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PubMed2001

Video cystometry in young infants with renal dilation or a history of urinary tract infection.

Cystometry is increasingly being used in infants to diagnose bladder dysfunction. However, infantile urodynamic patterns have not been fully established. In this study we investigated the urodynamic patterns in young infants with renal dilation or a history of urinary tract infection, but with no apparent lower urinary tract symptoms. We use video cystometry with simultaneous perineal EMG recording. Thirty-five infants (27 male and 8 female) with congenital renal dilatation or a history of urinary tract infection at age 2 days to 24 months old were involved. We found that detrusor instability occurred in 8.6% of these subjects. Bladder capacity increased with age but less than would nomally be expected. An intermittent voiding pattern was observed in 57% (20/35) of subjects and was characterized by a single or recurring increase in sphincter activity with a simultaneous rise in the voiding detrusor pressure curve. The maximum voiding detrusor pressure with pelvic floor overactivity was significantly higher than that with no pelvic floor overactivity (105+/-44 cmH2O vs 69+/-22 cmH2O, P < 0.001). The median post-voiding residual volume was 2 (range 0 to 65) ml. We conclud that in infants with no apparent lower urinary tract symptoms, bladder instability is uncommon, and the capacity is lower than the normally expected range; an intermittent voiding pattern is common and the residual urine volume showed great variation. This probably represents an immature detrusor-sphincter function.

Dilatation, Pathologic↗
PubMed2005

Mechanisms of Disease: specialized interstitial cells of the urinary tract--an assessment of current knowledge.

Scientists interested in the smooth muscles of the urinary tract, and their control, have recently been studying cells in the interstitium of tissues that express the c-kit antigen (Kit(+) cells). These cells have morphologic features that are reminiscent of the well-described pacemaker cells in the gut, the interstitial cells of Cajal (ICC). The spontaneous contractile behavior of muscles in the urinary tract varies widely, and it is clear that urinary tract Kit(+) interstitial cells cannot be playing an identical role to that played by the ICC in the gut. Nevertheless, there is increasing evidence that they do play a role in modulating the contractile behavior of adjacent smooth muscle, and might also be involved in mediating neural control. This review outlines the properties of ICC in the gut, and gives an account of the discovery of cells in the interstitium of the main components of the urinary tract. The physiologic properties of such cells and the functional implications of their presence are discussed, with particular reference to the bladder. In this organ, Kit(+) cells are found under the lamina propria, where they might interact with the urothelium and with sensory nerves, and also between and within the smooth-muscle bundles. Confocal microscopy and calcium imaging are being used to assess the physiology of ICC and their interactions with smooth muscles. Differences in the numbers of ICC are seen in smooth muscle specimens obtained from patients with various pathologies; in particular, bladder overactivity is associated with increased numbers of these cells.

Humans↗
PubMed2003

Antenatal urodynamic studies in the fetal lamb: experimental protocol and preliminary results.

OBJECTIVES: To set up a fetal lamb model for intrauterine fetal urodynamic studies. METHODS: Fourteen fetal lambs underwent placement of a bladder catheter at a mean gestational age of 87 days. Three fetuses also had a partial urethral obstruction by the simultaneous placement of a peri-urethral constricting ring. Urodynamic and ultrasound studies were performed weekly by the filling cystometry method. RESULTS: Hundred and six voiding cycles were recorded during 25 urodynamic studies between 84- and 133-days gestation. All voiding profiles were biphasic with a mean duration of 4.2 min (range 1-10), a mean voiding pressure of 23 cm of water (range 7-33) and a mean periodicity of 19.2 min (range 11-50). The obstructed animals had bladder overactivity. This correlated with ultrasound and post-mortem findings of megacystis and bilateral hydroureteronephrosis. The fetal mortality rate was 85.7% and the mean duration of survival post surgery was 45 +/- 5.7 days. CONCLUSION: Serial urodynamic studies could be performed in a fetal lamb model. Following partial urethral obstruction, bladder overactivity was observed.

