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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↗
PubMed2006

Nerve growth factor and prostaglandins in the urine of female patients with overactive bladder.

PURPOSE: NGF and PGs in the bladder can be affected by pathological changes in the bladder and these changes can be detected in urine. We investigated changes in urinary NGF and PGs in women with OAB. MATERIALS AND METHODS: The study groups included 65 women with OAB and 20 without bladder symptoms who served as controls. Evaluation included patient history, urinalysis, a voiding diary and urodynamic studies. Urine samples were collected. NGF, PGE2, PGF2alpha and PGI2 were measured using enzyme-linked immunosorbent assay and compared between the groups. In addition, correlations between urinary NGF and PG, and urodynamic parameters in patients with OAB were examined. RESULTS: Urinary NGF, PGE2 and PGF2alpha were significantly increased in patients with OAB compared with controls (p <0.05). However, urinary PGI2 was not different between controls and patients with OAB. In patients with OAB urinary PGE2 positively correlated with volume at first desire to void and maximum cystometric capacity (p <0.05). Urinary NGF, PGF2alpha and PGI2 did not correlate with urodynamic parameters in patients with OAB. CONCLUSIONS: NGF and PGs have important roles in the development of OAB symptoms in female patients. Urinary levels of these factors may be used as markers to evaluate OAB symptoms.

Adult↗
PubMed1996

Micturition in conscious rats with and without bladder outlet obstruction: role of spinal alpha 1-adrenoceptors.

1. In normal rats and rats with bladder hypertrophy secondary to outflow obstruction, undergoing continuous cytometry, we examined the responses to the selective alpha 1-adrenoceptor antagonist doxazosin given intrathecally (i.t.) and intra-arterially (i.a.). In addition, we investigated the effects of the drug on L-dopa-induced bladder hyperactivity in normal, unobstructed rats. 2. Doxazosin 50 nmol (approximately 60 micrograms kg-1), given i.t., decreased micturition pressure in normal rats and in animals with post-obstruction bladder hypertrophy. The effect was much more pronounced in the animals with hypertrophied/overactive bladders. Doxazosin did not markedly affect the frequency or amplitude of the unstable contractions observed in obstructed rats. In contrast, however, doxazosin reduced L-dopa-induced bladder overactivity. When tested, the enantiomers of doxazosin produced qualitatively similar effects to doxazosin, but there was no evidence of stereoselectivity. 3. The results suggest that in addition to the well documented action on prostatic and lower urinary tract smooth muscle, and an effect on the sympathetic outflow to the bladder, bladder neck, prostate, and external urethral sphincter, doxazosin may have an action at the level of the spinal cord and ganglia, thereby reducing activity in the parasympathetic nerves to the bladder. This effect is more pronounced in rats with bladder hypertrophy than in normal rats.

Adrenergic alpha-Antagonists↗
PubMed2002

Muscarinic receptor subtypes and management of the overactive bladder.

Anticholinergic agents are the most widely used therapy for urge incontinence despite exerting adverse effects, such as constipation, tachycardia, and dry mouth, that limit their use. These adverse effects result from a lack of selectivity for the bladder over other organs. Although M2-muscarinic receptors are the predominant cholinoreceptor present in urinary bladder, the smaller population of M3-receptors appears to be the most functionally important and mediates direct contraction of the detrusor muscle. M2-receptors modulate detrusor contraction by several mechanisms and may contribute more to contraction of the bladder in pathologic states, such as bladder denervation or spinal cord injury. Prejunctional inhibitory M2-receptors or M4-receptors and prejunctional facilitatory M1-muscarinic receptors in the bladder have also been reported, but their relevance to the clinical effectiveness of muscarinic antagonists is unknown. In clinical studies, tolterodine, a nonselective muscarinic antagonist, has been reported to be equally effective to oxybutynin but to induce less dry mouth. Controlled-release and intravesical, intravaginal, and rectal administrations of oxybutynin have all been reported to cause fewer adverse effects. Conversely, darifenacin, a new M3-selective antagonist, has been reported to have selectivity for the bladder over the salivary gland in vivo. Whether M3-selective or nonselective muscarinic antagonists will be the most clinically effective for the overactive bladder-preserving the best balance between efficacy and tolerability-has yet to be established, and comparative clinical trials between compounds, such as darifenacin (M3 selective) and tolterodine (nonselective) will be required.

