Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices

PURPOSE: We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms. MATERIALS AND METHODS: We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers. RESULTS: Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively. CONCLUSIONS: The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.     

Transverse myelitis in children: long-term urological outcomes

PURPOSE: Urological complications are well documented in patients with traumatic spinal cord injury. We examined the long-term urological outcomes in a large population of children affected by transverse myelitis. MATERIALS AND METHODS: We retrospectively reviewed the medical history, imaging studies and urodynamic findings in 22 children with transverse myelitis. Age at disease onset ranged from 3 months to 18 years (average 8.8 years). RESULTS: At a mean followup of 7.1 years 19 patients (86%) had persistent bladder dysfunction and 17 (77%) had persistent bowel dysfunction. Initial evaluation at least 1 month after disease onset revealed detrusor overactivity in 59% of patients, detrusor external sphincter dyssynergia in 41%, low compliance in 47% and detrusor leak point pressure greater than 40 cm water in 12%. Functional motor recovery and absence of lower extremity spasticity did not reflect normal urodynamic findings. Of the 19 patients with imaging available for review 5 (26%) had upper tract changes. One patient had development of chronic renal insufficiency. Low compliance (p = 0.02) and upper tract changes (p = 0.1) were more frequent in patients who started clean intermittent catheterization more than 2 years after disease onset. CONCLUSIONS: Persistent bowel and bladder dysfunction is common in transverse myelitis. Urodynamic abnormalities may be present despite normal neurological examination and absence of urinary symptoms. All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation to guide treatment. Early institution of clean intermittent catheterization appears to preserve bladder compliance and decrease upper tract disease, and should be instituted at disease onset.     

Urological manifestations of chronic schistosomal myeloradiculopathy

OBJECTIVE: To describe the clinical and urodynamic features of patients with chronic voiding dysfunction secondary to schistosomal myeloradiculopathy (SM), as the clinical involvement of the spinal cord is a well recognized complication of Schistosomiasis mansoni infection. PATIENTS AND METHODS: We reviewed the records and urodynamic studies of 26 consecutive patients (17 males and nine females, aged 8-58 years) with chronic neurological and urinary symptoms secondary to SM. The voiding function history, radiological and urodynamic findings and therapeutic approaches were reviewed. Patients with and without upper urinary tract complications were compared in terms of age, duration of voiding dysfunction and urodynamic pattern. RESULTS: The most common urinary symptoms were difficulty in emptying the bladder (17 patients, 65%), urinary incontinence (14, 54%), and urgency and frequency (13, 50%). Laboratory and radiographic evaluation showed urinary tract infection in eight (30%) patients, bilateral hydronephrosis in five (19%) and bladder calculi in five (19%). Urodynamics showed detrusor overactivity with detrusor-external sphincter dyssynergia (DESD) in 14 patients (54%), detrusor arreflexia in six (23%), detrusor overactivity with no dyssynergia in four (15%), and detrusor underactivity in two (8%). Comparing patients with and without upper tract complications showed no differences in age and duration of urinary symptoms, but there was a significant association of detrusor overactivity with DESD and upper urinary tract complications (P = 0.04). Urological management consisted of antibiotics, clean intermittent catheterization, anticholinergic medication and stone removal, as appropriate. Conservative treatment failed in three patients and they required an injection with botulinum-A toxin into the detrusor (two) or ileocystoplasty (one). CONCLUSION: Patients with chronic SM behave clinically like those with other causes of spinal cord disease and neurogenic bladder dysfunction requiring lifelong surveillance. The severity of illness in these patients should re-emphasize the need for early recognition and treatment of this condition, to prevent or reverse the neurological deficits.     

