Continuous urethral pressure measurement in women with unstable detrusor

To study the role of the urethra in bladder instability, we performed continuous urethrocystometry in 16 patients with verified unstable detrusor and found two qualitatively different pressure oscillations in the urethra: (1) continuous rhythmic pressure waves, characterized by frequency and pressure amplitude and (2) sudden and consistent urethral pressure drops of 35 cm H₂O occurring on average at mean time intervals of 3.5 seconds prior to the onset of the detrusor contraction. Simultaneous pelvic floor electromyographic (EMG) registration showed that the urethral pressure drop occurred either during decreased, unchanged, or increased pelvic floor activity. Restoration of the urethral pressure to its previous level was also unrelated to the pelvic floor EMG activity. Increased EMG activity at the onset of urethral pressure drops was not sufficient to suppress the urethral pressure drop, but could abolish the detrusor contraction. These findings suggest that the unstable detrusor is of a complex pathophysiological origin and involves both storage and micturition as well as detrusor and urethral function.     

Effect of voluntary attention on urethral pressure

We have systematically and simultaneously recorded vesical pressure and maximum urethral closure pressure (MUCP) in 109 women consulting for urinary incontinence over an extended period of time. During the recording, we asked them to peform a mental calculation (MC) test and other tests designed to induce an effort of voluntary attention. We found a significant increase in MUCP during the MC. At rest, 57 women displayed urethral pressure variations (UPV) higher than 15 cm H₂O. MC inhibited UPV in 80% of these cases. Such variations have never yet been reported. The effect of MC can be compared to an orienting reaction, which normally increases the sympathetic tonus. The role of the smooth and striated muscle fibers of the urethra, in the observed changes in urethral pressure, is discussed in light of the literature data.     

Observations on the function of the female urethra: I: relation between maximum urethral closure pressure at rest and urethral hypermobility

AIMS: To study the relation between maximum urethral closure pressure at rest and urethral hypermobility in female patients. PATIENTS AND METHODS: We selected 255 patients aged 20 years and older, with a stable bladder on multichannel urodynamics, without known neurological pathology, and without a history of pelvic or anti-incontinence surgery. A resting urethral pressure profile and the degree of urethral hypermobility were registered. Two-tailed analyses of variance (ANOVA) with Fisher's post-hoc tests were used to detect any statistically significant difference (P < 0.05) in urethral closure pressure between groups with varying degrees of urethral hypermobility. RESULTS: Mean age was 45.6 +/- 12.7 (range 20-77) years. Mean maximum urethral closure pressure for the entire group was 62.7 +/- 29 (range 10-150) cm of water. A statistically significant inverse relationship was found between age and maximum urethral closure pressure (r = 0.489, P < 0.0001) when both analyzed as continuous variables, and with age categorized in 10-year increments (P < 0.0001). When comparing mean urethral closure pressure in each group examined for urethral hypermobility, a statistically significant difference was noted when grades I, II, and III were compared to grade 0 hypermobility. No significant difference was observed when grades I, II, and III were compared to each other. Even if statistically non-significant, there exists an inverse relationship between the degree of urethral hypermobility and the maximum urethral closure pressure: a higher hypermobility is associated with a lesser urethral closure pressure. CONCLUSIONS: Urethral closure pressure falls significantly when urethral hypermobility is present. This decrease is not related to patient's age or parity. Our observations demonstrate an inverse relation between urethral closure pressure and the degree of cysto-urethrocele. As hypermobility increases, closure pressure decreases, even if this decrease does not reach the level of statistical significance.     

