Phenoxybenzamine in neurogenic bladder dysfunction. II. Clinical considerations

A 12-Week, Open Label, Multi-Center Study to Evaluate the Clinical Efficacy and Safety of Silodosin on Voiding Dysfunction in Patients with Neurogenic Bladder

OBJECTIVES

The purpose of this study is to evaluate clinical effect and safety of α1A -adrenoceptor blocker, silodosin, in patients with voiding dysfunction caused by neurogenic bladder.

METHODS

From April 2011 to January 2012, patients who were diagnosed as potential voiding dysfunction associated with neurogenic bladder, aged ≥ 20 years were enrolled. Silodosin (8 mg/day) was administered once daily in the morning with food. The efficacy was assessed at the baseline and after 12 weeks of the treatment having following parameters of international prostate symptom score and other measures including the maximum flow rate and the postvoid residual urine volume.

RESULTS

A total of 97 patients were screened and 95 were enrolled. Of these 95 patients, 82 patients were completed and included in analysis. After 12-weeks of treatment, mean total international prostate symptom score decreased significantly from 22.23 ± 6.80 to 14.98 ± 9.48 (P = 0.0002). Voiding symptoms and storage symptoms were also improved by decreasing in international prostate symptom score-QoL from 4.62 ± 0.92 to 3.48 ± 1.63 (P < 0.0001). Maximum flow rate increased significantly from 10.72 ± 2.66 to 15.14 ± 6.63 (P < 0.0001). The main adverse event was ejaculation disorder. No serious adverse events related to silodosin were noted.

CONCLUSIONS

This study indicates that silodosin was significantly effective, well tolerated and safe in patients who have voiding dysfunction associated with neurogenic bladder.

Preliminary evaluation of alpha-adrenergic blocking agents in children with neurogenic bladder due to myelomeningocele

Twenty children with myelomeningocele and neurogenic bladder dysfunction were treated with alpha-adrenergic blocking agents. The results were satisfactory and are considered to justify the use of these drugs, especially for children who have weak or absent detrusor activity and urethral outflow resistance not of the dyssynergic type. There are indications that urinary diversion in such cases may be able to be postponed when alpha-adrenergic blocking agents are used more routinely.

Urinary incontinence: classification and pharmacological therapy

Pharmacological therapy has been developed which can have significant impact in the management of many forms of urinary incontinence and voiding dysfunction. In general the clinical laboratory studies which have supported or challenged the efficacy of many of the commonly prescribed drugs for voiding dysfunction are often difficult to interpret and contradictory. The available clinical studies often do not demonstrate a lack of bias. Nor do they include an adequate number of subjects, use appropriate and sensitive methods of evaluation, employ double-blind placebo-controlled design, or appear statistically valid. Although the contribution of laboratory research has been of unquestionable value in the development of our current knowledge of lower urinary tract pharmacology it is difficult to interpret the results of in vitro pharmacological studies because of the array of experimental models used and the need to extrapolate to in vivo activity. This paper utilizes a functional scheme which classifies agents by their effects on urinary storage and emptying. The purpose of this review is to promote discussion of the application of uropharmacological investigation to the development of newer, more efficacious forms of drug therapy.

The use and rationale of selective alpha blockade in children with non-neurogenic neurogenic bladder dysfunction

INTRODUCTION

We present here a long-term observation of 2 children with a rare syndrome with a non-neurogenic neurogenic bladder dysfunction (Hinman's syndrome), and we investigated the safety and efficacy of long-term use of terazosine in association with prophylactic antibiotics, timed voiding and a bowel regimen.

MATERIALS AND METHODS

Two children, 7 years-old (22 kg) and 11 years-old (36 kg) presented in 1997 to our pediatric urology clinic with symptoms of urgency, frequency, urge incontinence and nocturnal enuresis. Both children were placed in a regimen of terazosine (starting with 0.5 mg increasing until 2 mg).

RESULTS

There were no significant side effects throughout the entire treatment. The first 7-year old boy however developed some dizziness when the dose of terazosine was increased to 2 mg (after 4 weeks of administrating 1 mg), and this disappeared immediately when the dosage was reduced back to 1 mg daily. The urgency symptoms improved in both boys after 3 weeks of 1 mg terazosine. The secondary enuresis in the 11 year-old boy resolved after 2 months of 2 mg terazosine.

