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Wöllner J, Krebs J, Richter JK, Neuenschwander J, Gunziger A, Hunkeler N, Abramovic M, Vallesi V, Mahler J, Verma RK, Berger MF, Pannek J, Wyss PO. Identification of brain functional connectivity during acute transcutaneous tibial nerve stimulation: A 3T fMRI study. Neurourol Urodyn 2024; 43:236-245. [PMID: 37767637 DOI: 10.1002/nau.25293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 08/28/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES A feasibility proof-of-concept study was conducted to assess the effects of acute tibial nerve stimulation (TNS) on the central nervous system in healthy volunteers using functional magnetic resonance imaging (fMRI). MATERIALS AND METHODS Fourteen healthy volunteers were included in a prospective, single-site study conducted on a clinical 3T MRI scanner. Four scans of functional MRI, each lasting 6 min, were acquired: two resting-state fMRI scans (prior and following the TNS intervention) and in-between two fMRI scans, both consisting of alternating rest periods and noninvasive acute transcutaneous TNS (TTNS). Whole brain seed-based functional connectivity (FC) correlation analysis was performed comparing TTNS stimulation with rest periods. Cluster-level familywise error (FWE) corrected p and a minimal cluster size of 200 voxels were used to explore FC patterns. RESULTS Increased FC is reported between inferior frontal gyrus, posterior cingulate gyrus, and middle temporal gyrus with the precuneus as central receiving node. In addition, decreased FC in the cerebellum, hippocampus, and parahippocampal areas was observed. CONCLUSIONS Altered FC is reported in areas which have been described to be also involved in lower urinary tract control. Although conducted with healthy controls, the assumption that the underlying therapeutic effect of TNS involves the central nervous system is supported and has to be further examined in patients with incomplete spinal cord injury.
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Affiliation(s)
- Jens Wöllner
- Department of Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Jörg Krebs
- Clinical Trial Unit, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Johannes K Richter
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, University Hospital of Bern, University of Bern, Bern, Switzerland
- Institute of Radiology and Nuclear Medicine, GZO Hospital Wetzikon, Wetzikon, Switzerland
| | | | - Andrea Gunziger
- Department of Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Nadine Hunkeler
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Mihael Abramovic
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Vanessa Vallesi
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Jasmin Mahler
- Department of Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Rajeev K Verma
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Markus F Berger
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Jürgen Pannek
- Department of Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Urology, Inselspital, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Patrik O Wyss
- Department of Radiology, Swiss Paraplegic Centre, Nottwil, Switzerland
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Kitta T. Editorial Comment to Heterogeneity of placebo effects on urinary incontinence in overactive bladder syndrome: A meta-analysis of Japanese placebo-controlled clinical trials. Int J Urol 2023; 30:905-906. [PMID: 37439576 DOI: 10.1111/iju.15255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Takeya Kitta
- Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Japan
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3
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Chen T, Zhan X, Xiao S, Fu B. U-shaped association between sleep duration and urgency urinary incontinence in women: a cross-sectional study. World J Urol 2023; 41:2429-2435. [PMID: 37522906 DOI: 10.1007/s00345-023-04537-2] [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: 04/07/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND To investigate the association between sleep duration and urgency urinary incontinence (UUI) among adult women. METHODS Cross-sectional data were retrieved from the 2005-2014 National Health and Nutrition Examination Survey. To explore the association between sleep duration and urgency urinary incontinence, multivariable logistic regression and restricted cubic spline (RCS) regression analysis was carried out. RESULTS Among 9204 adult women, the weighted urinary incontinence prevalence was 31% for urgency urinary incontinence (UUI). The fully adjusted multivariable model revealed that participants with short (< 7 h) or long (> 9 h) sleep duration were more likely to report UUI compared to participants with normal (7-9 h) sleep duration (OR 1.20, 95% CI 1.03-1.40, p = 0.02, OR 1.40, 95% CI 1.11-1.76, p = 0.005, respectively). Subgroup analysis showed no significant interaction. Furthermore, additional analysis demonstrated a U-shaped correlation between sleep duration and incident UUI. CONCLUSION The non-linear association exists between sleep duration and urgency urinary incontinence. Compared with insufficient or excessive sleep, normal sleep duration is related to lower prevalence of urgency urinary incontinence. Future prospective longitudinal studies should be conducted to further investigate and determine the degree of the association between sleep time and urgent urinary incontinence.
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Affiliation(s)
- Tao Chen
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiangpeng Zhan
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shucai Xiao
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Fu
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China.
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Mehnert U, Walter M, Leitner L, Kessler TM, Freund P, Liechti MD, Michels L. Abnormal Resting-State Network Presence in Females with Overactive Bladder. Biomedicines 2023; 11:1640. [PMID: 37371735 DOI: 10.3390/biomedicines11061640] [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: 03/04/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Overactive bladder (OAB) is a global problem reducing the quality of life of patients and increasing the costs of any healthcare system. The etiology of OAB is understudied but likely involves supraspinal network alterations. Here, we characterized supraspinal resting-state functional connectivity in 12 OAB patients and 12 healthy controls (HC) who were younger than 60 years. Independent component analysis showed that OAB patients had a weaker presence of the salience (Cohen's d = 0.9) and default mode network (Cohen's d = 1.1) and weaker directed connectivity between the fronto-parietal network and salience network with a longer lag time compared to HC. A region of interest analysis demonstrated weaker connectivity in OAB compared to HC (Cohen's d > 1.6 or < -1.6), particularly within the frontal and prefrontal cortices. In addition, weaker seed (insula, ventrolateral prefrontal cortex) to voxel (anterior cingulate cortex, frontal gyrus, superior parietal lobe, cerebellum) connectivity was found in OAB compared to HC (Cohen's d > 1.9). The degree of deviation in supraspinal connectivity in OAB patients (relative to HC) appears to be an indicator of the severity of the lower urinary tract symptoms and an indication that such symptoms are directly related to functional supraspinal alterations. Thus, future OAB therapy options should also consider supraspinal targets, while neuroimaging techniques should be given more consideration in the quest for better phenotyping of OAB.
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Affiliation(s)
- Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Matthias Walter
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, 04103 Leipzig, Germany
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London WC1N 3AR, UK
- Neuroscience Center Zürich, University of Zürich and Swiss Federal Institute of Technology Zürich, 8057 Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Lars Michels
- Neuroscience Center Zürich, University of Zürich and Swiss Federal Institute of Technology Zürich, 8057 Zürich, Switzerland
- Department of Neuroradiology, University Hospital Zürich, University of Zürich, 8091 Zürich, Switzerland
- Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland
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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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Fuentes-Aparicio L, Rejano-Campo M, López-Bueno L, Marie Donnelly G, Balasch-Bernat M. The effect of an abdominopelvic exercise program alone VS in addition to postural instructions on pelvic floor muscle function in climacteric women with stress urinary incontinence. A randomized controlled trial. Physiother Theory Pract 2023; 39:738-749. [PMID: 35068328 DOI: 10.1080/09593985.2022.2028323] [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: 10/19/2022]
Abstract
INTRODUCTION Scarce literature exists regarding the influence of posture-based interventions for the treatment of stress urinary incontinence (SUI). OBJECTIVE The aim of this randomized controlled trial with two parallel groups was to investigate whether the addition of postural instructions to a 12-week abdominopelvic exercise program is superior to an abdominopelvic exercise program alone, in terms of PFMs function and symptoms in climacteric women with SUI. METHODS Climacteric women aged between 40-75 years old who presented with SUI were included in this parallel study (NCT03727945). Two randomized groups performing one 40-minutes session per week for 12-weeks were compared: one performing an abdominopelvic exercise program (AEP) and a second one performing the same intervention with the addition of postural instructions (AEPPI). PFMs electromyographical (EMG) activity and strength (Oxford Grading Scale) were quantified during a maximal voluntary contraction. SUI symptoms were assessed using a 3-day bladder diary. These outcomes were collected at baseline, immediately after intervention, and 3-months after the intervention. RESULTS A total of 47 women were included in the study (AEP [n = 23], AEPPI [n = 24]). Between-group analysis showed significant differences for post-intervention EMG and strength values, showing higher values for the AEPPI compared to the AEP group. At 3-months follow-up, statistically significant differences were only obtained in strength, with higher values in the AEPPI group. No significant differences were obtained in terms of UI symptoms. CONCLUSION A 12-session abdominopelvic exercise program supplemented with postural instructions is superior to an abdominopelvic exercise program alone in terms of PFMs function in women with SUI.
