Showing papers in "Neurourology and Urodynamics in 2010"

An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction

Abstract: Introduction and hypothesis Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report. Methods This report combines the input of members of the Standardization and Terminology Committees of two Inter

6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence

Abstract: Scientific report of the proceedings from the 6th International Consultation on Incontinence, (Tokyo 2016).

A decade of functional brain imaging applied to bladder control.

Abstract: Over the last 10 years functional brain imaging has emerged as the most powerful technique for studying human brain function. Although the literature is now vast, including studies of every imaginable aspect of cortical function, the number of studies that have been carried out examining brain control of bladder function is relatively limited. Nevertheless those that have been reported have transformed our thinking. This article reviews that development in the context of emerging ideas of interoception and a working model of brain activity during bladder filling and emptying is proposed. Some studies have also been carried out using functional imaging methods to examine pathophysiological bladder conditions or the effect of treatments and these are reviewed and future work anticipated.

Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence.

Abstract: Aims To summarize current knowledge on the etiology, assessment, and management of urinary incontinence (UI) in frail older persons. “Frail” here indicates a person with a clinical phenotype combining impaired physical activity, mobility, muscle strength, cognition, nutrition, and endurance, associated with being homebound or in care institutions and a high risk of intercurrent disease, disability, and death. Methods Revision of 3rd ICI report using systematic review covering years 2004–2008. Results We focus on the etiologic, management, and treatment implications of the key concept that UI in frail persons constitutes a syndromic model with multiple interacting risk factors, including age-related physiologic changes, comorbidity, and the common pathways between them. We present new findings with evidence summaries based on all previous data, and an evidence-based algorithm for evaluation and management of UI in frail elderly. We also present new evidence and summarize the data on etiology and management of nocturia and urinary retention in frail elderly. Conclusions Despite the overwhelming burden of UI among this population, there remains a continuing paucity of new clinical trials in frail elderly, limiting evidence for the effectiveness of the full range of UI therapy. Future research is needed on current UI treatments (especially models of care delivery, and pharmacologic and surgical therapies), novel management approaches, and the etiologic mechanisms and pathways of the syndromic model. Neurourol. Urodynam. 29: 165–178, 2010. © 2009 Wiley-Liss, Inc.

Bladder pain syndrome international consultation on incontinence

Abstract: Aims of Study The Bladder Pain Syndrome Committee of the International Consultation on Incontinence was assigned the task by the consultation of reviewing the syndrome, formerly known as interstitial cystitis, in a comprehensive fashion. This included the topics of definition, nomenclature, taxonomy, epidemiology, etiology, pathology, diagnosis, symptom scales, outcome assessment, principles of management, specific therapies, and future directions in research. Study Design, Materials, Methods The emphasis was on new information developed since the last consultation 4 years previously. Where possible, existing evidence was assessed and a level of recommendation was developed according to the Oxford system of classification. Results The consultation decided to refer to the condition as “bladder pain syndrome” (BPS) because the designation is more descriptive of the clinical condition and better fits standard classification taxonomy. Reasonable definitions of BPS include the definition of the ESSIC European group and a slight modification made at a SUFU sponsored Miami meeting in early 2008. Males or females with pain, pressure, or discomfort that they perceive to be related to the bladder with at least one urinary symptom, such as frequency not obviously related to high fluid intake, or a persistent urge to void should be evaluated for possible BPS. The initial assessment consists of a frequency/volume chart, focused physical examination, urinalysis, and urine culture. Urine cytology and cystoscopy are recommended if clinically indicated. Treatment progresses from conservative management through various oral and intravesical therapies, with most surgical therapies reserved for unresponsive cases. Pain management is critical throughout the treatment process. The consultation believes that the disorder is best viewed as one of a group of chronic pain syndromes, rather than as primarily an inflammatory bladder disorder. Recommendations for future research pathways are suggested. Neurourol. Urodynam. 29: 191–198, 2010. © 2009 Wiley-Liss, Inc.

Surgical treatment of stress incontinence in men.

