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Ghatas MP, Burkett LS, Grob G, Daniels PT, Stothers L, Query HE, Shields MK, Speich JE, Klausner AP. A stepwise approach for functional near infrared spectroscopy measurement during natural bladder filling. Transl Androl Urol 2023; 12:1477-1486. [PMID: 37969775 PMCID: PMC10643392 DOI: 10.21037/tau-23-275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/18/2023] [Indexed: 11/17/2023] Open
Abstract
Background Functional near infrared spectroscopy (fNIRS) is a versatile, noninvasive, and inexpensive tool that can be used to measure oxyhemoglobin (O2Hb) changes in the cortical brain caused by increasing bladder sensation during filling in upright posture. This study's purpose is to provide a rigorous methodologic template that can be implemented for comparative studies of fNIRS in the diagnosis and management of lower urinary tract symptoms including overactive bladder (OAB) and other forms of lower urinary tract dysfunction. Methods Participants without any urologic conditions completed a validated oral hydration protocol facilitating and equilibrating natural bladder filling. First desire to void and real time bladder sensation (0-100%) were recorded using a Sensation Meter. A 24-channel fNIRS template simultaneously recorded prefrontal cortical O2Hb. Each channel was analyzed between "first desire" to void and 100% sensation, defined in this study as the period of "high sensation". Channels were sub-divided by cortical regions: right (nine channels), left (nine channels), middle (six channels). Results A total of eight participants (male: n=4, female: n=4) were enrolled with mean age 39±19.9 years and body mass index (BMI) of 25±3.93 kg/m2. There were no differences in age, BMI, race, or OAB survey scores based on biological sex. Signal acquisition improved with power bank use, postural head support for motion reduction, and head cap optimization. Acceleration-based concurrent motion measurement was effectively utilized to remove motion artifacts. O2Hb concentration patterns appeared irregular during low sensation and increased during high sensation after first desire across the frontal cortex. Conclusions Employing a stepwise approach, this study defined a methodological guide for improved prefrontal fNIRS signal acquisition and analysis during bladder filling. The technique demonstrated that prefrontal fNIRS cortical O2Hb increases with elevated bladder sensation in normal subjects and sets the stage for comparative studies in individuals with OAB and other forms of lower urinary tract dysfunction.
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Affiliation(s)
- Mina P. Ghatas
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Linda S. Burkett
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA, USA
| | - Gabrielle Grob
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Peter T. Daniels
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Lynn Stothers
- Department of Urology and Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA
| | - Helen E. Query
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael K. Shields
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - John E. Speich
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam P. Klausner
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Schott B, Choksi D, Tran K, Karmonik C, Salazar B, Boone T, Khavari R. Is the Brainstem Activation Different Between Healthy Young Male and Female Volunteers at Initiation of Voiding? A High Definition 7-Tesla Magnetic Resonance Imaging Study. Int Neurourol J 2023; 27:174-181. [PMID: 37798884 PMCID: PMC10556429 DOI: 10.5213/inj.2346104.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/05/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE Assessing brainstem function in humans through typical neuroimaging modalities has been challenging. Our objective was to evaluate brain and brainstem activation patterns during initiation of voiding in healthy males and females utilizing a 7 Tesla magnetic resonance imaging (MRI) scanner and a noninvasive brain-bladder functional MRI (fMRI) protocol. METHODS Twenty healthy adult volunteers (10 males and 10 females) with no history of urinary symptoms were recruited. Each volunteer underwent a clinic uroflow and postvoid residual assessment and was asked to consume water prior to entering the scanner. Anatomical and diffusion tensor images were obtained first, followed by a blood oxygenation level dependent (BOLD) resting-state fMRI (rs-fMRI) during the empty bladder. Subjects indicated when they felt the urge to void, and a full bladder rs-fMRI was obtained. Once completed, the subjects began 5 voiding cycles, where the first 7.5 seconds of each voiding cycle was identified as "initiation of voiding." BOLD activation maps were generated, and regions of interests with a t-value greater than 2.1 were deemed statistically significant. RESULTS We present 5 distinct regions within the periaqueductal gray (PAG) and pontine micturition center (PMC) with statistically significant activation associated with an initiation of voiding in both men and women, 3 within the PAG and 2 within the PMC. Several additional areas in the brain also demonstrated activation as well. When comparing males to females, there was an overall lower BOLD activation seen in females throughout all regions, with the exception of the caudate lobe. CONCLUSION Our study effectively defines regions within the PAG and PMC involved in initiation of voiding in healthy volunteers. To our knowledge, this is the first study investigating differences between male and female brainstem activation utilizing an ultra-high definition 7T MRI.
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Affiliation(s)
- Bradley Schott
- Interdisciplinary College of Engineering Medicine, Texas A&M, Houston, TX, USA
| | - Darshil Choksi
- Interdisciplinary College of Engineering Medicine, Texas A&M, Houston, TX, USA
| | - Khue Tran
- Interdisciplinary College of Engineering Medicine, Texas A&M, Houston, TX, USA
| | | | - Betsy Salazar
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
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Mazeaud C, Salazar BH, Braun M, Hossu G, Khavari R. Functional MRI in neuro-urology: A narrative review. Prog Urol 2023:S1166-7087(23)00082-9. [PMID: 37062631 DOI: 10.1016/j.purol.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/26/2023] [Indexed: 04/18/2023]
Abstract
Neuro-imaging has given urologists a new tool to investigate the neural control of the lower urinary tract. Using functional magnetic resonance imaging (fMRI), it is now possible to understand which areas of the brain contribute to the proper function of the storage and voiding of the lower urinary tract. This field of research has evolved from simple anatomical descriptions to elucidating the complex micturition network. A keyword search of the Medline database was conducted by two reviewers for relevant studies from January 1, 2010, to August 2022. Of 2047 peer-reviewed articles, 49 are included in this review. In the last decade, a detailed understanding of the brain-bladder network has been described, elucidating a dedicated network, as well as activated areas in the brainstem, cerebellum, and cortex that share reproducible connectivity patterns. Research has shown that various urological diseases can lead to specific changes in this network and that therapies used by urologists to treat lower urinary tract symptoms (LUTS) are also able to modify neuronal activity. This represents a set of potential new therapeutic targets for the management of the lower urinary tract symptoms (LUTS). fMRI technology has made it possible to identify subgroups of responders to various treatments (biofeedback, anticholinergic, neuromodulation) and predict favourable outcomes. Lastly, this breakthrough understanding of neural control over bladder function has led to treatments that directly target brain regions of interest to improve LUTS. One such example is the use of non-invasive transcranial neuromodulation to improve voiding symptoms in individuals with multiple sclerosis.
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Affiliation(s)
- C Mazeaud
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States of America; Department of Urology, Nancy University Hospital, Nancy, France; Université de Lorraine, Inserm, IADI U1254, 54000 Nancy, France
| | - B H Salazar
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States of America
| | - M Braun
- Université de Lorraine, Inserm, IADI U1254, 54000 Nancy, France; Department of Diagnostic and Interventional Neuroradiology, Nancy University Hospital, Nancy, France
| | - G Hossu
- Université de Lorraine, Inserm, IADI U1254, 54000 Nancy, France
| | - R Khavari
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States of America.
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Tran K, Salazar BH, Boone TB, Khavari R, Karmonik C. Classification of multiple sclerosis women with voiding dysfunction using machine learning: Is functional connectivity or structural connectivity a better predictor? BJUI COMPASS 2023; 4:277-284. [PMID: 37025479 PMCID: PMC10071087 DOI: 10.1002/bco2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/29/2023] Open
Abstract
Introduction Machine learning (ML) is an established technique that uses sets of training data to develop algorithms and perform data classification without using human intervention/supervision. This study aims to determine how functional and anatomical brain connectivity (FC and SC) data can be used to classify voiding dysfunction (VD) in female MS patients using ML. Methods Twenty-seven ambulatory MS individuals with lower urinary tract dysfunction were recruited and divided into two groups (Group 1: voiders [V, n = 14]; Group 2: VD [n = 13]). All patients underwent concurrent functional MRI/urodynamics testing. Results Best-performing ML algorithms, with highest area under the curve (AUC), were partial least squares (PLS, AUC = 0.86) using FC alone and random forest (RF) when using SC alone (AUC = 0.93) and combined (AUC = 0.96) as inputs. Our results show 10 predictors with the highest AUC values were associated with FC, indicating that although white matter was affected, new connections may have formed to preserve voiding initiation. Conclusions MS patients with and without VD exhibit distinct brain connectivity patterns when performing a voiding task. Our results demonstrate FC (grey matter) is of higher importance than SC (white matter) for this classification. Knowledge of these centres may help us further phenotype patients to appropriate centrally focused treatments in the future.
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Affiliation(s)
- Khue Tran
- EnMed Program Texas A&M School of Engineering Medicine Houston Texas USA
| | - Betsy H. Salazar
- Department of Urology Houston Methodist Hospital Houston Texas USA
| | - Timothy B. Boone
- Department of Urology Houston Methodist Hospital Houston Texas USA
| | - Rose Khavari
- Department of Urology Houston Methodist Hospital Houston Texas USA
| | - Christof Karmonik
- Translational Imaging Center Houston Methodist Research Institute Houston Texas USA
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Predictors for outcomes of noninvasive, individualized transcranial magnetic neuromodulation in multiple sclerosis women with neurogenic voiding dysfunction. CONTINENCE (AMSTERDAM, NETHERLANDS) 2022; 4:100517. [PMID: 36568960 PMCID: PMC9788803 DOI: 10.1016/j.cont.2022.100517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Purpose Multiple sclerosis (MS) is a multifocal demyelinating disease that affects the central nervous system (CNS) and commonly leads to neurogenic lower urinary tract dysfunction (NLUTD). Proper storage and release of urine relies on synchronized activity of the LUT, which is meticulously regulated by supraspinal circuits, making it vulnerable to diseases such as MS. NLUTD, characterized by voiding dysfunction (VD), storage issues, or a combination of both is a common occurrence in MS. Unfortunately, there are limited treatment options for NLUTD, making the search for alternative treatments such as transcranial rotating permanent magnet stimulation (TRPMS) of utmost importance. To assess effectiveness of treatment we also need to understand underlying factors that may affect outcomes, which we addressed here. Methods Ten MS subjects with VD and median age of 54.5 years received daily TRPMS sessions for two weeks. Five pre-determined regions of interest (ROIs) known to be involved in the micturition cycle were modulated (stimulated or inhibited) using TRPMS. Clinical data (non-instrumented uroflow and urodynamics parameters, PVR, bladder symptom questionnaires) and neuro-imaging data were collected at baseline and following TRPMS via 7-Tesla Siemens MAGNETOM Terra magnetic resonance imaging (MRI) scanner. Each participant underwent functional MRI (fMRI) concurrently with a repeated urodynamic study (UDS). Baseline data of each arm was evaluated to determine any indicators of successful response to treatment.
