Cystometry and mictometry as tools in diagnosing neurogenic impotence

Thirty-six males with erective impotence underwent neurological and urological examinations. Six of the patients were known to have a neurological disorder at the time of referral (four multiple sclerosis, one myelomeningocele, one diabetic polyneuropathy). Four further cases of neurological disorders were found (one multiple sclerosis, one myelopathy of unknown cause, one Shy-Drager syndrome, one sequelae of sacral herpes zoster). Five of these 10 patients gave a history of urinary troubles, but in all of them objective signs of bladder dysfunction were found at cystometry and/or mictometry. Among the 26 patients with impotence and no indication of a neurological disorder all invariably had normal cystometrograms, though some had abnormal mictiograms, probably due to local urological disorders.
A neurological examination should be included in the evaluation of patients with erective impotence. Cystometry and mictometry may be of value by giving additional indications that the impotence is neurogenic. This is explained by the fact that the anatomical structures regulating sexual function lie close to corresponding structures regulating bladder function at the spinal level.     

Clinical efficacy of distigmine bromide in the treatment of patients with underactive detrusor

Purpose: The aim of this study was to assess the clinical efficacy of distigmine bromide, an anti-cholinesterase agent, deemed to improve detrusor function thereby restoring normal voiding patterns in patients suffering from detrusor underactivity. Materials and methods: A total of 27 patients (11 men and 16 women) with poor detrusor function were included in the study. The diagnosis was established using pressure-flow studies. All patients received distigmine bromide at a dose of 5 mg three times daily for 4 weeks and re-attended for a follow-up urodynamic investigation. The results of baseline pressure-flow studies were compared to those after completion of treatment. Results: Treatment with distigmine bromide resulted in a statistically significant reduction of residual volume and percent residual volume, obviating the need for intermittent self-catheterisation in 11 patients. In addition, maximum flow rate and detrusor pressure at maximum flow increased, although not significantly. The drug was generally well tolerated by the majority of patients. Conclusion: Distigmine bromide shows clinical efficacy in patients with poor detrusor function and may therefore be used alternatively in selected cases.     

Urethral evoked sympathetic skin responses and viscerosensory evoked potentials as diagnostic tools to evaluate urogenital autonomic afferent innervation in spinal cord injured patients

PURPOSE: In most spinal cord injured (SCI) patients the objective assessment of afferent neuronal pathways from the lower urinary tract and the recording of a disturbed urethral sensation and/or desire to void are still difficult. Viscerosensory evoked potentials (VSEPs) might be helpful, but they remain technically difficult to obtain and interpretation is delicate. As a new approach, sympathetic skin response (SSR) of the hand and foot were recorded after electrical stimulation of the posterior urethral mucosa. This technique should allow assessment of the integrity or deterioration of the autonomic afferent pathway. MATERIALS AND METHODS: A total of 20 males and 8 females with SCI somatosensory incomplete 15, somatosensory complete 13 and 6 healthy male volunteers were prospectively examined. During urodynamic examination electrical stimulation (single square pulses of 0.2 ms, 2 to 3-fold sensory threshold, 60 mA in complete SCI patients) of the posterior urethra/bladder neck was performed using a bipolar electrode inserted into a microtip pressure catheter. SSR recordings of the right palm and sole were simultaneously taken using surface electrodes and were analyzed by an electromyography unit. Patient reports on evoked urethral sensations at individual sensory thresholds were simultaneously noted. Additionally, well-known electrophysiological measurements such as pudendal sensory evoked potential and urethral VSEP were recorded to check clinical assessed somatosensory and viscerosensory status, and to compare SSR results with these conventional methods. RESULTS: Electrical stimulation of the posterior urethra evoked clear urethral sensation and SSRs in normal subjects. In 14 of 15 sensory incomplete SCI patients with disturbed urethral sensation SSRs could be recorded as well. Electrically evoked urethral sensations resembled the subjective desire to void at full bladder reported by controls and patients. In 13 sensory complete SCI patients with loss of any urethral sensation SSRs could not be recorded even at maximal electrical stimulation strength. All subjects with electrically induced urethral sensation had positive evoked (supralesional) SSRs of the hand. However, none of the patients with absent urethral sensation presented SSRs. Simultaneously recorded VSEPs could not be recorded clearly in 5 patients and 2 control subjects, whereas SSRs delivered clear results in all controls and patients, matching their reports. CONCLUSIONS: SSR recordings above a spinal lesion level after urethral electrostimulation might provide a useful and technically simple objective diagnostic tool to assess integrity of autonomic (visceral) afferent nerves from the lower urinary tract. Somatosensory deficits are not always paralleled by viscerosensory loss and vice versa. In this study SSRs were superior to VSEPs, the latter being more difficult to record. The subjective sensations reported by subjects during stimulation could be confirmed in an objective way in 100% of cases by positive/negative SSR findings.     

