Unstable Detrusor Contractions Research Articles

Assessment of lower urinary tract function in children with Hirschsprung's disease

Usually, in Hirschsprung's disease (HD), long-term sequelae in children are related to abnormalities in defecation. However, some of these patients also develop lower urinary tract problems. The aim of this study was to assess and define the effects of transanal endorectal pull-through procedure in patients with HD on lower urinary tract function through urodynamic studies performed before and after surgery. Twenty-eight patients with HD were subjected to urodynamic studies before and after the different definitive surgical procedures. They were all males with a mean age of 3 years. The main outcome measurements were maximum cystometric capacity, compliance, unstable detrusor contraction, and residual urinary volume. Urodynamic findings were normal in 23 (82%) children, and abnormal in five (18%) children. In the uroflowmetric study, dysuria with detrusor sphincter dyssynergia and significant post-void urine residuals (> 20 mL) were found in the three symptomatic children. In the cystometric study, five children had unstable detrusor contraction, low bladder compliance, and small-capacity bladder. In HD, neurovesical dysfunction may exist preoperatively, and, although the incidence of postoperative changes in neurovesical function may appear high, children who present with urinary problems after surgery should be assessed urodynamically.

Assessment of lower urinary tract function in children before and after transanal endorectal pull through for Hirschsprung’s disease

Introduction: Usually, in Hirschsprung’s disease (HD), long-term sequelae in children are related to abnormalities in defecation. However, some of these patients also develop lower urinary tract problems. The aim of this study was to assess and define the effects of transanal endorectal pull-through procedure in patients with HD on lower urinary tract function through urodynamic studies performed before and after surgery. Patients and methods: The present study was conducted at Ibn Rochd University hospitals during the period from 2007 to 2016. Twenty-eight patients with HD were subjected to urodynamic studies before and after the different definitive surgical procedures. They were all males with a mean age of 3 years. The main outcome measurements were maximum cystometric capacity, compliance, unstable detrusor contraction, and residual urinary volume. Results: Urodynamic findings were normal in 23 (82%) children, and abnormal in five (18%) children. In the uroflowmetric study, dysuria with detrusor sphincter dyssynergia and significant postvoid urine residuals (> 20 ml) were found in the three symptomatic children. In the cystometric study, five children had unstable detrusor contraction, low bladder compliance, and small-capacity bladder. Conclusion: In HD, neurovesical dysfunction may exist preoperatively, and, although the incidence of postoperative changes in neurovesical function may appear high, children who present with urinary problems after surgery should be assessed urodynamically. Keywords: Hirschsprung’s disease, urinary dysfunction, urodynamic study

Assessment of lower urinary tract function in children before and after transanal endorectal pull through for Hirschsprung's disease

Usually in Hirschsprung's disease (HD), long-term sequelae in children are related to abnormalities in defecation. However, some of these patients also develop lower urinary tract problems. The aim of this study is to assess and define the effects of transanal endorectal pull through procedure in patients with HD on lower urinary tract function by means of urodynamic studies (UDS) performed before and after surgery. The study was conducted at Ibn Rochd University Hospitals from 2007 to 2016. Twenty-eight patients with HD were subjected to urodynamic studies before and after the different definitive surgical procedures. They were all males with a mean age of 3 years. The main outcome measurements were maximum cystometric capacity, compliance, unstable detrusor contraction and residual urinary volume. Urodynamic findings were normal in 23 (82%) children, and abnormal in 5 (18%) children. In uroflowmetric study, dysuria with detrusor sphincter dyssynergia and significant post-void urine residual (more than 20 mL) were found in the 3 symptomatic children. In cystometric study, five children had unstable detrusor contraction, low bladder compliance and small-capacity bladder. In HD, neurovesical dysfunction may exist preoperatively and though the incidence of postoperative changes in neurovesical function may appear high. Children who present with urinary problems after surgery should be assessed urodynamically.

