Voiding and MRI analysis of the brain

Observations of surgery, angiography and postmortem studies have indicated that the frontal lobe is a higher center important in the control of micturition. CT and MRI have made it possible to extend these early observations, and we report here the results of imaging in patients with hemispheric and brain-stem strokes. In a series of stroke patients urinary dysfunction was found in 68% with frontal lesions 20% with parietal, 14% with temporal and none with occipital lobe lesions. With lesions in the frontal lobe, it appears that medial aspects are particularly important in the prefrontal lobe, cingulate gyrus, paracentral lobule and the orbital area in micturition control. Frontal lobe disease may cause disorders of storage as well as voiding, as shown by urodynamics: detrusor hyperreflexia, detrusor areflexia, uninhibited sphincter relaxation and unrelaxing sphincter on voiding were found. We have also had the opportunity to make observations about the role of the basal ganglia and pons in micturition control in humans.

Tissue distribution of placenta-type 6-phosphofructo- 2-kinase/fructose-2,6-bisphosphatase

Several isozymes of 6-phosphofructo-2-kinase/fructose-2, 6-bisphosphatase have been characterized from mammalian tissues and, based on tissue origin, they are classified as liver, skeletal muscle, heart, testis, and placenta isozymes. In this paper, we examined the tissue distribution of placenta-type isozyme in rat tissues at the levels of transcription and translation. Analysis by Northern blotting showed that placenta, brain, testis, liver, kidney, and skeletal muscle expressed mRNA of placenta-type isozyme. Western blot analysis of fractions from POROS-HQ column chromatography of extracts from various rat tissues showed that proteins of placenta-type isozyme are expressed in placenta, brain, testis, liver, spleen, heart and lung, but not in kidney and skeletal muscle. An immunohistochemical study showed that, in liver, placenta-type isozyme is localized in Kupffer cells. These results indicate that isozymes of this particular enzyme may occur in particular cell types within each tissue.

Liposome oligomannose-coated with neoglycolipid, a new candidate for a safe adjuvant for induction of CD8+ cytotoxic T lymphocytes

The cytotoxic T lymphocyte (CTL) response has recently been shown to play a role in protection against human immunodeficiency virus (HIV) and it is therefore thought that a vaccine against HIV must be able to elicit a CTL response. The development of a safe, effective adjuvant is very important because alum, the only adjuvant available for use in humans at present, can barely induce a response of this type. We demonstrate here that liposomes that contain an immunodominant peptide (15 amino acids) of the envelope glycoprotein gp120 of HIV-1 and that are coated with mannopentaose-dipalmitoylphosphatidylethanolamine conjugate induce a major histocompatibility complex class I-restricted CD8+ CTL response in mice with a single subcutaneous immunization, whereas non-coated liposomes do not. Since no damage to the skin at the injection site was caused by the liposomes, and since the oligomannose-coated liposomes consist of innocuous materials ubiquitously distributed throughout the human body, they may be highly suitable for use as a safe adjuvant in vaccines inducing a CTL response against HIV.

Detrusor overactivity and penile erection in patients with lower lumbar spine lesions

OBJECTIVES

To investigate urodynamically detrusor overactivity and evaluate surgical outcome in patients with lower lumbar spine lesions.

METHODS

Eighty patients with spine lesions below the third lumbar spine including 31 patients with intervertebral disc prolapse (IDP) (mean age: 38.2 years) and 49 patients with spinal canal stenosis (SCS) (mean age: 56.7 years) were studied. Urinary symptoms and urodynamic data were recorded before and after orthopedic surgery.

RESULTS

Detrusor overactivity was noted in 17 patients: 3 IDP patients (10%) and 14 SCS patients (29%). Of these 17 patients (9 males and 8 females), 14 (82%) had voiding symptoms and 15 (88%) had storage symptoms. One patient was asymptomatic. Intermittent claudication was noted in 14 patients: 8 had urgency, 11 urge incontinence and 4 male patients showed erection on walking. Of 10 patients followed up after surgery, detrusor overactivity disappeared in 5 patients, improved in 1 patient and remained unchanged in 4 patients.

