Sympathetic activity in the proximal urethra in patients with urinary obstruction

"Z" Anatomical Needle Cut Leads Ejaculation (ZANCLE): Unilateral incision for bladder neck obstruction with ejaculation-sparing intent: A single-surgeon experience

This study aimed to evaluate functional outcomes and anterograde ejaculation rates in patients undergoing monopolar, unilateral transurethral incision of the prostate (TUIP) with "Z" shaped incision with ejaculatory sphincter sparing for primary bladder neck obstruction (PBNO) in a case series performed by a single surgeon. Between December 2018 and July 2023, data from patients who underwent monopolar, unilateral TUIP were prospectively collected. Patients with a prostate volume of less than 30 mL were included. Functional outcomes, including maximum flow rate (Qmax, mL/s), post-void residual volume (PVR, mL), International Prostate Symptom Score (IPSS), and IPSS Quality of Life (IPSS QoL) score, were assessed preoperatively and at 1, 6, and 12 months postoperatively. A total of 106 patients met the inclusion criteria, with a median age of 42 years (range: 37-57) and a median prostate volume of 27 mL (range: 20-29). The median hospital stay was 1 day, and the median catheterization time was 3 days. At 1-month follow-up, the mean Qmax increased from 10.2 ± 2.5 mL/s to 22.8 ± 3.9 mL/s, while the mean IPSS score and IPSS QoL score decreased from 16 ± 2.7 to 6.9 ± 1.5 and from 4.3 ± 0.9 to 1.9 ± 1.6, respectively (p < 0.001). The mean PVR volume decreased from 125.5 ± 16.1 mL to 27.7 ± 7.3 mL (p < 0.001). Uroflowmetry results remained statistically significant at 12 months of follow-up (each p < 0.001). Anterograde ejaculation was preserved in all cases. Unilateral monopolar TUIP confirms to be a feasible and safe procedure for the treatment of BNO in young and sexually active patients.

Primary bladder neck obstruction in men: The importance of urodynamic assessment and cystourethrography in measuring its severity

OBJECTIVE

Primary bladder neck obstruction (PBNO) is a condition primarily affecting young men, characterized by obstruction at the bladder neck, leading to lower urinary tract symptoms. The aim of this study was to identify a correlation between the severity of bladder neck opening impairment and urinary symptoms by means of urodynamic studies.

MATERIALS AND METHODS

A retrospective analysis was conducted in adult males diagnosed with PBNO at a university neurourology department between 2015 and 2022 who underwent voiding cystourethrography (VCUG) and pressure-flow studies. The cohort was divided into two groups: absence of bladder neck opening on VCUG (Group A) and incomplete bladder neck opening (Group B).

RESULTS

Out of the 82 patients with PBNO screened, 53 were included in the analysis. Nocturia was the only symptom more prevalent in Group A (65% in Group A vs. 30% in Group B, p = 0.02) but scores and subscores of the Urinary Symptom Profile questionnaire were not different between groups. In addition, the detrusor pressure at a maximum flow rate (PdetQmax), bladder outlet obstruction index (BOOI), and bladder contractility index (BCI) were higher in Group A than in Group B [PdetQmax (A = 93.7 ± 53.7 cmH2O vs. B = 65.7 ± 26.4 cmH2O; p = 0.01)-BOOI (A = 77 ± 58.3 vs. B = 48 ± 25.7; p = 0.03)-BCI (A = 136 ± 51.3 vs. B = 110 ± 41.7; p = 0.04)].

CONCLUSION

This study demonstrates a significant association between the extent of bladder neck opening impairment observed on VCUG and obstruction and contraction urodynamic parameters, but no association with the severity of urinary symptoms. Future studies should evaluate the predictive value of treatment response and the occurrence of complications based on clinical and urodynamic parameters.

Medical evaluation and management of male and female voiding dysfunction: a review

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.