Posterior tibial nerve stimulation in the treatment of voiding dysfunction: urodynamic data

OBJECTIVES: To determine urodynamic changes and predictive factors in patients with voiding dysfunction who underwent 12 percutaneous tibial nerve stimulations. METHODS: Thirty nine patients with chronic voiding dysfunction were enrolled in a prospective multicenter trial in the Netherlands (n = 19) and in Italy (n = 20). A 50% reduction in total catheterised volume per 24 hr was taken as a primary objective outcome measure. Patients' request for continuation of treatment was regarded as subjective success. Objective urodynamic parameters and bladder indices were determined. Odds ratios and their 95% confidence interval were computed as a measure for predictive power in order to reveal predictive factors (Pdet at Qmax, Qmax, BVE, and BCI). RESULTS: Primary outcome measure was obtained in 41%, an additional 26% reduced their 24 hr residuals with more than 25%. Fifty nine percent of patients chose to continue treatment. Detrusor pressure at maximal flow, cystometric residuals, and bladder indices improved significantly for all patients (P < 0.05). Patients with minor voiding dysfunction were more prone to notice success (Odds ratio: 0.73; 95% CI: 0.51-0.94). CONCLUSIONS: PTNS is a young treatment modality, minimally invasive, and easily accessible. It might be an attractive first line option for patients with (minor) voiding dysfunction.     

Pubo-fascial versus vaginal sling operation for the treatment of stress urinary incontinence: a prospective study

AIMS: To compare the long-term results of stress urinary incontinence (SUI) treatment involving the fascial or vaginal sling operations. MATERIAL AND METHODS: Two-hundred-thirty-two women were consecutively submitted to fascial or vaginal sling operations due to urodynamic proven SUI. The fascial group had a median age of 47.3 years with a parity of 2.2 and 1.8 surgeries/patient, while the vaginal group demonstrated a median age of 48.5 years with a median parity of 3.1 and 2.2 anterior surgeries/patient. The results were subjectively classified as cured--no further pads, greatly improved--very rare dribbling, improved--eventual dribbling necessitating one pad, no cure--with no urine loss change and worse. The number of pads/day, the presence of urgency or urge-incontinence episodes were all measured. Statistical analysis using Fisher's exact test was employed. RESULTS: The patients were followed up for an average time of 70.3 and 44.9 months, in the fascial and vaginal sling group respectively. Subjective clinical success rate was 93.7% for the fascial sling group and 79.8% for the vaginal one, however, the stratification of the results favored the fascial sling group mostly with 74.4% (94 cases) of the cases with total urinary control and no voiding dysfunctions. Only two cases (1.6%) in this group classified themselves as worsened. On the other hand, the vaginal sling subset revealed cure with total clinical satisfaction and no urinary complaint in 61.5% (62 females) (P > 0.05). Thirteen cases (12.5%) reported recurrence of the urine loss under stress and these constituted the failure group. The average number of pads diminished from 3.3 (+/- 0.8) to 0.2 (+/- 0.2) and from 3.2 (+/- 0.7) to 0.6 (+/- 0.5) after the surgery, for the fascial and vaginal sling operations respectively. Return to daily activities occurred after 9.3 days (+/- 1.2, max: 33, min: 2) for the fascial slings and 5.3 days (+/- 0.2, max: 17, min: 2) in the vaginal group. Surgical complications were compared between the groups. Time to urethral voiding varied according to expertise, demonstrating a diminishing tendency after the initial 20 cases. Female obstruction was observed in 11.1% of the fascial slings and 8.6% after vaginal approach, but none in the vaginal group required urethrolysis. Looking individually, the FS group migrated to the worse results while the VWS group started to lose the efficiency after 6 months. CONCLUSIONS: Sling operations are a safe and efficacious option to treat SUI, however, the results can vary according to the technique employed. Shorter efficacy and fewer complications are observed in vaginal wall sling operations, while durable results, but with a higher rate of voiding dysfunctions compromising the long-term clinical satisfaction may be observed after excessive urethral suspensions, as in fascial sling suspension.     