CONCLUSIONS

Detrusor overactivity was found in lower lumbar spine lesions. This phenomenon seemed to be caused by the irritation of sacral roots, especially on walking.

A common phosphorylation site for cyclic AMP-dependent protein kinase and protein kinase C in human placental 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase

Human placental 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase (HP2K) was phosphorylated by incubation with [gamma-32P]MgATP and cyclic AMP-dependent protein kinase (PKA) or protein kinase C (PKC). Approximately 0.8 mol of phosphate per mol subunit of HP2K was incorporated by either PKA or PKC. However, with additional incubation with PKA following incubation with PKC or vice versa, no additional phosphate was incorporated into the HP2K. The phosphorylation sites for the two protein kinases were identified by peptide mapping and microsequencing following digestion of phosphorylated-HP2K with clostripain. Evidence is also suggested for a common phosphorylation site (Ser-460) for PKA and PKC.

Efficiency of targeted gene delivery of ligand-poly-L-lysine hybrids with different crosslinks

Hybrids of a ligand protein crosslinked to a DNA binding protein have been developed as gene delivery vehicles mediated by receptors. To identify the effect of the crosslinks between the ligand and DNA binding protein on gene expression caused by an internalized hybrid-DNA complex, we prepared two kinds of transferrin-poly-L-lysine (TF-PL) hybrids: one was crosslinked by probably cleavable disulfide bonds (TF-ss-PL) and the other was linked by a probably uncleavable Schiff's base (TF-Schiff-PL). The binding affinity of the hybrids to HeLa cells was not different. However, the expression of a reporter gene (for luciferase) bound to these hybrids in HeLa cells transfected with TF-Schiff-PL was greater than that of TF-ss-PL.

Micturitional disturbance in patients with chronic inflammatory demyelinating polyneuropathy

Eight of 32 patients (25%) with chronic inflammatory demyelinating polyneuropathy (CIDP) had micturitional disturbance, which consisted of voiding difficulty (n = 4), urgency (n = 4), or urgency incontinence (n = 1). Urodynamic studies on four symptomatic patients showed disturbed bladder sensation in two, bladder areflexia in one, and neurogenic changes of the external sphincter in one, indicative of peripheral parasympathetic and somatic nerve dysfunctions. Cystometry also showed detrusor overactivity in two patients but no evidence of CNS involvement, evidence that bladder overactivity occurs by probable pelvic nerve irritation.

Stress induced urinary incontinence in patients with spinocerebellar degeneration

OBJECTIVES

To examine the pathophysiology of "stress induced urinary incontinence" (urinary incontinence evoked by abdominal straining) in patients with spinocerebellar degeneration.

METHODS

Micturitional symptoms of 184 patients with spinocerebellar degeneration who were admitted to hospital were studied repeatedly. Urodynamic studies were made in symptomatic patients, and consisted of uroflowmetry, measurement of residual urine, urethral pressure profilometry, medium fill water cystometry, and external sphincter EMG.

RESULTS

Twenty nine (15.8%) patients with spinocerebellar degeneration showed stress induced urinary incontinence. Twenty of the 29 patients had detrusor overactivity, low compliance detrusor, or residual urine, resembling urgency and overflow types of incontinence (complicated form). The other nine had none of these findings (pure form), but showed decreased maximum urethral closure pressure in four, absence of bulbocavernosus reflex in two, absence of voluntary sphincter contraction in one, incompetent urinary storage even at the first sensation in two, and high amplitude and polyphasic neurogenic changes in three of five patients studied, indicative of neurogenic sphincter dysfunction.

CONCLUSIONS

Stress induced urinary incontinence in spinocerebellar degeneration had various underlying mechanisms. Some of the patients only showed evidence of pudendal denervation, which can cause external sphincter weakness and may reflect lesions of the sacral Onuf's nucleus and the pudendal nerve. Urodynamic studies are necessary to evaluate stress induced urinary incontinence in patients with spinocerebellar degeneration, to prescribe appropriate therapies.