Abstract: Aims The committee was charged with the responsibility of reviewing and evaluating all published data relating to surgical treatment of male urinary incontinence since the previous consultation in 2004. Methods Articles from peer-reviewed journals, abstracts from scientific meetings, and literature searches by hand and electronically formed the basis of this review. The articles were evaluated using Levels of Evidences adapted by the ICUD from the Oxford Centre for Evidence Based Medicine. The Recommendations for Care were based on the level of evidence and discussed among the committee members to reach consensus. The incontinence problems were classified according to their etiology, that is, either primarily sphincter or bladder related. Results Specialist evaluation of the patient is primarily a clinical approach with history, frequency-volume chart, physical examination, and post-void residual urine. Other investigations such as radiographic imaging of the lower urinary tract, cystoscopy, and urodynamic studies can provide important information for the clinician. For stress incontinence of various etiologies the artificial urinary sphincter (AUS) has the longest record of satisfactory results. Consideration must be given to the need for revisions for mechanical breakdown, erosion/infection, and recurrent incontinence, as well as cost. Sling procedures are increasingly being reported to have good outcomes for mild to moderate incontinence. Injectable agents have not shown durable results but newer technologies such as volume-adjustable balloons have shown favorable early results. Incontinence following cystectomy with neobladder and pelvic trauma has been treated most commonly with the AUS. Conclusions Although the literature is replete with well-done cohort studies, there is a need for prospective randomized clinical trials. Recommendations for trials include standardized workup and outcome measures and complete reporting of adverse events and long-term results. Further research is also needed to elucidate the mechanism of post-prostatectomy incontinence. Neurourol. Urodynam. 29: 179–190, 2010. © 2009 Wiley-Liss, Inc.

Neural Control of the Lower Urinary Tract: Peripheral and Spinal Mechanisms

Abstract: This review deals with individual components regulating the neural control of the urinary bladder. This article will focus on factors and processes involved in the two modes of operation of the bladder: storage and elimination. Topics included in this review include: (1) The urothelium and its roles in sensor and transducer functions including interactions with other cell types within the bladder wall (“sensory web”), (2) The location and properties of bladder afferents including factors involved in regulating afferent sensitization, (3) The neural control of the pelvic floor muscle and pharmacology of urethral and anal sphincters (focusing on monoamine pathways), (4) Efferent pathways to the urinary bladder, and (5) Abnormalities in bladder function including mechanisms underlying comorbid disorders associated with bladder pain syndrome and incontinence.

Pelvic organ prolapse and overactive bladder

Abstract: The definitive version can be found at: http://onlinelibrary.wiley.com/ Copyright Wiley [Full text of this article is not available in the UHRA]

Chronic pudendal neuromodulation: expanding available treatment options for refractory urologic symptoms.

Abstract: Aims Chronic pudendal nerve stimulation (CPNS) is a logical alternative particularly in those who fail sacral stimulation. We evaluated symptoms, complications, and satisfaction after CPNS. Methods We retrospectively reviewed patients having a tined lead placed at the pudendal nerve via the ischial-rectal approach. Demographics, history, complications, and pre-implant voiding diary data were collected. In those responding to CPNS, post-implant symptom changes were measured with the Interstitial Cystitis Symptom and Problem indices (ICSI-PI) and voiding diaries at 3, 6, and 12 months, and a mailed survey. Results The majority of 84 patients (78.6% female; age 51.8 ± 16.9 years) had interstitial cystitis/painful bladder syndrome, or overactive bladder. Pudendal response (≥ 50% improvement) occurred in 60/84 (71.4%), however 5 of these chose sacral neuromodulation. Almost all (93.2%) who had previously failed sacral neuromodulation responded to pudendal stimulation. Outcomes were evaluated in 55 continuing on CPNS (median follow up 24.1 months). Seven complications requiring 5 revisions, and 4 other re-operations occurred. Five were explanted. Over time, significant improvements in frequency (P < 0.0001), voided volume (P < 0.0001), incontinence (P < 0.0001), and urgency (P = 0.0019) occurred. ICSI-PI scores significantly improved over 12 months (P < 0.0001). Survey responses indicated that most still had a device (35/40; 87.5%) continuously in use (24/29; 82.8%), and overall bladder, pelvic pain, incontinence, urgency, and frequency symptoms had improved. Conclusions CPNS is a reasonable alternative in complex patients refractory to other therapies including sacral neuromodulation. Continued research is needed to fully assess long-term outcomes and identify predictors of success. Neurourol. Urodynam. 29:1267–1271, 2010. © 2009 Wiley-Liss, Inc.

Changes in afferent activity after spinal cord injury.

