Intermittent self-catheterization training and effects on treatment adherence and infection.

BACKGROUND: Intermittent self-catheterization (CISC) is the preferred treatment for patients with bladder dysfunction due to spinal cord injuries or multiple sclerosis (MS). However, the learning phase plays a crucial role in the still frequent drop-out. AIM: To examine whether the timing of training affects the treatment compliance and the prevalence of urinary tract infections in patients with neurogenic urinary retention. DESIGN: This is a non-randomized observational study. SETTING: The study was carried out from January 2017 to December 2019 in outpatient settings at the Bari Polyclinic Unipolar Spinal Unit (Bari, Italy). POPULATION: The study included adults with a CISC prescription for neurogenic urinary retention and learning the technique for the first time. METHODS: One hundred patients were enrolled, 75 trained immediately after diagnosis and physician prescription, while 25 in the contest of a separate training visit, one or two days after physician prescription. After the training (T0), patient's data and number of prescribed daily catheterizations were recorded and compared with those collected after 6 and 12 months. Accuracy of the procedure and episodes of infections were assessed as well. RESULTS: Adherence to prescribed CISC frequency and complications were not affected by the timing of training. However, patients adherent to the prescribe frequency of catheterization had less risk of infection than those who were not. Further post-hoc analysis confirmed that urodynamic findings and the pathology did not impact the overall occurrence of complications, but infections occurred more frequently in patients with MS (P<0.03). CONCLUSIONS: The timing of CISC education does not affect treatment adherence or the occurrence of complications. However, the adherence to the CISC prescription seems to reduce the risk of infection. CLINICAL REHABILITATION IMPACT: Patient training can be scheduled according to the organization of the centers, as patient compliance and the occurrence of complications are not affected.

Randomized controlled trial on the efficacy of bladder training before removing the indwelling urinary catheter in patients with acute urinary retention associated with benign prostatic hyperplasia.

OBJECTIVE: The aim of this study was to investigate the efficacy of bladder training before removing the indwelling urinary catheter in patients with acute urinary retention (AUR) associated with benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: In total, 845 consecutive patients with their first episode of spontaneous AUR associated with BPH were enrolled in this prospective randomized controlled trial. They were randomly assigned to be given either pharmacological treatment combined with bladder training or pharmacological treatment (tamsulosin 0.2 mg and finasteride 5 mg once daily) with free drainage of urinary catheter for 7 days, and a trial without catheter (TWOC) was performed. Data on patients' baseline demographics, history of BPH, International Prostate Symptom Score, prostate size, serum prostate-specific antigen, intravesical prostatic protrusion, TWOC success rates and related complications were collected and statistically analysed. RESULTS: The two groups of spontaneous AUR patients with BPH were given pharmacological treatment combined with bladder training before catheter removal (n = 440) or pharmacological treatment alone (n = 405) for 7 days. All 845 patients underwent a first TWOC with an overall success rate of 66.9% after first 7 days' catheterization; TWOC was successful in 65.2% of cases in the intervention group and 68.6% in the control group. There was no statistically significant difference in TWOC success rate between the two groups (p > 0.05). CONCLUSION: This randomized controlled trial showed that bladder training before urinary catheter removal did not increase the chance of TWOC success significantly in spontaneous AUR patients with BPH.

Intravesical electrostimulation versus sacral neuromodulation for incomplete spinal cord patients suffering from neurogenic non-obstructive urinary retention.

