Dysfunctional voiding

The effect of pelvic floor muscle training in women with functional bladder outlet obstruction

INTRODUCTION AND HYPOTHESIS

Female voiding dysfunction is often due to bladder outlet obstruction (BOO). We investigated pelvic floor muscle training (PFMT) effectiveness in women with functional BOO.

METHODS

This is a prospective study recruiting 63 women functionally obstructed, over 18yo, maximum flow rate (Qmax) less than 12 ml/sec, naïve of voiding treatment. Exclusion criteria were anatomical BOO, neurological condition, pelvic intervention, psychiatric or anticholinergic medication, diabetes mellitus and affected upper urinary tract. At baseline, women underwent uroflow, post void residual (PVR) measurement, cystoscopy, cystogram and urodynamic study (UDS) with pelvic electromyography (EMG). Blaivas-Groutz nomogram has been used to define obstruction. After diagnosis, patients underwent six-month PFMT. Re-evaluation was offered four weeks after end of treatment. Data were analyzed with SPSSv22.0.

RESULTS

63 women were recruited and 48 finally included. At baseline, 20 reported 3 urinary tract infections (UTIs) during last year, and 12 had one episode of urine retention. Median Qmax was 7.5 ml/sec and median PVR 110 ml. 40 women were obstructed. 16 (40%) had mild, 16 (40%) moderate and 8 (20%) severe obstruction. All subjects had an overactive pelvic floor on EMG. Obstructed women were re-evaluated. Median Qmax was 8.5 ml/sec, close to baseline (p = 0.16). Median PVR was 65 ml, reduced to baseline (p = 0.02). 33 (82.5%) remained obstructed, 22 (66.67%) with mild, 8 (24.24%) moderate and 3 (9.09%) severe obstruction. 7 (17.5%) were non-obstructed. 4 patients reported one UTI episode with no cases of retention.

CONCLUSIONS

A 6 month PFMT reduced UTIs and PVR in women with functional BOO. Additionally, most patients had a de-escalation to milder obstruction.

Long-Term Follow-Up of Lower Urinary Tract Outcome in Children with Dysfunctional Voiding

Objective: To investigate the long-term clinical and urodynamic outcomes of a small cohort of children who received short-term urotherapy for confirmed dysfunctional voiding (DV) and lower urinary tract symptoms (LUTS). Materials and Methods: This study included 26 children with confirmed LUTS and DV via video urodynamic study (VUDS) and received standard urological therapy, pelvic floor muscle training, or surgical intervention in childhood. Their current lower urinary tract conditions were assessed by chart review and direct and telephone interviews. Charts of 14 patients who underwent follow-up VUDS were reviewed to investigate their bladder and voiding dysfunction or follow-up on previous treatment results. The satisfaction of lower urinary tract status was assessed using the global response assessment (GRA) scale. Results: At initial enrolment, the mean age was 9.54 ± 3.88 years, and urological treatment was performed during the first 1−5 years thereafter. Most patients were not regularly followed in the urology clinic. Among the 14 children available for follow-up, a GRA score of 3 was reported by 10 (71.4%) after a mean follow-up period of 10.3 ± 6.74 (range, 2−20) years, indicating satisfactory bladder and voiding conditions. Four children with less favorable outcomes (GRA score of <3) had significantly more post-void residual urine volume at baseline, and 75% of these patients had central nervous system diseases. Daytime incontinence and enuresis rates were significantly decreased at follow-up compared with the baseline. Significantly increased bladder capacity and sensation and significantly decreased voiding detrusor pressure were found on follow-up VUDS. Conclusions: Children with DV who received standard urotherapy upon diagnosis exhibited improved LUTS at a 10-year follow-up. Of the 14 children available for follow-up, 10 (71.4%) reported satisfactory bladder and voiding status without further medication or urotherapy, with significantly decreased voiding detrusor pressure.

Is biofeedback-assisted pelvic floor muscle training superior to pelvic floor muscle training alone in the treatment of dysfunctional voiding in women? A prospective randomized study

Purpose:

To compare the effectiveness of biofeedback-assisted pelvic floor muscle training (PFMT) and PFMT alone on voiding parameters in women with dysfunctional voiding (DV).

