Physiology and evaluation of overactive bladder

Detrusor overactivity is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked. There are certain patterns of detrusor overactivity. Phasic detrusor overactivity is defined by a characteristic wave form and may or may not lead to urinary incontinence. Terminal detrusor overactivity is defined as a single involuntary detrusor contraction occurring at cystometric capacity, which cannot be suppressed. Neurogenic detrusor overactivity is qualified as neurogenic when it is a relevant neurological condition (old term is "detrusor hyperreflexia"), idiopathic detrusor overactivity when there is no defined cause (this term replaces "detrusor instability"). In neurogenic patients, detrusor overactivity is secondary to various pathophysiologic factors: interruption of inhibitor pathways issued from cerebral regions, activation de novo of vesical C reflex mediated by unmyelinated capsaicin fibers, and ultrastructural modifications of bladder urothelium. Bladder overactivity treatment is necessary to avoid renal complications and improve quality of life of neurogenic patients.     

DETRUSOR INSTABILITY IN MEN: CORRELATION OF LOWER URINARY TRACT SYMPTOMS WITH URODYNAMIC FINDINGS

PURPOSE: We evaluated the correlation of lower urinary tract symptoms suggestive of detrusor instability with urodynamic findings in men. MATERIALS AND METHODS: Enrolled in our prospective study were 160 consecutive neurologically intact men referred for urodynamic evaluation of persistent lower urinary tract symptoms. All patients had storage symptoms suggestive of detrusor instability. Patients were further clinically categorized according to the chief complaint of urge incontinence, frequency and urgency, nocturia or difficult voiding. The clinical and urodynamic diagnosis in all patients as well as specific urodynamic characteristics of those with detrusor instability were analyzed according to the these 4 clinical categories. RESULTS: Mean patient age was 61 +/- 15 years. The chief complaint was urge incontinence in 28 cases (17%), frequency and urgency in 57 (36%), nocturia in 30 (19%) and difficult voiding in 45 (28%). Detrusor instability was diagnosed in 68 cases (43%). A higher incidence of detrusor instability was associated with urge incontinence than with the other clinical categories (75% versus 36%, p <0.01). Of the patients 109 (68%) had bladder outlet obstruction, including 50 (46%) with concomitant detrusor instability. The prevalence of bladder outlet obstruction was similar in all patients regardless of the chief complaint. All other urodynamic diagnoses were also similar in the 4 clinical categories. The mean bladder volume at which involuntary detrusor contractions occurred were lower in patients with urge incontinence and frequency and urgency than in those with nocturia and difficult voiding (277.1 +/- 149.4 and 267.7 +/- 221.7 versus 346.7 +/- 204.6 and 306.2 +/- 192.1 ml., respectively, not statistically significant, p = 0.07). CONCLUSIONS: Detrusor instability and bladder outlet obstruction are common in men with lower urinary tract symptoms. The symptom of urge incontinence strongly correlated with detrusor instability. Other lower urinary tract symptoms did not correlate well with any urodynamic findings. Therefore, we believe that an accurate urodynamic diagnosis may enable focused and more efficient management of lower urinary tract symptoms in men.     

Voiding urgency and detrusor contractility in women with overactive bladders.

AIMS: To check whether the contractility of overactive bladders would be affected by voiding urgency. METHODS: We urodynamically studied 100 women: 20 normal controls (group 1), 60 patients with idiopathic detrusor overactivity (DO), and 20 with neurogenic DO from intracerebral lesions. The idiopathic DO groups 2A (n = 20), 2B (n = 20), and 3 (n = 20) had moderate, severe, and no voiding urgency, respectively. The neurogenic DO group 4 had severe urgency. The delay time of urgent void at cystometry (2 minutes or more or, respectively, less than 2 minutes) defined moderate or severe urgency. Detrusor contractility was defined by the maximum bladder external voiding power (WF(max)). RESULTS: WF(max) was higher in the idiopathic DO patients than in the controls, had the highest values in group 2B, and did not differ significantly between groups 1-4 and 2A-3. CONCLUSIONS: We inferred from our data that idiopathic DO suggests a facilitation of voiding contractions and that such facilitation might be centrally amplified by severe urgency. This amplifying effect would probably be impaired in cases of neurogenic DO from intracerebral lesions.     