Abstract: Aims To summarize the changes that occur in the properties of bladder afferent neurons following spinal cord injury. Methods Literature review of anatomical, immunohistochemical, and pharmacologic studies of normal and dysfunctional bladder afferent pathways. Results Studies in animals indicate that the micturition reflex is mediated by a spinobulbospinal pathway passing through coordination centers (periaqueductal gray and pontine micturition center) located in the rostral brain stem. This reflex pathway, which is activated by small myelinated (Aδ) bladder afferent nerves, is in turn modulated by higher centers in the cerebral cortex involved in the voluntary control of micturition. Spinal cord injury at cervical or thoracic levels disrupts voluntary voiding, as well as the normal reflex pathways that coordinate bladder and sphincter function. Following spinal cord injury, the bladder is initially areflexic but then becomes hyperreflexic due to the emergence of a spinal micturition reflex pathway. The recovery of bladder function after spinal cord injury is dependent in part on the plasticity of bladder afferent pathways and the unmasking of reflexes triggered by unmyelinated, capsaicin-sensitive, C-fiber bladder afferent neurons. Plasticity is associated with morphologic, chemical, and electrical changes in bladder afferent neurons and appears to be mediated in part by neurotrophic factors released in the spinal cord and the peripheral target organs. Conclusions Spinal cord injury at sites remote from the lumbosacral spinal cord can indirectly influence properties of bladder afferent neurons by altering the function and chemical environment in the bladder or the spinal cord. Neurourol. Urodynam. 29: 63–76, 2010. © 2009 Wiley-Liss, Inc.

Interstitial cells in the urinary bladder--localization and function.

Abstract: Aims This review summarizes the currently available literature on the localization and proposed functions of a novel group of cells in the urinary bladder known as interstitial cells or interstitial cells of Cajal (ICC). Methods On-line searches of “Pubmed” for bladder, c-Kit, ICC, interstitial cell and myofibroblast were performed to identify relevant studies for the review. Results The literature contains substantial data that several sub-populations of ICC are present in the wall of the mammalian urinary bladder. These are located in the lamina propria and within the detrusor with distinctive cell shapes and morphological arrangements. Bladder ICC are identified with transmission electron microscopy or by immunohistochemical labeling using antibodies to the Kit receptor which is an established ICC marker. Lamina propria-ICC form a loose network connected via Cx43 gap junctions and are associated with mucosal nerves. Detrusor ICC track the smooth muscle bundles and make frequent contacts with intramural nerves. Both groups of ICC exhibit spontaneous electrical and Ca2+-signalling and also respond to application of neurotransmitter substances including ATP and carbachol. There is emerging evidence that the expression of ICC is upregulated in pathophysiological conditions including the overactive bladder. Conclusions There is now a convincing body of evidence that specialized ICC are present in the urinary bladder making important associations with other cells that make up the bladder wall and possessing physiological properties consistent with a role of bladder activity modulation. Neurourol. Urodynam. 29: 82–87, 2010. © 2009 Wiley-Liss, Inc.

Why do women have stress urinary incontinence

Abstract: This article reviews progress made in understanding the causes of stress urinary incontinence. Over the last century, several hypotheses have been proposed to explain stress urinary incontinence. These theories are based on clinical observations and focus primarily on the causative role of urethral support loss and an open vesical neck. Recently these hypotheses have been tested by comparing measurements of urethral support and function in women with primary stress urinary incontinence to asymptomatic volunteers who were recruited to be similar in age, race, and parity. Maximal urethral closure pressure is the parameter that differs the most between groups being 43% lower in women with stress incontinence than similar asymptomatic women having as effect size of 1.6. Measures of urethral support effect sizes range from 0.5 to 0.6. Because any one objective measure of support may not capture the full picture of urethrovesical mobility, review of blinded ultrasounds of movements during cough were reviewed by an expert panel. The panel was able to identify women with stress incontinence correctly 57% of the time; just 7% above the 50% that would be expected by chance alone, confirming that urethrovesical mobility is not strongly associated with stress incontinence. Although operations that provide differential support to the urethra are effective, urethral support is not the predominant cause of stress incontinence. Improving our understanding of factors affecting urethral closure may lead to novel treatments targeting the urethra and improved understanding of the small but persistent failure rate of current surgery.

Neural control of the lower urinary and gastrointestinal tracts: supraspinal CNS mechanisms.

Abstract: Normal urinary function is contingent upon a complex hierarchy of CNS regulation. Lower urinary tract afferents synapse in the dorsal horn of the spinal cord and ascend to the midbrain periaqueductal gray (PAG), with a separate nociception path to the thalamus. A spino-thalamo-cortical sensory pathway is present in some primates, including humans. In the brainstem, the pontine micturition center (PMC) is a convergence point of multiple influences, representing a co-ordinating center for voiding. Many PMC neurones have characteristics necessary to categorize the center as a pre-motor micturition nucleus. In the lateral pontine brainstem, a separate region has some characteristics to suggest a “continence center.” Cerebral control determines that voiding is permitted if necessary, socially acceptable and in a safe setting. The frontal cortex is crucial for decision making in an emotional and social context. The anterior cingulate gyrus and insula co-ordinate processes of autonomic arousal and visceral sensation. The influence of these centers on the PMC is primarily mediated via the PAG, which also integrates bladder sensory information, thereby moderating voiding and storage of urine, and the transition between the two phases. The parabrachial nucleus in the pons is also important in behavioral motivation of waste evacuation. Lower urinary tract afferents can be modulated at multiple levels by corticolimbic centers, determining the interoception of physiological condition and the consequent emotional motor responses. Alterations in cognitive modulation, descending modulation, and hypervigilance are important in functional (symptom-based) clinical disorders. Neurourol. Urodynam. 29: 119–127, 2010. © 2009 Wiley-Liss, Inc.

