Nocturia in men.

Nocturia is a common source of sleep disturbance in men and can result from many different causes. A patient-generated frequency/volume chart, along with several simple mathematical formulas, is used to classify nocturia according to its principal aetiology. The categories are nocturnal polyuria (NP), reduced voided volumes, 24-h polyuria and a combination of the aforementioned factors. Identification of the precise type of nocturia can help direct treatment in the cause-specific manner. In particular, use of the antidiuretic desmopressin can be of benefit in those with NP and may also be useful as part of a combination treatment approach in nocturia of mixed aetiology.

The role of neuromodulation in the management of urinary urge incontinence.

OBJECTIVE: To examine the benefit-risk profile of neuromodulation in treating refractory urinary urge incontinence and other voiding disorders. PATIENTS AND METHODS: The outcome measures from all patients in pivotal clinical trials who had undergone sacral nerve stimulation were analysed retrospectively. RESULTS: Neuromodulation was effective in several clinical studies; the response is durable and the benefit-risk profile good. CONCLUSION: Sacral nerve stimulation is becoming the standard of care for refractory overactive bladder and retention problems. The potential benefit of neuromodulation should be included in female urology and gynaecology training programmes.

Use of cadaveric solvent-dehydrated fascia lata for cystocele repair--preliminary results.

OBJECTIVES: To present a surgical technique in which cadaveric fascia lata is used for cystocele repair. METHODS: Twenty-one consecutive women (mean age 67 +/- 10 years) with severe cystocele were prospectively enrolled. All patients underwent meticulous clinical and urodynamic preoperative evaluations. Solvent-dehydrated, Tutoplast-processed, cadaveric fascia lata was used for cystocele repair. The fascia was anchored transversally between the bilateral arcus tendineus and the cardinal and uterosacral ligaments. Standard endopelvic plication was performed thereafter as a second layer. Patients with overt or occult sphincteric incontinence underwent concomitant pubovaginal sling (PVS) surgery as well, using the same material. The main outcome measures included recurrent urogenital prolapse, persistent or de novo urinary incontinence (stress or urge), and dyspareunia. RESULTS: Of the 21 patients, 19 underwent concomitant PVS, 3 concomitant vaginal hysterectomy, and 8 posterior colporrhaphy in addition to their cystocele repair. The mean follow-up was 20.1 +/- 6.7 months (range 12 to 30). No postoperative complications related to the material or technique occurred. None of the patients developed a recurrent cystocele. Two patients (9%), one of whom underwent concomitant posterior colporrhaphy, developed mild recto-enterocele at 4 to 6 months postoperatively. Six patients underwent concomitant PVS for occult sphincteric incontinence. None developed postoperative stress incontinence. Thirteen other patients underwent concomitant PVS for overt sphincteric incontinence. All but two were stress-continent postoperatively. One half of the patients with preoperative urge or mixed incontinence had persistent urge incontinence postoperatively. None of the patients developed postoperative de novo urge incontinence or dyspareunia. CONCLUSIONS: The use of solvent-dehydrated cadaveric fascia lata for cystocele repair, as well as PVS, is associated with encouraging short and medium-term results. Long-term follow-up is needed to evaluate whether these results are durable.

Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices.

PURPOSE: We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms. MATERIALS AND METHODS: We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers. RESULTS: Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively. CONCLUSIONS: The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.

Detrusor instability in men: correlation of lower urinary tract symptoms with urodynamic findings.

PURPOSE: We evaluated the correlation of lower urinary tract symptoms suggestive of detrusor instability with urodynamic findings in men. MATERIALS AND METHODS: Enrolled in our prospective study were 160 consecutive neurologically intact men referred for urodynamic evaluation of persistent lower urinary tract symptoms. All patients had storage symptoms suggestive of detrusor instability. Patients were further clinically categorized according to the chief complaint of urge incontinence, frequency and urgency, nocturia or difficult voiding. The clinical and urodynamic diagnosis in all patients as well as specific urodynamic characteristics of those with detrusor instability were analyzed according to the these 4 clinical categories. RESULTS: Mean patient age was 61 +/- 15 years. The chief complaint was urge incontinence in 28 cases (17%), frequency and urgency in 57 (36%), nocturia in 30 (19%) and difficult voiding in 45 (28%). Detrusor instability was diagnosed in 68 cases (43%). A higher incidence of detrusor instability was associated with urge incontinence than with the other clinical categories (75% versus 36%, p <0.01). Of the patients 109 (68%) had bladder outlet obstruction, including 50 (46%) with concomitant detrusor instability. The prevalence of bladder outlet obstruction was similar in all patients regardless of the chief complaint. All other urodynamic diagnoses were also similar in the 4 clinical categories. The mean bladder volume at which involuntary detrusor contractions occurred were lower in patients with urge incontinence and frequency and urgency than in those with nocturia and difficult voiding (277.1 +/- 149.4 and 267.7 +/- 221.7 versus 346.7 +/- 204.6 and 306.2 +/- 192.1 ml., respectively, not statistically significant, p = 0.07). CONCLUSIONS: Detrusor instability and bladder outlet obstruction are common in men with lower urinary tract symptoms. The symptom of urge incontinence strongly correlated with detrusor instability. Other lower urinary tract symptoms did not correlate well with any urodynamic findings. Therefore, we believe that an accurate urodynamic diagnosis may enable focused and more efficient management of lower urinary tract symptoms in men.