Gait analysis of young male patients diagnosed with primary bladder neck obstruction

Primary bladder neck obstruction (PBNO) represents an inappropriate or inadequate relaxation of the bladder neck during micturition. Based on the observation of an increased rate of postural imbalances in male patients with PBNO, we hypothesized a possible role of an unbalanced biomechanics of the pelvis on urethral sphincters activity. Our aim was to identify kinematic imbalances, usually disregarded in PBNO patients, and which could eventually be involved in the etiopathogenesis of the disease. Seven male adult patients (39.6±7.1years) were recruited; in all patients, PBNO was suspected at bladder diary and uroflowmetry, and was endoscopically confirmed with urethroscopy. Participants gait was recorded with a motion capture system (BTS Spa, Italy) to obtain three-dimensional joint angles and gait parameters. Multivariate statistics based on a Principal Component model allowed to assess the similarity of patients' gait patterns with respect to control subjects. The main finding is that patients with PBNO showed significant discordance in the observations at the ankle and pelvis level. Additionally, 6/7 patients demonstrated altered trunk positions compared to normal curves. We suggest that the identified postural imbalances could represent the cause for an anomalous activation of pelvic floor muscles (hypertonia). The consequent urinary sphincters hypercontraction may be responsible for the development of voiding dysfunction in male patients with no significant morphological alterations. Results reinforced the hypothesis of an etiopathogenetic role of postural imbalances on primary bladder neck obstruction in male patients.

Single laser incision for treatment of congenital bladder neck sclerosis: new technique

INTRODUCTION

The primary bladder neck obstruction (PBNO) has been recognized in 41-45% of young men suffering from a chronic lower urinary tract symptom (LUTS). Few studies are published in the literature about the use of laser devices in the surgical treatment of PBNO and none about the use of Thulium laser. The aim of our study is to report the results of our follow-up in the endoscopic treatment of PBNO with Thulium laser.

MATERIALS AND METHODS

From January 2012 to January 2015, we treated 214 patients using Thulium laser for primary bladder neck sclerosis. All patients had symptoms suggestive of LUTS or prostatism: filling or irritative symptoms and voiding or obstructive symptoms. In 157 patients, the incision was performed unilaterally at 7 o'clock of the bladder neck. In 57 cases, bilateral incision was performed at 5 and 7 o' clock without vaporizing the tissue between the two incisions. We chose to make the incision bilaterally in cases wherein a single incision was not enough to solve the obstruction from the bladder neck and prevent a recurrence. Bladder irrigation was used overnight in all cases, and the catheter was removed after 24 hours.

RESULTS

One hundred ninety-six patients enrolled completed 1-year follow-up: 157 patients underwent unilaterally incision and 39 bilateral incision. In 179 cases (91.3%), there was unchanged antegrade ejaculation, while reduced semen volume was reported by 14 men (7.1%) and retrograde ejaculation by only 3 (1.5%), but these patients underwent bilateral incision. The quality of orgasm and sexual satisfaction was not permanently changed by the operation.

CONCLUSIONS

In patients with PBNO, it is possible to perform endoscopic treatment with Thulium laser that we think is an effective and safe procedure, not affecting sexual functioning and particularly retrograde ejaculation.

Transurethral bladder neck incision in women with primary bladder neck obstruction

BACKGROUND

Bladder outlet obstruction is an uncommon condition in women. Primary bladder neck obstruction is one of the functional causes of bladder outlet obstruction. We evaluated surgical treatment in our patients with primary bladder neck obstruction.

PATIENTS AND METHODS

We retrospectively evaluated the medical data of 47 female patients from the Department of Urology who underwent transurethral incision of the bladder neck from January 2000 to December 2012. All patients underwent transurethral bladder neck incision at the vesical neck and proximal urethra at the 5- and 7-o'clock positions. We compared symptoms and urodynamic parameters before and after the operation.