The urodynamic profile of myelodysplasia in childhood with spinal closure during gestation

PURPOSE: Spinal dysraphism is the most common cause of neurogenic bladder dysfunction in newborns. Urodynamic findings in these patients include uninhibited bladder contractions, bladder areflexia, decreased compliance and detrusor-sphincter dyssynergia. Early urodynamic studies are recommended for spina bifida to help identify bladder characteristics that may cause a risk of upper tract deterioration. We recently evaluated a new early type of intervention involving closure of the neural tube defect during gestation in 25 patients at our institution. We hypothesize that this procedure results in decreased exposure of the spinal cord to amniotic fluid, which may improve neurological function. To date we have evaluated 16 of the 25 patients with video urodynamics. We compared the results to those in the literature on patients with myelomeningocele and without prenatal intervention. MATERIALS AND METHODS: We performed urodynamic testing in 16 patients with a mean age of 6.5 months, including cystometrography, fluoroscopic evaluation of filling and voiding, pelvic floor electromyography and post-void residual urine measurement. In addition, we retrospectively reviewed renal ultrasound, voiding cystourethrography, catheterization need, number of urinary tract infections and medication in these cases. RESULTS: Uninhibited detrusor contractions and an areflexic bladder were identified in 6% and 43% of patients, respectively, while 19% had decreased compliance and 75% had leak point pressure greater than 40 cm. water. Mean bladder capacity was 40 cc and 31% of patients had much lower capacity than expected for age. Previous renal ultrasound and voiding cystourethrography showed evidence of upper tract dilatation and reflux in 2 cases, respectively. Intermittent catheterization and anticholinergic therapy were required by 1 patient each and 1 had a significant urinary tract infection. CONCLUSIONS: Urodynamic findings in this population are comparable to those previously reported in the literature in patients with spina bifida without prenatal closure of the spinal defect. The lower incidence of urinary tract infection and reflux in our study probably represents more aggressive early urological management rather than neurological improvement. These urodynamic studies were performed early in life and future evaluation may ultimately reveal improved bladder function compared with that in others with myelodysplasia. However, at this time we recommend that patients who undergo spinal cord defect closure during gestation be evaluated and treated in the same manner as those with myelomeningocele but without fetal intervention.     

Síntomas de tramo urinario inferior y síndrome de apnea obstructiva del sueño: evolución urodinámica antes y después de un año de tratamiento con presión continua positiva de la vía aérea

ObjectiveTo report the clinical evolution and the urodynamic behaviour of several lower tract urinary symptoms in patients with obstructive sleep apnea syndrome before and after the treatment with continuous positive airway pressure (CPAP) devices.MethodsA prospective study was performed; patients with recent diagnosis of sleep apnea confirmed by nocturnal sleep polygraphy and absence of medical urological past history. In order to discard important lower urinary tract conditions, urological examinations were previously performed. Urinary symptoms were evaluated using the IPSS and OAB-V8 validated questionnaires, three-day Bladder Diary and invasive urodynamic examinations with a gap of one year before and one year after using the CPAP.Results84 urodynamic studies were carried out in 43 patients. The IPSS score decreased by 3.58 points. The OAB-V8 score decreased by 2.87 points. Nocturia episodes decreased to one per night. The percentage of patients with nocturnal polyuria went down to 26%. The bladder compliance significantly increased (97.39 vs 200.40 ml/cm H2O). The presence of detrusor overactivity decreased from 11 (before CPAP) to 5 patients (after CPAP).ConclusionThe proper treatment with CPAP showed a statistical and clinical improvement of several LUTS with limited urodynamic modifications.     