Rhythmic pressure variations in urethra and anal canal: Investigations in healthy fertile female volunteers

Ten healthy fertile female volunteers underwent one hour continuous urethral and anal canal pressure recordings. The recordings showed a median maximum urethral pressure (mMUP), of 74.0 cm H₂O and a median maximum anal canal pressure (mMAP) of 50.0 cm H₂O. The anal canal pressure variations (APV) showed the same frequency domains as found in the urethra ranging from 0.001 to 0.03 Hz. The APV amplitude was correspondingly diminished and the two pressure tracings were out of phase indicating the urethral pressure variations (UPV) and APV to be separate intrinsic spontaneous activities of the urethra and anal canal. Twenty-six months prior to the present study the women had a similar urethral pressure recording. Comparison of the mMUP, maximum urethral closure pressure (mMUCP), and UPV frequency and amplitude showed no difference between the two periods. The intraindividual variation was lower than the interindividual variation meaning that the individual woman had rather stable urethral pressures, whereas there was a considerable variation between the women. The rhythmic UPV frequencies and amplitudes were stable during the two year period. Consequently the study underlines the consistency of urethral pressure. The comparative investigations of urethral and anal pressure add evidence to our pressure statements that they originate from smooth muscle activity.     

女性尿道中静态尿道压力分布特点的研究

目的：探讨在女性尿道不同部位和不同方向上静态尿道压力图（RUPP）压力的分布特点。方法：本研究共包括因各种原因需做尿动力学检查的成年女性患者55例,年龄（41±11）岁,其中尿流动力学检查无异常者8例,压力性尿失禁19例,其他诊断（包括OAB、膀胱收缩无力等）28例。采用恒压恒速灌注法测压,将测压孔分别朝向尿道前壁（12点）、后壁（6点）、左侧壁（3点）及右侧壁（9点）四个方向描记RUPP,采用配伍区组方差分析进行统计学分析。结果：前壁的最大尿道闭合压（MUCP）最高（P％0．01）,后壁的MUCP最低（P〈0．001）,左右两侧MUCP无明显差异（P=0．571）;前壁的功能尿道长度（FUL）最短（P〈0．01）,后壁的FUL最长（P〈0．001）,左右两侧FUL无统计学差异（P=0．717）;RuPP曲线均呈抛物线形,高压区和MUCP的最大值位于尿道中段或中远段交界处。结论：本研究结果显示,静态尿道压力图在女性尿道压力分布上,前后壁方向上具有显著的方向性变异,而左右两侧具有对称性和一致性。尿道压力图的压力分布特点与女性尿道壁的组织结构和尿道腔的形态密切相关。     

Observations on the function of the female urethra: II: Relation between maximum urethral closure pressure at rest and the degree of urethral incompetence

AIMS: To study the relation between maximum urethral closure pressure (MUCP) at rest and the degree of urethral incompetence in the female. PATIENTS AND METHODS: Two hundred fifty five patients aged 20 years or older, with stable bladders on multichannel urodynamics, without known neurological pathology, and with no previous history of pelvic or anti-incontinence surgery were included in the study. Resting urethral pressure profile (UPP) and the grade of urethral incompetence was registered. RESULTS: Mean age of the group was 45.6+/-12.7 years; mean MUCP was 62.7+/-28.5 cm of water. There was a statistically significant difference in the MUCP when the different grades of urethral incompetence were compared to each other, the higher grades being associated with a lower maximal closure pressure. CONCLUSIONS: This study demonstrates that there is a highly significant relationship between MUCP and between all grades of urethral incompetence. This supports previous observations that MUCP decreases when abdominal leak point pressure (ALPP) is low and that this might be secondary to some mechanical failure in the pressure transmission from the abdominal cavity to the urethra. Studies should never compare continent to incontinent cohorts without considering their ALPP because in doing so they are comparing groups that are functionally heterogeneous.     

