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Sollini ML, Pellegrino C, Barone G, Capitanucci ML, Zaccara AM, Crescentini L, Castelli E, Della Bella G, Scorletti F, Papetti L, Monte G, Ferilli MAN, Valeriani M, Mosiello G. Lower Urinary Tract Dysfunction in Pediatric Patients with Multiple Sclerosis: Diagnostic and Management Concerns. CHILDREN (BASEL, SWITZERLAND) 2024; 11:601. [PMID: 38790596 PMCID: PMC11119741 DOI: 10.3390/children11050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is increasing in the pediatric population and, as in adults, symptoms vary among patients. In children the first manifestations can sometimes overlap with acute neurological symptoms. Urological symptoms have not been much studied in childhood. We shared our experience with MS urological manifestation in children. METHODS This article is a retrospective evaluation of all children with MS, according to the Krupp criteria, who also present with urological symptoms. We collected demographic and clinical history, the MR localization of demyelinating lesions, urological symptoms, and exams. RESULTS We report on six MS pediatric cases with urological manifestation. Urinary symptoms, characterized by urinary incontinence in five patients and urinary retention in one patient, appeared in a different time frame from MS diagnosis. Urodynamic exams showed both overactive and underactive bladder patterns. Treatment was defined according to lower urinary tract dysfunction, using clean intermittent catheterization, oxybutynin, and intradetrusor Onabotulinum Toxin-A injection. A low acceptance rate of invasive evaluation and urological management was observed. CONCLUSIONS The MS diagnosis was traumatic for all our patients. We believe it is important to address urological care in young people from the time of diagnosis for prompt management; it could be useful to include a pediatric urologist in multidisciplinary teams.
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Affiliation(s)
- Maria Laura Sollini
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
- Clinical Science and Translational Medicine, Tissue Engineering and Remodeling Biotechnologies for Body Function PhD School, University of Rome Tor Vergata, Via Cracovia 50, 00133 Rome, Italy
| | - Chiara Pellegrino
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
| | - Giulia Barone
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
- Pediatric Surgery, University of Genoa, DINOGMI, Largo Paolo Daneo 3, 16132 Genoa, Italy
| | - Maria Luisa Capitanucci
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
| | - Antonio Maria Zaccara
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
| | - Leonardo Crescentini
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
| | - Enrico Castelli
- Neurorehabilitation Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Gessica Della Bella
- Neurorehabilitation and Adapted Physical Activity Day Hospital, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Federico Scorletti
- Neonatal Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Laura Papetti
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (G.M.); (M.A.N.F.); (M.V.)
| | - Gabriele Monte
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (G.M.); (M.A.N.F.); (M.V.)
| | - Michela Ada Noris Ferilli
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (G.M.); (M.A.N.F.); (M.V.)
| | - Massimiliano Valeriani
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (G.M.); (M.A.N.F.); (M.V.)
| | - Giovanni Mosiello
- Division of Neuro-Urology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.S.); (G.B.); (M.L.C.); (A.M.Z.); (L.C.); (G.M.)
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Salazar BH, Hoffman KA, Lincoln JA, Karmonik C, Rajab H, Helekar SA, Khavari R. Evaluating noninvasive brain stimulation to treat overactive bladder in individuals with multiple sclerosis: a randomized controlled trial protocol. BMC Urol 2024; 24:20. [PMID: 38273296 PMCID: PMC10809615 DOI: 10.1186/s12894-023-01358-8] [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: 08/11/2023] [Accepted: 11/06/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Multiple Sclerosis (MS) is an often debilitating disease affecting the myelin sheath that encompasses neurons. It can be accompanied by a myriad of pathologies and adverse effects such as neurogenic lower urinary tract dysfunction (NLUTD). Current treatment modalities for resolving NLUTD focus mainly on alleviating symptoms while the source of the discomfort emanates from a disruption in brain to bladder neural circuitry. Here, we leverage functional magnetic resonance imaging (fMRI), repetitive transcranial magnetic stimulation (rTMS) protocols and the brains innate neural plasticity to aid in resolving overactive bladder (OAB) symptoms associated with NLUTD. METHODS By employing an advanced neuro-navigation technique along with processed fMRI and diffusion tensor imaging data to help locate specific targets in each participant brain, we are able to deliver tailored neuromodulation protocols and affect either an excitatory (20 min @ 10 Hz, applied to the lateral and medial pre-frontal cortex) or inhibitory (20 min @ 1 Hz, applied to the pelvic supplemental motor area) signal on neural circuitry fundamental to the micturition cycle in humans to restore or reroute autonomic and sensorimotor activity between the brain and bladder. Through a regimen of questionnaires, bladder diaries, stimulation sessions and analysis, we aim to gauge rTMS effectiveness in women with clinically stable MS. DISCUSSION Some limitations do exist with this study. In targeting the MS population, the stochastic nature of MS in general highlights difficulties in recruiting enough participants with similar symptomology to make meaningful comparisons. As well, for this neuromodulatory approach to achieve some rate of success, there must be enough intact white matter in specific brain regions to receive effective stimulation. While we understand that our results will represent only a subset of the MS community, we are confident that we will accomplish our goal of increasing the quality of life for those burdened with MS and NLUTD. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (NCT06072703), posted on Oct 10, 2023.
