Neurourology and Urodynamics最新文献

Objective: To determine if sociodemographic and health determinants of women with pelvic floor disorders (PFDs) affect health-seeking behavior, and whether this varies by disease subtype and severity.

Materials and methods: We conducted a retrospective cohort study of women with PFDs at an academic urogynecology practice between January 2021 and May 2022. Groups were compared across sociodemographic and clinical variables and by pelvic organ prolapse (POP) stage and urinary incontinence (UI) subtype/severity. The primary outcomes of interest were POP stage and UI severity at initial presentation with duration of symptoms as a key determinant. Statistical significance was set at p < 0.05.

Results: The study included 684 [307 POP (44.9%) and 377 UI (55.1%)] women. Of those with POP, 190 (61.9%) presented with stages I/II and 117 (38.1%) with stages III/IV. In women with UI, 188 (49.9%) had mild-moderate UI and 179 (47.5%) had severe UI. Approximately 76% of women reported PFD symptoms for over 6 months and 47% for 2 years or more upon presentation. Women with advanced-stage POP had 1.27 increased odds (95% CI: 1.01-1.61) of delaying care for > 24 months, were older (1.07 adjusted OR, 95% CI: 1.03-1.11), and had fewer healthcare visits (0.95 adjusted OR, 95%: CI: 0.91-0.98) in the prior year. Women with severe UI had 1.88 increased odds (95% CI: 1.52-2.35) of delaying care > 24 months, 1.20 odds with government insurance (CI: 1.01-1.32), and 1.18 odds of other comorbidities (CI: 1.02-1.40).

Conclusion: Most women with PFD reported symptoms for over 6 months at presentation. Women with advanced POP or severe UI were more likely to seek care over 24 months after the onset of symptoms.

Background: The diurnal rhythm in water and solute diuresis is known to be disturbed in older adults with nocturia due to nocturnal polyuria. We estimated the prevalence of increased natriuresis in nocturia due to nocturnal polyuria by comparing individuals with and without nocturnal polyuria.

Methods: We calculated the night-to-day ratio of excreted urinary sodium and potassium concentrations adjusted for urinary creatinine concentration and urinary osmolality using spot urine samples collected at 2 PM (daytime) and 6 AM (nighttime) and compared results among controls with nocturia and paitents with nocturia with and without nocturnal polyuria.

Results: Among 83 patients aged 50 to 86 years, the mean night-to-day ratio of excreted urinary sodium and potassium concentrations in the nocturia group with nocturnal polyuria (n = 40) was 2.5, which was significantly higher (p = 0.034) than those in the control group (n = 23; 0.7) and the nocturia group without nocturnal polyuria (n = 20; 0.9). After adjustment for age, no difference in potassium and urinary osmolality existed among groups. Thirteen patients (33%) in the nocturia group with nocturnal polyuria showed increased natriuresis when a 2.0 night-to-day ratio of excreted urinary sodium was applied as a cut-off for increased natriuresis, whereas only 3 (7%) patients in the combined groups without nocturnal polyuria had increased natriuresis (p = 0.005).

Conclusions: One-third of patients with nocturia due to nocturnal polyuria had increased natriuresis. Assessment of a night-to-day ratio of excreted urinary sodium using spot urine samples could facilitate a better understanding of the underlying pathophysiology and optimal management of nocturnal polyuria.

Purpose: We investigated whether severity of autonomic dysreflexia (AD) was associated with more patient-reported bladder and bowel symptoms and compared AD severity by bladder management strategy in people with spinal cord injury (SCI).

Methods: The Neurogenic Bladder Research Group SCI Registry is a prospective study which evaluated quality of life after SCI. Bladder and bowel symptoms were assessed through Neurogenic Bladder Symptom Score and Neurogenic Bowel Dysfunction score, respectively. AD severity was assessed with the Autonomic Dysreflexia Following Spinal Cord Injury (ADFSCI) instrument. Bladder management was classified as volitional voiding, clean intermittent catheterization (CIC), indwelling catheter (IDC), and surgery (augmentation and diversion).

