Technical aspects of botulinum toxin type A injection in the bladder to treat urinary incontinence: reviewing the procedure

AIMS

Standardise the injection technique with botulinum toxin type A (BoNT A) in the bladder of patients with overactive bladder (OAB) [idiopathic overactive bladder (iOAB) or neurogenic overactive bladder (nOAB) with urinary incontinence], using a literature review and a survey of an International expert panel.

METHODS

PubMed literature searches of BoNT A in adults with iOAB/nOAB together with a survey of 13 experts from 10 countries.

RESULTS

Data from 21 articles and completed questionnaires were collated. The procedure can be carried out in an out-/inpatient setting. Dose used in clinical studies vs. clinical practice was 300 and 200 U for nOAB and 200 and 100 U for iOAB. Recent studies have also demonstrated that there are no clinically relevant benefits between 100 and 150 U in iOAB or between 300 and 200 U in nOAB, though adverse effects are increased with higher doses. Usually, 30 sites for nOAB (range: 6.7-10 U/ml) and 20-30 sites for iOAB (range: 5-10 U/ml) are injected in clinical studies vs. 20-30 sites of 1 ml/injection for 200 U in nOAB and 10-20 sites of 0.5-1 ml/injection for 100 U in iOAB in clinical practice. BoNT A is usually injected directly into the detrusor, sparing the trigone. Flexible or rigid cystoscopes are used. The needle should be typically 22-27 gauge and 4 mm in length and should have a stopper to avoid any leakage or perforation of the bladder wall while ensuring a targeted injection.

CONCLUSION

Based on the literature and survey analysis, recommendations are proposed for the standardisation of the injection procedure.

Lower urinary tract symptoms and urodynamic dysfunction in clinically isolated syndromes suggestive of multiple sclerosis

BACKGROUND AND PURPOSE

Urinary symptoms associated with multiple sclerosis (MS) are common and negatively impact on quality of life, representing a considerable psychosocial and economic burden, often requiring care and hospitalization. Although the importance of identifying and adequately treating urinary symptoms in MS is now well recognized, there is no information, to date, about the real prevalence and impact of bladder symptoms in patients with clinically isolated syndromes (CISs) suggestive of MS.

METHODS

The aim of the present study was to investigate, in a cohort of patients with a diagnosis of CIS suggestive of MS, the prevalence of urinary tract symptoms, their impact on quality of life measures and their association with functional urodynamic dysfunctions. Patients underwent a complete neurological and urological visit, urodynamic investigation and the MSQoL-54 questionnaire.

RESULTS

Twenty-eight consecutive patients presenting with CISs were enrolled in the study; 53.6% of CIS patients reported urinary symptoms, 46.7% reporting irritative symptoms, 33.3% both irritative and obstructive symptoms and 20% obstructive symptoms alone. Urodynamic abnormalities were observed in 57.1% of the CIS patients. In 17.9% of the CIS patients urodynamic dysfunctions were asymptomatic. The presence of urinary symptoms was associated with lower scores on specific quality of life domains, particularly in women with obstructive symptoms.

CONCLUSIONS

A high prevalence of urinary symptoms and urodynamic dysfunctions in patients with CISs and an association of urinary symptoms with quality of life measures were found. These results highlight the importance of identifying and optimally treating urinary symptoms also at the very early stages of MS.

Botulinum toxin A modulates afferent fibers in neurogenic detrusor overactivity

BACKGROUND

  Although botulinum toxin (BoNT/A) injected into the detrusor muscle improves overactive bladder symptoms in patients with neurogenic detrusor overactivity, how it does so remains unclear. In this study, we investigated whether BoNT/A improves detrusor overactivity by modulating bladder afferent activity.

METHODS

  To do so, during urodynamic assessment, we tested the soleus muscle Hoffmann (H) reflex during bladder filling before and after intradetrusor BoNT/A in patients with Parkinson's disease (PD) and in patients with complete chronic spinal cord lesion (SCI) and detrusor overactivity refractory to conventional therapy. Healthy subjects underwent H reflex studies during urodynamic assessment and acted as controls.

RESULTS

  Our findings show that BoNT/A injected into the detrusor muscle effectively reduces clinical overactive bladder symptoms in patients with PD and SCI. In healthy subjects and patients with PD, bladder filling [at maximum cystometric capacity, (MCC)] significantly decreased the H reflex size, whereas in patients with SCI, it slightly facilitated the H reflex size. At MCC, in patients with PD, BoNT/A significantly reduced the expected H reflex inhibition, whereas in those with SCI, BoNT/A turned the H reflex facilitation at maximum bladder filling into a slight inhibition.

