[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.

[A suggested treatment algorithm in nocturnal enuresis with emphasis on partial responders]. / Therapiealgorithmus bei Enuresis nocturna.

Monotherapeutic strategies often have only partial success in primary nocturnal enuresis (PNE). This analysis evaluated whether adjuvant treatment strategies improve outcomes. PNE children were submitted to a distinct therapeutic strategy including urotherapy (behavioral modifications), a first-line and, if necessary, a second-line treatment period. Outcome was the relief of bedwetting, the follow-up was 3-79 months. Urotherapy was applied. Nonresponders were assigned to desmopressin as first-line treatment. For complete responders a structured withdrawal program was applied. Partial responders were assigned to adjuvant second-line treatment according to their individual symptomatology, masked at basic investigations, incorporating either anticholinergics (propiverine hydrochloride), biofeedback, alpha-blocker (alfuzosin), alarm or psychotherapy, in addition to desmopressin. Nonresponders were referred to specialized management. The study included 259 children suffering from PNE (92 girls, 167 boys, aged 5-18 years): 42 children were relieved from bedwetting after urotherapy and 136 children had a complete response to desmopressin. Three nonresponders were assigned to specialized management, 61 partial responders had adjuvant treatments, and 17 partial responders had no further treatment. The suggested treatment algorithm resulted in 227 complete responders, 29 partial responders, and 3 nonresponders. The need for preliminary urotherapy is evident. The proposed desmopressin monotherapeutic strategy, incorporating a structured withdrawal program, is more effective than the standard desmopressin treatment module. Applying adjuvant treatment modules improves the complete response rate up to 88%. In partial responders overall efficacy rates are improved further. Nonresponders (1.2%) will be referred to specialized management, but many partial responders will gain improvement sufficient to refrain from invasive procedures.

Conservative treatment of the neuropathic bladder in spinal cord injured patients.

Different conservative treatment modalities for the lower urinary tract dysfunction in patients with spinal cord lesion are reviewed. Conservative treatment is still the mainstay of the urological management in these patients. Growing experience has changed the classical approach. Spontaneous voiding with and without triggered voiding and/or bladder expression has proven to be less safe except in well defined patients with regular urological follow-up. Nowadays, intermittent catheterisation and self catheterisation with and without bladder relaxants are accepted as the methods of choice. Condom catheters are still needed if incontinence persists, while penile clamps have no place in the treatment of patients with spinal cord lesions. Long-term indwelling catheters should be avoided. External electrical stimulation can be used to correct the neurogenic dysfunction by neuromodulation and/or to induce a direct therapeutic response in the lower urinary tract.

Cortical evoked potentials of the vesicourethral junction--a predictor for the outcome of intravesical electrostimulation in patients with sensory and motor detrusor dysfunction.

The evaluation of cortical evoked potentials after stimulation of the vesicourethral junction shows accurate and reproducible results and offers an elegant technique for evaluation of the viscerosensory pathways in patients with lower urinary tract dysfunction. The results must be considered in context with the results of simultaneously investigated pudendal somatosensory evoked potentials and the clinical symptomatology. They are of great help (1) in differentiating between intraspinal and extraspinal lesions of the afferent pathways of the detrusor if the etiology is unknown, (2) in differentiating between neurogenic and myogenic damage to the urinary bladder, and (3) in selecting patients not suitable for intravesical electrotherapy for bladder rehabilitation.

[Incontinence--a problem in women and men]. / Die Inkontinenz--ein Problem von Frau und Mann.

Different pathophysiology causes different types of incontinence. Urge-, Stress-, Overflow-, Reflex- and Extrasphincteric incontinence therefore need different therapeutic strategies. The basic diagnostic work-up, which can be done by any doctor in free practice comprises history, clinical investigation, urine analysis, the micturition protocol (frequency-volume-chart = FVC) and post voiding residual urine (PVR). In 80% of the elderly incontinent persons incontinence can be evaluated by basic diagnostics to such an extent, that conservative therapy can be started. If after basic diagnostic work-up the type of incontinence remains unclear, if it is a postoperative recurrent urinary incontinence, if reflex incontinence is present, or if conservative therapy is not successful within 3 weeks a further diagnostic workup by the specialist is mandatory. The specialist will perform echography of the urinary tract, endoscopy and especially urodynamics to evaluate detrusor and sphincter dysfunction precisely, if necessary also combined with X-ray (video-urodynamics). In regards to urinary stress incontinence conservative treatment strategies e.g. pelvic floor training programs, if necessary combined with electrotherapy and biofeedback have gained increasing importance. For urge-incontinence continence training programs and pharmacotherapy as well as electrotherapy are the main therapies. Reflex-incontinence should be treated by the specialist. Overflow incontinence is easy to diagnose, however, the treatment of the underlying pathophysiology must be done by the urologist. Urinary incontinence in the elderly is a special problem. Treatment of incontinence with incontinence aids (pads) only is justified in immobile and demented people, in others active treatment, comprising continence training programs and pharmacotherapy should be the goal. A Foley catheter is only justified if urinary incontinence is combined with an insufficient bladder emptying with residual urine, which can not be treated otherwise.