Observations on the function of the female urethra: III: An overview with special reference to the relation between urethral hypermobility and urethral incompetence

AIMS: To analyze the relation between urethral hypermobility and urethral incompetence, and to summarize the interdependence between maximum urethral closure pressure (MUCP), urethral hypermobility, and urethral incompetence. PATIENTS AND METHODS: A group of 255 patients was selected from a large bank of cases. Inclusion criteria were age 20 years or above, no neurological disease, stable bladder, and no previous incontinence surgery or hysterectomy. The degree of hypermobility (cysto-urethrocele) and the degree of urethral incompetence (abdominal leak point pressure (ALPP)) were determined. Statistical analyses between urethral hypermobility and incompetence were performed with Spearman's correlation and the Jonckherre-Terpstra test. RESULTS: The Spearman's rank correlation test showed a statistically significant relation between urethral hypermobility and the degree of urethral incompetence (P = 0.0049). CONCLUSIONS: The statistically significant relation between urethral incompetence and hypermobility suggests that urethral incompetence will increase as the degree of urethral hypermobility does. Optimal conditions for urinary continence include a high maximum urethral closure pressure, absence of hypermobility, and a low degree of urethral incompetence. This last factor is assured by a strong support underneath the urethra permitting compression of the latter during straining. Failure of the urethral closure mechanism is highly probable with a diminished maximum closure pressure accompanied by urethral hypermobility often associated with a high degree of urethral incompetence. Clinically significant urinary incontinence may appear in many intermediate circumstances between these two extreme states, but stress urinary incontinence is essentially an activity-related phenomenon.     

Mechanical properties of the urethra in healthy female volunteers: Static measurements in the resting urethra

A pressure/cross-sectional area probe was used for measurement of related values of pressure (P_ura) and cross-sectional area (CA) at static circumstances in the resting urethra in 30 healthy females. Measurements were performed at the bladder neck in the high-pressure zone and distally in the urethra. From the two variables urethral elastance and hysteresis were calculated. The mean urethral elastance (i.e., dP_ura/dCA) was found to be of the order of 1 cm H₂O/mm² all along the urethra. No correlation could be established between the elastance and age or parity. The mean hysteresis was of the order of 20–25 cm H₂O along the urethra. Urethral hysteresis appeared to be a time-dependent phenomenon.     

尿动力学检查在女性尿道综合征的应用（附160例分析报告）

为探讨尿动力学检查(UDS)在女性尿道综合征(FUS)的临床价值,应用Laborie公司Encore 5.7尿动力分析仪检查FUS160例。结果发现剩余尿>50ml者占34.4％,初尿意尿量<60ml者28.1％,60～100ml者25.4％,由于有剩余尿和产生初尿意的尿量较少,产生初尿意的实际增加尿量更少,这些都可能是产生尿道综合征症状的部分原因。本组膀胱逼尿肌收缩无力或减弱55例,占34.4％,单纯使用平滑肌兴奋剂,如新斯的明和加兰他敏等提高了疗效。认为尿动力学检查女性尿道综合征患者,有助于了解其病因,分类治疗能提高疗效。     

A case of female large urethral diverticulum treated by electrofulguration

Female urethral diverticulum is not an uncommon disease. We report a case of female urethral diverticulum which caused severe urethral pain, but for which the diagnosis had not been obtained at many hospitals for many years. Transurethral electrocauterization of the diverticulum was very effective in this case.     

The effect of single oral doses of duloxetine,reboxetine, and midodrine on the urethral pressure in healthy female subjects,using urethral pressure reflectometry

Aims

To evaluate the effect on urethral pressure of reference drugs known to reduce stress urinary incontinence symptoms by different effect size and mechanisms of action on urethral musculature under four test conditions in healthy female subjects using urethral pressure reflectometry.

Methods

Healthy females aged 18‐55 years were recruited by advertising for this phase 1, single site, placebo‐controlled, randomized, four‐period, crossover study. The interventions were single oral doses of 10 mg Midodrine, 80 mg Duloxetine, 12 mg Reboxetine, and placebo. The endpoints were the opening urethral pressure measured in each period at four time points (predose and 2, 5.5, and 9 h after dosing).

