Recombinant PAI-1 therapy restores myoendothelial junctions and erectile function in PAI-1-deficient mice.

Myoendothelial junctions are specialised projections of cell : cell contact through the internal elastic lamina between endothelial cells and vascular smooth muscle cells. These junctions allow for endothelial cells and vascular smooth muscle cells to make direct membrane apposition and are involved in cell : cell communication. In this study, we evaluated for the presence of myoendothelial junctions in murine corporal tissue and used plasminogen activator inhibitor (PAI)-1-deficient mice, which lack myoendothelial junctions, to determine whether myoendothelial junctions affect erectile function. Transmission electron microscopy demonstrated the presence of myoendothelial junctions in the corporal tissue of wild-type mice and confirmed the decreased junction numbers in the tissue of PAI-1(-/-) mice. A potential role for myoendothelial junctions in tumescence was established; in that, PAI-1(-/-) mice demonstrated a significantly longer time to achieve maximal intracavernous pressure. Treatment of PAI-1(-/-) mice with recombinant PAI-1 restored the number of myoendothelial junctions in the corporal tissue and also induced a significant decrease in time to maximal corporal pressures. Myoendothelial junctions were similarly identified in the human corporal tissue. These results suggest a critical role for myoendothelial junctions in erectile pathophysiology and therapies aimed at restoring myoendothelial junction numbers in the corporal tissue may provide a novel therapy for erectile dysfunction.

Encouraging scholastic publishing by urologic trainees.

THERE ARE MANY REASONS WHY UROLOGIC TRAINEES SHOULD PUBLISH SCHOLARLY WORK: Personal, professional, and institutional. Publishing by trainees creates an environment that improves the specialty of urology, maintains the quality of our literature, and promotes professionalism of our practitioners. Strategies to encourage scholastic publishing distil down to providing recognition, time, and support to the individual trainee.

Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling.

PURPOSE: Urodynamic studies have been proposed as a means of identifying patients at risk for voiding dysfunction after surgery for stress urinary incontinence. We determined if preoperative urodynamic findings predict postoperative voiding dysfunction after pubovaginal sling or Burch colposuspension. MATERIALS AND METHODS: Data were analyzed from preoperative, standardized urodynamic studies performed on participants in the Stress Incontinence Treatment Efficacy Trial, in which women with stress urinary incontinence were randomized to undergo pubovaginal sling surgery or Burch colposuspension. Voiding dysfunction was defined as use of any bladder catheter after 6 weeks, or reoperation for takedown of a pubovaginal sling or Burch colposuspension. Urodynamic study parameters examined were post-void residual urine, maximum flow during noninvasive flowmetry, maximum flow during pressure flow study, change in vesical pressure at maximum flow during pressure flow study, change in abdominal pressure at maximum flow during pressure flow study and change in detrusor pressure at maximum flow during pressure flow study. The study excluded women with a preoperative post-void residual urine volume of more than 150 ml or a maximum flow during noninvasive flowmetry of less than 12 ml per second unless advanced pelvic prolapse was also present. RESULTS: Of the 655 women in whom data were analyzed voiding dysfunction developed in 57 including 8 in the Burch colposuspension and 49 in the pubovaginal sling groups. There were 9 patients who could not be categorized and, thus, were excluded from the remainder of the analysis (646). A total of 38 women used a catheter beyond week 6, 3 had a surgical takedown and 16 had both. All 19 women who had surgical takedown were in the pubovaginal sling group. The statistical analysis of urodynamic predictors is based on subsets of the entire cohort, including 579 women with preoperative uroflowmetry, 378 with change in vesical pressure, and 377 with change in abdominal and detrusor pressure values. No preoperative urodynamic study findings were associated with an increased risk of voiding dysfunction in any group. Mean maximum flow during noninvasive flowmetry values were similar among women with voiding dysfunction compared to those without voiding dysfunction in the entire group (23.4 vs 25.7 ml per second, p = 0.16), in the Burch colposuspension group (25.8 vs 25.7 ml per second, p = 0.98) and in the pubovaginal sling group (23.1 vs 25.7 ml per second, p = 0.17). Voiding pressures and degree of abdominal straining were not associated with postoperative voiding dysfunction. CONCLUSIONS: In this carefully selected group preoperative urodynamic studies did not predict postoperative voiding dysfunction or the risk of surgical revision in the pubovaginal sling group. Our findings may be limited by the stringent exclusion criteria and studying a group believed to be at greater risk for voiding dysfunction could alter these findings. Additional analysis using subjective measures to define voiding dysfunction is warranted to further determine the ability of urodynamic studies to stratify the risk of postoperative voiding dysfunction, which appears to be limited in the current study.

