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PubMed2000

Classification and treatment of functional incontinence in children.

Functional urinary incontinence in children may be caused by disturbances of the filling phase, the voiding phase or a combination of both. Detrusor overactivity may cause frequency and urgency, with or without urge incontinence. Girls present with symptoms of detrusor overactivity more often than boys, but sometimes other symptoms, e.g. urinary tract infections or constipation, prevail. Frequent contractions of the detrusor may cause the pelvic floor muscles to become overactive, resulting in staccato or fractionated voiding. When incontinence is the result of a voiding disorder the term 'dysfunctional voiding' is used. Bladder function in these children may be normal, but instability may be present. In children with a 'lazy' bladder, voiding occurs with no detrusor contractions, and postvoid residual volumes and overflow incontinence are the main characteristics. Diagnosis is based on the medical and voiding history, a physical examination, bladder diaries and uroflowmetry. The upper urinary tract should be evaluated in children with recurrent infections and dysfunctional voiding (reflux). Uroflowmetry can be combined with pelvic floor electromyography to detect overactivity of the pelvic floor muscles. Urodynamic studies are usually reserved for patients with dysfunctional voiding and those not responding to anticholinergic drugs. Treatment is usually a combination of 'standard therapy', behavioural therapy, bladder training, physiotherapy and medical treatment. The role of alpha-blockers needs to be evaluated further. Also, neuromodulation may have a place in treatment but the exact indications need to be defined. Clean intermittent self-catheterization is sometimes necessary in children with a lazy bladder and large residual volumes who do not respond to a more conservative approach. Future research needs to be directed towards improving understanding of the pathophysiology, epidemiology, classification and treatment modalities of functional incontinence in children.

Child↗

PubMed2004

Long-term bladder dysfunction and renal function in boys with posterior urethral valves based on urodynamic findings.

PURPOSE: Posterior urethral valves are the most common cause of congenital obstructive uropathy leading to renal failure in childhood. We investigate the influence of bladder dysfunction on renal function impairment. MATERIALS AND METHODS: We retrospectively reviewed the records of 116 patients with posterior urethral valves. After valve ablation urodynamic studies were performed in all patients. The presence of vesicoureteral reflux (VUR), renal dysplasia, serum creatinine during followup as well as urodynamic abnormalities were recorded. Mean followup was 10.3 years after valve ablation. RESULTS: All patients underwent endoscopic valve ablation and urinary diversion was performed in 32. Renal dysplasia was found in 9 patients. Renal function impairment at the end of followup was present in 35 patients. Urodynamic studies showed poor compliance in 30 boys, detrusor overactivity in 44, and poor compliance and detrusor overactivity in 17. Bilateral VUR was found in 17 boys at the time of diagnosis. Urodynamic studies were normal in 23 (20%) patients, of whom 4 had renal failure. Univariate analysis showed that poor compliance and detrusor overactivity had a significant correlation to renal function impairment in addition to bilateral VUR and renal dysplasia. In a multivariate analysis bilateral VUR was an independent prognostic factor for poor prognosis. CONCLUSIONS: Bladder dysfunction may contribute to renal function impairment eventually but normal urodynamic findings do not preclude renal deterioration. It is likely that loss of compliance and detrusor overactivity would actually result in a valve bladder reaching its end point function.

Child↗

PubMed2005

Clinical effects of suburothelial injection of botulinum A toxin on patients with nonneurogenic detrusor overactivity refractory to anticholinergics.

