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Evangelista RR, Silva Lopes B, Coutinho D, Moreira E, Silva A, Almeida PL, Ermida V, Caldas J, Gomes A, Carmezim I, Barreira V, Pinheiro-Guedes L. Subacute stroke: new-onset poststroke bladder and bowel dysfunctions and possible associated factors. Disabil Rehabil 2024; 46:1073-1081. [PMID: 36960634 DOI: 10.1080/09638288.2023.2189317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/04/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Bladder and bowel poststroke dysfunctions negatively impact patients' health. Stroke-related characteristics associated to these dysfunctions are poorly known. This study aims to estimate the prevalence of new-onset poststroke bladder and bowel dysfunctions, characterize their associated factors, and describe the dysfunctions' clinical approach. MATERIALS AND METHODS Cross-sectional study including 157 patients admitted to a single hospital's stroke unit with a first-ever stroke, during 3 months. An 18-item questionnaire was applied to assess dysfunctions pre and poststroke. The McNemar test was used to compare pre and poststroke prevalence. A logistic regression was used to estimate associations (OR, 95% CI) between individual characteristics and new-onset dysfunctions. RESULTS We had 113 (72%) respondents. There was a significant increase in the prevalence of bladder and bowel dysfunctions poststroke (p < 0.001). Higher stroke severity was significantly associated with both new-onset poststroke bladder and bowel dysfunctions (OR = 15.00, 95% CI [4.92,45.76] and OR = 5.87,95%CI [2.14,16.12], respectively). Total anterior circulation strokes, cardioembolic strokes, and lower functionality at discharge were also significantly associated with both dysfunctions. Thirteen patients (11.5%) reported that health professionals addressed these dysfunctions. CONCLUSIONS Poststroke bladder and bowel dysfunctions are highly prevalent. Being aware of their epidemiology helps draw attention to patients at higher risk of developing these dysfunctions, enhancing the rehabilitation process.IMPLICATIONS FOR REHABILITATIONPoststroke bladder and bowel dysfunctions are highly prevalent and under-recognised consequences of stroke.Being aware of their epidemiology and associated factors may help identify patients at higher risk of developing these dysfunctions.It is necessary to raise clinical awareness to ensure a more efficient diagnostic and therapeutic approach, enhancing patients' rehabilitation process, quality of life and lowering collateral societal burden.
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Affiliation(s)
| | - Bruno Silva Lopes
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - David Coutinho
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Elisa Moreira
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Andreia Silva
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Pedro Leonel Almeida
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Vera Ermida
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Jorge Caldas
- Department of Physical Medicine and Rehabilitation, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Ana Gomes
- Department of Internal Medicine, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Ilídia Carmezim
- Department of Internal Medicine, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Viviana Barreira
- General Practice and Family Medicine, USF Horizonte, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
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Gordon C, Davidson CE, Roffe C, Clegg A, Booth J, Lightbody CE, Harris C, Sohani A, Watkins C. Evaluating methods of detecting and determining the type of urinary incontinence in adults after stroke: A systematic review. Neurourol Urodyn 2024; 43:364-381. [PMID: 38078643 DOI: 10.1002/nau.25330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Urinary incontinence (UI) affects over half of people with stroke. It is unclear which methods are accurate in assessing presence and type of UI to inform clinical management. Diagnosis of UI based on inaccurate methods may lead to unnecessary interventions. The aims of this systematic review were to identify, for adults with stroke, clinically accurate methods to determine the presence of UI and type of UI. METHOD We searched seven electronic databases and additional conference proceedings. To be included, studies had to be primary research comparing two or more methods, or use a reference test. RESULTS We identified 3846 studies with eight eligible for inclusion. We identified 11 assessment methods within the eight studies. Only five studies had sufficient comparator data for synthesis. Due to heterogeneity of data, results on the following methods were narratively synthesized: Core Lower Urinary Tract Symptom Score (CLSS), clinical history and physical examination, Barthel Activities of Daily Living Index, International Consultation Incontinence Questionnaire Short Form (ICiQ-SF) and urodynamic studies (UDS). Most studies were small and of low to medium quality. All reported differences in sensitivity, and none compared the same assessment methods. CONCLUSION Current evidence is insufficient to support recommendations on the most accurate UI assessment for adults with stroke. Further research is needed.
