Voiding dysfunction in young,nulliparous women: symptoms and urodynamic findings

The objective was to determine urodynamic findings in young, premenopausal, nulliparous women with bothersome lower urinary tract symptoms and assess whether or not symptoms are predictive of specific urodynamic abnormalities. The records of 57 women were reviewed. Those with neurological disease or a primary complaint of stress incontinence were excluded. All completed the American Urological Association Symptom Index (AUASI) and underwent videourodynamics. Symptoms were compared in patients with and without bladder dysfunction and/or voiding phase dysfunction. Bladder dysfunction was diagnosed in 86% of patients with urge incontinence vs. 17% of those without (p<0.0001). Patients with voiding phase dysfunction had higher total and voiding AUASI scores. Occult neurological disease was later diagnosed in 4 women (24%) with urge incontinence and bladder dysfunction. Urge incontinence and voiding symptoms are frequently associated with urodynamically demonstrable abnormalities. Urge incontinence and bladder dysfunction may be a sign of occult neurological disease in this population. The presenting symptoms are useful in determining the utility of urodynamics in this population.Editorial Comment: Voiding dysfunction in young women tends to be an incompletely described phenomenon. This patient cadre is often treated presumptively, and as we see from this study, incorrectly. The clinical tendency for minimalist evaluation represents a disservice to these individuals as accruing data supports the use of urodynamics as an intrinsic component in the evaluation of these women. Obviously, data on pressure / flow dynamics would provide further insight into subtle pelvic floor and sphincteric dysfunctions manifested in this group. The authors are to be commended for this opus     

Voiding patterns in patients with post-prostatectomy incontinence: urodynamic and demographic analysis

PURPOSE: A significant percentage of patients with post-prostatectomy incontinence have been reported to void by Valsalva's maneuver, which is our observation as well. We determine the mechanism of voiding in patients with post-prostatectomy incontinence and correlate this to demographic data, urodynamic parameters and outcome after artificial urinary sphincter implantation, and identify possible risk factors. MATERIALS AND METHODS: Videourodynamic data from 61 consecutive patients with post-prostatectomy incontinence were reviewed to determine voiding patterns. The causes of incontinence were radical prostatectomy in 58 patients and transurethral resection of the prostate followed by radiation therapy in 3. The relationship between voiding patterns and demographic data (age, diabetes mellitus, degree and duration of incontinence, history of radiation therapy or treated bladder neck contracture) as well as urodynamic parameters (bladder capacity, compliance, instability, sensation, leak point pressure and residual urine) were studied. After artificial urinary sphincter implantation outcome was assessed in relation to the voiding patterns. RESULTS: Stress incontinence was present in all patients while concomitant urgency/urge incontinence was present in 48%. Of the patients 43 (70.5%) voided by detrusor contraction (group 1) while the remaining 18 (29.5%) voided by straining (group 2). Mean patient age +/- SD was 70.8 +/- 6.9 and 69.2 +/- 7.2 years, and duration of incontinence was 48 +/- 33 and 46 +/- 30 months in groups 1 and 2, respectively (p >0.05). Also, no significant differences were found between the groups with regard to other demographic data. Delayed first sensation (at volume greater than 140 ml.) was seen in 42.5% and 29.4%, capacity less than 300 ml. in 41.9% and 39%, impaired/poor compliance in 25.6% and 22.2%, bladder instability in 16.3% and 5.6%, abdominal leak point pressure 60 cm. H(2)O or less in 59.4% and 60% and residual urine greater than 50 ml. in 11.6% and 17.6% in groups 1 and 2, respectively (p >0.05). After artificial urinary sphincter implantation 35% and 22.2% of patients used greater than 1 pad a day in groups 1 and 2, respectively. One patient in each group reported difficulty during urination and both patients had no residual urine. CONCLUSIONS: No identifiable demographic or urodynamic risk factors could be detected in association with the strain pattern of voiding in patients with post-prostatectomy incontinence. The absence of a difference in bladder compliance, residual urine volume and outcome after artificial urinary sphincter implantation between detrusor and strain voiders would suggest no increased risk for complications in the strain voiding group.     