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White Matter Integrity in Men With Benign Prostatic Hyperplasia and Bladder Outlet Obstruction and Its Contribution to Lower Urinary Tract Symptoms. Int Neurourol J 2022; 26:219-226. [PMID: 36203254 PMCID: PMC9537432 DOI: 10.5213/inj.2244018.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/27/2022] [Indexed: 01/23/2023] Open
Abstract
Purpose Lower urinary tract symptoms (LUTS) associated with bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) can negatively impact quality of life. We evaluated the structural connectivity of the brain in men with BPH with chronic BOO using diffusion tensor imaging (DTI). Methods Ambulatory male patients aged ≥45 years with BPH and BOO were recruited. LUTS was defined as an International Prostate Symptom Score (IPSS) ≥12 and a maximum urinary flow rate ≤15 mL/sec. Upon recruitment, uroflowmetry and validated questionnaires regarding bladder status were collected. DTI images from each subject were aligned with the ICBM-DTI-81 atlas, defining 50 white matter tracts (WMTs). The mean values of DTI parameters—fractional anisotropy and mean diffusivity—for each WMT were extracted. These measures were then utilized to compute Pearson correlation coefficients with clinical parameters. Objective clinical parameters included uroflowmetry parameters, postvoid residual (PVR) volume, and bladder capacity. Subjective clinical parameters were assessed using validated questionnaires: the IPSS, Incontinence Symptom Index, and Sexual Health Inventory for Men. Results The correlation analysis revealed 15 WMTs that showed statistically significant associations (P<0.05) with objective and subjective clinical parameters. Eight tracts were associated with uroflowmetry parameters: maximum flow rate (Qmax), mean flow rate (Qmean), and PVR. Among these tracts, the middle cerebellar peduncles and left medial lemniscus were associated with Qmax; the genu of the corpus callosum, left superior corona radiata, corticospinal tract, right medial lemniscus, posterior corona radiata with Qmean; and the left posterior corona radiata with PVR. Seven tracts also demonstrated significant associations with the IPSS. Conclusions Our results suggest correlations between the preserved white matter integrity of specific WMTs and the severity of LUTS based on objective and subjective clinical parameters, leading us to believe that a distinct pathology of the central nervous system might exist.
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Shi Z, Karmonik C, Soltes A, Tran K, Boone T, Lincoln JA, Khavari R. Altered bladder-related brain network in multiple sclerosis women with voiding dysfunction. Neurourol Urodyn 2022; 41:1612-1619. [PMID: 35842826 PMCID: PMC9399000 DOI: 10.1002/nau.25008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/14/2022] [Accepted: 06/30/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES A number of neurourology imaging studies have mainly focused on investigating the brain activations during micturition in healthy and neuropathic patients. It is, however, also necessary to study brain functional connectivity (FC) within bladder-related regions to understand the brain organization during the execution of bladder function. This study aims to identify the altered brain network associated with bladder function in multiple sclerosis (MS) women with voiding dysfunction through comparisons with healthy subjects via concurrent urodynamic study (UDS)/functional magnetic resonance imaging (fMRI). MATERIALS AND METHODS Ten healthy adult women and nine adult ambulatory women with clinically stable MS for ≥6 months and symptomatic voiding phase neurogenic lower urinary tract dysfunction (NLUTD) underwent UDS/fMRI evaluation with a task of bladder filling/emptying that was repeated three to five times. We quantitatively compared their FC within 17 bladder-related brain regions during two UDS phases: "strong desire to void" and "(attempt at) voiding initiation." RESULTS At "strong desire to void," the healthy group showed significantly stronger FC in regions involved in bladder filling and suppression of voiding compared to the patient group. These regions included the bilateral anterior cingulate cortex, right supplementary motor area, and right middle frontal gyrus. During "(attempt at) voiding initiation," healthy subjects exhibited stronger FC in the right inferior frontal gyrus compared to MS patients. CONCLUSION Our study offers a new way to identify alterations in the neural mechanisms underlying NLUTD and provides potential targets for clinical interventions (such as cortical neuromodulation) aimed at restoring bladder functions in MS patients.
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Affiliation(s)
- Zhaoyue Shi
- Translational Imaging Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Christof Karmonik
- Translational Imaging Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Amelia Soltes
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Khue Tran
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
| | - John A Lincoln
- Department of Neurology, McGovern Medical School, Houston, Texas, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
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Pang D, Gao Y, Liao L. Functional brain imaging and central control of the bladder in health and disease. Front Physiol 2022; 13:914963. [PMID: 36035497 PMCID: PMC9411744 DOI: 10.3389/fphys.2022.914963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022] Open
Abstract
Central control of the bladder is a complex process. With the development of functional imaging technology and analysis methods, research on brain-bladder control has become more in-depth. Here, we review previous functional imaging studies and combine our latest findings to discuss brain regions related to bladder control, interactions between these regions, and brain networks, as well as changes in brain function in diseases such as urgency urinary incontinence, idiopathic overactive bladder, interstitial cystitis/bladder pain syndrome, urologic chronic pain syndrome, neurogenic overactive bladder, and nocturnal enuresis. Implicated brain regions include the pons, periaqueductal grey, thalamus, insula, prefrontal cortex, cingulate cortex, supplementary motor area, cerebellum, hypothalamus, basal ganglia, amygdala, and hippocampus. Because the brain is a complex information transmission and processing system, these regions do not work in isolation but through functional connections to form a number of subnetworks to achieve bladder control. In summarizing previous studies, we found changes in the brain functional connectivity networks related to bladder control in healthy subjects and patients involving the attentional network, central executive network or frontoparietal network, salience network, interoceptive network, default mode network, sensorimotor network, visual network, basal ganglia network, subcortical network, cerebella, and brainstem. We extend the working model proposed by Griffiths et al. from the brain network level, providing insights for current and future bladder-control research.
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Affiliation(s)
- Dongqing Pang
- China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing, China
- Department of Urology, China Rehabilitation Research Center, Beijing, China
- Department of Urology, Capital Medical University, Beijing, China
| | - Yi Gao
- China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing, China
- Department of Urology, China Rehabilitation Research Center, Beijing, China
- Department of Urology, Capital Medical University, Beijing, China
| | - Limin Liao
- China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing, China
- Department of Urology, China Rehabilitation Research Center, Beijing, China
- Department of Urology, Capital Medical University, Beijing, China
- *Correspondence: Limin Liao,
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Supraspinal Neural Changes in Men with Benign Prostatic Hyperplasia Undergoing Bladder Outlet Procedures: a Pilot Functional MRI Study. Urology 2022; 169:173-179. [PMID: 35863497 DOI: 10.1016/j.urology.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/19/2022] [Accepted: 07/04/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To explore brain activation patterns on functional MRI (fMRI) in men with BPH and BOO before and after outlet obstruction procedures. METHODS Men age ≥ 45 who failed conservative BPH therapy planning to undergo BOO procedures were recruited. Eligible men underwent a concurrent fMRI/urodynamics testing before and six months after BOO procedure. fMRI images were obtained via 3 Tesla MRI. Significant blood-oxygen-level-dependent (BOLD) signal activated voxels (p<0.05) were identified at strong desire to void and (attempt at) voiding initiation pre and post BOO procedure. RESULTS Eleven men were enrolled, of which seven men completed the baseline scan, and four men completed the six-month follow-up scan. Baseline decreased BOLD activity was observed in right inferior frontal gyrus (IFG), bilateral insula, inferior frontal gyrus (IFG) and thalamus. Significant changes in BOLD signal activity following BOO procedures were observed in the insula, IFG, and cingulate cortices. CONCLUSIONS This represents a pilot study evaluating cortical activity in men with BPH and BOO. Despite limitations we found important changes in supraspinal activity in men with BPH and BOO during filling and emptying phases at baseline and following BOO procedure, with the potential to improve our understanding of neuroplasticity secondary to BPH and BOO. This preliminary data may serve as the foundation for larger future trials.
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Clarkson BD, Wei Z, Karim HT, Tyagi S, Resnick NM, Salkeld R, Conklin C. Neuroimaging of situational urgency and incontinence provoked by personal urgency cues. Neurourol Urodyn 2022; 41:166-173. [PMID: 34570403 PMCID: PMC8738101 DOI: 10.1002/nau.24800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 09/15/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Situational triggers for urinary urgency and incontinence (UUI) such as "latchkey incontinence" and running water are often reported clinically, but no current clinical tools exist to directly address symptoms of UUI provoked by environmental stimuli. Previously we have shown that urgency and leakage can be reproduced during urodynamic studies with exposure to personal urgency-related images. Here we investigate the neural signatures associated with such situational triggers to inform potential therapies for reducing reactivity to these personal urgency-related cues among women with situational UUI. METHOD We recruited 23 women with situational UUI who took photographs of their personal "urgency trigger" and "safe" situations and were exposed to them in a magnetic resonance imaging (MRI) scanner. We identified brain areas that were more active during urgency versus safe image exposure. RESULTS We found that, during urgency image exposure, main components of the attention network and decision-related processes, the middle and medial frontal gyri, were more active (p < 0.01). In addition, areas well known to be involved in the continence mechanism, such as the cingulate and parahippocampal areas, were also more active during urgency image exposure. CONCLUSION Exposure to personal situational urgency images activated different areas of the brain compared with safe environments, highlighting the complex brain mechanisms that provoke real-world urgency. Using brain and behavioral-based therapies which target the attentional areas identified here and extinguish cue reactivity might reduce symptom burden in this subset of UUI sufferers.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Zhiyang Wei
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Shachi Tyagi
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Neil M Resnick
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Ronald Salkeld
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Cynthia Conklin
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Preliminary Analysis of Brain Footprints in Multiple Sclerosis Females with Detrusor Sphincter Dyssynergia: A Concurrent Urodynamic and Functional Magnetic Resonance Imaging Study. Int Neurourol J 2021; 26:S38-46. [PMID: 34856727 PMCID: PMC8896778 DOI: 10.5213/inj.2142012.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/29/2021] [Indexed: 11/08/2022] Open
Abstract
Purpose This study evaluates the grey and white brain matter characteristics in women with multiple sclerosis (MS) and detrusor sphincter dyssynergia (DSD). Grey matter is assessed via the functional connectivity (FC) of brain regions activated during voiding, using functional magnetic resonance imaging (fMRI). Two white matter tracts involved in bladder function, the anterior thalamic radiation (ATR) and superior longitudinal fasciculus (SLF), were evaluated using diffusion tensor imaging (DTI). Methods Twenty-seven women with MS (two groups: no-DSD (n=23) or DSD (n=4)), and eight healthy controls (HC) underwent concurrent urodynamic-fMRI evaluation with four cycles of bladder filling and emptying. A FC similarity measure (FC_sim) was calculated for each subject to express the similarity of individual FC at voiding initiation compared to all FC patterns. ATR and SLF tracts were traced and their fractional anisotropy (FA) and mean diffusivity (MD) were recorded. Results Mean FC_sim values were significantly different among the three groups indicating distinct FC patterns; however, no significant difference was found between DSD and no-DSD groups. DSD group showed trends of lower FA and higher MD - indicating loss of coherence - in all tracts compared to HCs, and in the left and right ATR when compared to MS women with neither DSD nor voiding dysfunction (VD), suggesting more damage in these tracts for MS women with DSD. Conclusions Women with MS show distinctly different FC patterns compared to HCs. There are trends showing more damage in the ATR in women with MS and DSD compared to those with neither DSD nor VD.
