External urethral sphincter electromyography in asymptomatic women and the influence of the menstrual cycle

What do we really know about the external urethral sphincter?

The external urethral sphincter (EUS), composed of skeletal muscle, along with a smooth muscle-lined internal urethral sphincter (IUS), have crucial roles in maintaining continence during bladder filling and facilitating urine flow during voiding. Disruption of this complex activity has profound consequences on normal lower urinary tract function during the micturition cycle. However, relatively little is known about the normal and pathological functions of these particular muscle types, how activity can be manipulated and regulated and why, for example, loss of EUS function and sarcopenia is associated with ageing. Here we discuss the unique physiological, biochemical and metabolic properties of striated and smooth muscle components of the urethral sphincter, which have distinct roles in maintaining continence during bladder filling. Relevant in vivo models for investigation of pathophysiological mechanisms, and for pre-clinical evaluation of therapeutic approaches are reviewed. Electromyography and Urethral Pressure Profile recordings are pivotal to understanding the function and dysfunction of the EUS and for clinical evaluation of e.g. urinary retention. Pre-clinical and clinical studies have revealed that age- or disease-related tissue remodelling that lead to filling/voiding disorders may be mitigated with emerging therapeutic approaches.

Chronic idiopathic urinary retention: Comorbidity and outcome in 102 individuals

OBJECTIVES

Chronic Idiopathic urinary retention is poorly understood. One small study suggests higher than expected rates of functional neurological disorder and pain comorbidity which may have implications for understanding the disorder. We investigated the frequency of functional neurological disorder, chronic pain other medical and psychiatric comorbidity, triggers of urinary retention, results of urodynamic assessment, medication history, management, and outcome in patients with chronic idiopathic urinary retention.

METHODS

A consecutive retrospective electronic notes analysis was undertaken of patients with chronic idiopathic urinary retention presenting to a secondary care urology clinic between Jan 2018-Jan 2021, with follow-up to their most recent urological appointment.

RESULTS

102 patients were identified (mean age of 41.9 years, 98% female). 25% had functional neurological disorder (n = 26), most commonly limb weakness (n = 19, 19%) and functional seizures (n = 16, 16%). Chronic pain (n = 58, 57%) was a common comorbidity. Surgical and medical riggers to urinary retention were found in almost half of patients (n = 49, 48%). 81% of patients underwent urodynamic assessment (n = 83). Most frequently no specific abnormality was reported (n = 30, 29%). Hypertonic urethral sphincter was the most identified urodynamic abnormality (n = 17, 17%). We noted high levels of opioid (n = 50, 49%) and benzodiazepine (n = 27, 26%) use. Urinary retention resolved in only a small number of patients (n = 6, 6%, median follow up 54 months), in three cases spontaneously.

CONCLUSION

This preliminary data suggests idiopathic urinary retention is commonly comorbid with functional neurological disorder, and chronic pain, suggesting shared mechanisms.

European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia

CONTEXT

Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions.

OBJECTIVE

To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females.

EVIDENCE ACQUISITION

The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline.

EVIDENCE SYNTHESIS

The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

CONCLUSIONS

Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format.

PATIENT SUMMARY

This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to the treatment of underactive bladder, obstruction of the bladder outlet, and nighttime urination.

An overview of sacral neuromodulation: a treatment for patients with symptoms of lower urinary tract dysfunction

This article provides an introduction to patient selection for, and the processes involved in, sacral neuromodulation (SNM) device implantation as a treatment for urinary symptoms. SNM has been an option to treat lower urinary tract dysfunction for more than 20 years and is a treatment for both overactive bladder syndrome (OAB) and female non-obstructed chronic urinary retention (FCUR). It is recognised by the National Institute for Health and Care Excellence as a therapeutic option for OAB and FCUR. SNM has its place in the pathway for the treatment of both conditions and, in the correctly assessed patient, can be the last option before considering major surgical intervention.

British Association of Urological Surgeons (BAUS) consensus document: Management of female voiding dysfunction

OBJECTIVES

To report the British Association of Urological Surgeon's (BAUS) guidance on the assessment and management of female voiding dysfunction.

METHODS

A contemporary literature search was conducted to identify the evidence base. The BAUS Section of Female, Neurological and Urodynamic Urology (FNUU) Executive Committee formed a guideline development group to draw up and review the recommendations. Where there was no supporting evidence, expert opinion of the BAUS FNUU executive committee, FNUU Section and BAUS members, including urology consultants working in units throughout the UK, was used.