OBJECTIVES: To investigate the clinical and urodynamic effects of suburothelial injection of botulinum A toxin on patients with nonneurogenic detrusor overactivity. Intradetrusor injection of botulinum A toxin has been used to treat patients with detrusor overactivity. Suburothelial injection of botulinum A toxin might effectively inhibit the occurrence of detrusor overactivity mediated by sensory nerves. METHODS: Twenty patients with nonneurogenic detrusor overactivity refractory to anticholinergics were enrolled and treated with injection of 200 U botulinum A toxin into the suburothelial space. The clinical effects on the lower urinary tract symptoms and urodynamic parameters were assessed. RESULTS: At 3 months after treatment, 9 patients had regained continence (45%), 8 had improvement (40%), and treatment had failed in 3 (15%). At 6 months after treatment, 7 patients remained continent, but treatment had failed in 5. Hematuria developed in 1 patient, urinary tract infection in 7 (35%), and a large postvoid residual urine volume requiring catheterization in 6 (30%). Hesitancy in initiation and difficult urination was also noted in 15 patients (75%). The volume of the first sensation of bladder filling and bladder capacity increased about two times; however, the voiding efficiency was reduced by 50% at 2 weeks after treatment. The postvoid residual urine volume was increased by seven times the baseline value at 2 weeks and had decreased to three times greater at 3 and 6 months after treatment. CONCLUSIONS: The results of this study have shown that suburothelial injection of 200 U botulinum A toxin impairs bladder sensation and voiding efficiency, but is effective in the treatment of nonneurogenic detrusor overactivity. Transient urinary retention and the development of urinary tract infection should be carefully monitored.

Adult↗

PubMed1998

Surgery for detrusor overactivity.

Intractable detrusor overactivity can result in considerable morbidity and, in the case of neurogenic bladder dysfunction, can put the upper tracts at risk. Once conservative treatments have been exhausted the aim of surgery is to increase functional bladder capacity and decrease the maximal detrusor pressure at this capacity. The mainstay of contemporary therapy has been augmentation cystoplasty; the different techniques and recent literature are reviewed herein. Bladder autoaugmentation is compared and contrasted with augmentation cystoplasty and its role is discussed, as is the less invasive technique of sacral neuromodulation with reference to their role within the range of surgical treatments for detrusor activity.

Animals↗

PubMed1988

Pathophysiology and differential diagnosis of benign prostatic hypertrophy.

Although the symptoms of benign prostatic hyperplasia are usually attributed to simple mechanical obstruction of the prostatic urethra by an enlarged prostate gland, the pathophysiology of this common urologic disorder actually involves multiple factors. These include abnormalities of detrusor function, neuromuscular abnormalities of the prostatic urethra, and sensory abnormalities of the bladder wall. Detrusor abnormalities include impaired detrusor contractility and involuntary detrusor contractions (detrusor instability or detrusor hyperreflexia). Neuromuscular abnormalities of the prostatic urethra are characterized by alpha-adrenergic overactivity which causes outlet obstruction or by alpha-adrenergic hypoactivity which may result in urinary incontinence. Sensory abnormalities of the bladder wall include hypersensitivity (sensory urgency) or hyposensitivity which can lead to overdistention and urinary retention. The diagnostic evaluation of patients with clinical prostatism must take these factors into account. Of particular importance is the recognition that a decreased urinary flow rate and/or increased postvoid residual urine volume may be caused by either bladder outlet obstruction or impaired detrusor contractility. Routine urodynamic studies do not permit a distinction between these two entities, but video/detrusor pressure/uroflow studies are usually definitive.

Humans↗

PubMed2006

Event driven electrical stimulation of the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in multiple sclerosis.

AIMS: The aim of this study was to evaluate the effect of automatic event driven electrical stimulation on the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in patients suffering from Multiple Sclerosis. METHODS: A total of 10 patients participated in the study. Detrusor pressure was recorded during physiological filling of the bladder and electrical stimulation was applied with surface electrodes whenever the detrusor pressure exceeded 10 cm H(2)O. RESULTS: In seven of the eight patients, where neurogenic detrusor overactivity was observed an average of 12 detrusor contractions could be inhibited by stimulation. In one patient, however, stimulation failed to inhibit the detrusor contractions. The average increase in bladder volume from first suppressed detrusor contraction until leakage was 94% (range: 22-366%). On average, the time from first suppressed contraction until leakage was 15 min and 50 sec (range: 4 min 58 sec-32 min 5 sec) with an average physiological filling rate of 8 ml/min. Urgency was effectively suppressed at the onset of stimulation. CONCLUSIONS: The results indicate that involuntary detrusor contractions in patients with multiple sclerosis can effectively be inhibited with event driven stimulation, hereby improving bladder capacity and reducing the number of incontinence episodes. However, the used method for detecting detrusor contractions is not suitable in a chronic setting and alternative techniques needs to be investigated if stimulation should be applied automatically.

