0.05) while idiopathic detrusor overactivity disorder-B and primary bladder neck dysfunction were more common in males (p <0.01). With treatment uroflowmetry parameters normalized for all types. Electromyography lag time increased in idiopathic detrusor overactivity disorder-A cases and decreased in primary bladder neck dysfunction cases. Noninvasive uroflowmetry with simultaneous electromyography offers an excellent alternative to invasive urodynamics to diagnose 4 urodynamically defined conditions. It identifies the most appropriate therapy for the specific condition and objectively monitors the treatment response.

The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding

Purpose The aim of the study was to compare the treatment outcome of two urotherapy programs in children with dysfunctional voiding (DV) through analyzing the clinical manifestations and uroflowmetry parameters. Materials and methods Eighty-six children with DV were randomly divided into two groups (A and B). Children in both groups were educated about the importance of regular voiding and hydratation, and about the appropriate posture during voiding. Simple voiding instructions were provided. In group A diaphragmatic breathing and pelvic floor muscles (PFM) retraining were additionally assigned to children. Constipation and recurrent urinary tract infections (UTIs) were treated in both groups. Selected children from both groups received pharmacotherapy (anticholinergics or desmopressin). Uroflowmetry with pelvic floor electromyography and ultrasound residual urine volumes were obtained before and at the end of the 12-month treatment period. Results After one year of therapy, urinary incontinence and nocturnal enuresis were cured in a significantly larger number of children in group A than in group B ( P < 0.001; P < 0.05). Although more children with UTIs were cured in group A, the difference was not statistically significant compared to group B. There was a significant recovery constipation-wise in both groups. Post-treatment uroflowmetry parameters and curve pattern were markedly improved only in group A. Conclusions Carefully planned and regularly controlled abdominal and PFM retraining is beneficial in children with DV for curing urinary incontinence, nocturnal enuresis, UTIs and normalizing urinary function. Further trials are needed to define the most effective treatment program for achieving the best treatment outcome.

2162 EMG LAG TIME AS A SPECIFIC FINDING IN THE DIAGNOSIS OF PRIMARY BLADDER NECK DYSFUNCTION

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Urodynamic Testing1 Apr 20112162 EMG LAG TIME AS A SPECIFIC FINDING IN THE DIAGNOSIS OF PRIMARY BLADDER NECK DYSFUNCTION Steven Weissbart, Leslie Schlachter, and Neil Grafstein Steven WeissbartSteven Weissbart New York City, NY More articles by this author , Leslie SchlachterLeslie Schlachter New York City, NY More articles by this author , and Neil GrafsteinNeil Grafstein New York City, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2399AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A key finding on videourodynamic studies (VUDS) in primary bladder neck dysfunction (PBND) is a prolongation of the time between the start of a voluntary detrusor contraction and the start of urine flow. A voluntary detrusor contraction is immediately preceded by pelvic floor relaxation, which may be seen on pelvic floor electromyography (EMG). It has, therefore, been suggested that measuring the EMG lag time, i.e. the time interval between pelvic floor relaxation and the start of urine flow, could be a minimally invasive alternative to VUDS to diagnose PBND. In addition, EMG lag time measurement might serve as a noninvasive modality for monitoring a patient's response to treatment with alpha-blockers. One critique of the use of prolonged EMG lag time to diagnose PBND is that this finding may also be present in all causes of bladder outlet obstruction (BOO), including benign prostatic hyperplasia (BPH), but there is no study to date that has examined this possibility. In this study, we compare the EMG lag times in patients who underwent VUDS prior to transurethral resection of the prostate (TURP) for BOO secondary to BPH with the EMG lag times in patients with PBND. METHODS Pelvic floor EMG lag time was measured in 16 patients who underwent VUDS prior to TURP for BOO caused by BPH. VUDS were conducted using a Laborie Aquarius TT system. Pelvic floor EMG activity was measured with patch electrodes placed at the 3- and 9-o'clock positions at the margin of the external anal sphincter. A Student's t-test was used to compare the mean EMG lag time in this cohort of patients with a previously reported mean EMG lag time for patients with PBND. RESULTS The mean age of patients who underwent VUDS prior to TURP for BOO caused by BPH was 68 (range, 60–79). The mean bladder outlet obstructive index on preoperative VUDS was 54.6. Operative findings in all patients at the time of TURP included prostatic tissue causing bladder outlet obstruction. Surgical pathology of the TURP chips revealed BPH in all specimens. Mean EMG lag time in our cohort of patients with BOO caused by BPH was 4.05 ±1.37 seconds (95% CI). The mean EMG lag time previously reported in a published cohort of patients with PBND was 23.9 seconds. A Student's t-test revealed a significantly lower EMG lag time in the patients with BOO caused by BPH compared to the published cohort of patients with known PBND (p<0.0001). CONCLUSIONS Our study demonstrates that the EMG lag time is not prolonged in patients with BOO secondary to BPH. Thus, EMG lag time prolongation remains a unique urodynamic finding in patients with PBND. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e865 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Steven Weissbart New York City, NY More articles by this author Leslie Schlachter New York City, NY More articles by this author Neil Grafstein New York City, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vesicoureteral Reflux and Primary Bladder Neck Dysfunction in Children: Urodynamic Evaluation and Randomized, Double-Blind, Clinical Trial on Effect of α-Blocker Therapy