RESULTS

Female patients with voiding dysfunction can present with mixed urinary symptoms or urinary retention in both elective and emergency settings. Voiding dysfunction is caused by a wide range of conditions which can be categorized into bladder outlet obstruction (attributable to functional or anatomical causes) or detrusor underactivity. Guidance on the assessment, investigation and treatment of women with voiding dysfunction and urinary retention, in the absence of a known underlying neurological condition, is provided.

CONCLUSION

Wa have produced a BAUS approved consensus on the management pathway for female voiding dysfunction with the aim to optimize assessment and treatment pathways for patients.

Fowler's Syndrome-The Cause of Urinary Retention in Young Women, Often Forgotten, but Significant and Challenging to Treat

Urinary retention in young women is a relatively rare clinical problem and is often underdiagnosed. In particular, functional causes of urinary retention pose a diagnostic challenge. One of them is Fowler's syndrome, which is associated with impaired urethral relaxation. Fowler's syndrome is characterized by a large bladder capacity, reduced sensation, increased maximal urethral closure pressure, and detrusor underactivity. Several hypotheses have arisen to explain the cause of urethral relaxation disorders: hormonal changes characteristic of Polycystic Ovary Syndrome (PCOS), causing abnormal stabilization of the muscle membrane, primary failure of relaxation of the striated muscle of the urethra sphincter, and increased urethral afferent activity, inhibiting the bladder afferent signals from reaching the brain by potentiating a spinal mechanism of urinary continence. Currently, sacral neuromodulation is the only intervention that can restore an atypical voiding pattern in women with Fowler's syndrome. The therapeutic effectiveness exceeds 70%, although the revision rate is relatively high, exceeding 50%. Well-designed, long-term prospective studies comparing sacral neuromodulation (SNM) with other therapies such as pelvic floor muscle physiotherapy are warranted to offer the best patient-tailored treatment.

Examination of pelvic floor muscle elasticity in patients with interstitial cystitis/bladder pain syndrome using real-time tissue elastography

INTRODUCTION AND HYPOTHESIS

The aim was to compare pelvic floor muscle (PFM) elasticity between interstitial cystitis/bladder pain syndrome (IC/BPS) patients and healthy women using real-time tissue elastography.

METHODS

The subjects were 17 IC/BPS female patients (IC/BPS group; age 34-84 years), 10 healthy middle-aged women (middle-aged group; 50-80 years), and 17 healthy young adult women (young group; 23-37 years). The target sites of elastography were the striated urethral sphincter (SUS) and adipose tissue as the reference site; muscle elasticity was calculated as the strain ratio (SR) of the SUS to the reference site. Evaluations were performed at rest and during PFM contraction. The IC/BPS group completed lower urinary tract symptom and pain questionnaires. SUS SR was compared among the three groups. SUS SR at rest and during PFM contraction was compared among the three groups with the t-test and the Wilcoxon test. Associations between questionnaire results and SUS SR were evaluated by correlation analysis.

RESULTS

There was no significant difference in age between the IC/BPS and middle-aged groups, but the young group was significantly younger than the other groups (p < 0.001). SUS SR at rest was significantly higher in the IC/BPS group than in the middle-aged (p = 0.014) and young groups (p = 0.002). Furthermore, in the IC/BPS group, there was no significant difference in SUS SR between at rest and during PFM contraction. SUS SR was not significantly correlated with questionnaire results for lower urinary tract symptoms.

CONCLUSIONS

SUS SR at rest was significantly higher in the IC/BPS group than in the young and middle-aged groups.

The Role of Pelvic Neurophysiology Testing in the Assessment of Patients with Voiding Dysfunction

Purpose of Review

The role of pelvic neurophysiology testing in the evaluation of patients with lower urinary tract (LUT) symptoms is explored in this review.

Recent Findings

Different neurophysiology tests such as sphincter EMG and pudendal somatosensory evoked potentials are useful in evaluating the sacral somatic afferent and efferent innervation. S2 and S3 dermatomal evoked potentials assess individual sacral roots and are feasible to perform using standard neurophysiology machines.