[Intravesical electrostimulation for treatment of bladder dysfunction. Initial experiences after gynecological operations]. / Intravesikale Elektrostimulation zur Behandlung von Blasenfunktionsstörungen. Erste Erfahrungen nach gynäkologischen Operationen.

OBJECTIVE: We investigated the role of intravesical electrical stimulation in the treatment of voiding dysfunctions following major gynecologic surgery. METHODS: 19 female patients with sensory and/or motor voiding dysfunction following gynecologic operations underwent intravesical electrostimulation after failure of traditional treatments. Before and after therapy, urodynamic examinations were performed. The follow-up was 6-24 months. RESULTS: All cases of sensory bladder dysfunction were cured. Volumes of residual urine significantly decreased (mean 274 vs. 53 ml: p = 0.0003) and maximum detrusor pressure increased (mean 6 vs. 27 cm H20; p = 0.0007). An early start of therapy (within 6 weeks after surgery) resulted in a better outcome. CONCLUSIONS: Intravesical electrical stimulation was effective in the treatment of sensory and motor voiding dysfunctions following major gynecologic surgery.

Sacral anterior root stimulation: prerequisites and indications.

An intact sacral reflex arc, or at least an intact second motor-neuron and a detrusor being able to contract, are the two prerequisites for implanting an anterior sacral root stimulator. Transrectal electrostimulation or direct needle stimulation of the sacral roots may reveal if patients despite absent or only weak detrusor contractions on routine investigation are suitable. Patients with a complete midthoracic paraplegia are the ideal candidates, but tetraplegics also benefit. Patients with incomplete lesions and preserved pain sensations are suitable provided that they can undergo posterior sacral root rhizotomy. Non-traumatic spinal cord lesions follow the same rules, provided that the type of lesion does not allow recovery and is not progressive. Myelomeningocele patients may be suitable provided that the pathoanatomy of the sacral roots permits the operation (may be possible only in thoracolumbar myelomeningocele). Vesico-uretero-renal reflux is no contraindication; it may even be a strong indication, if a low compliance bladder or high detrusor contractions are the main reasons for it. In most patients the procedure should or must be combined with posterior sacral root rhizotomy in order to normalize a low compliance, to abolish spontaneous reflex contractions, and to achieve continence. The benefit of following these rules is reflected in our own series of 30 patients. In all of them the operation has improved considerably the quality of life and no patient so far has regretted the operation.

[Urinary urgency and reflex incontinence]. / Harndrang- und Reflexinkontinenz.

Urge and reflex incontinence are caused by detrusor dysfunction:urgency may be due to hyperactivity or hypersensitivity of the bladder. Neurogenic hyperactivity of the detrusor is called detrusor hyperreflexia: the neurogenic uninhibited bladder is caused by incomplete, and the so-called reflex bladder by complete, suprasacral lesions. The pathophysiology of symptomatic and idiopathic detrusor hyperactivity and the therapeutic armentarium are described. Bladder drill together with biofeedback and pharmacotherapy with spasmolytic drugs - several potent spasmolytic drugs with different modes of action are available - are the basis of treatment for hyperactivity and hypersensitivity of the detrusor. An alternative is electrostimulation: stimulation of the afferents of the pudendal nerve, via the pelvic floor (anal, vaginal), percutaneously (dorsal nerve of the penis, clitoric nerve) or by the implantation of electrodes results in inhibition of the detrusor. Most (80-90%) patients can be treated successfully by conservative means. Operative measurements comprise bladder denervation and bladder augmentation. The results of bladder denervation by transtrigonal phenolization of the pelvic plexus are highly controversial. In patients with uncontrollable hyperactivity of the detrusor, augmentation of the bladder (e.g. clam ileocystoplasty) is the method of choice, while for those with uncontrollable hypersensitivity of the detrusor, cystectomy followed by bladder substitution should be performed as a last resort. Treatment for urinary incontinence due to detrusor hyperreflexia must be selected bearing in mind that bladder emptying is inadequate, in most cases because of dyssynergia between detrusor and external sphincter. Therapy is basically aimed at transforming hyperreflexia of the detrusor into hyporeflexia, primarily by potent spasmolytic drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Extradural implantation of sacral anterior root stimulators.