Animals↗
PubMed2004

The evaluation and treatment of female urinary incontinence--a comparison of clinical practice in the Republic of Ireland with the recommendations of the International Continence Society.

In 1998 the International Continence Society (ICS) developed a set of recommendations for the diagnostic evaluation and treatment of urinary incontinence. The aim of this study was to determine to what extent current clinical practice in the Republic of Ireland correlated with the ICS recommendations. We personally interviewed 100 gynaecologists at units around Ireland. Participants were presented with two clinical scenarios, one described a patient with predominantly genuine stress incontinence, the other described a patient with an overactive bladder. Ninety-five (95%) requested a midstream urine sample for culture and sensitivity, and 74 (74%) considered urodynamics an appropriate initial investigation for a woman with stress incontinence. Physiotherapy was recommended as a first line treatment for stress incontinence by 76 (76%). Burch colposuspension, chosen by 55 (55%), was the most common first line surgical procedure. Other first line surgical procedures were TVT [31(31%)] Marshall-Marchetti-Krants procedure [5(5%)], anterior colporrhaphy [4 (4%)] and a variety of other procedures [5 (5%)]. When considering the initial investigation for a woman with an overactive bladder, 95 (95%) asked for a midstream urine sample for culture and sensitivity and 85 (85%) requested urodynamic investigations. Initial management of this condition included anticholinergic therapy alone [57 (57%)], anticholinergic therapy combined with bladder retraining [36 (36%)], bladder retraining alone [5 (5%)], and cystoscopy and bladder distension 2 (2%). Seventy-six (76%) felt that cystoscopy was an appropriate investigation for a woman with symptoms of an overactive bladder who has failed to respond to initial therapy. The study reveals a significant degree of diversity in the evaluation and management of patients who present with symptoms of urinary incontinence. It also highlights a number of areas where current clinical practice deviates from the recommendations of the ICS. In particular, there is a high and inappropriate use of urodynamics in the initial management of these patients.

Adult↗
PubMed2005

Single-institution experience in 110 patients with botulinum toxin A injection into bladder or urethra.

OBJECTIVES: To detail, in a review, one institution's 6-year experience using botulinum toxin A (BTX-A) in the bladder and urethra in 110 patients for a variety of lower urinary tract disorders. METHODS: A total of 110 patients (35 men and 75 women, age range 19 to 82 years) received injections of BTX-A into the bladder (n = 42) or urethra (n = 68). Voiding dysfunction included neurogenic detrusor overactivity and/or detrusor sphincter dyssynergia, overactive bladder, bladder neck obstruction, and interstitial cystitis. Under light sedation in most cases, patients were treated with either 100 to 200 U of BTX-A in 4 mL divided in equal doses into the four quadrants of the external sphincter or by injection into the bladder base using 100 to 300 U of BTX-A diluted in approximately 10 to 30 mL of sterile saline. At last follow-up, 27 patients had received additional injections (up to six) at intervals of 6 months or longer. RESULTS: All patients who underwent bladder BTX-A injection had preoperative evidence of involuntary detrusor contractions during urodynamic testing. Analysis of the 110 patients indicated that 67.3% reported a decrease or absence of incontinence. Diaries indicated a decrease in both daytime and nighttime voiding symptoms. Maximal efficacy occurred between 7 and 30 days and lasted for at least 6 months. Condition-specific quality-of-life symptom scores also demonstrated improvement. No long-term complications had occurred at last follow-up. Two women with multiple sclerosis and mild baseline stress urinary incontinence reported increased leakage with stress after BTX-A external sphincter injection, and one woman with multiple sclerosis noted new onset stress urinary incontinence after external sphincter injection. However, they all reported significant improvement in their detrusor sphincter dyssynergia with decreased postvoid residual urine volume, improved uroflow, decreased urge incontinence, and decreased daytime and nighttime frequency. One woman with multiple sclerosis who underwent bladder injection had increased postvoid residual urine volume from 78 to 155 mL. She did not have to perform intermittent catheterization. CONCLUSIONS: BTX-A injection is a safe and promising treatment modality for a variety of lower urinary tract dysfunctions for both skeletal and smooth muscle dysfunction. In our series, BTX-A is equally effective in women as it is in men. When injected into the sphincter, the risk of stress incontinence is low. Bladder injections with BTX-A are effective for not only neurogenic detrusor overactivity, but also overactive bladder. BTX-A can even be considered for interstitial cystitis.