Summary

The innervation of the LUT has a substantial contribution from splanchnic and somatic nerves arising from the sacral segments. Pelvic neurophysiology tests, which assess somatic nerve functions, are therefore a useful tool in assessing sacral nerve functions in patients presenting with unexplained voiding dysfunction. In this review, the commonly performed neurophysiology studies that assess the S2, S3 and S4 sacral afferent and efferent pathways are outlined, and their clinical applications reviewed.

Retention of urine in women is alleviated by uterosacral ligament repair: implications for Fowler's syndrome

Introduction

The aim of this study was to independently evaluate idiopathic urinary retention and other known Fowler's syndrome (FS) descriptions in 24 women treated for posterior fornix syndrome (PFS) by reinforcement of the uterosacral ligaments (USL) using the tissue fixation system (TFS).

Material and methods

The main inclusion criterion was: idiopathic urinary retention with post-void residual urines (PVR) >100 ml.

Results

The mean patient age was 63 years (range 32–87). Except for peak urine flow, features typical of FS were statistically improved (p 0.015 to <0.0001), pre-op mean with post-op mean in brackets: PVR 272 ml (34 ml); abnormal emptying symptoms n = 24 (18/24 cured or 80% improved); natural bladder volume 598 ml (301 ml); emptying time 50 seconds (20 seconds): peak flow 42 ml/sec (37 ml/sec); chronic pelvic pain n = 18 (14/18 >80% improved); maximal urethral closure pressure >90 cm (n = 4) 93 cm H₂O (75 cm); frequency (14/14 improved); nocturia 110 episodes (33 episodes).

Conclusions

Functional disorders typical of FS, also present in posterior fornix syndrome, principally idiopathic urinary retention, were cured/improved by USL sling repair. Suggested anatomical pathway: lax USLs weaken the backward muscular forces, unbalancing bladder neck and urethral closure. Compensatory forward-acting closure muscles narrow the distal urethra, causing urinary flow difficulties, and retention. This functional imbalance can be relieved by posterior sling repair. We suggest that, rather than spasm from the (weak) rhabdosphincter (Fowler's syndrome), USL weakness is the most likely cause of idiopathic urinary retention in women.

New frontiers in molecular and imaging research on evaluation and diagnosis of bladder outlet obstruction in women

Purpose

Diagnosis of bladder outlet obstruction (BOO) often presents a challenge in female patients. Traditional diagnostic elements such as symptom history and urodynamic data are rarely clear cut in women. Therefore, we sought to review the current literature on diagnosis of female BOO, focusing on new frontiers in the realm of molecular markers and imaging modalities.

Recent Findings

In addition to fluoroscopy in the setting of videourodynamics, ultrasound and MRI can augment the diagnosis and aid in therapeutic planning in certain etiologies of female BOO. Furthermore, multiple potential biomarkers (i.e. nerve growth factor, prostaglandins, ATP) that have been studied in correlation to BOO in animal models as well as human subjects hold promise for diagnostic applications.

Summary

These novel techniques may augment standard clinical and urodynamic evaluation of BOO in females. Future directions include further studies of each of these biomarkers in female patients with BOO compared to normal controls to test their feasibility as potential screening tools.

Urologic symptoms and functional neurologic disorders

The term functional urologic disorders covers a wide range of conditions related broadly to altered function rather than structure of the lower urinary tract, mainly of impaired urine voiding or storage. Confusingly, for a neurologic readership, these disorders of function may often be due to a urologic, gynecologic, or neurologic cause. However, there is a subset of functional urologic disorders where the cause remains uncertain and, in this chapter, we describe the clinical features of these disorders in turn: psychogenic urinary retention; Fowler's syndrome; paruresis (shy-bladder syndrome); dysfunctional voiding; idiopathic overactive bladder, and interstitial cystitis/bladder pain syndrome. Some of these overlap in terms of symptoms, but have become historically separated. Psychogenic urinary retention in particular has now largely been abandoned as a concept, in part because of the finding of specific urethral electromyogram findings in patients with this symptom now described as having Fowler's syndrome, and their successful treatment with sacral neurostimulation. In this chapter we review the poorly researched interface between these "idiopathic" functional urologic disorders and other functional disorders (e.g., irritable-bowel syndrome, fibromyalgia) as well as specifically functional neurologic disorders. We conclude that there may be a relationship and overlap between them and that this requires further research, especially in those idiopathic functional urologic disorders which involve disorders of the urethral sphincter (i.e., voluntary muscle).