Results

Twenty‐nine females were enrolled; 25 randomized and 24 completed the study. The opening urethral pressure was higher in all measurements with filled bladder compared with empty bladder, and during squeezing compared to the resting condition. All three drugs increased the opening urethral pressure during all four conditions with a ranking of their effect on urethral pressure matching their reported clinical effect (difference vs. placebo at their reported time of peak plasma concentrations [T_max] during resting with filled bladder: Midodrine 9.3 cmH₂O [95%CI 3.0, 15.5], Duloxetine 24.2 cmH₂O [95%CI 17.9, 30.5], and Reboxetine 44.9 cmH₂O [95% CI 40.2, 52.8] cmH₂O).

Conclusions

Urethral pressure reflectometry is capable of detecting drug‐induced changes in urethral tone in various conditions. The magnitude of drug‐induced changes by the test drugs seems to match their clinical profile and differences in mode of action.     

Simultaneous urethral pressure profilometry using a microtip transducer catheter in the bitch: Effects of bitch position and transducer orientation

Simultaneous urethral pressure profilometry using a microtip transducer catheter was perfonned in 14 bitches to determnine the effects of the position of the animal and the transducer orientation. The technique was carried out in three positions of the bitch (right lateral, dorsal, and left lateral recumbency) and four orientations of the transducers (Diorsal, right, ventral, and left). Both functional profile length and maximum urethral closure pressure were significantly affected by the orientation of the transducer relative to the position of the bitch. The optimum position of the bitch and orientation of the transducers were detennined by evaluating the proportion of profiles from which measurements could not be made, the diagnostic value of profiles, and the Proportion of artefacts in functional profile length. It was concluded that the bitch should be positioned in right lateral recumbency with the transducers orientated dorsally as these positions result in the highest proportion of diagnostic and measurable profiles and the lowest proportion of artefacts in functional profile length.     

Abnormal urethral motor function is common in female stress, mixed, and urge incontinence

AIM: To investigate the urethral motor function in incontinent women. MATERIALS AND METHODS: The intraurethral pressure was measured continuously in the high-pressure zone of the urethra at rest and during repeated short squeezes around the microtip transducer catheter in a group of 205 women with clinically manifest urinary incontinence (severe), and compared with the findings of investigations in 87 middle-aged women (53-63 years) with treatment na?ve incontinence (mild-to-moderate) and healthy controls. RESULTS: Women with established incontinence significantly (P < 0.001) more often (66%) had a pressure fall during or immediately following squeeze than women with treatment na?ve incontinence (35%) or asymptomatic women (25%). The acceleration of urinary flow and the maximal flow rate were significantly (P < 0.01) increased in patients with incontinence: acceleration was 13 +/- 2.2 (17.8), 20 +/- 2.8 (18.9), and 32 +/- 4.9 (24.9) degrees (mean +/- SEM; SD) for incontinence, na?ve incontinence and no incontinence, respectively; maximum urinary flow rate was 23, 22, and 16 ml/sec. No statistical differences in any of these measures were seen when stress and urge incontinence were compared. CONCLUSION: Women with stress, urge, and mixed urinary incontinence seem to have a primary neuromuscular disorder in the urethra, which presents itself as an overactive opening mechanism with a urethral pressure fall instead of a pressure increase on provocation during the filling phase of the bladder, and during bladder emptying a more efficient opening of the bladder outlet than in normal women. We suggest that one and the same pathophysiological mechanism participates in female stress, urge, and mixed incontinence.     

Urethral pressure variations in healthy male volunteers

Summary Urethral pressures are usually considered to be static and only few authors have emphasized timerelated pressure changes. We conducted a study on 10 healthy male volunteers, monitoring the urethral pressures at maximal urethral closure pressure, 2.5 cm proximal (bladder neck) and 2.5 cm distal (pars bulbosa) respectively over 30 min periods. At the bladder neck only sporadic waves were seen. At maximal clusure pressure alsmost permanent oscillations were found, the wavelenghts and amplitudes showing big differences. At the pars bulbosa 2 persons showed only sporadic oscill ions and in 7 we found permanent pressure variatiens. The pressure variations are proposed to represent peristaltic activity with the ability of experlling the last drops of urine after micturition and posing a mechanical barrier to ascending microorganisms.     

