Biomedical subjects
Publications and source records attributed to H Madersbacher.
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In neurogenic bladder dysfunction conservative treatment is preferred whenever possible and preservation of renal function remains the main topic. Additionally, a patient-related form of bladder management with decreased intravesical pressure and social dryness is needed. Therefore many strategies are available and after evaluation of the underlying neurogenic bladder dysfunction an individual kind of treatment can be used. Possible options are the clean intermittent catherization, anticholinergic drugs, detrusor triggering, electrical stimulation and bladder emptying by Valsalva's manouvre.
AIMS OF THE STUDY: The aim of this double-blind, randomised, prospective, multicentre trial was to evaluate the efficacy of propiverine in patients suffering from detrusor hyperreflexia caused by spinal cord injury in comparison to placebo. STUDY DESIGN: The treatment period of 14 days comprised visits at baseline (V1) and after 14 days treatment (V2). Fifteen mg propiverine t.i.d. or placebo t.i.d. were administered as medication. The following efficacy parameters were adopted: the urodynamic parameters maximal cystometric bladder capacity, bladder volume on onset of the first as well as duration and amplitude of the maximum detrusor contraction, bladder compliance and residual urine, and subjective assessment of efficacy by physicians. For the evaluation of the safety of propiverine the incidence rate of adverse events by directly questioning as well as laboratory parameters were investigated. For biometrical evaluation t-test for independent groups was applied. RESULTS: One hundred and thirteen patients were investigated. The maximal cystometric bladder capacity increased significantly in the propiverine group, on average by 104 ml (V1: 262+/-132 ml. V2: 366+/-143 ml, P<0.001). The changes in bladder capacity during the first contraction and the maximum detrusor contraction in the verum group were both statistically significant. The bladder compliance documented a more pronounced increase under propiverine in comparison to placebo. Residual urine increased by 37+/-71 ml in the propiverine group, significantly more than in the placebo group (P=0.01). Sixty-three per cent of the patients expressed subjectively an improvement under propiverine in comparison with 23% of the placebo group. Expected anticholinergic adverse events occurred: dryness of the mouth (37% in the verum and 8% in the placebo group), accommodation disorders (28% and 2% respectively). Nausea, constipation, headache, dizziness, tiredness and palpitations were reported in almost comparable incidence rates between 3 and 13% in both treatment groups. Eight drop-outs were registered in the propiverine group (five due to adverse events) and three in the placebo group (one due to adverse events). The laboratory parameters revealed no changes. CONCLUSION: Propiverine proved its efficacy in detrusor hyperreflexia with regard to the urodynamic parameters of the maximal cystometric bladder capacity and detrusor contractility. Anticholinergic adverse events such as dryness of the mouth and accommodation disorders were considered being tolerable. The increase in residual urine reflects the therapeutically desired effect of detrusor relaxation because the majority of patients normally practise intermittent catheterisation for bladder emptying.
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The evaluation of cortical evoked potentials after stimulation of the vesicourethral junction shows accurate and reproducible results and offers an elegant technique for evaluation of the viscerosensory pathways in patients with lower urinary tract dysfunction. The results must be considered in context with the results of simultaneously investigated pudendal somatosensory evoked potentials and the clinical symptomatology. They are of great help (1) in differentiating between intraspinal and extraspinal lesions of the afferent pathways of the detrusor if the etiology is unknown, (2) in differentiating between neurogenic and myogenic damage to the urinary bladder, and (3) in selecting patients not suitable for intravesical electrotherapy for bladder rehabilitation.
Different pathophysiology causes different types of incontinence. Urge-, Stress-, Overflow-, Reflex- and Extrasphincteric incontinence therefore need different therapeutic strategies. The basic diagnostic work-up, which can be done by any doctor in free practice comprises history, clinical investigation, urine analysis, the micturition protocol (frequency-volume-chart = FVC) and post voiding residual urine (PVR). In 80% of the elderly incontinent persons incontinence can be evaluated by basic diagnostics to such an extent, that conservative therapy can be started. If after basic diagnostic work-up the type of incontinence remains unclear, if it is a postoperative recurrent urinary incontinence, if reflex incontinence is present, or if conservative therapy is not successful within 3 weeks a further diagnostic workup by the specialist is mandatory. The specialist will perform echography of the urinary tract, endoscopy and especially urodynamics to evaluate detrusor and sphincter dysfunction precisely, if necessary also combined with X-ray (video-urodynamics). In regards to urinary stress incontinence conservative treatment strategies e.g. pelvic floor training programs, if necessary combined with electrotherapy and biofeedback have gained increasing importance. For urge-incontinence continence training programs and pharmacotherapy as well as electrotherapy are the main therapies. Reflex-incontinence should be treated by the specialist. Overflow incontinence is easy to diagnose, however, the treatment of the underlying pathophysiology must be done by the urologist. Urinary incontinence in the elderly is a special problem. Treatment of incontinence with incontinence aids (pads) only is justified in immobile and demented people, in others active treatment, comprising continence training programs and pharmacotherapy should be the goal. A Foley catheter is only justified if urinary incontinence is combined with an insufficient bladder emptying with residual urine, which can not be treated otherwise.
