Application of improved glomerular filtration rate estimation by a neural network model in patients with neurogenic lower urinary tract dysfunction.

BACKGROUND: Previous studies have indicated that creatinine (Cr)-based glomerular filtration rate (GFR) estimating equations - including the new Chronic Kidney Disease Epidemiology creatinine (CKD-EPIcr) equation without race and the estimated glomerular filtration rate (eGFR) equation developed for the Chinese population - displayed suboptimal performance in patients with neurogenic lower urinary tract dysfunction (NLUTD), which limited their clinical application for detecting changes in GFR levels in all cohorts. OBJECTIVE: To develop a neural network model based on multilayer perceptron (MLP) for evaluating GFR in Chinese NLUTD patients, and compare the diagnostic performance with Cr-based multiple linear regression equations for Chinese and the CKD-EPIcr equation without race. DESIGN: Single-center, cross-sectional study of GFR estimation from serum Cr, demographic data, and clinical characteristics in Chinese patients with NLUTD. PATIENTS: A total of 204 NLUTD patients, from 27 different geographic regions of China, were selected. A random sample of 141 of these subjects was included in the training sample set, and the remaining 63 patients were included in the testing sample set. METHODS: The reference GFR (rGFR) was assessed by the technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) double plasma sample method. A neural network model based on MLP was developed to evaluate GFR in the training sample set, which was then validated in the testing sample set and compared with Cr-based GFR equations. RESULTS: The MLP-based model showed significant performance improvement in evaluating the difference, absolute difference, precision, and accuracy of GFR estimation compared with the Cr-based GFR equations. Additionally, compared with the rGFR, we found that the MLP-based model provided an acceptable level of accuracy (greater than 85%, which was within a 30% deviation from the rGFR). CONCLUSION: The MLP-based model offered significant advantages in estimating GFR in Chinese NLUTD patients, and its application could be suggested in clinical practice.

Bladder height to width ratio as a surrogate marker for non-physiological storage pressures in children with spinal dysraphism.

INTRODUCTION: Spinal dysraphism is the most frequent cause of neurogenic bladder. Urodynamic study (UDS) is an important component of the follow-up of a child with neurogenic bladder. However, it suffers from a lack of widespread availability and is further hampered by technical difficulties and difficulty in its interpretation in children. A neurogenic bladder often appears vertically elongated; only limited and sparse literature is available regarding objectively defining the bladder shape and the urodynamic parameters in the cohort. OBJECTIVES: This study aimed to investigate the usefulness of the bladder's height-to-width ratio (HWR) on cystogram as a screening tool for identifying "non-physiological" bladder pressures in children with spinal dysraphism. A prospective study was undertaken to evaluate children operated for spinal dysraphism. Cystogram, ultrasonography and UDS evaluation were performed. HWR was calculated by the ratio of the maximum height to the maximum bladder width at maximum cystometric capacity (MCC), where MCC was calculated using standard Koff's formula, given by (age in years + 2) *30 ml in children more than one year and weight *7 ml for infants. The children were categorised into groups based on maximum detrusor pressure (MDP) into two groups (MDP ≥ 30 cmH2O and MDP < 30 cmH2O). A receiver-operative characteristic curve was constructed to analyse the sensitivity and specificity of HWR in predicting the MDP. RESULTS: A total of 53 children, operated for spinal dysraphism, met the study criteria during the study period, from March 2021 to September 2022. The median age of children was 4 years (IQR-3-5.5 years). The HWR ratio was compared between the two groups and was significantly higher for the non-physiological pressure bladders than for physiological pressure bladders (mean of 1.55 vs 1.26, p = 0.001). On evaluating the sensitivity and specificity of HWR for discerning children with non-physiological bladder pressures were 87.5% and 48.28%, respectively. The area under the curve (AUC) was 0.781, with a cut-off value of 1.3. DISCUSSION: We attempted to evaluate the HWR based on bladder shape objectively. We demonstrated a moderate correlation between the bladder shape and the bladder pressures. An HWR of 1.3 or higher could be significant for identifying a non-physiological bladder storage pressure. CONCLUSION: The height to width ratio of the bladder on cystogram is a useful tool as a surrogate marker for non-physiological storage pressures in bladders of children with spinal dysraphism.

[DEVELOPMENT OF JAPANESE TRANSLATION OF THE NEUROGENIC BLADDER SYMPTOM SCORE].