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Affiliation(s)
- Laura Fuentes-Aparicio
- Department of Physical Therapy, University of Valencia, Valencia, Spain
- Physiotherapy in Motion, Multi-Speciality Research Group (Ptinmotion), University of Valencia, Valencia, Spain
| | | | - Laura López-Bueno
- Department of Physical Therapy, University of Valencia, Valencia, Spain
| | - Gráinne Marie Donnelly
- Perinatal Physical Activity Research Group, Canterbury Christ Church University, Canterbury, UK
- Pelvic Health department, Absolute Physio, Ireland, UK
| | - Mercè Balasch-Bernat
- Department of Physical Therapy, University of Valencia, Valencia, Spain
- Physiotherapy in Motion, Multi-Speciality Research Group (Ptinmotion), University of Valencia, Valencia, Spain
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Clarkson BD, Karim HT, Chermansky CJ, Banihashemi L, Tyagi S, Griffiths DJ, Resnick NM. Changes in brain response to urgency before and after treatment of urgency urinary incontinence with onabotulinumtoxin A. Neurourol Urodyn 2022; 41:1703-1710. [PMID: 35904238 DOI: 10.1002/nau.25012] [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: 03/15/2022] [Revised: 05/31/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION To better understand the role of the brain in urgency urinary incontinence (UUI), we used onabotulinumtoxin A (BoNTA) as a probe to evaluate changes in the brain's response to urgency in successful and unsuccessful treatment. Because BoNTA acts peripherally, brain changes observed should represent a reaction to changes in bladder function caused by BoNTA, or changes in the brain's compensatory mechanisms, rather than a direct effect of BoNTA on the brain. METHODS We recruited 20 women aged over 60 years with nonneurogenic UUI who were to undergo treatment with onabotulinum A toxin injected intravesically. We performed a baseline evaluation which included a 3-day bladder diary and functional magnetic resonance imaging with an urgency provocation task; we repeated this evaluation 6 weeks posttreatment. We performed an analysis of variance on a priori selected regions of interest and post hoc voxel-wise analysis on responders and nonresponders to treatment. RESULTS We found a significant interaction in the right insula [F(1,18) = 5.5, p = 0.031]; activity was different during urgency provocation in responders and non-responders to therapy, before and after therapy. The supramarginal gyrus (SMG) and inferior frontal gyrus (IFG) also displayed significant interactions (p < 0.005). Activity in the periaqueductal gray and prefrontal cortex was correlated with number of leakage episodes (p < 0.05). CONCLUSION The changes seen in the brain control mechanism after therapy likely reflect reduced bladder sensation caused by BoNTA's peripheral action. We ascribe the SMG and IFG changes to a coping mechanism for urgency which is reduced in those who respond well to treatment.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Layla Banihashemi
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shachi Tyagi
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek J Griffiths
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Neil M Resnick
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Roberts K, Dao A, Alfahmy A, Mitchell D, Sheyn D. Does gabapentin impact response to anticholinergics for overactive bladder? Int Urogynecol J 2022; 33:2501-2506. [PMID: 35648179 DOI: 10.1007/s00192-022-05231-4] [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: 03/02/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS It is unknown whether gabapentin modulates the therapeutic effect of anticholinergics (AC) in patients with overactive bladder. We hypothesized that pre-existing gabapentin use would improve response rates in these patients. METHODS Female patients treated with AC between 2010-2018 were identified. Data were collected on gabapentin use, indication, dose and duration of use as well as demographic and clinical characteristics. Patients were stratified by those that only took AC and those that took both AC and gabapentin ("combination therapy"). Response was determined through chart review. Descriptive statistics were expressed as medians and interquartile ranges (IQR). Pairwise analysis was performed using Wilcoxon rank-sum. Multivariable logistic regression was used to identify independent variables predicting response. A subgroup analysis was performed in patients with chronic pain disorders. RESULTS Seven hundred fifty-six subjects met all criteria; 16.5% (n = 125) were on combination therapy. Those taking gabapentin were more likely to have chronic (49.6% vs. 22.5%, p < 0.001) or neuropathic pain (25.6% vs. 9.4%, p < 0.001) and to use narcotics (41.6% vs. 15.5%, p < 0.001). Patients taking combination therapy were not more likely to improve compared to patients taking AC alone (41.6% vs. 47.7%, p = 0.211), which persisted after adjusting for confounders (aOR = 1.02, 95% CI: 0.63-1.65). In the 182 patients with chronic pain, those receiving combination therapy were more likely to respond than those taking AC alone (35.2% vs. 21.9%, p = 0.0015), although this did not persist after adjusting for confounders (aOR = 1.15, 95% CI: 0.70-1.90). CONCLUSIONS Pre-existing gabapentin use does not seem to influence response to AC in patients with overactive bladder.
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Affiliation(s)
- Kasey Roberts
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Angela Dao
- Division of Female Pelvic Medicine and Reconstructive Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Anood Alfahmy
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Diana Mitchell
- Division of Female Pelvic Medicine and Reconstructive Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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9
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Bou Kheir G, Verbakel I, Hervé F, Bauters W, Abou Karam A, Holm-Larsen T, Van Laecke E, Everaert K. OAB supraspinal control network, transition with age, and effect of treatment: A systematic review. Neurourol Urodyn 2022; 41:1224-1239. [PMID: 35537063 DOI: 10.1002/nau.24953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/05/2022] [Accepted: 04/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE In light of a better understanding of supraspinal control of nonneurogenic overactive bladder (OAB), the prevalence of which increases with age, functional imaging has gained significant momentum. The objective of this study was to perform a systematic review on the transition of supraspinal control of OAB with age, the effect of therapeutic modalities, and a coordinate-based meta-analysis of all neuroimaging evidence on supraspinal OAB control in response to bladder filling. METHODOLOGY We performed a systematic literature search of all relevant libraries in November 2021. The coordinates of brain activity were extracted from eligible neuroimaging studies to perform an activation likelihood estimation (ALE) meta-analysis. RESULTS A total of 16 studies out of 241 were selected for our systematic review. Coordinates were extracted from five experiments involving 70 patients. ALE meta-analysis showed activation of the insula, supplementary motor area, dorsolateral prefrontal cortex, anterior cingulate gyrus, and temporal gyrus with a transition of activation patterns with age, using a threshold of uncorrected p < 0.001. Among young patients, neuroplasticity allows the activation of accessory circuits to maintain continence, as in the cerebellum and temporoparietal lobes. Anticholinergics, pelvic floor muscle training, sacral neuromodulation, and hypnotherapy are correlated with supraspinal changes attributed to adaptability and possibly a substratum of an intrinsic supraspinal component. The latter is better demonstrated by a resting-state functional connectivity analysis, a promising tool to phenotype OAB with recent successful models of predicting severity and response to behavioral treatments. CONCLUSION Future neuroimaging studies are necessary to better define an OAB neurosignature to allocate patients to successful treatments.