CONCLUSION

It is possible to say that the alpha-blocker medication, terazosine can be administered safely to children with a non-neurogenic bladder dysfunction, also known as the Hinman's syndrome. These results have shown that dysfunctional voiding, postvoiding residual and upper tract involvement can disappear over time when long term terazosine is given in combination with timed voiding, prophylactic antibiotic therapy and treatment of the associated constipation. Our observations also suggest a permanent effect after discontinuing the medication.

Urodynamic effects of alpha1-blocker tamsulosin on voiding dysfunction in patients with neurogenic bladder

BACKGROUND

The therapeutic role of alpha-blockers in the treatment of voiding disorders due to benign prostatic hyperplasia has been extensively examined. To investigate a possible effect of alpha1-blocker on urodynamic voiding parameters in patients with neurogenic bladder, we conducted a clinical trial using tamsulosin.

METHODS

Twenty-four patients (14 men and 10 women) ranging from 24 to 82 years of age (mean age 61 years) with neurogenic bladder were analyzed. Urodynamic studies were performed before and after treatment with 0.4 mg tamsulosin daily for 4 weeks.

RESULTS

On uroflowmetry, the average flow rate (from 4.6 +/- 3.3 to 6.7 +/- 3.0 mL/s, P = 0.04), maximum flow rate (from 9.4 +/- 6.8 to 14.1 +/- 7.0 mL/s, P = 0.016) and residual urine rate (from 46 +/- 29 to 32 +/- 21%, P = 0.02) improved significantly. In patients with detrusor contraction during voiding, detrusor opening pressure and detrusor pressure at maximum flow decreased significantly from 69.0 +/- 36.2 to 49.2 +/- 26.4 cmH2O (P = 0.046) and from 66.7 +/- 34.6 to 53.6 +/- 26.5 cmH2O (P = 0.007), respectively. On the other hand, in patients with detrusor areflexia, vesical opening pressure (from 78.2 +/- 23.4 to 61.6 +/- 25.2 cmH2O), or vesical pressure at maximum flow (from 68.6 +/- 23.2 to 62.9 +/- 25.2 cmH2O) did not change significantly after treatment.

CONCLUSION

Tamsulosin reduces functional urethral resistance during voiding and improves flow rate in patients with neurogenic bladder. It has more beneficial urodynamic effects in patients with detrusor contraction during voiding than in patients with detrusor areflexia.

Tamsulosin: Efficacy and Safety in Patients With Neurogenic Lower Urinary Tract Dysfunction Due to Suprasacral Spinal Cord Injury

PURPOSE

We evaluated the efficacy and safety of tamsulosin in patients with neurogenic lower urinary tract dysfunction secondary to suprasacral spinal cord lesions in a 4-week randomized controlled trial (RCT) followed by a 1-year, open label, long-term study.

MATERIALS AND METHODS

A total of 263 patients were randomized to 4-week double-blind therapy with placebo, or 0.4 or 0.8 mg tamsulosin once daily. Of these, 244 patients completed the RCT, 186 continued long-term tamsulosin therapy (0.4 or 0.8 mg once daily) and 134 completed 1-year treatment. The primary efficacy parameter was maximum urethral pressure (MUP).

RESULTS

Although the mean decrease in MUP at 4 weeks in the RCT did not reach statistical significance over the placebo, it was more pronounced with 0.4 (-12.2 cm H2O or -10%) and 0.8 mg (-9.6 cm H2O or -9%) tamsulosin than placebo (-6.5 cm H2O or -3%). In the long-term study there was a statistically significant mean decrease in MUP (-18.0 cm H2O, p <0.001 or -15%) from baseline to end point. In the long-term study tamsulosin also decreased maximum urethral closure pressure, improved several cystometry parameters related to bladder storage and emptying, and increased to a statistically significantly degree, from baseline to end point, mean voided volume based on the micturition diary. There was statistically significant improvement for the International Prostate Symptom Score Quality of Life, as well as several questions about symptoms related to urinary leakage, and 1 question on bladder emptying and frequency, bother and severity of symptoms of autonomic dysreflexia. Finally, 71% of patients improved according to investigators (44% slightly and 27% much improved). Both doses were effective and well tolerated.

