Bladder and urethral pressures during bladder filling in patients with multiple sclerosis and urge incontinence

Twenty patients with multiple sclerosis and distressing urge incontinence underwent continuous measuring of bladder and urethral pressures during bladder filling. Hyperreflexia with high-pressure peaks resulted in more excessive leakage than detrusor instability with frequent recurring pressure rises of low amplitude and short duration. Atropine reduced leakage by decrease of amplitude as well as frequency of the detrusor contractions. In some patients atropine also normalized urethral instability. Thus it seems probable that both hyperreflexia and instability in patients with multiple sclerosis are mediated by cholinergic neurones in the bladder wall.     

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.     

Relationship of bladder dysfunction to lesion site in multiple sclerosis

PURPOSE: We investigated the relationship of voiding dysfunction type and the lesion site in patients with multiple sclerosis. MATERIALS AND METHODS: Voiding dysfunction was evaluated in 32 patients with multiple sclerosis using the International Prostate Symptom Score and urodynamic tests. Lesion sites were determined by combined neurological examination and magnetic resonance imaging findings. RESULTS: Compared with reports from Western countries the ratio of emptying-to-filling symptoms was high in Japan. Of urinary symptoms only filling correlated with disability status and disease duration. Urinary symptoms were not related to lesion sites. Urodynamic evaluation revealed detrusor hyperreflexia in 14 of 32 patients, hyporeflexia or areflexia in 12, detrusor hyperreflexia with impaired contractile function in 4, a low compliance bladder in 1 and normal function in 1. Of 14 patients with hyperreflexia 13 had overactive sphincter concurrently. Incompetent sphincter was identified in 2 patients who had detrusor hyperreflexia with impaired contractility and in 1 with a low compliance bladder. A significant correlation was noted for a pontine lesion and detrusor hyporeflexia, and for a cervical cord lesion and detrusor-sphincter dyssynergia. CONCLUSIONS: Detrusor hyporeflexia and detrusor-sphincter dyssynergia are indicative of a pontine and cervical spinal cord lesion, respectively. Thus, the lesion site in the central nervous system may be a major determinant of the type of bladder and urethral sphincter dysfunction. The high prevalence of emptying symptoms in Japanese patients may reflect the prevalence of detrusor hyporeflexia and detrusor-sphincter dyssynergia.     

Nocturia in patients with lower urinary tract symptoms: association with diurnal voiding patterns

OBJECTIVE: To determine whether diurnal voiding patterns predict nocturia in patients with lower urinary tract symptoms (LUTS), as few studies have evaluated the association between diurnal and nocturnal voiding patterns. PATIENTS AND METHODS: We prospectively analysed the frequency-volume charts (FVCs) of consecutive patients with LUTS. At the initial visit patients had a detailed clinical evaluation and subsequently were requested to complete a 72-h FVC. In all, 104 (41 men and 63 women, mean age 63 years, range 50-83) were included in the primary analyses. Associations between daytime variables and nocturia were described using maximum likelihood estimates of the relative risk and by 95% confidence intervals (CIs) based on logistic regression models. RESULTS: When at least one night-time void was used to define nocturia the multivariate logistic model showed a negative association of mean daytime voided volume with nocturia (P = 0.001). The odds ratio for nocturia decreased with this variable to 0.98 (95% CI 0.96-0.99). When 'voiding at least twice per night' was used to define nocturia only the number of daytime voids was positively related to nocturia (odds ratio 1.22; 95% CI 1.01-1.48; P= 0.040). CONCLUSION: Nocturia may be associated with diurnal voiding patterns; these results also suggest that the causes of nocturia of one or of two or more voids may differ. This highlights the role of bladder function in more severe forms of nocturia.     