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Affiliation(s)
- George Bou Kheir
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Irina Verbakel
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - François Hervé
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Wouter Bauters
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Anthony Abou Karam
- Department of Radiology, Yale New Haven Hospital, Yale, Connecticut, USA
| | - Tove Holm-Larsen
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Erik Van Laecke
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Karel Everaert
- Department of Urology, Ghent University Hospital, Ghent, Belgium
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When Two Is Better Than One: A Pilot Study on Transcranial Magnetic Stimulation Plus Muscle Vibration in Treating Chronic Pelvic Pain in Women. Brain Sci 2022; 12:brainsci12030396. [PMID: 35326352 PMCID: PMC8946237 DOI: 10.3390/brainsci12030396] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 02/04/2023] Open
Abstract
Chronic pelvic pain syndrome (CPPS) affects about 4–16% of adult women, and about one-third of them require medical assistance due to severe symptoms. Repetitive transcranial magnetic stimulation (rTMS) over the supplementary motor area (SMA) has been shown to manage pain in refractory CPPS. Focal muscle vibration (FMV) has also been reported to relieve pelvic pain. The objective of this study was to assess the feasibility and effect of rTMS coupled with FMV to reduce pain in seven adult women with refractory CPPS. This pilot, open-labeled, prospective trial examined treatment by 5 Hz rTMS over SMA and 150 Hz FMV over the perineum, suprapubic, and sacrococcygeal areas, with one daily session for five consecutive days for three weeks. We assessed tolerance and subjective pain changes (as per visual analog scale, VAS) until one month post-treatment, with a primary endpoint at day 7. No patients experienced serious adverse effects or a significant increase in pain. Six out of seven patients experienced a VAS improvement of at least 10% at T7; three of these individuals experienced a VAS improvement of more than 30%. Overall, we found a significant VAS reduction of 15 points (95% CI 8.4–21.6) at T7 (t = 6.3, p = 0.001; ES = 2.3 (1.1–3.9)). Three of the women who demonstrated a significant VAS reduction at T7 retained such VAS improvement at T30. VAS decreased by six points (95% CI 1.3–10.7) at T30 (t = 3.1, p = 0.02; ES = 1.5 (0.2–2.6)). This coupled approach seems promising for pain management in adult women with refractory CPPS and paves the way for future randomized controlled trials.
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11
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Qin C, Wang Y, Gao Y. Overactive Bladder Symptoms Within Nervous System: A Focus on Etiology. Front Physiol 2021; 12:747144. [PMID: 34955876 PMCID: PMC8703002 DOI: 10.3389/fphys.2021.747144] [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: 07/25/2021] [Accepted: 11/16/2021] [Indexed: 12/02/2022] Open
Abstract
Overactive bladder (OAB) is a common debilitating condition characterized by urgency symptoms with detrimental effects on the quality of life and survival. The exact etiology of OAB is still enigmatic, and none of therapeutic approaches seems curative. OAB is generally regarded as a separate syndrome, whereas in clinic, OAB symptoms could be found in numerous diseases of other non-urogenital systems, particularly nervous system. The OAB symptoms in neurological diseases are often poorly recognized and inadequately treated. This review provided a comprehensive overview of recent findings related to the neurogenic OAB symptoms. Relevant neurological diseases could be mainly divided into seven kinds as follows: multiple sclerosis and related neuroinflammatory disorders, Parkinson’s diseases, multiple system atrophy, spinal cord injury, dementia, peripheral neuropathy, and others. Concurrently, we also summarized the hypothetical reasonings and available animal models to elucidate the underlying mechanism of neurogenic OAB symptoms. This review highlighted the close association between OAB symptoms and neurological diseases and expanded the current knowledge of pathophysiological basis of OAB. This may increase the awareness of urological complaints in neurological disorders and inspire robust therapies with better outcomes.
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Affiliation(s)
- Chuying Qin
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yinhuai Wang
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yunliang Gao
- Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, China
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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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Takahashi S, Takei M, Asakura H, Gotoh M, Ishizuka O, Kato K, Koyama M, Takeyama M, Tomoe H, Yamanishi T, Yokoyama O, Yoshida M, Yoshimura Y, Yoshizawa T. Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition). Int J Urol 2021; 28:474-492. [PMID: 33650242 DOI: 10.1111/iju.14492] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.
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Affiliation(s)
- Satoru Takahashi
- Department of Urology, Nihon University School of Medicine, Tokyo, Japan
| | - Mineo Takei
- Department of Urology, Harasanshin Hospital, Fukuoka, Japan
| | | | - Momokazu Gotoh
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Osamu Ishizuka
- Department of Urology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kumiko Kato
- Department of Female Urology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Masayasu Koyama
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masami Takeyama
- Urogynecology Center, First Towakai Hospital, Takatsuki, Japan
| | - Hikaru Tomoe
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Tomonori Yamanishi
- Department of Urology, Continence Center, Dokkyo Medical University, Tochigi, Japan
| | - Osamu Yokoyama
- Department of Urology, Faculty of Medical Science, University of Fukui, Fukui, Japan
| | - Masaki Yoshida
- Department of Urology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Yasukuni Yoshimura
- Female Pelvic Health Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Tsuyoshi Yoshizawa
- Department of Urology, Nihon University School of Medicine, Tokyo, Japan
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15
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Cognitive components of behavioral therapy for overactive bladder: a systematic review. Int Urogynecol J 2021; 32:2619-2629. [PMID: 33609161 DOI: 10.1007/s00192-021-04720-2] [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: 10/29/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Behavioral therapy is the first-line treatment for overactive bladder (OAB); however, the cognitive components of behavioral therapy for OAB have not been evaluated. The purposes of this systematic review were to describe the cognitive components of behavioral therapy for OAB and evaluate their effectiveness as well as to describe their rationale and origins. METHODS Searches were conducted on the PubMed, CINAHL, Web of Science, Cochrane and PEDro databases. Inclusion criteria were single-arm or randomized controlled trials on OAB treatment that utilized behavioral therapy, with a description of a cognitive component of the behavioral therapy. Study participants were neurologically intact adults (n = 1169). Study methodological quality was assessed with the PEDro and Newcastle-Ottawa scales. RESULTS Five studies were included, published between 2009 and 2020. Methodological quality was variable. All studies reported a reduction of symptoms in participants receiving behavioral therapy. Cognitive components of behavioral therapy were not extensively described. Distraction was the most common cognitive strategy for managing urgency. The relative impact of the cognitive aspect of behavioral therapy could not be evaluated, and the cognitive aspects of behavioral therapy appear to be accepted wisdom, traceable to several key authors, that has not been subjected to scientific investigation. CONCLUSIONS Behavioral therapy for OAB appears useful, but its cognitive components are not well described, their relative importance has not been evaluated or ascertained, nor have they been rigorously studied.
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16
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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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17
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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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18
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Okumatsu K, Osuka Y, Suzuki T, Kim M, Kojima N, Yoshida Y, Hirano H, Kim H. Urinary incontinence onset predictors in community-dwelling older women: A prospective cohort study. Geriatr Gerontol Int 2020; 21:178-184. [PMID: 33350045 DOI: 10.1111/ggi.14108] [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: 03/24/2020] [Revised: 10/22/2020] [Accepted: 11/20/2020] [Indexed: 11/26/2022]
Abstract
AIM We aimed to investigate whether physical function was associated with urinary incontinence (UI) onset in community-dwelling older Japanese women. METHODS This was a 4-year prospective cohort study. After excluding participants with UI and missing data in the baseline survey, we included 890 participants in the analyses. Physical function including grip strength, maximal walking speed, knee extension strength, single-leg balance, and timed up and go (TUG) were measured. The primary outcome was the onset of all UI and different types of UI (urge, stress and mixed) based on the questionnaire survey. Binary logistic regression analysis was applied to calculate the adjusted odds ratios and 95% confidence intervals for the association between physical function and the risk of all UI and different types of UI incident. RESULTS Among the 890 participants, 221 (25%) developed UI during the 4-year follow-up. After adjusting for confounders, better knee extension strength, maximal walking speed and TUG were significantly associated with a lower risk of all UI and urge UI onset, and better single-leg balance and TUG were significantly associated with a lower risk of mixed UI onset (P for trend <0.05). No significant association was found between physical function and the risk of stress UI onset. CONCLUSIONS This study confirmed that better lower extremity physical function is associated with lower risk of urge and mixed UI onset, indicating that exercise programs focusing on maintaining and improving lower extremity physical function may be useful for reducing such events among older women. Geriatr Gerontol Int 2021; 21: 178-184.