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12
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Contemporary Review of MRI in Benign Genitourinary Pelvic Medicine: What Every Urologist Should Know. CURRENT BLADDER DYSFUNCTION REPORTS 2021. [DOI: 10.1007/s11884-021-00631-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Tran K, Shi Z, Karmonik C, John B, Rajab H, Helekar SA, Boone T, Khavari R. Therapeutic effects of non-invasive, individualized, transcranial neuromodulation treatment for voiding dysfunction in multiple sclerosis patients: study protocol for a pilot clinical trial. Pilot Feasibility Stud 2021; 7:83. [PMID: 33757581 PMCID: PMC7989407 DOI: 10.1186/s40814-021-00825-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/15/2021] [Indexed: 11/21/2022] Open
Abstract
Background Voiding dysfunction (VD) is a common neurogenic lower urinary tract dysfunction (NLUTD) in multiple sclerosis (MS) patients. Currently, the only effective management for VD and urinary retention in MS patients is catheterization, prompting us to look for novel therapeutic options beyond the bladder, such as the brain. Transcranial rotating permanent magnet stimulator (TRPMS) is a non-invasive, portable, multifocal neuromodulator that simultaneously modulates multiple cortical regions, enhancing or attenuating strengths of functional connections between these regions. The objective of this pilot clinical trial is to evaluate the feasibility of a TRPMS trial to address lower urinary tract symptoms in MS patients, through investigating the therapeutic effects of TRPMS in modulating brain regions during voiding initiation and mitigating VD in female MS individuals. Methods Ten adult female MS patients with VD (defined as having %post-void residual/bladder capacity (%PVR/BC) ≥ 40% or Liverpool nomogram percentile < 10%) will be recruited for this study. Concurrent urodynamic and functional MRI evaluation with a bladder filling/emptying task repeated three to four times will be performed at baseline and post-treatment. Predetermined regions of interest and their blood-oxygen-level-dependent (BOLD) activation at voiding initiation will be identified on each patient’s baseline anatomical and functional MRI scan, corresponding to the microstimulators placement on their individualized TRPMS treatment cap to either stimulate or inhibit these regions. Patients will receive 10 40-min treatment sessions. Non-instrumented uroflow and validated questionnaires will also be collected at baseline and post-treatment to evaluate clinical improvement. Discussion Despite the crucial role of the central nervous system in urinary control and its sensitivity to MS, there has been no treatment for urinary dysfunction targeting the brain centers that are involved in proper bladder function. This trial, to our knowledge, will be the first of its kind in humans to consider non-invasive and individualized cortical modulation for treating VD in MS patients. Results from this study will provide a better understanding of the brain control of neurogenic bladders and lay the foundation for a potential alternative therapy for VD in MS patients and other NLUTD in a larger neurogenic population in the future. Trial registration This trial is registered at ClinicalTrials.Gov (NCT03574610, 2 July 2018.) and Houston Methodist Research Institute IRB (PRO00019329)
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Affiliation(s)
- Khue Tran
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA
| | - Zhaoyue Shi
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
| | - Christof Karmonik
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
| | - Blessy John
- Department of Neurology, Houston Methodist Hospital, Houston, TX, USA
| | - Hamida Rajab
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA
| | - Santosh A Helekar
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, 6560 Fannin St. Suite 2100, Houston, TX, 77030, USA.
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14
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Groenendijk IM, Mehnert U, Groen J, Clarkson BD, Scheepe JR, Blok BFM. A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition. PLoS One 2021; 16:e0246042. [PMID: 33534812 PMCID: PMC7857581 DOI: 10.1371/journal.pone.0246042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 01/13/2021] [Indexed: 01/23/2023] Open
Abstract
Purpose Functional neuroimaging is a powerful and versatile tool to investigate central lower urinary tract (LUT) control. Despite the increasing body of literature there is a lack of comprehensive overviews on LUT control. Thus, we aimed to execute a coordinate based meta-analysis of all PET and fMRI evidence on descending central LUT control, i.e. pelvic floor muscle contraction (PFMC) and micturition. Materials and methods A systematic literature search of all relevant libraries was performed in August 2020. Coordinates of activity were extracted from eligible studies to perform an activation likelihood estimation (ALE) using a threshold of uncorrected p <0.001. Results 20 of 6858 identified studies, published between 1997 and 2020, were included. Twelve studies investigated PFMC (1xPET, 11xfMRI) and eight micturition (3xPET, 5xfMRI). The PFMC ALE analysis (n = 181, 133 foci) showed clusters in the primary motor cortex, supplementary motor cortex, cingulate gyrus, frontal gyrus, thalamus, supramarginal gyrus, and cerebellum. The micturition ALE analysis (n = 107, 98 foci) showed active clusters in the dorsal pons, including the pontine micturition center, the periaqueductal gray, cingulate gyrus, frontal gyrus, insula and ventral pons. Overlap of PFMC and micturition was found in the cingulate gyrus and thalamus. Conclusions For the first time the involved core brain areas of LUT motor control were determined using ALE. Furthermore, the involved brain areas for PFMC and micturition are partially distinct. Further neuroimaging studies are required to extend this ALE analysis and determine the differences between a healthy and a dysfunctional LUT. This requires standardization of protocols and task-execution.
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Affiliation(s)
- Ilse M. Groenendijk
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
- * E-mail:
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Becky D. Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jeroen R. Scheepe
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Bertil F. M. Blok
- Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
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15
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Shi Z, Tran K, Karmonik C, Boone T, Khavari R. 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. World J Urol 2021; 39:3525-3531. [PMID: 33512570 PMCID: PMC8344374 DOI: 10.1007/s00345-021-03599-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/08/2021] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Zhaoyue Shi
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
| | - Khue Tran
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Christof Karmonik
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA.
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16
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Are White Matter Tract Integrities Different in Multiple Sclerosis Women With Voiding Dysfunction? Female Pelvic Med Reconstr Surg 2021; 27:e101-e105. [PMID: 32265400 PMCID: PMC9744261 DOI: 10.1097/spv.0000000000000830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Two white matter tracts (WMTs) are proposed to be involved in bladder function: anterior thalamic radiation and superior longitudinal fasciculus. Multiple sclerosis (MS) patients with voiding dysfunction (VD) may have distinct changes in these 2 WMTs. This study aims to compare the fractional anisotropy (FA) and mean diffusivity (MD) from diffusion tensor imaging of MS females with and without VD versus healthy controls (HCs). METHODS Prospective observational cohorts of 28 female MS patients and 11 HCs were recruited. Multiple sclerosis patients were divided into 2 groups: voiders (patients without VD, n = 14) and VD (patients with VD, n = 14). Diffusion tensor imaging of each subject was obtained, from which FA and MD maps were generated. The mean FA and MD of each WMT on both sides were analyzed using one-way analysis of variance and pairwise comparison with adjusted P values. RESULTS Overall MS patients had significantly lower mean FA (loss of coherence) and significantly higher mean MD (increased free diffusion) than HCs in both WMTs, indicating more damage. Furthermore, VD showed a trend of loss of integrity in both WMTs when compared with voiders with lower FA and higher MD. CONCLUSIONS There is damage reflected by lower FA and higher MD values in the proposed WMTs involved in bladder function in MS women. Voiding dysfunction in this patient population can be attributed to these damages considering women with VD demonstrated a trend of deterioration in these WMTs compared with women without VD. Future studies with larger sample sizes should be done to further confirm this correlation.
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17
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Mawla I, Schrepf A, Ichesco E, Harte SE, Klumpp DJ, Griffith JW, Strachan E, Yang CC, Lai H, Andriole G, Magnotta VA, Kreder K, Clauw DJ, Harris RE, Clemens JQ, Landis JR, Mullins C, Rodriguez LV, Mayer EA, Kutch JJ. Natural bladder filling alters resting brain function at multiple spatial scales: a proof-of-concept MAPP Network Neuroimaging Study. Sci Rep 2020; 10:19901. [PMID: 33199816 PMCID: PMC7669903 DOI: 10.1038/s41598-020-76857-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/29/2020] [Indexed: 01/23/2023] Open
Abstract
Neural circuitry regulating urine storage in humans has been largely inferred from fMRI during urodynamic studies driven by catheter infusion of fluid into the bladder. However, urodynamic testing may be confounded by artificially filling the bladder repeatedly at a high rate and examining associated time-locked changes in fMRI signals. Here we describe and test a more ecologically-valid paradigm to study the brain response to bladder filling by (1) filling the bladder naturally with oral water ingestion, (2) examining resting state fMRI (rs-fMRI) which is more natural since it is not linked with a specific stimulus, and (3) relating rs-fMRI measures to self-report (urinary urge) and physiologic measures (voided volume). To establish appropriate controls and analyses for future clinical studies, here we analyze data collected from healthy individuals (N = 62) as part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. Participants orally ingested approximately 350 mL of water, and had a 10 min “fuller bladder” rs-fMRI scan approximately 1 h later. A second 10 min “empty bladder” rs-fMRI scan was conducted immediately following micturition. We examined multiple spatial scales of brain function, including local activity, circuits, and networks. We found changes in brain function distributed across micturition loci (e.g., subregions of the salience, sensorimotor, and default networks) that were significantly related to the stimulus (volume) and response (urinary urge). Based on our results, this paradigm can be applied in the future to study the neurobiological underpinnings of urologic conditions.
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Affiliation(s)
- Ishtiaq Mawla
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA.,Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Andrew Schrepf
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Eric Ichesco
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Steven E Harte
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - David J Klumpp
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - James W Griffith
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric Strachan
- Department of Psychiatry, University of Washington, Seattle, WA, USA
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Henry Lai
- Department of Anesthesiology, Washington University, St. Louis, MO, USA.,Division of Urologic Surgery, Department of Surgery, Washington University, St. Louis, MO, USA
| | - Gerald Andriole
- Division of Urologic Surgery, Department of Surgery, Washington University, St. Louis, MO, USA
| | | | - Karl Kreder
- Department of Urology, University of Iowa, Iowa City, IA, USA
| | - Daniel J Clauw
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Richard E Harris
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | | | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Mullins
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Larissa V Rodriguez
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Jason J Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 E. Alcazar Street, CHP 155, Los Angeles, CA, 90033, USA.
