Prolonged bladder distension as a treatment of urgency and urge incontinence of urine

A systematic review of the literature on cystodistension in bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

There is significant variability in technique for cystodistension and an international discrepancy in the role in its treatment of bladder pain syndrome (BPS). The authors evaluate the evidence base for the use of cystodistension for BPS with particular reference to patient-related outcomes.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement, a prospective search and evaluation protocol was prepared and registered with the PROSPERO database (ID CRD42017053710). A review of the literature was performed using the search terms cystodistension and hydrodistension of the bladder using the PubMed database on 6 October 2016.

RESULTS

A total of 59 papers were reviewed, but only 17 studies contained original data available for analysis from 1975 to 2016. Ten studies evaluated the outcome of cystodistension in a single arm design or used cystodistension as the control for evaluating adjunctive treatments. Seven studies evaluated cystodistension in combination with other agents or therapies. The best symptomatic responses reported a subjective improvement in 56% of men with moderate to severe prostatitis and 57% in patients with "inflammatory cystitis" respectively. There were no studies that employed a validated outcome measure, neither a questionnaire nor an analogue scale, to assess the effect of cystodistension alone.

CONCLUSIONS

Cystodistension is increasingly popular, despite a weak evidence base by current standards. The quality of available evidence falls below the level that would be expected of a new intervention. This review highlights the need for cystodistension to be further investigated with randomised control trials.

Cystodistension: Is there evidence to support its use in current practice for patients with overactive bladder?

Cystoscopy and cystodistension have been part of common treatment protocols for a variety of bladder conditions for many years. However, the science behind the procedure is not strong and continued use of the operation may not be justified. Much research is old and was not planned or executed with the current rigour demanded by current trial methods. Newer treatments such as intravesical botulinum toxin have been extensively researched and found to be effective. This review article aimed to review the evidence behind the use of cystodistension for overactive bladder (OAB) with the aim of identifying the weaknesses in the current evidence. The article aimed to identify whether a general anaesthetic cystoscopy and distension has sufficient evidence to recommend its continued use in current practice for patients with OAB resistant to conservative and drug therapies. Impact statement Cystodistension is often used in current practice in patients with overactive bladder (OAB) resistant to conservative and drug therapies. Older data suggested that this may be of benefit but there are no randomized controlled trails with appropriate assessment of symptoms and quality of life outcomes. This paper reviews the current evidence regarding the use of cystodistension in patients with OAB. There is no standardized method of cytodistension making direct comparisons difficult. The data consists of case series from individual units. Some series show benefit but in most cases this is not sustained. Initial improvement may fall to around 10-20% after 6 months. Urodynamic parameters may also fail to improve. The procedure is associated with a complication rate of 10-20%. A randomised controlled trial of cystodistension is needed to identify if this procedure should be performed for patients with OAB.

Cystodistension versus cystoscopy in patients with refractory detrusor overactivity: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Cystodistension may be offered as a treatment for patients with refractory overactive bladder. The reported efficacy is based on a number of case series. This study was designed to evaluate the efficacy of cystodistension in a randomized trial.

METHODS

This was a randomized study comparing cystoscopy combined with cystodistension with cystoscopy alone. The primary outcome was improvement in the Urgency Perception Scale (UPS) score. Symptoms were assessed using the ICIQ Female Lower Urinary Tract Symptoms (ICIQ-FLUTS). Quality of life was assessed using the Urinary Distress Inventory (UDI).

RESULTS

A total of 77 patients were recruited into the study with 42 randomized into the cystodistension arm and 35 into the cystoscopy-only arm. UPS scores had improved in both the cystodistension (41%) and cystoscopy (44%) arms at 6 weeks, but cystodistension provided no added benefit over cystoscopy alone. There was a significant improvement in ICIQ-FLUTS scores in the cystoscopy-only arm at 6 weeks (p = 0.01), but there was no significant improvement in the cystodistension arm (p = 0.09). At 6 weeks there were significant improvements in UDI scores in both arms (both p = 0.01). Despite statistical improvements at 6 weeks, no clinically therapeutic benefit was maintained by either procedure at 6 months.

CONCLUSIONS

Cystoscopy produces some short-term improvement in bladder symptoms, but cystodistension does not.

Purinergic signalling in the urinary tract in health and disease

Purinergic signalling is involved in a number of physiological and pathophysiological activities in the lower urinary tract. In the bladder of laboratory animals there is parasympathetic excitatory cotransmission with the purinergic and cholinergic components being approximately equal, acting via P2X1 and muscarinic receptors, respectively. Purinergic mechanosensory transduction occurs where ATP, released from urothelial cells during distension of bladder and ureter, acts on P2X3 and P2X2/3 receptors on suburothelial sensory nerves to initiate the voiding reflex, via low threshold fibres, and nociception, via high threshold fibres. In human bladder the purinergic component of parasympathetic cotransmission is less than 3 %, but in pathological conditions, such as interstitial cystitis, obstructed and neuropathic bladder, the purinergic component is increased to 40 %. Other pathological conditions of the bladder have been shown to involve purinoceptor-mediated activities, including multiple sclerosis, ischaemia, diabetes, cancer and bacterial infections. In the ureter, P2X7 receptors have been implicated in inflammation and fibrosis. Purinergic therapeutic strategies are being explored that hopefully will be developed and bring benefit and relief to many patients with urinary tract disorders.

