Bladder reservoir function in children with monosymptomatic nocturnal enuresis and healthy controls

PURPOSE: We investigated bladder reservoir function in children with monosymptomatic nocturnal enuresis and in healthy controls. MATERIALS AND METHODS: A total of 18 children with monosymptomatic nocturnal enuresis and 119 controls who were 7 to 13 years old were recruited. Children completed frequency volume charts and measurements of nocturnal urine production. Mean diuresis in the period preceding each voiding was calculated. Those with enuresis were grouped according to bladder capacity and hospitalized for 4 nights, including a baseline night and 3 with an oral water load. Enuresis volumes and post-void residual volume were estimated, allowing the calculation of bladder volume at the time of enuresis. RESULTS: Nine children with monosymptomatic nocturnal enuresis were characterized as having normal bladder capacity and 9 had decreased bladder capacity. We found large intra-individual variability in daytime voided volume in all 3 groups of participants. Children with enuresis and small bladder capacity generally voided with volumes close to maximal voided volume. A total of 93 enuresis episodes were recorded. Large intra-individual variability was seen in bladder volume at enuresis and it was lower than maximal voided volume in more than 50% of episodes. Variability in bladder volume at enuresis was greatest in the patient group with decreased bladder capacity. We found a significant correlation between diuresis and bladder capacity in all groups during the day and night. CONCLUSIONS: There is a great intra-individual diurnal variability in voided volume in children with enuresis and in healthy children. Enuresis seems to occur at bladder volumes that are smaller and larger than the maximal voided volume obtained from voiding charts.     

Relationship of fluid intake to voluntary micturition and urinary incontinence in geriatric patients

The aim of this study was to investigate, in a group of geriatric inpatients with established incontinence, the relationships among urine loss, voided volumes, frequency of voiding, and fluid intake. The investigated included 128 patients: 76 women and 52 men, with a median age of 79 years. One-half had significant cognitive impairment. Patients underwent 24-hr monitoring of fluid intake, urine loss, and voiding, as well as conventional videourodynamic testing. Diurnal and nocturnal voiding frequencies were significantly but relatively weakly related to fluid intake. Diurnal and nocturnal voided volumes were more closely related, however, to the fluid intake. There was a strong and easily interpretable relationship among nocturnal voided volume, nocturia, cystometric bladder capacity, and evening fluid intake. Sixty of 128 patients had urodynamically proven urge incontinence, and this group was studied separately. They were more cognitively impaired and had significantly greater urine loss and smaller fluid intake than was true of the other incontinent patients. Urine loss was significantly related to fluid intake in this group. Nocturnal urine loss increased by an average of 28 ml/dl of evening fluid intake and decreased by 17 ml/dl voided at night. These results suggest that nocturnal toileting and evening fluid restriction may reduce nocturnal urine loss by a small but useful amount in carefully selected older patients with severe urge incontinence. © 1993 Wiley-Liss, Inc.     

Effect of alarm treatment on bladder storage capacities in monosymptomatic nocturnal enuresis

OBJECTIVE: Despite a great number of studies, very little is known about the mechanism of action of enuresis alarm systems. Nevertheless, as a result of this treatment many children are able firstly to wake up before urination occurs and then, in time, to sleep through the night without voiding. The aim of this study was to investigate the effect of enuresis alarms on bladder storage capacities. MATERIAL AND METHODS: A total of 28 children aged >7 years who were not polyuric but who voided once every night, slept alone in their own bedroom and who were willing, along with their family members, to cooperate were recruited. Patients were asked to record their urine output using a frequency/volume chart for two consecutive days. After these records and the results of physical and laboratory examinations were taken into consideration, treatment was instituted with the bell-and-pad (alarm) system for a period of 12 weeks. At the end of this period, patients were asked to complete another frequency/volume chart. RESULTS: The pre- and post-treatment maximum functional bladder capacity was 178.35 +/- 87.86 ml and 243.03 +/- 102.84 ml, respectively and the pre- and post-treatment mean day-time bladder capacity was 111.11 +/- 45.87 and 148.445 +/- 7.68 ml. Both of these differences were statistically significant (p < 0.0001 and <0.0001, respectively). The maximum nocturnal bladder capacity was found to be increased from 177.85 +/- 84.95 to 255.25 +/- 124.52 ml after treatment (p < 0.0001). CONCLUSION: Treatment with the alarm system for a period of 12 weeks was seen to be associated with a significant increase in bladder storage capacities (maximum nocturnal bladder capacity, maximum functional bladder capacity and mean day-time bladder capacity).     

Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis

OBJECTIVE: To evaluate the diurnal and nocturnal bladder reservoir function in patients with refractory primary nocturnal enuresis (PNE). PATIENTS AND METHODS: Ninety-five children (68 boys, 27 girls, mean age 9.3 years) with significant PNE (>/=3 wet nights/week) that was refractory to treatment with desmopressin +/- an enuretic alarm were assessed using detailed recording of voiding frequency and urinary volume both day and night, natural filling cystometry during the day and continuous cystometry with simultaneous electroencephalogram monitoring during sleep at night. RESULTS: Patients could be broadly categorized into two groups. Group A comprised those with normal daytime urodynamics and functional bladder capacity (FBC) on detailed frequency-volume recording, but who developed marked detrusor instability associated with a significant reduction in nocturnal FBC and small-volume voiding only after sleep at night (33 patients, 35%); and group B, those with abnormal daytime urodynamics and with reduced FBC and small-volume voiding both day and night, but who somehow managed to mask their bladder symptoms during the day (62 patients, 65%). There was no evidence of nocturnal polyuria in either group and the ratios of day : night urinary output volumes for type A and type B patients were 1.48 and 1.99, respectively. CONCLUSION: A reduction in nocturnal FBC, either occurring only after sleep at night in association with the appearance of detrusor instability in patients with normal daytime urodynamics and FBC, or as a manifestation of occult voiding dysfunction or bladder outlet obstruction that affects the bladder reservoir function both day and night, appears to be a common factor and probably the main cause for a mismatch between nocturnal urine output and bladder storage capacity in patients with severe bed-wetting that was refractory to treatment.     

Intravesical atropine compared to oral oxybutynin for neurogenic detrusor overactivity: a double-blind, randomized crossover trial

PURPOSE: We tested the efficacy and side effect profiles of intravesical atropine compared to oxybutynin immediate release when used by individuals with multiple sclerosis. MATERIALS AND METHODS: We performed a study to determine the most effective dose of atropine. Eight participants used increasing doses of intravesical atropine during a 12-day period. Bladder diary data showed that the instillation of 6 mg atropine 4 times daily was most effective for increasing bladder capacity (voided/catheter volumes). We then did a randomized, double-blind crossover trial. Participants received 14 days of treatment with oral oxybutynin or with intravesical atropine, followed by 14 days of alternative treatment. Participants recorded a bladder diary and rated side effects and quality of life. The primary outcome variable was bladder capacity. RESULTS: A total of 57 participants with multiple sclerosis completed the study. Average change in bladder capacity was higher in the atropine arm. The mean +/- SD oxybutynin change was 55.5 +/- 67.2 ml, the mean atropine change was 79.6 +/- 89.6 ml and the mean difference between arms was 24.1 ml (95% CI -0.4, 49.7; p = 0.053). Changes in incontinence events and voiding frequency were not statistically different between the arms. Changes in total side effect and dry mouth scores were significantly better in the atropine treatment arm. CONCLUSIONS: Intravesical atropine was as effective as oxybutynin immediate release for increasing bladder capacity and it was probably better with less antimuscarinic side effects. We recommend that intravesical atropine should be made available to patients with neurogenic detrusor overactivity and voiding problems requiring intermittent catheterization as an alternative to oral therapy, which often has troublesome side effects.     