Tolterodine is a new competitive muscarinic receptor antagonist developed for the treatment of the unstable bladder. A total of 242 patients were enrolled in a multicenter, multinational, randomized, double-blind, placebo-controlled study conducted over a period of 4 weeks in patients with detrusor overactivity and symptoms of frequency, urgency, and urge incontinence. The objective of the study was to compare the efficacy and safety of tolterodine given at 1 or 2 mg b.i.d. versus placebo. At week 4 a statistically significant increase in the volume at first contraction (p = 0.030) and maximal cystometric capacity (p = 0.034) was only in the tolterodine 2 mg b.i.d. group. Tolterodine was safe and generally well tolerated. The incidence of dry mouth, as the most commonly reported adverse event, was only 9% and of mild to moderate intensity.
OBJECTIVE: To compare trospium chloride (TCl), a quaternary ammonium derivative with atropine-like effects and predominantly antispasmodic activity, with oxybutynin (Oxy) in terms of efficacy and adverse effects. PATIENTS AND METHODS: In a randomized, double-blind, multicentre trial, 95 patients with spinal cord injuries and detrusor hyper-reflexia were studied. Treatment consisted of three doses per day over a 2 week period, with either Oxy (5 mg three times daily) or with TCl (20 mg twice daily) with an additional placebo at midday. The results were evaluated with regard to changes in objective (urodynamic) data and subjective symptoms as well as the incidence/severity of adverse effects. RESULTS: With both drugs there was a significant increase in maximum bladder capacity, a significant decrease in maximum voiding detrusor pressure and a significant increase in compliance and residual urine; there were no statistically significant differences between the treatment groups. The percentage of patients who reported severe dryness of the mouth was considerably lower (4%) in those receiving TCl 2 x 20 mg/day than in those receiving Oxy (23%) 3 x 5 mg/day. Withdrawal from treatment was also less frequent in those receiving TCl (6%) than in those receiving Oxy (16%). CONCLUSION: Trospium chloride and oxybutynin, judged in terms of objective urodynamic parameters, are of substantially equal value as parasympathetic antagonists. However, assessment of tolerance in terms of adverse drug effects showed that TCl had certain advantages.
OBJECTIVE: We investigated the role of intravesical electrical stimulation in the treatment of voiding dysfunctions following major gynecologic surgery. METHODS: 19 female patients with sensory and/or motor voiding dysfunction following gynecologic operations underwent intravesical electrostimulation after failure of traditional treatments. Before and after therapy, urodynamic examinations were performed. The follow-up was 6-24 months. RESULTS: All cases of sensory bladder dysfunction were cured. Volumes of residual urine significantly decreased (mean 274 vs. 53 ml: p = 0.0003) and maximum detrusor pressure increased (mean 6 vs. 27 cm H20; p = 0.0007). An early start of therapy (within 6 weeks after surgery) resulted in a better outcome. CONCLUSIONS: Intravesical electrical stimulation was effective in the treatment of sensory and motor voiding dysfunctions following major gynecologic surgery.
Topical oxybutynine (Oxy) has been used successfully in neurogenic bladder patients who remained wet on oral anticholinergics or could not tolerate oral medication. However, little is known about the pharmacokinetics of intravesical Oxy. The aim of this study was to evaluate the resorption rate of intravesically given Oxy in the bladder in comparison with oral intake, and to find out which pharmacological properties of the drug are responsible for its effect when given intravesically. Our results indicate that peak plasma levels of intravesical Oxy appear later, are lower and stay longer compared to oral intake. Cystometries before, 20 min and 2 h after intravesical application of Oxy indicate that the main effect of intravesical Oxy on the detrusor is systemic due to its resorption. Our findings confirm the clinical experience that intravesical Oxy is well tolerated, very efficacious and better than oral medication.
