[Terminology and Pathophysiology of Overactive Bladder (OAB)]. / Terminologie und Pathophysiologie der Überaktiven Harnblase (ÜAB).

In 2002, the International Continence Society defined the term overactive bladder (OAB) as a symptom syndrome that is accompanied by urgency with or without urge incontinence, frequency and nocturia. A proven urinary tract infection or other obvious pathologies must be excluded.The pathophysiology of OAB has not been clarified in detail and is the subject of ongoing research, so partially overlapping hypotheses exist. The urothelium-based hypothesis suggests functional changes of urothelial receptors as well as functional changes regarding the sensitivity and coupling of the suburothelial myofibroblasts, which ultimately lead to increasing activity of afferent signals and urgency. The myogenic hypothesis is based on the assumption that unstable detrusor contractions may be triggered by changes in their excitability and coupling with other myocytes or myofibroblasts. Unstable detrusor contractions generate increased afferent activity followed by symptoms of overactive bladder. The hypothesis of abnormal processing of afferent signals assumes that damage to central inhibitory pathways and/or sensitisation of afferent nerves lead to the activation of the micturition reflex, which, in turn, induces unstable detrusor contractions. In addition, hormonal and psychological influences are discussed.

Establishment of the novel cystoscopic classification for bladder trabeculation of neurogenic bladder.

OBJECTIVE: To establish a cystoscopic grading system for trabeculation of neurogenic bladders. MATERIALS AND METHODS: A total of 140 neurogenic bladder patients who had undergone both fluoroscopic urodynamic study and cystoscopic examination were retrospectively reviewed. Cystoscopic images were categorized into 4 grades according to the formation of the muscle bundle layer and height-to-width ratio of the muscle bundle: 0 (none), 1 (mild), 2 (moderate), and 3 (severe). Test-retest reliability and interobserver reliability were assessed. Cystoscopic grade of the trabeculated bladder was correlated with urodynamic results and the fluoroscopic grades of trabeculation. RESULTS: The test-retest reliability showed almost perfect agreement with all levels of Cronbach alpha ranging from 0.925 to 0.970. The intraclass correlation coefficient was 0.986, indicative of an almost perfect level of interobserver reliability. The grading system showed clinical significance by correlation with urodynamic parameters (Qmax, P value = .016; postvoid residual, P value <.001; bladder outlet obstruction index, P value = .002). Cystoscopic grades correlated moderately well with fluoroscopic grades, showing comparable clinical significance with fluoroscopic grades. CONCLUSION: Our results showed that this novel cystoscopic classification of bladder trabeculation was highly reliable.

Cerebral palsy, neurogenic bladder, and outcomes of lifetime care.

AIM: To determine the prevalence of symptomatic neurogenic bladder (SNB) and social and functional variables in a large sample of people with cerebral palsy (CP). METHOD: The medical records of 214 individuals (96 females, 118 males) with CP between the years 1990 and 2000 were retrospectively reviewed. Individuals with frequency, urgency, or incontinence were assigned Gross Motor Function Classification System levels and underwent cystometrogram/electromyelogram studies. Neurogenic bladders were classified according to the nomenclature of the International Continence Society. RESULTS: Fifty-two patients had hemiplegia, 42 diplegia, 117 quadriplegia, and three dyskinesia. Educational levels ranged from full special education to those with graduate degrees. Thirty-five individuals in our group aged 5 to 66 years had SNB with a prevalence of 16.4%. The median age for the entire population was 9 years 7 months and for those with SNB 12 years 4 months (range 5-57y). Over 80% of individuals who underwent investigation were found to have spastic hyper-reflexic type bladders. Ninety-one percent obtained total continence or major improvement with conservative care. SNB was documented across the lifespan, educational spectrum, and functional level. Upper urinary tract pathology was infrequent. INTERPRETATION: SNB is a common finding in individuals with CP. In most patients it is readily diagnosed and treated with conservative interventions.

