Showing papers in "Neurourology and Urodynamics in 2002"

The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society.

Abstract: The standardisation of terminology of lower urinary tract function: Report from the standardistation sub-committee of the International Continence Society.

Good urodynamic practices: uroflowmetry, filling cystometry, and pressure-flow studies

Abstract: This is the first report of the International Continence Society (ICS) on the development of comprehensive guidelines for Good Urodynamic Practice for the measurement, quality control, and documentation of urodynamic investigations in both clinical and research environments. This report focuses on the most common urodynamics examinations; uroflowmetry, pressure recording during filling cystometry, and combined pressure-flow studies. The basic aspects of good urodynamic practice are discussed and a strategy for urodynamic measurement, equipment set-up and configuration, signal testing, plausibility controls, pattern recognition, and artifact correction are proposed. The problems of data analysis are mentioned only when they are relevant in the judgment of data quality. In general, recommendations are made for one specific technique. This does not imply that this technique is the only one possible. Rather, it means that this technique is well-established, and gives good results when used with the suggested standards of good urodynamic practice.

Standardisation of urethral pressure measurement: report from the Standardisation Sub-Committee of the International Continence Society.

Abstract: INTRODUCTIONUrethralpressuremeasurementsareusedtoassessurethralclosure and voiding function.The lack of general agreementon an explicit de¢nition of urethral pressure and standardi-sation of the methodology for measurement has limited theutilityofurethralpressuremeasurements.Thisreportde¢nesurethral pressure and recommends standards for measure-ment methodology to facilitate communication betweeninvestigators and to improve the quality of clinical practiceand research. The document can be integrated with earlierreports of the International Continence Society (ICS) Com-mittee on Standardisation with special reference to the col-lated 2002 report [Abrams et al., 2002] and the ICSrecommendations on goodurodynamic practice [manuscriptinpreparation].DEFINITION OF URETHRAL PRESSUREUrethral pressure is de¢ned asthe £uid pressure neededto just open a closed (collapsed) urethra [Gri⁄ths, 1985].This de¢nition suggests that the urethral pressure is similarto an ordinary £uid pressure, i.e., is a scalar (does not havea direction) quantity with a single value at each point alongthelengthoftheurethra.The concept of urethral pressure is only useful if theurethra collapses easily at attainable pressures to zerocross-sectionalarea,asisnormallythecase.Theuseofacathe-ter introduces a non-zero cross-sectional area (given by theprobe) and changesthe natural shape ofthelumen.The eiecton the measured urethral pressure is small for highly disten-sible/collapsibletubes[Gri⁄ths,1985].Microtip or ¢ber-optic catheters do not measure the ure-thral pressure directly; they measure the normal stress com-ponent on the surface of the transducer.This stress is due totheinteractionbetweentheurethraltissueandthetransducersurface. It depends inpart onthe stiiness of the catheter andthe form of the probe. It may cause directional variations inthemeasured‘‘urethralpressure’’whenthecatheterisrotatedwithin the lumen. From the de¢nition it follows that direc-tionalvariationsareartefacts.MATERIALS AND METHODSUrethralpressurescanbemeasuredatindividual locationswithintheurethra(pointpressures)oralongthewholelengthofthe urethra (urethralpressurepro¢le).Registration maybeoverashortperiodoftimeoroveraprotractedperiod(ambu-latory). Measurement can be carried out at diierent bladdervolumes and diierent subject positions (1) with the subjectatrest,or(2)duringcoughingorstraining.‘‘Pressuremeasure-mentsmadeintheurethraduringtheprocessofvoidingyieldan ordinary £uid pressure, not the urethral pressure de¢nedabove.’’

The risk of lower urinary tract symptoms five years after the first delivery.

Abstract: Aim of the study To estimate the prevalence and 5-year incidence of lower urinary tract symptoms (LUTS) after the first delivery and to evaluate the impact of pregnancy per se and delivery per se on long-lasting symptoms. Materials and methods A longitudinal cohort study of 305 primiparae questioned a few days, 3 months, and 5 years after their delivery. The questionnaire used was tested and validated, and the questions were formulated according to the definitions of the International Continence Society (ICS). Maternal, obstetric, and neonatal data concerning every delivery and objective data concerning surgeries during the observation period were obtained from the records. From the sample of 278 women (91%) who responded 5 years after their first delivery, three subpopulations were defined: 1) women without initial LUTS before or during the first pregnancy or during the puerperal period, 2) women with onset of LUTS during the first pregnancy, and 3) women with onset of LUTS during the first puerperium. The risk of LUTS 5 years after the first delivery was examined using bivariate analyses. The obstetric variables in the bivariate tests with a significant association with long-lasting urinary incontinence were entered into a multivariate logistic regression. Results The prevalence of stress and urge incontinence 5 years after first delivery was 30% and 15%, respectively, whereas the 5-year incidence was 19% and 11%, respectively. The prevalence of urgency, diurnal frequency, and nocturia 5 years after the first delivery was 18%, 24%, and 2%, respectively, whereas the 5-year incidence was 15%, 20%, and 0.5%, respectively. The prevalence of all LUTS except nocturia increased significantly during the 5 years of observation. The risk of long-lasting stress and urge incontinence was related to the onset and duration of the symptom after the first pregnancy and delivery in a dose-response–like manner. Vacuum extraction at the first delivery was used significantly more often in the group of women with onset of stress incontinence during the first puerperium, whereas an episiotomy at the first delivery was performed significantly more often in the group of women with onset of stress incontinence in the 5 years of observation. The prevalence of urgency and diurnal frequency 5 years after the first delivery was not increased in women with symptom onset during the first pregnancy or puerperium compared with those without such symptoms. The frequency of nocturia 5 years after the first delivery was too low for statistical analysis. Conclusion The first pregnancy and delivery may result in stress and urge incontinence 5 years later. Women with stress and urge incontinence 3 months after the first delivery have a very high risk of long-lasting symptoms. An episiotomy or a vacuum extraction at the first delivery seems to increase the risk. Subsequent childbearing or surgery seems without significant contribution. Long-lasting urgency, diurnal frequency, or nocturia cannot be predicted from onset during the first pregnancy or puerperium. Neurourol. Urodynam. 21:2–29, 2002. © 2002 Wiley-Liss, Inc.