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Bladder control is a developmental process which is determined by somatic, individual psychological and psychosocial factors. It depends on the maturation of bladder capacity and of adequate neuromuscular coordination, on the quantity of urine and on appropriate recognition of bladder expansion. The latter especially is clearly correlated to healthy individuation and psychosocial integration of the child. Statistically, 80-90% of children have successfully developed bladder control at the age of 4-6 years. In the remaining 10 or 20% who do not attain dryness during daytime or at night, wetting is often felt to be disturbing state, sometimes more by the parents than by the children. The state is called enuresis. The physician is expected to master the problem of night or daytime enuresis diagnostically as well as therapeutically. Although in most cases enuresis represents a retardation of normal development, it is important not to miss the rare, but, if present, important disturbing factors. Disorders can occur at all above mentioned levels, either in isolation or combined. Although proposing the simplest diagnostic measures, the present paper represents an optimal workup during which none of the rare somatic or complicated psychological disturbances, which would need specialized attention, should be missed. After this workup the therapeutic pathways are clear. On the one hand, relevant somatic and/or psychological disorders must be treated specifically (often in collaboration with the specialist). On the other side, there is the large number of enuretics who are, by all criteria, normal children. In these it is possible to accelerate the developmental process by performing an elaborate micturition protocol which has a good chance of success, provided, however, there is optimal cooperation between physician, parents and child.
An intact sacral reflex arc, or at least an intact second motor-neuron and a detrusor being able to contract, are the two prerequisites for implanting an anterior sacral root stimulator. Transrectal electrostimulation or direct needle stimulation of the sacral roots may reveal if patients despite absent or only weak detrusor contractions on routine investigation are suitable. Patients with a complete midthoracic paraplegia are the ideal candidates, but tetraplegics also benefit. Patients with incomplete lesions and preserved pain sensations are suitable provided that they can undergo posterior sacral root rhizotomy. Non-traumatic spinal cord lesions follow the same rules, provided that the type of lesion does not allow recovery and is not progressive. Myelomeningocele patients may be suitable provided that the pathoanatomy of the sacral roots permits the operation (may be possible only in thoracolumbar myelomeningocele). Vesico-uretero-renal reflux is no contraindication; it may even be a strong indication, if a low compliance bladder or high detrusor contractions are the main reasons for it. In most patients the procedure should or must be combined with posterior sacral root rhizotomy in order to normalize a low compliance, to abolish spontaneous reflex contractions, and to achieve continence. The benefit of following these rules is reflected in our own series of 30 patients. In all of them the operation has improved considerably the quality of life and no patient so far has regretted the operation.
One hundred and one patients with neurogenic lower urinary tract dysfunction due to myelomeningocele or sacral dysplasia, all older than 10 years of age, with a mean age of 15 years, and under regular urological control for many years were evaluated to discover if they had achieved urinary continence (dry day and night) or the status of socially dry (with dry intervals of more than 3 hours) with conservative means of treatment; or whether they remained incontinent or required operative procedures. The results were correlated with the urodynamic pattern of their detrusor-sphincter dysfunction and with the methods they used for bladder emptying. Special attention was paid to the effects of the various conservative treatment modalities nowadays available. The chances of becoming continent or at least socially dry by conservative therapy are best for patients with sphincter hyperreflexia provided that (1) the detrusor was already hypo- or areflexic, or detrusor hyperreflexia could be successfully controlled, and (2) that regular bladder emptying was achieved by clean intermittent (self) catheterisation. Twenty-four out of 45 patients in this group fulfilled these criteria: 18 are continent, 6 socially dry, a success rate of 54%. In patients with sphincter weakness the outlook is worse: in combination with detrusor hyperreflexia there is only a 16% chance, and in those with detrusor areflexia a 37% chance of becoming continent or socially dry, with the best results in wheelchair patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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While preservation of renal function continues to be the primary objective in the urological care of spinal cord injured patients, new treatment principles have resulted in increased attention being given also to restoration of lost urinary continence, a goal shared by the patient as well. The fact that intermittent catheterization has stood the test also for the long-term management of micturition, as well as the development of effective medication for hyperreflective detrusor relaxation have resulted in a treatment concept that enables 70 percent of those treated to achieve dry intervals between catheterizations. Effective electromiction is today enabled by the sacral anterior root stimulator (Brindley), with continence ensured by sacral deafferentation performed at the same time; both measures have proved successful at medium term. Bladder augmentation is another operative measure for controlling detrusor hyperreflexia. Neurogenic urinary stress incontinence can be tackled successfully by implanting an hydraulic sphincter system (Scott). Both the advantages and the possible disadvantages or risks of these new management concepts are set out, dealing also with their indications. Successful treatment of erectile dysfunction is possible today, and inseminable sperma can be obtained in some 40 to 50 percent of the spinal cord injured patients.