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18
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Past, Present, and Future in the Study of Neural Control of the Lower Urinary Tract. Int Neurourol J 2020; 24:191-199. [PMID: 33017890 PMCID: PMC7538290 DOI: 10.5213/inj.2040318.159] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
The neurological coordination of the lower urinary tract can be analyzed from the perspective of motor neurons or sensory neurons. First, sensory nerves with receptors in the bladder and urethra transmits stimuli to the cerebral cortex through the periaqueductal gray (PAG) of the midbrain. Upon the recognition of stimuli, the cerebrum carries out decision-making in response. Motor neurons are divided into upper motor neurons (UMNs) and lower motor neurons (LMNs) and UMNs coordinate storage and urination in the brainstem for synergic voiding. In contrast, LMNs, which originate in the spinal cord, cause muscles to contract. These neurons are present in the sacrum, and in particular, a specific neuron group called Onuf’s nucleus is responsible for the contraction of the external urethral sphincter and maintains continence in states of rising vesical pressure through voluntary contraction of the sphincter. Parasympathetic neurons originating from S2–S4 are responsible for the contraction of bladder muscles, while sympathetic neurons are responsible for contraction of the urethral smooth muscle, including the bladder neck, during the guarding reflex. UMNs are controlled in the pons where various motor stimuli to the LMNs are directed along with control to various other pelvic organs, and in the PAG, where complex signals from the brain are received and integrated. Future understanding of the complex mechanisms of micturition requires integrative knowledge from various fields encompassing these distinct disciplines.
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19
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Kreydin EI, Gad P, Gao B, Liu CY, Ginsberg DA, Jann K. The effect of stroke on micturition associated brain activity: A pilot fMRI study. Neurourol Urodyn 2020; 39:2198-2205. [PMID: 32761953 DOI: 10.1002/nau.24473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/25/2020] [Accepted: 07/09/2020] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Evgeniy I Kreydin
- Department of Urology, Keck School of Medicine of University of Southern California, Los Angeles, California.,Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California.,USC Neurorestoration Center, University of Southern California, Los Angeles, California
| | - Parag Gad
- Department of Neurobiology, University of California Los Angeles, Los Angeles, California
| | - Bingchen Gao
- Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Charles Y Liu
- Department of Urology, Keck School of Medicine of University of Southern California, Los Angeles, California.,Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California.,USC Neurorestoration Center, University of Southern California, Los Angeles, California
| | - David A Ginsberg
- Department of Urology, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Kay Jann
- Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of University of Southern California, Los Angeles, California
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20
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Bastide L, Herbaut AG. Cerebellum and micturition: what do we know? A systematic review. CEREBELLUM & ATAXIAS 2020; 7:9. [PMID: 32699638 PMCID: PMC7368785 DOI: 10.1186/s40673-020-00119-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 07/13/2020] [Indexed: 11/23/2022]
Abstract
Aims Micturition depends on a complex voluntary and involuntarily neuronal network located at various levels of the nervous system. The mechanism is highly dependent on the hierarchical organization of central nervous system pathways. If the role of the cortex and brainstem centres is well established, the role of other subcortical areas structures, such as the cerebellum is poorly understood. We are interested in discussing the current knowledge on the role of cerebellum in micturition. Methods A systematic search is performed in the medical literature, using the PubMed database with the keyword « cerebellum ». The latter is combined with «urination » OR « micturition » OR « urinary bladder ». Results Thirty-one articles were selected, focussing on micturition and describing the role of the cerebellum. They were grouped in 6 animal experimental studies, 20 functional brain imaging in micturition and 5 clinical studies. Conclusions Although very heterogeneous, experimental and clinical data clearly indicate the cerebellum role in the micturition control. Cerebellum modulates the micturition reflex and participates to the bladder sensory-motor information processing. The cerebellum is involved in the reflex micturition modulation through direct or indirect pathways to major brainstem or forebrain centres.
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Affiliation(s)
- Laure Bastide
- Service de Neurologie, Université Libre de Bruxelles-Hôpital Erasme, Route de Lennik 808, 1070 Bruxelles, Belgium
| | - Anne-Geneviève Herbaut
- Service de Neurologie, Université Libre de Bruxelles-Hôpital Erasme, Route de Lennik 808, 1070 Bruxelles, Belgium
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21
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Khavari R, Chen J, Boone T, Karmonik C. Brain activation patterns of female multiple sclerosis patients with voiding dysfunction. Neurourol Urodyn 2020; 39:969-977. [PMID: 32032447 DOI: 10.1002/nau.24304] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/23/2020] [Indexed: 12/20/2022]
Abstract
AIMS We compared brain activation patterns between female multiple sclerosis (MS) patients with voiding dysfunction (VD) and those without. We aim to expand current knowledge of supraspinal correlates of voiding initiation within a cohort of female MS patients with and without VD. MATERIALS AND METHODS Twenty-eight ambulatory female MS patients with stable disease and lower urinary tract dysfunction were recruited for this study. Subjects were divided into group 1, without VD (n = 14), and group 2, with VD (n = 14), defined as postvoid residual urine of ≥40% of maximum cystometric capacity or need for self-catheterization. We recorded brain activity via functional magnetic resonance imaging (fMRI) with simultaneous urodynamic testing. Average fMRI activation maps (the Student t test) were created for both groups, and areas of significant activation were identified (P < .05). A priori regions of interest (ROIs), identified by prior meta-analysis to be involved in voiding, were selected. RESULTS Group-averaged blood-oxygen level-dependent (BOLD) activation maps demonstrated significant differences between groups 1 and 2 during initiation of voiding with group 2 showing significantly lower levels of activation in all ROIs except for the left cerebellum and right cingulate gyrus. Interestingly, group 2 displayed negative BOLD signals, while group 1 displayed positive signals in the right and left pontine micturition center, right periaqueductal gray, left thalamus, and left cingulate gyrus. The activation map of group 1 was similar to healthy controls. CONCLUSIONS Our results support the hypothesis that distinct supraspinal activation patterns exist between female MS patients with VD and those without.
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Affiliation(s)
- Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Jessie Chen
- Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Christof Karmonik
- MRI Core, Research Institute, Houston Methodist Hospital, Houston, Texas
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22
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Khavari R, Hernandez N, Karmonik C, Shi Z, Miles B, Gonzalez RR. Higher neural contribution underlying persistent lower urinary tract symptoms in men with Benign Prostatic Hyperplasia undergoing bladder outlet procedures. Contemp Clin Trials Commun 2019; 17:100498. [PMID: 31886434 PMCID: PMC6920501 DOI: 10.1016/j.conctc.2019.100498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/10/2019] [Accepted: 11/21/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction and Background Benign Prostatic Hyperplasia (BPH) affects the micturition cycle. Lower urinary tract symptoms (LUTS) refers to storage symptoms such as urinary frequency, urgency, urge urinary incontinence and nocturia. Surgical options for bladder outlet obstruction (BOO) are currently offered for symptomatic improvement. However, 30% of patients report persistent LUTS after BOO procedures. Neuroplasticity induced by BPH and BOO can be contributory in these men, having different brain activation patterns during the micturition cycle. Our multimodal functional Magnetic Resonance Imaging (fMRI) study will identify for the first time, structural and functional brain contributions to LUTS in men with BPH and BOO at baseline and following BOO procedures. We hypothesize that men with symptomatic BPH with persistent LUTS following BOO procedures have a distinct brain activation pattern in regions of interest (ROIs) of the micturition cycle. Methods Male patients older than 45 years of age undergoing BOO procedures will be enrolled and categorized in two groups. Group 1: patients with BPH with significant improvement in storage symptoms after BOO procedures. Group 2: patients with BPH with persistent storage symptoms after BOO procedures. Our control group are male patients without LUTS undergoing radical prostatectomy. Patients will complete subjective questionnaires and post void residual at clinic visits. BOLD signals at full urge will be measured at baseline and following BOO procedures. All patients will undergo fMRI studies at baseline and at 6 months. Clinical data will be correlated to BOLD signal changes as well as to structural changes in white matter tracts. Ethics and dissemination After IRB approval, patients will be recruited and properly consented before enrolling to this study. Results of neural contribution to lower urinary tract symptoms will be presented at national and international meetings and will be published in scholarly journals.
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Affiliation(s)
- Rose Khavari
- Department of Urology, Houston Methodist Research Institute, Houston, Texas, USA
| | - Natalia Hernandez
- Department of Urology, Houston Methodist Research Institute, Houston, Texas, USA
| | - Christof Karmonik
- Department of MRI Core, Houston Methodist Research Institute, Houston, Texas, USA
| | - Zhaoyue Shi
- Department of MRI Core, Houston Methodist Research Institute, Houston, Texas, USA
| | - Brian Miles
- Department of Urology, Houston Methodist Research Institute, Houston, Texas, USA
| | - Ricardo R Gonzalez
- Department of Urology, Houston Methodist Research Institute, Houston, Texas, USA
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Abstract
Purpose of review Voiding dysfunction (VD) is morbid, costly, and leads to urinary tract infections, stones, sepsis, and permanent renal failure. Evaluation and diagnosis of VD in non-obstructed patients can be challenging. Potential diagnostic and therapeutic options beyond the bladder, such as brain centers involved in voiding have been proposed as promising targets. This review focuses on current and future applications of functional neuroimaging in human in voiding and in patients with VD. Recent findings The current understanding of brain centers, and their roles in initiating, maintaining and/or modulating voiding, is rudimentary in humans and in patients with VD. With the advent and advancement in functional neuroimaging we are gaining more insight into specific brain regions involved in the voiding phase of micturition. In healthy individuals, right dorsomedial pontine tegmentum, periaqueductal grey, hypothalamus, and the inferior, medial and superior frontal gyrus have been identified as regions of interest in voiding. Summary Functional neuroimaging could suggest new diagnostic methods and provides crucial steps towards therapeutic options for the morbid and intractable VD condition, in patients with neurogenic (e.g. MS or Strokes) or non-neurogenic VD (e.g. underactive bladder or Fowler's syndrome).