Colpocleisis for pelvic organ prolapse: patient goals, quality of life, and satisfaction.

OBJECTIVE: To assess patient-centered colpocleisis outcomes in women. METHODS: This is a prospective cohort study. Between March 2000 and December 2005, 94 patients underwent colpocleisis. Patients completed follow-up questionnaires about their personal postoperative goal attainment satisfaction with care, regrets about surgery, as well as the Incontinence Impact Questionnaire and Urogenital Distress Inventory. RESULTS: Forty patients (42.6% of all patients) returned questionnaires with complete data on study outcomes. Mean age was 75.4 years (+/-6.8 years), and mean weight was 70.9 kg (+/-10.8 kg). Mean follow up was 2.75 years (+/-1.90 years). Most women agreed or strongly agreed that their goals were met for vaginal pressure (100%), urinary incontinence (84.9%), bladder emptying (76.4%), urinary frequency/urgency (91.2%), physical activity (88.6%), restoration of normal anatomy (95 %), colorectal symptoms (65.0%), and self-image (96.9%). Mean goal attainment (1.4+/-0.6) was associated with the postsurgery Urogenital Distress Inventory (r=-0.45, P=.003.) although not the Incontinence Impact Questionnaire. Mean scores improved presurgery to postsurgery for both the Urogenital Distress Inventory (39.9+/-24.9 versus 21.0+/-20.3, P<.01) and the Incontinence Impact Questionnaire (35.4+/-29.3 versus 17.3+/-24.6, P<.01). Ninety-five percent of respondents were either "very satisfied" or "satisfied" with their surgical outcome, while 5% reported postoperative regret. Of the entire series, 19.1% experienced postoperative complications. CONCLUSION: Colpocleisis results in improved quality of life and substantial goal attainment, with a low proportion of regret. LEVEL OF EVIDENCE: II.

Solifenacin significantly improves all symptoms of overactive bladder syndrome.

Overactive bladder syndrome (OAB) is a chronic condition characterised by urgency, with or without associated urge incontinence. Solifenacin succinate is a once daily, bladder selective antimuscarinic available in two doses (5 and 10 mg). The recommended dose is 5 mg once daily and can be increased to 10 mg once daily if 5 mg is well tolerated. This article presents pooled efficacy and safety data from four large, placebo-controlled, multinational phase III trials of solifenacin succinate with a total enrolment of over 2800 patients. Data from these trials show that solifenacin 5 and 10 mg once daily is significantly more effective than placebo at reducing urgency, incontinence, micturition frequency and nocturia and at increasing volume voided per micturition. Adverse events were mainly mild-to-moderate in all treatment groups. The results of these phase III trials support the use of solifenacin in the treatment of OAB.

Clinical ease of using doxazosin in BPH patients with and without hypertension.

Clinical studies have demonstrated that doxazosin therapy reduced blood pressure (BP) in patients with benign prostatic hyperplasia (BPH) who were hypertensive at baseline but not in patients who were physiologically or pharmacologically normotensive at baseline. In patients with BPH and uncontrolled hypertension, despite treatment with other antihypertensive drugs, the addition of doxazosin resulted in improved control with significant reductions in BP. The new formulation, doxazosin gastrointestinal therapeutic system (GITS), is initiated at a therapeutic dose, simplifying dose titration. Based on its efficacy and pharmacokinetic and tolerability profiles, doxazosin GITS is an effective and well-tolerated treatment for normotensive and hypertensive patients with BPH.

5alpha-reductase activity in the prostate.

