[Overactive bladder syndrome in children]

According to recent terminology, the symptom complex of frequency and urgency with or without urge incontinence in childhood is called overactive bladder. The main etiologic factor seems to be a delayed maturation of complex neuroanatomic structures responsible for normal bladder control. Afflicted children show a typical pattern of reflex voiding with different degrees of severity. In many cases nocturnal incontinence is the main complaint and this may lead to the wrong diagnosis of nocturnal enuresis with resulting false treatment. The diagnostic work-up consists of standardized evaluation of children with enuresis and voiding dysfunction and should concentrate on the exclusion of any possible underlying neurological disorder. Treatment focuses primarily on behavioral modification and cognitive education with regard to bladder sensation and voluntary micturition. Muscarinic receptor antagonists are very useful as supportive medical treatment with a rather low rate of adverse effects. Children who fail to respond to treatment or children suffering from side effects can profit from alternative treatment modalities including biofeedback programs, pelvic floor stimulation, or acupuncture.

[Biofeedback for urinary bladder dysfunctions in childhood. Indications, practice and the results of therapy]

In children, abnormal behavior during micturition, i.e. detrusor/sphincter dyscoordination, causes persistent voiding problems, urinary incontinence and/or recurrent urinary tract infections in up to 15% of cases. Contractions of the external urethral sphincter during micturition lead to functional subvesical obstruction. Nowadays, biofeedback training is the most suitable therapy. Biofeedback training for children is based on the assumption that relaxation and contraction of the urinary external sphincter is a habitual phenomenon and can be restored. With specially developed, computer-assisted biofeedback programs, sphincter contraction and relaxation can be transformed into acoustic or visual signals. Acoustic or optical feedback indicates relaxation and contraction control to the patient. The residual urine volume should subsequently be assessed. The results should be reviewed after each micturition. Poor compliance sometimes makes biofeedback training impossible. Further biofeedback training at home is a reasonable suggestion. Good results-a response rate of up to 90%-demonstrates that biofeedback training is successful in the treatment of detrusor-sphincter dyscoordination. After effective therapy, associated urinary tract infections and vesicoureterorenal reflux may disappear.

Intravesical therapy options for neurogenic detrusor overactivity

STUDY DESIGN

Review article.

SETTING

Neuro-Urology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.

OBJECTIVES

This review considers intravesical treatment options of neurogenic detrusor overactivity and discusses the underlying mechanism of action, clinical safety and efficacy, and the future trends.

METHODS

The available literature was reviewed using medline services.

RESULTS

Oral anticholinergic drugs are widely used to treat detrusor overactivity, but they are ineffective in some patients or cause systemic side effects such as blurred vision or dry mouth. As an alternative, topical therapy strategies have been suggested to achieve a profound inhibition of the overactive detrusor and to avoid high systemic drug levels. Currently available intravesical treatment options either act on the afferent arc of the reflex such as local anaesthetics or vanilloids or on the efferent cholinergic transmission to the detrusor muscle such as intravesical oxybutynin or botulinum toxin. Although an established and effective therapy, intravesical oxybutynin is not widely used. Evidence for clinical significance of intravesical atropine and local anaesthetic is missing. Intravesical capsaicin has been shown to improve clinical and urodynamic parameters, but cause pain in some patients. The intravesical instillation of resiniferatoxin and the injection of botulinum-A toxin into the detrusor muscle are promising new options; however, randomised placebo-controlled studies to prove their safety and efficacy are still missing.

CONCLUSION

Intravesical treatment strategies in patients with neurogenic detrusor overactivity may provide alternatives to established therapies such as oral anticholinergics. The selectivity of the intravesical treatment and the reduction or even the absence of side effects are major advantages of this topical approach.

Reversal of hypertonic co-contraction after bilateral pallidal stimulation in generalised dystonia: a clinical and electromyogram case study

In a patient of generalised dystonia treated with bilateral pallidal stimulation, serial surface EMGs recorded from the neck muscles during alternating head movements revealed progressive reduction in hypertonic activity and reversal of co-contraction to reciprocal contraction, which preceded clinical improvement.