Involuntary detrusor contractions: correlation of urodynamic data to clinical categories.

Data regarding the prevalence and urodynamic characteristics of involuntary detrusor contractions (IDC) in various clinical settings, as well as in neurologically intact vs. neurologically impaired patients, are scarce. The aim of our study was to evaluate whether the urodynamic characteristics of IDC differ in various clinical categories. One hundred eleven consecutive neurologically intact patients and 21 consecutive neurologically impaired patients, referred for evaluation of persistent irritative voiding symptoms, were prospectively enrolled. All patients were presumed by history to have IDC, and underwent detailed clinical and urodynamic evaluation. Based on clinical evaluation, patients were placed into one of four categories according to the main presenting symptoms and the existence of neurological insult: 1) frequency/urgency; 2) urge incontinence; 3) mixed stress incontinence and irritative symptoms; and 4) neurogenic bladder. IDC was defined by detrusor pressure of > or = 15 cm H2O whether or not the patient perceived the contraction; or < 15 cm H2O if perceived by the patient. Eight urodynamic characteristics of IDC were analyzed and compared between the four groups. IDC were observed in all of the neurologically impaired patients, compared with 76% of the neurologically intact patients (P < 0.001). No correlation was found between amplitude of IDC and subjective report of urgency. All clinical categories demonstrated IDC at approximately 80% of cystometric capacity. Eighty-one percent of the neurologically impaired patients, compared with 97% of the neurologically intact patients, were aware of the IDC at the time of urodynamics (P < 0.04). The ability to abort the IDC was significantly higher among continent patients with frequency/urgency (77%) compared with urge incontinent patients (46%) and neurologically impaired patients (38%). In conclusion, when evaluating detrusor overactivity, the characteristics of the IDC are not distinct enough to aid in differential diagnosis. However, the ability to abort IDC and stop incontinent flow may have prognostic implications, especially for the response to behavior modification, biofeedback, and pelvic floor exercise.

Learned voiding dysfunction (non-neurogenic, neurogenic bladder) among adults.

Data concerning learned voiding dysfunction (Hinman syndrome; non-neurogenic, neurogenic bladder) in adults are scarce. The present study was conducted to assess the pre-valence and clinical characteristics of this dysfunction among adults referred for evaluation of lower urinary tract symptoms. Learned voiding dysfunction was suggested by a characteristic clinical history and intermittent "free" uroflow pattern and by the absence of any detectable neurological abnormality or anatomic urethral obstruction. A definitive diagnosis was made by the demonstration of typical external urethral sphincter contractions during micturition by EMG or fluoroscopy. A urodynamic database of 1,015 consecutive adults was reviewed. Twenty-one (2%) patients (age, 24-76 years) met our strict criteria of learned voiding dysfunction. Obstructive symptoms were the most common presenting symptoms, followed by frequency, nocturia, and urgency. Eight (35%) patients had recurrent urinary tract infections, seven of these being women. None of the patients had any clinically significant upper urinary tract damage. First sensation volume was significantly lower in women than in men. Both detrusor pressure at maximum flow and maximum detrusor pressure during voiding were found to be significantly higher in men than in women. Further differentiation between adult women and men failed to reveal any other clinically significant differences. In conclusion, by strict video-urodynamic criteria, 2% of our patients had learned voiding dysfunction. Other patients, with presumed learned voiding dysfunction, who did not undergo video-urodynamics were not included in the present series. Thus, the prevalence of learned voiding dysfunction among adults referred for evaluation of lower urinary tract symptoms is likely to be even higher.

Voiding dysfunction: definitions.