Efficacy of intranasal desmopressin in the treatment of nocturia due to nocturnal polyuria

Older adults often cite nocturia as one of the most bothersome lower urinary tract symptoms (LUTS). We investigated the efficacy and safety of intranasal desmopressin in the treatment of nocturia due to nocturnal polyuria on 12 patients (ten men, two women) ranging in age from 53 to 77 years (mean 67 years). All patients experienced more than two episodes of nocturia per night, and had a nocturnal urine volume greater than 35% of the daily voided volume, measured using a 3-day voiding diary with a frequency-volume chart. They began taking intranasal desmopressin (10 microg) at bedtime. When compared with the baseline data, the nocturnal urine volume, (928 +/- 307 versus 469 +/- 251 ml, p = 0.0007) and nocturnal frequency (4.8 +/- 2.0 versus 2.8 +/- 1.8, p = 0.0009) were significantly decreased. The daytime urine volume (1,008 +/- 458 versus 930 +/- 419 ml, p = 0.49) did not change significantly. The unine osmolarity (420 +/- 143 versus 598 +/- 158 mOsm/kg, p = 0.0065), and urine sodium levels (100 +/- 32 versus 140 +/- 60 mEq/l, p = 0.007) increased significantly, whereas the serum sodium levels (141 +/- 3 versus 135 +/- 7 mEq/l, p = 0.048) decreased significantly. Among the 12 patients, 5 (41.6%) patients reported side effects, including headache in 1, edema in 1 and hyponatremia in 3. The patient with edema discontinued medication, but the other 4 patients continued their medication and the side effects subsided. In conclusion, desmopressin is an effective treatment for adult patients complaining of nocturia due to nocturnal polyuria. One should be aware of the potential side effects including hyponatremia.     

Persistently increased voiding frequency despite relief of bladder outlet obstruction

PURPOSE: Bladder outlet obstruction (BOO) can increase urinary frequency. Even after surgical relief of obstruction, up to 30% of patient are still bothered by irritative voiding symptoms. We tested the hypothesis that deligation of a partial bladder outlet obstruction model mimics this clinical observation. MATERIALS AND METHODS: Female Wistar rats were obstructed for 3 weeks by partial urethral ligation and then were relieved of obstruction by urethral deligation. Measurements of voiding frequency and voided volumes were measured preoperatively, after ligation, and after deligation. Relief of obstruction was confirmed by measuring flow rates through ex vivo perfusion of deligated urethras. Urine osmolality and bladder weights were determined. Awake cystometrograms (CMGs) were performed 3 weeks after deligation to measure bladder function. RESULTS: Neither sham ligation nor sham deligation altered voiding frequency. Ligation doubled mean voiding frequency (in cc) from 2.01 +/- 0.32 to 3.96 +/- 0.22 per 4 hours (p = 0.0002). Three weeks after deligation, voiding behavior of the animals segregated into 2 groups: 20% had persistent hyperactive voiding frequency (6.67 +/- 1.23 per 4 hours) while 80% normalized voiding frequency (1.53 +/- 0.20 per 4 hours). The difference in voiding frequency in these 2 groups could not be attributed to alterations in urine osmolality, persistence of urethral obstruction, difference in bladder weights or severity of initial obstruction created. Awake CMGs revealed a higher peak micturition pressure and lower voided volume in the hyperactive voiders. CONCLUSIONS: 20% of the animals after urethral deligation had persistent hyperactive voiding which parallels clinical observations. Because the CMG data suggested persistent obstruction, yet urethral perfusion and bladder weights indicated no obstruction, we propose that these 20% of animals have a "functional" bladder outlet obstruction and can be used to study mechanisms underlying hyperactive voiding.     