CONCLUSIONS

  These findings show that BoNT/A injected into the detrusor muscle in patients with PD and SCI modulates bladder afferent activity. Modulation of bladder afferents possibly explains why BoNT/A improves detrusor overactivity.

Effect of botulinum neurotoxin on the urinary bladder: novel insights on mechanism of action

Botulinum neurotoxins (BoNTs) recently tarted to be used in common urologic practice for the treatment of neurogenic and non neurogenic detrusor overactivity (DO) refractory to all conventional treatments. The rationale was that botulinum toxin, particularly BoNT type A (BoNT/A), was able to block the presynaptic release of acetylcholine (ACh) from the parasympathetic efferent nerves thus paralyzing the detrusor smooth muscle, an action similar to that performed in skeletal muscles. With the present review we aimed at assessing the state of the art on the mechanisms of function of botulinum toxins in the management of urological dysfunctions. We searched PubMed using the medical subject heading (MeSH) term botulinum toxin in conjunction with any of the following terms: mechanism of action, bladder, afferent and efferent nervous transmission, urothelium and suburothelium, detrusor overactivity. Review articles and published abstracts were identified by limiting for review and abstract, respectively. The reference list of review and original papers were reviewed to identify any missed papers. A similar search strategy was applied in EMBASE using identical EMTREE terms. Recent evidences in in vivo and in in vitro studies suggest that in addition to a direct effect on detrusor motor innervation, BoNT/A also modulates intrinsic bladder reflexes through a multimodal effect on sensory pathways. Such mechanisms may contribute to the efficiency of this treatment and partly explain how it affects abnormal detrusor contractions more markedly than voluntary bladder emptying.

Is antibiotic prophylaxis in invasive urodynamics a useful procedure in postmenopausal subjects?

Objectives.

To define the incidence rate of urinary tract infections (UTI) and the usefulness of antibiotic prophylaxis in postmenopausal female undergoing invasive urodynamics (IU).

Methods.

262 postmenopausal females underwent IU, being previously double-blindly randomized in 2 homogenous age-matched groups. Group 1 (130 patients) received oral antibiotic prophylaxis with a single 400 mg dose of norfloxacin. Group 2 (132 patients) was given placebo. The statistical analysis was performed using a Chi-Square test, in order to evaluate any difference between groups for UTI incidence rate.

Results.

54 patients out of 262 (20.6%) developed a UTI [24 out of 130 subjects who received antibiotic prophylaxis (18.4%), and 30 out of 132 subjects who received placebo (22.7%)]. As per the UTI incidence rate, no statically significant difference (p>.05) was shown between patients receiving and those not receiving the antibiotic prophylaxis.

Conclusions.

The UTI incidence rate in postmenopausal women undergoing urodynamics is not affected by the administration of antibiotic prophylax.

Multicenter, randomized, phase III trial comparing radical retropubic prostatectomy with conventional external beam radiotherapy for localized prostate cancer: An interim report

4607

Background: We report the outcomes of a randomised trial comparing radical retropubic prostatectomy (RP) with conventional external beam radiotherapy (EBRT) in patients with clinically localized prostate cancer. Methods: Between January 1997 and September 2001, 137 patients with clinically localized diagnosed prostate cancer were randomly assigned to RP (n = 70) or EBRT (n = 67). Data collected at follow-up included evidence of clinical disease progression, survival rates and general and disease specific health-related quality of life. All data were measured by physical examination, digital rectal examination, PSA, annual TC and bone scan and questionnaire. Analysis was by intention to treat. Results: After a median follow-up of 67 months (range 24–88) 35 patients (32.8%) had evidence of biochemical disease progression, 22 (31.4%) in RP group and 23 (32.8%) in EBRT group respectively. The median time to biochemical failure was 55.5 months (range 1–86) in RP group and 56 (range 3–88) in EBRT group. A local progression was observed in 11 patients (15.79%) of RP group and 12 (17.9%) of EBRT group. The median time to local progression was 65 months (range 6–86) in RP group and 64 (range 6–88) in EBRT group. Distant metastases were observed in 4 patients (5.7%) in RP group and 6 (8.9%) in EBRT group. The median time to distant failure was 67 months (range 12–86) in RP group and 66 (range 12–88) in EBRT group. Death due to prostate cancer occurred in 3/70 of patients assigned to RP (4.3%) and in 1/67 of those assigned to EBRT (1.5%). A significant decrease in general HRQOL was evident only in the first month after RP (p < 0.001). At 2 years, patients undergoing RP report significantly worse urinary function (p < 0.001), but better bowel function than those treated with EBRT (p < 0.001). Sexual dysfunction was more prevalent in the RP than in the EBRT group (70.2% versus 61.2%). Conclusions: This interim analysis indicates that there was no significant difference between RP and EBRT in terms of clinical disease progression and survival rates in patients with clinically localized prostate cancer. However, additional larger sample size accrual and long-term follow-up data are warranted to confirm these results.