Micturitional disturbance in herpetic brainstem encephalitis; contribution of the pontine micturition centre

Micturitional disturbance is rarely mentioned in human herpetic brainstem encephalitis although the pontine tegmentum, called the pontine micturition centre, seems to regulate the lower urinary tract in experimental animals. The case of a 45 year old man, who developed subacute coma and hiccup-like dysrhythmic breathing, and needed assisted ventilation is reported. Examination of CSF showed mononuclear pleocytosis and antibody against herpes simplex virus type 1, but the opening pressure was 90 cm H2O. Brain CT showed brain swelling, predominantly in the posterior fossa, and bilateral subdural effusion. Herpetic brainstem encephalitis was diagnosed, and he received 900 mg/day vidarabine. On regaining consciousness, he had left trochlear nerve palsy, left corectopia, ageusia, and urinary retention. Brain MRI showed right side dominant, bilateral pontine segmental lesions extending slightly to the midbrain and medulla. After two weeks he was able to urinate but showed nocturnal urinary frequency, urinary incontinence, and voiding difficulty. Urodynamic studies showed a residual urine volume of 350 ml and detrusor hyporeflexia on voiding. Micturitional disturbance gradually disappeared together with the neurological signs. The bilateral pontine tegmental lesions in this patient are similar to those in previous findings on brainstem strokes, evidence of the presence of a pontine micturition centre in humans.

Expression of human placental-type 6-phosphofructo-2-kinase/fructose 2,6-bisphosphatase in various cells and cell lines

The expression of the human placental-type 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase (HP2K) in various human cells and cell lines was investigated at the levels of transcription and translation. Analyses by both Northern blotting and a reverse transcription-polymerase chain reaction (RT-PCR) showed that BeWo, U-937, SupT1, H9, HeLa, HepG2, and human mononuclear cells, as well as human placental chorionic cells, expressed HP2K mRNA. All the nucleotide sequences of RT-PCR products from these cell lines were identical to that of HP2K. The expression of HP2K protein was determined by Western blot analysis of fractions from POROS-HQ column chromatography of the cell extracts from U-937 cells, which was used as an example of HP2K-mRNA positive cell lines. As with the 6-phosphofructo-2-kinase activity of HP2K, the activity of 6-phosphofructo-2-kinase in extracts of U-937 cells was not inhibited by glycerol 3-phosphate, a known 6-phosphofructo-2-kinase inhibitor of liver- and testis-type isozymes. These results strongly suggested that various cell lines, in particular U-937 cells, express functional HP2K enzyme. Furthermore, 6-phosphofructo-2-kinase in U-937 cells was found to be activated by treatments with isoproterenol and phorbol 12-myristate 13-acetate, indicating regulation of 6-phosphofructo-2-kinase activity in U-937 cells by protein kinases A and C.

Pelvic floor electrical stimulation in the treatment of stress incontinence: an investigational study and a placebo controlled double-blind trial

PURPOSE

We designed an investigational study and a placebo controlled, double-blind study to evaluate the usefulness of electrical pelvic stimulation in stress incontinence.

MATERIALS AND METHODS

We studied 44 patients with stress incontinence (six men and 38 women, age 63 +/- 13), including 9 patients in the investigational study and 35 in the double-blind study. We used 50 Hz. square waves of 1 ms. pulse duration for stimulation. A vaginal electrode was used in women and an anal electrode in men. Urethral pressure profile before, during and after 15-minute stimulation was measured in the investigational study. In the double-blind trial an active device and a dummy device were used, and efficacy was judged from patient impressions, records in frequency/volume chart, results of 1-hour pad test and urodynamic parameters after 4-week treatment.

RESULTS

In the investigational study maximum urethral closure pressure (mean plus or minus standard deviation) before, during and after stimulation was 44.4 +/- 17.5, 64.5 +/- 28.8 and 46.8 +/- 25.6 cm. water, respectively. This parameter significantly increased (p = 0.0275) during stimulation. In the double-blind trial patient impressions were good in 60% of the active device group and 8% of the dummy device group (p = 0.0051). For the pad test significant improvement was noted in the active device group (p = 0.0100). Cure rate was 45% in the active device group and 7.7% in the dummy device group. There were significantly more cured or improved patients for frequency of leakage (p = 0.0196) and pad test (p = 0.0100).