Cholinergic Antagonists↗
PubMed2003

Bladder wall thickness on ultrasonographic cystourethrography: affecting factors and their implications.

OBJECTIVE: To explore factors affecting bladder wall thickness on ultrasonographic cystourethrography in female patients with lower urinary tract symptoms. METHODS: The records of 492 female patients with lower urinary tract symptoms who had undergone a urodynamic study and ultrasonography of the lower urinary tract and who had normal urinalysis findings, negative urine culture results, or both were identified from our urogynecologic database. These included 248 patients with urodynamic stress incontinence, 38 with detrusor overactivity, 39 with mixed incontinence, 35 with a hypersensitive bladder, 42 with voiding difficulty, and 90 with normal urodynamic findings. RESULTS: Age, resting bladder neck angle, urethral mobility, and maximum urethral closure pressure were significantly associated with bladder wall thickness at the trigone and dome. Bladder wall thickness at the trigone was correlated with that at the dome (P < .0001). Bladder wall thickness at the trigone was positively correlated with pressure transmission ratios in the first and second quarters of the urethra (P < .0001; P = .002, respectively), whereas that at the dome was positively correlated with intravesical pressure at maximum flow and with detrusor opening pressure (P = .027; P = .046, respectively). Age and intravesical pressure at maximum flow were independently associated with bladder wall thickness at the trigone and dome (P = .007; P = .028), respectively. A thickened bladder wall was a common finding in female lower urinary tract symptoms, except in the patients with a hypersensitive bladder. CONCLUSIONS: Demographic, anatomic, and urodynamic factors may affect the bladder wall thickness at the trigone, dome, or both.

Female↗
PubMed1997

Effects of the K+ channel opener, ZD6169, on volume and PGE2-stimulated bladder activity in conscious rats.

PURPOSE: To investigate the effects of the new K(ATP) channel opener, ZD6169, shown to have an in vivo selectivity for the bladder, on bladder activity in rats. MATERIALS AND METHODS: ZD6169 was given intra-arterially (i.a., 0.1 and 1 mg./kg.) or orally (3 mg./kg.) to conscious Sprague-Dawley rats undergoing continuous cystometry. Investigations were also performed before and after stimulation of bladder activity by intravesical prostaglandin (PG) E2. RESULTS: Intra-arterial ZD6169 increased residual volume, but caused no changes in other cystometric parameters. In rats receiving oral ZD6169, cystometric parameters were compared (every hour up to five hours) to those recorded in rats receiving oral vehicle. No differences were found, except in threshold pressure, which was significantly increased. Intravesical PGE2 20 microM increased micturition and basal pressures, and decreased bladder capacity and micturition volume. ZD6169 1 mg./kg., given i.a., reduced or completely prevented the activity induced by intravesical PGE2. Three hours after orally administered ZD6169 (3 mg./kg.), intravesical PGE2 20 microM had no effect. Three hours after oral administration of vehicle, the effects of PGE2 were attenuated, but still statistically significant. CONCLUSIONS: ZD6169, given i.a. or orally, increased threshold pressure, but had otherwise little effect on volume-induced micturition. However, the drug markedly reduced or prevented PGE2-induced bladder activity when given i.a.; it was also effective when given orally. If ZD6169 has inhibiting effects on bladder contraction in man without any cardiovascular actions, the drug may represent a novel, promising way of treating bladder overactivity.

Administration, Intravesical↗
PubMed2002

Role of cystometry in evaluating patients with overactive bladder.