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Fröhlich K, Wang R, Bobinger T, Schmidt M, Dörfler A, Nickel FT, Hilz MJ, Lee DH, Linker RA, Seifert F, Winder K. Voxel-wise lesion mapping of self-reported urinary incontinence in multiple sclerosis. Neurourol Urodyn 2019; 39:295-302. [PMID: 31663158 DOI: 10.1002/nau.24194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/29/2019] [Indexed: 11/08/2022]
Abstract
AIMS Besides spinal lesions, urinary incontinence may be attributed to particular cerebral lesion sites in multiple sclerosis (MS) patients. We intended to determine the contribution of suprapontine lesions to urinary incontinence in MS using a voxel-wise lesion analysis. METHODS In this retrospective study, we sought MS patients with documented urinary incontinence in a local database. We established a control group of MS-patients without documented urinary incontinence matched for gender, age, and disease severity. Patients with urinary incontinence due to local diseases of the urinary tract were excluded. The MS lesions were analyzed on T2-weighted magnetic resonance imaging scans (1.5 or 3T). After manual delineation and transformation into stereotaxic space, we determined the lesion overlap and compared the presence or absence of urinary incontinence voxel-wise between patients with and without lesions in a given voxel performing the Liebermeister test with 4000 permutations. RESULTS A total of 56 patients with urinary incontinence and MS fulfilled the criteria and were included. The analysis yielded associations between urinary incontinence and MS in the frontal white matter, temporo-occipital, and parahippocampal regions. CONCLUSIONS Our voxel-wise analysis indicated associations between self-reported urinary incontinence and lesions in the left frontal white matter and right parahippocampal region. Thus, our data suggest that dysfunction of supraspinal bladder control due to cerebral lesions may contribute to the pathophysiology of urinary incontinence in MS.
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Affiliation(s)
- Kilian Fröhlich
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Tobias Bobinger
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Manuel Schmidt
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Florian T Nickel
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Frank Seifert
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Tran T, Wang PT, Lee B, Liu CY, Kreydin EI, Nenadic Z, Do AH. Electrocorticographic Activity of the Brain During Micturition. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:3622-3625. [PMID: 30441161 DOI: 10.1109/embc.2018.8513047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Current therapies for neurogenic bladder do not allow spinal cord injury patients to regain conscious control of urine storage or voiding. Novel neural technologies may provide means to improve or restore the connection between the brain and the bladder; however, the specific brain areas and their underlying neural activities responsible for micturition must be better understood in order to design such technologies. In this retrospective study, we analyzed electrocorticographic (ECoG) data obtained from epilepsy patients who underwent ECoG grid implantation for epilepsy surgery evaluation, in the hopes of determining specific electrophysiological activity associated with micturition. Our results indicate modulation of the delta (δ, 0.1-4 Hz) and low-gamma (\gamma, 25-50 Hz) activity in the peri-Sylvian area and the inferior temporal lobe. These findings suggest involvement of the insular cortex and the uncinate fasciculus in micturition, important structures related to sensation and decision making. To date, this is the first known study utilizing ECoG data to elucidate the electrophysiological activity of the brain associated with bladder control and sensation.
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Data-Driven Machine-Learning Quantifies Differences in the Voiding Initiation Network in Neurogenic Voiding Dysfunction in Women With Multiple Sclerosis. Int Neurourol J 2019; 23:195-204. [PMID: 31607098 PMCID: PMC6790826 DOI: 10.5213/inj.1938058.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/27/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To quantify the relative importance of brain regions responsible for reduced functional connectivity (FC) in their Voiding Initiation Network in female multiple sclerosis (MS) patients with neurogenic lower urinary tract dysfunction (NLUTD) and voiding dysfunction (VD). A data-driven machine-learning approach is utilized for quantification. METHODS Twenty-seven ambulatory female patients with MS and NLUTD (group 1: voiders, n=15 and group 2: VD, n=12) participated in a functional magnetic resonance imaging (fMRI) voiding study. Brain activity was recorded by fMRI with simultaneous urodynamic testing. The Voiding Initiation Network was identified from averaged fMRI activation maps. Four machine-learning algorithms were employed to optimize the area under curve (AUC) of the receiver-operating characteristic curve. The optimal model was used to identify the relative importance of relevant brain regions. RESULTS The Voiding Initiation Network exhibited stronger FC for voiders in frontal regions and stronger disassociation in cerebellar regions. Highest AUC values were obtained with 'random forests' (0.86) and 'partial least squares' algorithms (0.89). While brain regions with highest relative importance (>75%) included superior, middle, inferior frontal and cingulate regions, relative importance was larger than 60% for 186 of the 227 brain regions of the Voiding Initiation Network, indicating a global effect. CONCLUSION Voiders and VD patients showed distinctly different FC in their Voiding Initiation Network. Machine-learning is able to identify brain centers contributing to these observed differences. Knowledge of these centers and their connectivity may allow phenotyping patients to centrally focused treatments such as cortical modulation.
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Roy HA, Green AL. The Central Autonomic Network and Regulation of Bladder Function. Front Neurosci 2019; 13:535. [PMID: 31263396 PMCID: PMC6585191 DOI: 10.3389/fnins.2019.00535] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/08/2019] [Indexed: 12/30/2022] Open
Abstract
The autonomic nervous system (ANS) is involved in the regulation of physiologic and homeostatic parameters relating particularly to the visceral organs and the co-ordination of physiological responses to threat. Blood pressure and heart rate, respiration, pupillomotor reactivity, sexual function, gastrointestinal secretions and motility, and urine storage and micturition are all under a degree of ANS control. Furthermore, there is close integration between the ANS and other neural functions such as emotion and cognition, and thus brain regions that are known to be important for autonomic control are also implicated in emotional functions. In this review we explore the role of the central ANS in the control of the bladder, and the implications of this for bladder dysfunction in diseases of the ANS.
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Affiliation(s)
- Holly Ann Roy
- Department of Neurosurgery, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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Zuo L, Zhou Y, Wang S, Wang B, Gu H, Chen J. Abnormal Brain Functional Connectivity Strength in the Overactive Bladder Syndrome: A Resting-State fMRI Study. Urology 2019; 131:64-70. [PMID: 31150692 DOI: 10.1016/j.urology.2019.05.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the whole-brain functional connectivity strength (FCS) of patients with the overactive bladder syndrome (OAB). METHODS This study investigates the changes of intrinsic whole brain functional connectivity pattern in OAB using FCS. We acquired resting-state fMRI data from 26 OAB patients and 28 healthy controls. FCS was used to compute the long-range and short-range FCS values for each voxel in the brain of each subject. The long or short-range FCS maps were compared between OAB patients and healthy controls. Pearson's correlation coefficients was also performed between abnormal FCS regions and clinical/psychometric scores in patients. RESULTS Compared with healthy control subjects, the OAB patients exhibited significantly decreased short-range FCS in the right medial superior frontal gyrus and bilateral anterior cingulate gyrus, and increased short-range FCS in the middle frontal gyrus, the precentral gyrus, and bilateral caudate nucleus. In addition, significantly decreased long-range FCS was found in bilateral middle cingulate gyrus and posterior cingulate gyrus. Furthermore, the abnormal FCS values in the right caudate nucleus showed significantly negative correlation with Self-Rating Depression Scale of OAB patients. CONCLUSION Patients with OAB have abnormal short-range and long-range FCS in brain regions associated with brain-bladder network. Our study provides new insights into the underlying brain network topology of OAB.
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Affiliation(s)
- Long Zuo
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yang Zhou
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shuangkun Wang
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Biao Wang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hua Gu
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jingnan Chen
- School of Economics and Management, Beihang University, Beijing, China
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Karmonik C, Boone TB, Khavari R. Workflow for Visualization of Neuroimaging Data with an Augmented Reality Device. J Digit Imaging 2019; 31:26-31. [PMID: 28685319 DOI: 10.1007/s10278-017-9991-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Commercial availability of three-dimensional (3D) augmented reality (AR) devices has increased interest in using this novel technology for visualizing neuroimaging data. Here, a technical workflow and algorithm for importing 3D surface-based segmentations derived from magnetic resonance imaging data into a head-mounted AR device is presented and illustrated on selected examples: the pial cortical surface of the human brain, fMRI BOLD maps, reconstructed white matter tracts, and a brain network of functional connectivity.
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Affiliation(s)
- Christof Karmonik
- MRI core, Houston Methodist Hospital Research Institute, 6565 Fannin Street, Houston, TX, 77030, USA.
| | - Timothy B Boone
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
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Khavari R, Elias SN, Pande R, Wu KM, Boone TB, Karmonik C. Higher Neural Correlates in Patients with Multiple Sclerosis and Neurogenic Overactive Bladder Following Treatment with Intradetrusor Injection of OnabotulinumtoxinA. J Urol 2019; 201:135-140. [PMID: 30076906 DOI: 10.1016/j.juro.2018.07.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OnabotulinumtoxinA is a well described treatment of neurogenic overactive bladder. While motor effects on the detrusor muscle have been extensively studied, the sensory effects have not. The aim of this study was to evaluate the impact of intradetrusor onabotulinumtoxinA injection on brain activity in female patients with multiple sclerosis and neurogenic overactive bladder. MATERIALS AND METHODS We prospectively studied 12 women with stable multiple sclerosis and neurogenic overactive bladder using concurrent functional magnetic resonance imaging and urodynamic studies prior to and 6 to 10 weeks following onabotulinumtoxinA injection. Individual functional magnetic resonance imaging activation maps at the time of strong urgency were averaged before and after onabotulinumtoxinA injection where areas of significant activation were identified. RESULTS After onabotulinumtoxinA injection functional magnetic resonance imaging activation increased in the right cingulate body (p = 0.0012), the left posterior cingulate (p = 0.02), the left anterior cingulate (p = 0.0015), the right prefrontal cortex (p = 0.0015), the insula (p = 0.0138) and the pons micturition center (p = 0.05). Sparse areas showed decreased activity, including the left cerebellum (p = 0.001), the left fusiform gyrus (p = 0.065) and the bilateral lentiform nucleus (p = 0.026). CONCLUSIONS Intradetrusor injection of onabotulinumtoxinA appeared to increase the activity of most brain regions known to be involved in the sensation and process of urinary urgency in female patients with multiple sclerosis and neurogenic overactive bladder. To our knowledge this is the first study of its kind to evaluate the possible effects of onabotulinumtoxinA at the human brain level where sensory awareness is located. This activation pattern may be used to further phenotype patients to optimize therapy or determine the sensory effects of onabotulinumtoxinA beyond the bladder.