Voiding pattern and acquisition of bladder control from birth to age 6 years--a longitudinal study

PURPOSE: We describe the voiding pattern and acquisition of bladder control in healthy children up to age 6 years. MATERIALS AND METHODS: We determined age for daytime and nighttime dryness, voiding patterns, voiding volumes and post-void residual volume per 4 hours individually and noninvasively every 3 months up to age 3 years and every 6 months up to age 6 years in 36 female and 23 male patients using 4-hour voiding observation and uroflowmetry/ultrasound. RESULTS: Median age for attaining daytime and nighttime dryness was 3.5 and 4 years, respectively. No significant difference was found between girls and boys. All but 1 child attained daytime dryness an average of 10 months before attaining nighttime dryness. Bladder sensation was reported in 31%, 79% and 100% of patients at ages 2, 3 and 4 years, respectively. Median bladder capacity was 67 ml, 123 ml and 140 ml at years 1, 3 and 6, respectively. Median post-void residual volume was 5.5 ml, 0 ml and 2 ml at ages 1, 3 and 6 years, respectively. CONCLUSIONS: Today bladder control is acquired at a later stage despite earlier awareness of bladder function. The occurrence of bladder sensation from age 1.5 years motivates an earlier start with toilet training. Infants with small post-void residual volume at age 6 months or large bladder capacity will probably attain daytime dryness earlier than those with large post-void residual volume at age 6 months or small bladder capacity.     

Outpatient biofeedback relaxation of the pelvic floor in treating pediatric dysfunctional voiding: a short-course program is effective

INTRODUCTION: We report the treatment results of a short course of biofeedback relaxation of the pelvic floor (BRPF) in treating children with dysfunctional voiding. MATERIALS AND METHODS: Fourteen girls and 6 boys with videourodynamically proved dysfunctional voiding were enrolled. To increase the awareness of the abnormal voiding pattern, the anatomy of the pelvis and the results of a voiding diary and videourodynamics were extensively explained to the patients/parents. Surface electromyography and uroflowmetry were used as biofeedback tools to teach the adequate relaxation of the pelvic floor during voiding. The child was asked to practice the relaxation technique at home at least twice a day. BRPF was performed once a week until the child had 2 consecutive normal bell-shaped uroflow recordings. Patients were reevaluated at 4, 8, 12 and 24 weeks after BRPF training. RESULTS: The mean patient age was 8.3 +/- 3.8 years. The mean number of BRPF training sessions was 2.2 +/- 0.9. The mean follow-up period was 18.9 months. Normalization of abnormal uroflowmetry was achieved in 18 patients (90%). The mean maximal uroflow rate and voided volume increased from 13.3 +/- 4.3 to 18.0 +/- 3.4 ml/s (p < 0.01) and from 138 +/- 56 to 193 +/- 65 ml (p < 0.01), respectively. The postvoiding residual urine decreased from 54.5 +/- 47.6 to 21.3 +/- 10.6 ml (p < 0.01). Complete and partial resolution of voiding symptoms was achieved in 14 (70%) and 6 patients (30%), respectively. Recurrence was noted in 2 of the 10 patients who had complete resolution of symptoms and who had been followed up for more than 6 months. CONCLUSIONS: Short-course outpatient BRPF is an effective treatment of pediatric dysfunctional voiding.     

Hyperbaric oxygen for the treatment of interstitial cystitis: long-term results of a prospective pilot study

OBJECTIVE: We conducted a prospective pilot study to assess the safety and efficacy of hyperbaric oxygen (HBO) for the treatment of interstitial cystitis (IC). METHODS: Six patients underwent 30 sessions of 100% oxygen inhalation in a hyperbaric chamber and were followed up over 15 months. The measures of efficacy were changes in pain and urgency (visual analog scales), alteration in the patient's assessment of overall change in his well-being (Patient Global Assessment Form), and changes in frequency and functional bladder capacity (48-hours voiding log). Evaluation of symptom severity regarding pain and voiding problems was done using the O'Leary-Sant index. RESULTS: Four patients rated the therapeutic result as either excellent or good and assessed their well-being after HBO treatment as improved. Two patients showed only short-term amelioration of some of their symptoms. At 12 months follow-up the baseline functional bladder capacity increased from 37-161 ml (range) to 160-200 ml in the responder group. The 24-hour voiding frequency decreased from 15-27 to 6-11 voids per day, a pain scale improvement from 20-97 mm at baseline to 3-30 mm at 12 months follow-up and an urgency scale improvement from 53-92 mm to 3-40 mm, respectively was observed at 12 month follow-up. The symptom and pain index score decreased from 23-35 at baseline to 3-17 at 12 months follow-up. CONCLUSION: HBO appears to be effective to treat IC patients. Treatment was well tolerated and resulted in a sustained decrease of pelvic pain and urgency, improvement of voiding patterns and increase of functional bladder capacity for at least 12 months.     