Overactive bladder (OAB) can be caused by a variety of conditions. We believe that cystometrography (CMG) is an essential part of the diagnostic evaluation, both in defining underlying pathophysiology and directing treatment. Essential to the diagnosis of OAB syndrome is some combination of urinary frequency, urgency, urge incontinence, and pain. CMG can be thought of simply as a provocative test to determine whether bladder filling, involuntary detrusor contractions, or low bladder compliance in fact reproduces any of these symptoms, and whether the symptoms abate when the bladder is empty or when the pressure decreases. At another level, the CMG has been likened to "the reflex hammer" of the lower urinary tract and, as such, provides important neurologic information. Finally, the voiding phase of the CMG is an essential component of the detrusor pressure/uroflow study, which is the only accurate method of diagnosing urethral obstruction and impaired detrusor contractility. Both of these conditions can coexist with detrusor overactivity. The treatment of OAB depends on the underlying cause. We believe that only by understanding the particular cystometric characteristics of patients with OAB can we determine the appropriate treatment. Urodynamic testing should serve as an essential part of therapy and guide future research in diagnosis and management.

Aged↗
PubMed2002

Etiology, pathogenesis, and diagnosis of interstitial cystitis.

Interstitial cystitis (IC) is a bladder syndrome of unknown etiology. The cause of IC is most likely multifactorial and includes genetic and environmental factors. Various pathophysiological changes in the bladder, pelvis, and peripheral and central nervous systems have been identified, and this has led to the emergence of biologically specific treatment modalities. Interstitial cystitis is being diagnosed with increasing frequency; however, current diagnostic criteria are non-uniform, and there is significant overlap between chronic pelvic pain syndromes in men and women, interstitial cystitis, recurrent "cystitis," and the overactive bladder syndrome. The diagnosis of interstitial cystitis can be made clinically and by cystoscopy and hydrodistension. The sensitivity and specificity of urinary markers and the potassium sensitivity test have not been prospectively studied.

Journal Article↗
PubMed1981

Pharmacological studies of the uninhibited neurogenic bladder. II. The influence of cholinergic excitatory and inhibitory drugs on the cystometrogram of neurological patients with normal and uninhibited neurogenic bladder.

In order to elucidate the parasympathetic activity of the uninhibited neurogenic bladder, controlled cystometry before and during influence of cholinergic and anticholinergic drugs has been performed on patients with normal and uninhibited neurogenic bladder. Cholinergic stimulation proved to increase the intravesical pressure to a great extent; to a higher degree in the normal than in the uninhibited bladder. In two patients with normal bladder, uninhibited detrusor contractions were induced by cholinergic stimulation. Cholinergic inhibition had only minor influence on the intravesical pressure during the filling phase. Opposite effects were obtained on the uninhibited detrusor contractions which are regarded as a part of the expulsive phase. Cholinergic stimulation increased the amplitude of the uninhibited bladder to some degree, but cholinergic inhibition markedly reduce the amplitude. Conclusively, the uninhibited neurogenic bladder is at least partly caused by an overactivity in cholinergic stimulation.

Adult↗
PubMed2006

The effects of isolated posterior compartment defects on lower urinary tract symptoms and urodynamic findings.

OBJECTIVES: To determine any significant patterns among subjective and/or objective storage or voiding variables in women with isolated rectoceles or posterior enteroceles. PATIENTS AND METHODS: We retrospectively reviewed the charts of 23 women with isolated posterior compartment defects. Patient histories, physical examination findings, catheterized postvoid residual urine volume (PVR) after uroflowmetry, and urodynamic evaluations were reviewed. Lower urinary tract symptoms (LUTS) were classed as pure storage (urgency, frequency, nocturia, etc.), pure voiding (hesitancy, straining, positional voiding, etc.), or mixed. RESULTS: The mean (range) age of the women was 67 (48-85) years. On physical examination, 15 women had a grade 3 defect, and eight a grade 2 defect. Thirteen women reported symptoms related to their prolapse (vaginal bulge, splinting with defecation): nine reported pure storage symptoms, one pure voiding symptoms, and 12 mixed symptoms; two women relied on catheterization for bladder emptying. Only one woman reported no LUTS. An elevated PVR (>100 mL) was found in 11 women (48%). Urodynamic studies were available for 17 women, and revealed detrusor overactivity in nine of them. There were low maximum urinary flow rates (Qmax < or = 15 mL/s) in 12 of the 17 women, and high voiding pressures at Qmax (P(det.Qmax) > or = 20 cmH2O) in 10. Both findings were present in seven of the 17 women. There was evidence of abdominal straining to void in nine of the 17 women. CONCLUSIONS: The overwhelming majority of women with isolated posterior compartment defects reported bothersome LUTS and most had abnormal urodynamic variables. The findings suggest that significant posterior prolapse defects can cause bladder outlet obstruction.