(Objectives) To develop Japanese translations of the standard and short forms of the Neurogenic Bladder Symptom Score (Subjects and methods) The questionnaires were forward translated by a Japanese healthcare professional and non-medical professional and backward translated by two native English-speaking translators. Then, the products were harmonized by the participants involved in the translational processes. Finally, 15 persons with spinal cord lesions were interviewed to improve the provisional Japanese translations based on their suggestions. (Results) Throughout the forward and backward translations and their harmonization, no major translational problems were encountered, other than those attributable to differences in syntax between English and Japanese. The persons could complete the provisional Japanese translations of the standard and short forms in median 7.0 and 3.0 minutes, respectively. Although none of them reported difficulty in answering the questions, 6, 3, and 5 persons pointed out that the tenth question (the seventh question in the short form) and the answers to the nineteenth and twenty-second questions, respectively, were not easy to understand. Taking their suggestions into consideration, we finalized the Japanese translations with the help of a developer of the questionnaire as well as the back-translators. (Conclusions) After a multi-step review process, linguistically valid Japanese translations of the standard and short forms of the Neurogenic Bladder Symptom Score (Neurogenic Bladder Symptom Score Japanese version 1.0) were completed. We hope that these Japanese translations will facilitate future research on patient-reported outcomes in persons with neurogenic lower urinary tract dysfunction.

Efficacy of Transcutaneous Electrical Nerve Stimulation in the Management of Neurogenic Overactive Bladder: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to investigate the therapeutic effect of transcutaneous electrical nerve stimulation on neurogenic overactive bladder that is refractory to pharmacotherapy. METHODS: This randomized trial recruited 83 participants with neurogenic overactive bladder that were nonresponsive to 3-mo first-line anticholinergic drug treatment. Participants were randomized into treatment and control groups. Transcutaneous electrical nerve stimulation current consisting of biphasic square wave with pulse durations of 150 µs and pulse frequency set at 20 Hz were applied to for 30 mins once a day for 90 days. Stimulation was provided over the lateral aspect of the sacrum bilaterally of the electrodes. Patients in the transcutaneous electrical nerve stimulation group stopped taking the anticholinergic drugs. The control group continued to receive anticholinergic drugs for 90 days. The participants' Overactive Bladder Symptom Score, the Medical Outcomes Study 36-Item Short-Form Health Survey scores, urodynamic values, and voiding diary data were assessed before and after the therapy. RESULTS: The transcutaneous electrical nerve stimulation treatment group had significantly decreased Overactive Bladder Symptom scores compared with the control group (P < 0.001); in addition, half of the Medical Outcomes Study 36-Item Short-Form Health Survey scores were significantly improved in the transcutaneous electrical nerve stimulation group (P < 0.05). The patients treated with transcutaneous electrical nerve stimulation improved significantly voiding diary parameters at P < 0.05. Similarly, urodynamic values at P < 0.05 favored the experimental group over the control group. CONCLUSIONS: Applying daily transcutaneous electrical nerve stimulation over the sacral region for 90 days to patient with neurogenic overactive bladder improved overactive bladder symptoms of patients whose response to anticholinergic drugs is far inferior. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the therapeutic effect of transcutaneous electrical nerve stimulation (TENS) on neurogenic overactive bladder (NOAB); (2) Demonstrate the effectiveness of reflex suppression of the bladder using the TENS applied over the sacral region as a stimulation location; and (3) Confirm the TENS method using biphasic square waves with pulse durations of 150 µs and pulse frequencies of 20 Hz as applied is shown to be superior to anticholinergic drugs in managing NOAB. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Noninvasive, Individualized Cortical Modulation Using Transcranial Rotating Permanent Magnet Stimulator for Voiding Dysfunction in Women with Multiple Sclerosis: A Pilot Trial.