Results: AD scores were identified for 1473 people. The mean age was 45. Bladder management was CIC in 754 (51%), IDC in 271 (18%), surgery in 195 (13%) and voiding in 259 (18%). On univariate analysis, higher ADFSCI scores occurred with complete injuries (3.1 vs 3.4, p = 0.03), cervical/thoracic injuries (3.8 vs 1.5, p < 0.0001), and chronic pain (3.9 vs 2.9, p = 0.0004). IDC (5.2) and surgery (4.5) had higher ADFSCI scores than CIC (3.0) and volitional voiding (2.8) (p < 0.0001). Sub-analysis showed bladder augmentation had significantly higher ADSCI scores than diversion (4.7 vs 3.7, p = 0.03). On multivariate analysis, level of injury, bladder management, and bowel and bladder symptoms remained associated with worse AD.

Conclusion: Level of injury, age, worse bowel and bladder symptoms and bladder management type were associated with higher AD scores. Bladder management with surgery, particularly bladder augment, and IDC had associated greater AD symptoms compared to CIC or voiding.

Trial registration: clinicaltrials.gov NTC06216081 and HSRP20153564, U.S. National Library of Medicine, wwwcf.nlm.nih.gov.

Introduction: Intravesical Onabotulinum Toxin A (Botox A) injections are an established minimally invasive therapy option for the treatment of refractory overactive bladder (OAB) symptoms in adults. We have assessed whether baseline urodynamic findings can predict self-reported patient outcomes and posttreatment voiding difficulties.

Methods: We have conducted a retrospective review of 407 patients (median age 61 years, range 22-94 years, 286 women) who have received intravesical Botox A injections for refractory non-neurogenic OAB symptoms between 2006 and 2018. Patient outcomes were assessed using the 5-point PGI-I scale and incidence of posttreatment voiding difficulties was noted. Results were correlated with the baseline urodynamic findings.

Results: Good response to Botox A injections was defined as PGI-I scores of 1 and 2, and was seen in 272 patients overall (67%). Women were significantly more likely to have successful outcomes comparing to men (p = 0.034) and the voiding detrusor contraction duration (DCD) was a further classifier for treatment success. Acute posttreatment voiding difficulties requiring catheterization were observed in 96 patients (24%) and were significantly more likely in those with good response.

Conclusion: Successful outcomes (based on the self-reported PGI-I score) were more likely in women and correlated positively with the increased duration of voiding detrusor contraction, but no other urodynamic parameters. The risk of developing de novo need to catheterize correlated with patient reported benefit, but not with any baseline urodynamic findings. We did not find pre-existing bladder outflow obstruction, concurrent stress urinary incontinence or complex previous surgical history to adversely affect treatment success.

Background: Adult neurogenic lower urinary tract dysfunction may be associated with detrusor sphincter dyssynergia (DSD). Given the sparsity of the literature and the absence of official guidelines regarding the use of oral medications in the management of DSD, this scoping review aims to critically assess the available evidence to guide future research and practice.

Methods: We conducted a systematic scoping review of articles published from 1950 to July 2023 using PubMed, MedLine, Scopus and CINAHL databases to assess all oral treatment options for DSD. All study designs were included. The search was limited to English and French literature regarding human patients over 18 years of age with DSD.

Results: Of the 899 records screened, 15 studies were included, involving a total of 257 participants. Alpha-adrenergic blockers, nitric oxyde and muscle relaxants have been used in the treatment of DSD. A decrease of postvoid residual volumes and an improvement of symptom scores as well as urine flow rates were reported in several studies. Regarding the alpha-adrenergic blockers, five of the six studies that detailed postvoid residual volumes and subjective improvement noted benefits in most patients. Additionally, two of the three studies that addressed mean flow rate observed improvements in most patients. All six studies that documented adverse effects found side effects in only a slight minority of patients.

Conclusions: Alpha-adrenergic blockers are promising, but there is lacking evidence on the oral treatment of DSD. This study highlights the importance of conducting more studies to draw solid conclusions and stop treating these patients empirically.