Urgency degree and bladder contraction velocity: sequential changes in women with idiopathic detrusor overactivity

AIMS: In patients with idiopathic detrusor overactivity (DO) who showed storage symptoms worsening with time, we checked whether and which urodynamic parameter changes are associated with an increased urgency degree. MATERIALS AND METHODS: We analyzed retrospectively the urodynamic findings in 54 women -27 with storage symptoms (Group A, mean age 32 +/- 7 years) and 27 controls (Group B, mean age 30 +/- 9 years). These latter had a history of recurrent UTIs (urinary tract infections), but when seen by us had no UTI, DO, lower urinary tract symptoms, or any other pathological finding. Group A had a first urodynamic examination when first referred (time 1) and were re-assessed a mean of 16 months later (time 2) for worsened storage symptoms. RESULTS: In Group A, an idiopathic DO was shown at both times 1 and 2; urgency of voiding could be delayed during cystometry for >or=2 min (= moderate urgency) at time 1 and for <2 min (= severe urgency) at time 2; detrusor contraction strength or contractility proved higher than in Group B (P < 0.001) and increased from time 1 to time 2 (P < 0.001), detrusor shortening velocity being always the major component of the higher contractility levels. CONCLUSIONS: A DO-related increase in bladder contractility may have been further enhanced by severe urgency through a positive feedback mechanism. The urgency degree proved closely associated in DO patients with the level of detrusor shortening velocity rather than with detrusor pressure.     

Age and bladder outlet obstruction are independently associated with detrusor overactivity in patients with benign prostatic hyperplasia

Background

Detrusor overactivity is one known cause of lower urinary tract symptoms and has been linked to bladder storage symptoms (urgency, frequency, or urge incontinence).

Objective

To determine clinical and urodynamic parameters associated with detrusor overactivity in patients with suspected benign prostatic hyperplasia.

Design, Setting, and Participants

During 1993–2003, urodynamic investigations were performed in patients aged 40 yr or older and with lower urinary tract symptoms, benign prostatic enlargement, and/or suspicion of bladder outlet obstruction (maximum flow rate < 15 ml/s or postvoid residual urine > 50 ml).

Measurements

Detrusor overactivity was defined according to the new International Continence Society classification (2002) as involuntary detrusor contractions during cystometry, which may be spontaneous or provoked, regardless of amplitude. The Schäfer algorithm was used to determine bladder outlet obstruction.

Results

In total, 1418 men were investigated (median age: 63 yr) of whom 864 men (60.9%) had detrusor overactivity. In univariate analysis, men with detrusor overactivity were significantly older, more obstructed, had larger prostates, higher irritative International Prostate Symptoms Score subscores, a lower voiding volume at free uroflowmetry, and a lower bladder capacity at cystometry. The prevalence of detrusor overactivity rose continuously with increasing bladder outlet obstruction grade. Multivariate analysis showed that only age and bladder outlet obstruction grade were independently associated with detrusor overactivity. After age adjustment, the odds ratios of detrusor overactivity compared to Schäfer class 0 were 1.2 for class I, 1.4 for class II, 1.9 for class III, 2.5 for class IV, 3.4 for class V, and 4.7 for class VI.

Conclusions

In patients with clinical benign prostatic hyperplasia, detrusor overactivity is independently associated with age and bladder outlet obstruction. The probability of detrusor overactivity rises with increasing age and bladder outlet obstruction grade.     