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Affiliation(s)
- Betsy H Salazar
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA
| | - Kristopher A Hoffman
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
| | - John A Lincoln
- Department of Neurology, The University of Texas Health Science Center, Houston, TX, USA
| | - Christof Karmonik
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
| | - Hamida Rajab
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA
| | - Santosh A Helekar
- Center for Translational Biomagnetics and Neurometry, Houston Methodist Research Institute, Houston, TX, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA.
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Licow-Kamińska AA, Ciećwież SM, Ptak M, Kotlęga D, Brodowska A. Quality of Life in Female Patients with Overactive Bladder after Botulinum Toxin Treatment. Toxins (Basel) 2023; 16:7. [PMID: 38276531 PMCID: PMC10819285 DOI: 10.3390/toxins16010007] [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: 11/15/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Manifestations of OAB can considerably diminish the quality of life. Botulinum toxin has emerged as a valuable treatment option in diseases whose symptoms cannot be controlled adequately with other available therapies. The aim of the present study was to compare the subjective quality of life of patients with OAB before the injection of botulinum toxin and three and six months after the intervention. METHODS This study was based on a diagnostic survey with three validated questionnaires, ICIQ-OAB, ICIQ-OABqol, and ICIQ-LUTSqol, and an additional questionnaire developed by the authors to collect sociodemographic characteristics and selected medical data. RESULTS This study demonstrated significant differences between pre-treatment scores and those at three and six months post injection. At three and six months after the intervention, mean scores for all three instruments (ICIQ-OAB, ICIQ-OABqol, ICIQ-LUTSqol) were significantly lower than the respective pre-treatment values, implying a significant attenuation of OAB symptoms and their lower impact on the quality of life. However, the severity of OAB symptoms and their impact on the quality of life at six months post intervention were significantly higher than at three months, except for the social interaction domain. CONCLUSIONS Botulinum toxin is an effective treatment for OAB.
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Affiliation(s)
- Agnieszka A. Licow-Kamińska
- Department of Neonates, Pathology and Intensive Therapy, Independent Public Specialist Institute of Health “Zdroje”, ul. Mączna 4, 70-780 Szczecin, Poland;
- Department of Children Disease and Children Nursing, Pomeranian Medical University in Szczecin, ul. Żołnierska 48, 71-210 Szczecin, Poland
| | - Sylwester M. Ciećwież
- Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland;
| | - Magdalena Ptak
- Independent Subdepartment of Perineological Physiotherapy, Pomeranian Medical University in Szczecin, ul. Żołnierska 54, 51-210 Szczecin, Poland;
| | - Dariusz Kotlęga
- Department of Pharmacology and Toxicology, University of Zielona Góra, ul. Licealna 9, 65-417 Zielona Góra, Poland
| | - Agnieszka Brodowska
- Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland;
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de Rijk MM, Drake MJ, von Gontard A, Solomon E, Dmochowski R, Schurch B, van Koeveringe GA. Functional neuroimaging related to lower urinary tract sensations: Future directions for study designs and selection of patient groups: ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37960970 DOI: 10.1002/nau.25333] [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: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Neuroimaging studies have advanced our understanding of the intricate central nervous system control network governing lower urinary tract (LUT) function, shedding light on mechanisms for urine storage and voiding. However, a lack of consensus in methodological approaches hinders the comparability of results among research groups and limits the translation of this knowledge to clinical applications, emphasizing the need for standardized methodologies and clinical utilization guidelines. METHODS This paper reports the discussions of a workshop at the 2023 meeting of the International Consultation on Incontinence Research Society, which reviewed uncertainties and research priorities to progress the field of neuroimaging in LUT control and dysfunction. RESULTS Neuroimaging holds great potential for improving our understanding of LUT control and pathophysiological conditions. To date, functional neuroimaging techniques have not yet achieved sufficient strength to make a direct clinical impact. Potential approaches that can improve the clinical utilization of neuroimaging were discussed and research questions proposed. CONCLUSIONS Neuroimaging offers a valuable tool for investigating LUT control, but it's essential to acknowledge the potential for oversimplification when interpreting brain activity due to the complex neural processing and filtering of sensory information. Moreover, technical limitations pose challenges in assessing key brain stem and spinal cord centers, particularly in cases of neurological dysfunction, highlighting the need for more reliable imaging of these centers to advance our understanding of LUT function and dysfunction.
