Differential Diagnosis of Overactive Bladder in Men

The Value of Ambulatory Urodynamics in the Evaluation of Treatment Effect of Sacral Neuromodulation

OBJECTIVES

To assess the improvement of symptoms by sacral neuromodulation (SNM) in an objective way by carrying out an ambulatory urodynamic study (ambulatory-UDS). Until now, successful treatment has been defined as a ≥50% improvement recorded on voiding diaries. Voiding diaries are a patient reported outcome tool. A tool with less bias is desired to evaluate the treatment results before an expensive permanent system is implanted.

METHODS

Between 2002 and 2015, a total of 334 patients with lower urinary tract symptoms were included consecutively in an ambulatory-UDS database. From this database, a subgroup of patients was selected which underwent SNM.

RESULTS

In 51 patients, an ambulatory-UDS was performed both at baseline and during the SNM test period. A positive treatment outcome after test stimulation based on the patients' voiding diary, correlated (p < 0.0001) with an improvement on ambulatory-UDS. Twenty-six of the 30 patients, who have showed improvement of more than 50% on voiding diary parameters and who had subjective improvement of their symptoms, showed an early improvement on ambulatory-UDS.

CONCLUSIONS

Ambulatory-UDS can be used in clinical decision making, as it is associated with voiding diary improvement during the SNM test period. Using ambulatory-UDS to confirm success could in the future justify the shortening of the test period.

Urogynecological conditions associated with overactive bladder symptoms in women

INTRODUCTION

Overactive bladder symptoms (OAB) affect 9-43% of women and are associated with underlying disorders, including pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The aim of this study is to identify urogynecological conditions associated with OAB symptoms.

METHODS

This prospective, institutional review board-approved study included women referred to a tertiary centre with lower urinary tract symptoms (LUTS). All women completed the self-administered OAB questionnaire (OABSS). Those with an OABSS ≥8, the cutoff, were considered to have OAB symptoms. Patients underwent a history and physical examination (including Baden-Walker prolapse grading and stress test), 24-hour voiding diary, pad test (for urinary incontinence), urinalysis, and uroflow with post-void residual volume. Patients were classified clinically into the following: idiopathic OAB, SUI, POP, bladder outlet obstruction (BOO) neurogenic bladder (NGB), recurrent urinary tract infection (UTI), and miscellaneous.

RESULTS

In total, 148 women met the inclusion criteria with a mean age of 67 years. Only 27% had no comorbid conditions and were considered idiopathic OAB. Associated urogynecological conditions included SUI in 37%, POP in 26%, miscellaneous conditions in 18%, recurrent UTI in 11%, NGB in 9%, and BOO in 8%. Some patients met criteria for more than one category, thus the total is greater than 100%.

CONCLUSIONS

In a tertiary care setting, a significant proportion of women with OAB symptoms have underlying conditions that may cause or contribute to their symptoms. Appropriate evaluation is desirable to enhance our understanding of the relationship of these conditions to the diagnosis, treatment, outcomes, and pathophysiology of OAB.

Effects of Panax ginseng on the nerve growth factor expression in testosterone induced benign prostatic hyperplasia

The prostatic hyperplasia in benign prostatic hyperplasia (BPH) leads to obstructive micturition symptoms. Previous studies showed that pontine micturition center (PMC), ventrolateral periaqueductal gray (vlPAG), and medial preopticnucleus (MPA) regions in the brain have been known to regulate the urinary bladder function. The present study shows the influences of Panax ginseng on nerve growth factor (NGF) expressions in PMC, vlPAG, and MPA regions in the brain. Wistar rats were used for the present study. The rats split into four groups; 4 groups (n = 6) in control group, BPH-induced group, BPH-induced and P. ginseng-treated group, and BPH-induced and finasteride-treated group. BPH in rats was induced by testosterone and the animals were evaluated for NGF expression in PMC, vlPAG, and MPA regions in the brain. The NGF expression was identified using immunohistochemistry (IHC). The NGF expression by IHC showed spots with dark brown color. In our results, NGF expressions in PMC, vlPAG, and MPA regions in the brainstem of the BPH-induced group showed increase than the control animal. These increased NGF expressions in three regions were decreased using treatment with P. ginseng (200 mg/kg). These results suggest that P. ginseng has therapeutic effects on the symptoms of BPH and is associated with the regulation of NGF expression in the brain. In conclusion, the administration of P. ginseng helps nerve growth factor activation.