Management of Fecal Incontinence in Adults

Abstract: This article summarises the findings from the Conservative Management of Faecal Incontinence in Adults Committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: "anal, anorectal, bowel, faecal, fecal, rectal, stool" and "continent$ or incontinent$," Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few "lifestyle" associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research.

Efficacy and adverse events of sacral nerve stimulation for overactive bladder: A systematic review.

Abstract: Aims To systematically review the literature regarding efficacy and adverse events of sacral nerve stimulation (SNS) via the InterStim device for treatment of women with refractory overactive bladder (OAB). Methods We searched MEDLINE, Embase, Web of Science, and the Cochrane Collaboration databases from 1980 to September 2008. All English studies reporting on efficacy or adverse events of SNS for the treatment of refractory OAB were considered. Only studies where 30 or more women received the complete therapy (implanted lead and generator) were included. The quality of the studies (good, fair, or poor) was assessed based on predefined criteria. Results Seven studies were designated “good” regarding efficacy of SNS for OAB. Multiple authors reported results from the same cohort of patients. In this instance, the highest quality study was chosen, leaving three independent studies regarding efficacy. In these studies, incontinent episodes per day and pad usage significantly improved after SNS therapy. Six studies were designated “good” regarding adverse events. Using tined leads, surgical revision rates ranged from 3% to 16%. Six percent of patients were explanted due to lack of efficacy and 5–11% of patients were explanted due to infection. Conclusions Based on observational data, SNS appears effective for treatment of OAB in women. Adverse event rates with tined leads are lower than previously published estimates using non-tined leads. High-quality studies are needed to confirm our findings and to provide additional data regarding reprogramming, quality of life, and efficacy when compared to other therapies. Neurourol. Urodynam. 29:S18–S23, 2010. © 2010 Wiley-Liss, Inc.

Cross-talk and sensitization of bladder afferent nerves.

Abstract: The coordination of pelvic physiologic function requires complex integrative sensory pathways that may converge both peripherally and/or centrally. Following a focal, acute irritative or infectious pelvic insult, these same afferent pathways may produce generalized pelvic sensitization or cross-sensitization as we show bi-directionally for the bladder and bowel in an animal model. Single unit bladder afferent recordings following intracolonic irritation reveal direct sensitization to both chemical and mechanical stimuli that's dependent upon both intact bladder sensory (C-fiber) innervation and neuropeptide content. Concurrent mastocytosis (preponderantly neurogenic) likely plays a role in long-term pelvic organ sensitization via the release of nociceptive and afferent-modulating molecules. Prolonged pelvic sensitization as mediated by these convergent and antidromic reflexive pathway may likewise lead to chronic pelvic pain and thus the overlap of chronic pelvic pain disorders.

The questionnaire for urinary incontinence diagnosis (QUID): Validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence†‡§

Abstract: Aims: The Questionnaire for Urinary Incontinence Diagnosis (QUID), a 6-item urinary incontinence (UI) symptom questionnaire, was developed and validated to distinguish stress and urge UI. This study’s objective was to evaluate QUID validity and responsiveness when used as a clinical trial outcome measure. Methods: Participants enrolled in a multi-center trial of non-surgical therapy (continence pessary, pelvic floor muscle training or combined) for stress-predominant UI and completed baseline and 3-month diaries, the Urinary Distress Inventory (UDI) and QUID. Data from all treatment groups were pooled. QUID internal consistency (Cronbach’s a) and convergent/ discriminant validity (Pearson correlations) were evaluated. Responsiveness to change was assessed with 3-month score outcomes and distribution-based measurements. Results: Four hundred forty-four women (mean age 50) were enrolled with stress (N ¼ 200) and mixed (N ¼ 244) UI; 344 had 3-month data. Baseline QUID Stress and Urge scores (both scaled 0–15, larger values indicating worse UI) were 8.4 � 3.2 and 4.5 � 3.3, respectively. Internal consistency of QUID Total, Stress, and Urge scores was 0.75, 0.64 and 0.87, respectively. QUID Stress scores correlated moderately with UDI-Stress scores (r ¼ 0.68, P < 0.0001) and diary stress UI episodes (r ¼ 0.41, P < 0.0001). QUID Urge scores correlated moderately with UDI-Irritative scores (r ¼ 0.68, P < 0.0001) and diary urge UI episodes (r ¼ 0.45, P < 0.0001). Three-month QUID Stress and Urge scores improved (4.1 � 3.4 and 2.2 � 2.7, both P < 0.0001). QUID Stress score effect size (1.3) and standardized response mean (1.2) suggested a large change after therapy. Conclusion: The QUID has acceptable psychometric characteristics and may be used as a UI outcome measure in clinical trials. Neurourol. Urodynam. 29:726–733, 2010. 2010 Wiley-Liss, Inc.