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Affiliation(s)
- Mathijs M de Rijk
- Department of Urology, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Urology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marcus J Drake
- Department of Surgery and Cancer, Imperial College, Hammersmith Hospital, London, UK
| | - Alexander von Gontard
- Parent-Child and Adolescent Department, Hochgebirgsklinik, Davos, Switzerland
- Governor Kremers Centre, Department of Urology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Eskinder Solomon
- Urology Centre, Guy's and St Thomas' NHS Trust, London, UK
- Paediatric Nephro-Urology, Evelina Children's Hospital, London, UK
| | - Roger Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brigitte Schurch
- Neuourology Unit, Clinique des Grangettes, Genève, Switzerland
- Department of Neuroscience, University Hospital Lausanne, Lausanne, Switzerland
| | - Gommert A van Koeveringe
- Department of Urology, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Urology, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Shawahna R, Hijaz H, Jallad K, Abushamma M, Sawafta M. Prevalence of overactive bladder symptoms and their impact on health-related quality of life of medical and dentistry students: a multicenter cross-sectional study. BMC Urol 2021; 21:142. [PMID: 34625087 PMCID: PMC8497683 DOI: 10.1186/s12894-021-00909-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Overactive bladder (OAB) is a popular distressing health condition that has negative impact on health-related quality of life (HRQoL) of the inflicted individuals. This multicenter study was conducted to determine the prevalence of OAB symptoms and their impact on the HRQoL of medical and dentistry students. Methods This study was conducted in a cross-sectional design in the 3 main universities in Palestine. In addition to the sociodemographic, health, and academic characteristics of the medical and dentistry students, the questionnaire also contained the OAB symptom bother (6-items) and HRQoL (13-items) Short-Form (OAB-q SF) scales. Kruskal–Wallis test, Mann–Whitney U test, Pearson Chi-Square/Fisher's Exact Test, Spearman’s rank correlations, and a multiple linear regression model were used to analyze the data. Results Responses were collected from medical and dentistry students (n = 402). The median OAB symptom bother score was 54.1 [44.8, 81.9] and the median HRQoL score was 94.4 [88.4, 94.4]. There was a strong negative correlation between the OAB and HRQoL scores (Spearman’s rho = 64.4%, p value < 0.001). OAB scores were significantly higher among dentistry students, females, who had chronic disease, and those who reported stressful life. HRQoL scores were significantly higher among medicine students, those who reported less stressful life, and those who reported satisfaction with their social life. Dentistry students, female, and those who self-reported high stress were 1.94-fold (95% CI 1.05, 3.56), 1.91-fold (95% CI 1.16, 3.14), and 1.88-fold (95% CI 1.21, 2.91) more likely to report less than optimal HRQoL compared to medicine students, male, and those who self-reported low stress, respectively. Conclusions Our findings suggested that OAB symptoms were prevalent among medical and dentistry students across Palestinian universities. Decision makers in academia, healthcare authorities, and advocacy groups might need to design appropriate interventions to address health and wellbeing issues of medical and dentistry students. Using appropriate diagnostic procedures, reducing stress, and improving the social life might help in reducing the burden on OAB and improve the HRQoL of medical and dentistry students. More investigations should be conducted to investigate if such interventions are effective in reducing OAB symptoms and improving HRQoL. Supplementary Information The online version contains supplementary material available at 10.1186/s12894-021-00909-1.