No significant financial relationships to disclose.

Urgency of micturition and detrusor contractility in men with prostatic obstruction and overactive bladders

AIMS

In men with prostatic obstruction and detrusor overactivity (DO), to ascertain whether urgency of micturition affects bladder contractility.

MATERIALS AND METHODS

We urodynamically assessed five groups of 20 men each who had bladder outflow obstruction (BOO) from benign prostatic enlargement-Groups 1 (with no DO and no urgency), 2 (with DO and no urgency), 3A (with DO and moderate urgency), 3B (with DO and severe urgency), and 4 (with DO, severe urgency and chronic ischemic cerebral lesions). Urgency was graded as moderate or severe by the ability to avert an urgent void at cystometry for > or =2 or <2 min, respectively. BOO was assessed by the "Abrams-Griffiths number" (AG) and bladder contractility by the parameters PIP and WF(max).

RESULTS

AG did not differ significantly in Groups 2, 3A, and 3B, proved higher in such groups than in Group 1, and was nearly the same in Groups 1 and 4. PIP and WF(max) were significantly higher in Groups 2, 3A, and 3B than in Groups 1 and 4, had the highest levels in Group 3B, and did not differ significantly in Groups 1-4 and 2-3A.

CONCLUSIONS

In DO patients with prostatic obstruction there seems to be a DO-related facilitation of bladder contractility. In the same patients, severe urgency of micturition might over-amplify (i.e., enhance a DO-related facilitation of) bladder contractility, provided there are no neurogenic (chronic ischemic cerebral) lesions.

New therapeutic options for refractory neurogenic detrusor overactivity

AIM

Current pharmacologic treatment of detrusor overactivity relies on anticholinergic drugs. However, they often have untolerable side effects so that they are administered in doses insufficient to restore urinary continence. Recently, intravesical instillations and injections into the detrusor muscle of new pharmacological agents have been developed. The present study report our own experience in the treatment of detrusor overactivity with intravesical administrations of vanilloid agents and with botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients. In particular, we compared the clinical and urodynamic effects of the 2 drugs in an attempt to find a new and valid therapeutic option in those cases unresponsive to conventional treatment.

METHODS

Seventy-five patients with spinal cord injury and refractory detrusor overactivity were included in the study: 35 patients received repeated intravesical instillations of resiniferatoxin (RTX) dissolved in normal saline; 40 patients received repeated injections of 300 units botulinum A-toxin diluted in 30 ml normal saline. Clinical assessment and urodynamics were performed at baseline and 6, 12 and 24 months after treatment.

RESULTS

With both treatments there was a significant reduction in mean catheterization and episodes of incontinence and a significant increase in mean first involuntary detrusor contraction and in mean maximum bladder capacity at 6, 12 and 24 months after therapy. We did not detect any local side effects with either treatment. Botulinum-A toxin significantly reduced also the maximum pressure of uninhibited detrusor contractions more than RTX at all follow-up time points.

CONCLUSION

In patients with spinal cord injury and refractory detrusor overactivity intravesical RTX and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with reduction of detrusor overactivity and restoration of urinary continence in most patients. Botulinum-A toxin injection provided better clinical and urodynamic benefits than intravesical RTX.

Transdermal electromotive administration of verapamil and dexamethasone for Peyronie's disease

OBJECTIVE

To evaluate the effects of the transdermal electromotive administration of verapamil and dexamethasone on plaque size, penile deviation, pain, erectile function and capacity for vaginal penetration in patients with Peyronie's disease.

PATIENTS AND METHODS

Forty-nine patients were treated four times weekly for six consecutive weeks. During each session the drug mixture was administered from a receptacle fixed to the skin overlying the plaques, using 2.4 mA pulsed current for 20 min. Plaque size and penile deviation were evaluated by dynamic penile duplex ultrasonography, X-ray and photographs; pain, erectile function and capacity for vaginal penetration were assessed using a questionnaire. Vital signs and side-effects were recorded. Differences before and after treatment were assessed.