Aged↗
PubMed2003

[Clinical manifestations of urinary disorders and their treatment in ageing men].

PROBLEMS OF THE PROSTATE: Benign hypertrophy of the prostate (BHP), when it occurs, is manifested by an obstruction or irritation related to overactivity of the bladder. The obstructive syndrome is defined by urodynamic tests. Urge incontinence and study of the pressure-flow ratio are the tests of choice. The functional handicap and impact on quality of life are assessed using the International Prostatism Symptoms Score (I-PSS). Efficient and fairly well tolerated medical treatment has reduced the indications for surgery. It relies on alpha-blockers, 5a-reductase inhibitors and phytotherapy. When indicated, the surgical treatment of choice is endoscopic resection of the prostate. Among the non-prostatic micturition disorders, urge micturition with, in extreme cases, incontinence are due to detrusor instability. This is of multifactor origin; enhanced by the local irritation or environmental factors, it usually occurs within a context of acute or chronic pathologies. Treatment is recommended with anticholinergic agents. New molecules have recently been launched, better tolerated than oxybutinine. Electrostimulation can be a good alternative in mentally normal patients. Micturition due to excess urine may be due to overactivity of the bladder, the major risk of which is acute urine retention. It can also be observed during neurological affections such as Parkinson's disease or during administration of certain drugs. Nocturnal polyuria is a frequent problem. However, simple hygiene and dietary measures and the control of certain concomitant diseases can usually relieve the symptoms. Medical treatment relies on desmopressine.

Adult↗
PubMed2003

Alpha blocker therapy for children with dysfunctional voiding and urinary retention.

PURPOSE: Alpha blocker therapy has been successfully used to decrease residual urine in children with complex neuropathic and nonneuropathic voiding dysfunction. We evaluated the safety and efficacy of using selective alpha blocker therapy for children with uncomplicated voiding dysfunction and underlying poor bladder emptying. MATERIALS AND METHODS: A total of 55 patients with a mean age of 7.9 years presented with symptoms of urinary incontinence, urgency and urinary tract infection. All patients had increased post-void residual (PVR) on bladder ultrasound, with a mean residual volume of 65 ml (22% of age expected capacity). All patients were treated with doxazosin, a selective alpha-1 adrenergic antagonist, at dosages of 0.5 mg to 2.0 mg daily. Of the patients 38 were treated at presentation with a regimen of anticholinergics, timed voiding and antibiotic prophylaxis before initiating alpha blocker therapy. Patients were reevaluated with post-void ultrasound of the bladder 6 weeks after initiating alpha blocker therapy. RESULTS: After starting doxazosin average PVR decreased to 8 ml (p <0.0001), representing an 88% reduction in residual urine (or reduction to only 2.7% of age expected bladder capacity). Medication was discontinued in 2 patients due to minor side effects. CONCLUSIONS: Selective alpha blocker therapy appears to be effective for improving bladder emptying in children with an overactive bladder, wetting, recurrent infection and increased PVR urine. This therapy may be used as either a replacement or in addition to biofeedback in patients with urinary retention. Further investigation, including a prospective randomized trial of alpha blocker therapy in children with urinary tract dysfunction, is warranted based on the findings of our study.

