Ambulatory urodynamics

Ambulatory monitoring of lower and upper urinary tract continues to develop. The addition of electronic urine-loss measurements to indicate the exact time-related loss is an important new feature. In the near future, quantitative urine-loss measurements will become available. The additional possibility of plugging in a flowmeter completes the technique with respect to pressure-flow analysis. At present, however, ambulatory urodynamics is still confined to specialized urodynamic centers. Ambulatory urodynamic monitoring has shown that de-novo detrusor instability after a suspension operation is frequently missed as a preoperative diagnosis of detrusor overactivity. The first steps are being taken toward giving a quantitative analysis of detrusor activity during the filling phase. This justifies a more widespread use of this ambulatory monitoring.     

Insufficient detrusor contractility: a urodynamic and morphologic entity in prostatism

OBJECTIVES: To analyze the urodynamic and ultrastructural characteristics of impaired detrusor contractility in patients with prostatism in comparison with lower urinary tract obstruction. METHODS: The study comprised 200 male patients (mean age 65.3 years) with prostatism submitted to a complete urodynamic study. An ultrastructural study was randomly performed in 40 patients and analyzed 600 detrusor muscle images to determine the smooth muscle cell and interstitial changes. Detrusor urodynamics were compared with the ultrastructural cell and interstitial changes of the bladder smooth muscle. RESULTS: Urinary symptoms or free flowmetry alone failed to predict detrusor urodynamics. Urodynamic diagnosis was based on the detrusor pressure-flow study. We observed ultrastructural degenerative cell changes with statistical significance in impaired detrusor contractility such as no branching and intertwining of cells, absence of caveoles, perinuclear degeneration with vacuolization, destructured myofilament system with diminished anchorage plates and collagen infiltrating the interstitium with loss of bladder muscle fascicle organization. CONCLUSIONS: Impaired detrusor contractility is a urodynamic diagnosis that should be taken into account in patients with prostatism. The diagnosis of this condition requires performing a pressure-flow study. Impaired detrusor contractility showed a morphological and ultrastructural correlation with degenerative changes of the bladder muscle.     

Efficacy and safety of fluorescein angiography with orally administered sodium fluorescein

OBJECTIVE: To investigate the clinical effects on detrusor overactivity of a new method of transcutaneous reciprocal electrical stimulation of the thigh muscles. PATIENTS AND METHODS: Nineteen patients with detrusor overactivity, comprising 14 with detrusor hyperreflexia (DH) and five with idiopathic detrusor instability (IDI), were studied. Electrical stimulation was applied alternately to the quadriceps and hamstring muscles of one or both legs through surface electrodes for 20 min. The treatment was given once a day for 14 days and then the patients were evaluated urodynamically. RESULTS: All 19 patients tolerated the therapy well and none reported any adverse effects. The mean maximum cystometric capacity increased significantly (P < 0.05) after treatment. In 11 of the 19 patients, the maximum cystometric capacity was increased by > 50% of the pretreatment value; this occurred in eight of 14 of those with DH and in three of five of those with IDI. In six of the 11 who responded in this way, there was a clinical improvement in their urinary incontinence and frequency for several weeks to 3 months after the period of therapy. A second 14-day treatment was also effective in all four patients who underwent a repeat trial. CONCLUSION: This method of transcutaneous electrical stimulation can inhibit DH as well as IDI with no adverse effects. The suppressive effect on detrusor overactivity may persist for several months and repeat trials appear to be effective. Thus, we believe that this new stimulation technique should be tried as an alternative to other types of electrical stimulation and augmentation cystoplasty.     