Neurogenic bladder dysfunction after sacrococcygeal teratoma resection

PURPOSE: SCT treatment in newborns consists of surgery and selective chemotherapy. Few reports document urological sequelae using this approach. This review focuses on the urological and neurourological findings following SCT treatment in the newborn period. MATERIALS AND METHODS: We reviewed the records of all infants with SCT resected in early infancy who underwent urodynamic evaluation for bladder dysfunction between 1986 and 2004. The radiological, neurological and urodynamic findings, and postoperative incontinence management were analyzed. RESULTS: We analyzed UDS of 14 patients who presented with urinary infection or incomplete bladder emptying after SCT resection. At the time of UDS an abnormal neurological examination was noted in 5 patients (36%). Detrusor overactivity was seen in 8 patients, underactivity in 2 and normal activity in 4. Abnormal urethral sphincter EMG potentials were observed in 7 of 13 patients (54%). Five of 13 patients (38%) had sphincter dyssynergia during voiding. Consequently, CIC was needed in 11 of the 14 patients (79%) to empty the bladder, of whom 5 also required anticholinergics to improve detrusor compliance and dryness. Only 3 patients voided spontaneously with normal bladder and sphincter function, of whom 2 were toilet trained. Hydronephrosis was seen in 6 patients and reflux was noted in 7 (including 5 of 6 with hydronephrosis). Antireflux surgery was performed in 6 patients, all of whom had up to grade 4 reflux due to recurrent urinary tract infection. One girl with grade 2 reflux had spontaneous resolution. CONCLUSIONS: SCT and its treatment can produce neurourological dysfunction of the lower urinary tract with high grade reflux, and abnormal bladder and urethral function. Complete assessment, including urodynamic studies, is imperative preoperatively and postoperatively. Constant vigilance is required to maintain as near normal bladder function as possible and to prevent upper urinary tract injury.     

Urological dysfunctions and upper urinary tract involvement in multiple sclerosis patients

The goal of the present study was to investigate the involvement of the upper urinary tract (UUT) in patients with multiple sclerosis and its relationship with other neurological and urological features of the disease. One hundred sixteen patients underwent complete neurological and urological assessments, urodynamic investigation, and morphofunctional study of the urinary tract by ultrasonography, voiding cistourethrography, and/or intravenous excretory pyelography. The most remarkable relationships were observed among disease duration, pyramidal system score, amplitude of uninhibited detrusor contractions and the presence of bladder morphological abnormalities (P = 0.03, 0.0008, and 0.018, respectively) and the relationship between pyramidal system score or the presence of bladder pathology and UUT abnormalities (P = 0.03 and 0.0006, respectively). A significant relationship was found between the maximum amplitude of uninhibited contractions and UUT involvement (P = 0.002). No other significant relationship was observed between UUT involvement and any other urodynamic or urological features of the disease (type of progression and progression rate, Expanded Disability Status Scale, and other functional system scores). The relationship among disease duration, high vesical pressures, and the lack of reliable clinical indices of risk to the UUT stress the importance for patients with multiple sclerosis to adhere to a strict follow-up program with urodynamic assessment and urinary tract imaging and to maintain detrusor relaxation with anticholinergic medications. Neurourol. Urodynam. 17:89–98, 1998. © 1998 Wiley-Liss, Inc.     

脊髓损伤并发上尿路扩张的危险因素分析

目的探讨脊髓损伤患者并发上尿路扩张的尿动力学危险因素。方法随机抽取唐山地震脊髓损伤患者96例,经B超检查并发上尿路扩张16例为A组,无上尿路扩张80例为对照组B组,分别进行尿动力学测定。而后对两组患者间性别、年龄和尿动力学等参数进行单因素和多因素分析。结果男性上尿路扩张发生率明显高于女性,A组残余尿量、最大膀胱容量、逼尿肌漏点压和膀胱低顺应性发生率明显高于B组,而两组年龄、逼尿肌反射亢进发生率、相对安全容量、逼尿肌括约肌协同失调发生率、最大尿流率和最大尿道关闭压差异无统计学意义。Logistic回归分析结果显示,膀胱低顺应性是筛选出的惟一危险因素。结论对脊髓损伤患者及时进行尿动力学检查,阻止或减缓膀胱顺应性的改变,可防止上尿路扩张的发生。     

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.     