CONCLUSIONS

Long-term tamsulosin treatment (0.4 and 0.8 mg once daily) seems to be effective and well tolerated in patients with neurogenic lower urinary tract dysfunction. The results suggest that it improves bladder storage and emptying, and decreases symptoms of autonomic dysreflexia.

The use of alpha1-adrenoceptor antagonists in lower urinary tract symptoms: beyond benign prostatic hyperplasia

The first empirical use of alpha(1)-adrenoceptor antagonists in urology occurred about 25 years ago in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), or LUTS/BPH. Today, many randomized, controlled trials have provided evidence for the efficacy and tolerability of alpha(1)-adrenoceptor antagonists in LUTS/BPH, and they are the most frequently used initial treatment option for this cause of LUTS. For many years, alpha(1)-adrenoceptor antagonists have also been used empirically in other types of lower urinary tract dysfunction (LUTD), such as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and neurogenic LUTD (NLUTD). Several investigators have shown that alpha(1)-adrenoceptor antagonists may be useful in patients with CP/CPPS. This was recently confirmed by a 6-week, double-blind, placebo-controlled pilot study evaluating the efficacy and safety of tamsulosin in 58 CP/CPPS patients. Further well-designed and -powered research into the use of alpha(1)-adrenoceptor antagonists in patients with CP/CPPS is currently ongoing. Several small-scale predominantly open-label studies have suggested that alpha(1)-adrenoceptor antagonists may be of benefit in patients with NLUTD. Data from 2 recent large-scale studies with tamsulosin in patients with NLUTD caused by suprasacral spinal cord injury suggest that long-term tamsulosin treatment improves bladder storage and emptying and also reduces symptoms of autonomic dysreflexia. Tamsulosin has also shown promise in ameliorating (early) storage symptoms and urinary retention associated with transurethral microwave thermotherapy, external-beam radiotherapy, and brachytherapy. In BPH patients presenting with the ultimate form of LUTS-acute urinary retention-treatment with tamsulosin before catheter removal results in a higher success rate of catheter-free voiding. Finally, it seems that alpha(1)-adrenoceptor antagonists may reduce the occurrence of urinary retention after (general) surgery. We can therefore conclude that alpha(1)-adrenoceptor antagonists, such as tamsulosin, may be useful for treating men with LUTS beyond BPH.

Formative years of the Urodynamics Society: reminiscences

This paper traces the roots and foundations of the Urodynamics Society as a scientific urologic research society back to the postwar information explosion of the 1950s and 1960s. It describes the then-separate islands of science and urologic practice which gradually became amalgamated through interdisciplinary and crossprofessional collaborations and networks, aided by generous government subsidies and wise university policies.

Urological dysfunctions and upper urinary tract involvement in multiple sclerosis patients

The goal of the present study was to investigate the involvement of the upper urinary tract (UUT) in patients with multiple sclerosis and its relationship with other neurological and urological features of the disease. One hundred sixteen patients underwent complete neurological and urological assessments, urodynamic investigation, and morphofunctional study of the urinary tract by ultrasonography, voiding cistourethrography, and/or intravenous excretory pyelography. The most remarkable relationships were observed among disease duration, pyramidal system score, amplitude of uninhibited detrusor contractions and the presence of bladder morphological abnormalities (P = 0.03, 0.0008, and 0.018, respectively) and the relationship between pyramidal system score or the presence of bladder pathology and UUT abnormalities (P = 0.03 and 0.0006, respectively). A significant relationship was found between the maximum amplitude of uninhibited contractions and UUT involvement (P = 0.002). No other significant relationship was observed between UUT involvement and any other urodynamic or urological features of the disease (type of progression and progression rate, Expanded Disability Status Scale, and other functional system scores). The relationship among disease duration, high vesical pressures, and the lack of reliable clinical indices of risk to the UUT stress the importance for patients with multiple sclerosis to adhere to a strict follow-up program with urodynamic assessment and urinary tract imaging and to maintain detrusor relaxation with anticholinergic medications.