Urodynamic classification of patients with symptoms of overactive bladder

PURPOSE: We describe a new classification of patients with overactive bladder symptoms. MATERIALS AND METHODS: The office records of 132 patients who presented for evaluation of symptoms of urinary frequency, urinary urgency and/or urge incontinence, and who underwent videourodynamics were identified. All patients completed a 24-hour voiding diary and 24-hour pad test. Data collection included age, sex, hormone status, number of voids and incontinence episodes per 24 hours, functional bladder capacity, pad weight and associated genitourinary conditions. Videourodynamics were reviewed and patients were divided into 4 clinical categories, including type 1-no evidence of involuntary detrusor contractions on videourodynamics, type 2-involuntary detrusor contractions present, and patient aware and able to abort them, type 3-contractions present, patient aware and able to contract the sphincter but not abort contractions and type 4-contractions present and patient unaware but unable to contract the sphincter or abort contractions. RESULTS: Average patient age +/- SD was 64 years +/- 13. There were an average of 13 +/- 5 voids and 3 +/- 5 incontinence episodes per 24 hours. Average functional bladder capacity was 306 +/- 146 cc and average pad weight was 94 +/- 165 gm. Associated diagnoses included benign prostatic hypertrophy in 28% of cases, sphincteric incontinence in 17%, idiopathic urge incontinence in 29% and uterovaginal or bladder prolapse in 17%. Another 11% of patients had bladder outlet obstruction, impaired detrusor contractility or neurogenic bladder conditions. Of the cases 72 (55%), 32 (25%), 23 (17%) and 5 (4%) were categorized as classes 1 to 4, respectively. ANOVA revealed no statistically significant differences in the number of voids or incontinence episodes, functional bladder capacity or pad test when individual categories were compared to each other. CONCLUSIONS: This overactive bladder classification stratifies patients according to degrees of awareness, and control of bladder and sphincter function. It may prove useful as a guide for prognosis and therapy. Patients can be stratified into clinical groups based on the presence or absence of involuntary detrusor contractions, the ability to abort contractions and the ability to contract the urinary sphincter in response to contractions. Limiting the definition of overactive bladder to apply only to patients with no proved infection or other pathological condition would have eliminated more than 75% of those in this sample with symptoms of urinary urgency, frequency and/or urge incontinence.     

Age related pathogenesis of nocturia in patients with overactive bladder

PURPOSE: Nocturia is caused by increased nocturnal urine output (nocturnal polyuria) and/or diminished nocturnal bladder capacity. We retrospectively evaluated the causes of nocturia in patients with overactive bladder and nocturia. MATERIALS AND METHODS: A total of 850 patients (18 years or older) with symptoms of overactive bladder (8 or more micturitions per 24 hours and urgency or urgency urinary incontinence) and nocturia (mean of 2.5 or more episodes per night) were enrolled in a 12-week study of tolterodine ER (4 mg QD) vs placebo. Of this total 845 patients (417 men and 428 women) completed 7-day bladder diaries. Patients were stratified post hoc by sex and age groups (less than 50, 50 to 70, more than 70 years). Indices of nocturnal urine production (nocturia index, nocturnal polyuria index and nocturnal bladder capacity index) were compared using ANOVA (alpha level 0.05). Higher nocturia index and nocturnal polyuria index values suggest that nocturia occurs because of nocturnal urine overproduction. Higher nocturnal bladder capacity index values suggest that nocturia occurs because of decreased nocturnal bladder capacity. RESULTS: There were no statistically significant gender or age related differences in baseline nocturnal micturitions. Nocturia index increased significantly with age (p <0.0001), and values were significantly higher among men than women for all age groups (p = 0.0064). Nocturnal polyuria index increased significantly with age (p <0.0001) and there were no gender differences. For nocturnal bladder capacity index there was a significant decrease with advancing age among men (1.75 greater than 1.16 greater than 0.90) and women (1.53 greater than 1.42 greater than 1.08, P(interaction) = 0.0148). CONCLUSIONS: In younger patients with overactive bladder, decreased nocturnal bladder capacity has a greater role in the pathogenesis of nocturia symptoms, whereas in older patients increased nocturnal urine output has a greater role.     

Computerized assessment of detrusor instability in patients treated with sacral neuromodulation

PURPOSE: We previously described an automatic procedure for diagnosing and grading detrusor instability using a cystometric study. In our current study we applied a modified version of the program in patients with urge incontinence treated with sacral neuromodulation to test its capacity to detect changes after therapeutic intervention and understand the mode of action of neuromodulation. MATERIALS AND METHODS: We analyzed cystometric studies before and after neuromodulation in 26 consecutive patients, including 22 women and 4 men, and evaluated parameter changes. We also assessed the relationship of instability parameters at baseline with symptomatic results, which were derived from voiding-incontinence diaries, in female patients to identify urodynamic prognosticators of success. RESULTS: The automatic procedure correctly diagnosed stability and instability in our patients in 51 of the 52 measurements considered. Neuromodulation had an average suppressive effect on the amplitude of unstable contractions. At baseline the amplitude of the maximum unstable contraction and mean active pressure during unstable episodes were significantly less in the 7 women who achieved stability than in the 15 who did not. However, no urodynamic parameters were identified that predicted the symptomatic outcome of treatment. CONCLUSIONS: Our algorithm accurately diagnoses and grades detrusor instability, and provides parameters with predictive value in regard to the probability that a bladder may or may not become stable with neuromodulation. However, the symptomatic result of this treatment option seems to depend on noncystometric factors.     

Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis

AIMS: We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms. METHODS: Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention. RESULTS: There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high. CONCLUSIONS: BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.