The incidence and etiology of overactive bladder in patients after cerebrovascular accident

Post-stroke urinary incontinence is associated with behavior control deficits and overactive bladder

BACKGROUND

Although urinary incontinence in stroke survivors can substantially impact the patient's quality of life, the underlying neuropsychological mechanisms and its neural basis have not been adequately investigated. Therefore, we investigated this topic via neuropsychological assessment and neuroimaging in a cross-sectional study.

METHODS

We recruited 71 individuals with cerebrovascular disease. The relationship between urinary incontinence and neuropsychological indices was investigated using simple linear regression analysis or Mann-Whitney U test, along with other explanatory variables, e.g., severity of overactive bladder. Variables with a p-value of <0.1 in the simple regression analysis were entered in the final multiple linear regression model to control for potential confounding factors. To carry out an in-depth examination of the neuroanatomical substrate for urinary incontinence, voxel-based lesion-behavior mapping was performed using MRIcron software.

RESULTS

Behavioral control deficits and severity of overactive bladder were closely related to severity of urinary incontinence. The voxel-based lesion-behavior mapping suggests a potential role for ventromedial prefrontal cortex lesioning in the severity of urinary incontinence, although this association is not statistically significant.

CONCLUSIONS

Post-stroke urinary incontinence is closely related to two factors: neurogenic overactive bladder, a physiological disinhibition of micturition reflex, and cognitive dysfunction, characterized by behavior control deficits.

Lower urinary tract dysfunction in the central nervous system neurogenic bladder and the real-life treatment outcome of botulinum toxin A

Neurogenic lower urinary tract dysfunction (NLUTD) is common in patients with central nervous system (CNS) lesions. Cases of cerebrovascular accidents (CVA), Parkinson's disease, dementia, and other intracranial lesions develop poor bladder control with or without urinary difficulty due to loss of cortical perception of bladder filling sensation and poor coordination of urethral sphincter relaxation during reflex micturition. Patients with CNS lesions usually have overactive bladder (OAB) symptoms, including urgency, frequency, incontinence, voiding symptoms of dysuria, large postvoid residual volume, and retention. In elderly patients with severe CNS disease the OAB symptoms are usually difficult to adequately relieve by medical treatment, and thus, their quality of life is greatly. Botulinum toxin A (BoNT-A) is currently licensed and has been applied in patients with idiopathic and neurogenic OAB due to spinal cord injury or multiple sclerosis. However, the application of BoNT-A in the treatment of urinary incontinence due to NLUTD in chronic CNS lesions has not been well-documented. Although cohort studies and case series support BoNT-A treatment for neurogenic OAB, chronic urine retention after intravesical BoNT-A injection for OAB and exacerbated urinary incontinence after urethral BoNT-A injection for voiding dysfunction have greatly limited its application among patients with NLUTD due to CNS lesions. This article reviews the pathophysiology and clinical characteristics of NLUTD in patients with CNS lesions and the clinical effects and adverse events of BoNT-A injection for patients with NLUTD. A flowchart was created to outline the patient selection and treatment strategy for neurogenic OAB.

Medical Treatment Incidence and Persistence After Surgical Relief of Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Obstruction: A Critical Analysis of the Literature

CONTEXT

The incidence and risk factors for persisting pharmacotherapy following surgical treatment of benign prostatic obstruction (BPO) remain unclear.

OBJECTIVE

To evaluate the evidence on persisting pharmacotherapy of lower urinary tract symptoms (LUTS) following surgical treatment of BPO.

EVIDENCE ACQUISITION

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist (PROSPERO ID CRD42022310598). PubMed and EMBASE databases were searched in February 2022, with an updated search in October 2022. Studies evaluating pharmacotherapy in men aged >18 yr following surgical treatment of BPO were included.