OBJECTIVES: To compare the efficacy of intravesical electrostimulation (IVES) versus sacral neuromodulation (SNM) in patients with incomplete spinal cord lesions (SCL) and neurogenic non-obstructive urinary retention (N-NOR). METHODS: In this retrospective study, 77 N-NOR patients underwent IVES (minimum 28 sessions), then after returning to voiding baseline symptoms, percutaneous first stage of SNM (lasting for minimum 4 weeks). After the two neuromodulation treatments, responders were categorized as patients experiencing both a 50% reduction of volume per catheterization per ml and a 50% reduction in number of catheterizations per day when comparing the 7-day voiding diaries at the end of both procedures to baselines. New urodynamics were performed subsequently. Responders to first stage of SNM underwent permanent SNM. RESULTS: Forty-eight patients responded to neither of the treatments, whereas 29 responded to both IVES and first-stage SNM. No significant statistical differences (P>0.05) were detected in the voiding diaries. Following the two procedures, the first sensation of bladder filling was either maintained or recovered by all responders, whereas the same 11 patients reached a bladder contractility index of >100. The 29 IVES responders lost their clinical benefits in a mean follow-up of 9.6 months. Only 10 out of the 29 patients became nonresponsive to permanent SNM, in a mean follow-up of 54 months. CONCLUSION: A strict correlation in terms of clinical and urodynamic patterns was demonstrated in patients with incomplete SCL and N-NOR, following IVES and first stage of SNM. However, voiding improvement through IVES was short-term when compared with the effects of permanent SNM.

A case of potential treatment of remote pain after sacral nerve stimulation for chronic urinary retention.

OBJECTIVE: A case is presented in which a 58-year-old man developed a potential unintended and durable treatment of pain at remote sites (cervical region and low back) after sacral nerve stimulation for chronic urinary retention. METHODS: Proper placement of the electrodes in the S3 foramen was confirmed by physiological response and fluoroscopy. RESULTS: Potential causality was shown by recurrent pain with the stimulators turned off and abatement of pain with the stimulators turned on. DISCUSSION: The current case presents a potential example of neurological crosstalk and highlights the inherent complexity in human neural physiology. Further research may reveal novel treatment strategies for patients with voiding dysfunction and chronic pain syndromes.

Effects of neuromodulation with sacral magnetic stimulation for intractable bowel or bladder dysfunction in postoperative patients with anorectal malformation: a preliminary report.

BACKGROUND AND PURPOSE: The effects of neuromodulation with sacral magnetic stimulation (SMS) were examined in postoperative patients with bowel or bladder dysfunction. PATIENTS AND METHODS: SMS was performed at the S3 level using a MagPro® instrument (Medtronic Inc., USA) while the patients were under light sedation. One treatment course consisted of stimulation delivered at 15 Hz for 5 s, 10 times over an interval of 1 min. Three patients with bladder or bowel dysfunction refractory to conservative treatment were examined. RESULTS: Case 1 is a 7-year-old male with a rectourethral fistula. This patient developed a hyperdynamic bladder after a laparoscopic pull-through operation at the age of 7 months. The administration of an anticholinergic agent slightly improved the condition. SMS was started at the age of 4 years with one trial each year. A marked expansion of bladder volume from 20 ml before trial to 120 ml after the third trial was obtained. Case 2 (a 4-year old female with a recto-vaginal fistula) and Case 3 (a 8-year-old female with an ano-vestibular fistula) showed severe constipation after radical surgery during infancy. Case 2 needed appendicostomy. After SMS, bowel movements could become controllable with enemas. No adverse effects were observed for any of the three cases. CONCLUSIONS: These results suggest that SMS might be a useful modality to improve postoperative bowel or bladder dysfunction.

Clean intermittent self-catheterization in neuro-urology.

Neurogenic lower urinary tract dysfunction (NLUTD) is commonly encountered in rehabilitation settings, and is caused by a variety of pathologies. The management of spinal cord injury (SCI) has been the model of reference for the management of other pathologies with NLUTD. The introduction of intermittent catheterization (IC) led to decline in renal related mortality in SCI patients and allowed an improvement of quality of life (QoL) in all neurogenic patients with NLUTD. IC could be sterile, aseptic or clean. Sterile intermittent catheterization (SIC) is the preferred method of bladder drainage in emergency medicine units and during spinal shock in SCI patients, but it is costly and time-consuming. Catheterizations performed in institutions, such as rehabilitation hospitals and nursing homes, are done aseptically. Clean intermittent catheterization (CIC), i.e. self-catheterization (CISC) or third party catheterization, represents the "gold standard" method for bladder emptying in all neuropathic patients with NLUTD: the technique is safe and effective and results in improved kidney and upper urinary tract status, lessening of vesico-ureteral reflux and amelioration of urinary continence. CISC is mandatory in patients with NLUTD secondary to detrusor areflexia/hypocontractility and in patients suffering from neurogenic detrusor overactivity with detrusor external sphincter dyssynergia and high post void residual of urine, often in combination with antimuscarinics/bladder relaxants. The review summarizes the most important aspects of IC and CISC. Attention was focused on the history of urethral catheterization, aims, materials, advantages, indications, and present-day techniques of CISC, emphasizing the importance of teaching in order to perform correctly the catheterization technique.

