The structure of the female lower urinary tract and pelvic floor

This article presents the salient features of the histology of the human female bladder, bladder neck, and urethra. Also described are the structure and relationships of the pelvic floor, with particular emphasis on aspects that concern the functional control of the urethra.     

Lower urinary tract function and pharmacologic management of lower urinary tract dysfunction

Because of renewed interest in the neuropharmacology and neurophysiology of the urinary bladder and its outlet, drug therapy can now help manage many types of voiding dysfunction. This article summarizes the scientific foundations on which this type of therapy is based and the current drug usage in this area.     

Taiwanese Continence Society clinical guidelines for diagnosis and management of neurogenic lower urinary tract dysfunction

This article reports the current evidence and expert opinions on diagnosis and management of neurogenic lower urinary tract dysfunction (NLUTD) in Taiwan. The main problems of NLUTD are failure to store, failure to empty, and combined failure to store and empty. The priority of management of NLUTD should follow the order of: (1) preservation of renal function; (2) freedom from urinary tract infection (UTI); (3) efficient bladder emptying; and (4) freedom from indwelling catheter, and patients' expectation of management should be respected. Management of the urinary tract in patients with spinal cord injury (SCI) or multiple sclerosis (MS) must be based on urodynamic findings, rather than inferences from the neurologic evaluation. Selecting high risk patients is important to prevent renal function impairment in patients with chronic NLUTD. Patients with NLUTD should be regularly followed up for their lower urinary tract dysfunction by urodynamic study and any urological complication should be adequately treated. Avoiding a chronic indwelling catheter can reduce the incidence of developing a low compliant bladder. Antimuscarinic agents with clean intermittent catheterization (CIC) may reduce urological complications and improve quality of life (QoL) in patients with NLUTD. Intravesical injection of botulinum toxin A provides an alternative treatment for refractory detrusor overactivity (DO) or low compliant bladder and can replace the need for bladder augmentation. When surgical intervention is necessary, we should consider the least invasive type of surgery and reversible procedure first and avoid any unnecessary surgery of the lower urinary tract. Keeping the bladder and urethra in a good condition without interference of the neuromuscular continuity provides patients with NLUTD a chance for future new technologies. It is most important to never give up on improving the QoL in patients with NLUTD.     

Recurrent urinary tract infections in women with symptoms of pelvic floor dysfunction

Introduction and hypothesis  The prevalence and clinical associations of recurrent (two or more symptomatic and medically documented in the previous 12 months) urinary tract infections (UTIs) have not been subjected to comprehensive analysis in a large group of women with symptoms of pelvic floor dysfunction. Methods  A prospective study was conducted involving 1,140 women presenting for their initial urogynecological assessment. Results  The overall prevalence of recurrent UTI was 19%. Significant positive associations of recurrent UTI were: (1) nulliparity with a 3.7× (up to 50 years) increase over the prevalence for parous women and 1.8× (over 50 years); and (2) women with an immediate postvoid residual (PVR) over 30 ml, which is significant in women over 50 years. Conclusions  The early age decline (18–45 years) in the prevalence of recurrent UTI might be related to increasing parity. The later increase (over 55 years) was probably due to the increasing PVR effect superimposed on the nulliparity effect.     

'Better than numbers...' A gentle critique of evidence-based medicine

Evidence-based medicine (EBM) has achieved cult status in the last 10 years or so. It is an altogether admirable movement in medicine, capable of a great deal of good. Its privileged status, however, has prevented critics from being heard, and there are problems with EBM. Eight features need further discussion if EBM is not to be discredited and superseded. They are its reductionism; its unwitting paternalism; its privileging of restricted kinds of evidence; its dependence on the questionable concept of equipoise; the instability of the 'truths' it produces; its capacity to eliminate individuals in favour of categories; its historical arrogance; and its contempt for the wisdom and integrity of our predecessors. Evidence-based medicine is here to stay; for the moment, at least. It is sufficiently well established to withstand critique. It needs criticism if it is to survive and flourish.     