Physiology and pathophysiology of purinergic neurotransmission

This review is focused on purinergic neurotransmission, i.e., ATP released from nerves as a transmitter or cotransmitter to act as an extracellular signaling molecule on both pre- and postjunctional membranes at neuroeffector junctions and synapses, as well as acting as a trophic factor during development and regeneration. Emphasis is placed on the physiology and pathophysiology of ATP, but extracellular roles of its breakdown product, adenosine, are also considered because of their intimate interactions. The early history of the involvement of ATP in autonomic and skeletal neuromuscular transmission and in activities in the central nervous system and ganglia is reviewed. Brief background information is given about the identification of receptor subtypes for purines and pyrimidines and about ATP storage, release, and ectoenzymatic breakdown. Evidence that ATP is a cotransmitter in most, if not all, peripheral and central neurons is presented, as well as full accounts of neurotransmission and neuromodulation in autonomic and sensory ganglia and in the brain and spinal cord. There is coverage of neuron-glia interactions and of purinergic neuroeffector transmission to nonmuscular cells. To establish the primitive and widespread nature of purinergic neurotransmission, both the ontogeny and phylogeny of purinergic signaling are considered. Finally, the pathophysiology of purinergic neurotransmission in both peripheral and central nervous systems is reviewed, and speculations are made about future developments.

The effects of piroxicam to the muscosal barrier of the bladder after overdistension--an experimental study in rabbits

The effects of piroxicam on the duration and severity of damage to the mucosal barrier of the urinary bladder after overdistension was investigated. Overdistension of the bladder was induced for 3 h in 16 New Zealand male rabbits by giving Ringer's lactate infusion (40 mL/kg/h) and furosemide (1 mg/kg) to the peritoneal cavity. Insertion of 8 Fr Foley catheter was used for obstruction of the bladder neck. In both control (C) and piroxicam (P) groups, 20 mL of 2% solution of Trypan blue in 0.9% NaCl solution was instilled into the bladder for 1 hr at 0, 24, 48 h and 7 days after overdistension. In group P daily intramuscular injection of 5 mg/kg piroxicam, and isotonic saline in group C was administrated for 7 days. Full-thickness samples were taken from the bladder at 0, 24, 48 h and 7 days after overdistension. The bladder wall was deep blue throughout in both groups at 0, 24, and 48 h. The severity and duration of inflammatory reaction was lower and nearly normalized on the 7th post procedure day in piroxicam group.

CONCLUSION

Inflammatory reaction can be prevented by administration of anti-inflammatory drugs such as piroxicam but the prevention of increased permeability is unclear after overdistension of the bladder.

Adjuvant hydrodistension under epidural anesthesia for interstitial cystitis

BACKGROUND

Hydrodistension is the first choice of treatment for interstitial cystitis because it allows for diagnosis, bladder biopsy and treatment. However, the method and efficacy of hydrodistension are variable. We performed adjuvant hydrodistension and examined the efficacy and factors that influence prognosis.

METHODS

Fifty-two patients participated in the present study as subjects; they satisfied the diagnostic inclusion and exclusion criteria established by the National Institute of Diabetes, Digestive and Kidney Disease (NIDDK) in 1987, USA. Under epidural anesthesia, the bladder was repeatedly distended up to the maximal bladder capacity for treatment, diagnosis and biopsy. Hydrodistension was performed again on the following day for approximately 30 min under epidural anesthesia in a ward until macroscopic hematuria disappeared.

RESULTS

Five patients were classified into the good, 30 into the moderate and 17 into the poor response group. In the good response group, three patients had type I allergy and one patient did not fulfil all of the positive factors in the NIDDK criteria. The poor response group included one patient with collagen disease. The poor response group was further divided into two subgroups based on bladder capacity. One subgroup included eight patients with a bladder capacity of less than 100 mL and vesicoureteral reflux (VUR). The other subgroup included nine patients with a bladder capacity of more than 100 mL. Among these nine patients there were five patients who lacked one or two positive factors in the NIDDK criteria.

CONCLUSION

Adjuvant hydrodistension under epidural anesthesia is effective for about 70% of patients for more than 3 months. It can be performed in a ward without any serious complications. It was observed that patients lacking one or two positive factors were included in the good and poor response groups.

Prolonged hydrodistention of the bladder for symptomatic treatment of interstitial cystitis: efficacy at 6 months and 1 year

OBJECTIVE

To determine the efficacy of hydrodistention of the bladder for symptomatic treatment of interstitial cystitis after 6 months and 1 year of follow-up and to identify a predictive factor.

METHODS

The study included 65 consecutive patients (a first retrospective series of 33 and a second prospective series of 32) treated by hydrodistention of the bladder for urinary symptoms attributed to interstitial cystitis. All experienced pain on bladder filling, which was relieved by micturition or bladder voiding, and had more than two nocturias. Glomerulations were detected at short hydrodistention during cystoscopy. No patients were subject to NIH exclusion criteria. Hydrodistention was performed continuously for 3 h without rest intervals under epidural anesthesia using a balloon with a pressure equal to the patient's mean arterial pressure. Efficacy was defined as the disappearance of pain on bladder filling or the persistence of moderate, non-disabling pain for which the patient did not request treatment, and a low frequency of nocturia (zero to two times). The efficacy period was estimated according to Kaplan-Meier methods for survival curves. The second series was used to verify the analytic results of the first series.