Primary bladder neck dysfunction has been under diagnosed as a treatable cause of vesicoureteral reflux. We evaluated the effect of prazosin administration on vesicoureteral reflux resolution and urodynamic parameters in children with idiopathic primary reflux and primary bladder neck dysfunction. A total of 62 children (mean ± SD age 7.9 ± 2.4 years) with documented vesicoureteral reflux and urodynamics proved primary bladder neck dysfunction were randomized to receive either 0.025 mg/kg α-blocker (prazosin, 40 patients) or placebo (22) nightly for 1 week with a subsequent increase to 2 divided doses. Patients were followed for 12 months with clinical evaluation and uroflowmetry performed every 2 months, and each patient underwent complete urodynamic study at 6-month intervals. In the placebo group no uroflowmetry or urodynamic parameter changed significantly at 1-year followup. A 60% decrease in reflux grade was observed in the treatment group compared to 17% in the placebo group. Mean maximal detrusor pressure, post-void residual and opening time were significantly decreased in both followup sessions in the prazosin group (p <0.05). Average flow rate improved from 4.30 to 12.80 ml per second at 6 months and to 13.10 ml per second at 12 months (both p <0.05). Special attention should be given to secondary causes of vesicoureteral reflux (such as primary bladder neck dysfunction, an underdiagnosed entity in children), since conventional treatment will most likely fail if these conditions are not addressed promptly. In this study prazosin was effective therapy for children with vesicoureteral reflux and primary bladder neck dysfunction.

Primary Bladder Neck Dysfunction in Children and Adolescents III: Results of Long-Term α-Blocker Therapy

Primary bladder neck dysfunction is a nonneurogenic voiding disorder frequently overlooked in pediatrics. The diagnosis classically is made by videourodynamics but can also be made with noninvasive uroflow studies with pelvic floor electromyography. We report our long-term results using alpha-blocker therapy in patients with primary bladder neck dysfunction. We reviewed 51 neurologically normal children (mean age 11.6 years, range 3.5 to 17.8) meeting criteria for primary bladder neck dysfunction who underwent alpha-blocker therapy for at least 1 year. All patients were symptomatic with abnormal flow parameters and an electromyogram lag time of 6 seconds or more on initial uroflow/electromyography. Pretreatment and on-treatment uroflow/electromyogram studies were performed in all patients. Average and maximum uroflow rates, electromyogram lag times and post-void residual volumes were compared. After a mean followup of 46.2 months (range 12 to 124) mean average and maximum uroflow rates improved from 7.0 to 12.4 cc per second and from 12.4 to 20.3 cc per second, respectively, while mean electromyogram lag time decreased from 30.8 to 5.8 seconds (all p <0.01). Of the patients 85% reported subjective symptomatic relief. A total of 15 patients (29%) stopped alpha-blocker therapy for various reasons, none related to side effects. Repeat off-treatment uroflow/electromyogram studies showed that measured parameters reverted to pretreatment values (all p <0.05). Eight of these 15 patients eventually resumed alpha-blocker therapy, while only 3 remained asymptomatic off of the alpha-blocker. alpha-Blocker therapy continues to benefit children with primary bladder neck dysfunction even after 3 years of treatment. Few patients can come off of alpha-blocker therapy without returning to their pretreatment state, suggesting the condition is likely chronic in most patients.