The effectiveness of terazosin, an alpha1-blocker, on bladder neck obstruction as assessed by urodynamic hydraulic energy

OBJECTIVE

To investigate the effectiveness of terazosin, an alpha1-adrenoceptor blocking agent, on bladder neck obstruction (BNO), by assessing the urodynamic hydraulic energy profile. Patients, subjects and methods The study included 17 men (mean age 60.1 years, range 24-84), comprising 11 patients with BNO (mean age 66.5 years) and six normal volunteers (mean age 48.1 years). A five-transducer microtip catheter was used to measure the pressure in the bladder and at the bladder neck, and in the membranous and bulbous urethra during voiding. All the subjects then received terazosin, 1 mg/day orally for 2 weeks, and were re-assessed.

RESULTS

The bladder neck diameter at maximum flow significantly (P < 0.02) increased in the 11 patients with BNO after treatment with terazosin. The relative hydraulic energy profiles before terazosin treatment showed the greatest hydraulic energy loss between the membranous and the bulbous urethra in the normal subjects, and between the bladder neck and the membranous urethra in the men with BNO. After terazosin treatment, the greatest energy loss was between the membranous and the bulbous urethra in men with BNO, similar to that in the normal controls, i.e. the whole profile of relative hydraulic energy became normal.

CONCLUSION

Terazosin was effective in opening the bladder neck and improving the hydraulic energy profile in men with BNO.

Phenoxybenzamine in the management of neuropathic bladder following spinal cord injury

BACKGROUND

The present study aims to show the clinical and urodynamic effects of phenoxybenzamine on the neuropathic bladder of spinal cord-injured patients who failed to be free of catheter by attaining satisfactory voiding function, despite initial bladder training.

METHODS

Forty-six spinal cord-injured patients were subjected to pharmacological manipulation with phenoxybenzamine. It was used as an adjunct in the management of neuropathic bladder dysfunction that caused failure of the bladder to empty, by tapping or crede to achieve satisfactory residual urine volume of < 100 mL. Phenoxybenzamine was started with a dose of 10 mg daily, increased by 10 mg every 3 days to a dose of 30 mg daily; this was maintained from 3 weeks to 6 months (mean: 39 days). The pre-treatment residual urine volume ranged between 100 and 1050 mL (mean: 360 mL). Follow-up periods ranged between 12 and 36 months (mean: 16 months).

RESULTS

Five patients (11%) were excluded due to either inadequate treatment or inadequate follow-up. Nineteen patients (41%) with reflex (upper motor neurone) bladders showed improvement of bladder evacuation. There was a reduction of the maximum urethral closure pressure, which ranged between 10 and 32 cm of water (mean: 22 cm). Twenty-two patients (48%) did not respond, requiring other measures to be taken which included transurethral surgery (n = 19). Nine of the failures involved areflex (lower motor neurone) bladders, and seven failures involved reflex bladders with an extremely tight outlet and urethral closure pressure of > 50 cm of water. Six failures involved reflex bladders that were lacking strong enough detrusor contractions to attain a balanced bladder responsive to abdominal tapping; response was achieved by administration of a parasympatheticomimetic drug. Neuropathic bladders with uninhibited detrusor contractions responded well to phenoxybenzamine.

CONCLUSIONS

Phenoxybenzamine proved useful in reducing bladder outlet resistance after spinal cord injury, provided that detrusor bladder contractions were present. It is useful in controlling detrusor-sphincter dyssynergia and autonomic hyperreflexia. It was not useful in areflex bladders, perhaps due to the development of spasticity of the striated muscle component of the external sphincter. The presence of bladder neck (internal sphincter) dysfunction may modify or abolish its effect.

alpha-Adrenergic blockade in children with neuropathic and nonneuropathic voiding dysfunction

PURPOSE

Inadequate bladder emptying is a common urinary dysfunction in children. The role of alpha-blockers for managing bladder outlet obstruction remains relatively unexplored in children. Because of the well established impact of alpha-blocker therapy in men, we investigated its use for treating inadequate bladder emptying in the pediatric population.

