Posterior tibial nerve stimulation as neuromodulative treatment of lower urinary tract dysfunction

PURPOSE: Recently, intermittent percutaneous posterior tibial nerve stimulation was introduced as a treatment modality filling the gap between conservative and surgical therapies in patients with certain types of lower urinary tract dysfunction. MATERIALS AND METHODS: In a prospective multicenter trial posterior tibial nerve stimulation was evaluated in 37 patients who presented with symptoms of bladder overactivity, that is the urgency and frequency syndrome and/or urge incontinence, and 12 with nonobstructive urinary retention. Results were recorded in voiding diaries and on quality of life questionnaires before and after treatment. Patients were classified as responders, including those in whom therapy was successful and chose to continue treatment after the initial 12 weeks, and nonresponders, those who chose to stop treatment. RESULTS: Overall, a positive response was seen in 60% of all patients. In patients with bladder overactivity a statistically significant decrease was observed in leakage episodes, number of pads used, voiding frequency and nocturia, and an equal increase in mean and smallest volume voided. Improvements were also seen in nonobstructive urinary retention, including number of catheterizations, total and mean volume catheterized, and total and mean volume voided. Disease specific quality of life and some domains of general quality of life improved, especially of bladder overactivity. Only mild side effects were observed. CONCLUSIONS: Posterior tibial nerve stimulation is a minimally invasive and successful treatment option for patients with certain types of lower urinary tract dysfunction.     

Percutaneous afferent neuromodulation for the refractory overactive bladder: results of a multicenter study

PURPOSE: More than 20 million Americans have an overactive bladder, the predominant symptoms being frequency, urgency, urge incontinence and pelvic pain. While the etiology is not completely understood, most investigators believe the causes to be many and the pelvic floor to be intimately related. Whatever the etiology, traditional therapies, including dietary manipulation, bladder drill, medications and physical therapy, are often poorly tolerated and/or ineffective. We report a prospective, multicenter clinical trial that was undertaken to determine the safety and efficacy of percutaneous peripheral afferent nerve stimulation for treatment of refractive overactive bladder and/or pelvic floor dysfunction. MATERIALS AND METHODS: A total of 53 patients with overactive bladders, in whom all traditional therapy failed, were enrolled in 1 of 5 sites within the United States. Patients received weekly percutaneous electrical stimulations via a 34 gauge needle placed near the tibial nerve 3 finger breadths above the ankle. Urodynamic studies, detailed voiding diaries, quality of life surveys, and incontinence impact questionnaires were completed before, during and after the study. RESULTS: Of the patients with a mean age of 57.4 years 89% (47 of 53) completed the 12-week study. A total of 71% of patients were classified as treatment successes by the investigators and were started on long-term treatment. On average patients noticed a 25% reduction in mean daytime and 21% reduction in mean nighttime voiding frequencies (p <0.05). Urge incontinence was reduced by an average of 35% (p <0.05). Statistically significant improvements were noted in selective pain and quality of life indexes. No significant adverse events related to treatment were noted in any patients. CONCLUSIONS: Percutaneous peripheral afferent nerve stimulation offers a safe, minimally invasive and effective treatment for managing refractive overactive bladder and/or pelvic floor dysfunction.     

Transcutaneous sacral neurostimulation for irritative voiding dysfunction

OBJECTIVE: Patients with irritative voiding dysfunction are often unresponsive to standard clinical treatment. We evaluated the response of such individuals to transcutaneous electrical stimulation of the third sacral nerve. METHODS: 32 patients with refractory irritative voiding dysfunction (31 female and 1 male; mean age 47 years) were recruited to the study. Ambulatory transcutaneous electrical neurostimulation was applied bilaterally to the third sacral dermatomes for 1 week. Symptoms of frequency, nocturia, urgency, and bladder pain were scored by each patient throughout and up to 6 months following treatment. RESULTS: The mean daytime frequency was reduced from 11.3 to 7.96 (p = 0.01). Nocturia episodes were reduced from a mean of 2.6 to 1.8 (p = 0.01). Urgency and bladder pain mean symptom scores were reduced from 5.97 to 4.89 and from 1.48 to 0.64, respectively. After stopping therapy, symptoms returned to pretreatment levels within 2 weeks in 40% of the patients and within 6 months in 100%. Three patients who continued with neurostimulation remained satisfied with this treatment modality at 6 months. CONCLUSIONS: Transcutaneous third sacral nerve stimulation may be an effective and noninvasive ambulatory technique for the treatment of patients with refractory irritative voiding dysfunction. Following an initial response, patients may successfully apply this treatment themselves to ensure long-term relief.     

