TRPV4 receptor as a functional sensory molecule in bladder urothelium: Stretch-independent, tissue-specific actions and pathological implications.

The newly recognized sensory role of bladder urothelium has generated intense interest in identifying its novel sensory molecules. Sensory receptor TRPV4 may serve such function. However, specific and physiologically relevant tissue actions of TRPV4, stretch-independent responses, and underlying mechanisms are unknown and its role in human conditions has not been examined. Here we showed TRPV4 expression in guinea-pig urothelium, suburothelium, and bladder smooth muscle, with urothelial predominance. Selective TRPV4 activation without stretch evoked significant ATP release-key urothelial sensory process, from live mucosa tissue, full-thickness bladder but not smooth muscle, and sustained muscle contractions. ATP release was mediated by Ca2+-dependent, pannexin/connexin-conductive pathway involving protein tyrosine kinase, but independent from vesicular transport and chloride channels. TRPV4 activation generated greater Ca2+ rise than purinergic activation in urothelial cells. There was intrinsic TRPV4 activity without exogeneous stimulus, causing ATP release. TRPV4 contributed to 50% stretch-induced ATP release. TRPV4 activation also triggered superoxide release. TRPV4 expression was increased with aging. Human bladder mucosa presented similarities to guinea pigs. Overactive bladders exhibited greater TRPV4-induced ATP release with age dependence. These data provide the first evidence in humans for the key functional role of TRPV4 in urothelium with specific mechanisms and identify TRPV4 up-regulation in aging and overactive bladders.

Radiofrequency ablation of symptomatic cervical inlet patch using a through-the-scope device: a pilot study.

BACKGROUND AND AIMS: The cervical inlet patch (CIP) is an area of heterotopic gastric mucosa at the proximal esophagus, which can secrete both acid and mucus. Attributable symptoms include chronic globus sensation and sore throat. Previous studies have demonstrated improvement in symptoms after ablation using argon plasma coagulation. Our aim was to assess a through-the-scope radiofrequency ablation (RFA) catheter for ablation of symptomatic CIP. METHODS: Ten patients with endoscopically and histologically proven CIP and symptoms of globus or sore throat were included in the study. An ablation protocol of 3 ablations at 12 J/cm2, without removal of coagulated tissue between ablations, was used. A maximum of 2 RFA sessions, 3 months apart, was allowed. A visual analog score was completed at baseline, 6 weeks (on proton pump inhibitor), 3 months (off proton pump inhibitor), and 12 months after treatment. RESULTS: Mean patient age was 56 years (±3 years, standard error of the mean), 60% were men, and 80% were white. Barrett's esophagus was present in 50%. The mean number of CIPs was 2 (range, 1-4) with a median surface area of 2 cm2 (range, .5-14). After a median of 2 treatments, 80% achieved complete endoscopic and histologic resolution, with a mean follow-up of 14 months (range, 12-17). Globus, sore throat, and cough significantly improved from baseline (P < .05). No strictures or buried glands were identified. CONCLUSIONS: This prospective pilot study demonstrates that RFA using a through-the-scope device is safe and effective for treating patients with symptomatic CIP. One-year follow-up data suggest the effect is durable.

Local receptors as novel regulators for peripheral clock expression.

Mammalian circadian control is determined by a central clock in the brain suprachiasmatic nucleus (SCN) and synchronized peripheral clocks in other tissues. Increasing evidence suggests that SCN-independent regulation of peripheral clocks also occurs. We examined how activation of excitatory receptors influences the clock protein PERIOD 2 (PER2) in a contractile organ, the urinary bladder. PERIOD2::LUCIFERASE-knock-in mice were used to report real-time PER2 circadian dynamics in the bladder tissue. Rhythmic PER2 activities occurred in the bladder wall with a cycle of ∼ 24 h and peak at ∼ 12 h. Activation of the muscarinic and purinergic receptors by agonists shifted the peak to an earlier time (7.2 ± 2.0 and 7.2 ± 0.9 h, respectively). PER2 expression was also sensitive to mechanical stimulation. Aging significantly dampened PER2 expression and its response to the agonists. Finally, muscarinic agonist-induced smooth muscle contraction also exhibited circadian rhythm. These data identified novel regulators, endogenous receptors, in determining local clock activity, in addition to mediating the central control. Furthermore, the local clock appears to reciprocally align receptor activity to circadian rhythm for muscle contraction. The interaction between receptors and peripheral clock represents an important mechanism for maintaining physiological functions and its dysregulation may contribute to age-related organ disorders.