Detrusor contractility and compliance characteristics in adult male patients with obstructive and nonobstructive voiding dysfunction

PURPOSE: To understand better the contractility and compliance characteristics of the detrusor in patients with varying degrees of outlet obstruction, we analyzed urodynamic studies in elderly men with obstructive and nonobstructive voiding dysfunction. MATERIALS AND METHODS: All patients were evaluated with video urodynamics, including cystometry, isometric tests, voiding profilometry and post-void residual measurement. Bladder compliance, detrusor contractility, detrusor reserve, detrusor instability and the severity of outlet obstruction were determined in each patient. Patients were stratified into 4 groups: urodynamically normal, detrusor instability, outlet obstruction and outlet obstruction with detrusor instability. RESULTS: A significant correlation was found between the maximum isometric contraction pressure and the severity of obstruction in 168 patients. Maximum isometric contraction pressure was significantly greater in patients with than without obstruction, independent of detrusor instability. Although compliance was not significantly different among the groups, the proportion of patients with poor compliance (less than 30 ml./cm. water) was lowest in the normal group. The detrusor reserve was significantly less in patients with chronic retention (post-void residual more than 200 ml.) than in those with lower post-void residuals. CONCLUSIONS: The increase in detrusor contractility with increasing outlet obstruction suggests a compensatory response to obstruction. Furthermore, a decrease in bladder compliance does not appear to be a consistent finding in patients with outlet obstruction, although the proportion of patients with poor compliance is higher in the group with obstruction and/or detrusor instability than in those with normal urodynamic findings. The decrease in detrusor reserve in patients with high post-void residual volumes suggests that the detrusor reserve reflects the degree of detrusor decompensation.     

Structural basis of geriatric voiding dysfunction. VI. Validation and update of diagnostic criteria in 71 detrusor biopsies

PURPOSE: Refined criteria of distinctive patterns of detrusor ultrastructure in geriatric voiding dysfunctions have been developed as standard protocols for pathological evaluation of detrusor biopsies. This study was performed to test completeness and routine applicability of these protocols, corroborate our original ultrastructural/urodynamic correlations in larger material and identify subtle correlations that may have been elusive in our original study of 35 cases. MATERIALS AND METHODS: A total of 71 endoscopic detrusor biopsies was obtained from 44 elderly subjects grouped following comprehensive clinical and urodynamic evaluation into those with normal aging bladder, detrusor overactivity, impaired detrusor contractility, bladder outlet obstruction or a combination. Biopsies were evaluated ultrastructurally and randomly, and blinded to clinical information. Using standard protocols the primary ultrastructural pattern(s) was identified, additional auxiliary features were recorded and pathological diagnoses were made. Biopsies were grouped accordingly, still blindly, and correlated with urodynamic groups determined independently prior to biopsy. RESULTS: Our observations confirmed that the standard protocols are complete and readily applicable to routine ultrastructural evaluation of detrusor biopsies. They corroborated our previously reported ultrastructural/urodynamic matching of the biopsies in every case and revealed new constant features of the normally aging detrusor. We identified ultrastructural correlates distinguishing moderate and severe from mild or borderline (but not moderate from severe) impairment of detrusor contractility. CONCLUSIONS: The proposed protocols are consistently applicable to the routine pathological diagnosis of geriatric voiding dysfunction in detrusor biopsies. A diagnostic algorithm was developed to serve as a practical guide for making such diagnoses, and gaining insights into the pathophysiology of geriatric and possibly other voiding dysfunctions.     

Parameters affecting the efficiency of affinity-based reversed micellar extraction and separation (ARMES) in glycoprotein purification

The Bladder Neck Support Prosthesis (BNSP) was used in 21 women with combined genuine stress incontinence (GSI) and detrusor instability (DI). Outcomes included frequency volume charts, pad tests, voiding cystometry and quality of life scores, up to the sixth month. Of the 21 recruits, 5 never wore the BNSP home, leaving 16 participants. A further 2 did not reach week 4 because of poor efficacy or inability to fit the device. In the 14 who reached week 4, the median number of leaks/day declined from 4.3 to 1.0 (p = 0.002). Median pad test loss fell from 53 to 7 mL (p = 0.012). Cystometry showed an increase in maximum bladder capacity (p < 0.05) and a modest reduction in severity of detrusor instability, with no evidence of outflow obstruction. Three further women discontinued because of poor efficacy (2) or a poorly fitting device (1), leaving 11 of 16 participants (69%) at week 8, when median pad test loss fell to 2 mL. The BNSP is a useful option in patients with the unfortunate combination of an unstable bladder and an incompetent urethra, but requires careful fitting and attention to detail.     

