Lower urinary tract dysfunction in patients with brain lesions

Relevance of Leg Rehabilitation to Modulating Neurogenic Lower Urinary Tract Symptoms: A Systematic Review

Neurogenic lower urinary tract dysfunction (NLUTD) is a secondary complication of a wide range of neurological disorders, which affects patients' everyday life and self-efficacy. Some brain imaging studies have shown an overlap between motor activation of the pelvic floor and lower limbs. This systematic review sought to examine the possibility of improving overactive bladder outcomes through a conservative approach based on lower limb training. We conducted a systematic literature review, following the PRISMA guidelines. The following databases were searched: PEDro, PubMed, TRIP, Cochrane Library, EDS base index, Google Scholar, and CINAHL. The PEDro Scale and Cochrane Risk of Bias Assessment Tool were used to assess the overall study quality and sources of bias. A total of 5567 records were retrieved through the systematic search, of which 104 were sought for retrieval; two cohort studies and one randomized controlled trial were finally included. Urodynamics and specific bladder functionality questionnaires showed preliminary evidence of improvement following lower limb stimulation, implemented according to different treatment types (exoskeleton training and weight-suspension walking training). Lower limb-focused exercises showed promising results for improving bladder function, despite the small number of studies and small sample sizes. Future research should confirm this hypothesis using larger samples.

Safety and Efficacy of Trospium Chloride and Solifenacin in Stroke-Induced Neurogenic Lower Urinary Tract Dysfunction: A Randomized Controlled Trial

BACKGROUND

Neurogenic dysfunction of the lower urinary tract is one of the challenging diseases with high burdens in urology. Our study aims to evaluate the efficacy of a 4-week treatment with Solifenacin and Trospium chloride and assess their safety and impact on quality of life.

METHODS

Following the selection of 206 stroke patients from two centers who met specific eligibility criteria, including a clinical diagnosis of stroke, normal cognitive function, and the presence of lower urinary tract symptoms (LUTS), participants were randomly assigned to receive oral Solifenacin, Trospium chloride, or a placebo. Under the supervision of the Ethics Committee, the baseline characteristics, compliance with medication, and outcomes were monitored, gathered, and analyzed.

RESULTS

The majority of participants were male, with a mean age of 67.3, and most had ischemic stroke. The groups had no significant difference in urinary symptoms after stroke. All of the symptoms in the study groups, according to the NBSS questionnaire, were decreased following treatment compared to the baseline (p < 0.05). After treatment, ICIQ-OAB, and ICIQ-LUTS-QOL total scores and bothersome scores decreased significantly compared to baseline (p < 0.001). When compared to the placebo, both Trospium chloride and Solifenacin alleviated symptoms according to the NBSS questionnaire and ICIQ-LUTS-QOL, total ICIQ-OAB, and the total score of ICIQ-OAB-Bothersome. However, the total LUTS-QOL-Bothersome score did not change in the active treatment groups compared to the placebo. While comparing the two drugs, these values were similar except for the total score of LUTS-QOL-Bothersome, ICIQ-OAB, and ICIQ-OAB-Bothersome in favor of the Solifenacin group. Moreover, Solifenacin had fewer side effects compared to Trospium chloride or placebo.

CONCLUSION

The study analyzed 206 stroke patients in two international centers and found both drug arms effective in treating overactive bladder. However, inconsistencies were found in efficacy and safety, necessitating further studies with larger populations.

TRIAL REGISTRATION

This triple-blind, multicenter, randomized controlled trial was done on 206 stroke patients after getting Ethical Committee approval and registering the project on IRCT (IRCT20160606028304N2).

Electroacupuncture for urinary retention after stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

Electroacupuncture (EA) is one of the non-pharmacological therapies in traditional Chinese medicine to treat urinary retention. The objective of this meta-analysis is to assess the efficacy of electroacupuncture in the treatment of urinary retention after stroke.

METHODS

Overall, seven electronic databases were searched until December 31, 2023, and randomized control trials about EA for urinary retention after stroke were reviewed. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias for included studies. The meta-analysis was conducted by RevMan 5.4 and Stata/MP 17.0 software.

RESULTS

Eleven studies with a total of 856 participants were included in this meta-analysis. EA treatment yielded an improved reduction in the post-void residual (PVR) (mean difference [MD]: 37.85, 95 % confidence interval [CI]: 55.09 to -20.61 p < 0.0001) and the weight of diaper pads (MD: 38.87, 95 % CI: 42.68 to -335.06). Further analysis indicated that EA improved the effectiveness ratio (risk ratio [RR]: 1.36, 95 % CI: 1.20 to 1.53, p < 0.00001), the function of the bladder (MD: 0.45, 95 % CI: 0.61 to -0.30), and the quality of life (MD: 1.15, 95 %: CI: 2.10 to -0.20) in comparison to normal treatment and simple acupuncture.

CONCLUSION

EA may be an effective way and reasonable modality to incorporate into the multiple prevention and therapy for urinary retention after stroke. The wide application of EA could be associated with the improvement of bladder and life quality and decline in the PVR for patients after stroke with urinary retention.

Lower urinary tract dysfunction in the central nervous system neurogenic bladder and the real-life treatment outcome of botulinum toxin A

Neurogenic lower urinary tract dysfunction (NLUTD) is common in patients with central nervous system (CNS) lesions. Cases of cerebrovascular accidents (CVA), Parkinson's disease, dementia, and other intracranial lesions develop poor bladder control with or without urinary difficulty due to loss of cortical perception of bladder filling sensation and poor coordination of urethral sphincter relaxation during reflex micturition. Patients with CNS lesions usually have overactive bladder (OAB) symptoms, including urgency, frequency, incontinence, voiding symptoms of dysuria, large postvoid residual volume, and retention. In elderly patients with severe CNS disease the OAB symptoms are usually difficult to adequately relieve by medical treatment, and thus, their quality of life is greatly. Botulinum toxin A (BoNT-A) is currently licensed and has been applied in patients with idiopathic and neurogenic OAB due to spinal cord injury or multiple sclerosis. However, the application of BoNT-A in the treatment of urinary incontinence due to NLUTD in chronic CNS lesions has not been well-documented. Although cohort studies and case series support BoNT-A treatment for neurogenic OAB, chronic urine retention after intravesical BoNT-A injection for OAB and exacerbated urinary incontinence after urethral BoNT-A injection for voiding dysfunction have greatly limited its application among patients with NLUTD due to CNS lesions. This article reviews the pathophysiology and clinical characteristics of NLUTD in patients with CNS lesions and the clinical effects and adverse events of BoNT-A injection for patients with NLUTD. A flowchart was created to outline the patient selection and treatment strategy for neurogenic OAB.