Overactive Bladder and Storage Lower Urinary Tract Symptoms Following Radical Prostatectomy

OBJECTIVE

To describe the rate of overactive bladder (OAB) and storage lower urinary tract symptoms following radical prostatectomy (RP) and determine if subsequent radiation increases the risk of OAB.

METHODS

We reviewed all patients who underwent open RP at our tertiary care institution from January 2006 to June 2011. Primary outcomes were the proportion of patients with new OAB and time to development of OAB in those treated with RP alone vs RP plus radiation. Secondary outcomes included the proportion of patients treated for OAB. A Cox survival analysis was used to assess the impact of radiation on development of OAB.

RESULTS

Of the 875 patients who met study criteria, 19% of patients developed de novo OAB defined as urgency with or without frequency and nocturia. A total of 256 patients (29%) developed 1 or more urinary symptoms including nocturia (22%), frequency (21%), urgency (19%), and urge incontinence (6%) following RP. After adjusting for age, body mass index, smoking status, cancer stage, and nerve-sparing status, radiation therapy was associated with an increased relative hazard of OAB (5.59; 95% CI 3.63-8.61, P < .001). Among men classified with de novo OAB, only 41% received treatment.

CONCLUSION

OAB and storage lower urinary tract symptoms are prevalent in men post-RP. Adjuvant or salvage radiation therapy increases the risk of developing OAB after RP. OAB may be undertreated in men following prostate cancer treatment.

'Tamsulosin and Darifenacin' Versus 'Tamsulosin Monotherapy' for 'BPH with Accompanying Overactive Bladder'

PURPOSE

To evaluate the efficacy/safety of 'tamsulosin and darifenacin' (TD) vs. 'tamsulosin and placebo' (TP) for patients with symptomatic benign prostrate hyperplasia (BPH) with accompanying overactive bladder (OAB) symptoms.

MATERIALS AND METHODS

This study included symptomatic patients of BPH with one or more of the following OAB symptoms; micturition frequency >8, nocturnal frequency > 2, urgency > 1 per 24 hour between November 2012 and February 2014. After protocol approval by ethics committee and obtaining informed consent, patients were randomly assigned to receive tamsulosin 0.4mg plus placebo (TP) (n=30) or tamsulosin 0.4 mg plus darifenacin 7.5 mg (TD) (n=30) for 8 weeks. The mean change from baseline in urinary frequency and incontinence episodes/24 hour (primary end points), and nocturnal frequency; mean change in PVR and changes in IPSS (secondary end points) were compared between groups at 0/eight week using voiding diary and ultrasonography.

RESULTS

The mean change in frequency, incontinence, nocturnal frequency/24 hour and IPSS (International prostrate symptom score) were (-4.83 vs. -3.93, p=0.023), (-1.50 vs. 1.08, p=0.001), (-2.20 vs. -1.87, p<0.001) and (-7.90 vs. -6.27, p<0.001) in the TD/TP group respectively (significant). Apart from some minor side effects (12 vs. 9) all interventions appeared to be safe and well tolerated. The mean change in the PVR (Postvoid residual) was marginal (+10.84ml and -16.93) and the incidence of urinary retention was 13% and 3% in the TD and TP groups respectively (p=0.35).

CONCLUSION

Treatment with tamsulosin and darifenacin for 8 weeks is an effective and safe treatment modality in select patients of BPH with accompanying OAB symptoms.

Stimulation of large-conductance calcium-activated potassium channels inhibits neurogenic contraction of human bladder from patients with urinary symptoms and reverses acetic acid-induced bladder hyperactivity in rats

We have analysed the effects of large-conductance calcium-activated potassium channel (BK) stimulation on neurogenic and myogenic contraction of human bladder from healthy subjects and patients with urinary symptoms and evaluated the efficacy of activating BK to relief bladder hyperactivity in rats. Bladder specimens were obtained from organ donors and from men with benign prostatic hyperplasia (BPH). Contractions elicited by electrical field stimulation (EFS) and carbachol (CCh) were evaluated in isolated bladder strips. in vivo cystometric recordings were obtained in anesthetized rats under control and acetic acid-induced hyperactive conditions. Neurogenic contractions of human bladder were potentiated by blockade of BK and small-conductance calcium-activated potassium channels (SK) but were unaffected by the blockade of intermediate calcium-activated potassium channels (IK). EFS-induced contractions were inhibited by BK stimulation with NS-8 or NS1619 or by SK/IK stimulation with NS309 (3µM). CCh-induced contractions were not modified by blockade or stimulation of BK, IK or SK. The anti-cholinergic agent, oxybutynin (0.3µM) inhibited either neurogenic or CCh-induced contractions. Neurogenic contractions of bladders from BPH patients were less sensitive to BK inhibition and more sensitive to BK activation than healthy bladders. The BK activator, NS-8 (5mg/kg; i.v.), reversed bladder hyperactivity induced by acetic acid in rats, while oxybutynin was ineffective. NS-8 did not significantly impact blood pressure or heart rate. BK stimulation specifically inhibits neurogenic contractions in patients with urinary symptoms and relieves bladder hyperactivity in vivo without compromising bladder contractile capacity or cardiovascular safety, supporting its potential therapeutic use for relieving bladder overactivity.