RESULTS

Treatment efficacy was 12/32 (37.7% CI: 20.7-54.3) at 6 months and 7/32 (21.9% CI: 7.6-36.2) at 1 year for the first series, and 18/30 (60.0% CI: 45.0-75.0) at 6 months and 13/30 (43.3% CI: 25.6-61.1) at 1 year for the second series. In both series, results were better for the subgroup of patients with a bladder capacity > or = 150 ml during cystometry before distention.

CONCLUSIONS

This study showed good but transient efficacy in the least developed or least severe forms of the disease.

The efficacy of bladder distention therapy in the treatment of frequency and urgency

BACKGROUND

The aim of this retrospective study was to evaluate whether bladder distention therapy is effective in relieving the symptoms of patients experiencing urinary frequency and urgency.

MATERIALS AND METHODS

Twenty-six female patients with a history of frequency and urgency who underwent multi-channel urodynamic assessment, were treated with bladder distention therapy for symptomatic relief of their symptoms. Their mean age was 51 years of age (range from 28 to 75 years old). No patient had detrusor-urethral sphincter dyssynergia. Bladder distention therapy was performed in the operating theatre under epidural anesthesia. Statistical analysis was performed with the Student's t-test.

RESULTS

The treatment was successful in 9 out of 26 patients after the first attempt (34.6%) and in 10 out of 26 patients after the second attempt (38%) at 1 month follow-up (FLU) and in 4 out of 28 patients at 9 months FLU (15%). Only one out of four patients who had this treatment twice showed improvement of her symptoms.

CONCLUSION

Bladder distention therapy in patients with symptoms of overactive bladder dysfunction has a very small success rate (15%) and therefore, has no place in the modern treatment of bladder dysfunction.

Evidence for a unique elastic sheath surrounding the vesicular arteries of the rabbit urinary bladder--studies of the microvasculature with microscopy and vascular corrosion casting

Because the urinary bladder stores and releases urine, its normal function includes filling and emptying, accompanied by distension and relaxation. It is known that chronic distension compromises blood flow. Recent studies of the rabbit bladder vasculature have described specializations of that vasculature that appear to enhance blood flow in the bladder wall during distension. The present report describes the location, orientation, and structure of an elastic sheath surrounding the vesicular arteries, which may represent one of these specializations. The location, vasculature, and structure of an accessory elastic sheath surrounding the vesicular arteries of the rabbit bladder is described using light and electron microscopy, India ink injection, and vascular corrosion casting. The common iliac arteries of rabbits were cannulated to permit perfusion of the distal vasculature including the urinary bladder. After the bladder vasculature was visually cleared of blood by perfusion with buffered saline, one of the following procedures was used: 1) for light or electron microscopy, the bladder was perfuse-fixed with buffered 2% glutaraldehyde; 2) the bladder vasculature was filled with India ink for vessel tracing; or 3) corrosion casts of the bladder vasculature were prepared by infusion of a Mercox resin mixture. Casts, cleaned of tissue with KOH, and water and formic acid rinses, are dried, and mounted for routine scanning electron microscopy. The presence of an accessory sheath surrounding the main vesicular arteries and some of their branches in the basal two thirds of the urinary bladder was observed on India ink injected specimens and confirmed by micrographs and vascular corrosion casts. The sheath consists of elastic and collagenous fibers and is separated from the tunica media of the arteries by a loose connective tissue layer of variable width. The sheath is circumscribed by a layer of fine blood vessels. The vesicular arteries undulate within the sheath to an extent which is dependent upon the degree of distension of the bladder. This sheath likely represents a specialization which permits the bladder vasculature to accommodate expansion and contraction of the wall during normal filling and emptying. Undulations or coiling of the vesicular arteries within the loose connective tissue core of the sheath increase with bladder contraction, and apparently the sheath simply holds the artery in position during such coiling. The sheath, may represent a modification of the external elastic lamina found in some muscular arteries.

Experiences with clam ileocystoplasty

Clam ileocystoplasty was performed in 18 patients with urge incontinence, total incontinence or enuresis with instable detrusor. Although the persistence of detrusor instability was observed in 33.33% of the patients, complete clinical cure was found in 72.23 and symptomatic improvement was 22.22%.

Influence of transient overdistension on bladder wall morphology and enzyme histochemistry

Bladder overdistension has been found to cause transitional morphological changes in innervation which correlate with changes in micturition and bladder contractility. We investigated the influence of overdistension on bladder wall morphology using histological and enzyme histochemical methods. Overdistension was induced in female rats for 3 h by forced diuresis and balloon obstruction of the bladder neck. Oedema was seen beneath the mucosa at 12 h, with hyperemia and haemorrhages. The urothelium was mostly intact, although enzymes leaked out of the epithelial cells. The changes were increased at 24 h. The urothelium also showed some disruptions and degenerative vacuolization. The oedema reached its maximum at 48 h, and large numbers of inflammatory cells were also seen. The urothelium was disruptured in many places and vacuolated, but the subendothelial capillaries remained normal. Damage to some muscle cells was seen. After 7 days the oedema had disappeared and the urothelium was continuous. Enlarged nuclei were seen as white spots in the epithelial cells. Numbers of inflammatory cells were similar to those in the controls. Overdistension causes damage primarily to the bladder urothelium, and to a lesser extent to the muscular layer. Urothelium integrity is destroyed for several days, which makes it possible for various substances to penetrate the bladder wall and allows for bacterial adherence. The damage however is, almost completely healed within one week.