MATERIALS AND METHODS

We treated 17 children 3 to 15 years old with documented poor bladder emptying of various etiologies, including dysfunctional voiding, the Hinman syndrome, the lazy bladder syndrome, posterior urethral valves, myelomeningocele and the prune-belly syndrome, using the alpha-1 adrenergic receptor antagonist, doxazosin. The initial dose of 0.5 to 1.0 mg. nightly was increased according to patient response and as tolerated. Patients were followed weekly to monthly by symptomatic history, and urine flow and/or post-void residual urine volume measurement. Two patients with neurogenic bladder were also followed with cystometrography and leak point pressure determination.

RESULTS

Bladder symptomatology and/or emptying improved in 14 patients (82%). Ten patients had decreased post-void residual urine during treatment and in 3 uroflowmetry showed increased maximum flow. Two patients with neuropathic bladder secondary to myelomeningocele had decreased leak point pressure on alpha-blocker therapy and in 2 with a history of posterior urethral valves new onset bilateral hydronephrosis completely resolved. Only 1 patient had mild postural hypotension, which resolved with dose reduction.

CONCLUSIONS

Selective alpha-blocker therapy seems to be well tolerated in children and appears effective for improving bladder emptying in various pediatric voiding disorders at short-term followup. Long-term followup and further investigation are warranted to validate the potential role of alpha-blocker therapy in pediatric urinary dysfunction.

Autonomic neuropathy, I. Clinical features, investigation, pathophysiology, and treatment

Autonomic dysfunction is a common complication of peripheral neuropathies. It is often of little clinical importance, but some conditions may cause profound disturbance of autonomic function, including postural hypotension, impotence and impairment of heart rate and bladder and bowel control. Autonomic function can be evaluated by a number of investigations, some of which can be performed in a neurophysiology laboratory. Diseases that primarily affect small nerve fibres or cause acute demyelination of small myelinated fibres are most likely to cause autonomic dysfunction. Management includes treating the underlying cause and symptomatic therapy.

A 10 year review of the endoscopic treatment of 125 spinal cord injured patients with vesical outlet obstruction: does bladder neck dyssynergia exist?

The management of 125 patients with post-traumatic neuropathic bladder and vesical outlet obstruction is described and a policy of endoscopic treatment is suggested. A total of 1652 spinal cord injured patients were treated during the period of 1983-1992. About 8% had an outlet of obstruction which required endoscopic treatment. The outcome of transurethral resection of the external sphincter and/or bladder neck was retrospectively analyzed in 82 patients, and a prospective study was conducted on the other 43 patients. We have demonstrated that patients with a complete spinal cord lesion at any level, and those with a high incomplete lesion (above T-9) have benefited from external sphincterotomy combined with bladder neck resection. We emphasize that patients with a low incomplete lesion (T-9 and below) have benefited from bladder neck resection alone. Bladder neck (internal sphincter) obstruction or dyssynergia may require to be considered in the management of the neuropathic bladder.

Detrusor bladder neck dyssynergia revisited

To our knowledge, direct measurement of active closure of the bladder neck during bladder contraction resulting in bladder neck dyssynergia and outflow obstruction has not yet been demonstrated. A total of 34 spinal cord injury patients underwent urodynamic investigation with 2 micro-transducer catheters in the urethrovesical and anorectal regions, respectively. Proper localization of the transducers was done with an image intensifier. The respective role of the striated and smooth muscles on bladder neck activity was evaluated after pudendal nerve blocks and phentolamine injections. Of the patients 25 had active bladder neck dyssynergia with concomitant detrusor-sphincter dyssynergia. Pressures were higher in the bladder neck than in the bladder. Pudendal blocks abolished detrusor-sphincter but not bladder neck dyssynergia, which was decreased by additional phentolamine but only in patients in whom bladder neck dyssynergia was associated with autonomic hyperreflexia. Evidence is presented that active bladder neck dyssynergia may exist in patients with a neurogenic bladder and that it is seemingly dependent on alpha 1-postsynaptic and alpha 2-presynaptic adrenoreceptors.