The prostate gland depends on androgen stimulation for its development and growth. However, testosterone is not the major androgen responsible for growth of the prostate. Testosterone is converted to dihydrotestosterone (DHT) by the enzyme Delta(4), 3 ketosteroid, 5alpha-reductase in prostatic stromal and basal cells. DHT is primarily responsible for prostate development and the pathogenesis of benign prostatic hyperplasia (BPH). Inhibitors of 5alpha-reductase reduce prostate size by 20% to 30%. This reduction in glandular tissue is achieved by the induction of apoptosis, which is histologically manifested by ductal atrophy. Inhibition also diminishes the number of blood vessels in the prostate because of a reduction in vascular-derived endothelial growth factor. 5alpha-Reductase occurs as 2 isozymes, type 1 and type 2, with the prostate expressing predominantly the type-2 isozyme, and the liver and skin expressing primarily the type-1 isozyme. Patients have been identified with deficiencies in the type-2 5alpha-reductase, but not type 1. Knockout mice with the type-2 5alpha-reductase demonstrate a phenotype similar to that seen in men with 5alpha-reductase deficiency. Type-1 5alpha-reductase knockout male mice are phenotypically normal. Enzymatic activity for 5alpha-reductase or immunohistochemical detection has been noted in other genitourinary tissues, such as the epididymis, testes, gubernaculum, and corporal cavernosal tissue. Preputial skin predominately expresses the type-1 5alpha-reductase, whereas stromal cells in the seminal vesicle also express type-2 isozyme. However, epithelial cells in the epididymis, but not surrounding stroma, express type-1 5alpha-reductase. In addition to influencing prostatic growth, 5alpha-reductase also influences the expression of neuronal nitric-oxide synthase in the corpus cavernosum. The contribution of DHT in the serum, which is partially derived from type-1 5alpha-reductase in the liver and the small amount of type-1 5alpha-reductase in the prostate, may play a role in maintaining prostatic enlargement. Thus, in an effort to increase efficacy of treatment for BPH, clinical trials are under way using new drugs, such as GI-198745 (Glaxo-Wellcome, Research Triangle Park, NC), PNU 157706 (Pharmacia & Upjohn, Peapack, NJ), FR146687 (Fujisawa, Osaka, Japan), and LY 320236 (Lilly, Indianapolis, IN), which inhibit both the type-1 and type-2 5alpha-reductase.

Histological and neurotrophic changes triggered by varying models of bladder inflammation.

PURPOSE: We determined whether bladder inflammation causes elevated expression of nerve growth factor by bladder parenchymal cells, leading to alterations in neurons innervating the bladder. To answer this question biochemical, histological and neuronal size data were obtained in rats following various experimental models of bladder inflammation. MATERIALS AND METHODS: Chemical (2.5% formalin), immune (lipopolysaccharide 2 x 104 cfu/ml.) and mechanical (chromic catgut) inflammation was evaluated at various times and compared to control bladders. Hematoxylin and eosin, and Giemsa staining was done to characterize inflammation and quantify mast cells in the bladder. Nerve growth factor protein and messenger RNA were assayed in the bladder and major pelvic ganglion using 2-site enzyme-linked immunosorbent assay and reverse transcriptase-polymerase chain reaction, respectively. Retrograde axonal tracing was done to size bladder neurons in the major pelvic and dorsal root ganglia. RESULTS: All forms of inflammation increased bladder weight and produced diffuse hyperplasia, intramural edema, acute and chronic inflammatory cells, infiltration and mastocytosis. Generally bladder inflammation resulted in a 50% increase in nerve growth factor and 52% to 58% enlargement of peripheral neurons. CONCLUSIONS: Inflammation results in altered nerve growth factor content of the bladder, and morphological changes in sensory and motor neurons innervating the bladder. Such neuroplasticity may be a possible explanation for the association of bladder inflammation with long-term symptoms and pain after inflammation subsides.

A model for predicting motor urge urinary incontinence.