EVIDENCE SYNTHESIS

Overall, ten nonrandomized studies and one post hoc analysis of two randomized controlled trials were included. The incidence of persisting medical treatment or medical retreatment varied strongly between time points and investigated surgical techniques. Among the investigated techniques, most data were available for transurethral resection of the prostate (TURP). Persistence of pharmacotherapy after TURP at 6 mo ranged from 8.7% to 57% for the use of alpha-blockers. The use of 5-alpha reductase inhibitors after TURP ranged from 5.5% at 6 mo to 19% at 6-24 mo, whereas the use of antimuscarinics ranged from 3.4% to 28.1% at 6 mo. Data on initiation of pharmacotherapy after TURP also differed between study and type of medication. At 12 yr, the use of alpha-blockers after TURP ranged from 12% to 38%. The risk factors associated with medication after BPO surgery were age, history of diabetes mellitus, history of cerebrovascular accident, preoperative medication use, as well as surgical techniques other than laser enucleation of the prostate.

CONCLUSIONS

Pharmacotherapy for LUTS is common after BPO surgery. The outcomes following different surgical techniques are heterogeneous, with limited data from randomized controlled trials. Future studies on surgical treatment of BPO should include the use of LUTS-related pharmacotherapy after BPO surgery as a secondary endpoint.

PATIENT SUMMARY

In the present systematic review, we investigated the risk of ongoing or novel therapy with drugs following surgery for benign prostate enlargement. We found that a non-negligible proportion of men will need to take drug therapy after surgery. Certain risk factors can be identified, which are associated with a higher risk of drug therapy after surgery.

Subacute stroke: new-onset poststroke bladder and bowel dysfunctions and possible associated factors

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.

Surgical outcome of male patients with chronic central nervous system disorders and voiding dysfunction due to bladder outlet obstruction

PURPOSE

Voiding dysfunction is common in patients with chronic central nervous system (CNS) diseases and has great impact on quality of life. Patients with chronic CNS disorders might have concomitant detrusor overactivity, detrusor underactivity, and voiding dysfunction. Although bladder outlet surgeries could relieve bladder outlet obstruction (BOO), patients might have persistent or exacerbated storage symptoms. This study investigated surgical outcome of patients with chronic CNS disorders after bladder outlet surgery.

METHODS

A total of 63 male patients with cerebrovascular accident (CVA, n = 44), Parkinson's disease (PD, n = 11), and early-stage dementia (n = 8), had received bladder outlet surgery after videourodynamic proven BOO refractory to medical treatment. The preoperative and postoperative lower urinary tract symptoms (LUTS) and uroflowmetry parameters were assessed. If the storage symptom subscore decreased or increased by 1, the outcome was considered improved or exacerbated after treatment. When patients had improvement in maximum flow rate (Qmax) and voiding efficiency (VE) and decreased voiding symptom subscore, they were considered having improvement of voiding dysfunction.

RESULTS

The mean age was 71.1 ± 9.8 years and mean duration from diagnosis of BOO to surgical intervention was 15.1 ± 25.0 months. Overall, there was significant improvement in voiding LUTS and urinary retention after surgery. The post-void residual volume (PVR), corrected Qmax (cQmax), and VE significantly improved after surgery. In subgroup analysis, although voiding symptoms improved in CVA patients, urgency and exacerbated urgency incontinence persisted after surgery. In PD patients, there was improvement in voiding condition such as PVR, cQmax and VE, but the storage symptoms did not change after surgery. Patients with dementia had no improvement both in storage and voiding symptoms.

CONCLUSIONS

Bladder outlet surgeries are effective to relieve voiding dysfunction in patients with CVA and PD, but have little effect on storage LUTS in patients with chronic brain lesions.

Video-urodynamic characteristics of lower urinary tract dysfunctions in patients with chronic brain disorders

AIMS

Lower urinary tract dysfunction (LUTD) is common in patients with chronic brain disorders. This study investigated the video-urodynamic study (VUDS) findings of LUTD in patients with chronic brain disorders, including cerebrovascular accident (CVA), Parkinson's disease (PD), and early dementia.

METHODS

A total of 169 patients with a history of chronic brain disorders, including 84 with CVA, 55 with PD, and 30 with early dementia were enrolled. All patients had a comprehensive chart review, including brain disorder subtype, the period from diagnosis to VUDS, the VUDS parameters, and final LUTD.