女性尿失禁患者尿动力学检查的意义

对６８例女性尿失禁的临床诊断和尿动力学检查结果进行了比较研究。根据病史、主诉、体查和辅助检查而做出的诊断，各型尿失禁之间有１５．０％到２７．８％与尿动力学检查不一致。详细的病史、体检、辅助检查与尿动力学检查结果相结合，才能对尿失禁做出正确的诊断。尿动力学检查对于拟手术的患者或基于临床诊断治疗失败的患者具有重要意义。     

盆腔肿瘤放疗后排尿功能障碍患者的尿动力学评估

目的:评估盆腔肿瘤放疗后患者下尿路功能,分析排尿功能障碍类型.方法:对放疗组21例患者:子宫颈癌15例,骶髓肿瘤2例,直肠癌4例;正常对照组17例,采用常规方法行尿动力学测定,按照美国泌尿协会症状评分(AUA评分)标准进行评分,分析评分与放疗剂量关系,以及尿频尿急、排尿困难、尿失禁三类排尿功能障碍发生的原因.结果:膀胱容量、顺应性、逼尿肌收缩强度、残余尿与对照组比较有显著性差异(P<0.05);放疗组尿失禁患者6例(28.6%),排尿困难11例(52.3%),尿频尿急4例(14.0%).放疗后患者的排尿功能障碍严重程度与放疗剂量有一定相关性(r=0.43,P<0.05).结论:盆腔肿瘤放疗对膀胱尿道功能有明显影响,尿动力学检查有助于放疗后复杂排尿功能障碍的评估.     

Effects of acute bolus and chronic continuous intrathecal baclofen on genitourinary dysfunction due to spinal cord pathology.

A prospective, blinded study was done to examine the effects of acute bolus and chronic continuous intrathecal baclofen on genitourinary function in 10 patients with severe spasticity due to spinal cord pathology. Genitourinary function was assessed by symptom questionnaires and urodynamic studies performed after a bolus dose of baclofen and 6 to 12 months after continuous intrathecal baclofen. Results were compared to placebo for acute bolus testing or to pre-continuous intrathecal baclofen values. In all patients with irritative voiding and urge incontinence uninhibited bladder contractions were eliminated. Of 3 patients with an indwelling urethral catheter for incontinence due to detrusor hyperreflexia 1 was converted to intermittent self-catheterization. Whereas bladder capacity, compliance, sensation and voiding pressures were not different after continuous intrathecal baclofen, when a mean of all patients was compiled, a 72% increase in capacity and 16% improvement in compliance were observed in subjects without cervical spinal cord pathology. Detrusor-sphincter dyssynergia was abolished in 40% of the patients. Continuous intrathecal baclofen may represent a novel approach to the management of patients with a neurogenic bladder who have decreased bladder compliance and detrusor hyperreflexia not controlled by oral medications.     

Sexual dysfunction associated with intrathecal baclofen use: a report of two cases

BACKGROUND/OBJECTIVE: Intrathecal baclofen is considered standard treatment for severe spasticity of spinal cord and cerebral origin. Recognized side effects include fatigue and constipation. There are few reported findings of sexual dysfunction in men and none in women. METHODS: Two case reports. RESULTS: A male and a female patient with spasticity treated with intrathecal baclofen were recognized to have sexual dysfunction side effects from treatment. On reduction of the intrathecal baclofen dose, complete return to baseline sexual function was achieved for both subjects. CONCLUSIONS: Intrathecal baclofen can impair sexual function and ejaculation in some patients. Clinicians should be aware of this risk and ask about it during routine clinic follow-up for spasticity. Dosing adjustments need to be considered in these patients.     

Voiding dysfunction after surgery for stress incontinence: literature review and survey results