BACKGROUND: While the historical interview has been shown to diagnose stress urinary incontinence (UI) with reasonable accuracy, it is less accurate in the diagnosis of urge or mixed UI. OBJECTIVES: To construct an optimal model for the diagnosis of motor urge UI, and to refine this model into a simplified instrument that can be used to diagnose motor urge UI during a routine incontinence evaluation. METHODS: A model was constructed to allow a more accurate diagnosis of motor urge UI using historical data. Initially, an optimal model was developed that used three key symptoms, age, gender, a history of neurologic disorder, obstruction diagnosed via voiding pressure study, and the urethral resistance algorithm to diagnose motor urge UI. A simplified model was then constructed using factors such as symptoms of motor urge UI, age, and gender that were readily accessible to the nurse when completing a routine UI evaluation. This simplified model was used to develop an instrument for the clinical diagnosis of motor urge UI. RESULTS: While the agreement between clinical and urodynamic diagnosis was relatively high among patients with genuine stress UI (93% accuracy rate), it was considerably less among patients with urge and mixed UI, yielding accuracy rates of 63% and 35%, respectively. An optimal model for diagnosing motor urge UI was constructed and provided an overall accuracy rate of 91%. A simplified model was then constructed and evaluated for performance by least squares fit test. It revealed an R2 of 0.85 and an adjusted R2 of 0.84. CONCLUSIONS: A combination of age, gender, and three key symptoms (diurnal frequency, nocturia, and symptom of urge incontinence) provide an accurate and clinically useful model for the diagnosis of motor urge UI. Additional research is recommended to test the validity and reliability of the instrument derived from this model.

Activation of the transcription factors nuclear factor-kappaB and activator protein-1 in bladder smooth muscle exposed to outlet obstruction and mechanical stretching.

PURPOSE: Transcriptional control of bladder genes in response to outlet obstruction, growth factors and mechanical force is poorly understood. We analyzed the effects of bladder obstruction, mechanical stretching and platelet derived growth factor on the activation of the major growth controlling transcription factors nuclear factor-kappaB and activator protein-1. MATERIALS AND METHODS: Complete outlet obstruction was created in female rats by proximal urethral ligation and bladders were harvested 3, 6 and 24 hours later, respectively. Bladder cells were grown in culture and stimulated with 10 ng./ml. platelet derived growth factor or 10 cycles per minute of mechanical stretching for 0.5 to 4 hours. Nuclear proteins were high salt extracted and incubated with 32phosphorus double strand oligonucleotides containing a consensus binding sequence for activator protein-1 or nuclear factor-kappaB. The resulting DNA protein complexes were analyzed by electrophoretic mobility shift assay. RESULTS: Nuclear extract isolated from obstructed bladders showed intense activator protein-1 binding activity 3, 6 and 24 hours after obstruction as well as increased nuclear factor-kappaB binding activity after 6 and 24 hours. Binding activity was absent or minimal in sham operated rats. Cultured cells exposed to mechanical stretching for 2 and 4 hours showed increased activator protein-1 and nuclear factor-kappaB DNA binding compared with unstretched cells. Likewise stimulation with platelet derived growth factor caused a consistent increase in activator protein-1 and nuclear factor-kappaB binding activity. The binding of nuclear proteins was abolished by a 40-fold excess of an unlabeled specific oligonucleotide but not by excess irrelevant oligonucleotide. Thus, the assays were specific for the factors involved. CONCLUSIONS: Bladder obstruction and mechanical stretching cause the formation of activator protein-1 and nuclear factor-kappaB DNA complexes, consistent with a role of these transcription factors in the control of hypertrophy associated gene activation.

In vivo and in vitro investigation of the effects of sildenafil on rat cavernous smooth muscle.

PURPOSE: We investigated the effect of sildenafil on rat erectile tissues in vivo and in vitro. MATERIALS AND METHODS: Intracavernous pressure was recorded in pentobarbital anesthetized, male Sprague-Dawley rats and we studied the effect of 100 or 200 microg/kg(-1) sildenafil given intravenously. In an isolated endothelin-1 contracted strip preparation of rat corpus cavernosum we also assessed the effect of sildenafil on the response to electrical field stimulation of the nerves. RESULTS: Electrical stimulation of the cavernous nerve induced a frequency dependent increase in intracavernous pressure of a mean plus or minus standard error of mean 55 +/- 3 mm Hg at 20 Hz, corresponding to a mean of 47% +/- 2% of mean arterial pressure. The 100 microg/kg(-1) dose did not increase intracavernous pressure but significantly increased mean decay time of the pressure response from 16 +/- 3 to 35 +/- 3 seconds (p <0.001). In vitro sildenafil significantly enhanced the amplitude and duration of the relaxation induced by the electrical stimulation of corpus cavernosum strips in a concentration dependent fashion. CONCLUSIONS: In anesthestized rats sildenafil significantly prolonged the decay period of the intracavernous pressure response induced by electrical stimulation of the cavernous nerve but it did not increase the amplitude. Sildenafil enhanced the amplitude and duration of the relaxant response to electrical field stimulation in isolated corpus cavernosum tissue.