RESULTS

The mean age of patients was 69.2 ± 10.5 years, and the interval from brain insult to VUDS was 61.3 ± 49.7 months. Urodynamic detrusor overactivity (DO) was noted in 73.4% of patients, detrusor underactivity in 10.1%, and detrusor overactivity with detrusor underactivity in 16.6%. Bladder outlet obstruction (BOO) was noted in 60.9% of patients, including bladder neck dysfunction in 21.3%, urethral sphincter dysfunction in 42%, and prostatic obstruction in 10.1% of male patients. Urethral sphincter dysfunction was noted in 60% of patients with PD, 32.1% with CVA, and 36.7% with dementia (p = 0.004). A low mean maximum flow rate increased post-void residual volume, and poor voiding efficiency was common in these patients, without significant differences among the subgroups.

CONCLUSIONS

Real-world VUDSs revealed that patients with chronic brain disorders not only had a high prevalence of DO but also impaired bladder contractility and a high rate of BOO at the level above the bladder neck and urethral sphincter.

Frontiers in the Clinical Applications of Botulinum Toxin A as Treatment for Neurogenic Lower Urinary Tract Dysfunction

Patients with neurogenic lower urinary tract dysfunction (NLUTD) experience urinary incontinence with or without difficult urination, which might promote recurrent urinary tract infection (UTI) and exacerbate upper urinary tract function. Nonetheless, appropriate bladder management has been shown to reduce urological complications and improve quality of life. In addition to pharmacological therapy and surgical intervention, botulinum toxin A (BoNT-A) has been widely utilized in NLUTD. The therapeutic efficacy of detrusor BoNT-A injections for neurogenic detrusor overactivity due to spinal cord injury (SCI), multiple sclerosis, or other central nervous system lesions, such as cerebrovascular accident, Parkinson disease, early dementia, and pediatric NLUTD due to myelomeningocele, has been well established, with repeated BoNT-A injections every 6 to 9 months being necessary to maintain its therapeutic effects. Urethral BoNT-A injection can decrease urethral sphincter resistance and facilitate efficient voiding in patients with NLUTD who wish to preserve self-voiding. Detrusor BoNT-A injection can also decrease the occurrence of autonomic dysreflexia in patients with SCI, even after failed augmentation enterocystoplasty, with additional benefits including reduced UTI episodes and preserved renal function with repeated injections. However, this treatment does have some side effects. Complete informed consent for BoNT-A injection therapy with full disclosure of its potential complications should therefore be obtained before this procedure is undertaken.

Nocturia and Nocturnal Polyuria in Neurological Patients: From Epidemiology to Treatment. A Systematic Review of the Literature

CONTEXT

Nocturia is among the most common and bothersome lower urinary tract symptoms (LUTS), but there is no clear consensus on how to identify and manage this symptom in the neurological population.

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

Studies were identified by electronic search of Cochrane and Medline databases. The studies were included if their participants had acquired neurological pathology among multiple sclerosis (MS), Parkinson's disease (PD), stroke, spinal cord injury (SCI), and reported data on the epidemiology, aetiology, diagnosis, or treatment of nocturia. An independent extraction of the articles was performed by two authors using predetermined datasets, including quality-of-study indicators.

EVIDENCE SYNTHESIS

A total of 132 studies were included; 46 evaluated the epidemiology of nocturia, 28 the possible aetiologies, 10 the diagnostic tools, and 60 the treatments. Nocturia prevalence ranged from 15% to 96% depending on the pathology and definition used. It was one of the most frequently reported LUTS in PD and stroke patients. Several validated questionnaires were found to screen for nocturia in this population. Causalities were numerous: LUT, renal, sleep, cardiovascular dysfunctions, etc. Treatments targeted these mechanisms, with an overall risk of bias assessed as high or serious. The highest level of evidence was seen in MS patients: pelvic floor muscle training, cannabinoids, and desmopressin were effective, but not melatonin. In stroke patients, transcutaneous sacral and transcutaneous tibial nerve stimulation (TTNS) improved nocturia; in PD patients, TTNS, solifenacin, and rotigotine did not.