Rehabilitation of partially edentulous patient with loss of vertical dimension

A case of rehabilitation of an edentulous patient with loss of vertical dimension is presented here. This patient presents with a Class III dental and skeletal malocclusion with an anterior cross-bite. The objective of this case report is to demonstrate that an accurate assessment of vertical dimension is necessary for good rehabilitation. The original vertical dimension was determined by a series of tests including, kinesiographic, electromyographic and transcutaneous electronic neural stimulation (TENS). Subsequently, the lost vertical dimension was re-established orthodontically. These examinations revealed a general hypertonicity of masticatory muscles due to the lost vertical dimension. Additionally, radiographs of the temporomandibular joint showed anteriorly displaced condyles. Following the completion of orthodontic treatment osseointegrated implants were placed to restore the dental arches.

Erste Ergebnisse der peripheren Neuromodulation nach Stoller (SANS) bei Blasenfunktionsst�rungen

PURPOSE

The Stoller peripheral neurostimulation (SANS) is a new therapeutic procedure for bladder dysfunction.

MATERIAL AND METHODS

Each of 11 patients (8 women, 3 men) underwent 12 SANS treatment sessions.

INDICATIONS

overactive bladder (5 patients), chronic nonobstructive urinary retention (3 patients) and pelvic pain (3 patients). Median follow-up was 3 months.

RESULTS

In 2 overactive bladder patients, the number of voids was reduced by at least 50%. In one patient with chronic retention, residual urine was temporarily decreased to <100 cc. 2 pelvic pain patients reported a slight improvement. In summary, 50% of the patients demonstrated a temporary response. Only 2 overactive bladder patients reported a permanent objective and subjective improvement. No complications were observed.

CONCLUSION

As the success rate was low and the procedure is time-consuming, we recommend the SANS procedure only in selected cases. We perform SANS treatment only in patients with overactive bladder refractory to conservative treatment. Prerequisites for a successful treatment is a high patient motivation.

Conditional stimulation of the dorsal penile/clitoral nerve may increase cystometric capacity in patients with spinal cord injury

AIMS

To investigate the feasibility of conditional short duration electrical stimulation of the penile/clitoral nerve as treatment for detrusor hyperreflexia, the present study was initiated.

METHODS

Ten patients with spinal cord injury, 4 women and 6 men, with lesions at different levels above the sacral micturition center had a standard cystometry performed. During a subsequent cystometry, conditional short duration electrical stimulation of the penile/clitoral nerve was performed as treatment for one or more detrusor hyperreflexic contractions.

RESULTS

In all patients, at least one contraction (mean, 7.8; range, 1-16 contractions) was inhibited by the stimulations. The mean cystometric capacity was increased significantly by conditional electrical stimulation, from 210 mL in the control cystometries to 349 mL in the stimulation cystometries (P=0.016). The maximal detrusor pressure during the first contraction in the control cystometries was mean 51 cm H(2)O, whereas the maximal pressure of the first contraction in the stimulation cystometries was reduced to mean 33 cm H(2)O (P=0.045).

CONCLUSIONS

The authors conclude that repeated conditional short duration electrical stimulation significantly increased cystometric capacity in patients with spinal cord injury. The increase was caused mainly by an inhibition of detrusor contractions. The need for a reliable technique for chronic bladder activity monitoring is emphasized, as it is a prerequisite for clinical application of this treatment modality.

The use of casts in the management of joint mobility and hypertonia following brain injury in adults: a systematic review

Many controversies exist regarding the practicality, the theoretical premises, and the supporting evidence for the use of casts in the management of joint hypomobility and hypertonia (ie, increase in joint resistance to passive movement resulting from hyperactivity of the stretch reflex and/or changes in the muscles and connective tissues). The purpose of this review was to determine current best practice for the use of casting in the rehabilitation of adults with brain injury. A systematic review was undertaken to find studies that quantified the effectiveness of casting in adults with brain injury. Thirteen articles that presented experimental or case report evidence on casting were analyzed using Sackett's levels of evidence and were examined for scientific rigor. A grade B recommendation is given for the use of casting to increase passive range of motion or to prevent its loss, and implications for further research are provided.