RESULTS

The plaque disappeared in 8% of patients, with a measurable reduction in volume in 74% and no change in 18% (P < 0.001). Penile deviation resolved in 10% of the men, decreased in 74% and remained unchanged in 16% (P < 0.001). The plaque volume was halved in two-thirds of the men, to a mean (sd) of 515 (301) mm3, and the penile deviation halved in 45% of patients, to 24 (5) degrees; pain was completely eliminated in 88% (P < 0.001). Erectile function was completely restored in 42% of patients with initial erectile dysfunction and improved in 17% (P < 0.001); vaginal penetration improved in 73%. No toxicity was noted, except for a transient skin erythema at the site of the penile and dispersive electrodes.

CONCLUSION

The transdermal electromotive administration of verapamil and dexamethasone is clinically safe and appears to be an effective treatment in patients with Peyronie's disease.

Intravesical oxybutynin: mode of action assessed by passive diffusion and electromotive administration with pharmacokinetics of oxybutynin and N-desethyl oxybutynin

PURPOSE

A proportion of patients with detrusor hyperreflexia who are unresponsive to oral oxybutynin often benefit from intravesical oxybutynin instillation. To our knowledge the precise mode of action of this method is obscure.

MATERIALS AND METHODS

In 12 patients with detrusor hyperreflexia who were previously unresponsive to oral and intravesical passive diffusion of 5 mg. oxybutynin we administered 5 mg. oxybutynin orally as well as increased doses of 15 mg. oxybutynin intravesically with passive diffusion and with 15 mA. associated electric current. Each administration mode per patient was associated with an 8-hour urodynamic monitoring session during which oxybutynin and N-desethyl oxybutynin plasma levels, and intravesical oxybutynin uptake were measured.

RESULTS

A dose of 5 mg. oxybutynin orally induced no urodynamic improvement with an area under the plasma concentration time curve of combined N-desethyl oxybutynin plus oxybutynin of 16,297 ng./8 hours and an area under the curve ratio of N-desethyl oxybutynin-to-oxybutynin of 11:1. Passive diffusion oxybutynin resulted in 12 mg. oxybutynin intravesical uptake and significant improvement in 3 of 8 urodynamic measurements, although the area under the curve of combined N-desethyl oxybutynin plus oxybutynin was only 2,123 ng./8 hours and the N-desethyl oxybutynin-to-oxybutynin ratio was 1.1:1.0. Electromotive administration of oxybutynin resulted in almost complete intravesical uptake of the 15 mg. dose, significant improvement in all 8 urodynamic measurements and an increased oxybutynin level versus oral and passive diffusion, although the area under the curve of combined N-desethyl oxybutynin plus oxybutynin was 4,574 ng./8 hours and the N-desethyl oxybutynin-to-oxybutynin ratio was inverted at 1.0:1.4. The oral dose of 5 mg. oxybutynin caused anticholinergic side effects in 8 of the 12 patients. Neither intravesical passive diffusion nor electromotive administration caused side effects with an uptake of 12 and 15 mg., respectively.

CONCLUSIONS

A large proportion of intravesical oxybutynin is sequestered, probably in the urothelium. Intravesical oxybutynin administration confers therapeutic benefits via localized direct action within the bladder wall.

Intermittent catheterization with a prelubricated catheter in spinal cord injured patients: a prospective randomized crossover study

PURPOSE

We compared the safety and patient acceptance of a conventional Nélaton and a prelubricated nonhydrophilic catheter in 18 spinal cord injured patients on intermittent catheterization.

MATERIALS AND METHODS

In a prospective crossover study each catheter was used for 7 weeks and the initial course was randomized. Urinalysis and urine culture were performed at 2, 4 and 7 weeks. Urethral trauma was evaluated by urethral cell count on the surface of each catheter used on the last day of each study period. Patient satisfaction was assessed at the end of the study by a questionnaire using multiple visual analog scales.

RESULTS

Urinary tract infection was identified in 12 and 4 patients on a Nélaton and a prelubricated nonhydrophilic catheter (p = 0.03), while asymptomatic bacteruria was identified in 18 and 8 (p = 0.0244), respectively. The mean urethral cell count plus or minus standard deviation on the catheter surface was 6.7 +/- 2.8 x 10(4) and 15.1 +/- 8.9 x 10(4) for the prelubricated nonhydrophilic and the Néelaton catheter, respectively (p = 0.01). The prelubricated nonhydrophilic catheter resulted in a better mean satisfaction score than the Nélaton catheter (2.33 +/- 1.06 versus 4.72 +/- 2.13, p = 0.022). Urethral bleeding was reported in 2 patients during the study period while using the Nélaton catheter.