PURPOSE: Voiding dysfunction (VD) leading to urinary retention is a common neurogenic lower urinary tract symptom in patients with multiple sclerosis (MS). Currently, the only effective management for patients with MS with VD is catheterization. Transcranial Rotating Permanent Magnet Stimulator (TRPMS) is a noninvasive, portable, multifocal neuromodulator that simultaneously modulates multiple cortical regions and the strength of their functional connections. In this pilot trial (ClinicalTrials.gov Identifier: NCT03574610), we investigated the safety and therapeutic effects of TRPMS in modulating brain regions of interest (ROIs) engaged with voiding initiation to improve VD in MS women. MATERIALS AND METHODS: Ten MS women with VD (having % post-void residual/bladder capacity [%PVR/BC] ≥40% or being in the lower 10th percentile of the Liverpool nomogram) underwent concurrent functional magnetic resonance imaging/urodynamic study (fMRI/UDS) with 3 cycles of bladder filling/emptying, at baseline and post-treatment. Predetermined ROIs and their activations at voiding initiation were identified on patients' baseline fMRI/UDS scans, corresponding to microstimulator placement. Patients received 10 consecutive 40-minute treatment sessions. Brain activation group analysis, noninstrumented uroflow, and validated questionnaires were compared at baseline and post-treatment. RESULTS: No treatment-related adverse effects were reported. Post-treatment, patients showed significantly increased activation in regions known to be involved at voiding initiation in healthy subjects. %PVR/BC significantly decreased. Significant improvement of bladder emptying symptoms were reported by patients via validated questionnaires. CONCLUSIONS: Both neuroimaging and clinical data suggested TRPMS effectively and safely modulated brain regions that are involved in the voiding phase of the micturition cycle, leading to clinical improvements in bladder emptying in patients with MS.

Slow development of bladder malfunction parallels spinal cord fiber sprouting and interneurons' loss after spinal cord transection.

Neurogenic lower urinary tract dysfunction typically develops after spinal cord injury. We investigated the time course and the anatomical changes in the spinal cord that may be causing lower urinary tract symptoms following injury. Rats were implanted with a bladder catheter and external urethral sphincter electromyography electrodes. Animals underwent a large, incomplete spinal transection at the T8/9 spinal level. At 1, 2-3, and 4 weeks after injury, the animals underwent urodynamic investigations. Urodynamic investigations showed detrusor overactivity and detrusor-sphincter-dyssynergia appearing over time at 3-4 weeks after injury. Lower urinary tract dysfunction was accompanied by an increase in density of C-fiber afferents in the lumbosacral dorsal horn. CRF-positive Barrington's and 5-HT-positive bulbospinal projections drastically decreased after injury, with partial compensation for the CRF fibers at 3-4 weeks. Interestingly, a decrease over time was observed in the number of GABAergic neurons in the lumbosacral dorsal horn and lamina X, and a decrease of glutamatergic cells in the dorsal horn. Detrusor overactivity and detrusor-sphincter-dyssynergia might therefore arise from a discrepancy in inhibitory/excitatory interneuron activity in the lumbosacral cord as well as input changes which develop over time after injury. The processes point to spinal plastic changes leading to malfunction of the important physiological pathway of lower urinary tract control.

Acute, severe traumatic spinal cord injury: improving urinary bladder function by optimizing spinal cord perfusion.

OBJECTIVE: The authors sought to investigate the effect of acute, severe traumatic spinal cord injury on the urinary bladder and the hypothesis that increasing the spinal cord perfusion pressure improves bladder function. METHODS: In 13 adults with traumatic spinal cord injury (American Spinal Injury Association Impairment Scale grades A-C), a pressure probe and a microdialysis catheter were placed intradurally at the injury site. We varied the spinal cord perfusion pressure and performed filling cystometry. Patients were followed up for 12 months on average. RESULTS: The 13 patients had 63 fill cycles; 38 cycles had unfavorable urodynamics, i.e., dangerously low compliance (< 20 mL/cmH2O), detrusor overactivity, or dangerously high end-fill pressure (> 40 cmH2O). Unfavorable urodynamics correlated with periods of injury site hypoperfusion (spinal cord perfusion pressure < 60 mm Hg), hyperperfusion (spinal cord perfusion pressure > 100 mm Hg), tissue glucose < 3 mM, and tissue lactate to pyruvate ratio > 30. Increasing spinal cord perfusion pressure from 67.0 ± 2.3 mm Hg (average ± SE) to 92.1 ± 3.0 mm Hg significantly reduced, from 534 to 365 mL, the median bladder volume at which the desire to void was first experienced. All patients with dangerously low average initial bladder compliance (< 20 mL/cmH2O) maintained low compliance at follow-up, whereas all patients with high average initial bladder compliance (> 100 mL/cmH2O) maintained high compliance at follow-up. CONCLUSIONS: We conclude that unfavorable urodynamics develop within days of traumatic spinal cord injury, thus challenging the prevailing notion that the detrusor is initially acontractile. Urodynamic studies performed acutely identify patients with dangerously low bladder compliance likely to benefit from early intervention. At this early stage, bladder function is dynamic and is influenced by fluctuations in the physiology and metabolism at the injury site; therefore, optimizing spinal cord perfusion is likely to improve urological outcome in patients with acute severe traumatic spinal cord injury.