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Affiliation(s)
- Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, New Campus, Building: 19, Office: 1340, P.O. Box 7, Nablus, Palestine. .,An-Najah BioSciences Unit, Centre for Poison Control, Chemical and Biological Analysis, An-Najah National University, Nablus, Palestine.
| | - Hatim Hijaz
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine.,An-Najah National University Hospital, An-Najah National University, Nablus, Palestine
| | - Khaled Jallad
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Mohammad Abushamma
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Mothana Sawafta
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Contemporary Review of MRI in Benign Genitourinary Pelvic Medicine: What Every Urologist Should Know. CURRENT BLADDER DYSFUNCTION REPORTS 2021. [DOI: 10.1007/s11884-021-00631-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Groenendijk IM, Mehnert U, Groen J, Clarkson BD, Scheepe JR, Blok BFM. A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition. PLoS One 2021; 16:e0246042. [PMID: 33534812 PMCID: PMC7857581 DOI: 10.1371/journal.pone.0246042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 01/13/2021] [Indexed: 01/23/2023] Open
Abstract
Purpose Functional neuroimaging is a powerful and versatile tool to investigate central lower urinary tract (LUT) control. Despite the increasing body of literature there is a lack of comprehensive overviews on LUT control. Thus, we aimed to execute a coordinate based meta-analysis of all PET and fMRI evidence on descending central LUT control, i.e. pelvic floor muscle contraction (PFMC) and micturition. Materials and methods A systematic literature search of all relevant libraries was performed in August 2020. Coordinates of activity were extracted from eligible studies to perform an activation likelihood estimation (ALE) using a threshold of uncorrected p <0.001. Results 20 of 6858 identified studies, published between 1997 and 2020, were included. Twelve studies investigated PFMC (1xPET, 11xfMRI) and eight micturition (3xPET, 5xfMRI). The PFMC ALE analysis (n = 181, 133 foci) showed clusters in the primary motor cortex, supplementary motor cortex, cingulate gyrus, frontal gyrus, thalamus, supramarginal gyrus, and cerebellum. The micturition ALE analysis (n = 107, 98 foci) showed active clusters in the dorsal pons, including the pontine micturition center, the periaqueductal gray, cingulate gyrus, frontal gyrus, insula and ventral pons. Overlap of PFMC and micturition was found in the cingulate gyrus and thalamus. Conclusions For the first time the involved core brain areas of LUT motor control were determined using ALE. Furthermore, the involved brain areas for PFMC and micturition are partially distinct. Further neuroimaging studies are required to extend this ALE analysis and determine the differences between a healthy and a dysfunctional LUT. This requires standardization of protocols and task-execution.
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Affiliation(s)
- Ilse M. Groenendijk
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
- * E-mail:
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Becky D. Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jeroen R. Scheepe
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Bertil F. M. Blok
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
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Are White Matter Tract Integrities Different in Multiple Sclerosis Women With Voiding Dysfunction? Female Pelvic Med Reconstr Surg 2021; 27:e101-e105. [PMID: 32265400 PMCID: PMC9744261 DOI: 10.1097/spv.0000000000000830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Two white matter tracts (WMTs) are proposed to be involved in bladder function: anterior thalamic radiation and superior longitudinal fasciculus. Multiple sclerosis (MS) patients with voiding dysfunction (VD) may have distinct changes in these 2 WMTs. This study aims to compare the fractional anisotropy (FA) and mean diffusivity (MD) from diffusion tensor imaging of MS females with and without VD versus healthy controls (HCs). METHODS Prospective observational cohorts of 28 female MS patients and 11 HCs were recruited. Multiple sclerosis patients were divided into 2 groups: voiders (patients without VD, n = 14) and VD (patients with VD, n = 14). Diffusion tensor imaging of each subject was obtained, from which FA and MD maps were generated. The mean FA and MD of each WMT on both sides were analyzed using one-way analysis of variance and pairwise comparison with adjusted P values. RESULTS Overall MS patients had significantly lower mean FA (loss of coherence) and significantly higher mean MD (increased free diffusion) than HCs in both WMTs, indicating more damage. Furthermore, VD showed a trend of loss of integrity in both WMTs when compared with voiders with lower FA and higher MD. CONCLUSIONS There is damage reflected by lower FA and higher MD values in the proposed WMTs involved in bladder function in MS women. Voiding dysfunction in this patient population can be attributed to these damages considering women with VD demonstrated a trend of deterioration in these WMTs compared with women without VD. Future studies with larger sample sizes should be done to further confirm this correlation.