The natural history of lower urinary tract dysfunction in men: the influence of detrusor underactivity on the outcome after transurethral resection of the prostate with a minimum 10-year urodynamic follow-up

OBJECTIVES: To assess the long-term outcome of the efficacy of transurethral resection of the prostate (TURP) in men with detrusor underactivity (DUA), a cause of lower urinary tract symptoms (LUTS) in a significant minority of men. PATIENTS AND METHODS: Neurologically intact men with LUTS, who were investigated in our department between 1972 and 1986, diagnosed with DUA and who underwent surgical intervention, were invited for a repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of the results. RESULTS: In all, 224 men were initially diagnosed with DUA; 87 (39%) of these died in the interim and 22 followed had a TURP, with a mean follow-up since surgery of 11.3 years. There were no significantly sustained reductions in any symptoms. There was a small but significant reduction of questionable clinical significance in the bladder outlet obstruction index, but this did not translate into an improved flow rate. Comparison with 58 age-matched patients with DUA who remained untreated showed no significant advantage of surgical intervention in the long-term; on the contrary, there was more chronic retention in those who had had surgery. CONCLUSIONS: There are no long-term symptomatic or urodynamic gains from TURP in men shown to have DUA. The results of TURP in men with DUA are important, as urologists who surgically treat patients based on the symptoms and uroflowmetry alone will do so in a significant minority of men with DUA. These results strengthen the argument for a routine preoperative urodynamic assessment.     

Prostaglandin E2 and bethanechol in combination for treating detrusor underactivity

OBJECTIVE: To test the hypothesis, in a prospective randomized double-blind study, that the combination of intravesical prostaglandin E2 (PGE2) and oral bethanechol chloride (BC) are additive or synergistic in improving bladder emptying, as they have been used alone for treating impaired detrusor contractility with little clinical benefit. PATIENTS AND METHODS: Nineteen patients with detrusor underactivity (17 men and two women) were eligible and randomized to one of two treatments. All had postvoid residual urine volumes (PVR) consistently of > 300 mL, most being reliant on clean intermittent self-catheterization (CISC). The experimental treatment group (nine patients) received once-weekly intravesical PGE2 (1.5 mg in 20 mL 0.9% saline) plus BC 50 mg four times daily, for a total of 6 weeks. The second group of 10 patients received a once-weekly instillation of saline together with placebo tablets, again for 6 weeks. RESULTS: Before treatment the median (interquartile range) PVR was 426 (405-480) mL for those receiving both drugs; this decreased to 325 (290-352) mL after completing the treatment (P < 0.015). In the placebo group the respective values were 576 (539-777) and 538 (350-775) mL (P = 0.09). Four of the patients receiving the active combination reported symptomatic improvement and were able to reduce the frequency of CISC. CONCLUSION: Although there was evidence of a pharmacological effect, BC and PGE2 had a limited therapeutic effect compared with placebo. Whilst we would not recommend this treatment as routine, it may be considered for the occasional treatment of a patient with detrusor underactivity.     