Materials and Methods:

The patients in group 1 (34 patients) were treated with biofeedback-assisted PFMT, and the patients in group 2 (34 patients) were treated with PFMT alone for 12 weeks. The 24-hour frequency, average voided volume, maximum urine flow rate (Q_max), average urine flow rate (Q_ave), post-void residual urine volume (PVR), and the validated Turkish Urogenital Distress Inventory (UDI-6) symptom scores were recorded before and after 12 weeks of treatment.

Results:

At the end of treatment sessions, the Q_max and Q_ave values of the patients in group 1 were significantly higher than those in group 2, and the PVR in the patients in group 1 was significantly lower than those in group 2 (p=.026, .043, and .023, respectively). The average UDI-6 symptom scores of the patients in group 1 were significantly lower than those in group 2 (p=.034). Electromyography activity during voiding, in group 1 was significantly lower than in group 2 (41.2 vs. 64.7, respectively, p=.009).

Conclusion:

Biofeedback-assisted PFMT is more effective than PFMT alone in improving clinical symptoms, uroflowmetry parameters, and EMG activity during voiding.

Therapeutic efficacy of biofeedback pelvic floor muscle exercise in women with dysfunctional voiding

Dysfunctional voiding (DV), a voiding dysfunction due to hyperactivity of the external urethral sphincter or pelvic floor muscles leading involuntary intermittent contractions during voiding, is not uncommon in neurologically normal women with lower urinary tract symptoms (LUTS). We aimed to investigate the therapeutic efficacy of biofeedback pelvic floor muscle training (PFMT) in female patients with DV and to identify the therapeutic efficacy. Thirty-one patients diagnosed with DV. All participates completed the 3-month biofeedback PFMT program, which was conducted by one experienced physiotherapist. At 3 months after treatment, the assessment of treatment outcomes included global response assessment (GRA), and the changes of clinical symptoms, quality of life index, and uroflowmetry parameters. 25 (80.6%) patients had successful outcomes (GRA ≥ 2), and clinical symptoms and quality of life index significantly improved after PFMT. Additionally, uroflowmetry parameters including maximum flow rate, voided volume, voiding efficiency, total bladder capacity, voiding time, and time to maximum flow rate significantly improved after PFMT treatment. Patients with the history of recurrent urinary tract infection in recent 1 year were found to have unsatisfied therapeutic outcomes. In conclusion, biofeedback PFMT is effective in female patients with DV with significant improvements in clinical symptoms, quality of life, and uroflowmetry parameters. The history of urinary tract infection in recent 1 year is a negative predictor of successful outcome.

The combination of loratadine with famotidine to relieve the symptoms of urinary frequency in female patients with bladder function disorders：First report of three cases

WHAT IS KNOWN AND OBJECTIVES

Urinary frequency is a common presentation of bladder function disorders in female patients. Few medicines are effective in all patients. The use of loratadine combined with famotidine had not been previously reported for this indication.

CASE DESCRIPTION

Three female patients complaining of urinary frequency had been given loratadine at 10 mg QD combined with famotidine 20 mg BID for about 5 months. They all achieved symptom improvement.

WHAT IS NEW AND CONCLUSION

The combination of loratadine with famotidine was used to treat urinary frequency. It was safe, effective, and convenient, and may be an option for oral medical therapy in female patients with bladder function disorders.

Pelvic floor dysfunction at transperineal ultrasound and voiding alteration in women with posterior deep endometriosis

INTRODUCTION AND HYPOTHESIS

Posterior deep infiltrating endometriosis (DIE) has been associated with pelvic floor muscle (PFM) alteration and voiding dysfunction (VD). The aim of this study is to evaluate the correlation between the presence of VD and altered PFM morphometry, objectively evaluated using 3D/4D transperineal ultrasound at rest and during dynamic maneuvers, in patients with posterior DIE.

METHODS

A prospective study was conducted on 108 symptomatic women scheduled for surgical removal of posterior DIE. The study population was divided in two groups according to presence or absence of VD on the Bristol Female Lower Urinary Tract Symptoms (BFLUTS). A 3D/4D transperineal ultrasound was performed to compare the following PFM morphometric parameters: levator hiatus area (LHA), antero-posterior (AP) and left-right (LR) diameters and levator ani muscle (LAM) coactivation. LAM coactivation was defined as the paradoxical contraction of the pelvic floor muscle during the Valsalva maneuver causing a smaller LHA than in the resting state.