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Mehnert U, van der Lely S, Seif M, Leitner L, Liechti MD, Michels L. Neuroimaging in Neuro-Urology. Eur Urol Focus 2020; 6:826-837. [DOI: 10.1016/j.euf.2019.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 12/11/2019] [Accepted: 12/26/2019] [Indexed: 11/25/2022]
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Yeh TC, Chen PC, Su YR, Kuo HC. Effect of Botulinum Toxin A on Bladder Pain-Molecular Evidence and Animal Studies. Toxins (Basel) 2020; 12:toxins12020098. [PMID: 32028597 PMCID: PMC7076962 DOI: 10.3390/toxins12020098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 12/15/2022] Open
Abstract
Botulinum toxin A (BTX-A) is a powerful neurotoxin with long-lasting activity that blocks muscle contractions. In addition to effects on neuromuscular junctions, BTX-A also plays a role in sensory feedback loops, suggesting the potentiality for pain relief. Although the only approved indications for BTX-A in the bladder are neurogenic detrusor overactivity and refractory overactive bladder, BTX-A injections to treat bladder pain refractory to conventional therapies are also recommended. The mechanism of BTX-A activity in bladder pain is complex, with several hypotheses proposed in recent studies. Here we comprehensively reviewed properties of BTX-A in peripheral afferent and efferent nerves, the inhibition of nociceptive neurotransmitter release, the reduction of stretch-related visceral pain, and its anti-inflammatory effects on the bladder urothelium. Studies have also revealed possible effects of BTX-A in the human brain. However, further basic and clinical studies are warranted to provide solid evidence-based support in using BTX-A to treat bladder pain.
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Affiliation(s)
- Ting-Chun Yeh
- Division of Urology, Department of Surgery, Taiwan Adventist Hospital, Taipei City 105, Taiwan;
| | - Po-Cheng Chen
- Department of Urology, En Chu Kong Hospital, New Taipei City 237, Taiwan;
| | - Yann-Rong Su
- Department of Urology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City 300, Taiwan;
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien City 970, Taiwan
- Correspondence:
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Malde S, Apostilidis A, Selai C, Rahnama'i MS, Marcelissen T, Cardozo L, Lovick T. Botulinum toxin A for refractory OAB and idiopathic urinary retention: Can phenotyping improve outcome for patients: ICI-RS 2019? Neurourol Urodyn 2019; 39 Suppl 3:S104-S112. [PMID: 31692092 DOI: 10.1002/nau.24207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/20/2019] [Indexed: 12/17/2022]
Abstract
AIMS Botulinum toxin A (BTX-A) is a well-established treatment for refractory idiopathic overactive bladder (OAB). It has also been used with short-term success in treating idiopathic urinary retention. However, efficacy and complication rates are variable and predicting those likely to benefit most from treatment would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society (ICI-RS) meeting in 2019 a Think Tank addressed the question of how we can improve the way we phenotype patients undergoing BTX-A treatment. METHODS The Think Tank conducted a literature review and expert consensus meeting focussing on how advances in basic science research of the mechanism of action of BTX-A, as well as assessment of psychological comorbidity, can be translated into clinical practice to improve patient selection for therapy. RESULTS Idiopathic OAB and idiopathic urinary retention are heterogenous conditions encompassing several phenotypes with multiple potential pathophysiological mechanisms. Animal models have demonstrated a central nervous system mechanism of action of intravesically injected BTX-A and this has been confirmed in human functional MRI studies, but whether this tool can be used to predict outcome from treatment remains to be determined. Phenotyping based on psychological comorbidity using validated screening tools should be studied as a way to potentially optimize patient selection for therapy. CONCLUSIONS Advances in basic science research into the mechanism of action of BTX-A have improved our understanding of the pathophysiology of OAB and may lead to novel ways to phenotype patients. Psychological assessment is another way in which phenotyping may be improved. Areas for further research are proposed.