URODYNAMIC CHARACTERIZATION OF NONOBSTRUCTIVE VOIDING DYSFUNCTION IN SYMPTOMATIC ELDERLY MEN

PURPOSE: The pathogenesis of lower urinary tract symptoms in men without bladder outlet obstruction has not been well characterized. Therefore, we defined the urodynamic abnormalities associated with symptomatic nonobstructive voiding dysfunction, and determined the relationship between age and type of dysfunction. MATERIALS AND METHODS: Video urodynamic studies of symptomatic men without outlet obstruction were examined. The criterion for a normal bladder outlet was a pressure gradient across the prostatic urethra of 5 cm. water or less in the absence of distal stricture. A maximum isometric contraction pressure less than 60 cm. water was regarded as impaired detrusor contractility. Detrusor instability was defined as involuntary detrusor contractions during filling or the inability to suppress a detrusor contraction after initiation of flow. Patients were categorized into 4 groups based on the urodynamic findings. RESULTS: Of 193 men (mean age 69.6+/-10.5 years) 40.9% had detrusor instability (group 1), 31.1% had impaired contractility (group 2), 10.8% had detrusor instability and impaired contractility (group 3), and 17.1% were urodynamically normal (group 4). Average patient age was significantly lower in group 4 than all other groups. Bladder capacity was lowest in group 1, and group 3 had the lowest voiding efficiency. Maximum flow rate, bladder compliance and symptom scores were not different among the 4 groups. The prevalence of detrusor instability with and without impaired contractility increased, while the proportion of patients without urodynamic abnormalities decreased with age. Bladder contractility did not correlate with age. CONCLUSIONS: The nonobstructed patient population comprises several groups that are functionally distinct while symptomatically similar. Thus, treatment of nonobstructed cases based on symptoms may lead to inappropriate pharmacological therapy and unsuccessful clinical outcomes.     

Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder

PURPOSE: Of the various treatments proposed for urge incontinence, frequency and urgency electrostimulation has been widely tested. Different techniques have been used with the necessity of surgical implantation (S3 neuromodulation or sacral root stimulation) or without requiring surgery (perineal transcutaneous electrostimulation). Recently peripheral electrical stimulation of the posterior tibial nerve was proposed for irritative symptoms in first intention or for intractable incontinence. Clinical studies have demonstrated good results and urodynamic parameters were improved after chronic treatment. However, to our knowledge no data concerning acute stimulation and immediate cystometry modifications have been reported. We verified urodynamic changes during acute posterior tibial nerve stimulation. MATERIALS AND METHODS: A total of 44 consecutive patients with urge incontinence, frequency and urgency secondary to overactive bladder were studied. There were 29 women and 15 men with a mean age +/-SD of 53.3 +/- 18.2 years. Of the patients 37 had detrusor hyperreflexia due to multiple sclerosis (13), spinal cord injury (15) or Parkinson's disease (9), and 7 had idiopathic detrusor instability. Routine cystometry at 50 ml. per minute was done to select the patients with involuntary detrusor contractions appearing before 400 ml. maximum filling volume. Repeat cystometry was performed immediately after the first study during left posterior tibial nerve stimulation using a surface self-adhesive electrode on the ankle skin behind the internal malleolus with shocks in continuous mode at 10 Hz. frequency and 200 milliseconds wide. Volume comparison was done at the first involuntary detrusor contraction and at maximum cystometric capacity. The test was considered positive if volume at the first involuntary detrusor contraction and/or at maximum cystometric capacity increased 100 ml. or 50% during stimulation in compared with standard cystometry volumes. RESULTS: Mean first involuntary detrusor contraction volume on standard cystometry was 162.9 +/- 96.4 ml. and it was 232.1 +/- 115.3 ml. during posterior tibial nerve stimulation. Mean maximum cystometric capacity on standard cystometry was 221 +/- 129.5 ml. and it was 277.4 +/- 117.9 ml. during stimulation. Posterior tibial nerve stimulation was associated with significant improvement in first involuntary detrusor contraction volume (p <0.0001) and significant improvement in maximum cystometric capacity (p <0.0001). The test was considered positive in 22 of the 44 patients. CONCLUSIONS: These results suggest an objective acute effect of posterior tibial nerve stimulation on urodynamic parameters. Improved bladder overactivity is an encouraging argument to propose posterior tibial nerve stimulation as a noninvasive treatment modality in clinical practice.     