RESULTS

Out of 47 female patients who underwent the operation, primary bladder neck obstruction was diagnosed in 42. The mean age was 44.3 ± 16.8 (range: 21-78) years. The postoperative maximal flow rates were significantly increased (20.6 ± 3.9 vs. 7.6 ± 3.2 mL/s, P < 0.0001), and the postvoid residual urine was decreased (31.3 ± 7.8 vs. 132.1 ± 22.24 mL, P = 0.0002) compared with preoperative findings. Improvement was evident in most patients (83.3 %). A repeat operation had to be performed in seven patients (16.7 %). Operative therapy failed in one patient (2.4 %).

DISCUSSION AND CONCLUSIONS

The diagnosis of primary bladder neck obstruction in women is based on typical symptoms, uroflowmetry and multichannel urodynamics, including electromyography. Videourodynamics is obligatory in doubtful cases. Transurethral bladder neck incision is an effective therapy for female patients with primary bladder neck obstruction, and if necessary, a second procedure can be safely performed.

Urodynamic differences between dysfunctional voiding and primary bladder neck obstruction in women

OBJECTIVE

To determine the clinical and urodynamic differences in the presentation and the value of simultaneous fluoroscopy in dysfunctional voiding (DV) and primary bladder neck obstruction (PBNO); the 2 most common causes of non-neurogenic "functional" bladder outlet obstruction in women.

METHODS

A review of our urodynamic study database (March 2003 to August 2009) was conducted. DV was diagnosed when increased external sphincter activity was found during voluntary voiding on electromyography (EMG) or fluoroscopy. PBNO was diagnosed when a failure of bladder neck opening was noted on fluoroscopy during voiding. The demographics, symptoms, and urodynamic study parameters were collected. Comparisons were done using chi-square and 2-tailed t-tests.

RESULTS

DV was diagnosed in 34 women and PBNO in 16. The patients with DV were younger than those with PBNO (40.9 vs 59.2 years, P < .001). Women with DV showed a clinical trend toward having more storage symptoms than those with PBNO and fewer voiding symptoms. Patients with DV had a greater mean maximal flow rate (12 vs 7 mL/s, P = .027) and lower mean postvoid residual urine volume (125 vs 400 mL, P = .012). No significant differences were found in maximal detrusor pressure, detrusor pressure at maximal flow rate, or detrusor overactivity. EMG showed increased activity during voiding in 79.4% of those with DV and 14.3% of those with PBNO (P < .001).

CONCLUSION

Clinically, women with DV and PBNO had similar presentations, although those with PBNO had poorer emptying. The flow rates and patterns seemed to differ between those with DV and PBNO, although the voiding pressures were similar. EMG alone would have given the wrong diagnosis in 20.6% of those with DV (false negative) and 14.3% of those with PBNO (false positive). When fluoroscopy is used to define these entities, the accuracy of EMG to differentiate them is questionable.

Primary bladder neck obstruction in men, women, and children

The understanding of the presentation, diagnosis, and treatment of primary bladder neck obstruction (PBNO) has evolved over the last 20 years. It was first identified 70 years ago, but the etiology is still unclear. There are multiple theories as to the etiology, including muscular and neurological dysfunction and fibrosis. Over the years, many voiding parameters and cut points and nomograms have been presented for diagnosis of nonneurogenic functional bladder outlet obstruction in young men. Until recently, there was a paucity of data on PBNO in women and children. Videourodynamics provide an accurate diagnosis of PBNO but for some patients are an invasive option. Treatments vary from watchful waiting to alpha-blockade to surgery, depending on the severity of symptoms, urodynamic findings, and response to medical therapy. This paper reviews the theories on etiology, incidence, presentation, and diagnostic evaluation, and briefly discusses treatment options for PBNO.

Diagnosis and treatment of primary bladder neck obstruction in men

Although primary bladder neck obstruction was first described approximately 70 years ago, it is within the past 20 years that the symptoms, signs, and methods of diagnosis and treatment have been elucidated. This article describes its typical presenting symptoms and signs that commonly may lead to a missed diagnosis for a number of years in many cases. The treatments typically available are pharmacologic or surgical. Unfortunately, most treatments have not been studied in prospective, randomized trials to assess true efficacy. The natural history of this disorder, both treated and untreated, demands much further study to determine its effect on progression of symptoms and bladder and renal function.