Botulinum toxin injections in the management of non-neurogenic overactive bladders in children

Introduction

Non-neurogenic detrusor overactivity in children leads to varying degrees of functional impairments (urinary urgency, pollakiuria, urge incontinence, nocturia). Botulinum toxin has shown its effectiveness in the management of detrusor overactivity in neurological patients.

Objectives

To evaluate the relevance of intravesical Botulinum toxin injections for the treatment of non-neurogenic overactive bladders in children. These pediatric patients were resistant to all the usual therapeutics (e.g. bladder/bowel rehabilitation, anticholinergic drugs, management of diet/hygiene habits and constipation, percutaneous posterior tibial nerve stimulation).

Materials and methods

8 children (mean age: 12.5 years), 5 girls, 3 boys with daytime and/or nighttime incontinence and non-neurogenic detrusor overactivity validated by urodynamic testing. Urodynamic testing was conducted before the injections as well as 6 weeks and 1 year post injections. We used Dysport® 8 Speywood Units/kg injected via cystoscopy into 25 different sites.

Results

We noted improvements without any complaints during bladder voiding for all patients, in 6 patients the overactivity disappeared after 1 injection. Compliance was improved early-on in half the cases and at 1 year for all cases (from 12% to 61%, p = 0.01). Noninhibited contractions decreased constantly in both frequency and intensity. Clinical symptoms improved: mean of 7.75 daytime urinary incontinence episodes (IE) per week before the injection vs. 3 after the procedure (p = 0.04). For nighttime IE the improvement was even more noticeable with 7.38 nighttime IE episodes per week before the injection vs. 2.06 after the procedure (p = 0,02).

Conclusion

Intradetrusor Botulinum toxin injections are a potential therapeutic option for the management of non-neurogenic detrusor overactivity in children resistant to the usual treatments.     

Early-Stage Ovarian Carcinoma presenting with Irritative Voiding Symptoms and Urge Incontinence

The detection of ovarian cancer remains a major challenge for gynecologists, as the majority of cases are symptomatically silent until regional metastases or ascites have occurred. This report examines a case of early-stage ovarian adenocarcinoma presenting with irritative voiding symptoms and urge incontinence, all of which resolved fully following surgery. We also report on the frequency of lower urinary tract symptoms leading to the detection of early-stage ovarian cancer, within a cohort of 52 consecutive patients surgically treated at our institution. Lower urinary tract symptoms may trigger the diagnosis of early ovarian cancer in up to 11% of surgically managed patients at our institution. To our knowledge there are no previous reports of early ovarian cancer causing transient irritative voiding symptoms or urge incontinence. This report highlights the importance of considering ovarian neoplasm as a relatively uncommon but critically important etiology accounting for these common female urologic complaints.     

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.     

Urgency is the core symptom of female overactive bladder syndrome, as demonstrated by a statistical analysis

PURPOSE: We determined overactive bladder symptoms in combination with other lower urinary tract symptoms and illustrated their relationships using a statistical analysis. Furthermore, we also describe the potential contributory factors and adaptation strategies in patients that are associated with overactive bladder subtypes. MATERIALS AND METHODS: A total of 1,930 women with a mean age +/- SD of 46 +/- 15 years (range 15 to 91) with troubling lower urinary tract symptoms were successfully interviewed with a validated questionnaire at the urology and urogynecology clinics at 14 medical centers in Taiwan. The questionnaire was constructed to evaluate 6 lower urinary tract symptoms and 7 adaptation strategies. A log linear statistical model and multiple logistic regression analysis were used to assess the associations among lower urinary tract symptoms and the potential overactive bladder contributory factors, respectively. RESULTS: No single or isolated symptom presented in patients with overactive bladder. Most patients reported a combination with other lower urinary tract symptoms. These female patients can be categorized into 3 groups, including 1 is associated with dry symptoms (urgency, frequency and nocturia), 1 associated with wet symptoms (urgency, urge incontinence and mixed stress incontinence) and a small group that may have overactive bladder symptoms combined with voiding difficulty symptoms. in contrast to patients with dry overactive bladder (urgency associated with frequency and/or nocturia without urge incontinence), after multiple logistic regression analysis patients with wet overactive bladder (urgency with urge incontinence) had a greater average age and higher body mass index, and made more adaptation efforts (p <0.05). CONCLUSIONS: We used statistical analysis to determine and suggest that urgency is the core symptom of female overactive bladder syndrome and there are 3 distinctive overactive bladder subtypes, which differ in their symptom combinations. Different symptom combinations and patient characteristics affect female adaptation to overactive bladder syndrome.     