Terminology and Pathophysiology of Overactive Bladder (OAB)

In 2002, the International Continence Society defined the term overactive bladder (OAB) as a symptom syndrome that is accompanied by urgency with or without urge incontinence, frequency and nocturia. A proven urinary tract infection or other obvious pathologies must be excluded.The pathophysiology of OAB has not been clarified in detail and is the subject of ongoing research, so partially overlapping hypotheses exist. The urothelium-based hypothesis suggests functional changes of urothelial receptors as well as functional changes regarding the sensitivity and coupling of the suburothelial myofibroblasts, which ultimately lead to increasing activity of afferent signals and urgency. The myogenic hypothesis is based on the assumption that unstable detrusor contractions may be triggered by changes in their excitability and coupling with other myocytes or myofibroblasts. Unstable detrusor contractions generate increased afferent activity followed by symptoms of overactive bladder. The hypothesis of abnormal processing of afferent signals assumes that damage to central inhibitory pathways and/or sensitisation of afferent nerves lead to the activation of the micturition reflex, which, in turn, induces unstable detrusor contractions. In addition, hormonal and psychological influences are discussed.

The effect of bladder diverticula on bladder function: An experimental study in rabbits

ObjectiveThis study aims to evaluate the effect of bladder diverticula (BD) on bladder function using a rabbit model, based on urodynamic findings. MethodsA total of 32 New Zealand white rabbits were randomly assigned to four groups: (1) sham surgery; (2) a single, 1-cm-diameter BD; (3) a single, large, 3-cm-diameter BD; and (4) four (multi) 1-cm-diameter BD. Urodynamic evaluations were performed preoperatively, and 1week and 1month postoperatively, to measure the postmicturition residual (PMR), maximum bladder capacity (MBC), filling and voiding detrusor pressure (Pdet), compliance, and unstable detrusor contractions. At the end of the study, the animals were sacrificed and assessed for pathologic evaluation and stone formation. ResultsIn groups 3 and 4, the rabbits all had PMR. At 30days postsurgery, the MBC was found to be 28% and 31% lower than the reference range in groups 3 and 4 and compliance was decreased (p<0.05). Further, the filling Pdet was significantly higher for large and multiple BD than in the 1-cm diverticula or sham groups (6.33±1.73, 4±1.26, p=0.0001). Groups 3 (62%) and 4 (50%) had unstable detrusor contractions. There was also a muscular/collagen ratio increase in the large and multiple BD groups. Four rabbits in the large group and one rabbit in the multiple BD group exhibited stone formation. ConclusionsLarge or multiple BD can alter bladder storage and emptying, and can decrease the capacity of the bladder and reduce its elasticity. Large or multiple bladder diverticula can lead to involuntary contractions, causing dysfunctional voiding.

Diabetes mellitus and female urinary incontinence: a time for change

Diabetes mellitus (DM), a chronic metabolic disease, is becoming a global health problem with increasing prevalence. The incidence of type I DM is fairly constant but that of type II DM is on the rise, most likely as a consequence of the contemporary changes in lifestyle, increasing obesity rates, and aging of the female population. DM is considered an independent risk factor for female urinary incontinence (UI); in a pooled analysis of 71,650 women aged 37–79 years, Danforth et al. [1] showed a 20 % increased odds of UI in women with DM [odds ratio (OR) 1.2, 95 % confidence interval (CI) 1.0– 1.3, p00.01)] This was largely because of urgency UI with no apparent association with stress or mixed UI. In a study of the Turkish population, Izci et al. [2] has shown a 2.5-fold increase in prevalence of UI in diabetic women, mainly of mixed UI. Similar results were shown in studies from Taiwanese, Chinese, and South American female populations. Despite this evidence, the management of incontinent diabetic women has been relatively neglected by the urogynecology community. This is partly because the etiology of DM is not well understood and partly due to lack of training in diabetic medicine in most urogynecology training programs. Traditionally, diabetic bladder dysfunction has been described as a triad of decreased sensation, increased capacity, and poor emptying causing a broad spectrum of symptoms including overactive bladder (OAB), voiding dysfunction, and urinary retention [3]. The role of DM in the pathophysiology of OAB and urgency UI is well described as a result of glycosuria, recurrent urinary tract infections (UTI), diabetic autonomic neuropathy, and diabetic cystopathy [4–6]. Hyperglycemia will often cause glycosuria and consequently osmotic diuresis leading to polyuria and increased frequency of micturition in diabetic women [7]. Autonomic neuropathy is a late complication of DM with a cumulative increase in prevalence over time [8]. Liu et al. [9] have recently shown that the prevalence of lower urinary tract symptoms is directly related to duration of DMwith 2.4and 4.2-fold increase with DM duration >10 years and age>50 years, respectively. The cause of diabetic neuropathy is multifocal and includes ischemia, superoxide-induced free radical formation, impaired axonal transport, and metabolic derangement of the Schwann cell resulting in segmental demyelination and impairment of nerve conduction [9]. Animal and research data suggest that diabetic cystopathy is caused by ultrastructural and microvascular damage to the detrusor muscle with alteration in its neural component ultimately resulting in alterations in detrusor muscle function [10]. Diabetic cystopathy affects up to 40–80 % of diabetic patients, is slowly progressive, and clinically characterized by decreased bladder sensation and either impaired or unstable detrusor contractions [8]. The metabolic syndrome associated with DM and characterized by dyslipidemia and hypertension can further decrease the blood flow to the detrusor muscle and compromise bladder function. Liu et al. [9] have shown that patients with DM and metabolic syndrome showed a higher trend for developing urgency UI. These studies provide an explanation for the fact that OAB is the main clinical feature of diabetic cystopathy which can also be associated with increased post-void residual M. Abdel-fattah Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK

Coital incontinence: Relation to detrusor overactivity and stress incontinence

The aim was to assess functional (demographic, clinical, and urodynamic) and anatomical (described by MRI) abnormalities associated with coital incontinence (CI). All consecutive sexually active women with urinary incontinence (UI) were invited. Women were asked if they experience urine leakage during sex; and its timing: during penetration (CIAP) versus during orgasm (CIAO). All women were studied with urodynamics. Pelvic MRI was done for selected group of women. MRI examination was done using 1.5 T superconducting magnet, supine, and during two phases: static and dynamic, using multiplanar T2-weighted turbo spin-echo and single short T2-wighted images. Ninety women with UI; 60 had CI while 30 had no CI. Prevalence of CI was significantly higher among women with stress incontinence (SUI) (89.4%) compared to those with detrusor overactivity (DOA) (33.3%); P = 0.000. Factors significantly associated with CI were parity, prolapse, and SUI. Among studied MRI variables, no factor was significantly associated with CI. CI showed significant positive correlation with severity of SUI (r = 0.327, P = 0.05) and significant negative correlation with Abdominal leak point pressure (r = -0.362, P = 0.01). Amplitude of unstable detrusor contraction as measured by urodynamics did not correlate with severity of CI. CI seems to be in the spectrum of SUI and POP. CI is almost invariably a symptom of SUI with urethral sphincter incompetence, even when it occurs during orgasm. Many women with DOA leak during sex; however, the potential role of associated urethral incompetence should be considered.

Assessment of lower urinary tract function in children before and after Swenson′s ′pull through′ for Hirschsprung′s disease

<b>Aims:</b> Long-term sequelae in children with Hirschsprung's disease (HD) are usually related to abnormalities in defecation. However, some of these patients also suffer from voiding dysfunction. The aim of this study is to assess and define the effects of Swenson's 'pull through' procedure in patients with HD on lower urinary tract function by means of urodynamic studies (UDS) performed before and after surgery. <br><b> Materials and Methods:</b> Six patients with Hirschsprung's disease underwent UDS before and after the definitive procedure. Parameters observed were maximum cystometric capacity, compliance, unstable detrusor contraction (UDCS), leak point pressure, residual volume, end filling pressure, volume at Pdet <20 cm H₂ O and volume at Pdet <30 cm H₂ O. <b> Results:</b> On UDS evaluation, one patient (16.6%) showed a small-capacity bladder and one patient (16.6%) showed a large-capacity bladder with occasional uninhibited detrusor contraction (UDCS) preoperatively. All the children had good compliant bladders. Postoperatively, one child was clinically symptomatic and showed hyporeflexic large-capacity bladder without any UDCS, one patient showed a small-capacity bladder with UDCS. <b> Conclusions:</b> In Hirschsprung's disease, neurovesical dysfunction may exist preoperatively and though the incidence of postoperative changes in neurovesical function may appear high, a larger study is required for statistical validation. Children who present with urinary problems after surgery should be assessed urodynamically.

Long-term results of Ingelman-Sundberg denervation procedure for urge incontinence refractory to medical therapy.

Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence. Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve. A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged. Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.

Giggle incontinence in children: a manifestation of detrusor instability.

To our knowledge the prevalence and cause of giggle incontinence in children is not known. We hypothesized that laughter may induce unstable detrusor contractions in children susceptible to detrusor instability. We evaluated the prevalence of diurnal voiding symptoms of urinary urgency, urge incontinence, pelvic withholding maneuvers and hesitancy in patients with giggle incontinence, the prevalence of giggle incontinence in patients with diurnal voiding symptoms, the prevalence of the 2 conditions in first degree relatives of patients with giggle incontinence, the influence of treatment for detrusor instability on the frequency of giggle incontinence and the prevalence of diurnal voiding symptoms in control children with giggle incontinence. Of 1,421 children 5 to 15 years old referred to the pediatric nephrology department for various problems 109 were diagnosed with giggle incontinence and 460 had diurnal voiding symptoms. A total of 627 children visiting the pediatrician office whose parents completed a survey questionnaire served as controls. Diurnal voiding symptoms were noted in 95% of the patients with giggle incontinence, while giggle incontinence was noted in 23% of those with diurnal voiding symptoms. Of the patients with giggle incontinence a positive family history for that entity and diurnal voiding symptoms was noted in 13% and 28%, respectively. Giggle incontinence improved in all patients after treatment for detrusor instability and it resolved completely in 89%. Giggle incontinence recurred with a relapse of diurnal voiding symptoms in 28 cases and improved with improved diurnal voiding symptoms during modification of therapy. Diurnal voiding symptoms were present in 43% of the 157 controls with giggle incontinence. Giggle incontinence results from detrusor instability induced by laughter and it improves with effective treatment of detrusor instability.

Encapsulation of a Porcine Dermis Pubovaginal Sling

Porcine dermis is one of several tissues available for use as a graft in pubovaginal sling surgery. Short-term success rates using this material approach those of autologous fascia, and no adverse events relating directly to the material itself have yet been described. Porcine dermis reportedly functions as a scaffold for ingrowth of the native tissue, and histological animal studies have confirmed prompt remodeling and neovascularization following implantation. However, to our knowledge no studies have investigated the eventual fate of the material in humans. We report a case of removal of a porcine dermis pubovaginal sling. CASE REPORT A 42-year-old female presented in complete urinary retention 4 months after undergoing porcine dermis pubovaginal slingplasty. According to records she was unable to urinate in the immediate postoperative period, and required indwelling and intermittent catheterization after failing several voiding trials. The patient was catheterizing up to 5 times per day following surgery. Physical examination revealed a fixed urethra and a small cystocele. There was a ridging effect at the bladder neck, which was confirmed with cystoscopy. Videourodynamics demonstrated an absence of unstable detrusor contractions and was suggestive of outlet obstruction. At urethrolysis the intact porcine sling was found encased in a well-defined capsule (fig. 1). The sling was easily removed in toto and the ridging effect resolved. The patient voided immediately after surgery and continues to empty efficiently 3 months after surgery. She remains continent. Pathological analysis showed a completely intact acellular porcine dermis sling without evidence of human tissue proliferation (fig. 2). Analysis of the capsule revealed benign fibrous tissue with evidence of chronic inflammation.

Urodynamic Patterns Following Ischemic Spinal Cord Events

The nature of bladder function following ischemic injuries to the spinal cord (vSCI) is poorly understood. We describe urodynamic (UD) findings in patients with vSCI and determined the optimal management of voiding dysfunction. From January 1997 through September 2001, 18 patients were diagnosed with vSCI. All underwent neurological and urodynamic evaluation. The etiology of vSCI was abdominal aortic aneurysm repair in 10 patients, another surgical procedure in 4 and a spontaneous spinal cord infarct in 2. Two patients (American Spinal Injury Association [ASIA] class A) had detrusor areflexia or hyporeflexia and performed clean intermittent catheterization. Of the 10 patients assigned to ASIA class C 50% had UD evidence of abnormal compliance, unstable detrusor contractions and detrusor-external sphincter dyssynergia (DESD). All 10 patients had thoracic or cervical sensory levels and 60% had detrusor hyporeflexia or areflexia. A single patient voided spontaneously, while the remainder performed continuous or intermittent catheterization. Five patients assigned to ASIA class D had no abnormal compliance, unstable detrusor contractions or DESD. Four patients voided spontaneously or by abdominal straining. The patients with a history of abdominal aortic aneurysm repair were a heterogeneous population. While the etiology or sensory level of vSCI does not appear to predict UD patterns with consistency, greater preservation of motor function may be associated with improved parameters. All patients with vSCI and lower urinary tract symptoms require thorough UD evaluation and ongoing surveillance is mandated because deterioration may develop with time. Clean intermittent catheterization may represent the most effective method of bladder emptying for patients unable to void voluntarily. However, early evidence of abnormal compliance and DESD has also been seen in these patients, underscoring the need for close UD surveillance.

