Definition and symptoms of underactive bladder

The Efficacy of Transvaginal Ultrasound-Guided BoNT-A External Sphincter Injection in Female Patients with Underactive Bladder

Owing to the diverse treatment outcomes after a botulinum toxin A (BoNT-A) injection to the external sphincter, this study aimed to develop a new technique: an ultrasound-guided BoNT-A external sphincter injection. This single-center prospective cohort study was conducted at a tertiary medical center in Taichung, Taiwan. From December 2020 to September 2022, 12 women were enrolled. The patients were evaluated for lower urinary tract syndrome using patient perception of bladder condition (PPBC), international prostate symptom score (IPSS), uroflowmetry, post-void residual volume (PVR), cystometry, and external sphincter electromyography. We evaluated the patients the day before surgery and 1 week after the BoNT-A injection. For the patients requiring self-catheterization, we recorded the number of times they required clean intermittent catheterization (CIC) per day before the procedure and 1 month after the procedure. The IPSS, PPBC, and PVR were significantly better after the transvaginal ultrasound-guided BoNT-A external sphincter injection. The number of times the patients required daily CIC was also reduced after the injection. Only one patient developed de novo urge urinary incontinence. Our results demonstrated that a transvaginal ultrasound-guided BoNT-A injection was efficacious and safe in the treatment of underactive bladder.

Irreversible Bladder Remodeling Induced by Fibrosis

Underactive bladder and impaired bladder compliance are irreversible problems associated with bladder fibrosis. Remodeling of the extracellular matrix is regarded as an important mechanism associated with bladder fibrosis. However, various risk factors and conditions contribute to the functional impairment of the bladder associated with fibrosis, and there is limited knowledge about bladder fibrosis-associated problems in the field of neurourology. Further studies are thus necessary to elucidate the underlying mechanism of bladder fibrosis and to identify effective treatment.

Improved global response outcome after intradetrusor injection of adult muscle-derived cells for the treatment of underactive bladder

We report on the first regulatory approved clinical trial of a prospective open-label physician-initiated study assessing the safety and efficacy of intradetrusor injected Autologous Muscle Derived Cells (AMDC) treatment for underactive bladder (UAB). 20 non-neurogenic UAB patients were treated. Approximately 50-250 mg of quadriceps femoris muscle was collected using a spirotome 8-gauge needle. The muscle biopsy samples were sent to Cook MyoSite (Pittsburgh, PA) for processing, isolation, and propagation of cells. Research patients received approximately 30 intradetrusor injections of 0.5 mL delivered to the bladder, for a total of 15 mL and 125 million AMDC, performed utilizing a flexible cystoscope under direct vision using topical local anesthesia. Follow-up assessments included adverse events and efficacy via voiding diary and urodynamic testing at 1, 3, 6 and 12 months post-injection. An optional second injection was offered at the end of the 6 months visit. 20 patients received the first injection and all 20 patients requested and received a second injection. Median patient age was 65 years old (range 41-82 years). There were 16 male (80%) and 4 female (20%) patients. Etiology included 7 men (35%) with persistent urinary retention after transurethral resection of the prostate for benign prostatic hyperplasia and 13 patients (65%) with idiopathic chronic urinary retention. At the primary outcome time point of 12 months, 11/19 patients (58%) reported a global response assessment (GRA) ≥ 5, showing slight to marked improvement in their UAB symptoms, compared to 6/20 (30%) patients at 3 months post-injection. No serious procedure or treatment-related adverse events occurred. Noted improvements included: decreased post void residual urine volume, increased voiding efficiency, and decreased catheter use. Intradetrusor-injected AMDC as a treatment for UAB was successfully completed in a 20-patient trial without serious adverse event and with signal of efficacy. Cellular therapy may be a promising novel treatment for catheter-dependent chronic urinary retention. A multicenter controlled trial is needed to further assess the promise of regenerative medicine in the treatment of lower urinary tract dysfunction.

Is Nocturia Associated With Detrusor Underactivity?

OBJECTIVES

Detrusor underactivity (DU) is diagnosed using urodynamic testing. We hypothesized that nocturia is associated with detrusor underactivity.