RESULTS

Forty-eight (45.2%) women presented VD, while 60 (54.8%) women did not report any voiding complaints. Baseline characteristics did not significantly differ between the two groups. We did not find any significant statistical differences in PFM parameters between the two groups, except for a higher rate of levator ani muscle coactivation in women with VD compared with women without VD [64.6% (31/48) versus 31.7% (19/60), respectively; p = < 0.001].

CONCLUSIONS

In women affected by posterior DIE, LAM coactivation at 3D/4D transperineal ultrasound seems to be more frequent in patients with than without VD.

Therapeutic effect of urethral sphincter onabotulinumtoxinA injection for urethral sphincter hyperactivity

PURPOSE

Urethral sphincter hyperactivity resulting in voiding dysfunction is frequently encountered. Medical treatment might not achieve a satisfactory result. OnabotlinumtoxinA urethral sphincter injection relaxes sphincter tonicity and possibly resumes efficient voiding. This study analyzed the treatment outcomes and predictor for successful onabotulinumtoxinA treatment on these patients.

METHODS

Patients with voiding dysfunction due to urethral sphincter hyperactivity and treated with injections of 100 U onabotulinumtoxinA into the urethral sphincter were retrospectively reviewed. Treatment outcomes were assessed 1 month after injection using the Global Response Assessment and were analyzed by demographic and baseline video-urodynamic characteristics.

RESULTS

Of the 95 patients included, satisfactory outcomes were reported in 58 (61.1%) patients. Treatment outcome was not related to age, gender, or voiding dysfunction subtype. Patients with satisfactory outcomes had a significantly smaller volume at first sensation of filling (P = 0.046), greater detrusor pressure (P = 0.027), higher maximum flow rate (P = 0.017), and smaller post-void residual (P = 0.006). In multivariate analysis, an open bladder neck during voiding was the only predictor for successful outcome (88% in satisfactory outcome, 12% in failure outcome, P < 0.001). Patients with non-neurogenic voiding dysfunction had a significantly longer therapeutic duration than those with neurogenic voiding dysfunction (9.55 ± 4.18 vs 7.44 ± 2.91 months, P = 0.033). Increased urinary incontinence was reported in 18 patients, including 6 with stress urinary incontinence and 12 with urgency urinary incontinence.

CONCLUSION

Subjective improvement was reported in 61.1% of patients with voiding dysfunction due to urethral sphincter hyperactivity after onabotulinumtoxinA urethral sphincter injection. An open bladder neck during voiding at baseline predicts a successful outcome.

How can we maximize the diagnostic utility of uroflow?: ICI-RS 2017

AIMS

To gauge the current level of diagnostic utility of uroflowmetry and to suggest areas needing research to improve this.

METHODS

A summary of the debate held at the 2017 meeting of the International Consultation on Incontinence Research Society, with subsequent analysis by the authors.

RESULTS

Limited diagnostic sensitivity and specificity exist for maximum flow rates, multiple uroflow measurements, and flow-volume nomograms. There is a lack of clarity in flow rate curve shape description and uroflow time measurement.

CONCLUSIONS

There is a need for research to combine uroflowmetry with other non-invasive indicators. Better standardizations of test technique, flow-volume nomograms, uroflow shape descriptions, and time measurements are required.

Impact of Preoperative Patient Characteristics and Flow Rate on Failure, Early Complications, and Voiding Dysfunction After a Transobturator Tape Procedure: A Multicentre Study

PURPOSE

To evaluate the impact of preoperative patient characteristics and flow rate on failure, early postoperative complications, and voiding in patients who underwent transvaginal tension-free vaginal tape-obturator (TVT-O) treatment for uncomplicated stress urinary incontinence (SUI).

METHODS

We retrospectively reviewed patients who underwent TVT-O for SUI at 3 Italian centres. The exclusion criteria were predominant voiding and storage symptoms suggestive of detrusor overactivity, the presence of grade >1 urogenital prolapse, previous pelvic radiotherapy or other clinical contraindications for surgical procedures, neurogenic bladder dysfunction, and collagen diseases. Multivariate logistic regression models were constructed to identify predictors of early voiding dysfunction after TVT-O.