Noradrenergic Pathways Involved in Micturition in an Animal Model of Hydrocephalus-Implications for Urinary Dysfunction

Hydrocephalus is characterized by enlargement of the cerebral ventricles, accompanied by distortion of the periventricular tissue. Patients with hydrocephalus usually experience urinary impairments. Although the underlying etiology is not fully described, the effects of hydrocephalus in the neuronal network responsible for the control of urination, which involves periventricular areas, including the periaqueductal gray (PAG) and the noradrenergic locus coeruleus (LC). In this study, we aimed to investigate the mechanisms behind urinary dysfunction in rats with kaolin-induced hydrocephalus. For that purpose, we used a validated model of hydrocephalus-the rat injected with kaolin in the cisterna magna-also presents urinary impairments in order to investigate the putative involvement of noradrenergic control from the brain to the spinal cord Onuf's nucleus, a key area in the motor control of micturition. We first evaluated bladder contraction capacity using cystometry. Since our previous characterization of the LC in hydrocephalic animals showed increased levels of noradrenaline, we then evaluated the noradrenergic innervation of the spinal cord's Onuf's nucleus by measuring levels of dopamine β-hydroxylase (DBH). We also evaluated the expression of the c-Fos protooncogene, the most widely used marker of neuronal activation, in the ventrolateral PAG (vlPAG), an area that plays a major role in the control of urination by its indirect control of the LC via pontine micturition center. Hydrocephalic rats showed an increased frequency of bladder contractions and lower minimum pressure. These animals also presented increased DBH levels at the Onuf´s nucleus, along with decreased c-Fos expression in the vlPAG. The present findings suggest that impairments in urinary function during hydrocephalus may be due to alterations in descending noradrenergic modulation. We propose that the effects of hydrocephalus in the decrease of vlPAG neuronal activation lead to a decrease in the control over the LC. The increased availability of noradrenaline production at the LC probably causes an exaggerated micturition reflex due to the increased innervation of the Onuf´s nucleus, accounting for the urinary impairments detected in hydrocephalic animals. The results of the study provide new insights into the neuronal underlying mechanisms of urinary dysfunction in hydrocephalus. Further research is needed to fully evaluate the translational perspectives of the current findings.

Identification of brain functional connectivity during acute transcutaneous tibial nerve stimulation: A 3T fMRI study

OBJECTIVES

A feasibility proof-of-concept study was conducted to assess the effects of acute tibial nerve stimulation (TNS) on the central nervous system in healthy volunteers using functional magnetic resonance imaging (fMRI).

MATERIALS AND METHODS

Fourteen healthy volunteers were included in a prospective, single-site study conducted on a clinical 3T MRI scanner. Four scans of functional MRI, each lasting 6 min, were acquired: two resting-state fMRI scans (prior and following the TNS intervention) and in-between two fMRI scans, both consisting of alternating rest periods and noninvasive acute transcutaneous TNS (TTNS). Whole brain seed-based functional connectivity (FC) correlation analysis was performed comparing TTNS stimulation with rest periods. Cluster-level familywise error (FWE) corrected p and a minimal cluster size of 200 voxels were used to explore FC patterns.

RESULTS

Increased FC is reported between inferior frontal gyrus, posterior cingulate gyrus, and middle temporal gyrus with the precuneus as central receiving node. In addition, decreased FC in the cerebellum, hippocampus, and parahippocampal areas was observed.

CONCLUSIONS

Altered FC is reported in areas which have been described to be also involved in lower urinary tract control. Although conducted with healthy controls, the assumption that the underlying therapeutic effect of TNS involves the central nervous system is supported and has to be further examined in patients with incomplete spinal cord injury.

Clinical practice guidelines for the management of adult patients with neurogenic lower urinary tract dysfunction: a systematic review protocol

INTRODUCTION

Neurogenic lower urinary tract dysfunction (NLUTD) both threatens the health of affected patients long-term and also has a significantly negative impact on the patients' quality of life. present, many clinical practice guidelines (CPGs) have been developed for NLUTD patients, but these CPGs may confuse healthcare professionals and patients due to their great difference in terms of scope, quality and content. This review aims to identify the CPGs for NLUTD patients published from 2012 to 2022, assess their quality and then analyse them in an integrated manner.

METHODS AND ANALYSIS

We will systematically search electronic healthcare databases (English databases including PubMed, EMBASE, OVID, Scopus, Web of Science, Cochrane Library, CINAHL, UpToDate, and Best Practice and Chinese databases including China National Knowledge Infrastructure, Wanfang Database, VIP Periodical Resource Integration Service Platform and SinoMed), online CPG repositories and relevant professional association websites to identify eligible CPGs. The CPGs published in English and Chinese with full texts available within the period from January 2012 to March 2022 will be included in this study. The Appraisal of Guidelines for Research and Evaluation (AGREE) II will be used to assess the quality of included CPGs. According to the predesigned data table, the general characteristics of these CPGs, proposed recommendations and their quality of evidence, strength of recommendation and other information will be extracted. Qualitative thematic analysis will be applied to the extracted recommendations. A summary of the proposed recommendations, their quality of evidence, strength of recommendation and other information will eventually be described in a table. This review is expected to identify knowledge gaps in current CPGs and to identify the areas of the proposed recommendations derived from low-level evidence. ETHICS AND DISSEMINATION : This systematic review does not involve the participation of any subjects, and therefore no ethical approval is required. The findings of this review will be published in a peer-reviewed journal and disseminated via conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022318180.