Treatment of aged rat sensory neurons in short-term, serum-free culture with nerve growth factor reverses the effect of aging on neurite outgrowth, calcium currents, and neuronal survival.

Impaired NGF production and release has been documented in aged animals, suggesting that decreased NGF receptor stimulation may be one factor contributing to neuronal dysfunction with aging. Other studies have suggested that aging may be associated with impaired intracellular responses to NGF. Because aging-associated neuronal dysfunction contributes to morbidity and mortality in the geriatric population, it is important to determine whether the effects of aging on sensory neuron function and survival are reversible. In the present study, we observed significantly decreased neurite outgrowth and neuronal survival in short-term cultures (0-96 h) of dorsal root ganglion (DRG) neurons from aged (>22 months) Fisher 344 x Brown Norway F1 hybrid rats, compared to young (4-6 month) and middle-aged (14 month) animals. From 24 to 96 h in culture, diminished survival of aged neurons appeared to be due to an increased rate of apoptotic cell death. DRG neurons from aged animals also exhibited significantly decreased whole cell, high-threshold voltage-dependent calcium currents, with a larger proportion of L-type current, compared to youthful and middle-aged animals. Treatment of aged DRG neurons with NGF restored neurite outgrowth, neuronal survival and calcium current amplitude and subtype distribution to those observed in youthful DRG neurons.

Depression and incontinence.

The urologic literature suggests that there is an association between a variety of psychiatric disorders and incontinence. Most notably, depression is found in a significant percentage of patients with urinary incontinence. Depression also occurs in other conditions associated with urinary urge incontinence, such as aging and dementia, and in neurologic disorders such as normal pressure hydrocephalus. Correction of some neurologic disorders eliminates both depression and urge incontinence. Although chronic medical disorders such as urge incontinence may lead to depression, an alternative hypothesis is that these two conditions share a common neurochemical pathogenesis. Lowering monoamines such as serotonin and noradrenaline in the central nervous system (CNS) leads to depression and urinary frequency and a hyperactive bladder in experimental animals. Thus, depression may not only be the result of persistent urinary incontinence, but individuals with altered CNS monoamines could manifest both depression and an overactive bladder. The latter condition may lead to urge incontinence, urinary frequency, urgency, or enuresis. Uncovering further evidence for such a linkage could serve as the basis for the development of genetic markers and novel therapeutic interventions for these two conditions.

Altered neural control of micturition in the aged F344 rat.

The purpose of this study was to determine whether micturition reflexes are altered in aged rats. Voiding frequencies and awake cystometrograms (CMGs) were measured in young (3-5 months old) and aged (24 months) F344 male rats. Bladder contractions induced by subcutaneous apomorphine and intravesical capsaicin stimulation were measured using awake CMGs. Urodynamic parameters were compared. Aged rats voided less frequently (4.1 vs 6.9 times/18 h, P = 0.006), with a higher volume per void (1.1 vs 0.7 ml, P = 0.02) and had a higher micturitional threshold pressure (8.7 vs 4.6 mmHg, P = 0.0001) than the young rats. Apomorphine induced a higher frequency of bladder contractions in aged animals compared to young animals (5.5 vs 3.1 contractions/min, P = 0.03). Intravesical capsaicin caused a lower pressure bladder response in the aged rats (38.5 vs 70.6 mmHg, P = 0.01) compared to the young rats. Bladder afferents and central micturition pathways may be altered in aged rats. Impaired bladder contractility in the elderly may be exacerbated by reduced sensory input, whereas the propensity for detrusor instability could result from altered central processing. This study demonstrated the utility of the F344 animal model to study micturitional changes resulting from aging.

Voiding dysfunction in the orthotopic neobladder.

