Intravesical Injection of Botulinum Toxin Type A in Men without Bladder Outlet Obstruction and Post-Deobstructive Prostate Surgery.

PURPOSE: A significant proportion of men without bladder outlet obstruction (BOO) have been reported to have overactive bladders (OAB). This article aimed to review the specific group of reports on the use of botulinum toxin type A (BTX-A) injections into the bladder wall. MATERIALS AND METHODS: Original articles reporting men with small prostates without BOO were identified through a literature search using the PubMed and EMBASE databases. Finally, we included 18 articles that reviewed the efficacy and adverse effects of BTX-A injections in men. RESULTS: Of the 18 articles screened, 13 demonstrated the therapeutic efficacy and adverse effects of BTX-A injections in men. Three studies compared BTX-A injection response between patients without prior prostate surgery and those undergoing prior prostate surgery, including transurethral resection of the prostate and radical prostatectomy (RP). Patients with prior RP experienced better efficacy and had a low risk of side effects. Two studies focused on patients who had undergone prior surgery for stress urinary incontinence, including male sling and artificial urethral sphincter surgery. The BTX-A injection was a safe and effective procedure for this specific group. OAB in men was found to have a different pathophysiology mechanism from that in female patients, which may decrease the efficacy of BTX-A injection in men. However, patients with small prostates and low prostate-specific antigen levels demonstrated better efficacy and tolerability after BTX-A injection. CONCLUSIONS: Although intravesical injection of BTX-A was a good option for controlling refractory OAB in men, the evidence-based guidelines are still limited. Further research is necessary to better understand the role of BTX-A injections on various aspects and histories. Therefore, treating patients using strategies tailored to their individual conditions is important.

Therapeutic efficacy of biofeedback pelvic floor muscle exercise in women with dysfunctional voiding.

Dysfunctional voiding (DV), a voiding dysfunction due to hyperactivity of the external urethral sphincter or pelvic floor muscles leading involuntary intermittent contractions during voiding, is not uncommon in neurologically normal women with lower urinary tract symptoms (LUTS). We aimed to investigate the therapeutic efficacy of biofeedback pelvic floor muscle training (PFMT) in female patients with DV and to identify the therapeutic efficacy. Thirty-one patients diagnosed with DV. All participates completed the 3-month biofeedback PFMT program, which was conducted by one experienced physiotherapist. At 3 months after treatment, the assessment of treatment outcomes included global response assessment (GRA), and the changes of clinical symptoms, quality of life index, and uroflowmetry parameters. 25 (80.6%) patients had successful outcomes (GRA ≥ 2), and clinical symptoms and quality of life index significantly improved after PFMT. Additionally, uroflowmetry parameters including maximum flow rate, voided volume, voiding efficiency, total bladder capacity, voiding time, and time to maximum flow rate significantly improved after PFMT treatment. Patients with the history of recurrent urinary tract infection in recent 1 year were found to have unsatisfied therapeutic outcomes. In conclusion, biofeedback PFMT is effective in female patients with DV with significant improvements in clinical symptoms, quality of life, and uroflowmetry parameters. The history of urinary tract infection in recent 1 year is a negative predictor of successful outcome.

Predictive factors for recovery of voiding function after transurethral prostate surgery in men with small prostate volume and very low detrusor contractility.

OBJECTIVES: Detrusor underactivity (DU) is a common but poorly understood clinical problem. The diagnosis and treatment are difficult and full of uncertainties. There are many overlaps between DU and bladder outlet obstruction (BOO) in men. Prostatic surgery might improve voiding efficiency (VE). This study aims to investigate effectiveness and predictors of voiding function recovery after prostate surgery in patients with DU. METHODS: Male patients with DU and small total prostate volume (TPV, <40 mL) who had undergone transurethral prostate surgery were retrospectively reviewed over the past two decades. Video-urodynamic studies were performed before and after the operation. The urodynamic parameters were recorded, and change of VE was used to determine treatment outcome. A postoperative VE of ≥50% was considered successful. RESULTS: A total of 48 patients were included, with a mean age of 74.4 ± 10.0 years. The mean follow-up period was 24.9 ± 30.5 months. At the most recent follow-up, 29 (60.4%) patients had positive results. Among them, 21 (72.4%) patients recovered within 1 month, and only one recovered later than 6 months after the operation. After surgery, the maximum flow rate, voided volume, postvoid residual urine, and VE all showed improvement. Patients with successful outcome had a higher baseline detrusor pressure (p = .029) and greater maximum flow rate (p = .034) than the nonrecovery group. The age and other parameters were not significantly different between recovery and nonrecovery group. CONCLUSIONS: Patients with DU and small TPV might also benefit from prostatic surgery if they had a higher detrusor pressure and maximum flow rate at baseline.