Multiple sclerosis and the urologist

PURPOSE: We provide an updated reference detailing the neurological and urological state of the art approach to multiple sclerosis (MS) with special emphasis on the pathology and physiology, effects on the genitourinary tract, diagnostic evaluation, and treatment of neurological and urological manifestations. MATERIALS AND METHODS: A MEDLINE computerized reference search and manual bibliography review were performed to find pertinent peer reviewed articles on the neurological and urological manifestations and treatment of MS. A meta-analysis was performed on the urodynamic findings of 22 studies involving 1,882 patients from well-defined MS populations. RESULTS: The majority of patients with MS have genitourinary symptoms ranging from urgency, urge incontinence and frequency to urinary retention. Symptoms do not accurately reflect the underlying urological pathology but parallel pyramidal tract dysfunction. Urodynamic evaluation has an important role in determining proper bladder management. The most common urodynamic finding is detrusor hyperreflexia in 62% of these patients, followed by detrusor-sphincter dyssynergia in 25% and hypocontractility in 20%. Less than 1% of patients has renal deterioration and most may be treated with conservative measures. If conservative measures fail, new forms of bladder reconstruction and diversion may be effectively used. The incidence of sexual dysfunction is up to 80% in men and 72% in women, and treatment focuses on improvement of overall disability and erectile or orgasmic function. CONCLUSIONS: Although the genitourinary consequences of MS are rarely life threatening, they can cause significant morbidity and patient frustration. With the rapid advances in the medical management of MS the urologist should be actively involved in multispecialty treatment of these patients.     

Upper and lower urinary tract evaluation of 104 patients with myelomeningocele without adequate urological management

To evaluate the upper and lower urinary tract and revise the urodynamic parameters on myelomeningocele patients without adequate urological management. 104 myelomeningocele patients without previous adequate urological management were assessed by clinical, urodynamic and imaging evaluation. The urodynamic.data were correlated with the status of the upper urinary tract (UUT). Thirty patients presented with vesico-ureteral reflux. Six patients presented signs of UUT damage without reflux. The cystometry showed detrusor overactivity (DO), poor compliance, increased bladder capacity and normal cystometry in 48, 49, 2 and 1% of the patients, respectively.Detrusor leak point pressure (DLPP) over 40 cm H₂O was associated with UUT damage. Patients with decrease on functional bladder capacity (FBC) ≤ 33% had more renal scars than their counterparts (P = 0.01). Overall, urological untreated myelomeningocele patients have 26% of kidney damage. DLPP ≥ 40cmH₂O and decrease in FBC ≤ 33% are associated with greater UUT damage. DO and poor compliance are predominant and pose similar risk of UUT damage.     

Clinical correlation of urodynamic findings in patients with localized partial lesions of the spinal cord and cauda equina

Urodynamic studies were undertaken in 70 patients with incomplete, confirmed, localized lesions involving the spinal cord and cauda equina, irrespective of clinically evident bladder disturbances. Both detrusor and urethral function were simultaneously evaluated and correlated with neurological deficits and symptoms of lower urinary tract dysfunction. It was evident that in those patients with localized spinal cord lesions, lower urinary tract disturbances were closely associated with disturbances of pinprick sensation. Clinically silent bladder and sphincter dysfunction was encountered in 14% of the patients, and the number of asymptomatic patients was significantly higher among those with upper motor neuron lesions. Incontinence was associated predominantly with conus lesions; however, the other symptoms had no relationship to the site of the lesion. Symptoms such as urgency, incontinence, and nocturnal incontinence were associated with detrusor hyperactivity, and urinary retention was associated with urethral overactivity and dyssynergia. The urodynamic findings could explain the pathogenesis of the symptoms in most instances, but were not necessarily related to them. It is concluded that the pathways subserving lower-urinary-tract function are closely associated with the pathways subserving pinprick sensation, and that a lesion along the spinal axis can affect the bladder, sphincter, or both in a variety of ways, thus leading to the widely variable clinical findings associated with neurogenic lower urinary tract dysfunction.     