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Affiliation(s)
- Clare Gordon
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
- Stroke Service, Department of Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Christine Roffe
- School of Medicine and Neurosciences, Keele University, Stoke-on-Trent, UK
- Stroke Service, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Andrew Clegg
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Joanne Booth
- Institute for Applied Health Research, School of Halth and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Catherine Harris
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Amin Sohani
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Caroline Watkins
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
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Arsava EM, Chang K, Tawakol A, Loggia ML, Goldstein JN, Brown J, Park KY, Singhal AB, Kalpathy-Cramer J, Sorensen AG, Rosen BR, Samuels MA, Ay H. Stroke-Related Visceral Alterations: A Voxel-Based Neuroanatomic Localization Study. Ann Neurol 2023; 94:1155-1163. [PMID: 37642641 PMCID: PMC10841239 DOI: 10.1002/ana.26785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Functional and morphologic changes in extracranial organs can occur after acute brain injury. The neuroanatomic correlates of such changes are not fully known. Herein, we tested the hypothesis that brain infarcts are associated with cardiac and systemic abnormalities (CSAs) in a regionally specific manner. METHODS We generated voxelwise p value maps of brain infarcts for poststroke plasma cardiac troponin T (cTnT) elevation, QTc prolongation, in-hospital infection, and acute stress hyperglycemia (ASH) in 1,208 acute ischemic stroke patients prospectively recruited into the Heart-Brain Interactions Study. We examined the relationship between infarct location and CSAs using a permutation-based approach and identified clusters of contiguous voxels associated with p < 0.05. RESULTS cTnT elevation not attributable to a known cardiac reason was detected in 5.5%, QTc prolongation in the absence of a known provoker in 21.2%, ASH in 33.9%, and poststroke infection in 13.6%. We identified significant, spatially segregated voxel clusters for each CSA. The clusters for troponin elevation and QTc prolongation mapped to the right hemisphere. There were 3 clusters for ASH, the largest of which was in the left hemisphere. We found 2 clusters for poststroke infection, one associated with pneumonia in the left and one with urinary tract infection in the right hemisphere. The relationship between infarct location and CSAs persisted after adjusting for infarct volume. INTERPRETATION Our results show that there are discrete regions of brain infarcts associated with CSAs. This information could be used to bootstrap toward new markers for better differentiation between neurogenic and non-neurogenic mechanisms of poststroke CSAs. ANN NEUROL 2023;94:1155-1163.
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Affiliation(s)
- Ethem Murat Arsava
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Ken Chang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmed Tawakol
- Cardiology Division and Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston MA, USA
| | - Marco L. Loggia
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - James Brown
- School of Computer Science, University of Lincoln, Lincoln, United Kingdom
| | - Kwang-Yeol Park
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
- Department of Neurology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Aneesh B. Singhal
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Alma Gregory Sorensen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Bruce R. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | | | - Hakan Ay
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
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Wang J, Ren L, Liu X, Liu J, Ling Q. Underactive Bladder and Detrusor Underactivity: New Advances and Prospectives. Int J Mol Sci 2023; 24:15517. [PMID: 37958499 PMCID: PMC10648240 DOI: 10.3390/ijms242115517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023] Open
Abstract
Underactive bladder (UAB) is a prevalent but under-researched lower urinary tract symptom that typically occurs alongside detrusor underactivity (DU). Unlike UAB, DU is a urodynamic diagnosis which the International Continence Society (ICS) defines as "a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span". Despite the widespread prevalence of UAB/DU, there are significant gaps in our understanding of its pathophysiological mechanisms, diagnosis, and treatment compared with overactive bladder (OAB) and detrusor overactivity (DO). These gaps are such that clinicians regard UAB/DU as an incurable condition. In recent years, the understanding of UAB has increased. The definition of UAB has been clarified, and the diagnostic criteria for DU have been considered more comprehensively. Meanwhile, a number of non-invasive diagnostic methods have also been reported. Clinical trials involving novel drugs, electrical stimulation, and stem cell therapy have shown promising results. Therefore, this review summarizes recent reports on UAB and DU and highlights the latest advances in their diagnosis and treatment.
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Affiliation(s)
- Jiaxin Wang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (J.W.)
- Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lida Ren
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (J.W.)
- Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xinqi Liu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (J.W.)
- Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jihong Liu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (J.W.)
- Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Qing Ling
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (J.W.)
- Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Tish MM, Geerling JC. The Brain and the Bladder: Forebrain Control of Urinary (In)Continence. Front Physiol 2020; 11:658. [PMID: 32719609 PMCID: PMC7349519 DOI: 10.3389/fphys.2020.00658] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/25/2020] [Indexed: 12/11/2022] Open
Abstract
Neural circuits extending from the cerebral cortex to the bladder maintain urinary continence and allow voiding when it is socially appropriate. Injuries to certain brain regions produce a specific disruption known as urge incontinence. This neurologic symptom is distinguished by bladder spasticity, with sudden urges to void and frequent inability to maintain continence. The precise localization of neural circuit disruptions responsible for urge incontinence remains poorly defined, partly because the brain regions, cell types, and circuit connections that normally maintain continence are unknown. Here, we review what is known about the micturition reflex circuit and about forebrain control of continence from experimental animal studies and human lesion data. Based on this information, we hypothesize that urge incontinence results from damage to a descending pathway that normally maintains urinary continence. This pathway begins with excitatory neurons in the prefrontal cortex and relays subcortically, through inhibitory neurons that may help suppress reflex micturition during sleep and until it is safe and socially appropriate to void. Identifying the specific cell types and circuit connections that constitute the continence-promoting pathway, from the forebrain to the brainstem, will help us better understand why some brain lesions and neurodegenerative diseases disrupt continence. This information is needed to pave the way toward better treatments for neurologic patients suffering from urge incontinence.
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Affiliation(s)
- Margaret M Tish
- Department of Neurology, University of Iowa, Iowa City, IA, United States
| | - Joel C Geerling
- Department of Neurology, University of Iowa, Iowa City, IA, United States
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Neural Correlates of Urinary Retention in Lateral Medullary Infarction. Int Neurourol J 2019; 23:205-210. [PMID: 31607099 PMCID: PMC6790816 DOI: 10.5213/inj.1836256.128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/01/2019] [Indexed: 12/04/2022] Open
Abstract
Purpose The brainstem plays an important role in the control of micturition, and brainstem strokes are known to present with micturition dysfunction. Micturition dysfunction in cases of lateral medullary infarction (LMI) is uncommon, but often manifests as urinary retention. In this study, we investigated the neuro-anatomical correlates of urinary retention in patients with LMI. Methods This was a hospital-based retrospective study conducted in the neurology unit of a quaternary-level teaching hospital. Inpatient records from January 2008 to May 2018 were searched using a computerized database. Cases of isolated LMI were identified and those with micturition dysfunction were reviewed. MRI brain images of all patients were viewed, and individual lesions were mapped onto the Montreal Neurological Institute (MNI) space manually using MRIcron. Nonparametric mapping toolbox software was used for voxel-based lesion-symptom analysis. The Liebermeister test was used for statistical analysis, and the resultant statistical map was displayed on the MNI template using MRIcron. Results During the study period, 31 patients with isolated LMI were identified. Their mean age was 48 years and 28 (90%) were male. Six of these patients (19%) developed micturition dysfunction. All 6 patients had urinary retention and 1 patient each had urge incontinence and overflow incontinence. In patients with LMI, the lateral tegmentum of the medulla showed a significant association with urinary retention. Conclusions In patients with isolated LMI, we postulate that disruption of the descending pathway from the pontine micturition centre to the sacral spinal cord at the level of the lateral tegmentum results in urinary retention.
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Chung JH, Kim JB, Kim JH. Lower urinary tract symptoms in male patients with stroke: A nationwide population-based study. Arch Gerontol Geriatr 2019; 83:309-314. [PMID: 31126672 DOI: 10.1016/j.archger.2019.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 04/27/2019] [Accepted: 05/15/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES There is a scarcity of large population-based studies investigating lower urinary tract symptoms (LUTS) using the International Prostate Symptom Score (IPSS) in stroke survivors. We investigated the prevalence and severity of LUTS in male stroke survivors and determined the independent effect of stroke on LUTS using data from a nationwide population-based survey. METHODS Cross-sectional data obtained from the 2011 Korean Community Health Survey were analyzed. The prevalence and severity of LUTS were compared between 1936 male stroke patients and 90,506 male non-stroke participants. Multivariable logistic regression was used to identify the independent effect of stroke on LUTS. RESULTS Male stroke patients more frequently reported both storage symptoms (frequency, urgency, and nocturia) and voiding symptoms (straining, weak stream, intermittency, and incomplete emptying) compared to male non-stroke population. The storage and voiding subscores of IPSS and quality of life score were higher in male stroke patients than in male non-stroke population. Multivariable logistic regression adjusted for age, socioeconomic factors, physical and mental health measures, and comorbidities, found stroke to be an independent risk factor for all 7 symptoms of LUTS. CONCLUSION The present study confirmed a high prevalence of LUTS in male stroke survivors that cannot be attributed only to potential confounders, implying that stroke may independently contribute to the development of LUTS. Our findings warrant the need for timely detection by physicians and proper management of LUTS to promote functional outcomes and quality of life in stroke population.