CONCLUSIONS

The prelubricated nonhydrophilic catheter is a safe, effective and comfortable option in spinal cord injured patients on intermittent self-catheterization.

Intravesical electromotive administration of oxybutynin in patients with detrusor hyperreflexia unresponsive to standard anticholinergic regimens

PURPOSE

About 15% to 20% of patients with detrusor hyperreflexia do not benefit from oral oxybutynin regimens, frequently because of unpleasant side effects. Several reports indicate that intravesical oxybutynin is effective in many of these patients but there are some who still fail to respond.

MATERIALS AND METHODS

A select group of 10 adults with detrusor hyperreflexia unresponsive to standard oral and intravesical oxybutynin regimens were treated at weekly intervals with 5 mg. oxybutynin orally, or 5 mg. oxybutynin in 100 ml. intravesically for 60 minutes of passive diffusion and for 30 minutes with 5 mA. electrical current. Each treatment (plus oral placebo and 2 intravesical controls) was associated with an 8-hour, full urodynamic monitoring session, and periodic blood and bladder content sampling.

RESULTS

There was no significant objective improvement with oral or intravesical passive diffusion oxybutynin. Conversely there was significant improvement in 5 of 6 objective urodynamic measurements with intravesical electromotive oxybutynin. Plasma profiles were a single peak and decay following oral oxybutynin and 2 distinct peaks with intravesical passive diffusion and electromotive oxybutynin. Area under the curve for intravesical passive diffusion were 709 ng. per 8 hours versus oral 1,485 (p <0.05) versus intravesical electromotive 2,781 (p <0.001). Bladder content samples confirmed oxybutynin absorption. Oral oxybutynin caused anticholinergic side effects in 7 of 10 patients. There were no side effects with intravesical passive diffusion or electromotive administrations.

CONCLUSIONS

Accelerated intravesical administration results in greater bioavailability and increased objective benefits without side effects in previously unresponsive patients compared with oral and intravesical passive diffusion oxybutynin administration.

[Ultrasonography of the upper urinary tract in patients with spinal cord injury]

A lesion of the upper urinary tract (UUT) is a possible outcome of the bladder dysfunction following a spinal cord injury (SCI). The most common findings are hydronephrosis, bladder-ureteral reflux and pyelonephritis. Aim of the study was to evaluate the prevalence of UUT abnormalities, evaluable by ultrasound (US), in a population of SCI patients; furthermore we correlated the presence of such abnormalities to clinical findings. We evaluated 115 consecutive patients who underwent US scan of UUT. Mean time between injury and our evaluation was 81.5 +/- 100.2 months. Lesion level was cervical (38/115), dorsal (59/115) and lumbar (18/115). Eight patients emptied their bladder spontaneously, 105 by means of intermittent catheterization, while 2 were wearing indwelling catheter. Seventy-four patients used anticholinergics drugs. It was evaluated the presence of: hydronephrosis, renal stones and chronic pyelonephritis using US. Afterward the presence of such alterations was correlated to sex and age of patients, time between injury and our evaluation, method of bladder emptying and use of anticholinergics drugs. In 25/115 patients (21.7%) were found abnormalities of UUT. A significative correlation was found between presence of UUT lesions and older age. In our series, prevalence of UUT abnormalities observed by means of US in SCI patients is 21.7%. This finding could be due to correct management and strict follow up of the patients.

One year follow up of spinal cord injury patients using a reciprocating gait orthosis: preliminary report

OBJECTIVE

To examine the influence of social, physical and psychological factors in determining the usage/non usage of reciprocating gait orthosis (RGO) in spinal cord injury (SCI) patients.

DESIGN

Prospective clinical trial.

SETTING

A large rehabilitation hospital in Rome, Italy.

PARTICIPANTS

Twenty four SCI patients of traumatic aetiology (all fulfilling the criteria to prescribe the device).

METHODS

Social, physical and neurological examination according to ASIA standards; psychological enquiry by means of the Eysenck Personality Questionnaire (EPQ) and the scale for self rating anxiety and depression of the Cognitive Behavioural Assessment.

RESULTS

After 1 year follow up 11 (46%) of our patients no longer used the RGO. There was no statistically significant difference between patients who used the RGO and those who rejected the orthosis with regard to social and physical data. There was a significant difference (P=0.005 at the end of training and P=0.003 at 1 year follow up) with regard to functional ambulation level. With regard to psychological enquiry RGO-non users showed a higher frequency of values over the mean in the E scale (extroversion) of the EPQ than RGO-users (P=0.05).