Overactive bladder symptoms: Do we need urodynamics?

AIMS: The aim of our study was to determine whether the urodynamic diagnosis is useful in the management of women with symptoms of an overactive bladder (OAB). METHODS: Women with lower urinary tract symptoms, attending a tertiary referral urogynaecology clinic were studied. All women were fully evaluated, with history, urinary symptoms questionnaire, frequency-volume chart, vaginal examination, and videocystourethrography. Women with symptoms consistent with an overactive bladder (urinary frequency, urgency, and/or urge incontinence) were selected. Women with neurological disorders were excluded. Finally, urinary symptoms and urodynamic diagnosis were correlated. All terms and definitions are in accordance with the International Continence Society [Abrams et al., 1988, Scand J Urol Nephrol 114(Suppl):5-19.]. RESULTS: A total of 4,500 women 22-73 years of age were studied. Only 843 women (18.7%) could be classified as having an OAB. Of these, 457 women (54.2%) had urodynamically proven detrusor instability, whereas 386 women (45.8%) had a stable urodynamic trace. Sixty-eight (8.1%) of the women studied had postvoid residual greater than 100 mL. Of the 4,500 women studied, 1,641 (36.5%) had detrusor instability on laboratory urodynamics. Only 27.5% of these women (457 of 1,641) had OAB symptoms. CONCLUSIONS: Symptomatic diagnosis of OAB does not correlate with a urodynamic diagnosis of detrusor instability. The diagnosis of overactive bladder based on urinary symptoms underdiagnoses the condition of detrusor instability in a population of women suffering from lower urinary tract symptoms. Therefore, symptomatic diagnosis of OAB alone is not recommended. Our study suggested that urodynamic evaluation is mandatory in the management of the women with symptoms of an overactive bladder.     

Die überaktive Blase im Kindesalter

Enuresis is one of the most frequent urinary symptoms in children. 80% suffer from primary enuresis nocturna. 20% have urinary incontinence with additional symptoms of frequency, urgency and daytime incontinence, which is also defined in children as overactive bladder in absence of urinary tract infections, neurological, anatomical or further local pathology (OAB in childhood). The underlying pathophysiology is a maturation arrest of the bladder control resulting in detrusor hyperactivity. In most of the cases the differentiation between enuresis and OAB is easily possible with non-invasive primary diagnostic procedures.Invasive diagnostic tools like video urodynamic studies may become necessary when first-line therapy fails. The treatment options comprise bladder training with timed voiding and drink protocols (urotherapy) as well as pharmacologic relaxation of detrusor instability by anticholinergic drugs.     

Bladder involvement in Behçet's syndrome

PURPOSE: We report our clinical experience with Beh?et's syndrome and bladder involvement. MATERIALS AND METHODS: From April 1991 through July 1996, 7 men and 1 woman 25 to 53 years old with Beh?et's syndrome were evaluated for lower urinary tract symptoms (7) or hematuria (1). Of 8 patients 5 had neurological involvement. Evaluation consisted of history, physical examination, urinalysis and urine culture, excretory urography, urodynamic studies, urethrocystoscopy, bladder biopsies and histopathological examination. RESULTS: Cystoscopy revealed bladder ulcer in 1 patient and an indurated, hypervascular lesion in another with bilateral hydronephrosis. The most common urodynamic finding was detrusor overactivity. Of 4 patients with poor compliance 1 had additional sphincteric deficiency. Common histopathological features were moderate and marked thickening of bladder vessel walls. Lymphocytic vascular reaction was present in 2 patients and lymphocytic vasculitis in 1. Clamshell augmentation ileocystoplasty was performed in 3 patients, including 1 who also underwent a sphincter enhancement procedure. The remaining 5 patients received various nonsurgical treatment. CONCLUSIONS: Various types of voiding dysfunction relating to bladder and sphincteric components in both phases of micturition can be seen in Beh?et's syndrome. Voiding dysfunction can be due to either neurological or direct bladder involvement. Augmentation ileocystoplasty is a good treatment option for Beh?et's syndrome with severe bladder involvement.     