Voiding and incontinence frequencies: Variability of diary data and required diary length

Abstract: Frequencies of voiding and urinary incontinence are commonly measured by a patient's recall or a diary. The recommended diary length varies from 1 to 14 days, with 7 days apparently being most common. To examine the statistical precision of these different modalities, we analyzed recall data and diary data of 74 patients with urinary frequency, incontinence, or both. Recall data on voiding and incontinence frequency were systematically higher and more variable than diary data. Longer diary length provided less variable diary data. The confidence interval of diary data was calculated by applying the normal distribution to daytime voiding frequency and the Poisson distribution to daytime incontinence frequency. For daytime voiding frequency, the 95% confidence interval was estimated to be (x - 2.65, x + 2.65) (x - 1.53, x + 1.53) (x - 1, x + 1), where x is the 1-day, 3-day, and 7-day diary mean, respectively. For daytime incontinence frequency, the confidence interval depended on both the diary length and the diary mean. It was estimated to be (0, 6.39), (1.72, 4.28), (2.36, 3.64), by using a diary mean of 3 or 1-day, 7-day, and 28-day diaries, respectively. Also, it was estimated to be (0, 1.02), (1.72, 4.28), (7.66, 12.34), when the 7-day diary mean was 0.5, 3, and 10, respectively. Studies with different samples of genuine stress incontinence (n = 37) and urge incontinence (n = 25) confirmed these results. In conclusion, we believe the 7-day diary is highly reliable for estimating voiding frequency and is a reasonable option for predicting incontinence episodes. However, the diary length should be extended in a patient with rarer events of incontinence, and it should be shortened for those who are incontinent more often or who are diagnosed with voiding frequency only.

Effects of pelvic floor muscle training on strength and predictors of response in the treatment of urinary incontinence

Abstract: Aims The objectives of this study were (1) to determine the effect of training on pelvic floor muscle strength; (2) to determine whether changes in pelvic floor muscle strength correlate with changes in continence; and (3) to determine whether demographic characteristics, clinical incontinence severity indices, or urodynamic measures predict response to pelvic floor muscle training. Methods One hundred thirty-four women with urinary incontinence (95=genuine stress incontinence [GSI]; 19=detrusor instability [DI]; 20=mixed incontinence [GSI+DI]) were randomized to pelvic floor muscle training (n=67) or bladder training (n=67). Urinary diaries, urodynamic evaluation, and vaginal pressure measurements by using balloon manometry were performed at baseline and after 12 weeks of therapy. Primary outcome measures consisted of incontinent episodes per week and vaginal pressure measurements. Results Both treatment groups had a reduction in incontinent episodes (P≤0.004). Vaginal pressures increased more with pelvic floor muscle training than with bladder training (P=0.0003). Other than a weak correlation between a reduction in incontinent episodes/week and an increase in maximum sustained vaginal pressure in women with GSI (r=0.32, P=0.04), there were no significant correlations between increases in pelvic floor muscle strength and improvement in continence status. There were no significant correlations between baseline demographic characteristics, clinical incontinence severity, or urodynamic measures and increases in vaginal pressure or improvement in clinical severity after pelvic floor muscle training. Conclusions Pelvic floor muscle training improves continence and increases vaginal pressure measurements, but the direct correlations between these alterations are weak. A woman's response to behavioral treatment does not depend on her demographic characteristics, clinical incontinence severity, urodynamic measures, or initial pelvic floor muscle strength. Neurourol. Urodynam. 21:486–490, 2002. © Wiley-Liss, Inc.

Effects of beta(3)-adrenoceptor stimulation on prostaglandin E(2)-induced bladder hyperactivity and on the cardiovascular system in conscious rats.