CONVENTIONAL AND AMBULATORY URODYNAMIC FINDINGS IN WOMEN WITH SYMPTOMS SUGGESTIVE OF BLADDER OVERACTIVITY

PURPOSE: We compared ambulatory urodynamics and conventional video cystometry findings in women with symptoms of bladder overactivity. MATERIALS AND METHODS: In a prospective randomized crossover study 106 women with symptoms of urinary urgency with or without incontinence were comprehensively investigated by video cystometry and ambulatory urodynamics in random order. In addition, all women completed a validated symptoms questionnaire and voiding diary. RESULTS: Involuntary detrusor activity was detected in 32 and 70 cases on video cystometry and ambulatory urodynamics, respectively (p <0.001). Video cystometry done according to International Continence Society standards diagnosed detrusor instability in 4 women with no involuntary detrusor activity on ambulatory urodynamics. Involuntary detrusor activity resulting in incontinence was observed in 39 cases on ambulatory urodynamics, including 20 (51%) with stable video cystometry results. Stress incontinence was diagnosed in 42 cases on video cystometry and in 34 on ambulatory urodynamics (p = 0.629). Increasingly severe urge and stress incontinence reported in the symptoms questionnaire correlated positively with the subsequent detection of detrusor overactivity and stress incontinence, respectively, on the 2 urodynamic tests. CONCLUSIONS: In contrast to video cystometry, ambulatory urodynamics provides objective evidence of clinically important bladder overactivity in the majority of women with symptoms suggestive of bladder overactivity. The correlation of symptoms with ambulatory urodynamic findings implies that greater reliance may be placed on symptomatic diagnosis of bladder overactivity. Improved objective assessment of detrusor function provided by ambulatory urodynamics has implications for the definition of bladder overactivity and relevance of conventional cystometry in this context. In women who complain of urgency stable conventional cystometrography findings should be interpreted with caution.     

Significant Correlation of the American Urological Association Symptom Score and a Novel Urodynamic Parameter: Detrusor Contraction Duration

Purpose

Various investigators have reported the lack of specificity of the American Urological Association (AUA) symptom score and its poor correlation with urodynamic parameters. A retrospective study was performed to ascertain the correlation of the AUA symptom score with various urodynamic parameters, including detrusor contraction duration.

Materials and Methods

The urodynamic records of 120 consecutive patients with moderate (scores 8 to 19) or severe (scores greater than 19) symptoms were retrospectively analyzed to ascertain if the AUA symptom score correlated with the urodynamic parameters of maximum detrusor pressure, detrusor pressure at maximum flow, compliance, involuntary detrusor contractions and, a novel parameter, detrusor contraction duration.

Results

There were 63 men (mean age 59.7 years) and 57 women (mean age 58.8 years). Men AUA symptom score plus or minus standard deviation was 17.8 plus/minus 3.7 and 15.4 plus/minus 2.9, respectively. There was no correlation between any urodynamic parameter and symptoms in women. In men increasing symptoms were associated with worsening urodynamic parameters. The 2 parameters that had the greatest correlation with symptom severity were incidence of involuntary detrusor contractions (r = 0.56, p less than 0.006) and detrusor contraction duration (r = 0.61, p less than 0.003). Furthermore, increasing incidence of involuntary detrusor contractions was associated with increasing irritative symptoms, while increasing detrusor contraction duration was correlated with increasing obstructive symptoms. Detrusor contraction duration was correlated with symptom severity and urodynamic outlet obstruction in men.

Conclusions

These data demonstrated that the AUA symptom score correlates with certain urodynamic parameters. Furthermore, this correlation occurs in men in contrast to women despite similar AUA symptom scores. In addition, increasing detrusor contraction duration is associated with worsening symptoms and may herald worsening obstruction. Further prospective studies are underway to determine the prognostic value of these urodynamic parameters in altering ultimate outcomes of treatment.     