Adult↗

PubMed1997

Efficacy and safety of two doses of tolterodine versus placebo in patients with detrusor overactivity and symptoms of frequency, urge incontinence, and urgency: urodynamic evaluation. The International Study Group.

Tolterodine is a new competitive muscarinic receptor antagonist developed for the treatment of the unstable bladder. A total of 242 patients were enrolled in a multicenter, multinational, randomized, double-blind, placebo-controlled study conducted over a period of 4 weeks in patients with detrusor overactivity and symptoms of frequency, urgency, and urge incontinence. The objective of the study was to compare the efficacy and safety of tolterodine given at 1 or 2 mg b.i.d. versus placebo. At week 4 a statistically significant increase in the volume at first contraction (p = 0.030) and maximal cystometric capacity (p = 0.034) was only in the tolterodine 2 mg b.i.d. group. Tolterodine was safe and generally well tolerated. The incidence of dry mouth, as the most commonly reported adverse event, was only 9% and of mild to moderate intensity.

Adult↗

PubMed2003

Tramadol inhibits rat detrusor overactivity caused by dopamine receptor stimulation.

PURPOSE: In patients with Parkinson's disease an imbalance between stimulatory D2-like receptors and inhibitory D1-like receptors may contribute to detrusor overactivity. Apomorphine, which stimulates D1-like and D2-like dopamine receptors, induces detrusor overactivity in rats. Tramadol is an analgesic drug that stimulates opioid receptors and inhibits reuptake of serotonin and noradrenaline. To evaluate a potentially inhibitory effect of tramadol the drug was given to rats with apomorphine induced detrusor overactivity. MATERIAL AND METHODS: Female Sprague-Dawley rats were used. During anesthesia catheters were introduced into the bladder dome, femoral vein and subcutaneously (SC). Three days later the rats were placed in a metabolism cage and voiding was stimulated by infusing saline into the bladder. Micturition parameters were recorded and compared after the administration of apomorphine and tramadol or vehicle. Desmopressin was given as pretreatment to suppress the diuresis produced by tramadol. RESULTS: While 30 microg kg-1 apomorphine SC was devoid of effect, 60 and 100 microg kg-1 apomorphine SC induced a transient detrusor overactivity. Tramadol (1 mg kg-1) was without effect but 5 and 10 mg kg-1 tramadol intravenously attenuated the effects of apomorphine, while inducing prominent diuresis. Pretreatment with desmopressin, which did not alter cystometry or the effects of apomorphine, abolished diuresis. In these rats 5 and 10 mg kg-1 tramadol intravenously abolished the overactivity caused by apomorphine SC. CONCLUSIONS: Tramadol effectively suppresses apomorphine induced detrusor overactivity in doses shown to have analgesic activity. Hence, tramadol may provide an approach to treat lower urinary tract disorders in which dopamine receptor activation is involved.

Analgesics, Opioid↗

PubMed2004

Voiding dysfunction and urodynamic abnormalities in elderly patients.

Lower urinary tract dysfunction is a major cause of morbidity and decreased quality of life in elderly men and women. With the progressive aging of the population, it is important to understand common micturitional disorders that may occur in this population. Most urinary problems in the elderly are multifactorial in origin, demanding a comprehensive assessment of the lower urinary tract organs, functional impairments, and concurrent medical diseases. Urodynamics is a highly valuable tool in the investigation of elderly patients with lower urinary tract symptoms. Urodynamic tests are not always necessary, being indicated after excluding potentially reversible conditions outside the urinary tract that may be causing or contributing to the symptoms. Although urodynamic tests may reveal common diagnoses such as bladder outlet obstruction and stress urinary incontinence in the elderly population, findings such as detrusor overactivity and impaired detrusor contractility are common and have important prognostic and therapeutic implications. The purpose of this article is to describe common urologic problems in the elderly and review the indications for and clinical aspects of urodynamic studies in these conditions.

Age Factors↗

PubMed1995

Pathology and pathophysiology of detrusor in incontinence.