Smooth muscle of the bladder in the normal and the diseased state: pathophysiology, diagnosis and treatment

The smooth muscle of the normal bladder wall must have some specific properties. It must be very compliant and able to reorganise itself during filling and emptying to accommodate the change in volume without generating any intravesical pressure, but whilst maintaining the normal shape of the bladder. It must be capable of synchronous activation to generate intravesical pressure at any length to allow voiding. The cells achieve this through spontaneous electrical activity combined with poor electrical coupling between cells, and a dense excitatory innervation. In the diseased state, alterations of the smooth muscle may lead to failure to store or failure to empty properly. The diseased states discussed are bladder instability and diabetic neuropathy. Bladder instability is characterised urodynamically by uninhibitable rises in pressure during filling, and is seen idiopathically and in association with bladder outflow obstruction and neuropathy. In diabetic neuropathy, many of the smooth muscle changes are a consequence of diuresis, but there is evidence for alterations in the sensory arm of the micturition reflex. In the unstable bladder, additional alterations of the smooth muscle are seen, which are probably caused by the patchy denervation that occurs. The causes of this denervation are not fully established. Nonsurgical treatment of instability is not yet satisfactory; neuromodulation has some promise, but is expensive, and the mechanisms poorly understood. Pharmacological treatment is largely through muscarinic receptor blockade. Drugs to reduce the excitability of the smooth muscle are being sought, since they may represent a better pharmacological option.

A possible use of color Doppler flow imaging in predicting the cause of bladder hypertrophy

The present study was designed to test the predictability of color Doppler flow imaging of the bladder in determining the cause of bladder hypertrophy. The blood flow in the anterior bladder wall was measured in 35 patients with an abnormally increased ultrasound estimated bladder weight (UEBW) of more than 35.0 g. Of these, 18 were diagnosed as having infravesical obstruction due to benign prostatic hyperplasia (obstructive group). The remaining 17 were diagnosed as having neurogenic bladder dysfunction (NB group). Scanning to detect blood flow was continued for 5 minutes, the bladder having been filled with 100 ml of saline. Blood flow was detected in 83.3% (15/18) of the obstructive group, compared to 23.5% (4/17) in the NB group (p < 0.001). Infravesical obstruction was detected with a diagnostic accuracy of 80.0% (28/35) by color Doppler flow imaging. Color Doppler flow imaging was useful in predicting the cause of bladder hypertrophy in patients with abnormally increased UEBW.

Microvasculature of the rabbit urinary bladder

BACKGROUND

The urinary bladder requires a rich blood supply to maintain its functions, the storage and release of urine. Specialized properties of the bladder vasculature might be anticipated to ensure the integrity of this blood supply, because it is known that blood flow is reduced by distension during bladder filling. However, the bladder vasculature has been described in detail only at the gross level. A comprehensive, three-dimensional view of the blood supply to the bladder wall is presented here.

METHODS

The microvasculature of the bladder of male New Zealand white rabbits was described using the combination of vascular corrosion casting, alkali digestion, light microscopy, and scanning and transmission electron microscopy. Following administration of an anticoagulant and an overdose of anesthetic, the abdominal aorta was cannulated just above the inferior mesenteric artery to permit flushing of the distal vasculature. The bladder vasculature was cleared of blood with buffered saline and then either perfuse-fixed with buffered 2% glutaraldehyde and sectioned, or filled with "Mercox" resin to prepare vascular corrosion casts. Casts were cleaned with NaOH, formic acid, and water. In some cases fixed bladders were partially digested with NaOH to expose the mucosal capillary plexus.

RESULTS

The bladder is supplied with blood by single, left and right vesicular branches of the internal or external iliac arteries. The serpentine vesicular arteries extend along the lateral borders of the bladder from base to apex just deep to the serosal surface and send dorsal and ventral branches to supply the dorsal and ventral bladder walls. Veins accompany the arteries and exhibit numerous valves. A very dense complex of vessels at the apex of the bladder apparently serves to accommodate bladder distension. The muscularis and submucosa contains few vessels, but the mucosa is well vascularized. An especially dense capillary plexus is present in the lamina propria at its junction with the transitional epithelium. In the relaxed bladder these capillaries lie in grooves formed by the basal layers of the epithelium. The endothelial cells of these capillaries display few cytoplasmic vesicles and are continuous or fenestrated. These capillaries are often invested with pericytes. The mucosal capillary plexus may be associated with an epithelial transport function or may be necessary for urothelial metabolism or maintenance of the barrier function of the urothelium. Unusual capillary tufts, possibly associated with vascular lymphatic tissue, are found associated with the main vessels on the lateral walls in the basal half of the bladder.

CONCLUSIONS

These methods present a clear, comprehensive, three-dimensional view of the microvasculature of the bladder wall. They also identify several unique features of this vasculature and provide a basis for studies of the response of this vasculature to pathologic states and experimental manipulation.

Vascular anatomy of the rabbit ureter

BACKGROUND

The success of kidney transplant surgery and ureteral reconstruction requires the preservation of the ureteral blood supply. Because of its potential vulnerability to surgical trauma during transplant and reconstructive surgery, the ureteral vasculature merits a full anatomical description.

