Neurourology and Urodynamics最新文献

Context: Improved continence outcomes are reliant on identification of unmet need, education delivery, and shared decision-making. The evidence base on which to derive innovative approaches in these areas was unclear.

Methods: A debate held at the International Consultation on Incontinence-Research Society meeting, held in Bristol in June 2024, considered ways to improve research requirements to advance these areas.

Results and conclusion: Artificial intelligence solutions and digital approaches to healthcare are emerging at pace and offer possibilities to improve these three key areas but this must be driven by person-centered approaches. Care must be taken to avoid increasing inequality through digital exclusion and language barriers. Research questions are highlighted to derive innovation in these three key areas.

Introduction: There is an increasing recognition of the impact of ageing on pelvic floor health and the consequences in populations with rising proportions of women over the age of 65 years. A think tank was held at the ICI-RS 2024 to discuss the evidence to support the personalisation of women's pelvic floor health during the perinatal and perimenopausal period.

Methods: Data was collected and presented on the evidence to support the development of tools to personalise pelvic floor health care. Epidemiological, imaging, patient-reported outcomes, and evidence of tool development questionnaires were discussed. The current evidence and research gaps for potential intervention to prevent the pelvic floor disorders of pelvic organ prolapse, overactive bladder, urinary incontinence and faecal incontinence during the perinatal and perimenopasual time periods were discussed and identified.

Results: Epidemiological studies highlight that vaginal delivery and in particular operative vaginal delivery is the single biggest modifiable risk factor for the future development of pelvic floor dysfunction. The oestrogen depletion resulting from the perimenopause and menopause can lead to the development of Genitourinary syndrome of menopause (GSM) which is associated with the risk of developing pelvic floor dysfunction. Ultrasound is a useful technique for assessing the pelvic floor and has been used to assess bladder neck mobility, distensibility of the puborectalis muscle and the striated urethral sphincter volume antenatally with some studies reporting a correlation between these measurements and the need for Caesarean section and development of postpartum stress urinary incontinence. Further studies are needed to standardise these measurements. There are no patient reported outcome questionnaires validated for use in the perinatal and postmenopausal period. The UR- choice tool has been developed to counsel women on the risk of postpartum pelvic floor disorders occurring. However, further evaluation in larger numbers is required.

Conclusion: There is significant interest in developing tools to counsel women on the risks of developing pelvic floor dysfunction post partum and after the menopause. Further evaluation of the UR-choice tool was considered a research priority. The timepoint of cervical screening for research into interventions such as pelvic floor health education, lifestyle optimisation and perimenopausal vaginal oestrogen supplementation was identified.

Aims: To answer the question of whether the bladder itself can to any extent control or modulate the initiation of voiding.

Methods: This subject was discussed at the International Consultation on Incontinence-Research Society (ICI-RS) 2024 conference in Bristol, UK in a proposal session.

Results: Cells in the bladder wall sense the local environment via a diverse array of ion channels and receptors which together provide input to motor-sensory and signal transduction mechanisms. A purinergic signal transduction system provides a high-gain mucosal chemosensitive transduction pathway between bladder wall stretch during filling and graded afferent activation. Recent studies established cross-species similarities in the regulation of urine storage which include the upregulation of aquaporin (water) channels during bladder filling/wall stretch, in the bladder. In addition to the endocrine hypothalamus/pituitary axis production, urothelial production of arginine vasopressin acts on urothelial vasopressin receptors in a paracrine manner causing aquaporin channel upregulation, reducing the bladder volume and delaying sensation of fullness. Bladder shape influences the sensory systems involved in the perception of bladder volume; moreover irregular bladder shapes may correlate with overactive bladder.

Conclusions: Volume measuring and signaling threshold-determining mechanisms in the bladder along with shape and permeability act to influence the timing and type of signaling to the CNS; although this is not always followed by a consecutive action. The hierarchical grading of the signals originating from the bladder among other peripheral bodily or central signals are crucial factors that determine whether the bladder is "allowed" to initiate voiding.