Aims: To provide a brief anatomical pathogenesis of the Working Group SUI publication recommendations.

Methods and results: The anatomical science and surgical practice presented here formed the original basis for the MUS and other bladder dysfunctions, updated to 2024 with videos: https://atm.amegroups.org/issue/view/1400. Bladder control is binary, from outside the bladder, with ONLY two modes, EITHER closed (continence) OR open (micturition). The key concept for surgical repair of stress (SUI) and other types of urinary dysfunctions, is the role of three balanced oppositely-acting muscle forces which contract against PUL (pubourethral ligament) and USL (uterosacral ligaments) to close urethra, open it before evacuation and stretch vagina to prevent premature activation of micturition, perceived as "urge to go." Collagen-induced weakness in PUL or USL may cause dysfunction in all three of these activities, which can be improved or cured by collagen-creating ligament repair techniques (e.g., slings). It is important to diagnose Tethered Vagina Syndrome (TVS), iatrogenic scarring at bladder neck, much more frequent since large vaginal mesh implantation. TVS is often confused with SUI, as its cardinal symptom is massive urine loss with the "effort" of getting out of bed. Sling surgery worsens TVS as it adds more scar. Vaginal skin graft is required to restore elasticity and continence.

Conclusions: "Anatomical defects in binary control may cause SUI, retention or urge," and are potentially repairable. With regard to SUI, "a normal PUL does not lengthen during effort."

Introduction: Children with spina bifida (SB) experience a reduced quality of life due to neurogenic bladder dysfunction and the risk of renal failure later in life. Pelvic floor rehabilitation (PFR) and transcutaneous electrical nerve stimulation (TENS) have gained prominence in recent years due to their positive effects in treating different types of bladder issues in both adults and children. Our study aims to investigate the effects of using these two methods together in children with SB and to delineate their potential value for clinical practice.

Materials and methods: Children with neurogenic bladder dysfunction due to SB who admitted to our spina bifida center were enrolled. Those patients, between 5 and 15 years of age, with only neurogenic detrusor overactivity (NDO) were randomly divided into two groups using an online computer application. While only the PFR was applied to Group PFR (n = 14), TENS was used in addition to this therapy in Group PFR + T (n = 14). The PFR sessions included abdominal massage, strength exercises, diaphragmatic breathing exercises, and contracting pelvic floor muscles. TENS was used in a standard fashion as previously described in patients with SB. Before and after treatment, patients' clinical data, dysfunctional voiding symptom score (DVSS), lower urinary tract symptoms, and quality of life scores due to urinary incontinence were evaluated. Urodynamic outcomes such as detrusor pressure, bladder capacity, contractility, and residual urine amount were also evaluated.

Results: Twenty eight children out of 750 SB patients were enrolled in our center. Children with only NDO due to SB were included in the study (Group PFR, mean age 8.3 ± + 2.7 years, 10 boys, four girls; Group PFR + T, 7.86 ± 2.03 years, eight boys, six girls). Treatment duration was 6 weeks (18 sessions). There was a decrease in voiding and lower urinary tract symptoms in both groups regardless of the use of TENS (p < 0.05). Maximum detrusor pressure significantly decreased only in the TENS group after treatment (from 82.143 ± 58.069 cmH2O to 58.077 ± 39.872 cmH2O) (p < 0.05). The difference in clinical parameters, quality of life scores and other urodynamic parameters were not found to be significant between groups.

Discussion: PFR and TENS may be effective in SB with NDO to reduce voiding symptoms, and protect bladder from increased pressures. PFR seems to be a useful conservative approach in patients with NDO, adjunt to standard treatment. Further studies are needed in delineation of a personalized holistic treatment approach in these patients.

Conclusion: Addition of TENS to standard PFR in NDO may be effective in reducing maximum detrusor pressures, however, it does not seem to specifically contribute for improving incontinence and incontinence-related quality of life.