在普通外科诊疗实践中正确掌握和合理运用循证医学原则

普通外科逐步进入循证医学时代。但目前外科领域的循证医学研究数量少,质量不高。外科医生应重视循证医学研究,更现实的是利用好现有的循证医学资料。在此过程中,应对循证医学资料仔细分析,并在临床实践中合理运用,即在适当的时候,适合的病人中应用循证医学原则。     

Quantification of lower urinary tract function and dysfunction

Computer software was developed that interprets urodynamic voiding studies in terms of urinary bladder contractility and urethral resistance. The software was successfully applied in a large number of clinical studies.     

Sacral neuromodulation for treatment of lower urinary tract dysfunction

Despite initial reservations, sacral neuromodulation has begun to develop as a new therapeutic tool for the treatment of lower urinary tract dysfunction. It bridges the gap between conservative treatment options and highly invasive procedures, such as urinary diversion. At present, there are no clinical variables that can reliably predict the efficacy of neuromodulation in an individual patient. All patients, regardless of indication, must therefore undergo a test stimulation before they can be offered chronic sacral neuromodulation with an implanted system. Evaluations in various clinical trials have confirmed that sacral neuromodulation, based on unilateral sacral foramen electrode implantation, has statistically significant therapeutic effects compared to controls, in patients with urge syndromes and failure to empty. The patients most likely to benefit from this treatment are those with detrusor hyperactivity or detrusor hypo-activity. Those with pain syndromes are less likely to respond and to benefit from treatment. Acute and subchronic sacral neuromodulation are associated with very low rates of complications. Complications of chronic sacral neuromodulation are caused either by surgery-related morbidity or hardware problems. Conservative treatment options should be exhausted before neuromodulation is considered. This rule has two purposes: First, it postpones surgery, with its potential morbidity, for as long as possible; second, the long-term efficacy of neuromodulation is still unclear and may be limited in some patients. A fully exploited conservative therapy, in combination with subsequent sacral neuromodulation, may therefore be the optimum way to pursue therapeutic options of relatively low invasiveness.     

Correlation of bladder base elevation with pelvic floor hypertonicity in women with lower urinary tract symptoms

AIMS: To determine whether the bladder base elevation as revealed by cystogram under fluoroscopy is associated with pelvic floor hypertonicity or bladder outlet obstruction (BOO) in women. METHODS: Sixty-two women who were referred to our videourodynamic laboratory for assessment of lower urinary tract symptoms (LUTS) were included in this retrospective analysis. Thirty-one of these women with bladder base elevation-revealed by cystogram under fluoroscopy during videourodynamic study-served as the experimental group, and another group of 31 women without bladder base elevation served as control. None of the patients had neuropathy, previous pelvic surgery or chronic urinary retention. The clinical symptoms, urodynamic diagnosis, and parameters were compared between the two groups. RESULTS: The mean voiding pressure (Pdet.Qmax) and postvoid residual (PVR) were significantly greater, and maximum flow rate (Qmax) and voided volume were significantly lower in the bladder base elevation group. When a Pdet.Qmax of >or=35 cmH2O combined with a Qmax of 相似文献   

Botulinum toxin in the management of lower urinary tract dysfunction: contemporary update

PURPOSE OF REVIEW: To review the most recent experience concerning the application of botulinum toxin in the human lower urinary tract. RECENT FINDINGS: Botulinum toxin was initially applied in the bladder of patients with spinal neurogenic detrusor overactivity and urinary incontinence, or in the urethra in cases of detrusor external sphincter dyssynergia. A large multicentric European study fully confirmed the initial expectancy in the former condition. In addition, the application of botulinum toxin was extended to the treatment of other urological disorders including non-neurogenic detrusor overactivity, non-relaxing urethral sphincter and detrusor underactivity. Interesting reports on the injection of botulinum toxin into the prostate of patients with benign prostatic hyperplasia are also reviewed. SUMMARY: Bladder injection of botulinum toxin is not yet an approved treatment for lower urinary tract dysfunction. Nevertheless, available data suggest that in the near future the toxin will become a standard therapeutic option in incontinent patients with neurogenic and non-neurogenic forms of overactive bladder, who do not respond to or do not tolerate anticholinergic medication. In addition, it might be expected that urethral botulinum toxin injections improve bladder emptying in patients with dysfunctional voiding problems besides detrusor external sphincter dyssynergia.