Abstract: Aims To investigate the effects of selective beta(2)- and selective beta(3)-adrenoceptor (AR) agonists on prostaglandin (PG) E-2-induced bladder hyperactivity in conscious free-moving rats Methods Female Sprague-Dawley rats were anesthetized for implantation of bladder, intravenous, and intra-arterial catheters The effects of a beta(3)-AR agonist (CL316,243) on cystometric and cardiovascular parameters were assessed in conscious rats Intravesical instillation of PGE(2) (20-60 muM, 6 mL/hr) in conscious rats produced a concentration-dependent increase in voiding frequency Results In this model iv CL316,243 (beta(3)-AR agonist) reduced basal bladder pressure, increased micturition volume, and prolonged micturition interval in a dose-dependent manner, without affecting threshold pressure or micturition pressure On the other hand, iv procaterol (beta(2)-AR agonist) did not counteract the bladder hyperactivity Atropine (muscarinic antagonist) reduced micturition pressure and micturition volume, and shortened micturition interval CL316,243 slightly decreased mean blood pressure and increased heart rate only when given at high doses (10 and 100 mug/kg, iv) In contrast, procaterol caused a significant decrease in mean blood pressure and a significant increase in heart rate Atropine significantly increased heart rate Conclusions The present results clearly demonstrated that the beta(3)-AR agonist prolonged the micturition interval without producing significant cardiovascular side effects The human detrusor, like the rat detrusor, relaxes on beta(3)-AR stimulation Provided that these results are valid in humans, selective beta(3)-AR agonists might be clinically useful for controlling a certain type of bladder overactivity (Less)

Development of a non-invasive strategy to classify bladder outlet obstruction in male patients with LUTS.

Abstract: To diagnose bladder outlet obstruction in male patients with lower urinary tract symptoms (LUTS), it is necessary to measure the bladder pressure via a transurethral (or suprapubic) catheter. This procedure incurs some risk of urinary tract infection and urethral trauma and is sometimes painful to the patient. We developed an external condom catheter to measure non-invasively the bladder pressure and developed a strategy to classify bladder outlet obstruction (BOO) based on this measurement. Seventy-five patients with a wide range of urological diagnoses underwent a pressure-flow study followed by a non-invasive study. We tested five different strategies to classify the patients using the provisional International Continence Society (ICS) method for definition of obstruction as the gold standard. Leakage of the external catheter occurred in eight (40%) of the first 20 tested patients. In the remaining 55 patients, only five (9%) of the measurements failed because of leakage. Of the 75 patients, 56 were successfully tested non-invasively. According to the ICS nomogram, the PFS showed that 22 of these patients were non-obstructed, 12 patients were equivocal, and 22 patients were obstructed. Ten of these 56 patients strained, and we found that the relatively high abdominal pressures in these patients were not reflected in the externally measured bladder pressure. Of the remaining 46 patients, 12 of 13 non-obstructed patients and 30 of 33 combined equivocal and obstructed patients could be correctly classified. We developed a simple, non-invasive classification strategy to identify BOO in those male patients who did not strain during voiding.

Urinary Incontinence symptom scores and urodynamic diagnoses

Abstract: The aim of this study was to determine whether scores on two validated urinary incontinence symptom scales predicted eventual urodynamic diagnoses. Two hundred ninety-three patients undergoing multi-channel urodynamic testing rated their symptoms of urinary incontinence and/or pelvic organ prolapse (POP), using the Incontinence Impact Questionnaire, the Urogenital Distress Inventory, and an obstructive symptom subscale from the long form of the Incontinence Impact Questionnaire. Among the 202 (69%) patients without advance-stage POP, increasing scores on scale items related to stress and urge incontinence predicted increasing frequency of the diagnoses of genuine stress incontinence (GSI) and detrusor instability, respectively. Among the 91 (31%) patients with advance-stage POP, there was no association. Among all patients with GSI, the presence of intrinsic sphincter deficiency could not be predicted by responses to the symptom scales. Scores on the symptom scales were inadequate predictors of eventual urodynamic diagnoses, especially among women with advance-stage POP.

Detrusor instability with equivocal obstruction: A predictor of unfavorable symptomatic outcomes after transurethral prostatectomy

Abstract: Aims To elucidate whether preoperative urodynamic findings can predict outcomes of transurethral resection of the prostate (TUR-P). Methods Sixty-two patients with symptomatic benign prostatic hyperplasia were categorized in three different ways based on findings of preoperative pressure-flow study (PFS) and cystometry: urodynamic obstruction (determined by the Abrams-Griffiths nomogram), detrusor instability (DI), and combination of both. Outcomes of TUR-P regarding symptom, function, and quality of life (QOL) were analyzed by changes in the International Prostate Symptom Score (I-PSS), maximum flow rate in uroflowmetry, and QOL index before and after TUR-P, respectively. Overall outcome was defined as success when all of the three categories showed successful improvement. Results Neither urodynamic obstruction alone nor DI alone predicted outcomes of TUR-P. However, symptomatic and overall outcomes were significantly worse in patients who were not obstructed but had DI. Postoperative persistent DI was more frequently noted in patients without clear obstruction (60%) than in those with obstruction (27%). Patients with equivocal obstruction showed less satisfactory symptomatic outcomes of TUR-P when DI was accompanied. Persistent DI might be the principle cause of unfavorable outcomes. Conclusions Preoperative evaluation of DI is of benefit because it enhances predictive value of the PFS. Neurourol. Urodynam. 21:444–449, 2002. © Wiley-Liss, Inc.

Effect of doxazosin on rat urinary bladder function after partial outlet obstruction.