Surgical outcome of male patients with chronic central nervous system disorders and voiding dysfunction due to bladder outlet obstruction

PURPOSE

Voiding dysfunction is common in patients with chronic central nervous system (CNS) diseases and has great impact on quality of life. Patients with chronic CNS disorders might have concomitant detrusor overactivity, detrusor underactivity, and voiding dysfunction. Although bladder outlet surgeries could relieve bladder outlet obstruction (BOO), patients might have persistent or exacerbated storage symptoms. This study investigated surgical outcome of patients with chronic CNS disorders after bladder outlet surgery.

METHODS

A total of 63 male patients with cerebrovascular accident (CVA, n = 44), Parkinson's disease (PD, n = 11), and early-stage dementia (n = 8), had received bladder outlet surgery after videourodynamic proven BOO refractory to medical treatment. The preoperative and postoperative lower urinary tract symptoms (LUTS) and uroflowmetry parameters were assessed. If the storage symptom subscore decreased or increased by 1, the outcome was considered improved or exacerbated after treatment. When patients had improvement in maximum flow rate (Qmax) and voiding efficiency (VE) and decreased voiding symptom subscore, they were considered having improvement of voiding dysfunction.

RESULTS

The mean age was 71.1 ± 9.8 years and mean duration from diagnosis of BOO to surgical intervention was 15.1 ± 25.0 months. Overall, there was significant improvement in voiding LUTS and urinary retention after surgery. The post-void residual volume (PVR), corrected Qmax (cQmax), and VE significantly improved after surgery. In subgroup analysis, although voiding symptoms improved in CVA patients, urgency and exacerbated urgency incontinence persisted after surgery. In PD patients, there was improvement in voiding condition such as PVR, cQmax and VE, but the storage symptoms did not change after surgery. Patients with dementia had no improvement both in storage and voiding symptoms.

CONCLUSIONS

Bladder outlet surgeries are effective to relieve voiding dysfunction in patients with CVA and PD, but have little effect on storage LUTS in patients with chronic brain lesions.

Case Report: Ventriculoperitoneal Shunting and Radiation Therapy Treatment in a Cat With a Suspected Choroid Plexus Tumor and Hypertensive Hydrocephalus

A 14-year-old male neutered domestic short-hair cat was presented for a history of behavioral changes and episodes of urinary retention. Neurological examination was consistent with a multifocal intracranial neuroanatomical localization, with suspected right sided lateralisation and suspected raised intracranial pressure (ICP). Brain magnetic resonance imaging (MRI) revealed an intraventricular multilobulated well-defined T2W-hyperintense and T1W-isointense, markedly contrast enhancing mass lesion within the dorsal aspect of the III ventricle extending into the left lateral ventricle, causing hypertensive obstructive hydrocephalus. A ventriculoperitoneal shunt (VPS) was placed within the left lateral ventricle, followed by a radiation therapy (RT) course of 45 Gy total dose in 18 daily fractions. Six-months post-RT, computed tomography revealed mild reduction in mass size and resolution of the hydrocephalus. The patient was neurologically normal with no medical treatment. Raised ICP causes severe clinical signs, can lead to brain ischaemia and herniation, and significantly increases anesthetic risk during RT. Placement of a VPS in cats with hypertensive obstructive hydrocephalus may allow improvement of neurological signs due to raised ICP, and therefore making the patient a more stable candidate for anesthesia and radiation therapy.

Serial transurethral cystometry: A novel method for longitudinal evaluation of reflex lower urinary tract function in adult female rats

AIMS

The aim of the study is to develop a minimally invasive method for longitudinal evaluation of lower urinary tract function that allows for simultaneous measurements of bladder pressure and external urethral sphincter (EUS) electromyographic (EMG) activity.

METHODS

To evaluate the reliability of serial transurethral cystometry (STUC), rats (n = 12) underwent three sessions of STUC, one session a week for 3 weeks. During each session, rats were anesthetized with ketamine-xylazine (90 mg/kg and 10 mg/kg), and micturition reflex data were acquired using transurethral cystometry and percutaneous recording of EUS (EMG) activity during continuous infusion of saline into the bladder. The reliability and consistency of the STUC method were assessed using intra-class correlation (ICC) analysis and repeated measures ANOVA.

RESULTS

ICC values calculated from five successive events during the first micturition session indicate good to excellent reliability for measurements of peak bladder pressure, threshold bladder pressure, minimum bladder pressure, volume threshold, duration of EUS bursting, and number of EUS burst events. Across the three recording sessions no significant difference was observed in peak bladder pressure, threshold bladder pressure, minimum bladder pressure, volume threshold, number of EUS burst events, and duration of EUS bursting using repeated measures ANOVA.

CONCLUSION

Serial transurethral cystometry under ketamine-xylazine anesthesia with simultaneous percutaneous EUS EMG recording is a novel, reliable, accurate, and minimally invasive method for quantitative assessment of lower urinary tract (LUT) function in adult female rats over extended periods of time.

Voiding and storage symptoms in depression/anxiety

We here described the frequency and nature of voiding and storage bladder symptoms in depression/anxiety, for which we propose the name "bladder somatic symptom disorder (SSD)" because such symptoms most probably have brain mechanisms. SSD was formerly called as various terms including "somatoform disorder", "medically unexplained physical symptoms", "functional somatic syndrome" and "hysterical neurosis/hysteria". Bladder SSD has the following specific features that are distinguishable from "true" neurologic/organic bladder dysfunction: 1) situation-dependence (close association with life event in some), 2) urodynamically increased bladder sensation/hypersensitivity and 3) absence of neurologic/organic diseases, in addition to 4) other stress symptoms (insomnia, etc.), are key clues to the possibility of bladder SSD. Urodynamics in these patients showed, to a lesser extent, underactive bladder without post-void residual. These findings might reflect the biological changes of the depressive brain; e.g., decreases in serotonin and GABA, and possible increases in CRH. Treatment of bladder SSD can follow that of general depression/anxiety, with the potential addition of anticholinergic or selective beta3 bladder drugs.