Selective co-stimulation of pudendal afferents enhances reflex bladder activation.

The loss of normal bladder function is common in persons with spinal cord injury (SCI) and negatively impacts their quality of life. Electrical stimulation of pudendal nerve afferents is a promising approach to restore control of bladder function. Pudendal afferent stimulation can generate reflex contraction of the bladder, but the resulting bladder voiding efficiency remains low. The objective of this work was t o evaluate selective co-stimulation of two branches of the pudendal nerve--the cranial urethral sensory nerve (CSN) and the dorsal nerve of the penis (DNP)--as a means to enhance reflex bladder activation and bladder voiding efficiency. In preclinical studies in anesthetized adult cats, co-stimulation of CSN and DNP evoked larger bladder contractions than individual stimulation of either CSN or DNP. In a parallel clinical experiment involving a participant with chronic SCI, co-stimulation of the proximal and distal urethra also produced synergistic augmentation of reflex bladder activity, and thus improved voiding efficiency when compared to reflex distension-evoked voiding. Selective co-stimulation of pudendal afferents is efficacious and should be considered in the development of neural prosthetics for restoration of bladder function in persons with SCI.

Clean intermittent self-catheterization in persons with multiple sclerosis: the influence of cognitive dysfunction.

BACKGROUND: Bladder problems are very common in persons with multiple sclerosis (PwMS). OBJECTIVE: The aim of this study was to investigate the ability of PwMS to learn clean intermittent self-catheterization (CISC). METHODS: The physical disability of 23 PwMS was evaluated with the Expanded Disability Status Scale (EDSS), and cognitive status was evaluated with the Brief Repeatable Battery of Neuropsychological Tests (BRB-N). CISC was taught by the same continence advisor who was blinded to the cognitive test results. The ability to learn CISC was evaluated immediately after sessions and 3 months later. Twenty-three consecutive PwMS participated in the study. RESULTS: In all, 87% (20/23) of the PwMS successfully finished CISC training. The number of lessons needed to acquire CISC skills differed significantly depending on the EDSS (Spearman r=0.682, P=0.0003), but the total cognitive decline subscore did not influence the ability to learn CISC. Only 13% (3/23) of the PwMS failed to learn CISC. The ability to learn CISC depended on the number of lessons needed to acquire CISC (r=-0.499, P=0.0313) and the EDSS score (r=-0.433, P=0.0390) but not on the course of the disease (r=0.125, P=0.5696) or on cognitive decline (r=-0.311, P=0.1480). After 3 months of follow-up, 30% (6/20) of the PwMS had ceased performing CISC. A follow-up indicated no statistically significant correlations among any of the subscores of the cognitive test battery, the EDSS score, the course of the disease, and the time required to learn CISC and effective bladder management. CONCLUSIONS: Our study thus confirmed that most (87%) PwMS were able to learn CISC in spite of cognitive dysfunction and therefore to improve their quality of life.

Improved bladder emptying in urinary retention by electrical stimulation of pudendal afferents.

Urinary retention is the inability to empty the bladder completely, and may result from bladder hypocontractility, increases in outlet resistance or both. Chronic urinary retention can lead to several urological complications and is often refractory to pharmacologic, behavioral and surgical treatments. We sought to determine whether electrical stimulation of sensory fibers in the pudendal nerve could engage an augmenting reflex and thereby improve bladder emptying in an animal model of urinary retention. We measured the efficiency of bladder emptying with and without concomitant electrical stimulation of pudendal nerve afferents in urethane-anesthetized rats. Voiding efficiency (VE = voided volume/initial volume) was reduced from 72 +/- 7% to 29 +/- 7% following unilateral transection of the sensory branch of the pudendal nerve (UST) and from 70 +/- 5% to 18 +/- 4% following bilateral transection (BST). Unilateral electrical stimulation of the proximal transected sensory pudendal nerve during distention-evoked voiding contractions significantly improved VE. Low-intensity stimulation at frequencies of 1-50 Hz increased VE to 40-51% following UST and to 39-49% following BST, while high-intensity stimulation was ineffective at increasing VE. The increase in VE was mediated by increases in the duration of distention-evoked voiding bladder contractions, rather than increases in contraction amplitude. These results are consistent with an essential role for pudendal sensory feedback in efficient bladder emptying, and raise the possibility that electrical activation of pudendal nerve afferents may provide a new approach to restore efficient bladder emptying in persons with urinary retention.