CONCLUSIONS

Electrical stimulation is effective for the treatment of stress incontinence.

Effect of replacement of the amino and the carboxyl termini of rat testis fructose 6-phosphate, 2-kinase:fructose 2,6-bisphosphatase with those of the liver and heart isozymes

Fru 6-P,2-kinase:Fru 2,6-Pase is a bifunctional enzyme, consisting of highly conserved catalytic domains and variable regulatory domains. The regulatory domains reside in either the N- or the C-terminus, depending upon the isozyme. The rat testis enzyme (RT2K) lacks the regulatory domain, but the rat liver and the bovine heart enzymes contain phosphorylation site(s) in the N- and the C-termini, respectively. In order to determine whether the regulatory domains can be swapped, we have constructed mutant enzymes in which the N- or the C-terminal tail of the testis enzyme was replaced with that of either the liver or the heart enzyme. The substitution with the N-terminus of the liver enzyme (RLN-RT2K) resulted in a small change in the kinetic properties of Fru 6-P,2-kinase, but that with the heart enzyme increased the KFru 6-P 18-fold without affecting the Vmax. The substitution with the C-terminus of the heart enzyme had little effect. The phosphorylation of RLN-RT2K increased KFru 6-P fivefold as in the liver enzyme but did not affect the Fru 2,6-Pase, unlike the liver enzyme. All these mutant enzymes were more thermally labile than the wild type testis enzyme. RLN-RT2K was more sensitive to the denaturant. These results suggest that the N-terminus of the liver enzyme could interact with the kinase domain of the testis enzyme, regulating the kinase activity but was unable to affect the phosphatase domain. These differences could be explained by the large differences in net charges of the terminal tails.

Human placental fructose-6-phosphate,2-kinase/fructose-2,6-bisphosphatase: its isozymic form, expression and characterization

The nucleotide sequence of 1981 bp cDNA containing the entire coding region of a human placental fructose-6-phosphate,2-kinase/fructose-2,6-bisphosphatase was determined. The sequence encodes 469 amino acids and, based on homology to the rat testis enzyme, appears to be the testis-type isozyme expressed in placenta. The enzyme was expressed in Escherichia coli BL21 (DE3) by using a T7 RNA polymerase-based expression system and purified to homogeneity. The expressed enzyme was bifunctional with specific activities of 75 and 80 mU/mg of kinase and phosphatase, respectively. Kinetic parameters of the expressed enzyme are similar to those of the rat testis enzyme.

Micturitional disturbance in patients with Guillain-Barré syndrome

OBJECTIVES

To examine the frequency and pathophysiology of micturitional disturbance in patients with Guillain-Barré syndrome.

METHODS

Micturitional symptoms were noted and neurological examinations made repeatedly during admission to hospital of patients with clinical and neurophysiologically definite Guillain-Barré syndrome. Urodynamic studies consisted of uroflowmetry, measurement of residual urine, urethral pressure profilometry, medium fill water cystometry, and external sphincter EMG.

RESULTS

Seven of 28 (25%) patients with Guillain-Barré syndrome showed micturitional disturbance. The symptoms included voiding difficulty in six, urinary retention in three, nocturnal urinary frequency in three, and urge incontinence in two. These micturitional symptoms appeared after weakness occurred, and improved gradually along with the neurological signs. All three patients who showed retention became able to urinate. Urodynamic studies were made on four symptomatic patients two of whom underwent repeated study. Disturbed bladder sensation was noted in one patient, bladder areflexia in one, and absence of the bulbocavernosus reflex in one. Cystometry showed decreased bladder volume in two and bladder overactivity in two, one of whom had urge urinary incontinence and the other urinary retention.

CONCLUSIONS

A quarter of the patients with Guillain-Barré syndrome tend to have micturitional disturbance. The patients studied had evacuation and storage disorders, as well as bladder areflexia and disturbed bladder sensation indicative of peripheral types of parasympathetic and somatic nerve dysfunction. Decreased bladder volume with bladder overactivity but no evidence of CNS involvement was also found, evidence that bladder overactivity also occurs in peripheral nerve lesions with probable pelvic nerve irritation.