Postoperative voiding dysfunction is a potential complication of anti-incontinence procedures. Reported rates of urethral obstruction range from 5% to 20%. There is a lack of consensus in the literature regarding the appropriate evaluation and management of this distressing problem. A literature search was carried out using Medline (1966–2001) for postoperative voiding dysfunction. The key word urethrolysis was cross-referenced with surgical complications and stress urinary incontinence to identify all published English-language articles. The bibliographies of reviewed articles were searched manually. We also mailed a survey to the members of American Urogynecologic Society (AUGS) regarding their management of this problem. Overall, 262 members (31.4%) responded to the survey. Success rates reported in the literature between retropubic and vaginal techniques of urethrolysis are comparable, but morbidity is lower with the vaginal approach. The success rates are equivalent with (68%) or without (74%) resuspension following transvaginal urethrolysis. The incidence of postoperative SUI is acceptably low even without resuspension of the urethra (6% for both). Results of the AUGS survey reveal that most providers favor a transvaginal approach (74%) when performing urethrolysis, and they do not routinely resupport the bladder neck (82%).Abbreviations MMK Marshall–Marchetti–Krantz - SUI Stress urinary incontinence - TVT Tension-free vaginal tape Editorial Comment: This is a thorough review of the current literature regarding management of the obstructed post anti-incontinence patient. It points out the lack of type A data on which to base a decision on management; however, it also demonstrates that this problem can be managed with a minimally invasive transvaginal release. This approach appears to work as well as the more invasive approach through an abdominal or suprameatal dissection. Fortunately these patients are somewhat uncommon, but they remain a challenge to the average practitioner and this paper provides some insight into how they should be surgically managed. More work in this area needs to be done before definitive recommendations can be made.     

Urodynamic and clinical evaluation of 91 female patients with urinary incontinence treated with perineal magnetic stimulation: 1-year followup

PURPOSE: We evaluate the perineal magnetic stimulation (PMS) effect on continence and quality of life in women with urinary incontinence. MATERIALS AND METHODS: We prospective studied 91 women with demonstrable urinary incontinence treated with 16 sessions of PMS. Pretreatment and posttreatment evaluation was done by clinical history, physical examination, voiding diary, validated quality of life survey (I-QOL) and urodynamic study (UDS). Patients with no leakage after treatment were evaluated at 3, 6 and 12 months. RESULTS: Mean patient age +/- SD was 60.5 +/- 10.1 years. Immediately after treatment the I-QOL score increased 35% (p <0.001), the number of pads daily decreased 40% (p <0.001), the number of leaks daily decreased 54% (p <0.001) and 34 patients (37%) became dry. Of the 91 patients 41 were evaluated before and after treatment by UDS. The average increase in vesical leak point pressure (VLPP) was 24.3% (p = 0.001) and initial VLPP in patients who became dry was greater than 80 cm H2O. After treatment 77% of patients with initial low pressure detrusor overactivity on UDS became free of this condition. One year after discontinuing PMS 94% of patients who became dry immediately after treatment had recurrence. CONCLUSIONS: Immediately after 16 sessions of PMS women with urinary incontinence have significant improvement in the I-QOL score with decreased daily pad use and leakage episodes but 63% had failure. Therapy is more effective in patients with a VLPP of greater than 80 cm H2O. The beneficial effect is temporary with high and early recurrence after discontinuing treatment.     

Urodynamic parameters in patients with slight and severe genuine stress incontinence: Is the stress profile useful?

This study evaluates the usefulness of the urethral pressure profile (UPP) parameters in assessing the severity of genuine stress incontinence (GSI). Functional length (FL), maximum urethral closure pressure (MUCP), pressure transmission ratio (PTR), residual area at stress (RAS), number of patients with incontinent spikes (IS), and distribution of IS on UPP were determined in supine and standing position for 54 patients (group I) with a 1 -hour pad test < 2 g and compared with the values of 63 patients (group 2) with a 1 -hour pad test > 2 g. The results were similar: FL (supine: 24 mm ± 6/26 mm ± 7 [P:0.2]; standing: 26 mm ± 8/24 mm ± 11 [P:0.5]); MUCP (supine: 51 cm H₂O ± 23/47 cm H₂O ± 20 [P:0.3]; standing: 45 cm H₂O ± 21/38 cm H₂O ± 18 [P:0.1]); and PTR (supine: 83% ± 27/84% ± 31 [P:0.9]; standing: 81% ± 25 and 88% ± 27 [P:0.3]). But the RAS was lower (supine: 502 mm² ± 497/246 mm² ± 268 [P < 0.009]; standing: 500 mm² ± 534/271 mm² ± 306 [P < 0.05]) in group 2. If the percentage of patients with IS was higher (supine: 57/93% [P < 0.001 ]; standing: 54/84% [P] < 0.011) in group 2, the distribution of IS over the entire FL demonstrated no differences between group 1 and 2. In conclusion, except for the RAS, standard UPP parameters cannot be considered determinant in assessing the severity of GSI. © 1994 Wiley-Liss, Inc.     