Role of poor urethral sphincter relaxation in men with voiding dysfunction refractory to α-blocker therapy: Clinical characteristics and predictive factors.

OBJECTIVES: This study evaluates the diagnostic value of poorly relaxed external sphincter (PRES) in men with voiding dysfunction. We analyzed clinical and video-urodynamic characteristics to identify predictive factors of PRES in patients with lower urinary tract symptoms (LUTS) refractory to α-1 adrenoceptor blocker (α-blocker) therapy. METHODS: This retrospective study included 3379 men with LUTS in whom the initial 1-month α-blocker therapy failed. Clinical parameters and video-urodynamic results were analyzed. Patients with bladder outlet disorders including bladder neck obstruction (BNO), benign prostatic obstruction (BPO), urethral stricture (US), or PRES were categorized according to video-urodynamic findings. Predictive factors for PRES were analyzed. RESULTS: A total of 3379 men were included in this study. Among the patients with voiding dysfunction, 905 (43.6%) had BPO, 624 (30.0%) had BNO, 487 (23.4%) had PRES, and 62 (3.0%) had US. Patients with PRES were younger and had a higher maximum flow rate, larger bladder capacity, smaller total prostate volume (TPV) and transition zone index, and a lower rate of LUTS of urgency or urge urinary incontinence (UUI) than other groups. On multivariate analysis, only small TPV and lower urgency/UUI rate were predictive factors of PRES. A scale composed of voided volume, TPV, and urgency/UUI predicted PRES with high specificity. CONCLUSIONS: PRES was the etiology of voiding dysfunction in 23.4% of the men with LUTS refractory to α-blocker therapy. A simple scale composed of voiding volume, TPV, and urgency/UUI was useful in predicting the presence of PRES before video-urodynamic studies.

Recovery of Voiding Efficiency and Bladder Function in Male Patients With Non-neurogenic Detrusor Underactivity After Transurethral Bladder Outlet Surgery.

OBJECTIVE: The aim of this study is to investigate the treatment outcome in men with detrusor underactivity (DU) and voiding dysfunction who underwent transurethral resection or incision of the prostate (TURP or TUIP). DU usually affects decision making whether bladder outlet surgery is necessary. MATERIALS AND METHODS: A total of 60 men with urodynamic DU and voiding dysfunction who underwent TURP or TUIP from 1998 to 2015 were retrospectively analyzed for their treatment outcome after follow-up for more than 1 year. DU was defined as urodynamic evidence of low detrusor pressure (<40 cm H2O), low flow rate (<10 mL/s), a postvoid residual urine volume >300 mL, and a voiding efficiency (VE) of <33%. Satisfactory outcome was defined as improved quality of life and having a VE of >50% after treatment. Predictive factor for a successful outcome was also analyzed. RESULTS: At a mean follow-up of 31 months, 49 (81.7%) patients had achieved a satisfactory treatment outcome. Among the patients who received TURP and TUIP, 38/44 (86.4%) and 11/16 (68.8%) had satisfactory outcome, respectively. The satisfactory group had significantly higher detrusor pressure and greater bladder compliance at baseline than the unsatisfactory group. There was significant improvement in the urodynamic parameters after treatment in the satisfactory group. Among the patients with satisfactory outcome, 34 (69.4%) patients had recovery of detrusor function within 3 months. CONCLUSION: Active surgical treatment such as TURP or TUIP results in recovery of VE and detrusor function within 3 months after treatment in the majority of patients with DU.