Introduction: Primary bladder neck obstruction (BNO) occurs when the bladder neck fails to open during voiding, causing urinary symptoms despite no anatomic obstruction. The cause of BNO is unclear but may involve neurogenic dysregulation related to the sympathic nervous system such as upper motor neuron lesion or peripheral autonomic neuropathy (small fiber neuropathy (SFN)). Another etiology can incuded increased sympathetic tone secondary to anxiety or stress conditons. Botulinum toxin A (BoNT-A) to the bladder neck has been used in our practice to treat women with BNO who failed conventional therapies (alpha blockers, relaxation strategies). This is the first report of patient-reported outcomes after BoNT-A treatment in women with pelvic pain and BNO.

Materials and methods: We included female patients with pelvic pain and BNO who received BoNT-A to the bladder neck between January 2022 and March 2023, and mailed self-reported outcome questionnaires. The primary outcome was the Global Response Assessment (GRA); secondary outcomes included pain scores on the Visual Analogue Scale (VAS) and symptom checklists. BNO was diagnosed using Nitti Criteria (high bladder pressure, low flow in bladder neck on video urodynamics), supplemented by additional criteria (e.g., high voiding pressure, prolonged attempts, Valsalva effort, and cystoscopic evidence or symptoms related to BNO). Urodynamic studies followed International Continence Society standards. Additionally, due to BNO's association with SFN, patient history of biopsy-confirmed SFN was recorded.

Results: Our inclusion criteria was satisfied among 18 patietns, with 17 completing the questionnaire. Out of those, 14 patients (77%) reported improvement on the GRA, with an average VAS of 8.3 ("Very Helpful"). The most commonly improved symptoms were feeling of incomplete emptying, difficulty starting stream, urethral burning, pain with urination, and pelvic pain. Postoperative symptom flares were reported in six patients for an average of 16 days. All six patients with biopsy-confirmed SFN showed significant improvement (VAS 8.7). Total of 14 patients (77%) indicated they would repeat the procedure.

Conclusions: BoNT-A to the bladder neck significantly improved pelvic pain and refractory hesitancy in women with bladder neck obstruction, especially in those with small fiber neuropathy. Symptom flares are common, but did not reduce interest in repeated treatments, and scheduling injections before symptom recurrence may mitigate these flares.

Aim: Posterior tibial nerve stimulation (PTNS) might stimulate the sacral nerves and lead to work pelvic floor muscles. We evaluated to effects of PTNS on continence results after extraperitoneal laparoscopic radical prostatectomy (eLRP) with three trocars during early post operative period.

Methods: Prospectively recorded data of eLRP with three trocars was retrospectively reviewed for continence results between January 2017 and April 2024. Demographic, clinical, and follow-up data including age, prostate-specific antigen, prostate volume, nerve sparing surgery, and Gleason score were considered for match-paired analysis criteria. Patients were divided into two groups according to whether received PTNS therapy after surgery or not. Group 1 consisted of patients without PTNS (n = 66), and Group 2 consisted of patients who were applied PTNS (n = 66) after eLRP. Continence status, urine loss ratio (ULR), ICIQ-SF, and SF-12 Quality of Life Scale were recorded during outpatient control after 2nd, 3rd, 6th and 12th months of surgery. Statistically significant p was p ≤ 0.05.

Results: Mean follow-up was 25 ± 8.7 months. There were 66 patients in each group and match-paired analyses were performed. Group 2 had significant lower incontinence rate and ICIQ-SF score at second and third months follow-up (p = 0.026 and p = 0.045; p = 0.044 and p = 0.031 respectively). Group 2 had significantly higher Physical Component Summary (PCS) and Mental Component Summary (MCS) (p = 0.005 and p = 0.011 for PCS; p = 0.008 and p = 0.025 for MCS, respectively) at second and third months follow-up. Additionally, ULR was significant better in Group 2 at second and third month of surgery (p = 0.042, p = 0.037, respectively). All these parameters were comparable between groups after sixth and 12th months.

Conclusions: PTNS can be safely applied to provide early continence in patients underwent eLRP. Due to improved functional outcomes, higher quality of life might be gained in early follow-up period.