Abstract: Hypoxia induced by partial outlet obstruction is believed to play a major role in both the hypertrophic and degenerative effects of partial outlet obstruction. Doxazosin (dox) is a clinically effective α-adrenergic antagonist used in the treatment of symptomatic benign prostatic hyperplasia (BPH). Although the major therapeutic effect of the agent is believed to occur on the smooth muscle components of the prostate by reducing prostatic urethral resistance and thus improving emptying, dox may have part of its clinical action via effects mediated by other actions, including via spinal α-adrenergic receptors or direct effects on the bladder, possibly via inhibition of vascular alpha receptors. The specific aim of the current study was to determine whether dox pretreatment on rats affects blood flow to the bladder and reduces the level of bladder dysfunction induced by partial outlet obstruction. In part 1, eight rats were separated into two groups of four rats each. Group 1 received oral administration of dox (30 mg/kg) for 4 weeks; group 2 received vehicle (5% dimethyl sulfoxide). After 4 weeks of treatment, blood flow studies were performed using fluorescent microspheres and the bladders excised, frozen, and submitted to Interactive Medical Technologies (IMT) for blood flow analysis. In part 2, 32 adult male rats were separated into four groups of eight rats each. Groups 1 and 2 received oral administration of dox (30 mg/kg) for 4 weeks, groups 3 and 4 received vehicle (5% dimethyl sulfoxide). At 4 weeks, the rats in groups 1 and 3 received partial outlet obstructions and treatment continued for an additional 2 weeks. After 6 weeks of treatment (total), each rat was anesthetized, the bladder excised, weighed, and isolated strips mounted and contractility studies performed. 1) Four weeks pretreatment of rats with dox increased blood flow to the bladder in both the control and obstructed groups. 2) Partial outlet obstruction induced a mild decrease in blood flow. 3) The magnitude of the increased bladder weight in the vehicle-treated obstructed group was significantly greater than in the dox-treated obstructed group. 4) Partial outlet obstruction resulted in significant decreases in the contractile response to field stimulation in both treated and non-treated rats. The magnitude of the decreased response was significantly greater in the non-treated rats. 5) The response to potassium chloride was significantly reduced by partial outlet obstruction in the vehicle-treated group but not in the dox-treated group. 6) The time to maximal tension was significantly increased in response to carbachol, adenosine triphosphate, and potassium chloride. However, the magnitude of the increase was significantly greater for the vehicle-treated obstructed groups stimulated by potassium chloride than for the dox-treated groups. Dox treatment of rats increased blood flow to the bladder and reduced the severity of the response to partial outlet obstruction. These beneficial effects would be due to pharmacological effects on α-adrenergic systems outside those present in the prostate. These include effects on blood flow to the bladder, effects on the micturition centers of the central nervous system, spinal reflexes, and α-adrenergic receptors in the urethra and bladder. Neurourol. Urodynam. 21:160–166, 2002. © 2002 Wiley-Liss, Inc.

Reliability of pelvic floor muscle strength measurement in elderly incontinent women

Abstract: Pelvic floor muscles (PFM) play an important role in maintaining urinary continence with increasing age. Therefore, their contractile properties need to be evaluated. The aim of the study was to examine the reliability and correlation of simple techniques to measure PFM strength in elderly women with urinary incontinence. An interview was used to evaluate the ability to stop the urinary stream during micturition and to calculate the incontinence index. A pad test was applied to objectively evaluate the severity of the disease. Functional testing included a digital examination to measure the force and duration of one contraction, a perineometer measurement (Peritron) to assess maximal contraction force and contraction force of 5 s, and a cone-retention test (Femcon) while walking for 1 min and during Valsalva's manoeuvre. This procedure was performed on three separate occasions within one week. The 37 participating women with a mean age of 62+/-8 (mean+/-SD) years had a severity index of 4.4+/-2.6 and a urine loss of 9.5+/-13.6 mg during the pad test. Sixteen women were able to completely stop the urinary stream during micturition. The digital examination showed no intratester variability. The perineometer measurement showed that the absolute difference in maximal contraction force and mean contraction force within 5 s was less than 5.3 mm Hg and 4.5 mm Hg, respectively, with a probability of 0.95. While walking and during Valsalva's manoeuvre, 19 and 20 women, respectively, held the same cone in place on all three occasions. The maximal contraction force and mean force during the 5-s contraction correlated well with the ability to stop the urinary stream and the digital examination but only weakly with the cone-retention tests. The reliability of PFM strength measurement is highest in the digital examination, followed by perineometer measurements, and then by vaginal cone tests. As PFM function is easy to assess, it should be routinely done in the assessment of urinary incontinence in elderly women.

Urge incontinence and impaired detrusor contractility in the elderly.

Abstract: Among the elderly, both urge incontinence and elevated residual urine are common. When they occur together, they present a challenging clinical problem, called detrusor hyperactivity with impaired contractile function (DHIC). Impaired detrusor contractility has two aspects: elevated post-void residual urine volume and reduced detrusor contraction strength. Geriatric urge incontinence, especially in combination with reduced bladder sensation, is associated with specific cortical abnormalities: frontal and global cortical underperfusion and cognitive impairment. We have investigated, in 73 elderly incontinent patients, whether either aspect of impaired contractility is associated with urge incontinence, reduced sensation or these cortical abnormalities. For post-void residual urine, there are no significant associations. Detrusor contraction strength, however, is significantly increased (not impaired) if there is urge incontinence, reduced bladder sensation, or cortical underperfusion. Thus, DHIC appears to be a coincidental occurrence of two common conditions with different etiological factors.

Test-retest reliability, validity, and sensitivity to change of the urogenital distress inventory and the incontinence impact questionnaire.