A technique for extradural deafferentation of the S2 to S5 segments and extradural implantation of stimulating electrodes is described, and its application to twelve patients with spinal cord lesions is reported. Nine patients use their implants for micturition, and seven are fully continent. The advantages and disadvantages of this technique compared with the more usual intrathecal procedure are discussed.

[Neurogenic urinary incontinence: current treatment concepts]. / Die neurogene Harninkontinenz: Aktuelle Behandlungskonzepte.

Neurogenic urinary tract dysfunction is characterized by inadequate voiding and urinary incontinence. The aim of therapy nowadays is adequate bladder emptying and control of urinary incontinence. Neurogenic urinary incontinence can be caused by (a) detrusor hyperreflexia, (b) sphincter hypo- or areflexia, (c) a combination of both, or also (d) detrusor hyporeflexia with consequent overlow incontinence. Based on a simple urodynamic classification the current treatment strategies are presented. (a) Detrusor hyperreflexia can be transformed into hypo- or are-flexia pharmacologically with potent drugs now available. Bladder emptying then has to be assisted or can be achieved by intermittent catheterization. If conservative therapy fails, sacral posterior root rhizotomy together with implantation of a sacral anterior root stimulator (Brindley) is an alternative, especially for women. If the anatomical situation does not allow sacral deafferentation (e.g. in patients with myelomeningocele or sacral dysplasia) bladder augmentation is the method of choice: a detubularized segment of ileum will serve as an energy destroyer for the pressure resulting from uncontrollable detrusor contractions. In contrast to detrusor hyperreflexia (b) hypo- or areflexia of the sphincter cannot be influenced pharmacologically. Method of choice for restoration of urinary continence in these patients is the implantation of a hydraulic sphincter system (Scott); in this way urinary continence is achieved without creating outflow obstruction. The alternative is conventional colposuspension with maximal elevation of the bladder neck in order to create bladder neck outflow obstruction allowing the achievement of continence. In this situation intermittent catheterization is essential for bladder emptying (and can sometimes be difficult). If (c) detrusor hyperreflexia is combined with sphincter hypo- or areflexia, urinary incontinence is due to detrusor and sphincter dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Rehabilitation of micturition by transurethral electrostimulation of the bladder in patients with incomplete spinal cord lesions.

The effect of direct transurethral electrostimulation of the saline-filled bladder in 29 patients with bladder dysfunction after incomplete spinal cord injury is described. Following investigation by cystourethrography and cystomanometry, treatment was started from 14 days to 8 months after injury (average 3 months after injury). The method was considered to be very helpful in the rehabilitation of micturition. Twenty-six out of 29 patients gained normal bladder sensation, 25 achieved satisfactory detrusor contractions and 29 had low residual urines. Seventeen patients developed perfect bladder control and ten more were socially dry without the need for appliances.

Rehabilitation of micturition in patients with incomplete spinal cord lesions by transurethral electrostimulation of the bladder.

Since the first description of the method of transurethral electrostimulation by Katona in 1956, controversial opinions have been published. In contrast to other types of electrical bladder stimulation the physiological basis for this method of treatment is the stimulation of receptors in the bladder wall. With the help of forceful stimuli damaged neurons may be activated leading to clinical success. This report presents our results over a 4-year period using stimulation parameters other than those published to date and studying the effects objectively by using urodynamic techniques. The results obtained in 30 adults with neurogenic bladder disturbance due to incomplete traumatic cord lesions will be presented under the following headings; development or alteration of bladder sensation or of detrusor contraction, the achievement of bladder control and the efficiency of micturition as shown by the decrease of residual urine. The method is helpful in the restoration of micturition in patients with incomplete traumatic spinal cord lesions: 26 out of 30 patients gained perfect bladder sensation, 25 of them achieved satisfactory bladder contractions, 28 ended the stimulation program with a residual below 50 cm3 and 17 out of 30 gained perfect bladder control, 10 others became at least socially dry without need for pads or urinals.