Intravesical resiniferatoxin for the treatment of women with idiopathic detrusor overactivity and urgency incontinence: A single dose, 4 weeks, double-blind, randomized, placebo controlled trial

AIMS: To assess the hypothesis that resiniferatoxin (RTX) can be useful in women with urgency incontinence and idiopathic detrusor overactivity (IDO), we conducted a prospective, double-blind, randomized, placebo-controlled, parallel trial comparing the effects of RTX and placebo. MATERIALS AND METHODS: Fifty-eight patients were randomly assigned to receive a single intravesical dose of 100 ml of either RTX 50 nM or placebo. Safety and efficacy were evaluated over 4 weeks. The primary efficacy endpoints were voiding symptoms evaluated through the voiding diary. Secondary efficacy endpoint was urodynamic response. Quality of life was measured by the Kings' Health Questionnaire RESULTS: Although improving trends were seen in both groups after the instillations, no statistically significant differences were found between the groups in any of the clinical or urodynamic parameters. RTX instillations were well tolerated with few and self-limited side-effects. CONCLUSION: A single 50 nM intravesical dose of RTX was not better than placebo for the treatment of women with IDO and urgency incontinence.     

Is sensory urgency part of the same spectrum of bladder dysfunction as detrusor overactivity?

It has been suggested that the urogynecological diagnosis of sensory urgency is an early form of detrusor overactivity and may be just earlier in the spectrum of disease. The former term is generally defined as increased perceived bladder sensation during filling, a low first desire to void and low bladder capacity in the absence of recorded urinary tract infection (UTI) or detrusor overactivity. The aims of this study are to determine the prevalence and associations of sensory urgency in comparison with detrusor overactivity, and whether sensory urgency is shown to be in the same spectrum of bladder dysfunction as detrusor overactivity. Five hundred and ninety-two women attending for an initial urogynecological/urodynamic assessment took part in this prospective study. In addition to a full clinical assessment, all women underwent free uroflowmetry, residual urine volume measurement (by vaginal ultrasound) and multichannel filling and voiding cystometry. Data were separated into those having (1) sensory urgency or (2) detrusor overactivity. Apart from prevalence figures, comparative associations were sought for (3) age; (4) parity; (5) presenting symptoms; (6) presence of at least one (medically) documented UTI in the previous 12 months; (7) two or more (recurrent) documented UTIs in the previous 12 months; (8) prior hysterectomy; (9) prior continence surgery; (10) menopause; (11) menopause and HRT use; (12) sign of clinical stress leakage; (13) retroverted uterus; (14) anterior vaginal wall prolapse; (15) uterine prolapse; (16) posterior vaginal wall prolapse; (17) apical vaginal prolapse; (18, 19) maximum, average urine flow rate (MUFR, AUFR) centiles, Liverpool Nomograms; (20) median residual urine volume (RUV) in milliliters; (21, 22) voiding difficulty: VD1,VD2 (MUFR, AUFR under 10th centile Liverpool Nomogram and/or RUV >30 ml); (23) diagnosis of urodynamic stress incontinence and (24) diagnosis of uterine and/or vaginal prolapse (grade >0). The prevalence of sensory urgency was 13%. The only differences in the clinical and urodynamic profiles of it and detrusor overactivity were (1) significantly increased prevalence of the symptom of urge incontinence and (2) (by definition) abnormal detrusor contractions during filling cystometry in women with detrusor overactivity. Overall, sensory urgency and detrusor overactivity appear to be part of the same spectrum of bladder dysfunction.     