Abstract: Aims. To evaluate two quality of life measures for urinary incontinence (UI) in Scottish females. Methods. Three groups with UI from two regions in Scotland were studied. Two groups were receiving treatment for incontinence; the third was not. Women completed the UDI and IIQ twice to allow assessment of test-retest reliability and validity. Treatment groups completed the questionnaires again, postintervention, to assess ability of the measures to detect change. Other measures used to assess validity were the SF-36, HADS, weight of urine leaked, and number of incontinence episodes. By design, the three subject groups differed significantly in their characteristics, ensuring a diverse sample of women. Results. Analysis of reliability showed a clinically trivial but statistically significant decrease in total UDI (mean, -6.1; 95% CI, -11.0 to -1.5) and IIQ (mean, -9.7; 95% CI, -15.5 to -3.9) scores between test and retest assessments, possibly due to a research effect. Most items of the UDI (18 of 19) and IIQ (28 of 30) performed very well on test-retest. The UDI and IIQ were valid in that higher scores (indicating more bothersomeness of symptoms/impact on daily living) were associated with greater severity of UI. Additionally the IIQ showed the expected associations with measures of anxiety and health status. Conclusions. Both the UDI and IIQ detected changes in women's conditions due to intervention. The measures had good psychometric properties, including test-retest reliability, across subject groups.

Short-term reproducibility of cystometry and pressure-flow micturition studies in healthy women.

Abstract: Aims To evaluate the reproducibility of cystometry and pressure flow studies in women. We wanted to explore any clinically relevant effect of repeated, same-session cystometry. Methods Thirty healthy women with a mean age of 52 years were investigated with repeat medium-fill water cystometry and pressure-flow micturition studies in a single session. Results Large test-retest variability was noted, with wide limits of agreement. Of statistical significance was an increase of first desire (FD) and normal desire (ND), and a decrease in bladder opening pressure. Maximum cystometric capacity was unchanged. Conclusions Although the nature of the conditioning effect of the first fill remains to be explored, the phenomenon could possibly be used for improved urodynamic diagnosis. Neurourol. Urodynam. 21:457–460, 2002. © Wiley-Liss, Inc.

Tension-free vaginal tape for stress urinary incontinence: Is there a learning curve?

Abstract: Aim To assess the learning curve characteristics of the first 30 tension-free vaginal tape (TVT) procedures carried out in our medical center and to evaluate its safety and short-term effectiveness. Methods A total of 30 incontinent women with urodynamically proven SUI were enrolled. None had undergone any previous anti-incontinence procedure. All were operated on by one surgeon, in accordance with the technique described by Ulmsten et al. in 1996. Mean follow-up was 11.4± 3.6 months (range, 5–17 months). Results Five (17%) bladder perforations occurred at the beginning of the study, due to inadvertent insertion of the applicator. All perforations were identified by intraoperative cystoscopy. Five other patients (17%) had increased intraoperative bleeding (>200 mL) necessitating vaginal tamponade. Blood transfusions were not required. Eight (27%) patients had immediate postoperative voiding difficulties, necessitating catheterization for 2–10 days, but none needed long-term catheterization. There was no local infection or rejection of the Prolene tape was found. All patients were subjectively cured of their stress incontinence; however, urodynamic evaluation revealed “asymptomatic genuine stress incontinence” in one patient. Sixteen of 21 patients (80%) with preoperative urge syndrome, had persistent postoperative symptoms. No patient developed de novo urge incontinence. Conclusion The TVT operation is a new, minimally invasive surgical procedure with excellent short- and medium-term cure rates. However, there is a definite learning curve, and we believe that the operation should only be performed by experienced surgeons. Neurourol. Urodynam. 21:470–472, 2002. © Wiley-Liss, Inc.

Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate, in patients with benign prostatic hypertrophy.

Abstract: One hundred patients with benign prostatic hypertrophy (BPH) were randomized to transurethral incision (TUIP) or transurethral resection of the prostate (TURP). The average prostate weight before operation was not more than 30.0 g. Indications for the operations were based on the disease history, physical examination, digital rectal examination, laboratory values, and pressure-flow examination. All operations were performed with patients under spinal anesthesia. TUIP was performed with a Collins knife, and TURP was performed with a resectoscope. Follow-up was performed 24 months after the operations. After treatment there were statistically significant daytime and nocturnal reduction in voiding frequencies of 2.9 and 1.7, respectively, after TUIP, and 2.0 and 1.5 after TURP. In both groups, there occurred significantly better maximal flow rate from 7.6 mL/s to 16.9 mL/s in group I and from 6.9 mL/s to 17.6 mL/s in group II. The mean values of linearized passive urethral resistance relation in both groups significantly decreased from 3.6 ± 0.6 to 1.0 ± 0.5 after TUIP and from 3.9 ± 04 to 1.4 ± 0.5 after TURP. The TUIP procedure is effective and safe for patients with a small number of complications. Neurourol. Urodynam. 21:112–116, 2002. © 2002 Wiley-Liss, Inc.