Adolescent↗
PubMed2005

Effects of pregnancy and child birth on urinary symptoms and urodynamics in women with multiple sclerosis.

OBJECTIVE: Our objective was to study the impact of pregnancy and delivery on vesicourethral disorders in patients with multiple sclerosis (MS). DESIGN AND SETTING: We performed a retrospective chart review of records of women diagnosed with MS who were referred to the clinic. PARTICIPANTS: A total of 102 women with MS (mean age of 44.7 +/- 11.4 years at the time of the study and mean age of 30.0 +/- 9.6 years at the onset of MS) participated in the study. The mean duration of disease was 15 +/- 10 years. The mean Expanded Disability Status Scale score was 5.4 +/- 1.8. MAIN OUTCOME MEASURES: For each patient, demographic data, disease characteristics, urological and obstetrical history and urodynamic data were collected. Urinary disorders were classified as irritative (urinary urgency and frequency) or as obstructive (hesitancy of micturition, reduced or interrupted urinary stream and sensation of incomplete bladder emptying). Urodynamic study consisted of cystometry with continuous recording of urethral sphincter electromyography in 77 (76%) cases. Intravesical and intraurethral pressures were recorded. Bladder dysfunctions were classified into neurogenic detrusor overactivity or detrusor underactivity. RESULTS: Pregnancies and deliveries did not influence symptoms. Moreover, the only statistical difference from a urodynamic point of view was a decrease in maximal urethral closure pressure. CONCLUSION: No interaction between pregnancy, delivery and urinary symptoms was found in this study. The effects of pregnancy and delivery seemed to be the same in women with MS and in healthy women, with a tendency towards a decrease in urethral pressure in women with MS.

Adult↗
PubMed2005

Videourodynamic characteristics and lower urinary tract symptoms of female bladder outlet obstruction.

OBJECTIVES: To analyze the lower urinary tract symptoms (LUTS) and videourodynamic characteristics of female bladder outlet obstruction (BOO). METHODS: Videourodynamic studies were performed in 207 women with signs and symptoms of BOO. Bladder outlet obstruction was defined as the radiologic evidence of bladder outlet narrowing plus a voiding pressure greater than 35 cm H2O and a maximum flow rate less than 15 mL/s or a voiding pressure greater than 40 cm H2O. Women with BOO were categorized into five groups on the basis of the videourodynamic findings. The LUTS and urodynamic parameters were analyzed according to these classifications. RESULTS: Videourodynamic study revealed bladder neck obstruction in 18 patients (8.7%), urethral sphincter obstruction in 56 (27.1%), pelvic floor muscle obstruction in 106 (51.2%), high-grade pelvic organ prolapse and BOO in 13 (6.3%), and urethral stricture in 14 (6.8%). Urgency frequency was reported by 94% and difficult urination by 57% of the total patients. Among the 17 patients with urinary retention, obstruction was noted at the urethral sphincter in 10, pelvic floor muscle in 5, bladder neck in 1, and urethral stricture in 1. Detrusor overactivity was found in 52.7% of total patients and was most frequent in those with urethral sphincter obstruction (78.6%). Patients with bladder neck obstruction had the highest voiding pressure and lowest maximum flow rate. CONCLUSIONS: Differences in videourodynamic characteristics of women with BOO might be associated with the underlying pathophysiology of the bladder, urethral, and pelvic floor muscle dysfunction.

Adolescent↗
PubMed2006

Predictives regarding outcome after transurethral resection for prostatic adenoma associated with detrusor underactivity.