Effect of spinal cord abnormalities on the function of the lower urinary tract in patients with anorectal abnormalities

PURPOSE: We evaluated the effect of spinal cord abnormalities on lower urinary tract function in patients with anorectal abnormalities. MATERIALS AND METHODS: We examined 30 patients with anorectal anomalies mainly because of fecal or urinary incontinence. All patients underwent spinal magnetic resonance imaging and urodynamic investigation. RESULTS: Major lumbosacral abnormalities were detected in 57% of patients, including 13, 4 and 3 with a tethered cord, syringomyelia and caudal regression, respectively. Significant dysfunction of the lower urinary tract in 57% of the cases involved an overactive detrusor in 11, detrusor-sphincter dyssynergia in 4, distended bladder in 4 and lazy bladder in 1. When the spinal cord was normal, 54% of the patients had abnormal urodynamic findings but when the spinal cord was abnormal, 59% had abnormal urodynamics. When the bony spine was normal, 33% of the patients had an abnormal spinal cord but when the bony spine was abnormal, 69% had an abnormal spinal cord. CONCLUSIONS: Patients with anorectal abnormalities and fecal or urinary incontinence problems often have an abnormal spinal cord and abnormal urodynamic findings. However, the state of the spinal cord is not the only factor explaining lower urinary tract function. Thus, the possibility of lower urinary tract dysfunction should be considered in each patient with anorectal abnormalities. If the patient has symptoms or findings suggesting abnormal lower urinary tract function urodynamic evaluation should be performed.     

Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response

OBJECTIVE: To investigate the place of urodynamics in the evaluation of patients with symptoms of the overactive bladder by comparing the response to antimuscarinic therapy in those with and with no urodynamically verified symptoms. PATIENTS AND METHODS: In a prospective observational study, 356 female patients with urinary frequency (> or = 8 voids/24 h) and urgency, with or without urge incontinence, underwent cystometry. Patients were diagnosed with detrusor instability if there were spontaneous, uninhibited increases in detrusor pressure during bladder filling. All patients, regardless of urodynamic findings, were subsequently treated with oxybutynin 2.5 mg twice daily and bladder retraining. The outcome was evaluated as the change in urinary frequency and incontinence episodes after 6-8 weeks of treatment. RESULTS: Among 352 evaluable patients, 266 (76%) had detrusor instability on cystometry and the remainder did not. There was no significant between-group difference in mean age, urinary frequency or the number of incontinence episodes at presentation. Both groups improved equally well during oxybutynin and bladder retraining therapy; after 6-8 weeks there was no significant between-group difference for the mean change from baseline in urinary frequency or incontinence episodes. Tolerability profiles were comparable for the two groups. CONCLUSION: Patients with symptoms of an overactive bladder, but apparently normal urodynamic findings, respond equally well to antimuscarinic therapy as those with urodynamically verified symptoms. Such findings cast further doubt on the clinical validity of using invasive urodynamic procedures to characterize patients with irritative lower urinary tract symptoms before starting antimuscarinic therapy.     