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Affiliation(s)
- Koki Okumatsu
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan.,Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Yosuke Osuka
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Takao Suzuki
- Institute of Gerontology, J.F. Oberlin University, Machida-shi, Japan
| | - Miji Kim
- Department of Biomedical Science and Technology, College of Medicine, East-West Medical Research Institute, Kyung Hee University, Seoul, Republic of Korea
| | - Narumi Kojima
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Yuko Yoshida
- Research Team for Human Care, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Hirohiko Hirano
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Hunkyung Kim
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
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19
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Clarkson BD, Karim HT, Griffiths DJ, Resnick NM. Testing a new, intensified infusion-withdrawal protocol for urinary urgency provocation in brain-bladder studies. Neurourol Urodyn 2020; 40:131-136. [PMID: 33118637 DOI: 10.1002/nau.24559] [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: 08/12/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The brain's role in bladder control has become an important area of study in the last 15 years. Typically, the brain's role in urinary urgency has been studied by repeated infusion and withdrawal of fluid, per catheter, to provoke urgency sensation during a whole brain magnetic resonance imaging (MRI) scan. Since this technique generally requires a large group size, we tested a more intense infusion-withdrawal protocol in an attempt to improve signal to noise ratio and repeatability of the signal which would, in turn, allow us to further probe subtypes of urgency urinary incontinence. METHODS A total of 12 women over the age of 60 were recruited to test a new "intense" infusion withdrawal protocol. They underwent this new protocol during a functional brain MRI scan. The primary outcome was comparison of activity within the insula, medial pre-frontal cortex and dorsal anterior cingulate cortex/supplementary motor area (dACC/SMA). Immediate test-retest repeatability was measured using intraclass correlation. Secondary exploratory evaluation of differences in the whole brain between protocols was conducted. RESULTS There was no significant difference in signal in any of the a priori regions of interest between protocols. Test-retest repeatability in the new protocol was poor compared to the original protocol, and variability was higher. Three participants were not able to tolerate the "intense" protocol. CONCLUSION The small improvement in signal to noise ratio of the new protocol was not sufficient to overcome the poorly tolerated intense filling protocol.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek J Griffiths
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Neil M Resnick
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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20
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Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol 2020; 31:485-493. [PMID: 31609735 DOI: 10.1097/gco.0000000000000584] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders. RECENT FINDINGS Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery. SUMMARY PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.
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21
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Clarkson BD, O Connell K, Conklin CA. Reproducing situationally triggered urgency incontinence in a controlled environment. Neurourol Urodyn 2020; 39:2520-2526. [PMID: 32976670 DOI: 10.1002/nau.24524] [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: 07/17/2020] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Patients with lower urinary tract symptoms often report urgency and incontinence episodes which are triggered by environmental scenarios, for example, "latch-key incontinence." To better understand the extent of this phenomenon, and how best to reduce its impact, we tested ways to recreate these situational cues in a controlled environment and obtain cue reactivity measures. METHODS We developed a standardized set of urgency cue scenarios from interviews with sufferers of situational urgency urinary incontinence (UUI), personalized urgency, and safe cue sets consisting of photographs of specific locations, and measurements of cue reactivity during computer-based presentation and urodynamic monitoring. RESULTS Common urgency and safe cues were identified for the standardized cue set. Exposure to these standardized cues elicited change in bladder sensation in 7 of 12 participants. Participants created personalized cue sets with photographs depicting their own urgency triggering scenarios; exposure to personalized cue photos elicited change in sensation in 11 of 12 participants. In addition, personalized cues elicited measurable detrusor overactivity and leakage during urodynamic monitoring. Safe cues reduced bladder sensation in five participants. CONCLUSION We developed a computer-based means of displaying cue photos which elicited cue reactivity from women suffering from situational urgency incontinence. Cue reactivity was increased by personalizing photos of cue scenarios and obtaining physiological measures from urodynamics. We have developed an appropriate way to test cue reactivity in women with situational UUI.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathleen O Connell
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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22
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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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23
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Alghamdi AA, Alyousif GF, Alghamdi RL, Almulhim FA, Alsadah HM, Almutawaa JM, Alnakhli KA, Almansour NA. The prevalence of urinary incontinence symptoms among multiparous women: a survey of Saudi health-care centers. Int Urogynecol J 2020; 32:403-411. [PMID: 32696184 DOI: 10.1007/s00192-020-04443-w] [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: 04/06/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the distribution of urinary incontinence (UI) symptoms and their relation to childbirth events. METHODS This cross-sectional study used a structured self-administered questionnaire that included the Questionnaire for Female Urinary Incontinence Diagnosis and the Urogenital Distress Inventory Short Form. The study included 802 women sampled from four primary health care centers in Dammam, KSA. A chi-square test and adjusted logistic regression models were used to examine the relation between UI symptoms and obstetric events. RESULTS Of the participants, 56.6% (n = 454) had at least one UI symptom. Symptoms were most commonly associated with grand multiparity (80.47%), a history of abortion (72%), assisted vaginal delivery (70%), an age of ≤ 18 years at first birth (66.67%) and ≥ 35 years at last birth (75.48%), and a history of macrosomia (84.62%) and episiotomy (67.89%). Unlike the risk of urgency UI, the risk of stress UI was statistically significantly linked to obstetric events. Grand multiparity was associated with a higher risk of both stress UI (odds ratio [OR]: 3.75, confidence interval [95% CI]: 1.68-8.40) and urgency UI (OR: 2.87, 95% CI: 1.07-7.73). CONCLUSION UI symptoms are common among grand multiparas. Unlike urgency UI, stress UI is associated with previous obstetric events.
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Affiliation(s)
- Amal A Alghamdi
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia.
| | - Ghada F Alyousif
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Reham L Alghamdi
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Fai A Almulhim
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Hawra M Alsadah
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Jehan M Almutawaa
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Kalthoom A Alnakhli
- Women Health Research Group, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Noura A Almansour
- Women Health Research Group, Department of Obstetrics and Gynaecology, King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia
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24
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Meyer I, Morgan SL, Markland AD, Szychowski JM, Richter HE. Pelvic floor disorder symptoms and bone strength in postmenopausal women. Int Urogynecol J 2020; 31:1777-1784. [PMID: 32114661 DOI: 10.1007/s00192-020-04254-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/04/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The current study is aimed at characterizing the association between pelvic floor disorder symptoms and bone strength reflecting a potential connective tissue pathophysiology in postmenopausal women. METHODS A cross-sectional study was conducted in postmenopausal women undergoing osteoporosis evaluation from 2007 to 2010. Urinary incontinence (UI) was defined as urinary leakage ≥2-3 times/week. UI types were defined using the 3 Incontinence Questionnaire. Fecal incontinence was defined as stool leakage ≥1/month, and pelvic organ prolapse as a positive response to "Do you have a bulge or something falling out that you can see or feel in your vaginal area?" Bone quality and quantity were assessed using the trabecular bone score (TBS) and bone mineral density respectively: bone strength was defined by combined quality/quantity index, low strength being equivalent to moderate to severe fracture risk; low quality as TBS ≤ 1.31; low quantity by T-score <-1 or on osteoporosis medication. RESULTS Of 681 subjects, 262 had low bone strength whereas 419 were normal using the combined quality/quantity bone assessment. Characteristics were similar except for age (low bone strength: 69.0 ± 8.2 vs normal: 65.0 ± 7.1, p < 0.01) and smoking (8.8% vs 3.3%, p < 0.01). Low bone strength was associated with any UI (adjusted odds ratio [aOR]: 1.48, 1.05-2.10), stress (aOR: 1.53, 1.06-2.21), and mixed (aOR :1.45, 1.02-2.05). Women with low bone quality had increased odds of UI (any, urgency, mixed), whereas none of the pelvic floor disorder symptoms was associated with low bone quantity. CONCLUSIONS Low bone strength defined by a combined quantity/quality index, as well as low bone quality alone, were associated with increased risk of UI.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL, 35233, USA.
| | - Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, UAB Osteoporosis Prevention and Treatment Clinic, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alayne D Markland
- Birmingham/Atlanta Geriatrics, Research, Education, and Clinical Center (GRECC) at the Birmingham VA Medical Center, Departments of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff M Szychowski
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL, 35233, USA
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Komesu YM, Schrader RM, Rogers RG, Sapien RE, Mayer AR, Ketai LH. Hypnotherapy or medications: a randomized noninferiority trial in urgency urinary incontinent women. Am J Obstet Gynecol 2020; 222:159.e1-159.e16. [PMID: 31449805 PMCID: PMC6995419 DOI: 10.1016/j.ajog.2019.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/03/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Urgency urinary incontinence afflicts many adults, and most commonly affects women. Medications, a standard treatment, may be poorly tolerated, with poor adherence. This warrants investigation of alternative interventions. Mind-body therapies such as hypnotherapy may offer additional treatment options for individuals with urgency urinary incontinence. OBJECTIVE To evaluate hypnotherapy's efficacy compared to medications in treating women with urgency urinary incontinence. MATERIALS AND METHODS This investigator-masked, noninferiority trial compared hypnotherapy to medications at an academic center in the southwestern United States, and randomized women with non-neurogenic urgency urinary incontinence to weekly hypnotherapy sessions for 2 months (and continued self-hypnosis thereafter) or to medication and weekly counseling for 2 months (and medication alone thereafter). The primary outcome was the between-group comparison of percent change in urgency incontinence on a 3-day bladder diary at 2 months. Important secondary outcomes were between-group comparisons of percent change in urgency incontinence at 6 and 12 months. Outcomes were analyzed based on noninferiority margins of 5% for between group differences (P < 0.025) (that is, for between group difference in percentage change in urgency incontinence, if the lower bound of the 95% confidence interval was greater than -5%, noninferiority would be proved). RESULTS A total of 152 women were randomized to treatment between April 2013 and October 2016. Of these women, 142 (70 hypnotherapy, 72 medications) had 3-day diary information at 2 months and were included in the primary outcome analysis. Secondary outcomes were analyzed for women with diary data at the 6-month and then 12-month time points (138 women [67 hypnotherapy, 71 medications] at 6 months, 140 women [69 hypnotherapy, 71 medications] at 12 months. There were no differences between groups' urgency incontinence episodes at baseline: median (quartile 1, quartile 3) for hypnotherapy was 8 (4, 14) and medication was 7 (4, 11) (P = .165). For the primary outcome, although both interventions showed improvement, hypnotherapy did not prove noninferior to medication at 2 months. Hypnotherapy's median percent improvement was 73.0% (95% confidence interval, 60.0-88˖9%), whereas medication's improvement was 88.6% (95% confidence interval, 78.6-100.0%). The median difference in percent change between groups was 0% (95% confidence interval, -16.7% to 0.0%); because the lower margin of the confidence interval did not meet the predetermined noninferiority margin of greater than -5%, hypnotherapy did not prove noninferior to medication. In contrast, hypnotherapy was noninferior to medication for the secondary outcomes at 6 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 75.0-100%; medications, 83.3% improvement, 95% confidence interval, 64.7-100%; median difference in percent change between groups of 0%, 95% confidence interval, 0.0-6.7%) and 12 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 66.7-94.4%; medications, 80% improvement, 95% confidence interval, 54.5-100%; median difference in percent change between groups of 0%, 95% confidence interval, -4.2% to -9.5%). CONCLUSION Both hypnotherapy and medications were associated with substantially improved urgency urinary incontinence at all follow-up. The study did not prove the noninferiority of hypnotherapy compared to medications at 2 months, the study's primary outcome. Hypnotherapy proved noninferior to medications at longer-term follow-up of 6 and 12 months. Hypnotherapy is a promising, alternative treatment for women with UUI.
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Affiliation(s)
- Yuko M Komesu
- University of New Mexico Health Sciences Center, Albuquerque, NM.
| | - Ronald M Schrader
- University of New Mexico Clinical and Translational Science Center, Albuquerque, NM
| | - Rebecca G Rogers
- University of New Mexico Health Sciences Center, Albuquerque, NM; University of Texas Dell Medical School, Austin, TX
| | - Robert E Sapien
- University of New Mexico Health Sciences Center, Albuquerque, NM
| | | | - Loren H Ketai
- University of New Mexico Health Sciences Center, Albuquerque, NM
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Chermansky C, Schurch B, Rahnama'i MS, Averbeck MA, Malde S, Mancini V, Valentini F, Sahai A. How can we better manage drug‐resistant OAB/DO? ICI‐RS 2018. Neurourol Urodyn 2019; 38 Suppl 5:S46-S55. [DOI: 10.1002/nau.24055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 03/31/2019] [Accepted: 05/19/2019] [Indexed: 01/20/2023]
Affiliation(s)
| | - Brigitte Schurch
- Department of Clinical Neurosciences, Neuropsychology and Neurorehabilitation ServiceVaudois University Hospital of LausanneLausanne Switzerland
| | - Mohammad S. Rahnama'i
- Department of UrologyUniversity Hospital RWTH AachenAachen Germany
- Maastricht UniversityMaastricht The Netherlands
| | | | - Sachin Malde
- Department of UrologyGuy's Hospital & King's College School of MedicineLondon United Kingdom
| | - Vito Mancini
- Urology and Renal Transplant Unit, Ospedali RiunitiUniversity of FoggiaFoggia Italy
| | - Francoise Valentini
- Department of Physical Medicine and RehabilitationHôpital RothschildParis France
| | - Arun Sahai
- Department of UrologyGuy's Hospital & King's College School of MedicineLondon United Kingdom
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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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Seseke S, Leitsmann C, Hijazi S, Trojan L, Dechent P. Functional MRI in patients with detrusor sphincter dyssynergia: Is the neural circuit affected? Neurourol Urodyn 2019; 38:2104-2111. [PMID: 31396992 DOI: 10.1002/nau.24112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/02/2019] [Indexed: 11/05/2022]
Abstract
AIMS In recent years, the human brain-bladder control network has been visualized in different functional magnetic resonance imaging (fMRI) studies. The role of the brainstem and suprapontine regions has been elucidated. Especially the pontine region and the periaqueductal gray, as the central structures of the micturition circuit, were demonstrated. Detrusor sphincter dyssynergia (DSD) is a common problem in patients with neurological diseases. Residual urine and consecutive urinary tract infections with the risk of kidney damage remain a problem. In the present study, we used fMRI of the brain to compare the activation sites of patients with DSD with those of our previously published healthy controls with special emphasis on the brainstem region. METHODS fMRI was performed in 11 patients with DSD who had an urge to void due to a filled bladder. In a nonvoiding model, they were instructed to contract or to relax the pelvic floor muscles repetitively. RESULTS In patients with DSD, we could reproduce the activation sites found in healthy subjects, showing the regions in the brainstem as well as the other micturition-related areas. The activation of the pontine region was more rostral/dorsal compared with the healthy volunteers. CONCLUSION Interestingly, we detected the well-known activation in the pontine region in the patients in the dorsal/rostral part compared with the more ventral activation in the healthy volunteers, suggesting that the L-region of the pontine micturition center is more prominent in cases of DSD.
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Affiliation(s)
- Sandra Seseke
- Department of Urology, Martha-Maria Hospital, Halle, Germany
| | - Conrad Leitsmann
- Department of Urology, Georg-August-University, Göttingen, Germany
| | - Sameh Hijazi
- Department of Urology, Ibbenbüren Hospital, Ibbenbüren, Germany
| | - Lutz Trojan
- Department of Urology, Georg-August-University, Göttingen, Germany
| | - Peter Dechent
- Department of Cognitive Neurology, MR-Research in Neurology and Psychiatry, Georg-August-University, Göttingen, Germany
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Yani MS, Fenske SJ, Rodriguez LV, Kutch JJ. Motor cortical neuromodulation of pelvic floor muscle tone: Potential implications for the treatment of urologic conditions. Neurourol Urodyn 2019; 38:1517-1523. [PMID: 31044482 DOI: 10.1002/nau.24014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/22/2019] [Accepted: 04/12/2019] [Indexed: 01/23/2023]
Abstract
AIMS In the human brain, supplementary motor area (SMA) is involved in the control of pelvic floor muscles (PFMs). SMA dysfunction has been implicated in several disorders involving PFMs, including urinary incontinence and urologic pain. Here, we aimed to provide a proof-of-concept study to demonstrate the feasibility of modulating resting PFM activity (tone) as well as SMA activity with noninvasive stimulation of SMA. METHODS We studied six patients (3 women + 3 men) with Urologic Chronic Pelvic Pain Syndrome. Repetitive transcranial magnetic stimulation (rTMS) was applied to SMA immediately after voiding. We tested two rTMS protocols: high-frequency (HF-rTMS) which is generally excitatory, and low-frequency (LF-rTMS) which is generally inhibitory. PFM activity was measured during rTMS using electromyography. Brain activity was measured immediately before and after rTMS using functional magnetic resonance imaging. RESULTS The rTMS protocols had significantly different effects on resting activity in PFMs (P = 0.03): HF-rTMS decreased and LF-rTMS increased pelvic floor tone. SMA activity showed a clear trend ( P = 0.06) toward the expected differential changes: HF-rTMS increased and LF-rTMS decreased SMA activity. CONCLUSIONS We interpret the differential effects of rTMS at the brain and muscle level as novel support for an important inhibitory influence of SMA activity on pelvic floor tone after voiding. This preliminary study provides a framework for designing future studies to determine if neuromodulation of SMA could augment therapy for chronic urologic conditions.