Similarities and differences in female and male rat voiding

Abstract: We measured in adult rats, under anaesthesia, bladder pressure by transvesical cystometry and flow rate by an ultrasound transducer in the distal urethra. The urinary flow was discontinuous in both sexes. No difference between the sexes in bladder pressure oscillations or in non-oscillatory voiding was found but during the oscillatory activity there was a difference in the relationship between bladder pressure and urinary flow. In the female, the bladder pressure decreased when the flow started and increased when the flow decreased resembling species whose urinary flow is continuous. Basically the flow was stable but it was divided into periods of variable duration by full or partial closure of urethral sphincter. In the male rat, the oscillatory flow consisted of short, fast spikes occurring just before the bladder pressure reached the maximum, after which the flow spike decreased slowly. Overall, no differences were seen in bladder pressure data between the genders. However, the maximal flow rate was lower and micturition time was shorter in female rats. When we recorded occasionally occurring micturitions without high-frequency oscillations of intraluminal pressure (IPHFOs) (non-oscillatory voiding), no differences between the genders were seen. The difference during oscillatory voiding between male and female rat can be understood against anatomical and hormonal backgrounds, and by the relative role of rhabdosphincter, which did not activate during non-oscillatory voidings when no differences were detected.

Selective suppression of sphincter activation during sacral anterior nerve root stimulation.

Abstract: The purpose of this work was to electrically activate small-diameter motor fibers in the sacral anterior roots innervating the urinary bladder, without activating the large-diameter fibers to the sphincter. Quasitrapezoidal current pulses were applied through tripolar spiral nerve electrodes on selected anterior sacral roots during acute experiments on eight dogs, maintained under pentobarbital anesthesia. Pressures were recorded from the bladder and sphincter with catheter-mounted gauges. Stimulation with biphasic quasitrapezoidal pulses showed decrease in sphincter recruitment with increasing pulse amplitudes. The minimum current amplitude that resulted in maximum sphincter suppression was used to stimulate the roots with trains of 20 Hz pulses, with 60 mL of saline filling the bladder. Pressures were also recorded when 100 micros rectangular pulse trains at 20 Hz, both continuous and intermittent, were applied. Trains of stimuli were applied before and after dorsal root rhizotomy. Suppression of sphincter activation was defined to be a percentage, [(Maximum pressure -Minimum pressure)/Maximum pressure x100. The results from 22 roots in eight animals show that with single pulses, the average percentage suppression of sphincter activation was 76.3% (+/-14.0). The minimum current for maximum sphincter suppression was 1.29 mA (+/-0.62). The average bladder pressure evoked was 50 cm of water during pulse train stimulation, with no significant difference due to pulse type. With pulse trains, the sphincter pressures were significantly higher when the bladder was filled. Evacuation of fluid occurred in three animals with average flow rates of 1.0 mL/s.

Urethral pressure profile: Is it affected by position?

Abstract: The aim of this study was to investigate the difference between sitting and standing passive urethral pressure measurements, and to determine the accuracy of urethral pressure profilometry in each position. Urethral pressure profilometry was performed in the sitting and standing position in 98 women. Stress incontinence due to urethral sphincter incompetence was demonstrated in 59 of whom 6 also had detrusor instability. The others were normal volunteers (7), women with a normal cystometrogram (23), and women with detrusor instability (9). MUCP tended to be higher in the standing than the sitting position but this did not reach statistical significance. Urethral lengthening appeared to occur on standing with a mean increase of FUL of 5 mm on standing. For both FUL and MUCP, there was a wide variation in the difference between sitting and standing values. There was poor reproducibility of measurements of MUCP and FUL in the standing position, limiting its clinical applicability. The difference between sitting and standing MUCP and FUL was not affected by age, parity, weight, height, BMI, or oestrogen status. In women with genuine stress incontinence, there was less difference between sitting and standing MUCP, but this explained only a small part of the variability. The increase in FUL in the standing position was unaffected by diagnosis.

Role of supraspinal serotonin receptors for micturition in normal conscious rats.

Abstract: Serotonin (5-HT) receptors are widely distributed in the central nervous system, including several areas involved in the control of micturition reflex pathways. However, the roles of the different subtypes of 5-HT receptors are not well known. We studied in normal, conscious rats, the effects on the cystometrogram of intracerebroventricular (i.c.v.) administration of 5-HT, 8-hydroxy-2-(di-N-propylaminotetralin) (8-OH-DPAT; agonist at 5-HT1A receptors), alpha-methol-5-hydroxytryptamine maleate (agonist at 5-HT2 receptors), 2-methyl-5-hydroxytryptamine hydrochloride (agonist at 5-HT3 receptors), and 1-(4-amino-5-chloro-2methoxyphenyl)-3-(1-n-butyl-4piperidinyl)-1-propano ne hydrochloride (RS67506; agonist at 5-HT4 receptors). Female Sprague-Dawley rats, weighing approximately 230 g, were used. A polyethylene catheter was inserted into the bladder through the dome for cystometric investigations. For administration of drugs, a catheter was implanted into the right cerebral ventricle. Three days after implantation of the bladder catheter, continuous cystometry was performed. Administration of 5-HT (6 nmol/kg i.c.v.), 8-OH-DPAT (6 nmol/kg), alpha-methyl-5-hydroxytryptamine maleate (6 nmol/kg), or RS67506 hydrochloride (6 nmol/kg) significantly (P < 0.05) increased micturition pressure and decreased bladder capacity and micturition volume. The effects increased in a dose-dependent manner (18, 60 nmol/kg). Intracerebroventricular administration of 2-methyl-5-hydroxytryptamine hydrochloride (60 nmol/kg) caused no change in the cystometric parameters. The results suggest that in normal conscious rats, at the supraspinal level, 5-HT (via 5-HT1A, 5-HT2, and 5-HT4 receptors) can enhance the micturition reflex induced by bladder filling. Whether this means that 5-HT1A, 5-HT2, and 5-HT4 receptors can be targets for drugs meant for treatment of bladder hyperactivity, should be explored. (C) 2002Wiley-Liss, Inc.