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.     

Effects of diabetes on female voiding behavior

PURPOSE: We studied voiding behavior in women with type 2 diabetes vs nondiabetic female controls and examined factors associated with voiding dysfunction in patients with diabetes. MATERIALS AND METHODS: After eliminating coexisting medical factors that could affect voiding function we evaluated voiding behaviors in 194 female patients with diabetes treated regularly at a diabetic clinic and 162 control women using a lower urinary tract symptom questionnaire based mainly on the American Urological Association Symptom Index questionnaire and free flow analyses with post-void residual urine estimates. Emptying efficiency was defined as 100% x volume voided/(volume voided + post-void residual urine). RESULTS: Compared with controls patients with diabetes had significantly higher nocturia scores (p = 0.003), weaker urinary streams (p = 0.02), less voided volumes (220 +/- 97 vs 280 +/- 104 ml, p = 0.04) and lower maximal flow rates (19.4 +/- 8.4 vs 25.9 +/- 8.5 ml per second, p <0.001). Remarkable residual urine (100 ml or greater) was detected in 1.8% of controls vs 13.9% of patients. After controlling for age and voided volume diabetes was significantly associated with a decrease in baseline maximum flow of 4.5 ml per second (95% CI 2.9 to 6.2). In patients with diabetes peripheral neuropathy was an independent factor associated with the decrease in emptying efficiency (p = 0.03). CONCLUSIONS: Diabetes significantly altered voiding patterns in a significant proportion of women treated at the diabetic clinic. Peripheral neuropathy is an important factor associated with diabetic voiding dysfunction.     

Urodynamic findings in patients with a urethral Kock pouch after radical cystectomy]

Urodynamic evaluation was performed in 11 male patients, who underwent radical cystectomy with pelvic lymph node dissection for bladder cancer followed by bladder replacement with a urethral Kock pouch, 3 to 21 months after the operation. Frequency of micturition were 4.9 +/- 1.5 times (mean +/- S.D.) during the day-time and 1.5 +/- 1.2 times during the night-time. Tidal volume of micturition ranged from 300 to 550 ml and residual volume from 10 to 30 ml. Urinary continence was completely preserved in all patients (100%) during the day-time and 8 (72.7%) during the night-time. On pouchmetry, maximum capacity of the pouch was 429.2 +/- 82.4 ml, and intra-pouch pressure was 16.2 +/- 5.4 cmH2O at the capacity of 200 ml and 38.7 +/- 11.5 cmH2O at the maximum capacity. Maximum intra-pouch pressure on voiding was 80.0 +/- 19.4 cmH2O. Uroflowmetry demonstrated intermittent voiding curves in all the patients, with maximum flow rate of 15.2 +/- 6.5 ml/sec, voided volume of 405.9 +/- 80.7 ml and residual rate of 4.5 +/- 2.6%. Maximum intra-urethral pressure at the external urethral sphincter was 28.0 +/- 11.3 cmH2O when the pouch was empty and increased in response to pouch filling up to 64.7 +/- 27.0 cmH2O. Maximum urethral closing pressure and total profile length on the urethral pressure profile were 30.2 +/- 12.4 cmH2O and 20.9 +/- 9.0 mm, respectively, with the pouch empty, and 23.2 +/- 14.5 cmH2O and 20.0 +/- 7.6 mm, respectively, with the pouch full.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nocturia in the adult: classification on the basis of largest voided volume and nocturnal urine production