Oxybutynin and tolterodine for treatment of neurogenic detrusor overactivity: a pharmacoeconomic evaluation in the Brazilian context

Antimuscarinic agents are the first-line choice for the treatment of neurogenic detrusor overactivity (NDO). The currently available antimuscarinic drugs have been widely studied in patients presenting idiopathic detrusor overactivity; however, investigations evaluating the effects of these drugs on NDO are scant, particularly with regard to cost-effectiveness analyses. A pharmacoeconomic evaluation was performed to compare the costs and effectiveness of oxybutynin and tolterodine in two different formulations, extended (ER) and immediate-release (IR), for the treatment of NDO (based on Brazilian maximal consumer price index). A systematic review of literature was conducted in order to obtain significant clinical and urodynamic data (based on expert opinion), concerning the effects of these drugs in the neurogenic population. Furthermore, a pharmacoeconomic evaluation was performed and costs involved were calculated based on percentage effectiveness obtained for the timeframes of one month and of one year. The best cost-effectiveness ratio (CER) was observed with oxybutynin IR for the urodynamic parameters. In terms of clinical parameters, oxybutynin IR and ER showed the best CER. Based on the key urological parameters analyzed, oxybutynin IR was considered the most cost-effective antimuscarinic agent.

A terapia antimuscarínica é vista como primeira escolha para o tratamento da hiperatividade detrusora de origem neurológica (HDON). No entanto, a maioria dos antimuscarínicos existentes é amplamente estudada em pacientes portadores de hiperatividade detrusora idiopática. Assim, existe escassez de pesquisas que avaliam esses fármacos na problemática da HDON, principalmente em termos de estudos de custo-efetividade. Diante isso, um estudo farmacoeconômico foi realizado (baseado no índice de preço máximo ao consumidor) para comparar os custos e a efetividade da oxibutinina e da tolterodina, em duas diferentes formulações, cápsulas de liberação imediata (LI) e controlada (LC), para o tratamento da HDON. Uma revisão sistemática da literatura foi conduzida para obtenção de dados urodinâmicos e clínicos relevantes (baseado em opinião de especialistas), quanto aos efeitos desses fármacos em pacientes com distúrbios urológicos de origem neurológica. Após essa etapa, um estudo farmacoeconômico foi conduzido e os custos envolvidos foram calculados sobre cada percentual de efetividade obtido, num horizonte temporal de 1 mês e 1 ano. A melhor razão de custo-efetividade (RCE) quanto aos parâmetros urodinâmicos foi obtida com uso de oxibutinina LI. Quantos aos parâmetros clínicos, oxibutinina LI e LC tiveram as melhores RCE. Baseando-se nos principais parâmetros urológicos analisados, oxibutinina LI foi considerada o antimuscarínico mais custo-efetivo.

Urodynamic study in the neurogenic bladder dysfunction caused by intervertebral disk hernia.

AIMS: To discuss the clinical significance of urodynamic studies in neurogenic bladder dysfunction caused by intervertebral disk hernia. METHODS: Thirty patients with neurogenic bladder dysfunction caused by intervertebral disk hernia were divided into three groups according to the category of detrusor muscle activity: neurogenic detrusor overactivity without detrusor sphincter dyssynergia (DSD), neurogenic detrusor overactivity with DSD, or detrusor underactivity. The patients were divided into three groups according to the condition of urinary retention and incontinence: urinary retention, urinary incontinence, or neither urinary retention nor urinary incontinence. Also they were divided into three groups according to the location of the intervertebral disk hernia: cervical hernia, thoracic hernia, or lumbar hernia. All patients underwent computer tomography (CT), magnetic resonance imaging (MRI), and urodynamic study. The results were analyzed statistically. RESULTS: There was significant correlation between the category of detrusor muscle activity, bladder compliance (BC, P < 0.05), and the pressure at maximum flow (P(det,Qmax), P < 0.01). There were significant differences in post void residual (PVR), cystometric capacity (CC), and maximum flow rate (Qmax) between the three groups of urinary retention, urinary incontinence, and the group of neither retention nor incontinence (P < 0.05). There was statistical correlation between the location of the intervertebral disk hernia and the urodynamic results. There was significant correlation between the BC (the threshold was 15 ml/cmH(2)O), detrusor pressure (Pdet, the threshold was 40 cmH(2)O), DSD, the location of intervertebral disk hernia, and the upper urinary tract lesion (P < 0.01). CONCLUSIONS: Urodynamic studies are indispensable in the classification, diagnosis, treatment, and prognosis of the neurogenic bladder dysfunction caused by intervertebral disk hernia.