Partial unilateral ureteral obstruction in rats.

Abstract: This review comprises an overview of the current knowledge on experimental partial unilateral ureteral obstruction (PUUO) and a summary of our latest original experimental PUUO studies in rats. Neonatal PUUO is the type of obstruction that is most often encountered in pediatric clinical practice. However, the pathogenesis of PUUO is still incompletely understood. Most of our knowledge on PUUO has been derived from experimental studies in a variety of animal models. Although progress has been made, the natural history of congenital hydronephrosis is still incompletely described. The effects on kidney functions of long-term urinary tract obstruction, especially PUUO, have been less intensively studied. Recently, we created models with mild and severe PUUO in young rats by embedding the upper one fourth or the upper two thirds of the left ureter into the psoas muscle, respectively. Thereafter, the technique was used to create mild and severe PUUO in newborn rats and magnetic resonance imaging studies showed that both mild and severe obstruction caused a time-dependent decrease in renal blood flow. Compensatory increase in total kidney volume and renal vein blood flow in contralateral non-obstructed kidneys was not detectable when functional deterioration in the partially obstructed kidneys was present. Finally, we investigated the dynamic changes in renal relative signal intensity (RSI) of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) using magnetic resonance imaging in rats with partial, complete unilateral ureteral obstruction and sham-operated controls. The results showed that changes in Gd-DTPA RSI are compatible with the known physiological and anatomical changes in kidneys in response to ureteral obstruction and useful for distinguishing an obstructed from a non-obstructed collecting system and also for differentiating a partially obstructed from a completely obstructed collecting system.

Computerised morphometric study of the paraurethral tissue in young and elderly women.

Abstract: Aim. Changes in structural support of the urethra and bladder neck have been proposed to be among the most important factors in the pathogenesis of stress urinary incontinence. In this context, we histologically investigated the paraurethral area in continent women to quantify the relative distribution of connective tissue, smooth muscle, vessels, nerves, and striated muscle. Previously published literature gives only descriptive evaluations of the relative distribution of these tissue components. Methods. We used a computerised morphometric method, which allowed us to estimate the paraurethral tissue distribution in a more objective way. The material was obtained by dissection during autopsy in five premenopausal and five postmenopausal women. Results. Paraurethral tissue consisted of 56% connective tissue (SD, 5%), 30% smooth muscle (SD, 5%), 11% blood vessel (SD, 6%), 2% striated muscle (SD, 3%), and 1% nerves (SD, 1%). We also found that the distribution of different tissue components along the length of the urethra did not differ at a statistically significant level. Furthermore, there was a statistically significant difference in the amount of connective tissue and blood vessels in the postmenopausal women compared with the premenopausal women. Conclusions. The present study shows that the paraurethral area is built of heterogeneous tissue with small changes in its composition along the course of urethra. Increase in connective tissue was found to be the dominating change in the process of ageing. Neurourol. Urodynam. 21:529–533, 2002. © 2002 Wiley-Liss, Inc.

Identifying cut‐off scores with neural networks for interpretation of the incontinence impact questionnaire

Abstract: We propose to determine cut-off scores for the Incontinence Impact Questionnaire (IIQ) based on the neural network (NN) approach. These cut-off scores should discriminate between patients having poor, moderate, or good quality of life (QoL) secondary to their incontinence problems. Data from two prospectively completed QoL questionnaires, the IIQ (n = 237) and the MOS 36-Item Short-Form Health Survey (SF-36) (n = 237), were analyzed using NN and conventional statistical tools. Kohonen networks identified three distinct clusters of IIQ scores. The three clusters represent the full spectrum of possible scores on the IIQ. We interpreted these clusters as reflecting good, moderate, and poor QoL. We estimated that a score of less than 50 on the IIQ would be representative of good QoL, between 50 and 70 would be moderate QoL, and greater than 70 would be indicative of poor QoL. Validation with the SF-36 data confirmed these categories. The present study demonstrated that the NN approach is opening new areas in the interpretation and clinical usefulness of QoL questionnaires. NN allowed the identification of three levels of QoL and should be useful in clinical decision making.

Clinical, urodynamic, and manometric findings in women with combined fecal and urinary incontinence

Abstract: Aims To determine the prevalence of fecal incontinence in patients with urinary incontinence, who were referred for urodynamic evaluation, and to compare clinical and manometric findings between double incontinence and isolated fecal incontinence. Methods Nine hundred women with urinary and/or fecal incontinence were prospectively investigated. Patients with double incontinence (group 1) were compared with 38 women with isolated fecal incontinence (group 2). Clinical data regarding obstetric and urogynecologic history, bowel habit, and type of fecal incontinence were collected. Urodynamics and anal manometry were performed. Results Seventy-eight patients (8.7%) presented double incontinence. A history of vaginal delivery and chronic straining was more frequent in patients with double incontinence (P=0.043). No differences were found in the severity of fecal incontinence. Physical examination showed a greater prevalence of rectocele (54% vs. 12%) in group 1. On urodynamics, 80% of women with double incontinence had stress urinary incontinence. Rectal sensation testing revealed a significantly higher rate of hyposensitivity in group 2 (22% vs. 43%). Conclusions This study supports a close association between combined stress urinary and fecal incontinence, history of vaginal delivery, and chronic straining.. Neurourol. Urodynam. 21:464–469, 2002. © Wiley-Liss, Inc.