Purinergic and muscarinic modulation of ATP release from the urothelium and its paracrine actions.

The urothelium is a newly recognized sensory structure that detects bladder fullness. Pivotal to this sensory role is the release of ATP from the urothelium. However, the routes for urothelial ATP release, its modulation by receptor-mediated pathways, and the autocrine/paracrine role of ATP are poorly understood, especially in native tissue. We examined the action of key neurotransmitters: purinergic and muscarinic agonists on ATP release and its paracrine effect. Guinea pig and human urothelial mucosa were mounted in a perfusion trough; superfusate ATP was measured using a luciferin-luciferase assay, and tissue contractions were recorded with a tension transducer. Intracellular Ca²âº was measured in isolated urothelial cells with fura-2. The P2Y agonist UTP but not the P2X agonist α,ß-methylene-ATP generated ATP release. The muscarinic agonist carbachol and the M2-preferential agonist oxotremorine also generated ATP release, which was antagonized by the M2-specific agent methoctramine. Agonist-evoked ATP release was accompanied by mucosal contractions. Urothelial ATP release was differentially mediated by intracellular Ca²âº release, cAMP, exocytosis, or connexins. Urothelium-attached smooth muscle exhibited spontaneous contractions that were augmented by subthreshold concentrations of carbachol, which had little direct effect on smooth muscle. This activity was attenuated by desensitizing P2X receptors on smooth muscle. Urothelial ATP release was increased in aging bladders. Purinergic and muscarinic agents produced similar effects in human urothelial tissue. This is the first demonstration of specific modulation of urothelial ATP release in native tissue by purinergic and muscarinic neurotransmitters via distinct mechanisms. Released ATP produces paracrine effects on underlying tissues. This process is altered during aging and has relevance to human bladder pathologies.

Extended Wireless pH Monitoring Significantly Increases Gastroesophageal Reflux Disease Diagnoses in Patients With a Normal pH Impedance Study.

Background/Aims: Extended wireless pH monitoring (WPM) is used to investigate gastroesophageal reflux disease (GERD) as subsequent or alternative investigation to 24-hour catheter-based studies. However, false negative catheter studies may occur in patients with intermittent reflux or due to catheter-induced discomfort or altered behavior. We aim to investigate the diagnostic yield of WPM after a negative 24-hour multichannel intraluminal impedance pH (MII-pH) monitoring study and to determine predictors of GERD on WPM given a negative MII-pH. Methods: Consecutive adult patients (> 18 years) who underwent WPM for further investigation of suspected GERD following a negative 24-hour MII-pH and upper endoscopy between January 2010 and December 2019 were retrospectively included. Clinical data, endoscopy, MII-pH, and WPM results were retrieved. Fisher's exact test, Wilcoxon rank sum test, or Student's t test were used to compare data. Logistic regression analysis was used to investigate predictors of positive WMP. Results: One hundred and eighty-one consecutive patients underwent WPM following a negative MII-pH study. On average and worst day analysis, 33.7% (61/181) and 34.2% (62/181) of the patients negative for GERD on MII-pH were given a diagnosis of GERD following WPM, respectively. On a stepwise multiple logistic regression analysis, the basal respiratory minimum pressure of the lower esophageal sphincter was a significant predictor of GERD with OR = 0.95 (0.90-1.00, P = 0.041). Conclusions: WPM increases GERD diagnostic yield in patients with a negative MII-pH selected for further testing based on clinical suspicion. Further studies are needed to assess the role of WPM as a first line investigation in patients with GERD symptoms.

Synergistic effects in neuromuscular activation and calcium-sensitization in the bladder trigone.