[Overactive bladder--which diagnosis investigations are necessary before initiating primary treatment?]

The symptom complex of frequency and urgency with or without urge incontinence is termed overactive bladder (OAB) according to the new definition by the International Continence Society. The background for this change in definition is the great economic and social importance of the disease, the rising costs in medicine, and the tendency to develop the simplest possible therapeutic strategies. Therapy consists of the administration of an anticholinergic/spasmolytic drug for at least 3 months. Although a great percentage of patients with OAB can be clinically identified, the required exclusion of "local pathologic and metabolic factors" calls for a minimal diagnostic program to come to fairly exact findings. This includes a detailed case history with standardized and evaluated questionnaires, a bladder diary, detailed clinical examination, urine analysis consisting of microscopic and microbiologic examination, uroflowmetry including measurement of residual urine, and examination of the kidneys and the upper urinary tract (determination of creatine and sonography). Minimally invasive tests to improve validity regarding obstruction and detrusor overactivity are being developed. These tests are intended to make an invasive pressure-flow study unnecessary. However, using the above-described minimal diagnostic program, one has to take into account that patients suffering from complaints without underlying idiopathic detrusor overactivity and with urgency/urge incontinence due to bladder outlet obstruction are referred for primary therapy with anticholinergic/antispastic drugs. In cases of neurologic signs, pathologic urinary findings, reduced urinary flow rate with residual urine, and problems of the upper urinary tract, further diagnostic studies are necessary. In any case, such patients need not undergo primary therapy on the basis of a clinical diagnosis. An ex iuvantibus therapy with anticholinergic drugs--even if limited to 3 months--is not acceptable if the diagnostic minimal program is not used.

[When is a urodynamic investigation indicated for overactive bladder?]

Overactive bladder (OAB) is generally not disease specific. Symptoms are frequency, nocturia, and urgency with or without urge incontinence. The prevalence of 16.6%, evaluated in six European countries, is surprisingly high. Causes for overactive bladder are an increase of sensory stimulation and/or a decrease of sensory threshold of the bladder or a disproportion between strength of afferent stimulation and central inhibition of micturition reflex resulting in detrusor overactivity. Overactive bladder is a symptom-based diagnosis. Urodynamics is an important diagnostic tool in daily routine. Urodynamics encompasses a spectrum of different techniques and is more than just cystometry. Simple cystometry or video cystometry should be carried out after evaluation with a frequency volume chart, flow rates, and residuals, mostly by ultrasound. Urodynamic observations should never be discussed separately but always together with history, symptoms, signs, and pathological findings. It is not necessary to perform a filling and voiding cystometry in each patient with symptoms and signs of overactive bladder. Indications for cystometry are prior to invasive therapy or where previous medical or surgical therapy has failed, after pelvic surgery or pelvic irradiation, in patients with signs or symptoms suggestive of an emptying disorder, in neurological disorders, or where there is any doubt about the diagnosis. Diagnostic evaluation of geriatric patients with overactive bladder can usually be accomplished with a basic assessment while invasive procedures should be the exception.

[Continuous bilateral sacral neuromodulation as a minimally invasive implantation technique in patients with functional bladder changes]

OBJECTIVE

Up to 50% of patients with bladder dysfunctions undergoing sacral neuromodulation treatment are non-responders. The most common treatment method today is the implantable neuromodulation system described by Tanagho and Schmidt; which allows unilateral sacral nerve stimulation. Our aim was to increase the number of responders and to improve the general efficiency of chronic sacral neuromodulation; therefore we have developed the bilateral electrode implantation by minimally invasive laminectomy.

METHODS

PNE-tests were carried out to assess which patients were likely to be good responders. Thirty patients (16 with detrusor instability, 14 with hypocontractile detrusors) were subjected to minimally invasive laminectomy and received implants of bilateral electrodes.