Improvement of urethral resistance after the administration of an alpha-adrenoceptor blocking agent, urapidil, for neuropathic voiding dysfunction

We assessed the effect of a new alpha-blocking agent, urapidil, on neuropathic voiding dysfunction, by urodynamic studies. The residual urine volume and rate significantly decreased, whereas the average and the maximum flow rate did not increase significantly. The pressure at maximum flow and minimum urethral resistance decreased significantly. These results suggest that improvement of the voiding dysfunction in some cases could be due to the decreased micturition pressure without increasing the flow rate. The urethral resistance calculated from the pressure/flow data seemed to be a valuable index in evaluating the effects of the drug on neuropathic voiding dysfunction.

Clinical effect of alpha-1 antagonism by terazosin on external and internal urinary sphincter function

The purpose of this investigation was to determine the effectiveness of alpha-1 blockade in the treatment of bladder outlet obstruction in the spinal cord injured (SCI) patient. We evaluated terazosin, a selective alpha-1 blocker, in 15 normotensive SCI patients. Detrusor-external sphincter dyssynergia (DESD), without obstruction of the bladder neck or prostate, was documented in all patients using video-urodynamic evaluation. Urodynamic testing was performed both before and during treatment with terazosin (5 mg nightly). Voiding pressure before and during terazosin therapy averaged 92 +/- 17 and 88 +/- 27 cm H2O, respectively (p = 0.48). After subsequent external sphincterotomy or sphincter stent placement, the voiding pressure was reduced to 38 +/- 15 cm H2O (p < 0.001). Nine other patients suffered from persistent difficulty voiding after previous sphincterotomy. Each was subsequently treated with oral terazosin. In five patients who improved with this treatment, urodynamic parameters demonstrated obstruction only at the bladder neck, with no evidence of obstruction at the level of the external sphincter. The four patients who failed to improve were documented to have an open bladder neck but obstruction at the level of the external sphincter. Our data show that alpha-1 sympathetic blockade has no effect on external sphincter function and does not significantly relieve functional obstruction caused by DESD. It was also noted that terazosin is helpful in diagnosing and treating internal sphincter (bladder neck and prostate) obstruction especially in patients who have persistent difficulty voiding after external sphincterotomy.

A study of the alpha-1 adrenoceptor blocker prazosin in the prophylactic management of autonomic dysreflexia in high spinal cord injury patients

The ability of the alpha-1 adrenoceptor antagonist, prazosin, to reduce the severity and duration of episodes of autonomic dysreflexia was studied in cervical and high thoracic spinal cord injury patients with documented episodes of autonomic dysreflexia. Sixteen patients participated in a double blind parallel group study comparing prazosin 3 mg b.d. with placebo given for 2 weeks. Both groups were matched for age, sex and baseline severity of autonomic dysreflexia episodes. Prazosin was well tolerated and did not produce a significant lowering of resting blood pressure. Compared to baseline measurements, patients allocated to prazosin therapy were found to have fewer severe episodes of autonomic dysreflexia and during these episodes to have significant reductions in average rise in systolic and diastolic blood pressure, symptom duration and requirement for acute antihypertensive medication. The severity of headache during individual autonomic dysreflexia episodes was also diminished with prazosin therapy. No symptom parameter was significantly altered by placebo therapy. It is concluded that prazosin is superior to placebo in the prophylactic management of autonomic dysreflexia and that these findings are consistent with suggestions that alpha-1 adrenoceptors play an important role in the pathogenesis of this syndrome.

Adrenergic and cholinergic innervation of the smooth and striated muscle components of the urethra from patients with spinal cord injury

The adrenergic and cholinergic innervation of the smooth and striated muscle components of the urethra from spinal cord injury patients with detrusor sphincter dyssynergia were investigated neurochemically and histochemically. Catecholamine fluorescence histochemistry provided no evidence for the presence of adrenergic nerves associated with the skeletal muscle. The noradrenaline content of this region probably reflects the endogenous levels in adrenergic nerves associated with the blood vessels supplying the skeletal muscle. Choline acetyltransferase activity in the skeletal muscle was significantly lower in patients with cervical lesions than in those with thoracic lesions (p less than 0.01). The noradrenaline content of the smooth muscle was significantly lower in cervical lesions than in thoracic lesions in both the mid (p less than 0.02) and the distal (p less than 0.001) regions of the urethra. The proximal region revealed similar noradrenaline levels in both groups of spinal cord injury patients. The results are discussed in relation to the role of the autonomic nervous system in the control of voiding and to the presence of increased sympathetic outflow in patients with spinal cord lesions at higher levels.