Sacral nerve stimulation for treatment of refractory urinary urge incontinence. Sacral Nerve Stimulation Study Group.

PURPOSE: A prospective, randomized study was performed to evaluate sacral nerve stimulation for the treatment of refractory urinary urge incontinence. MATERIALS AND METHODS: Primary outcome variables were obtained from voiding diaries. After baseline evaluation candidates who satisfied inclusion criteria were enrolled into the study. Test stimulation results determined eligibility for randomization into a stimulation (treatment) or delay (control) group. The stimulation group included 34 patients who underwent implantation and were followed for 6 months. The delay group comprised 42 patients who received standard medical therapy for 6 months and then were offered implantation. The stimulation group completed a therapy evaluation test (on versus off) after 6 months. RESULTS: At 6 months the number of daily incontinence episodes, severity of episodes and absorbent pads or diapers replaced daily due to incontinence were significantly reduced in the stimulation compared to the delay group (all p<0.0001). Of the 34 stimulation group patients 16 (47%) were completely dry and an additional 10 (29%) demonstrated a greater than 50% reduction in incontinence episodes 6 months after implantation. Efficacy appeared to be sustained for 18 months. During the therapy evaluation test the group returned to baseline levels of incontinence when stimulation was inactivated. Urodynamic testing confirmed that sacral nerve stimulation did not adversely affect voiding function. Complications included implantable pulse generator site pain in 15.9% of the patients, implant site pain in 19.1% and lead migration in 7.0%. Surgical revision was required in 32.5% of patients with implants to resolve a complication. There were no reports of permanent injury or nerve damage. CONCLUSIONS: Sacral nerve stimulation is safe and effective in treating refractory urinary urge incontinence.     

Correlation between quality of life and voiding variables in patients treated with percutaneous tibial nerve stimulation

OBJECTIVE: To investigate the relationship between quality of life (QoL) and voiding variables in patients with lower urinary tract dysfunction treated with percutaneous tibial nerve stimulation (PTNS), as it is assumed that improvements in voiding will lead to a better QoL in such patients. PATIENTS AND METHODS: The study included 30 patients with urge urinary incontinence who were treated with PTNS; 24-h bladder diaries and QoL questionnaires (Short Form, SF-36, and incontinence-specific QoL) were completed at baseline and after PTNS. RESULTS: There was a significant correlation (P < 0.05) between the number of pads used and the SF-36 domains of physical and vitality, between the number of incontinence episodes and the SF-36 domains of physical and role physical, between nocturia and the SF-36 domains of general and mental health, between the mean voided volume and the SF-36 domains of role physical and final, and between the mean voided volume and the incontinence-specific QoL score. CONCLUSIONS: PTNS is useful for treating refractory urge incontinence and should at least be considered as a therapeutic alternative before resorting to aggressive surgery, as voiding and QoL variables significantly and quantifiably correlate in patients with refractory urge urinary incontinence who are treated with PTNS. Patients must have a reduction of >or = two pads/day before their QoL improves, and this might be the best definition of successful therapy for patients with urge urinary incontinence.     

Alternative approaches to sacral nerve stimulation

Bladder dysfunction is a very prevalent disorder and often refractory to behavioral and pharmacologic therapies. Sacral nerve stimulation is an approved method of managing urinary urgency, frequency, urge incontinence, and urinary retention. Alternative approaches to neuromodulation are being developed. The purpose of this paper is to describe emerging approaches to neuromodulation for voiding dysfunction. A current review of alternative methods of neuromodulation is discussed. This includes stimulation of the tibial nerve via a percutaneous approach, methods of stimulating the pudendal nerve to obtain afferent stimulation through sacral roots S2–S4, chemo-neuromodulation using botulinum toxin, and anogenital stimulation. These various methods are described and the current literature reviewed. Neuromodulation is an alternative to traditional management of voiding dysfunction. A benefit of neuromodulation is that it is minimally invasive and reversible. New sites of stimulation are being developed to add to our treatment options.     