Classification and treatment of functional incontinence in children

Functional urinary incontinence in children may be caused by disturbances of the filling phase, the voiding phase or a combination of both. Detrusor overactivity may cause frequency and urgency, with or without urge incontinence. Girls present with symptoms of detrusor overactivity more often than boys, but sometimes other symptoms, e.g. urinary tract infections or constipation, prevail. Frequent contractions of the detrusor may cause the pelvic floor muscles to become overactive, resulting in staccato or fractionated voiding. When incontinence is the result of a voiding disorder the term 'dysfunctional voiding' is used. Bladder function in these children may be normal, but instability may be present. In children with a 'lazy' bladder, voiding occurs with no detrusor contractions, and postvoid residual volumes and overflow incontinence are the main characteristics. Diagnosis is based on the medical and voiding history, a physical examination, bladder diaries and uroflowmetry. The upper urinary tract should be evaluated in children with recurrent infections and dysfunctional voiding (reflux). Uroflowmetry can be combined with pelvic floor electromyography to detect overactivity of the pelvic floor muscles. Urodynamic studies are usually reserved for patients with dysfunctional voiding and those not responding to anticholinergic drugs. Treatment is usually a combination of 'standard therapy', behavioural therapy, bladder training, physiotherapy and medical treatment. The role of alpha-blockers needs to be evaluated further. Also, neuromodulation may have a place in treatment but the exact indications need to be defined. Clean intermittent self-catheterization is sometimes necessary in children with a lazy bladder and large residual volumes who do not respond to a more conservative approach. Future research needs to be directed towards improving understanding of the pathophysiology, epidemiology, classification and treatment modalities of functional incontinence in children.     

Voiding dysfunction after radical retropubic prostatectomy: more than external urethral sphincter deficiency

OBJECTIVES: To analyse the relationship between RRP and urodynamic bladder dysfunction, and compare preoperative and postoperative functional status over long-term follow-up. Hypothesis on the pathophysiologic mechanism underlying urodynamic dysfunction has been reported. METHODS: PubMed databank search for original articles followed by review of urodynamic parameters: bladder filling sensation, detrusor overactivity, bladder compliance, cystometric bladder capacity, impaired detrusor contractility, bladder outlet obstruction, urinary incontinence. RESULTS: Detrusor dysfunction was rarely present as the sole diagnosis and was usually coupled with intrinsic sphincter deficiency. Data on bladder filling sensation, cystometric capacity, detrusor overactivity, impaired detrusor contractility, and bladder outlet obstruction were limited and contradictory. Detrusor overactivity was a de novo dysfunction in 2%-77% of patients. Impaired bladder compliance was present in 8%-39% of patients and was de novo in about 50%. Impaired detrusor contractility was found in 29%-61% of patients, was de novo in 47%, and recovered in about 50% of patients. The role of these dysfunctions as etiologic agents of urinary incontinence or voiding symptoms was unevenly assessed. CONCLUSIONS: Postoperative decentralization of the bladder, inflammation and/or infection, and geometric bladder wall alteration associated with preexisting hypoxemia with/without neuroplasticity have been posited as causes of detrusor dysfunction. Nevertheless, the lack of consistent preoperative urodynamic investigation makes it difficult to assess the operation's exact role in causing these dysfunctions. Thus, urodynamics performed, at least in selected cases, preoperatively and during follow-up could help arrive at a precise diagnosis of the underlying dysfunction, indicate the appropriate treatment, and prevent the incidence and onset of postoperative urinary incontinence.     

The Incidence and Etiology of Overactive Bladder in Patients After Cerebrovascular Accident

Cerebrovascular accident or stroke is a devastating neurologic event that can have both short and long term urologic complications. The purpose of this article is to provide an up-to-date review of the incidence and causes of voiding dysfunction after stroke, the evaluation of voiding dysfunction in patients after stroke, and the recommendations on the management of voiding dysfunction following stroke. The reported incidence of urinary incontinence varies from 28-79?% and the causes of urinary incontinence following stroke are multifactorial. Detrusor overactivity is predominant and detrusor underactivity is somewhat less prevalent. Urodynamic findings in patients with stroke vary depending upon timing of the study and associated comorbidities. Currently there are no large longitudinal studies linking urodynamic findings with location or degree of infarct. Based on current studies, we conclude that patients with detrusor underactivity should be managed with clean intermittent catheterization or indwelling Foley catheter, while timed voiding with or without anticholinergic therapy may be an effective treatment for patients with detrusor overactivity after stroke.     