Cholinergic and purinergic contribution to the micturition reflex in conscious rats with long-term bladder outlet obstruction.

Abstract: The urethra of female Wistar rats was partially obstructed for 15 weeks. The effects of atropine (1 mg/kg i.v.), suramin (100 mg/kg i.v.), and a combination of atropine and suramin on the peak micturition pressure (MP) were compared during cystometry in conscious rats controls or subjected to outlet obstruction. On the isolated bladder dome, we studied the inhibitory effect of 1 micromol/L atropine, 1 mmol/L suramin, and the combination of the two drugs on contractions induced by electrical field stimulation (EFS). We studied also the contractile response to 80 mmol/L KCl and the concentration-response curves to noradrenaline, phenylephrine, and carbachol on the bladder dome and bladder neck and alpha, beta-methylene adenosine triphosphate on the bladder dome. In conscious rats, the MP, bladder capacity, and micturition volume were significantly higher in obstructed rats than in controls. Suramin induced the same inhibition in the two groups of animals (-30.7 +/- 13.3% in controls and -29.2 +/- 8.5% in obstructed rats). Atropine decreased the MP, but this effect was twofold greater in obstructed animals (-28.1 +/- 3.1% and -65.1 +/- 6.9% in control and obstructed animals, respectively). However, the combined effect of atropine and suramin was additive in controls but not in obstructed (-56.7 +/- 5.4% and -55.9 +/- 9.4%, respectively). Similar results were obtained in vitro using 1 micromol/L atropine and 1 mmol/L suramin. In the obstructed bladder dome and bladder neck, we found a great reduction in KCl- and carbachol-induced contractility but no difference in the response to EFS. Responses to noradrenaline and phenylephrine were moderately reduced in the bladder neck only, whereas responses to alpha, beta-methylene adenosine triphosphate in the bladder dome were not reduced except at the concentration of 300 micromol/L. We conclude that long-term obstruction in rats could induce cholinergic nerve fiber proliferation as suggested by the decrease in M(3) muscarinic receptor contractility (desensitization) and by a greater sensitivity of the MP to atropine.

Neurological signs are common in patients with urodynamically verified "idiopathic" bladder overactivity.

Abstract: Overactive bladder dysfunction is an expression of defective neuromuscular control of the lower urinary tract. The causes and the way to classify this problem are currently under debate. In some patients the overactive bladder is one sign of a neurological disorder, in so called "idiopathic detrusor instability" the cause is less obvious. That an overactive bladder has a neurogenic cause is a reasonable hypothesis. We made a detailed neurological investigation in 45 patients with idiopathic overactive bladder. Cerebrospinal fluid (CSF) was examined and blood tests for vitamin B(12)and folic acid deficiency were checked, too. In 37 of the 45 patients (82%) pathological signs were observed in the neurological tests. The most common finding was central or peripheral paresis of the legs appearing in 24 patients (53%). Of the 45 patients, eight received a neurological diagnosis, definite or possible MS or dorsal column sensation neuropathy. The results of this study give an indication of the importance of the neurological examination and suggest that neuropathy might not be uncommon in patients with so-called idiopathic detrusor instability. This also invites to reconsideration of the current classification. It is possible that a new classification based on a functional view could provide a better fundament in the search of etiologic and pathogenetic factors and also guide in the selection of the treatment most optimal for the individual patient.

Standardization of anal sphincter electromyography: Quantification of continuous activity during relaxation

Abstract: Aim. Sphincter motor units (MUs) are continuously firing during relaxation. The quantification of this activity is a potentially useful electromyographic (EMG) parameter related to the number of MUs innervating the muscle and the level of motor neuron excitation. The aim of the present study was to develop a reliable, quantitative measure of continuous sphincter muscle activity during relaxation. Methods. EMG activity was analyzed during relaxation, 1 minute after insertion of the concentric needle electrode into four sites in the external anal sphincter (EAS) muscle. In 10 control subjects, 8 interference pattern samples were obtained by “turn/amplitude” analysis. In 35 control subjects, a multi-MUP count of continuously firing motor unit potentials (MUPs) was used, quadruplets with scores of 0–6 obtained, and the lower reference limits (95th percentile) calculated. This approach was then evaluated in 57 patients (182 muscles) with cauda equina or conus medullaris lesion (CECML) and 7 patients (13 muscles) with “idiopathic fecal incontinence.” Results. The lower reference (“outlier”) limits for MUP count were 0 0 6 6 and 0 1 2 2 for the subcutaneous, and 0 0 0 6 and 0 0 1 1 for the deeper EAS muscles. Both patient groups had a significantly diminished number of continuously firing MUPs, which was below the reference range in 43% of the EAS muscles from CECM patients and in 85% of muscles from patients with idiopathic fecal incontinence. In patients with CECML, the decrease in MUP count correlated with the severity of the lesion, as defined by the sensory deficit. Conclusions. MUP count in sphincter muscles during relaxation is technically feasible, and it is a promising tool, particularly in patients with idiopathic fecal incontinence. Neurourol. Urodynam. 21:540–545, 2002. © 2002 Wiley-Liss, Inc.