Adolescent↗
PubMed2002

Overactive bladder--pharmacological aspects.

The micturition reflex can be initiated by contraction or distension of detrusor smooth muscle cells, or by signals from the urothelium. It has been shown that bladder distension causes release of ATP from the urothelium, and that ATP can activate P2X3 receptors on suburothelial afferent nerve terminals to evoke a neural discharge. However, most probably the activation of afferent fibres during bladder filling involves not only ATP, but a cascade of inhibitory and stimulatory transmitters/mediators. These mechanisms may be targets for future drugs. Both in the normal and functionally disturbed bladder, muscarinic receptor stimulation produces the main part of detrusor contraction, but evidence is accumulating that in disease states, such as neurogenic bladders, outflow obstruction, idiopathic detrusor instability, interstitial cystitis, and also in the ageing bladder, a non-cholinergic activation via purinergic receptors may occur. If this component of activation is responsible not only for part of the bladder contractions, but also for the symptoms of the overactive bladder, it should be considered an important target for therapeutic interventions. Drags blocking different P2X receptor subtypes, or counteracting bladder contraction via other mechanisms, e.g. beta3-adrenoceptor stimulation, may be developed for treatment of the overactive bladder.

Adenosine Triphosphate↗
PubMed1994

Urodynamic characteristics of women with complete posthysterectomy vaginal vault prolapse.

OBJECTIVES: To review the symptoms and lower urinary tract function in women with posthysterectomy vaginal vault prolapse. METHODS: A retrospective review was carried out of the urodynamic records of 19 women with posthysterectomy vaginal vault prolapse who had been evaluated in the Bladder Function Laboratory of the Department of Obstetrics and Gynecology at Duke University Medical Center. RESULTS: A full urodynamic evaluation was carried out on 19 women who had had a hysterectomy and who had subsequently experienced complete prolapse of the vaginal vault. Vaginal eversion produced massive distortion of the lower urinary tract and was associated with complex symptoms. Among the cystometric findings in these patients was an early average first desire to void (94 mL) and a reduced average cystometric capacity (370 mL). Symptoms of voiding difficulty were common. During noninstrumented uroflowmetry, the average peak and mean flow rates were reduced in these women (16.5 mL/s and 8.1 mL/s, respectively), suggestive of functional obstruction of the outlet due to the prolapse. Pressure-flow voiding studies showed a reduced peak flow rate (11 mL/s) with an increased detrusor pressure at peak flow (50 cm H2O), also indicative of functional obstruction. All women underwent urethrocystoscopy, and no patient had a urethral stricture or urethral stenosis. Although symptoms of urgency (79%) and urge incontinence (63%) were common, detrusor instability was confirmed by urodynamic studies in only 3 women (16%), suggesting that urge-related symptoms in these women may often be due to anatomic distortion of the lower urinary tract rather than to detrusor overactivity. "Genuine" stress incontinence was documented in only 2 women (11%) during cystometry; however, when these patients were examined with full bladders with their prolapses reduced and returned to a normal anatomic position with a single-bladed speculum, the physical sign of stress incontinence was demonstrated in all 9 women (47%) who had a complaint of stress incontinence. This suggests that massive vaginal prolapse may mask an incompetent continence mechanism, which may then be revealed after surgical repair of the prolapse. CONCLUSIONS: Women with posthysterectomy vaginal vault prolapse present complicated reconstructive problems for the pelvic surgeon. The same pathophysiological process may produce both voiding dysfunction and stress incontinence. These patients should be evaluated carefully before surgical repair is undertaken. Stress incontinence may not be demonstrated in these patients unless they are examined with a full bladder with their prolapse carefully reduced to a normal anatomic position. Women who demonstrate stress incontinence with the vaginal prolapse reduced and the urethra supported normally should be suspected of having "type III" incontinence (demonstrable stress incontinence in the presence of normal urethral support). Women with these findings may require a suburethral sling procedure if they are to remain continent after correction of posthysterectomy vaginal vault eversion.

Adult↗