Incontinence is a common urologic problem, especially in the elderly. Ultrastructural study of the detrusor is crucial for the understanding of its normal and abnormal functional behavior. Prospective, correlative, ultrastructural studies in the elderly revealed distinctive patterns of the overactive (unstable) detrusor, whether occurring alone or together with impaired detrusor contractility or bladder outlet obstruction. These patterns provide better insight into pathophysiology of the unstable bladder, and a great potential in diagnosis of detrusor dysfunction in general.

Aging↗

PubMed1989

Lower urinary tract function in vesicoureteral reflux.

Sixty patients with vesico-ureteral reflux underwent a thorough urodynamic investigation including multiple spontaneous voidings, a combined video voiding cystourethrography, cystometry and pressure flow study via suprapubic catheters. A final urodynamic assessment was derived from the compiled information with respect to the consistency of the findings. We chose the least abnormal finding. Stable bladder was diagnosed in 23 patients while 33 had various degrees of instability. The incidence of bladder instability showed a tendency to a decrease with age from 67% among children aged 2-6 years to 50% in the age group 12-16 years. Voiding was normal in 52 patients. Six patients showed consistent urethral overactivity and one patient had signs of minor infravesical obstruction. Patients with normal urodynamics showed a significantly lower incidence of nephropathy compared to those with pathological urodynamics although the prevalence and the degree of reflux were equally distributed over the whole material. A significant correlation was seen between the severeness of bladder instability and reflux nephropathy in high grade reflux (grade III or more). Consistent urethral overactivity did not influence the incidence of reflux and reflux nephropathy. The study underlines the relationship between abnormal bladder activity and reflux nephropathy.

Adolescent↗

PubMed2003

Effects of tramadol on rat detrusor overactivity induced by experimental cerebral infarction.

OBJECTIVE: Cerebrovascular disease, such as stroke, frequently results in incontinence by reducing suprapontine micturition control. Intraluminal occlusion of the middle cerebral artery (MCA), which produces detrusor overactivity, has been introduced as a useful model of stroke-induced lower urinary tract dysfunction. Recently, the effective analgesic tramadol, was found to possess inhibitory actions on normal rat micturition. The current study aimed to examine the potential effect of tramadol on rat detrusor overactivity due to cerebral infarction. METHODS: In female Sprague-Dawley rats, cerebral ischemia was induced by occlusion of the MCA and the urinary bladder was catheterised. Three days later, continuous cystometry was performed in awake animals and the effects of tramadol given intravenously were studied. RESULTS: In cerebral infarcted rats, bladder capacity was lower (48+/-9%) and micturition pressure higher (76+/-21%) than in control rats. Tramadol 5 mg x kg(-1) given i.v., increased bladder capacity (59+/-29%) and threshold pressure (47+/-32%) to values similar to those in control rats. However, micturition pressure was not significantly altered. Tramadol induced diuresis in some, but not all, cerebral infarcted rats. CONCLUSION: Tramadol normalised detrusor overactivity in MCA-occluded rats. The drug might have a treatment potential in patients with detrusor overactivity after stroke.

Analgesics, Opioid↗

PubMed1998

Detrusor myectomy for detrusor overactivity: a minimum 1-year follow-up.

OBJECTIVE: To evaluate the clinical and urodynamic outcome of partial detrusor myectomy in patients with idiopathic detrusor instability and neuropathic hyper-reflexia. PATIENTS AND METHODS: Seventeen patients with idiopathic detrusor instability and 10 with hyper-reflexia and symptoms not responding to non-surgical treatment underwent partial detrusor myectomy. The clinical and urodynamic results before and after myectomy were compared and the patient's subjective assessment of the outcome documented. RESULTS: There was an overall improvement in 17 of 27 patients (63%) but the success rate was higher in those with idiopathic instability (12 of 17) than in those with neuropathy (five of 10). There was urodynamic evidence of reduced bladder contractility and an improvement in the storage characteristics of the bladder in most of the patients treated. CONCLUSIONS: Partial detrusor myectomy is relatively simple and is associated with minimum morbidity and an acceptable success rate. The procedure alters the urodynamic behaviour of the bladder and leads to symptomatic and objective improvement, giving better results with idiopathic than with neuropathic detrusor overactivity. Detrusor myectomy may be offered to patients with detrusor overactivity unresponsive to conventional management. The option of enterocystoplasty is still open to patients with an unsuccessful outcome. However, the long-term results and surgical variations of the technique should be evaluated further.