Primary bladder neck dysfunction: An overlooked entity in children

Primary bladder neck dysfunction is a non-neurogenic voiding disorder commonly diagnosed in young and middle age adult men, but frequently overlooked in children. Because these children typically present with lower urinary tract symptoms that also are associated with other more common forms of dysfunctional voiding, the diagnosis may be missed and treated with a variety of empiric modalities that ultimately fail. Although its underlying pathogenesis remains debated, the hallmark of the diagnosis is a failure of the bladder neck to properly open and allow for unimpeded urine flow. Videourodynamic evaluation is the only diagnostic tool that can urodynamically document the obstructive pressure/flow parameters of the condition while simultaneously localizing the functional obstruction to the bladder neck fluoroscopically. This article reviews the clinical and urodynamic findings of this entity in children and adolescents and our experience with a adrenergic antagonists, the current approach in medical therapy.

Idiopathic detrusor-urethral dyssynergia in dogs: a retrospective analysis of 22 cases

Results of a retrospective study of 22 dogs with signs of dysuria and/or stranguria in which a diagnosis of idiopathic detrusor-urethral dyssynergia was made are presented. The diagnosis was based on the exclusion of detectable pathological conditions which could also cause urine outflow obstruction. The affected cases were 22 middle-aged male dogs (mean age 4.9 years) of large and giant breeds (mean bodyweight 36.7 kg). Nine dogs had had periodic clinical signs for longer than one year, one for seven months and eight for two to five weeks, while in four dogs signs had begun four to five days before referral. All dogs received the alpha-sympatholytic agent prazosin as an initial treatment and in 11 it remained the only therapy. There was a good effect in seven and a moderate response in the other four dogs. In one dog, prazosin was ineffective and was replaced by diazepam, which markedly reduced the signs. Three other dogs required frequent catheterisation and antibiotics were administered. These dogs responded favourably. Another three dogs with evidence of impaired bladder contractility were also treated with the parasympathomimetic agent carbachol. One did not improve and was euthanased. Four dogs developed bladder paralysis and severe infectious cystitis. Only one of these could be managed satisfactorily by long-term administration of prazosin, carbachol and antibiotics, and the others had to be euthanased.

Effect of choline ester analogues, noradrenaline and nifedipine on normal and hypertrophied human urinary bladder detrusor muscle

1. Acetylcholine, bethanechol, carbachol and propionylcholine were all agonists of normal human detrusor smooth muscle. The order of potency was found to be carbachol > acetylcholine > bethanachol > propionylcholine. 2. In hypertrophied detrusor smooth muscle carbachol was more potent than acetylcholine, but hypertrophied detrusor preparations were less sensitive to carbachol than normal detrusor smooth muscle. 3. Noradrenaline had no direct effect on either normal or hypertrophied detrusor muscle, but it had a reversible inhibitory effect on the spontaneous contractile activity of normal detrusor preparations. Hypertrophied detrusor preparations usually lacked such spontaneous activity. 4. In calcium-free saline, agonist-induced responses of both normal and hypertrophied detrusor muscle were dramatically reduced indicating that choline ester activity in the muscles was strongly dependent upon extracellular calcium. 5. Nifedipine at 10(-5) mol l-1 inhibited acetylcholine responses and K(+)-induced contractures of both normal and hypertrophied detrusor muscles. Acetylcholine-induced responses of normal detrusor preparations were much more sensitive to inhibition by nifedipine than were the responses of hypertrophied detrusor muscle. 6. The properties and densities of both the muscarinic cholinoreceptors and calcium channels appear to have been altered by the hypertrophic response secondary to benign prostatic hyperplasia.

Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option

PURPOSE

Chronic lower urinary tract symptoms in young men are often attributed to misdiagnosed chronic nonbacterial prostatitis. We analyzed contraction of the external urinary sphincter during voiding (pseudodyssynergia) as an etiology of voiding dysfunction in men with misdiagnosed chronic prostatitis.