CONCLUSIONS

None of the identified parameters were useful to predict the use/rejection of the orthosis. Although they need to be confirmed, our psychological data suggest that extensive psychological testing could be useful to sharpen the ability to predict.

Urodynamics in spinal cord injured patients walking with reciprocating gait orthosis

PURPOSE

We evaluated the effects of walking with reciprocating gait orthosis on bladder function and upper urinary tract status in spinal cord injured patients.

MATERIALS AND METHODS

Seven patients using reciprocating gait orthosis underwent urodynamics before and during walking. Abdominal ultrasound was performed before and after urodynamics.

RESULTS

Baseline urodynamics showed detrusor areflexia in 3 patients and hyperreflexia in 4. During walking urodynamics revealed hyperreflexia in 6 patients with worse uninhibited detrusor contraction amplitude (38.2 +/- 41.2 versus 73.7 +/- 44.4 cm. water, p = 0.006) and duration (2.1 +/- 2.1 versus 6.8 +/- 5.3 minutes, p = 0.023). After walking ultrasound demonstrated bilateral pyelectasia in 2 patients.

CONCLUSIONS

Spinal cord injured patients using reciprocating gait orthosis have worse urodynamic measurements and upper urinary tract disorders during walking. They require close urological followup.

Urological dysfunctions and upper urinary tract involvement in multiple sclerosis patients

The goal of the present study was to investigate the involvement of the upper urinary tract (UUT) in patients with multiple sclerosis and its relationship with other neurological and urological features of the disease. One hundred sixteen patients underwent complete neurological and urological assessments, urodynamic investigation, and morphofunctional study of the urinary tract by ultrasonography, voiding cistourethrography, and/or intravenous excretory pyelography. The most remarkable relationships were observed among disease duration, pyramidal system score, amplitude of uninhibited detrusor contractions and the presence of bladder morphological abnormalities (P = 0.03, 0.0008, and 0.018, respectively) and the relationship between pyramidal system score or the presence of bladder pathology and UUT abnormalities (P = 0.03 and 0.0006, respectively). A significant relationship was found between the maximum amplitude of uninhibited contractions and UUT involvement (P = 0.002). No other significant relationship was observed between UUT involvement and any other urodynamic or urological features of the disease (type of progression and progression rate, Expanded Disability Status Scale, and other functional system scores). The relationship among disease duration, high vesical pressures, and the lack of reliable clinical indices of risk to the UUT stress the importance for patients with multiple sclerosis to adhere to a strict follow-up program with urodynamic assessment and urinary tract imaging and to maintain detrusor relaxation with anticholinergic medications.

Extraction and determination of oxybutynin in human bladder samples by reversed-phase high-performance liquid chromatography

A reversed-phase high-performance liquid chromatography method is described for the determination of oxybutynin (OXB) in human bladder samples. Following homogenization, tissue samples underwent double extraction with hexane and eventually were concentrated by freeze-drying before analysis. Chromatographic separation was performed with a mobile phase of acetonitrile-water-1 M ammonium acetate, pH 7.0 (85:13:2, v/v/v) at a flow-rate of 0.5 ml/min and double (electrochemical and UV) detection was applied. The retention time of oxybutynin eluting peak was around 18 min. Using a standard curve range of 10 to 500 ng/ml the quantification limit with electrochemical detection was 5 ng/ml with an injection volume of 100 microl. Within-day and day-to-day relative standard deviation values were 4.9 and 9.81%, respectively, while a 94% accuracy and a 72% recovery was attained. We applied this method to compare the OXB levels into bladder wall tissue samples after passive diffusion and after electromotive drug administration (EMDA), using a two-chambered poly(vinyl chloride) diffusion cell designed and developed in our laboratory. The results obtained show that EMDA enhanced OXB penetration into bladder wall and that this novel way of local drug administration can be potentially used in patients with neurogenic bladder dysfunction or urinary incontinence.