METHODS

We performed a retrospective chart review of all women who underwent urodynamic testing at our institution between 2016 and 2018. Uroflowmetry and pressure-flow study parameters were compared between women with nocturia (≥2 voids/night) and without nocturia (0-1 void/night). Detrusor underactivity was diagnosed using 3 different criteria: (1) bladder voiding efficiency (BVE) of <90%, (2) bladder contractility index of <100, and (3) a composite of three urodynamic measures (Gammie criteria).

RESULTS

Of 358 women, 172 (48%) were in the nocturia group and 186 (52%) were in the no nocturia group. On uroflowmetry, median postvoid residual volume was similar (20 mL) in both groups. Median maximum flow rate (15 vs 17 mL/s, P < 0.05) and average flow rate (6 mL/s vs 7 mL/s, P < 0.05) were significantly lower in the nocturia group compared with the no nocturia group. During pressure-flow study, a significantly greater proportion of women with nocturia were unable to void around the catheter (30% vs 27%, P < 0.01). The overall rate of DU varied with the criteria used: BVE (54%), bladder contractility index (41%), and Gammie criteria (7%). The rate of DU using the BVE criteria was significantly higher in the nocturia group (63% vs 48%, P < 0.01), but no significant differences were noted using the other criteria.

CONCLUSIONS

Nocturia is associated with reduced voiding efficiency in women. The diagnosis of DU using urodynamics is challenging.

Symptoms of voiding dysfunction and other coexisting pelvic floor dysfunctions: the impact of transvaginal, mesh-augmented sacrospinous ligament fixation

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the prevalence for voiding dysfunction and if symptom improvement can be achieved by adequate pelvic floor surgery.

METHODS

We evaluated the Propel Study data from 281 women with pelvic organ prolapse (POP) stage 2-4. Bother caused by obstructive micturition, voiding dysfunction, and coexisting pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI) preoperatively and 6, 12, and 24 months after vaginal prolapse repair. Successful reconstruction (Pelvic Organ Prolapse Quantification [POP-Q] stage 0-I throughout the 2-year follow-up at all compartments, "responders"), was compared with all others ("non-responders").

RESULTS

Prevalence of voiding dysfunction was significantly reduced after surgery for all patients with "moderate" to "quite a bit" of bother ("R2") regarding all examined PFDI questions. Defects of the posterior/apical compartment and lower stage defects were found to cause obstructive micturition, which improved significantly after POP surgery. Six months after surgery, the prevalence of R2 for voiding dysfunction symptoms was reduced significantly for responders compared with non-responders. Significant reduction of R2 in patients with rectoceles could be shown for some PFDI questions, whereas the rate was lower in patients with cystoceles. Other pelvic floor symptoms often coexisted in patients with voiding dysfunction symptoms and improved significantly after surgery as well.

CONCLUSIONS

Symptoms of voiding dysfunction are frequent in female patients with POP and can significantly improve after vaginal mesh-augmented prolapse repair even for posterior and minor defects. Before counseling patients to undergo POP surgery because of their obstructive symptoms, other causes of voiding dysfunction must first have been ruled out.

Voiding Disorders in Pediatrician's Practice

Voiding disorders result usually from functional disturbance. However, relevant organic diseases must be excluded prior to diagnosis of functional disorders. Additional tests, such as urinalysis or abdominal ultrasound are required. Further diagnostics is necessary in the presence of alarm symptoms, such as secondary nocturnal enuresis, weak or intermittent urine flow, systemic symptoms, glucosuria, proteinuria, leukocyturia, erythrocyturia, skin lesions in the lumbar region, altered sensations in the perineum. Functional micturition disorders were thoroughly described in 2006, and revised in 2015 by ICCS (International Children’s Continence Society) and are divided into storage symptoms (increased and decreased voiding frequency, incontinence, urgency, nocturia), voiding symptoms hesitancy, straining, weak stream, intermittency, dysuria), and symptoms that cannot be assigned to any of the above groups (voiding postponement, holding maneuvers, feeling of incomplete emptying, urinary retention, post micturition dribble, spraying of the urinary stream). Functional voiding disorders are frequently associated with constipation. Bladder and bowel dysfunction (BBD) is diagnosed when lower urinary tract symptoms are accompanied by problems with defecation. Monosymptomatic enuresis is the most common voiding disorder encountered by pediatricians. It is diagnosed in children older than 5 years without any other lower urinary tract symptoms. Other types of voiding disorders such as: non-monosymptomatic enuresis, overactive and underactive bladder, voiding postponement, bladder outlet obstruction, stress or giggle incontinence, urethrovaginal reflux usually require specialized diagnostics and therapy. Treatment of all types of functional voiding disorders is based on non-pharmacological recommendations (urotherapy), and such education should be implemented by primary care pediatricians.