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.     

Sacral nerve stimulation in the elderly

Sacral neuromodulation has become a widely accepted form of therapy in the overall spectrum of treatment options for urinary urgency and frequency, urge urinary incontinence, and some forms of nonobstructive urinary retention. Voiding dysfunction is very common in geriatric patients, and urgency and urge urinary incontinence are among the most prevalent forms of urinary problems in this population. Despite the fact that many different treatment options are available for these conditions, successful treatment of voiding problems in the elderly is often quite challenging. This may be exacerbated by underlying comorbidities which preclude or limit the utility of some therapies including medications. Published literature on the use and clinical outcomes of sacral nerve stimulation in older adults was reviewed and summarized. Available clinical studies examining the use of sacral neuromodulation in geriatric patients are reviewed and placed in the context of the overall treatment of voiding dysfunction in the elderly population. Sacral neuromodulation may represent a viable, minimally invasive treatment option for some older adults.     

Sacral nerve stimulation in the elderly

Sacral neuromodulation has become a widely accepted form of therapy in the overall spectrum of treatment options for urinary urgency and frequency, urge urinary incontinence, and some forms of nonobstructive urinary retention. Voiding dysfunction is very common in geriatric patients, and urgency and urge urinary incontinence are among the most prevalent forms of urinary problems in this population. Despite the fact that many different treatment options are available for these conditions, successful treatment of voiding problems in the elderly is often quite challenging. This may be exacerbated by underlying comorbidities which preclude or limit the utility of some therapies including medications. Published literature on the use and clinical outcomes of sacral nerve stimulation in older adults was reviewed and summarized. Available clinical studies examining the use of sacral neuromodulation in geriatric patients are reviewed and placed in the context of the overall treatment of voiding dysfunction in the elderly population. Sacral neuromodulation may represent a viable, minimally invasive treatment option for some older adults.     

The Evaluation and Management of Refractory Neurogenic Overactive Bladder

Patients with neurologic disease commonly develop overactive bladder (OAB) symptoms of urgency, frequency, and/or urge incontinence that remain bothersome despite oral pharmacologic therapy. Management of refractory OAB in the neurogenic population is a complex issue with no uniform treatment strategy. When treatment fails or patients generally are dissatisfied with the adverse effects of oral therapy, available options include sacral neuromodulation, percutaneous tibial nerve stimulation (PTNS), botulinum toxin injections, and lower urinary tract reconstruction such as augmentation cystoplasty. A thorough knowledge and understanding of available and emerging treatment options for neurogenic detrusor overactivity is paramount to assisting clinicians in choosing an appropriate treatment. This article reviews the non-pharmacologic treatment options for neurogenic OAB, mainly botulinum toxin, neuromodulation, and lower urinary tract reconstruction, and discusses important relevant studies.     

Long-term effectiveness of sacral nerve stimulation for refractory urge incontinence

OBJECTIVES: To evaluate the long-term efficacy of sacral nerve stimulation for refractory urinary urge incontinence. STUDY DESIGN AND METHODS: Urge incontinent patients qualified for surgical implantation of a neurostimulator system after trial screening with percutaneous test stimulation. Surgical implantation of the InterStim System (Medtronic Inc., Minneapolis, Minn., USA) was performed in cases where a >50% reduction in incontinence symptoms was documented during the 3- to 7-day test stimulation period. The InterStim System consists of an implantable pulse generator, a transforamenally placed quadripolar lead, and an extension that connects these two devices for unilateral stimulation of the S3 or S4 sacral nerve. Efficacy for 96 implanted patients was based on urinary symptom changes as quantified in voiding diaries collected at baseline and annually after surgical implantation. RESULTS: As compared to baseline, the group of 96 implanted patients demonstrated significant reductions in urge incontinent symptoms at an average of 30.8+/-14.8 (range 12-60) months with respect to the number of urge incontinent episodes per day, severity of leaking, and the number of absorbent pads/diapers replaced per day due to incontinence (all p<0.0001, respectively). Gender, pretreatment variables, and age were not found to be relevant factors that affected these results. 11 of the 96 patients underwent device explant due to lack of efficacy, pain or bowel dysfunction. These data were conservatively included in the efficacy results. No permanent injuries associated with the devices or therapy were reported. CONCLUSION: Sacral nerve stimulation is an effective treatment for refractory urge incontinence with sustained long-term benefit through an average of 30.8 months.     

Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder

PURPOSE: Of the various treatments proposed for urge incontinence, frequency and urgency electrostimulation has been widely tested. Different techniques have been used with the necessity of surgical implantation (S3 neuromodulation or sacral root stimulation) or without requiring surgery (perineal transcutaneous electrostimulation). Recently peripheral electrical stimulation of the posterior tibial nerve was proposed for irritative symptoms in first intention or for intractable incontinence. Clinical studies have demonstrated good results and urodynamic parameters were improved after chronic treatment. However, to our knowledge no data concerning acute stimulation and immediate cystometry modifications have been reported. We verified urodynamic changes during acute posterior tibial nerve stimulation. MATERIALS AND METHODS: A total of 44 consecutive patients with urge incontinence, frequency and urgency secondary to overactive bladder were studied. There were 29 women and 15 men with a mean age +/-SD of 53.3 +/- 18.2 years. Of the patients 37 had detrusor hyperreflexia due to multiple sclerosis (13), spinal cord injury (15) or Parkinson's disease (9), and 7 had idiopathic detrusor instability. Routine cystometry at 50 ml. per minute was done to select the patients with involuntary detrusor contractions appearing before 400 ml. maximum filling volume. Repeat cystometry was performed immediately after the first study during left posterior tibial nerve stimulation using a surface self-adhesive electrode on the ankle skin behind the internal malleolus with shocks in continuous mode at 10 Hz. frequency and 200 milliseconds wide. Volume comparison was done at the first involuntary detrusor contraction and at maximum cystometric capacity. The test was considered positive if volume at the first involuntary detrusor contraction and/or at maximum cystometric capacity increased 100 ml. or 50% during stimulation in compared with standard cystometry volumes. RESULTS: Mean first involuntary detrusor contraction volume on standard cystometry was 162.9 +/- 96.4 ml. and it was 232.1 +/- 115.3 ml. during posterior tibial nerve stimulation. Mean maximum cystometric capacity on standard cystometry was 221 +/- 129.5 ml. and it was 277.4 +/- 117.9 ml. during stimulation. Posterior tibial nerve stimulation was associated with significant improvement in first involuntary detrusor contraction volume (p <0.0001) and significant improvement in maximum cystometric capacity (p <0.0001). The test was considered positive in 22 of the 44 patients. CONCLUSIONS: These results suggest an objective acute effect of posterior tibial nerve stimulation on urodynamic parameters. Improved bladder overactivity is an encouraging argument to propose posterior tibial nerve stimulation as a noninvasive treatment modality in clinical practice.     

Percutaneous electrical nerve stimulation in children with therapy resistant nonneuropathic bladder sphincter dysfunction: a pilot study

PURPOSE: We evaluated the effect of percutaneous electrical nerve stimulation on voiding dysfunction in a group of children with therapy resistant, nonneuropathic bladder sphincter dysfunction. MATERIALS AND METHODS: In a prospective study 17 boys and 15 girls with mean age of 11.7 years underwent percutaneous electrical nerve stimulation after the failure of more than 2 years of urological and/or pharmacotherapy. The device for percutaneous electrical nerve stimulation consists of an interface cable, a surface electrode, a percutaneous needle and a portable stimulator. The needle is inserted at the tibial nerve level and a portable stimulator provided pulsations at a frequency of 20 Hz. for 30 minutes once weekly. Every 6 weeks the children were evaluated. Evaluation parameters were urgency, daytime incontinence, voiding frequency, the uroflowmetry curve and bladder capacity. When favorable results were observed after 6 sessions, therapy was continued for another 12 sessions. In 24 children anticholinergics started before stimulation that had only a partial effect were continued during stimulation. RESULTS: In 7 of the 28 children with urgency before therapy it disappeared after therapy and in 10 it improved. Of the 23 children with daytime incontinence before treatment 4 became dry after stimulation and in 12 incontinence decreased. Of the 19 patients who reported disturbed voiding frequency of less than 4 or more than 8 voids daily 16 achieved a normal frequency of 4 to 6 voids daily. In 21 children an abnormal uroflowmetry curve was observed before stimulation, while in 9 the flow curve was normal after therapy. Mean bladder capacity increased significantly from 185.16 to 279.19 ml. CONCLUSIONS: Percutaneous electrical nerve stimulation has a significant effect on voiding frequency, the uroflowmetry curve and bladder capacity in children with nonneurogenic bladder sphincter dysfunction     

Is the bladder a reliable witness for predicting detrusor overactivity?