Follow-Up Studies↗

PubMed1989

[Neurogenic bladder dysfunction due to tethered spinal cord syndrome in adults: report of two cases].

Two cases of neurogenic bladder dysfunction due to tethered spinal cord syndrome in adults were experienced. They visited our hospital with the complaint of dysuria. The excretory urogram were almost normal. Urodynamic examinations revealed normoactive detrusor-overactive sphincter in case 1, and overactive detrusor-overactive sphincter in case 2. Cystometry-electromyogram demonstrated detrusor-external urethral sphincter dyssynergia in either cases. They were diagnosed as neurogenic bladder due to intraspinal tumor with spina bifida by myelography, computed tomography, and urodynamic examination. Laminectomy, subtotal extirpation of tumor and neurectomy of filum terminale were performed by orthopedists in both cases. The tumor was pathologically diagnosed as lipomas. Postoperatively they showed satisfactory recovery in micturition.

Adult↗

PubMed2006

Analysis of prognostic factors regarding the outcome after a transurethral resection for symptomatic benign prostatic enlargement.

AIMS: To identify preoperative predictive variables regarding treatment outcomes following transurethral resection of the prostate (TURP) of patients with symptomatic benign prostatic enlargement (BPE). METHODS: A retrospective study was conducted in 384 patients of 1,397 men who had undergone TURP for symptomatic BPE. All the patients had completed the evaluation of International Prostate Symptom Score (I-PSS), and quality of life (QOL) index, and had undergone full urodynamics before the surgery. Outcomes were assessed at 12 months after surgery. The association between baseline variables and the improvement in outcome variables was statistically analyzed. RESULTS: Preoperative urodynamic abnormalities included bladder outlet obstruction (BOO) in 315 (82.0%), detrusor underactivity in 91 (23.7%), and detrusor overactivity (DO) in 160 (41.7%). Multivariate analysis showed that the presence of DO and a higher degree of BOO were both associated with postoperative improvement both in I-PSS and the QOL. The initial level of storage symptoms correlated with an improvement in the QOL. CONCLUSIONS: The association between those variables obtained by preoperatively performed urodynamic analysis and the degree of improvement in lower urinary tract symptom and QOL following TURP was statistically elucidated in a large number of patients with symptomatic BPE. A higher degree of baseline BOO positively predicts the postoperative improvement in I-PSS and QOL, while the baseline DO negatively predict it.

Aged↗

PubMed1994

Lower urinary tract dysfunction in children with benign sacrococcygeal teratoma.

We evaluated 8 girls and 3 boys with benign sacrococcygeal teratoma for lower urinary tract dysfunction. All children underwent ultrasonography of the urinary tract, voiding cystourethrography and at least 2 standard urodynamic evaluations. Mean patient age at first urodynamic study was 59 months (range 1 to 136). Nine of the 11 children had abnormal studies, including detrusor instability and associated pelvic floor overactivity during micturition in 2, an anatomical infravesical obstruction in 2 and neurogenic bladder-sphincter dysfunction in 5 (2 detrusor hyperreflexia with sphincter dyssynergia, 2 hyporeflexic bladder-sphincter function and 1 detrusor hyporeflexia with normal sphincter function). Although the major cause of neurogenic lower urinary tract dysfunction seems to be related to surgical trauma of the pelvic plexus and sacral nerves, we observed tethered spinal cord as a primary cause in 2 patients. The incidence of voiding dysfunction in children with sacrococcygeal teratoma is high and is usually neurogenic in origin.

Abdominal Neoplasms↗

PubMed2004

Efficacy and safety of tolterodine in people with neurogenic detrusor overactivity.