The nature of detrusor bladder neck dyssynergia in non-neurogenic bladder dysfunction

There have been two major opinions on the pathology or nature of the bladder neck contracture. One is an organic fibrosis, and the other is an accentuated sympathetic nervous function, or detrusor bladder neck dyssynergia. The existence of active detrusor bladder neck dyssynergia in neurogenic bladder was reported in a urodynamical manner using microtip transducer catheters. However, it has not been confirmed whether or not detrusor bladder neck dyssynergia is responsible for bladder neck contracture in patient without neurogenic bladder. The present study was designed to determine by means of video urodynamic study whether or not bladder neck contracture would be of the same nature as detrusor bladder neck dyssynergia in non-neurogenic bladder subjects. The study included 32 male subjects of 16-84 years old (average 52.3): 17 bladder neck contracture subjects including 7 subjects associated with minimum complications (4 with trapped benign prostatic hyperplasia and 3 with incomplete neurological lesion) and 15 non-bladder neck contracture subjects (10 healthy volunteers, 2 chronic prostatitis, 3 prostatodynia). A 5-microtip transducer catheter was used to measure the pressure in the bladder and at the bladder neck, the external urethral sphincter and the bulbous urethra during voiding. Proper localization of the transducers was done with an image intensifier. Bladder outlet obstruction localized at the bladder neck (diameters smaller than 0.75 cm) on voiding cystourethrogram was defined as bladder neck contracture. Detrusor bladder neck dyssynergia was defined where pressures were higher at the level of bladder neck than in the bladder during detrusor contraction. An alpha-blocker, terazosin hydrochloride (0.5 mg, b.i.d., two weeks), was orally administered to subjects judged to have detrusor bladder neck dyssynergia by the above methods for the purpose of confirming whether detrusor bladder neck dyssynergia was really due to accentuated sympathetic nervous function. Detrusor bladder neck dyssynergia was found in seven cases with bladder neck contracture: 6 cases with bladder neck contracture with minimum complications and only 1 case with bladder neck contracture without complications (p < 0.01). Detrusor bladder neck dyssynergia was found at the beginning and ending of micturition, but not at maximum flow. In six cases with detrusor bladder neck dyssynergia, the condition disappeared after terazosin. In conclusion, detrusor bladder neck dyssynergia was not thought to be a major factor of voiding dysfunction in bladder neck contracture in non-neurogenic bladder. In the presence of sympathetic hyperactivity or in cases with increased number of alphareceptors, detrusor bladder neck dyssynergia occurs, being predominantly noted in trapped benign prostatic hyperplasia and neurological disorder patients.

Urodynamic and cardiovascular measurements in patients with micturition syncope

We describe the findings of urodynamic studies, together with blood pressure and heart rate monitoring, in five patients with micturition syncope. All patients had almost normal storage and evacuation function and no evidence of prostate hypertrophy. Conventional head-up tilt testing with an empty urinary bladder caused no change in arterial blood pressure, but a moderate increase in heart rate. Urinary bladder filling caused minimal increases of the arterial pressure and heart rate. The sitting posture with a distended bladder caused mild orthostatic hypotension. Urinary bladder evacuation caused a fall in arterial pressure with a decrease in heart rate. These responses were similar to those described in vasovagal syncope. The central mechanism for the initiation of urinary evacuation, or sensory input from the lower urinary tract, may trigger micturition syncope.

Characterization of a human placental fructose-6-phosphate, 2-kinase/fructose-2,6-bisphosphatase