'Lower urinary tract symptoms' is a term that describes symptoms related to both the storage and emptying phases of the micturition cycle. Storage symptoms include urinary frequency urgency, urge incontinence, nocturia, dysuria and other kinds of pain emanating from the bladder or urethra. Emptying symptoms consist of hesitancy, straining to void, difficulty starting, diminished stream, a feeling of incomplete bladder emptying and urinary retention. In both sexes, the etiology of lower urinary tract symptoms is multifactorial, and symptoms are a poor indicator of underlying pathophysiology. In men, lower urinary tract symptoms are most often attributed to prostatic obstruction, but only approximately two-thirds of men with lower urinary tract symptoms meet the accepted diagnostic criteria for obstruction. Approximately half have detrusor overactivity and a smaller number have impaired detrusor contractility, sensory urgency, sphincteric incontinence, polyuria or nocturnal polyuria. In women, lower urinary tract symptoms are often considered to result from hormonal abnormalities, childbirth, aging, or previous surgery, but the multifactorial underlying pathophysiology is similar to that seen in men, except for a much lower incidence of urethral obstruction and a high incidence of sphincteric incontinence. Treatment typically begins with empiric, conservative therapies aimed at resolving detrusor instability or bladder outlet obstruction. However, although either or both of these etiologies may exist in the individual with lower urinary tract symptoms, treatment may fail as a result of another cause. We believe that treatment based on the pathophysiology of the symptoms will lead to better outcomes than treatment based on symptoms alone.

Pubovaginal sling surgery for simple stress urinary incontinence: analysis by an outcome score.

PURPOSE: We assessed the results of pubovaginal sling surgery in women with simple stress urinary incontinence using strict subjective and objective criteria. MATERIALS AND METHODS: Simple incontinence was defined as sphincteric incontinence with no concomitant urge incontinence, pipe stem or fixed scarred urethra, urethral or vesicovaginal fistula, urethral diverticulum, grade 3 or 4 cystocele, or neurogenic bladder. A total of 67 consecutive women with a mean age plus or minus standard deviation of 56 +/- 11 years who underwent pubovaginal sling surgery for simple sphincteric incontinence were prospectively followed for 12 to 60 months (mean 33.9 +/- 22.2). Treatment outcomes were classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence, as documented by 24-hour diary and pad test, with the patient considering herself cured. Failure was defined as poor objective results with the patient considering surgery to have failed. Cases that did not fulfill these cure-failure criteria were considered improved and further classified into a good, fair or poor response. RESULTS: Of the 67 patients 46 (69%) had type II and 21 (31%) had type III incontinence. Preoperative diary and pad tests revealed a mean of 5.9 +/- 3.6 stress incontinence episodes and a mean urinary loss of 91.8 +/- 81.9 gm. per 24 hours. There were no major intraoperative, perioperative or postoperative complications. Two patients (3%) had persistent minimal stress incontinence and 7 (10%) had new onset urge incontinence within 1 year after surgery. Overall using the strict criteria of our outcome score 67% of the cases were classified as cured and the remaining 33% were classified as improved. The degree of improvement was defined as a good, fair and poor response in 21%, 9% and 3% of patients, respectively. CONCLUSIONS: Mid-term outcome results defined by strict subjective and objective criteria confirm that the pubovaginal sling is highly effective and safe surgery for simple sphincteric incontinence. A followup of more than 5 years is required to establish the long-term durability of this procedure.

Adult onset nocturnal enuresis.

PURPOSE: We determined the etiology and prognostic significance of adult onset enuresis with absent daytime incontinence. Adult onset nocturnal enuresis unassociated with daytime incontinence is uncommon and there is a paucity of information about its incidence, significance, evaluation and treatment. We present a retrospective evaluation of this condition based on a database review of more than 3,000 consecutive patients referred for the evaluation of lower urinary tract symptoms. MATERIALS AND METHODS: A database of 3,277 consecutive patients was searched for adult onset nocturnal enuresis. Patients with daytime incontinence were excluded from study. Evaluation consisted of history, physical examination, American Urological Association symptom score, voiding diary, uroflowmetry, estimation of post-void residual urine, video urodynamics, cystoscopy and radiographic evaluation of the upper tract. RESULTS: Of 3,277 patients 8 (0.02%) had adult onset nocturnal enuresis without daytime incontinence as a primary complaint. Average American Urological Association symptom score was 12.6 (range 3 to 25), average maximum urine flow was 8.5 ml. per second (range 5 to 15) and average post-void residual urine volume was 350 ml. (range 50 to 489). All patients were men with severe prostatic or vesical neck obstruction as well as bilateral or unilateral hydronephrosis in 63%, a bladder diverticulum in 38%, vesicoureteral reflux in 50% and low bladder compliance in 50%. Transurethral prostatic resection was recommended to all patients but only 5 agreed. The other 3 cases were managed by alpha-adrenergic antagonists, including 2 by adjunctive clean intermittent self-catheterization. In all patients who underwent transurethral prostatic resection symptoms resolved, as did hydronephrosis when present. CONCLUSIONS: Adult onset nocturnal enuresis with absent daytime incontinence is a serious symptom that usually heralds significant urethral obstruction, and a high incidence of bladder diverticulum, hydronephrosis and vesicoureteral reflux. It demands urological investigation and aggressive therapy.