Treatment of overactive bladder syndrome and detrusor overactivity

The overactive bladder syndrome is a relatively new-term defined by the International Continence Society in 2002. Previous definitions were based on urodynamic diagnoses; however, the overactive bladder syndrome is a symptomatic diagnosis with urgency as the cornerstone symptom, thus allowing treatment to be initiated by primary care physicians before embarking on complex investigations. It affects millions of people worldwide and has considerable economic costs. Its aetiology is unknown but some people suggest that it may be a nerve-related problem while others suggest that it may be a muscle-related problem. The true cause probably lies somewhere between the two theories. With this in mind, treatment is aimed at relief of symptoms and improving quality of life. Conservative treatments combined with antimuscarinic drugs are the main treatment for overactive bladders. There are many antimuscarinics available, with several under development, which have different specificities for the muscarinic receptors. Other drugs have also been tried but with limited success.If conservative and oral medical treatments fail, the options include intravesical therapy, neuromodulation or major surgery. However, urodynamics are essential for patients referred for these treatments, which are mainly initiated by specialists rather than primary care physicians. The aim of this review is to give an overview of the overactive bladder and detrusor overactivity, their diagnosis and treatment options.     

Videourodynamic studies

Videourodynamic evaluation that incorporates radiographic imaging with simultaneous measurement of bladder and urethral pressure is the most precise method available for diagnosing complex incontinence and voiding disorders. In addition, videourodynamics has been instrumental to the development of our present knowledge about urethral and bladder function including the concepts of detrusor and abdominal leak point pressures. Although these studies are more expensive and time consuming, the authors have found videourodynamic evaluation indispensable when the diagnosis remains in question after simple urodynamics and when the studies and clinical scenario do not agree.     

A statistics primer. Prevalence, incidence, relative risks, and odds ratios: some epidemiologic concepts in the sports medicine literature

OBJECTIVE: To assess the efficacy of salivary stimulant pastilles in improving tolerance of and compliance with oxybutynin chloride for detrusor instability. PATIENTS AND METHODS: Thirty women with detrusor instability were treated with oxybutynin in either a fixed or variable dose. After 3 weeks, patients were given salivary stimulant pastilles (Salivix, Thames Laboratories, Clwyd, UK) to chew as often as required. Symptom diaries were used to record episodes of dry mouth (xerostomia) together with a 100 mm visual analogue scale (VAS) score of the severity of xerostomia. RESULTS: The frequency of xerostomia was unchanged but there was a significant decrease in median severity from 71 to 39 on the VAS (P < 0.05, Mann-Whitney U-test). Nine patients on the variable-dose regimen tolerated a higher dose of oxybutynin when taking the pastilles (P < 0.01, Wilcoxon's matched-pairs test). CONCLUSION: Salivary stimulant pastilles appear to be a useful adjuvant therapy for patients receiving oxybutynin chloride for detrusor instability, allowing higher doses of oxybutynin to be tolerated.     

Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable?