Influence of intravesical potassium on pelvic floor activity in women with recurrent urinary tract infections: comparative urodynamics might lead to enhanced detection of dysfunctional voiding

To investigate the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with recurrent urinary tract infections (rUTIs) by using comparative urodynamics (CUD). CUD was conducted in 49 women (mean age 34.6 years, range 15-82) with rUTI. Every patient had two sessions of pressure-flow studies with simultaneous measurement of PFA by perineal surface electromyography (EMG); the first was with 0.9% saline and in the second the bladder was filled with 0.2 m KCl solution. All patients had voiding cysto-urethrography, and dysfunctional voiding (DV) was diagnosed when significant PFA was measured by EMG during voiding. Overall, DV was diagnosed in 37 patients (76%) using CUD; 16 (32%) had DV with saline on the pelvic floor EMG. In all these patients there were significantly greater EMG signals in the presence of KCL. In 21 patients (43%) DV was only detected using KCL; this improvement in the detection rate of DV was statistically significant (P = 0.006). Filling with KCl also prompted a statistically significant difference (P < 0.05) in maximum bladder capacity, maximum and average flow rates and in postvoid residual urine volume. The present data show that DV is present in most women with rUTI but cannot sufficiently be diagnosed by conventional urodynamics with standard 0.9% saline. The present study suggests that CUD might enhance the detection rates of DV.

Effect of lumbar‐epidural administration of tramadol on lower urinary tract function

Intrathecal and epidural administration of micro-agonist opioids is associated with urinary retention, a potentially serious adverse-event. In animal studies tramadol has been found not to affect voiding function. We evaluated urodynamic effects of epidural tramadol in humans. Fifteen adults planned for cystoscopy under local-anesthesia underwent urodynamics (UDS) at baseline and 30 min after administration of 100 mg tramadol in lumbar-epidural space. UDS consisted of filling cystometry, pressure-flow study and pelvic floor electromyography (EMG). Subsequently, all underwent cystoscopy and were observed for 6 hr. After injection of tramadol, a significant rise was observed in bladder capacity (391.8 +/- 179.6 ml vs. 432.7 +/- 208.8 ml; P = 0.019) and compliance (60.1 +/- 51.5 ml/cm H(2)O vs. 83.0 +/- 63.0 ml/cm H(2)O; P = 0.011) without a significant change in filling pressure (22.5 +/- 13.2 cm H(2)O vs. 24.1 +/- 15.1 cm H(2)O; P = 0.576). Filling sensations were delayed significantly (P < or = 0.05). EMG during filling phase showed a significant fall (P = 0.027). Peak flow-rate (Q(max)), average flow-rate, postvoid residue and detrusor pressure-at-Q(max) did not show significant change from baseline (P > 0.05). Three patients had bladder outlet obstruction which did not worsen after the injection. Guarding reflex was inhibited in seven out of 12 patients who had it at baseline (P = 0.016). Epidural tramadol increases the bladder capacity and compliance and delays filling-sensations, without ill effect on voiding. This seems true even for patients with obstructed outflow; however, due to small number of patients a definite conclusion cannot be derived. These results will guide clinician to avoid catheterization in cases where epidural tramadol is used for postoperative pain. The inhibitory effects of tramadol on EMG activity are intriguing and need further studies.