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Affiliation(s)
- Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Saba N Elias
- MRI Core, Houston Methodist Research Institute, Houston, Texas
| | - Rashmi Pande
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Katherine M Wu
- MRI Core, Houston Methodist Research Institute, Houston, Texas
| | - Timothy B Boone
- Department of Urology, Houston Methodist Hospital, Houston, Texas
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Roy HA, Griffiths DJ, Aziz TZ, Green AL, Menke RAL. Investigation of urinary storage symptoms in Parkinson's disease utilizing structural MRI techniques. Neurourol Urodyn 2019; 38:1168-1175. [PMID: 30869824 DOI: 10.1002/nau.23976] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/17/2019] [Accepted: 02/26/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Lower urinary tract symptoms occur in 27% to 86% of patients with Parkinson's disease (PD), however, the mechanisms responsible for bladder dysfunction are not fully understood. This study utilized magnetic resonance imaging (MRI) to test the hypothesis that key brainstem bladder control areas (including the pontine micturition center and the pontine continence center (PCC) and their links with the basal ganglia are important in the development of urinary storage symptoms in PD. METHODS Seventeen patients with PD completed a "bladder symptom questionnaire" and underwent diffusion-weighted MRI (1.5 T). Storage symptom severity and MRI measures of white matter microstructural integrity were correlated using tract-based spatial statistics. RESULTS Mean diffusivity in the ventral brainstem correlated significantly with the bladder symptom severity in areas close to the predicted anatomical co-ordinates of the PCC. Tracts seeded from these regions passed via areas involved in pelvic floor musculature control and urinary voiding including the cerebellum, pallidum, and precentral gyrus. CONCLUSION We used diffusion-weighted MRI to investigate the role of the brainstem and its structural connections in the development of urinary storage symptoms in PD. Our data suggest that the brainstem degenerative change in the vicinity of the PCC may be implicated in the pathogenesis of storage symptoms in these patients.
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Affiliation(s)
- Holly A Roy
- Department of Functional Neurosurgery, John Radcliffe Hospital, Oxford, United Kingdom.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Derek J Griffiths
- Division of Geriatric Medicine and Institute on Ageing (retired), University of Pittsburgh
| | - Tipu Z Aziz
- Department of Functional Neurosurgery, John Radcliffe Hospital, Oxford, United Kingdom.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Alexander L Green
- Department of Functional Neurosurgery, John Radcliffe Hospital, Oxford, United Kingdom.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Ricarda A L Menke
- Oxford Centre for Functional Magnetic Resonance of the Brain, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, United Kingdom.,Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Harvie C, Weissbart SJ, Kadam-Halani P, Rao H, Arya LA. Brain activation during the voiding phase of micturition in healthy adults: A meta-analysis of neuroimaging studies. Clin Anat 2018; 32:13-19. [PMID: 30069958 DOI: 10.1002/ca.23244] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 01/06/2023]
Abstract
Several studies have used a variety of neuroimaging techniques to measure brain activity during the voiding phase of micturition. However, there is a lack of consensus on which regions of the brain are activated during voiding. The aim of this meta-analysis is to identify the brain regions that are consistently activated during voiding in healthy adults across different studies. We searched the literature for neuroimaging studies that reported brain co-ordinates that were activated during voiding. We excluded studies that reported co-ordinates only for bladder filling, during pelvic floor contraction only, and studies that focused on abnormal bladder states such as the neurogenic bladder. We used the activation-likelihood estimation (ALE) approach to create a statistical map of the brain and identify the brain co-ordinates that were activated across different studies. We identified nine studies that reported brain activation during the task of voiding in 91 healthy subjects. Together, these studies reported 117 foci for ALE analysis. Our ALE map yielded six clusters of activation in the pons, cerebellum, insula, anterior cingulate cortex (ACC), thalamus, and the inferior frontal gyrus. Regions of the brain involved in executive control (frontal cortex), interoception (ACC, insula), motor control (cerebellum, thalamus), and brainstem (pons) are involved in micturition. This analysis provides insight into the supraspinal control of voiding in healthy adults and provides a framework to understand dysfunctional voiding. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Camryn Harvie
- Division of Urogynecology, Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Weissbart
- Department of Urology, Stony Brook School of Medicine, Stony Brook, New York
| | - Priyanka Kadam-Halani
- Division of Urogynecology, Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hengyi Rao
- Center for Functional Neuroimaging, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lily A Arya
- Division of Urogynecology, Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
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Khavari R, Elias SN, Boone T, Karmonik C. Similarity of functional connectivity patterns in patients with multiple sclerosis who void spontaneously versus patients with voiding dysfunction. Neurourol Urodyn 2018; 38:239-247. [PMID: 30311665 DOI: 10.1002/nau.23837] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/08/2018] [Indexed: 12/15/2022]
Abstract
AIM To investigate if Multiple Sclerosis (MS) lesion characteristics affect functional brain connectivity (FC) during bladder voiding. METHODS Twenty-seven ambulatory female patients with MS completed our functional magnetic resonance imaging (fMRI)/urodynamic testing (UDS) platform. Individual fMRI activation maps were generated at initiation of voiding. FC patterns of these regions were calculated and compared. Similarity of the FC pattern from one patient relative to all others was expressed by a parameter FC_sim. A statistical analysis was performed to reveal the relationship of the existence of an enhancing brain lesion, the size of the largest lesion and the ability to void spontaneously to this FC similarity measure. RESULTS FC_sim values were significantly lower for patients with an enhancing MS lesion (11.7 ± 3.1 vs 5.3 ± 2.1 P < 0.001). Lesion size smaller than 20 mm inversely correlated significantly with FC_sim (R = -0.43, P = 0.05). Patients with the ability to void spontaneously had a higher FC_sim value (12.0 ± 2.8 vs 9.3 ± 4.4 s, P = 0.08). Patients that exhibited a decrease of compliance also showed a significantly lower FC_sim value (11.3 ± 3.5 vs 4.7 ± 0.7, P < 1e-5). CONCLUSION FC connectivity analysis derived from an fMRI task-based study including repetitive voiding cycles is able to quantify the heterogeneity of connectivity patterns in the brain of MS patients. FC similarity decreased with maximum lesion size or the presence of enhancing lesions affecting the ability to void spontaneously.
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Affiliation(s)
- Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Saba N Elias
- Houston Methodist Research Institute, MRI Core, Huston, Texas
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, Houston, Texas
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Clarkson BD, Karim HT, Griffiths DJ, Resnick NM. Functional connectivity of the brain in older women with urgency urinary incontinence. Neurourol Urodyn 2018; 37:2763-2775. [PMID: 30054930 DOI: 10.1002/nau.23766] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/19/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND The brain's role in continence is critical but poorly understood. Although regions activated during bladder stimulation have been identified, little is known about the interaction between regions. In this secondary analysis we evaluate resting state and effective connectivity in older women treated for urgency urinary incontinence (UUI). METHOD 54 women ≥60 years old with UUI and 10 continent women underwent fMRI scanning during provocation of urinary urgency, both before and after therapy. Response was defined by >50% reduction in leaks on bladder diary. Regions of interest (RoIs) were selected a priori: right insula, medial prefrontal cortex, and dorsal anterior cingulate cortex. Generalized psycho-physiological interaction (gPPI) was used to calculate "effective connectivity" between RoIs during urgency. We performed a one-way ANOVA pre-treatment between groups (continent/responders/non-responders), as well as a two-way mixed ANOVA between group and time (responders/non-responders; pre-/post-therapy) using false discovery rate (FDR) correction. Principal component analysis was used to assess the variance within RoIs. Exploratory voxel-wise connectivity analyses were conducted between each RoI and the rest of the brain. RESULTS RoI-RoI connectivity analysis showed connectivity differences between controls, responders, and non-responders, although statistical significance was lost after extensive correction. Principal component analysis confirmed appropriate RoI selection. Voxel-wise analyses showed that connectivity in responders became more like that of controls after therapy (cluster-wise correction P < 0.05). In non-responders, no consistent changes were seen. CONCLUSION These data support the postulate that responders and non-responders to therapy may represent different subsets of UUI, one with more of a central etiology, and one without.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Helmet T Karim
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek J Griffiths
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neil M Resnick
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Re: Test-Retest Repeatability of Patterns of Brain Activation Provoked by Bladder Filling. J Urol 2018; 199:1403. [DOI: 10.1016/j.juro.2018.03.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Central Regulation of Micturition and Its Association With Epilepsy. Int Neurourol J 2018; 22:2-8. [PMID: 29609418 PMCID: PMC5885137 DOI: 10.5213/inj.1836040.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/20/2018] [Indexed: 01/23/2023] Open
Abstract
Micturition is a complex process involving the bladder, spinal cord, and the brain. Highly sophisticated central neural program controls bladder function by utilizing multiple brain regions, including pons and suprapontine structures. Periaqueductal grey, insula, anterior cingulate cortex, and medial prefrontal cortex are components of suprapontine micturition centers. Under pathologic conditions such as epilepsy, urinary dysfunction is a frequent symptom and it seems to be associated with increased suprapontine cortical activity. Interestingly, micturition can also trigger seizures known as reflex epilepsy. During voiding behavior, frontotemporal cortical activation has been reported and it may induce reflex seizures. As current researches are only limited to present clinical cases, more rigorous investigations are needed to elucidate biological mechanisms of micturition to advance our knowledge on the process of micturition in physiology and pathology.
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Roy HA, Aziz TZ, Fitzgerald JJ, Green AL. Beta oscillations and urinary voiding in Parkinson disease. Neurology 2018; 90:e1530-e1534. [PMID: 29572280 DOI: 10.1212/wnl.0000000000005355] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/18/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To investigate the role of beta oscillations in urinary voiding and their association with lower urinary tract symptoms in Parkinson disease (PD). METHODS We used surgically implanted deep brain stimulation electrodes to record local field potential signals from the subthalamic nucleus (STN) and globus pallidus interna (GPi) of patients with PD during urinary voiding. Five patients with STN electrodes and 5 patients with GPi electrodes were tested. We also explored correlations between beta oscillatory power and urinary symptoms assessed by the International Consultation on Incontinence Lower Urinary Tract Symptoms questionnaire. RESULTS Beta suppression occurred during urinary voiding in the GPi (p < 0.05) but not the STN. Furthermore, the beta signal in the GPi during voiding correlated significantly with severity of incontinence and urinary frequency (p < 0.05). CONCLUSIONS In this study, we have demonstrated that local field potentials can provide information about the neural control of the bladder. Our findings suggest that the GPi is implicated in the process of urinary voiding and that its mechanism of action is linked to signals in the beta frequency band. Moreover, our correlational analyses show that beta oscillations may be implicated more generally in the pathophysiology of lower urinary tract symptoms in PD.