PURPOSE: Some patients with acute urinary retention due to benign prostatic hyperplasia do not have successful outcome after prostatectomy and require either a chronic indwelling urethral catheter or clean intermittent catheterization. Urodynamic and clinical parameters were examined preoperatively in 81 men 56 to 93 years old (mean age 72 years) in search of an outcome predictor after prostatectomy. MATERIALS AND METHODS: International Prostate Symptom Score, prostate volume, retention episodes, retention volume and urodynamic parameters from a multichannel pressure-flow study were analyzed preoperatively and postoperatively. All patients underwent transurethral prostatectomy and were reexamined 2, 4, 12 and 24 weeks after surgery. A multichannel pressure-flow study was performed preoperatively and 12 weeks postoperatively. RESULTS: At 24 weeks postoperatively 11 patients (13%) were unable to void and therefore classified as treatment failures while the remaining patients voided spontaneously and were classified as treatment successes. There were statistically significant differences (p < 0.005) between treatment failure and treatment success regarding age (83.5 +/- 7 versus 70.1 +/- 8 years), preoperative volume of retention (1,780 versus 1,080 ml.), and maximal detrusor pressure (24.4 versus 73.5 cm. water), but not to International Prostate Symptom Score, episodes of retention and prostate volume. The ability to void during preoperative pressure flow study and the presence of detrusor instability predicted good outcome. In treatment success patients postoperative urodynamic data showed significant decrease in detrusor pressure at maximum flow rate (from 80.8 +/- 33 to 34.6 +/- 10 cm. water). Those with treatment failure had an increase in maximal detrusor pressure (from 26 +/- 12 to 42.6 +/- 13 cm. water), suggesting detrusor recovery. CONCLUSIONS: Patients with acute urinary retention, age 80 years or older, with retention volume greater than 1,500 ml., no evidence of instability and maximal detrusor pressure less than 28 cm. water are at high risk of treatment failure. However, despite treatment failure the detrusor may recover in patients younger than 80. Therefore, prostatectomy should still be performed in this group (less than 80 years old) even if preoperative urodynamics suggest an unfavorable outcome.     

Pubovaginal slings: past, present and future

Renewed interest in the pubovaginal sling procedure for stress urinary incontinence has occurred in response to recent reports of poor durability and inconsistent efficacy associated with simple cystourethropexy. Many of the failures are felt to represent patients with an unrecognized component of intrinsic sphincteric deficiency. Historically slings have a favourable cure rate, but have been perceived as having unacceptably high rates of prolonged urinary retention and secondary detrusor instability. This article reviews the preoperative evaluation and indications for pubovaginal slings, describes the evolution of the current techniques, and discusses choice of sling material, surgical approach, results and complications. It is hoped that this review will stimulate interest in this versatile but technically challenging procedure.     

Two-staged pancreatoduodenectomy with external drainage of pancreatic juice and omental graft technique

Massive bilateral vesicoureteral reflux (VUR) in a 7-year-old girl with spinal scoliosis was successfully treated by endoscopic correction. She was admitted due to a febrile urinary tract infection and urinary incontinence. A cystometrogram demonstrated normal detrusor function during storage. The endoscopic subureteric injection of polytetrafluoroethylene (Teflon) was performed, resulting in the disappearance of the VUR. A postoperative cystometrogram demonstrated overactive detrusor function during storage, necessitating anticholinergic medication. She has been free of febrile urinary tract infections and incontinence for 2 years postoperatively, although self-catheterization is necessary. In a case of neurogenic vesical dysfunction with massive reflux, endoscopic subureteric injection is not only a therapeutic tool, but also a useful diagnostic option for detecting occult detrusor overactivity during storage prior to open surgery.     

Tensions in setting health care priorities for South Africa''s children

Intractable detrusor overactivity can result in considerable morbidity and, in the case of neurogenic bladder dysfunction, can put the upper tracts at risk. Once conservative treatments have been exhausted the aim of surgery is to increase functional bladder capacity and decrease the maximal detrusor pressure at this capacity. The mainstay of contemporary therapy has been augmentation cystoplasty; the different techniques and recent literature are reviewed herein. Bladder autoaugmentation is compared and contrasted with augmentation cystoplasty and its role is discussed, as is the less invasive technique of sacral neuromodulation with reference to their role within the range of surgical treatments for detrusor activity.     