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Affiliation(s)
- Sachin Malde
- Department of Urology, Guy's Hospital, London, UK
| | - Apostolos Apostilidis
- 2nd Department of Urology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Caroline Selai
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Mohammad Sajjad Rahnama'i
- Department of Urology, Uniklinik Aachen RWTH, Aachen, Germany.,Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Tom Marcelissen
- Department of Urology, Uniklinik Aachen RWTH, Aachen, Germany
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Thelma Lovick
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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Abstract
Purpose of review Voiding dysfunction (VD) is morbid, costly, and leads to urinary tract infections, stones, sepsis, and permanent renal failure. Evaluation and diagnosis of VD in non-obstructed patients can be challenging. Potential diagnostic and therapeutic options beyond the bladder, such as brain centers involved in voiding have been proposed as promising targets. This review focuses on current and future applications of functional neuroimaging in human in voiding and in patients with VD. Recent findings The current understanding of brain centers, and their roles in initiating, maintaining and/or modulating voiding, is rudimentary in humans and in patients with VD. With the advent and advancement in functional neuroimaging we are gaining more insight into specific brain regions involved in the voiding phase of micturition. In healthy individuals, right dorsomedial pontine tegmentum, periaqueductal grey, hypothalamus, and the inferior, medial and superior frontal gyrus have been identified as regions of interest in voiding. Summary Functional neuroimaging could suggest new diagnostic methods and provides crucial steps towards therapeutic options for the morbid and intractable VD condition, in patients with neurogenic (e.g. MS or Strokes) or non-neurogenic VD (e.g. underactive bladder or Fowler's syndrome).
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Fröhlich K, Wang R, Bobinger T, Schmidt M, Dörfler A, Nickel FT, Hilz MJ, Lee DH, Linker RA, Seifert F, Winder K. Voxel-wise lesion mapping of self-reported urinary incontinence in multiple sclerosis. Neurourol Urodyn 2019; 39:295-302. [PMID: 31663158 DOI: 10.1002/nau.24194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/29/2019] [Indexed: 11/08/2022]
Abstract
AIMS Besides spinal lesions, urinary incontinence may be attributed to particular cerebral lesion sites in multiple sclerosis (MS) patients. We intended to determine the contribution of suprapontine lesions to urinary incontinence in MS using a voxel-wise lesion analysis. METHODS In this retrospective study, we sought MS patients with documented urinary incontinence in a local database. We established a control group of MS-patients without documented urinary incontinence matched for gender, age, and disease severity. Patients with urinary incontinence due to local diseases of the urinary tract were excluded. The MS lesions were analyzed on T2-weighted magnetic resonance imaging scans (1.5 or 3T). After manual delineation and transformation into stereotaxic space, we determined the lesion overlap and compared the presence or absence of urinary incontinence voxel-wise between patients with and without lesions in a given voxel performing the Liebermeister test with 4000 permutations. RESULTS A total of 56 patients with urinary incontinence and MS fulfilled the criteria and were included. The analysis yielded associations between urinary incontinence and MS in the frontal white matter, temporo-occipital, and parahippocampal regions. CONCLUSIONS Our voxel-wise analysis indicated associations between self-reported urinary incontinence and lesions in the left frontal white matter and right parahippocampal region. Thus, our data suggest that dysfunction of supraspinal bladder control due to cerebral lesions may contribute to the pathophysiology of urinary incontinence in MS.
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Affiliation(s)
- Kilian Fröhlich
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Tobias Bobinger
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Manuel Schmidt
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Florian T Nickel
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Frank Seifert
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Data-Driven Machine-Learning Quantifies Differences in the Voiding Initiation Network in Neurogenic Voiding Dysfunction in Women With Multiple Sclerosis. Int Neurourol J 2019; 23:195-204. [PMID: 31607098 PMCID: PMC6790826 DOI: 10.5213/inj.1938058.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/27/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To quantify the relative importance of brain regions responsible for reduced functional connectivity (FC) in their Voiding Initiation Network in female multiple sclerosis (MS) patients with neurogenic lower urinary tract dysfunction (NLUTD) and voiding dysfunction (VD). A data-driven machine-learning approach is utilized for quantification. METHODS Twenty-seven ambulatory female patients with MS and NLUTD (group 1: voiders, n=15 and group 2: VD, n=12) participated in a functional magnetic resonance imaging (fMRI) voiding study. Brain activity was recorded by fMRI with simultaneous urodynamic testing. The Voiding Initiation Network was identified from averaged fMRI activation maps. Four machine-learning algorithms were employed to optimize the area under curve (AUC) of the receiver-operating characteristic curve. The optimal model was used to identify the relative importance of relevant brain regions. RESULTS The Voiding Initiation Network exhibited stronger FC for voiders in frontal regions and stronger disassociation in cerebellar regions. Highest AUC values were obtained with 'random forests' (0.86) and 'partial least squares' algorithms (0.89). While brain regions with highest relative importance (>75%) included superior, middle, inferior frontal and cingulate regions, relative importance was larger than 60% for 186 of the 227 brain regions of the Voiding Initiation Network, indicating a global effect. CONCLUSION Voiders and VD patients showed distinctly different FC in their Voiding Initiation Network. Machine-learning is able to identify brain centers contributing to these observed differences. Knowledge of these centers and their connectivity may allow phenotyping patients to centrally focused treatments such as cortical modulation.
