Estimation of bladder contractility from intravesical pressure-volume measurements.

AIMS: To describe parameters from urodynamic pressure recordings that describe urinary bladder contractility through the use of principles of muscle mechanics. METHODS: Subtracted detrusor pressure and voided flow were recorded from patients undergoing filling cystometry. The isovolumetric increase of detrusor pressure, P, of a voluntary bladder contraction before voiding was used to generate a plot of (dP/dt)/P versus P. Extrapolation of the plot to the y-axis and the x-axis generated a contractility parameter, vCE (the maximum rate of pressure development) and the maximum isovolumetric pressure, P0 , respectively. Similar curves were obtained in ex vivo pig bladders with different concentrations of the inotropic agent carbachol and shown in a supplement. RESULTS: Values of vCE , but not P0 , diminished with age in female subjects. vCE was most significantly associated with the 20-80% duration of isovolumetric contraction t20-80 ; and a weaker association with maximum flow rate and BCI in women. P0 was not associated with any urodynamic variable in women, but in men was with t20-80 and isovolumetric pressure indices. CONCLUSIONS: The rate of isovolumetric subtracted detrusor pressure (t20-80 ) increase shows a very significant association with indices of bladder contractility as derived from a derived force-velocity curve. We propose that t20-80 is a detrusor contractility parameter (DCP). Neurourol. Urodynam. 36:1009-1014, 2017. © 2016 Wiley Periodicals, Inc.

Neurogenic lower urinary tract dysfunction: Clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013.

BACKGROUND: Evidence-based guidelines for the management of neurological disease and lower urinary tract dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance. AIMS: To update clinical management of neurogenic bladder dysfunction from the recommendations of the fourth ICI, 2009. MATERIALS AND METHODS: A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and consequently amended to deliver evidence-based conclusions and recommendations in 2013. RESULTS: The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic lower urinary tract dysfunction. The pathophysiology is categorized according to the nature of onset of neurological disease and the part(s) of the nervous system affected. Assessment requires clinical evaluation, general investigations, and specialized testing. Treatment primarily focuses on ensuring safety of the patient and optimizing quality of life. Symptom management covers conservative and interventional measures to aid urine storage and bladder emptying, along with containment of incontinence. A multidisciplinary approach to management is essential. DISCUSSION: The review offers a pragmatic review of management in the context of complex pathophysiology and varied evidence base. Neurourol. Urodynam. 35:657-665, 2016. © 2016 Wiley Periodicals, Inc.

Classification of stress urinary incontinence.

INTRODUCTION: The relevant terminology for stress urinary incontinence (SUI) is affected by the context, namely the clinical assessment (the symptom of SUI elicited on history taking and the sign of SUI observed during examination) or diagnostic investigations (urodynamic stress incontinence). In some cases, SUI may only be observed after the reduction in coexistent prolapse (occult SUI). Classifying SUI often relies on distinguishing between intrinsic sphincter deficiency (ISD), and urethral malposition or hypermobility, although this potentially an over-simplification. REVIEW: Classification systems have been derived based on clinical assessment and diagnostic testing, notably videourodynamics. Modern developments in imaging technology may allow other techniques such as ultrasound to offer additional basis for future developments in classification. Other urodynamic approaches include urethral pressure profilometry and Valsalva leak point pressure; these may offer indicators of thresholds below which ISD is more likely to explain SUI, but they are not generally accepted in routine practice. CONCLUSIONS: While SUI classification is potentially relevant to treatment selection, evidence for influence on management outcome is limited. Generating a high-quality evidence base for treatment selection on these criteria is problematic, particularly due to the range of confounding factors. In practice, the modern practitioner relies on various tools to form an opinion on some key aspects, using the findings to derive a treatment strategy. Accordingly, there remains a need to confirm how a classification of SUI translates into treatment selection and better outcomes.

The Association Between Constipation and Lower Urinary Tract Symptoms in Parous Middle-Aged Women: A Prospective Cohort Study.