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Affiliation(s)
- Holly A Roy
- From the Department of Functional Neurosurgery (H.A.R., T.Z.A., J.J.F., A.L.G.) and Nuffield Department of Surgical Sciences (H.A.R., T.Z.A., J.J.F., A.L.G.), John Radcliffe Hospital, Oxford; and Department of Neurosurgery (H.A.R.), Derriford Hospital, Plymouth, UK.
| | - Tipu Z Aziz
- From the Department of Functional Neurosurgery (H.A.R., T.Z.A., J.J.F., A.L.G.) and Nuffield Department of Surgical Sciences (H.A.R., T.Z.A., J.J.F., A.L.G.), John Radcliffe Hospital, Oxford; and Department of Neurosurgery (H.A.R.), Derriford Hospital, Plymouth, UK
| | - James J Fitzgerald
- From the Department of Functional Neurosurgery (H.A.R., T.Z.A., J.J.F., A.L.G.) and Nuffield Department of Surgical Sciences (H.A.R., T.Z.A., J.J.F., A.L.G.), John Radcliffe Hospital, Oxford; and Department of Neurosurgery (H.A.R.), Derriford Hospital, Plymouth, UK
| | - Alexander L Green
- From the Department of Functional Neurosurgery (H.A.R., T.Z.A., J.J.F., A.L.G.) and Nuffield Department of Surgical Sciences (H.A.R., T.Z.A., J.J.F., A.L.G.), John Radcliffe Hospital, Oxford; and Department of Neurosurgery (H.A.R.), Derriford Hospital, Plymouth, UK
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Naimi HA, Speich JE, Klausner AP. NEW CONCEPTS IN BLADDER SENSATION AND URINARY URGENCY. CURRENT BLADDER DYSFUNCTION REPORTS 2018; 13:132-138. [PMID: 31819779 DOI: 10.1007/s11884-018-0474-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of Review The purpose of this review is to summarize the current state of knowledge regarding the evaluation and measurement of urinary urgency and bladder sensation. Recent Findings New technologies have been developed to improve our diagnostic capabilities in urinary urgency and bladder sensation. Recent developments include MRI-based neuroimaging and novel tablet-based sensation meters that can be used during urodynamics as well as during oral hydration. Summary Commonly used metrics for urinary urgency and bladder sensation include the use of validated surveys/void diaries and standardized verbal sensory thresholds during urodynamics. However, these metrics are highly subjective and prone to significant bias. There has been an evolution in evaluation metrics ranging from the use of reflex testing to electrical perception testing to the use of neuroimaging and the development of sensation meters. Neuroimaging allows for mapping of specific brain areas involved in the different phases of voiding and provides an anatomic basis for different forms of overactive bladder. The sensation meter allows for generation of real-time sensation-capacity curves which enables easy and objective comparison between patients as well as potential sub-typing of different forms of overactive bladder. In addition, new research supports the concept of differing forms of urgency and the use of novel patient-derived terminologies for urinary urgency and bladder sensation.
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Affiliation(s)
- Hameeda A Naimi
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - John E Speich
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University School of Engineering, Richmond, Virginia
| | - Adam P Klausner
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia & the Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA
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New frontiers in molecular and imaging research on evaluation and diagnosis of bladder outlet obstruction in women. CURRENT BLADDER DYSFUNCTION REPORTS 2017; 12:291-297. [PMID: 29225720 DOI: 10.1007/s11884-017-0429-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose Diagnosis of bladder outlet obstruction (BOO) often presents a challenge in female patients. Traditional diagnostic elements such as symptom history and urodynamic data are rarely clear cut in women. Therefore, we sought to review the current literature on diagnosis of female BOO, focusing on new frontiers in the realm of molecular markers and imaging modalities. Recent Findings In addition to fluoroscopy in the setting of videourodynamics, ultrasound and MRI can augment the diagnosis and aid in therapeutic planning in certain etiologies of female BOO. Furthermore, multiple potential biomarkers (i.e. nerve growth factor, prostaglandins, ATP) that have been studied in correlation to BOO in animal models as well as human subjects hold promise for diagnostic applications. Summary These novel techniques may augment standard clinical and urodynamic evaluation of BOO in females. Future directions include further studies of each of these biomarkers in female patients with BOO compared to normal controls to test their feasibility as potential screening tools.
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Vigneswaran H, Abhyankar N, Kocjancic E. Using Advanced Imaging Including MRI to Detect Voiding Dysfunction in Neurogenic Bladder and Fowler Syndrome. CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0453-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Roy HA, Pond D, Roy C, Forrow B, Foltynie T, Zrinzo L, Akram H, Aziz TZ, FitzGerald JJ, Green AL. Effects of pedunculopontine nucleus stimulation on human bladder function. Neurourol Urodyn 2017; 37:726-734. [DOI: 10.1002/nau.23321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 04/11/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Holly A. Roy
- Department of Neurosurgery; Oxford University Hospitals Trust; Oxford UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - Debbie Pond
- OUH Adult Continence Service, Infection Control Department; Oxford University Hospitals Trust; Oxford UK
| | | | - Beth Forrow
- Department of Neurosurgery; Oxford University Hospitals Trust; Oxford UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience and Movement Disorders; University College London, Institute of Neurology; London UK
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience and Movement Disorders; University College London, Institute of Neurology; London UK
| | - Harith Akram
- Sobell Department of Motor Neuroscience and Movement Disorders; University College London, Institute of Neurology; London UK
| | - Tipu Z. Aziz
- Department of Neurosurgery; Oxford University Hospitals Trust; Oxford UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - James J. FitzGerald
- Department of Neurosurgery; Oxford University Hospitals Trust; Oxford UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - Alexander L. Green
- Department of Neurosurgery; Oxford University Hospitals Trust; Oxford UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
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Pasquet T, Durigneux J, Anselmetti A, Tessiot C, Beaumesnil M, Delion M, Dinomais M. Voiding dysfunction after isolated cerebellum stroke in a teenager. Ann Phys Rehabil Med 2017; 60:270-273. [PMID: 28438563 DOI: 10.1016/j.rehab.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Thibault Pasquet
- Physical Medicine and Rehabilitation Department, Pontchaillou University Hospital, 2, rue Henri-le-Guilloux, 35033 Rennes cedex 9, France.
| | - Julien Durigneux
- Department of Pediatric Physical and Rehabilitation Medicine, Centre des Capucins, 49933 Angers, France; LUNAM, University of Angers, Department of Pediatric Neurology, 49933 Angers, France
| | - Amélie Anselmetti
- Department of Pediatric Physical and Rehabilitation Medicine, Centre des Capucins, 49933 Angers, France
| | - Chantal Tessiot
- Department of Pediatric Physical and Rehabilitation Medicine, Centre des Capucins, 49933 Angers, France
| | - Marion Beaumesnil
- Department of Pediatric Physical and Rehabilitation Medicine, Centre des Capucins, 49933 Angers, France
| | - Matthieu Delion
- LUNAM, University of Angers, Department of Neurosurgery, 49933 Angers, France; LUNAM, University of Angers, Anatomy Laboratory, 49045 Angers, France
| | - Mickael Dinomais
- Department of Pediatric Physical and Rehabilitation Medicine, Centre des Capucins, 49933 Angers, France; LUNAM; University of Angers, Department of Physical and Rehabilitation Medicine, CHU Angers, 49933 Angers, France
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Elizondo RA, Karmonik C, Boone TB, Khavari R. Protocol for a prospective observational study of cortical lower urinary tract control changes following intradetrusor injection of botulinum toxin-A in patients with multiple sclerosis. BMJ Open 2017; 7:e013225. [PMID: 28159850 PMCID: PMC5293986 DOI: 10.1136/bmjopen-2016-013225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) is a severe debilitating disease that affects patients' quality of life. Up to 90% of patients with MS will develop lower urinary tract dysfunction within the first 18 years of the disease. If oral pharmacotherapy with anticholinergics, behavioural modifications and pelvic floor physical therapy are unsuccessful, intradetrusor injection of botulinum toxin-A (OnaBotA; Botox Allergan, Dublin, Ireland) is a highly effective option for these patients. The local effects of OnaBotA are well understood, but not much is known of its afferent/sensory effects while treating the end organ. Our study will use functional MRI (fMRI) and task-related blood oxygen level-dependent signals to evaluate patients with MS and neurogenic detrusor overactivity (NDO) prior to, and after, intradetrusor injection of OnaBotA with simultaneous urodynamic evaluation. Urinary concentration of brain-derived neurotrophic factor and nerve growth factor will also be collected since it has been shown that patients with an overactive bladder have higher concentrations of these neuropeptides. METHODS AND ANALYSIS Female patients with MS and lower urinary tract symptoms who previously have undergone urodynamic screening and are refractory to conservative and oral pharmacotherapy management for NDO and are interested in OnaBotA intradetrusor injection will be invited to participate in the study. An fMRI will be performed preintradetrusor injection and postintradetrusor injection of OnaBotA with simultaneous MRI compatible with material urodynamics. Images will be collected and analysed accordingly. ETHICS AND DISSEMINATION All of the patients are properly consented before enrolling in this study that has been previously approved by the Institutional Review Board. Results of neural connectivity activation will be presented at national and international meetings and published in scholarly journals.
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Affiliation(s)
- Rodolfo A Elizondo
- Department of Pediatric Urology, Texas Children's Hospital, Houston, Texas, USA
| | - Christof Karmonik
- Department of MRI Core, Methodist Research Institute, Houston, Texas, USA
| | - Timothy B Boone
- Department of Urology, Methodist Hospital, Houston, Texas, USA
| | - Rose Khavari
- Department of Urology, Methodist Hospital, Houston, Texas, USA
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Clarkson BD, Tyagi S, Griffiths DJ, Resnick NM. Test-retest repeatability of patterns of brain activation provoked by bladder filling. Neurourol Urodyn 2016; 36:1472-1478. [PMID: 27778370 DOI: 10.1002/nau.23153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/15/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess short-term repeatability of an fMRI protocol widely used to assess brain control of the bladder. fMRI offers the potential to discern incontinence phenotypes as well as the mechanisms mediating therapeutic response. If so, this could enable more targeted efforts to enhance therapy. Such data, however, require excellent test-retest repeatability. METHODS Fifty-nine older women (age ≥60 years) with urgency incontinence underwent two fMRI scans within 5-10 min with a concurrent bladder infusion/withdrawal protocol. Activity in three brain regions relevant to bladder control was compared using paired t tests and intra-class correlation. RESULTS There were no statistically significant differences in brain activity between the two consecutive scans in the regions of interest. Intra-class correlation was 0.19 in the right insula, 0.32 in the dorsal anterior cingulate cortex/supplementary motor area, and 0.44 in the medial pre-frontal cortex. Such correlations are considered fair or poor, but are comparable to those from studies of other repeated fMRI tasks. CONCLUSIONS This is the first evaluation of the repeatability of a bladder fMRI protocol. The technique used provides a framework for comparing different fMRI protocols applied to brain-bladder research. Despite universal patient response to the stimulus, brain response had limited repeatability within individuals. Improvement of the investigational protocol should magnify brain response and reduce variability. These results suggest that although analysis of fMRI data among groups of subjects yields valuable insight into bladder control, fMRI is not yet appropriate for evaluation of the brain's role in continence on an individual level.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shachi Tyagi
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek J Griffiths
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neil M Resnick
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Nagle AS, Speich JE, De Wachter SG, Ghamarian PP, Le DM, Colhoun AF, Ratz PH, Barbee RW, Klausner AP. Non-invasive characterization of real-time bladder sensation using accelerated hydration and a novel sensation meter: An initial experience. Neurourol Urodyn 2016; 36:1417-1426. [PMID: 27654469 DOI: 10.1002/nau.23137] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 08/29/2016] [Indexed: 12/20/2022]
Abstract
AIMS The purpose of this investigation was to develop a non-invasive, objective, and unprompted method to characterize real-time bladder sensation. METHODS Volunteers with and without overactive bladder (OAB) were prospectively enrolled in a preliminary accelerated hydration study. Participants drank 2L Gatorade-G2® and recorded real-time sensation (0-100% scale) and standardized verbal sensory thresholds using a novel, touch-screen "sensation meter." 3D bladder ultrasound images were recorded throughout fillings for a subset of participants. Sensation data were recorded for two consecutive complete fill-void cycles. RESULTS Data from 14 normal and 12 OAB participants were obtained (ICIq-OAB-5a = 0 vs. ≥3). Filling duration decreased in fill2 compared to fill1, but volume did not significantly change. In normals, adjacent verbal sensory thresholds (within fill) showed no overlap, and identical thresholds (between fill) were similar, demonstrating effective differentiation between degrees of %bladder capacity. In OAB, within-fill overlaps and between-fill differences were identified. Real-time %capacity-sensation curves left shifted from fill1 to fill2 in normals, consistent with expected viscoelastic behavior, but unexpectedly right shifted in OAB. 3D ultrasound volume data showed that fill rates started slowly and ramped up with variable end points. CONCLUSIONS This study establishes a non-invasive means to evaluate real-time bladder sensation using a two-fill accelerated hydration protocol and a sensation meter. Verbal thresholds were inconsistent in OAB, and the right shift in OAB %capacity-sensation curve suggests potential biomechanical and/or sensitization changes. This methodology could be used to gain valuable information on different forms of OAB in a completely non-invasive way.