PURPOSE: We propose a criterion to clarify the underlying etiologies of nocturia. MATERIALS AND METHODS: Frequency-volume charts were recorded for 24 hours by 35 men and 32 women who were subjectively free of lower urinary tract symptoms and had no evidence of voiding disorders. At least 5 subjects were included in each of 5 age groups of 20 to 49, 50 to 59, 60 to 69, 70 to 79, 80 to 89 years for both genders. The charts were used to make a tentative criterion, which was validated in 39 elderly individuals with nocturnal frequency. RESULTS: Correlation and regression analyses indicated that the quotients of nocturnal urine output divided by body weight (U(N)/BW) and largest voided volume divided by body weight (V(L)/BW) were useful classification factors. Cutoffs, which were set close to worst quartiles, were 10 ml./kg. for U(N)/BW and 4 ml./kg. for V(L)/BW, respectively. Correction by body weight made the same criterion applicable irrespective of weight. Symptomatic elderly patients were classified into 3 mutually exclusive groups of nocturnal polyuria (U(N)/BW greater than 10 ml./kg.), low bladder capacity (V(L)/BW less than 4 ml./kg.) and combined nocturia. Of 20 subjects who voided 2 times a night 11 (55%) were classified as having nocturnal polyuria and 15 of 19 who voided 3 or 4 times (79%) were classified as having low bladder capacity or combined nocturia. CONCLUSIONS: The criterion provides a reasonable distinction of etiologies of nocturia, and may be usefulness in examination and treatment.     

Voiding pattern of healthy Taiwanese women

AIM: Few studies have examined the voiding pattern of healthy females, despite the importance of such research for diagnosing abnormal voiding behavior. This study investigates the voiding behavior of healthy women in Taiwan. METHODS: 68 healthy women, aged 19-66 years and claiming to void normally were enrolled. Twenty-two of the subjects (32.4%) were postmenopausal. Each woman completed a 3-day voiding diary. The diary recorded urine volume, voiding frequency, urine volume per voiding for the whole day (24 h), and urine volume during both daytime and nighttime. Age and various other voiding parameters were correlated, and the voiding patterns were compared between premenopausal and postmenopausal women. RESULTS: All women voided 7.34 +/- 1.63 times daily. Higher age was associated with higher whole day and daytime voiding frequency. Nocturia was not common for the group as a whole, with a mean nocturnal voiding of 0.25 times per night. However, higher age was significantly associated with a higher nighttime voiding frequency. A significantly positive correlation was also observed between age and whole day urine volume. Compared with regularly menstruating women, postmenopausal women had a significantly higher whole day and nighttime voiding frequency. Menopause and age both independently affect voiding parameters after multivariate analysis. CONCLUSIONS: The results of this study provide invaluable baseline data on female voiding behavior. Additionally, this study found that for healthy women, age and menstruation status significantly affect voiding patterns. Analysis of female voiding behavior thus should consider these two factors.     

Normal voiding patterns assessed by means of a frequency-volume chart

OBJECTIVE: Voiding dysfunction is one of the commonest problems among the elderly. This study aimed to elucidate the mechanisms behind the diurnal and nocturnal urine output patterns in young and elderly male volunteers. Of particular interest was bladder reservoir function during the day and night. MATERIAL AND METHODS: Young males (n=25; median age 25.0 years; range 22-32 years) and elderly males (n=18; median age 61.1 years; range 55-73 years) were included in the study. Their voiding habits were assessed from a 3-day frequency-volume chart (FVC) detailing all fluid intake and urine output. Data on voided volume, voiding frequency, maximum voided volume (MVV) and average voided volume (AVV) were obtained from the FVC. RESULTS: The young males' average fluid intake was significantly higher than that of the elderly males. On average the elderly males had a slightly higher voiding frequency than the young males, although this was not statistically significant. There was no difference between the two groups regarding their AVVs at night (including the first morning void). The MVVs of the young and elderly males were significantly different, whereas the ratio between voided volume and MVV did not differ between the groups. CONCLUSIONS: The main finding was that young and elderly males void with equal average volumes of urine at night (first morning void inclusive), whereas the elderly void with smaller volumes than the young during the day-time. The elderly thus seem to have the capacity to adjust their AVV to night-time urine output size.     

Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia

BACKGROUND: Voiding before discharge is usually required after outpatient epidural or spinal anesthesia because of concern about bladder overdistention and dysfunction. Shorter duration spinal and epidural anesthesia may allow return of bladder function before overdistention occurs in low-risk patients (those younger than age 70, not having hernia, rectal, or urologic surgery, and without a history of voiding difficulty), and predischarge voiding may not be necessary. METHODS: After institutional review board approval and informed consent, 201 low-risk ambulatory patients were prospectively studied in either a standard or accelerated pathway after undergoing spinal or epidural anesthesia with procaine, lidocaine, 2-chloroprocaine, or less than 7 mg bupivacaine; epinephrine was not used in any anesthetic. Standard pathway patients (n = 70) were required to void before discharge. Accelerated pathway (n = 131) patients were not required to void. (After randomization of an initial 163 patients to one of the two tracks, 38 additional patients were assigned to the accelerated pathway.) If accelerated pathway patients voided, they were discharged when all other discharge criteria were met. If they did not spontaneously void after block resolution, a bladder ultrasound (BUS) was performed. If the BUS indicated a urine volume of less than 400 ml, the patients were discharged and instructed to return to the emergency department if they were unable to void within 8 h of discharge. If the BUS indicated a urine volume of greater than 400 ml, the patients were reassessed in 1 h and were discharged if they could void spontaneously. If they could not void spontaneously, they were catheterized to facilitate discharge. All patients were contacted the next day to assess the return of normal bladder function. RESULTS: All standard pathway patients voided without difficulty, and were discharged in 153 +/- 49 (SD) min. 62 patients in the accelerated pathway voided spontaneously after resolution of their block and were discharged in 127 +/- 41 min. 46 patients were discharged with a BUS less than 400 ml in 120 +/- 42 min. 23 patients had a BUS greater than 400 ml: of these, 20 patients voided within an hour and were discharged in 162 +/- 45 min. Three were catheterized after 1 h, and were discharged in 186 +/- 61 min. Mean discharge time for all patients in the accelerated pathway was 22 min shorter than the standard pathway (P = 0.002). No patients had difficulty voiding or returned to the hospital for urinary problems. None reported new urologic symptoms. CONCLUSIONS: Delay of discharge after outpatient spinal or epidural anesthesia with short-duration drugs for low-risk procedures is not necessary, and may result in prolonged discharge times.     

Ambulatory Surgery Patients May Be Discharged before Voiding after Short-acting Spinal and Epidural Anesthesia

Background: Voiding before discharge is usually required after outpatient epidural or spinal anesthesia because of concern about bladder overdistention and dysfunction. Shorter duration spinal and epidural anesthesia may allow return of bladder function before overdistention occurs in low-risk patients (those younger than age 70, not having hernia, rectal, or urologic surgery, and without a history of voiding difficulty), and predischarge voiding may not be necessary.

Methods: After institutional review board approval and informed consent, 201 low-risk ambulatory patients were prospectively studied in either a standard or accelerated pathway after undergoing spinal or epidural anesthesia with procaine, lidocaine, 2-chloroprocaine, or less than 7 mg bupivacaine; epinephrine was not used in any anesthetic. Standard pathway patients (n = 70) were required to void before discharge. Accelerated pathway (n = 131) patients were not required to void. (After randomization of an initial 163 patients to one of the two tracks, 38 additional patients were assigned to the accelerated pathway.) If accelerated pathway patients voided, they were discharged when all other discharge criteria were met. If they did not spontaneously void after block resolution, a bladder ultrasound (BUS) was performed. If the BUS indicated a urine volume of less than 400 ml, the patients were discharged and instructed to return to the emergency department if they were unable to void within 8 h of discharge. If the BUS indicated a urine volume of greater than 400 ml, the patients were reassessed in 1 h and were discharged if they could void spontaneously. If they could not void spontaneously, they were catheterized to facilitate discharge. All patients were contacted the next day to assess the return of normal bladder function.