Oxybutynin in the treatment of early detrusor instability after transurethral resection of the prostate

OBJECTIVE: To evaluate the symptomatic and urodynamic effects of oxybutynin in the control of irritative micturitional symptoms during the first week after transurethral resection of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Fifty-three patients (median age 67 years, interquartile range 62-72) were included prospectively in a double-blind placebo-controlled study. Pre-operatively, uroflowmetry and cystometrography (CMG) were performed, and the post-void residual volume (PVR) measured; symptoms were rated according to the Boyarski score. CMG was repeated on the first post-operative day and medication was started on the third day. Before withdrawing the catheter on the fifth day. CMG was repeated. Three days later, symptoms were evaluated according to the Boyarski score and uroflowmetry and the estimate of PVR reassessed. RESULTS: In comparison with placebo, oxybutynin significantly decreased frequency, urgency and detrusor pressure at first sensation of filling. However, oxybutynin did not lower the rate of pre-operative detrusor instability and exerted no effect on the maximal capacity of the bladder and corresponding detrusor pressure. Dryness of mouth was reported in 13% and 65% of patients receiving placebo and oxybutynin, respectively. CONCLUSION: Oxybutynin alleviates early irritative symptoms after transurethral resection of BPH, without consistently modifying bladder urodynamics.     

Tolterodine--a new bladder selective muscarinic receptor antagonist: preclinical pharmacological and clinical data

Tolterodine is a new, potent and competitive muscarinic receptor antagonist in clinical development for the treatment of urge incontinence and other symptoms of unstable bladder. Tolterodine has a high affinity and specificity for muscarinic receptors in vitro and it exhibits a selectivity for the urinary bladder over salivary glands in vivo. A major active metabolite, (PNU-200577) the 5-hydroxymethyl derivative of tolterodine, has a similar pharmacological profile. Based on pharmacological and pharmacokinetic data, it has been concluded that this metabolite contributes significantly to the therapeutic effect of tolterodine. The bladder selectivity demonstrated by tolterodine and PNU-200577 in vivo cannot be attributed to selectivity for a single muscarinic receptor subtype. Moreover, this favourable tissue-selectivity seems to occur also in humans. Tolterodine is well tolerated and it exerts a marked effect on bladder function in healthy volunteers. Phase II data indicate that tolterodine is an efficacious and safe treatment for patients with idiopathic detrusor instability or detrusor hyperreflexia. An optimal efficacy/side-effect profile is obtained with tolterodine, at a dosage of 1 or 2 mg twice daily, which seems to have less propensity to cause dry mouth than the currently available antimuscarinic drugs.     

Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine

STUDY DESIGN: A retrospective clinical study of patients with vertebral osteomyelitis of the lumbar spine necessitating surgical treatment. All patients underwent sequential (same-day) or simultaneous anterior decompression and posterior stabilization of the involved vertebrae. OBJECTIVE: To evaluate the efficacy and clinical out-come of sequential or simultaneous anterior and posterior surgical approaches in the management of vertebral osteomyelitis of the lumbar spine. SUMMARY OF BACKGROUND DATA: Anterior approach alone and staged anterior decompression and posterior stabilization have been advocated as the surgical treatment methods of choice for patients with vertebral osteomyelitis of the lumbar spine. The drawbacks of the latter management plan are the necessity to use external support or the delayed patient mobilization and the need for additional anesthesia and surgical trauma. Sequential (same-day) anterior and posterior approaches are used regularly in the surgical management of scoliosis and other spinal deformities. It would appear advantageous to also use the same strategy (i.e., combined same-day double approaches) in the management of vertebral osteomyelitis of the lumbar spine. METHODS: Ten consecutive patients who had a diagnosis of vertebral osteomyelitis of the lumbar spine underwent combined (same-day) anterior and posterior approaches either in a sequential or simultaneous manner. Indications for surgery included neurologic deficit, abscess formation, instability with localized kyphosis formation, and failure of nonoperative treatment. Patients were evaluated clinically and radiographically after surgery. RESULTS: All 10 patients had uneventful surgery. Only one patient required a second surgical procedure because of expulsion of the anterior bone graft and pull-out of instrumentation. All patients were mobilized within the 2 days immediately after surgery. At the mean follow-up examination 30 months after surgery, all patients had regained their motor function and prior ambulatory status. CONCLUSIONS: Patients with lumbar osteomyelitis necessitating surgery can undergo combined, same-day surgery either in a sequential or simultaneous manner. This is a safe and efficient way to control the infection and stabilize the affected segments, allowing for early mobilization of these sick elderly patients.     