Electromotive versus passive diffusion of mitomycin C into human bladder wall: concentration-depth profiles studies

The objectives of these investigations were: (a) to make a preliminary study to assess concentration-depth profiles of mitomycin C (MMC) in the bladder wall at specified time intervals after passive diffusion (PD); and (b) to conduct a major study to compare concentration-depth profiles after PD and electromotive drug administration (EMDA) of MMC. Full thickness sections of viable human bladder wall were placed in two-chamber cells with urothelium exposed to donor compartments containing 40 mg of MMC in 100 ml of 0.96% NaCl solutions and with serosa-facing receptor compartments containing 0.9% NaCl solutions. In the preliminary study during each of nine experimental sessions, five sections of bladder wall were individually exposed to MMC for either 5, 15, 30, 45, or 60 min. In the major study, an anode and a cathode were sited in the donor and receptor compartments, and 14 paired experiments--current (20 mA)/no current--were conducted over a 30-min period. Bladder wall sections were cut serially into 40-microm slices parallel to the urothelium and analyzed by high-performance liquid chromatography for MMC concentration (microg/g wet tissue weight). Tissue viability and morphology and MMC stability were assessed by trypan-blue exclusion test, histological examination, and mass spectrometry analysis. In the preliminary study (PD only), mean MMC concentrations (microg) at 5, 15, 30, 45, and 60 min were: (a) for urothelium, 15.3, 60.0, 58.2, 60.1, and 57.8, respectively; (b) for lamina propria, 2.2, 18.9, 19.3, 16.1, and 17.3, respectively; and (c) for muscularis, 0.4, 2.0, 1.8, 1.3, and 2.4, respectively. In the comparative study, MMC concentrations and coefficients of variation (CV) were as follows: (a) for urothelium after PD, 46.6 with CV = 69%, and after EMDA, 170.0 with CV = 43% (P < 0.0001); (b) for lamina propria after PD, 16.1, with CV = 60%, and after EMDA, 65.6 with CV = 29% (P < 0.0001); and (c) for muscularis after PD, 1.9 with CV = 82%, and after EMDA, 15.9 with CV = 82% (P < 0.0005). All of the bladder sections remained viable, and the chemical structure of MMC was unchanged. It was concluded that EMDA significantly enhances MMC transport into all of the layers of the bladder wall, and sections of viable human bladder are a reliable tool for assessing different modes of drug delivery.

Lower urinary tract dysfunction and disability status in patients with multiple sclerosis

OBJECTIVE

To investigate the correlation between neurologic and urologic status in patients with multiple sclerosis (MS).

MATERIALS AND METHODS

Between January 1993 and December 1995, 116 patients with MS symptoms were fully assessed neurologically and urologically with urodynamic studies.

RESULTS

Urodynamic abnormalities were detected in 104 patients (89.6%). Several significant relationships between urinary tract findings and neurologic dysfunction were: (1) the relation between voiding disorder as the presenting symptom of the disease and a higher severity of bladder dysfunction; (2) the relation between reduced bladder sensation and longer duration of voiding disorders, lower detrusor uninhibited contractions threshold, and lower bladder capacity; and (3) the relation between voiding disorders and cerebellar system score. Finally, a significant inverse relationship was found between detrusor hypocontractility and neurologic status (from the Expanded Disability Status Scale, pyramidal system score, and Barthel Index).

CONCLUSIONS

In this series a high incidence of patients reported voiding disorder as the presenting symptom of MS. These patients also showed a higher severity of urodynamic disorders. They should be rigorously followed up. Furthermore, our data suggest that although the most common cause of altered bladder control in MS is spinal cord pathology, involvement of cortical centers and/or peripheral neuronal lesions may occur.

Autonomic dysreflexia during urodynamics

Autonomic dysreflexia (AD) is an acute syndrome characterised by inappropriate and massive autonomic response that occurs in patients with spinal cord injury above the T6 level.

AIMS

to evaluate the incidence of AD during cystometry and the relationships with clinical and urodynamic features.

PATIENTS AND METHODS

Forty-eight spinal cord injury patients were studied by neurological and urological examination and urodynamic evaluation with concurrent recording of blood pressure, heart rate and symptoms and signs of AD. Patients were considered to have AD if blood pressure reached values higher than 150/100 mmHg.

RESULTS

All the patients showed a significant increase of both systolic and diastolic blood pressure, although only 20 showed pressure values higher than 150/100 mmHg (in seven of them without AD symptoms). AD was more frequent in cervical patients (P = 0.034), but did not correlate with any other clinical features: sex ratio, age, disease duration, completeness of lesion, incidence of detrusor hyperreflexia/areflexia and detrusor-sphincter dyssynergia, voiding modalities, usage of anticholinergic drugs. In three patients blood pressure increase began when uninhibited contraction started, in 11 it was coincident with uninhibited contraction peak and in the other six it appeared at maximum bladder capacity.

CONCLUSIONS

(1) during urodynamic evaluation all the patients with lesion level above T6 showed signs of sympathetic stimulation, although only some showed dangerous blood pressure values; (2) the relationship between urodynamic data and dysreflexia crisis shows that both the presence of detrusor uninhibited contractions and bladder distension are able to stimulate the crisis; (3) treatment with anticholinergic drugs is not sufficient to prevent autonomic dysreflexia starting from the bladder, unless it induces detrusor areflexia. These patients are at risk of developing autonomic dysreflexia following bladder distension.