METHODS

The microvascular anatomy of the ureter was studied in male New Zealand white rabbits by light microscopy and transmission electron microscopy and scanning electron microscopy of vascular corrosion casts and alkali digested tissue.

RESULTS

The rabbit ureter is supplied predominantly by a branch of the renal artery proximally (cranial ureteral artery) and by a branch of the vesicular artery distally (caudal ureteral artery). Minor vascular continuities are also present between the capillary beds of the ureter and those of the renal pelvis cranially and the bladder wall caudally. There are no external vascular connections to the middle ureter with the exception of a single, small vein which drains into the inferior vena cava. A single group of longitudinal arteries and veins runs the full length of the ureter within the adventitia. Branches of these longitudinal vessels pass tangentially through the muscularis to supply a vascular complex within the lamina propria. This complex in turn supports a rich, mucosal capillary plexus located at the junction between the transitional epithelium and the lamina propria. In the fixed ureter the capillary plexus lies in grooves formed by displacement of the basal layers of the overlying transitional epithelium. The capillaries are continuous or fenestrated, are often invested with pericytes, and are distributed uniformly around the entire circumference of the ureter.

CONCLUSIONS

The ureteral vasculature exhibits several unique features related to its function in urine conduction and its ability to accommodate expansion and contraction. The combination of techniques used provides a clear three-dimensional view of this vasculature. Our findings also confirm that, because of its limited blood supply, the ureter may be very susceptible to injury during renal transplantation or other abdominal surgery.

Outcome of endoscopic bladder transection

OBJECTIVE

To determine the clinical, symptomatic and objective urodynamic outcome of patients undergoing endoscopic bladder transection.

PATIENTS AND METHODS

The study included 20 men and 30 women (mean age of 50 +/- 15 years, range 20-86) who underwent endoscopic bladder transection. Their underlying diagnoses were idiopathic detrusor instability (41), enuresis with instability (6), multiple sclerosis (2) and Parkinson's disease (1). A full-thickness endoscopic transection of the bladder was performed under general anaesthesia. Subjective assessment was performed using symptom scores (0-14 points) and a Visick grading system (group A-E). Objective assessment was carried out using urodynamic studies. The mean follow-up period was 6 years (57 +/- 22 months, range 6-85).

RESULTS

The mean hospital stay was 8 +/- 3 days (range 3-22). No patients died after the operation. Postoperative complications included extra-peritoneal extravasation (2), recurrent urinary tract infection (5) and urethral stricture (1). Symptom scores before and after the operation were 9 +/- 2 (range 4-14) and 8 +/- 3 (range 1-14) points respectively. The overall outcome of the procedure was satisfactory in only eight (16%) patients. The mean duration of symptomatic relief was 17 weeks (range 3-53). There was no significant difference between urodynamic results before and after the operation. Bladder instability observed in all patients before operating was demonstrated in 93% of patients after the operation.

CONCLUSION

The results of our study suggests that endoscopic bladder transection produces only a transient symptomatic relief in a few of those patients who have failed to respond to pharmacological manipulations. We do not feel that its continued role is justified.

Blood flow rate and total blood flow related to length density and total length of blood vessels in mini-pig urinary bladder after chronic outflow obstruction and after recovery from obstruction

Chronic partial bladder outlet obstruction was created in mini-pigs by implanting a 6-7 mm ring around the proximal urethra. After a median obstruction period of 63 days the ring was removed, and after a median recovery period of 60 days the animals were sacrificed. At each study occasion the blood flow rate (ml per 100 g per min) was measured by washout of locally injected 133Xe in the bladder wall and the washout curves analyzed by the corrected initial slope method. Stereological estimation of length density and total length of blood vessels in the bladder were performed. The results can be summarized as follows: (1) no differences in the blood flow rate at the time of ring implantation, obstruction, or recovery, (2) no decrease in the blood flow rate in normal bladders after bladder distension, (3) a significant decrease in blood flow rate in obstructed bladders after distension, (4) a 6-fold increase in total bladder blood flow after obstruction, (5) an unchanged blood flow per length of blood vessels per min during the study, (6) no changes in length densities of blood vessels during the study, and (7) a 7-fold increase in total length of blood vessels after obstruction and reversion to control level after recovery. The unchanged blood flow per length of vessels implies that capillary proliferation matched the increased bladder mass during the study.

Bladder distention therapy for symptomatic relief of frequency and urgency: a ten-year review

OBJECTIVE

A retrospective review was undertaken to determine the efficacy of bladder distention therapy for the treatment of frequency and urgency, and to determine the relative value of prolonged versus short duration distention therapy.

METHOD

Prolonged bladder distention therapy was performed on 14 patients and short duration distention on 8 patients over a ten-year period. Indications for the procedure included severe urgency, frequency, and incontinence from a variety of etiologies.

RESULTS

Five of 14 patients (18 distentions, 2 bladder ruptures) who had prolonged distention, and 3 of 8 patients (9 distentions, 1 bladder rupture) who had short duration distention experienced symptomatic relief on follow-up (p > 0.7). Since there was no difference between the prolonged and short duration groups, the results were combined to yield 8 of 27 successful distentions (30%) in 8 of 22 patients (36%). All patients with detrusor hyperreflexia failed distention therapy. Complications included 3 cases of bladder rupture, 2 cases of urinary retention, and 1 case of urethral stricture. The rates of bladder rupture were identical in both groups (11%).