Stimulation signal modification in a porcine model for suppression of unstable detrusor contractions

Objectives To investigate, in an experimental study, the efficacy of a different stimulation signal in a porcine model to suppress formalin-induced unstable detrusor contractions. The current mode of stimulation in peripheral nerve evaluation tests and sacral neuromodulation is based on rectangular signal shapes. Published reports, however, have revealed that up to 80% of patients do not respond to peripheral nerve evaluation stimulation. Methods After placement of electrodes at S3 in 12 anesthetized Göttinger minipigs, unstable contractions were induced by intravesical instillation of formalin. Ten-minute stimulation phases with a quasi-trapezoidal signal and a rectangular signal followed. An interval of 30 minutes elapsed between the two series of stimulations. The pressure values were registered on a urodynamic unit and evaluated as contractions and amplitudes per minute. Six minipigs were treated in the same way but were not stimulated and served as the control group. Results After formalin instillation, the average number of involuntary detrusor contractions was 3.5/min (± 0.8) and the sum of amplitudes was 7.2/min (± 1.1). Subsequent NaCl instillation and quasi-trapezoidal stimulation reduced the contractions to 0.3/min (± 0.3) and the sum of amplitudes to 0.8/min (± 0.4). A contraction rate of 1.1/min (± 0.1) and a sum of amplitudes of 5.1/min (± 2.4) were recorded under stimulation with a rectangular signal. In the control group, no significant reduction was recorded. Conclusions The acquired data demonstrate that quasi-trapezoidal stimulation suppresses unstable detrusor contractions in the minipig more effectively than does conventional rectangular stimulation as presently applied in sacral neuromodulation.

Molecular and electrophysiological investigation of ATP-sensitive K+ channels in lower urinary tract function: the aims for clinical treatment of unstable detrusor

It is a common sequelae of bladder outlet obstruction caused by benign prostatic hyperplasia in adult males and gives rise to significant bladder dysfunction such as frequency and urgency of micturition. The unstable detrusor contractions may lead to urge incontinence. Since it has been reported that experimentally-induced bladder instability can be abolished by ATP-sensitive K+ channel (KATP channel) openers, various types of detrusor-selective KATP channels have been newly synthesized, targeting KATP channels in urinary bladder. Thus, the significant differences in molecular and pharmacological properties of KATP channels between urinary bladder and urethra hold out some hope for the development of tissue-selective KATP channel openers for urge urinary incontinence, and detrusor-selective KATP channel openers should be screened against urethral as well as vascular smooth muscle. In functional expression experiments, pharmacological and electrophysiological studies have reported that SUR1/Kir6.2 represents the pancreatic beta-cell KATP channel and that SUR2A/Kir6.2 is thought to represent the cardiac KATP channel, whereas SUR2B/Kir6.1 represents the smooth muscle-type KATP channel. In general, the smooth muscle type-KATP channel is (i) of a relatively small conductance (about 20 pS under quasi-physiological conditions, approximately 40 pS in symmetrical 140 mM K+ conditions), (ii) intracellular Ca(2+)-insensitive, (iii) inhibited by intracellular ATP, (iv) abolished by glibenclamide at a submicromolar concentration, and (v) reactivated by intracellular nucleoside diphosphates (NDPs). There has been no report concerning the properties of KATP channels in human detrusor by use of single-channel recordings. We would like to introduce our recent evidence of novel synthesized detrusor-selective KATP channel openers and properties of KATP channels in the lower urinary tract.

