Questionnaire-based assessment of pelvic organ dysfunction in multiple system atrophy.

Multiple system atrophy (MSA) is a neurodegenerative disease characterized clinically by any combination of autonomic, cerebellar, and extrapyramidal symptoms. Autonomic symptoms are usually severe, and urinary symptoms are one of the cardinal features of MSA. Bowel dysfunction and sexual dysfunction are also common in MSA. Quality of life (QOL) in patients with MSA is severely impaired by the presence of pelvic organ dysfunction. Therefore, we aimed to examine the prevalence of pelvic organ dysfunction in patients with MSA. We recruited 256 patients with MSA seen at our neurology clinic. The mean age was 62 years. The control group comprised 158 individuals, and the mean age was 52 years. We administered a questionnaire on pelvic organ dysfunction to the MSA and control groups. The questionnaire had sections focusing on the bladder, bowel, and sexual function. Dysfunction, as described in the responses, was evaluated as normal, mild (>once a month), moderate (>once a week), or severe (>once a day). The Mann-Whitney's U-test was used for statistical analysis. When compared with the control group, the prevalence of pelvic organ dysfunction in the MSA group was significantly higher for urinary storage and voiding dysfunction, bowel dysfunction, and sexual dysfunction. QOL in the MSA group was therefore significantly impaired because of urinary dysfunction (70%, 76%), bowel dysfunction (40% of the men), and sexual dysfunction (26%, 45%). Pelvic organ dysfunction is common in MSA, and QOL is severely impaired in patients with MSA.

Effects of milnacipran and paroxetine on overactive bladder due to neurologic diseases: a urodynamic assessment.

AIMS: To determine the effects of milnacipran hydrochloride, a serotonin-norepinephrine reuptake inhibitor (SNRI), or paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on overactive bladder (OAB) in neurologic diseases, given by objective measures of urodynamic studies. METHODS: This is a prospective open trial, and we enrolled 24 patients (16 men, 8 women; mean age, 63.9 years) with OAB in a neurology clinic. They were randomly allocated into two groups: the milnacipran group (11 patients), and paroxetine group (13 patients). We started with 100 mg/day of milnacipran or 40 mg/day of paroxetine. Before and 3 months after the treatment, we performed a urinary questionnaire and urodynamic studies. RESULTS: Milnacipran reduced daytime urinary frequency (average, from 9.4 to 7.1 times, p < 0.001), improved the quality of life index (p = 0.023), and increased bladder capacity (average, from 289 to 377 ml, p = 0.009) as shown in urodynamic studies. No such changes were noted in the other categories of the lower urinary tract symptoms questionnaire or urodynamic studies, or in the paroxetine group. One male patient complained of mild voiding difficulty. Other adverse effects were not seen during the observation period. CONCLUSION: Milnacipran, an SNRI, increased bladder capacity as shown in urodynamic studies, and thereby ameliorated OAB in patients with neurologic diseases without serious adverse effects.

Measurements of sweat response and skin vasomotor reflex for assessment of autonomic dysfunction in patients with diabetes.

AIMS: Some physical or arousal stimuli induce a rise in sweat secretion (sympathetic sweat response or SSwR) and a reduction in skin blood flow (skin vasomotor reflex or SkVR) to the palm. We recorded SSwRs and SkVRs in diabetic patients and assessed the usefulness of these parameters for evaluating autonomic dysfunction in diabetes. METHODS: We studied 42 diabetic patients (58+/-12 years) and 42 normal control subjects (59+/-11 years). Focal sweat secretion and skin blood flow were measured on the palm by a sudorometer and a Doppler flowmeter, respectively. SSwRs and SkVRs to deep inspiration, mental arithmetic, and isotonic exercise were recorded. SSwR amplitude was measured from baseline to peak, and SkVR amplitude (reduction rate) was calculated as: (blood flow reduction/basal blood flow)x100%. We also conducted head-up tilt tests and R-R interval variation tests (coefficient of variation of R-R intervals or CV(R-R)). RESULTS: The SSwR or SkVR amplitudes in the diabetic group were significantly lower than those in the control group for any stimulus. CV(R-R) in the diabetic group was significantly less than that in the control group. The diabetic group showed a significantly greater reduction in systolic blood pressure during head-up tilt compared with the control group. In the diabetic group, there were significant correlations in SSwR or SkVR amplitudes versus blood pressure falls during the head-up tilt test, and CV(R-R) values. CONCLUSION: We believe that SSwR and SkVR are useful indexes for the evaluation of autonomic involvement in diabetic patients.