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Affiliation(s)
- Moheb S Yani
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA
| | - Sonja J Fenske
- Neuroscience Graduate Program, University of Southern California, Los Angeles, CA
| | | | - Jason J Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA
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Urinary incontinence in postmenopausal women - causes, symptoms, treatment. MENOPAUSE REVIEW 2019; 18:46-50. [PMID: 31114458 PMCID: PMC6528037 DOI: 10.5114/pm.2019.84157] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/11/2019] [Indexed: 11/17/2022]
Abstract
Urinary incontinence (UI) is an important social problem that affects more than 50% of postmenopausal women. The number of patients increases from year to year. According to recent data, UI affects women twice as often as men. This condition occurs in about 20-30% of young women, 30-40% in middle age and up to 50% of women in old age. There are five types of urinary incontinence. The etiology of the problem of incontinence is not fully understood, because the problem can affect men and women of all ages and can be due to many changes in the human body. International Continence Society Guidelines indicate that treatment of urinary incontinence should begin with conservative treatment. Surgical treatment should be used when conservative treatment will not bring positive results. According to guidelines, conservative treatment should include pharmacotherapy, physiotherapy, and behavioral therapy. Numerous scientific reports indicate efficacy of physiotherapy in the treatment of urinary incontinence. Most recent reports indicate that physiotherapy gives a positive result in up to 80% of patients with stage I or stress urinary incontinence (SUI) and mixed form, and in 50% of patients with stage II SUI. Urinary incontinence is an interdisciplinary problem because in addition to the sphere directly related to medicine, it also concerns the economic and social spheres. The latest data show that incontinence in postmenopausal women occurs more often than other civilization diseases such as diabetes, hypertension or depression.
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Peyronnet B, Mironska E, Chapple C, Cardozo L, Oelke M, Dmochowski R, Amarenco G, Gamé X, Kirby R, Van Der Aa F, Cornu JN. A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment. Eur Urol 2019; 75:988-1000. [PMID: 30922690 DOI: 10.1016/j.eururo.2019.02.038] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 02/28/2019] [Indexed: 01/06/2023]
Abstract
CONTEXT Current literature suggests that several pathophysiological factors and mechanisms might be responsible for the nonspecific symptom complex of overactive bladder (OAB). OBJECTIVE To provide a comprehensive analysis of the potential pathophysiology underlying detrusor overactivity (DO) and OAB. EVIDENCE ACQUISITION A PubMed-based literature search was conducted in April 2018, to identify randomised controlled trials, prospective and retrospective series, animal model studies, and reviews. EVIDENCE SYNTHESIS OAB is a nonspecific storage symptom complex with poorly defined pathophysiology. OAB was historically thought to be caused by DO, which was either "myogenic" (urgency initiated from autonomous contraction of the detrusor muscle) or "neurogenic" (urgency signalled from the central nervous system, which initiates a detrusor contraction). Patients with OAB are often found to not have objective evidence of DO on urodynamic studies; therefore, alternative mechanisms for the development of OAB have been postulated. Increasing evidence on the role of urothelium/suburothelium and bladder afferent signalling arose in the early 2000s, emphasising an afferent "urotheliogenic" hypothesis, namely, that urgency is initiated from the urothelium/suburothelium. The urethra has also recently been regarded as a possible afferent origin of OAB-the "urethrogenic" hypothesis. Several other pathophysiological factors have been implicated, including metabolic syndrome, affective disorders, sex hormone deficiency, urinary microbiota, gastrointestinal functional disorders, and subclinical autonomic nervous system dysfunctions. These various possible mechanisms should be considered as contributing to diagnostic and treatment algorithms. CONCLUSIONS There is a temptation to label OAB as "idiopathic" without obvious causation, given the poorly understood nature of its pathophysiology. OAB should be seen as a complex, multifactorial symptom syndrome, resulting from multiple potential pathophysiological mechanisms. Identification of the underlying causes on an individual basis may lead to the definition of OAB phenotypes, paving the way for personalised medical care. PATIENT SUMMARY Overactive bladder (OAB) is a storage symptom syndrome with multiple possible causes. Identification of the mechanisms causing a patient to experience OAB symptoms may help tailor treatment to individual patients and improve outcomes.
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Affiliation(s)
- Benoit Peyronnet
- Department of Urology, University Hospital of Rennes, Rennes, France.
| | - Emma Mironska
- Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Linda Cardozo
- Department of Urology, St. Antonius Hospital, Gronau, Germany
| | - Matthias Oelke
- Department of Urology, Vanderbilt University, Nashville, TN, USA
| | | | - Gérard Amarenco
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Xavier Gamé
- Department of Urology, University Hospital of Toulouse, Toulouse, France
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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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Abstract
Understanding the pathophysiologic mechanisms responsible for overactive bladder (OAB) and urgency urinary incontinence (UUI) is critical to advancing the treatment options available to men and women with this prevalent and bothersome condition. Development of novel technologies and advanced functional neuroimaging modalities has provided us with new information to support and refine existing mechanistic theories. Emerging research on central pathophysiologic mechanisms of OAB from functional magnetic resonance imaging may provide new targets for therapeutic interventions and opens the door for novel treatment strategies. Several regions of interest—specifically the anterior cingulate gyrus, insula, and frontal cortices—have been implicated as areas of activation in women with OAB, suggesting a neural correlate of the experience of urgency. The cerebellum and parietal lobe have demonstrated increased activation during inhibition of voiding, and increased connectivity between the cerebellum and parietal lobe and the right insula and anterior cingulate gyrus has been demonstrated in women with UUI compared with controls. Evolving literature is beginning to shed light on the prerequisite effective connections between regions of interest in the healthy bladder and negative connectivity in OAB and UUI. Precision medicine with individualized care pathways may better select available treatment modalities for rightful recipients, thus improving efficacy with prescribed treatment approaches and adherence to therapy.
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Affiliation(s)
- Ariana L Smith
- Division of Urology, University of Pennsylvania , Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW This review will highlight our current understanding of age-related changes in bladder function and propose important clinical considerations in the management of overactive bladder (OAB) specific to older women. RECENT FINDINGS Frailty, functional and cognitive impairment, multimorbidity, polypharmacy, estrogen deficiency, and remaining life expectancy are important clinical factors to consider and may impact OAB symptom management in older women. Third-line therapies, particularly PTNS, may be preferable over second-line therapy in some cases. Due to the complexity within this population, the standard treatment algorithms may not be applicable, thus a broader, more holistic focus is recommended when managing OAB in older women.
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Parés D, Martínez-Vilalta M, Ortiz H, Soriano-Mas C, Maestre-Gonzalez Y, Pujol J, Grande L. Assessment of brain activity during voluntary anal sphincter contraction: Comparative study in women with and without fecal incontinence. Neurogastroenterol Motil 2018; 30:e13347. [PMID: 29655195 DOI: 10.1111/nmo.13347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/07/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Voluntary anal sphincter function is driven by an extended network of brain structures, most of which are still unknown. Disturbances in this function may cause fecal incontinence. The aim of this study was to characterize the cerebral areas involved in voluntary contraction of the anorectal sphincter in healthy women and in a group of patients with fecal incontinence by using a standardized functional magnetic resonance imaging (fMRI) protocol. METHODS This comparative study included 12 healthy women (mean age 53.17 ± 4.93 years) and 12 women with fecal incontinence (56.25 ± 6.94 years). An MRI-compatible anal manometer was used to register voluntary external anal sphincter contraction. During brain fMRI imaging, participants were cued to perform 10-s series of self-paced anal sphincter contractions at an approximate rate of 1 Hz. Brain structures linked to anal sphincter contractions were mapped and the findings were compared between the 2 study groups. KEY RESULTS There were no differences in the evoked brain activity between the 2 groups. In healthy women, group fMRI analysis revealed significant activations in medial primary motor cortices, supplementary motor area, bilateral putamen, and cerebellum, as well as in the supramarginal gyrus and visual areas. In patients with fecal incontinence, the activation pattern involved similar regions without significant differences with healthy women. CONCLUSIONS & INFERENCES This brain fMRI-anorectal protocol was able to map the brain regions linked to voluntary anal sphincter function in healthy and women with fecal incontinence.