Randomized, Controlled Trial Shows Biofeedback to be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-Type Constipation

This study was designed to determine whether biofeedback is more effective than diazepam or placebo in a randomized, controlled trial for patients with pelvic floor dyssynergia-type constipation, and whether instrumented biofeedback is necessary for successful training. A total of 117 patients participated in a four-week run-in (education and medical management). The 84 who remained constipated were randomized to biofeedback (n=30), diazepam (n=30), or placebo (n=24). All patients were trained to do pelvic floor muscle exercises to correct pelvic floor dyssynergia during six biweekly one-hour sessions, but only biofeedback patients received electromyography feedback. All other patients received pills one to two hours before attempting defecation. Diary data on cathartic use, straining, incomplete bowel movements, Bristol stool scores, and compliance with homework were reviewed biweekly. Before treatment, the groups did not differ on demographic (average age, 50 years; 85 percent females), physiologic or psychologic characteristics, severity of constipation, or expectation of benefit. Biofeedback was superior to diazepam by intention-to-treat analysis (70 vs. 23 percent reported adequate relief of constipation 3 months after treatment, chi-squared=13.1, P<0.001), and also superior to placebo (38 percent successful, chi-squared=5.7, P=0.017). Biofeedback patients had significantly more unassisted bowel movements at follow-up compared with placebo (P=0.005), with a trend favoring biofeedback over diazepam (P=0.067). Biofeedback patients reduced pelvic floor electromyography during straining significantly more than diazepam patients (P<0.001). This investigation provides definitive support for the efficacy of biofeedback for pelvic floor dyssynergia and shows that instrumented biofeedback is essential to successful treatment.

1380: A Non-Invasive Method to Screen Adults for Primary Bladder Neck Dysfunction and Monitor Response to Therapy:Uroflow with Pelvic Floor Electromyography

You have accessJournal of UrologyModerated Poster, Tuesday, May 23, 2006, 1:00 - 3:00 pm1 Apr 20061380: A Non-Invasive Method to Screen Adults for Primary Bladder Neck Dysfunction and Monitor Response to Therapy:Uroflow with Pelvic Floor Electromyography Andrew J. Combs, Neil H. Grafstein, Alex Lipansky, and Richard J. Macchia Andrew J. CombsAndrew J. Combs More articles by this author , Neil H. GrafsteinNeil H. Grafstein More articles by this author , Alex LipanskyAlex Lipansky More articles by this author , and Richard J. MacchiaRichard J. Macchia More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)33593-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1380: A Non-Invasive Method to Screen Adults for Primary Bladder Neck Dysfunction and Monitor Response to Therapy:Uroflow with Pelvic Floor Electromyography." The Journal of Urology, 175(4S), p. 445 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 175Issue 4SApril 2006Page: 445 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Andrew J. Combs More articles by this author Neil H. Grafstein More articles by this author Alex Lipansky More articles by this author Richard J. Macchia More articles by this author Expand All Advertisement Loading ...

Electrophysiological assessment of sensations arising from the bladder: are there objective criteria for subjective perceptions?

Initial bladder filling sensation, first and strong desire to void are subjective perceptions that occur periodically during the urine storage mode of bladder function, representing sensory input from the lower urinary tract. To our knowledge methods for evaluating sensory bladder function are not available. We studied a simple electrophysiological procedure for the objective assessment of bladder sensations using sympathetic skin responses and surface pelvic floor electromyography. Informed consent was provided by 8 healthy male subjects, who were administered 20 mg. furosemide and 1 l. fluid to drink. Palmar and plantar sympathetic skin responses, and surface pelvic floor electromyogram were continuously recorded during bladder filling, voluntary pelvic floor contraction and voiding. First desire to void evoked simultaneous sympathetic skin responses and pelvic floor contractions. This pattern appeared periodically with the desire to void sensation as well as with strong desire to void at maximum bladder capacity and it correlated well with the subjective sensation of the subjects. Voluntary pelvic floor contraction decreased the subjective intensity of the desire to void sensation as well as sympathetic skin response activity for the same short period. During voiding sympathetic skin responses almost complete absence of sympathetic skin responses was observed. Sensations arising from the bladder induce combined activation of sympathetic skin responses and pelvic floor activity. This coherence indicates synchronized activation and inactivation of the autonomic and somatic pathways necessary for appropriate urine storage and coordinated voiding. Our observations may introduce a new approach for objectively assessing subjective sensations arising from the urinary tract.