OBJECTIVE: To elucidate possible synergistic effects between adrenergic, muscarinic, and purinergic neuromuscular activation in the bladder trigone, and to examine the relevance of the Rho-kinase (ROCK)/protein kinase C (PKC) pathway as a possible underlying mechanism. MATERIALS AND METHODS: Muscle strips were dissected from the superficial trigone of male guinea-pigs. Contractions were elicited by electrical-field stimulation (EFS: 0.1 ms pulses, 1-64 Hz for 3 s) or exposure to exogenous agonists. RESULTS: There was evidence for functional adrenergic, purinergic, and muscarinic neurotransmission. Selective inhibition of individual components suggested synergistic interactions. The mean (sd) EFS contractions were enhanced by carbachol (0.3 microm) and phenylephrine (10 microm) to 2.4 (0.4) and 6.4 (1.5)-fold of control (32 Hz), respectively. Phenylephrine (10 microm) also augmented contractions induced by carbachol (1 microm) to 3.9 (1.2)-fold of control, alpha,beta-methylene ATP (1 microm) to 4.3 (0.4) and 20 mm superfusate K(+) to 5.0 (2.0). The PKC inhibitors GF 109203X (5 microm) and H-7 (100 microm), as well as the ROCK inhibitor Y-27632 (5 microm) reduced the phenylephrine contracture to 37.3 (7.4), 38.5 (11.2) and 54.9 (7.8)% of control, respectively. With the exception of H-7 they had no significant effect on the carbachol response. CONCLUSION: This study shows a synergistic effect between adrenergic, muscarinic, and purinergic receptor activation on the muscle of the superficial trigone. The study suggests that Ca(2+)-sensitization of contractile proteins plays a key role in this synergism, particularly for adrenergic activation.

Adreno-muscarinic synergy in the bladder trigone: calcium-dependent and -independent mechanisms.

We have recently demonstrated a strong synergy between both excitatory pathways in the trigone which--as part of the bladder base--is believed to play a key role in outflow control. The aim of this study was to reveal whether modulation of intracellular Ca2+, [Ca2+]i, is mainly responsible for this synergistic effect. Intact muscle strips from the superficial trigone of male guinea-pigs were used for tension experiments. In isolated trigonal cells, [Ca2+]i was measured by epifluorescence microscopy using the fluorescent Ca2+-indicator Fura-2. Phenylephrine (PE, 10 microM) augmented contractions induced by carbachol (1 microM) to 4.0+/-0.8-fold of control, while corresponding [Ca2+]i levels did not exceed 1.3+/-0.2-fold of control. Furthermore, PE generated significantly greater contractions for a given rise of [Ca2+]i, compared to depolarising KCl solutions. The protein kinase C inhibitor GF 109203X (5 microM) and the Rho-kinase inhibitor Y-27632 (5microM) reduced the PE contracture to 37.3+/-9.4 and 60.1+/-12.4% of control, respectively, without significantly altering the [Ca2+]i transients. GF 109203X reduced the augmentation of 1microM carbachol by PE to 1.5+/-0.1-fold. Muscarinic and adrenergic receptor activation exerts a strong synergistic effect in the bladder trigone without similar changes to the [Ca2+]i transient. Ca2+-sensitisation of contractile proteins is likely to play a key role in this synergism, particularly for adrenergic activation.

Characteristics of spontaneous activity in the bladder trigone.

BACKGROUND: During bladder filling, the trigone contracts help keep the ureteral orifices open and the bladder neck shut. The trigone generates spontaneous activity as well as responding to neuromuscular transmitters, but the relationship between these phenomena are unclear. OBJECTIVES: To characterise the cellular mechanisms that regulate and modify spontaneous activity in trigone smooth muscle. DESIGN, SETTING, AND PARTICIPANTS: Muscle strips from the superficial trigone of male guinea-pigs were used for tension experiments and immunofluorescent studies. MEASUREMENTS: In isolated trigonal cells, intracellular Ca(2+) was measured by epifluorescence microscopy using the fluorescent Ca(2+) indicator Fura-2. RESULTS AND LIMITATIONS: Spontaneous intracellular Ca(2+) transients and contractions were observed in trigonal single cells and strips and were significantly higher compared to the bladder dome. Ca-free superfusate and verapamil terminated spontaneity. T-type Ca(2+) channel block with NiCl(2) depressed slightly Ca(2+) transients but not spontaneous contractions. Neither the BK(Ca) channel blocker iberiotoxin nor the SK(Ca) channel blocker apamin had any effect on single cell activity. By contrast, the Cl(-) channel blocker niflumic acid attenuated significantly both Ca(2+) transients and muscle contractions. Agonist stimulation (carbachol, phenylephrine) up-regulated activity. Gap junction labelling (Cx43) was approximately 5 times denser in the trigone than in detrusor smooth muscle. The gap junction blocker 18-beta-glycyrrhetinic acid modulated spontaneous contractions in the trigone but not in the bladder dome. CONCLUSIONS: Trigone myocytes employ membrane L-type-Ca(2+) channels and Cl(-) channels to generate spontaneous activity. Intercellular electrical coupling ensures its propagation and, thus, sustains contraction of the whole trigone.