Evaluation of female external genitalia sensitivity to pressure/touch: a preliminary prospective study using Semmes-Weinstein monofilaments.

OBJECTIVES: To assess the use of pressure aesthesiometers (Semmes-Weinstein monofilaments) in the evaluation of female external genitalia. The pressure aesthesiometers are widely used to assess the pressure/touch perceptions of the hand, face, and breast dermatomes. METHODS: Thirty-two consecutive neurologically intact women (mean age 48.7 +/- 13.8 years) and 5 neurologically impaired women referred for a routine gynecologic examination were prospectively enrolled. The monofilaments were applied to the S2-S5 vulvar dermatomes using specific anatomic landmarks. Test-retest reliability studies were performed at the same clinical session. A comparison was made between premenopausal (n = 17) and postmenopausal (n = 15) women; hypoestrogenic (n = 9) and normoestrogenic (n = 23) women; postmenopausal women with (n = 6) and without (n = 9) estrogen replacement therapy; women with normal (n = 18) and abnormal (n = 14) sexual function; and neurologically impaired (n = 5) and neurologically intact (n = 5) women, matched by age, parity, and estrogen status. RESULTS: A clear association was found between reduced vulvar sensitivity to pressure/touch and estrogen deficiency, sexual dysfunction, and neurologic impairment. Postmenopausal women had significantly reduced sensitivity to pressure/touch compared with premenopausal women. Similar decreased sensitivity was found in hypoestrogenic compared with normoestrogenic women, with significantly reduced sensitivity in postmenopausal women not using estrogen replacement therapy. Women with sexual dysfunction and those with neurologic impairment had significantly reduced vulvar sensitivity to pressure/touch. No correlation was found between the sensitivity to pressure/touch and either levator ani muscle bulk or the levator contraction score, but significant differences were found between women with and without vulvovaginal atrophy at the time of the examination. Test-retest analysis confirmed the reliability of the monofilaments in testing vulvar sensation. CONCLUSIONS: The Semmes-Weinstein monofilaments may be used as a valid and reliable diagnostic tool in the evaluation of vulvar sensitivity to pressure/touch. Additional studies with larger series are needed to establish the role of this clinical tool in the evaluation of various treatment outcomes.

Does the method of cystometry affect the incidence of involuntary detrusor contractions? A prospective randomized urodynamic study.

The International Continence Society (ICS) defines overactive detrusor as "one that is shown objectively to contract during the filling phase while the patient is attempting to inhibit micturition." The aim of the present study was to assess whether instructing the patient neither to try void nor to inhibit micturition during filling cystometry may improve the detection rate of involuntary detrusor contractions (IDCs). Forty-two consecutive patients (mean age 65 +/- 13.5 years), referred for urodynamic evaluation of persistent irritative lower urinary tract symptoms were prospectively enrolled. All patients were presumed, by history, to have IDCs. Cystometry was performed twice at the same session, each time by using randomly different instructions: Method 1, patients were instructed to try to inhibit micturition during bladder filling; and Method 2, patients were instructed to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner. The occurrence, as well as the urodynamic characteristics of IDCs, were analyzed separately and compared between the two filling methods. Method 1 identified only 20 cases of IDCs, while Method 2 identified 27 cases (48 versus 64 % of the study population, respectively; P = 0.02). Analysis of urodynamic characteristics revealed a clear trend of reduced bladder volume at which IDCs occurred when patients were instructed to neither try to void nor to inhibit micturition during bladder filling; however, statistical significance was not established (189 +/- 122 versus 240 +/- 149 mL, respectively; P = 0.13). All other urodynamic characteristics of IDCs were similar in both methods. In conclusion, better detection rates of IDCs were achieved by instructing the patient to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner, during filling cystometry. If the patient is instructed to inhibit micturition during bladder filling-about 26 % of the IDC cases are misdiagnosed.