MATERIALS AND METHODS

The video urodynamic studies of 43 men 23 to 50 years old with chronic voiding dysfunction secondary to pseudodyssynergia performed between January 1990 and June 1996 were retrospectively analyzed. Pseudodyssynergia was diagnosed based on several criteria, including electrical activity of the external sphincter during voiding in the absence of abdominal straining, and brief and intermittent closing of the membranous urethra during voiding detected by electromyography and fluoroscopy. Patients with bacterial infection or excessive leukocytes in expressed prostatic secretions were excluded from the study.

RESULTS

Of the patients 39 (91%) were firstborn men. Duration of symptoms ranged from 17 to 146 months (mean 43.6). Average number of previous antibiotic days ranged from 53 to 186 (mean 67.6). In addition, empirical trials of alpha-blockers were unsuccessful. Mean American Urological Association symptom score plus or minus standard deviation was 17.5 +/- 3.7, mean maximum flow rate was 13.3 +/- 4.2 ml. per second, mean detrusor pressure at maximum flow was 46.3 +/- 13.7 cm. water and mean detrusor contraction duration was 132.8 +/- 27.7 seconds. Behavior modification and biofeedback were successful in decreasing symptoms in 35 patients (83%) at 6 months.

CONCLUSIONS

These results indicate that some men who are categorized as having and empirically treated for chronic nonbacterial prostatitis are misdiagnosed and, in fact, have functional bladder outlet obstruction. Urodynamics are helpful in diagnosing and predicting success with behavior modification and biofeedback in these patients.

Primary bladder neck obstruction: urodynamic findings and treatment results in 36 men

PURPOSE

We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction.

MATERIALS AND METHODS

A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases.

RESULTS

Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30% of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision.

CONCLUSIONS

Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.

Bladder neck dysynergia in spinal cord injury

Urodynamic evaluations were performed in 43 male patients with spinal cord injuries, before any therapeutic decisions, and a minimum of 5 mo following the injury. Results were subdivided according to level of injury. Mean detrusor contraction pressures, incidence of detrusor-sphincter dysynergia (DSD), and incidence of detrusor-bladder neck dysynergia (DBND) were calculated. The incidence pattern of DBND was found to follow closely the incidence pattern of DSD, with the highest incidence among the upper thoracic injuries, considerably more than among the cervical injuries. A significantly higher resting detrusor pressure differential was found among the patients with DBND. This was felt to represent sympathetic dysfunction and poor accommodation and is proposed to be secondary to adrenergic detrusor neoinnervation.

Effect of intravenous alfuzosin on urethral pressure in patients with neurogenic bladder dysfunction. DORALI Study Group

In order to assess the ability of a single intravenous (i.v.) injection of alfuzosin, a selective alpha-1 blocker, in reducing high urethral tone in patients with symptomatic neurogenic bladder dysfunction (NBD), 163 patients (mean maximal urethral pressure [MUP] 108 +/- 46 cm H2O) were enrolled in a double-blind, placebo-controlled, parallel-group trial and were randomly allocated to receive 0.5 mg (n = 45), 1 mg (n = 41), 2 mg (n = 39) alfuzosin or placebo (n = 38). The decrease in MUP was dose-dependent and statistically significant (P < or = 0.05) for 1 and 2 mg alfuzosin (respectively, 43 +/- 28 cm H2O and 46 +/- 27 cm H2O decreases vs. baseline) in comparison with placebo (23 +/- 30 cm H2O). The 2 mg dose level was the most effective leading to a > or = 30 or 50% decrease in MUP in, respectively, 69 and 44% of patients. The safety of all three alfuzosin dose levels was satisfactory and comparable to placebo. I.v. alfuzosin induces, in a dose-related manner, a clinically significant decrease in urethral pressure in patients with NBD and high urethral tone, and may be safely used as a pharmacological test as part of an urodynamic investigation.

