Sacral neuromodulation in lower urinary tract dysfunction

Add-on Therapy With the α-Blockers Tamsulosin and Naftopidil Improves Voiding Function by Enhancing Neuronal Activity in Prostatic Hyperplasia Rats

Purpose

Benign prostatic hyperplasia (BPH) impacts quality of life in men by causing lower urinary tract symptoms. α1-Adrenoceptor (α1-AR) blockers improve lower urinary tract symptoms. We investigated the efficacy of add-on therapy with α1-AR blockers on BPH rats.

Methods

Rats in the drug-treated groups were orally administered each drug once a day for 30 days after orchiectomy. To induce BPH, rats were castrated and testosterone (20 mg/kg) was injected subcutaneously once per day for 30 days. Cystometry was conducted to measure voiding contraction pressure and the interval contraction time, immunohistochemistry was performed to measure c-Fos and nerve growth factor (NGF) expression in the neuronal voiding centers, and nicotinamide adenine dinucleotide phosphate-diaphorase histochemistry was used to measure nitric oxide synthase (NOS) expression.

Results

Orchiectomy and testosterone injection decreased voiding contraction pressure and the interval contraction time, suggesting BPH symptoms. Voiding contraction pressure and the interval contraction time were greater in the group that received the combination treatment (tamsulosin with naftopidil) than in the tamsulosin monotherapy or naftopidil monotherapy groups. c-Fos, NGF, and NOS expression in the neuronal voiding centers was enhanced by BPH induction. c-Fos, NGF, and NOS expression was suppressed by the combination treatment (tamsulosin with naftopidil) to a greater extent than was the case for tamsulosin monotherapy or naftopidil monotherapy.

Conclusions

Combination therapy of tamsulosin and naftopidil showed greater efficacy for the treatment of BPH than tamsulosin monotherapy or naftopidil monotherapy; therefore, combination therapy can be considered as a novel therapeutic method for BPH.

Effects of Combination Treatment of Alpha 1-Adrenergic Receptor Antagonists on Voiding Dysfunction: Study on Target Organs in Overactive Bladder Rats

PURPOSE

Overactive bladder (OAB) causes urinary urgency, usually accompanied by frequency and nocturia. Alpha 1-adrenergic receptor (α₁-AR) antagonists are known to improve lower urinary tract symptoms associated with OAB. The α₁-AR antagonists constitute a variety of drugs according to the receptor subtype affinity. This study investigated the efficacy of tamsulosin, naftopidil, and a combination of the two on OAB rats.

METHODS

The OAB rat model was induced by an intraperitoneal injection of cyclophosphamide for 14 days. The experimental groups were divided into 5 groups: control group, OAB-induction group, OAB-induction and tamsulosin monotherapy group, OAB-induction and naftopidil monotherapy group, and OAB-induction and tamsulosin-naftopidil combination therapy group. For the drug-treated groups, each drug was administrated for 14 days after the OAB induction. Cystometry for urodynamic evaluation and immunohistochemical stain for c-Fos and nerve growth factor (NGF) expressions in the central micturition centers were performed.

RESULTS

Increased contraction pressure and time with enhanced c-Fos and NGF expressions in the central micturition centers were found in the OAB rats. Tamsulosin suppressed contraction pressure and time while inhibiting c-Fos and NGF expressions. Naftopidil showed no significant effect and combination therapy showed less of an effect on contraction pressure and time. Naftopidil and combination therapy exerted no significant effect on the c-Fos and NGF expressions.

CONCLUSIONS

Tamsulosin showed the most prominent efficacy for the treatment of OAB compared to the naftopidil and combination. The combination of tamsulosin with naftopidil showed no synergistic effects on OAB; however, further studies of addon therapy might provide opportunities to find a new modality.

Electroacupuncture for moderate and severe benign prostatic hyperplasia: a randomized controlled trial

PURPOSE

To evaluate the effects of electroacupuncture (EA) on the International Prostate Symptom Score (IPSS), postvoid residual urine (PVR), and maximum urinary flow rate (Qmax), and explore the difference between EA at acupoints and non-acupoints in patients with moderate to severe benign prostate hyperplasia (BPH).

SUBJECTS AND METHODS

Men with BPH and IPSS ≥8 were enrolled. Participants were randomly allocated to receive EA at acupoint (treatment group, n = 50) and EA at non-acupoint (control group, n = 50). The primary outcome measure includes the change of IPSS at the 6th week and the secondary outcome measures include changes of PVR and Qmax at the 6th week and change of IPSS at the 18th week.

RESULTS

100/192 patients were included. At the 6th week, treatment group patients had a 4.51 (p<0.001) and 4.12 (p<0.001) points greater decline in IPSS than the control group in the intention to treat (ITT) and per-protocol (PP) populations. At the 18th week, a 3.2 points (p = 0.001) greater decline was found in IPSS for the treatment. No significant differences were found between the two groups in Qmax at the 6th week (p = 0.819). No significant difference was observed in PVR (P = 0.35).