Intraspinal stimulation for bladder voiding in cats before and after chronic spinal cord injury.

The long-term objective of this study is to develop neural prostheses for people with spinal cord injuries who are unable to voluntarily control their bladder. This feasibility study was performed in 22 adult cats. We implanted an array of microelectrodes into locations in the sacral spinal cord that are involved in the control of micturition reflexes. The effect of microelectrode stimulation was studied under light Propofol anesthesia at monthly intervals for up to 14 months. We found that electrical stimulation in the sacral parasympathetic nucleus at S(2) level or in adjacent ventrolateral white matter produced bladder contractions insufficient for inducing voiding, while stimulation at or immediately dorsal to the dorsal gray commissure at S(1) level produced strong (at least 20 mmHg) bladder contractions as well as strong (at least 40 mm Hg) external urethral sphincter relaxation, resulting in bladder voiding in 14 animals. In a subset of three animals, spinal cord transection was performed. For several months after the transection, intraspinal stimulation continued to be similarly or even more effective in inducing the bladder voiding as before the transection. We speculate that in the absence of the supraspinal connections, the plasticity in the local spinal circuitry played a role in the improved responsiveness to intraspinal stimulation.

[The value of intravesical electrostimulation in the treatment of acute prolonged bladder overdistension]. / Der Stellenwert der intravesikalen Elektrostimulation in der Therapie der akuten prolongierten Blasenüberdehnung.

BACKGROUND: The effectiveness of intravesical electrostimulation (IVES) in the treatment of acute prolonged bladder overdistension (PBO) was investigated. METHODS: Sixteen patients (female 11, male 5, ø 54 years) after PBO (bladder filling volume: 1317+/-320 ml) were evaluated: 11 after surgery and 5 after polytrauma, psychosomatic disorder or LV4 fracture. After exclusion of a neurogenic aetiology and a urodynamic examination, IVES was performed besides IC or suprapubic catheter. RESULTS: Group 1: six patients with a weak detrusor (p(detr. max.)<30 cmH(2)O); group 2: ten patients had detrusor acontractility. After 25 IVES sessions, group 1 showed a significant increase of p(detr. max.) (p=0.01) as well as a decrease in PVR (31% to 3% of bladder capacity, p=0.02). Group 2 had no significant increase of p(detr. max). CONCLUSIONS: Two-thirds of patients with a weak detrusor after PBO will regain balanced voiding after IVES due to detrusor reinforcement. With an acontractile detrusor only bladder sensation improves.

Bladder-wall and pelvic-plexus stimulation with model microstimulators: Preliminary observations.

Severe urinary retention is not a common condition, but may occur following some pelvic surgeries or other medical conditions. Electrical stimulation of the bladder has been examined as a means of managing this difficult problem. We conducted preliminary investigations in cats to prove the hypothesis that pelvic-plexus (bladder-neck) stimulation would produce greater micturition response with reduced side effects, such as animal movement or discomfort, than bladder-wall stimulation with electrodes implanted higher on the bladder wall. We used model microstimulators that mimic the look and function of commercial microstimulators, but that we constructed. We instrumented four female cats during a survival surgery. Animals recovered well and studies were conducted over a 1-month period in the conscious animal and under anesthesia. We performed a variety of studies with different stimulation parameters and electrode locations to evaluate our hypothesis. In the active animal, we supplied only low currents, but two animals responded to stimulation with bladder contractions and voiding. Following anesthesia, higher stimulating currents resulted in greater bladder contractions during stimulation in two of the three animals. In two cases, pelvic-plexus (bladder-neck) stimulation induced greater micturition responses than direct bladder-wall stimulation. In conclusion, we learned from these preliminary observations that stimulation at the pelvic plexus (bladder neck) may induce a better micturition response than stimulation higher on the bladder-wall. Newly available commercial microstimulators should be further studied for the treatment of urinary retention.