CONCLUSIONS

Nocturia is highly prevalent in patients with neurological disorders. Causalities and treatments are not different from the general population, but are poorly studied in neurological patients.

PATIENT SUMMARY

In this report, we looked at the published studies about nocturia-the fact of waking to void during the hours of sleep-in patients with neurological diseases. We found that nocturia is very frequent in this population, that the causes are the same as in the general population but may be combined, and that treatments are also the same but have an overall weak level of evidence. We conclude that more research is needed on this topic.

The course of post-stroke bladder problems and their relation with functional and mental status and quality of life: A six-month, prospective, multicenter study

Objectives

The aim of this study was to evaluate the frequency and course of post-stroke lower urinary tract dysfunction (LUTD) from early term up to a period of six months and to investigate the relation of LUTD with functional and mental status and quality of life (QoL) in stroke patients.

Patients and methods

This prospective study included a total of 70 stroke patients (44 males, 26 females; mean age 62.7±7.0 years; range, 46 to 79 years) from five different centers across Turkey between June 2015 and January 2017. The patients were questioned using the Danish Prostatic Symptom Score (DAN-PSS) to evaluate LUTD and evaluated using the Modified Barthel Index (MBI), Incontinence QoL Questionnaire (I-QOL), and Mini-Mental State Examination (MMSE) at one, three, and six months.

Results

At least one symptom of LUTD was observed in 64 (91.4%), 58 (82.9%), and 56 (80%) of the patients according to the DAN-PSS at one, three, and six months, respectively. A statistically significant improvement was found in the DAN-PSS, MBI, MMSE, I-QOL total scores, avoidance and psychosocial subgroup scores at six months compared to the first month scores (p<0.05). There was a significant negative correlation between the DAN-PSS symptom score at one month and the MBI, MMSE, and QoL scores at six months. The DAN-PSS bother and total scores were found to be significantly and negatively correlated only with the subscales of the QoL questionnaire.

Conclusion

Based on our study results, LUTD was very common and the prevalence of LUTD findings decreased constantly during six-month follow-up, showing an association with a poor cognitive and functional status and QoL in stroke patients with LUTD.

Therapeutic efficacy of low-dose (25 mg) mirabegron therapy for patients with mild to moderate overactive bladder symptoms due to central nervous system diseases

OBJECTIVE

The incidence of overactive bladder (OAB) increases with age, especially in patients with central nervous system (CNS) disorders such as cerebrovascular accident (CVA) and Parkinson's disease (PD). Mirabegron is a novel medication for the treatment of OAB. The present study investigated the therapeutic effect of mirabegron on OAB patients with CNS diseases.

METHODS

Patients with CVA, PD, dementia, and OAB symptoms were consecutively enrolled in the study group, and mirabegron 25 mg q.d. was prescribed. Clinical effects, evaluated using the Overactive Bladder Symptom Score (OABSS), Urinary Sensation Scale (USS), International Prostate Symptom Score (IPSS), and Patient Perception of Bladder Condition (PPBC), as well as urodynamic parameters and adverse events were assessed at baseline and 4 and 12 weeks after treatment.

RESULTS

In all, 44 patients (mean [± SD] age 77.7 ± 9.49 years) with OAB due to CVA (n = 27), PD (n = 6), and dementia (n = 11) were included in the present prospective study. Mirabegron resulted in significant improvements in symptom scores on the OABSS (P = .02), USS (P = .009), total IPSS (P = .002), Storage and Voiding domains of the IPSS (P = .001 and .017, respectively), and PPBC (P = .001). No significant changes were noted in post-void residual, maximum flow rate, and voided volume after treatment. Only 5 patients dropped out due to poor therapeutic efficacy and shifted to antimuscarinics. Three patients complained of adverse effects, including dizziness and dysuria. No patient complained of urine retention or constipation.

CONCLUSION

Mirabegron 25 mg once daily effectively decreased urgency symptoms in elderly OAB patients with CNS lesions after the 12-week treatment period. The adverse events were mild and only noted in a few cases.