Aims: To discuss the role of screening and treatment of affective symptoms, like anxiety and depression in patients with LUTD. A review of the literature regarding the bidirectional association and multidisciplinary approaches integrating psychometric assessments with personalized treatment plans to improve diagnostic accuracy and therapeutic outcomes of LUTD.

Methods: This review summarizes discussions and a narrative review of (recent) literature during an International Consultation on Incontinence-Research Society 2024 research proposal with respect to the role of screening for anxiety and depression, effect of mental health symptoms on treatment outcomes and future implications.

Results: Consensus recognized the importance to incorporate attention to anxiety and depression in relation to LUTD. The awareness of this association can lead to better outcomes. Future research projects are proposed to evaluate the bidirectional relationship.

Conclusion: The relationship between affective symptoms and LUTD underscores the need for integrated treatment approaches that address both psychological and urological dimensions. Further research is required to identify specific patient subgroups that would benefit most from these interventions, to develop standardized screening tools, and to refine treatment protocols. Multidisciplinary care, incorporating psychological assessment and personalized treatment strategies, could enhance outcomes for LUTD patients.

Aims: After presentation with urinary symptoms, an underlying neurological mechanism sometimes emerges subsequently. Increased awareness may bring earlier diagnosis, improving prognosis and outcomes.

Methods: A 2024 International Consultation on Incontinence Research Society think-tank considered the clinical pathway for identification of an undiagnosed neurological or autonomic contribution precipitating urinary symptoms, and the implications for prognosis.

Results: Alongside adult-onset neurogenic conditions, potential for missed diagnosis includes congenital and pediatric-acquired neurogenic conditions, which may become symptomatic during a growth spurt due to spinal cord tethering. Detailed assessment is needed, also considering bowel and sexual dysfunction, with timely referral to neurology to reduce preventable progression of disease. In neurological assessment, control of micturition is often poorly characterized compared with other aspects of spinal cord function and the cranial nerves. Screening tools may be used to identify people who have increased likelihood of particular conditions, but currently available tools are either single-system or population specific. In addition to the general pelvic examination, the assessment of sacral reflexes and pelvic sensations can suggest a neurological mechanism, though the sensitivity and specificity of the neuro-urological examination is unknown. Including the results of the neuro-perineal examination in the urodynamic report may improve the interpretation of the results and potentially support a neurological aetiology.

Conclusion: Future research should consider the value of neuro-urological examination in diagnosis of occult neurological disease, the development of an occult neurology screening tool/risk scoring based on pelvic organ symptoms, and appropriateness of non-neurologist practitioners requesting neurological investigations such as MRI scanning.

Clinical trial registration: Does not apply.

Introduction: Pelvic organ prolapse (POP) is a common condition, affecting women worldwide and is known to have a significant impact on Health Related Quality of Life (HRQoL). Although there are various treatment options available, including pelvic floor muscle training and support pessaries, many women opt for or require surgery, with a lifetime risk of needing surgery of 12%-19%. As with any operation, this does not come without its complications and the reoperation rate following POP surgery is up to 36%. This International Consultation on Incontinence-Research Society (ICI-RS) report aims to look at the different factors which may play a role in objective and subjective outcomes following pelvic floor surgery and to summarize the evidence and uncertainties regarding prediction of POP surgical outcomes, how to optimize them and the tools available to predict them. Research question proposals to further this field have been highlighted.

Methods: At ICI-RS 2024, the evidence for predicting the outcomes from POP surgery and methods to optimize outcomes were discussed and presented in this paper.

Results: There are many reasons why POP surgery may fail, such as variations in lifestyle and occupation, persistent constipation, failure in the perineal body, connective tissue types or the shape of the pelvis. There may also be inherent conditions of the vagina, such as hormonal or microbial features. The literature lacks evidence about the potential use of advanced statistical modeling or supervised machine learning in the development of management plans for patients with POP. Furthermore, future research is needed to determine the role of UDS in the preoperative evaluation of POP patients.