RESULTS

In those patients with a hyopcontractile detrusor, the level of residual urine of initially 350 ml was reduced to 58 ml, and the maximum detrusor pressure during micturition increased from initially 12 cMH2O to 34 cmH2O. In the other patient group with detrusor instability, the average number of incontinence incidences could be reduced from initially 7.2 to 1 per day, while the bladder capacity rose from 198 ml to 348 ml. The modulation effect did not show any signs of deteriorating in any of the patients. The follow-up period was 28 months on average.

CONCLUSIONS

Clinical experience has shown that optimal neuromodulation in patients with bladder dysfunction can be achieved by this new approach involving bilateral electrode implantation. Moreover, the laminectomy implantation method guarantees a minimum of invasive trauma and enables optimal placement and fixation of the electrode.

[Conservative and surgical therapy of urinary incontinence and bladder complaints in the man]

Treatment of incontinence and bladder complaints in the male should be directed to the cause whenever possible. Frequently, however, only symptomatic therapy is possible. Urge incontinence or overactive bladder due to obstruction should primarily be treated by eliminating the obstruction. Medical and surgical treatment methods are available for benign prostatic hyperplasia, bladder neck hypertrophy and prostatic cancer. In contrast, bladder neck sclerosis and uretheral strictures can only be treated surgically. Anticholinergics are primarily indicated if urge symptoms/incontinence persist after obstruction has been relieved or if urge incontinence occurs without obstruction. Seldom, in special cases injection of Botulinustoxin A or augmentation of the bladder may be indicated. Another possible cause of urge symptoms is urinary tract infection. This should be adequately treated according to resistance studies and the cause of the infection determined. In cases of overflow incontinence the infravesicle obstruction must be sought and treated. If limited detrusor contractability is the cause of overflow incontinence and the bladder cannot be emptied through pressmicturition, parasympathicometics may be of help. By insufficient effect, the procedure of intermittent self-catheterization must be taught. If this is not possible, the last resort is placement of a transuretheral or percutaneous catheter for continuous drainage. Stress incontinence is a rare complication in men, usually following prostatic surgery. It can be treated conservatively with pelvic floor training and alpha-adrenergic receptor agonists and if necessary surgically with submucosal collagen or silicon injections in the sphincter area or implantation of a sphincter prosthesis. Supravesicular urinary diversion is occasionally necessary after conservative and less invasive surgical measures have been exhausted and symptomatic suffering persists. Neurogenic disturbances in bladder capacity and/or emptying can be treated conservatively, medically, surgically or a combination of these depending upon the site of the lesion and the resulting urodynamic patterns.

Effects of subthalamic nucleus stimulation on urodynamic findings in patients with Parkinson's disease

PURPOSE

Although the effects of subthalamic nucleus stimulation on the control of motor symptoms in patients with Parkinson's disease have been demonstrated, to our knowledge there are no data on effects of this treatment on voiding. We evaluated differences in urodynamic findings in patients with Parkinson's disease during on and off subthalamic nucleus stimulation status.

MATERIALS AND METHODS

We evaluated 3 males and 2 females with Parkinson's disease. All patients had undergone surgical bilateral implantation of subthalamic nucleus electrodes 4 to 9 months before our observation. Urodynamic evaluation was performed during chronic subthalamic nucleus stimulation and 30 minutes after turning off the stimulators. Certain parameters were evaluated, including bladder compliance and capacity, first desire to void volume, bladder volume of appearance (reflex volume) and amplitude of detrusor hyperreflexic contractions, maximum flow, detrusor pressure at maximum flow and detrusor-sphincter coordination. Results were compared statistically.

RESULTS

Statistically significant differences in urodynamic data obtained during on and off subthalamic nucleus stimulation status were noted. In particular bladder capacity and reflex volume were increased for on status (median 320 versus 130 ml., p = 0.043 and 250 versus 110, p = 0.043, respectively). The amplitude of detrusor hyperreflexic contractions was decreased for on status but the difference was not significant (median 23 versus 37 cm. H2O, p = 0.223). No differences were noted in the other urodynamic parameters considered during the filling and voiding phases.

