Identifying occult bladder outlet obstruction in women with detrusor-underactivity-like urodynamic profiles

Diagnoses and Treatment Recommendations-Interrater Reliability of Uroflowmetry in People with Multiple Sclerosis

BACKGROUND

Uroflowmetry (UF) is an established procedure in urology and is recommended before further investigations of neurogenic lower urinary tract dysfunction (NLUTD). Some authors even consider using UF instead of urodynamics (UD). Studies on the interrater reliability of UF regarding treatment recommendations are rare, and there are no relevant data on people with multiple sclerosis (PwMS). The aim of this study was to investigate the interrater reliability (IRR) of UF concerning diagnosis and therapy in PwMS prospectively.

METHODS

UF of 92 PwMS were assessed by 4 raters. The diagnostic criteria were normal findings (NFs), detrusor overactivity (DO), detrusor underactivity (DU), detrusor-sphincter dyssynergia (DSD) and bladder outlet obstruction (BOO). The possible treatment criteria were as follows: no treatment (NO), catheter placement (CAT), alpha-blockers, detrusor-attenuating medication, botulinum toxin (BTX), neuromodulation (NM), and physiotherapy/biofeedback (P/BF). IRR was assessed by kappa (κ).

RESULTS

κ of diagnoses were NFs = 0.22; DO = 0.17; DU = 0.07; DSD = 0.14; and BOO = 0.18. For therapies, the highest κ was BTX = 0.71, NO = 0.38 and CAT = 0.44.

CONCLUSIONS

There is a high influence of the individual rater. UD should be subject to the same analysis and a comparison should be made between UD and UF. This may have implications for the value of UF in the neuro-urological management of PwMS, although at present UD remains the gold standard for the diagnostics of NLUTD in PwMS.

Botulinum Toxin A Injection for Autonomic Dysreflexia-Detrusor Injection or Urethral Sphincter Injection?

Spinal cord injuries (SCI) have a profound impact on autonomic systems, sometimes resulting in multi-organ dysfunction, including of the neurogenic bladder. Autonomic dysreflexia (AD) is commonly seen in patients with SCI above T6 when the injured cord develops a deregulated sympathetic reflex, which can be induced by bladder sensation and can cause hypertensive crisis. While intravesical injection of botulinum toxin A (Botox) is a standard therapy for neurogenic detrusor overactivity, the role of Botox for AD has rarely been described. This study reviewed the medical records of SCI patients who reported AD and received either detrusor or urethral sphincter injection with Botox. The primary endpoint is the subjective improvement of AD. The secondary endpoint is a change in videourodynamic parameters before and after Botox injection. A total of 200 patients were enrolled for analysis. There were 125 (62.5%) patients in the detrusor injection group, and 75 (37.5%) in the urethral sphincter injection group. There were 79 (63.2%) patients in the detrusor injection group and 43 (57.3%) in the urethral sphincter injection group reporting moderate or marked improvement. Detrusor injection leads to a greater improvement in AD, probably because of decreased detrusor pressure and increased compliance after Botox injection. Urethral sphincter injection appears to have a modest effect on AD, despite general improvements in the voiding parameters of videourodynamic study.

Performance of urinary biomarkers in differentiating dysfunctional voiding in women with overactive bladder syndrome: a prospective pilot study

PURPOSE

Dysfunctional voiding (DV) in women is a common disorder that causes bladder outlet obstruction (BOO) and may aggravate overactive bladder (OAB) symptoms. The diagnosis of DV relies on clinical alertness and videourodynamic study (VUDS). In this pilot study, we aimed to explore the diagnostic potential of urinary biomarkers in women with DV.

METHODS

Women who visited our institute for the management of OAB were enrolled in this prospective study. Urine samples were collected before treatment and urinary proteins were quantified using enzyme-linked immunosorbent assay (ELISA) kits. Patients with DV and patients with normal tracings were included in the study and control group, respectively. The patients with DV were further divided into two subgroups: those with and those without detrusor overactivity (DO). VUDS parameters and urinary protein levels were compared between each subgroup.

RESULTS

A total of 67 women were enrolled. There were 47 patients with VUDS-diagnosed DV and 20 patients in the control group. Urinary 8-OHdG level (32.65 vs. 15.59, p < 0.001) and urinary TNF-α level (1.43 vs. 0.83, p = 0.031) were significantly higher in the DV group, and urinary IL-2 level (0.29 vs. 0.83, p < 0.001) was significantly lower in the DV group. Among the DV patients, urinary PGE2 level was higher in the DO group (240.4 vs 149.6, p = 0.049).

CONCLUSIONS

In women with DV, urinary 8-OHdG level is elevated compared to women with normal VUDS. Urinary PGE2 level is elevated in patients with DV and DO. These finding suggests increased reactive-oxidative stress response and detrusor hyperactivity in DV patients. Urinary biomarkers can serve as potential non-invasive diagnostic tools in women with OAB.