Modulation of bladder myofibroblast activity: implications for bladder function.

Bladder suburothelial myofibroblasts may modulate both sensory responses from the bladder wall and spontaneous activity. This study aimed to characterize further these cells in their response to exogenous agents implicated in mediating the above activity. Detrusor strips, with or without mucosa, and isolated suburothelial myofibroblasts were prepared from guinea pig bladders. Isometric tension, intracellular Ca(2+), and membrane current were recorded. Cell pairs were formed by pushing two cells together. Tension, intracellular Ca(2+), and membrane potential were also recorded from bladder sheets using normal or spinal cord-transected (SCT) rats. Spontaneous contractions were greater in detrusor strips with an intact mucosa and were augmented by 10 muM UTP. ATP, UTP, or reduced extracellular pH elicited Ca(2+) transients and inward currents (E(rev) -30 mV) in isolated cells. Capsaicin (5-30 muM) reduced membrane current (37 +/- 12% of control) with minor effects on Ca(2+) transients: sodium nitroprusside reduced membrane currents (40 +/- 21% of control). Cell pair formation, without an increase in cell capacitance, augmented ATP and pH responses (180 +/- 58% of control) and reduced the threshold to ATP and acidosis. Glivec (20-50 muM) reversibly blocked the augmentation and also reduced spontaneous activity in bladder sheets from SCT, but not normal, rats. Glivec also disrupted the spread of Ca(2+) waves in SCT sheets, generating patterns similar to normal bladders. Suburothelial myofibroblasts respond to exogenous agents implicated in modulating bladder sensory responses; responses augmented by physical intercellular contact. The action of glivec and its selective suppression of spontaneous activity in SCT rats identifies a possible pathway to attenuate bladder overactivity.

The association between T-type Ca2+ current and outward current in isolated human detrusor cells from stable and overactive bladders.

OBJECTIVE: To determine if bladder overactivity in humans is associated with an altered activity of Ca(2+) channels in detrusor smooth muscle and the consequent activation of other ion channels. MATERIAL AND METHODS: Samples of bladder were obtained from patients with urodynamically stable bladders, or with idiopathic detrusor overactivity. Isolated cells were patch-clamped with pipettes containing a Cs(+)-based filling solution to isolate inward currents, or a K(+)-filling solution to measure outward current. Components of inward current were separated according to their sensitivity to NiCl(2) (< or =100 microm) and nifedipine. RESULTS: Ni(2+)-sensitive (T-type) and nifedipine-sensitive (L-type) current was recorded in all cells. The voltage- and time-dependent properties were similar in cells from both patient groups. However, the current density of the L-type current was less, and that of the T-type current was greater, in myocytes from overactive bladders. In cells from overactive bladders, the mean K(+) current over the range - 80 to - 50 mV was also higher than in control cells. This current was sensitive to the large-conductance channel modulator iberiotoxin and to NiCl(2) (100 microm) CONCLUSIONS: Detrusor myocytes from overactive human bladders have a higher T-type Ca(2+) current density; we propose that this increases transient outward currents, and so might contribute to higher levels of spontaneous activity.

Characterization of the purinergic receptor subtype on guinea-pig suburothelial myofibroblasts.