Conclusions: High-quality powered studies are required to assess optimization for long-term outcomes of pelvic surgery and then, once these are well established, and possible interventions are elucidated, prediction modeling can have a real impact clinically.

Introduction: Detrusor muscle weakness is commonly noted on urodynamics in patients with refractory voiding difficulty. No clinical therapy has been proven to augment the strength of a detrusor contraction.

Methods: This subject was discussed at a think-tank at the International Consultation on Incontinence-Research Society (ICI-RS) held in Bristol, June 2024. The discussions of the think-tank are being published in two parts. This second part discusses the role of electrical stimulation therapies, treatment of bladder outlet obstruction, constipation, and pelvic floor disorders, in the enhancement of strength of a detrusor contraction.

Results: Electrical stimulation therapies, specifically sacral neuromodulation, have long been used in the salvage of patients with refractory nonobstructive voiding dysfunction. Clinical improvements can be noted in men following bladder outlet resistance reduction surgery especially, though not limited to those with demonstrable obstruction. Some patients may also show improvement with pelvic floor relaxation therapies and constipation care. However, there is a lack of high-quality urodynamic data to demonstrate an improvement in the strength of a detrusor contraction with these therapies. The think-tank recommends standards for future clinical studies examining treatments aimed at improving an underactive detrusor.

Conclusions: Studies need to examine whether clinical improvement following treatment of patients with an underactive detrusor is associated with improvement in strength of the detrusor contraction. New therapeutic options should apply specified standards for assessing and reporting the impact on detrusor contraction.

Aims: The goal of this study is to better understand the mechanisms and phenotypes of urinary urgency through the analysis of voiding patterns of clinical patients recorded in their bladder diaries.

Methods: A recently introduced, powerful dynamic analysis approach was used to analyze bladder diaries of a heterogeneous cohort of 227 patients treated in a single clinical practice. Individual voiding patterns were examined by performing intra-subject correlation analyzes of bladder diary variables and creating multivariable linear regression models. Individuals were clustered based on the characteristics of their voiding patterns.

Results: Five clusters of patients were identified based on their voiding patterns. Strong intra-subject correlations between bladder filling rate and urinary urge growth rate were demonstrated, indicating that bladder filling rate was the main driver of urinary frequency and of the intensity of the urge to void in most of the patients in each of the five clusters and in the whole heterogeneous clinical cohort.

Conclusions: Bladder filling rate was shown to be a driver of urinary urgency and frequency. Further studies are needed to explore the causes of the peaks of bladder filling rate and of the most beneficial behavioral modifications and treatments to reduce them, and therefore to minimize urinary urgency and frequency.

BACKGROUND : Adverse childhood experiences (ACE) are associated with later psychological and somatic problems, including the emotional sequelae of adverse events (depression, anxiety, and catastrophizing) and outcomes such as chronic pain intensity and pain-related functioning. ACE have rarely been studied in women with pelvic, urogenital, and/or bladder pain (PUBP).

Aims: Thus, we examined how childhood adversities are related to psychological and pain-related outcomes in adult women. We also tested whether negative affect and pain catastrophizing mediated the relationship between ACE and pain-related outcomes.

Methods: A consecutive series of 310 adult women who presented at a tertiary urology center and reported PUBP completed an intake packet, which included the ACE Questionnaire as well as measures of psychological mediators and pain-related outcomes.

Results: Elevated ACEs were significantly associated with higher pain interference and vaginal insertion pain, as well as significantly related to negative affect (depression and anxiety) and pain catastrophizing. Both negative affect and pain catastrophizing were found to mediate the relationship of ACE to pain intensity and interference; however, only pain catastrophizing mediated the relationship between ACE and vaginal insertion pain.

Conclusions: These results suggest that ACEs may impact some pain-related outcomes in women with PUBP by influencing negative affect and pain catastrophizing. Thus, these processes are important targets for intervention in individuals with PUBP and a history of adverse childhood events.

Trial registration: This study does not require a clinical trial registration because it is not a clinical trial.