CONCLUSIONS

Our experience shows that subthalamic nucleus stimulation seems to be effective for decreasing detrusor hyperreflexia in Parkinson's disease cases. This finding confirms a role for basal ganglia in voiding control.

Clinical efficacy of tolterodine with or without a simplified pelvic floor exercise regimen

OBJECTIVES

To investigate whether the combination of tolterodine plus (Tp) a simple pelvic floor muscle exercise (PFME) program would provide improved treatment benefits compared with tolterodine alone (Ta) in patients with symptoms of overactive bladder (OAB).

METHODS

After a 1-2 week run-in period, 480 patients with symptoms of urinary frequency (> or =8 micturitions/24 hr), urgency, and urge incontinence (> or =1 episode/24 hr), were randomized to receive tolterodine 2 mg bid with or without a simple PFME program for 24 weeks in this multinational study. Treatment efficacy was assessed by comparing the change from baseline in 3-day micturition diary recordings.

RESULTS

After 24 weeks' treatment, in the Ta group the urgency episodes reduced from mean of 4.1 to 1.5 (83% reduction) while in the Tp group the urgency episodes reduced from 4.2 to 2.1 (78.7% reduction). Mean incontinence episodes per day decreased from 3.21 (standard deviation (SD) 3.4) to 0.95 (SD 1.9) in Ta group and from 3.44 (SD 3.4) to 1.25 (SD 2.7) in the Tp group. Similarly, the number of micturition/24 hr were significantly reduced, from 12.78 to 9.20 (27.3% reduction) in the Ta group and from 11.87 to 9.29 (23% reduction) in the Tp group. There was an improvement in the patients' perception of urinary symptoms in 85.9% of patients on Ta and 81.7% patients on Tp PFME. There were no statistically significant differences between the groups with regard to any of the outcome parameters.

CONCLUSIONS

Tolterodine therapy for 24 weeks results in significant improvement in urgency, frequency, and incontinence, however, no additional benefit was demonstrated for a simple PFME program.

[Intercavitary electrical stimulation of the gastrointestinal tract and mucosa with a stand-alone electric stimulator in the treatment of patients in the physicochemical stage of gallbladder disease]

The use of the SAE for the GIT and MC has a stimulating effect on the processes of bile production and secretion for patients with the physical and chemical stage of the gallstone disease. Over a short period of time the SAE for the GIT and MC normalizes the biliary tract motor functions removing the dissynergism of the biliary tract sphincter organ and restoring the sphincter motor functions. The SAE for the GIT and MC has a positive effect on major factors of bile concentration and components ratio aimed at the reduction of lithogenicity and its colloid stability improvement. The intracavitary electrical stimulation with the SAE for the GIT and MC both as a monotherapy and one of the complex anti-relapse methods is an efficient and simple method and has no side effects or complications. Therefore, it may be recommended for the treatment of patients with the physical and chemical stage of the gallstone disease.

Biofeedback therapy expedites the resolution of reflux in older children

PURPOSE

In older children the spontaneous resolution rate of low grade vesicoureteral reflux is low and currently its management is controversial in regard to surgery versus prophylaxis versus observation alone. Bladder dysfunction in children with neurogenic bladders and to a less declarative degree in neurologically intact children has a role in the etiology or persistence of reflux. We determine the impact of biofeedback therapy on neurologically intact children with vesicoureteral reflux and detrusor-sphincter dyssynergia.

MATERIALS AND METHODS

Vesicoureteral reflux was detected by voiding cystourethrography in children evaluated for urinary tract infections. Children with breakthrough infections or dysfunctional voiding based on history underwent uroflowmetry with concomitant patch electromyography of the external sphincter. Dyssynergia was defined as increased or steady electromyography activity during micturition. Biofeedback was initially performed weekly and the interval increased as indicated. The goals were to eliminate dyssynergia and reduce or eliminate post-void residual urine. Voiding cystourethrography was performed 1 year later to determine the status of the reflux. Ureteral reimplantation was performed during the period of biofeedback when indicated.