Effects of CL316,243, a beta 3-adrenoceptor agonist, and intravesical prostaglandin E2 on the primary bladder afferent activity of the rat.

Abstract: Aims It has been suggested that β3-adrenoceptor (β3-AR) agonists affect not only the efferent but also the afferent pathways innervating the bladder. In addition, prostaglandin E2 (PGE2) causes bladder hyperactivity in conscious rats. We investigated the direct effects of a β3-AR agonist (CL316,243; CL) and PGE2 on single fiber activities of the primary bladder afferent nerves. Methods Female Sprague–Dawley rats were used. Under urethane anesthesia, a single nerve fiber primarily originating from the bladder was identified by electrical stimulation of the left pelvic nerve and by bladder distention, and was divided by conduction velocity (2.5 m/sec) as Aδ-fiber or C-fiber. The afferent activity measurements with constant bladder filling were repeated three times and the third measurement served as the base-line observation. Then, CL (10 µg/kg) or its vehicle was administrated intravenously. Thereafter, 10−4 M of PGE2 or saline was instilled intravesically and another three cycles recorded. Results Forty-three single afferent fibers (Aδ-fibers: n = 20, C-fibers: n = 23) were isolated from 34 rats. Intravenous administration of CL, but not vehicle, significantly decreased Aδ-fiber, but not C-fiber, activities in response to bladder filling with saline. Intravesical instillation of PGE2 significantly increased C-fiber activities, but not Aδ-fiber activities. The PGE2-induced increase in C-fiber activities was inhibited by pretreatment with CL. Conclusions The present results clearly demonstrate that the β3-AR agonist, CL316,243, can inhibit the mechanosensitive Aδ-fibers, but not the C-fibers, of the primary bladder afferents of the rat. In addition, the β3-AR agonist can inhibit PGE2-induced C-fiber hyperactivity. Neurourol. Urodynam. 29:771–776, 2010. © 2010 Wiley-Liss, Inc.

Detrusor myocyte activity and afferent signaling.

Abstract: Aims To discuss (1) mechanisms involved in the generation and control of myocyte contractions and consequent afferent nerve activity and (2) these mechanisms as targets for drugs aimed for treatment of overactive bladder (OAB) symptoms and detrusor overactivity (DO). Methods Literature review of myocyte activation, bladder afferent nerves, mediators in the bladder, and translational aspects of the findings. Results During bladder filling, there is normally no parasympathetic outflow from the spinal cord. Despite this, the bladder develops tone during filling and also exhibits non-synchronized local contractions and relaxations that are caused by a basal myogenic mechanical activity that may be reinforced by release of, for example, acetylcholine from non-neuronal and/or neuronal sources or local mediators, such as prostaglandins and endothelins. It is suggested that these spontaneous contractions are able to generate activity in afferent nerves (“afferent noise”) that may contribute to DO and OAB. Conclusions Spontaneous bladder myocyte contractions and factors that are able to modulate them, as well as the consequent afferent nerve activity, may be targets for drugs meant for treatment of OAB/DO. Neurourol. Urodynam. 29: 97–106, 2010. © 2009 Wiley-Liss, Inc.