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Affiliation(s)
- Jae Ho Chung
- Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Jung Bin Kim
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
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Jeanson G, Lebreton F. [Neuroanatomical correlates between stroke lesions and urinary disorders: A narrative review]. Prog Urol 2018; 29:226-234. [PMID: 30527571 DOI: 10.1016/j.purol.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 10/15/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
CONTEXT Stroke generates diverse urinary disorders, frequent but often under-diagnosed and thus untreated. Even though advances in the comprehension of the physiological voiding control and involved brain areas, the precise correspondence between lesion sites and observed urinary symptoms is not clearly established. OBJECTIVE This review aimed to update on this neuroanatomical correlates. DOCUMENTARY SOURCES The search focused on articles written in French or English, on PubMed, studying human beings or animals, published between the 1st of January 2000 and the 31st of August 2018 using the following keywords (stroke or hemiplegia) and (urinary incontinence or low urinary tract symptom or retention or overactive bladder or dysuria) and (anatomy or location or localization or area or lesion). STUDIES SELECTION The main author selected the most pertinent articles on abstracts and then on full text. RESULTS Twelve studies were included in our review. We could not fully confirm the neuroanatomical correlates based on the animal model. Frontoparietal lesions in urinary incontinence, role of the insula in the urinary retention, and systematic but different urinary symptoms in the brain stem lesions are the main findings. LIMITS Few studies were included, with varying methodologies and types of population. CONCLUSION A few cerebral areas damaged by stroke seem to be linked to certain urinary troubles, but new studies with a higher methodological quality are required to confirm this result.
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Affiliation(s)
- G Jeanson
- Service de MPR Neurologie, CHU Grenoble-Alpes, 38700 La Tronche, France.
| | - F Lebreton
- Service de neuro-urologie, hôpital Tenon, AP-HP, Paris 75020, France.
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Miyazato M, Tana T, Higa A, Wakugami K, Tokashiki T, Sakima H, Maehara A, Ashikari A, Oshiro T, Ohya Y, Saito S. A questionnaire survey to assess lower urinary tract symptoms in patients with chronic stroke. Neurourol Urodyn 2017; 36:1890-1895. [PMID: 28169449 DOI: 10.1002/nau.23206] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/10/2016] [Accepted: 12/10/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES In this study, we evaluated the prevalence of lower urinary tract symptoms and the associated clinical features in patients with chronic stroke. METHODS Patients with stroke who had been regularly followed up at general medical hospitals in Okinawa, Japan were enrolled in the study. The patients were asked to complete a self-reported questionnaire regarding their physical activity, medical history, and the core lower urinary tract symptom score (CLSS) questionnaire, with anonymity. The association between each urinary disturbance category and the clinical characteristics of the patients such as age, gender, physical activity, and underlying disease was evaluated. RESULTS In total, 51 patients (33 men and 18 women; mean age, 71.7 years) were eligible for analysis. The average time after the first stroke onset was 8.5 years. Nocturia and urgency incontinence had the greatest impact on the quality of life. Overactive bladder symptoms such as nocturia, urgency, urgency incontinence, and stress urinary incontinence were associated with age, female sex, and having a co-existing medical condition (such as ischemic heart disease, hypertension, and depression). Voiding symptoms such as slow stream and straining were associated with age and physical activity after stroke. CONCLUSIONS Storage symptom is associated with not only neurological deficits but also sex and the presence of general diseases, whereas voiding symptom is influenced by physical activity in patients with chronic stroke. Therefore, lower urinary tract symptoms should be carefully monitored and physical rehabilitation should also be considered in patients with stroke.
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Affiliation(s)
- Minoru Miyazato
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | | | - Akira Higa
- Shuri Jokamachi Clinic Daiichi, Okinawa, Japan
| | | | - Takashi Tokashiki
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus, Okinawa, Japan
| | - Hirokuni Sakima
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus, Okinawa, Japan
| | | | - Asuka Ashikari
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Takuma Oshiro
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus, Okinawa, Japan
| | - Seiichi Saito
- Department of Urology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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