Pelvic floor electromyography in men with chronic pelvic pain syndrome: A case‐control study

The objectives of this study were (1) to identify differences between men with chronic pelvic pain syndrome (CPPS), compared with pain-free men, in surface electromyography/biofeedback (sEMG/BFB) readings of pelvic floor muscles and (2) to determine which pelvic floor muscle sEMG readings may have differential diagnostic and treatment selection value by accurately predicting group membership, CPPS versus normal. Twenty-one men with CPPS and 21 healthy men without pelvic pain underwent a standardized sEMG examination by a licensed physical therapist. On group difference measures men with CPPS showed significantly greater sEMG instability in preliminary resting baseline. Three sEMG measures reliably categorized CPPS versus normals with CPPS showing greater preliminary resting baseline hypertonicity and instability with lowered voluntary endurance contraction amplitude. CPPS patients manifest pelvic floor muscle instability compared to normals. Prebaseline resting hypertonicity and instability along with endurance contraction weakness reliably predicts subject membership in the CPPS vs. normal group. Pelvic floor muscle sEMG may be a valuable screening tool to identify patients with CPPS who may benefit from therapies aimed at correcting pelvic floor muscle dysfunction.

PRIMARY BLADDER NECK DYSFUNCTION IN CHILDREN AND ADOLESCENTS I: PELVIC FLOOR ELECTROMYOGRAPHY LAG TIME—A NEW NONINVASIVE METHOD TO SCREEN FOR AND MONITOR THERAPEUTIC RESPONSE

One of the key findings for making the diagnosis of primary bladder neck dysfunction (PBND) on videourodynamics (VUDS) is prolongation of the time between the start of a voluntary detrusor contraction and the start of urine flow (opening time). Since normally this dynamic event is immediately preceded by pelvic floor relaxation, we determined if the interval between pelvic floor relaxation on pelvic floor electromyography (EMG) and the start of flow (pelvic floor EMG lag time), approximated opening time. Opening time measured on VUDS and pelvic floor EMG lag time measured on noninvasive uroflowmetry/EMG were compared in 22 consecutive patients with a mean age of 13.8 years diagnosed with PBND and a control group of 17 normal children. In addition, 19 patients with PBND were placed on alpha-blocker therapy, and pretreatment and on treatment uroflowmetry and pelvic floor EMG lag time values were compared. Mean opening time and mean pelvic floor EMG lag time were statistically indistinguishable from each other in the PBND and normal groups (27.4 vs 23.9 and 1.1 vs 1.3 seconds, respectively, p >0.550), but they differed significantly between the normal and PBND groups (p <0.001). On alpha-blocker therapy a decrease in mean pelvic floor EMG lag time from 24.47 to 6.67 seconds (p <0.001) corresponded with improved flow parameters, while no improvement was noted in untreated patients. Pelvic floor EMG lag time directly correlates with opening time and, when prolonged and associated with abnormal uroflowmetry, it is highly suggestive of PBND, thereby, justifying more invasive evaluation with VUDS or the initiation of empirical drug therapy. Most importantly, it provides an objective means of monitoring treatment response in a disorder that often has lingering symptoms.

Impact of urodynamics in treatment of primary nocturnal enuresis persisting into adulthood