Objective: To examine the prospective association between constipation and risk of developing lower urinary tract symptoms (LUTS) in parous middle-aged women. Materials and Methods: The study uses data from 3,729 women from the Avon Longitudinal Study of Parents and Children who provided self-reports of medication intake for constipation at two time points (Baseline): 2001-2003 and 2003-2005. Women with LUTS at baseline were excluded. After 10 years of follow-up, women provided self-reports of LUTS using an adapted version of the International Consultation on Incontinence Questionnaire on Female LUTS. LUTS were categorized according to International Continence Society definitions as stress urinary incontinence (UI), urgency UI, mixed UI, nocturia, increased daytime frequency, urgency, hesitancy, and intermittency. LUTS were considered present if symptoms were reported to occur at least "sometimes" for all subtypes, except for increased daytime frequency (≥9 times) and nocturia (≥2 times nightly). Results: At follow-up, the prevalence of any LUTS was 40%. Women (mean age 43.3 years, standard deviation 0.5), who took medication for constipation at either time point had increased risks of urgency (adjusted relative risks [RRs] = 1.35; 95% confidence interval [CI] 1.04-1.95) and hesitancy (adjusted RR = 1.72; 95% CI 1.04-3.01) compared with women who reported not using medication for constipation at either time point. The risk of urgency (adjusted RR = 1.94; 95% CI 1.15-3.29) and hesitancy (adjusted RR = 1.78; 95% CI 1.03-4.19) was greater for women who reported taking medication for constipation at both time points. There was no evidence that constipation was associated with stress UI, urgency UI, mixed UI, nocturia, increased daytime frequency, and intermittency. Conclusion: Constipation is prospectively associated with an increased risk of urgency and hesitancy among parous middle-aged women. If further research finds evidence that this association is causal, this implies that women should seek treatment to alleviate constipation to reduce their consequent risk of developing these LUTS.

Annual direct and indirect costs attributable to nocturia in Germany, Sweden, and the UK.

OBJECTIVE: Our aim was to estimate the prevalence-based cost of illness imposed by nocturia (≥2 nocturnal voids per night) in Germany, Sweden, and the UK in an average year. METHODS: Information obtained from a systematic review of published literature and clinicians was used to construct an algorithm depicting the management of nocturia in these three countries. This enabled an estimation of (1) annual levels of healthcare resource use, (2) annual cost of healthcare resource use, and (3) annual societal cost arising from presenteeism and absenteeism attributable to nocturia in each country. RESULTS: In an average year, there are an estimated 12.5, 1.2, and 8.6 million patients ≥20 years of age with nocturia in Germany, Sweden, and the UK, respectively. In an average year in each country, respectively, these patients were estimated to have 13.8, 1.4, and 10.0 million visits to a family practitioner or specialist, ~91,000, 9000, and 63,000 hospital admissions attributable to nocturia and 216,000, 19,000, and 130,000 subjects were estimated to incur a fracture resulting from nocturia. The annual direct cost of healthcare resource use attributable to managing nocturia was estimated to be approximately €2.32 billion in Germany, 5.11 billion kr (€0.54 billion) in Sweden, and £1.35 billion (€1.77 billion) in the UK. The annual indirect societal cost arising from both presenteeism and absenteeism was estimated to be approximately €20.76 billion in Germany and 19.65 billion kr (€2.10 billion) in Sweden. In addition, in the UK, the annual indirect cost due to absenteeism was an estimated £4.32 billion (€5.64 billion). CONCLUSIONS: Nocturia appears to impose a substantial socioeconomic burden in all three countries. Clinical and economic benefits could accrue from an increased awareness of the impact that nocturia imposes on patients, health services, and society as a whole.

The integrative physiology of the bladder.

Normal bladder function is complex, resulting from the co-operative interaction of numerous regulatory cell types, of which the interstitial cells and the peripheral neurones are particularly interesting. Collectively, these comprise the myovesical plexus, which appears to confer structural and functional characteristics on the bladder loosely akin to those of the gut. These include functional modularity, which gives rise to the potential for localised and propagating peristalsis-like movements in the bladder wall according to the prevailing physiological conditions. Localised modular activity during filling may contribute to normal generation of sensation and exaggerated modular activity may give rise to urinary urgency. Enhanced co-ordination of modular activity occurs in various models of detrusor overactivity; it leads to surges of contraction over a large part of the bladder wall, generating phasic changes in intravesical pressure. During voiding, the myovesical plexus sustains detrusor contraction at the behest of the brainstem, monitoring state of bladder fullness as it does so, as a guide to the required duration for which it has to keep up the effort. Accordingly, the bladder wall itself may house structures which render the bladder the effector level in a hierarchy of lower urinary tract regulation. Dysfunction in these vital regulatory structures is an underestimated factor in the pathophysiology of clinical bladder problems.