Giggle Incontinence in Children: A Manifestation of Detrusor Instability

To our knowledge the prevalence and cause of giggle incontinence in children is not known. We hypothesized that laughter may induce unstable detrusor contractions in children susceptible to detrusor instability. We evaluated the prevalence of diurnal voiding symptoms of urinary urgency, urge incontinence, pelvic withholding maneuvers and hesitancy in patients with giggle incontinence, the prevalence of giggle incontinence in patients with diurnal voiding symptoms, the prevalence of the 2 conditions in first degree relatives of patients with giggle incontinence, the influence of treatment for detrusor instability on the frequency of giggle incontinence and the prevalence of diurnal voiding symptoms in control children with giggle incontinence. Of 1,421 children 5 to 15 years old referred to the pediatric nephrology department for various problems 109 were diagnosed with giggle incontinence and 460 had diurnal voiding symptoms. A total of 627 children visiting the pediatrician office whose parents completed a survey questionnaire served as controls. Diurnal voiding symptoms were noted in 95% of the patients with giggle incontinence, while giggle incontinence was noted in 23% of those with diurnal voiding symptoms. Of the patients with giggle incontinence a positive family history for that entity and diurnal voiding symptoms was noted in 13% and 28%, respectively. Giggle incontinence improved in all patients after treatment for detrusor instability and it resolved completely in 89%. Giggle incontinence recurred with a relapse of diurnal voiding symptoms in 28 cases and improved with improved diurnal voiding symptoms during modification of therapy. Diurnal voiding symptoms were present in 43% of the 157 controls with giggle incontinence. Giggle incontinence results from detrusor instability induced by laughter and it improves with effective treatment of detrusor instability.

Long-Term Results of Ingelman-Sundberg Denervation Procedure for Urge Incontinence Refractory to Medical Therapy

Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence. Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve. A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged. Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.

Detrusor myotomy: a 5‐year review in unstable and non‐compliant bladders

To identify urodynamic factors that might determine the clinical outcome of detrusor myotomy in incontinent children. Six girls and three boys (aged 5-14 years) underwent detrusor myotomy for severe urinary incontinence. Seven children had spina bifida, one had traumatic paraplegia and one had low bladder compliance. The patients were followed for a minimum of 5 years. Urodynamic studies before surgery showed that three patients had normal compliance with grossly unstable detrusor contractions, and six had low bladder compliance with few phasic detrusor contractions. Detrusor leak-point pressures were > 40 cmH2O in five patients and < 40 cmH2O in four. Only two patients, both with grossly unstable detrusor contractions and leak-point pressures of > 40 cmH2O, had a successful 5-year outcome. The other seven patients remained incontinent; six underwent further surgery and one died from unrelated causes. Detrusor myotomy appears to have the best outcome in those patients with marked phasic unstable detrusor contractions with a competent urethral sphincter. In this group it may have distinct advantages over more commonly used procedures.

Efectos de la electroestimulación funcional periférica en la inestabilidad vesical obstructiva

IntroductionThe Aim of This study Was to Assess the Effects of Peripheral functional Electrical stimulation (Fes) In patients With detrusor Instability (Di) Secondary to Obstructive Benign Prostatic Hiperplasia (Bph). Subjects, Material & MethodsNine Patients with Urodynamically proven Di secondary To Bph Were investigated. Sensory and pudendo-anal Reflex thresholds Were determined In each Patient to Individually optimise Fes. A standard Fill cystometry Was then Performed and Individually optimised Fes was Given when An unstable Detrusor contraction occurred. Non stimulated Contractions were Used as controls. The effects Of Fes Were analysed By measuring The mean Area under The unstable Pressure curves With and Without Fes And were Expressed as Percentage suppression. ResultsThe Percentage suppression In the Mean area Under the Curves after Stimulation was <10%. There was No statistically Significant difference Between controls And FES Using a Two tailed, Paired students t-Test (p>0.1) At 95% Confidence level (p=0.05). ConclusionFes did Not significantly Suppress unstable Bladder contractions In patients With DI Secondary to BPH. This finding Suggests that Obstructive DI Does not Depend on Sacral reflex Mechanisms and Supports the View that It has A peripheral Pathophysiological origin (myogenic and/or Nerve endings).