Urodynamic patterns following ischemic spinal cord events

PURPOSE: The nature of bladder function following ischemic injuries to the spinal cord (vSCI) is poorly understood. We describe urodynamic (UD) findings in patients with vSCI and determined the optimal management of voiding dysfunction. MATERIALS AND METHODS: From January 1997 through September 2001, 18 patients were diagnosed with vSCI. All underwent neurological and urodynamic evaluation. The etiology of vSCI was abdominal aortic aneurysm repair in 10 patients, another surgical procedure in 4 and a spontaneous spinal cord infarct in 2. RESULTS: Two patients (American Spinal Injury Association [ASIA] class A) had detrusor areflexia or hyporeflexia and performed clean intermittent catheterization. Of the 10 patients assigned to ASIA class C 50% had UD evidence of abnormal compliance, unstable detrusor contractions and detrusor-external sphincter dyssynergia (DESD). All 10 patients had thoracic or cervical sensory levels and 60% had detrusor hyporeflexia or areflexia. A single patient voided spontaneously, while the remainder performed continuous or intermittent catheterization. Five patients assigned to ASIA class D had no abnormal compliance, unstable detrusor contractions or DESD. Four patients voided spontaneously or by abdominal straining. The patients with a history of abdominal aortic aneurysm repair were a heterogeneous population. CONCLUSIONS: While the etiology or sensory level of vSCI does not appear to predict UD patterns with consistency, greater preservation of motor function may be associated with improved parameters. All patients with vSCI and lower urinary tract symptoms require thorough UD evaluation and ongoing surveillance is mandated because deterioration may develop with time. Clean intermittent catheterization may represent the most effective method of bladder emptying for patients unable to void voluntarily. However, early evidence of abnormal compliance and DESD has also been seen in these patients, underscoring the need for close UD surveillance.     

小儿神经源性膀胱与上尿路损害

目的：探讨脊髓发育不良致神经源性膀胱造成上尿路损害的尿动力学危险因素,方法：对32例脊髓发育不良患儿行尿动力学和影像学检查。结果：18例（56％）有肾和输尿管积水,其中4例伴IV－V级膀胱输尿管返液,19例逼尿肌漏尿点压力大于等于40cmH2O(1cmH2O=0.098kPa)且膀胱顺应性小于等于40ml/cmH2O的患儿中,17例合并上尿路损害,13例逼尿肌漏尿点压力＜40cmH2O且膀胱顺应性＞40ml/c mH2O的患儿中,仅1例有双侧输尿管扩张,差别有非常显著性意义（P＜0．001）,结论：对脊髓发育不良致神经源性膀胱的患儿应行尿动力学检查,了解逼尿肌漏尿点压力和膀胱顺应性,确定与上尿路损害有关的危险因素,有助于避免上尿路进一步损害。     

The open bladder neck: a significant finding?

Women with lower urinary tract symptoms were retrospectively studied. They were all investigated using a urinary symptoms questionnaire, a frequency-volume chart and videocystourethrography. An open bladder neck was recorded at maximum cystometric capacity with the patient standing in the left lateral position, if contrast medium entered the proximal urethra at rest in the absence of a detrusor contraction or an increase in intra-abdominal pressure. Women with neurological disorders were excluded. Of 4500 women, 2,593 (57.6%) had a single urodynamics diagnosis and were included in the study: 1207 (46.5%) had urodynamics diagnosis of urodynamic stress incontinence, 558 (21.5%) had detrusor overactivity, 118 (4.6%) had sensory urgency, and 710 (27.4%) had a normal urodynamic study. Out of the 2,593 women included, 776 women (29.9%) had an open bladder neck at rest while 1817 (70.1%) had a closed bladder neck at rest. Only 45% (542/1207) of women with urodynamic stress incontinence had an open bladder neck at rest. Seventy percent (542/776) of women with an open bladder neck had a diagnosis of urodynamic stress incontinence whilst 73% of women with detrusor overactivity and 93% of those with sensory urgency had a closed bladder neck. An open bladder neck at rest is not diagnostic of urethral sphincter incompetence but is associated with urodynamic stress incontinence. It is not associated with urgency as few women with sensory urgency and detrusor overactivity were found to have an open bladder neck. Imaging the bladder neck at rest has questionable value.Editorial Comment: The authors report on a very large series of women who had video urodynamic studies. They concluded that an open bladder neck was not conclusive of Intrinsic Sphincter Deficiency. They also noted that most women with detrusor overactivity or sensory urgency did not have an open bladder neck, which contradicts previous theories regarding bladder neck funnelling have a high association with detrusor overactivity.