The orthotopic neobladder has become the preferred method of handling the urinary tract after removal of the bladder in men and women. However, an improved quality of life compared to urinary diversion fails to be realized when voiding dysfunction arises. These difficulties with urination range from retention to incontinence. Voiding dysfunction following neobladder construction that persists beyond 6-12 months warrants fluoro-urodynamic evaluation to determine the cause and plan therapy. Although colonic, ileocolonic, gastric, and ileal neobladders have all been deemed acceptable, the S or W-configured, spheroidal shaped neobladders created from ileum are the most popular. Voiding pressures and micturition patterns depend on the type, length, and configuration of bowel segment harvested. These variables also determine the risk of voiding dysfunction, along with the choice of surgical technique, and the age and sex of the patient. Urinary retention is more common in women, especially after urethral nerve sparing. Obstruction is often due to inferior displacement of the bladder neck, which can angulate the urethra. Daytime stress incontinence arises from reduced urethral outlet resistance accentuated by low neobladder capacity, reduced compliance, or elevated neobladder pressures. Night-time incontinence develops as a consequence of absent sensation that permits excessive nocturnal volumes to overcome the impaired continence mechanisms of the bladder outlet. This situation is exacerbated by the loss of physiological storage reflexes. Therapy for retention rests primarily with intermittent self-catheterization. Stress urinary incontinence can be treated with periurethral bulking agents or an artificial urethral sphincter. Nocturnal enuresis is often effectively managed by the use of an alarm clock to awaken the patient several times per night. Knowledge of the pathogenesis and identification of risk factors implies that prevention through proper design of the neobladder, meticulous surgical technique, and patient selection is paramount.

Neural pathways and central sites involved in penile erection: neuroanatomy and clinical implications.

Penile erection occurs in response to tactile, visual, and imaginative stimuli in humans. In animals olfactory and auditory cues are particularly important. The participation of multiple sites with the brain and spinal cord, and coordination of somatic and autonomic pathways make sexual behavior in general, and erection in particular, vulnerable to neurologic injury and disease. Sites within the brain and spinal cord act in concert to process, coordinate, then distribute the neural inputs necessary for sexual behavior including erection. Activation of neurons in some of these regions either pharmacologically or by electrical stimulation has been associated with penile tumescence. This review will provide a geographic framework for understanding the neuroanatomical basis of penile erection based primarily on animal data. Following discussion of the anatomical substrates, a clinical correlation is then provided to confirm and reinforce these experimental observations.

Stretch-activated signaling of nerve growth factor secretion in bladder and vascular smooth muscle cells from hypertensive and hyperactive rats.

Elevated vascular (VSMC) and bladder smooth muscle (BSMC) NGF are associated with altered visceral innervation in the spontaneously hypertensive rat (SHR: hypertensive, behaviorally hyperactive) compared with control Wistar-Kyotos (WKYs). Stretch stimulates increased NGF production in BSMCs. To elucidate whether stretch induces NGF synthesis in VSMCs, and to determine if disturbances in stretch-mediated NGF production contribute to the elevated tissue levels of NGF in SHRs, we subjected VSMCs and BSMCs cultured from four established inbred rat strains (WKY, WKHA: hyperactive; SHR and WKHT: hypertensive) to several stretch paradigms. For VSMCs, acute and cyclic stretch affected cells derived from hypertensive rats (80-100% increase over control) but not from normotensive strains. For BSMCs, cyclic and static stretch increased NGF secretion in all four strains, but had a two- to threefold greater effect in cells from SHRs and WKHTs (increase up to 600%) at early time points. At later time points of a 24-h experimental period, stretch increased NGF output up to 400% in SHR and WKHA cultures. Thus, defects that influence early induction of stretch-mediated SHR NGF secretion cosegregate with the hypertensive phenotype. Stretch-gated ion channel inhibitors, voltage-gated ion channel inhibitors, and protease inhibitors failed to affect stretch-induced BSMC NGF secretion. In contrast, gene transcription, intracellular calcium, protein kinase C (PKC), and autocrine release of an unknown factor may play a role in the elevated NGF secretion observed in smooth muscle from hypertensive animals. Altered stretch-induced smooth muscle NGF secretion may contribute to the augmented vascular and bladder NGF content associated with high blood pressure and hyperactive voiding in SHRs.