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Mechanisms of Botulinum Toxin Type A Action on Pain. Toxins (Basel) 2019; 11:toxins11080459. [PMID: 31387301 PMCID: PMC6723487 DOI: 10.3390/toxins11080459] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/31/2022] Open
Abstract
Already a well-established treatment for different autonomic and movement disorders, the use of botulinum toxin type A (BoNT/A) in pain conditions is now continuously expanding. Currently, the only approved use of BoNT/A in relation to pain is the treatment of chronic migraines. However, controlled clinical studies show promising results in neuropathic and other chronic pain disorders. In comparison with other conventional and non-conventional analgesic drugs, the greatest advantages of BoNT/A use are its sustained effect after a single application and its safety. Its efficacy in certain therapy-resistant pain conditions is of special importance. Novel results in recent years has led to a better understanding of its actions, although further experimental and clinical research is warranted. Here, we summarize the effects contributing to these advantageous properties of BoNT/A in pain therapy, specific actions along the nociceptive pathway, consequences of its central activities, the molecular mechanisms of actions in neurons, and general pharmacokinetic parameters.
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Rocca MA, Preziosa P, Filippi M. Application of advanced MRI techniques to monitor pharmacologic and rehabilitative treatment in multiple sclerosis: current status and future perspectives. Expert Rev Neurother 2018; 19:835-866. [PMID: 30500303 DOI: 10.1080/14737175.2019.1555038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Advances in magnetic resonance imaging (MRI) technology and analyses are improving our understanding of the pathophysiology of multiple sclerosis (MS). Due to their ability to grade the presence of irreversible tissue loss, microstructural tissue abnormalities, metabolic changes and functional plasticity, the application of these techniques is also expanding our knowledge on the efficacy and mechanisms of action of different pharmacological and rehabilitative treatments. Areas covered: This review discusses recent findings derived from the application of advanced MRI techniques to evaluate the structural and functional substrates underlying the effects of pharmacologic and rehabilitative treatments in patients with MS. Current applications as outcome in clinical trials and observational studies, their interpretation and possible pitfalls in their use are discussed. Finally, how these techniques could evolve in the future to improve monitoring of disease progression and treatment response is examined. Expert commentary: The number of treatments currently available for MS is increasing. The application of advanced MRI techniques is providing reliable and specific measures to better understand the targets of different treatments, including neuroprotection, tissue repair, and brain plasticity. This is a fundamental progress to move toward personalized medicine and individual treatment selection.
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Affiliation(s)
- Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University , Milan , Italy
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Abstract
Understanding the pathophysiologic mechanisms responsible for overactive bladder (OAB) and urgency urinary incontinence (UUI) is critical to advancing the treatment options available to men and women with this prevalent and bothersome condition. Development of novel technologies and advanced functional neuroimaging modalities has provided us with new information to support and refine existing mechanistic theories. Emerging research on central pathophysiologic mechanisms of OAB from functional magnetic resonance imaging may provide new targets for therapeutic interventions and opens the door for novel treatment strategies. Several regions of interest—specifically the anterior cingulate gyrus, insula, and frontal cortices—have been implicated as areas of activation in women with OAB, suggesting a neural correlate of the experience of urgency. The cerebellum and parietal lobe have demonstrated increased activation during inhibition of voiding, and increased connectivity between the cerebellum and parietal lobe and the right insula and anterior cingulate gyrus has been demonstrated in women with UUI compared with controls. Evolving literature is beginning to shed light on the prerequisite effective connections between regions of interest in the healthy bladder and negative connectivity in OAB and UUI. Precision medicine with individualized care pathways may better select available treatment modalities for rightful recipients, thus improving efficacy with prescribed treatment approaches and adherence to therapy.
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Affiliation(s)
- Ariana L Smith
- Division of Urology, University of Pennsylvania , Philadelphia, PA, USA
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