Urodynamic changes in patients with prostate cancer undergoing robotic-assisted radical prostatectomy: A comparison with laparoscopic radical prostatectomy

ObjectiveThis study investigated the urinary incontinence status and urodynamic changes of localized prostate cancer patients after laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RaRP).Materials and methodsWe enrolled 36 and 30 patients who underwent LRP and RaRP, respectively. The urinary incontinence status and videourodynamic studies (VUDS) of the LRP and RaRP groups during the first year after the surgery were compared.ResultsThe RaRP group was younger and had a smaller prostate volume, shorter operation time, less blood loss, and higher proportion of patients who received postoperative radiotherapy than the LRP group. Twenty RaRP and 26 LRP patients completed VUDS during the 1-year follow-up. Overall, reduced detrusor voiding pressure (Pdet), increased maximal urinary flow rate (Qmax), and reduced bladder outlet obstruction index (BOOI) were detected at 3, 6, and 12 months postoperatively. At 12 months, both the LRP and RaRP groups had similar significant reductions of Pdet. However, only the RaRP group had a significant increase of Qmax and significant reduction of BOOI. Overall, 56.5% of patients (26 of 46) had detrusor overactivity (DO) before the surgery. The de novo DO rate and DO remission rate were 15.2% and 19.6%, respectively, without significant difference between the LRP and RaRP groups. At 6 months, the RaRP group had a significantly lower rate of stress urinary incontinence (SUI) than the LRP group (4.5% versus 47.2%, p = 0.003). In the RaRP group, the greater degree of recovery of both stress and urgency urinary continence developed during the first 6 months postoperatively.ConclusionThe changes of VUDS at 12 months postoperatively for radical prostatectomy included reduced Pdet and BOOI, and increased Qmax. At 6 months, the RaRP group had a lower SUI rate then the LRP group. The key phase of urinary continence recovery was the first 6 months after the surgery.     

Treatment of cerebral origin spasticity with continuous intrathecal baclofen delivered via an implantable pump: long-term follow-up review of 18 patients.

OBJECT: The goal of this study was to assess the long-term benefits of managing severe spasticity by using continuous infusion of intrathecal baclofen delivered via an implantable pump. METHODS: Eighteen patients with severe spasticity of cerebral origin, who failed to respond adequately to more conservative treatments, have-been treated with continuous infusion of intrathecal baclofen delivered via an implanted pump. Follow-up review of these patients has lasted between 12 months and 9 years. The patients have been assessed using a variety of tools. Seventeen have had a significant reduction in tone and all have benefited by a reduced need for nursing care or increased function or both. CONCLUSION: Long-term continuous infusion of intrathecal baclofen delivered via an implantable pump offers an effective method for dealing with otherwise intractable spasticity.     

Effects of intrathecal morphine, clonidine and baclofen on allodynia after partial sciatic nerve injury in the rat

BACKGROUND: Increased response to mechanical or cold stimulation of hind paws was observed in rats with partial sciatic nerve injury as a result of photochemically induced ischemia. The present study examined the effects of intrathecal morphine, clonidine and baclofen on the allodynia-like responses. METHODS: The left sciatic nerves of rats were irradiated for 2 min with an argon ion laser under chloral hydrate anesthesia. The threshold of paw withdrawal to mechanical stimulation was determined with a series of monofilaments (von Frey hairs). The response to cold stimulation was tested by spraying ethyl chloride on the plantar surface of the paw. When rats were exhibiting stable mechanical and cold allodynia-like behaviors after nerve injury, the effects of i.t. morphine (1, 2, 7 microg), clonidine (1, 2, 7 microg) and baclofen (0.1, 0.2, 0.7, 9 microg) in a cumulative dose regime were investigated. RESULTS: Intrathecal morphine dose-dependently alleviated the mechanical and cold allodynia without inducing motor impairment or sedation. Intrathecal clonidine did not alter the response of hind paws to mechanical stimulation, but reduced the cold allodynia. Intrathecal baclofen reduced the responses of rats to mechanical stimulation only at doses that also induced profound motor deficits. CONCLUSIONS: The present data suggest that intrathecal morphine, and to some extent clonidine, but not baclofen, alleviated the abnormal pain-related behaviors in this new rat model of partial peripheral nerve injury. Differences in the pharmacological profile between the present model and other models of peripheral nerve injury are discussed.