Botulinum Toxin Injection for Medically Refractory Neurogenic Bladder in Children: A Systematic Review.

The objective was to evaluate the use of botulinum toxin A (BTX-A) injection in children with medically refractory neurogenic bladder. A systematic review of the literature was conducted using three databases (Medline via PubMed, Cochrane, and EMBASE). Articles evaluating BTX-A in children with neurogenic bladder were collected. The clinical and urodynamic parameters were reviewed for the safety and efficacy evaluation. Sixteen studies were selected into this study and a total of 455 children with medical refractory neurogenic bladder were evaluated. All of the patients had received traditional conservative medications such as antimuscarinics and intermittent catheterization as previous treatment. The duration of treatments ranged from 2 months to 5.7 years. Improvements in incontinence and vesicoureteral reflux were the most common clinical outcomes. The detrusor pressure, bladder capacity and bladder compliance improvement were the most common urodynamic parameters which had been reported. However, patient satisfaction with the procedure remained controversial. There was only a minimal risk of minor adverse effects. In all of the studies, BTX-A injection was well tolerated. In conclusion, BTX-A injection appears to be a safe and effective treatment in the management of medically unresponsive neurogenic bladder in children. There is currently no evidence that the use of BTX-A injection could be used as a first-line therapy for neurogenic bladder in children.

Time-dependent progression of neurogenic lower urinary tract dysfunction after spinal cord injury in the mouse model.

This study evaluated the time-course changes in bladder and external urinary sphincter (EUS) activity and the expression of mechanosensitive channels in lumbosacral dorsal root ganglia (DRG) after spinal cord injury (SCI). Female C57BL/6N mice in the SCI group underwent transection of the Th8/9 spinal cord. Spinal intact mice and SCI mice at 2, 4, and 6 wk post-SCI were evaluated by single-filling cystometry and EUS-electromyography (EMG). In another set of mice, the bladder and L6-S1 DRG were harvested for protein and mRNA analyses. In SCI mice, nonvoiding contractions were confirmed at 2 wk post-SCI and did not increase over time to 6 wk. In 2-wk SCI mice, EUS-EMG measurements revealed detrusor sphincter dyssynergia, but periodic EMG reductions during bladder contraction were hardly observed. At 4 wk, SCI mice showed increases of EMG activity reduction time with increased voiding efficiency. At 6 wk, SCI mice exhibited a further increase in EMG reduction time. RT-PCR of L6-S1 DRG showed increased mRNA levels of transient receptor potential vanilloid 1 and acid-sensing ion channels (ASIC1-ASIC3) in SCI mice with a decrease of ASIC2 and ASIC3 at 6 wk compared with 4 wk, whereas Piezo2 showed a slow increase at 6 wk. Protein assay showed SCI-induced overexpression of bladder brain-derived neurotrophic factor with a time-dependent decrease post-SCI. These results indicate that detrusor overactivity is established in the early phase, whereas detrusor sphincter dyssynergia is completed later at 4 wk with an improvement at 6 wk post-SCI, and that mechanosensitive channels may be involved in the time-dependent changes.NEW & NOTEWORTHY This is the first paper to evaluate the time-course changes of bladder dysfunction associated with mechanosensitive channels in a mouse model.

Low Interrater Reliability of Videourodynamic Diagnosis of Detrusor External Sphincter Dyssynergia.