Persistent detrusor overactivity after transurethral resection of the prostate

Detrusor overactivity is associated with aging and benign prostatic obstruction and often causes the troublesome symptoms of urgency and urgency incontinence (overactive bladder), persistent detrusor overactivity after transurethral resection of the prostate being the cause of more than a third of poor symptomatic outcomes following surgery. Most of the evidence currently suggests that neurons of the urothelium at the bladder neck play a significant role in the genesis of detrusor overactivity. Treatment options including botulinum toxin injections and intravesical vanilloids have been studied in the treatment of persistent detrusor overactivity, but further studies are needed specifically in patients with persistent detrusor overactivity after transurethral resection of the prostate. As urodynamic studies are able to predict a proportion of postoperative failures, more widespread use is advocated by many in the routine assessment of lower urinary tract symptoms thought to be due to benign prostatic obstruction.     

The effect of fluid intake on urinary symptoms in women

PURPOSE: We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life. RESULTS: A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms. CONCLUSIONS: Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.     

Voiding dynamics in women with stress urinary incontinence and high‐stage cystocele

Objectives: The aim of this study was to identify the urodynamic features of women with stress urinary incontinence (SUI) or with high‐stage (stage 3 or greater) cystocele (HSC) as compared with symptom‐free women. Methods: Fifty‐six neurologically intact women with SUI and 47 women with HSC but without SUI were prospectively evaluated. All patients underwent full urodynamics, in addition to basic clinical evaluations. The urodynamic parameters of SUI and HSC were compared to the ones obtained from 78 urologically symptom‐free normal women over the same period. Results: Patients with HSC, after correction of cystocele using a temporary vaginal pessary, had consistently lower maximum urinary flow rate with a lower detrusor pressure during micturition than the controls or those with SUI. On the other hand, patients with SUI had an equivalent to higher maximum urinary flow rate, normal detrusor contraction strength with a lower detrusor pressure during micturition than the controls. Both maximum Watts factor and bladder contractility index were significantly lower in the whole HSC cohort in comparison to the controls and patients with SUI. The urodynamic characteristics observed among the three groups were all maintained even after adjusting for age. Conclusions: Women with SUI demonstrate voiding with low‐pressure, normal contraction strength with an equivalent to high urinary flow rate. Women with HSC demonstrate voiding with low pressures with weak contraction strengths and low urinary flow rates, suggesting a higher prevalence of detrusor underactivity. Chronically decreased or increased urethral resistance might alter voiding dynamics and performance.     

Effectiveness of intravesical resiniferatoxin for anticholinergic treatment refractory detrusor overactivity due to nonspinal cord lesions