Overactive Bladder Symptoms Within Nervous System: A Focus on Etiology

Overactive bladder (OAB) is a common debilitating condition characterized by urgency symptoms with detrimental effects on the quality of life and survival. The exact etiology of OAB is still enigmatic, and none of therapeutic approaches seems curative. OAB is generally regarded as a separate syndrome, whereas in clinic, OAB symptoms could be found in numerous diseases of other non-urogenital systems, particularly nervous system. The OAB symptoms in neurological diseases are often poorly recognized and inadequately treated. This review provided a comprehensive overview of recent findings related to the neurogenic OAB symptoms. Relevant neurological diseases could be mainly divided into seven kinds as follows: multiple sclerosis and related neuroinflammatory disorders, Parkinson's diseases, multiple system atrophy, spinal cord injury, dementia, peripheral neuropathy, and others. Concurrently, we also summarized the hypothetical reasonings and available animal models to elucidate the underlying mechanism of neurogenic OAB symptoms. This review highlighted the close association between OAB symptoms and neurological diseases and expanded the current knowledge of pathophysiological basis of OAB. This may increase the awareness of urological complaints in neurological disorders and inspire robust therapies with better outcomes.

Video-urodynamic characteristics of lower urinary tract dysfunctions in patients with chronic brain disorders

AIMS

Lower urinary tract dysfunction (LUTD) is common in patients with chronic brain disorders. This study investigated the video-urodynamic study (VUDS) findings of LUTD in patients with chronic brain disorders, including cerebrovascular accident (CVA), Parkinson's disease (PD), and early dementia.

METHODS

A total of 169 patients with a history of chronic brain disorders, including 84 with CVA, 55 with PD, and 30 with early dementia were enrolled. All patients had a comprehensive chart review, including brain disorder subtype, the period from diagnosis to VUDS, the VUDS parameters, and final LUTD.

RESULTS

The mean age of patients was 69.2 ± 10.5 years, and the interval from brain insult to VUDS was 61.3 ± 49.7 months. Urodynamic detrusor overactivity (DO) was noted in 73.4% of patients, detrusor underactivity in 10.1%, and detrusor overactivity with detrusor underactivity in 16.6%. Bladder outlet obstruction (BOO) was noted in 60.9% of patients, including bladder neck dysfunction in 21.3%, urethral sphincter dysfunction in 42%, and prostatic obstruction in 10.1% of male patients. Urethral sphincter dysfunction was noted in 60% of patients with PD, 32.1% with CVA, and 36.7% with dementia (p = 0.004). A low mean maximum flow rate increased post-void residual volume, and poor voiding efficiency was common in these patients, without significant differences among the subgroups.

CONCLUSIONS

Real-world VUDSs revealed that patients with chronic brain disorders not only had a high prevalence of DO but also impaired bladder contractility and a high rate of BOO at the level above the bladder neck and urethral sphincter.

Future generation of combined multimodal approach to treat brain glioblastoma multiforme and potential impact on micturition control

Glioblastoma remains lethal even when treated with standard therapy. This review aims to outline the recent development of various advanced therapeutics for glioblastoma and briefly discuss the potential impact of glioblastoma and some of its therapeutic approaches on the neurological function micturition control. Although immunotherapy led to success in treating hematological malignancies, but no similar success occurred in treatment for brain glioblastoma. Neither regenerative medicine nor stem cell therapy led to astounding success in glioblastoma. However, CRISPR Cas system holds potential in multiple applications due to its capacity to knock-in and knock-out genes, modify immune cells and cell receptors, which will enable it to address clinical challenges in immunotherapy such as CAR-T and regenerative therapy for brain glioblastoma, improving the precision and safety of these approaches. The studies mentioned in this review could indicate that glioblastoma is a malignant disease with multiple sophisticated barriers to be overcome and more challenges might arise in the attempt of researchers to yield a successful cure. A multimodal approach of future generation of refined and safe therapeutics derived from CRISPR Cas therapeutics, immunotherapy, and regenerative therapeutics mentioned in this review might prolong survival or even contribute towards a potential cure for glioblastoma.

Gabapentin reduces painful bladder hypersensitivity in rats with lipopolysaccharide-induced chronic cystitis

Although interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition causing bladder pain and urinary symptoms, effective treatments have not been established. The aim of this study was to adapt a chronic cystitis model in rats using lipopolysaccharide (LPS), which reflects IC/BPS pathology, and characterize the model's histological and behavioral effects. Furthermore, we investigated the effect of an α2 δ subunit ligand, gabapentin (GBP), on bladder hypersensitivity of rats with chronic cystitis. Cystitis models were created by repeated intravesical injections of LPS. In the histological examination, the LPS-injected group had greater inflammatory response, fibrosis, and abnormally thick re-epithelialization. In the LPS-injected group, LPS prompted hyperalgesia in both the lower abdomen and hind paw regions after day 1 of the first injection compared with the saline-injected controls, without any recovery for 21 days at least. During cystometry, the LPS-injected group showed bladder hyperactivity at all times. Systemic administration of GBP reduced cystitis-related pain due to chronic inflammation and reduced the increased frequency of voiding in the LPS-injected group. These results suggest that repeated intravesical injections of LPS induce long-lasting bladder inflammation, pain, and overactivity in rats, while GBP is effective in the management of those symptoms in this chronic cystitis model. The current study identifies a relatively simple method to develop an animal model for chronic cystitis and provides evidence that GBP may be an effective treatment option for patients with IC/BPS.