CONCLUSIONS

The use of prolonged bladder distention therapy has no role in the treatment of detrusor hyperreflexia, and only limited success in the symptomatic relief of severe urgency, frequency, and incontinence of other etiologies. Equal efficacy of prolonged and short duration distention therapy would tend to favor the use of short duration distention to reduce possible anesthesia complications and cost.

The influence of acute overdistension on rat bladder function and DNA synthesis

Prolonged micturition problems are often encountered after long-term bladder overdistension caused by urinary retention. In animal studies, damage to the bladder wall innervation has been found following overdistension. Experimentally, acute overdistension has also been implicated in the pathogenesis of the response to partial outlet obstruction. In the present study we investigated the influence of overdistension on micturition volume and frequency, on in vitro bladder function using the whole bladder model and on 3H-thymidine uptake, localization and DNA synthesis. Overdistension was induced for 3 hours by forced diuresis and balloon obstruction. Another group of rats was catheterized for 3 hours but received no diuretic, nor was the balloon inflated. An additional group of controls was neither anesthetized nor catheterized. Overdistension caused a gradual increase in bladder mass which was maximal at 7 days. During the first 24 hours following overdistension, the frequency of micturition decreased, but normalized thereafter. A progressive decrease in the response to field stimulation was noted between 16 hours and 7 days following overdistension and remained at this level until 21 days. There were, however, no significant differences in the responses to carbachol, ATP and KCl. There was a 30% reduction in the ability of field stimulation to empty the bladder 16 hours after overdistension, but no impairment of the emptying ability of carbachol. Overdistension was followed by a significant increase in 3H-thymidine uptake, which was maximal at 2 days. 3H-thymidine labelling increased rapidly after overdistension and was maximal within 16 hours in the urothelium. In smooth muscle, connective tissue and lamina propria, maximal labelling occurred at 2 days. Catheterization alone caused a mild distension which was associated with a small, but statistically significant, increase in 3H-thymidine incorporation into DNA within 16 hours. The labelling was located primarily in the urothelium. Overdistension causes a proliferative reaction within the bladder wall. Its initial effects occur within the urothelium, and the later involvement of the subendothelial smooth muscle and connective tissue is directly proportional to the degree of bladder distension. Three weeks following overdistension, the bladder's functional state was not completely recovered, although the urinary bladder was found to have a good capacity to adapt and compensate for the stress-induced changes caused by overdistension. It is, therefore, clear that overdistension may have long-lasting effects on the bladder.

Combined trypan blue and glyoxylic acid-induced catecholamine fluorescence in the female rat urinary bladder after distension

The effect of short-term urinary bladder distension on bladder perfusion and adrenergic innervation was studied in Sprague-Dawley rats. Distension was induced for three hours by forced diuresis and balloon obstruction. A 2% solution of trypan blue was injected into the tail vein 12, 24, 36 and 48 hours after distension and the animals were killed 5-10 min after the injection. Whole thick biopsies were taken from the dome, anterior body and base. A combination of trypan blue and catecholamine fluorescence (GIF method) was used to correlate the distension induced changes in blood vessel perfusion and permeability with changes in adrenergic innervation. Both ischaemic damage and adrenergic hypoinnervation were observed after distension. Later marked extravasation of trypan blue was observed in the whole bladder after 12 hours and after 24 hours distension the dome was almost necrotic in appearance and highly ischaemic. After 36 hours a few exploded small, intensely fluorescent cells (SIF cells) were found to be scattered along the blood vessels, and degranulated mast cells had invaded the anterior body and dome. The adrenergic hypoinnervation reached its maximum 48 hours after distension. The hypoinnervation and possibly also the damage to SIF cells, would seem to be related to ischaemia during distension, probably attributable in turn to overstretching of the organ and its blood vessels. This may provide an explanation for the prolonged micturition problems found after bladder overdistension.

Urothelial permeability of the isolated whole bladder

The urothelium of the bladder presents an effective barrier to the penetration of solutes from the urine into the bladder wall. Previously, we have demonstrated that the dye indigocarmine can be utilized intravesically to study urothelial permeability. In general, intravesical indigocarmine (administered in vivo) will not penetrate the bladder wall unless the urothelium is damaged by overdistension, acetone administration, or mechanical damage. Unfortunately, using in vivo methodologies, one is limited in the study of the effect of specific conditions and permeations on bladder permeability. In the current study an isolated in vitro whole bladder model was developed to quantitatively study the permeability of the bladder urothelium. In these studies, the penetration of indigocarmine into and through the bladder wall was quantitated under various conditions. The in vitro bladder was filled by infusing 1% indigocarmine in saline in a step-wise manner at the rate of 10 ml in 10 minutes followed by a stabilization period of 10 minutes. Samples were taken from the bath at 20 minutes intervals for spectrophotometrical analysis of the dye. At the end of experiment the bladder was washed in saline for 10 minutes, and stored and extracted in formalin. In general, no indigocarmine penetrated the urothelium until the in vitro capacity was reached and exceeded. At intravesical volumes greater than capacity, the dye concentration in the bath increased very rapidly, even though the integrity of the bladder wall remained intact. In bladders treated with a gentle 50% acetone wash for 1 minute the dye started to penetrate into the bath at intravesical volumes of 25% of capacity and increased rapidly thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)

Is there still a place for prolonged bladder distension?