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Affiliation(s)
- D Parés
- Department of General Surgery, Colorectal Surgery Unit, Hospital Germans Trias i Pujol, School of Medicine, Universitat Autonoma de Barcelona, Badalona, Barcelona, Spain
| | | | - H Ortiz
- Department of Engineering Design, Universitat Politècnica de Barcelona, Barcelona, Spain
| | - C Soriano-Mas
- Department of Psychiatry, Bellvitge Biomedical Research Institute - IDIBELL and CIBERSAM G-17, Barcelona, Spain.,Department of Psychobiology and Methodology in Health Sciences, Universitat Autònoma de Barcelona, Spain
| | | | - J Pujol
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain
| | - L Grande
- Department of Surgery, Parc de Salut Mar, Barcelona, Spain
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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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Yani MS, Wondolowski JH, Eckel SP, Kulig K, Fisher BE, Gordon JE, Kutch JJ. Distributed representation of pelvic floor muscles in human motor cortex. Sci Rep 2018; 8:7213. [PMID: 29740105 PMCID: PMC5940845 DOI: 10.1038/s41598-018-25705-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/26/2018] [Indexed: 12/11/2022] Open
Abstract
Human motor cortex can activate pelvic floor muscles (PFM), but the motor cortical representation of the PFM is not well characterized. PFM representation is thought to be focused in the supplementary motor area (SMA). Here we examine the degree to which PFM representation is distributed between SMA and the primary motor cortex (M1), and how this representation is utilized to activate the PFM in different coordination patterns. We show that two types of coordination patterns involving PFM can be voluntarily accessed: one activates PFM independently of synergists and a second activates PFM prior to and in proportion with synergists (in this study, the gluteus maximus muscle - GMM). Functional magnetic resonance imaging (fMRI) showed that both coordination patterns involve overlapping activation in SMA and M1, suggesting the presence of intermingled but independent neural populations that access the different patterns. Transcranial magnetic stimulation (TMS) confirmed SMA and M1 representation for the PFM. TMS also showed that, equally for SMA and M1, PFM can be activated during rest but GMM can only be activated after voluntary drive to GMM, suggesting that these populations are distinguished by activation threshold. We conclude that PFM representation is broadly distributed in SMA and M1 in humans.
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Affiliation(s)
- Moheb S Yani
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, 90033, USA
| | - Joyce H Wondolowski
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, 90033, USA
| | - Sandrah P Eckel
- Division of Biostatistics, University of Southern California, Los Angeles, CA, 90033, USA
| | - Kornelia Kulig
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, 90033, USA
| | - Beth E Fisher
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, 90033, USA
| | - James E Gordon
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, 90033, USA
| | - Jason J Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, 90033, USA.
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Tam J, Cohen T, Kim J, Weissbart S. Insight Into the Central Control of Overactive Bladder Symptoms by Functional Brain Imaging. CURRENT BLADDER DYSFUNCTION REPORTS 2018. [DOI: 10.1007/s11884-018-0464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Clarkson BD, Griffiths D, Resnick NM. Do brain structural abnormalities differentiate separate forms of urgency urinary incontinence? Neurourol Urodyn 2018; 37:2597-2605. [PMID: 29672906 DOI: 10.1002/nau.23591] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/27/2018] [Indexed: 11/11/2022]
Abstract
AIMS Urgency urinary incontinence (UUI) is a major problem for seniors. The underlying mechanisms of disease and therapy are unknown. We sought structural brain abnormalities that might underlie the functional differences previously observed by functional Magnetic Resonance Imaging in UUI patients versus controls, or among UUI responders versus non-responders to therapy-and thereby reveal potential disease mechanisms and therapeutic targets. METHODS Secondary study of a trial of biofeedback-assisted pelvic floor muscle training (BFB) in 60 women (>60 yrs) with UUI, plus 11 age-matched continent controls. Brain structural abnormalities were investigated using: (1) white-matter hyperintensities (WMH); (2) diffusion tensor imaging (DTI) to reveal white-matter pathways with impaired integrity; and (3) voxel-based morphometry (VBM) to show regions of atrophy or hypertrophy. RESULTS WMH burden was greater in UUI patients than controls (globally and in superior longitudinal fasciculus and cingulum), suggesting a possible causal connection. WMH burden was unexpectedly greater in responders than non-responders to BFB, and appeared to increase in non-responders but not in responders. DTI revealed even worse integrity of the cingulum than was apparent by WMH. VBM showed parahippocampal atrophy in UUI. CONCLUSIONS Many women with UUI have white-matter damage that interferes with pathways critical to bladder control; they can be taught by techniques like BFB to exert stronger control over the bladder. For others, in whom abnormalities of key brain areas are less marked, UUI's cause may reside elsewhere, and therapy targeting these brain centers may be less effective than therapy targeting the bladder or other brain centers.
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Affiliation(s)
- Becky D Clarkson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek 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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Weissbart SJ, Bhavsar R, Rao H, Wein AJ, Detre JA, Arya LA, Smith AL. Specific Changes in Brain Activity during Urgency in Women with Overactive Bladder after Successful Sacral Neuromodulation: A Functional Magnetic Resonance Imaging Study. J Urol 2018; 200:382-388. [PMID: 29630979 DOI: 10.1016/j.juro.2018.03.129] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2018] [Indexed: 01/23/2023]
Abstract
PURPOSE The mechanism of sacral neuromodulation is poorly understood. We compared brain activity during urgency before and after sacral neuromodulation in women with overactive bladder and according to the response to treatment. MATERIALS AND METHODS Women with refractory overactive bladder who elected sacral neuromodulation were invited to undergo functional magnetic resonance imaging before and after treatment. During imaging the bladder was filled until urgency was experienced. Regions of interest were identified a priori and brain activity in these regions of interest was compared before and after treatment as well as according to the treatment response. Whole brain exploratory analysis with an uncorrected voxel level threshold of p <0.001 was also performed to identify additional brain regions which changed after sacral neuromodulation. RESULTS Of the 12 women who underwent a pretreatment functional magnetic resonance imaging examination 7 were successfully treated with sacral neuromodulation and underwent a posttreatment examination. After sacral neuromodulation brain activity decreased in the left anterior cingulate cortex, the bilateral insula, the left dorsolateral prefrontal cortex and the bilateral orbitofrontal cortex (each p <0.05). No new brain regions showed increased activity after sacral neuromodulation. Pretreatment brain activity levels in the bilateral anterior cingulate cortex, the right insula, the bilateral dorsolateral prefrontal cortex, the right orbitofrontal cortex, the right supplementary motor area and the right sensorimotor cortex were higher in women who underwent successful treatment (each p <0.05). CONCLUSIONS Brain activity during urgency changes after successful sacral neuromodulation. Sacral neuromodulation may be more effective in women with higher levels of pretreatment brain activity during urgency.
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Affiliation(s)
- Steven J Weissbart
- Department of Urology, Stony Brook University School of Medicine, Stony Brook, New York.
| | - Rupal Bhavsar
- Department of Neurology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Hengyi Rao
- Department of Neurology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alan J Wein
- Division of Urology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - John A Detre
- Department of Neurology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lily A Arya
- Department of Obstetrics and Gynecology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ariana L Smith
- Division of Urology, Perelman School of Medicine, Philadelphia, Pennsylvania
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Apostolidis A, Wagg A, Rahnam A'i MS, Panicker JN, Vrijens D, von Gontard A. Is there "brain OAB" and how can we recognize it? International Consultation on Incontinence-Research Society (ICI-RS) 2017. Neurourol Urodyn 2018; 37:S38-S45. [PMID: 29388707 DOI: 10.1002/nau.23506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/26/2017] [Indexed: 02/06/2023]
Abstract
AIMS In light of mounting evidence supporting the association of brain regions with the control of urine storage and voiding, the high placebo effect in OAB studies as well as certain anecdotal observations from clinical practice with OAB patients, the role of the brain in OAB was explored. METHODS At the ICI-RS 2017 meeting, a panel of Functional Urologists and Basic Scientists presented literature data generating a proposal to discuss whether there is "brain OAB" and how we could recognize it. RESULTS Existing data point toward organic brain causes of OAB, in particular concerning white matter disease (WMD) and aging, but with currently speculative mechanisms. Imaging techniques have revealed connectivity changes between brain regions which may explain brain-peripheral interactions in OAB patients, further to acknowledged structural and functional changes in the central nervous system (CNS). Furthermore, psychological disorders like stress and depression have been identified as causes of OAB, with animal and human studies proposing a neurochemical and neuroendocrine pathophysiological basis, involving either the serotoninergic system or the hypothalamic-pituitary-adrenal axis. Finally, childhood data suggest that OAB could be a developmental disorder involving the CNS, although childhood OAB could be a different condition than that of adults in many children. CONCLUSIONS Future research should aim to identify the pathogenesis of WMD and the aging processes affecting the brain and the bladder, with possible benefits in prevention strategies, as well as connectivity disorders within the CNS, the pathophysiology of OAB in childhood and the neurochemical pathways connecting affective disorders with OAB.