OBJECTIVES: Complex bladder dysfunction requires urodynamic testing, often under fluoroscopy termed videourodynamic study (VUDS), to assist the diagnosis and management. Videourodynamic study is an objective tool with high interrater reliability (IRR) for identifying detrusor overactivity. However, IRR has not been validated with disorders associated with neurogenic bladder (NGB). We aim to investigate the IRR of VUDS to diagnose detrusor external sphincter dyssynergia (DESD) among NGB patients and hypothesize a high IRR to DESD diagnosis on VUDS. METHODS: Videourodynamics tracings with fluoroscopic images were rated either positive or negative for evidence of DESD by 4 raters (2 neurourologists, neurourology fellow, and urology postgraduate year 2 resident), in patients who underwent VUDS from 2013 to 2017. The study population had known NGB without previous bladder reconstruction. The IRR was determined using percent agreement and κ values. RESULTS: The experts had a percent agreement of 82.1% (κ = 0.26). Expert 1 and expert 2 had a percent agreement of 63.6% (κ = 0.1497) and 68.9% (κ = 0.2967), respectively, when compared with the fellow. Sensitivity and specificity ranged from 28% to 75% and 64% to 93%, respectively. The negative predictive values ranged from 90% to 95%. CONCLUSIONS: The IRR to diagnose DESD on VUDS was much lower than expected, even among experts, and was likely multifactorial and partially owing to lack of clinical context and lack of standardized VUDS interpretation of the electromyogram. A high negative predictive value was found among all participants. Further research is needed to evaluate factors contributing to the low reproducibility of DESD diagnosis on VUDS.

Let's Talk About Sex: Special Considerations in Reproductive Care and Sexual Education in Young Women With Spina Bifida.

Medical advances in the last several decades have allowed an increasing number of children with spina bifida to reach adolescence and adulthood. As they reach puberty, girls with spina bifida face unique social and health challenges to their sexuality, such as orthopedic restrictions, continence, and pelvic floor disorders. Recent research efforts have focused on better understanding female sexual desires, dysfunctions, and activity and the role of the physician in educating this vulnerable population. This article aims to summarize current literature on sexual function, knowledge gaps, and the importance of tailored sexual education from providers in women with spina bifida.

Detrusor Pressures Change with Repeat Filling Cystometry in Myelodysplastic Children with Neurogenic Lower Urinary Tract Dysfunction.

PURPOSE: The International Children's Continence Society recommends urodynamics repeated at least twice for the optimal result. We aimed to search if 3 times repeat filling urodynamics in the same session would change the urodynamics parameters in children with neurogenic lower urinary tract dysfunction due to myelodysplasia. MATERIALS AND METHODS: We investigated urodynamic reports and charts of 80 consecutive children with neurogenic lower urinary tract dysfunction due to myelodysplasia who underwent 3 repeat, same session filling cystometry studies between June 2017 and December 2018. Maximum detrusor pressure, maximum cystometric capacity, detrusor leak point pressure, compliance, residual urine volume and maximum cystometric capacity/estimated bladder capacity for age ratio were compared among all 3 filling cystometries. RESULTS: The median age was 4.3 years (IQR 5.8). Of the patients 39 (48.75%) were girls and 41 (51.25%) were boys. Primary pathological finding was myelomeningocele in 69 patients (86.3%). Maximum cystometric capacity, compliance, residual urine and maximum cystometric capacity/estimated bladder capacity for age were found comparable in 3 repeat cystometries. However, maximum detrusor pressure at first filling was higher compared to others (second, p=0.015, and third, p=0.002). Detrusor leak point pressure at the first filling was also higher compared to the third (p <0.001). Detrusor overactivity was persistent in all 3 fillings in 85% of patients (68 of 80). Of the patients 68 (85%) remained in the same risk group according to detrusor leak point pressure (cutoff 40 cmH2O). CONCLUSIONS: Maximum cystometric capacity and detrusor overactivity are comparable in 3 repeat cystometries but detrusor pressures significantly decrease in the repeat fillings. In our practice we plan our management according to the most worrisome urodynamics parameters for a safer proactive approach.

Clinical Protocol for Identifying and Managing Bladder Dysfunction during Acute Care after Traumatic Spinal Cord Injury.