Over a 2-year period, 31 patients underwent prolonged hydrostatic bladder distension for benign and malignant bladder disease in this unit. Of these, 29 patients had benign functional disorders or bladder contracture, and in 2 patients hydrodistension was performed for complications of treatment for bladder neoplasia. Of the 29 patients with benign disease, 6 observed marked improvement and 8 some improvement in their symptoms, and 12 received no benefit. Patients with detrusor hypersensitivity fared better than those with detrusor instability or interstitial cystitis. A patient with malignant bladder disease died soon after the procedure as a result of a myocardial infarction. Problems attributed to the hydrostatic balloon catheter were responsible for 2 failures. The regional anaesthetic technique failed to provide adequate anaesthesia for hydrodistension in 9 procedures and limited the duration to 2 h in 13 others. Following recall of the perished balloon catheters by the manufacturer, and the introduction of continuous spinal anaesthesia, the number of technical failures has been reduced. This technique still has an important role to play in the relief of severe symptoms unresponsive to medical treatment, but it is important that ideal conditions are provided for hydrodistension in order to ensure maximum success, particularly when the alternative is major surgery.

Effect of acute distension on cholinergic innervation of the rat urinary bladder

The effect of short-term urinary bladder distension on its cholinergic innervation was studied in Sprague-Dawley rats. Distension was induced for 3 h by forced diuresis and balloon outlet obstruction, and whole thick biopsy specimens were taken from the dome and lateral side of the anterior body 2, 7 and 21 days afterwards. The acetylcholinesterase (AChE) method was used to demonstrate the cholinergic nerves in the distended bladder wall. Cholinergic hypoinnervation was observed 7 days after the distension, persisting up to 21 days, although AChE-reactive nerves were then observed to be more numerous. The distribution of hypoinnervation was uneven, being more marked in the lateral side of the anterior body than in the dome. The distribution of AChE-reactive nerves varied even in the same biopsies, with areas of total hypoinnervation occurring next to areas of slightly diminished innervation. This was especially true 21 days after distension. The findings indicate transient damage to the cholinergic innervation, which may in turn explain the prolonged voiding difficulties often seen after catheterization of an overdistended bladder in a patient with urinary retention. The short-lasting effect of bladder dilatation therapy used to treat detrusor instability or interstitial cystitis may be due to the fairly rapid regeneration of cholinergic innervation.

Changes in the noradrenaline content of the female rat urinary bladder after transient acute overdistension

The effect of transient acute overdistension produced by forced diuresis and outflow occlusion was examined in female Sprague-Dawley rats. Their bladders were distented for three hours and studied at selected intervals during the postoperative period using high performance liquid chromatography (HPLC) for the exact measurement of tissue noradrenaline. Biopsies were taken from the bladder dome and anterior body 10 hours, 2 days, 7 days and 21 days after overdistension. A reduction in NA concentration was found in both the dome and anterior body at 2 to 21 days after distension. The results demonstrated at least partial transient damage to the adrenergic nerves containing NA. The primary success of the distension therapy used to treat bladder instability may be due to this injury.

Rate of urinary bladder blood flow evaluated by 133Xe washout and radioactive microspheres in pigs

Urinary bladder blood flow as measured by the washout of locally injected 133Xe and by the simultaneously performed radioactive microsphere reference-sample method was studied in pigs. The washout curves were analyzed according to the initial slope, the corrected initial slope and the total curve. The corrected-initial-slope flow rates were not statistically significantly different from the microsphere whole-wall flow rates. The variability between the methods shown by the test-retest difference revealed only a minor lack of agreement. The bladder blood flow tended to decrease after the intravesical pressure had been increased to 20 cmH2O, but the difference was not statistically significant. Washout of locally injected 133Xe can be used for the evaluation of urinary bladder blood flow in humans and in longitudinal animal studies. The corrected-initial-slope method is recommended for the analysis of washout curves.

Clam enterocystoplasty in general urological practice

A series of 45 patients (31 female) underwent clam enterocystoplasty for urgency and incontinence. The majority had detrusor instability. Prolonged conservative treatment had failed in all cases. Improvement occurred in 71% and those younger than 30 years had better overall results; 29% remained incontinent, with 9% requiring a urinary diversion. Many patients did not achieve maximum benefit until 9 months post-operatively. Surgery had no statistically significant effect on any urodynamic parameter and post-operative complications were common. The operation was performed in either the coronal (19) or the sagittal plane (26); this did not influence results. In general, surgery was found to be technically simpler in the sagittal group and it is recommended that this becomes the standard procedure. We feel that this operation involves major surgery and should only be offered with reluctance.

Idiopathic bladder hyperactivity treated with Ditropan (oxybutynin chloride)

Ditropan (oxybutynin chloride), a tertiary amine with slight anticholinergic and marked "papaverine-like" direct spasmolytic effects has been administered to 25 patients with idiopathic hyperactive bladder function. The drug reduced voiding frequency and abolished urgency. Control cystometry confirmed a significant increase in bladder capacity. Oral dryness was a tolerable side effect.