ObjectivesTo investigate the urodynamic profiles of adults with primary nocturnal enuresis (PNE) and the association of the urodynamic profile findings with the efficacy of desmopressin and/or tolterodine pharmacotherapy. At least 2% of adults are enuretic during the night. The diagnostic and treatment approach for PNE is empirically the same in children and adults. MethodsA total of 20 nocturnal enuretic patients (12 women and 8 men) with a mean age of 27.1 years (range 20 to 42) were studied. They had wet their bed at least twice per week for the past 6 months. Urodynamic studies, including filling and voiding cystometry, pressure-flow study, and pelvic floor electromyography with superficial electrodes, were performed on all patients. Two of them had daytime symptoms, and two had prior failed desmopressin therapy. All patients began taking oral desmopressin 0.4 mg for 1 month. Their continence was assessed and tolterodine 4 mg was added for those in whom desmopressin alone failed. The patients responsive to desmopressin alone or desmopressin plus tolterodine were weaned from medication at 6 and 12 months to reassess continence. The mean follow-up period was 11.6 ± 3.3 months (range 4 to 14). ResultsUrodynamic studies of 20 PNE adult patients revealed detrusor instability in 10 (50%), hypocompliance in 8 (40%), nonneurogenic detrusor-sphincter dyssynergy in 1 (5%), and no abnormality in 10 (50%). Of the 20 patients, 19 (95%) had no voiding bladder problems. Of the 10 patients responsive to desmopressin alone, 6 (60%) had a normal urodynamic profile; the remaining 4 (40%) had detrusor instability and/or hypocompliance. Of the 5 patients who received desmopressin and tolterodine, 3 achieved continence. The overall continence rate was 86% (13 of 15), and 12 (92%) of the 15 patients required maintenance therapy. In 2 patients (13.3%), desmopressin and tolterodine therapy failed. The efficacy of desmopressin alone and of desmopressin plus tolterodine were not related to the urodynamic profile findings (P >0.05). The urodynamic profile was also not related to the relapse rate after any form of pharmacotherapy (P >0.05). ConclusionsPNE persisting into adulthood may be associated with abnormal urodynamic findings. Patients may benefit from urodynamic studies, because if the findings are abnormal, they might have the best chance of successful treatment.

Clinical significance of functional constipation categorized by colonic transit time and pelvic floor electromyography

Functional constipation (FC) is a common gastrointestinal disorder, the incidence of which is increasing each year with the changes in life style and diet, and the age of patients is becoming younger. Correct categorization will guide the treatment of FC and in the present study colonic transit time (CTT) and pelvic floor electromyography (PFE) were evaluated for their clinical significance in categorizing FC. Thirty-two cases of FC diagnosed by Rome II criteria with a duration of 6 months to 30 years were enrolled. Radio-opaque markers were used to detect CTT, the transit index (TI) and colonic evacuation rate; PFE was used to observe whether there was any paradoxical movement between the pelvic floor and abdominal muscles. Colonic transit time was recorded in 32 patients: 20 had outlet obstruction constipation and 12 had slow transit type. In the outlet obstruction type, PFE showed varying degrees of paradoxical movement between the muscles, whereas in the slow transit type, only 4 cases showed it. Functional constipation can be categorized by CTT and PFE, which are simple, painless and feasible to perform.

MONOSYMPTOMATIC NOCTURNAL ENURESIS IS ASSOCIATED WITH ABNORMAL NOCTURNAL BLADDER EMPTYING

We investigate the nature of enuresis episodes in monosymptomatic nocturnal enuresis using a fluid provocation model. The study included 18 children 7 to 13 years old with monosymptomatic nocturnal enuresis. Based on basal home recordings patients were subgrouped into those with a normal nocturnal urine output and those with nocturnal polyuria (mean nocturnal urine production on wet nights exceeding 130% of functional bladder capacity, normal functional bladder capacity for age provided). Children were admitted to the hospital for 4 consecutive nights. After an adaptation night all children received orally 25 ml/kg water, 30 minutes before bedtime on the remaining 3 nights. A cordless alarm device enabled registration of enuretic episodes from another room and diapers allowed the measurement of enuresis volumes. Post-void residual volumes were measured by ultrasound. Pelvic floor electromyography was continuously recorded throughout the night, and its association to bladder emptying was investigated. A total of 95 enuresis and 14 nocturia episodes were recorded. Significantly more enuresis episodes were registered on nights with oral fluid load, whereas no increase in number of nocturia episodes was seen. Of the enuresis episodes 46 were associated with incomplete bladder emptying (post-void residual volume greater than 10% of total bladder volume at time of enuresis). No difference between patient groups regarding post-void residual volume was seen. Abnormal bursts of electromyography activity were associated with incomplete micturitions. Enuresis nocturna episodes in polyuric and nonpolyuric patients are frequently incomplete micturitions. The present findings question the definition of nocturnal enuresis episode as normal complete voiding.