RECOGNITION OF BLADDER INSTABILITY ON VOIDING CYSTOURETHROGRAPHY IN INFANTS WITH URINARY TRACT INFECTION

We evaluate voiding cystourethrography as a method for identifying bladder instability in infants. Cystometry was combined with voiding cystourethrography in 79 male and 64 female infants with first time urinary tract infection. Bladder wall irregularity, elongation of bladder shape, and filling of the posterior urethra were transient radiological signs occurring during bladder filling and were considered to reflect bladder instability. A pediatric radiologist looked for these signs on all 480 films exposed during bladder filling. The results were correlated to simultaneous detrusor pressure recordings. The analysis was repeated independently by a urologist to evaluate the reliability of the radiological signs used. The sensitivity and specificity were both 90% in the evaluation of radiological signs of bladder instability. Filling of the posterior urethra was the least frequently reported radiological sign, which was seen at 53% of unstable contractions. However, when this sign was reported, instability was usually correctly detected (85%). Evaluation accuracy had improved with increasing numbers of noted signs per film. This accuracy had included 29%, 67% and 91% of unstable contractions that were correctly diagnosed when 1, 2 or 3 signs were noted, respectively. The number of noted signs was positively related to the strength of the unstable detrusor contraction. Urologist evaluations had similar results to the radiologist, although the sensitivity was somewhat lower (79% and 90%, respectively). Unstable detrusor contractions could be identified in infants by evaluation of radiological signs on voiding cystourethrography. Findings of bladder wall irregularity, elongation of bladder shape and filling of the posterior urethra indicated unstable detrusor contraction. The more such findings are observed, the stronger the indication.

Detrusor hypocontractility evolution in boys with posterior urethral valves detected by pressure flow analysis.

We evaluated the natural evolution of detrusor voiding contractility in boys who underwent posterior urethral valve ablation using pressure flow analysis, which is a mathematical computerized analysis of pressure flow studies. Among 30 boys with posterior urethral valves who were being prospectively followed, even if asymptomatic on serial pressure flow studies, 11 were included in our study. These 11 patients had had at least 2 evaluations performed between ages 5 and 15 years, a minimum interval of 4 years between the first and last examination, and all pressure flow studies records available for mathematical analysis of voiding contractility. The first examination had been done at ages 5 to 10 years (average 7 +/- 2.04) and the last one at ages 9 to 15 (12.5 +/- 2.5), including 6 evaluated after puberty. All but 1 patient underwent valve endoscopic resection as a newborn and none received urinary diversion. Voiding symptoms, post-void residual, cystometric bladder capacity and bladder instability were considered. Voiding phase maximal detrusor pressure and flow rate were evaluated and detrusor contractility was calculated by the pressure flow analysis parameters of contraction velocity, detrusor contractile power expressed as watt factor and Schafer's nomogram. Contraction velocity and contractile power factor were considered low if below 2 standard deviations of previously determined normal values. True hypocontractility was diagnosed when at least 2 pressure flow analysis parameters were low. True hypocontractility was detected in 3 of the 11 boys at the first examination and in 8 at the last pressure flow analysis. The remaining 8 and 3 cases of first and last examinations, respectively, were considered to have normal contractility even if 4 of the 8 and 1 of the 3 had 1 low pressure flow analysis parameter (covert hypocontractility). Detrusor contractility worsened in 6 patients, hypocontractility was detected at the first pressure flow analysis in 2, hypocontractility changed to normal in 1 and pressure flow analysis remained normal in 2. Of the 6 boys followed through puberty 5 had hypocontractility, including 3 with cystometric bladder capacity greater than 700 ml., high post-void residual and strained voiding. Of the 11 patients 8 had detrusor instability, including 7 with urge symptoms, at first evaluation which was not found at last examination. Pressure flow analysis extensively used in men has been confirmed as a useful tool to assess voiding contractility in children. The majority of boys with posterior urethral valves have progressive impairment of detrusor contractility at voiding many years after relief of obstruction. The pattern of hypocontractility, which is detected early on pressure flow analysis, follows a prolonged phase of instability in many cases and leads to an over distended bladder in most patients followed after puberty. Questions arise if this evolution may be prevented by early (pharmacological or rehabilitative) treatment and if it is partially determined by extensive use of drugs acting against unstable detrusor contractions.