Transurethral resection of the prostate: fate of the non-responders

BACKGROUND

Transurethral resection of the prostate (TURP) has been the standard method of surgical management of benign prostatic enlargement for decades. Some patients experience significant voiding dysfunction and discomfort postoperatively, without any apparent clinical complications from the procedure. Furthermore, a significant proportion of men still require postoperative catheterisation. This study analysed patients defined as non-responders after TURP with the principal aim to reveal their fate.

METHODS

A prospectively recruited cohort of 355 men, who underwent TURP during 2010-2012, was investigated. Non-responders were identified as still requiring catheterisation postoperatively and/or exhibiting all of the following voiding outcomes based on the de Wildt criteria: IPSS > 7, bother score > 2, Q_max < 15 mL/s and PVR > 100 mL. The non-responders were followed for a maximum period of three years using retrospective chart reviews.

RESULTS

Thirty-five men were defined as non-responders. Of these, 26 men were operated on due to urinary retention and nine men due to bothersome symptoms. The non-responders were followed for a mean time of 72 months. Seven men underwent a redo-TURP and two men a bladder neck incision. Eleven of the 35 men were finally judged as having satisfactory voiding parameters. Sixteen men used CISC. Eleven men reduced the frequency of CISC to a minimum. Seven men had to use an indwelling catheter indefinitely.

CONCLUSION

Men with preoperative urinary retention constituted the vast majority of non-responders. The use of postoperative urodynamic studies was remarkably low. Almost one in three non-responders finally had a satisfactory outcome with or without re-intervention.

Understanding underactive bladder: a review of the contemporary literature

Underactive bladder (UAB) is characterized by prolonged voiding, hesitancy, and slow and/or intermittent stream with or without a sensation of incomplete bladder emptying. The overlap of UAB lower urinary tract symptoms with those of overactive bladder or bladder outlet obstruction, as well as its multifactorial etiology, make UAB study, as well as its diagnosis and management, a very arduous and challenging task. Therefore, despite its incidence and significant impact in the quality of life of both men and women, UAB remains a poorly understood urologic condition with insufficient and ineffective treatment options available. In this review, we will focus on the etiology theories that have been proposed and the animal models available to test those theories.

Sensitivity of urethral flow-evoked voiding reflexes decline with age in the rat: insights into age-related underactive bladder

The prevalence of underactive bladder (UAB) increases with age, suggesting a link between age-related processes and lower urinary tract (LUT) symptoms; however, the underlying mechanisms of age-related UAB are poorly understood. Understanding how aging affects LUT reflexes may help in the development of new treatments by identifying mechanistic targets. In this work, we studied the relationship between age and systems-level function of the LUT and tested the hypothesis that aging is related to weakening of reflexes that control voiding. Three groups of anesthetized female rats, young (4–7 mo old), mature (11–14 mo old), and old (18–24 mo old), were used to quantify the effect of aging on LUT reflexes. A double-lumen catheter enabled us to control the bladder volume and urethral flow rate independently, under quasi-isovolumetric bladder conditions. We systematically investigated the reflex bladder contractions evoked by combinations of rates of urethral infusion and bladder fill volumes as a function of age. Urethral infusion with the same flow rate evoked bladder contractions (via the augmenting reflex) in old animals less often than in younger animals. Furthermore, old animals needed more fluid in their bladders (relative to their bladder capacity) before urethra flow-evoked bladder contractions could be triggered at all, suggesting a delay in the switch of the LUT to “voiding mode.” Old rats also showed longer and weaker bladder contractions than young or mature rats. Taken together, this suggests there is an age-related functional weakening and loss of sensitivity in LUT reflexes, which may contribute to age-related UAB symptoms.