OBJECTIVE: To compare tolterodine with oxybutynin and placebo in people with neurogenic detrusor overactivity. DESIGN: Prospective, randomized, double-blind, crossover trial plus open-label comparative stage. PARTICIPANTS: Ten participants with neurogenic detrusor overactivity due to spinal cord injury or multiple sclerosis who used intermittent catheterization. METHODS: Bladder capacity on cystometrogram, a 10-day record of catheterization volumes, number of incontinent episodes per day, and perceived dry mouth using a visual analog scale (VAS) were measured for the following: (a) a blinded comparison: tolterodine, 2 mg twice daily, vs placebo, twice daily; and (b) an unblinded comparison: oxybutynin vs tolterodine, each at self-selected doses (SSDs). RESULTS: Tolterodine, 2 mg twice daily, was superior to placebo in enhancing catheterization volumes (P < 0.0005) and reducing incontinence (P < 0.001), but was comparable with placebo in cystometric bladder capacity. Efficacy of tolterodine SSD was comparable with oxybutynin SSD with regard to catheterization volumes, degree of incontinence, and cystometric bladder capacity. The side effect profile (dry mouth) was comparable between tolterodine, 2 mg twice daily, and placebo, but differed significantly when comparing tolterodine SSD with oxybutynin SSD (P < 0.05). CONCLUSION: Tolterodine, when used at SSDs, is comparable with oxybutynin at SSDs in enhancing bladder volume and improving continence, but with less dry mouth. Tolterodine at the recommended dosage of 2 mg twice daily improves incontinence and bladder volumes compared with placebo, and without significant dry mouth. Larger doses of tolterodine may be needed to achieve best effect in this population, but further studies are required.

Adult↗

PubMed2005

A comparison between the response of patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity to the first intradetrusor injection of botulinum-A toxin.

PURPOSE: Several studies have shown that intradetrusor injections of botulinum neurotoxin type A (BoNT/A) may effectively treat intractable spinal neurogenic detrusor overactivity (NDO), but fewer reports exist on the use of BoNT/A in patients with idiopathic detrusor overactivity (IDO). The purpose of this study was to investigate whether comparable efficacy could be displayed in the response of patients with IDO to those with NDO. MATERIALS AND METHODS: In a prospective, open label study, patients with urgency, and/or urgency incontinence due to urodynamically proven intractable detrusor overactivity received 300 units (NDO) or 200 units (IDO) of Botox injected into the bladder with a minimally invasive outpatient technique. Urodynamic maximum cystometric capacity and maximum detrusor pressure during filling, frequency of voids (frequency), number of incontinence episodes (leak) and number of voids associated with urgency per 24 hours (urgency) from 4-day voiding diaries were compared between the 2 groups at baseline and for changes at 4 and 16 weeks after treatment. RESULTS: A total of 44 patients with spinal NDO and 31 with IDO were treated. At 16 weeks, mean +/- standard error maximum cystometric capacity increased from 229.1 +/- 24.8 to 427.0 +/- 26.9 ml, p <0.0001 in NDO and from 193.6 +/- 24.0 to 327.1 +/- 36.1 ml, p=0.0008 in IDO. Maximum detrusor pressure during filling decreased from 60.7 +/- 6.8 to 26.1 +/- 3.7 cm H2O, p <0.0001 in NDO and from 62.1 +/- 10.8 to 45.1 +/- 8.1 cm H2O, p=0.027 in IDO. Frequency decreased from 12.3 +/- 0.7 to 6.6 +/- 0.6 voids per 24 hours, p <0.0001 in NDO and from 13.6 +/- 1.1 to 8.3 +/- 0.7, p=0.0002 in IDO. Leak decreased from 3.9 +/- 0.5 to 0.7 +/- 0.2 incontinence episodes per 24 hours, p <0.0001 in NDO and from 3.2 +/- 0.8 to 0.6 +/- 0.3, p=0.0017 in IDO, and urgency decreased from 7.5 +/- 0.6 to 1.44 +/- 0.3 episodes per 24 hours, p <0.0001 in NDO and from 10.9 +/- 1.7 to 4.9 +/- 1.1, p <0.0001 in IDO. The 2 groups were comparable for baseline data, but percent improvement in urgency was greater in patients with NDO at 4 weeks (78.2% vs 56.3%, p=0.019) and 16 weeks (78.3% vs 50.7%, p=0.013). Of patients with NDO 69% required self-catheterization de novo posttreatment compared with 19.3% of those with IDO. CONCLUSIONS: Patients with intractable IDO respond to intradetrusor BoNT/A with equally significant improvements in urodynamic and lower urinary tract symptom parameters as those with spinal NDO, despite the lower dose of toxin used.

Adult↗