OBJECTIVE: To identify particular purinoceptor subtypes by immunohistochemical labelling, as a layer of suburothelial myofibroblasts has been identified in the urinary bladder, and these cells respond to exogenous ATP by generating an intracellular Ca2+ transient, but the particular purinoceptor that responds to ATP is unclear. MATERIALS AND METHODS: Tissue sections and isolated cells from the urothelial layer of the guinea-pig bladder were used. Preparations were labelled with primary antibodies to the intermediate-filament protein, vimentin, or the purinoceptors P2X3, P2Y1, P2Y2, P2Y4 and P2Y6. For single-labelling we used a secondary antibody tagged with the fluorescent marker Cy3, and for double-labelling also a secondary antibody tagged with fluorescein isothiocyanate or Cy2. Images were examined using a confocal microscope, with an argon (488 nm) or helium-neon (543 nm) laser. RESULTS: Vimentin-labelling was confined to the suburothelial layer and appeared as discrete signals. Isolated cells labelled with vimentin and strongly for the P2Y6 antibody. There was weaker staining for P2X3, P2Y2 and P2Y4, but none to P2Y1. With frozen sections there was P2Y6 labelling in the urothelial and suburothelial layer. CONCLUSION: The predominant purinoceptor in suburothelial myofibroblasts, from these labelling studies, is the P2Y6 subtype. However, there was weaker labelling to other subtypes, suggesting multiple receptor subtypes or heterogeneity of receptor subunits. The consequences of there being multiple purinoceptor subtypes in the suburothelial space with respect to sensory signalling are discussed.

Spontaneous activity and electrical coupling in human detrusor smooth muscle: implications for detrusor overactivity?

Large uncontrollable detrusor contractions, decreased compliance that increases luminal pressures during filling, and detrusor underactivity are all examples of abnormal bladder function. Studies of the nervous control of lower urinary tract function and measurement of the cellular properties of the component tissues of the bladder wall have been performed to deepen our knowledge of these problems. The resultant data have suggested that lower urinary tract smooth muscle should not be regarded solely as a collection of independent cellular contractile units that are each activated by separate neural inputs, but also as a syncytium of cells. Although this syncytial arrangement may not be as well developed as in other tissues, it should impose a new layer of activity that will affect overall bladder function. Recent studies have addressed this issue through investigation of spontaneous contractile activity, the cellular basis of syncytial function, and their normal and abnormal functional consequences. The results suggest that individual detrusor cells possess membrane properties that may lead to spontaneous activity fluctuations, which can affect adjacent cells and, thus, produce multicellular aberrant responses. It remains unclear whether these responses manifest themselves as dysfunctional activity in the whole bladder defects because the extent of local multicellular abnormalities is not known at present. The data do imply that myogenic defects can contribute to abnormal bladder function and, thus, suggest several new targeted drug models that should be explored.

Control of bladder function by peripheral nerves: avenues for novel drug targets.

The micturition reflex involves afferent nerve activation when the bladder is sufficiently full and subsequent controlled firing of parasympathetic efferent nerves to contract the detrusor muscle as part of the voiding mechanism. Alteration of the sensitivity of afferent activation or loss of control over transmitter release could lead to sensory- or motor-activated incontinence, respectively. The control mechanisms that regulate these 2 activities remain poorly understood. Current opinion is that the sensation of bladder fullness is relayed by afferent nerves in the mucosal layer, which are activated by the release of chemical mediators, such as adenosine triphosphate (ATP), from the urothelium when it is stretched as the bladder fills. This hypothesis supports the concept that other chemical signals that affect bladder sensation (eg, changes in urine composition and agents such as capsaicin) can modulate the sensitivity of the basic system. It has also been proposed that a layer of myofibroblasts immediately below the basal lamina of the urothelium acts as a variable gain regulator of the sensory process between ATP release and afferent excitation. These myofibroblasts are functionally connected to form an electrical syncytium, make close contact with nerves, and respond by generating electrical responses and transient increases in intracellular Ca2+ when exposed to ATP. On the efferent side, using a guinea pig detrusor model, possible modulators of transmitter release have been investigated, including adenosine (the breakdown product of the neurotransmitter ATP). Adenosine reduces the force of nerve-mediated contractions by acting predominantly at presynaptic sites at the nerve-muscle junction via a subtype of an adenosine receptor-the A1 receptor. An additional effect, possibly via A2 receptors, is also present on the detrusor muscle itself. These actions of adenosine are less evident in human detrusor muscle but remain a potential modulatory target. In summary, the cellular and molecular regulation of bladder fullness sensation and efferent transmitter release are becoming better understood and represent potential drug targets for the management of detrusor overactivity.