PURPOSE: We determined how well the symptoms of OAB syndrome correlate with urodynamic DO using International Continence Society definitions. MATERIALS AND METHODS: The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004. Patients were selected based on OAB syndrome symptoms (urgency, urgency urinary incontinence and frequency). The percent of patients who had symptoms alone or in combination and DO was calculated. RESULTS: There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women. Of men 69% and 44% of women with urgency (OAB dry) had DO, while 90% of men and 58% of women with urgency and urgency urinary incontinence (OAB wet) had DO. Stress urinary incontinence seems to have accounted for the decreased rates in women since 87% of women with urgency urinary incontinence also had the symptom of stress urinary incontinence. The ICS definition does not specify what constitutes abnormal voiding frequency. Analysis of results showed that increasing voiding frequency did not have any effect on increasing the accuracy of diagnosis of DO except in women with 10 or more daytime micturition episodes. CONCLUSIONS: The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO, more so in the OAB wet than in OAB dry patients.     

Sacral neuromodulation for the treatment of bladder dysfunction

S3 nerve root neuromodulation is becoming an accepted therapy for individuals afflicted with lower urinary tract symptoms, such as idiopathic urinary urge incontinence, frequency, urgency, and urinary retention, who fail current standard therapies. This patient population is difficult to treat, and this therapy offers an option that can restore quality of life to these individuals. While the precise pathophysiologic mechanisms underlying these voiding symptoms is unknown based on the physiology of bladder function, it is logical to conclude that they relate to some aberration of the neuromuscular apparatus of the bladder and/or its outlet (the urethra). These pathophysiologic defects are not overtly manifested outside the lower urinary tract because these patients routinely do not have any apparent neurologic deficits. The fact that S3 neuromodulation can clinically improve these lower urinary tract symptoms would support the notion that the neural regulation of the bladder is somehow altered in these patients. This paper presents a review of the current knowledge regarding sacral neuromodulation in treatment of non-neurogenic voiding dysfunction.     

Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women

PURPOSE: We determined the relative sensitivity of double balloon positive pressure urethrography and voiding cystourethrography for diagnosing urethral diverticula in women, and for evaluating which presenting symptoms should be considered clinically suspicious for even smaller diverticula. MATERIALS AND METHODS: The series comprised 32 women, including those with new onset urinary tract infections not related to intercourse, menopause or catheters, those with urethral symptoms, such as point urethral tenderness or a mass, urethral pain, dysuria, dyspareunia or post-void dribbling, and those with new onset urgency and frequency. All patients underwent a history and physical examination by the same physician. Each patient underwent double balloon urethrography and voiding cystourethrography on the same day at a single radiology department. RESULTS: Of the 32 women 30 (94%) were diagnosed with at least 1 diverticulum by double balloon urethrography. In 22 of these cases voiding cystourethrography failed to show the diverticulum. Only 11 of these patients (37%) had a palpable mass on clinical examination. The most common presenting symptoms in patients diagnosed with a diverticulum were recurrent urinary tract infection (52%), dysuria (52%), urgency (41%), frequency (38%), stress incontinence (38%) and urge incontinence (34%). Only 3 patients (9%) presented with 1 symptom. Diverticulectomy was performed in 16 patients. Double balloon urethrography had greater sensitivity (100%) than voiding cystourethrography (44%) relative to a confirmed surgical diagnosis (z test p = 0.002). Of 9 diverticula missed by voiding cystourethrography in the surgery group the maximum diameter was less than 15 mm. in 5. Average followup in the surgery cases is 34 months (median 35, range 17 to 50). None of these patients has had new symptoms suggestive of recurrent diverticulum, failure, new urethritis or new stress urinary incontinence. Conservative therapy consisted of long-term antibiotics in 6 patients and symptomatic treatment with short-term antibiotics in the remaining 8. Conservative therapy offered symptomatic relief in most cases but did not prevent recurrent symptoms. CONCLUSIONS: A diverticulum should be suspected in patients with new onset urinary tract infection, urgency and frequency as well as dyspareunia, post-void dribbling and dysuria. Double balloon urethrography is a more sensitive diagnostic test than voiding cystourethrography for diagnosing urethral diverticula. Patients with mild symptoms may be treated with conservative therapy, although we believe that satisfactory long-term treatment of diverticula is best achieved by surgical excision.