Incontinence of urine due to instability of micturition reflexes: Part I. Detrusor reflex instability

DYSFUNCTIONAL ELIMINATION SYNDROME AS AN ETIOLOGY OF IDIOPATHIC URETHRITIS IN CHILDHOOD

PURPOSE

Idiopathic urethritis (IU) of childhood or urethrorrhagia is a common problem characterized by blood spotting in the underwear between voiding. A clear etiology has not been established and treatments vary. We postulate that idiopathic urethritis is a manifestation of underlying dysfunctional elimination syndrome (DES).

MATERIALS AND METHODS

During a 5-year period we reviewed the records of all children diagnosed with IU in our practice. In total 72 children fit the analysis criteria. There were 68 boys and 4 girls. All children presented with either gross blood per urethra or microhematuria. Children with active infection, immunodeficiency, neurogenic bladder, vesicoureteral reflux, infravesical obstruction, urethral trauma or other genitourinary anomalies were excluded. Evaluation included thorough history and physical examination, urinalysis and urine culture. Renal and bladder ultrasound, voiding cystourethrogram and uroflow/electromyogram/post-void residual volume were obtained in select patients. Study children were divided into 2 cohorts. The first cohort (group 1, 37 patients) was treated with traditional remedies using antibiotics, urinary analgesics and/or anticholinergics. The second cohort (group 2, 35 patients) was treated by bowel and bladder regimens, laxatives when necessary, and biofeedback and/or alpha-blockers when sphincter dyssynergia was identified.

RESULTS

A total of 13 patients in group 1 (35%) had a full response to treatment, 6 (16%) had a partial response and 18 (49%) failed to respond. A total of 29 patients in group 2 (83%) had a full response to treatment, 2 (6%) had a partial response and 4 (11%) had no response. It took an average of 12.1 months to respond fully in group 1, while in group 2 the same full response took an average of 5.2 months. Of the 18 children who crossed over from group 1 to group 2, 15 (83%) had a full response with an average response time of 7.3 months.

CONCLUSIONS

Our data clearly reveal a higher cure rate when children with urethritis are treated according to DES guidelines. IU of childhood is a manifestation of underlying DES and should be treated as such.

The risk of lower urinary tract symptoms five years after the first delivery

AIM OF THE STUDY

To estimate the prevalence and 5-year incidence of lower urinary tract symptoms (LUTS) after the first delivery and to evaluate the impact of pregnancy per se and delivery per se on long-lasting symptoms.

MATERIALS AND METHODS

A longitudinal cohort study of 305 primiparae questioned a few days, 3 months, and 5 years after their delivery. The questionnaire used was tested and validated, and the questions were formulated according to the definitions of the International Continence Society (ICS). Maternal, obstetric, and neonatal data concerning every delivery and objective data concerning surgeries during the observation period were obtained from the records. From the sample of 278 women (91%) who responded 5 years after their first delivery, three subpopulations were defined: 1) women without initial LUTS before or during the first pregnancy or during the puerperal period, 2) women with onset of LUTS during the first pregnancy, and 3) women with onset of LUTS during the first puerperium. The risk of LUTS 5 years after the first delivery was examined using bivariate analyses. The obstetric variables in the bivariate tests with a significant association with long-lasting urinary incontinence were entered into a multivariate logistic regression.

RESULTS

The prevalence of stress and urge incontinence 5 years after first delivery was 30% and 15%, respectively, whereas the 5-year incidence was 19% and 11%, respectively. The prevalence of urgency, diurnal frequency, and nocturia 5 years after the first delivery was 18%, 24%, and 2%, respectively, whereas the 5-year incidence was 15%, 20%, and 0.5%, respectively. The prevalence of all LUTS except nocturia increased significantly during the 5 years of observation. The risk of long-lasting stress and urge incontinence was related to the onset and duration of the symptom after the first pregnancy and delivery in a dose-response-like manner. Vacuum extraction at the first delivery was used significantly more often in the group of women with onset of stress incontinence during the first puerperium, whereas an episiotomy at the first delivery was performed significantly more often in the group of women with onset of stress incontinence in the 5 years of observation. The prevalence of urgency and diurnal frequency 5 years after the first delivery was not increased in women with symptom onset during the first pregnancy or puerperium compared with those without such symptoms. The frequency of nocturia 5 years after the first delivery was too low for statistical analysis.