OBJECTIVES: To elucidate the predictive factors regarding the treatment outcomes after transurethral resection of the prostate for symptomatic benign prostatic enlargement with detrusor underactivity. METHODS: A retrospective study was conducted in 190 patients with detrusor underactivity of 1397 men who had undergone transurethral resection of the prostate. All patients had completed the International Prostate Symptom Score and quality-of-life (QOL) questionnaires and had undergone a full urodynamic analysis before surgery. The outcomes were assessed at 3 and 12 months postoperatively using the International Prostate Symptom Score, QOL score, and peak urinary flow rate. The association between the baseline variables and improvement in the outcome variables was analyzed statistically. RESULTS: Preoperative urodynamic abnormalities included bladder outlet obstruction in 58.9% and detrusor overactivity (DO) in 32.1%. Multivariate analysis suggested that the initial level of storage symptoms, as well as the QOL score, were predictive of an improvement in the QOL. Postoperative improvement in symptoms and QOL was consistently influenced by the presence of DO before surgery. The baseline degree of bladder outlet obstruction, as well as patient age, consistently influenced the improvement in the peak urinary flow rate. CONCLUSIONS: In selected patients with benign prostatic enlargement associated with detrusor underactivity, greater baseline storage symptom scores and the presence of DO were negative predictive factors for QOL improvement. Baseline DO was also predictive of poorer improvement in the subjective symptoms after transurethral resection of the prostate. A greater degree of baseline bladder outlet obstruction positively predicted for postoperative peak urinary flow rate improvement, and patient age predicted negatively for it.

Aged↗
PubMed2006

Neurogenic bladder dysfunction after sacrococcygeal teratoma resection.

PURPOSE: SCT treatment in newborns consists of surgery and selective chemotherapy. Few reports document urological sequelae using this approach. This review focuses on the urological and neurourological findings following SCT treatment in the newborn period. MATERIALS AND METHODS: We reviewed the records of all infants with SCT resected in early infancy who underwent urodynamic evaluation for bladder dysfunction between 1986 and 2004. The radiological, neurological and urodynamic findings, and postoperative incontinence management were analyzed. RESULTS: We analyzed UDS of 14 patients who presented with urinary infection or incomplete bladder emptying after SCT resection. At the time of UDS an abnormal neurological examination was noted in 5 patients (36%). Detrusor overactivity was seen in 8 patients, underactivity in 2 and normal activity in 4. Abnormal urethral sphincter EMG potentials were observed in 7 of 13 patients (54%). Five of 13 patients (38%) had sphincter dyssynergia during voiding. Consequently, CIC was needed in 11 of the 14 patients (79%) to empty the bladder, of whom 5 also required anticholinergics to improve detrusor compliance and dryness. Only 3 patients voided spontaneously with normal bladder and sphincter function, of whom 2 were toilet trained. Hydronephrosis was seen in 6 patients and reflux was noted in 7 (including 5 of 6 with hydronephrosis). Antireflux surgery was performed in 6 patients, all of whom had up to grade 4 reflux due to recurrent urinary tract infection. One girl with grade 2 reflux had spontaneous resolution. CONCLUSIONS: SCT and its treatment can produce neurourological dysfunction of the lower urinary tract with high grade reflux, and abnormal bladder and urethral function. Complete assessment, including urodynamic studies, is imperative preoperatively and postoperatively. Constant vigilance is required to maintain as near normal bladder function as possible and to prevent upper urinary tract injury.

Adolescent↗
PubMed2006

Perceptions and behaviours of women with bladder control problems.