Caffeine Intake and Risk of Stress, Urgency, and Mixed Urinary Incontinence

Abstract: PURPOSE Although caffeine consumption is common and generally believed to affect bladder function, little is known about caffeine intake and incident urinary incontinence. MATERIALS AND METHODS We performed a prospective cohort study in 65,176 women 37 to 79 years old without incontinence in the Nurses' Health Study and the Nurses' Health Study II. Incident incontinence was identified from questionnaires during 4 years of followup. Caffeine intake was measured using food frequency questionnaires administered before incontinence development. The multivariate adjusted relative risk of the relation between caffeine intake and incontinence risk as well as attributable risk were calculated. RESULTS Caffeine was not associated with incontinence monthly or more. However, there was a modest, significantly increased risk of incontinence at least weekly in women with the highest (greater than 450 mg) vs the lowest (less than 150 mg) daily intake (RR 1.19, 95% CI 1.06-1.34) and a significant trend of increasing risk with increasing intake (p for trend = 0.01). This risk appeared focused on incident urgency incontinence (greater than 450 vs less than 150 mg daily, RR 1.34, 95% CI 1.00-1.80, p for trend = 0.05) but not on stress or mixed incontinence (p for trend = 0.75 and 0.19, respectively). The attributable risk of urgency incontinence associated with high caffeine intake was 25%. CONCLUSIONS Findings suggest that high but not lower caffeine intake is associated with a modest increase in the incidence of frequent urgency incontinence. A fourth of the cases with the highest caffeine consumption would be eliminated if high caffeine intake were eliminated. Confirmation of these findings in other studies is needed before recommendations can be made.

International consultation on incontinence‐research society (ICI‐RS) report on non‐invasive urodynamics: The need of standardization of ultrasound bladder and detrusor wall thickness measurements to quantify bladder wall hypertrophy

Abstract: Introduction Ultrasonic measurements of urinary bladders are suitable to quantify bladder wall hypertrophy due to bladder outlet obstruction, detrusor overactivity, or neurogenic bladder dysfunction in adult men or women and in children. Quantification of bladder wall hypertrophy seems to be useful for the assessment of diseases, prediction of treatment outcomes, and longitudinal studies investigating disease development and progression. Measurement techniques Four distinct measurement techniques have been published using bladder wall thickness (BWT), detrusor wall thickness (DWT), or ultrasound-estimated bladder weight (UEBW) assessed by suprapubic or transvaginal positioning of ultrasound probes and different bladder filling volumes. As a result, different threshold and reference values were established causing confusion. This ICI-RS report summarizes the agreements of different research groups in terms of ultrasonic BWT or DWT measurements, critically discusses the four ultrasonic measurement techniques, suggests criteria for quality control, and proposes future research activities to unify measurement strategies. Proposed standardization and research For quality control, all future reports should provide information about frequency of the ultrasound probe, bladder filling volume at measurement, if BWT, DWT, or UEBW was measured, enlargement factor of the ultrasound image, and one ultrasound image with marker positioning. The ICI-RS intends to found a standardization committee that will initiate and judge studies on ultrasonic bladder wall measurements to clarify the most suitable, most accurate, and least invasive measurement technique. Neurourol. Urodynam. 29:634–639, 2010. © 2009 Wiley-Liss, Inc.

The emotional motor system and micturition control

Abstract: Micturition is, similar to all other movements of the body, the result of activation of the motor system in the central nervous system. This review explains how the brain and brainstem control micturition. The basic reflex system begins with a distinct cell group called Gert's Nucleus (GN) in the sacral cord. GN receives information about bladder contents via A-delta fibers from the bladder and bladder sphincter and relays this information to the central part of the midbrain periaqueductal gray (PAG), but not to the thalamus. The PAG, in turn, in case of substantial bladder filling, excites the pontine micturition center (PMC), which cell group, via its long descending pathways to the sacral cord, induces micturition. Higher brain regions in prefrontal cortex and limbic system, by means of its projections to the PAG are able to interrupt this basic reflex system. It allows the individual to postpone micturition until time and place are appropriate. Lesions in the pathways from prefrontal cortex and limbic system to the PAG probably cause urge-incontinence in the elderly.

Urinary nerve growth factor is a better biomarker than detrusor wall thickness for the assessment of overactive bladder with incontinence.

Abstract: Purpose To compare the differences in urinary nerve growth factor (NGF) and detrusor wall thickness (DWT) between patients with overactive bladder (OAB) and controls to evaluate their suitability as biomarkers in OAB. Materials and Methods A total of 81 patients including normal controls (n = 28), patients with OAB dry (n = 28) and OAB wet (n = 25) were enrolled in this study. Videourodynamic study was performed in 79 patients after confirmation of symptomatic classification by 3-day voiding diary. Urine NGF and DWT measurements were performed at full bladder and urge to void after natural-filling or catheter-filling during videourodynamic study. Urinary NGF level was measured by the ELISA method and DWT was measured by trans-abdominal ultrasound. These two parameters were compared among different symptomatic and urodynamic subgroups. Results DWT was not significantly different among subgroups at 250 ml bladder volume. Although patients with OAB wet had a significantly greater DWT at the maximal bladder volume, this difference was not significant from controls after correction of the volume factor. By contrast, urinary NGF levels were significantly increased in patients with OAB wet and those with urodynamic detrusor overactivity. However, elevated NGF levels in OAB wet were found only after natural-filling and not after catheter-filling. Conclusions Urinary NGF level in natural-filling urine sample is a better biomarker for assessment of OAB wet compared to DWT. Patients with OAB dry or hypersensitive bladder did not have an elevated urinary NGF level. Urine samples from catheter-filling do not have a detectably high NGF levels. Neurourol. Urodynam. 29:482–487, 2010. © 2009 Wiley-Liss, Inc.