High spatial correlation in brain connectivity between micturition and resting states within bladder-related networks using 7 T MRI in multiple sclerosis women with voiding dysfunction

Background

Several studies have reported brain activations and functional connectivity (FC) during micturition using functional magnetic resonance imaging (fMRI) and concurrent urodynamics (UDS) testing. However, due to the invasive nature of UDS procedure, non-invasive resting-state fMRI is being explored as a potential alternative. The purpose of this study is to evaluate the feasibility of utilizing resting states as a non-invasive alternative for investigating the bladder-related networks in the brain.

Methods

We quantitatively compared FC in brain regions belonging to the bladder-related network during the following states: ‘strong desire to void’, ‘voiding initiation (or attempt at voiding initiation)’, and ‘voiding (or continued attempt of voiding)’ with FC during rest in nine multiple sclerosis women with voiding dysfunction using fMRI data acquired at 7 T and 3 T.

Results

The inter-subject correlation analysis showed that voiding (or continued attempt of voiding) is achieved through similar network connections in all subjects. The task-based bladder-related network closely resembles the resting-state intrinsic network only during voiding (or continued attempt of voiding) process but not at other states.

Conclusion

Resting states fMRI can be potentially utilized to accurately reflect the voiding (or continued attempt of voiding) network. Concurrent UDS testing is still necessary for studying the effects of strong desire to void and initiation of voiding (or attempt at initiation of voiding).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03599-4.

Neurological and endocrinological manifestations of 49 children with intracranial pure germinoma at initial diagnosis in Taiwan

BACKGROUND

Intracranial pure germinoma is a rare extragonadal neoplasm. Affected patients may have motor impairment, visual disturbance, neurological signs, and endocrine disorder, depending on the size and location of the tumor. This study investigated and analyzed patients' demographic data and neuroimaging, clinical, laboratory, and endocrinological findings.

METHODS

We performed a retrospective chart review of 49 children diagnosed with pure germinoma in Taiwan from 1990 to 2018. The initial clinical presentation, tumor markers (beta-hCG, alpha fetoprotein, and carcinoembryonic antigen), pituitary function, and brain images were reviewed and analyzed.

RESULTS

This study included 49 patients (37 boys and 12 girls). Their ages ranged from 7.5 to 17.9 years, and the mean age at diagnosis was 13.6 years. Initial symptoms included visual disturbance (n = 23, 47.9%), motor impairment (n = 20, 40.8%), polyuria (n = 20, 40.8%), headache (n = 17, 34.7%), dizziness or vertigo (n = 14, 28.6%), nausea/vomiting (n = 13, 26.5%), and short stature (n = 8, 18.2%). Laboratory data indicated growth hormone deficiency or low IGF-1 levels (n = 18, 85.7%), adrenal insufficiency (n = 21, 77.8%), central diabetes insipidus (n = 27, 55.1%), central hypothyroidism (n = 15, 48.4%), and hypogonadotropic hypogonadism (n = 4, 44.4%).

CONCLUSION

Intracranial pure germinomas may initially manifest as neurological symptoms or endocrinological findings at diagnosis. As endocrinologic presentation is related to delayed diagnosis, clinicians should be aware of patients with such complaints. Laboratory data should be surveyed carefully, and neuroimaging must be considered if the result is abnormal.

Prevalence of nocturia after brain injury: a cross-sectional study in a single rehabilitation center

Aim: to analyze the prevalence of nocturia and its possible neuro-urological correlations in patients with a history of acquired brain injury (ABI).Methods: a single-centre population-based prospective study involving outpatients who were previously admitted to our Rehabilitation Hospital for acute ABI ≥ 18 months and ≤2 years prior. Impact of nocturia on QoL was evaluated by the standardized International Consultation on Incotinence Nocturia Quality of Life (ICIQ N-QoL). All participants were given a three-day frequency chart. Probability value <0.05 was statistically significant.Results: 48/138 subjects (35%) showed nocturia at 2-year follow-up visit. No, significant differences in age, gender, duration of coma, state of consciousness, disability, cognitive impairment and stroke severity were found in patients with or without nocturia. Subarachnoid haemorrhage (ESA) was the main reason for ABI in subjects showing nocturia (p = .037). The overall ICIQ N-QOL score ranged from 12 to 50 (mean 30.12 ± 8.87). Of them, 75% showed a total score >26. Increased diurnal frequency and small bladder capacity was statistically significantly associated with nocturia (p < .05).Conclusions: the rate of nocturia 2 years following ABI was lower compared to other neurological populations, although it was significantly associated with other storage urinary symptoms.

Lower urinary tract function in frontotemporal lobar degeneration: A preliminary observation

OBJECTIVE

The urodynamics underlying lower urinary tract (LUT) dysfunction in frontotemporal lobar degeneration (FTLD) has not been reported. Herein, we investigated LUT function in FTLD patients by performing a urodynamics analysis.

PATIENTS AND METHODS

We recruited five FTLD patients with LUT symptoms: three men, two women; mean age, 70.4 years; mean disease duration, 3.8 years; mean Hoehn-Yahr grade 1.0. We administered a urinary symptom questionnaire and performed a urodynamics study in each patient.

RESULTS

LUT symptoms were observed in all patients. Urinary urgency/frequency (also called overactive bladder, OAB) was noted in all; OAB wet in three (60%) and mild voiding difficulty in two (40%). The urodynamic abnormalities included detrusor overactivity in four (80%), increased bladder sensation in two, large post-void residual in one (comorbid spondylosis), and latent detrusor underactivity in two. None had apparent outlet obstruction or detrusor-sphincter dyssynergia. Sphincter electromyography was normal in the cases studied.

CONCLUSION

We observed detrusor overactivity in FTLD patients with LUT symptoms. Although a preliminary observation, this LUT feature, which might reflect the frontal/insular cortex pathology typically associated with FTLD, requires appropriate management and care.

The effect of stroke on micturition associated brain activity: A pilot fMRI study

OBJECTIVE

Cerebral stroke is a unique model for studying the role of the brain in lower urinary tract (LUT) control. By its nature, stroke must change the activity of the brain to cause LUT dysfunction. The objective of this study was to describe changes in micturition-related brain activity in patients who develop LUT symptoms (LUTS) after a cerebral stroke.