OBJECTIVES: To evaluate women's perceptions about bladder control problems. METHODS: 757 Women with one or more bladder control symptoms (frequency, urgency, stress or urge urinary incontinence and nocturia) participated in an Internet-based survey. A separate study involved 12 focus groups including a total of 180 women with bladder control problems. RESULTS: Respondents in the survey reported multiple symptoms, e.g. stress urinary incontinence (72%), frequency (56%), nocturia (45%), urge urinary incontinence (43%) and urgency (33%). Women in both the survey and the focus groups revealed extensive use of coping mechanisms to manage their symptoms. The focus groups revealed that many women were not aware that overactive bladder (OAB) is a pathophysiological condition. Approximately 30% of respondents in the survey felt uncomfortable talking to their doctor about their condition. Among women who did speak with their doctor, stress-related symptoms were described more readily than urge-related symptoms. In the survey, only about half (56%) of the women felt their OAB medication was effective, and half (50%) stopped taking their medication at some point. Information from the focus groups suggested that some women may have unrealistic expectations of onset of efficacy or extent of benefit and may be unprepared for managing side effects. CONCLUSIONS: Feelings of embarrassment and limited understanding of the pathophysiology of OAB can contribute to miscommunication between a woman and her doctor. Patient education regarding reasonable expectations coupled with suggestions for coping with unwanted side effects will likely result in better management.

Adaptation, Psychological↗
PubMed2006

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience.

OBJECTIVE: To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS). PATIENTS AND METHODS: UDS from consecutive women with symptomatic pelvic organ prolapse were reviewed. The protocol included a 'fill-void' study with a vaginal gauze pack, and then repeated without the pack. Tracings were categorized based on filling cystometrograms (CMGs) and pressure-flow studies (PFS). RESULTS: Of 202 women, 121 with a mean (sd) age of 67 (9.4) years contributed 221 interpretable 'pack, then no-pack' UDS (111 CMGs and 110 PFS); 77 of the women had a moderate cystocele and 44 had a large cystocele. Eighty-five women had urethral hypermobility (UH), and 36 had a well-supported urethra (WSU). The pack unmasked stress urinary incontinence (SUI) in 6% of women, with a mean (sd, range) Valsalva leak-point pressure of 54 (22, 23-90) cmH(2)O. SUI occurred more often in women with UH than WSU. Detrusor overactivity occurred similarly in pack (15%) and no-pack (14%) tracings. Bladder outlet obstruction (BOO) was relieved by the pack in 25 studies and caused by the pack in four. Women with WSU had BOO more often than those with UH (43% vs 22%, P < 0.05), regardless of the presence or absence of the pack. CONCLUSION: Unmasked SUI by pack reduction was uncommon, presumably due to anterior vaginal wall stabilization, as the pack rarely caused BOO. Those with SUI had Valsalva leak-point pressures suggestive of intrinsic sphincter deficiency. The pack did not significantly influence the presence of detrusor overactivity.

Adult↗
PubMed2005

Intravesical therapy for overactive bladder.

Overactive bladder and urgency incontinence are common conditions generally treated with oral anticholinergic therapy. Despite the development of new antimuscarinic agents, many patients do not tolerate or fail to respond to oral therapy. Intravesical instillation therapy can provide an alternative method of managing bladder overactivity. Intravesical instillation of anticholinergics such as oxybutynin and atropine can achieve cholinergic blockade without producing systemic side effects. Botulinum A toxin injected directly into the detrusor has been shown in preliminary studies to increase bladder capacity and decrease uncontrolled bladder contractility for up to 6 months. Intravesical local anesthetics such as lidocaine and bupivacaine block the conduction of unmyelinated C fibers and when administered into the bladder, lead to an increase in functional bladder capacity. Intravesical capsaicin and resiniferatoxin also affect afferent innervation by blocking C-fiber afferents, leading to decreased bladder contractility and increased bladder capacity. Intravesical instillation therapy can provide an alternative treatment for the management of overactive bladder.

Administration, Intravesical↗
PubMed2002

Beta3-adrenoceptors in human detrusor muscle.