Closed (occult) spinal dysraphism, e.g. lipomyelomeningocele, intraspinal lipoma, diastematomyelia, the tethered spinal cord in its various forms and dysgenesis of the sacrum, is often diagnosed late and only symptoms of neurogenic bladder dysfunction are present. A lipomyelomeningocele mostly causes detrusor and sphincter dysfunction, as was the case in five of six children among our patients. However, improvement of neurological and urological symptoms after the operation can only be achieved in about 40%. Four of eight children with diastematomyelia suffered from neurogenic bladder dysfunction; three have meanwhile undergone surgery with complete recovery in one, no relevant change in the second, and worsening in the third. Originally a specific term, the "tethered spinal cord" when associated with spinal dysraphism has taken on a more general meaning. Nowadays this term is not only used for a short, thickened and tight filum terminale, but comprises any pathology, which prevents the spinal cord from ascending. MRI examination of the craniovertebral junction and spinal cord of patients with treated myelomeningocele often reveals secondary pathologic changes: these may be areas of cord atrophy, hydromyelic cavitation or ventral compression from arachnoid cysts with clinical symptoms mostly after the age of 5 years. In these children a changing urodynamic pattern may therefore be caused by such a pathology and is an indication for a thorough neurological examination including MRI. Of all the dysrhaphic states mentioned above, sacral dysgenesis is the most frequent. The sacral osteological anomaly, as a numerical and as a structural anomaly, also determines the neuro-urological deficit.(ABSTRACT TRUNCATED AT 250 WORDS)
In 21 healthy volunteers and 42 patients with either neurogenic bladder dysfunction (24), partial peripheral denervation of the bladder (12) or nonneurogenic bladder dysfunction (6) scalp-derived evoked potentials after stimulation of the vesicourethral junction (cortical evoked potentials) were recorded. In addition, evoked potentials from the posterior tibial nerve (tibial somatosensory evoked potentials) and from the pudendal nerve (pudendal somatosensory evoked potentials) were evaluated. The results obtained in normal subjects were reproducible and comparable to those reported in previous studies. Cortical evoked potentials of vesicourethral junction consisted of a prominent negativity with a mean latency of 95 msec. Tibial and pudendal somatosensory evoked potentials were similar and showed a typical W-shaped complex. In normal subjects stimulation of the vesicourethral junction was described as a stimulus-synchronous pulsation combined with a continuous burning feeling and sometimes with a desire to void. In 4 normal subjects no cortical evoked potentials of the vesicourethral junction could be obtained because of a decreased pain threshold. In regard to clinical value, the results demonstrate that in patients with lesions of the central nervous system (in the group with cauda equina and conus medullaris lesions, and in the group with suprasacral spinal cord lesions) the results of cortical evoked potentials of the vesicourethral junction and pudendal somatosensory evoked potentials widely correlate due to similar afferent nervous pathways within the central nervous system. However, in patients with partial peripheral denervation of the bladder with suspected additional secondary local detrusor damage the results of cortical evoked potentials obtained by stimulation of the vesicourethral junction differ mostly from the results of somatosensory evoked potentials obtained by stimulation of the pudendal nerve. The pattern obtained (increased sensory and pain threshold, normal cortical evoked potentials of the vesicourethral junction with normal latencies and normal or increased amplitude) is indicative of local detrusor damage. In 21 patients the ability to detect cortical evoked potentials of the vesicourethral junction was combined with the sensation of stimulus-synchronous pulsation, whereas in the other 21 patients the absence of this sensation during stimulation was combined with the absence of cortical evoked potentials. On the other hand, no correlation was found between the ability of obtaining cortical evoked potentials of the vesicourethral junction and the stimulus-induced sensation of pain and/or desire to void.(ABSTRACT TRUNCATED AT 400 WORDS)