MATERIALS AND METHODS

Healthy controls (HC, n = 10) and patients who developed storage LUTS after a cerebral stroke (n = 7) were recruited. Functional magnetic resonance imaging was used to assess brain activity in each subject. In the task-based block design, blood-oxygen-level-dependent (BOLD) signal was detected during rest, active bladder filling, and bladder voiding. BOLD signal intensity was compared between HCs and stroke subjects during bladder filling, voiding, and voiding initiation.

RESULTS

Stroke subjects exhibited higher activity in the periaqueductal gray and cerebellum during bladder filling and bladder voiding. HCs exhibited more intense activity in higher centers, such as the cingulate cortex, motor cortex, and the dorsolateral prefrontal cortex in each of the phases examined.

CONCLUSIONS

Subjects with stroke-related LUTS exhibit a specific pattern of brain activity during bladder filling and voiding. There appears to be a greater reliance on primitive centers (cerebellum, midbrain) than in healthy controls during both phases of the micturition cycle. We hypothesize that these findings may reflect loss of connectivity with higher brain centers after a stroke.

Urodynamic Assessment of Neuronal Intranuclear Inclusion Disease

Neuronal intranuclear inclusion disease (NIID) is a disease that causes leukoencephalopathy (dementia) and peripheral neuropathy (variable manifestation including bladder dysfunction). This is the first urodynamic report to show that bladder dysfunction in NIID is a combination of detrusor overactivity, decreased bladder sensation, large post-void residual, and neurogenic changes in the sphincter electromyogram. This report will help managing bladder dysfunction in NIID.

The Brain and the Bladder: Forebrain Control of Urinary (In)Continence

Neural circuits extending from the cerebral cortex to the bladder maintain urinary continence and allow voiding when it is socially appropriate. Injuries to certain brain regions produce a specific disruption known as urge incontinence. This neurologic symptom is distinguished by bladder spasticity, with sudden urges to void and frequent inability to maintain continence. The precise localization of neural circuit disruptions responsible for urge incontinence remains poorly defined, partly because the brain regions, cell types, and circuit connections that normally maintain continence are unknown. Here, we review what is known about the micturition reflex circuit and about forebrain control of continence from experimental animal studies and human lesion data. Based on this information, we hypothesize that urge incontinence results from damage to a descending pathway that normally maintains urinary continence. This pathway begins with excitatory neurons in the prefrontal cortex and relays subcortically, through inhibitory neurons that may help suppress reflex micturition during sleep and until it is safe and socially appropriate to void. Identifying the specific cell types and circuit connections that constitute the continence-promoting pathway, from the forebrain to the brainstem, will help us better understand why some brain lesions and neurodegenerative diseases disrupt continence. This information is needed to pave the way toward better treatments for neurologic patients suffering from urge incontinence.

Bladder Autonomic Dysfunction after a Parietal Stroke

We describe a case of a 57-year-old man who, immediately after a right parietal ischemic stroke, showed urodynamically determined bladder sensory decrement during filling and an underactive detrusor during voiding, both of which were ameliorated during the course of his treatment. The lower urinary tract symptom (LUTS) occurs in stroke in up to 60% of patients, when it involves the frontal and insular cortices. In addition, LUTS does occur in parietal stroke as seen in our patient, presumably by sensory deafferentiation within the brain that is relevant to the central regulation of the micturition reflex.

Urinary dysfunction in acute brain injury: A narrative review

The frontal lobe urinary control center is an important regulator of urinary function. Neurologic injury often causes damage or temporary dysfunction of this center and other related urinary control pathways. Little has been reported about this topic in the literature although a majority of neurologic injury patients suffer from some type of urinary dysfunction. In this review, we highlight what is known about urinary dysfunction based on injury type (traumatic brain injury, hemorrhagic stroke, ischemic stroke, subarachnoid hemorrhage, subdural hematoma, and epilepsy). We discuss both clinical and pre-clinical data and pinpoint areas warranting further investigation. In the final section, we provide proposed practice suggestions for managing these patients clinically with the intended goal for refinement in these approaches following further clinical trials.

The course of post-stroke bladder problems and their relation with functional and mental status and quality of life: A six-month, prospective, multicenter study

Objectives

The aim of this study was to evaluate the frequency and course of post-stroke lower urinary tract dysfunction (LUTD) from early term up to a period of six months and to investigate the relation of LUTD with functional and mental status and quality of life (QoL) in stroke patients.

Patients and methods

This prospective study included a total of 70 stroke patients (44 males, 26 females; mean age 62.7±7.0 years; range, 46 to 79 years) from five different centers across Turkey between June 2015 and January 2017. The patients were questioned using the Danish Prostatic Symptom Score (DAN-PSS) to evaluate LUTD and evaluated using the Modified Barthel Index (MBI), Incontinence QoL Questionnaire (I-QOL), and Mini-Mental State Examination (MMSE) at one, three, and six months.

Results

At least one symptom of LUTD was observed in 64 (91.4%), 58 (82.9%), and 56 (80%) of the patients according to the DAN-PSS at one, three, and six months, respectively. A statistically significant improvement was found in the DAN-PSS, MBI, MMSE, I-QOL total scores, avoidance and psychosocial subgroup scores at six months compared to the first month scores (p<0.05). There was a significant negative correlation between the DAN-PSS symptom score at one month and the MBI, MMSE, and QoL scores at six months. The DAN-PSS bother and total scores were found to be significantly and negatively correlated only with the subscales of the QoL questionnaire.

Conclusion

Based on our study results, LUTD was very common and the prevalence of LUTD findings decreased constantly during six-month follow-up, showing an association with a poor cognitive and functional status and QoL in stroke patients with LUTD.