The performance of silk scaffolds in a rat model of augmentation cystoplasty

The diverse processing plasticity of silk-based biomaterials offers a versatile platform for understanding the impact of structural and mechanical matrix properties on bladder regenerative processes. Three distinct groups of 3-D matrices were fabricated from aqueous solutions of Bombyx mori silk fibroin either by a gel spinning technique (GS1 and GS2 groups) or a solvent-casting/salt-leaching method in combination with silk film casting (FF group). SEM analyses revealed that GS1 matrices consisted of smooth, compact multi-laminates of parallel-oriented silk fibers while GS2 scaffolds were composed of porous (pore size range, 5-50 μm) lamellar-like sheets buttressed by a dense outer layer. Bi-layer FF scaffolds were comprised of porous foams (pore size, ~400 μm) fused on their external face with a homogenous, nonporous silk film. Silk groups and small intestinal submucosa (SIS) matrices were evaluated in a rat model of augmentation cystoplasty for 10 weeks of implantation and compared to cystotomy controls. Gross tissue evaluations revealed the presence of intra-luminal stones in all experimental groups. The incidence and size of urinary calculi was the highest in animals implanted with gel spun silk matrices and SIS with frequencies ≥57% and stone diameters of 3-4 mm. In contrast, rats augmented with FF scaffolds displayed substantially lower rates (20%) and stone size (2 mm), similar to the levels observed in controls (13%, 2 mm). Histological (hematoxylin and eosin, Masson's trichrome) and immunohistochemical (IHC) analyses showed comparable extents of smooth muscle regeneration and contractile protein (α-smooth muscle actin and SM22α) expression within defect sites supported by all matrix groups similar to controls. Parallel evaluations demonstrated the formation of a transitional, multi-layered urothelium with prominent uroplakin and p63 protein expression in all experimental groups. De novo innervation and vascularization processes were evident in all regenerated tissues indicated by Fox3-positive neuronal cells and vessels lined with CD31 expressing endothelial cells. In comparison to other biomaterial groups, cystometric analyses at 10 weeks post-op revealed that animals implanted with the FF matrix configuration displayed superior urodynamic characteristics including compliance, functional capacity, as well as spontaneous non voiding contractions consistent with control levels. Our data demonstrate that variations in scaffold processing techniques can influence the in vivo functional performance of silk matrices in bladder reconstructive procedures.

How do urodynamics findings influence the treatment of the typical patient with overactive bladder?

Overactive bladder (OAB) is a clinical symptom complex whose hallmark is the symptom of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence. Historically, urodynamics (UDS) evaluation has not been recommended in the initial evaluation of OAB, since it is defined primarily by clinical symptoms. As the pathophysiology of the OAB complex has become more clearly elucidated from recent studies, the role of UDS has again become a topic of discussion as a tool that can provide objective data to reflect these new findings. The utility of UDS in the diagnosis and treatment of OAB is still evolving, but in certain clinical scenarios, especially when empiric treatment has failed, it can provide definitive information that can identify associated pathologies and/or alter the treatment course. Herein, we will discuss the current literature regarding use of UDS in OAB patients and offer our own opinions as to its use.

Defining Causes for Overactive Bladder Symptoms in Women

OBJECTIVES

The aim of the present study was to determine the causes for overactive bladder (OAB) symptoms in women visiting a urological clinic.

METHODS

We prospectively recruited female patients with OAB symptoms between December 2008 and February 2010. All patients were interviewed for their detailed personal and medical history. All patients completed a 3-day frequency-volume chart. Symptom severity was evaluated using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS) questionnaires. All patients underwent either conventional pressure-flow urodynamic studies or video-urodynamic studies. On the basis of these evaluations, patients were assigned to one of the following categories: idiopathic OAB, stress urinary incontinence (SUI)-associated, neurogenic bladder, or bladder outlet obstruction (BOO).