The detrusor muscle contains beta-adrenoceptors (beta-AR), and 2 subtypes-beta1-AR and beta2-AR-have been identified in most species. Although beta2-AR has an important role in muscle relaxation via activation of adenylate cyclase, evidence suggests that a third subtype, beta3-AR, which is implicated in metabolic functions of endogenous catecholamines, mediates relaxation of human detrusor muscle. There is a predominant expression of beta3-AR messenger RNA (mRNA) in human bladder tissue, with 97% of total beta-AR mRNA being represented by the beta3-AR subtype and only 1.5% and 1.4% by the beta1-AR and beta2-AR subtypes, respectively. Functionally, selective beta3-AR agonists relax human isolated detrusor, whereas selective beta1-AR/beta2-AR agonists do not. Isoproterenol-induced relaxation is inhibited by selective beta3-AR antagonists but not by selective beta1-AR or beta2-AR antagonists. In animal models, beta3-AR agonists increase bladder capacity and have only weak cardiovascular side effects. Although this evidence points toward the clinical utility of beta3-AR agonists as therapy for overactive bladder, clinical trials of beta3-AR agonists identified in animal models as antiobesity agents indicate side effects of tremor and tachycardia. Development of compounds with high selectivity for the human beta3-AR, identified by screening techniques using cell lines transfected with the human beta1-AR, beta2-AR, and beta3-AR genes, may mitigate such problems. Together with the preliminary finding that 49% (21 of 43) of patients with idiopathic detrusor instability have a tryptophan 64 arginine mutation of the beta3-AR gene, which may be a useful genetic marker, evidence points toward beta3-AR being a therapeutic target for treatment of overactive bladder disorder.

Adrenergic Agonists↗
PubMed2005

A developing view of the origins of urgency: the importance of animal models.

Although caution should be used when applying animal data to human physiology, if care is taken to differentiate between general principles and complications of detail, particular to the species being examined, then experimentation on animal models can reveal basic phenomena in the bladder that offer clues to the origin of urgency. Recent data from the whole isolated bladder of guinea pigs showed unexpected complexities in autonomous activity during the filling phase of the micturition cycle: small, transient increases in intravesical pressure were associated with propagating waves of contractile activity and localized stretches of bladder wall. This complex, coordinated activity suggests that there are mechanisms within the bladder wall devoted specifically to generating phasic activity. Thus, there appear to be two systems controlling detrusor contractions: one associated with overall contractions similar to the micturition contraction and the other generating phasic activity. The mechanisms generating the phasic activity appear to be the point of complex integration of both excitatory and inhibitory inputs. There is evidence that local activity in the bladder wall generates afferent discharge, which probably contributes to bladder sensations. Animal data suggest a novel motor/sensory system incorporating contractile (motor) events, which cause stretches resulting in activation of afferent nerves (sensory). The motor element of this system appears to be controlled in a highly complex fashion such that the amplitude and frequency of the motor activity can be modulated by a variety of inputs. This raises the possibility that the sensitivity of the system informing the central nervous system, and thus awareness of the bladder's state during the micturition cycle, can be manipulated, possibly via novel drugs targeted at areas involved in overactive bladder, including urgency incontinence.

Animals↗
PubMed2006

Botulinum toxin injection therapy in the management of lower urinary tract dysfunction.

We have great pleasure in introducing this supplement containing a collection of articles reviewing the contemporary clinical management of functional disorders of the lower urinary tract (LUT) with particular emphasis on the potential role of botulinum toxin injection therapy. Detrusor sphincter dyssynergia (DSD), detrusor overactivity (DO), painful bladder syndrome (PBS) and LUT symptoms consequent on bladder outflow obstruction (LUTS/BPH) have all been treated by the injection of botulinum toxin. This treatment can be administered as a minimally invasive, outpatient procedure which on the initial trials for DO (particularly of neurogenic aetiology) shows a remarkable efficacy with effects lasting up to a year after a single treatment with few significant side effects. Success has been reported with the management of detrusor sphincter dyssynergia and preliminary series report positive outcomes in the management of PBS and LUTS/BPH. However, most of the studies to date include small numbers and have a recruitment bias with few randomised controlled trials having been reported. The answers to some of the key questions are addressed with reference to our contemporary knowledge. It is clear that considerable work both clinical and basic science still needs to be performed to answer the many remaining questions with regard to this treatment modality but undoubtedly it will be a major future treatment option in those with intractable symptoms or those unable to tolerate medications. Currently, all botulinum toxin use for urological conditions is off-label and unlicensed, therefore caution should be exercised until future large randomised studies are reported.