A full-length cDNA, which encodes a human placental fructose-6-phosphate,2-kinase/ fructose-2,6-bisphosphatase, was constructed and expressed in Escherichia coli. The expressed protein, purified to homogeneity, showed a molecular weight of 58,000 by gel electrophoresis under denaturing conditions, compared to the deduced molecular weight of 59,410. The N-terminal sequence of 15 amino acids coincided with that of the deduced sequence. The active enzyme was a dimer as judged by molecular sieve filtration. The expressed enzyme was bifunctional with Vmax values of 142 and 0.2 milliunits/mg for the kinase and phosphatase activities, respectively. The phosphatase activity was extremely low, because one phosphatase active site residue was mutated, and consequently the kinase/phosphatase ratio was the highest among the known isozymes. Furthermore, the enzyme was phosphorylated by cAMP-dependent protein kinase, protein kinase C and also by [2-32P]fructose-2,6-bisphosphate. Phosphorylation by cAMP-dependent protein kinase and protein kinase C increased the maximal Fru-6-P,2-kinase activities by 1.8- and 1.1-fold, respectively. These results suggested that placental fructose-6-phosphate,2-kinase/ fructose-2,6-bisphosphatase is important in maintaining and regulating a relatively high rate of glycolysis in placenta.

Orthostatic hypotension in a case with multiple sclerosis

A 37-year-old woman with a 5-year history of multiple sclerosis is reported. She began having recurrent syncope even in the sitting position; other neurological features included hiccup, faciooro-lingual flushing and clumsiness of the hands. She had alternating Horner's syndrome, mild hypoalgesia of the right face, exaggerated deep tendon reflexes of the upper extremities, decreased deep sensation and ataxia of the upper extremities, and incomplete transverse myelopathy with a T4 sensory level. Head-up tilt testing confirmed orthostatic hypotension with relative preservation of the heart rate increase. Magnetic resonance imaging indicated abnormal intensities in the paramedian tegmentum and base of the medulla, which may have been additionally responsible for orthostatic hypotension. Steroid pulse therapy and L-threo-3,4-dihydroxyphenylserine caused regression of brainstem signs and reduced syncopal attacks.

Chronic intractable headache in a patient with Marfan's syndrome

A 30-year-old woman with Marfan's syndrome had chronic intractable headaches and spontaneous intracranial hypotension. The pain was concentrated over the occipitonuchal region, had elements of both migraine and tension headache, and was often aggravated by postural change. Myelography showed multiple, large, lumbosacral arachnoid diverticula. Radioisotope cisternography revealed a halolike accumulation in the lumbosacral region and rapid uptake of isotope in the urinary bladder, indicating cerebrospinal fluid leakage. Epidural blood patching brought immediate relief from the positional headaches. We concluded that patients with Marfan's syndrome and undifferentiated chronic headaches should be radiologically evaluated for spinal meningeal defects.

Inhibition of fructose-6-phosphate,2-kinase by N-bromoacetylethanolamine phosphate in vitro and in vivo

Fructose-6-phosphate,2-kinase/fructose-2,6-bisphosphatase (Fru-6-P,2-kinase/Fru-2,6-BPase), a bifunctional enzyme, catalyzes the synthesis and degradation of a potent activator, fructose-2,6-bisphosphate (Fru-2,6-P2), of phosphofructokinase, and has been postulated to be an important enzyme in the regulation of glycolysis in mammalian tissues. The purpose of this study was to determine whether or not N-bromoacetylethanolamine phosphate (BrAcNHEtOP), a specific active site-directed inactivator of Fru-6-P,2-kinase, is useful for studies on the role of Fru-6-P,2-kinase in the regulation of glycolysis in vivo. BrAcNHEtOP inactivated purified recombinant rat testis-type Fru-6-P,2-kinase as well as Fru-6-P,2-kinase in a rat liver extract, with half maximum inactivation concentrations of 2 and 15 mM, respectively, on 30 min incubation at 30 degrees C. The increases in Fru-6-P,2-kinase activity and the Fru-2,6-P2 concentration in livers, prepared from fasted rats, induced by high glucose (50 mM) perfusion were suppressed in parallel after pre-perfusion with 1 to 10 mM BrAcNHEtOP, dose-dependently. Five hours after intraperitoneal injection of BrAcNHEtOP (50 to 150 mg/kg) into mice, the Fru-6-P,2-kinase activity and Fru-2,6-P2 concentration in livers had decreased in parallel, dose-dependently. These effects continued for 24 h and were accompanied by decreases in the fructose-1,6-bisphosphate, triose phosphates, and lactate contents, although the contents of glucose-6-phosphate and fructose-6-phosphate did not change. These results suggested that BrAcNHEtOP inactivates Fru-6-P, 2-kinase, resulting in a decrease in the Fru-2,6-P2 level, which causes inactivation of phosphofructokinase and consequently inhibition of glycolysis in liver. Furthermore, the suppressed levels of Fru-6-P,2-kinase activity and metabolites in mice livers were sustained by daily injection of BrAcNHEtOP for 4 days, and body weight gain was also suppressed during the administration of BrAcNHEtOP. These results suggested that BrAcNHEtOP will be a useful reagent for studying the role of Fru-6-P,2-kinase in vivo.