RESULTS

A total of 108 female patients were recruited into the study. The mean age of the patients was 63.75 ± 14.02 years (range: 23-89). Detrusor overactivity was demonstrated in 55 patients (51%). The differential diagnosis was idiopathic OAB in 51 women (47.2%), SUI-associated in 46 (42.6%), neurogenic bladder in 13 (12.0%) and BOO in 7 (6.5%).

CONCLUSION

Our study suggests that the causes for OAB symptoms could be defined in half of the women visiting a urological clinic. Among them, SUI was the most common. Moreover, OAB symptoms in women might relate to BOO. Detailed history taking and sophisticated urodynamic studies are required for a substantial group of female patients with OAB symptoms to make the correct diagnosis and provide optimal therapy.

[Descriptive epidemiological study of the diagnosis of detrusor overactivity in urodynamic units in Spain]

OBJECTIVE

To know the relative weight of the diagnosis of detrusor overactivity (DO) in the Urodynamic Units of Spain and relate the prevalence of the overactive bladder (OB) syndrome.

MATERIAL AND METHOD

An epidemiological, descriptive, retrospective, multicenter, national study conducted according to registered data in 47 Urodynamic Units covering the Spanish geographic area in the different areas of health distributed among the regional communities. These data inform about the health care received by 35% of the Spanish population. Urodynamic diagnoses and related variables, recorded during 2007 and 2008, were collected.

RESULTS

A mean of 346.45 (SD=304.03) and 349.72 (SD=296.49) urodynamics studies per care unit were performed in women during 2007 and 2008, respectively and 181.20 (SD=212.71) and 195.68 (SD=257.58) in men. The relative weight of the diagnosis of non-neurogenic DO in women per unit was 31.39% and 35.28%, in 2007 and 2008, and in men was 21.06% and 20.43%. The diagnostic capacity of DO was 19.28 new cases per 100,000 inhabitants/year. The diagnosis of non-neurogenic DO in the woman accounts for one third of all the urodynamic/year diagnoses and more than half of the diagnoses of DO. In men, DO accounts for 25% of the diagnoses, the most frequent one being that associated with benign prostatic hyperplasia, followed by that of neurogenic cause. Approximately half of the DO diagnoses in children correspond to non-neurogenic DO.

CONCLUSIONS

The differences between the capacity of diagnosis of DO (ratio per 100,000 inhabitants) is far from many of the estimations of the prevalence of OB (relationship %). The doubt may exist about whether part of this quota is secondary and not-idiopathic, given the large difference between the frequency of OB and the capacity of diagnosis of DO.

Initial combined treatment with anticholinergics and α-blockers for men with lower urinary tract symptoms related to BPH and overactive bladder: a prospective, randomized, multi-center, double-blind, placebo-controlled study

We aimed to evaluate the efficacy and safety of combination treatment using anticholinergics with α-blocker for initial treatment of both overactive bladder (OAB) and other lower urinary tract symptoms (LUTS), secondary to BPH. A 12-week, randomized, double-blind, placebo-controlled trial was conducted at four urology clinics in Korea, involving men, aged 50 years or older, with LUTS related to BPH and OAB. A total of 176 patients were randomly assigned to receive doxazosin (4 mg) plus placebo or doxazosin (4 mg) plus tolterodine SR (4 mg), once a day for 12 weeks. Changes from baseline in total International Prostate Symptom Score (IPSS), bladder diary variables, patient perception of bladder condition (PPBC), uroflowmetry, postvoid residual volume and IPSS subscores (voiding and storage) were analyzed. Of the 176 enrolled patients, 91 had doxazosin gastrointestinal therapeutic system (GITS) and placebo, and 85 had combined medication with doxazosin GITS and tolterodine SR. Compared with the doxazosin plus placebo group, the doxazosin plus tolterodine group showed significant reductions in IPSS storage subscore and improvement in the quality of life item, urgency episodes, as well as in micturition frequency at weeks 4 and 12. However, it failed to improve PPBC at week 4 as well as at week 12. Earlier intervention with anticholinergics plus α-blocker was tolerated well, including the questions about urinary retention (n=1) and dry mouth (n=2). Initial combination treatment of anticholinergics plus α-blocker showed positive results for men with LUTS related to BPH and OAB symptoms and did not increase the risk of urinary retention.