[Pathophysiology of urge, stress, and mixed incontinence]. / Pathophysiologie von Drang-, Belastungs- und Mischinkontinenz.

According to the new ICS classification, urinary incontinence is subdivided by symptomatic, clinical, and urodynamic criteria. Understanding the pathophysiological interactions is important to find the correct diagnosis. Disturbances in bladder storage include urge incontinence due to neurogenic or non-neurogenic (idiopathic) detrusor hyperactivity as well as stress urinary incontinence caused by an insufficient urethral closure mechanism due to reduced pressure transmission (active-passive), hypotonic urethra, hyporeactivity of sphincter musculature, or involuntary relaxation of the urethra. Stress and urge incontinence can occur in combination and then be defined as mixed incontinence.

Can neurologic examination predict type of detrusor sphincter-dyssynergia in patients with spinal cord injury?

OBJECTIVES: To assess the correlations in males with spinal cord injury (SCI) between the neurologic status and type of detrusor-sphincter dyssynergia (DSD) observed during urodynamic examinations and to evaluate the change in the DSD pattern over time. METHODS: A total of 105 male patients with chronic SCI were neurologically examined according to the American Spinal Cord Injury Association protocol and underwent video-urodynamic examinations. DSD observed during urodynamic studies was classified according to the Blaivas classification. To assess the stability of the DSD over time, patients who had been recently injured were clinically and urodynamically controlled after 1 year and thereafter. RESULTS: A statistically significant positive correlation was found between the DSD type and completeness or incompleteness of the SCI lesion. Patients with an incomplete sensory and motor SCI lesion presented with DSD type 1 compared with patients with complete sensory and motor SCI lesion, who had DSD type 2 to type 3. A correlation was also found between the American Spinal Cord Injury Association scores and the DSD type. No correlation was found between the DSD type and lesion level. At medium to long-term follow-up, a significant change was found in the DSD type. CONCLUSIONS: The neurologic status and DSD type after SCI showed significant correlations. Therefore, neurologic examination and determination of the DSD type might be helpful to complete the neurourologic diagnosis and to assist in confirming completeness of the lesion after acute injury. Because DSD seems to become aggravated with time, regular urodynamic follow-up examinations are mandatory in patients with DSD to adjust their treatment, if necessary.

[Bladder dysfunction due to rare neurological disorders]. / Blasendysfunktion bei seltenen neurologischen Erkrankungen.

Diseases or lesions of the central or peripheral nervous system involving the innervation of the lower urinary tract lead to neurogenic bladder dysfunction. Results are typical changes in storage and voiding function of the bladder according to pathophysiological and urodynamical criteria. In case of neurological disorders the neurological symptoms are not always the leading ones. The differential diagnosis of correlating bladder dysfunction is often difficult and special pathophysiological knowledge is necessary. Etiological factors are congenital, degenerative, vascular, inflammatory and immunological processes or tumour-specific changes of the nervous system. In many cases urodynamic evaluation and early interdisciplinary cooperation is necessary for special differentiation and diagnosis, especially of those diseases which rarely lead to initial bladder symptoms. The "nonneurogenic neurogenic bladder" or "Hinman-Syndrom" is well known in the literature but shouldn't be diagnosed until possible neurological reasons are excluded by modern diagnostic tools with newest imaging techniques.

Comparison between conventional cystometry and stimulated filling cystometry by diuretics in a neurogenic bladder after spinal cord injury.

OBJECTIVE: To determine in the neurogenic bladder whether cystometry performed under near physiologic condition by filling stimulation using diuretics reveals different findings compared with conventional cystometry (CMG). DESIGN: One group of subjects from a university teaching hospital was tested in two conditions. The maximum detrusor pressure (MPdet) and compliance of the bladder in CMG and furosemide-stimulated filling cystometry (FCMG) were compared in 27 patients with neurogenic bladder after spinal cord injury. The MPdet was estimated. Compliance was calculated. For CMG, the bladder was filled. FCMG was performed 3 hr after CMG. For FCMG, furosemide was injected after infusion of normal saline. Recording intravesical pressure started after emptying the bladder immediately after furosemide injection. RESULTS: Significant differences were found between CMG and FCMG in hyperreflexic neurogenic bladders with respect to a decrease in MPdet and increase in compliance with FCMG. However, there were no significant differences in MPdet and compliance in hyporeflexic or areflexic neurogenic bladders between the two techniques. CONCLUSION: We have found that FCMG is useful in evaluating both genuine MPdet and compliance in patients with hyperreflexic neurogenic bladder dysfunction. FCMG provides more reliable information on detrusor characteristics than CMG in hyperreflexic neurogenic bladder. We suggest that FCMG is an alternative, effective, and near physiologic diagnostic method, having short assessment time for improving evaluation of the detrusor characteristics of hyperreflexic neurogenic bladder.