RESULTS

From February 1997 to March 2001, 25 children 6 to 10 years old (mean age 9) with vesicoureteral reflux and detrusor-sphincter dyssynergia were treated with biofeedback therapy. There were 31 units (5 bilateral) with reflux, which was grade I in 10, II in 15, III in 5 and IV in 1. Children underwent an average of 7 sessions of biofeedback (range 2 to 20). On followup voiding cystourethrography, vesicoureteral reflux resolved in 17 units (55%), grade improved in 5 (16%) and reflux remained unchanged in 9 (29%). All cured vesicoureteral reflux was grade I (8 cases) or II (9). Four children (5 renal units) underwent reimplantation. In cured children there were no breakthrough infections during or since therapy and post-void residual urine decreased from an average of 40% before to 10% after therapy. Symptoms of urgency, daytime wetting and hoarding of urine improved or were eliminated in all children with resolved vesicoureteral reflux.

CONCLUSIONS

Treating external detrusor-sphincter dyssynergia in older children with low grade vesicoureteral reflux, with biofeedback results in 1-year resolution rates that are considerably greater than historical resolution rates. External detrusor-sphincter dyssynergia should be screened for in children when surgery or discontinuation of chemoprophylaxis is considered so that biofeedback can be started.

Treatment of detrusor-sphincter dyssynergia by pudendal nerve block in patients with spinal cord injury

OBJECTIVE

To study the effects of pudendal nerve block with phenol on detrusor-sphincter dyssynergia in patients with spinal cord injury (SCI).

DESIGN

Before-after trial performed by using a consecutive sample.

SETTING

Rehabilitation hospital affiliated with a medical school.

PATIENTS

Twenty-two male SCI patients (mean age, 46.3+/-11.9y; mean duration postinjury, 2.7y) with voiding dysfunction resulting from external urethral sphincter hypertonicity.

INTERVENTION

Pudendal nerve block with 5% phenol solution under the guidance of electric stimulator.

MAIN OUTCOME MEASURES

Outcomes were measured using (1) postvoid residual volume, maximal detrusor pressure, leak point pressure, bladder volume at the first uninhibited contraction, maximal bladder capacity, and urethral pressure profile; (2) rectoanal rest and squeeze pressures; and (3) quality of life measures for urination, quantified by the Quality of Life Index (QLI). Changes in bowel habit or autonomic dysreflexia were recorded.

RESULTS

The mean decrease in postvoid residual volume was 242.8mL (mean decrease, 66%) after treatment (P<.001). The mean reduction in leak point pressure and maximal detrusor pressure were 37.1cmH(2)O and 43.3cmH(2)O, respectively (P<.05). The mean QLI significantly improved from -.74+/-.38 to.42+/-.47 (P<.001). The rectoanal pressures showed no significant difference. No complaints of fecal incontinence or other complications were noted after treatment.

CONCLUSION

Pudendal nerve block performed by using 5% phenol solution was safe, easy to perform, and effective as a treatment for detrusor-sphincter dyssynergia in selected patients with SCI.

Bladder injection of "naked" hSlo/pcDNA3 ameliorates detrusor hyperactivity in obstructed rats in vivo

The goal of these studies was to examine the potential utility of bladder instilled K+ channel gene therapy with hSlo cDNA (i.e., the maxi-K channel) to ameliorate bladder overactivity in a rat model of partial urinary outlet obstruction. Twenty-two female Sprague-Dawley rats were subjected to partial urethral (i.e., outlet) obstruction, with 17 sham-operated control rats run in parallel. After 6 wk of obstruction, suprapubic catheters were surgically placed in the dome of the bladder in all rats. Twelve obstructed rats received bladder instillation of 100 microg of hSlo/pcDNA in 1 ml PBS during catheterization, and another 10 obstructed rats received 1 ml PBS (7 rats) or 1 ml PBS containing pcDNA only (3 rats). Two days after surgery cystometry was performed on all animals to examine the characteristics of the micturition reflex in conscious and unrestrained rats. Obstruction was associated with a three- to fourfold increase in bladder weight and alterations in virtually every micturition parameter estimate. PBS-injected obstructed rats routinely displayed spontaneous bladder contractions between micturitions. In contrast, hSlo injection eliminated the obstruction-associated bladder hyperactivity, without detectably affecting any other cystometric parameter. Presumably, expression of hSlo in rat bladder functionally antagonizes the increased contractility normally observed in obstructed animals and thereby ameliorates bladder overactivity. These initial observations indicate a potential utility of gene therapy for urinary incontinence.