Validation of an efficient and continuous urodynamic monitoring system for awake, unrestrained, chronic rodent studies

The postvoid residual (PVR) is an important measure of bladder function, but obtaining PVR is burdensome because bladder volume must be measured at the time of voiding. The PVR measurement problem has led to experimental tricks in animal studies (infusing the bladder at supraphysiological rates and limiting animal observation windows) to keep the number of observed voids statistically robust while reducing the time an experimenter must be present. Our solution to the PVR measurement problem is a system called Automatic Monitoring for Efficient, Awake, Sensitive, Urine Residual Estimation (AMEASURE). AMEASURE combines metabolic cages and optimization algorithms to estimate continuously PVR for every voiding event 24 h/day for multiple weeks, without artificial bladder infusion, continuous experimenter supervision, anesthesia, or restraints. Using AMEASURE, we obtained voided volumes, PVRs, and other urodynamic parameters continuously for 21 days in 10 healthy female Sprague-Dawley rats. Importantly, this required only one manual measurement of animals' bladder volume every 12 h. We validated the accuracy of the system experimentally and in simulation. We detected marked differences in voiding frequency and efficiency between light and dark cycles and found that voiding frequency increased over time during the dark cycle (but not the light cycle), due to surgical recovery, cage acclimation, and socialization. This tool enhances the relevance of rodent models to the study of human lower urinary tract by expanding observation periods and obviating the need to infuse the bladder and facilitates the study of conditions for which behavioral, social, or circadian factors play essential roles.

Evaluation of Clinical Outcomes of Prostatic Urethral Lift for Benign Prostatic Hyperplasia: An Asian Population Study

PURPOSE

This study aimed to assess the clinical outcomes of prostatic urethral lift in Korean patients with bothersome lower urinary tract symptoms due to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Thirty-two men with symptomatic BPH were consecutively treated in a tertiary care center in Korea. To be included in the present analysis, patients had to meet the following criteria: age ≥50 years, International Prostatic Symptom Score (IPSS) >12, and prostate volume between 30 mL and 80 mL. Patients were evaluated up to a median follow-up period of 1 year post-procedure. The primary outcomes included symptom relief, improvement of quality of life (QOL), and preservation of sexual function.

RESULTS

All procedures were finished with a mean of 2.2 implants without any serious complication. The numbers of patients diagnosed with diabetes mellitus, hypertension, and ischemic heart disease were 16 (50.0%), 24 (75.0%), and 9 (28.1%), respectively. Patients experienced symptom relief by 1 week that was sustained for 12 months. The mean IPSS, QOL, and maximum flow rate improved to 43%, 70%, and 25% by 1 week, and to 41%, 60%, and 32% by 12 months (p<0.001), respectively. There were no occurrences of early urge incontinence, retrograde ejaculation, or erectile dysfunction. Patient-reported adverse events were mild and transient.

CONCLUSIONS

Prostatic urethral lift is a safe and effective treatment for BPH in the Asian population. This treatment is minimally invasive, can be performed under local anesthesia, and may be an appropriate method for fragile patients.

Underactive bladder may be caused by uterosacral ligament laxity - a critical review of two paradigms

Introduction

The aim of this study was to compare the posterior fornix syndrome (PFS), (abnormal bladder emptying, urge, frequency, nocturia, chronic pelvic pain) cured/improved by uterosacral ligament (USL) ligation, with ‘underactive bladder’ (UAB) [2], whose cause and cure of UAB are said to be unknown [2].

Material and methods

A limited literature search was carried out for the words posterior fornix syndrome; obstructed micturition; post-void residual.

Results

We found the diagnostic criteria used for UAB to be identical with PFS. Also, individual symptoms could be improved in the short term with squatting-based pelvic floor exercises, native tissue cardinal/uterosacral ligament repair, but requiring posterior ligament slings for a long term cure.

Conclusions

Because the similarity in symptoms may not be sufficient in the first instance to recommend surgery for UAB, we advise the use of a roll gauze or large tampon placed in the posterior fornix to support USLs ('simulated operation'), always with a full bladder, then observe any changes in PFS symptoms such as urge, pain, urine flow and post-void residual as a screening test before proceeding to surgery.

Is Urodynamics Necessary when Assessing a Patient with Male Lower Urinary Tract Symptoms?

Urodynamics can distinguish bladder outlet obstruction from detrusor underactivity. Clear identification of the mechanism of a man's voiding symptoms can help give the best chance of good outcome from surgery. Publication of results from the UPSTREAM study will help in establishing the exact place for urodynamic testing in male lower urinary tract symptoms.