Urodynamic evidence of vesical neck obstruction in men with misdiagnosed chronic nonbacterial prostatitis and the therapeutic role of endoscopic incision of the bladder neck

Many patients are misdiagnosed as having refractory chronic nonbacterial prostatitis, and are treated with antibiotics and/or alpha-blockers with variable success. This study was designed to ascertain the potential diagnostic role of synchronous video-pressure-flow urodynamics and the therapeutic role of transurethral incision of the bladder neck in 34 consecutive men (age 26 to 51 years) with a minimum of 2 years of misdiagnosis. Duration of symptoms ranged from 25 to 126 months (mean 38.3). The average number of previous antibiotic days ranged from 42 to 136 (mean 54.3). In addition, 24 men were given empiric trials of alpha-blockers, all unsuccessful. Patients with evidence of bacterial infection or excessive leukocytes in expressed prostatic secretions were excluded from the study. Of these 34 patients 31 had urodynamic evidence of bladder outlet obstruction localized fluoroscopically to the vesical neck, while the remaining 3 had normal studies. The mean pretreatment maximum urine flow was 9.2 ml. per second and the mean maximal detrusor pressure was 76.3 cm. water. In 31 patients the bladder neck was incised at the 5 o'clock position from the bladder neck to the verumontanum with the patient under caudal (22) or spinal (9) anesthesia. Of these 31 patients 30 had marked subjective improvement in symptoms with an increase in maximal urine flow to 16.4 and 15.7 ml. per second at 3 and 6 months, respectively. The remaining patient noticed continued symptoms despite urine flow improvement. All 31 patients reported postoperative antegrade ejaculation. These results indicate that many men who are categorized as having and empirically treated for chronic nonbacterial prostatitis are misdiagnosed and, in fact, have bladder outlet obstruction. Urodynamics are helpful in diagnosing and predicting success in these patients. Furthermore, transurethral incision of the bladder neck is an effective and safe therapeutic modality in this group.

Pharmacological evidence of distinct alpha 1-adrenoceptor subtypes mediating the contraction of human prostatic urethra and peripheral artery

1. The alpha 1-adrenoceptor subtypes mediating contractions of the smooth muscle in human prostatic urethra and branches of internal iliac artery were characterized in isometric contraction experiments. 2. Phenylephrine produced concentration-dependent contractions in both the urethra and artery. These responses were competitively inhibited by prazosin, WB4101 and 5-methyl-urapidil, and the slopes of Schild plots for all these antagonists were close to unity. 3. The pA2 values for prazosin were not significantly different between the urethra (9.42 +/- 0.11; mean +/- s.d.) and artery (9.50 +/- 0.27), while the pA2 values for WB4101 and 5-methyl-urapidil in the human prostatic urethra (8.94 +/- 0.19 and 8.42 +/- 0.14, respectively) were significantly greater than in the branches of human internal iliac artery (7.94 +/- 0.21 and 7.43 +/- 0.22, respectively; P < 0.01). 4. Pretreatment with chlorethylclonidine (CEC) at concentrations ranging from 0.1 microM to 100 microM attenuated the maximum contraction to phenylephrine in a concentration-dependent manner in both the urethra and artery. However, the urethra was significantly less affected by CEC than the artery. The pD'2 values (negative logarithm of the molar concentration of antagonist which reduced the maximum contraction to one half) in the urethra and artery were 4.35 +/- 0.27 and 5.20 +/- 0.37, respectively (P < 0.01). 5. The present results indicate that there are distinct populations of alpha 1-adrenoceptor subtypes in the human prostatic urethra and branches of the internal iliac artery. The alpha 1-adrenoceptors responsible for the contraction of the human internal iliac artery branches are predominantly alpha 1 B-subtype, whereas those in the human prostatic urethra are considered to be not alpha 1 B, but alpha 1 c or possibly alpha 1 A or alpha 1A/D-subtype.