Bladder outlet surgery in men with spinal cord injury

The effect of bladder outlet surgery on voiding ability, changes in the upper urinary tract and urinary infections was studied in 51 men with spinal cord injury. In 24 patients reoperation was required after varying periods of time to achieve satisfactory bladder voiding. Eight of the 22 men who had undergone external sphincterotomy had constant dribbling of urine postoperatively. Dilation of the upper urinary tract was completely reversed or reduced in 13 of 18 patients following the primary operation on the bladder outlet. Vesico-ureteric reflux was found in 6 of the 8 men in whom deterioration of the upper urinary tract persisted after the initial operation or appeared during the follow-up years. Bacteriuria usually persisted, despite bladder outlet surgery, but febrile attacks of urinary tract infection ceased or became less frequent in 15 of the 22 patients who had experienced such episodes preoperatively.

Vesicourethral motility following acute spinal cord transection in the cat

The cause of urinary retention during the phase of spinal shock is still uncertain. In the cat with intact spinal cord, reflex voiding shows a coordination between the longitudinal and circular urethral muscles, the detrusor and the periurethral striated muscles. After transection of the spinal cord in cervical and/or thoracic segments, 26 of 28 cats failed to void. An incoordination between longitudinal, circular, detrusor and periurethral striated muscles was noticed simulating a urethro-urethral and urethrovesical dyssynergia. The 2 cats that voided 6 hours after the cord section showed a return of synergism between longitudinal, circular, detrusor and periurethral striated muscles. The conventional pharmacologic manipulation used during the early period following spinal cord transection, bethanechol chloride and phentolamine, failed to achieve proper bladder emptying because it did not correct the dyssynergic pattern.

Effects of prazosin in patients with benign prostatic obstruction

Prazosin, a selective alpha-1-adrenoceptor blocker, was used in a double-blind crossover study in 20 men with benign prostatic obstruction. Maximum and average flow rates increased, and residual volume and obstructive symptoms were reduced. Voiding pressure parameters, bladder capacity and irritative symptoms did not change significantly. No side effects were noted. We conclude that prazosin seems to be an effective therapeutic alternative in patients with benign prostatic obstruction.

Neurologic implications of the pathologically open bladder neck

Normally the bladder neck remains closed except during voiding. We reviewed 550 consecutive patients who underwent synchronous video/flow/pressure/electromyography studies to identify whether neurologic factors are involved in the pathogenesis of an abnormally open bladder neck. A total of 33 patients who had not undergone prior bladder neck surgery had an open bladder neck at rest. The prevalence of neurologic lesions in patients with an open bladder neck was significantly greater than in those with a normal bladder neck. However, there was no correlation between any specific lesion and the incidence of an open bladder neck. Patients with myelodysplasia had an inordinately high incidence of open bladder neck. We conclude that abnormalities of bladder neck innervation may result in a pathologically open bladder neck.

Effect of phenoxybenzamine (dibenzyline) on sexual function in man

Phenoxybenzamine (Dibenzyline) has been extremely effective in treating patients with detrusor dyssynergia. Its minimal side effects include: mouth dryness, nasal congestion, drowsiness and fatigue, nausea and vomiting, palpitations, ejaculatory failure, and retrograde ejaculation. Nineteen men treated with phenoxybenzamine for detrusor dyssynergia reported ejaculatory failure during treatment; normal ejaculation returned after treatment was discontinued. Postmasturbation urine and semen samples were analyzed for sperm and fructose. The results of the study suggest that ejaculatory failure was due to the lack of seminal emission into the posterior urethra, rather than retrograde ejaculation. Some implications of this study are also discussed.