CONCLUSION

Acupoint EA at BL 33 had better effects on IPSS, but no difference on PVR and Qmax as compared with non-acupoint EA. The results indicate that EA is effective in improving patient's quality of life and acupoint may have better therapeutic effects than non-acupoints in acupuncture treatments of BPH.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01218243.

Sacral nerve stimulation for treatment of intractable pain associated with cauda equina syndrome

Sacral nerve stimulation (SNS) is an effective treatment for bladder and bowel dysfunction, and also has a role in the treatment of chronic pelvic pain. We report two cases of intractable pain associated with cauda equina syndrome (CES) that were treated successfully by SNS. The first patient suffered from intractable pelvic pain with urinary incontinence and fecal incontinence after surgery for a herniated lumbar disc. The second patient underwent surgery for treatment of a burst fracture and developed intractable pelvic area pain, right leg pain, excessive urinary frequency, urinary incontinence, voiding difficulty and constipation one year after surgery. A SNS trial was performed on both patients. Both patients' pain was significantly improved and urinary symptoms were much relieved. Neuromodulation of the sacral nerves is an effective treatment for idiopathic urinary frequency, urgency, and urge incontinence. Sacral neuromodulation has also been used to control various forms of pelvic pain. Although the mechanism of action of neuromodulation remains unexplained, numerous clinical success reports suggest that it is a therapy with efficacy and durability. From the results of our research, we believe that SNS can be a safe and effective option for the treatment of intractable pelvic pain with incomplete CES.

Sacral nerve stimulation: neuromodulation for voiding dysfunction and pain

Voiding dysfunction, which includes incontinence, retention, and chronic pelvic pain, is a relatively frequent problem that can be difficult to manage. Neuromodulation via stimulation of the sacral nerves has been shown to improve these symptoms, although the exact mechanisms remain elusive. Techniques for nerve stimulation may vary, depending on the disease, location of pain, and the patient's anatomy. In addition to placement of electrodes on the sacral nerve roots, modulation has also been reported by peripheral branches of the sacral nerves including the pudendal and posterior tibial nerves. Newer surgical techniques have significantly decreased the morbidity of the procedures and increased the probability of a successful outcome.

Botulinum Toxin Type A for Refractory Neurogenic Detrusor Overactivity in Spinal Cord Injured Patients in Singapore

Introduction: Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative. Materials and Methods: Spinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder. Results: Fifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 ± 1.79 pre-injection to 0.67 ± 1.31 and 1.5 ± 1.5 at 6 and 26 weeks post-injection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 ± 145.6 mL pre-injection to 484.6 ± 190 mL, 422.3 ± 157.3 mL and 490.0 ± 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 ± 22.6 cmH2O to 21.2 ± 23.1 cmH2O and 33.6 ± 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 ± 57.5 mL pre-injury to 305.7 ± 130.8 mL at 6 weeks and 288.3 ± 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 ± 69.2 mL to 305 ± 136.4 mL and 288.3 ± 13.0 mL at 6 and 26 weeks post- injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 ± 2.3 pre-injury to 7.2 ± 1.9 and 7.3 ± 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages. Conclusion: Botulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection. Key words: Anticholinergics, Spinal cord injury, Urodynamics, Voiding

Use of sympathetic alpha antagonists in the management of pediatric urologic disorders

PURPOSE OF REVIEW

To update the physician regarding the use of alpha-adrenergic antagonists in the management of various pediatric urologic problems.

RECENT FINDINGS

The use of alpha-adrenergic antagonist for the treatment of pediatric urologic disorders has expanded greatly over the past decade. This review summarizes the current use of these medications in the treatment of pediatric voiding dysfunction, neurogenic bladder, chronic lower urinary tract symptomatology, idiopathic urethritis, and the passage of ureteral calculi.

SUMMARY

Currently alpha antagonist therapy although not useful in the primary treatment of voiding dysfunction is equivalent in potency to biofeedback therapy for the treatment of recalcitrant voiding dysfunction. In the management of neurogenic bladder and chronic lower urinary tract symptomatology, alpha antagonists working alone or in conjunction with anticholinergic medications will improve clinical symptoms, increase bladder compliance, and decrease detrusor instability. In addition, alpha antagonists may decrease the intensity and duration of symptoms in patients with idiopathic urethritis. Compared with placebo, alpha-adrenergic antagonists will also aid significantly in the spontaneous passage of distal ureteral calculi, thereby reducing the need for surgical intervention and analgesia. The findings noted above significantly expand the clinical usefulness of alpha antagonist therapy within the field of pediatric urology.