Beyond neurons: Involvement of urothelial and glial cells in bladder function

Abstract: Aim The urothelium, or epithelial lining of the lower urinary tract (LUT), is likely to play an important role in bladder function by actively communicating with bladder nerves, smooth muscle, and cells of the immune and inflammatory systems. Recent evidence supports the importance of non-neuronal cells that may extend to both the peripheral and central processes of the neurons that transmit normal and nociceptive signals from the urinary bladder. Using cats diagnosed with a naturally occurring syndrome termed feline interstitial cystitis (FIC), we investigated whether changes in physiologic parameters occur within 3 cell types associated with sensory transduction in the urinary bladder: 1) the urothelium, 2) identified bladder dorsal root ganglion (DRG) neurons and 3) grey matter astrocytes in the lumbosacral (S1) spinal cord. As estrogen fluctuations may modulate the severity of many chronic pelvic pain syndromes, we also examined whether 17β-estradiol (E2) alters cell signaling in rat urothelial cells.

Pelvic floor muscle training in the treatment of lower urinary tract dysfunction in women with multiple sclerosis

Abstract: Aims Evaluate the role of Pelvic Floor Muscle Training (PFMT) on the treatment of Lower Urinary Tract Dysfunction (LUTD) in Multiple Sclerosis (MS) patients. Methods In this randomized controlled trial, twenty seven female patients with a diagnosis of MS and LUTD complaints were randomized, in two groups: Treatment group (GI) (N = 13) and Sham group (GII) (N = 14). Evaluation included urodynamic study, 24-hr Pad testing, three day voiding diary and pelvic floor evaluation according to PERFECT scheme. Intervention was performed twice a week for 12 weeks in both groups. GI intervention consisted of PFMT with assistance of a vaginal perineometer. GII received a sham treatment consisted on the introduction of a perineometer inside the vagina with no contraction required. Results At the end of the treatment GI was complaining less about storage and voiding symptoms than GII. Furthermore, differences found between groups were: reduction of pad weight (P = 0.00) (Mean: 87,51 grams initial and 6,03 grams final in GI. 69,46 grams initial and 75,88 grams final in GII), number of pads (P = 0.01) (Mean: 3,61 initial and 2,15 final in GI. 3,42 initial and 3,28 final in GII) and nocturia events (P < 0.00) (Mean: 2,38 initial and 0,46 final in GI. 2,55 initial and 2,47 final in GII) and improvements of muscle power (P = 0.00), endurance (P < 0.00), resistance (P < 0.00) and fast contractions (P < 0.00), domains of PERFECT scheme. Conclusions PFMT is an effective approach to treat LUTD in female with MS. Neurourol. Urodynam. 29:1410–1413, 2010. © 2010 Wiley-Liss, Inc.

Overactive bladder: Is there a link to the metabolic syndrome in men?†‡

Abstract: It is becoming increasingly clear that a variety of metabolic, cardiovascular, and endocrine factors contribute to male pelvic health. In particular, a growing body of evidence suggests a relationship between lower urinary tract symptoms, benign prostatic hyperplasia, overactive bladder, erectile dysfunction, and the metabolic syndrome. This article explores these relationships, focusing on the role of the autonomic nervous system and hyperinsulinemia, together with their implications for urological practice.

Is the Urothelium Intelligent

Abstract: The urothelium separates the urinary tract lumen from underlying tissues of the tract wall. Previously considered as merely an effective barrier between these two compartments it is now recognized as a more active tissue that senses and transduces information about physical and chemical conditions within the urinary tract, such as luminal pressure, urine composition, etc. To understand this sensory function it is useful to consider the urothelium and suburothelium as a functional unit; containing uroepithelial cells, afferent and efferent nerve fibers and suburothelial interstitial cells. This structure responds to alterations in its external environment through the release of diffusible agents, such as ATP and acetylcholine, and eventually modulates the activity of afferent nerves and underlying smooth muscles. This review considers different stresses the urothelium/suburothelium responds to; the particular chemicals released; the cellular receptors that are consequently affected; and how nerve and muscle function is modulated. Brief consideration is also to regional differences in the urothelium/suburothelium along the urinary tract. The importance of different pathways in relaying sensory information in the normal urinary tract, or whether they are significant only in pathological conditions is also discussed. An operational definition of intelligence is used, whereby a system (urothelium/suburothelium) responds to external changes, to maximize the possibility of the urinary tract achieving its normal function. If so, the urothelium can be regarded as intelligent. The advantage of this approach is that input-output functions can be mathematically formulated, and the importance of different components contributing to abnormal urinary tract function can be calculated.