Reliability and validity of the Turkish version of the Danish Prostatic Symptom Score to assess lower urinary tract symptoms in stroke patients

BACKGROUND

Lower urinary tract dysfunction (LUTD) is one of the most frequently encountered problems in stroke.OBJECTİVE:To assess the validity and reliability of the Turkish Danish Prostatic Symptom Score (DAN-PSS) in stroke patients with LUTD.

METHODS

A total of 50 patients were included in the study. The reliability was assessed using Cronbach α and intraclass correlation coefficient (ICC) methods, and the validity using the correlations between the subgroup and overall scores of DAN-PSS and the scores of the Barthel Index (BI), International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and Short Form 36 (SF-36).

RESULTS

The Cronbach α values were found >0.97 and ICC 0.953-0.990 for all subgroup scores. We found a significant negative correlation between all the sub-scores of DAN-PSS and the BI, and a significant positive correlation between all the sub-scores of DAN-PSS and ICIQ-SF (p < 0.05). The symptom score of DAN-PSS had a significant negative correlation with the physical functioning, physical and emotional role subdomains of the SF-36 survey (p < 0.05).

CONCLUSIONS

We have shown the reliability and validity of the Turkish DAN-PSS, and we think that it will be useful to utilize it in the monitoring of patients with stroke and in clinical studies.

Research Findings on Overactive Bladder

Several physiopathologic conditions lead to the manifestation of overactive bladder (OAB). These conditions include ageing, diabetes mellitus, bladder outlet obstruction, spinal cord injury, stroke and brain injury, Parkinson's disease, multiple sclerosis, interstitial cystitis, stress and depression. This review has discussed research findings in human and animal studies conducted on the above conditions. Several structural and functional changes under these conditions have not only been observed in the lower urinary tract, but also in the brain and spinal cord. Significant changes were observed in the following areas: neurotransmitters, prostaglandins, nerve growth factor, Rho-kinase, interstitial cells of Cajal, and ion and transient receptor potential channels. Interestingly, alterations in these areas showed great variation in each of the conditions of the OAB, suggesting that the pathophysiology of the OAB might be different in each condition of the disease. It is anticipated that this review will be helpful for further research on new and specific drug development against OAB.

Efficacy and safety of intravesical onabotulinumtoxinA injection on elderly patients with chronic central nervous system lesions and overactive bladder

PURPOSE

Intravesical injection of onabotulinumtoxinA is an effective treatment for overactive bladder (OAB). Nonetheless, the treatment outcome is unclear in OAB patients with central nervous system (CNS) lesions. This study evaluated the efficacy and safety of intravesical onabotulinumtoxinA treatment in elderly patients with chronic cerebrovascular accidents (CVAs), Parkinson's disease (PD) and dementia.

MATERIALS AND METHODS

Patients with CVA, PD, dementia, and OAB refractory to antimuscarinic therapy were consecutively enrolled in the study group. Age-matched OAB patients without CNS lesions were selected to serve as a control group. OnabotulinumtoxinA (100 U) was injected into the bladder suburothelium at 20 sites. The clinical effects, adverse events, and urodynamic parameters were assessed at baseline and 3 months post-treatment. The Kaplan-Meier method was used to compare long-term success rates between groups.

RESULTS

A total of 40 patients with OAB due to CVA (23), PD (9), dementia (8) and 160 control patients were included in this retrospetive analysis. Improvement of urgency severity scale, increased bladder capacity and increased post-void residual volume were comparable between the groups at 3 months. Patients with CNS lesions did not experience increased risks of acute urinary retention and urinary tract infection; nonetheless, patients with CVA experienced a higher rate of straining to void. Long-term success rates did not differ between the patients with and without CNS lesions.

CONCLUSION

Intravesical injection of 100 U of onabotulinumtoxinA effectively decreased urgency symptoms in elderly OAB patients with CNS lesions. The adverse events were acceptable, and long-term effects were comparable to OAB patients in general. Nonetheless, the possibility of longstanding urinary retention and chronic catheterization need careful evaluation for this very vulnerable population before choosing intravesical onabotulinumtoxinA treatment.