Radical transurethral resection of the prostate for neurogenic dysfunction of the bladder in male paraplegics

We herein report our experience with radical transurethral resection of the prostate in 50 paraplegics refractory to conventional conservative therapy, including the use of alpha-adrenolytic drugs and clean intermittent self-catheterization. The operation was successful in 46 patients (92 per cent) and unsuccessful in 4 tetraplegics with complete high cervical lesions. We discuss the rationales of this procedure for neurogenic dysfunction of the bladder and present urodynamic changes in the successful and unsuccessful cases. This extensive and, yet, microsurgically anatomical resection of the urethral sphincter is recommended for all refractory paraplegics except for complete tetraplegics with high cervical lesions.

Urodynamic evaluation of dysfunctional bladder neck obstruction in men

Dysfunctional bladder neck obstruction in young men has received increasing interest in recent years. The urodynamic characteristics of this disorder include elevated voiding pressure, normal reflex relaxation of the urethral rhabdosphincter, increased pressure gradient between the membranous urethra and the bladder, and inadequate radiographic bladder neck opening during detrusor activity. The functional changes occurring at the internal sphincter in 3 patients with dysfunctional bladder neck obstruction are described herein. It is demonstrated that the obstruction may result from either an active dyssynergic bladder neck contraction or failure of bladder neck relaxation. While the pathophysiology of dysfunctional bladder neck obstruction is uncertain possible mechanisms are discussed.

Neuropharmacologic evaluation in spinal cord injury patients using membrane catheter cystosphincterometry

Synchronous cystosphincterometry with a membrane catheter was done on spinal cord injury patients. Bladder and urethral pressures were monitored quantitatively during vesical filling and emptying. Phentolamine, propantheline and bethanechol chloride were administered to selected patients with bladder and urethral dysfunction. The membrane catheter technique was an excellent method to evaluate the pharmacology of detrusor and urethral function.

The effects of epidural anesthesia on the urethral closure pressure profile in patients with prostatic enlargement

In 10 patients with obstructive manifestations of prostatic enlargement the urethral closure pressure profile was observed before and after the effective blockade of thoracolumbar sympathetic outflow by epidural anesthesia. While epidural anesthesia significantly decreased urethral closure pressure considerable profile responses still remained in these patients. This fact suggests that the bulk of the prostatic tissue is responsible for the bladder outlet obstruction, since urethral closure pressure persists despite urethral smooth and skeletal muscular relaxation as a result of epidural anesthesia. After transurethral resection of the prostatic tissue in these patients the urethral closure pressure did decrease to zero. The result of the prostatic resection is to decrease the urethral closure pressure and, thereby, increase the efficiency of voiding.

Clinical and urodynamic assessment of alpha-adrenolytic therapy in patients with neurogenic bladder function

The efficacy of alpha-adrenolytic treatment with oral phenoxybenzamine chloride (40 mg per day during three to four months) has been assessed both clinically and urodynamically among 249 patients with neurogenic bladder function. The results were significantly better in patients with autonomous (n = 95) than in the ones with automatic (n = 154) bladders (urethral sphincter spasticity and detrusor sphincter dyssynergia dominating the clinical picture in the latter event). A further striking difference was noticed when the data were analysed with regard to the patient's age, a far better therpeutic response being regularly recorded in subjects below age 35, while minimal and inconsistent improvements were observed in the older age group. No major side effects were encountered. Caution is however required in tetraplegics where phenoxybenzamine may aggravate orthostatic hypotension. On the other side the drug proves highly beneficial in these same patients in that it markedly lowers the incidence of dysreflexic states.

Surgical management of massive neurogenic hydronephrosis

Permanent urinary diversion has been the standard recommended treatment of massive dilatation of the upper tracts in the child with neurogenic vesical dysfunction. Reimplantation of relatively normal caliber ureters into neurogenic bladders has been shown to be effective. However, attempts to save urinary diversion in 39 neurogenic megaureters have been unrewarding, with the salvage rate of 15 per cent, and 64 per cent have been diverted permanently. Upper tract decompression by continuous or intermittent catheterization, nephrostomy or end cutaneous ureterostomy was used in this series. When ureteral caliber responded to decompression a reasonable success rate from non-tailored reimplantation may be anticipated. However, in those instances in which ureteral caliber failed to respond or when tailoring or ureteral caliber was done in conjunction with reconstruction the success rate was much lower.