Neurologic urinary incontinence

Abstract: Introduction This manuscript summarizes the work of Committee 10 on neurologic bladder and bowel of the International Consultation on Incontinence in 2008–2009. As the data are very large the outcome is presented in different manuscripts. This manuscript deals with neurologic urinary incontinence. Methods Through in debt literature review all aspects of neurological urinary incontinence were studied for levels of evidence. Recommendations for diagnosis and treatment, and for future research were made. Results Pathophysiology was summarized for different levels of lesions. For epidemiology, specific diagnostics, conservative treatment and surgical treatment of neurologic urinary incontinence, levels of evidence and grades of recommendation were made following ICUD criteria. Conclusions Though data are available that advice and guide in the management of urinary incontinence in neurologic patients, not many data have a high level of evidence or permit a high grade of recommendation. More and well-structured research is needed. Neurourol. Urodynam. 29: 159–164, 2010. © 2009 Wiley-Liss, Inc.

Animal Models and Their Use in Understanding Lower Urinary Tract Dysfunction

Abstract: This review will highlight appropriate animal models for the study of a number of disorders involving changes to lower urinary tract function. A major hurdle to the development of animal models for human lower urinary tract disorders is that the clinical pathophysiology of the latter mostly remain idiopathic. Acute injury/inflammation of otherwise healthy animals has often been used to study effects on a target tissue/organ. However, these "acute" models may not adequately address the characteristics of "chronic" visceral disorders. In addition, the relevance of observed changes following acute injury/inflammation, in terms of possible therapeutic targets, may not reflect that which occurs in the human condition. We have therefore emphasized the situations when animal models are required to investigate lower urinary tract disorders and what they should set out to achieve. In particular we have discussed the merits and disadvantages of a number of paradigms that set out to investigate specific lower urinary tract disorders or situations associated with these conditions. These include animal models of overactive bladder, stress urinary incontinence, ageing and congenital defects of the urinary tract and bladder pain syndrome.

The effects of chronic hyperlipidemia on bladder function in myocardial infarction-prone Watanabe heritable hyperlipidemic (WHHLMI) rabbits.

Abstract: Aims Lower urinary tract symptoms (LUTS) are common in the aging population. LUTS cause profoundly negative impacts on their quality of life. Pathophysiology of LUTS is multifactorial, and recently, bladder ischemia and metabolic syndrome have been suggested as etiological factors. To evaluate chronic hyperlipidemia on bladder function, we examined the functional and histological changes of the bladder in myocardial infarction-prone Watanabe Heritable Hyperlipidemic (WHHLMI) rabbits. Methods 20- to 24-month-old WHHLMI rabbits and age- and sex-matched control rabbits were prepared. Bladder functions were evaluated using cystometrograms and functional experiments with isolated bladder specimens. Histological studies of bladder and internal iliac arteries were performed with hematoxylin and eosin staining. The bladder was also stained immunohistochemically with mouse monoclonal S-100 antibodies and sheep polyclonal calcitonin gene-related peptide (CGRP) antibodies. Results In cystometric examination, WHHLMI rabbits showed significantly shorter micturition interval, smaller voided volume with non-voiding contractions, and lower micturition pressure, as compared to control. The functional experiments showed that carbachol- and electrical field stimulation-induced contractions were significantly decreased in WHHLMI rabbits than those in control. In WHHLMI rabbits, cross-sections of internal iliac arteries showed significant atherosclerosis and thickening of media. Bladder showed thinner urothelium and decreased smooth muscle area in WHHLMI rabbits, as compared to control. WHHLMI rabbits showed a significant decrease in S-100 protein positive neurons, and an increased number of CGRP positive neurons. Conclusions This study demonstrated that WHHLMI rabbits showed detrusor overactivity with decreased detrusor contraction. It is suggested that chronic hyperlipidemia contributes to the bladder dysfunction. Neurourol. Urodynam. 29:1350–1354, 2010. © 2010 Wiley-Liss, Inc.