Results: All standard pathway patients voided without difficulty, and were discharged in 153 +/- 49 (SD) min. 62 patients in the accelerated pathway voided spontaneously after resolution of their block and were discharged in 127 +/- 41 min. 46 patients were discharged with a BUS less than 400 ml in 120 +/- 42 min. 23 patients had a BUS greater than 400 ml: of these, 20 patients voided within an hour and were discharged in 162 +/- 45 min. Three were catheterized after 1 h, and were discharged in 186 +/- 61 min. Mean discharge time for all patients in the accelerated pathway was 22 min shorter than the standard pathway (P = 0.002). No patients had difficulty voiding or returned to the hospital for urinary problems. None reported new urologic symptoms.     

Clinical efficacy and safety of tolterodine compared to placebo in detrusor overactivity

PURPOSE: We evaluated the efficacy, patient acceptability and side effect profile of tolterodine, a new antimuscarinic agent for treating bladder overactivity. MATERIALS AND METHODS: In our randomized, placebo controlled, parallel group study 123, 129 and 64 patients 18 years old or older with proved detrusor overactivity (idiopathic detrusor instability or detrusor hyperreflexia) were randomized to receive 1 or 2 mg. tolterodine, or placebo, respectively, twice daily for 12 weeks. Main outcome measures were number of voids per 24 hours, urine volume per void and episodes of urge incontinence per 24 hours on a frequency-volume chart with detailed recording of side effects. RESULTS: After 12 weeks of treatment mean number of voids per 24 hours plus or minus standard deviation decreased from 11.2 +/- 3.1 to 9.0 +/- 2.6 with the 2 mg. dosage (p = 0.0045 versus placebo). At this dose mean urine volume per void increased from 155 +/- 52 to 190 +/- 70 ml. (p <0.0001 versus placebo), while mean number of incontinence episodes per 24 hours decreased from 3.6 +/- 4.0 to 1.8 +/- 3.1 (p = 0.19 versus placebo). Similar efficacy was observed in patients receiving the 1 mg. dose. Severe dry mouth was reported by only 2, 1 and 2% of patients given the 1 and 2 mg. dose, and placebo, respectively. There was no clinical or electrocardiographic evidence of significant cardiac adverse events. CONCLUSIONS: Tolterodine administration resulted in a significant decrease in the frequency of voiding and improved voided volume but it was seldom associated with troublesome or severe side effects.     

A randomized double-blind placebo-controlled crossover trial of the efficacy of L-arginine in the treatment of interstitial cystitis

OBJECTIVES: To determine, in a double-blind placebo-controlled crossover study, whether L-arginine improves the symptoms of interstitial cystitis (IC), a chronic condition in which nitric oxide (NO) may be important, as previous open pilot studies suggested that L-arginine reduced the pain and frequency associated with IC. PATIENTS AND METHODS: Patients fulfilling the standard diagnostic criteria for IC were randomized to receive L-arginine (2.4 g/day) or placebo for one month. After a 2-week 'washout' period they received the other medication. Patients were assessed at each stage using a validated symptom index, a voiding diary, urine analysis and records of adverse events. Patients were asked about overall efficacy at the close of the study. The results were compared using a t-test, with significance indicated at P<0.05. RESULTS: Sixteen (16) patients (mean age 51.3 years) were enrolled; the mean duration of IC was 5.4 years, the IC symptom index score 29.1, their nocturnal frequency 3.5 (voided volume 182 mL) and daytime frequency 12.7 (124 mL). Patients on placebo showed no differences in any recorded variable over the baseline values. L-arginine caused a statistically significant reduction in the overall symptom score of 2.2 over baseline, but there was no difference in voided volume, frequency or nocturia. As there was no significant difference for any variable between L-arginine and placebo, this reduction in score should be regarded with caution. Three patients withdrew because of side-effects (severe headaches, night sweats and flushing). CONCLUSION: Oral L-arginine produces a statistically significant improvement in the IC symptom index in patients with IC, but the effect is small. This effect may not be clinically significant as there were no improvements in the other variables assessed and no significant difference between the response to L-arginine and placebo. From these results the use of L-arginine cannot be recommended for treating IC.