Psychogenic urinary dysfunction: a uro-neurological assessment.

AIMS: The diagnosis of psychogenic urinary dysfunction (PUD) is one of exclusion, particularly from urologic and neurologic causes, and is usually accompanied by more obvious psychologic/ psychiatric features. We here describe patients with PUD who were diagnosed in our uro- neurological laboratory. MATERIALS AND METHODS: We reviewed the digitized records of 2,300 urodynamic cases treated in the past 6 years to identify patients who fulfilled the diagnostic criteria of PUD. All 2,300 patients had completed a urinary questionnaire and undergone both electromyography (EMG)-cystometry and a detailed neurological examination. In addition, pressure-flow analysis, neurophysiology tests including sphincter EMG analysis, and MRI of the brain and spinal cord were performed as applicable. RESULTS: PUD was seen in 16 cases (0.7%): 6 men, 10 women, mean age 37 years. Lower urinary tract symptoms (LUTS) included overactive bladder (OAB) alone in 5, difficult urination alone in one, and both in 10. LUTS commonly occurred in particular situations, for example, OAB only while riding the train. Some patients showed extremely infrequent toileting. The urodynamic findings were normal except for increased bladder sensation (50%) for OAB and acontractile detrusor (31%) for difficulty. The final diagnosis was conversion reaction in six followed by anxiety in four. CONCLUSIONS: PUD patients experienced the situational occurrence of OAB and/or difficult urination and, in some patients, extremely infrequent toileting. The main urodynamic abnormalities were increased bladder sensation and acontractile detrusor. However, even in cases suggestive of PUD, a non-PUD pathology behind the symptoms should be explored.

Do BPH patients have neurogenic detrusor dysfunction? A uro-neurological assessment.

INTRODUCTION: Most men with benign prostatic hyperplasia (BPH) are middle- aged and elderly. Neurogenic detrusor dysfunction (NDD) may also occur in these populations. We made an uro-neurological assessment in such patients in order to investigate the possibility of a concurrent NDD in patients diagnosed with BPH, and to correlate the presence of NDD with treatment outcome. MATERIALS AND METHODS: 28 men, mean age 66.4 years, referred by urologists at the outpatient clinic as BPH (initial diagnosis: BPH alone, 24, BPH and NDD, 4) with regards to digital examination and lower urinary tract symptoms, underwent urodynamic study and neurological examination. MRI scans were performed to confirm the diagnosis. RESULTS: Urodynamic study (except for 2, acontractile detrusor (AD)) showed equivocal obstruction (EO), 6; underactive detrusor (UD), 9 (voiding phase); detrusor overactivity (DO), 12; urethral relaxation, 1, and reduced sensation, 5 (filling phase). EO correlated with the presence of UD (p = 0.03). DO did not correlate with the prostate size or urodynamically-defined outlet obstruction. Reduced sensation was common in patients >65 years of age (p = 0.05). Neurological examination/imaging showed exaggerated reflexes, 1; decreased reflexes, 6; multiple cerebral infarction, 8; cervical spondylosis, 1 (in patients with DO); lumbar spondylosis, 5 (in patients with AD/UD), and the final diagnosis was made: definite BPH, 6; probable BPH, 9; BPH and NDD, 13, and NDD were common in the patients aged >65 years (p = 0.015). Transurethral prostatectomy and alpha-blocker were mostly successful, but the failure rate was reported in definite BPH, none, probable BPH, 29%, and BPH and NDD, 33%. CONCLUSIONS: BPH patients, particularly those >65 years of age, commonly have NDD. Multiple cerebral infarction (upper neuron disorder) and lumbar spondylosis (lower neuron disorder) might contribute to DO and UD, respectively. A uro-neurological assessment is important to select typical BPH patients for maximizing therapeutic benefit.