Botulinum Toxins, Type A↗
PubMed2003

Simplified bladder training augments the effectiveness of tolterodine in patients with an overactive bladder.

OBJECTIVES: To compare the efficacy of tolterodine plus simplified bladder training (BT) with tolterodine alone in patients with an overactive bladder. PATIENTS AND METHODS: In a multicentre, single-blind study at 51 Scandinavian centres, 505 patients aged >or= 18 years with symptoms of urinary frequency (>or= 8 micturitions/24 h) and urgency, with or without urge incontinence, were randomized to oral treatment with either tolterodine 2 mg twice daily plus simplified BT or tolterodine alone. Changes in voiding diary variables were evaluated after 2, 12 and 24 weeks of treatment. The patients' perceptions of their bladder symptoms and tolerability (adverse events) were also determined. RESULTS: In all, 501 patients (75% women) were evaluable on an intention-to-treat basis (244 on tolterodine + BT and 257 on tolterodine alone). Tolterodine significantly reduced the voiding frequency and increased the volume voided per void at all sample times; these effects were significantly increased by adding BT. At the end of the study the median percentage reduction in voiding frequency was greater with tolterodine + BT than with tolterodine alone (33% vs 25%, P < 0.001), while the median percentage increase in volume voided per void was 31% with tolterodine + BT and 20% with tolterodine alone (P < 0.001). There was a median of 81% fewer incontinence episodes than at baseline with tolterodine alone, which was not significantly different from that with tolterodine + BT (- 87%). The two groups had comparable median percentage reductions in urgency episodes. Some 76% of patients on tolterodine + BT reported an improvement in their bladder symptoms relative to baseline, compared with 71% on tolterodine alone. Tolterodine was well tolerated; the most common adverse event was mild dry mouth. CONCLUSION: Tolterodine 2 mg twice daily is an effective and well tolerated treatment for an overactive bladder, the effectiveness of which can be augmented by a simplified BT regimen.

Administration, Oral↗
PubMed2006

Incomplete emptying and urinary retention in multiple-system atrophy: when does it occur and how do we manage it?

Neurogenic urinary retention can be a major cause of morbidity in multiple-system atrophy (MSA). However, the timing of its appearance has not been entirely clear, and neither have the medical and surgical modalities for managing patients. We present the data obtained from our uroneurological assessment and therapeutic interventions at various stages of MSA. We recruited 245 patients with probable MSA. We measured postvoid residuals (PVR) and performed EMG cystometry in all patients. The grand average volume of PVR was 140 mL (range, 0-760) in our patients. The average PVR volume was 71 mL in the first year, increasing to 129 mL in the second year and 170 mL by the fifth year. The percentages of patients with complete urinary retention, acontractile detrusor, and detrusor-sphincter dyssynergia (DSD) also increased. The increase in PVR resulted in a decrease in functional bladder capacity, together with an increase in detrusor overactivity and neurogenic sphincter EMG. Clean intermittent self-catheterization (CISC) was introduced in most patients. Bladder-oriented therapy (cholinergic agents) had a limited value, whereas urethra-oriented therapy benefited patients with DSD (surgery) for up to 2 years, but syncope occurred in a subset of patients (alpha-blockers). MSA patients present with large PVR by the second year of illness, and that large PVR secondarily causes urinary frequency. CISC is the recommended treatment for most patients. Urethra-oriented medication and surgery benefit patients who would have difficulty performing CISC, although careful consideration of the short-term efficacy and potential adverse effects of these alternatives is mandatory.

Adrenergic alpha-Antagonists↗