Micturitional disturbance in syringomyelia

Micturitional histories and urodynamic studies were performed in 14 patients with syringomyelia. Eleven patients were revealed to have urinary symptoms including difficulty of voiding in 8, urinary retention in 3, nocturnal and diurnal urinary frequency in 3, urinary incontinence in 2, and sense of urgency and enuresis in one. These urinary symptoms appeared after 5.3 years (ranging from 2 months to 13 years) from the occurrence of the neurological symptoms. Urodynamic studies revealed detrusor hyperreflexia in 7, detrusor areflexia in 4, detrusor-sphincter dyssynergia in 4 and uninhibited sphincter relaxation in 2 patients. Analysis of the motor unit potentials of the external sphincter revealed 5 of 6 patients had high amplitude or polyphasic neurogenic changes. Supranuclear as well as nuclear types of parasympathetic and somatic nerve dysfunctions seemed to be responsible for micturitional disturbance in our patients with syringomyelia. During the follow-up period of 2 to 63 months, urinary symptoms gradually improved in 4 of 6 patients after syringosubarachnoid shunts and in 3 of 4 after alpha-adrenoreceptor blocking agents.

Micturitional disturbance and the pontine tegmental lesion: urodynamic and MRI analyses of vascular cases

Micturitional histories were taken from 39 patients with acute brainstem stroke. Within 3 months from onset, 49% had irritative as well as obstructive urinary symptoms, the most common being voiding difficulty and nocturnal urinary frequency in 28%, followed by urinary retention in 21%. Urodynamic studies of 11 symptomatic patients revealed detrusor hyperreflexia in 73%, low compliance bladder in 9%, atonic cystometrogram in 27%, detrusor-sphincter dyssynergia in 45% and uninhibited sphincter relaxation in 27%. Three asymptomatic patients had normal urodynamic findings. Brain magnetic resonance images of the lesions of the symptomatic patients were concentrated in the dorsolateral pons including pontine reticular nucleus and the reticular formation adjacent to the medial parabrachial nucleus and the locus coeruleus. These regions seem to be mainly responsible for supranuclear types of pelvic and pudendal nerve dysfunction in our patients with brainstem stroke, corresponding to the pontine urinary storage and micturation center reported in animal studies.

Micturitional disturbance in acute disseminated encephalomyelitis (ADEM)

In eleven patients with acute disseminated encephalomyelitis (ADEM), micturitional histories taken during the acute stage revealed that nine were in a state of urinary retention, and the other two had urinary frequency and urge incontinence together with difficulty in voiding. After the follow-up period of 3 to 38 months seven of nine patients with retention became able to urinate, but five of them had difficulty in voiding and four of them developed urinary frequency or urge incontinence. Two patients had urinary retention even after 26 and 38 months from the onset. Ten patients underwent urodynamic studies and disclosed detrusor hyperreflexia in six, low compliance bladder in two, atonic cystometrogram in one and detrusor-sphincter dyssynergia in two patients. Motor unit analysis of the external sphincter revealed polyphasic neurogenic changes is one of four patients. The results were compared with our previous findings in multiple sclerosis (MS), and we found that micturitional disturbance in ADEM seemed to be as common and as severe as in MS. Supranuclear as well as nuclear types of pelvic and pudendal nerve dysfunction seemed to be responsible for micturitional disturbance in our patients with ADEM. Micturitional disturbance seemed to be related to the pyramidal tract involvement, and probably reflecting the severity of spinal cord lesions.