Medical treatment for urinary retention in rehabilitating elderly women: is it necessary?

BACKGROUND AND AIMS: It is unclear whether medical treatment of elderly women with acute urinary retention in geriatric rehabilitation centers affects the recovery rate. The aims of the present study were to assess the rate of spontaneous recovery from urinary retention in elderly women in rehabilitation centers and to determine whether medical treatment with a adrenergic receptor blockers (a blockers) is effective in resumption of urination in this population. METHODS: We surveyed 84 elderly women with urinary retention, admitted to a geriatric rehabilitation center between September 1998 and March 2000. Most had undergone orthopedic surgeries. Post-voiding urine residual (PVR) was measured 3 days after an acute episode of urinary retention. PVR of 250 mL and below was the desirable outcome. Patients with PVR over 250 mL were randomly assigned to two groups, placebo vs Doxazosin. Medication doses in both groups were increased every 3 days and catheterization was used until a desirable outcome was achieved. RESULTS: Seventy-eight out of the 84 patients entered the study, of whom 48 (62%) recovered spontaneously prior to initiation of medical treatment. Of the remaining 30, 7 patients dropped out and 23 began medical treatment. Twelve women recovered (a similar rate occurred in the placebo and Doxazosin groups), and 11 did not. The study was terminated due to the high rate of spontaneous recovery and because it became clear from the initial results that Doxazosin had no beneficial effect over placebo in the treatment of urinary retention. Diabetes and poor functional status were found to be prognostic factors for recovery failure. CONCLUSIONS: Most elderly women with urinary retention in geriatric rehabilitation centers will probably recover spontaneously. Alpha blockers appear to have no beneficial effect in this population.

Urinary retention after hysterectomy for benign disease: extended diagnostic evaluation and treatment with sacral nerve stimulation.

OBJECTIVE: To detect prospectively neurogenic damage in patients with urinary retention responding to sacral nerve stimulation (SNS) after hysterectomy for benign disease. PATIENTS AND METHODS: From August 1995 to February 2002, 13 of 15 patients (mean age 43 years, sd 7) with urine retention for a mean (sd, range) of 25 (22, 6-240) months after hysterectomy for benign disease, were prospectively evaluated and treated with SNS. They were assessed using urodynamics at baseline and during the test stimulation. Sensory evoked potentials (SEPs), electrical sensory threshold (EST) measurements of the pudendal nerve, bladder neck and the bladder (2 Hz, 0-300 V), and needle electromyography of the external urethral sphincter (EUS) were undertaken in all patients. RESULTS: De-afferentiation (EST >/= 200 V) was limited to the bladder in four of the 13 patients and extended to the bladder neck in one other, and was matched by no response at the SEP. Relative ESTs of the bladder neck correlated inversely with residual urine (r = - 0.76, P = 0.01, x = 546, fx = 1.22) and bladder capacity (r = - 0.77, P = 0.01, x = 611, fx = 1.26) at diagnosis. Complex repetitive discharges and decelerating bursts of the EUS were seen in these five patients. Unilateral SNS was applied in 10 patients (bilateral in three). A revision was needed in six patients. Uroflowmetry at the last follow-up showed a mean (sd) maximum urinary flow rate of 22 (18) mL/s (not significantly different from during trial stimulation) with residual urine of 50-100 mL in two and 200-400 mL in three patients. Intermittent catheterization was needed in four patients. CONCLUSION: Urinary retention after hysterectomy for benign disease is associated with de-afferentiation of the bladder wall in some patients and is correlated inversely with the relative EST of the bladder neck. A Fowler syndrome was detected in five patients. For residual urine, about half the patients have a good and a third a partial long-term effect; we now offer SNS as a further treatment option.