PURPOSE: Evidence suggests that unmyelinated C fibers become predominant in the mediation of the detrusor reflex in patients with chronic spinal cord lesions and possibly in idiopathic detrusor hyperactivity. Intravesical vanilloid therapy might be effective in treating refractory detrusor overactivity due to nonspinal cord lesion. This study investigated the clinical effect of intravesical resiniferatoxin in treating detrusor overactivity of nonspinal cord lesions refractory to anticholinergics. MATERIALS AND METHODS: A total of 41 patients received intravesical resiniferatoxin therapy with 10 ml of 100 nM resiniferatoxin in 10% ethanol solution for 40 minutes. The clinical effects on a decrease in incontinence episodes and urodynamic study were evaluated at baseline and after treatment. Clinical improvement was considered if patients became dry or had a decrease in incontinence episodes of 50%. Therapeutic results were analyzed by disease category and type of initial detrusor response. RESULTS: Of the 41 patients 10 had neurogenic lesions, 18 had previous transurethral prostatectomy and 13 had idiopathic detrusor overactivity. There were 20 women and 21 men with a mean age of 73.6 years (range 43 to 82) and a symptom duration of 3.6 +/- 4.5 years. After resiniferatoxin treatment 21 patients had clinical improvement (51.2%) including 5 with neurogenic (50%), 11 with previous transurethral prostatectomy (61.1%) and 5 with idiopathic detrusor overactivity (38.5%). An improvement was found in 11 patients with type I initial response (84.6%), 3 patients with type II response (23%) and 7 patients with type III response (46.7%). The 21 patients with improvement had a significant increase in cystometric capacity (208 +/- 80.7 vs 287.2 +/- 118.6 ml, p = 0.001) and a significant decrease in detrusor pressure (33.6 +/- 11.1 vs 27.4 +/- 11.8 cmH(2)O, p = 0.047), but no significant difference in maximal flow rate and residual urine volume. CONCLUSIONS: Intravesical resiniferatoxin was effective in treating refractory detrusor overactivity in 51.2% of patients with nonspinal cord lesions. Patients with detrusor overactivity due to previous bladder outlet obstruction benefited the most. Detrusor contractility decreased after resiniferatoxin treatment in the group with improvement but did not influence voiding efficiency. The initial detrusor response to resiniferatoxin treatment might predict the clinical outcome.     

Comparisons of urodynamic findings and voiding habits in patients with concomitant benign prostatic hyperplasia and detrusor overactivity presenting with or without the symptom of urgency

AIMS: The urodynamic findings and voiding habits in patients with concomitant clinical benign prostatic hyperplasia (BPH) and detrusor overactivity (DO) presenting with or without the symptom of urgency were compared. MATERIALS AND METHODS: 84 BPH patients with an urodynamic diagnosis of DO by conventional cystometry were included in the study. The patients were grouped according to the presence or absence of the symptom of urgency. The urodynamic findings, urinary diary and clinical information were analyzed. RESULTS: Among the 84 BPH-DO patients, 52 reported the symptom of urgency while 32 did not. There were no significant differences in mean age, International Prostate Symptom Score and flow rate between the two groups. Patients without urgency had a higher incidence of terminal DO and abnormal bladder sensation. The occurrence of unfelt phasic DO was also significantly higher in this group. Sphincter electromyography showed conscious and subconscious sphincter contractions associated with DO. The urinary diary showed lower 24-hour urinary output, smaller bladder functional capacity and average voided volume in the BPH-DO patients without urgency. CONCLUSIONS: BPH patients with DO may neglect the symptom of urgency due to abnormal bladder sensation, or negate the symptom by subconscious sphincter contraction to abort the overactivity. Some may avoid the symptom by drinking less fluid and emptying the bladder at a smaller volume.     

Incontinence of urine due to instability of micturition reflexes: Part I. Detrusor reflex instability

Micturition reflex instability may result from malfunction of the detrusor reflex or instability of the pudendal nucleus which innervates the pelvic floor muscles and external sphincter. Detrusor instability is the result of sacral micturition reflex center (SMRC) hyperexcitability. This may be caused by underinhibition or overfacilitation of the SMRC, and there are both central and peripheral causes of each. Detrusor hypertrophy may invoke chronic overactivity of the detrusodetrusor facilitative reflex causing SMRC overfacilitation. Similarly, distal urethral stricture and/or chronic urethritis causing chronic overactivity of the urethrodetrusor facilitative reflex is a common cause of SMRC overfacilitation. Pathologic relaxation and weakness of the striated muscles of the pelvic floor and perineum resulting in underactivity of the perineodetrusor inhibitory reflex, is a common cause of SMRC underinhibition. In adult women these factors often coexist. Each may predispose to stress-induced detrusor instability and are often seen in association with, or are confused with, true stress incontinence. The distinguishing characteristics of detrusor hypertonicity and detrusor hyperreflexia are reviewed, and the various mechanisms of pseudostress incontinence and of urgency incontinence are discussed in detail.