Clean intermittent catheterization and prevention of renal disease in spinal cord injury patients

Upper urinary tract complications have been reported in about 20-30% of spinal cord injury patients. Their pathogenesis is linked to the presence of high-pressure uninhibited detrusor contractions, high leak point pressure and low bladder compliance. The aim of this study was to evaluate the incidence of upper urinary tract complications in two homogeneous groups of spinal cord injury patients with different bladder emptying modalities (intermittent catheterization vs. tapping, abdominal straining, Crede's manoeuvre) and the relationship with clinic and urodynamic features. A total of 17 patients (22%) had upper urinary tract complications. The incidence of both urinary tract dilatation and vesicoureteral reflux was significantly lower in patients having intermittent catheterization (P = 0.03 and 0.04 respectively). Intermittent catheterization thus seems to be effective in preventing upper urinary tract disease in spinal cord injury patients requiring mechanical bladder emptying modalities. The finding of upper urinary tract complications also in patients having intermittent catheterization showing high intravesical pressures stresses the need of adding anticholinergic medications to the rehabilitation regimen of these patients.

Electromotive administration of oxybutynin into the human bladder wall

PURPOSE

To compare concentrations of oxybutynin in the human bladder wall after either passive delivery (PD) or electromotive administration (EMDA).

MATERIALS AND METHODS

Tissue sections of human bladder were inserted into a diffusion cell with urothelium exposed to the donor compartment containing oxybutynin (4.5 mg. in 100 ml. NaCl 0.45%) and an anode. Twelve paired experiments, "current 5 mA/no current", were conducted over 15 minutes. Oxybutynin tissue contents were measured and tissue viability, morphology and oxybutynin stability were assessed.

RESULTS

Mean oxybutynin tissue concentrations were 3.84 micrograms./gm. in samples exposed to EMDA and 0.87 microgram./gm. in samples exposed to PD (p = 0.0006). The mean coefficients of variation were 57.85% in EMDA experiments and 89.78% in PD experiments. Tissues were viable and undamaged histologically and no oxybutynin structural modification was observed.

CONCLUSIONS

EMDA enhances oxybutynin administration into viable bladder wall and reduces the variability in drug delivery rate.

Electromotive delivery of mitomycin C into human bladder wall

The aim of this investigation was to establish an appropriate tissue pharmacokinetic model to compare concentrations of mitomycin C (MMC) in the human bladder wall after either passive delivery or electromotive administration (EMDA) and to evaluate the effects of EMDA on tissue morphology and MMC structure. Tissue sections of human bladder were inserted into two chamber cells with urothelium exposed to donor compartments containing MMC (10 mg in 100 ml of 0.24% NaCl solution) and an anode and with serosa exposed to receptor compartments containing 100 ml of 0.9% NaCl solution and a cathode. Fourteen paired experiments ("current 5 mA/no current") were conducted over 15 min; MMC tissue content was assessed by high-pressure liquid chromatography. Tissue viability and morphology and MMC stability were assessed by trypan blue exclusion test, tissue pH, histological analysis, and mass spectrometry analysis. MMC concentrations were increased, and variability in drug delivery rate was reduced in all tissue in samples exposed to electric current. Tissues were viable and undamaged histologically, and no MMC structural modification was observed. In conclusion, EMDA enhances administration of MMC into viable bladder wall tissue and reduces the variability in drug delivery rates.

Voiding dysfunction in patients with spinal cord lesions at the thoracolumbar vertebral junction

Neurogenic voiding dysfunction invariably follows a complete spinal cord lesion. With spinal shock urodynamic investigation will show an areflexic bladder if the sacral spinal cord has been damaged, otherwise, if the lesion involves the suprasacral cord, an overactive bladder will result. There are some exceptions to this rule, particularly in those with lesions of the thoracolumbar vertebral junction, where the sacral cord is located, it may be difficult to predict urodynamic dysfunction merely on the basis of the vertebral body involved. 46 patients with a complete SCI neurological lesion at the thoraco-lumbar vertebral junction underwent a neurourological evaluation including multi-channel urodynamic studies. Overall in 20 to 36% of the patients the urodynamic pattern was different from what one would have expected considering the anatomical level of the vertebral body involved. Urodynamic study is confirmed as an essential tool in the correct diagnostic and therapeutic approach to the voiding dysfunction in these type of patients.