Clinical effect of alpha-1 antagonism by terazosin on external and internal urinary sphincter function

The purpose of this investigation was to determine the effectiveness of alpha-1 blockade in the treatment of bladder outlet obstruction in the spinal cord injured (SCI) patient. We evaluated terazosin, a selective alpha-1 blocker, in 15 normotensive SCI patients. Detrusor-external sphincter dyssynergia (DESD), without obstruction of the bladder neck or prostate, was documented in all patients using video-urodynamic evaluation. Urodynamic testing was performed both before and during treatment with terazosin (5 mg nightly). Voiding pressure before and during terazosin therapy averaged 92 +/- 17 and 88 +/- 27 cm H2O, respectively (p = 0.48). After subsequent external sphincterotomy or sphincter stent placement, the voiding pressure was reduced to 38 +/- 15 cm H2O (p < 0.001). Nine other patients suffered from persistent difficulty voiding after previous sphincterotomy. Each was subsequently treated with oral terazosin. In five patients who improved with this treatment, urodynamic parameters demonstrated obstruction only at the bladder neck, with no evidence of obstruction at the level of the external sphincter. The four patients who failed to improve were documented to have an open bladder neck but obstruction at the level of the external sphincter. Our data show that alpha-1 sympathetic blockade has no effect on external sphincter function and does not significantly relieve functional obstruction caused by DESD. It was also noted that terazosin is helpful in diagnosing and treating internal sphincter (bladder neck and prostate) obstruction especially in patients who have persistent difficulty voiding after external sphincterotomy.

Functional evaluation of sympathetically mediated responses in in vivo lower urinary tract of dogs

An in vivo procedure for evaluating local effects of alpha-adrenoceptor stimuli on the lower urinary tract was developed in anesthetized dogs. Electrical stimulation of hypogastric nerve at varied frequencies (1, 2, and 4 Hz) and intraarterial (i.a.) administration of an alpha 1-adrenoceptor agonist, phenylephrine (0.3, 1, and 3 micrograms) to the urethra and bladder through the cannulated right external iliac artery caused reproducible frequency- or dose-related increases in intraurethral pressure (IUP). Intrabladder pressure (IBP) was increased by the nerve stimulation but not by i.a. phenylephrine. Acetylcholine (10 micrograms) given i.a. elicited increases in both IUP and IBP. Prazosin (0.1, 1, and 10 micrograms/kg, i.v.) dose-dependently suppressed the urethral contractile responses to the nerve stimulation and i.a. phenylephrine, but it failed to affect the bladder contraction evoked by the nerve stimulation. The results suggest that the urethral contractile responses to hypogastric nerve stimulation as well as i.a. phenylephrine were mediated via alpha 1-adrenoceptors, whereas the IBP increasing effect of hypogastric nerve stimulation was not mediated via alpha 1-adrenoceptors.

Effects of prazosin in men with symptoms of bladder neck obstruction and a non-hyperplastic prostate

In a double blind cross-over study, the selective alpha 1-adrenoceptor blocker prazosin was given to eleven men with a non-hyperplastic prostate and with symptoms of bladder neck obstruction. During prazosin treatment maximum and average flow rates increased and residual urine was reduced. Prazosin did not change any pressure variables recorded. All patients had antegrade ejaculation and no side effects were reported. It is concluded that in selected patients with bladder outlet obstruction, prazosin may be a therapeutic alternative to bladder neck incision.

Unsuspected proximal urethral obstruction in young and middle-aged men

Proximal urethral obstruction, a common cause of prostatism in young and middle-aged men, often is misdiagnosed as prostatitis, neurogenic bladder or a psychogenic voiding disorder. Simple urodynamic studies (uroflowmetry and cystometry) do not distinguish a poor flow owing to bladder neck obstruction from that caused by poor detrusor contractility in these patients. Only the simultaneous measurement of detrusor pressure and uroflowmetry can make this distinction. A total of 23 patients with unsuspected proximal urethral obstruction underwent synchronous video-pressure-flow electromyography studies, and were treated and followed for a minimum of 1 year. Treatment by transurethral prostatic resection or bladder neck incision almost always was curative but alpha-adrenoceptor blocking agents have not been effective. All patients who underwent transurethral prostatic resection or bladder neck incision at the 5 and 7 o'clock positions have had retrograde ejaculation but both patients who underwent unilateral bladder neck incision reported antegrade ejaculation.