Preliminary communication: urodynamic assessment of donepezil hydrochloride in patients with Alzheimer's disease.

BACKGROUND AND AIMS: Donepezil hydrochloride, a central cholinergic drug, is widely used for improving cognitive decline in Alzheimer's disease (AD). We investigated whether donepezil might affect the lower urinary tract (LUT) function in AD. METHODS: Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog) (0-70, increase as impairment), urinary questionnaire, and electromyography (EMG)-cystometry were performed in eight patients with AD before and after treatment with 5 mg/day of donepezil. RESULTS: The first assessment (before donepezil) showed moderate cognitive decline in the patients as a mean ADAS-cog score of 27.0 (range: 17-35) (normal < 15). Seven patients had urinary symptoms including urinary urgency incontinence in five. EMG-cystometry revealed neurogenic detrusor overactivity in seven with a mean detrusor pressure of 44.9 cm H(2)O (20-101), mean bladder capacity of 202 ml (20-412), and post-void residuals in none. The second assessment (3 months after donepezil) showed a decrease in the ADAS-cog score to 23.3 (11-35) though without statistical significance. Urinary incontinence disappeared in one and none had a new onset of incontinence. EMG-cystometry revealed an increase in the detrusor pressure on overactivity to 54.1 cm H(2)O (20-122), but also an increase in the bladder capacity to 234 ml (80-400), and post-void residuals in one (40 ml). CONCLUSION: Although the number of our patients was small, it seems possibly that donepezil could ameliorate cognitive function without serious adverse effects on the LUT function in patients with AD.

Uroneurological assessment of spina bifida cystica and occulta.

AIMS: Spina bifida is a rare but well-documented congenital spinal anomaly comprising a cystic form, which appears in infancy, and an occult form, which appears in late childhood and in adulthood. Herein, we report the results of uroneurological assessment in patients with spina bifida cystica and occulta, with respect to diagnosis and management of the disorders. METHODS: We performed a neurological examination, urinary questionnaire, and urodynamic studies in 28 consecutive patients with urinary symptoms, including 16 with the cystic form (nine male and seven female patients, ages 2 to 25 years), all of whom underwent neonatal surgical management, and 12 with occult form (six men and six women, ages 7 to 32 years) diagnosed by myelography and spinal magnetic resonance imaging who did not undergo surgery. RESULTS: Neurological examination revealed a combination of flaccid and spastic paresis, with dominant lower motoneuron signs in the cystic form, whereas there were dominant upper motoneuron signs in the occult form. Four patients with occult spina bifida presented with urinary symptoms as the sole initial complaint. There was no correlation between neurological findings and urodynamic abnormalities. Urinary incontinence and enuresis were common at all ages, and large post-micturition residuals and vesicoureteral reflux were not uncommon, particularly in the cystic form. Bladder abnormalities in the cystic and occult forms included detrusor hyperreflexia during filling in 38% and 42%, low compliance detrusor in 81% and 67%, supersensitivity to bethanechol in two (100%) patients with the cystic form and in three of four (75%) with the occult form, and impaired bladder sensation in 25% and 8% in each form, respectively. Urethral abnormalities in cystic and occult forms included detrusor/sphincter dyssynergia in 50% and 27%, low Pure max in 56% and 17%, silent sphincter electromyographic activity in 25% and 0%, absent bulbocavernosus reflex in 87% and 56%, absent anal reflex in 100% and 57%, neurogenic motor unit potentials in one patient with cystic form studied and in two of three patients with occult form, respectively. CONCLUSIONS: Spina bifida cystica and occulta present with a wide spectrum of urodynamic abnormalities including upper and lower motoneuron types of bladder and urethral dysfunction. Careful uroneurological assessment and spinal magnetic resonance imaging are important for diagnosing young adult patients with spina bifida occulta because they may present with urinary symptoms as the sole initial complaint and have no other obvious neurological abnormalities.