庆大霉素局部注射治疗女性尿道综合征的临床研究

目的:研究在"女性前列腺"局部注射抗生素对女性尿道综合征的疗效,为其探索一种有效的治疗方法。方法:选择2009年7月至2010年12月在我院门诊就诊的患者,共入选163例。根据就诊顺序前瞻性随机分为A、B、C 3组,A组58例为实验组,B组55例、C组50例为对照组。A、B、C 3组均进行同样的常规治疗,除此之外A、B组同时采取局部注射治疗,A组注射庆大霉素8万单位(2 ml)+2%利多卡因2 ml的混合药液,B组注射生理盐水2 ml+2%利多卡因2 ml的混合药液。注射方法两组完全一致。浸润性注射在尿道后壁尿道旁腺及其周围,每周治疗2次,6次为1疗程。根据患者自主症状评分的改变评定疗效。疗程结束后第2、4周重复症状评分,症状消失为治愈,分值减少>1/2为为显效,分值减少>1/4分为有效,分值减少<1/4或者反增加为无效。结果:疗程结束后第2周症状评分,疗效A组(有效率为77.5%)明显高于B组(有效率为67.3%)和C组(有效率为68.0%),差异有显著性(P<0.05),而B、C组间无明显差异(P>0.05)。疗程结束后第4周复查,A组有效率略有下降,仍然高于B组和C组,差异有显著性(P<0.05)。结论:"女性前列腺"局部注射庆大霉素治疗女性尿道综合征有一定效果。     

Fundamentals and clinical perspective of urethral sphincter instability as a contributing factor in patients with lower urinary tract dysfunction—ICI‐RS 2014

Aims

Urethral pathophysiology is often neglected in discussions of bladder dysfunction. It has been debated whether “urethral sphincter instability,” referred to based on observed “urethral pressure variations,” is an important aspect of overactive bladder syndrome (OAB). The purpose of this report is to summarize current urethral pathophysiology evidence and outline directions for future research based on a literature review and discussions during the ICI‐RS meeting in Bristol in 2014.

Methods

Urethral pathophysiology with a focus on urethral pressure variation (UPV) was presented and discussed in a multidisciplinary think tank session at the ICI_R meeting in Bristol 2014. This think tank session was based on collaboration between physicians and basic science researchers.

Results

Experimental animal studies or studies performed in clinical series (predominantly symptomatic women) provided insights into UPV, but the findings were inconsistent and incomplete. However, UPV is certainly associated with lower urinary tract symptoms (likely OAB), and thus, future research on this topic is relevant.

Conclusions

Future research based on adequately defined clinical (and urodynamic) parameters with precisely defined patient groups might shed better light on the cause of OAB symptoms. Further fundamental investigation of urethral epithelial–neural interactions via the release of mediators should enhance our knowledge and improve the management of patients with OAB. Neurourol. Urodynam. 35:318–323, 2016. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.     

Adenocarcinoma of the female urethral diverticulum treated by multimodality therapy

A 75-year-old female presented with a 7-month history of intermittent macrohematuria and urinary retention. Physical examination revealed a firm, round mass on the anterior vaginal wall. The diagnosis by urethroscopy and radiological evaluation was localized urethral diverticular tumor. Pathological examination of the biopsy specimen revealed adenocarcinoma. The patient received two courses of intra-arterial and systemic chemotherapy using cisplatin, 5-fluorouracil and leucovorin, followed by radiation to the urethra. The tumor shrunk markedly after chemotherapy. The patient underwent total urethrectomy and vesicostomy. Two years after the operation, she had no evidence of recurrence. Adenocarcinoma of the female urethral diverticulum is rare and has been treated by surgery and/or radiation. The present case is the first case of it being treated by multimodality therapy including chemotherapy.