Bladder dysfunction is widespread following traumatic spinal cord injury (TSCI). Early diagnosis of bladder dysfunction is crucial in preventing complications, determining prognosis, and planning rehabilitation. We aim to suggest the first clinical protocol specifically designed to evaluate and manage bladder dysfunction in TSCI patients during acute care. A retrospective cohort study was conducted on 101 patients admitted for an acute TSCI between C1 and T12. Following spinal surgery, presence of voluntary anal contraction (VAC) was used as a criterion for removal of indwelling catheter and initiating trial of void (TOV). Absence of bladder dysfunction was determined from three consecutive post-void bladder scan residuals ≤200 mL without incontinence. All patients were reassessed 3 months post-injury using the Spinal Cord Independence Measure (SCIM). A total of 74.3% were diagnosed with bladder dysfunction during acute care, while 57.4% had a motor-complete TSCI. Three months later, 94.7% of them reported impaired bladder function. None of the patients discharged from acute care after a functional bladder was diagnosed reported impaired bladder function at the 3-month follow-up. A total of 95.7% patients without VAC had persisting impaired bladder function at follow-up. The proposed protocol is specifically adapted to the dynamic nature of neurogenic bladder function following TSCI. The assessment of VAC into the protocol provides major insight on the potential for reaching adequate bladder function during the subacute phase. Conducting TOV using bladder scan residuals in patients with VAC is a non-invasive and easy method to discriminate between a functional and an impaired bladder following acute TSCI.

Translation and cultural adaptation of SF Qualiveen questionnaire in Greek.

BACKGROUND: Most of neurologically impaired persons, who are suffering from spinal cord injury (SCI) or multiple sclerosis (MS), may face important lifestyle restrictions. Urinary disorders can further decrease their quality of life (QoL). SF Qualiveen is a validated questionnaire for the evaluation of QoL in this population related to neurogenic lower urinary tract dysfunction (NLUTD). AIM: The cross-cultural adaptation, the reliability check, and the validation of the SF Qualiveen in Greek. DESIGN: The design of this study was the observational cohort study. SETTING: Between November 2019 and May 2020, we addressed to 136 consecutive neurologic patients with MS or SCI from the outpatient clinic of the Unit of Neuro-urology of the National Rehabilitation Center in Athens. POPULATION: The study was based on 124 patients (68 males and 56 females). There were 55 paraplegics, 16 tetraplegics and 53 MS patients. METHODS: After a back forward translation of the SF Qualiveen between English and Greek, the patients completed the Greek version of SF Qualiveen and King's Health Questionnaire at baseline and 3 months later. Reliability check and validation were performed by factor analysis with the Explanatory Factor Analysis (EFA) method. Demographic data were collected as well. RESULTS: The Greek version of the questionnaire showed good internal consistency with Cronbach's α >70 for the total score and most of the four sub-scales for the test and retest. Test-retest reliability showed that all domains of the SF-Qualiveen (test) were correlated with the SF-Qualiveen total score (test) and the same applies to the SF-Qualiveen (retest). Domains of SF-Qualiveen (test) were poorly correlated with the domains of SF-Qualiveen (retest). Construct and criterion validity were satisfactory and CFA found that the model had good fit [χ2 (14)=19.133, GFI=0.964, NFI=0.954, RMSEA=0.055, CFI=0.987]. CONCLUSIONS: This Greek version of the SF Qualiveen was tested following well-established guidelines on measurement properties and showed good validity and reliability. It is reproducible, reliable, and valid for the Greek population. CLINICAL REHABILITATION IMPACT: This Greek version of the SF Qualiveen can be used as a tool to evaluate the impact of NLUTD on QoL in Greek-speaking patients with MS and SCI in research and clinical practice.

Continuous body impedance measurement to detect bladder volume changes during urodynamic study: A prospective study in pediatric patients.

AIMS: To assess the possibility of the body impedance (BI) reflecting bladder volumes (BV) in pediatric patients, the BI signals are measured continuously with the equipment that we have developed and reported previously, during the filling phase of urodynamic study (UDS). METHODS: A total of 30 children (5-12 years old) are included in this prospective study. The equipment uses two dry electrodes embedded inside a strap to collect impedance and electrocardiogram signals. The factors affecting baseline BI and its decreases during UDS have been investigated. RESULTS: The median age is 6.1 years and BI is accurately measured in 27 out of 30 patients (90.0% accuracy). The median value of baseline BI is 1958 Ω. It is higher when they are older, equal to or taller than 125 cm, or non-neurogenic bladder patients. BI decreases as the bladder is filled with saline in 21 patients (77.8%), and remains constant in 6 patients (22.2%). The median age of the Decreased Group is significantly higher than that of Nondecreased Group (p = .036). Height of 125 cm or more is significant in the Decreased Group (p = .020). Heart rates also have been simultaneously measured and revealed a mild decrease during the filling phase. CONCLUSIONS: The baseline BI is affected by the height and age of the children. BI is effectively measured and reflects a change in the BV in older children who are taller than 125 cm, with a small device using a smartphone and a strap.