Does preoperative health-related quality of life predict survival in high-grade glioma patients? - a prospective study

Purpose: To explore if preoperative patient-reported health-related quality of life (HRQoL) provides additional prognostic value as a supplement to other preoperatively known clinical factors in patients with high-grade glioma (HGG).Methods: In a prospective explorative study, 114 patients with high-grade glioma were included. The participants completed the generic HRQoL questionnaire EQ-5D 3L, and the disease-specific questionnaires EORTC QLQ-C30 and EORTC QLQ-BN20 1-3 days before surgery. Operating neurosurgeons scored the patient's preoperative functional level by using Karnofsky Performance Status (KPS). Univariate and multivariate Cox regression analyses were performed to identify HRQoL domains that were associated with survival. Kaplan-Meier survival curves and Log-rank tests were used to visualize differences in survival between groups.Results: In addition to preoperative KPS and age, the EORTC QLQ-BN20 subdomains 'seizures' (HR 0.98, p < .006), 'itchy skin' (HR 1.01, p < .036) and 'bladder control' (HR 1.01, p < .023) were statistically significant independent predictors of survival in a multivariate cox model.Conclusions: Our results suggest that in patients with HGG, certain preoperative symptom scales within EORTC QLQ-BN20 may provide additional prognostic information to supplement other clinical prognostic factors. However, further studies are required to validate our findings. Overall the instruments EQ-5D 3L and EORTC QLQ-C30 do not seem to provide much additional valuable prognostic information to already known prognostic factors.

Traumatic Brain Injury-related voiding dysfunction in mice is caused by damage to rostral pathways, altering inputs to the reflex pathways

Brain degeneration, including that caused by traumatic brain injury (TBI) often leads to severe bladder dysfunction, including incontinence and lower urinary tract symptoms; with the causes remaining unknown. Male C57BL/6J mice underwent repetitive moderate brain injury (rmdTBI) or sham injury, then mice received either cis P-tau monoclonal antibody (cis mAb), which prevents brain degeneration in TBI mice, or control (IgG). Void spot assays revealed age-dependent incontinence in IgG controls 8 months after injury, while cis mAb treated or sham mice showed no dysfunction. No obvious bladder pathology occurred in any group. Urodynamic cystometry in conscious mice revealed overactive bladder, reduced maximal voiding pressures and incontinence in IgG control, but not sham or cis mAb treated mice. Hyperphosphorylated tau deposition and neural tangle-like pathology occurred in cortical and hippocampal regions only of IgG control mice accompanied with post-traumatic neuroinflammation and was not seen in midbrain and hindbrain regions associated with bladder filling and voiding reflex arcs. In this model of brain degeneration bladder dysfunction results from rostral, and not hindbrain damage, indicating that rostral brain inputs are required for normal bladder functioning. Detailed analysis of the functioning of neural circuits controlling bladder function in TBI should lead to insights into how brain degeneration leads to bladder dysfunction, as well as novel strategies to treat these disorders.

Lower Urinary Tract Symptoms in Subjects with Subclinical Cerebral White Matter Lesions

Aim

We assessed the impact of cerebral white matter lesions (WMLs) on lower urinary tract symptoms in subjects with normal neurological and cognitive function.

Methods

A cohort of community-dwelling subjects aged ≥65 years were recruited to undergo MRI brain assessment. WMLs were graded using the Fazekas scale from 0 to 3. A separate telephone interview was carried out to assess the urinary symptoms in these subjects using the questionnaire Overactive Bladder-Validated 8-Question Awareness Tool (OAB-V8).

Results

800 community-dwelling elderly subjects were recruited to undergo MRI brain. In this cohort, 431 subjects responded to the telephone interview concerning their urinary symptoms. Among the respondents, 21.1% did not exhibit any WML on their MRI brain. Most of the subjects (52.6%) exhibited grade 1 WML. On logistic regression, age was found to be positively correlated with the Fazekas score (correlation coefficient 0.203, p ≤ 0.01). Using a cutoff of 8 on OAB-V8, 22% of the respondents experienced OAB. Presence of WML, hypertension, or diabetes mellitus was not found to be correlated with storage urinary symptoms or OAB-V8 total score. Multiple logistic regression analysis did not show the presence of WML to be associated with the diagnosis of OAB (adjusted OR 1.13, 95% CI 0.65–1.96, p=0.659).

Conclusions

WML is associated with age and is common in the elderly population. Mild WML is subclinical, with no obvious neurological and urinary symptoms. Our cohort did not demonstrate a relationship between WML and lower urinary tract symptoms.

Association of Urinary Incontinence with Cognition, Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

BACKGROUND

Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination.

OBJECTIVE

To examine if urinary incontinence is associated with inpatient-rehabilitation (IR) outcomes in cognition, transfers, and discharge destinations.

DESIGN

Retrospective observational study of 303 of 579(52%) acute-stroke patients admitted to IR 2012-2015 with complete urinary incontinence (total assistance for bladder management). Discharge Functional Independence Measure (FIM) scores were correlated for continence, cognition, transfers-(bed/chair/wheelchair), and discharge destination.

RESULTS

Patients were admitted to IR on average 7.4 days after acute stroke. Average length-of-stay in IR was 14 days. At discharge 118 of 303(39%) remained urinary incontinent (total assistance). Continence/bladder-management FIM scores at discharge were associated with cognition FIM scores at discharge (chi square =105.8; P < .0001), and associated with transfer FIM scores at discharge (chi square = 153.1; P < .0001). Patients total to moderate assistance for continence at discharge included greater percentage that were dependent to moderate assistance for cognition and transfers than those minimal assistance to independent for continence. Continence/bladder-management FIM scores at discharge were associated with discharge disposition destinations (chi square = 29.98; P < .002). Patients total to moderate assistance for continence at discharge included greater percentage of acute care transfers, and skilled-nursing-facility dispositions, than patients that recovered to minimal assist to independent for continence. Urinary-incontinence recovery to minimal assistance to independent was associated with a home/community disposition rate of 82%.