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Affiliation(s)
- Apostolos Apostolidis
- 2nd Department of Urology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Adrian Wagg
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammad S Rahnam A'i
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jalesh N Panicker
- Department of Uro-Neurology, UCL Institute of Neurology, London, United Kingdom
| | - Desiree Vrijens
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
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Abstract
PURPOSE OF REVIEW To summarize the advances in diagnostic modalities and management options for defecatory dysfunction and highlight the areas in need of further research. RECENT FINDINGS The diagnostic utility of high-resolution anorectal manometry (ARM), which has emerged as a promising tool for the diagnosis of defecatory dysfunction, appears to be questionable in differentiating disease from normal physiology. There also seems to be discrepancy between results of various tests of anorectal function in the diagnosis of defecatory dysfunction. New revisions in diagnostic criteria for defecatory dysfunction by Rome IV consortium, may enhance its diagnostic yield. Biofeedback remains to be the most effective evidence-based treatment option for patients with defecatory dysfunction. Anorectal pressure profile cannot predict or mediate the success of biofeedback. Biofeedback may improve the symptoms through central effects. SUMMARY Despite the advances in the ARM and defecography techniques, no one test has been able to be considered as the 'gold standard' for diagnosis of defecatory dysfunction. The mechanism of action of biofeedback in defecatory dysfunction remains poorly understood.
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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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Arnouk A, De E, Rehfuss A, Cappadocia C, Dickson S, Lian F. Physical, Complementary, and Alternative Medicine in the Treatment of Pelvic Floor Disorders. Curr Urol Rep 2017; 18:47. [DOI: 10.1007/s11934-017-0694-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
: Overactive bladder is a term used to describe a group of lower urinary tract symptoms that are prevalent in women, particularly as they age. Those with overactive bladder often experience related physical and psychological symptoms or conditions and report a poorer quality of life than other women. Many factors that increase the risk of developing overactive bladder are modifiable; therefore, lifestyle and behavioral interventions are first-line treatments. More treatment options are becoming available to women as research provides new information about the underlying pathophysiology of overactive bladder. Nurses play a major role in its screening, assessment, and management in women, many of whom do not seek help and try to self-manage symptoms, leading to a continuing cycle of unpredictable urgency and incontinence.
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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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Ketai LH, Komesu YM, Dodd AB, Rogers RG, Ling JM, Mayer AR. Urgency urinary incontinence and the interoceptive network: a functional magnetic resonance imaging study. Am J Obstet Gynecol 2016; 215:449.e1-449.e17. [PMID: 27173081 DOI: 10.1016/j.ajog.2016.04.056] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/21/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Treatment of urgency urinary incontinence has focused on pharmacologically treating detrusor overactivity. Recent recognition that altered perception of internal stimuli (interoception) plays a role in urgency urinary incontinence suggests that exploration of abnormalities of brain function in this disorder could lead to better understanding of urgency incontinence and its treatment. OBJECTIVE We sought to: (1) evaluate the relationship between bladder filling, perceived urgency, and activation at brain sites within the interoceptive network in urgency urinary incontinence; (2) identify coactivation of other brain networks that could affect interoception during bladder filling in urgency incontinence; and (3) demonstrate interaction between these sites prior to bladder filling by evaluating their resting-state connectivity. STUDY DESIGN We performed an observational cohort study using functional magnetic resonance imaging to compare brain function in 53 women with urgency urinary incontinence and 20 controls. Whole-brain voxelwise analyses of covariance were performed to examine differences in functional brain activation between groups during a task consisting of bladder filling, hold (static volume), and withdrawal phases. The task was performed at 3 previously established levels of baseline bladder volume, the highest exceeding strong desire to void volume. All women continuously rated their urge on a 0- to 10-point Likert scale throughout the task and a mixed measures analysis of variance was used to test for differences in urge ratings. Empirically derived regions of interest from analysis of activation during the task were used as seeds for examining group differences in resting-state functional connectivity. RESULTS In both urgency urinary incontinent participants and controls, changes in urge ratings were greatest during bladder filling initiated from a high baseline bladder volume and urgency incontinent participants' rating changes were greater than controls. During this bladder-filling phase urgency incontinent participant's activation of the interoceptive network was greater than controls, including in the left insula and the anterior and middle cingulate cortex. Urgency incontinent participant's activation was also greater than controls at sites in the ventral attention network and posterior default mode network. Urgency incontinent participant's connectivity was greater than controls between a middle cingulate seed point and the dorsal attention network, a "top-down" attentional network. Control connectivity was greater between the midcingulate seed point and the ventral attention network, a "bottom-up" attentional network. CONCLUSION Increasing urge was associated with greater urgency incontinent participant than control activation of the interoceptive network and activation in networks that are determinants of self-awareness (default mode network) and of response to unexpected external stimuli (ventral attention network). Differences in connectivity between interoceptive networks and opposing attentional networks (ventral attention network vs dorsal attention network) were present even before bladder filling (in the resting state). These findings are strong evidence for a central nervous system component of urgency urinary incontinence that could be mediated by brain-directed therapies.
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Tyagi S, Perera S, Clarkson BD, Tadic SD, Resnick NM. Nocturnal Polyuria in Older Women with Urge Urinary Incontinence: Role of Sleep Quality, Time in Bed and Medications Used. J Urol 2016; 197:753-758. [PMID: 27678299 DOI: 10.1016/j.juro.2016.09.080] [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] [Accepted: 09/20/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Nocturia is common and bothersome in older adults, especially those who are also incontinent. Since nocturnal polyuria is a major contributor, we examined factors associated with nocturnal polyuria in this population to identify those possibly amenable to intervention. MATERIALS AND METHODS We analyzed baseline data from 2 previously completed studies of urge urinary incontinence. The studies involved 284 women (mean age ± SD 72.9 ± 7.9 years) who also completed 3-day voiding diaries. Participants with a nocturnal polyuria index greater than 33% were categorized as having nocturnal polyuria (nocturnal polyuria index = nocturnal urinary volume per 24-hour urine volume). Associations between nocturnal polyuria and various demographic, clinical and sleep related parameters were determined. RESULTS Overall 55% of the participants had nocturnal polyuria. Multivariable regression analysis revealed that age, body mass index, use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker, time spent in bed and duration of first uninterrupted sleep were independent correlates of nocturnal polyuria. Participants with a larger nocturnal excretion reported a shorter duration of uninterrupted sleep before first awakening to void and worse sleep quality despite spending similar time in bed. CONCLUSIONS Body mass index, use of angiotensin converting enzyme inhibitor/angiotensin receptor blockers, time in bed and duration of uninterrupted sleep before first awakening to void are independently associated with nocturnal polyuria in older women with urge urinary incontinence, and are potentially modifiable. These findings also confirm the association between sleep and nocturnal polyuria. Further studies should explore whether interventions to reduce nocturnal polyuria and/or increase the duration of uninterrupted sleep before first awakening to void would help to improve sleep quality in this population and thereby reduce or eliminate the need for sedative hypnotics.
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Affiliation(s)
- Shachi Tyagi
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Subashan Perera
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Becky D Clarkson
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stasa D Tadic
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neil M Resnick
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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