Fluid Intake and Urinary Symptoms in Patients with Multiple Sclerosis.

PURPOSE: The relationship between fluid intake and lower urinary tract symptoms in individuals with neurogenic bladder is unknown. We investigated the association between fluid intake and urinary symptoms in patients with multiple sclerosis. MATERIALS AND METHODS: A prospective cross-sectional study of patients with multiple sclerosis presenting to the neurology office was conducted. Fluid intake and lower urinary tract symptoms were assessed by the questionnaire based voiding diary and the American Urological Association Symptom Score, respectively. The relationship between fluid intake and lower urinary tract symptoms was assessed using univariate and multivariate analyses. RESULTS: Among 200 individuals with multiple sclerosis the mean total daily fluid intake was 2,489 ml (SD 1,883) and did not differ according to severity (ie mild, moderate, severe) of lower urinary tract symptoms (F=0.30, p=0.74). Fluid restricting behavior to control urinary symptoms was reported by 47% of subjects. Subjects who reported fluid restricting were more likely to have worse urinary symptoms (OR 1.95, 95% CI 1.53-2.47, p <0.01). After accounting for fluid restricting behavior on multivariate analysis, there was a minimal relationship between caffeinated fluid intake and lower urinary tract symptom severity (OR 1.00, 95% CI 1.00-1.01, p=0.01), and there was no relationship between total fluid intake and lower urinary tract symptom severity (OR 1.00, 95% CI 1.00-1.00, p=0.07). CONCLUSIONS: Caffeinated fluid intake has a minimal effect on lower urinary tract symptoms in patients with multiple sclerosis. On average, patients with multiple sclerosis do not hydrate excessively and a considerable proportion restrict fluid intake to control urinary symptoms. Fluid intake may not contribute considerably to lower urinary tract symptoms in patients with multiple sclerosis.

Intradetrusor botulinum toxin injections (300 units) for the treatment of poorly compliant bladders in patients with adult neurogenic lower urinary tract dysfunction.

AIMS: To evaluate the therapeutic effects of intradetrusor onabotulinum toxin A (BTX) injections in patients with adult neurogenic lower urinary tract dysfunction (ANLUTD) and medically refractory poorly compliant bladders. METHODS: We retrospectively evaluated patients with urodynamic studies (UDS)-proven, medically refractory impaired bladder compliance (≤20 mL/cm H2 O) secondary to spinal myelopathy treated with 300 units of BTX cystoscopically injected into the detrusor muscle. Objective improvement in compliance was defined as an increase ≥5 mL/cm H2 O on repeat urodynamics. Characteristics were compared between patients who demonstrated symptomatic and objective improvement following treatment versus those without. RESULTS: Seventy-one individuals were included in the final analysis. Mean patient age was 37.2 years (range: 18-78) and ANLUTD duration was 14.5 years (range: 1-34). Average pre-injection bladder compliance was 9.2 mL/cm H2 O (range: 3.0-16.7). After treatment with BTX, 37 of 71 (52%) patients reported subjective reductions in lower urinary tract symptoms. Repeat UDS demonstrated objective bladder compliance improvements in 22 of 71 (31%). Individuals with shorter time intervals since neurologic injury responded better to BTX than those with longer durations (P = .032). CONCLUSION: BTX injections significantly improved symptoms and bladder compliance in 31% of ANLUTD patients with medical refractory poorly compliant bladders.

Effects of a new ß3-adrenoceptor agonist, vibegron, on neurogenic bladder dysfunction and remodeling in mice with spinal cord injury.