RESULTS

A total of 219 patients underwent TVT-O between January 2010 and December 2015. All patients received follow-up at 3, 6, and 12 months, and underwent a stress test, uroflowmetry, and bladder ultrasound to evaluate the postvoid residual volume. They also responded to the Urogenital Distress Inventory (UDI-6) questionnaire. The rates of persistent incontinence after TVT-O, postoperative complications, and satisfaction were 16.4% (36 of 219), 24.2% (53 of 219), and 86.3% (189 of 219), respectively. Nineteen patients (9.5%) experienced early voiding dysfunction. Based on an analysis of baseline characteristics, we determined that a cutoff value of 9.0 on the UDI-6 predicted postoperative SUI with 62% specificity, 72% sensitivity, and 66% accuracy. In the multivariate logistic regression analysis, a preoperative UDI-6≥9.0 was an independent predictor of postoperative SUI. The predictors of complications were menopause (P = 0.04) and the preoperative UDI-6 score (P = 0.01).

CONCLUSIONS

Menopause and UDI-6 scores could be prognostic factors for persistent SUI after TVT-O. Well-designed prospective studies with a suitable number of patients are needed to corroborate our findings.

Videourodynamic analysis of the urethral sphincter overactivity and the poor relaxing pelvic floor muscles in women with voiding dysfunction

AIMS

Voiding dysfunction due to dysfunctional voiding (DV) and poor relaxation of the external sphincter (PRES) are commonly found among adult women with lower urinary tract symptoms (LUTS) during videourodynamic study (VUDS). This study analyzed the VUDS characteristics of DV and PRES in female voiding dysfunction.

METHODS

This retrospective study involved 1914 women aged >18 years with refractory LUTS. The medical records and the VUDS parameters were reviewed. Patients diagnosed with DV and PRES participated in the study. The VUDS characteristics and urethral sphincter activities were compared with those of urodynamically normal women.

RESULTS

Of the 1914 women, 325 (17.0%) and 336 (17.6%) were diagnosed with DV and PRES, respectively. Detrusor overactivity (DO) occurred in 60% of the women with DV and in 5.7% of the women with PRES. Patients with DV had significantly increased bladder sensation, lower cystometric bladder capacity (CBC), lower bladder compliance, higher voiding detrusor pressure, smaller voided volume (VV), larger post-void residual volume (PVR), lower voiding efficiency (VE), and higher bladder outlet obstruction index (BOOI) than the women with PRES and the control individuals. Patients with PRES had significantly increased bladder sensation, lower CBC, lower maximum flow rate, smaller VV, larger PVR, and lower VE than the control individuals.

CONCLUSIONS

DV and PRES were highly prevalent among the adult women with voiding dysfunction. Patients with DV had VUDS characteristics of BOO and urodynamic DO. The clinical symptoms of PRES were similar to those of DV, but the patients had low detrusor contractility and low DO rates.

Pharmacologic management of non-neurogenic functional obstruction in women

INTRODUCTION

Impaired bladder emptying in women without neurologic disease may be related to urethral obstruction and/or impaired bladder contractility. Mechanical obstruction generally requires surgical management and options are limited for impaired bladder contractility. However, functional obstruction from voiding dysfunction or primary bladder neck obstruction may present an opportunity for pharmacologic intervention.

AREAS COVERED

In this review, the authors extensively reviewed available literature regarding the use of off-label medications for functional bladder outlet obstruction in women. In addition, side effect profiles and pharmacology of these medications determined from on-label indications are reviewed. Specific medications reviewed include vaginal diazepam, baclofen, urethral botulinum toxin injection, and alpha-adrenergic blockers.

EXPERT OPINION

Alpha-blockers in particular have demonstrated promise in women with demonstrable or suspected bladder outlet obstruction with side effect profiles similar to those observed in men. However, lack of quality data hinders informed decision making with alpha-blockers or any of the other agents studied in women with non-neurogenic functional outlet obstruction. In the absence of well-designed, placebo-controlled multi-institutional trials, those prescribing these medications must be aware of special considerations and side effects associated with relatively unfamiliar treatments in the context of uncertain benefit.