CONCLUSIONS

52% stroke patients were total assistance with bladder management for urinary incontinence on IR admission. Partial to complete continence recovery occurred in 61%. Continence/bladder-management FIM scores at discharge were associated with cognition and transfer FIM scores, and discharge destinations.

Urological dysfunction in synucleinopathies: epidemiology, pathophysiology and management

OBJECTIVE

Parkinson's disease (PD) and multiple system atrophy (MSA) are major neurogenerative diseases characterized pathologically by abnormal alpha-synuclein aggregation. PD and MSA are clinically characterized by motor disorder and bladder dysfunction (mainly urinary urgency and frequency, also called overactive bladder). However, few literatures are available concerning bladder dysfunction in PD or MSA.

METHOD

A systematic review.

RESULTS

The bladder dysfunction in MSA is more severe than that in PD for large post-void residual or urinary retention. These bladder dysfunctions presumably reflect the different nervous system pathologies. Overactive bladder in PD reflects lesions in the brain, e.g., in the prefrontal-nigrostriatal D1 dopaminergic bladder-inhibitory pathway. Overactive bladder in MSA reflects lesions similar to PD and the cerebellum (bladder-inhibitory), and the urinary retention in MSA presumably reflects lesions in the pontine micturition center and the sacral intermediolateral nucleus of the spinal cord (bladder-facilitatory). Bladder dysfunction not only impairs an individual's quality of life, it can also cause emergency hospitalizations due to acute retention and early institutionalization. Anticholinergics are the first-line treatment for bladder dysfunction in PD and MSA patients, but care should be taken for the management of bladder dysfunction-particularly in MSA patients due to the high prevalence of difficult emptying, which needs clean, intermittent catheterization.

CONCLUSIONS

This review summarizes the epidemiology, pathophysiology, and management of bladder dysfunction in individuals with PD or MSA.

Barrington's nucleus: Neuroanatomic landscape of the mouse "pontine micturition center"

Barrington's nucleus (Bar) is thought to contain neurons that trigger voiding and thereby function as the "pontine micturition center." Lacking detailed information on this region in mice, we examined gene and protein markers to characterize Bar and the neurons surrounding it. Like rats and cats, mice have an ovoid core of medium-sized Bar neurons located medial to the locus coeruleus (LC). Bar neurons express a GFP reporter for Vglut2, develop from a Math1/Atoh1 lineage, and exhibit immunoreactivity for NeuN. Many neurons in and around this core cluster express a reporter for corticotrophin-releasing hormone (BarCRH ). Axons from BarCRH neurons project to the lumbosacral spinal cord and ramify extensively in two regions: the dorsal gray commissural and intermediolateral nuclei. BarCRH neurons have unexpectedly long dendrites, which may receive synaptic input from the cerebral cortex and other brain regions beyond the core afferents identified previously. Finally, at least five populations of neurons surround Bar: rostral-dorsomedial cholinergic neurons in the laterodorsal tegmental nucleus; lateral noradrenergic neurons in the LC; medial GABAergic neurons in the pontine central gray; ventromedial, small GABAergic neurons that express FoxP2; and dorsolateral glutamatergic neurons that express FoxP2 in the pLC and form a wedge dividing Bar from the dorsal LC. We discuss the implications of this new information for interpreting existing data and future experiments targeting BarCRH neurons and their synaptic afferents to study micturition and other pelvic functions.

[Lower urinary tract dysfunction in normal pressure hydrocephalus: Review of the literature]

INTRODUCTION

Lower urinary tract dysfunction in normal pressure hydrocephalus has received little attention from the scientific community. The aim of this review article was to discuss diagnostic and therapeutic options for these patients.

SOURCES

A literature review of MedLine publications on urinary incontinence in normal pressure hydrocephalus was conducted. The following keywords were used: "hydrocephalus, normal pressure" and "bladder dysfunction" or "urinary incontinence" or "overactive bladder" or "urinary bladder, neurogenic". Prospective and retrospective studies as well as previous reviews were analyzed.

RESULTS

Urinary symptoms in normal pressure hydrocephalus are mainly represented by overactive bladder, which is a significant burden for the concerned patients. Isolated overactive bladder is more frequent (64%) than urinary incontinence (57%). Detrusor overactivity is seen in 95.2% of the cases. Neuro-surgery is efficient on urinary symptoms for 61.5% of the patients. Bladder recovery after surgery relates with increased mid-cingulate perfusion, probably linked with a functional restoration of the mid-cingulate that normally inhibits the micturition reflex. Medical options, added or not to surgery, include anticholinergic drugs unable to pass through the blood-brain barrier, Transcutaneous Electrical Nerve Stimulation and sacral neuromodulation.

CONCLUSION

There is actually an insufficient concern about urinary symptoms in normal pressure hydrocephalus. This article highlights the importance of a harmonization of neuro-urological practices in the pre-therapeutic evaluation of patients suffering from normal pressure hydrocephalus.

Urodynamic findings in patients with Creutzfeldt-Jakob disease: a case report

AIM OF STUDY

Urinary dysfunction in Creutzfeldt-Jakob disease (CJD) patients is attributed to functional incontinence, since they often have immobility and loss of motivation. In contrast, previously no urodynamic findings are available in CJD patients.

CASE REPORT

We had 2 CJD patients who had urinary frequency and urinary retention. We performed urodynamics with the spouse's informed consent in order to explore the mechanism of urinary dysfunction in those cases. Case 1 had typical acute cognitive deterioration with incontinence and urinary retention, while case 2 had subacute cognitive deterioration (that started after admission) and nocturia. The urodynamic findings were diverse. One feature was detrusor overactivity during bladder filling in case 1. Another feature of urodynamic finding includes neurogenic change of sphincter EMG in case 1 and decreased bladder sensation in case 2.

CONCLUSION

Urodynamics in our two CJD patients revealed detrusor overactivity and neurogenic sphincter electromyogram, presumably reflecting pathological lesions in the prefrontal cortex/basal ganglia as well as the sacral spinal cord in CJD.