Experimental evidence for a central nervous system site of action in the effect of alpha-adrenergic blockers on the external urinary sphincter

The present study was done to test the hypothesis that alpha-adrenoceptor blocking drugs (phentolamine and prazosin) could interfere with somatic control of the external sphincter through an action in the central nervous system. Stimulation of the hypogastric nerve in the chloralose-anesthetized cat caused a urethral constriction which could be antagonized by alpha-receptor blockers. However, the constriction produced by stimulation of the S1 or S2 ventral root was completely resistant to alpha blockade. The drugs therefore had the expected action against sympathetic stimulation of the urethra but had no peripheral effect on the somatic component. The central effect of these drugs was investigated by recording urethral perfusion pressure responses, or compound action potentials on the central cut end of the pudendal nerve, evoked by stimulation of the contralateral pudendal or pelvic nerve. The urethral constriction produced by stimulation of the central cut end of 1 pudendal nerve was antagonized by both prazosin and phentolamine. Action potentials evoked on the pudendal nerve by stimulation of the central cut end of the contralateral pudendal or pelvic nerve were substantially inhibited by prazosin. Phentolamine produced a more variable blockade of the pudendal-pudendal reflex. The results strongly indicate that these alpha-adrenoceptor antagonists and especially prazosin can influence pudendal nerve-dependent urethral responses through a central nervous system action and not through a peripheral mechanism.

Urinary incontinence secondary to drugs

With the current rapid introduction of new drugs on the market, drug toxicity and side effects have received increasing publicity in the literature. Bladder dysfunction, however, rarely has been reported as an adverse effect. The possible mechanisms in the induction of urinary incontinence by three main groups of drugs, the neuroleptics, the antihypertensive agents, and the drugs used in the treatment of neurogenic bladder obstruction, are reviewed. These drugs are thought to act peripherally at sympathetic neurons or through a centrally-mediated effect.

Possible use of indoramin in patients with chronic neurogenic bladder dysfunction

Indoramin, which has great selectivity for alpha-1-receptors, was administered orally for 10 days to 21 patients with urinary retention or residual urine caused by neurogenic vesicourethral dysfunction. After indoramin therapy 17 patients were able to empty the bladder with residual urine less than 50 ml. There was a significant decrease in the maximum urethral pressure (23.87 plus or minus 4.13 cm. water) and in the functional profile length (0.53 plus or minus 0.19 cm.). A diminution in the sphincter electromyography activity was observed in 3 patients. Two paraplegics who were investigated during spinal shock could not achieve voiding after indoramin therapy. However, involuntary urine leakage associated with a change of posture occurred in 2 patients but subsided after the dosage of indoramin was decreased. No other side effect was observed. It may be desirable to use drugs with selective action upon alpha-1-receptors since blockade of noradrenergic autoreceptors (alpha-2) also by nonspecific alpha-adrenoceptor blocking agents, namely phentolamine, phenoxybenzamine and so forth, causes the overflow of norepinephrine, which would produce symptoms such as tachycardia by stimulating beta-receptors.

Diagnostic advantages of fluoroscopic monitoring during urodynamic evaluation

Clinical abnormalities of micturition exist in which measurements of urethral, bladder and rectal pressures, and electromyography determination do not allow a precise diagnosis. The diagnostic accuracy of urodynamic evaluation can be improved by the addition of fluoroscopic monitoring. It allows the detection of even small amounts of urinary leakage, the recognition of disassociation of electromyography activity of the pelvic floor musculature, the diagnosis of dysfunction of the smooth muscular urethral sphincter and the accurate localization of urethral obstruction. In our experience fluoroscopy is essential to accurate interpretation of urodynamic results.