Medical attendance for lower urinary tract symptoms is associated with subsequent increased risk of outpatient visits and hospitalizations based on a nationwide population-based database.

INTRODUCTION: Lower urinary tract symptoms (LUTS), which encompass storage, voiding, and postmicturition symptoms, are highly prevalent and recognized globally. Based on a nationwide population-based database, this study tests the hypothesis that medical attendance for LUTS is associated with a subsequent increase in the number of outpatient visits and hospitalizations, with differences among medical specialties and age groups. METHODS: Participants were selected from a random population sample of approximately one million people as a representative cohort of National Health Insurance (NHI) enrollees in Taiwan. Participants had at least three outpatient service claims with a coding of LUTS during the recruitment period 2001-2004. Both the LUTS group and non-LUTS control group were monitored for subsequent outpatient visits and hospitalizations, excluding LUTS-related healthcare services, for 2 years following the index date. The results were categorized based on medical specialty and age group. RESULTS: The outpatient visit rates (no. per person-year) and adjusted incidence rate ratios (IRRs) (95% confidence interval (CI) were significantly higher in urology (4.51, 95%CI 4.15-4.91) and gynecology (1.82, 95%CI 1.76-1.89) for the LUTS group. They were also significantly high in other departments, including internal medicine (1.25), general practice (1.13), Chinese medicine (1.77), family medicine (1.19), surgery (1.38), and psychiatry (1.98). Similarly, the hospitalization rate (no. per 1000 person-year) and adjusted IRRs (95% CI) were significantly higher in urology (5.50, 95% CI = 4.60-6.50) and gynecology (1.60, 95% CI = 1.35-1.90), as well as in internal medicine (1.55) and surgery (1.56), but not in psychiatry (1.12). Furthermore, the IRRs differed among 3 age groups. CONCLUSIONS: A significantly higher number of outpatient visits and hospitalizations were observed for individuals with LUTS, compared to the control group, and the effects differed with the advancement of age. This study broadens understanding of LUTS by viewing their impact on healthcare services with multiple and overlapping systems, rather than considering them exclusively as symptoms of traditional diseases of the bladder and urethra.

Intravesical botulinum toxin A injections plus hydrodistension can reduce nerve growth factor production and control bladder pain in interstitial cystitis.

OBJECTIVES: To investigate the level of nerve growth factor (NGF) mRNA in bladder tissue and the effect of botulinum toxin A (BTX-A) treatment in patients with interstitial cystitis (IC). METHODS: A total of 19 patients with IC were treated with 100 U or 200 U of intravesical BTX-A injections followed by cystoscopic hydrodistension 2 weeks later. Bladder mucosa biopsies were performed before BTX-A injection and immediately after hydrodilation and in 12 controls. The NGF mRNA and protein levels in bladder tissues were assessed by real-time polymerase chain reaction and immunohistochemistry studies to determine differences in NGF expression between patients with IC before and after BTX-A treatment and compare with controls. RESULTS: At 3 months, 14 patients had symptomatic improvement (responders) and 5 did not (nonresponders). The NGF mRNA levels at baseline in the overall IC patient group were significantly greater than those in the controls (0.65 +/- 0.33 versus 0.42 +/- 0.25, P = 0.046). At 2 weeks after BTX-A treatment, the NGF mRNA levels had decreased to 0.47 +/- 0.23 (P = 0.002, compared with baseline) and were no longer significantly different from those of the controls. The NGF mRNA levels decreased significantly in responders and were significantly decreased after BTX-A in 11 patients with a visual analog pain scale reduction of 2 or more. The immunoreactivity study of bladder tissue from patients with IC showed greater NGF density at baseline compared with controls, but the difference was no longer significant after successful BTX-A treatment. CONCLUSIONS: Intravesical BTX-A injections plus hydrodistension reduce bladder pain in patients with IC. The NGF levels in the bladder tissue were significantly increased in patients with IC and decreased to normal level after treatment in responders.