CONCLUSION

The first pregnancy and delivery may result in stress and urge incontinence 5 years later. Women with stress and urge incontinence 3 months after the first delivery have a very high risk of long-lasting symptoms. An episiotomy or a vacuum extraction at the first delivery seems to increase the risk. Subsequent childbearing or surgery seems without significant contribution. Long-lasting urgency, diurnal frequency, or nocturia cannot be predicted from onset during the first pregnancy or puerperium.

Transurethral microwave thermotherapy: how does it work?

Although some authors have proposed that the favorable impact of transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia has only a placebo effect, this idea is inconsistent with the findings of a number of sham-controlled clinical trials. Histologic and immunohistochemical studies have shown that the nerve fibers in the periurethral tissue are damaged or ablated by TUMT, and it appears that the heat affects the innervation of the smooth muscle cells. Among the nerves damaged are the sensory neurons of the posterior urethra, and this change might reduce the excitatory signals from the urethrodetrusor facilitating reflexes. Necrosis and apoptosis within a limited area also have been described. Thus, there is likely more than one basis for the therapeutic effect of TUMT.

Elevation of sensory thresholds in the prostatic urethra after microwave thermotherapy

OBJECTIVES

To determine whether transurethral microwave thermotherapy (TUMT) affects the sensory threshold in the posterior urethra and whether such an effect influences urinary storage symptoms.

PATIENTS AND METHODS

The sensory threshold was measured before and at 3 and 12 weeks after TUMT in 13 men with minor obstructive symptoms caused by benign prostatic hyperplasia. Sensations were evoked by electrical stimulation at different frequencies, using a bipolar ring-electrode mounted on a urethral catheter. Changes in sensory thresholds were evaluated in the patients both as a group and individually. The patients were interviewed about their symptoms at each measurement.

RESULTS

After TUMT, 12 patients were satisfied and reported decreased irritative symptoms, primarily less frequent nocturnal micturition; two patients were cured of urgency incontinence. In 11 of the satisfied patients, and the unsuccessful patient, decreased urge accompanied increased sensory thresholds. Thresholds elevated by >/= 30% were correlated with decreased irritative symptoms.

CONCLUSIONS

TUMT decreases sensitivity in the posterior urethra, which may alleviate storage symptoms.

Frederick C. McLellan and clinical cystometrics

Precise analysis of lower urinary tract function was an unfulfilled dream only a century ago. By the late 19th century, water manometers and plethysmographs were utilized to measure bladder pressures. In the early 1900s, Rose developed a cystometer that was later improved by Munro. In 1938 Frederick C. McLellan, active in clinical research under Reed Nesbit at the University of Michigan, was the first to apply the earlier principles and cystometric tools to a large group of patients and created the first modern paradigm of bladder dysfunction. McLellan's work brought clinical relevance to the cystometer and thus precision to the analysis of lower urinary tract function.

Antibiotic prophylaxis after instrumentation for urodynamic testing

This study of 96 women shows that there is doubtful value in routine antibiotic prophylaxis after urodynamic investigation. An unexpectedly high number of women harboured unsuspected infections at the time of evaluation despite prior screening, which suggests prophylaxis would be more useful if given before the tests.

Studies of enuresis. IX. Evidence of a mild form of compensated detrusor hyperreflexia in enuretic children

We studied 41 consecutive enuretic boys and girls by supine cystometry followed by a cystometrogram in the standing position. The micturition stop test was performed on 30 of the 41 patients. The standard cystometrogram proved to be superior to the supine study in detecting stage II (overt) detrusor hyperreflexia. Furthermore, the stop test effectively demonstrated the presence of stage I (compensated) hyperreflexia, a mild degree of detrusor unsubstantiated but assumed to be present in many children with simple enuresis. Stage I detrusor hyperreflexia may now be defined clinically by normal standing and supine cystometrograms, and a positive micturition stop test.

Incontinence of urine due to instability of micturition reflexes. Part II. Pudendal nucleus instability

Overinhibition or underfacilitation of the pudendal nucleus may cause profound involuntary relaxation of the striated muscles of the pelvic floor and perineum, including the "external" striated urethral sphincter. Pudendal nucleus instability may adversely affect urethral closure pressure and preclude a successful voluntary "recovery" effort to limit stress incontinence. It may also result in the involuntary loss of an important source of inhibition to the sacral micturition reflex center, which can lead to detrusor instability. The bilateral reciprocal relationship which exists between the detrusor reflex and the pelvic floor muscle tonus is fundamental to micturition instability syndromes. In this article, the pathophysiology of interaction of pudendal nucleus instability, detrusor reflex instability, and stress is described, and the importance of careful diagnostic evaluation of each case of incontinence is emphasized.