AIMS: To examine vibegron effects on lower urinary tract dysfunction (LUTD) in mice with spinal cord injury (SCI). METHODS: Female mice underwent Th8-9 spinal cord transection and were orally administered vehicle or vibegron after SCI. We evaluated urodynamic parameters at 4 weeks after SCI with or without vibegron. Fibrosis- and ischemia-related messenger RNA (mRNA) and protein levels of collagen and elastin were measured in bladders of vehicle- and vibegron-treated SCI mice, and spinal intact mice. RESULTS: Non-voiding contractions (NVCs) were significantly fewer (15.3 ± 8.9 vs 29.7 ± 11.4 contractions; P < .05) and the time to the first NVC was significantly longer (1488.0 ± 409.5 vs 782.7 ± 399.7 seconds; P < .01) in vibegron-treated SCI mice vs vehicle-treated SCI mice. mRNAs levels of collagen types 1 and 3, transforming growth factor-ß1 (TGF-ß1), and hypoxia-inducible factor-1α (HIF-1α) were significantly upregulated in vehicle-treated SCI mice compared with spinal intact and vibegron-treated SCI mice (Col 1: 3.5 vs 1.0 and 2.0-fold; P < .01 and P < .05, Col 3: 2.1 vs 1.0 and 1.2-fold; P < .01 and P < .05, TGF-ß1: 1.2 vs 1.0 and 0.9-fold; P < .05 and P < .05, HIF-1α: 1.4 vs 1.0 and 1.0-fold; P < .05 and P < .01). Total collagen and elastin protein levels in vehicle- and vibegron-treated SCI mice did not differ. CONCLUSIONS: Vibegron reduced NVCs, delayed the first NVC, and improved collagen types 1 and 3, TGF-ß1, and HIF-1α mRNA expression in SCI mice. Vibegron might be effective for SCI-induced LUTD.

Dysfunctional bladder neurophysiology in urofacial syndrome Hpse2 mutant mice.

AIMS: Urofacial syndrome (UFS) is an autosomal recessive disease characterized by detrusor contraction against an incompletely dilated outflow tract. This dyssynergia causes dribbling incontinence and incomplete voiding. Around half of individuals with UFS have biallelic mutations of HPSE2 that encodes heparanase 2, a protein found in pelvic ganglia and bladder nerves. Homozygous Hpse2 mutant mice have abnormal patterns of nerves in the bladder body and outflow tract, and also have dysfunctional urinary voiding. We hypothesized that bladder neurophysiology is abnormal Hpse2 mutant mice. METHODS: Myography was used to study bladder bodies and outflow tracts isolated from juvenile mice. Myogenic function was analyzed after chemical stimulation or blockade of key receptors. Neurogenic function was assessed by electrical field stimulation (EFS). Muscarinic receptor expression was semi-quantified by Western blot analysis. RESULTS: Nitrergic nerve-mediated relaxation of precontracted mutant outflow tracts was significantly decreased vs littermate controls. The contractile ability of mutant outflow tracts was normal as assessed by KCl and the α1-adrenoceptor agonist phenylephrine. EFS of mutant bladder bodies induced significantly weaker contractions than controls. Conversely, the muscarinic agonist carbachol induced significantly stronger contractions of bladder body than controls. CONCLUSIONS: The Hpse2 model of UFS features aberrant bladder neuromuscular physiology. Further work is required to determine whether similar aberrations occur in patients with UFS.

[Course of neurogenic bladder dysfunction in patients with spinal cord injury under homeopathic treatment]. / Verlauf der neurogenen Blasenfunktionsstörung bei Patienten mit Rückenmarkschädigung unter klassisch homöopathischer Therapie.

BACKGROUND: Nearly all patients with spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD). Untreated NLUTD is a risk factor for renal damage and can significantly affect quality of life (QoL). Patients with SCI frequently use complementary medicine to alleviate symptoms, namely for urologic problems. OBJECTIVES: We evaluated whether homeopathic treatment influences objective urodynamic parameters. MATERIALS AND METHODS: In a retrospective study, urodynamic data of patients with NLUTD due to SCI who received constitutional homeopathic treatment by the consultants of our hospital were evaluated before initiation of homeopathic treatment and at the most recent follow-up. Modifications in urologic treatment were taken into account. RESULTS: Urodynamic results from 35 patients who underwent homeopathic treatment (14 women, 21 men, median age 46 years, tetraplegia: n = 14; paraplegia: n = 21) were available at both time points and could therefore be evaluated. In all, 20 patients used intermittent catheterization, 6 persons had an indwelling catheter, and 9 persons emptied their bladders without a catheter. There were no significant differences in the urodynamic parameters before and during treatment. Changes in urologic therapy correlated with significant improvement in urodynamic findings. CONCLUSIONS: As all patients were under urologic surveillance, and immediate urologic treatment was established if necessary, a retrospective study design proved not to be suitable to detect possible influences of homeopathic treatment on urodynamic parameters in patients with SCI. Thus, a prospective randomized study is essential.