Sacral neuromodulation in functional urinary retention: an effective way to restore voiding.

OBJECTIVE: To determine the long-term efficacy and complications of sacral nerve stimulation as an alternative therapy for functional unobstructive urinary retention, often considered to be psychogenic and effectively treated by clean intermittent catheterization, but for which pelvic floor dysfunction has been recognized as a possible cause. PATIENTS AND METHODS: Twenty patients (17 women and three men, mean age 48 years) with idiopathic, unobstructive functional urinary retention and in whom other forms of therapy had failed, had a pulse generator implanted (Medtronic, Minneapolis, MN, USA) and a sacral nerve implant. Their mean duration of symptoms was 68 months; 13 patients had chronic pelvic and perineal pain associated with their obstructive voiding symptoms. All patients were managed with clean intermittent catheterization and pharmacological therapy (alpha-blockers) before the procedure. All patients had a percutaneous nerve evaluation before the permanent implant, which showed> 50% improvement in their symptoms. All patients were evaluated at 1, 6 12, 18 and 24 months, then yearly thereafter. The results were assessed both subjectively by patient's symptoms and objectively by checking the postvoid residual volume (PVR) and voided volume. RESULTS: Eighteen patients were able to void spontaneously with a mean increase in voided volume from 48 to 198 mL, and a significant decrease in PVR from 315 to 60 mL. Eighteen of the patients had a > or = 50% improvement in their symptoms and said they would recommend the therapy to a friend or relative. Complications occurred in six patients. CONCLUSION: Sacral nerve stimulation is an effective and durable new approach to functional urinary retention, with few associated complications. Test stimulation provides a valuable tool for selecting patients.

A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere.

OBJECTIVES: To assess the safety and effectiveness of Durasphere compared with bovine collagen in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). METHODS: This multicenter, randomized, controlled, double-blind trial was composed of 355 women diagnosed with SUI due to ISD and used a standardized pad test and the Stamey continence grade as the primary endpoints. The participants' ages ranged from 26 to 84 years. All patients had an abdominal leak point pressure of less than 90 cm H(2)O (average 51). RESULTS: At 12 months after the first injection, the two materials were equivalent with respect to the improvement in continence grade and pad weight testing. Less Durasphere was injected to obtain comparable clinical results (Durasphere 4.83 mL versus bovine collagen 6.23 mL, P <0.001). When examined 1 year after the date of the last treatment, 49 (80.3%) of the 61 women treated with Durasphere showed improvement of 1 continence grade or more compared with 47 (69.1%) of 68 women treated with bovine collagen (P value for difference = 0.162). Although the adverse events reported for both groups were similar, the Durasphere group had an increased short-term risk of urgency and urinary retention. CONCLUSIONS: The use of Durasphere for the treatment of SUI due to ISD was equally effective as bovine collagen and used less material. The U.S. Food and Drug Administration granted market approval for Durasphere on September 13, 1999. The product design and initial clinical data suggest the potential for greater durability of the clinical benefit, with the possibility of a permanent solution for SUI due to ISD in some patients.

Urinary retention in patients in a geriatric rehabilitation unit: prevalence, risk factors, and validity of bladder scan evaluation.

The purpose of this study was to identify risk factors for urinary retention (UR) in frail, elderly patients, to determine its prevalence, and to assess the validity of the use of the BladderScan BVI 2500+ ultrasound scanner to measure postvoid residual urine volumes of > or = 150 ml. Probable UR was defined as two consecutive ultrasound scans with postvoid residual urine estimations of > or = 150 ml. The estimates were confirmed by in- and out-catheterization of actual postvoid residual urine (PVR). Risk factors for UR were the independent variables used in the regression analysis. Nineteen of the 167 people (11%) had UR. The risk of UR was greatest among patients who were older, or who were on anticholinergic medication, or who had diabetes of long standing, or who had fecal impaction. The correlation between paired scans and catheter volumes of > or = 150 ml was 0.87. The results suggest that the BladderScan BVI 2500+ ultrasound scanner, when used by trained nursing staff, provides conservative and valid estimates of PVR of > or = 150 ml in people undergoing geriatric rehabilitation.