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Affiliation(s)
- Anna S Nagle
- Department of Mechanical & Nuclear Engineering, Virginia Commonwealth University School of Engineering, Richmond, Virginia
| | - John E Speich
- Department of Mechanical & Nuclear Engineering, Virginia Commonwealth University School of Engineering, Richmond, Virginia
| | - Stefan G De Wachter
- Department of Urology, University Hospital Antwerpen, Edegem, University of Antwerpen, Wilrijk, Belgium
| | - Peter P Ghamarian
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - David M Le
- Department of Biomedical Engineering, Virginia Commonwealth University School of Engineering, Richmond, Virginia
| | - Andrew F Colhoun
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Paul H Ratz
- Department of Biochemistry & Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Robert W Barbee
- Department of Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Adam P Klausner
- Department of Surgery/Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia.,Department of Surgery/Division of Urology Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
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Khavari R, Karmonik C, Shy M, Fletcher S, Boone T. Functional Magnetic Resonance Imaging with Concurrent Urodynamic Testing Identifies Brain Structures Involved in Micturition Cycle in Patients with Multiple Sclerosis. J Urol 2016; 197:438-444. [PMID: 27664581 DOI: 10.1016/j.juro.2016.09.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 01/05/2023]
Abstract
PURPOSE Neurogenic lower urinary tract dysfunction, which is common in patients with multiple sclerosis, has a significant impact on quality of life. In this study we sought to determine brain activity processes during the micturition cycle in female patients with multiple sclerosis and neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS We report brain activity on functional magnetic resonance imaging and simultaneous urodynamic testing in 23 ambulatory female patients with multiple sclerosis. Individual functional magnetic resonance imaging activation maps at strong desire to void and at initiation of voiding were calculated and averaged at Montreal Neuroimaging Institute. Areas of significant activation were identified in these average maps. Subgroup analysis was performed in patients with elicitable neurogenic detrusor overactivity or detrusor-sphincter dyssynergia. RESULTS Group analysis of all patients at strong desire to void yielded areas of activation in regions associated with executive function (frontal gyrus), emotional regulation (cingulate gyrus) and motor control (putamen, cerebellum and precuneus). Comparison of the average change in activation between previously reported healthy controls and patients with multiple sclerosis showed predominantly stronger, more focal activation in the former and lower, more diffused activation in the latter. Patients with multiple sclerosis who had demonstrable neurogenic detrusor overactivity and detrusor-sphincter dyssynergia showed a trend toward distinct brain activation at full urge and at initiation of voiding respectively. CONCLUSIONS We successfully studied brain activation during the entire micturition cycle in female patients with neurogenic lower urinary tract dysfunction and multiple sclerosis using a concurrent functional magnetic resonance imaging/urodynamic testing platform. Understanding the central neural processes involved in specific parts of micturition in patients with neurogenic lower urinary tract dysfunction may identify areas of interest for future intervention.
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Affiliation(s)
- Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, Texas.
| | | | - Michael Shy
- Innovative Urology Practice of New York, Queens, New York
| | | | - Timothy Boone
- Department of Urology, Houston Methodist Hospital, Houston, Texas
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Deruyver Y, Hakim L, Franken J, De Ridder D. The use of imaging techniques in understanding lower urinary tract (dys)function. Auton Neurosci 2016; 200:11-20. [PMID: 27477680 DOI: 10.1016/j.autneu.2016.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/22/2015] [Accepted: 05/23/2016] [Indexed: 12/11/2022]
Abstract
The ability to store urine in the bladder and to void at an appropriate time depends on several complex mechanisms in the lower urinary tract (LUT) and its neural control. Normal LUT function requires coordination of the urinary bladder, urethra, pelvic floor, efferent and afferent neurons and specific spinal cord and brain areas. These structures can be visualised using different imaging modalities, such as ultrasound, X-ray and magnetic resonance imaging. The supraspinal neural control of the LUT can be studied using functional brain imaging. During the last two decades, the many technological improvements of these imaging techniques have increased our knowledge of voiding dysfunction. Here, we review the different imaging modalities of the LUT and its neural control and discuss their importance for diagnosing and understanding voiding dysfunction.
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Affiliation(s)
- Yves Deruyver
- Laboratory of Experimental Urology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Lukman Hakim
- Laboratory of Experimental Urology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Airlangga University School of Medicine and Dr. Soetomo General Hospital, Department of Urology, Surabaya, Indonesia
| | - Jan Franken
- Laboratory of Experimental Urology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Dirk De Ridder
- Laboratory of Experimental Urology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
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Karmonik C, Brandt A, Anderson J, Brooks F, Lytle J, Silverman E, Frazier JT. Music Listening modulates Functional Connectivity and Information Flow in the Human Brain. Brain Connect 2016; 6:632-641. [PMID: 27464741 DOI: 10.1089/brain.2016.0428] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Listening to familiar music has recently been reported to be beneficial during recovery from stroke. A better understanding of changes in functional connectivity and information flow is warranted in order to further optimize and target this approach through music therapy. Twelve healthy volunteers listened to seven different auditory samples during an fMRI scanning session: a musical piece chosen by the volunteer that evokes a strong emotional response (referred to as: "self-selected emotional"), two unfamiliar music pieces (Invention #1 by J. S. Bach* and Gagaku - Japanese classical opera, referred to as "unfamiliar"), the Bach piece repeated with visual guidance (DML: Directed Music Listening) and three spoken language pieces (unfamiliar African click language, an excerpt of emotionally charged language, and an unemotional reading of a news bulletin). Functional connectivity and betweenness (BTW) maps, a measure for information flow, were created with a graph-theoretical approach. Distinct variation in functional connectivity was found for different music pieces consistently for all subjects. Largest brain areas were recruited for processing self-selected music with emotional attachment or culturally unfamiliar music. Maps of information flow correlated significantly with fMRI BOLD activation maps (p<0.05). Observed differences in BOLD activation and functional connectivity may help explain previously observed beneficial effects in stroke recovery, as increased blood flow to damaged brain areas stimulated by active engagement through music listening may have supported a state more conducive to therapy.
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Affiliation(s)
- Christof Karmonik
- Houston Methodist Research Institute, 167626, Houston, Texas, United States ;
| | - Anthony Brandt
- Rice University, 3990, Shepard School of Music, Houston, Texas, United States ;
| | - Jeff Anderson
- Houston Methodist Research Institute, 167626, Houston, Texas, United States ;
| | - Forrest Brooks
- Houston Methodist Hospital, 23534, Center for Performing Arts Medicine, Houston, Texas, United States ;
| | - Julie Lytle
- Houston Methodist Hospital, 23534, Center for Performing Arts Medicine, Houston, Texas, United States ;
| | - Elliott Silverman
- Lahey Hospital and Medical Center Burlington, 2094, Burlington, Massachusetts, United States ;
| | - Jeff T Frazier
- Houston Methodist Hospital, 23534, Center for Performing Arts Medicine, Houston, Texas, United States ;
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50
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Arya NG, Weissbart SJ, Xu S, Rao H. Brain activation in response to bladder filling in healthy adults: An activation likelihood estimation meta-analysis of neuroimaging studies. Neurourol Urodyn 2016; 36:960-965. [PMID: 27367364 DOI: 10.1002/nau.23058] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/30/2016] [Indexed: 01/23/2023]
Abstract
AIMS Recent studies have used different neuroimaging techniques and identified various brain regions that are activated during bladder filling. However, there is a lack of consensus regarding which of these brain regions regulate the process of urine storage. The aim of this meta-analysis is to identify brain regions that are commonly activated during bladder filling in healthy adults across different studies. METHODS PubMed was searched for neuroimaging studies investigating the effects of bladder filling on regional brain activation. Studies were excluded if they did not report brain activation differences from whole-brain group analysis by comparing the state of bladder filling with the state of bladder rest. The current version of the activation likelihood estimation (ALE) approach was used for meta-analysis. RESULTS We identified 14 neuroimaging studies examining brain activation in response to experimental bladder filling in 181 healthy subjects, which reported 89 foci for ALE analysis. The meta-analysis revealed significant activation in multiple brain regions including thalamus (bilaterally), right insula, cerebellum, and brainstem (bilaterally). CONCLUSIONS Several key brain regions involved in sensory processing are commonly activated during bladder filling in healthy adults across different studies. Neurourol. Urodynam. 36:960-965, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Nisha G Arya
- Division of Urogynecology, Department of Obstetrics and Gynecology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Weissbart
- Division of Urogynecology, Department of Obstetrics and Gynecology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sihua Xu
- Laboratory of Applied Brain and Cognitive Sciences, Shanghai International Studies University, Shanghai, China.,Center for Functional Neuroimaging, Department of Neurology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hengyi Rao
- Laboratory of Applied Brain and Cognitive Sciences, Shanghai International Studies University, Shanghai, China.,Center for Functional Neuroimaging, Department of Neurology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
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