Managing incontinence due to detrusor instability

Urinary incontinence affects around 3.5 million people of all ages in the UK. For many, incontinence severely restricts their routine activities and damages their quality of life and self-esteem. In about one-third of women sufferers, and around a half of all men with incontinence, the cause is detrusor instability. This condition is characterised by involuntary bladder contractions or pressure rises during bladder filling, which result in a strong or uncontrollable urge to pass urine and, often, incontinence. Here, we consider a primary care-based approach to managing urinary incontinence in adults, concentrating on the medical management of detrusor instability.

[Treatment of dyskinetic disorders with tremor by lesioning and DBS of Vim]

OBJECTIVE

To explore the effect of stereotactic operation in treatment of dyskinetic disorders with tremor as the main symptom and to study the value of anatomic location and microelectrode functional location.

METHODS

Surgiplan system and microelectrode direction technique were used to locate the Vim, and then target lesioning and deep brain simulation (DBS) were performed in 22 patients with dyskinetic disorders with tremor. After the operation, a follow-up was conducted for 6 approximately 12 months.

RESULTS

After the operation, tremor disappeared in 21 patients and hypermyotonia was improved in 13 cases. During the follow-up tremor completely disappeared in 18 patients, including 3 cases treated with DBS, was markedly alleviated in 3 cases and was slightly improved in one case. Typical cell firing at tremor was recorded in 17 cases during the operation.

CONCLUSION

The surgiplan system and microelectrode recording technique play an important role in location of Vim. Accurate location is crucial for success of operation. The curative effect of DBS is similar as lesioning operation.

A crossover randomized trial of transcutaneous electrical nerve stimulation and oxybutynin in patients with detrusor instability

PURPOSE

Management of idiopathic detrusor instability is difficult in most patients mainly due to the lack of a complete understanding of the pathophysiology. Oxybutynin and transcutaneous electrical nerve stimulation have been used but to our knowledge no direct comparisons have been made.

MATERIALS AND METHODS

Patients with frequency, urgency, urge incontinence and proved detrusor instability were studied with urodynamics, quality of life instruments, and frequency and volume charts. Patients were randomized to transcutaneous electrical nerve stimulation or oxybutynin. After 6 weeks of treatment, they were reassessed and after a washout of 2 weeks, they were started on the second arm of treatment and reassessed 6 weeks later.

RESULTS

A total of 13 male and 30 female patients were studied. Functional capacity had increased and number of voids daily had decreased significantly compared with before treatment in both arms (p <0.005). There were significant improvements in symptom specific quality of life measures but no changes were found on the global Short Form 36 (SF-36) quality of life questionnaire. The volume to first desire to void and first unstable contraction had increased significantly with oxybutynin but not with transcutaneous electrical nerve stimulation. Of 23 patients 7 were stabilized with treatment, including 2 with oxybutynin only, 2 with either nerve stimulation or oxybutynin and the remaining 3 with only nerve stimulation. Total bladder capacity did not change significantly with either treatment but patients noticed side effects more commonly with oxybutynin.

CONCLUSIONS

Both treatments clearly improved subjective parameters. However, only oxybutynin showed significant improvements in objective urodynamic parameters. Transcutaneous electrical nerve stimulation can be used in patients who cannot take oxybutynin. Further studies are needed to show the long-term efficacy and cost analyses of nerve stimulation.