Urodynamic findings in primary progressive multiple sclerosis are associated with increased volumes of plaques and atrophy in the central nervous system

OBJECTIVE: Voiding dysfunction is more frequent in primary progressive multiple sclerosis (PPMS) than in other subtypes of MS. We investigated whether lower urinary tract disorders are reflected in the extent of changes in brain and spinal cord detected by magnetic resonance imaging (MRI). METHODS: Micturition symptoms and specific urodynamic findings in 24 patients with PPMS were related to MRI abnormalities as analysed by segmentation and volumetric analysis. RESULTS: Urgency and urge incontinence were the most frequent urinary symptoms (83 and 75 %), while detrusor sphincter dyssynergia (DSD) (71%), detrusor hyperreflexia (58%) and obstruction (58%) were the most common micturition dysfunctions. Comparison between patients with detrusor hyperreflexia and those with normal bladder function revealed higher volumes of T2-weighted plaques in the brains of former (P = 0.01). In patients with hypotonic bladder the total brain volume was smaller (P = 0.02) and the number of thoracic plaques in T2-weighted images higher (P = 0.02) compared to patients with normal bladder function. Furthermore, DSD was associated with a higher volume of T2-weighted plaques in the brain (P = 0.02). CONCLUSIONS: Voiding dysfunction in PPMS is associated with increasing brain and spinal cord abnormalities. Urodynamic investigation is, however, needed for specific definition of micturition disturbances and should be made before therapeutic decisions.     

Urodynamic changes induced by the intravaginal electrode during pelvic floor electrical stimulation

AIMS: The goal of this study was to evaluate whether the intravaginal electrode used to perform vaginal electrical stimulation could induce acute changes on the cystometrograms and urethral pressure profiles (UPP) recordings. METHODS: Three consecutive urodynamic examinations were performed on 30 women with stress urinary incontinence (SUI) symptoms. The first exam was performed without the electrode, the second with the electrode inserted into the vagina, but with the stimulator switched off and the third with the stimulator turned on. We used the INNOVA (Empi) stimulator with electrical parameters set at 50 Hz and 60 mA and on an intermittent cycle during the cystometries and a continuous stimulation during the UPP. The data of functional profile length (FPL), maximum urethral closure pressure (MUCP), and area of the resting UPP, as well as the filling sensations and its respective bladder volumes during the cystometries, were compared. With regard to the cystometries. RESULTS: No effect of the electrode was observed on cystometry. However, the simple presence of the electrode improved the FPL, MUCP, and areas of the UPP similar to those when the stimulation was applied. CONCLUSIONS: We conclude that, the presence of the intravaginal electrode induces changes in the UPP not related to the stimulation itself. The physiotherapeutic effect of the electrode itself is still to be evaluated.     

Which stop test is best? Measuring detrusor contractility in older females

PURPOSE: Impaired detrusor contractility has an important role in geriatric voiding dysfunction but there are many competing methods of measurement. We compared the performance of 3 methods of measuring detrusor contraction strength to identify the best one. MATERIALS AND METHODS: We retrospectively analyzed urodynamics data on 84 females 53 years old or older. All had urge incontinence and were enrolled in a placebo controlled oxybutynin trial. Stop tests (voluntary interruption, mechanical interruption and continuous mechanical occlusion of flow) were performed on each subject. RESULTS: At baseline the voluntary stop test measured lower mean isovolumetric detrusor pressure +/- SD than the mechanical and continuous methods (31.2 +/- 16.0 versus 47.2 +/- 26.5 and 48.7 +/- 24.4 cm. water, respectively). The latter 2 values also correlated highly (r = 0.87). Followup data on 76 women confirmed these results. Based on baseline and followup values in the 20 women who received placebo the continuous occlusion test showed highest test-retest reliability (r = 0.9, p <0.01), followed by the mechanical (r = 0.69, p = 0.01) and voluntary (r = 0.67, p <0.01) stop tests. Treatment with oxybutynin decreased isovolumetric detrusor pressure in all 3 stop tests by up to 6 cm. water. However, the decrease was statistically significant only for the continuous occlusion test. CONCLUSIONS: To assess detrusor contraction strength in elderly females with urge incontinence the mechanical stop and continuous occlusion tests are acceptable but the continuous occlusion test has better reliability and better detects slight drug induced changes. Voluntary stop tests greatly underestimate detrusor isovolumetric pressure and should no longer be used.