Effect of distension on adrenergic innervation of the rat urinary bladder

The effect of distension on adrenergic innervation was investigated in the rat urinary bladder. Bladders were distended for 3 h by forced diuresis and balloon obstruction, and specimens were taken from the bladder dome, body and neck for the demonstration of glyoxylic acid-induced fluorescence of catecholamines. Depletion of catecholamines started after 10 h and was almost complete after 2 days. The fluorescence had recovered part way after 5-7 days and was practically normal after 21 days. Small, intensely fluorescent (SIF) cells in the ganglia continued to leak catecholamines throughout the 21-day study period. The primary clinical success of distension therapy for the treatment of unstable bladder may be at least partly due to a reversible disturbance in the function of the adrenergic nerves, which have an excitatory alpha-adrenergic dominance in such cases, but the persistent leakage from SIF cells raises the question of whether distension causes prolonged disturbances in bladder function.

Trans-trigonal phenol failed the test of time

The results following 94 trans-trigonal phenol injections in 60 patients over a 5-year period are analysed. In only 1 patient was there a lasting effect. The others all required alternative treatment for bladder instability, hyper-reflexia or hypersensitivity. Older patients with normal bladder compliance and patients with a neuropathic aetiology had slightly better results but also failed to derive lasting benefit. The complications associated with the treatment and the general anaesthetic outweigh the transient benefits of this technique.

Urinary bladder blood flow. I. Comparison of clearance of locally injected 99mtechnetium pertechnate and radioactive microsphere technique in dogs

The blood flow of the dog urinary bladder measured by radioactive microsphere technique was compared to the clearance of locally injected 99mTechnetium pertechnate (99mTc) in the bladder wall. In semilogarithmic plots the 99mTc washout curves showed a multiexponential course. From the initial slopes (median 5.7 min) the bladder blood flow was calculated to be only 30-62% of the results obtained from the radioactive microsphere technique (blood flow in the muscular layer 21.7-44.8 ml/100 g/min). These lower values imply that the rate of removal of the hydrophilic tracer 99mTc at these flow rates is limited by the capillary diffusion capacity. The multiexponential curves reflect recirculation and excretion of 99mTc by the kidneys with accumulation of 99mTc in the bladder. It is concluded, that clearance studies of locally injected 99mTc in the bladder wall are unable to evaluate bladder blood flow.

Oxybutynin hydrochloride in the management of detrusor instability

The results of an investigation dealing with the therapy of instability of the detrusor using oxybutynin hydrochloride are presented. Out of an unselected group of patients 21 were enrolled in the trial. After therapy 19 patients showed significant improvement of subjective symptoms and objective urodynamic parameters. Twenty patients reported on tolerable side effects.

Bladder dysfunction after a stroke--it's not always inevitable

Bladder dysfunction frequently accompanies a stroke but, with appropriate management, is not necessarily a permanent deficit. Voiding problems most often experienced after a stroke include urgency, frequency, incontinence, and urinary retention. A clamping routine prior to indwelling urinary catheter removal did not affect the incidence of voiding dysfunction after a stroke. Checking consecutive post-voided residual urine volumes after a stroke is indicated to evaluate the effectiveness of bladder emptying; intermittent sterile catheterization is recommended if there is a problem.

Trial without catheter following acute retention of urine

A total of 60 patients with acute urinary retention were studied to establish whether a trial without a catheter was justified and to identify subgroups of patients most likely to benefit from this practice. The patients were randomly allocated to 3 groups; the catheters were removed either immediately after the bladder was emptied, or 24 or 48 h later; 17 patients urinated satisfactorily after removal of the catheter. Re-establishment of micturition was not associated with the length of history or severity of symptoms of prostatism, with age or the presence of urinary tract infection. The mean retained volume of urine in patients with a satisfactory result was 786 ml and 1069 ml in the failures. Of the 34 patients with retained volumes of less than 900 ml, 15 were successful in re-establishing micturition compared with 2 of 26 of those with retained volumes greater than 900 ml. The time of catheter removal was not important. The 17 successful patients were reviewed 6 months later. None reported further urinary retention; 6 had required prostatectomy for severe symptoms, 6 had minor symptoms and 5 were symptomless. It was concluded that a trial without a catheter is worthwhile, since 11 of 60 patients had not required surgery, but it should be avoided in patients with a residual volume exceeding 900 ml.

Comparison of long-term and short-term stretch on rat urinary bladder in vitro

Distension of the human urinary bladder often causes prolonged impairment of its function. To investigate the effects of the duration of stretch on bladder smooth muscle the active length-tension relation, electrically evoked, was described in rat detrusor strips during a short-term and a long-term stretch. The amplitude of active tension increased at first and then decreased abruptly at greater stretch lengths, the maximum being at muscle lengths 230-250% (100% = resting length) in both types of stretches. When the strips had been at maximum length (300%) for three hours the amplitude was significantly decreased during release as compared to the amplitude found during stretch to the maximum length at comparable lengths. If the strips were released immediately from the maximum length the amplitude responded in an opposite manner. Therefore we conclude that the duration of stretching of bladder smooth muscle significantly affects its mechanical activity.

Endoscopic bladder transection for detrusor instability

Eighteen patients with intractable detrusor instability were treated by endoscopic bladder transection. In two patients there was complete symptomatic relief. Two more were rendered continent but continued to complain of urgency and nocturia. The remaining 14 patients were not improved by the procedure. These results have caused us to abandon this operation as a treatment for detrusor instability.