Haptoglobin polymorphism, iron metabolism and mortality in HIV infection

Simultaneous ACL and PCL ruptures are rare but serious injuries resulting in distinct instability of the knee joint followed by an early degenerative arthritis. This combined trauma, which is often accompanied by additional ligament lesions, originates from a knee dislocation. While the conservative treatment of this complex instability is abandoned, the operative procedures are not yet standardised. The timing of the cruciate ligament reconstruction depends on the additional injuries, but generally the postprimary treatment is performed. Autografts and allografts, which can be also combined, are available for the reconstruction of the cruciate ligaments. The arthroscopic assisted operation starts with the drilling of all tibial and femoral tunnels using standard ACL and PCL arthroscopic instruments. The PCL is positioned after the graft has been transported into the joint through an anterolateral port, the ACL graft is positioned through the tibial drill hole and both are anchored first on the femoral and then on the tibial site i.e. with interference screws. In the postoperative rehabilitation neither immobilisation nor brace are used and progressive range of motion is allowed. The arthroscopic assisted reconstructions of the ACL and increasingly of the PCL are becoming standard procedures, but the technically difficult combined ACL/PCL reconstruction is restricted to a small number of arthroscopists. The first clinical results demonstrate, that the arthroscopic operation is comparable to the open reconstruction.     

Evaluation of the role of neurolinins and urecholine hypersensitivity in an animal model of infravesical outflow obstruction

OBJECTIVES: To determine whether detrusor muscle strips from a male rat with infravesical outflow obstruction model demonstrate supersensitivity to parasympathomimetic and neurokinin NK-1 and NK-2 selective agonists. METHODS: Bladder instability developed after 6 weeks of partial urethral obstruction. The micturition frequency and voided volume were determined in unanesthetized animals. Detrusor hypertrophy was confirmed by evaluation of bladder weight. In vitro organ bath was used to compare the affinity and maximal activity of bethanechol and neurokinin NK-1 and NK-2 selective agonists on strips from the detrusor muscle of sham and obstructed rats. Bethanechol, N-Ac[Arg6, Sar9, Met(O2)]-SP(6-11), and [beta-Ala8]-NKA(4-10) were used to characterize cholinergic muscarinic, neurokinin NK-1 and NK-2 receptors. Results. No significant differences in affinities and maximal responses were found using 10-mg detrusor muscle strips with each of the three agonists. CONCLUSIONS: Bladder instability produced by outlet obstruction does not involve changes in the affinity or maximal activity of cholinergic muscarinic, neurokinin NK-1 and NK-2 receptors. Furthermore, detrusor supersensitivity to neurokinins or bethanechol was not seen. This suggests that bladder instability is not due to an increased affinity or maximal response to neurokinins or parasympathomimetics.     

Phospholipase C isozymes in the human brain and their changes in Alzheimer''s disease

OBJECTIVE: We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes. STUDY DESIGN: A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests. RESULTS: The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site. CONCLUSIONS: Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.     

Prolonged bladder distension: experience in the treatment of detrusor overactivity and interstitial cystitis

Prolonged bladder distension continues to be recommended for the treatment of detrusor instability and other bladder conditions. We have reviewed our experience of the technique. A total of 45 patients have undergone 50 procedures. Only 1 of 29 patients with detrusor instability had sustained improvement. 6 of 7 patients with interstitial cystitis noted improvement, sustained in 3. All the other patients noted some improvement. There was a 20% complication rate. 33 (75%) of the living patients returned questionnaires with 27% feeling that the operation was worthwhile. We feel that prolonged distension of the bladder is unhelpful in the treatment of patients with detrusor instability. Its place in the management of patients with interstitial cystitis and irritative symptoms remains controversial. The place of simple bladder distension should be considered.