Assessment and conservative management of the neuropathic bladder.

The etiologies and forms of congenital neuropathic bladder are described: contractile (25%), acontractile (15%), and intermediate (60%). The terminology relating to neuropathic bladder is defined and the principles of bladder management are highlighted: (1) must achieve a bladder that can fill at low pressure, (2) must achieve a bladder that can store urine at low pressure, (3) must achieve sphincter resistance that is sufficient to allow urine storage, and (4) must put in place a mechanism of achieving complete voluntary bladder emptying. The approach to investigation is set out in a logical sequence, and the methods of achieving the goals highlighted above are described. All of this is put in the context of managing the handicapped patient as a whole. It also is stressed that the aim is not just to achieve continence but perhaps even more importantly to protect renal function.

Clinical patterns of neurogenic bladder.

The neurogenic bladder represents a vesical dysfunction secondary to a congenital or acquired neurologic lesion, spinal dysraphism being the most common cause in pediatric age. According to the lesion level and severity, neurogenic bladder can be hypertonic hyperreflexic, hypotonic hyporeflexic or of mixed type characterized by different clinical and urodynamic patterns and the potential cause of nephrourologic complications. These types of neurogenic bladder require diversified treatments as anticholinergic drugs, clean intermittent catheterization and antibiotic prophylaxis, separately or in various combinations. Close follow-up of children is necessary to control and prevent the onset of complications with changes in medical therapy or surgical treatment if required.

Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury.

OBJECTIVES: To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury. METHODS: A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury. RESULTS: Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found (P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications (P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period. CONCLUSIONS: The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Evaluation of the female with neurogenic voiding dysfunction.

Neurological disease can have a profound effect on the lower and upper urinary tracts. Symptoms, such as incontinence and inability to void, as well as sequelae of hydronephrosis and renal insufficiency, are not uncommon. It is imperative that neurogenic voiding dysfunction by aggressively treated to avoid these problems. Care of the patient with neurogenic voiding dysfunction starts with an understanding of the neurophysiology of micturition and how this can be affected by various neurological diseases. The clinician must also be able to classify voiding dysfunction through history and physical examination and urodynamic testing so that proper treatment can be instituted.

Definition of overactive bladder and epidemiology of urinary incontinence.

OBJECTIVES: To review the definition of the overactive bladder and to summarize the results of epidemiologic studies on this specific disorder as well as urinary incontinence (UI) in general. METHODS: From a literature search covering the time period from 1954 through 1995, 48 epidemiologic studies and several other publications dealing with the prevalence and natural history of UI were reviewed. A meta-analysis of reported data was performed with respect to incontinence definitions, investigation methods, home country of survey, sex, and age groups. RESULTS: Differences in definitions of incontinence, target populations, and study design in different investigations resulted in inhomogeneity and difficulties of comparing the available data. By grouping the studies with respect to similarities in the above-mentioned criteria and analyzing the results for each group of studies, an attempt was made to understand the great variation of reported results. Differences in prevalence of incontinence were identified for all examined groups of studies and for distinct ethnic populations. Scarce information about incidence, spontaneous remission rates, and risk factors was used to elucidate the natural history of UI in women and men. CONCLUSIONS: Although generally accepted definitions of the overactive bladder specifically and UI in general are highly desirable, they have not yet been established. Such definitions should comprise aspects of severity and demonstrability of the condition, bother factor, and impact on quality of life. Moreover, basic requirements for epidemiologic surveys of incontinence, such as validation of questionnaire results, need to be defined and standardized to create a sensible basis for useful epidemiologic studies in the future.

Diagnosis and significance of idiopathic overactive bladder.

OBJECTIVES: To offer a critical overview of the basis for the International Continence Society (ICS) classification of detrusor instability, to summarize current diagnostic methodologies, and to outline the etiologic factors that should be excluded in the diagnosis of idiopathic overactive bladder. METHODS: The current ICS definitions of overactive bladder are discussed. Issues related to the diagnosis of detrusor instability (DI) are addressed through a review of the literature. RESULTS: The term idiopathic overactive bladder reflects the present lack of knowledge concerning vesicourethral function and dysfunction. The term is used to apply to a wide spectrum of different conditions that may have a common final pathophysiologic pathway. This heterogeneous group of conditions could be subdivided on the basis of presumptive etiopathogenesis, urodynamic patterns, and response to treatment. The diagnosis of DI, its rate of detection, and its urodynamic patterns depend on the type of urodynamic test used and the way the test is performed. The ICS definitions of DI have been called into question by the results of studies using urodynamic tests in addition to, or instead of, provocative cystometry--for instance, ambulatory urodynamics, urethrocystometry, the ice-water test, and evaluation of the voiding phase. The literature supports a broadening of the ICS criteria for excluding all known causes of DI when establishing the diagnosis of idiopathic overactive bladder. CONCLUSIONS: Appropriate longitudinal studies, using contemporary urodynamic tests and knowledge, are needed to improve the identification of subsets of patients with overactive bladder who have different prognoses and outcomes. The ICS definitions and classification should be updated.

[Therapy of female urinary incontinence with the AMS 800 artificial sphincter. Indications, outcome, complications and risk factors]. / Therapie der weiblichen Harninkontinenz mit dem artifiziellen Sphinkter AMS 800. Indikationen, Ergebnisse, Komplikationen und Risikofaktoren.

Indications, results and complications of 144 women who have undergone implantation of the current model AMS 800 since 1983 and remained in continuous follow-up in our department are presented. Included are 70 patients suffering from stress urinary incontinence (SUI) type III after 208 previously unsuccessful incontinence procedures, 54 patients with incontinence due to neurogenic bladder dysfunction (NBD) and 20 patients with congenital or acquired internal sphincter weakness of other causes. In the NBD group, apart from sphincter implantation a total of 113 additional operations were necessary due to complex malfunctions of the urinary tract: augmentation ileocystoplasty in 51 patients, ureterocystoneostomy in 23 patients and 43 operations at the bladder neck. One hundred and twenty-six patients (86%) achieved total continence and 5 patients (3%) were significantly improved. In 9 females (6%) incontinence persisted, and 4 patients ultimately underwent urinary diversion into a Kock pouch. With the implanted artificial sphincter 116 patients (81%) are able to empty their bladder spontaneously, without residual urine and without the necessity of intermittent self catheterisation. Under the aforementioned conditions implantation of the artificial urinary sphincter AMS 800 is the most effective therapy for complex female incontinence.

Toward a new classification of overactive bladders.

Based on a large retrospective series, this study compares the International Continence Society's (ICS) classification of overactive bladders and a functional subtyping of our own, founded on clinical and urodynamic parameters. Functionally identical symptoms and urodynamic patterns were found within the Detrusor Hyperreflexia as well as the Unstable Detrusor categories. There are strong arguments for a revision of the current ICS classification system.

Detrusor hyperreflexia--are there two types?

The concept that elderly patients with urinary incontinence due to detrusor hyperreflexia can be divided into two groups with differing natural histories on the basis of the detrusor contractility found on cystometry is reassessed. Thirty patients shown to have hyperreflexia on urodynamic study for persistent urinary incontinence following a recent neurological lesion had their contractility measured by the suggested criteria of the residual urine following a hyperreflexic contraction and the rate of increase of detrusor pressure. The consistency of contractility on cystometry was also measured by repeating this three times on the same occasion. A spectrum of values for the post-contraction volumes and the rate of increase of detrusor pressure was found. On repetitive cystometry 11 out of 30 patients showed a variable post-contraction residual volume. While impaired contractility is common in detrusor hyperreflexia, the concept of two subgroups is not supported by these results. In some patients cystometric measures of contractility vary considerably on repeating the study on the same occasion.